The ideal prosthesis for tricuspid valve replacement (TVR) continues to be debated. There are few published data comparing mechanical and bioprosthetic valves, and all are retrospective studies with ...relatively small sample sizes.
This study was conducted to compare mechanical and bioprosthetic valves for TVR.
A literature search of six databases (PubMed, EMBASE, Ovid, ScienceDirect, JSTOR, and Wiley Blackwell's online library) was performed with the keywords “tricuspid valve disease, tricuspid valve replacement and (bioprosthetic or mechanical)”. Primary outcomes were hospital mortality, long-term survival, tricuspid valve reoperation, valve failure, thrombosis, and thrombo-embolism. Risk ratio (RR) was used to compare dichotomous parameters and time-to-event outcomes. “Survival and re-interventions” were pooled using a meta-analysis of hazard ratios (HR). Publication bias was accessed using a funnel plot.
A total of 23 retrospective studies involving 945 mechanical and 1,332 biological tricuspid prostheses were included. The studies were published between January 2002 and September 2019. Hospital mortality (30-day mortality) did not differ between groups (RR, 0.83; 95% confidence interval CI, 0.66–1.05; p=0.12). Long-term survival was evaluated in 15 studies, and it was not significantly different between patients with mechanical compared with those with bioprosthetic valves (pooled HR, 0.97; 95% CI, 0.61–1.54; p=0.88). Freedom from tricuspid valve reoperation was assessed in eight studies, and no difference was found between the groups (pooled HR, 1.03; 95% CI, 0.63–1.69; p=0.89). Valve failure in the 5-year postoperative period was evaluated by seven studies, and there was no statistically significant difference between the two groups (pooled RR, 1.33; 95% CI, 0.42–4.27; p=0.63).
The results of this meta-analysis suggest an equal risk of 30-day and late mortality, reoperation, and 5-year valve failure in patients with mechanical versus biological TVR. The choice of the prosthesis in the tricuspid position should depend mainly on the patient's risk factors and no superiority of one prosthesis over the other in this position.
Pulmonary needle embolization in intravenous drug users is rarely reported in the literature. The management of these patients is controversial. We presented a male patient aged 33 years old who ...presented with a broken needle in the left arm after a trial of self-drug injection. During the trial to retrieve the needle, it embolized to the lung. Chest X-ray and CT scan showed the needle in the right lower lobe. We managed the patient conservatively; then, the patient was discharged on antiplatelet therapy. After the 6-month follow-up, the patient was asymptomatic with no complication.
Background: The use of rivaroxaban in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) poses the risk of over- or underdosing. We aimed to compare rivaroxaban and warfarin in ...AF patients with moderate and severe renal impairment.
Methods: This retrospective study was conducted between 2015 and 2016 to compare the use of warfarin (n = 164) and rivaroxaban (n = 149) in patients with AF and moderate or severe CKD. The study outcomes were survival, stroke, and major bleeding events. The median follow-up was 50 months (interquartile range: 23-60).
Results: Thirty-six patients had major bleeding: 24 with rivaroxaban and 12 with warfarin (P = 0.01). The rivaroxaban group had major bleeding in 3 patients with moderate CKD, 4 with severe CKD, and 17 on dialysis. Multivariable analysis of factors affecting major bleeding revealed that warfarin use lowered the risk of bleeding (hazard ratio: 0.34; P = 0.004). Stroke occurred in 14 patients: 6 in the rivaroxaban group and 8 in the warfarin group (P = 0.44). Survival at 1, 3, and 5 years was 89%, 77%, and 71% with warfarin and 99%, 94%, and 88% with rivaroxaban, respectively (P < 0.001). Multivariable analysis showed higher mortality in patients with lower creatinine clearance and those on warfarin.
Conclusions: The safety of warfarin could be better than rivaroxaban in patients with CKD with fewer bleeding complications but similar stroke rates. Further studies on rivaroxaban dosing in patients on dialysis are required.
Background
The debate about the optimal approach for aortic valve replacement continues. We compared the hospital and long-term outcomes (survival, aortic valve reintervention, heart failure ...readmissions, and stroke) between transcatheter vs. surgical (TAVR vs. SAVR) aortic valve replacement. The study included 789 patients; 293 had isolated SAVR, and 496 had isolated TAVR. Patients with concomitant procedures were excluded. Propensity score matching identified 53 matched pairs.
