Background: Myocardial protection in reoperations in cardiac surgery is extremely difficult in patients with previous coronary surgery and a working LIMA-LAD graft, and it largely determines the outcome of surgery and long-term prognosis. We use a the method of percutaneous angiographic balloon LIMA occlusion and cardioplegic arrest. Aims: The aim of this study was to compare the data of patients with angiographic balloon LIMA-occlusion and those without occlusion in operations related to PVE, and previous coronary surgery with permeable LIMA graft, determining the degree of safety and benefits of method. Study design and Methods: A total of 20 patients undergoing surgery for prosthesis valve endocarditis with patent LIMA-LAD graft were analyzed retrospectively. We divide the patients into 2 groups. Group A patients - with LIMA occlusion and Group B patients - without LIMA occlusion). The pre-, intra- and postoperative results were compared and the degree of safety and benefits of the application of the method were studied. Results: 80% of patients in group A needed only dopamine infusion and 20% needed the addition of a second catecholamine (Adrenaline) at the end of CPB. In group B, the need for double catecholamine maintenance is in 50% of patients. The need for implantation of an intra-aortic balloon pump due to refractory heart failure was registered in 10% of patients in group A and in 20% of patients in group B. It was found that the average duration of mechanical ventilation in group A is 10.5 hours postoperatively, and in group B - 12.5 hours. The mean duration of catecholamine infusion in both groups was 3 days. The average stay in intensive care is shorter for patients in Group A - 2.5 days, and in Group B is 3.5 days. In terms of survival - mortality in the group with LIMA occlusion is 0%, while in the group without LIMA occlusion is 20%. Conclusion: Our reported results from the use of the LIMA balloon occlusion method in patients with prosthetic valve endocarditis who are high-risk and complicated patients and nevertheless the mortality in this group studied by us is 0% and no serious complications of the applied method have been registered. Therefore, we believe that the angiographic balloon LIMA occlusion is a reliable, easily applicable and relatively safe technique that improves the surgical results and prognosis of patients in need of reoperative cardiac surgery.
Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.
Epicardial exclusion of LAA has gained increasing popularity since its introduction in 2009. While the clip has demonstrated a success rate ranging from 93.9-100% in excluding the LAA, one significant complication is incomplete exclusion due to residual stump (> 1 cm) as a result of the clip being deployed too distally. We describe here the first reported case of implanting a second clip underneath the first clip to obliterate the residual stump for a 71-year-old male with AF evaluated for intervention for stroke risk reduction.
Background: Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its non-invasive, user-friendly, and relatively inexpensive nature. Aim of Study: To provide a comprehensive summary of cerebral oximetry in cardiac surgery. The review interrogates multiple systematic reviews assessing different outcomes in cardiac surgery to assess if cerebral oximetry is effective. Further, the review analyzes all available interventions for an acute desaturation to determine the efficacy of individual interventions. Methods: A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses were performed through August 2021. Results: There is significant heterogeneity amongst studies regarding the definition of a clinically significant cerebral desaturation. In addition, the assessment of neurocognitive outcomes has large variability, making metanalysis challenging. To date, cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality. The evidence to support particular interventions for an acute desaturation is equivocal. Conclusions: Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.
Background: Synovial sarcoma is a rare soft-tissue malignant tumor most commonly occurring in the extremities and head and neck region, and rarely occurring in the pericardium. Case presentation: We report a 7-year-old boy was admitted to the hospital with recurrent fever and chest pain over the past four months. A cardiac magnetic resonance imaging (MRI) revealed a tumor beneath the heart in the pericardial, and we surgical resection it completely. The postoperative histopathological examination resulted in a diagnosis of monophasic spindle cell type synovial sarcoma. After two weeks of hospitalization, the patient was discharged. Three months after discharge, the positron emission tomography (PET/CT) scans did not show any signs of recurrence. Conclusion: Pericardial synovial sarcoma is a rare disease that is detected early, and complete resection improves patient survival. We recommend CT be performed in patients with recurrent fever and sizeable pericardial effusion to rule out possible pericardial synovial sarcoma considering the echocardiography limitations.
