Aortic Valve Replacement Surgery Research Articles

Aortic Valve Surgery in Patients Over 75 Years Old: Early Results and Predictors of Hospital Mortality

Background: Aortic valve surgery is the most essential part of worldwide heart valve surgery. In recent decades, the patient profile has changed even in our country, with the age of patients undergoing aortic valve surgery increasing significantly. The primary objectives of this study are the early results of aortic valve replacement surgery in patients over 75 years old and the negative predictors that affect hospital mortality. Materials and Methods: This is a retrospective study of 73 patients over 75 who underwent aortic valve surgery in 2014-2021 in our Cardiac Surgery Service, University Hospital Center “Mother Theresa” in Tirana. The patients' data regarding demographic, preoperative, operative, and postoperative variables were collected from the hospital's medical records. The data are presented in mean values and standard deviation. T-test and chi-squared test are also used. Results: This study involved 73 patients, 50 males and 23 females. The age range was 75-85, averaging 77.12±2.31 years. Hospital mortality was 4.1%. The incidence of major perioperative complications such as low cardiac output, stroke, respiratory problems, bleeding, atrial fibrillation, wound infection, and conduction disturbances was 6.8%, 2.7 %, 4.1%, 2.7 %, 21.9 %, 2.6%, and 4.2 %. Conclusions: Aortic valve surgery for elderly patients over 75 can be performed well. Concomitant procedures, prolonged extracorporeal circulation, and emergency intervention expose the patient to a high operative risk.

Interpretation of intra-operative strain differences in ascending thoracic aortic repair patients

Local biaxial deformation plays a pivotal role in evaluating the tissue state of the ascending aorta and in driving intramural cell-mediated tissue remodeling. Unfortunately, the absence of anatomical markers on the ascending aorta presents challenges in capturing deformation. Utilizing our established intra-operative biaxial strain measurement method, we delineated local biaxial deformation characteristics in patients undergoing aortic valve replacement and coronary artery bypass graft surgery recipients (n = 20), and Aortic Repair surgery patients (n = 47). Expectedly, mean circumferential strains positively correlated with pulse pressure and negatively correlated with age and diameter. A new observation was that the mean axial strains exhibited the same trend as the mean circumferential strains when correlated with pulse pressure, age and diameter. Interestingly, on analyzing local biaxial strains, our findings revealed higher circumferential strains (by 1 %) proximal to the heart compared to distal regions across the cohorts and within each patient cohort. Furthermore, no discernible regional strain distinctions were noted between the medial and lateral sides of the ascending aorta for the entire patient population and individual cohorts. Patients undergoing Aortic Repair surgery indicated lower strains (ranging from 1 to 3 %) as compared to the other cohort. Our approach holds the potential to establish a foundational framework for the integrated examination of the mechanical and biological conditions and their role in ascending aortic aneurysm development.

Comparison of the results of aortic valve neocuspidalization (Ozaki procedure) with aortic valve bioprosthetics in patients with a narrow aortic annulus: a multicenter retrospective study

