... in this category include " xenograft " valves made from animal tissues (most often pig aorticvalves), " 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 aorticvalve implantation was developed to offer a therapeutic solution to patients with severe symptomatic aortic stenosis who are not candidates for conventional aorticvalve replacement. The improvement in transcatheter aorticvalve implantation outcomes is still of concern in the areas of stroke, vascular injury, heart block, paravalvular regurgitation and valve durability. Concomitantly, the progress, both technical and in terms of material advances of transcatheter valve systems, as well as in patient selection, renders transcatheter aorticvalve implantation an increasingly viable treatment for more and more patients with structural heart disease. PMID:25374670
Aorticvalve disease is common and has significant impact on prognosis and quality of life. In this educational review, we cover the pathophysiology, presentation and assessment of aortic stenosis (AS) and aortic regurgitation (AR), including the role of imaging modalities beyond echocardiography. We review current treatment strategies and emphasise the use and indications for transcatheter aorticvalve implantation (TAVI) in view of recent data highlighting its emergence as a novel treatment option for patients with AS, who are unsuitable for conventional aorticvalve replacement (AVR). We also describe novel surgical approaches for AR and potential future strategies for percutaneous intervention. PMID:24898790
Key Words Disease Name Definition\\/diagnostic criteria Etiology Clinical description Diagnostic Methods Epidemiology Genetic Councelling Management References Abstract The usual arrangement of the aorticvalve is for it to have three leaflets; these are termed the right and left coronary leaflets and the non-coronary leaflet. Bicuspid aorticvalve (BAV) describes a valve with two leaflets. It can be detected using cross-sectional
... or repair; Cardiac valvular surgery; Mini-sternotomy; Robotically-assisted endoscopic aorticvalve replacement ... type of valve. Biological -- made of human or animal tissue. These valves last 10 to 20 years, ...
While transcatheter aorticvalve replacement( TAVR) has spread rapidly all over the world for highrisk patients with severe aortic stenosis (AS), SAPIEN XT was approved in Japan in October 2013. Since that, approximately 400 TAVR cases were performed in Japan. In our institute, we have performed 164 cases since first case in Japan in 2009 and have achieved satisfactory early results(30-day mortality:1.2%). At the same time, however, simultaneously various TAVR-related complications including a paravalvular leak, stroke, vascular complications, and coronary obstruction were observed. A reduction in the incidence and severity of these complications had led technical improvements in various new devices(2nd generation TAVR device such as the SAPIEN 3, ACURATE, and JenaValve) and in implantation techniques including repositioning/recapturing features, paravalvular sealing technologies, and prevention of coronary obstruction. Furthermore, there is also increasing experience with special indications for TAVR such as pure aorticvalve insufficiency or valve-in-valve techniques. Currently, an increasing number of publications of midterm results demonstrate good prosthetic valve function and durability, with good quality of life and low morbidity after TAVR. There are also some randomized trials such as PARTNER 2 or SURTAVI to investigate potential benefits of TAVR for intermediate-risk patients. These improvements in the TAVR devices promises the expansion of TAVR towards the treatment of lower-risk patients in the near future. PMID:25138938
Transcatheter aorticvalve 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 aorticvalve replacement (SAVR). Surgical aorticvalve replacement is safe and improves symptoms along with survival. However, up to 1/3 of patients with aorticvalve 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 aorticvalve 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
Summary Two competitive soccer players aged 23 and 17 years with known bicuspid aorticvalve presented for sportsmedical preparticipation\\u000a screening. Both athletes were well trained and had a maximal oxygen uptake of 61 and 60 ml\\/min\\/kg, respectively. Echocardiography\\u000a of the first athlete revealed an eccentric hypertrophy of the left ventricle (end–diastolic diameter 58–59 mm, septal and\\u000a posterior myocardial wall thickness 12–13
Jürgen Scharhag; T. Meyer; I. Kindermann; G. Schneider; A. Urhausen; W. Kindermann
... There are two main types of new valves: Mechanical -- made of man-made materials, such as titanium ... Mechanical heart valves do not fail often. However, blood clots can develop on them. If a blood ...
Off-pump transcatheter, transapical valve-in-valveaorticvalve implantation into a failed surgically implanted aorticvalve was successfully performed in an 85-year-old man. He was discharged on postoperative day 5, and remained well at his 16-month follow-up. Echocardiography at 12 months showed normal prosthetic valve function without displacement, recoil, or regurgitation. Transcatheter transapical valve-in-valveaorticvalve implantation is feasible and could be a viable approach for selected patients. PMID:19766829
Ye, Jian; Webb, John G; Cheung, Anson; Masson, Jean-Bernard; Carere, Ronald G; Thompson, Christopher R; Munt, Brad; Moss, Robert; Lichtenstein, Samuel V
An 83-year-old woman with multiple comorbidities and severe aortic stenosis presented with recurrent pulmonary edema. In light of her high surgical risk, a percutaneous strategy for her aortic stenosis was decided. Transcatheter aorticvalve replacement using a balloon-expandable Edwards Sapien XT valve was performed under rapid ventricular pacing. Soon after valve deployment, the patient went into hemodynamic collapse due to annular root rupture with pericardial tamponade, necessitating urgent pericardial decompression. Using a valve-in-valve technique, with the deployment of a second Edward Sapien XT valve inside the first valve, the annular root rupture was successfully sealed leading to hemodynamic recovery. PMID:23913607
We describe a case of mitral valve aneurysm associated with concomitant aorticvalve endocarditis. Aneurysms appear as a localized saccular bulge of the anterior leaflet into the left atrium and thus are often misdiagnosed as mitral valve prolapse, myxomatous mitral valve, or atrial myxoma. The presentation and management of mitral valve aneurysms are the subject of this case report.? PMID:21447085
Ruparelia, Neil; Lawrence, David; Elkington, Andrew
Bicuspid aorticvalve (BAV) has long been associated with a spectrum of vascular complications such as ascending aortic dilatation, aortic aneurysms, and catastrophic aortic root dissec- tion. The mechanism responsible for the associated vascular complications in this seemingly benign and common congenital lesion of aorticvalve morphology remains controversial. Some argue that flow dynamics from the mis-shapen outflow valve result
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Is porcine or bovine valve better for aorticvalve replacement?' Altogether, 562 papers were found using the reported search, of which 15 represented the best evidence to answer the question. All papers represent either level 1 or 2 evidence. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This best evidence paper includes 9880 patients from 1974-2006 to compare both valve types. All studies compared either all or some of the following outcomes: complication, durability, mortality, functional status and haemodynamic function. Ten of 15 papers assessed the complication profile due to aorticvalve replacement in both valve types. Four papers concluded that bovine valves are superior, whereas only one favoured porcine valves. Five papers showed a similar complication profile between both valves. Six of 15 papers commented on valve durability. Both porcine and bovine valve groups have two papers each to support their superiority in valve durability. Two papers demonstrated similar durability in both valves. There are 11 papers comparing the postoperative mortality. We suggest that there is no difference in mortality profile as eight papers showed that both valves had similar mortality profiles. Two papers supported bovine valve and one paper supported porcine valve in this aspect. There were four papers assessing the postoperative functional status, with three papers suggesting that both valve types had similar clinical improvement postoperatively. Eleven papers compared the haemodynamic function. Nine papers were in favour of bovine valves. Two papers demonstrated similar haemodynamic profiles in both valves. In conclusion, the bovine valve is superior in its complication and haemodynamic profiles. Both bovine and porcine valves have comparable results with regard to the mortality, postoperative functional status and valve durability. Significant variability between the valve manufacturers, study designs, study period and patient population in the above studies impose limitations to the comparison of both valves. PMID:23211215
Objective: To compare the mid-term results after aorticvalve (AV) repair in bicuspid AVs with those in tricuspid AVs. Methods: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31\\/43 and 21\\/57 patients in the bicuspid AV
Catalin C. Badiu; Sabine Bleiziffer; Walter B. Eichinger; Iva Zaimova; Andrea Hutter; Domenico Mazzitelli; Bernhard Voss; Rüdiger Lange
ObjectivesPrevious studies have established familial clustering of bicuspid aorticvalve (BAV), presumably indicating genetic inheritance. Our objective was to statistically test whether the segregation pattern of BAV is consistent with genetic inheritance and to obtain an estimate of the size of the genetic effect (heritability).
Linda Cripe; Gregor Andelfinger; Lisa J. Martin; Kerry Shooner; D. Woodrow Benson
Bioprosthetic heart valves are often preferred over mechanical valves as they may preclude the need for anticoagulation. Reoperation is the standard treatment for structural failure of bioprosthetic valves; however, it carries significant risk especially in inoperable elderly patients. Valve-in-valve (ViV) transcatheter aorticvalve replacement (TAVR) seems to be an effective and promising procedure in patients with degenerated bioprosthetic aorticvalves avoiding the risks associated with the use of cardioplegia and redo cardiac surgery. We report an interesting case of a high-risk 74-year-old patient with a degenerated Sorin Freedom Solo stentless valve treated successfully with ViV TAVR. PMID:25091103
Halapas, A; Chrissoheris, M; Spargias, Konstantinos
We reported the case of unicuspid aorticvalve in sibling, suggesting the familial incidence and genetic relation. A 41-year-old man (elder brother) with 79 mmHg of aortic valvular peak pressure gradient (peak PG) underwent aorticvalve replacement with mechanical prosthetic valve (ATS 21 mm). The intraoperative finding showed the unicuspid aorticvalve with one rudimentary commissure. A 37-year-old woman (sister) had been followed by echocardiography as bicuspid aorticvalve since 10 years old. After 27 years, the peak PG had increased to 176 mmHg on preoperative echocardiography. The aorticvalve replacement was performed. The bioprosthetic valve (MOSAIC 21 mm) was implanted supra-annularly because the patient required pregnancy. The intraoperative finding showed the unicuspid aorticvalve with two rudimentary commissures and one opening of LCC-RCC commissure. The histopathological study of both patients confirmed as congenitally unicuspid aorticvalve. In our best knowledge, this is a first report of unicuspid aorticvalve in sibling. PMID:23709159
Transcatheter aorticvalve implantation (TAVI) is currently reserved for high or prohibitive surgical-risk patients with aorticvalve stenosis. We report on successful TAVI in two Jehovah's witness patients. It offers a simple and effective treatment of severe aorticvalve stenosis in high-risk patients who refuse the use of allogeneic blood and blood products. PMID:22753437
Buz, Semih; Pasic, Miralem; Unbehaun, Axel; Hetzer, Roland
Transcatheter aorticvalve implantation (TAVI) is currently reserved for high or prohibitive surgical-risk patients with aorticvalve stenosis. We report on successful TAVI in two Jehovah's witness patients. It offers a simple and effective treatment of severe aorticvalve stenosis in high-risk patients who refuse the use of allogeneic blood and blood products. PMID:22753437
Buz, Semih; Pasic, Miralem; Unbehaun, Axel; Hetzer, Roland
Acute aortic dissection after aorticvalve replacement is rare. A 57-year-old man presented with an acute type A aortic dissection 1 year after aorticvalve replacement, which originated from the previous aortotomy site. He underwent a Bentall procedure. Postoperatively, he developed complete heart block requiring permanent pacemaker implantation. During aorticvalve replacement, risk factors for aortic dissection (diameter of the aorta and fragility and thinness of the aortic wall) should be assessed. Prophylactic aortic root replacement should be undertaken if the aortic root is more than 45?mm in diameter. PMID:24887849
Behranwala, Ali Asgar; Handa, Shyam R; Mehta, Nihar P
Photogrammetric measurements of the surface topography of the aorticvalves obtained from silicon rubber molds of freshly excised human aorticvalves are presented. The data are part of an investigation into the design of a new prosthetic valve which will be a central-flow device, like the real valve and unlike previous central-occluding prostheses. Since the maximum stress on the heart valve is induced when the valve is closed and subject to diastolic back-pressure, it was decided to determine the valve geometry during diastole. That is, the molds were formed by pouring the rubber down the excised aortas, causing the valves to close. The molds were made under different pressures (20-120 torr); photogrammetry served as a vehicle for the assessment of the mold topography through the following outputs: digital models, surface profiles, and contour maps.
Frailty is a common occurrence in elderly persons and is present in approximately half of the patients being screened for transcatheter aorticvalve replacement (TAVR) therapy. Accurate assessment of the likelihood of benefit from intervention in the older patient with aortic stenosis is critical with both surgical aorticvalve replacement and TAVR now available. Whereas risk algorithms are available that are helpful in predicting outcomes in patients undergoing surgical procedures, measures of frailty are not included in the algorithms. When considering intervention in the elderly patient, the addition of frailty assessment to determine the true risk in this population is essential to determine potential benefit. Gait speed as determined by the 5-m walk test is the most commonly used single test objective measurement of frailty in patients undergoing cardiac surgery and is an independent predictor of mortality and major morbidity. Wider application of this and other objective measures of frailty in the population undergoing TAVR is necessary to determine whether it is predictive in this population also. PMID:23260463
The dimensions of the entire aorta at different anatomic levels were measured by transthoracic 2-dimensional echocardiography in 162 consecutive patients with isolated bicuspid aorticvalves (BAVs) without significant aorticvalve dysfunction. Aortic dilation involved the aortic root and the ascending aorta but was not present in the descending and abdominal aorta. A significant increase in the dimensions of the aortic arch was found in patients with BAVs aged >40 years. Ascending aortic diameter and the extension of aortic dilation were significantly correlated with age, but no correlation was found between aortic dimensions and aorticvalve morphology. PMID:15642575
Acute aorticvalve regurgitation due to thrombosed prosthetic valve can present as a surgical emergency. This article reports a successful and unusual management of a young pregnant female patient who presented with acute aorticvalve regurgitation due to a thrombosed mechanical aorticvalve. As the patient had previous multiple cardiac surgeries, the options were limited for repeat aorticvalve or aortic root replacement. The patient had caesarean section followed by implantation of a mechanical valve-on-valve in a previously placed composite valved conduit. This technique may be useful for reoperative valve replacement in the setting of a prior mechanical Bentall patient. PMID:25193228
Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aorticvalve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aorticvalve replacement (TAVR) allows implantation of a prosthetic heart valve within the diseased native aorticvalve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients. PMID:22916051
Siqueira, Dimytri; Abizaid, Alexandre; Arrais, Magaly; Sousa, J. Eduardo
The case is presented of a 75-year-old man referred for transcatheter aorticvalve implantation. During the procedure the prosthetic aorticvalve became dislocated into the left ventricle shortly after expansion. The subsequent steps taken to reposition the valve using only materials at hand are described. PMID:25296450
Natour, Ehsan; Douglas, Yvonne L; Jainandunsing, Jayant S; Schurer, Remco A J; van der Werf, Hendrik W; van den Heuvel, Ad F M
BackgroundBicuspid aorticvalve (BAV) is a risk factor for aortic dissection and aneurysm. We studied patients with BAV and tricuspid aorticvalve (TAV) to evaluate long-term changes in the ascending aorta after aorticvalve replacement (AVR).
Claudio F Russo; Simone Mazzetti; Andrea Garatti; Elena Ribera; Angela Milazzo; Giuseppe Bruschi; Marco Lanfranconi; Tiziano Colombo; Ettore Vitali
OBJECTIVE--To investigate the morphology of congenitally bicuspid aorticvalves causing pure valve regurgitation. DESIGN--A case series collected over five years. SETTING--An academic hospital. PATIENTS AND METHODS--One hundred and forty eight excised congenitally bicuspid aorticvalves. The morphological findings were correlated with sex, age, clinical history, and data on haemodynamic function before operation. Pure valve regurgitation was defined as grade 3-4\\/4
A S Sadee; A E Becker; H A Verheul; B Bouma; G Hoedemaker
The association of a bicuspid aorticvalve (BAV) with abnormalities of the proximal thoracic aorta, including dilatation, aneurysm and dissection, has been previously described, leading to the hypothesis of a common underlying developmental defect involving the aorticvalve and the aortic wall. Consequently, any patient with BAV should receive a careful assessment not only of the valve function, but also of the aortic root and the ascending aorta. Dilatation of the proximal thoracic aorta is a common finding in patients with BAV and is believed to be related to aortic rupture and dissection. Because progressive dilatation can occur, careful long-term surveillance of the aortic dimensions is required. Prophylactic surgical repair of the dilated aorta should be recommended more aggressively for patients with BAV than for those with a tricuspid aorticvalve. However, the optimal timing of aortic surgery in BAV patients remains uncertain because of the limited data available on the natural history of asymptomatic aortic dilatation. PMID:16645355
The aortic heart valve is a complex and sophisticated structure that functions in a mechanically challeng- ing environment. With each cardiac cycle, blood flow exerts shear stresses, bending stress and tensile and compressive forces on the valve tissue. These forces determine a plethora of biological responses, includ- ing gene expression, protein activation and cell phe- notype. Consequently, mechanical forces may
Jonathan T. Butcher; Craig A. Simmons; James N. Warnock
Congenital bicuspid aorticvalve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes\\u000a the patient to the development of dissecting aortic aneurysms. Between 1981 and October 1997, 7 patients with aortic dissection\\u000a associated with congenital bicuspid aorticvalve underwent surgical treatment at our institution. The patients consisted of\\u000a six males and one female. The
Objective: To examine the results of root replacement with aorticvalve-sparing in patients with bicuspid aorticvalve (BAV) or severe aortic regurgitation (AR). Methods: Between 2000 and 2009, 102 patients (mean age 47±17.5 years) underwent aorticvalve-sparing procedures for ascending aortic aneurysm or dissection. Patients were assigned to three different groups according to the aorticvalve pathology: BAV (n=11), tricuspid
Catalin Constantin Badiu; Walter Eichinger; Sabine Bleiziffer; Grit Hermes; Ina Hettich; Markus Krane; Robert Bauernschmitt; Rüdiger Lange
Treatment options for re-stenotic aorticvalve 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 aorticvalve 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
The efficacy of transcatheter aorticvalve implantation (TAVI) in high surgical risk and inoperable patients with severe aortic stenosis (AS) is rapidly gaining credibility with an ever-expanding body of supporting evidence. The potential of TAVI to be a treatment option for a significant cohort of patients with aortic stenosis has fuelled a drive for the optimum device and resulted in exponential advances in the technology with a focus on adverse event minimization and procedural simplification. Consequently, a plethora of new transcatheter valve choices are now available for clinical study or in the pipeline. The evaluation of past, current and emerging devices allows for an appreciation of the design considerations involved in this process and an insight to the future direction of the technology. PMID:23972363
Fanning, Jonathon P; Platts, David G; Walters, Darren L; Fraser, John F
A ortic root aneurysms are not rare in patients with bicuspid aorticvalve, but valve-sparing operations to treat them remain challenging. We describe our surgical method of reconstructing only two commissures, which is extremely simple and easy to reproduce without aortic stenosis.
A technique for aorticvalve replacement is described in which the aorticvalve is exposed through a partial sternotomy without transecting ("T'ing" off) the sternum. Aorticvalve replacement can be performed with standard aortic and right atrial cannulation. PMID:9456142
Objective:To assess the utility of transthoracic echocardiography (TTE) with second harmonic combined with transesophageal echocardiography (TEE) in defining aorticvalve morphology in a subset of patients with a high prevalence of bicuspid aorticvalve. Methods and Materials: Patients (n=174) with dilated aortic root were consecutively evaluated using, initially, TTE. The aorticvalve structure was assigned as tricuspid, bicuspid or undefined.
Josep M. Alegret; Oscar Palazón; Ignasi Duran; Josep M. Vernis
Conventional aorticvalve replacement (AVR) surgery has been in clinical use since 1960. Results, particularly in high-risk populations such as the very elderly and frail, continue to improve in response to the challenges posed by this growing segment of the patient population. Transcatheter aorticvalve implantation (TAVI) is a fairly recent development, performed for the first time in 2002. The last decade has seen an exponential growth in the application of this technology in higher-risk populations. Results of recent randomized prospective trials demonstrate both the future promise and current problems of the TAVI approach. Many patients deemed inoperable for AVR have been treated successfully by TAVI. However, elevated procedural and late mortality rates, excessive early and late stroke, and a significant incidence of periprosthetic aorticvalve insufficiency and patient-prosthesis mismatch all suggest caution in extending this technology to patients able to undergo conventional AVR with a low risk of early or late complications. PMID:22891120
The Medtronic freestyle aortic root bioprosthesis (Medtronic, Inc., Minneapolis, MN, USA) is a stentless valve with an effective orifice area that is larger than that observed on other bioprostheses. However, there have been sporadic reports of structural valve deterioration (SVD), such as aortic root wall rupture, leaflet tearing, and pseudoaneurysm formation. We report five cases of SVD of freestyle aortic root bioprostheses. doi: 10.1111/jocs.12235 (J Card Surg 2014;29:22-25) PMID:24251776
\\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
A positive acting valve suitable for operation in a corrosive environment is provided. The valve includes a hollow valve body defining an open-ended bore for receiving two, axially aligned, spaced-apart, cylindrical inserts. One insert, designated the seat insert, terminates inside the valve body in an annular face which lies within plane normal to the axis of the two inserts. An elastomeric O-ring seal is disposed in a groove extending about the annular face. The other insert, designated the wedge insert, terminates inside the valve body in at least two surfaces oppositely inclined with respect to each other and with respect to a plane normal to the axis of the two inserts. An elongated reciprocable gate, movable between the two inserts along a path normal to the axis of the two inserts, has a first flat face portion disposed adjacent and parallel to the annular face of the seat insert. The gate has a second face portion opposite to the first face portion provided with at least two oppositely inclined surfaces for mating with respective inclined surfaces of the wedge insert. An opening is provided through the gate which registers with a flow passage through the two inserts when the valve is open. Interaction of the respective inclined surfaces of the gate and wedge insert act to force the first flat face portion of the gate against the O-ring seal in the seat insert at the limits of gate displacement where it reaches its respective fully open and fully closed positions.
Traumatic injury to the aorticvalve is an uncommon clinical entity. Rarer still is the transport of such a patient using extracorporeal membrane oxygenation (ECMO) to a specialized ECMO center for definitive repair. We present a case of traumatic rupture of the aorticvalve complicated by severe acute respiratory distress syndrome with interhospital transport using ECMO and subsequent aorticvalve replacement. PMID:24658521
The families of 41 patients with surgically proved isolated bicuspid aorticvalves were examined. There were 275 first degree relatives of whom 220 were living, and 188 (85.5%) of these were examined. Seven first degree relatives were found to have aorticvalve disease, and in a further 11 there was 'doubtful' evidence of bicuspid aorticvalves. In 6 families there
Objectives : To study the pathology and determine the etiology and prevalence of aorticvalve disease from surgically removed aorticvalve specimens. Material and Method : All the native surgically excised aorticvalves (AV) received from June 1997 to March 1999 (22 months) were studied macroscopically including cuspal measurements and microscopically. By preoperative echocardiographic and macroscopic studies, they were classified
Bicuspid aorticvalves (BAVs) are a congenital anomaly of the aorticvalve with two fused leaflets, affecting about 1-2% of the population. BAV patients have much higher incidence of valve calcification & aortic dilatation, which may be related to altered mechanical forces from BAV hemodynamics. This study aims to characterize BAV hemodynamics using Particle Image Velocimetry(PIV). BAV models are constructed
Neelakantan Saikrishnan; Choon-Hwai Yap; Ajit P. Yoganathan
Collagen Bundle Orientation Explains AorticValve Leaflet Coaptation Peter E. Hammer1 , Christina A. The aorticvalve owes its strength and durability to a network of collagen fibers within the leaflets and quantified the macroscopically visible pattern of collagen fibers in seven porcine aorticvalves
Background: It has been well documented that patients with a congenital bicuspid aorticvalve suffer from earlier valve dysfunction and abnormalities of the ascending aorta, frequently requiring aorticvalve replacement and some requiring replacement of the ascending aorta. There have been a few reports with variable data on the frequency of aortic complications, including dilation, aneurysm and dissection, at the
Transcatheter aorticvalve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aorticvalve stenosis who are at high surgical risk or are unsuitable candidates for open heart surgery. However, concerns exist over treating patients who have previously undergone mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement who was successfully treated with TAVI using a CoreValve.
Transcatheter aorticvalve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aorticvalve stenosis who are at high surgical risk or are unsuitable candidates for open heart surgery. However, concerns exist over treating patients who have previously undergone mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement who was successfully treated with TAVI using a CoreValve. PMID:25278988
Calcific aorticvalve disease (CAVD) is the most common heart valve disorder. There is no medical treatment to prevent and/or promote the regression of CAVD. Hence, it is of foremost importance to delineate and understand the key basic underlying mechanisms involved in CAVD. In the past decade our comprehension of the underpinning processes leading to CAVD has expanded at a fast pace. Hence, our understanding of the basic pathobiological processes implicated in CAVD might lead eventually to the development of novel pharmaceutical therapies for CAVD. In this review, we discuss molecular processes that are implicated in fibrosis and mineralization of the aorticvalve. Specifically, we address the role of lipid retention, inflammation, phosphate signalling and osteogenic transition in the development of CAVD. Interplays between these different processes and the key regulation pathways are discussed along with their clinical relevance. PMID:25085215
The differential diagnosis of cardiac mass is important in determining the therapeutic plan and avoiding unnecessary surgical intervention. Non-invasive imaging methods would be useful in the diagnosis of suspected cardiac mass, because they may provide earlier diagnosis and more accurate assessment of cardiac mass. Native aorticvalve thrombosis is a rare disorder and difficult to differentiate from a tumor, and in particular, a papillary fibroelastoma. Thus, the clinical decision making with imaging modalities should be performed cautiously. We recently met a female patient who had a aorticvalve mass resembling papillary fibroelastoma in normal native valve. The patient underwent a surgical resection and the pathologic finding showed an organized thrombus with no evidence of papillary fibroelastoma. PMID:25309693
Kim, Minkwan; Kim, Suk-Hyun; Moon, Sang Yi; Jeong, Eu Gene; Jung, Eui Han; Nam, Hwa Seong; Choi, Jae-Hyuk
Gemella morbillorum is facultative anaerobic, Gram-positive cocci and are a commensal part of human flora. The reported patient in this case, with a prosthetic bovine aorticvalve, presented with fever, poor dental hygiene, new cardiac murmur and signs of congestive heart failure. Blood cultures were positive for a viridans streptococcal species; however, the organism could not be further identified at our institution. Echocardiogram demonstrated a decrease in ejection fraction and vegetation attached to the prosthetic aorticvalve associated with a perivalvular abscess. The patient was treated with a 6-week regimen of penicillin G with gentamicin for the first 2?weeks along with cardiac surgery. The results from the 16S rRNA gene sequencing of the viridans streptococcal species were available, which reported the organism as G. morbillorum. This case adds to the literature on G. morbillorum prosthetic valve endocarditis and provides additional evidence to consider infectious endocarditis in the setting of G. morbillorum bacteraemia. PMID:25406216
Purpose: Over the past 30 years there have been experimental efforts at catheter-based management of aorticvalve regurgitation with the idea of extending treatment to nonsurgical candidates. A new catheter-based aorticvalve design is described.Methods: The new catheter-delivered valve consists of a stent-based valve cage with locking mechanism and a prosthetic flexible tilting valve disc. The valve cage is delivered first followed by deployment and locking of the disc. In acute experiments, valve implantation was done in four dogs.Results: Valve implantation was successful in all four animals. The implanted valve functioned well for the duration of the experiments (up to 3 hr).Conclusion: The study showed the implantation feasibility and short-term function of the tested catheter-based aortic disc valve. Further experimental studies are warranted.
Sochman, Jan [Department of Cardiology, Institute for Clinical and Experimental Medicine, Videnska 1958/9, 140 21 Prague 4 (Czech Republic); Peregrin, Jan H. [Department of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Videnska 1958/9, 140 21 Prague 4 (Czech Republic); Pavcnik, Dusan; Timmermans, Hans; Roesch, Josef [Dotter Interventional Institute, Oregon Health Sciences University, 3181 S.W. Jackson Park Road, L342, Portland, Oregon, 97201-3098 (United States)
Transcatheter aorticvalve 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 aorticvalve 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 aorticvalve, 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
Surgical aorticvalve replacement (SAVR) which requires cardiopulmonary bypass (CPB) is still the gold standard for treatment of aortic stenosis (AS). But for elderly patients with severe AS and coexisting conditions, invasive surgery with CPB may lead to organ dysfunction and life-threatening complications. Transcatheter aorticvalve replacement (TAVR) is a novel treatment for AS. TAVR is performed by catheter techniques, which do not require sternotomy, CPB, and cardiac arrest, and are less invasive than SAVR. That is why TAVR is considered quite suitable for such patients at high risk. Anesthesiologists managing TAVR should aim at fast-track anesthesia in order to make the most of the minimal invasiveness of TAVR by stabilizing circulations and respiratory conditions, keeping body temperature, and controlling postoperative pain. PMID:23236924
Background. Intrinsic abnormality of the aortic wall may explain the association of bicuspid aorticvalves with ascending aortic aneurysms. Separate valve and graft repair of such lesions, rather than composite valve graft replacement, is more straightforward but leaves potentially abnormal sinuses behind.Methods. Between January 1985 and January 1998, 45 patients underwent separate valve and graft (n = 27) or composite
Thoralf M Sundt; Bassem N Mora; Marc R Moon; Marci S Bailey; Michael K Pasque; William A Gay
Background. Intrinsic abnormality of the aortic wall may explain the association of bicuspid aorticvalves with ascending aortic aneurysms. Separate valve and graft repair of such lesions, rather than composite valve graft replacement, is more straightforward but leaves potentially abnormal sinuses behind. Methods. Between January 1985 and January 1998, 45 patients underwent separate valve and graft (n 5 27) or
Thoralf M. Sundt III; Bassem N. Mora; Marc R. Moon; Marci S. Bailey; Michael K. Pasque; William A. Gay
Objective: Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aorticvalve disease is increasing, but use of the pulmonary autograft in the treatment of aorticvalve
Gosta Petterssona; Jens Tingleff; Frederic S. Joyce
Although conventional aorticvalve replacement (AVR) surgery remains the gold standard for patients with aortic stenosis, transcutaneous aorticvalve replacement is becoming increasingly common in high-risk patients. The techniques of minimal invasive surgery (MIS) have been well known for many years, but MIS is applied in a disappointingly low percentage of patients undergoing AVR surgery. The EDWARDS INTUITY rapid deployment aorticvalve system is designed to facilitate the performance of MIS AVR surgery. In addition, the reduced implantation times may be beneficial in higher risk patients or those requiring concomitant procedures. The system combines established pericardial valve technology with modern stent expertise obtained from the transcutaneous aorticvalve replacement experience. Preliminary results from a multicenter trial have shown low rates of morbidity and mortality, and excellent hemodynamic performance. The EDWARDS INTUITY promises to be an exciting device that may further change the landscape of aorticvalve intervention. PMID:23895073
Borger, Michael A; Dohmen, Pascal; Misfeld, Martin; Mohr, Friedrich W
Three patients demonstrated severe, central aortic insufficiency noted immediately upon removal of the aortic cross clamp after aorticvalve replacement with a bovine pericardial Edwards Magna valve. After maintaining left ventricular decompression, the aortic insufficiency resolved in less than 1 hour. Knowledge of this phenomenon will prevent unnecessary prosthetic valve explantation and re-replacement. PMID:19632443
Vander Salm, Thomas J; Toran, Ann J; Lewis, Wilfred; O'Connor, Johanna
Background. Patients with bicuspid aorticvalves tend to develop dilatation of the ascending aorta. The aim of this study was to analyze whether or not there is any histologic difference in the aortic media of patients with a bicuspid aorticvalve or a tricuspid aorticvalve.Methods. A morphometric analysis of the wall of the ascending aorta was performed in 107
Matthias Bauer; Miralem Pasic; Rudolf Meyer; Nadine Goetze; Ulrike Bauer; Henryk Siniawski; Roland Hetzer
Reoperative minimal access aorticvalve replacement (AVR) is performed through an upper hemisternotomy with peripheral cannulation. This approach limits dissection of mediastinum and especially the left internal mammary artery (LIMA) graft in patients with previous coronary artery bypass grafting (CABG) thus minimizing trauma to the patient. This approach is safe and feasible and may have some benefit over conventional full sternotomy in terms of mortality and morbidity. PMID:24251026
Background. The Ross procedure is useful, but at times an allograft valve is the only alternative to a mechanical aortic prosthesis. Since 1994 the Ross procedure or aortic allograft replacement has been used exclusively for aorticvalve replacement at our institution.Methods. Demographic, clinical, and echocardiographic data of 23 consecutive Ross and 8 allograft patients were compared.Results. Groups were similar in
Methods: Between November 1985 and July 1995, 36 patients underwent allograft aorticvalve replacement for endocarditis. The mean age of the 29 men and seven women was 53 years (range 25 to 79 years). Previous procedures included mechanical (n = 9), bioprosthetic (n = 5), and allograft (n = 2) aorticvalve replacement, aortic valvotomy (n = 1), and orthotopic
Joseph A. Dearani; Thomas A. Orszulak; Hartzell V. Schaff; Richard C. Daly; Betty J. Anderson; Gordon K. Danielson
Transcatheter aorticvalve implantation (TAVI) has recently emerged as a treatment option for patients with severe aorticvalve stenosis (AS). For patients who are deemed inoperable for surgical aorticvalve 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. PMID:22891126
Background—The freestanding aortic root, which is the currently preferred operative technique for pulmonary autografts, is reported to dilate and potentially promote aortic insufficiency, which has led to a controversial debate on the appropriate surgical technique, especially for congenital bicuspid aorticvalve disease. Desirable data on the time course of valve function and root dimensions for the alternative subcoronary technique comparing
Claudia Schmidtke; Matthias Bechtel; Michael Hueppe; Hans-H. Sievers
The timing of aorticvalve intervention (AVI) in pediatric patients with chronic aortic insufficiency (AI) is largely based on adult experience, which is fraught with uncertainty and controversy. Current adult guidelines in the absence of symptoms use left ventricular (LV) systolic function and LV dimensions to guide AVI timing, with few studies translating these recommendations to pediatric patients. This article reviews the current guidelines for AVI timing in chronic AI along with the emerging data for pediatric patients. PMID:25179463
The congenitally bicuspid aorticvalve with anomalous chordal attachment of the fused cusp to the aortic wall is a rare and unappreciated cause of aortic insufficiency. We report the case of a 43-year-old male patient who presented with severe aortic insufficiency caused by this anomaly and in whom surgical aorticvalve repair was successfully performed. To our knowledge, this is the first report to describe the successful surgical repair of this rare variant of bicuspid aorticvalve. PMID:25282245
Objective: To evaluate the early results of a new method to repair malfunctioning bicuspid aorticvalves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Material and methods: Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aorticvalve underwent repair with the principle of creating a tricuspid valve and
René Prêtre; Alexander Kadner; Hitendu Dave; Dominique Bettex; Michele Genoni
Computed tomography (CT) plays an important role in the workup of patients who are candidates for implantation of a catheter-based aorticvalve, a procedure referred to as transcatheter aorticvalve implantation (TAVI) or transcatheter aorticvalve replacement (TAVR). Contrast-enhanced CT imaging provides information on the suitability of the peripheral access vessels to accommodate the relatively large sheaths necessary to introduce the prosthesis. CT imaging also provides accurate dimensions of the ascending aorta, aortic root, and aortic annulus which are of importance for prosthesis sizing, and initial data indicate that compared with echocardiographic sizing, CT-based sizing of the prosthesis may lead to better results for postprocedural aorticvalve regurgitation. Finally, CT permits one to predict appropriate fluoroscopic projections which are oriented orthogonal to the aorticvalve plane. This consensus document provides recommendations about the use of CT imaging in patients scheduled for TAVR/TAVI, including data acquisition, interpretation, and reporting. PMID:23217460
Achenbach, Stephan; Delgado, Victoria; Hausleiter, Jörg; Schoenhagen, Paul; Min, James K; Leipsic, Jonathon A
Background. Extensive experience has accumulated with the use of aortic and pulmonary autografts for replacement of the aorticvalve and the aortic root. Three general techniques for insertion have been used: sub- coronary (free-hand) valve implantation, mini- or inclu- sion-root implantation, and aortic root replacement. Thir- ty-day mortality for elective operations with all of these techniques has not exceeded 5%.
