Aortic Valve Repair: Where Are We Now?

The advent of aortic valve repair alongside the well-established technique of valve replacement changed the landscape of cardiac surgery, as well as the lives of patients suffering from valvular disease. Repair represents a novel option in those unfit for replacement and avoids the burden of lifelong anticoagulation in younger patients. Despite this, the associated risk of persistence of aortic insufficiency, and therefore reoperation, with valvular repair renders clinical decision making between the two techniques difficult. Unlike the burden of evidence supporting mitral valve repair over replacement, the debate surrounding aortic valve surgery continues. This article aims to explore the development of operative techniques underlying aortic valve repair as well as summarising existing research into short- and long-term patient outcomes in both aortic valve repair and replacement.

Stented Versus Stentless Aortic Valve Replacement in Patients With Small Aortic Root: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less). METHODS: A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed. RESULTS: A total of seven studies with a total of 965 patients fulfilled the inclusion criteria. There was no significant difference in preoperative baselines including mean age between both groups (P = 0.08), peak aortic valve gradient (P = 0.06), and effective orifice area (P = 0.28), whereas higher mean aortic valve gradient in the stented group (P = 0.007). No difference in cardiopulmonary bypass time (P = 0.74), aortic cross-clamp times (P = 0.88), intensive care unit stay (P = 0.13), and stroke rate (P = 0.56) were noted. However, stented group of patients showed higher rate of patient prosthesis mismatch (P = 0.0001) and longer total hospital stay (P = 0.002). Postoperatively, stentless group showed lower peak and mean aortic valve gradient (P = 0.003 and P = 0.008, respectively) with a better effective orifice area (P < 0.00001) at 6 months of follow-up. Mortality rates while in-hospital and at 1 year were similar in both groups (P = 0.94 and P = 0.86, respectively). CONCLUSIONS: Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.

Postoperative seizures in meningioma patients: improving patient selection for antiepileptic drug therapy.

BACKGROUND: Epilepsy is a major cause of morbidity and mortality in meningioma patients. The aims of this study were to determine which factors predispose meningioma patients to developing perioperative seizures and to understand the impact of antiepileptic drugs. METHODS: Patients treated for a histologically-confirmed intracranial meningioma at the authors' institution between 2010 and 2015 were retrospectively examined. Clinical and imaging data were assessed. Multivariate analysis was performed using binary logistic regression. The effect of antiepileptic treatment was assessed using survival analysis. RESULTS: Two hundred and eighty-three patients met the selection criteria; seizures were present in 68 preoperatively (24%) and in 48 patients (17%) following surgery. Of the 68 with preoperative seizures, 19 continued to have them, whereas de-novo seizures arose postoperatively in 29 seizure-naïve patients. Risk factors of postoperative seizures were convexity location (OR 2.05 [95% CI 1.07-3.98], p = 0.030), fronto-parietal location (OR 4.42 [95% CI 1.49-13.16], p = 0.007) and preoperative seizures (OR 2.65 [95% CI 1.37-5.24], p = 0.005). The two locations, in addition to the presence of midline shift on preoperative imaging (OR 4.15 [95% CI 1.54-11.24], p = 0.005), were significantly correlated with postoperative seizures in seizure-naïve patients. Antiepileptic treatment in patients with those risk factors reduced the possibility of seizures at any time point within the 1st year postoperatively by approximately 40%, although this did not meet statistical significance. CONCLUSION: Prophylactic antiepileptic treatment might be warranted in seizure-naïve meningioma patients with ≥ 1 risk factor. High-quality randomised controlled trials are required to verify those factors and to define the role of antiepileptics in meningioma practice.

Incidental finding of anomalous circumflex coronary artery from right coronary sinus prior to aortic valve surgery.

Anomalous origin of the left circumflex (Cx) artery is a common and mostly benign coronary artery anomaly. We report the case of a man aged 52 years who presented to his local hospital with progressive breathlessness on exertion and syncopal episodes. His admission transthoracic echocardiography (TTE) showed bicuspid aortic valve, severe aortic stenosis with a valve area of 0.5 cm2 and his left ventricular ejection fraction (LVEF) was 27%. His coronary angiogram showed normal coronary arteries but anomalous origin of the Cx artery from the right coronary. He underwent elective bioprosthetic aortic valve replacement. His postoperative recovery was uneventful and he was discharged on day 5 postoperatively. His TTE postoperatively showed well-seated aortic valve, improved LVEF to 51%. We here report a case of incidental finding of anomalous Cx artery arising from the right coronary while the patient is being worked up for aortic valve replacement for congenital bicuspid aortic valve.

Midbrain Gliofibroma Presenting in Adulthood following "Cure" of a Childhood Intraventricular Pilocytic Astrocytoma.

INTRODUCTION: Gliofibromas are rare biphasic tumours with a good prognosis that usually occur in childhood. Rare adult spinal cases have been treated with radiotherapy. This report describes the case of a gliofibroma occurring in a young adult 10 years after treatment for a childhood pilocytic astrocytoma. CASE: A 14-year-old female underwent complete resection of a right lateral ventricle pilocytic astrocytoma confirmed on postoperative magnetic resonance imaging (MRI). At the age of 17, the tumour recurred, and a second complete resection was performed. Due to the early recurrence, she was placed on long-term MRI surveillance. At the age of 23, an enhancing left midbrain tumour was identified that was suspected to be a recurrent pilocytic astrocytoma. Following surgical resection the histopathology revealed a gliofibroma. Due to the growth of further tumour nodules she was treated with fractionated radiotherapy. There is no disease recurrence after 36 months of follow-up, and the patient remains well. DISCUSSION: Gliofibromas are tumours which usually occur in childhood; this case report identifies a rare occurrence in an adult. The childhood intraventricular pilocytic astrocytoma was in an anatomically distinct location to the midbrain gliofibroma. Radiotherapy can control these tumours, and follow-up is required to understand the long-term outcome and prognosis.