Early in-vivo hemodynamic comparison of supra-annular aortic bioprostheses: Trifecta versus Perimount Magna Ease.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare early postoperative hemodynamic gradients after supra-annular implantation of the Trifecta and Perimount Magna Ease aortic bioprostheses. METHODS: Between January 2010 and December 2011, a total of 235 patients (105 males, 130 females; mean age at surgery 73.8 +/- 10.2 years) underwent supra-annular aortic valve replacement (AVR), with or without concomitant procedures. The patients were divided into 2 groups receiving either the Perimount Magna Ease (n = 117) or Trifecta (n = 118). Concomitant procedures were performed in 133 patients (56.6%), and 25 procedures (10.6%) were redos. Patients with postoperative severe left ventricular dysfunction and moderate to severe mitral regurgitation were excluded. Gradients were calculated pre-discharge using transthoracic echocardiography. Effective orifice area calculations were not performed. Data were collected retrospectively from hospital databases and analyzed using SPSS 17. RESULTS: Both groups compared well for 14 variables. Group A had a higher number of redo operations and the patients were younger. Postoperative peak and mean gradients (in mmHg) for the Magna Ease group versus Trifecta group were: 19 mm valves, 33.5 +/- 16 versus 24.7 +/- 10 (p = 0.11) and 17.4 +/- 6.5 versus 12.7 +/- 4.4 (p = 0.05); 21 mm, 27.2 +/- 9.1 versus 21.8 +/- 7.2 (p = 0.001) and 13.8 +/- 4.7 versus 10.7 +/- 3.4 (p = 0.001); 23 mm, 25.6 +/- 7.8 versus 20.1 +/- 7.9 (p = 0.005) and 13 +/- 4 versus 10.1 +/- 4.3 (p = 0.002); 25 mm, 22.3 +/- 7.8 versus 15.6 +/- 5.1 (p = 0.01) and 12.8 +/- 4.1 versus 8 +/- 2.8 (p = 0.02). The overall mortality was 3.4%. The median hospital stay was nine days in both groups (p = 0.13). Mortality (p = 0.5), and incidences of perioperative stroke (p = 0.45), postoperative new-onset atrial fibrillation (p = 0.26) and permanent pacemaker implantation (p = 0.8) were similar in both groups. CONCLUSION: Early postoperative gradients were significantly lower in patients receiving Trifecta valves, although the long-term clinical outcome and durability of the valve will require further evaluation.

The outcomes of triple-valve surgery: eleven years' experience from a single center.

BACKGROUND AND AIM OF THE STUDY: Triple-valve surgery is a challenging and complex procedure with significant risk, even at centers experienced at performing such operations. The study aim was to investigate the early and late outcomes of this surgery, performed at a single center for the past 11 years. METHODS: A total of 45 consecutive patients (19 males, 26 females; mean age 69.42 +/- 12.72 years) underwent triple-valve surgery at the authors' institution between 2000 and 2011. The mean logistic EuroSCORE was 22.46 +/- 12.8%. The most common aortic valve pathology was calcific degeneration (40%), while the mitral valves were mostly rheumatic (31%) or degenerative (26%). The tricuspid valve pathology was functional regurgitation in 64% of patients. The aortic valve procedures were all replacements, while the mitral valves were either repaired (n = 20) or replaced (n = 25). The tricuspid valves were almost exclusively repaired (n = 43). Univariate and multivariate analyses were performed to highlight predictors of mortality. A Kaplan-Meier analysis was also performed. RESULTS: The operative mortality was 8.9% (n = 4). Survival at one, three, and five years was 91%, 85.5% and 66.4%, respectively. Morbidity was not particularly high: the incidence of all postoperative neurological complications was 13%, that of transient renal impairment was 18%, and pacemaker implantation 8.9%. CONCLUSION: The results of triple-valve surgery were considerably improved compared to historical reports. Early mortality was close to that occurring after less complex procedures, while late survival was comparable to that after single-valve surgery. It is believed that the best results are achieved by centers experienced in valve procedures. Compared to older studies, rheumatic disease was not the most frequent requirement for of triple-valve surgery among the present patients.

