The Journal Of Heart Valve Disease[JOURNAL]
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200 papers
Outcomes of a New-Generation Stentless Aortic Valve: A Single-Center Experience with 251 Consecutive Implants.
Stefanelli G, Pirro F, Danniballe G … +3 more , Olaru A, Meli M, Weltert L
J Heart Valve Dis · 2017 Sep · PMID 29762920
BACKGROUND: The study aim was to investigate the hemodynamic behavior over time and ease of implant and durability of the Sorin Pericarbon Freedom (SPF)® stentless pericardial aortic xenograft. METHODS: Between March 200...
BACKGROUND: The study aim was to investigate the hemodynamic behavior over time and ease of implant and durability of the Sorin Pericarbon Freedom (SPF)® stentless pericardial aortic xenograft. METHODS: Between March 2003 and April 2010, a total of 251 consecutive, non-selected patients (mean age 70.1 years; range: 17-89 years; 17.1% aged >80 years) received a SPF bioprosthesis as an aortic valve substitute at the authors' institution. All implantations were performed by a single surgeon using a classical, double-line, subcoronary implant technique. Of these patients. 108 (43%) underwent a concomitant procedure. The mean logistic EuroSCORE was 8.3. Patients were followed for complications and hemodynamic evaluation. Echocardiographic controls and clinical data were obtained at discharge, and at six months' and eight years' follow up. RESULTS: The in-hospital/30-day mortality was 1.2% for the entire group, but 0% for patients with isolated valve replacement. A total of 27 deaths had occurred at the time of the last follow up (22 were due to non-cardiac causes). At follow up (mean 3.7 years; range: 0-7.8 years), 91.1% of survivors were in NYHA classes I or II. Freedom from reoperation and from structural valve deterioration was 96.0% and 96.8%, respectively, at 7.8 years. The mean pressure gradient of the series (measured using echocardiography) was 10.3 ± 4.5 mmHg at discharge, and 8.3 ± 4.5mmHg at the time of the last follow up. The mean effective orifice area was 1.85 ± 0.70 cm2 for the entire series, and there was an absence of prosthesis-patient mismatch in 90% of patients. CONCLUSIONS: The study results confirmed the favourable hemodynamic behavior, low risk of implantation and acceptable durability of the pericardial stentless SPF aortic prosthesis. The data also endorsed use of the SPF as an aortic valve substitute, even in a young and active population, and particularly in the presence of a small aortic annulus. The accuracy of implantation remains a crucial factor for durability and subsequent satisfactory hemodynamic performance. A longer follow up would provide further information with regards to complications and durability of the SPF prosthesis.
Incremental Value of Transesophageal Echocardiography Integrated with Transthoracic Echocardiography in the Assessment of Aortic Stenosis Severity.
Schwartzenberg S, Vaturi M, Kazum S … +4 more , Monakier D, Sagie A, Kornowski R, Shapira Y
J Heart Valve Dis · 2017 Sep · PMID 29762919
BACKGROUND: Transthoracic echocardiography (TTE) is the standard method for evaluating the severity of aortic stenosis (AS), while transesophageal echocardiography (TEE) is useful for morphologic characterization. The st...
BACKGROUND: Transthoracic echocardiography (TTE) is the standard method for evaluating the severity of aortic stenosis (AS), while transesophageal echocardiography (TEE) is useful for morphologic characterization. The study aim was to assess the impact of complementary TEE to TTE in refining hemodynamic assessment of AS severity. METHODS: A retrospective analysis was conducted of sequential TTE and TEE studies performed in 100 patients with moderate or severe AS confirmed on prior TTE. The left ventricular outflow tract (LVOT) velocity-time-integral (VTI1) and the aortic valve velocity-time integral (VTI2) were measured for both modalities. The highest values of VTI1 and VTI2 and mean gradients and peak velocities were selected from the sequential TTE/TEE study for indexed aortic valve area (AVAi) calculation and AS severity determination through an integrated assessment. RESULTS: AVAi determined by TTE was not significantly different from that determined by TEE (mean difference -0.008 cm2; p = 0.38). The dimensionless velocity index (DVI) was higher when assessed by TTE than by TEE (mean difference 0.0126 ± 0.04; p = 0.003). Using the integrated AS assessment, six of 13 patients with a TTE-based diagnosis of moderate AS were re-classified as severe AS. A slight lowering of the recommended TTE-derived DVI threshold for severe AS, from 0.25 to 0.24, improved the ability to discriminate moderate versus severe AS, as determined by the integrated assessment. CONCLUSIONS: TEE integrated with TTE may improve the detection of severe AS, particularly in patients with moderate AS criteria assessed by TTE, but with a DVI ratio ≤0.24.
Impact of Heart Rate on Flow Measurements in Aortic Regurgitation.
