In vitro investigation of a novel elastic vascular prosthesis for valve-sparing aortic root and ascending aorta replacement.

PubMed

Scharfschwerdt, Michael; Leonhard, Moritz; Lehmann, Judith; Richardt, Doreen; Goldmann, Helmut; Sievers, Hans-Hinrich

2016-05-01

Prosthetic replacement of the thoracic aorta with common Dacron prostheses impairs the aortic 'windkessel' and, in valve-sparing procedures, also aortic valve function. Elastic graft material may overcome these deficiencies. Fresh porcine aortas including the root were set up in a mock circulation before and after replacement of the ascending part with a novel vascular prosthesis providing elastic behaviours. In a first series (n = 14), haemodynamics and leaflet motions of the aortic valve were investigated and also cyclic changes of aortic dimensions at different levels of the root. In a second series (n = 7), intravascular pressure and dimensions of the proximal descending aorta were measured and the corresponding wall tension was calculated. Haemodynamics of the aortic valve remain comparable after replacement. Though the novel prosthesis does not feature such high distensibility as the native aorta, the dynamic of the root was significantly increased compared with common Dacron prostheses at the commissural level, preserving 'windkessel' function. Thus, wall tension of the residual aorta remained unchanged; nevertheless, maximum pressure-time differential dp/dt increased by 13%. The use of the novel elastic prosthesis for replacement of the ascending aorta seems to be beneficial, especially with regard to the preservation of the aortic windkessel. Further studies will be needed to clarify long-term utilization of the material in vivo. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Aortic root replacement using a biovalsalva prosthesis in comparison to a "handsewn" composite bioprosthesis.

PubMed

Moorjani, Narain; Modi, Amit; Mattam, Kavita; Barlow, Clifford; Tsang, Geoffrey; Haw, Marcus; Livesey, Steven; Ohri, Sunil

2010-05-01

The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a "handsewn" composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. There was no significant difference in the preoperative variables between the two study groups including age (70.7 +/- 1.7 vs. 67.6 +/- 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 +/- 0.32 vs. 3.17 +/- 0.71 units, p < 0.05) and fresh frozen plasma (2.78 +/- 0.39 vs. 1.85 +/- 0.31, p < 0.05), and reduced mediastinal blood loss (416 +/- 52 vs. 583 +/- 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 +/- 6 vs. 170 +/- 17 minutes, p = NS) and aortic cross-clamp time (113 +/- 6 vs. 115 +/- 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 +/- 0.4 mm valved conduit) with a peak pressure gradient of 26.2 +/- 1.9 mmHg and no or trivial valvular regurgitation. The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an "off-the-shelf" preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties.

Ross procedure for ascending aortic replacement.

PubMed

Elkins, R C; Lane, M M; McCue, C

1999-06-01

Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.

Longevity after aortic root replacement: is the mechanically valved conduit really the gold standard for quinquagenarians?

PubMed

Etz, Christian D; Girrbach, Felix F; von Aspern, Konstantin; Battellini, Roberto; Dohmen, Pascal; Hoyer, Alexandro; Luehr, Maximilian; Misfeld, Martin; Borger, Michael A; Mohr, Friedrich W

2013-09-10

The choice of the best conduit for root/ascending disease and its impact on longevity remain controversial in quinquagenarians. A total of 205 patients (men=155) between 50 and 60 years (mean, 55.7 ± 2.9 years) received either a stentless porcine xenoroot (n=78) or a mechanically valved composite prosthesis (n=127) between February 1998 and July 2011. Of these, 166 patients underwent root replacement for aneurysmal disease (porcine: 39% [n=65]; mechanical: 61% [n=101]; P=0.5), 25 for acute type A aortic dissection (porcine: 32% [n=8]; mechanical: 68% [n=17]; P=0.51), and 14 for endocarditis/iatrogenic injury involving the aortic root (6.4% [n=5] versus 7.1% [n=9]; P=1.0). The predominant aortic valve pathology was stenosis in 19% (n=38), regurgitation in 50% (n=102), combined valvular dysfunction in 26% (n=54), and normal aortic valve function in 5% (n=11). Concomitant procedures included coronary artery bypass grafting (13%), mitral valve repair (7%), and partial/complete arch replacement (12%/4%), with no significant differences between porcine and mechanical root replacement. Overall hospital mortality was 7.3%, with no difference between the 2 types of valve prostheses (7.7% for porcine and 7.1% for mechanical root replacement; P=1.0). Follow-up averaged 5.4 ± 3.7 years (1096 patient-years) and was 100% complete. Freedom from aorta-related reoperation at 12 years was not statistically different between the groups (porcine: 94.9% versus mechanical: 96.1%; P=0.73). Survival was equivalent between both groups, with a 5-year survival of 86 ± 3% (porcine: 88 ± 4%; mechanical: 85 ± 3%; P=0.96) and a 10-year survival of 76% (porcine: 80 ± 7%; mechanical: 75 ± 5%; P=0.84). The linearized mortality rate was 3.1%/patient-year (porcine: 2.9%/patient-year; mechanical: 3.2%/patient-year). In quinquagenerians, long-term survival after stentless porcine xenograft aortic root replacement is equivalent to that after a mechanical Bentall procedure. These results bring into question the predominance of mechanical composite conduits for root replacement in quinquagenerians, particularly in the current era of transcatheter valve-in-valve procedures for structural valve deterioration.

Aortic root remodeling: ten-year experience with 274 patients.

PubMed

Aicher, Diana; Langer, Frank; Lausberg, Henning; Bierbach, Benjamin; Schäfers, Hans-Joachim

2007-10-01

Dilatation of the aortic root with concomitant aortic regurgitation can be treated by valve-preserving surgery. We have consistently chosen root remodeling rather than reimplantation whenever the aortoventricular junction was not dilated. We have analyzed our 11-year experience with root remodeling. Between October 1995 and October 2006, 274 patients (201 male; 73 female, aged 59 +/- 15 years) were treated by root remodeling in the presence of a preserved aortoventricular diameter (<30 mm). Acute aortic dissection was present in 46 patients. The valve anatomy was tricuspid in 193 and bicuspid in 81 patients. Cusp disease was additionally corrected in 173 (63%) patients. Follow-up was complete in 99%. Cumulative follow-up was 1045 patient-years (mean of 4.0 +/- 2.7 years). Hospital mortality was 3.6% (elective 3.1%; emergency 6.5%). One patient had endocarditis 2 months postoperatively and subsequently underwent valve replacement. Freedom from aortic regurgitation of grade II or more was 91% and 87% at 10 years for bicuspid and tricuspid aortic valves. Nine patients required reoperation: in 6 patients the valve was replaced and in 3 patients rerepaired. Freedom from reoperation was 96% at 5 and 10 years, and freedom from valve replacement was 98% at 5 and 10 years. A comparison of 3 operative periods (1995-1998, 1999-2002, and 2003-2006) showed that with increasing experience cusp prolapse was diagnosed and corrected more frequently (8/49 = 17%; 62/105 = 59%; 103/108 = 82%; P < .0001), and repair stability significantly improved over time (P = .007). Root remodeling leads to durable restoration of aortic valve function in both tricuspid and bicuspid valve anatomy. Aggressive correction of cusp prolapse seems to have a beneficial effect on aortic valve competence.

Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair†

PubMed Central

Urbanski, Paul P.; Lenos, Aristidis; Irimie, Vadim; Bougioukakis, Petros; Zacher, Michael; Diegeler, Anno

2016-01-01

OBJECTIVES The aim of the study was to evaluate operative and long-term results after surgery of acute aortic dissection involving the root, in which the proximal repair consisted of curative resection of all dissected aortic sinuses and was performed using either valve-sparing root repair or complete root replacement with a valve conduit. METHODS Between August 2002 and March 2013, 162 consecutive patients (mean age 63 ± 14 years) underwent surgery for acute type A aortic dissection. Eighty-six patients with an involvement of the aortic root underwent curative surgery of the proximal aorta consisting of valve-sparing root repair (n = 54, 62.8%) or complete valve and root replacement using composite valve grafts (n = 32, 37.2%). In patients with root repair, all dissected aortic walls were resected and root remodelling using the single patch technique (n = 53) or root repair with valve reimplantation (n = 1) was performed without the use of any glue. All perioperative data were collected prospectively and retrospective statistical examination was performed using univariate and multivariate analyses. RESULTS The mean follow-up was 5.2 ± 3.5 years for all patients (range 0–12 years) and 6.1 ± 3.3 years for survivors. The 30-day mortality rate was 5.8% (5 patients), being considerably lower in the repair sub-cohort (1.9 vs 12.5%). The estimated survival rate at 5 and 10 years was 80.0 ± 4.5 and 69.1 ± 6.7%, respectively. No patient required reoperation on the proximal aorta and/or aortic valve during the follow-up time and there were only two valve-related events (both embolic, one in each group). Among those patients with repaired valves, the last echocardiography available showed no insufficiency in 40 and an irrelevant insufficiency (1+) in 14. CONCLUSIONS Curative repair of the proximal aorta in acute dissection involving the root provides favourable operative and long-term outcome with very low risk of aortic complications and/or reoperations, regardless if a valve-sparing procedure or replacement with a valve conduit is used. Valve-sparing surgery is frequently suitable, providing excellent outcome and very high durability. PMID:26848190

[Intra-operative Acute Aortic Dissection during Aortic Root Reimplantation and Mitral Valve Reconstruction Surgery in a Patient with Marfan Syndrome;Report of a Case].

PubMed

Teramoto, Chikao; Kawaguchi, Osamu; Araki, Yoshimori; Yoshikawa, Masaharu; Uchida, Wataru; Takemura, Gennta; Makino, Naoki

2016-08-01

In patients with Marfan syndrome, cardiovascular complication due to aortic dissection represents the primary cause of death. Iatrogenic acute aortic dissection during cardiac surgery is a rare, but serious adverse event. A 51-year-old woman with Marfan syndrome underwent elective aortic surgery and mitral valve reconstruction surgery for the enlarged aortic root and severe mitral regurgitation. We replaced the aortic root and ascending aorta based on reimplantation technique. During subsequent mitral valve reconstruction, we found the heart pushed up from behind. Trans-esophageal echocardiography revealed a dissecting flap in the thoracic descending aorta. There was just weak signal of blood flow in the pseudolumen. We did not add any additional procedures such as an arch replacement. Cardio-pulmonary bypass was successfully discontinued. After protamine sulfate administration and blood transfusion, blood flow in the pseudolumen disappeared. The patient was successfully discharged from the hospital on 33th postoperative day without significant morbidities.

Aortic Root Replacement for Children With Loeys-Dietz Syndrome.

PubMed

Patel, Nishant D; Alejo, Diane; Crawford, Todd; Hibino, Narutoshi; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A

2017-05-01

Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality. Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1 (3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Modern aortic surgery in Marfan syndrome--2011].

PubMed

Kallenbach, K; Schwill, S; Karck, M

2011-09-01

Marfan syndrome is a hereditary disease with a prevalence of 2-3 in 10,000 births, leading to a fibrillin connective tissue disorder with manifestations in the skeleton, eye, skin, dura mater and in particular the cardiovascular system. Since other syndromes demonstrate similar vascular manifestations, but therapy may differ significantly, diagnosis should be established using the revised Ghent nosology in combination with genotypic analysis in specialized Marfan centres. The formation of aortic root aneurysms with the subsequent risk of acute aortic dissection type A (AADA) or aortic rupture limits life expectancy in patients with Marfan syndrome. Therefore, prophylactic replacement of the aortic root needs to be performed before the catastrophic event of AADA can occur. The goal of surgery is the complete resection of pathological aortic tissue. This can be achieved with excellent results by using a (mechanically) valved conduit that replaces both the aortic valve and the aortic root (Bentall operation). However, the need for lifelong anticoagulation with Coumadin can be avoided using the aortic valve sparing reimplantation technique according to David. The long-term durability of the reconstructed valve is favourable, and further technical improvements may improve longevity. Although results of prospective randomised long-term studies comparing surgical techniques are lacking, the David operation has become the surgical method of choice for aortic root aneurysms, not only at the Heidelberg Marfan Centre. Replacement of the aneurysmal dilated aortic arch is performed under moderate hypothermic circulatory arrest combined with antegrade cerebral perfusion using a heart-lung machine, which we also use in thoracic or thoracoabdominal aneurysms. Close post-operative follow-up in a Marfan centre is pivotal for the early detection of pathological changes on the diseased aorta.

Marfan syndrome associated aortic disease in neonates and children: a clinical-morphologic review.

PubMed

Ware, Adam L; Miller, Dylan V; Erickson, Lance K; Menon, Shaji C

2016-01-01

Marfan syndrome (MFS) is a multisystem connective tissue disorder that can lead to aortic dilation requiring aortic root replacement. Neonatal MFS (nMFS) is a rare and severe form of MFS compared to classic MFS (cMFS). Aortic root histology in MFS is thought to demonstrate predominantly medial degeneration (MD) of a translamellar mucoid extracellular matrix accumulation (MEMA-T) vs. the intralamellar mucoid extracellular matrix accumulation (MEMA-I) seen in other aortopathies. The objective of this study was to describe the clinical and histopathologic features of nMFS and cMFS patients undergoing aortic root replacement. Children with MFS who underwent aortic root replacement between 2000 and 2012 at a single institution were included. Medical records including clinical details, aortic dimensions (Z scores), and histology including MD type were obtained. Statistics were descriptive with univariate analysis of age at surgery and type of MD. Eleven patients, 3 (27%) with nMFS, were included. Root dilation at time of surgery was greater in nMFS compared to cMFS (Z=12.8 vs. 7.6, P=.005), and nMFS patients were younger at time of surgery (7.3 vs. 18.8 years, P=.002). Histology in the nMFS group demonstrated MEMA-I in one and no MD in two. In the cMFS group, there were three with MEMA-T, four with MEMA-I, and one with both types. In summary, nMFS has earlier root dilation often in the absence of MD. Both forms of MD were present in our cohort, and there was no correlation between age at surgery and type of MD. Copyright © 2016 Elsevier Inc. All rights reserved.

Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures.

PubMed

Price, Joel; Magruder, J Trent; Young, Allen; Grimm, Joshua C; Patel, Nishant D; Alejo, Diane; Dietz, Harry C; Vricella, Luca A; Cameron, Duke E

2016-02-01

Prophylactic aortic root replacement improves survival in patients with Marfan syndrome with aortic root aneurysms, but the optimal procedure remains undefined. Adult patients with Marfan syndrome who had Bentall or aortic valve-sparing root replacement (VSRR) procedures between 1997 and 2013 were identified. Comprehensive follow-up information was obtained from hospital charts and telephone contact. One hundred sixty-five adult patients with Marfan syndrome (aged > 20 years) had either VSRR (n = 98; 69 reimplantation, 29 remodeling) or Bentall (n = 67) procedures. Patients undergoing Bentall procedure were older (median, 37 vs 36 years; P = .03), had larger median preoperative sinus diameter (5.5 cm vs 5.0 cm; P = .003), more aortic dissections (25.4% vs 4.1%; P < .001), higher incidence of moderate or severe aortic insufficiency (49.3% vs 14.4%; P < .001) and more urgent or emergent operations (24.6% vs 3.3%; P < .001). There were no hospital deaths and 9 late deaths in more than 17 years of follow-up (median, 7.8 deaths). Ten-year survival was 90.5% in patients undergoing Bentall procedure and 96.3% in patients undergoing VSRR (P = .10). Multivariable analysis revealed that VSRR was associated with fewer thromboembolic or hemorrhagic events (hazard ratio, 0.16; 95% confidence interval, 0.03-0.85; P = .03). There was no independent difference in long-term survival, freedom from reoperation, or freedom from endocarditis between the 2 procedures. After prophylactic root replacement in patients with Marfan syndrome, patients undergoing Bentall and valve-sparing procedures have similar late survival, freedom from root reoperation, and freedom from endocarditis. However, valve-sparing procedures result in significantly fewer thromboembolic and hemorrhagic events. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Streptococcus pneumoniae endocarditis on replacement aortic valve with panopthalmitis and pseudoabscess

PubMed Central

O’Brien, Stephen; Dayer, Mark; Benzimra, James; Hardman, Susan; Townsend, Mandie

2011-01-01

A 63-year-old woman with a previous episode of Streptococcus agalactiae endocarditis requiring a bioprosthetic aortic valve replacement presented with a short history of malaise, a right panopthalmitis with a Roth spot on funduscopy of the left eye and Streptococcus pneumoniae grown from vitreous and aqueous taps as well as blood cultures. She developed first degree heart block and her ECG was suggestive of an aortic root abscess. This gradually resolved over 6 weeks, during which she was treated with intravenous antibiotics. After careful consideration, it is likely that what was thought to be an aortic root abscess was instead an area of perivalvular inflammation. PMID:22678733

Aortic root dynamics and surgery: from craft to science.

PubMed

Cheng, Allen; Dagum, Paul; Miller, D Craig

2007-08-29

Since the fifteenth century beginning with Leonardo da Vinci's studies, the precise structure and functional dynamics of the aortic root throughout the cardiac cycle continues to elude investigators. The last five decades of experimental work have contributed substantially to our current understanding of aortic root dynamics. In this article, we review and summarize the relevant structural analyses, using radiopaque markers and sonomicrometric crystals, concerning aortic root three-dimensional deformations and describe aortic root dynamics in detail throughout the cardiac cycle. We then compare data between different studies and discuss the mechanisms responsible for the modes of aortic root deformation, including the haemodynamics, anatomical and temporal determinants of those deformations. These modes of aortic root deformation are closely coupled to maximize ejection, optimize transvalvular ejection haemodynamics and-perhaps most importantly-reduce stress on the aortic valve cusps by optimal diastolic load sharing and minimizing transvalvular turbulence throughout the cardiac cycle. This more comprehensive understanding of aortic root mechanics and physiology will contribute to improved medical and surgical treatment methods, enhanced therapeutic decision making and better post-intervention care of patients. With a better understanding of aortic root physiology, future research on aortic valve repair and replacement should take into account the integrated structural and functional asymmetry of aortic root dynamics to minimize stress on the aortic cusps in order to prevent premature structural valve deterioration.

Aortic valve repair using a differentiated surgical strategy.

PubMed

Langer, Frank; Aicher, Diana; Kissinger, Anke; Wendler, Olaf; Lausberg, Henning; Fries, Roland; Schäfers, Hans-Joachim

2004-09-14

Reconstruction of the aortic valve for aortic regurgitation (AR) remains challenging, in part because of not only cusp or root pathology but also a combination of both can be responsible for this valve dysfunction. We have systematically tailored the repair to the individual pathology of cusps and root. Between October 1995 and August 2003, aortic valve repair was performed in 282 of 493 patients undergoing surgery for AR and concomitant disease. Root dilatation was corrected by subcommissural plication (n=59), supracommissural aortic replacement (n=27), root remodeling (n=175), or valve reimplantation within a graft (n=24). Cusp prolapse was corrected by plication of the free margin (n=157) or triangular resection (n =36), cusp defects were closed with a pericardial patch (n=16). Additional procedures were arch replacement (n=114), coronary artery bypass graft (n=60) or mitral repair (n=24). All patients were followed-up (follow-up 99.6% complete), and cumulative follow-up was 8425 patient-months (mean, 33+/-27 months).Results- Eleven patients died in hospital (3.9%). Nine patients underwent reoperation for recurrent AR (3.3%). Actuarial freedom from AR grade > or =II at 5 years was 81% for isolated valve repair, 84% for isolated root replacement, and 94% for combination of both; actuarial freedom from reoperation at 5 years was 93%, 95%, and 98%, respectively. No thromboembolic events occurred, and there was 1 episode of endocarditis 4.5 years postoperatively. Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Operative mortality is low and mid-term durability is encouraging. The incidence of valve-related morbidity is low compared with valve replacement.

Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement.

PubMed

Svensson, Lars G; Pillai, Saila T; Rajeswaran, Jeevanantham; Desai, Milind Y; Griffin, Brian; Grimm, Richard; Hammer, Donald F; Thamilarasan, Maran; Roselli, Eric E; Pettersson, Gösta B; Gillinov, A Marc; Navia, Jose L; Smedira, Nicholas G; Sabik, Joseph F; Lytle, Bruce W; Blackstone, Eugene H

2016-03-01

To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P < .05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities (P < .0001). These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Replacement of the aortic root with a composite valve-graft conduit: risk factor analysis in 246 consecutive patients.

PubMed

Woldendorp, Kei; Starra, Eric; Seco, Michael; Hendel, P Nicholas; Jeremy, Richmond W; Wilson, Michael K; Vallely, Michael P; Bannon, Paul G

2014-12-01

Composite valve-graft (CVG) replacement of the aortic root is a well-studied and recognised treatment for various aortic root conditions, including valvular disease with associated aortopathy. There have been few previous studies of the procedure in large numbers in an Australian setting. From January 2006 to June 2013, 246 successive patients underwent CVG root replacements at our institution. Mean age was 56.8 years, 85.4% were male, and 87 had evidence of bicuspid aortic valve. Indications for operation included ascending aortic aneurysm in 222 patients, annuloaortic ectasia in 67 patients, and aortic dissection in 38 patients. The overall unit 30-day mortality was 5.7%, including: elective 30-day mortality of 2.2%, and emergent 30-day mortality of 17.2%. Statistically significant multivariate predictors of 30-day mortality were: acute aortic dissection (OR=20.07), peripheral vascular disease (OR=11.17), new ventricular tachycardia (OR=30.17), re-operation for bleeding (OR=14.42), concomitant mitral stenosis (OR=68.30), and cerebrovascular accident (OR=144.85). Low postoperative mortality in our series matches closely with results from similar sized international studies, demonstrating that this procedure can be performed with low risk in centres with sufficient experience in the operative procedure. Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Valve repair in aortic regurgitation without root dilatation--aortic valve repair.

PubMed

Lausberg, H F; Aicher, D; Kissinger, A; Langer, F; Fries, R; Schäfers, H-J

2006-02-01

Aortic valve repair was established in the context of aortic root remodeling. Variable results have been reported for isolated valve repair. We analyzed our experience with isolated valve repair and compared the results with those of aortic root remodeling. Between October 1995 and August 2003, isolated repair of the aortic valve was performed in 83 patients (REP), remodeling of the aortic valve in 175 patients (REMO). The demographics of the two groups were comparable (REP: mean age 54.4 +/- 20.7 yrs, male-female ratio 2.1 : 1; REMO: mean age 60.8 +/- 13.6 yrs, male-female ratio 2.4 : 1; p = ns). In both groups the number of bicuspid valves was comparable (REP: 41 %, REMO: 32 %; p = ns). All patients were followed by echocardiography for a cumulative follow-up of 8204 patient months (mean 32 +/- 23 months). Overall in-hospital mortality was 2.4 % in REP and 4.6 % in REMO ( p = 0.62). Systolic gradients were comparable in both groups (REP: 5.8 +/- 2.2, REMO: 6.5 +/- 3.1 mm Hg, p = 0.09). The mean degree of aortic regurgitation 12 months postoperatively was 0.8 +/- 0.7 after REP and 0.7 +/- 0.7 after REMO ( p = 0.29). Freedom from significant regurgitation (> or = II degrees ) after 5 years was 86 % in REP and 89 % in REMO ( p = 0.17). Freedom from re-operation after 5 years was 94.4 % in REP and 98.2 % in REMO ( p = 0.33). Aortic regurgitation without concomitant root dilatation can be treated effectively by aortic valve repair. The functional results are equivalent to those obtained with valve-preserving root replacement. Aortic valve repair appears to be an alternative to valve replacement in aortic regurgitation.

Current surgical results of acute type A aortic dissection in Japan.

PubMed

Okita, Yutaka

2016-07-01

Current surgical results of acute type A aortic dissection in Japan are presented. According to the annual survey by the Japanese Association of Thoracic Surgery, 4,444 patients with acute type A aortic dissection underwent surgical procedures and the overall hospital mortality was 9.1% in 2013. The prevalence of aortic root replacement with a valve sparing technique, total arch replacement (TAR), and frozen stent graft are presented and strategies for thrombosed dissection or organ malperfusion syndrome secondary to acute aortic dissection are discussed.

A rare case of prosthetic endocarditis and dehiscence in a mechanical valved conduit

PubMed Central

Kannan, Arun; Smith, Cristy; Subramanian, Sreekumar; Janardhanan, Rajesh

2014-01-01

A middle-aged adult patient with a history of aortic root replacement with a mechanical valved conduit and remote chest trauma was referred to our institution with prosthetic endocarditis. Transoesophageal echocardiogram at our institution confirmed a near-complete dehiscence of the prosthetic aortic valve from the conduit, with significant perivalvular flow forming a pseudoaneurysm. The patient underwent a high-risk re-operation, involving redo aortic root replacement with a homograft after extensive debridement of the infected tissue. The patient was discharged to an outside facility after an uncomplicated hospital course, and remains stable. PMID:24510692

A rare case of prosthetic endocarditis and dehiscence in a mechanical valved conduit.

PubMed

Kannan, Arun; Smith, Cristy; Subramanian, Sreekumar; Janardhanan, Rajesh

2014-02-07

A middle-aged adult patient with a history of aortic root replacement with a mechanical valved conduit and remote chest trauma was referred to our institution with prosthetic endocarditis. Transoesophageal echocardiogram at our institution confirmed a near-complete dehiscence of the prosthetic aortic valve from the conduit, with significant perivalvular flow forming a pseudoaneurysm. The patient underwent a high-risk re-operation, involving redo aortic root replacement with a homograft after extensive debridement of the infected tissue. The patient was discharged to an outside facility after an uncomplicated hospital course, and remains stable.

Twenty-year analysis of autologous support of the pulmonary autograft in the Ross procedure.

PubMed

Skillington, Peter D; Mokhles, M Mostafa; Takkenberg, Johanna J M; O'Keefe, Michael; Grigg, Leeanne; Wilson, William; Larobina, Marco; Tatoulis, James

2013-09-01

The Ross procedure is seldom offered to adults less than 60 years of age who require aortic valve replacement except in a few high-volume centers with documented expertise. Inserting the pulmonary autograft as an unsupported root replacement may lead to increasing reoperations on the aortic valve in the second decade. Of 333 patients undergoing the Ross procedure between October 1992 and June 2012, the study group of 310 consecutive patients (mean age ± standard deviation, 39.3±12.7 years (limits 16-63) had the aortic root size adjusted to match the pulmonary autograft, which was inserted as a root replacement, with the aorta closed up around it to provide autologous support. The mean follow-up time was 9.4 years; the actuarial survival was 97% at 16 years; and freedom from the composite of all reoperations on the aortic valve and late echocardiographic-detected aortic regurgitation greater than mild was 95% at 5 years, 94% at 10 years, and 93% at 15 years. Overall freedom from all reoperations on aortic and pulmonary valves was 97% at 5 years, 94% at 10 years, and 93% at 15 years. All results were better for the patients presenting with predominant aortic stenosis (98% freedom at 15 years) than for those with aortic regurgitation (p=0.01). Autologous support of the pulmonary autograft leads to excellent results in the groups presenting with aortic stenosis and mixed aortic stenosis/regurgitation and to good results for those presenting with pure aortic regurgitation. The Ross procedure, using one of the proven, durable techniques available, should be considered for more widespread adoption. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Aortic root repair for thoracic aorta false aneurysm following Bentall procedure.

PubMed

Kumar, Sanjay; Jones, Steve; Sivananthan, U M; McGoldrick, J P

2008-08-01

The Bentall procedure for aortic root replacement in Marfan's syndrome is safe and durable. We describe successful repair of periprosthetic valvular leak, 12 years following Bentall repair with composite graft. The aim of this report is to analyse and evaluate technical factors leading to this unusual occurrence.

The use of a stentless porcine bioprosthesis to repair an ascending aortic aneurysm in combination with aortic valve regurgitation.

PubMed Central

Akpinar, B; Sanisoğlu, I; Konuralp, C; Akay, H; Güden, M; Sönmez, B

1999-01-01

Over the years, many surgical methods have evolved for the treatment of ascending aortic aneurysm in combination with aortic valve regurgitation; however, precise guidelines for optimal surgical techniques for varying presentations have not been defined. We describe the use of a stentless porcine bioprosthesis (Medtronic Freestyle) in a patient with an ascending aortic aneurysm and aortic regurgitation. We used the complete root replacement method, and anastomosed a Dacron graft (Hemashield) between the bioprosthetic valve and the native aorta to replace the distal part of the aneurysm. Images PMID:10524742

Early and late outcomes of 1000 minimally invasive aortic valve operations.

PubMed

Tabata, Minoru; Umakanthan, Ramanan; Cohn, Lawrence H; Bolman, Ralph Morton; Shekar, Prem S; Chen, Frederick Y; Couper, Gregory S; Aranki, Sary F

2008-04-01

Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.

Predictive risk models for proximal aortic surgery

PubMed Central

Díaz, Rocío; Pascual, Isaac; Álvarez, Rubén; Alperi, Alberto; Rozado, Jose; Morales, Carlos; Silva, Jacobo; Morís, César

2017-01-01

Predictive risk models help improve decision making, information to our patients and quality control comparing results between surgeons and between institutions. The use of these models promotes competitiveness and led to increasingly better results. All these virtues are of utmost importance when the surgical operation entails high-risk. Although proximal aortic surgery is less frequent than other cardiac surgery operations, this procedure itself is more challenging and technically demanding than other common cardiac surgery techniques. The aim of this study is to review the current status of predictive risk models for patients who undergo proximal aortic surgery, which means aortic root replacement, supracoronary ascending aortic replacement or aortic arch surgery. PMID:28616348

Long-term results of aortic valve replacement with Edwards Prima Plus stentless bioprosthesis: eleven years' follow up.

PubMed

Auriemma, Stefano; D'Onofrio, Augusto; Brunelli, Massimo; Magagna, Paolo; Paccanaro, Mariemma; Rulfo, Fanny; Fabbri, Alessandro

2006-09-01

The Edwards Lifesciences Prima Plus stentless valve (ELSV) is a bioprosthesis manufactured from a porcine aortic root. The study aim was to evaluate late clinical outcomes after aortic valve replacement (AVR) with ELSV implanted as a miniroot in patients with aortic valve disease. Between 1993 and 2004, 318 patients (232 males, 86 females; mean age 69 +/- 9 years; range: 37-83 years) underwent AVR with the ELSV. Preoperatively, 102 patients (32%), 162 (51%) and 54 (17%) were in NYHA classes I/II, III and IV, respectively. Aortic stenosis, aortic regurgitation and combined lesions were present in 124 patients (39%), 114 (36%) and 41 (13%), respectively. Twenty patients (6%) were referred for an acute aortic dissection, 20 (6%) for an aortic root aneurysm, and 139 (44%) had an associated aneurysmal dilatation of the ascending aorta. The ascending aorta was replaced in 159 patients (50%); aortic arch replacement was required in 10 (3%). Coronary artery bypass graft was performed in 86 patients (27%). The follow up was based on clinical data. Operative mortality was 5% (n = 17). There were 49 late deaths (5.2%/pt-yr). Valve-related mortality occurred in 10 patients (1%/pt-yr). Actuarial survival at five and 10 years was 78% and 33%, respectively. Actuarial freedom from valve reoperation and structural valve deterioration at 10 years were 100% and 64%. Actuarial freedom from embolic events and endocarditis at 10 years were 84% and 81%, respectively. The ELSV, when implanted as a miniroot, provided good early and long-term results in terms of survival and freedom from major complications.

3D Printing Based on Cardiac CT Assists Anatomic Visualization Prior to Transcatheter Aortic Valve Replacement

PubMed Central

Ripley, Beth; Kelil, Tatiana; Cheezum, Michael K.; Goncalves, Alexandra; Di Carli, Marcelo F.; Rybicki, Frank J.; Steigner, Mike; Mitsouras, Dimitrios; Blankstein, Ron

2017-01-01

Background 3D printing is a promising technique that may have applications in medicine, and there is expanding interest in the use of patient-specific 3D models to guide surgical interventions. Objective To determine the feasibility of using cardiac CT to print individual models of the aortic root complex for transcatheter aortic valve replacement (TAVR) planning as well as to determine the ability to predict paravalvular aortic regurgitation (PAR). Methods This retrospective study included 16 patients (9 with PAR identified on blinded interpretation of post-procedure trans-thoracic echocardiography and 7 age, sex, and valve size-matched controls with no PAR). 3D printed models of the aortic root were created from pre-TAVR cardiac computed tomography data. These models were fitted with printed valves and predictions regarding post-implant PAR were made using a light transmission test. Results Aortic root 3D models were highly accurate, with excellent agreement between annulus measurements made on 3D models and those made on corresponding 2D data (mean difference of −0.34 mm, 95% limits of agreement: ± 1.3 mm). The 3D printed valve models were within 0.1 mm of their designed dimensions. Examination of the fit of valves within patient-specific aortic root models correctly predicted PAR in 6 of 9 patients (6 true positive, 3 false negative) and absence of PAR in 5 of 7 patients (5 true negative, 2 false positive). Conclusions Pre-TAVR 3D-printing based on cardiac CT provides a unique patient-specific method to assess the physical interplay of the aortic root and implanted valves. With additional optimization, 3D models may complement traditional techniques used for predicting which patients are more likely to develop PAR. PMID:26732862

Mortality characteristics of aortic root surgery in North America†

PubMed Central

Caceres, Manuel; Ma, Yicheng; Rankin, J. Scott; Saha-Chaudhuri, Paramita; Englum, Brian R.; Gammie, James S.; Suri, Rakesh M.; Thourani, Vinod H.; Esmailian, Fardad; Czer, Lawrence S.; Puskas, John D.; Svensson, Lars G.

2014-01-01

OBJECTIVES Aortic root surgery is transitioning to aortic valve sparing (AVS), but little is known about the relative early outcomes of AVS versus composite graft-valve replacement (CVR). This study assessed mortality differences for AVS versus CVR to guide future practice decisions. METHODS From January 2000 to June 2011, 31 747 patients had aortic root replacement with AVS (n = 3585; 11%) or CVR (n = 28 162; 89%). The cohort of Overall patients was divided into two subgroups: high-risk patients (n = 20 356; 6% AVS) having age >75 years, endocarditis, aortic stenosis, dialysis, multiple valves, reoperation or emergency/salvage status, and the remaining low-risk patients (n = 11 388; 21% AVS). Using logistic regression analysis, outcomes were presented as unadjusted operative mortality (UOM), risk-adjusted operative mortality (AOM) and adjusted odds ratio (AOR) for mortality. RESULTS Baseline characteristics for the Overall group (AVS versus CVR) were: mean age (52 vs 57 years), endocarditis (1 vs 11%), aortic stenosis (4 vs 36%), dialysis (1 vs 2%), multiple valves (7 vs 10%), reoperation (6 vs 17%) and emergency status (14 vs 12%) (all P < 0.0001). In high- and low-risk groups, baseline differences narrowed, and lower mortality was generally observed with AVS: (AVS versus CVR) UOM group Overall (4.5 vs 8.9%)*, group High-risk (10.5 vs 11.7%), group Low-risk (1.4 vs 3.1%)*; AOM group Overall (6.2 vs 8.6%), group High-risk (10.1 vs 11.7%), group Low-risk (2.2 vs 2.8%); AOR group Overall (0.59)*, group High-risk (0.62)*, group Low-risk (0.69). *P < 0.05. CONCLUSIONS Relative risk-adjusted mortality seemed comparable with AVS versus CVR in low- and high-risk subgroups. These data support judicious expansion of aortic valve repair in patients having aortic root replacement. PMID:24639452

Mortality characteristics of aortic root surgery in North America.

PubMed

Caceres, Manuel; Ma, Yicheng; Rankin, J Scott; Saha-Chaudhuri, Paramita; Englum, Brian R; Gammie, James S; Suri, Rakesh M; Thourani, Vinod H; Esmailian, Fardad; Czer, Lawrence S; Puskas, John D; Svensson, Lars G

2014-11-01

Aortic root surgery is transitioning to aortic valve sparing (AVS), but little is known about the relative early outcomes of AVS versus composite graft-valve replacement (CVR). This study assessed mortality differences for AVS versus CVR to guide future practice decisions. From January 2000 to June 2011, 31 747 patients had aortic root replacement with AVS (n = 3585; 11%) or CVR (n = 28 162; 89%). The cohort of Overall patients was divided into two subgroups: high-risk patients (n = 20 356; 6% AVS) having age >75 years, endocarditis, aortic stenosis, dialysis, multiple valves, reoperation or emergency/salvage status, and the remaining low-risk patients (n = 11 388; 21% AVS). Using logistic regression analysis, outcomes were presented as unadjusted operative mortality (UOM), risk-adjusted operative mortality (AOM) and adjusted odds ratio (AOR) for mortality. Baseline characteristics for the Overall group (AVS versus CVR) were: mean age (52 vs 57 years), endocarditis (1 vs 11%), aortic stenosis (4 vs 36%), dialysis (1 vs 2%), multiple valves (7 vs 10%), reoperation (6 vs 17%) and emergency status (14 vs 12%) (all P < 0.0001). In high- and low-risk groups, baseline differences narrowed, and lower mortality was generally observed with AVS: (AVS versus CVR) UOM group Overall (4.5 vs 8.9%)*, group High-risk (10.5 vs 11.7%), group Low-risk (1.4 vs 3.1%)*; AOM group Overall (6.2 vs 8.6%), group High-risk (10.1 vs 11.7%), group Low-risk (2.2 vs 2.8%); AOR group Overall (0.59)*, group High-risk (0.62)*, group Low-risk (0.69). *P < 0.05. Relative risk-adjusted mortality seemed comparable with AVS versus CVR in low- and high-risk subgroups. These data support judicious expansion of aortic valve repair in patients having aortic root replacement. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

PubMed

Roubelakis, Apostolos; Karangelis, Dimos; Sadeque, Syed; Yanagawa, Bobby; Modi, Amit; Barlow, Clifford W; Livesey, Steven A; Ohri, Sunil K

2017-07-01

The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

Double-switch Ross procedure.

PubMed

Chang, Jen-Ping; Kao, Chiung-Lun; Hsieh, Ming-Jang

2002-06-01

Aortic root replacement with pulmonary autograft (Ross procedure) is a valuable technique. However, the best material for right ventricular outflow tract reconstruction remains controversial. We report on the experience with use of an aortic autograft with reimplantation of the diseased aortic valve for right ventricular outflow tract reconstruction in 3 patients with satisfactory result.

Systemic aspergilloma post aortic root surgery following coronary artery stenting: diagnostic and management dilemma

PubMed Central

Hussein, Nabil; Qamar, Sombul; Abid, Qamar

2015-01-01

Aspergillus infections such as Aspergillus endocarditis were once relatively rare occurrences, however, due to the increased use of intracardiac devices, the incidence has grown. With mortality rates close to 100%, in medically treated cases, it is paramount that early diagnosis and treatment are performed. An immunocompetent aviculturist presented 8 months post aortic root replacement for severe aortic regurgitation with a composite graft, with central crushing chest pain. Investigations confirmed ST elevation inferior myocardial infarction due to stenosis of the origin of the right coronary artery, which was stented. Echocardiogram demonstrated a mobile mass posterior to the left ventricular outflow tract. Following referral to our cardiothoracic surgeons, a polypoidal mass covering the right ostial button was noted along with systemic complications of the disease. Emergency redo aortic valve replacement with a homograft and coronary artery bypass was performed. Histological analysis confirmed A. fumigatus and the patient was started on intravenous voriconazole. PMID:26025972

Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate.

PubMed

Waterford, Stephen D; Gardner, Rita L; Moon, Marc R

2018-05-17

The proximal and distal extent of surgery for type A dissection is the subject of this review article. In this report, we summarize select series that illumine the issue at hand and provide insight into the surgical approach at our institution to DeBakey type I aortic dissections. For proximal extent, we discuss preservation of the aortic valve in the presence of aortic insufficiency, as well as management of the aortic root in the setting of root dilation. Distal extent of surgery for type A dissection has been a much more controversial topic. At our institution, we subscribe to the philosophy of ascending or hemiarch replacement alone for dissection under most circumstances. We describe when we believe a more aggressive arch replacement for type A dissection may be considered and detail the reports of other groups that have performed this operation more routinely. We also touch upon the frozen elephant trunk operation and its role in type A dissection, although we believe it should be reserved for high-volume dedicated aortic centers. Finally, we conclude by discussing the role of experience in choosing aortic operations for type A dissection. In our opinion, there is no single correct operation for a patient with type A dissection, but there is a correct operation for each surgeon and clinical scenario. Copyright © 2018. Published by Elsevier Inc.

Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results.

PubMed

Patel, Nishant D; Crawford, Todd; Magruder, J Trent; Alejo, Diane E; Hibino, Narutoshi; Black, James; Dietz, Harry C; Vricella, Luca A; Cameron, Duke E

2017-02-01

Early experience with Loeys-Dietz syndrome (LDS) suggested an aggressive aortopathy with high risk of aneurysm dissection and rupture at young ages and at smaller aortic diameters than in other connective tissue disorders. We reviewed our experience with LDS to re-examine our indications and outcomes of surgical management. We reviewed all patients with a diagnosis of LDS who underwent cardiovascular surgery at our institution. The primary endpoint was mortality, and secondary endpoints included postoperative complications and need for reintervention. Seventy-nine operated patients with LDS were identified. Mean age at first operation was 25 years, 39 (49%) were female, and 38 (48%) were children (age <18 years). Six (8%) patients presented with acute dissection. Five (6%) patients had a bicuspid aortic valve, and all presented with an ascending aortic aneurysm with a mean root diameter of 3.5cm. Twenty (25%) patients had a previous sternotomy. Sixty-five (82%) patients underwent aortic root replacement, of whom 52 underwent a valve-sparing operation and 4 had concomitant arch replacement. Mean aortic root diameter in this group was 4.2 cm. Nine (11%) patients underwent aortic arch replacement, 2 (3%) had isolated ascending aorta replacement, and 3 (4%) underwent open thoracoabdominal repair. There were 2 (3%) operative and 8 late deaths. Nineteen patients underwent subsequent operations for late aneurysm and/or dissection. Mean follow-up was 6 years (range 0-24 years). Kaplan-Meier survival was 88% at 10 years. Growing experience with LDS has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe. Surgical outcomes are favorable, but reintervention rates are high. Meticulous follow-up with cardiovascular surveillance imaging remain important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aortic valve repair leads to a low incidence of valve-related complications.

PubMed

Aicher, Diana; Fries, Roland; Rodionycheva, Svetlana; Schmidt, Kathrin; Langer, Frank; Schäfers, Hans-Joachim

2010-01-01

Aortic valve replacement for aortic regurgitation (AR) has been established as a standard treatment but implies prosthesis-related complications. Aortic valve repair is an alternative approach, but its mid- to long-term results still need to be defined. Over a 12-year period, 640 patients underwent aortic valve repair for regurgitation of a unicuspid (n=21), bicuspid (n=205), tricuspid (n=411) or quadricuspid (n=3) aortic valve. The mechanism of regurgitation involved prolapse (n=469) or retraction (n=20) of the cusps, and dilatation of the root (n=323) or combined pathologies. Treatment consisted of cusp repair (n=529), root repair (n=323) or a combination of both (n=208). The patients were followed clinically and echocardiographically; follow-up was complete in 98.5% (cumulative follow-up: 3035 patient years). Hospital mortality was 3.4% in the total patient cohort and 0.8% for isolated aortic valve repair. The incidences of thrombo-embolism (0.2% per patient per year) and endocarditis (0.16%per patient per year) were low. Freedom from re-operation at 5 and 10 years was 88% and 81% in bicuspid and 97% and 93% in tricuspid aortic valves (p=0.0013). At re-operation, 13 out of 36 valves could be re-repaired. Freedom from valve replacement was 95% and 90% in bicuspid and 97% and 94% in tricuspid aortic valves (p=0.36). Freedom from all valve-related complications at 10 years was 88%. Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement. Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

3D printing based on cardiac CT assists anatomic visualization prior to transcatheter aortic valve replacement.

PubMed

Ripley, Beth; Kelil, Tatiana; Cheezum, Michael K; Goncalves, Alexandra; Di Carli, Marcelo F; Rybicki, Frank J; Steigner, Mike; Mitsouras, Dimitrios; Blankstein, Ron

2016-01-01

3D printing is a promising technique that may have applications in medicine, and there is expanding interest in the use of patient-specific 3D models to guide surgical interventions. To determine the feasibility of using cardiac CT to print individual models of the aortic root complex for transcatheter aortic valve replacement (TAVR) planning as well as to determine the ability to predict paravalvular aortic regurgitation (PAR). This retrospective study included 16 patients (9 with PAR identified on blinded interpretation of post-procedure trans-thoracic echocardiography and 7 age, sex, and valve size-matched controls with no PAR). 3D printed models of the aortic root were created from pre-TAVR cardiac computed tomography data. These models were fitted with printed valves and predictions regarding post-implant PAR were made using a light transmission test. Aortic root 3D models were highly accurate, with excellent agreement between annulus measurements made on 3D models and those made on corresponding 2D data (mean difference of -0.34 mm, 95% limits of agreement: ± 1.3 mm). The 3D printed valve models were within 0.1 mm of their designed dimensions. Examination of the fit of valves within patient-specific aortic root models correctly predicted PAR in 6 of 9 patients (6 true positive, 3 false negative) and absence of PAR in 5 of 7 patients (5 true negative, 2 false positive). Pre-TAVR 3D-printing based on cardiac CT provides a unique patient-specific method to assess the physical interplay of the aortic root and implanted valves. With additional optimization, 3D models may complement traditional techniques used for predicting which patients are more likely to develop PAR. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Endovascular closure of ascending aortic pseudoaneurysm with a type II Amplatzer vascular plug.

PubMed

De Boo, Diederick W; Mott, Nigel; Kavnoudias, Helen; Walton, Antony; Lyon, Stuart M

2014-05-01

A 71-year-old man initially presented with an asymptomatic, incidentally detected ascending aortic pseudoaneurysm 25 years following aortic root repair with mechanical aortic valve replacement. This pseudoaneurysm was previously treated with coil embolization but due to coil impaction it reopened 8 years later. Endovascular closure of the pseudoaneurysm was achieved with the off-label use of a type II Amplatzer vascular plug.

Rupture of an Abdominal Aortic Aneurysm in a Young Man with Marfan Syndrome.

PubMed

Pedersen, Maria Weinkouff; Huynh, Khiem Dinh; Baandrup, Ulrik Thorngren; Nielsen, Dorte Guldbrand; Andersen, Niels Holmark

2018-04-01

Abdominal aortic aneurysms (AAAs) are very rare in Marfan syndrome. We present a case with a young nonsmoking and normotensive male with Marfan syndrome, who developed an infrarenal AAA that presented with rupture to the retroperitoneal cavity causing life-threatening bleeding shock. The patient had acute aortic surgery and survived. Five months before this incident, the patient had uneventful elective aortic root replacement (ad modum David) due to an enlarged aortic root. At that time, his abdominal aorta was assessed with a routine ultrasound scan that showed a normal-sized abdominal aorta. This documents that the aneurysm had evolved very rapidly despite young age and absence of risk factors. Copyright © 2018 Elsevier Inc. All rights reserved.

Haemodynamic outcome at four-dimensional flow magnetic resonance imaging following valve-sparing aortic root replacement with tricuspid and bicuspid valve morphology

PubMed Central

Semaan, Edouard; Markl, Michael; Chris Malaisrie, S.; Barker, Alex; Allen, Bradley; McCarthy, Patrick; Carr, James C.; Collins, Jeremy D.

2014-01-01

OBJECTIVE To provide a more complete characterization of aortic blood flow in patients following valve-sparing aortic root replacement (VSARR) compared with presurgical cohorts matched by tricuspid and bicuspid valve morphology, age and presurgical aorta size. METHODS Four-dimensional (4D) flow magnetic resonance imaging (MRI) was performed to analyse three-dimensional (3D) blood flow in the thoracic aorta of n = 13 patients after VSARR with reimplantation of native tricuspid aortic valve (TAV, n = 6) and bicuspid aortic valve (BAV, n = 7). Results were compared with presurgical age and aortic size-matched control cohorts with TAV (n = 10) and BAV (n = 10). Pre- and post-surgical aortic flow was evaluated using time-resolved 3D pathlines using a blinded grading system (0–2, 0 = small, 1 = moderate and 2 = prominent) analysing ascending aortic (AAo) helical flow. Systolic flow profile uniformity in the aortic root, proximal and mid-AAo was evaluated using a four-quadrant model. Further analysis in nine analysis planes distributed along the thoracic aorta quantified peak systolic velocity, retrograde fraction and peak systolic flow acceleration. RESULTS Pronounced AAo helical flow in presurgical control subjects (both BAV and TAV: helix grading = 1.8 ± 0.4) was significantly reduced (0.2 ± 0.4, P < 0.001) in cohorts after VSARR independent of aortic valve morphology. Presurgical AAo flow was highly eccentric for BAV patients but more uniform for TAV. VSARR resulted in less eccentric flow profiles. Systolic peak velocities were significantly (P < 0.05) increased in post-root repair BAV patients throughout the aorta (six of nine analysis planes) and to a lesser extent in TAV patients (three of nine analysis planes). BAV reimplantation resulted in significantly increased peak velocities in the proximal AAo compared with root repair with TAV (2.3 ± 0.6 vs 1.6 ± 0.4 m/s, P = 0.017). Post-surgical patients showed a non-significant trend towards higher systolic flow acceleration as a surrogate measure of reduced aortic compliance. CONCLUSIONS VSARR restored a cohesive flow pattern independent of native valve morphology but resulted in increased peak velocities throughout the aorta. 4D flow MRI methods can assess the clinical implications of altered aortic flow dynamics in patients undergoing VSARR. PMID:24317086

Tetralogy of Fallot and aortic root dilation: a long-term outlook.

PubMed

Nagy, Christian D; Alejo, Diane E; Corretti, Mary C; Ravekes, William J; Crosson, Jane E; Spevak, Philip J; Ringel, Richard; Carson, Kathryn A; Khalil, Sara; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A; Traill, Thomas A; Holmes, Kathryn W

2013-04-01

Dilation of the sinus of Valsalva (SoV) has been increasingly observed after repaired tetralogy of Fallot (TOF). We estimate the prevalence of SoV dilation in adults with repaired TOF and analyze possible factors related to aortic disease. Adults with TOF [n = 109, median age 33.2 years (range 18.1 to 69.5)] evaluated at Johns Hopkins Hospital from 2001 to 2009 were reviewed in an observational retrospective cohort study. Median follow-up was 27.3 (range 0.1-48.8) years. SoV dilation was defined as >95 % confidence interval adjusted for age and body surface area (z-score > 2). The prevalence of SoV dilation was 51 % compared with that of a normal population with a mean z-score of 2.03. Maximal aortic diameters were ≥ 4 cm in 39 % (42 of 109), ≥ 4.5 cm in 21 % (23 of 109), ≥ 5 cm in 8 % (9 of 109), and ≥ 5.5 cm in 2 % (2 of 109). There was no aortic dissection or death due contributable to aortic disease. Aortic valve replacement was performed in 1.8 % and aortic root or ascending aorta (AA) replacement surgery in 2.8 % of patients. By multivariate logistic regression analysis, aortic regurgitation (AR) [odds ratio (OR) = 3.09, p = 0.005], residual ventricular septal defect (VSD) (OR = 4.14, p < 0.02), and TOF with pulmonary atresia (TOF/PA) (OR = 6.75, p = 0.03) were associated with increased odds of dilated aortic root. SoV dilation after TOF repair is common and persists with aging. AR, residual VSD, and TOF/PA are associated with increased odds of dilation. AA evaluation beyond the SoV is important. Indexed values are imperative to avoid bias on the basis of age and body surface area.

Overview of current surgical strategies for aortic disease in patients with Marfan syndrome.

PubMed

Miyahara, Shunsuke; Okita, Yutaka

2016-09-01

Marfan syndrome is a heritable, systemic disorder of the connective tissue with a high penetrance, named after Dr. Antoine Marfan. The most clinically important manifestations of this syndrome are cardiovascular pathologies which cause life-threatening events, such as acute aortic dissections, aortic rupture and regurgitation of the aortic valve or other artrioventricular valves leading to heart failure. These events play important roles in the life expectancy of patients with this disorder, especially prior to the development of effective surgical approaches for proximal ascending aortic disease. To prevent such catastrophic aortic events, a lower threshold has been recommended for prophylactic interventions on the aortic root. After prophylactic root replacement, disease in the aorta beyond the root and distal to the arch remains a cause for concern. Multiple surgeries are required throughout a patient's lifetime that can be problematic due to distal lesions complicated by dissection. Many controversies in surgical strategies remain, such as endovascular repair, to manage such complex cases. This review examines the trends in surgical strategies for the treatment of cardiovascular disease in patients with Marfan syndrome, and current perspectives in this field.

Long-term performance of the Hancock bioprosthetic valved conduit in the aortic root position.

PubMed

Badiu, Catalin C; Bleiziffer, Sabine; Eichinger, Walter B; Hettich, Ina; Krane, Markus; Bauernschmitt, Robert; Lange, Rüdiger

2011-03-01

The study aim was to assess long-term morbidity and mortality with special regard to prosthesis durability after aortic root replacement with the Hancock bioprosthetic porcine conduit. Between 1975 and 2004, a total of 81 patients (55 males, 26 females; mean age 58 +/- 18 years) underwent aortic root replacement with the Hancock conduit for aortic dissection (n = 22; 27%), ascending aortic aneurysm (n = 57; 70%), or porcelain aorta (n = 2; 3%). Twenty-five patients (31%) underwent an emergency operation, 12 (15%) presented with Marfan syndrome, and eight (10%) had undergone previous cardiac surgery. Concomitant procedures were performed in 26 cases (32%). The follow up was 98% complete; the mean follow up was 4.8 +/- 4.0 years (range: 1 day to 16.7 years), and the cumulative follow up was 403 patient-years. Actuarial event-free rates were calculated, and valve-related complications classified according to guidelines for reporting morbidity and mortality after cardiac valvular operations. There were seven (9%) operative deaths and four (5%) in-hospital deaths. Actuarial survival rates at five and 10 years (excluding operative deaths) were 77.0 +/- 5.3% and 54.0 +/- 7.5%, respectively. Actuarial freedom from aortic valve reoperation at five and 10 years was 98 +/- 1.6% and 64 +/- 10.2%, from structural valve deterioration 88.1 +/- 4.7% and 49.9 +/- 9.6%, from thromboembolic events 87.4 +/- 4.6% and 75.1 +/- 9.5%, and from major bleeding events 90.2 +/- 3.9% and 75.4 +/- 8.1%, respectively. Among redo procedures, the stentless Hancock valve could be excised without separating the synthetic graft from the left ventricular outflow tract, and a stented valve prosthesis thus implanted. Hence, it was possible to avoid a second Bentall operation. The long-term survival rates after aortic root replacement with the bioprosthetic Hancock conduit were reasonable for this demanding patient cohort. However, the durability of the prosthesis was inferior to that reported for the stented Hancock valve substitute. The key benefit of this bioprosthetic valved conduit was the simplified redo procedure.

Hemiarch Reconstruction Vs Clamped Aortic Anastomosis for Concomitant Ascending Aortic Aneurysm.

PubMed

Sultan, Ibrahim; Bianco, Valentino; Yajzi, Ibrahim; Kilic, Arman; Dufendach, Keith; Cardounel, Arturo; Althouse, Andrew D; Masri, Ahmad; Navid, Forozan; Gleason, Thomas G

2018-05-03

Deep hypothermic circulatory arrest (DHCA) is often avoided in patients with concomitant ascending aortic pathology when treating other cardiac disease to avoid increased risk of morbidity and mortality. We hypothesized that the use of DHCA with retrograde cerebral perfusion (RCP) does not add incremental risk to ascending aortic replacement alone in the setting of concomitant cardiac surgery. 408 ascending aortic ± hemiarch replacements and aortic (root)/mitral/tricuspid valve(s), CABG, or MAZE procedures were performed for concomitant cardiac disease. DHCA with RCP was used for all hemiarch replacements or the ascending aorta was replaced with an aortic cross-clamp proximal to the innominate artery. Propensity-score matching was used to match similar ascending patients vs. hemiarch patients; the final propensity score matched patients on age, gender, BMI, previous heart surgery, pre-op aortic insufficiency, pre-op aortic stenosis, pre-op EF, and operative variables. Propensity-score matching yielded 116 pairs of Non-hemiarch patients vs. 116 hemiarch patients. Within the propensity-score matched cohort, there were no differences in postoperative stroke (1.7% vs. 3.4%, p = 0.41), new postoperative dialysis (6.0% vs. 5.2%, p = 0.78), postoperative renal insufficiency (27.6% vs. 19.8%, p = 0.16), 30-day mortality (2.6% vs. 3.4%, p = 0.701), or 1-year mortality (4.3% vs. 4.3%, p = 1.00) CONCLUSIONS: Hemiarch replacement using DHCA with RCP does not increase the risk of operative complications compared to a normothermic, clamped-distal aortic anastomosis, and therefore its use should not be limited when planning complex multi-procedural reconstructions during elective ascending thoracic aortic replacement with concomitant cardiac surgery. Copyright © 2018. Published by Elsevier Inc.

Medium-term outcome of Toronto aortic valve replacement: single center experience.

PubMed

Li, Wei; Price, Susanna; O'Sullivan, Christine A; Kumar, Pankaj; Jin, Xu Y; Henein, Michael Y; Pepper, John R

2008-09-26

Long-term competence of any aortic prosthesis is critical to its clinical durability. Bioprosthetic valves, and in particular the stentless type have been proposed to offer superior haemodynamic profiles with consequent potential for superior left-ventricular mass regression. These benefits however are balanced by the potential longevity of the implanted valve. The aims of this study were to assess medium-term Toronto aortic valve function and its effect on left-ventricular function. Between 1992 and 1996 86 patients underwent Toronto aortic valve replacement for aortic valve disease and were followed up annually. Prospectively collected data was analyzed for all patients where detailed echocardiographic follow-up was available. Echocardiographic studies were analyzed at 2+/-0.6 and 6+/-1.4 years after valve replacement. Data collected included left-ventricular systolic and diastolic dimensions, fractional shortening and left-ventricular mass. In addition, data on aortic valve and root morphology, peak aortic velocities, time velocity integral, stroke volume and the mechanism of valve failure where relevant, were also collected. Complete echocardiographic data were available for eighty-four patients, age 69+/-9 years, 62 male. Additional coronary artery bypass grafting was performed in 38% of patients. Twelve (14%) valves had failed during follow-up, 7 (8%) requiring re-operation. Valve failure was associated with morphologically bicuspid native aortic valve (9/12), and progressive dilatation of the aortic sinuses, sino-tubular junction and ascending aorta (11/12). Left-ventricular mass index remained high (184+/-75 g/m(2)) and did not continue to regress between early and medium-term follow-up (175.8+/-77 g/m(2)). Although more than 90% of implanted Toronto aortic valves remained haemodynamically stable with low gradient at medium-term follow-up, young age and larger aortic dimensions in patients with valve failure suggest better outcome if used in the elderly with normal aortic root geometry.

Functional Heart Valve Scaffolds Obtained by Complete Decellularization of Porcine Aortic Roots in a Novel Differential Pressure Gradient Perfusion System

PubMed Central

Sierad, Leslie Neil; Shaw, Eliza Laine; Bina, Alexander; Brazile, Bryn; Rierson, Nicholas; Patnaik, Sourav S.; Kennamer, Allison; Odum, Rebekah; Cotoi, Ovidiu; Terezia, Preda; Branzaniuc, Klara; Smallwood, Harrison; Deac, Radu; Egyed, Imre; Pavai, Zoltan; Szanto, Annamaria; Harceaga, Lucian; Suciu, Horatiu; Raicea, Victor; Olah, Peter; Simionescu, Agneta; Liao, Jun; Movileanu, Ionela

2015-01-01

There is a great need for living valve replacements for patients of all ages. Such constructs could be built by tissue engineering, with perspective of the unique structure and biology of the aortic root. The aortic valve root is composed of several different tissues, and careful structural and functional consideration has to be given to each segment and component. Previous work has shown that immersion techniques are inadequate for whole-root decellularization, with the aortic wall segment being particularly resistant to decellularization. The aim of this study was to develop a differential pressure gradient perfusion system capable of being rigorous enough to decellularize the aortic root wall while gentle enough to preserve the integrity of the cusps. Fresh porcine aortic roots have been subjected to various regimens of perfusion decellularization using detergents and enzymes and results compared to immersion decellularized roots. Success criteria for evaluation of each root segment (cusp, muscle, sinus, wall) for decellularization completeness, tissue integrity, and valve functionality were defined using complementary methods of cell analysis (histology with nuclear and matrix stains and DNA analysis), biomechanics (biaxial and bending tests), and physiologic heart valve bioreactor testing (with advanced image analysis of open–close cycles and geometric orifice area measurement). Fully acellular porcine roots treated with the optimized method exhibited preserved macroscopic structures and microscopic matrix components, which translated into conserved anisotropic mechanical properties, including bending and excellent valve functionality when tested in aortic flow and pressure conditions. This study highlighted the importance of (1) adapting decellularization methods to specific target tissues, (2) combining several methods of cell analysis compared to relying solely on histology, (3) developing relevant valve-specific mechanical tests, and (4) in vitro testing of valve functionality. PMID:26467108

Aortopathy in patients with bicuspid aortic valve stenosis: role of aortic root functional parameters.

PubMed

Girdauskas, Evaldas; Rouman, Mina; Disha, Kushtrim; Espinoza, Andres; Dubslaff, Georg; Fey, Beatrix; Theis, Bernhard; Petersen, Iver; Borger, Michael A; Kuntze, Thomas

2016-02-01

We prospectively examined functional characteristics of the aortic root and transvalvular haemodynamic flow in order to define factors associated with the severity of aortopathy in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis. A total of 103 consecutive patients with BAV stenosis (mean age 61 ± 9 years, 66% male) underwent aortic valve replacement ± concomitant aortic surgery from January 2012 through March 2014. All patients underwent preoperative cardiac magnetic resonance imaging (MRI) in order to evaluate the systolic transvalvular flow and the following functional parameters: (i) angulation between the left ventricular outflow axis and the aortic root, (ii) geometrical orientation of residual aortic valve orifice and (iii) BAV cusp fusion pattern. MRI data were used to guide sampling of the ascending aorta during surgery [i.e. jet-sample from the area where the flow-jet impacts on the aortic wall and control sample from the opposite aortic wall (obtained from the aortotomy site)]. Aortopathy was quantified by means of a histological sum-score (0 to 21+) in each sample. A significant correlation was found between histological sum-score in the jet-sample and the angle between the LV outflow axis and the aortic root (r = 0.6, P = 0.007). Moreover, there was a linear correlation between proximal aortic diameter and the angle between systolic flow-jet and ascending aortic wall (r = 0.5, P = 0.006). Logistic regression identified the angle between the LV outflow axis and the aortic root (OR 1.1, P = 0.04) and the angle between the flow-jet and the aortic wall (OR 1.2, P = 0.001) as independent predictors of an indexed proximal aortic diameter ≥22 mm/m(2). Functional parameters of the aortic root may be used to predict the severity of aortopathy in patients with BAV stenosis, and may be useful in predicting future risk of aortic disease in such patients. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Aortic valve dysfunction and aortic dilation in adults with coarctation of the aorta.

PubMed

Clair, Mathieu; Fernandes, Susan M; Khairy, Paul; Graham, Dionne A; Krieger, Eric V; Opotowsky, Alexander R; Singh, Michael N; Colan, Steven D; Meijboom, Erik J; Landzberg, Michael J

2014-01-01

To determine the prevalence of aortic valve dysfunction, aortic dilation, and aortic valve and ascending aortic intervention in adults with coarctation of the aorta (CoA). Aortic valve dysfunction and aortic dilation are rare among children and adolescents with CoA. With longer follow-up, adults may be more likely to have progressive disease. We retrospectively reviewed all adults with CoA, repaired or unrepaired, seen at our center between 2004 and 2010. Two hundred sixteen adults (56.0% male) with CoA were identified. Median age at last evaluation was 28.3 (range 18.0 to 75.3) years. Bicuspid aortic valve (BAV) was present in 65.7%. At last follow-up, 3.2% had moderate or severe aortic stenosis, and 3.7% had moderate or severe aortic regurgitation. Dilation of the aortic root or ascending aorta was present in 28.0% and 41.6% of patients, respectively. Moderate or severe aortic root or ascending aortic dilation (z-score > 4) was present in 8.2% and 13.7%, respectively. Patients with BAV were more likely to have moderate or severe ascending aortic dilation compared with those without BAV (19.5% vs. 0%; P < 0.001). Age was associated with ascending aortic dilation (P = 0.04). At most recent follow-up, 5.6% had undergone aortic valve intervention, and 3.2% had aortic root or ascending aortic replacement. In adults with CoA, significant aortic valve dysfunction and interventions during early adulthood were uncommon. However, aortic dilation was prevalent, especially of the ascending aorta, in patients with BAV. © 2013 Wiley Periodicals, Inc.

