Midterm Outcomes for Valve-in-Valve Transcatheter Aortic Valve Replacement in the Failed Freestyle Bioprosthesis.

BACKGROUND: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is acceptable in patients at high risk for reoperation. Studies suggest that ViV TAVR in stentless valves may be technically more challenging. This study sought to evaluate midterm outcomes for ViV TAVR in the degenerative Freestyle ((Medtronic, Minneapolis, MN)) stentless bioprosthesis. METHODS: Between October 2014 and January 2019, 56 patients underwent ViV TAVR for a failed Freestyle valve at a single institution using a commercially available self-expanding transcatheter aortic valve. Patient baseline characteristics and clinical outcomes data were collected retrospectively. Valve Academic Research Consortium-2 definitions were applied. RESULTS: Mean patient age was 75 ± 8 years and The Society of Thoracic Surgeons mean risk score was 9% ± 8%. The predominant mode of Freestyle valve failure was regurgitation (77%), and 36 patients (64%) required urgent intervention for refractory acute heart failure. Device success using a self-expanding TAVR was 82%, with 6 cases (11%) requiring deployment of two transcatheter valves. There were 3 operative mortalities (5%). At 30-day follow-up, no patient had greater than moderate perivalvular regurgitation. Device success was higher in the later patients compared with patients done earlier (P = .02). Mean aortic valve gradients at 30 days and 1 year were 11 ± 8 and 9 ± 8 mm Hg, respectively. For patients alive beyond day 30, 3-year survival was 82%. CONCLUSIONS: Performing ViV TAVR in the Freestyle valve using a self-expanding transcatheter valve presents a technical challenge, but may be feasible with good midterm results. Procedural success is associated with an early hazard learning curve.

A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction.

OBJECTIVE: We describe a novel and safe technique using a 12F-14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction. METHODS: Between January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C-26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10-15 mL/kg/min. Data were collected by retrospective chart review. RESULTS: Thirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury. CONCLUSIONS: Direct IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.

Long-Term Outcomes of Mosaic Versus Perimount Mitral Replacements: 17-Year Follow-Up of 940 Implants.

BACKGROUND: The objective of this study was to compare long-term outcomes of Mosaic (Medtronic, Minneapolis, MN) porcine mitral valves to Carpentier-Edwards (Edwards Lifesciences, Irving, CA) bovine pericardial mitral valves. METHODS: From 2001 through 2017 at a single institution, 940 patients received a mitral bioprosthesis, of which 463 (49.3%) were porcine and 477 (50.7%) were bovine pericardial. Retrospective review of the procedure and the postoperative clinical course, including echocardiography, through August 2018 were analyzed. All consecutive mitral valve replacements over the study period were included. Follow-up was 99% (929 patients) complete for a total of 6045 patient-years (mean, 6.4 ± 4.5 years). A propensity-matched cohort of 802 mitral bioprosthesis was used for outcome analyses. RESULTS: Operative mortality of the 940 patients was 5.4% (n = 51) and incidence of postoperative stroke was 2.1% (n = 20). Overall survival of the propensity-matched patients at 10 and 15 years was 49.7% (95% confidence interval [CI] 45.5%-53.7%) and 23.3% (95% CI 17.9%-29.3%), respectively. Survival at 15 years was 24.0% (95% CI 18.0%-30.5%) for porcine and 16.5% (95% CI 5.5%-32.6%) for bovine implants, which was not significantly different (P = .67). Overall cumulative incidence for reoperative structural valve deterioration at 15 years was 7.9% (95% CI 4.7%-12.3%) for porcine valves versus 13.2% (95% CI 8.1%-19.5%) for pericardial valves (P < .001). For patients age younger than 65 years, structural valve deterioration at 15 years was 15.8% (95% CI 7.4%-27.0%) versus 30.2% (95% CI 15.1%-46.8%) for porcine and pericardial valves, respectively (P = .009). Overall average time to reoperation for structural valve deterioration for porcine valves was 11.1 ± 2.3 years vs 6.8 ± 2.3 years for bovine pericardial valves (P < .001). CONCLUSIONS: In long-term follow-up, of patients younger than 65 years of age undergoing mitral valve replacement, bovine pericardial valves experienced earlier and more frequent structural valve deterioration than porcine valves.

Del Nido cardioplegia in isolated adult coronary artery bypass surgery.

