Surgical repair and replacement for native mitral valve infective endocarditis.

AIMS: The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established. METHODS: Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups. RESULTS: Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ±â€Š15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94). CONCLUSIONS: Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Elective Thoracic Aortic Aneurysm Surgery: A Tertiary Center Experience.

Background A thoracic aortic aneurysm (TAA) is a diseased expansion of the thoracic aorta. There is morbidity associated with a dilated aorta, as well as significant mortality. Open thoracic surgery is the fundamental management for proximal lesions, offering definitive treatment with excellent results. This study aimed to summarize preoperative data and operative outcomes of patients who underwent TAA repair at our institution. Methods Data were retrospectively collected from 234 patients that underwent elective open thoracic surgery at University Hospital Southampton for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures, were gathered. Results There were 166 males and 68 females, with an overall mean age of 66 years. The breakdown of operations comprised 105 aortic roots, 171 ascending aorta, 20 aortic arch, and 12 descending aorta cases. The mean follow-up was 370 days. 30-day mortality was 5.13%. Mortality was associated with female gender, aortic root surgery, and prosthetic valves. Mean aortic diameters at the time of surgery for the non-genetic aortopathy and genetic aortopathy groups were respectively 4.93cm and 4.63cm in the aortic root, 5.56cm and 4.88cm in the ascending aorta, 5.08cm and 3.87cm in the aortic arch, and 6.63cm and 5.50cm in the descending aorta. Conclusion Several factors are associated with complications and morbidity, which should be considered when discussing the risks of intervention with patients. There were no neuroprotective strategies that altered post-operative neurological function. Current practice in our unit fits in with current international guidance.

Reconsidered surgical aortic valve replacement after declined transcatheter valve implantation.

BACKGROUND: Outcomes for high surgical risk patients who declined transcatheter aortic valve implantation (TAVI) and then reconsidered for conventional aortic valve replacement (rSAVR) for severe calcific aortic stenosis are not well known. METHODS: This single-centre, case-control study (rSAVR vs Conservative group) retrospectively analysed patients for rSAVR (2009-2019). Multivariable logistic regression was used to identify independent predictors of composite of neurological sequelae/renal failure/deep sternal wound infection/re-exploration and death. Survival was compared using Kaplan-Meier curves and log-rank test. A Cox proportional hazards model was used to determine predictors of survival. RESULTS: TAVI was denied in 519/1095 patients, 114(10.4%) had rSAVR (cases) and 405 (37%) were managed conservatively (controls). Mean age for rSAVR was 80 years (IQR: 73.5-85 years). The commonest reason for declining TAVI was prohibitive high risk due to multiple comorbidities. Among rSAVR, hospital mortality was 2.2% and stroke was 4.4%. Median follow-up was conservative; 14.4 months versus rSAVR; 34.8 months. Five-year survival was conservative; 12.6% versus rSAVR; and 59.5% (overall conservative; 38.0% vs. rSAVR; 60.5%, p < 0.001). rSAVR was protective (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.26, 0.51, p < 0.001) and high comorbidities had high hazard (HR: 1.57, 95% CI: 1.19, 2.07, p = 0.001). rSAVR had fewer hospital readmission episodes (Conservative; 13.6/patient-year vs. rSAVR; 6.9/patient-year, p = 0.002). CONCLUSIONS: rSAVR may be considered in high surgical risk elderly patients who have been declined TAVI in centres with low operative mortality. rSAVR may be superior to conservative management in carefully selected patients.

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial.

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. Design, Setting, and Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). Conclusions and Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. Trial Registration: isrctn.com Identifier: ISRCTN57819173.

Early- and mid-term outcomes of reinterventions for aortic bioprosthesis failure.