Lidén M, Wodecki M, Thunberg P … +1 more , Rask P
J Heart Valve Dis · 2017 Sep · PMID 29762918
BACKGROUND: Flow measurements using cardiac magnetic resonance imaging (CMRI) enable quantification of the stroke volume, regurgitant volume (RV) and regurgitant fraction (RF) in patients with aortic regurgitation (AR)....
BACKGROUND: Flow measurements using cardiac magnetic resonance imaging (CMRI) enable quantification of the stroke volume, regurgitant volume (RV) and regurgitant fraction (RF) in patients with aortic regurgitation (AR). These variables are used to assess the severity of the valve disease and for the timing of surgery. The aim of the study was to investigate the impact of an increased heart rate on measurement of the RV and RF in patients with AR. METHODS: Among 13 patients with known moderate or severe AR, regurgitant flow measurements, using phase-contrast cine magnetic resonance imaging, were obtained in the ascending aorta. Flow measurements were obtained at rest and at increased heart rates after intravenous administration of atropine. RESULTS: The mean heart rate was 61 beats per min at rest and 91 beats per min after atropine administration. The RV and RF were 52 ml and 35% at rest, respectively, and 34 ml (p <0.001) and 30% (p = 0.065) at increased heart rate, respectively. CONCLUSIONS: An increased heart rate leads to a decreased RV. The RF is more stable and may therefore be preferable for severity grading in AR.
Association of Change in Patient-Reported Health Status after Transcatheter Aortic Valve Replacement, and Postoperative Outcomes.
Kofi Okoh A, Kang N, Chauhan D … +6 more , Haik N, Hanos D, Cohen M, Chen C, Haik B, Russo MJ
J Heart Valve Dis · 2017 Sep · PMID 29762917
BACKGROUND: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardi...
BACKGROUND: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). METHODS: The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores <10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days. RESULTS: A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p <0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p <0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009). CONCLUSIONS: TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.
Letter to the Editor: Thrombocytopenia After Sutureless Aortic Valve Implantation: Does It Really Matter?
Santarpino G, Vogt F
J Heart Valve Dis · 2017 Jul · PMID 29302952
Despite the limited clinical relevance of thrombocytopenia after bioprosthetic aortic valve replacement (AVR), the postoperative depletion of platelet count continues to attract the attention of many authors. The develop...
Despite the limited clinical relevance of thrombocytopenia after bioprosthetic aortic valve replacement (AVR), the postoperative depletion of platelet count continues to attract the attention of many authors. The development of thrombocytopenia has been evaluated either in patients receiving a sutureless bioprosthesis (1,2) or in those undergoing transcatheter aortic valve implantation, where cardiopulmonary bypass bears little or no relation to this phenomenon (3). Recently, Sánchez et al. (1) have published their findings on this topic, but their limited experience with the devices used makes their study of doubtful interest. Over three years, 27 patients were implanted with a sutureless bioprosthetic valve and were compared with 50 patients receiving a stented aortic valve. No risk factors that may have predisposed to platelet dysfunction were described in either group.Mortality and number of units of transfused red blood cells also seems to be extremely high for a patient population undergoing elective isolated AVR: it is not clear whether bleeding complications occurred in any patients and re-thoracotomy could not be performed, or whether more liberal transfusion protocols were used. In addition, platelet transfusions in patients from the sutureless group could represent a bias that renders the comparison of postoperative mean platelet volume and platelet distribution width between groups unreliable. It would have been more appropriate to consider postoperative echocardiographic findings because, in case of suboptimal placement of the prosthesis, paravalvular leakage may cause severe hemolysis and thrombocytopenia. At present, clinical data can be derived from other case series (4). At our Center, over a six-year period, AVR was performed using a sutureless, stentless, or stented bioprosthesis in 432, 193, and 180 patients, respectively, with all devices being supplied by the same manufacturer. Perioperative trends in platelet count after sutureless AVR did not show progression towards thrombocytopenia as occurs after stentless AVR (5), but compared favourably with conventional stented AVR (Fig. 1), where platelet depletion has no clinical relevance. Figure 1: Perioperative trends in platelet count after aorticvalve replacement with the sutureless Perceval, stentlessSolo, and stented Crown bioprosthetic valves.References1. Sánchez E, Corrales JA, Fantidis P, Tarhini IS, Khan I, Pineda T, González JR. Thrombocytopenia after aortic valve replacement with Perceval S sutureless bioprosthesis. J Heart Valve Dis 2016;25:75-812. Jiritano F, Cristodoro L, Malta E, Mastroroberto P. Thrombocytopenia after sutureless aortic valve implantation: Comparison between Intuity and Perceval bioprostheses. J Thorac Cardiovasc Surg 2016;152:1631-16333. McCabe JM, Huang PH, Riedl LA, et al. Incidence and implications of idiopathic thrombocytopenia following transcatheter aortic valve replacement with the Edwards Sapien® valves: A single center experience. Catheter Cardiovasc Interv 2014;83:633-6414. Santarpino G, Fischlein T, Pfeiffer S. A word of caution is needed before uttering a word of caution: Thrombocytopenia and sutureless valves. Heart Surg Forum 2016;19:E1695. Pozzoli A, De Maat GE, Hillege HL, Boogaard JJ, Natour E, Mariani MA. Severe thrombocytopenia and its clinical impact after implant of the stentless Freedom Solo bioprosthesis. Ann Thorac Surg 2013;96:1581-1586.
