Background Late survival and freedom from retreatment on the descending aorta was evaluated after ascending aortic repair for type A acute aortic dissection (TAAAD). Methods Between March 1992 and ...January 2006, 189 TAAAD patients (mean age, 52 ± 11; range, 17 to 83 years) were included; of these, 58 had a patent false lumen, and 49 had Marfan syndrome. The descending aorta was evaluated postoperatively with computed tomography (CT). Late outcomes were assessed by Cox regression analysis and actuarial survival and freedom from retreatment by the Kaplan-Meier method. Mean follow-up was 88 ± 44 months. Results There were 38 (20%) late deaths. At 10 years, survival was 89.8% ± 2.1% for patients with an occluded false lumen and 59.8% ± 3.5% for patients with a patent false lumen ( p = 0.001), and freedom from retreatment on the descending aorta was 94.2% ± 3.1% for an occluded false lumen and 63.7% ± 2.6% for a patent false lumen ( p < 0.0001). Descending aortic rupture ( p = 0.002) and a patent false lumen ( p = 0.001) were predictors for late death. Patent false lumen ( p = 0.0001), Marfan syndrome ( p = 0.03), and descending aortic diameter 4.5 cm or larger ( p = 0.002) were predictors for retreatment. Conclusions A patent false lumen was a predictor for late death and retreatment on the descending aorta. Marfan syndrome and aortic size exceeding 4.5 cm were predictors for late retreatment. These patients require very close follow-up and a plan for retreatment on the descending aorta to prevent sudden rupture and late death.
Subclinical leaflets valve thrombosis (SLT) is a recently identified phenomenon with multidetector computer tomography after tissue aortic valve replacement. Whether SLT is more frequent after ...transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is currently not known. Thus, the aim of this pairwise meta-analysis was to investigate the incidence of SLT after both TAVR and SAVR, the association with anticoagulation therapy, and the risk for neurological events. We searched PubMed, Google Scholar, and Ovid MEDLINE/Embase (January 02, 2023, last update) (PROSPERO registration: CRD42022383295). Statistical analysis was performed according to a prespecified statistical analysis plan. Time-to-event outcomes were summarized as incidence rate ratios (IRR). Pooled estimates were calculated using inverse variance method and random effect model. Overall, 2 registries, 2 randomized trials, and 1 observational study (1,593 patients) were included in this meta-analysis. There was a statistically significant difference in the incidence rate at follow-up of SLT between patients who underwent TAVR and SAVR (IRR 2.07, 95% confidence interval CI: 1.06; 4.03, I2 79%, 95% CI: 44; 92, p = 0.03). Oral anticoagulation therapy was associated with a reduced incidence of SLT (IRR 7.51, 95% CI: 3.24; 17.37, I2 62%, 95% CI: 0; 87, p <0.001). However, the incidence of later neurological events did not differ between patients with or without SLT (IRR 1.05, 95% CI: 0.32; 3.47, p = 0.93). In conclusion, SLT was more frequently detected after TAVR than SAVR. However, it was not associated with an increased risk for neurological events. Oral anticoagulation therapy seemed to reduce the incidence of SLT.