BACKGROUND: The aim of this study was to evaluate early- and mid-term results of our actual practice embedding redo aortic valve replacement and transcatheter procedures for aortic bioprosthetic failure. METHODS: Data for aortic valve reinterventions (redo surgical aortic valve replacement, isolated redo aortic valve replacement, and valve-in-valve transcatheter aortic valve implantation, transcatheter valve-in-valve procedure) were collected (2010-2019). Logistic regression analysis was performed to identify predictors favouring the choice of transcatheter against redo surgery. Cox analysis was used to study the association of preoperative variables with survival. Survival probabilities were calculated with Kaplan-Meier analysis and compared using a log-rank test. RESULTS: A total of 125 patients were included (redo surgical aortic valve replacement: 84 patients, valve-in-valve transcatheter aortic valve implantation: 41 patients). Median age was 74 [63-80] years, 58% of the patients were male and the median logistic EuroSCORE was 15 [8-26] %. There was no early mortality. Eighteen patients (redo surgical aortic valve replacement: 15, valve-in-valve transcatheter aortic valve implantation: 3) sustained at least one postoperative complication. At pre-discharge transthoracic echocardiogram, valve-in-valve transcatheter aortic valve implantation had significantly higher trans-prosthetic gradients (mean gradient: valve-in-valve transcatheter aortic valve implantation 18 mmHg vs. redo surgical aortic valve replacement 14 mmHg, p < 0.001). Overall survival probabilities were 94% and 73% at 1 year and 5 years, respectively. Previous coronary artery bypass surgery operation and age were independently associated with lower survival probabilities during the follow-up. CONCLUSIONS: Redo surgical aortic valve replacement and valve-in-valve transcatheter aortic valve implantation are both safe and effective for aortic bioprosthetic failure. Further valve-in-valve data are needed to determine the haemodynamic performance of transcatheter prostheses and its impact on long-term outcomes.

Re-sternotomy for aortic valve replacement in octogenarian patients in age of evolving transcatheter therapies.

BACKGROUND: The aim of this study was to analyze perioperative results and long-term survival of re-sternotomy for surgical aortic valve replacement (SAVR) in octogenarians in age of transcatheter therapies. METHODS: This is a retrospective, single-center study (April 2000 to December 2019). Perioperative data were compared for re-sternotomy with isolated SAVR (Isolated redoSAVR) and re-sternotomy with SAVR and concomitant cardiac procedure (Associated redoSAVR). Regression analyses were performed to identify predictors of in-patient mortality. Hazard ratios and Kaplan-Meier survival curves were compared for groups. RESULTS: There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). Emergency/salvage cases were excluded. The median age was 83 (81-85) years and the median logEuroSCORE was 19.2 (13.0-26.7)%. The follow-up was 4.2 ± 3.5 years. Inpatient mortality was 4.9% (1.4% vs. 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p = .08). TIA/stroke rate was 8% (9% vs. 7% for Isolated redoSAVR and Associated redoSAVR, respectively, p = .78). COPD was a predictor of inpatient mortality (odds ratio: 8.86; 95% confidence interval: 1.19-66.11, p = .03). Survival was 88.7%, 86.4%, 70.1%, 49.5%, and 26.3% at 1, 2, 5, 7, and 10 years. There was no survival difference between Isolated redoSAVR and Associated redoSAVR (log rank p = .36, Wilcoxon p = .84). Significant adverse predictors of long-term survival were COPD, postoperative TIA/stroke, and length of stay. Survival was lower than age and gender-matched first-time SAVR and general population of the United Kingdom. CONCLUSION: RedoSAVR in octogenarians is associated with significant morbidity and mortality. Shared decision-making should consider emerging transcatheter therapies as a valuable option in selected patients.

Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts.

OBJECTIVE: The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts. METHODS: Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival. RESULTS: Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population. CONCLUSIONS: Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Coronary artery bypass surgery in the UK, trends in activity and outcomes from a 15-year complete national series.

