Individualised surgical treatment strategy for subaortic stenosis

OBJECTIVES

The clinical data of patients with subaortic stenosis who underwent surgical treatment in our centre in the past 12 years were reviewed. The short-term and long-term clinical outcomes were analyzed, and the long-term outcomes of different surgical methods for subaortic stenosis were compared to determine the optimal surgical treatment strategy for subaortic stenosis.

METHODS

From December 2010 to December 2022, 90 patients undergoing surgical treatment for subaortic stenosis in our hospital were enrolled. There were 55 males and 35 females with a median age of 72 (46,132) months and an average surgical weight of (21.35 ± 15.84) kg. According to the operation method, 90 patients were divided into group A (50 patients with simple subaortic membrane resection) and group B (40 patients with subaortic membrane and muscle resection or modified Konno procedure).

RESULTS

There were three early deaths (3.33%). One late death occurred in group B. There was no significant difference in long-term survival rate between the two groups (p = 0.904). The preoperative left ventricular outflow tract pressure gradient in group B was (91.56 ± 36.98) mm Hg, which was higher than that in group A(51.13 ± 36.04)mm Hg(p < 0.001). There was no significant difference in immediate postoperative left ventricular outflow tract pressure gradient between group B [(5.44 ± 8.43) mm Hg] and group A [(7.82 ± 13.44) mm Hg] (p = 0.343). In the long-term follow-up, left ventricular outflow tract pressure gradient in group B was (5.86 ± 9.53) mm Hg, which was not statistically significant compared with group A (8.83 ± 14.52) mm Hg (p = 0.294). Eleven patients with moderate or greater aortic regurgitation (group A/group B: 3/8) underwent simultaneous aortic valvuloplasty. In group B, moderate or greater aortic regurgitation was significantly improved immediately after operation (p = 0.013) and was not significantly aggravated in long-term follow-up (p = 0.083), and there was no significant improvement in group A after operation and long-term follow-up.

CONCLUSIONS

According to the different anatomical lesions of left ventricular outflow tract, the individualised surgical treatment strategy for patients with subaortic stenosis can achieve good long-term outcomes. The long-term survival rate and freedom from reoperation due to late left ventricular outflow tract obstruction after simple subaortic membrane resection and extended left ventricular outflow tract resection are comparable. For patients with moderate or greater aortic regurgitation before extended left ventricular outflow tract resection, simultaneous aortic valvuloplasty is beneficial to improve postoperative aortic valve function.

National experience with pediatric surgical aortic valve repair: A Pediatric Health Information System analysis

OBJECTIVE

To characterize national experience with surgical aortic valve repair in pediatric patients.

METHODS

Patients in the Pediatric Health Information System database aged 17 years or younger with International Statistical Classification of Diseases and Related Health Problems codes for open aortic valve repair from 2003 to 2022 were included (n = 5582). Outcomes of reintervention during index admission (repeat repair, n = 54; replacement, n = 48; and endovascular intervention, n = 1), readmission (n = 2176), and in-hospital mortality (n = 178) were compared. A logistic regression was performed for in-hospital mortality.

RESULTS

One-quarter (26%) of patients were infants. The majority (61%) were boys. Heart failure was present in 16% of patients, congenital heart disease in 73%, and rheumatic disease in 4%. Valve disease was insufficiency in 22% of patients, stenosis in 29%, and mixed in 15%. The highest quartile of centers by volume (median, 101 cases; interquartile range, 55-155 cases) performed half (n = 2768) of cases. Infants had the highest prevalence of reintervention (3%; P < .001), readmission (53%; P < .001), and in-hospital mortality (10%; P < .001). Previously hospitalized patients (median, 6 days; interquartile range, 4-13 days) were at higher risk for reintervention (4%; P < .001), readmission (55%; P < .001), and in-hospital mortality (11%; P < .001), as were patients with heart failure (reintervention [6%; P < .001], readmission [42%; P = .050], and in-hospital mortality [10%; P < .001]). Stenosis was associated with reduced reintervention (1%; P < .001) and readmission (35%; P = .002). The median number of readmissions was 1 (range, 0-6) and time to readmission was 28 days (interquartile range, 7-125 days). A regression of in-hospital mortality identified heart failure (odds ratio, 3.05; 95% CI, 1.59-5.49), inpatient status (odds ratio, 2.40; 95% CI, 1.19-4.82), and infancy (odds ratio, 5.70; 95% CI, 2.60-12.46) as significant.

CONCLUSIONS

The Pediatric Health Information System cohort demonstrated success with aortic valve repair; however, early mortality remains high in infants, hospitalized patients, and patients with heart failure.

Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair

OBJECTIVE

The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair.

METHODS

From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes.

RESULTS

Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16).

CONCLUSIONS

Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.

