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The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated. 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 = 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.

Aortic valve bioprostheses are commonly implanted in the current era (also in younger patients) as they may obviate the need for anticoagulation while providing better hemodynamic performance and a more favorable quality of life. The steady increase in the use of biological valves has prompted the development of several different models of conventional stented bioprostheses. At present, there are four main types of stented aortic bioprostheses that compete in the market: the LivaNova Crown PRT (LivaNova Group, Burnaby, Canada), the St. Jude Medical Trifecta (St. Jude Medical, St. Paul, MN, USA), the Carpentier-Edwards Perimount Magna Ease (Edwards Lifesciences, Irvine, CA, USA), and the Medtronic Mosaic Ultra (Medtronic, Inc., Minneapolis, MN, USA). The purpose of this review is to describe the features of these bioprosthetic valve models and to compare the data provided by the manufacturers with those derived from the available literature.

Objective Stentless aortic valves have been developed to overcome obstructive limitations associated with stented bioprostheses. The aim of the current multi-institutional study was to compare hemodynamics of transcatheter (TAVR) and the Freedom SOLO Stentless (FS) valve in an intermediate risk population undergoing surgical aortic valve replacement. Methods From 2010 to 2014, 420 consecutive patients underwent isolated surgical aortic valve replacement with FS and 375 patients underwent TAVR. Only patients with intermediate operative risk (Society of Thoracic Surgeons score 4-10) and small aortic annulus (≤23 mm) were included. After a propensity matched analysis 142 patients in each group were selected. Thirty-day postoperative clinical and echocardiographic parameters were evaluated. Results Mean prosthesis diameter was 22.2 ± 0.9 mm for FS and 22.4 ± 1.0 mm for TAVR. In-hospital mortality was 2.1% for FS and 6.3% for TAVR (P = .02). Postoperative FS peak gradients were 19.1 ± 9.6 mm Hg (mean 10.8 ± 5.9 mm Hg); TAVR peak gradients were 20.2 ± 9.5 mm Hg (mean 10.7 ± 6.9 mm Hg) P = .57 (P = .88). Postoperative effective orifice area was 1.93 ± 0.52 cm2for FS and 1.83 ± 0.3 cm2for TAVR (P = .65). There was no prostheses-patient mismatch in either group. Postoperative grade 2-3 paravalvular leak was present in 3.5% for TAVR and 0.7% for FS. Postoperative permanent pacemaker implant rate was 12% for TAVR and only 1 case (0.7%) in the FS group (PÂ

Sutureless aortic bioprostheses have been developed for use in high-risk patients undergoing surgical aortic valve replacement due to severe aortic stenosis. These devices are mounted on a stent and are self-anchoring within the aortic annulus with no need for sutures, resulting in shorter operative and, hence, ischemic times. The use of these devices makes therefore valve implantation easier and faster, which seems to improve postoperative outcomes. At present, there are two commercially available sutureless aortic valves: the Perceval S (LivaNova Group, Milan, Italy) and the Intuity (Edwards Lifesciences, Irvine, CA, USA). In this paper the studies published to date evaluating these two bioprosthesis models are reviewed, along with future directions and indications for the target patient population.

