Transcatheter mitral valve repair: review of current techniques.

Mitral regurgitation is common and is associated with excess morbidity and mortality. Despite these poor outcomes, only a minority of affected patients undergo mitral surgery, for several reasons, which underlines the substantial unmet need for treatment for this disorder. Transcatheter mitral valve repair interventions have been developed to treat mitral regurgitation in an undertreated patient population. The aim of this status quo review is to provide an overview of currently available transcatheter mitral valve repair techniques, the different approaches and the clinical outcomes reported so far.

Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation.

OBJECTIVES: Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined. METHODS: From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed. RESULTS: Occurrences of ring dehiscence were acute (<30 days), early (≤1 year) and late (>1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients. CONCLUSIONS: Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.

Preoperative Predictors and Outcome of Triple Valve Surgery in 487 Consecutive Patients.

Background Triple valve surgery (TVS) is associated with an elevated risk for operative mortality and thus remains a surgical challenge. We report our experience and results of TVS procedures, especially with respect to identification of preoperative risk factors, to improve patient selection. Methods Between December 1994 and January 2013, 487 consecutive patients (240 male, 247 female) underwent TVS at the Heart Center Leipzig, University of Leipzig. The data were prospectively collected and retrospectively analyzed. Univariate and multivariable regression analyses were performed to identify risk factors. Results The 30-day mortality was 16.1% and the long-term survival at 1 year and 5 years was 71.8% and 54.6%, respectively. Multivariable logistic regression analysis identified previous myocardial infarction to be the only significant predictor for early mortality. Age, New York Heart Association functional class IV, previous myocardial infarction, dialysis, and liver dysfunction were identified as preoperative predictors for late mortality. Furthermore, an increase of operative risk, given for each year, was observed during the study period. In contrast, 30-day mortality decreased during the observation time. Conclusion TVS is associated with a high surgical risk. Long-term survival is decreased, but acceptable for these high-risk patients. The series demonstrates that increasing surgical risk, age, and comorbidities are the future challenges in TVS.

The role of the heart team in complicated transcatheter aortic valve implantation: a 7-year single-centre experience.

OBJECTIVES: European guidelines recommend to perform transcatheter aortic valve implantation (TAVI) within a multidisciplinary heart team. However, there is a strong drive--despite existing guidelines--to perform TAVI outside of specialized centres. The aim of this study was to clarify the necessity of on-site cardiac surgery by providing a clear insight into the complications during/after TAVI that needed surgical management. METHODS: A total of 2287 (1523 transfemoral, 752 transapical and 12 transaortic) patients, with a mean age of 84.5 ± 5.3 years, and a mean log EuroSCORE of 21.7 ± 16.3, of which 205 were female (84%), underwent TAVI since February 2006 at our institution. All procedure-related complications that required surgical interventions, whether immediate or delayed but within the initial hospital stay, were recorded and retrospectively analysed. RESULTS: Out of this cohort, 245 (10.7%) patients required surgical treatment due to major complications. A total of 42 patients (1.8%) underwent conversion to full sternotomy and 27 (1.2%) were dependent on the short-term use of the heart-lung machine. Vascular complications with surgical intervention were seen in 85 patients (3.7%), 54 patients (2.4%) had to have a rethoracotomy within their initial stay and 15 (0.7%) required a cardiac reoperation. CONCLUSIONS: Severe complications during TAVI that can only be resolved surgically will continue to occur. Therefore, each TAVI procedure should be conducted or accompanied by a cardiac surgeon and an experienced team within a specialized centre.

Improved mitral valve performance after transapical aortic valve implantation.

