Long-term outcomes comparison of mitral valve repair or replacement for secondary mitral valve regurgitation. An updated systematic review and reconstructed time-to-event study-level meta-analysis.

BACKGROUND AND AIM: The ideal surgical intervention for secondary mitral regurgitation (SMR), a disease of the left ventricle not the mitral valve itself, is still debated. We performed an updated systematic review and study-level meta-analysis investigating mitral valve repair (MVr) versus mitral valve replacement (MVR) for adult patients with SMR, with or without coronary artery disease (CAD). METHODS: PubMed, CENTRAL and EMBASE were searched for studies comparing MVr versus MVR. Randomized trial or observational studies were considered eligible. Primary endpoint was long-term mortality for any cause. Kaplan-Meier survival curves were reconstructed and compared with Cox linear regression. Landmark analysis and time-varying hazard ratio (HR) were analyzed. Sensitivity analyses included meta-regression and separate sub-analysis. A random effects model was used. RESULTS: Twenty-three studies (MVr=3,727 and MVR=2,839) were included. One study was a randomized trial, and 19 studies were adjusted. The mean weighted follow-up was 3.7±2.8 years. MVR was associated with significative greater late mortality (HR=1.26; 95 % CI, 1.14-1.39; P<0.0001) at 10-year follow-up. There was a time-varying trend showing an increased risk of mortality in the first 2 years after MVR (HR=1.38; 95 % CI, 1.21-1.56; P<0.0001), after which this difference dissipated (HR=0.94; 95 % CI, 0.81-1.09; P=0.41). Separate sub-analyses showed comparable long-term mortality in patients with concomitant coronary surgery ≥90 %, left ventricle ejection fraction ≤40 %, and sub-valvular apparatus preservation rate of 100 %. CONCLUSIONS: Compared to repair, MVR is associated with higher probability of mortality in the first 2 years following surgery, after which the two procedures showed comparable late mortality rate.

Long-Term Outcomes Comparison Between Surgical and Percutaneous Coronary Revascularization in Patients With Multivessel Coronary Disease or Left Main Disease: A Systematic Review and Study Level Meta-Analysis of Randomized Trials.

Recent randomized trials comparing coronary artery bypass graft (CABG) with percutaneous coronary intervention (PCI) utilizing drug-eluting stents in patients with left main disease (LMD) and/or multivessel disease (MVD), reported conflicting results. We performed a study level meta-analysis comparing the 2 interventions for the treatment of LMD or MVD. Using electronic databases, we retrieved 6 trials, between January, 2010 and December, 2022. Five-years Kaplan-Meier curves of endpoints where reconstructed. Comparisons were made by cox-linear regression frailty model and by landmark analysis. A random-effect method was applied. A total of 8269 patients were included and randomly assigned to CABG (n = 4135) or PCI (n = 4134). During 5-years follow-up, PCI showed a higher incidence of all-cause mortality (hazard ratio [HR] 1.28; 95% confidence interval [CI], 1.11-1.47; P < 0.0001]), myocardial infarction (HR 1.84; 95% CI, 1.54-2.19; P < 0.0001) and repeat coronary revascularization (HR 1.96; 95% CI, 1.72-2.24; P < 0.0001). There was no long-term difference between the 2 interventions for cardiovascular death (P = 0.14) and stroke (P = 0.20), although the incidence of stroke was higher with CABG within 30-days from intervention (P < 0.0001). PCI was associated with an increased risk for composite endpoints (P < 0.0001) and major cerebral and cardiovascular events. (P < 0.0001). In conclusion, at 5-year follow-up, in patients with LMD and/or MVD there was a significant higher incidence of all-cause mortality, myocardial infarction and repeat revascularization with PCI compared to CABG. The incidence of stroke was higher with CABG during the postprocedural period, but no difference was found during 5-years follow-up. Longer follow-up is mandatory to better define outcome difference between the 2 interventions.

Survival effect of radial artery usage in addition to bilateral internal thoracic arterial grafting: A meta-analysis.

OBJECTIVE: Little evidence shows whether the radial artery (RA) as third arterial graft provides superior outcomes compared with the use of the bilateral internal thoracic artery (BITA) and saphenous vein (SV) graft in patients undergoing coronary artery bypass grafting. A meta-analysis of propensity score-matched observational studies that compared the long-term outcomes of coronary artery bypass grafting with the use of BITA and the RA (BITA + RA) versus BITA and SV (BITA + SV) was performed. METHODS: Electronic databases from January 2000 to November 2020 were screened. Studies that reported long-term mortality were analyzed. The primary outcome was long-term overall mortality. A secondary end point was in-hospital/30-day mortality. Pooled hazard ratio with 95% confidence interval (CI) were calculated for survival and time-to-event analysis according to a random effect model. Differences were expressed as odds ratio with 95% CI for in-hospital/30-day mortality. RESULTS: Six propensity score-matched studies that reported on 2500 matched patients (BITA + RA: 1250; BITA + SV: 1250) were identified for comparison. The use of BITA + RA was not statistically associated with early mortality (odds ratio, 0.90; 95% CI, 0.36-2.28; P = .83). The mean follow-up time ranged from 7.5 to 12 years. The pooled analysis of long-term survival revealed a significant difference between the 2 groups favoring BITA + RA treatment (hazard ratio, 0.71; 95% CI, 0.50-0.91; P = .031). The survival rate for BITA + RA versus BITA + SV at 5, 10, and 15 years were: 96.2% versus 94.8%, 88.9% versus 87.4%, and 83% versus 77.9%, respectively (log rank test, P = .02). CONCLUSIONS: In patients with coronary artery bypass grafting, BITA + RA usage is not associated with higher rates of operative risk and is associated with superior long-term overall survival.

