Alternative Access Transcatheter Aortic Valve Replacement in Nonagenarians versus Younger Patients.

BACKGROUND: Numerous studies have documented the safety of alternatives access (AA) transcatheter aortic valve replacement (TAVR) for patients who are not candidates for transfemoral or surgical approach. There is a scarcity of studies relating use of AA TAVR in nonagenarian patients, a high-risk, frail group. Our study sought to investigate the clinical outcomes of nonagenarians who underwent AA TAVR for aortic stenosis, with comparison of nonagenarians age ≥90 years with patients age <90 years. METHODS: A cohort study of 171 consecutive patients undergoing AA TAVR (transapical [TA, n = 101, 59%], transaxillary [TAX, n = 56, 33%], transaortic [TAO, n = 11, 6%], and transcarotid [TC, n = 3, 2%]) from 2012 to 2019 was analyzed. Baseline, operative, and postoperative characteristics, as well as actuarial survival outcomes, were compared. RESULTS: AA TAVR patients had decreased aortic valve gradients with no difference detected in nonagenarians and younger patients. Operative mortality was 8% (n = 14; nine TA, three TAO, and two TAX). Compared to younger patients, significantly more nonagenarians were recorded to have new onset atrial fibrillation (7 vs. 5%, p < 0.01*). No significant difference in mortality or postoperative complications, such as stroke, pacemaker requirements, was detected. Actuarial survival at 1 and 5 years was 86 versus 87% (nonagenarians vs younger patients) and 36 versus 22%, respectively, with log-rank = 0.97. CONCLUSION: AA TAVR in nonagenarian patients who are not candidates for transfemoral approach can be efficaciously performed with comparable clinical outcomes to younger patients, age <90 years. Furthermore, some access sites should be avoided when possible; notably TA was associated with increased mortality, stroke, and new onset atrial fibrillation.

Predictors and outcomes of stroke after transcatheter aortic valve replacement.

OBJECTIVES: Stroke is a devastating complication of transcatheter aortic valve replacement (TAVR). Many studies have investigated risk factors for postoperative stroke, but reliable predictors are not yet well-established. The objective of this study was to further characterize the predictors and outcomes of stroke after TAVR. METHODS: This is a retrospective cohort study of 1022 patients who underwent TAVR at a single institution between 2012 and 2018. Multivariable logistic regression analysis was used to identify independent predictors of postoperative stroke and Kaplan-Meier method to compare 1-year survival in patients with and without postoperative stroke. RESULTS: Postoperatively, 36 patients experienced a stroke (3.5%) with most developing multiple (63.9%, N = 23), and often bilateral infarcts (50.0%, N = 18). Stroke patients more commonly had peripheral arterial disease (P = .032) and carotid stenosis (P = .013) and were less likely to receive predeployment balloon aortic valvuloplasty (P = .005). Alternative access approach (odds ratio [OR], 2.322; 95% confidence interval [CI]: 1.067-5.054) and history of transient ischemic attack (OR, 2.373; 95% CI: 1.026-5.489) were identified as independent predictors of postoperative stroke. Stroke patients more frequently developed postoperative complications, including prolonged ventilation (P < .001), major vascular complications (P < .001), and new-onset dialysis (P < .001). Operative mortality was greater in stroke patients (19.4% vs 3.7%; P < .001), and 1-year Kaplan-Meier estimates revealed worsened survival (log-rank P = .002). CONCLUSIONS: Alternative access approach and a history of transient ischemic attack emerged as independent predictors of postoperative stroke. Patients with stroke suffered more complications and had worse survival, underscoring the importance of characterizing the stroke risk in these patients.

Predictors and outcomes of patient-prosthesis mismatch after transcatheter aortic valve replacement.

