Transfemoral versus transapical transcatheter aortic valve implantation: a single-centre experience.

OBJECTIVES: Transapical transcatheter aortic valve implantation (TAVI) is associated with increased mortality as compared to the transfemoral (TF) access. Possible mechanisms include different patient risk profiles as well as an intrinsic injury caused by the access route itself. METHODS: All consecutive patients scheduled for TAVI between January 2009 and June 2016 at a single centre were evaluated. A comparison of 30-day mortality and morbidity rates for patients undergoing TF or transapical (TA) TAVI was performed according to the criteria of the Valve Academic Research Consortium 2. RESULTS: During the investigated period, 1130 patients (TF: n = 619, TA: n = 511) were scheduled for TAVI. TA patients had a higher operative risk profile (logistic EuroSCORE: 24% vs 17%; P < 0.001). Unadjusted 30-day mortality rate was higher in TA than in TF patients, albeit this difference was not significant [TA: 6.7%, TF: 4.8%; odds ratio (OR) 1.3 (0.8-2.3); P = 0.216]. The multivariate logistic regression analysis revealed the logistic EuroSCORE and institutional experience, but not the access mode as independent predictors of 30-day mortality. Major access-site complications occurred with a similar frequency in both groups [TA: 9.4%; TF: 9.2%; OR 1.02 (0.68-1.53); P = 0.915]. Unadjusted long-term mortality rate was higher after TA TAVI. After adjustment, the Cox regression analysis revealed similar long-term mortality rates after TF and TA TAVI [hazard ratio 1.1 (0.88-1.36)]. CONCLUSIONS: The increased mortality of patients undergoing TA TAVI is associated with the patient risk profile and the institutional experience but not with the access mode itself.

Impact of right and left ventricular systolic dysfunction on perioperative outcome and long-term survival after transcatheter aortic valve replacement.

BACKGROUND: Aim of the study was to determine the impact of right- and left-ventricular systolic dysfunction on perioperative outcome and long-term survival after TAVR. METHODS: Study population consisted of 702 TAVRs between 2009 and 2014, 345 by TF, 357 by TA route. RV and LV function were determined by TAPSE and LVEF measurement during baseline echocardiography. Patients were divided according to TAPSE (>18 mm/14-18 mm/<14 mm) and LVEF (>50%/30-50%/<30%) tertiles. Outcome at day-30 and Kaplan-Meier 4-year survival were analyzed. RESULTS: Impaired RV and LV-function did not adversely affect mortality, stroke, bleeding, and vascular-complications at 30 days. Patients with TAPSE < 14 mm displayed elevated rate of renal failure requiring dialysis (11%; P < 0.01). Kaplan-Meier survival was adversely affected by RV-systolic dysfunction RVSD (P < 0.01). Multivariate analysis revealed that impaired RVSD but not LVSD was an independent determinant for late mortality (hazard ratio TAPSE 14-18 mm: 1.53; P = 0.02; TAPSE <14 mm: 2.12; P < 0.01). CONCLUSIONS: Peri-operative mortality and risk of stroke after TAVR are not adversely affected by preexisting RV or LV dysfunction. Long-term survival is impaired in patients with RVSD. RVSD but not LVSD is an independent risk factor for late mortality. TAVR should be the preferred therapy for patients with RVSD and LVSD, especially when patient is suitable for TF.

Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation.

