Low-Risk Surgical Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation.

Open surgical aortic valve replacement (SAVR) is a viable alternative to transcatheter implantation in low-risk patients. In this light, we evaluated the safety and effectiveness of SAVR performed through conventional and less invasive surgical approaches in a high-volume center. We retrospectively reviewed the records of 395 consecutive patients who underwent open SAVR from January 2019 through December 2019 in our center. We evaluated and compared the operative results and postoperative major adverse outcomes of 3 surgical approaches: full median sternotomy (n=267), upper ministernotomy (ministernotomy) (n=106), and right anterior thoracotomy (minithoracotomy) (n=22). Overall, the 30-day all-cause mortality rate was 0.8% (3 patients). Stroke occurred in 8 patients (2%), disabling stroke in 4 patients (1%), myocardial infarction in 1 (0.2%), and surgical site infection in 13 (3.2%). There was no difference in 30-day mortality rate or incidence of postoperative major adverse events among the 3 surgical groups. Stroke and surgical site infection occurred more frequently, but not significantly so, in the full-sternotomy group. The mean hospital stay was longer after full sternotomy (9.1 ± 5.5 d) than after ministernotomy (7.5 ± 2.9 d) or minithoracotomy (7.4 ± 1.9 d) (P=0.012). Our findings suggest that open SAVR performed in a high-volume center is associated with a low early mortality rate and that less invasive approaches result in faster postoperative recovery and shorter hospital stays.

Alterações da Rigidez Arterial em Pacientes com Estenose Aórtica Grave Submetidos à Cirurgia de Troca Valvar / Arterial Stiffness Changes in Severe Aortic Stenosis Patients Submitted to Valve Replacement Surgery

Resumo Fundamento: Pouco se sabe sobre o impacto da estenose aórtica (EA) grave na rigidez aórtica e se ocorre alguma alteração após a remoção da barreira de EA com a cirurgia de substituição da válvula aórtica (SVA). Objetivo: Estimar as mudanças na velocidade de onda de pulso carotídeo-femoral (VOP) após a cirurgia de SVA e definir os preditores de VOP alta em pacientes com EA grave. Métodos: Estudo de coorte retrospectivo unicêntrico, incluindo pacientes com EA grave submetidos à cirurgia de SVA com bioprótese, entre fevereiro de 2017 e janeiro de 2019, e medições da VOP (Complior®) antes e depois do procedimento (2±1 meses). Antes e depois da SVA, os valores da VOP foram comparados por meio de testes pareados. foram analisadas as associações de VOP com dados clínicos, bem como aplicados modelos de regressão linear multivariada para estimar os preditores independentes da VOP pré- e pós-operatória. O nível de significância foi estabelecido em 5%. Resultados: Foram incluídos na amostra 150 pacientes, com média de idade de 72±8 anos, sendo 51% deles do sexo masculino. Identificamos um aumento estatisticamente significativo nos valores de VOP após a cirurgia (9,0 ± 2,1 m/s vs. 9,9 ± 2,2, p<0,001, antes e depois da SVA, respectivamente) e uma associação inversa com as variáveis de gravidade da EA. No modelo de regressão linear multivariada, idade e pressão arterial sistólica (PAS) foram estabelecidas como preditores independentes da VOP pré- e pós-operatória mais alta, enquanto o gradiente valvar médio mais alto foi considerado um determinante da VOP pré-SVA mais baixa. Conclusão: Identificamos uma correlação inversa da rigidez arterial com a gravidade da EA em pacientes acometidos, e um aumento significativo nos valores da VOP após a cirurgia de SVA. Idade avançada e PAS elevada foram associadas a valores mais altos da VOP, embora as medidas de função arterial estivessem dentro da normalidade. (Arq Bras Cardiol. 2021; 116(3):475-476)

Abstract Background: Little is known about the impact of severe aortic stenosis (AS) in aortic stiffness and if there is any change after removing AS barrier with aortic valve replacement (AVR) surgery. Objective: To estimate carotid-femoral pulse wave velocity (PWV) changes after AVR surgery and to define PWV predictors in severe AS patients. Methods: Single-center retrospective cohort, including patients with severe AS who underwent AVR surgery with bioprostheses, between February 2017 and January 2019 and performed PWV measurements (Complior®) before and after the procedure (2±1 months). Before and after AVR, PWV values were compared through paired tests. The associations of PWV with clinical data were studied and linear regression models were applied to estimate pre and postoperative PWV independent predictors. The significance level was set at 5%. Results: We included 150 patients in the sample, with mean age of 72±8 years, and 51% being males. We found a statistically significant increase in PWV values after surgery (9.0±2.1 m/s vs. 9.9±2.2, p<0.001, before and after AVR, respectively) and an inverse association with AS severity variables. In the linear regression model, age and systolic blood pressure (SBP) were established as independent predictors of higher pre- and postoperative PWV, while higher mean valvular gradient emerged as a determinant of lower pre-AVR PWV. Conclusion: We documented an inverse correlation of arterial stiffness with the severity of AS in patients with AS, and a significant increase in PWV values after AVR surgery. Advanced age and higher SBP were associated with higher PWV values, although arterial function measurements were within the normal range. (Arq Bras Cardiol. 2021; 116(3):475-482)

