Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience.

BACKGROUND: decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. METHODS: safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. RESULTS: seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). CONCLUSIONS: early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.

Aortic root geometry following composite valve graft implantation: Implications for future valve-in-valve procedures.

OBJECTIVES: Biological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions. METHODS: We retrospectively identified 64 patients following bioprosthetic CVG replacement with pre- and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation. RESULTS: In 64 patients (age, 67.6 ± 9.3 years; 76.6% men) the preoperative coronary height was 14.3 ± 6.8 mm for the left coronary artery (LCA) and 17.9 ± 5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7 ± 4.4 mm for the LCA and 11.3 ± 4.4 mm for the RCA (P < .001). The virtual valve-to-coronary distances measured 4.0 ± 1.3 mm (LCA) and 4.6 ± 1.4 mm (RCA). Overall, 59.4% (n = 38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n = 19) for LCA, 10.9% (n = 7) for RCA, and 18.8% (n = 12) for combined LCA and RCA. CONCLUSIONS: Coronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruction in future valve-in-valve procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population.

Novel Automated Suturing Technology for Minimally Invasive Mitral Chord Implantation: A Preclinical Evaluation Study.

OBJECTIVE: This study evaluated the ergonomics and time requirements of using a novel automated suturing and titanium fastener deployment technology for chordal replacement in human heart specimens in open and minimally invasive cardiac surgery (MICS) simulators. METHODS: Five cardiac surgeons used novel, manually powered expanded polytetrafluoroethylene (ePTFE) suturing devices to automate suture placement between mitral leaflets and papillary muscles in explanted cadaver hearts, along with customized titanium fastener delivery devices to secure suture and trim suture tails. This mitral chordal replacement test was conducted using surgical models simulating open and MICS mitral repair access. The study was approved by the institutional ethical board. RESULTS: After a brief introduction to this technique using plastic models, study surgeons performed 48 chordal replacements in human mitral valves, placing 18 in an open model and 30 in a right minithoracotomy model. The time range to complete a single chordal replacement was between 55 s and 8 min, with an overall mean duration of 3.6 ± 1.5 min. No difference in duration of implantation was recorded for the MICS and open sternotomy simulators used. Good control of suture delivery was reported in 95.8% (n = 46) of leaflet aspect of the sutures and in 100% (N = 48) of papillary muscle sutures. CONCLUSIONS: Automated mitral chordal ePTFE suturing simulated through open and MICS access demonstrated quality handling and accurate placement of sutures in human heart specimens. A clinical trial using this technology is currently ongoing. This innovation may present an important advance facilitating enhanced minimally invasive mitral valve repair.

Off-label transapical beating-heart transcatheter mitral valve replacement in severe mitral annular calcification.

The recent CE mark approval of a novel transapical transcatheter beating-heart replacement system, anchored by an apical pad, expanded the therapeutic options for patients with a significantly diseased mitral valve who are not eligible for conventional surgery. However, this self-expandable bioprosthesis is-despite promising data from the first European real-world experience-not approved for patients with severe mitral annular calcification. In this video tutorial, we provide a step-by-step description of an off-label transapical mitral valve replacement in a patient with severe degenerative mitral valve disease and limited alternative treatment options.

Long Term Results of the Modified Bentall Procedure With Mechanical and Biological Composite Valve Grafts.

Objectives: Despite the evident shift toward biological prostheses, the optimal choice of valve remains controversial in composite valve graft (CVG) replacement. We investigated long-term morbidity and mortality after CVG implantation in an all-comer cohort with a subgroup analysis of patients aged 50-70 years stratified after valve type. Methods: A total of 507 patients underwent the Bentall procedure with either a mechanical (MCVG, n = 299) or a biological (BCVG n = 208) CVG replacement between 2000 and 2020. A single-center analysis comprising clinical and telephone follow-up was conducted to investigate late mortality and morbidity. Results: The 30-day mortality in all patients [age 56 ± 14 years, 78.1% male, EuroSCORE II 3.12 (1.7; 7.1)] was 5.9%. Patients who were electively operated on had a 30-day mortality of 1.5% (n = 5) while it remained higher in urgent/emergent procedures (n = 25, 15.4%). Survival at 10 and 15 years was 78.19 ± 2.26% and 72.6 ± 3.2%, respectively. In patients aged 50-70 years (n = 261; MCVG = 151, BCVG = 110), survival did not differ significantly between the valve groups (p = 0.419). Multivariable analysis showed no significant impact of valve type on survival (p = 0.069). A time-varying relation with survival was notable, showing a higher risk in the MCVG group in the early postoperative phase, which declined compared to the BCVG group in the course of follow-up. Conclusions: The Bentall technique presents with excellent mortality when performed electively. The type of valve prosthesis showed no statistically significant effect on mortality in patients aged 50-70 years. However, a time-varying relation showing an initially higher risk with MCVG which decreased compared to BCVG at long-term follow-up was notable. Further studies with even longer follow-up of BCVGs will clarify the ideal choice of prosthesis in this patient subset.

