Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes

Surgeon Frequency of Aortic Root Enlargement and Long-Term Survival in Medicare Beneficiaries Undergoing Surgical Aortic Valve Replacement

Aortic root enlargement (ARE) is a variably performed during surgical aortic valve replacement (SAVR) to minimize patient-prothesis mismatch (PPM), but its impact on survival remains under-evaluated. We retrospectively analyzed Medicare beneficiaries (1999-2019) undergoing isolated SAVR with or without non-Konno ARE. Procedural details were doubly-adjudicated by ICD and CPT codes. Overlap propensity score weighting adjusted for confounders. Restricted mean survival times (RMST) at 30-days and 20-years were compared. Surgeons were stratified by ARE frequency, and survival was analyzed using risk-adjusted Kaplan-Meier estimates in both "as-treated" (SAVR vs SAVR+ARE) and "surgeon-preference" (never-ARE vs frequent-ARE surgeons) analyses. Of 214,266 beneficiaries undergoing isolated SAVR, 6,652 (3.1%) underwent SAVR+ARE. From 1999 to 2019, ARE utilization increased from 2.1% to 6.4% (Cochran-Armitage Z-statistic: 15.2). Among 3,018 surgeons, 1,513 never performed ARE (69,389 beneficiaries), 1,227 performed ARE in <10% of cases (128,258 beneficiaries), and 278 performed ARE in ≥10% of cases (16,619 beneficiaries). After risk-adjustment, survival was significantly lower in SAVR+ARE compared to SAVR recipients: 30-day RMST 28.73 (28.60,28.87) versus 29.35 (29.26,29.45) days (p = 0.013) and 20-year RMST 9.15 (8.96,9.35) vs 9.49 (9.30,9.69) years (p = 0.018). Similarly, beneficiaries treated by frequent-ARE surgeons experienced worse early risk-adjusted survival without any late survival benefit: 30-day RMST 29.19 (29.11,29.27) versus 29.33 (29.25-29.40) days (p = 0.013), 20-year RMST 9.04 (8.90,9.18) versus 9.13 (9.00,9.27) (p = 0.351). Landmark analysis of 1-year survivors showed no late survival difference (p = 0.456 "as-treated" analysis; p = 0.943 "surgeon-preference" analysis). Even among frequent-ARE surgeons, SAVR+ARE was associated with higher 30-day and reduced 20-year RMST relative to SAVR alone. In conclusion, ARE was associated with higher early mortality and no long-term survival advantage compared to SAVR alone (even among frequent-ARE surgeons), as was undergoing surgery by a frequent ARE surgeon. Further studies are required to assess the potential utility of ARE in younger patients, those with small annuli, and those at risk for PPM.

Cardiac Surgery 2024 Reviewed

For the 11th consecutive time, we systematically reviewed the cardio-surgical literature for the past year (2024), using the PRISMA approach for a results-oriented summary. In 2024, the discussion on the value of randomized and registry evidence increased, triggered by consistent findings in the field of coronary artery disease (CAD) and discrepant results in structural heart disease. The literature in 2024 again confirmed the excellent long-term outcomes of CABG compared with PCI in different scenarios, generating further validation for the CABG advantage reported in randomized studies. This has been reflected in the new guidelines for chronic CAD in 2024. Two studies indicate novel perspectives for CABG, showing that cardiac shockwave therapy in CABG improves myocardial function in ischemic hearts and that CABG guided by computed tomography is safe and feasible. For aortic stenosis, an early advantage for transcatheter (TAVI) compared with surgical (SAVR) treatment has found more support; however, long-term TAVI results keep being challenged, this year by new FDA and registry data in favor of SAVR. For failed aortic valves, redo-SAVR showed superior results compared with valve-in-valve TAVI. In the mitral field, studies showed short-term noninferiority for transcatheter treatment compared with surgery for secondary mitral regurgitation (MR), and significant long-term survival benefit in registries with surgery for primary MR. Finally, surgery was associated with better survival compared with medical therapy for acute type A aortic intramural hematoma. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation but provides up-to-date information for patient-specific decision-making.

Aortic Annular Enlargement vs Isolated Aortic Valve Replacement in Patients With Matched Annulus

BACKGROUND

We aimed to determine the effect of aortic annular enlargement on the midterm outcomes of aortic valve replacement surgery by comparing patients with the same-sized (≤23 mm) native aortic annuli.