Predição do Mapa de Estresse em Aorta Ascendente: Otimização da Posição Coaxial no Implante Valvar Aórtico Percutâneo / Prediction of Stress Map in Ascending Aorta - Optimization of the Coaxial Position in Transcatheter Aortic Valve Replacement

Resumo Fundamento O implante valvar aórtico percutâneo (TAVR, do inglês Transcatheter Aortic Valve Replacement) reduz a mortalidade de pacientes portadores de estenose aórtica grave. O conhecimento da distribuição da pressão e tensão de cisalhamento na parede aórtica pode ajudar na identificação de regiões críticas, onde o processo de remodelamento aórtico pode ocorrer. Neste trabalho é apresentado um estudo de simulação computacional da influência do posicionamento do orifício valvar protético na hemodinâmica na raiz de aorta e segmento ascendente. Objetivos A presente análise apresenta um estudo da variação do padrão de fluxo devido a alterações no ângulo do orifício valvar. Métodos Um modelo tridimensional foi gerado a partir do exame de angiotomografia computadorizada da aorta de um paciente que foi submetido ao procedimento de TAVR. Diferentes vazões de fluxo foram impostas através do orifício valvar. Resultados Pequenas variações no ângulo de inclinação causaram mudanças no padrão de fluxo, com deslocamento na posição dos vórtices, na distribuição de pressão e no local de alta tensão cisalhante na parede aórtica. Conclusão Essas características hemodinâmicas podem ser importantes no processo de remodelamento aórtico e distribuição de tensão, além de auxiliar, em um futuro próximo, a otimização do posicionamento da prótese valvar percutânea. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Backgroud Transcatheter aortic valve replacement (TAVR) can reduce mortality among patients with aortic stenosis. Knowledge of pressure distribution and shear stress at the aortic wall may help identify critical regions, where aortic remodeling process may occur. Here a numerical simulation study of the influence of positioning of the prosthetic valve orifice on the flow field is presented. Objective The present analysis provides a perspective of great variance on flow behavior due only to angle changes. Methods A 3D model was generated from computed tomography angiography of a patient who had undergone a TAVR. Different mass flow rates were imposed at the inlet valve. Results Small variations of the tilt angle could modify the nature of the flow, displacing the position of the vortices, and altering the prerssure distribution and the location of high wall shear stress. Conclusion These hemodynamic features may be relevant in the aortic remodeling process and distribution of the stress mapping and could help, in the near future, the optimization of the percutaneous prosthesis implantation. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Low Origin of the Coronary Arteries and a Small Aortic Annulus Complicating Aortic Valve Replacement.

Low origin of the coronary arteries, defined as an origin less than 10 mm above the functional aortic annulus, is not usually considered to be a notable anomaly because functional impairment is not intrinsic. We describe a case of severe complications after surgical aortic valve replacement in a 59-year-old woman who had symptomatic aortic valve stenosis, low origin of both main coronary arteries, and a hypoplastic aortic annulus less than 19 mm in diameter. The aortic prosthesis had to be implanted above the hypoplastic anatomic annulus. An inferior-wall myocardial infarction, hypotension, right-sided heart failure, and atrial fibrillation developed during the early perioperative period. Coronary angiograms showed occlusion of the right coronary artery ostium and critical stenosis of the left coronary ostium. During reoperation, posterior aortic patch annuloplasty enabled lower reimplantation of the prosthetic aortic valve, jointly with right coronary artery-venous grafting. To prevent potentially severe complications, we recommend that low origin of the coronary arteries be reported before patients undergo surgical aortic valve replacement. If the ostia are not seen when routine coronary angiography is used, computed tomography should be prospectively performed to characterize this anomaly.

