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Background and Objectives : Sutureless aortic valve prostheses have presented favorable hemodynamic performance while facilitating minimally invasive access approaches. As the population ages, the number of patients at risk for aortic valve reoperation constantly increases. The aim of the present study is to present our single-center experience in sutureless aortic valve replacement (SU-AVR) in reoperations. Materials and Methods : The data of 18 consecutive patients who underwent SU-AVR in a reoperation between May 2020 and January 2023 were retrospectively analyzed. Results : The mean age of the patients was 67.9 ± 11.1 years; patients showed a moderate-risk profile with a median logistic EuroSCORE II of 7.8 (IQR of 3.8-32.0) %. The implantation of the Perceval S prosthesis was technically successful in all patients. The mean cardiopulmonary bypass time was 103.3 ± 50.0 min, and the cross-clamp time was 69.1 ± 38.8 min. No patients required a permanent pacemaker implantation. The postoperative gradient was 7.3 ± 2.4 mmHg, and no cases of paravalvular leakage were observed. There was one case of intraprocedural death, while the thirty-day mortality was 11%. Conclusions : Sutureless bioprosthetic valves tend to simplify the surgical procedure of a redo AVR. By maximizing the effective orifice area, sutureless valves may present an important advantage, being a safe and effective alternative not only to traditional surgical prostheses but also to transcatheter valve-in-valve approaches in select cases.

Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to redo surgical mitral valve replacement (SMVR) in patients with degenerated mitral prostheses, with limited comparative data., Methods: We compared mid-term outcomes in patients with degenerated mitral valve prostheses treated with TMVR or redo SMVR. The primary endpoint was survival at 5 years of follow-up., Results: From 2014 to 2020, 215 patients presented with degenerated mitral valve prostheses. Of whom 86 (40%) were treated with TMVR (75[87%] valve-in-valve and 11[13%] valve-in-ring), while 129 patients (60%) underwent SMVR. The TMVR cohort was older (p < 0.0001), more symptomatic (p = 0.0003) and had more chronic lung disease (p = 0.02), worse renal function (p = 0.02) and higher right ventricular systolic pressures (p < 0.0001). Thirty-day mortality was lower with TMVR versus SMVR (2.4% vs. 10.2%, OR4.69 [95% CI 1.25-30.5], p = 0.04) with probability of mortality at 1, 2, and 5 years being 14.7% versus 17.5%, 24.5% versus 20.7%, and 49.9% versus 34.0%, respectively. Mode of prosthesis degeneration, baseline hemodynamics, and valve selection did not appreciably impact outcomes., Conclusions: TMVR for degenerated mitral prostheses is associated with better early survival compared to SMVR despite a greater burden of comorbidities. In contrast, 5 year survival rates appear more favorable with SMVR, which may reflect the lower baseline risk of this population. Clinical, hemodynamic, and echocardiographic follow-up support the mid-term durability of TMVR for degenerated mitral prostheses. Further dedicated studies, however, are required to optimize outcomes in this challenging patient cohort and to navigate the choice of approach for each individual patient., (© 2022 Wiley Periodicals LLC.)

Background: We have entered an era of renewed interest in novel approaches to surgical intervention and minimally invasive and transcatheter technique. With an aging population, isolated tricuspid valve regurgitation incidence is rising; however, referral for surgical intervention remains low., Aims: We undertook this retrospective review to assess outcomes and challenges associated with tricuspid valve intervention., Methods: A comprehensive retrospective review of all patients undergoing tricuspid valve intervention in our institution between 2004 and 2018 was carried out., Results: A total of 259 patients who underwent a tricuspid intervention between 2004 and 2018 were identified. Of those, 229 underwent a repair and 30 underwent a replacement. Median survival for repair was 3124 days, and replacement was 2294 days. In-patient mortality was 12% for those undergoing repair and 7% for the replacement patients. Of those undergoing redo tricuspid valve intervention, eight patients (61.5%) were alive at most recent follow-up. Eight patients required intraoperative pacemakers, 2 required postoperative pacemakers. Of those who had intraoperative epicardial pacing systems placed, 5 of the 8 remained pacing dependent on most recent follow up., Conclusion: Beyond technical challenges, decision making regarding pacemaker requirement requires further exploration. Redo tricuspid valve surgery carries a significant mortality risk and consideration should be given to earlier intervention in this context., (© 2021. Royal Academy of Medicine in Ireland.)