In aortic valve (AV) replacement surgery in patients with a narrow annulus fibrosus (AF), the likelihood of prosthesis-patient mismatch (PPM) is high. PPM, in turn, significantly affects the hemodynamic and functional capabilities of AV, morbidity and mortality in the postoperative period. The “gold standard” for the treatment of AV diseases is prosthetics with mechanical and biological prostheses. However, there are alternative methods, such as neocuspidalization of AV according to the S. Ozaki (AVNeo) method.Aim: To compare the immediate and medium-term results of AV prosthetics using the S. Ozaki (AVNeo) technique and AV prosthetics with a biological prosthesis in patients with a small aortic annulus.Material and Methods: A retrospective multicenter study of 309 patients with a narrow fibrous ring of the aortic valve (FR AV) who underwent surgery between February 2010 and December 2021 was conducted. Inclusion criteria: prosthetics of AV, FR AV = 21 mm, age 18 years and older. Exclusion criteria: left ventricle ejection fraction ≤ 40%, repeated interventions, mini-stop. 153 patients underwent Aveo and 156 patients underwent AV prosthetics using biological prostheses. After “pseudorandomization” (propensity score matching), 92 patients were selected: 46 patients in the AVNeo group and 46 patients in the biological prosthesis group. The primary endpoint was hospital mortality. Postoperative complications, transvalvular gradients, and medium-term outcomes (three-year overall survival and freedom from surgery on AV) were evaluated as secondary endpoints.Results. There was no statistically significant difference in the duration of surgery (275.9 ± 34.2 min in the AVNeo group and 285.8 ± 37 min in the bioprosthesis group, p < 0.4), artificial circulation (98 min in the AVNeo group and 115 min in the bioprosthesis group, p < 0.3), aortic compression (80 min in the AVNeo group and 93 min in the bioprosthesis group, p < 0.7). Hospital mortality among the studied patients did not differ: in the AVNeo group – 2 (4.3%) and 1 (2.2%) in the bioprosthesis group, p = 1.0. There were no significant differences in postoperative complications: wound surface infection (3 (6.5%) in the AVNeo group and 1 (2.2%) in the bioprosthesis group, p = 0.617), acute kidney injury (1 (2.2%) in the AVNeo group and 0 in the bioprosthesis group, p = 1.0), stroke ( 1 (2.2%) in the AVNeo group and 2 (4.3%) in the bioprosthesis group, p = 1.0), resternotomy for bleeding (0 in the AVNeo group and 2 (4.3%) in the bioprosthesis group, p = 0.495). Permanent pacemaker implantation was not required by any patient. There was also no statistically significant difference in the three-year overall survival and re–operation, in the AVNeo group it was 83% and 92.5% in the bioprosthesis group, p = 0.23; three-year freedom from re-operation was 96.4% in the AVNeo group and 97.1% in the bioprosthesis group, p = 0.27. However, peak and average gradients were statistically less after AVNeo surgery. The peak and average gradients after AVNeo were 12 and 6 mmHg, after prosthetics 32 and 20 mmHg, p < 0.001.Conclusions: There was no statistically significant difference in hospital mortality, postoperative complications, and three-year survival and re-operation. The values of the peak and average pressure gradient at discharge differed statistically significantly in favor of the AVNeo group.

Quantification of Replacement Fibrosis in Aortic Stenosis: A Narrative Review on the Utility of Cardiovascular Magnetic Resonance Imaging.

Aortic stenosis (AS) is associated with the development of replacement myocardial fibrosis/scar. Given the dose-dependent relationship between scar and clinical outcomes after aortic valve replacement (AVR) surgery, scar quantity may serve as an important risk-stratification tool to aid decision-making on the optimal timing of AVR. Scar is non-invasively assessed and quantified by cardiovascular magnetic resonance (CMR) imaging. Several quantification techniques exist, and consensus on the optimal technique is lacking. These techniques range from a visual manual method to fully automated ones. This review describes the different scar quantification techniques used and highlights their strengths and shortfalls within the context of AS. The two most commonly used techniques in AS include the semi-automated signal threshold versus reference mean (STRM) and full-width half-maximum (FWHM) techniques. The accuracy and reproducibility of these techniques may be hindered in AS by the coexistence of diffuse interstitial fibrosis and the presence of relatively small, non-bright scars. The validation of these techniques against histology, which is the current gold standard for scar quantification in AS, is limited. Based on the best current evidence, the STRM method using a threshold of three standard deviations above the mean signal intensity of remote myocardium is recommended. The high reproducibility of the FWHM technique in non-AS cohorts has been shown and merits further evaluation within the context of AS. Future directions include the use of quantitative T1 mapping for the detection and quantification of scar, as well as the development of serum biomarkers that reflect the fibrotic status of the myocardium in AS.

Prevalence and prognostic value of thrombocytopenia in aortic valve replacement surgery: bioprosthesis versus mechanical prosthesis

