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In recent years, sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve replacement (TAVR) have emerged as viable alternatives to standard surgical aortic valve replacement (AVR) in higher risk patients. We report 7 cases in which SU-AVR and TAVR were used as bailout procedures for each other. Between June 2011 and August 2018, 626 patients underwent SU-AVR with the Perceval S prosthesis, and 588 patients underwent TAVR at the Montreal Heart Institute. Herein, we report the cases of 7 patients who underwent both procedures within a short time frame: 3 patients who underwent SU-AVR with a Perceval prosthesis after a failed TAVR procedure, 3 patients who underwent TAVR after degeneration of a surgically implanted Perceval sutureless prosthesis, and 1 patient who was scheduled for multiple percutaneous interventions-including TAVR, right coronary angioplasty, atrial fibrillation ablation with left atrial appendage occlusion-who suffered a periprocedural complication requiring an emergent surgery, during which a Perceval sutureless prosthesis was deployed. All patients were discharged home alive. Two patients suffered a complete heart block requiring permanent pacemaker implantation. We demonstrate that SU-AVR with the Perceval S prosthesis and TAVR are complementary procedures within the therapeutic armamentarium to treat aortic valve disease in higher risk patients. Specifically, valve-in-valve TAVR is an attractive option in the setting of Perceval prosthesis degeneration, whereas SU-AVR is a useful bailout option in the context of periprocedural failure of a TAVR., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: A strong relationship between high circulating angiopoietin-like 2 (ANGPTL2) levels, a proinflammatory adipokine, and cardiovascular diseases has been reported. Our objective was to determine whether plasma ANGPTL2 and high-sensitivity C-reactive protein (hs-CRP) levels change postoperatively in patients who underwent heart valve surgery and/or coronary artery bypass grafting. We hypothesized that a corrective cardiac surgery would decrease ANGPTL2 levels., Methods: In 47 prospectively recruited patients who underwent coronary artery bypass grafting (n = 16), valve replacement (n = 16), or both (n = 15), we measured plasma ANGPTL2 and hs-CRP levels preoperatively, at 24 hours, at 3 to 5 days (hospital discharge), and at 30 to 90 days (follow-up) after surgery. Mediastinal adipose tissue and distal fragments of the left internal mammary artery (IMA) were harvested during surgery and mRNA expression of inflammatory and senescence markers was assessed using real-time quantitative polymerase chain reaction., Results: ANGPTL2 and hs-CRP levels were elevated 24 hours after surgery and then returned to baseline levels. We noted, however, a dichotomy among patients: compared with baseline, plasma ANGPTL2 levels either significantly decreased (n = 21/47) or increased (n = 26/47) after surgery. In contrast, hs-CRP levels were identical between groups (P = .997). Patients in the increased group were older (P = .002) with a higher systolic blood pressure (P = .038) at baseline. Moreover, changes in ANGPTL2 levels (ΔANGPTL2 = final minus initial levels) positively correlated with mRNA expression of tumor necrosis factor α and interleukin 8 in mediastinal adipose tissue and IMA (P < .05) and with the senescence-associated marker cyclin-dependent kinase inhibitor 1 in IMA (P = .009)., Conclusions: In younger patients with lower levels of tissue inflammation and arterial senescence load, ANGPTL2, but not hs-CRP levels decreased after cardiac surgery, suggesting that circulating ANGPTL2 reflects tissue inflammation and senescence., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Rapid-deployment valves could potentially reduce cross-clamping time and cardiopulmonary bypass time in complex combined procedures and facilitate minimally invasive surgery. This propensity-matched study compared clinical and echographic outcomes between patients undergoing rapid-deployment aortic valve replacement (RDAVR) compared with stented biological aortic valve replacement (SAVR), with or without concomitant procedures. Between 2012 and 2015, 61 consecutive patients (age 70 ± 7 years, European System for Cardiac Operative Risk Evaluation [EuroSCORE] II 2.1%) underwent aortic valve replacement with Intuity prosthesis (Edwards, Irvine, CA) at the Montreal Heart Institute. This group was compared to 1496 consecutive patients (age 74 ± 8 years, logistic EuroSCORE II 2.8%) who underwent SAVR in the same period. After propensity score matching (1:3), 59 patients in the RDAVR group were matched