Value of CT signs and measurements as a predictor of pulmonary hypertension and mortality in symptomatic severe aortic valve stenosis.

To assess the value of computed tomography (CT) for non-invasive detection of pulmonary hypertension (PH) in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and to correlate CT measurements and signs with mortality after TAVI. 257 TAVI patients (median 84 years; 134 females) with both right heart catheterisation (RHC) and CT within 3 days were retrospectively analyzed. According to guidelines PH was defined as mean pulmonary artery pressure ≥25 mmHg in RHC. CT-signs for PH assessment were evaluated. Clinical data was recorded before and at 30 days, 1 year and 2 years after TAVI. 161 patients exhibited PH (median 83 years; 90 females). In patients with PH, main pulmonary artery diameter (MPA; p < 0.001) and anterior pericardial recess (PR; p = 0.003) were significantly larger. Furthermore, pleural effusion (p < 0.001) was significantly more common. Sensitivity and specificity for predicting PH were calculated for MPA diameter ≥29 mm (56 and 61%), PR diameter ≥10 mm (37 and 82%), and presence of pleural effusion (42 and 91%). Patients with PH showed significantly higher 2 years mortality after TAVI (30 vs. 17%; p = 0.01) with a Hazard ratio (HR) of 2.5 (95% CI 1.1-5.8; p = 0.027). Pleural effusion was a predictor of higher 2-year-all-cause mortality after TAVI (42 vs. 20%; p = 0.022) with a HR of 2.0 (95% CI 1.0-3.8; p = 0.042). Patients with symptomatic AS and PH at baseline display higher 2 year-all-cause mortality after TAVI. Several CT-signs suggest the presence of PH in TAVI patients with moderate to high specificity, but low sensitivity. Pleural effusion in CT is a predictor of higher 2 year-all-cause mortality.

Frailty Assessed by the FORECAST Is a Valid Tool to Predict Short-Term Outcome After Transcatheter Aortic Valve Replacement.

OBJECTIVE: The term frailty is frequently used during decision-making in transcatheter heart valve procedures. Nevertheless, frailty is still measured by eyeballing rather than by using standardized frailty assessments. In a previous study, we developed a frailty score in a cardiac surgical patient population including patients, who underwent transcatheter aortic valve replacement (TAVR). Here, we present the results from the subsequent validation study focusing on the TAVR cohort. METHODS: One hundred thirty patients underwent TAVR. Frailty assessment using the FORECAST (Frailty predicts death One yeaR after Elective CArdiac Surgery Test) was performed. The European System for Cardiac Operative Risk Evaluation and The Society of Thoracic Surgeons (STS) score were assessed as well. Follow-up included assessment of in-hospital and 30-day mortality and morbidity and quality of life using the Short Form-36 questionnaire. RESULTS: Mean age was 83.3 years, and 50% were female. Logistic European System for Cardiac Operative Risk Evaluation was 14.9 ± 8.7%, and STS score was 5.1 ± 3.4%. Mean ± standard deviation FORECAST score was 4.8 ± 3.3 points of 15. In-hospital and 30-day mortality were 6.9% and 7.7%, respectively. Thirty-day Short Form-36 assessment showed a decrease in quality of life in five of ten items after the intervention. Receiver operating characteristic curves showed that the FORECAST is a valid tool to predict in-hospital mortality (area under the receiver operating characteristic curve, 0.73). By combining the FORECAST and the STS score, this effect was even higher (area under the receiver operating characteristic curve, 0.77; P = 0.021). Stratifying the patients according to the FORECAST score showed best survival in the lowest frailty group. CONCLUSIONS: The FORECAST is a valid tool to assess frailty in TAVR patients. The FORECAST is easily assessable and can be included in daily clinical routine.

A translational "humanised" porcine model for transcatheter mitral valve interventions: the neo inferior vena cava approach.

AIMS: Preclinical studies and translational animal models are fundamental for the development of new clinical interventions. Compared to human anatomy, pigs present a more anterior heart position in the chest which may jeopardise the imaging and testing of devices designed to be delivered to the human mitral valve. To imitate human anatomy, we developed a novel model to "humanise" a pig heart. METHODS AND RESULTS: The creation of a neo inferior vena cava with a Dacron tube grafted to the right atrium was tested for transseptal delivery of an experimental mitral annuloplasty device in 35 animals. In 15 animals with native anatomy a conventional right transfemoral access was used. Imaging guidance was achieved with intracardiac or epicardial echocardiography. In all transfemoral approaches (n=15), the delivery of the device was unsuccessful and the handling was dissimilar to a human implant. In all neo-cava approaches (n=35), the handling and manoeuvring were as expected in humans, the targets were reached as intended and all procedures but one were successful. CONCLUSIONS: A translational "humanised" animal model with the creation of a neo cava eliminates the differences between pig and human anatomy and is suitable for testing human grade devices.

Mid-Term Outcomes of Minimally Invasive Direct Coronary Artery Bypass Grafting.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCAB) has gained wide acceptance for the treatment of single vessel disease of the left anterior descending artery (LAD). Here, we present our single center experience of 152 consecutive patients. MATERIALS AND METHODS: All patients underwent MIDCAB through a left anterior minithoracotomy between January 1, 2009, and December 31, 2012. Preoperative, intraoperative, postoperative, and follow-up data including major adverse cardiac and cerebrovascular events (MACCE) and need for re-intervention were collected. RESULTS: Mean age was 64.4 ± 11 years, median additive EuroSCORE 3 (0-11), 84% were male. All except one patient were successfully operated without cardiopulmonary bypass. Seven patients with unexpected severely calcified LADs were converted to sternotomy (4.6%); 91.3% were extubated in the operating room or on the day of surgery. Median stay at the intensive care unit and in hospital were 1 (0-97) and 7 (1-49) days, respectively. Thirty-day mortality was 1.9%. There was no stroke. Five patients (3.2%) had to be re-explored for bleeding and 95% received no transfusion. Median follow-up was 24 months (0-97) and complete in 93.3% with overall survival of 92.4 ± 0.2% and MACCE-free survival of 96.1 ± 1.7%. Two patients had a re-intervention of the LAD. CONCLUSION: MIDCAB is a safe procedure with low postoperative morbidity, mortality, and favorable mid-term MACCE-free survival in selected patients that should be discussed in a heart team setting to evaluate the "ideal" individual treatment option.

Successful first-in-man Melody transcatheter valve implant in a dehisced mitral annuloplasty ring transapical valve-in-ring implant.

AIMS: A "valve-in-ring" (ViR) procedure involves the transcatheter implant of a valved stent in a prosthetic mitral ring. The presence of a partial dehiscence of the prosthetic ring is a major contraindication for a ViR due to inefficacious sealing. We describe an alternative method of ViR implant to achieve proper valve sealing in the case of ring dehiscence. METHODS AND RESULTS: A 76-year-old male patient suffered from severe central mitral regurgitation due to annuloplasty ring dehiscence and leaflet tethering. ECG-gated multidetector computed tomography was used for preoperative planning. Standard transapical access was gained through a minimally invasive left thoracotomy in the 5th intercostal space. A customised Melody valve with two PTFE sutures fixed to the apex was used. The intervention was performed without complications, the patient recovered well, and transthoracic echo revealed no mitral regurgitation through the implanted valve with a transvalvular gradient of 4 mmHg. CONCLUSIONS: The implantation of a long covered stent such as the Melody valve allows successful sealing following a ViR even in case of partially detached annuloplasty rings. This procedure is a proof of concept that proper sealing can be achieved at the leaflet level without the use of radial force at the annular level.

Repair rate and durability of video assisted minimally invasive mitral valve surgery.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) through a right lateral thoracotomy has emerged as another option in cardiac surgery. We present our single center experience with regards to repair rate and durability of the repair in patients undergoing MIMVS. METHODS: Between January 2009 and December 2012 a total of 312 consecutive patients underwent MIMVS. Baseline characteristics, operative variables, postoperative outcomes, and follow-up information about survival, major adverse cardiac and cerebrovascular event (MACCE)-free survival, valve competence, and freedom from reoperation were collected. RESULTS: Mean age was 61 ± 13.1 years, median Euroscore 4 (0-13). The predominant valve pathology was degenerative disease (96.2%) with regurgitation (95.2%) and atrial fibrillation (23.1%). Bypass time was 147 ± 46, cross-clamp time 94 ± 32 minutes. All degenerative valves planned for repair (n = 281) were successfully repaired except for two (0.7%) resulting in a 99.3% repair rate. Eight patients (2.8%) had to be converted to sternotomy. Median ventilation time was 6.6 hours (0 to 460), ICU stay one day (0 to 96), and hospital stay eight days (3 to 61). Most of the patients did not need red blood cell transfusion (78.2%). One patient died in hospital due to acute respiratory distress syndrome (0.3%) and five suffered a permanent stroke (1.6%). In 294 patients (94.5%) follow-up was completed for a median of 22 months (0 to 53) with 95.5 ± 1.2% overall survival, 96.8 ± 1.2%, MACCE-free survival, and 94.8 ± 0.1% freedom from reoperation. CONCLUSIONS: MIMVS is a safe approach with low morbidity and mortality that allows a high and durable repair rate with low reoperation rates and favorable short-term event-free survival.

Does body mass index impact the early outcome of surgical revascularization? A comparison between off-pump and on-pump coronary artery bypass grafting.

OBJECTIVES: To investigate the effects of body mass index (BMI) on early outcomes after revascularization using either on-pump or off-pump surgery. METHODS: Data for 3714 of 4314 patients who underwent surgical revascularization at our institution between 1999 and 2008 were analysed. Patients were divided into two groups [off-pump coronary artery bypass (OPCAB); n = 1958 and on-pump coronary artery bypass (ONCAB); n = 1756] and further assigned into five classes according to their BMI (underweight <20 kg/m(2), normal 20-24.99 kg/m(2), overweight 25-29.99 kg/m(2), obese 30-34.99 kg/m(2) and morbidly obese ≥35 kg/m(2)). Thirty-day mortality, occurrence of major adverse cardiac events (MACEs), occurrence of major non-cardiac adverse events (MNCAEs) and length of in-hospital stay were analysed in relation to BMI only (whole cohort analysis), to BMI and chosen surgical method (ONCAB versus OPCAB) as well as confounding factors. RESULTS: In the whole cohort analysis (n = 3714), no significant differences between BMI classes could be identified with regard to 30-day mortality (P = 0.78), MACEs (P = 0.72), MNCAEs (P = 0.45) or length of in-hospital stay (P = 0.94). With increasing BMI values, 30-day mortality tended to steadily increase (1.8% in BMI class 'underweight' vs 2.6% in BMI class 'morbidly obese'; P = 0.78), whereas MNCAEs tended to decrease with an increasing BMI (17.5% in BMI class 'underweight' vs 12.2% in BMI class 'morbidly obese'; P = 0.45). Compared with ONCAB, in patients with higher BMI values, OPCAB appeared to reduce slightly the frequency of 30-day mortality, MACEs and MNCAEs, while slightly increasing the length of in-hospital stay. Adjustment for other risk factors by covariate analysis in multiple regression models did not change the inferences drawn. CONCLUSIONS: Our study did not detect significant differences between BMI classes with regard to mortality and morbidity. However, a slight trend towards a steadily increasing short-term mortality was detectable for patients with higher BMI values. When comparing ONCAB versus OPCAB, patients with higher BMI values appeared to have a weak tendency towards a reduced short-term morbidity and mortality in favour of OPCAB.