Postoperative Pacemaker Implantation Research Articles

Early and Long-Term Outcomes of Patients Undergoing Surgery for Native and Prosthetic Valve Endocarditis: The Role of Preoperative Neutrophil-to-Lymphocyte Ratio, Neutrophil-to-Platelet Ratio, and Monocyte-to Lymphocyte Ratio.

Background/Objectives: Previous studies evaluated the prognostic role of hematological parameters in predicting outcome in patients with infective endocarditis (IE). However, only a few studies evaluated the role of hematological parameters in patients undergoing surgery for IE. The aim of this study was to review our 20-year experience with the treatment of native (NVE) and prosthetic (PVE) valve endocarditis and to evaluate the role of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), neutrophil-to monocyte ratio (NMR), and systemic inflammatory index (SII) on early and long-term outcomes of patients undergoing surgery for NVE and PVE. Methods: All adult patients undergoing surgery for NVE and PVE at our institution between January 2001 and December 2022 were included in the study. Preoperative NLR, NPR, PLR, MLR, NMR, and SII were calculated using hemograms with complete blood count. Results: During the study period, 503 patients, 371 (74%) males, median age 65 (52-73) years, underwent surgery for NVE (n = 337, 67%) or PVE (n = 166, 33%). Patients with PVE had significantly more aortic annulus abscess (95 (57%) vs. 51 (15%); p < 0.001), longer CPB (180 (131-235) vs. 105 (84-145) min; p < 0.001) and aortic cross-clamping times (129 (96-175) vs. 82 (64-114) min; p < 0.001), and received more aortic homografts (47 (28%) vs. 28 (9%); p < 0.001) and postoperative pacemaker implantation (25 (15%) vs. 20 (6%); p < 0.001 compared to patients with NVE. Preoperative NLR was 3.7 (2.4-6.1), NPR was 23 (16-37), PLR was 159 (106-210), NMR was 8.4 (6.6-12), MRL was 0.41 (0.29-0.62], and SII was 790 (485-1396). NLR, NPR, and MLR were significantly lower in patients with NVE compared to patients with PVE and in survivors compared to non-survivors. Overall mean survival time was 12.2 ± 0.5 years, with patients with NVE having better early and late survival compared to patients with PVE. Patients with preoperative NLR < 3.8, NPR < 30.9, and MLR < 0.4 had significantly better mean survival time compared to patients with preoperative NLR > 3.8, NPR > 30.9, and MLR > 0.4, respectively. Conclusions: In patients undergoing surgery for IE, preoperative higher NLR, NPR, and MLR are associated with increased early and long-term mortality.

Transcatheter aortic valve replacement with balloon-expandable and self-expandable valves in Japanese patients with large annulus: the OCEAN-TAVI registry

Abstract Background East Asians have smaller aortic valve complexes than individuals from Western countries, and few studies have reported transcatheter aortic valve replacement (TAVR) outcomes in Asian patients with a large annulus. Purpose We aimed to compare the acute and long-term outcomes of TAVR using balloon-expandable valves (BEVs) and self-expandable valves (SEVs) in Asian patients with a large annulus. Methods We retrospectively analyzed the data from the Optimized transCathEter vAlvular interveNtion Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry. A large annulus was defined by annular area ≥ 500 mm2 and average diameter ≥ 25 mm in computed tomography scans. The primary endpoint was the 3-year all-cause mortality. Secondary endpoints were 3-year heart-failure rehospitalization (HFR) after TAVR, acute outcomes of TAVR, and changes in valve function on echocardiography 2 years after TAVR. Results Among 773 patients, 671 (86.8%) underwent BEV-TAVR. The SEV-TAVR group showed a significantly higher incidence of above-moderate perivalvular leakage (2.1% vs. 7.8%; P &amp;lt; 0.001), and included a significantly greater percentage of patients who required postoperative pacemaker implantation (6.1% vs. 11.8%; P = 0.035). The incidence of moderate-to-severe prosthesis–patient mismatch did not differ between the two groups. The Kaplan–Meier curve showed no significant intergroup differences in the 3-year all-cause mortality and HFR rates (log-rank P = 0.900), and the echocardiography-indexed effective orifice area and mean transaortic valve pressure gradient at 2 years post-TAVR did not differ significantly between the two groups. Conclusions The benefits of BEV-TAVR may outweigh those of SEV-TAVR in patients with a large annulus.