Percutaneous Therapy of a Stenotic Parachute Mitral Valve Previously Treated by Surgery.
De Rosa R, Schranz D, Vasa-Nicotera M … +5 more , Assmus B, Risteski P, Moritz A, Zeiher AM, Fichtlscherer S
J Heart Valve Dis · 2017 Jul · PMID 29302951
Parachute mitral valve (PMV) is a congenital heart anomaly which consists of a unifocal attachment of the mitral valve chordae into a single or dominant papillary muscle. This morphological anomaly determines the impairm...
Parachute mitral valve (PMV) is a congenital heart anomaly which consists of a unifocal attachment of the mitral valve chordae into a single or dominant papillary muscle. This morphological anomaly determines the impairment of mitral leaflet motion, resulting in different grades of mitral stenosis. Due to its frequent association with other congenital cardiac defects requiring surgical correction, the therapy of a relevant stenotic PMV is usually represented by surgical commissurotomy. Herein is reported the case of a PMV treated by surgery in infancy, which showed a severe restenosis after 34 years and was successfully treated by percutaneous valvuloplasty with the additional creation of a restrictive atrial communication.
Use of Impella 5.0 Prior to Transcatheter Aortic Valve Replacement in a Patient with Severe Aortic Stenosis and Cardiogenic Shock.
Johnson DW, ErwinIII JP
J Heart Valve Dis · 2017 Jul · PMID 29302950
The use of transcatheter aortic valve replacement (TAVR) has risen dramatically during the past decade. Notably, the procedure can reduce symptoms and improve prognosis in patients who would otherwise be excluded from in...
The use of transcatheter aortic valve replacement (TAVR) has risen dramatically during the past decade. Notably, the procedure can reduce symptoms and improve prognosis in patients who would otherwise be excluded from intervention due to prohibitive surgical risk. During the same time period, the use of percutaneous mechanical circulatory support devices for patients with severe left ventricular dysfunction, including the Impella System (Abiomed, Inc., Danvers, MA, USA), has also increased. These devices provide superior hemodynamic effects compared to intra-aortic balloon pumping. However, data relating to use of the Impella in patients with both severe left ventricular dysfunction and significant aortic valve disease are limited. Herein is presented the case of a 59-year-old man with severe aortic stenosis and cardiogenic shock who was treated successfully with an Impella 5.0 as a temporizing measure prior to TAVR. A brief review is also provided of the use of mechanical circulatory support devices in this subset of patients. Video 1: Transesophageal echocardiography video demonstrating stenotic aortic valve pre-intervention in side-by-side long and short axes. Video 2: Transthoracic echocardiography video, parasternal short axis, demonstrating Impella 5 in the left ventricle. Video 3: Fluoroscopy video demonstrating deployment of the Edwards SAPIEN transcatheter aortic valve. Video 4: Transesophageal echocardiography video showing the Edwards SAPIEN transcatheter aortic valve in long axis. Video 5: Transesophageal echocardiography video showing the Edwards SAPIEN transcatheter aortic valve in short axis.
Simultaneous Transcatheter Intervention for Coarctation of the Aorta and Bicuspid Aortic Valve.
Mizutani Y, Tada N, Masuda T … +1 more , Hata M
J Heart Valve Dis · 2017 Jul · PMID 29302949
Coarctation of the aorta (CoA) is a relatively common congenital heart anomaly, and bicuspid aortic valve (BAV) is a common congenital heart disease that coexists with CoA. In larger children and adults with CoA, transca...
Coarctation of the aorta (CoA) is a relatively common congenital heart anomaly, and bicuspid aortic valve (BAV) is a common congenital heart disease that coexists with CoA. In larger children and adults with CoA, transcatheter intervention has gained acceptance, but for surgical high-risk patients with aortic stenosis, the use of transcatheter aortic valve implantation (TAVI) has been established. Recently, although favorable data have been reported for TAVI when treating BAV, simultaneous transcatheter intervention for CoA and BAV will prove to be a challenge because of the unique anatomy involved requires multiple procedural steps and also has problems of site access. Herein is reported a successful case of simultaneous thoracic endovascular repair (TEVAR) for CoA and transfemoral TAVI for congenital BAV dysfunction. A 62-year-old male with CoA and congenital BAV with severe aortic stenosis and aortic regurgitation had NYHA class IV heart failure symptoms. Because of the patient's extremely poor left ventricular function, the authors' heart team decided to perform simultaneous TEVAR for CoA and transfemoral TAVI. After deployment of a 32 mm stent graft, a 29 mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) was successfully deployed through the stent graft. This resulted in no significant pressure gradient within the aorta, and no aortic regurgitation. Video 1: Cineradiography showing delivery of the Edwards Commander delivery system through the stent graft. Video 2: Final aortography showing no residual aortic regurgitation.
