Emergency transapical mitral valve-in-valve implantation for bioprosthesis failure: transapical implantation of an Edwards Sapien-XT in a dysfunctional mitral bioprosthesis in a critical patient

Background

Valve-in-Valve (VIV) Transcatheter Aortic Valve Replacement (TAVR) is now the treatment of choice in high-surgical-risk patients with failing aortic bioprosthesis. Although less performed, VIV-Transcatheter Mitral Valve Replacement (TMVR) is a valid treatment option for selected high-risk patients with degenerated mitral bioprostheses. Several cases of elective ViV- TAVR and -TMVR have been reported but only few were performed in critical hemodynamic conditions.

Case presentation

We report the case of a patient underwent balloon-expandable transapical mitral valve-in-valve implantation in an emergency setting due to a severe stenosis of a bioprosthesis in mitral position. The procedure was successfully performed, with no residual mitral regurgitation or paravalvular leaks, and uneventful.

Conclusion

Transcatheter transapical mitral valve-in-valve implantation could represent a feasible and effective strategy even in critical setting.

The decellularized porcine heart valve matrix in tissue engineering

An approach in tissue engineering of heart valves is the use of decellularized xenogeneic matrices to avoid immune response after implantation. The decellularization process must preserve the structural components of the extracellular matrix to provide a biomechanically stable scaffold. However, it is known that in vascular lesions platelet adhesion to extracellular matrix components occurs and platelet activation is induced. In the present study we examined the effects of a decellularized porcine heart valve matrix on thrombocyte activation and the influence of re-endothelialisation in vitro. Porcine pulmonary conduits were decellularized using Triton X-100, Na-deoxycholate and Igepal CA-630® followed by a ribonuclease digestion. Cryostat sections of decellularized heart valves with and without seeding with human umbilical vein endothelial cells (HUVEC) were incubated with platelet rich plasma. Samples were either stained with fluorescent antibodies for CD41 and PAC-1 (recognizing the activated fibrinogen receptor) or fixed with glutaraldehyde. Thereafter, the samples were processed for laser scanning microscopy (LSM) or scanning electron microscopy (SEM). Examination by LSM showed numerous platelets with co-localized staining for CD41 and PAC-1 on the nonseeded decellularized heart valve matrix whereas after seeding with endothelial cells no platelet activation was detected. SEM revealed platelet adhesion and aggregate formation only on the surface of the non-seeded or partially denuded matrix specimens. We show in this study that the decellularized porcine matrix acts as a platelet-activating surface. Seeding with endothelial cells effectively abolishes the platelet adhesion and activation and therefore is necessary to eliminate thrombogenicity in tissue engineered heart valves.

Mechanical or Biologic Prostheses for Aortic-Valve and Mitral-Valve Replacement

BACKGROUND

In patients undergoing aortic-valve or mitral-valve replacement, either a mechanical or biologic prosthesis is used. Biologic prostheses have been increasingly favored despite limited evidence supporting this practice.

METHODS

We compared long-term mortality and rates of reoperation, stroke, and bleeding between inverse-probability-weighted cohorts of patients who underwent primary aortic-valve replacement or mitral-valve replacement with a mechanical or biologic prosthesis in California in the period from 1996 through 2013. Patients were stratified into different age groups on the basis of valve position (aortic vs. mitral valve).

RESULTS

From 1996 through 2013, the use of biologic prostheses increased substantially for aortic-valve and mitral-valve replacement, from 11.5% to 51.6% for aortic-valve replacement and from 16.8% to 53.7% for mitral-valve replacement. Among patients who underwent aortic-valve replacement, receipt of a biologic prosthesis was associated with significantly higher 15-year mortality than receipt of a mechanical prosthesis among patients 45 to 54 years of age (30.6% vs. 26.4% at 15 years; hazard ratio, 1.23; 95% confidence interval [CI], 1.02 to 1.48; P=0.03) but not among patients 55 to 64 years of age. Among patients who underwent mitral-valve replacement, receipt of a biologic prosthesis was associated with significantly higher mortality than receipt of a mechanical prosthesis among patients 40 to 49 years of age (44.1% vs. 27.1%; hazard ratio, 1.88; 95% CI, 1.35 to 2.63; P<0.001) and among those 50 to 69 years of age (50.0% vs. 45.3%; hazard ratio, 1.16; 95% CI, 1.04 to 1.30; P=0.01). The incidence of reoperation was significantly higher among recipients of a biologic prosthesis than among recipients of a mechanical prosthesis. Patients who received mechanical valves had a higher cumulative incidence of bleeding and, in some age groups, stroke than did recipients of a biologic prosthesis.

CONCLUSIONS

The long-term mortality benefit that was associated with a mechanical prosthesis, as compared with a biologic prosthesis, persisted until 70 years of age among patients undergoing mitral-valve replacement and until 55 years of age among those undergoing aortic-valve replacement. (Funded by the National Institutes of Health and the Agency for Healthcare Research and Quality.).

Usefulness of Mitral Valve Prosthetic or Bioprosthetic Time Velocity Index Ratio to Detect Prosthetic or Bioprosthetic Mitral Valve Dysfunction

This study aimed to investigate the utility of transthoracic echocardiographic (TTE) Doppler-derived parameters in detection of mitral prosthetic dysfunction and to define optimal cut-off values for identification of such dysfunction by valve type. In total, 971 TTE studies (647 mechanical prostheses; 324 bioprostheses) were compared with transesophageal echocardiography for evaluation of mitral prosthesis function. Among all prostheses, mitral valve prosthesis (MVP) ratio (ratio of time velocity integral of MVP to that of left ventricular outflow tract; odds ratio [OR] 10.34, 95% confidence interval [95% CI] 6.43 to 16.61, p<0.001), E velocity (OR 3.23, 95% CI 1.61 to 6.47, p<0.001), and mean gradient (OR 1.13, 95% CI 1.02 to 1.25, p=0.02) provided good discrimination of clinically normal and clinically abnormal prostheses. Optimal cut-off values by receiver operating characteristic analysis for differentiating clinically normal and abnormal prostheses varied by prosthesis type. Combining MVP ratio and E velocity improved specificity (92%) and positive predictive value (65%) compared with either parameter alone, with minimal decline in negative predictive value (92%). Pressure halftime (OR 0.99, 95% CI 0.98 to 1.00, p=0.04) did not differentiate between clinically normal and clinically abnormal prostheses but was useful in discriminating obstructed from normal and regurgitant prostheses. In conclusion, cut-off values for TTE-derived Doppler parameters of MVP function were specific to prosthesis type and carried high sensitivity and specificity for identifying prosthetic valve dysfunction. MVP ratio was the best predictor of prosthetic dysfunction and, combined with E velocity, provided a useful parameter for determining likelihood of dysfunction and need for further assessment.

Long-Term (up to 21 Years) Follow Up after Biological and Mechanical Aortic Valve Replacement in Younger Patients

BACKGROUND

Despite the limited durability of biological aortic valves, increasing numbers of younger patients are choosing to receive them, due mainly to the lack of a need for permanent anticoagulation. Few data exist, however, regarding the outcomes of valve replacement in patients aged <55 years, and additional data are required in this patient population.