Background. Extensive experience has accumulated with the use of aortic and pulmonary autografts for replacement of the aorticvalve and the aortic root. Three general techniques for insertion have been used: subcoronary (free-hand) valve implantation, mini- or inclusion-root implantation, and aortic root replacement. Thirty-day mortality for elective operations with all of these techniques has not exceeded 5%. Thromboembolic episodes have
In recent years, transcatheter aorticvalve implantation (TAVI) has become an established treatment option for selected high-risk patients with severe aortic stenosis (AS). Favorable results with regard to both hemodynamics and clinical outcome have been achieved with transcatheter valves. Aortic regurgitation (AR) remains a major concern after TAVI. Echocardiography is the imaging modality of choice to assess AR in these patients due to its wide accessibility and low cost. Mostly mild residual AR has been observed in up to 70% of patients. However, as even a mild degree of AR has been associated with a decreased survival up to two years after TAVI, accurate evaluation and classification of AR is important. AR in transcatheter valves can be divided into three types according to different pathophysiological mechanisms. Besides the well-known transvalvular and paravalvular forms of regurgitation, a third form termed supra-skirtal has recently been observed. A thorough understanding of AR in transcatheter valves may allow to improve device design and implantation techniques to overcome this complication. The aim of this review is to provide an overview of the three types of AR after TAVI focussing on the different pathophysiological mechanisms. PMID:24282741
Stahli, Barbara E.; Maier, Willibald; Corti, Roberto; Luscher, Thomas F.; Jenni, Rolf
Considering the structure and function of the aortic root, changes in the aorticvalve leaflets and changes in the geometry of the aortic root are the two primary causes of aorticvalve dysfunction. In adults, aorticvalve sparing reconstruction has a long history beginning in the 1970s, where tensor fascia was used for leaflet repair in patients with isolated aortic regurgitation and ascending aortic replacement was used in patients with ascending aortic aneurysms or aortic ectasia. Subsequent progress in the 1980s and 1990s led to pericardial leaflet replacement and aortic root re-implantation and remodeling. However, it has not been until the last decade that these concepts and techniques have been applied in younger patients focusing on the conotruncus, valvar apparatus, sino-tubular junction, and ascending aorta. PMID:22424502
Baird, Christopher W; Myers, Patrick O; del Nido, Pedro J
Here, we demonstrate the angiogenic response of valvular endothelial cells to aorticvalve (AV) stenosis using a new ex vivo model of aortic leaflets. Histological analysis revealed neovascularization within the cusps of stenotic but not of non-stenotic aorticvalves. Correspondingly, the number of capillary-like outgrowth in 3D collagen gel was significantly higher in stenotic than in non-stenotic valves. Capillary-like sprouting was developed significantly faster in stenotic than in non-stenotic valves. New capillary sprouts from stenotic aorticvalves exhibited the endothelial cell markers CD31, CD34 and von-Willebrand factor (vWF) as well as carcinoembryonic antigen cell adhesion molecule-1 (CEACAM1), Tie-2 and angiogenesis inhibitor endostatin. Western blot analyses revealed a significant increase of CEACAM1 and endostatin in stenotic aorticvalve tissue. Electron microscopic examinations demonstrate that these capillary-like tubes are formed by endothelial cells containing Weibel-Palade bodies. Remarkably, inter-endothelial junctions are established and basement membrane material is partially deposited on the basal side of the endothelial tubes. Our data demonstrate the capillary-like sprout formation from aorticvalves and suggest a role of angiogenesis in the pathogenesis of aorticvalve stenosis. These data provide new insights into the mechanisms of valvular disorders and open new perspectives for prevention and early treatment of calcified aortic stenosis. PMID:15265693
We report a 76-year-old female with Takayasu arteritis who was found to have multiple coronary arteriovenous fistulas (CAVFs), a pulmonary-to-systemic ratio of 2:1, and aorticvalve insufficiency. Aorticvalve replacement and ligation of multiple CAVFs with cardiopulmonary bypass were performed under cardioplegic arrest, thus minimizing coronary steal. PMID:23594082
Bicuspid aorticvalve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. Limited data exist regarding serial changes of aortic dilation in patients with BAV. We studied paired transthoracic echocardiograms of 68 patients with BAV (mean age 44 years) and with at least 2 examinations >12 months apart (mean follow-up 47 months) to characterize the progression
Transcatheter aorticvalve replacement (TAVR) is a transformative innovation that provides treatment for high or prohibitive surgical risk patients with symptomatic severe aortic stenosis who either were previously not referred for or were denied operative intervention. Trials have demonstrated improvements in survival and symptoms after TAVR versus medical therapy; however, there remains a sizable group of patients who die or lack improvement in quality of life soon after TAVR. This raises important questions about the need to identify and acknowledge the possibility of futility in some patients considered for TAVR. In this very elderly population, a number of factors in addition to traditional risk stratification need to be considered including multimorbidity, disability, frailty, and cognition in order to assess the anticipated benefit of TAVR. Consideration by a multidisciplinary heart valve team with broad areas of expertise is critical for assessing likely benefit from TAVR. Moreover, these complicated decisions should take place with clear communication around desired health outcomes on behalf of the patient and provider. The decision that treatment with TAVR is futile should include alternative plans to optimize the patient's health state or, in some cases, discussions related to end-of-life care. We review issues to be considered when making and communicating these difficult decisions. PMID:24954571
Lindman, Brian R; Alexander, Karen P; O'Gara, Patrick T; Afilalo, Jonathan
Transcatheter aorticvalve 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
Transcatheter aorticvalve implantation has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery, and is generally performed retrogradely with vascular access. However, in certain patients, this access is either not possible or deemed to carry a high risk of vascular injury. We report our experience of a direct aortic approach in a 78-year old man with severe aortic stenosis, excluded from standard aorticvalve replacement due to a porcelain aorta, and affected by severe aortic, iliac-femoral, and subclavian arteriopathy, rendering the transfemoral or subclavian approach unemployable. PMID:24887834
Bruschi, Giuseppe; Botta, Luca; De Marco, Federico; Colombo, Paola; Klugmann, Silvio; Martinelli, Luigi
BackgroundPatients with bicuspid aorticvalve malformations are at an increased risk of aortic dilatation, aneurysm formation, and dissection. Vascular tissues with deficient fibrillin-1 microfibrils release matrix metalloproteinases, enzymes that weaken the vessel wall by degrading elastic matrix components. In bicuspid aorticvalve disease a deficiency of fibrillin-1 and increased matrix metalloproteinase matrix degradation might result in aortic degeneration and dilatation.
Paul W. M. Fedak; Mauro P. L de Sa; Subodh Verma; Nafiseh Nili; Pedram Kazemian; Jagdish Butany; Bradley H Strauss; Richard D Weisel; Tirone E David
Background. Currently, isolated reconstruction of a regurgitant bicuspid aorticvalve can be performed with adequate early results. Dilatation of the proximal aorta is known to be associated with this valve anomaly and may be partially responsible for the development of primary regurgitation or secondary failure of valve repair. We have used repair of the bicuspid valve with remodeling of the
Hans-Joachim Schäfers; Frank Langer; Diana Aicher; Thomas P Graeter; Olaf Wendler
BackgroundAortic complications are more frequent after bicuspid aorticvalve (BAV) replacement (AVR), than tricuspid aorticvalve replacement. We studied the size of the proximal thoracic aorta in patients with BAV undergoing AVR for pure, severe aortic stenosis, looking for dilatation in comparison with patients with a matched tricuspid aorticvalve (TAV) and normograms of aortic size.
Gareth J Morgan-Hughes; Carl A Roobottom; Patrick E Owens; Andrew J Marshall
OBJECTIVETo evaluate the dimensions of the aortic root in a selected population of young males with isolated normally functioning bicuspid aorticvalve.DESIGN AND SETTINGEchocardiographic and Doppler evaluation of conscripts with bicuspid aorticvalve at the time of military pre-enrolment screening in two military hospitals.SUBJECTS AND METHODS66 consecutive young men with a normally functioning bicuspid aorticvalve were studied to assess
S Nistri; M D Sorbo; M Marin; M Palisi; R Scognamiglio; G Thiene
Objective: We sought to determine the morphology, mechanisms of deterioration, cellular viability, extracellular matrix integrity, and the role of immune responses in the dysfunction of cryopreserved aortic and pulmonic valve allografts. Methods: We studied 33 explanted left-sided ( n = 20) or right-sided (n = 13) cryopreserved human allograft heart valves explanted several hours to 9 years after operation, 14 nonimplanted allografts,
Richard N. Mitchell; Richard A. Jonas; Frederick J. Schoen
A 22-year-old female with no medical history presented to the emergency room with 2 weeks of rapidly worsening dyspnea on exertion, orthopnea, and cough. On cardiac auscultation, she was noted to have to-and-fro murmurs and a continuous murmur with signs of right heart failure. Echocardiographic images obtained showed moderate to severe aortic regurgitation, severe tricuspid regurgitation, and a "windsock" originating in the right coronary sinus of Valsalva and terminating in the right atrium. The aorticvalve had four leaflets, with the right leaflet function compromised by the ruptured sinus, causing aortic regurgitation. The patient underwent resection of the sinus aneurysm and aorticvalve replacement with a bioprosthetic valve. Quadricuspid aorticvalves are uncommon and are rarely associated with sinus of Valsalva aneurysm. The prevalence in the general population, clinical progression, and prognosis of this unique congenital abnormality are reviewed. PMID:21426530
Yang, Eric H; Rawal, Milan; Pillutla, Priya; Criley, John Michael
Aorticvalve stenosis, which causes considerable constriction of the flow passage, is one of the most frequent cardiovascular diseases and is the most common cause of the valvular replacements which take place for around 100,000 per year in North America. Furthermore, it is considered as the most frequent cardiac disease after arterial hypertension and coronary artery disease. The objective of this study is to develop an analytical model considering the coupling effect between fluid flow and elastic deformation with reasonable boundary conditions to describe the effect of AS on the left ventricle and the aorta. The pulsatile and Newtonian blood flow through aortic stenosis with vascular wall deformability is analyzed and its effects are discussed in terms of flow parameters such as velocity, resistance to flow, shear stress distribution and pressure loss. Meanwhile we developed analytical expressions to improve the comprehension of the transvalvular hemodynamics and the aortic stenosis hemodynamics which is of great interest because of one main reason. To medical scientists, an accurate knowledge of the mechanical properties of whole blood flow in the aorta can suggest a new diagnostic tool.
To identify multi-detector computed tomographic (MDCT) features discriminating bicuspid aorticvalves (BAVs) from tricuspid\\u000a aorticvalves (TAVs) in patients with aortic valvular disease using surgical findings as reference. Forty-five patients underwent\\u000a ECG-gated cardiac MDCT scans prior to aorticvalve replacement. Morphologic patterns of aorticvalves on MDCT were classified\\u000a into: bicuspid without raphe (A), fused valve with a fish-mouth opening (B),
Ijin Joo; Eun-Ah Park; Kyung-Hwan Kim; Whal Lee; Jin Wook Chung; Jae Hyung Park
Marfan's syndrome is an autosomal dominant disorder with risk of premature death from rupture of an aneurysm or aortic dissection. A case of acute severe aortic regurgitation due to flail aorticvalve in a patient with family history of Marfan's syndrome which may be a form fruste of this syndrome is reported. PMID:12974442
Background and aim of the study: Controversy exists with regard to the indications and technique for valve-preserving aortic root reconstruction. Here, the authors' clinical experience with three techniques is reported. Methods: Between October 1994 and October 2000, 71 patients (46 men, 25 women; median age 53 years; range: 21-81 years) underwent aortic root reconstruc- tion with preservation of the aortic
Harold M. Burkhart; Kenton J. Zehr; Hartzell V. Schaff; Richard C. Daly; Joseph A. Dearani; Thomas A. Orszulak
Previous studies have shown that congentially bicuspid aorticvalves develop degenerative diseases earlier than the standard trileaflet, but the causes are not well understood. It has been hypothesized that the asymmetrical flow patterns and turbulence found in the bileaflet valves together with abnormally high levels of strain may result in an early thickening and eventually calcification and stenosis. Central to
Kai Szeto; Tran Nguyen; Javier Rodriguez; Peter Pastuszko; Vishal Nigam; Juan Lasheras
Objective: Bicuspid aorticvalve 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 aorticvalve. The present study was undertaken to define the histologic condition of the aortic and pulmonary artery root in bicuspid aorticvalve disease and the relationship with pulmonary
Giovanni Battista Luciani; Luca Barozzi; Anna Tomezzoli; Gianluca Casali; Alessandro Mazzucco
BACKGROUND: Congenital Bicuspid AorticValve (BAV) is a significant risk factor for serious complications including valve dysfunction, aortic dilatation, dissection, and sudden death. Clinical tools for identification and monitoring of BAV patients at high risk for development of aortic dilatation, an early complication, are not available. METHODS: This paper reports an investigation in 18 pediatric BAV patients and 10 normal
P Martijn den Reijer; Denver Sallee III; Petra van der Velden; Eline R Zaaijer; W James Parks; Senthil Ramamurthy; Trevor Q Robbie; Giorgina Donati; Carey Lamphier; Rudolf P Beekman; Marijn E Brummer
Background—Aorticvalve stenosis (with or without aortic regurgitation and without associated mitral stenosis) in adults in the Western world has been considered in recent years to most commonly be the result of degenerative or atherosclerotic disease. Methods and Results—We examined operatively excised, stenotic aorticvalves from 932 patients aged 26 to 91 years (meanSD, 7012), and none had associated mitral
The stress analysis of the porcine aorticvalve leaflets in diastole at 80 mm Hg pressure in-vitro is presented. Incorporation of local geometrical asymmetry, material inhomogeneity, anistropy and non-linearity are applied. The stress theory used is a modified form of the thin membrane stress theory for a homogeneous linearly elastic and orthotropic lamina. Modifications are made so that the Hooke's law constitutive equations of stress may be applied to the inhomogeneous, non-lineary elastic and orthotropic thin (membrane) aorticvalve leaflets. Stress calculations are made on the premise that the valve is in pre-transition (i.e. low elastic modulus) in the circumferential direction and post-transition (i.e. high elastic modulus) in the radial direction. It is shown that sigmaCIR less than 1 gm/mm2, and for most of the noncoronary leaflet, 0 less than sigmaRAD less than 30 gm/mm2. The areas of highest stress concentrations are in the areas of mutual leaflet coaptation near the Node of Arantii. A progressive increase of radial stresses from the sinus-annulus edge toward the node is observed. PMID:728516
This study evaluated preoperative balloon aortic valvuloplasty (BAV) as a technique to decrease aorticvalve replacement (AVR) risk in patients who have severe symptomatic aorticvalve 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 aorticvalve 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 aorticvalve 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 aorticvalve 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. 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.
When left ventricular outflow tract obstruction develops after aorticvalve replacement, few treatment choices have been available until now. We present a patient with prior aorticvalve replacement who developed left ventricle outflow tract obstruction that was successfully treated with a percutaneous transcoronary myocardial septal alcohol ablation. This technique is a useful tool for the treatment of obstructive hypertrophic cardiomyopathy, especially in those patients with prior heart surgery. Copyright 2001 Wiley-Liss, Inc.
Sitges, M.; Kapadia, S.; Rubin, D. N.; Thomas, J. D.; Tuzcu, M. E.; Lever, H. M.
Background Because of a high prevalence of coronary artery disease in patients with aorticvalve disease, coronary angiography is recommended before aorticvalve replacement. However, during the last three decades, a decline in mortality due to coronary heart disease has been observed in the general population in both Western Europe and the United States. It is unknown whether preoperative angiography is still mandatory in all patients. Aim To assess the prevalence of angiographically defined coronary artery disease in patients with aorticvalve replacement and trends during a ten-year period. Methods We performed a retrospective cross-sectional study of patients undergoing aorticvalve replacement between 1988 and 1998 in our institution. Patients with a history of coronary artery disease and patients younger than 25 years were excluded. Coronary atherosclerosis was defined as one or more coronary artery luminal stenosis of 50% or more on preoperative coronary angiography. Results During the study period 1339 patients had aorticvalve replacement in our institution, data on 1322 (98%) were available for analysis. Previous coronary artery disease was documented in 124 patients (10%). After exclusion of 17 patients (no angiography), data on a total of 1181 patients were analysed. Coronary atherosclerosis was present in 472 patients (40%) on preoperative coronary angiography. Several well-known risk factors of ischaemic heart disease were associated with coronary atherosclerosis. The prevalence of angiographically defined coronary atherosclerosis varied between 30% and 50% per year. There was, however, no significant trend during the study period. Multivariate analyses, to adjust for potential differences in risk factors during the observation period, did not change this conclusion. Conclusions The prevalence of angiographically defined coronary artery disease in patients scheduled for aorticvalve replacement is still high. From 1988 to 1998, no significant change was observed in angiographic measures of coronary atherosclerosis in patients with aorticvalve replacement. Therefore, it is advised to perform coronary angiography before aorticvalve surgery. ImagesFigure 1
Ottervanger, J.P.; Thomas, K.; Sie, T.H.; Haalebos, M.M.P.; Zijlstra, F.
Transcatheter aorticvalve implantation (TAVI) improves the prognosis of patients with severe aortic stenosis who are deemed too high risk for surgical valve replacement.1 However, this evolving technology is associated with a wide range of potential complications — some specific to TAVI, some often fatal. Prevention, early recognition, and effective treatment of these complications will significantly improve the outcome of this procedure and are essential prerequisites before the therapy is extended to lower-risk patient subsets. PMID:22891127
Brecker, Stephen J.D.; Roy, David; Jahangiri, Marjan
Objective: Reoperation rates after repair of bicuspid aorticvalves are higher than for mitral valve reconstruction. Satisfactory results have been reported for patch augmentation for tricuspid aorticvalves. We have applied this technique for the repair of bicuspid aorticvalves. Methods: Autologous pericardium is sutured to the free edge of the prolapsing bicuspid leaflet. A large coaptation surface is created
Mirko Doss; Sami Sirat; Petar Risteski; Sven Martens; Anton Moritz
ObjectiveAscending aortic aneurysms (AscAAs) are a highly lethal condition whose pathobiology remains to be poorly understood. Although most AscAAs occur in the presence of a trileaflet aorticvalve (TAV), a bicuspid aorticvalve (BAV) is a common congenital anomaly associated with an increased risk for an AscAA and dissection independent of functional valve pathology but secondary to inherent structural abnormality
Ramanath Majumdar; Dylan V. Miller; Karla V. Ballman; Gopinathan Unnikrishnan; Stephen H. McKellar; Gobinda Sarkar; Raghavakaimal Sreekumar; Mark E. Bolander; Thoralf M. Sundt
Bicuspid aorticvalve is often associated with lesions of the ascending aorta, which differ histologically from those in tricuspid valve patients. We undertook proteomic analyses to assess differences at the proteome level. Aortic samples were collected from 20 patients undergoing aorticvalve and/or ascending aortic replacement; 9 had a bicuspid valve: 5 with aortic aneurysm (diameter > 50 mm) and 4 without dilation; 11 had a tricuspid valve: 6 with aortic aneurysm and 5 without dilation. Patients with histologically proven connective tissue disorders were excluded. Samples were dissected, solubilized, and subjected to 2-dimensional gel electrophoresis. Gel patterns showed an average of 580 protein spots in samples from bicuspid valve patients, and 564 spots in those with tricuspid valves. Comparative analysis revealed a correlation coefficient of 0.93 for protein expression in the bicuspid valve group compared to the tricuspid group. Three protein spots were significantly over-expressed and 4 were significantly down-regulated in the bicuspid group compared to the tricuspid group. The lowest correlation in protein expression was between non-dilated aortic tissues. These differences between aortic tissues of bicuspid and tricuspid valve patients suggest that mechanisms of aortic dilation might differ, at least in part, between such patients. PMID:17540984
In selected cases of aortic regurgitation, aorticvalve (AV) repair and AV sparing root reconstruction viable alternatives to aorticvalve replacement. Repair and preservation of the native valve avoids the use of long-term anticoagulation, lowers the incidence of subsequent thromboembolic events and reduces the risk of endocarditis. Additionally repair has a low operative mortality with reasonable mid-term durability. The success and longer term durability of AVPP has improved with surgical experience. An understanding of the mechanism of the AR is integral to determining feasibility and success of an AVPP. Assessment of AV morphology, anatomy of the functional aortic annulus (FAA) and the aortic root with transesophageal echocardiography (TEE) improves the understanding of the mechanisms of AR. Pre- and intra-operative TEE plays a pivotal role in guiding case selection, surgical planning, and in evaluating procedural success. Post-operative transthoracic echocardiography is useful to determine long-term success and monitor for recurrence of AR. PMID:24973839
A 61-year-old man was diagnosed with aortic stenoinsufficiency with periannular abscess, which involved the aortic root of noncoronary sinus (NCS) that invaded down to the central fibrous body, whole membranous septum, mitral valve (MV), and tricuspid valve (TV). The open complete debridement was executed from the aortic annulus at NCS down to the central fibrous body and annulus of the MV and the TV, followed by the left ventricular outflow tract reconstruction with implantation of a mechanical aorticvalve by using a leaflet of the half-folded elliptical bovine pericardial patch. Another leaflet of this patch was used for the repair of the right atrial wall with a defect and the TV.
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 aorticvalve 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 aorticvalve, increased from a baseline of 13 mmHg five months previously. Fluoroscopy revealed thrombosis of her mechanical aorticvalve. 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 aorticvalve 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
To overcome shortcomings of current heart valve prostheses, novel hybrid valves were fabricated from decellularized porcine aorticvalves coated with poly (3-hydroxybutyrate-co-3-hydroxyhexanoate (PHBHHx)). In the mechanical test in vitro, the biomechanical perfor- mance of hybrid valve was investigated. In an in vivo study, hybrid valve conduits were implanted in pulmonary posi- tion in sheep without cardiopulmonary bypass. Uncoated grafts were
Song Wu; Ying-Long Liu; Bin Cui; Xiang-Hua Qu; Guo-Qiang Chen
Aims Aorticvalve sclerosis (AVSc) is a hallmark of several cardiovascular conditions ranging from chronic heart failure and myocardial infarction to calcific aorticvalve 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 aorticvalve 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) AorticValve 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 aorticvalves can be induced to express marker of osteogenic-like phenotype typical of advanced severe aortic stenosis. PMID:23483047
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
Background One-year mortality outcomes in the PARTNER trial showed that transcatheter aorticvalve implantation (TAVI) was noninferior to surgical aorticvalve 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 aorticvalve 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 aorticvalve 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. PMID:23837106
A multiscale computational comparison of the bicuspid and tricuspid aorticvalves in relation Article history: Accepted 1 August 2008 Keywords: Aorticvalve Bicuspid Calcific aortic stenosis Multiscale FSI a b s t r a c t Patients with bicuspid aorticvalve (BAV) are more likely to develop
Opinion statement Bicuspid aorticvalve (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 aorticvalve dysfunction are
José T. Ortiz; David D. Shin; Nalini M. Rajamannan
The in vitro hemodynamic characteristics of a variety of mechanical and tissue heart valve designs used during the past two decades were investigated in the aortic position under pulsatile flow conditions. The following valve designs were studied: Starr-Edwards ball and cage (model 1260), Björk-Shiley tilting disc (convexo-concave model), Medtronic-Hall tilting disc, St. Jude Medical bileaflet, Carpentier-Edwards porcine and pericardial (models
Ajit P. Yoganathan; Yi-Ren Woo; Hsing-Wen Sung; Michael Jones
In recent years, experience with transcatheter aorticvalve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions. As the prevalence of AS increases, there is a need for improved assessment parameters to determine the patients most likely to benefit from this novel procedure. This review discusses the diagnostic criteria for severe AS and the trials available to aid in the decision to refer for aorticvalve procedures in the elderly. PMID:25216621
Transcatheter aorticvalve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aorticvalve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management. PMID:24327878
Mechanical artificial heart valves rely on reverse flow to close their leaflets. This mechanism creates regurgitation and water hammer effects that may form cavitations, damage blood cells, and cause thromboembolism. This study analyzes closing mechanisms of monoleaflet (Medtronic Hall 27), bileaflet (Carbo-Medics 27; St. Jude Medical 27; Duromedics 29), and trileaflet valves in a circulatory mock loop, including an aortic root with three sinuses. Downstream flow field velocity was measured via digital particle image velocimetry (DPIV). A high speed camera (PIVCAM 10-30 CCD video camera) tracked leaflet movement at 1000 frames/s. All valves open in 40-50 msec, but monoleaflet and bileaflet valves close in much less time (< 35 msec) than the trileaflet valve (>75 msec). During acceleration phase of systole, the monoleaflet forms a major and minor flow, the bileaflet has three jet flows, and the trileaflet produces a single central flow like physiologic valves. In deceleration phase, the aortic sinus vortices hinder monoleaflet and bileaflet valve closure until reverse flows and high negative transvalvular pressure push the leaflets rapidly for a hard closure. Conversely, the vortices help close the trileaflet valve more softly, probably causing less damage, lessening back flow, and providing a washing effect that may prevent thrombosis formation. PMID:15307536
Lu, Po-Chien; Liu, Jia-Shing; Huang, Ren-Hong; Lo, Chi-Wen; Lai, Ho-Cheng; Hwang, Ned H C
Objective: Prediction of aortic dissection or rupture is extremely difficult in patients with bicuspid aorticvalve. We aimed to identify clinical and echocardiographic predictors of histological abnormalities of the aortic wall in patients with bicuspid aorticvalve undergoing aortic surgery. Methods: We assessed the histology of the aortic wall and clinical and echocardiographic variables in a cohort of patients with
Ornella Leone; Elena Biagini; Davide Pacini; Silvia Zagnoni; Marinella Ferlito; Maddalena Graziosi; Roberto Di Bartolomeo; Claudio Rapezzi
Aorticvalve stenosis is becoming a burden to society due to the constantly aging population. After the onset of the first symptoms it usually follows an ominous route with high mortality levels even at two years without any medical intervention. The gold standard for treating aorticvalve stenosis is surgical replacement; nonetheless, 30% of patients are left untreated due to increased risk of surgery. A less invasive method has been developed in the past decade, transcatheter aorticvalve implantation (TAVI), which allows implantation of prosthesis in the native stenosed aorticvalve position, using a catheter that enters the body in a transvascular way or through a minimal surgical cut down. In this review, we briefly discuss where the TAVI field begun, focus on the recent valves that are being used and finally look at what lies ahead. The review of the patents will assist in the understanding of how this field evolved, how it became established and what is to be expected in the future. PMID:23116106
Toutouzas, Konstantinos P; Stathogiannis, Konstantinos E; Latsios, George S; Synetos, Andreas G; Stefanadis, Christodoulos I
Aortic stenosis is a common condition traditionally treated surgically. Transcatheter aorticvalve replacement (TAVR) is an exciting and new method allowing treatment of high risk and inoperable patients. Multimodality imaging is extremely important in the preprocedural evaluation, the performance of the procedure, and the post-procedural assessment and includes transthoracic echocardiography, transesophageal echocardiography, conventional angiography, multi-detector computed tomography, and cardiac magnetic resonance. This paper will review the role of various imaging modalities during the phases of the TAVR procedure with an emphasis on the advantages and limitations of each approach. PMID:23943424
Background Bicuspid aorticvalve (BAV), the most common form of congenital heart disease, is a leading cause of aortic stenosis (AS) and aortic insufficiency (AI). AS is typically due to calcific valve disease. Recently, microRNAs (miRNAs) have been shown to modulate gene expression. This study examined miRNAs that were altered in aorticvalve leaflets of patients with AS compared to patients with AI. Additionally, in vitro experiments were performed to examine if these miRNAs modulate calcification-related genes. Materials and Methods Aorticvalve samples (fused or unfused leaflets) were collected from 9 patients (mean age 44.9±13.8 years) undergoing aorticvalve replacement. PIQOR™ miRXplore Microarrays containing 1421 miRNAs were used and hybridized to fused leaflet samples labeled with Cy5; unfused samples were used as control and labeled with Cy3. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed to validate the miRNA array results. Cultured human aorticvalve cells (AVICs) were treated with miRNA mimics and qRT-PCR was performed to determine changes in mRNAs. Results Seven miRNAs were statistically different between the AS and AI patients by microarray. MiR-26a and miR-195 levels were reduced by 65% and 59% respectively with p<0.05 in the stenotic samples by qRT-PCR. MiR-30b was reduced by 62% (p<0.06) in the stenotic samples by qRT-PCR. Human AVICs treated with miR-26a or miR-30b mimics had decreased mRNA levels of calcification-related genes. MiR-26a repressed BMP2 by 36%, ALKALINE PHOSPHATASE (ALPL) by 38%, and SMAD1 by 26%. MiR-30b reduced expression of SMAD1 by 18% and SMAD3 by 12%. Whereas miR-195 treated AVICs had increased mRNA levels of calcification-related genes such as BMP2 by 68% and RUNX2 by 11%. Conclusions MiR-26a, miR-30b, and miR-195 were decreased in the aorticvalves of patients requiring valve replacement due to AS compared to those being replaced due to AI. These miRNAs appear to modulate calcification related genes in vitro. PMID:20845893
Nigam, Vishal; Sievers, Hans H.; Jensen, Brian C.; Sier, Holger A.; Simpson, Paul C.; Srivastava, Deepak; Mohamed, Salah A.
A patient with Turner syndrome presented with shortness of breath with exertion. Three-dimensional transesophageal echocardiogram revealed a bicuspid aorticvalve with severe aortic stenosis. There were multiple masses attached to the aorticvalve and tricuspid valve, which mimicked vegetations. The patient underwent aortic and tricuspid valve replacement. Histology revealed papillary fibroelastomas of the aortic and tricuspid valves. To our knowledge, this is the first report of papillary fibroelastomas involving the left- and the right-sided valves in a patient with Turner syndrome. PMID:25174858
We describe a patient with Cornelia de Lange syndrome (CdLS) and a severely calcified bicuspid aorticvalve. Cornelia de Lange syndrome is characterized by altered Notch signaling, and recent studies have provided a link between Notch signaling and heart valve development and calcific bicuspid aorticvalve disease. In this case report, we propose that altered Notch signaling in CdLS may
The condition known as ochronosis refers to the accumulation of oxidized homogentisic acid in the connective tissues of alkaptonuric patients. The diagnosis is usually made from the triad of degenerative arthritis, ochronotic connective tissue pigmentation and urine that turns dark brown or black on alkalinization. Cardiovascular disease is a less well appreciated aspect of this disorder. A patient with ochronosis of his stenotic aorticvalve is reported. The role of the pigment in the genesis of the valve degeneration is discussed. PMID:10504183
Allogenic aorticvalves are widely used in case of native aorticvalve or root disease as well as failed prosthetic valves\\u000a with great success. At the Department of Cardiovascular Surgery and Transplantology of the Jagiellonian University in Cracow,\\u000a aorticvalve or aortic root replacement with allogenic aorticvalve has been performed for 23 years. Allogenic heart valve\\u000a bank was founded in
J. Stoli?ski; G. Marek; Z. Marcinkowska; M. Jaskier; D. Barecka; K. Bartu?; B. Kapelak; J. Sadowski; A. Dziatkowiak
ObjectiveMatrix metalloproteinases are endopeptidases that function in cell matrix turnover. Abnormal matrix metalloproteinase activity has been implicated in the formation of atherosclerotic abdominal aortic aneurysms. Recent studies suggest that abnormal matrix metalloproteinase activity may also be associated with the formation of atherosclerotic and nonatherosclerotic thoracic aortic aneurysms. Bicuspid aorticvalves are associated with an intrinsic aortic pathology that predisposes to
Jon Boyum; Erika K Fellinger; Joseph D Schmoker; Lucy Trombley; Kenneth McPartland; Frank P Ittleman; Alan B Howard
Purpose: Abnormal matrix metalloproteinase (MMP) expression contributes to the development of infrarenal abdominal aortic aneurysms. Recent data have suggested that MMP-2 and MMP-9 may also play a role in thoracic aortic disease. We sought to determine whether the presence of a bicuspid aorticvalve (BAV) had an impact on the pattern of MMP expression in ascending aortic aneurysms. Methods: Intraoperative
X. Wang; S. A. LeMaire; L. D. Conklin; C. Chen; W. Fu; S. Wen; J. S. Coselli
Increased life expectancy has led to the presentation of more complicated patients in old age for the replacement of the aorticvalve. The emergence of Transcatheter AorticValve Implantation (TAVI) was considered as a significant breakthrough in the management of symptomatic, moribund patients suffering from aorticvalve 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. PMID:24602509
The bicuspid aorticvalve is the most common congenital cardiac anomaly in developed nations. The abnormal bicuspid morphology of the aorticvalve results in valvular dysfunction and subsequent hemodynamic derangements. However, the clinical presentation of bicuspid aorticvalve disease remains quite heterogeneous with patients presenting from infancy to late adulthood with variable degrees of valvular stenosis and insufficiency and associated abnormalities including aortic coarctation, hypoplastic left heart structures, and ascending aortic dilatation. Emerging evidence suggests that the heterogeneous presentation of bicuspid aorticvalve phenotypes may be a more complex matter related to congenital, genetic, and/or connective tissue abnormalities. Optimal management of patients with BAV disease and associated ascending aortic aneurysms often requires a thoughtful approach, carefully assessing various risk factors of the aorticvalve and the aorta and discerning individual indications for ongoing surveillance, medical management, and operative intervention. We review current concepts of anatomic classification, pathophysiology, natural history, and clinical management of bicuspid aorticvalve disease with associated ascending aortic aneurysms. PMID:23198270
Losenno, Katie L.; Goodman, Robert L.; Chu, Michael W. A.
