Results of aortic valve replacement for aortic stenosis and moderate functional mitral regurgitation.

BACKGROUND: Referral and admission echocardiography (ECHO) in patients scheduled for aortic valve replacement (AVR) with aortic stenosis (AS) may differ in the assessment of moderate functional mitral regurgitation (FMR). AIMS: Our study was to determine the truly moderate-FMR and evaluate its impact on survival. METHODS: We conducted an observational study of patients referred for AVR with AS and up to moderate FMR, between 2014 and 2019. Patients were divided into three groups: (1) no/mild (N-FMR); (2) moderate-FMR on one ECHO (either at referral or admission) termed incidental (I-FMR); (3) moderate FMR in two studies (both at referral and admission) termed permanent (PM-FMR). RESULTS: The referral and admission assessment were performed median 35 days apart. Of the 679 elective patients who underwent elective isolated AVR, 516 patients had N-FMR, 102 patients had I-FMR, and 61 patients had PM-FMR. Median follow-up was 46 months (22.5-58.5); max 73.3. 30-day mortality was 2.5% vs. 1% vs. 8.2% (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.01). Five-year survival was 84.1% in N-FMR vs. 88.5% in I-FMR vs. 60.6% in PM-FMR group, where was the lowest (P <0.001). In multivariable modeling PM-FMR increased mortality (hazard ratio [HR], 1.88 [1.05-3.37]; P = 0.03). The I-FMR had no effect on mortality (HR, 0.67 [0.32-1.37]; P = 0.28). Five-year survival after excluding 30-day mortality was 86.3% vs. 89.4% vs. 66.0%; (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.02). The PM-FMR increased late mortality (HR, 2.17 [1.14-4.15]; P = 0.01). CONCLUSIONS: In patients undergoing isolated AVR for AS, the presence of permanent moderate FMR significantly impacts 30-day and mid-term survival.

Surgical and transcatheter aortic valve replacement for severe aortic stenosis in low-risk elective patients: Analysis of the Aortic Valve Replacement in Elective Patients From the Aortic Valve Multicenter Registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) remains the preferred strategy for high-risk or elderly individuals with aortic valve (AV) stenosis who are not considered to be optimal surgical candidates. Recent evidence suggests that low-risk patients may benefit from TAVI as well. The current study evaluates midterm survival in low-risk patients undergoing elective surgical AV replacement (SAVR) versus TAVI. METHODS: The Aortic Valve Replacement in Elective Patients From the Aortic Valve Multicenter Registry (AVALON) compared isolated elective transfemoral TAVI or SAVR with sternotomy or minimally invasive approach in low-risk individuals performed between 2015 and 2019. Propensity score matching was conducted to determine SAVR controls for TAVI group in a 1-to-3 ratio with 0.2 caliper. RESULTS: A total of 2393 patients undergoing elective surgery (1765 SAVR and 629 TAVI) with median European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) score 1.81 (interquartile range [IQR], 1.36 to 2.53]) were initially included. Median follow-up was 2.72 years (IQR, 1.32-4.08; max 6.0). Propensity score matching returned 329 TAVI cases and 593 SAVR controls. Thirty-day mortality was 11 out of 329 (3.32%) in TAVI and 18 out of 593 (3.03%) in SAVR (risk ratio, 1.10; 95% CI, 0.52-2.37; P = .801) groups, respectively. At 2 years, survival curves began to diverge in favor of SAVR, which was associated with 30% lower mortality (hazard ratio, 0.70; 95% CI, 0.496-0.997; P = .048). CONCLUSIONS: Our data did not demonstrate a survival difference between TAVI and SAVR during the first 2 postprocedure years. After that time, SAVR is associated with improved survival. Extended observations from randomized trials in low-risk patients undergoing elective surgery are warranted to confirm these findings and draw definitive conclusions.

Stem cells mobilization by cardiopulmonary bypass after coronary artery bypass grafting.