Ascending aortic aneurysm causing hoarse voice: a variant of Ortner's syndrome

PubMed Central

Eccles, Sinan Robert; Banks, John; Kumar, Pankaj

2012-01-01

A 68-year-old man with a persistent hoarse voice was found to have a left vocal cord paralysis. Clinical examination revealed signs consistent with aortic regurgitation. Subsequent investigation revealed an ascending aortic aneurysm. He underwent aortic root and ascending aorta replacement and his hoarseness improved. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Recurrent laryngeal nerve palsy due to aneurysmal dilation of the ascending aorta is extremely rare, with aneurysms of the aortic arch being a more common cause. PMID:23060380

Aortic operation after previous coronary artery bypass grafting: management of patent grafts for myocardial protection.

PubMed

Nakajima, Masato; Tsuchiya, Koji; Fukuda, Shoji; Morimoto, Hironobu; Mitsumori, Yoshitaka; Kato, Kaori

2006-04-01

Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.

Automatic aortic root segmentation in CTA whole-body dataset

NASA Astrophysics Data System (ADS)

Gao, Xinpei; Kitslaar, Pieter H.; Scholte, Arthur J. H. A.; Lelieveldt, Boudewijn P. F.; Dijkstra, Jouke; Reiber, Johan H. C.

2016-03-01

Trans-catheter aortic valve replacement (TAVR) is an evolving technique for patients with serious aortic stenosis disease. Typically, in this application a CTA data set is obtained of the patient's arterial system from the subclavian artery to the femoral arteries, to evaluate the quality of the vascular access route and analyze the aortic root to determine if and which prosthesis should be used. In this paper, we concentrate on the automated segmentation of the aortic root. The purpose of this study was to automatically segment the aortic root in computed tomography angiography (CTA) datasets to support TAVR procedures. The method in this study includes 4 major steps. First, the patient's cardiac CTA image was resampled to reduce the computation time. Next, the cardiac CTA image was segmented using an atlas-based approach. The most similar atlas was selected from a total of 8 atlases based on its image similarity to the input CTA image. Third, the aortic root segmentation from the previous step was transferred to the patient's whole-body CTA image by affine registration and refined in the fourth step using a deformable subdivision surface model fitting procedure based on image intensity. The pipeline was applied to 20 patients. The ground truth was created by an analyst who semi-automatically corrected the contours of the automatic method, where necessary. The average Dice similarity index between the segmentations of the automatic method and the ground truth was found to be 0.965±0.024. In conclusion, the current results are very promising.

Ross operation in children: late results.

PubMed

Elkins, R C; Lane, M M; McCue, C

2001-11-01

Although the Ross operation has become the accepted aortic valve replacement in children, the long-term fate of the pulmonary autograft valve remains unknown. To assess mid-term and late results of autograft valve durability, patient survival and valve-related morbidity, a retrospective review of patients (age range: 3 days to 17 years) having a Ross operation between November 1986 and May 2001 were reviewed. Medical records and patient contacts with all but two of 167 current survivors of 178 consecutive patients having an aortic valve replacement as a Ross operation have been completed during the past two years. The most recent echocardiographic evaluation was reviewed for autograft valve and homograft valve function. Operative mortality was 4.5% (8/178), with three late deaths (two were non-valve-related) for an actuarial survival of 92+/-3% at 12 years. Actuarial freedom from autograft valve degeneration (reoperation or severe insufficiency of autograft valve or valve-related death) was 90+/-4% at 12 years. Autograft valve degeneration was not affected by technique of insertion (141 root replacement, 37 intra-aortic), aortic valve morphology (157 bicuspid or unicuspid, 26 tricuspid), or age at operation. Autograft valve degeneration was worse in patients with a primary lesion of aortic insufficiency than in those with aortic stenosis (p = 0.03). Autograft valve reoperation was required in 12 patients, with autograft valve replacement in seven. Actuarial freedom from autograft replacement was 93+/-3% at 12 years. Homograft valve replacement was required in seven patients, with actuarial freedom from replacement of 90+/-4% at 12 years. Eight additional patients have homograft valve obstruction (gradient > or =50 mmHg), and seven have severe pulmonary insufficiency. Survival and freedom from aortic valve replacement are excellent in children. Homograft valve late function remains a concern, and efforts to improve homograft durability should be encouraged.

Very Low Intravenous Contrast Volume Protocol for Computed Tomography Angiography Providing Comprehensive Cardiac and Vascular Assessment Prior to Transcatheter Aortic Valve Replacement in Patients with Chronic Kidney Disease

PubMed Central

Pulerwitz, Todd C.; Khalique, Omar K.; Nazif, Tamim N.; Rozenshtein, Anna; Pearson, Gregory D.N.; Hahn, Rebecca T.; Vahl, Torsten P.; Kodali, Susheel K.; George, Isaac; Leon, Martin B.; D'Souza, Belinda; Po, Ming Jack; Einstein, Andrew J.

2016-01-01

Background Transcatheter aortic valve replacement (TAVR) is a lifesaving procedure for many patients high risk for surgical aortic valve replacement. The prevalence of chronic kidney disease (CKD) is high in this population, and thus a very low contrast volume (VLCV) computed tomography angiography (CTA) protocol providing comprehensive cardiac and vascular imaging would be valuable. Methods 52 patients with severe, symptomatic aortic valve disease, undergoing pre-TAVR CTA assessment from 2013-4 at Columbia University Medical Center were studied, including all 26 patients with CKD (eGFR<30mL/min) who underwent a novel VLCV protocol (20mL of iohexol at 2.5mL/s), and 26 standard-contrast-volume (SCV) protocol patients. Using a 320-slice volumetric scanner, the protocol included ECG-gated volume scanning of the aortic root followed by medium-pitch helical vascular scanning through the femoral arteries. Two experienced cardiologists performed aortic annulus and root measurements. Vascular image quality was assessed by two radiologists using a 4-point scale. Results VLCV patients had mean(±SD) age 86±6.5, BMI 23.9±3.4 kg/m2 with 54% men; SCV patients age 83±8.8, BMI 28.7±5.3 kg/m2, 65% men. There was excellent intra- and inter-observer agreement for annular and root measurements, and excellent agreement with 3D-transesophageal echocardiographic measurements. Both radiologists found diagnostic-quality vascular imaging in 96% of VLCV and 100% of SCV cases, with excellent inter-observer agreement. Conclusions This study is the first of its kind to report the feasibility and reproducibility of measurements for a VLCV protocol for comprehensive pre-TAVR CTA. There was excellent agreement of cardiac measurements and almost all studies were diagnostic quality for vascular access assessment. PMID:27061253

Durability of Aortic Valve Cusp Repair With and Without Annular Support.

PubMed

Zeeshan, Ahmad; Idrees, Jay J; Johnston, Douglas R; Rajeswaran, Jeevanantham; Roselli, Eric E; Soltesz, Edward G; Gillinov, A Marc; Griffin, Brian; Grimm, Richard; Hammer, Donald F; Pettersson, Gösta B; Blackstone, Eugene H; Sabik, Joseph F; Svensson, Lars G

2018-03-01

To determine the value of aortic valve repair rather than replacement for valve dysfunction, we assessed late outcomes of various repair techniques in the contemporary era. From January 2001 to January 2011, aortic valve repair was planned in 1,124 patients. Techniques involved commissural figure-of-8 suspension sutures (n = 63 [6.2%]), cusp repair with commissuroplasty (n = 481 [48%]), debridement (n = 174 [17%]), free-margin plication (n = 271 [27%]) or resection (n = 75) or both, or annulus repair with resuspension (n = 230 [23%]), root reimplantation (n = 252 [25%]), or remodeling (n = 35 [3.5%]). Planned repair was aborted for replacement in 115 patients (10%); risk factors included greater severity of aortic regurgitation (AR; p = 0.0002) and valve calcification (p < 0.0001). In-hospital outcomes for the remaining 1,009 patients included death (12 [1.2%]), stroke (13 [1.3%]), and reoperation for valve dysfunction (14 [1.4%]). Freedom from aortic valve reoperation at 1, 5, and 10 years was 97%, 93%, and 90%, respectively. Figure-of-8 suspension sutures, valve resuspension, and root repair and replacement were least likely to require reoperation; cusp repair with commissural sutures, plication, and commissuroplasty was most likely (p < 0.05). Survival at 1, 5, and 10 years was 96%, 92%, and 83%. Immediate postoperative AR grade was none-mild (94%), moderate (5%), and severe (1%). At 10 years after repair, AR grade was none (20%), mild (33%), moderate (26%), and severe (21%). Patients undergoing root procedures were less likely to have higher-grade postoperative AR (p < 0.0001). Valve repair is effective and durable for treating aortic valve dysfunction. Greater severity of AR preoperatively is associated with higher likelihood of repair failure. Commissural figure-of-8 suspension sutures and repair with annular support have the best long-term durability. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Totally biological composite aortic stentless valved conduit for aortic root replacement: 10-year experience

PubMed Central

2011-01-01

Objectives To retrospectively analyze the clinical outcome of a totally biological composite stentless aortic valved conduit (No-React® BioConduit) implanted using the Bentall procedure over ten years in a single centre. Methods Between 27/10/99 and 19/01/08, the No-React® BioConduit composite graft was implanted in 67 patients. Data on these patients were collected from the in-hospital database, from patient notes and from questionnaires. A cohort of patients had 2D-echocardiogram with an average of 4.3 ± 0.45 years post-operatively to evaluate valve function, calcification, and the diameter of the conduit. Results Implantation in 67 patients represented a follow-up of 371.3 patient-year. Males were 60% of the operated population, with a mean age of 67.9 ± 1.3 years (range 34.1-83.8 years), 21 of them below the age of 65. After a mean follow-up of 7.1 ± 0.3 years (range of 2.2-10.5 years), more than 50% of the survivors were in NYHA I/II and more than 60% of the survivors were angina-free (CCS 0). The overall 10-year survival following replacement of the aortic valve and root was 51%. During this period, 88% of patients were free from valved-conduit related complications leading to mortality. Post-operative echocardiography studies showed no evidence of stenosis, dilatation, calcification or thrombosis. Importantly, during the 10-year follow-up period no failures of the valved conduit were reported, suggesting that the tissue of the conduit does not structurally change (histology of one explant showed normal cusp and conduit). Conclusions The No-React® BioConduit composite stentless aortic valved conduit provides excellent long-term clinical results for aortic root replacement with few prosthesis-related complications in the first post-operative decade. PMID:21699696

Evolution of surgical therapy for Stanford acute type A aortic dissection

PubMed Central

Chiu, Peter

2016-01-01

Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results. PMID:27563541

[Indications for and clinical outcome of the Ross procedure: a review].

PubMed

Morita, K; Kurosawa, H

2001-04-01

The Ross procedure has been used increasingly to treat aortic valve disease in children and young adults. The primary indication for the Ross procedure is to provide a permanent valve replacement in children with congenital aortic stenosis. More recently, it has been extended to young adults with a bicuspid aortic valve and small aortic annulus, especially women wishing to have children. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus. Conversely, Marfan syndrome is considered to an absolute contraindication, and this procedure should be used with caution in patients with rheumatic valve disease and a dysplastic dilated aortic root because of the higher associated incidence of autograft dysfunction. The technique of total aortic root replacement has become the preferred method of autograft implantation, because it carries the lowest risk of pulmonary autograft failure. In patients with marked graft-host size mismatch, either concomitant aortic annulus reduction and fixation or aortic annulus enlargement (i.e., the Ross-Konno procedure) should be performed. The Ross Procedure International Registry data document that in the modern era (post-1986) the early and late mortality rate is 2.5% and 1%, respectively. Excellent long-term results have been reported, and the benefits of this procedure include optimal hemodynamics, low risk of endocarditis, resistance to infection in patients with active endocarditis, and nonthrombogeneicity and therefore few anticoagulation-related complications. The Ross procedure can be performed with acceptable early and mid-term mortality and excellent autograft durability. Further long-term follow-up will confirm the role of this procedure in patients with various types of aortic valve disease.

Functional Aortic Root Parameters and Expression of Aortopathy in Bicuspid Versus Tricuspid Aortic Valve Stenosis.

PubMed

Girdauskas, Evaldas; Rouman, Mina; Disha, Kushtrim; Fey, Beatrix; Dubslaff, Georg; Theis, Bernhard; Petersen, Iver; Gutberlet, Matthias; Borger, Michael A; Kuntze, Thomas

2016-04-19

The correlation between bicuspid aortic valve (BAV) disease and aortopathy is not fully defined. This study aimed to prospectively analyze the correlation between functional parameters of the aortic root and expression of aortopathy in patients undergoing surgery for BAV versus tricuspid aortic valve (TAV) stenosis. From January 1, 2012 through December 31, 2014, 190 consecutive patients (63 ± 8 years, 67% male) underwent aortic valve replacement ± proximal aortic surgery for BAV stenosis (n = 137, BAV group) and TAV stenosis (n = 53, TAV group). All patients underwent pre-operative cardiac magnetic resonance imaging to evaluate morphological/functional parameters of the aortic root. Aortic tissue was sampled during surgery on the basis of the location of eccentric blood flow contact with the aortic wall, as determined by cardiac magnetic resonance (i.e., jet sample and control sample). Aortic wall lesions were graded using a histological sum score (0 to 21). The largest cross-sectional aortic diameters were at the mid-ascending level in both groups and were larger in BAV patients (40.2 ± 7.2 mm vs. 36.6 ± 3.3 mm, respectively, p < 0.001). The histological sum score was 2.9 ± 1.4 in the BAV group versus 3.4 ± 2.6 in the TAV group (p = 0.4). The correlation was linear and comparable between the maximum indexed aortic diameter and the angle between the left ventricular outflow axis and aortic root (left ventricle/aorta angle) in both groups (BAV group: r = 0.6, p < 0.001 vs. TAV group r = 0.45, p = 0.03, z = 1.26, p = 0.2). Logistic regression identified the left ventricle/aorta angle as an indicator of indexed aortic diameter >22 mm/m(2) (odds ratio: 1.2; p < 0.001). Comparable correlation patterns between functional aortic root parameters and expression of aortopathy are found in patients with BAV versus TAV stenosis. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

An unusual cause of hemolysis in a patient with an aortic valved conduit replacement.

PubMed

Allman, Christine; Rajaratnam, Rohan; Kachwalla, Hashim; Hughes, Clifford F; Bannon, Paul; Leung, Dominic Y

2003-02-01

Hemolytic anemia is a well-known but uncommon complication in patients with prosthetic heart valves. It is most commonly a result of prosthetic valve dysfunction, periprosthetic valvular regurgitation, or both. We report a case of a 41-year-old man who had a previous aortic valve and root replacement for acute proximal aortic dissection, now presenting with hemolytic anemia. This was a result of flow obstruction at the distal anastomosis of the aortic conduit by the presence of multiple dissection flaps resulting in severe flow turbulence. Although the pathology was at the blind spot for transesophageal echocardiography, the dissection flaps, the flow turbulence, and the degree of obstruction were well-demonstrated by this technique after careful manipulation of the probe and a high index of suspicion.

Outcome of aortic valve replacement for active infective endocarditis in patients on chronic hemodialysis.

PubMed

Dohmen, Pascal M; Binner, Christian; Mende, Meinhart; Bakhtiary, Farhad; Etz, Christian; Pfannmüller, Bettina; Davierwala, Piroze; Borger, Michael A; Misfeld, Martin; Mohr, Friedrich W

2015-02-01

The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed. Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause. In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Evidence-based Surgery of Aortic Regurgitation: Results of a Questionnaire in German-speaking Countries.

PubMed

Dinges, Christian; Steindl, Johannes; Hitzl, Wolfgang; Kiesslich, Tobias; Seitelberger, Rainald

2018-06-01

evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons ( n  = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed. Georg Thieme Verlag KG Stuttgart · New York.

Sixteen-Year Experience of David and Bentall Procedures in Acute Type A Aortic Dissection.

PubMed

Yang, Bo; Patel, Himanshu J; Sorek, Claire; Hornsby, Whitney E; Wu, Xiaoting; Ward, Sarah; Thomas, Marc; Driscoll, Anisa; Waidley, Victoria A; Norton, Elizabeth L; Likosky, Donald S; Deeb, G Michael

2018-03-01

To examine short-term and midterm outcomes after the David and Bentall procedures in patients with an acute type A aortic dissection. Between 2001 and 2017, patients (n = 135) with acute type A aortic dissection underwent an aortic root replacement with either the David (n = 40) or Bentall (n = 95) procedure. Perioperative outcome, reoperation rate, aortic valve function, and long-term survival were evaluated. The median age of the entire cohort was 56 years. Rates of malperfusion (21%), shock (16%), history of renal failure (4%), and extent of surgery were similar between David and Bentall groups. However, the David group was significantly younger (45 versus 61 years) with less hypertension (45% versus 66%), coronary artery disease (0% versus 17%), valvulopathy (5% versus 19%), and prior cardiac surgery (5% versus 21%). Overall operative mortality was 9.6% (David 3% and Bentall 13%). Composite outcome comprising myocardial infarction, stroke, new-onset renal failure, and operative mortality was 18% in the entire cohort (David 5% and Bentall 23%). In the David group, the freedom of moderate aortic insufficiency was 95% at 10 years. The rate of reoperation for pathology of the proximal aorta or aortic valve was 0% and 2% for the David and Bentall groups, respectively. Ten-year Kaplan-Meier survival was 66% (95% confidence interval: 51% to 77%) for the entire cohort, with 98% (95% confidence interval: 84% to 99%) survival in the David group and 57% (95% confidence interval: 42% to 70%) survival in the Bentall group. Both the David and Bentall procedures are appropriate surgical approaches for aortic root replacement in select patients with an acute type A aortic dissection. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The Ross operation: a 12-year experience.

PubMed

Elkins, R C

1999-09-01

The Ross operation, originally introduced as a scalloped subcoronary implant with an 80% survival and 85% freedom from reoperation, has recently been modified to a root replacement which is now the most utilized implant technique. The mid and late results of this operative technique and comparison of intra-aortic implants and root replacement in a single institution are reported. The records of 328 patients who had a Ross operation at the University of Oklahoma (August 1986 to July 1998) were reviewed to assess operative technique and patient-related factors on survival, autograft valve function, homograft valve function, valve-related complications, and need for reoperation. Operative survival was 95.4% with an actuarial survival of 89% +/- 5% at 8 years. Freedom from replacement of the pulmonary autograft was 94% +/- 3% at 8 years, freedom from reoperation on the pulmonary homograft was 90% +/- 4% at 8 years, and freedom from autograft valve reoperation or dysfunction (3+ autograft valve insufficiency) was 83% +/- 6% at 9 years. The incidence of autograft valve reoperation and late autograft valve dysfunction was decreased by root replacement. Annulus reduction and fixation improved early results in patients with aortic insufficiency and annulus dilatation. Early results have been excellent, as the development of late autograft valve dysfunction or dilatation has been rare. The excellent hemodynamic results with a limited incidence of reoperation and replacement of the autograft valve justify its continued use.

Feature-based US to CT registration of the aortic root

NASA Astrophysics Data System (ADS)

Lang, Pencilla; Chen, Elvis C. S.; Guiraudon, Gerard M.; Jones, Doug L.; Bainbridge, Daniel; Chu, Michael W.; Drangova, Maria; Hata, Noby; Jain, Ameet; Peters, Terry M.

2011-03-01

A feature-based registration was developed to align biplane and tracked ultrasound images of the aortic root with a preoperative CT volume. In transcatheter aortic valve replacement, a prosthetic valve is inserted into the aortic annulus via a catheter. Poor anatomical visualization of the aortic root region can result in incorrect positioning, leading to significant morbidity and mortality. Registration of pre-operative CT to transesophageal ultrasound and fluoroscopy images is a major step towards providing augmented image guidance for this procedure. The proposed registration approach uses an iterative closest point algorithm to register a surface mesh generated from CT to 3D US points reconstructed from a single biplane US acquisition, or multiple tracked US images. The use of a single simultaneous acquisition biplane image eliminates reconstruction error introduced by cardiac gating and TEE probe tracking, creating potential for real-time intra-operative registration. A simple initialization procedure is used to minimize changes to operating room workflow. The algorithm is tested on images acquired from excised porcine hearts. Results demonstrate a clinically acceptable accuracy of 2.6mm and 5mm for tracked US to CT and biplane US to CT registration respectively.

Very low intravenous contrast volume protocol for computed tomography angiography providing comprehensive cardiac and vascular assessment prior to transcatheter aortic valve replacement in patients with chronic kidney disease.

PubMed

Pulerwitz, Todd C; Khalique, Omar K; Nazif, Tamim N; Rozenshtein, Anna; Pearson, Gregory D N; Hahn, Rebecca T; Vahl, Torsten P; Kodali, Susheel K; George, Isaac; Leon, Martin B; D'Souza, Belinda; Po, Ming Jack; Einstein, Andrew J

2016-01-01

Transcatheter aortic valve replacement (TAVR) is a lifesaving procedure for many patients high risk for surgical aortic valve replacement. The prevalence of chronic kidney disease (CKD) is high in this population, and thus a very low contrast volume (VLCV) computed tomography angiography (CTA) protocol providing comprehensive cardiac and vascular imaging would be valuable. 52 patients with severe, symptomatic aortic valve disease, undergoing pre-TAVR CTA assessment from 2013-4 at Columbia University Medical Center were studied, including all 26 patients with CKD (eGFR<30 mL/min) who underwent a novel VLCV protocol (20 mL of iohexol at 2.5 mL/s), and 26 standard-contrast-volume (SCV) protocol patients. Using a 320-slice volumetric scanner, the protocol included ECG-gated volume scanning of the aortic root followed by medium-pitch helical vascular scanning through the femoral arteries. Two experienced cardiologists performed aortic annulus and root measurements. Vascular image quality was assessed by two radiologists using a 4-point scale. VLCV patients had mean (±SD) age 86 ± 6.5, BMI 23.9 ± 3.4 kg/m(2) with 54% men; SCV patients age 83 ± 8.8, BMI 28.7 ± 5.3 kg/m(2), 65% men. There was excellent intra- and inter-observer agreement for annular and root measurements, and excellent agreement with 3D-transesophageal echocardiographic measurements. Both radiologists found diagnostic-quality vascular imaging in 96% of VLCV and 100% of SCV cases, with excellent inter-observer agreement. This study is the first of its kind to report the feasibility and reproducibility of measurements for a VLCV protocol for comprehensive pre-TAVR CTA. There was excellent agreement of cardiac measurements and almost all studies were diagnostic quality for vascular access assessment. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Transaortic edge-to-edge mitral valve repair for moderate secondary/functional mitral regurgitation in patients undergoing aortic root/valve intervention.

PubMed

Choudhary, Shiv Kumar; Abraham, Atul; Bhoje, Amol; Gharde, Parag; Sahu, Manoj; Talwar, Sachin; Airan, Balram

2017-11-01

The present study evaluates the feasibility, safety, and efficacy of edge-to-edge repair for moderate secondary/functional mitral regurgitation in patients undergoing aortic valve/root interventions. Sixteen patients underwent transaortic edge-to-edge mitral valve repair. Mitral regurgitation was 2+ in 8 patients and 3+ in 6 patients. Two patients in whom cardiac arrest developed preoperatively had severe (4+) mitral regurgitation. Patients underwent operation for severe aortic regurgitation ± aortic root lesions. The mean left ventricular systolic and diastolic diameters were 51.5 ± 12.8 mm and 70.7 ± 10.7 mm, respectively. Left ventricular ejection fraction ranged from 20% to 60%. Primary surgical procedure included Bentall's ± hemiarch replacement in 10 patients, aortic valve replacement in 5 patients, and noncoronary sinus replacement with aortic valve repair in 1 patient. Severity of mitral regurgitation decreased to trivial or zero in 13 patients, 1+ in 2 patients, and 2+ in 1 patient. There were no gradients across the mitral valve in 9 patients, less than 5 mm Hg in 6 patients, and 9 mm Hg in 1 patient. There was no operative mortality. Follow-up ranged from 2 weeks to 54 months. Echocardiography showed trivial or no mitral regurgitation in 12 patients, 1+ in 2 patients, and 2+ in 2 patients. None of the patients had significant mitral stenosis. The mean left ventricular systolic and diastolic diameters decreased to 40.5 ± 10.3 mm and 58.7 ± 11.6 mm, respectively. Ejection fraction also improved slightly (22%-65%). Transaortic edge-to-edge mitral valve repair is a safe and effective technique to abolish secondary/functional mitral regurgitation. However, its impact on overall survival needs to be studied. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Evaluation of simulation training in cardiothoracic surgery: the Senior Tour perspective.

PubMed

Fann, James I; Feins, Richard H; Hicks, George L; Nesbitt, Jonathan C; Hammon, John W; Crawford, Fred A

2012-02-01

The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery. Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators. All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers. By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value. Published by Mosby, Inc.

Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging.

PubMed

Bolen, Michael A; Popovic, Zoran B; Dahiya, Arun; Kapadia, Samir R; Tuzcu, E Murat; Flamm, Scott D; Halliburton, Sandra S; Schoenhagen, Paul

2012-01-01

Transcatheter valve interventions rely on imaging for patient selection, preprocedural planning, and intraprocedural guidance. We explored the use of prospective electrocardiogram (ECG)-triggered 4-dimensional (4-D) CT imaging in patients evaluated for transcatheter aortic valve replacement (TAVR). A total of 47 consecutive patients underwent 128-slice dual-source CT with wide-window dose-modulated prospective ECG-triggered, axial acquisition of the aortic root, reconstructed during diastolic and systolic cardiac phases. Image quality was evaluated, aortic root and left ventricular (LV) geometry and function were analyzed, and radiation exposure was estimated. Image quality was generally good, with 41 of 47 (87%) patients scored as good or excellent. The mean aortic valve area was 0.93 ± 0.24 cm(2). Mean LV ejection fraction was 56.8% ± 16.4%, and mean LV mass was 130.4 ± 43.8 g. The minor diameter of the annulus was larger in systole (systole, 2.29 ± 0.24 cm; diastole, 2.14 ± 0.25 cm; P = 0.006), but the mean and major diameters did not vary significantly between systole and diastole. The mean estimated effective dose was 5.9 ± 2.4 mSv. Multiphase, prospective ECG-triggered axial image acquisition is a lower dose acquisition technique for 4-D aortic root imaging in patients being considered for TAVR. Copyright © 2012 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Assessment of Hemodynamic Conditions in the Aorta Following Root Replacement with Composite Valve-Conduit Graft.

PubMed

Cheng, Zhuo; Kidher, Emaddin; Jarral, Omar A; O'Regan, Declan P; Wood, Nigel B; Athanasiou, Thanos; Xu, Xiao Yun

2016-05-01

This paper presents the analysis of detailed hemodynamics in the aortas of four patients following replacement with a composite bio-prosthetic valve-conduit. Magnetic resonance image-based computational models were set up for each patient with boundary conditions comprising subject-specific three-dimensional inflow velocity profiles at the aortic root and central pressure waveform at the model outlet. Two normal subjects were also included for comparison. The purpose of the study was to investigate the effects of the valve-conduit on flow in the proximal and distal aorta. The results suggested that following the composite valve-conduit implantation, the vortical flow structure and hemodynamic parameters in the aorta were altered, with slightly reduced helical flow index, elevated wall shear stress and higher non-uniformity in wall shear compared to normal aortas. Inter-individual analysis revealed different hemodynamic conditions among the patients depending on the conduit configuration in the ascending aorta, which is a key factor in determining post-operative aortic flow. Introducing a natural curvature in the conduit to create a smooth transition between the conduit and native aorta may help prevent the occurrence of retrograde and recirculating flow in the aortic arch, which is particularly important when a large portion or the entire ascending aorta needs to be replaced.

Ascending Aortic Stenting for Acute Supraaortic Stenosis From Graft Collapse.

PubMed

Lader, Joshua M; Smith, Deane E; Staniloae, Cezar; Fallahi, Arzhang; Iqbal, Sohah N; Galloway, Aubrey C; Williams, Mathew R

2018-06-01

A 78-year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a polyester graft (Dacron) using the graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120 mm Hg intragraft gradient. Computed tomography arteriography was unrevealing, but intraaortic ultrasound demonstrated critical intragraft stenosis. A balloon expandable stent (Palmaz stent, Cordis, Milpitas, CA) was deployed in the stenotic region with gradient resolution. The patient later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

3D echocardiographic analysis of aortic annulus for transcatheter aortic valve replacement using novel aortic valve quantification software: Comparison with computed tomography.

PubMed

Mediratta, Anuj; Addetia, Karima; Medvedofsky, Diego; Schneider, Robert J; Kruse, Eric; Shah, Atman P; Nathan, Sandeep; Paul, Jonathan D; Blair, John E; Ota, Takeyoshi; Balkhy, Husam H; Patel, Amit R; Mor-Avi, Victor; Lang, Roberto M

2017-05-01

With the increasing use of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), computed tomography (CT) remains the standard for annulus sizing. However, 3D transesophageal echocardiography (TEE) has been an alternative in patients with contraindications to CT. We sought to (1) test the feasibility, accuracy, and reproducibility of prototype 3DTEE analysis software (Philips) for aortic annular measurements and (2) compare the new approach to the existing echocardiographic techniques. We prospectively studied 52 patients who underwent gated contrast CT, procedural 3DTEE, and TAVR. 3DTEE images were analyzed using novel semi-automated software designed for 3D measurements of the aortic root, which uses multiplanar reconstruction, similar to CT analysis. Aortic annulus measurements included area, perimeter, and diameter calculations from these measurements. The results were compared to CT-derived values. Additionally, 3D echocardiographic measurements (3D planimetry and mitral valve analysis software adapted for the aortic valve) were also compared to the CT reference values. 3DTEE image quality was sufficient in 90% of patients for aortic annulus measurements using the new software, which were in good agreement with CT (r-values: .89-.91) and small (<4%) inter-modality nonsignificant biases. Repeated measurements showed <10% measurements variability. The new 3D analysis was the more accurate and reproducible of the existing echocardiographic techniques. Novel semi-automated 3DTEE analysis software can accurately measure aortic annulus in patients with severe AS undergoing TAVR, in better agreement with CT than the existing methodology. Accordingly, intra-procedural TEE could potentially replace CT in patients where CT carries significant risk. © 2017, Wiley Periodicals, Inc.

A planning system for transapical aortic valve implantation

NASA Astrophysics Data System (ADS)

Gessat, Michael; Merk, Denis R.; Falk, Volkmar; Walther, Thomas; Jacobs, Stefan; Nöttling, Alois; Burgert, Oliver

2009-02-01

Stenosis of the aortic valve is a common cardiac disease. It is usually corrected surgically by replacing the valve with a mechanical or biological prosthesis. Transapical aortic valve implantation is an experimental minimally invasive surgical technique that is applied to patients with high operative risk to avoid pulmonary arrest. A stented biological prosthesis is mounted on a catheter. Through small incisions in the fifth intercostal space and the apex of the heart, the catheter is positioned under flouroscopy in the aortic root. The stent is expanded and unfolds the valve which is thereby implanted into the aortic root. Exact targeting is crucial, since major complications can arise from a misplaced valve. Planning software for the perioperative use is presented that allows for selection of the best fitting implant and calculation of the safe target area for that implant. The software uses contrast enhanced perioperative DynaCT images acquired under rapid pacing. In a semiautomatic process, a surface segmentation of the aortic root is created. User selected anatomical landmarks are used to calculate the geometric constraints for the size and position of the implant. The software is integrated into a PACS network based on DICOM communication to query and receive the images and implants templates from a PACS server. The planning results can be exported to the same server and from there can be rertieved by an intraoperative catheter guidance device.

Transcatheter JenaValve Implantation in a Stentless Prosthesis: A Challenging Case After 4 Previous Aortic Procedures.

PubMed

Sponga, Sandro; Mazzaro, Enzo; Bagur, Rodrigo; Livi, Ugolino

2017-04-01

A 40-year-old man underwent 4 aortic surgeries because of endocarditis and subsequent prosthesis dehiscence. At the last recurrence he presented with acute severe aortic regurgitation of a Pericarbon Freedom (LivaNova plc, London, UK) stentless bioprosthesis and a morphologically disarranged aortic root. He also presented with left ventricular dysfunction and a very low origin of the left coronary artery. Therefore, a fifth redo aortic valve replacement was considered at high surgical risk. Accordingly, before listing the patient for a heart transplantation, a transcatheter valve-in-valve implantation with the JenaValve (JenaValve Technology, GmbH, Munich, Germany) prosthesis was performed. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

[Late reoperations after repaired Stanford type A aortic dissection].

PubMed

Huang, F H; Li, L P; Su, C H; Qin, W; Xu, M; Wang, L M; Jiang, Y S; Qiu, Z B; Xiao, L Q; Zhang, C; Shi, H W; Chen, X

2017-04-01

Objective: To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection. Methods: From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun's procedure in 1 patient, Wheat combined with Sun's procedure in 1 patient, Bentall combined with Sun's procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun's procedure. Results: Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up. Conclusions: Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun's procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

Aortic annulus and root characteristics in severe aortic stenosis due to bicuspid aortic valve and tricuspid aortic valves: implications for transcatheter aortic valve therapies.

PubMed

Philip, Femi; Faza, Nadine Nadar; Schoenhagen, Paul; Desai, Milind Y; Tuzcu, E Murat; Svensson, Lars G; Kapadia, Samir R

2015-08-01

Patients with severe aortic stenosis due to BAV are excluded from transcatheter aortic valve replacement (TAVR) due to concern for asymmetric expansion and valve dysfunction. We sought to characterize the aortic root and annulus in bicuspid aortic valve (BAV) and tricuspid aortic valves (TAV). We identified patients with severe AS who underwent multi-detector computed tomographic (MDCT) imaging prior to surgical aortic valve replacement (SAVR, n = 200) for BAV and TAVR (n = 200) for TAV from 2010 to 2013. The presence of a BAV was confirmed on surgical and pathological review. Annulus measurements of the basal ring (short- and long-axis, area-derived diameter), coronary ostia height, sinus area (SA), sino-tubular junction area (STJ), calcification and eccentricity index (EI, 1-short axis/long axis) were made. Patients with TAV were older (78.8 years vs. 57.8 years, P = 0.04) than those with BAV. The aortic annulus area (5.21 ± 2.1 cm(2) vs. 4.63 ± 2.0 cm(2) , P = 0.0001), sinus of Valsalva diameter (3.7 ± 0.9 cm vs. 3.1 ± 0.1 cm, P = 0.001) and ascending aorta diameter (3.5 ± 0.7 cm vs. 2.97 ± 0.6 cm, P = 0.001) were significantly larger with BAV. Bicuspid aortic annuli were significantly less elliptical (EI, 1.24 ± 0.1 vs. 1.29 ± 0.1, P = 0.006) and more circular (39% vs. 4%, P < 0.001) compared to the TAV annulus. There was more eccentric annular calcification in BAV vs. TAV (68% vs. 32%, P < 0.001). The mean distance from the aortic annulus to the left main coronary ostium was less than the right coronary ostium. Less than 10% of the BAV annuli would not fit a currently available valved stents. Bicuspid aortic valves have a larger annulus size, sinus of Valsalva and ascending aorta dimensions. In addition, the BAV aortic annuli appear circular and most will fit currently available commercial valved stents. © 2015 Wiley Periodicals, Inc.

[Status of aortic valve reconstruction and Ross operation in aortic valve diseases].

PubMed

Sievers, Hans H

2002-08-01

At first glance the aortic valve is a relative simple valve mechanism connecting the left ventricle and the ascending aorta. Detailed analysis of the different components of the aortic valve including the leaflets and sinuses revealed a complex motion of each part leading to a perfect durable valve mechanism at rest and during exercise. Theoretically, the reconstruction or imitation of these structures in patients with aortic valve disease should lead to optimal results. Prerequisite is the exact knowledge of the important functional characteristics of the aortic valve. The dynamic behavior of the aortic root closely harmonizing with the leaflets not only warrants stress minimizing and valve durability, but also optimizes coronary flow, left ventricular function and aortic impedance. The newly discovered contractile capacity of the leaflets and the root components are important for tuning the dynamics. Isolated reconstruction of the aortic valve such as decalcification, commissurotomy, plication of ring or leaflets of a tricuspid aortic valve and cusp extension are seldom indicated in contrast to the reconstruction of the bicuspid insufficient valve. Proper indication and skilled techniques lead to excellent hemodynamic and clinical intermediate-term result up to 7 years after reconstruction. Latest follow-up revealed a mean aortic insufficiency of 0.7, maximal pressure gradient of 11.4 +/- 8.5 mm Hg with zero hospital or late mortality, reoperation or thromboembolic events in 22 patients. The reconstructive techniques for aortic root aneurysm and/or type A dissection according to David or Yacoub have become routine procedures in the last 10 years. The hemodynamic and clinical results are excellent with low reoperation rate and very low risk of thromboembolism. Generally, a maximal diameter of the root of 5 cm is indicative for performing the operation. In patients with Marfan's syndrome the reconstruction should be advanced even with smaller diameters especially if these are progressive and combined with aortic insufficiency. ROSS-OPERATION: The Ross-Operation includes the replacement of the diseased aortic valve with the pulmonary autograft and reconstruction of the right ventricular outflow tract using a homograft. The hemodynamic results are excellent regarding the autograft and also the clinical results with very low thromboembolic risk and acceptable reoperation rate. This method is especially indicated for active young patients, women, who desire children, athletes and patients in general, who like to avoid long-term anticoagulation. In some cases the homograft may develop a dysfunction predominantly a pulmonary stenosis requiring reoperation. In the author's series of 245 Ross-operations in 12 years the homograft had to be replaced in 4 cases without letality. Innovative, decellularized homografts with the potential to repopulate with autologeous cells show promising results after 1 year of clinical implantation without signs of antibody development. Probably these tissue-engineered modification may improve the homograft results. The reconstructive techniques of the aortic valve and the Ross-operation have a certain risk of reoperation that must be weighed against the advantages of very low hospital and late valve related death, excellent hemodynamics, very low risk of macro- and microembolism as well as bleeding, lack of long-term anticoagulation and unrestricted life-style.

Ferumoxytol MRA for transcatheter aortic valve replacement planning with renal insufficiency.

PubMed

Kallianos, Kimberly; Henry, Travis S; Yeghiazarians, Yerem; Zimmet, Jeffrey; Shunk, Kendrick A; Tseng, Elaine E; Mahadevan, Vaikom; Hope, Michael D

2017-03-15

Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcatheter aortic valve replacement (TAVR) candidates. The iodinated contrast required, however, increases the risk of renal dysfunction in patients with pre-existing renal failure. Ferumoxytol is a magnetic resonance imaging (MRI) contrast agent that can be used with renal failure. Its long vascular resonance time allows gated MRA sequences that approach CTA in image quality. We present respiratory and cardiac gated MRA enabled by ferumoxytol that can be post-processed in an analogous fashion to CTA. Seven patients with renal failure presenting for TAVR were imaged with respiratory and cardiac gated MRA at 3T using ferumoxtyol for contrast. Aortic annulus, root and peripheral access dimensions were calculated in a fashion identical to that used for CTA. Of these, 6 patients underwent a TAVR procedure and 5 had intraoperative valve assessment with transesophageal echocardiograph (TEE) using standard clinical protocols that employed both two- and three-dimensional techniques. Good correlation between MRA aortic annulus measurements and those from TEE were shown in 5 patients with mean annulus area of 392.4mm 2 (290-470 range) versus 374.1mm 2 (285-440 range), with a pairwise correlation coefficient of 0.92, p=0.029. All patients received Sapien valve implants (one 20mm, three 23mm, and two 26mm valves). Access decisions were guided by MRA with no complications. Annulus sizing resulted in no greater than trace/mild aortic regurgitation in all patients. Ferumoxytol MRA is a safe alternative to CTA in patients with renal failure for pre-TAVR analysis of the aortic root and peripheral access. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Valve-Sparing Root Replacement Compared With Composite Valve Graft Procedures in Patients With Aortic Root Dilation.

PubMed

Ouzounian, Maral; Rao, Vivek; Manlhiot, Cedric; Abraham, Nachum; David, Carolyn; Feindel, Christopher M; David, Tirone E

2016-10-25

Although aortic valve-sparing (AVS) operations are established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms, comparative long-term outcomes are lacking. This study sought to compare the results of patients undergoing AVS procedures with those undergoing CVG operations. From 1990 to 2010, a total of 616 patients age <70 years and without aortic stenosis underwent elective aortic root surgery (AVS, n = 253; CVG with a bioprosthesis [bio-CVG], n = 180; CVG with a mechanical prosthesis [m-CVG], n = 183). A propensity score was used as a covariate to adjust for unbalanced variables in group comparisons. Mean age was 46 ± 14 years, 83.3% were male, and mean follow-up was 9.8 ± 5.3 years. Patients undergoing AVS had higher rates of Marfan syndrome and lower rates of bicuspid aortic valve than those undergoing bio-CVG or m-CVG procedures. In-hospital mortality (0.3%) and stroke rate (1.3%) were similar among groups. After adjusting for clinical covariates, both bio-CVG and m-CVG procedures were associated with increased long-term major adverse valve-related events compared with patients undergoing AVS (hazard ratio [HR]: 3.4, p = 0.005; and HR: 5.2, p < 0.001, respectively). They were also associated with increased cardiac mortality (HR: 7.0, p = 0.001; and HR: 6.4, p = 0.003). Furthermore, bio-CVG procedures were associated with increased risk of reoperations (HR: 6.9; p = 0.003), and m-CVG procedures were associated with increased risk of anticoagulant-related hemorrhage (HR: 5.6; p = 0.008) compared with AVS procedures. This comparative study showed that AVS procedures were associated with reduced cardiac mortality and valve-related complications when compared with bio-CVG and m-CVG. AVS is the treatment of choice for young patients with aortic root aneurysm and normal or near-normal aortic cusps. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Comparison of aortic media changes in patients with bicuspid aortic valve stenosis versus bicuspid valve insufficiency and proximal aortic aneurysm.

PubMed

Girdauskas, Evaldas; Rouman, Mina; Borger, Michael A; Kuntze, Thomas

2013-12-01

The aim of this study was to evaluate aortic media changes in bicuspid aortic valve (BAV) patients who underwent aortic valve replacement (AVR) and simultaneous replacement of the proximal aorta for BAV stenosis vs BAV insufficiency. Review of our institutional BAV database identified a subgroup of 79 consecutive BAV patients (mean age 52.3 ± 13 years, 81% men) with BAV stenosis or insufficiency and concomitant proximal aortic dilatation of ≥50 mm who underwent AVR and simultaneous replacement of proximal aorta from 1995 through 2005. All cases of BAV disease and concomitant ascending aortic dilatation of 40-50 mm underwent isolated AVR and therefore were excluded from this analysis. Proximal aortic media elastic fibre loss (EFL) was assessed (graded 0 to 3+) and compared between patients with BAV stenosis (Group I, n = 44) vs BAV insufficiency (Group II, n = 35). Follow-up (690 patient-years) was 100% complete and 9.1 ± 4.6 years long. Mean aortic media EFL was 1.3 ± 0.7 in Group I vs 2.5 ± 0.8 in Group II (P = 0.03). Moderate/severe EFL (i.e. defined as grade 2+/3+) was found in 13 patients (29%) in Group I vs 28 patients (80%) in Group II (P < 0.001). Logistic regression identified BAV insufficiency as the strongest predictor of moderate/severe EFL (OR 9.3; 95% CI 3.2-29.8, P < 0.001). Valve-related event-free survival was 64 ± 8% in Group I vs 93% ± 5% in Group II at 10 years postoperatively (P = 0.05). A total of 4 patients (5%, 3 from Group I and 1 from Group II) underwent redo aortic root surgery for prosthetic valve endocarditis during follow-up. Patients with BAV insufficiency and a proximal aorta of ≥50 mm have a significantly higher rate of moderate/severe EFL as compared to their counterparts with BAV stenosis.

Monozygotic twins with Marfan's syndrome and ascending aortic aneurysm.

PubMed

Redruello, Héctor Jorge; Cianciulli, Tomas Francisco; Rostello, Eduardo Fernandez; Recalde, Barbara; Lax, Jorge Alberto; Picone, Victorio Próspero; Belforte, Sandro Mario; Prezioso, Horacio Alberto

2007-08-01

Marfan's syndrome is a hereditary connective tissue disease, in which cardiovascular abnormalities (especially aortic root dilatation) are the most important cause of morbidity and mortality. In this report, we describe two 24-year-old twins, with a history of surgery for lens subluxation and severe cardiovascular manifestations secondary to Marfan's syndrome. One of the twins suffered a type A aortic dissection, which required replacement of the ascending aorta, and the other twin had an aneurysmal dilatation of the ascending aorta (46mm) and was prescribed medical treatment with atenolol and periodic controls to detect the presence of a critical diameter (50mm) that would indicate the need for prophylactic surgery.

Genetic abnormalities in bicuspid aortic valve root phenotype: preliminary results.

PubMed

Girdauskas, Evaldas; Geist, Lisa; Disha, Kushtrim; Kazakbaev, Iliaz; Groß, Tatiana; Schulz, Solveig; Ungelenk, Martin; Kuntze, Thomas; Reichenspurner, Hermann; Kurth, Ingo

2017-07-01

Genetic defects associated with bicuspid aortopathy have been infrequently analysed. Our goal was to examine the prevalence of rare genetic variants in patients with a bicuspid aortic valve (BAV) with a root phenotype using next-generation sequencing technology. We investigated a total of 124 patients with BAV with a root dilatation phenotype who underwent aortic valve ± proximal aortic surgery at a single institution (BAV database, n  = 812) during a 20-year period (1995-2015). Cross-sectional follow-up revealed 63 (51%) patients who were still alive and willing to participate. Systematic follow-up visits were scheduled from March to December 2015 and included aortic imaging as well as peripheral blood sampling for genetic testing. Next-generation sequencing libraries were prepared using a custom-made HaloPlex HS gene panel and included 20 candidate genes known to be associated with aortopathy and BAV. The primary end-point was the prevalence of genetic defects in our study cohort. A total of 63 patients (mean age 46 ± 10 years, 92% men) with BAV root phenotype and mean post-aortic valve replacement follow-up of 10.3 ± 4.9 years were included. Our genetic analysis yielded a wide spectrum of rare, potentially or likely pathogenic variants in 19 (30%) patients, with NOTCH1 variants being the most common ( n  = 6). Moreover, deleterious variants were revealed in AXIN1 ( n  = 3), NOS3 ( n  = 3), ELN ( n  = 2), FBN1 ( n  = 2) , FN1 ( n  = 2) and rarely in other candidate genes. Our preliminary study demonstrates a high prevalence and a wide spectrum of rare genetic variants in patients with the BAV root phenotype, indicative of the potentially congenital origin of associated aortopathy in this specific BAV cohort. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Etiology impacts survival in patients with severe aortic regurgitation: results from a cohort of 756 patients.

PubMed

Varadarajan, Padmini; Patel, Reena; Turk, Rami; Kamath, Ashvin R; Sampath, Unnati; Khandhar, Sumit; Pai, Ramdas G

2013-01-01

Severe aortic regurgitation (AR) is caused by a variety of mechanisms, which include the degenerative process, bicuspid aortic valve (BAV), aortic root dilation, endocarditis or a combination of these. Their frequency in a contemporary clinical series, and their impact on survival, are currently unknown. The authors' echocardiographic database between 1993 and 2007 was screened for patients with severe AR, and yielded 756 patients. Detailed chart reviews were performed to acquire clinical and demographic data. Mortality data were obtained from the social security death index and analyzed as a function of the condition's etiology. The probable etiologies for AR were: degenerative in 29% of patients, BAV in 10%, aortic root pathology in 11%, endocarditis in 10%, and mixed or unclear mechanism in 40%. Survival was a function of the etiology (p < 0.0001), with degenerative mechanism having the worst prognosis and BAV the best. This differential impact on mortality remained significant after adjusting for age, gender, coronary artery disease, diabetes mellitus, renal insufficiency, left ventricular ejection fraction and aortic valve replacement, using the Cox regression model (p < 0.0001). Etiology has a significant independent impact on mortality in patients with severe AR, with the worst survival being seen in degenerative AR.

Comparison of in vitro flows past a mechanical heart valve in anatomical and axisymmetric aorta models

NASA Astrophysics Data System (ADS)

Haya, Laura; Tavoularis, Stavros

2017-06-01

Flow characteristics past a bileaflet mechanical heart valve were measured under physiological flow conditions in a straight tube with an axisymmetric expansion, similar to vessels used in previous studies, and in an anatomical model of the aorta. We found that anatomical features, including the three-lobed sinus and the aorta's curvature affected significantly the flow characteristics. The turbulent and viscous stresses were presented and discussed as indicators for potential blood damage and thrombosis. Both types of stresses, averaged over the two axial measurement planes, were significantly lower in the anatomical model than in the axisymmetric one. This difference was attributed to the lower height-to-width ratio and more gradual contraction of the anatomical aortic sinus. The curvature of the aorta caused asymmetries in the velocity and stress distributions during forward flow. Secondary flows resulting from the aorta's curvature are thought to have redistributed the fluid stresses transversely, resulting in a more homogeneous stress distribution in the anatomical aortic root than in the axisymmetric root. The results of this study demonstrate the importance of modelling accurately the aortic geometry in experimental and computational studies of prosthetic devices. Moreover, our findings suggest that grafts used for aortic root replacement should approximate as closely as possible the shape of the natural sinuses.

Contemporary experience with surgical treatment of aortic valve disease in children.

PubMed

Khan, Muhammad S; Samayoa, Andres X; Chen, Diane W; Petit, Christopher J; Fraser, Charles D

2013-09-01

Surgical treatment of aortic valve (AoV) disease in childhood involves complex decisions particularly in very small patients. There is no consensus regarding the optimum surgical option. The objective of this review was to analyze a contemporary experience of AoV surgery in a large children's hospital. A retrospective review of children (aged ≤ 18 years) undergoing AoV repair or replacement from June 1995 to December 2011 was carried out. A total of 285 AoV operations (97 repairs, 188 replacements) were performed on 241 patients. Hospital survival for repair was 98% and for replacements was 97%. At follow-up of repairs, there were 16 (17%) reoperations and 3 (3%) late deaths. Follow-up of AoV replacements demonstrated 31 (16%) reoperations (homograft 27, autograft 3, mechanical 1) and 8 (4%) late deaths (homograft 5, autograft 2, mechanical 1). Freedom from reintervention or death (FRD) was found to be lower in repairs for infants (P = .048) and truncal valves (P < .05). For AoV replacements, infants and patients who had concomitant CHD or homografts (P < .0001) had lower FRD. Cox regression analysis for AoV replacements identified infants and homograft root replacements at a higher risk for death/reoperation. AoV repairs and replacements were generally found to be associated with low death and reoperation rates at long-term follow-up. Infants had a lower freedom from reintervention or death after either an AoV repair or replacement, although truncal valve repairs and AoV replacement in patients with concomitant CHD were associated with lower valve survival. Among the valve options, homograft root replacement had a higher risk of death/reoperation and lowest freedom from reintervention or death. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Heart valve replacement with the Sorin tilting-disc prosthesis. A 10-year experience.

PubMed

Milano, A; Bortolotti, U; Mazzucco, A; Mossuto, E; Testolin, L; Thiene, G; Gallucci, V

1992-02-01

From 1978 to 1988, 697 patients with a mean age of 48 +/- 11 years (range 5 to 75 years) received a Sorin tilting-disc prosthesis; 358 had had aortic valve replacement, 247 mitral valve replacement, and 92 mitral and aortic valve replacement. Operative mortality rates were 7.8%, 11.3%, and 10.8%, respectively, in the three groups. Cumulative duration of follow-up is 1650 patient-years for aortic valve replacement (maximum follow-up 11.4 years), 963 patient-years for mitral valve replacement (maximum follow-up 9.9 years) and 328 patient-years for mitral and aortic valve replacement (maximum follow-up 9.4 years). Actuarial survival at 9 years is 72% +/- 4% after mitral valve replacement, 70% +/- 3% after aortic valve replacement, and 50% +/- 12% after mitral and aortic valve replacement, and actuarial freedom from valve-related deaths is 97% +/- 2% after mitral valve replacement, 92% +/- 2% after aortic valve replacement, and 62% +/- 15% after mitral and aortic valve replacement. Thromboembolic events occurred in 21 patients with aortic valve replacement (1.3% +/- 0.2%/pt-yr), in 12 with mitral valve replacement (1.2% +/- 0.3% pt-yr), and in seven with mitral and aortic valve replacement (2.1% +/- 0.8%), with one case of prosthetic thrombosis in each group; actuarial freedom from thromboembolism at 9 years is 92% +/- 3% after mitral valve replacement, 91% +/- 3% after aortic valve replacement, and 74% +/- 16% after mitral and aortic valve replacement. Anticoagulant-related hemorrhage was observed in 15 patients after aortic valve replacement (0.9% +/- 0.2%/pt-yr), in 9 after mitral valve replacement (0.9% +/- 0.3%/pt-yr), and in 6 with mitral and aortic valve replacement (0.9% +/- 0.5%/pt-yr); actuarial freedom from this complication at 9 years is 94% +/- 2% after aortic valve replacement, 91% +/- 4% after mitral valve replacement, and 68% +/- 16% after mitral and aortic valve replacement. Actuarial freedom from reoperation at 9 years is 97% +/- 2% after mitral and aortic valve replacement, 92% +/- 4% after mitral valve replacement, and 89% +/- 3% after aortic valve replacement, with no cases of mechanical fracture. The Sorin valve has shown a satisfactory long-term overall performance, comparable with other mechanical prostheses, and an excellent durability that renders it a reliable heart valve substitute for the mitral and aortic positions.

Aortic root, not valve, calcification correlates with coronary artery calcification in patients with severe aortic stenosis: A two-center study.

PubMed

Henein, Michael; Hällgren, Peter; Holmgren, Anders; Sörensen, Karen; Ibrahimi, Pranvera; Kofoed, Klaus Fuglsang; Larsen, Linnea Hornbech; Hassager, Christian

2015-12-01

The underlying pathology in aortic stenosis (AS) and coronary artery stenosis (CAS) is similar including atherosclerosis and calcification. We hypothesize that coronary artery calcification (CAC) is likely to correlate with aortic root calcification (ARC) rather than with aortic valve calcification (AVC), due to tissue similarity between the two types of vessel rather than with the valve leaflet tissue. We studied 212 consecutive patients (age 72.5 ± 7.9 years, 91 females) with AS requiring aortic valve replacement (AVR) in two Heart Centers, who underwent multidetector cardiac CT preoperatively. CAC, AVC and ARC were quantified using Agatston scoring. Correlations were tested by Spearman's test and Mann-Whitney U-test was used for comparing different subgroups; bicuspid (BAV) vs tricuspid (TAV) aortic valve. CAC was present in 92%, AVC in 100% and ARC in 82% of patients. CAC correlated with ARC (rho = 0.51, p < 0.001) but not with AVC. The number of calcified coronary arteries correlated with ARC (rho = 0.45, p < 0.001) but not with AVC. 29/152 patients had echocardiographic evidence of BAV and 123 TAV, who were older (p < 0.001) but CAC was associated with TAV even after adjusting for age (p = 0.01). AVC score was associated with BAV after adjusting for age (p = 0.03) but ARC was not. Of the total cohort, 82 patients (39%) had significant coronary stenosis (>50%), but these were not different in the pattern of calcification from those without CAS. CAC was consistently higher in patients with risk factors for atherosclerosis compared to those without. The observed relationship between coronary and aortic root calcification suggests a diffuse arterial disease. The lack of relationship between coronary and aortic valve calcification suggests a different pathology. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Transapical Implantation of a 2nd-Generation JenaValve Device in Patient with Extremely High Surgical Risk

PubMed Central

Mieres, Juan; Menéndez, Marcelo; Fernández-Pereira, Carlos; Rubio, Miguel; Rodríguez, Alfredo E.

2015-01-01

Transcatheter Aortic Valve Replacement (TAVR) is performed in patients who are poor surgical candidates. Many patients have inadequate femoral access, and alternative access sites have been used such as the transapical approach discussed in this paper. We present an elderly and fragile patient not suitable for surgery for unacceptable high risk, including poor ventricular function, previous myocardial infarction with percutaneous coronary intervention, pericardial effusion, and previous cardiac surgery with replacement of mechanical mitral valve. Transapical aortic valve replacement with a second-generation self-expanding JenaValve is performed. The JenaValve is a second-generation transapical TAVR valve consisting of a porcine root valve mounted on a low-profile nitinol stent. The valve is fully retrievable and repositionable. We discuss transapical access, implantation technique, and feasibility of valve implantation in this extremely high surgical risk patient. PMID:26346128

Transapical Implantation of a 2nd-Generation JenaValve Device in Patient with Extremely High Surgical Risk.

PubMed

Mieres, Juan; Menéndez, Marcelo; Fernández-Pereira, Carlos; Rubio, Miguel; Rodríguez, Alfredo E

2015-01-01

Transcatheter Aortic Valve Replacement (TAVR) is performed in patients who are poor surgical candidates. Many patients have inadequate femoral access, and alternative access sites have been used such as the transapical approach discussed in this paper. We present an elderly and fragile patient not suitable for surgery for unacceptable high risk, including poor ventricular function, previous myocardial infarction with percutaneous coronary intervention, pericardial effusion, and previous cardiac surgery with replacement of mechanical mitral valve. Transapical aortic valve replacement with a second-generation self-expanding JenaValve is performed. The JenaValve is a second-generation transapical TAVR valve consisting of a porcine root valve mounted on a low-profile nitinol stent. The valve is fully retrievable and repositionable. We discuss transapical access, implantation technique, and feasibility of valve implantation in this extremely high surgical risk patient.

Pathologic aneurysmal dilation of the ascending aorta and dilation of the main pulmonary artery in patients with Kabuki syndrome: valve-sparing aortic root replacement.

PubMed

Dyamenahalli, Umesh; Abraham, Boban; Fontenot, Eudice; Prasad, Vinay; Imamura, Michiaki

2007-01-01

We report the aneurysmal dilation of the ascending aorta and the main pulmonary artery in 2 children with Kabuki syndrome. In 1 patient, there was progressive aneurysmal dilation of the ascending aorta necessitating aortoplasty. Histologic examination of the resected aorta revealed disrupted and fragmented elastic fibers in the medial layer, along with mucinous degeneration of the aortic wall. This is the first recognition and report of these findings as part of the Kabuki syndrome.

3D Bioprinting of Heterogeneous Aortic Valve Conduits with Alginate/Gelatin Hydrogels

PubMed Central

Duan, Bin; Hockaday, Laura A.; Kang, Kevin H.; Butcher, Jonathan T.

2013-01-01

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 aortic valve 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 aortic valve 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. Aortic valve 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 aortic valve hydrogel conduits can be fabricated with 3D bioprinting. PMID:23015540

A comparison of conventional surgery, transcatheter aortic valve replacement, and sutureless valves in "real-world" patients with aortic stenosis and intermediate- to high-risk profile.

PubMed

Muneretto, Claudio; Alfieri, Ottavio; Cesana, Bruno Mario; Bisleri, Gianluigi; De Bonis, Michele; Di Bartolomeo, Roberto; Savini, Carlo; Folesani, Gianluca; Di Bacco, Lorenzo; Rambaldini, Manfredo; Maureira, Juan Pablo; Laborde, Francois; Tespili, Maurizio; Repossini, Alberto; Folliguet, Thierry

2015-12-01

We sought to investigate the clinical outcomes of patients with isolated severe aortic stenosis and an intermediate- to high-risk profile treated by means of conventional surgery (surgical aortic valve replacement), sutureless valve implantation, or transcatheter aortic valve replacement in a multicenter evaluation. Among 991 consecutive patients with isolated severe aortic stenosis and an intermediate- to high-risk profile (Society of Thoracic Surgeons score >4 and logistic European System for Cardiac Operative Risk Evaluation I >10), a propensity score analysis was performed on the basis of the therapeutic strategy: surgical aortic valve replacement (n = 204), sutureless valve implantation (n = 204), and transcatheter aortic valve replacement (n = 204). Primary end points were 30-day mortality and overall survival at 24-month follow-up; the secondary end point was survival free from a composite end point of major adverse cardiac events (defined as cardiac-related mortality, myocardial infarction, cerebrovascular accidents, and major hemorrhagic events) and periprosthetic regurgitation greater than 2. Thirty-day mortality was significantly higher in the transcatheter aortic valve replacement group (surgical aortic valve replacement = 3.4% vs sutureless = 5.8% vs transcatheter aortic valve replacement = 9.8%; P = .005). The incidence of postprocedural was 3.9% in asurgical aortic valve replacement vs 9.8% in sutureless vs 14.7% in transcatheter aortic valve replacement (P< .001) and peripheral vascular complications occurred in 0% of surgicalaortic valve replacement vs 0% of sutureless vs 9.8% transcatheter aortic valve replacement (P< .001). At 24-month follow-up, overall survival (surgical aortic valve replacement = 91.3% ± 2.4% vs sutureless = 94.9% ± 2.1% vs transcatheter aortic valve replacement = 79.5% ± 4.3%; P < .001) and survival free from the composite end point of major adverse cardiovascular events and periprosthetic regurgitation were significantly better in patients undergoing surgical aortic valve replacement and sutureless valve implantation than in patients undergoing transcatheter aortic valve replacement (surgical aortic valve replacement = 92.6% ± 2.3% vs sutureless = 96% ± 1.8% vs transcatheter aortic valve replacement = 77.1% ± 4.2%; P < .001). Multivariate Cox regression analysis identified transcatheter aortic valve replacement as an independent risk factor for overall mortality hazard ratio (hazard ratio, 2.5; confidence interval, 1.1-4.2; P = .018). The use of transcatheter aortic valve replacement in patients with an intermediate- to high-risk profile was associated with a significantly higher incidence of perioperative complications and decreased survival at short- and mid-term when compared with conventional surgery and sutureless valve implantation. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

A meta-analysis of aortic root size in elite athletes.

PubMed

Iskandar, Aline; Thompson, Paul D

2013-02-19

The aorta is exposed to hemodynamic stress during exercise, but whether or not the aorta is larger in athletes is not clear. We performed a systematic literature review and meta-analysis to examine whethere athletes demonstrate increased aortic root dimensions compared with nonathlete controls. We searched MEDLINE and Scopus from inception through August 12, 2012, for English-language studies reporting the aortic root size in elite athletes. Two investigators independently extracted athlete and study characteristics. A multivariate linear mixed model was used to conduct meta-regression analyses. We identified 71 studies reporting aortic root dimensions in 8564 unique athletes, but only 23 of these studies met our criteria by reporting aortic root dimensions at the aortic valve annulus or sinus of Valsalva in elite athletes (n=5580). Athletes were compared directly with controls (n=727) in 13 studies. On meta-regression, the weighted mean aortic root diameter measured at the sinuses of Valsalva was 3.2 mm (P=0.02) larger in athletes than in the nonathletic controls, whereas aortic root size at the aortic valve annulus was 1.6 mm (P=0.04) greater in athletes than in controls. Elite athletes have a small but significantly larger aortic root diameter at the sinuses of Valsalva and aortic valve annulus, but this difference is minor and clinically insignificant. Clinicians evaluating athletes should know that marked aortic root dilatation likely represents a pathological process and not a physiological adaptation to exercise.

Total ellipse of the heart valve: the impact of eccentric stent distortion on the regional dynamic deformation of pericardial tissue leaflets of a transcatheter aortic valve replacement

PubMed Central

Gunning, Paul S.; Saikrishnan, Neelakantan; Yoganathan, Ajit P.; McNamara, Laoise M.

