The unicuspid aortic valve is an extremely rare congenital anomaly. It usually presents with aortic stenosis and/or aortic regurgitation. Other cardiovascular complications, such as aortic dilatation and left ventricular hypertrophy can accompany it. Herein, we present a case report of a 50-year-old asymptomatic male patient with unicuspid aortic valve, complicated by ascending aortic aneurysm.
Kang, Seung-Dae; Park, Bo-Min; Kim, Dong-Kie; Kim, Ki-Hun; Kim, Doo-Il; Seo, Jeong-Sook; Kim, Dong-Soo; Kim, Hyun-Kuk; Song, Jong-Woon
Unicuspid aortic valve (UAV) is rare, but well-described congenital malformation in adults. Although aortic root and ascending aortic aneurysms can develop in unicommissural UAV, coexistence with left sinus of Valsalva aneurysm is an unusual event. Surgical correction is necessary to relieve left ventricular outflow tract obstruction associated with aortic stenosis in unicuspid aortic valve, and to decrease the substantial risk of impending rupture of sinus of Valsalva aneurysm. PMID:19344967
Ucak, Alper; Inan, Kaan; Onan, Burak; Temizkan, Veysel; Kilicaslan, Fethi; Yilmaz, Ahmet Turan
A unicuspid aortic valve (UAV) is a rare congenital defect that may manifest clinically as severe aortic stenosis or regurgitation in the third to fifth decade of life. This report describes two cases of UAV stenosis in adult patients diagnosed by transesophageal echocardiography (TEE). The utility of three-dimensional TEE in confirming valve morphology and its relevance to transcatheter valve replacement are discussed. PMID:22676160
Brantley, Hutton P; Nekkanti, Rajasekhar; Anderson, Curtis A; Kypson, Alan P
Cardiac CT angiography (CTA) is an ideal tool to investigate possible cardiac malformations. In this case, careful planning of the CTA acquisition and reconstruction provided high resolution images of cardiac anatomy revealing 2 extremely rare coexisting congenital defects; a unicuspid aortic valve (UAV) and sinus of Valsalva aneurysm (SVA). Detailed planning of CTA acquisition reconstruction protocols is essential in obtaining necessary information for clinical decision-making strategies and interventions in the patients with suspected cardiac anomalies. PMID:20960233
Dandes, Eric; Kirsch, Jacobo; Novaro, Gian
... in this category include " xenograft " valves made from animal tissues (most often pig aortic valves), " homograft " or " allograft " valves retrieved from human cadavers, and " pulmonary autograft " valves moved from the patient's pulmonary artery on the right side of the heart to the aortic position ...
Transcatheter aortic valve implantation (TAVI) was introduced experimentally in 1989, based on a newly developed heart valve prosthesis - the stentvalve. The valve was invented by a Danish cardiologist named Henning Rud Andersen. The new valve was revolutionary. It was foldable and could be inserted via a catheter through an artery in the groin, without the need for heart lung machine. This allowed for a new valve implantation technique, much less invasive than conventional surgical aortic valve replacement (SAVR). Surgical aortic valve replacement is safe and improves symptoms along with survival. However, up to 1/3 of patients with aortic valve stenosis cannot complete the procedure due to frailty. The catheter technique was hoped to provide a new treatment option for these patients. The first human case was in 2002, but more widespread clinical use did not begin until 2006-2010. Today, in 2011, more than 40,000 valves have been implanted worldwide. Initially, because of the experimental character of the procedure, TAVI was reserved for patients who could not undergo SAVR due to high risk. The results in this group of patients were promising. The procedural safety was acceptable, and the patients experienced significant improvements in their symptoms. Three of the papers in this PhD-thesis are based on the outcome of TAVI at Skejby Hospital, in this high-risk population [I, II and IV]. Along with other international publications, they support TAVI as being superior to standard medical treatment, despite a high risk of prosthetic regurgitation. These results only apply to high-risk patients, who cannot undergo SAVR. The main purpose of this PhD study has been to investigate the quality of TAVI compared to SAVR, in order to define the indications for this new procedure. The article attached [V] describes a prospective clinical randomised controlled trial, between TAVI to SAVR in surgically amenable patients over 75 years of age with isolated aortic valve stenosis. The study was terminated prematurely, as patients undergoing TAVI showed a statistically non-significant trend towards more complications than SAVR patients. Although non-significant the study was closed for ethical reasons. At present, scientific evidence supports TAVI as being superior to standard medical treatment, in patients who cannot undergo SAVR due to high- predicted risk. However, in patients who are surgically amenable, current publications suggest that TAVI using presently available devices is not competitive to SAVR, with regards to procedural safety and outcome. PMID:23290293
Nielsen, Hans Henrik Møller
In selected high-risk patients with aortic stenosis, transcatheter aortic valve implantation (TAVI) can provide comparable functional improvement and early survival after surgical aortic valve replacement. However, the long-term outcome after TAVI is still to be determined and the occurrence of aortic dissection has not been systematically reported. Herein, a case is presented of delayed aortic dissection and rupture several months after an uneventful TAVI in a patient with bicuspid aortic valve stenosis. PMID:24383384
Al-Attar, Nawwar; Himbert, Dominique; Barbier, François; Vahanian, Alec; Nataf, Patrick
Aortic valve stenosis is a complex inflammatory process, akin to arterial atherosclerosis, involving lymphocytic infiltrates, macrophages, foam cells, endothelial activation and dysfunction, increased cellularity and extracellular matrix deposition, and lipoprotein accumulation. A clonal population of aortic valve myofibroblasts spontaneously undergoes phenotypic transdifferentiation into osteoblast-like cells and forms calcific nodules in cell culture. Animal models complement these cell culture models by providing in vivo systems in which to study the complex molecular and cellular interactions that cause aortic valve disease in the native hemodynamic and biochemical environment. Whereas some species, such as swine, can develop spontaneous vascular and valvular atherosclerotic lesions, others, such as rabbits and mice, have not been shown to develop lesions naturally and require an inciting factor, such as hypercholesterolemia. In this article, we review the published cell culture and animal models available to study calcific aortic valve disease. PMID:17963676
Guerraty, Marie; Mohler Iii, Emile R
Congenital aortic valve anomalies are quite a rare finding in echocardiographic examinations. A case of a 19 year old man with a pentacuspid aortic valve without aortic stenosis and regurgitation, detected by transoesophageal echocardiography, is presented.???Keywords: pentacuspid aortic valve; echocardiography
Cemri, M; Cengel, A; Timurkaynak, T
Quadricuspid aortic valves are rare congenital anomalies which can be diagnosed by various imaging modalities. Described is the case of a 77 year old female with a quadricuspid aortic valve diagnosed by cardiac CT.
D'Mello, Nisha; Tandon, Vikas; Chow, Benjamin J. W.
Aortic valve replacement has traditionally been the treatment of choice for patients with aortic valve insufficiency with or without aortic root pathology. Aortic valve repair is emerging as an attractive treatment alternative that avoids the long-term risks associated with prosthetic valve implantation including thromboembolism, endocarditis, prosthetic valve deterioration, and anticoagulation related hemorrhage. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with varying cusp anatomy. As surgical techniques for aortic valve repair continue to evolve, clinical outcomes up to and beyond the first decade are promising with excellent survival and low risk of valve related events. PMID:24743899
Boodhwani, Munir; El Khoury, Gebrine
We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well. To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.
Flannery, Laura D.; Lowery, Robert C.; Sun, Xiumei; Satler, Lowell; Corso, Paul; Pichard, Augusto; Wang, Zuyue
A new central flow tilting disc valve has been introduced. The clinical experience from the first 50 patients treated with aortic valve replacement and followed up for 12 months is reported. The results obtained are so encouraging that the tilting disc valve is at present preferred for all aortic valve replacements in this institution.
Viking Olov Björk
The treatment of aortic stenosis in high-risk surgical patients is now possible by transcatheter aortic valve replacement. The CoreValve is a new transcatheter valve with a unique design expanding its application in patients with aortic stenosis. The CoreValve is just completing clinical trial in the United States and not yet available for commercial use in the United States but is widely used in Europe. PMID:23931099
Matthews, Ray V; Shavelle, David M
Surgical aortic valve replacement is the treatment of choice in patients with severe symptomatic aortic valve stenosis because it provides excellent early and long-term clinical outcomes in terms of hemodynamics, valve durability, and freedom from valve-related complications. In recent years, the number of high-risk patients being referred for surgical aortic valve replacement has increased. A considerable proportion of these patients are deemed operable despite the high risk. In order to modify the risk predominantly associated with duration of cardiopulmonary bypass and cross clamp time sutureless aortic valve technology has been developed. Sutureless aortic bioprosthetic valves, introduced in clinical practice in 2009, contrary to the conventional surgical technique for implantation (interrupted or continuous sutures, after thorough annular decalcification) are not hand sewn. This technological modification reduces the implantation time with potential translation into improved outcomes for high-risk patients undergoing surgical aortic valve replacement. Currently, three sutureless bioprostheses are available and amongst these the largest published experience is available for the patented and CE marked truly sutureless PERCEVAL S valve (Sorin Group, Saluggia, Italy). This article provides an overview of the published literature for Perceval S valve with an attempt to better define the role of sutureless aortic valve replacement in the treatment of critical aortic valve stenosis. PMID:23713960
Raja, Shahzad G
Approximately 30% to 40% of elderly patients with severe, symptomatic aortic valve stenosis are deemed ineligible for surgery because of high perioperative risk. We describe the use of an alternative transfemoral approach known as transcatheter aortic valve implantation in a nonagenarian patient with severe aortic stenosis. Our patient recovered successfully, and by the time of her most recent follow-up visit, 7 months after the procedure, she had regained a substantial degree of function. This result suggests that transcatheter aortic valve implantation can enable some high-risk patients who are ineligible for surgery to undergo valve replacement, thereby regaining both quality and length of life.
Kneitz, Abby; Clifton, William; Kar, Biswajit; Delgado, Reynolds M.
The bicuspid aortic valve is recognized as a frequent cause of aortic stenosis in adults. Aortic stenosis has been reported to occur in as many as 72 percent of adults with a congenital bicuspid aortic valve, with peak incidence occurring in the 5th and 6th decades of life. Review of the clinical records of 152 patients aged 20 years and older found to have a bicuspid aortic valve at autopsy revealed aortic stenosis in only 28 percent. The incidence of aortic stenosis increased progressively with age; 46 percent of patients over age 50 years and 73 percent over age 70 years had some degree of stenosis. The stenotic valves were obstructed by nodular, calcareous masses but commissural fusion was present in only eight cases. The largest group of patients in the series (40 percent) died of infective endocarditis; 77 percent of these were under age 50 years. Primary aortic regurgitation without infective endocarditis was uncommon. Thirty-two percent of the patients in this series had an apparently normally functioning aortic valve, and this rate remained relatively constant with increasing age; 37 percent of patients over age 50 years and 27 percent over age 70 years had an apparently normal valve. The bicuspid aortic valve in patients over age 20 does not invariably become stenotic or insufficient. PMID:835475
Fenoglio, J J; McAllister, H A; DeCastro, C M; Davia, J E; Cheitlin, M D
The occurrence of a quadricuspid aortic valve with single, central leaflet fenestrations causing aortic insufficiency has not previously been reported. We recently encountered these features during aortic valve replacement for severe aortic regurgitation in a 20-year-old man who had had a history of aortic insufficiency since age 2 years. The patient's late increase in symptoms was probably due to the fact that 1 of the 4 leaflets was somewhat flail, allowing incomplete coaptation and producing regurgitation over and above that caused by the central fenestrations. (Texas Heart Institute Journal 1988;15:187-188) Images
Coltharp, William H.; Warren, E. Taliaferro; Heath, Bobby J.
During the years 1965--75, 98 patients more than 65 years of age had aortic valve replacement in our hospital, 24 ball valves and 74 disc valves inserted in their aortic orifice. Actuarial analysis of survival in these patients shows that the operative risk is slightly higher in elder than in younger patients. The survival curve for the following years for those who had disc valve implantation runs parallel to that of younger patients, while those who had ball valve implantation showed a more rapid fall in survival after 3 years. After 10 years, only 30% of patients with ball valve transplantation were alive. PMID:495221
Storstein, O; Efskind, L
The main objective of this work is to track the aortic valve plane in intra-operative fluoroscopic images in order to optimize and secure Transcatheter Aortic Valve Implantation (TAVI) procedure. This paper is focused on the issue of aortic valve calcifications tracking in fluoroscopic images. We propose a new method based on the Tracking-Learning-Detection approach, applied to the aortic valve calcifications in order to determine the position of the aortic valve plane in intra-operative TAVI images. This main contribution concerns the improvement of object detection by updating the recursive tracker in which all features are tracked jointly. The approach has been evaluated on four patient databases, providing an absolute mean displacement error less than 10 pixels ? 2mm). Its suitability for the TAVI procedure has been analyzed.
Nguyen, Duc Long Hung; Garreau, Mireille; Auffret, Vincent; Le Breton, Herve; Verhoye, Jean-Philippe; Haigron, Pascal
Objective: Normalisation of aortic root and cusp configuration is a prerequisite for successful aortic valve repair (AVR). Using transthoracic echocardiography, we studied aortic root dimensions relative to body size in normal subjects and AVR patients. Methods: Aortic roots of healthy volunteers (n=130, age 27.9±16.9 years) were examined for aortoventricular (AV), sinus (S), sinutubular-junction diameters (ST) and effective height (height difference
Benjamin Oliver Bierbach; Diana Aicher; Omar Abu Issa; Hagen Bomberg; Stefan Gräber; Petra Glombitza; Hans-Joachim Schäfers
Acquired aortic valve disease and valvular calcification is highly prevalent in adult populations worldwide and is associated with significant cardiovascular morbidity and mortality. At present, there are no medical therapies that will prevent or regress aortic valve calcification or stenosis and surgical or transcatheter aortic valve replacement remain the only effective therapies for treating this disease. In the setting of valve injury as a result of exposure to biochemical mediators or hemodynamic forces, normal homeostatic processes are disrupted resulting in extracellular matrix degradation, aberrant matrix deposition and fibrosis, inflammatory cell infiltration, lipid accumulation, and neoangiogenesis of the valve tissue and, ultimately, calcification of the valve. Calcification of the aortic valve is now understood to be an active process that involves the coordinated actions of resident valve endothelial and interstitial cells, circulating inflammatory and immune cells, and bone marrow-derived cells. These cells may undergo a phenotype transition to become osteoblast-like cells and elaborate bone matrix, endothelial-to-mesenchymal transition, and form matrix vesicles that serve as a nidus for microcalcifications. Each of these mechanisms has been shown to contribute to aortic valve calcification suggesting that strategies that target these cellular events may lead to novel therapeutic interventions to halt the progression or reverse aortic valve calcification.
Leopold, Jane A.
Operative balloon dilatation of the aortic valve was performed in seven neonates with critical stenosis of the aortic valve. The procedure was followed by the development of severe aortic regurgitation in four patients. Necropsy was performed in three and revealed partial detachment of the right coronary cusp of the aortic valve. Damage to the valve leaflet caused by balloon dilatation was probably the result of using a balloon with a diameter that was too large in relation to the aortic valve ring diameter and of shearing forces created in the aortic wall by the contracting ventricle. The diameter of the inflated balloon should not be larger than the diameter of the aortic valve ring. Images Figure
Phillips, R R; Gerlis, L M; Wilson, N; Walker, D R
Background. With increased life expectancy, valve operations are more and more common in elderly patients. The choice of valve substitute—mechanical valve or bioprosthesis—remains debated.Methods. Two groups of patients of the same age (69, 70, and 71 years) with isolated aortic valve replacement (mechanical 240, bioprostheses 289) were compared for mortality, morbidity, and valve-related complications.Results. No significant difference was found in
Yves Logeais; Thierry Langanay; Hervé Corbineau; Régine Roussin; Claude Rioux; Alain Leguerrier
Patients with aneurysms of the ascending aorta or aortic root frequently have aortic insufficiency despite normal aortic leaflets. The aortic valve dysfunction is caused by dilatation of the sinotubular junction, distortion or dilatation of the sinuses of Valsalva, annuloaortic ectasia, or a combination of these problems. In the case of annuloaortic ectasia, reconstruction of the aortic root is performed by
Tirone E. David; Christopher M. Feindel; Joanne Bos
A 33-year-old man presented with severe aortic insufficiency due to a prolapsed bicuspid aortic valve. The ventriculoaortic junction was dilated to 29 mm without root dilatation, and external ring annuloplasty was performed using a Gelweave (Terumo, Tokyo, Japan) graft to reduce the size to 22 mm. The leaflets were repaired by dividing and suturing a raphe between the right and left cusps. This combination provided adequate coaptation depth (8 mm) and showed excellent results, with trivial aortic insufficiency. This approach is suitable for repair of a bicuspid aortic valve with a dilated ventriculoaortic junction without root dilatation. PMID:24694428
Yamaguchi, Hiroki; Nakao, Tatsuya; Kadowaki, Tasuku; Nakamura, Hiromasa; Tokunaga, Noriyuki; Yoda, Masataka; Takagaki, Masami
Aortic valve stenosis is known to be associated with loss of high molecular von Willebrand multimers. This can lead to gastrointestinal bleeding in patients with gastrointestinal angiodysplasia, the Heyde syndrome. Here we present a case of anaemia and severe epistaxis associated with acquired von Willebrand syndrome. Gastrointestinal endoscopy revealed no bleeding source. Calcifying aortic stenosis was confirmed by echocardiography. Loss of high molecular weight multimers of von Willebrand factor in our patient was shown by immunoblot analysis. If severe epistaxis occurs in the context of symptomatic aortic valve stenosis, it might be an additional reason to recommend valve replacement surgery to the patient. PMID:17150267
Schödel, Johannes; Obergfell, Achim; Maass, Alexander H
A 73-year old man developed an acute prosthetic aortic valve dehiscence for which emergent operation was undertaken. The intraoperative evidence of an aortic annular disruption and of a subannular abscess led to the hypothesis that an endocarditis process was involved. The aortic valve was replaced with a stentless porcine bioprosthesis. Cultures taken intraoperatively from the aortic area had a pure growth of aerobic, spore-forming, gram-positive bacilli identified as Bacillus licheniformis. The patient responded to specific antibiotic therapy with no relapse at a 20-month follow-up. The potentiality of B. licheniformis as a pathogen should be reconsidered.
Santini, F; Borghetti, V; Amalfitano, G; Mazzucco, A
Quadricuspid aortic valve is a rare congenital condition that occurs not only as an isolated anomaly, but also with other cardiac defects. We describe a 10-year-old boy whose aortic stenosis was diagnosed during infancy. Transthoracic echocardiography revealed dilation of the left ventricle, valvular and subvalvular aortic stenosis, bicuspid aortic valve, aortic regurgitation, and mitral valve prolapse. The results of cardiac catheterization and aortography showed severe aortic regurgitation, an aortic valve gradient of 76 mmHg, a bicuspid aortic valve, a subaortic membrane, and an ascending aortic aneurysm. The patient underwent elective valve replacement with a mechanical prosthesis, and during surgery, the valve was noted to be quadricuspid. The patient was diagnosed as having a quadricuspid aortic valve associated with aortic regurgitation, severe aortic stenosis, and an ascending aortic aneurysm. PMID:19102060
Yildirim, Selman Vefa; Gümü?, Ayten; Co?kun, Isa; Türköz, Riza
Transcatheter aortic valve implantation (TAVI) for failing aortic root and valve homografts has been described primarily via a transapical approach. We report the successful treatment of two patients with failing homografts by transfemoral (TF) TAVI. In both cases, TF TAVI was accomplished without technical difficulty and with good clinical outcomes. doi: 10.1111/jocs.12277 (J Card Surg 2014;29:333-336). PMID:24372714
Otalvaro, Lynda; Alfonso, Carlos E; O'Neill, William W; O'Neill, Brian P; Heldman, Alan W
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. PMID:24996712
Yamane, Kentaro; Nazif, Tamim M; Khalique, Omar; Hahn, Rebecca T; Leon, Martin B; Kodali, Susheel K; Williams, Mathew R; George, Isaac
Calcific aortic valve stenosis is the most common valvular disease in developed countries, and the major reason for operative valve replacement. In the US, the current annual cost of this surgery is approximately 1 billion dollars. Despite increasing morbidity and mortality, little is known of the cellular basis of the calcifications, which occur in high-perfusion zones of the heart. The case is presented of a patient with calcific aortic valve stenosis and colonies of progressively mineralized nanobacteria in the fibrocalcific nodules of the aortic cusps, as revealed by transmission electron microscopy. Consistent with their outstanding bioadhesivity, nanobacteria might serve as causative agents in the development of calcific aortic valve stenosis. PMID:17315391
Jelic, Tomislav M; Chang, Ho-Huang; Roque, Rod; Malas, Amer M; Warren, Stafford G; Sommer, Andrei P
Transcatheter aortic valve implantation, as well as interventional mitral valve repair, offer reasonable therapeutic options for high-risk surgical patients. We report a rare case of early post-interventional aortic valve prosthesis migration to the left ventricular outflow tract, with paravalvular leakage and causing severe mitral valve regurgitation. Initial successful interventional mitral valve repair using a clipped edge-to-edge technique revealed, in a subsequent procedure, the recurrence of mitral valve regurgitation leading to progressive heart failure and necessitating subsequent surgical aortic and mitral valve replacement. PMID:23864579
Wendeborn, Jens; Donndorf, Peter; Westphal, Bernd; Steinhoff, Gustav
Background—Aortic valve replacement with cardiopulmonary bypass is currently the treatment of choice for symptomatic aortic stenosis but carries a significant risk of morbidity and mortality, particularly in patients with comorbidities. Recently, percutaneous transfemoral aortic valve implantation has been proposed as a viable alternative in selected patients. We describe our experience with a new, minimally invasive, catheter-based approach to aortic valve
Samuel V. Lichtenstein; Anson Cheung; Jian Ye; Christopher R. Thompson; Ronald G. Carere; Sanjeevan Pasupati; John G. Webb
The use of the Ross procedure in young patients is gaining wider acceptance. The need for a foreign pulmonary valve that will require replacement, however, is a serious drawback. To circumvent this problem, we reimplanted the native aortic valve in the pulmonary position in four patients (ages 12, 15, 15 and 17 years old) operated on utilizing the Ross procedure for aortic insufficiency. One patient had congenital and three isolated rheumatic aortic insufficiency. The root replacement technique with coronary artery reimplantation was used. All patients did well initially with marked reduction of left ventricular dilatation and good function of the reimplanted native aortic valve. One patient, however, died a month later from rupture of a false aneurysm that developed at the pulmonary autograft to ascending aorta anastomosis. We feel that the use of the native aortic valve in the pulmonary position makes the Ross procedure more attractive and potentially curative. The diseased aortic valve works well in the pulmonary position because of lower pulmonary artery pressure and resistance. PMID:8751252
Deleon, S Y; Quinones, J A; Vitullo, D A; Hofstra, J; Fisher, E A; Gamponia, R; Torres, L; Lopez, W; Zamora, R
The prevalence and clinical significance of aortic valve prolapse were determined prospectively in 2000 consecutive patients undergoing routine clinical cross sectional echocardiography. Two hundred and twelve patients were excluded because the aortic cusps were not adequately visualised. Aortic valve prolapse was defined as downward displacement of cuspal material below a line joining the points of attachment of the aortic valve leaflets. Twenty four cases of aortic valve prolapse (1.2%) were identified. The patients were aged 12-64 years and nine were women. All had underlying valvar heart disease and the commonest lesion (in 11 cases) was prolapse of the larger cusp in bicuspid valves. Aortic valve prolapse was seen in four patients with mitral valve prolapse (two with severe regurgitation), one of whom had marfanoid aortic root dilatation. The remaining examples of aortic prolapse were seen in patients with various disorders including one with pulmonary atresia, two with aortic root disease (one with dissection and one with idiopathic dilatation), and one case of severe mitral regurgitation. Valves destroyed by infective endocarditis were seen in two cases. Aortic valve prolapse may be detected in various cardiac disorders and does not imply the presence of aortic regurgitation, but when bicuspid aortic valves are present it may well be important in producing such regurgitation. Although aortic valve prolapse may be associated with severe forms of mitral valve prolapse, these patients rarely have aortic regurgitation. Images
Shapiro, L M; Thwaites, B; Westgate, C; Donaldson, R
In the late 1980's, Denmark was the birthplace for the concept of transcatheter valve implantation. In 2002, the first successful transcatheter aortic valve implantation (TAVI) was performed in humans. TAVI has matured beyond the learning-curve period with a high overall procedural success rate and relatively few serious associated complications. TAVI is now an established treatment for severe aortic stenosis in patients who have prohibitive or high surgical risk; and the treatment has proven to yield symptomatic and prognostic benefits. Innovations and advances continue in this field. PMID:23095650
Bjerre Thygesen, Julie; Loh, Poay Huan; Franzen, Olaf; Søndergaard, Lars
Increased life expectancy and improvement in clinical outcome following surgery has led to an increasing number of elderly patients with a history of prior aortic valve replacement (AVR). As a consequence, a considerable number of patients may require reintervention due to a dysfunctional bioprosthesis with structural valve deterioration (SVD). Transcatheter aortic valve implantation (TAVI) has become an established surgical alternative in patients with aortic stenosis and severe comorbidities. For those patients requiring reoperation, the 'valve-in-valve' concept has been described. Here, the case is reported of a patient with a very small Sorin Soprano 18 bioprosthesis with SVD who underwent a reintervention with the transapical valve-in-valve technique. The implantation was uneventful, with no residual paravalvular leakage and a low mean transprosthetic gradient. The valve-in-valve procedure may represent a feasible alternative for redo AVR in patients with a very small, structurally deteriorated bioprosthesis. PMID:24151773
Bjursten, Henrik; Götberg, Matthias; Harnek, Jan; Nozohoor, Shahab
Transcatheter aortic valve replacement (TAVR) has emerged as an accepted indication for non-operable patients with severe symptomatic native aortic valve stenosis (AS) and as a reasonable alternative for high-risk surgical AS patients. Nonetheless, the safety and efficacy of performing TAVR in several other potential indications are yet unclear. In the present manuscript the authors review the current evidence supporting TAVR for other potential indications than the typical high-risk/non-operable AS patients, providing updated results of the main clinical trials and registries exploring these particular indications. Finally, the authors provide practical recommendations for TAVR in each of these conditions. PMID:24809383
Maluenda, Gabriel; Dvir, Danny
\\u000a Computational modeling is an excellent tool with which to investigate the mechanics of the aortic heart valve. The setting\\u000a of the heart valve presents complex dynamics and mechanical behavior in which solid structures interact with a fluid domain.\\u000a There currently exists no standard approach, a variety of strategies have been used to address the different aspects of modeling\\u000a the heart
Laura R. Croft; Mohammad R. Kaazempur Mofrad
Giant pseudoaneurysm of the ascending aorta is a rare but dreadful complication occurring several months or years after aortic surgery. Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture. We present a rare case of giant ascending aneurysm with Stanford type A aortic dissection occurring 6 years after aortic valve replacement and also illustrate the potential dimensions the ascending aorta may reach by a pseudoaneurysm and dissection after AVR.
Boran, Mertay; Parlar, Ali Ihsan; Boran, Ertay
Transcatheter aortic valve implantation (TAVI) is a disruptive technology as it satisfies a previously unmet need which is associated with a profound therapeutic benefit. In randomized clinical trials, TAVI has been shown to improve survival compared with medical treatment among patients considered not suitable candidates for surgical aortic valve replacement (SAVR), and to provide similar outcomes as SAVR in selected high-risk patients. Currently, TAVI is limited to selected elderly patients with symptomatic severe aortic stenosis. As this patient population frequently suffers from comorbid conditions, which may influence outcomes, the selection of patients to undergo TAVI underlies a complex decision process. Several clinical risk score algorithms are routinely used, although they fall short to fully appreciate the true risk among patients currently referred for TAVI. Beyond traditional risk scores, the clinical assessment by an interdisciplinary Heart Team as well as detailed imaging of the aortic valve, aortic root, descending and abdominal aorta as well as peripheral vasculature are important prerequisites to plan a successful procedure. This review will familiarize the reader with the concepts of the interdisciplinary Heart team, risk scores as well as the most important imaging algorithms suited to select appropriate TAVI patients. PMID:24096244
Stortecky, S; O'Sullivan, C J; Buellesfeld, L; Wenaweser, P; Windecker, S
The positive early experiences with TAVI however, revealed that vascular access remains a hindrance to broader application and success of the procedure. This article will review the most common vascular routes used to deliver transcatheter aortic valves, and describe a new technique via the right axillary/subclavian artery approach. PMID:21879288
da Gama Ribeiro, Vasco; Vouga, Luis; Markowitz, Alan; Bezerra, Hiram G; Braga, Pedro; Ansari, Muhammad; Leite, Daniel; Rocha, Joao; Carvalho, Monica; Simon, Daniel I; Costa, Marco A
Background. Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.Methods. Eighteen patients were operated on by means of an “I” ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was
Yu-Sheng Chang; Pyng Jing Lin; Chau-Hsiung Chang; Jaw-Ji Chu; Peter P. C Tan
We present a case of late infective endocarditis on the mechanical aortic valve prosthesis, complicated by large paraortic abscesus. It was dificult to diagnosed this patient, because of negative blood cultures results and not diagnostic view in transthoracic echocardiogram. Transesophageal echo was performed just before cardiac surgery because of very bad patient's condition. PMID:19105103
Lisowska, Anna; Knapp, Ma?gorzata; Sobkowicz, Bozena; Hirnle, Tomasz; Musia?, W?odzimierz
During a dissection class for anatomy, a white lipoid mass was found in the ascending aorta, which was partly attached to the wall and filled the sinuses ofValsalva and almost fitting as a cast. This mass prevented full opening of the mobile aortic valve leaflets, thereby causing an obstruction. Microscopic analysis revealed fibres and presence of polymorphonuclear white blood cells. It seems reasonable to assume that this mass has formed in the last weeks or months of the life of this subject, which is much quicker than for calcified aortic valve stenosis. Therefore, signs and symptoms of aortic obstruction might have been missed or misinterpreted. In case of timely detection during life, diagnostic imaging and therapeutic approach can be challenging. PMID:23882881
Mistiaen, Wilhelm P; Uyttebroek, Leen; Hubens, Guy; Van Nassauw, Luc
Valve-sparing aortic root remodeling is associated with the risk of bleeding from the proximal aortic-graft suture line and subsequent annular dilation leading to aortic valve failure. Herein we describe a simple technique that may be used in valve-sparing root operations to prevent bleeding and improve annular stability. PMID:19740295
Calcaterra, Domenico; Garcia, Lisardo; Panos, Anthony; Salerno, Tomas A; Ricci, Marco
Aortic valve replacement (AVR) is a treatment of choice for patients with symptomatic severe aortic stenosis (AS). However, a significant proportion of these patients do not undergo surgical AVR due to high-risk features. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative for patients with severe AS who are not candidates for open-heart surgery. Since the introduction of TAVI to the medical community in 2002, there has been an explosive growth in procedures. The balloon-expandable Edwards SAPIEN valve and the self-expanding CoreValve ReValvingTM system contribute the largest patient experience with more than 10,000 patients treated with TAVI to date. Clinical outcomes have stabilized in experienced hands, with 30-day mortality less than 10%. Careful patient selection, growing operator experience, and an integrated multidisciplinary team approach contribute to notable improvement in outcomes. In the first randomized pivotal PARTNER trial, in patients with severe AS not suitable candidates for surgical AVR, TAVI compared with standard therapy, significantly improved survival and cardiac symptoms, but was associated with higher incidence of major strokes and major vascular events. The results of randomized comparison of TAVI with AVR among high-risk patients with AS for whom surgery is a viable option are eagerly awaited to provide further evidence on the applicability of TAVI in these patients.
Leon, Martin B.; Nikolsky, Eugenia
Leukocyte function was studied in patients with prosthetic heart valves by oxygen consumption measurements during phagocytosis of polystyrene latex particles. The consumption reflects the phagocytotic capacity of the cells. In 38 patients with Starr-Edwards aortic ball valves the mean oxygen consumption was 3.95 nanoatoms per minute per 10(6) leukocytes, as compared to 4.15 in 50 healthy subjects, the difference not being statistically significant. The number of leukocytes per ml. of blood and the distribution of cell types was quite similar in the two groups, although slightly more younger cells were found in the patients. It is concluded that the capacity for phagocytosis is not significantly reduced after aortic ball valve implantation. PMID:263395
Kvarstein, B; Dale, J
Patients with a bicuspid aortic valve (BAV) constitute a heterogeneous population with variable clinical presentation and complications. More than 50% of the patients who require aortic valve replacement have a BAV, a condition that may be associated with dilation of ascending aorta and aortic insufficiency caused by cusp disease or aortic root pathology. Of the potential BAV-related complications, dilation of the aortic root and ascending aorta are among the most serious. The dilation of ascending aorta and aortic root have been the subject of controversy. Whereas some surgeons believe that the dilation of the aorta is caused by the hemodynamic properties of the BAV, others believe that the dilation of the aortic root is secondary to genetic defects associated with the BAV. Management of a BAV should be tailored to each patient's clinical condition. The surgical approach varies from aortic valve replacement to combined aortic valve and root replacement to aortic-valve-sparing root replacement. PMID:23138607
A quadricuspid aortic valve is an uncommon congenital anomaly that is often associated with other cardiac disorders. Most reported cases of quadricuspid aortic valves are detected incidentally during necropsy or aortic valve replacement and, therefore, the potential clinical course still remains unclear. A case of a 47-year-old woman with grade III to IV aortic insufficiency and mild left ventricular dilation with an end-diastolic diameter of 59 mm is presented. During surgery for aortic valve replacement (Ross procedure), a quadricuspid aortic valve was identified. Two years after the successful Ross procedure, a molecular genetic study of this rare anomaly was performed using karyotyping, fluorescence in situ hybridisation and polymerase chain reaction. Cytogenetic analysis detected chromosomal aberration 45,X0/46,XX, indicating a low-level X chromosome mosaicism; repeat karyotypes were normal. This is the first reported case of a quadricuspid aortic valve in a woman with Turner syndrome.
Mohamed, Salah A; Misfeld, Martin; Hanke, Thorsten; Belge, Gazanfer; Bullerdiek, Joern; Sievers, Hans H
The resection of pulmonary valves has already been demonstrated in an experimental beating-heart model. The aim of this study was to analyse the transapical laser-assisted resection of aortic valves in an in vivo porcine model in a non-beating heart. The resection was performed in a porcine model (n = 10) using a Thullium:YAG laser. After establishing a standard extracorporeal circulatory support, the aortic valve isolation chamber (AVIC) system was inserted transapically. The resection of the aortic leaflets was carried out step-by-step in the arrested heart. The AVIC implantation, the resection process, and the gross anatomy of intracardiac lesions were analysed. The procedure for installing the AVIC took 5.8 ± 1.5 min. A sealed chamber was achieved in 9/10 cases. The resection of the valves was performed in 8/10 and completed in 7/10 cases. The resection took, on average, 7.4 ± 2.7 min/cusp. In 9/10 cases, the sealing was sufficient. Gross anatomy and histological analysis demonstrated only superficial damage to the surrounding tissue. In this study, the in vivo on-pump isolation of the left ventricular outflow tract and the laser resection of the native aortic valve could be demonstrated successfully. Nevertheless, this model is the next step towards a beating-heart resection of the aortic valve using the isolation chamber. PMID:22707518
Bombien Quaden, René; Leester-Schaedel, Monika; Lozonschi, Lucian; Lutter, Georg
The resection of pulmonary valves has already been demonstrated in an experimental beating-heart model. The aim of this study was to analyse the transapical laser-assisted resection of aortic valves in an in vivo porcine model in a non-beating heart. The resection was performed in a porcine model (n = 10) using a Thullium:YAG laser. After establishing a standard extracorporeal circulatory support, the aortic valve isolation chamber (AVIC) system was inserted transapically. The resection of the aortic leaflets was carried out step-by-step in the arrested heart. The AVIC implantation, the resection process, and the gross anatomy of intracardiac lesions were analysed. The procedure for installing the AVIC took 5.8 ± 1.5 min. A sealed chamber was achieved in 9/10 cases. The resection of the valves was performed in 8/10 and completed in 7/10 cases. The resection took, on average, 7.4 ± 2.7 min/cusp. In 9/10 cases, the sealing was sufficient. Gross anatomy and histological analysis demonstrated only superficial damage to the surrounding tissue. In this study, the in vivo on-pump isolation of the left ventricular outflow tract and the laser resection of the native aortic valve could be demonstrated successfully. Nevertheless, this model is the next step towards a beating-heart resection of the aortic valve using the isolation chamber.
Bombien Quaden, Rene; Leester-Schaedel, Monika; Lozonschi, Lucian; Lutter, Georg
Although renal failure is one of the known comorbidities associated with rapid progression of aortic stenosis, it is unclear whether hemodialysis alters the progression of prosthetic aortic valve stenosis. We describe a 79-year-old female who underwent bioprosthetic aortic valve replacement 8 years ago with stable prosthetic valve area for the initial 6 years. In the last two years, coinciding with the initiation of maintenance hemodialysis, she developed progressive prosthetic valve stenosis to the point of clinical decompensation. She underwent a second prosthetic aortic valve replacement with symptom resolution. This case suggests that circulating milieu in end-stage renal failure and dialysis can accelerate the progression of prosthetic aortic valve stenosis. More frequent clinical followup and surveillance echocardiogram for dialysis patients with bioprosthetic aortic valve may facilitate timely management of valvular stenosis.
Mao, Michael; El Ters, Mirelle; Mankad, Sunil; Keddis, Mira; Park, Soon; Qian, Qi
Quadricuspid aortic valve is a rare congenital anomaly that may cause aortic regurgitation. A 77-year-old male patient was referred to our clinic with complaints of stable angina pectoris. We report a case of a quadricuspid aortic valve diagnosed by 3-dimentional transthoracic echocardiography.
Acar, Eser; Sahin, Tayfun; Y?lmaz, Irem; Celikyurt, Umut
Aortic valve calcification is the most common form of valvular heart disease, but the mechanisms of calcific aortic valve disease (CAVD) are unknown. NOTCH1 mutations are associated with aortic valve malformations and adult-onset calcification in families with inherited disease. The Notch signaling pathway is critical for multiple cell differentiation processes, but its role in the development of CAVD is not well understood. The aim of this study was to investigate the molecular changes that occur with inhibition of Notch signaling in the aortic valve. Notch signaling pathway members are expressed in adult aortic valve cusps, and examination of diseased human aortic valves revealed decreased expression of NOTCH1 in areas of calcium deposition. To identify downstream mediators of Notch1, we examined gene expression changes that occur with chemical inhibition of Notch signaling in rat aortic valve interstitial cells (AVICs). We found significant downregulation of Sox9 along with several cartilage-specific genes that were direct targets of the transcription factor, Sox9. Loss of Sox9 expression has been published to be associated with aortic valve calcification. Utilizing an in vitro porcine aortic valve calcification model system, inhibition of Notch activity resulted in accelerated calcification while stimulation of Notch signaling attenuated the calcific process. Finally, the addition of Sox9 was able to prevent the calcification of porcine AVICs that occurs with Notch inhibition. In conclusion, loss of Notch signaling contributes to aortic valve calcification via a Sox9-dependent mechanism.
Koenig, Sara N.; Nichols, Haley A.; Galindo, Cristi L.; Garner, Harold R.; Merrill, Walter H.; Hinton, Robert B.; Garg, Vidu
Transcatheter aortic valve replacement is a new method to treat patients with symptomatic, severe aortic stenosis who are at high surgical risk. Short- and midterm results have been encouraging, with more than 90,000 procedures performed worldwide. Patient selection, prosthesis sizing, and access strategies heavily rely on noninvasive imaging. Computed tomographic (CT) angiography is increasingly used for peri-interventional evaluation, as this modality allows for objective three-dimensional assessment of the aortic root, evaluation of the iliofemoral access route, and prediction of appropriate projection angles for prosthesis deployment. Compared with two-dimensional imaging techniques, CT provides comprehensive information about aortic annulus anatomy and geometry, supporting appropriate patient selection and prosthesis sizing. Recently, integration of CT measurements into sizing algorithms has been demonstrated to significantly reduce the incidence of paravalvular regurgitation, compared with prosthesis sizing with two-dimensional echocardiography. In addition, CT-based vascular access planning has been shown to reduce vascular access complications. Postprocedural CT imaging allows for the documentation of procedural success, evaluation of prosthesis positioning, and identification of asymptomatic complications. In this article, the rapidly emerging role of CT in the context of transcatheter aortic valve replacement will be described. Online supplemental material is available for this article. PMID:24261496
Blanke, Philipp; Schoepf, U Joseph; Leipsic, Jonathon A
Although heart valve replacement is among the most common cardiovascular surgical procedures, their outcome is often difficult to predict. One of the reasons is the design and choice of the materials used for the fabrication of the prostheses. This review paper describes the use of modeling techniques in prosthetic heart valve (HV) design and aims at the justification and development of a polymer based trileaflet mechanical heart valve (MHV). The closing/opening phase behavior of the bileaflet MHV was investigated. The potential problem of valve failure due to crack propagation in the brittle pyrolytic carbon leaflet was also discussed. These studies suggest that although bileaflet MHV performs satisfactorily, there are justifications for improvement. Since the native aortic HV is trileaflet and made of anisotropic and hyperelastic tissue, one possible approach to a better MHV design is based on our ability to closely mimic the natural geometry and biomaterial properties. PMID:20971672
Mohammadi, Hadi; Mequanint, Kibret
Stenosis of the aortic valve is a common cardiac disease. It is usually corrected surgically by replacing the valve with a mechanical or biological prosthesis. Transapical aortic valve implantation is an experimental minimally invasive surgical technique that is applied to patients with high operative risk to avoid pulmonary arrest. A stented biological prosthesis is mounted on a catheter. Through small
Michael Gessat; Denis R. Merk; Volkmar Falk; Thomas Walther; Stefan Jacobs; Alois Nöttling; Oliver Burgert
AIM: Incidental aortic valve calcification is often detected during computed tomography. The aim was to compare the severity of valvular stenosis and calcification in patients with aortic stenosis.MATERIALS AND METHODS: One hundred and fifty-seven patients aged 68±11 years (range: 34–85) with aortic valve stenosis underwent multislice helical computed tomography and Doppler echocardiography performed by independent, blinded observers. The aortic valve
S. J Cowell; D. E Newby; J Burton; A White; D. B Northridge; N. A Boon; J Reid
Fibroelastomas account for less than 10% of all cardiac tumours, representing the most common valvular and the second most common cardiac benign tumour, following myxomas. Fibroelastomas are histologically benign; they can result in life-threatening complications such as stroke, acute valvular dysfunction, embolism, ventricular fibrillation, and sudden death. Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1?cm in diameter. Valve-sparing excision produces good long-term results in most instances. We report our surgical experience of a giant fibroelastoma in the aortic valve.
di Summa, Michele; Iezzi, Federica
Background. We consider operative survival as the primary objective in acute type A dissection and believe that virtually all native aortic valves can be conserved. We sought to answer the question: “Does glue repair improve the long-term stability of proximal aortic repair?”Methods. We retrospectively studied 64 patients with an acute type A dissection, an ascending aortic tear, and aortic regurgitation
Stephen Westaby; Takahiro Katsumata; Edward Freitas
Alkaptonuric ochronosis is a heritable disorder of tyrosine metabolism, with various systemic abnormalities related to pigment deposition and degeneration of collagen and other tissues, including the heart and aorta. A 65-year-old woman with alkaptonuric ochronosis and a history of four joint replacements required aortic valve replacement for severe aortic stenosis. Operative findings included ochronosis of a partly calcified aortic valve and the aortic intima. The aortic valve was removed at surgery and histologically investigated. Light microscopic examination of the aortic valve revealed intracellular and extracellular deposits of ochronotic pigment and a chronic inflammatory infiltrate. Beside the case representation, the disease history, aetiology, pathogenesis, clinical presentation and treatment of aortic valve ochronosis are reviewed.
Steger, Christina Maria
Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aortic valve implantation in the native aortic valve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve-in-valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve-in-valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure. PMID:22744728
Cerillo, Alfredo Giuseppe; Berti, Sergio; Glauber, Mattia
The purpose of this paper is to present in vitro and in vivo experimental evaluation of a new, artificial, bicuspid, aortic and venous valve. Valves were constructed from square stents with barbs covered by porcine small intestine submucosa (SIS). A valve 15 mm in diameter was tested in a flow model (2.5 l/min) with pressure measurement. A 100-ml rubber bag attached to a side arm of the flow model simulated heart ejection fraction. In acute (n=6) and short-term (n=3) experiments conducted in four swine and four dogs, valves ranging from 16-28 mm in diameter were placed into the ascending aorta through 10 F sheaths; three were placed subcoronary and six in a supracoronary position. Function and stability of the valves were studied with pressure measurements and aortograms. Three short-term animals were sacrificed for gross and histologic evaluation at one, two and four weeks respectively. In an acute experiment, venous valves with four barbs were placed into the IVC through an 8 F guiding catheter in three dogs. For longer-term testing, valves were placed into the IVCs and iliac veins of three young swine. The animals were followed up after two weeks with venograms, then were sacrificed for gross and histologic evaluation. PMID:20156026
Pavcnik, D; Uchida, B T; Timmermans, H; Corless, C L; Keller, F S; Rösch, J
Transcatheter aortic valve implantation (TAVI) has recently emerged as a treatment option for patients with severe aortic valve stenosis (AS). For patients who are deemed inoperable for surgical aortic valve replacement (SAVR), TAVI has a significant mortality benefit compared to medical therapy. This review discusses established and emerging roles for multimodality imaging and focuses on the application of these technologies for patient selection, intraprocedural guidance, and the detection and quantification of acute and chronic complications of this novel procedure.
