Technique For Aortic Valve Replacement Research Articles

Evaluation of echocardiography and computed tomography characteristics related to aortic valve replacement technique through the right anterior thoracotomy at the 2nd intercostal space

Objective: evaluate echocardiographic and computed tomography characteristics related to minimally invasive aortic valve replacement technique through the right anterior thoracotomy at the 2nd intercostal space. Methods: study on 74 patients undergoing aortic valve replacement surgery through the right anterior thoracotomy at the 2nd intercostal space at Hanoi Heart Hospital and 108 Military Central Hospital, from October 2019 to December 2022. Patients underwent preoperative echocardiography and multiple slices computed tomography to assess the lessons of aortic valve, valve annulus diameter, and intercostal space width. Results: The ratio of aortic valve stenosis is 55.4%, stenosis combined with regurgitation is 31.1%, and aortic regurgitation is 13.5%. The average valve annulus diameter on computed tomography scans is 26.5 ± 3.1 mm (smallest 20; largest 36); average 2nd intercostal space width 18.1 ± 3.1 mm (smallest 11; largest 25). Valve annulus diameter measured by computed tomography correlates closely with actual prosthetic valve size (r = 0.54, p < 0.001); measured by echocardiography had a weak correlation and not statistically significant. The prosthetic valve size to be replaced is smaller than the valve annulus diameter measured on computed tomography, with an average of 4.8 ± 2.7 mm in aortic valve stenosis, 5.7 ± 2.0 mm in combined stenosis and regurgitation, and 7.2 ± 2.9 mm in aortic regurgitation, in which the difference between valve stenosis and regurgitation is statistically significant (p = 0.01). Conclusions: Minimally invasive aortic valve replacement technique through the 2nd intercostal space right thoracotomy, with cutting the 3rd rib, is suitable for Vietnamese anatomy. Valve annulus diameter measured by computed tomography has a good linear correlation and can be a predictor for prosthetic valve size before surgery.

Outcomes of Pledgeted versus Nonpledgeted Suture Technique for Isolated Aortic Valve Replacement

Objective: To compare outcomes of pledgeted versus nonplegdeted suture techniques for aortic valve replacement (AVR). Methods: This was a retrospective study utilizing an institutional database of AVRs performed at our center between 2010 and 2020. All patients who underwent isolated surgical AVR were included, while those who underwent concomitant procedures were excluded. Patients were dichotomized into those who underwent pledgeted vs. nonpledgeted AVR, and 1:1 propensity score matching (PSM) was employed. Clinical and echocardiographic outcomes were compared. Kaplan-Meier survival estimation and Cox regression were performed. Cumulative incidence functions were generated for all-cause readmissions and for heart-failure readmissions. Freedom from major adverse cardiac and cerebrovascular events (MACCE) were also analyzed and compared using Kaplan-Meier methods. Results: A total of 2240 patients were identified. PSM yielded 892 matched pairs. Mean gradient was significantly higher in the pledgeted group (p < 0.001), but patients in this group had a smaller median valve size implanted. There were no significant differences in paravalvular leak rates. Kaplan-Meier survival estimates, cumulative incidence of readmissions, and freedom from MACCE were not significantly different between groups. Conclusion: Long-term survival, readmission rates, and freedom from MACCE are comparable after pledgeted and nonpledgeted AVR. There were no differences in paravalvular leak rates between the two techniques.