2015-01-01

Transcatheter aortic valve replacements (TAVRs) are a percutaneous alternative to surgical aortic valve replacements and are used to treat patients with aortic valve stenosis. This minimally invasive procedure relies on expansion of the TAVR stent to radially displace calcified aortic valve leaflets against the aortic root wall. However, these calcium deposits can impede the expansion of the device causing distortion of the valve stent and pericardial tissue leaflets. The objective of this study was to elucidate the impact of eccentric TAVR stent distortion on the dynamic deformation of the tissue leaflets of the prosthesis in vitro. Dual-camera stereophotogrammetry was used to measure the regional variation in strain in a leaflet of a TAVR deployed in nominal circular and eccentric (eccentricity index = 28%) orifices, representative of deployed TAVRs in vivo. It was observed that (i) eccentric stent distortion caused incorrect coaptation of the leaflets at peak diastole resulting in a ‘peel-back’ leaflet geometry that was not present in the circular valve and (ii) adverse bending of the leaflet, arising in the eccentric valve at peak diastole, caused significantly higher commissure strains compared with the circular valve in both normotensive and hypertensive pressure conditions (normotension: eccentric = 13.76 ± 2.04% versus circular = 11.77 ± 1.61%, p = 0.0014, hypertension: eccentric = 15.07 ± 1.13% versus circular = 13.56 ± 0.87%, p = 0.0042). This study reveals that eccentric distortion of a TAVR stent can have a considerable impact on dynamic leaflet deformation, inducing deleterious bending of the leaflet and increasing commissures strains, which might expedite leaflet structural failure compared to leaflets in a circular deployed valve. PMID:26674192

Aortic wrapping for stanford type A acute aortic dissection: short and midterm outcome.

PubMed

Demondion, Pierre; Ramadan, Ramzi; Azmoun, Alexandre; Raoux, François; Angel, Claude; Nottin, Rémi; Deleuze, Philippe

2014-05-01

Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Mini-Bentall: An Interesting Approach for Selected Patients.

PubMed

Mikus, Elisa; Micari, Antonio; Calvi, Simone; Salomone, Maria; Panzavolta, Marco; Paris, Marco; Del Giglio, Mauro

Minimally invasive surgery through an upper hemisternotomy for aortic valve replacement has become the routine approach with excellent results. Actually, the same minimally invasive access is used for complex ascending aorta procedures only in few centers. We report our experience with minimally invasive approach for aortic valve and ascending aorta replacement using Bentall technique. From January 2010 to November 2015, a total of 238 patients received ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Low- and intermediate-risk patients underwent elective surgery with a minimally invasive approach. The "J"-shaped partial upper sternotomy was performed through a 6-cm skin incision from the notch to the third right intercostal space. Patients who had previous cardiac surgery or affected by active endocarditis were excluded. The study included 53 patients, 44 male (83 %) with a median age of 63 years [interquartile range (IQR), 51-73 years]. A bicuspid aortic valve was diagnosed in 27 patients (51%). A biological Bentall using a pericardial Mitroflow or Crown bioprosthesis implanted in a Valsalva graft was performed in 49 patents. The remaining four patients were treated with a traditional mechanical conduit. Median cardiopulmonary bypass time and median cross-clamp time were respectively 84 (IQR, 75-103) minutes and 73 (IQR, 64-89) minutes. Hospital mortality was zero as well as 30-day mortality. Median intensive care unit and hospital stay were 1.9 and 8 days, respectively. The study population compared with patients treated with standard full sternotomy and similar preoperative characteristics showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding operative times, incidence of atrial fibrillation, and postoperative ventilation times. A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy can be a safe alternative approach to the standard in selected patients presenting with complex aortic root pathology.

Effect of personalized external aortic root support on aortic root motion and distension in Marfan syndrome patients.

PubMed

Izgi, Cemil; Nyktari, Evangelia; Alpendurada, Francisco; Bruengger, Annina Studer; Pepper, John; Treasure, Tom; Mohiaddin, Raad

2015-10-15

Personalized external aortic root support (PEARS) is a novel surgical approach with the aim of stabilizing the aortic root size and decreasing risk of dissection in Marfan syndrome patients. A bespoke polymer mesh tailored to each patient's individual aorta shape is produced by modeling and then surgically implanted. The aim of this study is to assess the mechanical effects of PEARS on the aortic root systolic downward motion (an important determinant of aortic wall stress), aortic root distension and on the left ventricle (LV). A cohort of 27 Marfan patients had a prophylactic PEARS surgery between 2004 and 2012 with 24 having preoperative and follow-up cardiovascular magnetic resonance imaging studies. Systolic downward aortic root motion, aortic root distension, LV volumes/mass and mitral annular systolic excursion before the operation and in the latest follow-up were measured randomly and blinded. After a median follow-up of 50.5 (IQR 25.5-72) months following implantation of PEARS, systolic downward motion of aortic root was significantly decreased (12.6±3.6mm pre-operation vs 7.9±2.9mm latest follow-up, p<0.00001). There was a tendency for a decrease in systolic aortic root distension but this was not significant (median 4.5% vs 2%, p=0.35). There was no significant change in LV volumes, ejection fraction, mass and mitral annular systolic excursion in follow-up. PEARS surgery decreases systolic downward aortic root motion which is an important determinant of longitudinal aortic wall stress. Aortic wall distension and Windkessel function are not significantly impaired in the follow-up after implantation of the mesh which is also supported by the lack of deterioration of LV volumes or mass. Crown Copyright © 2015. Published by Elsevier Ireland Ltd. All rights reserved.

Atenolol versus Losartan in Children and Young Adults with Marfan's Syndrome

PubMed Central

Lacro, R.V.; Dietz, H.C.; Sleeper, L.A.; Yetman, A.T.; Bradley, T.J.; Colan, S.D.; Pearson, G.D.; Tierney, E.S. Selamet; Levine, J.C.; Atz, A.M.; Benson, D.W.; Braverman, A.C.; Chen, S.; De Backer, J.; Gelb, B.D.; Grossfeld, P.D.; Klein, G.L.; Lai, W.W.; Liou, A.; Loeys, B.L.; Markham, L.W.; Olson, A.K.; Paridon, S.M.; Pemberton, V.L.; Pierpont, M.E.; Pyeritz, R.E.; Radojewski, E.; Roman, M.J.; Sharkey, A.M.; Stylianou, M.P.; Wechsler, S. Burns; Young, L.T.; Mahony, L.

2015-01-01

BACKGROUND Aortic-root dissection is the leading cause of death in Marfan's syndrome. Studies suggest that with regard to slowing aortic-root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. METHODS We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan's syndrome. The primary outcome was the rate of aortic-root enlargement, expressed as the change in the maximum aortic-root-diameter z score indexed to body-surface area (hereafter, aortic-root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. RESULTS From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an aortic-root z score greater than 3.0. The baseline-adjusted rate of change (±SE) in the aortic-root z score did not differ significantly between the atenolol group and the losartan group (−0.139±0.013 and −0.107±0.013 standard-deviation units per year, respectively; P = 0.08). Both slopes were significantly less than zero, indicating a decrease in the degree of aortic-root dilatation relative to body-surface area with either treatment. The 3-year rates of aortic-root surgery, aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. CONCLUSIONS Among children and young adults with Marfan's syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364.) PMID:25405392

Atenolol versus losartan in children and young adults with Marfan's syndrome.

PubMed

Lacro, Ronald V; Dietz, Harry C; Sleeper, Lynn A; Yetman, Anji T; Bradley, Timothy J; Colan, Steven D; Pearson, Gail D; Selamet Tierney, E Seda; Levine, Jami C; Atz, Andrew M; Benson, D Woodrow; Braverman, Alan C; Chen, Shan; De Backer, Julie; Gelb, Bruce D; Grossfeld, Paul D; Klein, Gloria L; Lai, Wyman W; Liou, Aimee; Loeys, Bart L; Markham, Larry W; Olson, Aaron K; Paridon, Stephen M; Pemberton, Victoria L; Pierpont, Mary Ella; Pyeritz, Reed E; Radojewski, Elizabeth; Roman, Mary J; Sharkey, Angela M; Stylianou, Mario P; Wechsler, Stephanie Burns; Young, Luciana T; Mahony, Lynn

2014-11-27

Aortic-root dissection is the leading cause of death in Marfan's syndrome. Studies suggest that with regard to slowing aortic-root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan's syndrome. The primary outcome was the rate of aortic-root enlargement, expressed as the change in the maximum aortic-root-diameter z score indexed to body-surface area (hereafter, aortic-root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an aortic-root z score greater than 3.0. The baseline-adjusted rate of change in the mean (±SE) aortic-root z score did not differ significantly between the atenolol group and the losartan group (-0.139±0.013 and -0.107±0.013 standard-deviation units per year, respectively; P=0.08). Both slopes were significantly less than zero, indicating a decrease in the aortic-root diameter relative to body-surface area with either treatment. The 3-year rates of aortic-root surgery, aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. Among children and young adults with Marfan's syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364.).

Immersed boundary-finite element model of fluid-structure interaction in the aortic root

NASA Astrophysics Data System (ADS)

Flamini, Vittoria; DeAnda, Abe; Griffith, Boyce E.

2016-04-01

It has long been recognized that aortic root elasticity helps to ensure efficient aortic valve closure, but our understanding of the functional importance of the elasticity and geometry of the aortic root continues to evolve as increasingly detailed in vivo imaging data become available. Herein, we describe a fluid-structure interaction model of the aortic root, including the aortic valve leaflets, the sinuses of Valsalva, the aortic annulus, and the sinotubular junction, that employs a version of Peskin's immersed boundary (IB) method with a finite element description of the structural elasticity. As in earlier work, we use a fiber-based model of the valve leaflets, but this study extends earlier IB models of the aortic root by employing an incompressible hyperelastic model of the mechanics of the sinuses and ascending aorta using a constitutive law fit to experimental data from human aortic root tissue. In vivo pressure loading is accounted for by a backward displacement method that determines the unloaded configuration of the root model. Our model yields realistic cardiac output at physiological pressures, with low transvalvular pressure differences during forward flow, minimal regurgitation during valve closure, and realistic pressure loads when the valve is closed during diastole. Further, results from high-resolution computations indicate that although the detailed leaflet and root kinematics show some grid sensitivity, our IB model of the aortic root nonetheless produces essentially grid-converged flow rates and pressures at practical grid spacings for the high Reynolds number flows of the aortic root. These results thereby clarify minimum grid resolutions required by such models when used as stand-alone models of the aortic valve as well as when used to provide models of the outflow valves in models of left-ventricular fluid dynamics.

Mechanics of cryopreserved aortic and pulmonary homografts.

PubMed

Vesely, I; Casarotto, D C; Gerosa, G

2000-01-01

The surgical placement of pulmonary valve grafts into the aortic position (the Ross procedure) has been performed for three decades. Cryopreserved pulmonary valves have had mixed clinical results, however. The objectives of this study were to compare the mechanics of cryopreserved human aortic and pulmonary valve cusps and roots to determine if the pulmonary root can withstand the greater pressures of the aortic position. Six aortic and six pulmonary valve roots were obtained from the Oxford Valve Bank. They were harvested during cardiac transplantation from hearts explanted for dilated cardiomyopathy (mean patient age 68 years). The whole roots were initially stored frozen at -186 degrees C, then shipped packed on dry ice. After complete thawing, the roots were pressurized whole; test strips were then cut from the valve cusps, roots and sinuses and tested for stress/strain, stress relaxation, and ultimate failure strength. The pulmonary roots were more distensible (30% versus 20% strain to lock-up) and less compliant when loaded to aortic pressures. The pulmonary valve cusp and root tissue also showed greater extensibility and greater stiffness (lower compliance) when subjected to the same loads. We conclude that mechanical differences between aortic and pulmonary valve tissues are minimal. The pulmonary root should withstand the forces imposed on it when placed in the aortic position. However, if implanted whole, the pulmonary root will distend about 30% more than the aortic root when subjected to aortic pressures. These geometric changes may affect valve function in the long term and should be appreciated when implanting a pulmonary valve graft.

Effects of aortic root motion on wall stress in the Marfan aorta before and after personalised aortic root support (PEARS) surgery.

PubMed

Singh, S D; Xu, X Y; Pepper, J R; Izgi, C; Treasure, T; Mohiaddin, R H

2016-07-05

Aortic root motion was previously identified as a risk factor for aortic dissection due to increased longitudinal stresses in the ascending aorta. The aim of this study was to investigate the effects of aortic root motion on wall stress and strain in the ascending aorta and evaluate changes before and after implantation of personalised external aortic root support (PEARS). Finite element (FE) models of the aortic root and thoracic aorta were developed using patient-specific geometries reconstructed from pre- and post-PEARS cardiovascular magnetic resonance (CMR) images in three Marfan patients. The wall and PEARS materials were assumed to be isotropic, incompressible and linearly elastic. A static load on the inner wall corresponding to the patients' pulse pressure was applied. Cardiovascular MR cine images were used to quantify aortic root motion, which was imposed at the aortic root boundary of the FE model, with zero-displacement constraints at the distal ends of the aortic branches and descending aorta. Measurements of the systolic downward motion of the aortic root revealed a significant reduction in the axial displacement in all three patients post-PEARS compared with its pre-PEARS counterparts. Higher longitudinal stresses were observed in the ascending aorta when compared with models without the root motion. Implantation of PEARS reduced the longitudinal stresses in the ascending aorta by up to 52%. In contrast, the circumferential stresses at the interface between the supported and unsupported aorta were increase by up to 82%. However, all peak stresses were less than half the known yield stress for the dilated thoracic aorta. Copyright © 2016 Elsevier Ltd. All rights reserved.

Pre- and Postoperative Imaging of the Aortic Root

PubMed Central

Chan, Frandics P.; Mitchell, R. Scott; Miller, D. Craig; Fleischmann, Dominik

2016-01-01

Three-dimensional datasets acquired using computed tomography and magnetic resonance imaging are ideally suited for characterization of the aortic root. These modalities offer different advantages and limitations, which must be weighed according to the clinical context. This article provides an overview of current aortic root imaging, highlighting normal anatomy, pathologic conditions, imaging techniques, measurement thresholds, relevant surgical procedures, postoperative complications and potential imaging pitfalls. Patients with a range of clinical conditions are predisposed to aortic root disease, including Marfan syndrome, bicuspid aortic valve, vascular Ehlers-Danlos syndrome, and Loeys-Dietz syndrome. Various surgical techniques may be used to repair the aortic root, including placement of a composite valve graft, such as the Bentall and Cabrol procedures; placement of an aortic root graft with preservation of the native valve, such as the Yacoub and David techniques; and implantation of a biologic graft, such as a homograft, autograft, or xenograft. Potential imaging pitfalls in the postoperative period include mimickers of pathologic processes such as felt pledgets, graft folds, and nonabsorbable hemostatic agents. Postoperative complications that may be encountered include pseudoaneurysms, infection, and dehiscence. Radiologists should be familiar with normal aortic root anatomy, surgical procedures, and postoperative complications, to accurately interpret pre- and postoperative imaging performed for evaluation of the aortic root. Online supplemental material is available for this article. ©RSNA, 2015 PMID:26761529

The role of cardiovascular magnetic resonance in the assessment of severe aortic stenosis and in post-procedural evaluation following transcatheter aortic valve implantation and surgical aortic valve replacement.

PubMed

Musa, Tarique Al; Plein, Sven; Greenwood, John P

2016-06-01

Degenerative aortic stenosis (AS) is the most common valvular disease in the western world with a prevalence expected to double within the next 50 years. International guidelines advocate the use of cardiovascular magnetic resonance (CMR) as an investigative tool, both to guide diagnosis and to direct optimal treatment. CMR is the reference standard for quantifying both left and right ventricular volumes and mass, which is essential to assess the impact of AS upon global cardiac function. Given the ability to image any structure in any plane, CMR offers many other diagnostic strengths including full visualisation of valvular morphology, direct planimetry of orifice area, the quantification of stenotic jets and in particular, accurate quantification of valvular regurgitation. In addition, CMR permits reliable and accurate measurements of the aortic root and arch which can be fundamental to appropriate patient management. There is a growing evidence base to indicate tissue characterisation using CMR provides prognostic information, both in asymptomatic AS patients and those undergoing intervention. Furthermore, a number of current clinical trials will likely raise the importance of CMR in routine patient management. This article will focus on the incremental value of CMR in the assessment of severe AS and the insights it offers following valve replacement.

Computer-aided design of the human aortic root.

PubMed

Ovcharenko, E A; Klyshnikov, K U; Vlad, A R; Sizova, I N; Kokov, A N; Nushtaev, D V; Yuzhalin, A E; Zhuravleva, I U

2014-11-01

The development of computer-based 3D models of the aortic root is one of the most important problems in constructing the prostheses for transcatheter aortic valve implantation. In the current study, we analyzed data from 117 patients with and without aortic valve disease and computed tomography data from 20 patients without aortic valvular diseases in order to estimate the average values of the diameter of the aortic annulus and other aortic root parameters. Based on these data, we developed a 3D model of human aortic root with unique geometry. Furthermore, in this study we show that by applying different material properties to the aortic annulus zone in our model, we can significantly improve the quality of the results of finite element analysis. To summarize, here we present four 3D models of human aortic root with unique geometry based on computational analysis of ECHO and CT data. We suggest that our models can be utilized for the development of better prostheses for transcatheter aortic valve implantation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: Midterm outcomes and aortic remodeling.

PubMed

Faure, Elsa Madeleine; El Batti, Salma; Abou Rjeili, Marwan; Ben Abdallah, Iannis; Julia, Pierre; Alsac, Jean-Marc

2018-05-17

The study objective was to assess the midterm outcomes and aortic remodeling in patients with Marfan syndrome with complicated acute type B aortic dissection treated with stent-assisted, balloon-induced intimal disruption and relamination. We reviewed all patients treated with stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection associated with Marfan syndrome according to the revised Ghent criteria. Between 2015 and November 2017, 7 patients with Marfan syndrome underwent stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection. The median age of patients was 47 years (range, 23-70). Four patients had a history of aortic root replacement. Technical success was achieved in 100%. Three patients required an adjunctive procedure for renal artery stenting (n = 2) and iliac artery stenting (n = 1). There was no in-hospital death, 30-day postoperative stroke, spinal cord ischemia, ischemic colitis, or renal failure requiring dialysis. At a median follow-up of 15 months (range, 7-28), 1 patient required aortic arch replacement for aneurysmal degeneration associated with a type Ia endoleak at 2 years, giving a late reintervention rate of 14%. There was no other secondary endoleak. The primary visceral patency rate was 100%. There were no all-cause deaths reported. At last computed tomography scan, all patients had complete aortic remodeling of the treated thoracoabdominal aorta. Distally, at the nonstented infrarenal aortoiliac level, 6 patients had persistent false lumen flow with stable aorto-iliac diameter in 5. One patient had iliac diameter growth (27 mm diameter at last computed tomography scan). Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome is feasible, safe, and associated with an immediate and midterm persisting thoracoabdominal aortic remodeling. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience.

PubMed

Nicolo, Francesco; Romeo, Francesco; Lio, Antonio; Bovio, Emanuele; Scafuri, Antonio; Bassano, Carlo; Polisca, Patrizio; Pellegrino, Antonio; Nardi, Paolo; Chiariello, Luigi; Ruvolo, Giovanni

2017-07-01

The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation. Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29). No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33). The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

[Clinical amalysis of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection].

PubMed

Tang, Y F; Han, L; Lu, F L; Song, Z G; Lang, X L; Zou, L J; Xu, Z Y

2016-07-01

To summarize the results and methods of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection. Clinical data of 67 patients (54 male and 13 female, mean age of (50±10) years) underwent surgical treatment of left subclavian artery fenestration for acute Stanford A aortic dissection in Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical College between September 2008 and December 2014 were analyzed retrospectively. The origin of the left subclavian artery was in the true lumen and no dissection existed near the artery's starting. There were 18 cases of Marfan's syndrome. Preoperative echocardiography showed moderate to severe aortic regurgitation in 10 cases, and mitral regurgitation in 3 cases. Electrocardiogram showed myocardial ischemia in 5 cases. Three patients had acute impaired renal function. All the patients received total arch replacement combined with stented elephant trunk implantation. Left subclavian artery revascularization was performed by stented trunk fenestration as follows: firstly, stented elephant trunk was implanted to completely cover the left subclavian artery, then part of stented trunk's polyester lining was removed which is located at the origin of left subclavian artery. Aortic root procedures included aortic valve replacement in 2 cases, Bentall procedure in 21 cases and aortic valve sparing in 44 cases. Three patients received mitral valve repair and 6 patients received coronary artery bypass grafting. The cardiopulmonary bypass time, cross-clamp time, and circulatory arrest time were (179±32) minutes, (112±25) minutes, and (26±10) minutes, respectively. The in-hospital mortality was 7.5% (5/67): 2 patients died of multiple organ failure, 1 patient died of acute renal failure and another 2 patients died of severe infection shock. Two patients required reexploration for root bleeding. Transient neurology dysfunction developed in 6 patients. Six patients received tracheotomy and prolonged ventilation due to pulmonary infection. All patients discharged from the hospital were followed up for 1 to 5 years. During long-term follow-up, the survival rate was 100% and 89.8% at 1 and 5 years, respectively. CT angiography was performed once per year after discharged. The left subclavian artery perfusion was good. No dissection or anastomosis leakage was identified in any case. Stroke and left limb ischemia did not develope. For acute Stanford type A aortic dissection whose origin of the left subclavian artery is in the true lumen and no dissection existed near the artery's starting, the left subclavian artery revascularization by stented trunk fenestration technique during total arch replacement combined with stented elephant trunk implantation is reliable and effective.

Ross operation: 16-year experience.

PubMed

Elkins, Ronald C; Thompson, David M; Lane, Mary M; Elkins, C Craig; Peyton, Marvin D

2008-09-01

We performed a review of a consecutive series of 487 patients undergoing the Ross operation to identify surgical techniques and clinical parameters that affect outcome. We performed a prospective review of consecutive patients from August 1986 through June 2002 and follow-up through August 2004. Patient age was 2 days to 62 years (median, 24 years), and 197 patients were less than 18 years of age. The Ross operation was performed as a scalloped subcoronary implant in 26 patients, an inclusion cylinder in 54 patients, root replacement in 392 patients, and root-Konno procedure in 15 patients. Clinical follow-up in 96% and echocardiographic evaluation in 77% were performed within 2 years of closure. Actuarial survival was 82% +/- 6% at 16 years, and hospital mortality was 3.9%. Freedom from autograft failure (autograft reoperation and valve-related death) was 74% +/- 5%. Male sex and primary diagnosis of aortic insufficiency (no prior aortic stenosis) were significantly associated with autograft failure by means of multivariate analysis. Freedom from autograft valve replacement was 80% +/- 5%. Freedom from endocarditis was 95% +/- 2%. One late thromboembolic episode occurred. Freedom from allograft reoperation or reintervention was 82% +/- 4%. Freedom from all valve-related events was 63% +/- 6%. In children survival was 84% +/- 8%, and freedom from autograft valve failure was 83% +/- 6%. The Ross operation provides excellent survival in adults and children willing to accept a risk of reoperation. Male sex and a primary diagnosis of aortic insufficiency had a negative effect on late results.

Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement.

PubMed

Lenoir, Marien; Maesen, Bart; Stevens, Louis-Mathieu; Cartier, Raymond; Demers, Philippe; Poirier, Nancy; Tousch, Michaël; El-Hamamsy, Ismail

2018-02-08

Remodelling with extra-aortic ring annuloplasty has emerged as an alternative approach to root reimplantation. However, no studies have yet compared outcomes between procedures. The aim of this study was to compare mid-term outcomes in patients undergoing reimplantation versus remodelling with extra-aortic annuloplasty. From 2001 to 2017, 142 patients underwent root remodelling with extra-aortic annuloplasty (n = 83, 48 ± 13 years) or a reimplantation technique (n = 59, 48 ± 12 years) at the Montreal Heart Institute. No differences were observed in the incidence of connective tissue disease (24% vs 29%, P = 0.9) or preoperative aortic insufficiency ≥3 (37% vs 23%, P = 0.24). However, in the remodelling group, there were more bicuspid aortic valves (31% vs 9%; P < 0.01), and the mean preoperative aortic annulus diameter was larger (27.2 ± 3.6 mm vs 25.6 ± 2.4 mm; P = 0.01). The mean follow-up duration was 3.9 years (100% complete). There were no hospital deaths and 5 late deaths. At 5 years, overall survival was similar in both groups (100%, P = 0.98). Similarly, 5-year freedom from aortic valve reoperation was equivalent (97 ± 2% in both groups, P = 0.95). Furthermore, 5-year survival free from aortic insufficiency ≥2 or reoperation was 84 ± 5% in the remodelling with annuloplasty group vs 83 ± 6% in the reimplantation group (P = 0.62). The mean annular diameter was 24.3 ± 0.5 mm at 5 years vs 23.6 ± 0.3 mm at discharge in the remodelling group (P = 0.28) and 24.4 ± 0.6 mm vs 23.2 ± 0.3 mm, respectively, in the reimplantation group (P = 0.1). Despite a higher prevalence of bicuspid aortic valves and larger aortic annular diameters, mid-term outcomes after remodelling with extra-aortic annuloplasty and reimplantation are comparable. Extra-aortic ring annuloplasty is effective at stabilizing annular dimensions. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Numerical investigation on effect of aortic root geometry on flow induced structural stresses developed in a bileaflet mechanical heart valve

NASA Astrophysics Data System (ADS)

Abbas, S. S.; Nasif, M. S.; Said, M. A. M.; Kadhim, S. K.

2017-10-01

Structural stresses developed in an artificial bileaflet mechanical heart valve (BMHV) due to pulsed blood flow may cause valve failure due to yielding. In this paper, von-Mises stresses are computed and compared for BMHV placed in two types of aortic root geometries that are aortic root with axisymmetric sinuses and with axisymmetric bulb, at different physiological blood flow rates. With BMHV placed in an aortic root with axisymmetric sinuses, the von-Mises stresses developed in the valve were found to be up to 47% higher than BMHV placed in aortic root with axisymmetric bulb under similar physiological conditions. High velocity vectors and therefore high von-Mises stresses have been observed for BMHV placed in aortic root with axisymmetric sinuses, that can lead to valve failure.

Facilitating Hemostasis After Proximal Aortic Surgery: Results of The PROTECT Trial.

PubMed

Khoynezhad, Ali; DelaRosa, Jacob; Moon, Marc R; Brinkman, William T; Thompson, Richard B; Desai, Nimesh D; Malaisrie, S Chris; Girardi, Leonard N; Bavaria, Joseph E; Reece, T Brett

2018-05-01

This study intended to evaluate the safety and hemostatic efficacy of a novel vascular sealant (Tridyne; Neomend, Inc, Irvine, CA) compared with an accepted adjunctive hemostatic agent applied to aortotomy and sutures lines in cardiovascular operations. Patients undergoing aortic valve replacement, ascending aortic replacement, or aortic root replacement were randomly assigned 2:1 to Tridyne (n = 107) or Gelfoam Plus (Baxter Healthcare Corp, Hayward, CA) (n = 51). These groups were similar with regard to age, sex, race, medical history, duration of bypass and cross-clamping, and number of suture lines treated. Suture lines were treated after confirmation of some leakage but before formal removal of the clamp. The median bleeding time was significantly lower for Tridyne versus Gelfoam Plus (0 versus 10.0 minutes, p < 0.0001). Immediate hemostasis was achieved in 59.4% of the Tridyne group versus 16.0% of Gelfoam Plus group (p < 0.0001). A significantly greater proportion of patients in the Tridyne group achieved successful hemostasis at the aortic suture line than patients in the Gelfoam Plus group (85.7% versus 40.0%, p < 0.0001). The Clinical Events Committee adjudicated 7 patients with possible device-related serious adverse events: 3 patients (2.9%) in the Tridyne group and 4 patients (8.2%) in the Gelfoam Plus group (p = 0.2097). Tridyne was safe and effective when used as an adjunct to conventional hemostasis to treat high-pressure vessels in patients who receive anticoagulation agents, in reducing time to hemostasis, and in promoting both immediate and persistent hemostasis. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Aortic Cross-Sectional Area/Height Ratio and Outcomes in Patients With a Trileaflet Aortic Valve and a Dilated Aorta.

PubMed

Masri, Ahmad; Kalahasti, Vidyasagar; Svensson, Lars G; Roselli, Eric E; Johnston, Douglas; Hammer, Donald; Schoenhagen, Paul; Griffin, Brian P; Desai, Milind Y

2016-11-29

In patients with a dilated proximal ascending aorta and trileaflet aortic valve, we aimed to assess (1) factors independently associated with increased long-term mortality and (2) the incremental prognostic utility of indexing aortic root to patient height. We studied consecutive patients with a dilated aortic root (≥4 cm) that underwent echocardiography and gated contrast-enhanced thoracic aortic computed tomography or magnetic resonance angiography between 2003 and 2007. A ratio of aortic root area over height was calculated (cm 2 /m) on tomography, and a cutoff of 10 cm 2 /m was chosen as abnormal, on the basis of previous reports. All-cause death was recorded. The cohort comprised 771 patients (63 years [interquartile range, 53-71], 87% men, 85% hypertension, 51% hyperlipidemia, 56% smokers). Inherited aortopathies, moderate to severe aortic regurgitation, and severe aortic stenosis were seen in 7%, 18%, and 2%, whereas 91% and 54% were on β-blockers and angiotensin-converting enzyme inhibitors, respectively. Aortic root area/height ratio was ≥10 cm 2 /m in 24%. The Society of Thoracic Surgeons score and right ventricular systolic pressure were 3.3±3 and 31±7 mm Hg, respectively. At 7.8 years (interquartile range, 6.6-8.9), 280 (36%) patients underwent aortic surgery (76% within 1 year) and 130 (17%) died (1% in-hospital postoperative mortality). A lower proportion of patients in the surgical (versus nonsurgical) group died (13% versus 19%, P<0.01). On multivariable Cox proportional hazard analysis, aortic root area/height ratio (hazard ratio, 4.04; 95% confidence interval [CI], 2.69-6.231) was associated with death, whereas aortic surgery (hazard ratio, 0.47; 95% CI, 0.27-0.81) was associated with improved survival (both P<0.01). For longer-term mortality, the addition of aortic root area/height ratio ≥10 cm 2 /m to a clinical model (Society of Thoracic Surgeons score, inherited aortopathies, hypertension, hyperlipidemia, medications, aortic regurgitation, and right ventricular systolic pressure), increased the c-statistic from 0.57 (95% CI, 0.35-0.77) to 0.65 (95% CI, 0.52-0.73) and net reclassification index from 0.17 (95% CI, 0.02-0.31) to 0.23 (95% CI, 0.04-0.34), both P<0.01. Of the 327 patients with aortic root diameter between 4.5 and 5.5 cm, 44% had an abnormal aortic root area/height ratio, of which 78% died. In patients with dilated aortic root and trileaflet aortic valve, a ratio of aortic root area to height provides independent and improved stratification for prediction of death. © 2016 American Heart Association, Inc.

Aortic valve replacement for stenosis with or without coronary artery bypass grafting after 2 previous isolated coronary artery bypass grafting operations

PubMed Central

Lee Henry, Christopher; Ko, Jong Mi; Henry, Albert Carl; Matter, Gregory John

2011-01-01

Aortic valve replacement following an earlier coronary artery bypass grafting (CABG) procedure is fairly common. When this situation occurs, the type of valve dysfunction is usually stenosis (with or without regurgitation), and whether it was missed at the time of the earlier CABG or developed subsequently is usually unclear. We attempted to determine the survival in patients who had had aortic valve replacement after 2 previous CABG procedures. We describe 12 patients who had aortic valve replacement for aortic stenosis; rather than one previous CABG operation, all had had 2 previous CABG procedures. Only one patient died in the early postoperative period after aortic valve replacement, and the remaining 11 were improved substantially: all have lived at least 11 months, and one is still alive at over 101 months after aortic valve replacement. Aortic valve replacement remains beneficial for most patients even after 2 previous CABG procedures. PMID:21307968

Accuracy and reproducibility of novel echocardiographic three-dimensional automated software for the assessment of the aortic root in candidates for thanscatheter aortic valve replacement.

PubMed

García-Martín, Ana; Lázaro-Rivera, Carla; Fernández-Golfín, Covadonga; Salido-Tahoces, Luisa; Moya-Mur, Jose-Luis; Jiménez-Nacher, Jose-Julio; Casas-Rojo, Eduardo; Aquila, Iolanda; González-Gómez, Ariana; Hernández-Antolín, Rosana; Zamorano, José Luis

2016-07-01

A specialized three-dimensional transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced; the system automatically configures a geometric model of the aortic root from the images obtained by 3D-TOE and performs quantitative analysis of these structures. The aim of this study was to compare the measurements of the aortic annulus (AA) obtained by the new model to that obtained by 3D-TOE and multidetector computed tomography (MDCT) in candidates to transcatheter aortic valve implantation (TAVI) and to assess the reproducibility of this new method. We included 31 patients who underwent TAVI. The AA diameters and area were evaluated by the manual 3D-TOE method and by the automatic software. We showed an excellent correlation between the measurements obtained by both methods: intra-class correlation coefficient (ICC): 0.731 (0.508-0.862), r: 0.742 for AA diameter and ICC: 0.723 (0.662-0.923), r: 0.723 for the AA area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, we also found an excellent correlation between the automatic measurements and those obtained by MDCT, ICC: 0.941 (0.761-0.985), r: 0.901 for AA diameter and ICC: 0.853 (0.409-0.964), r: 0.744 for the AA area. The new automatic 3D-TOE software allows modelling and quantifying the aortic root from 3D-TOE data with high reproducibility. There is good correlation between the automated measurements and other 3D validated techniques. Our results support its use in clinical practice as an alternative to MDCT previous to TAVI. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Quantitative Prediction of Paravalvular Leak in Transcatheter Aortic Valve Replacement Based on Tissue-Mimicking 3D Printing.

PubMed

Qian, Zhen; Wang, Kan; Liu, Shizhen; Zhou, Xiao; Rajagopal, Vivek; Meduri, Christopher; Kauten, James R; Chang, Yung-Hang; Wu, Changsheng; Zhang, Chuck; Wang, Ben; Vannan, Mani A

2017-07-01

This study aimed to develop a procedure simulation platform for in vitro transcatheter aortic valve replacement (TAVR) using patient-specific 3-dimensional (3D) printed tissue-mimicking phantoms. We investigated the feasibility of using these 3D printed phantoms to quantitatively predict the occurrence, severity, and location of any degree of post-TAVR paravalvular leaks (PVL). We have previously shown that metamaterial 3D printing technique can be used to create patient-specific phantoms that mimic the mechanical properties of biological tissue. This may have applications in procedural planning for cardiovascular interventions. This retrospective study looked at 18 patients who underwent TAVR. Patient-specific aortic root phantoms were created using the tissue-mimicking 3D printing technique using pre-TAVR computed tomography. The CoreValve (self-expanding valve) prostheses were deployed in the phantoms to simulate the TAVR procedure, from which post-TAVR aortic root strain was quantified in vitro. A novel index, the annular bulge index, was measured to assess the post-TAVR annular strain unevenness in the phantoms. We tested the comparative predictive value of the bulge index and other known predictors of post-TAVR PVL. The maximum annular bulge index was significantly different among patient subgroups that had no PVL, trace-to-mild PVL, and moderate-to-severe PVL (p = 0.001). Compared with other known PVL predictors, bulge index was the only significant predictor of moderate-severe PVL (area under the curve = 95%; p < 0.0001). Also, in 12 patients with post-TAVR PVL, the annular bulge index predicted the major PVL location in 9 patients (accuracy = 75%). In this proof-of-concept study, we have demonstrated the feasibility of using 3D printed tissue-mimicking phantoms to quantitatively assess the post-TAVR aortic root strain in vitro. A novel indicator of the post-TAVR annular strain unevenness, the annular bulge index, outperformed the other established variables and achieved a high level of accuracy in predicting post-TAVR PVL, in terms of its occurrence, severity, and location. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Echocardiographic assessment of the aortic root dilatation in adult patients after tetralogy of Fallot repair.

PubMed

Cruz, Cristina; Pinho, Teresa; Lebreiro, Ana; Silva Cardoso, José; Maciel, Maria Júlia

2013-06-01

Transthoracic echocardiography is an important tool after tetralogy of Fallot repair, of which aortic root dilatation is a recognized complication. In this study we aimed to assess its prevalence and potential predictors. We consecutively assessed adult patients by transthoracic echocardiography after tetralogy of Fallot repair, and divided them into two groups based on the maximum internal aortic diameter at the sinuses of Valsalva in parasternal long-axis view: group 1 with aortic root dilatation (≥38 mm) and group 2 without dilatation (<38 mm). A total of 53 patients were included, mean age 32±10 years, with a mean time since surgery of 23±7 years. An aortopulmonary shunt had been performed prior to complete repair in 25 patients, and a transannular patch was used in 19 patients. Aortic root measurement was possible in all patients. Aortic root dilatation was identified in eight patients (15%), all male. Male gender (p=0.001), body surface area (1.93±0.10 vs. 1.70±0.20 m(2), p=0.03) and increased left ventricular end-diastolic diameter (p=0.005) were predictors of aortic root dilatation. None of the surgical variables studied were predictors of aortic root dilatation. The prevalence of aortic root dilatation in this cohort was low and male gender was a predictor of its occurrence. The type of repair and time to surgery did not influence its occurrence. Quantification of aortic root diameter is possible by transthoracic echocardiography; we suggest indexing it to body surface area in clinical practice. Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Further insights into normal aortic valve function: role of a compliant aortic root on leaflet opening and valve orifice area.

PubMed

Sripathi, Vangipuram Canchi; Kumar, Ramarathnam Krishna; Balakrishnan, Komarakshi R

2004-03-01

This study aims to find the fundamental differences in the mechanism of opening and closing of a normal aortic valve and a valve with a stiff root, using a dynamic finite element model. A dynamic, finite element model with time varying pressure was used in this study. Shell elements with linear elastic properties for the leaflet and root were used. Two different cases were analyzed: (1) normal leaflets inside a compliant root, and (2) normal leaflets inside a stiff root. A compliant aortic root contributes substantially to the smooth and symmetrical leaflet opening with minimal gradients. In contrast, the leaflet opening inside a stiff root is delayed, asymmetric, and wrinkled. However, this wrinkling is not associated with increased leaflet stresses. In compliant roots, the effective valve orifice area can substantially increase because of increased root pressure and transvalvular gradients. In stiff roots this effect is strikingly absent. A compliant aortic root contributes substantially to smooth and symmetrical leaflet opening with minimal gradients. The compliance also contributes much to the ability of the normal aortic valve to increase its effective valve orifice in response to physiologic demands of exercise. This effect is strikingly absent in stiff roots.

Aortic cusp extension valvuloplasty with or without tricuspidization in children and adolescents: long-term results and freedom from aortic valve replacement.

PubMed

Polimenakos, Anastasios C; Sathanandam, Shyam; Elzein, Chawki; Barth, Mary J; Higgins, Robert S D; Ilbawi, Michel N

2010-04-01

Aortic cusp extension valvuloplasty is increasingly used in the management of children and adolescents with aortic stenosis or regurgitation. The durability of this approach and the freedom from valve replacement are not well defined. A study was undertaken to investigate outcomes. From July 1987 to November 2008, 142 patients aged less than 19 years underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and tricuspidization (when needed). Three patients with truncus arteriosus and severe truncal valve insufficiency were excluded. From the available follow-up data of 139 patients, 50 had bicuspid aortic valves, 40 had congenital aortic valve stenosis, 41 had combined congenital aortic valve stenosis/insufficiency, and 8 had other diagnoses. Median follow-up was 14.4 years (0.1-21.4). Long-term mortality and freedom from aortic valve replacement were studied. There were no early, intermediate, or late deaths. Z-values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, and sinotubular junction diameter before aortic valve replacement were 4.2 +/- 3.11, 2.3 +/- 1.25, 4.4 +/- 1.23, and 1.84 +/- 1.28, respectively. During the follow-up period, 64 patients underwent aortic valve reinterventions. The Ross procedure was performed in 32 of 139 patients (23%) undergoing aortic cusp extension valvuloplasty. Other aortic valve replacements were undertaken after 16 aortic cusp extension valvuloplasties (11.5%). Freedom from a second aortic cusp extension valvuloplasty or aortic valve replacement at 18 years was 82.1% +/- 4.2% and 60.0% +/- 7.2%, respectively. Aortic cusp extension valvuloplasty is a safe and effective surgical option with excellent survival and good long-term outcomes in children and adolescents. The procedure provides acceptable durability and satisfactory freedom from aortic valve replacement. Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Surgery for Aortic Dilatation in Patients With Bicuspid Aortic Valves: A Statement of Clarification From the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

PubMed

Hiratzka, Loren F; Creager, Mark A; Isselbacher, Eric M; Svensson, Lars G; Nishimura, Rick A; Bonow, Robert O; Guyton, Robert A; Sundt, Thoralf M; Halperin, Jonathan L; Levine, Glenn N; Anderson, Jeffrey L; Albert, Nancy M; Al-Khatib, Sana M; Birtcher, Kim K; Bozkurt, Biykem; Brindis, Ralph G; Cigarroa, Joaquin E; Curtis, Lesley H; Fleisher, Lee A; Gentile, Federico; Gidding, Samuel; Hlatky, Mark A; Ikonomidis, John; Joglar, José; Kovacs, Richard J; Ohman, E Magnus; Pressler, Susan J; Sellke, Frank W; Shen, Win-Kuang; Wijeysundera, Duminda N

2016-02-16

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: the "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease" (Circulation. 2010;121:e266-e369) and the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" (Circulation. 2014;129:e521-e643). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline. © 2015 American College of Cardiology Foundation and American Heart Association, Inc.

Aortic Stenosis and Vascular Calcifications in Alkaptonuria

PubMed Central

Hannoush, Hwaida; Introne, Wendy J.; Chen, Marcus Y.; Lee, Sook-Jin; O'Brien, Kevin; Suwannarat, Pim; Kayser, Michael A.; Gahl, William A.; Sachdev, Vandana

2011-01-01

Alkaptonuria is a rare metabolic disorder of tyrosine catabolism in which homogentisic acid (HGA) accumulates and is deposited throughout the spine, large joints, cardiovascular system, and various tissues throughout the body. In the cardiovascular system, pigment deposition has been described in the heart valves, endocardium, pericardium, aortic intima and coronary arteries. The prevalence of cardiovascular disease in patients with alkaptonuria varies in previous reports . We present a series of 76 consecutive adult patients with alkaptonuria who underwent transthoracic echocardiography between 2000 and 2009. A subgroup of 40 patients enrolled in a treatment study underwent non-contrast CT scans and these were assessed for vascular calcifications. Six of the 76 patients had aortic valve replacement. In the remaining 70 patients, 12 patients had aortic sclerosis and 7 patients had aortic stenosis. Unlike degenerative aortic valve disease, we found no correlation with standard cardiac risk factors. There was a modest association between the severity of aortic valve disease and joint involvement, however, we saw no correlation with urine HGA levels. Vascular calcifications were seen in the coronaries, cardiac valves, aortic root, descending aorta and iliac arteries. These findings suggest an important role for echocardiographic screening of alkaptonuria patients to detect valvular heart disease and cardiac CT to detect coronary artery calcifications. PMID:22100375

Aortic stenosis and vascular calcifications in alkaptonuria.

PubMed

Hannoush, Hwaida; Introne, Wendy J; Chen, Marcus Y; Lee, Sook-Jin; O'Brien, Kevin; Suwannarat, Pim; Kayser, Michael A; Gahl, William A; Sachdev, Vandana

2012-02-01

Alkaptonuria is a rare metabolic disorder of tyrosine catabolism in which homogentisic acid (HGA) accumulates and is deposited throughout the spine, large joints, cardiovascular system, and various tissues throughout the body. In the cardiovascular system, pigment deposition has been described in the heart valves, endocardium, pericardium, aortic intima and coronary arteries. The prevalence of cardiovascular disease in patients with alkaptonuria varies in previous reports. We present a series of 76 consecutive adult patients with alkaptonuria who underwent transthoracic echocardiography between 2000 and 2009. A subgroup of 40 patients enrolled in a treatment study underwent non-contrast CT scans and these were assessed for vascular calcifications. Six of the 76 patients had aortic valve replacement. In the remaining 70 patients, 12 patients had aortic sclerosis and 7 patients had aortic stenosis. Unlike degenerative aortic valve disease, we found no correlation with standard cardiac risk factors. There was a modest association between the severity of aortic valve disease and joint involvement, however, we saw no correlation with urine HGA levels. Vascular calcifications were seen in the coronaries, cardiac valves, aortic root, descending aorta and iliac arteries. These findings suggest an important role for echocardiographic screening of alkaptonuria patients to detect valvular heart disease and cardiac CT to detect coronary artery calcifications. Published by Elsevier Inc.

Familial Thoracic Aortic Aneurysm with Dissection Presenting as Flash Pulmonary Edema in a 26-Year-Old Man

PubMed Central

Omar, Sabry; Moore, Tyler; Payne, Drew; Momeni, Parastoo; Mulkey, Zachary; Nugent, Kenneth

2014-01-01

We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a patient with familial TAAD and discusses the associated genetic loci and available screening methods. It is important to recognize potential cases of familial TAAD and understand the available screening methods since early diagnosis allows appropriate management of risk factors and treatment when necessary. PMID:25104961

Impact of aortic root size on left ventricular afterload and stroke volume.

PubMed

Sahlén, Anders; Hamid, Nadira; Amanullah, Mohammed Rizwan; Fam, Jiang Ming; Yeo, Khung Keong; Lau, Yee How; Lam, Carolyn S P; Ding, Zee Pin

2016-07-01

The left ventricle (LV) ejects blood into the proximal aorta. Age and hypertension are associated with stiffening and dilation of the aortic root, typically viewed as indicative of adverse remodeling. Based on analytical considerations, we hypothesized that a larger aortic root should be associated with lower global afterload (effective arterial elastance, EA) and larger stroke volume (SV). Moreover, as antihypertensive drugs differ in their effect on central blood pressure, we examined the role of antihypertensive drugs for the relation between aortic root size and afterload. We studied a large group of patients (n = 1250; 61 ± 12 years; 78 % males; 64 % hypertensives) from a single-center registry with known or suspected coronary artery disease. Aortic root size was measured by echocardiography as the diameter of the tubular portion of the ascending aorta. LV outflow tract Doppler was used to record SV. In the population as a whole, after adjusting for key covariates in separate regression models, aortic root size was an independent determinant of both SV and EA. This association was found to be heterogeneous and stronger in patients taking a calcium channel blocker (CCB; 10.6 % of entire population; aortic root size accounted for 8 % of the explained variance of EA). Larger aortic root size is an independent determinant of EA and SV. This association was heterogeneous and stronger in patients on CCB therapy.

Randomized controlled trial of moderate hypothermia versus deep hypothermia anesthesia on brain injury during Stanford A aortic dissection surgery.

PubMed

Sun, Xufang; Yang, Hua; Li, Xinyu; Wang, Yue; Zhang, Chuncheng; Song, Zhimin; Pan, Zhenxiang

2018-01-01

This study aimed to compare the effects of moderate versus deep hypothermia anesthesia for Stanford A aortic dissection surgery on brain injury. A total of 82 patients who would undergo Stanford A aortic dissection surgery were randomized into two groups: moderate hypothermia group (MH, n = 40, nasopharyngeal temperature 25 °C, and rectal temperature 28 °C) and deep hypothermia group (DH, n = 42, nasopharyngeal temperature 20 °C, and rectal temperature 25 °C). Different vascular replacement techniques including aortic root replacement, Bentall, and Wheat were used. The intraoperative and postoperative indicators of these patients were recorded. There were no differences in intraoperative and postoperative measures between MH and DH groups. The concentrations of neuron-specific enolase and S-100β increased with operation time, and were significantly lower in MH group than those in the DH group (P < 0.05). The occurrence rates of complications including chenosis, postoperative agitation, and neurological complications in MH group were significantly lower than in DH group. The recovery time, postoperative tube, and ICU intubation stay were significantly shorter in MH group than those in DH group (P < 0.05). There were no significant differences revealed in hospital stay and death rate. MH exhibited better cerebral protective effects, less complications, and shorter tube time than DH in surgery for Stanford A aortic dissection.

Selective Heart, Brain and Body Perfusion in Open Aortic Arch Replacement.

PubMed

Maier, Sven; Kari, Fabian; Rylski, Bartosz; Siepe, Matthias; Benk, Christoph; Beyersdorf, Friedhelm

2016-09-01

Open aortic arch replacement is a complex and challenging procedure, especially in post dissection aneurysms and in redo procedures after previous surgery of the ascending aorta or aortic root. We report our experience with the simultaneous selective perfusion of heart, brain, and remaining body to ensure optimal perfusion and to minimize perfusion-related risks during these procedures. We used a specially configured heart-lung machine with a centrifugal pump as arterial pump and an additional roller pump for the selective cerebral perfusion. Initial arterial cannulation is achieved via femoral artery or right axillary artery. After lower body circulatory arrest and selective antegrade cerebral perfusion for the distal arch anastomosis, we started selective lower body perfusion simultaneously to the selective antegrade cerebral perfusion and heart perfusion. Eighteen patients were successfully treated with this perfusion strategy from October 2012 to November 2015. No complications related to the heart-lung machine and the cannulation occurred during the procedures. Mean cardiopulmonary bypass time was 239 ± 33 minutes, the simultaneous selective perfusion of brain, heart, and remaining body lasted 55 ± 23 minutes. One patient suffered temporary neurological deficit that resolved completely during intensive care unit stay. No patient experienced a permanent neurological deficit or end-organ dysfunction. These high-risk procedures require a concept with a special setup of the heart-lung machine. Our perfusion strategy for aortic arch replacement ensures a selective perfusion of heart, brain, and lower body during this complex procedure and we observed excellent outcomes in this small series. This perfusion strategy is also applicable for redo procedures.

COMBINED REPLACEMENT OF THE AORTIC VALVE AND ASCENDING AORTA IN JEHOVAH'S WITNESSES: REPORT OF TWO CASES

PubMed Central

Beddermann, Christoph; Norman, John C.; Cooley, Denton A.

1979-01-01

Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aortic valve and the ascending aorta. One patient received a composite graft containing an aortic valve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aortic valve 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 aortic valve and ascending aorta in Jehovah's Witnesses. Images PMID:15216324

Aortic events in a nationwide Marfan syndrome cohort.

PubMed

Groth, Kristian A; Stochholm, Kirstine; Hove, Hanne; Kyhl, Kasper; Gregersen, Pernille A; Vejlstrup, Niels; Østergaard, John R; Gravholt, Claus H; Andersen, Niels H

2017-02-01

Marfan syndrome is associated with morbidity and mortality due to aortic dilatation and dissection. Preventive aortic root replacement has been the standard treatment in Marfan syndrome patients with aortic dilatation. In this study, we present aortic event data from a nationwide Marfan syndrome cohort. The nationwide cohort of Danish Marfan syndrome patients was established from the Danish National Patient Registry and the Cause of Death Register, where we retrieved information about aortic surgery and dissections. We associated aortic events with age, sex, and Marfan syndrome diagnosis prior or after the first aortic event. From the total cohort of 412 patients, 150 (36.4 %) had an aortic event. Fifty percent were event free at age 49.6. Eighty patients (53.3 %) had prophylactic surgery and seventy patients (46.7 %) a dissection. The yearly event rate was 0.02 events/year/patient in the period 1994-2014. Male patients had a significant higher risk of an aortic event at a younger age with a hazard ratio of 1.75 (CI 1.26-2.42, p = 0.001) compared with women. Fifty-three patients (12.9 %) were diagnosed with MFS after their first aortic event which primarily was aortic dissection [n = 44 (83.0 %)]. More than a third of MFS patients experienced an aortic event and male patients had significantly more aortic events than females. More than half of the total number of dissections was in patients undiagnosed with MFS at the time of their event. This emphasizes that diagnosing MFS is lifesaving and improves mortality risk by reducing the risk of aorta dissection.

Inter-ethnic differences in valve morphology, valvular dysfunction, and aortopathy between Asian and European patients with bicuspid aortic valve.

PubMed

Kong, William K F; Regeer, Madelien V; Poh, Kian K; Yip, James W; van Rosendael, Philippe J; Yeo, Tiong C; Tay, Edgar; Kamperidis, Vasileios; van der Velde, Enno T; Mertens, Bart; Ajmone Marsan, Nina; Delgado, Victoria; Bax, Jeroen J

2018-04-14

Transcatheter aortic valve replacement (TAVR) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of inter-ethnic differences in valve morphology and function and aortic root dimensions in patients with BAV is important for the worldwide spread of this therapy in this subgroup of patients. Comparisons between large European and Asian cohorts of patients with BAV have not been performed, and potential differences between populations may have important implications for TAVR. The present study evaluated the differences in valve morphology and function and aortic root dimensions between two large cohorts of European and Asian patients with BAV. Aortic valve morphology was defined on transthoracic echocardiography according to the number of commissures and raphe: type 0 = no raphe and two commissures, type 1 = one raphe and two commissures, type 2 = two raphes and one commissure. Aortic stenosis and regurgitation were graded according to current recommendations. For this study, aortic root dimensions were manually measured on transthoracic echocardiograms at the level of the aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), and ascending aorta (AA). Of 1427 patients with BAV (45.2 ± 18.1 years, 71.9% men), 794 (55.6%) were Europeans and 633 (44.4%) were Asians. The groups were comparable in age and proportion of male sex. Asians had higher prevalence of type 1 BAV with raphe between right and non-coronary cusps than Europeans (19.7% vs. 13.6%, respectively; P < 0.001), whereas the Europeans had higher prevalence of type 0 BAV (two commissures, no raphe) than Asians (14.5% vs. 6.8%, respectively; P < 0.001). The prevalence of moderate and severe aortic regurgitation was higher in Europeans than Asians (44.2% vs. 26.8%, respectively; P < 0.001) whereas there were no differences in BAV with normal function or aortic stenosis. After adjusting for demographics, comorbidities, and valve function, the dimensions of the aortic annulus [mean difference 1.17 mm/m2, 95% confidence interval (CI) 0.96-1.39], SOV (mean difference 1.86 mm/m2, 95% CI 1.47-2.24), STJ (mean difference 0.52 mm/m2, 95% CI 0.14-0.90) and AA (mean difference 1.05 mm/m2, 95% CI 0.57-1.52) were significantly larger among Asians compared with Europeans. This large multicentre registry reports for the first time that Asians with BAV showed more frequently type 1 BAV (with fusion between right and non-coronary cusp) and have larger aortic dimensions than Europeans. These findings have important implications for prosthesis type and size selection for TAVR.

Outcomes After Operations for Unicuspid Aortic Valve With or Without Ascending Repair in Adults

PubMed Central

Zhu, Yuanjia; Roselli, Eric E.; Idrees, Jay J.; Wojnarski, Charles M.; Griffin, Brian; Kalahasti, Vidyasagar; Pettersson, Gosta; Svensson, Lars G.

2016-01-01

Background Unicuspid aortic valve is an important subset of bicuspid aortic valve, and knowledge regarding its aortopathy pattern and surgical outcomes is limited. Our objectives were to characterize unicuspid aortic valve patients, associated aortopathy, and surgical outcomes. Methods From January 1990 to May 2013, 149 adult unicuspid aortic valve patients underwent aortic valve replacement or repair for aortic stenosis (n = 13), regurgitation (n = 13), or both (n = 123), and in 91 (61%) the aortic valve operation was combined with aortic repair. Data were obtained from the Cardiovascular Information Registry and medical record review. Three-dimensional imaging analysis was performed from preoperative computed tomography and magnetic resonance imaging scans. The Kaplan-Meier method was used for survival analysis. Results Patients had a mean maximum aortic diameter of 44 ± 8 mm and variably involved the aortic root, ascending, or arch, or both. Patients with valve operations alone were more likely to be hypertensive (p = 0.01) and to have severe aortic stenosis (p = 0.07) than those who underwent concurrent aortic operations. There were no operative deaths, strokes, or myocardial infarctions. Patients undergoing aortic repair had better long-term survival. Estimated survival at 1, 5, and 10 years was 100%, 100%, and 100% after combined operations and was 100%, 88%, and 88% after valve operations alone (p = 0.01). Conclusions Patients with a dysfunctional unicuspid aortic valve frequently present with an ascending aneurysm that requires repair. Combined aortic valve operations and aortic repair was associated with significantly better long-term survival than a valve operation alone. Further study of this association may direct decisions about timing of surgical intervention. PMID:26453423

[Comparison of aortic valve dysfunction and ascending aorta dimension between patients with different bicuspid aortic valve morphology].

PubMed

Ren, X S; Yu, Y T; Liu, K; Hou, Z H; Gao, Y; Yin, W H; Lyu, B

2017-06-24

Objective: To compare the characteristics of aortic valve dysfunction and ascending aorta dimension in patients with different bicuspid aortic valve (BAV) morphology. Methods: A total of 197 patients who underwent aortic valve replacement between April 2014 and March 2015 and were diagnosed with BAV by pathology were included, and their clinical data were retrospectively analyzed. Patients were divided into raphe(+) group(109 cases) and raphe(-) group(88 cases) according to the presence or absence of raphe, and L-R group(fusion of left and right cusp, 125 cases) and L/R-N group(fusion of left or right and noncoronary cusp, 72 cases) according to fusion type of the cusps. The characteristics of aortic valve dysfunction and ascending aorta dimension in patients with different BAV morphology were compared. Results: (1) Aortic stenosis incidence was lower in raphe(+) group than in raphe(-) group(22.9%(25/109) vs. 69.3%(61/88), P <0.001). Aortic regurgitation incidence was higher in raphe(+) group than in raphe(-) group (61.5%(67/109) vs. 22.7%(20/88), P <0.001). Incidence of type 1 of aortic root dilation was higher in raphe(+) group than in raphe(-) group (23.9%(26/109)vs.10.2%(9/88), P =0.024). (2) Aortic stenosis incidence was lower in L-R group than in L/R-N group(29.6%(37/125) vs. 68.1%(49/72), P <0.001). Aortic regurgitation incidence was higher in L-R group than in L/R-N group (59.2%(74/125) vs. 18.1%(13/72), P <0.001). Incidence of type 3 of aortic root dilation was lower in L-R group than in L/R-N group(10.4%(13/125) vs. 37.5%(27/72), P =0.006). (3) Aortic stenosis incidence was lower in L-R patients than in L/R-N patients(15.1%(13/86)vs. 52.2%(12/23), P =0.001), and aortic regurgitation incidence was higher in L-R patients than in L/R-N patients in raphe(+) group(73.3%(63/86)vs. 17.4%(4/23), P <0.001). Conclusion: There is significant difference in the type of valvular dysfunction and ascending aorta dilatation in patients with different morphological characteristics of BAV.

Accuracy assessment of fluoroscopy-transesophageal echocardiography registration

NASA Astrophysics Data System (ADS)

Lang, Pencilla; Seslija, Petar; Bainbridge, Daniel; Guiraudon, Gerard M.; Jones, Doug L.; Chu, Michael W.; Holdsworth, David W.; Peters, Terry M.

2011-03-01

This study assesses the accuracy of a new transesophageal (TEE) ultrasound (US) fluoroscopy registration technique designed to guide percutaneous aortic valve replacement. In this minimally invasive procedure, a valve is inserted into the aortic annulus via a catheter. Navigation and positioning of the valve is guided primarily by intra-operative fluoroscopy. Poor anatomical visualization of the aortic root region can result in incorrect positioning, leading to heart valve embolization, obstruction of the coronary ostia and acute kidney injury. The use of TEE US images to augment intra-operative fluoroscopy provides significant improvements to image-guidance. Registration is achieved using an image-based TEE probe tracking technique and US calibration. TEE probe tracking is accomplished using a single-perspective pose estimation algorithm. Pose estimation from a single image allows registration to be achieved using only images collected in standard OR workflow. Accuracy of this registration technique is assessed using three models: a point target phantom, a cadaveric porcine heart with implanted fiducials, and in-vivo porcine images. Results demonstrate that registration can be achieved with an RMS error of less than 1.5mm, which is within the clinical accuracy requirements of 5mm. US-fluoroscopy registration based on single-perspective pose estimation demonstrates promise as a method for providing guidance to percutaneous aortic valve replacement procedures. Future work will focus on real-time implementation and a visualization system that can be used in the operating room.

Doppler Imaging in Aortic Stenosis: The Importance of the Nonapical Imaging Windows to Determine Severity in a Contemporary Cohort.

PubMed

Thaden, Jeremy J; Nkomo, Vuyisile T; Lee, Kwang Je; Oh, Jae K

2015-07-01

Although the highest aortic valve velocity was thought to be obtained from imaging windows other than the apex in about 20% of patients with severe aortic stenosis (AS), its occurrence appears to be increasing as the age of patients has increased with the application of transcatheter aortic valve replacement. The aim of this study was to determine the frequency with which the highest peak jet velocity (Vmax) is found at each imaging window, the degree to which neglecting nonapical imaging windows underestimates AS severity, and factors influencing the location of the optimal imaging window in contemporary patients. Echocardiograms obtained in 100 consecutive patients with severe AS from January 3 to May 23, 2012, in which all imaging windows were interrogated, were retrospectively analyzed. AS severity (aortic valve area and mean gradient) was calculated on the basis of the apical imaging window alone and the imaging window with the highest peak jet velocity. The left ventricular-aortic root angle measured in the parasternal long-axis view as well as clinical variables were correlated with the location of highest peak jet velocity. Vmax was most frequently obtained in the right parasternal window (50%), followed by the apex (39%). Subjects with acute angulation more commonly had Vmax at the right parasternal window (65% vs 43%, P = .05) and less commonly had Vmax at the apical window (19% vs 48%, P = .005), but Vmax was still located outside the apical imaging window in 52% of patients with obtuse aortic root angles. If nonapical windows were neglected, 8% of patients (eight of 100) were misclassified from high-gradient severe AS to low-gradient severe AS, and another 15% (15 of 100) with severe AS (aortic valve area < 1.0 cm(2)) were misclassified as having moderate AS (aortic valve area > 1.0 cm(2)). In this contemporary cohort, Vmax was located outside the apical imaging window in 61% of patients, and neglecting the nonapical imaging windows resulted in the misclassification of AS severity in 23% of patients. Aortic root angulation as measured by two-dimensional echocardiography influences the location of Vmax modestly. Despite increasing time constraints on many echocardiography laboratories, these data confirm that routine Doppler interrogation from multiple imaging windows is critical to accurately determine the severity of AS in contemporary clinical practice. Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Landmark lecture: Perloff lecture: Tribute to Professor Joseph Kayle Perloff and lessons learned from him: aortopathy in adults with CHD.

PubMed

Niwa, Koichiro

2017-12-01

Marfan syndrome, bicuspid aortic valve, and/or coarctation of the aorta are associated with medial abnormalities of the ascending aortic or para-coarctation aorta. Medial abnormalities in the ascending aorta are prevalent in other type of patients with a variety of CHDs such as single ventricle, persistent truncus arteriosus, transposition of the great arteries, hypoplastic left heart syndrome, and tetralogy of Fallot, encompassing a wide age range and may predispose to dilatation, aneurysm, and rapture necessitating aortic valve and root surgery. These CHDs exhibit ongoing dilatation of the aortic root and reduced aortic elasticity and increased aortic stiffness that may relate to intrinsic properties of the aortic root. These aortic dilatation and increased stiffness can induce aortic aneurysm, rapture of the aorta, and aortic regurgitation, but also provoke left ventricular hypertrophy, reduced coronary artery flow, and left ventricular failure. Therefore, a new clinical entity can be used to call this association of aortic pathophysiological abnormality, aortic dilation, and aorto-left ventricular interaction - "aortopathy".

Clinical Outcomes of Root Reimplantation and Bentall Procedure: Propensity Score Matching Analysis.

