Impact of Myocardial Viability on Long-term Outcomes after Surgical Revascularization.

BACKGROUND: This study was conducted to evaluate whether myocardial viability assessed with cardiac magnetic resonance (CMR) affected long-term clinical outcomes after coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy (ICMP). METHODS: Preoperative CMR with late gadolinium enhancement (LGE) was performed in 103 patients (64.9 ± 10.1 years, male:female = 82:21) with 3-vessel disease and left ventricular dysfunction (ejection fraction ≤ 0.35). Transmural extent of LGE was evaluated on a 16-segment model, and transmurality was graded on a 5-point scale: grades-0, absence; 1, 1 to 25%; 2, 26 to 50%; 3, 51 to 75%; 4, 76 to 100%. Median follow-up duration was 65.5 months (interquartile range = 27.5-95.3 months). Primary endpoint was the composite of all-cause mortality or hospitalization for congestive heart failure. RESULTS: Operative mortality was 1.9%. During the follow-up, all-cause mortality and readmission for congestive heart failure occurred in 29 and 8 patients, respectively. The cumulative incidence of the primary endpoint was 31.3 and 46.8% at 5 and 10 years, respectively. Multivariable analysis demonstrated that the number of segments with LGE grade 4 was a significant risk factor (hazard ratio 1.42, 95% confidence interval 1.10-1.83, p = 0.007) for the primary endpoint among the variables assessed by CMR. Other risk factors included age, dialysis, chronic obstructive pulmonary disease, and EuroSCORE II. CONCLUSION: The number of myocardial segments with transmurality of LGE >75% might be a prognostic factor associated with the composite of all-cause mortality or hospitalization for congestive heart failure after CABG in patients with 3-vessel disease and ICMP.

Recent Outcomes of Surgical Redo Aortic Valve Replacement in Prosthetic Valve Failure.

BACKGROUND: As redo surgical aortic valve replacement (AVR) is relatively high risk, valve-in-valve transcatheter AVR has emerged as an alternative for failed prostheses. However, the majority of studies are outdated. This study assessed the current clinical outcomes of redo AVR. METHODS AND RESULTS: This study enrolled 324 patients who underwent redo AVR due to prosthetic valve failure from 2010 to 2021 in four tertiary centers. The primary outcome was operative mortality. The secondary outcomes were overall survival, cardiac death, and aortic valve-related events. Logistic regression analysis, clustered Cox proportional hazards models, and competing risk analysis were used to evaluate the independent risk factors. Redo AVR was performed in 242 patients without endocarditis and 82 patients with endocarditis. Overall operative mortality was 4.6% (15 deaths). Excluding patients with endocarditis, the operative mortality of redo AVR decreased to 2.5%. Multivariate analyses demonstrated that endocarditis (hazard ratio [HR]: 3.990, p = 0.014), longer cardiopulmonary bypass time (HR: 1.006, p = 0.037), and lower left ventricular ejection fraction (LVEF) (HR: 0.956, p = 0.034) were risk factors of operative mortality. Endocarditis and lower LVEF were independent predictors of overall survival. CONCLUSION: The relatively high risk of redo AVR was due to reoperation for prosthetic valve endocarditis. The outcomes of redo AVR for nonendocarditis are excellent. Our findings suggest that patients without endocarditis, especially with acceptable LVEF, can be treated safely with redo AVR.

Rapid-Deployment Aortic Valve Replacement in a Real-World All-Comers Population.