Deviations From the Ideal Plasma Volume and Isolated Tricuspid Valve Surgery-Paving the Way for New Risk Stratification Parameters.

Background: Congestion and plasma volume expansion are important features of heart failure, whose prognostic significance has been investigated in a range of surgical and non-surgical settings. The aim of this study was to evaluate the value of the estimated plasma volume status (ePVS) in patients undergoing isolated tricuspid valve surgery. Methods: This study included patients who underwent isolated tricuspid valve surgery at the Vienna General Hospital (Austria) between July 2008 and November 2018. The PVS cut-off was calculated using ROC analysis and Youden's Index. Results: Eighty eight patients (median age: 58 [IQR: 35-70] years; 44.3% male; 75.6% NYHA III/IV; median EuroSCORE II 2.65 [IQR: 1.70-5.10]; 33.0% endocarditis-related regurgitation; 60.2% isolated repair; 39.8% isolated replacement) were included in this study. Patients who died within 1 year following surgery had significantly higher baseline ePVS values than survivors (median ePVS 5.29 [IQR: -1.55-13.55] vs. -3.68 [IQR: -10.92-4.22]; p = 0.005). During a median actuarial follow-up of 3.02 (IQR: 0.36-6.80) years, patients with a preoperative ePVS ≥ -4.17 had a significantly increased mortality (log-rank p = 0.006). Conclusions: ePVS is an easily obtainable risk parameter for patients undergoing isolated tricuspid valve surgery capable of predicting mid- and long-term outcomes after isolated tricuspid valve surgery.

Rapid-deployment aortic valve replacement for patients with bicuspid aortic valve: a single-centre experience.

OBJECTIVES: The benefit of rapid-deployment aortic valve replacement (RD-AVR) in patients with a bicuspid aortic valve (BAV) is controversial due to aortic root asymmetry and potential increased risk for valve dislocation and paravalvular leak. This study aimed to analyse the outcomes of surgical aortic valve replacement with a rapid-deployment bioprosthesis in patients with a BAV. METHODS: Between May 2010 and December 2020, all consecutive patients who underwent RD-AVR at the Medical University of Vienna were included in our institutional database. Assessment of preoperative characteristics, operative outcomes, long-term survival and clinical events was performed. The outcomes of patients presenting with a native BAV were compared with a control group of patients with native tricuspid valve (TAV); reoperative aortic valve replacements were excluded. RESULTS: Out of 816 patients, who underwent RD-AVR at our institution, 107 patients with a BAV, mean age 68 (standard deviation: 8) years, were compared with a control group of 690 patients with a TAV, mean age 74 (standard deviation: 7) years; patients presenting with a BAV were significantly younger than patients with a TAV (P < 0.001). Concomitant procedures were performed in 44 (41.1%) patients in the BAV group and in 339 (49.1%) patients in the TAV group (P = 0.123); surgery of the ascending aorta was necessary in 24 (22.4%) in the BAV group, compared with 29 (4.2%) in the control group (P < 0.001). The 5-year cumulative incidence of moderate-to-severe paravalvular regurgitation in the BAV group was 10.7% [95% confidence interval (CI): 4.2-20.7%] and 3.9% (95% CI: 2.4-6.1%) in the TAV group (P = 0.057). Reoperation with valve explantation due to non-structural valve dysfunction at 5 years was 2.8% (95% CI: 0.5-8.8%) in the BAV group, compared to 1.9% (95% CI: 1.0-3.2%) in the TAV cohort (P = 0.89). The overall long-term survival rate in the BAV group was 92% (95% CI: 81-97%) at 5 years and 88% (95% CI: 73-95%), at 10 years, significantly better compared to the TAV group (log-rank test P = 0.002). CONCLUSIONS: RD-AVR can be performed in patients with a BAV with convincingly medical outcomes. However, a trend to increased frequency of moderate-severe paravalvular regurgitation was observed at long-term follow-up. Consequently, a different surgical approach, compared to tricuspid valves, with distinctly specific technical- and anatomical considerations and requirements, is recommended.

