Aortic valve replacement with rapid-deployment bioprosthesis in case of infective endocarditis: a literature review.

Purpose: Recently, the use of rapid deployment (RD) aortic valve prostheses has been introduced for the treatment of aortic valve replacement (AVR), showing excellent hemodynamic performances.According to these data, some groups have proposed new RD valves as an alternative solution in the case of infective aortic endocarditis (IAE) to reduce the use of foreign materials, and the manipulation of the annulus.The aim of this review is to report the results of early clinical experiences with the use of RD bioprostheses in the case of IAE, in order to discuss technical and clinical aspects of this emerging strategy to better elucidate its advantages and limitations as a potential therapeutic solution. Methods: An in-depth search of PubMed from January to March 2023 was performed. English-language articles were selected independently by authors following the criteria in order to consider all available experiences (full papers, case reports, and case series) that have investigated the use of RD in case of IAE. Results: The use of rapid deployment bioprosthesis represents a bailout strategy in case of severe aortic valve endocarditis and should be evaluated with caution in selected cases. This review collects the first, initial, and pioneering experiences of the use of the RD prosthesis in case of infective endocarditis, particularly when the fragility of the annular tissues precludes a secure anchoring of sutured prostheses.The reduced use of foreign materials by minimizing the number of stitches, the reduced cardiopulmonary bypass (CPB) and aortic cross-clamp times, and the excellent hemodynamic performances associated with the use of RD bioprosthesis represent the most important advantages that could justify their use in the setting of aortic valve endocarditis. Conclusion: Although there are few anecdotal experiences, surgical aortic valve replacement with the use of RD represents an emerging strategy in case of aortic valve endocarditis. Its advantages, pros, and cons are under debate, and robust clinical trials are needed to demonstrate its safety and efficacy.

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.

Paraplegia after coronary artery bypass surgery: An uncommon complication in a patient with history of thoracic endovascular aortic repair.

Neurologic lesions are unusual complications after coronary artery bypass surgery. Among them, paraplegia is one of the rarest, with only a few cases reported in the literature. We report a case of paraplegia after coronary artery bypass following previous thoracic endovascular aortic repair.

Cost-effectiveness of left ventricular assist devices for patients with end-stage heart failure: analysis of the French hospital discharge database.

AIMS: Although left ventricular assist devices (LVADs) are currently approved for coverage and reimbursement in France, no French cost-effectiveness (CE) data are available to support this decision. This study aimed at estimating the CE of LVAD compared with medical management in the French health system. METHODS AND RESULTS: Individual patient data from the 'French hospital discharge database' (Medicalization of information systems program) were analysed using Kaplan-Meier method. Outcomes were time to death, time to heart transplantation (HTx), and time to death after HTx. A micro-costing method was used to calculate the monthly costs extracted from the Program for the Medicalization of Information Systems. A multistate Markov monthly cycle model was developed to assess CE. The analysis over a lifetime horizon was performed from the perspective of the French healthcare payer; discount rates were 4%. Probabilistic and deterministic sensitivity analyses were performed. Outcomes were quality-adjusted life years (QALYs) and incremental CE ratio (ICER). Mean QALY for an LVAD patient was 1.5 at a lifetime cost of €190 739, delivering a probabilistic ICER of €125 580/QALY [95% confidence interval: 105 587 to 150 314]. The sensitivity analysis showed that the ICER was mainly sensitive to two factors: (i) the high acquisition cost of the device and (ii) the device performance in terms of patient survival. CONCLUSIONS: Our economic evaluation showed that the use of LVAD in patients with end-stage heart failure yields greater benefit in terms of survival than medical management at an extra lifetime cost exceeding the €100 000/QALY. Technological advances and device costs reduction shall hence lead to an improvement in overall CE.

Ascending Aorta Stenting After Off-Pump Aortic Wrapping in Stanford A Retrograde Aortic Dissection.

We report 4 cases of off-pump ascending aorta wrapping combined with ascending aorta stenting in retrograde Stanford A acute aortic dissection (SAAD). Since 2008, 18 patients have undergone wrapping of the ascending aorta at our institution. Four patients had a persistent circulating false lumen in the ascending aorta after wrapping, with a threat to the aortic root. We chose an endovascular approach with ascending aorta stenting. Follow-up computed tomography showed a reapplication of the intimal flap in the reinforced aorta. Ascending aorta stenting after aortic wrapping for retrograde SAAD is a safe and efficient technique to prevent proximal progression of the dissection.