BACKGROUND: Patient-prosthesis mismatch (PPM) has been shown to be associated with adverse outcomes after surgical aortic valve replacement. There is limited data on its risk and impact after transcatheter aortic valve replacement (TAVR), especially with the newer generation heart valves. OBJECTIVES: The objective of this study is to investigate the incidence, predictors, and clinical outcomes of PPM after TAVR. METHODS: This is a retrospective study of 991 consecutive patients who underwent TAVR procedure at a tertiary referral center, between April 2012 and February 2019. Patients were stratified by the presence or absence of PPM, defined as an effective orifice area/body surface area ratio ≤0.85 cm2 /m2 . Multivariable logistic regression analysis was used to determine independent predictors of PPM. Kaplan-Meier survival estimates were used to determine overall 5-year survival. RESULTS: PPM was encountered in 27.6% of patients. In multivariable analysis, age less than 70 years (P = .062), body mass index (BMI) more than 30 (P = .0057), history of atrial fibrillation (P = .0004), black race (P = .0078), and Sapien 3 sizes 20 and 23 mm (P < .0001)emerged as independent predictors of PPM. Sapien 3 valve size 20/23 mm was associated with higher risk of PPM compared to other valve types. Patients with PPM had comparable postoperative outcomes and overall 5-year survival. There was no significant difference in postoperative complications between patient groups. PPM was not associated with worse overall survival (56% for both PPM and no-PPM patients, log-rank P = .80). CONCLUSIONS: Younger age, atrial fibrillation, black race, higher BMI were predictors of PPM. Smaller sizes balloon-expandable valves had a higher risk of PPM.

Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture.

Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) has emerged as a preferable option for high surgical risk patients requiring redo aortic valve replacement. However, VIV TAVR may restrict flow, especially in small native aortic valves. To remedy this, bioprosthetic valve fracture has been utilized to increase the effective orifice area and improve hemodynamics. We present three cases in which bioprosthetic valve fracture was used to increase hemodynamic flow in VIV TAVR procedures.

Modified whole blood microplegia in high-risk patients.

BACKGROUND: Numerous studies have documented the safety of whole blood cardioplegia on clinical outcomes after cardiac surgery. However, there is a paucity of studies investigating the outcomes of whole blood microplegia after cardiac surgery. Our protocol of whole blood microplegia includes removal of the crystalloid portion and utilizing the Quest Myocardial Protection System, for delivery of del Nido cardioplegia additives in whole blood. This study sought to evaluate the effects of whole blood microplegia on clinical outcomes, following cardiac surgery, in high-risk cardiac surgery patients. METHODS: Between February 2016 and December 2017, 131 high-risk patients underwent cardiac surgery operations, utilizing whole blood microplegia and were compared with a contemporaneous control group of 236 low-risk patients. High-risk patients included those who underwent combined coronary artery bypass grafting (CABG) and valve repair or replacement, double-valve surgery, triple-valve repair or replacement, and patients with ejection fraction < 40%. Multivariable logistic regression analysis was performed to identify independent risk factors of mortality after cardiac surgery. RESULTS: Operative mortality was 7% for high-risk and 0% for low-risk patients (P < 0.001). Of those patients, five had isolated CABG (two had emergent CABG), two had double-valve surgery, two had combined valve/CABG. In multivariate analysis, high-risk classification (odds ratio = 3.66, 95% confidence intervals = 1.04-12.9, P = 0.04), emerged as an independent predictor of operative mortality. CONCLUSIONS: Whole blood microplegia, is a novel myocardial protection strategy that can be applied in high-risk cardiac surgery patients and prolonged operations, requiring cardioplegic arrest with acceptable early clinical outcomes.

Hybrid arch debranching and endograft repair in a patient with a ruptured thoracic aortic aneurysm.

Recent advances in hybrid techniques of aortic arch debranching allow for the repair of thoracic aortic arch aneurysm without requiring cardiopulmonary bypass or hypothermic circulatory arrest. We describe the repair of a ruptured proximal descending thoracic aortic aneurysm, using off-pump aortic arch debranching and antegrade transaortic deployment of a thoracic endograft in an elderly patient.

Whole Blood del Nido versus Cold Blood Microplegia in Adult Cardiac Surgery: A Propensity-Matched Analysis.