Long-term durability after surgical aortic valve replacement with the Trifecta and the Intuity valve-a comparative analysis.

OBJECTIVES: Long-term durability of surgical bio-prostheses is a key factor, especially in the era of transcatheter aortic valve replacement. We compared the incidence of structural valve deterioration (SVD) between patients undergoing surgical aortic valve replacement (SAVR) with the Trifecta (Abbott Laboratories, Abbott Park, IL, USA) or the Intuity valve (Edwards Lifesciences, Irvine, CA, USA). METHODS: Between April 2010 and May 2020, 1118 patients underwent SAVR with the Trifecta (n = 346) and the Intuity (n = 772) valve at a single centre. A total of 1070 patients (Trifecta n = 298, Intuity n = 772) were analysed after the exclusion of patients with pure regurgitation and endocarditis. Retro- and prospective echocardiographic and clinical follow-up was performed. Cox proportional hazards regression models were performed to identify prognostic factors for SVD, aortic re-interventions and mortality. RESULTS: With 27 cases (Trifecta n = 23, Intuity n = 4) of SVD observed, cumulative incidence of SVD was significantly higher in the Trifecta cohort (P < 0.001). Implantation of a Trifecta valve [hazard ratio (HR) 11.20; 95% confidence interval 3.79-33.09], log-transformed preoperative creatinine (HR 2.47; 1.37-4.44) and sex (male HR 0.42; 0.19-0.92) emerged as prognostic factors of SVD. A significantly higher cumulative incidence of re-interventions was observed in the Trifecta cohort (P = 0.004) and valve type was an independent time-varying risk factor (HR at 12 months 2.78; 95% confidence interval 1.42-5.45). Overall, no significant differences in all-cause mortality were observed between the groups (log-rank test: P = 0.052). CONCLUSIONS: SVD was significantly more frequent in patients receiving a Trifecta valve and its implantation was an independent risk factor for the occurrence of SVD and aortic valve re-interventions. This comparative analysis of 2 low-gradient bioprosthesis put the long-term durability of the Trifecta valve in question and need to be taken into consideration when performing bioprosthetic SAVR.

Conduction disturbances following surgical aortic valve replacement with a rapid-deployment bioprosthesis.

BACKGROUND: The implantation of rapid-deployment aortic valves may interfere with the conduction system of the heart. This study evaluates the occurrence and predictive factors of conduction anomalies in patients undergoing surgical aortic valve replacement (SAVR) with a rapid-deployment balloon-expandable bioprosthesis in a single-center, real-world experience. METHODS: Between May 2010 and April 2019, 700 consecutive patients were included in a prospective, ongoing database with a longitudinal follow-up preoperatively, at discharge, and at 3 months, 1 year, 3 years, and 5 years postoperatively. Thirty-seven patients (5.3%) had a permanent pacemaker at baseline and were excluded from further analysis, leaving 663 patients for analysis. Assessment of conduction anomalies was performed by electrocardiography (ECG) monitoring and repeated 12-lead ECG during the hospital stay and at postoperative follow-ups. RESULTS: Preoperatively, 126 patients (19.0%) presented with different conduction disturbances. New permanent pacemaker implantation (PPI) occurred in 61 patients during the first 14 days (cumulative incidence, 9.4%). The indication for PPI was complete atrioventricular block in 47 cases (77%). Preoperative conduction anomalies, such as right bundle branch block, as well as operative characteristics (concomitant procedures) were found to be independent predictors for new PPI. One-year survival was 98% in patients with new early PPI and 96% in those without new early PPI (P = .60). CONCLUSIONS: The PPI rate was in the range of previous reports for rapid-deployment prostheses. PPI did not have a significant influence on short- to intermediate-term survival. Case selection with exclusion of patients presenting with baseline conduction disturbances may decrease the rate of new PPIs after SAVR with rapid-deployment balloon-expandable bioprostheses.