Abstract Background Thrombocytopenia is a frequent complication of valve surgery, and is associated with different postoperative outcomes. Concern has recently arisen about thrombocytopenia following aortic valve replacement (AVR), as some authors have reported increased postoperative thrombocytopenia with certain biological aortic valves. In adittion, it is unclear whether thrombocytopenia predicts mortality in this type of surgery. Purpose The aim of this study was to determine the prevalence and prognostic value of thrombocytopenia in biological and mechanical aortic valve replacement. Methods The study was an observational analysis of patients undergoing AVR with or without associated coronary artery bypass grafting (CABG) at a single center between October 2014 and October 2023. Cardiac Surgery database was computerized and prospectively completed. Preoperative and first 4 days postoperative platelet counts were analyzed. Thrombocytopenia was defined as platelet count < 100 × 10³/mm³. To obtain comparable populations, a propensity score matching analysis was performed. Results A total of 1,197 patients underwent AVR with (n = 494) or without CABG (n = 703). Patients received either a mechanical prosthesis (n = 320), or a biological prosthesis (n = 877). The mean population age was 68 years (SD 6), with the majority being male (68%). Univariate analysis of the baseline characteristics of both groups of patients showed that they were not comparable. A risk-adjusted subanalysis was performed according to a propensity score (n=278). The nadir of bioprostheses was on the third postoperative day with an average of 93.8 × 10³/mm³, while in mechanical prostheses was also on the same day but with an average of 114.7 × 10³/mm³ (p: 0.001). (Figure 1) Bioprosthesis implantation was significantly associated with a higher prevalence of thrombocytopenia (72.7% vs. 45.3%, p<0.001). The presence of postoperative thrombocytopenia has been associated with higher in-hospital mortality (6.7% vs. 0.9%, p=0.019); but not with other postoperative complications. (Figure 2) Conclusions Patients undergoing AVR with bioprostheses had a significantly higher prevalence of thrombocytopenia, and also lower platelet counts than mechanical prothesis within the first 4 postoperative days. Thrombocytopenia was associated with higher in-hospital mortality in a risk score-adjusted population.Platelet counts after AVROutcomes according to platelet count

Comparative analysis of a novel preoperative stratification method versus traditional scores in patients with severe aortic stenosis undergoing aortic valve surgery

Abstract Introduction It is crucial to consider factors that complicate the indication of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), such as narrow valve ring, extensive calcification or inadequate vascular access. (1-4) Thus, aortic valve replacement surgery (SAVR) remains a recommended indication, with its pre-surgical stratification being a challenge. (1-3) Despite the widespread use of scores like the STS and EuroSCORE II, they exhibit limitations, being validated primarily for populations outside Latin America and focusing predominantly on individual factors while often neglecting structural parameters like left ventricular hypertrophy, diastolic dysfunction, or left atrium volume. (3-5) Purpose This study aimed to assess whether a novel modified Généreux stratification method offers superior predictive value for postoperative mortality in AS patients compared to traditional scoring systems. Methods We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent aortic valve replacement surgery between January 2017 and December 2021. The new stratification method categorized patients into three stages based on echocardiographic parameters (see Figure 1). Univariate and multivariate Cox regression analyses were conducted to identify predictors of mortality, with survival analysis performed using Kaplan-Meier curves. A p-value <0.05 was considered statistically significant. Results A total of 508 patients were included in the study. Stage 1 patients had a lower median age (62 years vs. 67 years in stages 2 and 3). The median EuroSCORE and STS were 2.75 and 2.62%, respectively, with stage 3 showing significantly higher scores (p ≤0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan-Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p≤0.001), as illustrated in Figure 1. Multivariate analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44-7.20], p=0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92-0.99], p=0.021) as independent predictors of mortality. The new stages demonstrated a superior area under the ROC curve of 0.758 compared to traditional scores (see Figure 1). Conclusions The novel three-stage preoperative classification and low transaortic gradient serve as significant predictors of mortality in patients undergoing SAVR. These stages exhibit robust predictive capability for mortality compared to EuroSCORE II and STS.Baseline and multivariate analysisKaplan-meier and ROC curve

Assessing aortic morphology post aortic valve replacement using unsupervised hierarchical clustering and statistical shape modelling

Abstract Introduction There are different surgical procedures used to treat aortic valve disease such as aortic valve replacement (AVR), the Ozaki procedure, the Ross procedure, and the valve-sparing procedure. There may be postoperative side effects associated with aortic morphology. Computational analyses that assess morphology are thus necessary in such scenario. Statistical shape modelling is used to assess three-dimensional morphology, discover unique shape features, create mean shapes, and create shape modes that display morphological variability. Hierarchical cluster analysis is a machine learning method used to classify a population into subgroups. Both of these statistical methods were applied to aortic valve replacement patients to evaluate morphological variability after aortic valve replacement (AVR) surgery. Purpose The purpose of this study is to assess the aortic morphology of AVR patients, identify morphological differences between different surgical procedures, identify subgroups postoperatively using statistical shape modelling and hierarchical cluster analysis, and assessing possible correlations between the resultant clusters and function i.e. ejection fraction. Methods Computed tomography and cardiac magnetic resonance images were used to reconstruct aortas into 3D models using segmentation and 3D reconstruction software. For each patient, two models were created (i.e. ascending aorta only and aorta including the arch and the descending aorta). N=35 patients were included in the study. Statistical shape analysis was run to create templates and shape modes. Statistical environment and language software was used to run hierarchical cluster analysis. Results Overall, the hierarchical cluster analysis did not classify the aortas based on type of surgery, but most patients in the Ross group demonstrated morphological differences from the other surgical groups and many of the aortas belonging to the Ross group were clustered together in both clustering analyses. No significant differences between clusters were seen (p=0.47 for ascending, p=0.19 for whole aorta). No correlation was found between clusters and ejection fraction (p=0.75, r2<0.01), possibly indicating that post-AVR aortic morphology in this sample does not reflect overt functional changes. Conclusion Both statistical shape modelling and hierarchical cluster analyses were successful in assessing morphological variability and identifying subgroups in this population. This framework could therefore be extended to larger samples to inform on surgical decision-making allowing surgeons to choose the appropriate surgery for the patient or design prosthetic valves that are more customised to the patient’s anatomy.Cluster-Ejection Fraction Correlation

