Transcatheter aortic valve­in­valve implantation for failed surgical bioprostheses: results from the Polish Transcatheter Aortic Valve-in-Valve Implantation (ViV­TAVI) Registry

INTRODUCTION: Transcatheter aortic valve­in ­valve implantation (ViV­TAVI) has emerged as an alternative to redo surgery in patients with failed surgical aortic bioprosthesis. OBJECTIVES: We evaluated the safety and efficacy of ViV­TAVI in Polish patients after surgical aortic valve replacement. PATIENTS AND METHODS: This was a nationwide multicenter registry of ViV­TAVI procedures. Data were collected using an online form, and the clinical follow ­up lasted 1 year. RESULTS: From 2008 to 2020, 130 ViV­TAVI procedures were performed (1.9% of all transcatheter aortic valve implantation [TAVI] cases). A considerable increase in ViV­TAVI procedures since 2018 has been observed (n = 59, 45% of ViV­TAVI cases). Hancock II, Freestyle, and homograft were the most frequently treated bioprostheses. The self ­expanding supra ­annular Corevalve / Evolut valve was used in 76% of cases. In 21% of cases, the mean postprocedural pressure gradient (PG) exceeded 20 mm Hg. All­cause mortal­ity at 1 year was 10.8%. Aortic valve stenosis was associated with a higher mean PG than aortic valve regurgitation or mixed disease (P = 0.004). Supra ­annular transcatheter aortic valves were associated with lower mean PGs than intra ­annular valves (P = 0.004). Second ­generation devices were associated with shorter procedure time (120 min vs 135 min, P = 0.04), less frequent need for additional TAVI (2% vs 10%, P = 0.04), and lower 1­year cardiovascular mortality (95% vs 82.8%, P = 0.03) than first­generation valves. CONCLUSIONS: Transcatheter treatment of failed bioprostheses is increasingly common, with the best hemodynamic effect shown for supra ­annular valves. The introduction of second­generation valves has improved procedural and clinical outcomes.

Erector spinae-plane block as an analgesic alternative in patients undergoing mitral and/or tricuspid valve repair through a right mini-thoracotomy - an observational cohort study.

INTRODUCTION: One of the main challenges in cardiac surgery is effective postoperative analgesia. Erector spinae-plane block (ESP block) is a novel regional technique, introduced by Forero in 2016 for neuropathic chest pain, then used successfully for mastectomy. AIM: To establish the efficacy of the ESP block in patients undergoing mitral and/or tricuspid valve repair through a right mini-thoracotomy. MATERIAL AND METHODS: It is a prospective observational cohort study performed in a tertiary health center. In the treatment group, a single-shot ESP block was performed before anesthetic induction. General anesthesia was induced with etomidate, remifentanil, and rocuronium, and continued with sevoflurane and remifentanil. Remifentanil infusion was continued for 2 h post-operatively, then stopped, and the patient's trachea was extubated. Patient-controlled analgesia was started with oxycodone immediately. Total oxycodone consumption and pain severity on the visual analog scale during the first 24 h were analyzed. In the control group, no regional block was performed. Instead of remifentanil, fentanyl was used. Patients were extubated on the second day. Pain was treated with morphine, administered according to nurses' discretion. Pain intensity was evaluated on the numerical rating scale. RESULTS: Nineteen patients were evaluated in the ESP and 25 in the control group. Mechanical ventilation time was shorter in the ESP group (0.6 (0.4-1.1) h) than in the control one (10 (8-17) h, p = 0.00001). Moreover, patients in the ESP group spent fewer days in the intensive care unit (1 (1-1) vs. (2 (2-2), p = 0.0001). CONCLUSIONS: The ESP block seems to be safe and efficient for pain control in patients undergoing right mini-thoracotomy for mitral and/or tricuspid valve repair.

Transcatheter aortic valve-in-valve implantation in failed stentless bioprostheses.