Valve-sparing root replacement-reimplantation technique

The first valve sparing root replacement (VSRR) was first described over thirty years ago. Reimplantation is favored at our institution to provide maximum annular support in the setting of annuloaortic ectasia. Multiple iterations for this operation have been reported. Surgical intervention varies in terms of graft sizing, the number and method of inflow suture placement, strategy for annular plication and stabilization, and finally choice of graft type. Our specific technique has evolved over the last eighteen years and the current approach is to use a larger straight graft loosely based on the original Feindel-David formula, six inflow sutures to anchor the graft, and some degree of annular plication with annular stabilization. The long-term results for both trileaflet and bicuspid valves are associated with a low reintervention rate. Herein we provide a clear outline for our specific approach to the reimplantation technique.

Comparison of aortic valve repair techniques with single and double ring annuloplasties

OBJECTIVES

For patients with isolated aortic regurgitation, a double sub- and supravalvular annuloplasty has been shown to reduce recurrent aortic regurgitation after aortic valve repair compared with a single subvalvular annuloplasty. The objective of this study was to compare the geometrical and dynamic properties of a single- and double ring annuloplasty in an in vitro model.

METHODS

Eighteen aortic roots from 80 kg pigs were randomized into a control, single ring, and double ring group. Experiments were conducted in a pulsatile in vitro model. Hydrodynamics, radial force measurements at annular and sinotubular level, and 2D echographic imaging were obtained.

RESULTS

Both the single- and double ring annuloplasty downsized the aortic annulus and sinotubular junction significantly, and increased the coaptation height. The double ring annuloplasty showed an additional significant increase in coaptation height compared with the single ring (8.5 (0.9) mm to 9.8 (0.8) mm, p < 0.01). The single ring annuloplasty reduced radial forces at both levels, whereas the double ring annuloplasty showed the greatest force reduction of the sinotubular junction.

CONCLUSIONS

By treating the whole functional aortic annulus, encompassing both the aortic annulus and the sinotubular junction, a greater force reduction is observed. A subvalvular annuloplasty alone is efficient in reducing aortic annulus diameter and increasing coaptation height, however, by treating the sinotubular junction as well, an additional effect is observed on coaptation height, creating a more efficient stabilization. Reduction of annular force-distensibility ratio with the double ring annuloplasty compared with the native controls indicate a sustained stabilizing effect.

Aortic Valve Regurgitation following Transaortic Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy - Incidence and Impact on Late Outcomes

OBJECTIVE

In this study, we describe the incidence, sites of valve injury, and the impact of aortic valve regurgitation (AR) on outcomes of septal myectomy for obstructive hypertrophic cardiomyopathy (HCM).

METHODS

We analyzed patients who underwent transaortic septal myectomy for obstructive HCM from 2001 to 2022. The primary study endpoint was incidence of procedure-related AR, defined as the need for an unplanned aortic valve (AV) procedure or new-onset moderate AR on early postoperative echocardiography.

RESULTS

There were 2807 patients who underwent transaortic septal myectomy for HCM and had pre- and post-operative transthoracic echocardiograms. Procedure-related AR was observed in 55 (2%) patients; 27 (1%) required unplanned AV procedures at the time of myectomy, and 29 (1%) additional patients developed moderate AR postoperatively. During follow-up, 9 total patients underwent late AV reoperation; one patient who developed new moderate AR postoperatively required late AVR due to severe calcific AS; none of the patients who had unplanned AV procedures required late reoperation. The overall cumulative incidence of aortic valve reoperation at 10 and 15 years was 1% and 5%. The predicted probability of moderate or severe AR at 5 and 10 years was 1.4% and 1.8%. There was no difference in survival comparing patients with or without early postoperative mild or worse AR (p=0.69).

CONCLUSIONS

Procedure-related AR was observed in 2% of patients undergoing transaortic septal myectomy, and unplanned AV procedures were necessary for half of these patients. Intraoperative identification and valve repair mitigate the impact of cusp injury on late reintervention and survival.

Molecular Linkage under the Bicuspid Aortic Valve with Dyslipidemia

Dyslipidemia is correlated with diverse cardiovascular problems, such as obesity, hypertension, and atherosclerosis, which are summarized as metabolic syndrome. Bicuspid aortic valve (BAV), as one of the congenital heart defects, is shown to influence approximately 2.2% of the general population worldwide, inducing the severe pathological development of aortic valve stenosis (AVS) or aortic valve regurgitation (AVR), and also to aortic dilatation. Notably, emerging evidence showed that BAV was correlated with not only the aortic valve and wall diseases but also the dyslipidemic related cardiovascular disorders. Recent results also proposed that multiple potential molecular mechanisms inducing the progression of dyslipidemia played important roles in BAV and the progression of AVS. Several altered serum biomarkers under dyslipidemic condition, including higher low-density lipoprotein cholesterol (LDL-C), higher lipoprotein (a) [Lp(a)], lower high-density lipoprotein cholesterol (HDL-C), and different pro-inflammatory signaling pathways, have proposed to embrace a vital function in the development of BAV correlated cardiovascular diseases. In this review, different molecular mechanisms which embrace an important role in personalized prognosis in the subjects with BAV was summarized. The illustration of those mechanisms might facilitate an accurate follow-up for patients with BAV and give new pharmacological strategies to improve development of dyslipidemia and BAV.