Pre- and Post-Operative Cognitive Assessment in Patients Undergoing Surgical Aortic Valve Replacement: Insights from the PEARL Project.

Aortic valve stenosis (AVS) is a common valvular heart disease affecting millions of people worldwide. It leads to significant neurocognitive and neuropsychological impairments, impacting patients' quality of life. The objective of this article is to identify and discuss the potential neurocognitive effects on patients with aortic stenosis before and after undergoing surgical aortic valve replacement (SAVR). Our study involved the assessment of 64 patients undergoing aortic valve replacement (SAVR) using a neurocognitive evaluation comprising a battery of 11 different cognitive tests. These tests were designed to analyze the patients' overall cognitive functioning, executive abilities, short- and long-term memory, and attentional performance. The tests were administered to patients before the aortic valve surgery (T0) and after the surgery (T1). From a statistical perspective, numerical variables are presented as means (±standard deviation) and medians (IQR), while categorical variables are presented as counts and percentages. Normality was assessed using the Shapiro-Wilk test. T0 and T1 scores were compared with the Wilcoxon signed rank test, with p < 0.05 considered significant. Analyses were performed using SAS version 9.4. Conducted as part of a fully financed Italian Ministry of Health project (RF-2016-02361069), the study found that most patients showed normal cognitive functioning at baseline. Cognitive assessments showed that executive functions, attention, language, and semantic knowledge were within the normal range for the majority of participants. After SAVR, cognitive outcomes remained stable or improved, particularly in executive functions and language. Notably, verbal episodic memory demonstrated significant improvement, with the percentage of patients scoring within the normal range on the BSRT increasing from 73.4% at T0 to 92.2% at T1 (p < 0.0001). However, visuospatial and visuoconstructive abilities showed stability or slight decline, while attentional skills remained relatively stable. The Clock Drawing Test indicated the maintenance of cognitive functions. The findings of our study indicate a global stability in cognitive status among patients after undergoing SAVR, with significant improvement noted in verbal episodic memory. While other cognitive domains did not demonstrate statistically significant changes, these insights are valuable for understanding the cognitive effects of SAVR and can guide future research and clinical practice in selecting the most effective surgical and rehabilitative options for patients. Monitoring cognitive outcomes in patients undergoing aortic valve replacement surgery remains crucial.

Bioprosthetic versus mechanical prostheses in patients aged 50 to 70 years undergoing aortic valve replacement surgery: outcomes analysis from propensity score matching

Abstract Introduction Despite increasing use of bioprosthetic surgical aortic valve replacement (bAVR) in patients ≤70 years [1, 2], the relative benefits compared to mechanical valve replacement (mAVR) remain uncertain [3, 4]. Purpose The current study aims to compare mortality and other important clinical endpoints by prosthesis type for patients aged 50-70 years who received an AVR in a well-characterised Australian cohort. Methods A retrospective cohort study was designed utilising the WAVES Patient Registry and incorporating linked administrative outcome data including all patients who had an AVR in Western Australian public hospitals between 2010-2020. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular (CV) mortality, separately and combined with non-fatal myocardial infarction and non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes were compared based on a propensity-matched analysis (including demographics, biometrics, and clinical characteristics). Results Within the initial cohort of 727 patients undergoing surgical AVR (mean age = 63 ± SD 6), a propensity-matched cohort identified 151 patients each with bAVR (mean age = 61 ± 4) and mAVR (mean age = 60 ± 5). Patients who received mAVR versus bAVR had improved all-cause survival (Hazard Ratio [HR] 0.50; 95% CI 0.25-0.99) but increased risk of major bleeding (HR 4.85; 95% CI 1.57-14.98). There were no significant differences in CV mortality (HR 0.58; 95% CI 0.19-1.74), MACE (HR 0.59; 95 % CI 0.32-1.07), or DAOH by prosthesis type (P = 0.452). Conclusions Patients aged 50-70 years who underwent mAVR had lower risk of all-cause mortality compared with bAVR, despite higher bleeding risk. Although risks of CV mortality and MACE were lower in mAVR, statistical significance was not reached, likely due to the small sample size. Larger studies are necessary to confirm these findings, which have important clinical implications.