Perioperative and mid-term outcomes of mitral valve surgery with and without concomitant surgical ablation for atrial fibrillation: a retrospective analysis.

We retrospectively analysed perioperative and mid-term outcomes for patients undergoing mitral valve surgery with and without atrial fibrillation. Patients who underwent mitral valve surgery between January 2018 and February 2023 were included and categorized into 3 groups: 'No AF' (no documented atrial fibrillation), 'AF no SA' (atrial fibrillation without surgical ablation) and 'AF and SA' (atrial fibrillation with concomitant surgical ablation). Groups were compared for perioperative and mid-term outcomes, including mortality, stroke, bleeding and pacemaker implantation. A P-value <0.05 was considered statistically significant. Of the 400 patients included, preoperative atrial fibrillation was present in 43%. Mean follow-up was 1.8 (standard deviation: 1.1) years. The patients who underwent surgical ablation for atrial fibrillation exhibited similar overall outcomes compared to patients without preoperative atrial fibrillation. Patients with untreated atrial fibrillation showed higher mortality ('No AF': 2.2% versus 'AF no SA': 8.3% versus 'AF and SA': 3.2%; P-value 0.027) and increased postoperative pacemaker implantation rates ('No AF': 5.7% versus 'AF no SA': 15.6% versus 'AF and SA': 7.9%, P-value: 0.011). In a composite analysis of adverse events (Mortality, Bleeding, Stroke), the highest incidence was observed in patients with untreated atrial fibrillation, while patients with treated atrial fibrillation had similar outcomes as those without preoperative documented atrial fibrillation ('No AF': 9.6% versus 'AF no SA': 20.2% versus 'AF and SA' 3: 9.5%, P-value: 0.018). Concomitant surgical ablation should be considered in mitral valve surgery for atrial fibrillation, as it leads to similar mid-term outcomes compared to patients without preoperative documented atrial fibrillation.

Transcatheter Aortic Valve Replacement in Patients With Small Aortic Annuli: A Propensity-Matched Analysis of Gender-Based Outcomes

Background: Patients with small aortic annuli (SAA) are predominantly women. We sought to compare sex-based and propensity-matched outcomes of index transcatheter aortic valve replacement (TAVR) in patients with SAA. Methods: In this retrospective institutional analysis (2012 – 2023), primary stratification was by gender. SAA was defined as aortic valve annulus diameter <23mm. 30-day and 1-year outcomes were compared between the groups. Results: A total of 3911 patients underwent TAVR. Of those, 661 patients had a small aortic annulus of whom 23.8% were men & 76.2% were women. Propensity matching (1:1) identified 152 pairs. The mean age was 81 years. History of prior surgical or percutaneous coronary intervention was more prevalent in men (72.4% vs 48%, p<0.001). Men had a higher incidence of postoperative pacemaker implantation (8.6% vs 3.3%, p=0.05) while only women had iliofemoral dissections (4.6% vs 0%, p=0.007). The rates of moderate (23.0% vs 25.7%) and severe (2.6% vs 0.7%) prosthesis-patient mismatch was not statistically significantly different between the groups (p=0.364). 30-day mortality was 0% while 1-year mortality was 4.3% with no difference between groups. Increase in preoperative creatinine was associated with higher risk of death (HR 1.206, 95% CI 1.025-1.418, p=0.02), while sex was not. Kaplan-Meier survival estimates (Logrank, p=0.768) and cumulative incidence of stroke readmission (p=0.842) were similar in both groups. Conclusion: Outcomes of TAVR in SAA do not differ by sex with safety and efficacy evident in both men and women.