Effect of conventional and rapid-deployment aortic valve replacement on the distance from the aortic annulus to coronary arteries.

OBJECTIVES: This study aimed to compare the effect of surgical aortic valve replacement (SAVR) on coronary height in patients undergoing SAVR with rapid-deployment or SAVR with several standard sutured bioprostheses. This study may identify patients at higher risk of coronary obstruction during valve-in-valve procedures. METHODS: We analysed 112 patients [mean age 71 (9 SD) years] who underwent SAVR with either a rapid-deployment aortic bioprosthesis (EDWARDS INTUITY Elite Valve) or other standard sutured biological valves. The coronary heights were assessed by computed tomography scan with the Philips 3D HeartNavigator system. RESULTS: Two groups of patients were analysed: 51 (45.5%) patients implanted with an RD-AVR, which is a supra-annular valve that requires 3 anchoring sutures without the use of pledgets, and 61 (54.5%) patients implanted with a conventional supra-annular sutured bioprosthesis. The mean right and left coronary artery-to-annulus (RCAA and LCAA) heights at baseline were 16.9 (4.6 SD) and 14.2 (4.0 SD) mm in the standard sutured group and 16.3 (3.5 SD) and 12.8 (2.9 SD) mm in the RD-AVR group, respectively; a significantly shorter distance was observed for the left coronary artery in the rapid-deployment group (P = 0.420 for RCAA height and P = 0.044 for LCAA). Postoperatively, the mean RCAA and LCAA heights were significantly decreased in both groups compared to baseline. A mean of 11.5 (4.8 SD) mm for the RCAA and 7.9 (4.3 SD) mm for the LCAA in the standard sutured group as well as 14.4 (3.9 SD) mm for the RCAA and 9.0 (3.1 SD) mm for the LCAA in the RD-AVR group were observed (P < 0.001 for RCAA and LCAA in both the sutured and rapid-deployment groups). Despite the significant difference in the mean distance from the left coronary artery to annulus between the groups at baseline, the postoperative mean distance of the LCAA to the sewing ring was still higher in the RD-AVR group. CONCLUSIONS: A significantly shorter coronary artery-to-aortic annulus distance for both the right and left main coronary arteries was observed after AVR with different conventional sutured supra-annular bioprostheses compared to AVR with rapid-deployment valves. These findings might be relevant for bioprosthesis selection, especially for young patients.

Anterior Right Thoracotomy for Rapid-Deployment Aortic Valve Replacement.

BACKGROUND: Minimally invasive aortic valve replacement through anterior right thoracotomy (ART) has shown to be safe and feasible. However, acceptance within the surgical community is low. Rapid-deployment aortic valves may be a game changer due to simplified surgical technique and shorter operative times. Therefore, the combination of advanced surgical techniques like the ART access with rapid-deployment aortic valves was assessed in this study. METHODS: We retrospectively analyzed all patients undergoing ART with the Edwards Intuity Elite (Edwards Lifesciences, Irvine, CA) valve system between 2011 and 2018. Patient data were collected prospectively in an ongoing, single-center registry. Data analysis regarding valve outcome was performed according to current guidelines. RESULTS: In all, 165 patients underwent aortic valve replacement through ART access with the Edwards Intuity valve system (age 73 ± 9 years, 49% female, median European System for Cardiac Operative Risk Evaluation II score 1.6 [range, 0.6 to 10.6]). Median cardiopulmonary bypass time was 114 minutes (range, 61 to 310) and median aortic cross-clamp time was 80 minutes (range, 45 to 230). Thirty-day as well as inhospital mortality was 0.6% (n = 1). Postoperative neurologic events occurred in 3%, resulting in major neurologic deficit in 1 patient. Intermediate and long-term survival was 99%, 98%, and 93% after 6 months, 1 year, and 3 years, respectively. CONCLUSIONS: Implantation of the Edwards Intuity valve system through ART is safe, feasible, and reproducible. The overall results of this single center experience are excellent compared with contemporary series of both surgical and transcatheter aortic valve replacements.

Structural valve deterioration after aortic valve replacement with the Trifecta valve.

