Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery.

BACKGROUND AND AIMS: Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR). METHODS AND RESULTS: In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups. CONCLUSIONS: For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

Impact of Sex on Long-Term Outcomes Following Surgical Aortic Valve Replacement.

BACKGROUND: The impact of sex on outcomes following surgical aortic valve replacement (SAVR) remains unclear. It has been proposed that females experience inferior outcomes, but this has yet to be conclusively established, particularly in the long term. The objective of this study is to identify discrepancies in postoperative outcomes between males and females following SAVR to better inform consideration for surgical intervention. METHOD: We retrospectively reviewed the outcomes of 4,927 patients who underwent SAVR from 2004 to 2018 at our centre. In total, 531 propensity-matched males and females were included in the final analysis. The primary outcome was mortality at any point during the follow-up period. Secondary outcomes included various measures of postoperative morbidity. Follow-up duration was 15 years. RESULTS: In SAVR all-comers, females experienced inferior short-term mortality, but equivalent mid-term and long-term mortality. Rates of mediastinal bleeding, sternal wound infections, sepsis, heart failure, and pacemaker insertion were all equivalent between the sexes; however, males experienced a higher rate of acute kidney injury and readmission for stroke at the longest follow-up while females experienced a longer intensive care unit and hospital length of stay. In a sub-analysis of isolated SAVR, males and females experienced equivalent early, mid, and late mortality. Of note, a trend towards increased aortic valve reoperation was noted in females at the longest follow-up. CONCLUSIONS: Males and females experience equivalent long-term mortality following isolated SAVR. Sex is not an independent risk factor of poor outcomes post-SAVR; however, the increased preoperative risk profile of females requires diligent consideration.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Patients With Three Vessel Coronary Artery Disease: A Comparison of Centers in the Same Jurisdiction With Differing Multidisciplinary Heart Team Approaches.

OBJECTIVES: Referral patterns and outcomes of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were compared between 2 centers within 1 jurisdiction wherein only 1 center utilizes multidisciplinary review for all patients. BACKGROUND: Management of advanced coronary artery disease often involves PCI and CABG for improvements in quality of life and survival. Indications exist for PCI and CABG, with CABG demonstrating benefit in three-vessel disease (TVD). METHODS: A total of 27,961 patients underwent cardiac catheterization in 2 centers within the same single-payer health jurisdiction (Center A and B) from 2017 to 2018. Rates of PCI, CABG, and outcomes of 1-year mortality, rehospitalization, myocardial infarction, and stroke were compared. RESULTS: More patients in Center A received PCI and less received CABG compared with Center B even among patients with TVD ( P <0.001). Multivariable logistic regression identified Center B as protective for mortality for TVD patients ( P <0.001) and those undergoing PCI ( P =0.004), but not CABG ( P =0.06). Center A's 1-year mortality was increased for all patients ( P =0.004) and those with TVD ( P =0.011). CONCLUSION: Discordant outcomes exist between these 2 centers. While patients in Center A were more likely to undergo PCI than Center B and experienced decreased 1-year survival, the difference was not significant for CABG. In part, the differences are attributable to contrasting referral practices and the discrepant rates of PCI and CABG between centers. Review of all coronary artery disease patients with a multidisciplinary Heart Team including a surgical opinion may lead to a more evidence-based referral practice aligned with current clinical guidelines.

Teaching heart valve surgery techniques using simulators: a systematic review.

The apprentice model has traditionally been the primary method of teaching cardiac surgery trainees. Limitations of this model include insufficient time to learn all necessary skills, minimal exposure to rare cases and to complex repair techniques, small number of patients in small centres, high cost and absence of objective measures of feedback. In recent years, simulation-based training (SBT) has been used in order to address the gaps left by the apprentice model. We performed a systematic review of PubMed and Embase for articles investigating the use of SBT in teaching surgical valve techniques published in 2022 or earlier in order to summarize the current literature regarding the use of SBT for trainees learning surgical valve repair and replacement techniques. We compiled data on the impact of SBT on time to completion of tasks, proportion of trainees who committed technical errors, skills scores and theoretical knowledge. Studies in which outcomes were evaluated showed significant improvement in these measures after participation in SBT. Simulation-based training has been shown to improve the surgical skills of trainees in a rela-tively short period. As hands-on experience in the field of cardiac surgery is invaluable and often difficult to reproduce effectively, it is likely that a combination of hands-on training and SBT will be adopted moving forward to provide optimal exposure for surgical trainees.