BACKGROUND: This study was conducted to evaluate the mid-term outcomes of rapid-deployment aortic valve replacement (AVR) using Edwards Intuity. METHODS: A total of 215 patients underwent rapid-deployment AVR using Edwards Intuity at our institution. The median follow-up duration was 22 months (interquartile range, 8-36). Primary outcomes were overall survival, cumulative incidence of cardiac death, and major adverse cardiac events. Secondary outcomes were early and 1-year hemodynamic performances of the bioprosthetic valve. RESULTS: The mean age was 68.6 ± 10.5 years, and EuroSCORE II was 3.09 ± 4.5. The study population included 113 patients (52.6%) with bicuspid valves (24 patients with type 0 bicuspid valves), 20 patients (9.3%) with pure aortic regurgitation, and 3 patients (1.4%) with infective endocarditis. Isolated AVR was performed in 70 patients (32.4%) and concomitant procedures were performed in 146 patients (67.6%), including aorta surgery (42.3%) and mitral valve procedure (22.3%). Operative mortality was 2.8%. Complete atrioventricular block occurred in 12 patients, but most of them were transient and only 3 patients received permanent pacemaker implantation before discharge. Overall survival at 3 years was 92.3%. Early hemodynamic data showed mean pressure gradients of 15.5 ± 5.0 and 12.7 ± 4.2 mm Hg in the 19 and 21 mm valve, respectively. One-year hemodynamics were also excellent with mean pressure gradients of 14.7 ± 5.3 and 10.7 ± 3.6 mm Hg in the 19 and 21 mm valve, respectively. CONCLUSION: Based on a real-world all-comers population, rapid-deployment AVR using Edwards Intuity could be performed for various indications, including bicuspid valve, pure aortic regurgitation, and infective endocarditis, and the clinical and hemodynamic outcomes were excellent.

Results after Tricuspid Valve Surgery for Preserved and Dysfunctional Right Ventricle.

BACKGROUND: This study aimed to compare long-term outcomes after tricuspid valve (TV) repair (TVr) with those after TV replacement (TVR) by adjusting the right ventricular (RV) volume and function. METHODS: We enrolled 147 patients who underwent TVr (n = 78) and TVR (n = 69) for grade 3 or 4 tricuspid regurgitation and had preoperative cardiac magnetic resonance data. Long-term clinical outcomes were compared between the two groups using inverse probability treatment weighting (IPTW) to adjust for differences in preoperative characteristics between the two groups. Subgroup analyses were performed in patients with preserved and dysfunctional RV (ejection fraction < 50%). RESULTS: There were no significant differences in operative mortality or postoperative complications between the two groups before and after the IPTW adjustment. Five- and 10-year overall survival rates were 84.2 and 67.1%, respectively. Five- and 10-year cumulative incidences of TV-related events (TVREs) were 33.1 and 55.6%, respectively. There were no significant differences in overall survival and cumulative incidence of TVREs after IPTW adjustment (p = 0.236 and p = 0.989, respectively). The risk-adjusted overall survival was marginally higher in the TVr group of patients with preserved RV function (p = 0.054), while no such significant difference was found between the two groups of patients with dysfunctional RV (p = 0.513). CONCLUSION: Adjusted long-term clinical outcomes after TVr and TVR were comparable. TVr might be beneficial for patients with preserved RV function in terms of long-term survival; however, this benefit might disappear in patients with RV dysfunction.

A Controlled Trial Comparing One-Year Hemodynamics of Two Bovine Pericardial Valves.

BACKGROUND: This randomized controlled trial was designed to compare 1-year hemodynamic performances and clinical outcomes after aortic valve replacement (AVR) using a recently introduced (the AVALUS group) and worldwide used (the CEPME group) bovine pericardial bioprostheses. METHODS: Patients were screened to enroll 70 patients in each group based on a noninferiority design. The primary endpoint of the trial was the mean pressure gradient across the aortic valve (AVMPG) at 1 year after surgery. One-year echocardiographic data were obtained from 92.1% (129 of 140 patients) of the study patients. RESULTS: There were no differences in baseline characteristics, including sex and body surface area (1.64 ± 0.18 vs. 1.65 ± 0.15 m2) between the groups. The AVMPG on 1-year echocardiography was 14.0 ± 4.3 and 13.9 ± 5.1 mmHg in the AVALUS and CEPME groups, respectively (the p-value for noninferiority was 0.0004). In the subgroup analyses for the respective size of the prostheses, AVMPG of the 19-mm prostheses was significantly lower in the AVALUS group than in the CEPME group (14.0 ± 4.3 vs. 20.0 ± 4.7 mmHg, p = 0.012), whereas those of the other sizes were not significantly different between the two groups. There were no significant differences in the effective orifice area (1.49 ± 0.40 vs. 1.53 ± 0.38 cm2, p = 0.500) or effective orifice area index (0.91 ± 0.22 vs 0.93 ± 0.23 cm2/m2, p = 0.570) in all the patients, or in the subgroup analysis for the 19-mm prosthesis. There were no differences in the 1-year clinical outcomes between the two groups. CONCLUSION: The 1-year hemodynamic and clinical outcomes of the AVALUS group were noninferior to those of the CEPME group (NCT03796442).

Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea.

BACKGROUND: In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea. METHODS: Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated. RESULTS: Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively. CONCLUSION: The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.

Long-Term Clinical Outcomes of the On-X Mechanical Prosthetic Valve in the Aortic or Mitral Position　- A Single-Center Experience of up to 20 Years' Follow up.

BACKGROUND: This study evaluated the long-term outcomes for up to 20 years after On-X mechanical valve implantation in the left side of the heart.Methods and Results:Between 1999 and 2015, 861 patients (mean age=51.6±10.9 years) who underwent prosthetic valve replacement using the On-X valve in the aortic or mitral position were enrolled (aortic=344, mitral=325, double=192). The mean clinical follow-up duration was 10.5±5.3 (median 10.9) years. Operative mortality occurred in 26 patients (3.0%), and linearized late cardiac mortality was 0.9%/patient-year without an intergroup difference. Linearized thromboembolism, bleeding, prosthetic valve endocarditis, non-structural valve deterioration (NSVD), and reoperation rates were 0.8%/patient-year, 0.6%/patient-year, 0.2%/patient-year, 0.5%/patient-year, and 0.5%/patient-year, respectively. Prosthetic valve endocarditis was more frequent after double valve replacement than after aortic or mitral valve replacement (P=0.008 and 0.005, respectively). NSVD and reoperation rates were significantly lower aortic valve replacement than after mitral or double valve replacement (P=0.001 and 0.002, P=0.001 and <0.001, respectively). Valve replacement in the mitral position was the only risk factor for NSVD (hazard ratio [95% confidence interval]=5.247 [1.608-17.116], P=0.006). CONCLUSIONS: On-X valve implantation in the left side heart had favorable clinical outcomes with acceptable early and late mortality and a low incidence of prosthetic valve-related complications. Particularly in the aortic position, the On-X valve had better long-term non-structural durability.

Comparative analysis of structural valve deterioration after bioprosthetic tricuspid valve replacement: Bovine pericardial versus porcine valves.

This study was conducted to compare the occurrence and the risk factors of structural valve deterioration (SVD) after bioprosthetic tricuspid valve replacement (TVR) between bovine pericardial valves and porcine valves. One-hundred and thirty-four TVR patients were enrolled; 108 patients underwent TVR with bovine pericardial bioprostheses (BTVR group) and 26 underwent TVR with porcine bioprostheses (PTVR group). The early results and long-term clinical outcomes were compared. The median follow-up duration was 90 (interquartile range: 33-135) months. Propensity score (PS) adjusted Cox regression and competing risk analyses were performed. The mean ages of the BTVR and PTVR groups were 62.2 ± 10.7 and 57.3 ± 13.9 years, respectively. The overall survival and cumulative incidence of cardiac death in the BTVR group were similar to those in the PTVR group (hazard ratio [95% confidence interval] = 1.399 [0.500-3.922] and 0.742 [0.249-2.212], respectively). SVD was significantly more frequent in the BTVR group (17.544 [1.070-243.902], P = .045). The tricuspid valve reoperation rate was significantly higher in the BTVR group (38.462 [2.591-476.190], P = .008). The cumulative incidence of SVD after bioprosthetic TVR was higher when using bovine pericardial valves than when using porcine valves.

Twenty-Year Experience with Truncus Arteriosus Repair: Changes in Risk Factors in the Current Era.