OBJECTIVES: The aim of this study was to review the UK national trends in activity and outcome in coronary artery bypass graft (CABG) over a 15-year period (2002-2016). METHODS: Validated data collected (2002-2016) and uploaded to National Institute for Cardiovascular Outcomes Research were used to generate summary data from the National Adult Cardiac Surgery Audit Database for the analysis. Logistic European System of Cardiac Operative Risk Evaluation was used for risk stratification with recalibration applied for governance. Data were analysed by financial year and presented as numerical, categorical, %, mean and standard deviation where appropriate. Mortality was recorded as death in hospital at any time after index CABG operation. RESULTS: A total of 347 626 CABG procedures (282 883 isolated CABG, 61 109 CABG and valve and 4132 redo CABG) were recorded. Over this period annual activity reduced from 66.6% of workload to 41.7%. The mean age for isolated CABG was 65.7 years. The mean log European System of Cardiac Operative Risk Evaluation was 3.1, 5.9 and 23.2 for elective, urgent and emergency isolated CABG, respectively. There was a decline in the observed mortality for all procedures. Overall mortality for isolated CABG surgery is now 1.0% and only 0.6% for elective operations. CONCLUSIONS: Quality of care and risk-adjusted mortality rates have consistently improved over the last 15 years despite the increasing risk profile of patients. There have been a consistent decline in overall case volumes and a three-fold increase in elderly cases.

Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.

Transcatheter aortic valve implantation is still inappropriate in low-risk, young patients: a UK perspective.

The PARTNER 3 and Evolut LRT trials have provided the evidence base for transcatheter aortic valve implantation in low-risk patients. However, there are still issues with durability, long-term follow up and complications before their widespread use can be considered appropriate in this group.

Survival benefit from a second arterial conduit to the circumflex circulation persists in elderly after coronary artery bypass surgery.

BACKGROUND: This retrospective propensity matched study investigated the impact of age on the survival benefit from a second arterial conduit to the left-sided circulation. METHODS: Data for isolated coronary artery bypass surgery were collected from October 2004 to March 2014. All patients with an internal mammary artery graft to left anterior descending artery and additional arterial or venous graft to the circumflex circulation were included. Propensity matching was used to balance co-variates and generate odds of death for each observation. Odds ratios (venous vs. arterial) were charted against age. RESULTS: The in-hospital mortality rate was 1.12% (arterial) vs. 1.24% (venous) (p = 0.77). The overall 10-year survival was 74.6% (venous) vs. 82.6% (arterial) (p = 0.001). A total of 1226 patients were successfully matched to the venous or arterial (second conduit to circumflex territory after left internal mammary artery to left anterior descending artery) cohorts. Odds ratio for death (venous to arterial) showed a linear decremental overall survival benefit for the second arterial graft to circumflex circulation with increasing age. CONCLUSIONS: The survival benefit of a second arterial graft persists through all age groups with a gradual decline with increasing age over the decades. Elderly patients should not be denied a second arterial graft to the circumflex circulation based on age criterion alone.

Impact of valve size, predicted effective and indexed effective orifice area after aortic valve replacement.

INTRODUCTION: The impact of manufacturer labeled prosthesis size and predicted effective orifice area (EOA) on long-term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival. METHODS: Data was retrospectively collected from Jan 2000-Dec 2019 for prosthesis type, model, and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labeled valve size, EOA and predicted patient prosthesis mismatch (PPM). RESULTS: A total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6%, respectively. Cumulative lifetime hazard was worse for biological valves (mortality: biological 77.7% vs. mechanical 64.8%, p = .001). Moderate prosthetic aortic stenosis (AS), (EOA = 1-1.5 cm2 ) was 12.1% and severe prosthetic AS (EOA ≤ 1 cm2 ) was 0.8%, respectively. Survival was 10.5 ± 0.4 years with moderate to severe prosthetic AS (EOA≤1.5 cm2 ) versus 12.6 ± 0.2 years with mild to no prosthetic AS (EOA>1.5 cm2 ), p = .001. Worse survival in the presence of moderate-severe prosthetic AS was seen with biological valves (9.7 ± 0.4 years vs. 11.2 ± 0.2 years, p = .001 for EOA≤1.5, >1.5 cm2 , respectively). Moderate to severe PPM was associated with worse survival (11.1 ± 0.4 years for iEOA ≤ 0.85 cm2 /m2 vs. 12.5 ± 0.2 years with iEOA > 0.85 cm2 /m2 , p = .001). Moderate to severe PPM predicted worse long term survival (hazard ratio: 3.56; 95% confidence interval: 1.37-9.25; p = .009). CONCLUSION: Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival.

