Aortic Valve Procedures Research Articles

Sternal Anomalies in Asymptomatic Patients after Median Sternotomy and Potential Influencing Factors.

We aimed to assess asymptomatic patients who had open-heart surgery with median sternotomy for potential sternal anomalies (SA), their related patient-specific risk factors, and treatment options for the prevention of SA. Multiplanar CT scans (CTs) from 131 asymptomatic consecutive patients were analyzed retrospectively. Of these, 83 underwent CABG (63.4%), and 48 had aortic valve (AV) procedures via median sternotomy. Sternal bone healing was analyzed for SA and their exact location. In total, 49 SA were identified in 42 (32.1%) patients; 65% SA were found in the manubrium (n = 32). Five hundred thirty-two wires were implanted (4.2 ± 0.5 wires/patient), out of which 96.1% (n = 511) were figure 8 wires. There was no difference between normal and abnormal sterna with regard to the number of wires used for sternal closure (4.2 ± 0.5 vs. 4.3 ± 0.6, p = ns). The distance between wire placement to the proximal edge of the manubrium in normal and abnormal sterna was comparable (11.2 ± 4.2 vs. 10.9 ± 4.8 mm, p = ns). Patients who underwent CABG had a significantly higher risk for SA (OR = 2.4, p ≤ 0.05, 95% CI [1.2-4.9]). The use of BIMA (OR = 4.4, p ≤ 0.05, 95% CI [1.1-17.9]) and body mass index (BMI) > 31 kg/m2 (OR = 3.4, p ≤ 0.01, 95% CI [1.4-8.3]) significantly increased the risk of SA. At least 30% of patients were at an increased risk for SA after receiving a median sternotomy. CABG, use of BIMA, and a BMI > 30 kg/m2 were potential risk factors for the development of SA and warrant close clinical follow-up. Sternal plate fixation, particularly in the manubrium, could be beneficial in such patients.

Congenital aortic valve repair using CorMatrix® : A histologic evaluation.

The reconstruction of heart valves provides substantial benefits, particularly in the pediatric population. We present our experience using decellularized extracellular matrix (dECM, CorMatrix® ) for aortic valve procedures. We retrospectively reviewed the case histories of 6 patients (aged from 2months - 14years) who underwent surgery for severe aortic valve stenosis (n=4) or regurgitation (n=2). Aortic valve repair was performed on all patients using dECM as a leaflet replacement or leaflet extension. Follow-ups were performed using echocardiography. Reoperation was necessary in 4 cases, and the dECM was explanted and examined histologically and immunohistochemically. The early post-operative period was uneventful, and the scaffold fulfilled the mechanical requirements. Significant valve insufficiency developed in 5 patients during the post-operative period (119-441days postoperatively). In all specimens, only a migration of inflammatory cells was identified, which induced structural and functional changes caused by the chronic inflammatory response. Our results suggest a mixed immunological response of remodeling and inflammation following the implantation. The expected process of seeding/migration and remodeling of the bioscaffold into the typical 3-layered architecture were not observed in our explanted specimens.

184 - TAVR for Treating Progressive Symptomatic Aortic Insufficiency in LVAD Patients

Background: Aortic insufficiency (AI) occurs up to 30% in patients with left ventricular assist devices (LVADs) on 1-year support or longer. AI is progressive and is associated with increased morbidity and mortality. Transcatheter aortic valve replacement (TAVR) has been approved as a treatment modality for high surgical risk patients with severe aortic stenosis but not for AI. Methods: We report a single center experience in managing HeartMate II LVAD patients with symptomatic progressive AI treated with TAVR. From October 2010 to March 2017, 275 HMII LVADs were implanted with 4 patients having concomitant aortic valve procedure for AI. 9 patients developed LVAD related symptomatic AI. We report on 6 patients (67% males, median age 50 years) who were managed with TAVR and had 6 months follow-up. Results: All patients required one-time intervention with one valve only (CoreValve, Evolute R). The median time from LVAD implantation to TAVR was 847 days. The median hospital stay post TAVR was 9 days. The RV function, degree of AI, and paravalvular leak (PVL) were assessed by transthoracic echocardiogram post implant and at 6 months. (Table 1) Conclusion: TAVR in LVAD patients with progressive AI is safe and successful. Both urgent heart transplantation or open valve surgery can be avoided.Table 1Patients with 6 months followup. *1 = mild, 2 = moderate, 3 = severeOutcomeTime of implantPost implant6 monthsMedian NYHA classificationIVIIIIMedian RV function311Median degree of AI311Median PVL post implantN/A11SurvivalN/A100%83% Open table in a new tab