Although the clinical outcomes of truncus arteriosus (TA) repair have been improving, few data are available on long-term outcomes after truncus arteriosus repair in the current era. This study evaluated long-term outcome after repair of TA. Fifty-one patients underwent total correction from April 1982 to June 2018. Since 2003, perioperative strategy has changed to minimal priming volume, modified ultrafiltration, and early total repair (n = 26). Mortality and reoperation rates were analyzed before and after 2003. There were 8 hospital deaths after initial operation, all before 1997. During the mean follow-up of 9.8 years, there were 2 deaths. The Kaplan-Meier estimate of survival among all hospital survivors was 94.7% at 5 years and 88.0% at 20 years. A significant independent risk factor for early mortality was operation before 2003 (Hazard ratio (HR) 9.710, p = 0.041) and REV operation (HR 8.000, p = 0.028). Freedom from reoperation for conduit change and TV repair were 88.3% and 41% at 1 and 5 years, and 96.2% and 85.4% at 1 and 5 years, respectively. After 2003, younger age and conduit choice were risk factors for conduit-related reoperation. Initial preoperative TV regurgitation was independent risk factor for sequential TV repair. Patients with TA can undergo total repair of TA with excellent results, especially in current era. Most of the patients require conduit-related reoperations. Younger age and the methods of RVOT reconstruction were risk factors for conduit-related reoperations. TV repair is necessary in limited patients, and initial regurgitation was a risk factor.

Competitive Flow of Terminal Anastomosis to Right Coronary Territory in "Y" Coronary Artery Bypass.

BACKGROUND: We evaluated the prevalence and outcomes of competitive flow in the terminal right coronary artery (RCA) graft after coronary artery bypass grafting (CABG) with left internal thoracic artery-based Y-composite grafting at 1 year after CABG. METHODS: We enrolled 642 patients who underwent Y-composite graft-based off-pump CABG with in situ left internal thoracic artery between 2014 and 2022. All patients underwent early postoperative angiography, and 1-year postoperative angiography was performed in 81.2% (522/642) of patients. RESULTS: The early occlusion rate of distal anastomoses with Y-composite graft was 2.1%. Competitive flow was observed in 69 of 642 anastomoses (10.7%). Multivariate analysis showed that the maximal degree of target vessel stenosis (odds ratio [OR], 0.909; 95% CI, 0.886-0.931; P < .001), maximal degree of non-terminal target vessel in Y-arm grafts (OR, 1.103; 95% CI, 1.047-1.172; P < .001), and diabetes mellitus (OR, 0.535; 95% CI, 0.303-0.934; P = .029) were factors associated with competitive flow to the RCA territory. The optimal cutoff value for the degree of terminal target vessel stenosis predicting competitive flow to the RCA territory was 92.5%. The 1-year graft failure rate of anastomoses with competitive flow of the terminal anastomosis was 30.9% (17/55). The presence of competitive flow on early angiography was the only factor associated with graft occlusion of the terminal anastomosis at 1 year (OR, 2.339; 95% CI, 1.165-4.481; P = .013). CONCLUSIONS: For terminal anastomosis to the RCA territory in Y-composite graft-based CABG, the presence of competitive flow on early angiography was associated with graft occlusion of the terminal anastomosis at 1 year. Notably, 30.9% of these grafts demonstrated failure on 1-year follow-up angiography.

The impact of perivascular tissue preservation on 5-year patency of saphenous vein composite grafts.

