Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics.

BACKGROUND: Heart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team. OBJECTIVE: To determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS). METHODS: Single-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations. RESULTS: 2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007). CONCLUSIONS: In patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.

Comparative analysis of LVAD patients in regard of ischaemic or idiopathic cardiomyopathy: A propensity-score analysis of EUROMACS data.

BACKGROUND: Despite recent advances in management of patients with advanced heart failure, mortality remains high. Aim of this study was to compare impact of different aetiology of ischaemic and idiopathic cardiomyopathy on early outcomes and long-term survival of patients after left ventricular assist device implantation. METHODS: European Registry for Patients with Mechanical Circulatory Support (EUROMACS) gathers clinical data and follow-up parameters of LVAD recipients. Patients enrolled in the EUROMACS registry with primary diagnosis of either ischaemic (n = 1190) or idiopathic (n = 812) cardiomyopathy were included. Primary Endpoints were early mortality as well as long-term survival. Secondary endpoint were major postoperative adverse events, such as need for rethoracotomy. Additionally, a propensity-score matching analysis was performed for patients with ischaemic (n = 509) and idiopathic (n = 509) cardiomyopathy. RESULTS: In terms of basic demographics and baseline parameters the two groups significantly differed as expected before propensity-score matching due to different aetiology of cardiomyopathy. Seven-day (52 (4.4%) versus 18 (2.2%); p = 0.009), 30-day (153 (12.9%) versus 73 (9.0%); p = 0.008) and in-hospital mortality (253 (19.7%) versus 123 (15.1%); p = 0.009) were significantly lower in the idiopathic cardiomyopathy group compared to the ischaemic cardiomyopathy group, whereas after propensity-score matching 30-day (p = 0.169) was comparable and in-hospital mortality (p = 0.051) was almost significant. Kaplan-Meier survival analysis revealed no significant difference in regard of long-term survival after propensity-score matching (Breslow-test p = 0.161 and LogRank-test p = 0.113). CONCLUSION: Though patients with ischaemic and idiopathic cardiomyopathy suffer from different cardiomyopathy aetiologies, 30-day-mortality and long-term survival of both groups were similar leading to the conclusion that covariates predominately influence mortality and survival of ischaemic and idiopathic cardiomyopathies.

The European Registry for Patients with Mechanical Circulatory Support of the European Association for Cardio-Thoracic Surgery: third report.

OBJECTIVES: In the third report of the European Registry for Patients with Mechanical Circulatory Support of the European Association for Cardio-Thoracic Surgery, outcomes of patients receiving mechanical circulatory support are reviewed in relation to implant era. METHODS: Procedures in adult patients (January 2011-June 2020) were included. Patients from centres with <60% follow-ups completed were excluded. Outcomes were stratified into 3 eras (2011-2013, 2014-2017 and 2018-2020). Adverse event rates (AERs) were calculated and stratified into early phase (<3 months) and late phase (>3 months). Risk factors for death were explored using univariable Cox regression with a stepwise time-varying hazard ratio (<3 vs >3 months). RESULTS: In total, 4834 procedures in 4486 individual patients (72 hospitals) were included, with a median follow-up of 1.1 (interquartile range: 0.3-2.6) years. The annual number of implants (range: 346-600) did not significantly change (P = 0.41). Both Interagency Registry for Mechanically Assisted Circulatory Support class (classes 4-7: 23, 25 and 33%; P < 0.001) and in-hospital deaths (18.5, 17.2 and 11.2; P < 0.001) decreased significantly between eras. Overall, mortality, transplants and the probability of weaning were 55, 25 and 2% at 5 years after the implant, respectively. Major infections were mainly noted early after the implant occurred (AER<3 months: 1.44 vs AER>3 months: 0.45). Bilirubin and creatinine levels were significant risk factors in the early phase but not in the late phase after the implant. CONCLUSIONS: In its 10 years of existence, EUROMACS has become a point of reference enabling benchmarking and outcome monitoring. Patient characteristics and outcomes changed between implant eras. In addition, both occurrence of outcomes and risk factor weights are time dependent.