OBJECTIVES: Significant coronary artery disease (CAD) is common among patients currently evaluated for transcatheter aortic valve implantation (TAVI). Limited data exist on the outcome of patients undergoing combined transcatheter treatment of aortic valve disease and CAD. The aim of the study was to analyse the impact of concomitant percutaneous coronary intervention (PCI) on early and late clinical outcomes of patients receiving TAVI. METHODS: TAVIs were performed through either transfemoral or transapical access using SAPIEN (XT), CoreValve or AcurateTA valves. PCI was decided by the interdisciplinary heart team and performed synchronously or as a staged procedure upfront. Standardized valve academic research consortium (VARC)-2 endpoints were used. In case of a staged approach, TAVI was defined as the index procedure. Thirty-day outcomes and Kaplan-Meier 2-year survival were analysed. RESULTS: Of 411 TAVIs, 65 (16%) received PCI. Mean age was 82 years (P = 0.92) and mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.7% (TAVI + PCI) and 20.3% (TAVI; P = 0.47). PCI was performed as staged procedure upfront (74%) or synchronously (26%). In 95% of PCIs, a single coronary artery was treated, and 71% received bare metal stents. Incidence of myocardial infarction (6 vs 1%; P = 0.01) and 30-day mortality (15 vs 5%; P = 0.01) were higher in the TAVI + PCI group, compared with the TAVI group. Synchronous (18%) vs staged (15%) approach for PCI had comparable early mortality (P = 1.0). Kaplan-Meier 2-year survival was poorer in the TAVI + PCI group (P = 0.03) with an odds ratio of 1.66 (P = 0.04). CONCLUSIONS: Concomitant PCI is--when based on current heart team practice--associated with increased early and late mortality in selected elderly patients undergoing TAVI.

Emergency cardiac surgery during transfemoral and transapical transcatheter aortic valve implantation: incidence, reasons, management, and outcome of 411 patients from a single center.

OBJECTIVES AND BACKGROUND: Transcatheter aortic valve implantation (TAVI) is increasingly performed in high-risk patients with severe aortic valve stenosis. Incidence and impact of emergency cardiac surgery (ECS) during TAVI is unclear. METHODS AND RESULTS: Two-hundred twenty one transapical (TA) and 190 transfemoral (TF) TAVIs were performed at our hospital between 01/2009 and 12/2012. Twenty patients (4.9%) required ECS, more frequently in the TF- (n = 11; 5.8%) than in the TA-group (n = 9; 4.1%; P = 0.017). ECS-cases were evenly distributed throughout the 4 years. Baseline characteristics of the ECS-patients were not different from the non-ECS-patients. Reasons were acute cardiac failure, coronary obstruction, annular rupture, valve migration, right- and left-ventricular perforation, severe paravalvular leakage, aortic dissection, and mitral valve damage. Surgical intervention consisted of peripheral CPB, switch to TA, thoracotomy and suture of perforated cardiac chambers and conventional aortic valve replacement with concomitant repair of associated cardiovascular injury. Thirty-day mortality was 35.0%, and 55.0% could be salvaged to hospital discharge. Kaplan-Meier 1-year survival curves were significantly impaired for patients requiring ECS (TF: P < 0.0001, HR 8.716; TA: P = 0.013, HR 2.813). CONCLUSIONS: Life-threatening complications requiring bail-out ECS occur in a substantial proportion during TAVI. ECS dramatically affects early and late outcome after TAVI. Under optimal conditions more than half of the ECS-patients can be salvaged. With the current technology of THV-systems ECS should be an integral part of the logistic conditions surrounding TAVI and is far from being futile in this patient population.

Simple, effective and safe vascular access site closure with the double-ProGlide preclose technique in 162 patients receiving transfemoral transcatheter aortic valve implantation.

