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One hundred consecutive aortograms, performed with careful attention to recommended technical details, were reviewed to identify cases of “factitious” aorticvalve insufficiency, viz. aortic regurgitation seen during aortography for which there is no clinical evidence. Five patients with this condition were identified. Two of these subsequently underwent mitral valve replacement under cardiopulmonary by-pass. Aortic insufficiency was not detected during this procedure and the aorticvalve appeared to be anatomically normal at postmortem examination. That factitious aortic insufficiency may exist should be remembered when aortography is used to differentiate aortic from pulmonary valve insufficiency. ImagesFig. 1Fig. 2Fig. 3Fig. 4
... leaflets, instead of three. The aorticvalve regulates blood flow from the heart into the aorta, the major blood vessel that ... The aorticvalve allows oxygen-rich blood to flow from the heart ... aorta into the heart when the pumping chamber relaxes. Bicuspid ...
Bicuspid aorticvalve is a common congenital heart defect, often diagnosed incidentally or as a consequence of an associated condition. Patients with this anomaly are at increased risk for a variety of cardiovascular complications and require surveillance...
Purpose Transapical aorticvalve implantation (TA-AVI) is a new minimally invasive surgical treatment of aortic stenosis for high-risk\\u000a patients. The placement of aorticvalve prosthesis (AVP) is performed under 2D X-ray fluoroscopic guidance. Difficult clinical\\u000a complications can arise if the implanted valve is misplaced. Therefore, we present a method to track the AVP in 2D X-ray fluoroscopic\\u000a images in order to
M. E. Karar; D. R. Merk; C. Chalopin; T. Walther; V. Falk; O. Burgert
Transapical aorticvalve implantation is being employed as a less invasive alternative to open heart surgery in high-risk patients with severe aortic stenosis. Here we report the case of an awake transapical aorticvalve implantation in a patient with severe chronic obstructive pulmonary disease. PMID:22345062
Petridis, Francesco Dimitri; Savini, Carlo; Castelli, Andrea; Di Bartolomeo, Roberto
Myxomatous tumours can arise from different cardiac structures. They have a special predilection for the left atrium and are an exceedingly uncommon finding in cardiac valves. We report the case of a 28-year old man who presented with a stroke and was found to have a mass arising from his aorticvalve. The patient underwent a successful surgical excision of the aorticvalve with the implantation of a mechanical prosthesis. The histopathological examination of the aorticvalve confirmed the diagnosis of myxoma. Some aspects related to the diagnosis and management of this entity are discussed in this article.
Fernandez, Angel L.; Vega, Marino; El-Diasty, Mohammad M.; Suarez, Jose M.
We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aorticvalve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aorticvalve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well. To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aorticvalve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aorticvalve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.
Flannery, Laura D.; Lowery, Robert C.; Sun, Xiumei; Satler, Lowell; Corso, Paul; Pichard, Augusto; Wang, Zuyue
Investigates various new prototypes of aorticvalves. The fabricated valve prototypes were then tested by various hydrodynamic and hemocompatibility tests. The various prototype values designed and fabricated were: (1) a bileaflet valve, (2) a conical poppet valve, (3) a disc poppet valve, and (4) a fluidic nozzle valve. These valves were tested for percentage regurgitation across them, for pressure drop
Bicuspid aorticvalve (BAV) is the most common congenital heart disease, whose natural history is characterized by the incidence of clinically relevant valvular (stenosis, regurgitation, endocarditis) and/or vascular complications regarding the thoracic aorta (dilation, aneurysm, dissection) and, rarely, intracranial and epiaortic arteries. BAV may be heritable, with an autosomal dominant pattern of inheritance with reduced penetrance; moreover, some data suggest that BAV and thoracic aorta aneurysm are independent manifestations of a single gene defect. The prevalence of BAV and its susceptibility to valvular and aortic complications during the whole life result into the need of strict clinical follow-up and appropriate therapies (medical as well as surgical) to be addressed according to guidelines specifically designed for these patients. PMID:22322469
Transcatheter aorticvalve implantation and transcatheter mitral valve repair (MitraClip) procedures have been performed worldwide. In this paper, we review the use of two-dimensional and three-dimensional transesophageal echo for guiding transcatheter aorticvalve replacement and mitral valve repair.
A new central flow tilting disc valve has been introduced. The clinical experience from the first 50 patients treated with aorticvalve replacement and followed up for 12 months is reported. The results obtained are so encouraging that the tilting disc valve is at present preferred for all aorticvalve replacements in this institution. Images
Aorticvalve stenosis is a complex inflammatory process, akin to arterial atherosclerosis, involving lymphocytic infiltrates, macrophages, foam cells, endothelial activation and dysfunction, increased cellularity and extracellular matrix deposition, and lipoprotein accumulation. A clonal population of aorticvalve myofibroblasts spontaneously undergoes phenotypic transdifferentiation into osteoblast-like cells and forms calcific nodules in cell culture. Animal models complement these cell culture models by providing in vivo systems in which to study the complex molecular and cellular interactions that cause aorticvalve disease in the native hemodynamic and biochemical environment. Whereas some species, such as swine, can develop spontaneous vascular and valvular atherosclerotic lesions, others, such as rabbits and mice, have not been shown to develop lesions naturally and require an inciting factor, such as hypercholesterolemia. In this article, we review the published cell culture and animal models available to study calcific aorticvalve disease. PMID:17963676
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
Valve repair has emerged as an important intervention for the management of bicuspid aorticvalve disease. This systematic review aims to assess the safety, efficacy and durability of bicuspid aorticvalve repair. Initial searches yielded 682 abstracts, reduced by de-duplication to 370, of which 56 full papers were accessed and 30 met the inclusion criteria. Overall, 163 unique outcomes for bicuspid aorticvalve-preserving surgery were reported on 280 occasions. Bicuspid aorticvalve-preserving surgery exhibited low operative mortality (0.0-5.2%), excellent 5-year survival (82-100%) and 43-100% 5-year freedom from reoperation. Bicuspid aorticvalve repair is safe and efficacious, but concerns regarding its durability necessitate further standardized outcome assessments. PMID:23293321
Vohra, Hunaid A; Whistance, Robert N; De Kerchove, Laurent; Punjabi, Prakash; El Khoury, Gebrine
OBJECTIVESThe present study evaluates the long-term course of aorticvalve disease and the need for aorticvalve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.BACKGROUNDLittle is known about the natural history of aorticvalve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the
Aorticvalve sparing operations were developed to preserve the native aorticvalve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aorticvalve sparing oprations: remodeling of the aortic root and reimplantation of the aorticvalve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aorticvalve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aorticvalve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aorticvalve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.
The incidence of valvular aortic stenosis has increased over the past decades due to improved life expectancy. Surgical aorticvalve replacement is currently the only treatment option for severe symptomatic aortic stenosis that has been shown to improve survival. However, up to one third of patients who require lifesaving surgical aorticvalve replacement are denied surgery due to high comorbidities resulting in a higher operative mortality rate. In the past such patients could only be treated with medical therapy or percutaneous aortic valvuloplasty, neither of which has been shown to improve mortality. With advances in interventional cardiology, transcatheter methods have been developed for aorticvalve replacement with the goal of offering a therapeutic solution for patients who are unfit for surgical therapy. Currently there are two catheter-based treatment systems in clinical application (the Edwards SAPIEN aorticvalve and the CoreValve ReValving System), utilizing either a balloon-expandable or a self-expanding stent platform, respectively.
Akin, Ibrahim; Kische, Stephan; Rehders, Tim C.; Nienaber, Christoph A.; Rauchhaus, Mathias; Schneider, Henrik; Liebold, Andreas
Cumulative evidence has demonstrated that transcatheter aorticvalve implantation (TAVI) constitutes an effective treatment option for patients with severe symptomatic aortic stenosis and a high operative risk. New valve designs and TAVI-enabling devices have simplified the procedure, reduced the risk of complications, and broadened the applications of this treatment. The global adoption of TAVI allows us to appreciate the advantages, potentialities and caveats of the technology, identify patients who would benefit from TAVI and stratify more accurately the risk of complications. The focus of this article is to discuss the advances in this field, present the current evidence, and highlight the developments and strategies proposed to address the limitations of TAVI treatment. PMID:24025965
Bourantas, Christos V; Van Mieghem, Nicolas M; Soliman, Osama; Campos, Carlos A M; Iqbal, Javaid; Serruys, Patrick W
We report a prospective comparison between transcatheter valve implantation (TAVI, n?=?13) and surgical aorticvalve replacement (AVR, n?=?10) in patients with severe aorticvalve stenosis and previous coronary bypass surgery (CABG). All patients had at least bilateral patent internal thoracic arteries bypass without indication of repeat revascularization. After a similar post-procedure outcome, despite one early death in TAVI group, the 1-year survival was 100% in surgical group and in transfemoral TAVI group, and 73% in transapical TAVI group. When previous CABG is the lone surgical risk factor, indications for a TAVI procedure have to be cautious, specially if transfemoral approach is not possible.
The changes and improvements in the surgical treatment of aorticvalve disease in 296 patients, who were operated on between 1953 and 1965, are illustrated and discussed in general terms. Several of the early techniques, such as transventricular dilation, insertion of a homograft aorticvalve in the descending thoracic aorta, fabric replacement of one cusp or the entire valve, and ice-chip arrest of the heart, are now obsolete. Total replacement with a ball-valve prosthesis or an aorticvalve homograft while the coronary arteries are perfused with blood is the currently popular technique. The results of a hemodynamic follow-up study two years after surgery are also included.
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.
Buz, Semih; Pasic, Miralem; Unbehaun, Axel; Hetzer, Roland
Aorticvalve-sparing procedures demonstrate excellent valvular function at midterm. Recently authors have reported acceptable early results with aorticvalve-sparing procedures on patients with regurgitant bicuspid valves. We report the case of a novel procedure to preserve bicuspid valves with a calcified raphe and root dilatation. This procedure includes raphe excision, pericardial patch elongation, free edge leaflet reinforcement, and a root reimplantation valve-sparing procedure. PMID:15797089
Dagenais, Francois; Bauset, Richard; Mathieu, Patrick
Microembolic signals (MES) can be detected in many recipients of mechanical aorticvalve prostheses by transcranial Doppler ultrasound. The nature and etiology of these MES have remained unclear for a long time. The solid and gaseous nature of MES are discussed, as well as whether or not MES may reflect artifacts. Recently, the gaseous nature of these MES has been widely established. To understand the physics of bubble formation related to mechanical heart valve prostheses, it is necessary to discuss the different types of cavitation occurring at the prostheses and the conditions leading to the degassing of blood. We describe the history of transcranial Doppler ultrasound-techniques and the current techniques in the measurement of these signals. Furthermore, the possible clinical impact of MES, as well as strategies for the design of new prostheses and surgical alternatives to diminish their load are discussed. PMID:17173501
Transcatheter aorticvalve implantation (TAVI) has become a feasible and effective therapeutic option for patients with severe aortic stenosis and high operative risk or relative contraindications for surgical aorticvalve replacement (SAVR). Patient selection plays a crucial role in the success of TAVI. Echocardiography is a mainstay during the whole process starting with the very important morphological evaluation and accurate measurement of the aortic root, followed by guiding the procedure and detecting possible complications, and ending with serial assessment of the patient's heart and the implanted prosthesis. This present article reviews the role of echocardiography before, during, and after transcatheter aorticvalve implantation. PMID:23846007
Six patients with early systolic closure of the aorticvalve are described with mitral regurgitation, double outlet right ventricle, left ventricular diverticulum, congestive cardiomyopathy, Eisenmenger ventricular septal defect, and aortic regurgitation with an aneurysmal ascending aorta, respectively. None had evidence of subaortic stenosis. Early sytolic closure of the aorticvalve is thus not diagnostic of subvalvular aortic stenosis but is a non-specific finding. Images
Nowadays transcatheter aorticvalve implantation (TAVI) is an accepted alternative to surgical aorticvalve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position. PMID:23933060
The main objective of this work is to track the aorticvalve plane in intra-operative fluoroscopic images in order to optimize and secure Transcatheter AorticValve Implantation (TAVI) procedure. This paper is focused on the issue of aorticvalve calcifications tracking in fluoroscopic images. We propose a new method based on the Tracking-Learning-Detection approach, applied to the aorticvalve calcifications in order to determine the position of the aorticvalve plane in intra-operative TAVI images. This main contribution concerns the improvement of object detection by updating the recursive tracker in which all features are tracked jointly. The approach has been evaluated on four patient databases, providing an absolute mean displacement error less than 10 pixels (?2mm). Its suitability for the TAVI procedure has been analyzed. PMID:24110703
Nguyen, Dlh; Garreau, M; Auffret, V; Le Breton, H; Verhoye, Jp; Haigron, P
A 52-year-old man was referred to our clinic because of chronic heart failure. A Levine 3/6 diastolic heart murmur was audible at the apex. Chest radiography showed an enlarged left ventricle. Transthoracic echocardiography showed moderately severe aortic regurgitation. Left ventricular end-diastolic/systolic diameter and ejection fraction were 75/59 mm and 41 %, respectively. Preoperative transesophageal 3-dimensional echocardiography revealed a quadricuspid aorticvalve whose cusps were of almost equal size. Aorticvalve replacement was performed via upper partial sternotomy. PMID:23115003
Transcatheter aorticvalve implantation (TAVI) emerged to be a viable treatment option for failing bioprosthesis in the aortic position. Transfemoral approach is the most common access route for TAVI and associated with most favorable clinical outcome. However, in the presence of unfavorable aortic root anatomy, TAVI via transfemoral approach provides inadequate support for device manipulation during valve positioning, particularly performed for the indication of severe aortic regurgitation. We report our experience on TAVI utilizing CoreValve for a patient with regurgitant failing bioprosthesis with horizontal aortic root where we encountered difficulties during implantation and retrieval of valve delivery system. PMID:22431290
Chan, Pak Hei; Alegria-Barrero, Eduardo; Di Mario, Carlo
We retrospectively investigated the impact of bicuspid aorticvalve on the prognosis of patients who had definite infective endocarditis of the native aorticvalve. Of 51 patients, a bicuspid aorticvalve was present in 22 (43%); the other 29 had tricuspid aorticvalves. On average, the patients who had bicuspid valves were younger than those who had tricuspid valves. Patients with a tricuspid valve had larger left atrial diameters and were more likely to have severe mitral regurgitation. Periannular complications, which we detected in 19 patients (37%), were much more common in the patients who had a bicuspid valve (64% vs 17%, P = 0.001). The presence of a bicuspid valve was the only significant independent predictor of periannular complications. The in-hospital mortality rate in the bicuspid group was lower than that in the tricuspid group; however, this figure did not reach statistical significance (9% vs 24%, P = 0.15). In multivariate analysis, left atrial diameter was the only independent predictor associated with an increased risk of death (hazard ratio, 2.19; 95% confidence interval, 1.1–4.5; P = 0.031). In our study, patients with infective endocarditis in a bicuspid aorticvalve were younger and had a higher incidence of periannular complications. Although a worse prognosis has been reported previously, we found that infective endocarditis in a native bicuspid aorticvalve is not likely to increase the risk of death in comparison with infective endocarditis in native tricuspid aorticvalves.
Mitral valve replacement using pig aorticvalve heterografts has been performed in 27 dogs, siting the grafts in the `atrial position'. Buffered acid formaldehyde sterilization offered the advantages that it is simple and, by de-naturing the proteins of the graft, may minimize `rejection' phenomena. It may offer some self-sterilizing property to the graft within the host post-operatively. The question whether
Background: Aorticvalve replacement with mechanical valves is associated with a small but constant risk of valve thrombosis and thromboembolic\\u000a and hemorrhagic complications. The surgical outcome of patients with Aortic Stenosis who had aorticvalve replacement with\\u000a mechanical valves is reported here.\\u000a \\u000a \\u000a Methods: Between January 1990 and October 1999, 275 patients underwent prosthetic valve replacement for isolated aortic stenosis.\\u000a The
V Devagourou; SK Choudhary; A Bhan; R Sharma; B Airan; P Venugopal; A Sampath Kumar
Bioprosthetic aorticvalve replacement is the treatment of choice for patients over 65 years of age suffering from aorticvalve disease, and for younger patients with contraindications to long-lasting anticoagulation. Despite several technical improvements to reduce the risk of structural valve degeneration (SVD), the risk of SVD still exists, in particular for hemodialysis patients and patients under 60 years of age at surgery. Redo open heart surgery is the treatment of choice in case of valve degeneration, but caries a higher surgical risk when elderly patients with comorbidities are concerned. In the last 5 years, transcatheter aortic “valve-in-valve” procedures represent a valid alternative to standard redo surgery in selected patients. Valve-in-valve procedures represent a less invasive approach in high-risk patients and the published results are very encouraging. Technical success rates of 100% have been reported, as have the absence of paravalvular leaks, acceptable trans-valvular gradients (depending on the size of the original bioprosthesis), and low complication rates. The current article focuses on choosing the correct transcutaneous valve to match the patient’s existing bioprosthesis for valve-in-valve procedures.
We report the dislocation of a stented aorticvalve prosthesis two weeks after the uneventful transapical implantation in a female who had underwent mitral valve replacement and CABG six years before. The initial implantation of the Edwards Sapien aorticvalve prosthesis (Edwards Lifesciences, Irvine, CA), as well as the postoperative recovery, was uneventfully. At the sixth postoperative day, the patient developed a progressive heart failure due to a severe aortic insufficiency. During conventional aorticvalve replacement, the dislocated prosthesis was found in the left ventricle. After uncomplicated postoperative recovery, the patient could be discharged in a good physical condition. Preexisting mitral valve prosthesis seems to be an important, complicating goal for transcatheter aorticvalve implantation. PMID:21801932
Baumbach, Hardy; Hill, Stephan; Hansen, Matthias; Franke, Ulrich F W
Transcatheter aorticvalve implantation for aortic stenosis has evolved as an alternative treatment for patients who are at high or excessive surgical risk. We report the case of an 84-year-old man with a degenerated surgically implanted valve in a subaortic position (9 mm below the native annulus) who underwent “valve-in-valve” transcatheter aorticvalve implantation with use of a Medtronic CoreValve system. We planned to deploy the CoreValve at a conventional depth in the left ventricular outflow tract; we realized that this might result in paravalvular regurgitation, but it would also afford a “deep” landing site for a second valve, if necessary. Ultimately, we implanted a second CoreValve deep in the left ventricular outflow tract to seal a paravalvular leak. The frame of the first valve—positioned at the conventional depth—enabled secure anchoring of the second valve in a deeper position, which in turn effected successful treatment of the failing subaortic surgical prosthesis without paravalvular regurgitation.
Nuis, Rutger-Jan; Benitez, Luis M.; Nader, Carlos A.; Perez, Sergio; de Marchena, Eduardo J.; Dager, Antonio E.
A consecutive series of 93 patients had homograft aorticvalve replacement at Green Lane Hospital over a six-month period. Except for 12 assessed at one or two months, the 85 survivors were examined at three months and the clinical degree of aortic incompetence was recorded. Thirty-four of the patients did not proceed to aortography for reasons unrelated to the state of the homograft valve. Fifty-one patients were submitted to cine aortography, using a technique designed to permit a radiological assessment of the degree of aortic incompetence and to reveal details of the anatomy of the homograft valve. Following a brief review of the surgical technique of homograft aorticvalve insertion, the radiological anatomy of homograft aorticvalves and the mechanism of peripheral aortic incompetence in this situation are described. A radiological method of grading aortic incompetence by cine aortography is presented an the results in the 51 patients are described. The incidence of peripheral space filling and incompetence was considerably lower in the second half of the consecutive series, apparently due to a modification of the surgical technique, namely, the addition of vertical mattress sutures beneath the valve commissures to promote closure of the potential peripheral space. In the whole series of 51 patients, 71% had no significant aortic incompetence. In the latter half of the study after the vertical mattress sutures had been introduced, 84% had no significant incompetence. These results were from operations by a total of six surgeons. A smaller series of patients operated on by one surgeon using vertical mattress sutures was studied by the same methods. Eighteen of 19 patients (95%) had no significant incompetence. Good agreement was found between the radiological and clinical assessment of aortic incompetence, indicating that standard clinical methods can be applied to patients with homograft aorticvalve incompetence. Images
Brandt, P. W. T.; Roche, A. H. G.; Barratt-Boyes, B. G.; Lowe, J. B.
Cogan's syndrome is a systemic vasculitis of autoimmunologic origin. The main disturbances involve the eye, the ear and the heart, but many other structures can also be affected. Nonspecific abnormal laboratory findings are also present. The disease usually involves a cranial nerve, followed by aortitis which can affect the aorticvalve and, more rarely, the cusps of the valve. Aortic lesions strongly influence the course of the disease and therefore the prognosis. When choosing the type of valve replacement, long-term corticosteroid therapy and the age and sex of the patient must be taken into account. PMID:1756049
Paolini, G; Mariani, M A; Zuccari, M; Sabbadini, M G; Gallorini, C; Margonato, A; Grossi, A
Although porcine aorticvalves or pericardial tissue mounted on a stent have made implantation techniques easier, these valves sacrifice orifice area and increase stress at the attachment of the stent, which causes primary tissue failure. Optimizing hemodynamics to prevent patient–prosthetic mismatch and improve durability, stentless bioprostheses use was revived in the early 1990s. The purpose of this review is to provide a current overview of stentless valves in the aortic position. Retrospective and prospective randomized controlled studies showed similar operative mortality and morbidity in stented and stentless aorticvalve replacement (AVR), though stentless AVR required longer cross-clamp and cardiopulmonary bypass time. Several cohort studies showed improved survival after stentless AVR, probably due to better hemodynamic performance and earlier left ventricular (LV) mass regression compared with stented AVR. However, there was a bias of operation age and nonrandomization. A randomized trial supported an improved 8-year survival of patients with the Freestyle or Toronto valves compared with Carpentier–Edwards porcine valves. On the contrary, another randomized study did not show improved clinical outcomes up to 12 years. Freedom from reoperation at 12 years in Toronto stentless porcine valves ranged from 69% to 75%, which is much lower than for Carpentier–Edwards Perimount valves. Cusp tear with consequent aortic regurgitation was the most common cause of structural valve deterioration. Cryolife O’Brien valves also have shorter durability compared with stent valves. Actuarial freedom from reoperation was 44% at 10 years. Early prosthetic valve failure was also reported in patients who underwent root replacement with Shelhigh stentless composite grafts. There was no level I or IIa evidence of more effective orifice area, mean pressure gradient, LV mass regression, surgical risk, durability, and late outcomes in stentless bioprostheses. There is no general recommendation to prefer stentless bioprostheses in all patients. For new-generation pericardial stentless valves, follow-up over 15 years is necessary to compare the excellent results of stented valves such as the Carpentier–Edwards Perimount and Hancock II valves.
Percutaneous transcatheter aorticvalve implantation (TAVI) is an established alternative to open heart surgery in patients with severe aortic stenosis (AS) unsuitable for conventional aorticvalve replacement due to comorbidities with a high perioperative risk or contraindications. Preprocedural imaging plays a major role for adequate determination of indications and prosthesis selection, prosthesis sizing and therefore for a reduction of periprocedural complications. Besides Doppler echocardiography which is mainly used for grading of the severity of aorticvalve stenosis and peri-interventional imaging, cardiac computed tomography (CCT) is the imaging modality of choice. The CCT procedure not only allows for reliably assessment and measuring of the complex 3-dimensional geometry of the aortic root but also for the aorta and the peripheral vessels used as potential access paths. PMID:24129987
Gutberlet, M; Foldyna, B; Grothoff, M; Lücke, C; Riese, F; Nitzsche, S; Haensig, M; von Aspern, K; Holzhey, D; Thiele, H; Schuler, G; Linke, A; Mohr, F-W; Lehmkuhl, L
Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aorticvalve implantation in the native aorticvalve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve-in-valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve-in-valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure. PMID:22744728
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 prevalence and clinical significance of aorticvalve prolapse were determined prospectively in 2000 consecutive patients undergoing routine clinical cross sectional echocardiography. Two hundred and twelve patients were excluded because the aortic cusps were not adequately visualised. Aorticvalve prolapse was defined as downward displacement of cuspal material below a line joining the points of attachment of the aorticvalve leaflets. Twenty four cases of aorticvalve prolapse (1.2%) were identified. The patients were aged 12-64 years and nine were women. All had underlying valvar heart disease and the commonest lesion (in 11 cases) was prolapse of the larger cusp in bicuspid valves. Aorticvalve prolapse was seen in four patients with mitral valve prolapse (two with severe regurgitation), one of whom had marfanoid aortic root dilatation. The remaining examples of aortic prolapse were seen in patients with various disorders including one with pulmonary atresia, two with aortic root disease (one with dissection and one with idiopathic dilatation), and one case of severe mitral regurgitation. Valves destroyed by infective endocarditis were seen in two cases. Aorticvalve prolapse may be detected in various cardiac disorders and does not imply the presence of aortic regurgitation, but when bicuspid aorticvalves are present it may well be important in producing such regurgitation. Although aorticvalve prolapse may be associated with severe forms of mitral valve prolapse, these patients rarely have aortic regurgitation. Images
Shapiro, L M; Thwaites, B; Westgate, C; Donaldson, R
In recent years percutaneous aorticvalve implantation has emerged as an alternative therapy to treat patients with symptomatic aortic stenosis considered to be high-risk surgical candidates. We report our experience of a percutaneous retrograde CoreValve implantation in a 77-year-old female with aortic bioprosthesis structural degeneration. The patient underwent aorticvalve replacement for aortic stenosis in 1999 with the implantation of a 23 mm Carpentier-Edwards; her last echocardiography showed a severe bioprosthesis stenosis. After evaluation by cardiac surgeons and cardiologist, considering the high risk re-do surgical procedure (Logistic Euroscore 30%) and severe comorbidities (severe pulmonary hypertension, hepatocellular carcinoma and severe osteoporosis), a percutaneous aorticvalve-in-valve replacement was preferred. A successful percutaneous 26 mm CoreValve prosthesis implantation was performed with the patient awake with local anesthesia and mild sedation. The patient was discharged after 10 days of hospitalization and she is in NYHA functional class I at follow-up. Our experience, characterized by a multidisciplinary approach, necessary to offer the safest conditions and care for patients, demonstrates the feasibility of a new, promising indication for the use of a transcatheter valve implantation: percutaneous treatment of a degenerated aortic bioprosthesis. PMID:19829135
\\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
Although safety and efficacy of TAVI was improved with next-generation equipment, experience, and careful patient selection, some worrisome complications associated with the procedure remain. Current hot topics in transcatheter aorticvalve implantation include patient selection, valve sizing, paravalvular regurgitation, cerebrovascular accidents, vascular complications and need for a permanent pacemaker. In this article we review the pathophysiology, avoidance and treatment options for these complications. PMID:23255233
The histopathological characteristics of congenital aorticvalve malformations in children were investigated. All the native\\u000a surgically excised aorticvalves from 32 pediatric patients suffering from symptomatic aorticvalve dysfunction due to congenital\\u000a aorticvalve malformations between January 2003 and December 2005 were studied macroscopically and microscopically. The patients’\\u000a medical records were reviewed and the clinical information was extracted. The diagnosis
We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aorticvalve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aorticvalve reoperation combined with mitral valve replacement was successfully performed. The patient's aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date. PMID:12735595
Paravalvular abscess is a serious complication of infective endocarditis. The aorticvalve and its adjacent ring are more susceptible to abscess formation and paravalvular extension than the mitral valve. A 15-years old patient with bicuspid aorticvalve presented with staphylococcal tricuspid valve endocarditis complicated by para-aortic abscess that ruptured into the aortic sinus. We report the clinical, laboratory and echocardiographic features and treatment of this patient and conduct a literature review on this subject.
Kim, Woo Shin; Kang, Seok Hyung; Lee, Shin A; Ryu, Min Sun
Paravalvular abscess is a serious complication of infective endocarditis. The aorticvalve and its adjacent ring are more susceptible to abscess formation and paravalvular extension than the mitral valve. A 15-years old patient with bicuspid aorticvalve presented with staphylococcal tricuspid valve endocarditis complicated by para-aortic abscess that ruptured into the aortic sinus. We report the clinical, laboratory and echocardiographic features and treatment of this patient and conduct a literature review on this subject. PMID:21949535
Kim, Woo Shin; Kang, Seok Hyung; Lee, Shin A; Ryu, Min Sun; Park, Seong-Hoon
Fine strands associated with prosthetic heart valves have been demonstrated with transesophageal echocardiography, but the pathologic identity of these strands is unclear. A case of a man with a prosthetic aortic Medtronic-Hall valve with prominent valve strands and recurrent strokes is discussed. The patient underwent valve replacement surgery, and histopathologic examination of the strands identified them as Lambl's excrescences. (J
Kendra Hutchinson; Faizain Hafeez; Timothy D Woods; Paramjeet S Chopra; Thomas F Warner; Ross L Levine; Timothy J Kamp
Aorticvalve replacement (AVR) is a treatment of choice for patients with symptomatic severe aortic stenosis (AS). However, a significant proportion of these patients do not undergo surgical AVR due to high-risk features. Transcatheter aorticvalve implantation (TAVI) has emerged as an alternative for patients with severe AS who are not candidates for open-heart surgery. Since the introduction of TAVI to the medical community in 2002, there has been an explosive growth in procedures. The balloon-expandable Edwards SAPIEN valve and the self-expanding CoreValve ReValvingTM system contribute the largest patient experience with more than 10,000 patients treated with TAVI to date. Clinical outcomes have stabilized in experienced hands, with 30-day mortality less than 10%. Careful patient selection, growing operator experience, and an integrated multidisciplinary team approach contribute to notable improvement in outcomes. In the first randomized pivotal PARTNER trial, in patients with severe AS not suitable candidates for surgical AVR, TAVI compared with standard therapy, significantly improved survival and cardiac symptoms, but was associated with higher incidence of major strokes and major vascular events. The results of randomized comparison of TAVI with AVR among high-risk patients with AS for whom surgery is a viable option are eagerly awaited to provide further evidence on the applicability of TAVI in these patients.
Although heart valve replacement is among the most common cardiovascular surgical procedures, their outcome is often difficult to predict. One of the reasons is the design and choice of the materials used for the fabrication of the prostheses. This review paper describes the use of modeling techniques in prosthetic heart valve (HV) design and aims at the justification and development of a polymer based trileaflet mechanical heart valve (MHV). The closing/opening phase behavior of the bileaflet MHV was investigated. The potential problem of valve failure due to crack propagation in the brittle pyrolytic carbon leaflet was also discussed. These studies suggest that although bileaflet MHV performs satisfactorily, there are justifications for improvement. Since the native aortic HV is trileaflet and made of anisotropic and hyperelastic tissue, one possible approach to a better MHV design is based on our ability to closely mimic the natural geometry and biomaterial properties. PMID:20971672
Objectives: To assess the potential benefits of the hemodynamic superiority of stentless valves, we conducted a case-match study among patients who underwent aorticvalve replacement with two types of porcine bioprostheses: the Toronto SPV and the stented Hancock II bioprosthesis. Methods: Preoperative clinical variables predictive of death after aorticvalve replacement were determined by a stepwise logistic regression analysis in
Tirone E. David; Rudolph Puschmann; Joan Ivanov; Joanne Bos; Susan Armstrong; Christopher M. Feindel; Hugh E. Scully
Myocardial abscess is a rare but life-threatening disease with various clinical presentations. We describe the case of a paravalvular abscess distending intramurally 7 years post surgery for aorticvalve replacement. Early detection and urgent surgical intervention is essential for this otherwise fatal disease entity. PMID:23019986
The present article reports a case involving a 29-year-old man who developed severe cardiac failure (New York Heart Association class IV). He had a complex surgical history, beginning with the repair of an anterior sinus of Valsalva aneurysm and closure of a ventricular septal defect at eight months of age. His residual Valsalva aneurysm and mixed aorticvalve disease necessitated mechanical aorticvalve replacement at 14 years of age. One year later, he developed coagulase-negative staphylococcal prosthetic valve infective endocarditis, necessitating an additional replacement of his valve with a pulmonary homograft. Subsequent follow-up revealed a dilated ascending aorta (6 cm) and increased regurgitation through his homograft, with significant dilation of the left ventricle. At 20 years of age, he underwent excision of the aneurysmal ascending aorta and arch of the aorta, and the aorticvalve was replaced with a 29 mm bioprosthetic valve. This proved satisfactory for nine years until he presented at Guy’s and St Thomas’ National Health Services Foundation Trust (London, United Kingdom) with severe aortic regurgitation. His logistic EuroScore was 5.9 and Parsonnet score was 17 but, due to extensive previous surgery, he was considered and accepted for transcatheter aorticvalve implantation. A 29 mm Edwards Sapien valve (Edwards Lifesciences, USA) was successfully implanted using a valve-in-valve procedure. The patient remained well and symptom free at early follow-up. Technical aspects of this complex adult congenital case that, to the authors’ knowledge is the youngest case of transcatheter aorticvalve implantation and the first 29 mm valve-in-valve procedure, are discussed.
The correspondence of aorticvalve area measurements from transesophageal echocardiography, transthoracic echocardiography, and cardiac catheterization was determined in 100 patients with severe aortic stenosis (aorticvalve area ? 0.75 cm2), moderate aortic stenosis (aorticvalve area >0.75 to ? 1.2 cm2), mild aortic stenosis (aorticvalve area > 1.2 to ?2.0 cm2), and nonstenotic aorticvalves (aorticvalve area >2.0
Chong-Jin Kim; Hans Berglund; Toshihiko Nishioka; Huai Luo; Robert J. Siegel
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)
Concerns exist in the field of transcatheter aorticvalve implantation regarding the treatment of patients with mechanical mitral valve for possible interference between the percutaneous aorticvalve and the mechanical mitral prosthesis. We report our experience with percutaneous aorticvalve implantation in 4 patients with severe aortic stenosis, previously operated on for mitral valve replacement with a mechanical prosthesis. All patients underwent uneventful percutaneous retrograde CoreValve implantation (CoreValve Inc, Irvine, CA). No deformation of the nitinol tubing of the prostheses (ie, neither distortion nor malfunction of the mechanical valve in the mitral position) occurred in any of the patients. All patients are alive and asymptomatic at a mean follow-up of 171 days. PMID:19853076
Quadricuspid aorticvalve is a rare congenital malformation of the aorticvalve. Its diagnosis is often missed even with the use of transthoracic echocardiogram. Many of these patients progress to aortic incompetence later in life, hence requiring surgical intervention. In the case described in this report, a 61-year-old woman is presented with the features of congestive heart failure. The preoperative transthoracic echocardiogram disclosed a moderate to severe aorticvalve insufficiency but failed to reveal the quadricuspid aortic value anomaly. This case underscores the important role of three-dimensional transesophageal echocardiography for the diagnosis of quadricuspid aorticvalve.
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
The anisotropic property of porcine aorticvalve leaflet has potentially significant effects on its mechanical behaviour and the failure mechanisms. However, due to its complex nature, testing and modelling the anisotropic porcine aorticvalves remains a continuing challenge to date. This study has developed a nonlinear anisotropic finite element model for porcine heart valves. The model is based on the
This review highlights aspects of calcific aorticvalve disease that encompass the entire range of aorticvalve disease progression from initial cellular changes to aorticvalve sclerosis and stenosis, which can be initiated by changes in blood flow (hemodynamics) and pressure across the aorticvalve. Appropriate hemodynamics is important for normal valve function and maintenance, but pathological blood velocities and pressure can have profound consequences at the macroscopic to microscopic scales. At the macroscopic scale, hemodynamic forces impart shear stresses on the surface of the valve leaflets and cause deformation of the leaflet tissue. As discussed in this review, these macroscale forces are transduced to the microscale, where they influence the functions of the valvular endothelial cells that line the leaflet surface and the valvular interstitial cells that populate the valve extracellular matrix. For example, pathological changes in blood flow-induced shear stress can cause dysfunction, impairing their homeostatic functions, and pathological stretching of valve tissue caused by elevated transvalvular pressure can activate valvular interstitial cells and latent paracrine signaling cytokines (eg, transforming growth factor-?1) to promote maladaptive tissue remodeling. Collectively, these coordinated and complex interactions adversely impact bulk valve tissue properties, feeding back to further deteriorate valve function and propagate valve cell pathological responses. Here, we review the role of hemodynamic forces in calcific aorticvalve disease initiation and progression, with focus on cellular responses and how they feed back to exacerbate aorticvalve dysfunction. PMID:23833293
Gould, Sarah T; Srigunapalan, Suthan; Simmons, Craig A; Anseth, Kristi S
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
Aorticvalve calcification is the most common form of valvular heart disease, but the mechanisms of calcific aorticvalve disease (CAVD) are unknown. NOTCH1 mutations are associated with aorticvalve malformations and adult-onset calcification in families with inherited disease. The Notch signaling pathway is critical for multiple cell differentiation processes, but its role in the development of CAVD is not well understood. The aim of this study was to investigate the molecular changes that occur with inhibition of Notch signaling in the aorticvalve. Notch signaling pathway members are expressed in adult aorticvalve cusps, and examination of diseased human aorticvalves revealed decreased expression of NOTCH1 in areas of calcium deposition. To identify downstream mediators of Notch1, we examined gene expression changes that occur with chemical inhibition of Notch signaling in rat aorticvalve interstitial cells (AVICs). We found significant downregulation of Sox9 along with several cartilage-specific genes that were direct targets of the transcription factor, Sox9. Loss of Sox9 expression has been published to be associated with aorticvalve calcification. Utilizing an in vitro porcine aorticvalve calcification model system, inhibition of Notch activity resulted in accelerated calcification while stimulation of Notch signaling attenuated the calcific process. Finally, the addition of Sox9 was able to prevent the calcification of porcine AVICs that occurs with Notch inhibition. In conclusion, loss of Notch signaling contributes to aorticvalve calcification via a Sox9-dependent mechanism.
Koenig, Sara N.; Nichols, Haley A.; Galindo, Cristi L.; Garner, Harold R.; Merrill, Walter H.; Hinton, Robert B.; Garg, Vidu
We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aorticvalve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aorticvalve reoperation combined with
Aorticvalve sparing procedures are increasingly being used to treat aortic root pathologies. Reimplantation of the aorticvalve, first described by Dr Tirone David, is a technically demanding procedure whose long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. There exists significant variation in how this procedure is performed by different surgeons, which is likely contributory to the heterogeneity in reported results. We describe a systematic approach to aorticvalve reimplantation procedure focusing on key technical aspects.
de Kerchove, Laurent; Nezhad, Zahra Mosala; Boodhwani, Munir
The material used for the studies consisted of allogenic aorticvalves (AAV) collected from 14 individuals. The necessity of AAV replacement arose from growing circulation insufficiency and AAV dysfunction. The aim the study was the determination of the elemental composition and crystallographic structure of the inorganic deposits in AAV. Moreover, the results of the physicochemical investigations were correlated with clinical data (age of the patient, time between valve replacement surgeries, endomyocarditis, number of infections during last 12 months, arterial hypertension and disturbance of the lipid balance) and with echocardiographic examinations (cusp mineralization and perforation, vegetation, systolic and diastolic dimensions of the left ventricle, maximal and average gradient through allograft valve as well as range of the recoil wave to left ventricle). It was found that mineralization of the AAV cusps was a time-dependent process and took place predominantly at the surface of the cusp. The elemental composition and crystallographic data revealed that the inorganic deposits in AAV were composed of hydroxyapatite crystals. However, the presence of other calcium salts was also found. The development of the mineralization process in AAV does not correlate with endomyocarditis, arterial hypertension and the disturbance of the lipid balance. Probably, endomyocarditis and arterial hypertension induce the pathologic alternations of AAV independently from the mineralization process. The echocardiographic estimations of the pathomorphologic changes of the aorticvalve cups are not always consistent with the results of the physicochemical studies. PMID:10085721
We have performed aorticvalve replacement (AVR) with mechanical valve, with/without annular enlargement in pediatric patients with left ventricular outflow tract obstruction (LVOT). Twenty-two patients underwent mechanical AVR between May 1993 and December 2012. The cumulative survival rates by the Kaplan-Meier method were 95% in 5 year, and 95% in 10 year. Long-term result of mechanical AVR with/without annular enlargement in children is excellent. Therefore, it should be the 1st choice of surgical treatment at our institute. In this strategy, we had total 10 re-operation cases. Two cases:Konno operation after performing surgical aortic valvotomy, 6 cases:Konno operation after resection of subaortic stenosis, 1 case:re-valve replacement because of thrombus formation at mechanical valve, and 1 case:re-operation with somatic growth. At the age of operation, 2 years old and over cases had postoperative estimated effective orifice area index (EOAI)>0.85 cm2/m2 in the time of 20 years old. Since some issues concerning anticoagulation-related complications remain, careful observation is mandatory. PMID:23917186
Background Transcatheter aorticvalve implantation (TAVI) represents a significant development in the treatment of high risk patients with aortic stenosis. As one of the first centers to perform transapical TAVI (taTAVI), we herein review our five-year experience with this technique. Methods All patients undergoing taTAVI with an Edwards Sapien valve at the Leipzig Heart Center between 2006 and 2011 (n=439) were analysed. Data was drawn from a prospective database and retrospectively analysed. The learning curve was reviewed by means of descriptive statistics as well as cumulative sum failure analysis (CUSUM). All results are presented in compliance with Valve Academic Research Consortium (VARC) criteria. Results The mean patient age was 81.5±6.4 years and 64.0% were female. The mean logistic EuroSCORE and STS risk of mortality were 29.7%±15.7% and 11.4%±7.6%, respectively. Procedural success was 90.2%. Stroke occurred in 2.1% of patients intra-operatively and a further 2.1% suffered stroke during their hospital stay. Mean transvalvular gradient was 9.0±3.9 mmHg and effective valve orifice area 1.3±0.6 cm2. Moderate or greater aortic insufficiency was present in 5.7% of patients and remained stable during follow up. Overall survival was 90% at 30 days, 73% at 1 year, 68% at 2 years, 58% at 3 years, 53% at 4 years, and 44% at 5 years. CUSUM analysis revealed a definitive learning curve regarding the occurrence of major complications, with a progressive improvement after the initial 150 cases. Conclusion TaTAVI has become a routine approach for high risk patients with symptomatic severe aortic stenosis. Although taTAVI is a safe procedure with reproducible results, future research should focus on methods of reducing known complications and the associated learning curve for this procedure.
Hansig, Martin; Walther, Thomas; Seeburger, Joerg; Misfeld, Martin; Linke, Axel; Borger, Michael A.; Mohr, Friedrich W.
A case of endocarditis of the aorticvalve in a 11 year old thoroughbred is presented. Diagnostic approach, the value of echocardiography, and the various symptoms, complications and prognosis are discussed. The horse with ruptured aorticvalves due to endocarditis with severe aortic and mitral regurgitation causing congestive heart failure, was euthanised due to bad prognosis. PMID:15503539
Fröhlich, W; Wlaschitz, S; Riedelberger, K; Reifinger, M
Two techniques for correcting malpositioning occurring during percutaneous aorticvalve replacement (PAVR) with the CoreValve ReValving™ System are described in this article. The “Removing and Reinserting Technique” was used in 2 patients, in whom the prosthesis was positioned too high. The “Snare Technique” was used in 1 patient, in whom the prosthesis was implanted too low. In all patients the
Manolis Vavouranakis; Dimitrios A. Vrachatis; Konstantinos P. Toutouzas; Christina Chrysohoou; Christodoulos Stefanadis
BackgroundLong-term survival and freedom from valve-related events of the St. Jude Toronto stentless porcine valve (SPV) are unknown. The aim of this study was to investigate late clinical outcomes after aorticvalve replacement with the Toronto SPV.
Nimesh D. Desai; Ofer Merin; Gideon N. Cohen; Jaclyn Herman; Sofia Mobilos; Jeri Y. Sever; Stephen E. Fremes; Bernard S. Goldman; George T. Christakis
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.
Regions of turbulence downstream of bioprosthetic heart valves may cause damage to blood components, vessel wall as well as to aorticvalve leaflets. Stentless aortic heart valves are known to posses several hemodynamic benefits such as larger effective orifice areas, lower aortic transvalvular pressure difference and faster left ventricular mass regression compared with their stented counterpart. Whether this is reflected by diminished turbulence formation, remains to be shown. We implanted either stented pericardial valve prostheses (Mitroflow), stentless valve prostheses (Solo or Toronto SPV) in pigs or they preserved their native valves. Following surgery, blood velocity was measured in the cross sectional area downstream of the valves using 10MHz ultrasonic probes connected to a dedicated pulsed Doppler equipment. As a measure of turbulence, Reynolds normal stress (RNS) was calculated at two different blood pressures (baseline and 50% increase). We found no difference in maximum RNS measurements between any of the investigated valve groups. The native valve had significantly lower mean RNS values than the Mitroflow (p=0.004), Toronto SPV (p=0.008) and Solo valve (p=0.02). There were no statistically significant differences between the artificial valve groups (p=0.3). The mean RNS was significantly larger when increasing blood pressure (p=0.0006). We, thus, found no advantages for the stentless aorticvalves compared with stented prosthesis in terms of lower maximum or mean RNS values. Native valves have a significantly lower mean RNS value than all investigated bioprostheses. PMID:21696741
Funder, Jonas Amstrup; Frost, Markus Winther; Wierup, Per; Klaaborg, Kaj-Erik; Hjortdal, Vibeke; Nygaard, Hans; Hasenkam, J Michael
The unicuspid aorticvalve is an extremely rare congenital anomaly. It usually presents with aortic stenosis and/or aortic regurgitation. Other cardiovascular complications, such as aortic dilatation and left ventricular hypertrophy can accompany it. Herein, we present a case report of a 50-year-old asymptomatic male patient with unicuspid aorticvalve, complicated by ascending aortic aneurysm.
Kang, Seung-Dae; Park, Bo-Min; Kim, Dong-Kie; Kim, Ki-Hun; Kim, Doo-Il; Seo, Jeong-Sook; Kim, Dong-Soo; Kim, Hyun-Kuk; Song, Jong-Woon
Calcific aortic stenosis is the third leading cause of adult heart disease and the most common form of acquired valvular disease in developed countries. However, the molecular pathways leading to calcification are poorly understood. We reported two families in which heterozygous mutations in NOTCH1 caused bicuspid aorticvalve and severe aorticvalve calcification. NOTCH1 is part of a highly conserved signaling pathway involved in cell fate decisions, cell differentiation, and cardiac valve formation. In this study, we examined the mechanism by which NOTCH1represses aorticvalve calcification. Heterozygous Notch1-null (Notch1+/?) mice had greater than fivefold more aorticvalve calcification than age- and sex-matched wildtype littermates. Inhibition of Notch signaling in cultured sheep aorticvalve interstitial cells (AVICs) also increased calcification more than fivefold and resulted in gene expression typical of osteoblasts. We found that Notch1 normally represses the gene encoding bone morphogenic protein 2 (Bmp2) in murine aorticvalves in vivo and in aorticvalve cells in vitro. siRNA-mediated knockdown of Bmp2 blocked the calcification induced by Notch inhibition in AVICs. These findings suggest that Notch1 signaling in aorticvalve cells represses osteoblast-like calcification pathways mediated by Bmp2.
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
Objectives. We sought to develop an index of flow dependence of valve area in aorticvalve (AoV) stenosis and to determine whether this index is related to structural characteristics of the diseased valve.Background. Many studies of AoV stenosis using Gorlin or continuity equation methods have demonstrated flow dependence (an increase in valve area with increased flow). Variation in flow dependence
Bruce K Shively; Gerald A Charlton; Michael H Crawford; Rachel K Chaney
Background—The surgical approach to aortic root aneurysm and\\/or dissection remains controversial. The use of valve-sparing operations, which are thought to have many advantages, is increasing. We hypothesized that the particular technique and type of surgery could influence valve motion characteristics and function. Therefore, we studied the instantaneous opening and closing characteristics of the aorticvalve after the main 2 types
Rainer G. Leyh; Claudia Schmidtke; Hans-Hinrich Sievers; Magdi H. Yacoub
Introduction and objectivesTransfemoral implantation of an Edwards-SAPIEN (ES) or Medtronic CoreValve (MCV) aorticvalve prosthesis is an alternative to surgical replacement for patients with severe aortic stenosis and a high surgical risk. The study's aim was to compare results obtained with these two devices.
Rosa Ana Hernández-Antolín; Eulogio García; Santiago Sandoval; Carlos Almería; Ana Cuadrado; Javier Serrano; Eduardo de Obeso; Raquel del Valle; Camino Bañuelos; Fernando Alfonso; Fernando Guerrero; Jerónimo Heredia; Juan Carlos Martín Benítez; Juan Carlos García-Rubira; Enrique Rodríguez; Carlos Macaya
Many patients with severe aortic stenosis never undergo surgical treatment for various reasons. Apart from the standard risks, some patients face an additional problem: their carrying of a mechanical mitral valve. In these patients, transcatheter aorticvalve implantation is a therapeutic option. The literature contains only few reports of this procedure being performed (usually transapically) in such patients. This paper
Eulogio García; Agustín Albarrán; Jerónimo Heredia-Mantrana; Fernando Guerrero-Pinedo; Julio Rodríguez; Rosana Hernández-Antolín; Juan Tascón; Carlos Macaya
OBJECTIVE: To determine the relative importance of the different causes of isolated aorticvalve stenosis in a surgical series, and to relate these to patient characteristics including the rate of insertion of bypass grafts for coronary artery disease. DESIGN: Survey of the clinical and pathological data on patients undergoing aorticvalve replacement for isolated stenosis. SETTING: Tertiary care cardiothoracic surgical
We describe the first case of prosthetic valve endocarditis due to a Streptomyces sp. The patient presented with fever, cutaneous embolic lesions, and bacteremia 3 months after aorticvalve replacement. Treatment required valve replacement and a long course of parenteral imipenem.
Mossad, S B; Tomford, J W; Stewart, R; Ratliff, N B; Hall, G S
The prevalence of aortic stenosis is increasing with aging population. However with multiple co-morbidities and prior procedures in this aging population, more and more patients are being declared unfit for the 'Gold Standard' treatment i.e. surgical aorticvalve replacement (AVR). Among the patients who are unfit or high risk for aorticvalve replacement (AVR) by open heart surgery, transcatheter aorticvalve implantation (TAVI) has been proven to be a valuable alternative improving survival and quality of life. We report first Indian experience of Core Valve (Medtronic Inc.) implantation in three high surgical risk patients performed on 22nd and 23rd February 2012. PMID:23993000
Seth, Ashok; Rastogi, Vishal; Kumar, Vijay; Maqbool, Syed; Mustaqueem, Arif; Sekar, V Ravi
OBJECTIVES The aim of this study was to assess the impact of aorticvalve morphology and different surgical aorticvalve repair techniques on long-term clinical outcomes. METHODS Between February 2003 and May 2010, 216 patients with aortic insufficiency underwent aorticvalve repair in our institution. Ages ranged between 26 and 82 years (mean 53 ± 15 years). Aorticvalve dysfunctions, according to functional classification, were: type I in 55 patients (25.5%), type II in 126 (58.3%) and type III in 35 (16.2%). Sixty-six patients (27.7%) had a bicuspid valve. Aorticvalve repair techniques included sub-commissural plasty in 138 patients, plication in 84, free-edge reinforcement in 80, resection of raphe plus re-suturing in 40 and the chordae technique in 52. Concomitant surgical procedures were CABG in 22 (10%) patients, mitral valve repair in 12 (5.5%), aorticvalve-sparing re-implantation in 78 (36%) and ascending aorta replacement in 69 (32%). Mean follow-up was 42 ± 16 months and was 100% complete. RESULTS There were six early deaths (2.7%). Overall late survival was 91.5% (18 late deaths). There were 15 (6.9%) late cardiac-related deaths. NYHA functional class was ?II in all patients. At follow-up, 28 (14.5%) patients had recurrent aortic insufficiency ? grade II. The freedom from valve-related events was significantly different between bicuspid and tricuspid valve implantation (P < 0.01), between type I + II and type III (P < 0.001) dysfunction and between the chordae technique and plication, compared to free-edge reinforcement (P < 0.01). Statistically-significant differences were found between patients who underwent aorticvalve repair plus root re-implantation, compared to those who underwent isolated aorticvalve repair (P = 0.02). CONCLUSIONS aorticvalve repair including aortic annulus stabilization is a safe surgical option with either tricuspid or bicuspid valves; even more so if associated with root re-implantation. Patients with calcified bicuspid valves have poor results.
Background. Our strategy has been to treat aortic prosthetic valve endocarditis (PVE) with radical debridement of infected tissue and aortic root replacement with a cryopreserved aortic allograft. This study examines the effectiveness of this strategy on hospital mortality and morbidity, recurrent endocarditis, and survival.Methods. From 1988 through 2000, 103 patients with aortic PVE underwent root replacement with a cryopreserved aortic
Joseph F. Sabik; Bruce W. Lytle; Eugene H. Blackstone; Antonino G. M. Marullo; Gosta B. Pettersson; Delos M. Cosgrove
OBJECTIVE--To assess the risk of aorticvalve replacement and long-term follow-up in elderly patients with dominant aortic stenosis. DESIGN--Retrospective analysis of patients who had aorticvalve replacement over a 10 year period and were routinely seen in an outpatient clinic. SETTING--University hospital. PATIENTS--93 patients aged > or = 60 and 47 patients > or = 70 years with symptomatic aortic stenosis undergoing aorticvalve replacement. MAIN OUTCOME MEASURES--Early and late mortality in different age groups. Influence of preoperative signs and symptoms on overall outcome. RESULTS--The proportion of patients older than 70 years increased from 11% in 1978 to 54% in 1986. Perioperative mortality was 3.6% and mortality after 2 and 5 years was 9% and 13% respectively. Survival was similar (85% and 83%, respectively) in patients aged 60-69 years (group 1, n = 93, mean age 64.5 (2.7) and patients aged > or = 70 years (group 2, n = 47, mean age 72.6 (2.5)). Additional coronary artery disease and coronary bypass grafting did not significantly affect survival. The cardiothoracic ratio was inversely related to survival (Cox regression, p < 0.05). Preoperative symptoms (syncope, angina pectoris, and dyspnoea) were similar in both patient groups. After a mean (SD) follow up of 51 (33) months 96% of surviving patients were in NYHA functional class I or II with no difference between the two age groups. Similarly, the cardiothoracic ratio and Sokolow index decreased to near normal values in both age groups. CONCLUSION--The risk of aorticvalve replacement in patients with dominant aortic stenosis is low and not significantly influenced by age. Therefore replacement may be performed without increased risk in elderly patients and with a good long-term outcome.
Straumann, E.; Kiowski, W.; Langer, I.; Gradel, E.; Stulz, P.; Burckhardt, D.; Pfisterer, M.; Burkart, F.
The location and the spatial arrangement of smooth muscle cells in aorticvalves have been assessed by a systematic analysis of serial semithin sections of plastic embedded porcine and human aortic leaflets, combined with an electron microscope study.
Structural failure of a Model 2400 Starr-Edwards aortic track valve occurred suddenly, 4 years after implantation. At operation, the valve cage was removed from the descending aorta. Examination of the excised prosthesis disclosed minimal cloth wear and no evidence of infective growth; however, three struts were fractured above their insertion into the valve ring. To our knowledge, this type of valve malfunction has not been previously noted. Images
Ringel, Richard E.; Moulton, Anthony L.; Burns, Janet E.; Brenner, Joel I.; Berman, Michael A.
Rupture of the normal aorticvalve after blunt trauma to the chest is seen infrequently. With the ever-increasing incidence of car and motorcycle accidents, this injury should be considered during the initial examination of an accident victim. Any patient without a history of heart disease presenting with heart murmurs after severe blunt trauma to the chest should give rise to the suspicion of aorticvalve damage. When the diagnosis is proved, aorticvalve expoloration is necessary. Review of the published cases establishes that valve replacement is the treatment of choice. Images
The Tascon valve, a new porcine bioprosthesis, features a detachable sewing ring designed to facilitate insertion and removal. Between April 1984 and June 1986, we implanted the Tascon valve in 25 patients, 12 of whom underwent aorticvalve replacement (AVR), and 13 of whom had mitral valve replacement (MVR). Most of the patients were in NYHA class III or IV. Four MVR patients had had previous mitral valve operations, and three AVR patients required composite graft valved conduits. The valve's screw-locking mechanism worked well in all cases, especially in the AVR cases. There were no hospital deaths, and no significant morbidity or valve-related complications were encountered. One late death occurred 3 months after surgery, owing to causes unrelated to the valve. At the end of the study period, most of the survivors had improved by at least two NYHA functional classes. Postoperative aortic and mitral valve gradients and mitral valve areas, as measured by Doppler methods, were excellent. No significant regurgitation was detected. These favorable results indicate that the Tascon valve is a safe, useful bioprosthesis, with satisfactory hemodynamic characteristics. PMID:15227327
Fernandez, J; Gonzalez-Lavin, L; Maranhao, V; Yang, S S
Background. Aorticvalve replacement in children remains challenging because of constraints imposed by available prosthetic devices. Potential risks of anticoagulation with mechanical valves and degeneration of other biological substitutes have kindled interest in the Ross procedure. This study outlines the evolution of our 27-year experience with prosthetic devices.Methods. Ninety-nine patients who underwent aorticvalve replacement (January 1973 through September 2000)
Mark W Turrentine; Mark Ruzmetov; Palaniswamy Vijay; Randall G Bills; John W Brown
Objective: The practice of minimally invasive valve surgery remains controversial. The aim of this study was to evaluate the technical\\u000a feasibility and postoperative course of aorticvalve replacement through limited upper sternotomy compared to conventional\\u000a full sternotomy. Methods: From May 1998 to August 2000, we performed 24 cases of isolated aorticvalve replacements through the limited upper sternotomy\\u000a approach (group
Transcatheter aorticvalve implantation (TAVI) is an alternative therapy for symptomatic severe aorticvalve stenosis in high-risk patients with several co-morbidities. We evaluated the 1-year effects of TAVI on quality of life, exercise capacity, neurohormonal activation, and myocardial hypertrophy. From June 2008 to October 2009, consecutive patients aged ?75 years with symptomatic severe aorticvalve stenosis (area <1 cm(2)) and a logistic euroSCORE ?15% or aged >60 years with additional specified risk factors underwent TAVI. An aorticvalve prosthesis (CoreValve) was inserted in a retrograde fashion. Examinations were performed before and 30 days and 1 year after TAVI. An assessment of the quality of life (Minnesota Living with Heart Failure Questionnaire), a 6-minute walking test, measurement of B-type natriuretic peptide, and echocardiography were performed. In 51 patients (mean age 78 ± 6.6 years, mean left ventricular ejection fraction 58.4 ± 12.2%), the follow-up examinations were performed after TAVI. The 1-year follow-up visit after TAVI revealed significantly improved quality of life (baseline Minnesota Living with Heart Failure Questionnaire score 39.6 ± 19 vs 26.1 ± 18, p <0.001) and more distance covered in the 6-minute walking test (baseline 185 ± 106 vs 266 ± 118 m, p <0.001). The B-type natriuretic peptide level had decreased (baseline 642 ± 634 vs 323 ± 266 pg/ml, p <0.001), and the left ventricular mass index had decreased (156 ± 45 vs 130 ± 42 g/m(2), p <0.001). The left ventricular diameter and ejection fraction remained unchanged. In conclusion, TAVI leads to significantly reduced neurohormonal activation, regression of myocardial hypertrophy, and lasting enhancement of quality of life and exercise capacity in patients with symptomatic and severe aortic stenosis 1 year after intervention. PMID:21439537
Surgical replacement of the aorticvalve is the standard therapy for severe aorticvalve stenosis. However, it is generally associated with increased mortality and morbidities in older individuals. Transcatheter aorticvalve implantation (TAVI) is a less invasive procedure and has shown similar clinical outcomes as surgical treatment in elderly patients at high risk for conventional surgery. In this report, we describe the first case of TAVI using a CoreValve in Korea. An 84-year-old man with symptomatic severe aorticvalve stenosis was successfully treated by transfemoral TAVI. The patient was discharged without any significant complications and remained free of adverse clinical event for a follow-up duration of 6 months.
Giant ascending aortic aneurysm formation following aorticvalve replacement is rare. A 28-year-old man who underwent aorticvalve replacement with a prosthetic valve for aortic regurgitation secondary to congenital bicuspid aorticvalve about 10 years ago was diagnosed with a giant ascending aortic aneurysm about 16?cm in diameter in follow-up. The aneurysm was resected leaving the functional old mechanical prosthesis in place and implanted a 34-mm Hemashield woven graft, associated with the left and right coronary artery button implantation. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. The postoperative course was uneventful and postoperative examination demonstrated good surgical results.
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.
Background. Our strategy has been to treat aortic pros- thetic valve endocarditis (PVE) with radical debridement of infected tissue and aortic root replacement with a cryopreserved aortic allograft. This study examines the effectiveness of this strategy on hospital mortality and morbidity, recurrent endocarditis, and survival. Methods. From 1988 through 2000, 103 patients with aortic PVE underwent root replacement with a
Joseph F. Sabik; Bruce W. Lytle; Eugene H. Blackstone; Antonino G. M. Marullo; Gosta B. Pettersson; Delos M. Cosgrove
Background. We consider operative survival as the primary objective in acute type A dissection and believe that virtually all native aorticvalves can be conserved. We sought to answer the question: “Does glue repair improve the long-term stability of proximal aortic repair?”Methods. We retrospectively studied 64 patients with an acute type A dissection, an ascending aortic tear, and aortic regurgitation
Stephen Westaby; Takahiro Katsumata; Edward Freitas
Since the first clinical implantation in 2002, transcatheter aorticvalve implantation or transcatheter aorticvalve replacement (TAVR) has become an established therapy in the treatment of symptomatic severe aortic stenosis in patients deemed too high risk for surgical aorticvalve replacement. With over 50,000 implants performed in more than 40 countries, a large amount of clinical data have emerged in this rapidly growing field. Careful patient selection, systematic risk stratification, optimal valve sizing, meticulous procedural techniques, and complications management are all important elements to achieve good outcomes. However, several critical issues exist with TAVR that need to be addressed before it can become more widely adopted. Quality of life improvement and cost-effectiveness of TAVR, when compared to surgical aorticvalve replacement, remain uncertain in lower risk patients. Stroke, paravalvular leak, vascular complication, bleeding, and heart block represent only a few of the key concerns in this therapy. Valve-in-valve procedures are becoming a novel application of transcatheter heart valve in the treatment of a degenerated bioprosthesis, and next generation heart valves that address some of these ongoing issues are currently under evaluation. Future prospective studies will allow us to refine this therapy and optimize outcomes in this high-risk patient population. PMID:23269035
Tang, Gilbert H L; Lansman, Steven L; Cohen, Martin; Spielvogel, David; Cuomo, Linda; Ahmad, Hasan; Dutta, Tanya
Objective: The Starr-Edwards aortic ball valve has passed 30 years of clinical follow-up. A detailed account of the long-term performance from a large series could thus give valuable guidance in managing patients who are still alive, depict the total remaining life-span after aorticvalve replacement (AVR) for the average patient, and set a record yet to be matched by modern
Ole Lund; Hans K. Pilegaard; Lars B. Ilkjaer; Sten Lyager Nielsen; Hanne Arildsen; Ole K. Albrechtsen
Background—The prosthesis used for aorticvalve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation. Methods and Results—The indexed valve effective orifice area (EOA) was estimated for each type and size
Claudia Blais; Jean G. Dumesnil; Richard Baillot; Serge Simard; Daniel Doyle; Philippe Pibarot
A 63-year-old female, who had undergone aortic and mitral valve replacement 16 years ago, was admitted because of urinary tract infection. The patient developed cerebral hemorrhage. Methicillinresistant Staphylococcus aureus was isolated from her blood culture. Transesophageal echocardiography revealed paravalvular aortic and mitral abscesses, and the diagnosis of prosthetic valve endocarditis was established. A redo double valve replacement was performed. Both paravalvular abscess cavities were debrided and closed with fresh autologous pericardial patches, and mechanical valves were implanted. The patient's postoperative course was uneventful, and she had no sign of recurrent infection 3 years postoperatively. PMID:22374598
Aortic regurgitation associated with relapsing polychondritis usually occurs late in the disease as a result of aortic root dilatation. A case where aortic regurgitation occurred early and was due to cusp rupture with a normal aortic root is reported. The patient required urgent aorticvalve replacement within six weeks of developing a murmur despite apparent control of inflammation with immunosuppressive treatment. The possibility of cusp rupture with sudden haemodynamic deterioration should be considered in patients with relapsing polychondritis who develop aortic regurgitation. Images
Aim: The AorticValve (AV) annular dimension with respect to the Body Surface Area (BSA) of the Indian population is compared against the standard values. Presence of discrepancies can lead to patient prosthesis mismatch during aorticvalve replacement surgeries. Methods: This study was conducted on 406 subjects. AV diameter was examined by using parasternal long axis view, where the imaging plane transects the AV in an anteroposterior direction and its x axis is aligned parallel to the long axis of aorta. Data were statistically analysed with western population. Results: The AV dimension ranged from 12.2 mm to 21.2 mm in the BSA range of 0.6 to 1.9 m2, showing a linear increase in diameter with increasing BSA. There was an increase of about 2 mm, from 0.61 - 0.7 m2 BSA to 0.71 - 0.8 m2 BSA. A linear increase which ranged from 0.3 to 1 mm was observed for BSA which ranged from 0.81 m2 to 1.2 m2. In the BSA range of 1.21 – 1.3 m2, there was an increase of 1.5 mm. A steady increase which ranged from 0.4–1 mm was observed in the BSA which ranged from 1.31- 1.9 m2. Conclusions: There is a significant difference between Indian and western population in the aortic dimension, in the body surface ranges of 0.61-0.7, 1.11-1.2, 1.21-1.3, 1.51-1.6, 1.61-1.7, 1.71-1.8 and 1.8-1.9 m2. In the range of 1.21-1.3 m2, the diameter was larger than standard, whereas in all the other ranges, AV diameter was smaller than standard values. BSA, as a good predictor of AV dimension, has also been proved.
We describe a case with left atrial volume reduction of a giant left atrium, treated successfully by partial cardiac autotransplantation, concomitant mitral and aorticvalve replacement, and tricuspid valve plasty. We obtained good results at the 1-year follow-up. PMID:23868606
Incidence of concomitant coronary disease and extent of coronary artery lesions were assessed in 250 patients with acquired post-rheumatic aorticvalve disease treated between 1976 and 1986 in National Institute of Cardiology. Patients' age ranged from 30 to 72 years. Hemodynamic examination with selective coronarography were performed in patients with typical effort or rest angina pain, with electrographically documented myocardial infarction in the past and also in those without (CAD clinical symptoms, but older than 45 years. Patients were divided into two groups: with isolated or dominated aorticvalve stenosis (139 patients) and with isolated or dominated aorticvalve incompetence. Patients younger and older than 45 years were separately analyzed. Concomitant CAD was proved if at least one coronary artery stenosis was stated. Lesions degree was proportionally graded: stenosis more than 70%, between 50-70% and 20-50% of a vessel lumen in relation to its diameter before lesion. Data were analyzed using ICL ME 29 computer. Study results indicate, that symptoms of coronary failure were observed in 82.8% of patients with acquired aorticvalve disease. In 37% of cases there were critical stenoses requiring simultaneous aorticvalve replacement with coronary artery by-pass grafting. Severe coronary artery stenosis was stated in 45% of patients with dominated or isolated aorticvalve incompetence, whereas only in 29.3% with dominated or isolated aorticvalve stenosis. 88.5% of patients younger than 45 years nevertheless coronary failure symptoms had normal coronary arteries. PMID:2273717
Rawczy?ska-Englert, I; Or?owska-Baranowska, E; Hoffman, M; Kapu?ci?ski, O; Purzycki, Z; Ruzy??o, W; Rydlewska-Sadowska, W; Zelenay, M
Transcatheter aorticvalve implantation has been designed to treat patients affected by severe symptomatic aortic stenosis considered extremely high risk for surgical aorticvalve replacement. The CoreValve® (Medtronic Inc., MN, USA) is a multilevel self-expanding and fully radiopaque nitinol frame with a diamond cell configuration that holds a trileaflet porcine pericardial tissue valve and anchors the device in the native anatomy. CoreValve was the first percutaneous valve to be granted the CE mark for transfemoral implantation in May 2007 and the CoreValve US Pivotal Trial is actively underway. The CoreValve is available in four sizes (23, 26, 29 and 31?mm) to serve a broad range of patients' annulus from 18 to 29?mm. All the valves fit into an 18-Fr size catheter. Currently, more than 35,000 patients have been treated in more than 60 countries worldwide from the femoral artery, the axillary artery and, more recently, from a direct aortic approach, with excellent results up to 4-year follow-up. PMID:23278219
Bruschi, Giuseppe; De Marco, Federico; Martinelli, Luigi; Klugmann, Silvio
AIM: Incidental aorticvalve calcification is often detected during computed tomography. The aim was to compare the severity of valvular stenosis and calcification in patients with aortic stenosis.MATERIALS AND METHODS: One hundred and fifty-seven patients aged 68±11 years (range: 34–85) with aorticvalve stenosis underwent multislice helical computed tomography and Doppler echocardiography performed by independent, blinded observers. The aorticvalve
S. J Cowell; D. E Newby; J Burton; A White; D. B Northridge; N. A Boon; J Reid
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
Calcific aorticvalve disease (CAVD), once thought to be a degenerative disease, is now recognized to be an active pathobiological process, with chronic inflammation emerging as a predominant, and possibly driving, factor. However, many details of the pathobiological mechanisms of CAVD remain to be described, and new approaches to treat CAVD need to be identified. Animal models are emerging as vital tools to this end, facilitated by the advent of new models and improved understanding of the utility of existing models. In this paper, we summarize and critically appraise current small and large animal models of CAVD, discuss the utility of animal models for priority CAVD research areas, and provide recommendations for future animal model studies of CAVD.
Sider, Krista L.; Blaser, Mark C.; Simmons, Craig A.
Aorticvalve leaflets experience varying applied loads during the cardiac cycle. These varying loads act on both cells types of the leaflets, endothelial and interstitial cells, and cause molecular signaling events that are required for repairing the leaflet tissue, which is continually damaged from the applied loads. However, with increasing age, this reparative mechanism appears to go awry as valve interstitial cells continue to remain in their ‘remodeling’ phenotype and subsequently cause the tissue to become stiff, which results in heart valve disease. The etiology of this disease remains elusive; however, multiple clues are beginning to coalesce and mechanical cues are turning out to be large predicators of cellular function in the aorticvalve leaflets, when compared to the cells from pulmonary valve, which is under a significantly less demanding mechanical loading regime. Finally this paper discusses the mechanical environment of the constitutive cell populations, mechanobiological processes that are currently unclear, and a mechano-potential etiology of aortic disease will be presented.
Background. Human aorticvalve allografts elicit a cellular and humoral immune response. It is not clear whether this is important in promoting valve damage. We investigated the changes in morphology, cell populations, and major histocompatibility complex antigen distribution in the rat aorticvalve allograft.Methods. Fresh heart valves from Lewis rats were transplanted into the abdominal aorta of DA rats. Valves
Marjorie K Green; Michael D Walsh; Anthony Dare; Patrick G Hogan; Xiao-Ming Zhao; Ian H Frazer; Amolak S Bansal; Mark F O’Brien
The bicuspid aorticvalve (BAV) is associated with a high prevalence of calcific aorticvalve disease (CAVD). Although abnormal hemodynamics has been proposed as a potential pathogenic contributor, the native BAV hemodynamic stresses remain largely unknown. Fluid-structure interaction models were designed to quantify the regional BAV leaflet wall-shear stress over the course of CAVD. Systolic flow and leaflet dynamics were computed in two-dimensional tricuspid aorticvalve (TAV) and type-1 BAV geometries with different degree of asymmetry (10 and 16% eccentricity) using an arbitrary Lagrangian–Eulerian approach. Valvular performance and regional leaflet wallshear stress were quantified in terms of valve effective orifice area (EOA), oscillatory shear index (OSI) and temporal shear magnitude (TSM). The dependence of those characteristics on the degree of leaflet calcification was also investigated. The models predicted an average reduction of 49% in BAV peak-systolic EOA relative to the TAV. Regardless of the anatomy, the leaflet wall-shear stress was side-specific and characterized by high magnitude and pulsatility on the ventricularis and low magnitude and oscillations on the fibrosa. While the TAV and non-coronary BAV leaflets shared similar shear stress characteristics, the base of the fused BAV leaflet fibrosa exhibited strong abnormalities, which were modulated by the degree of calcification (6-fold, 10-fold and 16-fold TSM increase in the normal, mildly and severely calcified BAV, respectively, relative to the normal TAV). This study reveals the existence of major differences in wall-shear stress pulsatility and magnitude on TAV and BAV leaflets. Given the ability of abnormal fluid shear stress to trigger valvular inflammation, the results support the existence of a mechano-etiology of CAVD in the BAV. PMID:22294208
Chandra, Santanu; Rajamannan, Nalini M; Sucosky, Philippe
A Smeloff-Cutter ball prosthetic valve was replaced in a 56-year-old woman 31 years after implantation. Prosthetic endocarditis developed after endoscopic mucosal resection of colon cancer. The excised aortic ball valve was almost intact, without any thrombus formation. PMID:21471264
Transcatheter aorticvalve implantation has been established as an alternative treatment option for those patients with aortic stenosis (AO), who are high risk or unsuitable for surgical aorticvalve replacement. Since its introduction, transcatheter aorticvalve implantation has been mainly performed either by a percutaneous approach through the femoral arteries or by using a transapical approach via a left-sided mini-thoracotomy. More recently, experience on alternative access routes such as the subclavian artery and the ascending aorta has been reported in a small number of patients. The Edwards SAPIENTM transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) was the first balloon-expandable transcatheter heart valve to receive CE-Mark certification in Europe for transfemoral and transapical aorticvalve implantation in 2007/2008. However, it also has been used for transcatheter procedures using access through ascending aorta and subclavian artery. Appropriate patient selection is key for a successful transcatheter aorticvalve program and should be in the responsibility of the heart team of interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthetists and geriatrists. Their mixture of skills will enable the team to build patient care pathways in which patients are assessed regarding cardiac and non-cardiac comorbidities, the most appropriate type of treatment is jointly agreed, and finally various treatment options are delivered. In this review we highlight the cornerstones of a successful transcatheter aorticvalve program using the Edwards SAPIENTM valve. We focus in particular on preoperative diagnostics, patient selection and potential strengths and weaknesses of the various access routes to offer a guideline for future experience. PMID:22322575
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
Prevalence and echocardiographic characteristics of strands on the leaflets of native aorticvalves were examined. According to our data, the strands we found in 39% of patients are most likely Lambl's excrescences. PMID:9185655
Menzel, T; Mohr-Kahaly, S; Arnold, K J; Kölsch, B; Kopp, H; Spiecker, M; Wagner, S R; Meinert, R; Meyer, J
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
Described herein are two brothers, both with a congenitally bicuspid aorticvalve—one of which was stenotic and one of which functioned normally—and one with associated aortic isthmic coarctation. Summarized also are previously reported families with more than one member with a congenitally bicuspid aorticvalve.
Objective: The treatment of choice for aorticvalve insufficiency due to root dilatation has become root replacement with aorticvalve sparing. However, root replacement with a synthetic graft may result in altered valve stresses. The purpose of this study was to compare the stress\\/strain patterns in the spared aorticvalve in different root replacement procedures by means of finite element
K. Jane Grande-Allen; Richard P. Cochran; Per G. Reinhall; Karyn S. Kunzelman
Aortic stenosis and coronary artery disease share comorbidities/risk factors; thus, it is not surprising they occur concomitantly. With increased life expectancy of patients who undergo transcatheter aorticvalve implantation (TAVI), the rate of post-TAVI percutaneous coronary intervention (PCI) is expected to rise. In the current report, we present two cases using PCI following CoreValve (Medtronic) implantation. Our cases indicated that the procedure is feasible and safe, but requires careful planning and understanding of the three-dimensional geometry of the prosthetic valve and its relation to the coronary ostia. PMID:23813067
This year marks the 50th anniversary of the first aorticvalve prosthesis implanted in the descending aorta on September 11, 1952 by Dr. Charles A. Hufnagel at the Georgetown University Hospital in Washington, D.C. At this time, before the era of the heart-lung machines with extracorporeal circulation, there was no surgical therapy for patients with aortic insufficiency. Hufnagel implanted his plexiglas ball valve prosthesis, providing a significant hemodynamic improvement to the patients and opening the field of cardiac valve replacement. PMID:12418293
Aortic ring abscess and mitral valve aneurysms complicating infective endocarditis have previously been described as surgical or autopsy findings. More recently, transesophageal echocardiography has been shown to be more sensitive than standard transthoracic echocardiography or other imaging modalities in detecting each of these complications. Since aortic ring abscess and mitral valve aneurysms virtually mandate surgical intervention, their early detection may be crucial. This report describes a 35-year-old male with congenitally abnormal aorticvalve which became infected and in whom both an aortic ring abscess and mitral valve aneurysm occurred. These findings are discussed and the pertinent literature is reviewed. PMID:7889443
Using a cardiovascular simulator to duplicate in vitro the flow conditions through valves in aortic position, bidimensional velocity maps very near the valve are reconstructed, from an ultrasonic 8 Mhz doppler system, in an elastic model of the ascending aortic arch. Three mechanical heart valves representative of the different types of commercial models (a tilting disc, a ball in cage and a two-leaflet valve) and a new bileaflet prototype were investigated. From examination of the velocity field, it is possible to define the main characteristics of the valve wake and to observe the development of negative velocities associated with regurgitant flows. From a comparison with tests in rigid tubes, the role played by the arch elasticity is analysed. PMID:1601515
Tonietto, G; Cassot, F; Rieu, R; Garitey, V; Pelissier, R
Transcatheter aortic-valve implantation is becoming the standard of care for inoperable patients with severe aortic stenosis and a valid alternative for those at high surgical risk. Since the first percutaneous transcatheter aortic-valve implantation in humans in 2002, over 50,000 transcatheter aorticvalves have been implanted in the last decade, with progressive improvement in the available devices. Overall, there are two main families of transcatheter prosthesis: self-expandable and nonself-expandable. The self-expandable devices, for which CoreValve(®) (Medtronic CV Luxembourg S.a.r.l., Luxembourg) represents the prototype, are characterized by a structure composed of shape memory materials, usually nitinol, which acquire its final shape once released. By contrast, the non-self-expandable prostheses, mainly represented by the Edwards(®) valve (Edwards Life Sciences, Inc., CA, USA), require balloon dilatation to reach its final shape. Although several publications have already provided positive data on both technologies, new clinical studies with improved systems are currently being conducted in order to provide more solid data and potentially expand the spectrum of patients who can benefit from this therapy. Thus, the aim of the present paper is to review the salient features of the two most used systems today (third-generation CoreValve and Edwards SAPIEN XT(®)) as well as to provide data on other emerging valves and future perspectives. PMID:23480088
INTRODUCTION Transcatheter aorticvalve implantation (TAVI) represents an emerging therapy for valve replacement in patients not suitable for traditional open repair. As awareness of the procedure grows, case numbers are increasing worldwide. Though this procedure represents a less invasive approach to aorticvalve replacement, it is not without complications. PRESENTATION OF CASE This case presentation describes a serious, previously unreported, complication incurred in an 83-year-old male in whom TAVI was attempted. During deployment of the valve at the aortic annulus, both the valve and accompanying balloon embolised into the thoracic aorta and this was further complicated by migration of the balloon into the abdominal aorta and an aortic dissection. The false lumen of the dissection at the level of the infrarenal aorta was tacked to the aortic adventitial wall using interrupted sutures through a laparotomy. A completion angiogram demonstrated that a flow limited dissection did extend up to both common iliac arteries. This was managed with balloon-expandable covered stents deployed in both common iliac arteries with satisfactory outcome. DISCUSSION This case occurred as a combination of multiple factors that include lack of burst pacing and poor timing of the balloon inflation. The aortic balloon and the valve had to be removed urgently to avoid ventricular embolization of these structures that can result in a fatal situation. CONCLUSION This case presentation describes the management of these complications using a combined open and endovascular approach in a well-equipped hybrid operating theatre, resulting in the patient survival.
Aortic false aneurysm (AFA) is a rare but life threatening complication after aortic surgery. We report a 13-year-old boy who developed AFA after double valve replacement consisting of the following: (1) Bentall procedure utilizing a 25-mm St. Jude aorticvalved composite Hemashield Dacron graft (Meadox Medicals, Oakland, NJ); and (2) replacement of right ventricle to pulmonary artery conduit with a 25-mm porcine valved conduit. The exterior metal ring of the pulmonary prosthetic valve conduit caused an abrasion of the Hemashield graft, resulting in the AFA. In addition to simple suture repair, the pulmonary conduit was wrapped with a Gore-Tex patch (W.L. Gore Assoc, Flagstaff, AZ) to prevent recurrence. PMID:23706444
Kobayashi, Daisuke; Walters, Henry L; Forbes, Thomas J; Aggarwal, Sanjeev
Chylopericardium after cardiac surgery is rare, and there are few reports of its occurrence after aorticvalve surgery. Chylous pericardial effusion 4 months after aorticvalve replacement for endocarditis is highly unusual. Herein, we report the case of a 54-year-old man who had undergone bioprosthetic aorticvalve replacement because of endocarditis and valvular dysfunction. Two months later, he underwent pericardiocentesis twice because of large pericardial effusions consisting of pinkish white fluid with predominant lymphocytes. Four months after valve replacement, he presented with recurrent effusion consistent with early tamponade, and a pericardial window was created. At surgery, 1,500 cc of milky white fluid was recovered, and the diagnosis of chylopericardium was made. Postoperative high-volume drainage prompted thoracic duct ligation, which was curative.
Mundra, Vishal; Savage, Edward B.; Novaro, Gian M.; Asher, Craig R.
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 from normal explanted porcine aorticvalves by suturing two leaflets together. The valves are mounted in an acrylic chamber with two sinuses & tested in a pulsatile flow loop at physiological conditions. 2D PIV is performed to obtain flow fields in three planes downstream of the valve. The stenosed BAV causes an eccentric jet, resulting in a very strong vortex in the normal sinus. The bicuspid sinus vortex appears much weaker, but more unstable. Unsteady oscillatory shear stresses are also observed, which have been associated with adverse biological response; characterization of the hemodynamics of BAVs will provide the first step to understanding these processes better. Results from multiple BAV models of varying levels of stenosis will be presented & higher stenosis corresponded to stronger jets & increased aortic wall shear stresses.
Saikrishnan, Neelakantan; Yap, Choon-Hwai; Yoganathan, Ajit P.
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
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
Purpose: Few recent studies have examined the long-term outcomes after aorticvalve replacement (AVR), and independent predictors for long-term survival and valve-related mortality have not been elucidated.Methods: From January 1993 to December 2009, 132 elderly patients (?70 years old) with aortic stenosis underwent AVR in our hospital. The patients comprised 61 men and71 women with a mean age of 76.1 ± 3.7 years. Patients with acute or old myocardial infarction, mitral valve disease, and re-do surgery were not included in this study. Risk factors for late valve-related mortality were examined.Results: The 5-year freedom from valve-related mortality rate was 89.6%. The following significant independent risk factors for late valve-related mortality were identified:increase in the preoperative left ventricular mass index (hazard ratio, 1.10 [per 10 g/m(2)];p = 0.040); lack of sinus rhythm (hazard ratio, 7.11; p = 0.005); peak transvalvular pressure gradient of <60 mmHg (hazard ratio, 7.48; p = 0.008).Conclusion: In the elderly, AVR should be performed at an early stage of aortic stenosis, before an increase in the left ventricular mass index has occured, and while the heart rhythm is in sinus rhythm and the peak transvalvular pressure gradient is high. PMID:23237930
Objective We aimed to determine the prevalence of dilatation and abnormal elastic properties of aortic root in first degree relatives (FDRs) of bicuspid aorticvalve patients. Background Evidence indicates that BAV is a genetic disorder. While FDRs of affected individuals have increased prevalence of BAV, their risk of aortic root abnormalities is unknown. Methods We studied dimensions as well as the elastic properties of the ascending aorta in 48 FDRs with morphologically normal, tricuspid aorticvalves, 54 BAV patients, and 45 controls using two-dimensional echocardiography. Results The prevalence of aortic root dilatation was 32% in FDRs and 53% in BAV patients, whereas all controls demonstrated normal aortic dimensions (p<0.001). FDRs and BAVs had significantly lower aortic distensibility (1.7±1.4 and 1.4±2.0 vs. 2.5±1.6×10?3 mmHg, p<0.001) and greater aortic stiffness index (26.7±25.8 and 55.92±76.8 vs. 18.7±40.1, p=0.001) compared to controls. This difference remained significant in subjects without aortic root dilatation or hypertension (p=0.002 and p=0.004, respectively). Conclusions The aortic root is functionally abnormal and dilatation is common (32%) in first degree relatives of patients with BAV. Screening of FDRs by transthoracic 2-dimensional echocardiography should be considered for detection of aorticvalve malformation and dilated ascending aorta.
Biner, Simon; Rafique, Asim M; Ray, Indraneil; Cuk, Olivera; Siegel, Robert J; Tolstrup, Kirsten
At our institutions, increasing numbers of aortic stenosis patients were not candidates for surgical aorticvalve replacement. Accordingly, we initiated the Cali Colombian Transcatheter AorticValve Implantation (TAVI) program. From March 2008 through January 2011, 53 consecutive patients (mean age, 79 ± 6 yr; men, 58%) underwent TAVI with the Medtronic CoreValve System, and data were prospectively collected. Our study's endpoints conformed with Valve Academic Research Consortium recommendations. We report our clinical results.Predicted mortality rates were 25% (interquartile range, 17%-34%) according to logistic EuroSCORE and 6% (interquartile range, 3%-8%) according to the Society of Thoracic Surgeons score. The 30-day mortality rate was 9% (3 intraprocedural deaths, 5 total). The combined 30-day safety endpoint was 30% (major vascular sequelae, 23%; life-threatening bleeding, 12%; myocardial infarction, 4%; major stroke, 4%; and acute kidney injury [stage 3], 2%). Eight patients (15%) required post-implantation balloon dilation and 2 (4%) required valve-in-valve implantation, for a technical device success rate of 77%. Mean peak transvalvular gradient decreased from 74 ± 29 to 17 ± 8 mmHg and mean transvalvular gradient from 40 ± 17 to 8 ± 4 mmHg (both P=0.001). Moderate or severe aortic regurgitation decreased from 32% to 18% (P=0.12) and mitral regurgitation from 32% to 13% (P=0.002). The 1-year survival rate was 81%.We found that TAVI with the CoreValve prosthesis was safe and feasible, with sustained long-term results, for treating aortic stenosis in patients at excessive surgical risk; nonetheless, serious adverse events occurred in 30% of the patients. PMID:22719143
Dager, Antonio E; Nuis, Rutger-Jan; Caicedo, Bernardo; Fonseca, Jaime A; Arana, Camilo; Cruz, Lidsa; Benitez, Luis M; Nader, Carlos A; Duenas, Eduardo; de Marchena, Eduardo J; O'Neill, William W; de Jaegere, Peter P
At our institutions, increasing numbers of aortic stenosis patients were not candidates for surgical aorticvalve replacement. Accordingly, we initiated the Cali Colombian Transcatheter AorticValve Implantation (TAVI) program. From March 2008 through January 2011, 53 consecutive patients (mean age, 79 ± 6 yr; men, 58%) underwent TAVI with the Medtronic CoreValve System, and data were prospectively collected. Our study's endpoints conformed with Valve Academic Research Consortium recommendations. We report our clinical results. Predicted mortality rates were 25% (interquartile range, 17%–34%) according to logistic EuroSCORE and 6% (interquartile range, 3%–8%) according to the Society of Thoracic Surgeons score. The 30-day mortality rate was 9% (3 intraprocedural deaths, 5 total). The combined 30-day safety endpoint was 30% (major vascular sequelae, 23%; life-threatening bleeding, 12%; myocardial infarction, 4%; major stroke, 4%; and acute kidney injury [stage 3], 2%). Eight patients (15%) required post-implantation balloon dilation and 2 (4%) required valve-in-valve implantation, for a technical device success rate of 77%. Mean peak transvalvular gradient decreased from 74 ± 29 to 17 ± 8 mmHg and mean transvalvular gradient from 40 ± 17 to 8 ± 4 mmHg (both P=0.001). Moderate or severe aortic regurgitation decreased from 32% to 18% (P=0.12) and mitral regurgitation from 32% to 13% (P=0.002). The 1-year survival rate was 81%. We found that TAVI with the CoreValve prosthesis was safe and feasible, with sustained long-term results, for treating aortic stenosis in patients at excessive surgical risk; nonetheless, serious adverse events occurred in 30% of the patients.
Dager, Antonio E.; Nuis, Rutger-Jan; Caicedo, Bernardo; Fonseca, Jaime A.; Arana, Camilo; Cruz, Lidsa; Benitez, Luis M.; Nader, Carlos A.; Duenas, Eduardo; de Marchena, Eduardo J.; O'Neill, William W.; de Jaegere, Peter P.
BACKGROUND: The technique of percutaneous aorticvalve implantation (PAVI) for the treatment of severe aortic stenosis (AS) has been introduced in 2002. Since then, many thousands such devices have worldwide been implanted in patients at high risk for conventional surgery. The procedure related mortality associated with PAVI as reported in published case series is substantial, although the intervention has never
In uniaxial tensile experiments in vitro mechanical properties of the different parts of porcine aorticvalves, i.e. the leaflets, the sinus wall and the aortic wall, have been dealt with. Tissue strips cut in different directions were investigated. The collagen bundles in the leaflets show a stiffening effect and cause a marked anisotropy: within the physiological range of strains the
A. A. H. J. Sauren; M. C. van Hout; A. A. van Steenhoven; Steenhoven van AA; FE Veldpaus
We report a case of a new developed aortic aneurysm 18 month after transcatheter aorticvalve implantation in an 80-year-old woman. The abnormality was an incidental finding during routine coronary angiography. PMID:22121067
Objective. To report the feasibility, safety and efficacy of percutaneous aorticvalve implantation (PAVI) with the CoreValve self-expanding aorticvalve bioprosthesis in elderly patients with aorticvalve stenosis who are rejected for surgery or have a high surgical risk.Methods. PAVI using the CoreValve ReValving System was performed under general anaesthesia in 30 high-risk (surgical) patients with a symptomatic severe aortic
J. Baan; Z. Y. Yong; K. T. Koch; J. P. S. Henriques; B. J. Bouma; Hert de S. G; Meulen van der J; J. G. P. Tijssen; J. J. Piek; Mol de B. A. J. M
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
The aim of the study is to estimate the operative risk of aorticvalve replacement for severe aorticvalve stenosis in patients with distinctly impaired left ventricular function (ejection fraction below 40%). From the population of 2512 pts, who underwent aorticvalve replacement in the years 1990 to 1999 because of acquired malformation, a group of 108 pts (4.3%), fulfilling the above mentioned conditions was selected. Between them prevailed men, 92 (85.2%), and the average age was 53.4 +/- 14.5. All pts remained in the NYHA functional class III/IV. The average ejection fraction was estimated 28.2 +/- 14.3%. The pts demonstrated concentric left ventricular hypertrophy, severe aorticvalve calcifications, the average valvular area was 0.91 cm2, and the pressure gradient over the valve was 71 +/- 44 mmHg. The pts were operated on by different surgeons but after the same protocol of extracorporeal circulation and cardioplegia administration. Low output syndrome occurred in ca 40% of pts, and cardiac failure was the main cause of death. The hospital mortality was 8.6%, and it was over two times higher then the whole population of pts, who underwent aorticvalve replacement. All survivors (91.4%) demonstrated clinical improvement already during the early observation. Conclusions: Low ejection fraction is an important risk factor of surgery for aorticvalve stenosis. However, the elevated operative mortality, comparable to other institutions, may be accepted taking for consideration, that surgery is the only way of treatment and improvement may be expected in about 90% of pts, including anatomical and hemodynamic parameters, as well as life longevity and comfort. In the extreme cases the HTX should be considered. PMID:15724639
Cie?la-Dul, Mariola; Pfitzner, Roman; Drwi?a, Rafa?; Górkiewicz-Kot, Izabela; Sadowski, Jerzy
We report the case of a patient who had undergone implantation of a Björk-Shiley Delrin valve in the aortic position 25 years earlier and who now presented with severe mitral stenosis. The patient underwent mitral valve replacement and aorticvalve re-replacement. We review the justification for prophylactic replacement of Björk-Shiley Delrin heart valves.
Objective: The purpose of this study was to optimize selection criteria of biologic versus mechanical valve prostheses for aorticvalve replacement. Methods: Retrospective analysis was performed for 841 patients undergoing isolated, first-time aorticvalve replacement with Carpentier-Edwards (n = 429) or St Jude Medical (n = 412) prostheses. Results: Patients with Carpentier-Edwards and St Jude Medical valves had similar characteristics.
David S. Peterseim; Ye-Ying Cen; Srinivas Cheruvu; Kevin Landolfo; Thomas M. Bashore; James E. Lowe; Walter G. Wolfe; Donald D. Glower
A 77-year-old, high-risk woman with symptomatic aorticvalve stenosis (aorticvalve area 0.77 cm(2)) underwent coronary artery catheterization and right heart catheterization. After catheterization, she suddenly developed hemoptysis, and became hypoxic and hypotonic. She was intubated and the bleeding was stopped using positive end-expiratory pressure. Chest X-ray and computed tomography showed a pulmonary artery (PA) pseudoaneurysm with a maximum diameter of 40 mm at the right middle lobe. Endovascular treatment approaches by coil embolization failed, so surgical resection was indicated. In preparation for the procedure and to reduce perioperative risk, transapical aorticvalve implantation was performed. The operation took about 40 minutes and the intraoperative activated clotting time was controlled at 180-200 sec. After successful transapical aorticvalve implantation, aneurysmectomy was performed. Intraoperatively, the PA pseudoaneurysm was found to occupy nearly the entire middle lobe. A right middle lobectomy was performed. The operative course was uneventful. Transapical aorticvalve implantation may have eliminated the risk of rupture or re-bleeding in such bleeding-prone patient. PMID:23380552
Asano, Mitsuru; Gäbel, Gabor; Allham, Omar; Weiss, Norbert; Bergert, Hendrik
The transesophageal echocardiographic assessment of prosthetic aorticvalve function is made more difficult by the presence of a mechanical mitral valve prosthesis because echocardiographic views conventionally used to assess the aorticvalve function are obscured by acoustic shadowing and artifacts. We report the use of intraoperative transesophageal echocardiography in a patient who developed severe prosthetic aorticvalve regurgitation after implantation
Background. The choice of a valve substitute in young adults requires a decision balancing the risks of long-term anticoagulation versus reoperation(s). This article analyzes the long-term risk and determinants of thromboembolic (TE) and bleeding (BLE) complications after mechanical aorticvalve replacement (AVR).Methods. From December 1963 to January 1974, 249 patients survived a mechanical AVR at our institution. Mean age was
Filip P Casselman; Michiel L Bots; Willem Van Lommel; Paul J Knaepen; Ruud Lensen; Freddy E. E Vermeulen
A bicuspid aorticvalve (BAV) demonstrating moderate valvular stenosis and mild insufficiency was identified in an asymptomatic 1-year-old male cryptorchid English bulldog by transthoracic and transesophageal echocardiography. The BAV was most consistent with type 3 morphology, based upon human classification. Pulmonary valve dysplasia with mild pulmonary stenosis and a suspected persistent left cranial vena cava were also identified. Although BAV is the most common congenital cardiac malformation in humans, it is rare in the dog. PMID:23434244
Aorticvalve reconstruction using leaflet grafts made from autologous pericardium is an effective surgical treatment for some forms of aortic regurgitation. Despite favorable outcomes in the hands of skilled surgeons, the procedure is underutilized because of the difficulty of sizing grafts to effectively seal with the native leaflets. Difficulty is largely due to the complex geometry and function of the valve and the lower distensibility of the graft material relative to native leaflet tissue. We used a structural finite element model to explore how a pericardial leaflet graft of various sizes interacts with two native leaflets when the valve is closed and loaded. Native leaflets and pericardium are described by anisotropic, hyperelastic constitutive laws, and we model all three leaflets explicitly and resolve leaflet contact in order to simulate repair strategies that are asymmetrical with respect to valve geometry and leaflet properties. We ran simulations with pericardial leaflet grafts of various widths (increase of 0%, 7%, 14%, 21% and 27%) and heights (increase of 0%, 13%, 27% and 40%) relative to the native leaflets. Effectiveness of valve closure was quantified based on the overlap between coapting leaflets. Results showed that graft width and height must both be increased to achieve proper valve closure, and that a graft 21% wider and 27% higher than the native leaflet creates a seal similar to a valve with three normal leaflets. Experimental validation in excised porcine aortas (n=9) corroborates the results of simulations.
Hammer, Peter E.; Chen, Peter C.; del Nido, Pedro J.; Howe, Robert D.
Vegetation of infective endocarditis presenting as a mobile mass at the left ventricular outflow tract (LVOT) in the absence of abnormalities of the cardiac chambers or the valves is unusual. Surgical removal is the treatment of choice for a mobile mass lesion in the LVOT to avoid its high risk for embolisation. A case of infective endocarditis caused by aminoglycoside-resistant
K. Jayaprakash; S. Abdul Khadar; Joby K. Thoams; K. J. Raihanathul Misiriya; V. L. Jayaprakash; Joseph M. Pappachan
Minimally invasive cardiac surgery is less traumatic and therefore leads to quicker recovery. With the assistance of engineering technologies on devices, imaging, and robotics, in conjunction with surgical technique, minimally invasive cardiac surgery will improve clinical outcomes and expand the cohort of patients that can be treated. We used transapical aorticvalve implantation as an example to demonstrate that minimally invasive cardiac surgery can be implemented with the integration of surgical techniques and engineering technologies. Feasibility studies and long-term evaluation results prove that transapical aorticvalve implantation under MRI guidance is feasible and practical. We are investigating an MRI compatible robotic surgical system to further assist the surgeon to precisely deliver aorticvalve prostheses via a transapical approach. Ex vivo experimentation results indicate that a robotic system can also be employed in in vivo models.
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
Background. The aim of this study was to determine the durability of aorticvalve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root.Methods. From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and
Filip P Casselman; M. Erwin S. H Tan; Freddy E. E Vermeulen; Johannes C Kelder; Wim J Morshuis; Marc A. A. M Schepens
Myxoma of the aorticvalve is an exceedingly uncommon condition. In this article, we report the case of a 72-year-old man with myxoma arising from the aorticvalve. We extirpated the mass and repaired the aorticvalve with the patient under cardiopulmonary bypass. The postoperative course was uneventful. Histological examination confirmed that the mass was a myxoma.
Kim, Hyung Yoon; Jang, Woo-Ik; Kim, Han-Seong; Kim, Jin Suk; Lee, Han Sang; Park, Min Yong; Kim, Taewan; Lee, Sung Yun; Doh, Joon Hyung; Namgung, June; Lee, Won Roo
Aorticvalve replacement (AVR) is the gold standard for the treatment of severe symptomatic aortic stenosis. Complications directly related to surgical procedure are relatively infrequent. Coronary ostial stenosis is, generally, referred as late complication. Anecdotal reports concern coronary ostial stenosis as acute complication. A unique fatal case of intraoperative, bilateral coronary ostial obstruction by prosthetic valve leading to an extensive myocardial infarction is reported. Surgeons must have a high level of vigilance regarding the occurrence of acute myocardial ischemia and sudden death soon after AVR.
Percutaneous aorticvalve replacement is an emerging alternative for high surgical risk patients with native aorticvalve stenosis. We describe for the first time a valve-in-valve procedure with a CoreValve prosthesis for the treatment of a severely stenotic degenerated aortic bioprosthesis. PMID:20407385
Giannini, Cristina; De Carlo, Marco; Guarracino, Fabio; Donne, Maria G D; Benedetti, Giovanni; Verunelli, Francesco; Petronio, Anna S
The need for reoperation remains a principal limitation of the Ross procedure and most commonly includes replacement of the neo-aorticvalve. Valve-preserving aortic root replacement has recently evolved into an increasingly accepted treatment modality for patients with neo-aorticvalve regurgitation. Leaflet prolapse, however, may be present, making composite replacement the most frequent choice. Alternatively, valve preservation may be combined with correction of leaflet prolapse. We describe the use of a valve-sparing procedure with correction of leaflet prolapse in a patient with progressive dilatation of the pulmonary autograft and severe regurgitation of the neo-aorticvalve. PMID:17669778
OBJECTIVESThe aim of this study was to examine the association between atherosclerosis risk factors, aortic atherosclerosis and aorticvalve abnormalities in the general population.BACKGROUNDClinical and experimental studies suggest that aorticvalve sclerosis (AVS) is a manifestation of the atherosclerotic process.METHODSThree hundred eighty-one subjects, a sample of the Olmsted County (Minnesota) population, were examined by transthoracic and transesophageal echocardiography. The presence
Yoram Agmon; Bijoy K Khandheria; Irene Meissner; JoRean D Sicks; W. Michael O’Fallon; David O Wiebers; Jack P Whisnant; James B Seward; A. Jamil Tajik
A 54 year old female presented with lower extremity edema, fatigue, and shortness of breath with physical findings indicative of advanced aortic insufficiency. Echocardiography showed severe aortic regurgitation and a probable quadricuspid aorticvalve. In anticipation of aorticvalve replacement, cardiac computed tomography (Cardiac CT) was performed using 100 kV, 420 mA which resulted in 6 mSv of radiation exposure. Advanced computing algorithmic software was performed with a non-linear interpolation to estimate potential physiological movement. Surgical photographs and in-vitro anatomic pathology exam reveal the accuracy and precision that preoperative Cardiac CT provided in this rare case of a quadricuspid aorticvalve. While there have been isolated reports of quadricuspid diagnosis with Cardiac CT, we report the correlation between echocardiography, Cardiac CT, and similar appearance at surgery with confirmed pathology and interesting post-processed rendered images. Cardiac CT may be an alternative to invasive coronary angiography for non-coronary cardiothoracic surgery with the advantage of providing detailed morphological dynamic imaging and the ability to define the coronary arteries non-invasively. The reduced noise and striking depiction of the valve motion with advanced algorithms will require validation studies to determine its role. PMID:22442640
Karlsberg, Daniel W; Elad, Yaron; Kass, Robert M; Karlsberg, Ronald P
Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone, and balloon aortic valvuloplasty has failed to provide durable clinical benefit. Open surgical replacement of the aorticvalve can improve symptoms and survival. Recently, transcatheter aorticvalve implantation (TAVI) has been demonstrated to improve survival, quality of life, and functional status in nonoperable patients and to be a viable option for patients in whom the risk of open surgical morbidity or mortality is high. This Canadian Cardiovascular Society position statement represents the consensus of a representative group of cardiologists and cardiac surgeons as to the current, but evolving, role of this less-invasive new therapy. Specific recommendations are provided for selection of patients for TAVI vs surgical aorticvalve replacement for native valves and for bioprostheses, approaches to patient evaluation for TAVI, appropriate constitution of multidisciplinary teams involved in performing TAVI, essential facilities that are needed to perform TAVI safely and effectively, and training/qualifications for TAVI operators. Cost considerations, complication rates, and the quality of the available evidence are also discussed. It is hoped that this consensus document will prove to be a useful resource for health professionals, institutions, departments, and decision-making bodies dealing with this important and rapidly evolving therapy. PMID:22703948
Renal failure is associated with aorticvalve calcification. Using our rat model of uremia-induced reversible aorticvalve calcification, we assessed the role of apoptosis and survival pathways in that disease. We also explored the effects of raloxifene, an estrogen receptor modulator, on valvular calcification. Gene array analysis was performed in aorticvalves obtained from three groups of rats (n = 7 rats/group): calcified valves obtained from rats fed with uremic diet, valves after calcification resolution following diet cessation, and control. In addition, four groups of rats (n = 10 rats/group) were used to evaluate the effect of raloxifene in aorticvalve calcification: three groups as mentioned above and a fourth group fed with the uremic diet that also received daily raloxifene. Evaluation included imaging, histology, and antigen expression analysis. Gene array results showed that the majority of the altered expressed genes were in diet group valves. Most apoptosis-related genes were changed in a proapoptotic direction in calcified valves. Apoptosis and decreases in several survival pathways were confirmed in calcified valves. Resolution of aorticvalve calcification was accompanied by decreased apoptosis and upregulation of survival pathways. Imaging and histology demonstrated that raloxifene significantly decreased aorticvalve calcification. In conclusion, downregulation of several survival pathways and apoptosis are involved in the pathogenesis of aorticvalve calcification. The beneficial effect of raloxifene in valve calcification is related to apoptosis modulation. This novel observation is important for developing remedies for aorticvalve calcification in patients with renal failure.
The complications associated with the implantation of prosthetic valves and the experimental attempts to graft the mitral valve are described. Because of the disadvantages connected with the use of artificial valves and as the experimental methods of grafting the mitral valve did not prove satisfactory for clinical use, the authors developed a technique for mitral valve replacement using heterologous aorticvalves—reinforced by a semirigid Teflon ring—placed above the mitral annulus inside the atrial cavity. The technique of collecting, preparing, and inserting these grafts is described in detail. Using this method, seven patients with mitral incompetence or mitral disease were operated upon between February and April, 1967. One patient died five weeks after the operation from bacterial endocarditis in a period of severe hospital infection with staphylococcus. The other six patients had a very good clinical result immediately after surgery. At the present time they are symptom-free and have normal heart sounds. Clinical and experimental data are discussed concerning the long-term fate of aortic heterografts in the mitral position. Images
Ionescu, M. I.; Wooler, G. H.; Smith, D. R.; Grimshaw, V. A.
OBJECTIVE: The authors determined in which patients tube graft replacement could be used. SUMMARY BACKGROUND DATA: Tube graft replacement of ascending aortic aneurysms requires no coronary anastomoses and preserves the native aorticvalve, but aortic insufficiency or aortic root aneurysms may develop requiring reoperation. Use of Bentall or Cabrol composite valve graft procedures obviates these problems but requires prosthetic valve replacement and coronary reattachment, both of which are associated with complications. These two procedures have been applied increasingly but because of renewed interest in aorticvalve preservation and reconstruction, the authors determined in which patients tube replacement could be used. METHODS: The authors analyzed the fate of 277 patients, mean age 49 +/- 14 years, operated on between 1953 and 1992 by techniques that preserved the aortic root. The most common pathology was atherosclerosis in 104 patients. Perioperative mortality since 1975 was 14%. RESULTS: Fifteen patients required reoperation on the ascending aorta or aortic root; ascending aneurysm reoperation (6 patients); aorticvalve replacement (8 patients), and a combined procedure (1 patient). Of these 15 patients, 8 had Marfan's syndrome, 10 had dissections, and 5 had medial degeneration/necrosis. CONCLUSIONS: Simple tube graft replacement of the ascending aorta was a durable technique in patients without Marfan's syndrome or medial degeneration/necrosis and allowed preservation of the native aorticvalve in many patients.
This research proposes an augmented magnetic navigation system for Transcatheter AorticValve Implantation (TAVI) employing a magnetic tracking system (MTS) combined with a dynamic aortic model and intra-operative ultrasound (US) images. The dynamic 3D aortic model is constructed based on the preoperative 4D computed tomography (CT), which is animated according to the real time electrocardiograph (ECG) input of patient. And a preoperative planning is performed to determine the target position of the aorticvalve prosthesis. The temporal alignment is performed to synchronize the ECG signals, intra-operative US image and tracking information. Afterwards, with the assistance of synchronized ECG signals, the contour of aortic root automatic extracted from short axis US image is registered to the dynamic aortic model by a feature based registration intra-operatively. Then the augmented MTS guides the interventionist to confidently position and deploy the aorticvalve prosthesis to target. The system was validated by animal studies on three porcine subjects, the deployment and tilting errors of which are 3.17 ± 0.91mm and 7.40 ± 2.89° respectively. PMID:24110937
Luo, Zhe; Cai, Junfeng; Nie, Yuanyuan; Wang, Guotai; Gu, Lixu
Starr-Edwards ball valves removed more than 15 years after implantation were retrospectively investigated macroscopically. Eight patients required re-operation. Valve models used in the initial operations were a non-cloth-covered valve in 2 patients and a cloth-covered valve in 6. Two patients had replacement of an aortic ball valve (model 1260 and model 2320) and 6 underwent mitral valve replacement (model 6120
Background. The effect of aorticvalve replacement on three-dimensional\\u000a mitral annular geometry has not been well described. Emerging\\u000a transcatheter approaches for aorticvalve replacement employ\\u000a fundamentally different mechanical techniques for achieving fixation and\\u000a seal of the prosthetic valve than standard surgical aorticvalve\\u000a replacement. This study compares the immediate impact of transcatheter\\u000a aorticvalve replacement (TAVR) and standard surgical aortic
Mathieu Vergnat; Melissa M. Levack; Benjamin M. Jackson; Joseph E. Bavaria; Howard C. Herrmann; Albert T. Cheung; Stuart J. Weiss; Joseph H. III Gorman; Robert C. Gorman
The recent development of transcatheter aorticvalve implantation (TAVI) to treat severe aortic stenosis (AS) offers a viable\\u000a option for high-risk patients categories. Our aim is to evaluate the early effects of implantation of CoreValveaorticvalve\\u000a prosthesis on arterial-ventricular coupling by two dimensional echocardiography. Sixty five patients with severe AS performed\\u000a 2D conventional echocardiography before, immediately after TAVI, at
Vitantonio Di Bello; Cristina Giannini; Marco De Carlo; Maria Grazia Delle Donne; Carmela Nardi; Caterina Palagi; Cuono Cucco; Frank Lloyd Dini; Fabio Guarracino; Mario Marzilli; Anna Sonia Petronio
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
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.
Grover, Peeyush M.; O'Neill, Brian P.; Velazquez, Omaida; Heldman, Alan W.; O'Neill, William W.; Cohen, Mauricio G.
Heart valve replacements fabricated from glutaraldehyde (Glut)-crosslinked heterograft materials, porcine aorticvalves or bovine pericardium, have been widely used in cardiac surgery to treat heart valve disease. However, these bioprosthetic heart valves often fail in long-term clinical implants due to pathologic calcification of the bioprosthetic leaflets, and for stentless porcine aorticvalve bioprostheses, bioprosthetic aortic wall calcification also typically occurs.
H. Scott Rapoport; Jeanne M. Connolly; James Fulmer; Ning Dai; Brandon H. Murti; Robert C. Gorman; Joseph H. Gorman; Ivan Alferiev; Robert J. Levy
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
Microscopic polyangiitis (MPA) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterized by inflammation of small-sized vessels. Although there have been some reports of ANCA-associated vasculitis presenting as aortitis syndrome, MPA rarely involves large-sized vessels such as the aorta. We report an unusual case of MPA combined with severe acute aorticvalve insufficiency in a 56-year-old man. He initially presented with prolonged fever, skin rash, and rapidly progressive glomerulonephritis. P-ANCA and anti-myeloperoxidase (MPO) antibodies were positive, but the c-ANCA and anti-proteinase-3 antibodies were negative. Skin biopsy of the lower leg showed necrotizing arteritis. Kidney biopsy was also performed, which revealed diffuse necrotizing and crescentic glomerulonephritis (GN) consistent with pauci-immune ANCA-associated GN. Serial echocardiographic evaluations revealed aorticvalve changes and worsening acute aorticvalve insufficiency over a two-month period. Despite intensive treatment, our patient developed sudden cardiac arrest and died. Our patient demonstrated typical clinical features and histopathologic findings for systemic vasculitis and had a positive anti-MPO antibody, all of which were consistent with the diagnosis of MPA. Thus, MPA may have been the cause of acute aorticvalve insufficiency in this case. PMID:21120499
Kim, Bae Keun; Park, So-Yeon; Choi, Chan-Bum; Kim, Tae-Hwan; Jun, Jae-Bum; Jang, Se Min; Park, Moon Hyang; Uhm, Wan-Sik
Transcatheter aorticvalve implantation (TAVI) is a new technology, which is rapidly growing to a routine procedure amenable for patients with symptomatic aorticvalve stenosis and higher than average risk for conventional aorticvalve surgery. The crucial disadvantage of TAVI remains the not well foreseeable risk of more than trivial degree of paravalvular leakage and a high rate of atrioventricular block and consecutive pacemaker implantation. In addition, current implantation techniques do not allow controlling the rotation of first-generation devices that might be beneficial regarding optimal physiological valve performance, optimal coronary flow and avoidance of placement of covered commissures in front of the coronary ostia. These shortcomings had pushed the development of second-generation self-expandable nitinol-based devices for subcoronary implantation that aim a reduction of paravalvular leak and AV-block by anatomical orientated positioning into the aortic root. This review focuses on the description of three different TAVI concepts, which are presently under early clinical evaluation, or have recently received commercial approval, using the transapical approach. PMID:23381378
Haensig, M; Holzhey, D M; Lehmkuhl, L; Lehmann, S; Linke, A; Schuler, G; Girrbach, F; Moscoso-Luduena, M; Borger, M A; Rastan, A J; Mohr, F W
Based on the natural mathematical relationships between the components of the human tri-leaflet aorticvalve, new calibrated cusp sizers were developed in order to facilitate aorticvalve assessment in the operating room and enhance the chance for a perfect restoration of aorticvalve competence. These sizers were used clinically to guide the implementation of established aorticvalve repair techniques in 10 consecutive patients with severe aorticvalve regurgitation. Valve repair was successful in all cases, and at a median follow-up was 5.5 months, aorticvalve function remained stable, with aortic regurgitation ?1+ in every patient and no significant gradient across the aorticvalves. This preliminary clinical experience indicates that the calibrated cusp sizers can provide reliable insight into the mechanism of aorticvalve insufficiency, and can guide aorticvalve repair techniques successfully. We hope that the simplicity and reproducibility of this method would assist in its dissemination and further increase the percentage of aorticvalves that are repaired when compared with current practice.
Background Although the aorticvalve-sparing procedure has gained popularity in recent years, it still remains challenging in patients with advanced aortic regurgitation (AR). We compared the long-term outcomes of the aorticvalve-sparing procedure with the Bentall operation in patients with advanced aortic regurgitation secondary to aortic root dilatation. Materials and Methods A retrospective review of 120 patients who underwent surgery for aortic root dilatation with moderate to severe AR between January 1999 and June 2009 was performed. Forty-eight patients underwent valve-sparing procedures (valve-sparing group), and 72 patients underwent the Bentall procedure (Bentall group). The two groups' overall survival, valve-related complications, and aorticvalve function were compared. Results The mean follow-up duration was 4.9±3.1 years. After adjustment, the valve-sparing group had similar risks of death (hazard ratio [HR], 0.61; p=0.45), and valve related complications (HR, 1.27; p=0.66). However, a significant number of patients developed moderate to severe AR in the valve-sparing group at a mean of 4.4±2.5 years of echocardiographic follow-up (p<0.001). Conclusion Both the Bentall operation and aorticvalve-sparing procedure showed comparable long-term clinical results in patients with advanced aortic regurgitation with aortic root dilatation. However, recurrent advanced aortic regurgitation was more frequently observed following valve-sparing procedures.
Lim, Ju Yong; Kim, Joon Bum; Jung, Sung-Ho; Choo, Suk Jung; Chung, Cheol Hyun
Results of long-term follow-up of an early cohort of patients receiving aorticvalve homografts for aortic stenosis and aortic insufficiency are presented. All patients were operated upon by a single surgeon from 1966 to 1971. Eighty-three patients underwent insertion of 85 homograft aorticvalves. Homografts were sterilized with either betapropiolactone (39 valves) or gamma irradiation (41 valves) and were inserted following storage in nutrient medium (16 valves) or after cryopreservation (51 valves). All homograft valves were sutured in the subcoronary position using a freehand technique. There was a 55 percent 15-year actuarial patient survival and a 16 percent 15-year actuarial homograft survival in this cohort. Homograft valve failure occurred gradually allowing the patients to be observed until they developed hemodynamic compromise at which time elective valve replacement was performed. PMID:3277801
Cohen, D J; Myerowitz, P D; Young, W P; Chopra, P S; Berkoff, H A; Kroncke, G M; Beatty, E
Background Aorticvalve repair has emerged as a feasible alternative to replacement in the surgical treatment of selected patients with aorticvalve (AV) pathology. In order to provide a synopsis of the current literature, we preformed a systematic review with a focus on valve-related events following AV repair. Methods Structured keyword searches of Embase and PubMed were performed in January 2012. A study was eligible for inclusion if it reported early mortality, late mortality, or valve-related morbidity in the adult population. Results Initial search results identified 3,507 unique studies. After applying inclusion and exclusion criteria, 111 studies remained for full-text review. Of these, 17 studies involving 2,891 patients were included for quantitative assessment. No randomized trials were identified. Tricuspid and bicuspid AV pathologies were present in 65% (range, 21-100%) and 13.5% (range, 5-100%) of the population, respectively. Cusp repair techniques were applied in a median of 46% (range, 5-100%) of patients. The median requirement for early reoperation for post-operative bleeding and early reintervention for primary AV repair failure was 3% (range, 0-10%) and 2% (range, 0-16%), respectively. Pooled early mortality was 2.6% (95% CI: 1.4-4.4%, I2 =0%). Late mortality and valve-related events were linearized [(number of events/number of patient-years) ×100] (%/pt-yr) for each study. Late operated valve endocarditis was reported at median event rate of 0.23%/pt-yr (range, 0-0.78%/pt-yr), while a composite outcome of neurological events and thromboembolism occurred at a median rate of 0.52%/pt-yr (0-0.95%/pt-yr). Late AV re-intervention requiring AV replacement or re-repair occurred at a rate of 2.4%/pt-yr (range, 0-4.2%/pt-yr). The median 5-year freedom from AV re-intervention and late recurrent aortic insufficiency >2+ estimated from survival curves was 92% (range, 87-98%) and 88% (range, 87-100%), respectively. Pooled late mortality produced summary estimate of 1.3%/pt-yr (95% CI: 0.9-2.1%, I2=0%). Conclusions The present systematic review confirmed the low operative risk of patients who underwent aorticvalve preservation and repair. There is a need for long-term follow-up studies with meticulous reporting of outcomes following AV repair, as well as comparative studies with aorticvalve replacement.
Saczkowski, Richard; Malas, Tarek; de Kerchove, Laurent; El Khoury, Gebrine
A 56-year-old man admitted with dyspnea had undergone aorticvalve replacement using a Starr-Edwards ball valve to treat aortic regurgitation 28 years earlier. Chest radiography showed moderate cardiomegaly, moderate pulmonary edema, and mild pleural effusion. Echocardiographic examination showed severe mitral regurgitation. The mitral valve was replaced using a St. Jude Medical prosthesis, and the Starr-Edwards aorticvalve was replaced using a CarboMedics prosthetic valve. The cloth covering on the Starr-Edwards valve had worn away and pannus had formed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 35. PMID:12229218
The Medtronic Freestyle bioprosthesis is a stentless porcine aortic root cross-linked in dilute glutaraldehyde solution with stress-free fixation for the valve leaflets. It has been treated by a process in which amino oleic acid is used to reduce the potential for calcification. As a complete aortic root, it has the same versatility as the aortic homograft but has the advantage
Colleen F. Sintek; Alden D. Fletcher; Siavosh Khonsari
An understanding of how mechanical forces impact cells within valve leaflets would greatly benefit the development of a tissue-engineered heart valve. In this study, the effect of constant ambient pressure on the biological properties of heart valve leaflets was evaluated using a custom-designed pressure system. Native porcine aorticvalve leaflets were exposed to static pressures of 100, 140, or 170
Yun Xing; Zhaoming He; James N. Warnock; Stephen L. Hilbert; Ajit. P. Yoganathan
As the first reliable prosthetic heart valve to be introduced, the Starr-Edwards ball valve prosthesis has gained worldwide clinical acceptance. Although very few instances have been described of valve durability exceeding 30 years, the case is reported of a patient with a well-functioning Starr-Edwards ball valve prosthesis in the aortic position, 43 years after implantation. PMID:19852151
Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aorticvalve and the ascending aorta. One patient received a composite graft containing an aorticvalve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aorticvalve and left supracoronary ascending aneurysm replacement, with reimplantation of the right coronary ostium into the graft. No blood or blood derivatives were administered. Both patients had uneventful recoveries and continue to do well. To our knowledge, they represent the first reported cases of successful combined replacement of the aorticvalve and ascending aorta in Jehovah's Witnesses. Images
Beddermann, Christoph; Norman, John C.; Cooley, Denton A.
Transcatheter aorticvalve replacement (TAVR) is rapidly becoming a widely used alternative to surgical aorticvalve replacement (SAVR) in patients with severe aortic stenosis at high surgical risk. In these patients, TAVR has been associated with markedly improved survival and relief from symptoms. Despite a very-high risk patient profile, recent multicenter registries have confirmed the safety and efficacy of this procedure. Moreover, the randomized, controlled PARTNER (Placement of AoRTic TraNscathetER Valves) trial has confirmed both the superiority of TAVR over medical treatment in patients not considered to be candidates for standard SAVR and the noninferiority of TAVR compared with SAVR in high-risk patients. The TAVR procedure requires a comprehensive preinterventional diagnostic workup. Above all, detailed information on the anatomy of the aortic annulus (AA) and the relation of the AA to the coronary arteries is essential to avoid complications. So far, no imaging reference standard for AA sizing has been established. Echocardiography, catheter angiography, and computed tomography angiography are widely and often complementarily used imaging techniques for this purpose. Compared with 2-dimensional imaging techniques, computed tomography (CT) has been proven to provide comprehensive information on AA anatomy and geometry, supporting appropriate patient selection and prosthesis sizing. In addition, CT is gaining an increasing role in evaluating the vascular access route before the procedure. This article describes the rapidly emerging role of CT in the context of pre-TAVR assessment. PMID:23736825
Apfaltrer, Paul; Henzler, Thomas; Blanke, Phillip; Krazinski, Aleksander W; Silverman, Justin R; Schoepf, U Joseph
Objectives. This study sought to 1) show that intracardiac echocardiography can allow direct measurement of the aorticvalve area, and 2) compare the directly measured aorticvalve area from intracardiac echocardiography with the calculated aorticvalve area from the Gorlin and continuity equations.Background. Intracardiac echocardiography has been used in the descriptive evaluation of the aorticvalve; however, direct measurement of
Gary P. Foster; Neil J. Weissman; Michael H. Picard; Phillip J. Fitzpatrick; Samuel J. Shubrooks Jr.; Stuart W. Zarich
Background: Severe peripheral arterial disease may pose a limitation to the applicability of trans-arterial aorticvalve implantation in patients who are otherwise candidates. For this reason, transapical aorticvalve implantation has been proposed as a possible alternative. Objective: To evaluate the acute safety and performance of a specially designed delivery system, the CoreValve Tranzap™ delivery catheter, for the transapical implantation
Arie-Pieter Kappetein; Nicolo Piazza; Jean-Claude Laborde; Peter P. de Jaegere; Patrick W. Serruys
It has been shown in clinical studies that patients with congenital bicuspid aorticvalves (CBAVs) develop degenerative calcification of the leaflets at young ages compared to patients with the normal tricuspid aorticvalves (TAVs). It has been hypothesized that the asymmetrical geometry of the leaflets in CBAVs, flow shear stresses (SS), disturbed flow, and excessive strain rate levels are possible causes for the early calcification and stenosis. Central to the validation of this hypothesis is the need to quantify the differences in strain rate levels between the BAVs and TAVs. We simulate the CBAVs by surgically stitching two of the leaflets of a porcine aorticvalve together. To quantify strain differences, we performed in-vitro experiments in both trileaflet and bileaflet valves by tracking the motion of small ink dots marked on each leaflet surface. We then used phase-locked stereo photogrammetry to reconstruct at each instant of time the 3D surface of the leaflets and measure the strain rates in both radial and circumferential directions during the whole cardiac cycle. Our results indicate that the total strain rate of the simulated BAVs is about 15 to 20% higher than the normal leaflets of TAVs at systole. In the BAVs' case, the fused leaflet stretches radially up to 25% higher than the reference length. The excessive stretching in both directions in the fused leaflet results in large changes in the flow patterns and associated wall SS.
Szeto, Kai; Rodriguez-Rodriguez, Javier; Pastuszko, Peter; Nigam, Vishal; Lasheras, Juan C.
Bicuspid aorticvalves (BAVs) are associated with ascending aortic aneurysms. We studied BAV patients before and after aorticvalve replacement (AVR) to determine the risk and predictors of aortic root dilatation after surgery. BAV patients (n=60) with an aortic root aortic root measured. No statistical difference was found between the preoperative and postoperative diameter of the aortic root as well as association with the variables studied. The use of statins or beta-blockers did not affect the follow-up on the aortic root diameter. Preoperative aortic root diameter between patients who died due to cardiovascular cause in the long-term did not vary when compared with those who survived. Even though the numbers of patients studied is low to make any kind of conclusions, our study permits us to suggest that AVR prevents aortic root dilation in BAV patients whose aortic root diameter at time of surgery was
The occurrence of paravalvular abscesses in the course of an acute endocarditis of the aorticvalve indicates an advanced stadium of the disease. The infection has spread beyond the limits of the valve leaflets, and ongoing destruction of the paravalvular tissue is to be expected, if the endocarditis is continually treated by antibiotics alone. Surgery of acute endocarditis with paravalvular abscess, however, supposedly carries an increased risk of early mortality and late morbidity. The following prospective study was carried out to determine whether a radical surgical approach together with aggressive postoperative antibiotic therapy could help to improve results. Between 1988 and 1995, 138 patients were operated during the acute phase of infective endocarditis; in 102 the aorticvalve was involved. Among these, 44 had paravalvular abscesses at the time of surgery. The mean age of both groups was the same, but there was a higher rate of concomitant coronary artery disease, multiple valve involvement, advanced NYHA-class, and staphylococcal disease among the patients with abscesses. All interventions were carried out with cardiopulmonary bypass and cardioplegic arrest. The aorticvalve was resected, abscesses were removed, and each part of potentially infected or necrotic tissue was resected as complete as possible, irrespective of the possibility to jeopardize the conduction system or to create large tissue defects. The aorticvalve was replaced with a mechanical prosthesis in each case. The postoperative antibiotic regimen was specifically directed against the microorganisms isolated preoperatively; therapy was only modified, if signs of systemic infection did not disappear three days after surgery. The operative mortality was 10% among patients without an abscess and 11% in patients with a paravalvular abscess. Early recurrent endocarditis was recorded in two patients without and in only one patient with an abscess. Late recurrent endocarditis was noted in three patients; none of them had abscesses at the time of surgery. We conclude that the operative risk of acute endocarditis of the aorticvalve with a paravalvular abscess does not have to be inevitably higher compared to cases without paravalvular involvement. To achieve these results, it is necessary to use a radical surgical approach and to adjust postoperative antibiotic therapy, if infectious signs do not disappear shortly after surgery. PMID:9610511
Bauernschmitt, R; DeSimone, R; Lange, R; Vahl, C F; Thomas, G; Hagl, S
The present report describes a rare case of aorticvalve aneurysm without any vegetation with complete heart block. A 26-year-old man with severe acute aortic regurgitation was admitted to our admitted to our hospital. Transthoracic echocardiography showed right cusp aneurysm without any vegetations. Transoesophageal echocardiography confirmed these findings. Colour Doppler echocardiography revealed severe aortic regurgitation. For complete heart block, a transvenous permanent pacemaker was inserted as a first stage of treatment. Successful aorticvalve replacement was performed as a second stage. The possible aetiology of this case is endocarditis.
Singh, Devender; Darbari, Anshuman; Sharma, Manish K
The mitral valve was replaced by a pig aorticvalve in 33 patients at Groote Schuur Hospital. Eleven of the failed heterograft aorticvalves were examined at intervals of from 2 to 32 months after insertion. Fourteen control pig aorticvalves were also examined. Electron microscopy was performed on two of the failed heterograft valves and three control pig valves. Failure of the heterograft was due to stretching and deformation of the cusps with resultant valvular incompetence. Stretching of the cusp was a result of reduction in the amount of its collagen content. The elastic tissue appeared little altered. A microscopic layer of fibrin thrombus was present on the surface of 8 of the 11 valves. Only 2 of the 11 valves showed invasion of the graft by immunologically competent cells. No valve showed any sign of infection or calcification. The denatured collagen of the heterograft has a low antigenicity and also, infortunately, a limited durability. Images
Transcatheter aorticvalve implantation (TAVI) has become an emerging alternative for high-risk patients with aortic stenosis unsuitable for surgical intervention. We report the case of a 26-mm Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) implanted into an insufficient 29-mm CoreValve prosthesis (Medtronic Inc, Minneapolis, MN) 1 year after implantation using the transapical approach in a 59-year-old man. Transesophageal echocardiography showed severe paravalvular regurgitation and computed tomography revealed the CoreValve to be located slightly below the aortic annulus with evidence of underdeployment. The balloon-expandable Sapien system caused a better expansion of the underdeployed CoreValve and the pericardial skirt adequately covered the leakage. The paravalvular regurgitation disappeared and the patient recovered. PMID:23438533
Schleger, Simone; Kasel, Markus; Vogel, Jayshree; Lieber, Michael; Antoni, Dietmar; Hoffmann, Ellen; Eichinger, Walter B
Objective. To report the feasibility, safety and efficacy of percutaneous aorticvalve implantation (PAVI) with the CoreValve self-expanding aorticvalve bioprosthesis in elderly patients with aorticvalve stenosis who are rejected for surgery or have a high surgical risk. Methods. PAVI using the CoreValve ReValving System was performed under general anaesthesia in 30 high-risk (surgical) patients with a symptomatic severe aorticvalve stenosis. Results. The patients had a mean age of 80.5±7.7 years, a mean aorticvalve area of 0.71±0.19 cm2, a peak transvalvular aortic gradient of 79±25 mmHg, as measured with echo Doppler, a logistic EuroSCORE of 15±10% and a Society of Thoracic Surgeons (STS) score of 5.2±2.9%. Device success was achieved in all patients and acute procedural success in 27 patients (90%). In the surviving patients, there was in a reduction of the peak aortic pressure gradient from 76±24 mmHg to 22±7 mmHg (n=24, p<0.00001) 30 days after successful device implantation. At 30 days, major adverse cardiovascular and cerebral events had occurred in seven patients (23%). This included mortality in six patients (20%), of which one death was cardiovascular. The other five non-cardiovascular deaths involved two patients who died of an exacerbation of severe pre-existent pulmonary disease and three of infectious complications. Conclusions. Percutaneous aorticvalve implantation was successfully performed in our centre in highrisk patients, with a 30-day mortality of 20%. When successful, marked haemodynamic improvement and relief of symptoms was achieved. (Neth Heart J 2010;18:18-24.)
Baan, J.; Yong, Z.Y.; Koch, K.T.; Henriques, J.P.S.; Bouma, B.J.; de Hert, S.G.; van der Meulen, J.; Tijssen, J.G.P.; Piek, J.J.; de Mol, B.A.J.M.
Transcatheter aorticvalve implantation (TAVI) has emerged for treating aortic stenosis in patients who are poor candidates for surgical aorticvalve replacement. Currently, the balloon-expandable Edwards Sapien valve-which is usually implanted via a transfemoral or transapical approach-and the self-expanding CoreValve ReValving system-which is designed for retrograde application-are the most widely implanted valves worldwide. Although a promising approach for high-risk patients, the indication may be expanded to intermediate- and eventually low-risk patients in the future; however, doing so will require a better understanding of potential complications, risk factors for these complications, and strategies to individualize each patient to a different access route and a specific valve. This paper reviews the most relevant complications that may occur in patients who undergo catheter-based aorticvalve implantation. PMID:23844292
Background:Anecdotal evidence suggests that transcatheter aorticvalve implantation (TAVI) is being used beyond pre-market label indications.Methods:To assess the frequency and outcomes associated with “off-label” use of TAVI, we conducted a retrospective study, examining adherence to patient selection criteria in 63 patients undergoing implantation with the 18F CoreValve ReValving System (CRS). Label status (on-label vs off-label) was determined by following (1)
N Piazza; A Otten; C Schultz; Y Onuma; H M Garcia-Garcia; E Boersma; P de Jaegere; P W Serruys
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.
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.
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, B B; Mac Donald, K A; Kasten, R W; Chang, C C; Wey, A C; Foley, J E; Thomas, W P; Kittleson, M D
Heated debates revolve around the hemodynamic performance of stented aortic tissue valves. Because the opening area strongly influences the generation of a pressure gradient over the prosthesis, and the outer diameter determines which valve actually fits into the aortic root, it would seem logical that the valve with the greatest opening area in relation to its outer diameter should allow the best hemodynamic performance. Interestingly, neither of these 2 parameters is reflected by the manufacturing companies' size labels or suggested sizing strategies. In addition, it is known that valves with the same size label from different companies may differ significantly in their actual dimension (outer diameter). Finally, the manufacturer-suggested sizing strategies differ so much that expected differences from valve design may get lost because of differences in sizing. These size and sizing differences and the lack of information on the geometric opening area complicate true hemodynamic comparisons significantly. Furthermore, some fluid dynamic considerations regarding the determination of opening area by echocardiography (the effective orifice area) introduce additional obscuring factors in the attempt to compare hemodynamic performance data of different stented tissue valves. We analyzed the true dimensions of different tissue prostheses and the manufacturer-suggested sizing strategies in relation to published effective orifice areas. We have demonstrated how sizing and implantation strategy have much greater impact on postoperative valve hemodynamics than valve brand or type. In addition, our findings may explain the different opinions regarding valve hemodynamics of different tissue valves. PMID:21703637
BackgroundThe use of prosthetic material (rather than a homograft) for ascending aorta\\/aorticvalve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval.
Christian Hagl; Jan D Galla; Steven L Lansman; Daniel Fink; Carol A Bodian; David Spielvogel; Randall B Griepp
The asymmetry of the aorticvalve and aortic root may influence their biomechanics, yet was not considered in previous valve models. This study developed an anatomically representative model to evaluate the regional stresses of the valve within the root environment. A finite-element model was created from magnetic-resonance images of nine human valve–root specimens, carefully preserving their asymmetry. Regional thicknesses and
K. Jane Grande; Richard P. Cochran; Per G. Reinhall; Karyn S. Kunzelman
During the last decade, the rapid evolution of transcatheter aorticvalve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis. Since the PARTNER A and B trials, this technique has become the treatment of reference for inoperable patients, and an attractive alternative to surgical aorticvalve replacement in those at high risk for surgery. Large multicenter registries conducted since 2007, mainly in Europe, confirmed the excellent hemodynamic performances of the 2 percutaneous valves currently available on the market, the Edwards SAPIEN, and the Medtronic CoreValve, as well as their benefits in terms of symptom relief and survival. The whole process of TAVR, from patient selection to post-procedural care and result evaluation, should be conducted by a dedicated multidisciplinary "heart team," within centers with expertise in valve disease. Though currently limited to those deemed at high risk for surgery or inoperable, indications for TAVR will likely be extended to a broader spectrum of patients, in particular those with surgical bioprosthetic failure or at intermediate risk for surgery. Beforehand, it will be essential to obtain more extensive data on the durability of percutaneous prostheses, since the available follow-up is seldom longer than 5 years, and in order to further decrease the rate of complications, mainly stroke, paravalvular regurgitation, and access site complications. Furthermore, the use of the transfemoral route will undoubtedly increase because of the miniaturization of the devices, at the expense of other approaches. Above all, multidisciplinary approach, excellent imaging, and careful evaluation will remain key to the success of this technique. PMID:23420448
The main problem with polymeric heart valves (which are already biocompatible) is that they usually fail in the long term owing to tearing and calcification of the leaflets under high dynamic tensile bending stress and oxidative reactions with blood. To overcome this shortcoming, it is hypothesized that synthetic valve leaflets which mimic native valve leaflet structure fabricated from fibre-reinforced composite material will optimize leaflet stresses and decrease tears and perforations. The objective of this study is to develop a PVA-BC (polyvinyl alcohol-bacterial cellulose)-based hydrogel that mimics not only the non-linear mechanical properties displayed by porcine heart valves, but also their anisotropic behaviour. By applying a controlled strain to the PVA samples, while undergoing low-temperature thermal cycling, it was possible to create oriented mechanical properties in PVA hydrogels. The oriented stress-strain properties of porcine aorticvalves were matched simultaneously by a PVA hydrogel (15 per cent PVA, 0.5 BC cycle 4, 75 per cent initial tensile strain). This novel technique allows the control of anisotropy to PVA hydrogel, and gives a broad range of control of its mechanical properties, for specific medical device applications. PMID:21870379
From August 1971 through November 1972, we implanted 62 Model 2 DeBakey-Surgitool aorticvalve prostheses in 62 patients, 4 of whom later had clinically asymptomatic strut fractures. In 1 case, the patient died suddenly, and autopsy revealed detachment of the ball-cage; in each of the other 3 cases, fractures of 2 struts close to the base of the prosthesis were diagnosed fluoroscopically, and the patients underwent successful reoperation. The interval between implantation and reoperation ranged from 11 months to 16 years, 9 months. In 1 patient, retrospective study of chest radiographs revealed that the fracture had been present for 2½ years. Larger valves (? A6) were affected significantly more often than smaller ones. We performed metallurgic analysis of 1 prosthesis: results revealed strut wear from fatigue cracking and secondary abrasion. Strut fracture was also promoted by suspension of the cage at right angles to the prosthetic ring and by use of a pyrolytic carbon ball in a titanium cage (i.e., an occluder harder than its holder). Patients with DeBakey-Surgitool aorticvalve prostheses should undergo annual radiologic examinations to enable early detection of strut fractures. Prophylactic valve replacement is not indicated. (Texas Heart Institute Journal 1990;17:223-7) Images
Von Der Emde, Jurgen; Eberlein, Ulrich; Breme, Jurgen
It is unclear whether ascending aorta dilation in patients with bicuspid aorticvalve is caused by abnormal hemodynamics or by a common developmental defect of the aorticvalve and aortic wall. We performed an echocardiographic study to examine the differences in hemodynamic stress at the ascending aorta in patients with bicuspid and tricuspid aorticvalve. We studied prospectively 58 consecutive patients referred for preoperative echocardiographic examination with aorticvalve stenosis and either bicuspid or tricuspid valve and an ascending aortic diameter of =4.5 cm. Echocardiographic examination was performed from the parasternal long-axis view using ALOKA SDD 5.500 (Aloka, Tokyo) with 3.5 MHz probe. With aortic wall tissue Doppler imaging we obtained wall motion velocity patterns from the anterolateral and posteromedial region of the ascending aorta. The tissue Doppler examination showed a significantly higher peak systolic wall velocity of the anterolateral region of the ascending aorta in patients with bicuspid aorticvalve (12.2 +/- 4.3 cm/sec vs. 8.8 +/- 2.6 cm/sec, p = 0.047). We conclude that in patients with bicuspid aorticvalve and aorticvalve stenosis the anterolateral region of the ascending aorta is subject to greater hemodynamic stress than in patients with tricuspid aorticvalve. PMID:16684044
Bauer, Matthias; Siniawski, Henryk; Pasic, Miralem; Schaumann, Beate; Hetzer, Roland
In the field of interventional cardiology, transcatheter aorticvalve implantation is the newest and most exciting development of recent years. With a growing evidence base for both prognostic and symptomatic benefit, more and more interventionalists are keen to learn the procedure. However, the concomitant risk associated with a technically challenging procedure in a high-risk patient population is significant, and complications can arise suddenly and often unexpectedly. It is essential that new, and even established, operators are meticulously aware of the potential for complications, are able to identify them at an early stage, and manage them quickly and effectively. We have significant experience with transcatheter aorticvalve implantation, through the implantation of 260 devices, which brings first-hand experience of most major complications. This article provides insight into the potential for complications, offering advice on effective treatment, recognition, and ultimately, prevention. It also suggests a number of procedural and technical modifications, which might improve outcomes in the future. PMID:21809973
The aim of this study was to evaluate and compare the calcification potential of kangaroo and porcine aorticvalves after glutaraldehyde fixation at both low (0.6%) and high (2.0%) concentrations of glutaraldehyde in the rat subcutaneous model. To our knowledge this is the first report comparing the time-related, progressive calcification of these two species in the rat subcutaneous model. Twenty-two
K. Narine; Cyrille C. Chéry; Els Goetghebeur; R. Forsyth; E. Claeys; Maria Cornelissen; L. Moens; G. Van Nooten
Objective: The Starr-Edwards aortic ball valve has passed 30 years of clinical follow-up. A detailed account of the long-term performance from a large series could thus give valuable guidance in managing patients who are still alive, depict the total remaining life-span after aorticvalve replacement (AVR) for the average patient, and set a record yet to be matched by modern
Ole Lund; Hans K. Pilegaard; Lars B. Ilkjaer; Sten Lyager Nielsen; Hanne Arildsen; Ole K. Albrechtsen
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
Appreciation of the frequency of the congenitally malformed aorticvalve has come about during the last 50 years, a period during which aorticvalve replacement became a predictably successful operation. Study of patients at necropsy with either a congenitally unicuspid (1 true commissure) or bicuspid (2 true commissures) valve in whom no aorticvalve operation has been performed has not been conducted during these 50 years, to our knowledge. We studied 218 patients at necropsy with congenitally malformed aorticvalves: 28 (13%) had a unicuspid valve and 190 (87%), a bicuspid valve. Their ages at death ranged from 21 to 89 years (mean, 55 yr), and 80% were men. Of the 218 adults, the aorticvalve functioned normally during life in 54 (25%) and abnormally in 164 (75%): aortic stenosis in 142 (65%), pure aortic regurgitation without superimposed infective endocarditis (IE) in 2 (1%), and IE superimposed on a previously normally functioning aorticvalve in 20 (9%). IE occurred in a total of 31 (14%) of the 218 patients: involving a previously normally functioning valve in 20 (65%) and a previously stenotic valve in 11 (35%). Of the 218 patients, at least 141 (65%) died as a consequence of aorticvalve disease (124 patients) or ascending aortic tears with or without dissection (17 patients). An estimated 1% of the population, maybe higher in men, has a congenitally malformed aorticvalve. Data from this study suggest that about 75% of them will develop a major complication. Conversely, and encouragingly, about 25% will go through life without a complication. PMID:23117850
Roberts, William Clifford; Vowels, Travis James; Ko, Jong Mi
Background Transcatheter aorticvalve implantation (TAVI) through a transapical approach (TAAVI) for severe aortic stenosis becomes the procedure of choice in cases where patients have peripheral artery disease and unfeasible access due to excessive atherosclerotic disease of the iliofemoral vessels and aorta. The present systematic review aimed to assess the safety, success rate, clinical outcomes, hemodynamic outcomes, and survival benefits of TAAVI. Methods Electronic searches were performed in 6 databases from January 2000 to February 2012. The primary end points included feasibility and safety. Other end points included echocardiographic findings, functional class improvement, and survival. Results After applying the inclusion and exclusion criteria, 48 out of 154 shortlisted potentially relevant articles were selected for assessment. Of these, 26 studies from 24 centers including total number of 2,807 patients were included for appraisal and data extraction. The current evidence on TAAVI for aortic stenosis is limited to observational studies. Successful TAAVI implantation occurred in >90% of patients. On average, the procedure took between 64 to 154 minutes to complete. The incidence of major adverse events included 30-day mortality (4.7-20.8%); cerebrovascular accident (0-16.3%); major tachyarrhythmia (0-48.8%); bradyarrhythmia requiring permanent pacemaker insertion (0-18.7%); cardiac tamponade (0-11%); major bleeding (1-17%); myocardial infarction (0-6%); aortic dissection/rupture (0-5%); moderate to severe paravalvular leak (0.7-24%); cardiopulmonary bypass support (0-15%); conversion to surgery (0-9.5%); and valve-in-valve implantation (0.6-8%). Mean aorticvalve area improved from 0.4-0.7 cm2 before TAAVI to 1.4-2.1 cm2 after TAAVI. The peak pressure gradient across the aorticvalve decreased from >70 mmHg to <20 mmHg after TAAVI. One-year survival ranged from 49.3% to 82% and the 3-year survival was 58% in 2 series. Conclusions TAAVI appears to be feasible with a reasonable safety and efficacy portfolio. Randomised controlled trials are required to compare transapical vs. transfemoral TAVI when both techniques are equally feasible.
Transcatheter valve implantation is becoming an alternative to conventional surgical valve replacement in patients at high surgical risk. While experience and acceptance with transcatheter techniques increased rapidly, transcatheter valve implantation within failing bioprostheses has emerged as a new concept (valve-in-valve implantation). Currently, the majority of prostheses implanted in patients are bioprosthetic valves that are expected to degenerate over time. Valve-in-valve implantation provides great utility in high-operative-risk patients since the mortality risk for reoperation can be significantly higher than for first-time isolated valve replacement. Although two current devices are CE Mark approved in Europe for implantation within native valves, off-label clinical implementation of valve-in-valve have been described in numerous case reports. In this article, we provide an overview of transcatheter valve implantation in failing bioprostheses with an emphasis on the aortic position. PMID:21142638
Background Transthoracic echocardiography (TTE) is routinely used to evaluate aorticvalve stenosis. However, it does not give reliable results in every patient. There is growing interest in electron-beam tomography (EBT) as a noninvasive cardiac imaging technique. The usefulness of EBT to evaluate aortic stenosis has yet to be evaluated. Aim To compare EBT with TTE in assessing severity of aortic stenosis. Methods In total 47 patients (18 females, 29 males) underwent a contrast-enhanced EBT scan and TTE within 6±20 days. The calcium score of the aorticvalve was determined and the aorticvalve area (AVA) was measured by planimetry. A complete TTE study, during which the peak pressure gradient across the aorticvalve was measured, was performed in all patients by an experienced sonographer. Results There was a significant correlation between AVA assessed by EBT and peak pressure gradient (r=-0.38, p=0.009). The calcium score of the aorticvalve assessed by EBT correlated with peak pressure gradient (r=0.48, p=0.001). Conclusion EBT is a useful noninvasive method to evaluate the severity of aortic stenosis. It holds the possibility of assessing the AVA as well as quantification of the degree of calcification. ImagesFigure 1
Piers, L.H.; Dikkers, R.; Tio, R.A.; van den Berg, M.P.; Willems, T.P.; Oudkerk, M.; Zijlstra, F.
Objective: Little attention has been paid to the occurrence of aortic regurgitation after complete repair in patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot. To highlight the development of aortic regurgitation or aortic root dilation severe enough to necessitate aorticvalve replacement with or without aortic aneurysmorrhaphy or aortic root replacement, we retrospectively reviewed the records
G. Alfred Dodds; Carole A. Warnes; Gordon K. Danielson
Patients with symptomatic aorticvalve disease who are inoperable or have high surgery-related risks may be treated with transcatheter aorticvalve implantation devices. With this method increasingly applied, device innovations are aimed at achieving improved procedural results and therapeutic outcome. This paper describes the innovations implemented in the St. Jude Medical Portico™ system for transcatheter aorticvalve implantation, the application of this system and initial clinical experience. PMID:23681129
Spence, M S; Lyons, K; McVerry, F; Smith, B; Manoharan, G B; Maguire, C; Doherty, R; Anderson, L; Morton, A; Hughes, S; Hoeritzauer, I; Manoharan, G
A rare case of bilateral coronary artery dissection with rupture of aorticvalve commissure following type A aortic dissection is described. 64-slice multidetector computed tomography (MDCT) was able to demonstrate both this findings along with involvement of other neck vessels. TEE demonstrated the severity and mechanisms of aorticvalve damage and assisted the surgeon in valve repair. MDCT has played an invaluable role in the diagnosis of the abnormal details of such life-threatening vascular complications. PMID:18384568
Das, K M; Abdou, Sayed M; El-Menyar, Ayman; Ayman, El Menyar; Khulaifi, A A; Nabti, A L
To explore reasons for a high accumulation of Ca and P occurring in the coronary artery of Thai with aging, the authors investigated age-related changes of elements in the coronary artery, ascending aorta near the heart, and cardiac valves in single individuals, and the relationships in the elements between the coronary artery and either the ascending aorta or cardiac valves. After an ordinary dissection by medical students at Chiang Mai University was finished, the anterior descending arteries of the left coronary artery, ascending aortas, mitral valves, and aorticvalves were resected from the subjects. The subjects consisted of 17 men and 9 women, ranging in age from 46 to 76 yr. The element content was analyzed by inductively coupled plasma-atomic emission spectrometry. The average content of Ca and P was the highest in the coronary artery and decreased in the order aorticvalve, ascending aorta, and mitral valve. The Ca, P, and Mg content increased in the coronary artery in the fifties and in the ascending aorta, aorticvalve, and mitral valve in the sixties. It should be noted that the accumulation of Ca, P, and Mg occurred earlier in the coronary artery than in the ascending aorta, aorticvalve, and mitral valve. It was found that with respect to the Ca, P, Mg, and Na contents, the coronary artery correlated well with both the aorticvalve and ascending aorta, especially with the aorticvalve, but it did not correlate with the mitral valves. This finding suggests that the accumulation of Ca, P, Mg, and Na occurs in the coronary artery together with the aorticvalve and ascending aorta, but not together with the mitral valve. Because regarding the accumulation of Ca, P, and Mg, the ascending aorta and aorticvalve are preceded by the coronary artery, it is unlikely that the accumulation of Ca, P, and Mg spreads from the ascending aorta or aorticvalve to the coronary artery. PMID:16943614
A 65-year-old male with a history of a total thoracic esophagectomy with a retrosternal gastric tube reconstruction required aorticvalve replacement for aorticvalve stenosis due to a bicuspid aorticvalve. Preoperative multidetector computed tomography demonstrated that the gastric tube occupied the retrosternal space and the gastroepiploic artery was located on the left side of the gastric tube. Aorticvalve replacement was performed through a median sternotomy approach. Blunt dissection on the anterior and right side of the gastric tube was performed without injury, and we could then perform cardiac surgery with the standard surgical view.? PMID:21790781
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
Recently, percutaneous aorticvalve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValveaortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under
José M. Hernández-García; Antonio J. Muñoz-García; Juan H. Alonso-Briales; Manuel F. Jiménez-Navarro; Antonio J. Domínguez-Franco; Isabel Rodríguez-Bailón; Eduardo Olalla-Mercadé; Eduardo de Teresa-Galván
Simultaneous replacement of the ascending aorta and aorticvalve with a valved conduit was performed in a patient with aorticvalve disease and totally calcified ascending aorta. Coronary circulation could be re-established by using the Cabrol technique, but only after extensive decalcification of the aortic wall surrounding the coronary ostia. This technique appears particularly suitable in patients who require combined replacement of the ascending aorta and aorticvalve in the presence of diffuse calcification of the aortic root. PMID:8162226
Criteria for selection of patients with aorticvalve disease for cardiac catheterization are described, based on a study of 81 cases. Children with aortic stenosis warrant catheterization at the time when the clinical diagnosis is made, but in adults this examination may be deferred until symptoms appear or left ventricular hypertrophy is recognized. In patients with pure aortic insufficiency catheterization may be deferred until symptoms appear. When severe stenosis and insufficiency co-exist, the valve is usually heavily calcified. Thirty-seven per cent of patients with aorticvalve disease have co-existing mitral lesions and these patients are usually women, are fibrillating and, as a rule, have atrial enlargement in contrast to those with aorticvalve disease only. On rare occasions, patients with mitral valve disease have clinically silent but angiographically demonstrable aortic insufficiency; therefore, aortography should precede open-heart correction of a mitral lesion so as to detect minor degrees of aortic insufficiency. ImagesFig. 2
Preliminary reports have documented the utility of balloon aortic valvuloplasty as a palliative treatment for high-risk patients with critical aortic stenosis, but the effect of this procedure on cardiac performance has not been studied in detail. Accordingly, 32 patients (mean age 79 years) with long-standing, calcific aortic stenosis were treated at the time of cardiac catheterization with balloon dilatation of the aorticvalve, and serial changes in left ventricular and valvular function were followed before and after valvuloplasty by radionuclide ventriculography, determination of systolic time intervals, and Doppler echocardiography. Prevalvuloplasty examination revealed heavily calcified aorticvalves in all patients, a mean peak-to-peak aorticvalve gradient of 77 +/- 27 mm Hg, a mean Fick cardiac output of 4.6 +/- 1.4 liters/min, and a mean calculated aorticvalve area of 0.6 +/- 0.2 cm2. Subsequent balloon dilatation with 12 to 23 mm valvuloplasty balloons resulted in a fall in aorticvalve gradient to 39 +/- 15 mm Hg, an increase in cardiac output to 5.2 +/- 1.8 liters/min, and an increase in calculated aorticvalve area to 0.9 +/- 0.3 cm2. Individual hemodynamic responses varied considerably, with some patients showing major increases in valve area, while others demonstrated only small increases. In no case was balloon dilatation accompanied by evidence of embolic phenomena. Supravalvular aortography obtained in 13 patients demonstrated no or a mild increase in aortic insufficiency. Serial radionuclide ventriculography in patients with a depressed left ventricular ejection fraction revealed a small increase in ejection fraction from 40 +/- 13% to 46 +/- 12%.
Aorticvalve stenosis (AS) is the most common form of valvular heart disease in the Western world, affecting ~40% of the population over the age of 80; to date the only established treatment is valve replacement. However, AS progression occurs over many years, and is associated from its earliest stages with increased risk of coronary events. Recent insight into the pathophysiology of AS has included central roles for angiotensin II, for diminished nitric oxide effect at the level of valve endothelium and matrix, and for inflammatory activation/redox stress culminating in activation of pro-calcific stimuli. Despite the presence of atheroma within the stenotic valve, hyperlipidemia per se does not play a critic role in the development of obstructive disease. We review emerging options for pharmacotherapy of AS, including in particular retardation of disease progression. The various clinical evaluations of lipid-reducing therapy have been uniformly unsuccessful in slowing AS progression. However, recent studies in animal models and retrospective evaluations in humans suggest that ACE inhibitors and/or angiotensin receptor blockers may be effective in this regard. Furthermore, agents normally utilized to treat osteoporosis also offer promise in retarding AS. Given the considerable morbidity, mortality and health care costs associated with AS, such therapeutic developments should be expedited. PMID:22516738
Background. This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction.Methods. From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 ± 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class
Background—The design of a percutaneous implantable prosthetic heart valve has become an important area for investigation. A percutaneously implanted heart valve (PHV) composed of 3 bovine pericardial leaflets mounted within a balloon-expandable stent was developed. After ex vivo testing and animal implantation studies, the first human implantation was performed in a 57-year-old man with calcific aortic stenosis, cardiogenic shock, subacute
Alain Cribier; Helene Eltchaninoff; Assaf Bash; Nicolas Borenstein; Christophe Tron; Fabrice Bauer; Genevieve Derumeaux; Frederic Anselme; François Laborde; Martin B. Leon
Transcatheter aorticvalve implantation (T-AVI) has been introduced into clinical practice to treat high-risk elderly patients with aortic stenosis. T-AVI can be performed by using a retrograde transfemoral (TF), transsubclavian, transaortic, and/or antegrade transapical (TA) approach. For TA-AVI, CE mark approval was granted in 2008 for the Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) prosthesis with the Ascendra delivery system and in 2010 for the second-generation Edwards SAPIEN XT prosthesis and the Ascendra II delivery system, with 23-mm and 26-mm valves. In 2011, CE mark approval has been granted for TA-AVI by using the SAPIEN XT 29-mm prosthesis. Several other devices from different companies (Jenavalve, Jena Valve Inc, Munich, Germany; Embracer, Medtronic Inc, Guilford, CT; Accurate, Symetis Inc, Geneva, Switzerland) have passed "first in man trials" successfully and are being evaluated within multicenter pivotal studies. In this article we will focus on specific aspects of the TA technique for AVI. PMID:21807300
Walther, Thomas; Möllmann, Helge; van Linden, Arnaud; Kempfert, Jörg
Background. Hemodynamic benefits of the Toronto stentless porcine valve have been documented. Clinical well-being and freedom from major valve-related events have been less well defined.Methods. A total of 447 patients were prospectively followed for up to 8 years (1,745.2 valve years total, 3.9 valve years\\/patient). The patient demographics included 66% men, mean age 65 years, New York Heart Association functional
Bernard S Goldman; Tirone E David; Jeremy R Wood; John R Pepper; Scott M Goldman; Edward D Verrier; Michael R Petracek
Background—Fluid energy loss across stenotic aorticvalves is influenced by factors other than the valve effective orifice area (EOA). We propose a new index that will provide a more accurate estimate of this energy loss. Methods and Results—An experimental model was designed to measure EOA and energy loss in 2 fixed stenoses and 7 bioprosthetic valves for different flow rates
Damien Garcia; Philippe Pibarot; Jean G. Dumesnil; Frederic Sakr; Louis-Gilles Durand
Objective: The synthesis of appropriate extracellular matrix by cells in tissue engineered heart valve constructs will be important for the maintenance of valve cusp integrity and function. We have examined and compared the capacity of mesenchymal stem cells to synthesise collagen in response to stretch in comparison with native aorticvalve interstitial cells. Methods: Cells were stretched on a Flexercell
Ching-Hsin Ku; Philip H. Johnson; Puspa Batten; Padmini Sarathchandra; Rachel C. Chambers; Patricia M. Taylor; Magdi H. Yacoub; Adrian H. Chester
Starr-Edwards ball valves removed more than 15 years after implantation were retrospectively investigated macroscopically. Eight patients required re-operation. Valve models used in the initial operations were a non-cloth-covered valve in 2 patients and a cloth-covered valve in 6. Two patients had replacement of an aortic ball valve (model 1260 and model 2320) and 6 underwent mitral valve replacement (model 6120 in one, model 6320 in 5). The mean time to re-operation was 23.0 +/- 4.8 years after implantation. Cloth wear causing significant hemolysis was observed in all cloth-covered valves, regardless of valve position. Autologous tissue growth was noted on the orifice ring and struts in both aortic and mitral prostheses. Thrombus formation was not found in any of the valves. Ball variance in silicone rubber balls was mild in the non-cloth-covered valves, even in the aortic position. The most significant problem with the cloth-covered ball valve was cloth wear. Cloth wear should always be considered when 15 years or more have passed since valve implantation. Significant hemolysis, elevation of lactate dehydrogenase values, and echocardiographic detection of transvalvular regurgitation are diagnostic of cloth wear, and are indications for replacement of a cloth-covered ball valve. PMID:17130320
There are numerous types of bicuspid aorticvalve (BAV) configurations. Recent findings suggest that various BAV types represent different pathophysiological substrates on the aortic media level. Data imply that the BAV type is probably not related to location and extent of the aneurysm. However, BAV type is likely linked to the severity of aortic media disease. Some BAVs with raphe seem more aggressive than BAV without a raphe. Cusp fusion pattern, altered hemodynamics, and the qualitative severity of the disease in the aortic media might on the one hand share the same substrate. On the other hand, the aortopathy's longitudinal extent and location may represent a different pathophysiological substrate, probably dictated by the heritable aspects of BAV disease. The exact nature of the relation between BAV type and the aneurysm's location and extent as well as to the risk of aortic complications remains unclear. This paper reviews results of recent human and experimental studies on the significance of BAV types for local aortic media disease and location and extent of the aortopathy. We describe the known and hypothesized hemodynamic and hereditary factors that may result in aortic aneurysm formation in BAV patients.
To reconstruct the aortic root for aneurysm of the ascending aorta accompanied by aortic regurgitation, annu- loaortic ectasia (AAE) and acute type-A dissection with root destruction, the Bentall operation using a prosthetic valve still is the standard procedure today. Valve-sparing procedures have actively been used for aortic root lesions, and have also been attempted in aortic root reconstruction for Marfan
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.
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
Abstract The diagnosis of infective endocarditis can be difficult, particularly with atypical presentation and negative blood cultures. A 61-year-old man with a porcine aorticvalve presented with fever, intermittent confusion, diarrhea, and fatigue. In the community clinic setting, a colonoscopy performed for anemia demonstrated colitis. Symptoms progressed for months; elicitation of a history of significant kitten exposure and the finding of an axillary lymph node prompted testing for Bartonella henselae antibodies. High titer antibodies by indirect immunofluorescence assay indicated chronic B. henselae infection. Surgical valve replacement followed by prolonged doxycycline and rifampin led to cure. This case illustrates the complexities of infective endocarditis and is the first description B. henselae endocarditis associated with colitis in an immunocompetent adult.
Karris, Maile Young; Litwin, Christine M.; Dong, Hong S.
Recently developed technologies allow aorticvalve implantation off-pump in a beating heart. In this procedure, the native, stenotic aorticvalve is not removed, but simply crushed by a pressure balloon mounted on a percutaneous catheter. Removal of the native aortic cusps before valve replacement may reduce the incidence of annular or cuspal calcium embolization and late perivalvular leaks and increase implantable valve size. However, a temporary valve system in the ascending aorta may be necessary to maintain hemodynamic stability by reducing acute aortic regurgitation and left ventricular volume overload. This study evaluates the hemodynamic effects of a wire-mounted, monoleaflet, temporary valve apparatus in a mechanical cardiovascular simulator. Aortic flow, systemic pressure and left ventricular pressure were continuously monitored. An intraluminal camera obtained real-time proximal and distal images of the valve in operation. Insertion of the parachute valve in the simulator increased diastolic pressure from 7 to 38 mm Hg. Cardiac output increased from 2.08 to 4.66 L/min and regurgitant volume decreased from 65 to 23 mL. In conclusion, placement of a temporary valve in the ascending aorta may help maintain hemodynamic stability and improve off-pump aorticvalve replacement. PMID:19033768
Background To evaluate the effect of higher post-operative valve gradient on freedom from valve re-intervention and death in patients undergoing aorticvalve repair (AVr). Methods Patients who underwent AVr between March 1996 and June 2010 were divided into 2 groups: I: peak gradient (PG) <20 mmHg (n=358) and II: PG ?20 mmHg (n=113). Age (53.6±16.0 vs. 50.6±16.4 years; P=0.08), impaired LV (n=44, 12.2% vs. n=12, 10.6%: P=0.73) as well as the body surface area (1.97 vs. 1.95 m2; P=0.4) were similar. Pre-operative AI >2+ was greater in Group II compared to Group I (n=78, 69.0% vs. n=192, 53.6%; P=0.004). Patients in Group II had higher proportion of bicuspid valves (BV) (n=58, 51.3% vs. n=106, 29.6%; P=0.0001) and restrictive valves (n=34, 30.0% vs. n=52, 14.5%; P=0.0001) while Marfan patients were seen only in Group I (n=19; P=0.010). Mean follow-up for Group I and Group II was 123.1±89.7 and 147.1±108.0 months, respectively. Results In-hospital mortality was n=2 (0.5%) for Group I and none for Group II (P=1.0). Valve-sparing was higher in Group I (P=0.0001) but sub-commissural annuloplasty was similar (P=0.15). Shaving and/or decalcification was performed more in Group II (n=68, 60.1% vs. n=117, 32.6%; P=0.0001). Logistic regression analysis identified calcified, restrictive and bicuspid valves as independent predictors of PG ?20 mmHg (P=0.04 for each). Predictors of re-operation were increased end-diastolic diameter (P=0.03) and younger age (P=0.007), but not PG ?20 mmHg (P=0.98) (based on logistic regression). Overall 10-year cardiac survival and freedom from AV re-intervention was 82.3±4.6% vs. 89.5±4.2% (P=0.53) and 89.1±3.0% vs. 76.8±8.4% (P=0.02), in Group I and II, respectively (based on Kaplan-Meier analysis). Sub-group analysis showed that Group II patients requiring re-intervention (n=10) were younger (41.8±13.1 vs. 51.0±16.0 years; P=0.08) with similar proportion of bicuspid valves (n=6; 60%; P=0.74). The main reason for AV re-operation was aortic insufficiency (n=7) and AI + stenosis (n=3). Conclusions Higher gradient after AVr is associated with a reduced freedom from AV re-intervention, especially in younger patients.
Vohra, Hunaid A; Whistance, Robert N; de Kerchove, Laurent; Glineur, David; Noirhomme, Philipe
Seven patients with aortic regurgitation, manifesting diastolic flutter of the aorticvalve cusps (DFAVC) in the echograms, are described. Five patients with infective endocarditis revealed coarse or fine, irregular DFAVC. Two patients with severe aortic regurgitation and a musical murmur manifested regular DFAVC with a frequency identical to that of a simultaneously recorded diastolic murmur. Of the 5 patients with infective endocarditis, 4 required urgent aorticvalve replacement and 1 died. The 2 patients with musical murmurs are clinically stable without surgery. This report extends the clinical spectrum of patients with DFAVC and describes the character of the flutter in patients with muscial murmurs. Furthermore, it suggests that DFAVC is a sign of severe aortic regurgitation. PMID:443598
Venkataraman, K; Bornheimer, J F; Pontius, S; Kim, S J; Allen, J W
Objective To compare the effects of transcatheter aorticvalve implantation (TAVI) and surgical aorticvalve replacement (SAVR) on aorticvalve haemodynamics, ventricular reverse remodelling and myocardial fibrosis (MF) by cardiovascular magnetic resonance (CMR) imaging. Design A 1.5?T CMR scan was performed preoperatively and 6?months postoperatively. Setting University hospitals of Leeds and Leicester, UK. Patients 50 (25 TAVI, 25 SAVR; age 77±8?years) high-risk severe symptomatic aortic stenosis (AS) patients. Main outcome measures Valve haemodynamics, ventricular volumes, ejection fraction (EF), mass and MF. Results Patients were matched for gender and AS severity but not for age (80±6 vs 73±7?years, p=0.001) or EuroSCORE (22±14 vs 7±3, p<0.001). Aorticvalve mean pressure gradient decreased to a greater degree post-TAVI compared to SAVR (21±8?mm?Hg vs 35±13?mm?Hg, p=0.017). Aortic regurgitation reduced by 8% in both groups, only reaching statistical significance for TAVI (p=0.003). TAVI and SAVR improved (p<0.05) left ventricular (LV) end-systolic volumes (46±18?ml/m2 vs 41±17?ml/m2; 44±22?ml/m2 vs32±6?ml/m2) and mass (83±20?g/m2 vs 65±15?g/m2; 74±11?g/m2 vs 59±8?g/m2). SAVR reduced end-diastolic volumes (92±19?ml/m2 vs 74±12?ml/m2, p<0.001) and TAVI increased EF (52±12% vs 56±10%, p=0.01). MF reduced post-TAVI (10.9±6% vs 8.5±5%, p=0.03) but not post-SAVR (4.2±2% vs 4.1±2%, p=0.98). Myocardial scar (p?0.01) and baseline ventricular volumes (p<0.001) were the major predictors of reverse remodelling. Conclusions TAVI was comparable to SAVR at LV reverse remodelling and superior at reducing the valvular pressure gradient and MF. Future work should assess the prognostic importance of reverse remodelling and fibrosis post-TAVI to aid patient selection.
Fairbairn, Timothy A; Steadman, Christopher D; Mather, Adam N; Motwani, Manish; Blackman, Daniel J; Plein, Sven; McCann, Gerry P; Greenwood, John P
Background We compared aortic stiffness, aortic impedance and pressure from wave reflections in the setting of bicuspid aorticvalve (BAV) to the tricuspid aorticvalve (TAV) in the absence of proximal aortic dilation. We hypothesized BAV is associated with abnormal arterial stiffness. Methods Ten BAV subjects (47 ± 4 years, 6 male) and 13 TAV subjects (46 ± 4 years, 10 male) without significant aorticvalve disease were prospectively recruited. Characteristic impedance (Zc) was derived from echocardiographic images and pulse wave Doppler of the left ventricular outflow tract. Applanation tonometry was performed to obtain pulse wave velocity (PWV) at several sites as measures of arterial stiffness and augmentation index (AIx) as a measure of wave reflection. Results There were no significant differences between BAV and TAV subjects with regard to heart rate or blood pressure. Zc was similar between BAV and TAV subjects (p=0.25) as was carotid-femoral pulse wave velocity (cf-PWV) and carotid-radial PWV (cr-PWV) between BAV and TAV subjects (p=0.99). Carotid AIx was significantly higher in BAV patients compared with TAV patients (14.3 ± 4.18% versus -3.02 ± 3.96%, p=0.007). Conclusions Aortic stiffness and impedance is similar between subjects with BAV and TAV with normal aortic dimensions. The significantly higher carotid AIx in BAV, a proxy of increased pressure from wave reflections, may reflect abnormal vascular function distal to the aorta.
Summary In 24 patients with aortic insufficiency undergoing aorticvalve replacement, a clinical and hemodynamic study was performed pre-operatively. Left ventricular biopsies were obtained perioperatively for morphometric study.
J. Perennec; F. Herreman; H. Cosma; F. Ilers; Z. Djigouadi; M. Degeorges; P.-Y. Hatt; M. Willemin
We report the exceptional longevity of a Björk-Shiley Delrin-disc prosthetic aorticvalve that had been implanted in a man who underwent surgical correction of an ascending aortic aneurysm 37 years later. Upon explantation of the valve, the Delrin disc had only shallow abrasion on the ventricular surface, and none on the aortic surface. We discuss the soundness and durability of this valve in our patient, in contrast with its short functional prosthetic life in other patients. The 37-year lifespan of this patient's Björk-Shiley Delrin-disc valve is among the longest reported.
As the elderly population in Japan increases, senile degenerative aortic valvular disease also tends to increase. These patients\\u000a often have a small aortic annulus. The problem of “valve-patient-mismatch” occurs when a small prosthesis is inserted into\\u000a a patient with a small aortic annulus. To avoid annular enlargement after aorticvalve replacement (AVR), we tried to use\\u000a a small-sized St. Jude
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
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
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 to display BAVs. Here we show that tissue-specific deletion of the gene encoding Activin Receptor Type I (Alk2 or Acvr1) in the cushion mesenchyme results in formation of aorticvalve defects including BAV. These defects are largely due to a failure of normal development of the embryonic aorticvalve leaflet precursor cushions in the outflow tract resulting in either a fused right- and non-coronary leaflet, or the presence of only a very small, rudimentary non-coronary leaflet. The surviving adult mutant mice display aortic stenosis with high frequency and occasional aorticvalve insufficiency. The thickened aorticvalve leaflets in such animals do not show changes in Bmp signaling activity, while Map kinase pathways are activated. Although dysfunction correlated with some pro-osteogenic differences in gene expression, neither calcification nor inflammation were detected in aorticvalves of Alk2 mutants with stenosis. We conclude that signaling via Alk2 is required for appropriate aorticvalve development in utero, and that defects in this process lead to indirect secondary complications later in life. PMID:22536403
Thomas, Penny S; Sridurongrit, Somyoth; Ruiz-Lozano, Pilar; Kaartinen, Vesa
In order to obtain better insight into the changes in material properties of aorticvalve tissue due to the treatment with glutaraldehyde, comparative tensile and relaxation experiments have been performed with strips taken from porcine aorticvalve tissue in a fresh condition and after the treatment. To eliminate biological deviations between different strips, the comparative experiments were done on the
E. P. M. Rousseau; EPM Rousseau; AAHJ Sauren; A. A. van Steenhoven
Aorticvalve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aorticvalve calcium and
Yehuda Adler; Mordehay Vaturi; Itay Wiser; Yaron Shapira; Itzhak Herz; Daniel Weisenberg; Noga Sela; Alexander Battler; Alex Sagie
Papillary fibroelastomas (PFEs) are benign cardiac tumors arising from endocardium. They are commonly found on valvular surfaces and average 1.0–1.5?cm in size. Though often asymptomatic, PFEs can lead to potentially severe complications, primarily due to their embolic potential. Surgical resection is recommended for all symptomatic or large PFEs. We report the case of a patient presenting with cardiovascular symptoms who was found to have a very large aorticvalve PFE, as diagnosed by histopathologic examination following surgical resection. Multimodality cardiovascular imaging demonstrates the classic morphologic findings, including a pedunculated appearance and oscillating “frond-like” surface projections.
Fine, Nowell M.; Foley, David A.; Breen, Jerome F.; Maleszewski, Joseph J.
We report a case of hydrops fetalis originating from critical aortic stenosis and pulmonary atresia with intact ventricular\\u000a septum that was diagnosed in utero by echocardiography. We performed a percutaneous balloon valvuloplasty of the bilateral semilunar valves on the 2nd day after\\u000a birth. We used a stiff-ended guidewire to perforate the pulmonary valve. After valvuloplasty, the aorticvalve pressure gradient
We report a case of hydrops fetalis originating from critical aortic stenosis and pulmonary atresia with intact ventricular septum that was diagnosed in utero by echocardiography. We performed a percutaneous balloon valvuloplasty of the bilateral semilunar valves on the 2nd day after birth. We used a stiff-ended guidewire to perforate the pulmonary valve. After valvuloplasty, the aorticvalve pressure gradient decreased from 55 to 25 mmHg. The procedure was successful, and the patient's heart condition improved. PMID:16235008
Transapical aorticvalve implantation (TA-AVI) has evolved as a routine procedure to treat selected high-risk elderly patients. In the vast majority, the balloon-expandable SAPIEN™ prosthesis has been used for TA-AVI. The new JenaValve™ prosthesis is designed for antegrade transapical implantation and consists of a self-expandable Nitinol™ stent with a porcine tissue-prosthesis mounted on a sheath-less delivery catheter. Key features of
Jörg Kempfert; Ardawan J. Rastan; Friedrich-W. Mohr; Thomas Walther
\\u000a C-arm CT is an emerging imaging technique in transcatheter aorticvalve implantation (TAVI) surgery. Automatic aorta segmentation\\u000a and valve landmark detection in a C-arm CT volume has important applications in TAVI by providing valuable 3D measurements\\u000a for surgery planning. Overlaying 3D segmentation onto 2D real time fluoroscopic images also provides critical visual guidance\\u000a during the surgery. In this paper, we
Yefeng Zheng; Matthias John; Rui Liao; Jan Boese; Uwe Kirschstein; Bogdan Georgescu; Shaohua Kevin Zhou; Jörg Kempfert; Thomas Walther; Gernot Brockmann; Dorin Comaniciu
C-arm CT is an emerging imaging technique in transcatheter aorticvalve implantation (TAVI) surgery. Automatic aorta segmentation and valve landmark detection in a C-arm CT volume has important applications in TAVI by providing valuable 3D measurements for surgery planning. Overlaying 3D segmentation onto 2D real time fluoroscopic images also provides critical visual guidance during the surgery. In this paper, we present a part-based aorta segmentation approach, which can handle aorta structure variation in case that the aortic arch and descending aorta are missing in the volume. The whole aorta model is split into four parts: aortic root, ascending aorta, aortic arch, and descending aorta. Discriminative learning is applied to train a detector for each part separately to exploit the rich domain knowledge embedded in an expert-annotated dataset. Eight important aorticvalve landmarks (three aortic hinge points, three commissure points, and two coronary ostia) are also detected automatically in our system. Under the guidance of the detected landmarks, the physicians can deploy the prosthetic valve properly. Our approach is robust under variations of contrast agent. Taking about 1.4 seconds to process one volume, it is also computationally efficient. PMID:20879265
Aorticvalve prolapse (AVP) was detected in 82 (7.5%) of 1096 patients with ventricular septal defect (VSD) (in 50 at initial\\u000a echocardiographic examination and in 32 at follow-up) by echocardiography. Of 82 patients with AVP, aortic regurgitation (AR)\\u000a was detected in 53 (65%) (in 28 at initial echocardiographic examination and in 25 at follow-up), resulting in an incidence\\u000a of AR
A. G. Eroglu; F. Öztunç; L. Saltik; S. Dedeoglu; S. Bakari; G. Ahunbay
Bicuspid (or bicommissural) aorticvalve (BAV) is the most common cardiovascular malformation in humans, with a prevalence\\u000a of 1% to 2% in the general population and a 2:1 male:female ratio. BAV is frequently associated with other cardiovascular\\u000a malformations, including aortic root dilatation, which affects about 40% of individuals with BAVs and is thought to be associated\\u000a with increased risk of
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
Hemodynamic research shows that thrombosis formation is closely tied to flow field turbulent stress. Design limitations cause flow separation at leaflet edges and the annular valve base, vortex mixing downstream, and high turbulent shear stress. The trileaflet design opens like a physiologic valve with central flow. Leaflet curvature approximates a completely circular orifice, maximizing effective flow area of the open valve. Semicircular aortic sinuses downstream of the valve allow vortex formation to help leaflet closure. The new trileaflet design was hemodynamically evaluated via digital particle image velocimetry and laser-Doppler anemometry. Measurements were made during peak flow of the fully open valve, immediately downstream of the valve, and compared with the 27-mm St. Jude Medical (SJM) bileaflet valve. The trileaflet valve central flow produces sufficient pressure to inhibit separation shear layers. Absence of downstream turbulent wake eddies indicates smooth, physiologic blood flow. In contrast, SJM produces strong turbulence because of unsteady separated shear layers where the jet flow meets the aortic sinus wall, resulting in higher turbulent shear stresses detrimental to blood cells. The trileaflet valve simulates the physiologic valve better than previous designs, produces smoother flow, and allows large scale recirculation in the aortic sinuses to help valve closure. PMID:16156295
Liu, Jia-Shing; Lu, Po-Chien; Lo, Chi-Wen; Lai, Ho-Cheng; Hwang, Ned H C
The follow-up of 22 patients (out of 31 patients after artificial aorticvalve and pacemaker implantation between 1982 and 2001) have been evaluated. There were 15 men aged 30-76 (x=55) and 7 women aged 43-69 (x=59). Aorticvalve replacement (AVR) was subsequently followed by pacemaker implantation (PI) after approximately 16 days. Indication for permanent stimulation were: atrio-ventricular complete block in 18 patients and atrial fibrillation with slow ventricular response in the remaining 4. There were implanted 15 devices of VVI type and 7 of VDD type. The duration of follow up was 9-196 (x=56) months. All these patients remained in good general state (II degree--19 patients or II/III degree--3 patients acc. to NYHA classification). In 21 out of 22 patients, atrioventricular conduction disturbances and bradyarrhythmia remained for the entire follow-up duration with permanent stimulation (VVI or VAT). In one patient the postoperative complete atrio-ventricular block disappeared during follow up, 24 months after AVR. Conclusions: 1. The main indication for PI after AVR was complete atrio-ventricular block, persisting 2-3 weeks after surgery, without accompanying atrial fibrillation. 2. In long term follow up after AVR and PI (VVI or VDD) the dominance of 100% capture ventricular pacing have been recorded in almost all cases, which holds the decision of early postoperative PI. PMID:15724671
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.
We report a case with echocardiographic demonstration of native congenital bicuspid aorticvalve endocarditis with multiple subaortic complications. Transesophageal echocardiography in this case revealed large vegetations with multiloculated aortic paravalvular abscess around the cusps; a high-acquired restrictive membranous ventricular septal defect with vegetations extending to the tricuspid leaflets and paravalvular aortic regurgitation caused by aortic leaflet perforation. PMID:14608296
Zelenka, Jason; Akel, Rami; Sawada, Stephen G; Mahenthiran, Jo
Background:Aortic wall pathology and concomitant aortic dilatation have been described in tetralogy of Fallot (TOF) patients, which may negatively affect aorticvalve and left ventricular systolic function.Objective:To assess aortic dimensions, aortic elasticity, aorticvalve competence and biventricular function in repaired TOF patients after pulmonary valve replacement (PVR) using magnetic resonance imaging (MRI).Methods:MRI was performed in 16 patients with TOF after
H. B. Grotenhuis; J. Ottenkamp; L de Bruijn; J. J. M. Westenberg; H. W. Vliegen; L. J. M. Kroft; A de Roos
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))
A 52-year-old man came to the local emergency department with symptoms of heart failure and transient chest pain. Transthoracic echocardiography showed severe aortic regurgitation and a dilated ascending aorta. Aortic dissection was suspected, and he was transferred to our institution. Transesophageal echocardiography appeared to confirm the presence of a type A dissection. A mobile, linear structure was present in the
Andrew C. Kupersmith; Robert N. Belkin; John A. McClung; Richard A. Moggio
Comparisons between transcatheter aorticvalve implantation without replacement (TAVI) and tissue aorticvalve replacement (AVR) in clinical trials might not reflect the outcomes in standard clinical practice. This could have important implications for the relative cost-effectiveness of these alternatives for management of severe aortic stenosis in high-risk patients for whom surgery is an option. The mean and variance of risks, transition probabilities, utilities, and cost of TAVI, AVR, and medical management derived from observational studies were entered into a Markov model that examined the progression of patients between relevant health states. The outcomes and cost were derived from 10,000 simulations. Sensitivity analyses were based on variations in the likelihood of mortality, stroke, and other commonly observed outcomes. Both TAVI and AVR were cost-effective compared to medical management. In the reference case (age 80 years, the perioperative TAVI and AVR mortality was 6.9% vs 9.8%, and annual mortality was 21% vs 24%), the utility of TAVI was greater than that of AVR (1.78 vs 1.72 quality-adjusted life years) and the lifetime cost of TAVI exceeded that of AVR ($59,503 vs $56,339). The incremental cost-effectiveness ratio was $52,773/quality-adjusted life years. Threshold analyses showed that variation in the probabilities of perioperative and annual mortality after AVR and after TAVI and annual stroke after TAVI were important determinants of the favored strategy. Sensitivity analyses defined the thresholds at which TAVI or AVR was the preferred strategy with regard to health outcomes and cost. In conclusion, TAVI satisfies current metrics of cost-effectiveness relative to AVR and might provide net health benefits at acceptable cost for selected high-risk patients among whom AVR is the current procedure of choice. PMID:22335853
Gada, Hemal; Kapadia, Samir R; Tuzcu, E Murat; Svensson, Lars G; Marwick, Thomas H
Mechanical occlusion of the right coronary artery during aorticvalve surgery is an infrequent but serious complication. Early recognition and expeditious management are important to reduce mortality. We developed a safe, quick, and easy technique to assess right coronary artery flow after aorticvalve surgery. Direct intraoperative right coronary artery flow was measured by placing a transit-time flowmeter probe around the right coronary artery. We were able to promptly detect severe right coronary artery insufficiency in patients with acute unexpected right ventricular failure after aorticvalve replacement. PMID:22115253
Fernández, Angel L; El-Diasty, Mohammad M; Martínez, Amparo; Alvarez, Julian; García-Bengochea, José B
A fibrous band connecting the middle of the free edge (nodulus Arantii) of the non-coronary aorticvalve cusp to the ascending aorta just above the level of the non-coronary sinus of Valsalva was observed in an asymptomatic, 11-year-old, male Border Collie. The fibrous band was unrelated to the cause of the death in this dog. Such fibrous bands are usually reported in humans with congenital bicuspid aorticvalves. To our knowledge, this is the first report of a fibrous band in the aorticvalve in a domestic animal. PMID:21641896
Ajithdoss, Dharani K; Arenas-Gamboa, Angela M; Edwards, John F
A 53-year-old man who had undergone aorticvalve replacement with a Starr-Edwards ball valve prosthesis 39 years previously was admitted to our hospital under the diagnosis of ascending aortic aneurysm. Operative findings revealed that the ball valve was functioning normally. The markedly dilated ascending aorta was replaced with a 30-mm prosthetic vascular graft, and the ball valve was replaced with a19-mm bileaflet valve prosthesis. The patient's postoperative course was uneventful, and he was discharged from our hospital 19 days after surgery. Dilatation of the ascending aorta in this case might have been caused by the poststenotic dilatation mechanism, which seems to be one of the long-term complications of Starr-Edwards ball valve implantation. PMID:20349304
Background Cardiac conduction disorders and requirement for permanent pacemaker implantation (PPI) are not uncommon after surgical aorticvalve replacement and have important clinical implications. We aimed to investigate the incidence of cardiac conduction disorders after percutaneous aorticvalve implantation (PAVI) and to identify possible clinical factors associated with their development. Methods We studied 34 patients (mean age 80 +\\/- 8
Jan Baan Jr.; Ze Yie Yong; Karel T. Koch; José P. S. Henriques; Berto J. Bouma; Marije M. Vis; Riccardo Cocchieri; Jan J. Piek
The clinical features of endocarditis of the aorticvalve in 24 dogs were reviewed. This condition was found most commonly in large-breed, middle-aged male dogs. Evidence of antecedent infection or immunosuppression was usually not historically verified or found at necropsy. However, an association with congenital heart disease, especially discrete subaortic stenosis, was demonstrated. The most frequent clinical findings were systolic and diastolic murmurs and bounding arterial pulses, with or without signs of congestive heart failure. The most commonly isolated organisms were Corynebacterium sp, Erysipelothrix rhusiopathiae, and Streptococcus sp. In addition to antibiotic therapy, treatment for congestive heart failure often was required. Despite aggressive therapy, most affected dogs died as a result of congestive heart failure, arrhythmias, infarction, sepsis, or renal failure. PMID:6706802
The penetration rate of devices in general, and in transcatheter aorticvalve replacement (TAVR) specifically, is significantly delayed in the United States of America (USA) compared with in Europe. This is mostly due to the mission statement of the regulatory agencies in the USA, which requires very rigorous clinical testing of a device prior to its approval. The USA had a major role in the development and evaluation of this technology and USA research has enabled clinicians inside and outside of the USA to conduct a concise scientifically based assessment of the performance of TAVR devices in terms of safety and efficacy. In the following review, we provide data on the development of TAVR in the USA, revealing the critical role the USA has played in this extraordinary process. PMID:22520799
Dvir, Danny; Barbash, Israel M; Ben-Dor, Itsik; Okubagzi, Petros; Satler, Lowell F; Waksman, Ron; Pichard, Augusto 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.
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/cm(2) 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
Yap, Choon Hwai; Saikrishnan, Neelakantan; Tamilselvan, Gowthami; Yoganathan, Ajit P
Sclerotic calcification of the aorticvalve is a common disease in advanced age. However, pathophysiologic processes leading to valve calcifications are poorly understood. Transformation of atherosclerotic triggers to osteogenic differentiation is controversially discussed and is thought as a trigger of bone transformation in end stage disease.This study focuses on the transcriptional gene-profiling of severe calcified stenotic human aorticvalves to
Thomas Anger; Walter Carson; Michael Weyand; Werner G. Daniel; Martin Hoeher; Christoph D. Garlichs
Question: What factors predict postoperative pulmonary and pleural complications following aorticvalve replacement? Design: Retrospective study. Participants: One thousand consecutive patients who underwent aorticvalve replacement with a pericardial valve between 1986 and 2006. Of these, 610 underwent also coronary artery surgery. Outcome measures: Thirty putative predictors were investigated. Postoperative pulmonary complications (defined as respiratory failure, pneumonia, atelectasis) and postoperative
Objective: This study represents the development of a treatment and seeding procedure to improve endothelial cellular adhesion on glutaraldehyde-fixed valves.Methods: Porcine aorticvalves were fixed with 0.2% glutaraldehyde. Wall pieces of these valves had either no additional treatment (n = 4), incubation in M199 Earle (1×), with sodium carbonate at 2.2 g\\/L without l-glutamine for 24 hours (n = 4),
Helmut Gulbins; Angelika Goldemund; Ingrid Anderson; Ulrike Haas; Antje Uhlig; Bruno Meiser; Bruno Reichart
Objective: Trans-apical aorticvalve implantation (TA-AVI) has evolved into a standard approach for high-risk, elderly patients using the balloon-expandable Edwards SAPIEN™ prosthesis. As an alternative device, a self-expanding sub-coronary trans-apical bioprosthesis was evaluated. Methods: The Symetis Acurate™ trans-catheter heart valve is composed of a porcine biologic valve attached to a self-expandable nitinol stent. It allows for anatomical orientation, and facilitates
Jörg Kempfert; Ardawan J. Rastan; Friedhelm Beyersdorf; Markus Schönburg; Gerhard Schuler; Stefan Sorg; Friedrich-W. Mohr; Thomas Walther
ObjectiveThis prospective study aimed to determine to what extent clinical symptoms and neurohumoral activation are improved in patients with severe aorticvalve stenosis after transcatheter aorticvalve implantation (TAVI) with the CoreValve prosthesis.MethodsFrom June 2008 to June 2009 consecutive patients with symptomatic severe aorticvalve stenosis (area60 years plus additional specified risk factors were evaluated for TAVI. Examinations of study
Michael Gotzmann; Tobias Hehen; Alfried Germing; Michael Lindstaedt; Aydan Yazar; Axel Laczkovics; Achim Mumme; Andreas Mügge; Waldemar Bojara
Objectives: To determine whether the contributions of genetics and bicuspid aorticvalve (BAV) independently influence aortic (Ao) dimensions. Background: Ao dilation is a risk factor for aneurysm, dissection, and sudden cardiac death. Frequent association of BAV with Ao dilation implicates a common underlying defect possibly due to genetic factors. Methods: Families enriched for BAV underwent standardized transthoracic echocardiography. In addition to BAV status, echocardiographic measures of Ao (annulus to descending Ao), pulmonary artery, and mitral valve annulus (MVA) diameters were obtained. Using variance components analysis, heritability was estimated with and without BAV status. Additionally, bivariate genetic analyses between Ao dimensions and BAV were performed. Results: Our cohort was obtained from 209 families enriched for BAV. After adjusting for age, body surface area, and sex, individuals with BAV had a statistically significant increase in all echocardiographic measurements (p?0.006) except descending Ao and MVA. Individuals with BAV were at greater odds of having Ao dilation (OR?=?4.44, 95% CI 2.93–6.72) than family members without BAV. All echocardiographic measurements exhibited moderate to strong heritability (0.25–0.53), and these estimates were not influenced by inclusion of BAV as a covariate. Bivariate genetic analyses supported that the genetic correlation between BAV and echo measures were not significantly different from zero. Conclusion: We show for the first time that echocardiographic measurements of Ao, pulmonary artery and MVA diameters are quantitative traits that exhibit significant heritability. In addition, our results suggest the presence of BAV independently influences the proximal Ao and pulmonary artery measures but not those in the descending Ao or MVA.
Martin, Lisa J.; Hinton, Robert B.; Zhang, Xue; Cripe, Linda H.; Benson, D. Woodrow
Fistula development between the left ventricular outflow tract and right atrium is a rare complication of aorticvalve replacement (AVR), typically seen with calcific aortic stenosis or endocarditis. The case is reported of a left ventricle-to-right atrial fistula following mechanical AVR for aortic insufficiency. PMID:22808839
Anderson, Curtis A; Rodriguez, Evelio; Kypson, Alan P
Percutaneous AorticValve (PAV) replacement is an attractive alternative to open heart surgery, especially for patients considered to be poor surgical candidates. Despite this, PAV replacement still has its limitations and associated risks. Bioprosthetic heart valves still have poor long-term durability due to calcification and mechanical failure. In addition, the implantation procedure often presents novel challenges, including damage to the
A. N. Smuts; D. C. Blaine; C. Scheffer; H. Weich; A. F. Doubell; K. H. Dellimore
Streptococcus constellatus endocarditis is associated with systemic embolism and frequently with a poor prognosis. We describe the first case reported in the literature of infective endocarditis by penicillin-resistant S. constellatus causing both mitral and aorticvalve regurgitation, treated successfully with double-valve replacement.
Objectives: In the Ross procedure, 3 different techniques are used for aorticvalve replacement with the pulmonary autograft: freestanding root, inclusion, and subcoronary implantation. The objective of this study was to evaluate echocardiographically the influence of the particular operative technique on dimension, distensibility, and valve function. Methods: Between February 1990 and August 1998, the Ross procedure was performed in 111
Claudia Schmidtke; J. F. Matthias Bechtel; Michael Hueppe; Axel Noetzold; Hans-Hinrich Sievers
Sutureless aorticvalve replacement is perceived to be an alternative treatment for high surgical risk patients with severe aortic stenosis. This work presents the results of a systematic review undertaken to assess the effectiveness and safety of this procedure. Eight low quality case series were identified. Six focused on prosthesis ATS 3f Enable(®) and 2 on Perceval S. Results show good haemodynamic and clinical results for both prosthesis. Implantation of ATS 3f Enable(®) valves was successful in more than 85% of the patients and the mean cardiopulmonary bypass (BCP) time ranged from 58 to 85 minutes. For Perceval S, implantation was successful in all patients and the mean BCP time was less than 30 minutes. Since there are no long term follow-up studies, the durability of the prosthesis and the appearance of late complications is uncertain. PMID:22818184
Varela-Lema, Leonor; De La Fuente Cid, Ramón; López García, María Luisa
We experienced a case of aorticvalve replacement after previous coronary artery bypass grafting with patent bypass grafts. Based on the retrosternal anatomy assessed by preoperative angiography and thoracic computed tomography, aorticvalve replacement was performed through a median resternotomy. After careful dissection of the right side of the heart and the ascending aorta, cardiopulmonary bypass was established with cannulation of the ascending aorta and bicaval venous cannulation. The patent bypass grafts were dissected only as required for clamping and were clamped during cardiac arrest. After aorticvalve replacement, the patient was uneventfully weaned from cardiopulmonary bypass and had a good postoperative recovery. It is important that surgeons have a meticulous strategy for reducing the risks associated with operating on patients with patent bypass grafts. We report on the surgical management of patients undergoing aorticvalve replacement after previous coronary artery bypass grafting, including careful planning during the first operation. PMID:23877203
A 34 year old man presented with an inferior non-Q-wave myocardial infarction. Echocardiography showed a bicuspid aorticvalve with aortic outflow obstruction. Left coronary cusp morphology was normal but the right coronary cusp was grossly distorted and replaced by a mobile echodense mass encroaching upon the aorticvalve orifice. The aorticvalve was replaced and pathological analysis of the excised valve showed primary amyloid infiltration of the right coronary cusp but a normal left coronary cusp. The mass adherent to the right coronary leaflet had the histological appearances of organised thrombus and this was assumed to be the source of coronary embolism. This is the first reported case of primary valvar amyloid presenting with clinical sequelae and it illustrates the need for careful clinical assessment in young patients presenting with acute ischaemic syndromes. Images
Heart valve disease is a serious and growing public health problem for which prosthetic replacement is most commonly indicated. Current prosthetic devices are inadequate for younger adults and growing children. Tissue engineered living aorticvalve conduits have potential for remodeling, regeneration, and growth, but fabricating natural anatomical complexity with cellular heterogeneity remain challenging. In the current study, we implement 3D bioprinting to fabricate living alginate/gelatin hydrogel valve conduits with anatomical architecture and direct incorporation of dual cell types in a regionally constrained manner. Encapsulated aortic root sinus smooth muscle cells (SMC) and aorticvalve leaflet interstitial cells (VIC) were viable within alginate/gelatin hydrogel discs over 7 days in culture. Acellular 3D printed hydrogels exhibited reduced modulus, ultimate strength, and peak strain reducing slightly over 7-day culture, while the tensile biomechanics of cell-laden hydrogels were maintained. Aorticvalve conduits were successfully bioprinted with direct encapsulation of SMC in the valve root and VIC in the leaflets. Both cell types were viable (81.4 ± 3.4% for SMC and 83.2 ± 4.0% for VIC) within 3D printed tissues. Encapsulated SMC expressed elevated alpha-smooth muscle actin, while VIC expressed elevated vimentin. These results demonstrate that anatomically complex, heterogeneously encapsulated aorticvalve hydrogel conduits can be fabricated with 3D bioprinting. PMID:23015540
Duan, Bin; Hockaday, Laura A; Kang, Kevin H; Butcher, Jonathan T
Heart valve disease is a serious and growing public health problem for which prosthetic replacement is most commonly indicated. Current prosthetic devices are inadequate for younger adults and growing children. Tissue engineered living aorticvalve conduits have potential for remodeling, regeneration, and growth, but fabricating natural anatomical complexity with cellular heterogeneity remain challenging. In the current study, we implement 3D bioprinting to fabricate living alginate/gelatin hydrogel valve conduits with anatomical architecture and direct incorporation of dual cell types in a regionally constrained manner. Encapsulated aortic root sinus smooth muscle cells (SMC) and aorticvalve leaflet interstitial cells (VIC) were viable within alginate/gelatin hydrogel discs over 7 days in culture. Acellular 3D printed hydrogels exhibited reduced modulus, ultimate strength, and peak strain reducing slightly over 7-day culture, while the tensile biomechanics of cell-laden hydrogels were maintained. Aorticvalve conduits were successfully bioprinted with direct encapsulation of SMC in the valve root and VIC in the leaflets. Both cell types were viable (81.4±3.4% for SMC and 83.2±4.0% for VIC) within 3D printed tissues. Encapsulated SMC expressed elevated alpha-smooth muscle actin when printed in stiff matrix, while VIC expressed elevated vimentin in soft matrix. These results demonstrate that anatomically complex, heterogeneously encapsulated aorticvalve hydrogel conduits can be fabricated with 3D bioprinting.
Duan, Bin; Hockaday, Laura A.; Kang, Kevin H.; Butcher, Jonathan T.
Aorticvalve (AV) calcification is a highly prevalent disease with serious impact on mortality and morbidity. The exact cause and mechanism of the progression of AV calcification is unknown, although mechanical forces have been known to play a role. It is thus important to characterize the mechanical environment of the AV. In the current study, we establish a methodology of measuring shear stresses experienced by the aortic surface of the AV leaflets using an in vitro valve model and adapting the laser Doppler velocimetry (LDV) technique. The valve model was constructed from a fresh porcine aorticvalve, which was trimmed and sutured onto a plastic stented ring, and inserted into an idealized three-lobed sinus acrylic chamber. Valve leaflet location was measured by obtaining the location of highest back-scattered LDV laser light intensity. The technique of performing LDV measurements near to biological surfaces as well as the leaflet locating technique was first validated in two phantom flow systems: (1) steady flow within a straight tube with AV leaflet adhered to the wall, and (2) steady flow within the actual valve model. Dynamic shear stresses were then obtained by applying the techniques on the valve model in a physiologic pulsatile flow loop. Results show that aortic surface shear stresses are low during early systole (<5 dyn/cm²) but elevated to its peak during mid to late systole at about 18-20 dyn/cm². Low magnitude shear stress (<5 dyn/cm²) was observed during early diastole and dissipated to zero over the diastolic duration. Systolic shear stress was observed to elevate only with the formation of sinus vortex flow. The presented technique can also be used on other in vitro valve models such as congenitally geometrically malformed valves, or to investigate effects of hemodynamics on valve shear stress. Shear stress data can be used for further experiments investigating effects of fluid shear stress on valve biology, for conditioning tissue engineered AV, and to validate numerical simulations. PMID:21744927
Yap, Choon Hwai; Saikrishnan, Neelakantan; Tamilselvan, Gowthami; Yoganathan, Ajit P
Current methods for assessing the severity of aortic stenosis depend primarily on measures of maximum systolic pressure drop\\u000a at the aorticvalve orifice and related calculations such as valve area. It is becoming increasingly obvious, however, that\\u000a the impact of the obstruction on the left ventricle is equally important in assessing its severity and could potentially be\\u000a influenced by geometric
Russell S. Heinrich; Arnold A. Fontaine; Randall Y. Grimes; Aniket Sidhaye; Serena Yang; Kristin E. Moore; Robert A. Levine; Ajit P. Yoganathan
The key to obtaining maximal valve coaptation from the aorticvalve-sparing procedure is in appreciating the optimal geometry of each component of the aortic root. We describe a new device called the Commissure Holder (patent pending) that aids in the selection of an appropriate graft size and in the determination of the optimal position at which each commissure should be sutured to the graft. PMID:11308206
Akimoto, H; Tsuru, Y; Yokoyama, H; Sadahiro, M; Tabayashi, K
Aorticvalve stenosis has already reached endemic proportions in Western countries. As the prognosis of low?flow aorticvalve stenosis under medical treatment is dismal, surgery is recommended in most patients. Preoperative dobutamine stress testing may help to assess surgical risk, but there is no strong scientific evidence to deny surgery based exclusively on the results of this test. The problems associated with clinical decision making in this condition are reviewed.
ABSTRACT Recent studies suggest that the hemodynamic,advantage of stentless bioprostheses over the stented type improves long-term survival after aorticvalve replacement, but the more complex,and time-consuming,implantation technique may increase the risks of operative death and postoperative complications. Between April 1996 and June 2001, 519 patients with a mean age of 76 ±5 years underwent aorticvalve replacement using a stentless
Jürgen Ennker; Ulrich Rosendahl; Ina Carolin Ennker; Stefan Bauer; Ines Florath
A case of Candida albicans endocarditis is described in which treatment with 5-fluorocytosine was started after aorticvalve replacement, but relapse followed discontinuance of treatment. At a second operation the aorticvalve was replaced under 5-fluorocytosine cover and treatment was continued with both 5-fluorocytosine and amphotericin-B. No resistance to 5-fluorocytosine developed, and the candida infection was eradicated. The patient is well 22 months after his operation.
We present patient with the Marfan syndrome in whom the dissecting abdominal aortic aneurysm comprising the left iliac and femoral artery was diagnosed two years after the implantation of an artificial aorticvalve. The chest CT showed the extention of the ascending aorta without the aortic dissection features. The patient was taken into the clinic in a very bad general condition with sinus tachycardia, the left ventricular failure together with pulse absence in all standard places of pulse measurement in the left lower limb. During the TEE examination the dissecting aneurysm of type I according to De Bakey's classification and the normal function of the artificial aorticvalve were recognized. Colour Doppler revealed the primary entry site above the sinus of Valsalva. The patient was qualified for an urgent surgical intervention. The diagnosis was confirmed during the operation. The patient had resection of aneurysm with Dacron tube replacement. After the cardiosurgical intervention the ischaemic symptoms of the left lower limb retreated, the size of the heart diminished in the chest X-ray and TTE examination. The left ventricular ejection fraction increased from 45% to 62%. The TEE of the patient proved the most accurate and precise method of the diagnosis of the aortic dissection. The obtained information was sufficient to decide on the surgical intervention. PMID:9695650
Hlawaty, M; Olszowska, M; Podolec, P; Tracz, W; Sadowski, J; Dziatkowiak, A
Aortal valve mineralization very frequently causes a genesis of aortic stenosis, which is the most often surgically treated heart disease. Hydroxyapatite deposits have been identified as one of the causes leading to the loss of elasticity of the aorticvalves. It is known that phosphates/calcium is accumulated in valve tissues during mineralization, but the mechanism of this process remains unclear. The work is focused mainly on the study of protein composition of mineralized aorticvalves by nano-liquid chromatography electrospray ionization in a quadrupole orthogonal acceleration time-of-flight mass spectrometry. New methodological approach based on direct enzymatic digestion of proteins contained in hydroxyapatite deposits was developed for the study of pathological processes connected with osteogenesis. Our objectives were to simplify the traditional analytical protocols of sample preparation and to analyze the organic components of the explanted aorticvalves for significant degenerative aortic stenosis. The study of aorticvalve mineralization on the molecular level should contribute to understanding this process, which should consequently lead to effective prevention as well as to new ways of treatment of this grave disease. PMID:23978938
A 66-year-old man with severe aortic stenosis had previously undergone esophagectomy with retrosternal gastric tube (GT) reconstruction for esophageal cancer. A chest computed tomography scan demonstrated severe aortic calcification, and we treated him with median sternotomy. A small upper laparotomy was made, and the surface of the GT was detected. The posterior and right sides of the GT were dissected, and the pericardium was then opened. An aortic cross clamp was performed in the least calcified lesion of the ascending aorta, and an aortotomy was performed just above the sinotubular junction. The aorticvalve was successfully replaced with a mechanical valve. PMID:19901892
There is a lack of clarity concerning the clinical implications of myocardial injury occurring after transcatheter aorticvalve implantation (TAVI) procedures. The aim of this study was to determine the incidence, degree, and timing of myocardial injury associated with TAVI procedures and to evaluate its 1-year prognostic value. Among 68 consecutive patients (mean age 80.9 ± 6.4 years) treated with TAVI, 3 patients who died within 24 hours, precluding cardiac biomarker measurements, and 3 patients with major procedural complications were excluded. Cardiac troponin I, creatine kinase-MB, and creatinine levels were determined at baseline and 6, 12, 24, 48, and 72 hours after TAVI. All complications were defined according to the Valve Academic Research Consortium. Myocardial injury was observed in all patients (n = 62), as determined by an increase in cardiac troponin I (median peak at 12 hours 3.8 ?g/L, interquartile range 1.8 to 25.67), and a higher degree of myocardial injury was observed in patients (n = 9) who developed acute kidney injury (AKI) (p = 0.026). Periprocedural myocardial infarction was not found. At 1-year follow-up, 5 patients had died, and 7 patients had been hospitalized for heart failure. The development of AKI, not the degree of peak cardiac troponin I (p = 0.348), was identified as the only strong independent predictor of 1-year mortality from any cause (including heart failure) after TAVI (hazard ratio 4.74, 95% confidence interval 1.12 to 20.03, p = 0.034). In conclusion, TAVI was systematically associated with myocardial injury, occurring with a higher degree in patients who developed AKI. However, the simultaneous development of AKI occurring after TAVI is the strongest predictor of 1-year mortality. PMID:23465097
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
During trascatheter aorticvalve implantation (TAVI) the native valve is not removed but crushed. Thus, a slight prosthesis insufficiency is not uncommon and has been reported in about 70% of patients for both available types of percutaneous valves. However, the definition of clinically “significant” valve regurgitation is not fully established yet. In most cases, aortic insufficiency is mild and clinical acceptable, however, severe insufficiency can occur. Paravalvular insufficiency is usually prevalent, and it may be the consequence of prosthesis/patient mismatch due to an undersizing of the implanted device or to an incomplete expansion of the prosthesis stent frame, or also to incorrect site of prosthesis implantation. Thus, an accurate assessment of the aorticvalve annulus before TAVI is mandatory in order to select the optimal size of the valve. The presence of large calcium burden or bicuspid valve as well as the correct implantation of the device are other key determinants of final valve insufficiency. When severe regurgitation is present, an integration of hemodynamic, angiographic, transthoracic and TEE data is necessary to tailor the best clinical decision on a per-patient basis.
The 3f Aortic Bioprosthesis (Medtronic, Inc, Minneapolis, MN) is a stentless aorticvalve with a novel design that resembles a "tube within a tube." Although it has the potential for improved durability and hemodynamic performance, long-term data on this valve remain elusive. We present here 3 patients in whom postoperative echocardiography revealed significantly elevated transvalvular gradients of the 3f valve while transcatheter gradients proved to be negligible. By virtue of the unique design of the 3f bioprosthesis, great caution should be taken when interpreting echocardiographically derived gradients. PMID:23816086
A 53-year-old woman who had undergone aorticvalve replacement with a Starr-Edwards (S-E) valve (Model 1260) and open mitral commissurotomy 28 years previously was hospitalized with cardiac failure. Echocardiography showed mitral stenosis, mitral regurgitation, and a normally functioning S-E prosthesis. At reoperation, the mitral and aorticvalves were replaced with St Jude bileaflet mechanical prostheses. Examination of the explanted S-E prosthesis revealed no structural abnormality other than lipid infiltration of the silastic ball. PMID:15118298
Objectives To propose standardized consensus definitions for important clinical endpoints in transcatheter aorticvalve implantation (TAVI), investigations in an effort to improve the quality of clinical research and to enable meaningful comparisons between clinical trials. To make these consensus definitions accessible to all stakeholders in TAVI clinical research through a peer reviewed publication, on behalf of the public health. Background Transcatheter aorticvalve implantation may provide a worthwhile less invasive treatment in many patients with severe aortic stenosis and since its introduction to the medical community in 2002, there has been an explosive growth in procedures. The integration of TAVI into daily clinical practice should be guided by academic activities, which requires a harmonized and structured process for data collection, interpretation, and reporting during well-conducted clinical trials. Methods and results The Valve Academic Research Consortium established an independent collaboration between Academic Research organizations and specialty societies (cardiology and cardiac surgery) in the USA and Europe. Two meetings, in San Francisco, California (September 2009) and in Amsterdam, the Netherlands (December 2009), including key physician experts, and representatives from the US Food and Drug Administration (FDA) and device manufacturers, were focused on creating consistent endpoint definitions and consensus recommendations for implementation in TAVI clinical research programs. Important considerations in developing endpoint definitions included (i) respect for the historical legacy of surgical valve guidelines; (ii) identification of pathophysiological mechanisms associated with clinical events; (iii) emphasis on clinical relevance. Consensus criteria were developed for the following endpoints: mortality, myocardial infarction, stroke, bleeding, acute kidney injury, vascular complications, and prosthetic valve performance. Composite endpoints for TAVI safety and effectiveness were also recommended. Conclusion Although consensus criteria will invariably include certain arbitrary features, an organized multidisciplinary process to develop specific definitions for TAVI clinical research should provide consistency across studies that can facilitate the evaluation of this new important catheter-based therapy. The broadly based consensus endpoint definitions described in this document may be useful for regulatory and clinical trial purposes.
Leon, Martin B.; Piazza, Nicolo; Nikolsky, Eugenia; Blackstone, Eugene H.; Cutlip, Donald E.; Kappetein, Arie Pieter; Krucoff, Mitchell W.; Mack, Michael; Mehran, Roxana; Miller, Craig; Morel, Marie-angele; Petersen, John; Popma, Jeffrey J.; Takkenberg, Johanna J.M.; Vahanian, Alec; van Es, Gerrit-Anne; Vranckx, Pascal; Webb, John G.; Windecker, Stephan; Serruys, Patrick W.
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 mm inner diameters (ID) were 3D printed with poly-ethylene glycol-diacrylate (PEG-DA) hydrogels (700 or 8000 MW) supplemented with alginate. 3D printing geometric accuracy was quantified and compared using Micro-CT. Porcine aorticvalve interstitial cells (PAVIC) seeded scaffolds were cultured for up to 21 days. Results showed that blended PEG-DA scaffolds could achieve over tenfold range in elastic modulus (5.3±0.9 to 74.6±1.5 kPa). 3D printing times for valve conduits with mechanically contrasting hydrogels were optimized to 14 to 45 min, increasing linearly with conduit diameter. Larger printed valves had greater shape fidelity (93.3±2.6, 85.1±2.0 and 73.3±5.2% for 22, 17 and 12 mm ID porcine valves; 89.1±4.0, 84.1±5.6 and 66.6±5.2% for simplified valves). PAVIC seeded scaffolds maintained near 100% viability over 21 days. These results demonstrate that 3D hydrogel printing with controlled photocrosslinking can rapidly fabricate anatomical heterogeneous valve conduits that support cell engraftment. PMID:22914604
Hockaday, L A; Kang, K H; Colangelo, N W; Cheung, P Y C; Duan, B; Malone, E; Wu, J; Girardi, L N; Bonassar, L J; Lipson, H; Chu, C C; Butcher, J T
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.
The safety and efficacy of transcatheter aorticvalve replacement procedures are directly related to proper imaging. This report revisits the existing noninvasive and invasive approaches that have concurrently evolved to meet the demands for optimal selection and guidance of patients undergoing transcatheter aorticvalve replacement. The authors summarize the published evidence and discuss the strengths and pitfalls of echocardiographic, computed tomographic, and calibrated aortic balloon valvuloplasty techniques in sizing the aorticvalve annulus. Specific proposals for 3-dimensional tomographic reconstructions of complex 3-dimensional aortic root anatomy are provided for reducing intermodality variability in annular sizing. Finally, on the basis of the sizing approaches discussed in this review, the authors provide practical recommendations for balloon-expandable and self-expandable prostheses selection. Strategic use of echocardiographic, multislice computed tomographic, and angiographic data may provide complementary information for determining the anatomical suitability, efficacy, and safety of the procedure. PMID:23489539
Kasel, Albert M; Cassese, Salvatore; Bleiziffer, Sabine; Amaki, Makoto; Hahn, Rebecca T; Kastrati, Adnan; Sengupta, Partho P
We describe a modified valve-sparing aortic root replacement technique for acute type A aortic dissection. After the normal root geometry was restored by removing blood and clots in the proximal false lumen and the valve insufficiency was corrected by simple resuspension of the aortic commissures, three teardrop-shaped patches were sutured inside the sinuses as neointima and then in situ coronary buttons were connected to the small holes created in the corresponding patches. Our initial application showed that this modified valve-sparing aortic root replacement technique is an easy and effective way to restore the geometry of the aortic root and avoid bleeding during surgery for acute type A dissection. PMID:22743079
Left ventricular outflow tract pseudoaneurysm is a rare but a potentially lethal complication, mainly after aortic root endocarditis or surgery. Usually, it originates from a dehiscence in the mitral-aortic intervalvular fibrosa and arises posteriorly to the aortic root. We report a rare case of a patient with cardiac tamponade due to left ventricular pseudoaneurysm after aorticvalve replacement. The subsequent surgical resection was performed successfully. PMID:23439359
Baydar, Onur; Co?kun, Ugur; Balaban, Betul; Cetin, Gurkan; Firatli, Inci; Ersanli, Murat Kazim; Kucukoglu, Mehmet Serdar
Mechanical aorticvalve dysfunction is a very rare event and is usually due to thrombosis, pannus overgrowth, or both. BioGlue as a cause for such a complication has been reported only occasionally. We describe a case of a 63-year-old woman who underwent operation for symptomatic tight aortic stenosis. After implantation of an aorticvalve (AGN-751, size 19; St. Jude Medical, St. Paul, MN, USA) because of a transverse tear of the aortic wall above the annulus occurring during the suturing of the aortotomy, a triangular Vascutek Dacron patch (Vascutek/Terumo, Inchinnan, Scotland, UK) was included. To secure hemostasis, BioGlue (CryoLife, Kennesaw, GA, USA) was applied. A transthoracic echocardiography (TTE) examination performed after signs of ischemia appeared in the electrocardiogram on postoperative day 5 revealed an aortic transvalvular gradient of 74/38 mm Hg and a functional valve area of 1.0 cm2. No coronary lesions were revealed in a coronarography evaluation, but cinefluoroscopy (CF) examination revealed immobility of 1 valve leaflet. The reoperation revealed a thick, rough layer of the glue on the inner side of the patch. This glue had run down to the valve, blocking a mechanical leaflet. Cleaning the valve was not possible, and the valve had to be changed. The subsequent postoperative course was uneventful. The transvalvular gradient was 39/20 mm Hg, and the functional valve area was 1.2 cm2. We believe that the use of BioGlue and other surgical sealants is justified to secure complex suture lines and for maintaining hemostasis in cardiac surgery, but some precautionary rules must be respected. Authors have indicated that the glue enters through the needle holes in such cases, but our findings suggest it can also pass to the Dacron patch itself. CF is superior to TTE and transesophageal echocardiography for analyzing movement of the mechanical valve leaflet, and cardiac catheterization is rarely needed. PMID:23262046
A 32-year-old pregnant woman was referred at 33 weeks' gestation for prenatal ultrasound demonstrating fetal hydrops due to absent aorticvalve with free aorticvalve insufficiency. Elective caesarian section at 34 week's gestation was performed. Surgical intervention was planned immediately after labor at which time mitral valve closure and atrial septostomy using cardiopulmonary bypass would be performed. However, before insertion of the cannula for cardiopulmonary bypass, a gush of air from the right atrium was noted. The surgical procedure was abandoned because systemic air embolism was suspected. The child died 2 h after birth. Autopsy showed absent aorticvalve with closed foramen ovale and left-ventricular hypertrophy. Microscopic findings showed pulmonary and systemic lymphangiectasis, which caused the introduction of air into systemic venous system by way of lymphatic duct just after birth. PMID:21455752
Klebsiella endocarditis rarely affects the native valve especially in the immunocompromised and the elderly. We report a case of Klebsiella endocarditis in a 60-year-old man who had a nidus of infection on the aorticvalve which led to severe aortic regurgitation. This possibly spread to the anterior mitral leaflet (AML) leading to AML perforation therefore causing moderate mitral regurgitation. The reason for this suspicion was that there was perforation of the AML in the absence of vegetation. Noteworthy is that he was asymptomatic apart from generalised fatigue. This case draws our attention to the nature of Klebsiella valvular affection due to the fact that it had bitten the aortic and mitral valve silently and compelled the patient to undergo double valve replacement without having a prolonged duration of symptomatic illness thereby calling for high suspicion especially in individuals in the extremes of ages where the symptoms are less-guiding than the signs. PMID:24057412
Srinivas, K H; Sharma, Rajni; Agrawal, Navin; Manjunath, C N
BACKGROUND: Transcatheter aorticvalve implantation plays a leading role in the management of aortic stenosis in patients with comorbidities but no data are available about cardiac rehabilitation in these subjects. This study aimed to compare safety and efficacy of an early, exercise-based, cardiac rehabilitation programme in octogenarians after a traditional surgical aorticvalve replacement versus transcatheter aorticvalve implantation. METHODS: Seventy-eight consecutive transcatheter aorticvalve implantation patients were studied in order to evaluate the effect of an exercise-based cardiac rehabilitation programme in comparison to 80 of a similar age having surgical aorticvalve replacement. Functional capacity was assessed by a 6?min walking test on admission and at the end of the programme. When possible, a cardiopulmonary exercise test was also performed before discharge. RESULTS: The two groups were similar in terms of gender and length of stay in cardiac rehabilitation; as expected, the transcatheter aorticvalve implantation group had more comorbidities but no major complications occurred in either group during rehabilitation. All patients enhanced autonomy and mobility and were able to walk at least with the assistance of a stick. In those patients who were able to perform the 6?min walking test, the distance walked at discharge did not significantly differ between the groups (272.7?±?108 vs. 294.2?±?101?m, p?=?0.42), neither did the exercise capacity assessed by cardiopulmonary exercise test (peak-VO2 12.5?±?3.6 vs. 13.9?±?2.7?ml/kg/min, p?=?0.16). CONCLUSIONS: Cardiac rehabilitation is feasible, safe and effective in octogenarian patients after transcatheter aorticvalve implantation as well as after traditional surgery. An early cardiac rehabilitation programme enhances independence, mobility and functional capacity and should be highly encouraged. PMID:23757283
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
The transcatheter route is an emerging approach to treating valvular disease in high-risk patients. The 1st clinical antegrade transcatheter placement of an aorticvalve prosthesis was reported in 2002. We describe the first retrograde transcatheter implantation of a new aorticvalve prosthesis, in a 62-year-old man with inoperable calcific aortic stenosis and multiple severe comorbidities. Via the right femoral artery, a Cook introducer was advanced into the abdominal aorta. The aorticvalve was crossed with a straight wire, and a pigtail catheter was advanced into the left ventricle to obtain pressure-gradient and anatomic measurements. An 18-mm valvuloplasty balloon was then used to predilate the aorticvalve. Initial attempts to position the prosthetic valve caused a transient cardiac arrest. Implantation was achieved by superimposing the right coronary angiogram onto fluoroscopic landmarks in the same radiographic plane. A balloon-expandable frame was used to deliver the valve. After device implantation, the transvalvular gradient was <5 mmHg. The cardiac output increased from 1 to 5 L/min, and urine production increased to 200 mL/h. The patient was extubated on the 2nd postimplant day. Twelve hours later, he had to be reintubated because of respiratory distress and high pulmonary pressures. His condition deteriorated, and he died of biventricular failure and refractory hypotension on day 5. Despite the severe hypotension, valve function was satisfactory on echo-Doppler evaluation. In our patient, retrograde transcatheter implantation of a prosthetic aorticvalve yielded excellent hemodynamic results and paved the way for further use of this technique in selected high-risk patients.
Paniagua, David; Condado, Jose A.; Besso, Jose; Velez, Manuel; Burger, Bruno; Bibbo, Salvatore; Cedeno, Douglas; Acquatella, Harry; Mejia, Carlos; Induni, Eduardo; Fish, R. David
Background: Calcific aorticvalve disease (CAVD) is a chronic disorder characterized by the mineralization of the aorticvalve and involving fibrosis. Objectives: In this work we sought to determine if the fibrotic component of the remodeling process of CAVD was related to the use of angiotensin-converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs). Methods: In 477 patients with CAVD, the aorticvalve was examined by histology. A semiquantitative score of fibrosis was generated and associations with clinical/cardiometabolic variables examined. In a subset of 103 patients the aorticvalve was available to study the infiltration by inflammatory cells and expression of interleukin-6 (IL-6) by quantitative real-time PCR. Results: The fibrosis score of the aorticvalve was independently related to the hemodynamic severity of CAVD measured by echocardiography. The fibrotic score of the aorticvalve was also related to the expression of IL-6. The use of ARBs but not of ACEi was associated with a lower fibrosis score of the aorticvalve even after correction for covariates. In addition, patients under ARBs had lower aorticvalve inflammation and expression of IL-6. Conclusions: These findings suggest that ARBs may alter the fibrotic process of the aorticvalve in CAVD, possibly by lowering tissue inflammation. PMID:23969418
Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aorticvalve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aorticvalves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aorticvalve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aorticvalve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population. PMID:23674060
During embryogenesis the heart valves develop from undifferentiated mesenchymal endocardial cushions (EC), and activated interstitial cells of adult diseased valves share characteristics of embryonic valve progenitors. Twist1, a class II basic-helix-loop-helix (bHLH) transcription factor, is expressed during early EC development and is downregulated later during valve remodeling. The requirements for Twist1 down-regulation in the remodeling valves and the consequences of prolonged Twist1 activity were examined in transgenic mice with persistent expression of Twist1 in developing and mature valves. Persistent Twist1 expression in the remodeling valves leads to increased valve cell proliferation, increased expression of Tbx20, and increased extracellular matrix (ECM) gene expression, characteristic of early valve progenitors. Among the ECM genes predominant in the EC, Col2a1 was identified as a direct transcriptional target of Twist1. Increased Twist1 expression also leads to dysregulation of fibrillar collagen and periostin expression, as well as enlarged hypercellular valve leaflets prior to birth. In human diseased aorticvalves, increased Twist1 expression and cell proliferation are observed adjacent to nodules of calcification. Overall, these data implicate Twist1 as a critical regulator of valve development and suggest that Twist1 influences ECM production and cell proliferation during disease.
Chakraborty, Santanu; Wirrig, Elaine E.; Hinton, Robert B.; Merrill, Walter H.; Spicer, Douglas B.; Yutzey, Katherine E.
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
The aim of the study was to investigate the multi-factorial phenomenon of possible postoperative thrombocytopenia after aorticvalve replacement (AVR) with the freedom SOLO (FS) bioprosthesis. A total of 254 patients underwent AVR with FS bioprosthesis in two cardiac surgery institutes. Platelet counts were measured preoperatively, immediately postoperatively and daily until the 11th day postoperatively. A multivariate generalized estimating equation model was applied to identify prognostic factors for whether or not patients postoperative platelet counts indicated no thrombocytopenia (platelet count >150 × 103/mm3) versus at least mild thrombocytopenia (?150 × 103/mm3). Preoperatively, 11.2% of patients showed thrombocytopenia. The preoperative platelet count averaged 233.0 ± 83.2 × 103/mm3. The postoperative mean of platelet counts decreased daily reaching a minimum mean of 88.4 ± 58.8 × 103/mm3 3 days after surgery and then started to increase, with the Day 11 postoperative mean of 173.3 ± 51.8 × 103/mm3. Compared with patients with no preoperative thrombocytopenia, patients with preoperative thrombocytopenia had an 8.69 increased odds of being in the group with postoperative platelet count <150 × 103/mm3. No major haemorrhagic or thromboembolic event was reported during hospitalization. This study shows that thrombocytopenia after the FS bioprosthesis replacement is a transient postoperative phenomenon, largely resolved within a few days after surgery, with no clinical consequences and haemodynamic dysfunction.
An 89-year-old woman with severe aortic stenosis underwent transfemoral aorticvalve replacement. The postoperative course was uneventful except transient bradycardia immediately after the procedure. Echocardiographic finding showed excellent valvular function. After discharge, the patient died suddenly. Autopsy findings showed compression of the atrioventricular conduction system region at the septum by the stent strut. Microscopic examination showed atrophy of the conduction fibers with eosinophilic degeneration of the cytoplasm or coagulation necrosis with pyknosis in the bundle of His and the left bundle branch. Compression by the stent strut triggering dysfunction of the conduction system could have caused fatal arrhythmic event. PMID:23277347
Since the first report by Cooley and colleagues in 1975 [Cooley DA, Norman JC, Mullins CE, Grace R. Left ventricle to abdominal aorta conduit for relief of aortic stenosis. Cardiovasc Dis 1975;2:376-83], an apicoaortic valved conduit bypass has been usually administrated to selected patients presenting with certain clinical conditions or complications such as aortic stenosis associated with porcelain aorta, unclampable atherosclerotic aorta, resternotomy, or previous coronary bypass surgery. On the other hand, thoracic endovascular aortic repair for various aortic lesions has become a promising and less invasive therapy. We encountered a critical case of a patient suffering from aortic graft stenosis due to malformation of a previous thoracic endovascular aortic repair procedure originally performed for acute type A aortic dissection. Because of a deep sternal wound infection, apicoaortic valved conduit bypass from the left ventricular apex to the abdominal aorta was successfully performed. PMID:23272850
To reconstruct the aortic root for aneurysm of the ascending aorta accompanied by aortic regurgitation, annuloaortic ectasia (AAE) and acute type-A dissection with root destruction, the Bentall operation using a prosthetic valve still is the standard procedure today. Valve-sparing procedures have actively been used for aortic root lesions, and have also been attempted in aortic root reconstruction for Marfan syndrome which may have abnormalities in the valve leaflets. We conducted a valve-sparing procedure in a female patient with Marfan syndrome who had AAE accompanied by type-A acute aortic dissection. The patient was a 37-year-old woman complaining of severe pain from the chest to the back. The limbs were long, and funnel breast was observed. Diastolic murmurs were heard. On chest computed tomography, a dissection cavity was present from the ascending aorta to the left common iliac artery, and the root dilated to 55 mm. Grade II aortic regurgitation was observed on ultrasound cardiography. Regarding her family history, her father had died suddenly at 54 years of age. She was diagnosed with type-A acute dissection concurrent with Marfan syndrome and AAE. The structure of the aorticvalve was normal, and root reconstruction by a valve-sparing operation and total replacement of the aortic arch was conducted. On postoperative ultrasound cardiography, the aortic regurgitation was within the allowable range, and the shortterm postoperative results were good. PMID:21302234
Valvular disease is estimated to account for as many as 20% of cardiac surgical procedures performed in the United States. It may be congenital in origin or secondary to another disease process. One congenital anomaly, bicuspid aorticvalve, is associated with increased incidence of stenosis, regurgitation, endocarditis, and aneurysmal dilatation of the aorta. A bicuspid valve has two cusps instead of the normal three; resultant fusion or poor excursion of the valve leaflets may lead to aortic stenosis, the presence of which is signaled by dephasing jets on magnetic resonance (MR) images. Surgery is generally recommended for patients with severe stenosis who are symptomatic or who have significant ventricular dysfunction; transcatheter aorticvalve implantation (TAVI) is an emerging therapeutic option for patients who are not eligible for surgical treatment. Computed tomography (CT) is an essential component of preoperative planning for TAVI; it is used to determine the aortic root dimensions, severity of peripheral vascular disease, and status of the coronary arteries. Aortic regurgitation, which is caused by incompetent closure of the aorticvalve, likewise leads to the appearance of jets on MR images. The severity of regurgitation is graded on the basis of valvular morphologic parameters; qualitative assessment of dephasing jets at Doppler ultrasonography; or measurements of the regurgitant fraction, volume, and orifice area. Mild regurgitation is managed conservatively, whereas severe or symptomatic regurgitation usually leads to valve replacement surgery, especially in the presence of substantial left ventricular enlargement or dysfunction. Bacterial endocarditis, although less common than aortic stenosis and regurgitation, is associated with substantial morbidity and mortality. Electrocardiographically gated CT reliably demonstrates infectious vegetations and benign excrescences of 1 cm or more on the valve surface, allowing the assessment of any embolic complications. PMID:22977027
Bennett, Christopher J; Maleszewski, Joseph J; Araoz, Philip A
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.
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
Excellent clinical results with pulmonary autografts and experimental evidence that pulmonary valves can withstand the higher stress in the systemic circulation led us to use the cryopreserved pulmonary allograft for aorticvalve replacement. From September 1988 until March 1993, 126 consecutive patients (61 +/- 10 years; 74 men and 52 women) underwent aorticvalve replacement with a cryopreserved pulmonary allograft. All allografts were inserted freehand in the subcoronary position. There were four in-hospital deaths (3.2%), and 1 patient had severe valvular incompetence immediately postoperatively, requiring reoperation after 4 weeks. One hundred twenty-one patients were followed up in 3- to 6-month intervals for 25.3 +/- 16.3 months (range, 6 to 66 months), and valve performance was assessed routinely by means of color-flow Doppler echocardiography. Nine patients (7.1%) died during follow-up. Two patients died of multiple septic emboli during bacterial endocarditis, and 1 patient died of a massive stroke. The other 6 patients died of myocardial infarction (4), respiratory insufficiency due to chronic obstructive lung disease (1), and carcinoma (1). Ninety-four patients (78%) had absent or trivial aorticvalve regurgitation. Valvular incompetence class II was present in 3 patients (2.5%), whereas 5 others (4%) demonstrated class II to III. Severe aortic regurgitation (class III or IV) could be detected in 10 patients (8.3%). All underwent reoperation and replacement of the valve with a prosthetic device. Bacterial endocarditis caused graft incompetence in 3 patients, valve degeneration was detected in another 3, and technical mistakes at valve implantation caused valve failure in the other 4.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7646156
Background. The risk of aorticvalve replacement (AVR) after previous coronary artery bypass grafting (CABG) is controversial. Its magnitude influences the threshold for recommending this procedure and has been cited in arguments regarding the optimal management of mild aortic stenosis at primary CABG. We therefore reviewed our experience with reoperative AVR ± CABG and the primary combined procedure.Methods. Between January
Thoralf M Sundt; Suzan F Murphy; Benico Barzilai; Richard B Schuessler; Eric N Mendeloff; Charles B Huddleston; Michael K Pasque; William A Gay
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.
Nascimbene, Angelo; Joggerst, Steven; Reddy, Kota J.; Cervera, Roberto D.; Ott, David A.; Wilson, James M.; Stainback, Raymond F.
Infective endocarditis is a rare but life-threatening complication of heart and heart-lung transplantation. We describe a 32-year-old woman who developed aortic valvular endocarditis following heart-lung transplantation. Enterococcus was the infective organism. The patient's condition was successfully managed using prolonged intravenous antibiotic therapy and aorticvalve replacement. PMID:16387164
Sayeed, R; Drain, A J; Sivasothy, P S; Large, S R; Wallwork, J
The effectiveness of ethanol pretreatment on pre- venting calcification of glutaraldehyde-fixed porcine aortic bioprosthetic heart valve (BPHV) cusps was previously demonstrated, and the mechanism of action of ethanol was attributed in part to both lipid removal and a specific colla- gen conformational change. In the present work, the effect of ethanol pretreatment on BPHV aortic wall calcification was investigated using
Chi-Hyun Lee; Narendra Vyavahare; Robert Zand; Howard Kruth; Frederick J. Schoen; Richard Bianco; Robert J. Levy
Because they had irreversible damage to the left ventricular myocardium none of 12 patients with critical aortic stenosis diagnosed prenatally survived after postnatal treatment. This experience prompted three attempts at intrauterine balloon dilatation of the aorticvalve in two fetuses with this condition. On each attempt the balloon catheter was successfully delivered to the left ventricle. In the first fetus
This study was undertaken to determine whether aorticvalve calcium (AVC) scores measured by electron beam tomography can identify patients with echocardiographically defined aortic stenosis. Electron beam tomography is increasingly being used to detect coronary artery calcium. AVC can also be measured on electron beam tomographic (EBT) scans obtained to screen for coronary calcium. Whether EBT AVC scores correlate with
David M. Shavelle; Matthew J. Budoff; Nediljka Buljubasic; Audrey H. Wu; Junichiro Takasu; Joseph Rosales; Catherine M. Otto; Xue-Qiao Zhao; Kevin D. O’Brien
Objectives We investigated our experience with combined transcatheter aorticvalve implantation (TAVI) and percutaneous coronary intervention\\u000a (PCI) as an alternative strategy in high-risk patients.\\u000a \\u000a \\u000a \\u000a \\u000a Background Combined surgical aorticvalve replacement and coronary artery bypass grafting are the gold standard treatment for patients\\u000a with aortic stenosis and concomitant coronary artery disease. However, a substantial share of patients is unfit for surgery\\u000a due to
Lenard Conradi; Moritz Seiffert; Olaf Franzen; Stephan Baldus; Johannes Schirmer; Thomas Meinertz; Hermann Reichenspurner; Hendrik Treede
Preventive surgical repair of the moderately dilated ascending aorta/aortic root in patients with bicuspid aorticvalve (BAV) is controversial. Most international reference centers are currently proposing a proactive approach for BAV patients with a maximum ascending aortic/root diameter of 45?mm since the risk of dissection/rupture raises significantly with an aneurysm diameter >50?mm. Current guidelines of the European Society of Cardiology (ESC) and the joint guidelines of the American College of Cardiology (ACC)/American Heart Association (AHA) recommend elective repair in symptomatic patients with dysfunctional BAV (aortic diameter ?45?mm). In asymptomatic patients with a well-functioning BAV, elective repair is recommended for diameters ?50?mm, or if the aneurysm is rapidly progressing (rate of 5?mm/year), or in case of a strong family history of dissection/rupture/sudden death, or with planned pregnancy. As diameter is likely not the most reliable predictor of rupture and dissection and the majority of BAV patients may never experience an aortic catastrophe at small diameters, an overly aggressive approach almost certainly will put some patients with BAV unnecessarily at risk of operative and early mortality. This paper discusses the indications for preventive, elective repair of the aortic root, and ascending aorta in patients with a BAV and a moderately dilated—or ectatic—ascending aorta.
Etz, Christian D.; Misfeld, Martin; Borger, Michael A.; Luehr, Maximilian; Strotdrees, Elfriede; Mohr, Friedrich-Wilhelm
An understanding of how mechanical forces impact cells within valve leaflets would greatly benefit the development of a tissue-engineered heart valve. Previous studies by this group have shown that exposure to constant static pressure leads to enhanced collagen synthesis in porcine aorticvalve leaflets. In this study, the effect of cyclic pressure was evaluated using a custom-designed pressure system. Different
Yun Xing; James N. Warnock; Zhaoming He; Stephen L. Hilbert; Ajit P. Yoganathan
Transcatheter aorticvalve implantation with the self-expandable CoreValve (CV) and the balloon-expandable Edwards SAPIEN (ES) bioprostheses has been widely used for the treatment of severe aortic stenosis. However, a direct comparison of the hemodynamic results associated with these 2 prostheses is lacking. The aim of the present study was to compare the hemodynamic performance of both bioprostheses. A total of 41 patients who underwent transcatheter aorticvalve implantation with the CV prosthesis were matched 1:1 for prosthesis size (26 mm), aortic annulus size, left ventricular ejection fraction, body surface area, and body mass index with patients who underwent transcatheter aorticvalve implantation with the ES prosthesis. Doppler-echocardiographic data were prospectively collected before the intervention and at hospital discharge, and all examinations were sent to, and analyzed in, a central echocardiography core laboratory. The mean transprosthetic residual gradient was lower (p = 0.024) in the CV group (7.9 ± 3.1 mm Hg) than in the ES group (9.7 ± 3.8 mm Hg). The effective orifice area tended to be greater in the CV group (1.58 ± 0.31 cm(2) vs 1.49 ± 0.24 cm(2), p = 0.10). The incidence of severe prosthesis-patient mismatch was, however, similar between the 2 groups (effective orifice area indexed to the body surface area ?0.65 cm(2)/m(2); CV 9.8%, ES 9.8%, p = 1.0). The incidence of paravalvular aortic regurgitation was greater with the CV (grade 1 or more in 85.4%, grade 2 or more in 39%) than with the ES (grade 1 or more in 58.5%, grade 2 or more in 22%; p = 0.001). The number and extent of paravalvular leaks were greater in the CV group (p <0.01 for both comparisons). In conclusion, transcatheter aorticvalve implantation with the CV prosthesis was associated with a lower residual gradient but a greater rate of paravalvular aortic regurgitation compared to the ES prosthesis. The potential clinical consequences of the differences in hemodynamic performance between these transcatheter heart valves needs to be addressed in future studies. PMID:23351465
The objective of this study was to develop a patient-specific computational model to quantify the biomechanical interaction between the transcatheter aorticvalve (TAV) stent and the stenotic aorticvalve during TAV intervention. Finite element models of a patient-specific stenotic aorticvalve were reconstructed from multi-slice computed tomography (MSCT) scans, and TAV stent deployment into the aortic root was simulated. Three initial aortic root geometries of this patient were analyzed: (a) aortic root geometry directly reconstructed from MSCT scans, (b) aortic root geometry at the rapid right ventricle pacing phase, and (c) aortic root geometry with surrounding myocardial tissue. The simulation results demonstrated that stress, strain, and contact forces of the aortic root model directly reconstructed from MSCT scans were significantly lower than those of the model at the rapid ventricular pacing phase. Moreover, the presence of surrounding myocardium slightly increased the mechanical responses. Peak stresses and strains were observed around the calcified regions in the leaflets, suggesting the calcified leaflets helped secure the stent in position. In addition, these elevated stresses induced during TAV stent deployment indicated a possibility of tissue tearing and breakdown of calcium deposits, which might lead to an increased risk of stroke. The potential of paravalvular leak and occlusion of coronary ostia can be evaluated from simulated post-deployment aortic root geometries. The developed computational models could be a valuable tool for pre-operative planning of TAV intervention and facilitate next generation TAV device design.
The objective of this study was to develop a patient-specific computational model to quantify the biomechanical interaction between the transcatheter aorticvalve (TAV) stent and the stenotic aorticvalve during TAV intervention. Finite element models of a patient-specific stenotic aorticvalve were reconstructed from multi-slice computed tomography (MSCT) scans, and TAV stent deployment into the aortic root was simulated. Three initial aortic root geometries of this patient were analyzed: (a) aortic root geometry directly reconstructed from MSCT scans, (b) aortic root geometry at the rapid right ventricle pacing phase, and (c) aortic root geometry with surrounding myocardial tissue. The simulation results demonstrated that stress, strain, and contact forces of the aortic root model directly reconstructed from MSCT scans were significantly lower than those of the model at the rapid ventricular pacing phase. Moreover, the presence of surrounding myocardium slightly increased the mechanical responses. Peak stresses and strains were observed around the calcified regions in the leaflets, suggesting the calcified leaflets helped secure the stent in position. In addition, these elevated stresses induced during TAV stent deployment indicated a possibility of tissue tearing and breakdown of calcium deposits, which might lead to an increased risk of stroke. The potential of paravalvular leak and occlusion of coronary ostia can be evaluated from simulated post-deployment aortic root geometries. The developed computational models could be a valuable tool for pre-operative planning of TAV intervention and facilitate next generation TAV device design. PMID:22698832
Background: The evaluation of prosthetic valves is very difficult with two-dimensional transthoracic echocardiography alone. Doppler and color flow imaging as well as transesophageal echocardiography are more reliable to detect prosthetic valve dysfunction. However, Doppler study sometimes tends to be misleading due to the load-depending characteristics of peak and mean pressure gradients. The peak-to-mean pressure decrease ratio is a load-independent measure, which was previously used for the detecting and grading of aorticvalve stenosis. We assessed the usefulness of this method for the evaluation of aorticvalve prosthesis obstruction. Methods: One hundred fifty-four patients with aorticvalve prostheses were included in this study. Transthoracic and transesophageal echocardiographic examinations were performed in all the patients. Peak velocity and velocity time integral of the aorticvalve and left ventricular outflow tract, peak and mean aorticvalve pressure gradients, peak-to-mean pressure gradient ratio, and time velocity integral (TVI) index were measured. Results: There was a significant relation between the TVI index (p value < 0.001) and aortic prosthesis obstruction. A TVI index < 0.2 had a sensitivity of 71% and specificity of 100% for the detection of aorticvalve prosthesis obstruction. However, no significant relation was found between the peak-to-mean pressure ratio and aorticvalve prosthesis obstruction (p value = 0.09). Conclusion: Although the peak-to-mean pressure gradient (PG/MG) ratio is a simple, quick, and load-independent method which may be useful for the grading of aorticvalve stenosis, it is poorly associated with aorticvalve prosthesis obstruction. The TVI index is a useful measure for the detection of aortic prosthesis obstruction.
The durability of the aorticvalve after aortic root reconstruction by an aorticvalve-sparing procedure is of particular concern because of the absence of the sinuses of Valsalva in the David type-I reimplantation method. Various improvements have been made to the David-I method. In particular, a new aortic root conduit with the sinuses of Valsalva was developed recently and is expected to improve the long-term follow-up results of the aorticvalve-sparing procedures. We used a Valsalva graft in two patients with aortic root dilation accompanied by aortic regurgitation and obtained good short-term results. PMID:21302229
A simplified technique has been used to enlarge the aortic annulus in a series of 13 patients undergoing aorticvalve replacement. The procedure basically consists of extending the aortotomy incision into the aortic annulus by dividing the commissure between the left and noncoronary sinuses, without involving the anterior mitral leaflet. Wide opening of the commissure is obtained and the resulting defect is closed, preferably using a patch of bovine pericardium sutured to the mitral annulus and aortic wall. This technique is simple, reproducible, avoids opening of the left atrium (reducing the potential bleeding sites), allows insertion of a prosthesis at least two sizes larger than the original annulus, and is also applicable in cases of mitral-aorticvalve replacement. Our preliminary results are satisfactory and seem to demonstrate that in many patients, even in the young age group, more complex procedures are often unnecessary when enlargement of the aortic annulus is required. PMID:1392231
Bortolotti, U; Mossuto, E; Maraglino, G; Sturaro, M; Milano, A; Livi, U; Stellin, G; Mazzucco, A
Transcatheter aorticvalve implantation is an emergent technique for high risk patients with aortic stenosis. Transcatheter aorticvalve implantation poses significant challenges about its management, due to the procedure itself (i.e. the passage of large stiff sheaths in diseased vessels, the valve dilatation and the prosthesis positioning during a partial cardiac standstill) and the population of elder and high-risk patients who undergo the implantation. Retrograde transfemoral approach is the most popular procedure and a great number of cases is reported. Nevertheless, there is not a consensus regarding the intraoperative anesthesiological strategies, which vary in the different Centers. Sedation plus local anesthesia or general anesthesia are both valid alternatives and can be applied according to patient's characteristics and procedural instances. Most groups started the implantation program with a general anesthesia; indeed, it offers many advantages, mainly regarding the possibility of an early diagnosis and treatment of potential complications, through the use of the transesophageal echocardiography. However, after the initial experiences, many groups began to employ routinely sedation plus local anesthesia for transcatheter aorticvalve implantation and their procedural and periprocedural success demonstrates that it is feasible, with many possible advantages. Many aspects about perioperative anesthetic management for transcatheter aorticvalve implantation are still to be defined. Aim of this work is to clarify the different management strategies through a review of the available literature published in pubmed till June 2011. PMID:23440259
Ruggeri, L; Gerli, C; Franco, A; Barile, L; Magnano di San Lio, M S; Villari, N; Zangrillo, A
A new valved conduit was developed using a canine aorticvalve. The bioprosthetic valve was fixed with glutaraldehyde and epoxy compound (Denacol-EX313/810). A vascular graft composed of ultra-fine polyester fiber (10 mm in diameter, 200 mm in length) was used. Four dogs underwent apico-aorticvalved conduit (AAVC) implantation and aortic banding (bypass group, BG), while another 4 dogs underwent aortic banding without AAVC implantation (control group, CG). Cardiac catheterization and angiocardiography were performed for assessment of hemodynamics 2 weeks and 6 months after surgery. Left ventricular systolic pressure, left ventricular end-diastolic pressure and the left ventricular-aortic pressure gradient differed significantly (P<0.01) between the BG and CG dogs. Left ventricular angiocardiography showed patency of the valved conduit in all the BG dogs. Echocardiography was performed before and 2, 4 and 6 months after surgery, and showed that while pressure overload caused concentric myocardial hypertrophy in the CG dogs, the left ventricle dilated eccentrically in the BG dogs. Furthermore, relief of left ventricular pressure overload by AAVC was maintained. PMID:15876784
Transcatheter aorticvalve replacement (TAVR) is an effective treatment option for patients with severe aortic stenosis who are at high surgical risk because of multiple comorbidities. Many of these patients have been treated with pacemakers for concomitant conduction disease. The combination of severe aortic stenosis, cardiomyopathy, and conduction abnormalities results in a state of low cardiac output. Here, we report 2 complex TAVR cases where Doppler echocardiography was used to guide adjustment of device settings, leading to improved cardiac hemodynamic profiles. PMID:23627861
Prosthetic aorticvalve replacement in the small aortic root raises concerns of its long-term effects. Between 1978 and 1994, 270 patients received only small aortic prostheses (? 21 mm). There were 117 men (43.3%) and 153 women (56.7%) with a mean age of 64.3 ± 11.6 years (range 19 to 87 years). The body surface areas ranged from 1.2 to
Dilip Sawant; Arun K. Singh; William C. Feng; Arthur A. Bert; Fred Rotenberg
Background. The entire experience with the Hancock modified orifice porcine bioprosthetic aorticvalve from 1976 to 1996 at the Brigham and Women’s Hospital has been reviewed. Eight hundred forty-three patients received this valve with a total follow-up of 61,114 months, and a mean follow-up of approximately 72.5 months. There were 490 men and 353 women, and the predominate lesion was
Lawrence H Cohn; John J Collins; Robert J Rizzo; David H Adams; Gregory S Couper; Sary F Aranki
Objective: Trans-apical aorticvalve implantation (TA-AVI) using the Edwards SAPIEN™ prosthesis has evolved to a routine procedure for selected high-risk elderly patients. In rare cases, misplacement of the SAPIEN™ valve (too low a position), dysfunction of the leaflets or perforation of the interventricular septum (ventricular septal defect, VSD) occurs and requires immediate implantation of a second prosthesis within the first
Jörg Kempfert; Ardawan J. Rastan; Gerhard Schuler; Axel Linke; David Holzhey; Arnaud van Linden; Friedrich-W. Mohr; Thomas Walther
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: firstname.lastname@example.org; 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)
Sirs: Sinus of Valsalva aneurysm is a rare congenital anomaly. The essential lesion is a lack of continuity between the aortic media and the annulus fibrosus . There is also an acquired form of weakness in the sinus due to excessive debridement of a calcified aortic annulus during valve replacement or if a systolic jet from a malpositioned mechanical valve
Background Cardiac computed tomography angiography (CTA) is feasible for aorticvalve evaluation, but retrospective gated protocols required high radiation doses for aorticvalve assessment. A prospectively triggered adaptive systolic (PTAS) cardiac CT protocol was recently described in arrhythmia using second-generation dual-source CT. In this study, we sought to evaluate the feasibility of PTAS CTA to assess the aorticvalve at a low radiation dose. Findings A retrospective cohort of 29 consecutive patients whom underwent PTAS protocols for clinical indications other than aorticvalve assessment and whom also received echocardiography within 2 months of CT, was identified. Images were reviewed for aorticvalve morphology (tricuspid/bicuspid/prosthetic) and stenosis (AS) by experienced blinded readers. Accuracy versus echocardiography and radiation doses were assessed. All PTAS coronary CTAs were clinically diagnostic with 0 un-evaluable coronary segments. The accuracy of PTAS for aorticvalve morphology was 92.6%, and for exclusion of severe AS was 93.1%. Two exams were un-evaluable for the aorticvalve due to inadequate number of phases archived for interpretation. Total radiation dose was a median of 2.8 mSv (interquartile range 1.4–4.4 mSv). Conclusions PTAS CTA protocols using second-generation dual-source CT for aorticvalve evaluation are feasible at low doses. This protocol should be investigated further in larger cohorts.
Objectives: An increasing number of elderly patients develop aorticvalve disease requiring surgery. Operative risk scores are currently used to identify patients at high operative risk who may benefit from interventional treatment options. The aim of this study was to analyze the predictive value of these risk scores in geriatric patients undergoing aorticvalve replacement. Methods: We reviewed data of
Birgit Frilling; Wolfgang von Renteln-Kruse; Friedrich-Christian Rie?
Transcatheter aorticvalve replacement (TAVR) is a procedure whose technique and devices are evolving rapidly, facilitating increased safety and efficacy. However, there remain challenging cases. Considering the concept of crossing a bulky prosthesis through a calcified and narrowed aorticvalve, it seems not unexpected that some of these procedures have difficulty. This is in fact rare, but can occur and demands special techniques, since the commercially available balloon-expandable prosthesis and its iterations are not retrievable when inserted into the body. The buddy-balloon technique for TAVR has a similar rationale. Sheiban et al reported the buddy-balloon technique as a solution to failed aorticvalve crossing, but it is not widely used, particularly in many lower-volume centers starting to perform TAVR. We report two cases that were effectively treated with the help of this technique. PMID:23995722
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
Ferrari, Enrico; Van Steenberghe, Mathieu; Namasivayam, Jegaruban; Berdajs, Denis; Niclauss, Lars; von Segesser, Ludwig Karl
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.
Operative treatment of acute valve endocarditis with paravalvular abscess remains a surgical challenge. The aim of the study was gaining insights into the influence of our surgical strategy on the short- and midterm results. Over a period of 7 years 18 patients underwent surgical treatment of a paravalvular abscess accompanying their acute aorticvalve endocarditis. All patients ranged preoperative in the NYHA class IV. Eleven patients suffered from native and 7 from prosthetic aorticvalve endocarditis. Staphylococcus aureus was found to have caused the infection in 50% of the cases. Surgical therapy consisted in all patients of thorough resection of the infected tissue followed by reconstruction of the defect with the aid of autologus pericardial patch and replacement of the aorticvalve using a prosthesis. Although the rate of complications continued high early lethality remained at 5.5%. Midterm results proved to be very good with a follow-up of 44 month. Both lethality and the reoperation rate stayed at 0%. The operative risk of acute aorticvalve endocarditis with paravalvular abscess is high but acceptable. Should a paravalvular abscess be diagnosed during a case of endocarditis urgent surgical therapy is highly advisable even there is only a minor deterioration of the patient' clinical state. Radical abscess debridement in combination with exclusion of the place of resection from circulation using an autologus pericard patch is a necessary condition for achieving good results. PMID:12836457
We represent a successful minimally invasive combined off-pump procedure consisting of a transapical aorticvalve implantation and a direct coronary artery bypass grafting in a woman with a severe aortic stenosis and a critical coronary artery disease. Due to her comorbidities, she was classified as a high-risk patient qualifying for a transcatheter procedure. We performed this combined procedure in a hybrid operation room, starting with the coronary bypass to maintain a coronary blood flow during the transapical valve implantation. The operation processed without any complications and she was discharged at the seventh postoperative day into the allocating hospital. PMID:22436775
Baumbach, Hardy; Adili, Sara; Ursulescu, Adrian; Franke, Ulrich F W
Cell-driven processes are now considered of relevance for the pathogenesis of aortic stenosis. In particular, during calcific valve degeneration, interstitial valve cells (VIC) resident in the leaflet can acquire an osteogenic/pro-calcific profile and actively contribute to matrix mineralization. The proteomic study described in this chapter is undertaken to investigate modifications in the proteome of bovine aortic VIC acquiring a calcifying phenotype. This approach can be useful to clarify cellular pathways involved in VIC pro-calcific differentiation and identify innovative therapeutic targets. PMID:23606251
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.
Comparisons of transcatheter aorticvalve implantation (TAVI) to surgical aorticvalve replacement (SAVR) in patients with severe aortic stenosis remain sparse or limited by a short follow-up. We sought to evaluate early and midterm outcomes of consecutive patients (n = 618) undergoing successful TAVI (n = 218) or isolated SAVR (n = 400) at 2 centers. The primary end point was incidence of Valvular Academic Research Consortium-defined major adverse cerebrovascular and cardiac events (MACCEs) up to 1 year. Control of potential confounders was attempted with extensive statistical adjustment by covariates and/or propensity score. In-hospital MACCEs occurred in 73 patients (11.8%) and was more frequent in patients treated with SAVR compared to those treated with TAVI (7.8% vs 14.0%, p = 0.022). After addressing potential confounders using 3 methods of statistical adjustment, SAVR was consistently associated with a higher risk of MACCEs than TAVI, with estimates of relative risk ranging from 2.2 to 2.6 at 30 days, 2.3 to 2.5 at 6 months, and 2.0 to 2.2 at 12 months. This difference was driven by an adjusted increased risk of life-threatening bleeding at 6 and 12 months and stroke at 12 months with SAVR. Conversely, no differences in adjusted risk of death, stroke and myocardial infarction were noted between TAVI and SAVR at each time point. In conclusion, in a large observational registry with admitted potential for selection bias and residual confounding, TAVI was not associated with a higher risk of 1-year MACCEs compared to SAVR. PMID:22356793
Tamburino, Corrado; Barbanti, Marco; Capodanno, Davide; Mignosa, Carmelo; Gentile, Maurizio; Aruta, Patrizia; Pistritto, Anna Maria; Bonanno, Claudio; Bonura, Salvatore; Cadoni, Alessandra; Gulino, Simona; Di Pasqua, Maria Concetta; Cammalleri, Valeria; Scarabelli, Marilena; Mulè, Massimiliano; Immè, Sebastiano; Del Campo, Giuliana; Ussia, Gian Paolo
OBJECTIVE: The study objective was to evaluate the safety and efficacy of sutureless self-expanding nitinol stent-frame aorticvalve prostheses made of equine pericardium implanted in patients with symptomatic aorticvalve disease. METHODS: We performed a retrospective analysis of 120 patients (mean age, 76.7 ± 5.9 years) who underwent isolated aorticvalve replacement or in combination with other cardiovascular procedures. Preoperatively, Society of Thoracic Surgeons score was determined. Transthoracic echocardiography and clinical outcome evaluation were performed at the time of discharge and at 6, 12, and 18 months follow-up, respectively. RESULTS: A total of 71 of 120 patients underwent isolated sutureless aorticvalve replacement (mean aortic crossclamp time, 37 ± 11 minutes; mean bypass time, 62 ± 18 minutes). Coronary bypass grafting was performed in 30 patients. Overall mean Society of Thoracic Surgeons score was 14.8% ± 10%. Thirty-day mortality rate was 6.7% overall and 1.4% in stand-alone procedures. During a mean follow-up of 313 days, 3 more deaths occurred. The reoperation rate was 4.2%. Mean and peak transvalvular pressure gradients were 9 mm Hg (4-13 mm Hg) and 14 mm Hg (8-22 mm Hg) at discharge, respectively. In 8 patients (6.7%), permanent pacemaker implantation was necessary. No thromboembolic events or bleedings related to the bioprosthesis were observed. CONCLUSIONS: In this large single-center experience with sutureless aorticvalve replacement, the surgical procedure is shown to be safe and time-saving. In view of the excellent hemodynamic results and shortening of aortic crossclamp and bypass times, we notice advantages especially in high-risk patients. Minimally invasive access seems to be facilitated. The long-term durability of this prosthesis has yet to be determined. PMID:23473011
Eichstaedt, Harald C; Easo, Jerry; Härle, Tobias; Dapunt, Otto E
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
Valvular heart disease in systemic lupus erythematosus (SLE) is associated with substantial morbidity and mortality. Current therapy includes symptomatic measures and valve replacement. SLE can present major challenges because of accrued organ damage, coagulation defects and complex management regimes. The peri-operative goals are to maintain strict asepsis, avoid use of nephrotoxic drugs and thereby renal insult, and to promote early ambulation post-operatively.
Kansara, Bhuvnesh; Singh, Ajmer; Karlekar, Anil; Mishra, Yugal K
Introduction: In order to improve the prognosis, repair of severe mitral regurgitation should be undertaken at the same time as aorticvalve replacement in patients with severe aorticvalve stenosis. However, mitral regurgitation may be secondary to pressure overload or ventricular dysfunction and improve after surgery. Aim: To assess the incidence of non-severe functional mitral regurgitation before and after isolated
Juan Caballero-Borrego; Juan José Gómez-Doblas; Fernando Cabrera-Bueno; José Manuel García-Pinilla; José María Melero; Carlos Porras; Eduardo Olalla; Eduardo De Teresa Galván
The aim of this study was to define the clinical, echocardiographic, and pathologic correlates of commissural dehiscence of aortic wall from the stent post of the porcine bioprostheses in the mitral position. This form of valve degeneration was found in 5 of 23 explanted mitral bioprostheses. A thickened, separated aortic wall at multiple commissural sites along with other evidence of
Tasneem Z Naqvi; Robert J Siegel; Neil A Buchbinder; Michael C Fishbein
Stroke is a devastating complication after transcatheter aorticvalve implantation (TAVI) and might partially be related to cardiac embolization. The aim of this single-center prospective study was to determine the incidence of intracardiac thrombi and left atrial spontaneous echo contrast (SEC), both known predictors of cardiac embolic stroke, in patients referred for potential TAVI. One hundred four consecutive patients with severe symptomatic aorticvalve stenosis and at high or very high risk for surgery were included and underwent transesophageal echocardiography. In 11 patients (10.6%), intracardiac thrombi were detected, and 25 patients (24%) showed dense grade 2 SEC. Atrial fibrillation (p <0.0001), diastolic dysfunction (p = 0.0005), and atrial size (p = 0.0038) were related to the presence of intracardiac thrombus and/or dense SEC on multivariate analysis. In conclusion, the incidence of intracardiac thrombi and dense SEC in (very) high-risk patients with severe aorticvalve stenosis referred for potential TAVI is high and can accurately be detected using transesophageal echocardiography. Systematic thromboembolic evaluation using transesophageal echocardiography is thus recommended in patients referred for TAVI. PMID:23433762
Lenders, Guy D; Paelinck, Bernard P; Wouters, Kristien; Claeys, Marc J; Rodrigus, Inez E; Van Herck, Paul L; Vrints, Christiaan J; Bosmans, Johan M
Aorticvalve replacement with a pulmonary autograft was performed in 24 patients between October 1993 and October 1994, at the All India Institute of Medical Sciences, New Delhi. There were 20 (83.3%) males and 4 (16.7%) females. Their ages ranged from 10 to 56 years (mean, 21.46 +/- 11.45 years). Associated procedures included 10 mitral valve procedures (4 open commissurotomies, 5 mitral valve repairs, and 1 homograft mitral valve replacement) and 1 tricuspid valve repair. There were 4 (16.7%) early deaths, 3 of which were due to bleeding or its sequelae and 1 due to septicemia. There were no late deaths. Follow-up ranged from 1 to 13 months (mean, 198.3 +/- 111.1 days). Nineteen (95%) patients are in New York Heart Association functional class I, and 1 patient (5%) is in class II, due to poor left ventricular function. Only 1 patient showed grade 2/4 aortic regurgitation on follow-up examinations, and none has shown progression of aortic regurgitation. Our early results with the pulmonary autograft are encouraging; however, long-term evaluation is needed.
Kumar, A S; Rao, P N; Dharmapuram, A K; Chander, H; Trehan, H
Within 10 years after transcatheter aorticvalve implantation (TAVI) was first accomplished for treatment of calcified aortic stenosis, this new technology has rapidly evolved to become clinical routine. Today it may be considered standard treatment for inoperable patients with superior outcomes compared to best medical therapy. Furthermore, it represents an alternative therapeutic option compared to surgical aorticvalve replacement in high-risk patients. According to current international guidelines and expert consensus statements, TAVI should be performed as a joint effort by an interdisciplinary heart team to ensure input from multiple skill sets for optimal patient outcome. Major safety concerns include neurologic complications, acute kidney injury, access site complications, procedure-related conduction disturbances, paravalvular leakage valve durability. At present, only one device for transapical TAVI is in widespread clinical use: the Edwards Sapien transcatheter valve (Edwards Lifesciences, Irvine, CA, USA). Recently, however, a number of second generation devices for transapical TAVI have been developed in order to address some of the limitations of first generation valves. In this paper, current data on second generation devices for transapical TAVI will be reviewed and ongoing trials discussed. PMID:23681137
Conradi, L; Seiffert, M; Blankenberg, S; Reichenspurner, H; Diemert, P; Treede, H
Calcification of glutaraldehyde-treated bioprosthetic heart valves is a major cause of long-term failure. We studied porcine aorticvalves treated by the L-Hydro process and implanted into 14 juvenile sheep (group 1). Another 10 sheep were implanted with glutaraldehyde-treated porcine bioprostheses (group 2). The animals were sacrificed after 150 days and the explanted valves were analyzed for calcification. Hemodynamic measurements by echocardiography and angiography were carried out prior to sacrifice. Macroscopic analysis showed calcification and loss of mobility of the leaflets in all group 2 implants and in one group 1 implant. Light microscopy showed foci of calcification in all group 2 implants and in 3 valves from group 1. A significant reduction in the level of calcification was found in porcine bioprostheses treated by the L-Hydro process and implanted into the juvenile sheep model. PMID:17911070
Santos, Paulo C; Gerola, Luís R; Casagrande, Ivan; Buffolo, Enio; Cheung, David T
The closing velocity of the leaflets of mechanical heart valves is excessively rapid and can cause the cavitation phenomenon. Cavitation bubbles collapse and produce high pressure which then damages red blood cells and platelets. The closure mechanism of the trileaflet valve uses the vortices in the aortic sinus to help close the leaflets, which differs from that of the monoleaflet or bileaflet mechanical heart valves which mainly depends on the reverse flow. We used the commercial software program Fluent to run numerical simulations of the St. Jude Medical bileaflet valve and a new trileaflet mechanical heart valve. The results of these numerical simulations were validated with flow field experiments. The closing velocity of the trileaflet valve was clearly slower than that of the St. Jude Medical bileaflet valve, which would effectively reduce the occurrence of cavitation. The findings of this study are expected to advance the development of the trileaflet valve. PMID:22692363
We report a case of thoracic aortic aneurysm and aorticvalve stenosis with chronic renal failure requiring hemodialysis. A 75-year-old man complained of back pain and hoarseness. He had been on dialysis for 15 years. A computed tomography scan of the chest showed marked calcification in the thoracic aortic arch, which is known as a porcelain aorta, and a distal arch aneurysm. Echocardiographic examination showed moderate aorticvalve stenosis with calcification. An operation was scheduled, and both the aorticvalve and the aortic arch aneurysm were successfully replaced with a mechanical valve and a prosthetic graft. Cardiovascular surgery for patients complicated by a porcelain aorta requires extra cares for the establishment of cardiopulmonary bypass and anastomoses of the aorta. PMID:22647336
Bicuspid aorticvalve (BAV) and thoracic aortic aneurysm (TAA) are two discrete cardiovascular phenotypes characterized by latent progressive disease states. There is a clear association between BAV and TAA; however the nature and extent of this relationship is unclear. There are both distinct and overlapping developmental pathways that have been established to contribute to the formation of the aorticvalve and the aortic root, and the mature anatomy of these different tissue types is intimately intertwined. Likewise, human genetics studies have established apparently separate and common contributions to these clinical phenotypes, suggesting complex inheritance and a shared genetic basis and translating 3 patient populations, namely, BAV, TAA, or both, into a common but diverse etiology. A better understanding of the BAV-TAA association will provide an opportunity to leverage molecular information to modify clinical care through more sophisticated diagnostic testing, improved counseling, and ultimately new pharmacologic therapies.
Diverter valve is disclosed for preventing blow-outs in oil wells during the early stages of drilling. The diverter valve has a simplified construction which reduces maintenance problems during use in the field.
Chronic encapsulated mediastinal abscess is an unusual complication of previous open heart surgery. We report on the case of a 79 year old male who presented with epigastric fistulization of an encapsulated anterior mediastinal abscess 12 years after a redo aorticvalve replacement for prosthetic valve endocarditis. The encapsulated abscess and its complex branching tracts and the cutaneous fistula were excised completely except the thin longitudinal strip of the ascending aorta which formed part of the posterior wall of the infected tract. This was covered with transposed greater omentum based on right gastroepiploic artery pedicle. Patient remains fit and well 2 years after his operation. This report is unusual on account of the length of the interval between previous heart surgery and the infective complication, the presumed dormancy of the abscess for as long as 12 years, the complex course, branching tracts and the contents of the abscess, the remote fistulization of the abscess at a distant anatomical site and, finally, the principle of successfully covering an infected tract which formed the adventia of the ascending aorta with pedicled omentum in the hope of avoiding an ascending aortic replacement in a frail 79 year old man. In the entire English language literature, this report represents the longest interval between a heart operation and a sternal or mediastinal abscess
A 26-year-old man with osteogenesis imperfecta and severe aortic regurgitation was scheduled for aorticvalve replacement. As previously described by other authors the operation was difficult owing to the friability and weakness of the tissues. Mean blood losses of 153 mL per hour during the first 7 postoperative hours were observed. Despite normal coagulation indicators the bleeding did not stop
Marc Kastrup; Christian von Heymann; Holger Hotz; Wolfgang F Konertz; Sabine Ziemer; Wolfgang J Kox; Claudia Spies
This patent describes a method of controlling the passage of material through a structure of the type which includes valve body means defining a valve chamber and having an inlet port and an outlet port each communicating between the valve chamber and the exterior of the valve body means; annular inlet seal means in the valve chamber and having an inlet passage therethrough communicating in seal engagement with the inlet port; annular outlet seal means in the valve chamber and having an outlet passage therethrough communicating in sealing engagement with the outlet port; valve member means for controlling the passage of material through the valve body means. The valve member means having a frustoconically shaped outer surface and being disposed within the valve chamber with the frustoconically shaped outer surface in close slidable sealing engagement with the annular outlet seal means and being adapted to rotate about its longitudinal axis within the valve chamber; the method comprising the steps of: (a) introducing fluid generally transversely into the inlet port at a point upstream of the annular inlet seal means; (b) supplying material to the inlet port upstream of the point of introduction of the fluid; and (c) rotating the valve member means relative to the valve body means to block flow of the material and the introduced fluid through the valve body means from the inlet port, and, alternately, to permit flow of the material and the introduced fluid into the valve body means via the inlet port and out of the valve body means via the outlet port.
A description is given of a valve apparatus for use in subterranean well and carriable on a fluid transmission conduit insertable therein, comprising: ball valve head means having camway slot means defined exteriorly theron; valve seat means having camway ball means secured thereto and carriable in said camway slot means to pivot said valve head means on said seat means to shift said appartus between open and closed positions in response to manipulation of said fluid transmission conduit.
Cardiac surgery in patients with previous pneumonectomy is infrequently reported. We report a case of combined coronary artery bypass grafting and aorticvalve replacement in a patient with left ventricular ejection fraction less then 35% and a previous right pneumonectomy. All steps in operative management of this rare condition are discussed. PMID:17685124
Sleilaty, Ghassan; Yazigi, Alexandre; El Asmar, Bechara; Hajj-Chahine, Jamil; Nakad, Joseph; Madi-Jebara, Samia; Aoun-Bacha, Zeina; Badaoui, Georges
There are no experimental studies regarding the prophylactic efficacy of linezolid against infective endo- carditis. Nonbacterial thrombotic endocarditis of the aorticvalve was induced in rabbits by the insertion of a polyethylene catheter. Twenty-four hours later, animals were randomly assigned to a control group, and groups receiving either ampicillin (two doses of 40 mg\\/kg of body weight each, given intravenously,
George Athanassopoulos; Angelos Pefanis; Vissaria Sakka; Dimitrios Iliopoulos; Despina Perrea; Helen Giamarellou
Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aorticvalve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The
The study investigates the mechanical properties of porcine aorticvalve leaflets fixed with a naturally occurring crosslinking agent, genipin, at distinct pressure heads. Fresh and the glutaraldehyde-fixed counterparts were used as controls. Subsequent to fixation, the changes in leaflet collagen crimps and its surface morphology were investigated by light microscopy and scanning electron microscopy (SEM). Also, the crosslinking characteristics of
Hsing-Wen Sung; Yen Chang; Chi-Tung Chiu; Chiun-Nan Chen; Huang-Chien Liang
Objective: Several decellularisation techniques have been developed to produce acellular matrix scaffolds for the purpose of tissue engineering, mostly comprising (non-)ionic detergents or enzymatic extraction methods. However, the effect of chemically induced decellularisation on the major structural and adhesion molecules as well as glycosaminoglycans, and the possible replenishment of lost compounds have escaped attention. Methods: Porcine aorticvalves were treated
Robert W. Grauss; Mark G. Hazekamp; Ferdinand Oppenhuizen; Conny J. van Munsteren; Adriana C. Gittenberger-de Groot; Marco C. DeRuiter
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.
Dobutamine stress testing and Doppler echocardiography were used to assess hemodynamics in 27 patients aged 16 to 54 years with various sizes and types of aorticvalve prosthesis. All patients underwent a symptom-limited treadmill exer- cise test within two days of the dobutamine test. There was no significant difference in ejection fractions and transvalvular gradients at rest and during dobutamine
Nese Ç; Hakan Gerçekoglu; Seden Ç; Metin Gürsürer; Gülsah Tayyareci; Hasan Karabulut; Ahmet Narin; Tuna Tezel; Besim Yigiter
The bicuspid aorticvalve (BAV) is a common congenital cardiac anomaly, having a prevalence of 0.9% to 1.37% in the general population and a male preponderance ratio of 2:1. The recognition of a BAV is clinically relevant because of its association with aortic stenosis or regurgitation, aortic aneurysm or dissection, and infective endocarditis. Although some patients with a BAV may go undetected without clinical complications for a lifetime, the vast majority will require intervention, most often surgery, at some point. In fact, the natural history of BAV is that of valve calcification and progressive stenosis that typically occurs at a faster rate than in tricuspid aorticvalves (AVs). This pattern of presentation supports the hypothesis that shear stress in patients with congenitally abnormal AV may contribute to an earlier leaflet calcification. However, there is emerging research data showing that the valve calcification process might have a similar pathophysiologic process as that of vascular atherosclerosis. This review focuses on the current knowledge of the cellular mechanisms of BAV.
OBJECTIVES: We sought to evaluate the effects of the reimplantation type versus the remodeling type of aorticvalve-sparing technique on the geometry of the same aortic root. METHODS: Fifteen fresh isolated porcine hearts with normal aorticvalves and a standard aortoventricular junction size of 23 mm were processed. An aorticvalve-sparing replacement was performed by reimplanting the native aortic root inside a 28-mm Valsalva graft (Vascutek Ltd, Renfrewshire, UK). Hearts were subsequently implanted with instruments in a test circuit, and the aortic roots were pressurized at a fixed pressure of 100 mm Hg. Diameters of the aortoventricular junction, of the sinuses, and of the sinotubular junction, as well as effective height and coaptation height of aorticvalve leaflets, were measured by echography. Transition from the reimplantation to the remodeling configuration was then achieved by longitudinally cutting the skirt of the graft from the annulus to the top of each commissure. The same measurements were then repeated. RESULTS: After transition from the reimplantation to the remodeling configuration, significant increases in the sizes of the aortoventricular junction and of the sinuses were observed. Effective height and coaptation height significantly decreased, and the rounded cross-sectional profile of the aorticvalve leaflets flattened. CONCLUSIONS: In the same aortic root, transition from the reimplantation to the remodeling configuration of aorticvalve-sparing surgery results in a significant increase in aortic root sizes and in a significant reduction of effective height and coaptation height, suggesting a less satisfactory result. PMID:23395101
Synthetic leaflet heart valves have been widely studied as possible alternatives to the current mechanical and bioprosthetic valves. Assessing the in vitro hydrodynamic function of these prostheses is of great importance to predict their hemodynamic behaviour prior to implantation. This study introduces an innovative concept of a low-profile semi-stented surgical aorticvalve (SSAV) made of a novel nanocomposite polyurethane with a polycarbonate soft segment (PCU) and polyhedral oligomeric silsesquioxane (POSS) nanoparticles covalently bonded as a pendant cage to the hard segment. The POSS-PCU is already used in surgical implants, including lacrimal duct, bypass graft, and recently, a tracheal replacement. Nine valves of three leaflet thicknesses (100, 150 and 200 ?m) and 21 mm internal diameter were prepared using an automated dip-coating procedure, and assessed in vitro for their hydrodynamic performance on a pulse duplicator system. A commercially available porcine bioprosthetic valve (Epic™, St. Jude Medical) of equivalent size was selected as a control model. Compared to the bioprosthetic valve, the SSAVs showed a considerably lower transvalvular pressure drop and larger effective orifice area (EOA). They were also characterised by a lower systolic energy loss, especially at high cardiac outputs. The leaflet thickness was found to significantly affect the hydrodynamics of these valves (P<0.01). The SSAVs with 100 ?m leaflets demonstrated improved flow characteristics compared to the bioprosthetic valve. The enhanced hydrodynamic function of the SSAV suggests that the proposed design together with the advanced POSS-PCU material can represent a significant step towards the introduction of polyurethane valves into the clinical application. PMID:22336198
Rahmani, Benyamin; Tzamtzis, Spyridon; Ghanbari, Hossein; Burriesci, Gaetano; Seifalian, Alexander M
This simple FlashTM animation depicts the function of a venous valve. It is shown in the context of a transverse section. During systole corpuscles are shown flowing through the open valve. As the pressure reverses during diastole, the valve closes and back flow is blocked.
PhD Jack D Thatcher (West Virginia School of Osteopathic Medicine Structural Biology)
The Center for the Advancement of Process Technology presents this free sample module on valves in the process industries. The interactive resource includes 55 screens and will help learners with both the details of valve systems and the process technician's role in valve operation and maintenance.
The aortic dissection (AoD) of an ascending thoracic aortic aneurysm (ATAA) initiates when the hemodynamic loads exerted on the aneurysmal wall overcome the adhesive forces holding the elastic layers together. Parallel coupled, two-way fluid-structure interaction (FSI) analyses were performed on patient-specific ATAAs obtained from patients with either bicuspid aorticvalve (BAV) or tricuspid aorticvalve (TAV) to evaluate hemodynamic predictors and wall stresses imparting aneurysm enlargement and AoD. Results showed a left-handed circumferential flow with slower-moving helical pattern in the aneurysm's center for BAV ATAAs whereas a slight deviation of the blood flow toward the anterolateral region of the ascending aorta was observed for TAV ATAAs. Blood pressure and wall shear stress were found key hemodynamic predictors of aneurysm dilatation, and their dissimilarities are likely associated to the morphological anatomy of the aorticvalve. We also observed discontinues, wall stresses on aneurysmal aorta, which was modeled as a composite with two elastic layers (i.e., inhomogeneity of vessel structural organization). This stress distribution was caused by differences on elastic material properties of aortic layers. Wall stress distribution suggests AoD just above sinotubular junction. Moreover, abnormal flow and lower elastic material properties that are likely intrinsic in BAV individuals render the aneurysm susceptible to the initiation of AoD. PMID:23664314
Pasta, Salvatore; Rinaudo, Antonino; Luca, Angelo; Pilato, Michele; Scardulla, Cesare; Gleason, Thomas G; Vorp, David A
Arterial endothelial cells maintain vascular homeostasis and vessel tone in part through the secretion of nitric oxide (NO). In this study, we determined how aorticvalve endothelial cells (VEC) regulate aorticvalve interstitial cell (VIC) phenotype and matrix calcification through NO. Using an anchored in vitro collagen hydrogel culture system, we demonstrate that three-dimensionally cultured porcine VIC do not calcify in osteogenic medium unless under mechanical stress. Co-culture with porcine VEC, however, significantly attenuated VIC calcification through inhibition of myofibroblastic activation, osteogenic differentiation, and calcium deposition. Incubation with the NO donor DETA-NO inhibited VIC osteogenic differentiation and matrix calcification, whereas incubation with the NO blocker l-NAME augmented calcification even in 3D VIC-VEC co-culture. Aortic VEC, but not VIC, expressed endothelial NO synthase (eNOS) in both porcine and human valves, which was reduced in osteogenic medium. eNOS expression was reduced in calcified human aorticvalves in a side-specific manner. Porcine leaflets exposed to the soluble guanylyl cyclase inhibitor ODQ increased osteocalcin and ?-smooth muscle actin expression. Finally, side-specific shear stress applied to porcine aorticvalve leaflet endothelial surfaces increased cGMP production in VEC. Valve endothelial-derived NO is a natural inhibitor of the early phases of valve calcification and therefore may be an important regulator of valve homeostasis and pathology. PMID:23499458
Richards, Jennifer; El-Hamamsy, Ismail; Chen, Si; Sarang, Zubair; Sarathchandra, Padmini; Yacoub, Magdi H; Chester, Adrian H; Butcher, Jonathan T
Whether the dilatation of proximal aorta in patients with bicuspid aorticvalve is secondary to hemodynamic effects related to the abnormal aorticvalve or a primary manifestation of the genetic disorder remains controversial. We discuss in this paper the recent data on the BAV function and transvalvular flow patterns in relation with the dilatation type of the proximal aorta. Different morphological forms of bicuspid aorticvalve in relation with the specific transvalvular blood flow patterns are focus of the first paragraph of this paper. In the second part of this paper we present the pathogenetic insight into the different clinically observed phenotypes of bicuspid aorticvalve disease (i.e., association of proximal aortic shapes with the specific cusp fusion patterns), based on the data from recent rheological studies.
Girdauskas, Evaldas; Disha, Kushtrim; Borger, Michael-Andrew; Kuntze, Thomas
Aims: To evaluate the two-step inflation technique aimed at achieving optimal valve implantation depth (defined as 40% of prosthesis height extending below the lower sinus border on angiography) during balloon-expandable transcatheter aorticvalve implantation (TAVI). Methods and results: Between September 2010 and March 2013, 103 patients (67 females, mean age 80.9±5.6 years) were treated with the Edwards SAPIEN XT prosthesis using the two-step inflation technique. Implantation depth was measured on angiography. A historical control group (treated with Edwards SAPIEN) was used for comparison (n=20). Deviation from the defined optimum implantation depth (expressed as a percentage of stent frame height) was significantly less in the study group versus controls (7.0 [3.4-14.1]% vs. 13.9 [5.4-18.9]%; p=0.048). Valve placement was graded "as intended"/"within range"/"out of range" (defined as ?10%, >10% but ?20% and >20% deviation, respectively) in 66%/22%/12% of the study group and 35%/40%/25% of historical controls (p=0.02). Corrections in valve position were made in 20 procedures (20%), resulting in placement as intended in 16 cases (80%), with highest efficacy in the transapical and direct aortic approaches. Conclusions: The two-step inflation technique improves valve placement towards optimal implantation depth and may thereby prevent adverse events due to malpositioning. PMID:24058073
Mechanical heart valve prostheses are known to activate coagulation and cause hemolysis. Both are particularly dependent on the leaflet dynamics, which in turn depends on the flow field in the aortic root influenced by the aortic root geometry and its compliance. Compliance reduction of large vessels occurs in aging patients, both in those who have atherosclerotic diseases and those who do not. In this study we investigated the correlation between hemolysis and the compliance of the proximal aorta in a novel, pulsatile in vitro blood tester using porcine blood. Two mechanical heart valves, the St Jude Medical (SJM) bileaflet valve and a trileaflet valve prototype (Triflo) were tested for hemolysis under physiological conditions (120/80 mm Hg, 4.5 l/min, 70 bpm) and using two different tester setups: with a stiff aorta and with a compliant aorta. Valve dynamics were subsequently analyzed via high-speed videos. In the tests with the Triflo valve, the free plasma hemoglobin increased by 13.4 mg/dl for the flexible and by 19.3 mg/dl for the stiff setup during the 3-hour test. The FFT spectra and closing speed showed slight differences for both setups. Free plasma hemoglobin for the SJM valve was up by 22.2 mg/dl in the flexible and 42.7 mg/dl in the stiff setup. Cavitation induced by the higher closing speed might be responsible for this, which is also indicated by the sound spectrum elevation above 16 kHz. PMID:22669587
Our aim is to investigate the elevation of matrix proteins in tissues obtained from distal, above the sinotubular junction (proximal), concave, and convex sites of aneurysms in the ascending aorta using a simultaneous multiplex protein detection system. Tissues were collected from 41 patients with ascending aortic aneurysms. A total of 31 patients had a bicuspid aorticvalve (BAV), whereas 10 had a tricuspid aorticvalve (TAV). Concave and convex aortic site samples were collected from all patients, whereas proximal and distal convexity samples were obtained from 19 patients with BAV and 7 patients with TAV. Simultaneous detection of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) was performed at each of the four aortic sites. MMP-2 levels were higher in the concave aortic sites than in the convex aortic sites. In contrast, MMP-8 levels were higher in the convex sites than in the concave sites, as were MMP-9 levels. In both BAV and TAV patients, TIMP-3 levels were higher in the concave sites than in the convex sites. However, TIMP-2 and TIMP-4 levels were significantly elevated in the sinotubular proximal aorta of BAV patients. Simultaneous detection of MMPs and TIMPs revealed different levels at different aortic sites in the same patient.
Mohamed, Salah A.; Noack, Frank; Schoellermann, Kerstin; Karluss, Anje; Radtke, Arlo; Schult-Badusche, Detlev; Radke, Peter W.; Wenzel, Bjoern E.; Sievers, Hans H.
Doppler echocardiographic characteristics of normally functioning Sorin Bicarbon prostheses were prospectively assessed in 226 consecutive patients (135 male and 91 female patients, mean age 61 +/- 10 years) with 233 valves in the mitral (n = 67) and aortic (n = 166) positions whose function was considered normal by clinical and echocardiographic evaluation. Patterns of "normal" transprosthetic leakage were assessed with transthoracic echocardiography in all valves and with transesophageal echocardiography in six selected mitral valve prostheses. For the mitral valve prostheses, we found that peak and mean gradient, as well as pressure half-time, were not significantly different in either the 25 or the 31 mm valves (median values from 15 to 10 mm Hg, from 4 to 4 mm Hg, and from 70 to 83 ms; p = Not significant for all). On transthoracic study, 12 patients (17%) with a Sorin Bicarbon valve in the mitral position showed minimal transprosthetic leakage. On transesophageal study, all patients showed a transprosthetic leakage whose spatial distribution had a complex pattern: in planes orthogonal to the leaflet axis, two to four jets arising from the hinge points and converging toward the center of the valve plane could be visualized; in planes parallel to the leaflet axis, there were three jets, the two lateral ones diverging and the central one perpendicular to the valve plane. For the aorticvalve prostheses, there was a significant decrease in transprosthetic gradients and an increase in effective orifice areas as prosthesis size increased. Peak and mean gradients decreased from a median value of 25 and 13 mm Hg in the 19 mm valves to 9 and 5 mm Hg in the 29 mm valves, respectively. Effective prosthetic valve area calculated with the continuity equation increased from a median value of 0.97 cm2 for the 19 mm size valves to 3.45 cm2 for the 29 mm size. With analysis of variance, effective prosthetic aorticvalve area differentiated various valve sizes (F = 40.9, p < 0.0001) better than peak (F = 10.3, p < 0.0001) or mean (F = 8.04, p < 0.0001) gradients alone did. Furthermore, effective prosthetic aorticvalve area correlated better than peak and mean gradients with prosthetic size (r = 0.76, r = -0.45, and r = -0.39, respectively). On transthoracic study, 109 patients (66%) showed minimal transprosthetic leakage. These normal values, obtained in a large number of patients with normofunctioning mitral and aortic Sorin Bicarbon valves, may help to identify Sorin Bicarbon prosthesis dysfunction. PMID:9282353
Badano, L; Mocchegiani, R; Bertoli, D; DeGaetano, G; Carratino, L; Pasetti, L; Caudullo, M; Budini, A; Mannello, B; Passerone, G
A 46-year-old woman known with relapsing Hodgkin's lymphoma diagnosed at age 5, treated with repeated cycles of radiotherapy and chemotherapy, presented with severe symptomatic radiation-induced aortic stenosis. She also had other late sequelae of radiotherapy including thyroid cancer, mediastinal fribrosis and left pulmonary fibrosis with severe restrictive lung disease and a newly diagnosed renal carcinoma. Due to the prohibitively high surgical risk and need for urgent treatment, she underwent successful transcatheter aorticvalve replacement with transfemoral implantation of a 23 mm Edwards SAPIEN-XT prosthesis, which was performed without valvuloplasty of the noncalcified fibrotic valve. The final result was excellent with reduction of the transaortic gradient and no residual aortic regurgitation. PMID:22450861
The fate of 1001 pericardial xenograft valves was analysed during a maximum follow-up period of 13 years. Two basic types of pericardial valves have been implanted. Between 1971 and 1975, 213 patients received 'hospital made' valves (single replacement). Between 1976 and 1983, 601 patients received 788 pericardial valves manufactured by Shiley Inc. (474 Standard and 314 Low profile valves) for both single and multiple replacement. There were 27 instances of valve dysfunction between 13 and 92 months after operation, 20 with 'hospital made' and 7 with Shiley valves. The actuarial freedom from valve failure at 8 years is 94.0 +/- 4.6% for aortic and 98.8 +/- 1.2% for mitral replacement in patients with Shiley valves. In patients with 'hospital made' valves the actuarial freedom from valve failure at 12 years of follow-up is 86.7 +/- 7.6% for aortic and 84.7 +/- 14.1% for mitral replacement. The linearised rate of valve dysfunction was 0.31% per annum for Shiley valves and 1.27% per annum for 'hospital made' valves. This analysis demonstrates that the pericardial xenograft has a low risk of valve failure and a predictable behaviour over a period of 13 years. The Shiley made valves have shown improved durability when compared with the 'hospital made' valves. PMID:6519096
Ionescu, M I; Tandon, A P; Chidambaram, M; Yakirevich, V S; Silverton, N P
The aim of this experimental study was to evaluate a newly designed cone-shaped aorticvalve prosthesis (CAVP) for one-step transcatheter placement in an orthotopic position. The study was conducted in 15 swine using either the transcarotid (11 animals) or the transfemoral (4 animals) artery approach. A 12- or 13-Fr sheath was inserted via arterial cutdown. The CAVP was deployed under fluoroscopic control and its struts, by design, induced significant native valve insufficiency. CAVP function was evaluated by aortography and aortic pressure curve tracing. In 11 of 15 swine the CAVP was properly deployed and functioned well throughout the scheduled period of 2-3 h. In three swine the CAVPs were placed lower than intended, however, they were functional even in the left ventricular outflow tract position. One swine expired due to inadvertent low CAVP placement that caused both aortic regurgitation and immobilization of the anterior mitral valve leaflet by the valve struts. We conclude that this design of CAVP is relatively easy to deploy, works well throughout a short time period (2-3 h), and, moreover, seems to be reliable even in a lower-than-orthotopic position (e.g., infra-annulary space). Longer-term studies are needed for its further evaluation.
Sochman, Jan, E-mail: email@example.com [Institute for Clinical and Experimental Medicine, Clinic of Cardiology (Czech Republic); Peregrin, Jan H.; Pulda, Zdenek [Institute for Clinical and Experimental Medicine, Department of Diagnostic and Interventional Radiology (Czech Republic); Pavcnik, Dusan; Uchida, Barry T.; Timmermans, Hans A.; Roesch, Josef [Oregon Health and Science University, Dotter Interventional Institute (United States)
We report a case of a male patient who received an implantation of a Starr-Edwards-caged-ball-valve-prosthesis in 1967. The surgery and postoperative course were without complications and the patient recovered well after the operation. For the next four decades, the patient remained asymptomatic--no restrictions on his lifestyle and without any complications. In 2006, 39 years after the initial operation, we performed a Bentall-Procedure to treat an aortic ascendens aneurysm with diameters of 6.0 x 6.5 cm: we explanted the old Starr-Edwards-aortic-caged-ball-valve-prosthesis and replaced the ascending aorta with a 29 mm St.Jude Medical aortic-valve-composite-graft and re-implanted the coronary arteries.This case represents the longest time period between Starr-Edwards-caged-ball-valve-prosthesis-implantation and Bentall-reoperation, thereby confirming the excellent durability of this valve. PMID:20298579
Schmitto, Jan D; Ortmann, Philipp; Popov, Aron F; Coskun, Kasim O; Schotola, Hanna; Friedrich, Martin; Wiese, Christoph H; Sohns, Christian; Mokashi, Suyog A; Didilis, Vassilios N; Schoendube, Friedrich A
BACKGROUND: The St Jude Medical Inc (St Paul, Minn) Trifecta valve is a novel aortic biological prosthesis that incorporates several design features, including a true supra-annular sewing cuff, a stent design that maximizes valve hemodynamics while minimizing leaflet stresses, and an ethanol-based anticalcification technology. This study establishes the safety and early clinical and hemodynamic performance of the Trifecta valve. METHODS: The Trifecta bioprosthesis was implanted in 1014 eligible patients between 2007 and 2009 at 31 centers. The mean age of the population was 72.5 ± 9.0 years, of whom 650 (64.1%) were male and 364 (35.9%) were female. Eighty-two subjects (8.1%) had undergone previous open surgery. Indications for aorticvalve replacement surgery included stenosis in 556 patients (54.8%), regurgitation in 61 patients (6.0%), and mixed pathology in 397 patients (39.2%). RESULTS: The overall follow-up included 844.3 late patient-years. Early (?30 day) mortality occurred in 18 patients (1.8%), and there were 23 late (?31 days) deaths yielding a linearized mortality rate of 2.72% per late patient-year. There were 27 early thromboembolic events, including 8 (0.8%) strokes, 17 (1.7%) reversible neurologic events, and 2 (0.2%) systemic embolic events. There were no instances of early valve thrombosis, endocarditis, or clinically significant hemolysis. There were 16 late thromboembolic events (linearized rate of 1.90% per year of follow-up), including 4 strokes and 12 reversible neurologic events. In total, there were 5 late valve explants, including 1 structural deterioration and 4 prosthetic valve endocarditis cases. Overall, freedom from valve explant was 99.4% at 2 years. At the time of discharge, average mean gradients ranged from 9.3 to 4.1 mm Hg and effective orifice area ranged from 1.58 to 2.50 cm(2) for valve sizes 19 to 29 mm, respectively. CONCLUSIONS: The St Jude Medical Trifecta valve is a unique pericardial bioprosthesis with design elements that provide excellent hemodynamic performance while providing ease of implantation. Long-term follow-up continues to confirm the promising results of this innovative bioprosthesis. PMID:23477687
Bavaria, Joseph E; Desai, Nimesh D; Cheung, Anson; Petracek, Michael R; Groh, Mark A; Borger, Michael A; Schaff, Hartzell V
The Ross procedure is an old surgical technique that is gaining popularity some 30 years after its introduction. The patient's own pulmonary valve is essentially used as a "spare part" to replace the diseased aorticvalve. The Ross procedure has become an accepted and attractive option for patients with a life expectancy of more than 20 years and for patients in whom long-term treatment with anticoagulants is undesirable or problematic. Careful preoperative evaluation and postoperative management, as well as proficient surgical techniques, are all necessary to achieve good outcomes. PMID:9354218
Mitral regurgitation due to 'floppy' valves is frequently associated with areas of medical necrosis in the ascending aorta. Application of the aortic clamp to such an area during valve replacement may produce an intimal tear followed by acute dissection. This complication occurred in three patients and was treated successfully by repair of the tear in the two cases where the dissection was observed at the time of operation. Is is suggested that infrequent clamping of the aorta and careful control of the pefusion pressure may decrease the risk of intimal trauma and acute dissection. Images
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.