Minimally invasive redo tricuspid valve replacement in patient with persistent left superior vena cava

INTRODUCTION

The management of cardiopulmonary bypass (CPB) is still challenging in certain circumstances, especially for patients with anatomical variations. This challenge is even harder for reoperations, which are associated with increased morbidity and mortality risk.

CASE REPORT

We describe a minimally invasive, beating-heart redo tricuspid valve replacement in a 71-years old woman with persistent left superior vena cava.

DISCUSSION

Preoperative planning via CT-scan, teamwork and custom-made management of CPB are crucial for reoperations with anatomical variations. The perfusionist has a pivotal role in constructing and managing the CPB.

CONCLUSION

We describe a strategy achieving the benefits of minimally invasive endoscopic and beating-heart surgery (avoidance of resternotomy risk and associated morbidity, right ventricular protection) in reoperative tricuspid surgery with persistent upper left vena cava.

Transient Monocular Blindness in a Man in His 30s

This case report discusses a diagnosis of giant ascending aortic aneurysm in a patient who presented with transient monocular blindness and no cardiovascular symptoms.

Clinical effects of permanent pacemaker implantation after transcatheter aortic valve implantation: Insights from the nationwide FRANCE-TAVI registry

BACKGROUND

The influence of permanent pacemaker implantation upon outcomes after transcatheter aortic valve implantation (TAVI) remains controversial.

AIMS

To evaluate the impact of permanent pacemaker implantation after TAVI on short- and long-term mortality, and on the risk of hospitalization for heart failure.

METHODS

Data from the large FRANCE-TAVI registry, linked to the French national health single-payer claims database, were analysed to compare 30-day and long-term mortality rates and hospitalization for heart failure rates among patients with versus without permanent pacemaker implantation after TAVI. Multivariable regressions were performed to adjust for confounders.

RESULTS

A total of 36,549 patients (mean age 82.6years; 51.6% female) who underwent TAVI from 2013 to 2019 were included in the present analysis. Among them, 6999 (19.1%) received permanent pacemaker implantation during the index hospitalization, whereas 232 (0.6%) underwent permanent pacemaker implantation between hospital discharge and 30days after TAVI, at a median of 11 (interquartile range: 7-18) days. In-hospital permanent pacemaker implantation was not associated with an increased risk of death between discharge and 30days (adjusted odds ratio: 0.91, 95% confidence interval: 0.64-1.29). At 5years, the incidence of all-cause death was higher among patients with versus without permanent pacemaker implantation within 30days of the procedure (adjusted hazard ratio: 1.13, 95% confidence interval: 1.07-1.19). Permanent pacemaker implantation within 30days of TAVI was also associated with a higher 5-year rate of hospitalization for heart failure (adjusted subhazard ratio: 1.17, 95% confidence interval: 1.11-1.23).

CONCLUSIONS

Permanent pacemaker implantation after TAVI is associated with an increased risk of long-term hospitalization for heart failure and all-cause mortality. Further research to mitigate the risk of postprocedural permanent pacemaker implantation is needed as TAVI indications expand to lower-risk patients.

Impact of Intraoperative Allogeneic Platelet Transfusion on Healthcare-Associated Infections in Cardiac Surgery: Insights From a Large Single-Center Cohort Study

OBJECTIVES

Despite significant improvement in patient blood management, cardiac surgery remains a high hemorrhagic risk procedure. Platelet transfusion is used commonly to treat thrombocytopenia-associated perioperative bleeding. Allogeneic platelet transfusion may induce transfusion-related immunomodulation. However, its association with postoperative healthcare-associated infections is still a matter of debate. The objective was to evaluate the impact of allogeneic platelet transfusion during cardiac surgery on postoperative healthcare-associated infection incidence.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral academic center.

PARTICIPANTS

Patients undergoing cardiac surgery from 2012 to 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Intraoperative platelet transfusion was defined as exposure in a causal model. The primary outcome was the incidence of healthcare-associated infections comprised of bloodstream infection, hospital-acquired pneumonia, and surgical-site infection. Among 7,662 included patients, 528 patients (6.8%) were exposed to intraoperative platelet transfusion, and 329 patients (4.3%) developed 454 postoperative infections. Bloodstream infection affected 106 patients (1.4%), hospital-acquired pneumonia affected 174 patients (2.3%), and surgical-site infection affected 148 patients (1.9%). Intraoperative platelet transfusion was associated with an increased risk of bloodstream infection after adjustment by multivariable logistic regression (odds ratio [OR] 2.85; 95% CI 1.40-5.8; p = 0.004; n = 7,662), propensity score matching (OR 3.95; 95% CI 1.57-12.0), p = 0.007; n = 766), and propensity score overlap weighting (OR 3.04; 95% CI 1.51-6.1, p = 0.002; n = 7,762). Surgical-site infection and hospital-acquired pneumonia were not significantly associated with platelet transfusion.

CONCLUSIONS

These results suggested that intraoperative allogeneic platelet transfusion is a risk factor for bloodstream infection after cardiac surgery. These results supported the development of patient blood management strategies aimed at minimizing perioperative platelet transfusion in cardiac surgery.

Late clinical and echocardiographic results with the Magna Ease© pericardial aortic bioprosthesis

OBJECTIVES

The population of candidates to surgical aortic valve replacement (SAVR) is evolving. The Perimount Magna Ease© bioprosthesis has been introduced relatively recently in the practice. We aimed at evaluating its long-term results.

METHODS

This article describes a single-centre cohort of 1016 consecutive SAVRs with the Magna Ease© valve (2008-2014), consisting of an all-comers population. We performed a prospective collection of in-hospital data, systematic clinical and echocardiographic follow-up. Valve-related events were as follows: structural valve deterioration (SVD; according to modified definition criteria), nonstructural valve dysfunction, patient-prosthesis mismatch (PPM).

RESULTS

Age at SAVR was 73.4 ± 9.5 years; calcified aortic stenosis was the indication to surgery in 59.6%. A total of 974 patients entered the follow-up; 564 were alive at the last follow-up (median duration: 9.8 years) (up to 13.4 years). New York Heart Association class was I or II in 92.1%. Overall survival at 10 years was 56.8 ± 1.8%. Freedom from SVD at 10 was 96.5 ± 0.8% (Kaplan-Meier) and 97.4 ± 0.6% (competing risks) (28 SVD events after 6.9 ± 3.3 years). There were 15 reinterventions for SVD (redo-SAVR and Transcatheter Aortic Valve Implantation (TAVI)); 10-year freedom from reintervention was 97.8 ± 0.6%. Moderate and severe PPM occurred in 26.8% and 5.4%, respectively, without association with late mortality (P = 0.12 for moderate and P = 0.70 for severe PPM). Freedom from valve-related mortality was 97.8 ± 0.5% at 10 years.