Targeted Panel Sequencing Identifies an Intronic c.5225-3C>G Variant of the FBN1 Gene Causing Sporadic Marfan Syndrome with Annuloaortic Ectasia

Marfan syndrome (MFS) is a hereditary connective tissue disease whose clinical severity varies widely. Mutations of the FBN1 gene encoding fibrillin-1 are the most common genetic cause of Marfanoid habitus; however, about 10% of MFS patients are unaware of their genetic defects. Herein, we report a Korean patient with MFS and annuloaortic ectasia caused by an intronic c.5225-3C>G variant of the FBN1 gene identified by targeted panel sequencing. The reverse transcription analysis of FBN1 revealed that the intron 43 sequence from positions c.5297-1516 to c.5297-1 was retained at the coding sequence as a consequence of the c.5225-3C>G variant enhancing a cryptic splice acceptor site (c.5297-1518_5297-1517AG) in intron 43. The retained sequence of the part of intron 43 caused the same effect as insertion mutation (NM_000138.5:c.5297_c.5298ins5297-1516_5297-1), resulting in a frameshift mutation resulting in p.Ile1767Trpfs*3. The patient underwent an urgent modified Bentall operation with a 29 mm mechanical valve for annuloaortic ectasia and severe aortic valve regurgitation. This report emphasizes the need for functional investigations into the diagnostic workflows of certain diseases or gene panels with suspected high rates of intronic variants and potential pathogenic effects. Hence, further descriptions of individuals with intronic variants causing alternative splicing expected to have pathogenic effects at different transcript levels are crucial for improving our understanding.

Quadricuspid aortic valve repair with a modified-tricuspidization technique

INTRODUCTION

Quadricuspid aortic valve (QAV) is an extremely rare developmental abnormality with an incidence of 0.006%. QAV is an incidental finding that in some patients (23%) may determine aortic regurgitation (AR). Altogether 16% of patients indeed require surgery with AR being the most frequent indication.

METHODS AND RESULTS

We describe a case report of a 46 year-old female affected by severe aortic regurgitation due to QAV successfully treated with a  modified-tricuspidization technique associated with cusp extension, prolapsing commissure suturing, and sub-commissural annuloplasty.

DISCUSSION

QAV repair represents an attractive perspective to overcome the drawbacks of either mechanical or biological prosthesis.

Revealing Unforeseen Diagnostic Image Features With Deep Learning by Detecting Cardiovascular Diseases From Apical 4-Chamber Ultrasounds

Background

With the increase of highly portable, wireless, and low‐cost ultrasound devices and automatic ultrasound acquisition techniques, an automated interpretation method requiring only a limited set of views as input could make preliminary cardiovascular disease diagnoses more accessible. In this study, we developed a deep learning method for automated detection of impaired left ventricular (LV) function and aortic valve (AV) regurgitation from apical 4‐chamber ultrasound cineloops and investigated which anatomical structures or temporal frames provided the most relevant information for the deep learning model to enable disease classification.

Methods and Results

Apical 4‐chamber ultrasounds were extracted from 3554 echocardiograms of patients with impaired LV function (n=928), AV regurgitation (n=738), or no significant abnormalities (n=1888). Two convolutional neural networks were trained separately to classify the respective disease cases against normal cases. The overall classification accuracy of the impaired LV function detection model was 86%, and that of the AV regurgitation detection model was 83%. Feature importance analyses demonstrated that the LV myocardium and mitral valve were important for detecting impaired LV function, whereas the tip of the mitral valve anterior leaflet, during opening, was considered important for detecting AV regurgitation.

Conclusions

The proposed method demonstrated the feasibility of a 3‐dimensional convolutional neural network approach in detection of impaired LV function and AV regurgitation using apical 4‐chamber ultrasound cineloops. The current study shows that deep learning methods can exploit large training data to detect diseases in a different way than conventionally agreed on methods, and potentially reveal unforeseen diagnostic image features.

Acute aortic regurgitation due to fibrous strand rupture

A 60-year-old male presented with sudden onset chest pain and pulmonary edema. The investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery, a ruptured fibrous strand was identified which had been supporting the left-right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that fibrous strands may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation and chordae tendineae rupture.

Concomitant aortic valve repair for aortic insufficiency and implantation of left ventricle mechanical support

Background

Moderate to severe aortic valve insufficiency (AI) in patients undergoing left ventricular assist device (LVAD) implantation is a significant complication which occurs in up to 10.7% of patients in the INTERMACS database and has profound consequences for survival. Preoperative Impella use is associaed with greater post‐LVAD AI.

Case Presentation

56 y/o Caucasian female with acute exacerbation of chronic congestive heart failure who needed urgent Impella placement followed by elective Heartmate III LVAD.

Conclusion

Patients who have aortic valve regurgitation at the time of implantation have been handled by several methods, including aortic valve leaflets approximation, to aortic valve replacement or even valve closure. We report a case of geometric ring annuloplasty for repair of a regurgitant aortic valve during destination LVAD implantation.