Patients with bicuspid aorticvalve (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 aorticvalves (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
Objective: To determine the durability of repair of a bicuspid aorticvalve with leaflet prolapse, and to identify factors associated with repair failure. Methods: From November 1988 to January 1997, 94 patients with a bicuspid aorticvalve and regurgitation from leaflet prolapse had aorticvalve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder
Filip P. Casselman; A. Marc Gillinov; Rami Akhrassa; Vigneshwar Kasirajan; Eugene H. Blackstonea; Delos M. Cosgrovea
The 16-mm ATS mechanical valve is one of the smallest prosthetic valves used for aorticvalve replacement (AVR) in patients with a very small aortic annulus, and its clinical outcomes are reportedly satisfactory. Here, we analyzed the left ventricular (LV) performance after AVR with the 16-mm ATS mechanical valve, based on the concept of cardiac energetics analysis. Eleven patients who underwent AVR with the 16-mm ATS mechanical valve were enrolled in this study. All underwent echocardiographic examination at three time points: before AVR, approximately 1 month after AVR, and approximately 1 year after AVR. LV contractility (end-systolic elastance [Ees]), afterload (effective arterial elastance [Ea]), and efficiency (ventriculoarterial coupling [Ea/Ees] and the stroke work to pressure-volume area ratio [SW/PVA]) were noninvasively measured by echocardiographic data and blood pressure measurement. Ees transiently decreased after AVR and then recovered to the pre-AVR level at the one-year follow-up. Ea significantly decreased in a stepwise manner. Consequently, Ea/Ees and SW/PVA were also significantly improved at the one-year follow-up compared with those before AVR. The midterm LV performance after AVR with the 16-mm ATS mechanical valve was satisfactory. AVR with the 16-mm ATS mechanical valve is validated as an effective treatment for patients with a very small aortic annulus. The cardiac energetics variables, coupling with the conventional hemodynamic variables, can contribute to a better understanding of the patients' clinical conditions, and those may serve as promising indices of the cardiac function. PMID:24859744
OBJECTIVE. The purpose of this article is to review the utility of ECG-gated MDCT in evaluating postsurgical findings in aortic and mitral valves. Normal and pathologic findings after aortic and mitral valve corrective surgery are shown in correlation with the findings of the traditionally used imaging modalities echocardiography and fluoroscopy to assist in accurate noninvasive anatomic and dynamic evaluation of postsurgical valvular abnormalities. CONCLUSION. Because of its superior spatial and adequate temporal resolution, ECG-gated MDCT has emerged as a robust diagnostic tool in the evaluation and treatment of patients with postsurgical valvular abnormalities. PMID:25415724
Ghersin, Eduard; Martinez, Claudia A; Singh, Vikas; Fishman, Joel E; Macon, Conrad J; Runco Therrien, Jennifer E; Litmanovich, Diana E
Clinical and morphologic observations are described in four patients who had severe aortic regurgitation from severe systemic hypertension unassociated with aortic dissection; each patient underwent aorticvalve replacement. Although aortic regurgitation of minimal or mild degree is well recognized to occur in patients with systemic hypertension, severe degrees of aortic regurgitation are rare in such patients; aorticvalve replacement in such patients has not previously been reported. Why these four patient had such severe aortic regurgitation was not determined. Although systemic hypertension is rarely a cause, it nevertheless must be added to the list of causes of severe pure aortic regurgitation. PMID:7058757
Waller, B F; Zoltick, J M; Rosen, J H; Katz, N M; Gomes, M N; Fletcher, R D; Wallace, R B; Roberts, W C
In patients with aorticvalve stenosis, the quantification of stenosis is usually performed using fluid-filled catheters and a computerized calculation program. The aim of this study was to determine the accuracy of this technique in comparison to the manual planimetry of the area between the curves of a simultaneous registration, using a multitip micromanometer catheter. The study was performed in 19 patients, in whom left and right heart catheterization was warranted. Systolic left ventricular and aortic peak pressures were significantly overestimated using a fluid-filled catheter (206 +/- 35 vs. 199 +/- 37 mm Hg, P = 0.0003, and 148 +/- 18 vs. 143 +/- 21 mm Hg, P = 0.0052). However, peak-to-peak pressure gradients were identical comparing both techniques (58 +/- 31 vs. 56 +/- 32 mm Hg, r = 0.983). The mean pressure gradients and aorticvalve areas based on simultaneous measurements of left ventricular and aortic pressures by micromanometer catheters were identical to the values determined by a computer-based program using fluid-filled catheters (54 +/- 21 vs. 52 +/- 21 mm Hg, r = 0.923, P < 0.05, and 0.75 +/- 0.25 vs. 0.77 +/- 0.25 cm2, r = 0.935). Thus, the conventional use of fluid-filled catheters and of a computerized calculation of aorticvalve area is valid for quantification of aortic stenosis in patients with sinus rhythm and without significant aortic regurgitation. PMID:9600516
Schöbel, W A; Voelker, W; Obergfell, S; Haase, K K; Karsch, K R
Background Transcatheter aorticvalve implantation (TAVI) has emerged as an acceptable treatment modality for patients with severe aortic stenosis who are deemed inoperable by conventional surgical aorticvalve replacement (AVR). However, the role of TAVI in patients who are potential surgical candidates remains controversial. Methods A systematic review was conducted using five electronic databases, identifying all relevant studies with comparative data on TAVI versus AVR. The primary endpoint was all-cause mortality. A number of periprocedural outcomes were also assessed according to the Valve Academic Research Consortium endpoint definitions. Results Fourteen studies were quantitatively assessed and included for meta-analysis, including two randomized controlled trials and eleven observational studies. Results indicated no significant differences between TAVI and AVR in terms of all-cause and cardiovascular related mortality, stroke, myocardial infarction or acute renal failure. A subgroup analysis of randomized controlled trials identified a higher combined incidence of stroke or transient ischemic attacks in the TAVI group compared to the AVR group. TAVI was also found to be associated with a significantly higher incidence of vascular complications, permanent pacemaker requirement and moderate or severe aortic regurgitation. However, patients who underwent AVR were more likely to experience major bleeding. Both treatment modalities appeared to effectively reduce the transvalvular mean pressure gradient. Conclusions The available data on TAVI versus AVR for patients at a higher surgical risk showed that major adverse outcomes such as mortality and stroke appeared to be similar between the two treatment modalities. Evidence on the outcomes of TAVI compared with AVR in the current literature is limited by inconsistent patient selection criteria, heterogeneous definitions of clinical endpoints and relatively short follow-up periods. The indications for TAVI should therefore be limited to inoperable surgical candidates until long-term data become available. PMID:23977554
Cao, Christopher; Ang, Su C.; Indraratna, Praveen; Manganas, Con; Bannon, Paul; Black, Deborah; Tian, David
Transcatheter aorticvalve 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 aorticvalve 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 aorticvalve replacement under cerebral protection. PMID:24082384
Grover, Peeyush M.; O'Neill, Brian P.; Velazquez, Omaida; Heldman, Alan W.; O'Neill, William W.; Cohen, Mauricio G.
Aorticvalve bypass (AVB [apicoaortic conduit]) surgery consists of the construction of a valved conduit between the left ventricular apex and the descending thoracic aorta. In our institution, AVB is routinely performed without cardiopulmonary bypass or manipulation of the ascending aorta or native aorticvalve. We report the case of an 83-year-old man with severe symptomatic bioprosthetic aortic stenosis, chronic thrombocytopenia, and a patent bypass graft who underwent robotically assisted beating-heart AVB through an anterior minithoracotomy. The distal anastomosis was constructed entirely using robotic telemanipulation. Robotic assistance enables the performance of beating-heart AVB through a small incision. PMID:21801931
Gammie, James S; Lehr, Eric J; Griffith, Bartley P; Dawood, Murtaza Y; Bonatti, Johannes
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 AorticValve 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 aorticvalve 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 aorticvalve 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 aorticvalve replacements is an alternative to conventional surgery in high risk and elderly patients. PMID:24022003
Despite the poor prognosis associated with severe, symptomatic aortic stenosis, treatment options were limited for a large subgroup of patients deemed high risk for surgical replacement. The introduction of transcatheter aorticvalve replacement (TAVR) over the past 10 years marks a new and exciting era in the treatment of valvular disease in these high-risk and inoperable patients. In this review, we outline the historical development, key clinical trials, current outcomes and future directions of TAVR. PMID:23375629
OBJECTIVE--To assess the pattern and progression of aorticvalve dysfunction by serial Doppler echocardiographic examinations in ambulatory adult patients with congenital bicuspid aorticvalve. 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 aorticvalve had serial Doppler echocardiographic studies at least six months
Aorticvalve 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 aorticvalve and the ascending aortic root. A novel physiological shape model is introduced, consisting of the aorticvalve 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 aorticvalve (including leaflets) and the ascending aortic root, estimated from CT, has been proposed.
Objectives. We sought to study the possible presence of Chlamydia pneumoniae in aorticvalve stenosis (AVS).Background. Inflammation and immune mechanisms are considered important for the pathogenesis of nonrheumatic AVS. All chlamydial species are able to cause heart infections, and seroepidemiologic studies have indicated an association between chronic C. pneumoniae infection and coronary artery disease. Furthermore, the organism has been demonstrated
Jukka Juvonen; Aino Laurila; Tatu Juvonen; Hannu Alakärppä; Heljä-Marja Surcel; Kari Lounatmaa; Johanna Kuusisto; Pekka Saikku
We report the case of a cardiac papillary fibroelastoma of the aorticvalve resected by simple shaving the pedicle. The macroscopic view showed a jelly-like aspect, with the classical appearance of a sea anemone under water, with multiple slender fronds and numerous little submillimetric thrombi disseminated among the branches of the tumor. PMID:22186454
ou are contacted by a concerned 34-year-old airline pilot with a leaky bicuspid aorticvalve recently diagnosed by an echocardiogram that had been requested by his new employer as part of a routine medical assessment. He claims that he is perfectly healthy but is at risk of losing his job over his condition. He is concerned that his disease is
Jagdish Butany; Paul W. M. Fedak; Tirone E. David; Richard L. Leask; Richard D. Weisel
The aorticvalve exhibits complex three-dimensional (3D) anatomy and heterogeneity essential for the long-term efficient biomechanical function. These are, however, challenging to mimic in de novo engineered living tissue valve strategies. We present a novel simultaneous 3D printing\\/photocrosslinking technique for rapidly engineering complex, heterogeneous aorticvalve scaffolds. Native anatomic and axisymmetric aorticvalve geometries (root wall and tri-leaflets) with 12–22
L A Hockaday; K H Kang; N W Colangelo; P Y C Cheung; B Duan; E Malone; J Wu; L N Girardi; L J Bonassar; H Lipson; C C Chu; J T Butcher
A mitral prosthesis, when implanted, can distort the aortic annulus, forcing to downsize the aortic prosthesis. Changing the sequence of tying the sutures (the aortic prosthesis first, then the mitral prosthesis) allows to insert an aortic true-sized prosthesis. In case of associated tricuspid valve surgery, the aortic prosthesis protrudes over the anteroseptal commissure area. The sutures on the tricuspid annulus can be passed before the aortic prosthesis is secured in place. PMID:25312523
Calafiore, Antonio Maria; Iaco, Angela Lorena; Shah, Aijaz; Di Mauro, Michele
Purpose: Bicuspid aorticvalve (BAV) is associated with increased prevalence of annulo-aortic ectasia, dissection and ascending aortic aneurysm. This study was undertaken to compare the amount of fibrillin-1 and elastin in the media of great vessels of patients with bicuspid and tricuspid aorticvalve disease. Method: Tissue samples of ascending aorta and pulmonary artery were obtained from 22 patients with
Mauro Paes Leme; Tirone E. David; Jagdish Butany; Diponkar Banerjee; Eduardo S. Bastos; Sylvio C. Provenzano; Leôncio A. Feitosa; Henrique Murad; Monica M. Ferreira Magnanini
Transcatheter aorticvalve replacement (TAVR) has proven to be a viable tool for the high-surgical-risk population with severe aorticvalve stenosis. Vascular access complications are not uncommon with TAVR and may increase early and late mortality. Avoiding these serious complications is the goal. With experience and careful screening, we are now able to risk-stratify patients who may be at increased risk of vascular complications. While the traditional iliofemoral access site remains the most common for TAVR, alternate access sites that have proven to be viable and safe alternatives include the transapical, direct-aortic, and subclavian techniques. TAVR teams should be familiar and comfortable with these approaches as each of them has its own advantages and weaknesses. The best option is usually one in which the procedure is tailored to the patient. The present review examines our current access planning and strategies for TAVR. PMID:22891124
Balloon aortic valvuloplasty has seen a revival in interest because of its role in predilation and preparation of the annulus before trans catheter aorticvalve implantation. Aorticvalve 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
Forty-one patients in whom the diagnosis of a non-stenotic bicuspid aorticvalve had been established by noninvasive techniques were followed up for a mean of 10.9 years. During this period, 2 patients required aorticvalve replacement because of the development of calcific aorticvalve stenosis at the ages of 52 and 64 and 5 others developed evidence of mild aortic
Primary school students (817 apparently healthy 10-year olds) were screened by transthoracic 2-dimensional echocardiography to assess for the prevalence of bicuspid aorticvalve. Bicuspid aorticvalve 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 aorticvalves.
Cristina Basso; Mauro Boschello; Cosimo Perrone; Alessandro Mecenero; Andrea Cera; Dario Bicego; Gaetano Thiene; Ennio De Dominicis
Background. Pulmonary autograft aortic root replace- ment was used in adults. Risk factors for aortic regurgi- tation (AR), and for pulmonary allograft valve stenosis are identified. Methods. From February 1991 through April 1998, 80 adults (mean age 34.4 years) underwent pulmonary au- tograft aortic root replacement. Primary diagnosis was AR in 43 (53.7%) patients, aortic stenosis in 13 (16.3%) and
Karl M. Dossche; Wim J. Morshuis; Marc A. A. M. Schepens; Sjef M. Ernst; Jurriaan J. van den Brand
Background. Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic regurgitation (AR), and for pulmonary allograft valve stenosis are identified.Methods. From February 1991 through April 1998, 80 adults (mean age 34.4 years) underwent pulmonary autograft aortic root replacement. Primary diagnosis was AR in 43 (53.7%) patients, aortic stenosis in 13 (16.3%) and mixed disease in 24
Karl M Dossche; Aart Brutel de la Riviére; Wim J Morshuis; Marc A. A. M Schepens; Sjef M Ernst; Jurriaan J van den Brand
From 1965 through 1986, 817 patients underwent aorticvalve 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) PMID:15227505
Pilegaard, Hans K.; Lund, Ole; Nielsen, Torsten T.; Magnussen, Karin; Knudsen, Mary A.; Albrechtsen, Ole K.
... position of the damaged valveaorticvalve TAVI/TAVR procedure — Transcatheter aorticvalve replacement Newer surgery options ... Replacement - Ross Procedure - Newer Surgery Options - What is TAVR? - Types of Replacement Valves • Healthy Living Goals • Personal ...
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 aorticvalve 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. PMID:11574571
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 aorticvalve may be affected by a wide range of congenital and acquired diseases. Echocardiography is the main non-invasive imaging technique for assessing patho-anatomical alterations of the aorticvalve and adjacent structures and in many cases is sufficient to establish a diagnosis and/or guide treatment decisions. Recent technological advances in magnetic resonance imaging (MRI) and multidetector computed tomography (MDCT) have enabled these techniques to play a complimentary role in certain clinical scenarios and as such can be useful problem-solving tools. Radiologists should be familiar with the indications, advantages, and limitations of MRI and MDCT in order to advise and direct an appropriate imaging strategy depending upon the clinical scenario. This article reviews the role of MRI and MDCT angiography for assessment of the aorticvalve including relevant anatomy, scan acquisition protocols, and post-processing methods. An approach to interpretation and the key imaging features of commonly encountered aortic valvular diseases are discussed. PMID:24034550
Ascending aortic dissection and aneurysm are rare but life-threatening complications after aorticvalve 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 aorticvalve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure. PMID:24839447
Hökenek, Faruk; Gürsoy, Mete; Gülcan, Füsun; Duygu, Egemen; ?ener, Murat
This thesis presents mathematical models describing the mechanical behavior of the human aortic heart valve over a range of length and time scales. In the human heart, the valves perform the vital function of controlling ...
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 aorticvalve replacement with a mechanical valve, accompanied by enlargement of the aortic annulus using an equine pericardial patch, for severe aorticvalve 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 aorticvalve. 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
Background. The immune rejection has been antici- pated as one of the major causes of allograft aorticvalve (AAV) degeneration. The purpose of this study was to prospectively serially measure the magnitude and evolu- tion of the recipient anti-HLA class I antibody response up to 6 years from AAV implant and to correlate sero- logic data with valve performance by
Giulio Pompilio; GianLuca Polvani; Giuseppe Piccolo; Anna Guarino; Angela Nocco; Annalisa Innocente; Massimo Porqueddu; Luca Dainese; Fabrizio Veglia; Andrea Sala; Paolo Biglioli
This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aorticvalve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aorticvalve replacement when the risks for surgery are considered to be too high. ImagesFigure 1
Swinkels, B.M.; Jaarsma, W.; Wely, L. Relik-van; van Swieten, H.A.; Ernst, J.M.P.G.; Plokker, H.W.M.
\\u000a Recent developments in aorticvalve replacement include the truly stentless pericardial bioprostheses with Single Point Attached\\u000a Commissures (SPAC). The leaflet geometry available for these valves can be a simple tubular or a complex three-dimensional\\u000a molded structure resembling the natural valve. We compared mechanical performance of these two valve designs via dynamic simulation.\\u000a Surface models representing a tubular valve and a
F. L. Xiong; W. A. Goetz; Y. L. Chua; P. Zhang; S. Pfeifer; E. Wintermantel; J. H. Yeo
Aortic dissection etiology involve many factors that are difficult to identify clearly. We report a 47-year-old man who underwent\\u000a a Bentall operation with reattachment of bypass grafts for a dissecting aneurysm (De Bakey type II) 4 years after combined\\u000a triple coronary artery bypass grafting and mitral valve replacement. This case appeared to be associated with factors leading\\u000a to dissecting aneurysm
Even in the modern era of antibiotic therapy and advanced diagnostic imaging, infective endocarditis continues to be a disease with a persistently high mortality and morbidity. We report a serious complication of infective endocarditis of bicuspid aorticvalve with aortic root abscess ruptured into the right atrium with fatal outcome, registered by transthoracic echocardiography. This complication should be suspected in
Transcatheter aorticvalve 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. PMID:24799924
Suwalski, Piotr; Pawlak, Agnieszka; Kulawik, Tomasz; Byczkowska, Katarzyna; Gil, Robert J.
Transcatheter aorticvalve 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
Calcific aorticvalve disease (CAVD) increasingly afflicts our aging population. One-third of our elderly have echocardiographic or radiological evidence of aorticvalve sclerosis (CAVS), an early and subclinical form of CAVD. Age, gender, tobacco use, hypercholesterolemia, hypertension, and type II diabetes all contribute to the risk of disease that has worldwide distribution. Upon progression to its most severe form --- calcific aortic stenosis (CAS) --- CAVD becomes debilitating and devastating, and 2% of individuals over age 60 suffer from CAS to the extent that surgical intervention is required. No effective pharmacotherapies exist for treating those at risk for clinical progression. It is becoming increasingly apparent that a diverse spectrum of cellular and molecular mechanisms converge to regulate valvular calcium load; this is evidenced not only in histopathologic heterogeneity of CAVD but also from the multiplicity of cell types that can participate in valve biomineralization. In this review, we highlight our current understanding of CAVD disease biology, emphasizing molecular and cellular aspects of its regulation. We end by pointing to important biological and clinical questions that must be answered to enable sophisticated disease staging and the development of new strategies to medically treat CAVD. PMID:23833294
Experiments performed on a 19 mm diameter bioprosthetic valve were used to successfully validate the fluid-structure interaction (FSI) simulation of an aorticvalve at 72 bpm. The FSI simulation was initialized via a novel approach utilizing a Doppler sonogram of the experimentally tested valve. Using this approach very close quantitative agreement (?12.5%) between the numerical predictions and experimental values for several key valve performance parameters, including the peak systolic transvalvular pressure gradient, rapid valve opening time and rapid valve closing time, was obtained. The predicted valve leaflet kinematics during opening and closing were also in good agreement with the experimental measurements. PMID:23907849
Calcific aorticvalve disease (CAVD) is increasingly prevalent worldwide with significant morbidity and mortality. Therapeutic options beyond surgical valve replacement are currently limited. In 2011, the National Heart Lung and Blood Institute assembled a working group on aortic stenosis. This group identified CAVD as an actively regulated disease process in need of further study. As a result, the Alliance of Investigators on CAVD was formed to coordinate and promote CAVD research, with the goals of identifying individuals at risk, developing new therapeutic approaches, and improving diagnostic methods. The group is composed of cardiologists, geneticists, imaging specialists, and basic science researchers. This report reviews the current status of CAVD research and treatment strategies with identification of areas in need of additional investigation for optimal management of this patient population. PMID:25189570
Yutzey, Katherine E; Demer, Linda L; Body, Simon C; Huggins, Gordon S; Towler, Dwight A; Giachelli, Cecilia M; Hofmann-Bowman, Marion A; Mortlock, Douglas P; Rogers, Melissa B; Sadeghi, Mehran M; Aikawa, Elena
Unicuspid aorticvalve (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 aorticvalve, and to decrease the substantial risk of impending rupture of sinus of Valsalva aneurysm. PMID:19344967
A 79-year-old man was admitted to Samsung Changwon Hospital due to chest pain and dyspnea. The ejection fraction was 31% and mean pressure gradient between the left ventricle and aorta was 69.4 mmHg on echocardiography. Chest computed tomography showed severe calcification of the ascending aorta. Aorticvalve replacement was successfully performed using a thoracic endovascular aortic repair balloon catheter without classic aortic cross clamping. The patient was discharged on the eleventh postoperative day. PMID:23772410
Kim, In Sook; Yoo, Byung Ha; Kim, Han Yong; Hwang, Sang Won; Song, Yun Gyu
Degenerative aortic stenosis (AS) is the most frequent type of valvular heart disease. In patients with symptomatic AS surgical aorticvalve 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 aorticvalve 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. PMID:24570756
We evaluated the aortic outflow tract (AOT) and coronary artery dimensions in pediatric patients with unicommissural aorticvalves. A retrospective review of an echocardiographic database identified 37 patients with unicommissural aorticvalves. A total of 115 echocardiograms were reviewed, and the right coronary artery (RCA), left main coronary artery (LM), left anterior descending coronary artery aorticvalve annulus, aortic root, sinotubular junction (STJ), and ascending aorta were measured and z scores determined. The aortic stenosis peak gradient and the amount of aortic regurgitation (AR) were also measured. The RCA diameter (z score, 1.85 +/- 1.8, p = 0.03) and LM diameter (z score, 1.74 +/- 1.47, p = 0.04) are significantly dilated, as are all the AOT measurements: aortic annulus (2.02 +/- 1.9, p = 0.02), aortic root (2.25 +/- 1.9, p = 0.02), STJ (2.22 +/- 1.74, p = 0.01), and ascending aorta (4.38 +/- 2.03, p < 0.001). Longitudinal follow-up showed that there was no significant variation over time in any variable. The AOT measurements were significantly correlated with each other. A trend was found in which an increasing amount of AR gave an increase in AOT measurements. The aortic gradient was not significantly associated with any measurement. Our study population demonstrated significant dilatation of the RCA and LM as well as the AOT. The dilatation of the AOT structures is likely caused by the same mechanism that accounts for the AOT dilatation in patients with bicommissural aorticvalves. Dilatation of the coronary arteries may represent an intrinsic abnormality in the vessel wall. Further studies are needed to define possible changes. PMID:15549618
Faber, M J; Zeiger, J S; Spevak, P J; Brenner, J I; Ravekes, W J
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 aorticvalve will lead to reduced opening and the development of left ventricular outflow obstruction, referred to as aorticvalve 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 aorticvalve 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 aorticvalve stenosis and aortic aneurysms, such as macromolecule transport, gene expression alterations, cell death pathways, calcification, inflammation, and neoangiogenesis directly depend on biomechanical factors. PMID:23459103
Back, Magnus; Gasser, T. Christian; Michel, Jean-Baptiste; Caligiuri, Giuseppina
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 aorticvalve will lead to reduced opening and the development of left ventricular outflow obstruction, referred to as aorticvalve 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 aorticvalve 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 aorticvalve stenosis and aortic aneurysms, such as macromolecule transport, gene expression alterations, cell death pathways, calcification, inflammation, and neoangiogenesis directly depend on biomechanical factors. PMID:23459103
Bäck, Magnus; Gasser, T Christian; Michel, Jean-Baptiste; Caligiuri, Giuseppina
This study was performed in order to determine the effects of the structural configuration of prosthetic aorticvalves upon coronary blood flow. A pulse-duplicating system was utilized to which a rigid model of the root of the aorta and the left artery were attached. A stented normal human valve, stented porcine valve, pivoting disc valve, tilting disc value and a caged ball valve were tested at stimulated resting conditions. The results showed that the pulse configuration and proportions of coronary flow that were systolic and diastolic changed with various valves. There was no significant reduction of the mean simulated coronary flow with the porcine valve or disc valves. Coronary flow was augmented with the caged ball valve. These differences were interpreted as being due to several fluid dynamic phenomena. These were piston effects, inertia of reversed blood flow, torque and the effects resulting from the unique pressure distribution on each valve. PMID:890277
Background Significant paravalvular leakage after transcatheter aorticvalve implantation (TAVI) correlates with increased morbidity and mortality, but adverse consequences of trivial paravalvular leakage have stimulated few investigations. Using a unique method distinctly different from other diagnostic approaches, we previously reported elevated backflow velocities of short duration (transients) in mechanical valve closure. In this study, similar transients were found in a transcatheter valve paravalvular leakage avatar. Methods Paravalvular leakage rate (zero to 58 mL/second) and aorticvalve incompetence (volumetric back flow/forward flow; zero to 32%) were made adjustable using a mock transcatheter aorticvalve device and tested in quasi-steady and pulsatile flow test systems. Projected dynamic valve area (PDVA) from the back illuminated mock transcatheter aorticvalve device was measured and regional backflow velocities were derived by dividing volumetric flow rate by the PDVA over the open and closing valve phase and the total closed valve area derived from backflow leakage. Results Aortic incompetence from 1-32% generated negative backflow transients from 8 to 267 meters/second, a range not dissimilar to that measured in mechanical valves with zero paravalvular leakage. Optimal paravalvular leakage was identified; not too small generating high backflow transients, not too large considering volume overload and cardiac energy loss caused by defective valve behavior and fluid motion. Conclusions Thrombogenic potential of transcatheter aorticvalves with trivial aortic incompetence and high magnitude regional backflow velocity transients was comparable to mechanical valves. This may have relevance to stroke rate, asymptomatic microembolic episodes and indications for anticoagulation therapy after transcatheter valve insertion. PMID:25333018
Background: Bicuspid aorticvalve is the most common congenital anomaly, oc- curring in 1% to 2% of the population. It is the most common reason for aorticvalve replacement, and such individuals are at significantly increased risk of aortic complications. Despite the clinical significance of bicuspid aorticvalve, its genetic basis remains unclear. The homeobox gene NKX2-5 occupies a central
Ramanath Majumdar; Marineh Yagubyan; Gobinda Sarkar; Mark E. Bolander; Thoralf M. Sundt
The regulation of valvular endothelial phenotypes by the hemodynamic environments of the human aorticvalve is poorly understood. The nodular lesions of calcific aortic stenosis (CAS) develop predominantly beneath the ...
A 34-year follow-up is described after a Konno aortoventriculoplasty to correct a restricted aortic annulus and a recurrent aortic prosthetic valve endocarditis with subannular and interventricular abscesses. PMID:22186453
Vermeulen, Freddy; Swinkels, Ben; van Boven, Wim Jan
Background The effect of aorticvalve replacement on three-dimensional (3D) mitral annular geometry has not been well-described. Emerging transcatheter approaches for aorticvalve replacement employ fundamentally different mechanical techniques for achieving fixation and seal of the prosthetic valve than standard surgical aorticvalve replacement. This study compares the immediate impact of transcatheter aorticvalve replacement (TAVR) and standard surgical aorticvalve replacement (AVR) on mitral annular anatomy. Methods Real-time 3D echocardiography was performed in patients undergoing TAVR using the Edwards Sapien® valve (n=10) or AVR (n=10) for severe aortic stenosis. Mitral annular geometric indexes were measured using Tomtec EchoView to assess regional and global annular geometry. Results Mixed between-within ANOVA showed no differences between TAVR and AVR groups in any of the mitral annular geometric indices pre-operatively. However, post-operative analysis did demonstrate an effect of AVR on geometry. Patients undergoing open AVR had significant decrease in annular height, septolateral diameter, mitral valve transverse diameter and mitral annular area after valve replacement (P?.006). Similar changes were not noted in the TAVR group. Conclusions TAVR preserves mitral annular geometry better than AVR. Thus, TAVR may be a more physiological approach to aortic replacement. PMID:23245440
Vergnat, Mathieu; Levack, Melissa M.; Jackson, Benjamin M.; Bavaria, Joseph E.; Herrmann, Howard C.; Cheung, Albert T.; Weiss, Stuart J.; Gorman, Joseph H.; Gorman, Robert C.
Transcatheter aorticvalve replacement (TAVR) is a rapidly-evolving technology for patients with severe, calcific aortic stenosis. Although these procedures lessen many of the risks and complications of open surgical aorticvalve replacement, there remain challenges with TAVR including electrophysiologic complications. Among TAVR prostheses, rates of conduction abnormalities (CAs) vary from less than 10% to more than 50%, with up to one-third of patients requiring placement of a permanent pacemaker following TAVR. Several predictors of CAs have been identified related to device selection, baseline conduction defects, and anatomical considerations. Current data support the hypothesis that CAs result primarily from mechanical compression of the specialized conduction system by the device, although other factors may be involved. Such abnormalities can arise immediately during the procedure or as late as several days after implantation, and can be transient or permanent. Currently, there are no clinical tools to identify patients at highest risk for CAs post-TAVR, or to predict the course of CAs in patients who experience them. Early data suggest outcomes may be worse in high-risk patients, and further studies are needed to identify these patients so as to minimize electrophysiologic complications and determine appropriate monitoring in this expanding population. PMID:23137496
Steinberg, Benjamin A; Harrison, J Kevin; Frazier-Mills, Camille; Hughes, G Chad; Piccini, Jonathan P
Calcific aorticvalve disease (CAVD) is a chronic process leading to fibrosis and mineralization of the aorticvalve. 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 aorticvalve. 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 aorticvalve 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
Background Transcatheter aorticvalve implantation (TAVI) has been established as a treatment option for inoperable patients with symptomatic aorticvalve 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 aorticvalve 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. PMID:23035864
A 25-year-old man presented with associated bicuspid aorticvalve and coarctation of the aorta. Following aorticvalve replacement, he underwent endovascular stenting of his native coarctation. We describe early failure of the latter procedure that necessitated definitive surgical correction. PMID:23475794
A series of 200 consecutive patients with acute Stanford type A dissection (157 men, 78%; 43 women, 22%) was analyzed to assess the validity of aorticvalve preservation or repair. Indication for the operation in most cases was based on echocardiographic examination alone, to reduce the delay. In the majority of patients (111\\/200, 56%) the aorticvalve was preserved or
Ludwig K. von Segesser; Enrico Lorenzetti; Mario Lachat; Urs Niederhäuser; Mariette Schönbeck; Paul R. Vogt; Marko I. Turina
A 50-year-old man was diagnosed as having absent pulmonary valve syndrome with aneurysmal dilatation of the pulmonary arteries. He also had a large subaortic ventricular septal defect and severe aortic regurgitation. He underwent successful intracardiac repair and aorticvalve replacement. This case is presented in view of its rarity and controversies in the surgical management.
Pankaj Goel; Sethurathinam Rajan; V. M Kurian; Raibhan Yadav; Kotturathu Mammen Cherian
Objective: We describe our center's experience with the use of allografts for aorticvalve or root replacement, illustrating the impact on outcome of the changes made in surgical and preservation techniques. Methods: Between 4\\/1987 and 1\\/2001 275 allografts were used in 267 consecutive patients to replace the aorticvalve or root. All patients were prospectively followed over time. Mean patient
J. J. M. Takkenberg; L. A. van Herwerden; M. J. C. Eijkemans; J. A Bekkers; A. J. J. C Bogers
Transcatheter aorticvalve replacement (TAVR) has become an alternative intervention in high-risk and inoperable patients with symptomatic aorticvalve stenosis. The procedure has been associated with favorable clinical outcomes and safety profile in patients with end stage renal disease (ESRD). We describe a case of improved kidney function in a patient with ESRD without further need for dialysis after TAVR. PMID:23857778
Damluji, Abdulla; Bilsker, Martin S; Cohen, Mauricio G
Factor XI (FXI) deficiency is rare and associated with bleeding after surgical procedures. We report a case of an 80-year-old woman with severe aorticvalve stenosis. FXI deficiency was diagnosed due to prolonged activated partial thromboplastin time. Aorticvalve replacement was performed using a porcine bioprosthetic valve. Intra-operation bleeding was controlled by the transfusion of a fresh frozen plasma. The postoperative course was uneventful. PMID:23743606
A unicuspid aorticvalve (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
Marfans syndrome is an Autosomal dominant disorder of the connective tissues resulting in abnormalities of the musculoskeletal system, cardiovascular system and eyes. It has a prevalence of 1 in 100,000 population1 and occurs in all ethnic groups. It may be familial or due to new mutation (30%), in the fibrillin gene on arm of chromosome 15. It is estimated that one person in every 3000-5000 has Marfans syndrome may have cardiovascular abnormalities and may be complicated by infective endocartditis. About 90% of Marfan patients will develop cardiac complications2. The patient under discussion has musculoskeletal (Tall stature, reduced upper-lower segment ratio, arm-span to height ratio > 1.05, high arched palate) and Cardiovascular features (Severe aortic regurgitation complicated with infective endocarditis). PMID:16400220
Objectives Bicuspid aorticvalve 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 aorticvalve 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 aorticvalve 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 aorticvalve 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 aorticvalve. Sequences were aligned and compared with the reference genomic sequence. Results Corroborating previous studies, analysis of the single sporadic patient with calcified aorticvalve 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 aorticvalve 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. PMID:23102684
Kent, Kathleen C.; Crenshaw, Melissa L.; Goh, Denise L. M.; Dietz, Harry C.
