Standard Aortic Valve Replacement Research Articles

Novel Aortic Valve Replacement Technique for Reducing Complete Heart Block.

Aortic valve replacement (AVR) may complicate conduction abnormalities and require permanent pacemaker (PPM) implantation. New techniques that lessen this challenge may lead to the development of new approaches. Our objective was to evaluate the contemporary incidence of early postoperative PPM implantation in patients undergoing isolated AVR and root disease with the standard AVR surgical technique compared with the novel suture AVR technique. The clinical data of 354 patients (250 male, 104 female) who underwent surgery for isolated AVR and root disease in different referral cardiology departments in Tabriz, Iran, over 4 years were analyzed. Patients with preoperative significant conduction abnormalities were excluded from the study. The patients were evaluated for in-hospital mortality, postoperative PPM implantation, and their stay in the ICU after surgery. The mean age of the patients was 52.46±16.13 years. Totally, 183 patients (51.7%) were operated on with the new suture AVR technique. In-hospital mortality was lower in this group than in the group that underwent the "classic" surgical technique (2.5% vs 3.7%). PPM implantation was required in 3 patients (0.8%) after the novel suture AVR technique, whereas it was needed in 12 patients (3.4%) in the other group (P=0.024). The mortality rate was 9 patients (2.5%) in group 1 and 13 patients (3.7%) in group 2, which was not statistically significant (P=0.296). According to the logistic regression, the survival rate in the group operated on with the classical surgical method was 0.27 times higher than that in the patients operated on with the new method. Permanent complete AV block is a critical complication after AVR surgery. A lower PPM requirement and higher survival in patients operated on with the new method was the main finding of this study. New techniques with lower PPM requirements may be suitable for cardiac surgery.

Intermediate-term Outcomes Following a Case Series of Reoperations for Medtronic Freestyle Stentless Aortic Valves

BackgroundData are limited on long-term outcomes in patients who have undergone a reoperation following failure of a stentless aortic valve. MethodsBetween 2006 and 2016, a retrospective analysis was performed on 24 patients who underwent open aortic valve replacement surgery for a failed stentless aortic valve prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was a low mortality rate from cardiac-related deaths after 5 years. ResultsAll patients underwent insertion of a Medtronic Freestyle bioprosthesis (Minneapolis, MN) implanted using the modified subcoronary technique for their initial operation. The interval from the first operation to the stentless redo surgery ranged from 6 to 13 years. Aortic valve reoperation was performed for structural valve deterioration in 96% (n = 23) of the cases. Reoperations involved a removal of the stented valve leaflets and standard aortic valve replacement within the stentless casing in 20% (n = 5) of the cases, with the remaining cases requiring complete removal of the stentless prosthesis and aortic valve replacement. In those in whom a complete removal of the stentless valve was possible (n = 19), no disruption of the native aortic root occurred, with a 0% rate of conversion to a Bentall procedure. No intraoperative mortality occurred. The 30-day and 10-year operative mortality rates were 4% and 16%, respectively. ConclusionsRedo surgery for failing stentless valves can be done with relatively low risk and with acceptable long-term outcomes without resorting to root-replacement techniques.

Computed tomography-guided aortic valve neocuspidization: details of preoperative assessment and surgical technique

The original Ozaki technique involves sizing and trimming the neovalve cusps during cross-clamp. It leads to prolongation of the ischaemic time, as compared to standard aortic valve replacement. We use preoperative computed tomography scanning of the patient's aortic root to develop personalized templates for each leaflet. With this method, autopericardial implants are prepared before the initiation of the bypass. It permits maximally adopting the procedure to the patient's individual anatomy and to shorten the cross-clamp time. We present a case of a computed tomography-guided aortic valve neocuspidization and concomitant coronary artery bypass grafting with excellent short-term results. We discuss the feasibility and technical details of the novel technique.

