Concomitant Aortic Valve Replacement Research Articles

B-55 | Trends and Outcomes of Intra-Aortic Balloon Pump Use in Patients with Concomitant Surgical Aortic Valve Replacement and Coronary Artery Bypass Graft: A 5-Year Cohort Study

B-55 | Trends and Outcomes of Intra-Aortic Balloon Pump Use in Patients with Concomitant Surgical Aortic Valve Replacement and Coronary Artery Bypass Graft: A 5-Year Cohort Study

Descriptive analysis of long-term survival after aortic valve replacement for dialysis patients: importance of renal pathologies and age.

This study analyzed the long-term survival of dialysis patients undergoing AVR using the Japanese National Clinical Database with additional survival data. De-novo AVR for dialysis-dependent patients between 2010 and 2012 who were registered in the Japan Cardiovascular Surgery Database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. An additional questionnaire was sent to each hospital regarding the underlying kidney disease, the duration of dialysis initiation to the surgery, and clinical outcomes. The Kaplan-Meier survival curve was descriptively shown for all cohorts and each renal pathology. Furthermore, we compared the incidence of bioprosthetic valve failure in patients who were < 65years old (group Y) and ≧65years old (group O). Of these 1529 patients, diabetic nephropathy was 517, chronic glomerulonephritis was 437, and renal sclerosis was 210, regarding renal pathology. 1, 3, and 5-year survival in each pathology was 78.4%, 58.6%, 45.9% in diabetic nephritis, 78.8%, 68.4%, 58.2% in chronic glomerulonephritis, 79.0%, 67.8%, 52.1% in renal sclerosis, and 74.4%, 62.6%, 49.2% in others. Active infectious endocarditis was more prevalent in group Y (O 2.7% vs. Y 9.6%). The incidence of bioprosthetic valve failure requiring re-hospitalization was too small to analyze. 1, 3, and 5-year survival was 76.0%, 63.4%, 49.2% in group O and 74.3%, 64.2%, and 47.7% in group Y. Long-term survival of AVR for dialysis-dependent was higher in patients with chronic glomerulonephritis and lower in patients with diabetic nephritis than in other pathologies.

Totally endoscopic concomitant aortic and mitral valve surgery in junctional epidermolysis bullosa: a case report

BackgroundJunctional epidermolysis bullosa is a rare skin and mucosal disorder characterized by blister formation in response to minor trauma and extracutaneous manifestations. There have been no reports of cardiac surgery and prognostication in patients with epidermolysis bullosa due to skin and mucosal fragility.Case presentationA 55-year-old man presented with congenital junctional epidermolysis bullosa, hypertension, and vasospastic angina. He complained of dyspnea on exertion, and transthoracic echocardiography revealed severe aortic valve regurgitation, moderate aortic valve stenosis (tricuspid valve), and severe mitral valve regurgitation. Considering that the skin condition in the right chest wall was relatively healthy, the right thoracotomy approach was preferred and totally endoscopic concomitant mitral valve repair and aortic valve replacement were performed using a sutureless bioprosthetic valve (Perceval™ (Corcym, Group, Milan, Italy)). Polyurethane and silicon dressing foams were used to protect the skin at the site of contact with the bag valve mask, arterial pressure catheter, intravenous catheter, and the tracheal intubation tube. Vertical mattress sutures were used for the skin sutures. The postoperative course was uneventful, and the patient was discharged nine days after the operation. There was no indication for reoperation until three years follow-up period.ConclusionsThe totally endoscopic concomitant aortic and mitral valve surgery using Perceval™ prosthesis can be performed safely in patients with junctional epidermolysis bullosa by adequate protection of the skin and mucosa.

