Operative management after transcatheter aortic valve replacement

With broadening applications of transcatheter aortic valve replacement (TAVR) and increasing use in intermediate- and low-risk patients, the incidence of surgical re-interventions after TAVR is growing. Transcatheter heart valves suffer from similar long-term complications as surgical heart valve prostheses that require surgical re-intervention, including endocarditis and structural valve deterioration. Catastrophic periprocedural complications — such as annular or aortic rupture requiring urgent surgical intervention — may also occur during TAVR procedures. This review summarizes the current knowledge on indications, methods, and outcomes of cardiac operations after TAVR, with a focus on how to improve results in a rapidly growing patient population

Nutritional status in tricuspid regurgitation: implications of transcatheter repair

Aims To characterize the prevalence and clinical relevance of malnutrition in patients undergoing transcatheter tricuspid valve edge-to-edge repair (TTVR). Methods and results Overall, 86 consecutive patients (mean age 78 ± 7 years) with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk were analysed. Mini Nutritional Assessment (MNA), quality of life assessment, 6-min walk test distance and laboratory analyses were performed before and 1 month after TTVR. A total of 43 patients (50%) underwent concomitant transcatheter mitral valve repair. According to MNA, 81 patients (94%) were malnourished or at risk of malnutrition before TTVR. Following TTVR, MNA improved in 64 patients (74%). As compared to patients without MNA improvement, patients with increased MNA score had greater reductions in TR [regurgitation volume −17.0 (interquartile range, IQR −25.0; −7.0) mL vs. −26.4 (IQR −40.3; −14.5) mL, P < 0.001] and inferior vena cava diameter. Only patients with increased MNA score displayed a decrease in N-terminal pro-brain natriuretic peptide levels [−320 (IQR −1294; 105) pg/mL vs. +708 (IQR −342; 2708) pg/mL, P = 0.009], improvements in cholinesterase levels (0.0 ± 11.9 μmoL/L vs. +10.9 ± 16.7 μmoL/L, P < 0.001) and renal function during follow-up. Beneficial effects on quality of life scores and 6-min walk test distance following TTVR were observed exclusively in patients with improvement in MNA. During a median follow-up of 6 months, patients with worsened MNA had an increased risk of death and rehospitalization for heart failure. Conclusion Nutritional impairment is common and of prognostic importance in patients undergoing TTVR. Hepatorenal function modestly improves after successful TTVR. Further study of extracardiac implications of TR-associated right heart failure is warranted to improve care in this vulnerable patient population

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-Out Significant Coronary Artery Disease

Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD. Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 mL iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay. Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B. Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster

10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease

BACKGROUND The optimal revascularization strategy for the elderly with complex coronary artery disease remains unclear. OBJECTIVES The goal of this study was to investigate 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year quality of life (QOL) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in elderly individuals (>70 years old) with 3-vessel disease (3VD) and/or left main disease (LMD). METHODS In the present pre-specified analysis on age of the SYNTAX Extended Survival study, 10-year all-cause death and 5-year MACCE were compared with Kaplan-Meier estimates and Cox proportional hazards models among elderly or nonelderly patients. Life expectancy was estimated by restricted mean survival time within 10 years, and QOL status according to the Seattle Angina Questionnaire up to 5 years was assessed by linear mixed-effects models. RESULTS Among 1,800 randomized patients, 575 patients (31.9%) were elderly. Ten-year mortality did not differ significantly between PCI and CABG in elderly (44.1% vs. 41.1%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40) and nonelderly patients (21.1% vs. 16.6%; HR: 1.30; 95% CI: 1.00 to 1.69; p(interaction) = 0.332). Among elderly patients, 5-year MACCE was comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56), whereas it was significantly higher in PCI over CABG among nonelderly patients (36.3% vs. 23.0%; HR: 1.69; 95% CI: 1.36 to 2.10; p(interaction) = 0.043). There were no significant difference in life expectancy (mean difference: 0.2 years in favor of CABG; 95% CI: -0.4 to 0.7) and 5-year QOL status between PCI and CABG among elderly patients. CONCLUSIONS Elderly patients with 3VD and/or LMD had comparable 10-year all-cause death, life expectancy, 5-year MACCE, and 5-year QOL status irrespective of revascularization mode. (C) 2021 by the American College of Cardiology Foundation

European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria

Correction: Volume16 Issue1 Article Number225 DOI10.1186/s13019-021-01606-8Background: Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient's conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. Methods: Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient's comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion: The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD.Peer reviewe

Transapical mitral valve implantation for treatment of symptomatic mitral valve disease: a real-world multicentre experience.

AIMS Transcatheter mitral valve implantation (TMVI) is a new treatment option for patients with symptomatic mitral valve (MV) disease. Real-world data have not yet been reported. This study aimed to assess procedural and 30-day outcomes of TMVI in a real-world patient cohort. METHOD AND RESULTS All consecutive patients undergoing implantation of a transapically delivered self-expanding valve at 26 European centres from January 2020 to April 2021 were included in this retrospective observational registry. Among 108 surgical high-risk patients included (43% female, mean age 75 ± 7 years, mean STS-PROM 7.2 ± 5.3%), 25% was treated for an off-label indication (e.g. previous MV intervention or surgery, mitral stenosis, mitral annular calcification). Patients were highly symptomatic (New York Heart Association [NYHA] functional class III/IV in 86%) and mitral regurgitation (MR) was graded 3+/4+ in 95% (38% primary, 37% secondary, and 25% mixed aetiology). Technical success rate was 96%, and MR reduction to ≤1+ was achieved in all patients with successful implantation. There were two procedural deaths and 30-day all-cause mortality was 12%. At early clinical follow-up, MR reduction was sustained and there were significant reductions of pulmonary pressure (systolic pulmonary artery pressure 52 vs. 42 mmHg, p < 0.001), and tricuspid regurgitation severity (p = 0.013). Heart failure symptoms improved significantly (73% in NYHA class I/II, p < 0.001). Procedural success rate according to MVARC criteria was 80% and was not different in patients treated for an off-label indication (74% vs. 81% for off- vs. on-label, p = 0.41). CONCLUSION In a real-world patient population, TMVI has a high technical and procedural success rate with efficient and durable MR reduction and symptomatic improvement

Rapid fuid shifts along the body axis during simulated and real short term microgravity

Motivation: Simulierte und reale Mikrogravitation führen beim Menschen infolge der Änderung des hydrostatischen Drucks zu einer kopfwärts gerichteten axialen Flüssigkeitsverschiebung. Die Flüssigkeitsverschiebung wurde während ultrakurzzeitigen Kipptischversuchen und Parabelflügen untersucht (t ≤ 25 s). Methoden: Es wurden die Änderungen der Gewebeschichtdicken der Haut mit A- und B-Mode-Sonographie (Gesamthautschichtdicke HSD, Schichtdicke Dermis SDD, Schichtdicke Subkutis SDS) und der mikrovaskulären Durchblutung der Haut (relative Hämoglobinmenge rHb, relativer Blutfluss rBF, relative Blutflussgeschwindigkeit rBFG, postkapilläre Sauerstoffsättigung SpO2) an der tempolateralen Stirn rechts und der medialen Seite der Tibia rechts bestimmt. Zwischen 2005 und 2008 nahmen 39 gesunde Probanden an einer 3-teiligen Studie teil. Im ersten Teil, der Kipptischstudie, nahmen 12 Probanden teil (7 Männlich, 5 Weiblich). Gewebeschichtdicken der Haut wurden in 65°-Kopfhochlage, in -6°-Kopftieflage und in 65°-Kopfhochlage. Im zweiten Teil, der ersten Parabelflugstudie, nahmen 13 Probanden teil (10 Männlich, 3 Weiblich). Gewebeschichtdicken wurden in Hyper-, Mikro- und erneuter Hypergravitation bestimmt. In der letzten Phase, der zweiten Parabelflugstudie, nahmen 14 Probanden teil (7 Männlich, 7 Weiblich). Die mikrovaskuläre Durchblutung wurde in Normalgravitation vor der Flugparabel, in hg, in μg und erneuter hg erfasst. Die Messungen der Normalwerte erfolgten in 0°-Horizontallage jeweils vor und nach den Versuchen (P_prae, P_post), mit Ausnahme der Mikrozirkulation, welche im Stehen erfolgte. Die Dauer t der wechselnden Kipptisch- und Gravitationsphasen waren t ≤ 25 s. Ergebnisse: Während der Kopftieflage konnten keine Änderungen der HSD gefunden werden. Die SDD nahm um 5,6 % signifikant zu. Während des Parabelfluges zeigten sich in μg an der Stirn Zunahmen der HSD (5,3 – 16,2 %; p ≤ 0,05), SDD (5,6 %; p ≥ 0,05), rHb (20,1 %, p ≤ 0,05), rBF (4,2 %; p ≥ 0,05) und rBFG (3,3 %; p ≥ 0,05). An der Tibia zeigten sich Abnahmen der HSD (10,0 – 13,5 %; p ≥ 0,05), SDD (18,2 %; p ≥ 0,05), rHb (14,5 %; p ≤ 0,05) und rBF (24,2 %; p ≥ 0,05) sowie Anstieg der rBFG (14,3 %, p ≥ 0,05). Die SpO2 zeigte keine relevanten Änderungen. Schlussfolgerungen: Änderungen der HSD und mikrovaskulären Durchblutung der Haut konnten nur während des Parabelfluges in Tendenzen abgebildet und signifikanten Unterschieden nachgewiesen werden. Die Ergebnisse belegen eine kopfwärts gerichtete Flüssigkeitsumverteilung während ultrakurzzeitiger realer Mikrogravitation. Das Kipptischmodel ist nur bedingt zur Simulation von ultrakurzzeitigen Flüssigkeitsverschiebungen geeignet. Die Gewebe- Photospektrometrie eignet sich zur Quantifizierung schneller Flüssigkeitsverschiebungen. Die A-Mode- und B-Mode-Sonographie sind aus versuchstechnischen Gründen nur bedingt in Mikrogravitation einsetzbar. Alle erfassten Messwerte spiegeln nur Tendenzen wieder, welche aber die Hypothese im Ansatz bestätigen können. Signifikante Unterschiede konnten nur in wenigen Fällen nachgewiesen werden. Bezüglich der Methode ist darauf zu verweisen, dass die vorliegende Studie mit der Untersuchung von 39 Probanden eine der umfangreichsten Studien zur Flüssigkeitsverschiebung in simulierter und realer Mikrogravitation in der Weltraummedizin darstellt.The present studie shows the effect of rapid fluid shifts along the body axis through an increase in tissue thickness on the forehead and decrease on the shinbone in real and simulated microgravity. This effects are based on the cardiovascular adaptation in microgravity. In addition the investigation of the tissue thickness will be help to understand the mechanism of the heat emission of the head in microgravity