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Background Aortic valve replacement (AVR) in small aortic roots remains a surgical dilemma with a higher risk of patient-prosthesis mismatch (PPM). The Perimount Magna Ease aortic valve (PMEAV) represents an attractive device in such cases. We examined the early hemodynamic performance, the mid-term outcomes of the PMEAV, and the impact of PPM on outcome and functional class. Methods We performed a retrospective analysis of prospectively collected in-hospital data, and a prospective single-center follow-up of 849 patients who received a 19 to 23 mm PMEAV (2008–2014). Concomitant mitral or tricuspid replacement was the exclusion criterion. Early hemodynamic features were prospectively collected; mid-term follow-up was conducted according to current guidelines. Results Size of implanted prosthesis was 19 mm in 11.5% of patients, 21 mm in 36.9%, and 23 mm in 51.5%. Operative mortality was 4.5% (3.1% for isolated AVR). The rate of severe and moderate PPMs was significantly higher in the 19 mm group. Follow-up was 99.9% complete (3.7 ± 2 years). Actuarial freedom from structural valve deterioration (SVD) at 5 years was 99.1%. At stratified Kaplan–Meier's analysis, PPM and age <70 years were associated with SVD. PPM was not associated with worse functional status (New York Heart Association class) or mortality at follow-up. Conclusion This series shows satisfactory clinical outcomes of the PMEAV implanted in small aortic annuli at mid-term follow-up. Although PPM may occur in smaller sizes, it has limited clinical impact, and it is not associated with mid-term mortality or worse functional class. Few SVD events are evidenced; nonetheless, limited follow-up duration and its methodology need to be considered. [ABSTRACT FROM AUTHOR]

Background and Aim Of the Study: Cardiac wounds have been described for centuries and still remain to be fatal. For a long period of time, the suturing of a myocardial laceration was thought to be absolutely impossible if not sacrilege.Methods: It is only at the end of the 19th century that pioneers decided to defy such a dogma in desperate cases.Results: Nowadays, it seems obvious that a cardiac stab wound requires emergent surgery whenever possible.Conclusions: The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine. [ABSTRACT FROM AUTHOR]

OBJECTIVES Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients. [ABSTRACT FROM AUTHOR]

Background We address the differential long-term results of tricuspid valve replacement and late valve-related events among bioprostheses versus mechanical prostheses. Methods In a single-institution investigation, we reviewed the patients’ prospectively collected data and performed a clinical follow-up. Both the Kaplan-Meier (actuarial) and the competing risks (actual) methodologies were used. Results Overall, 188 tricuspid valve replacements were performed during 1971 to 2012. In this complex population (reoperations, 48.1%; associated procedures in 71.3%), operative mortality was 27.6% (significantly declining in recent years). A bioprosthesis was used in 82.4%. Follow-up was 10.2 ± 9.1 years (as long as 37.3 years, or 1,270 patient-years; 91.2% complete). At 15 years, freedom from structural valve deterioration was 93.3% ± 6.4% (competing risks 94.7 ± 5.1%) in the mechanical group and 85.2% ± 5.4% (competing risks 92% ± 2.9%) in the bioprostheses group ( p = 0.19). Freedom from any valve-related adverse events was lower among mechanical valves versus bioprostheses (although not statistically significant). Mechanical valves showed significantly lower freedom from thromboembolic events (actuarial 62.3% ± 14.3% versus 97.7% ± 1.6%; competing risks 74.1% ± 10% versus 98% ± 1.4%; p < 0.001) and earlier adverse events (4.9 ± 4.5 versus 11.1 ± 9.4 years) than bioprostheses. There were 11 reoperations for bioprosthetic structural valve deterioration (89.8% and 94.3% actuarial and actual freedom, respectively). Conclusions Bioprostheses for tricuspid valve replacement have a very good long-term durability. Mechanical valves display earlier and more severe morbidity at follow-up. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the haemodynamic performance of the St Jude Trifecta valve for aortic valve replacement (AVR) at 3 years after implantation. METHODS: In a single-centre, prospective, observational, independent study, we enrolled 122 patients who had AVR using a Trifecta bioprosthesis in the July 2010-June 2011 period. A clinical and echocardiographic in-house follow-up was scheduled. RESULTS: In our series, 14.7% of patients received a 19-mm, 28.7% had a 21-mm, 35.2% had a 23-mm and 21.3% had a greater-size prosthesis. There were no cases of operative mortality or of valve-related complications both early and at follow-up (except one sudden unexplained death). Completeness of the 3-year echocardiographic follow-up was 80% among survivors. The average mean transvalvular gradient (mTVG) at 3 years was 14.2, 10.8, 8.6, 7.1 and 6.8 mmHg (sizes 19 to 27/29, respectively). There was no statistically significant difference between average mTVGs measured immediately after implantation versus at the 3-year follow-up in the overall population. The average peak transvalvular gradient (pTVG) at 3 years was 25, 20, 16.8, 13.9 and 14.4 mmHg (sizes 19 to 27/29, respectively). The average indexed effective orifice area (iEOA) at 3 years was 0.8, 0.9, 1, 1.3 and 1.3 cm²/m² (sizes 19-27, respectively). The rate of moderate patient- prosthesis mismatch (PPM) at 3 years was 15.7%; there were two instances of severe PPM (2.2%). All cases of PPM occurred in the 19, 21 and 23 mm size subgroups. CONCLUSIONS: The Trifecta valve retains its excellent haemodynamic properties at the 3-year follow-up. The rate of PPMis considerably low. [ABSTRACT FROM AUTHOR]

OBJECTIVES To describe the clinical results (both early and at follow-up) of patients currently receiving extracorporeal membrane oxygenation (ECMO) therapy for cardiac and/or pulmonary failure. To assess the effect of indications, clinical presentations and ECMO modalities on early/late clinical outcomes. To identify baseline factors associated with worse survival at follow-up. METHODS We reviewed the prospectively collected data of 325 patients receiving ECMO therapy at a tertiary referral centre during the 2005–2013 period. Follow-up was prospectively conducted by dedicated personnel (average: 84 ± 86 days, 100% complete). Survival was analysed by stratified Kaplan–Meier curves. RESULTS Veno-arterial (VA) ECMO was employed in 80% of cases (due to early graft failure (EGF) in 13% of cases, post-cardiotomy in 29%, primary cardiogenic shock in 42% for miscellaneous aetiologies, other indications in 15.4%) and veno-venous (VV) ECMO in the remainders (adult respiratory distress syndrome). In the VA and VV groups, weaning rates were 59 and 53%, survival at 30th postimplantation day was 44 and 45% and survival at the end of the follow-up was 41 and 45%, respectively. Implantation under advanced life support (ALS) occurred in 15% of cases (26% survival at 30 days). VA patients had a higher rate of thrombotic/haemorrhagic complications and of transfusion of blood products and shorter ventilation time. Worse early and follow-up survival were observed among patients aged ≥65 years, having pH ≤ 7, lactates >12 mmol/l, creatinine >200 μmol/l at implantation or receiving ECMO under ALS. No difference in survival was noted among VA vs VV patients. Patients receiving ECMO for EGF displayed better early and late survival (64% at 30 days and 53% at 6 months) than post-cardiotomy (36 and 34%, respectively), post-acute myocardial infarction (48 and 40%) and the remaining patients (46 and 45%). CONCLUSIONS Despite most critical baseline conditions, ECMO therapy is confirmed useful for the treatment of patients with acute cardiopulmonary failure refractory to conventional treatments. The ECMO modality (VA vs VV), as well as indications to support, identifies different patient profiles and dissimilar outcomes. Preimplantation markers of gravity and end-organ damage are useful in the stratification of expected survival. These may facilitate clinical decision-making and appropriate allocation of hospital resources. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) performed under local anesthesia (LA) is becoming increasingly common. We aimed to compare the clinical outcomes in patients who underwent transfemoral-TAVI under general anesthesia (GA) and LA.Data from 2326 patients in the French Aortic National CoreValve and Edwards 2 (FRANCE 2) registry who underwent transfemoral-TAVI were analyzed. During the study period, the percentage of LA procedures increased gradually from 14% in January 2010 to 59% in October 2011. The clinical outcomes for GA (n=1377) and LA (n=949) were compared. Numerous baseline characteristics differed between the 2 groups, and the use of transesophageal echocardiographic guidance was more common in GA than in LA (76.3% versus 16.9%; P<0.001). Device success and cumulative 30-day survival rates were similar in the 2 groups (97.6% versus 97.0%; P=0.41 and 91.6% versus 91.3%; P=0.69, respectively), whereas the incidence of postprocedural aortic regurgitation≥mild was significantly lower in GA than in LA (15.0% versus 19.1%; P=0.015). The groups were also analyzed using a propensity-matching model, including transesophageal echocardiographic usage (GA [n=401] versus LA [n=401]). This model indicated that there were no significant differences between the 2 groups in the rates of 30-day survival (GA [91.4%] versus LA [89.3%]; P=0.27] and postprocedural aortic regurgitation≥mild (GA [12.7%] versus LA [16.2%]; P=0.19).The less invasive transfemoral-TAVI under LA is preferred in clinical settings and seems to be acceptable; however, the higher incidence of postprocedural aortic regurgitation is emphasized. Therapeutic efforts should be made to reduce such complications during transfemoral-TAVI under LA. [ABSTRACT FROM AUTHOR]

Pulmonary hypertension (PH) is associated with poor prognosis in patients with severe aortic stenosis. The aim of this multicenter study was to describe clinical outcome after transcatheter aortic valve implantation.The FRANCE 2 Registry included all patients undergoing transcatheter aortic valve implantation in France in 2010 and 2011. Patients were divided into 3 groups depending on systolic pulmonary artery pressure (sPAP) estimated in transthoracic echocardiography: group I, sPAP <40 mm Hg (no PH); group II, sPAP 40 to 59 mm Hg (mild-to-moderate PH); and group III, sPAP ≥60 mm Hg (severe PH). Patients were followed up for 1 year. A total of 2435 patients whose pre-transcatheter aortic valve implantation sPAP was reported were included. A total of 845 were in group I (34.7%), 1112 in group II (45.7%), and 478 in group III (19.6%). Procedural success, early complications, and 30-day mortality were statistically similar across sPAP groups. One-year mortality was higher in groups II and III (group I, 22%; group II, 28%; and group III, 28%; P=0.032). Mild-to-moderate and severe PH were identified as an independent factor of all-cause mortality. The major adverse cardiovascular event rates did not differ according to sPAP. New York Health Association functional class improved significantly in all groups.PH (sPAP ≥40 mm Hg) in patients with aortic stenosis undergoing transcatheter aortic valve implantation was associated with increased 1-year mortality especially when severe (sPAP ≥60 mm Hg) but not with increased 30-day mortality, and functional status was significantly improved regardless of PAP level. [ABSTRACT FROM AUTHOR]

Orthotopic heart transplantation (OHT) is a well established and commonly utilized procedure for end-stage heart failure patients. Heterotopic heart transplantation (HHT) is a surgical procedure that allows the graft to be connected to the native heart in a parallel fashion. The main advantage of HHT is to assist the patient's native heart and to maintain circulation in the cases of severe acute rejection. HHT has also been proposed to overcome pulmonary hypertension, to increase the size of the donor pool and to decrease waiting times without increasing morbidity caused by the procedure. However, only a few papers have reported the short- or long-term results of HHT, and most of these studies have included <30 cases. OHT remains the standard technique and is preferable whenever the patient meets the current criteria and a suitable organ is available. HHT is far less useful than in the past because of the major advances in immunosuppression therapy and the development of long-term mechanical circulatory support. This study reviews the origin of HHT and discusses clinical developments, including their advantages and disadvantages. [ABSTRACT FROM AUTHOR]

Background: We evaluate the clinical results of the Carpentier-Edwards supraannular (CE SAV) aortic bioprosthesis at long-term follow-up (over 25 years). Methods: Between 1983 and 1994, 1,002 CE SAV prostheses were implanted. Data were prospectively collected, retrospectively analyzed, and stratified by age groups at the time of surgery (group 1, ≤60 years; group 2, 61 to 70 years; group 3, >70 years), using both the actuarial and the “actual” (cumulative risk) methods. Results: The operative mortality was 11.3% (valve-related in 2 cases). Follow-up included 8,164.09 patient-years (average 13.7 ± 6.6 years, up to 26.9 years). Overall survival at 25 years was significantly higher in group 1 (p < 0.001). Freedom from structural valve deterioration (SVD) at 15 years was 85.9% (actuarial) and 94.8% (actual). Freedom from reoperation for SVD was 91.8% (actuarial) and 97% (actual). There were no significant differences in valve-related endpoints among group 2 and group 3. Death was valve-related in 11.3%. Younger age at surgery was associated with higher incidence but not earlier presentation of SVD. Freedom from any valve-related complication at 15 years was 23.6%, 66%, and 68% in groups 1, 2, and 3 (actuarial), and 38.9%, 76.1%, and 81.2%, respectively (actual) (p = 0.6 among groups 2 and 3). Conclusions: The CE SAV bioprosthesis provides similar outcomes (SVD and reoperation) in patients aged 61 to 70 years and older individuals. Use of a bioprosthesis is justified in patients older than 60 years. Younger patients may be rightfully informed over the expected durability of the prosthesis. [ABSTRACT FROM AUTHOR]