CONCLUSIONS

In this follow-up of the Magna Ease bioprosthesis for SAVR, data indicate good late outcomes (30-day outcomes are excluded). Continued follow-up is required to further support its use in patients with life expectancy >10-12 years.

Analysis of a multicenter registry on evaluation of transit-time flow in coronary artery disease surgery

Objective

The Evaluation of Transit-Time Flow in Coronary Artery Disease Surgery (EFCAD) registry aims to assess the influence of transit-time flow measurement (TTFM) in daily practice.

Methods

EFCAD is a prospective, multicenter study involving 9 centers performing TTFM during isolated coronary artery bypass grafting. Primary end point was occurrence and risk factors of major adverse cardiac events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end points were rate of graft revision during surgery and factors affecting graft flow. We respected the limit values set by the experts: mean graft flow >15 mL/minute and pulsatility index ≤5.

Results

Between May 2017 and March 2021, 1616 patients were registered in the EFCAD database. After review, 1414 were included for analyses. Of those, 1176 were eligible for primary end point analysis. Graft revision, mainly due to inadequate TTFM values, occurred in 2% (29 patients). The primary end point occurred in 46 (3.9%) patients, and it was related with left anterior descending artery graft flow ≤15 mL/minute (odds ratio, 3.64; P < .001). Graft flow was related with number of grafts (3 vs 1-2, β = -1.6; 4-6 vs 1-2, β = -4.1; P < .001; β > 0 indicates higher flow), and graft origin (aorta vs Y, β = 9.2; in situ left internal thoracic artery vs Y, β = 3.2; in situ right internal thoracic artery vs Y, β = 2.3; P < .001).

Conclusions

Data from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of inadequate flow on left anterior descending artery anastomosis influence postoperative outcomes. In our opinion, TTFM assessment should be routinely used in coronary artery bypass procedures, even if interpretation depends on learning curves.

Porcine bioprostheses for surgical aortic valve replacement: very long-term performance of a third-generation device

AIMS

We aimed at investigating the long-term durability of the Epic bioprosthesis for surgical aortic valve replacement (SAVR) in a single-centre series of 888 implantations (2001-2018), expanding previous evaluations with shorter follow-up.

METHODS

We retrieved prospectively collected in-hospital data and performed a systematic follow-up focusing on valve-related events (SVD, structural valve deterioration; PPM, patient-prosthesis mismatch; reoperation) (competing risks, CIF and Kaplan--Meier methods). We distinguished between SVD (permanent changes in valve function due to evolutive structural deterioration, ≥10 mmHg average gradient vs. reference echocardiography) and PPM.

RESULTS

Average age at SAVR was 75.4 ± 7 years; 855 (96.3%) bioprostheses entered the follow-up and 396 (46.4%) were alive at last assessment. Follow-up was 99.9% complete, median duration was 7.7 years (entire cohort) and 9.9 years (survivors). At 10 years, overall survival was 50% ± 1.9, freedom from SVD was 99.4% ± 0.3 (competing risks) (seven SVD events after 8.1 ± 4.3 years). Freedom from SVD at 15 years was 98.4% ± 0.8 (competing risks). Prevalence of severe PPM was higher in 19 mm (6.5%) and 21 mm (10.2%) size cohorts. PPM (severe or moderate/severe) had no significant impact on overall survival (log-rank P = 0.27 and P = 0.21, respectively). Freedom from any reintervention (reoperation or TAVI Valve-in-Valve) for SVD at 10 years was 99.4% ± 0.3 (competing risks); freedom from any valve-related reintervention was 97.4% ± 0.6 (competing risks).

CONCLUSION

The Epic bioprosthesis for SAVR is limited by nonnegligible rates of PPM, which have nonetheless no impact on late survival. This device shows excellent durability and low rates of adverse valve-related events.

Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support

BACKGROUND

Acute distress respiratory syndrome (ARDS) patients with veno-venous extra corporeal membrane oxygenation (ECMO) support are particularly exposed to ECMO-associated infection (ECMO-AI). Unfortunately, data regarding AI prophylaxis in this setting are lacking. Selective decontamination regimens decrease AI incidence, including ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) in critically ill patients. We hypothesized that a multiple-site decontamination (MSD) regimen is associated with a reduction in the incidence of AI among VV-ECMO patients.

METHODS

We conducted a retrospective observational study in three French ECMO referral centers from January 2010 to December 2021. All adult patients (> 18 years old) who received VV-ECMO support for ARDS were eligible. In addition to standard care (SC), 2 ICUs used MSD, which consists of the administration of topical antibiotics four times daily in the oropharynx and the gastric tube, once daily chlorhexidine body-wash and a 5-day nasal mupirocin course. AIs were compared between the 2 ICUs using MSD (MSD group) and the last ICU using SC.

RESULTS

They were 241 patients available for the study. Sixty-nine were admitted in an ICU that applied MSD while the 172 others received standard care and constituted the SC group. There were 19 ECMO-AIs (12 VAP, 7 BSI) in the MSD group (1162 ECMO-days) compared to 143 AIs (104 VAP, 39 BSI) in the SC group (2376 ECMO-days), (p < 0.05 for all infection site). In a Poisson regression model, MSD was independently associated with a lower incidence of ECMO-AI (IRR = 0.42, 95% CI [0.23-0.60] p < 0.001). There were 30 multidrug resistant microorganisms (MDRO) acquisition in the SC group as compared with two in the MSD group (IRR = 0.13, 95% CI [0.03-0.56] p = 0.001). Mortality in ICU was similar in both groups (43% in the SC group vs 45% in the MSD group p = 0.90). Results were similar after propensity-score matching.

CONCLUSION

In this cohort of patients from different hospitals, MSD appeared to be safe in ECMO patients and may be associated with improved outcomes including lower ECMO-AI and MDRO acquisition incidences. Since residual confounders may persist, these promising results deserve confirmation by randomized controlled trials.

Risk of Bias in Randomized Clinical Trials Comparing Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-analysis

IMPORTANCE

Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines highlighted some concerns about the randomized clinical trials (RCTs) comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. Quantification of these biases has not been previously performed.