PubMed

Lee, Heemoon; Cho, Yang Hyun; Sung, Kiick; Kim, Wook Sung; Park, Kay-Hyun; Jeong, Dong Seop; Park, Pyo Won; Lee, Young Tak

2018-03-26

This study aimed to evaluate the clinical outcomes of aortic root replacement(ARR) surgery:Root reimplantation as valve-sparing root replacement(VSR) and the Bentall procedure. We retrospectively reviewed 216 patients who underwent ARR between 1995 and 2013 at Samsung Medical Center. Patients were divided into two groups, depending on the procedure they underwent: Bentall(n=134) and VSR(n=82). The mean follow-up duration was 100.9±56.4 months. There were 2 early deaths in the Bentall group and none in the VSR group(p=0.53). Early morbidities were not different between the groups. Overall mortality was significantly lower in the VSR group (HR=0.12,p=0.04). Despite the higher reoperation rate in the VSR group(p=0.03), major adverse valve-related events(MAVRE) did not differ between the groups(p=0.28). Bleeding events were significantly higher in the Bentall group during follow-up(10 in Bentall group, 0 in VSR group, p=0.04). here were 6 thromboembolic events only in the Bentall group(p=0.11). We performed a propensity score matching analysis comparing the groups(134 Bentall vs 43 VSR). Matched analysis gave similar results, i.e. HR=0.17 and p=0.10 for overall mortality and HR=1.01 and p=0.99 for MAVRE. Although there was marginal significance in the propensity matched analysis, it is plausible to anticipate a survival benefit with VSR during long-term follow-up. Despite a higher reoperation for aortic valves, VSR can be a viable option in patients who decline life-long anticoagulation, especially the young or the patients in whom anticoagulation is contraindicated. Copyright © 2018. Published by Elsevier Inc.

[Clinical analysis of different root treatment methods in acute Stanford type A aortic dissection].

PubMed

Xue, Y X; Zhou, Q; Pan, J; Wang, Q; Cao, H L; Fan, F D; Wang, D J

2017-04-01

Objective: To discuss the perioperative and follow-up results of different surgical methods for acute Stanford type A aortic dissection patients and analyzed the results. Methods: The clinic data of 351 acute Stanford type A aortic dissection patients received surgical therapy at Department of Thoracic and Cardiovascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital from January 2008 to December 2015 were analyzed retrospectively. There were 272 male and 79 female patients, aging from 22 to 83 years with a mean age of (52±13) years. According to root size, aortic valve structure and the status of dissection involvement, these patients were devided into three major groups: 218 cases with root reconstruction using Dacron felts, 34 cases with root reconstruction concomitant with aortic valve resuspension repair and 99 cases in with Bentall procedure. Proper shape based on the status of dissection involvement of Dacron patch was cut and put between the middle and outerlayer of aorta, then inside the inner layerone band Dacron felt was sutured with the aorta and the new middle layer with Dacron patch as mentioned above. In some cases the prolapsed aortic valve was re-suspended to the aortic cusp. Clinical outcomes among the 3 procedures were compared by χ(2) test, Fisher's exact test, t test and analysis of variance. Results: Cardiopulmonary bypass, cross-clamp, and circulatory arrest times of all the patients were (250±78), (171±70) and (31±10) minutes, respectively. The 30-day mortality was 9.2%(33/351), while no difference among the 3 procedures (9.6%, 8.8% and 9.1%). In the average follow-up time of (26.0±23.0) months (range from 0.5 to 90.0 months), survival rates were similar among the 3 procedures (77.7%, 77.4% and 77.8%). Only one patient received redo Bentall procedure because of severe aortic regurgitation and dilated aortic root (diameter of 50 mm). Conclusions: The indication of root management of acute Stanford type A aortic dissection is based on the diameter of aortic root, structure of aortic leaflets, and the dissection involvement. For most acute Stanford type A aortic dissection patients, aortic root reconstruction is a feasible and safe method.

Surgery for aortic dilatation in patients with bicuspid aortic valves: A statement of clarification from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

PubMed

Hiratzka, Loren F; Creager, Mark A; Isselbacher, Eric M; Svensson, Lars G; Nishimura, Rick A; Bonow, Robert O; Guyton, Robert A; Sundt, Thoralf M

2016-04-01

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: The "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease" (J Am Coll Cardiol. 2010;55:e27-130) and the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" (J Am Coll Cardiol. 2014;63:e57-185). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline. Copyright © 2016 American College of Cardiology Foundation and American Heart Association, Inc. Published by Elsevier Inc. All rights reserved.

Surgery for Aortic Dilatation in Patients With Bicuspid Aortic Valves: A Statement of Clarification From the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

PubMed

Hiratzka, Loren F; Creager, Mark A; Isselbacher, Eric M; Svensson, Lars G; Nishimura, Rick A; Bonow, Robert O; Guyton, Robert A; Sundt, Thoralf M

2016-02-16

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: the "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease" (J Am Coll Cardiol 2010;55:e27-130) and the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" (J Am Coll Cardiol 2014;63:e57-185). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline. Copyright © 2016 American College of Cardiology Foundation and American Heart Association, Inc. Published by Elsevier Inc. All rights reserved.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches

PubMed Central

Calcaterra, Domenico; Jazayeri, Mohammad-Ali; Turek, Joseph W.; Parekh, Kalpaj R.; Bashir, Mohammad; Karam, Karam; Farivar, Robert S.

2017-01-01

Background Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft. Methods Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique. Results There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient. Conclusions The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation. PMID:28868309

Modelling and numerical simulation of the in vivo mechanical response of the ascending aortic aneurysm in Marfan syndrome.

PubMed

García-Herrera, Claudio M; Celentano, Diego J; Herrera, Emilio A

2017-03-01

Marfan syndrome (MFS) is a genetic disorder that affects connective tissue, impairing cardiovascular structures and function, such as heart valves and aorta. Thus, patients with Marfan disease have a higher risk of developing circulatory problems associated with mitral and aortic valves prolapse, manifested as dilated aorta and aortic aneurysm. However, little is known about the biomechanical characteristics of these structures affected with MFS. This study presents the modelling and simulation of the mechanical response of human ascending aortic aneurysms in MFS under in vivo conditions with intraluminal pressures within normotensive and hypertensive ranges. We obtained ascending aortic segments from five adults with MFS subjected to a vascular prosthesis implantation replacing an aortic aneurysm. We characterised the arterial samples via ex vivo tensile test measurements that enable fitting the material parameters of a hyperelastic isotropic constitutive model. Then, these material parameters were used in a numerical simulation of an ascending aortic aneurysm subjected to in vivo normotensive and hypertensive conditions. In addition, we assessed different constraints related to the movement of the aortic root. Overall, our results provide not only a realistic description of the mechanical behaviour of the vessel, but also useful data about stress/stretch-based criteria to predict vascular rupture. This knowledge may be included in the clinical assessment to determine risk and indicate surgical intervention.

Characteristics of children and young adults with Marfan syndrome and aortic root dilation in a randomized trial comparing atenolol and losartan therapy

PubMed Central

Lacro, Ronald V.; Guey, Lin T.; Dietz, Harry C.; Pearson, Gail D.; Yetman, Anji T.; Gelb, Bruce D.; Loeys, Bart L.; Benson, D. Woodrow; Bradley, Timothy J.; De Backer, Julie; Forbus, Geoffrey A.; Klein, Gloria L.; Lai, Wyman W.; Levine, Jami C.; Lewin, Mark B.; Markham, Larry W.; Paridon, Stephen M.; Pierpont, Mary Ella; Radojewski, Elizabeth; Selamet Tierney, Elif Seda; Sharkey, Angela M.; Wechsler, Stephanie Burns; Mahony, Lynn

2013-01-01

Background The Pediatric Heart Network designed a clinical trial to compare aortic root growth and other short-term cardiovascular outcomes in children and young adults with Marfan syndrome randomized to receive atenolol or losartan. We report here the characteristics of the screened population and enrolled subjects. Methods and results Between 2007 and 2011, 21 clinical sites randomized 608 subjects, aged 6 months to 25 years who met the original Ghent criteria and had a body surface area–adjusted aortic root diameter z-score >3.0. The mean age at study entry was 11.2 years, 60% were male, and 25% were older teenagers and young adults. The median aortic root diameter z-score was 4.0. Aortic root diameter z-score did not vary with age. Mitral valve prolapse and mitral regurgitation were more common in females. Among those with a positive family history, 56% had a family member with aortic surgery, and 32% had a family member with a history of aortic dissection. Conclusions Baseline demographic, clinical, and anthropometric characteristics of the randomized cohort are representative of patients in this population with moderate to severe aortic root dilation. The high percentage of young subjects with relatives who have had aortic dissection or surgery illustrates the need for more definitive therapy; we expect that the results of the study and the wealth of systematic data collected will make an important contribution to the management of individuals with Marfan syndrome. PMID:23622922

Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience.

PubMed

Ius, Fabio; Fleissner, Felix; Pichlmaier, Maximilian; Karck, Matthias; Martens, Andreas; Haverich, Axel; Shrestha, Malakh

2013-11-01

Since August 2001, the frozen elephant trunk (FET) technique has been used at our institution to treat degenerative or dissecting aneurysms involving the aortic arch and descending aorta as a potential 'single-stage' procedure. The aim of this study was to review our FET experience and to present the 10-year results. Between August 2001 and January 2012, 131 patients underwent FET implant with three different prostheses: the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 30) and the Vascutek Thoraflex (n = 35) prostheses. Concomitant procedures included aortic valve-sparing operations (David, n = 17) and aortic root replacement (Bentall, n = 25). Patient records and the first postoperative and last available computer tomography (CT) were retrospectively reviewed. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and acute renal failure requiring dialysis were 18, 11, 1, 41 and 16%, respectively. In-hospital mortality was 15%. The mean follow-up was 42 ± 37 (range 1-134 months). At 1, 5 and 10 years, survivals were 82 ± 3, 72 ± 5 and 58 ± 8%, respectively. Freedoms from distal aortic operation were 81 ± 4, 67 ± 5 and 43 ± 13%, respectively. Thirty-six patients underwent 40 distal aortic operations, either open surgical (n = 22, 55%) or endovascular (n = 18, 45%). Chronic aortic dissection was identified as an independent risk factor for distal aortic operation (odds ratio = 3.8; 95% confidence interval 1.5-9.3; P = 0.004). At last CT control, false-lumen thrombosis rates up to 93% were achieved around the stent graft. An FET concept adds to the armament of the surgeon in the treatment of complex and diverse aortic arch pathologies. The preoperative patient risk profile explains the postoperative morbidity and in-hospital mortality. The FET can potentially be still a 'one-stage' procedure in selected patients. However, the extension of FET to patients with extensive aortic aneurysms has led to an increase in second-stage procedures.

Use of bovine pericardial tissue for aortic valve and aortic root replacement: long-term results.

PubMed

Vrandecic, M; Gontijo Filho, B; Fantini, F; Barbosa, J; Martins, I; de Oliveira, O C; Martins, C; Max, R; Drumond, L; Oliveira, C; Ferrufino, A; Alcocer, E; Silva, J A; Vrandecic, E

1998-03-01

The study aimed to determine the clinical performance of bovine pericardial aldehyde-treated products alone or in combination with aortic leaflets of porcine origin. These included a composite porcine stentless aortic valve attached to a scalloped pericardial tube (BSAV), and valved and non-valved bovine pericardial conduits for use in left-sided heart lesions (BPG). For BSAV grafts, between January 1990 and August 1996, 163 patients (119 males) had their aortic valves replaced by SJM Biocor BASV. Mean age was 37.9 +/- 17.6 years (range: 1 to 76 years). Rheumatic heart disease sequelae (n = 72) and replacement of a prosthetic heart valve (n = 46) were predominant. Preoperative NYHA functional class showed 90 patients (55.2%) in class III and 50 (30.7%) in class IV. BPVC and NVPC grafts were used in 166 patients: acute aortic dissection was the main indication in 52 (31.3%) and chronic in 36 (21/7%). The ascending aorta was involved in 141 patients (84.9%); grafts were seldom used at other sites. In most patients the graft implanted was either a non-valved (n = 79) or a valved (n = 75) pericardial conduit. Twelve patients had a localized lesion and required a patch repair. For BASV grafts, the non-valve-related hospital mortality rate was 4.9%. There were 14.7% non-fatal complications with full recovery of all patients. Mean follow up in 141 patients was 3.0 +/- 1.4 years (range: 1 month to 7.2 years); 14 patients were lost to follow up. Late, non-conduit-related, mortality occurred in seven patients (4.9%). Eight patients underwent reoperation. The current clinical follow up of 127 patients has shown 118 (92.9%) with competent valves and nine (7.0%) with mild stable aortic insufficiency. For BPVC and NVPC grafts, hospital mortality rate was 16.9%, death being related to poor preoperative clinical condition. Postoperative follow up was accomplished in 125 patients; reoperation was necessary in seven patients. Histology showed good tissue preservation up to five years; echocardiography revealed satisfactory findings. No valved conduit had to be reoperated for valve or pericardial tissue wear. Clinical results of left-sided heterologous pericardial grafts have shown excellent performance over time. The BASV (over seven years) and BPVC and NVPC (eight years) have demonstrated superior results as aortic valves alone or in combination with a pericardial conduit.

Standardized methodology for transfemoral transcatheter aortic valve replacement with the Edwards Sapien XT valve under fluoroscopy guidance.

PubMed

Kasel, Albert M; Shivaraju, Anupama; Schneider, Stephan; Krapf, Stephan; Oertel, Frank; Burgdorf, Christof; Ott, Ilka; Sumer, Christian; Kastrati, Adnan; von Scheidt, Wolfgang; Thilo, Christian

2014-09-01

To provide a simplified, standardized methodology for a successful transfemoral transcatheter aortic valve replacement (TAVR) procedure with the Sapien XT valve in patients with severe aortic stenosis (AS). TAVR is currently reserved for patients with severe, symptomatic AS who are inoperable or at high operative risk. In many institutions, TAVR is performed under general anesthesia with intubation or with conscious sedation. In addition, many institutions still use transesophageal echo (TEE) during the procedure for aortic root angulations and positioning of the valve prior to implantation. Methods. We enrolled 100 consecutive patients (mean age, 80 ± 7 years; range, 50-94 years; female n=59) with severe symptomatic AS. Annulus measurements were based on computed tomography angiograms. All patients underwent fluoroscopy-guided transfemoral TAVR with little to no sedation and without simultaneous TEE. TAVR was predominantly performed with the use of local and central analgesics; only 36% of our cohort received conscious sedation. Procedural success of TAVR was 99%. Transthoracic echocardiography before discharge excluded aortic regurgitation (AR) >2 in all patients (AR >1; n=6). In-hospital stroke rate was 6%. The vessel closure system was successfully employed in 96%. Major vascular complication rate was 1%. The 30-day mortality was 2%. Fluoroscopy-guided TAVR with the use of just analgesics with or without conscious sedation is safe and effective, and this potentially enables a more time-effective and cost-effective procedure. This paper provides simplified, stepwise guidance on how to perform transfemoral TAVR with the Sapien XT valve.

Extracellular matrix scaffold as a tubular graft for ascending aorta aneurysm repair.

PubMed

Abu Saleh, Walid K; Al Jabbari, Odeaa; Grande-Allen, Jane; Ramchandani, Mahesh

2015-08-01

Although extracellular xenograft repair has produced encouraging results when applied to cardiac, valvular, and specific aortic defects, its employment as a tube graft to replace the ascending aorta has not been reported. We describe a patient who underwent resection and replacement of an infected ascending aortic graft with an extracellular matrix conduit. The patient did well, but 14 months later developed a pseudoaneurysm from the staple line used to construct the extracellular matrix conduit. The patient underwent a repeat sternotomy and removal of the graft. Because of the increased risk of graft failure, a homograft was felt to be more appropriate in this setting. Ultimately, we were unable to implant the homograft because it was too small for the aortic root; therefore we decided to construct a tubular graft from Cormatrix extracellular matrix (CorMatrix, Roswell, GA, USA). Fourteen months later, he presented with shortness of breath. Computed tomography scan revealed a 3.5 cm pseudoaneurysm of the ascending aorta. It appeared as if there was a disruption of the staple line in the extra cellular matrix graft. The plan was to replace it with a Dacron graft. The Cormatrix graft material was removed and sent for culture and histological analysis. A 28-mm Gel weave graft (Terumo Cardiovascular Systems, Ann Arbor, MI, USA) was implanted. The patient tolerated the procedure well with good hemodynamics. Our experience suggests that the superior strength, handling characteristics, and resistance to infection make extra cellular matrix scaffold a possible alternative conduit to cryopreserved homografts. Applicability as an aortic conduit merits further investigation to better understand behavior of extra cellular matrix in this situation. © 2015 Wiley Periodicals, Inc.

Aortic root dilatation in athletic population.

PubMed

Pelliccia, Antonio; Di Paolo, Fernando M; Quattrini, Filippo M

2012-01-01

Remodeling of the aortic root may be expected to occur in athletes as a consequence of hemodynamic overload associated with exercise training; however, there are few data reporting its presence or extent. This review reports the current knowledge regarding the prevalence, upper limits, and clinical significance of aortic remodeling induced by athletic training. Several determinants impact aortic dimension in healthy, nonathletic individuals, including height, body size, age, sex, and blood pressure. Of these factors, anthropometric variables have the greatest impact. In athletes, the effect of exercise training appears to have only a modest additional influence on aortic dimension, although previous studies have produced some conflicting results. Specifically, data derived from the largest available athletic cohort suggest that the most hemodynamically intense endurance disciplines (eg, cycling and swimming) are associated with a significant but mild increase in aortic dimensions. Power disciplines, instead, (eg, weight lifting, throwing events) have only trivial, if any, impact. In contrast, selected data from a different athlete population suggest a more significant dimensional aortic remodeling in strength-trained individuals. In our experience, the 99th percentile value of aortic root diameter corresponds to 40 mm in males and 34 mm in females, which can reasonably be considered the upper limits of physiologic aortic root remodeling. However, a small proportion of apparently healthy male athletes (approximately 1%) show aortic enlargement above the upper limits, in the absence of systemic disease (ie, Marfan syndrome). Athletes presenting with aortic enlargement may demonstrate a further dimensional increase in midlife leading to clinically relevant aortic dilatation. Occasionally, dilation may be severe enough to warrant consideration for surgical treatment. Therefore, serial clinical and echocardiographic evaluations are recommended in athletes when aortic root exceeds the sex-specific thresholds. Copyright © 2012 Elsevier Inc. All rights reserved.

No Beneficial Effect of General and Specific Anti-Inflammatory Therapies on Aortic Dilatation in Marfan Mice

PubMed Central

den Hartog, Alexander W.; Radonic, Teodora; de Vries, Carlie J. M.; Zwinderman, Aeilko H.; Groenink, Maarten; Mulder, Barbara J. M.; de Waard, Vivian

2014-01-01

Aims Patients with Marfan syndrome have an increased risk of life-threatening aortic complications, mostly preceded by aortic dilatation. In the FBN1 C1039G/+ Marfan mouse model, losartan decreases aortic root dilatation. We recently confirmed this beneficial effect of losartan in adult patients with Marfan syndrome. The straightforward translation of this mouse model to man is reassuring to test novel treatment strategies. A number of studies have shown signs of inflammation in aortic tissue of Marfan patients. This study examined the efficacy of anti-inflammatory therapies in attenuating aortic root dilation in Marfan syndrome and compared effects to the main preventative agent, losartan. Methods and Results To inhibit inflammation in FBN1 C1039G/+ Marfan mice, we treated the mice with losartan (angiotensin II receptor type 1 inhibitor), methylprednisolone (corticosteroid) or abatacept (T-cell-specific inhibitor). Treatment was initiated in adult Marfan mice with already existing aortic root dilatation, and applied for eight weeks. Methylprednisolone- or abatacept-treated mice did not reveal a reduction in aortic root dilatation. In this short time frame, losartan was the only treatment that significantly reduced aorta inflammation, transforming growth factor-beta (TGF-β) signaling and aortic root dilatation rate in these adult Marfan mice. Moreover, the methylprednisolone-treated mice had significantly more aortic alcian blue staining as a marker for aortic damage. Conclusion Anti-inflammatory agents do not reduce the aortic dilatation rate in Marfan mice, but possibly increase aortic damage. Currently, the most promising therapeutic drug in Marfan syndrome is losartan, by blocking the angiotensin II receptor type 1 and thereby inhibiting pSmad2 signaling. PMID:25238161

Losartan added to β-blockade therapy for aortic root dilation in Marfan syndrome: a randomized, open-label pilot study.

PubMed

Chiu, Hsin-Hui; Wu, Mei-Hwan; Wang, Jou-Kou; Lu, Chun-Wei; Chiu, Shuenn-Nan; Chen, Chun-An; Lin, Ming-Tai; Hu, Fu-Chang

2013-03-01

To assess the tolerability and efficacy of the investigational use of the angiotensin II receptor blocker losartan added to β-blockade (BB) to prevent progressive aortic root dilation in patients with Marfan syndrome (MFS). Between May 1, 2007, and September 31, 2011, 28 patients with MFS (11 males [39%]; mean ± SD age, 13.1±6.3 years) with recognized aortic root dilation (z score >2.0) and receiving BB (atenolol or propranolol) treatment were enrolled. They were randomized to receive BB (BB: 13 patients) or β-blockade and losartan (BB-L: 15 patients) for 35 months. In the BB-L group, aortic root dilation was reduced with treatment, and the annual dilation rate of the aortic root was significantly lower than that of the BB group (0.10 mm/yr vs 0.89 mm/yr; P=.02). The absolute aortic diameters at the sinus of Valsalva, annulus, and sinotubular junction showed similar trends, with a reduced rate of dilation in the BB-L group (P=.02, P=.03, and P=.03, respectively). Five patients (33%) treated with BB-L were noted to have a reduced aortic root diameter. However, the differences between the groups regarding changes in aortic stiffness and cross-sectional compliance were not statistically significant. This randomized, open-label, active controlled trial mostly based on a pediatric population demonstrated for the first time that losartan add-on BB therapy is safe and provides more effective protection to slow the progression of aortic root dilation than does BB treatment alone in patients with MFS. clinicaltrials.gov Identifier: NCT00651235. Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit.

PubMed

De Paulis, R; De Matteis, G M; Nardi, P; Scaffa, R; Buratta, M M; Chiariello, L

2001-08-01

The durability of aortic valve-sparing procedures is negatively affected by increased leaflet stress in the absence of normally shaped sinuses of Valsalva. We compared valve motion after remodeling procedures using a standard conduit and a specifically designed aortic root conduit. Echocardiographic studies of the aortic valve dynamics were performed in 14 patients after remodeling of the aortic root (7 standard conduits, group A; 7 new conduits, group B) and in 7 controls (group C). Opening and closing leaflet velocities and percent of slow closing leaflet displacement were measured. Root distensibility and the pressure strain of the elastic modulus were measured at all root levels. Root distensibility and the pressure strain of the elastic modulus were different in group A and B only at the sinuses (p < 0.001). Opening and closing leaflet velocities were not different among groups. Slow closing leaflet displacement was markedly more evident in group B patients (24.2%+/-1.9% versus 2.5%+/-1.9% in group A, p < 0.001) and similar to controls (22.1%+/-7.9%). The new conduit guarantees dynamic features of the aortic valve leaflets superior to those obtained with standard conduits and more similar to normal subjects.

The early and midterm function of decellularized aortic valve allografts.

PubMed

da Costa, Francisco D A; Costa, Ana Claudia B A; Prestes, Roberta; Domanski, Ana Carolina; Balbi, Eduardo Mendel; Ferreira, Andreia D A; Lopes, Sergio Veiga

2010-12-01

This study evaluates the early and midterm results of decellularized aortic valve allografts (DAVA) as an aortic valve replacement. Between October 2005 and February 2010, 41 patients, 28 of whom were male, with a median age of 34 years (range, 0.1 to 71), had aortic valve replacement with DAVA. Decellularization was obtained with a 0.1% sodium dodecyl sulfate solution. Postoperative evaluation was performed with serial echocardiograms, magnetic resonance imaging, and multislice computed tomography studies to evaluate valve hemodynamics, allograft conduit dimensions, and calcification scores. There were 3 early deaths and 1 late death, with a mean follow-up of 19 months (range, 1 to 53). There was 1 reoperation due to a failed mitral valve repair. By echocardiography in all patients, the median immediate postoperative peak gradient was 7 mm Hg (range, 1 to 26 mm Hg), and at last follow-up it was 4 mm Hg (range, 1 to 16 mm Hg); valvular regurgitation was graded as none or trivial in all but 1 patient, who had a regurgitation graded as mild to moderate. By magnetic resonance imaging (n = 4), mean root dimensions were stable at the annulus (24 mm), sinus of Valsalva (33 mm), and sinotubular junction (28 mm). By computed tomography (n = 22), there was only discrete conduit calcification (median calcium score 63 Hounsfield units [HU]; range, 0 to 894 HU) to 3 years of follow-up. Conduit biopsy in the patient who underwent reoperation demonstrated well-preserved wall structure, absence of calcification, and limited in vivo host repopulation. The early and midterm results with DAVA demonstrated stable structural integrity, low rate of calcification, and adequate hemodynamics. Although longer periods of observation are necessary, DAVA appears to be a promising alternative for aortic valve replacement in selected patients. Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Vortex dynamics in Patient-Specific Stenotic Tricuspid and Bicuspid Aortic Valves pre- and post- Trans-catheter Aortic Valve Replacement

NASA Astrophysics Data System (ADS)

Hatoum, Hoda; Dasi, Lakshmi Prasad

2017-11-01

Understanding blood flow related adverse complications such as leaflet thrombosis post-transcatheter aortic valve implantation (TAVI) requires a deeper understanding of how patient-specific anatomic and hemodynamic factors, and relative valve positioning dictate sinus vortex flow and stasis regions. High resolution time-resolved particle image velocimetry measurements were conducted in compliant and transparent 3D printed patient-specific models of stenotic bicuspid and tricuspid aortic valve roots from patients who underwent TAVI. Using Lagrangian particle tracking analysis of sinus vortex flows and probability distributions of residence time and blood damage indices we show that (a) patient specific modeling provides a more realistic assessment of TAVI flows, (b) TAVI deployment alters sinus flow patterns by significantly decreasing sinus velocity and vorticity, and (c) relative valve positioning can control critical vortex structures that may explain preferential leaflet thrombosis corresponding to separated flow recirculation, secondary to valve jet vectoring relative to the aorta axis. This work provides new methods and understanding of the spatio-temporal aortic sinus vortex dynamics in post TAVI pathology. This study was supported by the Ohio State University DHLRI Trifit Challenge award.

[Arterial involvements in hereditary dysplasia of the connective tissue].

PubMed

Beylot, C; Doutre, M S; Beylot-Barry, M; Busquet, M

1994-03-01

Arterial involvement is an important feature of the diagnosis and, above all, prognosis of heritable disorders of connective tissue. In pseudoxanthoma elasticum, a progressive occlusive syndrome is associated with hemorrhage and especially with gastrointestinal bleeding. Aneurysms are uncommon. Hypertension occurs frequently. Cutaneous signs (yellowish pseudo xanthomatous papules of the large folds) the ocular changes (angioid streaks) and pathology showing numerous, thickened, fragmented, disorganized, calcified elastic fibers in the deep dermis and arterial walls, allow the diagnosis to be made. In the heterogeneous group of Ehlers-Danlos syndromes, type IV is characterized by sudden spontaneous rupture of the large arteries. Aneurysms and carotido-cavernous fistulae are rather frequent. Owing to friability of the arterial walls, arteriograms and other procedure requiring arterial puncture may prove hazardous and surgery difficult. Such patients have an acrogeric morphotype, and thin, fragile skin, but cutaneous hyperelasticity and joint hyperlaxity are usually minimal. Pathology evidences collagen hypoplasia in the skin and arterial walls. The severity of Marfan syndrome is due to aortic involvement. A fusiform aneurysm of the ascending aorta represents a vital risk of rupture. Aortic root dilatation is associated and responsible of severe aortic regurgitation. Aortic dissection is also a serious threat. Improved surgical techniques for repairing a dilated or dissected aortic root with simultaneous replacement of the aortic valve increases the life expectancy of such patients. Dolichomorphism is the characteristic skeletal abnormality, particularly with arachnodactyly and upward ectopia lentis, which is almost bilateral, is a very frequent feature of Marfan syndrome. The most typical histological finding is aortic cystic median necrosis. The basic defect in Marfan syndrome concerns the fibrillin, whose gene is located on chromosome 15. The three diseases detailed in this paper constitute the main areas of this subject, but arterial involvement may occur in other inheritable disorders of connective tissue (osteogenesis imperfecta, cutis laxa, Werner syndrome, Menkes syndrome, etc).

Mycobacterium chimaera Infection After Aortic Valve Replacement Presenting With Aortic Dissection and Pseudoaneurysm.

PubMed

O'Neil, C R; Taylor, G; Smith, S; Joffe, A M; Antonation, K; Shafran, S; Kunimoto, D

2018-02-01

We present a case of Mycobacterium chimaera infection presenting with aortic dissection and pseudoaneuysm in a 22-year-old man with a past history of aortic valve replacement. Clinicians should consider M. chimaera infection in those presenting with aortic dissection as a late complication of cardiovascular surgery.

Aortic root segmentation in 4D transesophageal echocardiography

NASA Astrophysics Data System (ADS)

Chechani, Shubham; Suresh, Rahul; Patwardhan, Kedar A.

2018-02-01

The Aortic Valve (AV) is an important anatomical structure which lies on the left side of the human heart. The AV regulates the flow of oxygenated blood from the Left Ventricle (LV) to the rest of the body through aorta. Pathologies associated with the AV manifest themselves in structural and functional abnormalities of the valve. Clinical management of pathologies often requires repair, reconstruction or even replacement of the valve through surgical intervention. Assessment of these pathologies as well as determination of specific intervention procedure requires quantitative evaluation of the valvular anatomy. 4D (3D + t) Transesophageal Echocardiography (TEE) is a widely used imaging technique that clinicians use for quantitative assessment of cardiac structures. However, manual quantification of 3D structures is complex, time consuming and suffers from inter-observer variability. Towards this goal, we present a semiautomated approach for segmentation of the aortic root (AR) structure. Our approach requires user-initialized landmarks in two reference frames to provide AR segmentation for full cardiac cycle. We use `coarse-to-fine' B-spline Explicit Active Surface (BEAS) for AR segmentation and Masked Normalized Cross Correlation (NCC) method for AR tracking. Our method results in approximately 0.51 mm average localization error in comparison with ground truth annotation performed by clinical experts on 10 real patient cases (139 3D volumes).

A geometric approach to aortic root surgical anatomy.

PubMed

Contino, Monica; Mangini, Andrea; Lemma, Massimo Giovanni; Romagnoni, Claudia; Zerbi, Pietro; Gelpi, Guido; Antona, Carlo

2016-01-01

The aim of this study was the analysis of the geometrical relationships between the different structures constituting the aortic root, with particular attention to interleaflet triangles, haemodynamic ventriculo-arterial junction and functional aortic annulus in normal subjects. Sixteen formol-fixed human hearts with normal aortic roots were studied. The aortic root was isolated, sectioned at the midpoint of the non-coronary sinus, spread apart and photographed by a high-resolution digital camera. After calibration and picture resizing, the software AutoCAD 2004 was used to identify and measure all the elements of the interleaflets triangles and of the aortic root that were objects of our analysis. Multiple comparisons were performed with one-way analysis of variance for continuous data and with Kruskal-Wallis analysis for non-continuous data. Linear regression and Pearson's product correlation were used to correlate root element dimensions when appropriate. Student's t-test was used to compare means for unpaired data. Heron's formula was applied to estimate the functional aortic annular diameters. The non coronary-left coronary interleaflets triangles were larger, followed by inter-coronary and right-non-coronary ones. The apical angle is <60° and its standard deviation can be considered an asymmetry index. The sinu-tubular junction was shown to be 10% larger than the virtual basal ring (VBR). The mathematical relationship between the haemodynamic ventriculo-arterial junction and the VBR calculated by linear regression and expressed in terms of the diameter was: haemodynamic ventriculo-arterial junction = 2.29 VBR (diameter) + 47. Conservative aortic surgery is based on a better understanding of aortic root anatomy and physiology. The relationships among its elements are of paramount importance during aortic valve repair/sparing procedures and they can be useful also in echocardiographic analysis and in computed tomography reconstruction. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Aortic root dynamism, geometry, and function after the remodeling operation: Clinical relevance.

PubMed

Yacoub, Magdi H; Aguib, Heba; Gamrah, Mazen Abou; Shehata, Nairouz; Nagy, Mohamed; Donia, Mohamed; Aguib, Yasmine; Saad, Hesham; Romeih, Soha; Torii, Ryo; Afifi, Ahmed; Lee, Su-Lin

2018-04-13

Valve-conserving operations for aneurysms of the ascending aorta and root offer many advantages, and their use is steadily increasing. Optimizing the results of these operations depends on providing the best conditions for normal function and durability of the new root. Multimodality imaging including 2-dimensional echocardiography, multislice computed tomography, and cardiovascular magnetic resonance combined with image processing and computational fluid dynamics were used to define geometry, dynamism and aortic root function, before and after the remodeling operation. This was compared with 4 age-matched controls. The size and shape of the ascending aorta, aortic root, and its component parts showed considerable changes postoperatively, with preservation of dynamism. The postoperative size of the aortic annulus was reduced without the use of external bands or foreign material. Importantly, the elliptical shape of the annulus was maintained and changed during the cardiac cycle (Δ ellipticity index was 15% and 28% in patients 1 and 2, respectively). The "cyclic" area of the annulus changed in size (Δarea: 11.3% in patient 1 and 13.1% in patient 2). Functional analysis showed preserved reservoir function of the aortic root, and computational fluid dynamics demonstrated normalized pattern of flow in the ascending aorta, sinuses of Valsalva, and distal aorta. The remodeling operation results in near-normal geometry of the aortic root while maintaining dynamism of the aortic root and its components. This could have very important functional implications; the influence of these effects on both early- and long-term outcomes needs to be studied further. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aortic valve replacement for aortic stenosis caused by alkaptonuria.

PubMed

Hiroyoshi, Junko; Saito, Aya; Panthee, Nirmal; Imai, Yasushi; Kawashima, Dai; Motomura, Noboru; Ono, Minoru

2013-03-01

We report a case of aortic stenosis associated with ochronosis in a 70-year-old man who underwent biologic aortic valve replacement. Intraoperative findings included ochronosis of a severely calcified pigmented aortic valve along with pigmentation of the intima of the aorta. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Evaluation of Aortic Valve Replacement via the Right Parasternal Approach without Rib Removal

PubMed Central

Hattori, Koji; Kato, Yasuyuki; Motoki, Manabu; Takahashi, Yosuke; Nishimura, Shinsuke; Shibata, Toshihiko

2014-01-01

Background: Although right parasternal approach (RPA) decreases the incidence of mediastinal infection, this approach is associated with lung hernia and flail chest. Our RPA employs thoracotomy with bending rib cartilages and wound closure performed by repositioning the ribs with underlying sheet reinforcement. Methods: We evaluated 16 patients who underwent aortic valve replacement via the RPA from January 2010 to August 2013. We compared outcomes of 15 male patients had the RPA with 30 male patients had full median sternotomy. Results: One patient with a history of radical breast cancer treatment underwent RPA with concomitant right coronary artery bypass grafting. No hospital deaths occurred. Four patients developed hospital-associated morbidity (re-exploration for bleeding, prolonged ventilation, cardiac tamponade, and perioperative myocardial infarction). There were no conversions to full median sternotomy, mediastinal infections, and lung hernias. Preoperative computed tomography showed that the distance from the right sternal border to the aortic root was significantly associated with operation times. With RPA, there was no significant difference in outcomes, despite significantly longer operation times compared with full median sternotomy. Conclusion: Our RPA provides satisfactory outcomes without lung hernia, especially in patients unsuitable for sternotomy. Preoperative computed tomography is useful for identifying appropriate candidates for the RPA. PMID:25167927

Left Ventricular Assist Device Implantation with Concomitant Aortic Valve and Ascending Aortic Replacement

PubMed Central

Panholzer, Bernd; Cremer, Jochen; Haneya, Assad

2018-01-01

Left ventricular assist device (LVAD) is nowadays a routine therapy for patients with advanced heart failure. We present the case of a 74-year-old male patient who was admitted to our center with terminal heart failure in dilated cardiomyopathy and ascending aortic aneurysm with aortic valve regurgitation. The LVAD implantation with simultaneous aortic valve and supracoronary ascending aortic replacement was successfully performed. PMID:29552039

Left Ventricular Assist Device Implantation with Concomitant Aortic Valve and Ascending Aortic Replacement.

PubMed

Huenges, Katharina; Panholzer, Bernd; Cremer, Jochen; Haneya, Assad

2018-01-01

Left ventricular assist device (LVAD) is nowadays a routine therapy for patients with advanced heart failure. We present the case of a 74-year-old male patient who was admitted to our center with terminal heart failure in dilated cardiomyopathy and ascending aortic aneurysm with aortic valve regurgitation. The LVAD implantation with simultaneous aortic valve and supracoronary ascending aortic replacement was successfully performed.

Quality and Safety in Health Care, Part XXX: Transcatheter Aortic Valve Therapy.

PubMed

Harolds, Jay A

2017-12-01

Initially, the transcatheter aortic valve replacement procedure was approved only for patients with aortic stenosis that was both severe and symptomatic who either also had too high a risk of aortic valve replacement surgery to have the surgery or who had a high risk for the surgery. Between the years 2012 and 2015, the death rate at 30 days declined from an initial rate of 7.5% to 4.6%. There has also been more use of the transfemoral approach over the years. In 2016, the transcatheter aortic valve replacement was approved for patients with aortic stenosis at intermediate risk of surgery.

Patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement. Experimental study.

PubMed

Manouguian, S; Abu-Aishah, N; Neitzel, J

1979-09-01

The experimental results of patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement are reported. The operative technique of this new surgical method is described and the indications are discussed.

Correction of aortic insufficiency with an external adjustable prosthetic aortic ring.

PubMed

Gogbashian, Andrew; Ghanta, Ravi K; Umakanthan, Ramanan; Rangaraj, Aravind T; Laurence, Rita G; Fox, John A; Cohn, Lawrence H; Chen, Frederick Y

2007-09-01

Less invasive, valve-sparing options are needed for patients with aortic insufficiency (AI). We sought to evaluate the feasibility of reducing AI with an external adjustable aortic ring in an ovine model. To create AI, five sheep underwent patch plasty enlargement of the aortic annulus and root by placement of a 10 x 15 mm pericardial patch between the right and noncoronary cusps. An adjustable external ring composed of a nylon band was fabricated and placed around the aortic root. Aortic flow, aortic pressure, and left ventricular pressures were measured with the ring loose (off) and tightened (on). Mean regurgitant orifice area decreased by 86%, from 0.07 +/- 0.03 cm2 (ring loose, off) to 0.01 +/- 0.00 cm2 (ring tightened, on) [p < 0.01]. The regurgitant fraction decreased from 18 +/- 4% to 2 +/- 1% [p < 0.01]. The ring did not significantly affect stroke volume and aortic pressure. An ovine model of aortic root dilatation resulting in acute AI has been developed. In this model, application of an external, adjustable constricting aortic ring eliminated AI. An aortic ring may be a useful adjunct in reducing AI secondary to annular dilatation.

Aortic valve replacement for papillary fibroelastoma.

PubMed

Arikan, Ali Ahmet; Omay, Oğuz; Aydın, Fatih; Kanko, Muhip; Gür, Sibel; Derviş, Emir; Yılmaz, Cansu Eda; Müezzinoğlu, Bahar

2017-06-01

Surgery is indicated for symptomatic patients with papillary fibroelastomas (PFE) on the aortic valve. The valve is commonly spared during tumor excision. Rarely, aortic valve replacement (AVR) is needed. We present a case requiring AVR for an aortic valve PFE and review the literature to determine the risk factors for failure of aortic valve-sparing techniques in patients with PFE. © 2017 Wiley Periodicals, Inc.

Longitudinal Changes in Segmental Aortic Stiffness Determined by Cardiac Magnetic Resonance in Children and Young Adults With Connective Tissue Disorders (the Marfan, Loeys-Dietz, and Ehlers-Danlos Syndromes, and Nonspecific Connective Tissue Disorders).

PubMed

Merlocco, Anthony; Lacro, Ronald V; Gauvreau, Kimberlee; Rabideau, Nicole; Singh, Michael N; Prakash, Ashwin

2017-10-01

Aortic stiffness measured by cardiac magnetic resonance (CMR) in connective tissue disorder (CTD) patients has been previously shown to be abnormal and to be associated with adverse aortic outcomes. The rate of increase in aortic stiffness with normal aging has been previously described. However, longitudinal changes in aortic stiffness have not been characterized in CTD patients. We examined longitudinal changes in CMR-derived aortic stiffness in children and young adults with CTDs. A retrospective analysis of 50 children and young adults (median age, 20 years; range, 0.2 to 49; 40% < 18 years old) with a CTD, and with at least 2 CMR examinations (total 152 examinations) over a median duration of 3.9 (1 to 13.2) years was performed. Aortic stiffness measures (strain, distensibility, and β stiffness index) were calculated on each examination at the aortic root (AoR), ascending aorta, and descending aorta. Longitudinal changes in parameters were analyzed using linear mixed-effects models. Aortic strain and distensibility decreased with age, whereas the β stiffness index increased at all aortic segments. The average rates of decline in distensibility (x10 -3  mm Hg -1 per 10-year increase in age) were 0.7, 1.3, and 1 at the AoR, ascending aorta, and descending aorta, respectively. The rates of decline in distensibility were not associated with the rates of AoR dilation or surgical AoR replacement. In conclusion, on serial CMR measurements in children and young adults with CTDs, aortic stiffness progressively increased with age, with rates of change only slightly higher than those previously reported in healthy adults. Copyright © 2017 Elsevier Inc. All rights reserved.

[Anesthesia for total and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis].

PubMed

Furuichi, Yuko; Shimizu, Jun; Sakamoto, Atsuhiro

2012-04-01

We experienced anesthesia for total arch and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis. Because there was possibility that post coarctectomy syndrome would occur after repair of coarctation of aorta, administration of depressor that acts on renin-angiotensin-aldosterone and careful observation were needed postoperatively. In consideration of the development of collateral vessels, preoperative imaging evaluation was added and operative method in cardiopulmonary bypass was adjusted. Careful preoperative evaluation is very important in cardiac anesthesia.

Left main coronary artery obstruction by dislodged native-valve calculus after transcatheter aortic valve replacement.

PubMed

Durmaz, Tahir; Ayhan, Huseyin; Keles, Telat; Aslan, Abdullah Nabi; Erdogan, Kemal Esref; Sari, Cenk; Bilen, Emine; Akcay, Murat; Bozkurt, Engin

2014-08-01

Transcatheter aortic valve replacement can be an effective, reliable treatment for severe aortic stenosis in surgically high-risk or ineligible patients. However, various sequelae like coronary artery obstruction can occur, not only in the long term, but also immediately after the procedure. We present the case of a 78-year-old woman whose left main coronary artery became obstructed with calculus 2 hours after the transfemoral implantation of an Edwards Sapien XT aortic valve. Despite percutaneous coronary intervention in that artery, the patient died. This case reminds us that early recognition of acute coronary obstruction and prompt intervention are crucial in patients with aortic stenosis who have undergone transcatheter aortic valve replacement.

TAVR and SAVR: Current Treatment of Aortic Stenosis.

PubMed

Hu, Patrick P

2012-01-01

Transcatheter aortic valve replacement (TAVR) was approved in the United States in late 2011, providing a critically needed alternative therapy for patients with severe aortic stenosis previously refused surgical aortic valve replacement (SAVR). Over 20,000 TAVR have been performed in patients worldwide since 2002 when Alain Cribier performed the first-in-man TAVR. This paper reviews the data from balloon expandable and self-expanding aortic stent valves as well as data comparing them with traditional surgical aortic valve replacement (SAVR). Complications using criteria established by the Valve Academic Research Consortium (VARC) are reviewed. Future challenges and possibilities are discussed and will make optimizing TAVR an important goal in the years to come.

TAVR and SAVR: Current Treatment of Aortic Stenosis

PubMed Central

Hu, Patrick P.

2012-01-01

Transcatheter aortic valve replacement (TAVR) was approved in the United States in late 2011, providing a critically needed alternative therapy for patients with severe aortic stenosis previously refused surgical aortic valve replacement (SAVR). Over 20,000 TAVR have been performed in patients worldwide since 2002 when Alain Cribier performed the first-in-man TAVR. This paper reviews the data from balloon expandable and self-expanding aortic stent valves as well as data comparing them with traditional surgical aortic valve replacement (SAVR). Complications using criteria established by the Valve Academic Research Consortium (VARC) are reviewed. Future challenges and possibilities are discussed and will make optimizing TAVR an important goal in the years to come. PMID:22952419

High Risk Aortic Valve Replacement - The Challenges of Multiple Treatment Strategies with an Evolving Technology.

PubMed

Booth, K; Beattie, R; McBride, M; Manoharan, G; Spence, M; Jones, J M

2016-01-01

Deciding on the optimal treatment strategy for high risk aortic valve replacement is challenging. Transcatheter Aortic Valve implantation (TAVI) has been available in our centre as an alternative treatment modality for patients since 2008. We present our early experience of TAVI and SAVR (surgical Aortic Valve Replacement) in high risk patients who required SAVR because TAVI could not be performed. The database for Surgical aortic valve and Transcatheter aortic valve replacement referrals was interrogated to identify relevant patients. Survival to hospital discharge was 95.5% in the forty five patients who had SAVR when TAVI was deemed technically unsuitable. One year survival was 86%. Defining who is appropriate for TAVI or high risk SAVR is challenging and multidisciplinary team discussion has never been more prudent in this field of evolving technology with ever decreasing risks of surgery. The introduction of TAVI at our institution has seen a rise in our surgical caseload by approximately by 25%. Overall, the option of aortic valve intervention is being offered to more patients in general which is a substantial benefit in the treatment of aortic valve disease.

High-risk Trans-Catheter Aortic Valve Replacement in a Failed Freestyle Valve with Low Coronary Height: A Case Report.

PubMed

Karimi, Ashkan; Pourafshar, Negiin; Dibu, George; Beaver, Thomas M; Bavry, Anthony A

2017-06-01

A 55-year-old male with a history of two prior cardiac surgeries presented with decompensated heart failure due to severe bioprosthetic aortic valve insufficiency. A third operation was viewed prohibitively high risk and valve-in-valve trans-catheter aortic valve replacement was considered. There were however several high-risk features and technically challenging aspects including low coronary ostia height, poor visualization of the aortic sinuses, and difficulty in identification of the coplanar view due to severe aortic insufficiency, and a highly mobile aortic valve mass. After meticulous peri-procedural planning, trans-catheter aortic valve replacement was carried out with a SAPIEN 3 balloon-expandable valve without any complication. Strategies undertaken to navigate the technically challenging aspects of the case are discussed.

Biomechanical properties of the Marfan's aortic root and ascending aorta before and after personalised external aortic root support surgery.

PubMed

Singh, S D; Xu, X Y; Pepper, J R; Treasure, T; Mohiaddin, R H

2015-08-01

Marfan syndrome is an inherited systemic connective tissue disease which may lead to aortic root disease causing dilatation, dissection and rupture of the aorta. The standard treatment is a major operation involving either an artificial valve and aorta or a complex valve repair. More recently, a personalised external aortic root support (PEARS) has been used to strengthen the aorta at an earlier stage of the disease avoiding risk of both rupture and major surgery. The aim of this study was to compare the stress and strain fields of the Marfan aortic root and ascending aorta before and after insertion of PEARS in order to understand its biomechanical implications. Finite element (FE) models were developed using patient-specific aortic geometries reconstructed from pre and post-PEARS magnetic resonance images in three Marfan patients. For the post-PEARS model, two scenarios were investigated-a bilayer model where PEARS and the aortic wall were treated as separate layers, and a single-layer model where PEARS was incorporated into the aortic wall. The wall and PEARS materials were assumed to be isotropic, incompressible and linearly elastic. A static load on the inner wall corresponding to the patients' pulse pressure was applied. Results from our FE models with patient-specific geometries show that peak aortic stresses and displacements before PEARS were located at the sinuses of Valsalva but following PEARS surgery, these peak values were shifted to the aortic arch, particularly at the interface between the supported and unsupported aorta. Further studies are required to assess the statistical significance of these findings and how PEARS compares with the standard treatment. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.

Indication for percutaneous aortic valve implantation

PubMed Central

Akin, Ibrahim; Kische, Stephan; Rehders, Tim C.; Nienaber, Christoph A.; Rauchhaus, Mathias; Schneider, Henrik; Liebold, Andreas

2010-01-01

The incidence of valvular aortic stenosis has increased over the past decades due to improved life expectancy. Surgical aortic valve 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 aortic valve 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 aortic valve 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 aortic valve and the CoreValve ReValving System), utilizing either a balloon-expandable or a self-expanding stent platform, respectively. PMID:22371763

Management of mitral regurgitation in Marfan syndrome: Outcomes of valve repair versus replacement and comparison with myxomatous mitral valve disease.

PubMed

Helder, Meghana R K; Schaff, Hartzell V; Dearani, Joseph A; Li, Zhuo; Stulak, John M; Suri, Rakesh M; Connolly, Heidi M

2014-09-01

The study objective was to evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing valve repair or replacement and to compare them with patients undergoing repair for myxomatous mitral valve disease. We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between March 17, 1960, and September 12, 2011, for mitral regurgitation and performed a subanalysis of those with repairs compared with case-matched patients with myxomatous mitral valve disease who had repairs (March 14, 1995, to July 5, 2013). Of 61 consecutive patients, 40 underwent mitral repair and 21 underwent mitral replacement (mean [standard deviation] age, 40 [18] vs 31 [19] years; P = .09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P = .87). Ten-year survival was significantly better in patients with Marfan syndrome with mitral repair than in those with replacement (80% vs 41%; P = .01). Mitral reintervention did not differ between mitral repair and replacement (cumulative risk of reoperation, 27% vs 15%; P = .64). In the matched cohort, 10-year survival after repair was similar for patients with Marfan syndrome and myxomatous mitral disease (84% vs 78%; P = .63), as was cumulative risk of reoperation (17% vs 12%; P = .61). Patients with Marfan syndrome and mitral regurgitation have better survival with repair than with replacement. Survival and risk of reoperation for patients with Marfan syndrome were similar to those for patients with myxomatous mitral disease. These results support the use of mitral valve repair in patients with Marfan syndrome and moderate or more mitral regurgitation, including those having composite replacement of the aortic root. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Late complications in patients with Björk-Shiley and St. Jude Medical heart valve replacement.

PubMed

Horstkotte, D; Körfer, R; Seipel, L; Bircks, W; Loogen, F

1983-09-01

Valve-related complications after Björk-Shiley mitral valve implantation (n = 475), aortic valve implantation (n = 424), or mitral-aortic valve implantation (n = 119) were compared with those after St. Jude Medical mitral valve replacement (n = 173), aortic valve replacement (n = 152), or mitral-aortic valve replacement (n = 69). All patients were placed on anticoagulant therapy with phenprocoumon early after operation. All patients had a comparable follow-up time of approximately 23 months, which showed that cumulative thromboembolic rates were significantly higher after St. Jude valve implantation than after Björk-Shiley valve implantation. Reoperations were necessary because of valve thrombosis (0.46%), perivalvular leakage (2.2%), or prosthetic valve endocarditis with perivalvular regurgitation (0.46%). One Björk-Shiley mitral valve prosthesis had to be replaced because of fracture of the outlet strut. Without significant intergroup differences, hemorrhage due to anticoagulant treatment was the most frequent complication. Thromboembolic complications were significantly more frequent after Björk-Shiley mitral, aortic, and double valve replacements than after St. Jude valve implantation. This may lead to consideration of changes in the prophylaxis of thrombus formations in the St. Jude valve, especially in aortic valve replacements, in patients with sinus rhythm.

Surgical Approaches to Aortic Valve Replacement and Repair—Insights and Challenges

PubMed Central

Ramchandani, Mahesh; Reardon, Michael J

2014-01-01

Since 1960, surgical aortic valve replacement (sAVR) had been the only effective treatment for symptomatic severe aortic stenosis until the recent development of transcatheter aortic valve replacement (TAVR). TAVR has offered an alternative, minimally invasive treatment approach particularly for patients whose age or co-morbidities make them unsuitable for sAVR. The rapid and enthusiastic utilization of this new technique has triggered some speculation about the imminent demise of sAVR. We believe that despite the recent advances in TAVR, surgical approach to aortic valve replacement has continued to develop and will continue to be highly relevant in the future. This article will discuss the recent developments and current approaches for sAVR, and how these approaches will keep pace with catheter-based technologies. PMID:29588775

Left Main Coronary Artery Obstruction by Dislodged Native-Valve Calculus after Transcatheter Aortic Valve Replacement

PubMed Central

Durmaz, Tahir; Keles, Telat; Aslan, Abdullah Nabi; Erdogan, Kemal Esref; Sari, Cenk; Bilen, Emine; Akcay, Murat; Bozkurt, Engin

2014-01-01

Transcatheter aortic valve replacement can be an effective, reliable treatment for severe aortic stenosis in surgically high-risk or ineligible patients. However, various sequelae like coronary artery obstruction can occur, not only in the long term, but also immediately after the procedure. We present the case of a 78-year-old woman whose left main coronary artery became obstructed with calculus 2 hours after the transfemoral implantation of an Edwards Sapien XT aortic valve. Despite percutaneous coronary intervention in that artery, the patient died. This case reminds us that early recognition of acute coronary obstruction and prompt intervention are crucial in patients with aortic stenosis who have undergone transcatheter aortic valve replacement. PMID:25120396

Evolving Practice Trends of Aortic Root Surgery in North America.

PubMed

Caceres, Manuel; Ma, Yicheng; Rankin, J Scott; Saha-Chaudhuri, Paramita; Gammie, James S; Suri, Rakesh M; Thourani, Vinod H; Englum, Brian R; Esmailian, Fardad; Czer, Lawrence S; Puskas, John D; Svensson, Lars G

2014-08-19

Aortic-valve sparing (AVS) techniques have emerged as alternatives to composite graft-valve replacement (CVR) for treatment of aortic root aneurysm. This study analyzed recent practice trends of aortic root surgery using the Society of Thoracic Surgeons database. From January 2000 through June 2011, 31,747, Overall patients received AVS (n=3,585/31,747; 11.3%) or CVR (n=28,162/31,747; 88.7%). A High-Risk Subgroup was defined as: age >75 years, endocarditis, aortic stenosis, dialysis, multi-valve surgery, valve reoperation, or emergency/salvage status, and high-risk patients were less likely to receive AVS (n=20,356/31,747 [64.1%]; 6% AVS; unadjusted operative mortality 10.5% AVS and 11.7% CVR). The remaining patients comprised a Low-Risk Subgroup, in which AVS was more common (n=11,388/31,747 [35.9%]; 21% AVS; unadjusted operative mortality 1.4% AVS and 3.1% CVR). Procedural changes over 3 equal time periods (P1-P2-P3) were evaluated by Cochran-Armitage trends analysis. Compared to AVS, Overall CVR patients had worse baseline risk profiles and higher unadjusted operative mortality. In High-Risk patients, AVS mortality was comparable to CVR (10.5% vs 11.7%, p=0.19), but AVS mortality was lower in the Low-Risk group (1.4% vs 3%, p<0.0001). For P1/P2/P3, AVS percentages and trend p-values were: High-Risk (6%/6%/7%, p=0.26) and Low-Risk (12%/21%/25%, p<0.0001). CVR prosthesis type (mechanical/bioprosthesis/homograft) also changed: P1 (63%/22%/15%), P2 (58%/38%/4%), and P3 (53%/44%/3%) (all p<0.0001, except mechanical valves in High-Risk patients p=0.18). Patients receiving CVR tended to have higher risk profiles. AVS increased over time in Low-Risk patients while bioprostheses increased in CVR. Favorable outcomes support the trend toward further expansion of AVS. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Early Outcomes for Valve-in-valve Transcatheter Aortic Valve Replacement in Degenerative Freestyle Bioprostheses.

PubMed

Sang, Stephane Leung Wai; Beute, Tyler; Heiser, John; Berkompas, Duane; Fanning, Justin; Merhi, William

2017-11-20

Transcatheter aortic valve replacement (TAVR) is used increasingly to treat bioprosthetic valve failure. A paucity of data exists regarding valve-in-valve (ViV) TAVR in degenerated Freestyle stentless bioprostheses (FSBs). This study sought to evaluate the feasibility and short-term outcomes of ViV TAVR in previously placed FSB. From October 2014 to September 2016, 22 patients at a single institution underwent ViV TAVR with a self-expanding transcatheter valve for a failing FSB. Patient baseline characteristics and clinical outcomes data were collected retrospectively and entered into a dedicated database. The mean patient age was 74 ± 9years, and the mean Society of Thoracic Surgeons' Risk score was 9.0 ± 7.4%. Ten patients presented with acute heart failure requiring urgent intervention. The most common mode of failure of the FSB was regurgitation caused by a flail or malcoapting leaflet. Seventeen (77%) patients had a modified subcoronary implantation, 3 (14%) had a full root replacement, and 2 (9%) had a root inclusion. Device success using a self-expanding transcatheter valve was 95%, all via transfemoral approach. The mean implant depth was 7 ± 3 mm. Thirty-day survival was 100%. No patient had more than mild paravalvular regurgitation at 30days, and the permanent pacemaker rate was 9%. The mean hospital stay after intervention was 5 ± 2days. ViV TAVR using a self-expanding transcatheter valve is safe, feasible, and can be used successfully to treat a failed FSB. Procedural challenges suggest referral to valve centers of excellence. Copyright © 2017 Elsevier Inc. All rights reserved.

A cost-utility analysis of transcatheter versus surgical aortic valve replacement for the treatment of aortic stenosis in the population with intermediate surgical risk.

PubMed

Tam, Derrick Y; Hughes, Avery; Fremes, Stephen E; Youn, Saerom; Hancock-Howard, Rebecca L; Coyte, Peter C; Wijeysundera, Harindra C

2018-05-01

Although transcatheter aortic valve implantation has been shown to be noninferior to surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk, the cost-effectiveness of this strategy in this population is unknown. Our objective was to conduct a cost-utility analysis comparing transcatheter aortic valve implantation with surgical aortic valve replacement in the population with intermediate risk severe aortic stenosis. A fully probabilistic Markov model with 30-day cycles was constructed from the Canadian third-party payer's perspective to estimate the difference in cost and effectiveness (measured as quality-adjusted life years) of transcatheter aortic valve implantation versus surgical aortic valve replacement for intermediate-risk patients over a lifetime time horizon, discounted at 1.5% per annum. Clinical trial data from The Placement of Aortic Transcatheter Valve 2 informed the efficacy inputs. Costs (adjusted to 2016 Canadian dollars) were obtained from the Canadian Institute of Health Information and the Ontario Schedule of Benefits. Incremental cost-effectiveness ratios were calculated. In the base-case analysis, total lifetime costs for transcatheter aortic valve implantation were $10,548 higher than surgical aortic valve replacement but added 0.23 quality-adjusted life years, for an incremental cost-effectiveness ratio of $46,083/quality-adjusted life-years gained. Deterministic 1-way analyses showed that the incremental cost-effectiveness ratio was sensitive to rates of complications and cost of the transcatheter aortic valve implantation prosthesis. There was moderate-to-high parameter uncertainty; transcatheter aortic valve implantation was the preferred option in only 52.7% and 55.4% of the simulations at a $50,000 and $100,000 per quality-adjusted life years willingness-to-pay thresholds, respectively. On the basis of current evidence, transcatheter aortic valve implantation may be cost-effective for the treatment of severe aortic stenosis in patients with intermediate surgical risk. There remains moderate-to-high uncertainty surrounding the base-case incremental cost-effectiveness ratio. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Hemolytic anemia caused by aortic flap and inversion of felt strip after ascending aorta replacement.

PubMed

Sakaguchi, Masayuki; Takano, Tamaki

2016-08-02

Hemolysis related to a kinked prosthetic graft or inner felt strip is a very rare complication after aortic surgery. We describe herein a case of hemolytic anemia that developed due to aortic flap of the dissection and inversion of an inner felt strip that was applied at the proximal anastomosis of a replaced ascending aorta 10 years previously. A 74-year-old woman presented with consistent hemolytic anemia 10 years after replacement of the ascending aorta to treat Stanford type A acute aortic dissection. The cause of hemolysis was attributed to mechanical injury of red blood cells at a site of stenosis caused by aortic flap of the dissection and inversion of the felt strip used for the proximal anastomosis. Repeated resection of the strip and graft replacement of the ascending aorta resolved this problem. We considered that blood flow disrupted by a jet of blood at the site of the proximal inner felt strip was the cause of severe hemolysis, we describe rare hemolytic anemia at the site of aortic flap and inverted felt strip after replacement of the ascending aorta.

Coronary artery narrowing after aortic root reconstruction with resorcin-formalin glue.

PubMed

Martinelli, L; Graffigna, A; Guarnerio, M; Bonmassari, R; Disertori, M

2000-11-01

Severe stenosis of right and left main coronary artery ostia developed after aortic root reconstruction with gelatin-resorcin-formol glue for correction of acute type A aortic dissection. Surgical treatment of this condition required grafting of the right and left anterior descending arteries with bilateral mammary arteries on the beating heart.

Structural deterioration of the Freestyle aortic valve: mode of presentation and mechanisms.

PubMed

Mohammadi, Siamak; Baillot, Richard; Voisine, Pierre; Mathieu, Patrick; Dagenais, François

2006-08-01

Structural valve deterioration is the major cause of bioprosthetic valve failure. Because of the unique design features and anti-calcification treatment of the Freestyle (Medtronic Inc, Minneapolis, Minn) stentless bioprosthesis, development of structural valve deterioration may differ in comparison with other bioprosthetic valves. This study evaluates the mechanisms and clinical presentation of structural valve deterioration in the Freestyle stentless bioprosthesis. Between January 1993 and August 2005, 608 patients underwent aortic valve replacement with a Freestyle stentless bioprosthesis. The implantation technique was subcoronary in 475 patients and a root replacement in 133 patients. Mean overall follow-up was 5.6 +/- 3.4 years. Follow-up was complete in all patients. Clinical and echocardiographic follow-ups were conducted prospectively. Freedom from structural valve deterioration was 95.8% at 10 years. Twelve patients showed evidence of structural valve deterioration and underwent reoperation for aortic regurgitation (n = 10) or aortic stenosis (n = 2). The mean age of patients with structural valve deterioration was significantly lower than patients without structural valve deterioration (62.6 +/- 8.2 years vs 68.6 +/- 8.3 years, P = .02). The median time between implantation and explantation was 8.7 years (range: 1.9-13.3 years). Eleven structural valve deteriorations occurred after subcoronary implantation, and 1 structural valve deterioration occurred after root implantation (P = .4). The mechanisms of structural valve deterioration were leaflet tears in 10 patients (6 in the left coronary cusp and 4 in the right coronary cusp), severe valve calcification in 1 patient, and cusp fibrosis in 1 patient. The interval between onset of symptoms and reoperation was acute or subacute in 10 patients. At 10 years, the Freestyle stentless bioprosthesis shows excellent freedom from structural valve deterioration. Structural valve deterioration in the Freestyle stentless bioprosthesis relates to leaflet tear with minimal calcification in the majority of cases. Because of the fast onset of symptoms with leaflet tear, patients with a Freestyle stentless bioprosthesis should be informed of the preferential mode of failure and time-frame of symptoms.

Detection of thoracic aortic prosthetic graft infection with 18F-fluorodeoxyglucose positron emission tomography/computed tomography.

PubMed

Tokuda, Yoshiyuki; Oshima, Hideki; Araki, Yoshimori; Narita, Yuji; Mutsuga, Masato; Kato, Katsuhiko; Usui, Akihiko

2013-06-01

To investigate the diagnostic value of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting thoracic aortic prosthetic graft infection. Nine patients with clinically suspected thoracic aortic graft infection underwent FDG-PET/CT scanning. In these patients, the diagnoses could not be confirmed using conventional modalities. The patients' clinical courses were retrospectively reviewed. On the basis of surgical, microbiological and clinical follow-up findings, the aortic grafts were considered infected in 4 patients and not infected in 5. All 4 patients with graft infection (root: 2 cases, arch: 1 case and descending: 1 case) eventually underwent in situ re-replacement. Two of the 4 patients also had abdominal grafts; however, only the thoracic grafts were replaced because uptake was low around the abdominal grafts. The maximal standardized uptake value (SUVmax) in the perigraft area was higher in the infected group than in the non-infected group (11.4 ± 4.5 vs 6.9 ± 6.4), although the difference was not statistically significant. According to the receiver operating characteristic analysis, SUVmax >8 appeared to be the cut-off value in distinguishing the two groups (sensitivity: 1.0 and specificity: 0.8). FDG-PET/CT is useful for confirming the presence of graft infection by detecting high uptake around grafts and excluding other causes of inflammation. An SUVmax value greater than 8 around a graft suggests the presence of graft infection. In addition, FDG-PET/CT can be used to clarify the precise extent of infection. This is especially useful if multiple separated prosthetic grafts have been implanted.