On-X aortic valve replacement patients treated with low-dose warfarin and low-dose aspirin.

OBJECTIVES: To assess if warfarin targeted to international normalized ratio (INR) 1.8 (range 1.5-2.0) is safe for all patients with an On-X aortic mechanical valve. METHODS: This prospective, observational registry follows patients receiving warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus daily aspirin (75-100 mg) after On-X aortic valve replacement. The primary end point is a composite of thromboembolism, valve thrombosis and major bleeding. Secondary end points include the individual rates of thromboembolism, valve thrombosis and major bleeding, as well as the composite in subgroups of home or clinic-monitored INR and risk categorization for thromboembolism. The control was the patient group randomized to standard-dose warfarin (INR 2.0-3.0) plus daily aspirin 81 mg from the PROACT trial. RESULTS: A total of 510 patients were enroled at 23 centres in the UK, USA and Canada. Currently, the median follow-up duration is 3.4 years, and median achieved INR is 1.9. The primary composite end point rate in the low INR patients is 2.31% vs 5.39% (95% confidence interval 4.12-6.93%) per patient-year in the PROACT control group, constituting a 57% reduction. Results are consistent in subgroups of home or clinic-monitored, and high-risk patients, with reductions of 56%, 57% and 57%, respectively. Major and total bleeding are decreased by 85% and 73%, respectively, with similar rates of thromboembolic events. No valve thrombosis occurred. CONCLUSIONS: Interim results suggest that warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus aspirin is safe and effective in patients with an On-X aortic mechanical valve with or without home INR monitoring.

Low-dose warfarin with a novel mechanical aortic valve: Interim registry results at 5-year follow-up.

OBJECTIVES: To evaluate whether warfarin targeted at an international normalized ratio of 1.8 (range, 1.5-2.0) after On-X mechanical aortic valve implant is safe for all patients. METHODS: This prospective, observational clinical registry assessed adverse event rates in adult patients receiving low-dose warfarin (target international normalized ratio, 1.8; range, 1.5-2.0) plus daily aspirin (75-100 mg) during a 5-year period after On-X aortic valve implant. The primary end point is the combined rate of major bleeding, valve thrombosis, and thromboembolism overall and in 4 subgroups. The comparator is the Prospective Randomized On-X Anticoagulation Trial control group patients on standard-dose warfarin (international normalized ratio, 2.0-3.0) plus aspirin 81 milligrams daily. RESULTS: A total of 510 patients were recruited at 23 centers in the United States, United Kingdom, and Canada between November 2015 and January 2022. This interim analysis includes 229 patients scheduled to complete 5-year follow-up by August 16, 2023. The linearized occurrence rate (in percent per patient-year) of the primary composite end point of major bleeding, valve thrombosis, and thromboembolism is 1.83% compared with 5.39% (95% confidence interval, 4.12%-6.93%) in the comparator group. Results are consistent in clinic-monitored and home-monitored patients and in those at high risk for thromboembolism. Major bleeding and total bleeding were reduced by 87% and 71%, respectively, versus the comparator group, without an increase in thromboembolic events. CONCLUSIONS: Interim results support the continued safety of the On-X aortic mechanical valve with a target international normalized ratio of 1.8 plus low-dose aspirin through 5 years after implant, with or without home monitoring.

Intraoperative Open Aortoscopy-A New Emerging Technique in Hybrid Aortic Arch Surgery.

Intraoperative open aortoscopy is a new emerging technique in hybrid aortic arch surgery using hybrid open stent grafts for frozen elephant trunk operation. It is performed on a detumescent open aortic arch during the period of deep hypothermic circulatory arrest. It aids in operative planning and choice of open stent graft and confirms proper deployment and distal seal prior to resumption of circulation.

Calcification of Gore-Tex Neochord After Mitral Repair: Electron Microscopy.

A 76-year-old woman presented with severe mitral valve regurgitation 6 years after mitral valve repair with Gore-Tex (expanded polytetrafluoroethylene, W.L. Gore & Associates Inc) neochords and ring annuloplasty. Echocardiography revealed a ruptured neochord. During successful mitral valve replacement, the explanted Gore-Tex neochords were found to be stiff and calcified, with a fracture. Electron microscopy was used to examine the explant and a control neochord. There was disruption of the microstructure with extensive calcium infiltration at the fracture point. Although this is a rare cause of late repair failure, it warrants yearly follow-up with echocardiography.

Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.

Is Resident Training Safe in Cardiac Surgery?

BACKGROUND: There exists a knowledge gap regarding the safety of training in cardiac surgery. The purpose of this analysis was to establish the safety of resident training in cardiac surgery and compare the results of the trainee cases to those performed by consultants. METHODS: In all, 5894 (trainee, 3343; consultant, 2551) major cardiac operations (European System for Cardiac Operative Risk Evaluation less than 10) from 2013 to 2018 were reviewed. Multivariate analysis was performed for inhospital mortality and composite outcome of length of stay longer than 30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, inhospital death, or reoperation. Observations were propensity matched to consultant or trainee with the 16 covariates. RESULTS: Trainees performed 56.7% of cases. Multivariate analysis identified renal disease (odds ratio [OR] 2.93; 95% confidence interval [CI], 1.3 to 6.7; P < .02), peripheral vascular disease (OR 4.62; 95% CI, 1.82 to 11.71; P < .01), and emergency/salvage procedure (OR 7.23; 95% CI, 2.00 to 26.11; P < .01) as predictors of inhospital mortality. Emergency/salvage procedure was the only predictor of worse composite outcomes (OR 2.65; 95% CI, 1.54 to 4.55; P < .001). Trainee cases had similar inhospital mortality and composite outcomes. After propensity matching (1842 observations), bypass time and cross-clamp time were significantly longer for trainees for isolated coronary artery bypass graft surgery and aortic valve replacement. There was no difference between deep sternal infection, new hemodialysis, new stroke/transient ischemic attack, inhospital death, or reoperation. Overall composite outcome differed between groups (trainee 9% vs consultant 16.6%, P = .001) owing to difference in the length of stay longer than 30 days (trainee 4.2% vs consultant 9.9%, P = .001). CONCLUSIONS: Resident training is safe in cardiac surgery without compromising the quality of patient care.

Feasibility of a novel, synthetic, self-assembling peptide for suture-line haemostasis in cardiac surgery.

BACKGROUD: To assess the feasibility and efficacy of PuraStat®, a novel haemostatic agent, in achieving suture line haemostasis in a wide range of cardiac surgical procedures and surgery of the thoracic aorta. METHODS: A prospective, non-randomised study was conducted at our institution. Operative data on fifty consecutive patients undergoing cardiac surgery where PuraStat® was utilised in cases of intraoperative suture line bleeding was prospectively collected. Questionnaires encompassing multiple aspects of the ease of use and efficacy of PuraStat® were completed by ten surgeons (five consultants and five senior registrars) and analysed to gauge the performance of the product. RESULTS: No major adverse cardiac events were reported in this cohort. Complications such as atrial fibrillation, pacemaker requirement and pleural effusions were comparable to the national average. Mean blood product use of packed red cells, platelets, fresh-frozen plasma (FFP) and cryoprecipitate was below the national average. There was one incidence of re-exploration, however this was due to pericardial constriction rather than bleeding. Analysis of questionnaire responses revealed that surgeons consistently rated PuraStat® highly (between a score of 7 and 10 in the various subcategories). The transparent nature or PuraStat® allowed unobscured visualisation of suture sites and possessed excellent qualities in terms of adherence to site of application. The application of PuraStat® did not interfere with the use of other haemostatic agents or manipulation of the suture site by the surgeon. CONCLUSION: PuraStat® is an easy-to-use and effective haemostatic agent in a wide range of cardiac and aortic surgical procedures.

Recurrent constrictive pericarditis associated with seropositive rheumatoid arthritis: A case report.

