Impact of aortic root geometry and degree of aortic calcification on outcomes of patients undergoing TAVI procedure.

AIMS: Adequate differentiation of calcifications in contrast-enhanced CT scans remains difficult to assess TAVI parameters. The size of the aortic leaflets has not been taken into account so far in present studies. The aim of our study was to establish a new method for optimized quantification of the aortic valve calcification degree in contrast-enhanced CT scans for better preoperative prediction of postoperative paravalvular leak after TAVI. METHODS AND RESULTS: We retrospectively analyzed preoperative contrast-enhanced CT scans of patients who underwent TAVI in our institution between 2014 and 2017. Calcium volume was quantified by a method using contrast enhanced computer tomography (3mensio-Structural Heart-7.2 software) with different iodine contents for better discrimination of contrast agent from calcium and by an individually set Houndsfield Unit (HU) threshold with 50HU above the individually determined reference value. Calcium volume was correlated with surface area of each aortic cusp. Perioperative variables were analyzed. All patients (n = 150) with severe aortic stenosis were treated with TAVI implantation. Overall incidence of postoperative trace to moderate PVL was 37%. The amount of calcium correlated with the incidence of PVL. In a logistic regression analysis total volume of calcification (p = .032) as well as calcification of each aortic cusp (NC_p = .001; RC_p < .001; LC_p = .001) were independent predictors. CONCLUSIONS: Calcification degree as well as its correlation with the surface area of each aortic cusp significantly influence incidence of PVL. Our new method improves preoperative quantification of the calcification degree by use of contrast agents with different iodine contents and thereby helps to improve patients' outcomes.

Transcatheter aortic valve implantation for pure aortic insufficiency in a patient following David-type aortic valve-sparing root replacement after aortic dissection-A successful off-label procedure.

Transcatheter aortic valve implantation (TAVI) has traditionally been indicated for the treatment of aortic stenosis. However, in this case report, we describe a successful TAVI procedure in a 46-year-old male patient who had previously undergone David aortic valve-sparing aortic root replacement for type 1 aortic dissection. The patient presented with aortic valve insufficiency 4 years after the initial surgery and was subsequently treated with a 34 mm Medtronic CoreValve Evolut R prosthesis via TAVI. This case highlights the feasibility of TAVI as a viable treatment option for postoperative aortic valve insufficiency in patients with prior ascending aortic or aortic arch surgery.

Does Comprehensive Geriatric Assessment Reduce the Incidence of Postoperative Delirium? A Quasi-experimental Study in Older Adults Undergoing Transcatheter Aortic Valve Implantation.

Purpose: Postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) is frequent in older adults and associated with multiple negative outcomes including a higher mortality. We aimed to investigate whether a comprehensive geriatric assessment (CGA) prior to TAVI reduces the odds of POD and results in a positive change in self-care ability, intended to lay a foundation for future geriatric comanagement. Patients and methods: We used a retrospective, single-center study with a quasi-experimental design enrolling patients aged 70 years and older undergoing CGA before elective TAVI, and a nonrandomized comparison group without preoperative CGA. Data on POD occurrence during the first 5 days after TAVI (primary outcome) and change in self-care ability index (SPI) between admission and discharge (secondary outcome) were collected from electronic health records and CGA data (exposure) by clinical assessment. To explore associations between (1) CGA and POD, and (2) CGA and SPI, multivariate logistic regression and linear regression models were applied adjusting for age, sex, BMI, and number of medications. Results: Among 435 patients (mean age 81.0 ± 5.6 years, 43.6% women, median [IQR] SPI at baseline 40 [39, 40] points), POD incidence was 14.3% in the CGA group vs 18.8% in the non-CGA group (P 0.219). Undergoing CGA before TAVI was not associated with the odds for POD (OR: 1.15; 95%CI: 0.65-2.04) or improved SPI (P 0.073). Conclusion: We observed no association of CGA prior to TAVI with POD incidence or postoperative self-care, highlighting the need for additional studies investigating the effect of POD preventive measures in older TAVI patients integrated into a comprehensive geriatric comanagement program.

Evaluation of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Criteria in a Multicenter Cohort of Patients With Suspected Infective Endocarditis.