OBJECTIVES: This retrospective study was conducted to evaluate the impact of saphenous vein (SV) harvesting with versus without perivascular tissue on the 5-year angiographic patency in coronary artery bypass grafting. METHODS: Among the 944 patients who received coronary artery bypass grafting between 2010 and 2015, 579 patients who received off-pump coronary artery bypass grafting using 1 SV as a Y-composite graft based on the in situ left internal thoracic artery were enrolled. SV harvesting was performed using no-touch technique without perivascular tissue (the NoPVT group) in 342 patients and with perivascular tissue (the PVT group) in 237 patients. Follow-up duration was 84.0 months (interquartile range 66.5-105.4). Propensity score matching was performed, and long-term clinical outcomes and angiographic patency were compared. RESULTS: The average number of distal anastomoses per patient was comparable between the groups, although more SV grafts were anastomosed to left anterior descending territory in the PVT group than in the NoPVT group. Overall survival and cumulative incidence of cardiac death were comparable between the groups, whereas cumulative incidence of target vessel revascularization (1.3% vs 4.3% at 5 year, P = 0.009) and that of major adverse cardiac events (7.3% vs 9.9% at 5 year, P = 0.035) were lower in the PVT group than in the NoPVT group. One-year and 5-year angiographic patency rates of the SV grafts were higher in the PVT group than in the NoPVT group [97.0% vs 91.7% (P = 0.004) and 96.3% vs 89.9% (P = 0.007), respectively]. CONCLUSIONS: SV grafts harvested using no-touch technique with perivascular tissue further improved the 5-year patency of SV composite grafts compared with those without perivascular tissue.

Clinical benefits of surgical ablation during isolated aortic valve replacement: a nationwide study.

OBJECTIVES: To compare the early- and long-term clinical outcomes of concomitant surgical ablation (SA) for atrial fibrillation (AF) during isolated aortic valve replacement (AVR) using data from the Korean National Health Insurance Service Database. METHODS: Of 23,332 adult patients who underwent AVR between 2003 and 2019, those with underlying AF with or without concomitant SA were extracted, and propensity score matching analysis was performed. RESULTS: Overall, 1,741 patients with underlying AF with (n = 445, group A) or without (n = 1,296, group N) concomitant SA during isolated AVR were enrolled, from whom 435 pairs were matched in a 1:1 ratio using propensity score matching analysis. The operative mortality and early postoperative morbidities, including bleeding reoperation, stroke, permanent pacemaker implantation and acute kidney injury were comparable between the groups. The overall survival showed no differences between the groups. However, the cumulative incidence of new-onset late ischaemic stroke was significantly lower in group A than group N in propensity score-matched patients [2.3 vs 3.5 per 100 patient-years, adjusted hazard ratio (95% confidence interval) 0.64 (0.43-0.96), Group A versus Group N, respectively]. The cumulative incidence of other morbidities such as reoperation, permanent pacemaker implantation and progression to chronic renal failure showed no difference between groups. CONCLUSIONS: The incidence of late ischaemic stroke was significantly lower when concomitant SA was performed during isolated AVR in patients with underlying AF. Therefore, concomitant SA should be actively considered in patients with underlying AF undergoing isolated AVR to prevent the occurrence of late ischaemic stroke.

Optimal timing of heart transplantation in patients with an implantable left ventricular assist device.

Heart transplantation (HTPL) has been established as the gold-standard surgical treatment for end-stage heart failure. However, the use of a left ventricular assist device (LVAD) as a bridge to HTPL has been increasing due to the limited availability of HTPL donors. Currently, more than half of HTPL patients have a durable LVAD. Advances in LVAD technology have provided many benefits for patients on the waiting list for HTPL. Despite their advantages, LVADs also have limitations such as loss of pulsatility, thromboembolism, bleeding, and infection. In this narrative review, the benefits and shortcomings of LVADs as a bridge to HTPL are summarized, and the available literature evaluating the optimal timing of HTPL after LVAD implantation is reviewed. Because only a few studies have been published on this issue in the current era of third-generation LVADs, future studies are needed to draw a definite conclusion.

Comparative effectiveness of clopidogrel versus aspirin as a maintenance monotherapy 1 year after coronary artery bypass grafting.