METHODS

From January 2011 to June 2022, 1328 patients underwent isolated aortic valve replacement-1163 without aortic annular enlargement (AVR group) and 165 with aortic annular enlargement (AVR+AAE group). Propensity score matching identified 112 pairs, controlling for native aortic annulus diameter, age, sex, diabetes, chronic lung disease, dialysis, ejection fraction, prior cardiac surgery, indication, hypertension, dyslipidemia, valve type, prior stroke, prior myocardial infarction, and case status.

RESULTS

Demographic and preoperative variables were similar, except body surface area was larger in the AVR+AAE group (2.1 m2 vs 1.9 m2). Median native aortic annulus diameter was 23 mm in both groups. Median prosthesis size was 25 in the AVR+AAE group and 23 in the AVR group. The AVR+AAE group had longer cardiopulmonary bypass (143 vs 111 minutes) and cross-clamp (115 vs 82 minutes) times. Incidences of perioperative complications, including operative mortality (1.8% AVR+AAE vs 3.6% AVR) were similar between groups. Survival at 6 years was 98% in the AVR+AAE group and 74% in the AVR group (P = .016). Aortic annular enlargement was an independent protective factor for midterm mortality, with a hazard ratio of 0.19 (P = .006). The rate of moderate/severe patient-prosthesis mismatch was 19% in the AVR+AAE group and 31% in the AVR group (P = .16).

CONCLUSIONS

Patients with small native aortic annuli (≤23 mm) undergoing isolated aortic valve replacement may benefit from aortic annular enlargement.

"Arc" Modification of the Patch for the Y-Incision Aortic Annular Enlargement

Y-incision aortic annular enlargement has been used for 4 years with favorable early outcomes. Occasionally, we have seen a tensed anastomotic suture line of the rectangular patch to the aortomitral curtain/mitral annulus. We developed an Arc modification of the rectangular patch that completely resolved this issue. The Arc modification has been our new routine since May 2024 for Y-incision aortic annular enlargement in all first-time aortic valve replacements or in some reoperative aortic valve replacements if the aortomitral curtain was preserved. The outcomes were favorable, and there were no issues of hemostasis of the suture line.

Long-term clinical outcomes in patients between the age of 50-70 years receiving biological versus mechanical aortic valve prostheses

OBJECTIVES

The last 2 decades have seen an incremental use of biological over mechanical prostheses. However, while short-term clinical outcomes are largely equivalent, there is still controversy about long-term outcomes.

METHODS

All patients between the ages of 50 and 70 years undergoing elective/urgent isolated aortic valve replacement at our institute between 1996 and 2023 were included. Trends, early, and long-term outcomes were investigated.

RESULTS

A total of 1708 (61% male) patients with a median age of 63.60 (interquartile range: 58.28-67.0) years were included of which 1191 (69.7%) received a biological prosthesis. After inverse propensity score weighting, there were no short-term differences when comparing patients receiving biological and mechanical valves. However, patients who received mechanical prostheses had better long-term survival (P < 0.001). Sub-group analysis revealed that patients with biological size 19 mm prosthesis had the worst long-term survival. Patients with a size 21-mm mechanical prosthesis had better survival compared to both size 19-mm [hazard ratio (HR) 0.25, 95% confidence interval (CI) 0.17-0.37, P < 0.001], 21-mm (HR 0.33, 95% CI 0.23-0.48, P < 0.001) and 23-mm (HR 0.40, 95% CI 0.27-0.60, P < 0.001) biological prosthesis. Additionally, patients with severe patient-prosthesis mismatch exhibited the lowest survival rate compared to those with moderate or no (HR 1.56, 95% CI 1.21-2.00, P < 0.001).

CONCLUSIONS

Patients aged between 50 and 70 years with a mechanical aortic prosthesis had better long-term survival compared to those with a biological prosthesis. Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group.

Lifetime Management for Aortic Stenosis: Strategy and Decision-Making in the Current Era

Aortic stenosis, the most common valvular disease in the Western world, has traditionally been treated with surgical aortic valve replacement (SAVR) but is increasingly treated by transcatheter aortic valve replacement (TAVR). Whereas patients older than 65 years are preferably treated with bioprosthetic tissue valves, there is considerable uncertainty in the choice between TAVR and SAVR. We present various considerations for optimizing the lifelong management of patients receiving bioprosthetic valves (SAVR or TAVR). To maximize life expectancy and to minimize cumulative lifetime risk, we suggest decision-making individualized for patient anatomy and overall (current and future) risk.