METHODS

Between 1993 and 2014, at the authors' institution, a total of 448 patients (237 males, 101 females; mean age 45.8 ± 8.0 years) underwent aortic valve replacement (AVR) with either a mechanical prosthesis (M1 group, n = 318) or a biological prosthesis (B1 group, n = 130). The mean follow up was 8.5 ± 5.8 years (range: 4 days to 20.8 years) in the M1 group, and 4.9 ± 4.6 years (range: 2 days to 21 years) in the B1 group. The entire collective (EC) (n = 448 patients) was compared and analyzed with a selective collective (SC) (n = 109 patients) after exclusion of patients with concomitant procedures or comorbidities (M2 group, n = 74; B2 group, n = 35).

RESULTS

Early mortality was greater after biological AVR in the EC (6.1% versus 1.9%), but in the SC no early deaths were observed after both primary and redo procedures. The reoperation rate was greater after biological AVR in both collectives. The late mortality, survival and endocarditis rates were comparable in both collectives. Bleeding occurred more often in the EC after mechanical AVR.

CONCLUSIONS

Biological AVR in patients aged <55 years provides satisfactory outcomes, whereas reoperations were performed less commonly in patients with mechanical valve substitutes. In selective patients, AVR can be performed with zero mortality.

Cusp Tear of Trifecta™ Aortic Bioprosthesis Resulting in Acute Heart Failure

Herein is presented the case of an 83-year-old male patient in cardiogenic shock with acute aortic regurgitation that occurred six years after aortic valve replacement (AVR) with a 23 mm Trifecta™ valve. Prosthesis endocarditis was initially suspected because of a floating structure attached to the aortic valve that was visible on echocardiography. Emergency redo-AVR surgery was performed, but no signs of endocarditis were found intraoperatively. Hence, cusp tearing of the implanted bioprosthesis was considered to be the reason for the severe aortic regurgitation.

Post-market surveillance to detect adverse events associated with Melody® valve implantation

OBJECTIVE

The aim of this study was to describe previously unrecognised or under-recognised adverse events associated with Melody® valve implantation.

BACKGROUND

In rare diseases and conditions, it is typically not feasible to conduct large-scale safety trials before drug or device approval. Therefore, post-market surveillance mechanisms are necessary to detect rare but potentially serious adverse events.

METHODS

We reviewed the United States Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database and conducted a structured literature review to evaluate adverse events associated with on- and off-label Melody® valve implantation. Adverse events were compared with those described in the prospective Investigational Device Exemption and Post-Market Approval Melody® transcatheter pulmonary valve trials.

RESULTS

We identified 631 adverse events associated with "on-label" Melody® valve implants and 84 adverse events associated with "off-label" implants. The most frequent "on-label" adverse events were similar to those described in the prospective trials including stent fracture (n=210) and endocarditis (n=104). Previously unrecognised or under-recognised adverse events included stent fragment embolisation (n=5), device erosion (n=4), immediate post-implant severe valvar insufficiency (n=2), and late coronary compression (n=2 cases at 5 days and 3 months after implantation). Under-recognised adverse events associated with off-label implantation included early valve failure due to insufficiency when implanted in the tricuspid position (n=7) and embolisation with percutaneous implantation in the mitral position (n=5).

CONCLUSION

Post-market passive surveillance does not demonstrate a high frequency of previously unrecognised serious adverse events with "on-label" Melody® valve implantation. Further study is needed to evaluate safety of "off-label" uses.

A Systematic Review of Infective Endocarditis in Patients With Bovine Jugular Vein Valves Compared With Other Valve Types

OBJECTIVES

The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle-to-pulmonary artery conduits and valves, comparing bovine jugular vein (BJV) valves with all others.

BACKGROUND

Recent evidence suggests that the incidence of IE is higher in patients with congenital heart disease who have undergone implantation of BJV valves in the pulmonary position compared with other valves.

METHODS

Systematic searches of published research were conducted using electronic databases (MEDLINE, Embase, and CINAHL) and citations cross-referenced current to April 2016. Included studies met the following criteria: patients had undergone right ventricle-to-pulmonary artery conduit or percutaneous pulmonary valve implantation, and investigators reported on the type of conduit or valve implanted, method of intervention (surgery or catheter based), IE incidence, and follow-up time.

RESULTS

Fifty studies (Levels of Evidence: 2 to 4) were identified involving 7,063 patients. The median cumulative incidence of IE was higher for BJV compared with other valves (5.4% vs. 1.2%; p < 0.0001) during a median follow-up period of 24.0 and 35.5 months, respectively (p = 0.03). For patients with BJV valves, the incidence of IE was not different between surgical and catheter-based valve implantation (p = 0.83).

CONCLUSIONS

There was a higher incidence of endocarditis with BJV valves than other types of right ventricle-to-pulmonary artery conduits. There was no difference in the incidence of endocarditis between catheter-based bovine valves and surgically implanted bovine valves, suggesting that the substrate for future infection is related to the tissue rather than the method of implantation.

Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study

BACKGROUND

Subclinical leaflet thrombosis of bioprosthetic aortic valves after transcatheter valve replacement (TAVR) and surgical aortic valve replacement (SAVR) has been found with CT imaging. The objective of this study was to report the prevalence of subclinical leaflet thrombosis in surgical and transcatheter aortic valves and the effect of novel oral anticoagulants (NOACs) on the subclinical leaflet thrombosis and subsequent valve haemodynamics and clinical outcomes on the basis of two registries of patients who had CT imaging done after TAVR or SAVR.

METHODS

Patients enrolled between Dec 22, 2014, and Jan 18, 2017, in the RESOLVE registry, and between June 2, 2014, and Sept 28, 2016, in the SAVORY registry, had CT imaging done with a dedicated four-dimensional volume-rendered imaging protocol at varying intervals after TAVR and SAVR. We defined subclinical leaflet thrombosis as the presence of reduced leaflet motion, along with corresponding hypoattenuating lesions shown with CT. We collected data for baseline demographics, antithrombotic therapy, and clinical outcomes. We analysed all CT scans, echocardiograms, and neurological events in a masked fashion.

FINDINGS

Of the 931 patients who had CT imaging done (657 [71%] in the RESOLVE registry and 274 [29%] in the SAVORY registry), 890 [96%] had interpretable CT scans (626 [70%] in the RESOLVE registry and 264 [30%] in the SAVORY registry). 106 (12%) of 890 patients had subclinical leaflet thrombosis, including five (4%) of 138 with thrombosis of surgical valves versus 101 (13%) of 752 with thrombosis of transcatheter valves (p=0·001). The median time from aortic valve replacement to CT for the entire cohort was 83 days (IQR 33-281). Subclinical leaflet thrombosis was less frequent among patients receiving anticoagulants (eight [4%] of 224) than among those receiving dual antiplatelet therapy (31 [15%] of 208; p<0·0001); NOACs were equally as effective as warfarin (three [3%] of 107 vs five [4%] of 117; p=0·72). Subclinical leaflet thrombosis resolved in 36 (100%) of 36 patients (warfarin 24 [67%]; NOACs 12 [33%]) receiving anticoagulants, whereas it persisted in 20 (91%) of 22 patients not receiving anticoagulants (p<0·0001). A greater proportion of patients with subclinical leaflet thrombosis had aortic valve gradients of more than 20 mm Hg and increases in aortic valve gradients of more than 10 mm Hg (12 [14%] of 88) than did those with normal leaflet motion (seven [1%] of 632; p<0·0001). Although stroke rates were not different between those with (4·12 strokes per 100 person-years) or without (1·92 strokes per 100 person-years) reduced leaflet motion (p=0·10), subclinical leaflet thrombosis was associated with increased rates of transient ischaemic attacks (TIAs; 4·18 TIAs per 100 person-years vs 0·60 TIAs per 100 person-years; p=0·0005) and all strokes or TIAs (7·85 vs 2·36 per 100 person-years; p=0·001).

