Annals of cardiothoracic surgery最新文献

Background: Minimally invasive approaches in cardiac surgery have transformed the field by reducing surgical trauma and improving recovery outcomes. The lateral approach, using robotic and endoscopic technologies, offers superior visualization for complex procedures, such as combined aortic and mitral valve surgery. Addressing concurrent pathologies in the aortic and mitral valves increases procedural complexity, requiring precise techniques and optimal patient selection.

Methods: This retrospective, single-center study evaluated adult patients who underwent robotic or endoscopic combined aortic and mitral valve surgery between January 2015 and November 2024. Data on patient demographics, perioperative details, and postoperative outcomes including complications, mortality rates, and improvements in New York Heart Association (NYHA) functional status were analyzed.

Results: A total of 67 patients were included, with 8 undergoing robotic and 59 endoscopic procedures. No mortality or conversion to open surgery was observed. Postoperative complications were minimal, with a low infection rate of 1.5% and an atrial fibrillation rate of 26.8%. Over 85% of patients experienced significant improvement in NYHA functional status.

Conclusions: Robotic and endoscopic combined aortic and mitral valve surgery using the lateral approach is safe and effective, yielding excellent outcomes in a well-selected patient population.

Background: Robotic aortic valve replacement (RAVR) has seen a rise in usage in recent years; however, follow-up data remain limited. This study aimed to assess the short- and mid-term clinical outcomes after RAVR.

Methods: This study included patients who underwent RAVR between 2022 and 2024. The primary outcomes were mortality and survival at follow-up. The secondary outcomes were hospital complications and echocardiographic parameters at follow-up.

Results: Fifteen patients underwent RAVR. The mean age was 38.6±14.4 years, and 86.7% were males. The median Society of Thoracic Surgery (STS) score was 0.6%. Isolated RAVR was performed in 66.7% of the patients (n=10), whereas five patients underwent concomitant surgery, including mitral valve repair (n=1), mitral valve replacement (n=3), and ascending aortoplasty (n=1). Mechanical valves were used in 10 patients (66.7%). The mean ischemic time was 150±33.9 min. No sternotomy conversion was required. The median length of hospital stay was 9 days [quartile (Q)1-Q3, 4-15 days]. Four patients had on-table extubation (26.7%). One patient required intensive care unit (ICU) readmission, and one patient was readmitted for pleural effusion. The median follow-up was 24 months (Q1-Q3, 15-29 months). No mortality was reported during this period. All patients were in New York Heart Association (NYHA) class I, except for one in NYHA II. There were no significant changes in left ventricular ejection fraction (LEVF) at the last follow-up compared with the preoperative value (P=0.741). However, the left ventricular end-diastolic diameter (LVEDD) was significantly lower at follow-up than preoperatively (P=0.003).

Conclusions: RAVR demonstrates promising short- and mid-term clinical outcomes. Its minimally invasive nature and the ability to use durable mechanical valves may offer potential advantages over traditional surgical and transcatheter approaches.

Patients desire a minimally invasive option for management of their valve disease. As transcatheter aortic valve replacement (TAVR) remains a straightforward short-term solution, it is incumbent upon surgeons to provide an alternative, and preferably non-sternotomy or anterior chest option with the longitudinal benefits of surgical aortic valve replacement (SAVR). The present review will focus on the novel use of robotic aortic valve replacement (RAVR) via right lateral transaxillary mini-thoracotomy to perform standard SAVR, which permits the additional ability to perform concomitant procedures using the standard lateral approach popularized in mitral and atrial fibrillation surgery. We will define a role for RAVR in the current landscape of TAVR to provide a minimally invasive and durable operation, allowing for performance of concomitant procedures. Furthermore, we will focus on current literature supporting the safe and stepwise expansion of RAVR worldwide to provide patients requiring aortic valve replacement another option.

Background: Despite ever-growing adoption of transcatheter aortic valve replacement (TAVR) in younger healthier patients, a limited number of studies have described post-TAVR valve reinterventions such as surgical explantation known as "TAVR explant".

Methods: We performed a systematic review to characterize the current state of TAVR explant in patients with a failing transcatheter heart valve (THV) using data published by April 30, 2024 in compliance with the PRISMA and MOOSE reporting guidelines. The protocol was registered in PROSPERO (CRD42024529188).