Coronary Revascularization for Patients with Diabetes Mellitus: A Contemporary Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis aims to review the contemporary literature comparing CABG and PCI in diabetic patients providing an up-to-date perspective on the differences between the interventions. BACKGROUND: Diabetes is common and diabetic patients are at a 2-to-4-fold increased risk of developing coronary artery disease. Approximately 75% of diabetic patients die of cardiovascular disease. Previous literature has identified CABG as superior to PCI for revascularization in diabetic patients with complex coronary artery diseas. METHODS: PubMed and Medline were systematically searched for articles published from January 1, 2015 to April 15, 2021. This systematic review included all retrospective, prospective, and randomized trial studies comparing CABG and PCI in diabetic patients. 1552 abstracts were reviewed and 25 studies were included in this review. The data was analyzed using the RevMan 5.4 software. RESULTS: Diabetic patients undergoing CABG experienced significantly reduced rates of 5-year mortality, major adverse cardiovascular and cerebrovascular events, myocardial infarction, and required repeat revascularization. Patients who underwent PCI experienced improved rates of stroke that trended toward significance. CONCLUSIONS: Previous literature regarding coronary revascularization in diabetic patients has consistently demonstrated superior outcomes for patients undergoing CABG over PCI. The development of 1st and 2nd generation DES have narrowed the gap between CABG and PCI, but CABG continues to be superior. Continued investigation with large randomized trials and retrospective studies including long term follow-up comparing CABG and 2nd generation DES is necessary to confirm the optimal intervention for diabetic patients.

Recellularized bovine pericardium with autologous mesenchymal stem cells reduces immune activation.

INTRODUCTION: Current bioprosthetic heart valve replacement options are limited by structural valvular deterioration (SVD) due to an immune response to the xenogenic scaffold. Autologous mesenchymal stem cell (MSC) recellularization is a method of concealing xenogenic scaffolds, preventing recipient immune recognition of xenogenic tissue heart valves, and potentially leading to reduction in SVD incidence. The purpose of this study is to examine the effects of autologous MSC recellularized tissue on the immune response of human whole blood to bovine pericardium (BP). We hypothesized that autologous MSC recellularization of BP will result in reduced pro-inflammatory cytokine production equivalent to autologous human pericardium. METHODS: Bone marrow, human pericardium, and whole blood were collected from adult patients undergoing elective cardiac surgery. Decellularized BP underwent recellularization with autologous MSCs, followed by co-incubation with autologous whole blood. Immunohistochemical, microscopic, and quantitative immune analysis approaches were used. RESULTS: We demonstrated that native BP, exposed to human whole blood, results in significant TNF-α and IL1ß production. When decellularized BP is recellularized with autologous MSCs and exposed to whole blood, there is a significant reduction in TNF-α and IL1ß production. Importantly, recellularized BP exposed to whole blood had similar production of TNF-α and IL1ß when compared to autologous human pericardium exposed to human whole blood. CONCLUSION: Our results suggest that preventing initial immune activation with autologous MSC recellularization may be an effective approach to decrease the recipient immune response, preventing recipient immune recognition of xenogeneic tissue engineered heart valves, and potentially leading to reduction in SVD incidence.

Sex-Related Differences in Transcatheter Mitral Valve Repair: A Systematic Review and Meta-Analysis.