Introduction: Expression of haematopoietic stem and progenitor cells occurs as a result of an inflammatory reaction caused by a damaged organ. Patients undergoing coronary artery bypass surgery (CABG) using cardiopulmonary bypass (CPB) are exposed to an inflammatory reaction, which may be a trigger in the mobilization of regenerative cells. Aim: To assess the impact of CPB on stem and progenitor cells mobilization in patients scheduled for CABG. Material and methods: Twenty patients with stable coronary disease, who were scheduled for CABG, were included in the study. Peripheral blood samples were collected perioperatively: 2 h before surgery, before CPB, at CPB weaning, 24 h postoperatively, and on the 6th postoperative day. Analyses of immune-labelled cells were carried out on an ImageStream (IS) system. Results: The following cell populations were identified during cardiac surgery: haematopoietic stem cells (HSC), mesenchymal cells (MSC), endothelial progenitors (EPC), and very small embryonic-like cells (VSEL). The profile of cell mobilization coincides with the perioperative inflammatory response. Mobilization of stem and progenitor cells induced by CPB did not occur in any of the isolated cell lines (p > 0.05). The expression profile of stem and progenitor cells was related with the inflammatory reaction associated with traumatic stress in all cell lines. Type 2 diabetes is a disease that is hampering the trend of MSC mobilization. Conclusions: Mobilization of haematopoietic stem and progenitor cells was not related with CPB. The inflammatory reaction was associated with perioperative trauma. Cell release was inhibited in patients with diabetes.

Surgical Treatment of Postinfarction Ventricular Septal Rupture.

Importance: Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. Objectives: To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. Design, Setting, and Participants: The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. Exposures: Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). Main Outcomes and Measures: The primary outcome was early mortality; secondary outcomes were postoperative complications. Results: Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery ≥7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality. Conclusions and Relevance: In this study, surgical repair of postinfarction VSR was associated with a high risk of early mortality; this risk has remained unchanged during the last 2 decades. Delayed surgery seemed associated with better survival. Age, preoperative cardiac arrest and percutaneous revascularization, and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with early mortality. Further prospective studies addressing preoperative and perioperative patient management are warranted to hopefully improve the currently suboptimal outcome.

Do we have to operate on moderate functional mitral regurgitation during aortic valve replacement for aortic stenosis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Do we have to operate on moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) for aortic stenosis (AS)?' Altogether 325 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The current evidence obtained from these papers revealed that the significant predictors of improvement outcome include lower preoperative mitral regurgitation and lower preoperative left ventricle fractional area change. We also know that persistent atrial fibrillation, enlarged left atrium, increased indexed left ventricular mass, pulmonary hypertension and preoperative peak aortic valve gradient <60 mmHg are predictors of deterioration. Generally, we observed a trend towards improvement or non-progression of FMR following AVR for AS. In the six papers that suggest conservative treatment of FMR, the degree of mitral regurgitation (MR) improved in 45-95%, remained unchanged in 19-38% and deteriorated in 1-14%. In the three papers favoring surgical treatment of MR, the degree of MR improved in 46-69%, stay unchanged in 34-53% and deteriorated in 10%. The current evidence suggests that moderate or less grade of FMR without predictors of deterioration should be treated conservatively and moderate-severe and severe FMR warrants additional surgical procedure. A clearly randomized study, especially in patients with moderate and moderate-severe FMR for AS, seems appropriate to further elucidate surgical strategy.

Coronary artery spasm following on-pump coronary artery bypass grafting with 20 months follow-up.

We report on a 69-year-old woman who demonstrated native coronary artery and grafted vessel spasm following on-pump coronary artery bypass grafting (CABG). Despite intraaortic balloon pump (IABP) insertion, electrocardiogram (ECG) abnormalities did not disappear. Emergency coronary angiography (CAG) was performed. The patient was successfully treated with systemic and intracoronary injection of vasodilator agents. ECG changes disappeared, with normalized and stable hemodynamic function. Intraaortic balloon pump was maintained for 48 h. The patient was discharged in good clinical condition. Coronary artery spasm (CAS) may result in life-threatening arrhythmias, circulatory collapse or death. The etiology of CAS is multifactorial and includes heart manipulation, exogenous vasoconstrictors, stress-related catecholamine release, hypoxia and oxidative stress. Postoperative CAS is most commonly manifested by ST-segment elevation and circulatory collapse without specific causes. The gold standard for revealing CAS is CAG. Infusion of vasodilators combined with IABP is adequate in most instances, but extracorporeal membrane oxygenation has been necessary for more extensive or resistant coronary spasm.