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology.

The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR). PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023. SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary. SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

Single-center real-world data and technical considerations from 100 consecutive patients treated with the Perceval aortic bioprosthesis.

Although the Perceval sutureless aortic valve bioprosthesis presents a feasible alternative to conventional aortic valve prostheses, the extent of its applicability with respect to technical considerations for a real-world patient collective is still under debate. One hundred patients received the Perceval prosthesis [males: 59; age: 72.5 (7.3-79) years] between December 2015 and February 2023 [EuroSCORE II: 2.8 (1.7-5.4)] for an aortic valve replacement (AVR), with additional concomitant procedures, for underlying severe aortic valve stenosis [n = 93 (93)], endocarditis [n = 5 (5)], and redo AVR [n = 7 (7)] including a prior surgical AVR [n = 4 (4)] and a failed transcatheter aortic valve implantation [n = 3 (3)]. Surgery was conducted primarily by median sternotomy [n = 71 (71)] and, alternatively, by the upper hemisternotomy approach [n = 29 (29)]. Over a median follow-up time of 36.5 (16.5-53) months, eight patients (8%) underwent postoperative pacemaker implantation, with five (5%) due to high-grade atrioventricular block, while nine patients experienced a stroke (9%). The median values of maximum and mean gradients across all valve sizes were 22 (18-27.5) mmHg and 10 (13-18) mmHg, respectively. Two patients (2%) had moderate and one (1%) had severe paravalvular leakage, with the latter presenting the only case of underlying valve migration and induced redo AVR with valve explantation 2 days following initial surgery. Thirty-day mortality (and overall mortality) was 5% and 26%, respectively. The implantation of the Perceval bioprosthesis is feasible for a variety of indications, with excellent hemodynamic results and low complication rates in a real-world high-risk patient collective.

Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

ObjectiveRandomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry. MethodsFrom 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied. ResultsPatients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation. ConclusionscTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.

Three Decades of Experience with Aortic Prosthetic Valve Endocarditis.

The objective of this study was to evaluate early and long-term outcomes of patients with aortic prosthetic valve endocarditis (a-PVE) treated with a prosthetic aortic valve (PAV), prosthetic valved conduit (PVC), or cryopreserved aortic homograft (CAH). A total of 144 patients, 115 male and 29 female, aged 67 ± 12 years, underwent surgery for a-PVE at our institution between 1994 and 2021. Median time from the original cardiac surgery was 1.9 [0.6-5.6] years, and 47 (33%) patients developed an early a-PVE. Of these patients, 73 (51%) underwent aortic valve replacement (AVR) with a biological or mechanical PAV, 12 (8%) underwent aortic root replacement (ARR) with a biological or mechanical PVC, and 59 (42%) underwent AVR or ARR with a CAH. Patients treated with a CAH had significantly more circumferential annular abscess multiple valve involvement, longer CPB and aortic cross-clamping times, and needed more postoperative pacemaker implantation than patients treated with a PAV. No difference was observed in survival, reoperation rates, or recurrence of IE between patients treated with a PAV, a PVC, or a CAH. CAHs are technically more demanding and more often used in patients who have extensive annular abscess and multiple valve involvement. However, the use of CAH is safe in patients with complex a-PVE, and it shows excellent early and long-term outcomes.

The Early neo2 Registry: Transcatheter Aortic Valve Implantation With ACURATE neo2 in a European Population.