Outcomes of Aortomitral Continuity Reconstruction During Concomitant Aortic and Mitral Valve Replacement

To describe outcomes of reconstruction of the aortomitral continuity (AMC) during concomitant aortic and mitral valve replacement (ie, the "Commando" procedure). A retrospective study of consecutive cardiac surgeries from 2010 to 2022. At a single institution. All patients undergoing double aortic and mitral valve replacement. Patients were dichotomized by the performance (or not) of AMC reconstruction. A total of 331 patients underwent double-valve replacement, of whom 21 patients (6.3%) had a Commando procedure. The Commando group was more likely to have had a previous aortic valve replacement (AVR) or mitral valve replacement (MVR) (66.7% v 27.4%, p < 0.001), redo cardiac surgery (71.4% v 31.3%, p < 0.001), and emergent/salvage surgery (14.3% v 1.61%, p = 0.001), whereas surgery was more often performed for endocarditis in the Commando group (52.4% v 22.9%, p = 0.003). The Commando group had higher operative mortality (28.6% v 10.7%, p = 0.014), more prolonged ventilation (61.9% v 31.9%, p = 0.005), longer cardiopulmonary bypass time (312 ± 118 v 218 ± 85 minutes, p < 0.001), and longer ischemic time (252 ± 90 v 176 ± 66 minutes, p < 0.001). Despite increased short-term morbidity in the Commando group, Kaplan-Meier survival estimation showed no difference in long-term survival between each group (p = 0.386, log-rank). On multivariate Cox analysis, the Commando procedure was not associated with an increased hazard of death, compared to MVR + AVR (hazard ratio 1.29, 95% CI: 0.65-2.59, p = 0.496). Although short-term postoperative morbidity and mortality were found to be higher for patients undergoing the Commando procedure, AMC reconstruction may be equally durable in the long term.

Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve.

Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR. There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded. In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05). The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.

Surgical coronary angioplasty of both coronary ostia after chest radiotherapy. Is it good alternative to conventional coronary bypass surgery?

Isolated coronary ostial stenosis of both ostia is a rare, potentially life-threatening condition, occurring in 0.1%-0.2% of patients undergoing coronary angiography. We present a case of a 69-year-old woman with a past medical history of breast cancer, who had been treated with radiotherapy, which most likely caused significant stenosis of both coronary ostia and likely accelerated aortic stenosis. Surgical angioplasty with autopericardium patch reconstruction of the left main coronary artery and right coronary arteries due to proximal stenotic disease was performed instead of venous or arterial bypasses with concomitant aortic valve replacement. The postoperative course was uneventful. There were no cardiovascular events 5years after operation, and the patient remained free of any symptoms. Surgical coronary angioplasty offers an alternative to conventional coronary artery bypass grafting in isolated coronary ostial lesions and is advantageous in restoring more physiological myocardial perfusion, especially in those cases when conduits are suspected to be fibrotic, scarred or stenosed after radiation therapy or if there is the need to preserve conduits for future myocardial revascularisation in young patients.

The Predictors and Outcomes of Functional Mitral Stenosis following Surgical Mitral Valve Repair: A Retrospective Analysis.

To optimize mitral valve repair outcomes, it is crucial to comprehend the predictors of functional mitral valve stenosis (FMS), to enhance preoperative assessments, and to adapt intraoperative treatment strategies. This study aimed to identify FMS risk factors, contributing valuable insights for refining surgical techniques. Among 228 selected patients, 215 underwent postoperative echocardiography follow-ups, and 36 met the FMS criteria based on a mean trans-mitral pressure gradient of >5 mmHg. Patients with FMS exhibited higher pulmonary systolic arterial pressure and increased late mortality during the follow-up. Univariable logistic regression analysis identified several risk factors for FMS, including end-stage renal disease, anterior leaflet lesion, concomitant aortic valve replacement, smaller ring size, ring type, and neochordae implantation. Conversely, resection alone and resection combined with neochordae implantation had protective effects against FMS. Multivariable logistic regression analysis revealed that smaller ring sizes and patch repair independently predicted FMS. When focusing on degenerative mitral regurgitation, the neochordae implantation without resection in leaflet repair, emerged as an independent predictor of FMS. Surgeons should weigh the substantial impact of surgical procedures on postoperative trans-mitral pressure gradients, emphasizing preoperative evaluation and techniques such as precise ring size assessment and effective leaflet management.

