Left Atrium Volume Reduction Procedure Concomitant With Cox-Maze Ablation in Patients Undergoing Mitral Valve Surgery: A Meta-Analysis of Clinical and Rhythm Outcomes

Background The management of an enlarged left atrium (LA) in mitral valve (MV) disease with atrial fibrillation (AF) is still being debated. It has been postulated that a reduction in LA size may improve patient outcomes. This meta-analysis aimed to assess rhythm and clinical outcomes of combined surgical AF treatment with or without LA volume reduction (LAVR) in patients undergoing MV surgery.Methods A systematic review was performed and all available literature to May 2022 was included. The primary endpoint was analysis of early and late mortality and rhythm outcomes. Secondary outcomes included early and late cerebrovascular accident (CVA) and permanent pacemaker implantation.Results The search strategy yielded 2,808 potentially relevant articles, and 19 papers were eventually included. The pooled estimated rate of 30-day mortality was 3.76% (95% CI 2.52-5.56). The incidence rate of late mortality and late cardiac-related mortality was 1.75%/year (95% CI 0.63-4.84) and 1.04%/year (95% CI 0.31-3.53), respectively. At subgroup analysis when comparing the surgical procedure with and without AF ablation, the ablation subgroup showed a significantly lower rate of postoperative CVA (p,0.0001) and higher restoration to sinus rhythm at discharge (p=0.0124), with only a trend of lower AF recurrence at 1 year (p=0.0608). At univariable meta-regression, reintervention was significantly associated with higher late mortality (p=0.0033). Conclusion In enlarged LA undergoing MV surgery, LAVR combined with AF ablation showed a trend of improved rhythm outcomes when compared with AF ablation without LAVR. Each LAVR technique has its advantages and disadvantages, which must be managed accordingly

Treatment of non-restrictive cor triatriatum sinister during concomitant cardiac surgery

Abstract Background Cor triatriatum is a rare congenital heart disease representing the 0.4% of all congenital cardiac anomalies. To date, no specific genetic alteration has been associated to cor triatriatum. The left-sided presentation (cor triatriatum sinister (CTS)) generally consists in a fibromuscular membrane that divides the left atrium into two chambers, therefore generating a varying grade of flow obstruction depending on the shape, location, and membrane fenestration size. Cor triatriatum sinister can be isolated or associated to other congenital heart defects such as ostium secundum atrial septal defect, patent foramen ovale or abnormal pulmonary veins drainage. Case presentation Our case is a 63-year-old woman who was diagnosed with a non-restrictive membrane during a hospitalization for acute heart failure. In the following 6 months, she started to become symptomatic. However, the onset of symptoms was more likely related to mitral valve regurgitation worsening and previously unknown coronary artery disease, rather than to CTS. She underwent bi-atrial surgical ablation (Cox Maze IV procedure) for atrial fibrillation (AF), surgical resection of interatrial membrane with mitral annuloplasty, and myocardial revascularization. Conclusion The onset and severity of symptoms in patients with CTS mostly depend on membrane fenestration size, grade of stenosis generated and pulmonary veins drainage site. However, some cases may remain asymptomatic until adulthood; the degree of pulmonary hypertension and congestive heart failure is determined by the presence of additional cardiac anomalies and the fibromuscular membrane fenestration. In some cases, CTS may remain asymptomatic, thus the diagnosis can be incidental

Hybrid strategies for stand-alone surgical ablation of atrial fibrillation

Atrial fibrillation (AF) has been reported as a major cause of cardiac morbidity and mortality, and significantly reduces the quality of life in symptomatic patients. Current guidelines recommend antiarrhythmic drugs and catheter ablation (CA) as first-line therapy. Despite CA showed to be associated with lower incidence of periprocedural complications, rhythm outcomes are far from optimal. Indeed, patients undergoing CA frequently require multiple AF ablation procedures, especially in those with persistent and long-standing persistent AF. While surgical ablation can provide transmural lesions, surgical invasiveness has limited the widespread use of this approach due to the increased perioperative complications. The development of minimally invasive thoracoscopic approaches has renewed the interest towards surgical ablation, thus favoring more simplified ablation sets. Therefore, the concept of "hybrid" ablation has emerged in order to theoretically enhance advantages of both minimally invasive and CA procedures while seeking to improve rhythm outcomes and reduce invasiveness and incidence of perioperative complications. On one hand, it provides the effectiveness of a surgical ablation, on the other, electrical mapping during CA can identify and treat any ablation gap or provide additional ablation lines, thus improving the chance of a stable sinus rhythm restoration at longterm follow-up. Three main thoracoscopic strategies are currently available. All of them can be performed in conjunction with the "catheter ablation procedure": the "Fusion" technique, the bipolar clamp technique, and the most recent "convergent" technique. CA can be performed either simultaneously or with a staged approach after a blanking period in order to allow the ablation lesion to stabilize. Excellent results of the hybrid procedures have been reported in terms of rhythm outcomes and incidence of perioperative complications. This narrative review aims to discuss the rationale behind the concept of hybrid ablation for the treatment of AF regarding different available strategies, results and expert opinions

Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data

Background: Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment. Methods: A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach. Results: Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256). Conclusions: The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA

Mitral valve surgery in acute infective endocarditis: long-term outcomes of mitral valve repair versus replacement

AimsTiming and surgical strategies in acute infective endocarditis are still questionable. We sought to investigate clinical outcomes of patients undergoing mitral valve repair (MVR) compared with mitral valve replacement [mitral valve prosthesis (MVP)] for acute infective endocarditis.MethodsFrom 2004 to 2019, 109 consecutive patients with acute mitral valve infective endocarditis were retrospectively investigated. Patients were divided into two groups according to surgical strategy: MVR 53/109 (48.6%) versus MVP 56/109 (51.4%). Primary end points were in-hospital mortality and overall survival at 10 years. Secondary end point was the freedom from infective endocarditis relapse.ResultsOur institutional surgical approach for infective endocarditis allowed us to achieve MVR in 48.6% of patients. Hospital mortality was comparable between the two groups [MVR: 1/53 (1.9%) versus MVP: 2/56 (3.6%), P = 1.000]. Overall 10-year survival was 80.0 +/- 14.1 and 77.2 +/- 13.5% for MVR and MVP, respectively (P = 0.648). MVR showed a lower incidence of infective endocarditis relapse compared with MVP (MVR: 93.6 +/- 7.1 versus MVP: 80.9 +/- 10.8%, P = 0.041). At Cox regression, infective endocarditis relapse was an independent risk factor for death (hazard ratio 4.03; 95% confidence interval 1.41-11.52; P = 0.009).ConclusionThe tendency to postpone surgery in stable patients with mitral infective endocarditis allowed achievement of MVR in almost 50% of patients. Although repair remains the approach of choice in our institution, no differences between MVR and MVP were reported in terms of early/late survival. However, MVP had a higher incidence of infective endocarditis relapse that represents an independent risk of mortality

Sutureless versus transcatheter valves in patients with aortic stenosis at intermediate risk: A multi-institutional European study

Background: Recent randomized controlled trials showed comparable short-term outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate and low-risk patients. However, independent studies comparing transcatheter aortic valve implantation results versus surgical aortic valve replacement at 5 years showed worsening outcomes in patients treated with transcatheter aortic valve implantation. The aim of this study was to analyze mid- to long-term outcomes of patients with isolated aortic stenosis and an intermediate-risk profile who underwent aortic valve replacement using a sutureless valve versus transcatheter aortic valve implantation. Methods: This retrospective multi-institutional European study investigated 2,123 consecutive patients with isolated aortic stenosis at intermediate risk profile treated with sutureless aortic valve replacement (824 patients) or transcatheter aortic valve implantation (1,299 patients) from 2013 to 2020. After 1:1 propensity score matching, 2 balanced groups of 517 patients were obtained. Primary endpoints were as follows: 30 days, late all-cause, and cardiac-related mortality. Secondary endpoints included major adverse cardiocerebrovascular events (all-cause death, stroke/transient ischemic attack, endocarditis, reoperation, permanent pacemaker implantation, and paravalvular leak grade >= 2).Results: Median follow-up was 4.3 years (interquartile range 1.1-7.4 years). Primary endpoints were as follows-30-day mortality sutureless aortic valve replacement: 2.13% versus transcatheter aortic valve implantation: 4.64% (P = .026), all-cause mortality sutureless aortic valve replacement: 36.7% +/- 7.8% vs transcatheter aortic valve implantation: 41.8% +/- 8.2% (P = .023), and cardiac-related mortality sutureless aortic valve replacement: 10.2% +/- 2.8% vs transcatheter aortic valve implantation: 19.2% +/- 3.5%;(P = .00043) at follow-up. Secondary endpoints were as follows-major adverse cardiocerebrovascular events in the sutureless aortic valve replacement group: 47.2% +/- 9.0% versus transcatheter aortic valve implantation: 57.3% +/- 7.5% (P = 2 (sutureless aortic valve replacement: 0.97% versus transcatheter aortic valve implantation: 4.84% [P = .0011) was significantly higher in transcatheter aortic valve implantation group. At Multivariable Cox regression analysis, paravalvular leak >= 2 (hazard ratio: 1.63%; 95% confidence interval: 1.06-2.53, P = .042) and permanent pacemaker implantation (hazard ratio: 1.49%; 95% confidence interval: 1.02-2.20, P = .039) were identified as predictors of mortality.Conclusion: Sutureless aortic valve replacement showed a significantly lower incidence of all-cause mortality, cardiac-related death, permanent pacemaker implantation, and paravalvular leak than transcatheter aortic valve implantation. Moreover, permanent pacemaker implantation and paravalvular leak negatively affected survival in patients treated for isolated aortic stenosis.(c) 2023 Elsevier Inc. All rights reserved