The Hancock® Valved Conduit for Right Ventricular Outflow Tract Reconstruction in Sheep for Assessing New Devices.
Carney JP, Zhang LM, Larson JJ … +4 more , Lahti MT, Robinson NA, Dalmasso AP, Bianco RW
J Heart Valve Dis · 2017 Jul · PMID 29302948
BACKGROUND AND AIM OF THE STUDY: Xenograft conduits have been used successfully to repair congenital heart defects, but are prone to failure over time. Hence, in order to improve patient outcomes, better xenografts are b...
BACKGROUND AND AIM OF THE STUDY: Xenograft conduits have been used successfully to repair congenital heart defects, but are prone to failure over time. Hence, in order to improve patient outcomes, better xenografts are being developed. When evaluating a conduit's performance and safety it must first be compared against a clinically available control in a large animal model. The study aim was to evaluate a clinically available xenograft conduit used in right ventricular outflow tract (RVOT) reconstruction in a sheep model. METHODS: RVOT reconstruction was performed in 13 adult and juvenile sheep, using the Medtronic Hancock® Bioprosthetic Valved Conduit (Hancock conduit). The method had previously been used on patients, and a newly modified variant termed 'RVOT Extraction' was employed to facilitate the surgical procedure. Animals were monitored over predetermined terms of 70 to 140 days. Serial transthoracic echocardiography, intracardiac pressure measurements and angiography were performed. On study completion the animals were euthanized and necropsies performed. RESULTS: Two animals died prior to their designated study term due to severe valvular stenosis and distal conduit narrowing, respectively. Thus, 11 animals survived the study term, with few or no complications. Generally, maximal and mean transvalvular pressure gradients across the implanted conduits were increased throughout the postoperative course. Among 11 full-term animals, seven conduits were patent with mild or no pseudointimal proliferation and with flexible leaflets maintaining the hemodynamic integrity of the valve. CONCLUSIONS: RVOT reconstruction using the Hancock conduit was shown to be successful in sheep, with durable and efficient performances. With its extensive clinical use in patients, and ability for long-term use in sheep (as described in the present study) it can be concluded that the Hancock conduit is an excellent control device for the evaluation of new xenografts in future preclinical studies.
Fenfluramine-Phentermine is Associated with an Increase in Cellular Proliferation Ex Vivo and In Vitro.
Rajamannan NM
J Heart Valve Dis · 2017 Jul · PMID 29302947
BACKGROUND AND AIM OF THE STUDY: Fenfluraminephentermine (FenPhen) has been implicated in accelerated valvular heart disease, characterized by valvular regurgitation and thickening, and resembling the histopathologic les...
BACKGROUND AND AIM OF THE STUDY: Fenfluraminephentermine (FenPhen) has been implicated in accelerated valvular heart disease, characterized by valvular regurgitation and thickening, and resembling the histopathologic lesions found in carcinoid. The study aim was to determine whether cellular proliferation is present in FenPhen-exposed valves, by utilizing an in-vitro model to test whether FenPhen has a direct mitogenic effect on cardiac valvular cells, as compared to serotonin. METHODS: Ex-vivo valves were tested for proliferation in surgically removed FenPhen-exposed valves (n = 10) and compared to proliferation levels in normal human cardiac valves removed at autopsy (n = 10). Immunostaining for a DNA polymerase, proliferating cell nuclear antigen (PCNA), was performed and quantified using digital imaging analysis. In-vitro assays were performed for direct proliferative effects of serotonin and FenPhen (10-6, 10-7 and 10-8 M) on porcine aortic valve subendothelial cells, using a [3H]-thymidine incorporation assay. RESULTS: Ex-vivo PCNA levels in human FenPhenexposed valves were elevated compared to controls (22.8 ± 4.54 versus 1.26 ± 0.47; p <0.001). In vivo, serotonin and FenPhen markedly increased (10-fold) cell proliferation (as measured by [3H]-thymidine incorporation) in subendothelial cells in vitro (p <0.001). This proliferative response was demonstrated by PCNA staining in carcinoid heart valves and FenPhen-exposed valves. Mechanistically, plateletderived growth factor increased cell proliferation in a dose-related manner (p <0.001), the response being inhibited by a MAP kinase inhibitor (determined by monitoring p42/44 levels). CONCLUSIONS: In vitro, FenPhen acts as a powerful mitogen on subendothelial myofibroblast valve cells. Ex vivo, cellular proliferation was significantly elevated in human FenPhen-exposed cells.
The Role of Protein Z and Protein Z-Dependent Protease Inhibitor Polymorphisms in the Development of Prosthetic Heart Valve Thrombosis.