International audience; INTRODUCTION: This study was planned to investigate the impact of severe bleeding and blood transfusion on the development of stroke after coronary surgery.METHODS: This cohort study includes 2357 patients undergoing isolated CABG from the prospective European Coronary Artery Bypass Grafting (E-CABG) registry. Severity of bleeding was categorized according to the Universal Definition of Perioperative Bleeding (UDPB), E-CABG and PLATO definitions.RESULTS: Thirty patients (1.3%) suffered postoperative stroke. The amount of transfused red blood cell (RBC) (OR 1.10, 95%CI 1.03-1.18), preoperative use of unfractioned heparin (OR 4.49, 95%CI 1.91-10.60), emergency operation (OR 3.97, 95%CI 1.47-10.74), diseased ascending aorta (OR 4.62, 95%CI 1.37-15.65) and use of cardiopulmonary bypass (p = 0.043, OR 4.85, 95%CI 1.05-22.36) were independent predictors of postoperative stroke. Adjusted analysis showed that UDPB classes 3-4 (crude rate: 3.6% vs. 1.0%; adjusted OR 2.66, 95%CI 1.05-6.73), E-CABG bleeding grades 2-3 (crudes rate: 6.3% vs. 0.9%; adjusted OR 5.91, 95%CI 2.43-14.36), and PLATO life-threatening bleeding (crude rate: 2.5% vs. 0.6%, adjusted OR 3.70, 95%CI 1.59-8.64) were associated with an increased risk of stroke compared with no or moderate bleeding.CONCLUSIONS: Bleeding and blood transfusion are associated with an increased risk of stroke after CABG, which is highest in patients with severe bleeding.

Minimally invasive aortic surgery is increasingly being utilized, in particular, through ministernotomy. The choice of the cannulation site is problematic. Venous cannulation may result in wound complications if the femoral vein is used, or may be bulky if the right atrial appendage is used. Our technique of superior vena cava cannulation not only avoids the risk of complications related to the groin but also provides good visualization of the aortic valve making valve implantation easier, especially when using sutureless bioprosthetic valves.

Objective There is an increase of old patients needing aortic valve surgery. Especially in this age group, a lot of new less-invasive strategies are proposed. Our goal was to study whether a sutureless aortic valve, which is implanted surgically after removal of the native valve, could be an alternative for a subgroup of patients. Methods The Sorin Perceval S is a biologic pericardial aortic valve assembled in a metal super elastic alloy stent and implanted in the aortic root without the need of suturing. As part of a premarketing multicenter study (Cavalier trial), 34 patients were screened for Perceval S implantation. All patients underwent cardiopulmonary bypass and mini-invasive approach (partial upper sternotomy). Results Fourteen patients were excluded due to standardized criteria. Twenty patients received a 21-mm valve (2 patients), 23-mm valve (6 patients), or 25-mm valve (12 patients). X-clamp time was 20.6 ± 7.6 minutes, and implantation time was 8.6 ± 3.1 minutes. Intra- and postoperative echocardiography showed no paravalvular leakage, low gradients (max 16.3 ± 5, mean 9.8 ± 4.2), and two patients with an intraprosthesis reflux (one patient with 1/4+, one patient with 2/4+). All patients were discharged without major in-hospital complications (intensive care unit stay 1.4 ± 0.5 days, hospital stay 7 ± 0.7 days). Conclusions The sutureless Perceval S aortic valve is hemodynamically excellent and a safe prosthesis in selected patients. Due to a simple and fast implantation technique, this valve could guarantee a shorter operation time in combination with a mini-invasive approach.

Objective: Postoperative thrombocytopenia after aortic valve replacement has been reported in the literature for many years, often associated with specific types of prosthetic valve models. Several...

Sternal instability, dehiscence and mediastinitis are major causes of morbidity and mortality in cardiac surgery. The aim of this analysis is to determine the effect of a Posthorax support vest (Epple Inc, Vienna, Austria) after median sternotomy. One thousand five hundred and sixty cases were included in a prospective randomized multicenter trial. Patients were randomized as follows: 905 received a flexible dressing postoperatively (group A) and 655 patients were given a Posthorax support vest (group B). Patients in groups A and B were well matched. Their mean age was 68 years (range: 34-87 years). The patient characteristics and operative data were equally distributed in both groups. The mean total hospital stay was significantly shorter in group B than in group A (A: 17.33+/-17.5; B: 14.76+/-7.7; P=0.04). Sternal wound complications necessitating reoperation during the 90 days follow-up period were observed in 4.5%. Reoperation rates were as follows: 3.9% in group A and 0.6% in group B (P

The sutureless Perceval aortic valve (Sorin Group, Saluggia, Italy) is a device increasingly used in many European cardiac surgery centers. Since the first reports evaluating implantation feasibility and valve safety in humans in 2007, an increasing amount of data have become available, including premarketing clinical results and experience in particular conditions. Overall, excellent performances have been demonstrated in hemodynamic outcomes, safety, and versatility of use. However, several questions remain unanswered, especially regarding long-term durability, risk for endocarditis, and the need for postoperative pacemaker implantation. In this article, the most important studies published until now in the literature will be described, providing a state-of-the-art overview of current knowledge as well as future directions and indications for the use of the Perceval valve based on preliminary results of ongoing studies.