Introduction: Opinion is divided about optimal early timing of the Fontan Operation (FO). While some studies have suggested 3 years-of-age, others have shown good outcomes below 2 years-of -age. We analyzed the impact of age ≤2-years as compared age >2-years on short-term outcome of the FO using a large national database. Methods: A retrospective analysis of the Kids Inpatient Database (2009-16) for the FO was done. The groups were divided into those who underwent FO at age ≤2-years (EF) as compared to age >2-years (LF). The data was abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. Results: 3381 patients underwent FO during this period of which 1482 (44%) were EF. The mean ages of the EF and LF were 1.6 and 4.3, respectively (p< 0.001). LF were more likely to be non-White, female, and have Heterotaxy syndrome. HLHS was more common in EF. There was no difference in the discharge mortality, length of stay, disposition (majority went home), and mean total charges incurred. The overall discharge mortality was low at 0.7% (24/3381). In multivariate analysis: cardiac arrest, acute kidney injury, mechanical ventilation >96 hours, endocardial cushion defect and non-White ethnicity were predictors of a mortality and not age. Conclusion: Contemporary outcomes for FO are excellent with equivalent short-term outcomes in both the age groups. Occurrence of postoperative complications, non-white ethnicity and endocardial cushion defect diagnosis were predictive of a negative outcome.
Impact of prior sternotomy on survival and allograft function after heart transplantation: a single-center matched analysisPrior sternotomy versus primary heart transplantEditorialE. Potapov, J. SteinIn the presented study, the authors showed that prior sternotomy in heart transplant candidates does not impact survival after heart transplantation (reference). The analysis was performed between 106 propensity score-matched pairs (212 patients).The results of published studies are contradictory and confusing. The small, single-center study published by Sert D, 2020, showed an increased early mortality in HTx recipients with prior sternotomy1, with no increased bleeding risk and a similar 4-year survival. In contrast, yet another single-center study with a similar design –no sternotomy vs. VAD-supported vs. prior sternotomy other than for VAD– published by Gaffey in 2015 showed no differences regarding early and long-term mortality, but a significantly higher risk of postoperative bleeding and a greater use of blood products2. A further single-center study with a comparable number of patients published in 2018 by Still S yet again showed that HTx recipients with prior sternotomy required more blood transfusions and showed an increased incidence in postoperative pneumonia, wound infection, and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of primary graft dysfunction with a subsequently higher short-term and 1-year mortality3. However, in these studies the impact of confounding variables was not eliminated.Having said that, the presented study attempts to overcome imbalances in confounding variables by comparing survival and complications between propensity score-matched patient groups. The matching procedure was based on established risk factors including recipients’ baseline characteristics, donor age, sex mismatch, risk scores, ECLS, PVR, serum creatinine, and serum bilirubin, and ultimately produced 106 matched pairs. However, the benefit of balanced confounders is achieved at the cost of a reduced number of patients and therefore less power to detect differences between patient groups. The lack of significant differences in this study cannot merely be explained by a low power, but is instead due to the similarity of effects: Authors report a 30-day mortality of 5.7 % for prior sternotomy vs. 7.5 % for first-time sternotomy and no impact of prior sternotomy on long-term survival with an HR of 0.87 [95% CI: 0.57, 1.56]. Contradicting the above-mentioned studies, these results do not even come close to indicating a trend towards worse long- and short-term survival for patients with prior sternotomy. This also holds true for long-term survival in the unmatched population of 131 patients with and 381 patients without redo surgery.Now how about a larger registry-based analysis? An analysis based on the UNOS database comprising 11,266 patients showed that prior sternotomy was associated with an excess 3.3 % mortality and higher morbidity within the first 60 days after heart transplantation, as measured by the frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy4. Five years later, another group performed an analysis of the same UNOS database (meanwhile comprising 14,730 patients) and showed again that prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to an increased early postoperative mortality5.Why are we interested in knowing the effect of prior sternotomy on post-transplant outcomes? Since a prospective, randomized study is not possible due to ethical reasons, we have to rely on retrospective analyses. From a practical perspective, a comparison is meaningless – patients with prior sternotomy would never be refused for HTx due to this fact alone, even if we knew that morbidity and mortality in these patients may be higher.In our opinion, such an analysis may be performed to identify and support the advantages of less invasive LVAD implantation regarding the outcome of later HTx, as was performed in a first analysis of 46 patients (sic!, the lowest number of patients among the discussed studies) published by Riebandt J, 20216. The study showed that patients