OBJECTIVE

To assess whether randomization protects RCTs comparing TAVI and SAVR from biases other than nonrandom allocation.

DATA SOURCES

A systematic review of the literature between January 1, 2007, and June 6, 2022, on MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was performed. Specialist websites were also checked for unpublished data.

STUDY SELECTION

The study included RCTs with random allocation to TAVI or SAVR with a maximum 5-year follow-up.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed by 2 independent investigators following the PRISMA guidelines. A random-effects meta-analysis was used for quantifying pooled rates and differential rates between treatments of deviation from random assigned treatment (DAT), loss to follow-up, and receipt of additional treatments.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the proportion of DAT, loss to follow-up, and patients who were provided additional treatments and myocardial revascularization, together with their ratio between treatments. The measures were the pooled overall proportion of the primary outcomes and the risk ratio (RR) in the TAVI vs SAVR groups.

RESULTS

The search identified 8 eligible trials including 8849 participants randomly assigned to undergo TAVI (n = 4458) or SAVR (n = 4391). The pooled proportion of DAT among the sample was 4.2% (95% CI, 3.0%-5.6%), favoring TAVI (pooled RR vs SAVR, 0.16; 95% CI, 0.08-0.36; P < .001). The pooled proportion of loss to follow-up was 4.8% (95% CI, 2.7%-7.3%). Meta-regression showed a significant association between the proportion of participants lost to follow-up and follow-up time (slope, 0.042; 95% CI, 0.017-0.066; P < .001). There was an imbalance of loss to follow-up favoring TAVI (RR, 0.39; 95% CI, 0.28-0.55; P < .001). The pooled proportion of patients who had additional procedures was 10.4% (95% CI, 4.4%-18.5%): 4.6% (95% CI, 1.5%-9.3%) in the TAVI group and 16.5% (95% CI, 7.5%-28.1%) in the SAVR group (RR, 0.27; 95% CI, 0.15-0.50; P < .001). The imbalance between groups also favored TAVI for additional myocardial revascularization (RR, 0.40; 95% CI, 0.24-0.68; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that, in RCTs comparing TAVI vs SAVR, there are substantial proportions of DAT, loss to follow-up, and additional procedures together with systematic selective imbalance in the same direction characterized by significantly lower proportions of patients undergoing TAVI that might affect internal validity.

Thoracic surgery in France

Until recently, thoracic surgery in France was associated with vascular or cardiac surgery. It is now increasingly performed as a specific activity. Training of a thoracic surgeon has a common part with cardiovascular surgery during a 6-year curriculum including theory and practical practice acquired both by simulation and clinical fellowship. There are 343 board-certified surgeons performing thoracic surgery in 147 authorized centers. To be authorized to perform thoracic surgery, these centers must have at least 2 qualified surgeons and perform a minimum of 40 procedures per year for thoracic cancer. The discussion of the cases in a multidisciplinary tumor board (MDTB), validated by a written conclusion, is also mandatory and is a prerequisite for operating on patient for any cancer. All thoracic surgery procedures are recorded in a national database, Epithor. This database gives a precise idea not only of the activity but also of operative data, morbidity, mortality and follow-up. In 2023, participation to Epithor database will be a prerequisite for the certification of thoracic surgeons. Major changes in diagnostic and therapeutic options, development and innovations in video-assisted and robotically-assisted surgery, forthcoming transbronchial approaches will more likely lead to reorganize thoracic surgery with specialized and expert multidisciplinary boards as well as a concentration in high volume centers.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Clinical Benefit of Extubation in Patients on Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes.

DESIGN

Retrospective cohort study with propensity score overlap weighting analysis.

SETTING

Three ICUs in a 1,500-bed tertiary university hospital.

PATIENTS

From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias.

MEASUREMENTS AND MAIN RESULTS

Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95-0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21-8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11-26 d] vs 18 d [7-25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51-1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19-1.59]; p = 0.27).As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation-supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0-24 d] vs 0 d [0-18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29-0.71]; p = 0.001).

CONCLUSIONS

Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.

The impact of iron store on red blood cell transfusion: a multicentre prospective cohort study in cardiac surgery

Background

Anaemia is common prior to cardiac surgery and contributes to perioperative morbidity. Iron deficiency is the main cause of anaemia but its impact remains controversial in the surgical setting. We aimed to estimate the impact of iron deficiency on in-hospital perioperative red blood cell transfusion for patients undergoing elective and urgent cardiac surgery. Secondary objectives were to identify risk factors associated with in-hospital red blood cell transfusion.

Methods

We conducted a prospective multicentre observational study in three university hospitals performing cardiac surgery. We determined iron status prior to surgery and collected all transfusion data to compare iron-deficient and iron-replete patients during hospital stay. We performed a multivariable logistic regression to compare transfusion among groups.

Results

Five hundred and two patients were included. A trend of low haemoglobin levels associated with iron deficiency persisted until discharge. Red blood cell transfusion was significantly higher in the group of iron deficient patients during surgery (22% vs 13%, p = 0.017), however the incidence during the whole hospital stay was 31% in the iron-deficient group, not significantly different with the non-deficient group (26%, p = 0.28). Iron deficiency was not independently associated with in-hospital red blood cell transfusion (adjusted OR = 0.85 [0.53–1.36], p = 0.49).

Conclusions

In-hospital red blood cell transfusion was not significantly higher in iron-deficient patients and iron deficiency was not associated with in-hospital red blood cell transfusion in patients undergoing elective and urgent cardiac surgery. Iron deficiency was the main cause of anaemia and anaemia was a strong driver of red blood cell transfusion. Further studies should identify sub-population of iron-deficient patients which may benefit from preoperative iron deficiency management and explore the long-term impact of lower haemoglobin levels at discharge in the iron deficient population.

The illusion of a chest wall tumor: a case-report of sternal tuberculosis

The incidence rate of tuberculosis in developed countries is low. The most common presentation of this disease is its pulmonary form but with the increasing use of immunosuppressive drugs, extra-pulmonary tuberculosis is re-emerging. Nevertheless, sternal bone involvement is uncommon. We report the case of an eighty-three-year-old man who presented a painful sternal mass which progressed towards cutaneous ulceration. The first diagnostic hypothesis was neoplasia. The pathological and microbiological diagnosis of tuberculosis was achieved after surgical biopsy. The patient received treatment against tuberculosis for nine months enabling recovery without surgery. This case illustrates the importance of having a diagnosis prior to any kind of treatment facing any voluminous parietal thoracic lesions.  This diagnosis is made possible by surgical samples and interdisciplinary teamwork. This case underlines that tuberculosis remains a differential diagnosis that must be evoked in case of unusual bone mass.