to 177 patients in the SAVR group. Preoperative characteristics and risk scores were similar in matched groups. Cardiopulmonary bypass, cross-clamp, and total surgical times were lower in the RDAVR group compared with the SAVR group (P < 0.001). Within 30 days, 1 patient died in the SAVR group and none died in the RDAVR group (P = 0.31). The need for pacemaker implantation was higher in the RDAVR group, although the difference was not significant (12% vs 5%, P = 0.13). RDAVR patients less frequently required transfusions (P = 0.025) and had a shorter intubation time (P = 0.002). RDAVR facilitates minimally invasive aortic valve replacement and is associated with shorter bypass and cross-clamp times. Moreover, RDAVR compares favorably with SAVR in terms of mortality and outcome variables., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Sutureless aortic valve replacement (AVR) is an emerging alternative to standard AVR in elderly and high-risk patients. This procedure is associated with a high rate of postoperative permanent pacemaker implantation (PPI). The study aim was to assess the impact on the rate of PPI of implanting the Perceval prosthesis without using balloon inflation., Methods: A total of 159 patients who underwent sutureless AVR using the Perceval prosthesis was included. Balloon inflation was used in 132 patients (Balloon group) and not used in the remaining 27 (No-Balloon group). Clinical, echocardiographic and electrocardiographic outcomes were assessed., Results: There was no significant difference in PPI rate between the two groups (26% for Balloon group versus 22% in No-Balloon group; p = 0.700). Balloon inflation had no significant impact on the incidence of paravalvular leaks (p = 0.839), or on the need to return to cardiopulmonary bypass (CPB) intraoperatively due to paravalvular leak or unsatisfactory deployment (p >0.999). Mean and peak transaortic pressure gradients were similar between the two groups (p = 0.417 and p = 0.522, respectively). Cross-clamp and CPB times were shorter in the No-Balloon group (49.6 ± 15.9 min versus 61.1 ± 25.6 min and 64.1 ± 26.3 min versus 79.6 ± 35.4 min, respectively; p = 0.027 and p = 0.012, respectively)., Conclusions: The two groups had similar postoperative PPI rates. Implanting the Perceval prosthesis without balloon inflation is safe and had no impact on paravalvular leaks, intraoperative complications or hemodynamic results. Reductions in aortic cross-clamp time and CPB time were observed when the balloon was not used.

Background: Sutureless self-expandable aortic bioprostheses rely on radial forces for stabilization, raising concern that these devices may increase the risk of postoperative conduction disease. The purpose of this study was to determine the incidence of conduction disorders after sutureless aortic valve replacement (AVR) with the Perceval S (Sorin Group, Saluggia, Italy) bioprosthesis., Methods: Between June 2011 and March 2013, 108 consecutive patients underwent sutureless AVR with the Perceval S prosthesis. Six patients (6%) had a permanent pacemaker (PPM) preoperatively and were excluded from the present study. Mean electrocardiographic follow-up was 14.6 ± 6.0 months., Results: Mean age was 79.2 ± 4.8 years (52% female). During the postoperative period, 34 patients (34%) had first-degree atrioventricular block, 2 (2%) had Mobitz-II atrioventricular block, and 16 (16%) had complete atrioventricular block. New-onset left bundle branch block and right bundle branch block were observed in 33 patients (33%) and 22 patients (22%), respectively. Inhospital postoperative PPM implantation was required in 23 patients (23%). Preoperative aortic valve area, age more than 85 years, and preoperative right bundle branch block were found to be independently associated with inhospital PPM implantation or new-onset postoperative conduction disorder. At follow-up, 3 more patients (3%) underwent PPM implantation. The cumulative incidences of PPM dependency and ventricular pacing more than 25% of the time were 18% ± 11% and 21% ± 10%, respectively, at 18 months., Conclusions: In the present study, the postoperative PPM implantation rate (23%) after sutureless AVR with the Perceval S prosthesis was high. Surgical strategies aimed at mitigating this risk should be further investigated., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a "J" ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p<0.001) was registered in the DNC group. In conclusion, the DNC is easy to use and safe during minimally invasive AVR, providing a myocardial protection at least equivalent to our SBC, improved surgical efficiency, minimal cost and less blood glucose perturbations.

