Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock after valve replacement.

BACKGROUND: Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves. METHODS: This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups. RESULTS: There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years. CONCLUSIONS: Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock: The impact of cannulation strategy on survival.

BACKGROUND: The optimal venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulation strategy in patients with postcardiotomy cardiogenic shock is still debatable. Studies evaluating the effect of cannulation strategy on long-term survival are scarce. OBJECTIVES: We investigated the impact of central versus peripheral cannulation strategy for ECMO insertion on hospital outcomes and survival in postcardiotomy cardiogenic shock patients. METHODS: This retrospective study involved 101 patients who had either central or peripheral ECMO due to postcardiotomy shock between June 2009 and December 2020. Study endpoints were limb ischemia, bleeding, blood transfusion, wound infection, and overall survival. RESULTS: Eighty-four patients received central (c) ECMO, and 17 patients had peripheral (p) ECMO. In the group of pECMO, limb ischemia was significantly higher (5 [29.41%] vs 6 [7.14%]; p = .01). Other endpoints were similar in both groups. Thirty-day mortality was nonsignificantly different between both cohorts (cECMO 34 [41.67%] vs pECMO 10 [58.82%]; p = .29). However, overall survival was better with cECMO (Log-rank p = .02). Patients' age [HR: 1.04 (95% CI: 1.02-1.06); p = .001], pECMO [HR: 1.98 (95% CI: 1.11-3.55), p = .002] and presence of infective endocarditis [HR: 3.54 (95% CI: 1.52-8.24), p = .03] were significant predictors of overall mortality. CONCLUSIONS: Peripheral ECMO was associated with an increased risk of limb ischemia; however, bleeding, blood transfusion, infection, and 30-day mortality were comparable to central ECMO. Central cannulation was associated with a better 1-year survival rate. Therefore, central cannulation might be the preferred strategy for patients with postcardiotomy cardiogenic shock.

The influence of mitral valve pathology on the concomitant tricuspid valve repair.

BACKGROUND: The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare long-term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease. METHODS: We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs. RESULTS: There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio [SHR]: 1.22 [0.77-1.95], p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 [1.5-2.16], p < .001); body mass index (SHR: 1.05 [1.03-1.08], p < .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 [0.41-0.99], p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 [1.03-2.78], p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 [0.56-1.04], p = .09) or after matching (OR: 0.98 [0.67-1.44]; p = .93). CONCLUSION: Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement.

Residual versus recurrent mitral regurgitation after transcatheter mitral valve edge-to-edge repair.

BACKGROUND: The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies. METHODS: From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR. RESULTS: The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007). CONCLUSION: The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip.

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves.

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

Reinterventions after transcatheter edge to edge mitral valve repair: Is early clipping warranted?

BACKGROUND: Reintervention after transcatheter edge to edge repair using MitraClip is still challenging. We aimed to report our experience in reinterventions after MitraClip procedures and describe the outcomes. METHODS: From 2012 to 2020, 167 patients had a transcatheter edge to edge repair; 10 of them needed reinterventions. At the time of the first MitraClip, the median EuroSCORE was 4.29 (2.62-7.52), and the ejection fraction was 30 (20-40)%. RESULTS: Emergency mitral valve replacement (MVR) was performed in two patients, elective MVR in three, cardiac transplantation in two, and repeat clipping in threepatients. The median time from MitraClip to the reintervention was 4.5 (2-13) months. One patient required extracorporeal membrane oxygenation support after elective MVR. Repeat clipping failed to control mitral regurgitation grade in all patients. Clip detachment was reported in five patients (50%). The median follow-up after the reintervention was 19.5 (9-75) months, and mortality occurred in two patients who had repeat clipping (20%). CONCLUSIONS: MVR after MitraClip is feasible with low morbidity and mortality. Repeat mitral valve clipping had a high failure rate. Mitral repair was not feasible in all patients in our series, and the use of MitraClip to delay surgical interventions may not be feasible if mitral repair is an option.

del Nido Cardioplegia in Adult Patients: A Propensity-Matched Study of 102 Consecutive Patients.