Midterm outcomes of aortic valve replacement using a rapid-deployment valve for aortic stenosis: TRANSFORM trial

BackgroundThe use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory–adjudicated data are scarce, however. Here we report final 7-year data on RDV use. MethodsTRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory–adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years. ResultsThe mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years. ConclusionsAVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.

Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients.

In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients. Eighty-six patients aged > 65years (mean 75years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39). The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10years. In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

Outcomes of mitral valve replacement with complete annular decalcification.

This study aimed to examine the clinical outcomes of mitral valve replacement (MVR) in patients with severe mitral annular calcification (MAC) who required extensive decalcification and mitral annular reconstruction. We reviewed 15 patients with severe MAC who underwent MVR between January 2016 and May 2022. In all cases, the calcified mitral annulus was resected completely using a Cavitron Ultrasound Surgical Aspirator, and a new annulus was created using bovine pericardium. In the acute postoperative phase, strict afterload reduction therapy using an intra-aortic balloon pump (IABP) was administered. The mean age of patients was 73 ± 8 years, and 13 (86.7%) were women. Concomitant aortic valve replacement was performed in 11 (73.3%) patients, tricuspid annuloplasty in 9 (60.0%), coronary artery bypass grafting in 1 (6.7%), and arrhythmia surgery in 7 (46.7%). The mean aortic cross-clamp and cardiopulmonary bypass times were 143 ± 32 min and 175 ± 34 min, respectively. In 13 patients, an IABP was used for 2 or 3 days postoperatively. There were no in-hospital deaths, left ventricular ruptures, or other MAC-related complications. Postoperative echocardiography revealed no paravalvular leakages. Our strategy for managing severe MAC is safe and reproducible even in relatively high-risk patients. Afterload reduction using an IABP in the acute postoperative phase may reduce the risk of fatal complications after extensive decalcification and mitral annular reconstruction.

Trends and outcomes of concomitant aortic valve replacement and coronary artery bypass grafting in the UK and a survey of practices.

Concomitant revascularization of coronary artery disease at the same time as treatment for aortic valvopathy favourably impacts survival. However, combined surgery may be associated with increased adverse outcomes compared to aortic valve replacement (AVR) or coronary artery bypass grafting in isolation. We retrospectively analyzed all patients who underwent AVR with bypass grafting between February 1996 and March 2019 using data from the National Adult Cardiac Surgery Audit. We used a generalized mixed-effects model to assess the effect of the number and type of bypass grafts associated with surgical AVR on in-hospital mortality, postoperative stroke, and the need for renal dialysis. Furthermore, we conducted an international cross-sectional survey of cardiac surgeons to explore their views about concomitant AVR with coronary bypass grafting interventions. Fifty-one thousand two hundred and seventy-two patients were included in the study. Patients receiving 2 or more bypass grafts demonstrated more significant preoperative comorbidity and disease severity. Patients undergoing 2 and >2 grafts in addition to AVR had increased mortality as compared to patients undergoing AVR and only 1 graft [odds ratio (OR) 1.17, 95% confidence interval (CI) [1.05-1.30], P = 0.005 and OR 1.15, 95% CI [1.02-1.30], P = 0.024 respectively]. A single arterial conduit was associated with a reduction in mortality (OR 0.75, 95% CI [0.68-0.82], P < 0.001) and postoperative dialysis (OR 0.87, 95% CI [0.78-0.96], P = 0.006), but this association was lost with >1 arterial conduit. One hundred and three surgeons responded to our survey, with only a small majority believing that the number of bypass grafts can influence short- or long-term postoperative outcomes in these patients, and an almost equal split in responders supporting the use of staged or hybrid interventions for patients with concomitant pathology. The number of grafts performed during combined AVR and coronary artery bypass grafting is associated with increased morbidity and mortality. The use of an arterial graft was also associated with reduced mortality. Future studies are needed to assess the effect of incomplete revascularization and measure long-term outcomes. Based on our data, current published evidence, and the collective expert opinion we gathered, we endorse future work to investigate the short and long-term efficacy and safety of hybrid intervention for patients with concomitant advanced coronary and aortic valve disease.