Objectives: Allografts offer many advantages over prosthetic valves, but allograft durability varies considerably. Methods: From 1969 through 1993, 618 patients aged 15 to 84 years underwent their first aorticvalve replacement with an aortic allograft. Concomitant surgery included aortic root tailoring (n = 58), replacement or tailoring of the ascending aorta (n = 56), and coronary artery bypass grafting (n
Ole Lund; V. Chandrasekaran; Richard Grocott-Mason; Hassan Elwidaa; Rashid Mazhar; Asghar Khaghani; Andrew Mitchell; Charles Ilsley; Magdi H. Yacoub
Patient: Female, 52 Final Diagnosis: Acute aortic syndrome with aorticvalve insufficiency post-PCI Symptoms: Chest pain Medication: — Clinical Procedure: Conservative Specialty: Cardiology Objective: Unusual or unexpected effect of treatment Background: Acute aortic syndrome is the modern term that includes aortic dissection, intramural hematoma, and symptomatic aortic ulcer. Iatrogenic coronary artery dissection extending to the aorta during percutaneous coronary intervention is a very rare but life-threatening complication. Despite some reports of spontaneous recovery, most of these patients are treated surgically as a spontaneous aortic dissection, especially if there is a complication of the aortic lesion. Case Report: A 52-year-old white female was submitted to an angioplasty in the right coronary without success and the procedure was complicated by a dissection in aortic root with progressive extension to the ascending aorta. This lesion deformed the aorticvalve, leaving it with an acute moderate regurgitation. Because of current use of clopidogrel and clinical stability of the patient, the local Heart Team decided to withdrawn this antiplatelet for 5 days before surgery despite the risk related to the aortic syndrome. A new echocardiogram 3 days later showed that the hematoma was reabsorbed with improvement of the aortic insufficiency. An angiotomography confirmed the reabsorption of the hematoma. The surgery was canceled and the patient was maintained in a conservative treatment and discharged. Seventeen months later, she was re-evaluated and was still asymptomatic without aortic regurgitation in the echocardiogram and showing progressive regression of the aortic hematoma in the tomography. Conclusions: Despite the conservative treatment, this case of iatrogenic aortic dissection complicated by an acute aortic regurgitation had a good evolution in a follow-up of 17 months. PMID:25413612
de Barros e Silva, Pedro G.M.; Aquino, Thiago; Resende, Marcos V.; Richter, Ivo; Barros, Cecilia M.; Andrioli, Vanessa G.; Baruzzi, Antonio C.; Medeiros, Caio C.J.; Furlan, Valter
The aorticvalve orifice area was measured in 95 patients with valvular aortic stenosis by means of transthoracic and transesophageal echocardiography. These results were compared to invasively determined measurements. The aortic-valve orifice area could be measured by transesophageal echocardiography in 87 patients (92%), and in 13 patients (14%) by the transthoracic approach. A comparison of the valve-orifice area determined by transthoracic and transesophageal echocardiography revealed a correlation coefficient of r = 0.91. There was also a good agreement when the aortic-valve orifice area determined by transesophageal echocardiography was compared to the invasive findings (r = 0.82; p less than 0.001). The morphology of the aorticvalve could be better delineated with the transesophageal approach. PMID:2238770
Kasper, W; Geibel, A; Hofmann, T; Meinertz, T; Just, H
An orifice equation is derived relating the effective aorticvalve area, A, the average aorticvalve pressure gradient, dP, the stroke volume, SV, and the heart frequency, FH, through considerations of momentum conservation across the aorticvalve. This leads to a formula consistent with Newton's second law of motion. The form of the new equation is A = (7.5 X 10(-5)) SV FH2/Pd, where A, VS, FH and Pd are expressed in cm2, ml, s-1 and mmHg, respectively. Aorticvalve areas computed with the new orifice equation are found to correlate with those computed by the Gorlin formula in conditions of resting haemodynamic states at a level of r = 0.86, SE = 0.25 cm2, N = 120. The results suggest that the new formula may be considered as an independent orifice equation having a similar domain of validity as the Gorlin formula. The new equation offers the possibility of deriving additional useful haemodynamic relationships through combination with established cardiological formulas and applying it in a noninvasive Doppler ultrasonic or echocardiographic context. PMID:3830201
Seitz, W; Oppenheimer, L; McIlroy, M; Nelson, D; Operschall, J
Background Aortic dilatation is common among adults with bicuspid aorticvalves (BAV). Predictors of risk and progression of aortic dilatation are not well described in this setting.Methods We analyzed retrospective data on the presence of dilation in several aortic segments in 156 adult patients with BAV who had serial echocardiograms performed at least 1 year apart. Various risk factors for
James WL Yip; Kris Filion; Michal Jamorski; Gary Webb; Samuel C Siu; Judith Therrien; George Thanassoulis
In bicuspid aorticvalve (BAV) disease, the role of genetic and hemodynamic factors influencing ascending aortic pathology is controversial. To test the effect of BAV geometry on ascending aortic flow, a finite element analysis was undertaken. A surface model of aortic root and ascending aorta was obtained from magnetic resonance images of patients with BAV and tricuspid aorticvalve using segmentation facilities of the image processing code Vascular Modeling Toolkit (developed at the Mario Negri Institute). Analytical models of bicuspid (antero-posterior [AP], type 1 and latero-lateral, type 2 commissures) and tricuspid orifices were mathematically defined and turned into a volumetric mesh of linear tetrahedra for computational fluid dynamics simulations. Numerical simulations were performed with the finite element code LifeV. Flow velocity fields were assessed for four levels: aortic annulus, sinus of Valsalva, sinotubular junction, and ascending aorta. Comparison of finite element analysis of bicuspid and tricuspid aorticvalve showed different blood flow velocity pattern. Flow in bicuspid configurations showed asymmetrical distribution of velocity field toward the convexity of mid-ascending aorta returning symmetrical in distal ascending aorta. On the contrary, tricuspid flow was symmetrical in each aortic segment. Comparing type 1 BAV with type 2 BAV, more pronounced recirculation zones were noticed in the latter. Finally, we found that in both BAV configurations, maximum wall shear stress is highly localized at the convex portion of the mid-ascending aorta level. Comparison between models showed asymmetrical and higher flow velocity in bicuspid models, in particular in the AP configuration. Asymmetry was more pronounced at the aortic level known to be more exposed to aneurysm formation in bicuspid patients. This supports the hypothesis that hemodynamic factors may contribute to ascending aortic pathology in this subset of patients. PMID:20618222
Background and Aims: Bicuspid aorticvalve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. Methods: Aviators with BAV were detected by reviewing
Dan Carter; Russell Pokroy; Bella Azaria; Shlomi Matetzky; Alex Prokopetz; Erez Barenboim; David Harpaz; Liav Goldstein
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 aorticvalve 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 aorticvalve prostheses showed excellent durability without any mechanical failures over a 10 year period. The long term outcome of isolated aorticvalve replacement with these models is associated with a low frequency of valve related complications. PMID:3580223
Summary Aim Transcatheter aorticvalve implantation (TAVI) is considered an alternative therapy in high risk patients with severe aortic stenosis. Despite this, such a minimally invasive procedure is not free from complications. Case report An 86-year-old woman underwent a 26-mm SAPIEN TAVI for aorticvalve stenosis. Procedure was complicated by valve embolization into the ascending aorta likely due to a sub-optimal positioning of prosthesis during its deployment. Patient was treated by surgical removal of stent-valve and conventional valve replacement. Patient was discharged from hospital 7 days after surgery. At six months follow-up she was asymptomatic and the valve had a good competence with a mean transaortic gradient of 8 mmHg. Conclusions After TAVI prosthesis embolization, conversion to conventional surgical treatment is imperative and can be associated with excellent outcome. PMID:24629815
CUTTONE, F.; IVASCAU, C.; GROLLIER, G.; MASSETTI, M.
The aorticvalve and adjacent structures should be routinely evaluated on all thoracic cross-sectional imaging studies. Echocardiography and magnetic resonance imaging (MRI) are the main imaging techniques used for assessment of the aorticvalve and related pathology but multi-detector computed tomography (MDCT) can offer valuable complimentary information in some clinical scenarios. MDCT is the definite means of assessing aortic valvular calcification, acute aortic syndrome and for non-invasive assessment of the coronary arteries. MDCT also has an emerging role in the planning and follow-up of trans-catheter aorticvalve replacement. This article reviews the spectrum of aorticvalve disease highlighting the key MDCT imaging features. PMID:25202663
Primary malignant cardiac lymphomas associated with grafts are extremely rare: to our knowledge, only 6 cases of prosthesis-associated B-cell lymphoma have been reported. Ours is the first report of recurrent diffuse large B-cell lymphoma associated with aorticvalve allografts. We treated a 60-year-old man who presented in early 2007 with aorticvalve endocarditis. He underwent aorticvalve replacement with an allograft; the resected native valve showed active endocarditis without tumor. In January 2011, the patient underwent repeat aorticvalve replacement because of symptomatic aortic regurgitation. The explanted valve specimen displayed diffuse large B-cell lymphoma. In September 2011, the patient presented with fever and a mass around the aorticvalve. He died in January 2012. On autopsy, the explanted replacement valve displayed recurrent diffuse large B-cell lymphoma. The recurrent lymphoma on a new graft leads us to believe that this tumor is more aggressive than had been thought. We propose early systemic chemotherapy, in addition to tumor resection, for the possibility of a better prognosis. We discuss our patient's case and review the relevant medical literature.
Quadricuspid aorticvalve (QAV) is a rare congenital anomaly associated with aorticvalve insufficiency and significant morbidity, and requires the replacement or, rarely, the repair of the malfunctioning heart valve. A QAV associated with an ascending aorta aneurysm is an extremely rare anatomic combination with a hypothetical, but not clear, shared embryological etiology. To date, only two cases of type B QAV with ascending aorta aneurysm have been reported. Herein is described the first ever case of a 38-year-old male suffering from severe symptomatic aorticvalve regurgitation due to a type A QAV, associated with an ascending aorta aneurism, who underwent a successful combined replacement of the aorticvalve and ascending aorta. PMID:22655506
Ferrari, Enrico; Marcucci, Carlo; Roumy, Aurelien; von Segesser, Ludwig Karl
Choosing the optimal aorticvalve prosthesis for middle-aged patients (late 40s to early 60s) with aortic stenosis presents a challenge. The available options all have substantial drawbacks that must be considered in the decision-making process. Current data indicate that there is little or no difference in survival between mechanical and bioprosthetic aorticvalve replacement in middle-aged patients at 10–15 years
Joanna Chikwe; Farzan Filsoufi; Alain F. Carpentier
Transcatheter valve implantation is developing into an effective and reproducible therapy for aorticvalve 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 aorticvalve 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
A 52-yr-old man who had a bioprosthetic aorticvalve developed Staphylococcus aureus bacteremia. Despite antibiotic therapy he had persistent pyrexia and developed new conduction system disturbances. Echocardiography did not demonstrate vegetations on the valve or an abscess, but gallium scintigraphy using SPECT clearly identified a focus of intense activity in the region of the aorticvalve. The presence of valvular vegetations and a septal abscess was confirmed at autopsy. Gallium scintigraphy, using SPECT, provided a useful noninvasive method for the demonstration of endocarditis and the associated valve ring abscess.
O'Brien, K.; Barnes, D.; Martin, R.H.; Rae, J.R. (Department of Diagnostic Radiology, Victoria General Hospital Halifax, Nova Scotia (Canada))
Background Ascending aortic dilation is important in bicuspid aorticvalve 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. PMID:23771987
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
Transapical transcatheter aorticvalve implantation (TA-TAVI) is the recognized first choice surgical TAVI access. Expansion of this well-established treatment modality with subsequent broader patient inclusion has accelerated development of second-generation TA-TAVI devices. The Swiss ACURATE TA Symetis valve allows for excellent anatomical positioning, resulting in a very low incidence of paravalvular leaks. The self-expanding stent features an hourglass shape to wedge the native aorticvalve annulus. A specially designed delivery system facilitates controlled release aided by tactile operator feedback. The ACURATE TA valve made of three native porcine non-coronary leaflets has received CE approval in September 2011. Since then, this valve is the third most frequently implanted TAVI device with over 1200 implants in Europe and South America. Results from the Symetis ACURATE TA™ Valve Implantation ('SAVI') Registry showed a procedural success rate of 98.0% and a survival rate of 93.2% at 30 days. This presentation provides technical considerations and detailed procedural aspects of device implantation. PMID:25298363
Objective Accumulation of reactive oxygen species (ROS) and remodeling of the microstructure of the cusp characterize aorticvalve sclerosis, the early phase of calcific aorticvalve 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 aorticvalve cusps and patient-matched VICs were collected from 39 patients both with and without calcific aorticvalve 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 aorticvalve 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 aorticvalve 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 aorticvalve disease. We unveiled an association among ROS, DNA-damage response, and cellular transdifferentiation, reversible by antioxidant enzymes delivery. PMID:23241403
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
Objective: To study in a rabbit model the expression of endothelial nitric oxide synthase (eNOS) in association with the development of calcification of the aorticvalve, and to assess the effects of atorvastatin on eNOS expression, nitrite concentration, and aorticvalve calcification. Methods: Rabbits (n ?=? 48) were treated for three months: 16, forming a control group, were fed a normal diet; 16 were fed a 0.5% (wt/wt) high cholesterol diet; and 16 were fed a 0.5% (wt/wt) cholesterol diet plus atorvastatin (2.5 mg/kg/day). The aorticvalves were examined with eNOS immunostains and western blotting. Cholesterol and high sensitivity C reactive protein (hsCRP) concentrations were determined by standard assays. Serum nitrite concentrations were measured with a nitric oxide analyser. eNOS was localised by electron microscopy and immunogold labelling. Calcification in the aorticvalve was evaluated by micro-computed tomography (CT). Results: Cholesterol, hsCRP, and aorticvalve calcification were increased in the cholesterol fed compared with control animals. Atorvastatin inhibited calcification in the aorticvalve as assessed by micro-CT. eNOS protein concentrations were unchanged in the control and cholesterol groups but increased in the atorvastatin treated group. Serum nitrite concentrations were decreased in the hypercholesterolaemic animals and increased in the group treated with atorvastatin. Conclusion: These data provide evidence that chronic experimental hypercholesterolaemia produces bone mineralisation in the aorticvalve, which is inhibited by atorvastatin. PMID:15894785
Rajamannan, N M; Subramaniam, M; Stock, S R; Stone, N J; Springett, M; Ignatiev, K I; McConnell, J P; Singh, R J; Bonow, R O; Spelsberg, T C
The aim of the study was to evaluate the transcatheter aorticvalve replacement (TAVR) in high-risk patients with severe bicuspid aorticvalve (BAV) stenosis and to compare the outcomes with a matched group of patients with tricuspid aorticvalve. TAVR became an alternative treatment method in high-risk patients with symptomatic aortic stenosis; however, BAV stenosis is regarded as a relative contraindication to TAVR. The study population comprised 28 patients with BAV who underwent TAVR. BAV was diagnosed based on a transesophageal echocardiography. CoreValve and Edwards SAPIEN prostheses were implanted. The control group consisted of 84 patients (3:1 matching) with significant tricuspid aorticvalve stenosis treated with TAVR. There were no significant differences between patients with and without BAV in device success (93% vs 93%, p = 1.0), risk of annulus rupture (0% in both groups), or conversion to cardiosurgery (4% vs 0%, respectively, p = 0.25). The postprocedural mean pressure gradient (11.5 ± 6.4 vs 10.4 ± 4.5 mm Hg, p = 0.33), aortic regurgitation grade ?2 of 4 (32% vs 23%, p = 0.45), 30-day mortality (4% vs 7%, p = 0.68), and 1-year all-cause mortality (19% vs 18%, p = 1.00) did not differ between the groups. Echocardiography showed well-functioning valve prosthesis with a mean prosthetic valve area of 1.6 ± 0.4 cm(2) versus 1.7 ± 0.3 cm(2) (p = 0.73), a mean pressure gradient of 10.3 ± 5.4 versus 9.8 ± 2.8 mm Hg (p = 0.64), and aortic regurgitation grade ?2 of 4 (22% vs 22%, p = 1.00) for the 2 groups. In conclusion, selected high-risk patients with BAV can be successfully treated with TAVR, and their outcomes are similar to those reported in patients without BAV. PMID:25037674
Aortic stenosis (AS) is the most common valvular heart disorder in older adults. Patients with severe AS are generally treated nonsurgically if asymptomatic and referred to aorticvalve replacement when symptoms develop. However, patients with severe asymptomatic AS with left ventricular dysfunction may benefit from early aorticvalve replacement. Although operative mortality in patients with severe AS and left ventricular dysfunction is greater than in patients with preserved left ventricular function, the overall mortality risk is substantially lower than that of watchful waiting. Operative risk in patients with severe AS and left ventricular dysfunction is often overestimated and, consequently, most are not referred to surgery despite clinical data in support of early aorticvalve replacement. Asymptomatic patients with echocardiographic confirmation of severe AS and left ventricular dysfunction should be referred for aorticvalve replacement. PMID:23580789
Miller, Larry E.; Miller, Valerie M.; Acers, Larry D.
The occurrence of dysfunctional aorticvalves is increasing every year, and current replacement heart valves, although having been shown to be clinically successful, are only short-term solutions and suffer from many agonizing long-term drawbacks. The tissue engineering of heart valves is recognized as one of the most promising answers for aorticvalve disease therapy, but overcoming current shortcomings will require multidisciplinary efforts. The use of a polymeric scaffold to guide the growth of the tissue is the most common approach to generate a new tissue for an aortic heart valve. However, optimizing the design of the scaffold, in terms of biocompatibility, surface morphology for cell attachments and the correct rate of degradation is critical in creating a viable tissue-engineered aortic heart valve. This paper highlights the bioengineering strategies that need to be followed to construct a polymeric scaffold of sufficient mechanical integrity, with superior surface morphologies, that is capable of mimicking the valve dynamics in vivo. The current challenges and future directions of research for creating tissue-engineered aortic heart valves are also discussed. PMID:25262629
Objective This study tested the hypothesis that valvular calcium deposition, pro-osteogenic signaling, and function can be altered in mice with advanced aorticvalve disease. Methods/Results “Reversa” mice were placed on a Western-type diet for 12 months and screened for the presence of aorticvalve stenosis. Mice with advanced valve disease were assigned to two groups: 1) continued progression for 2 months, and 2) “regression” for 2 months, in which lipid lowering was accomplished by a “genetic switch”. Control mice were normocholesterolemic for 14 months. Mice with advanced valve disease had massive valvular calcification that was associated with increases in bone morphogenetic protein signaling, Wnt/?-catenin signaling, and markers of osteoblast-like cell differentiation. Remarkably, reducing plasma lipids with a “genetic switch” dramatically reduced markers of pro-osteogenic signaling and significantly reduced valvular calcium deposition. Nevertheless, despite a marked reduction in valvular calcium deposition, valve function remained markedly impaired. Phospho-Smad2 levels and myofibroblast activation (indices of pro-fibrotic signaling) remained elevated. Conclusion Molecular processes that contribute to valvular calcification and osteogenesis remain remarkably labile during end stages of aorticvalve stenosis. While reductions in valvular calcium deposition were not sufficient to improve valvular function in our animals, these findings demonstrate that aorticvalve calcification is a remarkably dynamic process that can be modified therapeutically even in the presence of advanced aorticvalve disease. PMID:20864669
Miller, Jordan D.; Weiss, Robert M.; Serrano, Kristine M.; Castaneda, Lauren E.; Brooks, Robert M.; Zimmerman, Kathy; Heistad, Donald D.
Aorticvalve (AV) calcification is a highly prevalent disease with serious impact on mortality and morbidity. Although exact causes and mechanisms of AV calcification are unclear, previous studies suggest that mechanical forces play a role. Since calcium deposits occur almost exclusively on the aortic surfaces of AV leaflets, it has been hypothesized that adverse patterns of fluid shear stress on the aortic surface of AV leaflets promote calcification. The current study characterizes AV leaflet aortic surface fluid shear stresses using Laser Doppler velocimetry and an in vitro pulsatile flow loop. The valve model used was a native porcine valve mounted on a suturing ring and preserved using 0.15% glutaraldehyde solution. This valve model was inserted in a mounting chamber with sinus geometries, which is made of clear acrylic to provide optical access for measurements. To understand the effects of hemodynamics on fluid shear stress, shear stress was measured across a range of conditions: varying stroke volumes at the same heart rate and varying heart rates at the same stroke volume. Systolic shear stress magnitude was found to be much higher than diastolic shear stress magnitude due to the stronger flow in the sinuses during systole, reaching up to 20 dyn/cm2 at mid-systole. Upon increasing stroke volume, fluid shear stresses increased due to stronger sinus fluid motion. Upon increasing heart rate, fluid shear stresses decreased due to reduced systolic duration that restricted the formation of strong sinus flow. Significant changes in the shear stress waveform were observed at 90 beats/ min, most likely due to altered leaflet dynamics at this higher heart rate. Overall, this study represents the most well-resolved shear stress measurements to date across a range of conditions on the aortic side of the AV. The data presented can be used for further investigation to understand AV biological response to shear stresses. PMID:21416247
Vascular support structures are important devices for treating valve stenosis. Large population of patients is treated for valvular disease and the principal mode of treatment is the use of percutaneous valvuloplasty. Stent devices are proving to be an improved technology in minimal invasive cardiac surgery. This technology now accounts for 20% of treatments in Europe. This new technology provides highly effective results at minimal cost and short duration of hospitalization. During the development process, a number of specific designs and materials have come and gone, and a few have remained. Many design changes were successful, and many were not. This paper discusses the physical behavior of a hooked percutaneous aorticvalve stent design using a finite element analysis. Specifically, the effects of crimping was simulated and analyzed for two types of realistic but different Nitinol materials (NITI-1 and NITI-2). The results show that both NITI-1 and NITI-2 had good crimping performance. The analysis performed in this paper may aid in understanding the stent's displacement ranges when subjected to physiological pressures exerted by the heart and cardiac blood flow during abnormal cardiovascular conditions. It may also help to evaluate the suitability of a Nitinol for fabrication purposes. PMID:22981766
Cardiac conduction disturbances after transcatheter aorticvalve replacement (TAVR) are common and important. The risk factors and outcome effects of atrial fibrillation after TAVR recently have been appreciated. The paucity of clinical trials has resulted in the absence of clinical guidelines for the management of this important arrhythmia in this high-risk patient population. Given this evidence gap and clinical necessity, it is likely that clinical trials in the near future will be designed and implemented to address these issues. Prompt recognition and proper management of atrioventricular block remain essential in the management of patients undergoing TAVR, because heart block of all types is common and may require permanent pacemaker implantation. The current evidence base has described the incidence, risk factors, and current outcomes of this conduction disturbance in detail. As the practice of TAVR evolves and novel valve prostheses are developed, a focus on minimizing damage to the cardiac conductive system remains paramount. It remains to be seen how the next generation of TAVR prostheses will affect the incidence, risk factors, and clinical outcomes of associated conduction disturbances. PMID:24103715
Ghadimi, Kamrouz; Patel, Prakash A; Gutsche, Jacob T; Sophocles, Aris; Anwaruddin, Saif; Szeto, Wilson Y; Augoustides, John G T
Objective Management of intermediate degrees of mitral regurgitation (MR) during aorticvalve replacement (AVR) for aortic stenosis remains controversial. We sought to evaluate the degree of reduction of MR in patients undergoing AVR, as well as the relationship between the pre-operative gradient across the aorticvalve and the degree of reduction in MR. Methods We retrospectively analyzed demographic, intraoperative, and echocardiographic data on 802 patients that underwent AVR or aortic root replacement between January 2010 and March 2011. 578 patients underwent AVR or aortic root replacement without intervention on the mitral valve. We excluded 88 patients with severe aortic insufficiency, 3 patients that underwent ventricular assist device placement, 4 patients that underwent prior mitral valve replacement, and 21 patients with incomplete data yielding 462 patients for analysis. MR was graded for each patient and the degree of change in MR for each patient was determined by subtracting the grade of pre-operative MR from the degree of post-operative MR. Results Of the 462 patients, 289 patients had at least mild MR. On average, MR was downgraded by 0.24 degrees per patient for this cohort of 289 patients. Of the 56 patients with at least moderate MR, MR was downgraded 0.54 degrees per patient. Of 62 patients that underwent AVR only, had at least mild MR, and no evidence of structural mitral valve disease, downgrading of MR was 0.24 degrees per patient. Linear regression analysis revealed no relationship between reduction in MR and pre-operative gradient across the aorticvalve. Conclusions Reduction in MR after relief of aortic outflow tract obstruction is modest at best. Further, the magnitude of the pre-operative gradient across the aorticvalve has little influence on the degree of reduction in MR. These observations argue in favor of performing a prospective evaluation of the clinical benefits of addressing moderate MR at the time of aorticvalve intervention. PMID:23245347
Kaczorowski, David J.; MacArthur, John W.; Howard, Jessica; Kobrin, Dale; Fairman, Alex; Woo, Y. Joseph
Aortic calcium, aorticvalve 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, CAC was assessed by electron beam- or multidetector-computed tomography. We determined the prevalence of TAC and AVC in relation to CAC, CHD risk factors, and predicted 10-year risk of CHD. A close correspondence of TAC and AVC was observed with CAC. TAC and AVC increased with age; by the eighth decade of life, the prevalence of TAC was similar to that of CAC (>80%), and 36% of men and 24% of women had AVC. Age, male gender, and low-density lipoprotein cholesterol were directly related to the likelihood of CAC, TAC, and AVC; higher diastolic blood pressure and cigarette smoking additionally predicted CAC. Body mass index and higher systolic and lower diastolic blood pressures were also related to TAC, and higher body mass index and lower diastolic blood pressure were related to AVC. Calculated risk of CHD increased with the presence of AVC and TAC across levels of CAC. TAC and AVC provided incremental value over CAC in association with the 10-year calculated risk of CHD. If longitudinal studies show an incremental value of aortic and aorticvalve calcium over that of CAC for prediction of cardiovascular events, future guidelines for risk assessment incorporating CAC assessment may additionally incorporate the measurement of aortic and/or aorticvalve calcium. PMID:14556872
The introduction of minimally invasive techniques in general surgery, in the late 1980s, influenced cardiac surgery as well. This led to the emergence of several minimal access approaches for aorticvalve replacement (AVR). Currently, the upper partial sternotomy with unilateral J-shaped extension to the right through the fourth intercostal space is the most popular minimal access approach. This approach offers the comfort factor of sternotomy, improved cosmetic result, preserved respiratory mechanics, and last but not the least cost saving as no new equipment is required. On the other hand, inability to visualize the whole heart, adequately de-air the left heart, and failure to apply epicardial pacing wires are some of the perceived disadvantages of this approach. This article provides a comprehensive review of the indications, contraindications, technical aspects, outcomes, advantages and disadvantages of AVR through J-shaped partial upper sternotomy. PMID:24251025
he relationship between the size of the aorta, in partic- ular the cross-sectional area, and the patient's height expressed as a ratio and the risk of aortic dissection has not been determined in patients with bicuspid aorticvalves.
Lars G. Svensson; Kyung-Hwan Kim; Bruce W. Lytle; Delos M. Cosgrove
Cross Section of Heart With Valve Replacement Prosthetic AorticValve Right Atrium Right Ventricle Tricuspid Valve Left Atrium Mitral Valve Left Ventricle Aorta Vegetations Complications Associated With Heart Valve Infections Emboli Abscess Regurgitation ...
Percutaneous balloon dilatation of the aorticvalve was attempted in 25 consecutive patients with stenosis. The aorticvalve 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 aorticvalve 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 aorticvalve 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 aorticvalve. Images Fig 1 PMID:2475152
Vogel, M; Benson, L N; Burrows, P; Smallhorn, J F; Freedom, R M
Background. Bicuspid aorticvalve (BAV) may be associated with aneurysmal dilatation of the ascending aorta, even after successful aorticvalve replacement. There are as yet no biomarkers that correlate with the progression of such disease. Elevated levels of C-reactive protein (CRP), a marker of acute inflammation, are seen in chronic rheumatic valve disease, especially those with multivalvular disease, and have
M. Yagubyan; G. Sarkar; R. A. Nishimura; T. M. Sundt
The bicuspid aorticvalve (BAV) is the most common congenital cardiac and regurgitation, infective endocarditis and aortic dilation and dissection. Moreover, BAV may be associated with other cardiovascular anomalies, mainly aortic coarctation. There is greater awareness of BAV in the young population who practice sport, with an increasing interest on the impact of regular and competitive exercise on athletes with
Paola De Mozzi; Umile Giuseppe Longo; Giorgio Galanti; Nicola Maffulli
The safety valve contains a resilient gland to be held between a valve seat and a valve member and is secured to the valve member by a sleeve surrounding the end of the valve member adjacent to the valve seat. The sleeve is movable relative to the valve member through a limited axial distance and a gap exists between said valve member and said sleeve.
The development of transcatheter aorticvalve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve® clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009–2010) and TAVI (2011–2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aorticvalve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.
Hui, Dawn S.; Shavelle, David M.; Cunningham, Mark J.; Matthews, Ray V.; Starnes, Vaughn A.
ObjectiveIn this study, the impact of regular training on left ventricle morphology in a group of athletes with bicuspid aorticvalve (BAV) was evaluated.DesignLongitudinal cohort study. A group of competitive athletes with BAV was followed up with a yearly standard echocardiographic examination for 5 years.SettingSport Medicine Centre, University of Florence, Pre-Participation Protocol StudyParticipantsA group of 88 consecutive athletes diagnosed with
G. Galanti; L. Stefani; L. Toncelli; M. C. R. Vono; R. Mercuri; N. Maffulli
Bicuspid aorticvalve (BAV) is the most common congenital cardiac anomaly in humans. Despite recent advances, the molecular basis of BAV development is poorly understood. Previously it has been shown that mutations in the Notch1 gene lead to BAV and valve calcification both in human and mice, and mice deficient in Gata5 or its downstream target Nos3 have been shown
Penny S. Thomas; Somyoth Sridurongrit; Pilar Ruiz-Lozano; Vesa Kaartinen
Objective: There is relationship between a dilated ascending aorta and a bicuspid aorticvalve. Controversy exists concerning techniques available for surgical restoration of the functional and anatomical integrity of the aortic root. The present study was undertaken to define the histopathologic and molecular biologic condition of ascending aortic aneurysms associated with bicuspid (BAV) or tricuspid aorticvalve (TAV) and the
Franz-Xaver Schmid; Katrin Bielenberg; Anette Schneider; Andreas Haussler; Andreas Keyser; Dietrich Birnbaum
Chronic cough has a wide differential, of which thoracic aortic aneurysm is a rare but potentially devastating cause. We present a patient with previous aorticvalve replacement for a bicuspid valve who had been suffering from a chronic cough for 8?months and who developed subsequent voice hoarseness. This had been initially managed in the community with trials of steroid inhalers, steroid nasal sprays and proton pump inhibitors to no avail. He was referred to cardiology and chest clinics. An urgent CT aortogram was requested given his widened mediastinum on chest radiograph, cardiac history of bicuspid valve and symptoms. This revealed a large aneurysm of the thoracic aorta with chronic dissection that required urgent operative intervention. His cough resolved 6?weeks postoperatively. The purpose of this report is to highlight thoracic aortic aneurysms as a potential rare differential for chronic cough and as a complication of patients with bicuspid aorticvalves. PMID:25178892
Miller, Charles Philip; Firoozan, Soroosh; Woo, Eric K; Apps, Andrew
Purpose. Our physiopathological assumption is that u-PA, t-PA, and PAI-1 are released by calcified aorticvalves and play a role in the calcification of these valves. Methods. Sixty-five calcified aorticvalves were collected from patients suffering from aortic stenosis. Each valve was incubated for 24 hours in culture medium. The supernatants were used to measure u-PA, t-PA, and PAI-1 concentrations; the valve calcification was evaluated using biphotonic absorptiometry. Results. Aortic stenosis valves expressed normal plasminogen activators concentrations and overexpressed PAI-1 (u-PA, t-PA, and PAI-1 mean concentrations were, resp., 1.69?ng/mL ± 0.80, 2.76?ng/mL ± 1.33, and 53.27?ng/mL ± 36.39). There was no correlation between u-PA and PAI-1 (r = 0.3) but t-PA and PAI-1 were strongly correlated with each other (r = 0.6). Overexpression of PAI-1 was proportional to the calcium content of the AS valves. Conclusions. Our results demonstrate a consistent increase of PAI-1 proportional to the calcification. The overexpression of PAI-1 may be useful as a predictive indicator in patients with aortic stenosis. PMID:24693431
The principal objective of this investigation was to analyze the association between diffuse idiopathic skeletal hyperostosis (DISH) and the presence of aorticvalve sclerosis (AVS). For this study we used results from 1000 consecutive outpatients (473 males), older than 50 years of age (average 67.6 years), that had been examined with Doppler echocardiogram and anterior and lateral chest radiographs. Overall, 195 patients (19.5%) were diagnosed with DISH and 283 (28.3%) with AVS. DISH was more prevalent than AVS in males (66.7% vs. 42.6%, p< 0.0001) and in older patients (73.6 ± 9 years vs. 66.1 ± 9 years, p < 0.0001). Furthermore, 55.4% of patients with dorsal DISH presented aortic sclerosis calcification vs. 21.7% of patients free of DISH (OR = 4.47; 95% CI = 3.22-6.21). The adjusted odds ratio (OR) was calculated by sex and age resulting in 3.04 (95% CI = 2.12-4.36; p < .0001). A statistically significant association was found between DISH and AVS in accordance to age and sex. The biological plausibility of this association is based on similar risk factors, pathogenic mechanisms and vascular complications. PMID:24918668
Orden, Alberto O; David, José M; Díaz, Rosana P; Nardi, Norma N; Ejarque, Aida C; Yöchler, Adriana B
This paper intends to define an optimal range for the pump speed of Rotary Left Ventricular Assist Devices (LVADs) that are used in bridge-to-recovery treatments. If the pump is operating within that optimal range, the aorticvalve will be working properly (i.e. opening and closing) in each cardiac cycle. The proper operation of the aorticvalve is a very important
George Faragallah; Yu Wang; Eduardo Divo; Marwan Simaan
Objectives Studies have shown that patients harboring bicuspid aorticvalve (BAV) or bovine aortic arch (BAA) are more likely to develop ascending aortic aneurysm (AsAA) than the general population. A thorough quantification of the AsAA tissue properties for these patient groups may offer insight into the underlying mechanisms of AsAA development in these patients. Thus, the objective of this study was to investigate and compare the mechanical and microstructural properties of aortic tissues from AsAA patients with and without concomitant BAV or BAA. Materials and methods AsAA (n = 20), BAV (n = 20) and BAA (n = 15) human tissues were obtained from patients who underwent elective AsAA surgery. Planar biaxial and uniaxial failure tests were used to characterize the mechanical and failure properties of the tissues, respectively. Histological analysis was performed to detect the medial degenerative characteristics of aortic aneurysm. Individual layer thickness and composition were quantified for each patient group. Results The circumferential (CIRC) response of the BAV samples was stiffer than both AsAA (p = 0.473) and BAA (p = 0.152) tissues at low load. The BAV tissues were nearly isotropic while AsAA and BAA tissues were anisotropic. The areal strain of BAV samples were significantly less than AsAA (p = 0.041) and BAA (p = 0.004) tissues at a low load. The BAA samples were similar to the AsAA samples in both mechanical and failure properties. On the microstructural level, all samples displayed moderate medial degeneration characterized by elastin fragmentation, cell loss, mucoid accumulation and fibrosis. The ultimate tensile strength of BAV and BAA tissues were also found to decrease with age. Conclusions The BAV tissues were stiffer than both AsAA and BAA tissues, and the BAA tissues were similar to the AsAA tissues. The BAV samples were thinnest with less elastin than AsAA and BAA samples, which may attribute to the loss of extensibility at low load of these tissues. No apparent difference in failure mechanics among the tissue groups suggests that each of the patient groups may have a similar risk of rupture. PMID:23643809
While the mechanical behaviors of the fibrosa and ventricularis layers of the aorticvalve (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
A 54 years old male with undiagnosed chronic calcific degenerative aorticvalve incompetence presented with acute left anterior chordae tendinae rupture resulting in severe left heart failure and cardiogenic shock. He was successfully treated with emergency double valve replacement using mechanical valves. The pathogenesis of acute rupture of the anterior chordae tendinae, without any evidence of infective endocarditis or ischemic heart disease seems to have been attrition of the subvalvular mitral apparatus by the chronic regurgitant jet of aortic incompetence with chronic volume overload. We review the literature with specific focus on the occurrence of this unusual event. PMID:17026749
The effect of valve orientation on flow development in a model human aorta was studied by means of a qualitative flow visualization technique. The model replicated the geometry of the human aorta and the experiment simulated a physiologically realistic pulsatile flow. The following valves were studied: Starr-Edwards Stellite, Starr-Edwards silicone, Björk-Shiley spherical disc, Björk-Shiley convexo-concave disc, and Hall-Kaster tilting disc. All the valves had a tissue anulus diameter of 27 mm. With the ball-in-cage valves, the flow in the ascending aorta was predominantly axial and uniform throughout systole, while vortex formation was observed downstream from the ball. With the tilting disc valves, the flow development in the aorta was a function of the orientation of the valves. With the major flow orifice directed toward the commissure between the right and noncoronary cusps, the fluid motion was predominantly in the axial direction through early systole. A vortex developed along the wall of lesser curvature of the aorta with the progression of systole. In early diastole, a well-defined flow reversal was observed along the lesser curvature of the aorta. With the major flow orifice directed toward the left coronary cusp, the fluid motion, although predominantly axial, was not uniform in the ascending aorta. Regions of relative stasis present near the wall of greater curvature subsequently developed into a trapped vortex throughout the cardiac cycle. With the major flow orifice directed more posteriorly, an improved fluid dynamic characteristic was observed, and there was no trapped vortex present near the wall of greater curvature. The flow visualization study in the model human aorta suggests that, from a fluid dynamic point of view, orientation of the major flow orifice of the tilting disc valve toward the wall of lesser curvature is not advisable. PMID:6855259
Chandran, K B; Khalighi, B; Chen, C J; Falsetti, H L; Yearwood, T L; Hiratzka, L F
Congestive heart failure in patients surviving aorticvalve replacement has been associated with a high late mortality. To determine whether myocardial dysfunction in these patients occurred preoperatively, perioperatively, or during the early postoperative period, 19 consecutive patients undergoing aorticvalve replacement using cardioplegia and hypothermia were studied by multiple-gated cardiac blood pool imaging. The resting ejection fractions for 8 patients with aortic stenosis did not show significant changes following operation. The 11 patients with aortic insufficiency has resting preoperative values of 58 +/- 15%, which fell to 38 +/- 18% immediately postoperatively (p less than 0.01), with the late values being 51 +/- 16%. Eight of 18 patients (44%) showed deterioration of regional wall motion immediately after operation, which persisted in 3 during the late evaluation. The occurrence of new perioperative regional wall motion abnormalities and persistent perioperative depression in left ventricular function in some patients suggest the need for further improvement in myocardial protection during cardiopulmonary bypass for aorticvalve replacement.
Santinga, J.T.; Kirsh, M.M.; Brady, T.J.; Thrall, J.; Pitt, B.
