Transcatheter valve-in-valve interventions after aortic root replacement: A systematic review.

Structural valve deterioration after aortic root replacement (ARR) surgery may be treated by transcatheter valve-in-valve (ViV-TAVI) intervention. However, several technical challenges and outcomes are not well described. The aim of the present review was to analyze the outcomes of ViV-TAVI in deteriorated ARR. This review included studies reporting any form of transcatheter valvular intervention in patients with a previous ARR. All forms of ARR were considered, as long as the entire root was replaced. Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases were searched until September 2023. Overall, 86 patients were included from 31 articles that met our inclusion criteria out of 741 potentially eligible studies. In the entire population, the mean time from ARR to reintervention was 11.0 years (range: 0.33-22). The most frequently performed techniques/grafts for ARR was homograft (67.4%) and the main indication for intervention was aortic regurgitation (69.7%). Twenty-three articles reported no postoperative complications. Six (7.0%) patients required permanent pacemaker implantation (PPI) after the ViV-TAVI procedure, and 4 (4.7%) patients had a second ViV-TAVI implant. There were three device migrations (3.5%) and 1 stroke (1.2%). Patients with previous ARR present a high surgical risk. ViV-TAVI can be considered in selected patients, despite unique technical challenges that need to be carefully addressed according to the characteristics of the previous surgery and on computed tomography analysis.

Clinical Outcomes of Cryo Nerve Ablation Technique for Pain Management: An Exploratory Study in Patients Undergoing Left Thoracotomy Coronary Artery Bypass Grafting.

Background: To investigate the impact of Cryo Nerve Block with cryoICE™ device utilization, on post-operative pain in patients undergoing isolated coronary artery bypass grafting (CABG) through left thoracotomy. Methods: All consecutive patients undergoing isolated CABG through left thoracotomy between July 2021 and July 2022 from a single surgeon were included in the study. Patients using the cryoICE™ device for nerve block were compared for baseline demographics and pre-operative characteristics with those that did not use the cryoICE™ device. A propensity-adjusted analysis was used to compare the two groups. The primary outcome was degree of incisional pain and numbness. Results: A total of 103 patients underwent isolated CABG through left thoracotomy. After matching, the cryoICE™ device was used for nerve block in 60 patients while the control group included 43 patients. Mean follow-up was 5.7 months. The cryoICE™ device group had a mean value of incisional pain at hospital discharge was 1.5 (scale 0-10) while at follow-up was 0.69 (scale 0-10). Mean values of skin numbness at hospital discharge were 1 (scale 0-10) and 0.57 (scale 0-10) at follow-up. After univariate analysis comparison of cryoICE™ device group (60 patients) versus non-cryoICE™ device group (43 patients), the total in-hospital morphine use was 49% lower in the cryoICE™ versus the non-cryoICE™ cohort (73.8 + 79.37 mg vs 144.1 + 118.99 mg). Conclusions: Good clinical outcomes were observed in patients undergoing isolated left thoracotomy CABG with cryoICE™ utilization, including a very low incidence of post-operative pain, numbness, and hypersensitivity for all comers.

Coronary Artery Bypass Surgery: Comparing the Long-Term Impact of Total Arterial Grafting With Multiarterial Plus Saphenous Vein Grafting.

INTRODUCTION: This study aimed to compare the long-term outcomes in a propensity matched population receiving total arterial grafting (TAG) and multiple arterial grafts (MAG) in addition to saphenous vein graft (SVG) following multivessel coronary artery bypass grafting requiring at least three distal anastomoses. METHODS: In this retrospective study, 655 patients from two centers met the inclusion criteria and were divided into two groups: TAG group (n = 231) and MAG + SVG group (n = 424). Propensity score matching was performed resulting in 231 pairs. RESULTS: No significant differences were observed between both groups in terms of early outcomes. Survival probabilities at 5, 10, and 15 y were 89.1% versus 94.2%, 76.2% versus 76.1%, and 66.7% versus 69.8% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 0.90; 95% confidence interval [0.45-1.77]; P = 0.754). Freedom from major adverse cardiac and cerebral events (MACCE) in the matched cohort did not show any significant difference between both groups. Probabilities at 5, 10, and 15 y were 82.7% versus 85.6%, 62.2% versus 75.3%, and 48.8% versus 59.5% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 1.12; 95% confidence interval [0.65-1.92]; P = 0.679). Subgroup analyses of the matched cohort showed no significant difference between TAR with three arterial conduits compared to TAR with two arterial conduits with sequential grafting and MAG + SVG in terms of long-term survival and freedom from MACCE. CONCLUSIONS: Multiple arterial revascularizations in addition to SVG may yield comparable long-term outcomes in terms of survival and freedom from MACCE compared to total arterial revascularization.