Karakoyun S, Ozan Gürsoy M, Kalçık M … +7 more , Yesin M, Gündüz S, Ali Astarcıoğlu M, Bayram Z, Çakal B, Bayam E, Özkan M
J Heart Valve Dis · 2017 Jul · PMID 29302946
BACKGROUND AND AIM OF THE STUDY: Protein Z (PZ) is a vitamin K-dependent factor that is synthesized mainly by the liver. It acts as an activator of serpin, the protein Z-dependent inhibitor (ZPI), which inhibits factor X...
BACKGROUND AND AIM OF THE STUDY: Protein Z (PZ) is a vitamin K-dependent factor that is synthesized mainly by the liver. It acts as an activator of serpin, the protein Z-dependent inhibitor (ZPI), which inhibits factor Xa. The potential role of alterations in protein Z and/or ZPI levels in the pathogenesis of thrombotic and/or hemorrhagic diseases has been previously investigated, but results have been conflicting. The study aim was to evaluate the role of PZ/ZPI polymorphisms in the development of prosthetic valve thrombosis (PVT). METHODS: This prospective, observational cross-sectional study included 50 consecutive patients with PVT [non-obstructive thrombosis (NOT) in 35 patients; obstructive thrombosis (OT) in 15] and 50 consecutive healthy subjects with normally functioning prostheses. gDNA was extracted from ca. 5 × 106 leukocytes, using the QIAamp DNA Mini Kit (Qiagen), according to the manufacturer's recommendations. For mutational analysis, a minisequencing method was employed. Results of the analyses were compared between the PVT and control groups, and also between the OT and NOT subgroups. RESULTS: The frequency of A allele (mutant type) of PZG79A was equal in all PVT patients and in controls. With regards to PZ-A13G polymorphisms, frequency of the mutant G allele was 22% in PVT patients and 19% in controls. Serpina-R67X polymorphism was observed in 8% of PVT patients and 6% of controls. Normal variant CC was present in 47 controls (94%), whereas a heterozygotic mutation (CT) was detected in four PVT patients (8%). Frequency of the ZPI-R67X mutation was significantly higher in patients with OT than in those with NOT (p = 0.041). CONCLUSIONS: The present study was the first to evaluate the potential impact of PZ (PZ-A13G, PZG79A) and ZPI (R-67X, W303X) polymorphisms in the development of PVT. Based on the results of this small observational case-control study, PZ/ZPI polymorphisms do not appear to play an active role in the development of PVT. Hence, further extensive studies are necessary.
A New Method to Evaluate Atrial Hemodynamic and Quantify Mitral Regurgitation using Cardiovascular Magnetic Resonance: The Pulmonary Venous Flow Approach.
Benfari G, Vinco G, Sayegh K … +2 more , Friedrich M, Rossi A
J Heart Valve Dis · 2017 Jul · PMID 29302945
Pulmonary venous flow (PVF) provides incremental information on left ventricular (LV) diastolic function, and can support the diagnosis of severe mitral regurgitation (MR). The suggestion has been made to combine the lef...
Pulmonary venous flow (PVF) provides incremental information on left ventricular (LV) diastolic function, and can support the diagnosis of severe mitral regurgitation (MR). The suggestion has been made to combine the left atrial filling volume (LA Fill) and PVF for estimating the mitral regurgitant volume, but echocardiographic PVF evaluation is known to have many limitations. The present case report includes an example of how to assess PVF using cardiovascular magnetic resonance, and a new method is proposed for quantification of the mitral regurgitant volume.
Restrictive Mitral Annuloplasty With or Without Papillary Muscle Approximation for Functional Mitral Regurgitation.
Misumi Y, Masai T, Toda K … +11 more , Nakamura T, Miyagawa S, Yoshikawa Y, Fukushima S, Saito S, Domae K, Kainuma S, Ueno T, Kuratani T, Daimon T, Sawa Y
J Heart Valve Dis · 2017 Jul · PMID 29302944
BACKGROUND AND AIM OF THE STUDY: The impact of adding papillary muscle approximation (PMA) to restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) function is unknown. Changes in LV function param...
