Endoscopic aortic valve surgery in isolated and concomitant procedures.

OBJECTIVES: To evaluate early outcomes of endoscopic aortic valve replacement (AVR) and risks of concomitant procedures done through the same working port. METHODS: At our institution, we performed a data analysis of 342 consecutive patients (from July 2013 to May 2021) who underwent endoscopic AVR with or without associated major procedure. Preoperative, intraoperative, postoperative data were evaluated. Subsequently, we perform a comparative analysis between the isolated and concomitant surgery group. The surgical access was a 3- to 4-cm working port in the second right intercostal space and 3 additional 5-mm mini-ports for the introduction of the thoracoscope, the transthoracic clamp and the vent line. Cardiopulmonary by-pass was achieved through peripheral cannulation. RESULTS: 105 patients (30.7%) underwent combined procedure: 2 coronary artery bypass (1.9%), 21 ascending aorta replacement (19.6%), 41 mitral surgery (38.3%), 16 mitral and tricuspid surgery (15%) and 25 other procedure (27%). Death occurred in 1 patient (0.4%) in the isolated group versus 2 patients (1.9%) in the combined group (P = 0.175). Seven strokes were observed, 4 in isolated procedures (1.7%) and 3 in the concomitant ones (2.85%) (P = 0.481). Surgical revision for bleeding was performed always through the same access in 13 patients (5.4%) versus 11 patients (10.4%) (P = 0.096). Pacemaker implantation was necessary in 5 patients (2.1%) versus 8 patients (7.6%) (P = 0.014). Median intubation time was 5 (2) h vs 6 (8) (P < 0.080). CONCLUSIONS: Through a single working port made for endoscopic AVR, a concomitant procedure may be done without affecting in-hospital mortality and postoperative stroke rate.

Robotic Mitral Valve Repair: Indication for Surgery Does Not Influence Early Outcomes.

OBJECTIVE: To evaluate the outcomes of robotic mitral valve repair (MVr) by primary indication per American Heart Association guidelines for surgery: class I vs class IIa. PATIENTS AND METHODS: From January 1, 2008, through September 30, 2016, 603 patients underwent robotic MVr for severe primary mitral regurgitation. Medical records of 576 consenting patients were retrospectively reviewed to determine the primary indication for surgery. Patients were stratified into class I or class IIa, and preoperative, intraoperative, and postoperative variables were compared. RESULTS: Of 516 patients, 428 (83%) had class I indication and 88 (17%) had class IIa indication for surgery. Preoperatively, no significant differences were observed between both cohorts. Importantly, a significantly higher number of patients with class I indication underwent MVr for bileaflet prolapse (172 of 428 [40%] vs 21 of 88 [25%]; P=.03). Early MVr outcomes indicated recurrent mitral regurgitation (moderate or greater) in only 12 of 576 (2%), and no significant differences were observed between classes (P=.23). Apart from parameters for ventricular size, all other intraoperative and postoperative variables were comparable between both cohorts. CONCLUSION: Comparable outcomes were indicated across all classes of indications for MVr surgery. These results continue to support the use of this surgical technique, even in less sick patients. Early referral along with more extensive robotic MVr experience will likely result in further improvements in long-term outcomes.

Left Ventricular Assist Devices: How Do We Define Success?

Despite the growing acceptance of left ventricular assist device (LVAD) therapy to improve survival and quality of life in heart failure (HF) patients, uncertainties persist regarding the definition of a successful implant. We sought to define an innovative approach to assess success and subsequently compare preoperative variables affecting outcomes. From January 2007 to 2015, 278 patients underwent LVAD implantation. Median age at implant was 62 years and 81% patients were males. Indication for support was bridge-to-transplantation in 36% patients and the etiology of HF was ischemic in 49% patients. Based on clinically relevant and accepted standards, we defined successful LVAD implant as someone who was alive or transplanted at 2 years, had two or less readmissions in the first year, had no major adverse events in the first year, and had a New York Heart Association class of ≤ II at 6 months. Follow-up was obtained for a median of 1.7 years for a total of 605 patient-years-of-support. Based on our criteria, 81/278 (29%) patients were defined as having a successful implant. Univariate predictors of LVAD failure included destination therapy indication (hazard ratio [HR] = 2.11 [1.24, 3.58]), ischemic cardiomyopathy (HR = 1.73 [1.02, 2.94]), and a higher left ventricular ejection fraction (HR = 1.54 [1.07, 2.22]). After multivariable analysis, only destination therapy indication (HR = 2.2 [1.28, 3.78]) was found to be independently predictive of success failure. Despite an overall trend toward improved outcomes on device therapy, our criteria classified only one-third of patients as successful. Continued improvements in adverse event profiles, appropriate patient selection, and optimal time of implantation, together hold the key to improve outcomes after LVAD therapy.

Atrial Fibrillation Should Guide Prophylactic Tricuspid Procedures During Left Ventricular Assist Device Implantation.

Atrial fibrillation (AF) and tricuspid regurgitation (TR) are common in patients undergoing left ventricular assist device (LVAD) implantation. TR progression is associated with the presence of AF, and questions remain as to who benefits from tricuspid valve procedures (TVPs). We examined the impact of preoperative AF on TR progression after LVAD implantation. From February 2007 to May 2014, 250 patients underwent LVAD implantation at our institution. Patients with concomitant TVP were excluded from this analysis (113 patients). The indication for LVAD was destination therapy in 80 patients (58%) and the etiology of heart failure was ischemic in 73 (53%). Follow-up was available in all early survivors for a total of 393 patient-years of support. Of the 137 non-TVP patients, 52 (38%) had AF preoperatively. Observed overall survival at 1, 3, and 5 years was 82%, 67%, and 55%, respectively. Median grade of TR increased from 2 preoperatively to 3 (p = 0.04) in the AF group and 2.2 (p = 0.75) in the non-AF group at 5 years of follow-up. We also observed a significant difference in the degree of TR between groups at 3 months (p = 0.03) and 12 months (p = 0.01) postimplantation, and a trend toward significance at 18 (p = 0.06) and 24 (p = 0.07) months. The presence of AF is associated with early progression of TR after LVAD implantation. Addition of concomitant TVP in patients with preoperative AF may be considered in patients with less than severe TR. The impact of these findings on right ventricular failure/remodeling remains to be evaluated.