Objectives Few studies have evaluated the outcomes of whole blood microplegia in adult cardiac surgery. Our novel protocol includes removing the crystalloid portion and using the Quest Myocardial Protection System (MPS) for the delivery of del Nido additives in whole blood. This study sought to compare early and late clinical outcomes of whole blood del Nido microplegia (BDN) versus cold blood cardioplegia (CBC) following adult cardiac surgery. Materials and Methods A total of 361 patients who underwent cardiac surgery using BDN were compared with a contemporaneous control group of 934 patients receiving CBC. Propensity matching yielded 289 BDN and 289 CBC patients. Chi-square analysis and Fisher's exact test were performed to compare preoperative, operative, and postoperative characteristics on the matched data. Primary outcome was operative mortality, and secondary outcomes included clinical outcomes such as stroke, cardiac arrest, and intra-aortic balloon pump use. The Kaplan-Meier method was used to compare actuarial survival between the two groups using a log-rank test. Results After matching, preoperative characteristics and surgery type were similar between groups. Cardioplegia type did not affect the primary end point of operative mortality. The rate of postoperative intra-aortic balloon pump was lower in BDN patients compared with CBC patients (0 vs. 2%; p = 0.01). There was no difference in late survival. Conclusion Our novel protocol BDN was comparable with CBC, with similar clinical outcomes and no difference in operative mortality or actuarial survival. Further studies should evaluate the long-term outcomes of this technique.

Endovascular repair of thoracic aortoenteric fistulas.

Aortoesophageal fistula is a rare manifestation of thoracic aortic surgery or esophageal disease. We describe a patient who underwent emergent endovascular repair of an aortoesophageal fistula due to a ruptured penetrating ulcer of the descending thoracic aorta and review the literature on this subject.

Reoperative coronary artery bypass grafting via left thoracotomy and hypothermic fibrillation.

Left posterolateral thoracotomy approach for reoperative coronary artery bypass grafting (CABG) is a useful alternative to median sternotomy. We describe use of a left posterolateral thoracotomy and hypothermic fibrillation for reoperative CABG in a patient with patent bilateral internal thoracic artery grafts.

Thoracoabdominal aneurysm repair after failed endovascular abdominal aneurysm repair without endograft removal.

Open surgical repair after failed endovascular aneurysm repair usually involves complete aneurysm removal and replacement with a prosthetic surgical graft. We describe an alternative strategy of open surgical repair of a thoracoabdominal aneurysm repair after failed endovascular aneurysm repair that entails preserving the functioning portion of the endograft and sewing the thoracoabdominal graft on the existing abdominal endograft.

Management of Aortic Pseudoaneurysms: Evolving Concepts and Controversies.

BACKGROUND: Techniques to repair aortic pseudoaneurysms have been rapidly evolving. We present our results following open and endovascular repair of aortic pseudoaneurysms from 2009 to 2013. METHODS: A total of nine patients underwent pseudoaneurysm repair from April 2009 to February 2013. Of them, five underwent open repair and four underwent endovascular repair. The median age was 58 years (range, 40-72 years) and two (22%) were females. Preoperative, operative, and postoperative data are presented along with operative modality. RESULTS: Two patients died during the period of study. Patient 1 died from massive hemorrhage at the site of prior stenting. Patient 7 died from postoperative cardiac arrest and respiratory failure. A single patient required hemorrhage-related reexploration. None of the patients experienced stroke or acute renal failure following repair. Median hospital and intensive care unit length of stays were 7.1 (range, 1-20) and 2.0 (range, 1-5), respectively. CONCLUSIONS: Pseudoaneurysm repair can be effectively achieved through open or percutaneous repair but only after careful consideration of anatomical constraints, as well as patient comorbidities.

Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies.

Warm blood cardioplegia has been an established cardioplegic method since the 1990s, yet it remains controversial in regard to myocardial protection. This review will describe the physiologic and technical concepts behind warm blood cardioplegia, as well as outline the current basic and clinical research that evaluates its usefulness. Controversies regarding this technique will also be reviewed. A long history of experimental data indicates that warm blood cardioplegia is safe and effective and thus suitable myocardial protection during cardiopulmonary bypass surgeries.

Outcomes After Left Ventricular Outflow Tract Reconstruction With a Tube Graft for Annular Erosion.

BACKGROUND: Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries. METHODS: A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men. RESULTS: There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm2/m2. All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients. CONCLUSIONS: Extended experience with this technique confirms its safety and effectiveness for patients with extensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Quality improvement program increases early tracheal extubation rate and decreases pulmonary complications and resource utilization after cardiac surgery.