Randomized controlled trial between conventional versus sutureless bioprostheses for aortic valve replacement: Impact of mini and full sternotomy access at 1-year follow-up

BackgroundThe present study is a sub-analysis of the multicenter, randomized PERSIST-AVR trial (PERceval Sutureless Implant versus Standard Aortic Valve Replacement) comparing the in-hospital and 1-year results of sutureless versus conventional stented bioprostheses in isolated surgical aortic valve replacement (SAVR) within two different surgical approaches: mini-sternotomy (MS) and full-sternotomy (FS). MethodsA total of 819 patients (per-protocol population) underwent preoperative randomization to sutureless or stented biological valve at 47 centers worldwide. Sub-analysis on isolated SAVR was performed. Results were compared between sutureless and stented within the two different surgical approaches. Results285 patients were implanted with Perceval (67% in MS) and 293 with stented valves (65% in MS). Sutureless group showed significantly reduced surgical times both in FS and MS. In-hospital results show no differences between Perceval and stented valves in FS, while a lower incidence of new-onset of atrial fibrillation (3.7% vs 10.8%) with Perceval in MS. After 1-year, use of sutureless valve showed a significant reduction of MACCE (5.2% vs 10.8%), stroke rate (1.0% vs 5.4%), new-onset of atrial fibrillation (4.2% vs 11.4%) and re-hospitalizations (21.8 days vs 47.6 days), compared to stented valves but presented higher rate of pacemaker implantation (11% vs 1.6%). ConclusionsSutureless bioprosthesis showed significantly reduced procedural times during isolated SAVR in both surgical approaches. Patients with sutureless valves and MS access showed also better 1-year outcome regarding MACCEs, stroke, re-hospitalization and new-onset atrial fibrillation, but presented a higher rate of permanent pacemaker implantation compared to patients with stented bioprosthesis.

The role of sutureless or rapid-deployment aortic valve prosthesis in bicuspid aortic valve: Standard AVR, TAVR, or somewhere in between?

Journal of Cardiac SurgeryVolume 37, Issue 10 p. 3363-3364 COMMENTARY The role of sutureless or rapid-deployment aortic valve prosthesis in bicuspid aortic valve: Standard AVR, TAVR, or somewhere in between? Suguru Ohira MD, PhD, Corresponding Author Suguru Ohira MD, PhD Suguru.Ohira@wmchealth.org orcid.org/0000-0003-0247-865X Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA Correspondence: Suguru Ohira, MD, PhD, Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, 100 Woods Rd, Macy Pavilion, Valhalla, NY 10595, USA. Email: Suguru.Ohira@wmchealth.orgSearch for more papers by this authorCorazon De La Pena MD, Corazon De La Pena MD Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USASearch for more papers by this author Suguru Ohira MD, PhD, Corresponding Author Suguru Ohira MD, PhD Suguru.Ohira@wmchealth.org orcid.org/0000-0003-0247-865X Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA Correspondence: Suguru Ohira, MD, PhD, Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, 100 Woods Rd, Macy Pavilion, Valhalla, NY 10595, USA. Email: Suguru.Ohira@wmchealth.orgSearch for more papers by this authorCorazon De La Pena MD, Corazon De La Pena MD Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USASearch for more papers by this author First published: 28 July 2022 https://doi.org/10.1111/jocs.16802Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume37, Issue10October 2022Pages 3363-3364 RelatedInformation

Cost effectiveness of aortic valve therapies: a systematic review of the literature


 Background: we performed a systematic review on the cost effectiveness of transcatheter aortic valve implantation (TAVI) to standard aortic valve replacement and medical management in high-risk elderly patients with severe aortic stenosis.
 Methods: in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review on current literature for cost-effectiveness of TAVI, standard aortic valve replacement, and medical management for elderly patients with high-risk severe aortic stenosis was performed. Incremental cost effectiveness ratio is used to measure effectiveness through life years gained or quality adjusted life years. Drummond checklist was used to further assess the quality of the included studies.
 Results: the systematic literature search identified 4 primary publications (derived from 52 citations) that fulfilled the inclusion criteria. Tremendous discrepancy in incremental cost effectiveness ratio is demonstrated with operable patients similar to Cohort A of the PARTNER trial (€ 749 416 and € 39 577). Inoperable patients similar to Cohort B of the PARTNER trial suggest notable differences in favour for transcatheter aortic valve implantation with an increase in quality adjusted life years (0.06 versus 1.6, respectively). With lifetime horizon to transcatheter aortic valve implantation there is a more comparable incremental cost effectiveness ratio in the literature (€ 38 260 and € 37 432). Lowest incremental cost effectiveness ratio witnessed in the technical inoperable group at € 26 482. Lifetime horizon of 10 years with transcatheter aortic valve implantation differ (€ 39 388 versus € 19 947). Overall, a review of the literature suggests TAVI usage in patients for severe aortic stenosis whom are not eligible for surgery. All the studies were overall judged of medium-high quality.
 Conclusions: transcatheter aortic valve replacement is more cost effective with a lifetime horizon for the treatment of patients with high-risk aortic stenosis compared with medical management considering those ineligible for standard aortic valve replacement. Further cost effectiveness research is needed in the stratifications of patient risk and patient co-morbidities for those candidates eligible for surgery. 

