Shorter Cross-clamp Research Articles

Single-Center Real-World Experience with Sutureless Aortic Valve Prosthesis in Isolated and Combined Procedures.

Due to their favourable hemodynamic performance and the ability to enable minimally invasive access procedures, sutureless aortic valve prostheses have found their place in the armamentarium of cardiothoracic surgeons. In this study, we sought to review our institutional experience of sutureless aortic valve replacement (SU-AVR). We carried out a retrospective analysis of 200 consecutive patients who underwent an SU-AVR with a Perceval valve between December 2019 and February 2023. The mean age of patients was 69.3 ± 8.1 years, and patients showed a moderate-risk profile with a mean logistic EuroSCORE-II of 5.2 ± 8.1%. An isolated SU-AVR was performed in 85 (42.5%) patients, concomitant CABG was performed in 75 (37.5%) and 40 patients (20%) underwent a multivalve procedure involving SU-AVR. The cardiopulmonary bypass (CPB) and cross-clamp (CC) times were 82.1 ± 35.1 and 55.5 ± 27.8 min, respectively. In-hospital, 30-day, 6-month and 1-year mortality rates were 4.5%, 6.5%, 7.5% and 8.2%, respectively. The postoperative transvalvular mean pressure gradient was 6.3 ± 1.6 mmHg and stayed stable over the follow-up time. We reported no cases of paravalvular leakage, and the incidence of stroke was 0.5%. With their favourable hemodynamic performance and shorter CC and CPB times, sutureless aortic valve prostheses facilitate minimally invasive access surgery, being a safe and durable promising approach for the surgical AVR.

Teaching the Modified Single-Patch Technique for Complete Atrioventricular Septal Defect

Understanding the morphology of atrioventricular septal defects and learning the operative strategies for their repair is one of the more difficult tasks for congenital cardiac surgery residents to master. The modified single-patch technique for several reasons lends itself to being a strategy that is relatively easy to teach residents. It has shorter cross-clamp and bypass times than the standard two-patch technique, which allows more time for the instructor to safely take the resident through the case. The steps of the operation are quite standard and broadly applicable to the wide variety of cardiac morphologies found in children with atrioventricular septal defects. The purpose of this review is to carefully point out the technical details of each step of the modified single-patch technique focusing on teaching the resident surgeon. The ease of teaching this excellent technique is just another reason to use the modified single-patch technique.

Comparison of two cardioplegia solution—del Nido solution and St. Thomas solution used in adult cardiac surgery

Introduction: del Nido (DN) cardioplegia induces a depolarizing arrest during cardiac surgery. It is more dilute (1,4, blood crystalloid) as compared to the traditional 4:1 blood cardioplegia; it has lower Ca+2 and contains lidocaine. St. Thomas’ (ST) cardioplegia has been a popular crystalloid cardioplegia among cardiac surgeons; still, it must be administered constantly at short intervals during the surgery. Aim: To determine whether DN cardioplegia, with longer period of arrest provides better myocardial protection as compared to ST cardioplegia, with shorter period of arrest. Materials and Methods: The study population comprised 46 patients who undergone on pump coronary artery bypass grafting or any valve replacement surgery, which include aortic valve replacement, mitral valve replacement, and double valve replacement between February 2022 and June 2022. The patients were divided into two groups based on the type of cardioplegia given during surgery: (1) ST group (ST, n = 23) and (2) DN cardioplegia group (DN, n = 23). We compared the aortic cross clamp (CC) and cardiopulmonary bypass (CPB) times, number of doses required, and postoperative outcome in the two groups. Results: The CC of time of DN versus ST group (75.82 ± 27.24 vs 85.69 ± 37.20) min and bypass times of DN versus ST group (102.73 ± 35.28 vs 104.86 ± 38.9) min. The DN group was noticed to have shorter CC and CPB times with (P < 0.05). Fewer cardioplegia doses were required in the DN group versus the ST group (1.21 ± 0.42 vs 2.86 ± 1.28; P = 0.001), while a single cardioplegia dose was given to 18 DN patients (78.26%) versus 2 ST patients (8.69%) (P < 0.001). LVEF was better preserved in the DN group. Conclusions: The use of DN cardioplegia results in shorter CC and CPB times, reduces cardioplegia doses, and also provides better myocardial protection with a safety profile as compared to ST cardioplegia.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement.

ObjectiveSutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. MethodsIn this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared.ResultsMortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). ConclusionsSu-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

RF59 PERCEVAL SUTURELESS AORTIC VALVE PROSTHESIS: A PRECIOUS DEVICE TO SIMPLIFY COMPLEX PROCEDURES

Abstract Background and aim: The main feature of sutureless aortic valve implantation is the speed of insertion, thus making implantation easier for the surgeon. As a result, cross clamp times and myocardial ischemia may be reduced. The combined procedures with CABG can be done with a short cross clamp time and cardiopulmonary bypass times. The aim of this study is to evaluate the effects of Percevall sutureless aortic valve prosthesis on surgical outcome in patients underwent combined procedures. Methods: We selected 36 consecutive patients who underwent Perceval implantation combined with coronary artery bypass and or other valve repair or replacement. Clinical, echocardiographic and in-hospital complications were obtained from chart review. Results: The mean age was 76.4 ± 9.8 (median 80) years old, 50% male. Eight of them were previous operated (Redo cardiac surgery22.2%), 3 treated with chronic kidney injury requiring dialysis (8.3%) and two had active endocarditis. Concomitant procedures included: coronary artery bypass (20 pts, 56%), mitral valve replacement or repair (11 pts, 31%), mitral and tricuspid repair/replacement (5 pts, 5%), tricuspid valve repair (1pt,3%) and mitral valve replacement associated to coronary artery bypass (2 pts, 5%). Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was 13.4 ± 12.8. Conclusions: Perceval sutureless aortic prosthesis facilitates reduced aortic cross-clamp and cardiopulmonary bypass times particularly in patients undergoing concomitant procedures allowing promising outcomes especially in high risk patients.

Intraoperative Completion Studies, Local Anesthesia, and Antiplatelet Medication Are Associated With Lower Risk in Carotid Endarterectomy

In Germany, all surgical and endovascular procedures on the carotid bifurcation must be documented in a statutory nationwide quality assurance database. We aimed to analyze the association between procedural and perioperative variables and in-hospital stroke or death rates after carotid endarterectomy. Between 2009 and 2014, overall 142 074 elective carotid endarterectomy procedures for asymptomatic or symptomatic carotid artery stenosis were documented in the database. The primary outcome of this secondary data analysis was in-hospital stroke or death. Major stroke or death, stroke, and death, each until discharge were secondary outcomes. Adjusted relative risks (RRs) were assessed by multivariable multilevel regression analyses. The primary outcome occurred in 1.8% of patients, with a rate of 1.4% in asymptomatic and 2.5% in symptomatic patients, respectively. In the multivariable analysis, lower risks of stroke or death were independently associated with local anesthesia (versus general anesthesia: RR, 0.85; 95% confidence interval [CI], 0.75-0.95), carotid endarterectomy with patch plasty compared with primary closure (RR, 0.71; 95% CI, 0.52-0.97), intraoperative completion studies by duplex ultrasound (RR, 0.74; 95% CI, 0.63-0.88) or angiography (RR, 0.80; 95% CI, 0.71-0.90), and perioperative antiplatelet medication (RR, 0.83; 95% CI, 0.71-0.97). No shunting and a short cross-clamp time were also associated with lower risks; however, these are suspected to be confounded. Local anesthesia, patch plasty compared with primary closure, intraoperative completion studies by duplex ultrasound or angiography, and perioperative antiplatelet medication were independently associated with lower in-hospital stroke or death rates after carotid endarterectomy.

Perceval S and Coronary Artery Bypass Grafting, Contradiction or Full Harmony?

Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, female 35,7%. Cardiovascular risk factors: Hypertension 97,6%; Diabetes 38,1%, Dyslipidemia 69%, peripheral vascular disease 38,2%, prior stroke 9,5%, chronic renal failure 40,5%, obstructive pulmonary disease 21,4% of the patients. Mean Logistic EuroScoreI/II: 16,68/10,73% (expected mortality). Results and Conclusions: Excellent results were achieved in patients undergoing aortic valve replacement with Perceval S sutureless bioprostheses and concomitant coronary artery bypass grafting. Although high aortotomy is needed for Perceval S implantation, is possible to perform proximal anastomosis for saphenous grafts properly. Perceval S is a feasible alternative for patients with aortic valve stenosis and coronary artery disease, with shorter cross-clamp and extracorporeal circulation times and low rate of complications.

Perceval S and Coronary Artery Bypass Grafting, Contradiction or Full Harmony?

Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, female 35,7%. Cardiovascular risk factors: Hypertension 97,6%; Diabetes 38,1%, Dyslipidemia 69%, peripheral vascular disease 38,2%, prior stroke 9,5%, chronic renal failure 40,5%, obstructive pulmonary disease 21,4% of the patients. Mean Logistic EuroScoreI/II: 16,68/10,73% (expected mortality). Results and Conclusions: Excellent results were achieved in patients undergoing aortic valve replacement with Perceval S sutureless bioprostheses and concomitant coronary artery bypass grafting. Although high aortotomy is needed for Perceval S implantation, is possible to perform proximal anastomosis for saphenous grafts properly. Perceval S is a feasible alternative for patients with aortic valve stenosis and coronary artery disease, with shorter cross-clamp and extracorporeal circulation times and low rate of complications.

Abstract 16469: One Hundred Consecutive Patients With Perceval Sutureless Valve: A Good Alternative to Standard Avr and Tavr

Introduction:The recently introduced sutureless prostheses for aortic valve replacement allow short cross-clamp and CPB times with good clinical and haemodynamic performances. It is arguable that these factors can positively impact on post-operative morbidity and mortality, in particular in those patients with a medium- high risk profile. This study shows the mid-term results of a single center experience in patients undergoing AVR. with the Perceval sutureless bioprosthesis (Sorin Group, Saluggia, Italy) Methods:One hundred patients (64 female; mean age 78.2±4.7 years) with aortic valve stenosis (mean gradient of 51.3±14,2 mmHg) underwent aortic valve implantation with the sutureless Perceval bioprosthesis. High-thoracic epidural analgesia was used in 31 patients (31%). Associated CABG surgery was performed in 29 patients (29,%). The mean logistic EuroSCORE was 14.9±9.4% and the STS score was 3,3±1,7. Results:Thirty-day mortality was 2% (n=2). Mean CPB and cross-clamp times for isolated AVR were 38,1±18,6 and 24,2±9,8 minutes respectively. Perioperative echocardiography revealed significant paravalvular leakage in three patients (3%). Postoperative mean trans-valvular gradient was 13.6±5.2 mmHg. AV block requiring PM implantation occurred in 2 patients (2%). No thrombosis and no post-operative strokes were observed. At a mean follow-up of 13±6.7 months, no significant paravalvular leakage or valvular regurgitation was observed, and no migration or dislodgement of the prosthesis occurred. Conclusions:This study shows that sutureless implantation of the Perceval aortic valve bioprosthesis provides a simple and reproducible alternative for standard AVR and TAVR in medium-high risk patients eligible for AVR. The use of this self-anchoring valve was also associated in our patients with absence of embolic events and a very low incidence of AV blocks requiring PM implantation. These findings encourage the use of this valve in a broader spectrum of patients A control randomized trial is needed to confirm these promising findings.

Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial)†.