BACKGROUND: Since publication of Duke criteria for infective endocarditis (IE) diagnosis, several modifications have been proposed. We aimed to evaluate the diagnostic performance of the Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) 2023 criteria compared to prior versions from 2000 (Duke-Li 2000) and 2015 (Duke-ESC [European Society for Cardiology] 2015). METHODS: This study was conducted at 2 university hospitals between 2014 and 2022 among patients with suspected IE. A case was classified as IE (final IE diagnosis) by the Endocarditis Team. Sensitivity for each version of the Duke criteria was calculated among patients with confirmed IE based on pathological, surgical, and microbiological data. Specificity for each version of the Duke criteria was calculated among patients with suspected IE for whom IE diagnosis was ruled out. RESULTS: In total, 2132 episodes with suspected IE were included, of which 1101 (52%) had final IE diagnosis. Definite IE by pathologic criteria was found in 285 (13%), 285 (13%), and 345 (16%) patients using the Duke-Li 2000, Duke-ESC 2015, or the Duke-ISCVID 2023 criteria, respectively. IE was excluded by histopathology in 25 (1%) patients. The Duke-ISCVID 2023 clinical criteria showed a higher sensitivity (84%) compared to previous versions (70%). However, specificity of the new clinical criteria was lower (60%) compared to previous versions (74%). CONCLUSIONS: The Duke-ISCVID 2023 criteria led to an increase in sensitivity compared to previous versions. Further studies are needed to evaluate items that could increase sensitivity by reducing the number of IE patients misclassified as possible, but without having detrimental effect on specificity of Duke criteria.

Evaluation of the 2023 Duke-ISCVID and 2023 Duke-ESC Clinical Criteria for the Diagnosis of Infective Endocarditis in a Multicenter Cohort of Patients With Staphylococcus aureus Bacteremia.

BACKGROUND: The Duke criteria for infective endocarditis (IE) diagnosis underwent revisions in 2023 by the European Society of Cardiology (ESC) and the International Society for Cardiovascular Infectious Diseases (ISCVID). This study aims to assess the diagnostic accuracy of these criteria, focusing on patients with Staphylococcus aureus bacteremia (SAB). METHODS: This Swiss multicenter study conducted between 2014 and 2023 pooled data from three cohorts. It evaluated the performance of each iteration of the Duke criteria by assessing the degree of concordance between definite S. aureus IE (SAIE) and the diagnoses made by the Endocarditis Team (2018-23) or IE expert clinicians (2014-17). RESULTS: Among 1344 SAB episodes analyzed, 486 (36%) were identified as cases of SAIE. The 2023 Duke-ISCVID and 2023 Duke-ESC criteria demonstrated improved sensitivity for SAIE diagnosis (81% and 82%, respectively) compared to the 2015 Duke-ESC criteria (75%). However, the new criteria exhibited reduced specificity for SAIE (96% for both) compared to the 2015 criteria (99%). Spondylodiscitis was more prevalent among patients with SAIE compared to those with SAB alone (10% vs 7%, P = .026). However, when patients meeting the minor 2015 Duke-ESC vascular criterion were excluded, the incidence of spondylodiscitis was similar between SAIE and SAB patients (6% vs 5%, P = .461). CONCLUSIONS: The 2023 Duke-ISCVID and 2023 Duke-ESC clinical criteria show improved sensitivity for SAIE diagnosis compared to 2015 Duke-ESC criteria. However, this increase in sensitivity comes at the expense of reduced specificity. Future research should aim at evaluating the impact of each component introduced within these criteria.

Interventional versus Surgical Treatment of Degenerated Freestyle Prosthesis.

BACKGROUND: Bioprosthetic stentless aortic valves may degenerate over time and will require replacement. This study aimed to evaluate early- and mid-term outcomes after isolated surgical redo aortic valve replacement (redo-SAVR) and transcatheter valve-in-valve implantation (TAVI-VIV) for degenerated stentless Freestyle bioprostheses. METHODS: We reviewed records of 56 patients at a single center. Overall, 37 patients (66.1%) received TAVI-VIV and 19 (33.9%) received redo-SAVR. RESULTS: Thirty-day survival was similar in both groups (100%). One-year survival was comparable between groups (97.3% in TAVI-VIV and 100% in redo-SAVR, p = 1.0). The difference in mid-term survival after adjusting for age and EuroScore II was not significant (p = 0.41). The incidence of pacemaker implantation after TAVI-VIV was higher than after redo-SAVR (19.4% vs. 0%, p = 0.08). CONCLUSION: The 30-day and 1-year survival rates after both procedures were outstanding, irrespective of baseline characteristics. Isolated redo-SAVR should be favored in young patients, as the pacemaker implantation rate is lower. TAVI-VIV for degenerated Freestyle prosthesis can be a method of choice in elderly patients and those with high operative risk.

[Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies]. / Nutzen altersmedizinischer Abklärungen vor Operationen, Interventionen und onkologischen Therapien.

Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies Abstract: Older patients face an increased risk of complications and adverse outcomes during and after operations, interventions, and intense oncological therapies. At the same time, this patient group should not be excluded per se from potentially beneficial medical procedures based on chronological age alone. The timely identification of geriatric syndromes and increased vulnerability by means of comprehensive geriatric assessment is becoming increasingly important and is already recommended in the guidelines of professional societies of several medical disciplines. Nonetheless, the geriatric assessment should ideally be followed by proactive co-management in the sense of integrated care. The establishment of interdisciplinary and integrated care pathways for older hospital patients can contribute to significantly improved treatment outcomes. In addition to better patient-related outcomes and rising quality indicators, this approach may also offer positive health economic effects.

Antibiotic prophylaxis before dental procedures to prevent infective endocarditis: a systematic review.

PURPOSE: Infective endocarditis (IE) is a severe bacterial infection. As a measure of prevention, the administration of antibiotic prophylaxis (AP) prior to dental procedures was recommended in the past. However, between 2007 and 2009, guidelines for IE prophylaxis changed all around the word, limiting or supporting the complete cessation of AP. It remains unclear whether AP is effective or not against IE. METHODS: We conducted a systematic review whether the administration of AP in adults before any dental procedure, compared to the non-administration of such drugs, has an effect on the risk of developing IE. We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, and EMBASE. Two different authors filtered articles independently and data extraction was performed based on a pre-defined protocol. RESULTS: The only cohort study meeting our criteria included patients at high-risk of IE. Analysis of the extracted data showed a non-significant decrease in the risk of IE when high-risk patients take AP prior to invasive dental procedures (RR 0.39, p-value 0.11). We did not find other studies including patients at low or moderate risk of IE. Qualitative evaluation of the excluded articles reveals diversity of results and suggests that most of the state-of-the-art articles are underpowered. CONCLUSIONS: Evidence to support or discourage the use of AP prior to dental procedures as a prevention for IE is very low. New high-quality studies are needed, even though such studies would require big settings and might not be immediately feasible.

A retrospective analysis of blood culture-negative endocarditis at a tertiary care centre in Switzerland.

AIMS OF THE STUDY: Numerous studies from different countries have contributed to an improved understanding of blood culture-negative infective endocarditis. However, little is known about its epidemiology and microbiology in Switzerland. We aimed to assess the epidemiology and microbiology of blood culture-negative endocarditis at the University Hospital Zurich, Switzerland. METHODS: We screened all patients hospitalised between 1997 and 2020 with possible or definite endocarditis at our institution. Thereof, we identified all cases with blood culture-negative endocarditis and retrospectively retrieved patient characteristics, microbiological, histopathological, radiographic and surgical data from medical records. RESULTS: Among 861 patients screened, 66 (7.7%) cases of blood culture-negative endocarditis were identified. Thereof, 31 cases could be microbiologically documented or not documented (n = 30), and in five cases a non-infectious aetiology was confirmed. Endocarditis predominantly affected men (77%) and the left heart (79%); predisposing factors were prosthetic valves (42%), congenital heart disease (35%) and prior endocarditis (14%). The most common reasons for negative blood cultures were antibiotic treatment prior to blood culture sampling (35%), fastidious and slow growing microorganisms (30%) and definite non-infective endocarditis (8%). Coxiella burnetii and Bartonella spp. were the most common fastidious bacteria identified. In addition to serology, identification of causative microorganisms was possible by microbiological and/or histopathological analysis of tissue samples, of which polymerase chain reaction testing (PCR) of the 16S ribosomal RNA proved to be most successful. CONCLUSIONS: The present study provides a detailed analysis of blood culture-negative endocarditis over a time span of more than 20 years in Zurich, Switzerland. Antibiotic treatment prior to blood collection, and fastidious and slow growing organisms were identified as main reasons for sterile blood cultures. Typical culture-negative bacteria were mainly found by PCR and/or culture of tissue samples.