Importance of In-Hospital Prospective Registry and Infectious Endocarditis Heart Team to Monitor and Improve Quality of Care in Patients with Infectious Endocarditis.

AIM: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. METHODS: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. RESULTS: Median age was 72.5 y (62.75-80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). CONCLUSIONS: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes.

Changes in surgical revascularization strategy after fractional flow reserve.

AIMS: In the randomized GRAFFITI trial, surgeons drew their strategy based on coronary angiography. When patients were randomized to fractional flow reserve (FFR)-guidance, surgeons were informed of the FFR values and asked to redraw their strategy. The aim of this study was to investigate the changes induced by FFR knowledge. METHODS AND RESULTS: The intended and performed strategy (before and after FFR) were compared. Among 172 patients, 84 with 300 lesions were randomized to the FFR-guided group. The intended strategy was to bypass 236 stenoses:108 with a venous and 128 with an arterial graft. After disclosing FFR, a change in strategy occurred in 64 lesions (21.3%) of 48 (55%) patients. Among 64 lesions for which the intended strategy was medical therapy, 16 (25%) were bypassed after disclosing FFR. The number of procedures with >1 venous graft planned was significantly reduced from 37 to 27 patients (p = .031). The proportion of on-pump surgery was significantly reduced from 71 to 61 patients (p = .006). The rates of clinical events at 1 year were similar between patients with or without at least one change in strategy. DISCUSSION: FFR-guided CABG is associated with a simplified surgical procedure in 55% of the patients, with similar clinical outcomes.

Coronary Artery Bypass Grafting or Fractional Flow Reserve-Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease.

BACKGROUND: In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)-guided PCI compared with CABG. METHODS: From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%-70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke. RESULTS: A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15-2.22]; P=0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72-1.53]; P=0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93-6.40]; P<0.001). CONCLUSIONS: In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI. Graphic Abstract: A graphic abstract is available for this article.

Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization.

OBJECTIVE: The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies. METHODS: The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients. RESULTS: Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction (n = 11, 36.7%) and inadequate target vessel visualization (n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation (n = 1, 3.3%) and sustained ventricular arrhythmia (n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% (n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia (n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance. CONCLUSIONS: RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs.

The Belgian experience with concomitant surgical ablation of atrial fibrillation: a multi-centre prospective registry.

Background: The Belgian 'National Institute for Health and Disability Insurance (RIZIV-INAMI)' requested prospective collection of data on all ablations in Belgium to determine the outcomes of surgical ablation of atrial fibrillation (AF) during concomitant cardiac surgery.Methods: 890 patients undergoing concomitant ablation for AF between 2011 and 2016 were prospectively followed. Freedom from AF with and without anti-arrhythmic drugs was calculated for 817 patients with follow-up beyond the 3-month blanking period and for 574 patients with sufficient rhythm-related follow-up consisting of at least one Holter registration or a skipped Holter due to AF being evident on ECG. Besides preoperative AF type, concomitant procedure and ablation, potential covariates were entered into uni- and multivariable regression models to determine predictors of outcome.Results: The overall freedom from AF beyond 3 months was 69.9% (571/817) and without anti-arrhythmic drugs at last follow-up 51.0% (417/817), respectively, 61.3% (352/574) and 44.4% (255/574) for patients with sufficient rhythm-related follow-up. Using a Kaplan-Meier estimate, freedom from AF was 89.3%, 74.9% and 59%, without antiarrhythmic drugs 74.4%, 47.8% and 32.3% at 6, 12 and 24 months, respectively. In-hospital mortality was 1.7% (15/890) and the overall survival was 95.0% at 1 year and 92.3% at 2 years. Preoperative left atrial diameter and AF type were significant predictive factors of freedom from AF in a multivariable analysis.Conclusion: Analysis of the Belgian national registry shows that concomitant surgical ablation of atrial fibrillation is safe, achieves favourable freedom from AF and, therefore, deserves to be performed in accordance to the guidelines.

Fractional flow reserve in patients with reduced ejection fraction.

