Transcatheter and surgical treatment of the severe aortic valve stenosis in Hesperia Hospital Modena in the second decade of the twenty-first century

Scopo Confrontare il trattamento transcatetere (TAVI) balloon-expandable con il trattamento chirurgico di sostituzione valvolare aortica (AVR) della stenosi valvolare aortica severa (SVAS) nella pratica clinica real world. Materiali e metodi Nel decennio 2010-2020, 1486 pazienti con SVAS isolata sono stati sottoposti a AVR (n=1049) o TAVI balloon-expandable (n=437) presso Hesperia Hospital Modena. Sono stati analizzati la Mortality nell’intera popolazione e gli episodi di ricovero cardiovascolare nei 5 anni precedenti e durante il follow-up nella popolazione residente in Emilia Romagna (n=1196) al momento della procedura (AVR n=879, TAVI balloon-expandable n=317). Risultati La popolazione TAVI è risultata mediamente più anziana di quella AVR (età media 82.2 vs. 72.7 anni) e maggiormente gravata da comorbidità. L’In-hospital mortality è stata del 1.4% nella AVR e 2.1% nella TAVI (pNS). La sopravvivenza a 5 anni è stata del 85.74% nella AVR e del 59.45% nella TAVI, con la TAVI come fattore predittivo di All-cause mortality (HR 1.44 95%CI 1.14-1.82). La riospedalizzazione per Heart Failure a 5 anni è stata del 20.6% per AVR e 51.3% per TAVI, con dialisi preoperatoria (HR 5.67 95%CI 3.06-10.49) come principale fattore predittivo. Il tasso di All Stroke a 5 anni è stato del 3.7% nella AVR e del 7.5% nella TAVI, con fibrillazione atriale preoperatoria come principale fattore predittivo (HR 1.91 95%CI 1.06-3.45). Il tasso di angioplastica coronarica percutanea (PCI) a 5 anni è stato del 3.1% sia nella AVR che nella TAVI, con previous PCI come principale fattore predittivo (HR 4.86 95%CI 2.57-9.21). L’impianto di pacemaker a 30 giorni è stato del 2.9% nella AVR e 3.4% nella TAVI (pNS). Conclusioni Nella pratica clinica real-world 2010-2020 di un centro cardiochirurgico a medio volume, la TAVI balloon-expandable ha mostrato una eccellente performance a 30 giorni in confronto con la AVR, che invece ha evidenziato una migliore performance durante follow-up.Aim Compare the balloon-expandable transcatheter treatment (TAVI) with the surgical treatment [Aortic Valve Replacement (AVR)] for severe aortic valve stenosis (SAVS) in the real world clinical practice. Materials and Methods Between 2010-2020, 1486 consecutive patients with isolated SAVS underwent AVR (n=1049) o balloon-expandable TAVI (n=437) in Hesperia Hospital Modena. In-hospital and long-term mortality in the overall population as well as cardiovascular hospital admissions in the previous 5 years and during follow-up in patients living in Emilia Romagna when AVR (n=879) and balloon-expandable TAVI (n=317) were performed, were detected. Results TAVI population was older than AVR patients (mean age 82.2 vs. 72.7 years) and with more comorbidities. In-hospital mortality was 1.4% after AVR and 2.1% after TAVI (pNS). Five-year survival was 85.74% after AVR and 59.45% after TAVI, with TAVI as predictive factor of All-cause mortality (HR 1.44 95%CI 1.14-1.82). Five-year re-hospitalization due to Heart Failure was 20.6% after AVR and 51.3% after TAVI, with preoperative dialysis (HR 5.67 95%CI 3.06-10.49) as main predictive factor. Five-year All Stroke rate was 3.7% after AVR and 7.5% after TAVI, with preoperative atrial fibrillation as main predictive factor (HR 1.91 95%CI 1.06-3.45). Five-year Percutaneous Coronary Intervention (PCI) was 3.1% after both AVR and TAVI, with previous PCI as main predictive factor (HR 4.86 95%CI 2.57-9.21). Thirty-day pacemaker implantation rate was 2.9% after AVR and 3.4% after TAVI (pNS). Conclusions In the real world 2010-2020 clinical practice of a single medium volume cardiac center, the balloon-expandable TAVI showed an excellent 30-day performance in comparison to the AVR, which instead provided a better performance during the follow-up

Outcome after surgery for prosthetic valve endocarditis and the impact of preoperative treatment