INTERPRETATION

Subclinical leaflet thrombosis occurred frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. Anticoagulation (both NOACs and warfarin), but not dual antiplatelet therapy, was effective in prevention or treatment of subclinical leaflet thrombosis. Subclinical leaflet thrombosis was associated with increased rates of TIAs and strokes or TIAs. Despite excellent outcomes after TAVR with the new-generation valves, prevention and treatment of subclinical leaflet thrombosis might offer a potential opportunity for further improvement in valve haemodynamics and clinical outcomes.

FUNDING

RESOLVE (Cedars-Sinai Heart Institute) and SAVORY (Rigshospitalet).

Transcatheter Aortic Valve Replacement for Perceval Sutureless Aortic Valve Failure

As experience with Perceval aortic prosthesis and valve-in-valve TAVR grows, it will be crucial to meticulously document short- and long-term follow-up for establishment of real-world safety and durability of these new technologies.

Correlation between structural changes and acute thrombogenicity in transcatheter pericardium valves after crimping and balloon deployment

INTRODUCTION

Transcathether heart valve replacement has gained considerable acceptance during the last decades. It is now part of the armamentarium for aortic valve replacement. The procedure proved to be highly efficient. However the issues of the blood compatibility and tissue durability were not raised and the adverse events were probably under-reported, according to observations of thrombosis after deployment.

MATERIAL AND METHOD

Bovine pericardium leaflets were sewn inside a 26mm diameter stainless steel stent to manufacture these valves (one control and two experimental). The correlation between the trauma and the acute thombogenicity of bovine pericardium leaflets, after crimping and ballooning, was investigated via an in vitro blood flow with labeled platelets. These leaflets were processed for histology: scanning electron microscopy, light microscopy, and transmission electron microscopy.

RESULTS

The control specimens showed a regular pericardium structure with some blood cells deposited on the collagen fibrous surface (inflow) and scarce blood cells deposited on the serous surface (outflow). After crimping and ballooning, the structure of the pericardium was severely injured, eventually with delaminations and ruptures. The blood cell uptake was considerably increased compared to the control.

CONCLUSION

It would therefore be appropriate to pay more attention to the design of the valves. Specifically, the incorporation of a buffer tissue or fabric between the pericardium and the metallic stent is suggested. The issue of ballooning deserves detailed and in depth investigation regarding the lifetime of the device.

Bioprosthetic Aortic Paravalvular Leak: Is Valve-in-Valve Another Solution?

Paravalvular leak (PVL) following aortic valve implantation is a rare complication but may cause potentially serious consequences. It occurs in 2%-10% of surgical aortic valve replacements and 7%-17% of surgical mitral valve replacements. Transcatheter valve replacement data show that significant PVL occurs in 6%-8% of cases. The management of significant PVL has traditionally involved repeat surgical repair. However, many of these patients are considered too high risk to undergo a repeat surgical procedure; hence, a percutaneous transcatheter approach has often been utilized to treat these patients. Vascular plugs have been used to close PVLs, with variable results; the procedure is complex and technically demanding. Transcatheter aortic valve replacement, using a valve-in-valve approach, may provide an alternative approach for bioprosthetic PVL in the aortic position.

When Not to Go SOLO? Contraindications Based on Implant Experience

BACKGROUND AND AIM OF THE STUDY

Because of the design and specific implantation technique of the stentless Freedom SOLO bioprosthesis, patient selection is crucial. The aim of the study was to discuss the contraindications to this prosthesis based on the authors' implant experience.

METHODS

Between April 2005 and February 2015, one surgeon at the authors' center performed 292 aortic valve replacements using a bioprosthesis, with the initial intention of implanting a SOLO valve in every patient. A search was conducted for all of these patients and data collected on whether a SOLO valve was used, or not.

RESULTS

A SOLO valve was implanted in 238 patients (82%), and a stented bioprosthesis in 54 (18%). The predominant reasons not to implant a SOLO valve were asymmetric commissures (26%) and a large aortic annulus (24%). Only one patient had structural valve deterioration, and none of the patients had to undergo reoperation because of aortic valve insufficiency or paravalvular leakage.

CONCLUSIONS

Asymmetric commissures, large aortic annulus (>27 mm), calcified aortic sinuses, dilated sinotubular junction, aberrant location of coronary ostia and whenever the stent of a stented bioprosthesis is useful, were contraindications to implant a SOLO valve. When these contraindications were taken into account, a very good durability could be achieved with the SOLO valve during mid-term follow up.

Transfemoral Valve-in-Valve Transcatheter Aortic Valve Implantation (TAVI) in a Patient With Previous Endovascular Aortic Repair (EVAR)

A 90-year-old man presented with increasing exertional breathlessness. He had previous implantation of a Perimount bioprosthetic aortic valve (Edwards Lifesciences) and coronary artery bypass graft surgery. Due to severe transvalvular bioprosthetic regurgitation with preserved left ventricular dimensions and ejection fraction, the heart team decided on valve-in- valve transcatheter aortic valve implantation via the transfemoral route in view of the patient's prohibitively high surgical and anesthetic risk. The patient had an uncomplicated recovery and was symptomatically much improved at 3-month follow-up.

Cerebral Aneurysm from Cardiobacterium hominis Endocarditis

A 43-year-old male with a history of bioprosthetic aortic valve replacement and tricuspid valve annuloplasty presented with vertigo and was found to have an acute infarct in the left superior cerebellum, as well as a left-middle cerebral artery mycotic aneurysm. Blood cultures grew Cardiobacterium hominis and bioprosthetic aortic valve vegetation was found on transthoracic echocardiogram.

Subconjunctival Bevacizumab for the Treatment of Keratoprosthesis-Associated Cystoid Macular Edema

The authors present a case of keratoprosthesis-associated cystoid macular edema (CME) responsive to subconjunctival bevacizumab (Avastin; Genentech, South San Francisco, CA). A 40-year-old woman with a history of Stevens-Johnson syndrome (SJS) and Boston keratoprosthesis type I implantation developed CME 10 months after surgery and received sub-Tenon's kenalog with minimal improvement. Sixteen months after surgery, she received a subconjunctival injection of bevacizumab and demonstrated visual and anatomic improvement. Ten weeks later, she received a second subconjunctival injection of bevacizumab for worsening CME and again demonstrated a favorable response. Subconjunctival bevacizumab may be an effective and less-invasive alternative to intravitreal injections for the treatment of postoperative CME.