BackgroundBicuspid aorticvalves (BAV) are a common inherited abnormality with a very high rate of adverse cardiac events at an earlier age than tricuspid aorticvalves (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
BACKGROUND AND PURPOSE Aorticvalve stenosis (AVS) is associated with significant cardiovascular morbidity and mortality. To date, no therapeutic modality has been shown to be effective in retarding AVS progression. We evaluated the effect of angiotensin-converting enzyme inhibition with ramipril on disease progression in a recently developed rabbit model of AVS. EXPERIMENTAL APPROACH The effects of 8 weeks of treatment with either vitamin D2 at 25 000 IU for 4 days a week alone or in combination with ramipril (0.5 mg·kg?1) on aorticvalve structure and function were examined in New Zealand white rabbits. Echocardiographic aorticvalve backscatter (AVBS) and aorticvalve : outflow tract flow velocity ratio were utilized to quantify changes in valve structure and function. KEY RESULTS Treatment with ramipril significantly reduced AVBS and improved aorticvalve : outflow tract flow velocity ratio. The intravalvular content of the pro-oxidant thioredoxin-interacting protein was decreased significantly with ramipril treatment. Endothelial function, as measured by asymmetric dimethylarginine concentrations and vascular responses to ACh, was improved significantly with ramipril treatment. CONCLUSIONS AND IMPLICATIONS Ramipril retards the development of AVS, reduces valvular thioredoxin-interacting protein accumulation and limits endothelial dysfunction in this animal model. These findings provide important insights into the mechanisms of AVS development and an impetus for future human studies of AVS retardation using an angiotensin-converting enzyme inhibitor. PMID:20958293
Ngo, Doan TM; Stafford, Irene; Sverdlov, Aaron L; Qi, Weier; Wuttke, Ronald D; Zhang, Yuan; Kelly, Darren J; Weedon, Helen; Smith, Malcolm D; Kennedy, Jennifer A; Horowitz, John D
There is a paucity of data describing acute kidney injury (AKI) following transcatheter aorticvalve implantation and its impact on mortality remains unknown. We therefore evaluate the incidence, predictors and impact of AKI following transcatheter aorticvalve implantation. We searched MEDLINE for studies from 2008 to 2013, evaluating AKI after transcatheter aorticvalve implantation. All studies were compared according to the incidence, predictors and impact of AKI following transcatheter aorticvalve 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 aorticvalve 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
Introduction:Chlamydia pneumoniae has been identified in arterial atherosclerosis. Aorticvalves affected by senile calcific aortic stenosis (SCAS) or calcification of a congenital bicuspid valve (CCBAV) may have interior environments similar to atherosclerosis. This study aimed to detect C. pneumoniae within either SCAS or CCBAV. Methods: 60 valves showing either SCAS (n=36) or CCABV (n=22) and control valves (n=2) were studied
We describe a very rare case of human brucella multivalvular endocarditis. Patient presented in a state of cardiogenic shock with low urine output and a history of breathlessness. Patient was diagnosed to have brucellosis 2 months back by blood cultures and agglutination tests and was receiving doxycycline and rifampicin therapy. Echocardiography showed severe aortic regurgitation, moderate mitral regurgitation, severe left ventricular dysfunction and a mobile vegetation attached to the aorticvalve. Patient was scheduled for emergency surgery; while preparing for surgery hemodynamic monitoring, non-invasive ventilation and inotropic supports were started. During surgery, the aorticvalve was found perforated and the aortomitral continuity was disrupted. Aorticvalve replacement and mitral valve repair were performed. Hemofiltration was used during cardiopulmonary bypass. Weaning from bypass was achieved with the help of inodilators, dual chamber pacing and intra-aortic balloon pump. PMID:24107698
Only three cases of the combination of bicuspid aorticvalve and ruptured aneurysm of the sinus of Valsalva, associated with\\u000a previously repaired coarctation of aorta, have been reported. A twenty-year-old man with a sudden onset of CHF due to ruptured\\u000a aneurysm of the sinus of Valsalva underwent intracardiac repair by direct closure of the sinus Valsalva in combination with\\u000a patch
The aorticvalve and adjacent structures should be routinely evaluated on all thoracic cross-sectional imaging studies. Echocardiography and magnetic resonance imaging (MRI) are the main imaging techniques used for assessment of the aorticvalve and related pathology but multi-detector computed tomography (MDCT) can offer valuable complimentary information in some clinical scenarios. Radiologists should be familiar with the indications, advantages and limitations of MDCT for assessment of the aorticvalve. This article reviews aorticvalve anatomy and relevant terminology, technical aspects of MDCT image optimisation and describes a suggested approach to interpretation. PMID:25202662
The aorticvalve and adjacent structures should be routinely evaluated on all thoracic cross-sectional imaging studies. Echocardiography and magnetic resonance imaging (MRI) are the main imaging techniques used for assessment of the aorticvalve and related pathology but multi-detector computed tomography (MDCT) can offer valuable complimentary information in some clinical scenarios. Radiologists should be familiar with the indications, advantages and limitations of MDCT for assessment of the aorticvalve. This article reviews aorticvalve anatomy and relevant terminology, technical aspects of MDCT image optimisation and describes a suggested approach to interpretation. PMID:25202662
AorticValve (AV) stenosis if untreated leads to heart failure. From a mechanics standpoint, heart failure implies failure to generate sufficient mechanical power to overcome energy losses in the circulation. Thus energy efficiency-based measures are direct measures of AV disease severity, which unfortunately is not used in current clinical measures of stenosis severity. We present an analysis of the dynamic rate of energy dissipation through the AV from direct high temporal resolution measurements of flow and pressure drop across the AV in a pulsatile left heart setup. Porcine AV was used and measurements at various conditions were acquired: varying stroke volumes; heart rates; and stenosis levels. Energy dissipation waveform has a distinctive pattern of being skewed towards late systole, attributed to the explosive growth of flow instabilities from adverse pressure gradient. Increasing heart rate and stroke volume increases energy dissipation, but does not alter the normalized shape of the dissipation temporal profile. Stenosis increases energy dissipation and also alters the normalized shape of dissipation waveform with significantly more losses during late acceleration phase. Since stenosis produces a departure from the signature dissipation waveform shape, dynamic energy dissipation analysis can be extended into a clinical tool for AV evaluation.
Hwai Yap, Choon; Dasi, Laksmi P.; Yoganathan, Ajit P.
Aims To describe patient radiation utilisation during transcatheter aorticvalve replacement (TAVR) on a series of consecutive patients. Methods and results Data on radiation exposure were prospectively collected for consecutive patients undergoing TAVR and percutaneous coronary interventions at our centre. Radiation dose during the procedure was recorded using the US Food and Drug Administration (FDA) reference point (Ka,r) and the dose area product (PKA). In addition to quantifying overall radiation doses during TAVR, radiation exposure during transfemoral (TF) (n=79) and transapical (TA) (n=26) cases was compared. The median radiation dose during TAVR was 1,639 mGy (983–2,420), or 188 (106–321) Gy*cm2. Radiation dose was significantly lower among TA patients using either the reference point (TA: 946 [777–1,261] vs. TF: 1,932 [1,383–2,614] mGy; p<0.001) or the dose area product (TA: 89 [60–115] vs. TF: 236 [164–338] Gy*cm2; p<0.001). Fluoroscopy time was lower for TA patients (TA: 10 [8–11] vs. TF: 30 [24–34] minutes; p<0.001). Operators experience did not affect radiation exposure for TF cases. Conclusions Radiation exposure during TAVR appears similar to other percutaneous coronary interventions of moderate complexity. Radiation doses were significantly lower for TA procedures. A higher dose of radiation in TF patients may be related to additional imaging requirements to optimise percutaneous vascular access and closure. PMID:23086785
Daneault, Benoit; Balter, Stephen; Kodali, Susheel K.; Williams, Mathew R.; Genereux, Philippe; Reiss, George R.; Paradis, Jean-Michel; Green, Philip; Kirtane, Ajay J.; Smith, Craig; Moses, Jeffrey W.; Leon, Martin B.
We sought to demonstrate the feasibility of an endoscopic approach to transapical aorticvalve implantation (AVI), avoiding the morbidity of a thoracotomy incision. Using an experimental pig model, we performed three different approaches to transapical AVI, using a standard minithoracotomy (n=4), a robotic approach using the da Vinci telemanipulator (n=4) and an endoscopic approach using a port and camera access (n=4). The feasibility of the different techniques, exposure of the left ventricular apex, postoperative blood loss and total operative time were evaluated. Left ventricular apical exposure, 'purse-string' suture control and 33-F introducer access were successfully performed and confirmed videoscopically, fluoroscopically and at a post mortem in all 12 animals. The haemodynamics were stable in all animals. Mean intraoperative and postoperative (two-hour) blood losses were 88 and 65 ml with minithoracotomy, and 228 and 138 ml with the robotic and 130 and 43 ml with the endoscopic technique (P=0.26, P=0.14, respectively). There was no significant change in perioperative haematocrit (P=0.53). The mean total operative times were 1.4, 3.9 and 1.1 h (P=0.06), respectively. Percutaneous endoscopic and robotic transapical AVI are both feasible and can be performed in a timely manner with reasonable perioperative blood loss. Future research will focus on identifying optimal candidates for surgery based upon preoperative thoracic imaging. PMID:21700598
Chu, Michael W A; Falk, Volkmar; Mohr, Friedrich W; Walther, Thomas
Isolated right atrial compression occurred 31 months after aorticvalve replacement. Aortic bleeding contained by adjacent pericardium produced a pseudoaneurysm and local atrial tamponade. Transthoracic echocardiography could not distinguish the extracardiac hematoma from an intra-atrial thrombus, temporarily misleading investigators. Images PMID:8000271
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 aorticvalve, 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 aorticvalve regurgitation. PMID:24082388
Nascimbene, Angelo; Joggerst, Steven; Reddy, Kota J.; Cervera, Roberto D.; Ott, David A.; Wilson, James M.; Stainback, Raymond F.
, or with robot-assisted, annuloplasty. Index Terms-- AorticValve Annulus, Magnetic Reso- nance Imaging, Robot-Assisted Cardiac Surgery. 1. INTRODUCTION Aortic stenosis is the most common valvular heart disease prevalent Computer Graphics and Interactive Media Lab, and 2 Medical Robotics Lab, Department of Computer Science
The case is presented of a previously healthy infant with a known asymptomatic bicuspid aorticvalve who developed fungal endocarditis. The patient underwent aortic root replacement with a pulmonary autograft (Ross procedure). Cultured operative material revealed Aspergillus infection. The patient had an excellent recovery and remained well one year later. PMID:25192408
Mitropoulos, Fotios A; Kanakis, Meletios A; Contrafouris, Constantinos; Laskari, Cleo; Rammos, Spyridon; Apostolidis, Christos; Azariadis, Prodromos; Chatzis, Andrew C
OBJECTIVES This study reports the initial clinical and echocardiographic results of the Premium bioprosthetic aorticvalve up to 4 years of follow-up. METHODS Between October 2007 and July 2011, 121 consecutive patients were submitted for aorticvalve replacement with the Premium bioprosthetic valve. The mean age was 68 ± 9 years and 64 patients were males. The patients were periodically evaluated by clinical and echocardiographic examinations. The mean follow-up was 21 months (min = 2, max = 48), yielding 217 patients/year for the analysis. RESULTS The hospital mortality was 8%. Late survival at 3 years was 89% (95% CI: 81.9–93.3%), and 80% of the patients were in NYHA functional class I/II. The rates of valve-related complications were low, with a linearized incidence of 0.9%/100 patients/year for thromboembolic complications, 0% for haemorrhagic events and 0.9%/100 patients/year of bacterial endocarditis. There was no case of primary structural valve dysfunction. The mean effective orifice area was 1.61 ± 0.45 cm2; mean gradient 13 ± 5 mmHg and peak gradient 22 ± 9 mmHg. Significant patient–prosthesis mismatch was found in only 11% of the cases. CONCLUSIONS The Premium bioprosthetic aorticvalve demonstrated very satisfactory clinical and echocardiographic results up to 4 years, similar to other commercially available, third-generation bioprosthetic valves. PMID:22588029
Farias, Fabio Rocha; da Costa, Francisco Diniz Affonso; Balbi Filho, Eduardo Mendel; Fornazari, Daniele de Fatima; Collatusso, Claudinei; Ferreira, Andreia Dumsch de Aragon; Lopes, Sergio Veiga; Fernandes, Tadeu Augusto
Transcatheter aorticvalve replacement (TAVR) has emerged as an alternative therapy to open aorticvalve repair for high-risk patients with aortic stenosis, but larger delivery sheath size is associated with vascular complications. We report 2 cases in which a minimally invasive technique was used for the hybrid repair of confirmed or suspected large-bore sheath traumatic avulsion (i.e., "iliac on a stick") after TAVR. We believe our hybrid approach to rescuing the iliac artery in suspected or confirmed complete artery avulsion could improve outcomes for patients who require TAVR. PMID:23901016
Background and Purpose We have shown that infusions of apolipoprotein A-I (ApoA-I) mimetic peptide induced regression of aorticvalve stenosis (AVS) in rabbits. This study aimed at determining the effects of ApoA-I mimetic therapy in mice with calcific or fibrotic AVS. Experimental Approach Apolipoprotein E-deficient (ApoE?/?) mice and mice with Werner progeria gene deletion (Wrn?hel/?hel) received high-fat diets for 20 weeks. After developing AVS, mice were randomized to receive saline (placebo group) or ApoA-I mimetic peptide infusions (ApoA-I treated groups, 100 mg·kg?1 for ApoE?/? mice; 50 mg·kg?1 for Wrn mice), three times per week for 4 weeks. We evaluated effects on AVS using serial echocardiograms and valve histology. Key Results Aorticvalve area (AVA) increased in both ApoE?/? and Wrn mice treated with the ApoA-I mimetic compared with placebo. Maximal sinus wall thickness was lower in ApoA-I treated ApoE?/? mice. The type I/III collagen ratio was lower in the sinus wall of ApoA-I treated ApoE?/? mice compared with placebo. Total collagen content was reduced in aorticvalves of ApoA-I treated Wrn mice. Our 3D computer model and numerical simulations confirmed that the reduction in aortic root wall thickness resulted in improved AVA. Conclusions and Implications ApoA-I mimetic treatment reduced AVS by decreasing remodelling and fibrosis of the aortic root and valve in mice. PMID:23638718
The cooperative effort towards the development of a tri-leaflet prosthetic heart valve is described. The photogrammetric studies were conducted on silicone rubber molds. Information on data acquisition and data reduction phases is given, and certain accuracy aspects of the project are explained. The various outputs which are discussed include digital models, profiles, and contour maps.
Aorto-atrial fistulas are rare, but important complications resulting from aorticvalve infective endocarditis, aorticvalve surgery, or aortic dissection. We hereby report a case of a 20-year male, referred to us with infective endocarditis of the native aorticvalve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two-dimensional and three-dimensional transthoracic echocardiography revealed aorto-left atrial fistula secondary to the involvement of the mitral-aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aorticvalve replacement, and mitral valve repair. PMID:23931072
The aorticvalve has been described with variable anatomical definitions, and the consistency of 2D manual measurement of valve dimensions in medical image data has been questionable. Given the importance of image-based morphological assessment in the diagnosis and surgical treatment of aorticvalve disease, there is considerable need to develop a standardized framework for 3D valve segmentation and shape representation. Towards this goal, this work integrates template-based medial modeling and multi-atlas label fusion techniques to automatically delineate and quantitatively describe aortic leaflet geometry in 3D echocardiographic (3DE) images, a challenging task that has been explored only to a limited extent. The method makes use of expert knowledge of aortic leaflet image appearance, generates segmentations with consistent topology, and establishes a shape-based coordinate system on the aortic leaflets that enables standardized automated measurements. In this study, the algorithm is evaluated on 11 3DE images of normal human aortic leaflets acquired at mid systole. The clinical relevance of the method is its ability to capture leaflet geometry in 3DE image data with minimal user interaction while producing consistent measurements of 3D aortic leaflet geometry. PMID:24505702
Pouch, Alison M; Wang, Hongzhi; Takabe, Manabu; Jackson, Benjamin M; Sehgal, Chandra M; Gorman, Joseph H; Gorman, Robert C; Yushkevich, Paul A
Recently transcatheter aorticvalve implantation (TAVI) has been offered to selected patients and results have been good. In Europe, for example, TAVI is an established, evidence-based, alternative to open aorticvalve replacement for patients with aortic stenosis in whom conventional cardiac surgery would pose a high risk. Studies in the United States demonstrated that, in patients with severe aortic stenosis who are not candidates for surgery, TAVI using the Edwards SAPIEN valve resulted in significantly lower mortality than standard treatment. However, TAVI was associated with a nonsignificantly higher incidence of stroke and major vascular complications compared to standard aorticvalve replacement. Moreover, when strokes and transient ischemic attacks were considered together, there was a significant benefit in favor of surgery at both 30 days and 1 year (P=.04). Clearly, optimal patient selection is critical for the success of TAVI. In addition, it has been shown that the adoption of a multidisciplinary approach improves outcomes in complex procedures like these. To ensure successful outcomes with TAVI, a multidisciplinary heart valve team must collaborate at all stages of the program: during screening, during and after the procedure, and throughout follow-up. In particular, patients should be screened for inclusion in a TAVI program by a member of the multidisciplinary team, and not by an external individual specialist. Moreover, the selection of candidates for treatment should involve consultation between the different disciplines (i.e. between cardiologists, surgeons, imaging specialists, anesthesiologists, pulmonologist, and other specialists, if necessary). PMID:22921172
Patients with severe aortic stenosis and no obstructed coronary arteries are reported to have reduced coronary flow. Doppler evaluation of proximal coronary flow is feasible using transesophageal echocardiography. The present study aimed to assess the change in coronary flow in patients with severe aortic stenosis undergoing transcatheter aorticvalve implantation (TAVI). The left main coronary artery was visualized using transesophageal echocardiography in 90 patients undergoing TAVI using the Edwards SAPIEN valve. The peak systolic and diastolic velocities of the coronary flow and the time-velocity integral were obtained before and after TAVI using pulse-wave Doppler. Mean aortic gradients decreased from 47.1 ± 15.7 mm Hg before TAVI to 3.6 ± 2.6 mm Hg after TAVI (p <0.001). The aorticvalve area increased from 0.58 ± 0.17 to 1.99 ± 0.35 cm(2) (p <0.001). The cardiac output increased from 3.4 ± 1.1 to 3.8 ± 1.0 L/min (p <0.001). Left ventricular end-diastolic pressure (LVEDP) decreased from 19.8 ± 5.4 to 17.3 ± 4.1 mm Hg (p <0.001). The following coronary flow parameters increased significantly after TAVI: peak systolic velocity 24.2 ± 9.3 to 30.5 ± 14.9 cm/s (p <0.001), peak diastolic velocity 49.8 ± 16.9 to 53.7 ± 22.3 cm/s (p = 0.04), total velocity-time integral 26.7 ± 10.5 to 29.7 ± 14.1 cm (p = 0.002), and systolic velocity-time integral 6.1 ± 3.7 to 7.7 ± 5.0 cm (p = 0.001). Diastolic time-velocity integral increased from 20.6 ± 8.7 to 22.0 ± 10.1 cm (p = 0.04). Total velocity-time integral increased >10% in 43 patients (47.2%). Pearson's correlation coefficient revealed the change in LVEDP as the best correlate of change in coronary flow (R = -0.41, p = 0.003). In conclusion, TAVI resulted in a significant increase in coronary flow. The change in coronary flow was associated mostly with a decrease in LVEDP. PMID:25173443
Ben-Dor, Itsik; Malik, Rahul; Minha, Sa'ar; Goldstein, Steven A; Wang, Zuyue; Magalhaes, Marco A; Weissman, Gaby; Okubagzi, Petros G; Torguson, Rebecca; Lindsay, Joseph; Satler, Lowell F; Pichard, Augusto D; Waksman, Ron
The inability to reposition or retrieve balloon-expandable transcatheter aorticvalves 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 aorticvalve 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
Leaflet skin friction and stiffness were found to have a significant influence on the systolic performance of a 19 mm diameter bioprosthetic aorticvalve based on fluid-structure interaction simulations at a heart rate of 72 bpm. Four different leaflet skin friction coefficients (0.0, 9.2 × 10(-4), 4.8 × 10(-2) and 4.8 × 10(-1)) were simulated along with three different leaflet elastic moduli (3.0 × 10(6), 3.5 × 10(6), 4.0 × 10(6) N m(-2)). Higher leaflet skin friction was found to increase the magnitude of the systolic transvalvular pressure gradient and the peak velocity through the valve, as well as decrease the valve orifice area. The results for the leaflet opening and closing kinematics also showed that higher leaflet skin friction combined with higher leaflet stiffness produces longer rapid valve opening, closing and ejection times, as well as smaller valve orifice areas. These results are consistent with clinical findings for calcified aorticvalves and suggest that valve performance under stenotic conditions is strongly influenced by the combined effect of increasing leaflet stiffness and surface roughness caused by calcification. PMID:24264225
Dellimore, K; Kemp, I; Scheffer, C; Weich, H; Doubell, A
Left ventricular assist devices (LVADs), which pump blood from the left ventricle to the aorta are an important therapy option for patients with end-stage cardiovascular diseases. Recent publications show that even with optimized LVADs fatal complications can occur because of the blood deformations around the inflow cannula or through the LVAD outlet graft-aorta anastomosis. This study investigates the effects of the anastomosis geometry on the flow through the aorta, on the pressure and wall shear stress (WSS) distributions on the aortic wall and on the total entropy generation in the anastomosis region. Anastomosis geometry is defined with two angles, one on the coronal plane and the other on the transversal plane. Turbulent flow simulations are performed for each geometry. Results indicate that 3% to 5% of the work given by the LVAD is dissipated because of the viscous losses in the anastomosis region. The entropy generation, as well as the maximum WSS, increases as the inclination angle decreases. Some portion of the blood streaming out of the LVAD conduit flows toward the aorticvalve; therefore the reverse-flow region extends up to the aorticvalve in some cases, which may be one of the causes of aortic-valve dysfunction. Results of this study provide insight on the importance of the anastomosis geometry on the hemodynamics in the aorta and downstream the aorticvalve, stresses on the aortic wall, and viscous losses. PMID:22739783
Dilation of the wall of the thoracic aorta can be found in patients with a tricuspid (TAV) as well as a bicuspid aorticvalve (BAV) with and without a syndromic component. BAV is the most common congenital cardiovascular malformation, with a population prevalence of 0.5-2 %. The clinical course is often characterised by aneurysm formation and in some cases dissection. The non-dilated aortic wall is less well differentiated in all BAV as compared with TAV, thereby conferring inherent developmental susceptibility. Furthermore, a turbulent flow, caused by the inappropriate opening of the bicuspid valve, could accelerate the degenerative process in the aortic wall. However, not all patients with bicuspidy develop clinical complications during their life. We postulate that the increased vulnerability for aortic complications in a subset of patients with BAV is caused by a defect in the early development of the aorta and aorticvalve. This review discusses histological and molecular genetic aspects of the normal and abnormal development of the aortic wall and semilunar valves. Aortopathy associated with BAV could be the result of a shared developmental defect during embryogenesis. PMID:25074475
Grewal, N; DeRuiter, M C; Jongbloed, M R M; Goumans, M J; Klautz, R J M; Poelmann, R E; Gittenberger-de Groot, A C
Transcatheter aorticvalve implantation (TAVI) was introduced five years ago (2007) as an alternative treatment for patients with severe aortic stenosis, who are considered at too high a risk for surgical replacement. Few cases of postoperative infection by TAVI device are reported in the literature. We report the case of a patient with Osler-Weber-Rendu (OWR) syndrome, in which the TAVI procedure was preferred at the outset to avoid the risk of bleeding. He was diagnosed with endocarditis on the TAVI device one year later; he then underwent an uneventful surgical aorticvalve replacement. In these complex clinical cases it is difficult to determine a 'gold standard' treatment and the possibility of offering patients both the percutaneous treatment and the surgical replacement appears to be desirable. Correction of the valve disease improves the outcome, reducing the episodes of haemorrhage and the need for blood transfusions. PMID:22691380
Transcatheter aorticvalve implantation (TAVI) has been increasingly recognized as a curative treatment for severe aortic stenosis (AS). Despite important improvements in current device technology and implantation techniques, specific complications still remain and warrant consideration. Vascular complications and peri-procedural neurological events were the first concerns to emerge with this new technology. Recently, significant post procedural para-valvular leak has been shown to be more frequent after TAVI than after surgical aorticvalve replacement (SAVR), and its potential association with worse long-term prognostic has raised concerns. In moving toward treatment of lower risk populations, structural integrity and long-term durability of heat valve prosthesis are becoming of central importance. Emerging technologies and newer generations of devices seem promising in dealing with these matters. PMID:22851655
Généreux, Philippe; Head, Stuart J; Wood, David A; Kodali, Susheel K; Williams, Mathew R; Paradis, Jean-Michel; Spaziano, Marco; Kappetein, A Pieter; Webb, John G; Cribier, Alain; Leon, Martin B
Aortic root and sinotubular junction dilatation and aneurysm of ascending aorta are considered relative contra-indications to implantation of a stentless valve prosthesis, because the modified aortic geometry leads to aortic incompetence and early failure of the prosthesis. Aortic root reconstruction can be performed according to various techniques. We present a surgical technique in which a tubular graft, replacing an ascending aortic aneurysm, allows sinotubular remodeling and satisfactory implantation of a stentless prosthesis. The native aorta is inserted into the vascular prosthesis at the level of the sinotubular junction which is wrapped in order to prevent commissure spreading. Sizing of the vascular and valve prosthesis is made according to annular diameter. Since October 1999, 6 patients have been operated using this technique with good results. PMID:11269436
Massetti, M; Bruno, P; Babatasi, G; Le Page, O; Neri, E; Veron, S; Saloux, E; Khayat, A
Aortic stenosis is the most frequent valvular heart disease. The mean systolic value of the transvalvular pressure gradient (TPG) is commonly utilized during clinical examination to evaluate its severity and it can be determined either by cardiac catheterization or by Doppler echocardiography. TPG is highly time-dependent over systole and is known to depend upon the transvalvular flow rate, the effective orifice area (EOA) of the aorticvalve and the cross-sectional area of the ascending aorta. However it is still unclear how these parameters modify the TPG waveform. We thus derived a simple analytical model from the energy loss concept to describe the instantaneous TPG across the aorticvalve during systole. This theoretical model was validated with orifice plates and bioprosthetic heart valves in an in vitro aortic flow model. Instantaneous TPG was measured by catheter and its waveform was compared with the one determined from the transvalvular flow rate, the valvular EOA and the aortic cross-sectional area, using the derived equation. Our results showed a very good concordance between the measured and predicted instantaneous TPG. The analytical model proposed and validated in this study provides a comprehensive description of the aorticvalve hemodynamics that can be used to accurately predict the instantaneous transvalvular pressure gradient in native and bioprosthetic aorticvalves. The consideration of this model suggests that: (1) TPG waveform is exclusively dependent upon transvalvular flow rate and flow geometry, (2) the frequently applied simplified Bernoulli equation may overestimate mean TPG by more than 30% and (3) the measurement of ejection time by cardiac catheterization may underestimate the actual ejection time, especially in patients with mild/moderate aortic stenosis and low cardiac output. PMID:15863115
Transapical aorticvalve replacement is an established technique performed in high-risk patients with symptomatic aorticvalve 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 aorticvalve 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
Purpose. To evaluate the feasibility of one-step implantation of a new type of stent-based mechanical aortic disc valve prosthesis (MADVP) above and across the native aorticvalve and its short-term function in swine with both functional and dysfunctional native valves. Methods. The MADVP consisted of a folding disc valve made of silicone elastomer attached to either a nitinol Z-stent (Z model) or a nitinol cross-braided stent (SX model). Implantation of 10 MADVPs (6 Z and 4 SX models) was attempted in 10 swine: 4 (2 Z and 2 SX models) with a functional native valve and 6 (4 Z and 2 SX models) with aortic regurgitation induced either by intentional valve injury or by MADVP placement across the native valve. MADVP function was observed for up to 3 hr after implantation. Results. MADVP implantation was successful in 9 swine. One animal died of induced massive regurgitation prior to implantation. Four MADVPs implanted above functioning native valves exhibited good function. In 5 swine with regurgitation, MADVP implantation corrected the induced native valve dysfunction and the device's continuous good function was observed in 4 animals. One MADVP (SX model) placed across native valve gradually migrated into the left ventricle. Conclusion. The tested MADVP can be implanted above and across the native valve in a one-step procedure and can replace the function of the regurgitating native valve. Further technical development and testing are warranted, preferably with a manufactured MADVP.
Sochman, Jan [Institute for Clinical and Experimental Medicine, Intensive Care Unit, Clinic of Cardiology (Czech Republic)], E-mail: email@example.com; Peregrin, Jan H.; Rocek, Miloslav [Institute for Clinical and Experimental Medicine, Department of Diagnostic and Interventional Radiology (Czech Republic); Timmermans, Hans A.; Pavcnik, Dusan; Roesch, Josef [Oregon Health and Sciences University, Dotter Interventional Institute (United States)
An improved plug valve wherein a novel shape for the valve plug and valve chamber provide mating surfaces for improved wear characteristics. The novel shape of the valve plug is a frustum of a body of revolution of a curved known as a tractrix, a solid shape otherwise known as a peudosphere.
OBJECTIVETo evaluate changes in left ventricular function and the impact of ventricular hypertrophy and pressure gradient early and late after aorticvalve replacement in patients with isolated aortic stenosis.DESIGN41 patients with isolated aortic stenosis and normal systolic function underwent cross sectional and Doppler echocardiography two months before and two weeks and four years after aorticvalve replacement.RESULTSEarly after the operation,
I Ikonomidis; A Tsoukas; F Parthenakis; A Gournizakis; A Kassimatis; L Rallidis; P Nihoyannopoulos
Aorticvalve disease (AVD) and aortopathy are associated with substantial morbidity and mortality, representing a significant cardiovascular healthcare burden worldwide. These mechanobiological structures are morphogenetically related and function in unison from embryonic development through mature adult tissue homeostasis, serving both coordinated and distinct roles. In addition to sharing common developmental origins, diseases of the aorticvalve and proximal thoracic aorta often present together clinically. Current research efforts are focused on identifying etiologic factors and elucidating pathogenesis, including genetic predisposition, maladaptive cell-matrix remodeling processes, and hemodynamic and biomechanical perturbations. Here, we review the impact of these processes as they pertain to translational research efforts, emphasizing the overlapping relationship of these two disease processes. The successful application of new therapeutic strategies and novel tissue bioprostheses for AVD and/or aortopathy will require an understanding and integration of molecular and biomechanical processes for both diseases. PMID:25410134
Krishnamurthy, Varun K; Godby, Richard C; Liu, G R; Smith, J Michael; Hiratzka, Loren F; Narmoneva, Daria A; Hinton, Robert B
Bicuspid aorticvalve (BAV) is the most common adult congenital heart defect and is found in 0.5% to 2.0% of the general population. The term "BAV" refers to a heterogeneous group of disorders characterized by diverse aorticvalve malformations with associated aortopathy, congenital heart defects, and genetic syndromes. Even after decades of investigation, the genetic determinants of BAV and its complications remain largely undefined. Just as BAV phenotypes are highly variable, the genetic etiologies of BAV are equally diverse and vary from complex inheritance in families to sporadic cases without any evidence of inheritance. In this paper, the authors discuss current concepts in BAV genetics and propose a roadmap for unraveling unanswered questions about BAV through the integrated analysis of genetic and clinical data. PMID:25145529
Prakash, Siddharth K; Bossé, Yohan; Muehlschlegel, Jochen D; Michelena, Hector I; Limongelli, Giuseppe; Della Corte, Alessandro; Pluchinotta, Francesca R; Russo, Maria Giovanna; Evangelista, Artur; Benson, D Woodrow; Body, Simon C; Milewicz, Dianna M
This paper presents a novel numerical method for simulating the fluid-structure interaction (FSI) problems when blood flows over aorticvalves. The method uses the immersed boundary/element method and the smoothed finite element method and hence it is termed as IS-FEM. The IS-FEM is a partitioned approach and does not need a body-fitted mesh for FSI simulations. It consists of three main modules: the fluid solver, the solid solver and the FSI force solver. In this work, the blood is modeled as incompressible viscous flow and solved using the characteristic-based-split scheme with FEM for spacial discretization. The leaflets of the aorticvalve are modeled as Mooney-Rivlin hyperelastic materials and solved using smoothed finite element method (or S-FEM). The FSI force is calculated on the Lagrangian fictitious fluid mesh that is identical to the moving solid mesh. The octree search and neighbor-to-neighbor schemes are used to detect efficiently the FSI pairs of fluid and solid cells. As an example, a 3D idealized model of aorticvalve is modeled, and the opening process of the valve is simulated using the proposed IS-FEM. Numerical results indicate that the IS-FEM can serve as an efficient tool in the study of aorticvalve dynamics to reveal the details of stresses in the aorticvalves, the flow velocities in the blood, and the shear forces on the interfaces. This tool can also be applied to animal models studying disease processes and may ultimately translate to a new adaptive methods working with magnetic resonance images, leading to improvements on diagnostic and prognostic paradigms, as well as surgical planning, in the care of patients.
Yao, Jianyao; Liu, G. R.; Narmoneva, Daria A.; Hinton, Robert B.; Zhang, Zhi-Qian
Patients with aortic stenosis present with calcium deposits on the native aorticvalve, which can result in non-concentric expansion of Transcatheter AorticValve 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
In Europe and North America, aortic stenosis (AS) is the most frequent valvular heart disease and cardiovascular disease after systemic hypertension and coronary artery disease. Understanding blood flow through an aortic stenosis and developing new accurate non-invasive diagnostic parameters is, therefore, of primarily importance. However, simulating such flows is highly challenging. In this study, we considered the interaction between blood flow and the valve leaflets and compared the results obtained in healthy valves with stenotic ones. One effective method to model the interaction between the fluid and the structure is to use Arbitrary Lagrangian-Eulerian (ALE) approach. Our two-dimensional model includes appropriate nonlinear and anisotropic materials. It is loaded during the systolic phase by applying pressure curves to the fluid domain at the inflow. For modeling the calcified stenotic valve, calcium will be added on the aortic side of valve leaflets. Such simulations allow us to determine the effective orifice area of the valve, one of the main parameters used clinically to evaluate the severity of an AS, and to correlate it with changes in the structure of the leaflets.
Maleki, Hoda; Labrosse, Michel R.; Durand, Louis-Gilles; Kadem, Lyes
Autoimmune hemolytic anemia and deficiency of glucose-6-phosphate deyhdrogenase (G6PD) result in severe hemolysis with different mechanisms. In patients with both pathologies, the effects of cardiopulmonary bypass on red blood cells and thrombocytes demand special care before and after open heart surgery. We evaluated the preoperative management and postoperative care of a patient with severe aortic insufficiency associated with G6PD deficiency and autoimmune hemolytic anemia who underwent aorticvalve replacement. PMID:15985145
Tas, Serpil; Donmez, Arzu Antal; Kirali, Kaan; Alp, Mete H; Yakut, Cevat
Saccular aortic aneurysm arising in the ductal region, known as ductus diverticulum aneurysm, is a rare anomaly. Due to potentially malignant evolution, recognition of radiological signs associated with this anomaly during the asymptomatic phase may be important in order to plan surgical intervention in time. We report an unusual case of ductus diverticulum aneurysm combined with bicuspid aorticvalve, dilatation of ascending aorta, and coronary artery disease. PMID:9201123
Sagic, D; Miric, M; Popovic, Z; Grujicic, S; Bojic, M
A check valve for use in a GDCS of a nuclear reactor and having a motor driven disk including a rotatable armature for rotating the check valve disk over its entire range of motion is described. In one embodiment, the check valve includes a valve body having a coolant flow channel extending therethrough. The coolant flow channel includes an inlet end and an outlet end. A valve body seat is located on an inner surface of the valve body. The check valve further includes a disk assembly, sometimes referred to as the motor driven disc, having a counterweight and a disk shaped valve. The disk valve includes a disk base having a seat for seating with the valve body seat. The disk assembly further includes a first hinge pin member which extends at least partially through the disk assembly and is engaged to the disk. The disk valve is rotatable relative to the first hinge pin member. The check valve also includes a motor having a stator frame with a stator bore therein. An armature is rotatably positioned within the stator bore and the armature is coupled to the disk valve to cause the disk valve to rotate about its full range of motion. 5 figs.