A rare case of Neuhauser syndrome associated with a Kommerell diverticulum

Neuhauser syndrome is a rare vascular anomaly characterized by the esophagus and trachea circling via the ligamentum arteriosum and right aortic arch. Kommerell's diverticulum have the same characteristic by an outpouch at the onset of an aberrant left subclavian artery worsening this compression. The association between these pathologies is very rare and the operative strategy is unclear. We describe a case with the association with a computed tomography scanner aortic reconstruction and a repair's operative strategy.

Five-year outcomes in trials comparing transcatheter aortic valve implantation versus surgical aortic valve replacement: a pooled meta-analysis of reconstructed time-to-event data

OBJECTIVES

The incidence of outcomes in trials comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is expected to be different in the short and long term. We planned a meta-analysis of reconstructed time-to-event data from trials comparing TAVI and SAVR to evaluate their time-varying effects on outcomes.

METHODS

We performed a systematic review of the literature from January 2007 through September 2021 on Medline, Embase, the Cochrane Central Register of Controlled Trials and specialistic websites, including randomized trials with allocation to TAVI or SAVR that reported at least 1-year follow-up and that graphed Kaplan-Meier curves of end points. The comparisons were done with grouped frailty Cox models in a landmark framework and fully parametric models.

RESULTS

Seven trials were included (7770 participants). TAVI showed a lower incidence of the composite of death or stroke in the first 6 months [risk-stratified hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.56-0.77, P-value <0.001], with an HR reversal after 24 months favouring SAVR (risk-stratified HR 1.25; 95% CI 1.08-1.46; P-value 0.003). These outcomes were confirmed for all-cause death (risk-stratified HR after 24 months 1.18; 95% CI 1.03-1.35; P-value 0.01). TAVI was also associated with an increased incidence of rehospitalization after 6 months (risk-stratified HR 1.42; 95% CI 1.06-1.91; P-value 0.018) that got worse after 24 months (risk-stratified HR 1.67; 95% CI 1.24-2.24; P-value <0.001).

CONCLUSIONS

Although it could appear that there is no difference between TAVI and SAVR in the 5-year cumulative results, TAVI shows a strong protective effect in the short term that runs out after 1 year. TAVI becomes a risk factor for all-cause mortality and the composite end point after 24 months and for rehospitalization after 6 months.

Use of extracorporeal membrane oxygenation for heart graft dysfunction in adults: incidence, risk factors and outcomes in a multicentric study

Background:

The decision about whether to use venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiac graft dysfunction (GD) is usually made on a case-by-case basis and is guided by the team’s experience. We aimed to determine the incidence of VA-ECMO use after heart transplantation (HT), to assess early- and long-term outcomes and to assess risk factors for the need for VA-ECMO and early mortality in these patients.

Methods:

We included adults who underwent heart transplantation at 3 cardiac centres who met the most recent International Society for Heart and Lung Transplantation definition of graft dysfunction (GD) over a 10-year period. Pre-transplant, intraoperative and posttransplant characteristics of the heart recipients as well as donor characteristics were analyzed and compared among recipients with GD treated with and without VA-ECMO.

Results:

There were 135 patients with GD in this study, of whom 66 were treated with VA-ECMO and 69 were not. The mean follow-up averaged 81.2 months (standard deviation 36 mo, range 0–184 mo); follow-up was complete in 100% of patients. The overall incidence of GD (30%) and of VA-ECMO use increased over the study period. We did not identify any predictive pre-transplantation factors for VA-ECMO use, but patients who required VA-ECMO had higher serum lactate levels and higher inotropes doses after HT. The overall survival rates were 83% and 42% at 1 year and 78% and 40% at 5 years among patients who received only medical treatment and those who received VA-ECMO, respectively. Delayed initiation of VA-ECMO and postoperative bleeding were strongly associated with increased in-hospital mortality.

Conclusion:

The incidence of GD increased over the study period, and the need for VA-ECMO among patients with GD remains difficult to predict. In-hospital mortality decreased over time but remained high among patients who required VA-ECMO, especially among patients with delayed initiation of VA-ECMO.

Robotic vs. Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity Adjusted Analysis

BACKGROUND

Minimally-invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than thoracoscopic surgery (VATS) in obese populations.

METHODS

The STS GTSD, Epithor French National Database, and McMaster University Database were queried for obese (BMI≥30 kg/m²) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 NSCLC between 2015-2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts.

RESULTS

Overall, 8,108 patients (STS GTSD: n=7,473; Epithor: n=572; McMaster: n=63) met inclusion criteria with a mean age of 66.6 years (SD 9 years) and BMI of 34.7 kg/m² (SD 4.5 kg/m²). After propensity score adjusted multivariable analysis, patients who underwent VATS were over 5 times more likely to experience conversion to thoracotomy than those who underwent RTS (OR=5.33; 95% CI 4.14, 6.81, p<0.001). There was a linear association between degree of obesity and odds ratio of VATS conversion to thoracotomy compared to RTS. The VATS cohort had a longer mean length of stay (5.0 vs. 4.3 days, p<0.001), higher rate of respiratory failure (2.8% [168/5975] vs. 1.8% [39/2133], p=0.026), and were less likely to be discharged to their home (92.5% [5,525/5,975] vs. 94.3% [2,012/2,133]; p=0.013) compared to RTS patients.

CONCLUSIONS

In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.

Surgical aortic valve replacement in the modern era: Insights from the French Registry EPICARD

OBJECTIVE

We sought to assess the demographic changes and postoperative outcomes of surgical aortic valve replacement (SAVR) in recent years since the advent of trans-catheter aortic valve implantation (TAVI) in France.

METHODS

Demographic, surgical data, and early outcomes of patients undergoing SAVR for AS were reviewed from The French registry EPICARD before (2007-2012) and after (2013-2018) approval of TAVI by French health authorities. We included patients with less than 20% of missing data per variable and per patient. Univariate and multivariate analysis were conducted to assess for risk factors of mortality and acute kidney failure (AKF) requiring renal replacement therapy (RRT).