Transcatheter Valve-in-Valve Implantation in a Degenerated Mitral Bioprosthesis Using a Trans-Septal Anterograde Approach and 3-D Transesophageal Echocardiography Guidance

Degenerated and dysfunctional prosthetic valves are usually replaced surgically. However, repeated cardiac surgery can cause prohibitive risk, especially in patients with many associated co-morbidities. Transcatheter valve-in-valve implantation (TVIV) is a novel, technically very challenging, but less invasive alternative treatment for patients with unacceptably high surgical risk of degenerated prosthetic valves. The method is attractive because it takes advantage of the presence of the degenerated prosthesis, which serves as an anchoring zone. Here, the case is presented of TVIV in an 82-year-old female with significant stenosis of a biological mitral prosthesis. In 2011, Himbert et al. were the first to successfully insert a transcatheter heart valve in the mitral ring using a transfemoral approach. To date, only a small case series has been reported on the effectiveness of TVIV using a transfemoral venous access and a trans-septal anterograde approach. The present patient was the first in which TVIV was performed in Poland and Eastern Europe.

[Structural alterations of a biological prosthesis]

The authors studied dilatation of a biological prosthesis (a specially treated xenograft made of bovine arteries) used as a femoropopliteal bypass in patients presenting with diseases of peripheral arteries. Structural alterations (ectasia) were examined in a total of 15 patients within the terms varying from 1 year to 7 years after the operation, resulting in working out a methodology of calculating structural changes of the conduit with characteristics of the composite index of dilatation of the conduit. The presence of aneurysmatically dilated portions whose dimension exceeded the initial size of the xenograft 3-4-fold did not influence the long-term patency of the shunt with preserved blood flow approximated to the major one. This made it possible to avoid a repeat surgical intervention.

[A case of treating a patient with a false aneurysm of the xenoconduit of the ascending aorta and pronounced cardiac insufficiency]

Described in the article is a clinical case of treating a previously operated patient presenting with a pseudoaneurysm of the xenoconduit of the ascending aortic portion, functioning Cabrol fistula and pronounced cardiac insufficiency, who was admitted to our institution in the state of decompensation. The obtained outcomes of treating this patient demonstrated a possibility of successfully using vascular grafts for establishing an anastomosis between the left coronary artery and ascending portion of the aorta in complicated conditions of a repeat intervention.

Thrombocytopenia after Aortic Valve Replacement with Perceval S Sutureless Bioprosthesis

BACKGROUND AND AIM OF THE STUDY: Sutureless aortic bioprosthetic valves have become an alternative to conventional bioprostheses in high surgical risk cases. A significant decline in platelet count during the immediate postoperative period was observed in cases of Perceval S sutureless aortic valve implantation. The study aim was to determine how the reduction in platelet count after Perceval S prosthesis implantation compared to that after other bioprosthesis implants. METHODS: Between July 2011 and July 2014, a total of 77 isolated biological aortic valve replacements (AVRs) was performed at the authors’ institution. These included 27 Perceval S prostheses (35.1%) and 50 Mitroflow prostheses (64.9%). Platelet counts and mean platelet volumes (MPVs) were determined on the day before surgery (T0) and at 24 h (T1), 48 h (T2) and 72 h (T3) after surgery. RESULTS: There were no significant differences in inhospital mortality (three Perceval S (11.1%) versus four Mitroflow 8%); p = 0.65), nor in morbidity between groups. A total of 16 patients (20.8%) had severe postoperative thrombocytopenia (<50×103/mm3). The incidence of severe thrombocytopenia was significantly higher (p = 0.046) in Perceval S patients (n = 9; 33.3%) than in Mitroflow patients (n = 7; 14%). The platelet count recovered in all patients with severe thrombocytopenia. In an adjusted-propensity multivariate logistic regression analysis, the Perceval S prosthesis was the major independent predictor of severe thrombocytopenia after AVR (OR 0.06, 95% CI: 0008-0.5, p = 0.009). CONCLUSION: Aortic bioprosthesis implantation with the Perceval S sutureless bioprosthesis appears to be associated with the occurrence of postoperative thrombocytopenia, though without any clinical implication for the patients. Prospective randomized trials are required to confirm these data.

Quadruple Valve Reoperation after the Ross Procedure

Reoperations after the Ross procedure are rare, with autograft as well as homograft failure being the dominant causes for redo cardiac procedures. Due to increasing experience with valve-sparing aortic valve procedures, more valves can be preserved during redo surgery. Herein are reported the details of a patient who underwent quadruple valve reoperation comprising redo with a reconstructive approach after the short-term failure of pulmonary autograft and homograft with concomitant mitral and tricuspid regurgitation.

Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves

BACKGROUND

A finding of reduced aortic-valve leaflet motion was noted on computed tomography (CT) in a patient who had a stroke after transcatheter aortic-valve replacement (TAVR) during an ongoing clinical trial. This finding raised a concern about possible subclinical leaflet thrombosis and prompted further investigation.

METHODS

We analyzed data obtained from 55 patients in a clinical trial of TAVR and from two single-center registries that included 132 patients who were undergoing either TAVR or surgical aortic-valve bioprosthesis implantation. We obtained four-dimensional, volume-rendered CT scans along with data on anticoagulation and clinical outcomes (including strokes and transient ischemic attacks [TIAs]).

RESULTS

Reduced leaflet motion was noted on CT in 22 of 55 patients (40%) in the clinical trial and in 17 of 132 patients (13%) in the two registries. Reduced leaflet motion was detected among patients with multiple bioprosthesis types, including transcatheter and surgical bioprostheses. Therapeutic anticoagulation with warfarin, as compared with dual antiplatelet therapy, was associated with a decreased incidence of reduced leaflet motion (0% and 55%, respectively, P=0.01 in the clinical trial; and 0% and 29%, respectively, P=0.04 in the pooled registries). In patients who were reevaluated with follow-up CT, restoration of leaflet motion was noted in all 11 patients who were receiving anticoagulation and in 1 of 10 patients who were not receiving anticoagulation (P<0.001). There was no significant difference in the incidence of stroke or TIA between patients with reduced leaflet motion and those with normal leaflet motion in the clinical trial (2 of 22 patients and 0 of 33 patients, respectively; P=0.16), although in the pooled registries, a significant difference was detected (3 of 17 patients and 1 of 115 patients, respectively; P=0.007).

CONCLUSIONS

Reduced aortic-valve leaflet motion was shown in patients with bioprosthetic aortic valves. The condition resolved with therapeutic anticoagulation. The effect of this finding on clinical outcomes including stroke needs further investigation. (Funded by St. Jude Medical and Cedars-Sinai Heart Institute; Portico-IDE ClinicalTrials.gov number, NCT02000115; SAVORY registry, NCT02426307; and RESOLVE registry, NCT02318342.).

Risk of breast cancer among patients with bioprosthetic or mechanical valve replacement: a population-based study in Sweden

The association between breast cancer and warfarin is inconclusive as most previous studies examined their association using patients with thromboembolism, whereas thromboembolism itself is a risk factor for cancer. We explored this issue using patients received mechanical heart valves replacement as a proxy for warfarin exposure as these patients need a lifelong warfarin treatment, and compared them with patients received bioprosthesis valves replacement (short-term warfarin treatment) in Sweden between 1987 and 2010. Patients who were operated on for valve replacement were identified from the Swedish Hospital Discharge Registry and linked to the Swedish Cancer Registry to examine the hazard ratios of subsequent breast cancer. A total of 12,242 women were operated on for valve replacement (5481 with mechanical valve and 6401 with bioprosthetic valve). For the entire cohort, the HR of breast cancer was 1.49 (95 % CI 1.09-2.02) among patients with mechanical valve replacement compared to those with bioprosthetic valve replacement. After controlling for a number of confounding factors using propensity score weighting, the HR was 1.69 (95 % CI 1.15-2.47). Our study found that patients with mechanical valve replacement have an increased risk of breast cancer compared to those with bioprosthetic valve replacement. If confirmed, this increased risk should be considered when recommending breast cancer screening for women with mechanical valve replacement. Long-term use of warfarin may explain the observed increase. If so, patients who have used warfarin long-term for other reasons should be studied for a possible increased risk of breast cancer.