AIMS: Fractional flow reserve (FFR) has never been investigated in patients with reduced ejection fraction and associated coronary artery disease (CAD). We evaluated the impact of FFR on the management strategies of these patients and related outcomes. METHODS AND RESULTS: From 2002 to 2010, all consecutive patients with left ventricular ejection fraction (LVEF) ≤50% undergoing coronary angiography with ≥1 intermediate coronary stenosis [diameter stenosis (DS)% 50-70%] treated based on angiography (Angiography-guided group) or according to FFR (FFR-guided group) were screened for inclusion. In the FFR-guided group, 433 patients were matched with 866 contemporary patients of the Angiography-guided group. For outcome comparison, 617 control patients with LVEF >50% were included. After FFR, stenotic vessels per patient were significantly downgraded compared with the Angiography-guided group (1.43 ± 0.98 vs. 1.97 ± 0.84; P < 0.001). This was associated with lower revascularization rate (52% vs. 62%; P < 0.001) in the FFR-guided vs. the Angiography-guided group. All-cause death at 5 years of follow-up was significantly lower in the FFR-guided as compared with Angiography-guided group [22% vs. 31%. HR (95% CI) 0.64 (0.51-0.81); P < 0.001]. Similarly, rate of major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, revascularization, and stroke) was significantly lower in the FFR-guided group [40% vs. 46% in the Angiography-guided group. HR (95% CI) 0.81 (0.67-0.97); P = 0.019]. Higher rates of death and MACCE were observed in patients with reduced LVEF compared with the control cohort. CONCLUSIONS: In patients with reduced LVEF and CAD, FFR-guided revascularization was associated with lower rates of death and MACCE at 5 years as compared with the Angiography-guided strategy. This beneficial impact was observed in parallel with less coronary artery bypass grafting and more patients deferred to percutaneous coronary intervention or medical therapy.

Results of primary biventricular support: an analysis of data from the EUROMACS registry.

OBJECTIVES: The purpose of this study was to describe pre- and postoperative data from the EUROMACS registry with regard to indications, for and survival and complication rates of patients with primary continuous flow and pulsatile biventricular long-term assist devices (BiVADs) versus total artificial hearts (TAHs) or left ventricular assist devices (LVADs) + short-term right ventricular assist device (RVAD) implants. METHODS: We investigated patients who received implants between 1 January 2011 and 21 October 2017. Clinical baseline information about comorbidities, laboratory results, medical and device therapies and echocardiographic, haemodynamic and right ventricle (RV) parameters were evaluated along with the rates of deaths and complications. RESULTS: A total of 413 of 3282 patients (12.5%) needed a biventricular pump. We investigated 37 long-term BiVADs, 342 LVAD + short-term RVAD implants and 34 TAHs. Minor differences were found in the baseline characteristics of our population, which had an overall high morbidity profile. The 1-year survival rate was 55% for patients with a continuous flow BiVAD; 52% for patients with an LVAD + short-term RVAD; 37% for patients with pulsatile BiVADs; and 36% for patients with a TAH. No statistical difference was observed among the groups. Over 50% of patients with BiVAD support were classified as INTERMACS profiles 1 and 2. The percent of patients with ambulatory heart failure (INTERMACS 4‒7) undergoing BiVAD implants was modest at <15%. No patients with a pulsatile BiVAD (n = 15) or a TAH (n = 34) were implanted as destination therapy, but 27% of the patients with continuous flow BiVADs (n = 6) and 23% of the patients with LVAD + short-term RVAD (n = 342) were implanted as 'destination'. The adverse events profile remained high, with no significant difference among pump types. The right ventricular stroke work index and right heart failure scores indicated poor RV function in all groups. After 3 months of LVAD + short-term RVAD support, 46.7% still required ongoing support, and only 18.5% were weaned from RVAD support; 33.1% died. CONCLUSIONS: The mortality rate after BiVAD support was high. Survival rates and adverse events were statistically not different among the investigated groups. In the future, composite study end points examining quality of life and adverse events beyond survival may help in shared decision-making prior to general mechanical circulatory support, particularly in patients with BiVAD implants.

Graft patency after FFR-guided versus angiography-guided coronary artery bypass grafting: the GRAFFITI trial.