supported with LVAD implanted via full sternotomy required more packed red blood cells with no increased risk of bleeding, and subsequently developed more donor-specific antibodies, however, without any impact on short- and long-term survival, similar to the studies discussed above2,3.However, the virgin chest is not comparable to that of patients supported with an LVAD implanted via a less invasive approach, even if no7 or partial sternotomy8 is performed. In either of the groups the pericardium remains intact. Regardless of the technique used, the left pleura is opened, as is the pericardium around the ascending aorta and the apex of the right and left ventricles, and the graft is placed into the pericardial space, causing adhesions making any efforts to suggest, that the HTx in the “virgin chest”is similar to that after less invasive LVAD implantation not appropriate.Finally, the authors should nonetheless be congratulated on their outstanding surgical experience and the resulting very good outcomes in HTx – better than in the majority of centers worldwide.References1. Sert DE, Kervan Ü, Kocabeyoğlu SS, et al. Early and long-term results of heart transplantation with reoperative sternotomy. Turk gogus kalp damar cerrahisi dergisi 2020;28:120-6.2. Gaffey AC, Phillips EC, Howard J, et al. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. The Annals of thoracic surgery 2015;100:542-9.3. Still S, Shaikh AF, Qin H, et al. Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation. Interactive cardiovascular and thoracic surgery 2018;27:343-9.4. Kansara P, Czer L, Awad M, et al. Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database. Transplantation proceedings 2014;46:249-55.5. Axtell AL, Fiedler AG, Lewis G, et al. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2019;55:1136-43.6. Riebandt J, Wiedemann D, Sandner S, et al. Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes. Seminars in thoracic and cardiovascular surgery 2021.7. Potapov EV, Kukucka M, Falk V, Krabatsch T. Off-pump implantation of the HeartMate 3 left ventricular assist device through a bilateral thoracotomy approach. The Journal of thoracic and cardiovascular surgery 2017;153:104-5.8. Nersesian G, Potapov E, Starck CT, et al. Surgical Implantation Techniques of Modern Continuous Flow Ventricular Assist Devices. Surgical technology international 2021;37:263-9.
Around 3-4 children born with congenital heart diseases have univentricular hearts, where the prognosis of univentricular hearts is poor in the past, with a survival rate of less than 50% during the first year and 10% during the first ten years of life. Based on a literature search, current advances in perioperative management of neonates with complex congenital heart diseases have increased their survival rate by 85%. To aid cardiothoracic surgeons worldwide, this comprehensive literature review will focus on the perioperative management of staged palliation surgery for functional univentricular hearts, considering current trends as well as how we do it in our centre. Our review article specifially discusses perioperative strategies regarding surgical considerations, current techniques, to deal with overshunting and undershunting during the first stage of palliation surgery. This article also gives an overview on when a patient is suitable to go through with the next stage of the procedure, which is the implementation of a bidirectional cavopulmonary shunt or the Hemi-Fontan procedure. Lastly, this article gives a comprehensive approach regarding perioperative strategies of the Fontan procedure, which include patient criteria, current surgical techniques, postoperative management, as well as the use of anticoagulants after the Fontan procedure.
Background: Intraextracardiac Fontan procedure aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our experience in our patients with intraextracardiac fenestrated Fontan Procedure. Methods: A retrospective analysis was performed in order to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. Results: Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis prior to Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow up were 10 ± 2.4 mmHg and 91.3 ± 2.7 %, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. Conclusions: The mid-term results of intraextracardiac fenestrated Fontan procedure are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
Background: Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 hours post-ECMO on neurological outcome in VA-ECMO patients. Methods: This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 hours post-ECMO. Primary outcome was good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Results: Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 hours of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 hours while 18 of those 88 patients (14.2%) had a mean temperature<36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (Odds Ratio [OR]=1.16, 95% Confidence Interval [CI]=1.04-1.31, p=0.01) after adjusting for age, severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-hour PaO 2. Neither duration of mild hypothermia (OR=0.93, CI=0.84-1.03, p=0.17) nor mean temperature (OR=0.78, CI=0.29-2.08, p=0.62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p=0.47) and mean 24-hour temperature (p=0.76) were not significantly associated with frequency of systemic hemorrhages. Conclusions: In this single center study, longer duration of mild hypothermia during the first 24 hours of ECMO support was significantly associated with improved neurological outcome. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.
