Early Results of Simultaneous Aortic Valve and Ascending Aorta Surgery: 16-year Single-Center Experience

An 80-year-old woman was admitted to our institution because of shortness of breath (New York Heart Association grade III) and stable angina pectoris (Canadian Cardiovascular Society [CCS] grade II). Two years ago, the patient had a posterior wall infarction successfully treated by percutaneous coronary intervention and stent implantation. A low-gradient aortic stenosis with an aortic valve area of 1.1 cm2 was also diagnosed but was considered to be clinically insignificant at the time. Because of the progression of symptoms within the last 2 years, a re-evaluation of coronary and aortic valve disease was performed. Coronary angiography revealed a 1-vessel coronary disease with a patent stent in the right coronary artery without any evidence of restenosis. The left ventricular ejection fraction was only moderately impaired (55%). However, the aortic valve area, as determined invasively, had decreased to 0.5 cm2. This was confirmed by echocardiography; the cusps of the aortic valve were calcified and their motion was impaired (Supplemental Data Movie 1). On the basis of these findings, the necessity of an aortic valve replacement was discussed. However, because the patient was anxious and refused conventional aortic valve …

Introduction: The Euro Heart Survey on Valvular Heart Disease reports that approximately 17% of patients with valvular heart disease are affected by two or more valves simultaneously. The most common combination requiring simultaneous surgery is aortic and mitral valve surgery. This procedure remains highly demanding for all surgical teams, even today. The primary focus of this study is to present, for the first time, the early postoperative results of simultaneous aortic and mitral valve surgery at our clinic. We aim to compare our outcomes with those reported by other cardiovascular surgical centers, with a strong emphasis on patient well-being and survival rates. Materials and Methods: This is a retrospective study that included adult patients who underwent simultaneous aortic and mitral valve surgery between January 2007 and December 2023 at the Cardiac Surgery Service, UHC "Mother Theresa", Tirana, Albania. The Data collection was performed using operating room registers and hospital medical records. Demographic, clinical, and non-clinical data were gathered for each patient before, during, and after the surgery. Results: This study included 121 patients, comprising 55 males (45.5%) and 66 females (55.5%). The average age of the study population was 56.41 ± 10.35 years. Most patients underwent elective surgery (111, 91.7%), while 10 (8.3%) were urgent surgical cases. Aortic valve regurgitation was the most prevalent pathology, affecting 58 patients (47.9%). The hospital mortality rate was 6.6% (8 patients). The most common postoperative complications included low cardiac output (17.4%), conduction disturbances requiring permanent pacemaker implantation (8.3%), new-onset atrial fibrillation (8.3%), and postoperative hemorrhage (5.8%). Conclusions: Our study on simultaneous aortic and mitral valve surgery at our clinic has demonstrated satisfactory early outcomes, including low rates of early mortality and major postoperative complications. These findings offer valuable insights for the medical community and contribute to the ongoing discourse on cardiac surgery outcomes.

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Aortic valve replacement surgery is the only available treatment option able to improve survival in patients with symptomatic and severe aortic valve stenosis. Without surgical intervention, patients with symptomatic dyspnea and severe aortic valve stenosis have a median survival less than 2 years. In an ideal, patient-centered healthcare system, the decision whether to undergo risky yet potentially life-prolonging surgery should not only reflect judicious application of the evidence of safety and efficacy of the surgery, but it also should be consistent with the patient’s clinical and personal contexts, and their goals, values, and preferences for life and healthcare. Article see p 533 The report by Bach et al1 is the latest in their series of investigations to uncover why cardiac valve replacement surgery is underused among eligible candidates. In this report, they seek explanations among patient, clinician, and hospital-level characteristics and suggest the following hypothesis: clinicians, particularly cardiologists, are making apparently inconsistent judgments as to which patients should be referred to cardiac surgeons for consideration of aortic valve replacement. Among 191 patients with severe aortic valve stenosis who did not undergo cardiac surgery, a cardiologist evaluated 182 (95%), but referred only 57 (30%) to a cardiac surgeon. In this editorial, we will place this finding in the context of the evolving field of shared decision-making and suggest how this focus could improve the quality of care delivered to patients with valvular heart disease. Shared decision making is a 3-step process.2 The first step involves knowledge transfer. In its idealized form, shared decision making requires symmetrical and bidirectional exchange of information between patients and clinicians. This exchange aims to identify and distinguish the available options under consideration, including the option of no treatment. The other 2 steps require the patient and clinician to (1) actively engage in deliberating (ie, …