Shear-Sensing by C-Reactive Protein: Linking Aortic Stenosis and Inflammation.

CRP (C-reactive protein) is a prototypical acute phase reactant. Upon dissociation of the pentameric isoform (pCRP [pentameric CRP]) into its monomeric subunits (mCRP [monomeric CRP]), it exhibits prothrombotic and proinflammatory activity. Pathophysiological shear rates as observed in aortic valve stenosis (AS) can influence protein conformation and function as observed with vWF (von Willebrand factor). Given the proinflammatory function of dissociated CRP and the important role of inflammation in the pathogenesis of AS, we investigated whether shear stress can modify CRP conformation and induce inflammatory effects relevant to AS. To determine the effects of pathological shear rates on the function of human CRP, pCRP was subjected to pathophysiologically relevant shear rates and analyzed using biophysical and biochemical methods. To investigate the effect of shear on CRP conformation in vivo, we used a mouse model of arterial stenosis. Levels of mCRP and pCRP were measured in patients with severe AS pre- and post-transcatheter aortic valve implantation, and the presence of CRP was investigated on excised valves from patients undergoing aortic valve replacement surgery for severe AS. Microfluidic models of AS were then used to recapitulate the shear rates of patients with AS and to investigate this shear-dependent dissociation of pCRP and its inflammatory function. Exposed to high shear rates, pCRP dissociates into its proinflammatory monomers (mCRP) and aggregates into large particles. Our in vitro findings were further confirmed in a mouse carotid artery stenosis model, where the administration of human pCRP led to the deposition of mCRP poststenosis. Patients undergoing transcatheter aortic valve implantation demonstrated significantly higher mCRP bound to circulating microvesicles pre-transcatheter aortic valve implantation compared with post-transcatheter aortic valve implantation. Excised human stenotic aortic valves display mCRP deposition. pCRP dissociated in a microfluidic model of AS and induces endothelial cell activation as measured by increased ICAM-1 (intercellular adhesion molecule 1) and P-selectin expression. mCRP also induces platelet activation and TGF-β (transforming growth factor beta) expression on platelets. We identify a novel mechanism of shear-induced pCRP dissociation, which results in the activation of cells central to the development of AS. This novel mechanosensing mechanism of pCRP dissociation to mCRP is likely also relevant to other pathologies involving increased shear rates, such as in atherosclerotic and injured arteries.

Impact of a New Preoperative Stratification Based on Cardiac Structural Compromise in Patients with Severe Aortic Stenosis Undergoing Valve Replacement Surgery

Introduction and objectives: Aortic valve replacement surgery (SAVR) remains a recommended indication, though its pre-surgical stratification is an ongoing challenge. Despite the widespread use of scores like the STS and EuroSCORE II, they have a number of limitations, while often neglecting structural parameters like left ventricular hypertrophy or left atrium volume. This study aimed to evaluate whether a new adaptation of the Généreux classification in the preoperative risk stratification of severe aortic stenosis (AS) is associated with the primary outcome, and to compare it with the original classification versus the traditional scores in short- and long-term follow-up. Methods: We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent SAVR. The new stratification categorized patients into three stages. Cox regression analyses were conducted to identify factors associated with mortality, with survival analysis performed using Kaplan–Meier curves. A p-value &lt; 0.05 was considered statistically significant. Results: A total of 508 patients were included. Stage 3 patients had a lower median age (67 years). The median EuroSCORE II and STS scores were 2.75 and 2.62%, respectively (p ≤ 0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan–Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p ≤ 0.001). Multivariable analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44–7.20], p = 0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92–0.99], p = 0.021) as independent variables of mortality. The original Généreux scale AUC was higher (AUC: 0.760, 95% CI: 0.692–0.829) compared to the modified Généreux scale (AUC: 0.758, 95% CI: 0.687–0.829). However, no statistical differences were found between the different scales. Conclusions: Preoperative three-stage classification and low transaortic gradient are factors associated with increased all-cause mortality in patients undergoing SAVR. The proposed staging system performed better in the mortality analysis than EuroSCORE II and STS and was similar to the original classification.