Background: Freedom from structural valve deterioration (SVD) at 15 years with the Carpentier-Edwards (CE) Perimount pericardial valve in the aortic position was 60% in patients aged <60 years compared to 90% and 99% in patients aged 60-70 years and >70 years, respectively. The study aim was to focus on the causes of SVD requiring valve explant according to three different age groups: <60 years, 60-70 years, and >70 years. The short- and longterm clinical results of the patient cohort, followed for 25 years, are presented., Methods: A retrospective review was made of 89 patients among 2,405 who had undergone elective aortic valve replacement (AVR) with CE pericardial valves between November 1981 and March 2011, and in whom the prosthesis explant was secondary to degeneration of the valve., Results: Patients aged >70 years experienced more late complications such as endocarditis (p = 0.02) and mortality (p = 0.02). Following surgery for prosthesis explant and replacement, 39 of the 89 patients (44%) died. The average time to postoperative mortality in that population was 2.8 ± 3.6 years. On combining all causes of SVD, earlier dysfunction was noted in patients aged >60 years, and late dysfunction in patients aged <60 years (p = 0.003). However, there was no significant difference between groups in the process of degeneration (either calcification, pannus, tear, thrombus, endocarditis) (p = NS). No predictors were found of early and late dysfunction., Conclusions: Patients aged >60 years in whom a CE Perimount valve was implanted in the aortic position were more prone to early degeneration of their valve and related mortality. However, no predictors were found of early degeneration of the valve in that patient population.

Objective: Aortic valve replacement (AVR) in patients with a small aortic annulus is a challenging problem. The objective of this study was to compare 4 surgical approaches in terms of hemodynamics and perioperative outcomes., Methods: A retrospective single-center study included 351 consecutive patients with a small aortic annulus (≤21 mm) who underwent aortic valve surgery between January 2007 and December 2014. Surgical techniques included standard AVR in 259 (74%) patients, aortic root enlargement in 20 (6%), implantation of a stentless bioprosthesis in 23 (6%), and sutureless AVR in 49 (13%)., Results: Three hundred and eleven (89%) patients were female. The mean Logistic EuroSCORE II varied significantly among the groups and ranged from 6.5% ± 5.4% in the standard AVR group to 9.2% ± 4.7% in the stentless group. Early mortality occurred in 26 (7%) patients. Patients in the stentless group had the lowest aortic valve mean gradients on predischarge transthoracic echocardiography (10.9 ± 6.2 mm Hg; P < .001). In the stented group, the Trifecta prosthesis displayed the lowest postoperative mean transaortic gradient (10.3 ± 3.6; P < .001) with no severe prosthesis-patient mismatch. Postoperative gradients of the sutureless group were comparable with stented prostheses., Conclusions: In our study, stentless AVR and Trifecta bioprostheses had the best hemodynamic outcomes. The Perceval sutureless prosthesis provides reasonable hemodynamic performance and is a safe alternative., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Bicuspid aortic valve (BAV) is generally considered to be a contraindication to sutureless aortic valve replacement (AVR). The aim of this study was to evaluate the feasibility and perioperative outcomes of this technique in patients with BAV., Methods: From June 2011 to January 2014, a total of 25 patients who underwent sutureless AVR had documented BAV. Thirteen patients (52%) had median sternotomy, and 12 patients (48%) a minimally invasive approach., Results: The study population included 17 (68%) men with a median age of 77.8 ± 5.4 years. The mean EuroSCORE II was 3.4% ± 2.6%. Concomitant procedures included coronary artery bypass grafting in 8 patients (32%), 2 AVRs (8%), 1 mitral valve repair (4%), 1 septal myomectomy (4%), and 1 atrial septal defect closure (4%). The mean transaortic valve gradient decreased from 49.4 ± 15.7, to 14.5 ± 5.4 mm Hg postoperatively. The mean aortic valve area increased from 0.78 ± 0.18, to 1.75 ± 0.43 cm(2) postoperatively. Five patients (20%) suffered from atrioventricular block that required permanent pacemaker implantation. Two patients (8%) suffered a stroke. No major paravalvular leakage occurred, and no postoperative valve migration. In-hospital mortality occurred in 1 patient (4%). The mean intensive care unit length of stay was 3 ± 2 days postoperatively., Conclusions: This study demonstrates that a sutureless aortic valve can be deployed in patients with BAV without increasing the risk of paravalvular leakage. BAV should not be considered a contraindication to sutureless AVR., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sutureless aortic valve replacement (AVR) has recently been introduced as an alternative to standard AVR in elderly high-risk surgical patients. The purpose of this study was to report the early Canadian experience with sutureless AVR., Methods: A Canadian multicenter study included 215 consecutive patients from 6 centres who underwent sutureless AVR using the Perceval S bioprosthesis (Sorin Group, Saluggia, Italy) between June 2011 and May 2013. Perioperative clinical and echocardiographic outcomes were assessed in all patients., Results: Mean age was 79 ± 6 years, and 116 patients (54%) were women. Concomitant procedures included coronary artery bypass grafting in 86 patients (40%), multiple valve procedures in 24 (11%) patients, and septal myectomy in 9 (4%) patients. A full sternotomy was used in 173 cases (80%), a minithoracotomy in 23 (11%) cases, and a partial sternotomy in 19 (9%) cases. Nineteen cases (9%) were redo procedures. For isolated AVR, mean aortic cross-clamp time was 41 ± 12 minutes. In-hospital mortality occurred in 9 patients (4%). No postoperative valve migration was reported. A total of 37 patients (17%) underwent postoperative implantation of a permanent pacemaker, including 20 patients (9%) who had complete atrioventricular block. Postoperative stroke occurred in 7 patients (3%). Echocardiographic evaluation demonstrated well-seated valves with no significant (2+) valvular or paravalvular aortic insufficiency and a mean aortic gradient of 13 ± 6 mm Hg., Conclusions: Sutureless AVR using the Perceval S prosthesis is safe and reproducible and results in short operative times. Echocardiographic results are encouraging, with low gradients and no paravalvular aortic insufficiency. However, in this series, sutureless AVR was associated with a high risk of permanent pacemaker implantation., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: To review our experience with sutureless aortic valve replacement (AVR) in the setting of concomitant mitral valve (MV) surgery and discuss the technical considerations., Methods: Between January 2012 and March 2013, 10 patients underwent sutureless AVR with the Perceval prosthesis in the setting of concomitant mitral disease. Five patients underwent MV repair, 4 underwent MV replacement, and 1 had a previously implanted mechanical mitral prosthesis., Results: The median age was 79 years and 7 patients (70%) were male. Median logistic EuroSCORE II was 6.2%. All valves were successfully implanted with no 30-day mortality. There was no residual aortic paravalvular leak. Two patients had from third-degree atrioventricular block requiring permanent pacemaker implantation. At a mean follow-up of 8±4 months (range, 2-16 months), the overall survival was 80% with 2 non-valve-related deaths and the mean transaortic gradient and aortic valve area had improved to 11.1±4.6 mm Hg and 1.5±0.3 cm2, respectively. There was no evidence of mitral dysfunction in any patient., Conclusions: In our experience, sutureless AVR in the setting of concomitant mitral surgery is a feasible and reproducible procedure. Elderly patients undergoing multiple valve surgery present a higher operative risk, therefore extending the indication for sutureless AVR to patients with concomitant mitral disease could greatly benefit this specific population., (Copyright © 2014. Published by Elsevier Inc.)