Robotic aortic valve replacement

Developmental efforts to achieve percutaneous catheter-based therapies for cardiac valve repair and replacement have advanced rapidly over the past several years. A variety of methods to treat mitral regurgitation (MR) and to replace aortic and pulmonic valves have already been successfully employed in patients. These innovative clinical transcatheter valve therapies were anticipated more than a decade ago by creative experimentalists who helped develop predicate techniques in animal models. For example, in 1992, a catheter-delivered ball-in-cage prosthetic aortic valve was implanted in a canine model by Pavcnik1 and a stent-mounted bioprosthetic valve was placed by Andersen, who used a retrograde transarterial approach in a swine model.2 Clearly, the catheter-based technologies used in clinical studies today in patients with aortic stenosis were derived from the fusion of known successful aortic valve replacement (AVR) surgical devices and adaptive interventional modalities, first studied in experimental animal models. Similarly, approaches for transcatheter treatment of MR have also borrowed heavily from preexisting and accepted surgical techniques, such as the edge-to-edge leaflet coaptation technique and reduction ring mitral annuloplasty.3 Importantly, recognition that the coronary sinus parallels the mitral annulus has spurred unique catheter-based transvenous approaches to treat MR by indirectly reducing mitral annular dimensions.4 Because many of the new percutaneous approaches to valve therapy have been developed by surgeons, a collaboration has emerged between thoughtful surgeons and interventionalists, combining skill sets and experiences to accelerate the developmental pathways of less-invasive transcatheter valve therapies. Growing recognition exists that percutaneous alternatives to surgical therapies are required in some patient subgroups with valvular heart disease. Among patients with either mitral and/or aortic valve disease, an expanding population of elderly patients with significant comorbidities may benefit from traditional surgical methods, but these methods are associated with unacceptable perioperative mortality or prolonged postoperative recoveries. In the EuroHeart Survey …

Survey Reported Participation in Cardiac Rehabilitation and Survival After Mitral or Aortic Valve Surgery

Background and objective:It is not uncommon that patients requiring valve surgery have several simultaneous valvular dysfunctions. Combined aortic and mitral valve surgery is the most common form of double-valve surgery. The aim of this study was to analyze and present the outcomes of simultaneous aortic and mitral valve surgery in a single center in a real-life setting.Methods:The study population consisted of 150 patients operated in the Kuopio University Hospital from 2004 to 2020. All patients undergoing concomitant mitral and aortic valve surgery were included. Four groups were formed based on either the etiology or pathophysiology of the valvular dysfunction. The most common combination was mitral regurgitation with aortic regurgitation (n = 72, 48%), followed by mitral regurgitation with aortic stenosis (n = 37, 25%), endocarditis (n = 29, 19%), and mitral stenosis with aortic regurgitation or stenosis (n = 12, 8%). Concomitant coronary artery revascularization was performed in 37 (25%) patients and tricuspid valve repair in 26 (17%) patients.Results:Operative mortality was 2% and 30-day mortality was 7%. Overall survival was 86%, 78%, and 61% in 3, 5, and 10 years, respectively. Patients with endocarditis were significantly more morbid, and more often than other patients had to undergo an emergency operation. There were no significant differences between the groups in terms of early and late survival. In the overall cohort, the EuroSCORE II value, increased pulmonary artery pressure, decreased glomerular filtration, and length of the operation displayed a negative correlation with survival.Conclusions:Despite the challenging nature of multivalvular heart disease, surgery is a safe method of treatment with good short- and long-term outcomes.

Case presentation: A 66-year-old man is referred to a cardiologist for the evaluation of a heart murmur. The patient claims to be entirely asymptomatic, although his wife notes that he has decreased his physical activity over the past two years because he is “getting old.” At physical examination, his blood pressure was 120/70 mm Hg; pulse, 80 bpm; respiration, 13 breaths per minute; and temperature, 99.0°F. Cardiovascular examination revealed normal central venous pressure. His carotid upstrokes were reduced in volume and delayed in upstroke. Cardiac examination revealed a forceful sustained apical impulse in its normal position. There was a 3/6 late-peaking systolic ejection murmur heard at the right upper sternal border radiating to the neck. The rest of the physical examination was unremarkable. Echo-Doppler evaluation revealed an ejection fraction of 0.60, a left ventricular free wall thickness of 1.3 cm, and a peak transaortic flow velocity of 4.5 m/s. How should this patient be managed? Should he undergo aortic valve replacement now? Should he undergo longitudinal follow-up to monitor progression of his aortic stenosis? Over the past 40 years, diagnostic techniques, substitute cardiac valves, and valve implantation surgery have undergone continued improvement, reducing the risk of the valve replacement and enhancing its benefits. Thus, the risk-benefit analysis of valve surgery has tilted in favor of increasingly early intervention for valve disease. The following is a summary incorporating this concept into the current strategy for managing patients with aortic stenosis such as the one described above. The patient with severe aortic stenosis who presents with symptoms represents the most straightforward management strategy for the disease. Survival is nearly normal until the classic symptoms of angina, syncope, or dyspnea develop.1 However, only 50% of patients who present with angina survive 5 years, whereas 50% survival is 3 years for patients who …