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial

ObjectiveSutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab.MethodsPerceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance.ResultsThe site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups.ConclusionAt 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve

Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure. Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg. The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients. RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.

Single centre experience in 1202 biological prosthesis: a comparison between sutured, sutureless and surgical transcatheter aortic valve

Abstract Background/Introduction Different types of bio-prosthesis are now available for the treatment of aortic valve disease. In absence of the “ideal” heart valve prosthesis, the best choice may be customized on the basis of the patient's profile. Purpose The aim of this study was to compare results in different subgroups of bio-prosthesis in elderly patients (>75 years old) undergoing conventional or surgical trans-catheter aortic valve replacement (AVR). Primary outcome was all cause mortality, secondary outcomes were: early post-operative complications (stroke, AV-block, acute kidney injury requiring temporary dialysis), freedom from structural vascular disease (SVD) and from re-operation. Methods In this retrospective study we analysed 1202 patients over 75 years old, underwent AVR from 2002 to 2018. Inclusion criteria were: age >75 years underwent AVR; we divided our population in 3 groups according to different strategy: primary aortic valve replacement with sutured (group 1, n=1005), sutureless (group 2, n=103) or surgical trans-catheter aortic valve replacement (group 3, n=94). Exclusion criteria: concomitant cardiac procedure other than coronary artery by-pass graft (CABG) or endocarditis. Patient and disease characteristics are described as numbers and percentages, continuous data were expressed using mean and standard deviation. Differences between groups were evaluated using either Student t-test or Mann-Whitney U test or ANOVA test. Survival curves of the primary outcome and freedom from secondary outcomes were built with the Kaplan-Meier method. Results The mean age of the overall population was 80.5±3.6 years with a mean STS score of assessed at 2.79±2.2% (2.27±1.0 for standard AVR, 3.3±2.2% for sutureless and 6.4±4.5 for S-TAVR, p-value<0.001). Early outcomes are depicted in figure 1. The overall 30-day mortality was 2.9%; among the different groups we observed 2.3%, 4.9% and 7.2% for sutured, sutureless and surgical-TAVR, respectively (p-value=0.01). The groups statistically differed also for permanent pacemaker implantation (sutured AVR 2.2%, sutureless AVR 4.9%, TAVR 9.6% (p-value<0.001) and acute renal failure requiring temporary dialysis sutured AVR 3%, Sutureless AVR 1.9% and Surgical TAVR 9.6% (p-value=0.004). The survival rate at follow-up was significantly different among group (log-rank <0.001, figure 2). Instead, freedom from reoperation was similar between cohorts (figure 2.) Conclusion(s) The outcomes of surgical AVR in a elderly population could be safely guaranteed with different biological prosthesis and operative techniques. A patient tailored approach should be always advised to improve current available transcatheter options. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

