Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis.

BACKGROUND: Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM: We sought to compare the outcomes of these two strategies. METHODS: The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS: Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS: In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Postoperative Quality of Life After Full-sternotomy and Ministernotomy Aortic Valve Replacement.

BACKGROUND: Few longitudinal data exist comparing quality of life (QoL) after full sternotomy (fs) aortic valve replacement (AVR) (fsAVR) with ministernotomy AVR (msAVR). METHODS: A total of 1844 consecutive patients undergoing AVR who were prospectively enrolled in a European multicenter registry were dichotomized according to surgical access. Nonparsimonious propensity score matching selected 187 pairs of patients who underwent fsAVR or msAVR with comparable baseline characteristics. Hospital outcome was compared in the 2 groups. QoL was assessed with the Short Form-36, further detailed in its Physical Component Summary (PCS) score and the Mental Component Summary (MCS) score. QoL was investigated at hospital admission, at discharge, and at 1 month, 6 months, and 1 year thereafter. RESULTS: There were 1654 patients undergoing fsAVR and 190 undergoing msAVR in the entire population. The fsAVR group showed a worse preoperative risk profile, a longer intensive care unit length of stay (59.7 hours vs 38.8 hours; p = .002), and a higher rate of life-threatening or disabling bleeding (4.1% vs 0%; P = .011); the msAVR group had a higher rate of early reintervention for failed index intervention (2.1% vs 0.5%; P = .001). QoL investigations showed better PCS and MCS at 1 month after fsAVR, but no temporal trend differences (PCS group-time P = .202; MCS group-time P = .141). Propensity-matched pairs showed comparable baseline characteristics and hospital outcomes (P = not significant for all end points) and comparable improvements of PCS and MCS over time, but no between-group differences over time (PCS group time P = .834; MCS group time P = .737). CONCLUSIONS: Patients with similar baseline profiles report comparable hospital outcomes and comparable improvements of physical and mental health, up to 1 year after surgery, with both fsAVR and msAVR. As for QoL, ministernotomy does not seem to offer any advantage compared with the traditional approach.

Transfemoral versus transcarotid access for transcatheter aortic valve replacement.

Objectives: To compare the outcomes after transcatheter aortic valve replacement (TAVR) through a transfemoral (TF) and transcarotid (TC) access at our institution. Methods: From January 2014 to January 2020, 62 TC-TAVR and 449 TF-TAVR were performed using 2 prosthesis devices (Edwards SAPIEN 3, n = 369; Medtronic Evolut R, n = 142). Propensity score matching was used to adjust for imbalance in the baseline characteristics of the study groups. Results: Propensity score matching provided 62 matched pairs with comparable operative risk (mean European System for Cardiac Operative Risk Evaluation II, TC-TAVR 7.6% vs TF-TAVR 6.6%, P = .17). Thirty-day mortality (4.8% vs 3.2%, P = 1.00) and 2-year mortality (11.3% vs 12.9%, P = .64) after TC-TAVR were comparable with TF-TAVR. Strokes were numerically more frequent after TC-TAVR compared with TF-TAVR (3.2% vs 0%, P = .23), but the difference did not reach statistical significance. TF-TAVR was associated with a significantly greater risk of permanent pacemaker implantation (29.0% vs 12.9%, P = .04) compared with TC-TAVR. Other complications were not frequent and were similarly distributed between the matched groups. Conclusions: TC access for TAVR was associated with satisfactory results compared to the femoral access. TC-TAVR could be considered a valid and safe alternative to TF-TAVR when femoral access is contraindicated.

Aortic Valve Replacement for Aortic Stenosis in Low-, Intermediate-, and High-Risk Patients: Preliminary Results From a Prospective Multicenter Registry.