BACKGROUND: Paediatric del Nido cardioplegia (DNC) has been tested in selected populations of low-risk adult patients. This study examined its use in an unselected medium-to-high-risk adult population and compared the results with a propensity-matched population that received intermittent warm blood cardioplegia (IWBC). METHODS: Data from the last 1,000 consecutive adult patients who underwent a variety of surgical procedures under cardioplegic arrest with the use of IWBC or DNC between 2016 and 2018 were propensity score matched on preoperative clinical and demographic variables. Two (2) main populations were 102 patients who received DNC and another set of matched 102 patients from a total of 1,000 patients who received IWBC, along with a subgroup with an ejection fraction (EF) ≤40% (EFDNC vs EFIWBC). Postoperative outcomes were mortality, peak troponin T, postoperative EF%, and aortic cross-clamp time. RESULTS: There were no preoperative differences amongst the groups in the main cohort (Euroscore II: DNC 4.1±8, IWBC 4.0±7; EF%: DNC 47±10, IWBC 47±11) and in the subgroup (EF%: EFDNC 32±6%, EFIWBC 32±6%; p=0.45). There were also no differences in three of the outcomes. A significant postoperative improvement was noticed in the EF% in the DNC (32±6% 95% CI 29-34 to 39±12 95% CI 34-44; p=0.001) in the EFDNC group. CONCLUSIONS: This initial experience of del Nido cardioplegia proved to be effective in a variety of challenging pathologies in adult populations.

The role of 3D echocardiographic imaging in the differential diagnosis of an atypical left atrial myxoma.

We describe a case of a left atrial myxoma atypical for its anatomical features and site of attachment. Although an initial multimodality imaging was performed, the diagnosis of myxoma was possible only by three dimensional echocardiography (3DE) which was able to identify the pedicle and the attachment at the base of the interatrial septum, close to the origin of right inferior pulmonary vein. In fact the 3DE can electronically section the structures and obtain unique planes useful in visualizing correctly the anatomical features of the myxomas and as a result, it facilitates the surgical decision planning. Even the anatomical appearance was uncommon at surgery and the diagnosis could be confirmed only by pathology.  This case highlights the diagnostic ability of the 3DE in similar challenging scenarios.

Nickel allergy induced systemic reaction to an intracardiac amplatzer device.

Nickel hypersensitivity is reported in about 10-15% of the general population and manifests mainly with dermatological signs. Chest discomfort, palpitations, signs and symptoms of pericarditis, and migraine are symptoms reported in rare cases of nickel hypersensitivity after implantation of a cardiac device made of nickel. We present the case of a patient with a nickel allergy from an Amplatzer device in which the removal of the device produced resolution of the symptoms.

On pump evaluation of the anastomotic patency of in situ arterial grafts.

We describe a variation of the standard intraoperative transit time flow evaluation that allows the assessment of the anastomotic patency of in situ arterial grafts before the release of the aortic cross clamp. The advantages of this technique are the immediate correction of technical imperfections and the evaluation of native competitive flow situations that may compromise long-term patency.

Concomitant Mitral Valve Repair vs Replacement During Surgical Ventricular Restoration for Ischemic Cardiomyopathy.

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.

The Effect of Gender on Triple Heart Valve Surgery Outcomes; Reinforcing Women's Health.

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m2, P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females (P < .001), and they had lower concomitant coronary artery bypass grafting (P = .001). Bleeding and renal failure were lower in females (P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.

Age-Specific Outcomes of Bioprosthetic vs. Mechanical Aortic Valve Replacement: Balancing Reoperation Risk with Anticoagulation Burden.