AIMS: The aim of this study was to assess prospectively the clinical benefits of fractional flow reserve (FFR) in guiding coronary artery bypass grafting (CABG). METHODS AND RESULTS: GRAFFITI is a single-blinded, prospective, multicentre, randomised controlled trial of FFR-guided versus angiography-guided CABG. We enrolled patients undergoing coronary angiography, having a significantly diseased left anterior descending artery or left main stem and at least one more major coronary artery with intermediate stenosis, assessed by FFR. Surgical strategy was defined based on angiography, blinded to FFR values prior to randomisation. After randomisation, patients were operated on either following the angiography-based strategy (angiography-guided group) or according to FFR, i.e., with an FFR ≤0.80 as cut-off for grafting (FFR-guided group). The primary endpoint was graft patency at 12 months. Between March 2012 and December 2016, 172 patients were randomised either to the angiography-guided group (84 patients) or to the FFR-guided group (88 patients). The patients had a median of three [3; 4] lesions; diameter stenosis was 65% (50%; 80%), FFR was 0.72 (0.50; 0.82). Compared to the angiography-guided group, the FFR-guided group received fewer anastomoses (3 [3; 3] vs 2 [2; 3], respectively; p=0.004). One-year angiographic follow-up showed no difference in overall graft patency (126 [80%] vs 113 [81%], respectively; p=0.885). One-year clinical follow-up, available in 98% of patients, showed no difference in the composite of death, myocardial infarction, target vessel revascularisation and stroke. CONCLUSIONS: FFR guidance of CABG has no impact on one-year graft patency, but it is associated with a simplified surgical procedure. ClinicalTrials.gov Identifier: NCT01810224.

Six-Year Follow-Up of Fractional Flow Reserve-Guided Versus Angiography-Guided Coronary Artery Bypass Graft Surgery.

BACKGROUND: Fractional flow reserve (FFR)-guided coronary artery bypass graft (CABG) surgery has been associated with lower number of graft anastomoses, lower rate of on-pump surgery, and higher graft patency rate as compared with angiography-guided CABG surgery. However, no clinical benefit has been reported to date. METHODS AND RESULTS: Consecutive patients (n=627) treated by CABG between 2006 and 2010 were retrospectively included. In 198 patients, at least 1 stenosis was grafted according to FFR (FFR-guided group), whereas in 429 patients all stenoses were grafted based on angiography (angiography-guided group). The 2 coprimary end points were overall death or myocardial infarction and major adverse cardiovascular events (composite of overall death, myocardial infarction, and target vessel revascularization) up to 6-year follow-up. In the FFR-guided group, patients were significantly younger (66 [57-73] versus 70 [63-76]; P<0.001), more often male (82% versus 72%; P=0.008), and less often diabetic (21% versus 30%; P=0.023). Clinical follow-up (median, 85 [66-104] months) was analyzed in 396 patients after 1:1 propensity-score matching for these 3 variables. The rate of overall death or myocardial infarction was significantly lower in the FFR-guided (n=31 [16%] versus n=49 [25%]; hazard ratio, 0.59 [95% confidence interval, 0.38-0.93]; P=0.020) as compared with the angiography-guided group. Major adverse cardiovascular events rate was also numerically lower in the FFR-guided than in the angiography-guided group (n=42 [21%] versus n=52 [26%]; hazard ratio, 0.77 [95% confidence interval, 0.51-1.16]; P=0.21). CONCLUSIONS: FFR-guided CABG is associated with a significant reduction in the rate of overall death or myocardial infarction at 6-year follow-up as compared with angiography-guided CABG.

Endoscopic port access surgery for isolated atrioventricular valve endocarditis.

