Minimally Invasive and Full Sternotomy Aortic Valve Replacements Lead to Comparable Long-Term Outcomes in Elderly Higher-Risk Patients: A Propensity-Matched Comparison.

BACKGROUND: Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population. METHODS: Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52-93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7-42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs). RESULTS: FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47-194) vs. 100 (46-246) min (p = 0.039) and 57 (33-156) vs. 69 (32-118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596). CONCLUSIONS: In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.

Trilateral versus Bilateral Antegrade Cerebral Perfusion in Frozen Elephant Trunk: A Propensity Score Analysis.

OBJECTIVE: Spinal cord injury (SCI) with subsequent paraplegia and/or stroke after arch repair with frozen elephant trunk (FET) remain the most devastating complications. In this study, we aim to examine the impact of different cerebral perfusion strategies on the neurological outcome comparing bilateral antegrade cerebral perfusion (bACP) and trilateral antegrade cerebral perfusion (tACP). METHODS: Between 2009 and 2021, 88 patients underwent total arch replacement using a hybrid prosthesis in FET technique for acute (40.4%) and chronic (59.6%) aortic pathologies. After excluding 14 patients who underwent FET with unilateral ACP the remaining 74 patients were divided into two groups. Propensity score matching was performed based on pre- and perioperative patient characteristics resulting in 22 patients in each group. The primary endpoint was a combination of major cerebral event and SCI. Secondary end point was all-cause mortality. RESULTS: Major cerebral events occurred in 9% of the patients in bACP versus 13.6% in tACP group (p = 0.63). No postoperative SCI was observed in patients with bACP and only one patient suffered SCI with tACP (p = 0.31). There was no significant difference in 30-day mortality between the two groups (22.7% in bACP vs. 13.6% in tACP; p = 0.43). CONCLUSION: In patients undergoing total aortic arch repair using FET technique, both perfusion strategies (bilateral and trilateral ACP) are safe and effective. The rates of neurological complications as well as mortalities are acceptably low in both groups. Further studies with larger patient cohorts are warranted.

Correction: Hlavicka et al. Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population. J. Cardiovasc. Dev. Dis. 2022, 9, 197.

The authors would like to make the following corrections to the published paper [...].

Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population.

Background: Aortic valve and root replacement (AVRR) is a standardised procedure to treat patients with aortic valve and root disease. In centres with a well-established aortic valve and root repair program (valve repairs and Ross operations), only patients with very complex conditions receive AVRR; this procedure uses a mechanical or biological composite valve graft (modified Bentall-de Bono procedure). The aim of the study was to evaluate the short- and long-term results after AVRR in a high-risk population with complex pathologies. Methods: Between 2005 and 2018, a total of 273 consecutive patients (mean age 64 ± 12.8 years; 23% female) received AVRR. The indication for surgery was an acute type A aortic dissection in 18%, infective endocarditis in 36% and other pathologies in 46% patients; 39% were redo procedures. The median EuroSCORE II was 11.65% (range 1.48-95.63%). Concomitant surgery was required in 157 patients (58%). Results: The follow-up extended to 5.2 years (range 0.1-15 years) and it was complete in 96% of the patients. The 30-day mortality was 17%. The overall estimated survival at 5 and 10 years was 65% ± 3% and 49% ± 4%, respectively. Univariate and multivariate logistic regression analyses revealed the following risk factors for survival: perioperative neurological dysfunction (OR 5.45), peripheral artery disease (OR 4.4) and re-exploration for bleeding (OR 3.37). Conclusions: AVRR can be performed with acceptable short- and long-term results in a sick patient population. The Bentall-De Bono procedure may be determined to be suitable for only elderly or high-risk patients. Any other patients should receive an AV repair or the Ross procedure in well-established centres.

Type A aortic dissection repair with a dissection stent in presence of aberrant subclavian artery.

Aberrant right subclavian artery is a rare congenital aortic arch anomaly. We report on a case of type A aortic dissection and aberrant right subclavian artery. The 65-year-old female patient received a replacement of the ascending aorta and arch repair using an uncovered AMDS (Ascyrus Medical Dissection Stent; CryoLife Inc., Kennesaw, GA, USA) with debranching of both common carotid arteries. Postoperative computed tomography scan revealed regular aortic blood flow with the unrestricted carotid artery and aberrant right subclavian artery perfusion.

Minimally Invasive Treatment of Kommerell's Diverticulum and Left Aberrant Subclavian Artery.

Kommerell's diverticulum is an aneurysmatic offspring of the left aberrant subclavian artery, which is a rare vascular anomaly of the aortic arch. Here, we present our less invasive approach to the repair of a symptomatic Kommerell's diverticulum in a 31-year-old patient, without the use of cardiopulmonary bypass.

Homograft Treatment for Infected Frozen Elephant Trunk Prosthesis.

A 46-year-old male received total arch replacement with frozen elephant trunk for acute non-A/non-B aortic dissection. Two months later, he underwent emergency reoperation for contained rupture of the left common carotid ostium at its insertion on the aortic arch. Three months after the reoperation, he developed tracheoesophageal fistula and infection of the prosthesis in the region of the aortic arch and the proximal descending aorta. Second reoperation was performed with replacement of the aorta with a composite of three aortic homografts, and the fistula was permanently closed with a direct suture and intercostal muscle flap.

Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes.

BACKGROUND: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. METHODS: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). RESULTS: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. CONCLUSION: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.

Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes.

BACKGROUND: Aortic valve repair (AVR) is an attractive alternative to valve replacement for the treatment of aortic valve insufficiency. Here we report on the midterm outcomes after AVR for aortic valve insufficiency with an emphasis on durability of repair. METHODS: Between 1996 and 2017, 560 consecutive patients (mean age, 57 ± 16 years) underwent various AVR procedures on tricuspid (n = 415, 74%) and bicuspid (n = 145, 26%) aortic valves. In 313 patients (56%) the David procedure was performed, whereas in 247 patients (44%) cusp repair without aortic root procedure was conducted. Concomitant procedures were coronary artery bypass grafting in 82 patients (15%) and mitral valve repair in 47 patients (8%). Clinical and echocardiographic follow-up was complete in 97% of patients. Mean follow-up was 6.3 ± 4.6 years. RESULTS: Thirty-day mortality was 1.4% (n = 8). Late mortality was observed in 132 patients with cardiovascular events accounting for mortality in 13 patients: Survival at 10 years was 70%. Reoperation on the aortic valve was performed on 39 patients for recurrent insufficiency, isolated in 25, or combined with valve stenosis in 5 patients; endocarditis accounted for reoperation in 9 patients (0.2% per patient-year). Freedom from reoperation was 88% at 10 years. Cumulative linearized incidence of all valve-related complications was 2% per patient per year. CONCLUSIONS: AVR for insufficiency is a durable procedure with low valve-related morbidity and mortality in the midterm.

Triple valve surgery through a less invasive approach: early and mid-term results.

OBJECTIVES: A partial upper sternotomy has become established as a less invasive approach mainly for single and double valve surgery. This report evaluates the clinical outcomes of triple valve surgery performed through a partial upper sternotomy. METHODS: We reviewed the medical records of 37 consecutive patients (28 men, 76%) who underwent triple valve surgery through a partial upper sternotomy between 2005 and 2015. The patients' mean age was 67 ± 17 years; 27 (73%) were in New York Heart Association Class III or IV. Aortic and mitral valve insufficiency was more common than stenosis. Ninety-three percent of surviving patients were followed for a mean period of 58 ± 24 months. RESULTS: Aortic valve procedures consisted of 24 (65%) replacements and 13 (35%) repairs. The mitral valve was repaired in 28 (76%) patients, whereas tricuspid valve repair was feasible in all patients. No conversion to full sternotomy was necessary. Myocardial infarction was not observed. Chest tube drainage was 330 ± 190 ml, and 4 patients required reopening for bleeding (1, 3%) or tamponade (3, 8%). One stroke was observed due to heparin-induced thrombocytopaenia after initial unremarkable neurological recovery. Early mortality included 5 (13.5%) patients. Actuarial survival at 5 years was 52 ± 10%. CONCLUSIONS: A partial upper sternotomy provides adequate exposure to all heart valves. We did not experience technical limitations with this approach. Wound dehiscence, postoperative bleeding, intensive care unit and hospital stay and early deaths were low compared to data from other published series of triple valve surgery through a full median sternotomy. Early and mid-term outcomes were not adversely affected by this less invasive approach.