Transcarotid Transcatheter Aortic Valve Replacement: General or Local Anesthesia.

OBJECTIVES: The study sought to assess the safety and efficacy of a minimally invasive strategy (MIS) (local anesthesia and conscious sedation) compared to general anesthesia (GA) among the largest published cohort of patients undergoing transcarotid transcatheter aortic valve replacement (TAVR). BACKGROUND: Transcarotid TAVR has been shown to be feasible and safe. There is, however, no information pertaining to the mode anesthesia in these procedures. METHODS: Between 2009 and 2014, 174 patients underwent transcarotid TAVR at 2 French centers. All patients were unsuitable for transfemoral TAVR due to severe peripheral vascular disease. An MIS was undertaken in 29.8% (n = 52) and GA in 70.1% (n = 122). One-year clinical outcomes were available in all patients and were described according to the Valve Academic Research Consortium-2 consensus. RESULTS: Transcarotid vascular access and transcatheter valve deployment was successful in all cases. Thirty-day mortality was 7.4% (n = 13) and 1-year all-cause and cardiovascular mortality were 12.6% (n = 22) and 8.0% (n = 14), respectively. According to the type of anesthesia, there was no between group difference in 30-day mortality (GA 7.3% vs. MIS 7.6%; p = 0.94), 1-year mortality (GA 13.9% vs. MIS 9.6%; p = 0.43), 1-month clinical efficacy (GA 85.2% vs. MIS 94.2%; p = 0.09), and early safety (GA 77.8% vs. MIS 86.5%; p = 0.18). There were 10 (5.7%) periprocedural cerebrovascular events: 4 strokes (2.2%) and 6 transient ischemic attacks (3.4%) among those treated with GA. There was neither stroke nor transient ischemic attack in the MIS group (p < 0.001). CONCLUSIONS: The transcarotid approach for TAVR is feasible using general or local anesthesia. A higher rate of perioperative strokes was observed with GA.

Antiplatelet Therapy in TAVI: Current Clinical Practice and Recommendations.

Transcatheter aortic valve implantation (TAVI) is all the more used therapeutic option for patients suffering from symptomatic severe aortic valvular stenosis declined by surgeons because of high surgical risk. Given the high bleeding and ischemic risk of this vulnerable population, their antithrombotic treatment becomes a crucial issue. There is no consensus on antithrombotic treatment after TAVI and dual antiplatelet therapy (DAPT) with aspirin (indefinitely) and clopidogrel (1-6 months) is, in general, recommended. With regards to patients with an indication for oral anticoagulation (OAC), a combination of OAC plus aspirin or clopidogrel is commonly suggested. This review underscores that it is extremely difficult to compare different antithrombotic regimens in patients undergoing TAVI because of their variable demographic characteristics. Nevertheless, available data suggest that DAPT results to more bleeding events. Still, whether it positively affects ischemic episodes is doubtful. Ongoing trials are expected to draw a clearer picture on the field.

Long-term results of Freestyle stentless bioprosthesis in the aortic position: a single-center prospective cohort of 500 patients.

OBJECTIVE: Stentless xenograft bioprostheses may be the future valve of choice for aortic valve replacement. The study aim was to investigate the long-term clinical outcome after aortic valve replacement with the Medtronic Freestyle bioprosthesis (Medtronic Inc, Minneapolis, Minn). METHODS: Between April 1997 and November 2004, a total of 500 patients (mean age, 74.5±9.6 years; 52% were male) underwent aortic valve replacement with a Freestyle bioprosthesis, without population selection. The surgical procedure used a modified subcoronary technique in 479 patients and a complete root replacement in 21 patients, conducted with mini-extracorporeal circulation. Concomitant procedures included coronary artery bypass grafting in 122 patients (24%) and mitral valve repair/replacement in 11 patients. RESULTS: The mean cardiopulmonary bypass time was 98±26 minutes, and total aortic crossclamp time was 77±19 minutes. Operative mortality was 5.2%. The median follow-up time was 104.8±5.7 months. During this period, there were 224 deaths (n=122 cardiovascular and n=102 noncardiovascular deaths). The actuarial survivals from cardiovascular and valve-related mortality were 67%±3% and 70%±4%, respectively, at 10 years. Freedom from structural valve deterioration at 10 years was 94%±2%. The linearized structural valve deterioration incidence was 0.6% per patient/year. Multivariate Cox regression analysis revealed that older age, impaired renal function, and coronary artery disease were independent predictors of cardiovascular death. In the subgroup of patients aged less than 65 years at implantation (n=45), the actuarial cardiovascular survival was 83%±8% and freedom from structural valve deterioration was 89%±6% at 10 years. CONCLUSIONS: The use of the Freestyle bioprosthesis for aortic valve replacement resulted in good long-term cardiovascular survival and freedom from structural valve deterioration in this cohort regardless of age at implantation.

