Conventional Reoperation Research Articles

Balloon-expandable versus self-expanding transcatheter aortic valve replacement for bioprosthetic dysfunction: A systematic review and meta-analysis.

Transcatheter aortic valve-in-valve (VIV) procedure is a safe alternative to conventional reoperation for bioprosthetic dysfunction. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the 2 major types of devices used. Evidence regarding the comparison of the 2 valves remains scarce. A systematic review and meta-analysis was conducted to compare the outcomes of BEV and SEV in transcatheter VIV for aortic bioprostheses dysfunction. A computerized search of Medline, PubMed, Embase, and Cochrane databases was performed. English-language journal articles reporting SEV or BEV outcomes of at least 10 patients were included. In total, 27 studies were included, with 2,269 and 1,671 patients in the BEV and SEV groups, respectively. Rates of 30-day mortality and stroke did not differ significantly between the 2 groups. However, BEV was associated with significantly lower rates of postprocedural permanent pacemaker implantation (3.8% vs. 12%; P < 0.001). Regarding echocardiographic parameters, SEV was associated with larger postprocedural effective orifice area at 30 days (1.53 cm2 vs. 1.23 cm2; P < 0.001) and 1 year (1.55 cm2 vs. 1.22 cm2; P < 0.001). For patients who underwent transcatheter aortic VIV, SEV was associated with larger postprocedural effective orifice area but higher rates of permanent pacemaker implantation. These findings provide valuable information for optimizing device selection for transcatheter aortic VIV.

TCT-334 Treatment of degenerated aortic bioprostheses: a comparison between valve-in-valve transfemoral transcatheter aortic valve replacement and conventional reoperation

The use of bioprosthetic valves has increased over the last two decades. However, the major drawback is their deterioration and failure over time, requiring redo surgery. Conventional surgical replacement (re-SAVR) has been standard of care, but valve-in-valve deployment of transcatheter aortic

234Treatment of degenerated aortic bioprostheses: a comparison between conventional reoperation and valve-in-valve transfemoral transcatheter aortic valve replacement

234Treatment of degenerated aortic bioprostheses: a comparison between conventional reoperation and valve-in-valve transfemoral transcatheter aortic valve replacement

Reply to Dainese

We thank Dr Dainese from Milan for his comments [1], although we are a little surprised by his first comment. As was already stated in our paper [2], our first implantation was done on 16 December 2008, our second implantation was done in January 2009 and Dainese [3] performed an implantation on 3 February 2009. Nevertheless, we would like to congratulate Dr Dainese and his colleagues and we acknowledge his contribution to this new field of valve treatment. In the interests of correctness of information, we would also like to draw attention to the first published report regarding TAVI in a degenerated homograft [4] written by Schmoeckel et al. and published in October 2009 in the same journal ( JTCVS) as the paper by Dr Dainese [3]. The colleagues from Munich performed the reported procedure in 2009, as was stated in their publication [4]. Therefore, according to both the contemporary literature and information from the valve manufacturing company, the first ‘TAVI in homograft’ procedure with a balloon expandable valve was done in December 2008 (in Berlin), the second in January 2009 in Berlin and then in Milan (February 2009) and Munich (in 2009). We completely agree with Dr Dainese that conventional reoperation in patients with homograft degeneration may be a challenging procedure, either because of the patients’ comorbidities or because of completely calcified homograft (so-called ‘porcelain aorta’). As pointed out by Dr Dainese, TAVI represents a valid alternative in these cases. We also agree with Dr Dainese about the modified implantation technique [5]. We have used a similar technique almost from the very beginning of the TAVI programme at our institution in April 2008 [6]. We additionally prefer to perform simultaneous angiography during slow and gradual valve deployment which enables perfect visualization of the aortic root and the coronary arteries and fine adjustment to the position of the new valve [6].