Surgical dilemma - spare or replace regurgitant aortic valve: Late comparative outcomes of two strategies

BACKGROUND

To evaluate different aortic root surgery techniques and their contemporary clinical outcomes in patients with regurgitant aortic valve and aortic root aneurysm.

METHODS

The study consisted of 141 adult patients who underwent aortic valve reimplantation (David group = 73) or aortic valve replacement surgery (Bentall group = 68) for aortic valve regurgitation (AR) and dilatation of the aortic root at our institution within the same period (April 2004-October 2016). Kaplan-Meier method was used to estimate survival and other clinically relevant outcomes between the groups.

RESULTS

The completeness of clinical follow-up was 100%, with a mean time of 8.0 ± 3.8 years. Thirty-day (in-hospital) mortality rates were equivalent between groups (1.3 and 1.5%, p = 1.0). The overall survival rates at 10 years were significantly better for the David group patients comparing to Bentall group patients (95.3 ± 2.6% vs 79.7 ± 6.8%; p = 0.04) with similar freedom from AV related reoperation (94.4 ± 2.7% vs 98.5 ± 1.5%; p = 0.2). Freedom from bleeding events at 10 years was 90.7 ± 3.6% for Bentall group patients and none were observed among David group patients (p = 0.01).

CONCLUSIONS

Aortic valve and root surgery can be performed with equivalent safety and efficacy using either valve-sparing (David procedure) or valve-replacing (Bentall procedure) techniques in selected patients. Furthermore, patients after the David procedure demonstrated significantly improved survival and low risk of bleeding in comparison to the Bentall procedure with an acceptable risk of reoperation at 10 years follow-up.

Valvular changes after aortic valve neo-cuspidization in children: A case series

BACKGROUND

Aortic valve neo-cuspidization (AVNeo), a procedure wherein the aortic valve is reconstructed utilizing an autologous pericardium, has recently been more commonly performed in children. However, the postoperative morphological changes in the aortic valve of pediatric patients remain unknown. The current study aimed to describe the intraoperative and postoperative findings of aortic regurgitation (AR) and stenosis (AS) after AVNeo in children.

METHODS

This case series describes the morphological changes in AR and AS, and their severity, between the perioperative period and 3 months postoperative period after AVNeo in children (<18 years) who underwent AVNeo between April 2016 and March 2020. Data were collected at two measurement points: (i) intraoperative transesophageal echocardiography after weaning from cardiopulmonary bypass (io-TEE); (ii) postoperative transthoracic echocardiography 3 months after the procedure (po-TTE).

RESULTS

Seven patients were included in this case series. The number of postoperative AR sites and the ratio of AR jet area to the left ventricular outflow tract area showed a tendency to decrease between io-TEE and po-TTE. All AR sites were integrated during the postoperative period. One patient identified developed intraoperative AS, which maintained its severity after AVNeo.

CONCLUSIONS

Most cases exhibited spontaneous improvement in AR, while one developed postoperative AS. Further prospective investigation is, therefore, needed to explore surgical outcomes following AVNeo among children.

Midterm outcomes of aortic root surgery in patients with Marfan syndrome: A prospective, multicenter, comparative study

OBJECTIVE

The objective of this study was to compare midterm outcomes of aortic valve-replacing root replacement (AVR) and aortic valve-sparing root replacement (AVS) operations in patients with Marfan syndrome.

METHODS

Patients who met strict Ghent diagnostic criteria for Marfan syndrome and who underwent either AVR or AVS between March 1, 2005 and December 31, 2010 were enrolled in a 3-year follow-up prospective, multicenter, international registry study; the study was subsequently amended to include 20-year follow-up. Enrollees were followed clinically and echocardiographically.

RESULTS

Of the 316 patients enrolled, 77 underwent AVR and 239 underwent AVS; 214 gave reconsent for 20-year follow-up. The median clinical follow-up time for surviving patients was 64 months (interquartile range, 42-66 months). Survival rates for the AVR and AVS groups were similar at 88.2% ± 4.4% and 95.0% ± 1.5%, respectively (P = .1). Propensity score-adjusted competing risk modeling showed associations between AVS and higher cumulative incidences of major adverse valve-related events, valve-related morbidity, combined structural valve deterioration and nonstructural valve dysfunction, and aortic regurgitation ≥2+ (all P < .01). No differences were found for reintervention (P = .7), bleeding (P = .2), embolism (P = .3), or valve-related mortality (P = .8).

CONCLUSIONS

Five years postoperatively, major adverse valve-related events and valve-related morbidity were more frequent after AVS than after AVR procedures, primarily because of more frequent aortic valve dysfunction. No between-group differences were found in rates of survival, valve-related mortality, reintervention on the aortic valve, or bleeding. We plan to follow this homogenous cohort for 20 years after aortic root replacement.

Outcome of Pulmonary Autograft After the Ross Procedure

BACKGROUND

The purpose of this study was to assess autograft function after the Ross procedure and to review surgical outcomes associated with autograft reoperations.

METHODS

This is a retrospective study of patients undergoing the Ross procedure since 1993. Autograft function and autograft reoperation were studied. Autograft failure was defined as more than moderate autograft regurgitation or autograft dilatation to more than 50 mm diameter or z-score of more than +4 in children. One hospital death was excluded from analysis as were patients with unknown late autograft status.