Aortic valve replacement for moderate aortic stenosis during mitral surgery improves survival free from severe stenosis.

Optimal management of moderate aortic stenosis during surgery for another indication is unclear. We assessed the effects of surgical aortic valve replacement for moderate aortic stenosis during mitral surgery. An institutional mitral surgery database was queried for patients with preoperative moderate aortic stenosis. Patients were stratified by whether they underwent concomitant surgical aortic valve replacement. Morbidity was analyzed using Student's t tests, Wilcoxon rank sum, chi-squared, and Fisher's exact tests. Survival was analyzed using Kaplan-Meier estimation and Cox regression. Of 85 mitral surgery recipients with moderate aortic stenosis from 2012 to 2019, 62 (73%) underwent concomitant surgical aortic valve replacement. Surgical aortic valve replacement recipients were more likely to have bicuspid (11% vs. 0%, p = 0.019) or rheumatic (18% vs. 0%, p = 0.019) aortic valves, and to undergo mitral repair (32% vs. 9%, p = 0.028). Groups did not differ with respect to mitral etiology, New York Heart Association class, or cardiac intervention history (p > 0.05). Postoperatively, groups had similar stroke and gastrointestinal bleed rates (3% vs. 0% and 2% vs. 0% in the surgical aortic valve replacement vs. no surgical aortic valve replacement group respectively, both p > 0.99). Five-year survival free from severe aortic stenosis was higher in the surgical aortic valve replacement group (66% vs. 17%, p = 0.002). Surgical aortic valve replacement protected against the composite of death and progression to severe aortic stenosis at 5 years (hazard ratio: 0.32, p = 0.003). Surgical aortic valve replacement for moderate aortic stenosis at time of mitral surgery is a well-tolerated strategy to reduce aortic disease progression.

Novel concept of less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting avoiding full median sternotomy.

In the last decades, minimally invasive procedures have been developed in the therapy of aortic valve disorders. Recently, a novel concept of minimally invasive coronary revascularization in multivessel disease via left anterior mini-thoracotomy demonstrated promising results. Full median sternotomy, as a very invasive procedure, is the standard approach in concomitant surgical aortic valve replacement (sAVR) and coronary bypass grafting (CABG). The aim of our study was to show that the combination of minimal invasive aortic valve replacement via upper mini-sternotomy and coronary artery bypass grafting via left anterior mini-thoracotomy is feasible to avoid full median sternotomy. From 07/2022 to 09/2022, concomitant sAVR via upper partial sternotomy and CABG via left anterior mini-thoractomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in six consecutive patients (6 males; 69.8 ± 7.4 [60-79] years). All patients had severe aortic stenosis (MPG 45.5 ± 17.3mmHg) and a significant coronary artery disease (three-vessel: 33%, two-vessel: 33%, one-vessel: 33%) with indication to cardiac surgery. Mean EuroScore2 was 3.2. All patients underwent successful less invasive concomitant biological sAVR and CABG. 67% of patients received a 25mm, 33% received a 23mm biological aortic valve replacement (Edwards Lifesciences Perimount). A total of 11 distal anastomoses (1.8 ± 1.0 [1-3] per patient) were performed by using left internal artery mammary (50%), radial artery (17%) and saphenous venous graft (67%) for grafting the left anterior descending (83%), circumflex (67%) and right (33%) coronary artery. Hospital mortality was 0%, stroke rate was 0%, myocardial infarction was 0% and repeat revascularization rate was 0%, ICU stay was 1day in 83% of all patients and 50% left hospital within 8days after surgery. Less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting using upper mini-sternotomy and left anterior mini-thoracotomy is feasible without compromises in surgical principles and complete coronary revascularization while maintaining thoracic stability by avoiding full median sternotomy.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery

BackgroundThe applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types. MethodsA total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures. ResultsOf 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures. ConclusionsEndoscopic AVR can safely address concomitant valve diseases.