Valve-in-valve transcatheter aortic valve replacement in a young patient with a suspected COVID-19 infection: a surgical dilemma in the era of the COVID-19 pandemic.

We report on a case of a 57-year-old male patient, who underwent full root replacement in 2005 and now presented with high grade aortic insufficiency. On admission, the patient underwent a computed tomography scan which demonstrated interstitial infiltration in the left lung, highly suspicious for a COVID-19 infection that could not be confirmed by reverse transcription polymerase chain reaction (RT-PCR) testing. As there usually is a delay between infection and positive RT-PCR test results, the initial decision was to perform additional testing. However, the patient deteriorated quickly in spite of optimal medical therapy making urgent aortic valve replacement necessary. We decided to perform transcatheter aortic valve replacement to avoid cardiopulmonary bypass with shorter operative times, presumably shorter ventilation times and duration of intensive care unit stay, and thus a lesser risk for pulmonary complications.

Effects of pulsatile minimal invasive extracorporeal circulation on fibrinolysis and organ protection in adult cardiac surgery-a prospective randomized trial.

BACKGROUND: Minimal invasive extracorporeal circulation (MiECC) reduces the impact of cardiopulmonary bypass during cardiac surgery on inflammation and hemostasis. Pulsatile perfusion may enhance organ perfusion and help to prevent renal and neuronal damage. The present study investigated the impact of pulsatile MiECC in low-risk coronary artery bypass grafting (CABG) patients. METHODS: CABG patients were prospectively randomized for non-pulsatile (np: n=19) and pulsatile (p: n=21) MiECC. Blood and urine samples were collected at several time points until 72 h post-operative and analyzed for biochemical markers of fibrinolytic capacity, renal damage, and neuronal damage. RESULTS: Although intraoperative tissue plasminogen activator (tPA) levels tended to be higher in the p group, none of the fibrinolysis markers including plasminogen activator inhibitor (PAI-1) and the PAI-1/tPA ratio were significantly affected by pulsation. Hemolysis and markers of renal and neuronal damage were comparable between groups. Intraoperative urinary excretion [np: 400 mL (355 to 680) vs. p: 530 mL (360 to 900)] and cumulative 24 h volume intake [np: 7,090 mL (5,492 to 7,544) vs. p: 7,155 mL (6,682 to 8,710)] were increased by pulsation whereas blood losses up to 12 h post-operative [np: 365 mL (270 to 515) vs. p: 310 mL (225 to 470)] and up to 24 h post-operative [np: 760 mL (555 to 870) vs. p: 520 mL (460 to 670)] were attenuated. CONCLUSIONS: The present study did not find evidence for a beneficial effect of pulsation on markers of fibrinolysis, renal damage, and neuronal damage. However, pulsatile perfusion increased intraoperative urinary secretion and reduced post-operative blood losses.

Extent of size, shape and systolic variability of the left ventricular outflow tract in aortic stenosis determined by phase-contrast MRI.

PURPOSE: Left ventricular outflow tract (LVOT) dimensions are important for calculation of aortic valve areas and planning of valve repair. Mostly, LVOT areas are calculated from echocardiographic longitudinal measurements with the assumption of a round shape. Here, orthogonal phase contrast (PC) MRI with dynamic assessment of LVOT was compared to standard longitudinal cine MRI and 2D echocardiography. METHODS: In 19 patients with aortic stenosis (5 female; 69±10years), LVOT areas were determined on orthogonal PC images, either by planimetry (Aplan) or by two-diameter measurement (Aellip). Data were analyzed in early, middle and late systole (t1/t2/t3). Additionally, standard diameter-based calculation (A3CV) of LVOT on longitudinal three-chamber view (3CV) MRI images and 2D echocardiography was performed. RESULTS: Calculated PC LVOT areas strongly correlated to planimetry (r=0.95; p<0.001) with almost identical areas (Aplan 5.1±1.1cm2 vs. Aellip 5.3±1.0cm2). In PC changes of LVOT-eccentricity during systole were most pronounced in late systole (t1 vs. t3plan -7.4±18%). Cine 3CV calculation resulted in lower LVOT areas compared to Aplan (A3CV 3.7±0.9cm2; p<0.001), yet correlating to Aplan (r=0.66; p=0.002). 3CV LVOT areas correlated to echocardiography (r=0.56; p=0.014). CONCLUSIONS: Calculated LVOT areas seem to be sufficient for daily routine. Compared to the orthogonal view, standard long-axis 3CV underestimates the LVOT size and overestimates the systolic reduction of LVOT-size. Systolic changes are most pronounced in late systole.