Premature Structural Failure of Trifecta Bioprosthesis in Midterm Follow-up: A Single-Center Study.

BACKGROUND: A cluster of aortic bioprosthetic valve failures, most of which were Trifecta bioprostheses, was observed in Southampton General Hospital, Southampton, United Kingdom. This study was performed to assess whether the cluster represents a significant failure of this valve model or whether there is a selection bias that can explain the failure of these valves. METHODS: This retrospective study evaluated all bioprosthetic aortic valve replacement operations performed between 2011 and 2016 inclusive in our center. The study compared the performance of the Trifecta valve (Abbott, Abbott Park, IL) with that of Perimount (Edwards Lifesciences, Irvine, CA), Perimount Magna Ease, and Mitroflow (LivaNova, London, United Kingdom) bioprostheses. In addition, the study analyzed patient-related and valve-related risk factors for early failure in the failed valves. RESULTS: A total of 2807 bioprosthetic aortic valve replacements were performed. Of these, 836 were Trifecta valves, 1031 were Perimount, 449 were Perimount Magna Ease, and 351 were Mitroflow valves. A total of 24 Trifecta valves had premature structural failure, a number significantly higher than seen with Perimount or Perimount Magna Ease (no failure, P < .001 and P < .005, respectively) valves and the Mitroflow valve (1 failure, P < .05). There was no difference in the incidence of endocarditis or death. At the time of valve failure, 17 (71%) of the failed Trifecta valves had moderate or severe regurgitation, and the average peak gradient was 61 ± 29 mm Hg. The median failed prosthetic size was 23 mm. One failed valve had severe patient-prosthesis mismatch. The mean time to failure was 4.5 ± 1.7 years. CONCLUSIONS: The Trifecta bioprosthesis has an increased incidence of early structural valve failure, which is significantly higher than that of Perimount, Perimount Magna Ease, or Mitroflow. No patient-related or valve-related cause for the failure could be identified.

Surgical vs transfemoral aortic valve replacement in low-risk patients: An updated meta-analysis of trial and registry data.

BACKGROUND: Transfemoral aortic valve replacement (TAVR) has been studied extensively in patients with improving safety and efficacy in high to intermediate-risk patients with aortic stenosis. TAVR has been now approved for patients with low surgical risk. OBJECTIVE: The purpose of this study is to integrate the evidence from randomized controlled trials (RCT) and large registry data comparing TAVR to surgical aortic valve repair (SAVR). METHODS: Seven studies (three RCTs, one post hoc study of a RCT, and three registries) were included. Incidence rate ratios (IRR) of outcomes of interest (overall mortality, 30-day mortality, cardiovascular death, stroke, pacemaker implantation [PPMI], myocardial infarction, moderate-severe paravalvular leak [PVL], and re-intervention) were compared using a random-effects model. RESULTS: The pooled analysis included 24 819 patients (TAVR, 8227 and SAVR, 16 592). 2,952 (11.9%) patients were from RCTs and 21 867 (88.1%) were registry patients. Thirty-day mortality was lower in TAVR (logIRR, -0.43; 95% CI. -0.61 to -0.25; P < .001), whereas the rate of moderate-severe PVL (logIRR, 1.44; 95% CI, 0.58-2.3; P < .001) and PPMI (logIRR, 1.13; 95% CI, 1.02-1.24; P < .001) were higher. There were no significant differences in the rates of overall mortality, reintervention, cardiovascular death, myocardial infarction, or stroke between SAVR and TAVR. CONCLUSIONS: Early mortality is higher in SAVR while rates of PVL and PPMI are substantially higher in TAVR. There is no significant advantage with TAVR for overall survival, cardiovascular death, stroke, MI, and re-intervention rates.

Is Resident Training Safe in Cardiac Surgery?