Resultados hospitalarios de reemplazo valvular aórtico en dos hospitales comunitarios / In-hospital Outicomes of Aortic Valve Replacement in Two Community Hospitals

RESUMEN Introducción: El objetivo de esta comunicación fue presentar los resultados hospitalarios de la cirugía valvular aórtica realizada por nuestro grupo quirúrgico en los últimos tres años en dos hospitales comunitarios de Buenos Aires. Material y métodos: Entre enero del 2015 y diciembre de 2017 se intervinieron 125 pacientes con diagnóstico de estenosis aórtica grave sintomática aislada o asociada a enfermedad coronaria, en los servicios de cirugía cardíaca de los Hospitales Alemán y Británico de Buenos Aires. Resultados: Al aplicar el puntaje Stis se hallaron 103 pacientes (82,4%) en el grupo de bajo riesgo (Society of Thoracic Surgery Stis < 4), y 22 pacientes (17,6%) en el grupo de riesgo intermedio (Stis 4-7%). La mortalidad hospitalaria global fue 2,4% (n = 3), y la mortalidad por grupo de riesgo del Stis fue 1,9% para los de bajo riesgo, y 4,5% para los pacientes de riesgo intermedio. Conclusiones: Estos datos representan los resultados actuales del reemplazo valvular aórtico quirúrgico aislado o combinado con cirugía coronaria en los pacientes con riesgos bajo e intermedio en dos hospitales comunitarios.

ABSTRACT Background: The aim of this report is to present the in-hospital outicomes of surgical aortic valve replacement performed by our team within the past three years in two community hospitals in Buenos Aires. Methods: Between January 2015 and December 2017, 125 patientis with diagnosis of symptomatic severe aortic stenosis isolated or associated with coronary artery disease underwent surgery at the departmentis of cardiovascular surgery of the Resultis: 103 patientis (82.4%) belonged to the low risk category of the Society of Thoracic Surgeons (Stis) score (< 4) and 22 patientis (17.5%) were categorized as intermediate risk (Stis score 4-7%). Overall hospital mortality was 2.4% (n = 3) and mortality by Stis category was 1.9% for low-risk patientis and 4.5% for the intermediate risk category. Conclusions: These data represent the current resultis of surgical aortic valve replacement isolated or combined with coronary artery revascularization in low-risk and intermediate-risk patientis in two community hospitals.

Transcatheter aortic valve replacement: the experience of one brazilian health care center

Abstract Objective: Transcatheter aortic valve replacement has been an alternative to invasive treatment for symptomatic severe aortic stenosis in high risk patients. The primary endpoint was 30-day and 1-year mortality from any cause. Secondary endpoints were to compare the clinical and echocardiographic variation pre-and post- transcatheter aortic valve replacement, and the occurrence of complications throughout a 4-year follow-up period. Methods: This prospective cohort, nestled to a multicenter study (Registro Brasileiro de Implante de Bioprótese por Cateter), describes the experience of a public tertiary center in transcatheter aortic valve replacement. All patients who underwent this procedure between October 2011 and February 2016 were included. Results: Fifty-eight patients underwent transcatheter aortic valve replacement. The 30-day all-cause mortality was 5.2% (n=3) and after 1 year was 17.2% (n=10). A significant improvement in New York Heart Association functional classification was observed when comparing pre-and post- transcatheter aortic valve replacement (III or IV 84.4% versus 5.8%; P<0.001). A decline in peak was observed (P<0.001) and mean (P<0.001) systolic transaortic gradient. The results of peak and mean post-implant transaortic gradient were sustained after one year (P=0.29 and P=0.36, respectively). Left ventricular ejection fraction did not change significantly during follow-up (P=0.41). The most frequent complications were bleeding (28.9%), the need for permanent pacemaker (27.6%) and acute renal injury (20.6%). Conclusion: Mortality and complications in this study were consistent with worldwide experience. Transcatheter aortic valve replacement had positive clinical and hemodynamic results, when comparing pre-and post-procedure, and the hemodynamic profile of the prosthesis was sustained throughout follow-up.

Staged balloon aortic valvuloplasty before standard aortic valve replacement in selected patients with severe aortic valve stenosis.