IS THE ROSS PROCEDURE A REPRODUCIBLE OPERATION? A MULTICENTER PERSPECTIVE

<h3>BACKGROUND</h3> The Ross procedure offers several advantages in patients requiring aortic valve replacement (AVR). However, it is a more complex procedure than a standard AVR. Whether there is a risk associated with expanding its eligibility and having multiple surgeons performing this operation remains a matter of debate. <h3>METHODS AND RESULTS</h3> From 2011-2020, 568 Ross procedures were performed by 5 surgeons in 2 Canadian institutions. The cohort was divided in 5 periods of 100 patients (P1 through P5) per center to assess efficacy and safety throughout time. The efficacy endpoints were cross-clamp time, bypass time and aortic regurgitation (AR)>1 at discharge. Safety was assessed with a cumulative sum analysis (CUSUM) adjusted using the STS score. The mean age increased throughout the study period (P1: 45±13 years, P2: 47±12 years, P3: 47±12 years, P4: 48±11 years, P5: 53±10 years; p < 0.01) in center 1. The mean STS score for mortality increased (P1: 0.5 [0.4-0.7], P2: 0.5 [0.4-0.8], P3: 0.6 [0.5-0.8], P4: 0.7 [0.5-0.9], P5: 0.8 [0.7-1.3]; p < 0.01) between P1 and P5. The cross-clamp (P1: 194±29 min, P2: 181±24 min, P3: 166±29 min, P4: 147±30 min, P5: 144±22 min) and bypass times (P1: 225±43 min, P2: 207±33 min, P3: 186±35 min, P4: 165±36 min, P5: 160±29 min) decreased over time (p < 0.01 for both). Two patients were discharged with AR>1 (1 in P2 and 1 in P5; p=0.76). The CUSUM analysis showed that the risk of complications decreased after 100 cases (Figure 1). Three patients had a perioperative myocardial infarction (1 in P4 and 2 in P5; p=0.25) and 3 patients presented a transient ischemic attack (2 in P1 and 1 in P2; p=0.70). There was a non-statistically significant decrease in the need for temporary dialysis (P1: 5 patients, P2: 3 patients, P3: 0 patient, P4: 1 patient, P5: 1 patient; p=0.08). A similar trend was observed in terms of reintervention for bleeding (P1: 5 patients, P2: 1 patient, P3: 0 patient, P4: 2 patients, P5: 0 patient; p=0.10). The perioperative outcomes did not differ between centers. Two patients died within 30-days, both during P1 (p=0.20). There was no perioperative death in center 2. The overall mortality was 0.4%, (O/E ratio=0.24). <h3>CONCLUSION</h3> In dedicated programs, the learning curve for the Ross procedure is ≈70 cases. Following this initial phase, nor the addition of other experienced surgeon or increased patient comorbidities had a significant impact on safety and efficacy. Overall mortality remained lower than predicted.

Preoperative Ozaki technique measures on tridimensional engineered root

BackgroundThe aortic valve neocuspidalization (AVNeo) is an innovative surgical technique aiming at the reconstruction of the aortic valve using autologous pericardium. One of the main criticisms to AVNeo is the longer duration of the aortic clamping time (ACT) as compared to standard aortic valve replacement due to the sizing of the valve neocusps. MethodsWe retrospectively enrolled 30 consecutives patients underwent AVNeo. For each patient we developed a 3D aortic root model (ARM) based on CT-scan datasets. We retrospectively compared the leaflets measurements performed during surgery with those obtained on the corresponding ARMs. ResultsIn 100% of cases no difference between the in vitro and in vivo measurements exceeded the acceptable error limit of 2 ​mm. The correlation of each single in vitro versus in vivo measurements demonstrates a strong coincidence between the two different methods of sizing (r ​> ​0,9, p ​< ​.0001). By analyzing the data considering the annulus perimeter and not the single cusp size, the perfect coincidence was to be found in 89.9% with a slight acceptable discrepancy (2 ​mm on total) in the remaining 10.1%. Conclusions3D-ARMs, printed from CT-scan, represent a reproducible process to obtain overlapping cusp sizes compared to those measured in-vivo, possibly reducing the ACT.

Perioperative platelet reduction after sutureless or stented valve implantation: results from the PERSIST-AVR controlled randomized trial.