Cardiac angiofibroma is a very rare diagnosis when a patient develops an intracardiac mass. It is a primary benign cardiac tumor with a scarcity of information in the literature. This case report illustrates a 26-year-old man with a complaint of chronic chest tightness who was firstly diagnosed with right ventricle tumor by echocardiography then underwent cardiac MRI which confirmed the presence of a highly-vascular tumor with radiologically benign behavior. Then his tumor was excised, his postoperative course was uncomplicated and he was well within almost 2 months after discharge. Ultimately the histopathologic findings demonstrated vascular and stromal tissue in favor of angiofibroma and excluded the other diagnoses with IHC and trichrome staining. Angiofibroma is a benign, highly vascular tumor, mostly discovered in the nasopharynx. When it is found in the heart, CMR and pathology are pivotal to rule in its diagnosis. It is isointense in T1 weighted and hyperintense in T2 weighted sequences with intense enhancement following contrast injection. Its pathology contains an admixture of vasculatures with CD31 positive immunoreactivity for endothelial cells and fibrotic tissue with bluish coloration in trichrome staining. Eventually, its treatment includes merely surgical excision given its benign nature.
Background The aim of this study was to analyse the perioperative results and long term survival of re-sternotomy for surgical aortic valve replacement (SAVR) in octogenarians. Methods This is a retrospective, single centre study (Apr 2000 – Dec 2019). Perioperative data were compared for re-sternotomy with isolated SAVR (Isolated redoSAVR) and re-sternotomy with SAVR and concomitant cardiac procedure (Associated redoSAVR). Regression analyses were performed to identify predictors of in patient mortality. Hazard ratios were calculated, and Kaplan Meier survival curves were compared for groups. Results There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). Mean age was 83±3 years and mean logEuroSCORE was 21±12. Follow up was 4.2±3.5 years. Inpatient mortality was 4.9% (1.4% versus 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p=0.08). TIA/stroke rate was 8% (9% versus 7% for Isolated redoSAVR and Associated redoSAVR respectively, p=0.78). COPD was a predictor of inpatient mortality (OR; 8.86, 95%CI; 1.19, 66.11, p=0.03). Survival was 88.7% at 1 year, 86.4% at 2 years, 70.1% at 5 years, 49.5% at 7 years and 26.3% at 10 years. There was no survival difference between Isolated redoSAVR and Associated redoSAVR (logrank p=0.36, Wilcoxon p=0.84). Significant predictors of adverse long term survival were COPD, postoperative TIA/stroke and length of stay. Survival is lower than age and gender matched first time SAVR and general population of UK. Conclusions RedoSAVR in octogenarians is associated with acceptable but significant morbidity and mortality. Shared decision making should consider emerging transcatheter therapies as viable options in selected patients.
We report a rare case of successful left ventricular restoration of left ventricular hypertrabeculation/noncompaction (LVHT) after Bentall procedure in a patient with severe aortic regurgitation (AR) and aortic root aneurysm. At 1-year follow-up, he remained well with echocardiography showing the improved contractility of the noncompacted left ventricle. This case report emphasize that timely surgical correction of severe AR may also lead to improvement of systolic dysfunction along with concomitant LVHT.
Objective: To investigate whether it is better to have surgery before pregnancy for pregnant women with congenital heart disease (CHD). Methods: Patients with CHD in Beijing Anzhen Hospital from 2010 to 2019 were collected and divided into surgical and non-surgical group, and the differences of events between the two groups were compared. Results: A total of 999 patients with CHD (mean age, 28.7±4.3years) were collected, including 403 cases (40.0%) in the surgical group and 596 cases (60.0%) in the non-surgical group. The most common CHD was atrial septal defect(33.1%), followed by ventricular septal defect (26.9 %), patent ductus arteriosus (9.9 %), and Tetralogy of Fallot (6.9 %). There were significant statistical differences in region, education degree and gravidity (P＜0.05), and the percentage of almost all events in the surgical group was higher. Pre-term delivery (17.1 vs. 9.9), low birth weight (11.6 vs. 6.5), heart failure (6.7 vs. 2.7), cesarean section (85.9 vs. 75.7), pulmonary arterial hypertension (36.2 vs. 13.6), Eisenmenger syndrome (9.7 vs. 0.2), and death (2.3 vs. 0.5) had statistically significant (P＜0.05). A total of 16 (1.6%) patients died, 14 (87.5%) in the surgical group, more than 2 (12.5%) in the non-surgical group. Conclusions: The outcome of surgical group was better than that of non-surgical group, surgery before pregnancy can reduce maternal and infant risk.