OBJECTIVE: Inequalities in postoperative outcomes between males and females are well described with females often experiencing inferior outcomes after heart valve surgery. The recent literature has demonstrated equivalent or improved outcomes for females after transcatheter aortic valve replacement. Transcatheter mitral valve repair (TMVr) and replacement (TMVR) is a relatively newer field with significantly less literature comparing sex differences. This systematic review and meta-analysis looks to provide a comprehensive summary of the published literature comparing outcomes between males and females undergoing transcatheter MV interventions. METHODS: PubMed, MEDLINE, and Scopus were systematically searched for all studies comparing outcomes between males and females undergoing TMVr and TMVR. A total of 2,178 English manuscript titles and abstracts were reviewed. Articles were excluded if data were not provided regarding sex differences, transcatheter MV intervention, full-length text was not accessible, or if insufficient data was provided. A total of 2,170 articles were excluded, and 8 articles were included in this study. RESULTS: Pooled estimates of outcomes demonstrated rates of acute kidney injury (OR 1.28 [95% CI, 1.14-1.44; p < 0.0001]) favored females, while rates of major bleeding favored males (OR 0.85 [95% CI 0.76-0.96; p = 0.01]). Rates of mortality, postoperative MI, and stroke did not differ significantly. CONCLUSION: A trend has emerged in heart valve interventions with males tending to have improved outcomes after surgical intervention and females experiencing equivalent or improved outcomes after transcatheter interventions. This meta-analysis identified increased rates of acute kidney injury for males, increased rates of major bleeding for females, and otherwise comparable morbidity and mortality in males and females undergoing TMVr.

Coronary Artery Revascularization in Heart Transplant Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the primary cause of late mortality after heart transplantation. We look to provide a comprehensive review of contemporary revascularization strategies in CAV. METHODS: PubMed and Web of Science were systematically searched by 3 authors. 1,870 articles were initially screened and 24 were included in this review. RESULTS: PCI is the main revascularization technique utilized in CAV. The pooled estimates for restenosis significantly favored DES over BMS (OR 4.26; 95% CI: 2.54-7.13; p < 0.00001; I2 = 4%). There were insufficient data to quantitatively compare mortality following DES versus BMS. There was no difference in short-term mortality between CABG and PCI. In-hospital mortality was 0.0% for CABG and ranged from 0.0 to 8.34% for PCI. One-year mortality was 8.0% for CABG and 5.0-25.0% for PCI. CABG had a potential advantage at 5 years. Five-year mortality was 17.0% for CABG and ranged from 14 to 40.4% following PCI. Select measures of postoperative morbidity trended toward superior outcomes for CABG. CONCLUSION: In CAV, PCI is the primary revascularization strategy utilized, with DES exhibiting superiority to BMS regarding postoperative morbidity. Further investigation into outcomes following CABG in CAV is required to conclusively elucidate the superior management strategy in CAV.

Mortality and morbidity of surgical and transcatheter mitral valve repair in octogenarians: A systematic review.

BACKGROUND: Valvular heart disease (VHD) is a prominent problem in healthcare today with mitral regurgitation (MR) being the leading cause of VHD in the elderly population. While mitral valve repair (MVr) surgery is one of the only options for the end-stage disease, octogenarians are often denied MVr due to concerns with operative mortality and postoperative morbidity. To provide information on this underrepresented group of surgical patients, a systematic approach was taken to review the mortality and morbidity rates of octogenarians who received MVr. METHODS: Pubmed and Medline were searched for articles containing outcomes of octogenarians receiving surgical mitral valve repair (SMVr) or transcatheter mitral valve repair (TMVr) published after 2000. Ten articles met the inclusion criteria for a total of 7968 patients included in the analysis using Microsoft Excel, Version 2105. RESULTS: Short-term mortality rates for SMVr and TMVr were 2.6% and 1.4% for in-hospital, and 7.8% and 3.3% for 30 days, respectively. The average incidence of stroke, acute kidney injury, infection, and major bleeding for SMVr were 3.2%, 11.2%, 7.7%, and 24%, respectively, and 0.3%, 6.7%, 2.7%, and 7.9% for TMVr, respectively. CONCLUSION: Octogenarians receiving SMVr or TMVr experienced similar rates of short-term mortality and morbidity as younger populations, and when considering life expectancy, midterm mortality was also similar. With these results, denying octogenarians MVr operations based on age alone should be reconsidered. Depending on risk factors and comorbidities, either SMVr or TMVr is a viable and relatively safe option for octogenarians with severe MR.

The effects of body mass index on long-term outcomes and cardiac remodeling following mitral valve repair surgery.