BACKGROUND AND AIM OF THE STUDY: The impact of adding papillary muscle approximation (PMA) to restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) function is unknown. Changes in LV function parameters and clinical outcome were evaluated following RMA with and without PMA in patients with clinically relevant functional mitral regurgitation (FMR). METHODS: A total of 176 patients with advanced cardiomyopathy underwent RMA either with (n = 59) or without (n = 117) PMA. Propensity score analysis was used to adjust for group differences in several baseline characteristics, such as age, gender and LV ejection fraction (LVEF) (C-statistic = 0.80, goodness-of-fit value = 0.58). RESULTS: Serial echocardiography in 30 propensity score-matched pairs demonstrated decreases in LV end-systolic dimension (RMA alone: 57 ± 9 mm at baseline versus 54 ±11 mm at one month versus 56 ± 13 mm at latest examination; RMA + PMA: 56 ± 8 mm versus 53 ± 9 mm versus 48 ± 11 mm, respectively) and improvement in LVEF (RMA alone: 28 ± 8% versus 28 ± 11% versus 29 ± 10%; RMA + PMA: 30 ± 8% versus 30 ± 9% versus 36 ± 13%, respectively) in both groups. Greater degrees of changes in value were noted for patients receiving RMA + PMA (group effect p <0.05 for both). The two-year survival of both groups was similar (73 ± 8% versus 77 ± 23%, p = 0.7), but the RMA + PMA group showed a trend towards a greater freedom from composite events, defined as mortality and/or unscheduled heart failure re-admission (48 ± 9% versus 63 ± 9%, p = 0.1). CONCLUSIONS: RMA + PMA induced greater long-term effects on unloading of the left ventricle and improvements in LV systolic function than did RMA alone. PMA may be a useful adjunct repair in combination with RMA, although its clinical benefits remain to be determined.
Left Heart Ejection Fraction as a Load-Independent Parameter for Patients with Mitral Regurgitation.
Chen HY, Li J, Wang CS … +2 more , Pan CZ, Shu XH
J Heart Valve Dis · 2017 Jul · PMID 29302943
BACKGROUND AND AIM OF THE STUDY: The functions of the left ventricle and left atrium are closely associated with the outcomes of surgically treated patients with severe mitral regurgitation (MR). However, both parameters...
BACKGROUND AND AIM OF THE STUDY: The functions of the left ventricle and left atrium are closely associated with the outcomes of surgically treated patients with severe mitral regurgitation (MR). However, both parameters were overestimated in the presence of MR. The present study integrated the left atrium and left ventricle as the left heart (LH) to eliminate the influence of MR within the integrated structure. The study aim was to explore whether the emptying fraction of the LH is a load-independent parameter for patients with MR. METHODS: A total of 52 patients with isolated organic MR was enrolled as a patient group, and 48 age- and gender-matched healthy subjects as a control group. The left atrial emptying fraction (LAEF) and left ventricular ejection fraction (LVEF) were evaluated using apical four-chamber views. The global volume of the LH was calculated as the sum of left atrial (LA) and left ventricular (LV) volumes. The LH emptying fraction (LHEF) was assessed according to the volume-time curve of the LH. All patients underwent echocardiography one day before and within one week after surgery. RESULTS: The LA, LV and LH volumes were each increased in the patient group (p <0.05). The LVEF of the patient group was comparable to that of controls before surgery (p >0.05), and fell by 10% after surgery (p <0.05). The LAEF of the patient group fell before surgery and also suffered a 10% fall after surgery. Both, baseline and postoperative LHEF were decreased in the patient group (both p <0.05) and remained unchanged after the correction of MR (p >0.05). CONCLUSIONS: By integrating the left atrium and left ventricle as a whole, the LHEF avoided the influence of MR and proved to be a load-independent parameter for global left heart function in patients with MR.
Pathophysiological Factors Associated with Left Ventricular Perforation in Transcatheter Aortic Valve Implantation by Transfemoral Approach.
Owais T, El Garhy M, Fuchs J … +5 more , Disha K, Elkaffas S, Breuer M, Lauer B, Kuntze T
J Heart Valve Dis · 2017 Jul · PMID 29302942
BACKGROUND AND AIM OF THE STUDY: Left ventricular (LV) perforation is one of the rare and most serious complications of transcatheter aortic valve implantation (TAVI). The study aim was to determine the pathophysiologica...
BACKGROUND AND AIM OF THE STUDY: Left ventricular (LV) perforation is one of the rare and most serious complications of transcatheter aortic valve implantation (TAVI). The study aim was to determine the pathophysiological factors associated with this serious complication. METHODS: A retrospective study was conducted of pathophysiological factors shown in echocardiograms and computed tomography angiograms performed preoperatively in patients who developed LV perforation during transfemoral TAVI (study group) with regards to anatomic and functional variables. Results were then compared with data acquired from a randomly selected sample of patients without perforation (control group). Among 963 TAVI cases, LV perforation occurred in 11 patients (three males, eight females; mean age 79 years). These patients showed complications of LV perforation that required emergency sternotomy and repair of injury to the left ventricle. Ten patients were rescued by the procedure, but one patient died during surgery. RESULTS: Focus on preoperative factors and intraoperative steps was established in favor to identify possible predictors of LV perforation. A LV cavity size <4.2 cm and a hypercontractile ventricle were identified in 10 patients (90%). Only one patient had a dilated cardiomyopathic left ventricle, with a cavity size of 6.1 cm and an ejection fraction of 10%. The present study results revealed other specific patient-related factors, namely a narrow aorto-mitral angle and a thin ventricular muscular wall despite long-standing aortic stenosis. All 11 patients had an average mid-LV muscular wall thickness of 5 mm. An inverse proportional relationship between the aorto-mitral angle and the incidence of perforation was noted, where in all 11 patients the wire had directed itself towards the anterior free wall of the left ventricle, where it induced injury. CONCLUSIONS: A small LV cavity, a hypercontractile state, a thin muscular wall, and a narrow aorto-mitral angle may be considered potential predictors of the occurrence of LV perforation during TAVI.