OBJECTIVES: Data on the safety and efficacy of clopidogrel (CPD) monotherapy after coronary artery bypass grafting (CABG) are limited. We compared the clinical outcomes and graft patency rates during 4 years in CABG patients who maintained CPD or aspirin after 1 year of dual antiplatelet therapy (DAPT) use. METHODS: A total of 671 patients who maintained 1-year DAPT after CABG with all grafts patent on one-year follow-up angiography and switched to single antiplatelet therapy (SAPT) using CPD (n = 272) or aspirin (n = 399) between January 2009 and December 2015 were enrolled. Propensity score matching analysis was used, and 227 pairs were matched in a 1:1 ratio. Overall mortality, cardiac mortality, and major adverse events, including all-cause mortality, acute myocardial infarction, coronary reintervention or reoperation, ischaemic stroke, and major bleeding, were compared. Graft patency was evaluated using graft angiography 5 years post-surgery. RESULTS: Overall survival and the incidence of major adverse events during the 4-year follow-up did not differ significantly between the groups when un-matched (hazard ratio [HR], 95% confidence interval [CI]=1.24, 0.71 to 2.15, P = 0.46 and HR, 95% CI = 1.22, 0.77 to 1.92, P = 0.41, respectively) or matched (HR, 95% CI = 1.05, 0.55 to 2.01, P = 0.89 and HR, 95% CI = 1.01, 0.60 to 1.73, P = 0.96, respectively). In the postoperative 5-year graft angiography, new graft occlusion was found in 3.2% and 4.7% of patients and newly occurred graft occlusion rates of distal anastomoses were 1.2% and 1.6% in the CPD and aspirin groups, respectively, and were not statistically different between the 2 groups (P = 0.39 and 0.63, respectively). Changes of antiplatelet regimen were needed in 22.8% (91 of 399) of aspirin group and in 2.2% (6 of 272) of CPD group from the initiation of SAPT (P < 0.001). CONCLUSIONS: In this series of patients undergoing CABG who received DAPT and remained stable for 1 year, SAPT maintenance with CPD or aspirin did not show any significant differences in 4-year outcomes such as all-cause mortality, major adverse events, and newly occurring graft occlusion. However, more patients taking aspirin required changes in antiplatelet regimens to other antiplatelet or anticoagulation therapies.

Impact of Functional vs Anatomic Complete Revascularization in Coronary Artery Bypass Grafting.

BACKGROUND: This study was conducted to evaluate the impact of functional and anatomic complete revascularization on long-term clinical outcomes after coronary artery bypass grafting (CABG). METHODS: Of 2034 patients who underwent primary isolated CABG between 2006 and 2017, 1162 patients who underwent off-pump CABG for 3-vessel disease and for whom data on functional and anatomic completeness of revascularization were available on the basis of preoperative myocardial single photon emission computed tomography and early postoperative graft angiography were enrolled. The median follow-up duration was 82.4 months (interquartile range, 50.8-122.4 months). Univariate and multivariate analyses were performed to evaluate the impact of the functional and anatomic completeness of revascularization on long-term survival. RESULTS: Of 1162 patients, anatomic complete revascularization was achieved in 1014 patients (87.3%), whereas functional complete revascularization was achieved in 1077 patients (92.7%). Early mortality occurred in 7 patients. Late death occurred in 322 of 1155 early survivors. The 5- and 10-year overall survival rates were 84.3% and 66.7%, respectively. Univariate analyses demonstrated that functional completeness of revascularization was a statistically significant risk factor (P = .038), whereas anatomic completeness was not (P = .859). The multivariate analysis showed that functional completeness of revascularization (hazard ratio, 1.54; 95% CI, 1.08-2.22; P = .019) and age, underweight status, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and left ventricular dysfunction were significant factors associated with long-term survival. CONCLUSIONS: Functional rather than anatomic completeness of revascularization has a significant impact on the long-term survival in patients who undergo CABG.

Machine-learning-based prediction of survival and mitral regurgitation recurrence in patients undergoing mitral valve repair.