Modified-Bentall Single-Patch Konno Enlargement Technique for Aortic Stenosis and Prosthesis-Patient Mismatch

BACKGROUND

Aortic stenosis and prosthesis-patient mismatch complicate surgery for patients with small left ventricular outflow tracts. We present outcomes of a modified-Bentall single-patch Konno enlargement (BeSPoKE) technique for complex left ventricular outflow tract obstruction in adults.

METHODS

The BeSPoKE technique facilitates a true outflow tract enlargement through an anterior septoventriculoplasty, using a single pericardial patch, followed by composite aortic valve-graft root replacement. Postoperative outflow tract geometry and valvular physiology were compared against preoperative measurements using echocardiography and computed tomographic angiography. Clinical outcomes at 2 years were assessed.

RESULTS

From October 2017 to March 2022, 25 adults (median age, 60 years; 84% women) underwent a BeSPoKE repair. Mean preoperative aortic valve gradient was 44 ± 19 mm Hg. Twenty-one patients (84%) had previous aortic valve replacements with prosthesis-patient mismatch; median implant size preoperatively was 19 mm. Postoperatively, all patients received a prosthesis of at least 21 mm, with a median upsizing of 2 (15th-85th percentile, 2-3 sizes). Mean postoperative aortic valve gradient was 8.5 ± 4.1 mm Hg (P < .001). The mean 2-year gradient was 8.3 ± 1.3 mm Hg. All patients with bioprosthetic replacements qualified for future transcatheter valve replacements. Postoperative complications included atrial fibrillation in 9 (36%) and complete heart block requiring pacemaker placement in 8 (32%). There were no operative deaths, and no reoperations were reported. There were 2 late noncardiac-related deaths; 2-year survival was 92%.

CONCLUSIONS

The BeSPoKE technique facilitates larger prosthesis placement, improves hemodynamics, and enables future transcatheter reinterventions. This approach is a safe treatment for complex left ventricular outflow tract obstruction and prosthesis-patient mismatch in adults.

Prosthetic Valve Endocarditis After Y-Incision Aortic Annular Enlargement: A Simple Solution

The Y-incision aortic annular enlargement (AAE) has been established as a safe and effective technique for upsizing the aortic annulus by 3 to 4 valve sizes. However, concerns have been raised regarding its technical complexity during reoperations, particularly given the extensive enlargement of the aortic annulus and root. We present a case of reoperative aortic valve replacement after previous Y-incision AAE for prosthetic valve endocarditis and aortic root abscess. Our case highlights the simplicity and effectiveness of using a rectangular patch for root reconstruction and implanting the "roof" technique for aortotomy closure in reoperations after Y-incision AAE.

Impact of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 122 989 Patients With 592 952 Patient-Years

BACKGROUND

It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, rehospitalizations, and aortic valve reinterventions.

METHODS AND RESULTS

We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio [HR], 1.16 [95% CI, 1.13-1.18], P<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 [95% CI, 1.06-1.11], P<0.001; severe versus no PPM: HR, 1.29 [95% CI, 1.24-1.35], P<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (P<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM.

CONCLUSIONS

The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.

Aortic valve replacement with Y-incision/rectangular patch aortic annular enlargement

A small aortic root and annulus would need extensive aortic annular enlargement during valve replacement in adult patients to avoid patient-prosthesis mismatch. This report describes a technique that enlarges the aortic annulus by 4-5 valve sizes as well as a modification of the aortotomy with the roof technique to make the aortotomy closure easier and more hemostatic while enlarging the sinotubular junction and proximal ascending aorta effectively for future transcatheter valve-in-valve replacement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01606-4.

Prosthesis-Patient Mismatch and Aortic Root Enlargement: Indications, Techniques and Outcomes

Prosthesis-patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno-Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning.