Aortic wrapping for stanford type A acute aortic dissection: short and midterm outcome.

BACKGROUND: Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. METHODS: We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). RESULTS: Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. CONCLUSIONS: The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.

Transcatheter aortic valve implantation through carotid artery access under local anaesthesia.

OBJECTIVES: Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety. METHODS: From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patient's neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days. RESULTS: Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT and 14 Medtronic CoreValve). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days. CONCLUSIONS: TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.

Early and mid-term cardiovascular outcomes following TAVI: impact of pre-procedural transvalvular gradient.

OBJECTIVE: To assess the relation of aortic transvalvular gradient with outcomes following transcatheter aortic valve implantation (TAVI). BACKGROUND: Relatively little is known about the predictors of adverse outcomes in patients with severe aortic stenosis following TAVI. METHODS: We studied 126 consecutive patients (mean age 83.2 ± 6.3 years; 59% women) who underwent TAVI (23% transapical; 77% transfemoral) at our institution. All patients were followed for the incidence of major adverse cardiovascular events (MACE), including myocardial infarction, heart failure, stroke, and cardiovascular death. RESULTS: The acute procedural success rate was 98%; at 1 year, the cumulative incidence of MACE and cardiovascular death was 29% and 10%, respectively. In multivariable analyses adjusting for clinical and echocardiographic risk factors, presence of a baseline mean transvalvular gradient (MTG) <40 mmHg was a significant predictor of 30-day MACE in the total sample (OR 4.4, 95% CI 1.7-11.4; P=0.003) as well as in patients with an ejection fraction ≥ 50% (OR 10.3, 95% CI 3.0-33.4; P<0.001). In multivariable analyses, low MTG was also associated with 2-fold and 4-fold increased hazards for MACE (HR 4.2, 95% CI 2.0-8.9; P<0.001) and cardiovascular death (HR 4.2 95% CI 1.2-14.9; P=0.03), respectively, within 1 year following TAVI. CONCLUSION: Presence of a low MTG (<40 mmHg) prior to TAVI was associated with a greater risk of major adverse events, including cardiovascular death, up to 1 year following the procedure. Pre-procedural MTG could be used to identify patients at a high risk for adverse outcomes following TAVI.

Incidence, predictors and prognostic value of serious hemorrhagic complications following transcatheter aortic valve implantation.

BACKGROUND: TAVI is an alternative solution for patients with aortic valve stenosis (AS) who are refused for conventional surgery. We sought to evaluate the incidence, characteristics, predictors and prognosis impact of serious hemorrhagic complications following transcatheter aortic valve implantation (TAVI). METHODS: One hundred and seventy one consecutive patients with symptomatic severe AS (83.5 ± 6.1 y; 53% women; mean EuroSCORE=22.1 ± 12.3) underwent transapical (TA) or transfemoral (TF) TAVI in our institution using Edwards SAPIEN© and Medtronic CoreValve© devices. The primary evaluated criterion was the incidence of any bleeding complication, according to the Valve Academic Research Consortium (VARC) criteria. RESULTS: VARC serious hemorrhagic complications occurred in 34.5% of patients (n=23 life-threatening/disabling (LT/D) and n=36 major bleedings). Most of these complications were related to access site complications (69%). Multivariable analysis revealed that TA access, low weight and underlying coronary artery diseases were independent predictors for development of serious bleeding. The mortality was significantly higher in patients with serious events compared to patients without bleeding (p=0.008, log-rank analysis). Although the survival didn't significantly differ in patients with major hemorrhagic events, subjects with LT/D bleeding events had a higher mortality than the subjects with no hemorrhagic complications (p<0.001, log-rank analysis). Occurrence of VARC LT/D event independently predicted all-cause mortality (HR=5.35 [2.51-11.43], p<0.001) during the first year following TAVI in multivariate Cox regression analysis. CONCLUSION: Severe bleeding is frequent following TAVI procedure and is mainly related to local hemorrhage. VARC LT/D events are associated with decreased survival after AS correction.