Background: The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and low rates of valve-related complications and prosthesis-patient mismatch. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable with Perimount valves, with a few recent studies bringing into focus early structural valve deterioration (SVD), and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared with Perimount., Methods: The Maritime Heart Centre Database was searched for AVR between 2011 and 2016, inclusive. The primary endpoint of the study was all-cause reoperation rate., Results: In total, 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99; p = .02), female (vs. male): 0.35 (0.08-1.53; p = .16), smoker (vs. nonsmoker): 2.44 (0.85-7.02; p = .1), and Trifecta (vs. Perimount): 2.68 (0.97-7.39; p = .06). Kaplan-Meier survival analysis in subgroups-age <60, age ≥60, male, female, smoker, and nonsmoker-showed Perimount having lower reoperation rates than Trifecta in patients younger than 60 (p = .02) and current smokers (p < .01)., Conclusions: The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow-up, are needed to confirm these findings., (© 2020 Wiley Periodicals LLC.)

Background: Redo isolated tricuspid valve surgery is associated with a high morbidity and mortality, and its optimal timing remains controversial. Hence, here we reviewed the early and midterm results of simplified, minimally invasive, beating-heart technique for redo isolated tricuspid valve surgery in patients at high risk., Methods: A total of 32 consecutive patients underwent a redo isolated tricuspid valve surgery using minimally invasive, beating-heart technique through a right lateral thoracotomy in our center between June 2016 and April 2020. The mean age of patients was 57.4 ± 8.3 years, and 18 patients (56.3%) were women. The mean preoperative EuroSCORE was 7.8 ± 1.4 (range: 6-11). Follow-up was 87.1% complete, with a mean duration of 26.3 ± 12.3 months., Results: Both in-hospital and 30-day mortalities were 3.1%. Tricuspid valve replacement with bioprosthesis was performed in 30 patients (93.8%), and the remaining two patients (6.2%) underwent tricuspid repair (annuloplasty and leaflet reconstruction). The mean cardiopulmonary bypass time was 81.5 ± 29.0 min. The overall in-hospital duration and intensive care unit (ICU) times were 13.6 ± 7.6 days and 4.1 ± 2.8 days, respectively. Postoperative complications included prolonged ventilation in six patients (18.8%), acute kidney injury in three patients (9.4%), and neurologic event, wound infection, or permanent third-degree atrioventricular block, in one patient (3.1%) each. A total of 96.9% patients were discharged uneventfully. Four patients were lost to follow-up; there were no midterm deaths in patients who were followed up., Conclusions: Simplified, minimally invasive, beating-heart technique for redo tricuspid valve surgery is both feasible and safe, and the early and midterm results are excellent.

