Clinical trends in surgical, minimally invasive and transcatheter aortic valve replacement†.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (MIAVR) have emerged as alternatives to surgical aortic valve replacement (SAVR) via traditional sternotomy. However, their effect on clinical practice remains unclear. The study's objective is to describe clinical trends between TAVR, MIAVR and SAVR in patients with severe aortic stenosis (AS). METHODS: This retrospective observational study analyzed trends in isolated severe aortic valve replacement (AVR) among three high volume TAVR, MIAVR and SAVR centres in the United States. The cohort included 2571 patients from 2011 through 2014 undergoing SAVR ( n = 842), MIAVR ( n = 699) and TAVR ( n = 1030) further stratified into transapical (TA-TAVR) and trans-femoral (TF-TAVR). RESULTS: Total AVR volume increased +107% with increases in TF-TAVR (+595%) and MIAVR (+57%). However, SAVR (-15%) and TA-TAVR (-49%) decreased from 2013 to 2014. In the final year, risk stratification by age ≥ 80, redo AVR, patients receiving dialysis and STS score >8% revealed increases in TF-TAVR and MIAVR, while SAVR decreased for all groups. CONCLUSIONS: TF-TAVR and MIAVR increased while SAVR and TA-TAVR trended down in the latter periods, which underscore a paradigm shift in the treatment of severe AS and the importance of surgeon adoption of TF-TAVR and MIAVR techniques. As the demand for minimally invasive modalities increases, further studies comparing MIAVR versus TF-TAVR in low and intermediate risk patients are warranted.

Integrated cerebral perfusion for hypothermic circulatory arrest during transverse aortic arch repairs.

OBJECTIVES: Antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) for ascending/transverse arch repair is used for cerebral protection. This study evaluates ACP in combination with retrograde cerebral perfusion (RCP) during extended HCA and compares it to RCP-only. METHODS: Between January 2005 and April 2007, we performed 64 consecutive arch repairs requiring extended HCA (>40 min). RCP-only was used with 34 patients and ACP with brief RCP ('integrated') was used with 30 patients. Mean HCA time was 51 + or - 13 min. Mean RCP-only time was 47 + or - 9.6 min; in the integrated group, mean ACP time was 42 + or - 14.4 min with an added RCP time of 10.8 + or - 7.6 min. For the entire cohort, 95% (61/64) underwent total arch repair, and 67% (43/64) had elephant trunk reconstruction. Variables predictive of mortality and neurological outcomes were analysed prospectively, but technique selection was non-randomised. RESULTS: Preoperative and operative variables did not differ between the RCP-only and the integrated groups except for aortic valve replacement, which was more frequently performed in the integrated group (33% (10/30) vs 12% (4/34), P=0.05), and preoperative renal dysfunction, which was more frequent in the RCP group (26% (9/34) vs 7% (2/30), P=0.04). No significant difference was observed in outcomes between the groups; however, the integrated group had higher mortality, stroke and temporary neurological deficit than RCP-only. CONCLUSIONS: The observed trends in actual outcomes were a cause for concern. ACP combined with a short period of RCP did not provide better outcomes than RCP-only. The use of RCP remains warranted in our experience.