BACKGROUND: There exists a knowledge gap regarding the safety of training in cardiac surgery. The purpose of this analysis was to establish the safety of resident training in cardiac surgery and compare the results of the trainee cases to those performed by consultants. METHODS: In all, 5894 (trainee, 3343; consultant, 2551) major cardiac operations (European System for Cardiac Operative Risk Evaluation less than 10) from 2013 to 2018 were reviewed. Multivariate analysis was performed for inhospital mortality and composite outcome of length of stay longer than 30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, inhospital death, or reoperation. Observations were propensity matched to consultant or trainee with the 16 covariates. RESULTS: Trainees performed 56.7% of cases. Multivariate analysis identified renal disease (odds ratio [OR] 2.93; 95% confidence interval [CI], 1.3 to 6.7; P < .02), peripheral vascular disease (OR 4.62; 95% CI, 1.82 to 11.71; P < .01), and emergency/salvage procedure (OR 7.23; 95% CI, 2.00 to 26.11; P < .01) as predictors of inhospital mortality. Emergency/salvage procedure was the only predictor of worse composite outcomes (OR 2.65; 95% CI, 1.54 to 4.55; P < .001). Trainee cases had similar inhospital mortality and composite outcomes. After propensity matching (1842 observations), bypass time and cross-clamp time were significantly longer for trainees for isolated coronary artery bypass graft surgery and aortic valve replacement. There was no difference between deep sternal infection, new hemodialysis, new stroke/transient ischemic attack, inhospital death, or reoperation. Overall composite outcome differed between groups (trainee 9% vs consultant 16.6%, P = .001) owing to difference in the length of stay longer than 30 days (trainee 4.2% vs consultant 9.9%, P = .001). CONCLUSIONS: Resident training is safe in cardiac surgery without compromising the quality of patient care.

Defective NOTCH signalling drives smooth muscle cell death and differentiation in bicuspid aortic valve aortopathy.

OBJECTIVES: Bicuspid aortic valve disease is common and is associated with ascending aortic aneurysms. Vascular smooth muscle cell (VSMC) apoptosis is characteristic of the ascending aorta of bicuspid patients, and NOTCH1 gene mutations have also been linked to the disease. NOTCH signalling is a fundamental cell signalling pathway, which dictates cell fate decisions including apoptosis. Our objective was to elucidate the role of NOTCH signalling in VSMC apoptosis and differentiation in bicuspid aortopathy. METHODS: Ascending aortic biopsies were obtained from 19 bicuspid and 12 tricuspid aortic valve patients and were sub-classified into 4 groups according to the maximum ascending aortic diameter (aneurysmal ≥45 mm). Apoptotic VSMCs were counted by light microscopy using a TUNEL assay. Gene expression of key regulators of NOTCH signalling (NOTCH1 and HES1), apoptosis (BAX and BCL-2) and VSMC differentiation (MYH11, CNN1 and MYH10) were quantified using quantitative real-time PCR. Primary VSMCs were cultured from 2 tricuspid aortic valve and 2 bicuspid aortic valve patients, NOTCH signalling was inhibited with N-[N-(3,5-Difluorophenacetyl)-l-alanyl]-S-phenylglycine t-butyl ester, and the gene expression was again quantified. RESULTS: The apoptotic cell count was significantly higher in bicuspid aortic valve patients (3.2 cells/50 000 µm2 vs 1.1 cells/50 000 µm2; P = 0.033). There was a trend towards lower apoptotic cell count in the aneurysmal versus non-aneurysmal tricuspid and bicuspid groups and an increased ratio of proapoptotic gene expression, which was not statistically significant. This was associated with a 2.8-fold increase in contractile gene expression (P = 0.026) and a 2.0-fold increase in NOTCH signalling gene expression in bicuspid versus tricuspid aortic valve patients (P = 0.022). NOTCH inhibition in cultured VSMCs induced a similar pattern of increased proapoptotic and procontractile gene expressions. CONCLUSIONS: This preliminary study suggests that NOTCH activation in the non-aneurysmal bicuspid aortas may underlie aortopathy by influencing VSMC apoptosis and differentiation. NOTCH signalling manipulation may provide a therapeutic target for preventing aneurysms in bicuspid patients. Further studies with larger sample sizes are needed to substantiate the present findings.