Cerebral Perfusion and Neuromonitoring during Complex Aortic Arch Surgery: A Narrative Review

: Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed

Minimally Invasive Aortic Valve Replacement with Sutureless Valves:Results From an International Prospective Registry

Objective: To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry. Methods: Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy (n = 266) or ministernotomy (n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients. Results: Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%. Conclusions: In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up

Perceval valve intermediate outcomes: a systematic review and meta-analysis at 5-year follow-up

ObjectivesNew technologies for the treatment of Aortic Stenosis are evolving to minimize risk and treat an increasingly comorbid population. The Sutureless Perceval Valve is one such alternative. Whilst short-term data is promising, limited mid-term outcomes exist, until now. This is the first systematic review and meta-analysis to evaluate mid-term outcomes in the Perceval Valve in isolation.MethodsA systematic literature review of 5 databases was performed. Articles included evaluated echocardiographic and mortality outcomes beyond 5 years in patients who had undergone Perceval Valve AVR. Two reviewers extracted and reviewed the articles. Weighted estimates were performed for all post-operative and mid-term data. Aggregated Kaplan Meier curves were reconstructed from digitised images to evaluate long-term survival.ResultsSeven observational studies were identified, with a total number of 3196 patients analysed. 30-day mortality was 2.5%. Aggregated survival at 1, 2, 3, 4 and 5 years was 93.4%, 89.4%, 84.9%, 82% and 79.5% respectively. Permanent pacemaker implantation (7.9%), severe paravalvular leak (1.6%), structural valve deterioration (1.5%), stroke (4.4%), endocarditis (1.6%) and valve explant (2.3%) were acceptable at up to mid-term follow up. Haemodynamics were also acceptable at up mid-term with mean-valve gradient (range 9-13.6 mmHg), peak-valve gradient (17.8-22.3 mmHg) and effective orifice area (1.5-1.8 cm(2)) across all valve sizes. Cardiopulmonary bypass (78 min) and Aortic cross clamp times (52 min) were also favourable.ConclusionTo our knowledge, this represents the first meta-analysis to date evaluating mid-term outcomes in the Perceval Valve in isolation and demonstrates good 5-year mortality, haemodynamic and morbidity outcomes.Key questionWhat are the mid-term outcomes at up to 5 years follow up in Perceval Valve Aortic Valve Replacement?Key findingsPerceval Valve AVR achieves 80% freedom from mortality at 5 years with low valve gradients and minimal morbidity.Key outcomesPerceval Valve Aortic Valve Replacement has acceptable mid-term mortality, durability and haemodynamic outcomes

Sutureless and Rapid Deployment vs. Transcatheter Valves for Aortic Stenosis in Low-Risk Patients: Mid-Term Results

Background: Recent trials showed that TAVI is neither inferior nor superior to surgical aortic valve replacement. The aim of this study was to evaluate the outcomes of Sutureless and Rapid Deployment Valves (SuRD-AVR) when compared to TAVI in low surgical risk patients with isolated aortic stenosis. Methods: Data from five European Centers were retrospectively collected. We included 1306 consecutive patients at low surgical risk (EUROSCORE II = 2 (PVL) were higher in the TAVI group. Multivariate Cox Regression analysis identified PPI as an independent predictor for mortality. Conclusions: TAVI patients had a significantly lower five-year survival and survival freedom from MACCEs with a higher rate of PPI and PVL >= 2 when compared to SuRD-AVR