OBJECTIVES: Despite promising short- and mid-term results for durability of the Trifecta valve, contradictory reports of early structural valve deterioration (SVD) do exist. We investigated the incidence of SVD after surgical aortic valve replacement (SAVR) with the Trifecta in our single-centre experience. METHODS: Data of 347 consecutive patients (mean age 71.6 ± 9.5 years, 63.4% male) undergoing SAVR with the Trifecta between 2011 and 2017 were analysed. Clinical and echocardiographic reports were obtained with a median follow-up of 41 months (1114 patient years). RESULTS: Isolated SAVR was performed in 122 patients (35.2%), whereas 225 patients (64.8%) underwent concomitant procedures. The median EuroSCORE II was 4.0 (0.9; 7.1) and 30-day mortality was 3.7% (n = 13). Kaplan-Meier estimates for the freedom of overall mortality at 1, 5 and 7 years were 88.7 ± 1.7%, 73.7 ± 2.6% and 64.7 ± 4.2%, respectively. SVD was observed in 25 patients (7.2%) with a median time to first diagnosis of 73 months. Freedom of SVD was 92.5 ± 0.9% at 5 years and 65.5 ± 7.1% at 7 years. Thirteen patients underwent reintervention for SVD (6 re-SAVR, 7 valve-in-valve), resulting in a freedom of reintervention for the SVD of 98.5 ± 1.1% at 5 years and 76.9 ± 6.9% at 7 years. CONCLUSIONS: We herein report one of the highest rates of SVD after SAVR with the Trifecta. These data indicate that the durability of the prosthesis decreases at intermediate to long-term follow-up, leading to considerable rates of reintervention due to SVD.

Donor-specific HLA antibodies after fresh decellularized vs cryopreserved native allograft implantation.

This study aims to compare the immunogenicity of fresh decellularized with cryopreserved native heart valve allografts to identify potential immunological risks in subsequent organ transplantations. We measured the induction of allogeneic HLA class I and II specific antibodies and characterized donor-specific antibodies by Luminex-based single beads assay in both groups. Serum samples were collected before valve replacement, at 3 and 24 months postoperatively. Donor-specific HLA antibodies were assessed positive if the mean fluorescent intensity (MFI) was >1000. Between November 2016 and April 2017 patients with fresh decellularized homografts (n = 4) and cryopreserved native homografts (n = 4) were analyzed. Patients receiving cryopreserved native allografts reacted with broad HLA-specific antibody response. Antibodies were directed against mismatched HLA antigens of the donors but also against HLA specificities not present on the homograft with many antibodies having mean fluorescence intensity values >10 000. While HLA class I specific antibodies showed a significant increase (P = .002) in their MFI values on day 90, HLA class II specific antibodies did not show a significant increase (P = .069). In the fresh decellularized homografts group, no significant antibody induction was observed. Consequently, the native group presented significantly higher MFIs for HLA antibodies on day 90 compared with the patients receiving decellularized allografts (P = .021). No detectable HLA antibody response was observed after implantation of decellularized in comparison with cryopreserved native allografts. Lower immunogenicity as compared with native homografts might increase the chance of receiving a transplant if will be required later in the life of the patients.

Outcome of rapid deployment aortic valves: long-term experience after 700 implants.

BACKGROUND: The Edwards Intuity Valve System is a bioprosthesis with a balloon-expandable stent frame which enables rapid-deployment (RD). We aimed to analyze our single-center long-term experience with a follow-up until 9 years after aortic valve replacement (AVR) with this bioprosthesis. METHODS: Between May 2010 and May 2019, 700 consecutive patients with severe aortic stenosis or combined aortic valve disease, implanted with a RD valve at our institution, were included in a prospective database. Median follow-up was 19 months and the total accumulated follow-up was 2,140 patient-years. Pre-operative characteristics, operative parameters, survival rates, valve-related adverse events and valve hemodynamics were assessed. RESULTS: Mean age was 74±8 years, 45% female. Concomitant procedures were performed in 339 (48.4%) patients. In case of isolated AVR (361/700), a minimally invasive surgical (MIS) approach was conducted in 283 patients (78.4%). Cardio-pulmonary bypass (CPB) and cross-clamp times for isolated AVR were 107.7±28.2 and 73.8±21.3 minutes for MIS approaches and 92.8±28.8 and 57.5±20.6 minutes for full sternotomy (P<0.001), respectively. Mean gradients at discharge, 1, 3 and 5 years were 13±5, 11±4, 12±5 and 13±8 mmHg. New early pacemaker implantation was required in 8.9% of patients. Re-intervention or re-operation with valve explantation for structural degeneration, non-structural dysfunction or endocarditis, occurred in 21 cases (3%). Thirty-day mortality was 0.7% (5/700) and overall survival at 1, 3 and 5 years was 98%, 91% and 76%. CONCLUSIONS: We report excellent long-term results in this updated single center experience for RD aortic valves regarding durability, safety and hemodynamic performance.