BACKGROUND: The choice of prosthesis for aortic valve replacement (AVR) remains challenging. The risk of anticoagulation complications vs. the risk of aortic valve reintervention should be weighed. This study compared the outcomes of bioprosthetic vs. mechanical AVR in patients older and younger than 50. METHODS: This retrospective study was conducted from 2009 to 2019 and involved 292 adult patients who underwent isolated AVR. The patients were divided according to their age (above 50 years or 50 years and younger) and the type of valves used in each age group. The outcomes of bioprosthetic valves (Groups 1a (>50 years) and 1b (≤50 years)) were compared with those of mechanical valves (Groups 2a (>50 years) and 2b (≤50 years)) in each age group. RESULTS: The groups had nearly equal rates of preexisting comorbidities except for Group 1b, in which the rate of hypertension was greater (32.6% vs. 14.7%; p = 0.025). This group also had higher rates of old stroke (8.7% vs. 0%, p = 0.011) and higher creatinine clearance (127.62 (108.82-150.23) vs. 110.02 (84.87-144.49) mL/min; p = 0.026) than Group 1b. Patients in Group 1a were significantly older than Group 2a (64 (58-71) vs. 58 (54-67) years; p = 0.002). There was no significant difference in the NYHA class between the groups. The preoperative ejection fraction and other echocardiographic parameters did not differ significantly between the groups. Re-exploration for bleeding was more common in patients older than 50 years who underwent mechanical valve replacement (p = 0.021). There was no difference in other postoperative complications between the groups. The groups had no differences in survival, stroke, or bleeding rates. Aortic valve reintervention was significantly greater in patients ≤ 50 years old with bioprosthetic valves. There were no differences between groups in the changes in left ventricular mass, ejection fraction, or peak aortic valve pressure during the 5-year follow-up. CONCLUSIONS: The outcomes of mechanical and bioprosthetic valve replacement were comparable in patients older than 50 years. Using bioprosthetic valves in patients younger than 50 years was associated with a greater rate of valve reintervention, with no beneficial effect on the risk of bleeding or stroke.

Randomized trial of HTK versus warm blood cardioplegia for right ventricular protection in mitral surgery.

OBJECTIVES: To clarify the reliability of the one-shot histidine-tryptophane-ketoglutarate (HTK) cardioplegia for right ventricular (RV) myocardial protection during mitral surgery, in patients with or without pre-operative RV dysfunction. DESIGN: Sixty patients undergoing isolated mitral surgery were randomized to myocardial protection with either one-shot HTK or intermittent warm blood cardioplegia (WBC). The RV function was assessed by echocardiography and hemodynamic assessment. Pre-operative tricuspid annular plane systolic excursion (TAPSE), an index of RV systolic function was used to dichotomize groups into patients having impaired (TAPSE < 15) or preserved (TAPSE ≥ 15) RV function. RESULTS: There were no significant intergroup differences in the post-operative indexes of RV function in cases with TAPSE ≥ 15. In patients having TAPSE < 15 we observed statistically worse RV ejection fraction (RVEF, 15% ± 2% vs. 24% ± 3%), end-diastolic volume (RVEDV, 188 mL ± 20 vs. 179 mL ± 14) and fractional area change (RVFAC, 21% ± 6% vs. 30% ± 3%) after use of the HTK solution versus patients who received the WBC. These differences were associated with longer mechanical ventilation and ICU times in patients with impaired RV function and receiving HTK cardioplegia. In a substudy ten patients with TAPSE < 15 received intra-operative topical myocardial cooling in addition to HTK. The addition of topical cooling to HTK cardioplegia yielded statistically significant amelioration in post-operative RV function compared with patients who received the HTK solution without topical cooling (RVEF: 23% ± 3% vs. 15% ± 2%; RVEDV: 180 mL ± 9 vs. 188 mL ± 18; RVFAC: 8.5% ± 1% vs. 6% ± 2%). CONCLUSIONS: The one shot HTK solution offers inferior RV protection compared with WBC, mainly in patients with depressed pre-operative RV function. When adopting HTK cardioplegia the addition of topical cooling is strongly advised.

Acute aortic pathology, Munchausen syndrome, and confirmation bias.

