Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures.

BACKGROUND: Coronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed. METHODS: A prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany. RESULTS: 464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages (p < 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common (p = 0.027), and length of hospital stay shortest (p = 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%; p = 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17, p = 0.002) and TAVR/PCI (HR: 1.63, p = 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39, p = 0.003 and HR: 1.63, p = 0.033). CONCLUSIONS: TAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options.

Prognostic implications of psoas muscle area in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: This study sought to assess the incremental prognostic value of the psoas muscle area in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS: A total of 1076 consecutive patients undergoing TAVI at 2 centres between 2010 and 2017 were prospectively included in this study. Computed tomography-derived cross-sectional area of the psoas muscle was measured at the superior border of the third (L3) and fourth (L4) lumbar vertebra and indexed to body surface area (PMAi) as well as stratified into tertiles. Multivariable logistic regression and Cox regression analyses were performed to investigate the value of PMAi as a predictor of 30-day and cumulative mortality. The incremental prognostic value of PMAi over the Society of Thoracic Surgeons (STS) score was assessed using a net reclassification analysis. RESULTS: The rate of 30-day mortality was 5.8% (n = 62). PMAi at the level of L3 [odds ratio 0.082, 95% confidence interval (CI) 0.011-0.589; P = 0.013] and L4 (odds ratio 0.049, 95% CI 0.005-0.536; P = 0.013) was independently associated with 30-day mortality. During a median follow-up of 435 days (interquartile range 139-904), 292 patients (27.1%) died. PMAi of L3 (hazard ratio 0.200, 95% CI 0.083-0.482; P < 0.001) and L4 (hazard ratio 0.083, 95% CI 0.029-0.235; P < 0.001) was independently associated with mortality during follow-up. The addition of PMAi to the STS score led to a net reclassification improvement for 30-day and cumulative mortality. CONCLUSIONS: PMAi emerged as a valuable outcome predictor in patients undergoing TAVI. The addition of PMAi to the established STS score led to an increase in its prognostic ability.

Minimally Invasive versus Conventional LVAD-Implantation-An Analysis of the Literature.

This review aims to provide an overview on recent data to evaluate minimally invasive (MVAD) and conventional (CVAD) left ventricular assist device (LVAD) implantation. A comprehensive literature search of PubMed, Cochrane Library, and ClinicalTrials.gov was conducted up to April 2017. A total of 183 studies were identified; 13 studies met inclusion criteria. The review revealed a trend toward a lower rate of transfusion, and shorter time for cardiopulmonary bypass, as well as a lower 30-day mortality rate for MVAD. This review indicates that there are possible benefits of minimally invasive LVAD implantation, even though the state of literature is poor.

EuroSCORE II and the STS score are more accurate in transapical than in transfemoral transcatheter aortic valve implantation.

OBJECTIVES: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and the Society of Thoracic Surgeons (STS) score are currently used to estimate periprocedural risk of death in patients undergoing transcatheter aortic valve implantation (TAVI). However, data regarding the predictive ability and usefulness of these scores for TAVI are controversial, especially for different access sites. METHODS: Between 2008 and 2016, 1192 consecutive patients undergoing TAVI [transfemoral (TF): n = 607 (51%); transapical (TA): n = 585 (49%)] at 2 centres were included. All-cause mortality was assessed at a median of 533 days (interquartile range 153-1036). The value of the EuroSCORE II and the STS score in terms of predicting 30-day and cumulative mortality according to access site was investigated. RESULTS: The mean age was 83 (interquartile range 79-86) years. Overall, the 30-day mortality rate was 7.6% (n = 90), and the cumulative all-cause mortality rate was 35.1% (n = 418). The EuroSCORE II and the STS score were significantly increased in non-survivors compared with survivors (P < 0.001). The EuroSCORE II and the STS score emerged as independent predictors of 30-day mortality [EuroSCORE II: odds ratio (OR) 1.039, 95% confidence interval (CI) 1.013-1.065; P = 0.003; STS score: OR 1.055, 95% CI 1.023-1.088; P = 0.001] and cumulative all-cause mortality [EuroSCORE II: hazard ratio (HR) 1.026, 95% CI 1.013-1.038; P < 0.001; STS score: HR 1.05, 95% CI 1.03-1.06; P < 0.001]. In contrast to TF TAVI, the EuroSCORE II (OR 1.038, 95% CI 1.009-1.068; P = 0.010) and the STS score (OR: 1.063, 95% CI 1.025-1.102; P = 0.001) were independent predictors of 30-day mortality and cumulative mortality (EuroSCORE II: HR 1.023, 95% CI 1.009-1.037; P = 0.001; STS score: HR 1.055, 95% CI 1.037-1.073; P < 0.001) in patients undergoing TA TAVI. CONCLUSIONS: The EuroSCORE II and the STS score were independent predictors of 30-day and cumulative mortality rates in patients undergoing TAVI. The EuroSCORE II and the STS score were associated with 30-day mortality and mortality during follow-up period only in TA TAVI.