What if Valve-in-Valve TAVR fails? Is surgical re-replacement still an option in high-risk patients? A case report.

Redo surgical aortic valve replacement has been the gold standard for the treatment of degenerated bioprostheses; however it carries an inherent risk associated with a reoperative open heart surgery. Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as an alternative approach. Few articles in literature review transcatheter aortic valve replacement's failure rates, complications (i.e., valve dislocation, paravalvular leaks) and their surgical management. The rate of reoperations after a percutaneous approach is expected to increase, with the currently rising number of transcatheter procedures worldwide even in patients with a longer life expectancy. Valve dislocation is a rare but serious complication that can severely impact on the outcome of patients. Paravalvular leaks and structural valve degeneration are the most common causes of surgical re-intervention. We present the case of a complex patient with previous surgical aortic valve and ascending aorta replacement who underwent a transfemoral valve-in-valve TAVI for bioprosthesis degeneration, complicated by valve dislocation requiring surgical reoperation.

Radial Artery Versus Saphenous Vein as Third Conduit in Coronary Artery Bypass Graft Surgery for Multivessel Coronary Artery Disease: a Ten-Year Literature Review.

Coronary artery bypass grafting is the gold standard strategy for obtaining complete coronary revascularization in patients with multivessel coronary artery disease. The recent AHA and EACTS guidelines on myocardial revascularization recommend total arterial revascularization, especially in younger patients, whenever possible. However, the use of saphenous vein grafts in association with single or bilateral internal thoracic artery (SITA, BITA) instead of arterial grafts (radial arteries, right gastroepiploic artery and inferior epigastric artery) is widespread. We analyzed literature from the last ten years (January 2010 to December 2020) looking for evidence in favour of the use of a radial artery compared to a saphenous vein in association with BITA. We identified nine studies (4 Systematic Reviews and Meta-analyses and 6 large cohort observational studies with propensity score-matching) that compared arterial with saphenous grafts as third conduit. The main finding of the review is the higher rate of freedom from any cardiac adverse event in the population which reached Total Arterial myocardial Revascularization (TAR). A probable reason for the limited application of TAR as a strategy is the shortage of Randomized Controlled Trials (RCTs).

The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis.

In aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66-0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50-0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50-0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42-0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI 0.87-1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.

Long-Term Outcome of Mechanical and Biological Prostheses in Patients with Left-Side Infective Endocarditis: A Systematic Review and Meta-Analysis.

BACKGROUND: Long-term outcomes of patients with infective endocarditis (IE) who received either a mechanical (MP) or biological prosthesis (BP) are conflicting. A meta-analysis of observational studies comparing the long-term outcomes of left-side IE with the use of MP versus BP was performed. METHODS: Electronic databases from January 2000 to June 2021 were screened. Studies reporting long-term mortality were analyzed. The primary endpoint was long-term overall mortality. Secondary endpoints were in-hospital/.30-day mortality and freedom from both prosthesis reinfection and reintervention. The pooled hazard ratio (HR) with 95% confidence interval (CI) was calculated for survival according to the random effect model. RESULTS: Thirteen retrospective observational studies reporting on 8645 patients (MP: 4688; BP: 4137) were included for comparison. Twelve studies reported data of long-term survival for a total of 8285 patients (MP: 4517; BP: 3768). The pooled analysis revealed that the use of MP was statistically associated with longer benefits compared to BP (HR 0.74; 95% CI 0.63-0.86; p < 0.0001). The median follow-up time ranged from 1 to 15.3 years. The pooled analysis of five studies reporting data on prosthesis reinfection in 4491 patients (MP: 2433; BP: 2058) did not reveal significant differences (HR 0.60; 95% CI 0.30-1.21; p = 0.15). Five studies reported data on prosthesis reintervention in 4401 patients (MP: 2307; BP: 2094). The meta-analysis revealed a significant difference in favor of MP (HR 0.40; 95% CI 0.29-0.55; p < 0.0001). Meta-regression reported no effect of male gender (p = 0.09) and age (p = 0.77) on long-term survival. CONCLUSIONS: In a meta-analysis of retrospective observational studies comparing the long-term outcome of patients who underwent surgery for left-sided IE, the use of MP compared to BP is associated with a significant longer-term survival and with a reduced incidence of late reoperation. The incidence of late reinfection is comparable between the two prostheses.

The Histopathological Correlate of Peri-Vascular Adipose Tissue Attenuation on Computed Tomography in Surgical Ascending Aorta Aneurysms: Is This a Measure of Tissue Inflammation?

On computed tomography (CT) imaging, a peri-vascular adipose tissue attenuation (pVAT) measure has been proposed as a non-invasive correlate of inflammation in the coronary artery vessels, and a single research group provided histopathological demonstration of this radiological/pathological correspondence. Our group has shown that patients with surgical-grade ascending aorta (AA) aneurysm display higher pVAT compared with patients with smaller aneurysms or normal AA. Based on histopathological studies on coronary arteries, we speculated that this correlation may be related to a non-otherwise specified aortic inflammatory process. However, since adipose tissue around the AA is often scant, and there are no histopathological studies confirming such hypothesized association between higher pVAT and inflammation around the AA, we cannot exclude that this pVAT change is secondary to different mechanisms, unrelated to the actual presence of peri-vascular inflammation. We performed a retrospective clinical/radiological/pathological study in 78 patients who underwent AA surgery with the aim to correlate pre-operatory pVAT on CT with histopathological findings from the surgical specimens. Histopathological review and immunohistochemistry were performed on the surgical aortic samples. The AA adventitial/periadventitial adipose tissue had higher pVAT by an increasing collagen fiber deposition, which progressively makes the fat hypotrophic and, in the late stages of this process, it replaces the normal soft tissue composition in this location. In the ascending aorta, pVAT on CT imaging is probably not a proxy for the presence of current vascular inflammation, although it may track changes involving the progressive substitution of perivascular adipose cells by higher-pVAT tissues, mainly fibrotic replacement.

Left Ventricular Apex: A "Minimally Invasive Motorway" for Safe Cardiovascular Procedures.

Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative accesses, the number of transapical procedures has decreased significantly worldwide. The left ventricular apex, however, has proved to be a safe and valid alternative access for various other structural heart procedures such as mitral valve repair, mitral valve-in-valve or valve-in-ring replacement, transcatheter mitral valve replacement (TMVR), transcatheter mitral paravalvular leak repair, and thoracic aorta endovascular repair (TEVAR). We review the literature and our experience of various hybrid transcatheter structural heart procedures using the transapical surgical approach and discuss pros and cons.

Predictive scores for major bleeding after coronary artery bypass surgery in low operative risk patients.

BACKGROUND: Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk. METHODS: A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality. RESULTS: Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality. CONCLUSIONS: Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.

Current trends in surgical revascularization of multivessel coronary artery disease with arterial grafts.

It is well known that graft patency determines prognosis in coronary artery bypass grafting. Numerous reports over the past 20 years have documented superior patency and prognosis when multiple arterial grafts are used. The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. A considerable body of evidence suggests that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies suggest a performance comparing favorably with the saphenous vein. The right gastroepiploic artery has been recognized as a suitable and reliable conduit for coronary bypass surgery. However, the use of multiple other arterial grafts is performed in less than 10% of surgical procedures, probably because of perceptions of technical complexity, prolonged time for conduit harvesting, and increased perioperative complications. As a result, most patients with multivessel coronary artery disease do not benefit from extensive revascularization with arterial conduits. The aim of this review is to summarize the current evidence for the extensive use of arterial conduits in the revascularization of multivessel coronary artery disease.

Early neurological injury after cardiac surgery: insights from a single centre prospective study.

BACKGROUND AND AIM OF THE WORK: The aim of this study was to report the incidence of early neurological complications after heart surgery, to identify preoperative and procedural risk factors for these complications and to assess their influence on postoperative outcome. METHODS: Data were prospectively collected from 954 procedures: 520 coronary artery bypass grafting (CABG), 233 valve surgery, 100 combined CABG and valve surgery, 88 major aortic surgery, and 13 other procedures. Independent risk factors were analyzed by multivariate stepwise logistic regression model. RESULTS: Early cerebral complications occurred in 94 patients (9.85%). Eleven patients (11.7%) had permanent cerebral symptoms and 83 (88.3%) had transient neurological symptoms only. Risk factors for early neurological complications were older age, chronic obstructive pulmonary disease, open cardiac chambers procedures, higher end-cardiopulmonary bypass lactate levels, blood transfusion, and the use of insulin in ICU. CONCLUSION: The results of this study suggest a relationship between metabolic and technical aspects of cardiopulmonary bypass management and early occurrence of neurological injury. Preoperative screening and intraoperative measures that ensure adequate cerebral perfusion, minimize embolization and improve systemic inflammatory response and hemodynamic performance appear mandatory in these patients. Future efforts will be necessary to strongly validate surrogate markers of early neurologic damage to predict neuropsychological dysfunction after cardiac surgery.