OBJECTIVES: Aim of this study was to analyze feasibility, efficacy, and safety of a double-ProGlide preclose technique for access site closure after transfemoral transcatheter aortic valve implantation (TAVI). BACKGROUND: An effective and safe transcutaneous closure device is advantageous in transfemoral TAVI to avoid surgical cut down of the large caliber sheath insertion site. The use of two ProGlide sutures has not been described in this context in a large patient cohort. METHODS: ProGlide closure was used between 2010 and 2012 in 162 patients. ProGlide sutures were deployed in a preclose technique prior to insertion of the large caliber sheath. Success of the closure technique was defined as effective hemostasis and no further access site-related vascular or bleeding complications during the index hospitalization. RESULTS: Patients were 82 ± 5 years old with a logistic EuroSCORE of 16.7 ± 12.5. Edwards SAPIEN valves were used in 81.5% and Medtronic CoreValves in 18.5%. The overall success rate of the double-ProGlide technique was 93.9%. Success rate was only 40.0% under circumstances of prolonged high-dose heparinization. Success rate was 96.8% among the patients on dual-antiplatelet therapy (DAPT). All 10 ProGlide failures could effectively be managed by either percutaneous angioplasty or surgical reconstruction. The rate of VARC major vascular complications was 4.3%. Thirty-day mortality was 5.6%. CONCLUSION: The double-ProGlide preclose technique offers a simple, highly effective, and safe method for closure of the arterial access site after transfemoral TAVI. The double-ProGlide strategy results in low rates of major vascular complications and translates into favorable early outcome.

Insufficient unilateral cerebral perfusion during emergent aortic arch surgery.

A rare case of insufficient right-sided unilateral cerebral perfusion during emergent aortic arch replacement in a patient with an acute aortic dissection is reported. On the basis of intraoperative monitoring using near-infrared spectroscopy, the insufficient perfusion of the contralateral hemisphere was detected and the bilateral perfusion was performed, which led to normalization of cerebral perfusion and an uncomplicated neurological outcome.

Valve-in-valve transcatheter aortic valve implantation for degenerated bioprosthetic heart valves.

OBJECTIVES: We sought to analyze outcomes of patients with degenerated surgically implanted bioprosthetic heart valves undergoing valve-in-valve (viv) transcatheter aortic valve implantation (TAVI). BACKGROUND: Redo cardiac surgery for degenerated bioprosthetic heart valves is associated with increased risks, particular in elderly patients with comorbidities. For these patients, TAVI may be an attractive, less invasive treatment option. METHODS: Data from 47 patients age 64 to 97 years (logistic euroSCORE: 35.0 ± 18.5%) undergoing transfemoral (n = 25) or transapical (n = 22) viv-TAVI for failed bioprosthetic aortic valves 113 ± 65 months after initial surgery at 9 clinical sites in Germany and Switzerland were analyzed. RESULTS: Valve-in-valve TAVI was technically successful in all patients, with 2 patients requiring bailout implantation of a second TAVI prosthesis for severe regurgitation during the procedure. There was 1 procedural death as the result of low-output failure. Valvular function after viv-TAVI was excellent with respect to valve competence, but increased transvalvular gradients ≥20 mm Hg were noted in 44% of patients. Vascular access complications occurred in 6 (13%) patients, and 5 (11%) patients required new pacemaker implantation after viv-TAVI. Renal failure requiring dialysis occurred in 4 (9%) patients. Mortality at 30 days was 17% (1 procedural and 7 post-procedural deaths), with 3 of 8 fatalities the result of non-valve-related septic complications. CONCLUSIONS: Valve-in-valve TAVI can be performed with high technical success rates, acceptable post-procedural valvular function, and excellent functional improvement. However, in these predominantly elderly high-risk patients with multiple comorbidities, viv-TAVI was associated with 17% mortality, often because of septic complications arising in the post-operative phase.

Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping.

Aortic cross-clamping during cardiac operations may injure the vessel wall and cause tissue lesions. This experimental study analyses the influence of the intravascular and external pressure and the duration of aortic cross-clamping on endothelial tissue damage. Fresh porcine aortas (n=20) were tested with intravascular pressures from 30 to 80 mmHg. The external clamp pressure, necessary to occlude the aorta, was applied by using the second cog of a commercial aortic clamp and cross-clamping was performed for 1 and 30 min. The observed pressure curves were compared to the histological findings. For occlusion of the aorta, an external pressure of at least 10-fold higher than the intravascular pressure (max. 812 mmHg) had to be applied. After 30 min of clamping, a complete endothelial destruction was observed, irrespective of intra-aortic pressure. The aortic media remained intact. After 1 min clamping, fractions of intact endothelial cells were left, ranging from 40 to 70% at different intra-aortic pressures. These results indicate that endothelial tissue lesions due to aortic cross-clamping are not avoidable, even in moderate clamp application. The duration of aortic cross-clamping but not intravascular pressure is the pivotal factor. The integrity of the aortic media can be preserved if low-force cross-clamping is achieved.