Transcatheter Aortic Valve-in-Valve Procedure in Patients with Bioprosthetic Structural Valve Deterioration

PubMed Central

Reul, Ross M.; Ramchandani, Mahesh K.; Reardon, Michael J.

2017-01-01

Surgical aortic valve replacement is the gold standard procedure to treat patients with severe, symptomatic aortic valve stenosis or insufficiency. Bioprosthetic valves are used for surgical aortic valve replacement with a much greater prevalence than mechanical valves. However, bioprosthetic valves may fail over time because of structural valve deterioration; this often requires intervention due to severe bioprosthetic valve stenosis or regurgitation or a combination of both. In select patients, transcatheter aortic valve replacement is an alternative to surgical aortic valve replacement. Transcatheter valve-in-valve (ViV) replacement is performed by implanting a transcatheter heart valve within a failing bioprosthetic valve. The transcatheter ViV operation is a less invasive procedure compared with reoperative surgical aortic valve replacement, but it has been associated with specific complications and requires extensive preoperative work-up and planning by the heart team. Data from experimental studies and analyses of results from clinical procedures have led to strategies to improve outcomes of these procedures. The type, size, and implant position of the transcatheter valve can be optimized for individual patients with knowledge of detailed dimensions of the surgical valve and radiographic and echocardiographic measurements of the patient's anatomy. Understanding the complexities of the ViV procedure can lead surgeons to make choices during the original surgical valve implantation that can make a future ViV operation more technically feasible years before it is required. PMID:29743998

Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons ≥15 years of age.

PubMed

Devereux, Richard B; de Simone, Giovanni; Arnett, Donna K; Best, Lyle G; Boerwinkle, Eric; Howard, Barbara V; Kitzman, Dalane; Lee, Elisa T; Mosley, Thomas H; Weder, Alan; Roman, Mary J

2012-10-15

Nomograms to predict normal aortic root diameter for body surface area (BSA) in broad ranges of age have been widely used but are limited by lack of consideration of gender effects, jumps in upper limits of aortic diameter among age strata, and data from older teenagers. Sinus of Valsalva diameter was measured by American Society of Echocardiography convention in normal-weight, nonhypertensive, nondiabetic subjects ≥15 years old without aortic valve disease from clinical or population-based samples. Analyses of covariance and linear regression with assessment of residuals identified determinants and developed predictive models for normal aortic root diameter. In 1,207 apparently normal subjects ≥15 years old (54% women), aortic root diameter was 2.1 to 4.3 cm. Aortic root diameter was strongly related to BSA and height (r = 0.48 for the 2 comparisons), age (r = 0.36), and male gender (+2.7 mm adjusted for BSA and age, p <0.001 for all comparisons). Multivariable equations using age, gender, and BSA or height predicted aortic diameter strongly (R = 0.674 for the 2 comparisons, p <0.001) with minimal relation of residuals to age or body size: for BSA 2.423 + (age [years] × 0.009) + (BSA [square meters] × 0.461) - (gender [1 = man, 2 = woman] × 0.267), SEE 0.261 cm; for height 1.519 + (age [years] × 0.010) + (height [centimeters] × 0.010) - (gender [1 = man, 2 = woman] × 0.247), SEE 0.215 cm. In conclusion, aortic root diameter is larger in men and increases with body size and age. Regression models incorporating body size, age, and gender are applicable to adolescents and adults without limitations of previous nomograms. Copyright © 2012 Elsevier Inc. All rights reserved.

The impact of the metabolic syndrome on the outcome after aortic valve replacement.

PubMed

Tadic, Marijana; Vukadinovic, Davor; Cvijanovic, Dane; Celic, Vera; Kocica, Mladen; Putnik, Svetozar; Ivanovic, Branislava

2014-10-01

The aim of this study was to examine the influence of the metabolic syndrome on the left ventricular geometry as well as on the early and mid-time outcome in patients with aortic stenosis who underwent aortic valve replacement. The study included 182 patients who underwent aortic valve replacement due to aortic stenosis. The metabolic syndrome was defined by the presence of at least three AHA-NHLB (American Heart Association/National Heart, Lung and Blood Institute) criteria. All the patients were followed for at least 2 years after the surgery. The metabolic syndrome did not influence the severity of aortic stenosis (mean gradient and aortic valve area). However, the metabolic syndrome was associated with the reduced prevalence of the normal left ventricular geometry and the increased risk of concentric left ventricular hypertrophy in patients with aortic stenosis. Among the metabolic syndrome criteria, only increased blood pressure was simultaneously associated with the short-term and mid-term outcome, independently of other risk factors. Increased fasting glucose level was an independent predictor of the only 30-day outcome after the valve replacement. The metabolic syndrome and left ventricular hypertrophy were, independently of hypertension and diabetes, associated with the 30-day outcome, as well as incidence of major cerebrovascular and cardiovascular events in the 2-year postoperative period. The metabolic syndrome does not change severity of the aortic stenosis, but significantly impacts the left ventricular remodeling in these patients. The metabolic syndrome and left ventricular hypertrophy, irrespective of hypertension and diabetes, are predictors of the short-term and mid-term outcome of patients with aortic stenosis who underwent aortic valve replacement.

SMAD4 gene mutation increases the risk of aortic dilation in patients with hereditary haemorrhagic telangiectasia.

PubMed

Vorselaars, V M M; Diederik, A; Prabhudesai, V; Velthuis, S; Vos, J-A; Snijder, R J; Westermann, C J J; Mulder, B J; Ploos van Amstel, J K; Mager, J J; Faughnan, M E; Post, M C

2017-10-15

Mutations in the genes ENG, ACVRL1 and SMAD4 that are part of the transforming growth factor-beta signalling pathway cause hereditary haemorrhagic telangiectasia (HHT). Mutations in non-HHT genes within this same pathway have been found to associate with aortic dilation. Therefore, we investigated the presence of aortic dilation in a large cohort of HHT patients as compared to non-HHT controls. Chest computed tomography of consecutive HHT patients (ENG, ACVRL1 and SMAD4 mutation carriers) and non-HHT controls were reviewed. Aortic root dilation was defined as a z-score>1.96. Ascending and descending aorta dimensions were corrected for age, gender and body surface area. In total 178 subjects (57.3% female, mean age 43.9±14.9years) were included (32 SMAD4, 47 ENG, 50 ACVRL1 mutation carriers and 49 non-HHT controls). Aortopathy was present in a total of 42 subjects (24% of total). Aortic root dilatation was found in 31% of SMAD4, 2% of ENG, 6% of ACVRL1 mutation carriers, and 4% in non-HHT controls (p<0.001). The aortic root diameter was 36.3±5.2mm in SMAD4 versus 32.7±3.9mm in the non-SMAD4 group (p=0.001). SMAD4 was an independent predictor for increased aortic root (β-coefficient 3.5, p<0.001) and ascending aorta diameter (β-coefficient 1.6, p=0.04). SMAD4 gene mutation in HHT patients is independently associated with a higher risk of aortic root and ascending aortic dilation as compared to other HHT patients and non-HHT controls. Copyright © 2017 Elsevier B.V. All rights reserved.

Successful surgical treatment of intramural aortoatrial fistula, severe aortic regurgitation, mitral prolapse, and tricuspid insufficiency in a patient with Ehlers-Danlos syndrome type IV.

PubMed

Jiang, Shengli; Gao, Changqing; Ren, Chonglei; Zhang, Tao

2012-06-01

Patients with Ehlers-Danlos syndrome (EDS) type IV, an inherited connective tissue disorder, are predisposed to vascular and digestive ruptures, and arterial ruptures account for the majority of deaths. A 31-year-old man with EDS presented with an intramural aortoatrial fistula, severe aortic regurgitation, mitral valve prolapse, and severe tricuspid valve insufficiency combined with a severely dilated left ventricle. Determining the best surgical option for the patient was not easy, especially regarding the course of action for the aortic root with a tear in the sinus of Valsalva. The fistula tract was closed at the aorta with suture and with a patch in the right atrium, the mitral valve was repaired with edge-to-edge suture and then annuloplasty with a Cosgrove ring, the aortic valve was replaced with a mechanical prosthesis, and a modified De Vega technique was used for the tricuspid valvuloplasty. The postoperative course was uncomplicated, and the patient was discharged 2 weeks later. The considerations made to arrive at the chosen surgical course of action in this complex case are reviewed.

Computational comparison of aortic root stresses in presence of stentless and stented aortic valve bio-prostheses.

PubMed

Nestola, M G C; Faggiano, E; Vergara, C; Lancellotti, R M; Ippolito, S; Antona, C; Filippi, S; Quarteroni, A; Scrofani, R

2017-02-01

We provide a computational comparison of the performance of stentless and stented aortic prostheses, in terms of aortic root displacements and internal stresses. To this aim, we consider three real patients; for each of them, we draw the two prostheses configurations, which are characterized by different mechanical properties and we also consider the native configuration. For each of these scenarios, we solve the fluid-structure interaction problem arising between blood and aortic root, through Finite Elements. In particular, the Arbitrary Lagrangian-Eulerian formulation is used for the numerical solution of the fluid-dynamic equations and a hyperelastic material model is adopted to predict the mechanical response of the aortic wall and the two prostheses. The computational results are analyzed in terms of aortic flow, internal wall stresses and aortic wall/prosthesis displacements; a quantitative comparison of the mechanical behavior of the three scenarios is reported. The numerical results highlight a good agreement between stentless and native displacements and internal wall stresses, whereas higher/non-physiological stresses are found for the stented case.

CardiaMed mechanical valve: mid-term results of a multicenter clinical trial.

PubMed

Nazarov, Vladimir M; Zheleznev, Sergey I; Bogachev-Prokophiev, Alexandr V; Afanasyev, Alexandr V; Nemchenko, Eugene V; Jeltovskiy, Yuri V; Lavinyukov, Sergey O

2014-01-01

Prosthesis choice is a major concern in valvular surgery. A multicenter clinical trial was performed to assess the efficacy and safety of the CardiaMed prosthetic heart valve. The study enrolled 420 patients who underwent mitral (209) or aortic (211) valve replacement from 2003 to 2004 at 7 institutions in Russia, and who were followed up from 2006 to 2011. The mean age was 52.2 ± 10.2 years (range, 12-78 years), 47.4% were female, and 99.05% completed the study. The maximum observation term was 7.5 years (2188.5 patient-years); 1081.6 patient-years for aortic and 1106.9 patient-years for mitral valve replacement. The overall 7-year survival rate was 85.1%  ± 3.7%; 86.1%  ± 4.8% and 84.4%  ± 5.4% for aortic and mitral valve replacement, respectively. The 7-year freedom from valve-related death was 93.9%  ± 3.7% and 94.5%  ± 3.2% for aortic and mitral valve replacement, respectively. When early mortality (<30 days) was excluded, these rates were 94.8%  ± 3.1% and 93.8%  ± 3.82%, respectively. Linearized valve-dependent complication rates were determined for structural valve failure (0%/patient-year overall), thrombosis (0.63%/patient-year, all for mitral valve replacement), thromboembolic complications including transient neurologic deficits (0.13%/patient-year overall, 0.5%/patient-year for aortic valve replacement, 0.8%/patient-year for mitral valve replacement), hemorrhagic bleeding (0.64%/patient-year overall, 0.55%/patient-year for aortic valve replacement, 0.09%/patient-year for mitral valve replacement), prosthetic endocarditis (0.28%/patient-year overall, 0.28%/patient-year for aortic valve replacement, 0%/patient-year for mitral valve replacement), and hemolysis (0%/patient-year overall). The CardiaMed mechanical heart valve prostheses meets world standards of safety and efficacy.

Concomitant replacement of the dilated ascending aorta during aortic valve replacement; does it increase the perioperative morbidity and mortality risks?

PubMed

Lim, Ju Y; Jung, Sung H; Kim, Joon B; Kim, Dong K; Chung, Cheol H; Song, Hyun; Lee, Jae W; Choo, Suk J

2013-05-01

Concerns of increased surgical risks with ascending aortic replacement have led surgeons to manage post-stenotic aortic dilatation more conservatively during aortic valve replacement (AVR). The present study aimed to assess the prognostic implications and surgical risks of replacing the dilated aorta during AVR. Between January 1999 and March 2010, 134 patients who received surgery for aortic stenosis and post-stenotic dilatation (aorta size ≥40 mm) were included in the present study. AVR was performed in 92 patients (AVR group) while aortic valve and ascending aorta replacement (AVR + aorta group) were performed in 42 patients. Overall survival was compared between the two groups using Cox proportional hazard model after adjustment with inverse-probability-of-treatment weighting. The mean follow-up duration was 3.5 ± 3 years. There were no significant differences in the operative mortality and morbidity between the two groups. The late cardiac deaths were also not significantly different between the two groups (p = 1.00). In the AVR group, the ascending aortic expansion rate which was 0.18 mm/year over a mean follow-up duration of 2.3 ± 2.2 years by echocardiography showed a positive correlation with time (r = 0.3, p = 0.08). A relatively greater aortic expansion rate was identified as a risk factor for late mortality (p = 0.015, HR 1.08 (CI: 1.02 to 1.15). Concomitant replacement of the dilated ascending aorta during AVR did not increase the immediate postoperative morbidity or mortality risks and tended to exert a long-term beneficial effect on the risk of late mortality. © 2013 Wiley Periodicals, Inc.

The effect of X-ray beam distortion on the Edwards Sapien XT(™) trans-catheter aortic valve replacement prosthesis.

PubMed

Crowhurst, James A; Poon, Karl K; Murdoch, Dale; Incani, Alexander; Raffel, Owen C; Liddicoat, Annelise; Walters, Darren

2015-12-01

Profiling the Aortic root perpendicular to the fluoroscopic image plane will achieve a more successful implant position for trans-catheter aortic valve replacement (TAVR). This study aimed to investigate whether the divergent nature of the X-ray beam from the C-arm altered the appearance of the TAVR device. Under bench-top testing, a 23, 26 and 29 mm Edwards Sapien XT valve was positioned coaxially at the bottom of a fluoroscopic image utilising 22 and 32 cm fields of view (FOV). The table was then moved so that the valve was positioned at the top of the image. The valve's appearance was scored using a previously published three tier classification tool (excellent, satisfactory and poor) and quantified with measurements. The number of degrees of C-arm rotation that were required to bring the valve back to a coaxial appearance was recorded. When using the 32 cm FOV, the valve's appearance changes from excellent to satisfactory. When a 22 cm FOV was used, the change is less marked. More C-arm rotation is required to bring the appearance back to coaxial with the 32 cm FOV. Not maintaining the valve in the centre of the image can distort the valves appearance. This has the potential to affect the final implantation depth.

Pravastatin reduces Marfan aortic dilation.

PubMed

McLoughlin, Darren; McGuinness, Jonathan; Byrne, John; Terzo, Eloisa; Huuskonen, Vilhelmiina; McAllister, Hester; Black, Alexander; Kearney, Sinead; Kay, Elaine; Hill, Arnold D K; Dietz, Harry C; Redmond, J Mark

2011-09-13

The sequelae of aortic root dilation are the lethal consequences of Marfan syndrome. The root dilation is attributable to an imbalance between deposition of matrix elements and metalloproteinases in the aortic medial layer as a result of excessive transforming growth factor-beta signaling. This study examined the efficacy and mechanism of statins in attenuating aortic root dilation in Marfan syndrome and compared effects to the other main proposed preventative agent, losartan. Marfan mice heterozygous for a mutant allele encoding a cysteine substitution in fibrillin-1 (C1039G) were treated daily from 6 weeks old with pravastatin 0.5 g/L or losartan 0.6 g/L. The end points of aortic root diameter (n=25), aortic thickness, and architecture (n=10), elastin volume (n=5), dp/dtmax (maximal rate of change of pressure) (cardiac catheter; n=20), and ultrastructural analysis with stereology (electron microscopy; n=5) were examined. The aortic root diameters of untreated Marfan mice were significantly increased in comparison to normal mice (0.161 ± 0.001 cm vs 0.252 ± 0.004 cm; P<0.01). Pravastatin (0.22 ± 0.003 cm; P<0.01) and losartan (0.221 ± 0.004 cm; P<0.01) produced a significant reduction in aortic root dilation. Both drugs also preserved elastin volume within the medial layer (pravastatin 0.23 ± 0.02 and losartan 0.29 ± 0.03 vs untreated Marfan 0.19 ± 0.02; P=0.01; normal mice 0.27 ± 0.02). Ultrastructural analysis showed a reduction of rough endoplasmic reticulum in smooth muscle cells with pravastatin (0.022 ± 0.004) and losartan (0.013 ± 0.001) compared to untreated Marfan mice (0.035 ± 0.004; P<0.01). Statins are similar to losartan in attenuating aortic root dilation in a mouse model of Marfan syndrome. They appear to act through reducing the excessive protein manufacture by vascular smooth muscle cells, which occurs in the Marfan aorta. As a drug that is relatively well-tolerated for long-term use, it may be useful clinically.

Injuries to the Aorta, Aortic Annulus, and Left Ventricle During Transcatheter Aortic Valve Replacement: Management and Outcomes.

PubMed

Langer, Nathaniel B; Hamid, Nadira B; Nazif, Tamim M; Khalique, Omar K; Vahl, Torsten P; White, Jonathon; Terre, Juan; Hastings, Ramin; Leung, Diana; Hahn, Rebecca T; Leon, Martin; Kodali, Susheel; George, Isaac

2017-01-01

The experience with transcatheter aortic valve replacement is increasing worldwide; however, the incidence of potentially catastrophic cardiac or aortic complications has not decreased. In most cases, significant injuries to the aorta, aortic valve annulus, and left ventricle require open surgical repair. However, the transcatheter aortic valve replacement patient presents a unique challenge as many patients are at high or prohibitive surgical risk and, therefore, an open surgical procedure may not be feasible or appropriate. Consequently, prevention of these potentially catastrophic injuries is vital, and practitioners need to understand when open surgical repair is required and when alternative management strategies can be used. The goal of this article is to provide an overview of current management and prevention strategies for major complications involving the aorta, aortic valve annulus, and left ventricle. © 2016 American Heart Association, Inc.

Surgical treatment of infective endocarditis with aortic and tricuspid valve involvement using cryopreserved aortic and mitral valve allografts.

PubMed

Ostrovsky, Yury; Spirydonau, Siarhei; Shchatsinka, Mikalai; Shket, Aliaksandr

2015-05-01

Surgical treatment of infective and prosthetic endocarditis using allografts gives good results. Aortic allograft implantation is a common technique, while tricuspid valve replacement with a mitral allograft is very rare. Multiple valve disease in case of infective endocarditis is a surgical challenge as such patients are usually in a grave condition and results of surgical treatment are often unsatisfactory. In this article we describe a clinical case of successful surgical treatment in a patient with active infective endocarditis of aortic and tricuspid valve, complicated by an aortic-right ventricular fistula. The aortic valve and ascending aorta were replaced with a cryopreserved aortic allograft; the tricuspid valve was replaced with a cryopreserved mitral allograft. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Natural history and outcome of aortic stenosis diagnosed prenatally.

PubMed Central

Simpson, J. M.; Sharland, G. K.

1997-01-01

OBJECTIVE: To document the growth of the left heart structures and outcome of fetuses with aortic stenosis. DESIGN: Retrospective echocardiographic and clinical study. SETTING: Tertiary centre for fetal cardiology. PATIENTS: 27 consecutive fetuses with aortic stenosis. MAIN OUTCOME MEASURES: Survival of affected fetuses. Measurement of left ventricular end diastolic volume (LVEDV), aortic root diameter, and ejection fraction. RESULTS: Before 25 weeks' gestation, the LVEDV was normal or increased in all cases. In six of eight fetuses studied sequentially, the LVEDV fell across normal centiles. Initial ejection fraction was reduced in 23 fetuses (88%). Before 28 weeks' gestation, the aortic root was normal in all but one case, but after 29 weeks, 11 of 13 fetuses had values below the 50th centile. In two fetuses prenatal aortic valvoplasty was attempted, 10 babies had postnatal interventions, and there were six survivors. Biventricular repair was attempted in eight cases, of whom five survived. A first stage Norwood operation was performed in three babies, of whom one survived. The four fetuses with the highest aortic root z scores had successful biventricular repair. The two fetuses with initially normal ejection fractions survived. Successful biventricular repair was achieved even where the LVEDV was below the 5th centile. CONCLUSIONS: In aortic stenosis diagnosed prenatally, failure of growth of the left ventricle and aortic root often occurs. The outcome of affected fetuses is better than previously reported. Prenatal echocardiography may assist selection of suitable candidates for biventricular versus Norwood repair. Images PMID:9093035

Surgical repair for acute type A aortic dissection in octogenarians.

PubMed

El-Sayed Ahmad, Ali; Papadopoulos, Nestoras; Detho, Faisal; Srndic, Edin; Risteski, Petar; Moritz, Anton; Zierer, Andreas

2015-02-01

Despite limited data, the necessity for immediate surgical intervention in octogenarians with acute type A aortic dissection (AAD) has recently been questioned because the surgical risk may outweigh its potential benefits. At the same time, evolving stent graft technologies are pushing in the market for pathology within the ascending aorta, even for treatment of AAD. Against this background, we analyzed our institutional experience in this patient cohort during the last 8 years. Between October 2005 and October 2013, 39 patients aged older than 80 years (82 ± 2 years) underwent surgical repair for AAD, of which 29 patients (74%) were men. Owing to patient age and comorbidities, we aimed to limit the operation to supracoronary hemiarch replacement whenever possible. Clinical data were prospectively entered into our institutional database. Late follow-up was 3.6 ± 2.8 years and was 100% complete. Hemiarch replacement was performed in 32 patients (82%), and full arch replacement was necessary in the remaining 7. In 31 patients (79%), the aortic root could be glued and reconstructed or remained untouched. The remaining 8 patients (21%) underwent the bio-Bentall procedure. Mean ventilation time was 46 ± 23 hours, and the intensive care unit stay was 5 ± 9 days. We observed new postoperative permanent neurologic deficits in 2 patients (5%) and transient neurologic deficits in 3 (8%). The 30-day mortality was 26% (n = 10). Kaplan-Meier estimates for late survival were 46% ± 16% at 5 years. Given the guidelines regarding the predicted risk of death in patients with untreated AAD, current data suggest a survival benefit with immediate open surgical intervention even in octogenarians. Similarly to the early days of transcatheter-based aortic valve implantation, open surgical reference data are warranted to set the bar for upcoming endovascular treatment of AAD in octogenarians. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Aortic or Mitral Valve Replacement With the Biocor and Biocor Supra

ClinicalTrials.gov

2017-04-26

Aortic Valve Insufficiency; Aortic Valve Regurgitation; Aortic Valve Stenosis; Aortic Valve Incompetence; Mitral Valve Insufficiency; Mitral Valve Regurgitation; Mitral Valve Stenosis; Mitral Valve Incompetence

Resveratrol Inhibits Aortic Root Dilatation in the Fbn1C1039G/+ Marfan Mouse Model.

PubMed

Hibender, Stijntje; Franken, Romy; van Roomen, Cindy; Ter Braake, Anique; van der Made, Ingeborg; Schermer, Edith E; Gunst, Quinn; van den Hoff, Maurice J; Lutgens, Esther; Pinto, Yigal M; Groenink, Maarten; Zwinderman, Aeilko H; Mulder, Barbara J M; de Vries, Carlie J M; de Waard, Vivian

2016-08-01

Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the fibrillin-1 gene. Patients with MFS are at risk of aortic aneurysm formation and dissection. Usually, blood pressure-lowering drugs are used to reduce aortic events; however, this is not sufficient for most patients. In the aorta of smooth muscle cell-specific sirtuin-1-deficient mice, spontaneous aneurysm formation and senescence are observed. Resveratrol is known to enhance sirtuin-1 activity and to reduce senescence, which prompted us to investigate the effectiveness of resveratrol in inhibition of aortic dilatation in the Fbn1(C1039G/+) MFS mouse model. Aortic senescence strongly correlates with aortic root dilatation rate in MFS mice. However, although resveratrol inhibits aortic dilatation, it only shows a trend toward reduced aortic senescence. Resveratrol enhances nuclear localization of sirtuin-1 in the vessel wall and, in contrast to losartan, does not affect leukocyte infiltration nor activation of SMAD2 and extracellular signal-regulated kinases 1/2 (ERK1/2). Interestingly, specific sirtuin-1 activation (SRT1720) or inhibition (sirtinol) in MFS mice does not affect aortic root dilatation rate, although senescence is changed. Resveratrol reduces aortic elastin breaks and decreases micro-RNA-29b expression coinciding with enhanced antiapoptotic Bcl-2 expression and decreased number of terminal apoptotic cells. In cultured smooth muscle cells, the resveratrol effect on micro-RNA-29b downregulation is endothelial cell and nuclear factor κB-dependent. Resveratrol inhibits aortic root dilatation in MFS mice by promoting elastin integrity and smooth muscle cell survival, involving downregulation of the aneurysm-related micro-RNA-29b in the aorta. On the basis of these data, resveratrol holds promise as a novel intervention strategy for patients with MFS. © 2016 The Authors.

Resveratrol Inhibits Aortic Root Dilatation in the Fbn1C1039G/+ Marfan Mouse Model

PubMed Central

Hibender, Stijntje; Franken, Romy; van Roomen, Cindy; ter Braake, Anique; van der Made, Ingeborg; Schermer, Edith E.; Gunst, Quinn; van den Hoff, Maurice J.; Lutgens, Esther; Pinto, Yigal M.; Groenink, Maarten; Zwinderman, Aeilko H.; Mulder, Barbara J.M.; de Vries, Carlie J.M.

2016-01-01

Objective— Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the fibrillin-1 gene. Patients with MFS are at risk of aortic aneurysm formation and dissection. Usually, blood pressure–lowering drugs are used to reduce aortic events; however, this is not sufficient for most patients. In the aorta of smooth muscle cell–specific sirtuin-1–deficient mice, spontaneous aneurysm formation and senescence are observed. Resveratrol is known to enhance sirtuin-1 activity and to reduce senescence, which prompted us to investigate the effectiveness of resveratrol in inhibition of aortic dilatation in the Fbn1C1039G/+ MFS mouse model. Approach and Results— Aortic senescence strongly correlates with aortic root dilatation rate in MFS mice. However, although resveratrol inhibits aortic dilatation, it only shows a trend toward reduced aortic senescence. Resveratrol enhances nuclear localization of sirtuin-1 in the vessel wall and, in contrast to losartan, does not affect leukocyte infiltration nor activation of SMAD2 and extracellular signal–regulated kinases 1/2 (ERK1/2). Interestingly, specific sirtuin-1 activation (SRT1720) or inhibition (sirtinol) in MFS mice does not affect aortic root dilatation rate, although senescence is changed. Resveratrol reduces aortic elastin breaks and decreases micro-RNA-29b expression coinciding with enhanced antiapoptotic Bcl-2 expression and decreased number of terminal apoptotic cells. In cultured smooth muscle cells, the resveratrol effect on micro-RNA-29b downregulation is endothelial cell and nuclear factor κB-dependent. Conclusions— Resveratrol inhibits aortic root dilatation in MFS mice by promoting elastin integrity and smooth muscle cell survival, involving downregulation of the aneurysm-related micro-RNA-29b in the aorta. On the basis of these data, resveratrol holds promise as a novel intervention strategy for patients with MFS. PMID:27283746

Aortic valve ochronosis: a rare manifestation of alkaptonuria

PubMed Central

Steger, Christina Maria

2011-01-01

Alkaptonuric ochronosis is a heritable disorder of tyrosine metabolism, with various systemic abnormalities related to pigment deposition and degeneration of collagen and other tissues, including the heart and aorta. A 65-year-old woman with alkaptonuric ochronosis and a history of four joint replacements required aortic valve replacement for severe aortic stenosis. Operative findings included ochronosis of a partly calcified aortic valve and the aortic intima. The aortic valve was removed at surgery and histologically investigated. Light microscopic examination of the aortic valve revealed intracellular and extracellular deposits of ochronotic pigment and a chronic inflammatory infiltrate. Beside the case representation, the disease history, aetiology, pathogenesis, clinical presentation and treatment of aortic valve ochronosis are reviewed. PMID:22689837

Aortic valve ochronosis: a rare manifestation of alkaptonuria.

PubMed

Steger, Christina Maria

2011-07-28

Alkaptonuric ochronosis is a heritable disorder of tyrosine metabolism, with various systemic abnormalities related to pigment deposition and degeneration of collagen and other tissues, including the heart and aorta. A 65-year-old woman with alkaptonuric ochronosis and a history of four joint replacements required aortic valve replacement for severe aortic stenosis. Operative findings included ochronosis of a partly calcified aortic valve and the aortic intima. The aortic valve was removed at surgery and histologically investigated. Light microscopic examination of the aortic valve revealed intracellular and extracellular deposits of ochronotic pigment and a chronic inflammatory infiltrate. Beside the case representation, the disease history, aetiology, pathogenesis, clinical presentation and treatment of aortic valve ochronosis are reviewed.

[Late complications following Björk-Shiley and St. Jude Medical heart valve replacement].

PubMed

Horstkotte, D; Körfer, R; Budde, T; Haerten, K; Schulte, H D; Bircks, W; Loogen, F

1983-05-01

Valve-related complications after Björk-Shiley mitral (n = 475), aortic (n = 424), or mitral-aortic implantation (n = 119) were compared to complications after St. Jude mitral (n = 173), aortic (n = 152), and St. Jude mitral and aortic (n = 63) replacements. The 1,018 consecutive patients with Björk-Shiley valves had been operated upon between 1974 and 1982, those with St. Jude valves between 1978 and 1982. All patients were placed on anticoagulant therapy with phenprocoumon early after operation and no significant intergroup differences in the effectiveness of the anticoagulant therapy were found. At a comparable follow-up time of approximately 23 months, 24 major thromboembolic episodes were observed after Björk-Shiley mitral (BSM) and 3 after St. Jude mitral valve implantation (SJM), corresponding to a thromboembolic rate of 2.82/100 patient years with BSM and 0.93/100 patient years with SJM. After aortic valve replacements, 1.93 events in 100 patient years occurred after Björk-Shiley aortic (BSA) and 0.73 after St. Jude aortic implantation (SJA). In patients with double valve replacements, these rates were 3.2 (BSM + BSA) and 0.88 (SJM + SJA), respectively. The cerebral vessels were involved in 52% and the arteries of the extremities in 22% of these major events. Six Björk-Shiley prostheses had to be replaced because of valve thrombosis. The overall incidence of severe hemorrhagic complications was 2.94/100 patient years in BSM and 1.79 in SJM. After aortic valve replacement, we found rates of 1.80/100 patient years (BSA) and 2.57/100 patient years (SJA), respectively. Intravascular hemolysis no longer seems to be a significant clinical problem. However, indications of red cell damage after heart valve replacement were significantly greater in patients with perivalvular leakage, valve thrombosis, or dysfunction than in those with normally functioning prostheses. Reoperations were necessary because of valve thrombosis (0.46%), perivalvular leakage (2.2%), or prosthetic valve endocarditis with concomitant perivalvular regurgitation (0.46%). One valve had to be replaced because of fracture of the outlet strut of a BSM prosthesis. Hemorrhage due to the anticoagulant treatment was thus the most frequent complication, without significant intergroup differences, while thromboembolic complications were significantly more frequent after Björk-Shiley mitral, aortic, and double valve replacements than after St. Jude implantation. This may lead to the consideration of a change in the prophylaxis of thrombus formations with the St. Jude valve, especially in aortic valve replacements with sinus rhythm.

Transforming Growth Factor Beta-2 Mutations in Barlow's Disease and Aortic Dilatation.

PubMed

Disha, Kushtrim; Schulz, Solveig; Kuntze, Thomas; Girdauskas, Evaldas

2017-07-01

We report on a patient operated on for degenerative myxomatous mitral and tricuspid valve disease (Barlow's disease) and aortic root dilatation. A valve repair operation and the postoperative course were uneventful. Multigenerational genetic analyses revealed two different mutations in the transforming growth factor beta-2 gene in the same patient. The two mutations in different exons were inherited from both parents each. None of the parents presented with either valve dysfunction or aortic root dilatation. This rare case illustrates potentially common genetic and signaling pathways of concomitant myxomatous valve disease and aortic root dilatation. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Aortic root dilatation rate in pediatric patients with Marfan syndrome treated with losartan].

PubMed

Mariucci, Elisabetta; Guidarini, Marta; Donti, Andrea; Lovato, Luigi; Wischmeijer, Anita; Angeli, Emanuela; Gargiulo, Gaetano D; Picchio, Fernando M; Bonvicini, Marco

2015-12-01

Medical therapy with angiotensin II receptor blockers/angiotensin-converting enzyme inhibitors and/or beta-blockers was reported to reduce aortic root dilatation rates in pediatric patients with Marfan syndrome. No data are available in the literature on losartan effects after 3 years of therapy. The aim of our study was to establish whether losartan reduces aortic root dilatation rates in pediatric patients with Marfan syndrome in the mid and long term. This is a retrospective analysis of 38 pediatric patients with Marfan syndrome followed at the Marfan Clinic of S. Orsola-Malpighi Hospital of the University of Bologna (Italy). Aortic diameters were measured at sinuses of Valsalva and proximal ascending aorta with transthoracic echocardiography. After a mean follow-up of 4.5 ± 2.5 years (range 2-9 years), aortic root z score at sinuses of Valsalva and proximal ascending aorta remained stable. The average annual rate of change in aortic root z score was -0.1 ± 0.4 and 0 ± 0.3 at sinuses of Valsalva and proximal ascending aorta, respectively. The mean dose of losartan was 0.7 ± 0.3 mg/kg/day. Three patients were non-responders, probably because of late beginning or low dose of therapy. Eight patients underwent cardiac surgery (aortic root surgery in 5 and mitral valve repair in 3), all of them started losartan later in life. Despite the retrospective design of the study and the small sample size, a beneficial effect of losartan therapy was observed in pediatric patients with Marfan syndrome in the mid and long term. Late beginning or low doses of losartan can turn off the effects of therapy.

Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

PubMed Central

Poon, Shi Sum; Theologou, Thomas; Harrington, Deborah; Kuduvalli, Manoj; Oo, Aung

2016-01-01

Background Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection. Methods A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. Result Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56–0.94; P=0.02; I2=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65–1.09; P=0.20; I2=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation. Conclusions Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation. PMID:27386403

Percutaneous transluminal alcohol septal myocardial ablation after aortic valve replacement

NASA Technical Reports Server (NTRS)

Sitges, M.; Kapadia, S.; Rubin, D. N.; Thomas, J. D.; Tuzcu, M. E.; Lever, H. M.

2001-01-01

When left ventricular outflow tract obstruction develops after aortic valve replacement, few treatment choices have been available until now. We present a patient with prior aortic valve replacement who developed left ventricle outflow tract obstruction that was successfully treated with a percutaneous transcoronary myocardial septal alcohol ablation. This technique is a useful tool for the treatment of obstructive hypertrophic cardiomyopathy, especially in those patients with prior heart surgery. Copyright 2001 Wiley-Liss, Inc.

Complementary role of cardiac CT in the assessment of aortic valve replacement dysfunction

PubMed Central

Moss, Alastair J; Dweck, Marc R; Dreisbach, John G; Williams, Michelle C; Mak, Sze Mun; Cartlidge, Timothy; Nicol, Edward D; Morgan-Hughes, Gareth J

2016-01-01

Aortic valve replacement is the second most common cardiothoracic procedure in the UK. With an ageing population, there are an increasing number of patients with prosthetic valves that require follow-up. Imaging of prosthetic valves is challenging with conventional echocardiographic techniques making early detection of valve dysfunction or complications difficult. CT has recently emerged as a complementary approach offering excellent spatial resolution and the ability to identify a range of aortic valve replacement complications including structural valve dysfunction, thrombus development, pannus formation and prosthetic valve infective endocarditis. This review discusses each and how CT might be incorporated into a multimodal cardiovascular imaging pathway for the assessment of aortic valve replacements and in guiding clinical management. PMID:27843568

Correlation of echo-Doppler aortic valve regurgitation index with angiographic aortic regurgitation severity.

PubMed

Chen, Ming; Luo, Huai; Miyamoto, Takashi; Atar, Shaul; Kobal, Sergio; Rahban, Masoud; Brasch, Andrea V; Makkar, Rajendra; Neuman, Yoram; Naqvi, Tasneem Z; Tolstrup, Kirsten; Siegel, Robert J

2003-09-01

We assessed aortic regurgitation (AR) severity by utilizing multiple echo-Doppler variables in comparison with AR severity by aortic root angiography. Patients were divided into 3 groups: mild, moderate, and severe. An AR index (ARI) was developed, comprising 5 echocardiographic parameters: ratio of color AR jet height to left ventricular outlet flow diameter, AR signal density from continuous-wave Doppler, pressure half-time, left ventricular end-diastolic diameter, and aortic root diameter. There was a strong correlation between AR severity by angiography and the calculated echo-Doppler ARI (r = 0.84, p = 0.0001). As validated by aortic angiography, the ARI is an accurate reflection of AR severity.

Elephant trunk in a small-calibre true lumen for chronic aortic dissection: cause of haemolytic anaemia?

PubMed

Araki, Haruna; Kitamura, Tadashi; Horai, Tetsuya; Shibata, Ko; Miyaji, Kagami

2014-12-01

The elephant trunk technique for aortic dissection is useful for reducing false lumen pressure; however, a folded vascular prosthesis inside the aorta can cause haemolysis. The purpose of this study was to investigate whether an elephant trunk in a small-calibre lumen can cause haemolysis. Inpatient and outpatient records were retrospectively reviewed. Two cases of haemolytic anaemia after aortic surgery using the elephant trunk technique were identified from 2011 to 2013. A 64-year-old man, who underwent graft replacement of the ascending aorta for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta and moderate aortic regurgitation. A two-stage surgery was scheduled. Total arch replacement with an elephant trunk in the true lumen and concomitant aortic valve replacement were performed. Postoperatively, he developed severe haemolytic anaemia because of the folded elephant trunk. The anaemia improved after the second surgery, including graft replacement of the descending aorta. Similarly, a 61-year-old man, who underwent total arch replacement for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta. Graft replacement of the descending aorta with an elephant trunk inserted into the true lumen was performed. The patient postoperatively developed haemolytic anaemia because of the folded elephant trunk, which improved after additional stent grafting into the elephant trunk. A folded elephant trunk in a small-calibre lumen can cause haemolysis. Therefore, inserting an elephant trunk in a small-calibre true lumen during surgery for chronic aortic dissection should be avoided. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Comparison of the structure of the aortic valve and ascending aorta in adults having aortic valve replacement for aortic stenosis versus for pure aortic regurgitation and resection of the ascending aorta for aneurysm.

PubMed

Roberts, William Clifford; Vowels, Travis James; Ko, Jong Mi; Filardo, Giovanni; Hebeler, Robert Frederick; Henry, Albert Carl; Matter, Gregory John; Hamman, Baron Lloyd

2011-03-01

There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken. Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.

Three-dimensional flow structures past a bio-prosthetic valve in an in-vitro model of the aortic root.

PubMed

Hasler, David; Obrist, Dominik

2018-01-01

The flow field past a prosthetic aortic valve comprises many details that indicate whether the prosthesis is functioning well or not. It is, however, not yet fully understood how an optimal flow scenario would look, i.e. which subtleties of the fluid dynamics in place are essential regarding the durability and compatibility of a prosthetic valve. In this study, we measured and analyzed the 3D flow field in the vicinity of a bio-prosthetic heart valve in function of the aortic root size. The measurements were conducted within aortic root phantoms of different size, mounted in a custom-built hydraulic setup, which mimicked physiological flow conditions in the aorta. Tomographic particle image velocimetry was used to measure the 3D instantaneous velocity field at various instances. Several 3D fields (e.g. instantaneous and mean velocity, 3D shear rate) were analyzed and compared focusing on the impact of the aortic root size, but also in order to gain general insight in the 3D flow structure past the bio-prosthetic valve. We found that the diameter of the aortic jet relative to the diameter of the ascending aorta is the most important parameter in determining the characteristics of the flow. A large aortic cross-section, relative to the cross-section of the aortic jet, was associated with higher levels of turbulence intensity and higher retrograde flow in the ascending aorta.

Reoperation for composite valve graft failure: Operative results and midterm survival.

PubMed

Maroto, Luis C; Carnero, Manuel; Cobiella, Javier; García, Mónica; Vilacosta, Isidre; Reguillo, Fernando; Villagrán, Enrique; Olmos, Carmen

2018-06-01

The replacement of a failed composite valve graft is technically more demanding and is associated with increased morbidity and mortality. We present our technique and outcomes for reoperations for composite graft failures. Between September 2011 and June 2017, 14 patients underwent a redo composite graft replacement. Twelve patients (85.7%) were male, and mean age was 58.4 years ± 12 standard deviation (SD). One patient had two previous root replacements. Indications for reoperation were endocarditis (8), aortic pseudoaneurysm (3), and aortic prosthesis thrombosis (3). Mean logistic EuroSCORE and EuroSCORE II were 30.8% and 14.7%, respectively. A mechanical composite graft was used in 12 patients and biological composite grafts were used in two patients. Hospital mortality was 14.3% (n = 2). One patient (7.1%) required reoperation for bleeding, One patient (7.1%) had mechanical ventilation >24 h, and four patients (28.6%) required implantation of a permanent pacemaker. Median intensive care unit and hospital stays were 3 days (interquartile range [IQR] 1-5) and 10 days (IQR 6.5-38.5). One patient experienced recurrent prosthetic valve endocarditis 14 months after operation. On follow-up, 11 of 12 survivors were in New York Heart Association class I or II. Survival at 3 years was 85.7% ± 9.4% SD. Composite valve graft replacement can be performed with acceptable morbidity and mortality with good mid-term survival. © 2018 Wiley Periodicals, Inc.

Possible extracardiac predictors of aortic dissection in Marfan syndrome

PubMed Central

2014-01-01

Background According to previous studies, aortic diameter alone seems to be insufficient to predict the event of aortic dissection in Marfan syndrome (MFS). Determining the optimal schedule for preventive aortic root replacement (ARR) aortic growth rate is of importance, as well as family history, however, none of them appear to be decisive. Thus, the aim of this study was to search for potential predictors of aortic dissection in MFS. Methods A Marfan Biobank consisting of 79 MFS patients was established. Thirty-nine MFS patients who underwent ARR were assigned into three groups based on the indication for surgery (dissection, annuloaortic ectasia and prophylactic surgery). The prophylactic surgery group was excluded from the study. Transforming growth factor-β (TGF-β) serum levels were measured by ELISA, relative expression of c-Fos, matrix metalloproteinase 3 and 9 (MMP-3 and −9) were assessed by RT-PCR. Clinical parameters, including anthropometric variables - based on the original Ghent criteria were also analyzed. Results Among patients with aortic dissection, TGF-β serum level was elevated (43.78 ± 6.51 vs. 31.64 ± 4.99 ng/l, p < 0.0001), MMP-3 was up-regulated (Ln2α = 1.87, p = 0.062) and striae atrophicae were more common (92% vs. 41% p = 0.027) compared to the annuloaortic ectasia group. Conclusions We found three easily measurable parameters (striae atrophicae, TGF-β serum level, MMP-3) that may help to predict the risk of aortic dissection in MFS. Based on these findings a new classification of MFS, that is benign or malignant is also proposed, which could be taken into consideration in determining the timing of prophylactic ARR. PMID:24720641

Aortic Root Aneurism Found in a 42-Year-Old Epitomizes the Importance of Auscultation in Routine Exams.

PubMed

Fredricks, Todd R; Benseler, Jeffrey S

2016-05-01

Bicuspid aortic valve disease (BAV) is the most common cardiac valve pathology. BAV is associated with aortic root disorders. The literature has few case reports identifying this condition during routine physical exam. A 42-yr-old military reservist flight medic presented for his annual military flight physical. He was found to have a faint cardiac murmur. His past family and medical history were remarkable for familial essential hypertension and being told at age 9 that he had a "murmur." He was referred for cardiology consultation, echocardiography, stress testing, and a computerized tomography angiogram (CTa), which identified BAV with a 4.3-cm aortic root aneurysm. A follow-up at 1 yr was recommended. In the interim he developed severe aortic valve insufficiency, a 4.6-cm aortic root aneurysm. The valve and aortic root were repaired and a single left anterior descending coronary artery lesion was bypassed during surgery. The flight medic made a full recovery but was not returned to flight status. This case emphasizes the importance of periodic reassessment by thorough history and careful cardiac auscultation during flight physicals. BAV aortopathy is an uncommon condition seen in the military aviation community. Most flight surgeons will not have the opportunity to identify it specifically via auscultation. This patient had over nine annual flight physicals prior to the one reported and no pathology was ever identified through routine auscultation. The potential role of point-of-care ultrasound (POCUS) for survey of vascular and valve status of aviation personnel merits further research.

Rapid pannus formation after few months of obstructing aortic mechanical prosthesis.

PubMed

Al-Alao, Bassel; Simoniuk, Urszula; Heron, Brian; Parissis, Haralabos

2015-11-01

We report a rare case of a prosthetic aortic valve obstruction due to pannus formation only 3 months following aortic and mitral valve replacement. Fragments of asymmetrical pannus formation affected one of the leaflets of the bi-leaflet mechanical valve; the leaflet appeared immobile due to pannus ingrowth into the mechanical skeleton resulting in encroachment of the leaflet, which in turn became immobile. The patient successfully underwent emergency redo-aortic valve replacement.

Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

PubMed

Yu, Pey-Jen; Mattia, Allan; Cassiere, Hugh A; Esposito, Rick; Manetta, Frank; Kohn, Nina; Hartman, Alan R

2017-12-29

Significant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The aim of this study is to determine if surgical correction of both aortic and mitral valves in high risk patients with concomitant valvular disease would offer patients better outcomes than TAVR alone. A retrospective analysis of 43 high-risk patients who underwent concomitant surgical aortic valve replacement and mitral valve surgery from 2008 to 2012 was performed. Immediate and long term survival were assessed. There were 43 high-risk patients with severe aortic stenosis undergoing concomitant surgical aortic valve replacement and mitral valve surgery. The average age was 80 ± 6 years old. Nineteen (44%) patients had prior cardiac surgery, 15 (34.9%) patients had chronic obstructive lung disease, and 39 (91%) patients were in congestive heart failure. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for isolated surgical aortic valve replacement for the cohort was 10.1% ± 6.4%. Five patients (11.6%) died during the index admission and/or within thirty days of surgery. Mortality rate was 25% at six months, 35% at 1 year and 45% at 2 years. There was no correlation between individual preoperative risk factors and mortality. High-risk patients with severe aortic stenosis and mitral valve disease undergoing concomitant surgical aortic valve replacement and mitral valve surgery may have similar long term survival as that described for such patients undergoing TAVR. Surgical correction of double valvular disease in this patient population may not confer mortality benefit compared to TAVR alone.

Aortic root dilation in kidney transplant recipients.

PubMed

Obremska, Marta; Boratyńska, Maria; Szymczak, Maciej; Zyśko, Dorota; Płonek, Tomasz; Goździk, Anna; Klinger, Marian

2018-05-30

INTRODUCTION Aortic root (AoR) dilation is associated with cardiac damage and higher cardiovascular risk. Cardiovascular disease is the most common cause of death in patients after kidney transplantation (KTx ). OBJECTIVES The aim of this study was to assess the prevalence of enlarged AoR diameter in KTx recipients. Patients with bicuspid aortic valve, significant valvular disease, or evidence of connective tissue disorder were excluded. PATIENTS AND METHODS A total of 87 KTx recipients were divided into 2 groups depending on immunosuppressive regimen: 41 patients receiving mammalian target of rapamycin inhibitors (mTORi) and 46 patients treated with calcineurin inhibitors (CNIs). In all patients, echocardiography was performed, laboratory and clinical markers of cardiovascular risk were assessed, and the AoR diameter was calculated. RESULTS There were no differences between groups in age, sex, body surface area, body mass index, frequency of diabetes, hypertension, dyslipidemia, time after replacement therapy, creatinine levels, and estimated glomerular filtration rate. In the CNI group, the observed and calculated AoR diameters were similar (P = 0.8). In the mTORi group, the observed AoR diameter was higher than the calculated one (P = 0.002). The concentric and eccentric left ventricular hypertrophy was similar in both groups (P = 0.12 and P = 0.69, respectively). In the stepwise regression analysis, the AoR diameter was associated with body surface area and mTORi treatment. CONCLUSIONS KTx recipients have a high prevalence of AoR dilation. Immunosuppressive regimen based on mTORi increases the incidence of AoR enlargement.

Long-Term Mortality Effect of Early Pacemaker Implantation After Surgical Aortic Valve Replacement.

PubMed

Greason, Kevin L; Lahr, Brian D; Stulak, John M; Cha, Yong-Mei; Rea, Robert F; Schaff, Hartzell V; Dearani, Joseph A

2017-10-01

The need for pacemaker implantation is a well-described complication of aortic valve replacement. Not so well described is the effect such an event has on long-term outcome. This study reviewed a 21-year experience at the Mayo Clinic (Rochester, Minnesota) with aortic valve replacement to understand the influence of early postoperative pacemaker implantation on long-term mortality rates more clearly. This study retrospectively reviewed the records of 5,842 patients without previous pacemaker implantation who underwent surgical aortic valve replacement from January 1993 through June 2014. The median age of these patients was 73 years (range, 65 to 79 years), the median ejection fraction was 62% (range, 53% to 68%), 3,853 patients were male (66%), and coronary artery bypass graft operation was performed in 2,553 (44%) of the patients studied. Early pacemaker implantation occurred in 146 patients (2.5%) within 30 days of surgical aortic valve replacement. The median follow-up of patients was 11.1 years (range, 5.8 to 16.5 years), and all-cause mortality rates were 2.4% at 30 days, 6.4% at 1 year, 23.1% at 5 years, 48.3% at 10 years, and 67.9% at 15 years postoperatively. Early pacemaker implantation was associated with an increased risk of death after multivariable adjustment for baseline patients' characteristics (hazard ratio, 1.49; 95% confidence interval, 1.20, 1.84; p < 0.001). Early pacemaker implantation as a complication of surgical aortic valve replacement is associated with an increased risk of long-term death. Valve replacement-related pacemaker implantation rates should be important considerations with respect to new valve replacement paradigms, especially in younger and lower-risk patients. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Intra-Operative Vector Flow Imaging Using Ultrasound of the Ascending Aorta among 40 Patients with Normal, Stenotic and Replaced Aortic Valves.

PubMed

Hansen, Kristoffer Lindskov; Møller-Sørensen, Hasse; Kjaergaard, Jesper; Jensen, Maiken Brit; Lund, Jens Teglgaard; Pedersen, Mads Møller; Lange, Theis; Jensen, Jørgen Arendt; Nielsen, Michael Bachmann

2016-10-01

Stenosis of the aortic valve gives rise to more complex blood flows with increased velocities. The angle-independent vector flow ultrasound technique transverse oscillation was employed intra-operatively on the ascending aorta of (I) 20 patients with a healthy aortic valve and 20 patients with aortic stenosis before (IIa) and after (IIb) valve replacement. The results indicate that aortic stenosis increased flow complexity (p < 0.0001), induced systolic backflow (p < 0.003) and reduced systolic jet width (p < 0.0001). After valve replacement, the systolic backflow and jet width were normalized (p < 0.52 and p < 0.22), but flow complexity was not (p < 0.0001). Flow complexity (p < 0.0001), systolic jet width (p < 0.0001) and systolic backflow (p < 0.001) were associated with peak systolic velocity. The study found that aortic stenosis changes blood flow in the ascending aorta and valve replacement corrects some of these changes. Transverse oscillation may be useful for assessment of aortic stenosis and optimization of valve surgery. Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

Transcatheter aortic-valve replacement with a self-expanding prosthesis.

PubMed

Adams, David H; Popma, Jeffrey J; Reardon, Michael J; Yakubov, Steven J; Coselli, Joseph S; Deeb, G Michael; Gleason, Thomas G; Buchbinder, Maurice; Hermiller, James; Kleiman, Neal S; Chetcuti, Stan; Heiser, John; Merhi, William; Zorn, George; Tadros, Peter; Robinson, Newell; Petrossian, George; Hughes, G Chad; Harrison, J Kevin; Conte, John; Maini, Brijeshwar; Mumtaz, Mubashir; Chenoweth, Sharla; Oh, Jae K

2014-05-08

We compared transcatheter aortic-valve replacement (TAVR), using a self-expanding transcatheter aortic-valve bioprosthesis, with surgical aortic-valve replacement in patients with severe aortic stenosis and an increased risk of death during surgery. We recruited patients with severe aortic stenosis who were at increased surgical risk as determined by the heart team at each study center. Risk assessment included the Society of Thoracic Surgeons Predictor Risk of Mortality estimate and consideration of other key risk factors. Eligible patients were randomly assigned in a 1:1 ratio to TAVR with the self-expanding transcatheter valve (TAVR group) or to surgical aortic-valve replacement (surgical group). The primary end point was the rate of death from any cause at 1 year, evaluated with the use of both noninferiority and superiority testing. A total of 795 patients underwent randomization at 45 centers in the United States. In the as-treated analysis, the rate of death from any cause at 1 year was significantly lower in the TAVR group than in the surgical group (14.2% vs. 19.1%), with an absolute reduction in risk of 4.9 percentage points (upper boundary of the 95% confidence interval, -0.4; P<0.001 for noninferiority; P = 0.04 for superiority). The results were similar in the intention-to-treat analysis. In a hierarchical testing procedure, TAVR was noninferior with respect to echocardiographic indexes of valve stenosis, functional status, and quality of life. Exploratory analyses suggested a reduction in the rate of major adverse cardiovascular and cerebrovascular events and no increase in the risk of stroke. In patients with severe aortic stenosis who are at increased surgical risk, TAVR with a self-expanding transcatheter aortic-valve bioprosthesis was associated with a significantly higher rate of survival at 1 year than surgical aortic-valve replacement. (Funded by Medtronic; U.S. CoreValve High Risk Study ClinicalTrials.gov number, NCT01240902.).

Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients.

PubMed

Reardon, Michael J; Van Mieghem, Nicolas M; Popma, Jeffrey J; Kleiman, Neal S; Søndergaard, Lars; Mumtaz, Mubashir; Adams, David H; Deeb, G Michael; Maini, Brijeshwar; Gada, Hemal; Chetcuti, Stanley; Gleason, Thomas; Heiser, John; Lange, Rüdiger; Merhi, William; Oh, Jae K; Olsen, Peter S; Piazza, Nicolo; Williams, Mathew; Windecker, Stephan; Yakubov, Steven J; Grube, Eberhard; Makkar, Raj; Lee, Joon S; Conte, John; Vang, Eric; Nguyen, Hang; Chang, Yanping; Mugglin, Andrew S; Serruys, Patrick W J C; Kappetein, Arie P

2017-04-06

Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk. We evaluated the clinical outcomes in intermediate-risk patients with severe, symptomatic aortic stenosis in a randomized trial comparing TAVR (performed with the use of a self-expanding prosthesis) with surgical aortic-valve replacement. The primary end point was a composite of death from any cause or disabling stroke at 24 months in patients undergoing attempted aortic-valve replacement. We used Bayesian analytical methods (with a margin of 0.07) to evaluate the noninferiority of TAVR as compared with surgical valve replacement. A total of 1746 patients underwent randomization at 87 centers. Of these patients, 1660 underwent an attempted TAVR or surgical procedure. The mean (±SD) age of the patients was 79.8±6.2 years, and all were at intermediate risk for surgery (Society of Thoracic Surgeons Predicted Risk of Mortality, 4.5±1.6%). At 24 months, the estimated incidence of the primary end point was 12.6% in the TAVR group and 14.0% in the surgery group (95% credible interval [Bayesian analysis] for difference, -5.2 to 2.3%; posterior probability of noninferiority, >0.999). Surgery was associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements, whereas TAVR had higher rates of residual aortic regurgitation and need for pacemaker implantation. TAVR resulted in lower mean gradients and larger aortic-valve areas than surgery. Structural valve deterioration at 24 months did not occur in either group. TAVR was a noninferior alternative to surgery in patients with severe aortic stenosis at intermediate surgical risk, with a different pattern of adverse events associated with each procedure. (Funded by Medtronic; SURTAVI ClinicalTrials.gov number, NCT01586910 .).

[Pannus Formation Two Years after Bioprosthetic Aortic Valve Implantation;Report of a Case].

PubMed

Ono, Kimiyo; Kuroda, Hiroaki

2015-08-01

We report a case of early deterioration of the bioprosthetic aortic valve 23 months postoperatively. A 77-year-old man who had undergone aortic valve replacement with a 23-mm Epic valve( St. Jude Medical [SJM])presented to us after a syncopal episode. Echocardiography revealed severe aortic stenosis, and redo aortic valve replacement with a 21-mm SJM mechanical valve was performed. All 3 cusps of the tissue valve were thickened by fibrous pannus overgrowth. Neither calcification nor invasion of inflammatory cells was observed. The cause of pannus formation at such an early stage after implantation remains unknown.

Atrioventricular and intraventricular block after transcatheter aortic valve implantation.

PubMed

Lee, Jane J; Goldschlager, Nora; Mahadevan, Vaikom S

2018-06-24

Aortic stenosis is the most common valvular heart disease in industrialized countries and the most common cause of left ventricular outflow tract (LVOT) obstruction. Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement for intermediate to high-risk surgical candidates with symptomatic severe aortic stenosis. Conduction system abnormalities, including atrioventricular (AV) and intraventricular (IV) block, are the most common complication of TAVR. In this review, we aim to explore the anatomical issues relevant to atrioventricular block, the relevant clinical and procedural aspects, and the management and long-term implications of AV and IV block.

Haemodynamic results of replacement of mitral and aortic valves with autologous fascia lata prostheses

PubMed Central

Talavlikar, P. H.; Walbaum, P. R.; Kitchin, A. H.

1973-01-01

Twelve patients undergoing aortic and 28 undergoing mitral valve replacement with autologous fascia lata valves were studied before and six months after surgery. One aortic and 10 mitral valves were found to be significantly incompetent. Of the incompetent mitral valves, two appeared to have perivalvular leaks. Six of the remainder were associated with abnormal ventricular filling patterns. Valve failure was much less common when the design was modified to provide a loose cusp structure; out of 12 such valves none was incompetent. Transvalvular gradients persist with fascial valves though they are lower than with most mechanical prostheses. Ventricular function was greatly improved in successful aortic replacement but remained impaired in the case of mitral replacement. Valve failure appeared to be associated with, or accelerated by, haemodynamic stress rather than due to inevitable degenerative pathological processes. PMID:4731108

Cardiovascular Benefits of Moderate Exercise Training in Marfan Syndrome: Insights From an Animal Model.

PubMed

Mas-Stachurska, Aleksandra; Siegert, Anna-Maria; Batlle, Monsterrat; Gorbenko Del Blanco, Darya; Meirelles, Thayna; Rubies, Cira; Bonorino, Fabio; Serra-Peinado, Carla; Bijnens, Bart; Baudin, Julio; Sitges, Marta; Mont, Lluís; Guasch, Eduard; Egea, Gustavo

2017-09-25

Marfan syndrome (MF) leads to aortic root dilatation and a predisposition to aortic dissection, mitral valve prolapse, and primary and secondary cardiomyopathy. Overall, regular physical exercise is recommended for a healthy lifestyle, but dynamic sports are strongly discouraged in MF patients. Nonetheless, evidence supporting this recommendation is lacking. Therefore, we studied the role of long-term dynamic exercise of moderate intensity on the MF cardiovascular phenotype. In a transgenic mouse model of MF ( Fbn1 C1039G/+ ), 4-month-old wild-type and MF mice were subjected to training on a treadmill for 5 months; sedentary littermates served as controls for each group. Aortic and cardiac remodeling was assessed by echocardiography and histology. The 4-month-old MF mice showed aortic root dilatation, elastic lamina rupture, and tunica media fibrosis, as well as cardiac hypertrophy, left ventricular fibrosis, and intramyocardial vessel remodeling. Over the 5-month experimental period, aortic root dilation rate was significantly greater in the sedentary MF group, compared with the wild-type group (∆mm, 0.27±0.07 versus 0.13±0.02, respectively). Exercise significantly blunted the aortic root dilation rate in MF mice compared with sedentary MF littermates (∆mm, 0.10±0.04 versus 0.27±0.07, respectively). However, these 2 groups were indistinguishable by aortic root stiffness, tunica media fibrosis, and elastic lamina ruptures. In MF mice, exercise also produced cardiac hypertrophy regression without changes in left ventricular fibrosis. Our results in a transgenic mouse model of MF indicate that moderate dynamic exercise mitigates the progression of the MF cardiovascular phenotype. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Concomitant Transapical Transcatheter Valve Implantations: Edwards Sapien Valve for Severe Mitral Regurgitation in a Patient with Failing Mitral Bioprostheses and JenaValve for the Treatment of Pure Aortic Regurgitation.

PubMed

Aydin, Unal; Gul, Mehmet; Aslan, Serkan; Akkaya, Emre; Yildirim, Aydin

2015-04-28

Transcatheter valve implantation is a novel interventional technique, which was developed as an  alternative therapy for surgical aortic valve replacement in inoperable patients with severe aortic stenosis. Despite limited experience in using transcatheter valve implantation for mitral and aortic regurgitation, transapical transcatheter aortic valve implantation and valve-in-valve implantation for degenerated mitral valve bioprosthesis can be performed in high-risk patients who are not candidates for conventional replacement surgery. In this case, we present the simultaneous transcatheter valve implantation via transapical approach for both degenerated bioprosthetic mitral valve with severe regurgitation and pure severe aortic regurgitation.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience.

PubMed

Lio, Antonio; Nicolò, Francesca; Bovio, Emanuele; Serrao, Andrea; Zeitani, Jacob; Scafuri, Antonio; Chiariello, Luigi; Ruvolo, Giovanni

2016-12-01

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch ( P =0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P =0.002), body mass index >30 kg/m 2 (OR=9.9; 95% CI, 1.28-19; P =0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P =0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P =0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% ( P =NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Outcomes of Aortic Valve-Sparing Operations in Marfan Syndrome.

PubMed

David, Tirone E; David, Carolyn M; Manlhiot, Cedric; Colman, Jack; Crean, Andrew M; Bradley, Timothy

2015-09-29

In many cardiac units, aortic valve-sparing operations have become the preferred surgical procedure to treat aortic root aneurysm in patients with Marfan syndrome, based on relatively short-term outcomes. This study examined the long-term outcomes of aortic valve-sparing operations in patients with Marfan syndrome. All patients with Marfan syndrome operated on for aortic root aneurysm from 1988 through 2012 were followed prospectively for a median of 10 years. Follow-up was 100% complete. Time-to-event analyses were calculated using the Kaplan-Meier method with log-rank test for comparisons. A total of 146 patients with Marfan syndrome had aortic valve-sparing operations. Reimplantation of the aortic valve was performed in 121 and remodeling of the aortic root was performed in 25 patients. Mean age was 35.7 ± 11.4 years and two-thirds were men. Nine patients had acute, 2 had chronic type A, and 3 had chronic type B aortic dissections before surgery. There were 1 operative and 6 late deaths, 5 caused by complications of dissections. Mortality rate at 15 years was 6.8 ± 2.9%, higher than the general population matched for age and sex. Five patients required reoperation on the aortic valve: 2 for endocarditis and 3 for aortic insufficiency. Three patients developed severe, 4 moderate, and 3 mild-to-moderate aortic insufficiency. Rate of aortic insufficiency at 15 years was 7.9 ± 3.3%, lower after reimplantation than remodeling. Nine patients developed new distal aortic dissections during follow-up. Rate of dissection at 15 years was 16.5 ± 3.4%. Aortic valve-sparing operations in patients with Marfan syndrome were associated with low rates of valve-related complications in long-term follow-up. Residual and new aortic dissections were the leading cause of death. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

PubMed Central

Valente, Acrisio Sales; Alencar, Polyanna; Santos, Alana Neiva; Lobo, Roberto Augusto de Mesquita; de Mesquita, Fernando Antônio; Guimarães, Aloyra Guedis

2013-01-01

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course. PMID:24598962

Reference Values of Aortic Root in Male and Female White Elite Athletes According to Sport.

