Search

OBJECTIVES Due to increasing clinical experience with transcatheter aortic valve implantation (TAVI) procedures, sophisticated imaging and advanced device technology, TAVI complication rates are low; however, patients requiring conversion to surgery are confronted with an increased mortality risk. In this retrospective study, we evaluated the predictors for conversion and the outcomes of these patients. METHODS We analysed the records of all patients undergoing TAVI in our centre from 2011 to 2016 and focused on cases that required conversion to sternotomy. We investigated reasons and risk factors for conversion as well as 30-day and 1-year outcomes. RESULTS During the study period, 32 (2.1%) of 1775 patients undergoing TAVI required immediate conversion to sternotomy. Annular rupture (5 of 32; 16%), device embolization (9 of 32; 28%) and pericardial tamponade (15 of 32; 47%) were the most common reasons for conversion. Usage of a self-expandable valve showed to be the only predictor for conversion (odds ratio 0.38, 95% confidence interval 0.16–0.90; P  = 0.03). Survival at 30 days and 1 year was 56% and 41%, respectively. Patients who survived 30 days after conversion showed higher preoperative ejection fraction, shorter duration of surgery and shorter perfusion time. CONCLUSIONS In this high-volume, single-centre experience, conversion to sternotomy during TAVI occurred in about 2%, with annular rupture, device embolization and pericardial tamponade being the most common causes. Complications requiring conversion showed to be unpredictable. However, in view of these life-threatening complications, the 30-day survival rate exceeding 50% emphasizes the importance of an experienced and well-attuned heart team providing immediate access to surgical bailout procedures. [ABSTRACT FROM AUTHOR]

OBJECTIVES Although data from large series indicate the satisfactory performance of bioprosthetic valves in the right ventricular outflow tract (RVOT), replacement of the pulmonary valve in adult patients undergoing the Ross procedure is usually performed with pulmonary allografts. We evaluated the outcomes of homografts vs. bioprosthetic RVOT replacement after the Ross procedure in adults. METHODS Between 1996 and 2011, a total of 186 adult patients (141 male; mean age 44 ± 10 years) underwent aortic root replacement with a pulmonary autograft. The RVOT was replaced with a homograft in 113 patients and with stentless bioprostheses (Medtronic Freestyle®) in 73. Patients were followed for a mean of 6 years (range 1–15 years; 1106 patient years). RESULTS Twelve patients required reintervention owing to dysfunction of the RVOT replacement, which was caused by endocarditis (n = 4), degeneration (n = 2) or stricture at the proximal suture line (n = 6). For homografts, the incidence of reintervention was 1 in 150 patient years, compared with 1 in 36 patient years for stentless bioprostheses (P = 0.007). The median gradient was 15 mmHg for the homograft group and 24 mmHg for bioprosthesis (P < 0.0001). The incidence of gradients >40 mmHg was 10-fold higher in the bioprosthetic group. CONCLUSIONS Patients with bioprostheses in the RVOT position after the Ross procedure showed a significantly higher risk of reintervention or pulmonary valve dysfunction. The main problem, early development of a stricture at the proximal suture line, has to be solved to achieve satisfactory bioprosthetic function in the RVOT. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The unreinforced aortic root, in bicuspid aortic valve disease, has been shown to dilate and cause recurrent regurgitation. The objective of this study was to determine whether reduction aortoplasty can reliably prevent aortic root dilatation after aortic valve repair in bicuspid disease. Methods: A total of 66 patients, with a mean age of 41.2±12 years and with incompetent bicuspid aortic valves and concomitant dilatation of the aortic root, were included in this study. As many as 49 patients had patch augmentation of the free edge of the bicuspid aortic leaflets and reduction aortoplasty, and a further 17 patients had patch augmentation and a modified David type repair. Patients were followed up by echocardiography and clinically in yearly intervals. Results: At midterm (mean follow-up was 5.1±2.1 years), only one patient in the reduction aortoplasty group showed aortic root dilatation, leading to significant aortic valve regurgitation. Other than that, there was no progression of regurgitation in the whole group of patients. In the David type repair group, no re-operations, progression of aortic root dilatation or recurrent regurgitation occurred. In general, there was only one death in the reduction aortoplasty group. This patient developed endocarditis after 1 year and died of acute heart failure prior to readmission to our hospital. Conclusion: Both reduction aortoplasty and modified David type repair, paired with patch augmentation of the incompetent bicuspid valve, provide excellent midterm results. The reduction of the diameter of the ascending aorta by reduction aortoplasty seems to provide reliable stability that is comparable to the David type repair. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. Methods: Autologous pericardium is sutured to the free edge of the prolapsing bicuspid leaflet. A large coaptation surface is created and competence of the bicuspid valve is achieved. Forty patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. Patients were followed up at regular intervals by echocardiography in yearly intervals. Results: There were no perioperative deaths. One year postoperatively, one patient died due to endocarditis. Seven patients (17.5%) had aortic regurgitation grade I, and the other 33 patients had non or trivial aortic regurgitation at discharge. At 4.2±3.1 years postoperatively, only four patients (10%) had aortic regurgitation grade I. There were no cases of progression of regurgitation. Planimetric effective orifice areas ranged above 2cm2. Mean aortic gradients dropped from 8.2±4.8mmHg at discharge to 3.8±3 at four years and the mean height of coaptation surface from 14.7±2mm to 12.3±4, respectively. Conclusions: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early and midterm competence of reconstructed bicuspid aortic valves. [Copyright &y& Elsevier]

Objective: The purpose of our study was to compare vacuum-assisted suction drainage (VASD) to conventional wound management, in the treatment of poststernotomy osteomyelitis (SOM). Methods: We included a total of 42 patients that developed poststernotomy osteomyelitis and required open wound management, between 1998 and 2000, in this study. Twenty of these patients were treated by VASD and the other 22 by conventional wound management. The patients were well comparable with regards to age, presenting postoperative day, infecting organism and risk factors for osteomyelitis. This was a retrospective study. Results: The patients treated by VASD had a significantly reduced treatment duration (mean 17.2±5.8 vs. 22.9±10.8 days, P=0.009) and total hospital stay (mean 27.2±6.5 vs. 33.0±11.0 days, P=0.03). Perioperative mortality was similar, with one early death in each group. Conclusion: We conclude from our experience in the treatment of 42 patients with poststernotomy osteomyelitis that VASD shortened wound healing and hospital stay and thus proved to be an excellent alternative to conventional open management of these wounds. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate the interim results of the initial multicenter feasibility trial for trans-apical aortic-valve implantation (TA-AVI) in high-risk elderly patients with severe aortic stenosis. Methods: A total of 168 patients were prospectively included in three European centers between February 2006 and April 2008. The Cribier–Edwards or Edwards SAPIEN™ Trans-catheter Heart Valve (23mm and 26mm) was implanted using an oversizing concept. Interventions were performed in a hybrid operative room (OR) (one center), with a mobile C-arm in the OR (one) and in the catheterization laboratory (one). Inclusion criteria included age ≥70 years and an increased risk profile (additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥9). Results: Patient age was 82.1±5.6 years, 76% were female and the EuroSCORE was 11.3±1.8 (additive) and 27±12.7% (logistic). Cardiopulmonary bypass was used by intention in 14.2% during the initial phase, secondarily in 10.1% and 75% of the patients were treated off-pump. Valve implantation led to a good immediate result in 161 (95.8%) patients and problems were encountered in seven patients (malposition (two patients), migration (three patients) and severe incompetence (two patients)). Nine patients were converted to conventional surgery, early stroke occurred in two (1.2%) patients and 10 (6%) patients received a new pacemaker. At 30 days, 25 patients died, 48% of them due to cardiac-related causes. Overall survival at 30 days, 6 months and 1 year was 85%, 70% and 63%, respectively. Conclusions: The initial multicenter feasibility trial for TA-AVI (TRAVERCE) shows acceptable results of this promising technique, especially in view of the high-risk profile of the patients. [Copyright &y& Elsevier]

Abstract: Objective: The performance of the Ross procedure in the case of geometric mismatch between pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused autograft dysfunction, a modification of the surgical technique is necessary. Methods: Between January 1996 and January 2007, 50 patients (33 male, 17 female; mean age 50±14 years; range 13–63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted partially in supra-annular position to correct the geometric mismatch between the deeper base of the non-coronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde treated autologous pericardial patch to prevent pseudoaneurysm formation. Patients were followed up 1, 2, 5 and 10 years postoperatively. Results: There were no early or late deaths. There were six reoperations. One patient was reoperated because of persistent severe aortic valve insufficiency 9 months postoperatively. Three patients were reoperated for formation of subannular pseudoaneurysm, 6, 9 and 30 months postoperatively. One patient was reoperated for closure of a paravalvular dehiscence. Another patient was reoperated 1 year postoperatively because of a severe pulmonary stenosis due to excessive calcification of the bioprosthesis. Echocardiographic follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Conclusion: Autograft replacement of the bicuspid aortic valve is challenging, as the geometric mismatch has to be adjusted. Valve dysfunction is avoided by a supra-annular implantation technique, but pseudoaneurysm formation at the base of the non-coronary sinus is a worrying aspect. Patch reinforcement may solve this issue. [Copyright &y& Elsevier]

Abstract: Objective: Percutaneous aortic valve implantation has been performed in patients with severe aortic stenosis judged as nonsurgical candidates. We evaluated a facilitated transapical antegrade approach for potential use in surgical high-risk patients. Methods: A pericardial xenograft fixed within a 23-mm stent (Cribier–Edwards aortic prosthesis, Edwards Inc., Irvine, CA, USA) was implanted using a transapical approach in fifteen 35–45kg pigs. A limited or a full sternotomy was used to transapically introduce a crimped valve through a 24-F sheath. Deployments were performed on the beating heart either with ventricular unloading using femoro-femoral cardiopulmonary bypass (CPB) or rapid ventricular pacing (RVP), all under fluoroscopic and echocardiographic visualization. Results: All valves were successfully deployed at the target site with acceptable visualization of the noncalcified annulus. Valve migration occurred in six procedures (three distal and three retrograde) secondary to inadequate reduction of ventricular output, unfavorable annular anatomy, excessive crimping of the valve, and dislodgement by the delivery balloon. Exact positioning of the valve into the target area was confirmed by autopsy at the end of the procedures. Paravalvular leak was noted in five implants. Conclusions: The transapical approach provides a safe, accurate, and effective route for facilitated antegrade delivery of a stent-fixed valve. Advanced stent design will lead to better stability of the implant and may minimize the risk of paravalvular leakage in future. Identifying the appropriate population for human feasibility trials remains a challenge. [Copyright &y& Elsevier]

Objective: Emboli generated during cardiac surgery have been associated with aortic clamping and manipulation. Proximal anastomotic devices are thought to be less traumatic by eliminating partial clamping, potentially resulting in fewer adverse outcomes. Intra-aortic filtration has been shown to effectively capture particulate debris. We compared the amount of debris released using intra-aortic filtration and the clinical outcomes between conventionally handsewn and automated proximal anastomoses. Methods: Seventy-seven patients undergoing primary coronary artery bypass grafting with cardiopulmonary bypass were enrolled in a prospective randomized study. Patients were assigned to the anastomotic device Group I (Symmetry™ Aortic Connector, n=39) or the conventional handsewn anastomosis control Group II (n=38). Proximal anastomoses were performed before cardiopulmonary bypass in both groups. Intra-aortic Filter 1 (EMBOL-XTM) was deployed prior to partial clamping or puncturing the aorta for device application and removed after the proximal anastomosis was completed. Prior to cross-clamp removal, a second filter was inserted (Filter 2). A core laboratory performed quantitative and histologic analyses of the debris captured. Clinical outcomes included adverse events, neurocognitive test scores, graft patency, and mortality. Results: Preoperative variables and risk factors were not significantly different between Groups I and II (EuroSCORE 3.9±2.6 vs. 4.2±2.5). Filter analyses showed no significant difference between Groups I and II in Filter 1 or 2 for either surface area of particles or total number of particles (P>0.05). There was a significant decrease between Filters 1 and 2 in both Groups for surface area of particles (Group I: 18.5±23.8 mm2 vs. 10.7±16.3 mm2, P=0.017; Group II: 15.0±15.4 mm2 vs. 6.9±.6.5 mm2, P=0.004), and for total number of particles in Group II (8.6±3.7 vs. 7.1±2.4, P=0.023). No significant differences were observed between Group I (device) and Group II (control) outcomes for myocardial infarction, neurocognitive deficit, stroke, length of stay, graft occlusion, or mortality. Conclusions: The application of proximal aortic connectors without partial clamping does not reduce particulate emboli or affect clinical outcomes compared with conventional anastomoses. Cross-clamping during cardiopulmonary bypass produces less particulate debris than conventional or automated proximal anastomoses performed off-pump, suggesting a major source of emboli is the anastomotic process. [Copyright &y& Elsevier]