Simultaneous surgery of the aortic valve and sternal osteomyelitis.

A 64-year-old man was referred for aortic valve replacement due to severe stenosis. He also suffered chronic sternal osteomyelitis with skin fistula subsequent to radiation therapy. Both pathologies were approached simultaneously by sternal resection, omental plasty, and valve replacement, which led to favorable primary and mid-term result.

Reduced rate of microembolism by optimized aortic cannula position does not influence early postoperative cognitive performance in CABG patients.

BACKGROUND AND PURPOSE: The number of microemboli as measured by Doppler ultrasound during coronary artery bypass grafting (CABG) can be reduced by positioning the arterial cannula into the aorta descendens. The aim of this study was to prospectively evaluate whether this alternative aortic cannulation procedure leads to better neuropsychologic outcome early after surgery along with embolus reduction. METHODS: Sixty patients with elective CABG were randomized to either using a short aorta ascendens cannula or an elongated cannula placed in the aorta descendens. All patients were tested by seven neuropsychologic tests preoperatively. Intraoperative embolus detection could be performed by transcranial Doppler in 32 patients. The neuropsychologic tests could be repeated serially until the 9th postoperative day in 54 patients. Patient groups did not differ in terms of preoperative psychometric performance and of the surgical characteristics except cannula positioning. All data were analyzed by a blinded assessor. RESULTS: Neuropsychologic test scores showed in all individual patients a transient decline with subsequent recovery, but did not differ significantly between the groups except for the letter cancellation test at discharge favoring the patients with the longer cannula (102.3 +/- 11.6 vs. 94.5 +/- 11.5 mean +/- SD; p = 0.025). In the subgroup who had Doppler sonography, neuropsychologic test scores did not differ between the groups. However, microembolic signals were markedly reduced in patients with the elongated cannula (median 174.5 vs. 413.0; p = 0.011). CONCLUSIONS: Though reducing brain microembolism, use of an elongated aortic cannula does not appear to influence overall cognitive performance early after CABG in this pilot study.

Cannabinoids acting on CB1 receptors decrease contractile performance in human atrial muscle.

Cannabinoids elicit hypotension mainly via activated CB(1) receptors and show complex cardiovascular actions. Effects on human heart muscle have not been studied yet. Isolated human atrial heart muscle preparations were stimulated by electrical field with 1 Hz to contract isometrically at optimal length and were challenged with the endogenous cannabinoid arachidonyl ethanolamide (anandamide), the metabolically stable analogue R-methanandamide, and the potent synthetic CB(1) receptor agonist HU-210. Anandamide dose-dependently decreased systolic force (82.2 +/- 4.8% and 60.8 +/- 6.8% of maximal systolic force for 0.1 and 1 microM, respectively, P < 0.05). The selective CB(1) receptor antagonist AM-251 (1 microM, P < 0.05), but not the CB(2) receptor antagonist, AM-630 (1 microM), the nitric oxide synthase inhibitor N omega-nitro-l-arginine methyl ester (l-NAME) (500 microM), or the cyclooxygenase inhibitor indomethacin (100 microM), prevented the effect. Contrary to indomethacin, l-NAME alone showed negative inotropic effects (72.1 +/- 3.54%, P < 0.001). The R-methanandamide (1 microM: 50.4 +/- 3.5%, P < 0.001) and HU-210 (1 microM: 60.1 +/- 3.8%, P < 0.001) had similar negative inotropic effects. The existence of CB(1) receptors on heart muscle was verified using Western blot analysis and immunofluorescence staining. The conclusion is that anandamide, R-methanandamide, and HU-210 decrease contractile performance in human atrial muscle via CB(1) receptors.