Objectives: There are minimal data regarding clinical outcomes and echocardiographic findings after transcatheter mitral valve-in-valve replacement (TMVR) compared with redo surgical mitral valve replacement (SMVR)., Background: TMVR therapy has emerged as therapy for a degenerated bioprosthetic valve failure., Methods: The authors retrospectively identified patients with degenerated mitral bioprostheses who underwent redo SMVR or TMVR at 3 U.S. institutions. The authors compared clinical and echocardiographic outcomes of patients who had TMVR with those of patients who underwent redo SMVR., Results: Sixty-two patients underwent TMVR and 59 patients underwent SMVR during the study period. Mean age and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) scores were significantly higher in patients with TMVR than in those with SMVR (age 74.9 ± 9.4 years vs. 63.7 ± 14.9 years; p < 0.001; STS PROM 12.7 ± 8.0% vs. 8.7 ± 10.1%; p < 0.0001). Total procedure time, intensive care unit hours, and post-procedure length of stay were all significantly shorter in the TMVR group. There was no difference in mortality at 1 year between the 2 groups (TMVR 11.3% vs. SMVR 11.9%; p = 0.92). Mean mitral valve pressure gradient and the grade of mitral regurgitation (MR) were similar between the TMVR group and the SMVR group (mitral valve pressure gradient 7.1 ± 2.5 mm Hg vs. 6.5 ± 2.5 mm Hg; p = 0.42; MR [≥moderate] 3.8% vs. 5.6%; p = 1.00) at 30 days. At 1 year, the mitral valve pressure gradient was higher in the TMVR group (TMVR 7.2 ± 2.7 vs. SMVR 5.5 ± 1.8; p = 0.01), although there was no difference in the grade of MR., Conclusions: Despite the higher STS PROM in TMVR patients, there was no difference in 1-year mortality between the TMVR and SMVR groups. Echocardiographic findings after TMVR were similar to SMVR at 30 days. There was a statistically significant difference in mitral gradient at 1 year, though this is likely not clinically important. TMVR may be an alternative to SMVR in patients with previous mitral bioprosthetic valves., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Transcatheter mitral valve-in-valve/valve-in-ring procedures (TM-VIVoR) are increasing. The authors aimed to identify independent predictors for hospital mortality in redo mitral valve surgery as possible future selection criteria for TM-VIVoR., Design: Retrospective multicenter registry., Setting: Tertiary university and community hospitals., Participants: Two-hundred and sixty patients (out of 920 enrolled) who are potentially candidates for TM-VIVoR undergoing redo-surgery., Interventions: Redo mitral surgery., Measurements and Main Results: Regression analyzes and receiver operating characteristic (ROC) curves identified independent predictors of death. Patients potentially candidates for TM-VIVoR reported significant hospital mortality (9.2%; EuroSCORE II: 13.2 ± 13.1, Society of Thoracic Surgeons [STS] score: 6.2 ± 3.1) and major morbidity (3.8% acute myocardial infarction, 5% stroke, 16.9% perioperative respiratory failure, 16.5% acute renal insufficiency, 25% massive transfusions). EuroSCORE II (odds ration [OR] 1.06; confidence interval [CI] 1.01-1.10; p = 0.005), STS score (OR 1.58; CI 1.27-1.97; p = 0.001), age at surgery (OR 1.05; CI 1.00-1.15; p = 0.05), preoperative dialysis (OR 2.5; CI 1.8-12.6; p = 0.042), left ventricular ejection fraction (LVEF) <30% (OR 4.8; CI 1.12-37.1; p = 0.021), severe pulmonary hypertension (OR 7.5; CI 1.9-29.4; p = 0.003), and previous coronary artery bypass grafting (CABG) (OR 11.8; CI 1.7-36.9; p = 0.002) were independent predictors of hospital mortality. ROC analyses reported good prediction for EuroSCORE II (AUC: 0.76; cut-off value: >13.1; 70.8% sensitivity and 68.2% specificity) and better prediction for STS score (AUC: 0.81; cut-off value: 7.4; 75.0% sensitivity and 66.2% specificity). Quintiles stratification identified EuroSCORE II ≥18.7 (5th quintile, observed mortality: 19.3%) and STS score >9.1 as strong predictors of death within each risk-categorization (OR 5.9 and 12.1, respectively)., Conclusions: High EuroSCORE II and STS scores, advanced age at surgery, LVEF <30%, previous CABG, severe pulmonary hypertension or preoperative dialysis might represent in the future preferred indications for TM-VIVoR in the redo-mitral surgery scenario., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated., Methods: Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses., Results: A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P  = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR., Conclusions: A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We report the case of a 50-year old patient with deterioration of an aortic homograft, who successfully underwent aortic valve replacement using an Edwards Intuity sutureless bioprosthesis. The patient presented with rupture of the cusps and severe calcification of the aortic annulus of the homograft, which prevented us from using a standard bioprosthesis for the replacement., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR., Methods: Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis]., Results: Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04)., Conclusions: RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The present analysis compared clinical and mid-term outcomes of patients with previous cardiac surgery undergoing transapical transcatheter aortic valve implantation (TAVI) with propensity-matched patients undergoing conventional redo aortic valve replacement (cAVR)., Methods: Since 2008, 508 patients were treated with TAVI. Fifty-three of these patients presented with a history of cardiac surgery and underwent transapical TAVI using the Edwards SAPIEN bioprosthesis. A propensity-matched control group of 53 patients receiving cAVR was generated out of the hospital's database. The mean age for all the patients was 77.8 ± 4.5 years. The logistic EuroSCORE was 28.4 ± 13.6% in mean, and mean EuroSCORE II was 8.56 ± 3.93%. The mean follow-up time was 245 ± 323 days, which equated to a total of 700 patient-months., Results: The observed hospital mortality did not differ significantly between TAVI and cAVR (TAVI: 9.4% and cAVR: 5.7%; P = 0.695). Six-month survival was 83.0% for the TAVI and 86.8% for the cAVR patients (P = 0.768). Postoperative bleedings (TAVI: 725 ± 1770 ml and cAVR: 1884 ± 6387; P = 0.022), the need for transfusion (TAVI: 1.7 ± 5.3 vs cAVR: 6.2 ± 13.7 units packed red blood cells (PRBC); P = 0.030), consecutive rethoracotomy (TAVI: 1.9% vs cAVR: 16.9%; P = 0.002) and postoperative delirium (TAVI: 11.5% vs cAVR: 28.3%; P = 0.046) were more common in the cAVR patients. The TAVI patients suffered more frequently from respiratory failure (TAVI: 11.3% vs cAVR: 0.0%; P = 0.017) and mean grade of paravalvular regurgitation (TAVI: 0.8 ± 0.2 vs cAVR: 0.0; P = 0.047). Although primary ventilation time (P = 0.020) and intensive care unit stay (P = 0.022) were shorter in the TAVI patients, mean hospital stay did not differ significantly (P = 0.108)., Conclusions: Transapical TAVI as well as surgical aortic valve replacement provided good clinical results. The pattern of postoperative morbidity and mortality was different for both entities, but the final clinical outcome did not differ significantly. Both techniques can be seen as complementary approaches by means of developing a tailor-made and patient-orientated surgery.

Background: "valve‐in‐valve" TAVR (VIV‐TAVR) is established and provides good initial clinical and hemodynamic outcomes. Lacking long‐term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3‐years follow‐up. Methods: A total of 77 patients underwent VIV‐TAVR for failing aortic bioprosthesis during a 7‐years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4 ± 5.8 years and a logistic EuroSCORE of 30.8 ± 15.7%. The Society of Thoracic Surgeons‐PROM averaged 5.79 ± 2.63%. Clinical results and hemodynamic outcomes are reported for 30‐days, 1‐, 2‐, and 3‐years. Completeness of follow‐up was 100% with 44 patients at risk after 3‐years. Follow‐up ranged up to 7.1 years. Results: Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1 ± 2.3 mm and true‐ID of 20.4 ± 2.6 mm. A true‐ID ≤21 mm had 58.4% of the patients. Self‐expanding valves were implanted in 68.8% (mean labeled size 24.1 ± 1.8 mm) and balloon‐expanded in 31.2% (mean size 24.1 ± 1.8 mm). No patient died intraoperatively. Hospital mortality was 1.3% and three‐years survival 57.1%. All patients experienced an initial significant dPmean‐reduction to 16.8 ± 7.1 mmHg. After 3‐years mean dPmean raised to 26.0 ± 12.2 mmHg. This observation was independent from true‐ID or type of transcatheter aortic valve replacement (TAVR)‐prosthesis. Patients with a true‐ID ≤21 mm had a higher initial (18.3 ± 5.3 vs. 14.9 ± 7.1 mmHg; p =.005) and dPmean after 1‐year (29.2 ± 8.2 vs. 13.0 ± 6.7 mmHg; p =.004). There were no significant differences in survival. Conclusions: VIV‐TAVR is safe and effective in the early period. In surgical valves with a true‐ID ≤21 mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true‐IDs showed steadily increasing transvalvular gradients. This raises concern about durability. [ABSTRACT FROM AUTHOR]