Modified composite-graft technique for aortic root replacement.

This report describes a novel modification of a self-assembled composite graft to replace the aortic root and left ventricular outflow tract (LVOT). This technique enables the implantation of a larger valve than conventional ways and simultaneous reconstruction of LVOT. This technique comprises Inspiris Resilia aortic valve and Gelweave Valsalva graft. By placing the valve in the sinus portion of the graft, the bioprosthesis that is 1 mm smaller than the graft can be accommodated, providing a proper length of the collar for LVOT reconstruction. This technique is useful for patients who require redo-aortic root replacement and have restricted LVOT.

Intermittent Papillary Muscle Suction: A Rare Cause of Left Ventricular Assist Device Low Flow.

Low flow alarms represent a management challenge in patients with left ventricular assist devices because they are often a consequence of complex patient-device interactions. We present a case of intermittent suction of the postero-medial papillary muscle into the left ventricular assist device inflow cannula during diastole, causing low flows. This case highlights the importance of a systematic approach and use of multiple investigation modalities in making an accurate diagnosis. (Level of Difficulty: Advanced.).

Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Aortic Valve Replacement for Aortic Stenosis (SAVR): A Cost-Comparison Study.

BACKGROUND: Comparative costing studies using real-world data stratified by patient case-mix, are valuable to decision makers for making reimbursement decisions of new interventions. This study evaluated real-world hospital admissions and short-term costs of transcatheter aortic valve implantation (TAVI) and isolated surgical aortic valve replacement (SAVR) for patients with aortic stenosis, stratified by the Society of Thoracic Surgeons (STS) risk scores. METHODS: Retrospective analysis of consecutive patients with a principal diagnosis of aortic stenosis who underwent isolated valve replacement at a single tertiary hospital, January 2012-December 2017. Patients were followed-up for 30 days post-procedure or until hospital discharge if index hospitalisation was greater than 30 days. Intensive care unit (ICU) and hospital length of stay (days), and costs in 2018 Australian dollars for the index procedure and 30-day follow-up were assessed. Multivariable generalised linear and two-part models with gamma distribution and log link function adjusting for Society of Thoracic Surgeons (STS) risk group and key sociodemographic characteristics were used. RESULTS: Of 488 patients, 61% males, median age 78 years (IQR 14 years), 221 (45%) received transcatheter aortic valve replacement (TAVI) and 267 (55%) received surgical aortic valve replacement (SAVR). STS risk scores were low (28%), intermediate (46%) and high (26%) for TAVI patients, and low (85%), intermediate (12%) and high (3%) for SAVR patients. When adjusted, TAVI length of stay was 57% shorter than SAVR (95% CI 31-83%, p<0.001) for intensive care unit (ICU) admission, and 64% shorter (95% CI 47-81%, p<0.001) for hospital admissions. TAVI costs were 13% lower than SAVR (95% CI 4-22%, p=0.005). CONCLUSION: This data suggests short-term health care costs are lower for patients with aortic stenosis undergoing TAVI than SAVR. A further roll-out of the TAVI program in hospitals across Australia may result in savings to the health system.

Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies.

BACKGROUND: Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. METHODS: Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. RESULTS: Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37-1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13-1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16-0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01-0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13-1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25-4.16, P=0.007). CONCLUSIONS: In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.

Epidemiology of infective endocarditis before versus after change of international guidelines: a systematic review.

