Transapical Valve Implantation and Resuscitation: Risk of Valve Destruction

In this article we illustrate our experience with the destruction of a transapically implanted aortic valve prosthesis due to postoperative cardiopulmonary resuscitation. The fact of the existing risk of the valve damage by chest compression during cardiopulmonary resuscitation should be taken into consideration when discussing the potential exposure of this technology to lower the risk for patients. Furthermore, we introduce a technique of less invasive cardiopulmonary resuscitation that offers the possibility of lowering the risk of compressing the valve. (Ann Thorac Surg 2011;92:1909-10) (C) 2011 by The Society of Thoracic Surgeon

Transapical Valve Implantation After David Operation and Stenting of the Descending Aorta

This case report illustrates our experience with transapical minimally invasive aortic valve implantation in a patient with an extended aneurysm of the thoracoab-dominal aorta, who had previously undergone a replacement of the ascending aorta with concomitant aortic valve reconstruction (David procedure). Endovascular stent grafting of the descending aorta was also performed. The implantation of a 23-mm SAPIEN valve (Edwards Lifesciences, Irvine, CA) did not interfere with the existing 26-mm aortic Hemashield prosthesis (Boston Scientific, Natick, MA) or the previously implanted endograft in the descending aortic position. No paravalvular leakage with aortic valve regurgitation, prosthesis instability, or coronary malperfusion was seen after valve implementation. (Ann Thorac Surg 2010;90:2035-7) (C) 2010 by The Society of Thoracic Surgeon

Impact of Pump Flow Rate During Selective Cerebral Perfusion on Cerebral Hemodynamics and Metabolism

Background. Although hypothermic selective cerebral perfusion (SCP) is widely used for cerebral protection during aortic surgery, little is known about the ideal pump-flow management during this procedure. This study explored cerebral hemodynamics and metabolism at two different flow rates. Methods. Fourteen pigs (33 to 38 kg) were cooled on cardiopulmonary bypass to 25 degrees C. After 10 minutes of hypothermic circulatory arrest, the animals were randomly assigned to 60 minutes of SCP at two different pump flow rates: 8 mL . kg(-1) . min(-1) (n = 7) and 18 mL . kg(-1) . min(-1) (n = 7). Microspheres were injected at baseline, coolest temperature, and at 5, 15, 25, and 60 minutes of SCP to calculate cerebral blood flow, cerebral vascular resistance, metabolic rate, and intracranial pressure. Results. Cerebral blood flow decreased during cooling to 41% of the baseline value (from 57 +/- 10 to 23 +/- 4 mL . min(-1) . 100 g(-1)). It recovered during the initial 15 minutes of SCP, showing a significantly higher increase (p = 0.017) at high-flow versus low-flow perfusion (139 +/- 41 versus 75 +/- 22 mL . min(-1) . 100 g(-1)). After 60 minutes of SCP the cerebral blood flow almost returned to baseline values in the low-flow group (43 +/- 25 mL . min(-1) . 100 g(-1)), but showed an unexpected decrease (30 +/- 7 mL . min(-1) . 100 g(-1)) in the high-flow group. The highest regional cerebral blood flow was seen in the cortex (66 +/- 12 mL . min(-1) . 100 g(-1)), followed by the cerebellum (63 +/- 12 mL . min(-1) . 100 g(-1)), the pons (51 +/- 17 mL . min(-1) . 100 g(-1)), and the hippocampus (36 +/- 9 mL . min(-1) . 100 g(-1)). Intracranial pressure increased from 11 +/- 3 to 13 +/- 5 mm Hg during cooling on cardiopulmonary bypass. During low-flow SCP, it stayed stable at baseline values, whereas high-flow perfusion resulted in significantly higher intracranial pressures (17 +/- 3 mm Hg; p = 0.001). Changes in cerebral vascular resistance and metabolic rate showed no significant differences between the groups. Conclusions. High-flow SCP provides no benefit during long-term SCP at 25 degrees C. Higher cerebral blood flow during the initial SCP period leads to cerebral edema, with no profit in metabolic rate. (Ann Thorac Surg 2010;90:1975-84) (C) 2010 by The Society of Thoracic Surgeon

Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients

The aim of this retrospective study was to assess pre- and intraoperative factors leading to neurological complications and early death following repair of acute type A aortic dissection (ATAAD). There were 122 patients (85 male, age: 58.6 +/- 12.5 years) with ATAAD, treated consecutively from August 2003 to August 2010. Pre- and intraoperative variables were analysed using a logistic regression model in order to identify risk factors for temporary neurological dysfunction (TND) and adverse outcome (AO), defined as stroke and 30-day mortality. The 30-day mortality rate was 16.4%. Forty-one patients (33.6%) suffered transient neurological dysfunction and 20 (16.4%) had a postoperative stroke. Mean hypothermic circulatory arrest (HCA) temperature was 24 +/- 4 degrees C. Selective cerebral perfusion (SCP) was performed in 99 (82%) patients, with a mean SCP flow rate of 10.3 ml/kg/min. The duration of lower body ischaemia (LBI) was 36 +/- 27 min, of HCA 8.7 +/- 15.5 min and of SCP 34 +/- 28 min, respectively. Male gender [odds ratio (OR): 3.30, 95% confidence interval (CI): 1.15-9.47], diabetes (OR: 3.95, 95% CI: 1.18-13.24), compromised consciousness (OR: 6.65, 95% CI: 1.41-31.48) and manifest arterial atherosclerosis (OR: 6.68, 95% CI: 1.31-34.09) were detected as risk factors for TND, whereas a high body mass index (OR: 1.14, 95% CI: 1.01-1.3), a preoperative malperfusion syndrome (OR: 2.28, 95% CI: 0.84-6.18) and left ventricular ejection fraction < 50% (OR: 3.84, 95% CI: 1.41-10.43) were detected as independent predictors for an AO. A dissection entry localized in the aortic arch or the descending aorta independently increased the risk for a postoperative stroke. A prolonged LBI increased the risk for AO (OR: 1.02, 95% CI: 1.00-1.04), whereas femoral cannulation showed a trend to an increased stroke incidence (OR: 4.2, 95% CI: 0.8-21.3). Regardless of standardized neuroprotective techniques, treatment of ATAAD remains a high-risk operation. Preoperatively, the presence of a reduced ejection fraction, a malperfusion syndrome or a high body mass index may increase the perioperative risk for an adverse outcome. A dissection 'entry' localized in the aortic arch or the descending aorta may increase the risk for postoperative stroke. Intraoperatively, cannulation of the femoral artery and extension of the LBI time over 45 min should be avoided. Especially in patients with manifest preoperative cerebral and/or end-organ malperfusion, the cannulation modality as well as the entire neuroprotective management should be chosen individually, respecting its limitations

Transapical Aortic Valve Implantation: Experiences and Survival Analysis up to Three Years

Background: We determined our 30-day results after transapical aortic valve implantation (TA-AVI) according to Valve Academic Research Consortium criteria, analyzed midterm outcome, and summarize our institutional learning experience. Methods: From February 2008 to July 2011, 150 high-risk patients underwent TA-AVI. Endpoints of this retrospective analysis were safety as indicated by morbidity and 30-day mortality and midterm survival with a follow-up period up to 3.4 years (mean follow-up 14.1 months). In addition we analyzed our institutional learning curve by comparing the outcome of our first 50 patients (group 1) to the following 100 patients (group 2). Results: Procedural success was 98% (147 patients). All-cause and cardiovascular cause 30-day mortality was 11.3% (n = 17) and 7.3% (n = 11), respectively. The cumulative survival rates were 78.7% at one year, 62.8% at two years, and 50.8% at three years. As compared to group 1, there was a significantly reduced incidence of relevant bleeding complications (0% vs. 14%[n = 7]; p < 0.001) and a reduced incidence of acute kidney injury (35%[n = 35] versus 56% (n = 28); p < 0.05) in group 2, resulting in a combined safety endpoint at 30 days of 22% in group 2 versus 40% in group 1 (p < 0.05). One-year mortality (group 2, n = 20 [20%] versus group 1, n = 10 [20%]; p = 1) and midterm survival (p = 0.998; Hazard ratio 1.001; 95% CI 0.5141 to 1.949) did not differ significantly. Conclusions: Although the incidence of technical complications decreased significantly over time, 30-day and midterm mortality were unaltered, most likely due to patients' comorbidities. The development of more accurate risk scores may improve future outcome. (J Card Surg 2012;27:653-661

Real-world 6-month outcomes of minimally invasive aortic valve replacement with the EDWARDS INTUITY Elite valve system

Objectives: We report on real-world safety and performance outcomes of minimally invasive rapid-deployment aortic valve replacement using the EDWARDS INTUITY Elite aortic valve system. Methods: The study valve system was used in a European, prospective, multicentre post-market study. Various procedural, haemodynamic and clinical outcomes were evaluated through 6 months of post-implant. Results: A total of 276 patients out of 280 (98.6%) enrolments were successfully implanted with the study valve using a minimally invasive approach between February 2016 and April 2017. Of these 276 patients, 240 (87%) underwent partial sternotomy and 36 (13%) patients underwent right thoracotomy. Mean cross-clamp time was 51.9 [standard deviation (SD): 16.0] min. From baseline to 6 months, the mean effective orifice area increased from 0.8 (SD: 0.3) to 1.8 (SD: 0.6) cm2 and the mean systolic gradient decreased from 46.0 (SD: 14.1) to 8.8 (SD: 3.7) mmHg. After 6 months, 70.7% and 26.4% of patients were in New York Heart Association class I and II, respectively. Freedom from death, major bleeding, major paravalvular leak, reoperation and device explant at 6 months were 96.0%, 98.5%, 98.8%, 99.2% and 99.2%, respectively. Conclusions: These results demonstrate that the study valve is a safe and effective choice for patients undergoing aortic valve replacement via minimally invasive surgery. Name and registration of registry: MISSION (Assessing clinical outcomes using the EDWARDS INTUITY Elite Valve System in isolated AVR using Minimally InvaSive Surgery In a EurOpean multi-ceNter, active, post-market registry). clinicaltrials.gov ID #NCT02907463