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As the population ages and treatment options for heart valve disease increase, the number of patients with intracardiac valve prostheses is growing rapidly. Although all devices have the potential to cause thrombus formation, the propensity depends on the type of prosthesis as well as risk of the individual patient. Mechanical valve prostheses carry the highest (and persistent) risk of thromboembolism, and these patients require anticoagulation with vitamin K antagonists (warfarin). Required international normalised ratio levels are dependent on the location of the valve (mitral>aortic), type of valve (ball and cage vs bilealfet vs On-X bilealfet) and rhythm. The risk of tissue (biological) prosthesis is highest soon after surgery and is dependent on individual patient risk including age, valve location (mitral>aortic), history of thromboembolic events and rhythm. In patients with no other indication for anticoagulation, there is uncertainty on the benefits of anticoagulation versus antiplatelet therapy in patients with tissue prostheses or repaired native valves. Patients with an a priori indication for anticoagulation with a direct oral anticoagulant can continue taking this class of drug. Patients with transcatheter aortic valve implantation devices and no additional evidence-based indication for dual antiplatelet therapy or anticoagulation can be maintained on aspirin monotherapy. Patients undergoing transcatheter instrumentation in the mitral valve position should be anticoagulated, although there is currently no published evidence for antithrombotic management in this group of patients. Patients with thrombosed devices (commonly mitral mechanical) should preferably be treated surgically. Patients at high risk of thromboembolism (with mechanical prostheses) should undergo bridging therapy when undergoing surgery.

Decision aids as part of shared care are underutilized in surgery. Patient-Reported Outcome Measures (PROMS) are rapidly gaining interest as useful tools for various purposes in all fields of surgery. In this article, the author describes how PROMS can be used as decision aids in shared care between patients and health care workers, including surgeons.

Conventional surgical aortic valve replacement (AVR) is the ‘gold standard’ for treatment of severe or symptomatic aortic valve stenosis. The increasing age of patients and increasing comorbidities has led to the development of procedures to minimise operative time and reduce risks of surgery. One method of reducing operative times is the use of sutureless aortic valves (SU-AVR). We examine the current literature surrounding the use of SU-AVR. Alternatives to AVR are SU-AVR, sometimes referred to as rapid deployment valves, or transcatheter aortic valve implantation (TAVI). TAVI has been demonstrated to be superior over medical therapy in patients deemed inoperable and non-inferior in high and intermediate-risk patients compared with surgical AVR. However, the lack of excision of the calcified aortic valve and annulus raises concerns regarding long-term durability and possibly thromboembolic complications. TAVI patients have increased rates of paravalvular leaks, major vascular complications and pacemaker implantation when compared with conventional AVR. SU-AVR minimises the need for suturing, leading to reduced operative times, while enabling complete removal of the calcified valve. The increase in use of SU-AVR has been mostly driven by minimally invasive surgery. Other indications include patients with a small and/or calcified aortic root, as well as patients requiring AVR and concomitant surgery. SU-AVR is associated with decreased operative times and possibly improved haemodynamics when compared with conventional AVR. However, this has to be weighed against the increased risk of paravalvular leak and pacemaker implantation when deciding which prosthesis to use for AVR.

OBJECTIVES There is a lack of high-quality data informing the optimal antithrombotic drug strategy following bioprosthetic heart valve replacement or valve repair. Disparity in recommendations from international guidelines reflects this. This study aimed to document current patterns of antithrombotic prescribing after heart valve surgery in the UK. METHODS All UK consultant cardiac surgeons were e-mailed a custom-designed survey. The use of oral anticoagulant (OAC) and/or antiplatelet drugs following bioprosthetic aortic valve replacement or mitral valve replacement, or mitral valve repair (MVrep), for patients in sinus rhythm, without additional indications for antithrombotic medication, was assessed. Additionally, we evaluated anticoagulant choice following MVrep in patients with atrial fibrillation. RESULTS We identified 260 UK consultant cardiac surgeons from 36 units, of whom 103 (40%) responded, with 33 units (92%) having at least 1 respondent. The greatest consensus was for patients undergoing bioprosthetic aortic valve replacement, in which 76% of surgeons favour initial antiplatelet therapy and 53% prescribe lifelong treatment. Only 8% recommend initial OAC. After bioprosthetic mitral valve replacement, 48% of surgeons use an initial OAC strategy (versus 42% antiplatelet), with 66% subsequently prescribing lifelong antiplatelet therapy. After MVrep, recommendations were lifelong antiplatelet agent alone (34%) or following 3 months OAC (20%), no antithrombotic agent (20%), or 3 months OAC (16%). After MVrep for patients with established atrial fibrillation, surgeons recommend warfarin (38%), a direct oral anticoagulant (37%) or have no preference between the 2 (25%). CONCLUSIONS There is considerable variation in the use of antithrombotic drugs after heart valve surgery in the UK and a lack of high-quality evidence to guide practice, underscoring the need for randomized studies. The first 2 decades of this century have witnessed a shift in the choice of prosthetic heart valves amongst patients undergoing surgery for heart valve disease, with a fall in the use of mechanical valves and reciprocal increase in use of bioprosthetic valves and valve repair [1]. Graphical Abstract