Concomitant therapy: off-pump coronary revascularization and transcatheter aortic valve implantation.

OBJECTIVES: Significant coronary artery disease (CAD) is common among patients evaluated for transcatheter aortic valve implantation (TAVI). Only little data exist on outcome of patients undergoing concomitant off-pump coronary revascularization and TAVI. The goal of this study was to analyse the impact of concomitant off-pump revascularization on early clinical outcome and 2-year follow-up of patients undergoing TAVI. METHODS: A total of 70 patients with significant CAD and aortic valve stenosis were included between January 2011 and January 2016. Decision to perform concomitant off-pump coronary revascularization and TAVI was made by the interdisciplinary heart team according to the SYNTAX score. Prospectively assigned data were analysed retrospectively and follow-up was performed up to 2 years. RESULTS: Mean age was 82.2 ± 4.0 years and 43 (61.4%) patients were male. Mean logistic European system for cardiac operative risk evaluation and Society of Thoracic Surgeons European system for cardiac operative risk evaluation score were 35.9 ± 21.9% and 12.2 ± 7.9%, respectively. SYNTAX score was 29.0 ± 12.9. Access site for TAVI was transapical in 60.0% and transaortic in 40.0%. Procedural success was 94.3%. Eighty percent of the patients had none or trace paravalvular leakage after TAVI. Severe complications requiring consecutive surgical aortic valve replacement occurred in 2 patients (2.9%). The use of cardiopulmonary bypass due to haemodynamic instability or conversion to surgical aortic valve replacement was necessary in 7 patients (10.0%). Stroke occurred in 1 patient (1.4%). Re-exploration for bleeding was necessary in 6 patients (8.6%). Thirty-day mortality was 14.3%. Two-year survival was 68.4% (95% confidence interval: 55.7-81.1%). CONCLUSIONS: Simultaneously performed complete off-pump coronary revascularization is a feasible and valid option in patients with significant CAD undergoing TAVI.

Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement.

Objectives: This study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy. Methods: One hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation ( n = 17, 8.9%), dilatation of the aortic root ( n = 95, 49.5%) or a combination of both pathologies ( n = 80, 41.7%) were included. Patients with systemic disorders, such as Marfan's syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted. Results: One hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5 ± 13.6 vs 64.8 ± 11.6, P < 0.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 ( n = 7 [6.0%] vs n = 48 [64.0%], P < 0.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P = 0.562). Blood loss was significantly less in Group 1 (542.6 ± 441.8 vs 996.7 ± 822.6 ml, P < 0.001). Duration of mechanical ventilation (10.2 ± 21.8 vs 26.9 ± 109.0 h, P < 0.001) and ICU-stay (1.9 ± 3.6 vs 3.2 ± 5.6 days, P < 0.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life. Conclusions: Minimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.

Conventional versus Transapical Aortic Valve Replacement: Is It Time for Shift in Indications?