RESULTS

Among 75 patients analyzed, preoperative diagnosis before the Ross procedure included aortic regurgitation in 26, aortic stenosis in 19, combined lesions in 28, and 2 mechanical valve malfunctions. Median age at the Ross procedure was 12.1 (0.4-43.6) years with 44 children less than 15 years old. Six patients had greater than mild autograft regurgitation at post-Ross hospital discharge. During median follow-up of 14.9 years, there were 23 autograft failures. Eighteen autograft reoperations were performed on 17 patients (13 children), including 12 aortic valve replacements, 5 aortic root replacements (including 1 valve-sparing root replacement), and 1 Konno procedure. Freedom from autograft failure and autograft reoperation at 20 years after the Ross procedure was 52.0% and 66.3%, respectively. Multivariate analysis identified greater than mild autograft regurgitation at hospital discharge from Ross procedure as a risk factor for autograft failure (P < .01). All patients who underwent autograft reoperation survived and had good health status at a median of 6.9 years after the reoperation.

CONCLUSIONS

The Ross procedure is effective in delaying prosthetic aortic valve replacement, although the time-related risk of autograft failure is a real consideration.

Aortic Root Reconstruction with TachoSil Fibrin Sealant Patch in Acute Type A Aortic Dissection

Purpose: We propose a novel technique for reconstruction of the dissected aortic root with the use of TachoSil fibrin sealant patch.

Methods: Patients with acute type A aortic dissection involving the aortic root were included. Appropriately prepared TachoSil fibrin sealant patch was placed between the dissected layers of the aortic root to achieve their durable fusion. Thus, the false lumen was eliminated, and the anatomical and functional structure of the aortic wall was restored.

Results: In all, 13 patients mean aged 57 ± 10.3 years underwent surgery for acute type A aortic dissection with the use of TachoSil fibrin sealant patch. All patients survived the surgery. The mean follow-up time was 30.8 ± 16.4 months. Follow-up computed tomography angiography (CTA) scans confirmed no aortic root dissection in all patients.

Conclusions: This technique ensures durable restoration of the aortic wall structure, eliminates the secondary aortic valve regurgitation, and allows for the preservation of patients’ native aortic valve.

Valvular complications following the Impella device implantation

BACKGROUND

Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device.

METHODS

To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic.

RESULTS AND CONCLUSION

Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.

History, development and clinical perspectives of sutureless and rapid deployment surgical aortic valve replacement

Degenerative aortic stenosis is the most frequent valvular heart disease in industrialized countries. Conservative treatment may beneficially influence symptoms but is never successful. Surgical aortic valve replacement (SAVR) was the only recognized treatment option to provide substantially prolonged survival until 2008. Operative mortality of isolated SAVR has been reported as low as 0.5% to 1% in experienced institutions, while long-term survival is close to that observed in a control healthy population of similar age. A multitude of studies have demonstrated the beneficial effects of SAVR with regard to improvement in quality of life and physical performance in the majority of symptomatic patients. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as an equal treatment modality, first in patients with high surgical risk and more recently in patients with intermediate and low surgical risk. Paravalvular regurgitation and the higher rate of pacemaker implantation remain points of consideration. Additionally, the long-term durability of TAVI devices and occurrence of stroke late after TAVI require additional analyses. Sutureless (SU-SAVR) and rapid deployment valve (R-SAVR) were designed to simplify and accelerate a conventional or less invasive surgical procedure while allowing complete excision of the calcified native valve. From 3 different implants tested more than 10 to 15 years ago, only two are available on the market today: the Perceval^® valve from Liva Nova and the Intuity^® sutureless prosthesis from Edwards Lifesciences. There has been extensive experience with these two devices in previous years and the results obtained are comparable to those observed following the use of conventional implants. The sutureless devices may be of particular interest for more complex and combined surgical procedures. This review summarizes the sutureless (SU-SAVR) and rapid deployment valve technologies and presents a clinical outlook for the patient population managed with these devices.

Comparison of outcomes following isolated repair of tricuspid versus bicuspid aortic valves

Background

Aortic valve repair (AV-repair) is an alternative treatment option for patients with aortic regurgitation (AR), but durability is still reason for concern, especially for bicuspid aortic valves (BAV). We retrospectively evaluated mid-term results after AV-repair in patients with BAV or tricuspid aortic valves (TAV), including reoperation rates, recurrence of regurgitation, and survival.

Methods

Patients undergoing AV-repair between November 2004 and March 2016 without procedures involving the aortic root were included. Echocardiographic examinations were performed before and after the operation and at follow-up. Repair techniques were recorded and evaluated.

