Outcomes of surgery for acute type A dissection in octogenarians versus non-octogenarians: a systematic review and meta analysis.

INTRODUCTION: Acute Type A Aortic Dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly age over 80, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short- and mid-term mortality and morbidity in octogenarians following surgery for ATAAD. METHODS: A systematic review was conducted for studies published since January 2000. The primary endpoint was short-term mortality, either reported as 30-day mortality or in-hospital mortality and medium-term (five year) survival. Secondary endpoints were rates of postoperative complications, namely stroke, acute renal failure (ARF), re-exploration and intensive care unit (ICU) length of stay (LOS). RESULTS: A total of 16 retrospective studies, with a total of 16, 641 patients were included in the systematic review and meta-analysis. Pooled analysis demonstrated that octogenarian cohorts are at significantly higher risk of short-term mortality than non-octogenarians (OR 1.93; 95% CI 1.33-2.81; P < 0.001). Actuarial survival was significantly lower in the octogenarian cohort, with a five-year survival in the octogenarian cohort of 54% compared to 76% in the non-octogenarian cohort (P < 0.001). There were no significant differences between the cohorts in terms of secondary outcomes: stroke, ARF, re-exploration or ICU LOS. CONCLUSION: Octogenarians are twice as likely to die in the short-term following surgery for ATAAD and demonstrate a significantly lower five-year actuarial survival. Patients and family members should be well informed of the risks of surgery and suitable octogenarians selected for surgery.

Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: a systematic review and meta-analysis of randomised control trials and propensity matched studies.

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia. Hybrid convergent ablation (HCA) is an emerging procedure for treating longstanding AF with promising results. HCA consists of a subxiphoid, surgical ablation followed by completion endocardial ablation. This meta-analysis of randomized control trials (RCT's) and propensity score-matched studies aims to examine the efficacy and safety of HCA compared to endocardial catheter ablation (ECA) alone on patients with AF. METHODS: This review was written in accordance with preferred reporting items for systematic reviews and meta-analyses recommendations and guidance. The primary outcome for the analysis was freedom from AF (FFAF) at final follow up. Secondary outcomes were mortality and significant complications such as tamponade, sternotomy, esophageal injury, atrio-esophageal fistulae post procedurally. RESULTS: Four studies where included, with a total of 233 patients undergoing HCA and 189 patients undergoing ECA only. Pooled analysis demonstrated that HCA cohorts had significantly higher rates of FFAF than ECA cohorts, with an OR of 2.78 (95% CI 1.82-4.24, P < 0.01, I2 = 0). Major post-operative complications were observed in significantly more patients in the HCA group, with an OR of 5.14 (95% CI 1.70-15.54, P < 0.01). There was only one death reported in the HCA cohorts, with no deaths in the ECA cohort. CONCLUSION: HCA is associated with a significantly higher FFAF than ECA, however, it is associated with increased post-procedural complications. There was only one death in the HCA cohort. Large RCT's comparing the HCA and ECA techniques may further validate these results.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect.

Background: Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease. Methods: The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD. Results: Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality. Conclusions: Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

Systematic review and meta-analysis of long-term outcomes in adults undergoing the Ross procedure.

BACKGROUND: The management of aortic valve disease is becoming increasingly complicated with the evolution of treatment options available to cardiac surgeons and cardiologist. Pulmonary autograft replacement of the aortic valve, commonly known as the Ross procedure, involves excision of the pulmonary valve from the right ventricular outflow tract and implantation in the aortic position. This systematic review aims to evaluate the long-term outcomes, following the Ross procedure. METHODS: An electronic search strategy queried five online medical referencing databases from inception to 21 August 2020. All studies detailing the long-term outcomes of adults undergoing the Ross procedure were included. A random effects model was used to determine pooled continuous data. Enhanced secondary survival analysis was performed on reconstructed individual patient data. RESULTS: Twenty-three studies were included in the qualitative synthesis, including a total of 6,278 patients with a mean follow-up duration of 6.0±2.8 years. Long-term survival was 95.6%, 91.8%, 86.3% and 80.5% at five, ten, fifteen and twenty years, respectively. Freedom from autograft reoperation was 95.7%, 91.2%, 84.9% and 76.1% at five, ten, fifteen and twenty years, respectively. CONCLUSIONS: When performed in experienced centres and for appropriately selected patients, the Ross procedure represents a durable replacement of the aortic valve with excellent long-term survival.

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies.