OBJECTIVES: This study was conducted to assess long-term clinical outcomes after mitral valve repair using machine-learning techniques. METHODS: We retrospectively evaluated 436 consecutive patients (mean age: 54.7 ± 15.4; 235 males) who underwent mitral valve repair between January 2000 and December 2017. Actuarial survival and freedom from significant (≥ moderate) mitral regurgitation (MR) were clinical end points. To evaluate the independent risk factors, random survival forest (RSF), extreme gradient boost (XGBoost), support vector machine, Cox proportional hazards model and general linear models with elastic net regularization were used. Concordance indices (C-indices) of each model were estimated. RESULTS: The operative mortality was 0.9% (N = 4). Reoperation was required in 15 patients (3.5%). In terms of C-index, the overall performance of the XGBoost (C-index 0.806) and RSF models (C-index 0.814) was better than that of the Cox model (C-index 0.733) in overall survival. For the recurrent MR, the C-index for XGBoost was 0.718, which was the highest among the 5 models. Compared to the Cox model (C-index 0.545), the C-indices of the XGBoost (C-index 0.718) and RSF models (C-index 0.692) were higher. CONCLUSIONS: Machine-learning techniques can be a useful tool for both prediction and interpretation in the survival and recurrent MR. From the machine-learning techniques examined here, the long-term clinical outcomes of mitral valve repair were excellent. The complexity of MV increased the risk of late mitral valve-related reoperation.

Comparable Outcomes of Bicuspid Aortic Valves for Rapid-Deployment Aortic Valve Replacement.

Background: Edwards Intuity is recognized as a relatively contraindicated bioprosthesis for bicuspid aortic valve disease. This study compared the early echocardiographic and clinical outcomes of rapid-deployment aortic valve replacement for bicuspid versus tricuspid aortic valves. Methods: Of 278 patients who underwent rapid-deployment aortic valve replacement using Intuity at Seoul National University Hospital, 252 patients were enrolled after excluding those with pure aortic regurgitation, prosthetic valve failure, endocarditis, and quadricuspid valves. The bicuspid and tricuspid groups included 147 and 105 patients, respectively. Early outcomes and the incidence of paravalvular leak were compared between the groups. A subgroup analysis compared the outcomes for type 0 versus type 1 or 2 bicuspid valves. Results: The bicuspid group had more male and younger patients. Comorbidities, including diabetes mellitus, hypertension, chronic kidney disease, and coronary artery disease, were less prevalent in the bicuspid group. Early echocardiographic evaluations demonstrated that the incidence of ≥mild paravalvular leak did not differ significantly between the groups (5.5% vs. 1.0% in the bicuspid vs. tricuspid groups, p=0.09), and the early clinical outcomes were also comparable between the groups. In the subgroup analysis between type 0 and type 1 or 2 bicuspid valves, the incidence of mild or greater paravalvular leak (2.4% vs. 6.7% in type 0 vs. type 1 or 2, p=0.34) and clinical outcomes were comparable. Conclusion: Rapid-deployment aortic valve replacement for bicuspid aortic valves demonstrated comparable early echocardiographic and clinical outcomes to those for tricuspid aortic valves, and the outcomes were also satisfactory for type 0 bicuspid aortic valves.

Rapid deployment versus its conventional counterpart in aortic valve replacement: comparison of early hemodynamic outcomes.

Background: Edwards Intuity is designed for rapid deployment based on the structure of Magna Ease. This study was conducted to compare early hemodynamic performance between the two valves. Methods: Patients who underwent aortic valve replacement (AVR) using Edwards Intuity or Carpentier-Edwards PERIMOUNT Magna Ease in our institution from June 2016 to July 2021 were enrolled. Intuity valve was used in 215 patients, and Magna Ease valve was used in 198 patients, respectively. Early postoperative echocardiographic data were available in 99.0% (409/413) of the patients. The transvalvular mean pressure gradient, effective orifice area, and effective orifice area index were compared between the valves stratified by prosthesis size. Results: There were no differences in the proportion of female patients or body surface area between the groups. Mean pressure gradient on early postoperative echocardiography was significantly lower in Intuity valve than Magna Ease valve for 19, 21, 23, and 25 mm valves (15.5±5.0 vs. 20.8±9.1 mmHg, P=0.004; 12.7±4.2 vs. 15.6±5.3 mmHg, P=0.001; 11.5±3.3 vs. 13.4±5.8 mmHg, P=0.034; and 9.9±3.1 vs. 12.3±4.0 mmHg, P=0.029; respectively). Effective orifice area was larger in Intuity valve than Magna Ease valve for 19 mm valve (1.45±0.38 vs. 1.19±0.28 cm2, P=0.002), and effective orifice area index was also larger in Intuity valve than Magna Ease valve for 19 mm valve (0.96±0.26 vs. 0.80±0.20 cm2/m2, P=0.005). Early clinical outcomes, including operative mortality and postoperative complications, demonstrated no significant differences between the groups. Conclusions: Edwards Intuity demonstrated superior early hemodynamic performance compared with Magna Ease in a size-by-size comparison, and this superiority was more definite for small prostheses.