The aim of the Cavalier trial was to evaluate the safety and performance of the Perceval sutureless aortic valve in patients undergoing aortic valve replacement (AVR). We report the 30-day clinical and haemodynamic outcomes from the largest study cohort with a sutureless valve. From February 2010 to September 2013, 658 consecutive patients (mean age 77.8 years; 64.4% females; mean logistic EuroSCORE 10.2%) underwent AVR in 25 European Centres. Isolated AVRs were performed in 451 (68.5%) patients with a less invasive approach in 219 (33.3%) cases. Of the total, 40.0% were octogenarians. Congenital bicuspid aortic valve was considered an exclusion criterion. Implantation was successful in 628 patients (95.4%). In isolated AVR through sternotomy, the mean cross-clamp time and the cardiopulmonary bypass (CPB) time were 32.6 and 53.7 min, and with the less invasive approach 38.8 and 64.5 min, respectively. The 30-day overall and valve-related mortality rates were 3.7 and 0.5%, respectively. Valve explants, stroke and endocarditis occurred in 0.6, 2.1 and in 0.1% of cases, respectively. Preoperative mean and peak pressure gradients decreased from 44.8 and 73.24 mmHg to 10.24 and 19.27 mmHg at discharge, respectively. The mean effective orifice area improved from 0.72 to 1.46 cm(2). The current 30-day results show that the Perceval valve is safe (favourable haemodynamic effect and low complication rate), and can be implanted with a fast and reproducible technique after a short learning period. Short cross-clamp and CPB times were achieved in both isolated and combined procedures. The Perceval valve represents a promising alternative to biological AVR, especially with a less invasive approach and in older patients.

Perceval Sutureless Valve - are Sutureless Valves Here?

With the advent of transcatheter aortic valve implantation (TAVI) techniques, a renewed interest has developed in sutureless aortic valve concepts in the last decade. The main feature of sutureless aortic valve implantation is the speed of insertion, thus making implantation easier for the surgeon. As a result, cross clamp times and myocardial ischemia may be reduced. The combined procedures (CABG with AVR in particular) can be done with a short cross clamp time. Perceval valve also provides an increased effective orifice area as compared with a stented bioprosthesis. Sutureless implantation of the Perceval valve is not only associated with shorter cross-clamp and cardiopulmonary bypass times but improved clinical outcomes too. This review covers the sutureless aortic valves and their evolution, with elaborate details on Perceval S valve in particular (which is the most widely used sutureless valve around the globe).

Minimal access rapid deployment aortic valve replacement: Initial single-center experience and 12-month outcomes

A single-center observational study was initialized to evaluate the feasibility of rapid deployment aortic valve replacement using the Edwards Intuity valve system (Edwards Lifesciences Corp, Irvine, Calif) in a minimally invasive setting. A total of 60 implantations have been performed at the Ruhr University Hospital Bergmannsheil using a minimal access technique. We present the first short-term and 12-month clinical and hemodynamic results. Aortic valve replacement using a partial sternotomy was performed in all patients. Patients' mean age was 75.5 (±6.2) years. The mean logistic European System for Cardiac Operative Risk Evaluation was 8.4 ± 4.2, and 39% (n = 23) of patients were female. A clinical follow-up for echocardiographic assessment was performed after 12 months. The 30-day mortality rate was 1.7% (n = 1). The mean postoperative transprosthetic gradient was 11.7 (±4.3) mm Hg. The mean effective orifice area was 1.8 (±0.3) cm(2). One case of higher-grade regurgitation (aortic insufficiency >+1) occurred. The late mortality rate was 5.1% (3/59). After 12 months, the mean transprosthetic gradient was 10.3 (±3.8) mm Hg. The mean effective orifice area of 1.8 (±0.3) cm(2) remained unchanged. The mean implantation time was 9 (±3) minutes. The mean crossclamp time was 26 (±7) minutes. The average bypass time was 56 (±16) minutes. Reproducible short crossclamp and bypass times were achieved in a minimally invasive setting. The valve shows good hemodynamic performance comparable to other sutureless or rapid deployment valves. Nevertheless, future follow-up investigation has to be awaited to gain more data concerning durability and safety issues.

SUTURELESS AORTIC VALVE REPLACEMENT USING THE PERCEVAL S PROSTHESIS: SHOULD BICUSPID DISEASE BE A CONTRAINDICATION?

