Faculty Bibliography

The elderly population is the fastest growing demographic in Western countries. As the population ages, the incidence of age-related comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, renal disease, cerebrovascular disease, and cardiovascular disease increases. With cardiovascular disease occurring in approximately one-quarter of the population over the age of 75 years and more than half of all cardiac procedures performed on this age group, the number of potential elderly surgical candidates is increasing. However, data suggest that old age is associated with increased morbidity and mortality following cardiac surgery. Over the past 2 decades, improvements in myocardial protection, extracorporeal circulation, anesthesia, and surgical techniques have significantly reduced the morbidity and mortality associated with cardiac surgery. Although most prospective studies exclude elderly patients, data from large retrospective studies and subgroup analyses suggest that cardiac surgery is a viable option for many elderly patients with cardiovascular disease, with good outcomes observed in reasonable-risk candidates; moreover, there are a growing number of available less-invasive options for them when surgical risk becomes prohibitive. In this article, we discuss the current state of cardiovascular surgery in the elderly as well as emerging technologies on the horizon.

Aims: Opportunities remain to improve TAVI outcomes. We evaluated the associations of aortic valve calcification, suboptimal sizing and implant depth with the need for permanent pacemaker implantation (PPI) from the pooled Evolut R CE and US Studies Methods and results: All patients from the Evolut R CE Study (n=60) and the first 91 patients in the CoreValve Evolut R US Clinical Trial were combined. The 23 mm Evolut R self-expanding valve was only studied in US patients. Aortic valve calcium volumes were obtained by using 3mensio software (Pie Medical Imaging, Maastricht, The Netherlands) from pre-implant multislice computer tomography (MSCT) Aortic root dimensions were measured from pre-implant MSCT. Percent oversizing was defined as 100*[(valve perimeter - annulus perimeter)/annulus perimeter]. Recommended implant depth was 3-5 mm below the aortic annulus. Left coronary cusp and non-coronary cusp depth of implant were determined from site-read implant angiograms. The need for PPI was determined at the investigator"s discretion. The 30-day PPI rate was used for analyses. Univariable and multivariable analyses were conducted to determine predictors of PPI. Mean age was 83.7+/-6.6 years and 68.9% were women. The mean Society of Thoracic Surgeons score was 7.3+/-3.5% and 73.5% had New York Heart Association class III/IV symptoms. General anaesthesia was used in 72.8%, pre-TAVI balloon valvuloplasty was performed in 56.3%, and 24.5% underwent post-TAVI balloon valvuloplasty. Most patients were treated via the iliofemoral route (94.7%). Implanted valve sizes were 29 mm (62.9%), 26 mm (35.8%) and 23 mm (1.3%). A PPI was required in 20 patients (13.3%) at 30 days. A pre-existing conduction disturbance was present in 12 patients (right bundle branch block =7 atrioventricular block =5). The reasons for PPI were; 2nd or 3rd degree atrioventricular block (n=18), right bundle branch block (n=1) and tachy/brady syndrome (n=1). Implant depth was significantly greater in patients who received a new PPI (average depth of 6.6 mm vs. 4.1 mm, P<0.0001). Neither aortic valve calcification (PPI=551.6+/-285.7m 3 ; no PPI=585.9 +/- 435.5m 3 , p=ns) nor percent oversizing (PPI=19.6+/-7.5%; no PPI=19.3+/-5.8%; p=ns) appeared to influence the rate of new PPI. Preexisting right bundle branch block and left coronary cusp depth of implant >5 mm were significant predictors of new PPI Conclusions: We found that both pre-existing conduction defects and not achieving the recommended implant depth were correlated with the need for a new pacemaker

Importance: Low-flow (LF) severe aortic stenosis (AS) is an independent predictor of mortality in patients undergoing aortic valve replacement (AVR). Little is known about improvement in flow after AVR and its effects on survival. Objective: To determine whether higher flow (left-ventricular stroke volume index [LVSVI]) after transcatheter AVR (TAVR) would indicate better clinical outcomes in this at-risk population. Design, Setting, and Participants: A substudy analysis of data from the Placement of Aortic Transcatheter Valves (PARTNER) randomized clinical trial and continued-access registry was conducted. A total of 984 participants with evaluable echocardiograms and baseline LF AS (LVSVI