First successful transcatheter double valve replacement from a transapical access and nine-month follow-up.

AIMS: While TAVI is the treatment of choice in patients with aortic stenosis considered inoperable or at high risk, interventional replacement of the mitral valve is still in the preclinical or early clinical phase. Our aim was to report on the first transcatheter double valve replacement into native valves from a transapical access. METHODS AND RESULTS: A 67-year-old, highly symptomatic female patient considered inoperable due to severe calcification of the mitral annulus and comorbidities was scheduled for transcatheter double valve replacement by the local Heart Team. Preoperative planning was carried out by multiplanar reconstruction from cardiac CT. Through a transapical access, the mitral valve was replaced first by an inverted 29 mm Edwards SAPIEN 3 prosthesis, then the aortic valve by a 23 mm SAPIEN 3, both during rapid pacing. Both prostheses revealed excellent function in angiography and echocardiography. The patient was extubated early after surgery and transferred to the normal ward the following day. After five months, she exhibited signs of cardiac failure again. Migration of the mitral prosthesis was detected, and the mitral valve was replaced surgically. CONCLUSIONS: Transcatheter double valve replacement can be performed through a transapical access. The key to success is thorough preoperative planning based on CT, not only for sizing, but also for estimating the anatomical relationship of the prostheses. However, late migration can be expected and may lead to LVOT obstruction.

The feasibility and safety of Algisyl-LVR™ as a method of left ventricular augmentation in patients with dilated cardiomyopathy: initial first in man clinical results.

BACKGROUND: A tissue engineering approach to augment the left ventricular wall has been suggested as a means to treat patients with advanced heart failure. This study evaluated the safety and feasibility of Algisyl-LVR™ as a method of left ventricular augmentation in patients with dilated cardiomyopathy undergoing open-heart surgery. METHODS AND RESULTS: Eleven male patients (aged 44 to 74years) with advanced heart failure (NYHA class 3 or 4), a left ventricular ejection fraction (LVEF) of <40% and requiring conventional heart surgery received Algisyl-LVR delivered into the LV myocardial free wall. Serial echocardiography, assessment of NYHA class, Kansas City Cardiomyopathy Questionnaire (KCCQ) and 24-hour Holter monitoring were obtained at baseline, days 3 and 8 (for echocardiography and Holter monitoring), and at 3, 6, 12, 18 and 24months. A total of 9 (81.8%) patients completed 24months of follow-up. Two patients withdrew consent after day 8 and at the 3month visit. Operative mortality was 0% (n=10 with 30day follow-up). There were no adverse events attributed to Algisyl-LVR. Mean LVEF improved from 27.1 (±7.3) % at screening to a mean LVEF of 34.8 (±18.6) % 24months post-discharge. Improvements of NYHA class were corroborated with improvements in KCCQ summary scores. Holter monitor data showed a significant decrease in the episodes of nonsustained ventricular tachycardia following administration of Algisyl-LVR. CONCLUSIONS: Administration of Algisyl-LVR to patients with advanced HF at the time of cardiac surgery is feasible and safe; warranting continued development of Algisyl-LVR as a potential therapy in patients with advanced HF.

Treatment of aortic stenosis with a self-expanding transcatheter valve: the International Multi-centre ADVANCE Study.