The most appropriate approach for high-risk patients with degenerated bioprostheses remains a matter of debate. The aim of the study was to evaluate the clinical and hemodynamic outcome of redo patients undergoing transcatheter aortic valve-in-valve implantation (VinV-TAVI) and sutureless aortic valve replacement (AVR), with assessment of patient-prosthesis mismatch (PPM) in the perioperative and follow-up period.From 2010, 343 patients underwent TAVI and 220 patients underwent sutureless AVR at our institution. Among these, 14 patients had prior bioprosthetic AVR and indication for reintervention because of valve degeneration. Patients from the TAVI group (N.=6) underwent VinV-TAVI, and patients from the sutureless group (N.=8) underwent redo AVR.Mean age was 78.8±3 years in the sutureless group and 80.2±2.3 in the VinV-TAVI group. Logistic EuroSCORE was 36.4±24.1% and 33.8±13.8% in the sutureless and VinV-TAVI group, respectively. There was no in-hospital death. No patient was lost to follow-up (21±13 months, range 6 to 42). Quality of life measured with the EQ-5D questionnaire improved by 65% in the sutureless group and by 67% in the VinV-TAVI group. At follow-up echocardiographic evaluation, no paravalvular leak or intraprosthetic regurgitation was observed in either group. The mean iEOA was 0.96±0.08 vs. 0.71±0.15 cm2/m2 in the sutureless vs. VinV-TAVI group.In patients undergoing redo aortic valve surgery for degenerated bioprostheses, both VinV-TAVI and sutureless AVR are effective in terms of clinical outcome. As regards echocardiographic evaluation, no leak was observed in either group and no cases of severe PPM were recorded in the sutureless group.

Objective: Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (SU-AVR) are suitable alternatives to conventional surgery. The aim of this study is to compare early outcomes of patients undergoing TAVI and SU-AVR.Methods: Data were analyzed on patients who underwent TAVI and patients who underwent SU-AVR. Two matched cohorts (TAVI vs SU-AVR) were created using propensity scores; all analyses were repeated for transapical TAVI and transfemoral TAVI, separately. Outcomes were defined according to Valve Academic Research Consortium-2 criteria.Results: A total of 2177 patients were included in the analysis: 1885 (86.6%) treated with TAVI; 292 (13.4%) treated with SU-AVR. Mortality in unmatched TAVI and SU-AVR patients was 7.1% and 2.1%, respectively, at 30 days, and 12.9% and 4.6%, respectively, at 1 year. No differences were found in 30-day mortality in the 214 matched patient pairs (3.7% vs 2.3%; P = .4), but patients treated with TAVI showed a lower incidence of device success (85.9% vs 98.6%; P < .001) and pacemaker implantation (2.8% vs 9.4%; P = .005), and a higher incidence of any paravalvular leakage (PVL).Conclusions: SU-AVR is associated with better device success and a lower incidence of PVL, compared with TAVI. Nevertheless, patients treated with SU-AVR were more likely to receive a permanent pacemaker. SU-AVR and TAVI provide good results in patients who have severe symptomatic aortic valve stenosis. Given the multiple therapeutic options available, patients may receive the treatment that is most appropriate for their clinical and anatomical characteristics.