Efficacy of posterior pericardiotomy in prevention of atrial fibrillation and pericardial effusion after aortic valve replacement: a randomized controlled trial

Aim. Postoperative atrial fibrillation is one of the most frequent complications in cardiac surgery. The aim of this trial was to evaluate the effectiveness of posterior pericardiotomy in the prevention of postoperative atrial fibrillation and pericardial effusion in patients undergoing isolated primary aortic valve replacement.Methods. The trial was approved by the local ethics committee. It included adult patients under 70 y.o. who had signed the informed consent for participation in the study and who were planned to undergo isolated primary aortic valve replacement. Exclusion criteria were a history of atrial fibrillation, hyperthyroidism, amiodarone intake, severe chronic obstructive pulmonary disease, left ventricle ejection fraction less than 30%, the size of the left atrium exceeding 50 mm, active infective endocarditis, the presence of adhesions in the pericardium and/or left pleural cavity and mini-sternotomy. From October 2013 to April 2015 607 patients in our clinic underwent different aortic valve procedures. 507 patients were excluded from the study because of the inclusion and exclusion criteria. The remaining 100 patients were randomized into two groups: 49 patients underwent posterior pericardiotomy and 51 patients made up the control group. In both groups the frequency of postoperative atrial fibrillation, pericardial effusion greater than 5 mm, surgery-discharge time, as well as posterior-pericardiotomy-related complications were studied. Trial number: ISRCTN11129539.Results. There were no deaths, stroke or cardiac tamponade during the postoperative stay. Neither were there any complications associated with the performance of posterior pericardiotomy. The incidence of atrial fibrillation, pericardial effusion and average duration of the postoperative stay were similar in both groups: 16% in posterior pericardiotomy group vs 14% in the control group (p=0.71), 10% in posterior pericardiotomy group vs 12% in the control group (p=0.80) and 12.4±4.3 days in posterior pericardiotomy group vs 11.9±4.1 days in the control group (p=0.27), respectively.Conclusion. The trial did not confirm the effectiveness of posterior pericardiotomy in preventing postoperative atrial fibrillation and pericardial effusion during the in-hospital period after isolated primary aortic valve replacement in low risk patients. However, further investigations are needed.Received 1 December 2016. Accepted 14 February 2017.Funding: The trial was carried out within the dissertation research and according to the research calendar of Kuban State Medical University. There was no additional funding except for the resources allocated for postgraduate scholarships.Conflict of interest: The authors declare no conflict of interest.Author contributionsConception and study design: V.I. Kaleda, K.O. Barbuhatti.Data collection and analysis: V.I. Kaleda, S.Yu. Boldyrev, S.A. Belash, I.I. Yakuba, S.S. Babeshko, I.A. Belan. Drafting the article: V.I. Kaleda.Critical revision of the article: V.I. Kaleda.Final approval of the version to be published: V.I. Kaleda, S.Yu. Boldyrev, S.A. Belash, I.I. Yakuba, S.S. Babeshko, I.A. Belan, K.O. Barbuhatti.Acknowledgements: The authors would like to express their gratitude to Cand. Sci. (Engineering) V.P. Leonov (“Biometrika”) for assistance in statistical data processing.