RESULTS

A total of 27,398 patients from the EPICARD registry were included: 8819, in the early cohort (2007-2012) and 18,579 in the recent cohort (2013-2018). In-hospital and 30-day mortality rates were lower in the recent cohort compared to the early cohort, respectively 1.22% versus 2.20 (p < .001) and 1.22% versus 2.34% (p < .001). The bioprosthesis-to-mechanical prosthesis ratio significantly increased over the time: from 5.3 to 8.1. In the recent cohort, rates of postoperative blood transfusions, prolonged mechanical ventilation, and AKF requiring RRT were lower. In-hospital and 30-day mortality risks were decreased in the recent cohort, with odds ratio respectively of 0.668 [0.466-0.958] and 0.66 [0.460-0.945] in multivariate (p ≤ .005) and univariate analysis (p < .001). Risk of AKF with RRT was unchanged.

CONCLUSION

This nationwide study from the French registry EPICARD shows significant reduced hospital mortality and persistent favourable early outcomes of SAVR since TAVI implementation.

Neutrophil function and bactericidal activity against Staphylococcus aureus after cardiac surgery with cardiopulmonary bypass

Staphylococcus aureus is the main bacterial pathogen encountered in mediastinitis after cardiac surgical procedures; it remains a devastating complication with a high mortality rate. As neutrophils have a primordial role in the defense against staphylococcus infection and cardiopulmonary bypass (CPB) is known to induce immunosuppression, the aim of this study was to investigate CPB impact on neutrophil functions. Patients without known immunosuppression scheduled for cardiac surgery with CPB were included. Bone marrow and blood samples were harvested before, during, and after surgery. Neutrophil phenotypic maturation and functions (migration, adhesion, neutrophil extracellular trap [NET] release, reactive oxygen species (ROS) production, phagocytosis, and bacteria killing) were investigated. Two types of Staphylococcus aureus strains (one from asymptomatic nasal carriage and another from mediastinitis infected tissues) were used to assess in vitro bacterial direct impact on neutrophils. We found that CPB induced a systemic inflammation with an increase in circulating mature neutrophils after surgery. Bone marrow sample analysis did not reveal any modification of neutrophil maturation during CPB. Neutrophil lifespan was significantly increased and functions such as NET release and ROS production were enhanced after CPB whereas bacteria killing and phagocytosis were not impacted. Results were similar with the two different isolates of Staphylococcus aureus. These data suggest that CPB induces a recruitment of mature neutrophils via a demargination process rather than impacting their maturation in the bone marrow. In addition, neutrophils are fully efficient after CPB and do not contribute to postoperative immunosuppression.

Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience

AIMS

The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke.

METHODS

Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included.

RESULTS

The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ± 0.9°C; n = 350; 82.5%) or moderate (23.9 ± 1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke.

CONCLUSION

HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.

Current results of left ventricular assist device therapy in France: the ASSIST-ICD registry

OBJECTIVES

Our goal was to provide a picture of left ventricular assist device (LVAD) activity in France between 2007 and 2016 based on the multicentric ASSIST-ICD registry.

METHODS

We retrospectively collected 136 variables including in-hospital data, follow-up survival rates and adverse events from 671 LVAD recipients at 20 out of 24 LVAD implant centres in France. The average follow-up time was 1.2 years (standard deviation: 1.4); the total follow-up time was 807.5 patient-years.

RESULTS

The included devices were the HeartMate II®, HeartWare LVAS® or Jarvik 2000®. The overall likelihood of being alive while on LVAD support or having a transplant (primary end point) at 1, 2, 3 and 5 years postimplantation was 65.2%, 59.7%, 55.9% and 47.7%, respectively, given a cumulative incidence of 29.2% of receiving a transplant at year 5. At implantation, 21.5% of patients were on extracorporeal life support. The overall rate of cardiogenic shock at implantation was 53%. The major complications were driveline infection (26.1%), pump pocket or cannula infection (12.6%), LVAD thrombosis (12.2%), ischaemic (12.8%) or haemorrhagic stroke (5.4%; all strokes 18.2%), non-cerebral haemorrhage (9.1%) and LVAD exchange (5.2%). The primary end point (survival) was stratified by age at surgery and by the type of device used, with inference from baseline profiles. The primary end point combined with an absence of complications (secondary end point) was also stratified by device type.

CONCLUSIONS

The ASSIST-ICD registry provides a real-life picture of LVAD use in 20 of the 24 implant centres in France. Despite older average age and a higher proportion of patients chosen for destination therapy, survival rates improved compared to those in previous national registry results. This LVAD registry contrasts with other international registries because patients with implants have more severe disease, and the national policy for graft attribution is distinct. We recommend referring patients for LVAD earlier and suggest a discussion of the optimal timing of a transplant for bridged patients (more dismal results after the second year of support?).

Epinephrine administration in venoarterial extracorporeal membrane oxygenation patients is associated with mortality: a retrospective cohort study

Aims

Knowledge about the impact of epinephrine on the outcome in venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients is limited, and existing data are conflicting.

Methods and results

We conducted a retrospective cohort study in a 1500 bed tertiary university hospital. Five hundred and eighty‐nine VA‐ECMO patients were analysed. The median age was 57 years [47–65], 68% of male. The major indications for ECMO were post‐cardiotomy cardiogenic shock (CS) (38%) and medical CS (36%). Two hundred and sixty‐two (44.5%) patients received epinephrine alone or associated with another catecholamine while on ECMO. Baseline factors significantly associated with epinephrine administration were younger age, higher sequential organ failure assessment score, cardiac arrest at implantation, and intra‐aortic balloon pump support at implantation, whereas medical CS and dobutamine administration were significantly associated with a lower risk of epinephrine administration. Epinephrine administration was independently associated with death [hazard ratio = 1.68 (1.44–2.23); P < 0.01]. A sensitivity analysis with propensity score inverse probability weighting in complete cases confirmed a significant association of epinephrine administration with death [hazard ratio = 1.69 (1.43–2.00); P < 0.001].

Conclusions

Among patients who required VA‐ECMO, epinephrine administration was associated with an increased risk for death.

Successful heart transplantation for COVID-19-associated post-infectious fulminant myocarditis

Various clinical presentations of the 2019 coronavirus disease (COVID‐19) have been described, including post‐infectious acute and fulminant myocarditis. Here, we describe the case of a young patient admitted for COVID‐19‐associated post‐infectious fulminant myocarditis. Despite optimal pharmacologic management, haemodynamic status worsened requiring support by veno‐arterial extracorporeal membrane oxygenation. Emergent heart transplantation was required at Day 11 given the absence of cardiac function improvement. The diagnosis of post‐infectious COVID‐19‐associated myocarditis was made from both pathologic examination of the explanted heart and positive SARS‐CoV‐2 serology.

