Is a minimally invasive approach for re-operative aortic valve replacement superior to standard full resternotomy?

A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'is a minimally invasive approach for re-operative aortic valve replacement (AVR) superior to standard full resternotomy?' A total of 193 papers were found using the reported search of which 13 represented the best evidence to answer the clinical question. The authors, country, journal and date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that minimally invasive re-operative AVR can be performed with an operative morbidity and mortality at least similar to the standard full sternotomy approach. A shorter hospital length of stay and less blood product requirements are the main advantages of this technique. The incidence of prolonged ventilation, bleeding requiring re-operation, sternal wound infections and in-hospital mortality may be reduced with a minimally invasive approach. Prospective studies are required to confirm the potential benefits of minimally invasive surgery and, up to date, conventional full re-sternotomy is still the standard approach for re-operative AVR.     

Is repair of aortic valve regurgitation a safe alternative to valve replacement?

OBJECTIVE: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. METHODS: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). RESULTS: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. CONCLUSIONS: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.     

Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement?

OBJECTIVES: Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution. METHODS: Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006). RESULTS: Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis. CONCLUSIONS: Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.     

Are bicuspid aortic valves a limitation for aortic valve repair?

Objective: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. Methods: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n = 43) and tricuspid AV (n = 57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. Results: Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years’ survival was 93 ± 4.2% without significant differences between the two groups. Overall actuarial 3 years’ freedom from AV-related reoperation was 86 ± 5.1% without significant differences between the groups (85 ± 9.7% for bicuspid AV, 86 ± 6.0% for tricuspid AV; log-rank test: p = 0.98). Overall actuarial 3 years’ freedom from recurrent AR ≥ moderate was 100% and AR > trace was 71.3 ± 8.2% without significant differences between the groups (76.5 ± 11.7% for bicuspid AV, 71.4 ± 9.4 for tricuspid AV; log-rank test: p = 0.97). Conclusions: The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.     

Is prophylactic aortic valve replacement indicated during mitral valve surgery for mild to moderate aortic valve disease?

BACKGROUND: Determining the need for surgical treatment of coexisting mild to moderate aortic valve disease in patients referred for mitral valve surgery is often difficult. The purpose of this study was to assess long-term clinical outcome and the need for subsequent aortic valve replacement in patients with mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery. METHODS: A total of 275 patients (90 men and 185 women, mean age 43 years) with rheumatic disease who underwent mitral valve surgery were followed up for an average of 9 years. Patients were classified into two groups: those with coexisting mild to moderate aortic valve disease at the time of mitral valve surgery (141 patients, group A) and those without (134 patients, group B). Primary outcomes (death and subsequent aortic valve surgery) were compared between the two groups. RESULTS: At the time of mitral valve surgery, 104 patients (74%) in group A had mild aortic regurgitation, 37 (26%) had moderate aortic regurgitation, 5 had (4%) mild aortic stenosis, and 2 (1%) had moderate aortic stenosis. At the end of follow-up, no patient had severe aortic valve disease. In all, 12 patients (5%) in group A had primary events (eight deaths and four subsequent aortic valve replacements), and 12 patients (9%) in group B had such events (12 deaths). According to Kaplan-Meier analysis, neither the survival rate nor the event-free survival rate differed significantly over the follow-up period between the two groups. CONCLUSIONS: In most patients who have mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery, the long-term outcome is comparable to that of subjects without aortic valve disease at the time of mitral valve surgery. Subsequent aortic valve replacement is rarely needed after a long follow-up period.     

In patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve repair superior to double valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve plasty (MVP) superior to double valve replacement (DVR) in terms of improved long-term survival? Altogether 156 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Out of seven papers, that simultaneously compare these two treatment modalities, three favor MVP combined with aortic valve replacement (AVR) over DVR, two papers advocate the opposite and two failed to find any significant difference in long-term survival, freedom from reoperation and thromboembolic and bleeding complications between these two surgical options. All data presented derive from level 2b evidence. Critical appraisal of these studies is constricted by the large heterogeneity of the patients, diversity in treatment protocols and inherent selection bias. We conclude that currently the available evidence is insufficient to prove that AVR with MVP is superior to DVR in patients with double valve disease.     

Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial

BACKGROUND: Although stentless aortic bioprostheses are believed to offer improved outcomes, hemodynamic benefits remain unsubstantiated. METHODS: Fifty-three patients were randomized to receive the stented C-E pericardial valve (CE) and 46 patients the Toronto Stentless Porcine valve (SPV). Annuli were sized for the optimal insertion of both valve types, such that surgeons were required to commit to specific valve sizes before randomization. Echocardiographic measurements and functional status (Duke Activity Status Index) were assessed at 3 and 12 months postoperatively. RESULTS: Although cardiopulmonary bypass times (CE: 118.6+/-36.3 minutes; SPV: 148.5+/-30.9 minutes; p = 0.0001) and aortic cross-clamp times (CE: 95.4+/-28.6 minutes; SPV: 123.6+/-24.1 minutes; p = 0.0001) were significantly prolonged in the SPV group, perioperative morbidity and mortality was similar between groups. Neither valve offered a superior internal diameter for any given annular diameter (mean decrease in left ventricular outflow tract diameter after valvular implantation: SPV: 3.4+/-1.11 mm versus CE: 3.7+/-1.33 mm; p = 0.25). Although labeled mean valve size was significantly larger in the SPV group, the actual mean valve size based on internal valvular diameter was no different between groups (CE: 21.9+/-2.0 mm; SPV: 22.3+/-2.0 mm; p = 0.286). Although effective orifice areas increased, and mean and peak transvalvular gradients decreased in both groups over time, no differences were demonstrated between groups at 12 months. Similarly, although significant regression of left ventricular mass was accomplished in both groups over time, no differences were demonstrated between groups. Finally, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups at 12 months postoperatively. CONCLUSIONS: Although offering excellent outcomes, stentless valves did not demonstrate superior hemodynamic indices in comparison to stented valves up to 12 months after implantation.     

Optimal thromboprophylaxis following bioprosthetic aortic valve replacement: still a matter of debate?

Optimal thromboprophylaxis following bioprosthetic aortic valve replacement (AVR) remains controversial. The main objective, which is the effective prevention of central nervous or peripheral embolic events, especially in the early postoperative period, will have to be weighed against the haemorrhagic risk that is associated with the utilization of different antithrombotic regimes. Most governing bodies in cardiovascular medicine have issued recommendations on thromboprophylaxis after the surgical implantation of aortic bioprostheses. However, the level of evidence to support these recommendations remains low, largely due to the inherent limitations of conducting appropriately randomized and adequately powered clinical research in this area. It is apparent from the recent surveys and large registries that there is a great variability in antithrombotic practice at an institutional or individual-clinician level reflecting this controversy and the lack of robust evidence. While organizational, financial or conceptual limitations could hinder the conduct and availability of conclusive research on optimal thromboprophylaxis after aortic bioprosthesis, it is imperative that all evidence is presented in a systematic way in order to assist the decision-making for the modern clinician. In this review, we provide an outline of the current recommendations for thromboprophylaxis, followed by a comprehensive and analytical presentation of all comparative studies examining anticoagulation vs. antiplatelet therapy after bioprosthetic AVR.     

Is routine computed tomography angiography justified in patients undergoing aortic valve replacement for bicuspid aortic valve disease?

Background

Role of Computed Tomography Angiography (CTA) in patients with Bicuspid Aortic Valve (BAV) undergoing Aortic Valve Replacement (AVR) needs assessment.

Patients and Methods

After echocardiography, 54 patients with BAV were referred for AVR. CTA was performed routinely. Pre-operative characteristics, echocardiographic and CTA findings, and details of surgery were obtained.

Results

The study population had 54 subjects (48 males). Median age was 35.5 years (range 7 to 78 years), and median weight was 57.5 Kg (range 14 to 83 kg). On echocardiography, aortic sinus diameter ranged from 13 to 38 mm (median 28 mm). In none of the patients, ascending aorta was reported to be dilated. On CT angiography, the sinus diameter ranged from 16 to 46 mm (median 35 mm). Sinus diameter was ≥40 mm in 13 patients. The sinus diameter on echocardiography was within the range of 0 to 2 mm of CT angiographic estimates in 31 patients, within 2.1 to 5 mm in 22 patients, and more than 5 mm in one patient. The ascending aortic diameter ranged from 19 to 70 mm (median 43 mm). In 26 patients, ascending aortic diameter was ≥45 mm. In 12 patients, the proximal arch diameter was ≥40 mm. In two patients, the distal ascending aorta and proximal arch were aneurysmally dilated (48 mm and 57 mm). In 12 patients, the ascending aorta was dilated (≥ 45 mm) without any sinus dilatation. In one patient, the distal ascending aorta and proximal arch were aneurysmally dilated (57 mm) without any proximal dilatation. Based on CT angiographic findings, 25 patients (46.3 %) underwent additional aortic replacement in the form of Bentall’s procedure (n?=?7), Bentall’s + Hemiarch replacement (n?=?6), aortoplasty (n?=?5), Wheat procedure (n?=?6) and Wheat procedure?+?Hemiarch replacement (n?=?1).

Conclusion

CT angiography is justified as a routine pre-operative evaluation tool in all patients with BAV who are undergoing open heart surgery for significant aortic valve dysfunction.     

Sleeve gastrectomy to aortic valve replacement: safe?