Outcome of cardiac surgery in patients with congenital heart disease in England between 1997 and 2015.

BackgroundThe number of patients with congenital heart disease (CHD) is increasing worldwide and most of them will require cardiac surgery, once or more, during their lifetime. The total volume of cardiac surgery in CHD patients at a national level and the associated mortality and predictors of death associated with surgery are not known. We aimed to investigate the surgical volume and associated mortality in CHD patients in England.MethodsUsing a national hospital episode statistics database, we identified all CHD patients undergoing cardiac surgery in England between 1997 and 2015.ResultsWe evaluated 57,293 patients (median age 11.9years, 46.7% being adult, 56.7% female). There was a linear increase in the number of operations performed per year from 1,717 in 1997 to 5,299 performed in 2014. The most common intervention at the last surgical event was an aortic valve procedure (9,276; 16.2%), followed by repair of atrial septal defect (9,154; 16.0%), ventricular septal defect (7,746; 13.5%), tetralogy of Fallot (3,523; 6.1%) and atrioventricular septal defect (3,330; 5.8%) repair. Associated mortality remained raised up to six months following cardiac surgery. Several parameters were predictive of post-operative mortality, including age, complexity of surgery, need for emergency surgery and socioeconomic status. The relationship of age with mortality was “U”-shaped, and mortality was highest amongst youngest children and adults above 60 years of age.ConclusionsThe number of cardiac operations performed in CHD patients in England has been increasing, particularly in adults. Mortality remains raised up to 6-months after surgery and was highest amongst young children and seniors.

Aortic Valve Bioprostheses: Leaflet Immobility and Valve Thrombosis.

Leaflet immobility and valve thrombosis have been reported with both transcatheter and surgical aortic valve bioprostheses. The relationships between these abnormalities and their incidence, time course, clinical significance, predisposing factors, optimal imaging modality, and current therapeutic options remain uncertain but are rapidly evolving. Four-dimensional computerized tomographic imaging has been determined to have the highest sensitivity in studies evaluating leaflet immobility and valve thrombosis. Echocardiography is also used during surveillance, but it appears to be less sensitive. The definitive diagnosis of valve thrombosis is based on a combination of diagnostic 4-dimensional computerized tomographic imaging findings, resolution of imaging abnormalities, and elevated transcatheter gradients with anticoagulation or surgical or pathological confirmation. Uncertainty about the incidence and clinical significance of the findings is the basis of 2 US Food and Drug Administration-approved studies comparing transcatheter and surgical aortic valve replacement with a subset undergoing surveillance 4-dimensional computerized tomographic imaging. Given the expansion of transcatheter aortic valve procedures, including potentially lower-risk patients, the resolution of these uncertainties is critical.

Rapid Deployment Aortic Valve Replacement via Partial Sternotomy: A Reasonable Option in Times of TAVI?

Objective: The Edwards Intuity valve (IV) system was designed as a further development of stented bioprostheses for aortic valve replacement (AVR). The application in a minimally invasive setting via partial sternotomy (PS) may represent an alternative to transcatheter aortic valve procedures (TAVI) in selected patients. Herein we present our initial, short-term findings with the IV.