Rapid-Deployment Aortic Valves for Patients With a Small Aortic Root: A Single-Center Experience.

BACKGROUND: Aortic valve replacement in patients with a small aortic root is a matter of concern in terms of prosthesis-patient mismatch. We evaluated the survival and hemodynamic performance after implantation of a small rapid-deployment aortic valve (EDWARDS INTUITY valve system sizes 19 and 21 mm). METHODS: Between May 2010 and November 2018, 659 consecutive patients with severe aortic stenosis who received a rapid-deployment valve were included in a prospective and ongoing database. A small aortic bioprosthesis (sizes 19 mm and 21 mm) was implanted in 217 (32.9%) patients (mean age 74.9 ± 7.9 years, 85.3% women). Preoperative characteristics, operative parameters, and postoperative outcomes were assessed. RESULTS: Mean gradients at discharge and 1 year were 14.8 ± 5.6 mm Hg and 13.6 ± 4.9 mm Hg, respectively. Mean effective orifice area and the indexed effective orifice area at discharge were 1.55 ± 0.36 cm2 and 0.87 ± 0.22 cm2/m2, respectively, and prosthesis-patient mismatch occurred in 77 (35.5%) patients (25.8% moderate and 9.7% severe). Perioperative mortality was 1.8% (n = 4 of 217) and overall survival at 1 year and 5 years was 91% and 79%, respectively. The presence of any prosthesis-patient mismatch degree did not have a significant influence on overall survival (hazard ratio, 0.95; 95% confidence interval, 0.75-1.19; P = .638). At the last follow-up, mean New York Heart Association functional class was 1.5 ± 0.7 vs 2.8 ± 0.6 at baseline (P < .001). CONCLUSIONS: Surgical aortic valve replacement with rapid-deployment valves has shown improved results concerning hemodynamic performance, with decreased rates of prosthesis-patient mismatch. We observed excellent early-term and midterm survival and a significant improvement in functional class in this subgroup of patients with a small annulus.

Atrial Fibrillation After Cardiac Surgery: Electrophysiological Mechanism and Outcome.

BACKGROUND: Postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with an inferior outcome. The high cure rate compared with non-POAF raises questions regarding the electrophysiologic mechanism. Despite being common, until now the electrophysiologic mechanism of POAF was never assessed. METHODS: Ten patients (5 men; mean age, 75 ± 5 years) with POAF underwent noninvasive 3-dimensional beat-by-beat mapping and were compared with 10 patients (6 men; mean age, 70 ± 10 years) with preoperative persistent AF (PEAF) undergoing open heart procedures. Three-dimensional mappings were compared by the nature and location of focal and rotor activity using the validated Bordeaux classification. RESULTS: Rotor activity was present in both atria of all patients; 299 rotors (mean, 30 ± 12) were mapped in the POAF group and 289 (mean, 29 ± 22) in the PEAF group. The most common region for macro reentry in both groups was the pulmonary vein area. Left atrium and left atrial appendage activity accounted for 59% (177/299 POAF group) and 62% (180/289 PEAF group) of all drivers. Rotor activity in the right atrium was documented in all patients. Focal activity was captured in only 2 patients in the POAF group and in 6 patients in the PEAF group. CONCLUSIONS: The mechanism of POAF is comparable with that of PEAF. Rotor activity was similar in both groups, but focal activity was numerically less common in the POAF group, which may be related to differences in atrial tissue remodeling. In POAF, transient substrate changes seem to facilitate the development of AF. A better understanding of atrial tissue changes by mapping and tissue analysis should lead to better preventive approaches.

A rare case of quadruple valve surgery with bioprosthetic pulmonary valve replacement in an octogenarian for degenerative valvular disease: Technical aspects.