Background ACURATE neo2 is a transcatheter aortic valve implantation system consisting of a self-expanding bioprosthetic valve with supra-annular leaflet position and featuring innovations to facilitate placement accuracy and reduce paravalvular regurgitation. Methods and Results The goal of the Early neo2 (Early neo2 Registry of the ACURATE neo2 TAVI Prosthesis) was to gather real-life data on safety and efficacy in a European transcatheter aortic valve implantation population treated with ACURATE neo2. Data were collected from 554 consecutive patients treated with ACURATE neo2 at 12 European sites (mean age, 82 years; 66% women; mean European System for Cardiac Operative Risk Evaluation II, 4.5%±3.8%) between September 2020 and March 2021. The composite primary end point was the occurrence of any of the following: postoperative (in-hospital) paravalvular regurgitation grade ≥2, in-hospital acute kidney injury stage 3, postoperative pacemaker implantation, 30-day death, and 30-day stroke. The primary end point occurred in 12.6% of patients. The 30-day rates for all-cause death and all stroke were 1.3% and 2.7%, respectively, and 1.5% of patients exhibited stage 3 acute kidney injury. A total of 34 patients (6.2%) received a postoperative permanent pacemaker. Per core laboratory-adjudicated echocardiographic analysis, mean postoperative aortic valve gradient was 7.6±3.3 mm Hg, and 2.8% of patients exhibited paravalvular regurgitation grade ≥2. Conclusions In this report of postmarket use of the ACURATE neo2 valve in a real-world transcatheter aortic valve implantation population, patients exhibited favorable postoperative hemodynamics and clinical outcomes and a low rate of postoperative pacemaker implantation.

Efficacy and safety of transcatheter aortic valve replacement in the treatment of severe aortic stenosis

Objective: To investigate the efficacy and safety of transcatheter aortic valve replacement (TAVR) in the treatment of severe aortic stenosis. Methods: The clinical data of patients with severe aortic stenosis who underwent TAVR at the People's Hospital of Xinjiang Uygur Autonomous Region between September 2016 and September 2022 were retrospectively analyzed. Changes in aortic transvalvular pressure gradients, valve orifice area, and activity tolerance of patients before and after the surgery were compared. Moreover, postoperative complications and follow-up results from 30 days to 6 years after the surgery were recorded. Results: A total of 76 patients were included in the study (50 males and 26 females), with an average age of (71.3±7.6) years, including 16 rheumatic valvular diseases, 60 senile degenerative diseases, 46 bicuspid valves and 30 tricuspid valves. The success rate of the operation was 96.1% (73/76). Compared with that before the operation, the mean aortic transvalvular pressure gradients decreased [(8.5±2.8) mmHg vs (68.5±19.2) mmHg (1 mmHg=0.133 kPa),P<0.001], but the valve orifice area increased [(1.91±0.31) cm2 vs (0.65±0.21) cm2, P<0.001]. Likewise, six-minute walking test (6MWT) showed that walking distance was longer after the surgery [(430±13) m vs (201±28) m, P<0.001]. There were 1 case of retroperitoneal hematoma, 1 case of stricture balloon dilatation after femoral artery suture concomitant with postoperative puncture site infection, 1 case of femoral artery surgical incision, 2 cases of valve-in-valve (ViV) and 5 cases of perivalvular leakage (4 cases were mild and 1 case was moderate) after the surgery, respectively. Moreover, acute left main artery occlusion during operation occurred in 1 case, ventricular rupture during operation occurred in 1 case and the patient was transferred to valve replacement surgery and finally dead, delayed coronary artery occlusion and death happened in 1 case, and all of the above-mentioned 3 cases were due to surgical failure. Postoperative pacemaker implantation due to third-degree atrioventricular block was performed in 5 cases. There were 1 case of pulmonary embolism, 1 case of transient right limb disorder, 1 case of gastrointestinal bleeding and 1 case of urethral bleeding after the surgery, respectively. The patients were followed up for (1.0±0.1) years (30 days to 6 years), and the results showed that 2 cases died, including 1 case died suddenly at home (the cause of death was unknown) and 1 case died of acute heart failure 8 months after the surgery. Chronic heart failure occurred repeatedly in 6 cases. The quality of life of other patients improved significantly. Conclusion: TAVR is effective and safe for patients with severe aortic stenosis.