The FORGOTTEN (TRICUSPID) VALVE; THIRD TIME, RIGHT TIME

Tricuspid regurgitation (TR) remains a challenging condition, the indication, timing and type of surgery for which are not yet well established. A 42-year-old woman was referred to the authors' institution with recurrent, symptomatic TR at one year after she had undergone tricuspid valve repair for an Ebstein's anomaly. At 14 months after the first surgery a bioprosthesis was implanted for a detached annuloplasty ring, and she made a complete recovery. However, at 15 months after valve replacement she presented again with right heart failure and massive TR due to rare early pannus formation. A re-redo tricuspid valve replacement was performed. Tricuspid valve replacement with a bioprosthesis is a valid option if repair is unsuccessful. However, there is a need to be aware of concomitant problems such as a requirement for pacemaker implantation, the risk for prosthesis thrombosis or pannus formation, and the importance of anticoagulation therapy. Annual transthoracic echocardiographic follow up is advisable to exclude subclinical TR.

Treatment of Aortic, Mitral and Tricuspid Structural Bioprosthetic Valve Deterioration Using the Valve-in-Valve Technique

BACKGROUND AND AIM OF THE STUDY

The percutaneous approach for a failed bioprosthetic valve is an emerging alternative to redo-valve surgery in patients at high surgical risk. The study aim was to describe the treatment of patients with structural bioprosthetic valve deterioration, using the valve-in-valve technique.

METHODS

A total of 33 consecutive patients with symptomatic structural bioprosthetic valve deterioration was treated at the authors' institution, using the valve-in-valve technique.

RESULTS

The valve-in-valve procedure in the aortic position was performed in 23 patients (mean age 81.4 ± 5.9 years; mean STS score 9.6 ± 5.4). The self-expandable and balloon-expandable devices were used in 21 cases (91.3%) and two cases (8.7%), respectively. Procedures were performed via the trans-femoral, trans-axillary and trans-apical routes in 18 (78.2%), three (13%) and two (8.7%) cases, respectively. After the procedure, all patients were in NYHA class I/II. Survival rates were 95.6% at the one-year follow up. The valve-in-valve procedure in the mitral position was performed in 10 patients (mean age 73.6 ± 15 years; mean STS score 7.7 ± 4.1). All procedures were performed using the balloon-expandable device via the trans-apical route. The composite end point of device success was achieved in all patients. Survival rates were 100% and 75% at one month and two years' follow up, respectively. A single valve-in-valve implantation within a failed tricuspid bioprosthetic valve was also successfully performed.

CONCLUSION

In the authors' experience, the valve-in-valve technique for the treatment of a wide range of bioprosthetic valve deterioration modes of failure in different valve positions is safe and very effective.

Survival and outcomes following bioprosthetic vs mechanical mitral valve replacement in patients aged 50 to 69 years

IMPORTANCE

In nonelderly patients with mitral disease requiring valve replacement, deciding between bioprosthetic and mechanical prosthetic valves is challenging because long-term survival and morbidity are not well defined.

OBJECTIVE

To quantify survival and major morbidity after mitral valve replacement in patients aged 50 to 69 years.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis of 3433 patients (aged 50-69 years) who underwent primary, isolated mitral valve replacement in New York State hospitals from 1997-2007. Follow-up ended November 30, 2013; median duration was 8.2 years (range, 0-16.8 years). Propensity score matching for 19 baseline characteristics yielded 664 patient pairs.

EXPOSURES

Bioprosthetic vs mechanical prosthetic mitral valve replacement.

MAIN OUTCOMES AND MEASURES

All-cause mortality, stroke, reoperation, and major bleeding events.

RESULTS

No survival difference was observed between use of mechanical prosthetic and bioprosthetic mitral valves in patients aged 50 to 69 years matched by propensity score or in a subgroup analysis of age by decade. Among patients matched by propensity score, the incidences of stroke and bleeding events were both significantly higher in those who received mechanical prosthetic mitral valves compared with those who received bioprosthetic mitral valves; however, the incidence of reoperation was lower in the mechanical prosthesis group compared with the bioprosthesis group. [table: see text]

CONCLUSIONS AND RELEVANCE

Among patients aged 50 to 69 years undergoing mitral valve replacement in New York State, there was no significant survival difference at 15 years in patients matched by propensity score who underwent mechanical prosthetic vs bioprosthetic mitral valve replacement. Mechanical prosthetic valves were associated with lower risk of reoperation but greater risk of bleeding and stroke. Even though these findings suggest bioprosthetic mitral valve replacement may be a reasonable alternative to mechanical prosthetic valve replacement in patients aged 50 to 69 years, the 15-year follow-up was insufficient to fully assess lifetime risks, particularly of reoperation.

[Use of a biological graft for subclavian-femoral bypassing in patients at operational-anaesthesiological risk]

Analysed herein are the results of an experimental study performed on 30 rabbits and a clinical study of treating a total of 60 patients presenting with critical ischaemia of lower limbs on the background of bilateral atherosclerotic lesions of the aortoiliac segment and running high operational-anaesthesiological risk. The animals were subdivided into three groups: an intact group consisting of 6 animals and two study groups comprising 12 rabbits each. In the first study group onto the wall of the abdominal aorta we implanted a synthetic polytetrafluoroethylene prosthesis, the second study group animals received biological graft "Kemangioprotez" from bovine internal thoracic arteries. The biological prosthesis on day three after implantation onto the arterial wall induced 3.2 times and on day seven 1.2 times more pronounced inflammatory reaction than the polytetrafluoroethylene prosthesis. 30 days after implantation of the synthetic graft the degree of repair connective-tissue processes in the arterial wall was 1.8-fold and 70 days after was 3.3-fold more pronounced than after implantation of the biological prosthesis at the same terms. In the connective-tissue capsule around the synthetic prosthesis predominated cellular elements while around the biological prosthesis - fibrous structures predominated. The patients were subdivided into 2 groups consisting of 30 patients each. In Group One patients the shunt used was a synthetic polytetrafluoroethylene prosthesis, in Group Two being a biological graft from bovine internal thoracic arteries. All patients suffered from severe concomitant diseases in the decompensation stage and a multi-level lesion of lower-limb arteries. Revascularization of the ischaemized extremity was carried out through the system of the deep femoral artery system. The use of a biological prosthesis made it possible in the immediate postoperative period to decrease the frequency of early postoperative complications by 13.3%, that of late graft thromboses by 30%, to prolong the average term of grafts functioning 1.8-fold, to increase the physical component of health by 12.8% and the mental one by 9.1%.

CONCLUSION

For femorosubclavian shunting in high-risk patients it is appropriate to use a biological graft while establishing a distal anastomosis with the deep femoral artery.