Computer-assisted valve in valve in a deteriorated Mosaic valve using a library of bioprostheses

Valve-in-valve (ViV) procedures have emerged from an off-label procedure to a safe and efficient alternative to redo aortic valve replacement in the treatment of symptomatic structural valve deterioration (SVD). During ViV procedures, optimal placement of the transcatheter heart valve (THV) inside the degenerated bioprosthesis is of paramount importance regarding complications such as device embolization, coronary obstruction, periprosthetic regurgitation, residual gradients, and mitral valve injury, but also for the attainment of optimal hemodynamics. In the case of the Mosaic (Medtronic, Minneapolis, MN) valve, the limited radiopaque landmarks represent a challenge to a reproducible, optimal implantation. Such implantation may require multiple contrast injections and transesophageal echocardiogram (TEE) guidance. We herein describe a computer-assisted ViV procedure inside a deteriorated Mosaic valve, achieving reproducible optimal placement using a preacquired library of bioprostheses 3D models. Our approach suggests an evolving paradigm in ViV procedures, from safe and efficient toward optimal therapy for symptomatic SVD.

DURABILITY OF MITRAL VALVE REPLACEMENT WITH A 3RD GENERATION BIOPROSTHESIS

BACKGROUND

To evaluate the durability of a third-generation porcine bioprosthesis (Epic® valve) in the mitral position, according to patients' age at surgery.

METHODS

A total of 482 mitral valve replacements (MVR) using the Epic® valve at a single center were included (2009-2018). Perioperative and early postoperative data were prospectively collected. A systematic follow-up was performed (99% complete, 1,609.5 patient/years, average: 3.8 ± 2.5 years). Standardized definitions of valve-related events were adopted. Age at MVR was 68.1 ± 10.4 years.

RESULTS

Operative mortality was 9.3%. The were 5 early valve-related reoperations, mainly due to recurrent infectious endocarditis. Global survival at 8.8 years was 69.5% ± 5. There were 9 SVD events during the follow-up (3 receiving reoperations, 4 TMVR valve-in-valve, and 2 medical treatment only). The freedom from SVD at 5 and 10 years was 97.4% ± 1.2 and 89.6% ± 4.4 (actuarial), and 97.8% ± 1 and 91.9% ± 3.3, respectively (competing risks). After stratification into subgroups by age at surgery (≤59: 50.8%, 60-69: 32.8%, ≥70: 16.4%) there was no significant intergroup difference in freedom from SVD (log-rank p=0.24). The overall freedom from any reintervention for SVD at 10 years was 90.5% ± 4.4 (actuarial) and 92.7% ± 3.3 (competing risks), with no intergroup difference (log-rank p=0.14). The freedom from any valve-related complication at 8.4 years was 83.2% ± 4.5 (actuarial).

CONCLUSIONS

The Epic® bioprosthesis shows good durability at 5 to 10 years in the mitral position.

Transcatheter Aortic Valve Implantation for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device (from the Prospective VIVA Post Market Study)

Patients with symptomatic aortic stenosis are often treated with a surgical valve replacement. Surgical bioprosthetic valves degenerate over time and therefore may necessitate a redo surgery. This analysis reports the 2-year clinical outcomes of the Valve-in-Valve study, which evaluated transcatheter aortic valve implantation using the CoreValve and Evolut R devices in patients with degenerated surgical aortic bioprostheses at high risk for surgery. The prospective Valve-in-Valve study enrolled 202 eligible patients with failing surgical aortic bioprostheses due to stenosis, regurgitation, or a combination of both. The Evolut R bioprosthesis was used in 90.5% of valve-in-valve transcatheter aortic valve implantation cases. Two-year all-cause and cardiovascular mortality rates were 16.5% and 11.1%, respectively. Other clinical events included stroke (7.9%), disabling stroke (1.7%), and new pacemaker implantation (10.1%). The 2-year all-cause mortality rate was significantly higher in patients with discharge mean gradients ≥20 mmHg vs. those with lower mean gradients (21.0% vs 7.6%, p = 0.025). Discharge mean gradients ≥20 mm Hg were associated with smaller surgical bioprostheses (OR, 7.2 [95% CI 2.3 to 22.1]. In patients with failing surgical aortic bioprostheses, valve-in-valve treatment using a supra-annular self-expanding bioprosthesis provides significant functional improvements with acceptable rates of complications, especially if a postprocedural mean gradient of <20 mmHg can be achieved.

Does Hypothermic Circulatory Arrest for Aortic Surgery Trigger Near-Death Experience? Incidence of Near-Death Experiences after Aortic Surgeries Performed under Hypothermic Circulatory Arrest

BACKGROUND

 Understanding near-death experiences (NDE) could provide a new insight into the analysis of human consciousness and the neurocognitive processes happening upon the approach of death. With a temporary interruption of systemic perfusion, aortic surgery under hypothermic circulatory arrest (HCA) may be the only available model of reversible clinical death. We present, herein, the results of an observational study designed to assess the incidence of NDE after aortic surgery.

METHODS

 We performed a prospective study including consecutive patients who underwent thoracic aortic surgery between July 2018 and September 2019 at our institution. Procedures without HCA were included to constitute a control group. The primary outcome was the incidence of NDE assessed with the Greyson NDE scale during the immediate postoperative course, via a standardized interview of the patients in the surgical ward.

RESULTS

 One hundred and one patients were included. Twenty-one patients (20.8%) underwent nonelective interventions for aortic dissection. Ninety-one patients had hemiarch replacement (90.1%). Sixty-seven (66.3%) interventions were performed with HCA, with an average circulatory arrest duration of 26.9 ± 25.5 minutes, and a mean body temperature of 23.7 ± 3.8°C. None of the patients reported any recollection from their period of unconsciousness. There was no NDE experiencer in the study cohort.

CONCLUSION

 Several confounding factors regarding anesthesia, or NDE evaluation, might have impaired the chance of NDE recollections, and might have contributed to this negative result. Whether HCA may trigger NDE remains unknown.

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care.

AIM

To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019.

METHODS

This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications.

RESULTS

With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge.

CONCLUSIONS

Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

Venoarterial extracorporeal membrane oxygenation induces early immune alterations

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides heart mechanical support in critically ill patients with cardiogenic shock. Despite important progresses in the management of patients under VA-ECMO, acquired infections remain extremely frequent and increase mortality rate. Since immune dysfunctions have been described in both critically ill patients and after surgery with cardiopulmonary bypass, VA-ECMO initiation may be responsible for immune alterations that may expose patients to nosocomial infections (NI). Therefore, in this prospective study, we aimed to study immune alterations induced within the first days by VA-ECMO initiation.