Cognitive performance after coronary artery bypass grafting: a follow-up study.

The authors studied 52 of an initial cohort of 91 patients who underwent coronary artery bypass grafting and survived the perioperative period without stroke or other comorbidities, after a median follow-up of 55 months. Baseline data of the followed patients were comparable to those lost for follow-up. No patient showed a decline in neuropsychological test performance as compared to baseline. Vascular risk factor control was good in all patients, possibly contributing to the favorable outcome.

Brain damage after coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) is associated with a risk for focal neurological deficits and neuropsychological impairment postoperatively. OBJECTIVES: To examine the brain damage after CABG using diffusion-weighted magnetic resonance imaging and (1)H-magnetic resonance spectroscopy (MRS) and to correlate the results with neurological and neuropsychological findings. PATIENTS AND METHODS: Thirty-five consecutive patients undergoing elective CABG were included. Patients underwent a neurological and neuropsychological examination before and after CABG. The magnetic resonance protocol was applied before and after (mean, 3 days) surgery and included a diffusion-weighted sequence and single-voxel MRS measurements in the frontal lobes. RESULTS: None of the patients revealed a new focal neurological deficit after surgery. Diffusion-weighted magnetic resonance imaging demonstrated new ischemic lesions in 9 (26%) of the patients. The presence of an ischemic lesion was not related to impaired postoperative test performance (P>.50). The apparent diffusion coefficient values in the cerebellum and the centrum semiovale exhibited an increase after surgery (P<.01), consistent with vasogenic edema. Following surgery, MRS revealed a significant decrease in the metabolite ratio of N-acetylaspartate-creatine (mean +/- SD, 1.69 +/- 0.20 vs 1.52 +/- 0.19; P<.001). The extent of deterioration in neuropsychological test performance after surgery was closely related to the degree of the N-acetylaspartate-creatine ratio decrease (P<.01). A follow-up MRS scan revealed a normalization of the N-acetylaspartate-creatine ratio, which accompanied the recovery in psychological test performance. CONCLUSIONS: Postoperative impairment in neuropsychological test performance is associated with a transient metabolic neuronal disturbance. Focal ischemic lesions after CABG are more frequent than the apparent neurological complication rate; however, they are not related to the diffuse postoperative encephalopathy.

Cardiopulmonary bypass: Evidence or experience based?

OBJECTIVE: Evidence-based medicine is emerging as a new paradigm for medical practice. The purpose of this study was to evaluate the amount and quality of scientific evidence supporting principles that are currently applied for cardiopulmonary bypass performance. METHODS: A survey of all German departments of cardiac surgery regarding cardiopulmonary bypass performance disclosed major differences. Consequently, for 48 major principles of cardiopulmonary bypass performance, relevant Medical Subject Headings were identified, and a literature search of the Medline database was performed. Two sequentially applied sets of inclusion-exclusion criteria were selected to assess the best available evidence. RESULTS: Thirty-three thousand articles relating to the subject were identified. Among these, 1500 fulfilled the first set of inclusion criteria: meta-analysis of (randomized) controlled clinical trials and in vitro and animal studies. Rigorous methodological criteria were then applied to further select remaining publications. Ultimately, 225 articles referring to major cardiopulmonary bypass principles were identified as providing the best available evidence. These were graded according to their methodological rigor (susceptibility to bias). The scientific evidence on the investigated cardiopulmonary bypass principles did not prove to be of a high enough level to allow general recommendations to be made. CONCLUSIONS: The scientific data concerning the effectiveness and safety of key principles of cardiopulmonary bypass are insufficient in both amount and quality of scientific evidence to serve as a basis for practical, evidence-based guidelines.