Results
Patients who had TAVR were significantly older (
P
˂ 0.001) and had significantly higher EuroSCORE II (
P
˂ 0.001), NYHA class (
P
˂ 0.001), and more prevalence of diabetes mellitus (
P
˂ 0.001), hypertension (
P
˂ 0.001), chronic lung disease (
P
= 0.001), recent myocardial infarction (
P
= 0.002), and heart failure (
P
˂ 0.001), stroke (
P
= 0.02), atrial fibrillation (
P
= 0.004), and previous percutaneous coronary interventions (
P
˂ 0.001) than SAVR patients. In the matched cohort, atrial fibrillation occurred more frequently after SAVR (
P
= 0.01), and hospital stay was significantly longer in SAVR patients (
P
˂ 0.001). There were no differences in hospital mortality between groups (
P
˃ 0.99). Survival at 1, 3, and 5 years was 97%, 95%, and 94% for SAVR and 91%, 79%, and 58% for TAVR patients. Survival was lower in TAVR patients before matching (
P
˂ 0.001) and after matching (
P
= 0.045). Freedom from the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission at 1, 3, and 5 years was 98.9%, 96%, and 94% for SAVR and 94%, 86%, and 75% for TAVR. The composite endpoint was significantly higher in the TAVR group than in SVR before matching (
P
˂ 0.001), while there was no difference after matching (
P
= 0.07). There was no significant difference in the change in ejection fraction between groups (
β
: −0.88 (95%
CI
: −2.20–0.43),
P
= 0.19), and the reduction of the aortic valve peak gradient was significantly higher with TAVR (
β
: −7.80 (95%
CI
: −10.70 to −4.91);
P
˂ 0.001).
Conclusions
TAVR could reduce postoperative atrial fibrillation and hospital stay. SAVR could have long-term survival benefits over TAVR with comparable long-term stroke, heart failure readmission, and aortic valve reinterventions between SAVR and TAVR.
Bleeding after transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The predictive value of the HAS-BLED score in TAVR patients is still to be evaluated. We assessed ...the value of the HAS-BLED score to predict in-hospital bleeding and mortality after TAVR and the impact of diferent renal impairment definitions on the predictive value of the score system.
We retrospectively included 574 patients who underwent TAVR at a single center. Study outcomes were 30-day mortality and the composite endpoint of major and life-threatening bleeding as defined by The Valve Academic Research Consortium-2. The predictive value of the HAS-BLED score was calculated and compared to a modified model. The performance of the score was compared using two definitions of renal impairment. Model discrimination was tested using C-statistic and the Net Reclassification Index.
Bleeding occurred in 78 patients (13.59%). HAS-BLED category 3 was a significant predictor of bleeding (OR: 1.99 1.18- 3.37, C-index: 0.56, P=0.01). C-index increased to 0.64 after adding body surface area and extracardiac arteriopathy to the model. The Net Reclassification Index showed an increase in the predic tive value of the model by 11.4% (P=0.002). The C-index increased to 0.61 using renal impairment definition based on creatinine clearance. Operative mortality was significantly associated with the HAS-BLED score (OR: 7.54 95% CI: 2.73- 20.82, C-index: 0.73, P<0.001).
The HAS-BLED score could be a good predictor of in-hospital mortality after TAVR. Its predictive value for bleeding was poor but improved by adding procedure-specific factors and using creatinine clearance to define renal impairment.
Background Blood-based cardioplegia is the standard myocardial protection strategy in pediatric cardiac surgery. Custadiol (histidine-tryptophan-ketoglutarate), an alternative, may have some ...advantages but is potentially less effective at myocardial protection. This study aimed to test whether custadiol is not inferior to blood-based cardioplegia in pediatric cardiac surgery. Methods The study was designed as a randomized controlled trial with a blinded outcome assessment. All pediatric patients undergoing cardiac surgery with cardiopulmonary bypass and cardioplegia, including neonates, were eligible. Emergency surgery was excluded. The primary outcome was a composite of death within 30 days, an ICU stay longer than 5 days, or arrhythmia requiring intervention. Secondary endpoints included total hospital stay, inotropic score, cardiac troponin levels, ventricular function, and extended survival postdischarge. The sample size was determined a priori for a noninferiority design with an expected primary outcome of 40% and a clinical significance difference of 20%. Results Between January 2018 and January 2021, 226 patients, divided into the Custodiol cardioplegia (CC) group (n = 107) and the blood cardioplegia (BC) group (n = 119), completed the study protocol. There was no difference in the composite endpoint between the CC and BC groups, 65 (60.75%) vs. 71 (59.66%), respectively (P = 0.87). The total length of stay in the hospital was 14 (Q2-Q3: 10-19) days in the CC group vs. 13 (10-21) days in the BC group (P = 0.85). The inotropic score was not significantly different between the CC and BC groups, 5 (2.6-7.45) vs. 5 (2.6-7.5), respectively (P = 0.82). The cardiac troponin level and ventricular function did not differ significantly between the two groups (P = 0.34 and P = 0.85, respectively). The median duration of follow-up was 32.75 (Q2-Q3: 18.73-41.53) months, and there was no difference in survival between the two groups (log-rank P = 0.55). Conclusions Custodial cardioplegia is not inferior to blood cardioplegia for myocardial protection in pediatric patients. Trial registration The trial was registered in Clinicaltrials.gov, and the ClinicalTrials.gov Identifier number is NCT03082716 Date: 17/03/2017 Keywords: Cardioplegia, Custadiol, Blood cardioplegia, Histidine-tryptophan-ketoglutarate
A primary cavopulmonary shunt as a component of the initial Norwood palliation could be an option in patients with hypoplastic left heart syndrome and single-ventricle lesions. We present our initial ...experience with this approach in carefully selected patients with unrestricted pulmonary blood flow and low pulmonary vascular resistance.