Methods

We studied immune alterations induced by VA-ECMO initiation using cytometry analysis to characterize immune cell changes and enzyme-linked immunosorbent assay (ELISA) to explore plasma cytokine levels. To analyze specific changes induced by VA-ECMO initiation, nine patients under VA-ECMO (VA-ECMO patients) were compared to nine patients with cardiogenic shock (control patients).

Results

Baseline immune parameters were similar between the two groups. VA-ECMO was associated with a significant increase in circulating immature neutrophils with a significant decrease in C5a receptor expression. Furthermore, we found that VA-ECMO initiation was followed by lymphocyte dysfunction along with myeloid-derived suppressor cells (MDSC) expansion. ELISA analysis revealed that VA-ECMO initiation was followed by an increase in pro-inflammatory cytokines such as IL-6, IL-8 and TNF-α along with IL-10, a highly immunosuppressive cytokine.

Conclusion

VA-ECMO is associated with early immune changes that may be responsible for innate and adaptive immune alterations that could confer an increased risk of infection.

Endovascular Repair of a Dacron Pseudoaneurysm in an Ascending-to-Descending Aortic Bypass

In the setting of postcoarctation aortic repair, Dacron graft dilatation and late aneurysms are not uncommon. Reintervention usually involves redo open surgery and replacement of the aneurysmal graft or the pseudoaneurysmal suture line. The present case describes the endovascular repair of a Dacron anastomotic false aneurysm in an extra-anatomic ascending-to-descending aortic bypass, 19 years after surgical correction of aortic recoarctation.

Late surgical explantation of a transcatheter heart valve in a patient with a porcelain aorta

Structural valve deterioration is a well-studied phenomenon in bioprosthetic heart valves. Conversely, structural valve deterioration after transcatheter aortic valve implantation is not as well-elucidated. Therefore, late surgical explantation after transcatheter aortic valve implantation is an infrequent procedure, and thus, surgical findings and management of such cases remain unclear, particularly in patients previously labelled as 'inoperable' or at 'high risk'. Herein, we report the case of a late surgical explantation of a transcatheter heart valve (THV) 7 years after its implantation in a patient with a porcelain aorta and periprosthetic regurgitation.

Continued follow-up of the free margin running suture technique for mitral repair

OBJECTIVES

The free margin running suture (FMRS) technique was recently proposed to treat complex degenerative mitral lesions. Limited follow-up data are available. We evaluated the midterm reliability of this technique and the associated mitral valve parameters using rest/stress echocardiography.

METHODS

One-hundred-eight consecutive patients at 2 European centres were included. Prospective follow-up was performed (266.1 patient-years, average duration 2.5 ± 2.5 years). Echocardiographic scans at rest were obtained for all patients at hospital discharge and at follow-up. Stress echocardiography was also performed in 17 patients.

RESULTS

There were no operative deaths. FMRS was performed through a right minithoracotomy in 86.1% of patients, with a robotic-assisted technique in 5.6% and through a sternotomy in 8.3%. Bileaflet disease was noted in 31.4%. One patient (0.9%) presented a 2+/4+ residual mitral regurgitation at discharge; lower-degree or no residual regurgitation was noted in the remaining patients. At the follow-up examination, 1 patient (0.9%) presented with a 2+/4+ mitral regurgitation. Coaptation length at discharge versus that at follow-up was 1.3 ± 0.2 vs 1.3 ± 0.1 cm (P = 0.13); the average transmitral gradient was 4.8 ± 1.5 vs 3.5 ± 0.9 mmHg (P < 0.001). In a subpopulation, follow-up echocardiography indicated that the average transmitral gradient at rest versus that at peak effort was 3.2 ± 0.7 vs 5.1 ± 1.3 mmHg (P < 0.001), with no appearance of significant mitral regurgitation and marginally significant increases in pulmonary artery systolic pressures (P = 0.049).

CONCLUSIONS

Data indicate effectiveness and reproducibility of FMRS, with stability of valve function at midterm. FMRS was also associated with promising outcomes in diastolic performance both at rest and during exercise.

Mortality due to hospital-acquired infection after cardiac surgery

PURPOSE

Hospital-acquired infections have been associated with significant morbidity and mortality in critically ill surgical patients. However, little is known about mortality due to hospital-acquired infections in cardiac surgery.

METHODS

We conducted a retrospective analysis of prospectively collected data from the cardiac surgery unit of a university hospital. All patients who underwent cardiac surgery over a 7-year period were included. Patients with hospital-acquired infections were matched 1:1 with patients with nonhospital-acquired infections based on risk factors for hospital-acquired infections and death after cardiac surgery using propensity score matching. We performed a competitive risk analysis to study the mortality fraction due to hospital-acquired infections.

RESULTS

Of 8853 patients who underwent cardiac surgery, 370 (4.2%) developed 500 postoperative infections (incidence density rate 4.2 hospital-acquired infections per 1000 patient-days). Crude hospital mortality was significantly higher in patients with hospital-acquired infections than in matched patients who did not develop hospital-acquired infections, 15.4% and 5.7%, respectively (P < .001). The in-hospital mortality fraction due to hospital-acquired infections in our cohort was 17.1% (12.3%-22.8%). Pseudomonas aeruginosa infection (hazard ratio, 2.09; 95% confidence interval, 1.23-3.49; P = .005), bloodstream infection (hazard ratio, 2.08; 95% confidence interval, 1.19-3.63; P = .010), and pneumonia (hazard ratio, 1.68; 95% confidence interval, 1.02-2.77; P = .04) were each independently associated with increased hospital mortality.

CONCLUSIONS

Although hospital-acquired infections are relatively uncommon after cardiac surgery (4.2%), these infections have a major impact on postoperative mortality (attributable mortality fraction, 17.1%).

TAVR for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device: 1-Year Results From the Prospective VIVA Postmarket Study

OBJECTIVES

The VIVA (Valve in Valve) trial was designed to systematically and prospectively collect data regarding the use of transcatheter aortic valve replacement in patients with failing surgical aortic bioprostheses at high-risk for reoperation.

BACKGROUND

Surgical aortic valve replacement has been the standard of care in symptomatic patients with aortic valve disease. However, bioprosthetic valves degenerate over time, requiring redo surgery.