Objective: Functional ischemic mitral regurgitation (FIMR) increases mortality independently of the baseline characteristics and ventricular function. The effect of treating FIMR with annuloplasty is unclear when mitral regurgitation is moderate. Myocardial revascularization alone has been shown to improve mitral valve function., Methods: We randomized 31 patients with moderate (grade 2-4) FIMR to receive either coronary artery bypass grafting (CABG) alone or CABG plus downsizing mitral ring annuloplasty. The patients were followed up for clinical outcomes and echocardiographic assessment of mitral valve function and left ventricular dimensions at 3 and 12 months. Clinical improvement was assessed using the Minnesota quality-of-life questionnaire, 6-minute walk test, and brain natriuretic peptide levels., Results: The clinical course was similar in the 2 groups of patients during the study period. FIMR was perfectly corrected intraoperatively in the ring group. Echocardiographic follow-up at 3 months showed no difference in the FIMR grade between the 2 groups (66% less than grade 2 in the CABG alone and 86% in the CABG plus ring group; P = .316). The improvement in the CABG alone group was even more marked at 12 months (85% less than grade 2 in the CABG group and 85% in the CABG plus ring group). The left ventricular ejection fraction was significantly better at 3 months in the CABG alone group, although at 12 months, the left ventricular ejection fraction in the 2 groups had improved similarly., Conclusions: Although initially effective at reducing moderate FIMR, the addition of a ring did not change the clinical course after CABG surgery. At 12 months, no echocardiographic difference was found in terms of residual mitral regurgitation, left ventricular dimensions and function, or clinical outcomes., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: With improved durability of contemporary bioprostheses, surgeons are now recommending biologic valves in younger patients. However, long-term outcomes of patients younger than 60 years old undergoing biologic aortic valve implantation are not well known., Methods: From November 1991 to March 2011, 144 patients less than 60 years old underwent aortic valve replacement (AVR) with Carpentier-Edwards pericardial valves (Edwards Lifesciences, Irvine, CA). Mean follow-up was 10±4 years. Outcomes were reported according to published guidelines., Results: Seventy-five percent of patients were male, with a mean age of 51±9 years. Actuarial survival rates including early deaths were 89%±3%, 79%±4%, and 57%±6% after 5, 10, and 15 years of follow-up, respectively. Survival of patients was comparatively lower than a gender- and age-matched general population at all time points. The freedom from major adverse cardiac events (myocardial infarction, heart failure, hemorrhage, thromboembolic event, and endocarditis) was 89%±3%, 87%±3%, and 75%±6% at 5, 10, and 15 years after surgery. The freedom rate from prosthetic valve dysfunction was 97%±2%, 84%±4%, and 57%±6% at 5, 10, and 15 years after surgery. Patients with a diagnosis of structural valve deterioration (29 of 37, 78%) underwent reoperation 11±5 years after the initial valve replacement with no perioperative mortality., Conclusions: In patients younger than 60 years undergoing AVR, the Carpentier-Edwards Perimount bioprosthesis provided satisfactory clinical outcomes. However, late survival was inferior to an age- and gender-matched population. Structural valve deterioration and the need for reintervention were common late after implantation, but reoperation for prosthetic valve dysfunction was associated with a very low risk of mortality., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The impact of a transvalvular pacemaker lead on the progression of tricuspid regurgitation (TR) after tricuspid valve (TV) repair has not been clearly demonstrated. The aim of this study was to evaluate the presence of a transvalvular pacemaker lead as a risk factor for TR after TV repair in a large patient cohort., Methods: A retrospective review included 791 patients who underwent TV repair at our institution from 1977 to 2008. All patients bearing a transvenous pacemaker implanted either preoperatively or within 30 days of surgery were categorized in the "PACE" group (n=176), the remaining patients were categorized in the "NO PACE" group (n=615)., Results: Mean age was 61±11 years, and 575 patients (73%) were female. Mean follow-up was 5.8±5.5 years. Operative mortality was 13%. At discharge, TR severity was 3+ or