Early and Midterm Clinical Outcomes of Transcatheter Valve-in-Valve Implantation Versus Redo Surgical Aortic Valve Replacement for Aortic Bioprosthetic Valve Degeneration: Two Faces of the Same Medal.

OBJECTIVE: To compare early and midterm outcomes of transcatheter valve-in-valve implantation (ViV-TAVI) and redo surgical aortic valve replacement (re-SAVR) for aortic bioprosthetic valve degeneration. DESIGN: Patients who underwent ViV-TAVI and re-SAVR for aortic bioprosthetic valve degeneration between January 2010 and October 2018 were retrospectively analyzed. Mean follow-up was 3.0 years. SETTING: In-hospital, early, and mid-term outcomes. PARTICIPANTS: Eighty-eight patients were included in the analysis. INTERVENTIONS: Thirty-one patients (37.3%) had ViV-TAVI, and 57 patients (62.7%) had re-SAVR. MEASUREMENTS AND MAIN RESULTS: In the ViV-TAVI group, patients were older (79.1 ± 7.4 v 67.2 ± 14.1, p < 0.01). The total operative time, intubation time, intensive care unit length of stay, total hospital length of stay, inotropes infusion, intubation >24 hours, total amount of chest tube losses, red blood cell transfusions, plasma transfusions, and reoperation for bleeding were significantly higher in the re-SAVR cohort (p < 0.01). There was no difference regarding in-hospital permanent pacemaker implantation (ViV-TAVI = 3.2% v re-SAVR = 8.8%, p = 0.27), patient-prosthesis mismatch (ViV-TAVI = 12 patients [mean 0.53 ± 0.07] and re-SAVR = ten patients [mean 0.56 ± 0.08], p = 0.4), stroke (ViV-TAVI = 3.2% v re-SAVR = 7%, p = 0.43), acute kidney injury (ViV-TAVI = 9.7% v re-SAVR = 15.8%, p = 0.1), and all-cause infections (ViV-TAVI = 0% v re-SAVR = 8.8%, p = 0.02), between the two groups. In-hospital mortality was 0% and 7% for ViV-TAVI and re-SAVR, respectively (p = 0.08). At three-years' follow-up, the incidence of pacemaker implantation was higher in the re-SAVR group (ViV-TAVI = 0 v re-SAVR = 13.4%, p < 0.01). There were no differences in reintervention (ViV-TAVI = 3.8% v re-SAVR = 0%, p = 0.32) and survival (ViV-TAVI = 83.9% v re-SAVR = 93%, p = 0.10) between the two cohorts. CONCLUSIONS: ViV-TAVI is a safe, feasible, and reliable procedure.

Learning curve predictors for minimally invasive mitral valve surgery; how far should the rabbit hole go?

OBJECTIVE: To analyze predictors that influence the learning curve of minimally invasive mitral valve surgery (MIMVS). METHODS: Patients who underwent MIMVS between March 2010 to March 2015 were retrospectively analyzed. Predictive factors that influence the learning curve were analyzed. RESULTS: One hundred and five patients were included in the analysis. Cardiopulmonary bypass (CPB) time in minutes was 158.72 ± 40.98 and the aortic cross-clamp (ACC) time in minutes was 114.48 ± 27.29. There were three operative mortalities, one stroke and five >2+ mitral regurgitation. ACC time in minutes was higher in the low logistic Euroscore II (LES) group (LES < 5% = 118.42 ± 27.94) versus (LES ≥ 5 = 88.66 ± 22.26), P < .05 while creatinine clearance in µmol/L was higher in the LES < 5% group (LES < 5% = 84.32 ± 33.7) versus (LES ≥ 5% = 41.66 ± 17.14), (P < .05). One patient from each group required chest tube insertion for pleural effusion P < .05. The cumulative sum analysis (CUSUM) for the first 25 patients had CPB and ACC times that reached the upper limits. Between 25 to 64 patients the curve remained stable while with the introduction of reoperations and complex surgical procedures the CUSUM reached the upper limits. CONCLUSIONS: The learning curve is affected by many factors but this should not desist surgeons from approaching this technique. The introduction of high-risk patients in clinical practice should be carefully measured based on surgeon experience.