BACKGROUND: Concomitant mitral regurgitation (MR) is frequently present before the performance of transapical aortic valve implantation (TA-AVI). Our aim was to study the impact of MR on outcome and the effect of TA-AVI on MR using the Edwards SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA). METHODS: A total of 439 patients aged 81.5±6.4 years, 64.0% of whom were women, underwent TA-AVI between February 2006 and August 2011. The mean logistic EuroSCORE was 29.7%±15.7% and the mean Society of Thoracic Surgeons (STS) score was 11.4%±7.6%. Outcome was assessed in patients with absent (9.8%), mild or trivial (58.5%), moderate (29.7%), and severe (2.0%) MR by pre- and postoperative echocardiography. RESULTS: Patients with moderate/severe MR versus mild or trivial MR had an increased in-hospital mortality (adjusted hazard ratio [HR], 3.98; 95% confidence interval [CI], 1.79-8.84; p=0.001) but a comparable 4-year survival (adjusted HR, 1.29; 95% CI, 0.47-3.49; p=0.623). During postoperative echocardiographic examination, there was an overall improvement in mitral incompetence (absent in 23.6%, mild in 58.6%, moderate in 17.8%, and severe in none). Independent multivariate variables associated with improved MR were MR greater than 1+ (odds ratio [OR], 7.73; p<0.001), the presence of functional MR (OR, 3.66; p=0.011), left ventricular ejection fraction (LVEF) of 60% or more (OR, 3.28; p=0.002), and a mean transaortic gradient (OR, 1.03; p=0.005). CONCLUSIONS: Moderate/severe MR before TA-AVI is associated with an increased early, but a comparable late, mortality. We observed an overall improved mitral valve performance, possibly resulting from reducing both subvalvular traction and closure forces acting on the mitral valve.

Is the new EuroSCORE II a better predictor for transapical aortic valve implantation?

OBJECTIVES: Conventional surgical risk scores are used to identify suitable candidates for transapical aortic valve implantation (TA-AVI) at present. However, these scores do not consider multiple high-risk conditions, including porcelain aorta, mediastinal irradiation or frailty. The aim of this study was to compare the predictive ability of the new EuroSCORE II with the surgical risk scores currently in use. METHODS: From February 2006 to May 2011, 360 consecutive high-risk patients, age 81.6 ± 6.4 years, 64.4% female, were included using the Edwards SAPIEN™ prosthesis. The prognostic value of the EuroSCORE II was evaluated and compared with the logistic EuroSCORE and STS mortality score by receiver operating characteristics (ROC) curve analysis. In addition, a Spearman correlation analysis was performed, and a stepwise multivariate Cox regression used to identify the independent risk factors of mortality. RESULTS: The STS score and EuroSCORE II (r = 0.504, P < 0.001) showed a good correlation, while a strong correlation was found between the logistic EuroSCORE and EuroSCORE II (r = 0.717, P < 0.001). Thirty-day and in-hospital mortality rates were 10.6% (38 of 360) and 11.4% (41 of 360), respectively. In-hospital mortality rate was estimated by the logistic EuroSCORE: 30.0 ± 15.7%, the STS score: 11.7 ± 7.8% and the EuroSCORE II: 6.7 ± 5.1%. The prognostic values of the STS score, logistic EuroSCORE and the recent EuroSCORE II systems were analysed by ROC curve analysis for the prediction of 30-day (area under the curve, AUC: 0.64 vs 0.55 vs 0.50) and in-hospital mortality (AUC: 0.65 vs 0.54 vs 0.49). Multivariate regression analysis revealed length of preoperative hospital stay >5 days, body weight <65 kg, preoperative aortic annular diameter ≤ 20 mm, vital capacity <70% and concomitant mitral regurgitation >1+ as independent risk factors. CONCLUSION: In patients undergoing TA-AVI, the new EuroSCORE II correlates strongly with the logistic EuroSCORE, but is a poorer predictor of 30-day and in-hospital mortality than the STS score. A true transcatheter aortic valve implantation risk score would be desirable beyond the established scores.

Transapical aortic valve-in-valve-in-valve implantation as a procedural rescue option.