Objectives The surgical approach for ischemic mitral regurgitation remains unclear. Many studies are in favor of adding the subvalvular procedure to mitral annuloplasty to reduce recurrent mitral ...regurgitation. This study reports the clinical and echocardiographic outcomes of papillary muscle relocation combined with mitral annuloplasty. Methods From 2003, 115 patients with severe ischemic mitral regurgitation who underwent papillary muscle relocation plus nonrestrictive mitral annuloplasty and coronary artery bypass grafting were retrospective analyzed. Patients' mean age was 52 ± 12.8 years, New York Heart Association class III or IV was 71%, and preoperative left ventricular ejection fraction was 43% ± 6%. The study end points were New York Heart Association functional class, reversal in left ventricle remodeling, reduction of mean tenting area and mean coaptation depth, freedom from cardiac-related deaths and events, and freedom from recurrent mitral regurgitation. Follow-up data were obtained in all patients and were 100% complete. Mean follow-up was 45 ± 6 months. Results Five-year freedom from cardiac-related death and events was 91.3% ± 1.6% and 84% ± 2.2%, respectively. Recurrent mitral regurgitation more than moderate occurred in 3 patients (2.7%). Reversal in left ventricular remodeling, measured by a change in the end-diastolic and systolic diameter, was observed in our patients ( P < .05). The postoperative mean tenting area and mean coaptation depth were 1.1 ± 0.2 cm2 and 0.5 ± 0.2 cm, respectively; 95% of the patients were in New York Heart Association functional class I and II. Conclusions In patients with ischemic mitral regurgitation, papillary muscle relocation plus nonrestrictive mitral annuloplasty promotes a significant reversal in left ventricular remodeling, with a considerable decrease in tenting area and coaptation depth. Our approach is a durable method to reduce the recurrence of mitral insufficiency.
The incidence of non-uniform expansion in the context of the self-expandable transcatheter heart valve (THV) is little investigated, along with stent-frame decoupling, which is a form of stent ...adaptation, in which the lower part of the THV stent conforms to both the ellipticity of the left ventricle outflow tract and the native annulus while maintaining the higher part of the valve more circular. We analyzed post-implant multi-detector computed tomography scans in 50 patients. Prosthesis non-uniform expansion was assessed by computing the prosthesis eccentricity on 6 prespecified levels: (1) frame inflow, (2) native annulus, (3) leaflet inflow, (4) prosthesis waist, (5) leaflet outflow, and (6) frame outflow. Stent-frame decoupling was assessed by comparing the mean eccentricity on 6 different prosthesis levels. Implantation depth, leaflet expansion and alignment, and residual anatomic sinus area ratios were also calculated. Subclinical leaflet thrombosis was defined as hypoattenuated lesion of a meniscal shape. At a 12-month follow-up, non-uniform expansion was consistently detected at each valvular level. Highest eccentricity was measured at the native annulus level (eccentricity: 0.54 ± 0.12), while the lowest index at the frame outflow level (0.23 ± 0.11). Similar results were observed in the subgroup analyses of sizes 23, 26, 29, and 34. Eccentricity significantly decreased from the annulus level to the prosthesis frame outflow (p <0.001). Notably, the incidence of mild-to-severe subclinical leaflet thrombosis was relevant (16%). In conclusion, prosthesis non-uniform expansion and stent frame decoupling frequently occur after self-expandable THV replacement. The clinical and hemodynamic implications remain uncertain.
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Objective Surgical management of moderate chronic ischemic mitral valve regurgitation is still debated. The aim of this study was to evaluate the effect of adding mitral valve repair to coronary ...artery bypass grafting on clinical outcomes and left ventricular remodeling in patients who underwent coronary artery bypass grafting alone versus coronary artery bypass grafting plus mitral valve repair in a randomized trial. Methods Between February 2003 and May 2007, 102 patients were eligible for this study and were randomly assigned to one of 2 groups by means of card allocation: coronary artery bypass grafting plus mitral valve repair (CABG plus MVR group; 48 patients, 47%) or coronary artery bypass grafting alone (CABG group; 54 patients, 53%). The 2 groups were similar regarding demographics, perioperative clinical data, and outcomes. There were differences regarding cardiopulmonary bypass ( P < .0001) and aortic crossclamp ( P < .0001) times. Exercise tests were performed for all survivors to evaluate tolerance to exercise and variability on grade of mitral regurgitation and systolic pulmonary arterial pressure. The study was blinded for physicians and nurses involved in postoperative care and clinical follow-up. The mean follow-up was 32 ± 18 months. Results Overall in-hospital mortality was 3% (3 patients). One (1.8%) patient died in the CABG group, and 2 (4.1%) patients died in the CABG plus MVR group. Survival rates ± standard error at 5 years for patients in the CABG and CABG plus MVR groups were 88.8% ± 3.2% and 93.7% ± 3.1%, respectively. A significant difference was found between the 2 groups with regard to mean New York Heart Association class ( P < .0001), left ventricular end-diastolic diameter ( P < .01), left ventricular end-systolic diameter ( P < .01), pulmonary arterial pressure ( P < .0001), and left atrial size ( P < .01). At follow-up, coronary artery bypass grafting alone was able to reduce mitral regurgitation grade in 40% of patients, whereas in the remaining patients mitral regurgitation grade remained stable or worsened. In the CABG group, among the 17 patients with mild mitral regurgitation and 12 patients with moderate mitral regurgitation at rest, 7 (40%) and 9 (75%) patients, respectively, had worsening in mitral regurgitation grade and pulmonary artery pressure during exercise. Conclusions The efficacy of adding mitral valve repair to coronary artery bypass grafting is well demonstrated by the improvement of New York Heart Association functional class and percentage of left ventricular ejection fraction and by the decrease of mitral regurgitation grade, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, pulmonary artery pressure, and left atrial size. Moreover, coronary artery bypass grafting alone left more patients with heart failure symptoms at rest and during exercise. Combined coronary artery bypass grafting and mitral valve repair have no effect on survival at short-term follow-up, and the trends that are evident will likely become more significant with time.
In recent years, several studies have used the measurement of carotid intima-media thickness (IMT) as a marker of early atherosclerosis: IMT has been shown to correlate significantly with the ...presence of coronary artery disease (CAD) and to predict fatal and not fatal cerebro- and cardio-vascular events. These findings highlight the importance of recognizing and managing early stages of atherosclerosis for effective cardiovascular prevention. Beyond traditional established cardiovascular risk factors, inflammation has been shown to be crucial throughout atherosclerosis from endothelial dysfunction to plaque rupture and thrombosis. Several studies have shown the existence of a strong relation between CAD and fibrinogen or highly sensitive C-reactive protein (hs-CRP) levels and their predictive role has been examined through stratification or multivariable statistical analyses: levels of these markers of inflammation have been independently associated with the incidence of coronary events after adjusting for traditional cardiovascular risk factors. Recent studies have further addressed the importance of therapeutical modulation of hs-CRP levels in high-risk patients for the prevention of vascular events. The strong relationship between hs-CRP and IMT may potentially account for the complex role of hs-CRP and IMT in the pathogenesis of cardiovascular events. However, beyond the utility of measuring markers of inflammation to assess patients with subclinical carotid atherosclerosis at higher risk of vascular events, further studies are needed to evaluate the therapeutic implications in this category of patients.
Background Minimally invasive valve surgery is related to certain better postoperative outcomes. We aimed to assess the role of minimally invasive mitral valve surgery in high-risk patients. Methods ...A systematic literature review identified eight studies of which seven fulfilled criteria for meta-analysis. Outcomes for a total of 1,254 patients (731 were conventional standard sternotomy and 523 were minimally invasive mitral valve surgery) were submitted to meta-analysis using random effects modeling. Heterogeneity and subgroup analysis with quality scoring were assessed. The primary end point was early mortality. Secondary end points were intraoperative and postoperative outcomes and long-term follow-up. Results Minimally invasive mitral valve surgery conferred comparable early mortality to standard sternotomy ( p = 0.19); it was also associated with a lower number of units of blood transfused (weighted mean difference, −1.93; 95% confidence interval CI, −3.04 to −0.82; p = 0.0006) and atrial fibrillation rate (odds ratio, 0.49; 95% CI, 0.32 to 0.74; p = 0.0007); however, cardiopulmonary bypass time was longer (weighted mean difference, 20.88; 95% CI, −1.90 to 43.65; p = 0.07). There was no difference in terms of valve repair rate (odds ratio, 1.51; 95% CI, 0.89 to 2.54; p = 0.12), and the incidence of stroke was significantly lower in the high-quality analysis with no heterogeneity (odds ratio, 0.35; 95% CI, 0.15 to 0.82; p = 0.02; χ2 , 1.67; I2 , 0%; p = 0.43). Conclusions Minimally invasive mitral valve surgery is a safe and comparable alternative to standard sternotomy in patients at high risk, with similar early mortality and repair rate and better postoperative outcomes, although a longer cardiopulmonary bypass time is required.