Outcomes of concomitant surgical ablation in patients undergoing surgical myectomy for hypertrophic obstructive cardiomyopathy: A systematic review and meta-analysis

ObjectiveStudies investigating the efficacy of concomitant surgical atrial fibrillation (AF) ablation in hypertrophic obstructive cardiomyopathy (HOCM) patients undergoing myectomy are scarce and limited in terms of sample size. We aim to summarize current outcomes of concomitant surgical AF ablation in HOCM patients undergoing surgical myectomy. MethodsThis systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all studies reporting any of the following outcomes of concomitant surgical AF ablation in HOCM patients: freedom from recurrence of AF, overall survival and complications. Outcomes were evaluated using traditional meta-analysis at given time-points and using pooled Kaplan-Meier curves. ResultsA total of 13 studies were included, resulting in a total of 616 individual patients available for analysis. AF was paroxysmal in 68.1% of the patients (95% CI 56.0–78.2%; I2 = 87.1%; 8 studies, 583 participants). The majority of patients (86.2%) underwent either conventional Cox Maze III or IV (95% CI 39.7–98.3%; I2 = 92.4%; 8 studies, 616 patients) procedure. The incidence of early post-operative pacemaker implantation was 6.1% (95% CI 3.1–11.8%). Overall survival at 3, 5 and 7 years was 95.6% (95% CI 93.4–97.9%), 93.6% (95% CI 90.8–96.5%) and 90.5% (95% CI 86.5–94.6%), respectively. Freedom from recurrent AF at 3, 5 and 7 years was 77.6% (95% CI 73.7–81.7%), 70.6% (95% CI 65.8–75.7) and 63.2% (95% CI 56.2–73.8%), respectively. ConclusionThis meta-analysis supports concomitant surgical AF ablation at the time of surgical myectomy in HOCM patients, as it seems to be safe and effective in terminating AF.

In-Hospital Mortality and Risk Prediction in Minimally Invasive Sutureless versus Conventional Aortic Valve Replacement.

Available evidence suggests that a minimally invasive approach with the use of sutureless bioprostheses has a favorable impact on the outcome of patients undergoing aortic valve replacement (AVR). From 2010 to 2019, 2732 patients underwent conventional AVR through median sternotomy with a stented bioprosthesis (n = 2048) or minimally invasive AVR with a sutureless bioprosthesis (n = 684). Using the propensity score, 206 patients in each group were matched, and the matched groups were well balanced regarding preoperative risk factors. Both unmatched and matched patients of the sutureless + minimally invasive group showed significantly shorter cross-clamp times and longer ICU stay. In-hospital mortality was the only outcome measure that was confirmed in both analyses, and was higher in the stented + conventional group (2.54% and 2.43% in unmatched and matched patients, respectively) compared with the sutureless + minimally invasive group (0.88% and 0.97% in unmatched and matched patients, respectively) (p = 0.0047 and p &lt; 0.0001, respectively). No differences in postoperative pacemaker implantation were recorded in matched patients of both groups (n = 2 [1%] in the stented + conventional group vs. n = 4 [2%] in the sutureless + minimally invasive group; p = 0.41). The discrimination power of EuroSCORE II was not confirmed in the sutureless + minimally invasive group, yielding an area under the ROC curve of 0.568. Minimally invasive sutureless AVR has a favorable impact on the immediate outcome and is associated with significantly lower in-hospital mortality rates compared with conventional AVR, resulting in the absence of the discrimination power of EuroSCORE II for predicting AVR outcomes.

Optimizing Anastomoses Technique in Orthotopic Heart Transplantation: Comparison of Biatrial, Bicaval and Modified Bicaval Technique.

