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Cardiovascular Surgery

Position Papers and Consensus Documents from the ESC Working Group on Cardiovascular Surgery

Management of tricuspid valve regurgitation: Position statement of the European Society of Cardiology Working Groups of Cardiovascular Surgery and Valvular Heart Disease

Authors: Manuel J. Antunes, José Rodríguez-Palomares, Bernard Prendergast, Michele De Bonis, Raphael Rosenhek, Nawwar Al-Attar, Fabio Barili, Filip Casselman, Thierry Folliguet, Bernard Iung, Patrizio Lancellotti, Claudio Muneretto, Jean-François Obadia, Luc Pierard, Piotr Suwalski, Pepe Zamorano

On behalf of the ESC Working Groups of Cardiovascular Surgery and Valvular Heart Disease

European Journal of Cardio-Thoracic Surgery, ezx279, Doi: 10.1093/ejcts/ezx279, Published: 21 August 2017

Abstract: Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for left-sided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease.

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ESC Joint Working Groups on Cardiovascular Surgery and the Cellular Biology of the Heart Position Paper: Peri-operative myocardial injury and infarction in patients undergoing coronary artery bypass graft surgery

Authors: Matthias Thielmann, Vikram Sharma, Nawwar Al-Attar, Heerajnarain Bulluck, Gianluigi Bisleri, Jeroen JH Bunge, Martin Czerny, Péter Ferdinandy, Ulrich H. Frey, Gerd Heusch, Johannes Holfeld, Petra Kleinbongard, Gudrun Kunst, Irene Lang, Salvatore Lentini, Rosalinda Madonna, Patrick Meybohm, Claudio Muneretto, Jean-Francois Obadia, Cinzia Perrino, Fabrice Prunier, Joost P.G. Sluijter, Linda W. Van Laake, Miguel Sousa-Uva, Derek J. Hausenloy

Eur Heart J ehx383; doi: 10.1093/eurheartj/ehx383; Published: 25 July 2017

Introduction: Coronary artery disease (CAD) is one of the leading causes of death and disability in Europe and worldwide. For patients with multi-vessel CAD, coronary artery bypass graft (CABG) surgery is a common approach for coronary revascularization, and is of proven symptomatic and prognostic benefit. Due to an aging population, higher prevalence of co-morbidities (such as diabetes mellitus, heart failure, hypertension, and renal failure), and a growing requirement for concomitant surgical procedures (such as valve and aortic surgery), higher risk patients are undergoing surgery. This has resulted in an increased risk of peri-operative myocardial injury (PMI) and Type 5 myocardial infarction (MI), both of which are associated with worsened clinical outcomes following CABG surgery. The aetiology and determinants of PMI and Type 5 MI are multi-factorial (see Tables 1 and 2 for summary). Although diagnostic criteria have been proposed for Type 5 MI (based on an elevation in cardiac biomarkers in the 48-h post-operative period and electrocardiogram/angiography/imaging evidence of MI), there is currently no clear definition for prognostically significant PMI, in terms of the level of post-operative cardiac biomarker elevation, which is associated with worsened clinical outcomes following CABG surgery. 

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Surgical and interventional management of mitral valve regurgitation

A position statement from the European Society of CardiologyWorking Groups on Cardiovascular Surgery and Valvular Heart Disease

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Authors: Michele De Bonis, Nawwar Al-Attar, Manuel Antunes, Michael Borger, Filip Casselman, Volkmar Falk, Thierry Folliguet, Bernard Iung, Patrizio Lancellotti, Salvatore Lentini, Francesco Maisano, David Messika-Zeitoun, Claudio Muneretto, Phillipe Pibarot, Luc Pierard, Prakash Punjabi, Raphael Rosenhek, Piotr Suwalski, Alec Vahanian, Olaf Wendler, Bernard Prendergast

References: Eur Heart J (2014); DOI:; First published online: 7 July 2015

Mitral regurgitation (MR) has a prevalence of 2% in the general population and is even more common in the elderly.1 Organic (or primary) MR arises as a result of pathology affecting one or more components of the mitral valve (MV) apparatus, whereas functional (or secondary) MR is a consequence of annular dilatation and geometrical distortion of the sub-valvular apparatus secondary to left ventricular (LV) remodelling and dyssynchrony, most usually associated with cardiomyopathy or coronary artery disease.

Primary MR is usually a consequence of degenerative disease, which may remain asymptomatic for many years—intervention has generally been withheld until the onset of symptoms or evidence of haemodynamic decompensation. However, treatment algorithms have been redefined in recent years as a result of the excellent outcomes of surgical repair. International guidelines now recommend risk stratification and earlier intervention when the probability of durable repair is high and when surgery can be undertaken by experienced teams with high repair rates and low operative mortality and morbidity.

Secondary MR has worse prognosis and treatment options are complex, including optimized medical therapy, biventricular pacing, valve surgery (with or without revascularization), long-term LV assist devices or cardiac transplantation. Surgery is challenging with inferior outcomes than in primary MR and the indications and choice of technique are not supported by robust evidence.

In recent years, a variety of approaches to percutaneous treatment of primary and secondary MR has emerged. The most widely adopted has been the edge-to-edge (EE) procedure with promising results in large registries and small randomized trials. Meanwhile, numerous alternative technologies (including percutaneous MV replacement) are in development.

Herein, a Task Force of the European Society of Cardiology (ESC) Working Groups on Cardiovascular Surgery and Valvular Heart Disease outline the indications and limitations of surgical and percutaneous treatment of MR, and propose recommendations for case selection, team working and outcome monitoring.

Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery

Joint paper with the WG on Cardiovascular Surgery

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Authors: Miguel Sousa-Uva, Robert Storey, Kurt Huber, Volkmar Falk, Adeline Leite-Moreira, Julien Amour, Nawwar Al- Attar, Raimondo Ascione, David Taggart , and Jean-Philippe Collet

References: Eur Heart J (2014); doi: 10.1093/eurheartj/ehu158; First published online: April 18, 2014

Coronary artery bypass grafting (CABG)-related bleeding complications and perioperative coronary events are strongly influenced by the management of antithrombotic therapy before and after CABG. Bleeding but also blood products transfusion increase the risk of death and compromise the long-term benefits of CABG.1 The use of new P2Y12 inhibitors, increasing pre-CABG percutaneous coronary interventions (PCI) with drug eluting stents (DES) requiring specific antiplatelet regimens, and advances in surgical technique has prompted the ESC Working Group on Cardiovascular Surgery and the ESC Working Group on Thrombosis to review the evidence of peri-CABG recommendations on antithrombotic management. Due to the paucity of randomized trials, most of the evidence is still derived from observational studies and expert consensus, further reinforcing the importance of a multidisciplinary consultation for optimal decision making.