Platelet activation after sorin freedom solo valve implantation: a comparative study with Carpentier-Edwards Perimount Magna

BACKGROUND AND AIM OF THE STUDY

As platelet activation is known to be a side effect of cardiac surgery, recent analyses have been conducted to identify the association between thrombocytopenia and aortic valve replacement (AVR) using a bioprosthesis. The type of bioprosthesis has been indicated as an independent risk factor for a lower postoperative platelet count, an association which has been mainly observed with the Sorin Freedom Solo valve. The study aim was to analyze platelet activation after AVR with two different bioprostheses, the Sorin Freedom SOLO (FS) and the Carpentier-Edwards Magna (CE).

METHODS

Thirty-eight consecutive patients undergoing aortic valve surgery were enrolled prospectively and assigned to either the FS group (n = 18) or the CE group (n = 20) according to their clinical evaluation. Five patients who underwent isolated coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) were included as a control group. Clinical biochemical parameters (von Willebrand factor (vWF), prothrombin fragments 1+2 (F1+2), P-selectin, and beta-thromboglobulin (beta-TG)) were assessed preoperatively (TO), and at 1 h (T1), 48 h (T2) and seven days (T3) postoperatively.

RESULTS

The two groups differed in terms of age (FS 77.3 +/- 7.0 years; CE 65.4 +/- 8.4 years; p < 0.05). Intraoperatively, parameters such as CPB time (FS 106.8 +/- 25.5 min; CE 108.2 +/- 23.4 min, p = NS) and aortic cross-clamp time (FS 78.1 +/- 22.8 min; CE 80.7 +/- 19.4 min, p = NS) were comparable. The platelet count was significantly reduced after FS implantation compared to the other groups. Factors involving platelet activation and blood coagulation activation assessed by means of prothrombin F1+2 (FS: TO = 0.48; T1 = 0.66; T2 = 0.46; T3 = 0.52 nmol/ml versus CE: T0 = 0.38; T1 = 0.68; T2 = 0.41; T3 = 0.49 nmol/ml); P-selectin (FS: T0 = 89.6; T1= 130.4; T2 = 92.6; T3 = 94.3 ng/ml versus CE: T0 = 81.4; T1 = 115.9; T2 = 92.2; T3 = 85.7 ng/ml); and beta-TG (FS: T0 = 6.7; T1 = 17.6; T2 = 8.6; T3 = 7.7 ng/ml versus CE: T0 = 7.1; T1 = 15.6; T2 = 9,1; T3 = 7.5 ng/ml) were not significantly different.

CONCLUSION

The previously described phenomenon of enhanced platelet reduction shortly after valve implantation in the FS group compared to another bioprosthesis is likely to be confirmed, but platelet activation should not be considered as the underlying mechanism. Superior (but not significant) preoperative values of biochemical parameters were found in FS versus CE patients, influencing postoperative levels without any variation in the trend pattern. The type of bioprosthesis implanted appeared not to influence platelet and blood coagulation activation.

Collagen cross-linking of the Boston keratoprosthesis donor carrier to prevent corneal melting in high-risk patients

OBJECTIVE

To examine the clinical relevance and pathophysiology of Boston keratoprosthesis (B-KPro)-related corneal keratolysis (cornea melt) and to describe a novel method of preventing corneal melt using ex vivo crosslinked cornea tissue carrier.

METHODS

A review of B-KPro literature was performed to highlight cases of corneal melt. Studies examining the effect of corneal collagen cross-linking (CXL) on the biomechanical properties of corneal tissue are summarized. The use of crosslinked corneal tissue as a carrier to the B-KPro is illustrated with a case.

RESULTS

Corneal melting after B-KPro is a relatively rare event, occurring in 3% of eyes during the first 3 years of postoperative follow-up. The risk of post-KPro corneal melting is heightened in eyes with chronic ocular surface inflammation such as eyes with Stevens-Johnson syndrome and mucous membrane pemphigoid. This chronic inflammation results in high tear levels of matrix metalloproteinases, the enzymes responsible for collagenolysis and corneal melt. Crosslinked corneal tissue has been shown to have stiffer biomechanical properties and to be more resistant to degradation by collagenolytic enzymes. We have previously optimized the technique for ex vivo corneal CXL and are currently studying its impact on the prevention of corneal melting after B-KPro surgery in high-risk eyes. Crosslinked carrier tissue was used in a 52-year-old man with familial aniridia and severe post-KPro corneal melt. The patient maintained his visual acuity and showed no evidence of corneal thinning or melt in the first postoperative year.

CONCLUSION

Collagen crosslinking was previously shown to halt the enzymatic degradation of corneal buttons ex vivo. This study demonstrates the safety and potential benefit of using crosslinked corneal grafts as carriers for the B-KPro, especially in eyes at higher risk of postoperative melt.

Determinants of persistent or recurrent congestive heart failure after contemporary surgical aortic valve replacement

BACKGROUND AND AIM OF THE STUDY

Although one of the goals of surgical aortic valve replacement (AVR) is to alleviate congestive heart failure (CHF), the latter often occurs after AVR. Surprisingly, the incidence of CHF after AVR remains unclear, as outcomes are reported according to valve-related complications, each of which may result in CHF. The study aim was to: (i) validate a previously described model predicting persistent or recurrent CHF after AVR in a contemporary cohort; and (ii) apply the model to predict late outcomes following AVR with the Trifecta valve.

METHODS

A previously described statistical model was validated in a cohort of 1,014 patients who received the St. Jude Trifecta prosthesis between 2007 and 2009. A sensitivity analysis was performed to determine the influence of risk factors associated with late CHF. Model prediction was verified with a Monte Carlo simulation employing 10,000 iterations.

RESULTS

The model accurately predicted late CHF events in a contemporary cohort. Sensitivity analysis identified mean transprosthesis gradient (MTG), body surface area (BSA), and preoperative NYHA class as important CHF risk factors. Based on the model, a 5 mmHg decrease in MTG was associated with 2.5% and 10.4% reductions in late CHF at five and 15 years, respectively. A 10% decrease in mean BSA and preoperative NYHA class IV symptoms were associated with a 1% decrease and a 5% increase in CHF events at 15 years after AVR.

CONCLUSION

The authors' previously described model predicting persistent or recurrent CHF after AVR was validated in a contemporary cohort. This model may be applied to predict outcomes in patients who receive modern prostheses, without long-term follow up.

Valve-in-valve procedure: importance of the anatomy of surgical bioprostheses

Transcatheter aortic valve implantation is an accepted and established alternative to surgical aortic valve replacement for patients with severe symptomatic aortic valve stenosis and multiple comorbidities that would make open surgery a high-risk option. It has also evolved as a suitable treatment option for degenerative surgical heart valve disease, with considerable experience in the aortic and mitral positions. To enable a successful procedure, avoiding malposition, valve embolization and coronary obstruction, clinicians should be familiar with the design, fluoroscopic appearances and implantation technique of the degenerated surgical bioprosthetic valve in situ, as well as its compatibility with currently available transcatheter valves.

Pseudoaneurysm formation after medtronic freestyle porcine aortic bioprosthesis implantation: a word of caution

BACKGROUND

A growing literature describes aneurysmal deterioration after implantation of the stentless porcine aortic Medtronic Freestyle bioprosthesis (MFB; Medtronic Inc, Minneapolis, MN), with some suggesting inadequate tissue fixation with immune response as a cause. However, disjointed reports make the significance of these findings difficult to interpret. We address this concern by aggregating available data.