This study evaluated preoperative balloon aortic valvuloplasty (BAV) as a technique to decrease aortic valve replacement (AVR) risk in patients who have severe symptomatic aortic valve stenosis with substantial comorbidity. We report the outcomes of 18 high-risk patients who received BAV within 180 days before AVR from November 1993 through December 2011. Their median age was 78 years (range, 51-93 yr), and there were 11 men (61%). The pre-BAV median calculated Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) was 18.3% (range, 9.4%-50.7%). Preoperative left ventricular ejection fraction measured a median of 0.23 (range, 0.05-0.68), and the median aortic valve area index was 0.4 cm(2)/m(2) (range, 0.2-0.7 cm(2)/m(2)). The median interval from BAV to AVR was 28 days (range, 1-155 d). There were no strokes or deaths after BAV; however, 4 patients (22%) required mechanical circulatory support, 3 (17%) required femoral artery operation, and 1 (6%) developed severe aortic valve regurgitation. After BAV, the median STS PROM fell to 9.1% (range, 2.6%-25.7%) (compared with pre-BAV, P <0.001). Echocardiography before AVR showed that the median left ventricular ejection fraction had improved to 0.35 (range, 0.15-0.66), and the aortic valve area index to 0.5 cm(2)/m(2) (range, 0.3-0.7 cm(2)/m(2)) (compared with pre-BAV, both P <0.05). All patients received AVR. Operative death occurred in 2 patients (11%), and combined operative death and morbidity in 7 patients (39%). Staged BAV substantially reduces the operative risk associated with AVR in selected patients.

Experiência Inicial de Dois Centros Nacionais no Implante de Prótese Aórtica Transcateter / Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Fundamento: O implante de prótese aórtica transcateter é uma alternativa efetiva para o tratamento cirúrgico para a correção de estenose aórtica grave em pacientes inoperáveis ou de alto risco cirúrgico. Objetivos: Apresentar os resultados clínicos e ecocardiográficos imediatos e no médio prazo da experiência inicial do implante de prótese aórtica transcateter. Métodos: Entre junho de 2009 e fevereiro de 2013, 112 pacientes foram submetidos a implante de prótese aórtica transcateter. Resultados: A idade média foi 82,5 ± 6,5 anos e o Euro SCORE logístico foi 23,6 ± 13,5. O sucesso do procedimento foi de 84%. Após o implante, houve queda do gradiente sistólico médio (pré = 54,7 ± 15,3 mmHg vs. pós = 11,7 ± 4,0 mmHg; p < 0,01). Acidente vascular cerebral ocorreu em 3,6% dos pacientes, complicações vasculares em 19%, e foi necessário o implante de marca-passo definitivo em 13% dos pacientes nos primeiros 30 dias pós-implante. A mortalidade aos 30 dias e no seguimento médio de 16 ± 11 meses foi, respectivamente, de 14 e de 8,9%. A presença de doença pulmonar obstrutiva crônica foi o único preditor de mortalidade em 30 dias e no seguimento. A área valvar aórtica e o gradiente sistólico médio não apresentaram variações significativas durante o seguimento. Conclusões: O implante de prótese aórtica transcateter é um procedimento eficaz e seguro para o tratamento da estenose aórtica em pacientes de alto risco cirúrgico ou inoperáveis. A presença de doença pulmonar obstrutiva crônica foi o único preditor independente de mortalidade identificado, tanto no primeiro mês pós-intervenção quanto no seguimento mais tardio. .

Background: Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk. Objectives: To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation. Methods: From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation. Results: Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly. Conclusions: Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up. .

Does minimal-access aortic valve replacement reduce the incidence of postoperative atrial fibrillation?

As the most common sequela of cardiac valvular surgery, atrial fibrillation (AF) has an important impact on postoperative morbidity. Minimal-access aortic valve replacement (AVR), with purported benefits on operative outcomes, has emerged as an alternative to conventional AVR. We used meta-analysis to determine whether minimal access influences the incidence of postoperative AF after AVR. Further, we sought first to evaluate via sensitivity analysis the impact of any differences and to identify the sources of possible heterogeneity between studies; second, we sought to evaluate any indirect effect of minimal-access AVR on other surrogate outcomes related to postoperative AF. We identified 10 studies from 26 comparative randomized and nonrandomized reports that documented the primary outcome of interest: new-onset AF. Overall meta-analysis showed no significant difference between minimal-access and conventional AVR in the incidence of postoperative AF (odds ratio, 0.85; 2,262 patients; P=0.24; 95% confidence interval, 0.66-1.11). Nor were there any apparent differences in surrogate outcome measures of intensive care unit stay, total length of stay, or stroke among studies that displayed a notable difference in AF incidence between groups. Sensitivity analysis that included only high-quality studies similarly showed no significant difference in the incidence of AF and further showed several intraoperative variables as potential sources of heterogeneity between studies. Therefore, minimal access may not have a significant effect on postoperative AF. Future randomized studies must take into account the potential sources of heterogeneity identified here to better demonstrate any differences between the 2 approaches in the onset of AF.