Early and late outcomes of surgical aortic valve replacement with sutureless and rapid-deployment valves versus transcatheter aortic valve implantation: Meta-analysis with reconstructed time-to-event data of matched studies.

Sutureless/rapid-deployment (SURD) valves are options different from the stented prostheses included in the pivotal trials comparing surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation (TAVI). We performed a meta-analysis with reconstructed time-to-event data of matched studies published by November 2021 to compare SURD-AVR and TAVI. Primary endpoints were 30-day mortality and overall survival in the follow-up. Secondary endpoints included: 30-day stroke, acute kidney injury (AKI), major bleeding, permanent pacemaker implantation (PPI), paravalvular leak (PVL), prosthesis-patient mismatch (PPM), postoperative aortic valve area (AVA), and mean gradients. Ten studies met our eligibility criteria, including a total of 5134 patients (2567 underwent SURD-AVR and 2567 underwent TAVI). Pooled risk of 30-day mortality did not favor any group (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.31-1.53; p = 0.360). Patients undergoing SURD-AVR had lower risk of PVL (OR: 0.09; 95% CI: 0.05-0.17; p < 0.001). No statistically significant differences were observed for 30-day stroke, AKI, major bleeding, PPI, PPM, and postoperative AVA. In the follow-up, we observed a higher risk of mortality (hazard ratio: 1.74; 95% CI: 1.26-2.40; p < 0.001) with TAVI. Patients who underwent SURD-AVR experienced better survival, however, the interpretation of these results warrant caution due to the fact that SURD-AVR patients tended to be younger than TAVI patients. Structural heart surgeons and interventional cardiologists should consider initial risk and life expectancy when referring patients for one approach over the other.

Late Outcomes After Aortic Root Enlargement During Aortic Valve Replacement: Meta-Analysis With Reconstructed Time-To-Event Data.

OBJECTIVES: The present authors aimed to assess the late outcomes of patients undergoing aortic root enlargement (ARE) at the time of surgical aortic valve replacement (SAVR). DESIGN: Study-level meta-analysis with reconstructed time-to-event data. SETTING: Follow-up of patients after surgical procedure. PARTICIPANTS: Adult patients with aortic valve disease requiring surgery. INTERVENTIONS: SAVR with ARE versus SAVR without ARE. MEASUREMENTS AND MAIN RESULTS: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The following databases were searched for studies meeting the authors' inclusion criteria and published by November 30, 2021: PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar. Nine nonrandomized studies met the authors' eligibility criteria. All studies were nonrandomized. A total of 213,134 patients (SAVR with ARE: 7,556 patients; SAVR without ARE: 205,578 patients) were included from studies published from 1997 to 2021. The total rate of AAE was 3.7%, varying in the studies from 2.9% to 28.1%. The studies consisted of patients whose mean age varied from 63 to 79 years. Patients in the SAVR with ARE group had a significantly better overall survival (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.99, p = 0.016) in the unmatched populations, but the matched analysis revealed no difference between SAVR with/without ARE in terms of overall survival (HR, 1.06; 95% CI, 0.90-1.25; p = 0.474). CONCLUSIONS: In the context of patients undergoing SAVR with or without ARE, patients who undergo ARE do not experience worse late outcomes. Further randomized controlled trials are needed to confirm or refute the authors' current findings.

Robotic totally endoscopic triple bypass with bilateral internal mammary arteries and two different anastomotic techniques.

Robotic totally endoscopic coronary artery bypass (TECAB) offers several advantages over conventional sternotomy coronary artery bypass grafting. TECAB allows the increased use of bilateral internal mammary artery grafts independent of gender, body mass index or diabetes, minimizes the risk of wound infection, decreases the length of hospital stay, and improves the postoperative quality of life. Off-pump beating heart TECAB has been used to offer one or two grafts generally on the anterior wall. We describe our approach to perform beating heart, triple-vessel TECAB with targets on the lateral and posterolateral wall of the left ventricle.

Aortic valve neocuspidization: Frequently asked technical questions.

Since the first description by Professor Ozaki in 2011, more than 5500 aortic valve neocuspidization procedures have been performed worldwide, with promising short- and mid-term outcomes. We here report the nuances required to master this highly reproducible, standardized technique for the treatment of aortic valve disease.

Urgent robotic hybrid coronary revascularization in patient with high STS score. A case report.

INTRODUCTION: Robotic-assisted coronary artery bypass grafting (CABG) outcomes in patients with a high society of thoracic surgery (STS) score in urgent settings remain hindered. PRESENTATION OF CASE: A high-risk female patient presented with dyspnea and low ejection fraction (EF = 15%) and was diagnosed with pulmonary edema post myocardial infarction. She was medically stabilized with intraaortic balloon pump and the heart-team decided to intervene with off-pump robotic hybrid coronary revascularization (HCR). The patient had the planned with left internal mammary artery (LITA) anastomosis to the left anterior descending artery (LAD) and the postoperative recovery was uneventful and patients discharged after few days at home. DISCUSSION: CABG has proven to be superior to percutaneous coronary intervention (PCI) even when guided by fractional flow rate and using the last generation stents according to fractional flow reserve versus angiography for multivessel evaluation 3 clinical trial. In moderate SYNTAX score patients that have been historically (SYNTAX trial) treated with multivessels PCI, robotic CABG has been shown to offer the advantage of LITA-LAD in combination with stent for non-LAD territory. CONCLUSION: High-risk, fragile patients, with low EF and high STS score that undergo urgent CABG can benefit from heart-team collaboration, and HCR is an important tool in the armamentarium.

Impact of left ventricle outflow tract calcification on the outcomes of transcatheter aortic valve implantation: A study-level meta-analysis.

OBJECTIVES: To assess the impact of left ventricle outflow tract calcification (LVOT) on the outcomes of transcatheter aortic valve implantation (TAVI). METHODS: Meta-analysis including studies published by October 2021. Primary endpoints were operative and 1-year mortality. The secondary endpoints were stroke, myocardial infarction, paravalvular leakage (PVL), new permanent pacemaker implantation (PPI), aortic annulus/root rupture. RESULTS: Nine studies met our eligibility criteria, including a total of 4459 patients (1330 patients with significant LVOT calcification and 3129 patients without significant LVOT calcification). Pooled risk of operative death was higher in the group with significant LVOT calcification (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.33-3.91; p < .001). Worse 1-year survival was observed in the group with LVOT calcification (hazard ratio 1.53, 95% CI: 1.26-1.87, p < .001). Patients with significant LVOT calcification had higher risk of stroke (OR: 1.83; 95% CI: 1.08-3.09; p = .032), myocardial infarction (OR: 1.74; 95% CI: 1.08-2.80; p = .034), PVL (OR: 1.88; 95% CI: 1.09-3.22; p = .028) and aortic annulus/root rupture (OR: 7.48; 95% CI: 3.58-15.65; p = .002). We did not observe a statistically significant difference in the pooled results for new PPI between the groups (OR: 1.19; 95% CI: 0.79-1.80; p = .337). CONCLUSION: The presence of significant LVOT calcification increases the risk of periprocedural and 1-year mortality, stroke, myocardial infarction, PVL and aortic annulus/root rupture after TAVI. Self-expandable valves may be a preferrable option in this scenario. Structural heart surgeons and interventional cardiologists should consider this factor when referring patients for TAVI and technical aspects (such as the type of transcatheter heart valve to be deployed or the use of pre-/post-dilatation) should be factored in.

Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease.

BACKGROUND: Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD. METHODS AND RESULTS: We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202). CONCLUSIONS: Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.

Hybrid robotic off-pump versus conventional on-pump and off-pump coronary artery bypass graft surgery in women.

OBJECTIVE: To compare outcomes of three methods of coronary artery bypass graft surgery (CABG): robotic off-pump hybrid coronary revascularization (HCR) versus conventional CABG off-pump (off-pump coronary artery bypass [OPCAB]) and on-pump (on-pump coronary artery bypass [ONCAB]) in women. METHODS: Data on women who underwent robotic off-pump HCR or conventional OPCAB or conventional ONCAB between May 2005 and January 2021 were collected. Inverse probability of treatment weighting (IPTW) with doubly robust method was used to analyze the data. RESULTS: A total of 731 women were included (181 robotic off-pump HCR, 138 conventional ONCAB, and 412 conventional OPCAB cases). IPTW-adjusted analyses revealed the following: (1) for operative times, robotic off-pump HCR presented longer times when compared with OPCAB, but shorter times when compared with ONCAB; (2) compared with ONCAB and OPCAB, robotic off-pump HCR presented lower rates of reintervention for bleeding, intra- and postoperative blood transfusions, higher rates of extubation in the OR with less prolonged ventilation, lower rates of postoperative atrial fibrillation, and shorter intensive care unit and hospital length of stay; (3) no statistically significant differences for operative mortality were observed comparing robotic off-pump HCR with ONCAB (IPTW-adjusted odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.07-7.85; p = .822) and with OPCAB (IPTW-adjusted OR: 4.27; 95% CI: 0.27-66.88; p = .301); 4. long-term survival was similar with HCR compared with ONCAB (hazard ratio [HR]: 0.74, 95% CI: 0.36-1.50, p = .401) and OPCAB (HR: 0.89, 95% CI: 0.50-1.58, p = .683). CONCLUSIONS: In our local experience, robotic off-pump HCR in women was as safe as conventional ONCAB and OPCAB and may further improve postoperative outcomes when performed frequently by a dedicated team, producing better perioperative outcomes without compromising survival in the long run.

Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied. OBJECTIVES: To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes. METHODS: Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics. RESULTS: In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization. CONCLUSIONS: Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.

Immediate and late outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in bicuspid valves: Meta-analysis of reconstructed time-to-event data.

BACKGROUND: Outcomes of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with aortic stenosis and bicuspid aortic valve (BAV) must be better investigated. METHODS: A meta-analysis including studies published by January 2022 reporting immediate outcomes (in-hospital death, stroke, acute kidney injury [AKI], major bleeding, new permanent pacemaker implantation [PPI], paravalvular leakage [PVL]), mortality in the follow-up (with Kaplan-Meier curves for reconstruction of individual patient data). RESULTS: Five studies met our eligibility criteria. No statistically significant difference was observed for in-hospital death, stroke, AKI, and PVL. TAVI was associated with lower risk of major bleeding (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.12-0.69; p = .025), but higher risk of PPI (OR: 2.00; 95% CI: 1.05-3.77; p = .041). In the follow-up, mortality after TAVI was significantly higher in the analysis with the largest samples (HR: 1.24, 95% CI: 1.01-1.53, p = .043), but no statistically significant difference was observed with risk-adjusted populations (HR: 1.06, 95% CI: 0.86-1.32, p = .57). Landmark analyses suggested a time-varying risk with TAVI after 10 and 13 months in both largest and risk-adjusted populations (HR: 2.13, 95% CI: 1.45-3.12, p < .001; HR: 1.7, 95% CI: 1.11-2.61, p = .015, respectively). CONCLUSION: Considering the immediate outcomes and comparable overall survival observed in risk-adjusted populations, TAVI can be used safely in selected BAV patients. However, a time-varying risk is present (favoring SAVR over TAVI at a later timepoint). This finding was likely driven by higher rates of PPI with TAVI.

Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data.

OBJECTIVES: To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD). METHODS: We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD. RESULTS: Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025). CONCLUSION: The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.

Pearls, pitfalls, and surgical indications of the Intuity TM heart valve: A rapid deployment bioprosthesis. A systematic review of the literature.

OBJECTIVES: To highlight short- and long-term clinical outcomes of the Intuity TM rapid deployment prosthesis for surgical aortic valve replacement. METHODS: We reviewed on PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar for clinical trials, retrospective clinical studies, meta-analysis, and gray literature. RESULTS: Fourty-five clinical studies with 12.714 patients were included in the analysis. Thirty-day mortality ranged from 3.8% for Intuity and 3.9% for transcatheter aortic valve replacement (TAVR). The incidence of paravalvular leak (PVL) (Intuity 0% and TAVR 2.17%), permanent pacemaker implantation (Intuity 11.11% and TAVR 12.5%), stroke (Intuity 2.2% and TAVR 2.6%), myocardial infarction (MI) (Intuity 0% and TAVR 1%), were all higher in the TAVR group. Compared to other sutured bioprosthesis (SB), mortality ranged from 0% to 3.9% for Intuity and 0%-6.9% for SB. Long-term cardiac mortality ranged from 0.9% to 1.55% for Intuity and 1.4%-3.3% for the Perceval valve. The incidence of PVL (Intuity 0.24%-0.7% and Perceval 0%-1%), endocarditis (Intuity 0.2%-0.7% and Perceval 1.6%-6.6%), stroke (Intuity 0.36%-1.4% and Perceval 0%-0.8%), MI (Intuity 0.07%-0.26%), and SVD (Intuity 0.12%-0.7% and Perceval 0%) were comparable. Compared to standard full sternotomy (SFS), minimally invasive surgery (MINV) mortality ranged from 0% to 4.3% for MINV and 0%-2.1% for SFS. Hospital costs outcomes ranged from $37,187-$44,368 for the Intuity, $69,389 for TAVR, and $13,543 for SB. Intuity short-term mortality ranged between 0.9% and 12.4% while long-term mortality ranged between 2.6% and 20%. CONCLUSIONS: This manuscript provides a 360° overview of the current rapid deployments, sutureless, and TAVR prosthesis.

Complete transcatheter versus complete surgical treatment in patients with aortic valve stenosis and concomitant coronary artery disease: Study-level meta-analysis with reconstructed time-to-event data.

OBJECTIVES: To compare outcomes of complete transcatheter (TAVI plus PCI) versus complete surgical (SAVR plus CABG) approach to treat patients with aortic stenosis (AS) and concomitant coronary artery disease (CAD). METHODS: Study-level meta-analysis with reconstructed time-to-event data including studies published by November 2021. The primary endpoints were 30-day mortality, overall survival, and major adverse cardiovascular and cerebrovascular events (MACCE). The secondary endpoints were 30-day stroke, myocardial infarction, and permanent pacemaker implantation (PPI); in-hospital major vascular events and acute kidney injury (AKI). RESULTS: Eight studies met our eligibility criteria, including a total of 33,286 patients (3448 for TAVI plus PCI and 29,838 for SAVR plus CABG). The pooled risk of 30-day mortality was lower for TAVI plus PCI (OR 0.63; 95% CI 0.51-0.80; p < .001). Patients undergoing TAVI plus PCI had lower risk of in-hospital AKI (OR 0.49; 95% CI 0.28-0.85; p = .01), however, higher risk of major vascular events (OR 7.33; 95% CI 1.80-29.85; p = .005) and higher risk of PPI (OR 2.96; 95% CI 1.80-4.85; p < .001). No statistically significant difference was observed for myocardial infarction and stroke between the groups. In the follow-up analyses, we observed a higher risk of mortality (HR 1.64, 95% CI 1.36-1.96, p < .001) and MACCE with TAVI plus PCI (HR 1.35 (95% CI 1.08-1.69, p = .009). CONCLUSION: Patients who undergo TAVI plus PCI (in comparison with SAVR plus CABG) initially experience lower rates of in-hospital death and AKI; however, they experience significantly lower survival rates and more MACCE at 5-year follow up. Structural heart surgeons and interventional cardiologists should consider these aspects when referring patients for one approach or the other.

Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future.

Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.

Transcatheter mitral valve implantation in the ongoing structural heart revolution.

Transcatheter mitral valve implantation (TMVI) has emerged as a less invasive approach potentially surmounting some of the current hurdles associated with transcatheter edge-to-edge repair and high-risk mitral valve surgery. In this review, we aimed to outline the main scenarios in the TMVI field, highlight current and upcoming devices, and describe challenges and clinical results. Finally, we briefly discuss the future perspectives for this emerging field and how TMVI might further advance the field of transcatheter treatments of mitral valve disease.

Mirror mirror on the wall, who is going to be readmitted after all?

In the jungle of biomarkers that predicts long-term outcome, there are many discrepancies and there is more evidence from single-center retrospective studies rather than clinical trials. While some of these biomarkers such as high sensitivity troponin levels, creatine kinase (CK), and CK-MB have demonstrated a good pattern for patients' follow-up, other biomarkers are still struggling to get validated and internationally renown due to the small number of patients included in the studies and their retrospective nature. In this context, Brown and colleagues must be congratulated as they have marked the pathway for future clinical trials.

Bioprosthetic valve fracture for valve-in-valve transcatheter aortic valve implantation in patients with structural valve degeneration: Systematic review with meta-analysis.

OBJECTIVES: To determine the outcomes of bioprosthetic valve fracture (BVF) in valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for patients with structural valve degeneration (SVD) of bioprosthetic surgical valves (BSV) implanted during surgical aortic valve replacement (SAVR). METHODS: A systematic review was conducted including studies published by May 2021. The primary endpoints of the study were 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation, and coronary obstruction. The secondary endpoints were mean valve gradients (mmHg) and aortic valve area (AVA-cm2 ). A meta-analysis was conducted using the software R, version 3.6.3 (R Foundation for Statistical Computing). RESULTS: Four studies including 242 patients met our eligibility criteria. The overall proportions for 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation and coronary obstruction were 2.1%, <1.0%, <1.5%, <1.0%, <1.0%, and <1.5%, respectively. After ViV-TAVI with BVF, the difference in means for mean valve gradients showed a significant reduction (random-effects model: -26.7; -28.8 to -24.7; p < .001), whereas the difference in means for AVA showed a significant increase (random-effects model: 0.55 cm2 ; 0.13-0.97; p = .029). Despite the improvement in AVA means, these remain too low after the procedure highly likely due to the small size of the bioprosthetic valves implanted during the index SAVR. CONCLUSION: ViV-TAVI with BVF has proven to be a promising option but data are still too scarce to enable us to draw definitive conclusions. Despite the decrease in gradients, postprocedural AVA remains worrisome. Studies with better designs and larger sample sizes are needed to advance this treatment option.