Sutureless aortic valve replacement (AVR) is a relatively new technique for the treatment of aortic stenosis. Bicuspid aortic valve is generally considered a contraindication to sutureless AVR. The aim of this study was to evaluate the feasibility and perioperative outcomes of this technique in patients with bicuspid aortic disease. Between June 2011 and January 2014, 25 patients with aortic bicuspid disease underwent sutureless AVR. Data were collected from preoperative and postoperative transthoracic echocardiography reports (maximum 28 days post-op) and from intensive care unit charts. Surgical approach consisted in a median sternotomy in 13 patients (52%), partial sternotomy in 5 (20%) and minithoracotomy in 7 (28%). Due to advanced age and presence of comorbidities, these patients were selected for AVR. Sutureless AVR was successfully performed in all patients (n=25, 100%). The study population included 17 (68%) male and 8 (32%) female, with a median age of 77.8 ± 5.4 years old. Eleven (44%) of these patients had a preoperative New York Heart Association functional class of III-IV/IV. The mean Euroscore II was 3.4 ± 2.6 %. Concomitant procedures included CABG in 8 patients (32%), ascending aortic replacement in 2 (8%), mitral valve repair in 1 (4%), septal myomectomy in 1 (4%) and atrial septal defect closure in 1 (4%). Mean aortic cross-clamp time was 46 ± 14 minutes in patients who had sutureless AVR alone and 56 ± 14 minutes in those who had concomitant procedures. Mean trans-aortic valve gradient decreased from an average of 49.4 ± 15.7 mmHg preoperatively to 14.5 ± 5.4 mmHg postoperatively. Mean aortic valve area increased from 0.78 ± 0.18 cm2 preoperatively to 1.75 ± 0.43 cm2 postoperatively. Five patients suffered from atrio-ventricular block requiring permanent pacemaker implantation. Two patients suffered from stroke, one of which resulted in permanent hemiparesis. There was no paravalvular leak at the pre-discharge TTE. No postoperative valve migration or embolization was reported. In-hospital mortality occurred in one patient (4%). Mean ICU length of stay was 3 ± 2 days postoperatively. This study demonstrates that Perceval S sutureless valve can be deployed in patients with bicuspid aortic disease without increasing the risk of paravalvular leak, allowing short cross-clamp times, satisfactory postoperative mean trans-aortic gradients and good perioperative mortality and morbidity, considering the high baseline risk status of this population. Bicuspid aortic valve disease should not be considered a contraindication to sutureless AVR.

Direct Reimplantation as an Alternative Approach for Treatment of Anomalous Aortic Origin of the Right Coronary Artery

Anomalous aortic origin of the coronary artery (AAOCA) is a rare cardiac anomaly associated with myocardial ischemia, infarction, and even sudden death. We report 2 patients presenting with AAOCA of the right coronary artery originating from the left coronary sinus with an initial intramural course. In both patients, we performed uncomplicated direct reimplantation of the right coronary artery into the right coronary sinus. For this purpose, the right coronary artery was dissected from the transmural emersion point out of the aortic wall, subsequently as proximal as possible transected and directly reimplanted into the right coronary sinus. In both cases, the postoperative course was uneventful, and cardiac computed tomography confirmed excellent postoperative results after 1 year of follow-up. This technique is a convenient and easily performable approach, characterized by short cross-clamp times and avoidance of aortotomy, and thus is an excellent alternative strategy.

Sutureless aortic valve replacement: a systematic review and meta-analysis.

Sutureless aortic valve replacement (SU-AVR) has emerged as an innovative alternative for treatment of aortic stenosis. By avoiding the placement of sutures, this approach aims to reduce cross-clamp and cardiopulmonary bypass (CPB) duration and thereby improve surgical outcomes and facilitate a minimally invasive approach suitable for higher risk patients. The present systematic review and meta-analysis aims to assess the safety and efficacy of SU-AVR approach in the current literature. Electronic searches were performed using six databases from their inception to January 2014. Relevant studies utilizing sutureless valves for aortic valve implantation were identified. Data were extracted and analyzed according to predefined clinical endpoints. Twelve studies were identified for inclusion of qualitative and quantitative analyses, all of which were observational reports. The minimally invasive approach was used in 40.4% of included patients, while 22.8% underwent concomitant coronary bypass surgery. Pooled cross-clamp and CPB duration for isolated AVR was 56.7 and 46.5 minutes, respectively. Pooled 30-day and 1-year mortality rates were 2.1% and 4.9%, respectively, while the incidences of strokes (1.5%), valve degenerations (0.4%) and paravalvular leaks (PVL) (3.0%) were acceptable. The evaluation of current observational evidence suggests that sutureless aortic valve implantation is a safe procedure associated with shorter cross-clamp and CPB duration, and comparable complication rates to the conventional approach in the short-term.

Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used

Although controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO. Between 1988 and 2011, 147 CEAs (111 men [75%], 36 women [25%]) were routinely performed without a shunt despite CCO. Of these patients, 76% were asymptomatic. CEAs were performed by seven surgeons using standard techniques (not eversion), with patients under general anesthesia and blood pressure maintained at >130 mm Hg. All patients received heparin (7500 U), and protamine reversal was routine. Median cross-clamp time was 20 minutes (range, 14-40 minutes). Three neurologic events occurred ≤ 30 days (2.0%). One transient ischemic attack (TIA) occurred immediately, and one occurred on the first postoperative day due to occlusion of the endarterectomy site. One patient sustained an immediate stroke and died of a large computed tomography-documented atheroembolic shower. Our data demonstrate the safety of CEA in the presence of a CCO, even when performed without a shunt. It is unlikely that the stroke or delayed TIA could be attributed to nonshunting or CCO. Even if so, the stroke and death rates would be lower than those previously reported for patients undergoing CEA in the presence of a CCO. This may be due to short cross-clamp times, careful technique, general anesthesia, and blood pressure support. Given these low adverse event rates, our experience refutes the assumption that patients with a CCO are at such a high risk for CEA that the only alternative is CAS.

Aortic valve replacement in geriatric patients with small aortic roots: are sutureless valves the future?

Aortic valve replacement (AVR) in geriatric patients (>75 years) with small aortic roots is a challenge. Patient-prosthesis mismatch and the long cross-clamp time necessary for stentless valves or root enlargement are matters of concern. We compared the results of AVR with sutureless valves (Sorin Perceval), against those with conventional biological valves. Between April 2007 and December 2012, 120 isolated AVRs were performed in patients with a small annulus (<22 mm) at our centre. In 70 patients (68 females, age 77.4 ± 5.5 years), conventional valves (C group) and in 50 patients (47 females, age 79.8 ± 4.5 years), sutureless valves (P group) were implanted. The Logistic EuroSCORE of the C group was 16.7 ± 10.4 and that of the P group 20.4 ± 10.7, (P = 0.054). Minimal-access surgery was performed in 4.3% (3/70) patients in the C group and 72% (36/50) patients in the P group. The cardiopulmonary bypass (CPB) and cross-clamp times of the C group were 75.3 ± 23 and 50.3 ± 14.2 min vs 58.7 ± 20.9 and 30.1 ± 9 min in the P group, (P < 0.001). In the C group, two annulus enlargements were performed. Thirty-day mortality was 4.3% (n = 3) in the C group and 0 in the P group, (n.s.). At follow-up (up to 5 years), mortalities were 17.4% (n = 12) in the C group and 14% (n = 7) in the P group, (n.s.). This study highlights the advantages of sutureless valves for geriatric patients with small aortic roots reflected by shorter cross-clamp and CPB times, even though most of these patients were operated on via a minimally invasive access. Moreover, due to the absence of a sewing ring, these valves are also almost stentless, with greater effective orifice area (EOA) for any given size. This may potentially result in better haemodynamics even without the root enlargement. This is of advantage, as several studies have shown that aortic root enlargement can significantly increase the risks of AVR. Moreover, as seen in this series, these valves may also enable a broader application of minimally invasive AVR.

The Perceval S Aortic Valve Has the Potential of Shortening Surgical Time: Does It Also Result in Improved Outcome?