PubMed

Boraita, Araceli; Heras, Maria-Eugenia; Morales, Francisco; Marina-Breysse, Manuel; Canda, Alicia; Rabadan, Manuel; Barriopedro, Maria-Isabel; Varela, Amai; de la Rosa, Alejandro; Tuñón, José

2016-10-01

There is limited information regarding the aortic root upper physiological limits in all planes in elite athletes according to static and dynamic cardiovascular demands and sex. A cross-sectional study was performed in 3281 healthy elite athletes (2039 men and 1242 women) aged 23.1±5.7 years, with body surface area of 1.9±0.2 m 2 and 8.9±4.9 years and 19.2±9.6 hours/week of training. Maximum end-diastolic aortic root diameters were measured in the parasternal long axis by 2-dimensional echocardiography. Age, left ventricular mass, and body surface area were the main predictors of aortic dimensions. Raw values were greater in males than in females (P<0.0001) at all aortic root levels. Dimensions corrected by body surface area were higher in men than in women at the aortic annulus (13.1±1.7 versus 12.9±1.7 mm/m 2 ; P=0.007), without significant differences at the sinus of Valsalva (16.3±1.9 versus 16.3±1.9 mm/m 2 ; P=0.797), and were smaller in men at the sinotubular junction (13.6±1.8 versus 13.8±1.8 mm/m 2 ; P=0.008) and the proximal ascending aorta (13.8±1.9 versus 14.1±1.9 mm/m 2 ; P=0.001). Only 1.8% of men and 1.5% of women had values >40 mm and 34 mm, respectively. Raw and corrected aortic measures at all levels were significantly greater in sports, with a high dynamic component in both sexes, except for corrected values of the sinotubular junction in women. Aortic root dimensions in healthy elite athletes are within the established limits for the general population. This study describes the normal dimensions for healthy elite athletes classified according to sex and dynamic and static components of their sports. © 2016 American Heart Association, Inc.

Missed aortic valve endocarditis resulting in complete atrioventricular block and redo mechanical valve replacement.

PubMed

Harky, Amer; Garner, Megan; Popa, Miruna; Shipolini, Alex

2017-08-03

Infective endocarditis is a rare disease associated with high morbidity and mortality. As a result, early diagnosis and prompt antibiotic treatment with or without surgical intervention is crucial in the management of such condition.We report a case of missed infective endocarditis of the aortic valve. The patient underwent mechanical aortic valve replacement, with the native valve being sent for histopathological examination. On re-admission 16 months later, he presented with syncope, shortness of breathing and complete heart block. On review of the histopathology of native aortic valve, endocarditis was identified which had not been acted on. The patient underwent redo aortic valve replacement for severe aortic regurgitation.We highlight the importance of following up histopathological results as well as the need for multidisciplinary treatment of endocarditis with a combination of surgical and antibiotic therapy. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Trends in Aortic Valve Replacement Procedures Between 2009 and 2015: Has Transcatheter Aortic Valve Replacement Made a Difference?

PubMed

Culler, Steven D; Cohen, David J; Brown, Phillip P; Kugelmass, Aaron D; Reynolds, Matthew R; Ambrose, Karen; Schlosser, Michael L; Simon, April W; Katz, Marc R

2018-04-01

This study reports trends in volume and adverse events associated with isolated aortic valve procedures performed in Medicare beneficiaries between 2009 and 2015. This retrospective study used the annual fiscal year Medicare Provider Analysis and Review file to identify all Medicare beneficiaries undergoing an isolated aortic valve procedure. Outcome measures included three mortality rates and nine in-hospital adverse events. The final study population consisted of 233,660 hospitalizations. During the study period, Medicare beneficiaries undergoing an aortic valve procedure increased from 22,076 to 49,362, for an average annual growth rate of 14.45%. Transcatheter aortic valve replacement (TAVR) procedures per 100,000 Medicare beneficiaries grew from 10.7 in 2012 to 41.1 in 2015. Overall, in-hospital mortality rates, cumulative 30-day mortality rates, and 90-day postdischarge mortality rates declined annually during the study period. However, the 90-day mortality rate for TAVR was nearly double the rate for the tissue surgical aortic valve replacement group. Nearly 68% of Medicare beneficiaries experienced at least one in-hospital adverse event during their index hospitalization. Medicare beneficiaries undergoing TAVR had the lowest observed adverse events rates among the aortic valve procedures in 2015. The total number of Medicare beneficiaries undergoing isolated aortic valve procedures increased from 47.5 to 88.9 per 100,000 Medicare beneficiaries during the study period. Aortic valve procedures increased significantly during this study period primarily due to the increase in TAVR, with clinical outcomes improving as well. Although long-term outcomes of TAVR are still under investigation, these results are promising. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery.

PubMed

Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki; Takamoto, Shinichi

2008-09-30

The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery. The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively. This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients.

PubMed

Leon, Martin B; Smith, Craig R; Mack, Michael J; Makkar, Raj R; Svensson, Lars G; Kodali, Susheel K; Thourani, Vinod H; Tuzcu, E Murat; Miller, D Craig; Herrmann, Howard C; Doshi, Darshan; Cohen, David J; Pichard, Augusto D; Kapadia, Samir; Dewey, Todd; Babaliaros, Vasilis; Szeto, Wilson Y; Williams, Mathew R; Kereiakes, Dean; Zajarias, Alan; Greason, Kevin L; Whisenant, Brian K; Hodson, Robert W; Moses, Jeffrey W; Trento, Alfredo; Brown, David L; Fearon, William F; Pibarot, Philippe; Hahn, Rebecca T; Jaber, Wael A; Anderson, William N; Alu, Maria C; Webb, John G

2016-04-28

Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement. We evaluated the two procedures in a randomized trial involving intermediate-risk patients. We randomly assigned 2032 intermediate-risk patients with severe aortic stenosis, at 57 centers, to undergo either TAVR or surgical replacement. The primary end point was death from any cause or disabling stroke at 2 years. The primary hypothesis was that TAVR would not be inferior to surgical replacement. Before randomization, patients were entered into one of two cohorts on the basis of clinical and imaging findings; 76.3% of the patients were included in the transfemoral-access cohort and 23.7% in the transthoracic-access cohort. The rate of death from any cause or disabling stroke was similar in the TAVR group and the surgery group (P=0.001 for noninferiority). At 2 years, the Kaplan-Meier event rates were 19.3% in the TAVR group and 21.1% in the surgery group (hazard ratio in the TAVR group, 0.89; 95% confidence interval [CI], 0.73 to 1.09; P=0.25). In the transfemoral-access cohort, TAVR resulted in a lower rate of death or disabling stroke than surgery (hazard ratio, 0.79; 95% CI, 0.62 to 1.00; P=0.05), whereas in the transthoracic-access cohort, outcomes were similar in the two groups. TAVR resulted in larger aortic-valve areas than did surgery and also resulted in lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation. In intermediate-risk patients, TAVR was similar to surgical aortic-valve replacement with respect to the primary end point of death or disabling stroke. (Funded by Edwards Lifesciences; PARTNER 2 ClinicalTrials.gov number, NCT01314313.).

Correlation between plasma N-terminal pro-brain natriuretic peptide levels and changes in New York Heart Association functional class, left atrial size, left ventricular size and function after mitral and/or aortic valve replacement.

PubMed

Elasfar, Abdelfatah

2012-01-01

Elevated plasma brain natriuretic peptide (BNP) levels have been demonstrated in patients with chronic valvular disease. We designed the present study to assess whether changes in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels after mitral, aortic and double mitral and aortic valve replacement reflect changes in heart failure (HF) symptoms including New York Heart Association (NYHA) class and changes in left atrium (LA) size, left ventricle (LV) size and LV function. A prospective observational nonrandomized study among consecutive patients undergoing mitral and/or aortic valve replacement in our center. The study population consisted of 24 patients (mean [SD] age of 55.3 [16.2] years, 58% were males) who underwent surgical mitral valve replacement (12 patients), aortic valve replacement (8 patients) and combined mitral and aortic valve replacement (4 patients). NT-proBNP measurements, transthoracic echocardiography and NYHA class assessments were performed before and 6 months after surgery. The decrease in NT-proBNP was associated with decrease in left atrial dimension (r = 0.73, P < .002), LV end-diastolic dimension (r=0.65, P=.001), LV end-systolic dimension (r=0.53, P=.036), and increase in ejection fraction (r=-0.65, P=.001) after 6 months postoperatively. Furthermore, a decreasing NT-proBNP was associated with improvement in NYHA class. NT-proBNP levels after mitral, aortic and double valve replacement correlates with changes in HF manifestations as well as changes in LA size and LV dimension and function. Thus, we hypothesize that interval measurement of the NT-proBNP level at clinic visits can allow early detection of any clinical deterioration as well as the possibility of assessment of the long-term outcome of those patients.

New Paradigms and Improved Results for the Surgical Treatment of Acute Type A Dissection

PubMed Central

Bavaria, Joseph E.; Pochettino, Alberto; Brinster, Derek R.; Gorman, Robert C.; McGarvey, Michael L.; Gorman, Joseph H.; Escherich, Alison; Gardner, Timothy J.

2001-01-01

Objective To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Summary Background Data Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. Methods From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt “neo-media”; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt “neo-media” and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). Results Mean age was 59 ± 15 (range 22–86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 ± 50 minutes. Mean HCA with RCP time was 42 ± 12 minutes (range 19–84). Mean cardiac ischemic time was 140 ± 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. Conclusion The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair. PMID:11524586

The value of aortic valve replacement in elderly patients: an economic analysis.

PubMed

Wu, YingXing; Grunkemeier, Gary L; Starr, Albert

2007-03-01

Economists have designed frameworks to measure the economic value of improvements in health and longevity. Heart valve replacement surgery has significantly prolonged life expectancy and quality of life. For the example of aortic valve replacement, what is its economic value according to this framework? From 1961 through 2003, a total of 4617 adult patients underwent aortic valve replacement by one team of cardiac surgeons. These patients were provided with a prospective lifetime follow-up service. As of 2005, observed follow-up was 31,671 patient-years, with a maximum of 41 years. A statistical model was used to generate the future life-years of patients currently alive. The value of life-years proposed by economists was applied to determine the economic value of the additional life given to these patients by aortic valve replacement. The total life-years after aortic valve replacement were 53,323, with a gross value of 14.6 billion dollars. The total expected life-years without surgery were 10,157, with an estimated value of 3.0 billion dollars. Thus the net life-years gained by AVR were 43,166, worth 11.6 billion dollars. Subtracting the 451 million dollars total lifetime cost of surgery, the net value of the life-years gained by AVR was 11.2 billion dollars. The mean net value decreases according to age at surgery but is still worth 600,000 dollars for octogenarians and 200,000 dollars for nonagenarians. According to the economic concept of the value of a statistical life, the return on the investment for aortic valve replacement is enormous for patients of all ages, even very elderly patients.

Aortic valve replacement and tricuspid valve annuloplasty via a left thoracotomy in an adult with left pulmonary agenesis.

PubMed

Furutachi, Akira; Furukawa, Kojiro; Shimauchi, Kouta; Yunoki, Junji; Itoh, Manabu; Takamatsu, Masanori; Nogami, Eijiro; Mukae, Yosuke; Nishida, Takahiro

2018-06-06

We report a case of a 66-year-old man who was diagnosed with severe aortic regurgitation, moderate tricuspid regurgitation and chronic atrial fibrillation. Preoperative computed tomography showed left lung agenesis. We performed aortic valve replacement, tricuspid valve annuloplasty and right pulmonary vein isolation via a left thoracotomy. This approach provided an adequate field of view.

Transcatheter aortic valve replacement

MedlinePlus

... fully will restrict blood flow. This is called aortic stenosis. If there is also a leak, it is ... TAVR is used for people with severe aortic stenosis who aren't ... valve . In adults, aortic stenosis usually occurs due to calcium ...

Pledget-Armed Sutures Affect the Haemodynamic Performance of Biologic Aortic Valve Substitutes: A Preliminary Experimental and Computational Study.

PubMed

Capelli, Claudio; Corsini, Chiara; Biscarini, Dario; Ruffini, Francesco; Migliavacca, Francesco; Kocher, Alfred; Laufer, Guenther; Taylor, Andrew M; Schievano, Silvia; Andreas, Martin; Burriesci, Gaetano; Rath, Claus

2017-03-01

Surgical aortic valve replacement is the most common procedure of choice for the treatment of severe aortic stenosis. Bioprosthetic valves are traditionally sewed-in the aortic root by means of pledget-armed sutures during open-heart surgery. Recently, novel bioprostheses which include a stent-based anchoring system have been introduced to allow rapid implantation, therefore reducing the duration and invasiveness of the intervention. Different effects on the hemodynamics were clinically reported associated with the two technologies. The aim of this study was therefore to investigate whether the differences in hemodynamic performances are an effect of different anchoring systems. Two commercially available bio-prosthetic aortic valves, one sewed-in with pledget-armed sutures and one rapid-deployment, were thus tested in this study by means of a combined approach of experimental and computational tools. In vitro experiments were performed to evaluate the overall hydrodynamic performance under identical standard conditions; computational fluid dynamics analyses were set-up to explore local flow variations due to different design of the anchoring system. The results showed how the performance of cardiac valve substitutes is negatively affected by the presence of pledget-armed sutures. These are causing flow disturbances, which in turn increase the mean pressure gradient and decrease the effective orifice area. The combined approach of experiments and numerical simulations can be effectively used to quantify the detailed relationship between local fluid-dynamics and overall performances associated with different valve technologies.

Aortic valve replacement and concomitant right coronary artery bypass grafting performed via a right minithoracotomy approach.

PubMed

Mihos, Christos G; Santana, Orlando; Pineda, Andres M; La Pietra, Angelo; Lamelas, Joseph

2014-01-01

We present our experience of concomitant right coronary artery bypass grafting (CABG) and aortic valve replacement performed via a right minithoracotomy in patients with coronary lesions not amenable to percutaneous intervention. A total of 17 patients underwent concomitant aortic valve replacement and right CABG between April 2008 and July 2013. A 5- to 6-cm minithoracotomy incision was made over the right second or third intercostal space, and the costochondral cartilage was transected. A saphenous vein bypass to the right coronary artery was then performed, initiating the anastomosis from the toe of the graft. Subsequently, the aortic valve was replaced using standard techniques. There were 6 men and 11 women. The median European System for Cardiac Operative Risk Evaluation II score mortality risk was 5% [interquartile range (IQR), 2%-8%]. The mean (SD) age was 77 (10) years, the left ventricular ejection fraction was 59% (8%), and the New York Heart Association functional class was 2.4 (0.8). One patient had a history of CABG. The mean (SD) cardiopulmonary bypass time was 168 (57) minutes, and the aortic cross-clamp time was 133 (36) minutes. Three patients underwent concomitant mitral valve surgery (replacement, 2; repair, 1). The median intensive care unit and hospital lengths of stay were 47 hours (IQR, 24-90) and 9 days (IQR, 5-13), respectively. There was one reoperation for bleeding, and there was one postoperative stroke. All patients were alive at a mean (SD) follow-up of 2 (1.1) years. Aortic valve replacement with concomitant CABG performed via a right minithoracotomy approach is feasible.

The effects of contrast media volume on acute kidney injury after transcatheter aortic valve replacement: a systematic review and meta-analysis.

PubMed

Thongprayoon, Charat; Cheungpasitporn, Wisit; Podboy, Alexander J; Gillaspie, Erin A; Greason, Kevin L; Kashani, Kianoush B

2016-11-01

The goal of this systematic review was to assess the effects of contrast media volume on transcatheter aortic valve replacement-related acute kidney injury. A literature search was performed using Medline, EMbase, the Cochrane Database of Systematic Reviews, and clinicaltrials.gov from the inception of these databases through December 2015. Studies that reported relative risk, odds ratio, or hazard ratio comparing the risks of acute kidney injury following transcatheter aortic valve replacement in patients who received high contrast media volume were included. Pooled risk ratio (RR) and 95% confidence intervals (95% CI) were calculated using a random-effect, generic inverse variance method. Four cohort studies composed of 891 patients were included in the analyses to assess the risk of acute kidney injury after transcatheter aortic valve replacement in patients who received high contrast media volume. The pooled RR of acute kidney injury after transcatheter aortic valve replacement in patients who received a large volume of contrast media was 1.41 (95% CI, 0.87 to 2.28) compared with low contrast media volume. The meta-analysis was limited to studies using standard acute kidney injury definitions, and the pooled RR of acute kidney injury in patients who received high contrast media volume is 1.12 (95% CI, 0.78 to 1.62). Our meta-analysis shows no significant association between contrast media volume and risk of acute kidney injury after transcatheter aortic valve replacement. © 2016 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.

Minimally invasive aortic valve replacement – pros and cons of keyhole aortic surgery

PubMed Central

Szałański, Przemysław; Zembala, Michał; Filipiak, Krzysztof; Karolak, Wojciech; Wojarski, Jacek; Garbacz, Marcin; Kaczmarczyk, Aleksandra; Kwiecień, Anna; Zembala, Marian

2015-01-01

Over the last twenty years, minimally invasive aortic valve replacement (MIAVR) has evolved into a safe, well-tolerated and efficient surgical treatment option for aortic valve disease. It has been shown to reduce postoperative morbidity, providing faster recovery and rehabilitation, shorter hospital stay and better cosmetic results compared with conventional surgery. A variety of minimally invasive accesses have been developed and utilized to date. This concise review demonstrates and discusses surgical techniques used in contemporary approaches to MIAVR and presents the most important results of MIAVR procedures. PMID:26336491

Recent Clinical Drug Trials Evidence in Marfan Syndrome and Clinical Implications.

PubMed

Singh, Michael N; Lacro, Ronald V

2016-01-01

Marfan syndrome is a genetic disorder of connective tissue with principal manifestations in the cardiovascular, ocular, and skeletal systems. Cardiovascular disease, mainly progressive aortic root dilation and aortic dissection, is the leading cause of morbidity and mortality. The primary aims of this report were to examine the evidence related to medical therapy for Marfan syndrome, including recently completed randomized clinical trials on the efficacy of β-blockers and angiotensin II receptor blockers for the prophylactic treatment of aortic enlargement in Marfan syndrome, and to provide recommendations for medical therapy on the basis of available evidence. Medical therapy for Marfan syndrome should be individualized according to patient tolerance and risk factors such as age, aortic size, and family history of aortic dissection. The Pediatric Heart Network trial showed that atenolol and losartan each reduced the rate of aortic dilation. All patients with known or suspected Marfan syndrome and aortic root dilation should receive medical therapy with adequate doses of either β-blocker or angiotensin receptor blocker. The Pediatric Heart Network trial also showed that atenolol and losartan are more effective at reduction of aortic root z score in younger subjects, which suggests that medical therapy should be prescribed even in the youngest children with aortic dilation. For patients with Marfan syndrome without aortic dilation, the available evidence is less clear. If aortic dilation is severe and/or progressive, therapy with a combination of β-blocker and angiotensin receptor blocker should be considered, although trial results are mixed with respect to the efficacy of combination therapy vs monotherapy. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Society of Thoracic Surgeons Risk Score predicts hospital charges and resource use after aortic valve replacement.

PubMed

Arnaoutakis, George J; George, Timothy J; Alejo, Diane E; Merlo, Christian A; Baumgartner, William A; Cameron, Duke E; Shah, Ashish S

2011-09-01

The impact of Society of Thoracic Surgeons predicted mortality risk score on resource use has not been previously studied. We hypothesize that increasing Society of Thoracic Surgeons risk scores in patients undergoing aortic valve replacement are associated with greater hospital charges. Clinical and financial data for patients undergoing aortic valve replacement at The Johns Hopkins Hospital over a 10-year period (January 2000 to December 2009) were reviewed. The current Society of Thoracic Surgeons formula (v2.61) for in-hospital mortality was used for all patients. After stratification into risk quartiles, index admission hospital charges were compared across risk strata with rank-sum and Kruskal-Wallis tests. Linear regression and Spearman's coefficient assessed correlation and goodness of fit. Multivariable analysis assessed relative contributions of individual variables on overall charges. A total of 553 patients underwent aortic valve replacement during the study period. Average predicted mortality was 2.9% (±3.4) and actual mortality was 3.4% for aortic valve replacement. Median charges were greater in the upper quartile of patients undergoing aortic valve replacement (quartiles 1-3, $39,949 [interquartile range, 32,708-51,323] vs quartile 4, $62,301 [interquartile range, 45,952-97,103], P < .01]. On univariate linear regression, there was a positive correlation between Society of Thoracic Surgeons risk score and log-transformed charges (coefficient, 0.06; 95% confidence interval, 0.05-0.07; P < .01). Spearman's correlation R-value was 0.51. This positive correlation persisted in risk-adjusted multivariable linear regression. Each 1% increase in Society of Thoracic Surgeons risk score was associated with an added $3000 in hospital charges. This is the first study to show that increasing Society of Thoracic Surgeons risk score predicts greater charges after aortic valve replacement. As competing therapies, such as percutaneous valve replacement, emerge to treat high-risk patients, these results serve as a benchmark to compare resource use. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Thromboembolism in patients with pericardial valves in the absence of chronic anticoagulation: 12 years' experience.

PubMed

García-Bengoechea, J B; González-Juanatey, J R; Rubio, J; Durán, D; Sierra, J

1991-01-01

Between January 1977 and January 1989, 465 pericardial bioprostheses were implanted in 424 patients. The mean age of patients was 59.1 years (range 16-81 y.) At the time of surgery, 68% of the patients suffered from chronic atrial fibrillation. Mitral valve replacement was performed in 167 patients, aortic valve replacement in 216, multiple replacement in 40 (36 mitral and aortic, 3 mitral and tricuspid, and 1 mitral, aortic and tricuspid), and 1 pulmonary valve replacement. The different types of pericardial valve used were: Ionescu-Shiley 408, Mitral Medical 23, Bioflo 30, and Hancock 4. Hospital mortality was 10.1% with an attrition rate of 1.8 episodes per 100 patients/year. The 12-year actuarial survival rate was 65.1%. No patient underwent long-term anticoagulant treatment. The first 144 patients undergoing mitral and multiple valve replacements received temporary anticoagulation for the first 8 weeks after surgery. There was no valve thrombosis observed. Altogether 19 thromboembolic events (6 early and 13 late) were clinically documented. One patient died after an embolic event. The linearized rates of thromboembolism were 1.64 episodes per 100 patients/year for mitral and multiple valve replacements and 0.33 episodes per 100 patients/year for aortic valve replacement, with an overall rate of 1.0 episodes per 100 patients/year. Excluding early thromboembolism, the linearized rate was 1.02 episodes per 100 patients/year overall. The actuarial freedom from embolism was 92.4% overall, 88.2% for the mitral and multiple valve replacement group, and 97.6% for the aortic valve replacement group at a maximum follow-up of 12 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency aortic valve replacement and Caesarian section in a primigravida with severe aortic stenosis: a case report.

PubMed

Kochhar, Puneet K; Zutshi, V; Shamsunder, S; Batra, S; Ghosh, P

2011-01-01

Congenital bicuspid aortic valve with severe aortic stenosis (AS) is a rare condition (3-6% of patients with congenital heart disease). Pregnancy in these patients carries a high risk of maternal and fetal mortality. With advancing gestational age, these women may develop cardiac failure due to increased cardiorespiratory requirements. When medical therapy proves insufficient, cardiac surgery becomes mandatory to save the patient's life. Balloon valvuloplasty is only palliative treatment, the duration of benefit being only 6 months. Valve replacement is thus recommended. Cardiopulmonary bypass (CPB) surgery with valve replacement has been reported to carry a lower risk of maternal mortality (1.5-13%) but a very high fetal risk (16-40%). This paper reports the case of a 30-year-old primigravida with severe AS with bicuspid aortic valve and pulmonary congestion clinically uncontrolled, in whom CPB surgery and aortic valve replacement was performed as an emergency procedure, along with a lower segment Caesarian section. The outcome of unrelieved severe symptomatic AS in pregnancy is poor. Multidisciplinary management is important to avoid deterioration in cardiac performance in parturients with severe AS. CPB during pregnancy carries a high risk to the fetus. Therefore, open heart surgery during pregnancy should be advised only in extreme emergencies (ie, heart failure refractory to conventional therapy).

Aortic elasticity and left ventricular function after arterial switch operation: MR imaging--initial experience.

PubMed

Grotenhuis, Heynric B; Ottenkamp, Jaap; Fontein, Duveken; Vliegen, Hubert W; Westenberg, Jos J M; Kroft, Lucia J M; de Roos, Albert

2008-12-01

To prospectively assess aortic dimensions, aortic elasticity, aortic valve competence, and left ventricular (LV) systolic function in patients after the arterial switch operation (ASO) by using magnetic resonance (MR) imaging. Informed consent was obtained from all participants for this local ethics committee-approved study. Fifteen patients (11 male patients, four female patients; mean age, 16 years +/- 4 [standard deviation]; imaging performed 16.1 years after surgery +/- 3.7) and 15 age- and sex-matched control subjects (11 male subjects, four female subjects; mean age, 16 years +/- 4) were evaluated. Velocity-encoded MR imaging was used to assess aortic pulse wave velocity (PWV), and a balanced turbo-field-echo sequence was used to assess aortic root distensibility. Standard velocity-encoded and multisection-multiphase imaging sequences were used to assess aortic valve function, systolic LV function, and LV mass. The two-tailed Mann-Whitney U test and Spearman rank correlation coefficient were used for statistical analysis. Patients treated with the ASO showed aortic root dilatation at three predefined levels (mean difference, 5.7-9.4 mm; P < or = .007) and reduced aortic elasticity (PWV of aortic arch, 5.1 m/sec +/- 1.2 vs 3.9 m/sec +/- 0.7, P = .004; aortic root distensibility, [2.2 x 10(-3)] x mm Hg(-1) +/- 1.8 vs [4.9 x 10(-3)] x mm Hg(-1) +/- 2.9, P < .01) compared with control subjects. Minor degrees of aortic regurgitation (AR) were present (AR fraction, 5% +/- 3 in patients vs 1% +/- 1 in control subjects; P < .001). Patients had impaired systolic LV function (LV ejection fraction [LVEF], 51% +/- 6 vs 58% +/- 5 in control subjects; P = .003), in addition to enlarged LV dimensions (end-diastolic volume [EDV], 112 mL/m(2) +/- 13 vs 95 mL/m(2) +/- 16, P = .007; end-systolic volume [ESV], 54 mL/m(2) +/- 11 vs 39 mL/m(2) +/- 7, P < .001). Degree of AR predicted decreased LVEF (r = 0.41, P = .026) and was correlated with increased LV dimensions (LV EDV: r = 0.48, P = .008; LV ESV: r = 0.67, P < .001). Aortic root dilatation and reduced elasticity of the proximal aorta are frequently observed in patients who have undergone the ASO, in addition to minor degrees of AR, reduced LV systolic function, and increased LV dimensions. RSNA, 2008

Evaluation and Influence of Brachiocephalic Branch Re-entry in Patients With Type A Acute Aortic Dissection.

PubMed

Yasuda, Shota; Imoto, Kiyotaka; Uchida, Keiji; Karube, Norihisa; Minami, Tomoyuki; Goda, Motohiko; Suzuki, Shinichi; Masuda, Munetaka

2016-12-22

Stanford type A acute aortic dissection (A-AAD) extends to the brachiocephalic branches in some patients. After ascending aortic replacement, a remaining re-entry tear in the distal brachiocephalic branches may act as an entry and result in a patent false lumen in the aortic arch. However, the effect of brachiocephalic branch re-entry concomitant with A-AAD remains unknown.Methods and Results:Eighty-five patients with A-AAD who underwent ascending aortic replacement in which both preoperative and postoperative multiple-detector computed tomography (MDCT) scans could be evaluated were retrospectively studied. The presence of a patent false lumen in at least one of the brachiocephalic branches on preoperative MDCT was defined as brachiocephalic branch re-entry, and 41 patients (48%) had this. Postoperatively, 47 of 85 (55%) patients had a patent false lumen in the aortic arch. False lumen remained patent after operation in 34 out of the 41 (83%) patients with brachiocephalic branch re-entry, as compared to that in 13 of the 44 (30%) patients without such re-entry (P<0.001). Brachiocephalic branch re-entry was a significant risk factor for a late increase in the aortic arch diameter greater than 10 mm (P=0.047). Brachiocephalic branch re-entry in patients with A-AAD is related to a patent false lumen in the aortic arch early after ascending aortic replacement and is a risk factor for late aortic arch enlargement.

Pledget Induced Cardiogenic Shock Following a Minimally Invasive Aortic Valve Replacement.

PubMed

Tedesco, Alexandra E; Tedesco, Victor E

2017-01-01

Within the last decade, minimally invasive valve replacements have become exceedingly popular, and as a result, so has the rise of technology aimed at refining and simplifying these techniques. With new technology, new complications are inevitable. We present a routine Minimally invasive aortic valve replacement through a right anterior minithoracotomy complicated by pledget impaction in a coronary artery.

Pregnancy with aortic dissection in Ehler-Danlos syndrome. Staged replacement of the total aorta (10-year follow-up).

PubMed

Babatasi, G; Massetti, M; Bhoyroo, S; Khayat, A

1997-10-01

Pregnancy complicated by aortic dissection in patients with hereditary disorder of connective tissue presents interesting considerations including management of caesarean section with the unexpected need for cardiac surgery in emergency. Generalizations can be made on management principles with long-term follow-up requiring an aggressive individualized approach by a multidisciplinary team. A 33-year-old parturient presenting an aortic dissection at 37 weeks gestation required prompt diagnosis of Ehlers-Danlos syndrome in combination with correct surgical therapy resulted in the survival of both the mother and infant. During the 10-year follow-up, multiple complex dissection required transverse aortic arch and thoracoabdominal aortic replacement.

Aortic expansion rate in patients with dilated post-stenotic ascending aorta submitted only to aortic valve replacement long-term follow-up.

PubMed

Gaudino, Mario; Anselmi, Amedeo; Morelli, Mauro; Pragliola, Claudio; Tsiopoulos, Vasileios; Glieca, Franco; Possati, Gianfederico

2011-08-02

This study was conceived to describe the evolution of aortic dimensions in patients with moderate post-stenotic ascending aorta dilation (50 to 59 mm) submitted to aortic valve replacement (AVR) alone. The appropriate treatment of post-stenotic ascending aorta dilation has been poorly investigated. Ninety-three patients affected by severe isolated calcific aortic valve stenosis in the tricuspid aortic valve accompanied by moderate dilation of the ascending aorta (50 to 59 mm) were submitted to AVR only. All patients were followed for a mean of 14.7 ± 4.8 years by means of periodic clinical evaluations and echocardiography and tomography scans of the thorax. Operative mortality was 1.0% (1 patient). During the follow-up, 16 patients died and 2 had to be reoperated for valve dysfunction. No patients experienced acute aortic events (rupture, dissection, pseudoaneurysm), and no patient had to be reoperated on the aorta. There was not a substantial increase in aortic dimensions: mean aortic diameter was 57 ± 11 mm at the end of the follow-up versus 56 ± 02 mm pre-operatively (p = NS). The mean ascending aorta expansion rate was 0.3 ± 0.2 mm/year. In the absence of connective tissue disorders, AVR alone is sufficient to prevent further aortic expansion in patients with moderate post-stenotic dilation of the ascending aorta. Aortic replacement can probably be reserved for patients with a long life expectancy. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Dietary fatty acids on aortic root calcification in mice with metabolic syndrome.

PubMed

Naranjo, Maria C; Bermudez, Beatriz; Garcia, Indara; Lopez, Sergio; Abia, Rocio; Muriana, Francisco J G; Montserrat-de la Paz, Sergio

2017-04-19

Metabolic syndrome (MetS) is associated with obesity, dyslipidemia, type 2 diabetes, and chronic low-grade inflammation. The aim of this study was to determine the role of high-fat low-cholesterol diets (HFLCDs) rich in SFAs (HFLCD-SFAs), MUFAs (HFLCD-MUFAs) or MUFAs plus omega-3 long-chain PUFAs (HFLCD-PUFAs) on vascular calcification by the modulation of the RANKL/RANK/OPG system in the aortic roots of Lep ob/ob LDLR -/- mice. Animals fed with HFLCD-SFAs had increased weight and a greater atheroma plaque size, calcification, and RANKL/CATHK expression in the aortic root than mice on MUFA-enriched diets, with an increasing OPG expression in the aortic roots of the latter. Our study demonstrates that compared to dietary SFAs, MUFAs from olive oil protect against atherosclerosis by interfering with vascular calcification via the RANKL/RANK/OPG system in the setting of MetS. These findings open opportunities for developing novel nutritional strategies with olive oil as the most important dietary source of MUFAs (notably oleic acid) to prevent cardiovascular complications in MetS.

Rapid prototyping of compliant human aortic roots for assessment of valved stents.

PubMed

Kalejs, Martins; von Segesser, Ludwig Karl

2009-02-01

Adequate in-vitro training in valved stents deployment as well as testing of the latter devices requires compliant real-size models of the human aortic root. The casting methods utilized up to now are multi-step, time consuming and complicated. We pursued a goal of building a flexible 3D model in a single-step procedure. We created a precise 3D CAD model of a human aortic root using previously published anatomical and geometrical data and printed it using a novel rapid prototyping system developed by the Fab@Home project. As a material for 3D fabrication we used common house-hold silicone and afterwards dip-coated several models with dispersion silicone one or two times. To assess the production precision we compared the size of the final product with the CAD model. Compliance of the models was measured and compared with native porcine aortic root. Total fabrication time was 3 h and 20 min. Dip-coating one or two times with dispersion silicone if applied took one or two extra days, respectively. The error in dimensions of non-coated aortic root model compared to the CAD design was <3.0% along X, Y-axes and 4.1% along Z-axis. Compliance of a non-coated model as judged by the changes of radius values in the radial direction by 16.39% is significantly different (P<0.001) from native aortic tissue--23.54% at the pressure of 80-100 mmHg. Rapid prototyping of compliant, life-size anatomical models with the Fab@Home 3D printer is feasible--it is very quick compared to previous casting methods.

Early signs that predict later haemodynamically significant patent ductus arteriosus.

PubMed

Engür, Defne; Deveci, Murat; Türkmen, Münevver K

2016-03-01

Our aim was to determine the optimal cut-off values, sensitivity, specificity, and diagnostic power of 12 echocardiographic parameters on the second day of life to predict subsequent ductal patency. We evaluated preterm infants, born at ⩽32 weeks of gestation, starting on their second day of life, and they were evaluated every other day until ductal closure or until there were clinical signs of re-opening. We measured transductal diameter; pulmonary arterial diastolic flow; retrograde aortic diastolic flow; pulsatility index of the left pulmonary artery and descending aorta; left atrium and ventricle/aortic root ratio; left ventricular output; left ventricular flow velocity time integral; mitral early/late diastolic flow; and superior caval vein diameter and flow as well as performed receiver operating curve analysis. Transductal diameter (>1.5 mm); pulmonary arterial diastolic flow (>25.6 cm/second); presence of retrograde aortic diastolic flow; ductal diameter by body weight (>1.07 mm/kg); left pulmonary arterial pulsatility index (⩽0.71); and left ventricle to aortic root ratio (>2.2) displayed high sensitivity and specificity (p0.9). Parameters with moderate sensitivity and specificity were as follows: left atrial to aortic root ratio; left ventricular output; left ventricular flow velocity time integral; and mitral early/late diastolic flow ratio (p0.05) had low diagnostic value. Left pulmonary arterial pulsatility index, left ventricle/aortic root ratio, and ductal diameter by body weight are useful adjuncts offering a broader outlook for predicting ductal patency.

Calcification Characteristics of Low-Flow Low-Gradient Severe Aortic Stenosis in Patients Undergoing Transcatheter Aortic Valve Replacement

PubMed Central

Stähli, Barbara E.; Nguyen-Kim, Thi Dan Linh; Gebhard, Cathérine; Frauenfelder, Thomas; Tanner, Felix C.; Nietlispach, Fabian; Maisano, Francesco; Falk, Volkmar; Lüscher, Thomas F.; Maier, Willibald; Binder, Ronald K.

2015-01-01

Low-flow low-gradient severe aortic stenosis (LFLGAS) is associated with worse outcomes. Aortic valve calcification patterns of LFLGAS as compared to non-LFLGAS have not yet been thoroughly assessed. 137 patients undergoing transcatheter aortic valve replacement (TAVR) with preprocedural multidetector computed tomography (MDCT) and postprocedural transthoracic echocardiography were enrolled. Calcification characteristics were assessed by MDCT both for the total aortic valve and separately for each leaflet. 34 patients had LFLGAS and 103 non-LFLGAS. Total aortic valve calcification volume (p < 0.001), mass (p < 0.001), and density (p = 0.004) were lower in LFLGAS as compared to non-LFLGAS patients. At 30-day follow-up, mean transaortic pressure gradients and more than mild paravalvular regurgitation did not differ between groups. In conclusion, LFLGAS and non-LFLGAS express different calcification patterns which, however, did not impact on device success after TAVR. PMID:26435875

Focused physician-performed echocardiography in sports medicine: a potential screening tool for detecting aortic root dilatation in athletes.

PubMed

Yim, Eugene S; Kao, Daniel; Gillis, Edward F; Basilico, Frederick C; Corrado, Gianmichael D

2013-12-01

The purpose of this study was to investigate whether sports medicine physicians can obtain accurate measurements of the aortic root in young athletes. Twenty male collegiate athletes, aged 18 to 21 years, were prospectively enrolled. Focused echocardiography was performed by a board-certified sports medicine physician and a medical student, followed by comprehensive echocardiography within 2 weeks by a cardiac sonographer. A left parasternal long-axis view was acquired to measure the aortic root diameter at the sinuses of Valsalva. Intraclass correlation coefficients (ICCs) were used to assess inter-rater reliability compared to a reference standard and intra-rater reliability of repeated measurements obtained by the sports medicine physician and medical student. The ICCs between the sports medicine physician and cardiac sonographer and between the medical student and cardiac sonographer were strong: 0.80 and 0.76, respectively. Across all 3 readers, the ICC was 0.89, indicating strong inter-rater reliability and concordance. The ICC for the 2 measurements taken by the sports medicine physician for each athlete was 0.75, indicating strong intra-rater reliability. The medical student had moderate intra-rater reliability, with an ICC of 0.59. Sports medicine physicians are able to obtain measurements of the aortic root by focused echocardiography that are consistent with those obtained by a cardiac sonographer. Focused physician-performed echocardiography may serve as a promising technique for detecting aortic root dilatation and may contribute in this manner to preparticipation cardiovascular screening for athletes.

Survival after Aortic Valve Replacement with Bovine or Porcine Valve Prostheses: A Systematic Review and Meta-Analysis.

PubMed

Glaser, Natalie; Jackson, Veronica; Franco-Cereceda, Anders; Sartipy, Ulrik

2018-05-17

 Bovine and porcine bioprostheses are commonly used for surgical aortic valve replacement. It is unknown if the long-term survival differs between the two valve types.We performed a systematic review and meta-analysis to compare survival in patients who underwent aortic valve replacement and received a bovine or a porcine prosthesis.  We performed a systematic search of Medline, Embase, Web of Science, and the Cochrane Library. Cohort studies that compared survival between patients who underwent aortic valve replacement and received either a bovine or a porcine bioprosthesis and that reported overall long-term survival with hazard ratio (HR) and 95% confidence interval (CI) were included. Two authors independently reviewed articles considered for inclusion, extracted the information from each study, and performed the quality assessment. We performed a meta-analysis using a random effects model to calculate the pooled HR (95% CI) for all-cause mortality. We did sensitivity analyses to assess the robustness of our findings.  Seven studies published between 2010 and 2015 were included, and the combined study population was 49,190 patients. Of these, 32,235 (66%) received a bovine, and 16,955 (34%) received a porcine bioprosthesis. There was no significant difference in all-cause mortality between patients who received a bovine compared with a porcine bioprosthesis (pooled HR 1.00, 95% CI: 0.92-1.09). Heterogeneity between studies was moderate (55.8%, p  = 0.04).  This systematic review and meta-analysis suggest no difference in survival between patients who received a bovine versus a porcine bioprosthesis after aortic valve replacement. Our study provides valuable evidence for the continuing use of both bovine and porcine bioprosthetic valves for surgical aortic valve replacement. Georg Thieme Verlag KG Stuttgart · New York.

Abscisic acid ameliorates atherosclerosis by suppressing macrophage and CD4+ T cell recruitment into the aortic wall

PubMed Central

Guri, Amir J.; Misyak, Sarah A.; Hontecillas, Raquel; Hasty, Alyssa; Liu, Dongmin; Si, Hongwei; Bassaganya-Riera, Josep

2009-01-01

Abscisic acid (ABA) is a natural phytohormone which improves insulin sensitivity and reduces adipose tissue inflammation when supplemented into diets of obese mice. The objective of this study was to investigate the mechanisms by which abscisic acid (ABA) prevents or ameliorates atherosclerosis. Apolipoprotein E-deficient (ApoE −/−) mice were fed high-fat diets with or without ABA for 84 days. Systolic blood pressure was assessed on days 0, 28, 56, and 72. Gene expression, immune cell infiltration, and histological lesions were evaluated in the aortic root wall. Human aortic endothelial cells were used to examine the effect of ABA on 3’, 5’-cyclic adenosine monophosphate (cAMP) and nitric oxide (NO) production in vitro. We report that ABA-treated mice had significantly improved systolic blood pressure and decreased accumulation of F4/80+CD11b+ macrophages and CD4+ T cells in aortic root walls. At the molecular level, ABA significantly enhanced aortic endothelial nitric oxide synthase (eNOS) and tended to suppress aortic vascular cell adhesion molecule-1 (VCAM-1) and monocyte chemoattractant protein-1 (MCP-1) expression and plasma MCP-1 concentrations. ABA also caused a dose-dependent increase in intracellular concentrations of cAMP and NO and upregulated eNOS mRNA expression in human aortic endothelial cells. This is the first report showing that ABA prevents or ameliorates atherosclerosis-induced hypertension, immune cell recruitment into the aortic root wall, and upregulates aortic eNOS expression in ApoE−/− mice. PMID:20092994

Abscisic acid ameliorates atherosclerosis by suppressing macrophage and CD4+ T cell recruitment into the aortic wall.

PubMed

Guri, Amir J; Misyak, Sarah A; Hontecillas, Raquel; Hasty, Alyssa; Liu, Dongmin; Si, Hongwei; Bassaganya-Riera, Josep

2010-12-01

Abscisic acid (ABA) is a natural phytohormone which improves insulin sensitivity and reduces adipose tissue inflammation when supplemented into diets of obese mice. The objective of this study was to investigate the mechanisms by which ABA prevents or ameliorates atherosclerosis. apolipoprotein E-deficient (ApoE(-/-)) mice were fed high-fat diets with or without ABA for 84 days. Systolic blood pressure was assessed on Days 0, 28, 56 and 72. Gene expression, immune cell infiltration and histological lesions were evaluated in the aortic root wall. Human aortic endothelial cells were used to examine the effect of ABA on 3',5'-cyclic adenosine monophosphate (cAMP) and nitric oxide (NO) production in vitro. We report that ABA-treated mice had significantly improved systolic blood pressure and decreased accumulation of F4/80(+)CD11b(+) macrophages and CD4(+) T cells in aortic root walls. At the molecular level, ABA significantly enhanced aortic endothelial nitric oxide synthase (eNOS) and tended to suppress aortic vascular cell adhesion molecule-1 (VCAM-1) and monocyte chemoattractant protein-1 (MCP-1) expression and plasma MCP-1 concentrations. ABA also caused a dose-dependent increase in intracellular concentrations of cAMP and NO and up-regulated eNOS mRNA expression in human aortic endothelial cells. This is the first report showing that ABA prevents or ameliorates atherosclerosis-induced hypertension, immune cell recruitment into the aortic root wall and up-regulates aortic eNOS expression in ApoE(-/-) mice. Copyright © 2010 Elsevier Inc. All rights reserved.

Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery.

PubMed

Popma, Jeffrey J; Adams, David H; Reardon, Michael J; Yakubov, Steven J; Kleiman, Neal S; Heimansohn, David; Hermiller, James; Hughes, G Chad; Harrison, J Kevin; Coselli, Joseph; Diez, Jose; Kafi, Ali; Schreiber, Theodore; Gleason, Thomas G; Conte, John; Buchbinder, Maurice; Deeb, G Michael; Carabello, Blasé; Serruys, Patrick W; Chenoweth, Sharla; Oh, Jae K

2014-05-20

This study sought to evaluate the safety and efficacy of the CoreValve transcatheter heart valve (THV) for the treatment of severe aortic stenosis in patients at extreme risk for surgery. Untreated severe aortic stenosis is a progressive disease with a poor prognosis. Transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis is a potentially effective therapy. We performed a prospective, multicenter, nonrandomized investigation evaluating the safety and efficacy of self-expanding TAVR in patients with symptomatic severe aortic stenosis with prohibitive risks for surgery. The primary endpoint was a composite of all-cause mortality or major stroke at 12 months, which was compared with a pre-specified objective performance goal (OPG). A total of 41 sites in the United States recruited 506 patients, of whom 489 underwent attempted treatment with the CoreValve THV. The rate of all-cause mortality or major stroke at 12 months was 26.0% (upper 2-sided 95% confidence bound: 29.9%) versus 43.0% with the OPG (p < 0.0001). Individual 30-day and 12-month events included all-cause mortality (8.4% and 24.3%, respectively) and major stroke (2.3% and 4.3%, respectively). Procedural events at 30 days included life-threatening/disabling bleeding (12.7%), major vascular complications (8.2%), and need for permanent pacemaker placement (21.6%). The frequency of moderate or severe paravalvular aortic regurgitation was lower 12 months after self-expanding TAVR (4.2%) than at discharge (10.7%; p = 0.004 for paired analysis). TAVR with a self-expanding bioprosthesis was safe and effective in patients with symptomatic severe aortic stenosis at prohibitive risk for surgical valve replacement. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902). Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Proximal thoracic aorta dimensions after continuous-flow left ventricular assist device implantation: Longitudinal changes and relation to aortic valve insufficiency.

PubMed

Fine, Nowell M; Park, Soon J; Stulak, John M; Topilsky, Yan; Daly, Richard C; Joyce, Lyle D; Pereira, Naveen L; Schirger, John A; Edwards, Brooks S; Lin, Grace; Kushwaha, Sudhir S

2016-04-01

In this study we examined the impact of continuous-flow left ventricular assist device (CF-LVAD) support on proximal thoracic aorta dimensions. Aortic root and ascending aorta diameter were measured from serial echocardiograms before and after CF-LVAD implantation in patients with ≥6 months of support, and correlated with the development of >mild aortic valve insufficiency (AI). Of 162 patients included, mean age was 58 ± 11 years and 128 (79%) were male. Seventy-nine (63%) were destination therapy patients. Mean aortic root and ascending aorta diameters at baseline, 1 month, 6 months, 12 months and long-term follow-up (mean 2.0 ± 1.4 years) were 3.5 ± 0.4, 3.5 ± 0.3, 3.9 ± 0.3, 3.9 ± 0.2 and 4.0 ± 0.3, and 3.3 ± 0.2, 3.3 ± 0.3, 3.6 ± 0.2, 3.6 ± 0.3 and 3.6 ± 0.3 cm, respectively. Only change in aortic root diameter from 1-month to 6-month follow-up reached statistical significance (p = 0.03). Nine (6%) patients had accelerated proximal thoracic aorta expansion (>0.5 cm/year), occurring predominantly in the first 6 months after implantation. These patients were older and more likely to have hypertension and baseline proximal thoracic aorta dilation. Forty-five (28%) patients developed >mild AI at long-term follow-up, including 7 of 9 (78%) of those with accelerated proximal thoracic aorta expansion. All 7 had aortic valves that remained closed throughout the cardiac cycle, and this, along with duration of CF-LVAD support and increase in aortic root diameter, were significantly associated with developing >mild AI. CF-LVAD patients have small increases in proximal thoracic aorta dimensions that predominantly occur within the first 6 months after implantation and then stabilize. Increasing aortic root diameter was associated with AI development. Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Sex, pregnancy and aortic disease in Marfan syndrome.

PubMed

Renard, Marjolijn; Muiño-Mosquera, Laura; Manalo, Elise C; Tufa, Sara; Carlson, Eric J; Keene, Douglas R; De Backer, Julie; Sakai, Lynn Y

2017-01-01

Sex-related differences as well as the adverse effect of pregnancy on aortic disease outcome are well-established phenomena in humans with Marfan syndrome (MFS). The underlying mechanisms of these observations are largely unknown. In an initial (pilot) step we aimed to confirm the differences between male and female MFS patients as well as between females with and without previous pregnancy. We then sought to evaluate whether these findings are recapitulated in a pre-clinical model and performed in-depth cardiovascular phenotyping of mutant male and both nulliparous and multiparous female Marfan mice. The effect of 17β-estradiol on fibrillin-1 protein synthesis was compared in vitro using human aortic smooth muscle cells and fibroblasts. Our small retrospective study of aortic dimensions in a cohort of 10 men and 20 women with MFS (10 pregnant and 10 non-pregnant) confirmed that aortic root growth was significantly increased in the pregnant group compared to the non-pregnant group (0.64mm/year vs. 0.12mm/year, p = 0.018). Male MFS patients had significantly larger aortic root diameters compared to the non-pregnant and pregnant females at baseline and follow-up (p = 0.002 and p = 0.007, respectively), but no significant increase in aortic root growth was observed compared to the females after follow-up (p = 0.559 and p = 0.352). In the GT-8/+ MFS mouse model, multiparous female Marfan mice showed increased aortic diameters when compared to nulliparous females. Aortic dilatation in multiparous females was comparable to Marfan male mice. Moreover, increased aortic diameters were associated with more severe fragmentation of the elastic lamellae. In addition, 17β-estradiol was found to promote fibrillin-1 production by human aortic smooth muscle cells. Pregnancy-related changes influence aortic disease severity in otherwise protected female MFS mice and patients. There may be a role for estrogen in the female sex protective effect.

Vascular complications of transcatheter aortic valve replacement: A concise literature review

PubMed Central

Chaudhry, Muhammad Ali; Sardar, Muhammad Rizwan

2017-01-01

Transcatheter aortic valve replacement (TAVR) is a relatively newer therapeutic modality which offers a promising alternative to surgical aortic valve replacement for patients with prohibitive, high and intermediate surgical risk. The increasing trend to pursue TAVR in these patients has also led to growing awareness of the associated potential vascular complications. The significant impact of these complications on eventual clinical outcome and mortality makes prompt recognition and timely management a critical factor in TAVR patients. We hereby present a concise review with emphasis on diverse vascular complications associated with TAVR and their effective management to improve overall clinical outcomes. PMID:28824787

Percutaneous closure of acute aorto-right ventricular fistula following transcatheter bicuspid aortic valve replacement.

PubMed

Nakamura, Kenta; Passeri, Jonathan J; Inglessis-Azuaje, Ignacio

2017-07-01

We report a case of acute aorto-right ventricular fistula following transcatheter bicuspid aortic valve replacement and subsequent percutaneous closure. The diagnosis and treatment of this rare complication is illustrated through multi-modality imaging. We hypothesize that the patient's heavily calcified bicuspid aortic valve anatomy led to asymmetric deployment of the transcatheter aortic valve replacement (TAVR) prosthesis, traumatizing the right sinus of Valsalva at the distal edge of the TAVR stent and ultimately fistulized to the right ventricle. The patient acutely decompensated with heart failure five days after TAVR and underwent emergent intervention. The aorto-right ventricular fistula was closed using an 18-mm septal occluder device with marked clinical recovery. Transcatheter closure is a viable treatment option for acute aorto-right ventricular fistula. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Latest-Generation Transcatheter Aortic Valve Replacement Devices and Procedures.

PubMed

Chamandi, Chekrallah; Puri, Rishi; Rodriguez-Gabella, Tania; Rodés-Cabau, Josep

2017-09-01

Transcatheter aortic valve replacement (TAVR) is a well-established treatment for patients with severe symptomatic aortic stenosis who are at high or prohibitive surgical risk. More recently, TAVR has emerged as a valid alternative to surgical aortic valve replacement for treating intermediate-risk patients, and several studies are currently evaluating the role of TAVR in low-risk patients. Transcatheter heart valve (THV) technologies have evolved considerably over time, and important iterations have been implemented in many of the latest-generation devices to (1) reduce the size and improve delivery system properties; (2) improve valve deployment, repositioning, and retrievability; and (3) reduce paravalvular leaks. This article reviews the main characteristics of, and clinical results associated with, the newer-generation THVs while providing an overview of novel TAVR indications. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Machine-learning phenotypic classification of bicuspid aortopathy.

PubMed

Wojnarski, Charles M; Roselli, Eric E; Idrees, Jay J; Zhu, Yuanjia; Carnes, Theresa A; Lowry, Ashley M; Collier, Patrick H; Griffin, Brian; Ehrlinger, John; Blackstone, Eugene H; Svensson, Lars G; Lytle, Bruce W

2018-02-01

Bicuspid aortic valves (BAV) are associated with incompletely characterized aortopathy. Our objectives were to identify distinct patterns of aortopathy using machine-learning methods and characterize their association with valve morphology and patient characteristics. We analyzed preoperative 3-dimensional computed tomography reconstructions for 656 patients with BAV undergoing ascending aorta surgery between January 2002 and January 2014. Unsupervised partitioning around medoids was used to cluster aortic dimensions. Group differences were identified using polytomous random forest analysis. Three distinct aneurysm phenotypes were identified: root (n = 83; 13%), with predominant dilatation at sinuses of Valsalva; ascending (n = 364; 55%), with supracoronary enlargement rarely extending past the brachiocephalic artery; and arch (n = 209; 32%), with aortic arch dilatation. The arch phenotype had the greatest association with right-noncoronary cusp fusion: 29%, versus 13% for ascending and 15% for root phenotypes (P < .0001). Severe valve regurgitation was most prevalent in root phenotype (57%), followed by ascending (34%) and arch phenotypes (25%; P < .0001). Aortic stenosis was most prevalent in arch phenotype (62%), followed by ascending (50%) and root phenotypes (28%; P < .0001). Patient age increased as the extent of aneurysm became more distal (root, 49 years; ascending, 53 years; arch, 57 years; P < .0001), and root phenotype was associated with greater male predominance compared with ascending and arch phenotypes (94%, 76%, and 70%, respectively; P < .0001). Phenotypes were visually recognizable with 94% accuracy. Three distinct phenotypes of bicuspid valve-associated aortopathy were identified using machine-learning methodology. Patient characteristics and valvular dysfunction vary by phenotype, suggesting that the location of aortic pathology may be related to the underlying pathophysiology of this disease. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Poor performances of EuroSCORE and CARE score for prediction of perioperative mortality in octogenarians undergoing aortic valve replacement for aortic stenosis.

PubMed

Chhor, Vibol; Merceron, Sybille; Ricome, Sylvie; Baron, Gabriel; Daoud, Omar; Dilly, Marie-Pierre; Aubier, Benjamin; Provenchere, Sophie; Philip, Ivan

2010-08-01

Although results of cardiac surgery are improving, octogenarians have a higher procedure-related mortality and more complications with increased length of stay in ICU. Consequently, careful evaluation of perioperative risk seems necessary. The aims of our study were to assess and compare the performances of EuroSCORE and CARE score in the prediction of perioperative mortality among octogenarians undergoing aortic valve replacement for aortic stenosis and to compare these predictive performances with those obtained in younger patients. This retrospective study included all consecutive patients undergoing cardiac surgery in our institution between November 2005 and December 2007. For each patient, risk assessment for mortality was performed using logistic EuroSCORE, additive EuroSCORE and CARE score. The main outcome measure was early postoperative mortality. Predictive performances of these scores were assessed by calibration and discrimination using goodness-of-fit test and area under the receiver operating characteristic curve, respectively. During this 2-year period, we studied 2117 patients, among whom 134/211 octogenarians and 335/1906 nonoctogenarians underwent an aortic valve replacement for aortic stenosis. When considering patients with aortic stenosis, discrimination was poor in octogenarians and the difference from nonoctogenarians was significant for each score (0.58, 0.59 and 0.56 vs. 0.82, 0.81 and 0.77 for additive EuroSCORE, logistic EuroSCORE and CARE score in octogenarians and nonoctogenarians, respectively, P < 0.05). Moreover, in the whole cohort, logistic EuroSCORE significantly overestimated mortality among octogenarians. Predictive performances of these scores are poor in octogenarians undergoing cardiac surgery, especially aortic valve replacement. Risk assessment and therapeutic decisions in octogenarians should not be made with these scoring systems alone.

Aortic valve insufficiency in the teenager and young adult: the role of prosthetic valve replacement.

PubMed

Bradley, Scott M

2013-10-01

The contents of this article were presented in the session "Aortic insufficiency in the teenager" at the congenital parallel symposium of the 2013 Society of Thoracic Surgeons (STS) annual meeting. The accompanying articles detail the approaches of aortic valve repair and the Ross procedure.(1,2) The current article focuses on prosthetic valve replacement. For many young patients requiring aortic valve surgery, either aortic valve repair or a Ross procedure provides a good option. The advantages include avoidance of anticoagulation and potential for growth. In other patients, a prosthetic valve is an appropriate alternative. This article discusses the current state of knowledge regarding mechanical and bioprosthetic valve prostheses and their specific advantages relative to valve repair or a Ross procedure. In current practice, young patients requiring aortic valve surgery frequently undergo valve replacement with a prosthetic valve. In STS adult cardiac database, among patients ≤30 years of age undergoing aortic valve surgery, 34% had placement of a mechanical valve, 51% had placement of a bioprosthetic valve, 9% had aortic valve repair, and 2% had a Ross procedure. In the STS congenital database, among patients 12 to 30 years of age undergoing aortic valve surgery, 21% had placement of a mechanical valve, 18% had placement of a bioprosthetic valve, 30% had aortic valve repair, and 24% had a Ross procedure. In the future, the balance among these options may be altered by design improvements in prosthetic valves, alternatives to warfarin, the development of new patch materials for valve repair, and techniques to avoid Ross autograft failure.

Body surface area as a key determinant of aortic root and arch dimensions in a population-based study.

PubMed

Wang, Yan-Li; Wang, Qing-Ling; Wang, Liang; Wu, Ying-Biao; Wang, Zhi-Bin; Cameron, James; Liang, Yu-Lu

2013-02-01

The associations between the aortic dimensions (of the aortic sinus, aortic annulus and aortic arch) and physiological variables have not been established in the Chinese population. The present study examined the associations among physiological variables to determine the aortic root and arch dimensions echocardiographically. The diameters of the aortic sinus, annulus and arch were measured in 1,010 subjects via 2-D echocardiography with a 3.5-MHz transducer in a trans-thoracic position. The images of the aortic sinus and aortic annulus were obtained from a standard parasternal long-axis view. The maximum diameter of the valve orifice was measured at the end of systole. The aortic arch dimension was visualized in the long-axis using a suprasternal notch window and the maximum transverse diameter was measured. Epidata 3.0, Excel 2007 and SPSS version 17.0 were used to collect and analyze the data. A total of 1,010 subjects were enrolled. The mean age was 55.0±17.0 years (range of 18 to 90 years). The body surface area (BSA) was the best predictor of all the studied physiological variables and may be used to predict aortic sinus, annulus and arch dimensions independently (r=0.54, 0.37 and 0.39, respectively). Gender, blood pressure, age and BSA are significant predictors of the aortic dimensions. Of these, BSA was the best predictor.

Apico-Aortic Conduit for severe aortic stenosis: Technique, applications, and systematic review

PubMed Central

Elmistekawy, Elsayed; Lapierre, Harry; Mesana, Thierry; Ruel, Marc

2010-01-01

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass. PMID:23960619

Natural history of the ascending aorta after aortic valve replacement: risk factor analysis for late aortic complications after aortic valve replacement.

PubMed

Tsutsumi, Koji; Hashizume, Kenichi; Inoue, Yoshito

2016-05-01

The purpose of this study was to clarify the natural history of the ascending aorta and to identify risk factors for late ascending aortic events after first isolated aortic valve replacement (AVR). A total of 287 patients undergoing AVR were enrolled. The patients were categorized into two groups based on the diameter of the ascending aorta at the time of AVR, as determined by computed tomography: Group A (n = 233) was defined as an ascending aortic diameter <40 mm, and Group B (n = 54) was defined as an ascending aortic diameter ≥40 mm. The mean follow-up period was 7.6 years. The baseline diameter of the ascending aorta was 31.4 ± 4.8 mm in Group A and 44.7 ± 4.2 mm in Group B. These values increased to 35.9 ± 7.4 mm in Group A and 50.1 ± 7.3 mm in Group B during the follow-up period (P < 0.001). Ten patients had acute type A aortic dissection (Group A: 1 patient vs. Group B: 9 patients; P < 0.001), and three patients had enlargement of the ascending aorta to ≥55 mm in diameter (Group A: 1 patient vs. Group B: 2 patients). Multivariate analysis revealed that the baseline ascending aortic diameter was the only significant risk factor for developing late ascending aortic events (P < 0.001). AVR alone may not prevent further enlargement of the ascending aorta. An ascending aorta ≥40 mm in diameter at the time of AVR increased the risk of late ascending aortic events.

Risks and Challenges of Surgery for Aortic Prosthetic Valve Endocarditis.

PubMed

Grubitzsch, Herko; Tarar, Waharat; Claus, Benjamin; Gabbieri, Davide; Falk, Volkmar; Christ, Torsten

2018-03-01

Prosthetic valve endocarditis is the most severe form of infective endocarditis. This study assessed the risks and challenges of surgery for aortic prosthetic valve endocarditis. In total, 116 consecutive patients (98 males, age 65.2±12.7years), who underwent redo-surgery for active aortic prosthetic valve endocarditis between 2000 and 2014, were reviewed. Cox regression analysis was used to identify factors for aortic root destructions as well as for morbidity and mortality. Median follow-up was 3.8 years (0-13.9 years). Aortic root destructions (42 limited and 29 multiple lesions) were associated with early prosthetic valve endocarditis and delayed diagnosis (≥14 d), but not with mortality. There were 16 (13.8%) early (≤30 d) and 32 (27.6%) late (>30 days) deaths. Survival at 1, 5, and 10 years was 72±4.3%, 56±5.4%, and 46±6.4%, respectively. The cumulative incidence of death, reinfection, and reoperation was 19.0% at 30days and 36.2% at 1year. Delayed diagnosis, concomitant procedures, and EuroSCORE II >20% were predictors for early mortality and need for mechanical circulatory support, age >70years, and critical preoperative state were predictors for late mortality. In their absence, survival at 10 years was 70±8.4%. Reinfections and reoperations occurred more frequently if ≥1 risk factor for endocarditis and aortic root destructions were present. At 10 years, freedom from reinfection and reoperation was 89±4.2% and 91±4.0%. The risks of death, reinfection, and reoperation are significant within the first year after surgery for aortic prosthetic valve endocarditis. Early diagnosis and aortic root destructions are the most important challenges, but advanced age, critical preoperative state, and the need for mechanical circulatory support determine long-term survival. Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

The influence of emotional stress on Doppler-derived aortic peak velocity in boxer dogs.