ObjectivesThis study examined the outcomes of surgery for active prosthetic valve endocarditis in a recent decade, with special interest in preoperative treatment and predictors for early and late events.MethodsFrom 2000 to 2010, a cohort of 149 consecutive patients (mean age, 64 ± 13.9 years; 72% were male) underwent redo-surgery for prosthetic valve endocarditis and were reviewed regarding early (≤60 days) and late (>60 days) events (death, reinfection, reoperation). Kaplan–Meier survival curves and Cox regression analysis were used to investigate the impact of preoperative intervals and predictors for events, respectively.ResultsPreoperative status was critical (European System for Cardiac Operative Risk Evaluation >20%) in 121 patients (81.2%). Staphylococci were the most common infecting microorganisms (27.5%). The median interval between onset of symptoms and diagnosis and between diagnosis and operation was 2 days (interquartile range, 1-5) and 8 days (interquartile range, 2-23), respectively. Operative mortality (≤30 days) was 12.8%. Mean follow-up was 4 ± 2.9 years. In 53 patients, 47 early (24 deaths, 14 recurrences, 9 reoperations) and 22 late events (11 deaths, 9 recurrences, 2 reoperations) occurred. Overall and event-free survivals at 10 years were 75% ± 3.8% and 64% ± 4.0%, respectively. Freedom from recurrent infection and reoperation at 10 years were 81% ± 3.6% and 91% ± 2.6%, respectively. In multivariate Cox regression, mechanical circulatory support, prolongation between onset of symptoms and diagnosis more than 30 days, and preoperative presence of renal failure predicted early events, and double valve replacement predicted late events.ConclusionsCardiac and renal function, need for double valve replacement, and preoperative treatment predicted outcomes. A prolonged interval in which patients were left untreated while symptomatic, but not prolongation of preoperative antibiotic treatment, increased risk

Long-Term Outcomes of Conventional Aortic Valve Replacement in High-Risk Patients: Where Do We Stand?

Purpose: The introduction of transcatheter aortic valves has focused attention on the results of conventional aortic valve surgery in high-risk patients. The aim of the study was to evaluate 5-years outcomes in this category of patients in the current surgical era. Methods: This is an observational retrospective study of 581 high-risk patients undergoing aortic valve replacement from 2008 to 2013, with a mean logistic EuroSCORE of 26.6% ± 14.6%. Data were prospectively collected in a database of Emilia-Romagna region (Italy). Results: Overall 30-day mortality was 9.3%. Stroke rate was 1.5%. At 1-, 3-, and 5-years overall mortality was 18.2%, 30.4%, and 42.2%, cardiac death rate was 3.9%, 9.2%, and 12.9%, stroke rate 2.5%, 7.7%, and 10.2%, re-operation occurrence 0.2%, 0.9% and 1.3%, and new pacemaker implantation was 2.3%, 5.1% and 7.8%. At multivariate analysis, urgency, hemodynamic instability, LVEF ≤30%, NYHA III-IV, severe chronic obstructive pulmonary disease (COPD), extra-cardiac arteriopathy, cerebrovascular disease, and creatinine >2.0 mg/dL remained independent predictors of 5-year mortality. Conclusion: The results of the current study add weight to the evidence that traditional aortic valve replacement can be performed in high-risk patients with satisfactory 5-year mortality and morbidity. Our study may help to improve decision-making in this category of high-risk patients with aortic valve disease

Expert Consensus on Sizing and Positioning of SAPIEN 3/Ultra in Bicuspid Aortic Valves

Vàlvula aòrtica bicúspide; Talla del bicúspide; SAPIEN 3/UltraVálvula aórtica bicúspide; Talla del bicúspide; SAPIEN 3/UltraBicuspid aortic valve; Bicuspid sizing; SAPIEN 3/UltraSevere aortic stenosis patients with bicuspid anatomy have been excluded from the major transcatheter aortic valve replacement (TAVI) randomized clinical trials. As a result, there is no official recommendation on bicuspid TAVI. A panel of bicuspid experts was created to fill this gap. In this consensus statement, an algorithm is proposed to guide the choice of surgery or TAVI within this complex patient population, depending on aortic dilatation, age, surgical risk score, and anatomy. A step-by-step guide for sizing and positioning of the SAPIEN 3/Ultra TAVI bioprostheses is presented. Annular sizing remains the primary strategy in most bicuspid patients. However, some anatomies may require sizing at the supra-annular level, for which patients the panel recommends the circle method, a dedicated sizing and positioning approach for SAPIEN 3/Ultra. The consensus provides valuable pre-operative insights on the interactions between SAPIEN 3/Ultra and the bicuspid anatomy; understanding the valve–anatomy relationship is critical to avoid complications and to optimize outcomes for patients.The journal’s Rapid Service Fee was supported by Edwards Lifesciences

Gender differences in outcomes following isolated coronary artery bypass grafting: long-term results

Background: The main purpose of this study was to evaluate the impact of gender on outcomes after isolated coronary artery bypass grafting, in terms of 5-year rates of overall death, cardiac-related death, myocardial infarction, re-hospitalization, repeat percutaneous or surgical revascularization, stroke, new pacemaker implantation, postoperative renal failure, heart failure and need for long-term care. Methods: Two propensity-score matched cohorts, each of 1331 patients, undergoing isolated surgical coronary revascularization at the regional public and private centers of Emilia-Romagna region (Italy) from January 1st 2003 to December 31th 2013, were used to compare long-term outcomes of male (5976 patients) versus female gender (1332 patients). Results: In the matched cohort, males received significantly more bypass grafts (3.0 ± 1.0 vs 2.8 ± 1.0, p = 0.001). Left internal mammary artery use and total arterial revascularization were similarly performed in both matched subgroups. Both groups reported similar cumulative rate of all-cause, cardiac-related mortality and stroke at five years. Females experienced significantly higher rate of myocardial infarction, and not significantly higher occurrence of heart failure, and need for long-term care. Males experienced significantly higher rate of cumulative re-hospitalization and higher need for pacemaker implantation. Female gender was not an independent predictor of death at long-term follow-up. Conclusions: Women are more likely to be readmitted with myocardial infarction and congestive heart failure after CABG but experience survival similar to that observed in men. Female gender was not an independent risk factor for mortality. Prevention of new occurrence of postoperative myocardial infarction and enhancement of complete coronary revascularization should be future endpoints