Background The European CE Mark approval study and the MOMENTUM 3 trial demonstrated safety and a reduction in hemocompatibility-related adverse events with use of HeartMate 3 (HM3) device. This single center study investigated the real-world experience in HM3 patients since FDA approval. Methods This retrospective, observational study included patients implanted with the HM3 LVAD as a primary implant between October 2017-March 2020. Patients were divided into trial group and postapproval group. Primary endpoint was survival at 6 months. Secondary endpoints were adverse events including pump thrombosis (requiring pump exchange), stroke, renal failure, acute limb ischemia, re-exploratory for bleeding, gastrointestinal bleeding, right ventricular failure, and driveline infection. Results A total of 189 patients were implanted with HM3 device during the study period. 174 patients met the inclusion criteria: 82 patients in the trial group and 92 patients in the postapproval group. The postapproval group had younger patients, higher pre-operative mean international normalized ratio, and greater numbers of patients with bridge to transplant (BTT) indications, IINTERMACS profile 1, and use of mechanical assist devices (other than IABP) than the trial group. Other characteristics between the two groups were comparable. Overall survival at 6 months in the postapproval group was 93.3% vs. 93.8% ( p=0.88). The postapproval group demonstrated a statistically significant lower incidence of re-explorative surgery for bleeding (10.9% vs 46.3, p=0.01) than the trial group. Conclusion In this single-center study, the real-world 6-month survival in the postapproval group was comparable to the trial results. Further studies are needed to monitor long-term outcomes.
Introduction: Postoperative atrial fibrillation (POAF) is a frequently reported complication of cardiac surgery, leading to increased in-hospital and long-term mortality rates. Many studies have suggested using statins to protect against POAF. Thus, we aim to investigate if statin pre-treatment may effectively lower the incidence of POAF. Method: We performed a systematic literature search of PubMed for potential studies between January 2006 and August 2021. Principal inclusion criteria were: randomized clinical trials study design; statin-naive patients; total study participants ≥ 50 units. We used the fixed-effects model to obtain the odds ratio (OR) and 95% confidence interval (CI) for each analyzed intervention. Results: Overall, statin pre-treatment reduced the incidence of POAF compared to placebo (OR 0.71; 95% CI: 0.60-0.85, p-value < 0.00001). Analyzing subclasses, atorvastatin was associated with lower incidence of POAF (OR 0.54; 95% CI: 0.41-0.70, p-value = 0.002), but rosuvastatin was not (OR 0.90; 95% CI: 0.71-1.14, p-value = 0.38). Selecting studies with ≥ 199 patients, results were divergent. There was not statistically significant difference between statin pre-treatment and placebo (OR 0.89; 95% CI: 0.74-1.09, p-value = 0.26), as well as for atorvastatin (OR 0.74; 95% CI: 0.54-1.03, p-value = 0.08) and rosuvastatin (OR 0.87; 95% CI: 0.68-1.12, p-value = 0,29). Conclusion: Statin pre-treatment before cardiac surgery is not associated with a significant reduction in POAF occurrence. Thus, based upon our results and considering possible renal complications, we discourage statin pre-treatment in preventing POAF.
Objectives: Subclavian (SC) and transapical (TA) approach are the main alternatives to the default femoral delivery for transcatheter aortic valve implantation (TAVI). Aim of this study was to compare, complications and morbidity/mortality associated with SC and TA in a long-term time frame. Methods: From January 2007 to July 2015, 1,506 patients underwent TAVI surgery in 36 United Kingdom TAVI centres. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival. Results: The enrolled patients were distributed as follows: 1,216 in the trans-apical (TA) group and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, paravalvular leak, balloon post dilatation, cardiac tamponade, stroke, renal replacement therapy, vascular injuries, and 30-days mortality among the groups. Conversely, the rate of permanent pacemaker implantation (p = 0.02), the procedural time duration (p = 0.04), and the 12-month mortality (p = 0.03) was higher in SC than in TA, while in-hospital length of stay was reduced in SC than in TA (p = 0.01). Up to 8-years, the long-term mortality was not different among groups (p = 0.77), and no difference in long-term survival between self vs balloon expandable device was found (p = 0.26). Conclusions: According to our results, TA provided the best 12-months survival compared to SC, while the long-term survival up to 2, 900 days is not significantly different between groups, so SC and TA may both represent a safe non-femoral access if femoral is precluded.
Background The ideal aortic valve replacement strategy in young- and middle-aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long-term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients. Methods Data were retrospectively collected for patients 18 to 50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well-matched pairs from a total of 216 eligible patients. Results Demographic and preoperative characteristics were similar between the two groups. Median follow-up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population ( p < 0.01). Overall survival ( p = 0.93), freedom from reintervention and valve dysfunction free survival ( p = 0.91) were equivalent. Conclusions In this mid-term propensity score-matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long-term anticoagulation. At specialized centers with sufficient expertise, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.