OBJECTIVE: To compare the safety and efficacy of transcathether aortic valve-in-valve implantation (ViV-TAVI) in degenerated stentless bioprostheses with failed stented valves and degenerated native aortic valves. INTRODUCTION: Little is known about ViV-TAVI in degenerated stentless valves. METHODS: Out of 45 ViV-TAVI procedures reported in the POL-TAVI registry, 20 failed stentless valves were compared with 25 stented prostheses and propensity-matched with 45 native TAVI cases. The mean follow-up was 633 (95% confidence interval [CI], 471-795) days and Valve Academic Research Consortium-2 (VARC-2) definitions were applied. RESULTS: Patients with degenerated stentless valves were younger (65.6, CI 58-73.1 years vs 75.6, CI 72.2-78 [stented] vs 80.1, CI 78.7-81.6 y. [native], P < 0.001). Implantation was required later after surgery (11.5, CI 8-14.9 years) in the stentless cohort as compared with the stented one (6.2, CI 4.7-7.6 years, P = 0.006). ViV-TAVI in the stentless group was also associated with larger amount of contrast (211, CI 157-266 mL vs 135, CI 104-167 mL [stented] vs 132 (119-145) mL [native], P = 0.022). Using VARC-2 composite endpoints, ViV-TAVI in stentless prostheses was characterized by a lower device success (50% vs 76% in stented vs 88.9% in native TAVI, P < 0.001), but comparable early safety up to 30 days (73.7% vs 84% vs 81.8%, respectively, log-rank P = 0.667) and long-term clinical efficacy beyond 30 days (72.2% vs 72% vs 73.8%, respectively, log-rank P = 0.963). CONCLUSIONS: Despite technical challenges and a lower device success, ViV-TAVI in stentless aortic bioprostheses achieves similar safety, efficacy, and functional improvement as in stented or degenerated native valves.

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society .

Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone, and surgical aortic valve replacement can improve symptoms and survival. In recent years, transcatheter aortic valve implantation (TAVI) has been demonstrated to improve survival in inoperable patients and to be an alternative treatment in patients in whom the risk of surgical morbidity or mortality is high or intermediate. A representative expert committee, summoned by the Association of Cardiovascular Interventions of the Polish Cardiac Society (ACVI) and the Polish Society of Cardio-Thoracic Surgeons, devel-oped this Consensus Statement in transcatheter aortic valve implantation. It endorses the important role of a multi-disciplinary "TAVI team" in selecting patients for TAVI and defines operator and institutional requirements fundamental to the establish-ment of a successful TAVI programme. The article summarises current evidence and provides specific recommendations on organisation and conduct of transcatheter treatment of patients with aortic valve disease in Poland.

Effect of coronary artery bypass graft in patients with unstable angina on left ventricular remodelling in medium-term follow-up.

INTRODUCTION: Left ventricular remodelling is a process of change in size, shape, wall thickness and heart function, initiated by a noxious stimulus such as ischaemia. Methods of pharmacological and surgical inhibition or reversal of remodelling are being sought. AIM: To assess the influence of coronary artery bypass grafting on echocardiographic measures of left ventricular size and shape in medium-term follow-up. METHODS: In a group of 30 patients three echocardiographic examinations were performed: before CABG operation, 3 months after and 20 months after the operation. Left ventricular area and volumes as well as indices of sphericity, thinning and expansion were calculated. RESULTS: After the operation, left ventricular areas measured in short axis and in apical four-chamber view increased among patients with a history of myocardial infarction. Improvement in the sphericity index occurred after the operation in patients with a history of myocardial infarction in whom the ejection fraction before the operation was less than 50%. CONCLUSIONS: The left ventricular remodelling process progresses after coronary artery bypass grafting in patients with a history of myocardial infarction. Inhibition of remodelling may be expected in patients without myocardial infarction, with preserved left ventricular systolic function.

[Mediastinal abscess as a remote complication of CABG combined with temporary cardiac pacing--a case report]. / Ropien sródpiersia jako odlegle powiklanie pomostowania tetnic wiencowych z zastosowaniem czasowej stymulacji serca. Opis przypadku.

A case of a 74 year old patient with a history of CABG with temporary epicardial cardiac pacing, is described. Five years later the patient developed wound infection. Computerised tomography revealed the presence of mediastinal abscess containing surgical material. The patients underwent surgical removal of the abscess with a distal part of an epicardial pacing lead which was left after CABG and was the most probable cause of infection.

Minimally invasive mitral valve surgery -- first experience in Poland.

BACKGROUND: Minimally invasive cardiac surgery has been introduced to treat various cardiac disorders, predominantly ischaemic heart disease. Its usage in valvular disorders has been only recently proposed. AIM: To assess safety and efficacy of minimally invasive mitral valve surgery. METHODS: The procedure was performed in 10 patients (6 females, 4 males, mean age 59+/-7 years). All but one had preserved left ventricular ejection fraction. Two patients underwent mitral valvuloplasty, and mitral valve replacement was performed in all remaining cases. One procedure was a redo surgery following mitral commisurotomy. RESULTS: In all patients the procedure was effective. Prolongation of cardiopulmonary bypass and aorta cross-clamping time did not increase the complication rate which included one wound infection, one repeated cannulation of the femoral vessels and one minor stroke. Rehabilitation process seemed to be shorter than after standard procedures. CONCLUSIONS: Minimally invasive mitral valve surgery is a safe and alternative method of treatment, and is associated with excellent cosmetic results.