OBJECTIVES: Our goal was to report the clinical and echocardiographic outcomes of endoscopic port access surgery for isolated active and convalescent atrioventricular valve endocarditis (AVVE). METHODS: Our current surgical team performed endoscopic port access surgery in 66 consecutive patients with isolated AVVE (mean age, 65.5 ± 12.7 years, 37.9% women, mean EuroSCORE II 31.2 ± 24.9%, 45.5% prosthetic AVVE, Staphylococcus aureus 22.2%), between 1 May 2004 and 31 July 2015. Isolated mitral valve endocarditis was present in 53 (80.4%) patients, including 11 (16.7%) with periannular abscesses. RESULTS: Procedures performed included mitral valve repair (n = 15, 22.7%) and left ventricular septal myomectomy (n = 1, 1.5%). Reasons for sternotomy conversion (n = 6, 9.1%) included lung adhesions (n = 3, 4.5%). The mean cardiopulmonary bypass and ischaemic times were 167.2 ±48.7 and 112.6 ± 33.3 min, respectively. In-hospital morbidities included revision for bleeding (n = 6, 9.1%). The 30-day survival rate was 87.9%. Causes of in-hospital deaths (n = 12) included low cardiac output syndrome (n = 3, 4.5%). Age, critical preoperative status and EuroSCORE II score predicted deaths individually at the 5% level of significance. The Kaplan-Meier analyses (mean 63.2 ± 42.5 months) for survival and freedom from AVVE reintervention at 10 years were 69.4% and 98.4%, respectively. Of the mid-term survivors (n = 50, 93.9% complete), 94.0% (n = 47) classified as New York Heart Association (NYHA) II or less with no mitral valve regurgitation greater than Grade I. CONCLUSIONS: Complex atrioventricular valve surgery in the context of AVVE can be endoscopically performed in experienced centres and should not deter surgeons from offering patients with AVVE the potential benefits of minimally invasive cardiac surgery.

Reasons for conversion and adverse intraoperative events in Endoscopic Port Access™ atrioventricular valve surgery and minimally invasive aortic valve surgery.

OBJECTIVES: This study reports the factors that contribute to sternotomy conversions (SCs) and adverse intraoperative events in minimally invasive aortic valve surgery (MI-AVS) and minimally invasive Endoscopic Port Access™ atrioventricular valve surgery (MI-PAS). METHODS: In total, 3780 consecutive patients with either aortic valve disease or atrioventricular valve disease underwent minimally invasive valve surgery (MIVS) at our institution between 1 February 1997 and 31 March 2016. MI-AVS was performed in 908 patients (mean age 69.2 ± 11.3 years, 45.2% women, 6.2% redo cardiac surgery) and MI-PAS in 2872 patients (mean age 64.1 ± 13.3 years, 46.7% women, 12.2% redo cardiac surgery). RESULTS: A cumulative total of 4415 MIVS procedures (MI-AVS = 908, MI-PAS = 3507) included 1537 valve replacements (MI-AVS = 896, MI-PAS = 641) and 2878 isolated or combined valve repairs (MI-AVS = 12, MI-PAS = 2866). SC was required in 3.0% (n = 114 of 3780) of MIVS patients, which occurred in 3.1% (n = 28 of 908) of MI-AVS patients and 3.0% (n = 86 of 2872) of MI-PAS patients, respectively. Reasons for SC in MI-AVS included inadequate visualization (n = 4, 0.4%) and arterial cannulation difficulty (n = 7, 0.8%). For MI-PAS, SC was required in 54 (2.5%) isolated mitral valve procedures (n = 2183). Factors that contributed to SC in MI-PAS included lung adhesions (n = 35, 1.2%), inadequate visualization (n = 2, 0.1%), ventricular bleeding (n = 3, 0.1%) and atrioventricular dehiscence (n = 5, 0.2%). Neurological deficit occurred in 1 (0.1%) and 3 (3.5%) MI-AVS and MI-PAS conversions, respectively. No operative or 30-day mortalities were observed in MI-AVS conversions (n = 28). The 30-day mortality associated with SC in MI-PAS (n = 86) was 10.5% (n = 9). CONCLUSIONS: MIVS is increasingly being recognized as the 'gold-standard' for surgical valve interventions in the context of rapidly expanding catheter-based technology and increasing patient expectations. Surgeons need to be aware of factors that contribute to SC and adverse intraoperative outcomes to ensure that patients enjoy the maximum potential benefit of MIVS and to apply effective risk reduction strategies that encourage safer and sustainable MIVS programmes.