BACKGROUND: Munchausen syndrome is a psychiatric disease characterized by pathological lying and malingering. Patients who are affected can set up such complex and compelling clinical scenarios that they can lead to a bias in the diagnostic process and even to unnecessary surgery. CASE REPORTS: Two cases of Munchausen syndrome misrepresenting acute aortic dissection are reported. The two cases occurred at two different institutions where there was considerable expertise in the management of aortic pathology. In both patients, a wrong diagnosis of acute aortic syndrome was made, leading to unnecessary surgery. CONCLUSIONS: Retrospective analysis of the clinical events and the diagnostic process suggests that a confirmation bias played a major role in determining the misdiagnosis. The same mistake is likely to have occurred in the only other case reported in the literature.

Management of Tricuspid Valve Regurgitation During Surgical Ventricular Restoration for Ischemic Cardiomyopathy.

INTRODUCTION: We studied the effect of tricuspid valve (TV) surgery combined with surgical ventricular restoration (SVR) on operative outcomes, rehospitalization, recurrent tricuspid regurgitation, and survival of patients with ischemic cardiomyopathy. Additionally, surgery was compared to conservative management in patients with mild or moderate tricuspid regurgitation. To the best of our knowledge, the advantage of combining TV surgery with SVR in patients with ischemic cardiomyopathy had not been investigated before. METHODS: This retrospective cohort study included 137 SVR patients who were recruited from 2009 to 2020. Patients were divided into two groups - those with no concomitant TV surgery (n=74) and those with concomitant TV repair or replacement (n=63). RESULTS: Extracorporeal membrane oxygenation use was higher in SVR patients without TV surgery (P=0.015). Re-exploration and blood transfusion were significantly higher in those with TV surgery (P=0.048 and P=0.037, respectively). Hospital mortality occurred in eight (10.81%) patients with no TV surgery vs. five (7.94%) in the TV surgery group (P=0.771). Neither rehospitalization (log-rank P=0.749) nor survival (log-rank P=0.515) differed in patients with mild and moderate tricuspid regurgitation in both groups. Freedom from recurrent tricuspid regurgitation was non-significantly higher in mild and moderate tricuspid regurgitation patients with no TV surgery (P=0.059). Conservative management predicted the recurrence of tricuspid regurgitation. CONCLUSION: TV surgery concomitant with SVR could reduce the recurrence of tricuspid regurgitation; however, its effect on the clinical outcomes of rehospitalization and survival was not evident. The same effects were observed in patients with mild and moderate tricuspid regurgitation.

Five-year outcomes of tricuspid valve repair versus replacement; a propensity score-matched analysis.

BACKGROUND: Tricuspid valve repair (TVr) is the recommended approach for managing tricuspid regurgitation; however, there is a concern about the long-term durability of the repair. Therefore, this study aimed to compare the long-term outcomes of TVr versus tricuspid valve replacement (TVR) in a matched cohort of patients. METHODS: This study included 1161 patients who underwent tricuspid valve (TV) surgery from 2009 to 2020. Patients were grouped according to the procedure into two groups: patients who underwent TVr (n = 1020) and patients who underwent TVR (n = 159). The propensity score identified 135 matched pairs. RESULTS: Renal replacement therapy and bleeding were significantly higher in the TVR group compared to the TVr group both before and after matching. Thirty-day mortality occurred in 38 (3.79%) patients in TVr group versus 3 (1.89%) in the TVR group (P ≤ 0.001) but was not significant after matching. After matching, TV reintervention (hazard ratio (HR): 21.44 (95% CI: 2.17-211.95); P = 0.009) and heart failure rehospitalization (HR: 1.89 (95% CI: 1.13-3.16); P = 0.015) were significantly higher in the TVR group. There was no difference in mortality in the matched cohort (HR: 1.63 (95% CI: 0.72-3.70); P = 0.25). CONCLUSIONS: TVr was associated with lower renal impairment, reintervention, and heart failure rehospitalization than replacement. TVr remains the preferred approach whenever feasible.

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

Surgical vs Transcatheter Aortic Valve Replacement in Patients With a Low Ejection Fraction.

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P < .001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P < .001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P = .03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P < .001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio: .95 (.37-2.45); P = .92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (ß: .28 (.23-.33); P < 0.001) with no difference between groups (P = .85). In conclusion, TAVR could be as safe as SAVR in patients with low EF.