Minimally Invasive Versus Conventional Aortic Valve Replacement: A Propensity-Matched Study From the UK National Data.

OBJECTIVE: Minimally invasive aortic valve replacement (MIAVR) has been demonstrated as a safe and effective option but remains underused. We aimed to evaluate outcomes of isolated MIAVR compared with conventional aortic valve replacement (CAVR). METHODS: Data from The National Institute for Cardiovascular Outcomes Research (NICOR) were analyzed at seven volunteer centers (2006-2012). Primary outcomes were in-hospital mortality and midterm survival. Secondary outcomes were postoperative length of stay as well as cumulative bypass and cross-clamp times. Propensity modeling with matched cohort analysis was used. RESULTS: Of 307 consecutive MIAVR patients, 151 (49%) were performed during the last 2 years of study with a continued increase in numbers. The 307 MIAVR patients were matched on a 1:1 ratio. In the matched CAVR group, there was no statistically significant difference in in-hospital mortality [MIAVR, 4/307,(1.3%); 95% confidence interval (CI), 0.4%-3.4% vs CAVR, 6/307 (2.0%); 95% CI, 0.8%-4.3%; P = 0.752]. One-year survival rates in the MIAVR and CAVR groups were 94.4% and 94.6%, respectively. There was no statistically significant difference in midterm survival (P = 0.677; hazard ratio, 0.90; 95% CI, 0.56-1.46). Median postoperative length of stay was lower in the MIAVR patients by 1 day (P = 0.009). The mean cumulative bypass time (94.8 vs 91.3 minutes; P = 0.333) and cross-clamp time (74.6 vs 68.4 minutes; P = 0.006) were longer in the MIAVR group; however, this was significant only in the cross-clamp time comparison. CONCLUSIONS: Minimally invasive aortic valve replacement is a safe alternative to CAVR with respect to operative and 1-year mortality and is associated with a shorter postoperative stay. Further studies are required in high-risk (logistic EuroSCORE > 10) patients to define the role of MIAVR.

Transaortic transcatheter aortic valve implantation for failed surgical aortic valve replacement due to 'porcelain aorta'.

Transcatheter aortic valve implantation (TAVI) is an emerging surgical approach in patients with severe aortic stenosis unsuitable for conventional aortic valve replacement (AVR). TAVI has been performed through both transfemoral and transapical approaches, each with a specific suitability criterion. A transaortic (TAo-TAVI) approach has been recently established at the authors' institution for high-risk patients who are unsuited to the above techniques. Herein, the case is described of a successful aortic valve implantation using TAo-TAVI in a patient with porcelain ascending aorta that was identified as an incidental finding during conventional AVR. The patient recovered well and was discharged home without any complications.

Aspergillus endocarditis: a case of near complete left ventricular outflow obstruction.

A 60-year old woman presented with dyspnoea and fatigue. She was frail and cachectic (BMI 17.5) with a pancytopenia. Previously she had received chemotherapy for chronic lymphatic leukaemia. She relapsed one year ago necessitating a reduced intensity conditioning allogeneic haematopoietic cell transplantation. Subsequently, graft versus host disease required high-dose immunosuppressants. Computerized tomography on admission showed bilateral lung nodules and a suspicious cardiac mass. Bronchial biopsies demonstrated abundant hypae consistent with Aspergillus fumigatus infection. Echocardiography demonstrated a large fungus ball attached to the right coronary cusp of the aortic valve with near complete obliteration of the left ventricular outflow tract. Due to the high risk of embolization this was resected under cardiopulmonary bypass. The mass was attached subvalvularly to the ventricular septal free wall and eroding through it. It peeled off leaving intact aortic leaflets. Unresectable fungal deposits were discovered on the interventricular septum, the left ventricle free wall and posterior aortic wall. High-dose systemic antifungal therapy (Voriconazole and Amphoteracin B) was given for 4 months. After discharge she remained well till a 4-month follow-up, after which she eventually succumbed to her disease. We discuss the clinical difficulties in managing patients with fungal infective endocarditis and present a brief review of cardiac aspergillosis management.

Bovine pericardial versus porcine stented replacement aortic valves: early results of a randomized comparison of the Perimount and the Mosaic valves.

OBJECTIVE: A stented bovine pericardial valve might be less obstructive than a stented porcine valve. This study compared early hemodynamic function in a prospective series of 99 patients randomized to receive either a Mosaic or Perimount replacement aortic valve. METHODS: Echocardiography was performed early after surgery and at 1 year after surgery. Patients also filled in psychologic questionnaires and underwent a 6-minute walk. RESULTS: The groups were matched demographically. The Perimount valve was significantly less obstructive in terms of mean pressure difference (11 +/- 5 vs 17 +/- 7 mm Hg; P < .0001), with a trend in favor of a larger effective orifice area (1.47 +/- 0.45 vs 1.28 +/- 0.46 cm(2); P = .05) postoperatively. There were no differences in left ventricular mass regression, aortic regurgitation, 6-minute walk, psychologic questionnaires, or mortality and clinical events. CONCLUSION: The stented bovine pericardial valve was less obstructive than the stented porcine valve. Both valves were associated with similar and significant improvements in quality of life, exercise ability, and regression of left ventricular mass.

Cost-effectiveness of preoperative positron emission tomography in ischemic heart disease.

BACKGROUND: Revascularization of patients with ischemic heart disease and poor left ventricular function for surgical procedures is expensive and carries considerable risks, but may improve survival for patients with hibernating myocardium. Positron emission tomography can detect hibernating myocardium, and may be cost-effective if used to select patients for operation. METHODS: An economic model was developed to compare the cost-effectiveness of three management strategies: (1) coronary artery bypass grafting for all patients; (2) using positron emission tomography to select candidates for coronary artery bypass grafting, those without hibernation remaining on medical therapy; and (3) medical therapy for all patients. The model used data from our hospital and the published literature. A sensitivity analysis was also undertaken. RESULTS: Positron emission tomography was cost-effective in selecting patients for operation. In a hypothetical population of 1,000 patients, using positron emission tomography saved marginally more life-years and cost approximately Pound Sterling 3 million less. Using positron emission tomography before coronary artery bypass grafting instead of all patients receiving medical treatment saved lives but was more expensive. The incremental cost per life-year saved was Pound Sterling 77,000. The sensitivity analysis showed that the prevalence of hibernation and the survival rate of patients refused revascularization on the basis of the positron emission tomography scan were the areas most likely to influence cost-effectiveness. CONCLUSIONS: Positron emission tomography may be cost-effective to select patients with poor left ventricular function for coronary artery bypass grafting.