INTRODUCTION: Constrictive pericarditis is an uncommon disease characterized by impaired diastolic filling of the ventricles, encased in a fibrotic pericardium resulting from an inflammatory process. Rheumatoid arthritis is a rare cause of constrictive pericarditis, usually due to a concomitant acute or chronic serositis. PRESENTATION OF CASE: This paper presents a unique case of recurrent constrictive pericarditis associated with seropositive rheumatoid arthritis, requiring pericardiectomy and complicated three years later by recurrent fibrosis, demanding a second pericardiectomy. DISCUSSION: Defining this entity as recurrent constrictive "pericarditis" might be a mistake, given that a total pericardiectomy was performed in first instance. No risk factors for recurrent fibrosis have been identified in the current medical literature, apart from partial pericardiectomy. We cannot demonstrate exclusively that rheumatoid arthritis is a risk factor for recurrent pericardial/epicardial fibrosis due to the rare nature of the disease. CONCLUSION: Further large scale studies are necessary to identify the risk factors for recurrence.

Hemodynamic performance of Trifecta: single-center experience of 400 patients.

OBJECTIVE: To evaluate postoperative hemodynamic gradients and early outcomes of aortic valve replacement with the Trifecta bioprosthesis. METHODS: Between 2011 and 2013, 400 patients underwent aortic valve replacement with a Trifecta bioprosthesis. Gradients were calculated by transthoracic echocardiography before discharge. Data were collected retrospectively; patients with postoperative severe left ventricular dysfunction or > mild mitral regurgitation were excluded. RESULTS: The mean age was 75.9 ± 8.5 years, 197 (49.25%) patients were male, and 140 (35%) were >80-years old. Concomitant procedures were performed in 207 (51.75%) patients, and 30 (7.5%) had redo procedures. Supraannular aortoplasty with bovine pericardium was necessary in 25 (6.25%) cases. Hospital mortality was 2.75% (11 patients). Postoperative peak and mean gradients were 21.7 ± 9.3 and 11.1 ± 4.3 mm Hg for 19-mm valves (n = 29); 19.5 ± 7 and 9.7 ± 3.6 mm Hg for 21-mm valves (n = 158); 17.3 ± 6.6 and 8.7 ± 3.2 mm Hg for 23-mm valves (n = 134); 15.1 ± 6.1 and 7.8 ± 3.3 mm Hg for 25-mm valves (n = 56); 13.2 ± 3.7 and 6.9 ± 2.6 mm Hg for 27-mm valves (n = 11). Nine patients had trivial and one had mild transvalvular regurgitation. Mean follow-up was 1 ± 0.62 years; no patient required reoperation. Kaplan-Meier survival at 1 and 2 years was 94.3% ± 1.3% and 93.7% ± 1.4%. CONCLUSION: Early postoperative gradients are low after Trifecta implantation. Significant transvalvular regurgitation was not observed, but the incidence of supraannular aortoplasty may be increased.

Repair of acute type A aortic dissection: results in 100 patients.

To determine short- and long-term outcomes after repair of type A aortic dissection, we reviewed data of 100 consecutive patients (64 men; mean age, 63 ± 12.2 years) who underwent acute type A aortic dissection repair between January 2000 and June 2008. They were divided into group A, open anastomosis (circulatory arrest; n = 59) and group B, closed anastomosis (no circulatory arrest; n = 41). Aortic valve re-suspension or replacement was performed in 77 patients, aortic root replacement in 29, and aortic arch procedures in 31. The median follow-up was 2.8 years (range, 0-8.6 years). The 30-day mortality was 14%; 16.9% in group A and 9.8% in group B. None of the 23 variables analyzed to determine predictors of death or stroke was significant on multivariate analysis. Postoperatively, there was no difference between the 2 groups with respect to stroke, sepsis, renal failure, multiorgan failure, or reoperation. Overall actuarial survival at 1, 3, 5, and 8 years was not significantly different between the 2 groups. Considerable morbidity is still associated with repair of type A aortic dissection, despite a significant improvement in mortality.

Outcome after redo-mitral valve replacement in adult patients: a 10-year single-centre experience.