METHODS

VIVA is an international, observational, single-arm, postmarket study conducted at 23 sites that enrolled 202 patients with symptomatic degeneration of an aortic bioprosthesis eligible for elective treatment with a CoreValve or Evolut R self-expanding transcatheter aortic valve.

RESULTS

Patients were elderly (mean age 79.9 years), 47.5% were men, and they had a mean Society of Thoracic Surgeons score of 6.6%. Although 41.8% of patients had surgical bioprostheses with labeled size ≤21 mm, valve hemodynamic parameters were markedly improved from baseline (mean aortic valve gradient 35.0 ± 16.3 mm Hg) to discharge (17.5 ± 8.6 mm Hg) and were sustained at 1 year (15.5 ± 7.5 mm Hg). At 1 year, total aortic regurgitation greater than mild was measured in 1.1% of patients. Clinical outcomes at 30 days demonstrated low mortality (2.5%), no disabling strokes, a 0.5% rate of acute kidney injury, and an 8.0% rate of new pacemaker implantation. At 1 year, the mortality rate remained low (8.8%), with 1 disabling stroke (0.6%). Five patients (2.5%) experienced coronary artery obstructions, 3 during and 1 immediately after the procedure and 1 several months later.

CONCLUSIONS

Degenerated surgical bioprostheses can be safely treated with the CoreValve or Evolut R platform using the catheter-based valve-in-valve procedure. Excellent 1-year clinical and hemodynamic outcomes were achieved in this real-world patient population. (CoreValve VIVA Study Evaluation of the Clinical Outcomes of CoreValve in Degenerative Surgical Aortic Bioprosthesis; NCT02209298).

Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement

Background:

Heart failure (HF) readmission is common post–transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death.

Methods:

Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death.

Results:

Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99–1.85]). However, late (HR, 1.90 [95% CI, 1.30–2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17–3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48–0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37–0.98]) of the optimal daily dose.

Conclusions:

HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.

Long-term follow-up of the Shelhigh™ superstentless bioprosthesis aortic valve and valved conduit in a monocentric experience

BACKGROUND

The Shelhigh™ SuperStentless (Shelhigh, INC., Union, NJ, USA) is a stentless aortic valve bioprosthesis and aortic root valved conduit. In 2007, this device was recalled by FDA due to malfunction, and subsequently reintegrated by BioIntegral Surgical™ Few data are available over late durability of this device. We performed a long-term follow-up of Shelhigh™ devices implanted at our center.

METHODS

Between 2002 and 2007, 44 patients underwent aortic valve replacement with a Shelhigh™ device (40 aortic valve bioprosthesis and 4 valved conduit). We performed a clinical and echocardiographic follow-up (9.2 years±4.3). Standardized definitions of valve-related events were adopted.

RESULTS

At discharge, maximum and mean aortic gradients averaged 36.1±11.3 and 21.0±6.8 mmHg, respectively. The 30-days mortality was 2.3%. Over the follow-up period, 29 patients died (65.9%); 2 deaths were valve related. Overall survival at 1, 5 and 10 years was 97.7%, 85.8% and 54% respectively. At last echocardiography, average transvalvular gradients had remained globally stable in the population (33.6±12 and 20.4±10.5 mmHg). Eight (19%) structural valve deterioration (SVD) events were reported. Two (5%) non-structural valve dysfunction (NSVD) events occurred (periprosthetic leak). Two (5%) infectious endocarditis events and two (5%) valve thromboses were also deplored. Three (7%) patients required re-operation (2 due to SVD and 1 due to endocarditis).

CONCLUSIONS

The immediate hemodynamic performance of the Shelhigh™ aortic bioprostheses was unexpectedly suboptimal. Despite this, hemodynamic performance remained stable over time. Patients survival at follow-up was satisfactory, however, continued surveillance is necessary.

Patient-specific access planning in minimally invasive mitral valve surgery

BACKGROUND

Minimally invasive mitral valve repair or replacement (MIMVR) approaches have been increasingly adopted for the treatment of mitral regurgitation, allowing a shorter recovery time and improving postoperative quality of life. However, inadequate positioning of the right mini thoracotomy access (working port) translates into suboptimal exposure, prolonged operative times and, potentially, reduction in the quality of mitral repair. At present, we are missing tools to further improve the positioning of the working port in order to ameliorate surgical exposure in a patient- specific fashion.

METHODS AND EVALUATION OF THE HYPOTHESIS

We hypothesized that computation of relevant anatomical measurements from preoperative CT scans in patients undergoing MIMVR may provide patient-specific information in order to propose the surgical access that best fits to the patient's morphology. We hypothesized that this may systematize optimal mitral valve exposure, facilitating the procedure and potentially ameliorating the outcomes. We also hypothesized that preoperative simulation of the working port site and surgical instruments' insertion using a three-dimensional virtual model of the patient is feasible and may help in the customization of ports positioning. The hypothesis was evaluated by a multidisciplinary team including cardiac surgeons, experts in medical image processing and biomedical engineers. CT scans of 14 patients undergoing MIMVR were segmented to visualize 3D chest bones and heart structures meshes. The mitral valve annulus is pointed manually by the expert or extracted automatically when contrast-enhanced CT scan was available. The valve plane was then calculated and the optimal incision location analyzed according to a) the perpendicularity and b) the distance between the intercostal spaces and the valve plane. An angle-chart representation for the 4th, 5th and 6th intercostal spaces and a color map illustrating the distance between the skin and the mitral valve were created. We started the development of a simulation tool for preoperative planning using 3D Slicer software.

CONCLUSIONS

Several patient-specific factors (including the orientation of the mitral valve plane and the morphology of the chest cage) may influence the performance of a MIMVR procedure, but they are not quantitatively considered in the current planning strategy. We suggest that the clinical results of MIMVR can be improved through preoperative virtual simulation and computer-assisted surgery (through determination of working port and surgical instruments insertion positioning). Further research is justified and the development of a software tool for clinical evaluation is warranted to verify the current hypothesis.

Simultaneous transapical aortic and mitral valve implantation in a patient with porcelain aorta

Left-sided double valve disease in the setting of extensive mitral annular calcifications and porcelain aorta raises multiple surgical challenges when considering an open surgical repair. We herein present the case of a 67-year-old patient with severe symptomatic aortic and mitral stenosis associated with extensive mitral annular calcifications and porcelain aorta, successfully treated by simultaneous transapical transcatheter aortic and mitral valve implantation.