Current Management of Patients with Severe Aortic Regurgitation

Chronic aortic regurgitation can result from various congenital and acquired anomalies and can be associated with proximal aortic disease. As the number of aortic valve procedures is growing, the incidence of post-procedural regurgitation also increases with associated morbidity. Typical evolution is characterized by a clinically silent phase of variable duration followed by a rather rapid decline with high incidence of adverse events. A challenge remains to find the optimal timing for an intervention: Patients are exposed to unnecessary surgical risks if treated prematurely, but peri- and post-operative prognosis is worse when the intervention is performed too late. Clinical evaluation and serial imaging tests can optimize the timing for intervention. Clinical follow-up should try to elucidate associated symptoms, with quantitative measurement of functional capacity as needed. Serial imaging examinations are required to identify sub-clinical left ventricular dysfunction or severe dilatation that should prompt a surgery. At least in selected cases, newer imaging modalities (MRI, 3D echocardiography) and/or biomarkers can help for the management of these patients, and more research is needed to determine if their systematic use can be beneficial. Medical treatment with vasodilators and anti-remodeling drugs can be helpful in some patients but should not replace or delay aortic valve surgery when indicated. Most patients will eventually be treated with surgical aortic valve replacement. Although possible in selected cases, transcatheter aortic valve replacement is not commonly used for patients with pure aortic regurgitation. For patients with prior aortic valve replacement and aortic regurgitation (paravalvular or intravalvular), emerging percutaneous approaches can be considered when available, especially for those at high surgical risk.

Implantation of the Sorin Perceval® sutureless aortic valve: a step by step approach.

Since the introduction of the sutureless Perceval® (Sorin Group, Saluggia, Italy) in Europe after CE mark in 2012, the "sutureless approach" is becoming more and more popular. Sutureless implantation in general is easy, fast and safe, but bears several potential pitfalls. This might result in inferior functional results affecting also clinical outcomes. In our center, more than 300 implant procedures have been performed up to date by mainly two senior surgeons. The technique is in the process of spreading to all surgeons performing aortic valve procedures. Proctored activities are completed at our and other institutions, and wetlab activities are conducted in collaboration with the manufacturer's research and development laboratory. This article was written to give a step-by-step advice for surgeons who want to start a sutureless program or even have made limited experience with this approach wanting to reconfirm their technique. The focus is kept on surgical aspects regarding indication, access, intra-operative exposure and implantation of the prosthesis.

Fast track minimally invasive aortic valve surgery: patient selection and optimizing

Fast track cardiac surgery started in the late 1980s due to a rapid growing amount of operations putting a high pressure on resources, particularly on intensive care capacity. The early fast track studies showed that this technique is feasible and safe for selected patients and procedures. Although some limitations of fast tracking such as patient age, co-morbidities and prolonged operation time were later described, this did not stop further extension of patient and procedure selection criteria. Nowadays, fast track pathways are used to improve patient care as a shorter ICU stay seems to decrease mortality. These pathways are applicable to various surgeries, including aortic valve procedures and combined surgery, because of the development of surgical and bypass techniques which allow less invasive anaesthesia or even conscious sedation. In principle, every patient could be treated as a fast track patient if preparation of the patient and scheduling of the operations are considered. Several strategies could optimise the physiological condition of patients and broaden the patient selection criteria. Avoidance of perioperative anaemia might be as important as keeping the haemodynamic condition stable to achieve optimal organ protection. Current selection criteria should be based on surgical parameters and augmented with the patient s frailty and performance status. All of them should be continuously adjusted during the process. However, most important is a concerted team approach with all contributors having the same mindset.

Dacron Skirt Reconstruction of the Left Ventricular Outflow Tract: Extending the Capabilities of a Valved Conduit

Aortic root reconstruction in the setting of redo aortic valve procedures or infective endocarditis may be technically challenging, particularly because of variable destruction or distortion of the left ventricular outflow tract. Homograft aortic root replacement is an excellent option for aortic root abscesses but is limited by homograft availability. We describe a simple technique of a bioprosthetic valved conduit constructed on the table using a Dacron (DuPont, Wilmington, DE) skirt below the valve. The use of the Dacron skirt facilitates easy reconstruction of the left ventricular outflow tract.