Right anterior mini-thoracotomy as first-line strategy for isolated aortic valve replacement: a retrospective study.

Minimally invasive procedures are increasingly implemented in aortic valve replacement (AVR) surgeries to minimize surgical trauma and achieve early patient recovery. We aimed to compare between short- and mid-term outcomes for isolated AVR using the representative minimally invasive approaches of right anterior mini-thoracotomy (RAMT) and partial upper sternotomy [J-sternotomy (JS)]. Patients (n=832) who had undergone surgical AVR between March 2009 and September 2022 were included. We retrospectively examined and compared data from these two minimally invasive approaches, and performed propensity score matching to account for differences in patient baseline characteristics. Early outcomes and late mortality were compared between the matched groups. After applying exclusion criteria, the study comprised 315 patients who underwent RAMT and 92 who underwent JS. Patients who underwent JS had more comorbidities, compared with those who underwent RAMT. Propensity score matching of 16 variables yielded similar groups for comparison (n=90). Thirty-day mortality was similar between the two groups (0% vs. 1%, respectively; P>0.99). In the RAMT group, the rate of on-table extubation was significantly higher (P<0.001), whereas the blood transfusion rate was lower and length of stay was shorter, compared with the JS group. The 5-year survival rate was higher in the RAMT group than in the JS group (95.0% vs. 85.6%, respectively; P=0.03). AVR via RAMT was associated with improved early clinical outcomes, shorter length of stay, and increased survival, compared with JS. Despite the technical challenges associated with RAMT, this procedure can be considered a primary strategy for isolated AVR.

Safety of Non-vitamin K Antagonist Oral Anticoagulants on Outcomes After Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis.

The existing evidence on the use of non-vitamin K oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR) surgery is inconclusive and contradictory. Likewise, major society guidelines remain ambivalent about NOAC use around the time of TAVR. The objective of our meta-analysis was to assess the efficacy of NOACs in comparison to vitamin K antagonists (VKAs) in lowering complications following TAVR. An electronic literature search was conducted using MEDLINE, EMBASE, the international clinical trials database, and Cochrane Library. The primary endpoint was all-cause mortality, and the secondary endpoints included cardiovascular-related death, myocardial infarction, all-cause stroke, and various bleeding events. Forest plots were constructed for the pooled analysis of data. Subgroup and sensitivity analyses were also performed. No significant difference was noted between the NOAC and VKA groups with respect to the risk of all-cause mortality (14.14% vs. 20.28%; risk ratio (RR): 0.82; 95% confidence interval (CI): 0.61 to 1.10; p = 0.18), cardiovascular-related deaths (6.10% vs. 8.55%; RR: 1.02; 95% CI: 0.78 to 1.33; p = 0.91), myocardial infarction (1.52% vs. 2.51%; RR: 1.13; 95% CI: 0.50 to 2.56; p = 0.77), all-cause stroke (2.74% vs. 2.68%; RR: 1.02; 95% CI: 0.75 to 1.39; p = 0.89), major bleeding (7.74% vs. 9.62%; RR: 0.97; 95% CI: 0.58 to 1.61; p = 0.90), minor clinically relevant bleeding (14.33% vs. 13.73%; RR: 0.91; 95% CI: 0.67 to 1.24; p = 0.55), and other bleeding events. The risk of intracranial hemorrhage was lower in the NOAC group than in the VKA group (0.45% vs. 0.67%; RR: 0.61; 95% CI: 0.42 to 0.88; p = 0.008). Our study found NOACs to be non-inferior to VKAs in several outcomes, such as all-cause mortality, cardiovascular-related deaths, myocardial infarction, all-cause stroke, and bleeding events. In fact, NOACs were favored over VKAs, as the VKA group had a higher risk of developing intracranial hemorrhage.

Computational Model for Early-Stage Aortic Valve Calcification Shows Hemodynamic Biomarkers.