Background The incidence of degenerative aortic valve diseases has increased along with the life expectancy of our population. Although conventional aortic valve replacement (AVR) is the gold standard for symptomatic aortic stenosis, transcatheter procedures have proven to be a valid therapeutic option in high-risk patients. The aim of this study was to compare these procedures in a high-risk cohort. Methods We retrospectively analyzed all symptomatic (dyspnea or angina) high-risk patients (logistic EuroSCORE ≥ 15%) fulfilling the transcatheter aortic valve implantation (TAVI) indications. Most of the AVR patients (n = 180) were operated on before the implementation of TAVI. All TAVI procedures (n = 127) were performed transapically (TA). After matching for age, logistic EuroSCORE, and left ventricular ejection fraction, 82 pairs of patients were evaluated. Results When comparing AVR with TA-TAVI, there was no difference between groups in survival after 1 year (Kaplan-Meier analysis, 81.1% [95% CI: 72.5-89.7%] vs. 75.8% [95% CI: 66.2-75.9%], Log tank p = 0.660) and the complication rates (n for AVR vs. TA-TAVI: stroke, 2 vs. 0, p = 0.580; acute renal insufficiency, 8 vs. 12, p = 0.340; atrial fibrillation, 24 vs. 26, p = 0.813; pacemaker implantation, 4 vs. 4, p > 0.999). In addition, quality of life did not differ between groups. Patients in the TA-TAVI group had lower mean valvular gradients postoperatively compared with the AVR group (14.6 ± 6.6 vs. 10.2 ± 4.9 mm Hg, p < 0.001). Conclusion For high-risk patients, the TAVI procedure is comparable with conventional AVR, but is not advantageous. These results do not support the expansion of TAVI to low- or intermediate-risk patients.

Expanding Surgical Opportunities: Endoscopic Harvesting of the Vena Saphena Parva in Supine Position.

The small saphenous vein (SSV) has proved to be a valid graft option for coronary artery bypass grafting (CABG), if other grafts are absent or unsuitable. Beside the described open technique we herein present our approach to endoscopic harvesting in supine position in seven patients. Harvesting was successful in six patients. Mean skin-to-skin time was 29.8 minutes. There were no infections or neurological deficits and the intraoperatively measured graft flow was excellent according to mean flow and low pulsatility index. Therefore, endoscopic harvesting of the SSV extends surgical opportunities not only in CABG, but also in surgery of peripheral artery disease.

Transaortic Transcatheter Aortic Valve Implantation and Concomitant Off Pump Revascularization.

An increasing number of patients with severe aortic stenosis and concomitant critical coronary artery disease were referred to our hospital. Some of those patients were classified as high-risk patients qualifying for a transcatheter therapy with the additional need for coronary revascularization. As a consequence of their comorbidities, the established transapical as well as transfemoral approach were either not possible or not favored owing to the indispensable need for coronary revascularization. We present 4 successfully combined off-pump procedures consisting of a transcatheter aortic valve implantation (Edwards SAPIEN XT) via the transaortic approach and an off-pump coronary artery bypass grafting. All patients were discharged free from stroke, myocardial infarction, or access site complications either to rehabilitation facility or to the referring hospital with none or trace aortic regurgitation and patent grafts. These cases confirm the feasibility of those combined operations and should be considered as realistic alternative for surgical treatment in high-risk patients who are clearly identified to benefit from transcatheter approach to treat aortic stenosis and who have severe concomitant coronary artery disease.

Transapical aortic valve implantation in patients with pre-existing mitral valve prostheses: a case report.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has proven to be a valid option for patients with severe aortic stenosis who are at high perioperative risk, particularly in patients with previous cardiac surgery. Several patients with previous mitral valve surgery were reported to have been successfully treated with TAVI. CASE PRESENTATION: Two patients, one with mechanical and one with biological mitral valve prosthesis, presented with symptomatic severe aortic stenosis. After discussion among our multidisciplinary heart team transapical approach and a JenaValve™ prosthesis was used for TAVI. Main reasons were to decrease the perioperative risk, avoid a re-opening of the chest via median sternotomy, and discuss the possible superiority of the JenaValve™ device due to its design. The patients were successfully treated and discharged on the 11th and 14th post-operative day, respectively. Echocardiographic follow up before discharge and up to 2.8 years post-operatively showed excellent results. CONCLUSIONS: In conclusion, TAVI in patients with preexisting mitral prostheses-mechanical or biological-is feasible, safe, and effective and offers a valid alternative to conventional aortic valve replacement in this particular re-operation scenario. The JenaValve™ device does not interact with the mitral prosthesis and offers therefore due to its unique design a potential advantage.

Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?

BACKGROUND: Valve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results. METHODS: Data of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (n = 77), decalcification (n = 45), or pericardial patch (n = 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years. RESULTS: Mean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (p = 0.058). Freedom from moderate or severe aortic insufficiency at 5 years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (p = 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (n = 3), Ross procedure (n = 2), and biologicical aortic valve replacement (n = 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (p = 0.305). CONCLUSIONS: Overall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.