Device malposition and dysfunction with resultant severe aortic insufficiency are known complications of transcatheter aortic valve implantation (TAVI). Fortunately, these complications can often be successfully treated with a transcatheter valve-in-valve (VinV) implantation. However, prosthetic leaflet dysfunction or immobility from the VinV configuration can lead to severe central aortic insufficiency. We report the first known case of implantation of a third SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA) during TAVI as a valuable bailout strategy to deal with severe aortic insufficiency after VinV implantation.

Surgical therapy of atrial fibrillation.

Atrial fibrillation (AF) can be found in an increasing number of cardiac surgical patients due to a higher patient's age and comorbidities. Atrial fibrillation is known, however, to be a risk factor for a greater mortality, and one aim of intraoperative AF treatment is to approximate early and long-term survival of AF patients to survival of patients with preoperative sinus rhythm. Today, surgeons are more and more able to perform less complex, that is, minimally invasive cardiac surgical procedures. The evolution of alternative ablation technologies using different energy sources has revolutionized the surgical therapy of atrial fibrillation and allows adding the ablation therapy without adding significant risk. Thus, the surgical treatment of atrial fibrillation in combination with the cardiac surgery procedure allows to improve the postoperative long-term survival and to reduce permanent anticoagulation in these patients. This paper focuses on the variety of incisions, lesion sets, and surgical techniques, as well as energy modalities and results of AF ablation and also summarizes future trends and current devices in use.

Aortic valve calcium scoring is a predictor of significant paravalvular aortic insufficiency in transapical-aortic valve implantation.

OBJECTIVE: Transapical-aortic valve implantation (TA-AVI) has evolved as routine for selected high-risk patients. However, paravalvular leaks >1+ remain an unsolved issue using current generations of transcatheter valve devices. The purpose of this study was to investigate the impact of native aortic valve calcification on paravalvular leaks and outcomes using the Edwards SAPIEN™ prosthesis. METHODS: One hundred and twenty consecutive patients (out of 307 TA-AVIs) with preoperative computed tomography aged 82.6 ± 6.2 years, 75.0% female were included. Implanted prosthetic valve sizes were 23 mm (n = 31) and 26 mm (n = 89), respectively. Mean logistic European System for Cardiac Operative Risk Evaluation-Score was 30.1 ± 15.5% and mean Society of Thoracic Surgeons-Score was 12.8 ± 7.9%. Electrocardiographic (ECG)-gated cardiac computed tomography allowed to quantify the amount of calcification of aortic valve leaflets using a scoring analogous to the Agatston calcium scoring of coronary arteries [Aortic Valve Calcium Scoring (AVCS)]. Paravalvular leaks were assessed intraoperatively by echocardiography and root angiography. RESULTS: All valves were implanted successfully. The mean AVCS in patients without paravalvular leaks (n = 66) was 2704 ± 1510; with mild paravalvular leaks (n = 31) was 3804 ± 2739 (P = 0.05); and with moderate paravalvular leaks (n = 4) was 7387 ± 1044 (P = 0.002). There was a significant association between the AVCS and paravalvular leaks [odds ratio (OR; per AVCS of 1000), 11.38; 95% confidence interval (CI) 2.33-55.53; P = 0.001)] and a trend towards a higher incidence of new pacemaker implantation (OR 1.27; 95% CI 0.85-1.89; P = 0.26). No association was found to 30-day mortality, major cardiac events and stroke rate (OR 1.05; 95% CI 0.84-1.32; P = 0.68; OR 0.92; 95% CI 0.68-1.25; P = 0.57 and OR 0.90; 95% CI 0.41-1.96; P = 0.79, respectively). Overall 30-day mortality was 14.2%. CONCLUSION: Severe native valve calcifications are predictive for postoperative relevant paravalvular leak. AVCS prior to TA-AVI might serve as an additional tool to reconsider the TAVI indication to reduce the risk of paravalvular leaks especially in so-called operable patients.