OBJECTIVES To evaluate the results of aortic valve replacement through sternotomic approach in redo scenarios (RAVR) vs transapical transcatheter aortic valve replacement (TAVR), in patients in the eighth decade of life or older already undergone previous coronary artery bypass grafting (CABG). METHODS One hundred and twenty-six patients undergoing RAVR were compared with 113 patients undergoing TaTAVR in terms of 30-day mortality and Valve Academic Research Consortium-2 outcomes. The two groups were also analysed after propensity-matching. RESULTS TaTAVR patients demonstrated a higher incidence of 30-day mortality (P = 0.03), stroke (P = 0.04), major bleeding (P = 0.03), worse 'early safety' (P = 0.04) and lower permanent pacemaker implantation (P = 0.03). TaTAVR had higher follow-up hazard in all-cause mortality [hazard ratio (HR) 3.15, 95% confidence interval (CI) 1.28-6.62; P < 0.01] and cardiovascular mortality (HR 1.66, 95% CI 1.02-4.88; P = 0.04). Propensity-matched patients showed comparable 30-day outcome in terms of survival, major morbidity and early safety, with only a lower incidence of transfusions after TaTAVR (10.7% vs RAVR: 57.1%; P < 0.01). A trend towards lower Acute Kidney Injury Network Classification 2/3 (3.6% vs RAVR 21.4%; P = 0.05) and towards a lower freedom from all-cause mortality at follow-up (TaTAVR: 44.3 ± 21.3% vs RAVR: 86.6 ± 9.3%; P =. 08) was demonstrated after TaTAVR, although cardiovascular mortality was comparable (TaTAVR: 86.5 ± 9.7% vs RAVR: 95.2 ± 4.6%; P = 0.52). Follow-up freedom from stroke, acute heart failure, reintervention on AVR and thrombo-embolisms were comparable (P = NS). EuroSCORE II (P = 0.02), perioperative stroke (P = 0.01) and length of hospitalization (P = 0.02) were the determinants of all-cause mortality at follow-up, whereas perioperative stroke (P = 0.03) and length of hospitalization (P = 0.04) impacted cardiovascular mortality at follow-up. CONCLUSIONS Reported differences in mortality and morbidity after TaTAVR and RAVR reflect differences in baseline risk profiles. Given the lower trend for renal complications, patients at higher perioperative renal risk might be better served by TaTAVR.

Background The Freedom Solo (FS) bovine pericardial valve (Sorin Group, Milan, Italy) is a stentless bioprosthesis that was introduced in 2004 and approved by the United States Food and Drug Administration in 2014. No long-term follow-up series are available to date. We report the multicenter experience of 4 European institutions that began implanting FS extensively from its introduction, providing the largest series with long-term follow-up. Methods From 2004 to 2009, 565 patients (242 women [42.8%]; mean age, 74.6 ± 8.3 years) underwent isolated (n = 350) or combined (n = 215) aortic valve replacement with the FS. Mean follow-up, including clinical and strict echocardiographic evaluation, was 6.9 ± 3.7 years (maximum, 11.8 years; cumulative 2,965 patient-years). Primary end point was freedom from structural valve deterioration (SVD), and secondary end points were freedom from reoperation and overall survival. Results Mean logistic European System for Cardiac Operative Risk Evaluation I was 10.3% ± 6.7%. Overall 30-day mortality was 3.7%, and no deaths were valve related. There was no severe prostheses-patient mismatch, and moderate prostheses-patient mismatch occurred only in 1 patient (0.17%). Twenty-eight patients (5.2%) underwent reoperation (20 surgical replacements, 8 transcatheter aortic valve-in-valve replacements) due to endocarditis in 9, blunt trauma in 1, and SVD in 18. SVD was reported in 5 other patients alive at time of censoring. Freedom from SVD and reoperation was 90.8% (95% confidence interval, 89.1% to 92.5%) and 87.3% (95% confidence interval, 85.6% to 89.0%), respectively, at 10 years of follow-up, and the overall actuarial survival was 56.4% (95% confidence interval, 53.3% to 59.5%). Conclusions The FS valve provided excellent long-term durability and hemodynamic performance in this large, multicenter European experience. Moreover, the FS, given the low rate of SVD, along with a simple implantability, proved to be a reliable bioprosthesis in the aortic position as a valid alternative to stented bioprostheses.