2016 Annual Report of The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

BackgroundThe Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry captures all procedures with Food and Drug Administration–approved transcatheter valve devices performed in the United States, and is mandated as a condition of reimbursement by the Centers for Medicaid & Medicare Services. ObjectivesThis annual report focuses on patient characteristics, trends, and outcomes of transcatheter aortic and mitral valve catheter-based valve procedures in the United States. MethodsWe reviewed data for all patients receiving commercially approved devices from 2012 through December 31, 2015, that are entered in the TVT Registry. ResultsThe 54,782 patients with transcatheter aortic valve replacement demonstrated decreases in expected risk of 30-day operative mortality (STS Predicted Risk of Mortality [PROM]) of 7% to 6% and transcatheter aortic valve replacement PROM (TVT PROM) of 4% to 3% (both p < 0.0001) from 2012 to 2015. Observed in-hospital mortality decreased from 5.7% to 2.9%, and 1-year mortality decreased from 25.8% to 21.6%. However, 30-day post-procedure pacemaker insertion increased from 8.8% in 2013 to 12.0% in 2015. The 2,556 patients who underwent transcatheter mitral leaflet clip in 2015 were similar to patients from 2013 to 2014, with hospital mortality of 2% and with mitral regurgitation reduced to grade ≤2 in 87% of patients (p < 0.0001). The 349 patients who underwent mitral valve-in-valve and mitral valve-in-ring procedures were high risk, with an STS PROM for mitral valve replacement of 11%. The observed hospital mortality was 7.2%, and 30-day post-procedure mortality was 8.5%. ConclusionsThe TVT Registry is an innovative registry that that monitors quality, patient safety and trends for these rapidly evolving new technologies.

2016 Annual Report of The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry captures all procedures with Food and Drug Administration-approved transcatheter valve devices performed in the United States, and is mandated as a condition of reimbursement by the Centers for Medicaid & Medicare Services. This annual report focuses on patient characteristics, trends, and outcomes of transcatheter aortic and mitral valve catheter-based valve procedures in the United States. We reviewed data for all patients receiving commercially approved devices from 2012 through December 31, 2015, that are entered in the TVT Registry. The 54,782 patients with transcatheter aortic valve replacement demonstrated decreases in expected risk of 30-day operative mortality (STS Predicted Risk of Mortality [PROM]) of 7% to 6% and transcatheter aortic valve replacement PROM (TVT PROM) of 4% to 3% (both p< 0.0001) from 2012 to 2015. Observed in-hospital mortality decreased from 5.7% to 2.9%, and 1-year mortality decreased from 25.8% to 21.6%. However, 30-day post-procedure pacemaker insertion increased from 8.8% in 2013 to 12.0% in 2015. The 2,556 patients who underwent transcatheter mitral leaflet clip in 2015 were similar to patients from 2013 to 2014, with hospital mortality of 2% and with mitral regurgitation reduced to grade≤2 in 87% of patients (p< 0.0001). The 349 patients who underwent mitral valve-in-valve and mitral valve-in-ring procedures were high risk, with an STS PROM for mitral valve replacement of 11%. Theobserved hospital mortality was 7.2%, and 30-day post-procedure mortality was 8.5%. The TVT Registry is an innovative registry that that monitors quality, patient safety and trends for these rapidly evolving new technologies.

Bağcılar Eğitim ve Araştırma Hastanesi’nde ilk transapikal aort kapak replasmanı

Transcatheter-based aortic valve procedures have undergone a tremendous evolution and have led to great changes in the treatment of aortic valvular disease. In patients with severe peripheral arterial disease, transapical aortic valve implantation is an important alternative to surgical aortic valve replacement. Hereby we present our first case of transapical aortic valve implantation in an 80 year-old patient. An 80-year old female patient applied with dyspnea on minimal exertion (NYHA Class III). Transthoracic echocardiography showed severe aortic stenosis (gradients of 76/45 mmHg, aortic valve area of 0.72 cm2). Patient had a history of coronary artery bypass grafting and chronic obstructive pulmonary disease. Calculated Euroscore was 16.4% and due to the high surgical risk and presence of diffuse vascular disease, transapical aortic valve implantation was decided to be the optimal choice for the patient. The procedure was performed in the catheter laboratory under general anesthesia via a 5-6 cm anterolateral thoracotomy and via transapical approach. Fluoroscopy was used to guide the catheter across the native valve and direct deployment of the stent at the level of the annulus. A 26 mm Edwards Novoflex (Edwards Lifesciences, Irvine, CA) aortic valve was used. Postoperative echocardiography showed no transvalvular gradient and aortic regurgitation. Aorta flow was 1.1 m/s. Transcatheter-based aortic valve procedures avoid the risks associated with open heart surgery and therefore are generally indicated in patients with high surgical risk. Although TAVI is the first alternative to SAVR in high risk patients, TA-TAVI is a safe and effective option in those unsuitable for TAVI.

