Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement.

Reoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques. We identified 105 patients, aged ≥80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival. Of the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 ± 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% ± 11.7% vs 92% ± 7.8%) and 5 years (38% ± 17.6% vs 65% ± 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality. Octogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this population.

Kaneko T ，Loberman D ，Gosev I ，Rassam F ，McGurk S ，Leacche M ，Cohn L ... -  《-》

Outcomes of surgical aortic valve replacement in moderate risk patients: implications for determination of equipoise in the transcatheter era.

To determine the contemporary outcomes of surgical aortic valve replacement (SAVR) in a moderate surgical risk population. We studied 502 consecutive adults who had undergone isolated SAVR from January 2002 to June 2011 for severe aortic valve stenosis with a Society of Thoracic Surgery predicted risk of mortality of 4% to 8%. We included concomitant coronary artery bypass and aortic annular enlargement but not other concomitant procedures. The updated Valve Academic Research Consortium definitions were used, as appropriate. The median age was 80 years (range, 49-96), 323 (64.3%) had New York Heart Association class III-IV symptoms, and 101 (20.1%) had undergone previous coronary artery bypass grafting. The mean predicted risk of mortality was 5.6%. Concomitant coronary artery bypass grafting was performed in 270 (53.8%). Re-exploration for bleeding occurred in 29 (5.8%), stroke in 9 (1.8%), and vascular complications in 2 (0.4%). In the cohort, 14 early deaths (2.8%) occurred. During follow-up (1174 days), 175 patients died. Using multivariate logistic regression analysis, the significant independent predictors of mid-term death included chronic pulmonary disease (hazard ratio, 2.00, 95% confidence interval, 1.41-2.84; P < .001), peripheral vascular disease (hazard ratio, 1.58; 95% confidence interval, 1.05-2.37; P = .029), and atrial fibrillation (hazard ratio, 1.75; 95% confidence interval, 1.16-2.65; P = .008). SAVR in moderate-risk patients is currently performed with one half of the early predicted risk (2.8%) and a low likelihood of complications, including a 1.8% incidence of stroke. Patients counseled for randomization to transcatheter aortic valve insertion should be informed of the excellent early to mid-term outcomes of SAVR, particularly those without pulmonary impairment, peripheral vascular disease, or atrial fibrillation.

Iturra SA ，Suri RM ，Greason KL ，Stulak JM ，Burkhart HM ，Dearani JA ，Schaff HV ... -  《-》

Full sternotomy versus right anterior minithoracotomy for isolated aortic valve replacement in octogenarians: a propensity-matched study †.

Surgical aortic valve replacement (AVR) is increasingly performed in elderly patients with good perioperative outcomes and long-term survival, resulting in significant health-related quality-of-life benefits. This study aimed to evaluate the outcome of patients aged ≥ 80 years undergoing isolated AVR through a right anterior minithoracotomy (RAMT) and compare it with a full sternotomy (FS). Two hundred and eighty-three elderly patients aged 80 years or more underwent isolated AVR between February 2001 and September 2013. With propensity score matching (1 : 1), the outcomes of patients having minimally invasive surgery (RAMT) were compared with those in whom the FS approach had been employed (100 vs 100 patients). TAVRs and partial sternotomy cases were excluded from the analysis. There were two conversions in the RAMT group. Operative times did not significantly differ in the two groups. Patients in the RAMT group received a larger-sized prosthesis (P < 0.001) and were more likely to receive sutureless valves (P < 0.001). Shorter time for extubation (P < 0.001) and shorter hospital length of stay (P = 0.005) were observed in the RAMT group. Zero vs 4 (4.0%) (P = 0.043) patients had postoperative stroke and 2 (2.0%) vs zero (P = 0.16) had a transient ischaemic attack in the RAMT versus FS group, respectively. We registered the same rate of permanent pacemaker implant (P = 0.47) and that of new-onset atrial fibrillation (P = 0.28) for both groups. Six patients died, with no significant difference for in-hospital mortality (P = 0.68). No variable had a statistically significant predictive value for in-hospital mortality. RAMT patients were more likely to be discharged home directly or via rehabilitation (P = 0.031). FS, along with four other factors, independently predicted longer hospital stay. Though the median follow-up duration was longer in the FS group (59 vs 24 months, P < 0.001), the two groups had similar survival rates at 5 years (80 vs 81%, P = 0.37). Ten factors were associated with long-term survival by Cox regression analysis, and RAMT had no statistical impact (P = 0.38). Minimally invasive AVR through right anterior minithoracotomy can be safely performed in patients aged ≥80 years with acceptable morbidity and mortality rates. It is an expeditious and effective alternative to full sternotomy AVR and might be associated with lower postoperative stroke incidence, earlier extubation and shorter hospital stay.

Gilmanov D ，Farneti PA ，Ferrarini M ，Santarelli F ，Murzi M ，Miceli A ，Solinas M ，Glauber M ... -  《-》

What is the best approach in a patient with a failed aortic bioprosthetic valve: transcatheter aortic valve replacement or redo aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether transcatheter aortic valve-in-valve replacement (viv-TAVR) or redo aortic valve replacement (rAVR) is the best strategy in a patient with a degenerative bioprosthetic aortic valve. Altogether, 162 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The results of the studies provided interesting results. All the studies are retrospective. Four papers reported the results of redo aortic valve replacement in patients with failed aortic bioprosthetic valve, six papers demonstrated their results with transcatheter aortic valve-in-valve replacement for the same indication and two papers reported their propensity-matched analysis of outcomes between viv-TAVR and rAVR in patients with previous cardiac surgery. Thirty-day mortality for rAVR was 2.3-15.5% and 0-17% for viv-TAVR. For rAVR, survival rate at 30 days was 83.6%, 76.1% at 1 year, 70.8% at 3 years, at 51.3-66% at 5 years, 61% at 8 years and 61.5% at 10 years. For viv-TAVR, the overall Kaplan-Meier survival rate at 1 year was 83.2%. After viv-TAVR at 1 year, 86.2% of surviving patients were at New York Heart Association (NYHA) class I/II. The complications after rAVR were stroke (4.6-5.8%), reoperation for bleeding (6.9-9.7%), low-cardiac output syndrome (9.9%) whereas complications after viv-TAVR at 30 days were major stroke (1.7%), aortic regurgitation of at least moderate degree (25%), new permanent pacemaker implantation rate (0-11%), ostial coronary obstruction (2%), need for implantation of a second device (5.7%) and major vascular complications (9.2%). It is noteworthy to mention that there is a valve-in-valve application that provides information to surgeons for choosing the correct size of the TAVR valve. Transcatheter aortic valve-in-valve procedures are clinically effective, at least in the short term, and could be an acceptable approach in selected high-risk patients with degenerative bioprosthetic valves. Redo AVR achieves acceptable medium and long-term results. Both techniques could be seen as complementary approaches for high-risk patients.

Tourmousoglou C ，Rao V ，Lalos S ，Dougenis D ... -  《-》

Conventional surgery, sutureless valves, and transapical aortic valve replacement: what is the best option for patients with aortic valve stenosis? A multicenter, propensity-matched analysis.

Although surgical aortic valve replacement (SAVR) is the treatment of choice for patients with aortic valve stenosis, transcatheter aortic valve replacement (TAVR) and sutureless aortic valve replacement (SU-AVR) have shown good results. The aim of our multicenter, propensity-matched study was to compare the clinical and hemodynamic outcomes of surgical SAVR, transapical TAVR (TA-TAVR), and SU-AVR. We analyzed data from 566 TA-TAVR, 349 SAVR, and 38 SU-AVR patients treated from January 2009 to March 2012. We used a propensity-matching strategy to compare on-pump (SAVR, SU-AVR) and off-pump (TA-TAVR) surgical techniques. The outcomes were analyzed using multivariate weighted logistic regression or multinomial logistic analysis. In the matched cohorts, the 30-day overall mortality was significantly lower after SAVR than TA-TAVR (7% vs 1.8%, P = .026), with no differences in mortality between SU-AVR and TA-TAVR. Multivariate analysis showed SU-AVR to have a protective effect, although not statistically significant, against aortic regurgitation, pacemaker implantation, and renal replacement therapy compared with TA-TAVR. Compared with TA-TAVR, SAVR demonstrated significant protection against aortic regurgitation (odds ratio, 0.04; P < .001) and a trend toward protection against death, pacemaker implantation, and myocardial infarction. The mean transaortic gradient was 10.3 ± 4.4 mm Hg, 11 ± 3.4 mm Hg, and 16.5 ± 5.8 mm Hg in the TA-TAVR, SU-AVR, and SAVR patients, respectively. SAVR was associated with lower 30-day mortality than TA-TAVR. SAVR was also associated with a lower risk of postoperative aortic regurgitation compared with TA-TAVR. We did not find other significant differences in outcomes among matched patients treated with SAVR, SU-AVR, and TA-TAVR.

D'Onofrio A ，Rizzoli G ，Messina A ，Alfieri O ，Lorusso R ，Salizzoni S ，Glauber M ，Di Bartolomeo R ，Besola L ，Rinaldi M ，Troise G ，Gerosa G ... -  《-》