Citations

Abstract Objectives This study examined the indications, frequency, and outcomes of cardiac surgery following transcatheter aortic valve replacement (TAVR) at a single institution. As TAVR volumes increase, understanding the nature and outcomes of subsequent cardiac operations is critical, particularly as the procedure expands to younger, lower-risk populations. Methods We analysed outcomes of 61 patients who underwent cardiac surgery after TAVR at our institution from August 2011 to September 2023, excluding periprocedural complications and staged procedures. Patients were stratified into 2 groups: those requiring surgical aortic valve replacement (SAVR) with or without concomitant procedures (n = 33) and those undergoing non-SAVR cardiac operations (n = 28). Data were collected from a prospectively maintained cardiovascular surgery database and electronic health records. Indications for surgery, operative characteristics, and outcomes were analysed, with survival assessed using Kaplan-Meier estimates. Results The median interval between TAVR and cardiac surgery was 19 months. Indications for SAVR included infective endocarditis (36%), non-structural valve deterioration (36%), structural valve deterioration (12%), and valve thrombosis (6%). Non-SAVR operations primarily addressed mitral valve disease (43%) and coronary artery disease (29%). Operative mortality was 6.6%, with no deaths in the endocarditis subgroup. Postoperative complications included prolonged mechanical ventilation (18%), new-onset renal failure (7%), and stroke (2%). Kaplan-Meier survival estimates were 83% at 1 year and 50% at 5 years. Conclusions Although complex, cardiac operations in patients who have undergone TAVR can be performed with acceptable mortality rates. Structural valve deterioration, paravalvular leak, and endocarditis were the primary indications for SAVR, while mitral valve and coronary artery disease predominated in non-SAVR cases. These findings highlight the importance of considering nonaortic valve pathologies in TAVR planning, particularly as the procedure expands to younger, lower-risk populations.

Abstract Mitral annular calcification with severe mitral valve (MV) stenosis can be difficult to treat with conventional MV replacement. Annular decalcification can cause atrioventricular groove disruption and bleeding. An alternative is to bypass the narrowed MV using a valved left-atrial-to-left-ventricle conduit. A 48-year-old gentleman with obstructive-hypertrophic cardiomyopathy and severe calcific MV stenosis presented with progressive dyspnea, syncope, and fatigue. Medical history included hypertension, dialysis dependent ESRD, chronic-AF, pulmonary-hypertension, and NSVT. A grade III/IV mid-systolic murmur was audible at the LSE, and a grade II/IV mid-diastolic rumble. Echocardiography showed sigmoid septum with maximum thickness of 24-mm, severe calcific MV-inflow obstruction (MVA 0.87 cm2, mean gradient 15-mmHg, heart rate 60-bpm), and midventricular LVOT obstruction (resting gradient 96-mmHg). Because of NYHA class III symptoms, surgery was performed with plans for MV-bypass using a valved-conduit and midventricular myectomy. Following institution of CPB and cardioplegic arrest, the LAA was excised and a 26-mm Hemashield graft was beveled and sewn into the atriotomy. An anterolateral ventriculotomy was made near the apex of the heart and an extensive midventricular myectomy was performed through the incision. A 25-mm Hancock-II bioprosthesis was sewn into the conduit. Distal end of the conduit was beveled and anastomosed to the ventriculotomy. Postoperatively, median native-MV gradient reduced to 7-mmHg (heart rate 86-bpm). Recovery was uneventful. He was dismissed on postoperative-day 8 and continues to do well 5-months later. MV-bypass using a valved LA-to-LV conduit is safe alternative to conventional MVR for relief of severe MS with MAC, particularly in patients with oHCM who require midventricular myectomy.

Abstract Aim Describe the mechanism(s) of residual or recurrent obstruction in patients who have previously undergone septal myectomy for hypertrophic cardiomyopathy and assess early outcomes of reoperation. Method From January 1989 to March 2022, we performed 73 repeat myectomies at our institution. Patients’ demographics, operative details, echocardiographic parameters, and postoperative complications were retrieved from a prospectively maintained surgical database and electronic healthrecords. Results Median age at reoperation was 48.3 years (IQR 38.6-58.6); 51 patients were women (69.9%). 90.4% presented with NYHA class III/IV symptoms. Median interval between previous myectomy and reoperation was 2.7 years (IQR 1.2-4.5). Mechanism of obstruction was an inadequate length of previous septectomy in 41 patients (56.2%), a combination of inadequate length and midventricular obstruction in 30 (41.1%), and isolated midventricular obstruction in 2 patients (2.7%). There were no instances of recurrent LVOT obstruction due to muscle regrowth at the site of previous resection. All patients had an extended transaortic septal myectomy; 14 patients (19.2%) had concomitant transapical myectomy. Preoperatively, the median LVOT gradient was 83 mmHg (IQR 60-122), which reduced to 2 mmHg (IQR 0-7) following repeat myectomy. There were no perioperative deaths. Postoperatively, 4 patients (5.5%) developed a new CHB, necessitating PPM implantation. The 5-,10-, and 20-year survival after reoperation were 100%, 91%, and 76%, respectively. Conclusions Inadequate resection at the time of primary septal myectomy is the commonest cause of residual or recurrent obstruction in oHCM patients. However, repeat myectomy, including a combined transaortic and transapical approach has minimal risk with excellent hemodynamic and long-term survival outcomes.