Respect versus resect approaches for mitral valve repair: A study-level meta-analysis.

Mitral valve repair (MVr) restores leaflets coaptation while preserving the patient's own valve. The two main techniques are: (a) chordal replacement ("respect approach"), whereby artificial neochordae are used to resuspend prolapsed segments of the affected leaflet - and (b) leaflet resection ("resect approach"), whereby diseased leaflet segment is resected, and the remaining segments are sutured together. Both techniques of MVr are associated with better long-term results, fewer valve-related complications and lower mortality when compared with mitral valve replacement (MVR). They also restore quality of life and improve survival to rates equivalent to those of the general population. We performed a meta-analysis to pool data of clinical studies that compared outcomes of MVr stratified by the surgical technique. Seventeen studies accounting for 6,046 patients fulfilled our eligibility criteria. The "respect approach" outperformed the "resect approach" with lower permanent pacemaker implantation rates and lower mean gradients. Despite any possible advantages of one technique over the other, which approach is best for each patient must be decided on a case-by-case basis and more long-term follow-up data are warranted.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis.

OBJECTIVES: Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures. METHODS: We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed. RESULTS: Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay. CONCLUSIONS: In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Bioprosthetic valve fracture for valve-in-valve transcatheter aortic valve implantation in patients with structural valve degeneration: Systematic review with meta-analysis.

OBJECTIVES: To determine the outcomes of bioprosthetic valve fracture (BVF) in valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for patients with structural valve degeneration (SVD) of bioprosthetic surgical valves (BSV) implanted during surgical aortic valve replacement (SAVR). METHODS: A systematic review was conducted including studies published by May 2021. The primary endpoints of the study were 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation, and coronary obstruction. The secondary endpoints were mean valve gradients (mmHg) and aortic valve area (AVA-cm2 ). A meta-analysis was conducted using the software R, version 3.6.3 (R Foundation for Statistical Computing). RESULTS: Four studies including 242 patients met our eligibility criteria. The overall proportions for 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation and coronary obstruction were 2.1%, <1.0%, <1.5%, <1.0%, <1.0%, and <1.5%, respectively. After ViV-TAVI with BVF, the difference in means for mean valve gradients showed a significant reduction (random-effects model: -26.7; -28.8 to -24.7; p < .001), whereas the difference in means for AVA showed a significant increase (random-effects model: 0.55 cm2 ; 0.13-0.97; p = .029). Despite the improvement in AVA means, these remain too low after the procedure highly likely due to the small size of the bioprosthetic valves implanted during the index SAVR. CONCLUSION: ViV-TAVI with BVF has proven to be a promising option but data are still too scarce to enable us to draw definitive conclusions. Despite the decrease in gradients, postprocedural AVA remains worrisome. Studies with better designs and larger sample sizes are needed to advance this treatment option.

Percutaneous closure of left ventricular pseudoaneurysm in a patient with concomitant true left ventricular aneurysm.

BACKGROUND: Left ventricular aneurysms (LVA) are serious complications of myocardial infarction, being divided into true and false type. The false one-pseudoaneurysm (PA), is a life-threatening condition that requires urgent treatment due to the high risk of rupture. CASE PRESENTATION: An 84-year-old female presented with progressive heart failure symptoms. Investigation showed a small true LVA and a large PA. Open surgical repair was ruled out as Euroscore and Society of Thoracic Surgeons (STS) score were 42.80% and 39.97%, respectively. After discussion at our Heart Team meeting, percutaneous approach was found to be the best option. Guided by transesophageal echocardiography, we used an interventricular septal defect occluder to close the gap between the LV and the PA. Control ventriculography showed full closure of the gap, with no residual flow to the PA cavity. The patient was discharged from the hospital on the fifth postoperative day and has remained asymptomatic since then. CONCLUSION: Percutaneous approach proved to be a safe and effective modality to treat LV PA. The device implanted achieved the goal of blocking blood flow through the communication between LV and the PA.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adults: Collateral circulation does not preclude direct reimplantation.

BACKGROUND: The adult type of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is characterized by late presentation due to collateral coronary flow. Patients often present with long time recurrent angina or dyspnea. Surgical correction can be a challenge due to the vast collateral coronary circulation. CASE PRESENTATION: A previously healthy 41-year-old male presented in the emergency room referring typical angina and dyspnea. Coronary angiography revealed ALCAPA. Surgical correction was indicated. Under cardiopulmonary bypass, the left main coronary artery ostium was isolated and directly reimplanted in the aorta. The patient was discharged from the hospital without complications and asymptomatic. Control coronary angiography showed enlarged left main coronary artery and regression of the collateral circulation. CONCLUSION: Even with a well-developed collateral circulation, detachment of the left coronary artery and direct implantation in the aorta is feasible, achieving good long-term results.

Impact of Aortic Annulus Enlargement on the Outcomes of Aortic Valve Replacement: A Meta-analysis.

We sought to evaluate the impact of surgical aortic annulus enlargement (ARE) on the perioperative outcomes of surgical aortic valve replacement. Databases were searched for articles published by October 2019 in order to carry out a systematic review followed by meta-analysis. Thirteen studies with 40,447 patients (aortic valve replacement [AVR] with aortic annulus enlargement [AAE]: 4686 patients; AVR without AAE: 35,761 patients) were included. The total rate of AAE was 11.6%, ranging from 4.1%-28.1%. The overall unadjusted odds ratio (OR) (95% confidence interval [CI]) for operative mortality showed a statistically significant difference between the groups, with higher risk in the "AVR with AAE" group (OR 1.388; 95% CI 1.049-1.836, P < 0.001), but not for isolated AVR+AAE (OR 1.341; 95% CI 0.920-1.956, P = 0.127) and also not in matched populations (OR 1.003; 95% CI 0.773-1.300, P = 0.984). The "AVR with AAE" group showed an overall lower risk of significant patient-prosthesis mismatch (PPM) (OR 0.567; 95% CI 0.376-0.854, P = 0.007) and a higher overall difference in means of indexed effective orifice area (iEOA) (random effect model: 0.058 cm2/m2; 95% CI 0.024-0.092, P < 0.001). The overall ORs for myocardial infarction, stroke, complete heart block/permanent pacemaker implantation and reoperation for bleeding showed no statistically significant difference between the groups. AAE is a useful adjunct to AVR, but the benefit of reduced PPM must be balanced against a possibly higher risk of perioperative mortality.

Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications.

PURPOSE OF REVIEW: This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment. RECENT FINDINGS: Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm.

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis-zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch-from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk-zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.

German aortic valve score in risk assessment for surgical aortic valve replacement in a brazilian center

Abstract Objective: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. Results: The mortality rate was 8.04% (18 patients). The patients' mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff "1.8" turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. Conclusion: The GAV score applies to our population with high predictive accuracy.