BACKGROUND: The treatment of aortic valve disease is the most common valvular surgery in industrialized nations, with 3-9% of the population over the age of eighty having at least moderate aortic stenosis. As transcatheter aortic valve replacement (TAVR) has become more established, newer surgical prostheses have been developed with a variety of anchoring systems that do not rely solely on sutures to hold the valve in an appropriate position. The Edwards Intuity valve is a bovine pericardial prosthesis that is modelled on the widely implanted Perimount MagnaEase aortic prosthesis. The Perceval valve is a bovine pericardial valve attached to a self-expanding nitinol stent, which uses the radial force exerted on the patient's aortic annulus and aortic root by the stent portion to hold the valve in position. This meta-analysis compares the outcomes of comparative studies of these two valve systems. METHODS: This systematic review and meta-analysis compares the outcomes of rapid deployment valves (RDV) and sutureless valves (SURD) and was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and guidance. The search strategy interrogated six electronic databases. Outcomes measured included all-cause mortality at latest follow up, stroke, cross-clamp and cardiopulmonary bypass (CPB) times, pacemaker implantation rates, paravalvular leak and post-operative transvalvular gradient. RESULTS: The search strategy identified 407 unique papers for initial assessment with seven studies qualifying for inclusion in the analysis. The outcomes of 4,076 patients (1,650 RDV, 2,426 SURD) were included. There was no difference in mortality, stroke or moderate or worse paravalvular regurgitation between the two groups. SURD had significantly shorter CPB time by 15.7 minutes [95% confidence interval (CI): 4.2-27.1; P=0.007] and a shorter cross-clamp time by 11.3 minutes (95% CI: 6.3-16.3; P<0.001) compared to RDV. RDV had a lower post-operative transvalvular gradient by 2.5 mmHg (95% CI: 1.2-3.8; P<0.001) and a lower rate of mild paravalvular regurgitation (OR 2.51; 95% CI: 1.435-4.768; P=0.004). CONCLUSIONS: Both valve types have an adequate safety profile and are comparable to conventional sutured prostheses. There was a significant reduction in cross-clamp and CPB times associated with SURD. This may be of benefit for patients requiring multiple concomitant procedures and increases the utility of minimally invasive valve replacement. However, SURD was associated with higher post-operative transvalvular gradients and a higher incidence of paravalvular regurgitation.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND: Sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has become a prominent area of research as the medical community evaluate its place amongst other aortic valve interventions. The main advantages of SURD-AVR established to date are the reduced cross-clamp and cardiopulmonary bypass (CPB) times, as well as facilitating minimally invasive surgery in high-risk surgical patients. This current systematic review and meta-analysis, to our knowledge, is the first focusing on long-term outcomes regarding safety, efficacy and durability of SURD-AVR from available current literature. METHODS: A literature search via six electronic databases was performed from their inception to November 2019. Inclusion criteria for this systematic review included survival and postoperative echocardiographic outcomes greater than five years in patients who underwent SURD-AVR with either Perceval or Intuity valves. Studies were identified and data extracted by two independent reviewers. Long-term survival outcomes were aggregated using digitized Kaplan-Meier curves where available. RESULTS: After applying predefined inclusion and exclusion criteria, four studies were identified for review. All four studies were observational and in total reported data for 1,998 patients. Almost half (42.4%) of patients underwent SURD-AVR via full sternotomy, with almost one third (30.1%) also undergoing concomitant cardiac procedures. Aggregate overall survival rates at 1-, 2-, 3-, and 5-year follow-up were 94.9%, 91.2%, 89.0%, and 84.2%, respectively. Incidence of strokes (4.8%), severe paravalvular leaks (PVLs) (1.5%) and permanent pacemaker (PPM) insertion (8.2%) at up to 5-year follow-up were acceptable. At 5-year follow-up hemodynamic outcomes were also acceptable for mean pressure gradient (MPG) (range, 8.8-13.6 mmHg), peak pressure gradient (PPG) (range, 18.9-21.1 mmHg) and effective orifice area (EOA) (range, 1.5-1.8 cm2). CONCLUSIONS: Evaluation of the evidence reporting long-term outcomes of SURD-AVR suggests that it is a safe procedure for AVR with low rates of complications. Long-term outcomes presented in this review show that not only does SURD-AVR have acceptable survival rates, but also good hemodynamic performance at 5-year follow-up.

Systematic review and meta-analysis of surgical outcomes comparing mechanical valve replacement and bioprosthetic valve replacement in infective endocarditis.

BACKGROUND: Infective endocarditis (IE) is an infection involving either native or prosthetic heart valves, the endocardial surface of the heart or any implanted intracardiac devices. IE is a rare condition affecting 3-15 patients per 100,000 population. In-hospital mortality rates in patients with IE remain high at around 20% despite treatment advances. There is no consensus recommendation favoring either bioprosthetic valve or mechanical valve implantation in the setting of IE; patient age, co-morbidities and preferences should be considered selecting the replacement prosthesis. METHODS: A systematic review and meta-analysis of studies reporting the outcomes of patients undergoing bioprosthetic or mechanical valve replacement for infective endocarditis with data extracted for overall survival, valve reinfection rates and valve reoperation. RESULTS: Eleven relevant studies were identified, with 2,336 patients receiving a mechanical valve replacement and 2,057 patients receiving a bioprosthetic valve replacement. There was no significant difference for overall survival between patients treated with mechanical valves and those treated with bioprosthetic valves [hazard ratio (HR) 0.94, 95% confidence interval (CI): 0.73-1.21, P=0.62]. There was no significant difference in reoperation rates between patients treated with a bioprosthetic valve and those treated with a mechanical valve (HR 0.82, 95% CI: 0.34-1.98, P=0.66) and there was no significant difference in the rate of valve reinfection rates (HR 0.95, 95% CI: 0.48-1.89, P=0.89). CONCLUSIONS: The presence of infective endocarditis alone should not influence the decision of which type of valve prosthesis that should be implanted. This decision should be based on patient age, co-morbidities and preferences.

Novel mitral valve technologies-transcatheter mitral valve implantation: a systematic review.

BACKGROUND: Valvular heart disease is an important cause of morbidity and mortality throughout the world; in industrialized nations, mitral regurgitation (MR) is the most common valvular lesion. Untreated, severe MR has a poor prognosis, with a 5-year mortality rate of up to 50%. Surgical repair of symptomatic, severe primary MR has been demonstrated to improve survival. The aim of this review is to assess the early outcomes of newly developed transcatheter mitral valve implantation technologies for the treatment of secondary native valve disease. Furthermore, the outcomes of patients receiving transcatheter treatment of regurgitant failure of surgically repaired or replaced mitral valve has also been addressed. METHODS: A systematic review of twenty-five studies assessing the outcomes of patients undergoing transcatheter mitral valve implantation for native mitral regurgitation or failed prior surgical repair or bioprosthetic replacement was carried out. RESULTS: The outcomes of 112 patients undergoing transcatheter mitral valve replacement for secondary mitral regurgitation using six different valve systems were assessed. There were 15 early deaths and 24 deaths over the follow-up period. The outcomes of 44 patients undergoing transcatheter valve-in-valve replacement were assessed with an overall mortality of ten patients. There were 20 patients included who had valve-in-ring transcatheter mitral replacement for previous failed repair. The total mortality was five patients during the follow-up period. CONCLUSIONS: Transcatheter mitral valve implantation represents a new evolution in management of valvular disease and affords management options to patients who historically may not have been offered treatment. Early results have demonstrated some promise and improvements in technology, imaging modalities and patient selection will surely result in a reliable and durable valve.

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement.

BACKGROUND: A major, life-limiting feature of Marfan syndrome (MFS) is the presence of aneurysmal disease. Cardiovascular intervention has dramatically improved the life expectancy of Marfan patients. Traditionally, the management of aortic root disease has been undertaken with composite-valve graft replacing the aortic valve and proximal aorta; more recently, valve sparing procedures have been developed to avoid the need for anticoagulation. This meta-analysis assesses the important surgical outcomes of the two surgical techniques. METHODS: A systematic review and meta-analysis of 23 studies reporting the outcomes of aortic root surgery in Marfan patients with data extracted for outcomes of early and late mortality, thromboembolic events, late bleeding complications and surgical reintervention rates. RESULTS: The outcomes of 2,976 Marfan patients undergoing aortic root surgery were analysed, 1,624 patients were treated with composite valve graft (CVG) and 1,352 patients were treated with valve sparing root replacement (VSRR). When compared against CVG, VSRR was associated with reduced risk of thromboembolism (OR =0.32; 95% CI, 0.16-0.62, P=0.0008), late hemorrhagic complications (OR =0.18; 95% CI, 0.07-0.45; P=0.0003) and endocarditis (OR =0.27; 95% CI, 0.10-0.68; P=0.006). Importantly there was no significant difference in reintervention rates between VSRR and CVG (OR =0.89; 95% CI, 0.35-2.24; P=0.80). CONCLUSIONS: There is an increasing body of evidence that VSRR can be reliably performed in Marfan patients, resulting in a durable repair with no increased risk of re-operation compared to CVG, thus avoiding the need for systemic anticoagulation in selected patients.

Robotically Assisted Minimally Invasive Off-Pump Coronary Artery Bypass Surgery in a Patient With Permanent Tracheostomy.

BACKGROUND: Patients with a permanent tracheostomy requiring coronary surgery represent a unique challenge, being at increased risk of sternal wound complications, mediastinitis and stoma necrosis. Several techniques have been described including manubrium sparing sternotomy, thoracoscopic internal mammary harvest and hybrid revascularisation. METHODS: We report a case of robotic assisted (daVinci®Xi™ Surgical System) total arterial off-pump revascularisation in a patient with previous laryngectomy and permanent tracheostomy. The main advantage of this approach was to minimise the risk of postoperative sternal complication and mediastinatis, whilst still providing the prognostic benefit of total arterial grafting and the neurological advantage of the aorta no-touch technique.