BackgroundBariatric surgery has favorable results on cardiac structure and function, but there is minimal research on its utility in the cardiac comorbid population.ObjectivesTo determine if laparoscopic sleeve gastrectomy (SG) is safe in patients with symptomatic aortic stenosis (AS).SettingCommunity hospital/bariatric center of excellence in Pennsylvania.MethodsRetrospective single center review of 18 patients with morbid obesity and clinically significant AS. All SGs were performed between June 2016 and June 2020. Outcomes including hospital length of stay, 30-day readmission, and 30-day mortality in the study population (n = 18) were compared with 100 patients without AS who underwent SG at the same institution during the same time.ResultsThere were no perioperative deaths. Mean hospital stay in the study group was 1.78 days compared with 1.3 days in the noncardiac group (P = .1154). Two of 18 patients (11.1%) required readmission within 30 days, both for clinically significant bleeding, compared with 2 of 100 noncardiac patients (2.0%) (P = .1097). Seventeen of 18 study patients went on to have definitive aortic valve replacement surgery.ConclusionSG appears safe in patients with clinically significant AS. Although the AS group did have a higher rate of complications, these were manageable and did not increase mortality or LOS. Further studies are required to determine if outcomes of definitive aortic valve replacement are improved after bariatric surgery.     

Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option?

OBJECTIVES: Aortic dilatation occurs in many patients with bicuspid aortic valves. We have added root replacement using the remodeling technique originally designed for tricuspid aortic valves to bicuspid aortic valve repair for treatment of the dilated root. We compared the results of remodeling in bicuspid aortic valves with those in tricuspid aortic valves. METHODS: From October 1995 through January 2004, 60 patients underwent root remodeling for bicuspid aortic valves (group A), and 130 patients underwent root remodeling for tricuspid aortic valves (group B). Correction of cusp prolapse was more often performed in group A (group A, 50/60; group B, 47/130; P < .0001). Transthoracic echocardiography was performed at 1 week, 6 and 12 months, and every year thereafter. Cumulative follow-up was 527 patient-years (mean, 2.9 +/- 2 years). RESULTS: No patient died in group A. Hospital mortality in group B was 5% (5/100; 95% confidence interval,1.6%-11.3%) after elective operations and 10% (3/30; 95% confidence interval, 2.1%-26.5%) after emergency operations. Mean systolic gradients were identical at 1 year (group A, 4.8 +/- 2.1 mm Hg; group B, 4.0 +/- 2 mm Hg) and 5 years (group A, 4.5 +/- 2.3 mm Hg; group B, 3.9 +/- 2.2 mm Hg). Freedom from aortic regurgitation of grade 2 or higher at 5 years was 96% in group A and 83% in group B ( P = .07), and freedom from reoperation at 5 years was 98% in group A and 98% in group B ( P = .73). CONCLUSIONS: Valve-sparing aortic replacement with root remodeling can be applied to aortic dilatation and a regurgitant bicuspid aortic valve. Hemodynamic function and valve stability of a repaired bicuspid aortic valve are comparable with those seen in cases of tricuspid anatomy.     

Is mitral valve repair superior to replacement for chronic ischemic mitral regurgitation with left ventricular dysfunction?

Background  

This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation (IMR) with left ventricular dysfunction (LVD). Specifically, we sought to determine whether the choice of mitral valve procedure affected survival, and discover which patients were predicted to benefit from mitral valve repair and which from replacement.     

Is tricuspid valve replacement a catastrophic operation?

Objective: Tricuspid valve replacement (TVR) has a high postoperative mortality, despite recent advances in perioperative care. We report the results of our experience in TVR with an emphasis on early mortality and morbidity and long-term follow-up. Methods: Between October 1994 and August 2007, 80 consecutive TVRs were performed in 78 patients. The mean age was 48 ± 14 (range: 20–70) years. The underlying disease of the patients was classified as rheumatic (n = 54), congenital (n = 12), endocarditis (n = 10) or degenerative (n = 4). Previous cardiac surgery had been performed in 40 patients (50%). Isolated TVR was performed in 24 patients (30%). Results: Hospital mortality occurred in one patient (1.4%). Postoperative morbidities included intra-aortic balloon pump (n = 5), bleeding re-operation (n = 4), delayed sternal closure (n = 3), acute renal failure (n = 3), subdural haematoma (n = 3), extracorporeal membrane oxygenation (n = 1), mediastinitis (n = 1) and pacemaker insertion (n = 4). In 42 patients, ventilator support was needed for more than 72 h. Based on multivariate analysis, age (p < 0.001) and the cardiopulmonary time (p = 0.004) were the identified risk factors. Follow-up was completed in all patients with a mean duration of 56 ± 37 (range: 0–158) months. During the follow-up period, there were seven deaths (8.8%), including five cardiac deaths. The 5- and 8-year survival rates were 95 ± 3% and 79 ± 9% and event-free survival rates were 76 ± 6% and 61 ± 9%, respectively. Based on multivariate analysis, the only identified predictors of late deaths was a postoperative low cardiac output (p = 0.024). Conclusions: TVR can be performed and low operative mortality can be achieved thorough optimal perioperative management in the current era.