Decision-making in aortic root surgery in Marfan syndrome: bleeding, thromboembolism and risk of reintervention after valve-sparing or mechanical aortic root replacement†

OBJECTIVES Valve-sparing root replacement (VSRR) is thought to reduce the rate of thromboembolic and bleeding events compared with aortic root replacement using a mechanical aortic root replacement (MRR) with a composite graft by avoiding oral anticoagulation. But as VSRR carries a certain risk for subsequent reinterventions, decision-making in the individual patient can be challenging. METHODS Of 100 Marfan syndrome (MFS) patients who underwent 169 aortic surgeries and were followed at our institution since 1995, 59 consecutive patients without a history of dissection or prior aortic surgery underwent elective VSRR or MRR and were retrospectively analysed. RESULTS VSRR was performed in 29 (David n = 24, Yacoub n = 5) and MRR in 30 patients. The mean age was 33 ± 15 years. The mean follow-up after VSRR was 6.5 ± 4 years (180 patient-years) compared with 8.8 ± 9 years (274 patient-years) after MRR. Reoperation rates after root remodelling (Yacoub) were significantly higher than after the reimplantation (David) procedure (60 vs 4.2%, P = 0.01). The need for reinterventions after the reimplantation procedure (0.8% per patient-year) was not significantly higher than after MRR (P = 0.44) but follow-up after VSRR was significantly shorter (P = 0.03). There was neither significant morbidity nor mortality associated with root reoperations. There were no neurological events after VSRR compared with four stroke/intracranial bleeding events in the MRR group (log-rank, P = 0.11), translating into an event rate of 1.46% per patient-year following MRR. CONCLUSION The calculated annual failure rate after VSRR using the reimplantation technique was lower than the annual risk for thromboembolic or bleeding events. Since the perioperative risk of reinterventions following VSRR is low, patients might benefit from VSRR even if redo surgery may become necessary during follow-u

Surgical antegrade transcatheter mitral valve implantation for symptomatic mitral valve disease and heavily calcified annulus.

Surgical techniques for the treatment of mitral valve disease (MVD) have continuously evolved; however, anatomical details like severe annular calcification remain challenging and require sophisticated surgical strategies. Among patients with symptomatic MVD referred for surgical valve repair or replacement, four presented with circumferential calcification of the mitral annulus precluding conventional surgical techniques. Successful treatment by implanting a balloon-expandable transcatheter aortic heart valve using an antegrade surgical access was performed. The perioperative course and follow-up assessment (19.3 ± 21 months) were uneventful. Echocardiographic assessment confirmed a well-seated valve with normal function (mean 4.5 ± 0.6 mmHg). Surgical mitral valve replacement using a balloon-expandable transcatheter aortic bioprosthesis can be a valuable and attractive bailout strategy in patients with a heavily calcified mitral annulus

Decision-making in aortic root surgery in Marfan syndrome: bleeding, thromboembolism and risk of reintervention after valve-sparing or mechanical aortic root replacement

OBJECTIVES Valve-sparing root replacement (VSRR) is thought to reduce the rate of thromboembolic and bleeding events compared with aortic root replacement using a mechanical aortic root replacement (MRR) with a composite graft by avoiding oral anticoagulation. But as VSRR carries a certain risk for subsequent reinterventions, decision-making in the individual patient can be challenging. METHODS Of 100 Marfan syndrome (MFS) patients who underwent 169 aortic surgeries and were followed at our institution since 1995, 59 consecutive patients without a history of dissection or prior aortic surgery underwent elective VSRR or MRR and were retrospectively analysed. RESULTS VSRR was performed in 29 (David n = 24, Yacoub n = 5) and MRR in 30 patients. The mean age was 33 ± 15 years. The mean follow-up after VSRR was 6.5 ± 4 years (180 patient-years) compared with 8.8 ± 9 years (274 patient-years) after MRR. Reoperation rates after root remodelling (Yacoub) were significantly higher than after the reimplantation (David) procedure (60 vs 4.2%, P = 0.01). The need for reinterventions after the reimplantation procedure (0.8% per patient-year) was not significantly higher than after MRR (P = 0.44) but follow-up after VSRR was significantly shorter (P = 0.03). There was neither significant morbidity nor mortality associated with root reoperations. There were no neurological events after VSRR compared with four stroke/intracranial bleeding events in the MRR group (log-rank, P = 0.11), translating into an event rate of 1.46% per patient-year following MRR. CONCLUSION The calculated annual failure rate after VSRR using the reimplantation technique was lower than the annual risk for thromboembolic or bleeding events. Since the perioperative risk of reinterventions following VSRR is low, patients might benefit from VSRR even if redo surgery may become necessary during follow-up

Validation of 3D-reconstructed computed tomography images using OsiriX® software for pre-transcatheter aortic valve implantation aortic annulus sizing

Abstract OBJECTIVES We report validation of OsiriX® —an image processing freeware—to measure multi-slice computed tomography-derived annulus diameters for preprocedural transcatheter aortic valve implantation planning. METHODS A total of 137 patients (82 ± 6.5 years, 42.3% male, logistic EuroSCORE 24.1 ± 14.2%) with severe aortic stenosis at high surgical risk underwent transcatheter aortic valve implantation assessment: transoesophageal echocardiography, angiography and multi-slice computed tomography. Retrospectively, 3D multi-slice computed tomography reconstructions were generated using OsiriX and the reliability evaluated regarding inter- and intraobserver variability, intermodality correlation and estimation of the clinical impact on transcatheter aortic valve implantation sizing. RESULTS Reliability of the novel OsiriX software was high with an interobserver mean difference of 0.6 ± 1.4 mm and intraclass correlation of absolute agreement of 0.84 (95% confidence interval 0.74-0.90). The intermodality accuracy between OsiriX measurements and conventional 2D computed tomography reconstructions, transoesophageal echocardiography and angiography revealed significantly larger sizing with OsiriX, with a mean difference to 2D computed tomography of 0.4 ± 2.2 mm, which would have changed valve sizing in 38% of patients. In 28%, a larger size would have been chosen, and this correlated highly with the occurrence of postoperative severe aortic regurgitation (P < 0.001). CONCLUSIONS While OsiriX measurements are an accurate and reproducible assessment of the aortic annulus, there are distinct and clinically relevant differences in aortic annulus dimensions between OsiriX measurements and previously standard imaging modalities. Sizing with OsiriX resulted in a larger perimeter compared with conventional 2D imaging. Careful assessment of valve size will take into account multiple imaging modalities

Validation of 3D-reconstructed computed tomography images using OsiriX® software for pre-transcatheter aortic valve implantation aortic annulus sizing

We report validation of OsiriX -an image processing freeware-to measure multi-slice computed tomography-derived annulus diameters for preprocedural transcatheter aortic valve implantation planning

The fate of nonaortic arterial segments in Marfan patients.

OBJECTIVES The aim of this study was to investigate the fate of nonaortic arterial segments in patients with Marfan syndrome (MFS). METHODS This was a retrospective analysis of 100 consecutive patients with MFS fulfilling Ghent criteria who underwent 192 interventions on any segment of the arterial tree and were followed over the past 20 years. A review of the available imaging regarding 9 defined regions of interest of the carotid, innominate, subclavian, iliac, and femoral arteries was performed. RESULTS Mean follow-up interval was 11.6 ± 7.7 years. Of 600 measurements that were performed, 414 (69%) arterial segments showed dilatation above the upper range of normal. There were no significant sex differences. In 100 patients, 66 dissections in nonaortic arterial segments in 33 patients were identified. Nineteen patients with or without previous dissection underwent 34 interventions. Most interventions were performed on the iliac arteries (56%), followed by the subclavian arteries (21%), the intercostal arteries (9%), the carotid arteries (6%), the visceral arteries (6%), and the innominate artery (3%). Most iliac artery interventions (88%) were caused by dilatations due to previous dissections, whereas this was only the case in 17% of interventions on the subclavian arteries. CONCLUSIONS Most patients with MFS presented with at least 2 dilated nonaortic arterial segments. The current data suggest that 20% of MFS patients will need some form of intervention on nonaortic arterial segments 5 to 6 years after their first aortic intervention, referring to the first aortic dissection of the patient if the patient had a history of dissection. Routine long-term follow-up imaging should include the iliac arteries as well as the supra-aortic branches

Discharge Location and Outcomes after Transcatheter Aortic Valve Implantation.

The relationship between discharge location and outcomes after transcatheter aortic valve implantation (TAVI) is largely unknown. Thus, the objective of this study was to investigate the impact of discharge location on clinical outcomes after TAVI. Between August 2007 and December 2018, consecutive patients undergoing transfemoral TAVI at Bern University Hospital were grouped according to discharge location. Clinical adverse events were adjudicated according to VARC-2 endpoint definitions. Of 1,902 eligible patients, 520 (27.3%) were discharged home, 945 (49.7%) were discharged to a rehabilitation clinic and 437 (23.0%) were transferred to another institution. Compared with patients discharged to a rehabilitation facility or another institution, patients discharged home were younger (80.8±6.5 vs. 82.9±5.4 and 82.8±6.4 years), less likely female (37.3% vs. 59.7% and 54.2%) and at lower risk according to STS-PROM (4.5±3.0% vs. 5.5±3.8% and 6.6±4.4%). At 1 year follow-up, patients discharged home had similar rates of all-cause mortality (HRadj 0.82; 95%CI 0.54-1.24), cerebrovascular events (HRadj 1.04; 95%CI 0.52-2.08) and bleeding complications (HRadj 0.93; 95%CI 0.61-1.41) compared to patients discharged to a rehabilitation facility. Patients discharged home or to rehabilitation were at lower risk for death (HRadj 0.37; 95%CI 0.24-0.56 and HRadj 0.44; 95%CI 0.32-0.60) and bleeding (HRadj 0.48; 95%CI 0.30-0.76 and HRadj 0.66; 95%CI 0.45-0.96) during the first year after hospital discharge compared to patients transferred to another institution. In conclusion, discharge location is associated with outcomes after TAVI with patients discharged home or to a rehabilitation facility having better clinical outcomes than patients transferred to another institution. Clinical Trial Registration: https://www.clinicaltrials.gov. NCT01368250