Results

Of 150 patients, 89 (59.3%) had TAV and 61 (40.7%) BAV. AR ≥ moderate was found in 66 patients with TAV (74.2%) and 49 with BAV (80.3%). At discharge, 74 TAV-patients had ≤ mild AR (84.4%), 11 (12.4%) moderate. 57 patients (93.4%) with BAV had ≤ mild AR, 1 (1.6%) moderate and 2 (3.3%) severe. Mean follow-up was 4.4±2.7 years with ≤ mild AR in 56 TAV patients (73.7%) and moderate in 18 (20.2%). In patients with BAV, 43 (76.8%) had ≤ mild AR and 4 (6.6%) moderate. Survival in patients with TAV was significantly decreased compared to BAV (P=0.033), but reoperation-rates did not differ significantly (P=0.651).

Conclusions

AV-repair is a safe and feasible option in patients with AR and can achieve similar results in patients with TAV and BAV. The complexity of the repair technique predicts repair failure.

The impact of moderate Aortic Valve Disease in patients undergoing MitraClip for severe MR

BACKGROUND

High surgical risk patients presenting with severe mitral valve regurgitation (MR) and concomitant aortic valve disease are frequently a challenge for the interdisciplinary heart team meeting. If open-heart surgery for severe MR is performed, aortic stenosis (AS) or regurgitation (AR) is corrected during the same procedure if at least moderate severity of AS or AR has been confirmed. In patients with prohibitive surgical risk, optimal management strategies in the light of available transcatheter interventions still needs to be established.

METHODS AND RESULTS

In this retrospective single center study, we aimed to investigate the impact of coincident moderate aortic valve disease on the outcome of patients undergoing MitraClip for severe MR. In 286 MitraClip procedures performed in our institution, 21 patients (7,3%) were identified to suffer from concomitant moderate AS and 28 patients had moderate AR (9,8%). Patients with AS were found to have a higher incidence of >moderate MR following the procedure when compared to patients without aortic valve disease (14,3% vs. 8,9%, p = 0.001). No differences between the groups were found regarding a combined endpoint of all cause deaths and heart failure hospitalizations after 1 year follow up (no aortic-valve disease vs. moderate AS: 19% vs 18%; p = 0,881 and no aortic valve disease vs moderate AR: 19% vs. 25%; p = 0.477). However, mortality was significantly higher in patients with coincidental moderate AR (3.8% patients without aortic valve disease, 5% in patients with AS, 17,9% in patients with AR; p = 0.006).

CONCLUSION

According to our analysis coincidental Aortic valve stenosis may be associated with worse technical results regarding residual MR after MitraClip. Although our results regarding a combined endpoint of all-cause mortality and heart failure hospitalizations within one year of follow up were comparable between the groups, patients with moderate AR had significantly higher mortality rates. Due to the limited number of patients, our study is only hypothesis generating. Larger trials are necessary to confirm our result.

Very late-onset endocarditis complicated by non-significant aortic regurgitation after device closure of perimembranous ventricular septal defect

INTRODUCTION

Aortic regurgitation (AR) was recognized as a major, but rare complication after device closure for perimembranous ventricular septal defects (PmVSD). Most of them are temporary and non-significant. Infectious endocarditis (IE) is another extremely rare post-procedure complication of PmVSD. Theoretically, AR could increase risk for post-interventional IE. However, no cases have been documented thus far. We firstly described a case of very late-onset IE associated with non-significant AR after transcatheter closure of PmVSD with modified symmetrical double-disk device, underscoring the need for reassessing long-term prognostic implications of non-significant post-procedure AR after PmVSD occlusion and the most appropriate treatment strategy.

PATIENT CONCERNS

A 15-year old male received transcatheter closure of a 6.4 mm sized PmVSD with a 9-mm modified symmetric double-disk occluder (SHAMA) 11 years ago in our hospital. A new-onset mild eccentric AR was noted on transthoracic echocardiography (TTE) examination 1-year post procedure, without progression and heart enlargement. At this time, the child was admitted with a complaint of persistent fever for 16 days and nonresponse to 2-weeks course of amoxicillin and cefoxitin.

DIAGNOSIS

The diagnosis of post-procedure IE was established since a vegetation (14 × 4 mm) was found to be attached to the tricuspid valve, an anechoic area (8 × 7 mm) on left upper side of ventricular septum and below right aortic sinus, and severe eccentric AR as well as the isolation of Staphylococcus aureus from all three-blood cultures.

INTERVENTIONS

Treatment with vancomycin was initially adopted. However, surgical interventions including removal of vegetation, abscess and occluder, closure of VSD with a pericardial patch, tricuspid valvuloplasty, and aortic valvuloplasty were ultimately performed because of recurrent fever and a new-onset complete atrioventricular block 12-days later. The child continued with antibiotic therapy up to six weeks post operation.

OUTCOMES

The child's temperature gradually returned to normal with alleviation of AR (mild) and heart block (first degree). The following course was uneventful.

CONCLUSION

Late-onset IE could occur following device closure of PmVSD and be associated with post-procedure AR. For non-significant AR after device closure of PmVSD, early surgical intervention could be an alternative for reducing the aggravation of aortic valve damage and the risk of associated IE.

Aortic root replacement in a patient with unoperated tricuspid atresia

A 42-year-old man was referred to our hospital with heart failure and unoperated tricuspid atresia with pulmonary valve stenosis. His condition was initially managed with medical therapy; however, he required repeat hospitalisations for congestive heart failure. We diagnosed the chief cause of his heart failure as aortic valve regurgitation secondary to aortic root dilatation. Aortic root replacement was performed and then his heart failure was controlled.

Effect of Aortic Valve Disease on 3D Hemodynamics in Patients With Aortic Dilation and Trileaflet Aortic Valve Morphology

BACKGROUND

The effect of different expressions of aortic valve disease on 3D aortic hemodynamics is unclear.

PURPOSE

To investigate changes in aortic hemodynamics in patients with dilated ascending aorta (AAo) but different severity of aortic valve stenosis (AS) and/or regurgitation (AR).

STUDY TYPE

Retrospective.

POPULATION

A total of 111 subjects (86 patients with AAo diameter ≥ 40 mm and 25 healthy controls, all with trileaflet aortic valve [TAV]). Patients were further stratified by TAV dysfunction: n = 9 with combined moderate or severe AS and AR (ASR, 56 ± 13 years), n = 14 with moderate or severe AS (AS, 64 ± 14 years), n = 33 with moderate or severe AR (AR, 62 ± 14 years), n = 30 with neither AS nor AR (no AS/AR, 63 ± 9 years).

FIELD STRENGTH/SEQUENCE

4D flow MRI on 1.5/3T systems for the in vivo analysis of aortic blood flow dynamics.

ASSESSMENT

Data analysis included grading of 3D AAo vortex/helix flow and AAo flow eccentricity as well as quantification of systolic peak velocities and wall shear stress (WSS).

STATISTICAL TESTS

Continuous variables were compared by one-way analysis of variance or Kruskal-Wallis, followed by a pairwise Tukey or Dunn test if there was a significant difference.

RESULTS

All patients demonstrated markedly elevated vortex and helix flow compared with controls (P < 0.05). Peak velocities were significantly elevated in ASR, AS, and AR patients compared with controls (P < 0.05). Increased flow eccentricity was observed in entire AAo for AR, at the mid and distal AAo for ASR and AS, and at the proximal AAo for no AS/AR. Compared with controls, WSS in the AAo was significantly elevated in ASR and AS patients (P < 0.05) and reduced in no AS/AR patients (P < 0.05).

DATA CONCLUSION

The presence of TAV dysfunction is associated with aberrant hemodynamics and altered WSS, which may play a role in the development of aortopathy.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:481-491.

Discovery of an Experimental Model of Unicuspid Aortic Valve

Background

The epithelial growth factor receptor family of tyrosine kinases modulates embryonic formation of semilunar valves. We hypothesized that mice heterozygous for a dominant loss‐of‐function mutation in epithelial growth factor receptor, which are Egfr^Vel/+ mice, would develop anomalous aortic valves, valve dysfunction, and valvular cardiomyopathy.

Methods and Results

Aortic valves from Egfr^Vel/+ mice and control mice were examined by light microscopy at 2.5 to 4 months of age. Additional Egfr^Vel/+ and control mice underwent echocardiography at 2.5, 4.5, 8, and 12 months of age, followed by histologic examination. In young mice, microscopy revealed anatomic anomalies in 79% of Egfr^Vel/+ aortic valves, which resembled human unicuspid aortic valves. Anomalies were not observed in control mice. At 12 months of age, histologic architecture was grossly distorted in Egfr^Vel/+ aortic valves. Echocardiography detected moderate or severe aortic regurgitation, or aortic stenosis was present in 38% of Egfr^Vel/+ mice at 2.5 months of age (N=24) and in 74% by 8 months of age. Left ventricular enlargement, hypertrophy, and reversion to a fetal myocardial gene expression program occurred in Egfr^Vel/+ mice with aortic valve dysfunction, but not in Egfr^Vel/+ mice with near‐normal aortic valve function. Myocardial fibrosis was minimal or absent in all groups.

Conclusions

A new mouse model uniquely recapitulates salient functional, structural, and histologic features of human unicuspid aortic valve disease, which are phenotypically distinct from other forms of congenital aortic valve disease. The new model may be useful for elucidating mechanisms by which congenitally anomalous aortic valves become critically dysfunctional.

The association between aortic regurgitation and undetermined embolic infarction with aortic complex plaque

Background Retrograde embolism from the descending thoracic aorta is one possible cause of undetermined ischemic stroke. Significant aortic regurgitation can increase the amount of reversed flow in the thoracic aorta and thus is associated with an increased incidence of stroke. Aims This study aimed to examine the association between significant aortic regurgitation and undetermined embolic infarction with aortic complex plaques. Methods This study included 380 patients with undetermined embolic stroke who did not have abnormal flow such as atrial septal defect, patent foramen ovale determined by agitated saline bubble test, intracardiac thrombi on transesophageal echocardiography, atrial fibrillation, or small vessel stroke, cerebral artery, and carotid stenosis on the brain magnetic resonance imaging. The patients were divided into the complex aortic plaques group (n = 63), which was defined as having plaque with >4 mm in thickness, ulceration, or high mobility, and the no complex aortic plaques group (n = 317). Results Transesophageal echocardiography with a bubble study, brain MRI, and laboratory tests were performed for all subjects. Significant aortic regurgitation was more prevalent in patients with undetermined embolic stroke and complex aortic plaques than in patients without complex aortic plaques (adjusted OR = 4.981; 95% CI = 1.323-18.876, P = 0.028). In addition, the distribution of complex aortic plaques according to the severity of aortic regurgitation in patients with undetermined embolic stroke had a tendency toward the ascending thoracic aorta and proximal aortic arch. Conclusions Significant aortic regurgitation may affect undetermined embolic stroke in patients with complex aortic plaques.