Long-Term Outcomes in Patients Undergoing Consecutive Bioprosthetic Aortic Valve Replacement.
Haydock MD, Wilkes CF, Ramanathan T … +1 more , Haydock DA
J Heart Valve Dis · 2017 Jul · PMID 29302941
BACKGROUND AND AIM OF THE STUDY: Worldwide, there is increased use of bioprosthetic valves in the aortic position. Part of this increase has been patient-driven for quality of life reasons. More recently, bioprosthetic v...
BACKGROUND AND AIM OF THE STUDY: Worldwide, there is increased use of bioprosthetic valves in the aortic position. Part of this increase has been patient-driven for quality of life reasons. More recently, bioprosthetic valves have been chosen by progressively younger patients, with a strategy of performing a valve-in-valve TAVI if the prosthesis should wear out. Thus, a review was undertaken of the present authors' experience with patients whose first two aortic valve replacements (AVRs) were with bioprosthetic valves. METHODS: Patients receiving consecutive bioprosthetic AVRs at the Green Lane Cardiothoracic Surgical Unit were identified from a departmental database. Data were retrieved from prospective databases, electronic and archived clinical records. Outcomes of interest were overall survival and freedom from a third or more AVR. RESULTS: A total of 267 patients met the inclusion criteria, with a mean follow up of 22.3 years. Concurrent procedures (e.g., coronary artery bypass grafting) were performed in 65.2% of patients that underwent two bioprosthetic AVRs, and in 79.8% of patients undergoing three or more bioprosthetic AVRs. Median survival of the cohort was 31.7 years. Age at operation was the best predictor of needing a third or more AVR. Receiver operating characteristic curve analysis identified that age <45 years at the first operation and <56 years at the second operation were the optimal cut-off point for the likelihood of needing a third or more aortic valve intervention. CONCLUSIONS: Overall survival for consecutive bioprosthetic AVRs was remarkably good. Data relating to consecutive bioprosthetic AVRs is of particular interest in the context of TAVI and valve-in-valve TAVI, which will likely significantly increase the number of patients receiving consecutive bioprosthetic valves. However, it must be noted that the majority of patients in this cohort required concurrent cardiac surgical procedures. The study results provided encouraging data for consecutive bioprosthetic AVRs, as well as data that may be of interest in the setting of TAVI being performed in younger cohorts of patients.
Determinants and Outcome of Decision Making Among Patients with Severe Aortic Stenosis.
Hussain AI, Auensen A, Brunborg C … +4 more , Aakhus S, Fiane A, Pettersen KI, Gullestad L
J Heart Valve Dis · 2017 Jul · PMID 29302940
BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) improves survival and quality of life in patients with severe aortic stenosis (AS), but despite clear indications for surgical treatment a significant propo...
BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) improves survival and quality of life in patients with severe aortic stenosis (AS), but despite clear indications for surgical treatment a significant proportion of patients do not undergo AVR. The study aim was to identify clinical variables associated with the decision to perform AVR, and to assess the prognostic effect of surgery versus medical treatment in patients with severe AS adjusted for significant confounders and effect modifiers. METHODS: A prospective observational study of consenting patients aged >18 years who were under consideration for AVR at the authors' tertiary teaching hospital was conducted. The main outcomes of the study were treatment decisions and survival. RESULTS: Among 480 patients with severe AS who were evaluated, 351 had surgical AVR, 38 had transcatheter AVR, and 91 were declined operative treatment. Typically, non-operated patients were older, were in a lower NYHA class, had fewer symptoms, a lower peak aortic jet velocity, a higher NT-proBNP level, and a lower physical summary score (SF-36). Higher age showed the strongest correlation against AVR (OR 0.91; 95% CI 0.87-0.94). One-, three-, and five-year cumulative survival rates, respectively, were 95%, 87%, and 73% among operated patients, and 82%, 47%, and 27% among non-operated patients. The median survival time was 1,604 days (95% CI 1,554-1,655) in operated patients versus 1,090 days (95% CI 954-1,226) in non-operated patients (p <0.001). The effect of operation on mortality was shown to depend on the interaction with diabetes, when adjusted for significant confounders (i.e., age, atrial fibrillation, NT-proBNP, hs-Troponin T, and NYHA class). An effect of AVR on mortality was found in patients without diabetes (HR 0.29; 95% CI 0.19-0.468; p <0.001), but not among patients with diabetes. CONCLUSIONS: Supplemental and better parameters to improve patient selection are warranted. Surgical AVR shows a greater prognostic effect in patients without diabetes.