The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone.Design, Setting, and Participants: This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.Results: Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group.Conclusions and Relevance: In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

Sclerotic calcification of the aortic valve is a common disease in advanced age. Its pathophysiology is unclear. However, pathobiological similarities to atherosclerosis have been shown in several studies. The current study assesses gene profiling of severe calcified stenotic human aortic valves identifying transforming growth factor (TGF)-beta, Eotaxin3, vascular adhesion protein-1 (VAP-1) and monokine induced by interferon-gamma (MIG) as potential atherosclerotic target genes in severe calcified and stenotic aortic valves, and analyzes the effects of statins on their expression as part of an anti-inflammatory treatment strategy. We collected human severe calcified and stenotic aortic valves with (CSAV+) or without (CSAV-) statin pre-treatment prior to valve replacement and investigated gene profiling by using micro-array technique and real-time PCR for the TGF-beta, Eotaxin3, VAP-1 and MIG expression. In comparison to atherosclerotic plaques of carotid arteries, immunohistochemical staining was investigated. Results were contrasted to human normal non-calcified aortic valves as controls (C). As compared to C, TGF-beta, Eotaxin3, MIG or VAP-1 was significantly upregulated in CSAV-. In CSAV+ no significant change in gene expression was found for Eotaxin3 and MIG. In contrast, VAP-1 and TGF-beta were still upregulated. Corresponding gene expression was confirmed on atherosclerotic plaque formations of carotid arteries. Monocyte/Macrophage infiltration (presence of CD68) on aortic valves (CSAV+, CSAV-, or C) confirmed inflammatory nature of the disease. Our data support further evidence for atherosclerotic inflammation as a trigger for sclerosis in end-stage calcified stenotic aortic valves by showing upregulation of gene expression for TGF-beta, VAP-1, MIG and Eotaxin3, which is only partially inhibited by previous statin therapy. Potent benefits of statin treatment on early stages of valve disease are still propagated.

The presence of a mechanical heart valve in the aortic position is usually considered a contraindication for the use of cardiac assist devices. Only a few cases with the combination of mechanical circulatory support and valve prostheses have been reported in the literature to date, and the experience is even more limited in the new generation of miniaturized axial flow pumps. We present a case report of a patient with a mechanical aortic heart valve who was successfully supported with a continuous flow pump and discuss the literature available on this problem. Further on, the patient was weaned from his ventricular assist device after 456 days of support.

Retained blood occurs when drainage systems fail to adequately evacuate blood during recovery from cardiothoracic surgery. As a result, a spectrum of mechanical and inflammatory complications can ensue in the acute, subacute, and chronic setting. The objectives of this review were to define the clinical syndrome associated with retained blood over the spectrum of recovery and to review existing literature regarding how this may lead to complications and contributes to poor outcomes. To better understand and prevent this constellation of clinical complications, a literature review was conducted, which led us to create a new label that better defines the clinical entity we have titled retained blood syndrome. Analysis of published reports revealed that 13.8% to 22.7% of cardiac surgical patients develop one or more components of retained blood syndrome. This can present in the acute, subacute, or chronic setting, with different pathophysiologic mechanisms active at different times. The development of retained blood syndrome has been linked to other clinical outcomes, including the development of postoperative atrial fibrillation and infection and the need for hospital readmission. Grouping multiple objectively measurable and potentially preventable postoperative complications that share a common etiology of retained blood over the continuum of recovery demonstrates a high prevalence of retained blood syndrome. This suggests the need to develop, implement, and test clinical strategies to enhance surgical drainage and reduce postoperative complications in patients undergoing cardiothoracic surgery.