BACKGROUND: Early tracheal extubation is a common goal after cardiac surgery and may improve postoperative outcomes. Our study evaluates the impact of a quality improvement program (QIP) on early extubation, pulmonary complications, and resource utilization after cardiac surgery. METHODS: Between 2002 and 2006, 980 patients underwent early tracheal extubation (<6 hours after surgery) and 1231 had conventional extubation (> 6 hours after surgery, conventional group). Outcomes compared between the two groups included: (1) pneumonia, (2) sepsis, (3) intensive care unit (ICU) length of stay, (4) hospital length of stay, (5) ICU readmission, and (6) reintubation. Logistic regression analysis and propensity score adjustment were used to adjust for imbalances in the patients' preoperative characteristics. RESULTS: Early extubation rates were significantly increased with QIP (QIP 53% vs. Non-QIP 38%, p = 0.01). Early extubation was associated with a lower rate of (1) pneumonia (odds ratio [OR]= 0.35, 95% confidence intervals [CI]= 0.22-0.55, p <0.001), (2) sepsis (OR = 0.38, CI = 0.20-0.74, p <0.004), (3) prolonged ICU length of stay (OR = 0.42, CI = 0.35-0.50, p <0.001), (4) hospital length of stay (OR = 0.37, CI = 0.29-0.47, p <0.001), (5) ICU readmission (OR = 0.55, CI = 0.39-0.78, p <0.001), and (6) reintubation (OR = 0.53, CI = 0.34-0.81, p <0.003) both in multivariable logistic regression analysis and propensity score adjustment. CONCLUSIONS: QIP and early tracheal extubation reduce pulmonary complications and resource utilization after cardiac surgery.

Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies.

Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

Continuous Suture Technique for Aortic Valve Replacement: Technical Considerations and Controversies.

Continuous suture technique (CST) for aortic valve replacement (AVR) is a simple, secure, and fast surgical technique that has been shown to significantly decrease cross clamp time and cardiac bypass time, ultimately resulting in decreased myocardial ischemic injury, operation time, and hospital stay. However, previous studies have reported increased risk of periprosthetic regurgitation with CST for AVR. We describe our technique for AVR using CST in 100 patients with low complication rate and no perioperative paravalvular aortic insufficiency.

Early Experience With Embolic Protection Devices During Transcatheter Aortic Valve Replacement.

OBJECTIVES: Embolic protection devices (EPDs) have been employed to combat the risk of cerebrovascular events during transcatheter aortic valve replacement (TAVR). The use of EPD has been shown in some studies to decrease periprocedural stroke incidence when compared with non-EPD TAVR. Our study aimed to compare the postoperative outcomes of TAVR with versus without EPD. METHODS: Thirty-three patients who underwent TAVR with EPD at our institution between October 2018 and February 2019 were compared with a contemporaneous control group of 50 patients who underwent TAVR during the same time period without EPD. Baseline characteristics, operative characteristics, and postoperative outcomes were compared between groups. Exclusion criteria for utilization of EPD included arch vessel tortuosity, calcified arch branches, and size discrepancy between the device and host arteries. RESULTS: The non-EPD group had a higher Society of Thoracic Surgeons risk score (6.8% vs 3.3% in the EPD group; P<.01) and more frequently had a prior diagnosis of diabetes mellitus (52% vs 21% in EPD patients; P<.01). Intraoperative characteristics were comparable, without significant differences in access site used, valve type (Sapien 3 vs Evolut), utilization of rapid pacing, or utilization of balloon aortic valvuloplasty. CONCLUSION: EPD was used in lower-risk patients, possibly related to lower incidence of vessel calcification in those patients that may preclude EPD use. Although postoperative outcomes between groups were comparable, current EPD design use precludes its utilization in higher-risk patients.

Alternative Access Versus Transfemoral Transcatheter Aortic Valve Replacement in Nonagenarians.