PubMed

Pradelli, D; Quintavalla, C; Crosta, M C; Mazzoni, L; Oliveira, P; Scotti, L; Brambilla, P; Bussadori, C

2014-01-01

Subaortic stenosis (SAS) is a common congenital heart disease in Boxers. Doppler-derived aortic peak velocity (AoPV) is a diagnostic criterion for the disease. To investigate the influence of emotional stress during echocardiographic examination on AoPV in normal and SAS-affected Boxers. To evaluate the effects of aortic root diameters on AoPV in normal Boxers. DOGS: Two hundred and fifteen normal and 19 SAS-affected Boxers. The AoPV was recorded at the beginning of echocardiographic examination (T0), and when the emotional stress of the dog was assumed to decrease based on behavioral parameters and heart rate (T1). AoPV0-AoPV1 was calculated. In normal dogs, stroke volume index was calculated at T0 and T1. Aortic root diameters were measured and their relationship with AoPV and AoPV0-AoPV1 was evaluated. In normal dogs, AoPV was higher at T0 (median, 1.95 m/s; range, 1.60-2.50 m/s) than at T1 (median, 1.76 m/s; range, 1.40-2.20 m/s; P < .0001; reduction 9.2%). The stroke volume index at T0 also was greater than at T1 (P < .0001). Weak negative correlations were detected between aortic root size and aortic velocities. In SAS-affected dogs, AoPV0 was higher than AoPV1 (P < .0001; reduction 7.3%). Aortic peak velocity was affected by emotional stress during echocardiographic examination both in SAS-affected and normal Boxers. In normal Boxers, aortic root size weakly affected AoPVs, but did not affect AoPV0-AoPV1. Stroke volume seems to play a major role in stress-related AoPV increases in normal Boxers. Emotional stress should be taken into account when screening for SAS in the Boxer breed. Copyright © 2014 by the American College of Veterinary Internal Medicine.

The prevalence and clinical impact of obesity in adults with Marfan syndrome

PubMed Central

Yetman, Anji T; McCrindle, Brian W

2010-01-01

BACKGROUND: Patients with Marfan syndrome characteristically have an asthenic body habitus and are considered to be exempt from the obesity epidemic. OBJECTIVE: To examine the prevalence and clinical impact of obesity in a cohort of adults with Marfan syndrome. METHODS: Fifty outpatients (30 female) with a mean (± SD) age of 38±13 years were studied. Demographic variables including previously identified risk factors for aortic dissection were recorded. Body mass index (BMI) was determined and patients were classified as normal (BMI less than 25 kg/m2), overweight (BMI 25 kg/m2 to 29.9 kg/m2) or obese (BMI 30 kg/m2 or greater). Other cardiovascular risk factors were examined. An adverse clinical outcome was defined as either the attainment of surgical criteria for aortic root replacement or the presence of aortic dissection. RESULTS: A family history of aortic dissection was present in 13 (26%) patients. In 23 (46%) patients, there was no known family history of Marfan syndrome. Mean BMI was 25.4±7.4 kg/m2, with 18 (36%) patients having an elevated BMI. Positive smoking status was present in 15 (30%), hypertension in 13 (26%) and hyperlipidemia in 19 (38%) patients. Adverse clinical outcome was present in 27 (54%) patients. Logistic regression analysis revealed only index case (OR 44; P<0.001) and higher BMI (OR 1.2; P=0.04) to be significantly and independently associated with increased risk of adverse clinical outcome. CONCLUSIONS: Obesity is common in adults with Marfan syndrome and is associated with an increased risk of aortic complications. PMID:20386774

Pre-operative Rehabilitation for Reduction of Hospitalization After Coronary Bypass and Valvular Surgery.

ClinicalTrials.gov

2017-11-28

Patients Waiting for Elective Isolated Coronary Artery Bypass Grafting (CABG); Patients Waiting for Aortic Valve Repair/Replacement for Moderate Aortic Stenosis or Severe Regurgitation; Patients Waiting for Mitral Valve Repair/Replacement for Moderate Stenosis or Severe Regurgitation; Patients Waiting for Combined Procedures. (CAGB and Valve)

Aortic valve replacement for Libman-Sacks endocarditis

PubMed Central

Keenan, Jack B; Janardhanan, Rajesh; Larsen, Brandon T; Khalpey, Zain

2016-01-01

A 24-year-old man with systemic lupus erythematosus and antiphospholipid syndrome complicated by lupus nephritis presented with acute limb ischaemia secondary to an embolus. Following embolectomy, the patient underwent a transthoracic echocardiogram which revealed a large vegetation on all three cusps of the aortic valve. The patient was taken for an urgent aortic valve replacement with a mechanical valve. Cultures of one cusp remained sterile. Histopathological examination of the remaining two cusps revealed sterile fibrin-rich thrombotic vegetations characteristic of non-bacterial thrombotic endocarditis. PMID:27702929

Treatment and outcomes of aortic endograft infection.

PubMed

Smeds, Matthew R; Duncan, Audra A; Harlander-Locke, Michael P; Lawrence, Peter F; Lyden, Sean; Fatima, Javariah; Eskandari, Mark K

2016-02-01

This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Transcatheter Aortic Valve Replacement: a Kidney’s Perspective

PubMed Central

Cheungpasitporn, Wisit; Thongprayoon, Charat; Kashani, Kianoush

2016-01-01

Transcatheter aortic valve replacement (TAVR) has now emerged as a viable treatment option for high-risk patients with severe aortic stenosis (AS) who are not suitable candidates for surgical aortic valve replacement (SAVR). Despite encouraging published outcomes, acute kidney injury (AKI) is common and lowers the survival of patients after TAVR. The pathogenesis of AKI after TAVR is multifactorial including TAVR specific factors such as the use of contrast agents, hypotension during rapid pacing, and embolization; preventive measures may include pre-procedural hydration, limitation of contrast dye exposure, and avoidance of intraprocedural hypotension. In recent years, the number of TAVR performed worldwide has been increasing, as well as published data on renal perspectives of TAVR including AKI, chronic kidney disease, end-stage kidney disease, and kidney transplantation. This review aims to present the current literature on the nephrology aspects of TAVR, ultimately to improve the patients’ quality of care and outcomes. PMID:27069960

Hemodynamic deterioration after aortic valve replacement in a patient with mixed systemic amyloidosis.

PubMed

Seki, Tatsuya; Hattori, Atsuo; Yoshida, Toshihito

2017-08-01

We report a case of hemodynamic deterioration after aortic valve replacement in a patient with mixed systemic amyloidosis. A 77-year-old male with severe aortic valve stenosis and 19 years hemodialysis underwent aortic valve replacement. Postoperatively, the patient died of hemodynamic deterioration. Autopsy findings showed massive, whole-body edema and mixed systemic amyloidosis (dialysis-related and AA amyloidosis). Clinical and autopsy findings implied that hemodynamic deterioration was caused by increased vascular permeability. The amyloid deposit to the vessel causes inflammatory changes and increases vascular permeability. Mixed systemic amyloidosis occurs very rarely and could increases vascular permeability even more than each single type of amyloidosis. Systemic amyloidosis may be a risk factor for hemodynamic deterioration after cardiac surgery. Patients with longtime hemodialysis and a history associated with dialysis-related amyloidosis would have at least single systemic amyloidosis, which should be considered a contraindication to cardiac surgery with cardiopulmonary bypass.

[Pannus Formation Six-years after Aortic and Mitral Valve Replacement with Tissue Valves;Report of a Case].

PubMed

Nakamura, Makoto; Muraoka, Arata; Aizawa, Kei; Akutsu, Hirohiko; Kurumisawa, Soki; Misawa, Yoshio

2015-07-01

A 77-year-old man presented with exertional dyspnea. He had undergone aortic and mitral valve replacement with tissue valves 6-years earlier. The patient's hemoglobin level was 9.8 g/dl and serum aspartate aminotransferase (70 mU/ml) and lactate dehydrogenase (1,112 mU/ml) were elevated. Echocardiography revealed stenosis of the prosthetic valve in the aortic position with peak flow velocity of 3.8 m/second and massive mitral regurgitation. The patient underwent repeat valve replacement. Pannus formation around both implanted valves was observed. The aortic valve orifice was narrowed by the pannus, and one cusp of the prosthesis in the mitral position was fixed and caused the regurgitation, but they were free from cusp laceration or calcification. The patient's postoperative course was uneventful, and he continues to do well 14 months after surgery.

Cost-effectiveness of aortic valve replacement in the elderly: an introductory study.

PubMed

Wu, YingXing; Jin, Ruyun; Gao, Guangqiang; Grunkemeier, Gary L; Starr, Albert

2007-03-01

With increased life expectancy and improved technology, valve replacement is being offered to increasing numbers of elderly patients with satisfactory clinical results. By using standard econometric techniques, we estimated the relative cost-effectiveness of aortic valve replacement by drawing on a large prospective database at our institution. By using aortic valve replacement as an example, this introductory report paves the way to more definitive studies of these issues in the future. From 1961 to 2003, 4617 adult patients underwent aortic valve replacement at our service. These patients were provided with a prospective lifetime follow-up. As of 2005, these patients had accumulated 31,671 patient-years of follow-up (maximum 41 years) and had returned 22,396 yearly questionnaires. A statistical model was used to estimate the future life years of patients who are currently alive. In the absence of direct estimates of utility, quality-adjusted life years were estimated from New York Heart Association class. The cost-effectiveness ratio was calculated by the patient's age at surgery. The overall cost-effectiveness ratio was approximately 13,528 dollars per quality-adjusted life year gained. The cost-effectiveness ratio increased according to age at surgery, up to 19,826 dollars per quality-adjusted life year for octogenarians and 27,182 dollars per quality-adjusted life year for nonagenarians. Given the limited scope of this introductory study, aortic valve replacement is cost-effective for all age groups and is very cost-effective for all but the most elderly according to standard econometric rules of thumb.

Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement.

PubMed

López-Mínguez, José Ramón; Millán-Núñez, Victoria; González-Fernández, Reyes; Nogales-Asensio, Juan Manuel; Fuentes-Cañamero, María Eugenia; Merchán-Herrera, Antonio

2016-04-01

Transcatheter aortic valve replacement (TAVR) is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery. It has been shown that implantation without aortic regurgitation is related to lower mortality. Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape. Central regurgitation is less common, but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation. However, there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction. We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus. The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway: Minimalist Approach, Standardized Care, and Discharge Criteria to Reduce Length of Stay.

PubMed

Lauck, Sandra B; Wood, David A; Baumbusch, Jennifer; Kwon, Jae-Yung; Stub, Dion; Achtem, Leslie; Blanke, Philipp; Boone, Robert H; Cheung, Anson; Dvir, Danny; Gibson, Jennifer A; Lee, Bobby; Leipsic, Jonathan; Moss, Robert; Perlman, Gidon; Polderman, Jopie; Ramanathan, Krishnan; Ye, Jian; Webb, John G

2016-05-01

We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility. © 2016 American Heart Association, Inc.

Clinical efficacy of transcatheter aortic valve replacement for severe aortic stenosis in high-risk patients: the PREVAIL JAPAN trial.

PubMed

Sawa, Yoshiki; Takayama, Morimasa; Mitsudo, Kazuaki; Nanto, Shinsuke; Takanashi, Shuichiro; Komiya, Tatsuhiko; Kuratani, Toru; Tobaru, Tetsuya; Goto, Tsuyoshi

2015-01-01

Transcatheter aortic valve replacement (TAVR) is suggested to be less invasive and/or equally effective in comparison to conventional aortic valve replacement for high-risk symptomatic aortic stenosis patients. We herein report the initial results of a pivotal clinical trial of TAVR in Japan (the PREVAIL JAPAN). Sixty-four aortic stenosis patients (mean age 84.3 ± 6.1 years) not suitable for surgery were enrolled at three centers in Japan, with a primary composite endpoint of the 6-month post-procedure improvements in the aortic valve area and New York Heart Association (NYHA) functional classification. A transfemoral approach was used in 37 patients and a transapical approach was used in 27. The device success rate was 91.9 %. After 30 days and 6 months, the rates of mortality from any cause were 8.1 and 11.3 %, respectively. At 6 months, symptomatic stroke was found in 3.1 % of the patients, and silent infarction in 7.8 %. The aortic valve area and mean pressure gradient were significantly improved over time with both approaches (p < 0.001). At 6 months, the NYHA functional classification based on a conventional physician's assessment was improved in 87.9 % of the patients. We found results that were equivalent to those in other major TAVR trials, such as an acceptable 30-day survival (91.9 %), suggesting that balloon-expandable TAVR is effective for small Japanese AS patients classified as high-risk or inoperable.

Totally normothermic aortic arch replacement without circulatory arrest.

PubMed

Touati, Gilles D; Marticho, Paul; Farag, Moataz; Carmi, Doron; Szymanski, Catherine; Barry, Misbaou; Trojette, Faouzi; Caus, Thierry

2007-08-01

Various techniques have been proposed for cerebral protection during the surgical treatment of complex aortic disease. The authors propose a revisited strategy of normothermic replacement of the aortic arch to avoid limitations and complications of profound hypothermic circulatory arrest. From April 2000 to May 2006, 19 patients with an aneurysm of the aortic arch and 10 patients with an acute (7) or a chronic (3) aortic dissection underwent a totally normothermic, complete replacement of the aortic arch using three pumps: One pump ensured antegrade cerebral perfusion, at a flow rate adapted to obtain a pressure of 70 mmHg in the right radial artery, and required a selective cannulation of the supra-aortic vessels. A second pump ensured body perfusion at a flow rate adapted to obtain a pressure of 55 mmHg in the left femoral artery and was situated between the right femoral artery and the right atrium. A special balloon aortic occlusion catheter was placed in the descending thoracic aorta. A third pump ensured intermittent normothermic myocardial perfusion via the coronary venous sinus. The arch reconstruction was performed with no time limit. There were two operative, in-hospital (6.8%) mortalities. All others patients were rapidly extubated, except one, with no neurological sequelae, and postoperative course was uneventful, without coagulopathy or hepato-renal impairment. In the light of these results, a normothermic procedure is possible for arch surgery and may ensure a more physiological autoregulation of cerebral blood flow while maintaining body perfusion without high vascular resistances.

Thirty-Seven-Year Durability of a Starr-Edwards Aortic Prosthesis

PubMed Central

Ozkokeli, Mehmet; Ates, Mehmet; Ekinci, Abdurrahman; Akcar, Murat

2005-01-01

We report the case of a patient who was diagnosed with prosthetic valve endocarditis caused by Staphylococcus aureus. He had undergone aortic valve replacement with a Starr-Edwards prosthesis 37 years earlier. Because of uncontrolled infection despite antibiotic treatment, the patient underwent successful surgical replacement of the prosthetic valve. PMID:15902834

[Valvular heart disease associated with coronary artery disease].

PubMed

Yildirir, Aylin

2009-07-01

Nowadays, age-related degenerative etiologies have largely replaced the rheumatic ones and as a natural result of this etiologic change, coronary artery disease has become associated with valvular heart disease to a greater extent. Degenerative aortic valve disease has an important pathophysiological similarity to atherosclerosis and is the leader in this association. There is a general consensus that severely stenotic aortic valve should be replaced during bypass surgery for severe coronary artery disease. For moderate degree aortic stenosis, aortic valve replacement is usually performed during coronary bypass surgery. Ischemic mitral regurgitation has recently received great attention from both diagnostic and therapeutic points of view. Ischemic mitral regurgitation significantly alters the prognosis of the patient with coronary artery disease. Severe ischemic mitral regurgitation should be corrected during coronary bypass surgery and mitral valve repair should be preferred to valve replacement. For moderate degree ischemic mitral regurgitation, many authors prefer valve surgery with coronary bypass surgery. In this review, the main characteristics of patients with coronary artery disease accompanying valvular heart disease and the therapeutic options based on individual valve pathology are discussed.

Heterogeneity in the Segmental Development of the Aortic Tree: Impact on Management of Genetically Triggered Aortic Aneurysms

PubMed Central

Sherif, Hisham M.F.

2014-01-01

An extensive search of the medical literature examining the development of the thoracic aortic tree reveals that the thoracic aorta does not develop as one unit or in one stage: the oldest part of the thoracic aorta is the descending aorta with the aortic arch being the second oldest, developing under influence from the neural crest cell. Following in chronological order are the proximal ascending aorta and aortic root, which develop from a conotruncal origin. Different areas of the thoracic aorta develop under the influence of different gene sets. These parts develop from different cell lineages: the aortic root (the conotruncus), developing from the mesoderm; the ascending aorta and aortic arch, developing from the neural crest cells; and the descending aorta from the mesoderm. Findings illustrate that the thoracic aorta is not a single entity, in developmental terms. It develops from three or four distinct areas, at different stages of embryonic life, and under different sets of genes and signaling pathways. Genetically triggered thoracic aortic aneurysms are not a monolithic group but rather share a multi-genetic origin. Identification of therapeutic targets should be based on the predilection of certain genes to cause aneurysmal disease in specific aortic segments. PMID:26798739

Aortic assessment of bicuspid aortic valve patients and their first-degree relatives.

PubMed

Straneo, Pablo; Parma, Gabriel; Lluberas, Natalia; Marichal, Alvaro; Soca, Gerardo; Cura, Leandro; Paganini, Juan J; Brusich, Daniel; Florio, Lucia; Dayan, Victor

2017-03-01

Background Bicuspid aortic valve patients have an increased risk of aortic dilatation. A deficit of nitric oxide synthase has been proposed as the causative factor. No correlation between flow-mediated dilation and aortic diameter has been performed in patients with bicuspid aortic valves and normal aortic diameters. Being a hereditary disease, we compared echocardiographic features and endothelial function in these patients and their first-degree relatives. Methods Comprehensive physical examinations, routine laboratory tests, transthoracic echocardiography, and measurements of endothelium-dependent and non-dependent flow-mediated vasodilatation were performed in 18 bicuspid aortic valve patients (14 type 1 and 4 type 2) and 19 of their first-degree relatives. Results The first-degree relatives were younger (36.7 ± 18.8 vs. 50.5 ± 13.9 years, p = 0.019) with higher ejection fractions (64.6% ± 1.7% vs. 58.4% ± 9.5%, p = 0.015). Aortic diameters indexed to body surface area were similar in both groups, the except the tubular aorta which was larger in bicuspid aortic valve patients (19.3 ± 2.7 vs. 17.4 ± 2.2 mm·m -2 , p = 0.033). Flow-dependent vasodilation was similar in both groups. A significant inverse correlation was found between non-flow-dependent vasodilation and aortic root diameter in patients with bicuspid aortic valve ( R = -0.57, p = 0.05). Conclusions Bicuspid aortic valve patients without aortopathy have larger ascending aortic diameters than their first-degree relatives. Endothelial function is similar in both groups, and there is no correlation with ascending aorta diameter. Nonetheless, an inverse correlation exists between non-endothelial-dependent dilation and aortic root diameter in bicuspid aortic valve patients.

Long-Term Risk for Aortic Complications After Aortic Valve Replacement in Patients With Bicuspid Aortic Valve Versus Marfan Syndrome.

PubMed

Itagaki, Shinobu; Chikwe, Joanna P; Chiang, Yuting P; Egorova, Natalia N; Adams, David H

2015-06-09

Bicuspid aortic valves are associated with valve dysfunction, ascending aortic aneurysm and dissection. Management of the ascending aorta at the time of aortic valve replacement (AVR) in these patients is controversial and has been extrapolated from experience with Marfan syndrome, despite the absence of comparative long-term outcome data. This study sought to assess whether the natural history of thoracic aortopathy after AVR in patients with bicuspid aortic valve disease is substantially different from that seen in patients with Marfan syndrome. In this retrospective comparison, outcomes of 13,205 adults (2,079 with bicuspid aortic valves, 73 with Marfan syndrome, and 11,053 control patients with acquired aortic valve disease) who underwent primary AVR without replacement of the ascending aorta in New York State between 1995 and 2010 were compared. The median follow-up time was 6.6 years. The long-term incidence of thoracic aortic dissection was significantly higher in patients with Marfan syndrome (5.5 ± 2.7%) compared with those with bicuspid valves (0.55 ± 0.21%) and control group patients (0.41 ± 0.08%, p < 0.001). Thoracic aortic aneurysms were significantly more likely to be diagnosed in late follow-up in patients with Marfan syndrome (10.8 ± 4.4%) compared with those with bicuspid valves (4.8 ± 0.8%) and control group patients (1.4 ± 0.2%) (p < 0.001). Patients with Marfan syndrome were significantly more likely to undergo thoracic aortic surgery in late follow-up (10.4 ± 4.3%) compared with those with bicuspid valves (2.5 ± 0.6%) and control group patients (0.50 ± 0.09%) (p < 0.001). The much higher long-term rates of aortic complications after AVR observed in patients with Marfan syndrome compared with those with bicuspid aortic valves confirm that operative management of patients with bicuspid aortic valves should not be extrapolated from Marfan syndrome and support discrete treatment algorithms for these different clinical entities. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement.

PubMed

Al-Khadra, Yasser; Darmoch, Fahed; Baibars, Motaz; Kaki, Amir; Fanari, Zaher; Alraies, M Chadi

2018-05-17

The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR). Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility. A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group. In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR. © 2018, Wiley Periodicals, Inc.

Dilatation of the initially non-aneurysmal ascending aorta after replacement of a bicuspid versus tricuspid aortic valve.

PubMed

Zhang, Jing; Fan, Guangpu; Zhao, Hui; Wang, Xu; Wang, Zhiwei; Zhang, Peide; Wang, Wei

2016-12-01

Objective To compare the aortic diameter after isolated aortic valve replacement (AVR) in patients with a bicuspid (BAV) or tricuspid aortic valve (TAV) and an initially normal ascending aorta. Methods Patients with an ascending aortic diameter of < 45 mm who had undergone isolated AVR were studied. Ultrasonic cardiographic measurements of the ascending aortic diameter made pre- and postoperatively and follow-up data concerning adverse aortic events and death were analyzed. Results A total of 613 patients were included in this retrospective study; of these, 211 had a BAV and 402 had a TAV. In both groups, the ascending aorta significantly expanded but was non-aneurysmal during follow-up; however, the difference between the two groups was not significant. Cox regression analysis showed no significant effect associated with the presence of a BAV on adverse aortic events or death. Conclusion Dilatation of the ascending aorta was observed after AVR in both groups, but was not more pronounced in patients with a BAV. Long-term follow-up for ascending aortic aneurysm is necessary after AVR in both patients with a BAV and those with a TAV.

Dilatation of the initially non-aneurysmal ascending aorta after replacement of a bicuspid versus tricuspid aortic valve

PubMed Central

Zhang, Jing; Fan, Guangpu; Zhao, Hui; Wang, Xu; Wang, Zhiwei; Zhang, Peide

2016-01-01

Objective To compare the aortic diameter after isolated aortic valve replacement (AVR) in patients with a bicuspid (BAV) or tricuspid aortic valve (TAV) and an initially normal ascending aorta. Methods Patients with an ascending aortic diameter of < 45 mm who had undergone isolated AVR were studied. Ultrasonic cardiographic measurements of the ascending aortic diameter made pre- and postoperatively and follow-up data concerning adverse aortic events and death were analyzed. Results A total of 613 patients were included in this retrospective study; of these, 211 had a BAV and 402 had a TAV. In both groups, the ascending aorta significantly expanded but was non-aneurysmal during follow-up; however, the difference between the two groups was not significant. Cox regression analysis showed no significant effect associated with the presence of a BAV on adverse aortic events or death. Conclusion Dilatation of the ascending aorta was observed after AVR in both groups, but was not more pronounced in patients with a BAV. Long-term follow-up for ascending aortic aneurysm is necessary after AVR in both patients with a BAV and those with a TAV. PMID:27484890

Aortic valve replacement with the Biocor PSB stentless xenograft.

PubMed

Bertolini, P; Luciani, G B; Vecchi, B; Pugliese, P; Mazzucco, A

1998-08-01

The midterm clinical results after aortic valve replacement with the Biocor PSB stentless xenograft on all patients operated between October 1992 and October 1996 were reviewed. One hundred six patients, aged 70+/-6 years, had aortic valve replacement for aortic stenosis (67%), regurgitation (11%), or both (22%). Associated procedures were done in 49 patients (46%), including coronary artery bypass in 30 patients, mitral valve repair/replacement in 16, and ascending aorta replacement in 5 patients. Aortic cross-clamp and cardiopulmonary bypass times were 96+/-24 and 129+/-31 minutes, respectively. There were 3 (3%) early deaths due to low output (2 patients) and cerebrovascular accident (1 patient). Follow-up of survivors ranged from 6 to 66 months (mean, 39+/-14 months). Survival was 94%+/-2% and 90%+/-3% at 1 and 5 years. There were 5 late deaths due to cardiac cause (2), cancer (2), and pulmonary embolism (1 patient). No patient had structural valve deterioration, whereas 100% and 95%+/-3% were free from valve-related events at 1 and 5 years. There were two reoperations due to narrowing of the left coronary ostium and endocarditis, with an actuarial freedom from reoperation of 99%+/-1% and 98+/-1% at 1 and 5 years, respectively. Functional results demonstrated a mean peak transprosthetic gradient of 16+/-12 mm Hg, with only 1 patient (1%) with a 55 mm Hg gradient. No cases of valve regurgitation greater than mild were recorded at follow-up. Assessment of New York Heart Association functional class demonstrated a significant improvement (2.9+/-0.6 versus 1.4+/-0.7; p=0.01). All patients were free from anticoagulation. Aortic valve replacement using the Biocor PSB stentless xenograft offers excellent midterm survival, negligible valve deterioration, and a very low rate of valve-related events, which are comparable to estimates reported with other models of stentless xenografts and currently available stented xenografts. Hemodynamic performance is favorable and quality of life satisfactory.

Recent Surgical Results for Active Endocarditis Complicated With Perivalvular Abscess.

PubMed

Yoshioka, Daisuke; Toda, Koichi; Yokoyama, Jun-Ya; Matsuura, Ryohei; Miyagawa, Shigeru; Shirakawa, Yukitoshi; Takahashi, Toshiki; Sakaguchi, Taichi; Fukuda, Hirotsugu; Sawa, Yoshiki

2017-10-25

Surgical treatment for endocarditis patients with a perivalvular abscess is still challenging.Methods and Results:From 2009 to 2016, 470 patients underwent surgery for active endocarditis at 11 hospitals. Of these, 226 patients underwent aortic valve surgery. We compared the clinical results of 162 patients without a perivalvular abscess, 37 patients who required patch reconstruction of the aortic annulus (PR group) and 27 who underwent aortic root replacement (ARR group). Patients with a perivalvular abscess had a greater number ofStaphylococcusspecies and prosthetic valve endocarditis, a greater level of inflammation at diagnosis and symptomatic heart failure before surgery, especially in the ARR group. Nevertheless, the duration between diagnosis and surgery was similar, because of a high prevalence of intracranial hemorrhage in the ARR group. Hospital death occurred in 13 (9%) patients without a perivalvular abscess, in 4 (12%) in the PR and in 7 (32%) in the ARR group. Postoperative inflammation and end-organ function were similar between the groups. Overall survival of patients without a perivalvular abscess and that of the PR group was similar, but was significantly worse in the ARR group (P=0.050, 0.026). Freedom from endocarditis recurrence was similar among all patients. Patients treated with patch reconstruction showed favorable clinical results. Early surgical intervention is necessary when a refractory invasive infection is suspected.

Coronary ostia obstruction after replacement of aortic valve prostesis

PubMed Central

2011-01-01

Aortic valve 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. PMID:21810231

Aortic valve replacement for Libman-Sacks endocarditis.

PubMed

Keenan, Jack B; Janardhanan, Rajesh; Larsen, Brandon T; Khalpey, Zain

2016-10-04

A 24-year-old man with systemic lupus erythematosus and antiphospholipid syndrome complicated by lupus nephritis presented with acute limb ischaemia secondary to an embolus. Following embolectomy, the patient underwent a transthoracic echocardiogram which revealed a large vegetation on all three cusps of the aortic valve. The patient was taken for an urgent aortic valve replacement with a mechanical valve. Cultures of one cusp remained sterile. Histopathological examination of the remaining two cusps revealed sterile fibrin-rich thrombotic vegetations characteristic of non-bacterial thrombotic endocarditis. 2016 BMJ Publishing Group Ltd.

Anatomic relationship between left coronary artery and left atrium in patients undergoing atrial fibrillation ablation.

PubMed

Anselmino, Matteo; Torri, Federica; Ferraris, Federico; Calò, Leonardo; Castagno, Davide; Gili, Sebastiano; Rovera, Chiara; Giustetto, Carla; Gaita, Fiorenzo

2017-07-01

Atrial fibrillation transcatheter ablation (TCA) is, within available atrial fibrillation rhythm control strategies, one of the most effective. To potentially improve ablation outcome in case of recurrent atrial fibrillation after a first procedure or in presence of structural myocardial disease, isolation of the pulmonary veins may be associated with extensive lesions within the left atrium. To avoid rare, but potentially life-threatening, complications, thorough knowledge and assessment of left atrium anatomy and its relation to structures in close proximity are, therefore, mandatory. Aim of the present study is to describe, by cardiac computed tomography, the anatomic relationship between aortic root, left coronary artery and left atrium in patients undergoing atrial fibrillation TCA. The cardiac computed tomography scan of 21 patients affected by atrial fibrillation was elaborated to segment left atrium, aortic root and left coronary artery from the surrounding structures and the following distances measured: left atrium and aortic root; left atrium roof and aortic root; left main coronary artery and left atrium; circumflex artery and left atrium appendage; and circumflex artery and mitral valve annulus. Above all, the median distance between left atrium and aortic root (1.9, 1.5-2.1 mm), and between circumflex artery and left atrium appendage ostium (3.0, 2.1-3.4 mm) were minimal (≤3 mm). None of measured distances significantly varied between patients presenting paroxysmal versus persistent atrial fibrillation. The anatomic relationship between left atrium and coronary arteries is extremely relevant when performing atrial fibrillation TCA by extensive lesions. Therefore, at least in the latter case, preablation imaging should be recommended to avoid rare, but potentially life-threatening, complications with the aim of an as well tolerated as possible procedure.

[Value of bedside echocardiography in diagnosis and risk assessment of in-hospital death for patients with Stanford type A aortic dissection].

PubMed

Wang, H J; Xiao, Z Y; Gu, G R; Xue, Y; Shao, M; Deng, Z; Tao, Z G; Yao, C L; Tong, C Y

2017-11-24

Objective: To investigate the value of bedside echocardiography in diagnosis and risk assessment of in-hospital death of patients with Stanford type A aortic dissection. Methods: The clinical data of 229 patients with Stanford type A aortic dissection diagnosed by CT angiography in Zhongshan Hospital affiliated to Fudan University between January 2009 and January 2016 were retrospectively analyzed. The patients were divided into survival group(191 cases)and non-survival group(38 cases)according to presence or absence of in-hospital death. The bedside echocardiography features were analyzed, and influence factors of in-hospital death were determined by multivariate logistic regression analysis. Results: (1) Compared with the survival group, the non-survival group had lower surgery rate (60.52%(23/38) vs. 85.34%(163/191), P <0.01). Age, gender and Debakey classification were similar between survival group and death group (all P >0.05). (2) The bedside echocardiography results showed that prevalence of aortic valve involvement(65.79%(25/38) vs.34.03%(65/191), P <0.01) and severe aortic regurgitation (44.74%(17/38) vs. 14.14%(27/191), P <0.01) were significantly higher in non-survival group than in survival group. The non-survival group had larger aortic root diameter than the survival group ((55.5±6.4)mm vs. (42.3±7.8)mm, P <0.01). There were no significant differences in pericardial effusion, expansion of aortic sinus, and left ventricular ejection fraction between survival group and non-survival group (all P >0.05). (3) The multivariate logistic regression analysis showed that aortic valve involvement( OR =3.275, 95% CI 1.290-8.313, P <0.05), aortic root diameter( OR =1.202, 95% CI 1.134-1.275, P <0.01), and surgery ( OR =0.224, 95% CI 0.079-0.629, P <0.01) were independent risk factors for in-hospital death in patients with Stanford type A aortic dissection. Conclusions: Bedside echocardiography has significant diagnostic value for Stanford type A aortic dissection. Aortic valve involvement, enlargement of aortic root diameter and without surgery are independent risk factors for patients with Stanford type A aortic dissection.

Impact of pregnancy on autograft dilatation and aortic valve function following the Ross procedure.

PubMed

Carvajal, Horacio G; Lindley, Kathryn J; Shah, Trupti; Brar, Anoop K; Barger, Philip M; Billadello, Joseph J; Eghtesady, Pirooz

2018-03-01

The effects of pregnancy on autograft dilatation and neoaortic valve function in patients with a Ross procedure have not been studied. We sought to evaluate the effect of pregnancy on autograft dilatation and valve function in these patients with the goal of determining whether pregnancy is safe after the Ross procedure. A retrospective chart review of female patients who underwent a Ross procedure was conducted. Medical records for 51 patients were reviewed. Among the 33 patients who met inclusion criteria, 11 became pregnant after surgery and 22 did not. Echocardiographic reports were used to record aortic root diameter and aortic insufficiency before, during, and after pregnancy. Patient's charts were reviewed for reinterventions and complications. Primary endpoints included reinterventions, aortic root dilation of ≥5 cm, aortic insufficiency degree ≥ moderate, and death. There were 18 pregnancies carried beyond 20 weeks in 11 patients. There was no significant difference in aortic root diameter between nulliparous patients and parous patients prior to their first pregnancy (3.53 ± 0.44 vs 3.57 ± 0.69 cm, P = .74). There was no significant change in aortic root diameter after first pregnancy (3.7 ± 0.4 cm, P = .056) although there was significant dilatation after the second (4.3 ± 0.7 cm, P = .009) and third (4.5 ± 0.7 cm, P = .009) pregnancies. Freedom from combined endpoints was significantly higher for patients in the pregnancy group than those in the nonpregnancy group (P = .002). Pregnancy was not associated with significantly increased adverse events in patients following the Ross procedure. Special care should be taken after the first pregnancy, as multiparity may lead to increased neoaortic dilatation. © 2017 Wiley Periodicals, Inc.

Aortic valve replacement and repair of left ventricular pseudoaneurysm in a Jehovah’s Witness

PubMed Central

Perrotti, Andrea; Vaislic, Claude; Chocron, Sidney

2013-01-01

The preoperative and surgical management of a giant left ventricular pseudoaneurysm(LVP) associated with aortic valve replacement in a 76 year old male Jehovah’s Witness patient is reported. The satisfactory recovery observed in this patient demonstrates the feasibility of this complex surgical procedure even in this particular patient population. PMID:25478494

[Re-operation for Saccular Aneurysm after Ascending Aortic Replacement with Homograft;Report of a Case].

PubMed

Ikeda, Masahiro; Asakura, Toshihisa; Uwabe, Kazuhiko; Morita, Kozo; Iguchi, Atsushi; Niinami, Hiroshi

2017-09-01

A 62-years-old female had undergone ascending aortic replacement with homograft for graft infection and mediastinitis after initial replacement of ascending aorta due to acute type A dissection. Ten years after homograft replacement, follow up computed tomography showed acute growing saccular aneurysm of the homograft without infectious symptoms. We urgently performed Bentall procedure and hemiarch replacement successfully. Pathological diagnosis was true aneurysm of the homograft. She was discharged from hospital without any complication and has been quite uneventful 7 years after surgery. True aneurysm of the homograft is very rare and our case is the 1st report of successful reoperation.

Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and predictors of survival.

PubMed

Eleid, Mackram F; Sorajja, Paul; Michelena, Hector I; Malouf, Joseph F; Scott, Christopher G; Pellikka, Patricia A

2013-10-15

Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m(2) [low flow, LF] versus ≥35 mL/m(2) [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.

Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices.

PubMed

Pak, Sang-Woo; Uriel, Nir; Takayama, Hiroo; Cappleman, Sarah; Song, Robert; Colombo, Paolo C; Charles, Sandy; Mancini, Donna; Gillam, Linda; Naka, Yoshifumi; Jorde, Ulrich P

2010-10-01

Left ventricular assist devices (LVADs) are increasingly used as long-term therapy for end-stage heart failure patients. We compared the prevalence of aortic insufficiency (AI) after HeartMate II (HMII) vs HeartMate XVE (HMI) support and assessed the role of aortic root diameter and aortic valve opening in the development of AI. Pre-operative and post-operative echocardiograms of 93 HMI and 73 HMII patients who received implants at our center between January 2004 and September 2009 were retrospectively reviewed. After excluding patients with prior or concurrent surgical manipulation of the aortic valve, with baseline AI, or without baseline echoes, 67 HMI and 63 HMII patients were studied. AI was deemed significant if mild to moderate or greater. Pathology reports were reviewed for 77 patients who underwent heart transplant. AI developed in 4 of 67 HMI (6.0%) and in 9 of 63 HMII patients (14.3%). The median times to AI development were 48 days for HMI patients and 90 days for HMII patients. For patients who remained on device support at 6 and 12 months, freedom from AI was 94.5% and 88.9% in HMI patients and 83.6% and 75.2% in HMII patients (log rank p = 0.194). Aortic root diameters, as determined by echocardiography for the patients with AI, trended to be larger at baseline (3.43 ± 0.43 vs 3.15 ± 0.40; p = 0.067) and follow-up (3.58 ± 0.54 vs 3.29 ± 0.50; p = 0.130) compared with those who did not have AI. Aortic root circumferences were assessed directly by a pathologist in those patients who underwent transplant and were significantly larger in HMII patients who had developed AI compared with those patients who did not (8.44 ± 0.89 vs 7.36 ± 1.02 cm; p = 0.034). Lastly, AI was more common in patients whose aortic valve did not open (11 of 26 vs 1 of 14; p = 0.03). Aortic insufficiency occurs frequently in patients who receive continuous-flow support with a HMII LVAD, and may be associated with aortic root diameter enlargement and aortic valve opening. These findings warrant a more thorough preoperative patient evaluation and additional studies to investigate the factors, that may be associated with AI development. Copyright © 2010 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Echocardiographic measurements of the aorta in normal children and young adults.

PubMed

Kaldararova, M; Balazova, E; Tittel, P; Stankovicova, I; Brucknerova, I; Masura, J

2007-01-01

To be able to determine aortic valve and ascending aorta pathology, especially aortic root dilatation, it is important to establish normal aortic dimensions. The aim of the study was to measure the dimensions of the aorta in normal healthy children and young adults in Slovakia. 702 healthy subjects, from newborns to 20 years of age, were examined at our institution. The study was carried out prospectively, by a single observer, using digitized two-dimensional (2D), Doppler and M-mode echocardiography. The aorta was measured at 3 sites: 1. aortic valve annulus, 2. sinuses of Valsalva, 3. sinotubular junction. Patients were divided into 28 groups according to their body surface area (BSA)--from 0.15 to 2.0 m2. All data were statistically evaluated (mean value, 5th and 95th percentile for all BSA groups) and regression equations were calculated for each parameter. All 3 measured aortic parameters correlated closely. Measures of correlation (R-squared) for aortic parameters with the square root of BSA were high: 0.89 for aortic valve annulus, 0.86 for sinuses of Valsalva and 0.86 for sinotubular junction (Tab. 3, Fig. 7, Ref 13). Full Text (Free, PDF) www.bmj.sk

[Aortic Valve Replacement after Balloon Valvuloplasty for Aortic Valve Stenosis in a Dialysis Patient with Cardiogenic Shock;Report of a Case].

PubMed

Takamatsu, Masanori; Hirotani, Takashi; Ohtsubo, Satoshi; Saito, Sumikatsu; Takeuchi, Shigeyuki; Hasegawa, Tasuku; Endo, Ayaka; Yamasaki, Yu; Hayashida, Kentaro

2015-06-01

A 67-year-old man on chronic hemodialysis was admitted with worsening congestive heart failure due to critical aortic stenosis. Echocardiography showed severe aortic stenosis with a valve area of 0.67 cm2 and an ejection fraction of 0.31. Cardiac catheterization revealed severe pulmonary hypertension with pulmonary artery pressures of 62/32 mmHg. In the middle of cardiac catheterization, the systolic pressure declined to 60 mmHg due to cardiogenic shock. Dopamine hydrochloride and dobutamine hydrochloride infusions were necessary to maintain a systolic pressure greater than 80 mmHg. Balloon aortic valvuloplasty was urgently performed. The patient's symptoms rapidly resolved except for angina on exertion. One month later, elective aortic valve replacement was performed. The postoperative course was uneventful and the he was discharged on the 60th postoperative day. A follow-up echocardiogram 6 months postoperatively revealed normal prosthetic valve function and an ejection fraction of 0.6.

Aortic valve surgery of the 21st century: sutureless AVR versus TAVI.

PubMed

Costache, Victor S; Moldovan, Horatiu; Arsenescu, Catalina; Costache, Andreea

2018-04-01

Surgical aortic valve replacement (sAVR) has been a safe, effective and time-proven technique and is still the standard of care all over the world for aortic valve treatment. The vast majority of centers perform this procedure by doing a median sternotomy with several disadvantages. While many others specialties went minimally invasive decades ago, in cardiovascular field transcatheter valve implantation was the first minimally invasive valvular procedure that gained rapid worldwide acceptance. Transcatheter valve replacement (TAVR) is now marketed as a procedure that should be performed under local anesthesia, by an interventional cardiologist via trans femoral route with no other healthcare professional invited to the patient selection or case planning. An increasing number of surgeons are promoting minimally invasive aortic valve replacement, which is gaining grounds, especially with the help of the new sutureless valve technology. With these two new technologies emerging, legitimate questions arise and need to be answered - which has the longest durability, lower complication rate and lower overall mortality.

Practical considerations for optimizing cardiac computed tomography protocols for comprehensive acquisition prior to transcatheter aortic valve replacement.

PubMed

Khalique, Omar K; Pulerwitz, Todd C; Halliburton, Sandra S; Kodali, Susheel K; Hahn, Rebecca T; Nazif, Tamim M; Vahl, Torsten P; George, Isaac; Leon, Martin B; D'Souza, Belinda; Einstein, Andrew J

2016-01-01

Transcatheter aortic valve replacement (TAVR) is performed frequently in patients with severe, symptomatic aortic stenosis who are at high risk or inoperable for open surgical aortic valve replacement. Computed tomography angiography (CTA) has become the gold standard imaging modality for pre-TAVR cardiac anatomic and vascular access assessment. Traditionally, cardiac CTA has been most frequently used for assessment of coronary artery stenosis, and scanning protocols have generally been tailored for this purpose. Pre-TAVR CTA has different goals than coronary CTA and the high prevalence of chronic kidney disease in the TAVR patient population creates a particular need to optimize protocols for a reduction in iodinated contrast volume. This document reviews details which allow the physician to tailor CTA examinations to maximize image quality and minimize harm, while factoring in multiple patient and scanner variables which must be considered in customizing a pre-TAVR protocol. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Mechanical valve replacement in congenital heart disease.

PubMed

Fiane, A E; Lindberg, H L; Saatvedt, K; Svennevig, J L

1996-05-01

Mechanical valves are the prosthesis of choice in valve replacement in children. However, the problem of somatic growth leading to patient-valve mismatch remains present, and the appropriate anticoagulation regimen remains controversial. We present our experience of valve replacement in a young population over 20 years. Between 1972 and 1992, 48 patients (34 males and 14 females), mean age 11.2 years (range 0.4-27.4 years), underwent mechanical valve replacement at our institution. Aortic valve replacement was performed in 28 patients (58.3%), mitral valve replacement in 13 (27.1%), tricuspid valve replacement in six (12.5%) and pulmonary valve replacement in one patient (2.1%). The prostheses used were: St. Jude Medical (n = 2), Björk-Shiley (n = 14), Medtronic Hall (n = 16), Duromedics (n = 2) and CarboMedics (n = 14). Early mortality was 14.3%, 10.7% for aortic valve replacement and 30.8% for mitral valve replacement. Mean follow up for all patients was 8.3 years (range 0-22 years), with a total of 398 patient-years. Seven patients died during the follow up (17.1%). Survival after 10 years, including operative mortality, was 81% for aortic valve replacement, 33% for mitral valve replacement, 83% for tricuspid valve replacement and 100% for pulmonary valve replacement. All patients were anticoagulated with warfarin. In eight patients (16.7%) an antiplatelet drug (aspirin or dipyridamole) was added. Major events included paravalvular leak in six patients (1.5%/pty), valve thrombosis in five (mitral position in two, tricuspid in three) (1.3%/pty) and endocarditis in one patient (0.3%/pty). Minor thromboembolic events occurred in three patients (0.8%/pty) and minor hemorrhagic events in three (0.8%/pty). No patients developed hemolytic anemia and there was no case of structural failure. In our experience, mechanical prostheses in congenital heart disease were associated with significant morbidity and mortality, however long term survival after aortic valve replacement was good (81% at 10 years). Thromboembolic and hemorrhagic events were of minor significance. Atrio-ventricular valve replacement carried the highest risk of valve thrombosis and we now give warfarin and an antiplatelet drug to children undergoing mechanical valve implantation in this position.

Effect of tricuspid regurgitation and the right heart on survival after transcatheter aortic valve replacement: insights from the Placement of Aortic Transcatheter Valves II inoperable cohort.

PubMed

Lindman, Brian R; Maniar, Hersh S; Jaber, Wael A; Lerakis, Stamatios; Mack, Michael J; Suri, Rakesh M; Thourani, Vinod H; Babaliaros, Vasilis; Kereiakes, Dean J; Whisenant, Brian; Miller, D Craig; Tuzcu, E Murat; Svensson, Lars G; Xu, Ke; Doshi, Darshan; Leon, Martin B; Zajarias, Alan

2015-04-01

Tricuspid regurgitation (TR) and right ventricular (RV) dysfunction adversely affect outcomes in patients with heart failure or mitral valve disease, but their impact on outcomes in patients with aortic stenosis treated with transcatheter aortic valve replacement has not been well characterized. Among 542 patients with symptomatic aortic stenosis treated in the Placement of Aortic Transcatheter Valves (PARTNER) II trial (inoperable cohort) with a Sapien or Sapien XT valve via a transfemoral approach, baseline TR severity, right atrial and RV size and RV function were evaluated by echocardiography according to established guidelines. One-year mortality was 16.9%, 17.2%, 32.6%, and 61.1% for patients with no/trace (n=167), mild (n=205), moderate (n=117), and severe (n=18) TR, respectively (P<0.001). Increasing severity of RV dysfunction as well as right atrial and RV enlargement were also associated with increased mortality (P<0.001). After multivariable adjustment, severe TR (hazard ratio, 3.20; 95% confidence interval, 1.50-6.82; P=0.003) and moderate TR (hazard ratio, 1.60; 95% confidence interval, 1.02-2.52; P=0.042) remained associated with increased mortality as did right atrial and RV enlargement, but not RV dysfunction. There was an interaction between TR and mitral regurgitation severity (P=0.04); the increased hazard of death associated with moderate/severe TR only occurred in those with no/trace/mild mitral regurgitation. In inoperable patients treated with transcatheter aortic valve replacement, moderate or severe TR and right heart enlargement are independently associated with increased 1-year mortality; however, the association between moderate or severe TR and an increased hazard of death was only found in those with minimal mitral regurgitation at baseline. These findings may improve our assessment of anticipated benefit from transcatheter aortic valve replacement and support the need for future studies on TR and the right heart, including whether concomitant treatment of TR in operable but high-risk patients with aortic stenosis is warranted. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01314313. © 2015 American Heart Association, Inc.

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography.

PubMed

Huded, Chetan P; Masri, Ahmad; Kusunose, Kenya; Goodman, Andrew L; Grimm, Richard A; Gillinov, A Marc; Johnston, Douglas R; Rodriguez, L Leonardo; Popovic, Zoran B; Svensson, Lars G; Griffin, Brian P; Desai, Milind Y

2018-04-12

In asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV-GLS) to treadmill stress echocardiography. We studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age-sex predicted metabolic equivalents [%AGP-METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV-stroke volume index]) and LV-GLS (measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV-GLS were 0.46±0.1 cm 2 /m 2 , 4.5±0.9 mm Hg/mL per m 2 and -16±4%, respectively; only 50% achieved >100% AGP-METs. Sixty-four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP-METS (HR 1.16), higher Zva (HR 1.25) and lower LV-GLS (HR 1.12) were associated with higher longer-term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all P <0.01). Sequential addition of ZVa and LV-GLS to clinical model (Society of Thoracic Surgeons score and %AGP-METs) increased the c-statistic from 0.65 to 0.69 and 0.75, respectively, both P <0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement. In asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV-GLS and ZVa offer incremental prognostic value. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

PubMed

Hsu, Hung-Lung; Chen, Yin-Yin; Huang, Chun-Yang; Huang, Jih-Hsin; Chen, Jer-Shen

2016-07-01

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Surgical treatment of Behçet's disease involving aortic regurgitation.

PubMed

Ando, M; Kosakai, Y; Okita, Y; Nakano, K; Kitamura, S

1999-12-01

Behçet's disease involving aortic regurgitation is rare, and prosthetic valve detachment after aortic valve replacement is one of the most serious complications reported. We investigated the surgical results in 10 patients with aortic regurgitation caused by Behçet's disease. Between 1981 and 1997, 10 patients with aortic regurgitation secondary to Behçet's disease had surgery. There were 8 men and 2 women, and their ages ranged from 33 to 60 years (mean, 46+/-8 years). The surgical procedures for aortic regurgitation were aortic valve replacement in 6 patients and Bentall type operation in 4. No patient died during the hospital stay. The follow-up periods ranged from 11 to 185 months (mean, 87 months). Two patients died during the follow-up period. The acturial survival rate was 89% at 5 years and 67% at 10 years. Prosthetic valve detachment or suture detachment requiring redo operation occurred in 4 patients, 3 of whom had redo operations twice. Four patients had a composite graft replacement, and 1 patient died after the operation. No prosthetic valve detachment was noted in 64% of the patients at 5 years and in 43% at 10 years. The rate of prosthetic valve detachment was 40% (4 of 10 patients), with a higher incidence in patients with Behçet's disease than in those treated during the same period at the same hospital for aortitis caused by other diseases. Surgical techniques for treatment of this condition should be modified to improve the surgical outcome in these patients.

Coronary artery compression by teflon pledget granuloma following aortic valve replacement.

PubMed

Cohle, S D; Delavan, J W

1997-09-01

We describe a massive fatal posterior myocardial infarct resulting from compression of the right coronary artery by a Teflon pledget granuloma in a patient who had undergone aortic valve replacement six months before death. Other iatrogenic causes of coronary artery occlusion or compression are discussed in this paper. To our knowledge this is the first report of this surgical complication.

Sex Differences in Phenotypes of Bicuspid Aortic Valve and Aortopathy: Insights From a Large Multicenter, International Registry.

PubMed

Kong, William K F; Regeer, Madelien V; Ng, Arnold C T; McCormack, Louise; Poh, Kian Keong; Yeo, Tiong Cheng; Shanks, Miriam; Parent, Sarah; Enache, Roxana; Popescu, Bogdan A; Yip, James W; Ma, Lawrence; Kamperidis, Vasileios; van der Velde, Enno T; Mertens, Bart; Ajmone Marsan, Nina; Delgado, Victoria; Bax, Jeroen J

2017-03-01

This large multicenter, international bicuspid aortic valve (BAV) registry aimed to define the sex differences in prevalence, valve morphology, dysfunction (aortic stenosis/regurgitation), aortopathy, and complications (endocarditis and aortic dissection). Demographic, clinical, and echocardiographic data at first presentation of 1992 patients with BAV (71.5% men) were retrospectively analyzed. BAV morphology and valve function were assessed; aortopathy configuration was defined as isolated dilatation of the sinus of Valsalva or sinotubular junction, isolated dilatation of the ascending aorta distal to the sinotubular junction, or diffuse dilatation of the aortic root and ascending aorta. New cases of endocarditis and aortic dissection were recorded. There were no significant sex differences regarding BAV morphology and frequency of normal valve function. When presenting with moderate/severe aortic valve dysfunction, men had more frequent aortic regurgitation than women (33.8% versus 22.2%, P <0.001), whereas women were more likely to have aortic stenosis (34.5% versus 44.1%, P <0.001). Men had more frequently isolated dilatation of the sinus of Valsalva or sinotubular junction (14.2% versus 6.7%, P <0.001) and diffuse dilatation of the aortic root and ascending aorta (16.2% versus 7.3%, P <0.001) than women. Endocarditis (4.5% versus 2.5%, P =0.037) and aortic dissections (0.5% versus 0%, P <0.001) occurred more frequently in men. Although there is a male predominance among patients with BAV, men with BAV had more frequently moderate/severe aortic regurgitation at first presentation compared with women, whereas women presented more often with moderate/severe aortic stenosis compared with men. Furthermore, men had more frequent aortopathy than women. © 2017 American Heart Association, Inc.

Delayed Infective Endocarditis with Mycotic Aneurysm Rupture below the Mechanical Valved Conduit after the Bentall Procedure.

PubMed

Chen, Mei-Ling; Chen, Michael Y; Yin, Wei-Hsian; Wei, Jeng; Wang, Ji-Hung

2014-07-01

The Bentall procedure is the gold standard for treating aortic dissection complicated with valvular and ascending aorta disease. Recent results for this procedure have been excellent; nearly 100% of patients remain free of infective endocarditis in long-term follow-up. We report a case of delayed Streptococcus agalactiae infective endocarditis complicated by mycotic aneurysm in a man who had undergone the Bentall procedure with a mechanical valve conduit 15 years previously. The mycotic aneurysm was located in the remnant aortic root, below the mechanical valve conduit, and later ruptured into the right atrium. The patient was treated conservatively and survived the acute period. Later, the aortic root defect was repaired successfully by means of a hybrid technique using a Amplatzer duct occluder. Amplatzer duct occluder; Aortic dissection; Bentall technique; Infective endocarditis; Mycotic aneurysm.

Aortic valve replacement in a dialysis-dependent Jehovah's Witness: successful use of a minicircuit, microplegia, and multimodality blood conservation technique

PubMed Central

Sutton, Steve W.; Marcel, Randy

2007-01-01

We present the first reported case of an aortic valve replacement operation without blood transfusion in a 62-year-old Jehovah's Witness with dialysis-dependent chronic renal failure, severe anemia, severe aortic stenosis, and symptomatic angina with minimal exertion after an accident in which she suffered fractures of both her right arm and leg. She underwent successful valve replacement surgery after preoperative stabilization of her fractures and high-dose erythropoietin and iron supplement therapy preoperatively and postoperatively. The intraoperative blood conservation technique included a novel approach with a miniature cardiopulmonary bypass circuit and microplegia with limited hemodilution. High-risk valve surgery in patients who are Jehovah's Witnesses can be successful with a carefully planned multimodality blood conservation strategy. PMID:17256040

Aortic annulus and ascending aorta: comparison of preoperative and periooperative measurement in patients with aortic stenosis.

PubMed

Smíd, Michal; Ferda, Jirí; Baxa, Jan; Cech, Jakub; Hájek, Tomás; Kreuzberg, Boris; Rokyta, Richard

2010-04-01

Precise determination of the aortic annulus size constitutes an integral part of the preoperative evaluation prior to aortic valve replacement. It enables the estimation of the size of prosthesis to be implanted. Knowledge of the size of the ascending aorta is required in the preoperative analysis and monitoring of its dilation enables the precise timing of the operation. Our goal was to compare the precision of measurement of the aortic annulus and ascending aorta using magnetic resonance (MR), multidetector-row computed tomography (MDCT), transthoracic echocardiography (TTE), and transoesophageal echocardiography (TEE) in patients with degenerative aortic stenosis. A total of 15 patients scheduled to have aortic valve replacement were enrolled into this prospective study. TTE was performed in all patients and was supplemented with TEE, CT and MR in the majority of patients. The values obtained were compared with perioperative measurements. For the measurement of aortic annulus, MR was found to be the most precise technique, followed by MDCT, TTE, and TEE. For the measurement of ascending aorta, MR again was found to be the most precise technique, followed by MDCT, TEE, and TTE. In our study, magnetic resonance was found to be the most precise technique for the measurement of aortic annulus and ascending aorta in patients with severe degenerative aortic stenosis. Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Aortic Root Biomechanics After Sleeve and David Sparing Techniques: A Finite Element Analysis.

PubMed

Tasca, Giordano; Selmi, Matteo; Votta, Emiliano; Redaelli, Paola; Sturla, Francesco; Redaelli, Alberto; Gamba, Amando

2017-05-01

Aortic root aneurysm can be treated with valve-sparing procedures. The David and Yacoub techniques have shown excellent long-term results but are technically demanding. Recently, a new and simpler procedure, the Sleeve technique, was proposed with encouraging results. We aimed to quantify the biomechanics of the initially aneurysmal aortic root (AR) after the Sleeve procedure to assess whether it induces abnormal stresses, potentially undermining its durability. Two finite element (FE) models of the physiologic and aneurysmal AR were built, accounting for the anatomical asymmetry and the nonlinear and anisotropic mechanical properties of human AR tissues. On the aneurysmal model, the Sleeve and David techniques were simulated based on the corresponding published technical features. Aortic root biomechanics throughout 2 consecutive cardiac cycles were computed in each simulated configuration. Both sparing techniques restored physiologic-like kinematics of aortic valve (AV) leaflets but induced different leaflets stresses. The time course averaged over the leaflets' bellies was 35% higher in the David model than in the Sleeve model. Commissural stresses, which were equal to 153 and 318 kPa in the physiologic and aneurysmal models, respectively, became 369 and 208 kPa in the David and Sleeve models, respectively. No intrinsic structural problems were detected in the Sleeve model that might jeopardize the durability of the procedure. If corroborated by long-term clinical outcomes, the results obtained suggest that using this new technique could successfully simplify the surgical repair of AR aneurysms and reduce intraoperative complications. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

77 FR 53202 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-31

... efficacy of the TAVR technologies for the treatment of aortic stenosis. The data will also include the... surveillance of the quality, safety and efficacy of new medical devices to treat aortic stenosis. For purposes... Determination (NCD) entitled, ``Transcatheter Aortic Valve Replacement (TAVR)''. The TAVR device is only covered...

The utility of trans-catheter aortic valve replacement after commercialization: does the European experience provide a glimpse into the future use of this technology in the United States?

PubMed

Linke, Axel; Walther, Thomas; Schuler, Gerhard

2010-03-01

Treatment of aortic stenosis remains challenging in older individuals, as their perioperative mortality for open heart surgery is increased due to comorbidities. Transcatheter aortic valve implantation using the CoreValve ReValving System (Medtronic, Minneapolis, USA) and the Edwards SAPIEN transcatheter heart valve (THV; Edwards Lifescience, Irvine, California, USA) represents an alternative to conventional valve replacement in elderly patients that have a high risk for conventional surgery. This article summarizes the evidence-base from recent clinical trials. The early results of these landmark studies suggest that transcatheter aortic valve implantation with either one of the prosthesis is feasible, safe, improves hemodynamics and, therefore, might be an alternative to conventional aortic valve replacement in very high-risk patients. However, all of the available transcatheter heart valves have certain disadvantages, limiting their use in daily clinical practice. The process of decision making, which valve to use and which access route to choose is illustrated in this article through clinical case scenarios. Additionally, the lessons learned thus far from the European perspective and the potential impact on the future use in the US are discussed. Despite of the progress in this field, we are still lacking an optimal transcatheter heart valve. Once it is available, we can take the plunge to compare transcatheter valve implantation with convention surgery in severe aortic stenosis!

Predictive factor of secondary tricuspid regurgitation after aortic valve replacement for aortic stenosis: the importance of myocardial hypertrophy and diastolic dysfunction.

PubMed

Igarashi, Takashi; Tanji, Masahiro; Takahashi, Koki; Ishida, Keiichi; Sasaki, Satomi; Yokoyama, Hitoshi

2017-05-01

The aim of this study is to determine the predictors of secondary tricuspid regurgitation after aortic valve replacement for aortic stenosis. Seventy-one patients, who underwent aortic valve replacement for aortic stenosis at our institute from January 2006 to July 2011, were divided into two groups: an STR group, which included 15 patients with moderate or greater than moderate secondary tricuspid regurgitation at a follow-up visit and a control group. Echocardiography was performed before surgery, at discharge, and at a late follow-up visit (mean follow-up 36 ± 19 months, range 0-77). Preoperatively, the number of women (p < .01), body surface area (p < .001), and relative wall thickness (0.60 ± 0.15 vs 0.71 ± 0.13, p = .022) showed significant differences between the two groups. At a follow-up visit, moderate or severe mitral regurgitation (p = .0001) and severe diastolic dysfunction (p = .003) showed significant differences between the two groups. In the Cox regression analysis, moderate or severe mitral regurgitation at follow-up (p = .038, hazard ratio 4.394, 95% CI 1.085-17.791) was the only independent predictor of secondary tricuspid regurgitation. This study suggested that preoperative concentric myocardial hypertrophy and diastolic dysfunction were associated with development of the secondary tricuspid regurgitation at late follow-up.

Retrograde Ascending Aortic Dissection after Stent Grafting for Stanford Type B Aortic Dissection with Severe Limb Ischemia.

PubMed

Higuchi, Yoshiro; Tochii, Masato; Takami, Yoshiyuki; Kobayashi, Akihiro; Yanagisawa, Tsutomu; Amano, Kentaro; Sakurai, Yusuke; Ishida, Michiko; Ishikawa, Hiroshi; Hattori, Koji; Takagi, Yasushi

2017-03-24

We report a rare case of retrograde Stanford type A aortic dissection after endovascular repair for complicated Stanford type B aortic dissection. A 45-year-old man presented with a sudden onset of back pain and was transferred to our hospital. Computed tomography demonstrated acute Stanford type B aortic dissection with lower limb ischemia. Emergency endovascular surgery was planned for repair of the Stanford type B aortic dissection. The patient suddenly developed recurrent chest pain 10 days after the initial procedure. Computed tomography revealed retrograde Stanford type A aortic dissection involving the ascending aorta and aortic arch. The patient underwent a successful emergency total aortic arch replacement.

Relationship between fibrillin-1 genotype and severity of cardiovascular involvement in Marfan syndrome.

PubMed

Franken, Romy; Teixido-Tura, Gisela; Brion, Maria; Forteza, Alberto; Rodriguez-Palomares, Jose; Gutierrez, Laura; Garcia Dorado, David; Pals, Gerard; Mulder, Barbara Jm; Evangelista, Artur

2017-11-01

The effect of FBN1 mutation type on the severity of cardiovascular manifestations in patients with Marfan syndrome (MFS) has been reported with disparity results. This study aims to determine the impact of the FBN1 mutation type on aortic diameters, aortic dilation rates and on cardiovascular events (ie, aortic dissection and cardiovascular mortality). MFS patients with a pathogenic FBN1 mutation followed at two specialised units were included. FBN1 mutations were classified as being dominant negative (DN; incorporation of non-mutated and mutated fibrillin-1 in the extracellular matrix) or having haploinsufficiency (HI; only incorporation of non-mutated fibrillin-1, thus a decreased amount of fibrillin-1 protein). Aortic diameters and the aortic dilation rate at the level of the aortic root, ascending aorta, arch, descending thoracic aorta and abdominal aorta by echocardiography and clinical endpoints comprising dissection and death were compared between HI and DN patients. Two hundred and ninety patients with MFS were included: 113 (39%) with an HI- FBN1 mutation and 177 (61%) with a DN- FBN1 . At baseline, patients with HI- FBN1 had a larger aortic root diameter than patients with DN- FBN1 (HI: 39.3±7.2 mm vs DN: 37.3±6.8 mm, p=0.022), with no differences in age or body surface area. After a mean follow-up of 4.9±2.0 years, aortic root and ascending dilation rates were increased in patients with HI- FBN1 (HI: 0.57±0.8 vs DN: 0.28±0.5 mm/year, p=0.004 and HI: 0.59±0.9 vs DN: 0.30±0.7 mm/year, p=0.032, respectively). Furthermore, patients with HI- FBN1 tended to be at increased risk for the combined endpoint of dissection and death compared with patients with DN- FBN1 (HR: 3.3, 95% CI 1.0 to 11.4, p=0.060). Patients with an HI mutation had a more severely affected aortic phenotype, with larger aortic root diameters and a more rapid dilation rate, and tended to have an increased risk of death and dissections compared with patients with a DN mutation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Echocardiographic Methods, Quality Review, and Measurement Accuracy in a Randomized Multicenter Clinical Trial of Marfan Syndrome

PubMed Central

Selamet Tierney, Elif Seda; Levine, Jami C.; Chen, Shan; Bradley, Timothy J.; Pearson, Gail D.; Colan, Steven D.; Sleeper, Lynn A.; Campbell, M. Jay; Cohen, Meryl S.; Backer, Julie De; Guey, Lin T.; Heydarian, Haleh; Lai, Wyman W.; Lewin, Mark B.; Marcus, Edward; Mart, Christopher R.; Pignatelli, Ricardo H.; Printz, Beth F.; Sharkey, Angela M.; Shirali, Girish S.; Srivastava, Shubhika; Lacro, Ronald V.