Implantation techniques for orthotopic heart transplantation (HTx) have evolved over the centuries. Recently new approaches of modified bicaval techniques to minimize warm ischemia are gaining popularity in the literature. Between 2010 and 2022 n = 238 patients underwent HTx in our department. The recipients were retrospectively reviewed and divided regarding their anastomoses' technique. Anastomoses were sutured either in biatrial (n = 37), bicaval (n = 191) or in a modified bicaval (n = 10) manner with suturing of the superior cava vein and A. pulmonalis anastomosis after removing the aortic cross-clamp during the reperfusion. Warm ischemia was 62 ± 11 min for biatrial, 66 ± 15 min for bicaval, but only 48 ± 10 min for modified bicaval technique (p &lt; 0.001). The incidence of severe primary graft dysfunction (PGD) was comparable between biatrial (27.0%) and bicaval (28.8%) anastomoses. In contrast, in patients with modified bicaval technique PGD occurred only in a single patient (10.0%). The incidence of postoperative pacemaker implantation was 18.2% for biatrial compared to 3.0% for bicaval and 0.0% for modified bicaval technique (p = 0.01). The modified bicaval technique enables to decrease the crucial warm ischemia during HTx compared to both biatrial and regular bicaval techniques. Therefore, we strongly recommend bicaval anastomoses, ideally in a modified manner.

Surgical Outcomes of Congenital Heart Disease in Down Syndrome: Tertiary CenterExperience-Focus on the Electrical Conduction System.

To document outcomes of cardiac surgical repair in Down syndrome (DS) patients with specific focus on the associated electrical conduction morbidities, ultimately leading to a higher incidence of pacemaker implantation (PMI). A retrospective study conducted between 2011 and 2020. A total of 167 DS patients undergoing 204 surgeries were included. The mean gestational age (GA) and mean weight were 37.3weeks and 5.5kg, respectively. Complete atrioventricular septal defect (AVSD) was the most common diagnosis. Pre-operative ECG revealed superior axis deviation (SAD) in 92 and 32% of patients with AVSD and isolated perimembranous ventricular septal defect (VSD), respectively (p < 0.01). Postoperative right bundle branch block (RBBB) was observed in 83 and 55% of patients with AVSD and following perimembranous VSD repair, respectively (p = 0.04). Ten patients underwent post-operative pacemaker implantation (PMI). Reintervention rate was around 8.9%. Three mortalities were encountered throughout the study period, 2 of which were in-hospital deaths. Low mortality was observed, however, a higher rate of PMI requirements noted with risk factors including lower age and weight.

Avoiding oversizing in sutureless valves leads to lower transvalvular gradients and less permanent pacemaker implants postoperatively.

OBJECTIVESThe aim of this study was to evaluate the impact of changing the sizing strategy in aortic valve replacement using the Perceval sutureless prosthesis on haemodynamic outcomes and postoperative pacemaker implantation.METHODSRetrospective analysis of patients implanted with the Perceval valve between 2007 and 2019 was performed by comparing patients implanted before the modification of sizing strategy (OLD group) and after (NEW group). The outcome parameters evaluated were the implanted prosthesis size, haemodynamical profile and postoperative pacemaker implantation.RESULTSThe entire patient cohort (784 patients) consisted of 52% female patients, with a mean age of 78.53 [standard deviation (SD): 5.8] years and a mean EuroSCORE II of 6.3 (range 0.7–76). In 55.5% of cases, surgery was combined. The NEW cohort had more male patients (54.6% vs 43.4%) (P = 0.002). Mean implanted valve size, corrected for body surface area, was significantly lower in the NEW cohort (13.1, SD: 1.4 vs 13.5, SD: 1.4 mm/m2, P < 0.001). The 30-day mortality was 3.4%. Peak and mean transvalvular gradients at discharge were significantly lower in the NEW versus OLD groups: 24.4 mmHg (SD: 9.2) versus 28.4 mmHg (SD: 10.3) (P < 0.001) and 13.6 mmHg (SD: 5.3) versus 15.5 mmHg (SD: 6.0) (P < 0.001). The mean effective opening area and the indexed effective opening area, respectively, increased from 1.5 cm2 (SD: 0.5) and 0.85 cm2/m2 (SD: 0.27) in the OLD group to 1.7 cm2 (SD: 0.5) and 0.93 cm2/m2 (SD: 0.30) in the NEW group (P < 0.001). No difference was found in paravalvular leakage ≥1/4. Centrovalvular leakage ≥1/4 significantly decreased from 18% to 7.9% (P < 0.001). With the new sizing, the new postoperative pacemaker implantation rate decreased significantly from 11% to 6.1% (P = 0.016).CONCLUSIONSCorrect sizing of sutureless aortic valves is crucial to obtain the best possible haemodynamics and avoid complications.