The Polish Interventional Cardiology TAVI Survey (PICTS): adoption and practice of transcatheter aortic valve implantation in Poland

Introduction

Few studies have assessed the development of transcatheter aortic valve implantation (TAVI) in Poland since its introduction in 2008, and data on current TAVI activity or practice are missing.

Aim

To assess the dynamics of TAVI adoption in Poland and to detect differences among Polish centres in TAVI practice and decision-making.

Material and methods

The Polish Interventional Cardiology TAVI Survey (PICTS) was approved by the Polish Association of Cardiovascular Interventions and presented to all 21 national TAVI centres. Between 2008 and 2015 the cumulative number of TAVI performed in Poland was 2189. The annual number of TAVI rose from 8 in 2008 to 670 in 2015 (0.21 to 17.4 implants per million inhabitants, respectively).

Results

The median TAVI experience per centre was 80 procedures (95% CI: 38.1–154.6). In 2015 the TAVI penetration rate reached 5.12% of the estimated eligible Polish population. Inoperable and high-risk patients are treated with TAVI in all centres, with 52% of Heart Teams also qualifying medium-risk patients. The rate of transfemoral implantations increased to 83.2% of all procedures in 2015, while transapical implantations decreased to 12%. The frequency of subclavian, direct aortic or transcarotid routes in 2015 was below 3% each.

Conclusions

The PICTS survey observed a positive but slow rate of adoption of TAVI in Poland. When compared to Western European countries, our findings highlight a significant treatment gap in high or prohibitive surgical risk patients with severe aortic stenosis. Remarkable variations in TAVI practices among Polish TAVI centres warrant publication of joint national guidelines and recommendations.

Repositionable Versus Balloon-Expandable Devices for Transcatheter Aortic Valve Implantation in Patients With Aortic Stenosis

Background

The safety and effectiveness of the fully repositionable LOTUS valve system as compared with the balloon‐expandable Edwards SAPIEN 3 prosthesis for the treatment of aortic stenosis has not been evaluated to date.

Methods and Results

All patients undergoing transcatheter aortic valve implantation with the Edwards SAPIEN 3 or the LOTUS valve system were included into the Swiss Transcatheter Aortic Valve Implantation Registry. An adjusted analysis was performed to compare the early clinical safety outcome according to the Valve Academic Research Consortium‐2 definition. Between February 2014 and September 2015, 140 and 815 patients were treated with the LOTUS and the Edwards SAPIEN 3 valve, respectively. There was no difference in crude and adjusted analyses of the early safety outcome between patients treated with LOTUS (14.3%) and those treated with Edwards SAPIEN 3 (14.6%) (crude hazard ratio, 0.97; 95% CI, 0.61–1.56 [P=0.915]; adjusted hazard ratio, 1.03; 95% CI, 0.64–1.67 [P=0.909]). More than mild aortic regurgitation was <2% for both devices. A total of 34.3% of patients treated with LOTUS and 14.1% of patients treated with Edwards SAPIEN 3 required a permanent pacemaker (HR, 2.76; 95% CI, 1.97–3.87 [P<0.001]).

Conclusions

The repositionable LOTUS valve system and the balloon‐expandable Edwards SAPIEN 3 prosthesis appeared comparable in regard to the Valve Academic Research Consortium‐2 early safety outcome, and the rates of more than mild aortic regurgitation were exceedingly low for both devices. The need for new permanent pacemaker implantation was more frequent among patients treated with the LOTUS valve.

Left ventricular non-compaction revealed by aortic regurgitation due to Kawasaki disease in a boy with LDB3 mutation

Kawasaki disease (KD) is an acute febrile illness of childhood characterized by systemic vasculitis, especially coronary arteritis. Aortic valve regurgitation (AVR) is a relatively common complication. There have been no reports to date of heart failure and left ventricular non-compaction (LVNC) after acute KD, although the precise etiology of this condition remains unclear. A 6-month-old boy with KD was admitted to hospital. Despite high-dose i.v. gammaglobulin for dilation of the coronary artery, moderate AVR appeared, and thereafter he developed heart failure. A rough, dense LV myocardium indicated LVNC. On genetic testing a heterogenous 163G > A substitution changing a valine to isoleucine in LIM domain binding protein 3 (LDB3) was identified. Additional cardiac stress, such as that caused by AVR and/or KD might have triggered cardiac failure in the form of LVNC due to LDB3 mutation.