Results: Twenty-eight studies met the eligibility criteria. Almost all studies were non-randomized, observational, and retrospective. The incidence of TAVR explant ranged from 0.2% to 2.8% in patients with a mean age of 67.3-79.0 years, and women representing 25.0-47.1% of cases. The mean time between TAVR implant and explant was 17.0-674.9 days, with most studies reporting a mean time <365 days. Whereas the Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score at the time of the TAVR implant ranged between 2.6% and 7.7% (with only one study with score >5%), the STS-PROM score at the time of the TAVR explant ranged between 3.9% and 9.9% (with 17 studies with score >5%). Isolated surgical aortic valve replacement (SAVR) happened in 16.2-100% of cases, aortic root replacement was required in 2.6-41.2%, ascending aortic replacement was performed in 3.2-33.3% of cases. Mitral valve repair/replacement was necessary in 11.8-43.5% and tricuspid valve/repair replacement was done in 2.8-25.0%. Stroke rates were between 0.0% and 20.0% with most studies with rates above 4.0%. The 30-day death rate ranged from 4.8% to 50.0% with most studies with mortality rates higher than 10%. Observed-to-expected mortality ratio was higher than 1.0 in almost all the studies that reported this variable.

Conclusions: TAVR explant remains a rare event, but its clinical impact is non-negligible. Lifetime management strategies should be adopted in younger lower-risk patients when choosing THVs for the index TAVR.

Surgical aortic valve replacement (SAVR) has long been the gold standard for treating significant aortic valve dysfunction. Since the introduction of transcatheter aortic valve replacement (TAVR) in 2011, the number of TAVRs has grown rapidly, surpassing SAVR volumes by 2018 and now accounting for approximately 80% of all aortic valve replacements (AVRs) performed in the United States. In conjunction with the rapid expansion of TAVR, the number of TAVR valves requiring surgical explantation (TAVR-explant) has also increased due to procedure-related failure, endocarditis, structural valve degeneration with unfavorable anatomy for redo-TAVR, paravalvular leak, delayed migration, or prosthesis-patient mismatch. Often involving concomitant cardiac surgery, TAVR-explant has been associated with higher operative mortality than redo-SAVR. TAVR-explant is currently the fastest-growing cardiac procedure in the United States and is expected to continue growing, especially as TAVR is increasingly used for lower surgical risk and younger patients. Accordingly, describing and disseminating a standardized set of technical principles for performing TAVR-explant is essential for preparing all cardiac surgeons to appropriately treat these patients. TAVR-explant requires a comprehensive preoperative clinical and cross-sectional imaging assessment to plan an effective operation, including cannulation, aortotomy, explantation, and implantation strategies. Particular considerations for self-expanding and balloon-expandable TAVR valves are important for guiding the operation and optimizing outcomes. Special considerations, such as the need for concomitant aortic, coronary, or mitral valve surgery and the presence of snorkel coronary artery stents adjacent to the TAVR valve, must be considered and addressed at the time of TAVR-explant surgery. Currently, TAVR-explant confers a high operative mortality and is performed at very low volumes per surgeon. As this operation becomes increasingly common, it will become essential for all cardiac surgeons to understand and implement the operation's various techniques to optimize patient outcomes.

Background: Prosthetic valve endocarditis is a rare yet devastating complication following transcatheter aortic valve replacement (TAVR). This study aims to investigate the outcomes of surgical versus medical management of post-TAVR endocarditis.

Methods: Between 2011 and 2024, 67 patients with post-TAVR endocarditis were identified, comprising 24 (35.8%) patients managed surgically and 43 (64.2%) managed medically. All cases were reviewed by our multidisciplinary endocarditis team to determine the optimal treatment strategy.

Results: The overall incidence of post-TAVR endocarditis was 1.4%. The number of endocarditis cases increased over time from 1-2 in 2015-2018 to 18 in 2023. The most frequent source of endocarditis was unknown (32.8%), and the predominant causative organism was enterococcus species (25.4%). Notably, among the 43 medically managed patients, 19 (44.2%) exhibited surgical indications, predominantly due to large vegetations with or without embolic complications (n=11; 57.9%). The medical management group had a higher proportion of females and more frequent use of self-expandable valves compared to the surgical group. The time interval between TAVR and endocarditis diagnosis was similar across both groups. In the surgically managed cohort, isolated aortic valve replacement was uncommon, with most patients undergoing complex TAVR explantations coupled with concomitant procedures, most frequently aortic root repair (n=11; 45.8%). The 30-day and 1-year mortality rates for the three groups (surgical, medical without surgical indications, and medical with surgical indications) were 0%, 4.2%, and 31.6% (P=0.002), and 4.2%, 20.8%, and 73.7% (P<0.001), respectively.

Conclusions: Surgical management was associated with significantly improved survival compared to medical management for post-TAVR endocarditis. The poor clinical outcomes in the medically managed group were primarily due to patients who did not undergo surgery despite having surgical indications. Prudent clinical judgment and timely surgical intervention when indicated are critical to enhancing the overall clinical outcomes of this challenging condition.