METHODS

We reviewed institutional data, the Food and Drug Administration's Manufacturer and User Facility Device Experience registry, and the medical literature for mention of aneurysm or pseudoaneurysm after MFB. Case details were aggregated, and the rate of aneurysmal deterioration was estimated. Immunohistopathologic examination of institutional explanted specimens was performed to elucidate a cause.

RESULTS

We found 42 cases of aneurysmal deterioration with adequate detail for analysis; all occurred with full root replacement and valve sizes ranging from 23 to 29 mm. The rate of aneurysmal deterioration considering all data sources was 1.1% (9 of 851; 95% confidence interval, 0.5% to 2.0%) vs 4.7% (4 of 86; 95% confidence interval, 1.3% to 11.5%) at our institution, where yearly surveillance imaging is performed. Rate of aneurysmal deterioration appeared constant until 5 years after the operation; however, events are reported out to 10 years. Consistent with previous reports, histopathology demonstrated an immune cell infiltrate in areas of MFB wall breakdown.

CONCLUSIONS

Aneurysmal deterioration is an increasingly described complication of MFB implantation as a full root, with an incidence as high as 4.7%. Given the observed immune reaction and lack of occurrence in smaller (19-mm and 21-mm) valve sizes, inadequate pressure fixation of larger valves is a potential etiology. Patients with MFB require annual surveillance imaging, and consideration of this complication should factor into preoperative decision making because treatment mandates redo root replacement, which may not be feasible in high-risk patients.

Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years

IMPORTANCE

The choice between bioprosthetic and mechanical aortic valve replacement in younger patients is controversial because long-term survival and major morbidity are poorly characterized.

OBJECTIVE

To quantify survival and major morbidity in patients aged 50 to 69 years undergoing aortic valve replacement.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis of 4253 patients aged 50 to 69 years who underwent primary isolated aortic valve replacement using bioprosthetic vs mechanical valves in New York State from 1997 through 2004, identified using the Statewide Planning and Research Cooperative System. Median follow-up time was 10.8 years (range, 0 to 16.9 years); the last follow-up date for mortality was November 30, 2013. Propensity matching yielded 1001 patient pairs.

MAIN OUTCOMES AND MEASURES

Primary outcome was all-cause mortality; secondary outcomes were stroke, reoperation, and major bleeding.

RESULTS

No differences in survival or stroke rates were observed in patients with bioprosthetic compared with mechanical valves. Actuarial 15-year survival was 60.6% (95% CI, 56.3%-64.9%) in the bioprosthesis group compared with 62.1% (95% CI, 58.2%-66.0%) in the mechanical prosthesis group (hazard ratio, 0.97 [95% CI, 0.83-1.14]). The 15-year cumulative incidence of stroke was 7.7% (95% CI, 5.7%-9.7%) in the bioprosthesis group and 8.6% (95% CI, 6.2%-11.0%) in the mechanical prosthesis group (hazard ratio, 1.04 [95% CI, 0.75-1.43). The 15-year cumulative incidence of reoperation was higher in the bioprosthesis group (12.1% [95% CI, 8.8%-15.4%] vs 6.9% [95% CI, 4.2%-9.6%]; hazard ratio, 0.52 [95% CI, 0.36-0.75]). The 15-year cumulative incidence of major bleeding was higher in the mechanical prosthesis group (13.0% [95% CI, 9.9%-16.1%] vs 6.6% [95% CI, 4.8%-8.4%]; hazard ratio, 1.75 [95% CI, 1.27-2.43]). The 30-day mortality rate was 18.7% after stroke, 9.0% after reoperation, and 13.2% after major bleeding.

CONCLUSIONS AND RELEVANCE

Among propensity-matched patients aged 50 to 69 years who underwent aortic valve replacement with bioprosthetic compared with mechanical valves, there was no significant difference in 15-year survival or stroke. Patients in the bioprosthetic valve group had a greater likelihood of reoperation but a lower likelihood of major bleeding. These findings suggest that bioprosthetic valves may be a reasonable choice in patients aged 50 to 69 years.

[Redo double valve replacement in a patient with bioprosthetic valve malfunction by pannus formation; report of a case]

A 76-year-old female, who had received Carpentier-Edwards perimount (CEP) pericardial bioprostheses for aortic and mitral valves 6 years before, was diagnosed with reduced mobility of the valvular cusps by echocardiogram 2 years after the surgery. The symptoms of heart failure gradually aggravated. Significant stenosis and regurgitation were observed of the prosthetic valves, and a second surgery was performed. Calcification and severe pannnus formation were observed of both CEP valves that were excised.

Routine cine-CMR for prosthesis-associated mitral regurgitation: a multicenter comparison to echocardiography

BACKGROUND AND AIM OF THE STUDY

Mitral regurgitation (MR) is an important complication after prosthetic mitral valve (PMV) implantation. Transthoracic echocardiography is widely used to screen for native MR, but can be limited with PMV. Cine-cardiac magnetic resonance (CMR) holds the potential for the non-invasive assessment of regurgitant severity based on MR-induced inter-voxel dephasing. The study aim was to evaluate routine cine-CMR for the visual assessment of PMV-associated MR.

METHODS

Routine cine-CMR was performed at nine sites. A uniform protocol was used to grade MR based on jet size in relation to the left atrium (mild < 1/3, moderate 1/3-2/3, severe > 2/3). MR was graded in each long-axis orientation, with overall severity based on cumulative grade. Cine-CMR was also scored for MR density and pulmonary vein systolic flow reversal (PVSFR). Visual interpretation was compared to quantitative analysis in a single-center (derivation) cohort, and to transesophageal echocardiography (TEE) in a multicenter (validation) cohort.

RESULTS

The population comprised 85 PMV patients (59% mechanical valves, 41% bioprostheses). Among the derivation cohort (n = 25), quantitative indices paralleled visual scores, with stepwise increases in jet size and density in relation to visually graded MR severity (both p = 0.001). Patients with severe MR had an almost three-fold increase in quantitative jet area (p = 0.002), and a two-fold increase in density (p = 0.04) than did other patients. Among the multicenter cohort, cine-CMR and TEE (Δ =. 2 ± 3 days) demonstrated moderate agreement (κ = 0.44); 64% of discordances differed by ≤ 1 grade (Δ = 1.2 ± 0.5). Using a TEE reference, cine-CMR yielded excellent diagnostic performance for severe MR (sensitivity, negative predictive value = 100%). Patients with visually graded severe MR also had more frequent PVSFR (p < 0.001), denser jets (p < 0.001), and larger left atria (p = 0.01) on cine-CMR.

CONCLUSION

Cine-CMR is useful for the assessment of PMV-associated MR, which manifests concordant quantitative and qualitative changes in size and density of inter-voxel dephasing. Visual MR assessment based on jet size provides an accurate non-invasive means of screening for TEE-evidenced severe MR.

Challenging transfemoral valve-in-valve implantation in a degenerated stentless bioprosthetic aortic valve

Bioprosthetic heart valves are often preferred over mechanical valves as they may preclude the need for anticoagulation. Reoperation is the standard treatment for structural failure of bioprosthetic valves; however, it carries significant risk especially in inoperable elderly patients. Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) seems to be an effective and promising procedure in patients with degenerated bioprosthetic aortic valves avoiding the risks associated with the use of cardioplegia and redo cardiac surgery. We report an interesting case of a high-risk 74-year-old patient with a degenerated Sorin Freedom Solo stentless valve treated successfully with ViV TAVR.