BACKGROUND: Del Nido cardioplegia (DC) offers prolonged single-dose myocardial protection in pediatric cardiac surgery. We set out to evaluate the efficacy of DC in adult patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: From January 2012 to October 2017, 851 consecutive isolated CABG surgeries were performed by 2 study surgeons at our center with blood cardioplegia (BC, n = 350), used from January 2012 to April 2014, and DC (n = 501), used from May 2014 to October 2017. Propensity matching was used to yield 325 well-matched pairs. Clinical data were extracted from our local Society of Thoracic Surgeons database and mortality data from the Michigan State Social Security Death Index. RESULTS: Single-dose administration was used in 83% (417/501) of patients receiving DC. In propensity-matched groups, postoperative median troponin T levels (0.28 [0.16-0.59] ng/mL vs 0.46 [0.27-0.81] ng/mL; P < .01) were lower for patients receiving DC, and no difference in ejection fraction on postoperative echocardiography was observed (54 ± 12% and 53 ± 13% for BC and DC, respectively; P = .36). Perioperative outcomes were similar except for greater rate of atrial fibrillation (33% vs 23%; P = .01) in the DC group. Subgroup analyses revealed equivalent myocardial protection and clinical outcomes in patients with age ≥75 years, left ventricular ejection fraction ≤35%, left main disease, or Society of Thoracic Surgeons score ≥2.5%. Four-year survival did not differ between patients undergoing BC or DC. CONCLUSIONS: The current study revealed noninferior myocardial protection and clinical outcomes with DC versus BC in both routine and greater-risk patients undergoing isolated CABG. DC demonstrated the feasibility of single-dose administration for isolated CABG surgery. Larger randomized studies are needed to further explore the safety and efficacy of DC in adult cardiac surgery with longer crossclamp times.

Use of an Automated Suture Fastening Device in Minimally Invasive Aortic Valve Replacement.

BACKGROUND: Minimally invasive aortic valve replacement (mAVR) is gaining clinical acceptance; however, it is associated with increased operative times because of the limited surgical field and access. The Cor-Knot (CK; LSI Solutions, Victor, NY) is an automated fastening device designed to facilitate suture fastening, but clinical data in mAVR are lacking. METHODS: From May 2014 to February 2017, 92 patients underwent mAVR at Spectrum Health in Grand Rapids, Michigan; 39 valves were secured with manually tied sutures, and 53 valves were entirely secured with the CK device. Preoperative characteristics and 30-day outcomes data were extracted from the local The Society of Thoracic Surgeons database and the patients' electronic medical records. Survival data were obtained from the Michigan State Social Security Death Index. RESULTS: No significant differences in preoperative characteristics were noted between the two groups. Aortic cross-clamp time (72 ± 12 minutes vs 82 ± 15 minutes; p = 0.001) was significantly shorter with CK. There was no difference in the rate of postoperative mortality (0% vs 0%), stroke (0% vs 1.9%), atrial fibrillation (28% vs 33%), renal failure (0% vs 3.8%), or pacemaker implantation (5.1% vs 5.7%) between patients with manually tied sutures and patients with sutures fastened with the CK. Valve function on postoperative echocardiography and 1-year patient survival rates were similar. CONCLUSIONS: In mAVR, the CK device was associated with reduced aortic cross-clamp time while providing equivalent clinical outcomes. Larger studies are needed to confirm the efficacy, safety, and cost-effectiveness of the CK device in minimally invasive aortic valve surgery.

Early Outcomes for Valve-in-valve Transcatheter Aortic Valve Replacement in Degenerative Freestyle Bioprostheses.

Transcatheter aortic valve replacement (TAVR) is used increasingly to treat bioprosthetic valve failure. A paucity of data exists regarding valve-in-valve (ViV) TAVR in degenerated Freestyle stentless bioprostheses (FSBs). This study sought to evaluate the feasibility and short-term outcomes of ViV TAVR in previously placed FSB. From October 2014 to September 2016, 22 patients at a single institution underwent ViV TAVR with a self-expanding transcatheter valve for a failing FSB. Patient baseline characteristics and clinical outcomes data were collected retrospectively and entered into a dedicated database. The mean patient age was 74 ± 9 years, and the mean Society of Thoracic Surgeons' Risk score was 9.0 ± 7.4%. Ten patients presented with acute heart failure requiring urgent intervention. The most common mode of failure of the FSB was regurgitation caused by a flail or malcoapting leaflet. Seventeen (77%) patients had a modified subcoronary implantation, 3 (14%) had a full root replacement, and 2 (9%) had a root inclusion. Device success using a self-expanding transcatheter valve was 95%, all via transfemoral approach. The mean implant depth was 7 ± 3 mm. Thirty-day survival was 100%. No patient had more than mild paravalvular regurgitation at 30 days, and the permanent pacemaker rate was 9%. The mean hospital stay after intervention was 5 ± 2 days. ViV TAVR using a self-expanding transcatheter valve is safe, feasible, and can be used successfully to treat a failed FSB. Procedural challenges suggest referral to valve centers of excellence.

Use of EN Snare device for successful repositioning of the newest self-expanding transcatheter heart valve.

Once a self-expanding transcatheter aortic valve replacement is fully deployed, a snare device must be used to retrieve it. Minimal data are available regarding technique, efficacy, and complications associated with the retrieval of such valves. Here, we present two patients in which an EN Snare® Device (Merit Medical System, South Jordan, UT, USA) was safely and effectively used to retrieve and reposition the latest generation self-expanding transcatheter aortic valve replacement.