Shah, Dipan J.; Mahmarian, John J.
Heyde’s syndrome is the association between calcific aortic stenosis and gastrointestinal bleeding due to angiodysplasia. Alterations in von Willebrand factor due to turbulence across the diseased aortic valve have been incriminated in the pathophysiology of this syndrome. Replacement of the aortic valve has been reported to stop the bleeding, but this is debatable. Along with a review of the relevant medical literature, we hereby report a 68 year old patient with aortic stenosis and severe recurrent gastrointestinal bleeding that completely subsided following aortic valve replacement.
Abi-akar, Ramzi; El-rassi, Issam; Karam, Nicole; Jassar, Yehya; Slim, Rita; Jebara, Victor
Calcific aortic stenosis is the third leading cause of adult heart disease and the most common form of acquired valvular disease in developed countries. However, the molecular pathways leading to calcification are poorly understood. We reported two families in which heterozygous mutations in NOTCH1 caused bicuspid aortic valve and severe aortic valve calcification. NOTCH1 is part of a highly conserved signaling pathway involved in cell fate decisions, cell differentiation, and cardiac valve formation. In this study, we examined the mechanism by which NOTCH1represses aortic valve calcification. Heterozygous Notch1-null (Notch1+/?) mice had greater than fivefold more aortic valve calcification than age- and sex-matched wildtype littermates. Inhibition of Notch signaling in cultured sheep aortic valve interstitial cells (AVICs) also increased calcification more than fivefold and resulted in gene expression typical of osteoblasts. We found that Notch1 normally represses the gene encoding bone morphogenic protein 2 (Bmp2) in murine aortic valves in vivo and in aortic valve cells in vitro. siRNA-mediated knockdown of Bmp2 blocked the calcification induced by Notch inhibition in AVICs. These findings suggest that Notch1 signaling in aortic valve cells represses osteoblast-like calcification pathways mediated by Bmp2.
Nigam, Vishal; Srivastava, Deepak
Background: Historically, surgical replacement of the aortic root in Marfan syndrome patients involved replacing the native valve with a mechanical valve resulting in the need for life-long anticoagulation. Recently, surgeons have developed procedures that spare, rather than replace the aortic valve during aortic root replacement. The goal of this systematic review is to compare valve-sparing aortic root replacement with traditional
Gabriel R Smith
The hearts of nine children with clinical evidence of congenital valve stenosis and a congenital bicuspid aortic valve were reviewed. Aortic stenosis was diagnosed on the basis of cardiac catheterization data in four patients, operative findings in two and auscultatory findings in three. The patients were 1 month to 9 years old; six were male and three female. In each patient the two commissures of the valve were free to the aortic wall. The cusps were thickened, rolled and redundant; microscopic studies revealed that they consisted of immature loose connective tissue consistent with a dysplastic or incompletely differentiated valve. The valve orifice was obstructed by the dysplastic cusps, and dysplastic changes rather than the commissural fusion were responsible for the observed aortic stenosis. These valves do not appear amenable to valvotomy because obstruction is due to the abnormal valve tissue. These findings may explain the occasional poor results of valvotomy in infants and children with congenital aortic valve stenosis. PMID:677024
Cheitlin, M D; Fenoglio, J J; McAllister, H A; Davia, J E; DeCastro, C M
Percutaneous stents are used in vascular applications in conjunction with angioplasty and in combination with graft material for repair of abdominal aneurysms. The authors have designed a collapsible bioprosthetic aortic valve for placement by a transluminal catheter technique. This trileaflet stent valve is composed of stainless steel and bovine pericardium. Stent valves, 23 and 29 mm, were tested in a pulse duplicator system with rigid rings from 21 to 31 mm in 2 mm increments. At a mean flow of 3.1 L/min (+/-0.7), normal systemic aortic pressure was generated with a transvalvular gradient of 14.9 +/- 7 mmHg (mean +/- SD). Regurgitation fraction ranged from 10 to 18% (mean 13.8 +/- 3%) in the best ring size. Valves with the best hemodynamic profile were used for implantation in three 70 kg pigs in an open chest model. The valve was collapsed in a 24 Fr catheter designed to allow slow, controlled release. After resection of the native leaflets, the new valve was placed in the subcoronary position. No additional sutures were used for securing the valve. Two animals were successfully weaned from cardiopulmonary bypass and maintained systemic pressures of 100/45 (+/-10) and 116/70 (+/-15) mmHg, respectively. Intraoperative color echocardiography revealed minimal regurgitation, central flow, full apposition of all leaflets, and no interference with coronary blood flow. Both animals were sacrificed after being off bypass for 2 hr. Postmortem examination revealed the valves to be securely anchored. The third animal was weaned from cardiopulmonary bypass but developed refractory ventricular fibrillation because of valve dislodgment due to structural failure. Although long term survival data are needed, development of a hemodynamically acceptable prosthetic aortic valve for transluminal placement is feasible. PMID:8944912
Moazami, N; Bessler, M; Argenziano, M; Choudhri, A F; Cabreriza, S E; Allendorf, J D; Rose, E A; Oz, M C
In the last years, an increasing proportion of high-risk patients undergo surgical aortic valve replacement. In order to reduce the risk associated with cross-clamp time or cardioplegic ischemic time, sutureless aortic prostheses have been developed. These bioprosthetic valves are not hand sewn, and this technological advance translates into reduced implantation times, thus improving outcome of patients referred for aortic valve replacement. At present, three sutureless bioprostheses are available on the market: 3f Enable (Medtronic Inc., Minneapolis, Minnesota, USA), Perceval (Sorin Group, Saluggia, Italy) and Intuity (Edwards Lifesciences, Irvine, California, USA). This article provides an overview of the available literature on sutureless aortic valves with the aim to better define current role and future perspectives of sutureless aortic bioprostheses for the treatment of aortic valve stenosis. PMID:24770430
Santarpino, Giuseppe; Fischlein, Theodor
Thoracic aortic aneurysm is often an asymptomatic but potentially lethal disease if its most catastrophic complication – aortic dissection – occurs. Thoracic aortic dissection is associated with a high mortality rate despite ongoing improvement in its management. We report a fatal outcome of thoracic aortic aneurysm in a male patient with bicuspid aortic valve. The patient was qualified for elective surgery of the ascending aorta and aortic valve at the age of 39 but he did not agree to undergo the proposed procedure. Three years later, he experienced acute aortic dissection and died despite a prompt diagnosis and complex management.
Michalak, Ewa; Michalowska, Ilona; Szpakowski, Eugeniusz; Konopka, Anna; Klisiewicz, Anna; Teresa Bilinska, Zofia
The prevalence of aortic stenosis is increasing with aging population. However with multiple co-morbidities and prior procedures in this aging population, more and more patients are being declared unfit for the ‘Gold Standard’ treatment i.e. surgical aortic valve replacement (AVR). Among the patients who are unfit or high risk for aortic valve replacement (AVR) by open heart surgery, transcatheter aortic valve implantation (TAVI) has been proven to be a valuable alternative improving survival and quality of life. We report first Indian experience of Core Valve (Medtronic Inc.) implantation in three high surgical risk patients performed on 22nd and 23rd February 2012.
Seth, Ashok; Rastogi, Vishal; Kumar, Vijay; Maqbool, Syed; Mustaqueem, Arif; Sekar, V. Ravi
The prevalence of aortic stenosis is increasing with aging population. However with multiple co-morbidities and prior procedures in this aging population, more and more patients are being declared unfit for the 'Gold Standard' treatment i.e. surgical aortic valve replacement (AVR). Among the patients who are unfit or high risk for aortic valve replacement (AVR) by open heart surgery, transcatheter aortic valve implantation (TAVI) has been proven to be a valuable alternative improving survival and quality of life. We report first Indian experience of Core Valve (Medtronic Inc.) implantation in three high surgical risk patients performed on 22nd and 23rd February 2012. PMID:23993000
Seth, Ashok; Rastogi, Vishal; Kumar, Vijay; Maqbool, Syed; Mustaqueem, Arif; Sekar, V Ravi
Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration. PMID:23200074
Aicher, Diana; Schäfers, Hans-Joachim
Aortoventricular disruption after aortic valve replacement is extremely rare. A case of aortoventricular disruption following aortic valve replacement is described in detail, and related case reports are reviewed. A 76-year-old male underwent aortic valve replacement with a tissue valve using everting mattress sutures, repair of the ascending aortic aneurysm, and mitral valve repair. After cardiopulmonary bypass was terminated, pulsatile bleeding behind the aortic root was observed, which required cardiopulmonary bypass. The ventricular rupture was located just below the left coronary annulus, and appeared secondary to a tear through the ventricular myocardium by the valve sutures. The tear was internally repaired by pledgeted sutures and Dacron patch reinforcement. The patient recovered and was discharged without major complications. Although this serious complication is extremely rare, surgeons should be aware that deep everting stitches on the left coronary annulus potentially causes aortoventricular disruption. Overstretching the posterior aortoventricular junction may contribute to this type of injury. PMID:20595361
Nakamura, Teruya; Izutani, Hironori; Shibukawa, Takanori; Higuchi, Takuya
We report the clinical course of a patient with a history of transapical aortic "valve-in-valve" transcatheter aortic valve implantation (TAVI), actually suffering from prosthetic valve endocarditis. The patient now underwent cardiac surgery as a salvage procedure. The procedure itself was uneventful, but the patient died several days postoperative due to persisting sepsis. The present case raises the question, how to deal with high-risk patients, once considered unsuitable for cardiac surgery in presence of prosthetic valve infection? Up to now, there exists only insufficient knowledge about incidence, clinical course, and effectiveness of treatment strategies for prosthetic valve endocarditis after TAVI. A review of the available literature is given. PMID:23344757
Wilbring, Manuel; Tugtekin, Sems Malte; Matschke, Klaus; Kappert, Utz
OBJECTIVE--To assess the pattern and progression of aortic valve dysfunction by serial Doppler echocardiographic examinations in ambulatory adult patients with congenital bicuspid aortic valve. DESIGN AND SETTING--Retrospective analysis of patients referred for Doppler echocardiography over a four year period. SUBJECTS--Fifty one adult patients with echocardiographic diagnosis of congenital bicuspid aortic valve had serial Doppler echocardiographic studies at least six months apart. There were 40 men and 11 women with a mean age of 36 years. MAIN OUTCOME MEASURE--Doppler echocardiographic values of aortic valve dysfunction. Cardiac events including endocarditis and aortic valve replacement were also evaluated. RESULT--Coarctation was present in five patients. 31 (61%) patients had a functionally normal bicuspid aortic valve defined as a mean gradient < 25 mm Hg and mild regurgitation. Significant aortic regurgitation was present in 15 patients (moderate in 12 and severe in three). Three patients had isolated aortic stenosis and two patients had combined aortic valve dysfunction. At a median follow up of 21 months (range six to 46 months), six patients had aortic valve surgery (one for aortic stenosis, three for aortic regurgitation, and two for endocarditis). Only 22 patients (43%) continued to have a functionally normal aortic valve. CONCLUSION--In this cohort of fairly young patients, aortic regurgitation is more common than aortic stenosis. Progression of aortic valve dysfunction occurs in patients with pre-existing valve dysfunction and even in those with normal aortic valve function at the initial echocardiographic examination.
Pachulski, R T; Chan, K L
Transcatheter aortic valve implantation (TAVI) represents a therapeutic option of increasing impact for the treatment of high-risk patients with symptomatic, severe aortic valve stenosis. We report here the case of an 86-year old patient with a cutaneo-pericardial fistula after a transapical TAVI procedure.
Scheid, Michael; Grothusen, Christina; Lutter, Georg; Petzina, Rainer
This study evaluated preoperative balloon aortic valvuloplasty (BAV) as a technique to decrease aortic valve replacement (AVR) risk in patients who have severe symptomatic aortic valve stenosis with substantial comorbidity. We report the outcomes of 18 high-risk patients who received BAV within 180 days before AVR from November 1993 through December 2011. Their median age was 78 years (range, 51-93 yr), and there were 11 men (61%). The pre-BAV median calculated Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) was 18.3% (range, 9.4%-50.7%). Preoperative left ventricular ejection fraction measured a median of 0.23 (range, 0.05-0.68), and the median aortic valve area index was 0.4 cm(2)/m(2) (range, 0.2-0.7 cm(2)/m(2)). The median interval from BAV to AVR was 28 days (range, 1-155 d). There were no strokes or deaths after BAV; however, 4 patients (22%) required mechanical circulatory support, 3 (17%) required femoral artery operation, and 1 (6%) developed severe aortic valve regurgitation. After BAV, the median STS PROM fell to 9.1% (range, 2.6%-25.7%) (compared with pre-BAV, P <0.001). Echocardiography before AVR showed that the median left ventricular ejection fraction had improved to 0.35 (range, 0.15-0.66), and the aortic valve area index to 0.5 cm(2)/m(2) (range, 0.3-0.7 cm(2)/m(2)) (compared with pre-BAV, both P <0.05). All patients received AVR. Operative death occurred in 2 patients (11%), and combined operative death and morbidity in 7 patients (39%). Staged BAV substantially reduces the operative risk associated with AVR in selected patients. PMID:24808774
Altarabsheh, Salah Eldien; Greason, Kevin L; Schaff, Hartzell V; Suri, Rakesh M; Li, Zhuo; Mathew, Verghese; Joyce, Lyle D; Park, Soon J; Dearani, Joseph A
This study evaluated preoperative balloon aortic valvuloplasty (BAV) as a technique to decrease aortic valve replacement (AVR) risk in patients who have severe symptomatic aortic valve stenosis with substantial comorbidity. We report the outcomes of 18 high-risk patients who received BAV within 180 days before AVR from November 1993 through December 2011. Their median age was 78 years (range, 51–93 yr), and there were 11 men (61%). The pre-BAV median calculated Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) was 18.3% (range, 9.4%–50.7%). Preoperative left ventricular ejection fraction measured a median of 0.23 (range, 0.05–0.68), and the median aortic valve area index was 0.4 cm2/m2 (range, 0.2–0.7 cm2/m2). The median interval from BAV to AVR was 28 days (range, 1–155 d). There were no strokes or deaths after BAV; however, 4 patients (22%) required mechanical circulatory support, 3 (17%) required femoral artery operation, and 1 (6%) developed severe aortic valve regurgitation. After BAV, the median STS PROM fell to 9.1% (range, 2.6%–25.7%) (compared with pre-BAV, P <0.001). Echocardiography before AVR showed that the median left ventricular ejection fraction had improved to 0.35 (range, 0.15–0.66), and the aortic valve area index to 0.5 cm2/m2 (range, 0.3–0.7 cm2/m2) (compared with pre-BAV, both P <0.05). All patients received AVR. Operative death occurred in 2 patients (11%), and combined operative death and morbidity in 7 patients (39%). Staged BAV substantially reduces the operative risk associated with AVR in selected patients.
Altarabsheh, Salah Eldien; Greason, Kevin L.; Schaff, Hartzell V.; Suri, Rakesh M.; Li, Zhuo; Mathew, Verghese; Joyce, Lyle D.; Park, Soon J.; Dearani, Joseph A.
Transcatheter aortic valve replacement has a place in the therapy for valvular aortic stenosis in a selected population of patients with increased risk for standard aortic valve replacement. The SAPIEN family of balloon-expandable transcatheter heart valves is the prototype that initiated this therapy and has undergone rapid development and evolution. The SAPIEN system has taught cardiologists and cardiac surgeons much about the nature of aortic stenosis and the potential for less invasive therapy. This article will review the SAPIEN transcatheter heart valves and the clinical experience. PMID:23931098
Huang, Pei-Hsiu; Eisenhauer, Andrew C
Bicuspid aortic valve (BAV) is the most common congenital heart defect, affecting 1-2% of the population. It is generally diagnosed late in adulthood when deterioration of the abnormal leaflet becomes clinically evident. BAV patients have an increased risk of developing serious complications, including stenosis, regurgitation, endocarditis, dilation of the aorta, aortic dissection, and aneurysm. BAV is a heritable trait, but the genetic basis underlying this cardiac malformation remains poorly understood. In the last decade, thanks to studies in animal models as well as genetic and biochemical approaches, a large number of genes that play important roles in heart development have been identified. These discoveries provided valuable insight into cardiac morphogenesis and uncovered congenital-heart-disease-causing genes. This paper will summarize the current knowledge of valve morphogenesis as well as our current understanding of the genetic pathways involved in BAV formation. The impact of these advances on human health including diagnosis of BAV and prevention of cardiovascular complications in individuals with BAV or with a family history of BAV is also discussed.
Laforest, Brigitte; Nemer, Mona
Background Transcatheter aortic valve implantation (TAVI) was established as an important alternative for high-risk patients with severe aortic stenosis. However, there are few data in the literature regarding coronary obstruction, that although rare, is a potentially fatal complication. Objective Evaluate this complication in Brazil. Methods We evaluated all patients presenting coronary obstruction from the Brazilian Registry of TAVI. Main baseline and procedural characteristics, management of the complication, and clinical outcomes were collected from all patients. Results From 418 consecutive TAVI procedures, coronary obstruction occurred in 3 cases (incidence of 0.72%). All patients were women, without prior coronary artery bypass grafting (CABG), and with mean age of 85 ± 3 years, logistic EuroSCORE of 15 ± 6% and STS-PROM score of 9 ± 4%. All of the cases were performed with balloon-expandable Sapien XT prosthesis. In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva. All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally. Conclusion Coronary obstruction following TAVI is a rare but potentially fatal complication, being more frequent in women and with the balloon-expandable prosthesis. Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.
Ribeiro, Henrique Barbosa; Sarmento-Leite, Rogerio; Siqueira, Dimytri A. A.; Carvalho, Luiz Antonio; Mangione, Jose Armando; Rodes-Cabau, Josep; Perin, Marco A.; de Brito, Fabio Sandoli
Objective: Bicuspid aortic valve disease has been associated with histologic abnormalities of the aortic root. Recent reports have suggested similar alterations may exist in the pulmonary artery of patients with bicuspid aortic valve. The present study was undertaken to define the histologic condition of the aortic and pulmonary artery root in bicuspid aortic valve disease and the relationship with pulmonary
Giovanni Battista Luciani; Luca Barozzi; Anna Tomezzoli; Gianluca Casali; Alessandro Mazzucco
We describe the first case of prosthetic valve endocarditis due to a Streptomyces sp. The patient presented with fever, cutaneous embolic lesions, and bacteremia 3 months after aortic valve replacement. Treatment required valve replacement and a long course of parenteral imipenem.
Mossad, S B; Tomford, J W; Stewart, R; Ratliff, N B; Hall, G S
Reconstructive valve surgery in acute aortic dissection type A (AADTA) remains challenging. We describe a case of successful combined repair of the aortic and mitral valves, and replacement of the ascending aorta after AADTA with aortic and mitral insufficiency. Mitral valve repair was achieved by quadrangular resection of the posterior leaflet, combined with ring annuloplasty. Aortic valve repair was achieved by Cabrol commissural sutures with resuspension of the annulus. The postoperative clinical course was uneventful and an echocardiogram revealed competent mitral and aortic valves. Mitral and aortic valve repair is an option in AADTA with mitral and aortic valve insufficiency. PMID:22832477
Adademir, Taylan; Tuncer, Altug; Ozkokeli, Mehmet; Sasmazel, Ahmet; Erdem, Hasan; Zeybek, Rahmi
Hearn, K., Somerville, Jane, Sutton, R., Wright, J., and Ross, D. (1973).Thorax, 28, 603-607. Aortic valve replacement with unsupported fascia lata. Twenty-five patients in the National Heart Hospital have had aortic valve replacement with unsupported autologous fascia lata and have been followed for two to three and a half years. Three patients died before leaving hospital. Nine of the 22 survivors required re-operation for severe aortic regurgitation and the other 13 developed aortic incompetence. In 11, regurgitation dated from the operation and progressed; and in 11 it appeared later and progressed. In view of the disappointing results which were obvious within six months unsupported autologous fascia lata valves have not been used for aortic valve replacement since December 1970. Images
Hearn, Kenneth; Somerville, Jane; Sutton, Richard; Wright, John; Ross, Donald
We report a case of severe mechanical hemolysis occurring 8 years after insertion of a bioprosthetic mitral valve in a patient who also suffered from aortic valve stenosis. It is suggested that the coexistence of two malfunctioning valves may lead to hemolysis via hemodynamic and turbulence alteration and that this condition is more frequent than expected for isolated valve involvement.Copyright
Kostas Konstantopoulos; Tasos Kasparian; John Sideris; Ersi Voskaridou; Dimitris Loukopoulos
Ascending aortic dissection and aneurysm are rare but life-threatening complications after aortic valve replacement. Preoperative evaluation of risk factors such as aortic diameter, structural features of aortic wall, and associated diseases may decrease complication rate. We herein present analysis of risk factors of proximal aortic events following aortic valve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure.
Hokenek, Faruk; Gursoy, Mete; Gulcan, Fusun; Duygu, Egemen; Sener, Murat
There are no previous reports of rupture of a heterologous pericardial patch after aortic annulus enlargement. Our patient, a 72-year-old Japanese female, presented with congestive heart failure resulting from heart compression from pseudoaneurysm formation in the aortic root. At 57 years of age the patient had undergone replacement of the ascending aorta for Stanford type A acute aortic dissection. At 66 years of age she had undergone aortic valve replacement with a mechanical valve, accompanied by enlargement of the aortic annulus using an equine pericardial patch, for severe aortic valve stenosis with a narrow aortic annulus. Equine pericardial patch was used in the aortic annulus enlargement to form the aortic root from the ascending aortic vascular prosthesis to the non-coronary cusp of the aortic valve. We performed repeat median sternotomy under cardiopulmonary bypass with moderate hypothermia. The ascending aorta was balloon-occluded because of dense adhesions around the superior vena cava and ascending aorta due to the pseudoaneurysm. A tear in the equine pericardial patch was noted at the aortic root. The patient underwent pseudoaneurysm excision and repair of the aortic root using a double-layered, Hemashield-reinforced bovine pericardial patch. Routine follow-up with computed tomography should be performed for early detection of complications from a heterologous pericardial patch.
There are no previous reports of rupture of a heterologous pericardial patch after aortic annulus enlargement. Our patient, a 72-year-old Japanese female, presented with congestive heart failure resulting from heart compression from pseudoaneurysm formation in the aortic root. At 57 years of age the patient had undergone replacement of the ascending aorta for Stanford type A acute aortic dissection. At 66 years of age she had undergone aortic valve replacement with a mechanical valve, accompanied by enlargement of the aortic annulus using an equine pericardial patch, for severe aortic valve stenosis with a narrow aortic annulus. Equine pericardial patch was used in the aortic annulus enlargement to form the aortic root from the ascending aortic vascular prosthesis to the non-coronary cusp of the aortic valve. We performed repeat median sternotomy under cardiopulmonary bypass with moderate hypothermia. The ascending aorta was balloon-occluded because of dense adhesions around the superior vena cava and ascending aorta due to the pseudoaneurysm. A tear in the equine pericardial patch was noted at the aortic root. The patient underwent pseudoaneurysm excision and repair of the aortic root using a double-layered, Hemashield-reinforced bovine pericardial patch. Routine follow-up with computed tomography should be performed for early detection of complications from a heterologous pericardial patch. PMID:24947732
Morisaki, Akimasa; Kato, Yasuyuki; Motoki, Manabu; Takahashi, Yosuke; Nishimura, Shinsuke; Shibata, Toshihiko
Treatment options for re-stenotic aortic valve prosthesis implanted by transcatheter technique have not been evaluated systematically. We describe the case of a 75-year-old dialysis patient who was treated by transcatheter aortic valve implantation 3.5 years ago and now presented with severe stenosis of the percutaneous heart valve. The patient was initially treated with a trans-apical implantation of an Edwards Sapien 26 mm balloon expandable valve. The patient remained asymptomatic for 3 years when he presented with increasing shortness of breath and significant calcification of the valve prosthesis on transesophageal echocardiography. Valve-in-valve percutaneous heart valve implantation using a 26-mm CoreValve prosthesis was performed under local anesthesia. The prosthesis was implanted without prior valvuloplasty. Pacing with a frequency of 140/min was applied during placement of the valve prosthesis. Positioning was done with great care using only fluoroscopic guidance with the aim to have the ventricular strut end of the CoreValve prosthesis 5 mm higher than the ventricular strut end of the Edwards Sapien prosthesis. After placement of the CoreValve prosthesis within the Edwards Sapien valve additional valvuloplasty with rapid pacing was performed in order to further expand the CoreValve prosthesis. The final result was associated with a remaining mean gradient of 5 mm Hg and no aortic regurgitation. In conclusion, implantation of a CoreValve prosthesis for treatment of a restenotic Edwards Sapien prosthesis is feasible and is associated with a good functional result. PMID:22707435
Hoffmann, Rainer; Möllmann, Helge; Lotfi, Shahram
30% of patients with significant aortic stenosis are not considered for operative aortic valve replacement because of the high perioperative risk. An alternative catheter based option for these patients is the transcatheter aortic valve replacement (TAVI). In general, there are two approaches for TAVI: transfemoral and transapical. Transfemoral aortic valve replacement is performed by transcatheter replacement of an aortic valve via the femoral arteries. Transapical valve replacement is achieved by transcatheter implantation via the fifth intercostal space. The most common complications are vessel injuries, bleeding complications, new onset of AV-block, development of paravalvular insufficiency, acute kidney injury, stroke and TIA. The first long-term observations suggest positive results. First clinical trials in a high-risk population show a promising outcome. Therefore TAVI offers a reasonable therapy option for patients with high perioperative risk. Further long-term clinical trials are still pending. PMID:22864727
Motloch, Lukas Jaroslaw; Reda, Sara; Rottlaender, Dennis; Heigert, Matthias; Hoppe, Uta C
Aortic calcium, aortic valve calcium (AVC), and coronary artery calcium (CAC) have been associated with cardiovascular event risk. We examined the prevalence of thoracic aortic calcium (TAC) and AVC in relation to the presence and extent of CAC, cardiovascular risk factors, and estimated risk of coronary heart disease (CHD). In 2,740 persons without known CHD aged 20 to 79 years,
Nathan D Wong; Maria Sciammarella; Yadon Arad; Romalisa Miranda-Peats; Donna Polk; Rory Hachamovich; John Friedman; Sean Hayes; Anthony Daniell; Daniel S Berman
A ten year old boy with pulmonary hypertension and a ductus arteriosus had severe aortic valve stenosis relieved by balloon aortic valvotomy. Subsequent aortic regurgitation was mild. This procedure avoided open heart operation, which would have been hazardous in this patient. Images Figure
Rickards, A F; Somerville, J
The implantation of a transcatheter heart valve (THV) through a balloon-expandable system played a major role in the early stages of transcatheter aortic valve replacement (TAVR). The technology consists of sewing a foldable biological cardiac valve inside a metallic stent frame, and then crimping the device into a balloon in order to implant the valve at the level of the aortic annulus through balloon inflation. The use of balloon-expandable valves underwent a rapid expansion in the years following the pioneering experience of 2002, and recent large multicenter trials and registries have confirmed the safety and efficacy of TAVR using balloon-expandable valves. The randomized Placement of Aortic Transcatheter Valves (PARTNER) trial showed both the superiority and non-inferiority of TAVR with the balloon-expandable Edwards-Sapien system compared to medical treatment (non-operable patients) and surgical aortic valve replacement (high risk patients), respectively. Balloon-expandable valves have been associated with excellent hemodynamic results (residual mean gradient <15 mm Hg in most cases), though residual paravalvular aortic regurgitation is frequent (trivial or mild in the majority of patients, moderate or severe in <10%). Valve durability studies with up to 5-year follow-up have shown maintained valve hemodynamics over time with only a minimal decrease in valve area and no increase in aortic regurgitation. Future improvements in the balloon-expandable THV technology such as implementing anti-paravalvular leak features (ex. Sapien 3 valve), and showing its efficacy for the treatment of non-high risk patients (ongoing PARTNER II trial) will probably lead to broader use in a lower risk population in the near future. PMID:24838134
Ribeiro, Henrique Barbosa; Urena, Marina; Allende, Ricardo; Amat-Santos, Ignacio J; Rodés-Cabau, Josep
Invasive hemodynamic evaluation in the patient with a mechanical aortic valve has in the past required transseptal or apical left ventricular puncture in order to obtain left ventricular pressure measurements. Over the last few years, several case reports have described the feasibility of using a coronary pressure-sensing guidewire to cross mechanical prosthetic aortic valves. In the current manuscript, we report four cases in which the use of a pressure-sensing guidewire was utilized for invasive hemodynamic diagnostic evaluation in patients with mechanical aortic valves. Furthermore, we present a detailed description of the technical approach to this technique and the limitations of this approach. PMID:23345088
Kiefer, Todd L; Wang, Andrew; Harrison, J Kevin
Transcatheter aortic valve implantation is a feasible therapeutic option for selected patients with severe aortic stenosis and high or prohibitive risk for standard surgery. Lung transplant recipients are often considered high-risk patients for heart surgery because of their specific transplant-associated characteristics and comorbidities. We report a case of successful transfemoral transcatheter aortic valve replacement in a lung transplant recipient with a symptomatic severe aortic stenosis, severe left ventricular dysfunction, and end-stage renal failure 9 years after bilateral lung transplantation. PMID:24882332
Brill, Anne-Kathrin; Gloekler, Steffen; Aubert, John-David; Wenaweser, Peter M; Geiser, Thomas
Transcatheter aortic valve replacement (TAVR) is a new technology that recently has been shown to improve survival and quality of life in patients with severe symptomatic aortic stenosis who are not surgical candidates . The development and design of transcatheter valves has been ongoing for the past 20 years, and TAVR has now been approved by the FDA as a treatment for aortic stenosis in patients who are not surgical candidates. In the United States, there are currently two transcatheter valves available: the Edwards Sapien Valve and the Medtronic CoreValve. While similar in some design elements, they also have characteristic differences that affect both the mechanism of delivery as well as performance in patients. This review aims to take a closer look at the development of this new technology, review the published clinical results, and look toward the future of transcatheter valve therapeutics and the challenges therein.
Forrest, John K.
Transcatheter aortic valve replacement (TAVR) is a new technology that recently has been shown to improve survival and quality of life in patients with severe symptomatic aortic stenosis who are not surgical candidates. The development and design of transcatheter valves has been ongoing for the past 20 years, and TAVR has now been approved by the FDA as a treatment for aortic stenosis in patients who are not surgical candidates. In the United States, there are currently two transcatheter valves available: the Edwards Sapien Valve and the Medtronic CoreValve. While similar in some design elements, they also have characteristic differences that affect both the mechanism of delivery as well as performance in patients. This review aims to take a closer look at the development of this new technology, review the published clinical results, and look toward the future of transcatheter valve therapeutics and the challenges therein. PMID:22737052
Forrest, John K
Calcified aortic stenosis is the predominant valve disease in the western world. Currently, surgical aortic valve replacement is the gold standard procedure for symptomatic severe aortic stenosis that can be performed with low morbidity and mortality. The prevalence of aortic stenosis increases with age, and the incidence of several comorbidities also unavoidably elevates the risk of surgical treatment. Therefore, the most adequate and gentle treatment is needed especially for this population. Since the first transcatheter aortic valve implantation (TAVI) was performed in 2002, the main implanting routes are the transfemoral, retrograde access through the common femoral artery, and the antegrade, transapical approach via anterolateral minithoracotomy. Meanwhile, TAVI has become an alternative treatment for patients who are not suitable candidates for surgical therapy in some centers.The initial clinical results are promising and have confirmed the feasibility of this technique. Due to the restricted long-term data, conventional aortic valve replacement still remains the standard for the treatment of aortic stenosis. Selection of the suitable therapy approach (surgical replacement, transfemoral or transapical aortic valve implantation) must consider each patient's specific risk profile and individual indication. Prospective, randomized trials will be necessary to assess the individual survival benefit of TAVI for various risk populations and to extend the indication. PMID:22528178
Kappert, U; Joskowiak, Dominik; Tugtekin, S M; Matschke, K
Aortic valve disorders are the most frequent form of valvular heart disorders (VHD) affecting nearly 3% of the global population. A large fraction among them are aortic root diseases, such as aortic root aneurysm, often requiring surgical procedures (valve-sparing) as a treatment. Visual non-invasive assessment techniques could assist during pre-selection of adequate patients, planning procedures and afterward evaluation of the same. However state of the art approaches try to model a rather short part of the aortic root, insufficient to assist the physician during intervention planning. In this paper we propose a novel approach for morphological and functional quantification of both the aortic valve and the ascending aortic root. A novel physiological shape model is introduced, consisting of the aortic valve root, leaflets and the ascending aortic root. The model parameters are hierarchically estimated using robust and fast learning-based methods. Experiments performed on 63 CT sequences (630 Volumes) and 20 single phase CT volumes demonstrated an accuracy of 1.45mm and an performance of 30 seconds (3D+t) for this approach. To the best of our knowledge this is the first time a complete model of the aortic valve (including leaflets) and the ascending aortic root, estimated from CT, has been proposed.
Grbic, Saša; Ionasec, Razvan I.; Zäuner, Dominik; Zheng, Yefeng; Georgescu, Bogdan; Comaniciu, Dorin
Calcific aortic valve disease (CAVD), once thought to be a degenerative disease, is now recognized to be an active pathobiological process, with chronic inflammation emerging as a predominant, and possibly driving, factor. However, many details of the pathobiological mechanisms of CAVD remain to be described, and new approaches to treat CAVD need to be identified. Animal models are emerging as vital tools to this end, facilitated by the advent of new models and improved understanding of the utility of existing models. In this paper, we summarize and critically appraise current small and large animal models of CAVD, discuss the utility of animal models for priority CAVD research areas, and provide recommendations for future animal model studies of CAVD.
Sider, Krista L.; Blaser, Mark C.; Simmons, Craig A.
Transcatheter aortic valve replacement is an increasingly common treatment of critical aortic stenosis. Many aortic stenosis patients have concomitant left ventricular dysfunction, which can instigate the formation of thrombus resistant to anticoagulation. Recent trials evaluating transcatheter aortic valve replacement have excluded patients with left ventricular thrombus. We present a case in which an 86-year-old man with known left ventricular thrombus underwent successful transcatheter aortic valve replacement under cerebral protection.
Grover, Peeyush M.; O'Neill, Brian P.; Velazquez, Omaida; Heldman, Alan W.; O'Neill, William W.; Cohen, Mauricio G.
Transcatheter aortic valve implantation (TAVI) has become the preferred treatment option for patients with symptomatic severe aortic stenosis who are inoperable or at high risk for surgical aortic valve replacement. TAVI has shown a clear mortality benefit compared to conservative treatment in inoperable patients, and is at least non-inferior to surgical aortic valve replacement in high-risk operable patients. Through improvements in the field of imaging, refinement in valve technologies, increasing operator and team experience and continuous valuable research, TAVI has developed rapidly in the past years and is expected to further boost in the near future. In this review, we discuss the technical and procedural aspects of TAVI, the acute and late outcomes, and highlight the current expectations and potential future development of this rapidly evolving technology. PMID:25017331
El-Mawardy, Mohamed; Abdel-Wahab, Mohamed; Richardt, Gert
Background. We sought to investigate the effect of patient prosthesis mismatch on hemodynamic profile using dobutamine stress echocardiography, and to evaluate midterm survival of patients undergoing aor- tic valve replacement with 19-mm Perimount (Baxter Healthcare, Santa Ana, California) aortic prosthetic valves. Methods. Between December 1, 1999, and August 17, 2005, 147 patients (mean age, 76.8 5.51 years) had aortic valves
Pradeep Narayan; Barnaby C. Reeves; Syad I. A. Rizvi; Kayvan Shokrollahi; Huda Ismail; Gianni D. Angelini; Angus Nightingale; Massimo Caputo
Background—The surgical approach to aortic root aneurysm and\\/or dissection remains controversial. The use of valve-sparing operations, which are thought to have many advantages, is increasing. We hypothesized that the particular technique and type of surgery could influence valve motion characteristics and function. Therefore, we studied the instantaneous opening and closing characteristics of the aortic valve after the main 2 types
Rainer G. Leyh; Claudia Schmidtke; Hans-Hinrich Sievers; Magdi H. Yacoub
The aortic valve lies in a unique hemodynamic environment, one characterized by a range of stresses (shear stress, bending forces, loading forces and strain) that vary in intensity and direction throughout the cardiac cycle. Yet, despite its changing environment, the aortic valve opens and closes over 100,000 times a day and, in the majority of human beings, will function normally over a lifespan of 70–90 years. Until relatively recently heart valves were considered passive structures that play no active role in the functioning of a valve, or in the maintenance of its integrity and durability. However, through clinical experience and basic research the aortic valve can now be characterized as a living, dynamic organ with the capacity to adapt to its complex mechanical and biomechanical environment through active and passive communication between its constituent parts. The clinical relevance of a living valve substitute in patients requiring aortic valve replacement has been confirmed. This highlights the importance of using tissue engineering to develop heart valve substitutes containing living cells which have the ability to assume the complex functioning of the native valve.
Chester, Adrian H.; El-Hamamsy, Ismail; Butcher, Jonathan T.; Latif, Najma; Bertazzo, Sergio; Yacoub, Magdi H.
Transcatheter aortic valve implantation has been designed to treat patients affected by severe symptomatic aortic stenosis considered extremely high risk for surgical aortic valve replacement. The CoreValve® (Medtronic Inc., MN, USA) is a multilevel self-expanding and fully radiopaque nitinol frame with a diamond cell configuration that holds a trileaflet porcine pericardial tissue valve and anchors the device in the native anatomy. CoreValve was the first percutaneous valve to be granted the CE mark for transfemoral implantation in May 2007 and the CoreValve US Pivotal Trial is actively underway. The CoreValve is available in four sizes (23, 26, 29 and 31?mm) to serve a broad range of patients' annulus from 18 to 29?mm. All the valves fit into an 18-Fr size catheter. Currently, more than 35,000 patients have been treated in more than 60 countries worldwide from the femoral artery, the axillary artery and, more recently, from a direct aortic approach, with excellent results up to 4-year follow-up. PMID:23278219
Bruschi, Giuseppe; De Marco, Federico; Martinelli, Luigi; Klugmann, Silvio
Although aortic valve replacement is the definitive therapy for severe aortic stenosis, almost half of patients with severe aortic stenosis are unable to undergo conventional aortic valve replacement because of advanced age, comorbidities, or prohibitive surgical risk. Treatment options have been recently expanded with the introduction of catheter-based implantation of a bioprosthetic aortic valve, referred to as transcatheter aortic valve replacement. Because this procedure is characterized by lack of exposure of the operative field, image guidance plays a critical role in preprocedural planning. This guideline document evaluates several preintervention imaging examinations that focus on both imaging at the aortic valve plane and planning in the supravalvular aorta and iliofemoral system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. PMID:24183748
Dill, Karin E; George, Elizabeth; Abbara, Suhny; Cummings, Kristopher; Francois, Christopher J; Gerhard-Herman, Marie D; Gornik, Heather L; Hanley, Michael; Kalva, Sanjeeva P; Kirsch, Jacobo; Kramer, Christopher M; Majdalany, Bill S; Moriarty, John M; Oliva, Isabel B; Schenker, Matthew P; Strax, Richard; Rybicki, Frank J
Aortic valve leaflets experience varying applied loads during the cardiac cycle. These varying loads act on both cells types of the leaflets, endothelial and interstitial cells, and cause molecular signaling events that are required for repairing the leaflet tissue, which is continually damaged from the applied loads. However, with increasing age, this reparative mechanism appears to go awry as valve interstitial cells continue to remain in their ‘remodeling’ phenotype and subsequently cause the tissue to become stiff, which results in heart valve disease. The etiology of this disease remains elusive; however, multiple clues are beginning to coalesce and mechanical cues are turning out to be large predicators of cellular function in the aortic valve leaflets, when compared to the cells from pulmonary valve, which is under a significantly less demanding mechanical loading regime. Finally this paper discusses the mechanical environment of the constitutive cell populations, mechanobiological processes that are currently unclear, and a mechano-potential etiology of aortic disease will be presented.
Merryman, W. David
Cardio Vascular Disease (CVD) is the major cause of death in India as well as in many other countries of the world, in which heart valve failure plays a significant role. The two main aortic valve diseases are aortic stenosis and aortic regurgitation. If the aortic valve is damaged mildly, it can be treated by suitable interventions. On the other
C Jamuna; M Anburajan
Opinion statement Bicuspid aortic valve (BAV) disease is a common congenital heart valve abnormality accounting for a large number of valve\\u000a replacements in the United States. Although still incompletely understood, the natural history of BAV disease is severe aortic\\u000a stenosis and associated ascending aortic dilatation. In addition to the increased risk of endocarditis, aortic dissection\\u000a and severe aortic valve dysfunction are
José T. Ortiz; David D. Shin; Nalini M. Rajamannan
Balloon aortic valvuloplasty has seen a revival in interest because of its role in predilation and preparation of the annulus before trans catheter aortic valve implantation. Aortic valve cusp perforation is a serious complication that needs early recognition and prompt corrective measures to prevent a poor procedural outcome or conversion to emergent surgery. A number of useful angiographic and technical findings can alert the operator about the possibility of this complication. Failure to recognize cusp perforation can lead to serious procedural complications like severe aortic regurgitation, suboptimal prosthesis deployment, and function that can necessitate emergent open cardiac surgery. PMID:21413122
Ussia, Gian Paolo; Sarkar, Kunal; Tamburino, Corrado
After follow up for seven years a 10 year old boy with congenital aortic regurgitation was found to have a tricuspid non-stenotic aortic valve at operation. The right coronary cusp was dysplastic, thickened, and contracted; the gap between its free margin and aortic wall was bridged with two fibrous bands; and the left coronary and non-coronary cusps were almost normal. The aortic valve was replaced with a prosthesis (St Jude Medical No 23), and the postoperative course was uneventful. Images
Hashimoto, R; Miyamura, H; Eguchi, S
Transfemoral aortic valve implantation has emerged as a promising alternative to surgical aortic valve replacement for high-risk patients with severe symptomatic aortic stenosis. In the setting of previous mechanical mitral valve replacement, the procedure represents a challenge due to the risk of interference and subsequent functional impairment of the mechanical prosthesis. The authors report a case of successful transfemoral implantation of a selfexpandable aortic bioprosthesis in a patient with a Björk-Shiley tilting-disk valve in mitral position demonstrating that the implantation is also feasible in this setting but requires careful preinterventional evaluation. Prior balloon aortic valvuloplasty with thorough observation of the mitral prosthesis during balloon inflation may be a helpful tool for indicating feasibility of this approach. PMID:20024645
Kahlert, Philipp; Eggebrecht, Holger; Thielmann, Matthias; Wendt, Daniel; Jakob, Heinz G; Sack, Stefan; Erbel, Raimund
The most widely used heart valve worldwide is the Edwards Sapien, which currently has 60% of the worldwide transcatheter aortic valve implantation (TAVI) market. The CoreValve is next in line in popularity, encompassing 35% of the worldwide TAVI market. Although these two valves dominate the TAVI market, a number of newer transcatheter valves have been introduced and others are in early clinical evaluation. The new valves are designed to reduce catheter delivery diameter, improve ease of positioning and sealing, and facilitate repositioning or removal. The most recent transcatheter valves for transapical use include Acurate TA (Symetis), Engager (Medtronic), and JenaValve the Portico (St Jude), Sadra Lotus Medical (Boston Scientific), and the Direct Flow Medical. These new inventions may introduce more effective treatment options for high-risk patients with severe aortic stenosis. Improvements in transcatheter valves and the developing variability among them may allow for more tailored approaches with respect to patient's anatomy, while giving operators the opportunity to choose devices they feel more comfortable with. Moreover, introducing new devices to the market will create a competitive environment among producers that will reduce high prices and expand availability. The present review article includes a discussion of recent patents related to Transcatheter Aortic Valves. PMID:24279506
Neragi-Miandoab, Siyamek; Skripochnik, Edvard; Salemi, Arash; Girardi, Leonard
We report a case of mechanical aortic valve replacement that was complicated by acute occlusion of one of the valve leaflets by the BioGlue (CryoLife Inc, Kennesaw, GA) that had seeped through the suture line on the aorta. This uncommon, but life-threatening complication is one that may go unrecognized, but is preventable. PMID:19632442
Goldberg, Steven P; Campbell, David N
Thrombotic occlusion of a prosthetic Bjork-Shiley valve is a potentially fatal complication. We present the case of a male, 62 years of age, diagnosed with thrombotic occlusion of prosthetic Bjork-Shiley aortic valve approximately 17 years post implantation. A brief review of the literature focusing on potential risk factors associated with the development of this condition and currently available diagnostic modalities
Sumeesh Dhawan; Param Sharma
The opening and closing behavior of the valve is a delicate interaction between blood flow and geometrical and stiffness properties of the heart valve leaflets and aortic root. Numerical analysis of the opening and closing behavior is complicated by the three-dimensional finite motion of the very flexible leaflets in a compliant system of fluid and structure. Fluid-structure interaction models of
J. De Hart; G. W. M. Peters; P. J. G. Schreurs; F. P. T. Baaijens
Aortic valve abnormality is the most frequent form of valvular heart disease. Notably, aortic stenosis in the elderly population has been increasingly common. Aortic valve replacement (AVR) using prosthetic valve has been still believed as a gold standard surgical intervention for various types of diseased aortic valve. The numerous reports and studies evaluating the clinical outcomes and durability of prosthesis were revealed, however, prosthesis selection for AVR is still debated. In twenty-first century, paradigm shift of prosthesis preference might be emerged from mechanical valves to bioprosthesis due to the development of the technology. Moreover, transcatheter aortic valve implantation accelerated among the worldwide trends. It could be developed having the potential to reduce the mortality and morbidity associated with high-risk traditional AVR. After the current guidelines for the management of patients with valvular heart disease, we should consider the valve choice in various patients' profile setting. This review summarizes the current status of prosthesis selection and future perspectives of ideal aortic valve intervention, including minimal invasive care. PMID:23722587
Furukawa, Hiroshi; Tanemoto, Kazuo
Sixty porcine aortic valves were fixed under dynamic conditions at specific durations, pressures and vibration rates in a 0.5% glutaraldehyde phosphate buffer (pH7.4, 0.2M). Tensile relaxation tests were performed at low through high extension rates (0.3, 3 and 30 mm s?1) and tissue denaturation temperatures were determined by the hydrothermal isometric tension method. Conventional statically fixed valves and fresh valves
Anthony C. Duncan; Derek Boughner; Ivan Vesely
A 75-year old woman with a history of coronary disease status post 3-vessel coronary artery bypass grafting (CABG) 8 years ago and a repeat one-vessel CABG 2 years ago in the setting of aortic valve replacement with a #19 mm St. Jude bileaflet mechanical valve for severe aortic stenosis presented with two to three weeks of progressive dyspnea and increasing substernal chest discomfort. Echocardiography revealed a gradient to 31 mmHg across her aortic valve, increased from a baseline of 13 mmHg five months previously. Fluoroscopy revealed thrombosis of her mechanical aortic valve. She was not a candidate for surgery given her multiple comorbidities, and fibrinolysis was contraindicated given a recent subdural hematoma 1 year prior to presentation. She was treated with heparin and eptifibatide and subsequently demonstrated resolution of her aortic valve thrombosis. We report the first described successful use of eptifibatide in addition to unfractionated heparin for the management of subacute valve thrombosis in a patient at high risk for repeat surgery or fibrinolysis. PMID:24469337
Vora, Amit N; Gehrig, Thomas; Bashore, Thomas M; Kiefer, Todd L
We present a case of fulminant diffuse systemic sclerosis (dSSc) developed after the aortic valve replacement followed by fatal congestive heart failure within the 6months from the initial symptoms. A 61-year-old male developed rapidly progressive diffuse systemic sclerosis following aortic valve replacement due to stenosis of bicuspid aortic valve. He presented with diarrhoea, weight loss, mialgia and arthralgia after cardiac surgery. Heart failure, due to myocardial fibrosis, was noted as a cause of death. We hypothesize that artificial materials like the ones used in mechanical valves or silicon materials in breast implants may induce fulminant course of pre-existing systemic sclerosis or create a new onset in predisposed individual. PMID:24735843
Marasovic-Krstulovic, Daniela; Jurisic, Zrinka; Perkovic, Dijana; Aljinovic, Jure; Martinovic-Kaliterna, Dusanka
Background One-year mortality outcomes in the PARTNER trial showed that transcatheter aortic valve implantation (TAVI) was noninferior to surgical aortic valve replacement (sAVR) in patients who were eligible for sAVR (cohort A), and superior to standard treatment in patients who were ineligible for sAVR (cohort B). Objective To update a previous report on the safety, effectiveness, and cost-effectiveness of TAVI, published in 2012. Data Sources A literature search was performed on September 11, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 2011, until September 11, 2012. Review Methods Randomized controlled trials investigating TAVI in comparison to sAVR or standard treatment were included for analysis. Results were summarized descriptively. Results At 2-year follow-up, mortality in cohort A was similar between the TAVI and sAVR groups. Rates of stroke/transient ischemic attack, major vascular complications, and moderate/severe paravalvular aortic regurgitation were significantly higher in the TAVI group, but rate of major bleeding was significantly higher in the sAVR group. Mortality in cohort B was significantly lower with transfemoral (TF) TAVI than with standard treatment, but rate of stroke was significantly higher with TF TAVI. TF TAVI resulted in a more rapid improvement in quality of life scores than sAVR, but this difference was not sustained at 6 and 12 months. Patients who underwent transapical TAVI did not have a greater early improvement in quality of life compared to sAVR patients. Compared to standard treatment, TF TAVI resulted in a greater improvement in quality of life scores at all time points. Incremental cost-effectiveness ratios were in favour of TAVI for inoperable patients in the base-case analysis, but varied widely for operable patients. Conclusions The findings of the 2-year follow-up with respect to mortality and adverse events were consistent with those of the 1-year follow-up. TAVI was also associated with improvement in quality of life, although results varied by cohort. Consistent with the 2012 report, TAVI may be cost-effective for patients who are not candidates for surgery. Plain Language Summary Narrowing of 1 of the heart valves (called aortic valve stenosis) makes it difficult for the heart to work properly. Often, patients have surgery to replace the narrowed valve, but surgery is too risky for some. In 2012, Health Quality Ontario published a report on a less invasive treatment option called transcatheter aortic valve implantation (TAVI). This report reviews information published since the 2012 report: the results of a 2-year follow-up of TAVI patients, and studies exploring patients’ quality of life.
Sehatzadeh, S; Doble, B; Xie, F; Blackhouse, G; Campbell, K; Kaulback, K; Chandra, K; Goeree, R
A best evidence topic was written according to a structured protocol. The question addressed was whether sutureless aortic valves have a clinical and haemodynamic benefit in high-risk patients with aortic valve disease. A total of 307 papers were found using the reported searches; of which, six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the outcomes of sutureless aortic valve implantation in high-risk patients undergoing aortic valve replacement. Reported measures included mortality; post-operative complications namely stroke, renal failure, endocarditis and bleeding; valve deployment, cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times; echocardiographic assessment of paravalvular leaks (PVLs) and valve haemodynamics; and symptomatic functional class. Hospital mortality ranged between 3.1 and 12.5% and long-term mortality ranged between 3.1 and 10%. Incidence of PVL was found to be between 0.0 and 11%. Stroke was observed in 0.7%, renal failure in 3.1%, prosthetic valve endocarditis in 2.1–3.1% and major bleeding in 3.1%. The valve deployment time was 9–21 min, CPB time 35–111 min and ACC time 17–70 min. Short-term mean and peak valve gradients were in the ranges of 10–11 and 18–22 mmHg, respectively, reducing to 8–9 and 16.4–19 mmHg, respectively, at follow-up. Owing to the lack of comparative studies analysing the outcomes of sutureless and conventional aortic valves, we compared these results with the recently published PARTNER Trial (Transcatheter vs. Surgical Aortic-Valve Replacement in High-Risk Patients), and it can be shown that the outcomes of sutureless aortic valves compare favourably with conventional valves in terms of mortality, neurological deficit, renal failure and post-operative bleeding. However, there is increased incidence of endocarditis and PVLs, together with raised mean valve gradients, perhaps owing to the mechanical properties and deployment techniques of sutureless aortic valves.
Sepehripour, Amir H.; Harling, Leanne; Athanasiou, Thanos
Little is known about transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve stenosis, which usually represents a contraindication. The aim of this study was to assess the feasibility and the results of TAVI in this patient subset. Of 316 high-risk patients with severe aortic stenosis who underwent TAVI from January 2009 to January 2012, 15 (5%) had documented bicuspid aortic valves. They were treated using a transarterial approach, using the Medtronic CoreValve system. Patients were aged 80 ± 10 years, in New York Heart Association functional classes III and IV. The mean aortic valve area was 0.8 ± 0.3 cm(2), and the mean gradient was 60 ± 19 mm Hg. The mean calcium score, calculated using multislice computed tomography, was 4,553 ± 1,872 arbitrary units. The procedure was successful in all but 1 patient. Major adverse events, according to Valvular Academic Research Consortium definitions, were encountered in 1 patient (death). The mean postimplantation prosthetic gradient was 11 ± 4 mm Hg, and ?1+ periprosthetic leaks were observed in all but 2 patients. The mean prosthetic ellipticity index was 0.7 ± 0.2 at the level of the native annulus and 0.8 ± 0.2 at the level of the prosthetic leaflets. After a mean follow-up period of 8 ± 7 months, 1 patient had died from aortic dissection; there were no additional adverse events. All but 2 hospital survivors were in New York Heart Association class I or II. In conclusion, the present series suggests that transarterial Medtronic CoreValve implantation is feasible in selected patients with bicuspid aortic valve and may lead to short-term hemodynamic and clinical improvement. PMID:22677157
Himbert, Dominique; Pontnau, Florence; Messika-Zeitoun, David; Descoutures, Fleur; Détaint, Delphine; Cueff, Caroline; Sordi, Martina; Laissy, Jean-Pierre; Alkhoder, Soleiman; Brochet, Eric; Iung, Bernard; Depoix, Jean-Pol; Nataf, Patrick; Vahanian, Alec
Forty-one patients in whom the diagnosis of a non-stenotic bicuspid aortic valve had been established by noninvasive techniques were followed up for a mean of 10.9 years. During this period, 2 patients required aortic valve replacement because of the development of calcific aortic valve stenosis at the ages of 52 and 64 and 5 others developed evidence of mild aortic valve stenosis. The appearance of calcium in a bicuspid aortic valve suggests the possibility of subsequent calcific aortic stenosis, and patients with this feature should be carefully followed up. Bacterial endocarditis on the aortic valve occurred in 3 patients, one of whom developed severe aortic regurgitation and subsequently died. Patients with a bicuspid aortic valve are at definite risk from bacterial endocarditis and should receive appropriate antibiotic prophylaxis. In 26/41 (63%) patients there was no clinical change during the follow-up period, including 7 of the patients over the age of 50. Images
Mills, P; Leech, G; Davies, M; Leathan, A
Stenosis of the aortic valve is a common cardiac disease. It is usually corrected surgically by replacing the valve with a mechanical or biological prosthesis. Transapical aortic valve implantation is an experimental minimally invasive surgical technique that is applied to patients with high operative risk to avoid pulmonary arrest. A stented biological prosthesis is mounted on a catheter. Through small incisions in the fifth intercostal space and the apex of the heart, the catheter is positioned under flouroscopy in the aortic root. The stent is expanded and unfolds the valve which is thereby implanted into the aortic root. Exact targeting is crucial, since major complications can arise from a misplaced valve. Planning software for the perioperative use is presented that allows for selection of the best fitting implant and calculation of the safe target area for that implant. The software uses contrast enhanced perioperative DynaCT images acquired under rapid pacing. In a semiautomatic process, a surface segmentation of the aortic root is created. User selected anatomical landmarks are used to calculate the geometric constraints for the size and position of the implant. The software is integrated into a PACS network based on DICOM communication to query and receive the images and implants templates from a PACS server. The planning results can be exported to the same server and from there can be rertieved by an intraoperative catheter guidance device.
Gessat, Michael; Merk, Denis R.; Falk, Volkmar; Walther, Thomas; Jacobs, Stefan; Nöttling, Alois; Burgert, Oliver
The aim of this study was to explore the medium-term clinical outcome and the risk of progression of aortic valve disease and aortic dilation in pediatric patients with isolated bicuspid aortic valve (BAV). 179 pediatric patients with isolated BAV were prospectively followed from January 1995 to December 2010. Patients with severe valve dysfunction at baseline were excluded. Clinical outcome included cardiac death, infective endocarditis, aortic complications, cardiac surgery and percutaneous valvuloplasty. Echocardiographic endpoints were: progression of aortic stenosis (AS) or regurgitation (AR) and progressive aortic enlargement at different levels of the aortic root, evaluated as z-score. The median age at diagnosis was 7.8 [2.7-12.0] years. After a median followup of 5.4 [2.3-9.2] years, all patients were alive. The clinical endpoint occurred in 4 (2.2 %) patients (0.41 events per 100 patient-years). A progression of AS and AR was observed in 9 (5.0 %) and 29 (16.2 %) patients, respectively. The z-scores at the end of follow-up were not significantly different from baseline at the annulus, Valsalva sinuses and sinotubular junction, whereas a slight increase was observed at the level of the ascending aorta (1.9 vs 1.5, p = 0.046). Significant progressive aortic dilation occurred in a minority of patients (10.6, 5.6, 9.5, and 19.0 % respectively). The clinical outcome in pediatric patients with isolated BAV is favourable and the progression of aortic valve dysfunction and aortic dilation is relatively slow. These findings may be taken into account to better guide risk assessment and clinical follow-up in these patients. PMID:24362596
Spaziani, Gaia; Ballo, Piercarlo; Favilli, Silvia; Fibbi, Veronica; Buonincontri, Lorenzo; Pollini, Iva; Zuppiroli, Alfredo; Chiappa, Enrico
Aortic valve replacement (AVR) is a common surgical intervention for symptomatic aortic stenosis. For many high-risk patients with severe symptomatic aortic stenosis, AVR is not an option. Aortic valve bypass (AVB), a less common surgical procedure compared to AVR surgery, can bypass a stenotic aortic valve in lieu of replacing it and can offer surgical intervention for candidates unable to undergo AVR. AVB is an alternative to AVR that avoids median sternotomy, cardiopulmonary bypass, cross clamping the aorta, manipulation of the native aortic valve, and aortic cannulation. This case summary reviews the anesthetic management of a patient undergoing AVB. PMID:23513324
A new clinical entity is described in which free aortic regurgitation from congenital aortic valve disease caused rupture of the chordae to the anterior leaflet of the mitral valve in 7 men aged 45 to 63 years (mean 52 years); 2 of the patients also had rupture of chordae to the posterior leaflet. Comparing these patients with those with ruptured mitral chordae in association with rheumatic heart disease and patients with spontaneous chordal rupture, differences were evident. No patient had a history of rheumatic fever and none had active infection. The typical clinical presentation was of acute mitral regurgitation into a small left atrium, with severe pulmonary oedema which was often resistant to medical treatment. The cause of chordal rupture in these patients was in part the result of progressive left ventricular dilatation, of direct trauma to the anterior cusp of the mitral valve, and possibly of a genetic factor. The anatomical features of both aortic and mitral valves are described, and in 3 histology of the mitral valve was available; 2 had myxomatous degeneration similar to that seen in patients with spontaneous chordal rupture, and in 1 there was degeneration of collagen tissue. All patients were treated surgically but the mortality was high (5 out of 7,70%). Early operation with replacement of the aortic and mitral valves is recommended if this high mortality is to be reduced. Images
Joseph, S; Emanuel, R; Sturridge, M; Olsen, E
Seventeen consecutive patients undergoing 20 planned aortic valve replacements with allograft valves at Stanford University Medical Center were studied with intraoperative epicardial echocardiography and Doppler color flow mapping before and after cardiopulmonary bypass. Native aortic valves were replaced in 12 of the 20 patients, and eight patients underwent second aortic valve procedures. In 17 of 20 patients allograft selection was guided by prebypass echocardiographic estimates of annular diameter and/or length of allograft aortic root required. Other prebypass findings included unanticipated severe mitral regurgitation in one patient (which precluded allograft aortic valve replacement), left-to-right shunts in five patients, ascending aortic dissection in one, and aortic root disease necessitating coronary reimplantation or bypass in two. Postbypass echocardiography demonstrated acceptable competency of 18 of 19 allograft valves (mild or no aortic insufficiency). Postbypass echocardiography also documented successful repair of four of five shunts and mild mitral regurgitation in 15 of 19 patients (versus 11 of 19 before bypass). Conclusions: Intraoperative echocardiography-Doppler mapping is a useful adjunct for allograft aortic valve or aortic root replacement; it allows confident selection of appropriate tissue size before aortic cross clamping, which minimizes delay from allograft thawing procedures. It also provides helpful information about the extent of aortic root disease and coronary ostial anatomy before bypass, confirms allograft competency after bypass, and detects accompanying valvular and other hemodynamic lesions before and after allograft valve replacement. PMID:1999949
Bartzokis, T; St Goar, F; DiBiase, A; Miller, D C; Bolger, A F
Increased life expectancy has led to the presentation of more complicated patients in old age for the replacement of the aortic valve. The emergence of Transcatheter Aortic Valve Implantation (TAVI) was considered as a significant breakthrough in the management of symptomatic, moribund patients suffering from aortic valve stenosis who had been rejected for surgical intervention. A novel technology often has a long journey from the point at which it is created to its every-day-use. It is now obvious that TAVI practice in multiple institutes around the world has gone beyond the evidence. Serious concerns have been raised questioning the current TAVI practice. Analysis of future TAVI use may assist clinicians and healthcare managers to understand and deploy this technology in accordance with the evidence.
Minimally invasive cardiac surgery is less traumatic and therefore leads to quicker recovery. With the assistance of engineering technologies on devices, imaging, and robotics, in conjunction with surgical technique, minimally invasive cardiac surgery will improve clinical outcomes and expand the cohort of patients that can be treated. We used transapical aortic valve implantation as an example to demonstrate that minimally invasive cardiac surgery can be implemented with the integration of surgical techniques and engineering technologies. Feasibility studies and long-term evaluation results prove that transapical aortic valve implantation under MRI guidance is feasible and practical. We are investigating an MRI compatible robotic surgical system to further assist the surgeon to precisely deliver aortic valve prostheses via a transapical approach. Ex vivo experimentation results indicate that a robotic system can also be employed in in vivo models.
Li, Ming; Mazilu, Dumitru; Horvath, Keith A.
Calcified aortic valve stenosis is the most frequent valvular heart disease in developed countries with a very poor outcome when symptoms develop. However, several of these patients are denied for surgery. The main reasons are their advanced age (elderly patient), co-morbidities, technical limitations and a very high surgical risk. It is currently possible to propose a Transcatheter Aortic Valve Implantation (TAVI). After selection of candidates, the feasibility of the intervention is analysed. The size of the aortic bioprosthesis must be selected according to the cardiac anatomy. Several cardiac imaging modalities (echocardiography, computed tomography and cardiac MRI) can be used to identify unsuitable situations. Heavy calcifications or tortuosity can thwart the retrograde approach use. The sub-clavian arteries (for the CoreValve) and trans-apical approach (for the Edwards-Sapien) constitute alternatives ways. PMID:23469489
Davin, L; Bruyère, P J; Lancellotti, P; Piérard, L; Legrand, V
Objective: We developed techniques for partial upper hemisternotomy for reoperative aortic valve replacement and compared the results with those of reoperative aortic valve replacement by way of conventional full resternotomy. Methods: We retrospectively analyzed data from 19 patients who underwent conventional full sternotomy and 20 patients who underwent partial hemisternotomy for isolated elective reoperative aortic valve replacements performed between November
John G. Byrne; Sary F. Aranki; Gregory S. Couper; David H. Adams; Elizabeth N. Allred; Lawrence H. Cohn
Background Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement (sAVR) for patients at high risk for surgery. Objective To evaluate the safety, effectiveness, and cost-effectiveness of TAVI for treatment of aortic valve stenosis in symptomatic older adults. Review Methods A literature search was performed on September 6, 2011, for studies published from January 1, 2007, to September 6, 2011. A combined decision tree and Markov model was developed to compare costs, life years, and quality-adjusted life-years (QALYs) of all treatment options in their respective patient populations over a 20-year time horizon. Results Two studies from the PARTNER trial were identified. The first study compared TAVI to sAVR in patients who were candidates for sAVR. The second study compared TAVI to standard treatment in patients who were not eligible for sAVR. The first study showed that TAVI and sAVR had similar mortality rates at 1 year. The second study showed a significant improvement in patient survival in those undergoing TAVI. However, in both studies, the TAVI group had significantly higher rates of stroke/transient ischemic attack, and major vascular complications. Rates of major bleeding were significantly higher in sAVR group in the first study and significantly higher in TAVI group in the second study. The base-case cost-effectiveness of TAVI was $48,912 per QALY, but the incremental cost-effectiveness ratio ranged from $36,000 to $291,000 per QALY depending on the assumptions made in the longer-term prediction portion of the model (i.e., beyond the follow-up period of the PARTNER trial). Conclusions TAVI improves survival in patients who cannot undergo surgery. For those who are candidates for surgery, TAVI has a mortality rate similar to sAVR, but it is associated with significant adverse effects. TAVI may be cost-effective for patients who cannot undergo surgery, but is not cost-effective for patients who can.
Sehatzadeh, S; Doble, B; Xie, F; Blackhouse, G; Campbell, K; Kaulback, K; Chandra, K; Goeree, R
OBJECTIVES This study aimed to report on original aortic valve reconstruction for patients on dialysis. METHODS Aortic valve reconstruction has been performed on 404 cases from April 2007 through September 2011. Among them, 54 cases on haemodialysis were retrospectively studied. Forty-seven patients had aortic stenosis, 5 had aortic regurgitation (AR), and 2 had infective endocarditis. Mean age was 70.2 ± 8.5 years. There were 35 males and 19 females. There were 27 primary aortic valve reconstructions, 11 with CABG, 6 with ascending aortic replacement, 5 with mitral valve repair and 4 with maze. First, in the procedure, harvested pericardium was treated with 0.6% glutaraldehyde solution. After resecting the cusps, we measured the distance between commissures with original sizing instrument. Then, the pericardium was trimmed with the original template. Three cusps were sutured to each annulus. RESULTS Peak pressure gradient averaged to 66.0 ± 28.2 mmHg preoperatively, and decreased to 23.4 ± 10.7, 13.8 ± 5.5 and 13.3 ± 2.3 mmHg, 1 week, 1 year, and 3 years after the operation, respectively. No calcification was detected with echocardiographic follow-up. Recurrence of AR was not recorded with the mean follow-up of 847 days except for 1 case reoperated on for infective endocarditis 2.5 years after the operation. Three hospital deaths were recorded due to non-cardiac causes. Other patients were in good condition. There was no thromboembolic event. CONCLUSIONS Medium-term results are excellent. Since warfarin for dialysis patients becomes problematic, a postoperative warfarin-free status is desirable. Aortic valve reconstruction can provide patients with a better quality of life without warfarin.
Kawase, Isamu; Ozaki, Shigeyuki; Yamashita, Hiromasa; Uchida, Shin; Nozawa, Yukinari; Matsuyama, Takayoshi; Takatoh, Mikio; Hagiwara, So
OBJECTIVE. The purpose of this study was to correlate the severity and location of aortic valve calcifications, as an incidental finding at chest CT of elderly persons, with pressure gra- dients across the valve. MATERIALS AND METHODS. One hundred fifteen subjects who were 60 years old or older and who showed aortic valve calcification on chest CT (5-mm reconstructed section
Franklin Liu; Courtney A. Coursey; Cairistine Grahame-Clarke; Robert R. Sciacca; Anna Rozenshtein; Shunichi Homma; John H. M. Austin
Various techniques of stentless aortic valve implantation with or without wall components exist. We investigated the in-vitro performance of stentless valves without or with aortic wall removal mimicking root versus subcoronary implantation. Glutaraldehyde-preserved stentless aortic valves (gpSVG), cryo-preserved human homografts (cpHG), cryo-preserved xenografts (cpXG), and fresh xenografts (fXG) were used. Valves were mounted as full roots or trimmed in a mock circuit. Mean transvalvular gradient (MTVG, mmHg) was measured. Distensibility was quantified using post-systolic backflow volume (BV, ml) - after valve closure. Function was visualized by means of a high-speed camera. Glutaraldehyde-preserved valves exhibited higher MTVG than cryo-preserved or fresh substitutes. After trimming, cpHG, cpXG, and fXG demonstrated marked reduction of MTVG (cpHG: 7.6-5.2 mmHg; cpXG: 6.7-4.9 mmHg; fXG: 8.4-5.2 mmHg). In contrast, after trimming gpSVG exhibited a significant increase of MTVG (7.1-9.2 mmHg). BV remained constant. Visualization indicated maintained distension of all valves and types of all sizes after trimming. In fresh and cryo-preserved grafts, aortic wall trimming resulted in significantly improved systolic performance while glutaraldehyde-preserved stentless valves demonstrated systolic impairment after wall resection. Subcoronary implantation of fresh or cryo-preserved aortic valves may therefore be preferred. In contrast, glutaraldehyde-preserved valves are dependent on wall suspension and may therefore be implanted as a root. PMID:17669805
Kuehnel, Ralf-U; Stock, Ullrich A; Wendt, Max O; Degenkolbe, Ilka; Jainski, Ute; Hartrumpf, Martin; Pohl, Manfred; Albes, Johannes M
A 28-year-old man with a bicuspid aortic valve presented with facial droop and slurred speech with several months of constitutional symptoms of night sweats, weight loss and productive cough. Examination confirmed aortic regurgitation, palpable spleen and left facial droop. Multiple peripheral blood cultures were negative. Inflammatory markers, cytoplasmic staining antineutrophil cytoplasmic antibodies (cANCA) and anti-PR3 antibody were all elevated. MRI of the brain and CT of the chest and abdomen confirmed embolic infarcts to brain, kidney and spleen. Transoesophageal echocardiogram (ECG) showed valve vegetations and severe aortic regurgitation. Endocardial Wegener's granulomatosis was considered. Aortic valve replacement was performed. Grindings from aortic valve leaflets were analysed for rpoB gene, which confirmed the presence of Bartonella henselae. Serological assays demonstrated B henselae IgM 20 (normal <20) and IgG >2048 (normal < 64). The patient completely recovered after prolonged antibiotic treatment. Culture-negative infective endocarditis may mimic vasculitis and be associated with positive cANCA. Serology and molecular techniques may aid diagnosis. PMID:22791485
Teoh, Laurence S G; Hart, Hamish H; Soh, May Ching; Christiansen, Jonathan P; Bhally, Hasan; Philips, Martin S; Rai-Chaudhuri, Dominic S
Although annulus rupture is one of the most severe complications of transcatheter aortic valve implantation (TAVI), the incidence and mechanism of this complication remain unclear. Out of 387 consecutive TAVI cases in our institution, the incidence of annulus rupture was 1.0% (4/387). The first two patients died because of hemodynamic collapse due to tamponade on day 0. Both surviving patients had undergone preprocedural multidetector computed tomography which revealed large calcifications in the epicardial fat part of the aortic annulus. In both cases, annulus rupture occurred after deployment of a balloon expandable valve suggesting that mechanical compression of this "vulnerable area" by calcification may cause annulus rupture. PMID:22718400
Hayashida, Kentaro; Bouvier, Erik; Lefèvre, Thierry; Hovasse, Thomas; Morice, Marie-Claude; Chevalier, Bernard; Romano, Mauro; Garot, Philippe; Farge, Arnaud; Donzeau-Gouge, Patrick; Cormier, Bertrand
Minimally invasive aortic valve replacement has been performed via partial sternotomy, the parasternal approach, and anterior intercostal approaches. We successfully performed aortic valve replacement through a small right infraaxillary thoracotomy in 25 patients, with the aid of a thoracoscope and a knot-pusher. The patients were 9 men and 16 women with a mean age of 72.6 years. Our approach had better cosmetic results than traditional approaches through the anterior chest wall. This method did not require rib transection or sacrifice of the internal thoracic artery. PMID:23910127
Ito, Toshiaki; Maekawa, Atsuo; Hoshino, Satoshi; Hayashi, Yasunari
Aortic valve endocarditis with perivalvular abscess formation remains a demanding condition and the results of the surgery are not optimal. Abscess localized in the aortic basis area can weaken the aortic wall, leading to further deterioration and rupture. The presented case allows us to recommend a maximal aggressive approach in patients, in whom the aortic wall seems to be rearranged due to abscess formation. Sometimes only the resection of the abscess hole and replacement of the entire ascending aorta offers a safe therapy option. PMID:20956402
Szlapka, Michal; Joskowiak, Dominik; Matschke, Klaus; Tugtekin, Sems Malte
Thrombotic occlusion of a prosthetic Bjork-Shiley valve is a potentially fatal complication. We present the case of a male, 62 years of age, diagnosed with thrombotic occlusion of prosthetic Bjork-Shiley aortic valve approximately 17 years post implantation. A brief review of the literature focusing on potential risk factors associated with the development of this condition and currently available diagnostic modalities used for evaluation and treatment are presented. PMID:15931324
Dhawan, Sumeesh; Sharma, Param; Tak, Tahir
This study presents a combined computational and experimental approach for the nonlinear structural simulations of polymeric tri-leaflet aortic valves (PAVs). Nonlinear shell-based and quasi-static finite-element (FE) structural models are generated for a prosthetic valve geometry that includes the leaflets, stents and root materials, such as the bottom base and outside walls. The PAV structural model is subject to an ensemble
Rami Haj-Ali; Lakshmi P. Dasi; Hee-Sun Kim; Joonho Choi; H. W. Leo; Ajit P. Yoganathan
Transcatheter aortic valve implantation using the Medtronic CoreValve is a well-established procedure. Although previously carried out only through the common femoral artery, today it is possible to perform the procedure through different arterial alternative access sites. A direct aortic approach through the ascending aorta could be carried out via a right anterior mini-thoracotomy in the second intercostal space. The pericardium is opened to expose the aorta. Two purse-string sutures are then placed on the ascending aorta and a standard retrograde CoreValve implantation is performed with the standard delivery system. Advantages, contraindications, surgical technique and results are discussed. PMID:24448561
Bruschi, Giuseppe; Botta, Luca; De Marco, Federico; Colombo, Paola; Nonini, Sandra; Klugmann, Silvio; Martinelli, Luigi
Background—The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation. Methods and Results—The indexed valve effective orifice area (EOA) was estimated for each type and size
Claudia Blais; Jean G. Dumesnil; Richard Baillot; Serge Simard; Daniel Doyle; Philippe Pibarot
A flow model for analyzing the fluid mechanics of left ventricular-aortic valved conduits has been established. The model is based on a parallel flow circuit analogy of Ohm's law, the classic analysis of Gorlin and Gorlin1 for the determination of valvular areas, and an empirical constant, introduced by Gentle,2 that is descriptive of prosthetic heart valve performance. Favorable comparisons with clinical data indicate that the flow model is capable of predicting volumetric rates of flow through the valved conduit and through the aorta. Applications of the model are discussed in terms of altering the design of the valved conduit to improve its performance. The effect of valvular efficiency on conduit performance is investigated, and it is concluded that the Starr-Edwards ball valve and the Hancock 250 valve offer attractive alternatives if the objective is to increase the volumetric rate of flow through the valved conduit, or to decrease the volumetric rate of flow through the stenotic aortic valve, or both.
Shanebrook, J. Richard; Levine, Mathew L.
Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis (AS), about one third of patients are considered inoperable due to unacceptable surgical risk. Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50% at 2 years. Transcatheter aortic valve implantation (TAVI) has been used in these patients, and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far. In this review, we will focus on the two commercially available systems: Edwards SAPIEN valve and CoreValve Revalving system. Both systems have demonstrated success rates of over 90% with 30-d mortality rates below 10% in the most recent transfemoral TAVI studies. Moreover, long-term studies have shown that the valves have good haemodynamic performance. Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients, and long-term clinical results of the percutaneous valves. In this article we review the current status of TAVI including selection of patients, a comparison of available prostheses, results and complications of the procedure, clinical outcomes, and future perspectives.
Salinas, Pablo; Moreno, Raul; Lopez-Sendon, Jose L
The degree of intravascular hemolysis was evaluated in 315 patients in the late course of aortic valve replacement. Starr-Edwards aortic ball valves of series 2300 caused significantly more hemolysis than did those of series 1200, as estimated from the serum lactate dehydrogenase levels. Smaller valves of series 2300 caused a higher degree of hemolysis than did the larger ones. Aortic disc valves induced a more moderate red cell destruction than did the ball valves, the Lillehei-Kaster significantly more than the Bjørk-Shiley prostheses. Crushing of red cells is thought to be a more important cause of hemolysis than shearing forces in turbulent blood. Hemolytic anemia represented a problem only in some patients with Starr-Edwards valve type 2300, although iron substitution was necessary also in some with other prostheses, since the hemoglobin-binding capacity of haptoglobin was exceeded in several patients. Valvular or paravalvular leakage was associated with stronger hemolysis in some patients, and should be suspected whenever the rate of red cell destruction increases. Longstanding intravascular hemolysis did not seriously affect renal function. PMID:655106
Dale, J; Myhre, E
The biomechanical factors that result from the haemodynamic load on the cardiovascular system are a common denominator of several vascular pathologies. Thickening and calcification of the aortic valve will lead to reduced opening and the development of left ventricular outflow obstruction, referred to as aortic valve stenosis. The most common pathology of the aorta is the formation of an aneurysm, morphologically defined as a progressive dilatation of a vessel segment by more than 50% of its normal diameter. The aortic valve is exposed to both haemodynamic forces and structural leaflet deformation as it opens and closes with each heartbeat to assure unidirectional flow from the left ventricle to the aorta. The arterial pressure is translated into tension-dominated mechanical wall stress in the aorta. In addition, stress and strain are related through the aortic stiffness. Furthermore, blood flow over the valvular and vascular endothelial layer induces wall shear stress. Several pathophysiological processes of aortic valve stenosis and aortic aneurysms, such as macromolecule transport, gene expression alterations, cell death pathways, calcification, inflammation, and neoangiogenesis directly depend on biomechanical factors.
Back, Magnus; Gasser, T. Christian; Michel, Jean-Baptiste; Caligiuri, Giuseppina
Background Aortic stenosis is a frequent valvular disease especially in elderly patients. Catheter-based valve implantation has emerged as a valuable treatment approach for these patients being either at very high risk for conventional surgery or even deemed inoperable. The German Aortic Valve Registry (GARY) provides data on conventional and catheter-based aortic procedures on an all-comers basis. Methods and results A total of 13 860 consecutive patients undergoing repair for aortic valve disease [conventional surgery and transvascular (TV) or transapical (TA) catheter-based techniques] have been enrolled in this registry during 2011 and baseline, procedural, and outcome data have been acquired. The registry summarizes the results of 6523 conventional aortic valve replacements without (AVR) and 3464 with concomitant coronary bypass surgery (AVR + CABG) as well as 2695 TV AVI and 1181 TA interventions (TA AVI). Patients undergoing catheter-based techniques were significantly older and had higher risk profiles. The stroke rate was low in all groups with 1.3% (AVR), 1.9% (AVR + CABG), 1.7% (TV AVI), and 2.3% (TA AVI). The in-hospital mortality was 2.1% (AVR) and 4.5% (AVR + CABG) for patients undergoing conventional surgery, and 5.1% (TV AVI) and AVI 7.7% (TA AVI). Conclusion The in-hospital outcome results of this registry show that conventional surgery yields excellent results in all risk groups and that catheter-based aortic valve replacements is an alternative to conventional surgery in high risk and elderly patients.
Hamm, Christian W.; Mollmann, Helge; Holzhey, David; Beckmann, Andreas; Veit, Christof; Figulla, Hans-Reiner; Cremer, J.; Kuck, Karl-Heinz; Lange, Rudiger; Zahn, Ralf; Sack, Stefan; Schuler, Gerhard; Walther, Thomas; Beyersdorf, Friedhelm; Bohm, Michael; Heusch, Gerd; Funkat, Anne-Kathrin; Meinertz, Thomas; Neumann, Till; Papoutsis, Konstantinos; Schneider, Steffen; Welz, Armin; Mohr, Friedrich W.
Balloon dilatation of the aortic valve was attempted in 34 consecutive children aged 16 months to 17 years (median 7 years), weight range 9-60 (median 22) kg. Previous surgical valvotomy had been performed in two patients (twice in one of them). The valve was not crossed in one patient. In the remaining 33 patients the pressure difference between the left ventricle and the ascending aorta during systole was reduced from 71 (30) to 28 (19) mm Hg. In 24 patients recatheterisation 2-19 (mean 9) months later showed gradients that were similar to those immediately after balloon dilatation (35 (20) v 31 (20) mm Hg). The two patients with the highest residual gradients immediately after balloon dilatation showed a spontaneous reduction in gradient at repeat catheterisation, whereas the patient who had twice had previous surgical valvotomy showed an increase in gradient from 37 to 99 mm Hg over nine months and required aortic root replacement. Balloon dilatation was repeated in two patients and this caused a further reduction in gradient. New aortic regurgitation occurred in nine (27%) patients (grade I, 8; grade II, 1) and aortic regurgitation was exacerbated (grade I to II) in two of the nine with pre-existing aortic regurgitation. External iliac artery avulsion occurred in one (3%) patient and two (6%) required intravenous streptokinase because the femoral artery became occluded. There were no other complications. Open valvotomy was performed in the child in whom the valve was not crossed, but no other child required aortic valve operation. Balloon dilatation of the aortic valve gave reasonable short term palliation and was well tolerated. It is an alternative to surgical valvotomy for initial palliation of congenital aortic stenosis in many children.
Sullivan, I D; Wren, C; Bain, H; Hunter, S; Rees, P G; Taylor, J F; Bull, C; Deanfield, J E
We present the case of a 49-year-old man with an abnormal aortic valve formed by four cusps (three equal large cusps and one smaller cusp; type 1 according to Hurwits and Roberts classification) with a marked lack of coaptation that caused a severe aortic valve insufficiency. The patient underwent a repair of the defect with a tricuspidalization of the aortic valve, restoring the normal coaptation of the cusps and the normal function of the aortic valve. Postoperative course was unremarkable. The early follow-up showed a mild aortic valve insufficiency. PMID:23272891
Daprati, Andrea; Generali, Tommaso; Arlati, Francesco; Roberto, Maurizio
Red cell survival was studied in 21 patients following homograft replacement of the aortic valve. Autologous cells labelled with 51Cr were used. The T½ 51Cr varied between 24 and 34 days, with only one patient below the normal limit of normal variations. The absence of haemolysis was confirmed by other haematological studies, including estimation of reticulocytes, serum lactic dehydrogenase, and urinary haemosiderin. Haptoglobin levels were low in most of the patients studied. In contrast to prosthetic valves there was no haemolysis in patients with regurgitation around or through the homograft valve. Images
Yacoub, M. H.; Kothari, M.; Keeling, D.; Patterson, M.; Ross, D. N.
Asymptomatic traumatic diaphragmatic hernia, which presents in an adult, is an extremely rare entity. We discuss the management of a 63-year-old male with an asymptomatic traumatic diaphragmatic hernia discovered during aortic valve replacement. doi: 10.1111/jocs.12341 (J Card Surg 2014;29:473-475). PMID:24750139
Fukunaga, Naoto; Seo, Hideya; Hamakawa, Hiroshi; Koyama, Tadaaki
Degenerative valvular heart disease, the most common form of valve disease in the Western world, can lead to aortic stenosis (AS) or mitral regurgitation (MR). In current guidelines for the management of patients with degenerative valvular disease, surgical intervention is recommended at the onset of symptoms or in the presence of left ventricular systolic impairment. Whether surgery is appropriate for
Valentin Fuster; Martin Goldman; Robert O. Bonow; Prashant Vaishnava
Primary school students (817 apparently healthy 10-year olds) were screened by transthoracic 2-dimensional echocardiography to assess for the prevalence of bicuspid aortic valve. Bicuspid aortic valve was found in 0.5% of cases, with a higher prevalence in males than females (0.75% vs 0.24%), and was significantly associated with aortic root enlargement compared with children who had tricuspid aortic valves.
Cristina Basso; Mauro Boschello; Cosimo Perrone; Alessandro Mecenero; Andrea Cera; Dario Bicego; Gaetano Thiene; Ennio De Dominicis
Aortic valve reconstruction using leaflet grafts made from autologous pericardium is an effective surgical treatment for some forms of aortic regurgitation. Despite favorable outcomes in the hands of skilled surgeons, the procedure is underutilized because of the difficulty of sizing grafts to effectively seal with the native leaflets. Difficulty is largely due to the complex geometry and function of the valve and the lower distensibility of the graft material relative to native leaflet tissue. We used a structural finite element model to explore how a pericardial leaflet graft of various sizes interacts with two native leaflets when the valve is closed and loaded. Native leaflets and pericardium are described by anisotropic, hyperelastic constitutive laws, and we model all three leaflets explicitly and resolve leaflet contact in order to simulate repair strategies that are asymmetrical with respect to valve geometry and leaflet properties. We ran simulations with pericardial leaflet grafts of various widths (increase of 0%, 7%, 14%, 21% and 27%) and heights (increase of 0%, 13%, 27% and 40%) relative to the native leaflets. Effectiveness of valve closure was quantified based on the overlap between coapting leaflets. Results showed that graft width and height must both be increased to achieve proper valve closure, and that a graft 21% wider and 27% higher than the native leaflet creates a seal similar to a valve with three normal leaflets. Experimental validation in excised porcine aortas (n=9) corroborates the results of simulations.
Hammer, Peter E.; Chen, Peter C.; del Nido, Pedro J.; Howe, Robert D.
We report a rare case of acute right coronary artery stenosis developing in a patient undergoing aortic valve replacement. We present a case report with a brief overview of the literature relating to coronary artery occlusion associated with cardiac valve surgery – the theories and treatments are discussed. A 85 year-old female was admitted under the care of the cardiothoracic team with signs and symptoms of heart failure. Investigations, including cardiac echocardiography and coronary angiography, indicated a critical aortic valve stenosis. Intraoperative right ventricular failure ensued post aortic valve replacement. Subsequent investigations revealed an acute occlusion of the proximal right coronary artery with resultant absence of distal flow supplying the right ventricle. An immediate right coronary artery bypass procedure was performed with resolution of the right ventricular failure. Subsequent weaning off cardiopulmonary bypass was uneventful and the patient continued to make excellent recovery in the postoperative phase. To our knowledge this is one of the few documented cases of intraoperative acute coronary artery occlusion developing during valve surgery. However, surgeons should be aware of the potential for acute occlusion so that early recognition and rapid intervention can be instituted.
Umran, Sarwar; Chetty, Govind; Sarkar, Pradip K
Aims Aortic valve sclerosis (AVSc) is a hallmark of several cardiovascular conditions ranging from chronic heart failure and myocardial infarction to calcific aortic valve stenosis (AVS). AVSc, present in 25–30% of patients over 65 years of age, is characterized by thickening of the leaflets with marginal effects on the mechanical proprieties of the valve making its presentation asymptomatic. Despite its clinical prevalence, few studies have investigated the pathogenesis of this disease using human AVSc specimens. Here, we investigate in vitro and ex vivo BMP4-mediated transdifferentiation of human valve interstitial cells (VICs) towards an osteogenic-like phenotype in AVSc. Methods and results Human specimens from 60 patients were collected at the time of aortic valve replacement (AVS) or through the heart transplant programme (Controls and AVSc). We show that non-calcified leaflets from AVSc patients can be induced to express markers of osteogenic transdifferentiation and biomineralization through the combinatory effect of BMP4 and mechanical stimulation. We show that BMP4 antagonist Noggin attenuates VIC activation and biomineralization. Additionally, patient-derived VICs were induced to transdifferentiate using either cell culture or a Tissue Engineering (TE) Aortic Valve model. We determine that while BMP4 alone is not sufficient to induce osteogenic transdifferentiation of AVSc-derived cells, the combinatory effect of BMP4 and mechanical stretch induces VIC activation towards a phenotype typical of late calcified stage of the disease. Conclusion This work demonstrates, for the first time using AVSc specimens, that human sclerotic aortic valves can be induced to express marker of osteogenic-like phenotype typical of advanced severe aortic stenosis.
Poggio, Paolo; Sainger, Rachana; Branchetti, Emanuela; Grau, Juan B.; Lai, Eric K.; Gorman, Robert C.; Sacks, Michael S.; Parolari, Alessandro; Bavaria, Joseph E.; Ferrari, Giovanni
Cardiac valves function in a mechanically complex environment, opening and closing close to a billion times during the average human lifetime, experiencing transvalvular pressures and pulsatile and oscillatory shear stresses, as well as bending and axial stress. Although valves were originally thought to be passive pieces of tissue, recent evidence points to an intimate interplay between the hemodynamic environment and biological response of the valve. Several decades of study have been devoted to understanding these varied mechanical stimuli and how they might induce valve pathology. Here, we review efforts taken in understanding the valvular response to its mechanical milieu and key insights gained from in vitro and ex vivo whole-tissue studies in the mechanobiology of aortic valve remodeling, inflammation, and calcification.
Balachandran, Kartik; Sucosky, Philippe; Yoganathan, Ajit P.
The DeBakey-Surgitool aortic valve differs from popular cloth-covered prostheses by having a bare metal cage and a pyrolytic carbon ball. This valve was implanted in 37 patients. There were 7 operative deaths (19%), none of which was related to the valve design. Thirty survivors have been followed up to five years with 12 late deaths. The single thromboembolic event resulted in the only valve-related death. One patient developed a periprosthetic leak and another has hemolytic anemia. The incidence of thromboembolism in small series (3%) is comparable to that with the cloth-covered valves. This and the absence of complications related to cloth wear are important considerations when selecting a prosthesis. PMID:132145
Scott, S M; Sethi, G K; Bridgman, A H; Takaro, T
Bicuspid (or bicommissural) aortic valve (BAV) is the most common cardiovascular malformation in humans, with a prevalence\\u000a of 1% to 2% in the general population and a 2:1 male:female ratio. BAV is frequently associated with other cardiovascular\\u000a malformations, including aortic root dilatation, which affects about 40% of individuals with BAVs and is thought to be associated\\u000a with increased risk of
Ismail El-Hamamsy; Magdi H. Yacoub
Trileaflet polymeric prosthetic aortic valves (AVs) produce hemodynamic characteristics akin to the natural AV and may be most suitable for applications such as transcatheter implantation and mechanical circulatory support (MCS) devices. Their success has not yet been realized due to problems of calcification, durability, and thrombosis. We address the latter by comparing the platelet activation rates (PARs) of an improved polymer valve design (Innovia LLC) made from poly(styrene-block-isobutylene-block-styrene) (SIBS) with the commercially available Carpentier-Edwards Perimount Magna Aortic Bioprosthetic Valve. We used our modified prothrombinase platelet activity state (PAS) assay and flow cytometry methods to measure platelet activation of a pair of 19 mm valves mounted inside a pulsatile Berlin left ventricular assist device (LVAD). The PAR of the polymer valve measured with the PAS assay was fivefold lower than that of the tissue valve (p = 0.005) and fourfold lower with flow cytometry measurements (p = 0.007). In vitro hydrodynamic tests showed clinically similar performance of the Innovia and Magna valves. These results demonstrate a significant improvement in thrombogenic performance of the polymer valve compared with our previous study of the former valve design and encourage further development of SIBS for use in heart valve prostheses. PMID:20930618
Claiborne, Thomas E; Girdhar, Gaurav; Gallocher-Lowe, Siobhain; Sheriff, Jawaad; Kato, Yasushi P; Pinchuk, Leonard; Schoephoerster, Richard T; Jesty, Jolyon; Bluestein, Danny
Although heart valve replacement is among the most common cardiovascular surgical procedures, their outcome is often difficult to predict. One of the reasons is the design and choice of the materials used for the fabrication of the prostheses. This review paper describes the use of modeling techniques in prosthetic heart valve (HV) design and aims at the justification and development
Hadi Mohammadi; Kibret Mequanint
Aortic valve disease in the setting of a left ventricular assist device presents unique challenges. We present the case of a patient who underwent transcatheter aortic valve implantation to replace a stenotic aortic valve to facilitate left ventricular assist device explantation. Thirty-three days later, the porcine pericardial valve cusps were fused and a thick pseudomembrane had occluded the left ventricular outflow tract, forcing the explant to be aborted. PMID:24484841
Parry, Dominic; Rao, Vivek; Butany, Jagdish; Catrip, Jorge; Wilson, William; McDonald, Michael; Billia, Phyllis Filio; Horlick, Eric; Cusimano, Robert James
Introduction Transcatheter aortic valve implantation is a promising alternative to high risk surgical aortic valve replacement. The procedure is mainly indicated in patients with severe symptomatic aortic stenosis who cannot undergo surgery or who are at very high surgical risk. Aim Description early results of our single-center experience with balloon expandable aortic valve implantation. Material and methods Between July 2011 and August 2012, we screened in total 75 consecutive patients with severe aortic stenosis and high risk for surgery. Twenty-one of them were found ineligible for transcatheter aortic valve implantation (TAVI) because of various reasons, and finally we treated a total of 54 patients with symptomatic severe aortic stenosis (AS) who could not be treated by open heart surgery (inoperable) because of high-risk criteria. The average age of the patients was 77.4 ±7.1; 27.8% were male and 72.2% were female. The number of patients in NYHA class II was 7 while the number of patients in class III and class IV was 47. Results The average mortality score of patients according to the STS scoring system was 8.5%. Pre-implantation mean and maximal aortic valve gradients were measured as 53.2 ±14.1 mm Hg and 85.5 ±18.9 mm Hg, respectively. Post-implantation mean and maximal aortic valve gradients were 9.0 ±3.0 and 18.2 ±5.6, respectively (p < 0.0001). The left ventricular ejection fraction was calculated as 54.7 ±14.4% before the operation and 58.0 ±11.1% after the operation (p < 0.0001). The duration of discharge after the operation was 5.29 days, and a statistically significant correlation between the duration of discharge after the operation and STS was found (r = 0385, p = 0.004). Conclusions We consider that with decreasing cost and increasing treatment experience, TAVI will be used more frequently in broader indications. Our experience with TAVI using the Edwards-Sapien XT (Edwards Lifesciences, Irvine, CA) devices suggests that this is an effective and relatively safe procedure for the treatment of severe aortic stenosis in suitable patients.
Bozkurt, Engin; Keles, Telat; Durmaz, Tahir; Akcay, Murat; Ayhan, Huseyin; Bayram, Nihal Akar; Aslan, Abdullah Nabi; Bastug, Serdal; Bilen, Emine
OBJECTIVE Metabolic syndrome (MetS) has been associated with increased prevalence of aortic valve calcium (AVC) and with increased progression of aortic stenosis. The purpose of this study was to determine whether MetS is associated with increased risks for the development of new (“incident”) AVC or for progression of established AVC as assessed by CT. RESEARCH DESIGN AND METHODS The relationships of MetS or its components as well as of diabetes to risks for incident AVC or AVC progression were studied among participants with CT scans performed at baseline and at either year 2 or year 3 examinations in the Multi-Ethnic Study of Atherosclerosis (MESA). RESULTS Of 5,723 MESA participants meeting criteria for inclusion, 1,674 had MetS by Adult Treatment Panel III criteria, whereas 761 had diabetes. Among the 5,123 participants without baseline AVC, risks for incident AVC, adjusted for time between scans, age, sex, race/ethnicity, LDL cholesterol, lipid-lowering medications, and smoking, were increased significantly for MetS (odds ratio [OR] 1.67 [95% CI 1.21–2.31]) or diabetes (2.06 [1.39–3.06]). In addition, there was an increase in incident AVC risk with increasing number of MetS components. Similar results were found using the International Diabetes Federation MetS criteria. Among the 600 participants (10.5%) with baseline AVC, neither MetS nor diabetes was associated with AVC progression. CONCLUSIONS In the MESA cohort, MetS was associated with a significant increase in incident (“new”) AVC, raising the possibility that MetS may be a potential therapeutic target to prevent AVC development.
Katz, Ronit; Budoff, Matthew J.; Takasu, Junichiro; Shavelle, David M.; Bertoni, Alain; Blumenthal, Roger S.; Ouyang, Pamela; Wong, Nathan D.; O'Brien, Kevin D.
Aortic insufficiency from iatrogenic valve perforation from nonaortic valve operations is rarely reported despite the prevalence of these procedures. Rapid diagnosis of these defects is essential to prevent deterioration of cardiac function. In this paper, we describe a young man who reported to our institution after two open cardiac surgeries with new aortic regurgitation found to be due to an iatrogenic perforation of his noncoronary aortic valve cusp. This defect was not appreciated by previous intraoperative transesophageal echocardiography and was inadequately visualized on follow-up transthoracic and transesophageal echocardiograms. In contrast, cardiac gated computed tomography clearly visualized the defect and its surrounding structures. This case highlights the utility of cardiac gated computed tomography for cases of suspected valvular perforation when echocardiography is not readily available or inadequate imaging is obtained.
Love, Kathleen; Ramirez, Alfredo; Boswell, Gilbert; Nayak, Keshav
There are numerous types of bicuspid aortic valve (BAV) configurations. Recent findings suggest that various BAV types represent different pathophysiological substrates on the aortic media level. Data imply that the BAV type is probably not related to location and extent of the aneurysm. However, BAV type is likely linked to the severity of aortic media disease. Some BAVs with raphe seem more aggressive than BAV without a raphe. Cusp fusion pattern, altered hemodynamics, and the qualitative severity of the disease in the aortic media might on the one hand share the same substrate. On the other hand, the aortopathy's longitudinal extent and location may represent a different pathophysiological substrate, probably dictated by the heritable aspects of BAV disease. The exact nature of the relation between BAV type and the aneurysm's location and extent as well as to the risk of aortic complications remains unclear. This paper reviews results of recent human and experimental studies on the significance of BAV types for local aortic media disease and location and extent of the aortopathy. We describe the known and hypothesized hemodynamic and hereditary factors that may result in aortic aneurysm formation in BAV patients.
Kari, F. A.; Beyersdorf, F.; Siepe, M.
We present the unusual case of a "disappearing" aortic valve in an infant with hypoplastic left heart syndrome (mitral and aortic stenosis) that underwent Norwood palliation at birth and subsequently a Glenn operation. Angiographic images at the time of operation showed no apparent insufficiency of the native aortic valve. Over the course of 14 months following operation, the patient developed significant cardiomegaly with a workup revealing severe native aortic valve insufficiency. Following orthotopic heart transplantation, examination of the explanted heart revealed a complete absence of native aortic valve leaflets. PMID:24668988
Loftus, Patrick D; Erickson, Lance K; Everitt, Melanie D; Kaza, Aditya K
We prospectively evaluated the hemodynamic performance of the SORIN Freedom SOLO aortic bioprosthesis, a stentless bovine pericardial valve designed for supra-annular implantation. Forty patients (mean age, 71.68 ± 5.25 yr; 29 men) with severe aortic stenosis underwent aortic valve replacement from January 2008 through August 2009. Patients were evaluated by transthoracic echocardiography and clinical examination, both preoperatively and again at 6 and 24 postoperative months. Peak and mean transvalvular gradients, end-diastolic and end-systolic diameters, interventricular septal and posterior wall thicknesses, indexed volumes of ventricular mass, degrees of aortic regurgitation, and left ventricular ejection fractions were calculated echocardiographically. The valves were implanted with single polypropylene sutures. In the early postoperative period, 1 patient (2.5%) died of multiorgan failure. The mean aortic cross-clamp time was 86.05 ± 34.2 min. Echocardiographic peak gradients were 84.54 ± 16.85 mmHg (preoperative), 29.59 ± 6.27 mmHg (6 mo postoperative), and 24.33 ± 4.67 mmHg (24 mo postoperative) (P < 0.001); left ventricular mass indices were 176.26 ± 39.98 g/m(2) (preoperative), 139.21 ± 30.1 (6 mo postoperative), and 120.51 ± 23.88 g/m(2) (24 mo postoperative) (P < 0.001). During follow-up, the maximum aortic insufficiency recorded was trace, and no valve dysfunctions were observed. Temporary thrombocytopenia was documented in all patients during early postoperative follow-up (lowest level at day 3); recovery to preoperative levels occurred by day 10. The Freedom SOLO aortic bioprosthesis is an easy-to-implant valve with excellent hemodynamic performance. The thrombocytopenia appears to be a transient laboratory finding. PMID:23466929
Altintas, Garip; Diken, Adem Ilkay; Hanedan, Onur; Yurdakok, Okan; Ozyalcin, Sertan; Kucuker, Seref Alp; Ozatik, Mehmet Ali
We report the first documented case of endocarditis associated with Bartonella clarridgeiae in any species. B. clarridgeiae was identified as a possible etiological agent of human cat scratch disease. Infective vegetative valvular aortic endocarditis was diagnosed in a 2.5-year-old male neutered boxer. Historically, the dog had been diagnosed with a systolic murmur at 16 months of age and underwent balloon valvuloplasty for severe valvular aortic stenosis. Six months later, the dog was brought to a veterinary hospital with an acute third-degree atrioventricular block and was diagnosed with infective endocarditis. The dog died of cardiopulmonary arrest prior to pacemaker implantation. Necropsy confirmed severe aortic vegetative endocarditis. Blood culture grew a fastidious, gram-negative organism 8 days after being plated. Phenotypic and genotypic characterization of the isolate, including partial sequencing of the citrate synthase (gltA) and 16S rRNA genes indicated that this organism was B. clarridgeiae. DNA extraction from the deformed aortic valve and the healthy pulmonic valve revealed the presence of B. clarridgeiae DNA only from the diseased valve. No Borrelia burgdorferi or Ehrlichia sp. DNA could be identified. Using indirect immunofluorescence tests, the dog was seropositive for B. clarridgeiae and had antibodies against Ehrlichia phagocytophila but not against Ehrlichia canis, Ehrlichia ewingii, B. burgdorferi, or Coxiella burnetii.
Chomel, Bruno B.; Mac Donald, Kristin A.; Kasten, Rickie W.; Chang, Chao-Chin; Wey, Aaron C.; Foley, Janet E.; Thomas, William P.; Kittleson, Mark D.
The short-term surgical results for mixed aortic valve disease (MAVD) and the long-term effects on the left ventricle (LV) are unknown. Retrospective review identified patients with at least both moderate aortic stenosis (AS) and aortic regurgitation (AR) before surgical intervention. A one-to-one comparison cohort of patients with MAVD not referred for surgical intervention was identified. The 45 patients in this study underwent surgical management for MAVD. A control group of 45 medically managed patients with MAVD also was identified. Both groups had elevated LV end-diastolic volume (EDV), elevated LV mass, a normal LV mass:volume ratio (MVR), and a normal ejection fraction. Both groups had diastolic dysfunction shown by early diastolic pulsed-Doppler mitral inflow/early diastolic tissue Doppler velocity z-score. The LV end-diastolic pressure (EDP) was correlated with age (R = 0.4; p = 0.03) and LV MVR (R = 0.4; p = 0.03) but not with AS, AR, or the score combining gradient and LV size. As shown by 6- to 12-month postoperative echocardiograms, aortic valve gradients and AR significantly improved (gradient 65 ± 17 to 28 ± 18 mmHg, p = 0.01; median regurgitation grade moderate to mild; p < 0.01), LV EDV normalized, and LV mass significantly improved (p < 0.01). Diastolic dysfunction was unchanged. Symptoms did not correlate with any measured parameter, but the preoperative symptoms resolved. In conclusion, despite diastolic dysfunction, systolic function is invariably preserved, and symptoms are not correlated with aortic valve function or LV EDP. Current surgical practice preserves LV mechanics and results in short-term improvement in valve function and symptoms. PMID:24563072
Hill, Allison C; Brown, David W; Colan, Steven D; Gauvreau, Kimberly; Del Nido, Pedro J; Lock, James E; Rathod, Rahul H
Several retrospective and nonrandomized studies have indicated that lowering atherogenic lipoprotein, in particular low-density lipoprotein cholesterol, may retard the hemodynamic progression of aortic stenosis (AS). This valvular disease shares pathogenic and pathoanatomic similarities with atherosclerosis, at least in their early developments. Two randomized placebo-controlled studies researching the effect of lowering low-density lipoprotein on AS progression and its clinical consequences have been published recently-the Scottish Aortic Stenosis and Lipid Lowering Trial, Impact on Regression (SALTIRE) study and the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Both of these studies had neutral outcomes. The causes for the negative outcome may be that cholesterol lowering does not influence AS development in a clinically significant way or it may be due to traits in the design of the studies or treatments. Therefore, statin treatment for prevention of AS progression cannot be ruled out as a future therapeutic option in AS. The outcome of the ongoing Aortic Stenosis Progression Observation: Measuring Effects of Rosuvastatin (ASTRONOMER) study, which is examining lipid lowering as a treatment for AS, is greatly anticipated. PMID:19664382
Olsson, Anders G
Wall shear distributions during the cardiac cycle at the valve rings of Starr-Edwards, Björk-Shiley and Lillehei-Kaster aortic valves are measured and compared with thresholds reported for shear-induced trauma of blood components. Further, for the disk valves, the influence of pulse rate on wall shear stresses is evaluated. Hot film anemometry with flush-mounted wall shear probes is used as measurement technique in a pulsatile flow mock circuit. The experimental systolic data support the better hemodynamic characteristics of the disk valves over the ball valve also with respect to the threshold shear stresses of flow induced blood trauma. These results are confirmed by postoperative clinical studies, where lower LDH-values are found with the disk than with the ball valves. During diastole, however, high shear stresses are measured and calculated at the valve ring of the Björk-Shiley prosthesis, which can be referred to the non-overlapping closing mechanism. This result is discussed with respect to the often observed thrombus formation at the disk downstream of the smaller orifice of the Björk-Shiley valve. PMID:6736063
Tillmann, W; Reul, H; Herold, M; Bruss, K H; van Gilse, J
Transcatheter aortic valve replacement (TAVR) is a new therapy for severe aortic stenosis now available in the United States. Initial patients eligible for TAVR are defined by high operative risk, with advanced age and multiple comorbidities. Following TAVR, patients experience acute hemodynamic changes and several possible complications, including hypotension, vascular injury, anemia, stroke, new-onset atrial fibrillation, conduction disturbances and kidney injury, requiring an acute phase of intensive care. Alongside improvements in TAVR technology and technique, improvements in care after TAVR may contribute to improved outcomes. This review presents an approach to post-TAVR critical care and identifies directions for future research. PMID:24188224
Tomey, Matthew I; Gidwani, Umesh K; Sharma, Samin K
Iatrogenic aortic valve leaflet perforation and aorto-right atrial fistula are rare adverse events of transcatheter interventions and transseptal radiofrequency ablations, respectively. We present the case of a 62-year-old man who experienced acute, severe aortic insufficiency as a result of leaflet entrapment by a septal occluder device during attempted percutaneous closure of an iatrogenic aorto-right atrial fistula. This rare adverse event emphasizes the need for a thorough understanding of cardiac anatomy to minimize transcatheter adverse events and to recognize and treat them appropriately when they occur. PMID:24996746
Tuluca, Alexandra; Omer, Shuab; Cornwell, Lorraine; Blaustein, Alvin; Kar, Biswajit; Weldon, Scott; Bakaeen, Faisal G
Transcatheter aortic valve implantation (TAVI) is indicated for patients with severe aortic stenosis and high or prohibitive surgical risk. Patients' selection requires clinical and anatomical selection criteria, being the later determined by multimodality imaging evaluation. Echocardiography, multislice computed tomography (MSCT), angiography, and cardiovascular magnetic resonance (CMR) are the methods available to determine the anatomical suitability for the procedure. Imaging assists in the selection of bioprosthesis type, prosthetic sizing and in the decision of the best vascular access. In this review, we present our critical appraisal on the use of imaging to best patients' selection and procedure guidance in TAVI. PMID:24459198
Zamorano, José Luis; Gonçalves, Alexandra; Lang, Roberto
Transcatheter aortic valve replacement (TAVR) is a revolutionary therapy for patients with aortic stenosis. Large registries and randomized controlled trials have demonstrated that TAVR is safe and effective in patients considered inoperable because of severe comorbidities and those who are high-risk surgical candidates. As TAVR evolves for lower-risk patients, attention will need to focus on reducing the rates of vascular injury, stroke, and paravalvular regurgitation. In this review, we discuss the status of TAVR in clinical practice, including patient selection, preoperative evaluation, techniques, and complications. PMID:24331140
Desai, Chintan S; Roselli, Eric E; Svensson, Lars G; Bonow, Robert O
Transcatheter aortic valve replacement (TAVR) is now an accepted standard of care for patients with symptomatic severe aortic stenosis who are not candidates for surgery or have high surgical risk. Despite its more widespread adoption as a treatment option and increasing experience of centers, TAVR is still associated with several complications. We therefore report a case of TAVR complicated by acute pericardial tamponade, one of the most severe potential complications of this procedure. We describe the way we approached the problem and we try to give a potential take-home message for others who might encounter such a situation in their own cath lab.
Suwalski, Piotr; Pawlak, Agnieszka; Kulawik, Tomasz; Byczkowska, Katarzyna; Gil, Robert J.
Numerical analysis of the aortic valve has mainly been focused on the closing behaviour during the diastolic phase rather than the kinematic opening and closing behaviour during the systolic phase of the cardiac cycle. Moreover, the fluid–structure interaction in the aortic valve system is most frequently ignored in numerical modelling. The effect of this interaction on the valve's behaviour during
J. De Hart; G. W. M. Peters; P. J. G. Schreurs; F. P. T. Baaijens
OBJECTIVES The recent introduction of transcatheter aortic heart valves into clinical practice has driven the need to develop methodologies to size such valves without access to the annulus in the manner hitherto possible with open heart surgery. To date, sizing has largely been done according to manufacturer-supplied guidelines based on transoesophageal echocardiography or multidetector computed tomography. We sought to examine how the diameter of the aortic valve annulus stretches under typical pressures encountered in normal and diseased states. In particular, we sought to measure how the area-derived diameter, Dcsa, i.e. the diameter derived from a cross-sectional area, varies with distending pressure. METHODS We conducted testing on 14 explanted pig hearts. Placing each heart in a 37°C bath, an EndoFLIP EF-325 catheter (Crospon, Galway, Ireland) was introduced into the aortic valve transapically. The catheter allows intra-balloon pressure and up to 16 area-derived diameters to be measured simultaneously, thus permitting the shape of a lumen to be observed. By dividing the minimum area-derived diameter by distending pressure, a measure of distensibility (mm/mmHg) could be determined. Once the balloon was centred, balloon pressure was ramped between 100 and 200 mmHg, and the area-derived diameter was calculated at each pressure. RESULTS Between 100 and 200 mmHg, the mean (SD) increase in diameter was found to be 3.0 (1.5) mm. Distensibility in the different hearts ranged from 0 to 0.05 mm/mmHg. In some cases, the diameter change over the pressure range was negligible, whereas in one case, the diameter change over the range was 5 mm. Whereas different nominal values of diameter are to be expected, a significant variation in the degree of distensibility was observed. CONCLUSIONS Distensibility of the aortic valve annulus is highly variable. Measurement of this parameter in addition to nominal annulus diameter may suggest occasions where a larger transcatheter aortic-valve implantation valve than would be suggested by annulus diameter measurement alone, could be deployed safely with an objective of reducing regurgitation where the annulus is sufficiently distensible.
O'Dea, John; Nolan, David J.
OBJECTIVES The recent introduction of transcatheter aortic heart valves into clinical practice has driven the need to develop methodologies to size such valves without access to the annulus in the manner hitherto possible with open heart surgery. To date, sizing has largely been done according to manufacturer-supplied guidelines based on transoesophageal echocardiography or multidetector computed tomography. We sought to examine how the diameter of the aortic valve annulus stretches under typical pressures encountered in normal and diseased states. In particular, we sought to measure how the area-derived diameter, Dcsa, i.e. the diameter derived from a cross-sectional area, varies with distending pressure. METHODS We conducted testing on 14 explanted pig hearts. Placing each heart in a 37 °C bath, an EndoFLIP EF-325 catheter (Crospon, Galway, Ireland) was introduced into the aortic valve transapically. The catheter allows intra-balloon pressure and up to 16 area-derived diameters to be measured simultaneously, thus permitting the shape of a lumen to be observed. By dividing the minimum area-derived diameter by distending pressure, a measure of distensibility (mm/mmHg) could be determined. Once the balloon was centred, balloon pressure was ramped between 100 and 200 mmHg, and the area-derived diameter was calculated at each pressure. RESULTS Between 100 and 200 mmHg, the mean (SD) increase in diameter was found to be 3.0 (1.5) mm. Distensibility in the different hearts ranged from 0 to 0.05 mm/mmHg. In some cases, the diameter change over the pressure range was negligible, whereas in one case, the diameter change over the range was 5 mm. Whereas different nominal values of diameter are to be expected, a significant variation in the degree of distensibility was observed. CONCLUSIONS Distensibility of the aortic valve annulus is highly variable. Measurement of this parameter in addition to nominal annulus diameter may suggest occasions where a larger transcatheter aortic-valve implantation valve than would be suggested by annulus diameter measurement alone, could be deployed safely with an objective of reducing regurgitation where the annulus is sufficiently distensible. PMID:22695515
O'Dea, John; Nolan, David J
Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients. PMID:24681140
Nombela-Franco, Luis; Ribeiro, Henrique Barbosa; Urena, Marina; Allende, Ricardo; Amat-Santos, Ignacio; DeLarochellière, Robert; Dumont, Eric; Doyle, Daniel; DeLarochellière, Hugo; Laflamme, Jerôme; Laflamme, Louis; García, Eulogio; Macaya, Carlos; Jiménez-Quevedo, Pilar; Côté, Mélanie; Bergeron, Sebastien; Beaudoin, Jonathan; Pibarot, Philippe; Rodés-Cabau, Josep
Objective: This study evaluated the impact of patient–prosthesis mismatch on myocardial function and high-energy phosphate metabolism after aortic valve replacement for pure aortic stenosis. Patients with and without patient–prosthesis mismatch were compared using magnetic resonance techniques. Methods: Thirty patients who had undergone aortic valve replacement with Medtronic Mosaic bioprosthesis were evaluated. Fifteen patients with patient–prosthesis mismatch were compared to 15
Vito Mannacio; Luigi Di Tommaso; Paolo Stassano; Vincenzo De Amicis; Carlo Vosa
Cloth-covered Starr-Edwards caged ball valves implanted in the aortic and mitral valve positions for 39 years were extracted. Both showed valve dysfunction resulting from pannus overgrowth. The metal cages of the Starr-Edwards valves were covered with worn cloth. This case indicates the extended durability of Starr-Edwards valves and the importance of the design and materials of prosthetic heart valves to avoid pannus overgrowth and prosthetic valve abrasion. PMID:21674313
Misawa, Shun-ichi; Aizawa, Kei; Kaminishi, Yuichiro; Muraoka, Arata; Misawa, Yoshio
The following paper is on a 49-year-old man who presented to accident and emergency department having experienced five hours of left-sided chest pain, tightness in the chest, and shortness of breath. He also reported paresthesia and an ache in the left arm. Further investigations revealed an aortic valve papillary fibroelastoma. Although histologically papillary fibroelastomas are described as benign, they carry with them considerable risk of morbidity and mortality. This patient experienced recurrent transient ischemic attacks (TIAs'). He was taken to theatre on urgent basis to remove the papillary fibroelastoma. His aortic valve was preserved during the operation. The patient had an uneventful recovery following the surgery. His neurologic symptoms resolved following the operation. The operation was curative and no further symptoms were reported at followup.
Gowland, Penelope-Anne; Hasan, Ragheb
A variety of minimally-invasive approaches for aortic valve replacement (AVR) have been developed and are increasingly being utilized. The different approaches described, such as partial upper sternotomy, right parasternal thoracotomy or transverse sternotomy have the aim to decrease invasiveness and reduce surgical trauma. Whereas port access surgery with remote cannulation has the attendant risks inherent with peripheral cardiopulmonary bypass and limitations in terms of myocardial protection and adequate cardiac dearing, partial sternotomies or thoracotomies may be associated with suboptimal chest wall reconstruction. Here described is a technique of minimal-access aortic valve replacement, which entails limited skin incision and full median sternotomy. Advantages of the present approach include a superior cosmetic result, when compared to standard sternotomy incision, and the safety of the midline access, which may be immediately converted into standard approach, in case of need, and is associated with stable chest wall reconstruction. Selective indications and outcome of minimal-access AVR are discussed.
Background Transcatheter aortic valve implantation (TAVI) through a transapical approach (TAAVI) for severe aortic stenosis becomes the procedure of choice in cases where patients have peripheral artery disease and unfeasible access due to excessive atherosclerotic disease of the iliofemoral vessels and aorta. The present systematic review aimed to assess the safety, success rate, clinical outcomes, hemodynamic outcomes, and survival benefits of TAAVI. Methods Electronic searches were performed in 6 databases from January 2000 to February 2012. The primary end points included feasibility and safety. Other end points included echocardiographic findings, functional class improvement, and survival. Results After applying the inclusion and exclusion criteria, 48 out of 154 shortlisted potentially relevant articles were selected for assessment. Of these, 26 studies from 24 centers including total number of 2,807 patients were included for appraisal and data extraction. The current evidence on TAAVI for aortic stenosis is limited to observational studies. Successful TAAVI implantation occurred in >90% of patients. On average, the procedure took between 64 to 154 minutes to complete. The incidence of major adverse events included 30-day mortality (4.7-20.8%); cerebrovascular accident (0-16.3%); major tachyarrhythmia (0-48.8%); bradyarrhythmia requiring permanent pacemaker insertion (0-18.7%); cardiac tamponade (0-11%); major bleeding (1-17%); myocardial infarction (0-6%); aortic dissection/rupture (0-5%); moderate to severe paravalvular leak (0.7-24%); cardiopulmonary bypass support (0-15%); conversion to surgery (0-9.5%); and valve-in-valve implantation (0.6-8%). Mean aortic valve area improved from 0.4-0.7 cm2 before TAAVI to 1.4-2.1 cm2 after TAAVI. The peak pressure gradient across the aortic valve decreased from >70 mmHg to <20 mmHg after TAAVI. One-year survival ranged from 49.3% to 82% and the 3-year survival was 58% in 2 series. Conclusions TAAVI appears to be feasible with a reasonable safety and efficacy portfolio. Randomised controlled trials are required to compare transapical vs. transfemoral TAVI when both techniques are equally feasible.
Rahnavardi, Mohammad; Santibanez, Jaime; Sian, Karan
We report a case of a 54-year-old patient who was denied surgical replacement for severe aortic stenosis because of complicated acquired immunodeficiency syndrome and who successfully underwent transcatheter aortic valve implantation at our institution. PMID:24749120
Salizzoni, Stefano; D'Ascenzo, Fabrizio; Moretti, Claudio; Bonora, Stefano; Calcagno, Andrea; Omedè, Pierluigi; Montrucchio, Chiara; Cerrato, Enrico; Colaci, Chiara; Sheiban, Imad; Marra, Sebastiano; Rinaldi, Mauro; Gaita, Fiorenzo
We report a case of a 54-year-old patient who was denied surgical replacement for severe aortic stenosis because of complicated acquired immunodeficiency syndrome and who successfully underwent transcatheter aortic valve implantation at our institution.
Salizzoni, Stefano; D'Ascenzo, Fabrizio; Moretti, Claudio; Bonora, Stefano; Calcagno, Andrea; Omede, Pierluigi; Montrucchio, Chiara; Cerrato, Enrico; Colaci, Chiara; Sheiban, Imad; Marra, Sebastiano; Rinaldi, Mauro; Gaita, Fiorenzo
Balloon predilatation has been regarded as an essential step before implanting the self-expandable prosthesis during transcatheter aortic valve implantation (TAVI). Recent evidence showed that without balloon predilatation, an implantation success rate of >95% could be achieved. We report two cases in which balloon predilatation was not performed initially during TAVI but eventually required it to facilitate device crossing and implantation. They illustrated the importance of case selection and alerted us the potential limitation in performing TAVI without balloon predilatation. PMID:22517798
Chan, Pak Hei; Mario, Carlo Di; Moat, Neil
Objectives To retrospectively analyze the clinical outcome of a totally biological composite stentless aortic valved conduit (No-React® BioConduit) implanted using the Bentall procedure over ten years in a single centre. Methods Between 27/10/99 and 19/01/08, the No-React® BioConduit composite graft was implanted in 67 patients. Data on these patients were collected from the in-hospital database, from patient notes and from questionnaires. A cohort of patients had 2D-echocardiogram with an average of 4.3 ± 0.45 years post-operatively to evaluate valve function, calcification, and the diameter of the conduit. Results Implantation in 67 patients represented a follow-up of 371.3 patient-year. Males were 60% of the operated population, with a mean age of 67.9 ± 1.3 years (range 34.1-83.8 years), 21 of them below the age of 65. After a mean follow-up of 7.1 ± 0.3 years (range of 2.2-10.5 years), more than 50% of the survivors were in NYHA I/II and more than 60% of the survivors were angina-free (CCS 0). The overall 10-year survival following replacement of the aortic valve and root was 51%. During this period, 88% of patients were free from valved-conduit related complications leading to mortality. Post-operative echocardiography studies showed no evidence of stenosis, dilatation, calcification or thrombosis. Importantly, during the 10-year follow-up period no failures of the valved conduit were reported, suggesting that the tissue of the conduit does not structurally change (histology of one explant showed normal cusp and conduit). Conclusions The No-React® BioConduit composite stentless aortic valved conduit provides excellent long-term clinical results for aortic root replacement with few prosthesis-related complications in the first post-operative decade.
There has been growing interest in the mechanobiological function of the aortic valve interstitial cell (AVIC) due to its role in valve tissue homeostasis and remodeling. In a recent study we determined the relation between diastolic loading of the aortic valve (AV) leaflet and the resulting AVIC deformation, which was found to be substantial. However, due to the rapid loading time of the AV leaflets during closure ( approximately 0.05 s), time-dependent effects may play a role in AVIC deformation during physiological function. In the present study, we explored AVIC viscoelastic behavior using the micropipette aspiration technique. We then modeled the resulting time-length data over the 100 s test period using a standard linear solid model, which included Boltzmann superposition. To quantify the degree of creep and stress relaxation during physiological time scales, simulations of micropipette aspiration were preformed with a valve loading time of 0.05 s and a full valve closure time of 0.3 s. The 0.05 s loading simulations suggest that, during valve closure, AVICs act elastically. During diastole, simulations revealed creep (4.65%) and stress relaxation (4.39%) over the 0.3 s physiological time scale. Simulations also indicated that if Boltzmann superposition was not used in parameter estimation, as in much of the micropipette literature, creep and stress relaxation predicted values were nearly doubled (7.92% and 7.35%, respectively). We conclude that while AVIC viscoelastic effects are negligible during valve closure, they likely contribute to the deformation time-history of AVIC deformation during diastole. PMID:19275434
Merryman, W David; Bieniek, Paul D; Guilak, Farshid; Sacks, Michael S
Degenerative aortic stenosis (AS) is the most frequent type of valvular heart disease. In patients with symptomatic AS surgical aortic valve replacement (SAVR) is a recommended treatment strategy. Due to a high risk of perioperative mortality, up to 30% of patients with AS are considered not suitable for SAVR. In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery. In the two randomized trials published so far and numerous registries, stroke and transient ischemic attack still remain serious periprocedural complications after TAVI. Because the majority of these episodes are driven by microembolization during the procedure, different neuroprotection devices were developed and clinically tested. Embrella and SMT are deflector devices, using a microporous membrane mounted on a nitinol frame, designed to cover the ostia of the brachiocephalic trunk and the left carotid artery. The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery. Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR. However, to date the efficacy of the neuroprotection systems has not been assessed in randomized trials. Before we know the results of such trials, the use of the devices should be limited to patients at high risk of neurological complications, such as patients with previous stroke, massive calcification on aortic leaflets, annulus and porcelain aorta.
We prospectively evaluated 46 patients who underwent aortic valve repair (AVR) for AV regurgitation. Rest/stress echocardiography follow-up was performed. Follow-up duration was 30.7 months, age 56 ± 14 years, ejection fraction% 57.5 ± 10.5%. Preoperative bicuspid AV was present in 14 (30.4%), leaflets calcifications in 8 (17.4%), thickening in 17 (37.0%) and prolapse in 22 (47.8%). Surgical technique included commissuroplasty (22, 47.8%), leaflet remodelling (17, 37.0%), decalcification (7, 15.2%) and raphe removal (14, 30.4%). At follow-up, rest/stress echocardiography median AV regurgitation (rest 1.0 vs. stress 1.0) and mean indexed AV area (IAVA) (rest 2.6 ± 0.74 cm2/m2 vs. stress 2.8 ± 0.4 cm2/m2) were unchanged (P = ns). Mean (rest 4.7 ± 3.9 mmHg vs. stress 9.7 ± 5.8 mmHg) and peak (rest 9.5 ± 7.2 mmHg vs. stress 19.0 ± 10.5 mmHg) transvalvular gradients were significantly increased (P < 0.0001). At linear regression, there was an independent inverse correlation between commissuroplasty and AV gradients during stress (B = ?9.9, P = 0.01, confidence interval= ?17.7 to ?2.1). Although follow-up haemodynamics of repaired AVs are satisfactory, there was a fixed IAVA and significant increase in AV gradients. We were not able to identify any pre-existing anatomical condition independently related to this non-physiological behaviour under stress. Moreover, commissuroplasty seems to prevent abnormal increase of the AV gradients.
D'Ancona, Giuseppe; Amaducci, Andrea; Prodromo, John; Pirone, Francesco; Follis, Marco; Falletta, Calogero; Pilato, Michele
Transcatheter aortic valve replacement (TAVR) is currently a therapeutic alternative to open aortic valve replacement for high-risk patients with severe symptomatic aortic valve stenosis. The procedure is associated with some life-threatening complications including circulatory collapse which may require temporary hemodynamic support. We describe our experience with the use of the Impella 2.5 system to provide emergent left ventricular support in cases of hemodynamic collapse after TAVR with the Edwards SAPIEN prosthesis. PMID:22888042
Martinez, Claudia A; Singh, Vikas; Heldman, Alan W; O'Neill, William W
The aortic valve is highly responsive to cyclical and continuous mechanical forces, at the macroscopic and cellular levels. In this report, we delineate mechanokinetics (effects of mechanical inputs on the cells) and mechanodynamics (effects of cells and pathologic processes on the mechanics) of the aortic valve, with a particular focus on how mechanical inputs synergize with the inflammatory cytokine and other biomolecular signaling to contribute to the process of aortic valve calcification.
Merryman, W. David; Schoen, Frederick J.
The mitro-aortic disease in high-risk patients is a challenge for the cardiac surgeon because minimally invasive techniques are difficult to apply. We report the first case in the literature of a 78-year-old woman affected by severe rheumatic steno-insufficiency of aortic and mitral valves at high surgical risk. The patient was successfully treated by mitral valve replacement with a biological prosthesis and concomitant aortic valve replacement with a sutureless prosthesis. PMID:24625854
Pollari, Francesco; Santarpino, Giuseppe; Pfeiffer, Steffen; Fischlein, Theodor
In transcatheter aortic valve implantation procedures using balloon-expandable valves, the valve is deployed by rapid balloon inflation within a short period of rapid ventricular pacing. This system and deployment technique is generally considered to be nonrepositionable. We illustrate with two cases (transapical and transfemoral) the possibility to partially reposition the valve during its deployment if a slow balloon inflation technique were employed-a technique that may minimize the risk of valve mal-positioning and its attendant complications. PMID:22757754
Mok, Michael; Dumont, Eric; Doyle, Daniel; Rodés-Cabau, Josep
From August 1971 through November 1972, we implanted 62 Model 2 DeBakey-Surgitool aortic valve prostheses in 62 patients, 4 of whom later had clinically asymptomatic strut fractures. In 1 case, the patient died suddenly, and autopsy revealed detachment of the ball-cage; in each of the other 3 cases, fractures of 2 struts close to the base of the prosthesis were diagnosed fluoroscopically, and the patients underwent successful reoperation. The interval between implantation and reoperation ranged from 11 months to 16 years, 9 months. In 1 patient, retrospective study of chest radiographs revealed that the fracture had been present for 2½ years. Larger valves (? A6) were affected significantly more often than smaller ones. We performed metallurgic analysis of 1 prosthesis: results revealed strut wear from fatigue cracking and secondary abrasion. Strut fracture was also promoted by suspension of the cage at right angles to the prosthetic ring and by use of a pyrolytic carbon ball in a titanium cage (i.e., an occluder harder than its holder). Patients with DeBakey-Surgitool aortic valve prostheses should undergo annual radiologic examinations to enable early detection of strut fractures. Prophylactic valve replacement is not indicated. (Texas Heart Institute Journal 1990;17:223-7) Images
Von Der Emde, Jurgen; Eberlein, Ulrich; Breme, Jurgen
BackgroundThe Medtronic Mosaic bioprosthesis (MMB) is a porcine valve of third generation. The purpose of this study was to evaluate the long-term clinical performance of MMB after aortic valve replacement (AVR).
Michele Celiento; Giacomo Ravenni; Aldo D. Milano; Stefano Pratali; Giovanni Scioti; Carmela Nardi; Uberto Bortolotti
While aortic valve root compliance and leaflet coaptation have significant influence on valve closure, their implications have not yet been fully evaluated. The present study developed a full fluid-structure interaction (FSI) model that is able to cope with arbitrary coaptation between the leaflets of the aortic valve during the closing phase. Two simplifications were also evaluated for the simulation of the closing phase only. One employs an FSI model with a rigid root and the other uses a "dry" (without flow) model. Numerical tests were performed to verify the model. New metrics were defined to process the results in terms of leaflet coaptation area and contact pressure. The axial displacement of the leaflets, closure time and coaptation parameters were similar in the two FSI models, whereas the dry model, with imposed uniform load on the leaflets, produced larger coaptation area and contact pressure, larger axial displacement and faster closure time compared with the FSI model. The differences were up to 30% in the coaptation area, 55% in the contact pressure and 170% in the closure time. Consequently, an FSI model should be used to accurately resolve the kinematics of the aortic valve and leaflet coaptation details during the end-closing stage. PMID:22170305
Marom, Gil; Haj-Ali, Rami; Raanani, Ehud; Schäfers, Hans-Joachim; Rosenfeld, Moshe
Experimental results are presented on physiological pulsatile flow past caged ball and tilting disc aortic valve prostheses mounted in an axisymmetric chamber incorporated in a mock circulatory system. The measurements of velocity profiles and turbulent normal stresses during several times in a cardiac cycle were obtained using laser-Doppler anemometry. Our results show that with increased angle of opening for the tilting disc valves, a large but locally confined vortex is observed along the wall in the minor flow region throughout most of the cardiac cycle. The turbulent normal stresses measured downstream to the tilting disc in the minor flow region parallel to the tilt axis were found to be larger than those measured downstream to the caged ball valves. Comparison of measurements with steady flow at flow rates comparable to peak pulsatile flow rate show that the turbulent normal stresses are larger by a factor of two in pulsatile flow with a frequency of 1.2 Hz. PMID:6643525
Chandran, K B; Cabell, G N; Khalighi, B; Chen, C J
Background The purpose of this study is to examine our experience with aortic root replacement using composite valve grafts in patients\\u000a with proximal aortic disease.\\u000a \\u000a \\u000a \\u000a Methods and Results Since 1986, 16 patients underwent aortic root replacement using composite valve grafts for various indications which were\\u000a Marfan's syndrome with annuloaortic ectasia (n=2), aortic regurgitation with ascending aortic aneurysm (n=3), aortic stenosis\\u000a with regurgitation
Muthialu Nagarajan; Shashi Kumar Varma; Sundar Ramanathan; Padmanabhan Chandrasekar; Kolli Madhusudana Rao; Srinivasan Muralidharan
We present a 55-year-old female patient who underwent burr-hole drainage due to chronic subdural hematoma, with obstructive prosthetic aortic valve dysfunction. Anesthetic management of a patient with severe obstructive prosthetic aortic valve dysfunction can be challenging. Similar considerations should be given to patients with aortic stenosis with an additional emphasis on thrombotic complication due to discontinuation of anticoagulation, which may further jeopardize the valve dysfunction. This case emphasizes the importance of a comprehensive understanding of the etiology and hemodynamic consequences of obstructive prosthetic valve dysfunction and the adequacy of anticoagulation for patients undergoing noncardiac surgery even after a successful valve replacement.
Lee, Bo Ra; Lee, Jeong-Rim
Background Ascending aortic dilation is important in bicuspid aortic valve disease (BAV), with increased risk of aortic dissection. We used cardiovascular magnetic resonance (CMR) to understand the pathophysiology better by examining the links between 3-dimensional flow abnormalities, aortic function and aortic dilation. Methods and Results 142 subjects underwent CMR (mean age 40 years; 95 with BAV, 47 healthy volunteers [HV]). BAV patients had predominantly abnormal right-handed helical flow in the ascending aorta, larger ascending aortas (18.3 ±3.3 vs. 15.2 ±2.2mm/m2, p<0.001), and higher rotational (helical) flow (31.7 ±15.8 vs. 2.9 ±3.9mm2/s, p<0.001), systolic flow angle (23.1 ±12.5 vs. 7.0 ±4.6°, p<0.001) and systolic wall shear stress (WSS) (0.85 ±0.28 vs. 0.59 ±0.17N/m2, p<0.001) compared to HV. BAV with right-handed flow and right-non coronary cusp fusion (n= 31) showed more severe flow abnormalities (rotational flow 38.5 ±16.5 vs. 27.8 ±12.4mm2/s, p<0.001; systolic flow angle 29.4 ±10.9 vs. 19.4 ±11.4°, p<0.001; in-plane WSS 0.64 ±0.23 vs. 0.47 ±0.22N/m2, p<0.001) and larger aortas (19.5 ±3.4 vs. 17.5 ±3.1mm/m2, p<0.05) than right-left cusp fusion (n=55). BAV patients with normal flow patterns had similar aortic dimensions and WSS to HV and younger BAV patients showed abnormal flow patterns but no aortic dilation, both further supporting the importance of flow pattern in the etiology of aortic dilation. Aortic function measures (distensibility, aortic strain and pulse wave velocity) were similar across all groups. Conclusions Flow abnormalities may be a major contributor to aortic dilation in BAV. Fusion type affects the severity of flow abnormalities, and may allow better risk prediction and selection of patients for earlier surgical intervention.
Bissell, Malenka M.; Hess, Aaron T.; Biasiolli, Luca; Glaze, Steffan J.; Loudon, Margaret; Pitcher, Alex; Davis, Anne; Prendergast, Bernard; Markl, Michael; Barker, Alex J.; Neubauer, Stefan; Myerson, Saul G
Intraoperative epicardial echocardiography and color flow Doppler were performed before and after cardiopulmonary bypass in 17 consecutive patients undergoing 20 freehand allograft aortic valve replacements. Native aortic valves were replaced in 12, and prostheses in 8 patients. Precardiopulmonary bypass echocardiography estimates of annular diameter guided allograft selection and predicted length of allograft aortic root required, defined coronary situs, and revealed other cardiac abnormalities. These included unanticipated severe mitral regurgitation (which precluded allograft aortic valve replacements in one patient), left-to-right shunts in the membranous septum, ascending aortic dissection, and aortic root pathology requiring coronary reimplantation or bypass. Postcardiopulmonary bypass echocardiography demonstrated acceptable competency of 18/19 allograft valves (mild or no aortic insufficiency), and successful repair of 3/4 shunts. Mild mitral regurgitation was detected more often at postcardiopulmonary bypass than precardiopulmonary bypass (15 vs 11 cases) and postcardiopulmonary bypass estimates of mitral regurgitation severity corollated well with subsequent postoperative follow-up. IOE allows selection and thawing of the allograft valves prior to aortic cross clamping, minimizing cross-clamp time. It detects important concomitant cardiac abnormalities, and predicts postoperative allograft valve and mitral competency. Intraoperative echocardiography Doppler, is therefore, a useful adjunct for allograft aortic valve replacements or aortic root replacement. PMID:10149225
Bolger, A F; Bartzokis, T; Miller, D C
Objective: Current prosthetic heart valves necessitate permanent anticoagulation or have limited durability and impaired hemodynamic performance compared to natural valves. Recently a polymeric valve prostheses with special design for mitral position demonstrated excellent in vitro and in vivo results with improved durability and no need for permanent anticoagulation. In this study, a respective flexible polymeric aortic valve is presented and
Sabine H Daebritz; Bernd Fausten; Benita Hermanns; Joerg Schroeder; Jan Groetzner; Ruediger Autschbach; Bruno J Messmer; Jörg S Sachweh
Objective: Current prosthetic heart valves necessitate permanent anticoagulation or have limited durability and impaired hemodynamic performance compared to natural valves. Recently a polymeric valve prostheses with special design for mitral position demonstrated excellent in vitro and in vivo results with improved durability and no need for permanent anticoagulation. In this study, a respective flexible polymeric aortic valve is presented and
Sabine H. Daebritz; Bernd Fausten; Bruno J. Messmer
Having passed the 30th anniversary of the first implantation of a Björk-Shiley convexo-concave tilting mechanical valve, recognition of the life-threatening complication of strut fracture is not widespread. The authors report the case of a 48-year-old man with acute-onset chest pain and dyspnea found to have strut fracture and disk embolization of a 26-year-old Björk-Shiley prosthetic aortic valve. The value of echocardiography in the diagnosis of this condition is discussed. PMID:20708374
Grande, Robert D; Katz, William E
From 1965 through 1986, 817 patients underwent aortic valve replacement at our institution. Six hundred forty-five patients received Starr-Edwards ball valves, including 286 Silastic ball valves (Models 1200/1260), 165 cloth-covered caged-ball prostheses (Models 2300/2310/2320), and 194 track-valve prostheses (Model 2400). In contrast, 172 patients received disc-valve prostheses, including 126 St. Jude Medical aortic bi-leaflet disc valves, 32 Lillehei-Kaster pivoting disc valves, and 14 Björk-Shiley valves (6 convexoconcave and 8 monostrut). With respect to preoperative data, the 2 groups were comparable, with the following differences. The Starr-Edwards group included 1) more men (77% versus 51%; p < 0.0001); 2) a significantly older patient population (59 ± 10 years versus 56 ± 15 years; p < 0.0001); 3) more patients in New York Heart Association functional class III or IV (72% versus 65%; p < 0.01); 4) fewer patients with angina pectoris as a limiting symptom (20% versus 36%; p < 0.0001); and 5) patients who tended to receive larger prostheses (26 ± 2 mm versus 23 ± 3 mm, p < 0.0001). The overall 10-year survival rate ± standard error was 59% ± 2% for patients receiving Starr-Edwards valves and 63% ± 6% for those with disc valves. The linearized complication rates (expressed as percentage per patient-year ± standard error) for the Starr-Edwards and disc-valve groups, respectively, were 2.0% ± 0.2% and 1.4% ± 0.5% for thromboembolism, 2.1% ± 0.2% and 3.9% ± 0.8% for Coumadin-related hemorrhage, 0.5% ± 0.1% and 0.3% ± 0.2% for endocarditis, 0.3% ± 0.1% and 0.7% ± 0.3% for other prosthesis-related complications, and 4.8% ± 0.1% and 6.4% ± 1.0% for all complications together. There were no instances of thrombotic occlusion or mechanical failure. After the 6th postoperative year, no thromboembolic events were encountered in patients with a Silastic ball valve; the 15-year freedom from thromboembolic events was 89%. Cox regression analysis showed that 1) a prosthetic orifice diameter of 15 mm or less was associated with an increased mortality; 2) disc valves entailed an increased rate of hemorrhage and prosthesis-related complications considered as a whole; 3) and Lillehei-Kaster valves led to an increased rate of prosthesis-related complications other than thromboembolism, hemorrhage, and endocarditis. Neither the type of prosthesis nor the size influenced the rate of thromboembolism, endocarditis, or prosthesis replacement. Because of their proven durability and relatively low price, we advocate the continued use of Starr-Edwards Model 1260 Silastic ball valves that have an orifice diameter of 16 mm or more. (Texas Heart Institute Journal 1991;18:24-33)
Pilegaard, Hans K.; Lund, Ole; Nielsen, Torsten T.; Magnussen, Karin; Knudsen, Mary A.; Albrechtsen, Ole K.
We presented an unique case of portal vein thrombosis (PVT) after aortic valve replacement due to antithrombin III (ATIII) deficiency. PVT after aortic valve replacement (AVR) is a serious complication, which has not previously been reported.
Recent studies indicate a role of atherosclerosis-like changes involved in the pathogenesis of aortic valve stenosis. Interestingly, one of the major advanced glycation end products (AGEs), N(omega)-(carboxymethyl)lysine (CML) has been related to the process of atherosclerosis in blood vessels. In the present study, we have analyzed the presence of CML in degenerative altered aortic valves with atherosclerosis-like changes, and in degenerated mitral valves without atherosclerosis-like changes, derived from patients suffering from acute rheumatism during childhood. Degenerated and non-degenerated valves were derived from autopsy or obtained during cardiac surgery. The presence of CML was examined by immunohistochemistry. CML was found on the endothelium and fibroblasts in control aortic and mitral valves. Minor differences in CML staining were observed between control and degeneratively affected mitral valves. In contrast, in degenerated aortic valves, CML accumulation was found in macrophages and on calcification sites, comparable to that in atherosclerotic arteries, while the presence of CML staining on the endothelium and fibroblasts was significantly less as compared with control aortic valves. Our data support the hypothesis that the process of degeneration of aortic valves resembles that of atherosclerosis in blood vessels. They suggest that CML also plays a role in the process of atherosclerosis in aortic valves. PMID:15136058
Baidoshvili, Alexi; Niessen, Hans W M; Stooker, Wim; Huybregts, Rien A J M; Hack, C Erik; Rauwerda, Jan A; Meijer, Chris J L M; Eijsman, Leon; van Hinsbergh, Victor W M; Schalkwijk, Casper G
Understanding the mechanics of the aortic valve has been a focus of attention for many years in the biomechanics literature, with the aim of improving the longevity of prosthetic replacements. Finite element models have been extensively used to investigate stresses and deformations in the valve in considerable detail. However, the effect of uncertainties in loading, material properties and model dimensions has remained uninvestigated. This paper presents a formal statistical consideration of a selected set of uncertainties on a fluid-driven finite element model of the aortic valve and examines the magnitudes of the resulting output uncertainties. Furthermore, the importance of each parameter is investigated by means of a global sensitivity analysis. To reduce computational cost, a Bayesian emulator-based approach is adopted whereby a Gaussian process is fitted to a small set of training data and then used to infer detailed sensitivity analysis information. From the set of uncertain parameters considered, it was found that output standard deviations were as high as 44% of the mean. It was also found that the material properties of the sinus and aorta were considerably more important in determining leaflet stress than the material properties of the leaflets themselves. PMID:21481873
Becker, W; Rowson, J; Oakley, J E; Yoxall, A; Manson, G; Worden, K
Aims: To describe a technique of simultaneous aortography and balloon aortic valvuloplasty (BAV) before transcatheter aortic valve replacement (TAVR), and to show how this technique affected TAVR prosthesis selection and procedural outcomes. Methods and results: One hundred and eleven patients underwent simultaneous contrast injection during valvuloplasty pre-TAVR to confirm the indication for prosthesis size provided by non-invasive imaging studies. A successful injection was achieved in 95 patients (85.5%). No events occurred during simultaneous BAV and contrast injection. In 12 (10.8%) patients the prosthesis size implanted was different from the recommendations provided by the non-invasive imaging examinations. In nine of these cases (75.0%) it was decided to implant a larger prosthesis than that originally suggested, in the remaining three cases (25.0%) a smaller valve was implanted. Device success in this particular subset of patients was 100%. Overall device success was 92.8%. Post-procedural moderate paravalvular regurgitation was reported in 5.4% of patients. Conclusions: In patients with severe aortic valve stenosis, a technique of simultaneous aortography and balloon valvuloplasty as an adjunct to non-invasive imaging modalities for transcatheter prosthesis selection is feasible, and leads to a change in TAVR strategy in a modest number of patients. Larger studies are necessary to confirm these findings, and to assess whether this method is capable of enhancing the safety of the TAVR procedure. PMID:24334876
Barbanti, Marco; Sgroi, Carmelo; Immè, Sebastiano; Aruta, Patrizia; Deste, Wanda; Gulino, Simona; Cannata, Stefano; Giarratana, Alessandra; Bottari, Vera; Giannazzo, Daniela; Garretto, Valeria; Patanè, Martina; Benvenuto, Emanuele; Capodanno, Davide; Tamburino, Corrado
Computational fluid dynamics (CFD) simulations quantifying thoracic aortic flow patterns have not included disturbances from the aortic valve (AoV). 80% of patients with aortic coarctation (CoA) have a bicuspid aortic valve (BAV) which may cause adverse flow patterns contributing to morbidity. Our objectives were to develop a method to account for the AoV in CFD simulations, and quantify its impact on local hemodynamics. The method developed facilitates segmentation of the AoV, spatiotemporal interpolation of segments, and anatomic positioning of segments at the CFD model inlet. The AoV was included in CFD model examples of a normal (tricuspid AoV) and a post-surgical CoA patient (BAV). Velocity, turbulent kinetic energy (TKE), time-averaged wall shear stress (TAWSS), and oscillatory shear index (OSI) results were compared to equivalent simulations using a plug inlet profile. The plug inlet greatly underestimated TKE for both examples. TAWSS differences extended throughout the thoracic aorta for the CoA BAV, but were limited to the arch for the normal example. OSI differences existed mainly in the ascending aorta for both cases. The impact of AoV can now be included with CFD simulations to identify regions of deleterious hemodynamics thereby advancing simulations of the thoracic aorta one step closer to reality.
Wendell, David C.; Samyn, Margaret M.; Cava, Joseph R.; Ellwein, Laura M.; Krolikowski, Mary M.; Gandy, Kimberly L.; Pelech, Andrew N.; Shadden, Shawn C.; LaDisa, John F.
Stenosis of systemic semilunar valve in cyanotic congenital heart defects is rare. It can happen in truncus arteriosus with truncal valve stenosis and the very rare anomaly of tetralogy of fallot with aortic valve stenosis. Here we describe a neonate with pulmonary atresia, ventricular septal defect and associated aortic valve stenosis and discuss the points of differentiation from truncus arteriosus.
Kumar, Saktheeswaran Mahesh; Bijulal, Sasidharan; Sivasankaran, Sivasubramonian
Objectives Bicuspid aortic valve is the most common congenital cardiac abnormality, occurring in 1% to 2% of the population, and often associates with ascending aortic aneurysm. Based on familial studies, bicuspid aortic valve with aneurysm segregates in an autosomal dominant manner with incomplete penetrance. NOTCH1 mutations have been reported in 6 families with prominent valve calcification and dysfunction and low penetrance of aneurysm. We sought to determine the contribution of NOTCH1 mutations to the more common phenotype of highly penetrant aneurysms with low penetrance of bicuspid aortic valve and with rare valve calcification or dysfunction. Methods All exons and splice junctions of NOTCH1 were sequenced in probands from 13 affected families presenting with bicuspid aortic valve with ascending aortic aneurysm in the absence of valve calcification. In addition, mutation analysis was performed on a single individual with aneurysm and calcified tricuspid aortic valve. Sequences were aligned and compared with the reference genomic sequence. Results Corroborating previous studies, analysis of the single sporadic patient with calcified aortic valve in the presence of ascending aortic aneurysm revealed a novel heterozygous missense mutation in NOTCH1 resulting in a nonsynonymous amino acid substitution (p.T1090S, c.C3269G) of an evolutionarily conserved residue. This change was not observed in controls. In contrast, we did not identify any pathologic NOTCH1 mutations in the 13 families segregating noncalcified bicuspid aortic valve with highly penetrant aortic aneurysm. Conclusions These data suggest that there are phenotypic differences that distinguish families with and without NOTCH1 mutations, indicating a genotype–phenotype correlation with potential implications for patient diagnosis, counseling, and management.
Kent, Kathleen C.; Crenshaw, Melissa L.; Goh, Denise L. M.; Dietz, Harry C.
Two groups of elderly patients with calcified aortic stenosis were treated by balloon dilatation. In group 1, the valve was dilated just before surgical replacement of the valve. The valvar and annular changes occurring during dilatation were examined visually. In 20 of the 26 patients in this group there was no change. In the six remaining patients mobilisation of friable calcific deposits (1 case), slight tearing of the commissure (4 cases), or tearing of the aortic ring (1 case) were seen. Dilatation did not appear to alter valvar rigidity. In 14 patients (group 2) the haemodynamic gradient across the aortic valve was measured before and immediately after dilatation and one week after the procedure. Dilatation produced an immediate significant decrease of the aortic mean gradient and a significant increase of the aortic valve area. Eight days later the mean gradient had increased and the aortic valve area had decreased. Nevertheless there was a significant difference between the initial gradient and the gradient eight days after dilatation. The initial aortic valve area was also significantly larger than the area eight days after dilatation. The aortic valve gradient rose significantly in the eight days after dilatation and at follow up the gradients were those of severe aortic stenosis. Images Fig 1 Fig 2 Fig 3 Fig 4 Fig 5 Fig 6 Fig 7
Commeau, P; Grollier, G; Lamy, E; Foucault, J P; Durand, C; Maffei, G; Maiza, D; Khayat, A; Potier, J C
A 90-year-old woman with symptomatic degenerative aortic stenosis had a logistic Euroscore greater than 53.29%, indicating a high surgical risk. She was therefore advised to undergo transcatheter aortic valve implantation. Both iliac arteries showed subocclusive calcifications, and the left subclavian artery was narrow and calcified. The left common carotid (LCC) artery was chosen as the access route. After surgical exposure of the LCC artery, the Corevalve Revalving 29-mm bioprosthesis was implanted successfully. No access-site complications occurred. In our experience, a substantial proportion of elderly patients have vascular lesions precluding use of the femoral route. Brachiocephalic access routes may be valuable when no other options are available. PMID:21735532
Mouillet, Gauthier; Desgranges, Pascal; Teiger, Emmanuel
Objective: In patients with aneurysm of the ascending aorta, dilatation of the sinotubular junction is the major cause of aortic valve regurgitation. Valve sparing aortic root replacement in patients without valvular structural defects offers a new form of treatment. The aim of this study was the assessment of the perioperative course and early complications of this method compared to composite
K. Kallenbach; K. Pethig; M. Schwarz; A. Milz; A. Haverich; W. Harringer
OBJECTIVE--To determine the incidence and prognosis of congenital aortic valve stenosis in the five Health Districts of Liverpool that make up the Merseyside area. DESIGN--The records of the Liverpool Congenital Malformations Registry and the Royal Liverpool Children's Hospital identified 239 patients (155 male, 84 female) born with aortic valve stenosis between 1960 and 1990. Patients were traced to assess the
D J Kitchiner; M Jackson; K Walsh; I Peart; R Arnold
This article puts forward a modified technique of Konno aortoventriculoplasty for repeat procedures. After incision of the ventricular septum, this approach involves aortic valve replacement using a mechanical valved conduit, reimplantation of the coronary arteries, and graft replacement of the ascending aorta. This modification allows the removal of the diseased ascending aortic wall caused by a previous patch enlargement or poststenotic dilation. PMID:24683179
Bobylev, Dmitry; Breymann, Thomas; Ono, Masamichi
We report a case of aortic valve replacement( AVR) for recurrent aortic stenosis(AS) after percutaneous transluminal balloon aortic valvuloplasty( PTAV) in a patient with left renal pelvis carcinoma. A 65-year-old female had been suffering from shortness of breath and syncope due to severe AS. She was considered to be a candidate for AVR. Preoperative examination revealed advanced left renal pelvis carcinoma that was a critical comorbidity for AVR. Ureteronephrectomy was also considered to be a contraindication. Despite conservative treatment, her condition was deteriorated. Emergency PTAV was performed when she was transferred to our hospital with circulatory shock. Her symptoms were ameliorated and left ureteronephrectomy was conducted 8 month after the PTAV. She was readmitted to our hospital 16 month after the PTAV and AVR was performed successfully.Antegrade transseptal PTAV is a very useful palliative therapy for AS with severe comorbidities as a bridge to surgery. PMID:24743477
Kobayashi, Kensuke; Suto, Yukio; Akashi, Okihiko; Sakata, Yoshihito; Hayama, Yasufumi
Background Transcatheter aortic valve implantation (TAVI) has been established as a treatment option for inoperable patients with symptomatic aortic valve stenosis. However, patients suffer frequently from conduction disturbances after TAVI. Methods Baseline, procedural as well as surface and intracardiac ECG parameters were evaluated for patients treated with TAVI and a comparison between patients requiring pacemaker with those not suffering from relevant conduction disorders were done. Results TAVI was successfully in all patients (n=45). Baseline surface and intracardiac ECG recording revealed longer PQ (197.1±51.2 msec versus 154.1±32.1 msec; p<0.001), longer AH (153.6±43.4 msec versus 116.1±31.2 msec; p<0.001) and HV interval (81.7±17.8 msec versus 56.8±8.5 msec; p<0.001) in patients with need for a pacemaker (n=23) versus control group (n=22); furthermore, 7-day follow-up analysis showed a higher prevalence of new left bundle branch block (LBBB) (87.0% versus 31.9%; p<0.001). Multivariate analysis revealed that only new LBBB, QRS duration >120 msec and a PQ interval >200 msec immediately (within 60 minutes) after implantation of the aortic valve were predictors for high-grade (type II second-degree and third-degree) AV block. Other clinical parameters as well as baseline electrocardiographic parameters had no impact on critical conduction delay. Conclusion Cardiac conduction disturbances are common after TAVI. The need for pacing after TAVI is predictable by surface ECG evaluation immediately (within 60 minutes) after the procedure.
Objective Irradiation of the chest or chest wall has been shown to caause calcific aortic stenosis. However, the mechanisms are unknown. Aortic valve interstitial cells (AVICs) have been implicated in the pathogenesis of aortic stenosis; they have been shown to change from the phenotype of a myofibroblast to an osteoblast-like cell. We therefore hypothesized that irradiation of human AVICs induces an osteogenic phenotype. In isolated human AVICs, our purpose was to determine the effect of irradiation on the production of osteogenic factors: (a) bone morphogenetic protein-2 (BMP-2) (b) osteopontin (OPN) (c) alkaline phosphatase (ALP), and (d) the transcription factor Runx2. Methods Human AVICs were isolated from normal aortic valves obtained from explanted hearts of patients undergoing cardiac transplantation (n=4) and grown in culture. The cells were grown to confluence, irradiated with 10 Gy using a cesium-137 irradiator and then lysed 24 hours following irradiation. Cell lysates were analyzed via immunoblot and densitometry for BMP-2, OPN, ALP and Runx2. Statistics were by ANOVA. P < 0.05 was significant. Results Irradiation induced an osteogenic phenotype in human AVICs. Irradiation induced a 2-fold increase in BMP-2, a 7-fold increase in OPN, a 3-fold increase in ALP, and a 2-fold increase in Runx2. Conclusions Radiation induces an osteogenic phenotype in human AVICs. The irradiated cells had significantly increased expression of the osteogenic factors BMP-2, OPN, ALP and Runx2. These data offer mechanistic insight into the pathogenesis of radiation-induced valvular heart disease.
Nadlonek, Nicole A; Weyant, Michael J; Yu, Jessica A; Cleveland, Joseph C; Reece, T Brett; Meng, Xianzhong; Fullerton, David A.
Mild to moderate neoaortic root dilatation late after arterial switch operation (ASO) is a well-documented morbidity, but rarely needs surgical replacement. Here, we report on a 22-year-old man, who developed marked dilatation of neoaortic root and needed an aortic root replacement with mechanical conduit. His aortic valve was bicuspid. Only three cases have been reported for surgical replacement of aortic root after ASO, and two of them had bicuspid neoaortic valves. We suspect that a bicuspid neoaortic valve may be a risk factor for marked dilatation of the aortic root late after ASO. PMID:23208843
Bobylev, Dmitry; Breymann, Thomas; Boethig, Dietmar; Ono, Masamichi
This case study concerns a patient with disruption of both tricuspid and aortic valves: a previously healthy, adult man, who sustained a 5-meter fall from a building under construction. The mechanism of the injury was acceleration and deceleration, acting in two different phases of the cardiac cycle, i.e. systole and diastole. Simultaneous occurrence of these injuries is exceedingly rare and in a careful literature review, we did not find any such combination of injury. The possible mechanisms of this injury, as well as surgical techniques are discussed. PMID:23511124
Sabzi, Feridoun; Niazi, Mojtaba; Ahmadi, Alireza
Two dimensional echocardiographic criteria for bicuspid aortic valve recognition have greater specificity than previously proposed M-mode echocardiographic criteria. The potential clinical use of the two dimensional technique is, however, limited by the technical inability to image adequately the aortic valve leaflets in many patients. One hundred consecutive adult patients undergoing two dimensional echocardiography were prospectively studied. Valve cusp number could not be determined because of dense calcification in eight patients. A bicuspid aortic valve was diagnosed in a single subject. A parasternal short axis view disclosed three commissures (diastolic "Y" configuration) in only 26 patients. Technically adequate parasternal short axis imaging was more likely in younger patients and in non-smokers. In patients not successfully imaged from the parasternal approach, an anteriorly tilted apical four chamber view showed a diastolic "Y" configuration in an additional eight cases. Considering the high prevalence in our population of incomplete two dimensional echocardiographic aortic valve leaflet imaging, angiographic and/or pathological studies must be performed to establish the correlation between these incomplete echocardiographic patterns and aortic valve anatomy if two dimensional echocardiography is to have widespread application in the diagnosis of the congenital bicuspid aortic valve. Images
Zema, M J; Caccavano, M
Massive aortic regurgitation following paravalvular balloon valvuloplasty of an Edwards SAPIEN valve treated by emergent CoreValve implantation: never cross a transcatheter aortic valve without a pigtail.
A 72-year-old patient, with a history of coronary artery bypass and aorto-bifemoral graft, was diagnosed with a symptomatic severe aortic valve stenosis in the presence of moderately decreased left ventricular function. The Heart team decision was to implant an Edwards SAPIEN XT 26 mm valve by transapical approach, therefore avoiding access through the aorto-bifemoral graft. At the end of the procedure, grades 2-3 aortic regurgitation was observed. Since each run of rapid pacing ended in ventricular fibrillation, it was decided to treat the aortic regurgitation conservatively with the option of post-dilation in a second procedure if hemodynamic deterioration was observed. Six days later balloon valvuloplasty was performed because of heart failure requiring endotracheal intubation. Despite transesophageal echocardiography guidance the balloon was inadvertently advanced through the paravalvular space. As a consequence, balloon valvuloplasty was complicated by massive aortic regurgitation and severe hemodynamic instability which was resolved after emergency transfemoral implantation of a CoreValve. Without any further complications, the patient was discharged eight days later. PMID:23460365
Noble, Stéphane; Cikirikcioglu, Mustafa; Roffi, Marco
Summary Aortic valve calcification (AVC) is a common disease of the elderly. It is a progressive disease ranging from mild valve thickening to severe calcification with aortic valve stenosis. Risk factors for AVC are similar to those for atherosclerosis: age, gender, hypercholesterolemia, diabetes, hypertension, smoking and renal failure. AVC shares many similarities to atherosclerosis, including inflammatory cells and calcium deposits, and correlates with coronary plaque burden. Presence of AVC is associated with increased risk of adverse cardiovascular events. The objective for this review is to discuss the clinical features, natural history and prognostic significance of aortic valve calcifications, including mechanical and hemodynamic factors of flow distribution.
Wasilewski, Jaroslaw; Mirota, Kryspin; Wilczek, Krzysztof; Glowacki, Jan; Polonski, Lech
Double orifice mitral valve is a rare congenital anomaly presenting as the division of the mitral orifice into two anatomically distinct orifices, it is most often associated with other congenital heart defects such as left-sided obstructive lesions, ventricular septal defects or aortic coarctation. We report the case of a 15 year’s old boy, admitted for arterial hypertension, auscultation revealed a rude aortic systolic murmur. Femoral pulses were weak. Owing to the suspicion of aortic coarctation, transthoracic echocardiography was performed, the aortic coarctation with dilation of the aorta proximal to the stenosis was confirmed and bicuspid aortic valve was found with good function. The mitral valve was dysmorphic, having two orifices; it was divided into 2 separate valve orifices by a fibrous bridge. No mitral or aortic regurgitation was documented by color Doppler flow imaging. The left ventricular ejection fraction was normal. There was a small peri membranous ventricular septal defect with left to right shunt. Owing to the severity of the aortic coarctation and taking into account the anatomy and characteristics of the patient, he was made a surgical correction of aortic coarctation with good outcome.
Double orifice mitral valve is a rare congenital anomaly presenting as the division of the mitral orifice into two anatomically distinct orifices, it is most often associated with other congenital heart defects such as left-sided obstructive lesions, ventricular septal defects or aortic coarctation. We report the case of a 15 year's old boy, admitted for arterial hypertension, auscultation revealed a rude aortic systolic murmur. Femoral pulses were weak. Owing to the suspicion of aortic coarctation, transthoracic echocardiography was performed, the aortic coarctation with dilation of the aorta proximal to the stenosis was confirmed and bicuspid aortic valve was found with good function. The mitral valve was dysmorphic, having two orifices; it was divided into 2 separate valve orifices by a fibrous bridge. No mitral or aortic regurgitation was documented by color Doppler flow imaging. The left ventricular ejection fraction was normal. There was a small peri membranous ventricular septal defect with left to right shunt. Owing to the severity of the aortic coarctation and taking into account the anatomy and characteristics of the patient, he was made a surgical correction of aortic coarctation with good outcome. PMID:24693935
Mouine, Najat; Amri, Rachida; Cherti, Mohamed
We report the case of a contained rupture of the aortic annulus after transcatheter aortic valve implantation. The landing zone tear extended cranially to the aortic root and caudally into the perimembranous septum, creating a restrictive ventricular septal defect and severe paravalvular regurgitation into both ventricles, but no pericardial effusion or hemodynamic collapse. We elected conservative management, which proved to be a reasonable option. PMID:24793514
Rodgers, Valérie; Gobeil, François; Noiseux, Nicolas; Stevens, Louis-Mathieu; Bérubé, Lyne; Provost, Yves; Masson, Jean-Bernard
Transcatheter aortic valve implantation (TAVI) has emerged as a feasible and effective alternative to aortic valve replacement in patients at high surgical risk, and is associated with a lower risk of death at 1 year follow-up when compared with standard therapy. In a recent large study, enrolling 663 high risk patients with symptomatic severe aortic stenosis TAVI with the use of CoreValve system has been associated with early and sustained clinical and hemodynamic benefits, with a cumulative mortality of 15.0% at 1 year follow-up. This study has shown that paravalvular aortic regurgitation after successful TAVI is a frequent finding, being of mild entity in the vast majority of cases, whereas valvular regurgitation is almost entirely absent or mild. Of note, no cases of structural valve deterioration were reported. We report a case of a successful implantation of a CoreValve that complicated with late onset massive intravalvular aortic regurgitation, due to CoreValve cusp rupture, leading to low output state with acute pulmonary edema, which was successfully treated with "valve in valve" implantation. © 2011 Wiley Periodicals, Inc. PMID:21542120
Pagnotta, Paolo; Ferrante, Giuseppe; Presbitero, Patrizia
Platelet functions were studied in normal subjects and patients with single Staff-Edwards aortic ball valves of series 1200 and 2300. The most pronounced changes were found in platelet adhesiveness, measured with Hellem's modified method. The mean percentage of adhesive platelets was reduced from 71.8 in normal subjects to 50.9 in patients with valve type 1200 and to 27.2 in those with type 2300. An inverse correlation was found between platelet adhesiveness and the degree of intravascular hemolysis, as reflected by serum LDH levels. The mean bleeding time was significantly prolonged in patients with valve 2300, and the individual values correlated inversely to the adhesiveness. The mean values of platelet counts, or irreversible aggregation induced by collagen or epinephrine, and of platelet survival were all moderately-but significantly-reduced as compared to normal. The most important mechanism behind the disturbed platelet reactivity is probably mechanical damage of the platelets by the valve, whereas refractoriness of platelets toward ADP liberated from red cells as well as consumption of adhesive platelets by thrombus formation is thought to have limited influence on platelet behavior. Platelet function was altered to the same extent in patients with a history of arterial thromboembolic complications as in those without. The disturbed platelet reactivity may predispose to bleeding, but may also offer some protection against arterial thromboembolism. PMID:888769
Dale, J; Myhre, E
There has been growing interest in the mechanobiological function of the aortic valve interstitial cell (AVIC), due to its role in valve tissue homeostasis and remodeling. In a recent study we determined the relation between diastolic loading of the AV leaflet and the resulting AVIC deformation, which was found to be substantial. However, due to the rapid loading time of the AV leaflets during closure (~0.05 s), time-dependent effects may play a role in AVIC deformation during physiological function. In the present study, we explored AVIC viscoelastic behavior using the micropipette aspiration technique. We then modeled the resulting time-length data over the 100 sec test period using a standard linear solid (SLS) model which included Boltzmann superposition. To quantify the degree of creep and stress relaxation during physiological timescales, simulations of micropipette aspiration were preformed with a valve loading time of 0.05 s and a full valve closure time of 0.3 s. The 0.05 s loading simulations suggest that, during valve closure, AVICs act elastically. During diastole, simulations revealed creep (4.65%) and stress relaxation (4.39%) over the 0.3 s physiological timescale. Simulations also indicated that if Boltzmann superposition was not used in parameter estimation, as in much of the micropipette literature, creep and stress relaxation predicted values were nearly doubled (7.92% and 7.35%, respectively). We conclude that while AVIC viscoelastic effects are negligible during valve closure, they likely contribute to the deformation time-history of AVIC deformation during diastole.
Merryman, W. David; Bieniek, Paul D.; Guilak, Farshid; Sacks, Michael S.
Calcific aortic valve disease (CAVD) is a chronic process leading to fibrosis and mineralization of the aortic valve. Investigations in the last several years have emphasized that key underlying molecular processes are involved in the pathogenesis of CAVD. In this regard, the processing of lipids and their retention has been underlined as an important mechanism that triggers inflammation. In turn, inflammation promotes/enhances the mineralization of valve interstitial cells, the main cellular component of the aortic valve. On the other hand, transformation of valve interstitial cells into myofibroblasts and osteoblast-like cells is determined by several signaling pathways having reciprocal cross-talks. In addition, the mineralization of the aortic valve has been shown to rely on ectonucleotidase and purinergic signaling. In this review, the authors have highlighted key molecular underpinnings of CAVD that may have significant relevance for the development of novel pharmaceutical therapies. PMID:24857537
Mathieu, Patrick; Boulanger, Marie-Chloé; Bouchareb, Rihab
The results after 282 consecutive double (aortic & mitral) valve replacements (DVR) are compared with our previously reported experience after mitral (MVR, n=810) and aortic valve re- placement (AVR, n = 1753). All but one patient re- ceived Bjork-Shiley valves. The follow-up which closed on August 1, 1985 was 99.3% and covered 16 869 patient-years (mean 6.3 years\\/patient). Autopsies were
D. Lindblom; U. Lindblom; B. Aberg
Background:?The Trifecta valve (St Jude Medical) is a novel supra-annular aortic bioprosthesis designed to improve hemodynamic performance. We hypothesized that the Trifecta may offer better hemodynamic performance in Japanese patients, in whom the annulus is smaller, compared with Western populations. We compared the early results of hemodynamic performance between the Trifecta and the Magna (Edwards Lifescience) valves at our institution. Methods and Results:?The Trifecta was implanted in 33 patients and the Magna was implanted in 41 patients who had aortic valve disease. Postoperative echocardiography was performed just before discharge, and the mean pressure gradient (MPG), effective orifice area (EOA) index and energy loss coefficient (ELCo) index were compared between the 2 groups. The average prosthesis size was similar between the 2 groups (21.1 vs. 21.3mm). The Trifecta group had a significantly lower MPG (P=0.001) and larger EOA index and ELCo index than the Magna group (P<0.001 for both). On multivariate linear regression analysis, use of the Trifecta was the strongest independent determinant of postoperative MPG, EOA and ELCo index. Conclusions:?The Trifecta valve provides excellent early postoperative hemodynamic performance in Japanese patients. Patients with a small annulus size relative to body size may benefit more from the Trifecta in terms of postoperative hemodynamic performance.??(Circ J?2014; 78: 1372-1378). PMID:24717287
Maruyama, Masaki; Daimon, Masao; Kawata, Takayuki; Kasai, Takatoshi; Ichikawa, Ryoko; Miyazaki, Sakiko; Ohmura, Hirotoshi; Yamamoto, Taira; Amano, Atsushi; Daida, Hiroyuki
Glutaraldehyde-treated porcine aortic valve xenografts frequently fail due to calcification. Calcification in the prostheses begins intracellularly. In a previous study, various types of cell injury to canine valvular fibroblasts, including glutaraldehyde treatment, led to calcification. An influx of extracellular Ca2+ into the phosphate-rich cytosol was theorized to be the mechanism of calcification. To test the Ca2+ influx theory, cytosolic Ca2+ and Pi concentrations were assessed in glutaraldehyde-treated porcine aortic valve fibroblasts, and their relationship to a subsequent calcification was studied. Glutaraldehyde caused an immediate and sustained massive cytosolic Ca2+ increase that was dose dependent and a several-fold increase in Pi. Calcification of cells followed within a week. The earliest calcification was observed in blebs formed on glutaraldehyde-treated cells. Live control cells or cells fixed with glutaraldehyde in Ca2+-free solution did not calcify under the same conditions. Concomitant increases in Ca2+ and Pi in glutaraldehyde-treated cells appear to underlie the mechanism of calcification, and the presence of extracellular Ca2+ during glutaraldehyde fixation promotes calcification.
Kim, Kookmin M.; Herrera, Guillermo A.; Battarbee, Harold D.
Glutaraldehyde-treated porcine aortic valve xenografts frequently fail due to calcification. Calcification in the prostheses begins intracellularly. In a previous study, various types of cell injury to canine valvular fibroblasts, including glutaraldehyde treatment, led to calcification. An influx of extracellular Ca2+ into the phosphate-rich cytosol was theorized to be the mechanism of calcification. To test the Ca2+ influx theory, cytosolic Ca2+ and Pi concentrations were assessed in glutaraldehyde-treated porcine aortic valve fibroblasts, and their relationship to a subsequent calcification was studied. Glutaraldehyde caused an immediate and sustained massive cytosolic Ca2+ increase that was dose dependent and a several-fold increase in Pi. Calcification of cells followed within a week. The earliest calcification was observed in blebs formed on glutaraldehyde-treated cells. Live control cells or cells fixed with glutaraldehyde in Ca2+-free solution did not calcify under the same conditions. Concomitant increases in Ca2+ and Pi in glutaraldehyde-treated cells appear to underlie the mechanism of calcification, and the presence of extracellular Ca2+ during glutaraldehyde fixation promotes calcification. PMID:10079262
Kim, K M; Herrera, G A; Battarbee, H D
Aortic valve calcification can aggravate aortic stenoses, and it is a significant cause of sudden cardiac death. The increasing number of patients with age-related calcification is a problem in developed nations. However, the only treatment option currently available is highly invasive cardiac valve replacement. Therefore, clarification of the etiology of calcification is urgently needed to develop drug therapies and prevention methods. Recent studies have revealed that calcification is not a simple sedimentation of a mineral through a physicochemical phenomenon; various factors dynamically contribute to the mechanism. Further, we are finally beginning to understand the cellular origins of calcification, which had been unclear for a long time. Based on these findings that help to clarify potential drug targets, we expect to establish drug therapies that reduce the stress on patients. In this paper, I introduce the latest findings on cells that are most likely to contribute to calcification and on calcification-related factors that may lead to the development of drug therapies. PMID:24463776
Assessment of valve haemodynamics, reverse ventricular remodelling and myocardial fibrosis following transcatheter aortic valve implantation compared to surgical aortic valve replacement: a cardiovascular magnetic resonance study
Objective To compare the effects of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) on aortic valve haemodynamics, ventricular reverse remodelling and myocardial fibrosis (MF) by cardiovascular magnetic resonance (CMR) imaging. Design A 1.5?T CMR scan was performed preoperatively and 6?months postoperatively. Setting University hospitals of Leeds and Leicester, UK. Patients 50 (25 TAVI, 25 SAVR; age 77±8?years) high-risk severe symptomatic aortic stenosis (AS) patients. Main outcome measures Valve haemodynamics, ventricular volumes, ejection fraction (EF), mass and MF. Results Patients were matched for gender and AS severity but not for age (80±6 vs 73±7?years, p=0.001) or EuroSCORE (22±14 vs 7±3, p<0.001). Aortic valve mean pressure gradient decreased to a greater degree post-TAVI compared to SAVR (21±8?mm?Hg vs 35±13?mm?Hg, p=0.017). Aortic regurgitation reduced by 8% in both groups, only reaching statistical significance for TAVI (p=0.003). TAVI and SAVR improved (p<0.05) left ventricular (LV) end-systolic volumes (46±18?ml/m2 vs 41±17?ml/m2; 44±22?ml/m2 vs32±6?ml/m2) and mass (83±20?g/m2 vs 65±15?g/m2; 74±11?g/m2 vs 59±8?g/m2). SAVR reduced end-diastolic volumes (92±19?ml/m2 vs 74±12?ml/m2, p<0.001) and TAVI increased EF (52±12% vs 56±10%, p=0.01). MF reduced post-TAVI (10.9±6% vs 8.5±5%, p=0.03) but not post-SAVR (4.2±2% vs 4.1±2%, p=0.98). Myocardial scar (p?0.01) and baseline ventricular volumes (p<0.001) were the major predictors of reverse remodelling. Conclusions TAVI was comparable to SAVR at LV reverse remodelling and superior at reducing the valvular pressure gradient and MF. Future work should assess the prognostic importance of reverse remodelling and fibrosis post-TAVI to aid patient selection.
Fairbairn, Timothy A; Steadman, Christopher D; Mather, Adam N; Motwani, Manish; Blackman, Daniel J; Plein, Sven; McCann, Gerry P; Greenwood, John P
Anticoagulation is mandatory in all mechanical valve replacements and, when well-managed, permits both embolism and valve thrombosis to be kept at low levels. Here, we report the case of a male patient who has survived 30 years without anticoagulation following aortic valve replacement with the Björk-Shiley prosthesis. PMID:11499606
Kücükaksu, D S; Akgül, A; Uzun, A; Tarcan, O; Cagli, K; Sener, E; Tasdemir, O; Bayazit, K
We describe the case of a 66-year-old male, who was referred to our cardiology department with suspected endocarditis, following an enterococcal bacteremia. Transesophageal echocardiography showed vegetations on a native trileaflet aortic valve. Having been prescribed intravenous amoxicillin and gentamicin, to which he initially responded, the patient became increasingly breathless during the third week of treatment. Although lung fields were clear and there were no changes to a pre-existing heart murmur on physical examination, transthoracic echocardiography and Doppler color flow imaging revealed that an aortic root abscess had ruptured and formed a left-to-right shunt. The patient was transferred to a specialist cardiac center, but was unsuitable for major surgery and died a week later. We discuss this rare and devastating complication of infective endocarditis. PMID:24863073
Razii, Nima; Izzat, Lena M
Objective Accumulation of reactive oxygen species (ROS) and remodeling of the microstructure of the cusp characterize aortic valve sclerosis, the early phase of calcific aortic valve disease. These events are associated with activation of valvular interstitial cells (VICs) toward an osteogenic-like phenotype. Because ROS cause DNA damage and transcriptional activation we investigated the relationship between ROS, DNA damage response, and transdifferentiation of VICs. Methods and Results Human aortic valve cusps and patient-matched VICs were collected from 39 patients both with and without calcific aortic valve disease. VICs were exposed to hydrogen peroxide (0.1–1 mmol/L) after cell transduction with extracellular superoxide dismutase/catalase adenoviruses and characterized for DNA-damage response, osteogenic transdifferentiation, and calcification. ROS induce relocalization of phosphorylated ?H2AX, MRE11, and XRCC1 proteins with expression of osteogenic signaling molecule RUNX2 via AKT. We report a sustained activation of ?H2AX in aortic valve sclerosis-derived VICs suggesting their impaired ability to repair DNA damage. Adenovirus superoxide dismutase/catalase transduction decreases ROS-induced DNA damage and VIC transdifferentiation in aortic valve sclerosis-derived cells. Finally, adenoviral transduction with catalase reverts ROS-mediated calcification and cellular transdifferentiation. Conclusion We conclude that the ROS-induced DNA damage response is dysfunctional in early asymptomatic stages of calcific aortic valve disease. We unveiled an association among ROS, DNA-damage response, and cellular transdifferentiation, reversible by antioxidant enzymes delivery.
Branchetti, Emanuela; Sainger, Rachana; Poggio, Paolo; Grau, Juan B.; Patterson-Fortin, Jeffrey; Bavaria, Joseph E.; Chorny, Michael; Lai, Eric; Gorman, Robert C.; Levy, Robert J.; Ferrari, Giovanni
Calcific aortic valve disease (CAVD) is a major contributor to cardiovascular morbidity and mortality and, given its association with age, the prevalence of CAVD is expected to continue to rise as global life expectancy increases. No drug strategies currently exist to prevent or treat CAVD. Given that valve replacement is the only available clinical option, patients often cope with a deteriorating quality of life until diminished valve function demands intervention. The recognition that CAVD results from active cellular mechanisms suggests that the underlying pathways might be targeted to treat the condition. However, no such therapeutic strategy has been successfully developed to date. One hope was that drugs already used to treat vascular complications might also improve CAVD outcomes, but the mechanisms of CAVD progression and the desired therapeutic outcomes are often different from those of vascular diseases. Therefore, we discuss the benchmarks that must be met by a CAVD treatment approach, and highlight advances in the understanding of CAVD mechanisms to identify potential novel therapeutic targets. PMID:24445487
Hutcheson, Joshua D; Aikawa, Elena; Merryman, W David
Recently, moderate and severe postprocedure aortic regurgitations (ARs) have been identified as independent risk factors for short- and midterm mortality after transcatheter aortic valve implantation (TAVI). However, very few data exist on the long-term outcome of postprocedure AR. From 2008 to 2011, 198 consecutive patients with severe aortic stenosis successfully underwent TAVI with the CoreValve prosthesis (Medtronic CV, Minneapolis, Minnesota). After the procedure, patients were subdivided into groups depending on the presence of moderate/severe AR. The primary study end point was death from any cause after TAVI. The secondary end point was defined as cardiovascular death. In study patients (80 ± 6 years old, logistic European System for Cardiac Operative Risk Evaluation 22 ± 16%, left ventricular ejection fraction 53 ± 13%), moderate/severe AR occurred in 28 patients (14%). Despite similar baseline characteristics, patients with moderate/severe AR had higher 30-day and 1-year mortality rates than patients with none/mild AR (21% vs 6%, p = 0.019; 57% vs 16%, p <0.001, respectively). During a mean follow-up of 535 ± 333 days, the primary end point was reached in 54 and the secondary end point in 33 patients. Moderate/severe AR was the strongest independent risk factor of all-cause-mortality (hazard ratio 4.89, 95% confidence interval 2.78 to 8.56, p <0.001) and the strongest independent risk factor of cardiovascular mortality (hazard ratio 7.90, 95% confidence interval 3.95 to 15.81, p <0.001). In conclusion, moderate and severe postprocedure ARs are not uncommon complications after TAVI. Although long-term outcome of patients with none/mild AR is favorable, outcome of patients with moderate/severe AR is dismal. PMID:22863177
Gotzmann, Michael; Korten, Michael; Bojara, Waldemar; Lindstaedt, Michael; Rahlmann, Pia; Mügge, Andreas; Ewers, Aydan
Congenital quadricuspid aortic valve (QAV) is a rare cardiac anomaly. Several different anatomical variations of a quadricuspid aortic valve have been described. Aortic regurgitation is the predominant valvular dysfunction associated with QAV and patients tend to present in their 5(th) or 6(th) decade of life. This anomaly is rarely picked up by transthoracic echocardiogram (TTE). A comprehensive transoesophageal echocardiography (TOE) study is more likely to diagnose it. We describe a very rare type of QAV - Type F in a 52-year-old lady who presented with symptoms of shortness of breath and pre-syncope. We include TOE images and intra-operative valve images. PMID:24707324
Garg, Pankaj; Kamaruddin, Hazlyna; Orme, Rachel; Watt, Victoria
Congenital quadricuspid aortic valve (QAV) is a rare cardiac anomaly. Several different anatomical variations of a quadricuspid aortic valve have been described. Aortic regurgitation is the predominant valvular dysfunction associated with QAV and patients tend to present in their 5th or 6th decade of life. This anomaly is rarely picked up by transthoracic echocardiogram (TTE). A comprehensive transoesophageal echocardiography (TOE) study is more likely to diagnose it. We describe a very rare type of QAV – Type F in a 52-year-old lady who presented with symptoms of shortness of breath and pre-syncope. We include TOE images and intra-operative valve images.
Garg, Pankaj; Kamaruddin, Hazlyna; Orme, Rachel; Watt, Victoria
A fibrous band connecting the middle of the free edge (nodulus Arantii) of the non-coronary aortic valve cusp to the ascending aorta just above the level of the non-coronary sinus of Valsalva was observed in an asymptomatic, 11-year-old, male Border Collie. The fibrous band was unrelated to the cause of the death in this dog. Such fibrous bands are usually reported in humans with congenital bicuspid aortic valves. To our knowledge, this is the first report of a fibrous band in the aortic valve in a domestic animal. PMID:21641896
Ajithdoss, Dharani K; Arenas-Gamboa, Angela M; Edwards, John F
Loeys-Dietz syndrome (LDS) is a recently recognized connective tissue disorder caused by mutations of the transforming growth factor (TGF)-? receptors. It is an autosomal dominant syndrome characterized by the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula or cleft palate. We treated an 18-year-old woman with a 100-mm-diameter aortic root aneurysm and severe aortic valve regurgitation. She underwent urgent aortic root replacement and bioprosthetic valve implantation. LDS was diagnosed by postoperative genetic screening results. Histopathologic examination of the aortic wall showed diffuse degeneration and elastin fragmentation in the media. PMID:24882305
Nakajima, Tomohiro; Tachibana, Kazutoshi; Miyaki, Yasuko; Takagi, Nobuyuki; Morisaki, Takayuki; Higami, Tetsuya
Starr-Edwards ball valves removed more than 15 years after implantation were retrospectively investigated macroscopically. Eight patients required re-operation. Valve models used in the initial operations were a non-cloth-covered valve in 2 patients and a cloth-covered valve in 6. Two patients had replacement of an aortic ball valve (model 1260 and model 2320) and 6 underwent mitral valve replacement (model 6120 in one, model 6320 in 5). The mean time to re-operation was 23.0 +/- 4.8 years after implantation. Cloth wear causing significant hemolysis was observed in all cloth-covered valves, regardless of valve position. Autologous tissue growth was noted on the orifice ring and struts in both aortic and mitral prostheses. Thrombus formation was not found in any of the valves. Ball variance in silicone rubber balls was mild in the non-cloth-covered valves, even in the aortic position. The most significant problem with the cloth-covered ball valve was cloth wear. Cloth wear should always be considered when 15 years or more have passed since valve implantation. Significant hemolysis, elevation of lactate dehydrogenase values, and echocardiographic detection of transvalvular regurgitation are diagnostic of cloth wear, and are indications for replacement of a cloth-covered ball valve. PMID:17130320
Aoyagi, Shigeaki; Fukunaga, Shuji; Arinaga, Koichi; Yokokura, Yoshinori; Yokokura, Hiroko; Egawa, Noriko
In a necropsy study, the conjoined cusps of 50 congenitally and 50 acquired bicuspid aortic valves most commonly involved the right and left aortic cusps. In hearts with congenitally bicuspid aortic valves, the left coronary ostium arose at or above the aortic sinotubular junction in 44 per cent, whereas the incidence for the left coronary ostium in the acquired group was 20 per cent and that for the right coronary ostium in both groups was less than 20 per cent. In hearts with congenitally bicuspid aortic valves, the incidence of left coronary dominance (26%) was higher than in normal hearts. In hearts with apparently acquired bicuspid aortic valves, this incidence was also higher than normal, possibly because of acquired fusion of atypical congenitally bicuspid valves in some cases. In both types of aortic valve disease, the length of the left main coronary artery was similar; this length, however, was significantly shorter in hearts with left coronary dominance than in those with right or shared dominance.
Lerer, P K; Edwards, W D
We report a case of a 61-year-old man with aortic dissection, which was detected after mitral valve replacement. The presenting manifestation was a moderate, dull and steady pain in his right scapular region, which started on the 40th postoperative day and irradiated to the back and lower limbs. The dissection and its extent was diagnosed on transthoracic echocardiography and CT scanning and the patient improved on conservative management with beta blockers. The main purpose of reporting this case is to emphasize challenges involved with early diagnosis of this ominous condition due to nonspecific symptoms and unreliable clinical examination, and to highlight the role of the imaging studies to confirm the diagnosis of this entity. PMID:21798138
dos Santos, Vitorino Modesto; Martins, Rosane Rodrigues; dos Santos Barcelos, Maria; Andrade, Loana Márquez; Silva Paz, Bruno César; Soares, Liliane Aparecida
From 1965 through 1986, 817 patients underwent aortic valve replacement at our institution. Six hundred forty-five patients received Starr-Edwards ball valves, including 286 Silastic ball valves (Models 1200/1260), 165 cloth-covered caged-ball prostheses (Models 2300/2310/2320), and 194 track-valve prostheses (Model 2400). In contrast, 172 patients received disc-valve prostheses, including 126 St. Jude Medical aortic bi-leaflet disc valves, 32 Lillehei-Kaster pivoting disc valves, and 14 Björk-Shiley valves (6 convexoconcave and 8 monostrut). With respect to preoperative data, the 2 groups were comparable, with the following differences. The Starr-Edwards group included 1) more men (77% versus 51%; p < 0.0001); 2) a significantly older patient population (59 +/- 10 years versus 56 +/- 15 years; p < 0.0001); 3) more patients in New York Heart Association functional class III or IV (72% versus 65%; p < 0.01); 4) fewer patients with angina pectoris as a limiting symptom (20% versus 36%; p < 0.0001); and 5) patients who tended to receive larger prostheses (26 +/- 2 mm versus 23 +/- 3 mm, p < 0.0001). The overall 10-year survival rate +/- standard error was 59% +/- 2% for patients receiving Starr-Edwards valves and 63% +/- 6% for those with disc valves. The linearized complication rates (expressed as percentage per patient-year +/- standard error) for the Starr-Edwards and disc-valve groups, respectively, were 2.0% +/- 0.2% and 1.4% +/- 0.5% for thromboembolism, 2.1% +/- 0.2% and 3.9% +/- 0.8% for Coumadin-related hemorrhage, 0.5% +/- 0.1% and 0.3% +/- 0.2% for endocarditis, 0.3% +/- 0.1% and 0.7% +/- 0.3% for other prosthesis-related complications, and 4.8% +/- 0.1% and 6.4% +/- 1.0% for all complications together. There were no instances of thrombotic occlusion or mechanical failure. After the 6th postoperative year, no thromboembolic events were encountered in patients with a Silastic ball valve; the 15-year freedom from thromboembolic events was 89%. Cox regression analysis showed that 1) a prosthetic orifice diameter of 15 mm or less was associated with an increased mortality; 2) disc valves entailed an increased rate of hemorrhage and prosthesis-related complications considered as a whole; 3) and Lillehei-Kaster valves led to an increased rate of prosthesis-related complications other than thromboembolism, hemorrhage, and endocarditis. Neither the type of prosthesis nor the size influenced the rate of thromboembolism, endocarditis, or prosthesis replacement. Because of their proven durability and relatively low price, we advocate the continued use of Starr-Edwards Model 1260 Silastic ball valves that have an orifice diameter of 16 mm or more. PMID:15227505
Pilegaard, H K; Lund, O; Nielsen, T T; Magnussen, K; Knudsen, M A; Albrechtsen, O K
Percutaneous balloon dilatation of the aortic valve was attempted in 25 consecutive patients with stenosis. The aortic valve diameters were normal for age. The balloon catheters were placed retrogradely, and their diameters were within 1-2 mm of the valve diameter and 3 (13 patients) or 6 cm (recent 12 patients) long. After dilatation the pressure gradients across the aortic valve were reduced significantly and the valve areas, measured in 10 patients, increased. Aortic regurgitation was detected in six patients before (grade I) the procedure and in 15 patients (6 grade I, 6 grade II, 3 grade III) after the procedure. In one patient the aortic valve could not be crossed and in three there was no reduction in the pressure drop. Nine patients have a sustained reduction in Doppler assessed gradients. There were vascular complications in 12 and these required surgical intervention in three patients. Balloon dilatation seems to be an effective short term palliative procedure in patients with congenital stenosis of the aortic valve. Images Fig 1
Vogel, M; Benson, L N; Burrows, P; Smallhorn, J F; Freedom, R M
Aortic valve regurgitation due to blunt thoracic trauma is a rare complication. Autopsy studies have been shown that the aortic valve is the most often lacerated one among the heart valves. Actually, we describe a case of a 47 year old man with the signs of heart failure after a blunt thoracic trauma 2 months before caused by aortic insufficiency due to a partial left-coronary aortic valve prolapse. Furthermore, transthoracic and transesophageal echocardiography revealed two small jets between the left and the right atrium. PMID:17064799
Szabo, S; Oikonomopoulos, T; Marx, R; Hoffmeister, H M
Transcatheter aortic valve implantation (TAVI) is effective in treating severe aortic stenosis in high-risk surgical patients. We evaluated the value of the QRS duration (QRSd) in predicting the mid-term morbidity and mortality after TAVI. We conducted a prospective cohort study of 91 consecutive patients who underwent TAVI using the CoreValve at our teaching hospital cardiology unit in 2008 to 2010 who survived to hospital discharge; 57% were women, and their mean age was 84 ± 7 years. The QRSd at discharge was used to classify the patients into 3 groups: QRSd ?120 ms, n = 18 (20%); QRSd >120 ms but ?150 ms, n = 30 (33%); and QRSd >150 ms, n = 43 (47%). We used 2 end points: (1) all-cause mortality and (2) all-cause mortality or admission for heart failure. After a median of 12 months, the normal-QRSd patients showed a trend toward, or had, significantly better overall survival and survival free of admission for heart failure compared with the intermediate-QRSd group (p = 0.084 and p = 0.002, respectively) and the long-QRSd group (p = 0.015 and p = 0.001, respectively). The factors significantly associated with all-cause mortality were the Society of Thoracic Surgeons score, aortic valve area, post-TAVI dilation, acute kidney injury, hospital days after TAVI, and QRSd at discharge. On multivariate analysis, QRSd was the strongest independent predictor of all-cause mortality (hazard ratio 1.036, 95% confidence interval 1.016 to 1.056; p <0.001) and all-cause mortality or heart failure admission (hazard ratio 1.025, 95% confidence interval 1.011 to 1.039; p <0.001). The other independent predictors were the Society of Thoracic Surgeons score, acute kidney injury, and post-TAVI hospital days. In conclusion, a longer QRSd after TAVI was associated with greater morbidity and mortality after 12 months. The QRSd at discharge independently predicted mortality and morbidity after TAVI. PMID:23528030
Meguro, Kentaro; Lellouche, Nicolas; Yamamoto, Masanori; Fougeres, Emilie; Monin, Jean-Luc; Lim, Pascal; Mouillet, Gauthier; Dubois-Rande, Jean-Luc; Teiger, Emmanuel
The long term performance characteristics of the 2400 and 1260 series of Starr-Edwards aortic prostheses were investigated by a follow up study of clinical outcome of 327 patients discharged from hospital with isolated aortic valve replacement. Follow up lasted for up to 10 years and was based on 1616 patient-years. The 2400 series cloth covered tracked valve was implanted in 182 patients from 1974 to 1980 and the 1260 series bare strut silastic ball valve was inserted in 145 patients from 1979 to 1983. Total 10 year mortality and valve related morbidity were low and no cases of mechanical valve failure were recorded. There were no significant actuarial differences in mortality or valve related morbidity between the 2400 and 1260 valves. Starr-Edwards models 2400 and 1260 aortic valve prostheses showed excellent durability without any mechanical failures over a 10 year period. The long term outcome of isolated aortic valve replacement with these models is associated with a low frequency of valve related complications.
Hackett, D; Fessatidis, I; Sapsford, R; Oakley, C
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether therapy with statins significantly slows the progression of aortic valve stenosis. Altogether 226 papers were found using the reported search, of which twelve represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided conflicting results. There are twelve studies. Ten retrospective studies and one prospective had been promising with a slower rate of hemodynamic progression in patients taking statins. One retrospective and one randomized controlled trial did not halt the progression of calcific aortic stenosis or induce its regression. The data are discrepant as to whether this effect is related to serum lipid levels or to other effects of statins. While the data are not yet strong enough to change clinical practice, two large randomized controlled trials (ASTRONOMER and SEAS) which have recruited 272 and 1873 patients, respectively, will provide important new evidence in this area in the near future. PMID:18413348
Tourmousoglou, Christos E; Lalos, Spiros; Psarros, Themistokles
Transcatheter valve implantation is developing into an effective and reproducible therapy for aortic valve stenosis. The origin of this technique was pursued in 1992 when Andersen demonstrated the feasibility of percutaneous implantation of catheter-based valve prosthesis. Since then a lot of technical and device advances have been made and to date, transcatheter aortic valve implantation has became a concrete alternative to surgical replacement. This paper aims to go over all the current devices, from the most widely used to the newest technology, focusing on device description, procedural issues, potential complications and clinical studies currently available in literature. PMID:20014989
Tamburino, Corrado; Barbanti, Marco; Capodanno, Davide; Ussia, Gian Paolo
BackgroundBicuspid aortic valves (BAV) are a common inherited abnormality with a very high rate of adverse cardiac events at an earlier age than tricuspid aortic valves (TAV). Risk stratification for moderate to severe aortic stenosis, in both bicuspid and tricuspid disease, remains a significant clinical challenge. It is unknown whether pathological left ventricular (LV) remodelling, a strong predictor of adverse
S Bull; J Suttie; N Blundell; J M Francis; T D Karamitsos; A Pitcher; J DArcy; B Prendergast; S Neubauer; S G Myerson
Arterial endothelial cells maintain vascular homeostasis and vessel tone in part through the secretion of nitric oxide (NO). In this study, we determined how aortic valve endothelial cells (VEC) regulate aortic valve interstitial cell (VIC) phenotype and matrix calcification through NO. Using an anchored in vitro collagen hydrogel culture system, we demonstrate that three-dimensionally cultured porcine VIC do not calcify in osteogenic medium unless under mechanical stress. Co-culture with porcine VEC, however, significantly attenuated VIC calcification through inhibition of myofibroblastic activation, osteogenic differentiation, and calcium deposition. Incubation with the NO donor DETA-NO inhibited VIC osteogenic differentiation and matrix calcification, whereas incubation with the NO blocker l-NAME augmented calcification even in 3D VIC–VEC co-culture. Aortic VEC, but not VIC, expressed endothelial NO synthase (eNOS) in both porcine and human valves, which was reduced in osteogenic medium. eNOS expression was reduced in calcified human aortic valves in a side-specific manner. Porcine leaflets exposed to the soluble guanylyl cyclase inhibitor ODQ increased osteocalcin and ?-smooth muscle actin expression. Finally, side-specific shear stress applied to porcine aortic valve leaflet endothelial surfaces increased cGMP production in VEC. Valve endothelial-derived NO is a natural inhibitor of the early phases of valve calcification and therefore may be an important regulator of valve homeostasis and pathology.
Richards, Jennifer; El-Hamamsy, Ismail; Chen, Si; Sarang, Zubair; Sarathchandra, Padmini; Yacoub, Magdi H.; Chester, Adrian H.; Butcher, Jonathan T.
Transcatheter aortic valve implantation is a minimal-invasive intervention for implanting prosthetic valves in patients with aortic stenosis. Accurate automated sizing for planning and patient selection is expected to reduce adverse effects such as paravalvular leakage and stroke. Segmentation of the aortic root in CTA is pivotal to enable automated sizing and planning. We present a fully automated segmentation algorithm to extract the aortic root from CTA volumes consisting of a number of steps: first, the volume of interest is automatically detected, and the centerline through the ascending aorta and aortic root centerline are determined. Subsequently, high intensities due to calcifications are masked. Next, the aortic root is represented in cylindrical coordinates. Finally, the aortic root is segmented using 3D normalized cuts. The method was validated against manual delineations by calculating Dice coefficients and average distance error in 20 patients. The method successfully segmented the aortic root in all 20 cases. The mean Dice coefficient was 0.95 ± 0.03, and the mean radial absolute error was 0.74 ± 0.39 mm, where the interobserver Dice coefficient was 0.95 ± 0.03 and the mean error was 0.68 ± 0.34?mm. The proposed algorithm showed accurate results compared to manual segmentations. PMID:24903606
Elattar, M A; Wiegerinck, E M; Planken, R N; Vanbavel, E; van Assen, H C; Baan, J; Marquering, H A
We describe a case of transcatheter aortic valve implantation (TAVI) using the LUCAS® Chest Compression System in an elderly high risk patient with severe aortic stenosis and heart failure. In this case, the patient developed severe aortic regurgitation following predilatation of the native aortic valve and automated cardiopulmonary resuscitation (A-CPR) was initiated. The procedure was performed under ongoing A-CPR for a total of 28 min. The patient was transferred to the intensive care unit and to a step down unit the following day. At follow-up 30 days later, she showed no signs of neurologic or cardiac damage. This case report shows, that it is possible to perform the TAVI procedure under ongoing A-CPR and that A-CPR, judged by invasive blood pressures, was capable of maintaining a satisfactory perfusion pressure even with a damaged aortic valve. PMID:23436538
Jensen, Peter Blom; Andersen, Claus; Nissen, Henrik
Because they had irreversible damage to the left ventricular myocardium none of 12 patients with critical aortic stenosis diagnosed prenatally survived after postnatal treatment. This experience prompted three attempts at intrauterine balloon dilatation of the aortic valve in two fetuses with this condition. On each attempt the balloon catheter was successfully delivered to the left ventricle. In the first fetus the aortic valve was not crossed and the fetus died the next day. In the second fetus the balloon was correctly positioned across the aortic valve and inflated in the valve ring. After delivery, a further balloon angioplasty was performed; this relieved the stenosis but the patient died five weeks later from persisting left ventricular dysfunction related to endocardial fibroelastosis. Balloon angioplasty is feasible in fetal life but the prognosis depends on the ability of the relief of stenosis to limit, prevent, or allow regression of left ventricular damage before delivery.
Maxwell, D; Allan, L; Tynan, M J
A fatal case of aortic valve endocarditis due to Abiotrophia defectiva was reported in Brazil. An overview of cases of endocarditis and other human infections related to A. defectiva in developing countries was also accomplished. PMID:24510585
Ramos, J N; dos Santos, L S; Vidal, L M R; Pereira, P M A; Salgado, A A; Fortes, C Q; Vieira, V V; Mattos-Guaraldi, A L; Júnior, R H; Damasco, P V
Bicuspid aortic valve (BAV) and thoracic aortic aneurysm (TAA) are two discrete cardiovascular phenotypes characterized by latent progressive disease states. There is a clear association between BAV and TAA; however the nature and extent of this relationship is unclear. There are both distinct and overlapping developmental pathways that have been established to contribute to the formation of the aortic valve and the aortic root, and the mature anatomy of these different tissue types is intimately intertwined. Likewise, human genetics studies have established apparently separate and common contributions to these clinical phenotypes, suggesting complex inheritance and a shared genetic basis and translating 3 patient populations, namely, BAV, TAA, or both, into a common but diverse etiology. A better understanding of the BAV-TAA association will provide an opportunity to leverage molecular information to modify clinical care through more sophisticated diagnostic testing, improved counseling, and ultimately new pharmacologic therapies.
Hinton, Robert B.
Patients with bicuspid aortic valve (BAV) are more likely to develop a calcific aortic stenosis (CAS), as well as a number of other ailments, as compared to their cohorts with normal tricuspid aortic valves (TAV). It is currently unknown whether the increase in risk of CAS is caused by the geometric differences between the tricuspid and bicuspid valves or whether the increase in risk is caused by the same underlying factors that produce the geometric difference. CAS progression is understood to be a multiscale process, mediated at the cell level. In this study, we employ multiscale finite-element simulations of the valves. We isolate the effect of one geometric factor, the number of cusps, in order to explore its effect on multiscale valve mechanics, particularly in relation to CAS. The BAV and TAV are modeled by a set of simulations describing the cell, tissue, and organ length scales. These simulations are linked across the length scales to create a coherent multiscale model. At each scale, the models are three-dimensional, dynamic, and incorporate accurate nonlinear constitutive models of the valve leaflet tissue. We compare results between the TAV and BAV at each length scale. At the cell-scale, our region of interest is the location where calcification develops, near the aortic-facing surface of the leaflet. Our simulations show the observed differences between the tricuspid and bicuspid valves at the organ scale: the bicuspid valve shows greater flexure in the solid phase and stronger jet formation in the fluid phase relative to the tricuspid. At the cell-scale, however, we show that the region of interest is shielded against strain by the wrinkling of the fibrosa. Thus, the cellular deformations are not significantly different between the TAV and BAV in the calcification-prone region. This result supports the assertion that the difference in calcification observed in the BAV versus TAV may be due primarily to factors other than the simple geometric difference between the two valves. PMID:18996528
Weinberg, Eli J; Kaazempur Mofrad, Mohammad R
Transcatheter aortic valve implantation (TAVI) is maturing strongly as an alternative to surgical aortic valve replacement (SAVR) in patients who are inoperable/high risk for open heart surgery. General anesthesia (GA) is the usual mode of anesthesia in these patients, but local anesthesia with conscious sedation (LACS) has recently been described as a safe alternative with some added advantages. We report 2 cases who were unfit for GA and were done successfully under LACS. PMID:24814117
Maqbool, Syed; Kumar, Vijay; Rastogi, Vishal; Seth, Ashok
Transcatheter aortic valve implantation (TAVI) is maturing strongly as an alternative to surgical aortic valve replacement (SAVR) in patients who are inoperable/high risk for open heart surgery. General anesthesia (GA) is the usual mode of anesthesia in these patients, but local anesthesia with conscious sedation (LACS) has recently been described as a safe alternative with some added advantages. We report 2 cases who were unfit for GA and were done successfully under LACS.
Maqbool, Syed; Kumar, Vijay; Rastogi, Vishal; Seth, Ashok
Background. This is a retrospective study of early and long-term results of composite valve graft replacement of the aortic root.Methods and Results. Between July 1974 and July 1997, 244 patients underwent aortic root replacement with a composite valve graft. Mean age was 54 ± 15 years. The inclusion technique was used in 178 patients (73.0%), the open technique in 65
Karl M Dossche; Marc A. A. M Schepens; Wim J Morshuis; Aart Brutel de la Rivière; Paul J Knaepen; Freddy E. E Vermeulen
Aortic valve stenosis has already reached endemic proportions in Western countries. As the prognosis of low?flow aortic valve stenosis under medical treatment is dismal, surgery is recommended in most patients. Preoperative dobutamine stress testing may help to assess surgical risk, but there is no strong scientific evidence to deny surgery based exclusively on the results of this test. The problems associated with clinical decision making in this condition are reviewed.
Bermejo, J; Yotti, R
A meta-analysis of mortality and major adverse cardiovascular and cerebrovascular events following transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis.
The purpose of this meta-analysis was to compare postprocedural mortality and major adverse cardiovascular and cerebrovascular events between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic stenosis. Seventeen studies (n = 4,659) comparing TAVI (n = 2,267) and SAVR (n = 2,392) were included. End points were baseline logistic European System for Cardiac Operative Risk Evaluation score, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, transient ischemic attack, and major bleeding events. Mean differences or risk ratios with 95% confidence intervals were computed, and p values <0.05 were considered significant. The population was matched for risk between the 2 groups on the basis of logistic European System for Cardiac Operative Risk Evaluation score for all outcomes except 30-day all-cause mortality, which had a high-risk population in the TAVI group (p = 0.02). There was no significant difference found in all-cause mortality at 30 days (p = 0.97) and at an average of 85 weeks (p = 0.07). There was no significant difference in cardiovascular mortality (p = 0.54) as well as the incidence of myocardial infarction (p = 0.59), stroke (p = 0.36), and transient ischemic attack (p = 0.85) at averages of 86, 72, 66, and 89 weeks, respectively. Compared with patients who underwent TAVI, those who underwent SAVR had a significantly higher frequency of major bleeding events (p <0.0001) at mean follow-up of 66 weeks. In conclusion, TAVI has similar cardiovascular and all-cause mortality to SAVR at early and long-term follow-up. TAVI is superior to SAVR for major bleeding complications and noninferior to SAVR for postprocedural myocardial infarctions and cerebrovascular events. TAVI is a safe alternative to SAVR in selected high-risk elderly patients with severe aortic stenosis. PMID:23756547
Panchal, Hemang B; Ladia, Vatsal; Desai, Saurabh; Shah, Tejaskumar; Ramu, Vijay
Background The management of mild to moderate dilatation of the ascending aorta of less than 5 cm is controversial, particularly when concomitant surgical correction of aortic valve is required. We investigate the impact of a simple method of aorta reduction using Dacron graft wrapping during aortic valve replacement on the rest of the aorta. Methods We studied 14 patients who had ascending aorta dilatation of 4-5 cm before undergoing aortic wrapping during their aortic valve replacement and compared with their post-operative imaging within a month. Results The diameters of the ascending aorta wrapped with the Dacron graft were significantly reduced within 4 weeks after surgery from 44.7 ± 2.6 to 33.6 ± 3.9 mm (p < 0.001). This was associated with significant reduction in the diameter of rest of ascending aorta: coronary sinuses (from 37.9 ± 4.9 mm to 33.3 ± 6.1 mm; p < 0.001), sinotubular junction (from 33.2 ± 4.7 mm to 30.6 ± 4.4 mm, p = 0.02), and aortic arch (from 34.7 ± 4.3 mm to 32.6 ± 4.1 mm, p = 0.03). Conclusions Reduction of ascending aortic dilatation by wrapping with a Dacron graft in this preliminary study is associated with favourable early reversed aortic remodelling. This supports the hypothesis that correction of mild-moderate dilatation of the ascending aorta with Dacron wrapping at the time of aortic valve surgery may prevent the progression of the dilatation, although the long-term study on a larger population is needed to confirm its benefits.
Objectives The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States. Methods We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery. Results Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars). Conclusions There was a marked increase in the use of thoracic aortic surgery among patients with BAV.
Opotowsky, Alexander R.; Perlstein, Todd; Landzberg, Michael J.; Colan, Steven D.; O'Gara, Patrick T.; Body, Simon C.; Ryan, Liam F.; Aranki, Sary; Singh, Michael N.
Tissue engineering the aortic heart valve is a challenging endeavor because of the particular hemodynamic and biologic conditions present in the native aortic heart valve. The backbone of an ideal valve substitute should be a scaffold that is strong enough to withstand billions of repetitive bending, flexing and stretching cycles, while also being slowly degradable to allow for remodeling. In this review we highlight three overlooked aspects that might influence the long term durability of tissue engineered valves: replication of the native valve trilayered histoarchitecture, duplication of the three-dimensional shape of the valve and cell integration efforts focused on getting the right number and type of cells to the right place within the valve structure and driving them towards homeostatic maintenance of the valve matrix. We propose that the trilayered structure in the native aortic valve that includes a middle spongiosa layer cushioning the motions of the two external fibrous layers should be our template for creation of novel scaffolds with improved mechanical durability. Furthermore, since cells adapt to micro-loads within the valve structure, we believe that interstitial cell remodeling of the valvular matrix will depend on the accurate replication of the structures and loads, resulting in successful regeneration of the valve tissue and extended durability.
Simionescu, Dan T.; Chen, Joseph; Jaeggli, Michael; Wang, Bo; Liao, Jun
The aortic heart valve undergoes geometric and mechanical changes over time. The cusps of a normal, healthy valve thicken and become less extensible over time. In the disease calcific aortic stenosis (CAS), calcified nodules progressively stiffen the cusps. The local mechanical changes in the cusps, due to either normal aging or pathological processes, affect overall function of the valve. In this paper, we propose a computational model for the aging aortic valve that connects local changes to overall valve function. We extend a previous model for the healthy valve to describe aging. To model normal/uncomplicated aging, leaflet thickness and extensibility are varied versus age according to experimental data. To model calcification, initial sites are defined and a simple growth law is assumed. The nodules then grow over time, so that the area of calcification increases from one model to the next model representing greater age. Overall valve function is recorded for each individual model to yield a single simulation of valve function over time. This simulation is the first theoretical tool to describe the temporal behavior of aortic valve calcification. The ability to better understand and predict disease progression will aid in design and timing of patient treatments for CAS.
Weinberg, Eli J.; Schoen, Frederick J.; Mofrad, Mohammad R. K.
Significant aortic regurgitation after TAVI results in lack of symptomatic and prognostic benefit from the procedure and generally requires intervention. While most of the regurgitations can be successfully targeted with standard techniques, occasional patients have restrictive calcification resistant to post-dilatation and significant regurgitation persists. We present a case of refractory aortic regurgitation successfully treated with percutaneous paravalvular leak closure. An 81-year-old man with symptomatic severe aortic stenosis underwent a transfemoral CoreValve TAVI in December 2009. He had significant aortic regurgitation refractory to medical and interventional therapy including balloon post-dilatation, valve repositioning and valve-in-valve reimplantation. Aortic regurgitation remained severe and therefore in early 2013, we proceeded with an attempted percutaneous closure of the residual paraprosthetic leak. Using 6-French femoral access and a Terumo wire, the defect was successfully crossed with a 4-French Multipurpose catheter and an 8 mm Amplatzer Vascular Plug 4 device (St. Jude Medical) was deployed through this catheter, resulting in abolition of aortic regurgitation on aortography and TOE, with associated excellent clinical response. Refractory paravalvular aortic regurgitation post CoreValve implantation can be successfully treated using the Amplatzer Vascular Plug 4 device. © 2013 Wiley Periodicals, Inc. PMID:24130146
Poliacikova, Petra; Hildick-Smith, David
Aortal valve mineralization very frequently causes a genesis of aortic stenosis, which is the most often surgically treated heart disease. Hydroxyapatite deposits have been identified as one of the causes leading to the loss of elasticity of the aortic valves. It is known that phosphates/calcium is accumulated in valve tissues during mineralization, but the mechanism of this process remains unclear. The work is focused mainly on the study of protein composition of mineralized aortic valves by nano-liquid chromatography electrospray ionization in a quadrupole orthogonal acceleration time-of-flight mass spectrometry. New methodological approach based on direct enzymatic digestion of proteins contained in hydroxyapatite deposits was developed for the study of pathological processes connected with osteogenesis. Our objectives were to simplify the traditional analytical protocols of sample preparation and to analyze the organic components of the explanted aortic valves for significant degenerative aortic stenosis. The study of aortic valve mineralization on the molecular level should contribute to understanding this process, which should consequently lead to effective prevention as well as to new ways of treatment of this grave disease. PMID:23978938
Coufalova, Lucie; Kuckova, Stepanka; Velcovska, Martina; Zeman, Antonin; Smid, Michal; Havelcova, Martina; Hynek, Radovan
The Ross operation is the procedure of choice for aortic valve disease in paediatric patients, because of the potential for growth of the pulmonary autograft and because anticoagulation is not required. However, early and late autograft dilatation and severe aortic regurgitation may occur. Transcatheter aortic valve implantation (TAVI) is an effective procedure for treatment of severe degenerative aortic stenosis in patients deemed inoperable or high surgical risk. Off-label treatment of severe non-calcified aortic regurgitation with transcatheter heart valves has occasionally been reported. We describe the first case of TAVI for severe aortic regurgitation in a young woman 10 years after a Ross operation. The procedure was performed on a compassionate basis after the patient was deemed inoperable because of severe reactive pulmonary hypertension (95/55/68 mmHg; pulmonary resistance 18.3 UR) and haemodynamic compromise. A 29 mm CoreValve™ (Medtronic, Minneapolis, MN, USA) was implanted. A second prosthesis was deployed "valve-in-valve" for residual severe paravalvular leak, caused by the peculiar post-surgical anatomy of the left ventricular outflow tract. The procedure was successful and the in-hospital course was uncomplicated. During follow-up, pulmonary pressure and resistances were significantly lowered and at four years the patient showed markedly improved exercise tolerance. PMID:24035838
Saia, Francesco; Galiè, Nazzareno; Laborde, Jean-Claude; Di Bartolomeo, Roberto; Manes, Alessandra; Marzocchi, Antonio
A computational, three-dimensional coupled fluid-structure dynamics model was developed for a generic pericardial aortic valve in a rigid aortic root graft with physiologic sinuses. Valve geometry was based on that of the natural valve. Blood flow was modeled as pulsatile, laminar, Newtonian, incompressible flow. The structural model accounted for material and geometric nonlinearities and also simulated leaflet coaptation. A body fitted grid was used to subdivide the flow domain into computational finite volume cells. Shell finite elements were used to discretize the leaflet volume. A finite volume computational fluid dynamics code and finite element structure dynamics code were used to solve the flow and structure equations, respectively. The fluid flow and structural equations were coupled using an implicit "influence coefficient" technique. Physiologic ventricular and aortic pressure waveforms were prescribed as the flow boundary conditions. The aortic flow field, valve structural configuration, and leaflet stresses were computed at 2 msec intervals. Model predictions on aortic flow and transient variation in valve orifice area were in close agreement with corresponding experimental in vitro data. These findings suggest that the computer model has potential for being a powerful design tool for bioprosthetic aortic valves. PMID:9360067
Makhijani, V B; Yang, H Q; Dionne, P J; Thubrikar, M J
Background—Despite the common occurrence of aortic stenosis, the cellular causes of the disorder are unknown, in part because of the absence of experimental models. We hypothesized that atherosclerosis and early bone matrix expression in the aortic valve occurs secondary to experimental hypercholesterolemia and that treatment with atorvastatin modifies this transformation. Methods and Results—To test this hypothesis, we developed an experimental
Nalini M. Rajamannan; Malayannan Subramaniam; Margaret Springett; Thomas C. Sebo; Marek Niekrasz; Joseph P. McConnell; Ravinder J. Singh; Neil J. Stone; Robert O. Bonow; Thomas C. Spelsberg
Background Preoperative recognition of the presence of bicuspid aortic valve can be important in the planning of procedures. Multiplane transesophageal echocardiography may allow more accurate detection of valvular morphology than does biplane transesophageal echocardiography.Methods and Results The studies of 710 patients who subsequently underwent valvular or aortic surgery were reviewed in a blinded fashion. The inclusion criteria were adequate short-axis
Miguel Espinal; Anthon R. Fuisz; Navin C. Nanda; Srinivasa Reddy Aaluri; Osman Mukhtar; Padmini C. Sekar
Sinus of Valsalva aneurysms appear to be rare. They occur most frequently in the right sinus of Valsalva (52%) and the noncoronary sinus (33%). More of these aneurysms originate from the right coronary cusp than from the noncoronary cusp. Surgical intervention is usually recommended when symptoms become evident. We report the case of a 34-year-old woman who presented with a congenital, ruptured sinus of Valsalva aneurysm that originated from the noncoronary cusp. Moderate aortic regurgitation was associated with this lesion. Simple, direct patch closure of the ruptured aneurysm resolved the patient's left-to-right shunt and was associated with decreased aortic regurgitation to a degree that valve replacement was not necessary. Only trace residual aortic regurgitation was evident after 3 months, and the patient remained free of symptoms after 6 months. Our observations support the idea that substantial runoff blood flow in the immediate supra-annular region can be responsible for aortic regurgitation in the absence of a notable structural defect in the aortic valve, and that restoring physiologic flow in this region and equalizing aortic-cusp closure pressure can largely or completely resolve aortic insufficiency. Accordingly, valve replacement may not be necessary in all cases of ruptured sinus of Valsalva aneurysms with associated aortic valve regurgitation. PMID:24082388
Nascimbene, Angelo; Joggerst, Steven; Reddy, Kota J; Cervera, Roberto D; Ott, David A; Wilson, James M; Stainback, Raymond F
Sinus of Valsalva aneurysms appear to be rare. They occur most frequently in the right sinus of Valsalva (52%) and the noncoronary sinus (33%). More of these aneurysms originate from the right coronary cusp than from the noncoronary cusp. Surgical intervention is usually recommended when symptoms become evident. We report the case of a 34-year-old woman who presented with a congenital, ruptured sinus of Valsalva aneurysm that originated from the noncoronary cusp. Moderate aortic regurgitation was associated with this lesion. Simple, direct patch closure of the ruptured aneurysm resolved the patient's left-to-right shunt and was associated with decreased aortic regurgitation to a degree that valve replacement was not necessary. Only trace residual aortic regurgitation was evident after 3 months, and the patient remained free of symptoms after 6 months. Our observations support the idea that substantial runoff blood flow in the immediate supra-annular region can be responsible for aortic regurgitation in the absence of a notable structural defect in the aortic valve, and that restoring physiologic flow in this region and equalizing aortic-cusp closure pressure can largely or completely resolve aortic insufficiency. Accordingly, valve replacement may not be necessary in all cases of ruptured sinus of Valsalva aneurysms with associated aortic valve regurgitation.
Nascimbene, Angelo; Joggerst, Steven; Reddy, Kota J.; Cervera, Roberto D.; Ott, David A.; Wilson, James M.; Stainback, Raymond F.
Objective. – Recent studies have suggested that valvular calcification in calcific aortic stenosis (AS) may be actively regulated. “Receptor Activator of Nuclear factor ?B Ligand” (RANKL) and osteoprotegerin (OPG) are members of a cytokine system involved in bone turnover and vascular calcification. Their role in calcific AS is not known.Methods and Results. – By immunohistochemistry using human aortic valves, RANKL
Jens J. Kaden; Svetlana Bickelhaupt; Rainer Grobholz; Karl K. Haase; Asl?han Sar?koç; Ref?ka K?l?ç; Martina Brueckmann; Siegfried Lang; Ingrid Zahn; Christian Vahl; Siegfried Hagl; Carl-Erik Dempfle; Martin Borggrefe
A pair of finite element models has been employed to study the interaction of blood flow with the operation of the aortic valve. A three-dimensional model of the left ventricle with applied wall displacements has been used to generate data for the spatially and time-varying blood velocity profile across the aortic aperture. These data have been used as the inlet
C. J. Carmody; G. Burriesci; I. C. Howard; E. A. Patterson
The aortic dissection (AoD) of an ascending thoracic aortic aneurysm (ATAA) initiates when the hemodynamic loads exerted on the aneurysmal wall overcome the adhesive forces holding the elastic layers together. Parallel coupled, two-way fluid–structure interaction (FSI) analyses were performed on patient-specific ATAAs obtained from patients with either bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) to evaluate hemodynamic predictors and wall stresses imparting aneurysm enlargement and AoD. Results showed a left-handed circumferential flow with slower-moving helical pattern in the aneurysm's center for BAV ATAAs whereas a slight deviation of the blood flow toward the anterolateral region of the ascending aorta was observed for TAV ATAAs. Blood pressure and wall shear stress were found key hemodynamic predictors of aneurysm dilatation, and their dissimilarities are likely associated to the morphological anatomy of the aortic valve. We also observed discontinues, wall stresses on aneurysmal aorta, which was modeled as a composite with two elastic layers (i.e., inhomogeneity of vessel structural organization). This stress distribution was caused by differences on elastic material properties of aortic layers. Wall stress distribution suggests AoD just above sinotubular junction. Moreover, abnormal flow and lower elastic material properties that are likely intrinsic in BAV individuals render the aneurysm susceptible to the initiation of AoD.
Pasta, Salvatore; Rinaudo, Antonino; Luca, Angelo; Pilato, Michele; Scardulla, Cesare; Gleason, Thomas G.; Vorp, David A.
Aims: To assess outcomes with a new fully repositionable and retrievable valve for transcatheter aortic valve replacement (TAVR). Methods and results: The Lotus Aortic Valve System is designed to facilitate precise positioning and minimise paravalvular regurgitation. REPRISE I enrolled symptomatic, high-surgical-risk patients with severe aortic stenosis. The primary endpoint (clinical procedural success) included successful implantation without major adverse cardiovascular or cerebrovascular events (MACCE). In all patients (N=11) the first Lotus Valve was successfully deployed. Partial resheathing to facilitate accurate placement was attempted and successfully performed in four patients; none required full retrieval. The primary endpoint was achieved in 9/11 with no in-hospital MACCE in 10/11. There was one major stroke; in another patient, discharge mean aortic gradient was 22 mmHg (above the primary endpoint threshold of 20 mmHg), but improved to 15 mmHg at 30 days. The cohort's mean aortic gradient decreased from 53.9±20.9 mmHg at baseline to 15.4±4.6 mmHg (p<0.001) at one year; valve area increased from 0.7±0.2 cm2 to 1.5±0.2 cm2 (p<0.001). Discharge paravalvular aortic regurgitation, adjudicated by an independent core laboratory, was mild (n=2), trivial (n=1), or absent (n=8). Four patients required a permanent pacemaker post-procedure. There were no deaths, myocardial infarctions or new strokes through one year. Conclusions: Initial results support proof-of-concept with the Lotus Valve for TAVR. PMID:24169077
Meredith, Ian T; Worthley, Stephen G; Whitbourn, Robert J; Antonis, Paul; Montarello, Joseph K; Newcomb, Andrew E; Lockwood, Siohban; Haratani, Nicole; Allocco, Dominic J; Dawkins, Keith D
Objective: High intensity transient signals (HITS) representing microembolization to the brain have been found to contribute to cognitive impairment and psychoneurological dysfunction in patients carrying a mechanical aortic valve. It is unknown, whether HITS represent gaseous or solid emboli. This animal study evaluates the impact of valve orientation on HITS for two different mechanical valves with both valves implanted in
Peter Kleine; Mathias Perthel; J. Michael Hasenkam; Hans Nygaard; Søren B. Hansen; Joachim Laas
Objective: High intensity transient signals (HITS) representing microembolization to the brain have been found to contribute to cognitive impairment and psychoneurological dysfunction in patients carrying a mechanical aortic valve. It is unknown, whether HITS represent gaseous or solid emboli. This animal study evaluates the impact of valve orientation on HITS for two different mechanical valves with both valves implanted in
Peter Kleine; Mathias Perthel; J. Michael Hasenkam; Hans Nygaard; Søren B. Hansen; Joachim Laas
Calcific aortic valve disease is frequently driven by ageing and the obesity-associated metabolic syndrome, and the increasing impact of these factors indicates that valve disease will become a cardiovascular disease of considerable significance. This disease is now thought to be an active cell-based disease process, which may therefore be amenable to therapeutic intervention. Some similarities are apparent with atherosclerosis. The
K. J. Grande-Allen; N. Osman; M. L. Ballinger; H. Dadlani; S. Marasco; P. J. Little
We describe our experience using the Edwards Sapien transfemoral Retroflex 3 catheter delivery system for transcatheter aortic valve replacement through the transapical and transaortic approaches. Transthoracic transcatheter valve replacement by the transapical and transaortic approaches can be safely and effectively performed with the Retroflex 3 delivery catheter, which affords several advantages over other available delivery devices. PMID:24996727
George, Isaac; Kriegel, Jacob; Nazif, Tamim; Kalesan, Bindu; Paradis, Jean-Michel; Khalique, Omar; Hahn, Rebecca T; Leon, Martin B; Kodali, Susheel; Williams, Mathew R
We report a case of discrete type subaortic stenosis disclosed by hemolytic anemia 7 years after aortic and mitral prosthetic valve replacement. A 53-year-old female complained of general fatigue, dyspnea, macrohematuria and hemolysis. She had undergone aortic valve replacement for non-coronary cusp perforation 15 years before, and mitral valve replacement and tricuspid annuloplasty 7 years before. Echocardiography showed mitral prosthetic valve regurgitation (III/IV degree) and symptomatic hemolysis might be caused by accelerated blood flow through the prosthetic valve. A mild aortic stenosis (peak flow verocity:3.73 m/s) was alsopointed out. The redo double valve replacement was performed. Intraoperative findings showed discrete type subaortic stenosis due to extensive pannus formation, but that the previously implanted prosthetic valves were intact. The blood flow biased by the interference of the subaortic stenosis might have obstructed closure of the mitral prosthetic valve and caused mitral regurgitation. Postoperatively, hemolysis and mitral regurgitation were diminished, and aortic stenosis was improved. PMID:24743533
Kawahara, Yu; Inage, Yuichi; Masaki, Naoki; Kobayashi, Yuriko; Jinbu, Ryota; Toyama, Shuji; Fukasawa, Manabu
A 50-year-old female was admitted to Pusan National University Hospital with complaints of fatigue and sweating. Echocardiography showed a small patent ductus arteriosus (PDA) and highly mobile vegetations on the aortic valve. Emergency operation was performed due to the high risk of embolization and severe aortic regurgitation. When the pulmonary artery opened, we found unexpected fresh vegetation. The tissue of the PDA was fragile and infected. We successfully removed the infected tissue, closed the PDA with a patch, and replaced the aortic valve with a mechanical prosthesis.
Kim, Seon Hee; Kim, Min Su; Kim, Sang-pil; Choi, Jung Hyun
Transcatheter aortic valve implantation (TAVI) is becoming a valuable alternative to surgical aortic valve replacement in non-operable and high-risk surgical patients. As the population of heart donors and recipients ages, the prevalence of degenerative valvular disease after transplantation will increase. The optimal treatment strategy of valvulopathies in these patients with extensive comorbidity is still unknown because of insufficient published experience. We present a heart transplant recipient with renal failure, systolic heart failure and severe aortic stenosis who was successfully treated with transapical TAVI.
De Praetere, Herbert; Ciarka, Agnieszka; Dubois, Christophe; Herijgers, Paul
In aortic stenosis plasma lipoprotein-derived lipids accumulate in aortic valves. Here, we first compared the lipid compositions of stenotic aortic valves and atherosclerotic plaque cores. Both pathological tissues were found to be enriched in cholesteryl linoleate, a marker of extracellularly accumulated lipoproteins. In addition, a large proportion of the phospholipids were found to contain arachidonic acid, the common precursor of a number of proinflammatory lipid mediators. Next, we isolated and characterized extracellular lipid particles from human stenotic and non-stenotic control valves, and compared them to plasma lipoproteins from the same subjects. The extracellular valvular lipid particles were isolated from 15 stenotic and 14 non-stenotic aortic valves. Significantly more apoB-100-containing lipid particles were found in the stenotic than in the non-stenotic valves. The majority of the lipid particles isolated from the non-stenotic valves had sizes (23±6.2 nm in diameter) similar to those of plasma low density lipoprotein (LDL) (22±1.5 nm), while the lipid particles from stenotic valves were not of uniform size, their sizes ranging from 18 to more than 500 nm. The lipid particles showed signs of oxidative modifications, and when compared to isolated plasma LDL particles, the lipid particles isolated from the stenotic valves had a higher sphingomyelin/phosphatidylcholine –ratio, and also higher contents of lysophosphatidylcholine and unesterified cholesterol. The findings of the present study reveal, for the first time, that in stenotic human aortic valves, infiltrated plasma lipoproteins have undergone oxidative and lipolytic modifications, and become fused and aggregated. The generated large lipid particles may contribute to the pathogenesis of human aortic stenosis.
Lehti, Satu; Kakela, Reijo; Horkko, Sohvi; Kummu, Outi; Helske-Suihko, Satu; Kupari, Markku; Werkkala, Kalervo; Kovanen, Petri T.; Oorni, Katariina
Background The objectives were to determine and assess the reliability of criteria for identification of aortic valve prolapse (AVP) using echocardiography in the horse. Results Opinion of equine cardiologists indicated that a long-axis view of the aortic valve (AoV) was most commonly used for identification of AVP (46%; n=13). There was consensus that AVP could be mimicked by ultrasound probe malignment. This was confirmed in 7 healthy horses, where the appearance of AVP could be induced by malalignment. In a study of a further 8 healthy horses (5 with AVP) examined daily for 5 days, by two echocardiographers standardized imaging guidelines gave good to excellent agreement for the assessment of AVP (kappa>0.80) and good agreement between days and observers (kappa >0.6). The technique allowed for assessment of the degree of prolapse and measurement of the prolapse distance that provided excellent agreement between echocardiographers, days and observers (kappa/ICC>0.8). Assessments made using real-time zoomed images provided similar measurements to the standard views (ICC=0.9), with agreement for the identification of AVP (kappa>0.8). Short axis views of the AoV were used for identification of AVP by fewer respondents (23%), however provided less agreement for the identification of AVP (kappa>0.6) and only adequate agreement with observations made in long axis (kappa>0.5), with AVP being identified more often in short axis (92%) compared to long axis (76%). Orthogonal views were used by 31% of respondents to identify the presence of AVP, and 85% to identify cusp. Its identification on both views on 4 days was used to categorise horses as having AVP, providing a positive predictive value of 79% and negative predictive value of 18%. Only the non-coronary cusp (NCC) of the AoV was observed to prolapse in these studies. Prolapse of the NCC was confirmed during the optimisation study using four-dimensional echocardiography, which concurred with the findings of two-dimensional echocardiography. Conclusions This study has demonstrated reliable diagnostic criteria for the identification and assessment of AVP that can be used for longitudinal research studies to better define the prevalence and natural history of this condition.
Patients with rheumatic valvular heart disease who have undergone valve surgery may present later with progression of disease in other valves. We report a case of successful percutaneous transvenous mitral commissurotomy (PTMC) in a 58-year-old male who underwent aortic valve replacement (AVR) with a No. 23 Björk-Shiley valve for severe rheumatic aortic regurgitation in 1982. At AVR, echocardiography revealed mild mitral stenosis (MS) and mitral valve area (MVA) 2.5 cm2. Over 18 years, the mitral valve disease progressed to severe MS and the patient presented with class III exertional dyspnea. He underwent successful PTMC (Inoue balloon technique). Post-procedure echocardiography revealed a MVA of 2.0cm2 and grade II mitral regurgitation. Anticoagulation management, infective endocarditis prophylaxis and procedural modifications are discussed. PMID:11767192
Faizal, A; Umesan, C V; Radhakrishnan, N; Lakshmi, V; Hemalatha, R
If left untreated, symptomatic, severe aortic stenosis (AS) is associated with a dismal prognosis. Open-heart surgical valve replacement is the treatment of choice and is associated with excellent short and long-term outcome. However, many older patients with multiple co-morbidities and anticipated increased surgical risk are excluded from surgical intervention. For these patients, transcatheter aortic valve implantation (TAVI) is emerging as a viable treatment alternative. Transcatheter valvular heart procedures are characterized by lack of exposure and visualization of the operative field, therefore relying on image guidance, both for patient selection and preparation and the implantation procedure itself. This article describes the role of multi-detector row computed tomography (MDCT) for detailed assessment of the aortic valve, aortic root, and iliac arteries in the context of TAVI.
Hausleiter, Jorg; Achenbach, Stephan; Desai, Milind Y.; Tuzcu, E. Murat
While the mechanical behaviors of the fibrosa and ventricularis layers of the aortic valve (AV) leaflet are understood, little information exists on their mechanical interactions mediated by the GAG-rich central spongiosa layer. Parametric simulations of the interlayer interactions of the AV leaflets in flexure utilized a tri-layered finite element (FE) model of circumferentially oriented tissue sections to investigate inter-layer sliding hypothesized to occur. Simulation results indicated that the leaflet tissue functions as a tightly bonded structure when the spongiosa effective modulus was at least 25 % that of the fibrosa and ventricularis layers. Novel studies that directly measured transmural strain in flexure of AV leaflet tissue specimens validated these findings. Interestingly, a smooth transmural strain distribution indicated that the layers of the leaflet indeed act as a bonded unit, consistent with our previous observations (Stella and Sacks in J Biomech Eng 129:757-766, 2007) of a large number of transverse collagen fibers interconnecting the fibrosa and ventricularis layers. Additionally, when the tri-layered FE model was refined to match the transmural deformations, a layer-specific bimodular material model (resulting in four total moduli) accurately matched the transmural strain and moment-curvature relations simultaneously. Collectively, these results provide evidence, contrary to previous assumptions, that the valve layers function as a bonded structure in the low-strain flexure deformation mode. Most likely, this results directly from the transverse collagen fibers that bind the layers together to disable physical sliding and maintain layer residual stresses. Further, the spongiosa may function as a general dampening layer while the AV leaflets deforms as a homogenous structure despite its heterogeneous architecture. PMID:24292631
Buchanan, Rachel M; Sacks, Michael S
Abstract Background and aim. It has been demonstrated that right ventricular systolic dysfunction develops soon after surgical aortic valve replacement (s-AVR). While the impact of s-AVR or TAVI on the function of the left ventricle has been studied with various imaging modalities, little is known about the impact on right ventricular function (RVF). In the current study, we evaluated the impact of TAVI on RVF using conventional echocardiography parameters. Methods and results. Echocardiography was performed prior to 24 h, 1 month and 6 months after TAVI. RVF was assessed using (1) tricuspid annular plane systolic excursion (TAPSE); (2) RV Tissue Doppler Imaging (S'); (3) right ventricular systolic pressure (RVSP); (4) Fractional area change (FAC); and (5) RV ejection fraction (RVEF). TAVI was performed through the subclavian artery in two patients and femoral artery in 48 patients with an Edwards Sapien XT valve. TAVI was performed on 50 patients between the dates of December 2012 and June 2013. After TAVI, a statistically significant improvement was observed for all parameters related to RVF (RVSP, RVEF, TAPSE, FAC, RVTDI S'). During the 1st and 6th months this statistically significant improvement continued in TAPSE and FAC, and there was no deterioration in RVSP, RVEF, and RVTDI S during the 1st month but a statistically significant improvement continued in the 6th month. Conclusion. RVF assessed by conventional echocardiography did not deteriorate after TAVI in early and midterm follow-up. Further, TAVI provides improvement of RVF and can safely and efficiently be performed in patients with impaired RVF. PMID:24491180
Ayhan, Hüseyin; Durmaz, Tahir; Kele?, Telat; Sari, Cenk; Aslan, Abdullah Nabi; Kasapkara, Haci Ahmet; Bozkurt, Engin
The use of percutaneous aortic valve implantation is limited, as the native calcified valve is left in situ. A new device\\u000a has been developed for resecting calcified aortic valves, using collapsible nickel-titanium blades: laser-cut T-structures\\u000a of Nitinol sheet-material (Ni51Ti49 at.%) have been grinded on a high-speed milling cutter to produce cutting edges which\\u000a have been given the shape of half-circles
Florian Hauck; Daniel Wendt; Sebastian Stühle; Emilia Kawa; Hermann Wendt; Wiebke Müller; Matthias Thielmann; Brigitte Kipfmüller; Bernd Vogel; Heinz Jakob
Abstract: Cardiothoracic surgeons have utilized the surgical robot to provide a minimally invasive approach to a number of intracardiac operations, including tumor resection, valve repair, and ablation of atrial arrhythmia. We report the case of a 58 year-old woman who was found to have a mobile mass on her aortic valve during evaluation of atrial fibrillation. Both of these conditions were addressed when she underwent a combined robotic biatrial Maze procedure and excision of the mass, which proved to be a papillary fibroelastoma of the aortic valve.
Murphy, Edward T
We propose a new image guidance system for assisting transapical minimally invasive aortic valve implantation. The goal is to define the exact positioning of aortic valve prosthesis, preventing the misplacement of the valve. The proposed system consists of two stand-alone modules. First, preoperative planning software uses DynaCT images with manual anatomical landmarks to calculate the size and optimal position of the prosthesis. Second, an intraoperative system is developed for tracking of the prosthesis and the coronary ostia in 2-D fluoroscopic images. Then the safe area of implantation is defined. The preliminary experimental results of preoperative planning and intraoperative tracking system are promising. PMID:19963592
Karar, M E; Gessat, M; Walther, T; Falk, V; Burgert, O
Objective: Trans-apical aortic valve implantation (TA-AVI) has evolved into a standard approach for high-risk, elderly patients using the balloon-expandable Edwards SAPIEN™ prosthesis. As an alternative device, a self-expanding sub-coronary trans-apical bioprosthesis was evaluated. Methods: The Symetis Acurate™ trans-catheter heart valve is composed of a porcine biologic valve attached to a self-expandable nitinol stent. It allows for anatomical orientation, and facilitates
Jörg Kempfert; Ardawan J. Rastan; Friedhelm Beyersdorf; Markus Schönburg; Gerhard Schuler; Stefan Sorg; Friedrich-W. Mohr; Thomas Walther
Objecti6e: The choice of a valve substitute remains a challenge in young patients, with numerous reports of early degeneration and calcification of biological valves in this age group. Therefore an assessment of the long-term results after mechanical aortic valve replacement in children was initiated. Methods: A retrospective study was conducted in 54 consecutive patients aged 1.1 to 17 years (mean
Gerard Champsaur; Jacques Robin; Francois Tronca; Jean Nineta
There is a paucity of data describing acute kidney injury (AKI) following transcatheter aortic valve implantation and its impact on mortality remains unknown. We therefore evaluate the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. We searched MEDLINE for studies from 2008 to 2013, evaluating AKI after transcatheter aortic valve implantation. All studies were compared according to the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. AKI was diagnosed according to the Valve Academic Research Consortium definition using the RIFLE criteria. Thirteen studies with more than 1900 patients were included. AKI occurred in 8.3-57% of the patients. The following factors were associated with AKI: blood transfusion; transapical access; preoperative creatinine concentration; peripheral vascular disease; hypertension; and procedural bleeding events. The 30-day mortality rate in patients with AKI ranged from 13.3% to 44.4% and was 2-6-fold higher than in patients without AKI. The amount of contrast agent used was not associated with the occurrence of AKI. AKI is a common complication, with an incidence of 8.3-57% following transcatheter aortic valve implantation. Patients with AKI had higher 30-day and late mortality rates. However, AKI was related to the amount of contrast volume used in only one study. PMID:24556191
Elhmidi, Yacine; Bleiziffer, Sabine; Deutsch, Marcus-André; Krane, Markus; Mazzitelli, Domenico; Lange, Rüdiger; Piazza, Nicolo
BACKGROUND Bicuspid aortic valve (BAV) is one of the most common and important congenital heart disorders in adults. If a patient with congenital disorders is not diagnosed early, the patient’s disease may progress to a severe condition and thus diagnosis of the main disorder will be rendered difficult. CASE REPORT A 34 year-old male patient referred to a referral medical care unit for cardiac electrophysiological study with cardiac shock due to complete heart block 3 months ago and he underwent Dual-Chamber permanent pacemaker (PPM) implantation. Thick and calcified bicuspid AV with invasion to interventricular septum, moderate to severe valve insufficiency (AI), severe aortic valve stenosis (AS), and dilated ascending aorta were observed at his echocardiography. Aortic valve replacement (AVR), aneurysm of ascending aorta, root replacement with tube graft (Bentall Procedure), and also a 3 chambers intracardiac defibrillator (ICD) were used. After 2 weeks of operation, he was discharged and at the first post-hospitalization visit (1 week later), his cardiovascular condition was acceptable. CONCLUSION Thick calcified aortic root is a less studied and potential contributing risk factor for AV block after AVR. Therefore, in candidates of aortic valve replacement, considering conductive disorders, especially in patients with calcified valve, is mandatory. Irreversible AV block requiring PPM implantation is a rare condition following AVR.
Karbasi-Afshar, Reza; Jonaidi-Jafari, Nematollah; Saburi, Amin; Khosravi, Arezoo
In children, systemic heart valve replacement with bioprostheses is associated with accelerated valve degeneration, and mechanical prostheses require permanent anticoagulation. Novel "biomechanical" polymeric valve prostheses ("bio" = flexible, "mechanical" = synthetic), solely made of polycarbonate urethane (PCU), were tested in vitro and in a growing animal (calf) model with the aim of improved durability without permanent anticoagulation. The trileaflet aortic prosthesis has diminished pressure loss and reduced stress and strain peaks. The asymmetric bileaflet mitral valve mimics natural nonaxial inflow. The valves underwent long-term in vitro testing and in vivo testing in growing calves for 20 weeks [mitral (7), aortic (7)] with comparison to different commercial bioprostheses [mitral (7), aortic (2)]. In vitro durability of PCU valves was proved up to 20 years. Survival of PCU valves versus bioprostheses was 7 versus 2 mitral and 5 versus 0 aortic valves, respectively. Two animals with PCU aortic valves died of pannus overgrowth causing left ventricular outflow tract obstruction. Degeneration and calcification were mild (mitral) and moderate (aortic) in PCU valves but were severe in biological valves. There was no increased thrombogenicity of the PCU valves compared to bioprostheses. The novel polymeric valve prostheses revealed superior durability compared to current bioprostheses in growing animal model without permanent anticoagulation and thus, may be a future option for pediatric patients. PMID:16966862
Sachweh, Joerg S; Daebritz, Sabine H
Non-invasive recording of aortic blood flow velocity patterns in the ascending aorta and in the arch of the aorta was performed in 12 normal subjects, 38 patients with confirmed aortic valve disease, and 13 patients with aortic prostheses using pulse echo Doppler velocity recordings. In normal subjects, the velocity recordings correlated well with those obtained by other authors using invasive
C Veyrat; N Cholot; G Abitbol; D Kalmanson
The bicuspid aortic valve (BAV) and specific systemic autoimmune diseases are associated with cardiovascular manifestation, including aortic aneurysm. We reported a case of 64 year-old patient with BAV and a history of ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE), and who developed ascending thoracic aortic aneurysm. The patient presented also the homozygosity for genetic variants of MMP9, ACE, MTHFR
Ilenia Foffa; Pier Luigi Festa; Lamia Ait-Ali; Annamaria Mazzone; Stefano Bevilacqua; Maria Grazia Andreassi
Aortic valve disease (AVD) occurs in 2.5% of the general population and often requires surgical intervention. Aortic valve malformation (AVM) underlies the majority of cases, suggesting a developmental etiology. Elastin haploinsufficiency results in complex cardiovascular problems, and 20–45% of patients have AVM and/or AVD. Elastin insufficient (Eln+/?) mice demonstrate AVM and latent AVD due to abnormalities in the valve annulus region. The objective of this study was to examine extracellular matrix (ECM) remodeling and biomechanical properties in regional aortic valve tissue and determine the impact of early AVM on late AVD in the Eln+/? mouse model. Aortic valve ECM composition and remodeling from juvenile, adult, and aged stages were evaluated in Eln+/? mice using histology, ELISA, immunohistochemistry and gelatin zymography. Aortic valve tissue biomechanical properties were determined using micropipette aspiration. Cartilage-like nodules were demonstrated within the valve annulus region at all stages identifying a developmental abnormality preceding AVD. Interestingly, maladaptive ECM remodeling was observed in early AVM without AVD and worsened with late AVD, as evidenced by increased MMP-2 and MMP-9 expression and activity, as well as abnormalities in ADAMTS-mediated versican processing. Cleaved versican was increased in the valve annulus region of aged Eln+/? mice, and this abnormality correlated temporally with adverse alterations in valve tissue biomechanical properties and the manifestation of AVD. These findings identify maladaptive ECM remodeling in functional AVM as an early disease process with a progressive natural history, similar to that seen in human AVD, emphasizing the importance of the annulus region in pathogenesis. Combining molecular and engineering approaches provides complementary mechanistic insights that may be informative in the search for new therapeutic targets and durable valve bioprostheses.
Krishnamurthy, Varun K.; Opoka, Amy M.; Kern, Christine B.; Guilak, Farshid; Narmoneva, Daria A.; Hinton, Robert B.
Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement (AVR) and most of them have been diagnosed as a late complication. We present a case of this unusual complication after AVR. Intraoperative transoesophageal echocardiography identified and diagnosed this rare and potentially disastrous surgical complication and confirmed adequacy of its surgical repair. PMID:24732620
Ahmad, Tanveer; Chithiraichelvan, Satish; Patil, Thimmangouda Ayangouda; Jawali, Vivek
Transcatheter aortic valve implantation for patients with severe aortic stenosis at a high-operative risk has been demonstrated to improve mortality compared to standard medical therapy. Registry data and the PARTNER trial have shown a significant risk of stroke (3-5%) following the procedure. Studies using cerebral diffusion-weighted magnetic resonance imaging have suggested the mechanism of stroke to be multiple small embolic infarcts, possibly from aortic atheroma dislodged during the movement of the valve and its apparatus around the thoracic aorta. The incidence of these infarcts is higher than clinically apparent. The Medtronic CoreValve (Medtronic, Minneapolis, Minnesota) prosthesis is a self-expanding nitinol frame with porcine valve, whose deployment is achieved by the retraction of the delivery catheter. Potential complications of this method include valve mal-positioning and dislocation. The partially deployed valve may then be resheathed following retraction back into the descending aorta and subsequently redeployed. We present two such cases with evidence of both "silent" and clinically evident cerebral infarction. PMID:21954023
Fairbairn, Timothy A; Greenwood, John P; Blackman, Daniel J
Historically, many patients with severe senile calcific aortic valve stenosis (AS) were not offered surgery, largely due to the perception that the risks of operation were prohibitive. Such patients have subsequently been formally designated as 'high risk' or 'inoperable' with respect to their suitability for surgical aortic valve replacement (SAVR) in the evolving lexicon of heart valve disease. The recent availability of transcatheter aortic valve replacement (TAVR) represents an alternative treatment option, and permits the opportunity to re-examine algorithms for assessing operative risk. As the experience with TAVR grows, expanded use in new patient populations can be anticipated. While TAVR in high risk AS patients has demonstrated benefits, the emerging indication in intermediate AS is less clear and conclusions will necessarily await the availability of results from ongoing clinical trials. This article will discuss current outcomes for SAVR among high- and intermediate-risk patients with AS as a barometer in assessing the results of nascent percutaneous therapies. PMID:24838137
Bajona, Pietro; Suri, Rakesh M; Greason, Kevin L; Schaff, Hartzell V
Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated. We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk-Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used. Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk-Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus. PMID:16998706
Sakamoto, Yoshimasa; Hashimoto, Kazuhiro; Okuyama, Hiroshi; Ishii, Shinichi; Shingo, Taguchi; Kagawa, Hiroshi
Aims. Dysregulated expression of the endothelial nitric oxide synthase (eNOS) is observed in aortic aneurysms associated with bicuspid aortic valve (BAV). We determined eNOS protein levels in various areas in ascending aortic aneurysms. Methods and Results. Aneurysmal specimens were collected from 19 patients, 14 with BAV and 5 with tricuspid aortic valve (TAV). ENOS protein levels were measured in the outer curve (convexity), the opposite side (concavity), the distal and above the sinotubular junction (proximal) aneurysm. Cultured aortic cells were treated with NO synthesis inhibitor L-NAME and the amounts of 35 apoptosis-related proteins were determined. In patients with BAV, eNOS levels were significantly lower in the proximal aorta than in the concavity and distal aorta. ENOS protein levels were also lower in the convexity than in the concavity. While the convexity and distal aorta showed similar eNOS protein levels in BAV and TAV patients, levels were higher in TAV proximal aorta. Inhibition of NO synthesis in aneurysmal aortic cells by L-NAME led to a cytosolic increase in the levels of mitochondrial serine protease HTRA2/Omi. Conclusion. ENOS protein levels were varied at different areas of the aneurysmal aorta. The dysregulation of nitric oxide can lead to an increase in proapoptotic HTRA2/Omi. PMID:22745920
Mohamed, Salah A; Radtke, Arlo; Saraei, Roza; Bullerdiek, Joern; Sorani, Hajar; Nimzyk, Rolf; Karluss, Antje; Sievers, Hans H; Belge, Gazanfer
Calcific aortic valve stenosis (CAVS) is a major health problem facing aging societies. The identification of osteoblast-like and osteoclast-like cells in human tissue has led to a major paradigm shift in the field. CAVS was thought to be a passive, degenerative process, whereas now the progression of calcification in CAVS is considered to be actively regulated. Mechanistic studies examining the contributions of true ectopic osteogenesis, non-osseous calcification, and ectopic osteoblast-like cells (that appear to function differently from skeletal osteoblasts) to valvular dysfunction have been facilitated by the development of mouse models of CAVS. Recent studies also suggest that valvular fibrosis, as well as calcification, may play an important role in restricting cusp movement, and CAVS may be more appropriately viewed as a fibrocalcific disease. High resolution echocardiography and magnetic resonance imaging have emerged as useful tools for testing the efficacy of pharmacological and genetic interventions in vivo. Key studies in humans and animals are reviewed that have shaped current paradigms in the field of CAVS, and suggest promising future areas for research.
Miller, Jordan D.; Weiss, Robert M.; Heistad, Donald D.
Transcatheter aortic valve implantation for severe, non-calcified aortic regurgitation and narrow aortic root: description from a case report of a new approach to potentially avoid coronary artery obstruction.
Transcatheter aortic valve implantation is a possible, although off-label, alternative to conventional aortic valve replacement for high-surgical-risk patients with severe, non-calcified aortic regurgitation (AR). To date, feasibility has only been demonstrated with the Medtronic CoreValve prosthesis (MCV). This prosthesis needs the aortic sinuses to have enough width to avoid coronary obstruction. We report a case of MCV implantation for severe AR where the narrow aortic root theoretically precluded the technique. Good procedural outcome was achieved thanks to a strategy of implantation with planned positioning of the prosthesis leaflets away from the coronary arteries. PMID:22744753
Dumonteil, Nicolas; Marcheix, Bertrand; Lairez, Olivier; Laborde, Jean-Claude
To analyze velocity spectral energy distribution in humans, blood velocities were recorded by means of hot-film anemometry at 41 predetermined measurement points in the cross-sectional area of the ascending aorta approximately 6 cm downstream of the aortic valves. Measurements were made in 8 patients with normal aortic valves, in 4 after insertion of a St. Jude Medical (SJM) aortic valve and in 3 after insertion of a Starr-Edwards Silastic Ball (SSB) aortic valve. Data analysis based on Fast Fourier Transform demonstrated that turbulence energy was lower in patients with normal aortic valves than in patients after insertion of an artificial valve in the aortic position and probably more pronounced after SSB valves than after SJM valves. The spatial distribution of the turbulence energy above 100 Hz was more irregular than corresponding laminar velocities previously presented. The VER100 (Velocity Energy Ratio at 100 Hz, i.e. the velocity energy above 100 Hz divided by the total velocity energy) proved useful for evaluating differences in flow disturbances downstream of different aortic valves. The mean VER100 in the three categories of patients were respectively 0.3, 1.4, and 2.1%. PMID:2970441
Paulsen, P K; Nygaard, H; Hasenkam, J M; Gormsen, J; Stødkilde-Jørgensen, H; Albrechtsen, O
Hypertension and congenital aortic valve malformations are frequent causes of ascending aortic aneurysms. The molecular mechanisms of aneurysm formation under these circumstances are not well understood. Reference genes for gene activity studies in aortic tissue that are not influenced by aortic valve morphology and its hemodynamic consequences, aortic dilatation, hypertension, or antihypertensive medication are not available so far. This study determines genes in ascending aortic tissue that are independent of these parameters. Tissue specimens from dilated and undilated ascending aortas were obtained from 60 patients (age ?70 years) with different morphologies of the aortic valve (tricuspid undilated n?=?24, dilated n?=?11; bicuspid undilated n?=?6, dilated n?=?15; unicuspid dilated n?=?4). Of the studied individuals, 36 had hypertension, and 31 received ACE inhibitors or AT1 receptor antagonists. The specimens were obtained intraoperatively from the wall of the ascending aorta. We analyzed the expression levels of 32 candidate reference genes by quantitative RT-PCR (RT-qPCR). Differential expression levels were assessed by parametric statistics. The expression analysis of these 32 genes by RT-qPCR showed that EIF2B1, ELF1, and PPIA remained constant in their expression levels in the different specimen groups, thus being insensitive to aortic valve morphology, aortic dilatation, hypertension, and medication with ACE inhibitors or AT1 receptor antagonists. Unlike many other commonly used reference genes, the genes EIF2B1, ELF1, and PPIA are neither confounded by aortic comorbidities nor by antihypertensive medication and therefore are most suitable for gene expression analysis of ascending aortic tissue.
Henn, Dominic; Bandner-Risch, Doris; Perttunen, Hilja; Schmied, Wolfram; Porras, Carlos; Ceballos, Francisco; Rodriguez-Losada, Noela; Schafers, Hans-Joachim
Mechanical aortic valve dysfunction is a very rare event and is usually due to thrombosis, pannus overgrowth, or both. BioGlue as a cause for such a complication has been reported only occasionally. We describe a case of a 63-year-old woman who underwent operation for symptomatic tight aortic stenosis. After implantation of an aortic valve (AGN-751, size 19; St. Jude Medical, St. Paul, MN, USA) because of a transverse tear of the aortic wall above the annulus occurring during the suturing of the aortotomy, a triangular Vascutek Dacron patch (Vascutek/Terumo, Inchinnan, Scotland, UK) was included. To secure hemostasis, BioGlue (CryoLife, Kennesaw, GA, USA) was applied. A transthoracic echocardiography (TTE) examination performed after signs of ischemia appeared in the electrocardiogram on postoperative day 5 revealed an aortic transvalvular gradient of 74/38 mm Hg and a functional valve area of 1.0 cm2. No coronary lesions were revealed in a coronarography evaluation, but cinefluoroscopy (CF) examination revealed immobility of 1 valve leaflet. The reoperation revealed a thick, rough layer of the glue on the inner side of the patch. This glue had run down to the valve, blocking a mechanical leaflet. Cleaning the valve was not possible, and the valve had to be changed. The subsequent postoperative course was uneventful. The transvalvular gradient was 39/20 mm Hg, and the functional valve area was 1.2 cm2. We believe that the use of BioGlue and other surgical sealants is justified to secure complex suture lines and for maintaining hemostasis in cardiac surgery, but some precautionary rules must be respected. Authors have indicated that the glue enters through the needle holes in such cases, but our findings suggest it can also pass to the Dacron patch itself. CF is superior to TTE and transesophageal echocardiography for analyzing movement of the mechanical valve leaflet, and cardiac catheterization is rarely needed. PMID:23262046
To date, the gold standard of aortic stenosis treatment is surgical valve replacement. However, in inoperable or high risk patients a valid alternative is transcatheter aortic valve implantation (TAVI). Several trials showed feasibility, efficacy and safety of TAVI, with a tailored strategy for these patients on the basis of their clinical and anatomical conditions. The selection of valve type (CoreValve® or Edwards Sapien®) and transcatheter approach (transfemoral, transapical, subclavian or direct aortic approach) is an important step in the management of aortic stenosis. However, mortality is high and it is mainly related to non-cardiac reasons, given the high clinical risk profile of these patients. Moreover, the less invasive approach, the faster recovery, the reduced morbidity and the improved psychological tolerance, typical of TAVI, suggest that this technique could be used in a broader spectrum of cases, becoming a valid therapeutic alternative even in patients with severe aortic stenosis with a low surgical risk or asymptomatics. The identification of aortic stenosis patients by the medical community and their assessment over time, before they become candidates only for "extreme" strategies, remains the main challenge. PMID:24686997
Niglio, T; Galasso, G; Piccolo, R; Di Gioia, G; Strisciuglio, T; Esposito, G; Trimarco, B; Piscione, F
The scientific and technological progress in the field of medicine has allowed to treat patients with severe aortic valve stenosis and with a high perioperative risk. Before the introduction of transcatheter aortic valve implantation (TAVI), patients considered at high risk for surgical treatment were managed with medical therapy or with balloon aortic valvuloplasty. With more than 50000 transcatheter aortic valves implanted in patients around the world, TAVI has demonstrated to be a valid alternative to surgical aortic valve replacement in inoperable and high-risk patients. The PARTNER trial was the first randomized controlled trial to demonstrate that TAVI is not inferior to SAVR in high-risk patients. However, despite some encouraging short-term results medium and long-term outcomes are not always so encouraging. In this review, we will present the immediate results and distinct TAVI-related drawbacks and relative impact on the long-term outcome. New technology advances promise to simplify TAVI and to improve the results by reducing the rate of TAVI-specific issues such as paravalvular aortic regurgitation, annular rupture, and conduction disturbances which may impact on the clinical outcome. Therefore, we believe that when some of these weaknesses will be overcome, even patients at lower risk might benefit from TAVI in the near future. PMID:23846006
Godino, C; Pavon, A G; Colombo, A
Objective “Patient-prosthesis mismatch” (PPM) after aortic valve replacement (AVR) has been reported to increase morbidity and mortality. Although algorithms have been developed to avoid PPM, factors favouring its occurrence have not been well defined. Design and Setting This was a prospective cohort study performed at the Medical University of Vienna. Patients 361 consecutive patients who underwent aortic valve replacement for isolated severe aortic stenosis were enrolled. Main Outcome Measures Patient- as well as prosthesis-related factors determining the occurrence of moderate and severe PPM (defined as effective orifice area indexed to body surface area ? 0.8 cm2/m2) were studied. Results Postoperatively, 172 patients (48%) were diagnosed with PPM. The fact that predominantly female patients were affected (58% with PPM diagnosis in women versus 36% in men, p<0.001) was explained by the finding that they had smaller aortic root diameters (30.5±4.7 mm versus 35.3±4.2 mm, p<0.0001) and a higher proportion of bioprosthetic valves (82% versus 62%, p<0.0001), both independent predictors of PPM (aortic root diameter: OR 0.009 [95% CI, 0.004;0.013]; p?=?0.0003, presence of bioprosthetic valve: OR 0.126 [95% CI, 0.078;0.175]; p<0.0001). Conclusions The occurrence of PPM is determined by aortic root diameter and prosthesis type. Novel sutureless bioprostheses with optimized hemodynamic performance or transcatheter aortic valves may become a promising alternative to conventional bioprosthetic valves in the future.
Bonderman, Diana; Graf, Alexandra; Kammerlander, Andreas A.; Kocher, Alfred; Laufer, Guenter; Lang, Irene M.; Mascherbauer, Julia
Bicuspid aortic valve (BAV) is a congenital anomaly associated with structural weakness of the aortic wall. Sudden onset of symptoms in patients with BAV, such as sudden severe back pain, and pulse inequality between the extremities or tension disparity should alert clinicians to acute aortic syndromes, as they require prompt diagnosis and management. Retrograde aortic dissection, which is a rare form of acute aortic syndrome, is an uncommon life-threatening entity and may produce atypical computed tomography (CT) or magnetic resonance imaging findings, leading to difficulty in diagnosis. We report on a 51-year-old male patient with BAV and spontaneous retrograde ascending aortic dissection. CT findings were confusing and the diagnosis was made via transoesophageal echocardiography. After the diagnosis, the patient was treated with a modified Bentall procedure. He did not have any complications and was stable four months after the operation. PMID:24217212
Akgullu, Cagdas; Hekim, Tolga; Eryilmaz, Ufuk; Kurto?lu, Tünay; Gürcün, U?ur
The network of collagen fibers in the aortic valve leaflet is believed to play an important role in the strength and durability of the valve. However, in addition to its stress-bearing role, such a fiber network has the potential to produce functionally important shape changes in the closed valve under pressure load. We measured the average pattern of the collagen network in porcine aortic valve leaflets after staining for collagen. We then used finite element simulation to explore how this collagen pattern influences the shape of the closed valve. We observed a curved or bent pattern, with collagen fibers angled downward from the commissures toward the center of the leaflet to form a pattern that is concave toward the leaflet free edge. Simulations showed that these curved fiber trajectories straighten under pressure load, leading to functionally important changes in closed valve shape. Relative to a pattern of straight collagen fibers running parallel to the leaflet free edge, the concave pattern of curved fibers produces a closed valve with a 40% increase in central leaflet coaptation height and with decreased leaflet billow, resulting in a more physiological closed valve shape. Furthermore, simulations show that these changes in loaded leaflet shape reflect changes in leaflet curvature due to modulation of in-plane membrane stress resulting from straightening of the curved fibers. This effect appears to play an important role in normal valve function and may have important implications for the design of prosthetic and tissue engineered replacement valves. PMID:24315286
Hammer, Peter E; Pacak, Christina A; Howe, Robert D; del Nido, Pedro J
Aortic valve disease is an important cardio-vascular disorder, which affects 2.5% of the global population and often requires elaborate clinical management. Experts agree that visual and quantitative evaluation of the valve, crucial throughout the clinical workflow, is currently limited to 2D imaging which can potentially yield inaccurate measurements. In this paper, we propose a novel approach for morphological and functional quantification of the aortic valve based on a 4D model estimated from computed tomography data. A physiological model of the aortic valve, capable to express large shape variations, is generated using parametric splines together with anatomically-driven topological and geometrical constraints. Recent advances in discriminative learning and incremental searching methods allow rapid estimation of the model parameters from 4D Cardiac CT specifically for each patient. The proposed approach enables precise valve evaluation with model-based dynamic measurements and advanced visualization. Extensive experiments and initial clinical validation demonstrate the efficiency and accuracy of the proposed approach. To the best of our knowledge this is the first time such a patient specific 4D aortic valve model is proposed. PMID:18979806
Ionasec, Razvan Ioan; Georgescu, Bogdan; Gassner, Eva; Vogt, Sebastian; Kutter, Oliver; Scheuering, Michael; Navab, Nassir; Comaniciu, Dorin
Studies of human diseased aortic valves have demonstrated increased expression of genetic markers of valve progenitors and osteogenic differentiation associated with pathogenesis. Three potential mouse models of valve disease were examined for cellular pathology, morphology, and induction of valvulogenic, chondrogenic, and osteogenic markers. Osteogenesis imperfecta murine (Oim) mice, with a mutation in Col1a2, have distal leaflet thickening and increased proteoglycan composition characteristic of myxomatous valve disease. Periostin null mice also exhibit dysregulation of the ECM with thickening in the aortic midvalve region, but do not have an overall increase in valve leaflet surface area. Klotho null mice are a model for premature aging and exhibit calcific nodules in the aortic valve hinge-region, but do not exhibit leaflet thickening, ECM disorganization, or inflammation. Oim/oim mice have increased expression of valve progenitor markers Twist1, Col2a1, Mmp13, Sox9 and Hapln1, in addition to increased Col10a1 and Asporin expression, consistent with increased proteoglycan composition. Periostin null aortic valves exhibit relatively normal gene expression with slightly increased expression of Mmp13 and Hapln1. In contrast, Klotho null aortic valves have increased expression of Runx2, consistent with the calcified phenotype, in addition to increased expression of Sox9, Col10a1, and osteopontin. Together these studies demonstrate that oim/oim mice exhibit histological and molecular characteristics of myxomatous valve disease and Klotho null mice are a new model for calcific aortic valve disease.
Cheek, Jonathan D.; Wirrig, Elaine E.; Alfieri, Christina M.; James, Jeanne F.; Yutzey, Katherine E.
We report a case of a staged surgical and endovascular management in a 62-year-old woman with aortic coarctation associated with aortic valve stenosis and mitral regurgitation. The patient was admitted for severe aortic valve stenosis and mitral valve incompetence. During hospitalization and preoperative imaging, a previously undiagnosed aortic coarctation was discovered. The patient underwent a 2-stage approach that combined a Bentall procedure and mitral valve replacement in the first stage, followed by correction of the aortic coarctation by percutaneous placement of an Advanta V12 large-diameter stent graft (Atrium, Mijdrecht, The Netherlands) which to our knowledge has not been used in an adult patient with this combination of additional cardiac comorbidities. A staged approach combining surgical treatment first and endovascular placement of an Advanta V12 stent graft in the second stage can be effective and safe in adult patients with coarctation of the aorta and additional cardiac comorbidities. PMID:24332897
Novosel, Luka; Perkov, Dražen; Dobrota, Savko; ?ori?, Vedran; Štern Padovan, Ranka
OBJECTIVE--To determine the incidence and prognosis of congenital aortic valve stenosis in the five Health Districts of Liverpool that make up the Merseyside area. DESIGN--The records of the Liverpool Congenital Malformations Registry and the Royal Liverpool Children's Hospital identified 239 patients (155 male, 84 female) born with aortic valve stenosis between 1960 and 1990. Patients were traced to assess the severity of stenosis at follow up. Information on the severity at presentation and all subsequent events was obtained. RESULTS--Congenital aortic valve stenosis occurred in 5.7% of patients with congenital heart disease born in the Merseyside area. The median age at presentation was 16 months (range 0-20 years). Stenosis was mild at presentation in 145 patients, moderate in 33, severe in one and critical in 21 and 39 had a bicuspid valve without stenosis. Additional cardiac lesions were significantly more common in children presenting under one year of age and in those with critical stenosis. The median duration of follow up was 9.2 years (range 1-28 years) and seven patients were lost to follow up. 81 operations were performed in 60 patients. The reoperation rate was 28.3% after a median duration of 8.7 years (range 2.5-18 years). 15% of patients who presented with mild stenosis subsequently required operation compared with 67% of those with moderate stenosis. There were no sudden unexpected deaths and no deaths after aortic valvotomy, except in those presenting with critical stenosis. Mortality was 16.7% but patients presenting with critical aortic stenosis had a much worse prognosis. Actuarial and hazard analysis showed that the survival and absence of serious events (aortic valve surgery or balloon dilatation, endocarditis, or death) were significantly better in patients who presented with mild aortic stenosis than in those who presented with moderate aortic stenosis. 75% of patients presenting with mild stenosis had not progressed to moderate stenosis after 10 years of follow up. CONCLUSIONS--Congenital aortic valve stenosis may be progressive even when it is mild at presentation. Patients presenting with mild stenosis, however, have a significantly better prognosis than those presenting with moderate stenosis. An accurate clinical and echocardiographic assessment of the severity of aortic valve stenosis at presentation provides a good guide to prognosis into early adult life.
Kitchiner, D J; Jackson, M; Walsh, K; Peart, I; Arnold, R
Background Since 2002, transapical aortic valve replacement has been developed as a clinical pathway for transcatheter aortic valve implantation (TAVI). However the appropriate role of TA in the AS population versus TF remains unclear. We performed a meta-analysis to assess if TF has any benefit in reduction of 30-day clinical complications in AS. Methods We conducted a comprehensive search on pub-med and web of knowledge from 2002 through September 2012 using following terms: aortic stenosis, aortic valve replacement, transcatheter aortic valve implantation, TAVI, trans-artery, transfemoral, trans-apical. Studies in the original research or review articles were also considered. Included studies must meet the preconditioned criterias. Two investigators independently browsed the studies by title and abstract, finally making decision according to full-text. Disagreements were discussed in group. Results A total of 20 studies met inclusion criteria’s and were included in the analysis (including 4267 patients in TF group, 2242 in TA group). No random clinical trial, one was a retrospective study, others were prospective trials. Our meta-analysis found that TF had the low incidence of 30-day mortality compared with TA procedure (7.5% versus 11.3%). The incidence of stroke at???30 days was relatively low (3.8% in TF versus 4.0% in TA). Although the incidence of post-operative heart block was high (8.5% versus 7.5%), but no differences were indicated [1.06,95% CI(0.85,1.33)]. Conclusions The result of our meta-analysis suggested that TF may have a low risk for 30-day mortality against TA procedure. No difference was found in the incidence of post-operative stroke and heart block.
The impact of aortic valve replacement (AVR) on the dynamic geometry and motion of the mitral annulus remains unknown. We analyzed the effects of AVR on the dynamic geometry and motion of the mitral annulus. We used 3-dimensional transesophageal echocardiography to analyze 39 consecutive patients undergoing elective surgical AVR for aortic stenosis. Intraoperative 3-dimensional transesophageal echocardiography was performed immediately before and after AVR. Volumetric data sets were analyzed using a software package capable of dynamically tracking the mitral annulus and leaflets during the entire systolic ejection phase. After AVR, there were significant decreases (p <0.01) in annular dimensions such as anteroposterior (3.5 ± 0.1 vs 3.2 ± 0.1 cm), anterolateral-posteromedial (3.7 ± 0.1 vs 3.5 ± 0.1 cm), and commissural diameters (3.7 ± 0.1 vs 3.3 ± 0.1 cm), as well as annular circumference (12.0 ± 0.30 vs 11.1 ± 0.2 cm) and 3-dimensional mitral annular area (mean 10.9 ± 0.6 vs 9.3 ± 0.3 cm(3)). Vertical mitral annular displacement was also reduced (6.2 ± 3.1 vs 4.3 ± 2.2 mm). Mitral annular nonplanarity angle (154 ± 1.5° vs 161 ± 1.6°) and aorto-mitral angle (133 ± 3.3° vs 142 ± 2.0°) were both increased after AVR, suggesting reduced nonplanar shape of the mitral annulus and reduced aorto-mitral flexion. In conclusion, these data demonstrate that mitral annular size is reduced immediately after AVR and that the dynamic motion of the mitral annulus is restricted. These findings may have important clinical implications for patients undergoing AVR with concurrent mitral regurgitation. PMID:23891429
Warraich, Haider J; Matyal, Robina; Bergman, Remco; Hess, Philip E; Khabbaz, Kamal; Manning, Warren J; Mahmood, Feroze
Background and Objectives:Aortic valve sclerosis (AVS) is often considered to be benign and it is also consi- dered to be a manifestation of generalized atherosclerosis that involves the aortic valve. However, it is associated with high cardiovascular morbidity and mortality in a population-based study. This study was performed to evaluate the significance of AVS in patients with suspected coronary artery
Young-Woo Park; Dong-Soo Kim; Yong-Suk Jeong; Seok-Ju Park; Han-Young Jin; Seong-Gill Park; Yang-Chun Han; Jeong-Sook Seo; Su-Kyong Cho; Tae-Hyun Yang; Seong-Man Kim; Dae-Kyeong Kim; Doo-Il Kim
Objectives. Rickettsiae, which causes vasculitis, has not been linked to atherosclerotic cardiovascular disease in contrast to Chlamydia pneumoniae whose association with coronary artery disease and with sclerotic heart valves in patients undergoing aortic valve replacement is well established, even if causality is yet to unproven. In the search for any of these infectious agents, 84 pathological and 15 normal aortic
K. Nilsson; A. Liu; C. Påhlson; O. Lindquist
Papillary fibroelastoma of the aortic valve is an uncommon benign tumor of the heart that can present with embolic events. We report a case of 54-year-old lady with exertional chest pain and prior history of ST segment elevation myocardial infarction who was subsequently found to have a fibroelastoma of the aortic valve. The absence of angiographically significant coronary artery disease and resolution of anginal symptoms post-surgery in our patient points to the possibility of fibroelastoma causing these anginal symptoms. Although uncommon, fibroelastoma are being recognized more frequently with the help of transesophageal echocardiography. Hence, in the absence of significant coronary artery disease, we emphasize the importance of consideration of papillary fibroelastoma of the aortic valve as a cause of angina. We also discuss the key aspects of the fibroelastoma including presentation, diagnostic modalities and treatment options.
Aryal, Madan Raj; Badal, Madan; Mainali, Naba Raj; Jalota, Leena; Pradhan, Rajesh
Bicuspid aortic valve is the most common congenital cardiac anomaly and it may often coexist with other congenital cardiac anomalies. Its coexistence with discrete subaortic membrane, causing obstruction of the left ventricular outflow tract is very rare. A 21-year-old male patient presented with complaints of exertional dyspnea and dizziness. On transthoracic echocardiography, the parasternal short-axis view showed a bicuspid aortic valve, and parasternal long-axis color Doppler view showed a mosaic pattern in the subaortic region. A more careful examination of the parasternal long-axis views revealed a discrete subaortic membrane. Continuous-wave Doppler flow velocity obtained from the aortic valve was normal; however, a peak gradient of 30 mmHg was observed with the Valsalva maneuver. The fact that there are very few reports on this rare coexistence may be due to failure to recognize discrete subaortic membrane during echocardiographic examination. PMID:19155662
Koz, Cem; Yoku?o?lu, Mehmet; Baysan, Oben; Uzun, Mehmet
Transcatheter aortic valve implantation (TAVI) has now become an acceptable alternative to surgical aortic valve replacement for patients with severe aortic stenosis at high risk. The early enthusiasm for this technology has not diminished but rather has developed at an unprecedented rate over the last decade. Alongside the developments in implantation technique, transcatheter design, and postprocedural care, cardiac imaging modalities have also had to concurrently evolve to meet the perpetual demand for lower peri- and postprocedural complication rates. Although transthoracic and transesophageal echocardiography remain vital in patient's selection and periprocedural guidance, there is now emerging evidence that indicates that multidetector-computed tomography (MDCT) may also have an equally important role to play. The aim of the current review is to examine the modern role of MDCT in assessing patients with aortic stenosis being considered for TAVI. PMID:22926967
Rajani, Ronak; Brum, Roberta L; Barden, Edward; Drake, Sarah; Preston, Rebecca L; Carr-White, Gerald; Chambers, John B
Bicuspid aortic valve is the most common birth defect affecting the heart and is present in 1-2% of the population. The abnormal valve structure leads to turbulent flow, fibrosis, calcification, and aortic stenosis. Aortic stenosis increases perioperative morbidity and mortality. Anesthetic techniques that reduce systemic vascular resistance (regional neuraxial techniques) must be used with extreme caution. Hashimoto's disease or chronic thyroiditis or autoimmune thyroiditis is the most common cause of hypothyroidism in adults. Regional anesthesia is preferred in patients with hypothyroidism as recovery from general anesthesia may be delayed by hypothermia, respiratory depression, or slow drug biotransformation. This is a case report of anesthetic management of a middle-aged female with co-existing aortic stenosis, hypothyroidism, and fibroid uterus posted for abdominal hysterectomy. PMID:23603628
Holyachi, Renuka; Patil, Basavaraj; Karigar, Shivanand L
The Edwards MIRA bileaflet mechanical prosthesis, a heart valve not yet available in the United States, is designed with a unique hinge mechanism, curved leaflets, and thin titanium housing. We performed this study to investigate its clinical performance and postoperative hemodynamic results. We implanted 58 Edwards MIRA prostheses in 51 patients in the aortic (n=18), mitral (n=26), and aortic and mitral (n=7) positions. Patients' ages ranged from 25 to 84 years (mean age, 53.7 ± 13.6). Operative mortality was 2% (n=1), and late mortality was 4% (n=2). Thromboembolic events were observed in 2 patients (valve thrombosis in 1 and a cerebrovascular event in 1). There were no complications related to anticoagulation. No signs of valvular dysfunction or paravalvular leakage were observed. Peak transvalvular gradients of the aortic prostheses ranged from 24.25 ± 5.32 mmHg for the 21-mm valve to 11 ± 1.41 mmHg for the 25-mm valve. The effective orifice area ranged from 1.99 ± 0.12 cm2 for the 21-mm valve to 2.44 ± 0.17 cm2 for the 25-mm valve. The mean transvalvular gradients of the mitral prostheses ranged from 5.85 ± 2.91 mmHg for the 27-mm valve to 4.5 ± 0 mmHg for the 31-mm valve. The effective orifice area ranged from 2.31 ± 0.03 cm2 for the 27-mm valve to 2.64 ± 0.05 cm2 for the 33-mm valve. These preliminary data suggest good hemodynamic function and a low rate of valve-related complications in the use of the Edwards MIRA mechanical prosthesis.
Kale, Arzum; Yildiz, Ulku; Can, Benhur; Kandemir, Ozer; Tokmakoglu, Hilmi; Tezcaner, Tevfik; Zorlutuna, Yaman
Objective: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. Methods: TAP-AVI was performed via a small anterolateral minithoracotomy with or without femoral extracorporeal circulation (ECC) on the beating heart. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Cribier-Edwards, Edwards Lifesciences, Irvine, CA, USA) was used.
Thomas Walther; Volkmar Falk; Michael A. Borger; Todd Dewey; Gerhard Wimmer-Greinecker; Gerhard Schuler; Michael Mack; Friedrich W. Mohr
tions during the 11-year follow-up period was 27·1% in the prosthetic group and 3·2% in the allograft group. The actuarial 11-year survival rate was 82·1% in the allograft group and 64·7% in the prosthetic group. Conclusion Aortic allografts are an effective treatment for infective aortic valve endocarditis with associated peri- annular abscess. The operative mortality and recurrent infection rates are
C. Knosalla; Y. Weng; A. C. Yankah; H. Siniawski; J. Hofmeister; R. Hammerschmidt; M. Loebe; R. Hetzer
Background. Nationally representative estimates of in-hospital mortality after aortic valve replacement are needed to evaluate whether results from The Society of Thoracic Surgeons National Cardiac Surgery Database are applicable to other institutions in the United States performing these procedures.Methods. Data from the 1994 Nationwide Inpatient Sample were used to estimate the patient characteristics and in-hospital mortality rates associated with aortic
Brad C Astor; Ronald G Kaczmarek; Brockton Hefflin; W. Randolph Daley
We describe a patient previously implanted with a SAPIEN Edwards valve by the transapical approach, who subsequently experienced a valve thrombosis. The literature on this subject is reviewed. PMID:24330134
Pergolini, Amedeo; Pino, Paolo Giuseppe; Zampi, Giordano; Polizzi, Vincenzo; Musumeci, Francesco
Transapical aortic valve replacement is an established technique performed in high-risk patients with symptomatic aortic valve stenosis and vascular disease contraindicating trans-vascular and trans-aortic procedures. The presence of a left ventricular apical diverticulum is a rare event and the treatment depends on dimensions and estimated risk of embolisation, rupture, or onset of ventricular arrhythmias. The diagnosis is based on standard cardiac imaging and symptoms are very rare. In this case report we illustrate our experience with a 81 years old female patient suffering from symptomatic aortic valve stenosis, respiratory disease, chronic renal failure and severe peripheral vascular disease (logistic euroscore: 42%), who successfully underwent a transapical 23 mm balloon-expandable stent-valve implantation through an apical diverticulum of the left ventricle. Intra-luminal thrombi were absent and during the same procedure were able to treat the valve disease and to successfully exclude the apical diverticulum without complications and through a mini thoracotomy. To the best of our knowledge, this is the first time that a transapical procedure is successfully performed through an apical diverticulum.
Transapical aortic valve replacement is an established technique performed in high-risk patients with symptomatic aortic valve stenosis and vascular disease contraindicating trans-vascular and trans-aortic procedures. The presence of a left ventricular apical diverticulum is a rare event and the treatment depends on dimensions and estimated risk of embolisation, rupture, or onset of ventricular arrhythmias. The diagnosis is based on standard cardiac imaging and symptoms are very rare. In this case report we illustrate our experience with a 81 years old female patient suffering from symptomatic aortic valve stenosis, respiratory disease, chronic renal failure and severe peripheral vascular disease (logistic euroscore: 42%), who successfully underwent a transapical 23 mm balloon-expandable stent-valve implantation through an apical diverticulum of the left ventricle. Intra-luminal thrombi were absent and during the same procedure were able to treat the valve disease and to successfully exclude the apical diverticulum without complications and through a mini thoracotomy. To the best of our knowledge, this is the first time that a transapical procedure is successfully performed through an apical diverticulum. PMID:23294524
Ferrari, Enrico; Van Steenberghe, Mathieu; Namasivayam, Jegaruban; Berdajs, Denis; Niclauss, Lars; von Segesser, Ludwig Karl
Valvular heart disease is a significant cause of morbidity and mortality with valve replacement being the favored solution in most cases. Current replacement options (mechanical valves and decellularized porcine valves) lack the ability to grow or remodel in response to patient needs. This limitation is a major problem for pediatric patients who may require multiple surgical procedures before reaching adulthood.
We describe a 55-year-old man who presented with a stroke resulting from active infective endocarditis (IE) involving a heavily calcified bicuspid aortic valve. The case highlights the infrequency of IE involving a heavily calcified valve, the inability of the infection to penetrate the calcific deposits, and the ability of the infection to spread to the adjacent soft tissues, leading to ring abscess and its multiple complications.
Schussler, Jeffrey M.; Ko, Jong M.; Roberts, William C.
To evaluate the ability of a newly designed balloon catheter with check valves to temporarily relieve hemodynamic deterioration in acute aortic regurgitation, we produced an experimental model of acute aortic regurgitation in closed-chest dogs using endomyocardial biopsy forceps. Aortic regurgitation was produced until an increase in aortic pulse pressure of over 50% was achieved. Left ventricular end-diastolic pressure rapidly increased after the production of aortic regurgitation. Immediately after the catheter began functioning, pulse pressure decreased from 133 +/- 1 to 78 +/- 5 mm Hg (mean +/- SEM) and left ventricular end-diastolic pressure also decreased from 26 +/- 1 to 13 +/- 1 mm Hg. These effects lasted as long as the catheter functioned. Although a mild (21 +/- 8 mm Hg) pressure gradient between the left ventricular peak systolic pressure and the aortic peak systolic pressure was observed when this catheter was used, forward stroke volume was no less than in the group in which the catheter had not been used. These findings suggest that the balloon catheter with check valves may effectively reduce aortic regurgitation. PMID:1529874
Matsubara, T; Yamazoe, M; Tamura, Y; Ohshima, M; Yamazaki, Y; Suzuki, M; Izumi, T; Shibata, A
We present a series of 130 consecutive patients operated for aortic valve replacement (AVR) using the standard MIRA prosthesis between January 1999 and March 2001. Most of the patients were male (sex ratio ¼ 2) with a mean age of 61.5 ^ 9.5 years. The prosthesis was implanted using the continuous suture technique. The mean diameter of the implanted prostheses
J. P. Remadi; P. Marticho; A. Nzomvuama; A. Degandt
OBJECTIVE--To evaluate the immediate and long-term results of transcatheter balloon dilatation of the aortic valve for restenosis after previous surgical valvotomy. DESIGN--Prospective follow up by clinical examination and cross sectional Doppler echocardiography of all patients fulfilling the above criteria. SETTING--Tertiary paediatric cardiology referral centre. PATIENTS AND METHODS--22 patients (18 male, 4 female)--median (range) age 157.5 (12-254) months--underwent 25 balloon dilatation procedures at a median of 72 (8-155) months after surgery. The median age at surgical valvotomy was 82.5 (0.5-230) months and the systolic gradient across the aortic valve immediately after surgery was 31 (0-49) mm Hg. The indication for dilatation was a Doppler derived peak instantaneous gradient of > 60 mm Hg with grade 2 or less aortic regurgitation. A single balloon was used, and the median balloon to annulus ratio was 1 (0.9-1). RESULTS--After dilatation the catheter pullback gradient decreased acutely from 55 (35-75) to 30 (0-75) mm Hg (p < 0.01) and the Doppler gradient from 74 (52-92) to 40.5 (30-96) mm Hg (p < 0.01). In three patients who underwent a second dilatation of the aortic valve eight months after the first procedure, the pullback gradient decreased from 50 (50-60) to 15 (15-16) mm Hg. Aortic regurgitation grade increased from 1 (0-2) to 2 (1-3); only one patient had grade 3 regurgitation. Over a median follow up of 33 (2-67) months seven patients had aortic valve replacement for recurrent stenosis (six patients) or severe regurgitation (one patient with grade 3 regurgitation after dilatation, who had partial detachment of one of the valve leaflets). There was no significant difference for the pullback gradient (median of 19 v 32.5 mm Hg), Doppler gradient 24 hours after dilatation (33.5 v 50.5 mm Hg; p = 0.03), or the duration of follow up (27.5 v 18 months) between the 12 patients who did not require further dilatation or surgery and the 10 patients who did. CONCLUSIONS--Balloon dilatation of the aortic valve is a safe and feasible option for palliation of restenosis after surgical valvotomy for congenital aortic valve stenosis. In many patients, however, stenosis progressed and a further intervention was required.
Sreeram, N.; Kitchiner, D.; Williams, D.; Jackson, M.
Supravalvular aortic stenosis (SVAS) is an uncommon congenital cardiac anomaly. We report sudden death, occurring during exercise, of a child who had SVAS with fusion of the right coronary aortic leaflet to the supravalvular aortic ridge, resulting in a closed sinus of Valsalva except for a few pinpoint fenestrations in the dysplastic leaflet. In addition, both aortic and pulmonic valves were dysplastic and stenotic. We postulate that near total isolation of the right coronary artery ostium from the aortic lumen compromised the blood supply to the hypertrophied ventricles. We emphasize the importance of other cardiac anomalies associated with SVAS as well as the development of coronary insufficiency. PMID:1437889
Sun, C C; Jacot, J; Brenner, J I
Risk factors for fibrocalcific aortic valve disease (FCAVD) are associated with systemic decreases in bioavailability of endothelium-derived nitric oxide (EDNO). In patients with bicuspid aortic valve (BAV), vascular expression of endothelial nitric oxide synthase (eNOS) is decreased, and eNOS(-/-) mice have increased prevalence of BAV. The goal of this study was to test the hypotheses that EDNO attenuates profibrotic actions of valve interstitial cells (VICs) in vitro and that EDNO deficiency accelerates development of FCAVD in vivo. As a result of the study, coculture of VICs with aortic valve endothelial cells (vlvECs) significantly decreased VIC activation, a critical early phase of FCAVD. Inhibition of VIC activation by vlvECs was attenuated by N(G)-nitro-l-arginine methyl ester or indomethacin. Coculture with vlvECs attenuated VIC expression of matrix metalloproteinase-9, which depended on stiffness of the culture matrix. Coculture with vlvECs preferentially inhibited collagen-3, compared with collagen-1, gene expression. BAV occurred in 30% of eNOS(-/-) mice. At age 6 mo, collagen was increased in both bicuspid and trileaflet eNOS(-/-) aortic valves, compared with wild-type valves. At 18 mo, total collagen was similar in eNOS(-/-) and wild-type mice, but collagen-3 was preferentially increased in eNOS(-/-) mice. Calcification and apoptosis were significantly increased in BAV of eNOS(-/-) mice at ages 6 and 18 mo. Remarkably, these histological changes were not accompanied by physiologically significant valve stenosis or regurgitation. In conclusion, coculture with vlvECs inhibits specific profibrotic VIC processes. In vivo, eNOS deficiency produces fibrosis in both trileaflet and BAVs but produces calcification only in BAVs. PMID:24610917
El Accaoui, Ramzi N; Gould, Sarah T; Hajj, Georges P; Chu, Yi; Davis, Melissa K; Kraft, Diane C; Lund, Donald D; Brooks, Robert M; Doshi, Hardik; Zimmerman, Kathy A; Kutschke, William; Anseth, Kristi S; Heistad, Donald D; Weiss, Robert M
A 60-year-old man was admitted to our hospital because of aortic stenosis with a peak pressure gradient of 61 mmHg, moderate aortic regurgitation, and a dilatation of the ascending aorta of 50 mm in diameter, which had grown 5 mm in 2 years. Because of severe aortic stenosis with a bicuspid valve and fast progression of the ascending aorta in size, replacements of both the aortic valve and the ascending aorta were planned.He had experienced severe acute renal failure with hemolysis because of cold agglutinin one year before the operation. The hemoglobin had decreased to 4.3 g/dL during hemolytic attack. His titer of cold agglutinin was extremely high. The titer of cold agglutinin has kept above than 1:131072 at 4 degree Celsius. It once increased to 1:524288.Both the replacement of the aortic valve and the ascending aorta under normothermic cardiopulmonary bypass using intermittent warm blood cardioplegia were completed uneventfully. He was discharged from the hospital on postoperative day 11. PMID:22791002
Kansaku, Rei; Kuwaki, Kenji; Amano, Atsushi; Inaba, Hirotaka; Tambara, Keiichi; Yamamoto, Taira; Sakakibara, Naoki
Aortic stenosis is the most frequently acquired heart disease, and the prevalence is rising because of the aging population. If the disease is left untreated, survival in symptomatic patients averages only 2 to 3 years. Surgical aortic valve replacement is the only definitive treatment, yet 30% of elderly patients are not considered candidates because the presence of comorbidities makes the risk of sternotomy and cardiopulmonary bypass prohibitively high. Transcatheter aortic valve replacement (TAVR) is an innovative, high-tech, less invasive alternative. The procedure is usually performed using general anesthesia and a multidisciplinary team from interventional cardiology and cardiothoracic surgery in a "hybrid" operating environment with advanced imaging capabilities. There are 2 major catheter-based approaches to the aortic valve: retrograde percutaneous through the femoral artery and aorta or direct antegrade through a thoracotomy and the left ventricular apex. Apnea and rapid ventricular pacing are used to interrupt cardiac ejection during balloon valvuloplasty and prosthesis implantation. The most significant complications include vascular damage, stroke, paravalvular aortic insufficiency, and heart block. Outcomes studies comparing TAVR with medical management demonstrate improved patient survival, functional status, and quality of life. Currently TAVR is considered the treatment of choice for patients who are not surgical candidates and is a proven alternative for high-risk surgical candidates. PMID:24354078
Contrera, Peggy; Cushing, Mary
In this study, the correlation dimension analysis has been applied to the aortic valve Doppler signals to investigate the complexity of the Doppler signals which belong to aortic stenosis (AS) and aortic insufficiency (AI) diseases and healthy case. The Doppler signals of 20 healthy subjects, ten AS and ten AI patients were acquired via the Doppler echocardiography system that is a noninvasive and reliable technique for assessment of AS and AI diseases. The correlation dimension estimations have been performed for different time delay values to investigate the influence of time delay on the correlation dimension calculation. The correlation dimension of healthy group has been found lower those found in AI and AS disorder groups and the correlation dimension of AS group has also been found higher than those found in AI group, significantly. The results of this study have indicated that the aortic valve Doppler signals exhibit high level chaotic behaviour in AI and AS diseases than healthy case. Additionally, the correlation dimension analysis is sensitive to the time delay and has successfully characterized the blood flow dynamics for proper time delay value. As a result, the correlation dimension can be used as an efficient method to determine the healthy or pathological cases of aortic valve. PMID:20703615
Y?lmaz, Derya; Güler, N Fatma
Important progress has been achieved in recent years in simulating the fluid-structure interaction around cardiac valves. An important step in making these computational tools useful to clinical practice is the development of postprocessing techniques to extract clinically relevant information from these simulations. This work focuses on flow through the aortic valve and illustrates how the computation of Lagrangian coherent structures can be used to improve insight into the transport mechanics of the flow downstream of the valve, toward the goal of aiding clinical decision making and the understanding of pathophysiology.
Shadden, Shawn C.; Astorino, Matteo; Gerbeau, Jean-Frédéric
Degenerative aortic stenosis has become a common and dangerous disease in recent decades. This disease leads to the mineralization of aortic valves, their gradual thickening and loss of functionality. We studied the detailed assessment of the proportion and composition of inorganic and organic components in the ossified aortic valve, using a set of analytical methods applied in science: polarized light microscopy, scanning electron microscopy, X-ray fluorescence, X-ray diffraction, gas chromatography/mass spectrometry and liquid chromatography-tandem mass spectrometry. The sample valves showed the occurrence of phosphorus and calcium in the form of phosphate and calcium carbonate, hydroxyapatite, fluorapatite and hydroxy-fluorapatite, with varying content of inorganic components from 65 to 90 wt%, and with phased development of degenerative disability. The outer layers of the plaque contained an organic component with peptide bonds, fatty acids, proteins and cholesterol. The results show a correlation between the formation of fluorapatite in aortic valves and in other parts of the human bodies, associated with the formation of bones.
Zeman, Antonín; Šmíd, Michal; Havelcová, Martina; Coufalová, Lucie; Ku?ková, Št?pánka; Vel?ovská, Martina; Hynek, Radovan
Background—Treatment of hyperlipidemia produces functional and structural improvements in atherosclerotic vessels. However, the effects of treating hyperlipidemia on the structure and function of the aortic valve have been controversial, and any effects could be confounded by pleiotropic effects of hypolipidemic treatment. The goal of this study was to determine whether reducing elevated plasma lipid levels with a \\
Jordan D. Miller; Robert M. Weiss; Kristine M. Serrano; Robert M. Brooks II; Christopher J. Berry; Kathy Zimmerman; Stephen G. Young; Donald D. Heistad
Background. Dehydration of tissue due to glutaraldehyde fixation has been reported and was examined in this study of porcine aortic valve cusps. The effect of altered hydration on cusp internal shear properties was also examined.Methods. Hydration level was assessed by wet mass measurement of cusps stored in solutions for times up to 1000 minutes. Solutions used in this study included
Eric A Talman; Derek R Boughner
We report a case of bacterial endocarditis due to Erysipelothrix rhusiopathiae in a homeless man with no animal exposure. His course was complicated by an allergic reaction to ampicillin, urinary bladder infection, respiratory failure, and acute kidney injury. He recovered completely after aortic valve replacement and a 6-week course of intravenous ceftriaxone.
Hydrophilic polymer coated introducer sheaths and medical devices are widely used in interventional cardiology. Despite the potential procedural advantages that these provide, a risk of polymer embolization has been recently reported. We describe the first reported case of hydrophilic polymer induced acute transcatheter aortic valve thrombosis. © 2014 Wiley Periodicals, Inc. PMID:24403026
Sanon, Saurabh; Maleszewski, Joseph J; Rihal, Charanjit S
Background The development and progression of calcific aortic valve disease (CAVD) shares a number of similarities with atherosclerosis. Recently we could demonstrate that regular exercise training (ET) as primary prevention prevents aortic valve disease in LDL-receptor deficient (LDLR?/?) mice. We aimed to investigate the impact of exercise training on the progression of CAVD in LDLR?/? mice in the setting of secondary prevention Methods and Results Sixty-four LDLR?/? mice were fed with high cholesterol diet to induce aortic valve sclerosis. Thereafter the animals were divided into 3 groups: group 1 continuing on high cholesterol diet, group 2 continuing with cholesterol diet plus 1 h ET per day, group 3 continuing with normal mouse chow. After another 16 weeks the animal were sacrificed. Histological analysis of the aortic valve thickness demonstrated no significant difference between the three groups (control 98.3±4.5 µm, ET 88.2±6.6 µm, change in diet 87.5±4.0). Immunohistochemical staining for endothelial cells revealed a disrupted endothelial cell layer to the same extend in all groups. Furthermore no difference between the groups was evident with respect to the expression of inflammatory, fibroblastic and osteoblastic markers. Conclusion Based on the present study we have to conclude that once the development of a CAVD is initiated, exercise training or a change in diet does not have the potential to attenuate the progress of the CAVD.
Schlotter, Florian; Matsumoto, Yasuharu; Mangner, Norman; Schuler, Gerhard; Linke, Axel; Adams, Volker
We describe a patient with unstable angina due to occlusion of the orifice of the right coronary artery by thrombus formation after aortic valvular replacement using a Björk-Shiley valve. After strict anticoagulant treatment, transesophageal echocardiography demonstrated disappearance of the thrombus formation around the orifice of the right coronary artery. PMID:12620134
Nakayama, Yasunori; Ninomiya, Hideki; Kido, Masakuni; Ueda, Hiroyasu; Yoshimaru, Kiyomichi; Tsumura, Kei
Aortic valve sclerosis (AVS) may predispose to a prothrombotic state, as AVS is predictor of cardiovascular events in hypertensive populations. Thrombin exerts non-thrombotic effects such as vessel tone regulation, progression of atherosclerosis and stimulation of atrial natriuretic peptide (ANP) secretion. We hypothesized that hypertensive patients with AVS may have a persistently activated thrombin generation. We studied 234 asymptomatic never-treated hypertensive
M Iida; M Yamamoto; M Yamazaki; M Sawaguchi; H Honjo; I Kodama; K Kamiya
Retrospective analysis of 306 patients following aortic valve replacement (AVR) was carried out between 1985-89. Patients were divided into two groups: group 1 patients were < 70 years of age and group 2 were > 70 years of age. The multivariant analysis of risk factors showed the only increased risk for surgery was the NYHA class IV in either group.
W. C. Feng; A. A. Bert; A. K. Singh
An implantable aortic valve-pump was designed. There were a central rotor and a stator in the device. The rotor was consisted of driven magnets and an impeller, the stator was consisted of a motor coil with an iron core, an inducer and a diffuser. This pump has promisingly better antithrombogenicity than other heart pumps, for neither connecting conduits nor “bypass”
Kunxi Qian; Qinlin Wu; Fangqun Wang
Background. Nationally representative estimates of in- hospital mortality after aortic valve replacement are needed to evaluate whether results from The Society of Thoracic Surgeons National Cardiac Surgery Database are applicable to other institutions in the United States performing these procedures. Methods. Data from the 1994 Nationwide Inpatient Sample were used to estimate the patient characteristics and in-hospital mortality rates associated
Brad C. Astor; Ronald G. Kaczmarek; Brockton Hefflin; W. Randolph Daley
Damage to blood corpuscles seems to be related to the magnitude and exposure time of the turbulent shear stresses (TSS). According to in vitro studies the critical TSS level for lethal erythrocyte and thrombocyte damage is 150-400 N/m2, for exposure times within physiological ranges. To study the distribution of TSS in the human ascending aorta, a hot-film anemometer needle probe was used to register blood velocities at 41 evenly distributed measuring points in the cross-sectional area 5-6 cm downstream of the aortic annulus. Measurements were made in the ascending aorta after normal aortic valves (prior to coronary bypass surgery), after stenotic aortic valves, and after implantation of either St. Jude Medical or Starr Edwards Silastic Ball valves. Three-dimensional visualization of velocity profiles were performed and Reynolds normal stresses (RNS) were calculated within 50-ms overlapping time windows in systole. By coordinating the mean RNS for each time window and for all 41 measuring points, 2-dimensional color-coded mapping of the RNS distribution was made. Based on the velocity profiles and the RNS distribution a relative blood damage index (RBDI) was calculated to incorporate the magnitude and exposure time for RNS in the entire cross-sectional area into one parameter. Turbulent shear stresses were estimated by using a previously determined correlation equation between RNS and TSS. After normal aortic valves, RNS was below 4 N/m2.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1449814
Nygaard, H; Paulsen, P K; Hasenkam, J M; Kromann-Hansen, O; Pedersen, E M; Rovsing, P E
The recent development of transcatheter aortic valve implantation (TAVI) to treat severe aortic stenosis (AS) offers a viable option for high-risk patients categories. Our aim is to evaluate the early effects of implantation of CoreValve aortic valve prosthesis on arterial-ventricular coupling by two dimensional echocardiography. Sixty five patients with severe AS performed 2D conventional echocardiography before, immediately after TAVI, at discharge (mean age: 82.6 ± 5.9 years; female: 60%). The current third generation (18-F) CoreValve Revalving system (Medtronic, Minneapolis, MN) was used in all cases. Vascular access was obtained by percutaneous approach through the common femoral artery; the procedure was performed with the patient under local anesthesia. We calculated, apart the conventional parameters regarding left ventricular geometry and the Doppler parameters of aortic flow (valvular load), the vascular load and the global left ventricular hemodynamic load. After TAVI we showed, by echocardiography, an improvement of valvular load. In particular we observed an immediate reduction of transaortic peak pressure gradient (P < 0.0001), of mean pressure gradient (P < 0.0001) and a concomitant increase in aortic valve area (AVA) (0.97 ± 0.3 cm(2)). Left ventricular ejection fraction improved early after TAVI (before: 47 ± 11, after: 54 ± 11; P < .0001). Vascular load, expressed by systemic arterial compliance, showed a low but significant improvement after procedure (P < 0.01), while systemic vascular resistances showed a significant reduction after procedure (P < 0.001). As a global effect of the integrated changes of these hemodynamic parameters, we observed a significant improvement of global left ventricular hemodynamic load, in particular through a significant reduction of end-systolic meridional stress (before: 80 ± 34 and after: 55 ± 29, P < 0.0001). The arterial-valvular impedance showed a significant reduction (before: 7.6 ± 2 vs after: 5.8 ± 2; P < 0.0001. Furthermore we observed a significant reduction with a normalization of arterial-ventricular coupling (P < 0.005). With regard to left ventricular (LV) efficiency, we observed, after the procedure, a significant reduction of stroke work (P < 0.001) and potential energy (P < 0.001), with a significant increase of work efficiency early after the procedure (P < 0.001). Our results showed that the TAVI procedure was able to determine an early improvement of the global left ventricular hemodynamic load, allowing a better global LV performance. Further follow-up investigations are needed to evaluate these results in a more prolonged time observation. PMID:21222040
Di Bello, Vitantonio; Giannini, Cristina; De Carlo, Marco; Delle Donne, Maria Grazia; Nardi, Carmela; Palagi, Caterina; Cucco, Cuono; Dini, Frank Lloyd; Guarracino, Fabio; Marzilli, Mario; Petronio, Anna Sonia
Success of the deployment and function in transcatheter aortic valve replacement (TAVR) is heavily reliant on the tissue-stent interaction. The present study quantified important tissue-stent contact variables of self-expanding transcatheter aortic valve (TAV) stents when deployed into ovine and porcine aortic roots, such as the stent radial expansion force, stent pullout force, the annulus deformation response and the coefficient of friction on the tissue-stent contact interface. Braided Nitinol stents were developed, tested to determine stent crimped diameter vs. stent radial force from a stent crimp experiment, and deployed in vitro to quantify stent pullout, aortic annulus deformation, and the coefficient of friction between the stent and the aortic tissue from an aortic root-stent interaction experiment. The results indicated that when crimped at body temperature from 26 mm to 19, 21 and 23 mm stent radial forces were approximately 30-40% higher than those crimped at room temperature. Coefficients of friction leveled to approximately 0.10 ± 0.01 as stent wire diameter increased and annulus size decreased from 23 to 19 mm. Regardless of aortic annulus size and species tested, it appeared that a minimum of about 2.5 mm in annular dilatation, caused by about 60N of radial force from stent expansion, was needed to anchor the stent against a pullout into the left ventricle. The study of the contact biomechanics in animal aortic tissues may help us better understand characteristics of tissue-stent interactions and quantify the baseline responses of non-calcified aortic tissues.
Mummert, Joseph; Sirois, Eric; Sun, Wei
Transcatheter aortic valve replacement (TAVR) has been shown to significantly impact mortality and quality of life in patients with severe aortic stenosis (AS) who are deemed high risk for surgical aortic valve replacement (SAVR). Essential to these outcomes is proper patient selection. The multidisciplinary TAVR heart team was created to provide comprehensive patient evaluation and aid in proper selection. This review with outline the history and components of the heart team, and delineate the team's role in risk and frailty assessment, evaluation of common co-morbidities that impact outcomes, and the complex multi-modality imaging necessary for procedural planning and patient selection. The heart team is critical in determining patient eligibility and benefit and the optimal operative approach for TAVR. The future of structural heart disease will certainly require a team approach, and the TAVR heart team will serve as the successful model. PMID:24838133
Sintek, Marc; Zajarias, Alan
Objectives To propose standardized consensus definitions for important clinical endpoints in transcatheter aortic valve implantation (TAVI), investigations in an effort to improve the quality of clinical research and to enable meaningful comparisons between clinical trials. To make these consensus definitions accessible to all stakeholders in TAVI clinical research through a peer reviewed publication, on behalf of the public health. Background Transcatheter aortic valve implantation may provide a worthwhile less invasive treatment in many patients with severe aortic stenosis and since its introduction to the medical community in 2002, there has been an explosive growth in procedures. The integration of TAVI into daily clinical practice should be guided by academic activities, which requires a harmonized and structured process for data collection, interpretation, and reporting during well-conducted clinical trials. Methods and results The Valve Academic Research Consortium established an independent collaboration between Academic Research organizations and specialty societies (cardiology and cardiac surgery) in the USA and Europe. Two meetings, in San Francisco, California (September 2009) and in Amsterdam, the Netherlands (December 2009), including key physician experts, and representatives from the US Food and Drug Administration (FDA) and device manufacturers, were focused on creating consistent endpoint definitions and consensus recommendations for implementation in TAVI clinical research programs. Important considerations in developing endpoint definitions included (i) respect for the historical legacy of surgical valve guidelines; (ii) identification of pathophysiological mechanisms associated with clinical events; (iii) emphasis on clinical relevance. Consensus criteria were developed for the following endpoints: mortality, myocardial infarction, stroke, bleeding, acute kidney injury, vascular complications, and prosthetic valve performance. Composite endpoints for TAVI safety and effectiveness were also recommended. Conclusion Although consensus criteria will invariably include certain arbitrary features, an organized multidisciplinary process to develop specific definitions for TAVI clinical research should provide consistency across studies that can facilitate the evaluation of this new important catheter-based therapy. The broadly based consensus endpoint definitions described in this document may be useful for regulatory and clinical trial purposes.
Leon, Martin B.; Piazza, Nicolo; Nikolsky, Eugenia; Blackstone, Eugene H.; Cutlip, Donald E.; Kappetein, Arie Pieter; Krucoff, Mitchell W.; Mack, Michael; Mehran, Roxana; Miller, Craig; Morel, Marie-angele; Petersen, John; Popma, Jeffrey J.; Takkenberg, Johanna J.M.; Vahanian, Alec; van Es, Gerrit-Anne; Vranckx, Pascal; Webb, John G.; Windecker, Stephan; Serruys, Patrick W.
Interobserver variability in echocardiographic estimates of the area of stenosed aortic valves was assessed in 30 consecutive patients. Using the continuity equation, two independent observers calculated the area of stenosis from separate recordings of the diameter of the aortic orifice and the velocity time integral in the left ventricular outflow tract and in the stenotic jet. No significant difference between the observers was noted for any measurement. With respect to the area of stenosis, a high correlation between the observers was found (r = 0.92, P less than 0.001) and the regression line was close to the line of identity. The 95% limits of agreement were less than +/- 0.3 cm2. No discrepancy between the observers was found in the assessment of cases for aortic stenosis less than 0.8 cm2. Regression analyses showed good interobserver agreement also for the diameter of the orifice, the velocity time integrals, and the mean pressure gradient (r greater than 0.90, P less than 0.001). The greatest variability was noted for the diameter of the aortic orifice (95% limits of agreement +/- 1.4 cm2). We conclude that echocardiography enables reproducible estimates of the orificial area of stenosed aortic valves. Changes greater than 0.3 cm2 can be detected with a confidence probability of 95%. The greatest source of error is the measurement of the diameter of the outflow tract at the basal attachments of the aortic leaflets. PMID:2312203
Myreng, Y; Mølstad, P; Endresen, K; Ihlen, H
Advanced valvular lesions often contain ectopic mesenchymal tissues, which may be elaborated by an unidentified multipotent progenitor subpopulation within the valve interstitium. The identity, frequency, and differentiation potential of the putative progenitor subpopulation are unknown. The objectives of this study were to determine whether valve interstitial cells (VICs) contain a subpopulation of multipotent mesenchymal progenitor cells, to measure the frequencies of the mesenchymal progenitors and osteoprogenitors, and to characterize the osteoprogenitor subpopulation because of its potential role in calcific aortic valve disease. The multilineage potential of freshly isolated and subcultured porcine aortic VICs was tested in vitro. Progenitor frequencies and self-renewal capacity were determined by limiting dilution and colony-forming unit assays. VICs were inducible to osteogenic, adipogenic, chondrogenic, and myofibrogenic lineages. Osteogenic differentiation was also observed in situ in sclerotic porcine leaflets. Primary VICs had strikingly high frequencies of mesenchymal progenitors (48.0 ± 5.7%) and osteoprogenitors (44.1 ± 12.0%). High frequencies were maintained for up to six population doublings, but decreased after nine population doublings to 28.2 ± 9.9% and 5.8 ± 1.3%, for mesenchymal progenitors and osteoprogenitors, respectively. We further identified the putative osteoprogenitor subpopulation as morphologically distinct cells that occur at high frequency, self-renew, and elaborate bone matrix from single cells. These findings demonstrate that the aortic valve is rich in a mesenchyma l progenitor cell population that has strong potential to contribute to valve calcification.
Chen, Jan-Hung; Yip, Cindy Ying Yin; Sone, Eli D.; Simmons, Craig A.
Within 10 years after transcatheter aortic valve implantation (TAVI) was first accomplished for treatment of calcified aortic stenosis, this new technology has rapidly evolved to become clinical routine. Today it may be considered standard treatment for inoperable patients with superior outcomes compared to best medical therapy. Furthermore, it represents an alternative therapeutic option compared to surgical aortic valve replacement in high-risk patients. According to current international guidelines and expert consensus statements, TAVI should be performed as a joint effort by an interdisciplinary heart team to ensure input from multiple skill sets for optimal patient outcome. Major safety concerns include neurologic complications, acute kidney injury, access site complications, procedure-related conduction disturbances, paravalvular leakage valve durability. At present, only one device for transapical TAVI is in widespread clinical use: the Edwards Sapien transcatheter valve (Edwards Lifesciences, Irvine, CA, USA). Recently, however, a number of second generation devices for transapical TAVI have been developed in order to address some of the limitations of first generation valves. In this paper, current data on second generation devices for transapical TAVI will be reviewed and ongoing trials discussed. PMID:23681137
Conradi, L; Seiffert, M; Blankenberg, S; Reichenspurner, H; Diemert, P; Treede, H
Patients with aortic stenosis present with calcium deposits on the native aortic valve, which can result in non-concentric expansion of Transcatheter Aortic Valve Replacement (TAVR) stents. The objective of this study is to evaluate whether eccentric deployment of TAVRs lead to turbulent blood flow and blood cell damage. Particle Image Velocimetry was used to quantitatively characterize fluid velocity fields, shear stress and turbulent kinetic energy downstream of TAVRs deployed in circular and eccentric orifices representative of deployed TAVRs in vivo. Effective orifice area (EOA) and mean transvalvular pressure gradient (TVG) values did not differ substantially in circular and eccentric deployed valves, with only a minor decrease in EOA observed in the eccentric valve (2.0 cm(2) for circular, 1.9 cm(2) for eccentric). Eccentric deployed TAVR lead to asymmetric systolic jet formation, with increased shear stresses (circular = 97 N/m(2) vs. eccentric = 119 N/m(2)) and regions of turbulence intensity (circular = 180 N/m(2) vs. eccentric = 230 N/m(2)) downstream that was not present in the circular deployed TAVR. The results of this study indicate that eccentric deployment of TAVRs can lead to altered flow characteristics and may potentially increase the hemolytic potential of the valve, which were not captured through hemodynamic evaluation alone. PMID:24719050
Gunning, Paul S; Saikrishnan, Neelakantan; McNamara, Laoise M; Yoganathan, Ajit P
Background Before trans-catheter aortic valve implantation (TAVI), assessment of cardiac function and accurate measurement of the aortic root are key to determine the correct size and type of the prosthesis. The aim of this study was to compare cardiovascular magnetic resonance (CMR) and trans-thoracic echocardiography (TTE) for the assessment of aortic valve measurements and left ventricular function in high-risk elderly patients submitted to TAVI. Methods Consecutive patients with severe aortic stenosis and contraindications for surgical aortic valve replacement were screened from April 2009 to January 2011 and imaged with TTE and CMR. Results Patients who underwent both TTE and CMR (n = 49) had a mean age of 80.8 ± 4.8 years and a mean logistic EuroSCORE of 14.9 ± 9.3%. There was a good correlation between TTE and CMR in terms of annulus size (R2 = 0.48, p < 0.001), left ventricular outflow tract (LVOT) diameter (R2 = 0.62, p < 0.001) and left ventricular ejection fraction (LVEF) (R2 = 0.47, p < 0.001) and a moderate correlation in terms of aortic valve area (AVA) (R2 = 0.24, p < 0.001). CMR generally tended to report larger values than TTE for all measurements. The Bland-Altman test indicated that the 95% limits of agreement between TTE and CMR ranged from -5.6 mm to + 1.0 mm for annulus size, from -0.45 mm to + 0.25 mm for LVOT, from -0.45 mm2 to + 0.25 mm2 for AVA and from -29.2% to 13.2% for LVEF. Conclusions In elderly patients candidates to TAVI, CMR represents a viable complement to transthoracic echocardiography.
High levels of turbulent stresses resulting from disturbed blood flow may cause damage to red blood cells and platelets. The purpose of this study was to evaluate the spatial distribution and temporal development of turbulent stresses downstream of three mechanical aortic valve prostheses in human subjects: the St. Jude Medical, the CarboMedics, and the Starr-Edwards silicone rubber ball. Blood velocity measurements were taken at 17 measuring points in the cross-sectional area of the ascending aorta 5 to 6 cm downstream of the aortic anulus with the use of a perivascular pulsed Doppler ultrasound system. Turbulence analysis was done for each of the 17 measuring points by calculating the radial Reynolds normal stresses within 50 msec overlapping time windows during systole. By coordinating the calculated Reynolds normal stress values for each time window and for all measuring points, computerized two-dimensional color-coded mapping of the turbulent stress distribution during systole was done. For the St. Jude Medical valves the highest Reynolds normal stress (27 to 63 N/m2) were found along the central slit near the vessel walls. The temporal development and spatial distribution of Reynolds normal stresses for the CarboMedics valves were quite similar to those of the St. Jude Medical valves with maximum Reynolds normal stress values ranging from 19 to 72 N/m2. The typical Reynolds normal stress distribution for the Starr-Edwards silicone rubber ball valves was asymmetric, revealing the highest Reynolds normal stresses (11 to 56 N/m2) at various locations in the annular region between the ball and the vessel wall. The spatial distribution and temporal development of turbulent stresses downstream of the three investigated mechanical aortic valve prostheses correlated well with the superstructure of the valves. The maximum Reynolds normal stresses for the three valve types were in the same order of magnitude with exposure times sufficient to cause sublethal damage to red blood cells and platelets. PMID:8302062
Nygaard, H; Paulsen, P K; Hasenkam, J M; Pedersen, E M; Rovsing, P E
Thoracic aortic aneurysm is a pathological local dilatation of the aorta, potentially leading to aortic rupture or dissection. The disease is a common complication of patients with bicuspid aortic valve, a congenital disorder present in 1–2% of the population. Using two dimensional fluorescence difference gel electrophoresis proteomics followed by mRNA expression, and alternative splicing analysis of the identified proteins, differences in dilated and nondilated aorta tissues between 44 patients with bicuspid and tricuspid valves was examined. The pattern of protein expression was successfully validated with LC-MS/MS. A multivariate analysis of protein expression data revealed diverging protein expression fingerprints in patients with tricuspid compared with the patients with bicuspid aortic valves. From 302 protein spots included in the analysis, 69 and 38 spots were differentially expressed between dilated and nondilated aorta specifically in patients with tricuspid and bicuspid aortic valve, respectively. 92 protein spots were differentially expressed between dilated and nondilated aorta in both phenotypes. Similarly, mRNA expression together with alternative splicing analysis of the identified proteins also showed diverging fingerprints in the two patient groups. Differential splicing was abundant but the expression levels of differentially spliced mRNA transcripts were low compared with the wild type transcript and there was no correlation between splicing and the number of spots. Therefore, the different spots are likely to represent post-translational modifications. The identification of differentially expressed proteins suggests that dilatation in patients with a tricuspid aortic valve involves inflammatory processes whereas aortic aneurysm in patients with BAV may be the consequence of impaired repair capacity. The results imply that aortic aneurysm formation in patients with bicuspid and tricuspid aortic valves involve different biological pathways leading to the same phenotype.
Kjellqvist, Sanela; Maleki, Shohreh; Olsson, Therese; Chwastyniak, Maggy; Branca, Rui Miguel Mamede; Lehtio, Janne; Pinet, Florence; Franco-Cereceda, Anders; Eriksson, Per
Background The aim of this study was to compare outcome of patients with previous cardiac surgery undergoing transapical aortic valve implantation (Redo-TAVI) to those undergoing classic aortic valve replacement (Redo-AVR) by using propensity analysis. Methods From January 2005 through May 2012, 52 high-risk patients underwent Redo-TAVI using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN™). During the same period of time 167 patients underwent classic Redo-AVR. Logistic regression analysis was used to identify covariates among 11 baseline patient variables including the type of initial surgery. Using the significant regression coefficients, each patient’s propensity score was calculated, allowing selectively matched subgroups of 40 patients each. Initial surgery included coronary artery bypass grafting in 30 patients, aortic valve replacement in 7 patients and mitral valve reconstruction in 3 patients in each group. Follow-up was 4?±?2 years and was 100% complete. Results Postoperative chest tube drainage (163?±?214 vs. 562?±?332 ml/24 h, p?=?0.02) and incidence of early permanent neurologic deficit (0 vs. 13%, p?=?0.04) was lower in patients with Redo-TAVI and there was a trend towards improved 30-day survival (p?=?0.06). Also we detected a decreased ventilation time (p?=?0.04) and lower transfusion rate of allogenic blood products (p???0.05) in the Redo-TAVI group. At late follow up differences regarding incidence of major adverse events, including death and permanent neurologic deficits (25% vs. 43%, p?=?0.01) statistically supported early postoperative findings. Conclusion The encouraging results regarding early and long-term outcomes following TAVI in patients with previous cardiac surgery show, that this evolving approach may be particularly beneficial in this patient cohort.
The inability to reposition or retrieve balloon-expandable transcatheter aortic valves once they have been deployed requires implantation of the valve in the descending aorta or open surgical procedures to extract the valve. We describe the challenging transfemoral delivery of an Edwards Lifesciences Sapien valve wherein we had difficulty crossing the aortic valve and the guidewire position was compromised. We performed a transapical puncture to snare the guidewire and create a left ventricular to femoral wire rail, allowing us to deliver the transfemoral transcatheter valve, salvaging a situation where we would have been required to implant the valve in the descending aorta. We believe this is the first time this technique has been reported and represents an important method to facilitate delivery of transcatheter valves where guidewire support is insufficient or lost. PMID:24907088
Don, Creighton W; Kim, Michael S; Verrier, Edward D; Aldea, Gabriel S; Dean, Larry S; Reisman, Mark; Mokadam, Nahush A
OBJECTIVE: We sought to assess whether aortic valve replacement (AVR) among patients with severe aortic stenosis (AS), severe left ventricular (LV) dysfunction and a low transvalvular gradient (TVG) is associated with improved survival. BACKGROUND: The optimal management of patients with severe AS with severe LV dysfunction and a low TVG remains controversial. METHODS: Between 1990 and 1998, we evaluated 68 patients who underwent AVR at our institution (AVR group) and 89 patients who did not undergo AVR (control group), with an aortic valve area < or = 0.75 cm(2), LV ejection fraction < or = 35% and mean gradient < or = 30 mm Hg. Using propensity analysis, survival was compared between a cohort of 39 patients in the AVR group and 56 patients in the control group. RESULTS: Despite well-matched baseline characteristics among propensity-matched patients, the one- and four-year survival rates were markedly improved in patients in the AVR group (82% and 78%), as compared with patients in the control group (41% and 15%; p < 0.0001). By multivariable analysis, the main predictor of improved survival was AVR (adjusted risk ratio 0.19, 95% confidence interval 0.09 to 0.39; p < 0.0001). The only other predictors of mortality were age and the serum creatinine level. CONCLUSIONS: Among select patients with severe AS, severe LV dysfunction and a low TVG, AVR was associated with significantly improved survival.
Pereira, Jeremy J.; Lauer, Michael S.; Bashir, Mohammad; Afridi, Imran; Blackstone, Eugene H.; Stewart, William J.; McCarthy, Patrick M.; Thomas, James D.; Asher, Craig R.
Background Cardiac function and myocardial strain are affected by cardiac afterload, which is in part due to the stiffness of the aortic wall. In this study, we hypothesize that aortic pulse wave velocity (PWV) as a marker of aortic stiffness correlates with conventional clinical and biochemical markers of cardiac function and perioperative myocardial strain in aortic valve replacement (AVR). Methods Patients undergoing AVR for aortic stenosis between June 2010 and August 2012 were re