BACKGROUND: Previous literature has demonstrated equivalent or improved survival post mitral valve (MV) surgery amongst patients with obesity when compared to their normal-weight counterparts. This relationship is poorly understood and the impact of body mass index (BMI) on cardiac remodeling has not been established. METHODS: In this retrospective, single-center study, we sought to identify the impact that BMI may have on long-term outcomes and cardiac remodeling post-MV repair. Outcomes were compared between patients of varying BMI undergoing MV repair between 2004 and 2018. The primary outcome was mortality and secondary outcomes included stroke, myocardial infarction, reoperation of the MV, rehospitalization, and cardiac remodeling. RESULTS: A total of 32 underweight, 249 normal weight, 249 overweight, 121 obese, and 50 morbidly obese patients were included in this study. Underweight patients had increased mortality at longest follow-up. Patients with morbid obesity were found to have higher rates of readmission for heart failure. Only underweight patients did not demonstrate a significant reduction in LVEF. Patients with normal weight and overweight had a significant reduction in left atrial size, and patients with obesity had a significant reduction in MV area. CONCLUSIONS: An obesity paradox has been identified in cardiac surgery. While patients with obesity have higher rates of comorbidities preoperatively, their rates of mortality are equivalent or even superior to those with lower BMI. The results of our study confirm this finding with patients of high BMI undergoing MV repair demonstrating equivalent rates of morbidity to their normal BMI counterparts. While the obesity paradox has been relatively consistent in the literature, the understanding of its cause and long-term impacts are not well understood. Further focused investigation is necessary to elucidate the cause of this relationship.

A review of the immune response stimulated by xenogenic tissue heart valves.

Valvular heart disease continues to afflict millions of people around the world. In many cases, the only corrective treatment for valvular heart disease is valve replacement. Valve replacement options are currently limited, and the most common construct utilized are xenogenic tissue heart valves. The main limitation with the use of this valve type is the development of valvular deterioration. Valve deterioration results in intrinsic permanent changes in the valve structure, often leading to hemodynamic compromise and clinical symptoms of valve re-stenosis. A significant amount of research has been performed regarding the incidence of valve deterioration and determination of significant risk factors for its development. As a result, many believe that the underlying driver of valve deterioration is a chronic immune-mediated rejection process of the foreign xenogenic-derived tissue. The underlying mechanisms of how this occurs are an area of ongoing research and active debate. In this review, we provide an overview of the important components of the immune system and how they respond to xenografts. A review of the proposed mechanisms of xenogenic heart valve deterioration is provided including the immune response to xenografts. Finally, we discuss the role of strategies to combat valve degeneration such as preservation protocols, epitope modification and decellularization.

Transcatheter mitral valve repair and replacement: the next frontier of transcatheter valve intervention.

PURPOSE OF REVIEW: We summarize the recent developments in transcatheter mitral valve repair (TMVr) and replacement (TMVR), discuss determinants of MitraClip outcomes in various mitral regurgitation causes, and highlight newly emerging devices and randomized trials. RECENT FINDINGS: The discordant results published in the two recent randomized trials for MitraClip, the COAPT and the MITRA-FR trial have led to the emergence of a new conceptual framework such as the proportionate versus disproportionate mitral regurgitation and hemodynamics assessment tools like the real-time continuous left atrial pressure monitoring. Learning curve and volume-outcome analyses and studies examining the MitraClip usage in patients with degenerative mitral regurgitation are recent developments that have influenced MitraClip regulation and coverage. Several trials for TMVr devices that take an alternative approach to the edge-to-edge repair are underway and advancements in the TMVR technologies are continuing to progress to fill the unmet needs of treating high surgical risk patients whose complex valve anatomy make TMVr unfeasible. SUMMARY: Evidence supports careful analysis of the valve area and left ventricular function in addition to the left atrial hemodynamics will improve the MitraClip outcome. Operator experience plays a greater effect when achieving excellent results with 1+ or less residual mitral regurgitation whereas surgical MVr volume did not influence TMVr outcome. Interventions on the complex primary mitral regurgitation remain under the surgical domain, but MITRA high risk (HR) and REPAIR mitral regurgitation trials are underway to evaluate the role of MitraClip in high to intermediate surgical risk patients with primary mitral regurgitation. Despite the slow developments in TMVR, the results of the early trials of its devices are promising.

Review of the differences in outcomes between males and females after revascularization.

PURPOSE OF REVIEW: This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB). RECENT FINDINGS: Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB. SUMMARY: Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.

Factors Associated With Early Extubation After Cardiac Surgery: A Retrospective Single-Center Experience.