We have with interest and thoroughness read the article by Senage et al1 reporting a high incidence of structural valve disease (SVD) in the small Mitroflow generation 11, 12, and LX. The article, to our understanding, leaves several unanswered questions, and conclusions cannot be left uncommented. Senage et al report a cohort 2109 patients, of whom 617 patients (29%) received Mitroflow implants. In the same time period, 1173 Carpentier-Edwards Perimount (56%), 206 Medtronic Mosaic (10%), and 113 miscellaneous (5%) bioprostheses were implanted. What was the authors’ rationale for choosing 1 implant over another? As Mitroflow users, we know its advantages very well, especially now that the …

Thrombocytopenia occurring after surgical bioprosthetic valve implantation is a phenomenon that has been long investigated, and various explanations have been provided [Santarpino 2012a]. Our group has been addressing this topic over several years, extending back to the original description of this phenomenon in Freedom Solo (Sorin Group, Saluggia, Italy). However, we observed that this was a transitory and self-limited phenomenon without clinical consequence [Santarpino 2011; Santarpino 2012a]. Our center began implanting the Perceval aortic valve (Sorin Group, Saluggia, Italy) in 2010, and we have gained a vast experience in sutureless aortic valve replacement with Perceval, with more than 300 implants performed to date [Fischlein 2015].

The implantation of sutureless bioprosthesis is currently not recommended in patients affected by bicuspid aortic valve because lacking data and follow up. We report the first case of a patient affected by bicuspid aortic valve stenosis and aneurysm of non coronary sinus of Valsalva that underwent a successful substitution of aneurysmatic sinus and minimal invasive sutureless implantation.

Surgical sutureless and interventional transcatheter aortic valve prostheses are nowadays extensively adopted in high-risk elderly patients. An explorative analysis was carried out to compare the clinical outcome and costs associated to these approaches. Since 2010, a total of 626 patients were distributed between transcatheter aortic valve implantation (TAVI; n = 364) and sutureless (n = 262) groups. Patients of both groups were not comparable for clinical and surgical characteristics, but many patients were in a "gray zone"; therefore, a retrospective propensity score analysis was possible and performed. For the matched pair samples, postoperative, follow-up clinical data, and costs data were obtained. In-hospital death occurred in 5 patients in sutureless group and 3 patients in TAVI group (p = 0.36). Blood transfusions were higher in sutureless group (2.1 ± 2.3 vs 0.4 ± 1.0 U). TAVI group had a shorter intensive care unit and hospital stay (2.2 ± 2.7 vs 3.2 ± 3.5 days, p = 0.037; 12 ± 6 vs 14 ± 6 days, p = 0.017). No differences in postoperative neurologic (p = 0.361), renal (p = 0.106), or respiratory (p = 0.391) complications were observed between groups. At follow-up (24.5 ± 13.8 months), 1 patient in sutureless group and 7 patients in TAVI group died (p = 0.032). Paravalvular leakage occurred more frequently in patients in TAVI group (35 [34%] vs 7 [6.9%]; p

OBJECTIVES - After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves. METHODS - Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts. RESULTS - Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19–27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves. CONCLUSION - The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.

BACKGROUND The aim of this study was to investigate necessity and outcome of late pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF). METHODS Hospital records from patients operated on for TOF at our institution between 1960 and 2002 were reviewed and patients were interviewed by questionnaires. RESULTS Out of 411 long-term survivors after TOF-repair, 47 (11.4 %) patients required reoperation after 13.2 +/- 7.4 years. Preoperative right ventricular (RV) dilatation was present in 36 (76.6 %) patients including 16 (34 %) with impaired RV function. Isolated PVR was performed in 12 patients (25.5 %). Additional procedures were necessary in 35 patients (74.5 %), including closure of residual defects (VSD, n = 11), tricuspid valve replacement (n = 1) and repair (n = 3). Obstructive right ventricular or pulmonary artery lesions (34 patients, 72.3 %) were all surgically addressed. RV pressure decreased from 61.1 +/- 27.7 to 42.9 +/- 13.3 mm Hg (p < 0.01) after PVR. RV size was reduced and RV function improved compared to preoperative values. Early mortality after reoperation was 2.1 % (n = 1) with one patient dying from biventricular failure. There was no late mortality. CONCLUSIONS PVR after Fallot repair is frequently required because of progressive RV enlargement with dysfunction. It can be performed with relatively low risk, even in the setting of multiple reoperation. Obstructive lesions (RVOTO, PA stenosis) and residual defects are frequently observed in patients needing late PVR and may play a crucial role in the development of RV failure. Timely valve replacement with repair of all obstructive lesions proximal and distal to the implanted valve is the key to preserving RV function.