Survival and cardiovascular events after coarctation-repair in long-term follow-up (COAFU): Predictive value of clinical variables

ObjectiveLong-term sequelae and events after coarctation repair are well described. However, the predictive value of variables from clinical follow-up investigation for late events and survival has rarely been investigated. MethodsAll patients who participated in the prospective cross-sectional COALA Study in 2000 with a structural clinical investigation including blood pressure measurement and symptom-limited exercise test were contacted for reevaluation of survival, current clinical status and major cardiovascular events. ResultsOf 273 eligible patients, 209 were available for follow-up. Nine patients had died at a median age of 46years (range 30–64years), five of them due to cardiovascular complications. Late mortality after surgical intervention was 5.7% with a median age of 41years (range 16–64years). Twenty-five patients had a major cardiovascular event: 12 had procedures at the aortic valve or aortic arch, 8 had procedures for restenosis, 2 had endocarditis, 2 had a cerebrovascular insult and 1 an aortic dissection. The presence of bicuspid aortic valve (p=0.009), brachial-ankle blood pressure gradient >20mmHg (p<0.001) and reduced left ventricular function (p=0.002) correlated with major cardiovascular events. ConclusionSurgical correction of coarctation of the aorta shows fairly low mortality in the long-term follow-up. Late morbidities include recoarctation, but also the consequences of the hemodynamics produced by a congenital bicuspid aortic valve, presence of which is predictive for aortic valve procedures: however the predictive value of clinical variables is limited.

Surgically Corrected Mitral Regurgitation During Left Ventricular Assist Device Implantation Is Associated With Low Recurrence Rate and Improved Midterm Survival

Indications for concomitant intervention for mitral regurgitation (MR) during left ventricular assist device (LVAD) implantation remain controversial. The objective of this study was to determine the impact of the surgical correction of MR during LVAD implantation. From July 2008 to December 2014, 164 patients with significant preoperative MR underwent LVAD (HeartMate II; Thoratec, Pleasanton, CA) implantation. The MR resolved after LVAD implantation in 110 of 164 patients (67.1%) with either surgical or spontaneous correction. The cohort (n= 110) without significant postoperative MR was divided into two groups: a spontaneous correction group (n= 54, MR spontaneously resolved after LVAD implantation); and a surgical correction group (n= 56, MR surgically corrected). Patients who received aortic valve procedures (n= 17) were excluded from this study. Patient demographics, perioperative outcomes including bleeding, prolonged intubation, and stroke, and inhospital mortality did not differ in the two groups except for significantly longer cardiopulmonary bypass time in the surgical correction group (spontaneous correction 123 minutes [interquartile range (IQR): 107 to 150] versus surgical correction 177 minutes [IQR: 132 to 198], p < 0.001). During follow-up, pulmonary wedge pressure (spontaneous correction 17 mm Hg [IQR: 12 to 23 mm Hg] versus surgical correction 12 mm Hg [IQR: 4 to 17 mm Hg], p= 0.015) and pulmonary vascular resistance (spontaneous correction 2.0 Wood units [IQR: 1.5 to 2.4] versus surgical correction 1.7 Wood units [IQR: 0.8 to 2.1], p= 0.047) were significantly improved in the surgical correction group compared with the spontaneous correction group. Overall survival rate and freedom from recurrent MR were significantly better in the surgical correction group compared with the spontaneous correction group (1-year survival, spontaneous correction 59.4% ± 6.9% versus surgical correction 69.6% ± 6.4%, log rank p= 0.030; 1-year freedom from recurrent MR, spontaneous correction 76.2% ± 7.5% versus surgical correction 95.0% ± 3.5%, log rank p=0.028). The LVAD patients with surgically corrected MR had improved midterm hemodynamics and survival compared with spontaneously resolved MR, along with low recurrence of MR. Aggressive surgical mitral valve intervention during LVAD implantation may be recommended.