INTRODUCTION: All major international guidelines for the management of infective endocarditis (IE) have undergone major revisions, recommending antibiotic prophylaxis (AP) restriction to high-risk patients or foregoing AP completely. We performed a systematic review to investigate the effect of these guideline changes on the global incidence of IE. METHODS: Electronic database searches were performed using Ovid Medline, EMBASE and Web of Science. Studies were included if they compared the incidence of IE prior to and following any change in international guideline recommendations. Relevant studies fulfilling the predefined search criteria were categorized according to their inclusion of either adult or pediatric patients. Incidence of IE, causative microorganisms and AP prescription rates were compared following international guideline updates. RESULTS: Sixteen studies were included, reporting over 1.3 million cases of IE. The crude incidence of IE following guideline updates has increased globally. Adjusted incidence increased in one study after European guideline updates, while North American rates did not increase. Cases of IE with a causative pathogen identified ranged from 62% to 91%. Rates of streptococcal IE varied across adult and pediatric populations, while the relative proportion of staphylococcal IE increased (range pre-guidelines 16-24.8%, range post-guidelines 26-43%). AP prescription trends were reduced in both moderate and high-risk patients following guideline updates. DISCUSSION: The restriction of AP to only high-risk patients has not resulted in an increase in the incidence of streptococcal IE in North American populations. The evidence of the impact of AP restriction on IE incidence is still unclear for other populations. Future population-based studies with adjusted incidence of IE, AP prescription rates and accurate pathogen identification are required to delineate findings further in these other regions.

Patient Safety During Chest Drain Insertion-A Survey of Current Practice.

OBJECTIVES: The aim of this study was to identify the degree of awareness of the current guidelines and common practices for pleural drain insertion. METHODS: A 10-item questionnaire was sent electronically to junior physicians from 4 different hospitals in the South Eastern Sydney and Illawarra Shoalhaven Local Health District. Participants were asked to give their level of experience and management practices for chest drain insertion. RESULTS: A total of 94 junior medical officers from 4 hospitals in the district completed the survey. More than 20% had never inserted a chest drain at the time; 72% had primarily learned from bedside teaching and peer learning, but 11% had no training at all. More than 50% of physicians felt that the biggest threat to the procedure was their own lack of confidence for drain insertion. Despite current guidelines, 25% insert chest drains routinely without the aid of ultrasound. A third of interviewees were aware of local guidelines but had not read them. Most physicians (86%) believe that formal standardized training should be available for junior physicians. CONCLUSIONS: Our findings demonstrate the ongoing need for improved procedural training in chest drain insertion, with emphasis on mandatory thoracic ultrasound. We consider it important to continue to raise concern and awareness that chest drain insertion is not a harmless procedure, and further physician procedural competence is required.

Subclinical valve thrombosis in transcatheter aortic valve implantation: A systematic review and meta-analysis.

BACKGROUND: Recent high-resolution computed tomography studies after transcatheter aortic valve insertion (TAVI) have reported a high prevalence of subclinical valve thrombosis (SCVT), potentially contributing to increased risk of late stroke. We aimed to investigate SCVT in patients after TAVI, with a focus on prevalence, predisposing factors, management, and potential sequelae. METHODS: A comprehensive literature review of patients with SCVT after TAVI was carried out on all published studies in 3 major electronic databases from their inception until October 2019. Studies with sufficient data were included in a meta-analysis comparing the risk of stroke between patients with SCVT and those with normal valve function, as well as the protective effects of antiplatelet and anticoagulation on preventing SCVT. RESULTS: From 3456 patients examined in a comprehensive review, 398 patients (11.5%) demonstrated evidence of SCVT during follow-up. Dual antiplatelet therapy was given in 45.5% of cases, single antiplatelet therapy in 19.8%, and oral anticoagulation in 28.5%. A meta-analysis demonstrated that rates of stroke were more than 3 times greater in patients with SCVT compared with those without (logistic odds, 1.10; 95% confidence interval, 0.63-1.57, P < .0001). Oral anticoagulation was superior to dual antiplatelet therapy or single antiplatelet therapy, preventing the formation of SCVT (logistic odds, -1.05, 95% confidence interval, -1.71 to -0.39, P < .0001). CONCLUSIONS: Subclinical valve thrombosis is seen in 11.5% of patients after TAVI and is associated with increased risk of stroke. When oral anticoagulation is used postprocedurally, it is more effective than either dual or single-antiplatelet therapy in preventing subclinical valve thrombosis. These findings suggest that further studies are needed to define the optimal antithrombotic regimen to mitigate thrombotic and embolic sequelae after TAVI.

Octogenarians and aortic valve surgery: surgical outcomes in the geriatric population.

BACKGROUND: The era of percutaneous aortic valve intervention has challenged the continuing indication for surgical aortic valve replacement (SAVR). AIM: The aim of this study is to evaluate clinical outcomes of the elderly patients who underwent surgical aortic valve replacement via median sternotomy, in order to assess the impact of surgery on patient outcomes and discharge destination. METHODS: The study involves a retrospective observational analysis in a single centre, including all octogenarian patients who underwent aortic valve surgery between January of 2011 and July of 2016. The study assessed pre-operative co-morbidities and post-operative outcomes, including long-term mortality and discharge destination following on from surgery. RESULTS: The mean age of patients was 82.7 years (± 2.9), 67% of whom were male. The mean EuroSCORE II was 8.1 (± 7.6). The most common pre-operative co-morbidities were dyslipidaemia (82%), hypertension (80%), and ischaemic heart disease (78.8%). The median length of stay was 10 days (± 6.9 days). Discharge home occurred in 71.8% of patients, with 21.2% of patients requiring transfer to a rehabilitation facility, and 1.2% of patients required placement into an aged care facility. There were five peri-operative deaths, equating to 5.9% of the cohort. CONCLUSION: Despite high EuroSCORE II values for the majority of our patients, our data adds to overall suggestions that the octogenarian population can be considered eligible for SAVR and should not be excluded due to age alone. The use of the EuroSCORE II index more accurately predicts adequacy for treatment however does not entirely predict overall course of events, and proceduralist discretion should still be used.

A systematic review and meta-analysis of the clinical outcomes of TAVI versus SAVR in the octogenarian population.

BACKGROUND: Surgical aortic valve replacement (SAVR) has shown safe, robust results in elderly populations, and up until recently, was the gold standard for management of severe aortic stenosis. The approach to severe aortic stenosis in high-risk populations, such as octogenarians, has been challenged with the development of transcatheter-based strategies. We sought to systematically analyse outcomes between surgical and transcatheter aortic valve replacement (TAVI) in octogenarians. METHOD: Electronic databases were searched from their inception until November 2018 for studies comparing SAVR to TAVI in octogenarians, according to a predefined search criterion. The primary end point was mortality, and secondary end points included post-procedural complications. RESULTS: The review yielded four observational studies. The total number of patients included was 1221 including 395 who underwent TAVI and 826 SAVR. On average, patients from both subgroups carried a high number of cardiac risk factors, and STS-PROM scoring yielded mean values equating to high-risk population groups, with significantly higher values for TAVI patients across the board. The presence of post-procedural moderate aortic regurgitation was noted only in the TAVI population (OR = 8.88; 95% CI (1.47-53.64), χ2 = 1.22; p = 0.02; I 2 = 0%). Otherwise, there were no significant differences when accounting for mortality (OR = 0.68; 95% CI (0.44-1.05), χ2 = 1.88; p = 0.60; I 2 = 0%), permanent pacemaker implantation groups (OR = 0.45; 95% CI (0.44-1.49), χ2 = 0.11; p = 0.19; I 2 = 0%), and neurological events (OR = 0.72; 95% CI (0.42-1.23), χ2 = 2.57; p = 0.23; I 2 = 22%). DISCUSSION: The analysed data on TAVI versus SAVR in the octogenarian population show that TAVI shows similar outcomes with relation to mortality and inpatient admission times, in a population with significantly higher risk profiles than their SAVR counterparts. TAVI has higher occurrences of post-procedural AR. TAVI still does not have robust long-term data to ensure its efficacy and rate of complications, but is showing promising results nonetheless.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis.

BACKGROUND: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. METHODS: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. RESULTS: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. CONCLUSIONS: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Changes in the Preterm Heart From Birth to Young Adulthood: A Meta-analysis.

CONTEXT: Preterm birth is associated with incident heart failure in children and young adults. OBJECTIVE: To determine the effect size of preterm birth on cardiac remodeling from birth to young adulthood. DATA SOURCES: Data sources include Medline, Embase, Scopus, Cochrane databases, and clinical trial registries (inception to March 25, 2020). STUDY SELECTION: Studies in which cardiac phenotype was compared between preterm individuals born at <37 weeks' gestation and age-matched term controls were included. DATA EXTRACTION: Random-effects models were used to calculate weighted mean differences with corresponding 95% confidence intervals. RESULTS: Thirty-two observational studies were included (preterm = 1471; term = 1665). All measures of left ventricular (LV) and right ventricular (RV) systolic function were lower in preterm neonates, including LV ejection fraction (P = .01). Preterm LV ejection fraction was similar from infancy, although LV stroke volume index was lower in young adulthood. Preterm LV peak early diastolic tissue velocity was lower throughout development, although preterm diastolic function worsened with higher estimated filling pressures from infancy. RV longitudinal strain was lower in preterm-born individuals of all ages, proportional to the degree of prematurity (R 2 = 0.64; P = .002). Preterm-born individuals had persistently smaller LV internal dimensions, lower indexed LV end-diastolic volume in young adulthood, and an increase in indexed LV mass, compared with controls, of 0.71 g/m2 per year from childhood (P = .007). LIMITATIONS: The influence of preterm-related complications on cardiac phenotype could not be fully explored. CONCLUSIONS: Preterm-born individuals have morphologic and functional cardiac impairments across developmental stages. These changes may make the preterm heart more vulnerable to secondary insults, potentially underlying their increased risk of early heart failure.

Direct Innominate Artery Cannulation as a Sole Systemic and Cerebral Perfusion Technique in Aortic Surgery.

Arterial cannulation is often challenging in thoracic aortic surgery due to the location of the surgery and need for cerebral protection during periods of circulatory arrest. Cannulation sites including the ascending and descending aorta, axillary, carotid and femoral arteries have limitations and are associated with complications due to their proximity to surrounding structures. Therefore, the innominate artery can be used by either direct cannulation or indirect cannulation via a graft as an alternative site. We present a technique of sole direct innominate artery cannulation that is able to provide both systemic and selective antegrade cerebral perfusion during aortic surgery.

Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Aerobic exercise is a critical component of cardiac rehabilitation following cardiac surgery. Aerobic exercise is traditionally commenced 2-6 weeks following hospital discharge and most commonly includes stationary cycling or treadmill walking. The initiation of aerobic exercise within this early postoperative period not only introduces the benefits associated with aerobic activity sooner, but also ameliorates the negative effects of immobilization associated with the early postoperative period. METHODS: A systematic review identified all studies reporting safety and efficacy outcomes of aerobic exercise commenced within two weeks of cardiac surgery. A meta-analysis was performed comparing functional, aerobic and safety outcomes in patients receiving early postoperative aerobic exercise compared with usual postoperative care. RESULTS: Six-minute walk test distance at hospital discharge was 419 ± 88 m in early aerobic exercise patients versus 341 ± 81 m in those receiving usual care (mean difference 69.5 m, 95% confidence interval (CI) 39.2-99.7 m, p < 0.00001). Peak aerobic power was 18.6 ± 3.8 ml·kg-1·min-1 in those receiving early exercise versus 15.0 ± 2.1 ml·kg-1·min-1 in usual care (mean difference 3.20 ml·kg-1·min-1, 95% CI 1.45-4.95, p = 0.0003). There was no significant difference in adverse events rates between the two groups (odds ratio 0.41, 95% CI 0.12-1.42, p = 0.16). CONCLUSION: Aerobic exercise commenced early after cardiac surgery significantly improves functional and aerobic capacity following cardiac surgery. While adverse event rates did not differ significantly, patients included were very low risk. Further studies are required to adequately assess safety outcomes of aerobic exercise commenced early after cardiac surgery.

Complex disease management of pregnant young patient with familial hypercholesterolaemia complicated by coronary artery disease and cerebrovascular disease.

Inherited disorders of lipid metabolism may cause a heavy burden of cardiovascular disease early in life. Familial hypercholesterolaemia (FH) with abnormalities of LDL metabolism results in marked LDL elevations and accelerated, multivessel atherosclerosis presenting in teenage or young adulthood. We describe the case of a 33-year-old woman who presented with exertional angina in the setting of pregnancy who was found post-partum to have severe triple-vessel disease including left main disease on coronary angiography (Figs. 1 and 2). She was also noted to have a typical supravalvular "hourglass" [1] abnormality of the aortic root (Fig. 3), and heavy calcification of the proximal aorta precluding conventional aortic cross clamping and bypass surgery. After discussion with the multidisciplinary team, her disease was felt to be amenable to a beating-heart coronary bypass technique with an anaortic approach to minimise the possibility of cerebral embolism. Significant extracranial cerebrovascular disease, a major risk for cardiopulmonary bypass, reinforced the beating-heart technique. Her ongoing management has consisted of medical therapy with cessation of breast feeding, statins, ezetimibe, and introduction of PCSK9-inhibitor therapy. This case illustrates a number of the difficulties associated with management of widespread atherosclerotic disease associated with FH, in which an excellent outcome was achieved with the assistance of a multi-disciplinary team.

Improving informed consent in cardiac surgery by enhancing preoperative education.

OBJECTIVE: To investigate the effect of enhancing preoperative education in improving recall and understanding of a surgical procedure and its application to the informed consent process in cardiac surgery. METHODS: Four electronic database searches were performed from January 2000 to August 2017. A total of 282 articles were identified from which 22 prospective studies assessing an intervention were selected according to predefined selection criteria. RESULTS: Most articles that used additional written information and all that used multimedia presentations to enhance informed consent showed that their intervention improved risk recall and patient's understanding of the procedure. A single randomised controlled trial in cardiac surgery showed that audiotaped consultations improved patient's knowledge of the operation. CONCLUSIONS: Patient recall and understanding of pre-operative information can significantly improve with a variety of educational tools. Procedure-specific forms with or without illustrations as well as interactive multimedia interventions enhance patient recall and understanding of information. In cardiac surgery patients, interventions need to meet patients' preferences, be repetitive on crucial points and consider the nature of the procedure.

Surgical Removal of an Unusual Massive Mediastinal Tumour Preceded by Interventional Embolisation.

Massive mediastinal tumours are rare in clinical practice and complete surgical resection may be associated with serious complications. Preoperative angiography and embolisation are valuable adjuncts in the management of giant tumours to decrease perioperative blood loss, provide a clear operative field and facilitate complete resection. We report the safe use of preoperative embolisation which facilitated excision via clamshell incision, of a highly vascular massive anterior mediastinal tumour with an unusual final diagnosis.

A systematic review on robotic coronary artery bypass graft surgery.

BACKGROUND: Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival. METHODS: Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB). RESULTS: The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques. CONCLUSIONS: A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.

Transcatheter aortic valve implantation versus surgical aortic valve replacement: A meta-analysis of randomized controlled trials.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a widely utilized method of treatment of severe aortic valve stenosis. The present meta-analysis included all published relevant randomized controlled trials (RCTs) and aimed to compare the safety and efficacy of TAVI compared to surgical aortic valve replacement (AVR). METHOD: Nine electronic databases were comprehensively searched. Eligible studies were required to be randomized controlled trials which reported comparative endpoints on both TAVI and AVR. RESULTS: Five published RCTs were included in the meta-analysis. A total of 3828 patients were studied. The overall mortality and stroke rates at 30days and 1year were not significantly different between TAVI and AVR. Patients undergoing TAVI were more likely to experience vascular complications, aortic regurgitation and permanent pacemaker insertion, however, they were less likely to encounter acute renal failure and major haemorrhage. CONCLUSIONS: The data suggest that TAVI is a safe and efficacious alternative to surgical aortic valve replacement in judiciously selected patients.