ObjectivesTo date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice.DesignRetrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed.Setting27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis.Participants31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG.ResultsIn-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60–75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes.ConclusionsSurgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Average life expectancy is increasing in the western world resulting in a growing number of frail individuals with coronary heart disease, often associated with comorbidities. Decisions to proceed to invasive interventions in elderly frail patients is challenging because they may gain benefit, but are also at risk of procedure-related complications. Current risk scores designed to predict mortality in cardiac procedures are mainly based on clinical and angiographic factors, with limitations in the elderly because they are mainly derived from a middle-aged population, do not account for frailty and do not predict the impact of the procedure on quality of life which often matters more to elderly patients than mortality. Frailty assessment has emerged as a measure of biological age that correlates well with quality of life, hospital admissions and mortality. Potentially, the incorporation of frailty into current risk assessment models will cause a shift towards more appropriate care. The need for a more accurate method of risk stratification incorporating frailty, particularly for elderly patients is pressing. This article reviews the association between frailty and cardiovascular disease, the impact of frailty on outcomes of cardiac interventions and suggests ways in which frailty assessment could be incorporated into cardiology clinical practice.

Concomitant surgical ablation (SA) is recommended at the time of cardiac surgery in patients with AF but it remains widely underperformed. We sought to report on the safety and long-term efficacy of concomitant SA and the associated incidence of stroke and survival. A retrospective observational study was performed on patients with AF undergoing cardiac surgery between April 2011 and March 2022 with grouping based on whether or not they received concomitant SA. Thirty-day complications and long-term atrial tachyarrhythmia recurrence, stroke and mortality were compared between groups after propensity score matching. A total of 1,205 patients were included; two groups were obtained after matching (n=326 each). Post-operative length of stay was slightly longer in matched patients receiving concomitant SA (median 10 versus 9 days; p=0.048) but length of stay on intensive care and complication rates were similar in both groups. Freedom from atrial tachyarrhythmia in the SA group was 74% at 1 year and 58% at 3 years compared with 10% and 8%, respectively, for the no-SA group. Ten-year survival was increased for matched patients in the SA group compared with patients in the no-SA group (adjusted HR 0.61; 95% CI [0.45-0.82]; p=0.001) but the incidence of ischaemic stroke was similar (subdistribution HR 1.11; 95% CI [0.53-2.30]; p=0.790). In patients with AF undergoing cardiac surgery, concomitant SA was associated with improved long-term survival without increasing complications. Concomitant SA was not associated with an independent reduction in the long-term incidence of ischaemic stroke.

The first aortic valve prosthesis, implanted more than 50 years ago, was a mechanical prosthesis (ball-and-cage design). Over the ensuing decades, tissue prostheses and new mechanical designs were introduced to mitigate the need for anticoagulation with its associated side effects. Tissue and mechanical heart valve prostheses were compared in two head-to-head randomised control trials. Both of these confirmed that mechanical prostheses were durable but patients suffered anticoagulant-related bleeds. Patients who received a tissue prosthesis were more likely to suffer prosthetic dysfunction and require reoperation. This trend was stronger in younger patients. Since the publication of those two trials, several large retrospective studies using data from meta-analyses of published papers or registries have failed to show a survival advantage of either prostheses when implanted in the aortic position in younger patients. This equipoise has been reflected in the heart valve disease guidelines published by European and US societies. In recent years, the primacy of patient choice, the rapid increase in life expectancy of populations, the increased incidence of atrial fibrillation with requirement for anticoagulation, the advent of transcatheter techniques to treat degenerating tissue valves as well as advances in anticoagulant therapy and in new tissue and to a lesser extent mechanical prosthetic design continue to influence choice of aortic valve prosthesis in younger patients undergoing aortic valve replacement.

Echocardiography plays a vital role in the follow-up of patients with replacement heart valves. However, there is considerable variation in international guidelines regarding the recommended time points after implantation at which routine echocardiography should be performed. The purpose of routine echocardiography is to detect early structural valve deterioration in biological valves to improve the timing of redo interventions. However, the risk of valve deterioration depends on many valve-related factors (valve design and patient prosthesis mismatch) and patient-related factors (age, diabetes, systemic hypertension, renal dysfunction and smoking). In this statement, the British Heart Valve Society and the British Society of Echocardiography suggest practical guidance. A plan should be made soon after implantation, but this may need to be modified for individual patients and as circumstances change. It is important that patients are managed in a multidisciplinary valve clinic.