Asymptomatic Severe Aortic Stenosis in the Elderly

ObjectivesThis study sought to assess the natural history and optimal timing of surgery in elderly patients with severe asymptomatic aortic stenosis (AS). BackgroundAS is increasingly diagnosed in an aging population, and large numbers of elderly patients are undergoing aortic valve procedures. However, the average age of patients represented in most natural history studies on AS is between 60 and 70 years. MethodsA total of 103 consecutive patients >70 years of age (51 female; mean age 77 ± 5 years) with asymptomatic severe AS (peak aortic jet velocity [AV-Vel] 4.7 ± 0.6 m/s) were prospectively followed. ResultsDuring follow-up, 91 events occurred, including an indication for aortic valve replacement in 82 patients and cardiac deaths in 9, respectively. Event-free survival was 73%, 43%, 23%, and 16% at 1, 2, 3, and 4 years, respectively. Physical mobility was impaired in 29% of the patients, and symptom onset was severe (New York Heart Association functional class ≥III) in 43% of those who developed symptoms. Patients with AV-Vel ≥5.0 m/s had event-free survival rates of 21% and 6% at 2 and 4 years, respectively, compared with 57% and 23% for patients with AV-Vel <5.0 m/s (p < 0.001). Seventy-one patients underwent aortic valve replacement, and post-operative survival was 89% and 77% after 1 and 3 years, respectively. ConclusionsIn elderly patients with severe but asymptomatic AS, mild symptoms may be difficult to detect, particularly when mobility is impaired and severe symptom onset is common, warranting close clinical follow-up. Furthermore, a very high event rate can be expected, and cardiac deaths are not infrequent. Thus, elective aortic valve procedures may be considered in selected elderly patients at low procedural risk.

Left-Sided Surgical Ablation for Patients With Atrial Fibrillation Who Are Undergoing Concomitant Cardiac Surgical Procedures

Growing evidence indicates the effectiveness of surgical ablation confined to the left atrium, especially with short duration of atrial fibrillation (AF) and smaller left atrial (LA) size. This study examined rhythm status and predictors of failure in this group of patients. Of 800 patients who underwent concomitant surgical ablation (2005 to 2015), 110 had LA-only ablation. Rhythm status was defined according to Heart Rhythm Society guidelines: sinus rhythm (SR) without class I/III antiarrhythmic drugs (AADs). Multivariate analyses examined predictors for SR without AADs. Predictors of failure were also stratified as age 75 years or older, LA size 5 cm or larger, AF duration 5 years or more, and nonparoxysmal AF type for secondary analyses. Mean age was 70.7 ± 9.4 years, mean EuroSCORE II (European System for Cardiac Operative Risk Evaluation) was 4.7 ± 4.3%, mean LA size was 4.4 ± 0.8 cm, median (interquartile range) AF duration was 3.5 months (range, 0.4 to 21 months), 26% of patients were female, 59% had coronary artery bypass graft procedures, 36% had aortic valve procedures, and 25% had mitral valve procedures. SR without AADs at 6, 12, and 24 months was 82% (79 of 96), 87% (78 of 90), and 79% (61 of 77), respectively. The only independent predictor of SR without AADs at 6 months was smaller LA size (odds ratio, 0.35; p= 0.014). Return to SR without AADs at 6, 12, and 24 months was as follows: 92%, 93%, and 91%, respectively, for patients with no traditional predictors of failure (n= 32); 88%, 90%, and 77%, respectively, for one predictor (n= 47); and 66%, 76%, and 70% for two or more predictors (n= 31). LA-only ablation yielded acceptable success rates, primarily in patients with shorter AF duration and smaller LA. However, success was reduced in patients with traditional predictors of failure. Well-designed studies with standardized lesion sets and ablation tools are required to determine whether full Cox maze yields better outcomes in patients with more advanced AF.

