Transapical aortic valve implantation in high-risk patients with severe aortic valve stenosis.

BACKGROUND: Transapical aortic valve implantation (TA-TAVI) represents an alternative in patients with symptomatic severe aortic valve stenosis (SSAVS) who cannot be operated on or have a high surgical risk. The aim of this prospective multicenter observational study was to assess early and 2-year clinical and hemodynamic outcomes after TA-TAVI. METHODS: From May 2008 to September 2010, 179 patients with inoperable conditions or high-risk patients underwent TA-TAVI at 4 institutions. Indications for TA-TAVI were SSAVS and logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) greater than 20% or porcelain aorta in patients with severe aortoiliac disease. Patients underwent clinical and echocardiographic follow-up visits at hospital discharge, 3 and 6 months after TA-TAVI, and every 6 months thereafter. The impact of the learning curve for the centers and of intraoperative complications on patient outcomes was also evaluated. RESULTS: Mean age was 81 ± 6 years. Mean logistic EuroSCORE was 22% ± 12%. Transapical delivery was successful in all patients. Seventeen severe intraoperative complications occurred in 13 (7.3%) patients. Thirty-day mortality was 3.9% (7 patients). Mean follow-up was 9.2 ± 6.5 months. Late mortality occurred in 9 patients. Two-year survival was 88% ± 3%. An intraoperative severe complication was identified as the only significant independent predictor of 1-year mortality. A significant benefit was found when comparing 2-year survival of the second versus the first 50% patients at each center (93% ± 2% versus 84% ± 3 %; p = 0.046). A significant reduction of both mean and peak gradients from the preoperative to the postoperative period, which remained stable during follow-up, was found. CONCLUSIONS: TA-TAVI provides excellent early and 2-year results in terms of survival, valve-related adverse events, and hemodynamic performance. Survival after TA-TAVI is affected by the center learning curve and by the occurrence of an intraoperative complication.

Endovascular treatment of aberrant right subclavian (lusorian) artery to oesophagus fistula: a case report.

The creation of a fistula between the subclavian artery and the oesophagus is extremely rare. All the reported cases of subclavian oesophagus-arterial fistulae have been described either in aberrant subclavian arteries or as caused by foreign bodies in the oesophagus. In this article, a case of fistulous communication between an aberrant right subclavian and the oesophagus managed with the positioning of endovascular prosthesis is presented.

Intraoperative coronary angiography in postinfarction ventricular free wall rupture: how technology can change diagnostic and therapeutic timing.

Left ventricular free wall rupture often presents with an abrupt onset and rapidly progresses towards cardiogenic shock or electromechanical dissociation. The diagnostic pathway is still a matter of debate: echocardiography is commonly decisive but the assessment of coronary artery status is essential in order to optimize the surgical procedure. However, a preoperative coronary angiography could generate a dramatic delay of surgery. We report a case of a patient with a post-infarction left ventricular free wall rupture presenting with cardiac tamponade and cardiogenic shock who underwent emergency surgery. After cardiopulmonary bypass institution, an intraoperative coronary angiography was performed. Successful repair of the ventricular free wall rupture associated with a well-targeted surgical myocardial revascularization were carried out. This case illustrates how the development of technologically advanced hybrid operating rooms could lead to a new diagnostic and therapeutic approach to this potentially fatal complication.

Aortic valve replacement with the Sorin Pericarbon Freedom stentless prosthesis: 7 years' experience in 130 patients.

OBJECTIVES: Aortic stentless pericardial valves were introduced into clinical practice to combine properties of both stentless and pericardial prostheses. The aim of this single-center retrospective study was to assess midterm clinical and hemodynamic results of aortic valve replacement with the Sorin Pericarbon Freedom stentless bioprosthesis. METHODS: From July 1999 through November 2005, 130 consecutive patients (73 [56.1%] male patients) underwent aortic valve replacement with the Sorin Pericarbon Freedom bioprosthesis at our institution. Mean age was 76 +/- 5 years (range, 42-86 years), and associated procedures were performed in 50 (38.4%) patients; of these, 41 were coronary artery bypass grafts. Surgical intervention under urgent/emergency conditions and reoperations were performed in 18 (13.8%) and 7 (5.3%) patients, respectively. Mean crossclamp and cardiopulmonary bypass times were 82 +/- 24 and 125 +/- 40 minutes, respectively. All patients underwent clinical and echocardiographic follow-up (100% complete), and the total cumulative follow-up was 324 patient/years (mean, 2.5 +/- 1.8; range, 6 months-7 years). RESULTS: Overall hospital mortality was 8.4%. Overall patient survival was 63% +/- 6% and 50% +/- 10% at 5 and 7 years, respectively. Late deaths occurred in 23 patients, and 6 of them were valve related (1.8% patient/years). Freedom from valve-related death and reoperation was 91% +/- 4% and 94% +/- 4%, respectively, at 7 years. No structural valve deterioration was observed. Endocarditis, thromboembolism, and hemorrhagic complications occurred in 2 (0.6% patient/years), 1 (0.3% patient/years), and 1 (0.3% patient/years) patients, respectively. Mean transprosthetic gradients for valve sizes 23, 25, and 27 were 12.1 +/- 3.8, 10.8 +/- 3.8, and 9 +/- 3.1 mm Hg, respectively. CONCLUSIONS: The Sorin Pericarbon Freedom stentless bioprosthesis provides good early and midterm results in terms of hemodynamic performance, survival, and freedom from valve-related complications.