The study included 16 patients; the mean age was 137.9 ± 84.2 days. All patients underwent a Norwood palliation consisting of atrial septectomy, Damus-Kaye-Stansel connection, and arch augmentation in addition to the cavopulmonary shunt as the initial palliation.
The mean preoperative pulmonary to systemic blood flow (Qp/Qs) ratio on room air (n = 9) and with 100% oxygen (n = 8) was 5.3 ± 3.2 and 8.6 ± 4.3, respectively. The mean pulmonary vascular resistance on room air (n = 10) and 100% oxygen (n = 9) was 4.8 ± 3.1 and 1.7 ± 0.97 WU/m2, respectively. Delayed chest closure was needed in 12 patients, and 6 patients required postoperative inhaled nitric oxide. One patient underwent takedown of the cavopulmonary shunt and construction of the right ventricle to pulmonary artery conduit after 1 month. The mean intensive care unit stay was 18.9 ± 15.4 days. There were 2 in-hospital deaths (48 hours and 8 days after surgery) and 2 postdischarge deaths (6 months and 2 years after hospital discharge). Seven patients have undergone the Fontan completion successfully, and 5 patients await further surgery.
First-stage Norwood palliation with cavopulmonary shunt for patients with hypoplastic left heart syndrome or single-ventricle lesions is feasible in late presenters with low pulmonary vascular resistance.
This graphical abstract shows the methods, results, survival, and future implications of combined Norwood and cavopulmonary shunts (CPS) as first stage palliation for late presenter with hypoplastic left heart syndrome (HLHS) or single ventricle variants. DORV, Double outlet right ventricle; MA, mitral atresia; DILV, double inlet left ventricle; COA, coarctation; TA, tricuspid atresia; TGA, transposition of the great arteries; AVSD, atrioventricular septal defect; RV-PA, right ventricle- pulmonary artery; VVM, veno-venous malformation. Display omitted
Background
The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare ...long‐term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease.
Methods
We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs.
Results
There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio SHR: 1.22 0.77−1.95, p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 1.5−2.16, p < .001); body mass index (SHR: 1.05 1.03−1.08, p < .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 0.41−0.99, p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 1.03−2.78, p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 0.56−1.04, p = .09) or after matching (OR: 0.98 0.67−1.44; p = .93).
Conclusion
Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement.
New-onset postoperative atrial fibrillation (PoAF) is one of the most frequent yet serious complications following cardiac surgery. Long-term consequences have not been thoroughly investigated, and ...studies have included different cardiac operations. The objectives were to report the incidence and short- and long-term outcomes in patients with PoAF after mitral valve surgery.
This is a retrospective cohort study of 1401 patients who underwent mitral valve surgery from 2009 to 2020. Patients were grouped according to the occurrence of PoAF (
= 236) and the nonoccurrence of PoAF (
= 1165). Long-term outcomes included mortality, heart failure rehospitalization, stroke, and mitral valve reinterventions.
The overall incidence of PoAF was 16.8%. PoAF was associated with higher rates of operative mortality (8.9% vs. 3.3%,
< 0.001), stroke (6.9% vs. 1.5%,
< 0.001), and dialysis (13.6% vs. 3.5%,
< 0.001). ICU and hospital stays were significantly longer in patients with PoAF (
< 0.001 for both). PoAF was significantly associated with an increased risk of mortality HR: 1.613 (95% CI: 1.048-2.483);
= 0.03, heart failure rehospitalization HR: 2.156 (95% CI: 1.276-3.642);
= 0.004, and stroke HR: 2.722 (95% CI: 1.321-5.607);
= 0.007. However, PoAF was not associated with increased mitral valve reinterventions HR: 0.938 (95% CI: 0.422-2.087);
= 0.875.
Atrial fibrillation after mitral valve surgery is a common complication, with an increased risk of operative mortality. PoAF was associated with lower long-term survival, increased heart failure rehospitalization, and stroke risk. Future studies are needed to evaluate strategies that can be implemented to improve the outcomes of these patients.
Management of patients with end‐stage heart failure is still challenging. We report a case of idiopathic dilated cardiomyopathy who went through a challenging course. The case was presented as acute ...heart failure syndrome, which rapidly declined into cardiogenic shock and cardiac arrest that required an extracorporeal membrane oxygenator, then biventricular assist device implantation for circulatory support. The course was complicated with severe gastrointestinal bleeding and multiorgan failure until achieving full cardiac and organ recovery. The left ventricle ejection fraction improved from 10% to 50% at discharge.
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