Lessons learned from the EACTS-MSTCVS quality fellowship: a call to action for continuous improvement of cardiothoracic surgery outcomes in Europe

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings annually. It actively engages cardiac and general thoracic surgeons, data managers and researchers from all 32 non-federally funded cardiothoracic surgery sites across Michigan. Broadening its influence on joint learning and clinical outcomes, the MSTCVS-QC formed a strategic partnership with Blue Cross Blue Shield of Michigan, the state's largest private insurer, to further promote its initiatives. The MSTCVS-QC, operating from a dedicated QC centre employs an STS-associated database with additional aspects for data collection and analysis. The QC centre also organizes audits, facilitates collaborative meetings, disseminates surgical outcomes and champions the development and implementation of quality improvement initiatives related to cardiothoracic surgery in Michigan. Recognizing the MSTCVS-QC's successful efforts in advancing quality improvement, the European Association for Cardiothoracic Surgery (EACTS) introduced a fellowship program in 2018, facilitated through the EACTS Francis Fontan Fund (FFF). This program allows early-career academic physicians to spend 4-6 months with the MSTCVS-QC team in Ann Arbor. This article chronicles the evolution and functionality of the MSTCVS-QC, enriched by the experiences of the inaugural 4 EACTS/FFF fellows. Our objective is to emphasize the critical importance of fostering a culture of quality improvement and patient safety in the field of cardiothoracic surgery with open discussion of audited, high-quality data points. This principle, while implemented locally, has implications and value extending far beyond Europe, resonating globally.

Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

Background

The advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras.

Methods

From January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000-2011, n = 2,426) and post-TAVR era (2012-2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed.

Results

The median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p < 0.0001). There were more urgent/emergent/salvage SAVRs (38% vs. 24%) and fewer elective SAVRs (63% vs. 76%), (p < 0.0001) in the post-TAVR group. More bioprosthetic valves were implanted in the post-TAVR group (85% vs. 74%, p < 0.0001). Larger aortic valves were implanted (25 vs. 23 mm, p < 0.0001) and more annular enlargements were performed (5.9% vs. 1.6%, p < 0.0001) in the post-TAVR era. Postoperatively, the post-TAVR group had less blood product transfusion (49% vs. 58%, p < 0.0001), renal failure (1.4% vs. 4.3%, p < 0.0001), pneumonia (2.3% vs. 3.8%, p = 0.01), shorter lengths of stay, and lower in-hospital mortality (1.5% vs. 3.3%, p = 0.0007).

Conclusion

The approval of TAVR changed the landscape of aortic valve disease management. At a quaternary academic cardiac surgery center with a well-established structural heart program, patients undergoing isolated SAVR in the post-TAVR era had lower STS PROM, more implantation of bioprosthetic valves, utilization of larger valves, annular enlargement, and lower in-hospital mortality. Isolated SAVR continues to be performed in the TAVR era with excellent outcomes. SAVR remains an essential tool in the lifetime management of aortic valve disease.

Outcomes of Root Enlargement Vs Root Replacement for Aortic Stenosis

BACKGROUND

Stentless aortic root replacement (ARR) and aortic root enlargement (ARE) are established strategies to avoid prosthesis-patient mismatch in patients with aortic stenosis (AS) and small annuli. We sought to compare outcomes of these 2 procedures.

METHODS

This was an observational study using an institutional database of aortic valve replacements from 2010 to 2021. The study compared patients who underwent ARE vs ARR for AS. Those with endocarditis or aortic aneurysms were excluded. Postoperative outcomes were compared between groups. Kaplan-Meier survival estimation and multivariable Cox regression for survival were performed. Cumulative incidence functions were generated for all-cause readmissions.

RESULTS

A total of 533 patients underwent either ARE or ARR for AS. Of these, 193 (36.2%) underwent ARE and 340 (63.8%) underwent ARR with a stentless xenograft. There were no significant differences in operative mortality, stroke, length of stay, or new-onset renal failure requiring dialysis. There were also no significant differences in aortic valve reintervention rates (3.1% vs 1.8%; P = .314). Patients in the ARR group had larger valves implanted, larger indexed effective orifice areas, lower rates of prosthesis-patient mismatch, and lower transprosthetic gradients (P < .001). Median follow-up was 5.02 (2.70-7.8) years. Kaplan-Meier survival estimates were comparable, and on multivariable Cox regression, ARR vs ARE was not significantly associated with an increased hazard of death (hazard ratio, 1.00; 95% CI, 0.69-1.45; P = .996). Cumulative incidence estimates for all-cause readmissions were also comparable between groups.

CONCLUSIONS

ARE and stentless xenograft ARR for AS were associated with comparable postoperative complications, aortic valve reinterventions, freedom from readmission, and 5-year survival.