Reoperative Aortic Root Replacement in Patients with Previous Aortic Root or Aortic Valve Procedures.

BackgroundGeneralization of standardized surgical techniques to treat aortic valve (AV) and aortic root diseases has benefited large numbers of patients. As a consequence of the proliferation of patients receiving aortic root surgeries, surgeons are more frequently challenged by reoperative aortic root procedures. The aim of this study was to evaluate the outcomes of redo-aortic root replacement (ARR).MethodsWe retrospectively reviewed 66 patients (36 male; mean age, 44.5±9.5 years) who underwent redo-ARR following AV or aortic root procedures between April 1995 and June 2015.ResultsEmergency surgeries comprised 43.9% (n=29). Indications for the redo-ARR were aneurysm (n=12), pseudoaneurysm (n=1), or dissection (n=6) of the residual native aortic sinus in 19 patients (28.8%), native AV dysfunction in 8 patients (12.1%), structural dysfunction of an implanted bioprosthetic AV in 19 patients (28.8%), and infection of previously replaced AV or proximal aortic grafts in 30 patients (45.5%). There were 3 early deaths (4.5%). During follow-up (median, 54.65 months; quartile 1–3, 17.93 to 95.71 months), there were 14 late deaths (21.2%), and 9 valve-related complications including reoperation of the aortic root in 1 patient, infective endocarditis in 3 patients, and hemorrhagic events in 5 patients. Overall survival and event-free survival rates at 5 years were 81.5%±5.1% and 76.4%±5.4%, respectively.ConclusionDespite technical challenges and a high rate of emergency conditions in patients requiring redo-ARR, early and late outcomes were acceptable in these patients.

Undersized Rigid Nonplanar Annuloplasty: The Key to Effective and Durable Repair of Functional Tricuspid Regurgitation

Previous clinical experiences have demonstrated high early and late recurrence rates after repair of functional tricuspid regurgitation (TR). We investigated the results of functional TR repair with undersized rigid nonplanar annuloplasty rings. From January 2007 to December 2013, 216 consecutive patients with moderate or greater functional TR were treated with undersized (size 26 mm or 28 mm) rigid nonplanar annuloplasty rings. The mean age was 69 ± 13 years. There was a previous history of cardiac operation in 25% (54 of 216 patients). Tricuspid regurgitation was graded as severe in 47% (102 of 216) and moderate in 53% (114 of 216). Concomitant operations included mitral valve procedures in 92% (198 of 216), coronary artery bypass grafting in 21% (45 of 216), aortic valve procedures in 9% (20 of 216), and cryomaze procedures in 35% (76 of 216). Size 26 mm rings were used in 38% of patients (81 of 216), and size 28 mm in 62% (135 of 216). The perioperative mortality rate was 6% (14 of 216). On predischarge echocardiography, TR grade was none or mild in 94% (176 of 187 patients), moderate in 4% (7 of 187), and severe in 2% (4 of 187). At a mean follow-up of 33.0 ± 24.0 months, TR grade was none or mild in 81% of patients (130 of 160), moderate in 16% (26 of 160), and severe in 2% (4 of 160). There were no reoperations for recurrent TR, and no patients have had tricuspid stenosis or annuloplasty ring dehiscence. Treatment of functional TR with undersized (26 mm or 28 mm) nonplanar rigid annuloplasty rings is safe and highly effective, with a near absence of recurrent severe TR at midterm follow-up.