OBJECTIVES: To identify factors associated with early extubation in cardiac surgery patients. DESIGN: Single center, retrospective. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 8,872 adult patients who underwent cardiothoracic surgery from 2011-2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 8,872 patients, 2,950 (33%) were extubated within six hours after surgery. Early extubated patients were younger, had a higher body mass index (BMI), were more likely to be male, and were fast-track designated. These patients more frequently underwent isolated coronary artery bypass graft, isolated valve, or adult congenital surgeries than did late extubated patients. Early extubated patients had a greater incidence of coronary artery disease (CAD) and anxiety and a higher left ventricular ejection fraction. They also were less likely to have difficult intubation or require mechanical circulatory support, reintubation, or readmission. Analysis of the 8,872 patients showed that male sex (odds ratio [OR] 1.222, 95% confidence interval [CI] 1.096-1.363), a BMI >30 kg/m2 (OR 1.702, 95% CI 1.475-1.965), undergoing isolated valve surgery (OR 1.187, 95% CI 1.060-1.328), and having a fast-track designation (OR 1.455, 95% CI 1.208-1.751) and CAD (OR 1.122, 95% CI 1.005-1.253) were associated with early extubation. Data on intensive care unit (ICU) admission after surgery were available only from 2014-2018. Within this subgroup of 5,977 patients, variables associated with early extubation included male sex (OR 1.356, 95% CI 1.193-1.541), BMI >30 kg/m2 (OR 1.267, 95% CI 1.084-1.480), daytime admission to the ICU (OR 1.712, 95% CI 1.527-1.919), and fast-track designation (OR 1.423, 95% CI 1.123-1.802). CONCLUSIONS: Male sex; a BMI >30 kg/m2; undergoing isolated valve surgery; and having a fast-track designation, CAD, and daytime admission to the ICU are associated with early extubation.

Impact of sex on cardiac remodeling and long-term outcomes, following mitral valve replacement.

BACKGROUND: Differences in cardiac remodeling after mitral valve (MV) surgery between the sexes is poorly understood. Inferior outcomes for females undergoing MV surgery compared with males have been suggested in the literature, although causative factors behind this discrepancy have not been identified. MATERIALS AND METHODS: In this propensity-matched, retrospective, single-center study, we sought to identify the impact that sex may have on cardiac remodeling and long-term outcomes to better inform clinical decision-making in MV surgical intervention. Outcomes were compared between males and females undergoing MV replacement (MVR) between 2004 and 2018. The primary outcome was cardiac remodeling 1 year postoperatively. Secondary outcomes included mortality, stroke, myocardial infarction (MI), reoperation of the MV, and rehospitalization. RESULTS: A total of 311 males and 311 females were included after propensity matching. Both groups demonstrated significant improvement in left atrial remodeling, although only males demonstrated a significant degree of improved left ventricular remodeling while their female counterparts did not. Mortality rates were relatively equivalent between the two groups, although males were more likely to develop sepsis and require rehospitalization due to MI. CONCLUSIONS: There has been little research exploring the differences in cardiac remodeling between the sexes after MVR. The results of this study have suggested that MVR is equally safe for both sexes and has demonstrated a difference in the heart's ability to remodel after MVR. The significance of this difference has the potential to result in largely different clinical outcomes for males and females. Further study is necessary to fully elucidate this relationship.

Is there a problem with respect? Risk of neochordal rupture.

PURPOSE OF REVIEW: In this review, we summarize the history of mitral valve repair, discuss the broad principles of neochord preparation and implantation, and highlight comparative outcomes between mitral valve repair strategies while focusing on the risk of neochordal rupture. RECENT FINDINGS: There have been several recent studies comparing outcomes been leaflet-resection and nonresection, neochord-based mitral valve repair. Operative mortality was very low regardless of repair strategy; however, the rate of mitral valve reoperation is lower in those that undergo a neochord-based repair with overall lower mean mitral gradients postrepair. The introduction of minimally invasive approaches to mitral valve repair has preferentially favored an increase in neochord-based repair, given the technical simplicity compared with resection-based approaches. In very rare cases, neochord rupture can occur, likely secondary to a combination of chordal calcification and mechanical stress. SUMMARY: The method of performing mitral valve repair with neochord implantation has demonstrated superior durability over leaflet resection approaches with equivalent operative outcomes. Although the risk of neochord rupture exists, it is exceedingly rare, and should not be considered a limitation to a neochord-based mitral valve repair. Recurrent mitral regurgitation secondary to neochord rupture is incredibly rare; however, regular echocardiographic evaluation of these patients appears warranted, especially when follow-up extends over 10 years.