Endoscopic Port Access Surgery for Late Orthotopic Cardiac Transplantation Atrioventricular Valve Disease.

BACKGROUND: The study aim was to present details of the perioperative and long-term outcomes of redo-endoscopic port access surgery (REPAS) for late atrioventricular valve disease (AVVD) in orthotopic cardiac transplant (OCT) patients. METHODS: Between February 2004 and October 2015, REPAS was performed for late AVVD in seven consecutive OCT patients (mean age 57.9 ± 17.2 years; EuroSCORE II 21.2 ± 14.7%) at the authors' institution. The mean OCT-REPAS time interval was 7.8 ± 4.6 years (range: 1.3-13.8 years). NYHA class III or IV symptoms were present in four patients (57%). The mean left ventricular ejection fraction was 52.9 ± 3.9%, and surgical indications included severe mitral valve (MV) and tricuspid valve (TV) regurgitation in three patients (44%) and six patients (86%), respectively. Etiological factors included endomyocardial biopsy trauma (n = 6; 86%), degenerative disease (n = 2; 29%), and fungal endocarditis (n = 1; 14%). RESULTS: Procedures performed included MV repair (n = 3; 43%) and TV replacement (n = 3; 43%). There were no sternotomy conversions or revisions for any cause. The mean cardiopulmonary bypass and ischemic times were 178.4 ± 48.6 min and 118.3 ± 39.5 min, respectively. In-hospital morbidities included hospital-acquired pneumonia (n = 2; 29%). There were no wound infections or 30-day mortalities. The mean duration of hospitalization was 18.3 ± 11.0 days. A mean of 29.2 ± 45.6 patient-months (total 204.3 patient-months) was available for long-term clinical and echocardiographic analysis (n = 7; 100% complete). No MV or TV reinterventions were required. NYHA class ≤II was achieved in five patients (71%). No patient presented with residual MV regurgitation greater than grade I. CONCLUSIONS: REPAS for late AVVD in OCT patients is a safe and durable procedure with favorable technique-related mortality, in-hospital morbidity, and long-term cardiac-specific outcomes at experienced centers. The present technique provided an attractive benchmark against which emerging percutaneous interventions may be measured, and earlier referral of patients should be considered.

Robotic-enhanced coronary surgery in octogenarians.

Objectives: Robotic-enhanced minimally invasive direct coronary artery bypass grafting surgery (RE-MIDCAB) is based on the use of a robotic console and instrumentation for the dissection of the left internal thoracic artery (LITA). The LITA to left anterior descending (LAD) artery anastomosis is subsequently constructed through a mini thoracotomy. The purpose of this study is to present our experience of RE-MIDCAB outcomes in elderly patients. Methods: From 2002 until 2015, 44 octogenarians (the mean age of 82.9 years) underwent RE-MIDCAB. The mean logistic EuroSCORE was 9.2. The majority of the patients were male with a medical history of hypertension, dyslipidaemia and previous coronary interventions. Of these patients 25% underwent RE-MIDCAB combined with percutaneous coronary intervention (PCI) for the treatment of multi-vessel disease (hybrid revascularization). Results: All RE-MIDCABs and combined 'hybrid' PCI procedures were successfully completed. The mean intensive care unit (ICU) and hospital stay were 1.6 days and 10.9 days, respectively. There was 1 in-hospital mortality (2.3%). After an average follow-up period of 29.2 months, 5 patients required repeat revascularization procedures (9.1%). Mortality on follow-up was estimated at 25.6%. Conclusions: Our report suggests that considering the age and frailty of the octogenarian population, RE-MIDCAB is a feasible and safe procedure which is associated with acceptable mid-term results.

Endoscopic atrioventricular valve surgery in adults with difficult-to-access uncorrected congenital chest wall deformities.