Long-term results of a stented bioprosthetic valve in the aortic position: structural valve deterioration and valve haemodynamic deterioration of bovine pericardial and porcine valves.

OBJECTIVES: This study compared the clinical outcomes of bovine and porcine bioprosthetic valves based on structural valve deterioration (SVD) and valve haemodynamic deterioration (VHD) in the aortic position. METHODS: From January 1995 to December 2014, patients who underwent aortic valve replacement (AVR) using a bovine pericardial valve or porcine valve were enrolled. SVD and VHD were defined according to the mean transprosthetic gradient and the grade of aortic regurgitation on transthoracic echocardiography. The propensity score matching was used to adjust for differences in preoperative and operative characteristics. RESULTS: A total of 520 patients were enrolled. Of these, 372 patients underwent AVR using a bovine pericardial valve and 148 patients underwent AVR using a porcine valve. Then, 135 pairs of patients were extracted after propensity score matching. The median follow-up duration was 8.2 years (interquartile range, 5.4-11.3). Among the matched patients, no significant differences occurred in overall survival (survival at 10 years: 64.7% vs 70.9%) or cardiac death (cumulative incidence at 10 years: 14.2% vs 13.1%) between the 2 groups. The cumulative incidence of moderate or greater SVD and VHD was significantly higher in the porcine valve group than in the bovine valve group (SVD at 10 years-porcine: 29.8% vs bovine: 13%; VHD at 10 years-porcine: 19.8% vs bovine: 3.8%, respectively). However, no significant differences were noted in the cumulative incidence of severe SVD and severe VHD between the 2 groups. CONCLUSIONS: The bovine pericardial valve should be considered in AVR because the cumulative incidences of moderate or greater SVD and VHD were significantly lower than those of the porcine valve.

The long-term outcomes of surgical ablation for atrial fibrillation during redo left-sided valvular surgery.

Background: This study evaluated the outcome of surgical ablation (SA) for atrial fibrillation (AF) concomitant with redo left-sided valvular surgery. Methods: The study enrolled 224 AF patients (paroxysmal: 13 patients, persistent: 76 patients, long-standing persistent AF: 135 patients) undergoing redo open heart surgery for left-sided valve disease. The early results and long-term clinical outcomes were compared between those who underwent concomitant SA for AF (SA group) and did not (NSA group). Propensity score adjusted Cox regression analysis of overall survival and competing risk analysis of the other clinical outcomes were performed. Results: Seventy-three patients were classified as the SA group and 151 as the NSA group. The median follow-up duration was 124 (1.0-249.5) months. The median ages of the patients in the SA and NSA groups were 54.1±11.3 and 58.4±11.1 years, respectively. There were no significant differences between the groups in the early in-hospital mortality rate (5.5% vs. 9.3%, P=0.474) or postoperative complications, except for low cardiac output syndrome (11.0% vs. 23.8%, P=0.036). Overall survival was better in the SA group [hazard ratio, 0.452; 95% confidence interval (CI): 0.218-0.936, P=0.032]. The incidence of recurrent AF was significantly higher in the SA group on multivariate analysis [hazard ratio, 3.440; 95% CI: 1.987-5.950, P<0.001]. The cumulative incidence of the composite of thromboembolism and bleeding was lower in the SA than NSA group [hazard ratio, 0.338; 95% CI: 0.127-0.897, P=0.029]. Conclusions: The concomitant surgical arrhythmia ablation with redo cardiac surgery for left-sided heart disease resulted in a better overall survival, higher incidence of sinus conversion, and lower incidence of a composite of thromboembolism and major bleeding. Concomitant SA procedure should be considered in patients undergoing redo cardiac surgery.