P97: Concomitant Aortic Valve Replacement and Left Ventricular Assist Device Implantation in Patients with Aortic Insufficiency

Background: Preoperative aortic insufficiency (AI) is one of the most important predictors of progression to moderate to severe AI during left ventricular assist device (LVAD) support. Our group has aggressively corrected preexistent AI, including mild AI, with bioprosthetic aortic valve replacement (AVR). We analyzed the operative and postoperative results of our patients. Methods: We reviewed data of all patients who underwent LVAD implantation and had concomitant AVR in our center between May 2012 and June 2022. We used either a St. Jude or Edwards bioprosthetic aortic valve. Results: Twenty-five patients (19 men, 6 women) with an average age of 61±12 years had concomitant AVR and LVAD implantation (23 patients as destination therapy and 2 as bridge to transplantation). Eight patients were INTERMACS profile 1, 12 profile 2, and 5 profile 3. Twelve patients had mild, 7 mild to moderate, 4 moderate, 1 moderate to severe and 1 severe AVI. Cardiopulmonary bypass time was on average 136±30 min with cross-clamp time of 63±19 min. The median length of stay after LVAD implantation was 24 (IQR 19-32) days. Target INR ranged from 2 to 3. Five patients had gastrointestinal bleeding; thus, their INR target was between 1.8 -2.2. Four patients had strokes 66, 105, 762 and 1127 days after implantation. The median length of LVAD support was 1143 (range 33-2470) days. One patient died in the hospital 33 days after surgery due to nonischemic bowel perforation-related sepsis. Three other patients died 469, 772 and 1710 days after LVAD implantation. Six patients had heart transplantation. Fifteen patients are alive on LVAD support with a median of 1290 days (range 231 to 2470). All 22 patients who reached 1-year follow-up had normal aortic values with 2 patients having trace and 4 mild AI starting 6 months after AVR. One patient had a valvular thrombus 15 months after surgery. Conclusion: Utilization of concomitant bioprosthetic AVR in patients undergoing LVAD implant who had mild to severe AI seems not to be harmful to patient postoperative management or survival.

Commentary: What Is the Optimal Graft Strategy for Coronary Bypass Grafting with Concomitant Aortic Valve Replacement?

Commentary: What Is the Optimal Graft Strategy for Coronary Bypass Grafting with Concomitant Aortic Valve Replacement?

Coronary artery disease and TAVI: Current evidence on a recurrent issue

Coronary artery disease (CAD) is a frequent finding in patients with aortic stenosis (AS). Concomitant coronary artery bypass and aortic valve replacement is considered the gold standard treatment in surgical candidates. However, limited evidence is available regarding the role of coronary revascularization in patients undergoing transcatheter aortic valve implantation (TAVI).How to evaluate CAD severity in patients with AS, whether percutaneous coronary intervention (PCI) needs to be performed and what is the timing for revascularization to minimize procedural risks, remains matters of debate. The aim of this review is to summarize epidemiology, diagnostic tools and possible options for CAD management in patients undergoing TAVI with specific focus on the pros and the cons of the different timing of PCI.

Single-Center Retrospective Analysis of Acute Type A Aortic Dissection Outcome and Reoperation Focusing on Extended Versus Limited Initial Repair.

The optimal management strategy for acute aortic type A dissection remains controversial. Whether a limited primary (index) repair would increase the need for late aortic reintervention is still an open debate. A total of 393 consecutive adult patients with acute type A aortic dissection who underwent cardiac surgery were analyzed. Our research hypothesis was whether limited aortic index repair (i.e., isolated aorta ascending replacement without an open distal anastomosis with and without a concomitant aortic valve replacement, including hemiarch replacement procedure) is associated with a higher incidence of late aortic reoperation compared with extended repair (i.e., any other surgical procedure that goes beyond that limited approach). Type of the initial repair had no statically significant relationship with in-hospital mortality with a P-value of 0.12, however in multivariable analysis, cross-clamp time had a statistically significant relation with mortality (P = 0.4). From the patients who survived until discharge (N = 311), 40 patients needed a reoperation on the aorta; the mean interval until reoperation was 4.5 years. The relationship between the type of the initial repair and the need for reoperation didn't reach a statically significant value (P = 0.9). In-hospitable mortality after the second operation was 10% (N = 4). We reached two conclusions. 1) An extended prophylactic repair in the initial operation of an acute type A aortic dissection might not lead to a lower incidence of reoperations on the aorta and could increase in-hospital mortality by increasing cross-clamp time, and 2) Reoperation on the aorta could be done safely with acceptable mortality outcomes.