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Chronic Severe Aortic Regurgitation: Should We Lower Operating Thresholds?

ObjectiveThis study investigated the morphological and functional characteristics of the aortic valve and the left ventricular (LV) systolic functional parameters and myocardial mass related to the severity of myocardial fibrosis (MF) in patients with severe aortic valve stenosis (AS).Materials and MethodsWe retrospectively enrolled 81 patients (48 men; mean age: 59±12 years) with severe AS who underwent transthoracic echocardiography (TTE), cardiac computed tomography (CCT), and cardiovascular magnetic resonance (CMR) within 1 month and subsequent aortic valve surgery. Degree of MF was determined on delayed contrast-enhanced CMR with visual sub-segmental analysis-based quantification and was classified into three groups (no, mild, and severe) for identifying the differences in LV function and characteristics of the aortic valve. One-way ANOVA, Chi-square test or Fisher’s exact test were used to compare variables of the three groups. Univariate multinomial logistic regression analysis was performed to determine the association between the severity of MF and variables on imaging modalities.ResultsOf 81 patients, 34 (42%) had MF (mild, n = 18; severe, n = 16). Aortic valve calcium volume score on CCT, aortic valve area, LV mass index, LV end-diastolic volume index on CMR, presence of mild aortic regurgitation (AR), transaortic mean pressure gradient, and peak velocity on TTE were significantly different among the three groups and were associated with severity of MF on a univariate multinomial logistic regression analysis. Aortic valve calcium grade was different (p = 0.008) among the three groups but not associated with severity of MF (p = 0.375).ConclusionsA multi-imaging approach shows that severe AS with MF is significantly associated with more severe calcific AS, higher LV end-diastolic volume, higher LV mass, and higher prevalence of mild AR.

Concomitant atrial fibrillation ablation during aortic valve and aneurysm surgery

Objective: We aimed to evaluate recent trends and outcomes of thoracic aortic intervention in comparison to isolated Aortic Valve Surgery (AVR) in patients with a Bicuspid Aortic Valve (BAV). Methods: Patients with BAV from the National Inpatient Sample (2009-2020) who underwent thoracic aortic and/or aortic valve surgery were identified. Covariates included age, sex, aortic aneurysm, dissection, concomitant comorbidities, concomitant surgeries, insurance, and hospital status. A sensitivity analysis was performed in patients without isolated aortic surgery, endocarditis, aortic dissection, or non-elective admission. Results: There were 122,104 patients with BAV, of which 38,973 underwent direct aortic surgery with or without AVR while 83,129 underwent isolated AVR. The proportion of AVR decreased from 68% in 2009/2010 to 61% in 2019/2020, with a peak of 82% in 2015/2016. In aortic surgery patients, mortality risk increased by 86% (aOR:1.86, CI:1.29-2.69), with an independent increased risk of mortality for females by 35% (aOR:1.35, CI: 1.04-1.73), aortic dissection by 5-fold (aOR:5.10, CI:3.06-8.48), and concomitant cardiac surgery by 101% (aOR:2.01, CI:1.55-2.63). After excluding patients for the sensitivity analysis, female sex was no longer associated with higher mortality risk. In-hospital complications such as stroke, sternal wound complications, bleeding, cardiac arrest, and respiratory complications were all higher in direct aortic surgery patients. Conclusion: Direct aortic surgery management for BAV has been increasingly advised. As expected, in-hospital mortality and complications were more frequent in aortic surgery. Continued effort to select on patients who would benefit from addressing aortopathy at the time of their index operation is important.

103 Preoperative anemia is a risk factor for mortality and morbidity following aortic valve surgery