OBJECTIVE: To evaluate current results of surgical aortic valve replacement (SAVR) ± coronary artery bypass grafting surgery. DESIGN: Independent, multicenter, prospective registry. SETTING: Tertiary university hospitals. PARTICIPANTS: The study comprised 1,192 consecutive patients, stratified as low-, intermediate-, and high-risk according to EuroSCORE II (<4, 4-9, >9, respectively). INTERVENTIONS: SAVR ± coronary artery bypass grafting surgery. MEASUREMENTS AND MAIN RESULTS: Thirty-day mortality and major morbidity, 2-year actuarial survival and freedom from stroke, and independent predictors of mortality in each risk category were assessed. These data were considered in light of published randomized controlled trials. Thirty-day mortality was 1.0%, 3.0% and 2.1% in the low-, intermediate-, and high-risk patients, with a 2-year actuarial survival of 98.6%, 93.8%, and 94.0%, respectively. Preoperative atrial fibrillation (odds ratio [OR] 8.3), minithoracotomy access (OR 5.8), postoperative dialysis (OR 3.4), type V acute myocardial infarction (OR 20.4), and moderate aortic regurgitation (OR 28.8) predicted 30-day mortality in the low-risk group. Preoperative dialysis (OR 18.3), critical state (OR 36.7), postoperative transfusions of plasma (OR 1.9 per unit transfused), and de-novo dialysis (OR 6.2) predicted 30-day mortality in the intermediate-risk group. Prior cardiac surgery (OR 18.1), postoperative extracorporeal membrane oxygenation (OR 9.8), and gastrointestinal complications (OR 17.2) predicted 30-day mortality in the high-risk group. Although baseline differences existed, low-risk patients demonstrated low 30-day mortality and 30-day to 12-month stroke in light of the PARTNER 3 and EVOLUT Low Risk trial results. Intermediate-risk patients demonstrated low 30-day to 2-year mortality, when the PARTNER 2 trial was considered, and low 30-day to 2-year stroke, when the PARTNER 2 and SURTAVI trials were considered. High-risk patients showed low 30-day to 2-year mortality in light of the results of the PARTNER 1 and CoreValve US trials. CONCLUSIONS: SAVR is still a safe and effective surgery for aortic stenosis regardless of risk category.

Transcarotid Approach for Transcatheter Aortic Valve Replacement With the Sapien 3 Prosthesis: A Multicenter French Registry.

OBJECTIVES: This study sought to describe the procedural and clinical outcomes of patients undergoing transcarotid (TC) transcatheter aortic valve replacement (TAVR) with the Edwards Sapien 3 device. BACKGROUND: The TC approach for TAVR holds the potential to become the optimal alternative to the transfemoral gold standard. Limited data exist regarding safety and efficacy of TC-TAVR using the Edwards Sapien 3 device. METHODS: The French Transcarotid TAVR prospective multicenter registry included patients between 2014 and 2018. Consecutive patients treated in 1 of the 13 participating centers ineligible for transfemoral TAVR were screened for TC-TAVR. Clinical and echocardiographic data were prospectively collected. Perioperative and 30-day outcomes were reported according to the updated Valve Academic Research Consortium (VARC-2). RESULTS: A total of 314 patients were included with a median (interquartile range) age of 83 (78 to 88) years, 63% were males, Society of Thoracic Surgeons mortality risk score 5.8% (4% to 8.3%). Most patients presented with peripheral artery disease (64%). TC-TAVR was performed under general anesthesia in 91% of cases, mostly using the left carotid artery (73.6%) with a procedural success of 97%. Three annulus ruptures were reported, all resulting in patient death. At 30 days, rates of major bleeding, new permanent pacemaker, and stroke or transient ischemic attack were 4.1%, 16%, and 1.6%, respectively. The 30-day mortality was 3.2%. CONCLUSIONS: TC-TAVR using the Edwards Sapien 3 device was safe and effective in this prospective multicenter registry. The TC approach might be considered, in selected patients, as the first-line alternative approach for TAVR whenever the transfemoral access is prohibited. Sapien 3 device was safe and effective in our multicenter cohort.

Rapid-deployment or transcatheter aortic valves in intermediate-risk patients?