greater in 10% and 15% of patients in the PACE and NO PACE groups, respectively (p=0.19). Multivariate analysis using a Cox regression model identified the presence of a transvenous pacemaker as an independent risk factor for recurrence of TR 2+ or greater (hazard ratio [HR] 1.60, p=0.008) and TR 3+ or greater (HR 1.47, p=0.046) at last follow-up. The presence of a transvenous pacemaker was also a significant independent predictor of late mortality (HR 2.12, p=0.02)., Conclusions: In patients undergoing tricuspid valve surgery, the presence of a transvenous pacemaker implanted either preoperatively or within 30 days of surgery is associated with a significantly increased risk of persistent or recurrent TR at late follow-up., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the perioperative predictors of long-term mortality after aortic valve replacement (AVR). The authors hypothesized that perioperative variables are more important predictors of mortality than patient-prosthesis mismatch (PPM)., Design: A retrospective study of prospectively collected data., Setting: A tertiary care university hospital., Participants: One-hundred-ninety-nine adult patients who underwent AVR., Interventions: After Research and Ethics Committee approval, the authors studied consecutive adult patients that underwent AVR in 1999 from the time of procedure to 5 years later. Demographic data, hemodynamic profile obtained after the induction of anesthesia, and perioperative data were analyzed. Primary endpoint was 5-year survival., Measurements and Main Results: Actuarial survival rate was 95.98%, 91.46%, and 81.91% at 30 days, 1 year, and 5 years, respectively. On univariate analysis, patients who died were significantly older (p<0.0001), had pulmonary hypertension (PHT), longer cardiopulmonary bypass (CPB) (p = 0.0001) and cross-clamping duration (p = 0.003), more frequent return to CPB (p = 0.036), or the use of an intra-aortic balloon pump to wean from CPB (p = 0.015). PPM was not related to 5-year mortality (p = 0.0649). Using Cox survival analysis, the only independent risk factors related to 5-year mortality after AVR were PHT using the mean arterial pressure-to-mean pulmonary artery pressure ratio (HR: 1.39, 95% CI 1.01-1.92, p = 0.0413) and the presence of complex separation from CPB (HR: 2.66, 95% CI 1.08-6.50, p = 0.0324)., Conclusions: In patients undergoing AVR, 5-year survival was mostly related to the severity of PHT and intraoperative factors, mainly complexity of weaning from CPB., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Transcatheter aortic valve implantation (TAVI) is a relatively new technology for the treatment of severe and symptomatic aortic valve stenosis. TAVI offers an alternative therapy for patients unable to be treated surgically because of contraindications or severe comorbidities. It is being rapidly dispersed in Canada, as it is worldwide. The objective of this article is to present our recommendations for the use of TAVI, based on a multidisciplinary evaluation of recently published evidence. We systematically searched and summarized published data (2008-2011) on benefits, risks, and cost-effectiveness of TAVI. We also examined ethical issues and organizational aspects of delivering the intervention. We discussed the soundness and applicability of our recommendations with clinical experts active in the field. The published TAVI results for high-risk and/or inoperable patients are promising in terms of survival, function, quality of life, and cost-effectiveness, although we noted large variability in the survival rates at 1 year and in the frequency of important adverse outcomes such as stroke. Until more data from randomized controlled trials and registries become available, prudence and discernment are necessary in the choice of patients most likely to benefit. Patients need to be well-informed about gaps in the evidence base. Our recommendations support the use of TAVI in the context of strict conditions with respect to patient eligibility, the patient selection process, organizational requirements, and the tracking of patient outcomes with a mandatory registry., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence., Methods: A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women., Results: Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001)., Conclusion: Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background and Aim of Study: This study evaluated the long-term outcome of linear, endocardial, radiofrequency (RF) atrial ablation for the treatment of