Oncological outcomes of transanal local excision for high risk T1rectal cancers

To evaluate the oncological outcomes of transanal local excision and the need for immediate conventional reoperation in the treatment of patients with high risk T(1) rectal cancers. Twenty five high risk T(1) rectal cancers treated by transanal local excision at the Guangdong General Hospital were analyzed retrospectively. Twelve patients received transanal local excision and 13 patients underwent subsequent immediate surgical rescue after transanal local excision within 4 wk. Differences in the local recurrence rates and 5-year overall survival rates between the two groups were analyzed. The prognostic value of immediate conventional reoperation for high risk T(1) rectal cancers was also evaluated. The median follow-up period was 62 mo. The local recurrence rates after transanal local excision for high risk T(1) rectal cancer were 50%. By immediate conventional reoperation, the local recurrence rates were significantly reduced to 7.7%. The difference between these two groups was statistically significant (P = 0.030). Kaplan-Meier survival analysis showed a trend for decreased 5-year overall survival rates for patients treated by transanal local excision compared with immediate conventional reoperation (63% vs 89%). Transanal local excision cannot be considered sufficient treatment for patients with high risk T(1) rectal cancers. Immediate conventional reoperation should be performed if the pathology of the local excision is high risk.

Transatrial Stent-Valve Implantation in a Stenotic Tricuspid Valve Bioprosthesis

A 69-year-old man presented with symptoms of right heart failure due to stenosis of a tricuspid valve bioprosthesis. Echocardiography revealed right atrial dilatation and an estimated tricuspid valve area of 0.4 cm2. Because of advanced poor general condition and comorbidities, he was found unfit for conventional reoperation. Instead, transcatheter transatrial stent-valve implantation through a right thoracotomy was scheduled. The procedure resulted in a markedly improved clinical condition and an increased valve area measured to 2.5 cm2. In conclusion, transcatheter transatrial stent-valve implantation in stenotic valves is technically feasible and may lead to substantial improvement of the clinical condition.

Endoscopic haemostasis of staple‐line haemorrhage following colorectal resection

Bleeding from stapled colonic stapled anastomoses is rare, but occasionally may be severe enough to require re-operation, with associated morbidity. Endoscopic therapy is a potential alternative. We examined a large 15-year prospective series of patients who had undergone colorectal resection with stapled anastomosis. We reviewed the management of cases where severe postoperative rectal bleeding had occurred. In six of 777 (0.8%) patients, bleeding occurred that was severe enough to require intervention. In the first three cases, conventional re-operation was performed. In the latter three cases, endoscopic therapy (adrenaline injection, diathermy or endoscopic clipping) was used to control the bleeding. No complications occurred as a result of endoscopic therapy, either patient or anastomosis related. Endoscopic management using standard endoscopic techniques appears safe and effective for haemostasis in colorectal stapled anastomotic bleeding. Endoscopic therapy should probably be attempted before re-operation is considered.

Local excision for more advanced rectal tumors

Over the past 20 years, local excision (LE) of T1 rectal cancer was increasingly established and represents an oncologically established technique. In contrast, the situation for T2 tumors is less clear and has only been investigated in small patient collectives. LE for T2 tumors is thus discussed controversially. Materials and Methods. In addition to our own patients with T2 rectal cancer treated locally (n=40), we have analysed the local recurrence (LR) rates after LE alone (n=124), after immediate conventional radical reoperation (n=29), after adjuvant (chemo)-radiotherapy (n=294) and those after neoadjuvant chemoradiotherapy (nCRT) (n=269) using a PubMed search. Results. LR rates of low-grade T2 tumors after R0 resection by LE alone was 19%. If additional prognostically unfavorable findings were present, the LR rate rose to 52%. By immediate radical reoperation the LR rate was decreased to 7%, whereas that after adjuvant therapy was 16%. In contrast, LE of more advanced tumors after nCRT resulted in LR rates of 9%. Discussion. LE alone of T2 rectal cancer should not be performed, and after adjuvant chemoradiotherapy the risk of developing LR was also high. In cases with unexpected T2 finding after LE, immediate conventional reoperation can represent an adequate oncological therapy, because it reveals comparable results to those obtained by primary radical resection. First results after nCRT followed by LE showed favorable results with low LR rates. If the indication for LE of T2 cancers can be extended to patients after nCRT in the future will have to be determined in prospective mutlticentre studies.