Abstract
OBJECTIVES
We performed a literature meta-analysis to estimate the rate of pacemaker implantation after Perceval sutureless aortic valve replacement.
METHODS
Pertinent articles were ...identified from the PubMed, Google Scholar, Ovid MEDLINE and Ovid EMBASE databases. Eligible studies reported the de novo incidence of postoperative pacemaker implantation after Perceval valve surgery. Among 394 articles retrieved, 26 studies including 9492 patients met the inclusion criteria.
RESULTS
The pooled event rate for postoperative pacemaker implantation was 7% 95% confidence interval (CI) 6–9%; however, significant heterogeneity was observed across studies. In a sub-analysis, there was no difference between the rates of pacemaker implantation calculated from multicentre and registry studies (8 studies, 6845 patients; 7%, 95% CI 5–10%) and single-centre studies (18 studies, 2647 patients; 7%, 95% CI 5–9%; P = 0.75). Implantation rates were similar in high-volume studies (16 studies, 9121 patients; 7%, 95% CI 5–8%) than in low-volume studies (10 studies, 371 patients; pooled rate: 7%, 95% CI 4–14%; P = 0.5). Postoperative pacemaker implantation rates tended to decrease over time.
CONCLUSIONS
With a pooled event rate of 7%, postoperative pacemaker implantation remains an important limitation of Perceval sutureless valve surgery, although we observed a degree of variability across included studies. The resultant findings provide a useful estimate for physicians and patients and can serve as a benchmark for future comparative studies.
PROSPERO registration number
CRD42020188397.
Aortic valve replacement (AVR) with the Perceval sutureless aortic valve (Livanova PLC, London, UK) is associated with excellent operative and clinical outcomes, yet concerns still exist regarding the postoperative incidence of new atrioventricular conduction disturbances requiring permanent pacemaker implantation (PPI) 1, 2.
The severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) outbreak is a public health emergency affecting different regions around the world. The lungs are often damaged due to the presence of ...Sars-CoV-2 binding receptor ACE2 on epithelial alveolar cells. Severity of infection varies from complete absence of symptomatology to more aggressive symptoms, characterized by sudden acute respiratory distress syndrome (ARDS), multiorgan failure, and sepsis, requiring treatment in intensive care unit (ICU). It is not still clear why the immune system is not able to efficiently suppress viral replication in a small percentage of patients. It has been documented as pathological conditions affecting the cardiovascular system, strongly associated to atherosclerotic progression, such as heart failure (HF), coronary heart disease (CHD), hypertension (HTN) and diabetes mellitus (DM), could serve as predictive factors for severity and susceptibility during Sars-CoV-2 infection. Atherosclerotic progression, as a chronic inflammation process, is characterized by immune system dysregulation leading to pro-inflammatory patterns, including interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), and IL-1β. Reviewing immune system and inflammation profiles in atherosclerosis and laboratory results reported in severe COVID-19 infections, we hypothesized a pathogenetic correlation. Atherosclerosis may be an ideal pathogenetic substrate for high viral replication ability, leading to adverse outcomes, as reported in patients with cardiovascular factors. The level of atherosclerotic progression may affect a different degree of severe infection; in a vicious circle, feeding itself, Sars-CoV-2 may exacerbate atherosclerotic evolution due to excessive and aberrant plasmatic concentration of cytokines.
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