A check valve for use in a GDCS of a nuclear reactor and having a motor driven disk including a rotatable armature for rotating the check valve disk over its entire range of motion is described. In one embodiment, the check valve includes a valve body having a coolant flow channel extending therethrough. The coolant flow channel includes an inlet end and an outlet end. A valve body seat is located on an inner surface of the valve body. The check valve further includes a disk assembly, sometimes referred to as the motor driven disc, having a counterweight and a disk shaped valve. The disk valve includes a disk base having a seat for seating with the valve body seat. The disk assembly further includes a first hinge pin member which extends at least partially through the disk assembly and is engaged to the disk. The disk valve is rotatable relative to the first hinge pin member. The check valve also includes a motor having a stator frame with a stator bore therein. An armature is rotatably positioned within the stator bore and the armature is coupled to the disk valve to cause the disk valve to rotate about its full range of motion.
Upton, Hubert Allen (Morgan Hill, CA); Garcia, Pablo (Stanford, CA)
Transcatheter aorticvalve implantation (TAVI) is evolving rapidly as a therapeutic option in patients deemed to be at high risk for surgical aorticvalve replacement. Early outcome and survival of controlled feasibility trials and single- center experience with TAVI have been previously reported. Valve performance and hemodynamics seem to improve significantly after TAVI. Long-term outcome up to 3 years have been demonstrated in recent studies. Admittedly, the results are encouraging with a survival rate at 2 and 3 years ranging from 62 to 74% and from 56 to 61% respectively. The improvement in hemodynamical and clinical status sustained beyond the 3 years follows up. However, paravalvular leakage after TAVI remains an important issue in this rapidely evolving field. PMID:24313645
Elhmidi, Y.; Bleiziffer, S.; Piazza, N.; Voss, B.; Krane, M.; Deutsch, M-A.; Lange, R.
BackgroundThe availability of an ideal prosthesis for aorticvalve replacement (AVR) in children remains controversial due to an early degeneration of xenografts and the potential risks related to anticoagulation with mechanical prostheses. This has led many surgeons to the Ross procedure. This study outlines the evolution of our 30-year experience with AVR in children.
Mark Ruzmetov; Palaniswamy Vijay; Mark D. Rodefeld; Mark W. Turrentine; John W. Brown
Degenerative aortic stenosis has become a common and dangerous disease in recent decades. This disease leads to the mineralization of aorticvalves, 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 aorticvalve, 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 aorticvalves and in other parts of the human bodies, associated with the formation of bones.
Mitral valve prolapse was sought clinically and with phonocardiography and M mode and sector echocardiography in 15 women aged 22-57 years with joint hypermobility syndrome. The type III:III + I collagen ratio was measured in skin biopsy specimens and was found to be raised in seven of 10 patients sampled. Thirteen patients had increased aortic wall compliance measured by the
To optimize the mechanical properties and integrity of tissue-engineered aortic heart valves, it is necessary to gain insight into the effects of mechanical stimuli on the me- chanical behavior of the tissue using mathematical models. In this study, a finite-element (FE) model is presented to relate changes in collagen fiber content and orientation to the mechanical loading condition within the
Niels J. B. Driessen; Ralf A. Boerboom; Jacques M. Huyghe; Carlijn V. C. Bouten; Frank P. T. Baaijens
Hemodynamic instability during transcatheter aorticvalve replacement procedures may require transient cardiopulmonary bypass for support. In patients with severe atherosclerosis, peripheral cannulation may not be possible. This method of direct left ventricle cannulation during transapical TAVR is a facile means to provide arterial inflow. PMID:25282226
Brinster, Derek R; Patel, Jay A; McCarthy, Harry L; Aron, Ty M; Gertz, Zachary M
Background. Individuals with bicuspid aorticvalve tend to develop a dilatation of the ascending aorta. It is controversial whether the dilated ascending aorta should be replaced with a tube graft or whether the diameter of the aorta should be reduced by reduction aortoplasty. Furthermore, it is unclear whether an external prosthetic support of the reduction aortoplasty is necessary. The aim
Matthias Bauer; Miralem Pasic; Raymond Schaffarzyk; Henryk Siniawski; Friedrich Knollmann; Rudolf Meyer; Roland Hetzer
Published reports of aorto–left atrial fistula are very rare. We report a 20-year-old man who had an aorto–left atrial fistula with bicuspid aorticvalve and coronary artery origin anomaly. Because acquired etiologic factors were not detected, we believe that the lesions were structural defects of congenital origin.
Mehmet ?ah Topcuo?lu; Mustafa ?an; Cem Kayhan; Tümer Ulus
A severely dysfunctioning congenitally bicuspid aorticvalve may require surgical treatment within the fourth decade of life. Among conventional options, the pulmonary autograft (PA) offers many theoretical advantages particularly for young patients, including potential for growth, hemodynamic performance, no need for anticoagulants and freedom from endocarditis. However the operation is more complex and longer, may interfere with coronary and right
Francesco Santini; Giuseppe Gatti; Antonia Prioli; Alessandro Mazzucco
We experienced three cases with anomalous right coronary arteries during aorticvalve surgery. By rotating a Freestyle bioprosthesis by a subcoronary technique, the anomalous artery was secured in one patient. The anomalous artery was injured during the routine aortotomy incision in another patient; a saphenous vein graft was interposed between the ascending aorta and the separated artery. In the third
This study was designed to compare the mid-term outcomes after aorticvalve replacement (AVR) between 17-mm mechanical heart valves (MV) and 19-mm bioprosthetic valves (BV) in elderly patients with small aortic annuli. Between 2000 and 2011, 127 consecutive patients (mean age 79 years; 87 % female) underwent AVR for aorticvalve stenosis with a small aortic annulus. 19-mm BV (n = 67) was implanted. When the 19-mm BV did not fit the annulus, 17-mm St. Jude Medical Regent prosthetic mechanical valve (n = 60) was used instead of an aortic root-enlargement procedure. The follow-up rate was 94.0 % in the BV group, and 98.5 % in the MV group. No significant differences in survival rate and valve-related complications were found between the 2 groups. In-hospital mortality rates were 1.5 % (n = 1) in the BV group and 5.0 % (n = 3) in the MV group. Late mortality rates were 3.9 % per patient-years (p-y; n = 8) in the BV group, and 6.0 % per p-y (n = 10) in the MV group. Five-year Kaplan-Meier survival rates were 62 % in the BV group, and 72 % in the MV group (log-rank P = 0.280). Freedom from major adverse valve-related stroke and cerebral bleeding events was 92.5 and 98.5 % in the BV group, and 94.7 and 100 % in the MV group. AVR using 17-mm MV in elder patients with small aortic annuli provided equivalent mid-term clinical results to that with 19-mm BV. PMID:24878870
As a result of recent randomised controlled trials and registry observations, transcatheter aorticvalve replacement (TAVR) enjoys growing appeal for the treatment of patients at high or extreme risk from surgical aorticvalve replacement. However, the current technologies and techniques have important limitations, including risk of stroke, vascular complications and paravalvular aortic regurgitation, which may in turn influence survival. While careful patient selection and screening may improve outcomes, new valve designs and iterations are required. The Lotus aorticvalve replacement system is a new fully repositionable device designed to facilitate more precise delivery and minimise paravalvular regurgitation. The safety and efficacy of the Lotus valve are being studied systematically in the REPRISE clinical trial programme. PMID:22995115
Meredith, Ian T; Hood, Kristin L; Haratani, Nicole; Allocco, Dominic J; Dawkins, Keith D
... a more common problem. As we age, our heart valves can become lined with calcium deposits that cause the valve flaps to thicken and become stiffer. ... increase a persons’ risk for sudden death or cause rapid development of problems in ... like a bicuspid aorticvalve, mitral valve prolapse or a mild form of ...
Transcatheter aorticvalve 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
Studies in vitro and in vivo continue to identify complex regulated mechanisms leading to overt fibrocalcific aorticvalve disease (FCAVD). Assessment of the functional impact of those processes requires careful studies of models of FCAVD in vivo. Although the genetic basis for FCVAD is unknown for most patients with FCAVD, several disease-associated genes have been identified in humans and mice. Some gene products which regulate valve development in utero also protect against fibro-calcific disease during postnatal aging. Valve calcification can occur via processes that resemble bone formation. But valve calcification can also occur by non-osteogenic mechanisms, such as formation of calcific apoptotic nodules. Anti-calcific interventions might preferentially target either osteogenic or non-osteogenic calcification. Although FCAVD and atherosclerosis share several risk factors and mechanisms, there are fundamental differences between arteries and the aorticvalve, with respect to disease mechanisms and responses to therapeutic interventions. Both innate and acquired immunity are likely to contribute to FCAVD. Angiogenesis is a feature of inflammation, but may also contribute independently to progression of FCAVD, possibly by actions of pericytes that are associated with new blood vessels. Several therapeutic interventions appear to be effective in attenuating development of FCAVD in mice. Therapies which are effective early in the course of FCAVD, however, are not necessarily effective in established disease. PMID:23833295
Weiss, Robert M.; Miller, Jordan D.; Heistad, Donald D.
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 aorticvalve 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 aorticvalve 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 aorticvalve: 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
A 63-year-old woman with a previous episode of Streptococcus agalactiae endocarditis requiring a bioprosthetic aorticvalve replacement presented with a short history of malaise, a right panopthalmitis with a Roth spot on funduscopy of the left eye and Streptococcus pneumoniae grown from vitreous and aqueous taps as well as blood cultures. She developed first degree heart block and her ECG was suggestive of an aortic root abscess. This gradually resolved over 6 weeks, during which she was treated with intravenous antibiotics. After careful consideration, it is likely that what was thought to be an aortic root abscess was instead an area of perivalvular inflammation. PMID:22678733
Cardiac magnetic resonance imaging (CMR) demonstrated a sinus of Valsalva aneurysm (SVA) with severe dilatation of the right coronary sinus in association with a congenital bicuspid aorticvalve (BAV) and sub-aortic membrane. The SVA had not been apparent on echocardiography as the dilatation was outside standard echo image planes. On both CMR and echo, blood flow was eccentrically directed into the right coronary sinus by the domed posterior leaflet of the BAV. The impact of the aortic jet on the wall of the right coronary sinus is probably important in the aetiology of the sinus dilatation. CMR proved valuable in demonstrating the SVA and understanding its aetiology. PMID:24765333
An internally piloted shut-off valve is described for use with cryogenic fluids incorporates a short valve housing with normally closed valve closure means incorporated therein and fluid passages with ports for fluid flow therethrough including an elongated extended stem protruding therefrom on top of which a solenoid operator is received in the stem end opening so as to define a
Background Before trans-catheter aorticvalve 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 aorticvalve measurements and left ventricular function in high-risk elderly patients submitted to TAVI. Methods Consecutive patients with severe aortic stenosis and contraindications for surgical aorticvalve 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 aorticvalve 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. PMID:22202669
A fast valve is disclosed that can close on the order of 7 milliseconds. It is closed by the force of a compressed air spring with the moving parts of the valve designed to be of very light weight and the valve gate being of wedge shaped with O-ring sealed faces to provide sealing contact without metal to metal contact. The combination of the O-ring seal and an air cushion create a soft final movement of the valve closure to prevent the fast air acting valve from having a harsh closing. 4 figs.
We report a case of a staged surgical and endovascular management in a 62-year-old woman with aortic coarctation associated with aorticvalve stenosis and mitral regurgitation. The patient was admitted for severe aorticvalve 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
Bicuspid AorticValve (BAV) is a highly heritable congenital heart defect. The low frequency of BAV (1% of general population) limits our ability to perform genome-wide association studies. We present the application of ...
Up to 80% of patients with coarctation of the aorta (COA) have a bicuspid aorticvalve (BAV). Patients with COA and BAV have elevated risks of aortic complications despite successful surgical repair. The development of such complications involves the interplay between the mechanical forces applied on the artery and the biological processes occurring at the cellular level. The focus of this study is on hemodynamic modifications induced in the aorta in the presence of a COA and a BAV. For this purpose, numerical investigations and magnetic resonance imaging measurements were conducted with different configurations: (1) normal: normal aorta and normal aorticvalve; (2) isolated COA: aorta with COA (75% reduction by area) and normal aorticvalve; (3) complex COA: aorta with the same severity of COA (75% reduction by area) and BAV. The results show that the coexistence of COA and BAV significantly alters blood flow in the aorta with a significant increase in the maximal velocity, secondary flow, pressure loss, time-averaged wall shear stress and oscillatory shear index downstream of the COA. These findings can contribute to a better understanding of why patients with complex COA have adverse outcome even following a successful surgery. PMID:24015239
Background AorticValve Replacement (AVR) is usually done through median sternotomy. The present study aimed to compare the right anterolateral thoracotomy and median sternotomy approaches for AVR. Materials and Methods The present prospective study was conducted on 60 patients who had aorticvalve disease and were subjected to AVR. Thirty patients underwent aorticvalve replacement via right anterolateral thoracotomy (study group) and thirty patients via median sternotomy (control group). Statistical analysis was done using Mann Whitney U test and Fischer’s Exact test. Statistical Package SPSS 17 was used for data analysis. Results The mean length of the incision was 18.7±1.8 cm in the patients who had undergone AVR through median sternotomy, while 7.8±0.9 cm in the study group patients. Besides, the mean bypass time was 121.8±18.6 minutes for the patients who had undergone AVR through median sternotomy, while 122.1±20.8 minutes for the study group. In addition, the mean aortic cross clamp time was 67.7±13.4 minutes for the patients who had undergone AVR through median sternotomy, while 68.0±8.9 minutes for the study group. The mean operating time was 181.6±31.5 minutes for the patients who had undergone AVR through median sternotomy, while 190.8±29.8 minutes for the study group. Patient satisfaction with respect to cosmesis was higher in the study group. Only 50% of the patients who had undergone AVR through median sternotomy in comparison to 73.3% of those in the study group were satisfied with the cosmesis. Conclusions The right anterolateral thoracotomy approach for aorticvalve replacement proved to be easy to perform whilst maintaining the maximum security for the patients. Besides its better cosmetic result especially in female patients, this approach proved to have several advantages. PMID:24757629
Ahangar, Abdul Gani; Charag, Aakib Hamid; Wani, Mohd Lateef; Ganie, Farooq Ahmad; Singh, Shyam; Ahmad Qadri, Syed Asrar; Ahmad Shah, Zameer
We tested the hypothesis that the disproportionate increase of body surface area in obesity may lead to the overestimation of aortic stenosis (AS) severity when the aorticvalve area (AVA) is indexed (AVAI) for body surface area in 1,524 patients enrolled in the Simvastatin and Ezetimibe in AS study. Obesity was defined as a body mass index of ?30 kg/m(2). Peak aortic jet velocity, mean aortic gradient, AVA, and energy loss (EL) did not differ, although AVAI and EL indexed (ELI) for body surface area were significantly smaller in the obese group (n = 321) compared with the nonobese (n = 1,203) group (both p <0.05). Severe AS by AVAI (<0.6 cm(2)/m(2)) but nonsevere by AVA (>1.0 cm(2); AVAI/AVA discordance) was found in 15% of the patients, whereas severe AS by ELI (<0.6 cm(2)/m(2)) but nonsevere by EL (>1.0 cm(2); ELI/EL discordance) was found in 9% of the patients. Obesity was associated with a 2.4-fold higher prevalence of AVAI/AVA discordance and a 1.6-fold higher prevalence of ELI/EL discordance. Discordant grading was also associated with male gender, larger body size, higher mean aortic gradient, and stroke volume (all p <0.05). During a median follow-up of 4.3 years, 419 patients were referred for aorticvalve replacement and 177 patients died or were hospitalized because of heart failure. In the Cox regression analyses, AVAI/AVA discordance was associated with a 28% higher rate of aorticvalve replacement (p <0.05) but did not predict the rate of combined death and hospitalization for heart failure. In conclusion, using AVAI and ELI for the grading of stenosis in patients with obesity may lead to overestimation of true AS severity. PMID:24630788
Rogge, Barbara P; Gerdts, Eva; Cramariuc, Dana; Bahlmann, Edda; Jander, Nikolaus; Gohlke-Bärwolf, Christa; Pedersen, Terje R; Lønnebakken, Mai Tone
Acute kidney injury (AKI) is associated with a poor prognosis after transcatheter aorticvalve replacement (TAVR). A paucity of data exists regarding the incidence and effect of AKI after TAVR using the new recommended Valve Academic Research Consortium criteria. At Columbia University Medical Center, 218 TAVR procedures (64.2% transfemoral, 35.8% transapical) were performed from 2008 to July 2011. The creatinine level was evaluated daily until discharge. Using the Valve Academic Research Consortium definitions, the 30-day and 1-year outcomes were compared between patients with significant AKI (AKI stage 2 or 3) and those without significant AKI (AKI stage 0 or 1). Significant AKI occurred in 18 patients (8.3%). Of these 18 patients, 10 (55.6%) had AKI stage 3 and 9 (50%) required dialysis. AKI was associated with a lower baseline mean transvalvular gradient (37.6 ± 11.4 vs 45.6 ± 14.8 mm Hg for no AKI, p = 0.03). After TAVR, the AKI group had a greater hemoglobin decrease (3.6 ± 2.0 vs 2.4 ± 1.3 g/dl, p = 0.01), greater white blood cell elevation at 72 hours (21.09 ± 12.99 vs 13.18 ± 4.82 × 103/?l, p = 0.001), a more severe platelet decrease (118 ± 40 vs 75 ± 43 × 103/?l, p <0.0001), and longer hospitalization (10.7 ± 6.4 vs 7.7 ± 8.5 days, p <0.001). One stroke (5.6%) occurred in the AKI group compared with 3 (1.5%) in the group without AKI (p = 0.29). The 30-day and 1-year rates of death were significantly greater in the AKI group than in the no-AKI group (44.4% vs 3.0%, hazard ratio 18.1, 95% confidence interval 6.25 to 52.20, p <0.0001; and 55.6% vs 16.0%, hazard ratio 6.32, 95% confidence interval 3.06 to 13.10, p <0.0001, respectively). Periprocedural life-threatening bleeding was the strongest predictor of AKI after TAVR. In conclusion, the occurrence of AKI, as defined by the Valve Academic Research Consortium criteria, is associated with periprocedural complications and a poor prognosis after TAVR. PMID:23040657
Genereux, Philippe; Kodali, Susheel K.; Green, Philip; Paradis, Jean-Michel; Daneault, Benoit; Rene, Garvey; Hueter, Irene; Georges, Isaac; Kirtane, Ajay; Hahn, Rebecca T.; Smith, Craig; Leon, Martin B.; Williams, Mathew R.
Ascending aortic aneurysm (AsAA) is a consequence of medial degeneration (MD), deriving from apoptotic loss of smooth muscle cells (SMC) and fragmentation of elastin and collagen fibers. Alterations of extracellular matrix structure and protein composition, typical of medial degeneration, can modulate intracellular pathways. In this study we examined the relevance of extracellular superoxide dismutase (SOD3) and Akt in AsAA pathogenesis, evaluating their tissue distribution and protein levels in ascending aortic tissues from controls (n=6), patients affected by AsAA associated to tricuspid aorticvalve (TAV, n=9) or bicuspid aorticvalve (BAV, n=9). The results showed a significant reduction of SOD3, phospho-Akt and Akt protein levels in AsAA tissues from patients with BAV, compared to controls, whereas the differences observed between controls and patients with TAV were not significant. The decreased levels of SOD3 and Akt in BAV aortic tissues are associated with decreased Erk1/Erk2 phosphorylation and MMP-9 levels increase. The authors suggest a role of decreased SOD3 protein levels in the progression of AsAA with BAV and a link between ECM modifications of aortic media layer and impaired Erk1/Erk2 and Akt signaling in the late stages of the aortopathy associated with BAV.
Arcucci, A.; Ruocco, M.R.; Albano, F.; Granato, G.; Romano, V.; Corso, G.; Bancone, C.; De Vendittis, E.; Corte, A. Della
Ascending aortic aneurysm (AsAA) is a consequence of medial degeneration (MD), deriving from apoptotic loss of smooth muscle cells (SMC) and fragmentation of elastin and collagen fibers. Alterations of extracellular matrix structure and protein composition, typical of medial degeneration, can modulate intracellular pathways. In this study we examined the relevance of superoxide dismutase (SOD3) and Akt in AsAA pathogenesis, evaluating their tissue distribution and protein levels in ascending aortic tissues from controls (n=6), patients affected by AsAA associated to tricuspid aorticvalve (TAV, n=9) or bicuspid aorticvalve (BAV, n=9). The results showed a significant reduction of SOD3, phospho-Akt and Akt protein levels in AsAA tissues from patients with BAV, compared to controls, whereas the differences observed between controls and patients with TAV were not significant. The decreased levels of SOD3 and Akt in BAV aortic tissues are associated with decreased Erk1/Erk2 phosphorylation and MMP-9 levels increase. The authors suggest a role of decreased SOD3 protein levels in the progression of AsAA with BAV and a link between ECM modifications of aortic media layer and impaired Erk1/Erk2 and Akt signaling in the late stages of the aortopathy associated with BAV. PMID:25308842
Arcucci, A; Ruocco, M R; Albano, F; Granato, G; Romano, V; Corso, G; Bancone, C; De Vendittis, E; Della Corte, A; Montagnani, S
The M-mode echocardiogram is considered a satisfactory diagnostic tool for the determination of the presence of a bicuspid aorticvalve. M-mode echocardiographic failure to determine this condition is occasionally encoun tered and has been suggested to be due to the anatomic configuration wherein the two aorticvalve leaflets are nearly equal in size. By employing a specific angiographic study (orifice-view
The bicuspid aorticvalve (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
We report a case series of three patients with periaortic hematomas following transcatheter aorticvalve replacement (TAVR). The TAVRs were performed by either trans-apical or transfemoral approach. An intraprocedural transesophageal echocardiogram (TEE) was performed in all patients. Clinical features of all three cases included advanced age, female gender, and small body weight. In addition, the following characteristics were present in all cases: presence of bulky calcification of the noncoronary cusp (NCC) of the aorticvalve, mismatch between the annulus and device diameter, and severe intraprocedural hypertension immediately following TAVR. These characteristics may be potential causative factors. Early recognition of this complication by intra-procedural TEE was integral to the initiation of rapid and appropriate therapy, resulting in a favorable outcome. Herein, we present possible theories for the occurrence of this rare complication. PMID:21805578
Généreux, Philippe; Reiss, George R; Kodali, Susheel K; Williams, Mathew R; Hahn, Rebecca T
The type-I bicuspid aorticvalve (BAV), which differs from the normal tricuspid aorticvalve (TAV) most commonly by left-right coronary cusp fusion, is frequently associated with secondary aortopathies. While BAV aortic dilation has been linked to a genetic predisposition, hemodynamics has emerged as a potential alternate etiology. However, the link between BAV hemodynamics and aortic medial degeneration has not been established. The objective of this study was to compare the regional wall shear stresses (WSS) in a TAV and BAV ascending aorta (AA) and to isolate ex vivo their respective impact on aortic wall remodeling. The WSS environments generated in the convex region of a TAV and BAV AA were predicted through fluid-structure interaction (FSI) simulations in an aorta model subjected to both valvular flows. Remodeling of porcine aortic tissue exposed to TAV and BAV AA WSS for 48 h in a cone-and-plate bioreactor was investigated via immunostaining, immunoblotting and zymography. FSI simulations revealed the existence of larger and more unidirectional WSS in the BAV than in the TAV AA convexity. Exposure of normal aortic tissue to BAV AA WSS resulted in increased MMP-2 and MMP-9 expressions and MMP-2 activity but similar fibrillin-1 content and microfibril organization relative to the TAV AA WSS treatment. This study confirms the sensitivity of aortic tissue to WSS abnormalities and demonstrates the susceptibility of BAV hemodynamic stresses to focally mediate aortic medial degradation. The results provide compelling support to the important role of hemodynamics in BAV secondary aortopathy. PMID:24599392
Atkins, Samantha K; Cao, Kai; Rajamannan, Nalini M; Sucosky, Philippe
Success of the deployment and function in transcatheter aorticvalve replacement is heavily reliant on the tissue-stent interaction. The present study quantified important tissue-stent contact variables of self-expanding transcatheter aorticvalve 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 60 N 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. PMID:23161165
Success of the deployment and function in transcatheter aorticvalve replacement (TAVR) is heavily reliant on the tissue-stent interaction. The present study quantified important tissue-stent contact variables of self-expanding transcatheter aorticvalve (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. PMID:23161165
A 73-year-old man with a severely stenosed bicuspid valve and an aneurysm of the ascending aorta underwent valve and aortic surgery. Preoperative imaging revealed a single coronary artery arising from the right side of the sinus of Valsalva and a branch that perfused into the left side of the heart to pass through the front of the pulmonary artery. We replaced the aorticvalve and ascending aorta, painstakingly avoiding damage to the coronary artery and obstruction of the sole coronary ostium. PMID:23624612
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 aorticvalve (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
Aims Renal failure is associated with aorticvalve calcification (AVC). Our aim was to develop an animal model for exploring the pathophysiology and reversibility of AVC, utilizing rats with diet-induced kidney disease. Methods and results Sprague-Dawley rats (n ¼ 23) were fed a phosphate-enriched, uraemia-inducing diet for 7 weeks followed by a normal diet for 2 weeks ('diet group'). These
Mony Shuvy; Suzan Abedat; Ronen Beeri; Haim D. Danenberg; David Planer; Iddo Z. Ben-Dov; Karen Meir; Jacob Sosna; Chaim Lotan
Objectives. This study sought to determine the rate of familial occurrence of congenital bicuspid aorticvalve (BAV) by using echocardiography to screen family members.Background. Congenital BAV is a common anomaly that carries with it a significant risk of potential long-term cardiac complications. Despite several reports of the familial occurrence of BAV, the condition is not generally considered to be inherited.Methods.
Katrina Huntington; Alasdair G. W Hunter; Kwan-Leung Chan
Introduction A 41-year-old Cuban man with Down syndrome and mental retardation was brought to the Emergency Department for episodes of\\u000a worsening shortness of breath over one day. Bedside color Doppler ultrasound subcostal and apical four-chamber examination\\u000a of the heart revealed atrial and ventricular septal defects with left-to-right shunting of blood. A right ventricular outflow\\u000a tract view revealed a bicuspid aorticvalve,
David C. RileyInho; Inho Kim; Dana Sacco; Tony Rosen
Predictors of aortic dilatation are not well described in patients with bicuspid aorticvalves (BAV). This study sought to\\u000a examine the relationship between proximal aortic dilatation and matrix metalloproteinase-9 (MMP-9) and alpha 1-antitrypsin\\u000a (?1AT) levels in patients with BAV. All patients underwent echocardiography using a standard protocol, and aortic measurements\\u000a were taken in end-diastole. We studied 82 patients with BAV
Kadriye Orta Kilickesmez; Okay Abaci; Cuneyt KocasAhmet YildizAysem Kaya; Ahmet Yildiz; Aysem Kaya; Baris Okcun; Serdar Kucukoglu
Objective: Bicuspid aorticvalve disease is often associated with dilation of the aortic root and ascending aorta. This study examines the histologic features of the ascending aorta and main pulmonary artery of patients with and without aorticvalve disease. Methods: Samples from ascending aorta and main pulmonary artery were obtained at the time of the operation from 20 patients with
Mauro de Sa; Yaron Moshkovitz; Jagdish Butany; Tirone E. David
Isolated spontaneous dissection of celiac trunk is a rare entity. The spontaneous dissection of the visceral artery occurs without aortic dissection. The most consistent presenting symptom is acute onset abdominal pain. Complications consist of ischemia, aneurysm formation, and rupture. We report an exceptional case of an isolated spontaneous dissection of the celiac trunk which occurred in a 49 year old male with a previously undiagnosed bicuspid aorticvalve (BAV). We also describe the classical appearance in different imaging modalities with a particular emphasis on multidetector computed tomography, and discuss the clinical manifestation and its relationship to BAV. PMID:20539840
Aorticvalve stenosis (AS) is common in the elderly. Although surgical replacement of the valve has been the gold standard of management, many patients have been excluded from surgery because they were very old, frail, or had co-morbidities that increased operative risks. In the last decade, transcatheter aorticvalve implantation (TAVI) has emerged as a new treatment option suitable for these patients. This article reviews the available literature on the role of TAVI in elderly patients with severe aortic stenosis. Published studies showed that elderly individuals who underwent TAVI experienced better in-hospital recovery, and similar short and mid-term mortality compared to those underwent surgical treatment of AS. However, long-term outcomes of TAVI in elderly patients are still unknown. The available data in the literature on the effect of advanced age on clinical outcomes of TAVI are limited, but the data that are available suggest that TAVI is a beneficial and tolerable procedure in very old patients. Some of the expected complications after TAVI are reported more in the oldest patients such as vascular injures. Other complications were comparable in TAVI patients regardless of their age group. However, very old patients may need closer monitoring to avoid further morbidities and mortality. PMID:25009568
Patients with severe aortic stenosis are commonly elderly and with significant comorbidity. Surgical intervention can improve symptoms and survival in severe aortic stenosis. However, a large proportion of patients do not undergo surgical intervention because they are deemed to be inoperable or too high risk. Over the last decade, transcatheter aorticvalve replacement (TAVR) has been developed, providing an effective, less-invasive alternative to open cardiac surgery for inoperable or high-risk patients. The purpose of this review is to provide an overview of risk assessment in TAVR. Specifically, this article reviews the epidemiology of aortic stenosis, describes the risks and benefits of TAVR across multiple outcome measures, explores frailty and other elderly risk factors as metrics for improved risk assessment and discusses the application of improved risk assessment in TAVR decisions. PMID:23750685
Transcatheter aorticvalve implantation (TAVI) is a minimally invasive procedure introduced to treat aorticvalve stenosis in elder patients. Its clinical outcomes are strictly related to patient selection, operator skills, and dedicated pre-procedural planning based on accurate medical imaging analysis. The goal of this work is to define a finite element framework to realistically reproduce TAVI and evaluate the impact of aortic root anatomy on procedure outcomes starting from two real patient datasets. Patient-specific aortic root models including native leaflets, calcific plaques extracted from medical images, and an accurate stent geometry based on micro-tomography reconstruction are key aspects included in the present study. Through the proposed simulation strategy we observe that, in both patients, stent apposition significantly induces anatomical configuration changes, while it leads to different stress distributions on the aortic wall. Moreover, for one patient, a possible risk of paravalvular leakage has been found while an asymmetric coaptation occurs in both investigated cases. Post-operative clinical data, that have been analyzed to prove reliability of the performed simulations, show a good agreement with analysis results. The proposed work thus represents a further step towards the use of realistic computer-based simulations of TAVI procedures, aiming at improving the efficacy of the operation technique and supporting device optimization. PMID:24998989
Morganti, S; Conti, M; Aiello, M; Valentini, A; Mazzola, A; Reali, A; Auricchio, F
Background Poly (ethylene glycol) (PEG) has attracted broad interest for tissue engineering applications. The aim of this study was to synthesize 4-arm -PEG-20kDa with the terminal group of diacrylate (4-arm-PEG-DA) and evaluate its dual functionality for decellularized porcine aorticvalve (DAV) based on its mechanical and biological properties. Methods 4-arm-PEG-DA was synthesized by graft copolymerization of linear PEG 20,000 monomers, and characterized by IR1H NMR and 13C NMR; PEGylation of DAV was achieved by the Michael addition reaction between propylene acyl and thiol, its effect was tested by uniaxial planar tensile testing, hematoxylin and eosin (HE) and scanning electron microscopy (SEM). Gly-Arg-Gly-Asp-Ser-Pro-Cys (GRGDSPC) peptides and vascular endothelial growth factor-165 (VEGF165) were conjugated onto DAV by branched PEG-DA (GRGDSPC-PEG-DAV-PEG-VEGF165). Results Mechanical testing confirmed that PEG-cross-linking significantly enhanced the tensile strength of DAV. Immunofluoresce confirmed the GRGDSPC peptides and VEGF165 were conjugated effectively onto DAV; the quantification of conjunction was completed roughly using spectrophotometry and ELISA. The human umbilical vein endothelial cells (HUVECs) grew and spread well on the GRGDSPC-PEG-DAV-PEG-VEGF165. Conclusions Therefore, PEGylation of DAV not only can improve the tensile strength of DAV, and can also mediate the conjugation of bioactive molecule (VEGF165 and GRGDSPC peptides) on DAV, which might be suitable for further development of tissue engineered heart valve. PMID:24006837
Recently, transcatheter aorticvalve replacement (TAVR) has emerged as an alternative for the treatment of severe symptomatic aortic stenosis patients. Although experience with TAVR is increasing exponentially, few cases of post-TAVR endocarditis are reported. We present a case of 76-year-old man with infective endocarditis after TAVR who was definitely diagnosed by echocardiography. PMID:25309690
Lee, Hak Seung; Lee, Seung-Pyo; Jung, Ji-Hyun; Kim, Hyue Mee; Kim, Chee Hae; Park, Jun-Bean; Kim, Hyung-Kwan; Kim, Yong-Jin; Kim, Hyo-Soo; Sohn, Dae-Won
Recently, transcatheter aorticvalve replacement (TAVR) has emerged as an alternative for the treatment of severe symptomatic aortic stenosis patients. Although experience with TAVR is increasing exponentially, few cases of post-TAVR endocarditis are reported. We present a case of 76-year-old man with infective endocarditis after TAVR who was definitely diagnosed by echocardiography. PMID:25309690
Lee, Hak Seung; Jung, Ji-Hyun; Kim, Hyue Mee; Kim, Chee Hae; Park, Jun-Bean; Kim, Hyung-Kwan; Kim, Yong-Jin; Kim, Hyo-Soo; Sohn, Dae-Won
It is unclear how often patients with very mild aortic stenosis (gradients <25 mmHg) need interval follow-up. The purpose\\u000a of this study was to define the determinants of disease severity progression and to propose appropriate management strategies.\\u000a It is known that congenital aortic stenosis is a progressive disease that requires long-term follow-up at consistent intervals.\\u000a We studied 89 patients with
P. J. Bartz; D. J. Driscoll; J. F. Keane; W. M. Gersony; C. J. Hayes; J. I. Brenner; W. M. O’Fallon; D. R. Pieroni; R. R. Wolfe; W. H. Weidman
... Heart valves play key roles in this one-way blood flow, opening and closing with each heartbeat. Pressure changes behind and in front of the valves allow them to open their flap-like "doors" (called cusps or leaflets) at just the right time, then close them tightly to prevent a ...
Background In patients with severe aortic stenosis, left ventricular hypertrophy is associated with increased myocardial stiffness and dysfunction linked to cardiac morbidity and mortality. We aimed at systematically investigating the degree of left ventricular mass regression and changes in left ventricular function six months after transcatheter aorticvalve implantation (TAVI) by cardiovascular magnetic resonance (CMR). Methods Left ventricular mass indexed to body surface area (LVMi), end diastolic volume indexed to body surface area (LVEDVi), left ventricular ejection fraction (LVEF) and stroke volume (SV) were investigated by CMR before and six months after TAVI in patients with severe aortic stenosis and contraindications for surgical aorticvalve replacement. Results Twenty-sevent patients had paired CMR at baseline and at 6-month follow-up (N=27), with a mean age of 80.7±5.2 years. LVMi decreased from 84.5±25.2 g/m2 at baseline to 69.4±18.4 g/m2 at six months follow-up (P<0.001). LVEDVi (87.2±30.1 ml /m2vs 86.4±22.3 ml/m2; P=0.84), LVEF (61.5±14.5% vs 65.1±7.2%, P=0.08) and SV (89.2±22 ml vs 94.7±26.5 ml; P=0.25) did not change significantly. Conclusions Based on CMR, significant left ventricular reverse remodeling occurs six months after TAVI. PMID:23692630
We report a 27 years old male who presented with a combination of both congenital and acquired cardiac defects. This syndrome complex includes congenital bicuspid aorticvalve, Seller's grade II aortic regurgitation, juxta- subclavian coarctation, stenosis of ostium of left subclavian artery and ruptured sinus of Valsalva aneurysm without any evidence of infective endocarditis. This type of constellation is extremely rare. Neither coarctation of aorta with left subclavian artery stenosis nor the rupture of sinus Valsalva had a favorable pathology for percutaneus intervention. Taking account into morbidity associated with repeated surgery and anesthesia patient underwent a single stage surgical repair of both the defects by two surgical incisions. The approaches include median sternotomy for rupture of sinus of Valsalva and lateral thoracotomy for coarctation with left subclavian artery stenosis. The surgery was uneventful. After three months follow up echocardiography showed mild residual gradient across the repaired coarctation segment, mild aortic regurgitation and no residual left to right shunt. This patient is under follow up. This is an extremely rare case of single stage successful repair of coarctation and rupture of sinus of Valsalva associated with congenital bicuspid aorticvalve. PMID:22629035
Barik, Ramachandra; Patnaik, A. N.; Mishra, Ramesh C.; Kumari, N. Rama; Gulati, A. S.
Percutaneous trans-catheter aorticvalve implantation (TAVI) is recommended for inoperable patients with severe aortic stenosis at high risk for conventional aorticvalve replacement. Originally, TAVI was mostly performed under general anesthesia. Here we describe two cases of transfemoral TAVI performed under monitored anesthesia care (MAC) with dexmedetomidine. Dexmedetomidine provides sedation, analgesia with minimal respiratory depression. Although MAC during transfemoral TAVI has limitations, such as unexpected patient movement and difficulty in intra-procedural use of transesophageal echocardiography, MAC with dexmedetomidine is feasible with close monitoring, fluoroscopic guidance and the participation of experienced anesthesiologists. PMID:24851170
Park, Hee-Sun; Kim, Kyung-Mi; Joung, Kyoung-Woon; Choi, In-Cheol; Sim, Ji-Yeon
Background Aorticvalve stenosis is one of the most common heart diseases in older patients. Nowadays, surgical aorticvalve replacement is the ‘gold standard’ treatment for this pathology and the most implanted prostheses are biological ones. The three most implanted bovine bioprostheses are the Trifecta valve (St. Jude Medical, Minneapolis, MN, USA), the Mitroflow valve (Sorin Group, Saluggia, Italy), and the Carpentier-Edwards Magna Ease valve (Edwards Lifesciences, Irvine, CA, USA). We propose a randomized trial to objectively assess the hemodynamic performances of these bioprostheses. Methods and design First, we will measure the aortic annulus diameter using CT-scan, echocardiography and by direct sizing in the operating room after native aorticvalve resection. The accuracy of information, in terms of size and spatial dimensions of each bioprosthesis provided by manufacturers, will be checked. Their hemodynamic performances will be assessed postoperatively at the seventh day and the sixth month after surgery. Discussion This prospective controlled randomized trial aims to verify and compare the hemodynamic performances and the sizing of these three bioprostheses. The data obtained may help surgeons to choose the best suitable bioprosthesis according to each patient’s morphological characteristics. Trial registration ClinicalTrials.gov Identifier: NCT01522352 PMID:24299218
This study assesses whether aorticvalve sclerosis (AVS) and mitral annulus calcification (MAC) are associated with carotid artery atherosclerosis, independently of traditional cardiovascular risk factors. A total of 1065 patients underwent both echocardiography and carotid artery ultrasound scanning. AVS and MAC were defined as focal areas of increased echogenicity and thickening of the aortic leaflets or mitral valve annulus. Carotid artery atherosclerosis was defined as presence/absence of any atherosclerotic plaque or presence/absence of plaque >50 %. Of 1065 patients (65 ± 9 years; 38 % female) who comprised the study population, 642 (60 %) had at least one atherosclerotic plaque. AVS, but not mitral valve sclerosis; was associated with the presence of carotid atherosclerosis (odds ratio (OR) 1.9, 95 % confidence interval (CI) 1.2-3.9; P = 0.005) and the degree of carotid atherosclerosis (OR 2.1, 95 % CI 1.2-3.9; P = 0.01) in a multivariate model including age, gender, previous ischemic heart disease, hypertension, dyslipidemia, smoking, diabetes, family cardiovascular history, left ventricular size, mass, and ejection fraction, and left atrial size. AVS is a significant predictor of carotid atherosclerosis, independently of other cardiovascular clinical and echocardiographic risk factors. PMID:24196525
Background Calcification is an independent predictor of mortality in calcific aorticvalve disease (CAVD). The aim of this study was to evaluate the use of non-invasive, non-ionizing echocardiographic calibrated integrated backscatter (cIB) for monitoring progression and subsequent regression of aortic valvular calcifications in a rat model of reversible renal failure with CAVD, compared to histology. Methods 28 male Wistar rats were prospectively followed during 21 weeks. Group 1 (N=14) was fed with a 0.5% adenine diet for 9 weeks to induce renal failure and CAVD. Group 2 (N=14) received a standard diet. At week 9, six animals of each group were killed. The remaining animals of group 1 (N=8) and group 2 (N=8) were kept on a standard diet for an additional 12 weeks. cIB of the aorticvalve was calculated at baseline, 9 and 21 weeks, followed by measurement of the calcified area (Ca Area) on histology. Results At week 9, cIB values and Ca Area of the aorticvalve were significantly increased in the adenine-fed rats compared to baseline and controls. After 12 weeks of adenine diet cessation, cIB values and Ca Area of group 1 decreased compared to week 9, while there was no longer a significant difference compared to age-matched controls of group 2. Conclusions cIB is a non-invasive tool allowing quantitative monitoring of CAVD progression and regression in a rat model of reversible renal failure, as validated by comparison with histology. This technique might become useful for assessing CAVD during targeted therapy. PMID:23351880
In recent years, transcatheter aorticvalve replacement (TAVR) has emerged as a revolutionary alternative for surgical aorticvalve replacement (SAVR) for the treatment of severe symptomatic aortic stenosis in patients at high risk for surgery. Prosthetic aorticvalve endocarditis is a serious complication after SAVR with high morbidity and mortality. Although numerous TAVR procedures have been performed worldwide, infective endocarditis (IE) after TAVR was reported in the literature in few cases only and in 0% to 2.3% of patients enrolled in large TAVR cohorts. Our aim was to review the literature for IE following TAVR and to discuss the diagnostic and management strategies of this rare complication. Ten case reports of IE after TAVR were identified, 8 of which were published as case reports and 2 of which were presented in congresses. Infective endocarditis occurred in a mean time period of 186 days (median, 90 days) after TAVR. Most cases were characterized by fever and elevated inflammatory markers. Infective endocarditis after TAVR shared some common characteristics with IE after SAVR, yet it has some unique features. Echocardiographic findings included leaflet vegetations, severe mitral regurgitation with rupture of the anterior leaflet, and left ventricle outflow tract to left atrium fistula. Bacteriologic findings included several atypical bacteria or fungi. Cases of IE were managed either conservatively by antibiotics and/or using surgery, and the overall prognosis was poor. Infective endocarditis after TAVR deserves prompt diagnosis and treatment. Until further evidence is present, IE after TAVR should be managed according to SAVR guidelines with modifications as needed on a case-by-case basis. PMID:22990884
Eisen, Alon; Shapira, Yaron; Sagie, Alex; Kornowski, Ran
A depressurization valve for use in relieving completely the pressure in a simplified boiling water reactor is disclosed. The normally closed and sealed valve is provided with a valve body defining a conduit from an outlet of a manifold from the reactor through a valve seat. A closing valve disk is configured for fitting to the valve seat to normally close the valve. The seat below the disk is provided with a radially extending annulus extending a short distance into the aperture defined by the seat. The disk is correspondingly provided with a longitudinally extending annulus that extends downwardly through the aperture defined by the seat towards the high pressure side of the valve body. A ring shaped membrane is endlessly welded to the seat annulus and to the disk annulus. The membrane is conformed over the confronted surface of the seat and disk in a C-sectioned configuration to seal the depressurization valve against the possibility of weeping. The disk is held to the closed position by an elongate stem extending away from the high pressure side of the valve body. The stem has a flange configured integrally to the stem for bias by two springs. The first spring acts from a portion of the housing overlying the disk on the stem flange adjacent the disk. This spring urges the stem and attached disk away from the seat and thus will cause the valve to open at any pressure. A second spring--preferably of the Belleville variety--acts on a latch plate surrounding and freely moving relative to the end of the stem. This second spring overcomes the bias of the first spring and any pressure acting upon the disk. This Belleville spring maintains through its spring force the valve in the closed position. At the same time, the latch plate with its freedom of movement relative to the stem allows the stem to thermally expand during valve temperature excursion. The latch plate in surrounding the stem is limited in its outward movement by a boss attached to the stem at the end of the stem remote from the disk. The latch plate is held normally closed by three radial latches spaced at 120.degree. around the periphery of the plate.
Transcatheter aorticvalve implantation (TAVI) using stent-based bioprostheses has recently emerged as a promising alternative to surgical valve replacement in selected patients. The main route for TAVI is retrograde access from the femoral artery using large sheaths (16-24 F). Vascular access complications are a clinically relevant issue in TAVI procedures since they are reported to occur in up to one fourth of patients and are strongly associated with adverse outcomes. In the present paper, we review the different types of vascular access site complications associated with transfemoral TAVI. Moreover, we discuss the possible optimal management strategies with particular attention to the relevance of early diagnosis and prompt treatment using endovascular techniques.
Dato, Ilaria; Burzotta, Francesco; Trani, Carlo; Crea, Filippo; Ussia, Gian Paolo
The objective of this study is to provide a precise means of evaluating the hydrodynamic performance of prosthetic aortic and mitral valves. Particle Image Velocimetry is used to measure the in-plane velocity components in selected planes of the flow, from which the turbulent shear stress is derived. The experimental facility used in this study is made of plexiglas tube, and has a circular cross section with a diameter that matches that of the valve. To ensure optical access the test fluid used matches the refractive index of plexiglas and the test section incorporates a square housing filled with the same fluid. The fluid used in this experiment is a mixture of glycerol, water and sodium iodide. Pulsatile flow is achieved by means of a pump and monitored in real time by means of an electronic flowmeter. Dynamic similarity is ensured in these experiments as the viscosity of the fluid mixture closely approximates that of blood.
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 aorticvalve, 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 aorticvalves. 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 aorticvalve, 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 aorticvalve 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 aorticvalves involve different biological pathways leading to the same phenotype. PMID:23184916
Kjellqvist, Sanela; Maleki, Shohreh; Olsson, Therese; Chwastyniak, Maggy; Branca, Rui Miguel Mamede; Lehtio, Janne; Pinet, Florence; Franco-Cereceda, Anders; Eriksson, Per
ABSTRACT: BACKGROUND: To investigate aortic dimensions in women with Turner syndrome (TS) in relation to aorticvalve morphology, blood pressure, karyotype, and clinical characteristics. METHODS AND RESULTS: A cross sectional study of 102 women with TS (mean age 37.7; 18-62 years) examined by cardiovascular magnetic resonance (CMR- successful in 95), echocardiography, and 24-hour ambulatory blood pressure. Aortic diameters were measured
Britta E Hjerrild; Kristian H Mortensen; Keld E Sørensen; Erik M Pedersen; Niels H Andersen; Erik Lundorf; Klavs W Hansen; Arne Hørlyck; Alfred Hager; Jens S Christiansen; Claus H Gravholt
Background Calcific aorticvalve disease is the most common indication for surgical valve replacement in the United States. The cellular mechanisms of valve calcification are not well understood. We have previously shown that cellular proliferation and osteoblastogenesis are important in the development of valvular heart disease. Lrp5, a known low-density receptor-related protein, plays an essential role in cellular proliferation and osteoblastogenesis via the ?-catenin signaling pathway. We hypothesize that Lrp5 also plays a role in aorticvalve (AV) calcification in experimental hypercholesterolemia. Methods and Results We examined the effects of cholesterol and atorvastatin in Watanabe rabbits (n=54). Group I (n=18) received a normal diet, group II (n=18) a 0.25% cholesterol diet, and group III (n=18) a 0.25% (w/w) cholesterol diet with atorvastatin for the development of calcification. The AVs were examined for cellular proliferation, Lrp5/?-catenin, and bone matrix markers. Bone formation was assessed by micro-computed tomography, calcein injection, and osteopontin expression. Low-density lipoprotein with and without atorvastatin was also tested in AV myofibroblasts for cellular proliferation and regulation of the Lrp5/?-catenin pathway. Our results demonstrate that the cholesterol diet induced complex bone formations in the calcified AVs with an increase in the Lrp5 receptors, osteopontin, and p42/44 expression. Atorvastatin reduced bone formation, cellular proliferation, and Lrp5/?-catenin protein levels in the AVs. In vitro analysis confirmed the Lrp5/?-catenin expression in myofibroblast cell proliferation. Conclusion Hypercholesterolemic AV calcification is attenuated by atorvastatin and is mediated in part by the Lrp5/?-catenin pathway. This developmental pathway may be important in the signaling pathway of this disease. PMID:16159822
Rajamannan, Nalini M.; Subramaniam, Malayannan; Caira, Frank; Stock, Stuart R.; Spelsberg, Thomas C.
Transcatheter aorticvalve replacement (TAVR) is performed with increasing frequency in the United States since Food and Drug Administration approval in 2011. The procedure involves the replacement of a severely stenosed native or bioprosthetic aorticvalve with a specially constructed valvular prosthesis that is mounted onto a stent, without the use of cardiopulmonary bypass and the complications of a major open surgical procedure. TAVR has been performed mostly in elderly patients with multiple comorbidities or who have undergone previous cardiac surgery. The most commonly used access routes are the femoral artery (transfemoral) or the cardiac apex (transapical), but the transaortic and transubclavian approaches are also used with varying frequency. Conscious sedation may be used in patients undergoing transfemoral TAVR, but the use of general anesthesia has not been shown to carry greater risk and permits the use of transesophageal echocardiography to assist in valve positioning and diagnose complications. Cardiovascular instability during TAVR is relatively common, necessitating invasive monitoring and frequent use of vasoactive medications. Complications of the procedure are still relatively common and the most frequent is vascular injury to the access sites or the aorta. Cardiovascular collapse may be the result of major hemorrhage pericardial effusion with tamponade or coronary occlusion due to incorrect valve placement. Persistent hypotension, myocardial stunning, or injury requiring open surgical intervention may necessitate the use of cardiopulmonary bypass, the facilities for which should always be immediately available. Ongoing and planned trials comparing conventional surgery with TAVR in lower risk and younger patients should determine the place of TAVR in the medium- to long-term future. PMID:25232691
BackgroundMeasurement of the degree of aorticvalve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low
Caroline Cueff; Jean-Michel Serfaty; Claire Cimadevilla; Jean-Pierre Laissy; Dominique Himbert; Florence Tubach; Xavier Duval; Bernard Iung; Maurice Enriquez-Sarano; Alec Vahanian; David Messika-Zeitoun
OBJECTIVESWe examined the hypothesis that mitral annulus calcification (MAC), aorticvalve sclerosis (AVS) and aortic root calcification (ARC) are associated with coronary artery disease (CAD) in subjects age ?65 years.BACKGROUNDMitral annulus calcification, AVS and ARC frequently coexist and are associated with coronary risk factors and CAD in the elderly.METHODSWe studied 338 subjects age ?65 years who underwent evaluation of chest
Doo-Soo Jeon; Shaul Atar; Andrea V Brasch; Huai Luo; James Mirocha; Tasneem Z Naqvi; Robert Kraus; Daniel S Berman; Robert J Siegel
Whether or not there are molecular differences, at the intra- and extracellular level, between aortic dilatation in patients with bicuspid (BAV) and those with a tricuspid aorticvalve (TAV) has remained controversial for years. We have performed 2-dimensional gel electrophoresis and mass spectrometry coupled with dephosphorylation and phosphostaining experiments to reveal and define protein alterations and the high abundant structural
Peter Matt; Zongming Fu; Thierry Carrel; David L. Huso; Stefan Dirnhofer; Ivan Lefkovits; Hans-Reinhard Zerkowski; Jennifer E. Van Eyk
OBJECTIVE: We sought to assess whether aorticvalve 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 aorticvalve 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.
Accurate assessment of aortic annular dimensions is essential for successful transcatheter aorticvalve implantation (TAVI). Annular dimensions are conventionally measured in mid-systole by multidetector computed tomography (MDCT), echocardiography and angiography. Significant differences in systolic and diastolic aortic annular dimensions have been demonstrated in cohorts without aortic stenosis (AS), but it is unknown whether similar dynamic variation in annular dimensions exists in patients with severe calcific AS in whom aortic compliance is likely to be substantially reduced. We investigated the variation in aortic annular dimensions between systole and diastole in patients with severe calcific AS. Patients with severe calcific AS referred for TAVI were evaluated by 128-slice MDCT. Aortic annular diameter was measured during diastole and systole in the modified coronal, modified sagittal, and basal ring planes (maximal, minimal and mean diameters). Differences between systole and diastole were analysed by paired t test. Fifty-nine patients were included in the analysis. Three of the five aortic dimensions measured increased significantly during systole. The largest change was a 0.75 mm (3.4%) mean increase in the minimal diameter of the basal ring during systole (p = 0.004). This corresponds closely to the modified sagittal view, which also increased by mean 0.42 mm (1.9%) during systole (p = 0.008). There was no significant change in the maximal diameter of the basal ring or the modified coronal view during systole (p > 0.05). There is a small magnitude but statistically significant difference in aortic annulus dimensions of patients with severe AS referred for TAVI when measured in diastole and systole. This small difference is unlikely to alter clinical decisions regarding prosthesis size or suitability for TAVI. PMID:22318541
Bertaso, Angela G; Wong, Dennis T L; Liew, Gary Y H; Cunnington, Michael S; Richardson, James D; Thomson, Viji S; Lorraine, Brett; Kourlis, George; Leech, Diana; Worthley, Matthew I; Worthley, Stephen G
Abstract Objective: The degeneration of bicuspid aorticvalve and its frequent association with ascending aortic pathology, point to a still unidentified genetic tissue defect with unknown,mediators. Metalloproteinases (MMPs) are lytic enzymes,that have been strongly implicated in aneurysm,formation. The purpose of this study was to detect the presence of these enzymes,in aortic valvular tissue in healthy and diseased aorticvalves with
George J. Koullias; Dimitris P. KorkolisSUPaS; Pars Ravichandran; Amanda Psyrri; Ioannis Hatzaras; John A. Elefteriades
Bicuspid aorticvalve (BAV) predisposes to aortic aneurysms with a high prevalence. A first hypothesis for this phenomenon is related to fibrillin deficiency (genetic hypothesis). The present article focused on a complementary, hemodynamic hypothesis stating that it is the peculiar fluid dynamics of blood in the ascending aorta of patients with BAV configurations that leads to aneurysm formation. To corroborate this hypothesis, a parametric study was performed based on numerical simulations of ascending aorta hemodynamics with different configurations of orifice area and valve orientation. The resulting wall shear stress (WSS) distributions and degree of asymmetry of the blood jet were investigated, and surrogate indices introduced. The results showed that WSS was more pronounced in subjects with BAV morphologies, also in the nonstenotic case. In particular, a maximum WSS of 3Pa was found (vs. 1.5Pa in subjects with a tricuspid configuration). It is localized at the mid-ascending aorta, the segment more prone to dilate as shown by the index related to maximum WSS (0.869 in BAV vs. 0.322 in tricuspid). Moreover, the asymmetry of the blood flow was found larger for decreasing valve area, the related index at mid-ascending aorta being more than three times higher than that found for tricuspid configuration (0.70 vs. 0.20). Further, WSS and flow asymmetry were higher also at the sinus of Valsalva and sinotubolar junction for a latero-lateral (LL) BAV configuration in keeping with the clinical observation on association between BAV configurations and different aortic aneurysm morphology. These findings may help explain the higher risk of aneurysm formation in BAV patients. The proposed indices will require validation prior to application in clinical settings. PMID:21995712
Vergara, Christian; Viscardi, Francesca; Antiga, Luca; Luciani, Giovanni Battista
Background?Transcatheter aorticvalve implantation (TAVI) has become routine for the treatment of high-risk patients with aortic stenosis. We assessed safety and feasibility of a left ventricular apical access and closure device combined with second-generation transapical (TA) TAVI transcatheter heart valves (THV). Methods and Results?Three elderly, comorbid patients (logEuroSCORE I 13.0-31.1%) received transapical aorticvalve implantation (TA-AVI) via the Apica ASC device (Apica Cardiovascular Ltd., Galway, Ireland) using second-generation THV (Medtronic Engager [Medtronic 3F Therapeutics, Santa Ana, California, United States], JenaValve [JenaValve Technology GmbH, Munich, Germany], Symetis Acurate [Symetis S.A., Ecublens, Switzerland]). Access was gained using a non-rib-spreading technique and a novel access and closure device. THV deployment was successful with excellent hemodynamic outcome (no PVL, n?=?2; trace PVL, n?=?1; mean transvalvular gradients, 5-19?mm Hg) and complete apical hemostasis. No periprocedural major adverse events occurred and Valve Academic Research Consortium-2-defined composite end point of device success was met in all cases. Conclusion?Safety and feasibility of TA-AVI using the ASC device with second-generation THV was demonstrated. Combining latest available technology is a major step toward improved functional outcome and decreased surgical trauma in TA-AVI. Potentially, technical enhancements may eventually pave the way toward a fully percutaneous TA-AVI procedure. PMID:24911901
OBJECTIVE--To assess whether and to what extent myocardial oxygen consumption is modified by hypertrophy and alterations in contractility in patients with aorticvalve disease and to evaluate the influence of regression of left ventricular hypertrophy and improvement of contractility on myocardial oxygen consumption after successful aorticvalve replacement. DESIGN--A cohort analytical study to investigate the influence of the "explanatory" variables of myocardial oxygen consumption by multiple regression analysis. A comparison of myocardial oxygen consumption in preoperative patients with that after operation in a group with comparable severity of aorticvalve disease before operation (analysis of covariance). PATIENTS--In six controls and in 43 patients with aorticvalve disease and normal coronary arteries standard haemodynamic variables were measured, left ventricular biplane cineangiography performed, and coronary sinus blood flow measured by thermodilution. The patients were divided into three groups: 19 preoperative patients with normal ejection fraction (greater than or equal to 57%) (group 1); nine preoperative patients with reduced ejection fraction (less than 57%) (group 2); 16 postoperative patients (one with preoperative and postoperative measurements (group 3). Postoperative evaluation was performed 12-51 months after surgery. MAIN OUTCOME MEASUREMENTS--Myocardial oxygen consumption/100 g left ventricular muscle mass and its suspected "explanatory" variables--that is, peak systolic left ventricular circumferential wall stress, heart rate, contractility (assessed by left ventricular ejection fraction), and left ventricular muscle mass index. RESULTS--Multiple regression analysis showed that the product of peak systolic stress and heart rate (p less than 0.0001) and ejection fraction (p less than 0.03) were positively correlated with myocardial oxygen consumption/100 g and that left ventricular muscle mass index (p less than 0.002) was negatively correlated with myocardial oxygen consumption/100 g (r = 0.72; n = 50 measurements). Myocardial oxygen consumption per 100 g at a given stress-rate product was higher in the controls than in group 1 (hypertrophied ventricles with normal ejection fraction) and was also higher in group 1 than in group 2 (hypertrophied ventricles with reduced ejection fraction). In a subgroup of the postoperative patients with complete regression of hypertrophy and normalisation of contractility, myocardial oxygen consumption per 100 g at a given stress-rate product was indistinguishable from that in controls. CONCLUSIONS--When the actual stress-rate product was used as an index of overall left ventricular performance the results suggested that mechanical efficiency was increased in hypertrophied ventricles especially when contractility was decreased. These changes in mechanical efficiency seemed to be reversible during the postoperative course when muscle mass and contractility returned to normal. PMID:1531759
Schwitter, J; Eberli, F R; Ritter, M; Turina, M; Krayenbuehl, H P
We report our experience with a low-volume (100 mL), single-shot crystalloid cardioplegia (Cardioplexol) in 61 consecutive patients undergoing isolated aorticvalve replacement (AVR). Cardioplexol resulted in immediate cardiac arrest. Intraoperative courses were uneventful. Postoperative markers of myocardial damage, Troponin T and CK-MB levels, were low but steadily increased with longer cross-clamp time. Thirty-day mortality was 3% and all noncardiac. Cardioplexol not only simplifies and speeds up the procedure but also seems to be safe for patients undergoing AVR. PMID:22207363
Matt, Peter; Arbeleaz, Emilio; Schwirtz, Goetz; Doebele, Thomas; Eckstein, Friedrich
Papillary fibroelastomas are rare primary tumours of cardiac origin accounting for approximately 10% of all primary cardiac neoplasms. Due to a high thromboembolic risk, surgical excision is the mainstay of treatment in these patients and median sternotomy the most widely used approach. We describe the case of a 43 year-old lady presenting with acute myocardial infarction secondary to aorticvalve papillary fibroelastoma subsequently excised using a minimal access technique. From our experience mini-sternotomy offers excellent exposure and allows for safe resection in such cases, improving cosmesis without compromising either intra or post-operative outcome. PMID:22943845
Papillary fibroelastomas are rare primary tumours of cardiac origin accounting for approximately 10% of all primary cardiac neoplasms. Due to a high thromboembolic risk, surgical excision is the mainstay of treatment in these patients and median sternotomy the most widely used approach. We describe the case of a 43 year-old lady presenting with acute myocardial infarction secondary to aorticvalve papillary fibroelastoma subsequently excised using a minimal access technique. From our experience mini-sternotomy offers excellent exposure and allows for safe resection in such cases, improving cosmesis without compromising either intra or post-operative outcome. PMID:22943845
The aim of this study was to identify regions of the genome that harbor genes influencing inheritance of bicuspid aorticvalve\\u000a (BAV) and\\/or associated cardiovascular malformation (CVM). Aorticvalve disease is an important clinical problem, which often\\u000a results in valve replacement, the second most common cardiac surgery in the United States. In every age group, a majority\\u000a of cases of
Lisa J. Martin; Vijaya Ramachandran; Linda H. Cripe; Robert B. Hinton; Gregor Andelfinger; Meredith Tabangin; Kerry Shooner; Mehdi Keddache; D. Woodrow Benson
Background Bicuspid aorticvalve (BAV) is the most frequent congenital heart disease with frequent involvement in thoracic aortic dilatation, aneurysm and dissection. Although BAV and Marfan syndrome (MFS) share some clinical features, and some MFS patients with BAV display mutations in FBN1, the gene encoding fibrillin-1, the genetic background of isolated BAV is poorly defined. Methods Ten consecutive BAV patients [8 men, age range 24–42 years] without MFS were clinically characterized. BAV phenotype and function, together with evaluation of aortic morphology, were comprehensively assessed by Doppler echocardiography. Direct sequencing of each FBN1 exon with flanking intron sequences was performed on eight patients. Results We detected three FBN1 mutations in two patients (aged 24 and 25 years) displaying aortic root aneurysm ?50 mm and moderate aortic regurgitation. In particular, one patient had two mutations (p.Arg2726Trp and p.Arg636Gly) one of which has been previously associated with variable Marfanoid phenotypes. The other patient showed a pArg529Gln substitution reported to be associated with an incomplete MFS phenotype. Conclusions The present findings enlarge the clinical spectrum of isolated BAV to include patients with BAV without MFS who have involvement of FBN1 gene. These results underscore the importance of accurate phenotyping of BAV aortopathy and of clinical characterization of BAV patients, including investigation of systemic connective tissue manifestations and genetic testing. PMID:24564502
We introduce a simple, less invasive surgical technique for treating neoaortic valve regurgitation (neoAR) after the Norwood procedure, with the aim of delaying reoperation for neoAR. A 31-month-old girl, with hypoplastic left heart syndrome, previously underwent 4 median sternotomies and was admitted to our hospital for a fenestrated Fontan operation. She presented with moderate neoAR, originating from a tricuspid neoaortic valve (neoAV), with the regurgitation oriented from the centre. Her neoAV annulus was dilated to twice its normal size. With the aim of delaying future neoAV intervention and minimizing the surgical invasiveness, we performed extra-aortic commissuroplasties on the 2 commissures that could be approached from the front during the Fontan operation, without inducing cardiac arrest. We used direct echocardiography and transoesophageal echocardiography to confirm the feasibility before applying this procedure. Her postoperative course was uneventful, and the postoperative echocardiography did not reveal any residual neoAR 5 months postoperatively. We believe that this technique is a useful surgical option for patients with moderate neoAR oriented from its centre and well-balanced tricuspid native pulmonary valves, and it might help to delay future neoAV interventions, with minimal surgical risk. PMID:24813901
A 43-year-old young lady had closed mitral valvotomy (CMV) in 1994 and aorticvalve replacement (AVR) in June 2007. Shortly thereafter, she presented with unstable angina in October 2007 with on-going pain and haemodynamic instability. Coronary angiogram showed tight left main bifurcation stenosis in a left dominant system. Having had open heart surgery (AVR) recently, and being on oral anticoagulation, with on-going ischaemia and unstable haemodynamics, percutaneous coronary intervention (PCI) was considered the most suitable option. She underwent successful PCI with two drug-eluting stents (T-stenting) to left main bifurcation through transradial approach and intra-aortic balloon support. Clinically she remained symptom free and coronary angiogram after 5 months and 15 months of follow-up showed patent stents. This case demonstrates the acute effectiveness of PCI for the treatment of critical left main disease following open heart surgery in patients who are not appropriate surgical candidates. PMID:22572431
The number of patients with severe aortic stenosis getting treated with transcatheter aorticvalve replacement (TAVR) is rapidly growing and the outcome after the procedure is very good. However, the incidence of new persistent left bundle branch block (LBBB) following the TAVR procedure is high and the impact of this new conduction disturbance has been studied in four major studies with divergent result. This review investigates the differences between these studies that might explain the divergent results and concludes that future studies are needed to characterize whether or not new LBBB after TAVR fulfills the new strict LBBB criteria, whether these new LBBB patients develops left ventricular dyssynchrony, and which, if any, might benefit from cardiac resyncronization therapy (CRT). PMID:25085101
Details are presented concerning 59 patients who left hospital between January 1964 and January 1969 after aorticvalve replacement with the Starr-Edwards prosthesis. Of the 14 late deaths, 7 are known to have been due to causes related to the prosthesis and 4 to other causes. The 45 surviving patients have nearly all shown clinical improvement and only 3 are unable to work as a result of some complication of the operation. Aortic regurgitation and its consequences appear to be the most significant factor leading to symptoms. In 11 of 16 patients with anaemia there was evidence of intravascular haemolysis. The long-term consequence of this complication is not known. Images PMID:5212355
Morgans, C M; Barritt, D W; Belsey, R H; Keen, G; Wensley, R
Background Congenital heart disease (CHD) is a cardinal feature of X chromosome monosomy, or Turner syndrome (TS). Haploinsufficiency for gene(s) located on Xp have been implicated in the short stature characteristic of the syndrome, but the chromosomal region related to the CHD phenotype has not been established. Design We used cardiac MRI to diagnose cardiovascular abnormalities in four non-mosaic karyotype groups based on 50-metaphase analyses: 45,X (n=152); 46,X,del(Xp) (n=15); 46,X,del(Xq) (n=4); and 46,X,i(Xq) (n=14) from peripheral blood cells. Results Bicuspid aorticvalves (BAV) were found in 52/152 (34%) 45,X study subjects and aortic coarctation (COA) in 19/152 (12.5%). Isolated anomalous pulmonary veins (APV) were detected in 15/152 (10%) for the 45,X study group, and this defect was not correlated with the presence of BAV or COA. BAVs were present in 28.6% of subjects with Xp deletions and COA in 6.7%. APV were not found in subjects with Xp deletions. The most distal break associated with the BAV/COA trait was at cytologic band Xp11.4 and ChrX:41,500?000. One of 14 subjects (7%) with the 46,X,i(Xq) karyotype had a BAV and no cases of COA or APV were found in this group. No cardiovascular defects were found among four patients with Xq deletions. Conclusions The high prevalence of BAV and COA in subjects missing only the X chromosome short arm indicates that haploinsufficiency for Xp genes contributes to abnormal aorticvalve and aortic arch development in TS. PMID:23825392
Bondy, Carolyn; Bakalov, Vladimir K; Cheng, Clara; Olivieri, Laura; Rosing, Douglas R; Arai, Andrew E
Detailed characterization of the subdermal model is a significant tool for better understanding of calcification mechanisms occurring in heart valves. In previous ultrastructural investigation on six-week-implantated aorticvalve leaflets, modified pre-embedding glutaraldehyde-cuprolinic-blue reactions (GA-CB) enabled sample decalcification with concurrent retention/staining of lipid-containing polyanionic material, which lined cells and cell-derived matrix-vesicle-like bodies (phthalocyanin-positive layers: PPLs) co-localizing with the earliest apatite nucleation sites. Additional post-embedding silver staining (GA-CB-S) revealed PPLs to contain calcium-binding sites. This investigation concerns valve leaflets subjected to shorter implantation times to shed light on the modifications associated with PPLs generation and calcification onset/progression. Spectrometric estimations revealed time-dependent calcium increase, for unreacted samples, and copper modifications indicating an increase in acidic, non-glycanic material, for GA-CB-reacted samples. Two-day-implant thin sections showed emission and subsequent reabsorption of lamellipodium-like protrusions by cells, originating ECM-containing vacuoles, and/or degeneration stages characterized by the appearance of GA-CB-S-reactive, organule-derived dense bodies and progressive dissolution of all cell membranes. In one-week-implants, the first PPL-lined cells were found to co-exist with cells where GA-CB-S-reactive material accumulated, or exudated towards their edges, or outcropped at the ECM milieu, so acquiring PPL features. PPL-derived material was observed increasingly to affect the ECM on thin sections of one-week- to six-week-implants. These results show an endogenous source for PPLs and reveal that a peculiar cascade of cell degenerative steps is associated with valve mineralization in the subdermal model, providing new useful parameters for more reliable comparison of this experimental calcification process versus the physiological and pathological processes. PMID:17163400
Ortolani, F; Bonetti, A; Tubaro, F; Petrelli, L; Contin, M; Nori, S L; Spina, M; Marchini, M
Purpose Gentamicin is a widely employed antibiotic, but may reduce calcium uptake by eukaryotic cells. This study was conducted to determine whether gentamicin reduces calcification by porcine aortic valvular interstitial cells (pAVICs) grown in 2D culture, which is a common model for calcific aorticvalve disease (CAVD). Methods and Results The presence of gentamicin (up to 0.2 mM) in the medium of pAVICs cultured for 8 days significantly lowered calcification and alkaline phosphatase content in a dose-dependent manner compared to pAVICs cultured without gentamicin. Gentamicin also significantly increased cell proliferation and apoptosis at concentrations of 0.1–0.2 mM. Next, gentamicin was applied to previously calcified pAVIC cultures (grown for 8 days) to determine whether it could stop or reverse the calcification process. Daily application of gentamicin for 8 additional days significantly reduced calcification to below the pre-calcification levels. Conclusions These results confirm that gentamicin should be used cautiously with in vitro studies of calcification, and suggest that gentamicin may have the ability to reverse calcification by pAVICs. Given the nephrotoxicity and ototoxicity of this antibiotic, its clinical potential for the treatment of calcification in heart valves is limited. However, further investigation of the pathways through which gentamicin alters calcium uptake by valvular cells may provide insight into novel therapies for CAVD.
Kumar, Aditya; Wiltz, Dena C.; Grande-Allen, K. Jane
Background Quadricuspid aorticvalve (QAV) and ventricular septal defect (VSD) are congenital heart defects and have been described in both human and veterinary medical literature. Case presentation A 5-year-old half-bred bay stallion was referred for surgical castration. Cardiac murmurs were heard on the presurgical clinical examination and the cardiac examination revealed subcutaneous oedema, tachycardia with a precodrial thrill and a grade 5/6 pansystolic murmur, which was heard on auscultation of the right and left side of the chest. Examination of the B-mode echocardiograms revealed the presence of a QAV (one small cusp, two equal-sized cusps, and one large cusp) and VSD in the membranous portion of the intraventricular septum. These two congenital cardiac defects were accompanied by mild aorticvalve regurgitation and severe tricuspid regurgitation. Despite the presence of these cardiac defects, the horse underwent surgical castration under general anesthesia. Surgery, anaesthesia and recovery from anaesthesia were uneventful. The gelding was euthanasied after 17 months because of a progressive loss of body weight, weakness and recumbency. Conclusion A QAV in combination with VSD in a horse is an interesting finding, because to the best of our knowledge, this has not been previously described in equine literature. PMID:24981768
The prevalence of primary cardiac tumour ranges from 0.0017-0.28% and papillary fibroelastoma is rare but not uncommon benign cardiac neoplasm. Currently, with the advent of higher-resolution imaging technology especially transoesophageal echocardiography such cases being recognized frequently. The clinical presentation of these tumours varies from asymptomatic to severe ischaemic or embolic complications. We herein, present a 50-year-old female patient with a papillary fibroelastoma of the aorticvalve arising from the endocardium of the right coronary cusp very close to the commissure between the right and non-coronary cusps. The patient presented with angina-like chest pain and was investigated using echocardiography and CT angiographic modalities in addition to the usual investigations. The differential diagnosis considered was a thrombus, myxoma, Lambl's excrescence and infective vegetation. The surgical management included a prompt resection of the tumour on cardiopulmonary bypass avoiding injury to the aorticvalve. The patient recovered well. A review of the literature suggests that the cardiac papillary fibroelastoma is a rare but potentially treatable cause of embolic stroke and other fatal complications, therefore, a strong suspicion; appropriate use of imaging modality, preoperative anticoagulation and urgent surgical resection is warranted. Also, possibility of this diagnosis should be kept in mind while managing cardiac or valvular tumours. PMID:20950491
Patients with severe aortic stenosis are sometimes not candidates for conventional open heart surgery because of severe deconditioning, excessive risk factors, and multiple comorbidities. Transcatheter aorticvalve implantation (TAVI) is a relatively recent intervention, which was initially addressed to individuals with severe symptomatic aortic stenosis at substantial or prohibitive surgical risk. Despite the documented beneficial effects of this therapeutic intervention in certain carefully selected individuals, it has not yet been applied to lower risk patients. This is a review of the current literature and accumulated clinical data of this rapidly evolving invasive procedure in an attempt to resolve whether it can now be applied to a wider portion of patients with aortic stenosis.
We propose a navigation system for transcatheter aorticvalve implantation that employs a magnetic tracking system (MTS) along with a dynamic aortic model and intra-operative ultrasound (US) images. This work is motivated by the desire of our cardiology and cardiac surgical colleagues to minimize or eliminate the use of radiation in the interventional suite or operating room. The dynamic 3-D aortic model is constructed from a preoperative 4-D computed tomography dataset that is animated in synchrony with the real time electrocardiograph input of patient, and then preoperative planning is performed to determine the target position of the aorticvalve prosthesis. The contours of the aortic root are extracted automatically from short axis US images in real-time for registering the 2-D intra-operative US image to the preoperative dynamic aortic model. The augmented MTS guides the interventionist during positioning and deployment of the aorticvalve prosthesis to the target. The results of the aortic root segmentation algorithm demonstrate an error of 0.92±0.85 mm with a computational time of 36.13±6.26 ms. The navigation approach was validated in porcine studies, yielding fiducial localization errors, target registration errors, deployment distance, and tilting errors of 3.02±0.39 mm, 3.31±1.55 mm, 3.23±0.94 mm, and 5.85±3.06(°) , respectively. PMID:23912499
A 19 mm diameter prototype bioprosthetic valve mounted in a cardiac pulse duplicator was characterized using Doppler echocardiography and qualitative flow visualization at a heart rate of 72 bpm. Analysis of the flow visualization images revealed that the prototype and control valve leaflets open symmetrically but close asymmetrically. The asymmetry in the closing of the valves is likely due to the large pressure gradients across the valves and may have implications for the long term mechanical failure of the valves. The relatively high peak systolic velocity of 309.9 cm/s, which was measured in the prototype 19 mm valve, can be attributed to the small valve diameter and the high cardiac output used in the current study. PMID:23367452
Background and aim of the study Aorticvalve sclerosis (AVSc), the early asymptomatic stage of calcific aorticvalve disease (CAVD), is characterized by a progressive thickening of the aortic cusps without obstruction of the left ventricular outflow. In spite of its high prevalence, there are no molecular markers to characterize the early stages of CAVD before it progresses to a severe, symptomatic stage of aorticvalve stenosis (AVS). The study aim was to identify any correlation between circulating biomarkers and transesophageal echocardiography (TEE) evaluation. Methods A total of 330 patients with various degrees of CAVD was enrolled into the study. Blood was collected from each patient prior to surgery, and analyzed using ELISA kits following the manufacturers' instructions. Results Significantly higher plasma osteopontin (OPN) levels were observed in AVSc patients (72.7 ± 1.8 ng/ml; p <0.001) and AVS patients (64.3 ± 5.1 ng/ml; p <0.001) when compared to controls (30.3 ± 1.8 ng/ml). Parathyroid hormone (PTH) levels in AVSc and AVS patients (164.1 ± 16.5 and 134.3 ± 14.6 pg/ml; p <0.001 and p = 0.04, respectively) were also significantly higher than in controls (61.8 ± 4.92 pg/ml). Upon further analysis, plasma levels of OPN (p <0.001) and PTH (p <0.001) were found to be significantly higher in asymptomatic AVSc patients, even before calcium deposition was detected on TEE evaluation. Fetuin-A levels were lower at all stages of CAVD when compared to controls (p <0.001 and p ?0.05, respectively), but were comparable among the patient groups. NT-levels were significantly higher in AVS patients than in controls (p ?0.01). Conclusion Serum levels of OPN, PTH, and fetuin-A showed a significant association with different stages of CAVD, with variations in their levels occurring before calcium nodules are visualized during TEE evaluation. The study results may help not only to provide a better understanding of the progression of CAVD but also to develop new tools that can be used to stage these patients. PMID:23798203
Sainger, Rachana; Grau, Juan B.; Branchetti, Emanuela; Poggio, Paolo; Lai, Eric; Koka, Erblina; Vernick, William J.; Gorman, Robert C.; Bavaria, Joseph E.; Ferrari, Giovanni
Objectives: To describe the incidence and rate of dilatation of the ascending aorta in children with bicuspid aorticvalve (BAV) and to determine factors that predict rapid aortic dilatation.Design: Retrospective cohort study.Setting: Regional tertiary care children’s hospital.Patients: All children aged 0–18 years seen at the authors’ institution between 1990 and 2003 with an “isolated” BAV. All patients had had more
Purpose Transcatheter aorticvalve implantation (TAVI) has become an attractive therapeutic strategy for severe aortic stenosis (AS) in elderly patients due to its minimally-invasive nature. Therefore, early results of its clinical outcomes in elderly Korean patients were evaluated. Materials and Methods We compared early clinical outcomes of TAVI, surgical aorticvalve replacement (SAVR), and optimal medical therapy (OMT) in patients aged ?80 years with symptomatic severe AS. Treatment groups were allocated as follows: TAVI (n=10), SAVR (n=14), and OMT (n=42). Results Baseline clinical characteristics including predicted operative mortality were similar among the three groups. However, patients with New York Heart Association functional class III or IV symptoms and smaller aorticvalve area were treated with TAVI or SAVR rather than OMT. In-hospital combined safety endpoints (all-cause mortality, major stroke, peri-procedural myocardial infarction, life-threatening bleeding, major vascular complication, and acute kidney injury) after TAVI or SAVR were significantly lower in the TAVI group than in the SAVR group (10.0% vs. 71.4%, respectively, p=0.005), along with an acceptable rate of symptom improvement and device success. During the follow-up period, the TAVI group showed the lowest rate of 3-month major adverse cardiovascular and cerebrovascular events, a composite of all-cause mortality, myocardial infarction, major stroke, and re-hospitalization (TAVI 0.0% vs. SAVR 50.0% vs. OMT 42.9%, p=0.017). Conclusion Treatment with TAVI was associated with lower event rates compared to SAVR or OMT. Therefore, TAVI may be considered as the first therapeutic strategy in selected patients aged ?80 years with symptomatic severe AS. PMID:23549802
Im, Eui; Ko, Young-Guk; Shin, Dong-Ho; Kim, Jung-Sun; Kim, Byeong-Keuk; Choi, Donghoon; Shim, Chi Young; Chang, Hyuk-Jae; Shim, Jae-Kwang; Kwak, Young-Lan; Lee, Sak; Chang, Byung-Chul; Jang, Yangsoo
A motorized valve has a housing having an inlet and an outlet to be connected to a pipeline, a saddle connected with the housing, a turn plug having a rod, the turn plug cooperating with the saddle, and a drive for turning the valve body and formed as a piezoelectric drive, the piezoelectric drive including a piezoelectric generator of radially directed standing acoustic waves, which is connected with the housing and is connectable with a pulse current source, and a rotor operatively connected with the piezoelectric generator and kinematically connected with the rod of the turn plug so as to turn the turn plug when the rotor is actuated by the piezoelectric generator.
Due to demographic changes in average life expectancy, the age of patients undergoing cardiac surgery is increasing. We have reviewed the short- and long-term outcome after aorticvalve replacement with or without concomitant coronary artery bypass grafting in patients over 80 years of age. From 1 January 1995 until 30 June 1999, 114 patients (83 women and 31 men, 80-89
Jürgen Ennker; Amir Mortasawi; Stefan Gehle; Mehran Yaghmaie; Thomas Schröder; Ulrich Rosendahl; Ina Carolin Ennker
Background A bicuspid aorticvalve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. The aim of our study was to assess the degree of ascending aortic dilatation by measuring the ratio of the dimension of the AAo to that of the descending aorta (DAo) using preoperative computerized tomography (CT). Methods A review of our institutional clinical database identified 76 patients undergoing aorticvalve replacement (AVR) and 73 control patients undergoing off-pump coronary artery bypass (OPCAB group) between September 2009 and April 2012. Results There were 17 patients diagnosed with BAV (BAV group), and the remaining 59 patients had a tricuspid aorticvalve (TAV group). The ratios of the dimensions of the AAo to that of the DAo (AAo/DAo) for each group were: BAV, 1.58?±?0.25; TAV, 1.32?±?0.11; and OPCAB, 1.29?±?0.12. Interestingly, the AAo/DAo of the BAV group was significantly larger than that of the other groups. Conclusions Although progressive AAo dilatation for BAV is well documented, the diameter of the AAo is currently the only estimate of aortic dilatation. In this study, we report that the ratio of the AAo and DAo diameters in patients with BAV can be a new index for assessing the dilatation of the AAo and differentiating the patients with BAV from those with TAV. PMID:24947564
OBJECTIVES Guidelines proposed bioprosthesis implantation for aorticvalve disease if the patients were at least 65 years old at the time of surgery, with a trend towards even younger patients in recent years. Considering the adverse effects of lifetime anticoagulation, new biological valves (less prone to degeneration) and new technologies may lead patients and surgeons to different choices. Therefore, it is interesting to analyse the results of aortic bioprosthetic valve replacement in patients aged <65 years at the time of surgery. METHODS From January 2000 to December 2010, 84 patients aged <65 years at the time of surgery had undergone an aortic bio-prosthetic valve replacement. A mid-term follow-up [(FU) mean FU time: 54.4 ± 39.2 months] was done in August 2011 in all patients (FU completeness: 100%). Results were compared with patients who had a mechanical prosthetic aorticvalve replacement during the same period. RESULTS The reoperation rate for structural valve degeneration (SVD) of bioprostheses was 6% and occurred exclusively among patients <56 years. Contraindications for anticoagulation determined the choice of a bioprosthesis among 83% of these patients. The personal preference to avoid anticoagulation was the leading cause in 68% of the older patients (56–65 years). Neurological complications occurred more frequently in the mechanical control group. CONCLUSIONS Reoperations for SVD after bioprosthesis implantation occurred exclusively among younger patients (<56 years), not suitable for systemic anticoagulation. Previous studies, together with our experience, are in favour of an age limit between 56 and 60 years, taking into consideration alternative transcatheter approaches to SVD treatment. PMID:23287588
Niclauss, Lars; von Segesser, Ludwig Karl; Ferrari, Enrico
This is the first report of rare simultaneous complication of three cardiac malformations: bicuspid aorticvalve with annuloaortic ectasia, single coronary artery, and patent foramen ovale. We successfully operated to replace the aorticvalve and ascending aorta, and to close the patent foramen ovale. PMID:24916464
Background Preoperative assessment of patients with aorticvalve stenosis (AS) relies on the evaluation of AS severity (aorticvalve area, AVA) and left ventricular ejection fraction (LVEF) by echocardiography, and of coronary artery anatomy by coronary angiography. Aim To evaluate the feasibility and accuracy of contrast?enhanced multidetector computed tomography (MDCT), as a single non?invasive preoperative test, for simultaneous evaluation of the AVA, LVEF and coronary status in patients with AS. Methods 40 consecutive patients with AS scheduled for aorticvalve replacement underwent transthoracic echocardiography, electrocardiogram (ECG)?gated MDCT and coronary angiography within a time span of 1?week. Results MDCT measurements could be performed in all patients. A good correlation but a slight overestimation was observed between mean (SD) AVA measured by MDCT and by echocardiography (0.87 (0.22) vs 0.81 (0.20)?cm2, p?=?0.01; r?=?0.77, p<0.001). Mean difference between methods was 0.06 (0.15)?cm2. LVEF measured by MDCT correlated well with, and did not differ from, electrocardiographic measurements (59% (13%) vs 61% (10%), p?=?0.34; r?=?0.76, p<0.001; mean difference 1% (8%)). Coronary angiography displayed 33 lesions in 13 patients. MDCT correctly identified 26 of these 33 lesions and overestimated three <50% stenosis. On a segment?by?segment analysis, MDCT sensitivity, specificity, positive and negative predictive values were 79%, 99%, 90% and 98%, respectively. For each patient, MDCT had a sensitivity of 85% (11/13 patients), a specificity of 93% (25/27 patients) and positive and negative predictive values of 85% (11/13 patients) and 93% (25/27 patients), respectively. Conclusion MDCT can provide a simultaneous and accurate evaluation of the AVA, LVEF and coronary artery anatomy in patients with AS. In the near future, with technological improvements, MDCT could achieve an exhaustive and comprehensive preoperative assessment of patients with AS. In addition, for the assessment of AS severity in difficult cases, MDCT could be considered as an alternative to transoesophageal echocardiography or cardiac catheterisation. PMID:17483132
Background Transcatheter AorticValve Replacement (TAVR) has emerged as a less invasive option for valve replacement for high-risk patients with severe aortic stenosis. However, not all patients derive a mortality or quality of life (QoL) benefit from TAVR. As such, we sought to build and validate a prediction model to identify patients at high risk for a poor outcome after TAVR, using a novel definition of outcome that integrates QoL with mortality. Methods and Results We examined QoL and mortality outcomes among 2137 patients who underwent TAVR in the PARTNER randomized trial or the associated continued access registry. QoL was assessed using the Overall Summary Scale of the Kansas City Cardiomyopathy Questionnaire (KCCQ-OS, range 0-100; higher=better) at baseline and at 1, 6, and 12 months. A poor 6-month outcome—defined as death, KCCQ-OS <45, or a decrease in KCCQ-OS by ?10 points compared with baseline—occurred in 704 patients (33%). A multivariable model was constructed using a split-sample design to identify a parsimonious set of covariates to identify patients at high-risk for poor outcome. The resulting model demonstrated adequate discrimination (c-index=0.66) and good calibration with the observed data and performed similarly in the separate validation cohort. Based on pre-procedure characteristics alone, the model identified 211 patients (10% of the population) with a ?50% likelihood of a poor outcome after TAVR. These individuals were more likely to have low body weights, low mean aorticvalve gradients, oxygen-dependent lung disease, and poor baseline functional and cognitive status. A second model that explored predictors of poor outcome at 1 year identified similar predictors as the original model and was able to identify 1102 patients (52%) with ?50% likelihood and 178 (8%) with ?70% likelihood of a poor 1-year outcome after TAVR Conclusions Using a large, multicenter cohort of patients undergoing TAVR, we have developed and validated predictive models that can identify patients at high-risk for a poor outcome after TAVR. These models may help guide treatment choices and offer patients realistic expectations of outcomes based on their presenting characteristics. PMID:24958751
Arnold, Suzanne V.; Reynolds, Matthew R.; Lei, Yang; Magnuson, Elizabeth A.; Kirtane, Ajay J.; Kodali, Susheel K.; Zajarias, Alan; Thourani, Vinod H.; Green, Philip; Rodes-Cabau, Josep; Beohar, Nirat; Mack, Michael J.; Leon, Martin B.; Cohen, David J.
A plasma valve includes a confinement channel and primary anode and cathode disposed therein. An ignition cathode is disposed adjacent the primary cathode. Power supplies are joined to the cathodes and anode for rapidly igniting and maintaining a plasma in the channel for preventing leakage of atmospheric pressure through the channel.
Hershcovitch, Ady (Mount Sinai, NY); Sharma, Sushil (Hinsdale, IL); Noonan, John (Naperville, IL); Rotela, Elbio (Clarendon Hills, IL); Khounsary, Ali (Hinsdale, IL)
Adequate in-vitro training in valved stents deployment as well as testing of the latter devices requires compliant real-size models of the human aortic root. The casting methods utilized up to now are multi-step, time consuming and complicated. We pursued a goal of building a flexible 3D model in a single-step procedure. We created a precise 3D CAD model of a human aortic root using previously published anatomical and geometrical data and printed it using a novel rapid prototyping system developed by the Fab@Home project. As a material for 3D fabrication we used common house-hold silicone and afterwards dip-coated several models with dispersion silicone one or two times. To assess the production precision we compared the size of the final product with the CAD model. Compliance of the models was measured and compared with native porcine aortic root. Total fabrication time was 3 h and 20 min. Dip-coating one or two times with dispersion silicone if applied took one or two extra days, respectively. The error in dimensions of non-coated aortic root model compared to the CAD design was <3.0% along X, Y-axes and 4.1% along Z-axis. Compliance of a non-coated model as judged by the changes of radius values in the radial direction by 16.39% is significantly different (P<0.001) from native aortic tissue--23.54% at the pressure of 80-100 mmHg. Rapid prototyping of compliant, life-size anatomical models with the Fab@Home 3D printer is feasible--it is very quick compared to previous casting methods. PMID:19036761
Optimal thromboprophylaxis following bioprosthetic aorticvalve replacement (AVR) remains controversial. The main objective, which is the effective prevention of central nervous or peripheral embolic events, especially in the early postoperative period, will have to be weighed against the haemorrhagic risk that is associated with the utilization of different antithrombotic regimes. Most governing bodies in cardiovascular medicine have issued recommendations on thromboprophylaxis after the surgical implantation of aortic bioprostheses. However, the level of evidence to support these recommendations remains low, largely due to the inherent limitations of conducting appropriately randomized and adequately powered clinical research in this area. It is apparent from the recent surveys and large registries that there is a great variability in antithrombotic practice at an institutional or individual-clinician level reflecting this controversy and the lack of robust evidence. While organizational, financial or conceptual limitations could hinder the conduct and availability of conclusive research on optimal thromboprophylaxis after aortic bioprosthesis, it is imperative that all evidence is presented in a systematic way in order to assist the decision-making for the modern clinician. In this review, we provide an outline of the current recommendations for thromboprophylaxis, followed by a comprehensive and analytical presentation of all comparative studies examining anticoagulation vs. antiplatelet therapy after bioprosthetic AVR. PMID:22493097
BACKGROUND: 3D transesophageal echocardiography (TEE) may provide more accurate aortic annular and left ventricular outflow tract (LVOT) dimensions and geometries compared with 2D TEE. We assessed agreements between 2D and 3D TEE measurements with multislice computed tomography (MSCT) and changes in annular\\/LVOT areas and geometries after transcatheter aorticvalve implantations (TAVI). METHODS AND RESULTS: Two-dimensional circular (pixr(2)), 3D circular, and
A. C. T. Ng; V. Delgado; F. van der Kley; M. Shanks; N. R. L. van de Veire; M. Bertini; G. Nucifora; R. J. van Bommel; L. F. Tops; A. de Weger; G. Tavilla; A. de Roos; L. J. Kroft; D. Y. Leung; J. Schuijf; M. J. Schalij; J. J. Bax
Transcatheter aorticvalve replacement (TAVR) is increasingly accepted as a feasible and safe therapeutic alternative to open heart surgery in select patients. Procedural success and technological advances combined with favorable clinical outcomes and demonstrated prolonged survival are establishing TAVR as the standard of care in symptomatic patients who are at higher risk or not candidates for conventional surgery. The growing number of referrals and complexities of care of TAVR candidates warrants a program that ensures appropriate patient assessment and triage, establishes appropriate processes, and promotes continuity of care. To address these needs and prepare for the anticipated growth of transcatheter heart valve (THV) therapeutic options, the TAVR program at St. Paul's Hospital, Vancouver, Canada, implemented an electronic centralized and clinically managed referral and triage program, and a THV Nurse Coordinator position to support the program and patients, conduct a global functioning assessment, and provide clinical triage coordination, waitlist management, patient and family education and communication with clinicians. Interdisciplinary rounds assist in the selection of candidates, while a clinical data management system facilitates standardized documentation and quality assurance from referral to follow-up. The unique needs of TAVR patients and programs require the implementation of unique processes of care and tailored assessment. PMID:21782520
Lauck, Sandra; Achtem, Leslie; Boone, Robert H; Cheung, Anson; Lawlor, Cindy; Ye, Jian; Wood, David A; Webb, John G
The case of a 63-year-old woman who underwent minimal invasive mitral and tricuspid valve repair and a concomitant CryoMaze is described. During creation of the last lesion of the right-sided maze procedure, dissection of the ascending aorta occurred that necessitated emergency sternotomy, replacement of the ascending aorta, and aortocoronary bypass grafting to the right coronary artery (RCA) because of detachment of the RCA from the aortic annulus. Repair of this complication was successful; nevertheless, the patient died 5 days after the operation because of multiorgan failure. The cause of this complication can only be speculated, but a relation to the CyroMaze is obvious. Because of the restricted incision with impaired vision especially in the area of the right atrial appendage, the cryoprobe could have come into contact with the orifice of the RCA during the last lesion, with subsequent detachment of the RCA from the aorta, which could subsequently have caused dissection. PMID:23274873
The widely popular quasi-linear viscoelasticity (QLV) theory has been employed extensively in the literature for characterising the time-dependent behaviour of many biological tissues, including the aorticvalve (AV). However, in contrast to other tissues, application of QLV to AV data has been met with varying success, with studies reporting discrepancies in the values of the associated quantified parameters for data collected from different timescales in experiments. Furthermore, some studies investigating the stress-relaxation phenomenon in valvular tissues have suggested discrete relaxation spectra, as an alternative to the continuous spectrum proposed by the QLV. These indications put forward a more fundamental question: Is the time-dependent behaviour of the aorticvalve intrinsically quasi-linear? In other words, can the inherent characteristics of the tissue that govern its biomechanical behaviour facilitate a quasi-linear time-dependent behaviour? This paper attempts to address these questions by presenting a mathematical analysis to derive the expressions for the stress-relaxation G( t) and creep J( t) functions for the AV tissue within the QLV theory. The principal inherent characteristic of the tissue is incorporated into the QLV formulation in the form of the well-established gradual fibre recruitment model, and the corresponding expressions for G( t) and J( t) are derived. The outcomes indicate that the resulting stress-relaxation and creep functions do not appear to voluntarily follow the observed experimental trends reported in previous studies. These results highlight that the time-dependent behaviour of the AV may not be quasi-linear, and more suitable theoretical criteria and models may be required to explain the phenomenon based on tissue's microstructure, and for more accurate estimation of the associated material parameters. In general, these results may further be applicable to other planar soft tissues of the same class, i.e. with the same representation for fibre recruitment mechanism and discrete time-dependent spectra.
Background The hypothesis of this study was that local anesthesia with monitored anesthesia care (MAC) is not harmful in comparison to general anesthesia (GA) for patients undergoing Transcatheter AorticValve Implantation (TAVR). TAVR is a rapidly spreading treatment option for severe aorticvalve stenosis. Traditionally, in most centers, this procedure is done under GA, but more recently procedures with MAC have been reported. Methods This is a systematic review and meta-analysis comparing MAC versus GA in patients undergoing transfemoral TAVR. Trials were identified through a literature search covering publications from 1 January 2005 through 31 January 2013. The main outcomes of interest of this literature meta-analysis were 30-day overall mortality, cardiac-/procedure-related mortality, stroke, myocardial infarction, sepsis, acute kidney injury, procedure time and duration of hospital stay. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals. Results Seven observational studies and a total of 1,542 patients were included in this analysis. None of the studies were randomized. Compared to GA, MAC was associated with a shorter hospital stay (-3.0 days (-5.0 to -1.0); P?=?0.004) and a shorter procedure time (MD -36.3 minutes (-58.0 to -15.0 minutes); P <0.001). Overall 30-day mortality was not significantly different between MAC and GA (RR 0.77 (0.38 to 1.56); P?=?0.460), also cardiac- and procedure-related mortality was similar between both groups (RR 0.90 (0.34 to 2.39); P?=?0.830). Conclusion These data did not show a significant difference in short-term outcomes for MAC or GA in TAVR. MAC may be associated with reduced procedural time and shorter hospital stay. Now randomized trials are needed for further evaluation of MAC in the setting of TAVR. PMID:24612945
Background The incidence of clinically apparent stroke in transcatheter aorticvalve implantation (TAVI) exceeds that of any other procedure performed by interventional cardiologists and, in the index admission, occurs more than twice as frequently with TAVI than with surgical aorticvalve replacement (SAVR). However, this represents only a small component of the vast burden of neurological injury that occurs during TAVI, with recent evidence suggesting that many strokes are clinically silent or only subtly apparent. Additionally, insult may manifest as slight neurocognitive dysfunction rather than overt neurological deficits. Characterisation of the incidence and underlying aetiology of these neurological events may lead to identification of currently unrecognised neuroprotective strategies. Methods The Silent and Apparent Neurological Injury in TAVI (SANITY) Study is a prospective, multicentre, observational study comparing the incidence of neurological injury after TAVI versus SAVR. It introduces an intensive, standardised, formal neurologic and neurocognitive disease assessment for all aorticvalve recipients, regardless of intervention (SAVR, TAVI), valve-type (bioprosthetic, Edwards SAPIEN-XT) or access route (sternotomy, transfemoral, transapical or transaortic). Comprehensive monitoring of neurological insult will also be recorded to more fully define and compare the neurological burden of the procedures and identify targets for harm minimisation strategies. Discussion The SANITY study undertakes the most rigorous assessment of neurological injury reported in the literature to date. It attempts to accurately characterise the insult and sustained injury associated with both TAVI and SAVR in an attempt to advance understanding of this complication and associations thus allowing for improved patient selection and procedural modification. PMID:24708720
Objective: Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aorticvalve disease is increasing, but use of the pulmonary autograft in the treatment of aorticvalve
Gösta Pettersson; Jens Tingleff; Frederic S. Joyce
Objective: The degeneration of bicuspid aorticvalve and its frequent association with ascending aortic pathology, point to a still unidentified genetic tissue defect with unknown mediators. Metalloproteinases (MMPs) are lytic enzymes that have been strongly implicated in aneurysm formation. The purpose of this study was to detect the presence of these enzymes in aortic valvular tissue in healthy and diseased
George J. Koullias; Dimitris P. Korkolis; Pars Ravichandran; Amanda Psyrri; Ioannis Hatzaras; John A. Elefteriades
BACKGROUND: Cardiovascular magnetic resonance (CMR) is considered an attractive alternative for guiding transarterial aorticvalve implantation (TAVI) featuring unlimited scan plane orientation and unsurpassed soft-tissue contrast with simultaneous device visualization. We sought to evaluate the CMR characteristics of both currently commercially available transcatheter heart valves (Edwards SAPIEN™, Medtronic CoreValve®) including their dedicated delivery devices and of a custom-built, CMR-compatible delivery
Philipp Kahlert; Holger Eggebrecht; Björn Plicht; Oliver Kraff; Ian McDougall; Brad Decker; Raimund Erbel; Mark E Ladd; Harald H Quick
Background—The Medtronic-Hall valve was developed and for the first time implanted in Oslo, Norway, in 1977. A total of 1104 patients received this valve at Rikshospitalet from 1977 to 1987. In the present study, we followed up on all 816 patients undergoing aorticvalve replacement over a 25-year period. Methods and Results—This is a retrospective cohort analysis of 816 consecutive
Jan L. Svennevig; Michel Abdelnoor; Sigurd Nitter-Hauge
OBJECTIVES Although many studies have evaluated the impact of obesity on various medical treatments, it is not known whether obesity is related to late mortality with implantation of small aortic prostheses. This study evaluated the effect of obesity on the late survival of patients after aorticvalve replacement (AVR) with implantation of a small aortic prosthesis (size ?21 mm). METHODS From January 1998 to December 2008, 307 patients in our institution who underwent primary AVR with smaller prostheses survived 30 days after surgery. Patients were categorized as normal weight if body mass index (BMI) was <24 kg/m2, overweight if BMI 24–27.9 kg/m2 and obese if BMI ?28 kg/m2. Data of the New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF), effective orifice area index (EOAI) and left ventricular mass index of the patients were collected at the third month, sixth month, first year, third year, fifth year and eighth year after operation. RESULTS By multivariable analysis, obesity was a significant independent factor of late mortality (hazard ratio: 1.62; P = 0.01). The obese and overweight groups of patients exhibited lower survival (P < 0.001) and a higher proportion in NYHA Class III/IV (P < 0.01) compared with the normal group. A lower EOAI and higher left ventricular mass index were found in the obese and overweight groups, but we saw no significant variance in LVEF among the three groups. CONCLUSIONS Obesity is associated with increased late mortality of patients after AVR with implantation of small aortic prosthesis. Obesity or/and overweight may also affect the NYHA classification, even in the longer term. EOAI should be improved where possible, as it may reduce late mortality and improve quality of life in obese or overweight patients. PMID:23529754
Early intervention is necessary in neonates with critical aortic stenosis. The advent of alternate therapy, particularly balloon aortic valvuloplasty, requires a reappraisal of the traditional surgical approach, including the efficacy of intiail transvalvar gradient reduction and freedom from recurrence of obstruction in the longer term. This report describes a series of 33 consecutive infants who underwent surgical aortic valvotomy in
Hans Peter Gildein; Sabine Kleinert; Robert G. Weintraub; James L. Wilkinson; Tom R. Karl; Roger B. B. Mee
. For an analysis of stem cells, two-color flow cytometry of isolated cells stained with Hoechst 33342 demonstrated as assessed by the SMA incorporation into stress fibers. When compared with normal valves, diseased valves that in VICs, cofilin is a marker for myofibroblasts in vivo and in vitro that arise from a rare population
An improved EGR valve controller is described which consists of: (A) body means defining an exhaust gas recirculation passage having an inlet, an outlet and a valve seat disposed in the passage intermediate the inlet and the outlet; (B) a valve member disposed in the EGR passage, the valve member moveable with respect to the valve seat for controlling flow
A. A. Kenny; R. G. Sokalski; L. E. Egle; D. C. Stahly
Artificial Heart Valve Design Your Chance to be a Biomedical Engineer #12;Circulatory System Video #12;What is a Heart Valve? Â· Heart Valve Video #12;#12;What Does a Heart Valve Do? Â· Maintain the one direction flow of blood through the heart Â· Heart valves allow blood to flow through in a forward direction
Transcatheter aorticvalve replacement (TAVR) is increasingly used to treat patients with aortic stenosis deemed high or extreme surgical risk candidates. Despite improved survival and quality of life following the procedure, TAVR is not without its complications. Stroke is a major source of morbidity and mortality in patients undergoing the procedure, with rates similar to and often higher than those associated with surgery. Most studies show a consistent link between TAVR and embolic lesions visualized on diffusion-weighted magnetic resonance imaging. The question of whether these lesions lead to long-term cognitive consequences remains open, but given the large literature on silent strokes and cognition, this association is probable. Initial studies implementing cerebral embolic protection devices in TAVR have yielded promising results with decreased neurological complications and appearance of new lesions on imaging. In this article, we will review the evidence linking silent stroke with cognitive decline, and potential therapeutic options to prevent stroke related to TAVR, including cerebral protection devices currently under investigation. PMID:23460315
Meller, Stephanie M; Baumbach, Andreas; Brickman, Adam M; Lansky, Alexandra J
The impact of gender-related pathophysiologic features of severe aortic stenosis on transcatheter aorticvalve implantation (TAVI) outcomes remains to be determined, as does the consistency of predictors of mortality between the genders. All consecutive patients who underwent TAVI at 6 institutions were enrolled in this study and stratified according to gender. Midterm all-cause mortality was the primary end point, with events at 30 days and at midterm as secondary end points. All events were adjudicated according to Valve Academic Research Consortium definitions. Eight hundred thirty-six patients were enrolled, 464 (55.5%) of whom were female. At midterm follow-up (median 365 days, interquartile range 100 to 516) women had similar rates of all-cause mortality compared with men (18.1% vs 22.6%, p = 0.11) and similar incidence of myocardial infarction and cerebrovascular accident. Gender did not affect mortality also on multivariate analysis. Among clinical and procedural features, glomerular filtration rate <30 ml/min/1.73 m(2) (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.36 to 4.79) and systolic pulmonary arterial pressure >50 mm Hg (HR 2.26, 95% CI 1.26 to 4.02) independently predicted mortality in women, while insulin-treated diabetes (HR 3.45, 95% CI 1.47 to 8.09), previous stroke (HR 3.42, 95% CI 1.43 to 8.18), and an ejection fraction <30% (HR 3.82, 95% CI 1.41 to 10.37) were related to mortality in men. Postprocedural aortic regurgitation was independently related to midterm mortality in the 2 groups (HR 11.19, 95% CI 3.3 to 37.9). In conclusion, women and men had the same life expectancy after TAVI, but different predictors of adverse events stratified by gender were demonstrated. These findings underline the importance of a gender-tailored clinical risk assessment in TAVI patients. PMID:25159239
Objectives This study sought to evaluate the impact of frailty in older adults undergoing transcatheter aorticvalve replacement (TAVR) for symptomatic aortic stenosis. Background Frailty status impacts prognosis in older adults with heart disease; however, the impact of frailty on prognosis after TAVR is unknown. Methods Gait speed, grip strength, serum albumin, and activities of daily living status were collected at baseline and used to derive a frailty score among patients who underwent TAVR procedures at a single large-volume institution. The cohort was dichotomized on the basis of median frailty score into frail and not frail groups. The impact of frailty on procedural outcomes (stroke, bleeding, vascular complications, acute kidney injury, and mortality at 30 days) and 1-year mortality was evaluated. Results Frailty status was assessed in 159 subjects who underwent TAVR (age 86 ± 8 years, Society of Thoracic Surgery Risk Score 12 ± 4). Baseline frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score. Although high frailty score was associated with a longer post-TAVR hospital stay when compared with lower frailty score (9 ± 6 days vs. 6 ± 5 days, respectively, p = 0.004), there were no significant crude associations between frailty status and procedural outcomes, suggesting adequacy of the standard selection process for identifying patients at risk for periprocedural complications after TAVR. Frailty status was independently associated with increased 1-year mortality (hazard ratio: 3.5, 95% confidence interval: 1.4 to 8.5, p = 0.007) after TAVR. Conclusions Frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR but was associated with increased 1-year mortality after TAVR. Further studies will evaluate the independent value of this frailty composite in older adults with aortic stenosis. PMID:22995885
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