Expert Consensus on Sizing and Positioning of SAPIEN 3/Ultra in Bicuspid Aortic Valves

Severe aortic stenosis patients with bicuspid anatomy have been excluded from the major transcatheter aortic valve replacement (TAVI) randomized clinical trials. As a result, there is no official recommendation on bicuspid TAVI. A panel of bicuspid experts was created to fill this gap. In this consensus statement, an algorithm is proposed to guide the choice of surgery or TAVI within this complex patient population, depending on aortic dilatation, age, surgical risk score, and anatomy. A step-by-step guide for sizing and positioning of the SAPIEN 3/Ultra TAVI bioprostheses is presented. Annular sizing remains the primary strategy in most bicuspid patients. However, some anatomies may require sizing at the supra-annular level, for which patients the panel recommends the circle method, a dedicated sizing and positioning approach for SAPIEN 3/Ultra. The consensus provides valuable pre-operative insights on the interactions between SAPIEN 3/Ultra and the bicuspid anatomy; understanding the valve-anatomy relationship is critical to avoid complications and to optimize outcomes for patients.Peer reviewe

Early and Midterm Clinical and Hemodynamic Outcomes of Transcatheter Valve-in-Valve Implantation: Results From a Multicenter Experience

BACKGROUND: Transcatheter valve-in-valve (VIV) implantation is an alternative option in inoperable or high-risk patients with prosthetic valve dysfunction. Aim of this retrospective multicenter study was to evaluate early and midterm clinical and hemodynamic outcomes of patients undergoing aortic (VIV-A) and mitral VIV (VIV-M). METHODS: We analyzed data of 66 procedures performed in 65 patients who underwent VIV procedures in the VIV-A and VIV-M position at 5 Italian institutions from January 2008 to May 2015. VIV-A and VIV-M were 44 (68%) and 22 (32%), respectively; 1 patient underwent combined mitroaortic VIV. Study devices were both balloon-expandable and self-expandable. Outcomes were defined according to the updated Valve Academic Research Consortium definitions. RESULTS: Overall all-cause 30-day mortality was 6% (4 patients), and it was 4.5% and 9% in VIV-A and VIV-M, respectively (2 patients in each group). Mean follow-up was 14 \ub1 14 months. Kaplan-Meier survival of the entire cohort at 1, 2, 3, and 4 years was 84.4% \ub1 4.9%, 80.5% \ub1 6%, 74.3 \ub1 8.1%, and 62% \ub1 13.2%, respectively. Age (hazard ratio: 1.1; 95% confidence interval: 1.0 to 1.3; p = 0.035) and diabetes (hazard ratio: 7.2, 95% confidence interval: 2.1 to 23.7; p = 0.001) were identified as independent predictors of mortality. Degenerated surgical aortic prostheses with an internal diameter (ID) less than 20 mm had significantly higher gradients if compared to prostheses with ID 21 to 23 mm and greater than 23 mm. After VIV-A, a severe stenosis (mean gradient greater than 35 mm Hg) was detected in 3 (6.8%) cases, all with ID less than 20 mm. CONCLUSIONS: VIV provides good early and midterm results in high-risk or inoperable patients with mitral or aortic bioprosthesis dysfunction. Age and diabetes are independently associated with mortality. Size of bioprosthesis ID has a significant impact on postoperative gradients

Outcomes of patients undergoing concomitant mitral and aortic valve surgery: results from an Italian regional cardiac surgery registry

OBJECTIVES: There are limited reliable data on the long-term survival of patients operated upon with double-valve surgery (DVS) in the lit-erature. In this study, in-hospital mortality and 5-year survival were determined and the potential risk factors for increased mortality were identified and discussed. METHODS: This is a report of an observational retrospective study of 1167 patients undergoing concomitant aortic and mitral valve surgery from 2002 to 2011. Data were prospectively collected in a regional database from Emilia-Romagna (Italy). RESULTS: The overall in-hospital mortality rate for DVS was 6.9%. Both in-hospital and 1-year mortality were statistically significant between age groups. In-hospital mortality was significantly higher for patients with a smaller body mass index (BMI), for those who had concomitant coronary artery bypass grafting (CABG) and those who received mitral valve replacement (MVR) instead of plasty (MVP). In-hospital and 1-year mortality were highest in patients ≥70 who had implantation of mitral and aortic mechanical valves. There were signifi