OBJECTIVES: Previous studies suggest that alternative access (AA) such as transapical (TA) approach to transcatheter aortic valve replacement (TAVR) is inferior to transfemoral (TF) approach. However, there is a paucity of data characterizing these outcomes, and studies often do not consider transaortic (TAO) and transaxillary (TAX) TAVR approaches. Therefore, the purpose of this study was to compare the outcomes of nonagenarians undergoing AA-TAVR compared to TF-TAVR. METHODS: A concurrent cohort study of 148 consecutive nonagenarian patients (≥90 years old) undergoing TAVR from April 2012 to July 2017 was carried out. We stratified the patient cohort into two groups based on access approach: TF-TAVR (n = 112); and AA-TAVR (n = 36), which included TA (n = 24), TAX (n = 8), and TAO (n = 4) approaches. Preoperative, operative, and postoperative outcomes and 5-year actuarial survival rates were analyzed. RESULTS: Compared to TF-TAVR, patients undergoing AA-TAVR were more likely to require blood transfusions (28% vs 69%; P<.001) and readmission (16% vs 58%; P<.001). AA-TAVR also resulted in significantly higher rates of postoperative complications, such as stroke (1% vs 8%; P=.02) and atrial fibrillation (19% vs 36%; P=.03). There was no significant difference in aortic valve gradients (P>.05), operative mortality rate (6% vs 8%; P=.66), or actuarial 5-year survival rate (68% vs 44%, log-rank P=.10). CONCLUSION: There is a higher risk of adverse events following AA-TAVR compared with TF-TAVR. Therefore, TF-TAVR is recommended when feasible, with AA approach as a viable back-up option in nonagenarians.

Continuous quality improvement program and major morbidity after cardiac surgery.

The aim of this study was to investigate how a continuous quality improvement (CQI) program affected major morbidity and postoperative outcomes after cardiac surgery. Patients were divided into 2 groups: those who underwent surgery (coronary artery bypass grafting, isolated valve surgery, or coronary artery bypass grafting and valve surgery) after the establishment of a CQI program (from January 2005 to December 2006, n = 922) and those who underwent surgery beforehand (from January 2002 to December 2003, n = 1,289). Patients who had surgery in 2004, when the system and processes were reengineered, were not included in the analysis. Outcomes compared between the 2 groups included (1) acute renal failure, (2) stroke, (3) sepsis, (4) hemorrhage-related reexploration, (5) cardiac tamponade, (6) mediastinitis, and (7) prolonged length of stay. Logistic regression analysis and propensity score adjustment were used to adjust for imbalances in the patients' preoperative characteristics. After propensity score adjustment, CQI was found to decrease the rate of sepsis (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.3 to 0.9, p = 0.02) and cardiac tamponade (OR 0.2, 95% CI 0.04 to 0.8, p = 0.02) but to only marginally decrease the rate of acute renal failure (OR 0.7, 95% CI 0.5 to 1.0, p = 0.07). CQI did not emerge as an independent risk factor for hemorrhage-related reexploration, prolonged length of stay, mediastinitis, or stroke in either multivariate logistic regression analysis or propensity score adjustment. In conclusion, the systematic implementation of a CQI program and the application of multidisciplinary protocols decrease sepsis and cardiac tamponade after cardiac surgery.

Role of Moderate Hypothermia and Antegrade Cerebral Perfusion during Repair of Type A Aortic Dissection.

The goal of this study was to compare early postoperative outcomes and actuarial survival between patients who underwent repair of acute type A aortic dissection with deep or moderate hypothermia. A total of 132 consecutive patients from a single academic medical center underwent repair of acute type A aortic dissection between January 2000 and June 2014. Of those, 105 patients were repaired under deep hypothermia (< 24 C°), while 27 patients were repaired under moderate hypothermia (≥24 C°). Median ages were 62 years (range: 27-86) and 59 years (range: 35-83) for patients repaired under deep hypothermia compared with patients repaired under moderate hypothermia, respectively ( p = 0.451). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Operative mortality was 17.1 and 7.4% in the deep and moderate hypothermia groups, respectively ( p = 0.208). Incidence of permanent stroke was 12.4% in the deep hypothermic circulatory arrest group and 0% in the moderate hypothermia group ( p = 0.054). Actuarial 5- and 10-year survival demonstrated a trend for lower long-term mortality with moderate hypothermia compared with deep hypothermia (69% 5-year and 54% 10-year for deep hypothermia vs. 79% 5-year and 10-year for moderate hypothermia, log-rank p = 0.161). Moderate hypothermia is a safe and efficient alternative to deep hypothermia and may have protective benefits. Stroke rate was lower with moderate hypothermia.