A comparison of surgical, total percutaneous, and hybrid approaches to treatment of combined coronary artery and valvular heart disease.

PURPOSE OF REVIEW: The purpose of this review is to compare outcomes of surgical valve replacement (SVR) and coronary artery bypass grafting (CABG), minimally invasive cardiac surgery (MICS) SVR and percutaneous coronary intervention (PCI), and transcatheter aortic valve replacement and PCI for the treatment of combined coronary artery disease (CAD) and valvular heart disease (VHD). RECENT FINDINGS: Several studies have attempted to identify key differences in outcomes with hybrid MICS SVR and PCI approaches to combined CAD and VHD. Recent studies have demonstrated that MICS SVR and PCI, when compared with conventional open SVR and CABG, demonstrate reduced or unchanged morbidity and mortality. However, the rate of bleeding in MICS SVR and PCI is consistently higher likely because of the effects of antiplatelet therapy. SUMMARY: A shift toward MICS has occurred in the preceding decades, with outcomes improving in recent years. With limited ability to perform CABG through MICS approaches, attempts have been made at hybrid procedures to address multiple presenting concerns while allowing for the benefits of MICS approaches. Hybrid MICS SVR and PCI approaches may provide suitable alternatives to traditional surgical approaches with reduced intra and postoperative morbidity and mortality, with the notable exception of bleeding complications.

The effects of body mass index on outcomes for patients undergoing surgical aortic valve replacement.

BACKGROUND: Most of the studies of obesity and postoperative outcome have looked predominantly at coronary artery bypass grafting with fewer focused on valvular disease. The purpose of this study was to compare the outcomes of patients undergoing aortic valve replacement stratified by body mass index (BMI, kg/m^2). METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry captured 4780 aortic valve replacements in Alberta, Canada from January 2004 to December 2018. All recipients were stratified by BMI into five groups (BMI: < 20, 20-24.9, 25-29.9, 30-34.9, and > = 35). Log-rank test and Cox regression were used to examine the crude and adjusted survival differences. RESULTS: Intra-operative clamp time and pump time were similar among the five groups. Significant statistical differences between groups existed for the incidence of isolated AVR, AVR and CABG, hemorrhage, septic infection, and deep sternal infection (p < 0.05). While there was no significant statistical difference in the mortality rate across the BMI groups, the underweight AVR patients (BMI < 20) were associated with increased hazard ratio (1.519; 95% confidence interval: 1.028-2.245) with regards to all-cause mortality at the longest follow-up compared with normal weight patients. CONCLUSION: Overweight and obese patients should be considered as readily for AVR as normal BMI patients.

Subclavian transcatheter aortic valve implantation (TAVI): superficial cervical plexus block combined with low-dose interscalene block.

PURPOSE: Transcatheter aortic valve implantation (TAVI) has become a widely used technique for treating aortic stenosis. Subclavian access may be warranted in the presence of poor vasculature that precludes femoral access. Conscious sedation is increasingly being adopted with some evidence suggesting better outcomes compared with those of general anesthesia. We describe the use of two regional anesthetic techniques to facilitate subclavian access for TAVI. CLINICAL FEATURES: Our case report involves the successful management of a challenging patient with severe peripheral vasculopathy and respiratory compromise undergoing a trans-subclavian TAVI. Surgical anesthesia was provided by low-dose local anesthetic titrated via an interscalene perineural catheter and a single-shot superficial cervical plexus block while preserving respiratory function. CONCLUSIONS: The interscalene catheter in situ allowed for low-dose local anesthetic titration without further jeopardizing the pulmonary function throughout the procedure. Unlike other interfascial plane blocks, combined low-dose superficial cervical plexus and interscalene brachial plexus blocks offer surgical anesthesia and limb immobility, thus providing optimal condition for subclavian TAVI to be performed with minimal sedation.