TRANSCATHETER AORTIC VALVE REPLACEMENT: FROM IDEA TO IMPLEMENTATION

HighlightsTranscatheter aortic valve replacement is an innovative trend in modern cardiovascular surgery. This minimally invasive image-guided endovascular technology is becoming more and more safe, nowadays it can involve a minimalistic approach in which the aortic valve replacement is performed without incisions, anesthesia and cardiopulmonary bypass - patients are conscious and spontaneously breathing. The article describes a paradigm shift in modern cardiology, in which the concept of treating patients with degenerative aortic valve stenosis has changed over the 20 years of existence of the transcatheter replacement, starting as a method used only in small number of extremely high-risk patients unsuitable for cardiac surgery and now being the most prevalent treatment modality in patients at intermediate and even low surgical risk. The main clinical and technical principles of transcatheter aortic valve replacement, as well as the prospects for the development of this technique, are highlighted. Abstract Transcatheter aortic valve replacement technique was first implemented about 20 years ago, in April 2002. A quarter of a century ago, specialists involved in image-guided surgery would have never believed that they would perform transcatheter interventions on heart valves. Transcatheter interventions are an alternative to open-heart surgery for acquired heart disease. Transcatheter heart valve replacement or repeat transcatheter aortic valve replacement, which do not require incisions, cardiopulmonary bypass, and in some cases general anesthesia, to this day continue to be perceived as revolutionary and breakthrough, saving the lives of many patients. The article presents the main milestones in the development of image-guided endovascular surgery and transcatheter aortic valve replacement technique, the number of which in the United States and several European countries increases by 10–15% annually, reaching hundreds of thousands per year. The etiology and pathophysiology of aortic stenosis, the technique of transcatheter aortic valve replacement and the outcome of this promising minimally invasive procedure are presented.

Ross procedure with personalized external aortic root support

The Ross–Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.

Drivers of vascular growth and remodeling: A computational framework to promote benign adaptation in the Ross procedure

In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients’ own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior.

Signal intensity coefficient as a detector of aortic stenosis-induced myocardial fibrosis and its correlation to the long term outcome

ObjectiveDespite advanced aortic valve replacement techniques, aortic stenosis (AS)-induced irreversible myocardial fibrosis contributes to poorer outcomes. Therefore, in addition to early diagnosis of AS, detecting myocardial fibrosis is crucial for physicians to determine the timing of surgery. The Signal Intensity Coefficient (SIC) was used to detect subtle myocardial deformation. Hence, we aimed to investigate whether SIC correlated with myocardial dysfunction and fibrosis from both clinical and preclinical perspectives. MethodsWe collected medical records and echocardiography images, including the SIC of patients who underwent surgical aortic valve replacement (AVR) for AS from 2010 to 2015. The endpoint of the study was mortality. Median follow-up period was 80 months. ResultsAmong 109 patients, 15 died due to cardiovascular causes. Although SIC decreased in all patients post-AVR, patients with an SIC ≥0.34 before surgeries presented with a higher probability of cardiovascular death. In contrast, changes in the left ventricular (LV) ejection fraction, LV mass index, and LV volume failed to predict outcomes. Similarly, SIC was obtained in mice undergoing aortic banding and debanding surgery for comparison with the degree of myocardial fibrosis. SIC was continuously elevated after aortic banding and declined gradually after debanding surgery in mice. Debanding surgery indicated the regression of aortic banding-induced myocardial fibrosis. ConclusionPre-AVR SIC was associated with the risk of cardiovascular death and reflected the degree of myocardial fibrosis. Further investigations are required to study the clinical application of SIC in patients with AS.

The scope of the evolution in the transcatheter aortic valve replacement technique.

The scope of the evolution in the transcatheter aortic valve replacement technique.

Complications of TAVR From an Anesthesia Perspective.

Description Transcatheter aortic valve replacement (TAVR) has become the predominant technique for aortic valve replacement in the United States. Initially approved for high surgical risk patients, TAVR is now approved for most patients requiring valve therapy, including younger, lower-risk patients. The procedure is ideally performed in a hybrid operating room equipped with fluoroscopic equipment and transesophageal echocardiogram (TEE) imaging that can be viewed simultaneously by the operating team. The operating room should also be equipped to allow initiation of cardiopulmonary bypass, if necessary. Cardiac anesthesia teams are often involved with the management of these patients. This mini-review is designed to summarize potential complications that anesthesiologists may contend with during TAVR.

Early outcomes of the suprasternal transcatheter aortic valve replacement technique.