Aortic Valve Replacement and Concomitant Multi-Vessel Coronary Artery Bypass: The Impact of Using the Bilateral Internal Thoracic Arteries on Early and Late Clinical Outcomes.

The survival benefit of coronary artery bypass grafting (CABG) using the bilateral internal thoracic arteries (BITA) is well known; however, the role of BITA in concomitant aortic valve replacement (AVR) and CABG has not been studied. We retrospectively reviewed patients who underwent concomitant AVR and CABG. Cases not using an internal thoracic artery and less than 2 bypass grafts were excluded. We enrolled 114 patients in this study. The mean follow-up duration was 61.5±43.5 months. Forty patients (35.1%) underwent CABG with a single internal thoracic artery (SITA) and 74 patients (64.9%) underwent CABG with BITA. The preoperative clinical characteristics were not significantly different between the 2 groups, with the exception of a higher prevalence of atrial fibrillation in the SITA group. Postoperative mortality and morbidity were not significantly higher in the BITA group than in the SITA group. In the univariable analysis, the survival of the BITA group was similar to that of the SITA group (p=0.157). Multivariable analysis showed that only mean age was a predictor of death (p=0.042), but using BITA was not an independent predictor (p=0.094). In low-risk patients whose preoperative ejection fraction was >45%, the survival of the BITA group was significantly better than that of the SITA group (p=0.043). BITA use in concomitant AVR and CABG showed no difference in mortality compared to using SITA. Although its impact on long-term survival was inconclusive, BITA use can be considered for low-risk patients.

Mechanical vs Bioprosthetic Aortic Valve Replacement in Patients on Dialysis: Long-term Outcomes

BackgroundUsing the Japan National Clinical Database and additional data, this study is an analysis of long-term survival of dialysis-dependent patients who underwent aortic valve replacement (AVR). MethodsDialysis-dependent patients who underwent de novo AVR between 2010 and 2012 and who were registered in the database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. Additional data on the underlying kidney disease, the duration of dialysis, and clinical outcomes were registered between October 29, 2019, and August 30, 2020. The primary outcome was all-cause mortality. The secondary outcomes were cerebral infarction, cerebral bleeding, gastrointestinal bleeding, and prosthetic valve failure. ResultsAfter propensity score matching, 1016 cases (508 each in the bioprosthetic and mechanical valve groups) were matched. The median follow-up period was 3.29 years (interquartile range [IQR], 0.59 years, 6.25 years). The median survival time was 5.38 years (IQR, 1.20 and 9.26 years) in the mechanical valve group and 4.98 years (IQR, 1.69 and 9.62 years) in the bioprosthetic valve group. The Cox regression model showed no significant difference in long-term survival between the groups (mechanical valve: hazard ratio [HR], 0.895; 95% CI, 0.719-1.113; P = .318). The incidences of cerebral infarction and prosthetic valve failure requiring admission were similar between the groups. Cerebral bleeding (HR, 2.143; 95% CI, 1.125-4.080; P = .002) and gastrointestinal bleeding (HR, 2.071; 95% CI, 1.243-3.451; P = .0005) were more frequent in the mechanical valve group. ConclusionsLong-term survival of dialysis-dependent patients was similar regardless of whether mechanical valves or bioprosthetic valves were implanted. The incidences of cerebral and gastrointestinal bleeding were 2-fold higher in the mechanical valve group.