The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement (redo-MVR) at our institution. Forty-nine patients (24 males) underwent redo-MVR with either bioprosthetic (n = 24) or mechanical valves (n = 25) between January 2000 and 2010. Median age of patients was 63 years (range 21-80 years), and the mean additive EuroSCORE was 12 ± 4. Median time to re-operation was 8.2 ± 6.6 years for first time redo-MVR and 6.4 ± 5.6 years for second-time redo-MVR. Indications included prosthetic endocarditis (n = 22), para-prosthetic leak (n = 12), structural valve degeneration (n = 8), prosthetic valve thrombosis (n = 6) and malignancy (n = 1). The mean follow-up was 47.5 ± 37.0 months (range 0.1-112.3 months). In-hospital mortality was 12% (n = 6). Mean hospital stay was 17 ± 11 days (range 8-50 days). Actuarial survival at 1 and 5 years was 81 ± 5% and 72 ± 6%, respectively. Three patients required re-intervention: two for prosthetic valve endocarditis and one for para-prosthetic leak. Multivariate analysis showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P < 0.001) and urgent surgery (P = 0.03).

Aortic valve replacement in patients with previous coronary artery bypass grafting: 10-year experience.

UNLABELLED: OBJECTIVES; This study aimed to investigate the early and late outcomes of patients undergoing aortic valve replacement (AVR) with previous coronary artery bypass grafting (CABG) and patent grafts. METHODS: Between January 2000 and March 2010, 104 patients (87 males) with previous CABG ± concomitant surgery and patent grafts underwent AVR. The median age of the patients was 75 years (range: 37-90 years; inter-quartile range: 69-79 years) and the mean logistic EuroScore was 25.37 ± 16.8. The median time since the previous operation was 9 years (range 1-25; inter-quartile range: 7-14 years). The left internal mammary artery (LIMA) had been used in 75 patients (72.1%) and remained patent in 72 cases (96.0%). RESULTS: Thirty-day mortality was 7.7% (n = 8), which is less than the predicted mean logistic EuroScore. Isolated AVR was performed in 66 patients (63.5%). The LIMA was dissected and isolated (clamped or blocked with balloon) in 60 patients. The median hospital stay was 10 days (range: 4-183 days; inter-quartile range: 7-15.25 days). Nineteen patients (18.3%) had pulmonary complications, while 12 (11.5%) had acute kidney injury. Seven patients (6.7%) required permanent pacemaker. Six LIMAs (8.3%) were injured and repaired. Prolonged aortic cross-clamp (AXC) time (P = 0.038) and the presence of a previous LIMA graft (P = 0.045) were identified as independent predictors of 30-day mortality. The actuarial survival at 1 and 5 years was 89.4 ± 0.3 and 81.5 ± 0.5%, respectively. Perioperative intra-aortic balloon pump use (P = 0.036), prolonged AXC time (P = 0.004) and prolonged cardiopulmonary bypass time (P = 0.022) were associated with worse long-term overall survival on multivariate analysis. CONCLUSIONS: AVR post-CABG with patent grafts can be performed in high-risk patients with excellent short- and long-term outcomes and appears to be superior to published catheter-based interventions. In the absence of randomized trial data, we believe that open AVR remains the treatment of choice for aortic valve disease following prior CABG.

Long-term outcome following repair of acute type A aortic dissection after previous cardiac surgery.

We evaluated the outcome after repair for acute spontaneous type A aortic dissection in patients with previous cardiac surgery. From January 2000 to December 2009, 114 patients underwent emergency repair for acute spontaneous type A dissection at Southampton University Hospital. Eleven (median age 64 years; range 36-83 years; two females) patients (9.8%) had undergone previous cardiac surgery and were included in this study. Aortic root replacement was performed in three patients (27%), aortic arch replacement in four patients (36%) and two patients (18%) required aortic valve re-suspension. The elephant trunk operation was performed in two patients (18%). There were two hospital deaths (18%). Two patients (18%) suffered a stroke, two needed re-opening for bleeding (18%) and two patients (18%) required haemofiltration postoperatively. Median length of hospital stay was 16 days (range 6-34 days). Actuarial survival at five and eight years for redo compared to first-time surgery was 68±3.63% vs. 81±5.34% and 51±3.8% vs. 61±5.4%, respectively (P=0.365). In conclusion, acute type A aortic dissection repair in patients with previous cardiac surgery has an acceptable mortality and comparable long-term outcome to first-time surgery.