Transseptal versus left atrial approach for mitral valve surgery: postoperative need for pacemaker.

Concerns exist about higher rates of pacemaker implantation using the extended superior transseptal approach for mitral valve surgery. This study aims to compare the extended superior transseptal and the left atrial approach regarding the need for pacemaker implantation after mitral valve surgery. We performed a retrospective analysis of the data of patients undergoing mitral valve surgery through either a sternotomy and transseptal approach or a mini-thoracotomy and left atrial approach in a single centre in the period January 2010 to May 2021. The primary outcome was the evaluation of the postoperative pacemaker implantation rate. Overall, 677 patients were included, 333 with transseptal and 344 with left atrial approach, and 58 (8.6%) patients underwent pacemaker implantation postoperatively. There was no significant difference in the rate of pacemaker implantation between the 2 groups [overall: 34 (10.2%) vs 24 (7%), P = 0.133; for sinus node dysfunction: 12 (3.6%) vs 9 (2.6%), P = 0.459; for high-degree atrioventricular block: 22 (6.6%) vs 15 (4.4%), P = 0.199; transseptal vs left atrial approach, respectively]. A subgroup analysis of the relative effect of transseptal versus left atrial approach on the rate of postoperative pacemaker implantation revealed mitral replacement as a statistically significant confounder (P = 0.019). The exclusion of patients undergoing concomitant cardiac procedures did not lead to a statistically significant difference in the pacemaker implantation rate between the 2 approaches. The analysis of the data of these patients shows no significant difference in the rate of permanent pacemaker implantation between the extended superior transseptal and the left atrial approach for mitral valve surgery.

Impact of a Modified Bicaval Anastomoses Technique on Outcome After Orthotopic Heart Transplantation

<h3>Purpose</h3> Implantation techniques for orthotopic heart transplantation (HTx) have evolved during the centuries. By now, bicaval anastomosis are preferred compared to biatrial as they are reported to cause less pacemaker implantation, however they can increase duration of warm ischemia. Recently new approaches of modified bicaval techniques in order to minimize warm ischemia are gaining popularity in the literature. <h3>Methods</h3> Between 2010 and 2021 n=218 patients underwent HTx in our department. The recipients were retrospectively reviewed and divided regarding their anastomoses technique. Anastomoses were sutured either in biatrial, bicaval or in a modified bicaval manner with suturing of the superior cava vein and A. pulmonalis anastomosis after removing the aortic cross-clamp during the reperfusion. <h3>Results</h3> The majority of patients were transplanted in bicaval (n=179), followed by biatrial (n=34) and modified bicaval technique (n=5). Warm ischemia was 66±15 min for bicaval, 62±11 min for biatrial but only 42±8 min for modified bicaval technique (p<0.01). Bonferroni correction revealed no significant differences between bicaval and biatrial (p=0.18) but between both bicaval and modified bicaval (p<0.01) and biatrial and modified bicaval technique (p=0.05). Incidence of severe primary graft dysfunction was comparable between bicaval (29.9 %) and biatrial (27.3 %) anastomosis. In contrast, in patients with modified bicaval technique primary graft dysfunction did not occur. The same effect was observed for perioperative neurological events as well as thoracic bleeding. In addition, stay on intensive care unit was significantly shorter for modified bicaval patients (p=0.02). Incidence of postoperative pacemaker implantation was 16.7 % for biatrial compared to 3.2 % for bicaval and 0 % for modified bicaval technique (p=0.03). <h3>Conclusion</h3> While incidence of postoperative need for pacemaker implantation was increased in patients with biatrial anastomoses, there was no significant difference regarding warm ischemia and perioperative adverse events compared to bicaval technique. Although the results for modified bicaval technique are only preliminary by now, we were able to report promising results with significant shorter duration of warm ischemia and decreased perioperative complications indicating an optimized anastomoses technique for HTx.

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

OBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.

401 Conventional Aortic Valves Versus Rapidly Deployed Valves in The Elderly Population. A Comparative Study in A Single Centre Experience

Abstract Aim Current recommendations favour TAVI over Surgical Aortic valve replacement (SAVR) for patients aged&amp;gt;75 years. However, in current practice a significant proportion of patients in this group are offered SAVR. Rapidly deployed valves are of increasing popularity among surgeons as they shorten the procedure time, but their benefits are yet to be investigated. Method Patients aged &amp;gt;75 years undergoing Aortic valve replacement with or without any concomitant procedure were included between January 2014 and January 2020 (total: 597). Patients were divided into two groups: Group A (495 patients) conventional Aortic valve and Group2 (102 patients) rapidly deployed valve. Results Preoperative variables including mean age, EuroScore II, and body mass index were of no statistical significance between the two groups. More females and Octogenarians were in the rapidly deployed valve group versus the conventional valve group, respectively. Bypass time and Cross-clamp times were shorter in rapidly deployed group. However, the length of ICU and hospital stay was not significant between the two groups. Early post-operative pacemaker implantation (Conventional 2% Vs RDV 7%) (P &amp;lt; 0.05) differed significantly between groups. At follow up echocardiography, pressure gradients were comparable between groups. Thirty-day mortality and valve-related complications were insignificant. Conclusions RDVs show comparable early and medium-term outcomes and valve hemodynamics. RDVs are associated with shortened operative time and cross-clamp time but may carry an increased risk of need for permanent pacing.

Atrial fibrillation recurrence and spontaneous conversion to sinus rhythm after cardiac surgery: Insights from 426 patients with continuous rhythm monitoring.

Cardiac surgery may influence occurrence and persistence of atrial fibrillation (AF). In patients with a history of cardiac surgery and postoperative pacemaker or implantable cardioverter defibrillator implantation we attempted to quantify AF characteristics and investigate factors that influence AF recurrence. In 426 patients (319 male; age: 73 SD: 9 years) with a history of cardiac surgery (364 CABG; 69 mitral valve; 57 aortic valve and 59 combination procedures) the heart rhythm history (mean: 351 days SD: 54 days) was reconstructed and investigated for AF recurrence patterns. AF developed and subsequently recurred in 75% of patients (n = 320). The mean AF burden in these patients was 0.21 (21% of the total observed time spent in AF) and 4085 episodes of AF were observed and analyzed. AF episodes spontaneously terminated within 24 h (n = 2509), 48 h (n = 700), 72 h (n = 279), and 1 week (n = 31). The probability of spontaneous conversion to sinus rhythm (SR) decreased with time spent in AF and plateaued after approximately 7 days. Patient age, LVEF and presence of coronary artery disease significantly influenced the probability of spontaneous conversion to SR. Type of cardiac surgery also significantly influenced AF episode characteristics. AF episodes are common in patients with a history of cardiac surgery. Spontaneous conversion to SR diminishes with increasing time spent in AF and is influenced by AF characteristics and several patient-related factors. Continuous monitoring can provide detailed information about AF recurrence that may immensely improve our understanding and influence the clinical management of AF.