OBJECTIVES This study assessed the safety and efficacy of an internal geometric annuloplasty ring in a regulatory trial of aortic valve reconstruction (ClinicalTrials.gov Identifier: NCT01400841). METHODS Sixty-five patients with predominant moderate-to-severe trileaflet aortic insufficiency (AI) underwent aortic valve repair with an average age of 63 ± 13 years (mean ± SD). All had initial implantation of an internal aortic annuloplasty ring to correct annular dilatation and facilitate leaflet reconstruction. Leaflet plication was performed for prolapse in 80% of patients, and more complex leaflet procedures, usually employing autologous pericardium, were required in 22%. Ascending aortic and/or root aneurysms were replaced in 62%. RESULTS Follow-up was for a maximum of 3 years and a mean of 2 years. No in-hospital operative mortalities, major complications or early or late valve-related events occurred. The annular diameter before repair was 26.5 ± 2.3 mm, and the average ring diameter used was 21.5 ± 1.6 mm. The preoperative AI grade (0-4) was 2.9 ± 0.8 and improved after repair to 0.6 ± 0.7 (P < 0.0001), as did the NYHA class. The mean valve gradient was 8.6 ± 4.3 mmHg, and at 3 years, the Kaplan-Meier survival rate was 95%, with no valve-related mortality. Over the 3 years, aortic valve replacement was required in 7 patients (10.8%) for reasons usually related to surgical technique. Most repair failures occurred early, and results stabilized after 6 months. No structural complications of the rings were observed. CONCLUSIONS Geometric ring annuloplasty was a safe and effective adjunct to aortic valve repair. Initial correction of annular dilatation seemed to facilitate overall reconstruction. Because most early repair failures were technical, increasing experience with geometric ring annuloplasty for aortic valve reconstruction has the potential to standardize and improve outcomes.

Objectives: The aim of this European multicenter-experience was to report on surgical outcomes in terms of mortality and complications of proximal reoperation after intial repair of acute typ A dissection (AAD). Methods: Between May 1998 and January 2014, 71 isolated proximal aortic re-operation (mean time from the first procedure was 3.67 years, range 0.15–16.6) were performed in 66 patients (mean age 60.8 ± 12.4 years, males 50). Proximal causes for re-operation were aortic root aneurysm in 17, root re-dissection in 13, aortic valve insufficiency in 24 and proximal anastomic pseudoaneurysm in 19 patients. Result: The most frequent proximal procedure during redo was the composite aortic root replacement (Bentall procedure) (40 operations, 56.35%), followed by isolated aortic valve replacement (13 pts., 18,31%) and ascending aorta replacement (9 pts., 12,68%). David procedure was performed in 4 patients (5.63%). In-hospital mortality was 14% (10 pts.), of them 7 deaths were reported after emergency operations and 3 in elective or urgent setting. Causes of deaths were cardiac in 5, neurological in 2, MOF in 3. Major adverse event included low output syndrome in 7, neurological complications in 7, acute renal failure 7 and bleeding complications in 10 patients and lung failure in 5 patients. Conclusion: Proximal re-operations can be performed with acceptable in-hospital results. Thus conservative approach of the proximal aorta for AAD should not be considered a concern for late reoperations. Strict follow-up after AAD is mandatory to avoid emergency re-operations.