Sutureless aortic valve prostheses have the potential of shortening surgical time. However, whether shorter operative times may also result in improved patient outcomes remains to be established. One hundred patients underwent minimally invasive isolated aortic valve replacement. Of these, 50 patients received a Perceval (Sorin Group, Saluggia, Italy) bioprosthesis (group P) and 50 patients received a non-Perceval valve (group NP). The group P patients were older (77.5 ± 5.3 versus 71.7 ± 10 years, p = 0.001) and at higher risk (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE] 9.9 ± 6.5 versus 4.3 ± 1, p = 0.001) than group NP patients. One implant failure occurred in group P (p = 0.5), and conversion to full sternotomy was necessary in 1 patient from each group. Aortic cross-clamp and cardiopulmonary bypass times were 39.4% and 34% shorter in group P (both p < 0.001). Within 30 days, a total of 5 patients died (2 in group P and 3 in group NP, p = 0.5). No significant differences were observed between groups in postoperative arrhythmias and need for pacemaker implantation (p = 0.3 and p = 0.5, respectively). Despite the higher surgical risk, group P patients less frequently required blood transfusion (1.1 ± 1.1 units versus 2.3 ± 2.8 units, p = 0.007), and had a shorter intensive care unit stay (1.9 ± 0.7 versus 2.8 ± 1.9 days, p = 0.002) and a shorter intubation time (9.2 ± 3.6 hours versus 15 ± 13.8 hours, p = 0.01). Group NP patients had a mean prosthesis size significantly smaller than for group P (23 ± 2 mm versus 23.9 ± 1.1 mm, p = 0.01). The Perceval valve provided comparable hemodynamic performance to that of non-Perceval valves (mean gradient 8.4 ± 6 mm Hg versus 10 ± 4.9 mm Hg, p = 0.24). Sutureless implantation of the Perceval valve is associated with shorter cross-clamp and cardiopulmonary bypass times, resulting in improved clinical outcome. In addition, it compares favorably with conventional valves in terms of mortality and outcome variables.

Minimal access median sternotomy for aortic valve replacement in elderly patients

BackgroundWe report our clinical experience with a approach for aortic valve replacement (AVR) via minimal access skin incision and complete median sternotomy. This approach was used in patients with higher age and multiple co-morbidities, facilitating an easy access with short bypass and cross clamp times. It was especially performed in patients asking for an excellent cosmetic result, who did not qualifying for minimally-invasive AVR via partial upper sternotomy.MethodsAVR via minimal-access median sternotomy, was performed in 58 patients between 01/2009 and 11/2011. Intra- and postoperative data including cross clamp time, cardiopulmonary bypass time, mortality, stroke, pacemaker implantation, re-operation for bleeding, ventilation time, ICU and hospital stay, wound infection, sternal dehiscence or fracture and 30 day mortality were collected.ResultsMean patients age was 76.1 +/−9.4 years, 72% were female. Minimal-access AVR could be performed with a mean length of midline skin incision of 7.8 cm. Aortic cross-clamping time was 54.6 +/−6.3 min, cardiopulmonary bypass time 71.2+/−11.3 min and time of surgery 154.1 +/−26.8 min. Re-operation for bleeding had to be performed in 1 case (1.7%). There were no strokes or pacemaker implantations needed. Mean ventilation time was 4.5 h, ICU stay was 2 days and mean length of hospital stay was 6 days. 6 months follow up showed mortality of 0% and no sternal dehiscence or wound infection was observed.ConclusionMinimal-access AVR via complete median sternotomy can be performed safely,in this elderly patient cohort without adding additional operative risk compared to conventional AVR. By avoidiance of large skin incisions this approach combines excellent cosmetic results with fast surgery time and excellent postoperative recovery.

Short crossclamp heart transplantation: a modified technique

Prolongation of the ischemic time in heart transplantation adversely affects the performance of the donor heart. We compared the impact of ischemic time in 30 patients who had the conventional bicaval method with declamping just after the last anastomosis (group A) and 28 who had a modified short crossclamp technique with declamping after left atrial stump, aorta, and inferior vena caval anastomosis (group B). In the operating room, 4 (13.3%) group A patients need one inotropic and 26 (86.6%) need 2 or more; one (3.3%) needed intraaortic balloon pumping. In group B, one inotropic was used in 7 (25%) patients, 4 (14.2%) need 2 or more, and 17 (60.7%) needed no inotropic. Mean crossclamp time was 80.5 ± 4.7 min in group A and 62.4 ± 5.8 min in group B. Weaning from bypass was faster in group B. Transesophageal echocardiography at the end of the operation showed more complete de-airing in group B. There were no significant differences in intensive care unit stay or the incidence of postoperative neurologic complications between the 2 groups. Easier separation from bypass, even without a hot shot, and better echocardiographic systolic parameters postoperatively are the advantages of this modified technique.