Heart disease is a leading cause of mortality, with calcific aortic valve disease (CAVD) being the most prevalent subset. Being able to predict this disease in its early stages is important for monitoring patients before they need aortic valve replacement surgery. Thus, this study explored hydrodynamic, mechanical, and hemodynamic differences in healthy and very mildly calcified porcine small intestinal submucosa (PSIS) bioscaffold valves to determine any notable parameters between groups that could, possibly, be used for disease tracking purposes. Three valve groups were tested: raw PSIS as a control and two calcified groups that were seeded with human valvular interstitial and endothelial cells (VICs/VECs) and cultivated in calcifying media. These two calcified groups were cultured in either static or bioreactor-induced oscillatory flow conditions. Hydrodynamic assessments showed metrics were below thresholds associated for even mild calcification. Young's modulus, however, was significantly higher in calcified valves when compared to raw PSIS, indicating the morphological changes to the tissue structure. Fluid-structure interaction (FSI) simulations agreed well with hydrodynamic results and, most notably, showed a significant increase in time-averaged wall shear stress (TAWSS) between raw and calcified groups. We conclude that tracking hemodynamics may be a viable biomarker for early-stage CAVD tracking.

Incidence of Clinical Outcomes in Minimally Invasive Valvular Surgery at the Ignacio Chávez National Institute of Cardiology.

Minimally invasive cardiac valve replacement surgery (MICS) is a technique that has reported equivalent rates of mortality and reintervention when compared to conventional median sternotomy (CS). Additionally, MICS has inconsistently been reported to be associated with fewer postoperative complications, better cosmetic outcomes, and shorter hospital stays at the expense of longer surgical time, aortic clamp time, and extracorporeal circulation time. When comparing populations undergoing MICS vs CS at the Ignacio Chávez National Institute of Cardiology (INCICh), it was proven that there is a longer surgical, extracorporeal circulation, and aortic clamp durations in the MICS intervention, but no statistically significant difference in global mortality. MICS was also associated with a shorter hospital stay and less surgical discomfort. MICS can be considered an alternative and equivalent approach to CS for patients undergoing aortic and mitral valve replacement surgery in the Mexican population.

Incidence and Prognostic Significance of Silent Coronary Disease in Asymptomatic Patients with Severe Aortic Stenosis.

Background and Objectives: The aim of this study was to estimate the prevalence of silent coronary artery disease (CAD) in asymptomatic patients with severe aortic stenosis (AS) and assess long-term prognosis in terms of major adverse cardiovascular event (MACE)-free survival. Materials and Methods: This was a prospective study conducted at the Clinic for Cardiac Surgery, University Clinical Center of Serbia, in asymptomatic patients with severe AS, normal LVEF and stress test without signs of myocardial ischemia. Adverse cardiovascular events (cardiac death, myocardial infarction and any hospitalization due to heart disease) was monitored during one year of follow up. Results: A total of 116 asymptomatic patients with severe AS were included in the study. The average age was 67.3 ± 9.6 years, and 56.9% of patients were men. The most common cause of AS was degenerative valvular disease (83.5%). The incidence of significant CAD was 30 out of 116 patients (25.9%). The median Society for Thoracic Surgeons (STS) predicted risk of mortality score was 1.62% (25th to 75th percentile: 1.15-2.76%). The overall mean gradient across aortic valve (Pmean) was 52.30 mmHg ± 12.16, and the mean indexed AVA (AVAi) was 0.37 ± 0.09 cm2/m2. The mean LVEF was 68.40% ± 8.01%. Early surgery for aortic valve replacement was performed in 55 patients (55.2%), while 52 (44.8%) patients received conservative treatment. Twenty-two patients (42.3%) in the conservative treatment group underwent surgery during follow up. There were a total of 44 (37.9%) patients with MACE during one year of follow up. Univariate Cox regression analyses identified the following significant risk factors for MACE-free survival: presence of CAD and early conservative treatment (p = 0.004), age (p = 0.003), diabetes mellitus (p = 0.016) and STS score (p = 0.039). According to multivariate analysis, the presence of CAD with early conservative treatment was the most important predictor of MACE-free survival in asymptomatic patients with severe aortic stenosis (p ≤ 0.001). Conclusions: Early surgery for aortic valve replacement in asymptomatic patients with severe AS and concomitant CAD is beneficial for long-term survival.

Determinants of Prosthesis-Patient Mismatch after Aortic Valve Replacement-Ten-Year Cohort Data in Single Center of Taiwan.