RéSUMé: OBJECTIF: Le remplacement valvulaire aortique percutané (TAVI) est devenu une technique très répandue pour le traitement de la sténose aortique. En présence d'une maladie vasculaire périphérique excluant un accès fémoral, un accès par voie sous-clavière pourrait être justifié. La sédation consciente est de plus en plus privilégiée, certaines données probantes suggérant de meilleurs devenirs par rapport à l'anesthésie générale. Nous décrivons l'utilisation de deux techniques d'anesthésie régionale visant à faciliter l'accès sous-clavier pour un TAVI. ÉLéMENTS CLINIQUES: Notre présentation de cas relate la prise en charge réussie d'un patient complexe atteint de vasculopathie périphérique sévère et d'insuffisance respiratoire subissant un TAVI par voie trans-sous-clavière. L'anesthésie pour la chirurgie a été réalisée à l'aide d'anesthésique local à faible dose, titré via un cathéter périnerveux interscalénique, et d'un bloc du plexus cervical superficiel par injection unique, afin de préserver la fonction respiratoire. CONCLUSION: Le cathéter interscalénique in situ a permis la titration de l'anesthésique local à faible dose sans compromettre la fonction pulmonaire tout au long de l'intervention. Au contraire d'autres blocs du plan interfascial, la combinaison d'un bloc du plexus cervical superficiel à un bloc du plexus brachial interscalénique à faible dose offre une anesthésie chirurgicale et une immobilité du membre visé, créant ainsi les conditions optimales à la réalisation d'un TAVI sous-clavier sous sédation minimale.

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies.

BACKGROUND: Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease. METHODS: We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate. RESULTS: We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small. CONCLUSION: Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

CONTEXTE: Le pontage aortocoronarien assisté par robot (PACAR) a été proposé comme solution de rechange au pontage aortocoronarien classique (PACC) pour la prise en charge des coronaropathies, mais on manque de données probantes claires comparant son efficacité à celle d'autres traitements. La présente étude visait à évaluer, dans le cadre d'une revue systématique d'études comparatives, la sûreté et l'efficacité clinique du PACAR, comparativement à celles du PACC et d'autres interventions à effraction minimale visant le traitement des coronaropathies. MÉTHODES: Nous avons réalisé une revue systématique d'études primaires publiées en anglais comparant le PACAR à d'autres options thérapeutiques (PACC, pontage aortocoronarien direct à effraction minimale [PACDEM] et pontage aortocoronarien par voie percutanée [PACVP]) selon les lignes directrices de la Collaboration Cochrane, et avons réalisé des méta-analyses lorsque c'était approprié. RÉSULTATS: Nous avons retenu 13 études : 11 études primaires sur le PACAR (comparativement à 7 études sur le PACC, à 3 études sur le PACDEM et à 1 étude sur le PACVP) et 2 études multicentriques fondées sur des bases de données (PACAR contre tout autre type de PAC). Dans l'ensemble, les données probantes étaient considérées de faible qualité. Selon la plupart des études, le PACAR ne présentait aucun avantage significatif par rapport aux autres traitements, et ce, pour la majorité des issues. Les méta-analyses ont montré que le PACAR était associé à des taux de pneumonie et d'infection de la plaie plus faibles que le PACC, de même qu'à une durée d'hospitalisation en soins intensifs plus courte que le PACC et le PACDEM. Des études individuelles ont montré que le PACAR donnait lieu à de meilleures issues pour certains paramètres que le PACC (temps de ventilation, besoin de transfusion, douleur postopératoire et durée d'hospitalisation) et que le PACDEM (besoin de transfusion, douleur postopératoire, temps nécessaire pour la reprise des activités normales, fonctionnement physique et durée d'hospitalisation). La revue des études fondées sur des bases de données a indiqué que le PACAR était supérieur, sur le plan statistique, aux autres types de PAC en ce qui a trait à la douleur postopératoire, à l'insuffisance rénale, au besoin de transfusion, à la réalisation d'une autre chirurgie en raison de saignements, à l'accident vasculaire cérébral et à la durée d'hospitalisation; cependant, pour plusieurs de ces paramètres, les différences entre les 2 groupes étaient petites. CONCLUSION: Bien que les résultats de cette revue d'études comparatives sur le PACAR semblent prometteurs et laissent penser que cette intervention comporte des avantages pour les patients, ils devraient être interprétés avec prudence étant donné l'absence d'études cliniques randomisées.