Wrapping of the ascending aorta in acute type A retrograde aortic dissection.

We describe off-pump wrapping of the ascending aorta in 3 high-risk patients with acute type A aortic dissection when the primary intimal tear was not located in the ascending aorta and in the absence of aortic insufficiency. A Teflon plaque (Bard Inc, Murray Hill, NJ) was tailored to tightly wrap the aorta from the coronary ostia to the innominate artery. The mean age of the patients was 80.3 years. All patients were at high risk for conventional surgery. A postoperative computed tomographic scan showed a reapplication of the intimal flap and containment of the false lumen in the reinforced ascending aorta in all patients.

Exclusive internal thoracic artery grafting in triple-vessel-disease patients: angiographic control.

BACKGROUND: The internal thoracic artery (ITA) is considered to be the conduit of choice for coronary artery bypass grafting surgery (CABG). In triple-vessel-disease patients, CABG can be performed exclusively using both ITAs in a Y fashion with multiple sequential side-to-side coronary anastomoses. The aim of this prospective study was to evaluate by early postoperative angiographic control, the patency and particularly the quality of ITA grafts and coronary anastomoses in this configuration. METHODS: Between October 2002 and October 2003, 92 triple-vessel-disease patients underwent CABG with this technique and consented to immediate postoperative angiographic control. The right ITA was divided at its origin and connected to the in-situ left ITA (ITA-Y anastomosis). The left ITA was anastomosed to anterior coronary arteries and the right ITA was anastomosed to lateral and inferior coronary arteries, for a total of 374 coronary anastomoses (4.1 anastomoses per patient; range, 3 to 6). RESULTS: There was 1 hospital death by septic shock. Two patients were reoperated on for superficial wound infection. There was no postoperative myocardial infarction or stroke. On postoperative angiograms, all ITA-Y (92) and ITA-coronary anastomoses (374) were patent. Competition of flow in right ITA to the moderately stenosed right coronary artery was observed in 9 patients, and there were 4 distal ITA-coronary stenoses, both without clinical consequences. CONCLUSIONS: In triple-vessel-disease patients, this procedure allows CABG without increasing operative risk. ITA-Y anastomoses and multiple sequential side-to-side ITA-coronary anastomoses are safe to perform and demonstrate excellent patency and quality in early postoperative angiographic control, particularly when coronary artery stenoses are significant (>70%).

Aortic valve translocation for severe prosthetic valve endocarditis: early results and long-term follow-up.

BACKGROUND: Surgical management of ventriculo-aortic disconnection and aortic root abscesses after prosthetic aortic valve endocarditis carries high mortality and morbidity. Initial experience with translocation of the aortic valve and distal coronary artery bypass grafting was disappointing in terms of short-term and long-term success in the few published reports. We describe a technique of translocation of the aortic valve into the ascending aorta with direct antegrade myocardial revascularization. METHODS: Between 1980 and 1992, we included 21 patients and evaluated their long-term outcome. The surgical technique included extracting the aortic valve prosthesis, resecting all infected tissue, restoring the left ventricular outflow tract, and translocating the aortic valve into the ascending aorta, associated with myocardial revascularization of the left main trunk and the proximal right coronary artery. RESULTS: All patients required emergency surgery: 15 patients were in severe congestive heart failure, 3 patients were in cardiogenic shock, and 3 patients had multiple neurologic and peripheral signs of distal embolization. Fifteen patients had active prosthetic valve endocarditis. Intraoperative findings dictated the translocation. The overall hospital mortality was 14%. None of the 18 hospital survivors had prosthetic aortic valve endocarditis recurrence. All patients were observed from 12 to 22 years, are alive, and have resumed normal activities. CONCLUSIONS: In severe forms of prosthetic valve endocarditis, this technique provides a safe and reliable alternative to homograft replacement. The long-term results are satisfactory.