Background Transcatheter aortic valve implantation and rapid-deployment aortic valve replacement represent two emerging therapies for patients with intermediate surgical risk and severe aortic stenosis. However, head-to-head comparisons between such novel therapies are lacking. Methods Severe aortic stenosis patients with intermediate surgical risk treated with rapid-deployment valve replacement at our institution were identified and compared with a propensity-matched population of patients who underwent transcatheter aortic valve replacement. Postoperative echocardiographic findings, in-hospital and midterm clinical outcomes were compared. Results We identified 60 patients who received transcatheter ( n = 30) or rapid-deployment ( n = 30) valve replacement. On postoperative echocardiography, freedom from paravalvular regurgitation was higher in the rapid-deployment valve group ( p < 0.001), while postoperative mean transprosthetic gradient was lower in the transcatheter valve group ( p = 0.03). Permanent pacemaker implantation was required more frequently in transcatheter valve patients ( p = 0.01). Postoperative atrial fibrillation was more common in the rapid-deployment valve group ( p = 0.03). Hospital mortality was similarly low in both groups ( p = 0.33). At midterm follow-up, mortality was comparable ( p = 0.42) but the rapid-deployment valve group still had a lower degree of paravalvular regurgitation. Conclusions Transcatheter and rapid-deployment valve replacement are promising treatment options for patients with intermediate surgical risk. These two techniques are associated with specific patterns of prosthesis function and postoperative complications. Further evaluation of the clinical impact of these therapies in this patient population is needed.

Mini-aortic surgery with percutaneous cannulation and rapid-deployment valve.

BACKGROUND: We aimed to evaluate the results of the combined use of rapid-deployment valves, percutaneous cardioplegia delivery and left heart venting during minimally invasive aortic valve replacement surgery. METHODS: We identified 2 propensity-matched cohorts of patients who underwent primary elective isolated minimally invasive aortic valve surgery at our center over a 3-years period: 30 patients in group A had a conventional valve prosthesis and 30 patients in group B received a rapid-deployment valve using percutaneous cardioplegia delivery and percutaneous left heart venting. Skin incision length, intraoperative times, postoperative hospital outcomes, and 30-day echocardiographic results were compared between the 2 groups. RESULTS: Patients in group B had significantly shorter operative times and shorter skin incisions compared to group A (total operative time 196.0 ± 40.6 vs. 225.1 ± 30.8 min, respectively, p < 0.003; cardiopulmonary bypass time 79.9 ± 10.6 vs. 92.9 ± 17.2 min respectively, p < 0.001; crossclamp time 52.3 ± 9.6 vs. 74.9 ± 10.2 min, respectively, p < 0.001; incision length 3.6 ± 0.5 vs. 6.0 ± 0.6 cm, respectively, p < 0.001). Postoperative hospital outcomes and echocardiographic evaluation showed no significant differences. CONCLUSIONS: The combined use of rapid-deployment valves, percutaneous cardioplegia, and left heart venting is safe and effective and allows a significant reduction of the skin incision together with a significant reduction of intraoperative times without affecting hospital outcomes or hemodynamic performance of the prosthetic valves.

Acute aortic pathology, Munchausen syndrome, and confirmation bias.

BACKGROUND: Munchausen syndrome is a psychiatric disease characterized by pathological lying and malingering. Patients who are affected can set up such complex and compelling clinical scenarios that they can lead to a bias in the diagnostic process and even to unnecessary surgery. CASE REPORTS: Two cases of Munchausen syndrome misrepresenting acute aortic dissection are reported. The two cases occurred at two different institutions where there was considerable expertise in the management of aortic pathology. In both patients, a wrong diagnosis of acute aortic syndrome was made, leading to unnecessary surgery. CONCLUSIONS: Retrospective analysis of the clinical events and the diagnostic process suggests that a confirmation bias played a major role in determining the misdiagnosis. The same mistake is likely to have occurred in the only other case reported in the literature.