Transcatheter Aortic Valve Implantation in High-Risk/Inoperable Patients: Repositionable versus Non-Repositionable Self-Expanding Valve.
Veulemans V, Sötemann DB, Kleinebrecht L … +5 more , Keymel S, Jung C, Zeus T, Kelm M, Westenfeld R
J Heart Valve Dis · 2017 Jul · PMID 29302939
BACKGROUND AND AIM OF THE STUDY: Although next-generation cardiac prostheses have shown favorable results in transcatheter aortic valve implantation (TAVI), these have mostly been documented in intermediate-risk patients...
BACKGROUND AND AIM OF THE STUDY: Although next-generation cardiac prostheses have shown favorable results in transcatheter aortic valve implantation (TAVI), these have mostly been documented in intermediate-risk patients. Whether this could be translated to high-risk patients is not known. Hence, the safety and clinical performance of the new, repositionable CoreValve Evolut R-System (ERS) was evaluated by comparison with a non-repositionable CoreValve-System (CVS), in 96 high-risk/inoperable (HRI) patients. METHODS: The primary safety end points were mortality and stroke, defined by VARC-2 criteria, at 30 days. Clinical performance end points were described by VARC-2 criteria, focusing on: (i) higher-grade atrioventricular conduction blocks with concomitant permanent pacemaker (PM) implantation; (ii) vascular complications (VCs); and (iii) aortic regurgitation (AR). The ERS and CVS patients underwent TAVI in equal proportions. RESULTS: In this study, 63% of patients in the CVS group and 82% in the ERS group were defined as HRI. One in-hospital death was documented after 30 days. With regards to the HRI cohort, no difference in rates of PM use were noted (ERS 20% versus CVS 20%; p >0.9999). ERS patients were characterized by a higher prevalence of peripheral vascular disease (PVD) (46% versus 21%; p <0.05), but fewer VCs (13% versus 41%; p <0.01). Both cohorts showed low rates of moderate-to-severe paravalvular AR (ERS 6% versus CVS 5%; p = 0.8639). However, ERS seemed to offer a favorable hemodynamic performance, with a significantly improved AR index (26.3 versus 22.3; p <0.05). TAVI with the ERS was associated with a higher stroke rate (3% versus 0%; p = 0.1232) after necessary postdilatation processes. CONCLUSIONS: In comparison to last-generation CVS, the repositionable ERS is safe and effective in HRI patients. Similar rates of PM use were noted for each group. together with a favorable hemodynamic performance and fewer vascular complications.
Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience.
Nicolo F, Romeo F, Lio A … +8 more , Bovio E, Scafuri A, Bassano C, Polisca P, Pellegrino A, Nardi P, Chiariello L, Ruvolo G
J Heart Valve Dis · 2017 Jul · PMID 29302938
BACKGROUND AND AIM OF THE STUDY: The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation. ME...
BACKGROUND AND AIM OF THE STUDY: The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation. METHODS: Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29). RESULTS: No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33). CONCLUSIONS: The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.
Stress Analysis of Transcatheter Aortic Valve Leaflets Under Dynamic Loading: Effect of Reduced Tissue Thickness.
Abbasi M, Azadani AN
J Heart Valve Dis · 2017 Jul · PMID 29302937
BACKGROUND AND AIM OF THE STUDY: In order to accommodate transcatheter valves to miniaturized catheters, the leaflet thickness must be reduced to a value which is typically less than that of surgical bioprostheses. The s...
BACKGROUND AND AIM OF THE STUDY: In order to accommodate transcatheter valves to miniaturized catheters, the leaflet thickness must be reduced to a value which is typically less than that of surgical bioprostheses. The study aim was to use finite-element simulations to determine the impact of the thickness reduction on stress and strain distribution. METHODS: A 23 mm transcatheter aortic valve (TAV) was modelled based on the Edwards SAPIEN XT (Edwards Lifesciences, Irvine, CA, USA). Finite-element (FE) analysis was performed using the ABAQUS/Explicit solver. An ensemble-averaged transvalvular pressure waveform measured from in-vitro tests conducted in a pulse duplicator was applied to the leaflets. Through a parametric study, uniform TAV leaflet thickness was reduced from 0.5 to 0.18 mm. RESULTS: By reducing leaflet thickness, significantly higher stress values were found in the leaflet's fixed edge during systole, and in the commissures during diastole. Through dynamic FE simulations, the highest stress values were found during systole in the leaflet fixed edge. In contrast, at the peak of diastole high-stress regions were mainly observed in the commissures. The peak stress was increased by 178% and 507% within the leaflets after reducing the thickness of 0.5 mm to 0.18 mm at the peak of systole and diastole, respectively. CONCLUSIONS: The study results indicated that, the smaller the leaflet thickness, the higher the maximum principal stress. Increased mechanical stress on TAV leaflets may lead to accelerated tissue degeneration. By using a thinner leaflet, TAV durability may not atch with that of surgical bioprostheses.
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