Postoperative conduction disorders after implantation of the self-expandable sutureless Perceval S bioprosthesis

BACKGROUND AND AIM OF THE STUDY

Minimally invasive techniques for aortic valve replacement (AVR) have been developed as an alternative to conventional AVR for patients with high operative risk. Yet, these techniques are still associated with an increased risk of postoperative conduction disorders. The study aim was to identify the incidence and fate of postoperative conduction disorders in patients undergoing sutureless (SU) AVR with the Perceval S bioprosthesis.

METHODS

In this observational study, patients who underwent SU AVR with the Perceval S prosthesis at the Catharina Hospital, Eindhoven, were analyzed. Electrocardiograms (ECGs) recorded at baseline, within 24 h postoperatively, before hospital discharge and at follow up were collected by reviewing patients' records. The ECGs were analyzed by two independent investigators to record QRS-duration and conduction disorders.

RESULTS

All patients (n = 31) who underwent implantation of the Perceval S bioprosthesis between September 2010 and September 2012 were included. At baseline, three patients (9.7%) had preexisting left bundle branch block (LBBB), and one patient (3.2%) had a permanent pacemaker (PPM). New-onset LBBB developed in 11 patients (39.3%), and was transient in three patients (10.7%). Postoperatively, four patients (13.3%) required PPM implantation because of total atrioventricular block; all of these patients had either pre-existing LBBB (n = 1) or new LBBB (n = 3).

CONCLUSION

Sutureless AVR with the Perceval S bioprosthesis was frequently complicated by new LBBB, which was persistent in the majority of patients. A relatively high incidence of postoperative PPM implantation was also observed.

Pulmonary homograft endocarditis and aortic autograft failure after Ross procedure: a double stentless bioprosthesis approach

The case is reported of a 38-year-old male patient with pulmonary homograft acute infective endocarditis and aortic root dilation that occurred 13 years after a Ross procedure for bicuspid aortic valve regurgitation. Aortic and pulmonary root replacements were performed, using a Freestyle stentless aortic root bioprosthesis in both cases, with excellent hemodynamics on postoperative echocardiography. In addition, preoperative systemic septic embolization had occurred despite an absence of left-sided endocarditis, presumably due to an intrapulmonary shunt. This case report demonstrates the feasibility of a double stentless bioprosthesis approach, and stresses the need to remain vigilant for septic embolization even in isolated right-sided endocarditis.

Study of the porcine dermal collagen repair patch in morpho-functional recovery of the rotator cuff after minimum follow-up of 2.5 years

Tendon augmentation grafts have the potential to facilitate the repair of massive or otherwise unrepairable rotator cuff tears. In our clinic, between 2009 and 2013, 25 patients underwent surgery to treat massive symptomatic rotator cuff tears with porcine dermal collagen patch. This study is a clinical and instrumental assessment of 9 patients with the longest follow-up. These patients were evaluated with Constant score, the American Shoulder and Elbow Surgeons Evaluation Form, ultrasound imaging, magnetic resonance imaging, and electromyography. The clinical evaluations have shown good outcomes. The magnetic resonance imaging results were comparable with those of the ultrasound scan. In all cases, we found covering of humeral head, centering of the humeral head, maintenance of the tropism of the supraspinatus, no appearance of fatty degeneration, no worse in cases with fatty degeneration. With the electromyographic examination a complete functional recovery was observed with the possibility of performing maximal contraction against resistance in all cases. We believe that porcine dermal collagen is effective as an augmentation graft in the treatment of chronic extensive rotator cuff tears, providing excellent pain relief with an improvement in active ranges of motion and strength.

Contegra®conduit: current outcomes and concerns

A variety of congenital cardiac anomalies with severe right ventricular outflow tract (RVOT) obstruction or RVOT interruption require surgical reconstruction from the infundibulum up to the pulmonary artery bifurcation or even into the branches of the pulmonary arteries. Ideally, the conduit or valve required for such reconstruction has to be formed of autologous tissue that grows, resists infection, lasts for the life span of the patient and is readily available in all sizes. Such conduits, however, are not available and although several alternatives have been used, none of which are without potential drawbacks. Contegra valved bovine internal jugular vein conduit (Medtronic Inc., MN, USA) has recently emerged as a promising option for pediatric RVOT reconstruction and has been advocated for its 'off-the-shelf' availability in sizes ranging from 12 to 22 mm, surgical pliability and encouraging short- and mid-term success in experimental animal, as well as clinical studies. This review focuses on the current outcomes of Contegra conduit and highlights some of the major concerns related to the use of this conduit and strategies to tackle these concerns.

[Atherosclerotic risk factors in development of bioprosthetic valve failure]

Calcification of xenotissue as main cause of structural failure of bioprosthetic valves significantly limits their application in clinical practice. The assumptions about universal mechanisms of abnormal soft tissues calcification and impact of recipients metabolic factors on this process have been known. This article is an overview of studies investigating traditional cardiovascular risk factors which appear to be predictors of bioprosthetic structural failure.

Simultaneous transapical paraprosthetic leak occlusion and valve-in-valve implantation into a degenerated mitral bioprosthesis

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing mitral bioprostheses. The presence of a paravalvular leak is considered a contraindication to this procedure that would leave the patient with significant residual regurgitation. The case is described of a patient with a severely degenerated 29 mm Carpentier-Edwards mitral bioprosthesis successfully treated by simultaneous transapical transcatheter valve-in-valve implantation and paraprosthetic leak occlusion. The potential advantages of this approach are discussed.

Severe bioprosthetic mitral valve stenosis in pregnancy

A 21-year-old woman in the 16th week of pregnancy was admitted due to acute presentation of severe exertional dyspnea. She had undergone mitral valve replacement (MVR) with bioprosthetic valve for infective endocarditis 2 years ago. She developed congestive heart failure from mitral bioprosthetic valve stenosis due to early structural valve deterioration. She also had severe pulmonary hypertension and underwent a redo MVR using a mechanical valve prosthesis with good maternal outcome but fetal demise. This report brings up the debate about what type of valve should be used in women in reproductive age, and discusses the management of severe mitral stenosis and stenosis of a bioprosthetic valve during pregnancy. Surgical options can almost always be delayed until fetal maturity is achieved and a simultaneous cesarean section can be performed. However, under certain circumstances when the maternal welfare is in jeopardy the surgical intervention is mandatory even before the fetus reaches viability.

Transcatheter aortic valve replacement for aortic bioprosthetic valve failure with cardiogenic shock

Acutely failing bioprosthetic valves represent a clinical emergency and are exceedingly challenging given the paucity of therapeutic options. Oftentimes, these patients are not re-operative candidates due to clinical instability. We present 2 cases of acute degenerative aortic bioprosthetic valve failure with cardiogenic shock treated with transcatheter aortic valve replacement (TAVR). These cases were characterized by hemodynamic instability with vasopressor dependence and (multiple) organ failure. These 2 cases demonstrate that TAVR should be considered as a treatment option for unstable patients with bioprosthetic failure.

Antithrombotic strategy in the three first months following bioprosthetic heart valve implantation

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)? After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up). Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients.