Trends in SAVR with biological vs. mechanical valves in middle-aged patients: results from a French large multi-centric survey.

Background/introduction: Currently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure. Purpose: To assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD. Methods: Patients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age. Results: We considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p < 0.001) while patients above 60 years-old received principally biological SAVR (p < 0.0001). Concerning patients between 50 and 60 years-old patients, MPVR was 1.04 (p = 0.03). Patients 50-60 years-old from the first and second study duration quartile (before August 2015) received preferentially mechanical SAVR (p < 0.001). We observed a shift towards more biological SAVR (p < 0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, simultaneous mitral valve replacement were more common in case of mechanical SAVR (p < 0.0001), while associated CABGs were more frequent in case of biological SAVR (p < 0.0001). Conclusion: In a large contemporary French patient population, real world practice showed a recent shift towards a lower age-threshold for biological SAVR as compared to what would suggest contemporary guidelines.

Clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making.

OBJECTIVES: The aim of this study using decision curve analysis (DCA) was to evaluate the clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making compared with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and to 2 machine-learning models. METHODS: Using data from a French prospective database, this retrospective study evaluated all patients who underwent cardiac surgery in 43 hospital centers between January 2012 and December 2020. A receiver operating characteristic analysis was performed to compare the accuracy of the EuroSCORE II, machine-learning models, and an adapted Tabular Bidirectional Encoder Representations from Transformers deep-learning model in predicting postoperative in-hospital mortality. The clinical utility of these models for cardiac surgery decision making was compared using DCA. RESULTS: Over the study period, 165,640 patients underwent cardiac surgery, with a mean EuroSCORE II of 3.99 ± 6.67%. In the receiver operating characteristic analysis, the area under the curve was significantly greater for the deep-learning model (0.834; 95% confidence interval, 0.831-0.838) than the EuroSCORE II (P < .001), the random forest model (P = .03), and the Extreme Gradient Boosting model (P = .03). In the DCA, the clinical utility of the 3 artificial intelligence models was superior to that of the EuroSCORE II, especially when the threshold probability of death was high (>45%). The deep-learning model showed the greatest advantage over the EuroSCORE II. CONCLUSIONS: The deep-learning model had better predictive accuracy and greater clinical utility than the EuroSCORE II and the 2 machine-learning models. These findings suggest that deep learning with Tabular Bidirectional Encoder Representations from Transformers prediction model could be used in the future as the gold standard for cardiac surgery decision making.

Surgical aortic valve replacement in the modern era: Insights from the French Registry EPICARD.

OBJECTIVE: We sought to assess the demographic changes and postoperative outcomes of surgical aortic valve replacement (SAVR) in recent years since the advent of trans-catheter aortic valve implantation (TAVI) in France. METHODS: Demographic, surgical data, and early outcomes of patients undergoing SAVR for AS were reviewed from The French registry EPICARD before (2007-2012) and after (2013-2018) approval of TAVI by French health authorities. We included patients with less than 20% of missing data per variable and per patient. Univariate and multivariate analysis were conducted to assess for risk factors of mortality and acute kidney failure (AKF) requiring renal replacement therapy (RRT). RESULTS: A total of 27,398 patients from the EPICARD registry were included: 8819, in the early cohort (2007-2012) and 18,579 in the recent cohort (2013-2018). In-hospital and 30-day mortality rates were lower in the recent cohort compared to the early cohort, respectively 1.22% versus 2.20 (p < .001) and 1.22% versus 2.34% (p < .001). The bioprosthesis-to-mechanical prosthesis ratio significantly increased over the time: from 5.3 to 8.1. In the recent cohort, rates of postoperative blood transfusions, prolonged mechanical ventilation, and AKF requiring RRT were lower. In-hospital and 30-day mortality risks were decreased in the recent cohort, with odds ratio respectively of 0.668 [0.466-0.958] and 0.66 [0.460-0.945] in multivariate (p ≤ .005) and univariate analysis (p < .001). Risk of AKF with RRT was unchanged. CONCLUSION: This nationwide study from the French registry EPICARD shows significant reduced hospital mortality and persistent favourable early outcomes of SAVR since TAVI implementation.

Influence of stentless versus stented valves on ventricular remodeling assessed at 6 months by magnetic resonance imaging and long-term follow-up.

BACKGROUND: To compare the effect of stented versus stentless bioprostheses on left ventricular remodeling and assess their impact on long-term survival. METHODS: From January 2002 to December 2009, 62 severe aortic stenosis patients without coronary artery disease were randomized for bioprosthetic aortic valve replacement. After randomization, a cross-over was possible based on intraoperative data. Ventricular remodeling was studied by cardiovascular magnetic resonance imaging six months after surgery. Long-term survival was assessed by telephone survey. RESULTS: Thirty-five patients received a porcine Mosaïc® Medtronic bioprosthesis (Stented Group; Medtronic, Minneapolis, MN, USA) inserted using the usual supra-annular technique and 27 received a porcine Freestyle® Medtronic bioprosthesis (Stentless Group) inserted in the subcoronary position. Mean age was 75±3 and 73±4 years in the stentless and stented group, respectively. Nine patients who should have been implanted with a stentless bioprosthesis received a stented bioprosthesis for anatomical reasons. At 6 months, the left ventricular mass (LVM) decreased significantly in both groups (Stentless Group: 214.6±56.1g and 156.3±23g and Stented Group: 237±75.7g and 181±53.3g, respectively after surgery and at 6 months), this decrease was significantly greater in the stentless group (p=0.026). Reserve and coronary flow were increased in both groups at 6 months. Mean follow-up duration was 6.6±3.0 years and 7.2±4.0 years in the stentless and stented group, respectively. The 5-year actuarial survival was 87.5±11.7% and 82.5±17.1% for the stentless and stented group, respectively (p=0.81). CONCLUSION: Porcine stentless prosthesis results in a better LVM regression than a stented valve at 6 months without changing the long-term survival.

Remote ischemic preconditioning in aortic valve surgery: Results of a randomized controlled study.

BACKGROUND: Although remote ischemic preconditioning (RIPC) has emerged as an attractive strategy to reduce cardiac injury in patients undergoing diverse cardiac surgical procedures, it is unclear whether RIPC has protective effects in patients undergoing aortic valve replacement surgery without coronary artery bypass grafting (CABG). METHODS: Hence, 100 adult patients undergoing elective aortic valve replacement for aortic valve stenosis, without combined surgery with CABG, were prospectively randomly assigned in a 1:1 ratio to either the RIPC group or the control group. The RIPC group underwent three cycles of 5-min inflation to 200mmHg and 5-min deflation of an automated upper-arm cuff inflator after induction of anesthesia. The control group had a deflated cuff placed on upper arm for 30min. The primary endpoint was 72-h area under curve (AUC) for troponin I (cTnI). Secondary endpoints were 72-h AUC for creatine kinase-MB isoenzyme (CK-MB) release, incidence of acute kidney injury, extubation time, length of stay in intensive care unit, and simplified acute physiology score (SAPS II). RESULTS: There were no significant differences in cTnI AUC [195±190 arbitrary units (a.u.) in RIPC group vs. 169±117 a.u. in the control group; p=0.41] and CK-MB AUC between groups. None of the other secondary endpoints differed between groups. Acute kidney injury occurred in 12 patients (24.5%) in the control group and in 13 (26.0%) in the RIPC group (p=0.86). CONCLUSIONS: RIPC did not exhibit significant cardiac or kidney protective effects in patients undergoing aortic valve replacement surgery without CABG.

Safety and efficacy of biocompatible perfusion strategy in a contemporary series of patients undergoing coronary artery bypass grafting - a two-center study.

OBJECTIVE: The profile of patients referred for coronary artery bypass grafting (CABG) is continuously changing to include older patients with multiple comorbidities. We assessed the safety and efficacy of a biocompatible perfusion strategy (BPS) in a contemporary series of patients undergoing isolated CABG. METHODS: BPS consisted of a membrane oxygenator, tip-to-tip closed-system heparin-bonded cardiopulmonary bypass circuits without a cardiotomy reservoir, low systemic anticoagulation (target ACT - 250-300 sec) using heparin titration curves, low prime volume, avoidance of systemic cooling, and routine use of cell saver and anti-fibrinolytics. Data were prospectively collected using the American Society of Thoracic Surgeons National Adult Cardiac Surgery Database definitions. RESULTS: 964 consecutive patients (mean age 66 ± 11 years, 83% male) undergoing CABG between 2008 and 2012 were enrolled. 30-day mortality was 1.4%. Rates of postoperative stroke, myocardial infarction, sternal infection and reoperation for bleeding were 0.9%, 1.3%, 1.9% and 4.2%, respectively. Average 24-hour chest tube drainage was 440 ± 280 ml. Blood products were used in 34% of patients (total donor exposure of 1.7 ± 4.7 units/patient). Predictors of hospital mortality in multivariable analysis were left main disease and preoperative treatment with anti-arrhythmic or immunosuppressive medications. Predictors of allogeneic blood transfusions included older age, small body surface area, female gender, increased serum creatinine, lower preoperative LVEF and hematocrit. Priority of surgery, dual antiplatelet therapy and cardiopulmonary bypass time were not predictors of adverse outcomes or blood transfusions. CONCLUSIONS: In a contemporary cohort of patients undergoing CABG, the use of BPS is safe and effective. It is associated with excellent clinical outcomes and reduced allogeneic blood transfusions.

CMR assessment after a transapical-transcatheter aortic valve implantation.

AIMS: To describe the time course of myocardial scarring after transapical-transcatheter aortic valve implantation (TA-TAVI) with the Edwards SAPIEN XT™ and the Edwards SAPIEN™ prosthesis in a 3-month follow-up study using cardiac magnetic resonance imaging (CMR). METHODS: In 20 TA-TAVI patients, CMR was performed at discharge and 3 months (3M). Cine-MRI was used for left ventricular (LV) functional assessment, and late gadolinium enhancement (LGE) imaging was employed for detecting the presence of myocardial scarring. Special attention was given to any artifacts caused by the prosthesis, which were consequently defined using a three-grade artifact scale. RESULTS: We systematically reported the presence of small LGE hyperintensity relating to the apical segment, with no variation found between discharge and 3M (2.8±1.6g vs. 2.35±1.1g). LV ejection fraction, end-diastolic, and end-systolic volumes did not significantly vary. A small area of apical akinesia was observed, with no improvement at follow-up. Whereas the Edwards SAPIEN XT™ prosthesis and the Edwards SAPIEN™ prosthesis are both constituted by metallic stenting structure, the Edwards SAPIEN™ was responsible for a larger signal void, thus potentially limiting the diagnostic performance of CMR. CONCLUSIONS: CMR may be performed safely in the context of TA-TAVI. The presence of a very small apical infarction correlating with focal akinesia was observed. As expected, the Edwards SAPIEN XT™ prosthesis was shown to be particularly suitable for CMR assessment.

Brain injury and neuropsychological outcome after coronary artery surgery are affected by complement activation.

BACKGROUND: The impact of the postoperative inflammatory response on the central nervous system after cardiac surgery is uncertain. The goal of the study was to evaluate the role of complement activation on cellular brain injury in patients undergoing coronary artery bypass grafting. In addition, neuropsychological functioning was assessed. METHODS: We randomly assigned 30 patients to undergo surgery using either standard noncoated or heparin-coated extracorporeal circuits. Closed cardiopulmonary bypass and controlled suctions of pericardial shed blood were standardized in both groups. Complement activation and cellular brain injury were assessed by measuring sC5b-9 and protein s100beta. Neuropsychometric tests were performed at least 2 weeks before operation and at discharge. They served to calculate z scores of cognitive domains and changes in neuropsychological functioning. RESULTS: Peak value of sC5b-9 at the end of cardiopulmonary bypass in the noncoated group was significantly higher than in the heparin-coated group (p = 0.005). Changes in the heparin-coated group were not significant. Glial injury started after initiation of surgery and peaked at the end of cardiopulmonary bypass with significantly higher concentration of s100beta in the noncoated than in the heparin-coated group (p = 0.008). Values of s100beta and of sC5b-9 were significantly correlated (p = 0.03). Although no statistically significant between group difference was detected, z scores of attention and flexibility or executive functions were lowered postoperatively within the noncoated group (p = 0.033 and p = 0.028), whereas z scores were unchanged within the heparin-coated group. CONCLUSIONS: Inhibition of complement activation by heparin-coated cardiopulmonary bypass reduced brain cell injury and was associated with preserved neuropsychological functioning after coronary artery bypass grafting.

Transesophageal echocardiography-guided chordal replacement for tricuspid regurgitation.

A 29-year-old man was referred to our institution for severe tricuspid regurgitation. Preoperative transesophageal echocardiography revealed dilation of the tricuspid annulus with prolapse of the anterior leaflet and progressive increase in right ventricular diameter. The anterior papillary muscle was elongated. Annuloplasty was completed by polytetrafluoroethylene artificial chordae implanted on the free margin of the anterior leaflet, and thereafter, tied outside the right ventricle, under echocardiography control to achieve appropriate length. The patient recovered well, and 6 months after surgery, repeat echocardiography revealed only mild tricuspid regurgitation with recovery of normal right ventricular dimensions.

A combined approach for improving cardiopulmonary bypass in coronary artery surgery: a pilot study.

BACKGROUND: This is a pilot study carried out to assess the feasibility and the clinical impact of a combined approach of cardiopulmonary bypass (CPB) with reduced anti-coagulation. METHODS: We used a retrospective, non-randomized analysis of 45 consecutive patients undergoing coronary artery bypass using standard CPB with full anticoagulation (activated clotting time, ACT, > 450 s) (Group 1; n = 23) or closed, heparin-coated CPB with low anticoagulation (ACT>250 s), precise heparin and protamine titration, controlled suction, and retrograde autologous prime (Group 2; n = 22). RESULTS: Patients were similar except for a higher incidence of three-vessel disease in Group 2 (77.3% versus 47.8%; p < 0.03). Heparin was reduced by 41% in Group 2 and protamine by 56% (p < 0.0001). Total postoperative blood loss was similar between Groups 1 and 2 (429 +/- 149 versus 435+/-168 ml, respectively). However, the operative hematocrit decrease was lower in Group 2 (-1.6 +/- 7.5% versus -6.9 +/- 4.8%; p = 0.007), although hemodilution was similar, as reflected by the blood protein level. The need for postoperative inotropic support was less frequent in Group 2 (36.4% versus 65.2%; p = 0.05). Within the subgroup of patients weaned from CPB without requiring inotropic support (n = 35), the cardiac index dropped significantly in Group 1 (p = 0.003) 6 h after the start of CPB, whereas it remained stable in Group 2 (p = 0.92). Using multivariate analyses, Group 2 was found to be more protected than Group 1 against myocardial cellular injury (p = 0.046) and need for postoperative inotropic support (p = 0.014). CONCLUSION: The pejorative postoperative outcome in coronary artery surgery was attenuated through a combined approach aimed at improving CPB.