atrial fibrillation (AF) concomitantly to open-heart procedures for acquired cardiac organic disease., Methods: A saline-irrigated "pen-like" RF ablation catheter (Cardioblate(®), Medtronic, Minneapolis, MN, USA) was used to perform endocardial lines of conduction block in 293 patients with AF who underwent open-heart procedures between September 2000 and February 2008., Results: Patients (age of 65 ± 11 years) underwent left atrial ablation for permanent (44%), paroxysmal (51%), or undetermined (4.4%) AF. Maintenance in sinus rhythm (SR) at discharge and at the end of follow-up (average 3.3 ± 1.2 years) was observed in 52% and 71% of patients, respectively. Preoperative type or duration of AF did not influence the results (p = NS). Multivariate analysis with a logistic regression model showed left atrial diameter and increasing age were independent predictors of recurrent AF. In this study, return to SR did not influence survival., Conclusions: This study confirmed that concomitant intraoperative RF ablation is an effective technique to restore long-term SR after cardiac surgery in patients with preoperative AF but does not influence long-term survival. , (© 2010 Wiley Periodicals, Inc.)

Background and Aim of the Study: The purpose of this investigation was to evaluate both long-term functional status and quality of life (QoL) following valvular replacement surgery in octogenarians. The influence of gender and discharge location was also examined., Methods: A total of 133 patients (age range: 80-89 years) who underwent surgical valve replacement between January 2003 and December 2006 was identified. Two questionnaires evaluating QoL (SF-12v2 and MLHFQ), as well as a demographic questionnaire, were sent to these patients., Results: The response rate was 64.4%. Among the participants, the mean NYHA functional class improved from 2.7 to 1.4 after surgery. Men showed results similar to those of the age-matched general Canadian population on the mental and physical component scales of the SF-12v2. The data on women were similar to those of the general population on the physical component scale, but their scores were significantly lower on the mental component scale of the SF-12v2. Further analysis of the results comparing discharge location for each gender revealed that women discharged to a convalescence resource had significantly better QoL scores than those discharged to home with regards to the physical component scale of the SF-12v2, the total score of the MLHFQ, and the physical dimension score of the MLHFQ., Conclusion: Patients aged > or = 80 years benefit from heart valve replacement surgery in terms of both QoL and functional status. Women may be at increased risk of a decline in their emotional well-being and, postoperatively, may benefit more from convalescence than from discharge to home.

Background: Surgically addressing moderate mitral regurgitation (MR) at the time of aortic valve replacement (AVR) for aortic stenosis remains uncertain. The purpose of this study was to examine the change in moderate (2+) or moderate-severe (3+) MR after isolated AVR for aortic stenosis to determine preoperative factors predictive of improvement in MR., Methods: Using an institutional databank of prospectively collected data, all patients undergoing isolated AVR for aortic stenosis with moderate (2+) to moderate-severe (3+) MR between 1994 and 1996 at the Montreal Heart Institute were evaluated., Results: Eighty patients with preoperative and postoperative transthoracic echocardiographic follow-up were identified. Preoperative MR was moderate (2+) in 78 patients (97.5%) and moderate-severe (3+) in 2 patients (2.5%). Mitral regurgitation was classified as rheumatic (32%), ischemic (32%), functional (21%), and myxomatous (15%). At 1-year follow-up transthoracic echocardiography, MR improved by 1 or 2 grades in 29 patients (35%), was unchanged in 44 (55%), and worsened in 7 (10%). On multivariate analysis, isolated ischemic and functional MR were the only preoperative factors predictive of MR improvement after AVR (p = 0.01): 54% of ischemic and 44% of functional MR patients showed improvement in MR after AVR compared with 23% of rheumatic and 17% of myxomatous MR patients., Conclusions: Etiology of MR was a significant prognostic factor for improvement in MR grade. Since there was little improvement in the rheumatoid and myxomatous group, replacement or repair should strongly be considered. For functional and ischemic mitral regurgitation, a surgical correction should be performed on an individual basis.

Objective: This study was designed to assess the prevalence, characteristics, effect, and predictors of chronic postoperative pain 1 to 3 years after cardiac surgery., Methods: Seven hundred thirty-six patients who underwent coronary artery bypass surgery, valve replacement, or both between 1999 and 2002 were mailed questionnaires (response rate, 79% [n = 579]; 564 questionnaires were analyzed), and their hospital records were reviewed., Results: Nonanginal chronic postoperative pain affected 23% of patients. Eighty percent of them had pain 1 or more days per week. The worst and usual pain intensities during the week preceding the survey reached moderate to severe levels (> or =4/10) in more than half of the patients. Thirty-one percent of the patients with chronic postoperative pain had taken analgesic pain medication during that week. During the same period, pain interfered significantly (> or =4/10) with various aspects of patients' daily life (eg, general activity level: 39.1%, sleep: 36.7%). When patients with and without chronic postoperative pain were compared, the former group had significantly higher levels of anxiety and depression, and they perceived their health-related quality of life as more compromised. Multivariate logistic regression analysis revealed that greater analgesic needs in the first few days postoperatively were associated with an increased risk of chronic postoperative pain. The only other significant factor was the time elapsed from surgical intervention to survey: the longer it was, the less likely the patients were to report chronic postoperative pain., Conclusion: The prevalence, severity, and effect of chronic postoperative pain after cardiac surgery should not be underestimated. Longitudinal prospective studies are needed to further evaluate risk factors, including inadequate postoperative pain relief in the acute period.

Background and Aim of the Study: Tricuspid regurgitation secondary to pulmonary hypertension due to left-sided heart valve lesions is common. Here, the results are reported of 25 years' experience with three surgical techniques; the De Vega semicircular annuloplasty, the Bex flexible linear reducer, and the Carpentier-Edwards prosthetic ring annuloplasty., Methods: Between 1976 and 2002, 463 patients underwent 478 tricuspid annuloplasty procedures to correct valve regurgitation during associated left-sided valve surgery. Patients were followed prospectively at the Montreal Heart Institute Valve Clinic., Results: A total of 107 patients (23%) underwent the De Vega semicircular annuloplasty, 267 (58%) the Bex flexible linear reducer, and 89 (19%) the Carpentier-Edwards prosthetic ring annuloplasty. Excluding 30-day mortality, the mean 5-, 10- and 15-year patient survival was 82+/-4%, 58+/-6% and 30+/-6% respectively after the De Vega semicircular annuloplasty, 76+/-3%, 54+/-4% and 36+/-6% respectively after the Bex flexible linear reducer, and the mean five-year patient survival was 88+/-4% after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.65, for comparison of the three survival curves). The mean freedom rate from tricuspid repair failure (clinical right heart failure, redo annuloplasty, tricuspid valve replacement at follow up) was 95+/-3%, 93+/-3% and 72+/-8% at 5, 10 and 15 years respectively after the De Vega semicircular annuloplasty, and 97+/-1%, 87+/-4% and 66+/-9% after the Bex flexible linear reducer. The mean freedom rate from repair failure was 94+/-3% at five years after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.18 for comparison of the three freedom from failure curves)., Conclusion: All three techniques of tricuspid valve repair resulted in a low rate of failure, and in good patient survival at long-term follow up.

Background: Whether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves., Methods: All 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed., Results: Thirty patients averaging 62+/-10 years of age underwent primary triple valve surgery and 43 patients averaging 60+/-10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80%+/-7%, 75%+/-8%, and 41%+/-15%, and 70%+/-7%, 57%+/-9%, and 50%+/-10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87%+/-6% and 95%+/-3% in primary and reoperative patients, respectively, 5 years following surgery., Conclusions: Triple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.