AIM: Transcatheter aortic valve implantation has become an alternative to surgery in higher risk patients with symptomatic aortic stenosis. The aim of the ADVANCE study was to evaluate outcomes following implantation of a self-expanding transcatheter aortic valve system in a fully monitored, multi-centre 'real-world' patient population in highly experienced centres. METHODS AND RESULTS: Patients with severe aortic stenosis at a higher surgical risk in whom implantation of the CoreValve System was decided by the Heart Team were included. Endpoints were a composite of major adverse cardiovascular and cerebrovascular events (MACCE; all-cause mortality, myocardial infarction, stroke, or reintervention) and mortality at 30 days and 1 year. Endpoint-related events were independently adjudicated based on Valve Academic Research Consortium definitions. A total of 1015 patients [mean logistic EuroSCORE 19.4 ± 12.3% [median (Q1,Q3), 16.0% (10.3, 25.3%)], age 81 ± 6 years] were enrolled. Implantation of the CoreValve System led to a significant improvement in haemodynamics and an increase in the effective aortic valve orifice area. At 30 days, the MACCE rate was 8.0% (95% CI: 6.3-9.7%), all-cause mortality was 4.5% (3.2-5.8%), cardiovascular mortality was 3.4% (2.3-4.6%), and the rate of stroke was 3.0% (2.0-4.1%). The life-threatening or disabling bleeding rate was 4.0% (2.8-6.3%). The 12-month rates of MACCE, all-cause mortality, cardiovascular mortality, and stroke were 21.2% (18.4-24.1%), 17.9% (15.2-20.5%), 11.7% (9.4-14.1%), and 4.5% (2.9-6.1%), respectively. The 12-month rates of all-cause mortality were 11.1, 16.5, and 23.6% among patients with a logistic EuroSCORE ≤10%, EuroSCORE 10-20%, and EuroSCORE >20% (P< 0.05), respectively. CONCLUSION: The ADVANCE study demonstrates the safety and effectiveness of the CoreValve System with low mortality and stroke rates in higher risk real-world patients with severe aortic stenosis.

Polymer-based restoration of left ventricular mechanics.

Heart failure continues to be a major health care concern with relatively few options for severely advanced heart failure patients. The hallmark of heart failure is the progressive dilatation of the left ventricle, thinning of the left ventricular wall leading to increased wall stress and increased myocardial oxygen consumption. Applying Laplace's law to the failing dilated ventricle, left ventricular augmentation utilizes a tissue engineering strategy to increase wall thickness and reduce chamber diameter, resulting in a decrease in wall stress and improved left ventricular function. A review of the rationale for an in situ tissue engineering approach for this treatment of heart failure and early clinical results of the Algisyl-LVR™ program are presented.

Selective automation and skill transfer in medical robotics: a demonstration on surgical knot-tying.

BACKGROUND: Transferring non-trivial human manipulation skills to robot systems is a challenging task. There have been a number of attempts to design research systems for skill transfer, but the level of the complexity of the actual skills transferable to the robot was rather limited, and delicate operations requiring a high dexterity and long action sequences with many sub-operations were impossible to transfer. METHODS: A novel approach to human-machine skill transfer for multi-arm robot systems is presented. The methodology capitalizes on the metaphor of 'scaffolded learning', which has gained widespread acceptance in psychology. The main idea is to formalize the superior knowledge of a teacher in a certain way to generate support for a trainee. In our case, the scaffolding is constituted by abstract patterns, which facilitate the structuring and segmentation of information during 'learning by demonstration'. The actual skill generalization is then based on simulating fluid dynamics. RESULTS: The approach has been successfully evaluated in the medical domain for the delicate task of automated knot-tying for suturing with standard surgical instruments and a realistic minimally invasive robotic surgery system.

Short- and mid-term safety and effectiveness of transcatheter aortic valve implantation in a failing surgical aortic bioprosthesis.