Transcatheter aortic valve replacement (TAVR) is now an established treatment option for patients with severe aortic stenosis. The most utilized approach remains transfemoral. In patients with difficult femoral access a variety of alternate approaches have been used. Recently, suprasternal access has emerged as a viable alternate approach in patients with very complex vascular access. We describe our 30-day outcomes of patients who underwent suprasternal transcatheter aortic valve replacement (suprasternal [SS]-TAVR), which constitutes the largest single-center cohort to date. From May 2016 to September 2021, 658 patients underwent TAVR at our institution. Of which 29underwent SS-TAVR. We performed a retrospective analysis to evaluate early (30 days) outcomes of this procedure. Main outcomes evaluated included 30-day mortality, stroke and pacemaker rates, length of stay, readmission, and valvular function. All patients were alive 30 days after the procedure. The median hospital length-of-stay was 2 days. Two patients (6.9%) had a stroke on the contra-lateral side of access. Two patients (6.90%) had significant cardiac arrhythmias requiring pacemaker placement. In 30 days, one patient was readmitted (3.45%). Our data confirmthe SS-TAVR as a feasible and safe alternative with comparable results to established approaches in patients who are unsuitable for femoral artery access and offers clinicians another access site in patients with very complex anatomy.

Totally endoscopic aortic valve replacement with concomitant trans-aortic mitral valve repair for mitral regurgitation

BackgroundMinimally invasive aortic valve procedures through a hemi-sternotomy or a right anterior mini-thoracotomy have gained popularity over the last several years. Totally endoscopic aortic valve replacement (TEAVR) is an innovative and a less invasive (incision-wise) surgical aortic valve replacement technique. The operative steps of TEAVR have been reported previously from our group. Mitral regurgitation (MR) frequently accompanies aortic valve disease that at times may also require repair. Totally endoscopic surgery in such cases has not been tested.Presentation of the techniqueWe present a surgical technique for a totally endoscopic approach to aortic valve replacement and concomitant mitral valve repair for primary and secondary MR. An aortotomy incision was used avoiding an atriotomy, which results in an increase in cross-clamp (XC) and cardiopulmonary bypass (CPB) times that could be associated with higher mortality and morbidity. Neochords (artificial chordae tendineae) were used for primary MR and an edge-to-edge approach for secondary MR.ConclusionTEAVR and concomitant mitral valve repair can be performed successfully with reasonable XC and CPB times with excellent short-term results.

Advancements in Transcatheter Aortic Valve Implantation: A Focused Update.

Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65–75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).

Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional cohort study

BackgroundRecently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.MethodsTrans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.ResultsA total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001).ConclusionThere is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.Trial registry numberclinicaltrials.gov, NCT02697786 14.

A new technique that prevents paravalvular leakage after aortic valve replacement using a rapid-deployment valve system.

We report our 1-year single-center experience of a new technique of aortic valve replacement using a rapid-deployment valve (RD-AVR) to avoid postoperative complications. We also report the unexpected pitfalls and handling techniques that we have seen in past cases. We performed aortic valve replacement on 38 patients between May 2019 and April 2020. Their mean age was 74 years. The primary outcomes were in-hospital mortality and short-term results during a 1-year follow-up period, while the secondary outcomes were related to prosthetic valve function, especially paravalvular leakage (PVL). We further analyzed the relationship between the new technique and its outcomes. The mean operative time was 196 min. There were no in-hospital deaths, and the mean duration of postoperative hospital stay was 11.8 days. Valvular measurements using three-dimensional computed tomography were larger and more accurate than those measured using ultrasonic echocardiography. Postoperative RD-AVR prosthetic valve function was excellent. However, PVL occurred in four cases 1 week and 1 year postoperatively and regurgitation did not improve. A gap associated with PVL was identified below the right-noncoronary commissure. To prevent PVL, we additionally stitched this gap in the later 18 cases; there was no case of PVL and no new pacemaker implantation in these cases. PVL is more likely to occur if there is a gap below the R-N commissure, especially in cases with a large annulus; therefore, applying an additional stitch to the R-N commissure is extremely useful.

Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Minithoracotomy for All Comers With Aortic Valve Disease.

Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years. Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database. Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%). Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.