Platelet count reduction is a common but not fully understood phenomenon after aortic valve replacement (AVR) with bioprosthesis implantation. The aim of the present study was to investigate the occurrence and the clinical impact of platelet count reduction in patients receiving the Perceval bioprosthesis compared to those receiving standard sutured stented bioprosthetic aortic valve in a randomized, controlled AVR study. PERceval Sutureless Implant versus STandard Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016-September 2018) to AVR with a sutureless or stented valve. Ad hoc analyses have been performed to evaluate the occurrence of platelet count reduction and the clinical impact of the platelet variations in the 2 groups. The Perceval group showed a higher platelet reduction than the control group (46% vs 32%). The phenomenon was transient in both groups, with a slow recovery of the platelet count by hospital discharge. No differences were observed between groups regarding need of transfusions, blood loss, major bleeding and stroke events. The Perceval sutureless aortic bioprosthesis implantation is associated with higher rate of transient platelet reduction as compared to stented bioprostheses for AVR. However, the platelet count reduction is transient and the decline does not affect the patient's clinical outcomes. Current explanations for this phenomenon are speculative, and further investigations are required to elucidate it. NCT02673697-ClinicalTrials.gov-4 February 2016.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

BackgroundEarly treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.MethodsSURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.ResultsThe study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.ConclusionsThese results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Use of an Aortic Valve Replacement Simulation Model to Understand Hospital Costs and Resource Utilization Associated With Rapid-deployment Valves

PurposeAortic stenosis (AS) is the most common cause of adult valvular heart disease. In the past decade, minimally invasive surgery (MIS) to treat AS has gained popularity, especially if performed in combination with rapid deployment valves (RDVs), which shorten cross-clamp time (XCT). This study examines specific outcomes and related costs of aortic valve replacement (AVR) before and after the introduction of RDVs. MethodsWe used the AVR simulator, an economic model developed to correlate cost and resource utilization associated with the adoption of RDVs, to compare 2 scenarios: (1) a current scenario based on standard AVR practices and (2) a proposed scenario based on increasing use of RDVs and an MIS approach. Both scenarios involved 3 subgroups of patients treated with (1) conventional AVR, (2) MIS, and (3) AVR combined with a coronary artery bypass graft. The current scenario (status quo) involved patients treated with traditional biological valves, and the proposed scenario involved patients who underwent implantation with an RDV. The AVR simulator was fed with real-world input data to estimate complication rates and resource consumption in the proposed scenario. Real-world input data for this analysis were obtained from patients diagnosed with a symptomatic heart valve disease between 2015 and 2018, at Clinica-San-Gaudenzio, Novara, Italy. Lastly, the AVR simulator estimated hospital savings by comparing the 2 scenarios. FindingsA total of 132 patients underwent implantation with a traditional biological valve, and 107 were treated with a commercial valve system. The RDV was associated with an increase of 52% of patients undergoing MIS, which generated a 6.1-h reduction of XCT and a total savings of €6695. RDVs also reduced intensive care unit (ICU) and hospital ward length of stay (LOS), leading to savings of €677 and €595 per patient, respectively. Mortality and blood transfusions also improved. The savings for the hospital (related to shorter XCT, hospital ward LOS, and ICU LOS) amounted to €144.111. Our findings were consistent with data gathered from our real-word setting, and results of a sensitivity analysis indicate that our findings were robust across different possible situations. ImplicationsSwitching to RDVs and MIS procedures for AVRs was associated with a reduction of costs related to XCT, hospital ward LOS, and ICU LOS. Hospitals can upload literature- and experience-based clinical and cost values to the AVR simulator to estimate a hospital's performance with the introduction of RDVs compared with standard biological valves. This study was not randomized, so more extensive studies could confirm our results in the future.

Solo Smart stentless bioprosthesis for extensive aortic annular defects caused by infective endocarditis.

The optimal valve and prosthesis in patients with aortic valve infective endocarditis with annular abscess is controversial. If extensive annular defects occur after debridement, standard techniques are difficult; more complex aortic root replacement (ARR) or aortic valve translocation technique are inevitable. The Solo Smart stentless bioprosthesis is specially designed for supra-annular implantation without annular stitches. Nineteen patients with active aortic valve infective endocarditis underwent aortic valve replacement in the past 3 years. Of these, we performed aortic valve replacement using the Solo Smart valve in four patients with extensive annular destruction and complex aortic root pathologies requiring reconstruction. Although more than two-thirds of the annular structure was missing after radical debridement of infected tissues, supra-annular aortic valve replacement with the Solo Smart valve could be performed successfully in all four patients. All patients are doing well without prosthetic valve dysfunction and/or recurrent infection. The supra-annular aortic valve replacement using the Solo Smart valve is considered to be a useful alternative to standard aortic valve replacement in patients complicated with extensive annular defect. It is a simple and technically less demanding alternative to ARR or aortic valve translocation technique.

WHICH METHOD SHOULD BE PREFERRED IN NARROW AORTIC ROOTS? RISKS AND PROGNOSES OF MANOUGUIAN AND NICKS PROCEDURES

Objective: To analyze the superiority, feasibility and problems of Nicks and Manougianprocedures in the light of literature data, independent of valve type and BSA values. Methodology: The study was a cross-sectional study from June 2009 and September2017 conducted at Health Sciences University Haydarpasa Numune Hospital. Thestudy included patients who underwent Manougian and Nicks procedures between2009-2017. The effects of the procedures on left ventricular functions at thepostoperative 0-12th months, postoperative complications and mortality wereevaluated. Cases with (I) isolated aortic stenosis without additional valve pathologywho undergone ARE, with (II) BSA index between 1,40-1,70 m , and cases undergone 2(III) standard mechanical aortic valve (Carbomedics) replacement with Manougian andNicksmethodswere included. Echocardiographical data of the caseswere evaluated. Results: The study included 104 patients who underwent Manougian (n=40;46,5%)and Nicks(n=46;53,5%) procedures between 2009-2017. Postoperative effectiveorifice area index was higher in the Manougian procedure (1,28Vs1,17cm/m ;p=0,001). NYHA functional capacity was decreased by 1.58±0.7 postoperatively 2(inter-procedures p=0,809). Early and late mortality rates for Manougian and Nicksprocedures were 0% , 2,2% and 2,5%, 2,2%, respectively (p=0,641). Reoperation ratedue to bleeding, thrombosis, infection and the paravalvular leak was 15% at the end ofthe first year (inter-procedures p=0,565).The changes of echocardiographicparameters were significant in all cases against time. On the other hand, fractionalshortening and gradient changes were significantly higher for Manougian procedurecompared to Nicks, while ejection fraction and septum thickness change were notsignificant. Conclusion: Although both methods had a positive effect on left ventricular function,Manougian procedure was more effective because it provided a larger valve area andnear-normal left ventricular function. Considering risk factors for the optimal size valveimplant, the choice of root dilatation method instead of alternative prostheses doesn'taffect morbidity and mortality. Key Words: Effective orifice area index, Manougian procedure, Nicks procedure, Aorticroot enlargement, Patient-prosthesis mismatch, Septum thickness

Comparative study between standard aortic valve replacement and ministernotomy aortic valve replacement

Objectives The aim of this study is to evaluate the outcome of the recalled upper minimally invasive aortic valve replacement (MIAVR) J-shaped technique and full standard median sternotomy techniques aortic valve replacement (AVR). Background Over the past 20 years, MIAVR has evolved into a safe, well-tolerated, and efficient surgical treatment option for aortic valve disease. It has been shown to reduce postoperative morbidity, providing faster recovery and rehabilitation, shorter hospital stays, and better cosmetic results, as it reduces the incidences of wound infection owing to small incision length, especially in our diabetic fatty Egyptian female patients. Patients and methods Between September 2017 and March 2019, this study included 50 patients with isolated aortic valve disease. A total of 25 patients (group A) underwent (MIAVR) J-shaped technique and 25 patients (group B) underwent standard AVR, and they were compared with each other. Results In operative data, there were highly significant differences between both groups regarding aortic cross-clamp time, total bypass time, and total operative time (P Conclusion MIAVR is a feasible procedure despite the narrow operative field that induced long operative times. It is safe with minimal postoperative morbidities, early rehabilitation, and less postoperative pain. Moreover, MIAVR provided cosmetically better wound results, which was immensely satisfying to the patients.

Increased Expression of miR-146a in Valvular Tissue From Patients With Aortic Valve Stenosis.

miR-146a has been implicated in the regulation of the immune response as well as in inflammatory process of atherosclerosis. In the present study, we have investigated the expression of miR-146a and its targets, TLR4 a IRAK1, in aortic valve stenosis. A total of 58 patients with aortic stenosis (non- and atherosclerotic; tissue obtained during standard aortic valve replacement) were enrolled. The relative expression of mir-146a was higher in valvular tissue from patients with atherosclerosis compared to those without atherosclerosis (p = 0.01). Number of the IRAK1 and TLR4 transcripts did not differ between the investigated groups. There was a trend toward elevation of miR-146a expression in context of inflammatory infiltrate observed in the valvular tissue from patients with atherosclerosis (p = 0.06). In conclusion, in line with the acknowledged role of miR-146a in atherosclerotic inflammation, our data suggest it may be extended to the specific location of aortic valves in aortic stenosis.

Right Anterior Minithoracotomy for Aortic Valve Replacement: A Widely Applicable, Simple, and Stepwise Approach.

A stepwise approach for right anterior minithoracotomy aortic valve replacement (RAT-AVR), without sutureless valves, special instruments, or preoperative imaging, was developed. We report our experience with this widely applicable, simplified approach. Patients with a history of previous chest surgery, documented PVD, severe COPD, LVOT size <2.0 cm, and root size <2.8 cm were excluded. Chest CT was not mandatory. The stepwise surgical approach consists of 1) tolerability of single-lung ventilation; 2) 5-cm long incision on third right anterior ICS; 3) small pericardial opening to localize the aortic valve annular plane by digital palpation; 4) shingling of the correct rib to create a box field; 5) optimizing exposure with stay sutures; 6) femoral or central cannulation with right superior pulmonary vein venting and usual antegrade cardioplegia; 7) performing a standard AVR without adjunct instruments; and 8) reconstructing 1 costochondral cartilage. Fifty-five patients were operated. The mean age was 68.5 years (SD 10.4); 29.1% were female. Median STS PROM was 1.18 (0.4 to 6.6). Pump and cross-clamp times were 104.8 minutes (SD 27.9) and 73.2 minutes (SD 22.8), respectively. There was no need for a knot pusher. There was 1 conversion, 1 reopening for bleeding, and 1 pacemaker insertion. No patient had a stroke, MI, or death at 30 days. The median LOS was 6 days (3 to 19). RAT-AVR can be applicable and performed safely in a wide range of patients by adopting a simple, stepwise approach with intraoperative assessment, without the need for special imaging, instrumentation, or advanced training.

Long-term assessment of the Ross procedure in adults: Clinical and echocardiographic follow-up at 20 years

IntroductionThe Ross procedure is an alternative to standard aortic valve (AV) replacement in young and middle-aged patients. However, durability and incidence of reoperation remain a concern for most cardiac surgeons. Our aim was to assess very long-term clinical and echocardiographic outcomes of the Ross procedure. MethodsWe conducted a single-center retrospective analysis of 56 consecutive adult patients who underwent the Ross procedure. Mean age at surgery was 44±12 years (range, 16-65 years) and 55% were male. Clinical endpoints included overall mortality and the need for valve reoperation due to graft failure. The echocardiographic endpoint was the presence of any graft deterioration. Median clinical follow-up was 20 years (1120 patient/years). ResultsIndications for surgery were dominant aortic stenosis in 50% and isolated aortic regurgitation in 21%. Concomitant mitral valve repair was performed in 21% and a subcoronary technique was most commonly used (86%). Overall long-term survival was 91%, 80% and 77% at 15, 20 and 24 years, respectively. The survival rate was similar to the age- and gender-matched general population (p=0.44). During the follow-up period, freedom from graft reoperation was 80%. Eleven patients (31%) developed moderate AV regurgitation, three (8.6%) developed moderate pulmonary regurgitation and one (2.9%) presented moderate pulmonary stenosis. ConclusionThe Ross procedure, mostly using a subcoronary approach, proved to have good clinical and hemodynamic results, with low reoperation rates in long-term follow-up. Moderate autograft regurgitation was a frequent finding but had no significant clinical impact.