OBJECTIVES: This study presents the first report on in-hospital and long-term outcomes of endoscopic port access atrioventricular valve surgery (EPAAVVS) in adult patients with uncorrected congenital chest wall deformities (CCWDs). METHODS: Our current surgical team performed EPAAVVS in 7 consecutive adult patients (mean age 51.3 ± 16.4 years, 14.3% female, 50% older than 60 years, mean EuroSCORE II 0.8 ± 0.1%) with uncorrected CCWDs between 1 November 2009 and 30 November 2015. The mean left ventricular ejection fraction was 66.0 ± 8.5%. Surgical indications included isolated or combined symptomatic mitral valve (MV) regurgitation (n = 7, 100%), left ventricular outflow tract (LVOT) obstruction (n = 1, 14.3%) and patent foramen ovale (n = 3, 42.9%). Fibro-elastic deficiency accounted for 57.1% of MV pathology and 5 patients (74.1%) presented with New York Heart Association (NYHA) Class III symptoms. CCWDs included isolated pectus excavatum (n = 5, 71.4%) and mixed pectus excavatum and carinatum (n = 2, 28.6%). The mean Haller-index and correction index scores were 2.7 ± 0.5 and 21.4 ± 10.2%, respectively. RESULTS: Procedures performed included MV repair (n = 7, 100%), tricuspid valve (TV) repair (n = 1, 14.3%) and left ventricular septal myomectomy (n = 1, 14.3%). There were no sternotomy conversions or complications with chest wall entry or atrioventricular valve exposure. The mean cardiopulmonary bypass and cross-clamp times were 162.1 ± 48.1 and 113.7 ± 33.5 min, respectively. No patient required mechanical ventilation or intensive care treatment longer than 24 h. There were no surgical revisions, in-hospital respiratory or chest wall morbidities. The mean length of hospital stay was 7.4 ± 1.0 days. A total of 208 patient-months (mean 29.7 ± 26.5) were available for long-term clinical and echocardiographic analysis. There were no 30-day or long-term mortalities and no patient required reintervention for residual atrioventricular valve pathology. All patients were classified as NYHA I during recent consultations, and echocardiographic follow-up confirmed no residual MV regurgitation greater than Grade 1 in any patient. CONCLUSIONS: EPAAVVS in adults with uncorrected CCWD is safe, feasible and durable and can successfully be performed by experienced teams to achieve Haller index and correction index scores of up to 3.3 and 38.3%, respectively, with favourable long-term clinical and echocardiographic outcomes. The mere presence of uncorrected CCWDs should not deter surgeons from offering these patients the full benefits of minimally invasive cardiac surgery.

Minimally invasive mitral valve repair for functional mitral regurgitation in severe heart failure: MitraClip versus minimally invasive surgical approach.

OBJECTIVES: To compare the outcomes of MitraClip versus minimally invasive surgical mitral valve repair in high-risk patients with significant functional mitral regurgitation (FMR) and severe heart failure in a centre having pilot versus extensive experience with the MitraClip and the minimally invasive surgical approach, respectively. METHODS: The MitraClip group consisted of 24 high-surgical-risk patients [age 75 ± 9 years, 75% males, NYHA III/IV 88%, left ventricular (LV) ejection fraction 31 ± 9%, EuroSCORE II 18 ± 14%], while the surgical group consisted of 48 patients matched for age, NYHA class and LV ejection fraction. RESULTS: Patients undergoing MitraClip versus those undergoing surgical repair showed higher prevalence of ischaemic LV dysfunction and larger LV end-diastolic diameter (both P < 0.05). Both the MitraClip and the surgical repair groups had similar 30-day mortality rates (4 vs 13%, P = 0.41) and prevalence of serious adverse events (25 vs 38%, P = 0.43). The median follow-up was 1028 days (IQR: 272-1564 days) in the MitraClip group and 890 days (IQR: 436-1381 days) in the surgical group (P = 0.95). Total all-cause mortality (54 vs 60%, log-rank P = 0.64) and rates of rehospitalizations for heart failure (42 vs 29%, log-rank P = 0.68) did not differ significantly between groups. Both techniques were associated with significant decrease in NYHA class and severity of FMR (P < 0.001 for all) and with a similar degree of stabilization of LV remodelling (P = NS). CONCLUSION: Despite the significant baseline differences in accumulated expertise and risk profile between the surgical and the MitraClip groups, both minimally invasive techniques were associated with similar 30-day and long-term outcomes.