Reversed C-shaped Scanner-guided Ministernotomy for Isolated Aortic Valve Replacement

Here we present our technique of aortic valve replacement through a reversed C-shaped ministernotomy in 36 patients operated between 2017 and 2019. All patients had a preoperative computed tomography that guided the surgical approach. The sternum was incised at the level of the first and third or the second and fourth intercostal spaces. Cross-clamp time was of 65.2 ± 15.9 minutes. Median extubation time was of 2 hours. There was no postoperative 30-day mortality. Because the upper and lower parts of the sternum remain intact, this approach may improve postoperative thoracic stability.

Video-assisted minimally invasive aortic valve replacement through left anterior mini-thoracotomy in a patient with situs inversus totalis.

We describe herein the first experience with a surgical technique for aortic valve replacement using a video-assisted minimally invasive approach via a left anterior mini-thoracotomy in patient with dextrocardia and situs inversus totalis. This procedure was performed safely with good clinical and cosmetic results.

In vitro comparison of everting vs. non-everting suture techniques for the implantation of a supra-annular biological heart valve.

BackgroundThe aim of this study was to evaluate the hemodynamic effect of different suturing techniques for aortic valve replacement (AVR) in vitro. Whether or not the applied suturing technique impacts the outflow tract diameter by narrowing the annulus diameter was examined.MethodsThe commonly applied non-everting pledget forced suture technique (NE, n=13) was compared with an everting pledget forced suture (ET, n=13) for AVR using the 25 mm St. Jude Trifecta aortic valve. Hemodynamic parameters were obtained in a pulsatile flow simulator. A high speed camera captured the visual aspects of the suturing technique.ResultsDespite some kind of left ventricular outflow narrowing due to protruding pledgets using the NE suture technique, mean pressure gradients of both techniques were nearly similar (NE 5.88±2.7 mmHg, ET 5.23±1.31 mmHg, P=0.44). Closing volume (NE 3.16±0.48 mL; ET 3.51±0.68 mL; P=0.14) and the leakage volume (NE: 8.09±2.53 mL; ET: 8.35±3.65 mL; P=0.83) also showed no differences.ConclusionsAVR using either suturing techniques leads to a similar hemodynamic performance in vitro. The impact of the suturing technique may be higher in a smaller annulus. Therefore, further studies using smaller prostheses are necessary.

Invited Commentary

Invited Commentary

EVALUATION OF THE RESULT OF SUTURELESS AORTIC VALVE REPLACEMENT

Background: Aortic valve stenosis is the most frequent cardiac valve pathology in the western world. In the last few years, sutureless valves have been strongly developed with a lot of applications. The aim of this study was to evaluate the feasibility, mid-term outcomes of sutureless aortic valve replacement technique. Subjects and methods: 13 patients who underwent sutureless aortic valve replacement between 12/2015 to 05/2018 at Clermont – Ferrand University Hospital, France. Descriptive study, postoperative follow-up, clinical evaluation, and echocardiography. Results: mean cross-clamp time was 84.8 ± 22.9 min, mean cardiopulmonary bypass time was 113.4 ± 21.2 min. Improved mean preoperative and postoperative aortic gradients: 40.3 ± 17.4 mmHg versus 10.5 ± 4.8 mmHg (1 month) and 12.0 ± 4.5 mmHg (6 months). Mean intensive care unit stay was 7.8 ± 11.8 days, mean hospital stay was 23.2 ± 15.5 days. No case of death was reported after 6 months. Conclusion: sutureless aortic valve replacement technique is feasible, with good short-term and mid-term outcomes, improve hemodynamics, can be applied in intermediate and high-risk patients. Key words: aortic valve stenosis, aortic valve replacement, sutureless aortic valve

Improved operative and recovery times with mini-thoracotomy aortic valve replacement

BackgroundThe small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy.MethodsWe retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared.ResultsOf the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67–113) minutes; vs. 117 (93.5–139.5); vs. 102.5 (85.5–132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5–9) days; vs. 7 (5–14.5); vs 9 (6–15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)].ConclusionsMinimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.