Quadruple valve surgery represents a complex and rare surgical procedure, requiring a systematic and standardized approach. In this intervention, pulmonary valve replacement (PVR) in patients without pre-existing congenital heart disease represents a challenge and no large data have been reported yet. We hereby report a case of bioprosthetic PVR in an octogenarian within a quadruple valve procedure, illustrating our preferred technique of PVR with bioprosthetic implantation and right ventricular outflow tract reconstruction.

Noninvasive mapping before surgical ablation for persistent, long-standing atrial fibrillation.

OBJECTIVE: The study objective was to study the electrophysiologic mechanism of atrial fibrillation using a noninvasive, beat-by-beat, 3-dimensional mapping technique in patients with persistent and long-standing persistent atrial fibrillation undergoing concomitant surgical ablation. METHODS: In this pilot trial, 10 patients (6 male; mean age, 70 ± 10 years) with persistent atrial fibrillation were mapped preoperatively with a noninvasive surface system (ECVUE, CardioInsight, Medtronic Inc, Minneapolis, Minn). Eight patients were candidates for mitral valve surgery, 1 patient was a candidate for aortic valve and ascending aortic replacement, and 1 patient was a candidate for coronary bypass surgery. In 5 patients, tricuspid valve repair was also performed. The Cox-Maze III/IV was performed using combined cryoablation and bipolar radiofrequency, and the left appendage was removed in all cases. The median preprocedural duration of atrial fibrillation was 30 months, and the diameter of the left atrium was 63 mm. Atrial regions were divided according to the Bordeaux classification. RESULTS: Preoperative mapping was successful in all patients with clear identification of the potential mechanism of atrial fibrillation. Biatrial pathology was recognized in all subjects. Rotor and macro re-entry activity were present in all patients, whereas focal activity was demonstrated in only 6 patients. Rotor activity in the right atrium was documented in all patients. CONCLUSIONS: This is the first report on the preoperative use of the ECUVE in surgical candidates for concomitant surgical procedures. The fact that a biatrial mechanism for atrial fibrillation was detected in all patients emphasizes the importance of a Cox-Maze III/IV procedure to treat patients with valvular heart disease and nonparoxysmal atrial fibrillation. Preoperative mapping has the potential to significantly improve our understanding of the pathophysiology in atrial fibrillation and better guide the surgical ablation procedure of choice in a single patient.

Intermediate-term outcome of 500 consecutive rapid-deployment surgical aortic valve procedures†.

OBJECTIVES: The Edwards INTUITY Valve System is a balloon-expandable bioprosthesis, inspired from the Edwards Magna valve and transcatheter technology, with a subvalvular stent frame to enable rapid deployment. We report a single-centre experience of aortic valve replacement with this novel bioprosthesis. METHODS: Five hundred consecutive patients, of whom 45.6% were female with a mean age of 73.5 [standard deviation (SD) 7.9 years], with severe aortic stenosis who received a rapid deployment aortic valve between May 2010 and July 2017 were included in a prospective and ongoing database. The median follow-up time was 12 months, and the total accumulated follow-up time was 818 patient years. Preoperative characteristics, operative parameters, survival, valve-related adverse events and valve haemodynamics were assessed. RESULTS: Thirty-day mortality was 0.8% (4/500), and overall survival at 1, 3 and 5 years was 94%, 89% and 81%, respectively. A minimally invasive surgical approach was chosen in 236 patients (47%), of which 122 (24%) were operated on through an anterior right thoracotomy. Cross-clamp and cardiopulmonary bypass times for isolated aortic valve replacement were 53 (SD 17) and 89 (SD 29) min for full sternotomy as well as 75 (SD 23) and 110 (SD 31) min for minimally invasive surgery approaches (P < 0.001). Mean gradients at discharge, 1, 3 and 5 years were 13 (SD 5), 11 (SD 4), 12 (SD 5) and 11 (SD 3) mmHg, respectively. New pacemaker implantation was necessary in 8.6% of patients. A single case (0.2%) of structural degeneration was registered after 6 years. Valve explantation for non-structural dysfunction or endocarditis occurred in 9 patients (1.8%). CONCLUSIONS: This rapid deployment aortic valve has shown excellent results concerning haemodynamic performance, durability and safety. Implantation requires specific training, and the rate of pacemaker implantation remains a matter of concern. This novel valve also facilitates minimally invasive approaches and may be beneficial in complex combined procedures.