[Pulmonary embolism in a patient with unstable angina treated with surgical revascularisation--a case report]. / Zator tetnicy plucnej w niestabilnej dlawicy piersiowej poddanej chirurgicznej rewaskularyzacji.

A case of a 58-year-old female patient with unstable angina is presented. Two weeks earlier the patient suffered from acute myocardial infarction treated with thrombolysis. The patient underwent surgical revascularisation which was complicated by acute pulmonary embolism. Repeated surgery and inspection of pulmonary arteries revealed the presence of thrombus which was successfully removed. The post-operative course was uneventful. The causes and treatment of pulmonary embolism complicating coronary artery by-pass grafting are discussed.

[In-stent thrombosis following coronary artery by-pass grafting - a case report]. / Zakrzepica w stencie powiklaniem zabiegu pomostowania aortalno-wiencowego.

A case of a 60 year old male with a history of myocardial infarction treated with coronary angioplasty with stent implantation, who was admitted to the hospital for coronary artery by-pass grafting (CABG), is presented. The post-operative course was complicated by new acute MI due to the in-stent thrombosis. The patient received aspirin and ticlopidine, and underwent intra-aortic balloon pumping followed-by an effective coronary angioplasty of the infarct-related coronary artery.

Primary OPCAB as a strategy for acute coronary syndrome and acute myocardial infarction.

BACKGROUND: Conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB) carries higher mortality and morbidity for patients undergoing surgery during acute coronary syndrome (ACS). The aim of this retrospective study was to evaluate potential benefits of avoiding CPB by instead performing off-pump CAB (OPCAB) during surgery on patients in ACS. METHODS: Among 624 patients who underwent OPCAB between January 1999 and June 2001, 143 underwent surgery during ACS (group 1). The ACS patients in group 1 were divided into 2 subgroups: 66 underwent surgery during acute myocardial infarction (AMI group) and 77 during unstable angina classified as class III or IV according to the Braumwald classification (unstable coronary artery disease [CAD] group). Group 2 (the elective CAD group) consisted of 481 patients who underwent isolated elective OPCAB during the same time period. RESULTS: Overall 30-day mortality was 4.9% (n = 7) for the ACS group and 0.83% (n = 4) for the elective CAD group (P < .0001). Differences between groups were found in use of inotropes, intraaortic balloon pump, and subsequent conversion of OPCAB to CPB (P < .0001, P < .01, and P < .03, respectively), as well as use of blood transfusion (P < .0003). Multivariate logistic regression analysis for 641 patients revealed ACS (P < .015), AMI (P < .019), renal failure (P < .017), and left ventricle aneurysm (P < .028) as independent risk factors for 30-day mortality in ACS reoperation (P = .02), whereas in AMI renal failure (P = .02) appeared to be an independent risk factor. CONCLUSIONS: OPCAB is a valuable treatment strategy in ACS patients; however, it carries significant mortality and morbidity. Careful preselection and timing of intervention are required in order for patients to fully benefit from the OPCAB strategy.

Dysfunction of left ventricle as an indication for off-pump coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass carries significant risk for patients with severe left ventricular (LV) dysfunction. METHODS: Between 1997 and 2000, 240 patients underwent OPCAB. The patients were retrospectively divided into 2 groups with regard to LV function. Group 1 consisted of 90 patients with ejection fraction (EF) <35% and grou p 2 of 150 patients without severe LV impairment and EF >35%. Patients were compared for preoperative risk factors, perioperative mortality, and postoperative complications. RESULTS: Preoperative expected mortality according to EuroSCORE was higher in group 1, 5.95, compared with group 2, 2.66 (P =.0005). A few preoperative risk factors were more common in group 1: urgent operation (P =.00001), unstable angina (P =.0018), Canadian Cardiovascular Society class (P =.001), myocardial infarction (P =.0001), and peripheral arteriopathy (P =.0006). Mean number of grafts was 1.51 in group 1 and 1.55 in group 2 with the same internal thoracic artery utilization. Perioperative drainage, anesthesia and intubation time, transfusion rate, and use of inotropes were comparable. Actual, nonadjusted mortality was 2.5% in group 1 and 1.4% in group 2 (P = not significant). Overall rates of postoperative complications were comparable; only use of an intraoperative balloon pump was more frequent in group 1 (P =.006). Postoperative stay was shorter in group 1 (P equals). CONCLUSIONS: Off-pump CABG for patients with LV impairment is associated with surgical outcome similar to that among patients with normal LV function, in spite of the presence of unfavorable risk factors. Off-pump surgery with selective anterior (including right main) arterial revascularization can be indicated in the presence of poor LV function.