OBJECTIVES: The feasibility of transcatheter aortic valve implantation (TAVI) in patients with a failing surgical aortic bioprosthesis has been reported from single centres. We present results from a multi-centre feasibility study in such patients followed for 1 year after TAVI. METHODS: This study evaluated 18 patients undergoing implantation with the 18-Fr CoreValve TAVI prosthesis in a failing surgical aortic bioprosthesis at three centres in Germany. Subject inclusion requirements included ≥ 75 years old and either surgical risk with logistic European System for Cardiac Operative Risk Evaluation ≥ 15% or ≥ 1 high-risk co-morbidity. RESULTS: Implanted subjects were 79 ± 4 years old, 67% males, 78% NYHA Class III/IV, with logistic EuroSCORE 34 ± 14, and had failed surgical bioprostheses from six manufacturers. The procedure was considered technically successful in 94% (17/18) of cases. One subject was converted to surgery during the procedure. Mortality at 30 days and 1 year was 11% (2/18) and 28% (5/18), respectively. Two cardiac deaths occurred, including 1 within 30 days. Two subjects had strokes, both within 30 days. After 30 days and 1 year, respectively, 86 and 73% of subjects improved at least 1 NYHA class and the remainder had no change. No aortic regurgitation was reported beyond mild (Grade 1) at 6- and 12-month follow-up. CONCLUSIONS: Most patients with a failing aortic surgical bioprosthesis were successfully implanted with a TAVI prosthesis in this multi-centre feasibility study. Outcomes at 30 days were within expectations for this very high-risk subgroup and improvements were sustained through 12 months.

Preserved autonomic regulation in patients undergoing transcatheter aortic valve implantation (TAVI): a prospective, comparative study.

Heart rate and blood pressure variability as well as baroreflex sensitivity (BRS) lead to additional insights on the patients' prognosis after cardiovascular events. The following study was performed to assess the differences in the postoperative recovery of the autonomic regulation after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Fifty-eight consecutive patients were enrolled in a prospective study; 24 underwent TAVI and 34 SAVR. BRS was calculated according to the Dual Sequence Method, heart rate variability (HRV) was evaluated using standard linear as well as nonlinear parameters. HRV and BRS parameters were reduced after surgery in patients with SAVR only (meanNN: p<0.001, sdNN: p<0.05, Shannon: p<0.01, BRS: p<0.01), while these indexes were preserved in patients after TAVI. Simultaneously, an increased complexity of blood pressure (BP) in SAVR patients (fwShannon: p<0.001, fwRenyi4: p<0.001), but not in TAVI patients was recorded. In this study we were able to demonstrate for the first time that, in contrast to patients undergoing conventional open surgery, there are fewer alterations of the cardiovascular autonomic system in patients with TAVI.

Long-term performance of the Hancock bioprosthetic valved conduit in the aortic root position.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess long-term morbidity and mortality with special regard to prosthesis durability after aortic root replacement with the Hancock bioprosthetic porcine conduit. METHODS: Between 1975 and 2004, a total of 81 patients (55 males, 26 females; mean age 58 +/- 18 years) underwent aortic root replacement with the Hancock conduit for aortic dissection (n = 22; 27%), ascending aortic aneurysm (n = 57; 70%), or porcelain aorta (n = 2; 3%). Twenty-five patients (31%) underwent an emergency operation, 12 (15%) presented with Marfan syndrome, and eight (10%) had undergone previous cardiac surgery. Concomitant procedures were performed in 26 cases (32%). The follow up was 98% complete; the mean follow up was 4.8 +/- 4.0 years (range: 1 day to 16.7 years), and the cumulative follow up was 403 patient-years. Actuarial event-free rates were calculated, and valve-related complications classified according to guidelines for reporting morbidity and mortality after cardiac valvular operations. RESULTS: There were seven (9%) operative deaths and four (5%) in-hospital deaths. Actuarial survival rates at five and 10 years (excluding operative deaths) were 77.0 +/- 5.3% and 54.0 +/- 7.5%, respectively. Actuarial freedom from aortic valve reoperation at five and 10 years was 98 +/- 1.6% and 64 +/- 10.2%, from structural valve deterioration 88.1 +/- 4.7% and 49.9 +/- 9.6%, from thromboembolic events 87.4 +/- 4.6% and 75.1 +/- 9.5%, and from major bleeding events 90.2 +/- 3.9% and 75.4 +/- 8.1%, respectively. Among redo procedures, the stentless Hancock valve could be excised without separating the synthetic graft from the left ventricular outflow tract, and a stented valve prosthesis thus implanted. Hence, it was possible to avoid a second Bentall operation. CONCLUSION: The long-term survival rates after aortic root replacement with the bioprosthetic Hancock conduit were reasonable for this demanding patient cohort. However, the durability of the prosthesis was inferior to that reported for the stented Hancock valve substitute. The key benefit of this bioprosthetic valved conduit was the simplified redo procedure.