Patient-prosthesis mismatch (PPM) after surgical aortic valve replacement for severe aortic stenosis has a significant effect on survival. Few studies have identified the risk factors for PPM and related outcomes. This study investigated these risk factors and clarified the outcomes. This study enrolled consecutive patients who underwent aortic valve replacement surgery between January 2010 and June 2020 in our hospital. Data on clinical profiles, prosthesis types, echocardiographic parameters before and after surgery, and clinical outcomes including the composite of all-cause mortality and redo valve replacement were collected. We defined moderate and severe PPM as an effective orifice area index value of ≤ 0.85 and ≤ 0.65 cm2/m2, respectively, measured postoperatively through echocardiography. Potential risk factors for PPM and clinical outcomes were evaluated. A total of 185 patients were enrolled. Body surface area (BSA; 1.68 ± 0.02 vs. 1.62 ± 0.01 m2, p = 0.036), renal insufficiency (32.50% vs. 11.70%, p = 0.026), and aortic annulus diameter (1.99 ± 0.05 vs. 2.17 ± 0.03 cm, p = 0.013) were statistically significant risk factors for severe PPM. The primary outcome was observed in 30.00% and 15.86% of the patients with and without severe PPM, respectively (log-rank p = 0.023). Multivariate Cox proportional hazards analysis indicated that severe PPM was a risk factor for the primary outcome (hazard ratio: 2.688, 95% confidence interval: 1.094-6.622, p = 0.031). Our study demonstrated that large BSA, renal insufficiency, and small annulus diameter were risk factors for severe PPM after aortic valve replacement surgery. Severe PPM was associated with worse clinical outcomes.

Aortic Annular Enlargement versus Isolated Aortic Valve Replacement in Patients with Matched Annulus

We aimed to determine the effect of aortic annular enlargement on the mid-term outcomes of aortic valve replacement surgery by comparing patients with the same-sized (≤23 mm) native aortic annuli. From January 2011 to June 2022, 1,328 patients underwent isolated aortic valve replacement-1,163 without aortic annular enlargement (AVR group) and 165 with aortic annular enlargement (AVR+AAE group). Propensity score matching identified 112 pairs, controlling for native aortic annulus diameter, age, sex, diabetes, chronic lung disease, dialysis, ejection fraction, prior cardiac surgery, indication, hypertension, dyslipidemia, valve type, prior stroke, prior myocardial infarction, and case status. Demographic and preoperative parameters were similar, except body surface area was larger in the AVR+AAE group (2.1 m2 vs 1.9 m2). Median native aortic annulus diameter was 23 mm in both groups. Median prosthesis size was 25 and 23 in the AVR+AAE and AVR groups, respectively. The AVR+AAE group had longer cardiopulmonary bypass (143 vs 111 mins) and cross-clamp (115 vs 82 mins) times. Incidences of perioperative complications including operative mortality (1.8% AVR+AAE vs 3.6% AVR) were similar between groups. 6-year survival was 98% in the AVR+AAE group and 74% in the AVR group (p=0.016). Aortic annular enlargement was an independent protective factor for mid-term mortality with a hazard ratio of 0.19 (p=0.006). The rate of moderate/severe patient-prosthesis mismatch was 19% in the AVR+AAE group and 31% in the AVR group (p=0.16). Patients with small native aortic annuli (≤23 mm) undergoing isolated aortic valve replacement may benefit from aortic annular enlargement.

Bioprosthetic Versus Mechanical Prostheses in Patients Aged 50 to 70 Years Undergoing Aortic Valve Replacement Surgery: Outcomes Analysis From Propensity Score Matching

Bioprosthetic Versus Mechanical Prostheses in Patients Aged 50 to 70 Years Undergoing Aortic Valve Replacement Surgery: Outcomes Analysis From Propensity Score Matching

Intraoperative Assessment of Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing Aortic Valve Replacement

ObjectivesEvaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two- and three-dimensional echocardiographic measurements and strain analysis. DesignProspective observational study SettingAt single university hospital Participants25 patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course. InterventionsTransesophageal echocardiography (TEE) was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. Measurements and Main ResultsEchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D- and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D- and 3D-EF, GWI and GCW decreased significantly after AVR [T1 v T2, 1647 ± 380 mmHg% v 1021 ± 233 mmHg%, p<0.001; T1 v T2, 2095 ± 433 mmHg% v 1402 ± 242 mmHg%, p<0.001, respectively], while GWW remained unchanged [T1 v T2, 296 mmHg% (IQR 178-452) v 309 mmHg% (IQR 255-438), p=0.97]. This resulted in a decreased GWE directly after bypass [T1 v T2, 84 ± 6 % v 78 ± 5 %, p<0.001], but GWE already improved at the end of surgery [T2 v T3, 78 ± 5 % v 81 ± 5 %, p=0.003]. There was no significant change in the values of GWI, GCW, 2D- and 3D-LVEF before and after sternal closure [T2 v T3]. ConclusionLV MW analysis showed a reduction of LV work load after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery.