Transcatheter Aortic Valve Implantation (TAVI) in Bicuspid Aortic Valve Disease: A Systematic Review.

Transcatheter aortic valve implantation (TAVI) is effective and safe, but its outcomes for patients with bicuspid aortic valve (BAV) disease are relatively unclear. A comprehensive search of PubMed, Medline, and Google Scholar till November 2023 yielded studies evaluating TAVI in BAV patients. Inclusion criteria were applied, and data were extracted on clinical and procedural outcomes, including echocardiographic measures and complications. Statistical analyses included descriptive statistics, subgroup analysis, and sensitivity analysis. From the 29 studies covering 8045 BAV patients, the mean age was found to be 72.5 ± 10.35 years with a male predominance of 56.4% ± 7.9%. TAVI was significantly beneficial, decreasing the mean aortic gradient from 46.9 to 10.4 mm Hg postprocedure and increasing aortic valve area, evidencing improved hemodynamics. A high procedural success rate of 93.3% was noted, predominantly through femoral access. However, complications included pacemaker need (12.6%), minor bleeding, and acute kidney injury. All-cause mortality escalated from 3.7% perioperatively to 16.8% after 1 year. Hazard ratios and P values highlighted significant outcomes: perioperative hazard ratio for mortality at 3.7% (P < 0.05), reduction in perioperative versus postoperative gradients (P < 0.001), and increase in postoperative aortic valve area (P < 0.001). The need for postdilatation was less than predilatation (P < 0.05), and significant differences were noted in device sizes (P < 0.05). TAVI in BAV patients showed good perioperative outcomes but with moderate complication rates. Notably, there was a significant rise in 1-year mortality, underscoring the importance of careful patient selection and strict postoperative care. More studies are necessary to determine long-term results and refine procedures for this group.

The Results of Urgent and Emergent Transcatheter Mitral Valve Repair (MitraClip®): A Comparison with Standard Elective Repair.

Background: Mitral regurgitation (MR) is the most common valvular disease worldwide. MR has been managed surgically, with either a mitral valve replacement or repair. Percutaneous transcatheter mitral valve repair (TMVr) with MitraClip® insertion has gained wide popularity and success over medical and surgical therapy for MR. Some patients with acute MR or decompensated heart failure could benefit from urgent TMVr. This meta-analysis aims to compare clinical outcomes of urgent versus elective TMVr. Methods: We performed a study-level meta-analysis to compare the clinical outcomes of urgent versus elective TMVr using the MitraClip system. The primary endpoint outcome was all-cause mortality. Additional outcomes included procedural success, postoperative acute kidney injury (AKI), stroke, and length of in-hospital stay. Results: Overall, 30-day mortality was significantly higher in the urgent group (odds ratio [OR]: 2.74; 95% confidence interval [CI] [2.17, 3.48]; P < 0.00001; I² =0%). However, subgroup analysis of matched cohorts showed no significant difference between both groups (OR: 1.80; 95% CI [0.94, 3.46]; P = 0.08; I² =0%). One-year mortality was similar between both groups (and: 1.67; 95% CI [0.96, 2.90]; P = 0.07; I² =0%). Procedural success was similar between both groups (89.4% vs. 89.8%; P = 0.43). Postoperative AKI was significantly higher in the urgent group (OR: 4.12; 95% CI [2.87, 5.91]; P < 0.00001; I² =0%). Conclusion: Urgent TMVr should be indicated in select populations as it is considered therapeutic with acceptable outcomes therein.

Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review.

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Novel approaches for leadless pacemaker implantation in the extra-cardiac Fontan cohort: Options to avoid leaded systems or epicardial pacing.

BACKGROUND: Fontan surgery, a palliative procedure for single ventricle patients, often leads to the need for permanent pacing. Epicardial pacing has limitations, while transvenous pacing carries risks in the Fontan circulation. This case series introduces a novel approach of leadless pacemaker implantation in the extra-cardiac Fontan (ECF) cohort to overcome these limitations. METHODS: The study includes four cases of leadless pacemaker (Micra™) implantation in patients with ECF. Procedures were performed under general anesthesia with guidance from trans-esophageal echocardiography. Various access routes were used, including trans-carotid and trans-fenestration approaches. Procedural details, parameters, and follow-up data were collected. RESULTS: All leadless pacemaker implantations were successful, with satisfactory electrical parameters and stable pacing postprocedural outcomes during short-term follow-up. One patient required closure of their fenestration for symptomatic desaturation post procedurally. CONCLUSIONS: Leadless pacemaker implantation via trans-carotid and trans-fenestration approaches appears to be a feasible back up option for pacing in Fontan patients where other options have been exhausted or there is a patient choice to avoid surgery. These techniques provide an option to avoid leaded systems or epicardial pacing, reducing the need for multiple thoracotomies and addressing challenges associated with surgical pacing leads. Further studies are needed to evaluate long-term outcomes and assess the broader application of leadless pacemakers in the Fontan population.

Optimising risk factors for atrial fibrillation post-cardiac surgery.

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.

Understanding UK medical students' perspectives on a career in cardiothoracic surgery.

Objectives: The UK postgraduate training program in cardiothoracic surgery is challenging and competitive, with trainees choosing the field for different reasons. This study aims to identify factors that influence medical students in pursuing a career within cardiothoracic surgery. Methods: A cross-sectional study was carried out in which a questionnaire was anonymously filled out by medical students across 17 medical schools in the United Kingdom. An online survey platform was used for survey distribution and analysis. A mixed-methods approach was employed to gather quantitative and qualitative data. Data collection consisted of a series of closed questions and 1 open-ended question. The questions focused on the attitudes toward, knowledge of, and exposure to cardiothoracic surgery. Results: The survey yielded 265 responses. Interest in cardiothoracic surgery was seen in 45.3% of participants, with the leading factor for pursuing this career being lifestyle factors (50%), closely followed by the career opportunities (42.9%) and the aid of mentors (31%). Some discouraging factors were: Difficulty of learning material (37.7%), length of the training program (27.4%), competition in the field (26%), stress (24.3%), and lifestyle factors (22.1%). Conclusions: Whilst UK medical schools try to provide an introduction to specialties like cardiothoracic surgery, there remains a proportion of medical students who do not have access to opportunities needed to make a balanced career decision. Additionally, individual circumstances and aspirations tend to change from students' first year of study to their final year, which can alter their perceptions about the field.

Conventional versus miniaturized cardiopulmonary bypass: A systematic review and meta-analysis.

Objective: A meta-analysis of randomized controlled trials was performed to compare the effects of miniaturized extracorporeal circulation (MECC) and conventional extracorporeal circulation (CECC) on morbidity and mortality rates after cardiac surgery. Methods: A comprehensive literature search was conducted using Ovid, PubMed, Medline, EMBASE, and the Cochrane databases. Randomized controlled trials from the year 2000 with n > 40 patients were considered. Key search terms included variations of "mini," "cardiopulmonary," "bypass," "extracorporeal," "perfusion," and "circuit." Studies were assessed for bias using the Cochrane Risk of Bias tool. The primary outcomes were postoperative mortality and stroke. Secondary outcomes included arrhythmia, myocardial infarction, renal failure, blood loss, and a composite outcome comprised of mortality, stroke, myocardial infarction and renal failure. Duration of intensive care unit, and hospital stay was also recorded. Results: The 42 studies eligible for this study included a total of 2154 patients who underwent CECC and 2196 patients who underwent MECC. There were no significant differences in any preoperative or demographic characteristics. Compared with CECC, MECC did not reduce the incidence of mortality, stroke, myocardial infarction, and renal failure but did significantly decrease the composite of these outcomes (odds ratio, 0.64; 95% confidence interval [CI], 0.50-0.81; P = .0002). MECC was also associated with reductions in arrhythmia (odds ratio, 0.67; 95% CI, 0.54-0.83; P = .0003), blood loss (mean difference [MD], -96.37 mL; 95% CI, -152.70 to -40.05 mL; P = .0008), hospital stay (MD, -0.70 days; 95% CI, -1.21 to -0.20 days; P = .006), and intensive care unit stay (MD, -2.27 hours; 95% CI, -3.03 to -1.50 hours; P < .001). Conclusions: MECC demonstrates clinical benefits compared with CECC. Further studies are required to perform a cost-utility analysis and to assess the long-term outcomes of MECC. These should use standardized definitions of endpoints such as mortality and renal failure to reduce inconsistency in outcome reporting.