2013-01-01

Background The Pediatric Heart Network is conducting a large international randomized trial to compare aortic root growth and other cardiovascular outcomes in 608 subjects with Marfan syndrome randomized to receive atenolol or losartan for 3 years. The authors report here the echocardiographic methods and baseline echocardiographic characteristics of the randomized subjects, describe the interobserver agreement of aortic measurements, and identify factors influencing agreement. Methods Individuals aged 6 months to 25 years who met the original Ghent criteria and had body surface area–adjusted maximum aortic root diameter (ROOTmax) Z scores > 3 were eligible for inclusion. The primary outcome measure for the trial is the change over time in ROOTmax Z score. A detailed echocardiographic protocol was established and implemented across 22 centers, with an extensive training and quality review process. Results Interobserver agreement for the aortic measurements was excellent, with intraclass correlation coefficients ranging from 0.921 to 0.989. Lower interobserver percentage error in ROOTmax measurements was independently associated (model R2 = 0.15) with better image quality (P = .002) and later study reading date (P < .001). Echocardiographic characteristics of the randomized subjects did not differ by treatment arm. Subjects with ROOTmax Z scores ≥ 4.5 (36%) were more likely to have mitral valve prolapse and dilation of the main pulmonary artery and left ventricle, but there were no differences in aortic regurgitation, aortic stiffness indices, mitral regurgitation, or left ventricular function compared with subjects with ROOTmax Z scores < 4.5. Conclusions The echocardiographic methodology, training, and quality review process resulted in a robust evaluation of aortic root dimensions, with excellent reproducibility. PMID:23582510

Improvement of aortic valve stenosis by ApoA-I mimetic therapy is associated with decreased aortic root and valve remodelling in mice

PubMed Central

Trapeaux, J; Busseuil, D; Shi, Y; Nobari, S; Shustik, D; Mecteau, M; El-Hamamsy, I; Lebel, M; Mongrain, R; Rhéaume, E; Tardif, J-C

2013-01-01

Background and Purpose We have shown that infusions of apolipoprotein A-I (ApoA-I) mimetic peptide induced regression of aortic valve stenosis (AVS) in rabbits. This study aimed at determining the effects of ApoA-I mimetic therapy in mice with calcific or fibrotic AVS. Experimental Approach Apolipoprotein E-deficient (ApoE−/−) mice and mice with Werner progeria gene deletion (WrnΔhel/Δhel) received high-fat diets for 20 weeks. After developing AVS, mice were randomized to receive saline (placebo group) or ApoA-I mimetic peptide infusions (ApoA-I treated groups, 100 mg·kg−1 for ApoE−/− mice; 50 mg·kg−1 for Wrn mice), three times per week for 4 weeks. We evaluated effects on AVS using serial echocardiograms and valve histology. Key Results Aortic valve area (AVA) increased in both ApoE−/− and Wrn mice treated with the ApoA-I mimetic compared with placebo. Maximal sinus wall thickness was lower in ApoA-I treated ApoE−/− mice. The type I/III collagen ratio was lower in the sinus wall of ApoA-I treated ApoE−/− mice compared with placebo. Total collagen content was reduced in aortic valves of ApoA-I treated Wrn mice. Our 3D computer model and numerical simulations confirmed that the reduction in aortic root wall thickness resulted in improved AVA. Conclusions and Implications ApoA-I mimetic treatment reduced AVS by decreasing remodelling and fibrosis of the aortic root and valve in mice. PMID:23638718

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis.

PubMed

Lindman, Brian R; Otto, Catherine M; Douglas, Pamela S; Hahn, Rebecca T; Elmariah, Sammy; Weissman, Neil J; Stewart, William J; Ayele, Girma M; Zhang, Feifan; Zajarias, Alan; Maniar, Hersh S; Jilaihawi, Hasan; Blackstone, Eugene; Chinnakondepalli, Khaja M; Tuzcu, E Murat; Leon, Martin B; Pibarot, Philippe

2017-07-01

After aortic valve replacement, left ventricular afterload is often characterized by the residual valve obstruction. Our objective was to determine whether higher systemic arterial afterload-as reflected in blood pressure, pulsatile and resistive load-is associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). Total, pulsatile, and resistive arterial load were measured in 2141 patients with severe aortic stenosis treated with TAVR in the PARTNER I trial (Placement of Aortic Transcatheter Valve) who had systolic blood pressure (SBP) and an echocardiogram obtained 30 days after TAVR. The primary end point was 30-day to 1-year all-cause mortality. Lower SBP at 30 days after TAVR was associated with higher mortality (20.0% for SBP 100-129 mm Hg versus 12.0% for SBP 130-170 mm Hg; P <0.001). This association remained significant after adjustment, was consistent across subgroups, and confirmed in sensitivity analyses. In adjusted models that included SBP, higher total and pulsatile arterial load were associated with increased mortality ( P <0.001 for all), but resistive load was not. Patients with low 30-day SBP and high pulsatile load had a 3-fold higher mortality than those with high 30-day SBP and low pulsatile load (26.1% versus 8.1%; hazard ratio, 3.62; 95% confidence interval, 2.36-5.55). Even after relief of valve obstruction in patients with aortic stenosis, there is an independent association between post-TAVR blood pressure, systemic arterial load, and mortality. Blood pressure goals in patients with a history of aortic stenosis may need to be redefined. Increased pulsatile arterial load, rather than blood pressure, may be a target for adjunctive medical therapy to improve outcomes after TAVR. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894. © 2017 American Heart Association, Inc.

Aortic arch/elephant trunk procedure with Sienna(TM) graft and endovascular stenting of thoraco-abdominal aorta for treatment of complex chronic dissection.

PubMed

Wong, Randolph H L; Baghai, Max; Yu, Simon C H; Underwood, Malcolm J

2013-05-01

Aneurismal dilatation of the remaining thoracic aorta after ascending aortic interposition grafting for type 'A' aortic dissection is not uncommon. For such complex cases, one treatment option is total arch replacement and elephant trunk procedure with the Sienna(TM) collared graft (Vascutek, Inchinnan, UK) technique followed by a staged thoracic endovascular aortic repair (TEVAR). The video illustrates our technique in a 56-year-old man with an extensive aortic arch and descending thoracic aortic dissecting aneurysm. For the 'open' procedure femoral arterial and venous cannulation was used along with systemic cooling and circulatory arrest at 22 °C. Upon circulatory arrest, the aortic arch was incised and antegrade cerebral perfusion achieved via selective cannulation to the right brachiocephalic and left common carotid artery, keeping flow rates at 10-15 mL/kg/min and perfusion pressure at 50-60 mmHg. Arch replacement with an elephant trunk component was then performed and after completion of the distal aortic anastomosis antegrade perfusion via a side-arm in the graft was started and the operation completed using a variation of the 'sequential' clamping technique to maximize cerebral perfusion. The second endovascular stage was performed two weeks after discharge. Two covered stents were landing from the elephant trunk to the distal descending thoracic aorta, to secure the distal landing a bare stent of was placed to cover the aorta just distal to the origin of the celiac axis. The left subclavian artery was embolised with fibre coils. Post TEVAR angiogram showed no endoleak Although re-operative total arch replacement and elephant trunk procedure and subsequent TEVAR remained a challenging procedure, we believe excellent surgical outcome can be achieved with carefully planned operative strategy.

[Short and long term results of aortic valve replacement in patients 80 years of age and older].

PubMed

Mortasawi, A; Gehle, S; Yaghmaie, M; Schröder, T; Ennker, I C; Rosendahl, U; Albert, A; Ennker, J

2001-03-01

Due to demographic changes in average life expectancy the age of patients undergoing cardiac surgery is increasing as well. We have reviewed the short- and long-term outcome in patients over 80 years of age after aortic valve replacement with or without concomitant coronary grafting. From 1.1.1995 until 31.12.1999, 126 patients (93 women, 33 men between 80 and 89 years, 82.8 +/- 2.4) underwent aortic valve replacement. 64 patients (group A) received isolated valve replacement, 62 (group B) underwent myocardial revascularization as well. The 30-day hospital mortality rate was 6.3% for group A and 14.5% for group B. The follow-up time ranged between 3 and 63 months (32 +/- 16). None of the patients had to be reoperated for prosthetic valve dysfunction or endocarditis. Bleeding complications due to anticoagulation therapy were observed by one patient from group A 3 years after the operation. Of the 15 deaths during the follow-up period seven (47%) were cardiac in nature and two (13%) related to stroke. Acturial survival rates for group A were 89%, 85% and 77% at 1, 2 and 3 years, and for group B 76%, 72% and 70%. Permanent nursing care was not required 1 year after the operation by 100% of patients in group A (2 years: 98%, 3 years 95%) and by 100% of patients in group B (2 years: 93%, 3 years: 90%). At an interval of 1 year after the operation 96% of patients in group A had not been hospitalized as a result of cardiac disorders (2 years: 96%, 3 years: 94%). The rates for group B were 88%, 81% and 75%. Compared with younger age groups, aortic valve replacement in patients 80 years of age and older is associated with a distinctly increased mortality and morbidity. However, our data suggest that considering the poor prognosis of conservative therapy of symptomatic aortic valve disease, functional status as well as life expectancy in this age group seem to be positively influenced by aortic valve replacement.

Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian Society of Cardiology and GISE.

PubMed

Indolfi, Ciro; Bartorelli, Antonio L; Berti, Sergio; Golino, Paolo; Esposito, Giovanni; Musumeci, Giuseppe; Petronio, Sonia; Tamburino, Corrado; Tarantini, Giuseppe; Ussia, Gianpaolo; Vassanelli, Corrado; Spaccarotella, Carmen; Violini, Roberto; Mercuro, Giuseppe; Romeo, Francesco

2018-05-01

: The introduction of percutaneous treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) remains one of the greatest achievements of interventional cardiology. In fact, TAVI emerged as a better option than either medical therapy or balloon aortic valvuloplasty for patients who cannot undergo surgical aortic valve replacement (SAVR) or are at high surgical risk. Recently, increased operator experience and improved device systems have led to a worldwide trend toward the extension of TAVI to low-risk or intermediate-risk patients. In this expert opinion paper, we first discuss the basic pathophysiology of aortic stenosis in different settings then the key results of recent clinical investigations on TAVI in intermediate-risk aortic stenosis patients are summarized. Particular emphasis is placed on the results of the nordic aortic valve intervention, placement of aortic transcatheter valves (PARTNER) 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation Randomized trials. The PARTNER 2 was the first large randomized trial that evaluated the outcome of TAVI in patients at intermediate risk. The PARTNER 2 data demonstrated that TAVI is a feasible and reasonable alternative to surgery in intermediate-risk patients (Society of Thoracic Surgeons 4-8%), especially if they are elderly or frail. There was a significant interaction between TAVI approach and mortality, with transfemoral TAVI showing superiority over SAVR. Moreover, we examine the complementary results of the recently concluded Surgical Replacement and Transcatheter Aortic Valve Implantation trial. This prospective randomized trial demonstrated that TAVI is comparable with surgery (primary end point 12.6% in the TAVI group vs. 14.0% in the SAVR group) in severe aortic stenosis patients deemed to be at intermediate risk. We review the most relevant clinical evidence deriving from nonrandomized studies and meta-analyses. Altogether, clinical outcome available data suggest that TAVI with a newer generation device might be the preferred treatment option in this patient subgroup. Finally, the differences between the latest European and American Guidelines on TAVI were reported and discussed. The conclusion of this expert opinion article is that TAVI, if feasible, is the treatment of choice in patients with prohibitive or high surgical risk and may lead to similar or lower early and midterm mortality rates compared with SAVR in intermediate-risk patients with severe aortic stenosis.

Successful simultaneous ipsilateral stenting of common iliac artery stenosis and transfemoral aortic valve replacement.

PubMed

Aslan, Abdullah Nabi; Kasapkara, Hacı Ahmet; Sivri, Serkan; Güney, Murat Can; Bozkurt, Engin

2017-01-01

Transcatheter aortic valve replacement (TAVR) was designed to treat elderly patients with severe aortic stenosis at high risk for surgery, and is most commonly performed with retrograde approach through femoral arteries. However, in up to 30% of cases, it is either not possible to use this access route or it is considered to have high risk of vascular injury. Alternative approaches have been described for patients with no suitable femoral access: trans-subclavian, transaortic, or direct aortic access; however, since the introduction of new valves deployed with low-profile delivery systems, another alternative transcatheter approach has been discovered. Presently described is experience in 2 cases in which patients were treated with transfemoral TAVR using Edwards SAPIEN 3 transcatheter heart valves immediately following ipsilateral common iliac artery stenting.

Outcomes of Transcatheter and Surgical Aortic Valve Replacement in Patients on Maintenance Dialysis.

PubMed

Alqahtani, Fahad; Aljohani, Sami; Boobes, Khaled; Maor, Elad; Sherieh, Assem; Rihal, Charanjit S; Holmes, David R; Alkhouli, Mohamad

2017-12-01

The introduction of transcatheter aortic valve replacement (TAVR) expanded definitive therapy of aortic stenosis to many high-risk patients, but it has not been fully evaluated in the dialysis population. We aimed to evaluate the current trend and in-hospital outcome of surgical aortic valve replacement (SAVR) and TAVR in the dialysis population. Severe aortic stenosis patients on maintenance dialysis who underwent SAVR or TAVR in the Nationwide Inpatient Sample database from January 1, 2005, through December 31, 2014, were included in our comparative analysis. The trends of SAVR and TAVR were assessed. In-hospital mortality, rates of major adverse events, hospital length of stay, cost of care, and intermediate care facility utilization were compared between the 2 groups using both unadjusted and propensity-matched data. Utilization of aortic valve replacement in dialysis patients increased 3-fold; a total of 2531 dialysis patients who underwent either SAVR (n = 2264) or TAVR (n = 267) between 2005 and 2014 were identified. Propensity score matching yielded 197 matched pairs. After matching, a 2-fold increase in in-hospital mortality was found with SAVR compared with TAVR (13.7% vs 6.1%, P = .021). Patients who underwent TAVR had more permanent pacemaker implantation (13.2% vs 5.6%, P = .012) but less blood transfusion (43.7% vs 56.8%, P = .02). Rates of other key morbidities were similar. Hospital length of stay (19 ± 16 vs 11 ± 11 days, P <.001) and non-home discharges (44.7% vs 31.5%, P = .002) were significantly higher with SAVR. Cost of hospitalization was 25% less with TAVR. In patients on maintenance dialysis, TAVR is associated with lower hospital mortality, resource utilization, and cost in comparison with SAVR. Copyright © 2017 Elsevier Inc. All rights reserved.

Aortic cusp extension for surgical correction of rheumatic aortic valve insufficiency in children.

PubMed

Kalangos, Afksendiyos; Myers, Patrick O

2013-10-01

Surgical management of aortic insufficiency in the young is problematic because of the lack of an ideal valve substitute. Potential advantages of aortic valve repair include low incidences of thromboembolism and endocarditis, avoiding conduit replacements, the maintenance of growth potential, and improved quality of life. Aortic valve repair is still far from fulfilling the three key factors that have allowed the phenomenal development of mitral valve repair (standardization, reproducibility, and stable long-term results); however, techniques of aortic valve repair have been refined, and subsets of patients amenable to repair have been identified. We have focused on the oldest technique of aortic valve repair, cusp extension, focusing on children with rheumatic aortic insufficiency. Among 77 children operated from 2003 to 2007, there was one early death from ventricular failure and one late death from sudden cardiac arrhythmia. During a mean follow-up of 12.8 ± 5.9 years, there were 16 (20.5%) reoperations on the aortic valve, at a median of 3.4 years (range, 2 months to 18.3 years) from repair. Freedom from aortic valve reoperation was 96.2% ± 2.2% at 1 year, 94.9% ± 2.5% at 2 years, 88.5% ± 3.6% at 5 years, 81.7% ± 4.4% at 10 years, 79.7% ± 4.8% at 15 years, and 76.2% ± 5.7% at 20 years. Although aortic cusp extension is technically more demanding, it remains particularly more suitable in the context of evolving rheumatic aortic insufficiency in children with a small aortic annulus as a bridge surgical approach to late aortic valve replacement with a larger valvular prosthesis.

Diminutive Porcelain Ascending Aorta With Supravalvular Aortic Stenosis.

PubMed

Houmsse, Mustafa; McDavid, Asia; Kilic, Ahmet

2018-05-01

This report describes the case of a 49-year-old man with a medical history significant for congenital aortic stenosis. The patient presented with progressive shortness of breath and decreased stamina and was found to have a concentric, diminutive porcelain ascending aorta with diffuse supravalvular aortic stenosis. We describe treatment with an aortic root augmentation and Bentall procedure using hypothermic circulatory arrest. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Prosthetic Aortic Valves: Challenges and Solutions

PubMed Central

Musumeci, Lucia; Jacques, Nicolas; Hego, Alexandre; Nchimi, Alain; Lancellotti, Patrizio; Oury, Cécile

2018-01-01

Aortic Valve Disease (AVD) is the most common Valvular Heart Disease (VHD), affecting millions of people worldwide. Severe AVD is treated in most cases with prosthetic aortic valve replacement, which involves the substitution of the native aortic valve with a prosthetic one. In this review we will discuss the different types of prosthetic aortic valves available for implantation and the challenges faced by patients, medical doctors, researchers and manufacturers, as well as the approaches that are taken to overcome them. PMID:29868612

Transcatheter aortic valve replacement: historical perspectives, current evidence, and future directions.

PubMed

Horne, Aaron; Reineck, Elizabeth A; Hasan, Rani K; Resar, Jon R; Chacko, Matthews

2014-10-01

Severe aortic stenosis (AS) results in considerable morbidity and mortality without aortic valve replacement and is expected to increase in prevalence with the aging population. Because AS primarily affects the elderly, many patients with comorbidities are poor candidates for surgical aortic valve replacement (SAVR) and may not be referred. Transcatheter aortic valve replacement (TAVR) has emerged as transformative technology for the management of AS over the past decade. Randomized trials have established the safety and efficacy of TAVR with improved mortality and quality of life compared with medical therapy in inoperable patients, while demonstrating noninferiority and even superiority to SAVR among high-risk operative candidates. However, early studies demonstrated an early penalty of stroke and vascular complications with TAVR as well as increased paravalvular leak as compared with SAVR. Two device platforms have been evaluated and approved for use in the United States: the Edwards SAPIEN and the Medtronic CoreValve. Early studies also suggest cost-effectiveness for TAVR. Ongoing studies are evaluating new iterations of the aforementioned TAVR devices, novel device designs, and applications of TAVR in expanded populations of patients including those with lower risk profiles as well as those with comorbidities that were excluded from early clinical trials. Future improvements in TAVR technology will likely reduce periprocedural and long-term complications. Further studies are needed to confirm device durability over long-term follow-up and explore the applicability of TAVR to broader AS patient populations. Copyright © 2014 Mosby, Inc. All rights reserved.

Realistic Vascular Replicator for TAVR Procedures.

PubMed

Rotman, Oren M; Kovarovic, Brandon; Sadasivan, Chander; Gruberg, Luis; Lieber, Baruch B; Bluestein, Danny

2018-04-13

Transcatheter aortic valve replacement (TAVR) is an over-the-wire procedure for treatment of severe aortic stenosis (AS). TAVR valves are conventionally tested using simplified left heart simulators (LHS). While those provide baseline performance reliably, their aortic root geometries are far from the anatomical in situ configuration, often overestimating the valves' performance. We report on a novel benchtop patient-specific arterial replicator designed for testing TAVR and training interventional cardiologists in the procedure. The Replicator is an accurate model of the human upper body vasculature for training physicians in percutaneous interventions. It comprises of fully-automated Windkessel mechanism to recreate physiological flow conditions. Calcified aortic valve models were fabricated and incorporated into the Replicator, then tested for performing TAVR procedure by an experienced cardiologist using the Inovare valve. EOA, pressures, and angiograms were monitored pre- and post-TAVR. A St. Jude mechanical valve was tested as a reference that is less affected by the AS anatomy. Results in the Replicator of both valves were compared to the performance in a commercial ISO-compliant LHS. The AS anatomy in the Replicator resulted in a significant decrease of the TAVR valve performance relative to the simplified LHS, with EOA and transvalvular pressures comparable to clinical data. Minor change was seen in the mechanical valve performance. The Replicator showed to be an effective platform for TAVR testing. Unlike a simplified geometric anatomy LHS, it conservatively provides clinically-relevant outcomes and complement it. The Replicator can be most valuable for testing new valves under challenging patient anatomies, physicians training, and procedural planning.

[Evaluation of the antithrombotic strategy in low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis].

PubMed

Aceves-Velázquez, Eduardo; Vieyra-Herrera, Gerardo; Rodríguez-Chávez, Laura; Herrera-Alarcón, Valentín

2017-07-16

According to current guidelines, in patients without additional risk factors who have undergone aortic valve replacement with a bioprosthesis, anticoagulation in the first 3 months after surgery is still a matter of debate. According to current evidence, aspirin in low doses is a reasonable alternative to vitamin K antagonists (VKA). A comparison is made between the incidence of thrombotic and haemorrhagic complications in patients with low thrombotic risk who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico. The hypothesis: aspirin as monotherapy has a beneficial effect compared to VKA. The studied patients were the low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico from 2011 to 2015. The groups studied were: aspirin only, VKA only, and the combination of VKA plus aspirin. The patients were retrospectively followed-up for 12 months, and the thrombotic and haemorrhagic complications were documented. Of the 231 patients included in the study, only one patient in the VKA only group presented with a haemorrhagic complication. No thrombotic complications were observed. In the present study no thrombotic complications were observed in patients who did not receive anticoagulation in the first 3 months after an aortic valve replacement with a bioprosthesis after a follow up period of 12 months. This suggests that the use of aspirin only is safe during this period. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement.

PubMed

Tanaka, Akiko; Estrera, Anthony L

2018-01-01

Cerebral complication is a major concern after aortic arch surgery, which may lead to death. Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair. Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain. However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field-and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution.

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

PubMed Central

Tanaka, Akiko

2018-01-01

Cerebral complication is a major concern after aortic arch surgery, which may lead to death. Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair. Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain. However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field—and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution. PMID:29682460

Surgical outcomes in native valve infectious endocarditis: the experience of the Cardiovascular Surgery Department - Cluj-Napoca Heart Institute.

PubMed

Molnar, Adrian; Muresan, Ioan; Trifan, Catalin; Pop, Dana; Sacui, Diana

2015-01-01

The introduction of Duke's criteria and the improvement of imaging methods has lead to an earlier and a more accurate diagnosis of infectious endocarditis (IE). The options for the best therapeutic approach and the timing of surgery are still a matter of debate and require a close colaboration between the cardiologist, the infectionist and the cardiac surgeon. We undertook a retrospective, descriptive study, spanning over a period of five years (from January 1st, 2007 to December 31st, 2012), on 100 patients who underwent surgery for native valve infectious endocarditis in our unit. The patients' age varied between 13 and 77 years (with a mean of 54 years), of which 85 were males (85%). The main microorganisms responsible for IE were: Streptococcus Spp. (21 cases - 21%), Staphylococcus Spp. (15 cases - 15%), and Enterococcus Spp. (9 cases - 9%). The potential source of infection was identified in 26 patients (26%), with most cases being in the dental area (16 cases - 16%). The lesions caused by IE were situated in the left heart in 96 patients (96%), mostly on the aortic valve (50 cases - 50%). In most cases (82%) we found preexisting endocardial lesions which predisposed to the development of IE, most of them being degenerative valvular lesions (38 cases - 38%). We performed the following surgical procedures: surgery on a single valve - aortic valve replacement (40 cases), mitral valve replacement (19 cases), mitral valve repair (1 case), surgery on more than one valve - mitral and aortic valve replacement (20 cases), aortic and tricuspid valve replacement (1 case), aortic valve replacement with a mechanical valve associated with mitral valve repair (5 cases), aortic valve replacement with a biological valve associated with mitral valve repair (2 cases), and mitral valve replacement with a mechanical valve combined with De Vega procedure on the tricuspid valve (1 case). In 5 patients (5%) the bacteriological examination of valve pieces excised during surgery was positive. In 3 cases it matched the germ identified in the hemocultures, and in 2 cases it evidenced another bacterium. The overall mortality of 5% is well between the limits presented in literature, being higher (30%) in patients who required emergency surgery. For the patients who return into our clinic with prosthetic valve endocarditis, the mortality after surgery was even higher (50%).

Patient selection for transcatheter aortic valve replacement: A combined clinical and multimodality imaging approach

PubMed Central

Cocchia, Rosangela; D’Andrea, Antonello; Conte, Marianna; Cavallaro, Massimo; Riegler, Lucia; Citro, Rodolfo; Sirignano, Cesare; Imbriaco, Massimo; Cappelli, Maurizio; Gregorio, Giovanni; Calabrò, Raffaele; Bossone, Eduardo

2017-01-01

Transcatheter aortic valve replacement (TAVR) has been validated as a new therapy for patients affected by severe symptomatic aortic stenosis who are not eligible for surgical intervention because of major contraindication or high operative risk. Patient selection for TAVR should be based not only on accurate assessment of aortic stenosis morphology, but also on several clinical and functional data. Multi-Imaging modalities should be preferred for assessing the anatomy and the dimensions of the aortic valve and annulus before TAVR. Ultrasounds represent the first line tool in evaluation of this patients giving detailed anatomic description of aortic valve complex and allowing estimating with enough reliability the hemodynamic entity of valvular stenosis. Angiography should be used to assess coronary involvement and plan a revascularization strategy before the implant. Multislice computed tomography play a central role as it can give anatomical details in order to choice the best fitting prosthesis, evaluate the morphology of the access path and detect other relevant comorbidities. Cardiovascular magnetic resonance and positron emission tomography are emergent modality helpful in aortic stenosis evaluation. The aim of this review is to give an overview on TAVR clinical and technical aspects essential for adequate selection. PMID:28400918

Percutaneous Implantation of the self-expanding valve Prosthesis a patient with homozygous familial hypercholesterolemia severe aortic stenosis and porcelain aorta.

PubMed

Sahiner, Levent; Asil, Serkan; Kaya, Ergün Baris; Ozer, Necla; Aytemir, Kudret

2016-10-01

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or inappropriate for open heart surgery. However, concerns exist over treating patients who have porcelain aorta and familial hypercholesterolemia, due to the potential complications of aortic root and aortic annulus. In this case report, we present a patient with familial hypercholesterolemia, symptomatic severe aortic stenosis, previous coronary artery bypass grafting and porcelain aorta, who was successfully treated with TAVI using a CoreValve. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Efficacy of losartan vs. atenolol for the prevention of aortic dilation in Marfan syndrome: a randomized clinical trial.

PubMed

Forteza, Alberto; Evangelista, Arturo; Sánchez, Violeta; Teixidó-Turà, Gisela; Sanz, Paz; Gutiérrez, Laura; Gracia, Teresa; Centeno, Jorge; Rodríguez-Palomares, José; Rufilanchas, Juan Jose; Cortina, José; Ferreira-González, Ignacio; García-Dorado, David

2016-03-21

To determine the efficacy of losartan vs. atenolol in aortic dilation progression in Marfan syndrome (MFS) patients. A phase IIIb, randomized, parallel, double-blind study was conducted in 140 MFS patients, age range: 5-60 years, with maximum aortic diameter <45 mm who received losartan (n = 70) or atenolol (n = 70). Doses were raised to a maximum of 1.4 mg/kg/day or 100 mg/day. The primary end-point was the change in aortic root and ascending aorta maximum diameter indexed by body surface area on magnetic resonance imaging after 36 months of treatment. No serious drug-related adverse effects were observed. Five patients presented aortic events during a follow-up (one in the losartan and four in the atenolol groups, P = 0.366). After 3 years of follow-up, aortic root diameter increased significantly in both groups: 1.1 mm (95% CI 0.6-1.6) in the losartan and 1.4 mm (95% CI 0.9-1.9) in the atenolol group, with aortic dilatation progression being similar in both groups: absolute difference between losartan and atenolol -0.3 mm (95% CI -1.1 to 0.4, P = 0.382) and indexed by BSA -0.5 mm/m2 (95% CI -1.2 to 0.1, P = 0.092). Similarly, no significant differences were found in indexed ascending aorta diameter changes between the losartan and atenolol groups: -0.3 mm/m2 (95% CI -0.8 to 0.3, P = 0.326). Among patients with MFS, the use of losartan compared with atenolol did not result in significant differences in the progression of aortic root and ascending aorta diameters over 3 years of follow-up. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Prognostic Implications of Raphe in Bicuspid Aortic Valve Anatomy.

PubMed

Kong, William K F; Delgado, Victoria; Poh, Kian Keong; Regeer, Madelien V; Ng, Arnold C T; McCormack, Louise; Yeo, Tiong Cheng; Shanks, Miriam; Parent, Sarah; Enache, Roxana; Popescu, Bogdan A; Liang, Michael; Yip, James W; Ma, Lawrence C W; Kamperidis, Vasileios; van Rosendael, Philippe J; van der Velde, Enno T; Ajmone Marsan, Nina; Bax, Jeroen J

2017-03-01

Little is known about the association between bicuspid aortic valve (BAV) morphologic findings and the degree of valvular dysfunction, presence of aortopathy, and complications, including aortic valve surgery, aortic dissection, and all-cause mortality. To investigate the association between BAV morphologic findings (raphe vs nonraphe) and the degree of valve dysfunction, presence of aortopathy, and prognosis (including need for aortic valve surgery, aortic dissection, and all-cause mortality). In this large international multicenter registry of patients with BAV treated at tertiary referral centers, 2118 patients with BAV were evaluated. Patients referred for echocardiography from June 1, 1991, through November 31, 2015, were included in the study. Clinical and echocardiographic data were analyzed retrospectively. The morphologic BAV findings were categorized according to the Sievers and Schmidtke classification. Aortic valve function was divided into normal, regurgitation, or stenosis. Patterns of BAV aortopathy included the following: type 1, dilation of the ascending aorta and aortic root; type 2, isolated dilation of the ascending aorta; and type 3, isolated dilation of the sinus of Valsalva and/or sinotubular junction. Association between the presence and location of raphe and the risk of significant (moderate and severe) aortic valve dysfunction and aortic dilation and/or dissection. Of the 2118 patients (mean [SD] age, 47 [18] years; 1525 [72.0%] male), 1881 (88.8%) had BAV with fusion raphe, whereas 237 (11.2%) had BAV without raphe. Bicuspid aortic valves with raphe had a significantly higher prevalence of valve dysfunction, with a significantly higher frequency of aortic regurgitation (622 [33.1%] vs 57 [24.1%], P < .001) and aortic stenosis (728 [38.7%] vs 51 [21.5%], P < .001). Furthermore, aortic valve replacement event rates were significantly higher among patients with BAV with raphe (364 [19.9%] at 1 year, 393 [21.4%] at 2 years, and 447 [24.4%] at 5 years) vs patients without raphe (30 [14.0%] at 1 year, 32 [15.0%] at 2 years, and 40 [18.0%] at 5 years) (P = .02). In addition, the all-cause mortality event rates were significantly higher among patients with BAV with raphe (77 [5.1%] at 1 year, 87 [6.2%] at 2 years, and 110 [9.5%] at 5 years) vs patients without raphe (2 [1.8%] at 1 year, 3 [3.0%] at 2 years, and 5 [4.4%] at 5 years) (P = .03). However, on multivariable analysis, the presence of raphe was not significantly associated with all-cause mortality. In this large multicenter, international BAV registry, the presence of raphe was associated with a higher prevalence of significant aortic stenosis and regurgitation. The presence of raphe was also associated with increased rates of aortic valve and aortic surgery. Although patients with BAV and raphe had higher mortality rates than patients without, the presence of a raphe was not independently associated with increased all-cause mortality.

Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature.

PubMed

Smith, Katherine; Gros, Bernard

2017-05-01

A well-established association exists between acute aortic dissection and pregnancy, particularly in women with Marfan syndrome. However, there is debate regarding appropriate management guidelines. In particular, there are differing opinions regarding when prophylactic aortic root repair should be recommended as well as the efficacy of beta blockers in this clinical scenario. The current study evaluated 10 years of published literature (2005-2015) in the PubMed/Medline database. Fifty articles, describing 72 cases of women who presented with aortic dissection in the antepartum or postpartum period were identified. Comparisons on demographic variables and clinical outcomes between cases of women with Marfan syndrome (n = 36) and without Marfan syndrome (n = 36) were conducted. There were no significant differences in demographics (age, gravidity, parity) between the Marfan and non-Marfan cases. Marfan patients presented with antepartum dissections significantly earlier in pregnancy than those without Marfan syndrome (P = .002). However, there were no significant difference between the 2 groups in maternal mortality, fetal mortality, or obstetric outcomes (mode of delivery and gestational age at delivery). Eight cases described events in Marfan women with an aortic root diameter ≤40 mm. Six events occurred in Marfan women who were managed with beta blockers. Current guidelines rely on aortic root diameter for stratification of Marfan women into risk categories, but we identified several cases that would be missed by these guidelines. Specifically, the existing literature suggest that women with Marfan syndrome should take precautions throughout pregnancy, rather than the third trimester. © 2017 Wiley Periodicals, Inc.

Intracardiac echocardiography to diagnose pannus formation after aortic valve replacement.

PubMed

Yamamoto, Yoshiya; Ohara, Takahiro; Funada, Akira; Takahama, Hiroyuki; Amaki, Makoto; Hasegawa, Takuya; Sugano, Yasuo; Kanzaki, Hideaki; Anzai, Toshihisa

2016-03-01

A 66-year-old female, under regular follow-up for 20 years after aortic valve replacement (19-mm Carbomedics), presented dyspnea on effort and hypotension during hemodialysis. A transthoracic echocardiogram showed elevation of transvalvular velocity up to 4 m/s, but the structure around the aortic prosthesis was difficult to observe due to artifacts. Fluoroscopy revealed normal motion of the leaflets of the mechanical valve. Intracardiac echocardiography (ICE) revealed a pannus-like structure in the left ventricular outflow tract. Transesophageal echocardiogram also revealed this structure. ICE can visualize structural abnormalities around a prosthetic valve after cardiac surgery even in patients in whom conventional imaging modalities failed.

Cardiac Surgery in Patients Infected with Human Immunodeficiency Virus

PubMed Central

Abad, Cipriano; Cárdenes, Miguel Angel; Jiménez, Pedro Conrado; Armas, Mario-Vicente; Betancor, Pedro

2000-01-01

From January 1991 through December 1999, 5 consecutive patients who were infected with human immunodeficiency virus presented in need of cardiac surgery. All were men; the median age was 44 years. Two of them presented with mitral and aortic infectious valve endocarditis, 1 with tricuspid endocarditis, 1 with prosthetic valve endocarditis, and 1 with pericarditis and pericardial tamponade. Under cardiopulmonary bypass, the 4 patients with endocarditis underwent these procedures: mitral and aortic valve replacement (2), tricuspid valve replacement (1), and aortic valve replacement (reoperation) and concomitant repair of a mycotic ascending aortic aneurysm (1). In the patient who had pericardial effusion, subxifoid pericardiostomy and drainage were performed, and a pericardial window was created. There was no intraoperative mortality. The patient with pericardial effusion died 8 days after surgery; he was in septic shock and had multiple organ failure. Two deaths occurred at 2 and 63 months, due to hemoptysis and sudden death, respectively. The 2 patients who underwent double valve replacement are alive and in good condition after a median follow-up of 71 months. Cardiac surgery is indicated in selected patients infected by the human immunodeficiency virus. These patients are frequently drug abusers or homosexual. Valvular endocarditis is the most common finding. Hospital morbidity and mortality rates are higher than usual in this group of patients. PMID:11198308

Intracardiac echocardiographic guidance for hemodynamic assessment in a patient with congenital abnormalities and a prosthetic aortic valve.

PubMed

Papafaklis, M I; Ligthart, J M R; Vaina, S; Witsenburg, M; Bogers, A J J C; Serruys, P W

2005-01-01

In this case report, we present the use of intracardiac echocardiography (ICE) for guiding the cardiac catheterization and subsequent hemodynamic investigation in an unusual patient case with multiple congenital abnormalities (bicuspid aortic valve, left cervical aortic arch, two aortic coarctations) and two aortic valve replacement operations in the past. The ICE catheter (AcuNav) permitted us to accurately and safely puncture the interatrial septum and place the Swan-Ganz catheter in the left ventricle; additionally, visualization of the aortic coarctation in the ascending aorta was also achieved.

Natural history of aortic root dilation through young adulthood in a hypermobile Ehlers-Danlos syndrome cohort.

PubMed

Ritter, Alyssa; Atzinger, Carrie; Hays, Brandon; James, Jeanne; Shikany, Amy; Neilson, Derek; Martin, Lisa; Weaver, Kathryn Nicole

2017-06-01

Hypermobile Ehlers-Danlos syndrome (hEDS) is a common inherited connective tissue disorder characterized by joint hypermobility. The natural history of aortic root dilation (AoD), a potential complication of EDS, has not been well characterized in this population. We describe the natural history of aortic root size in a large cohort of patients with hEDS. A cohort of 325 patients with HEDS was identified at Cincinnati Children's Hospital Medical Center (CCHMC), including 163 patients from a previous study. Medical records were reviewed and each participant's height, weight, and aortic dimensions from up to four echocardiograms were documented. Aortic root z-scores were calculated using two established formulas based on age (Boston or Devereux). Overall prevalence of AoD and prevalence by age were calculated and longitudinal regression was performed. The prevalence of AoD with a z-score ≥ 2.0 was 14.2% (46/325) and with a z-score of ≥3.0 was 5.5% (18/325). No significant increases in z-score were seen over time for patients with multiple echocardiograms. Participants under the age of 15 years had an average decline of 0.1 standard deviations (SDs)/year. No significant change was found after 15 of age. Between the ages of 15 and 21 years, Boston z-scores were 0.96 higher than Devereux z-scores. The nearly 1 z-score unit difference between formulas indicates caution prior to diagnosing AoD in patients with hEDS. In light of the low prevalence and lack of progression of AoD, routine echocardiograms may not be warranted for pediatric patients with hEDS. © 2017 Wiley Periodicals, Inc.

Does altered aortic flow in marfan syndrome relate to aortic root dilatation?

PubMed

Wang, Hung-Hsuan; Chiu, Hsin-Hui; Tseng, Wen-Yih Isaac; Peng, Hsu-Hsia

2016-08-01

To examine possible hemodynamic alterations in adolescent to adult Marfan syndrome (MFS) patients with aortic root dilatation. Four-dimensional flow MRI was performed in 20 MFS patients and 12 age-matched normal subjects with a 3T system. The cross-sectional areas of 10 planes along the aorta were segmented for calculating the axial and circumferential wall shear stress (WSSaxial , WSScirc ), oscillatory shear index (OSIaxial , OSIcirc ), and the nonroundness (NR), presenting the asymmetry of segmental WSS. Pearson's correlation analysis was performed to present the correlations between the quantified indices and the body surface area (BSA), aortic root diameter (ARD), and Z score of the ARD. P < 0.05 indicated statistical significance. Patients exhibited lower WSSaxial in the aortic root and the WSScirc in the arch (P < 0.05-0.001). MFS patients exhibited higher OSIaxial and OSIcirc in the sinotubular junction and arch, but lower OSIcirc in the descending aorta (all P < 0.05). The NR values were lower in patients (P < 0.05). The WSSaxial or WSScirc exhibited moderate to strong correlations with BSA, ARD, or Z score (R(2)  = 0.50-0.72) in MFS patients. The significant differences in the quantified indices, which were associated with BSA, ARD, or Z score, in MFS were opposite to previous reports for younger MFS patients, indicating that altered flows in MFS patients may depend on the disease progress. The possible time dependency of hemodynamic alterations in MFS patients strongly suggests that longitudinal follow-up of 4D Flow is needed to comprehend disease progress. J. Magn. Reson. Imaging 2016;44:500-508. © 2016 Wiley Periodicals, Inc.

Does altered aortic flow in marfan syndrome relate to aortic root dilatation?

PubMed Central

Wang, Hung‐Hsuan; Chiu, Hsin‐Hui; Tseng, Wen‐Yih Isaac

2016-01-01

Purpose To examine possible hemodynamic alterations in adolescent to adult Marfan syndrome (MFS) patients with aortic root dilatation. Materials and Methods Four‐dimensional flow MRI was performed in 20 MFS patients and 12 age‐matched normal subjects with a 3T system. The cross‐sectional areas of 10 planes along the aorta were segmented for calculating the axial and circumferential wall shear stress (WSSaxial, WSScirc), oscillatory shear index (OSIaxial, OSIcirc), and the nonroundness (NR), presenting the asymmetry of segmental WSS. Pearson's correlation analysis was performed to present the correlations between the quantified indices and the body surface area (BSA), aortic root diameter (ARD), and Z score of the ARD. P < 0.05 indicated statistical significance. Results Patients exhibited lower WSSaxial in the aortic root and the WSScirc in the arch (P < 0.05–0.001). MFS patients exhibited higher OSIaxial and OSIcirc in the sinotubular junction and arch, but lower OSIcirc in the descending aorta (all P < 0.05). The NR values were lower in patients (P < 0.05). The WSSaxial or WSScirc exhibited moderate to strong correlations with BSA, ARD, or Z score (R2 = 0.50–0.72) in MFS patients. Conclusion The significant differences in the quantified indices, which were associated with BSA, ARD, or Z score, in MFS were opposite to previous reports for younger MFS patients, indicating that altered flows in MFS patients may depend on the disease progress. The possible time dependency of hemodynamic alterations in MFS patients strongly suggests that longitudinal follow‐up of 4D Flow is needed to comprehend disease progress. J. Magn. Reson. Imaging 2016;44:500–508. PMID:26854646

Rationale and design of a trial evaluating the effects of losartan vs. nebivolol vs. the association of both on the progression of aortic root dilation in Marfan syndrome with FBN1 gene mutations.

PubMed

Gambarin, Fabiana I; Favalli, Valentina; Serio, Alessandra; Regazzi, Mario; Pasotti, Michele; Klersy, Catherine; Dore, Roberto; Mannarino, Savina; Viganò, Mario; Odero, Attilio; Amato, Simona; Tavazzi, Luigi; Arbustini, Eloisa

2009-04-01

The major clinical problem of Marfan syndrome (MFS) is the aortic root aneurysm, with risk of dissection when the root diameter approximates 5 cm. In MFS, a key molecule, transforming growth factor-beta (TGF-beta), normally bound to the extracellular matrix, is free and activated. In an experimental setting, TGF-beta blockade prevents the aortic root structural damage and dilatation. The angiotensin receptor 1 blockers (sartanics) exert an anti-TGF-beta effect; trials are now ongoing for evaluating the effect of losartan compared with atenolol in MFS. beta-Adrenergic blockers are the drugs most commonly used in MFS. The third-generation beta-adrenergic blocker nebivolol retains the beta-adrenergic blocker effects on heart rate and further exerts antistiffness effects, typically increased in MFS. The open-label phase III study will include 291 patients with MFS and proven FBN1 gene mutations, with aortic root dilation (z-score > or =2.5). The patients will be randomized to nebivolol, losartan and the combination of the two drugs. The primary end point is the comparative evaluation of the effects of losartan, nebivolol and the association of both on the progression of aortic root growth rate. Secondary end points include the pharmacokinetics of the two drugs, comparative evaluation of serum levels of total and active TGF-beta, quantitative assessment of the expression of the mutated gene (FBN1, both 5' and 3'), pharmacogenetic bases of drug responsiveness. The quality of life evaluation in the three groups will be assessed. Statistical evaluation includes an interim analysis at month 24 and conclusive analyses at month 48. The present study will add information about pharmacological therapy in MFS, supporting the new application of angiotensin receptor 1 blockers and finding beta-adrenergic blockers that may give more specific effects. Moreover, the study will further deepen understanding of the pathogenetic mechanisms that are active in Marfan syndrome through the pharmacogenomic and transcriptomic mechanisms that may explain MFS phenotype variability.

Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection?

PubMed

Ge, Yi-Peng; Li, Cheng-Nan; Chen, Lei; Liu, Wei; Cheng, Li-Jian; Liu, Yong-Min; Zheng, Jun; Ma, Wei-Guo; Zhu, Jun-Ming; Sun, Li-Zhong

2015-11-01

The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Aortic Dissection in Patients With Bicuspid Aortic Valve–Associated Aneurysms

PubMed Central

Wojnarski, Charles M.; Svensson, Lars G.; Roselli, Eric E.; Idrees, Jay J.; Lowry, Ashley M.; Ehrlinger, John; Pettersson, Gösta B.; Gillinov, A. Marc; Johnston, Douglas R.; Soltesz, Edward G.; Navia, Jose L.; Hammer, Donald F.; Griffin, Brian; Thamilarasan, Maran; Kalahasti, Vidyasagar; Sabik, Joseph F.; Blackstone, Eugene H.; Lytle, Bruce W.

2016-01-01

Background Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging. Methods From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention. Results Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm—from 4.1% to 13% at 7.2 cm—and then increased steeply at an ascending aortic diameter of 5.3 cm—from 3.8% to 35% at 8.4 cm—corresponding to a cross-sectional area to height ratio of 10 cm2/m for sinuses of Valsalva and 13 cm2/m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73). Conclusions Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm2/m. PMID:26209494

What Is Heart Valve Surgery?

MedlinePlus

... working correctly. Most valve replacements involve the aortic Tricuspid valve and mitral valves. The aortic valve separates ... where it shouldn’t. This is called incompetence, insufficiency or regurgitation. • Prolapse — mitral valve flaps don’t ...

Aortic Arch Aneurysms: Treatment with Extra anatomical Bypass and Endovascular Stent-Grafting

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kato, Noriyuki; Shimono, Takatsugu; Hirano, Tadanori

2002-10-15

Endovascular repair of thoracic aortic aneurysms is emerging as an attractive alternative to surgical graft replacement. However,patients with aortic arch aneurysms are often excluded from the target of endovascular repair because of lack of suitable landing zones, especially at the proximal ones. In this paper we describe our method for treating patients with aortic arch aneurysms using a combination of extra anatomical bypass surgery and endovascular stent-grafting.

Multidetector computed tomography sizing of aortic annulus prior to transcatheter aortic valve replacement (TAVR): Variability and impact of observer experience.

PubMed

Le Couteulx, S; Caudron, J; Dubourg, B; Cauchois, G; Dupré, M; Michelin, P; Durand, E; Eltchaninoff, H; Dacher, J-N

2018-05-01

To evaluate intra- and inter-observer variability of multidetector computed tomography (MDCT) sizing of the aortic annulus before transcatheter aortic valve replacement (TAVR) and the effect of observer experience, aortic valve calcification and image quality. MDCT examinations of 52 consecutive patients with tricuspid aortic valve (30 women, 22 men) with a mean age of 83±7 (SD) years (range: 64-93 years) were evaluated retrospectively. The maximum and minimum diameters, area and circumference of the aortic annulus were measured twice at diastole and systole with a standardized approach by three independent observers with different levels of experience (expert [observer 1]; resident with intensive 6 months practice [observer 2]; trained resident with starting experience [observer 3]). Observers were requested to recommend the valve prosthesis size. Calcification volume of the aortic valve and signal to noise ratio were evaluated. Intra- and inter-observer reproducibility was excellent for all aortic annulus dimensions, with an intraclass correlation coefficient ranging respectively from 0.84 to 0.98 and from 0.82 to 0.97. Agreement for selection of prosthesis size was almost perfect between the two most experienced observers (k=0.82) and substantial with the inexperienced observer (k=0.67). Aortic valve calcification did not influence intra-observer reproducibility. Image quality influenced reproducibility of the inexperienced observer. Intra- and inter-observer variability of aortic annulus sizing by MDCT is low. Nevertheless, the less experienced observer showed lower reliability suggesting a learning curve. Copyright © 2017. Published by Elsevier Masson SAS.

Pros and cons of transcatheter aortic valve implantation (TAVI).

PubMed

Terré, Juan A; George, Isaac; Smith, Craig R

2017-09-01

Transcatheter aortic valve implantation (TAVI) or replacement (TAVR) was recently approved by the FDA for intermediate risk patients with severe aortic stenosis (AS). This technique was already worldwide adopted for inoperable and high-risk patients. Improved device technology, imaging analysis and operator expertise has reduced the initial worrisome higher complications rate associated with TAVR, making it comparable to surgical aortic valve replacement (SAVR). However, many answers need to be addressed before adoption in lower risk patients. This paper highlights the pros and cons of TAVI based mostly on randomized clinical trials involving the two device platforms approved in the United States. We focused our analysis on metrics that will play a key role in expanding TAVR indication in healthier individuals. We review the significance and gave a perspective on paravalvular leak (PVL), valve performance, valve durability, leaflet thrombosis, stroke and pacemaker requirement.

Manual, semiautomated, and fully automated measurement of the aortic annulus for planning of transcatheter aortic valve replacement (TAVR/TAVI): analysis of interchangeability.

PubMed

Lou, Junyang; Obuchowski, Nancy A; Krishnaswamy, Amar; Popovic, Zoran; Flamm, Scott D; Kapadia, Samir R; Svensson, Lars G; Bolen, Michael A; Desai, Milind Y; Halliburton, Sandra S; Tuzcu, E Murat; Schoenhagen, Paul

2015-01-01

Preprocedural 3-dimensional CT imaging of the aortic annular plane plays a critical role for transcatheter aortic valve replacement (TAVR) planning; however, manual reconstructions are complex. Automated analysis software may improve reproducibility and agreement between readers but is incompletely validated. In 110 TAVR patients (mean age, 81 years; 37% female) undergoing preprocedural multidetector CT, automated reconstruction of the aortic annular plane and planimetry of the annulus was performed with a prototype of now commercially available software (syngo.CT Cardiac Function-Valve Pilot; Siemens Healthcare, Erlangen, Germany). Fully automated, semiautomated, and manual annulus measurements were compared. Intrareader and inter-reader agreement, intermodality agreement, and interchangeability were analyzed. Finally, the impact of these measurements on recommended valve size was evaluated. Semiautomated analysis required major correction in 5 patients (4.5%). In the remaining 95.5%, only minor correction was performed. Mean manual annulus area was significantly smaller than fully automated results (P < .001 for both readers) but similar to semiautomated measurements (5.0 vs 5.4 vs 4.9 cm(2), respectively). The frequency of concordant recommendations for valve size increased if manual analysis was replaced with the semiautomated method (60% agreement was improved to 82.4%; 95% confidence interval for the difference [69.1%-83.4%]). Semiautomated aortic annulus analysis, with minor correction by the user, provides reliable results in the context of TAVR annulus evaluation. Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Transapical aortic valve implantation – a rescue procedure for patients with aortic stenosis and “porcelain aorta”

PubMed Central

Czerwinska, Katarzyna; Orłowska-Baranowska, Ewa; Witkowski, Adam; Demkow, Marcin; Abramczuk, Elżbieta; Michałek, Piotr; Greszata, Lidia; Stoklosa, Patrycjusz; Kuśmierski, Krzysztof; Kowal, Jaroslaw; Stepinska, Janina

2011-01-01

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta (“porcelain aorta”) is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and “porcelain aorta”, in whom the only available life-saving intervention was TAAVI. PMID:22295040

Aortic Valve Replacement for Moderate Aortic Stenosis with Severe Calcification and Left Ventricualr Dysfunction-A Case Report and Review of the Literature.

PubMed

Narang, Nikhil; Lang, Roberto M; Liarski, Vladimir M; Jeevanandam, Valluvan; Hofmann Bowman, Marion A

2017-01-01

A 55-year-old man with a history of erosive, seropositive rheumatoid arthritis (RA), and interstitial lung disease presented with shortness of breath. Echocardiography showed new-onset severe left ventricular (LV) dysfunction with an ejection fraction (EF) of 15% and moderately increased mean aortic valve gradient of 20 mmHg in a trileaflet aortic valve with severe sclero-calcific degeneration. Coronary angiography revealed no significant obstructive coronary disease. Invasive hemodynamic studies and dobutamine stress echocardiography were consistent with moderate aortic stenosis. Guideline directed medical therapy for heart failure with reduced EF was initiated; however, diuretics and neurohormonal blockade (beta-blocker and angiotensin receptor blocker) provided minimal improvement, and the patient remained functionally limited. Of interest, echocardiography performed 1 year prior to his presentation showed normal LV EF and mild aortic leaflet calcification with moderate stenosis, suggesting a rapid progressing of calcific aortic valve disease. Subsequently, the patient underwent surgical aortic valve replacement and demonstrated excellent postsurgical recovery of LV EF (55%). Calcific aortic valve disease is commonly associated with aging, bicuspid aortic valve, and chronic kidney disease. Pathophysiological mechanism for valvular calcification is incompletely understood but include osteogenic transformation of valvular interstitial cells mediated by local and systemic inflammatory processes. Several rheumatologic diseases including RA are associated with premature atherosclerosis and arterial calcification, and we speculated a similar role of RA accelerating calcific aortic valve disease. We present a case of accelerated aortic valve calcification with (only) moderate stenosis, complicated by a rapid decline in LV systolic performance. Guidelines for AVR in moderate stenosis without concomitant cardiac surgery are not well established, although it should be considered in selected patients.

Aortic valve replacement during acute rheumatic fever.

PubMed

Khan, A; Chi, S; Gonzalez-Lavin, L

1978-07-01

Emergency aortic valve replacement was performed during an attack of acute rheumatic fever in a 12-year-old black boy. He had an uneventful recovery and has remained asymptomatic 27 months after operation. In the light of this experience and that of others, one might conclude that the decision to operate on these patients should be based on the severity of the haemodynamic derangement rather than on the state of activity in the rheumatic process.

Evolving trends in aortic valve replacement: A statewide experience.

PubMed

Kim, Karen M; Shannon, Francis; Paone, Gaetano; Lall, Shelly; Batra, Sanjay; Boeve, Theodore; DeLucia, Alphonse; Patel, Himanshu J; Theurer, Patricia F; He, Chang; Clark, Melissa J; Sultan, Ibrahim; Deeb, George Michael; Prager, Richard L

2018-06-17

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of aortic stenosis in patients at intermediate, high, and extreme risk for mortality from SAVR. We examined recent trends in aortic valve replacement (AVR) in Michigan. The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC) database was used to determine the number of SAVR and TAVR cases performed from January 2012 through June 2017. Patients were divided into low, intermediate, high, and extreme risk groups based on STS predicted risk of mortality (PROM). TAVR patients in the MSTCVS-QC database were also matched with those in the Transcatheter Valve Therapy Registry to determine their Heart Team-designated risk category. During the study period 9517 SAVR and 4470 TAVR cases were performed. Total annual AVR volume increased by 40.0% (from 2086 to 2920), with a 13.3% decrease in number of SAVR cases (from 1892 to 1640) and a 560% increase in number of TAVR cases (from 194 to 1280). Greater than 90% of SAVR patients had PROM ≤8%. While >70% of TAVR patients had PROM ≤ 8%, they were mostly designated as high or extreme risk by a Heart Team. During the study period, SAVR volume gradually declined and TAVR volume dramatically increased. This was mostly due to a new group of patients with lower STS PROM who were designated as higher risk by a Heart Team due to characteristics not completely captured by the STS PROM score. © 2018 Wiley Periodicals, Inc.

Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German-Dutch Ross Registry.

PubMed

Sievers, Hans-H; Stierle, Ulrich; Charitos, Efstratios I; Hanke, Thorsten; Misfeld, Martin; Matthias Bechtel, J F; Gorski, Armin; Franke, Ulrich F W; Graf, Bernhard; Robinson, Derek R; Bogers, Ad J J C; Dodge-Khatami, Ali; Boehm, Juergen O; Rein, Joachim G; Botha, Cornelius A; Lange, Ruediger; Hoerer, Juergen; Moritz, Anton; Wahlers, Thorsten; Breuer, Martin; Ferrari-Kuehne, Katharina; Hetzer, Roland; Huebler, Michael; Ziemer, Gerhard; Takkenberg, Johanna J M; Hemmer, Wolfgang

2010-09-14

The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

Valve in valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-Surgical aortic valve replacement (redo-SAVR): A systematic review and meta-analysis.

PubMed

Nalluri, Nikhil; Atti, Varunsiri; Munir, Abdullah B; Karam, Boutros; Patel, Nileshkumar J; Kumar, Varun; Vemula, Praveen; Edla, Sushruth; Asti, Deepak; Paturu, Amrutha; Gayam, Sriramya; Spagnola, Jonathan; Barsoum, Emad; Maniatis, Gregory A; Tamburrino, Frank; Kandov, Ruben; Lafferty, James; Kliger, Chad

2018-05-20

Bioprosthetic (BP) valves have been increasingly used for aortic valve replacement over the last decade. Due to their limited durability, patients presenting with failed BP valves are rising. Valve in Valve - Transcatheter Aortic Valve Implantation (ViV-TAVI) emerged as an alternative to the gold standard redo-Surgical Aortic Valve Replacement (redo-SAVR). However, the utility of ViV-TAVI is poorly understood. A systematic electronic search of the scientific literature was done in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Only studies which compared the safety and efficacy of ViV-TAVI and redo-SAVR head to head in failed BP valves were included. Six observational studies were eligible and included 594 patients, of whom 255 underwent ViV- TAVI and 339 underwent redo-SAVR. There was no significant difference between ViV-TAVI and redo- SAVR for procedural, 30 day and 1 year mortality rates. ViV-TAVI was associated with lower risk of permanent pacemaker implantation (PPI) (OR: 0.43, CI: 0.21-0.89; P = 0.02) and a trend toward increased risk of paravalvular leak (PVL) (OR: 5.45, CI: 0.94-31.58; P = 0.06). There was no significant difference for stroke, major bleeding, vascular complications and postprocedural aortic valvular gradients more than 20 mm-hg. Our results reiterate the safety and feasibility of ViV-TAVI for failed aortic BP valves in patients deemed to be at high risk for surgery. VIV-TAVI was associated with lower risk of permanent pacemaker implantation with a trend toward increased risk of paravalvular leak. © 2018, Wiley Periodicals, Inc.

Midterm Follow-Up of the Stentless Freedom Solo Bioprosthesis in 350 Patients.

PubMed

Wollersheim, Laurens W; Li, Wilson W; Bouma, Berto J; Kaya, Abdullah; van Boven, Wim J; van der Meulen, Jan; de Mol, Bas A

2016-07-01

The stentless Freedom Solo aortic bioprosthesis is implanted supraannularly using one running suture line in the sinuses of Valsalva. We report our 9-year experience with this bioprosthesis. From April 2005 to July 2014, 350 consecutive patients at our institution underwent aortic valve replacement with the Freedom Solo bioprosthesis. Follow-up and echocardiographic data were collected retrospectively from referring cardiology centers. The mean age was 76 ± 6 years, 48% were male, and 46% underwent a concomitant procedure. Median EuroSCORE II was 3.0 (interquartile range, 1.9 to 4.9). Operative mortality was 5.1% for all procedures and 2.1% for isolated aortic valve replacement. The 1-, 5-, and 9-year overall survival was 92%, 74%, and 47%, respectively. At 6 years, freedom from structural valve deterioration and freedom from aortic valve reoperation were 98% and 96%, respectively. Prosthetic valve endocarditis occurred at a rate of 0.8% per patient-year. Permanent pacemaker implantation was necessary in 2.3% (n = 8), and moderate and severe prosthesis-patient mismatch occurred in 30 patients overall (9.6%). Postoperative maximum and mean valvular gradients were 17 mm Hg and 10 mm Hg, respectively, and remained stable during follow-up. Aortic valve replacement with the Freedom Solo is safe and has a low rate of permanent pacemaker implantations and prosthesis-patient mismatch. Survival is comparable to that with other aortic bioprostheses, and structural valve deterioration and aortic valve reoperation are infrequent during midterm follow-up. Hemodynamic performance is excellent, with low valvular gradients that remain stable during follow-up. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Multi-detector CT angiography of the aortic valve—Part 2: disease specific findings

PubMed Central

Ganeshan, Arul

2014-01-01

The aortic valve and adjacent structures should be routinely evaluated on all thoracic cross-sectional imaging studies. Echocardiography and magnetic resonance imaging (MRI) are the main imaging techniques used for assessment of the aortic valve and related pathology but multi-detector computed tomography (MDCT) can offer valuable complimentary information in some clinical scenarios. MDCT is the definite means of assessing aortic valvular calcification, acute aortic syndrome and for non-invasive assessment of the coronary arteries. MDCT also has an emerging role in the planning and follow-up of trans-catheter aortic valve replacement. This article reviews the spectrum of aortic valve disease highlighting the key MDCT imaging features. PMID:25202663

Impact of different aortic valve calcification patterns on the outcome of transcatheter aortic valve implantation: A finite element study.

PubMed

Sturla, Francesco; Ronzoni, Mattia; Vitali, Mattia; Dimasi, Annalisa; Vismara, Riccardo; Preston-Maher, Georgia; Burriesci, Gaetano; Votta, Emiliano; Redaelli, Alberto

2016-08-16

Transcatheter aortic valve implantation (TAVI) can treat symptomatic patients with calcific aortic stenosis. However, the severity and distribution of the calcification of valve leaflets can impair the TAVI efficacy. Here we tackle this issue from a biomechanical standpoint, by finite element simulation of a widely adopted balloon-expandable TAVI in three models representing the aortic root with different scenarios of calcific aortic stenosis. We developed a modeling approach realistically accounting for aortic root pressurization and complex anatomy, detailed calcification patterns, and for the actual stent deployment through balloon-expansion. Numerical results highlighted the dependency on the specific calcification pattern of the "dog-boning" of the stent. Also, local stent distortions were associated with leaflet calcifications, and led to localized gaps between the TAVI stent and the aortic tissues, with potential implications in terms of paravalvular leakage. High stresses were found on calcium deposits, which may be a risk factor for stroke; their magnitude and the extent of the affected regions substantially increased for the case of an "arc-shaped" calcification, running from commissure to commissure. Moreover, high stresses due to the interaction between the aortic wall and the leaflet calcifications were computed in the annular region, suggesting an increased risk for annular damage. Our analyses suggest a relation between the alteration of the stresses in the native anatomical components and prosthetic implant with the presence and distribution of relevant calcifications. This alteration is dependent on the patient-specific features of the calcific aortic stenosis and may be a relevant indicator of suboptimal TAVI results. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement.

PubMed

Reynolds, Matthew R; Lei, Yang; Wang, Kaijun; Chinnakondepalli, Khaja; Vilain, Katherine A; Magnuson, Elizabeth A; Galper, Benjamin Z; Meduri, Christopher U; Arnold, Suzanne V; Baron, Suzanne J; Reardon, Michael J; Adams, David H; Popma, Jeffrey J; Cohen, David J

2016-01-05

Previous studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system. The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk. We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S. Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years ([QALY]; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ∼$1,650 would lead to an incremental cost-effectiveness ratio <$50,000/QALY gained. In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S. With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Aortic valve replacement using continuous suture technique in patients with aortic valve disease.

PubMed

Choi, Jong Bum; Kim, Jong Hun; Park, Hyun Kyu; Kim, Kyung Hwa; Kim, Min Ho; Kuh, Ja Hong; Jo, Jung Ku

2013-08-01

The continuous suture (CS) technique has several advantages as a method for simple, fast, and secure aortic valve replacement (AVR). We used a simple CS technique without the use of a pledget for AVR and evaluated the surgical outcomes. Between October 2007 and 2012, 123 patients with aortic valve disease underwent AVR alone (n=28) or with other concomitant cardiac procedures (n=95), such as mitral, tricuspid, or aortic surgery. The patients were divided into two groups: the interrupted suture (IS) group (n=47), in which the conventional IS technique was used, and the CS group (n=76), in which the simple CS technique was used. There were two hospital deaths (1.6%), which were not related to the suture technique. There were no significant differences in cardiopulmonary bypass time or aortic cross-clamp time between the two groups for AVR alone or AVR with concomitant cardiac procedures. In the IS group, two patients had prosthetic endocarditis and one patient experienced significant perivalvular leak. These patients underwent reoperations. In the CS group, there were no complications related to the surgery. Postoperatively, the two groups had similar aortic valve gradients. The simple CS method is useful and secure for AVR in patients with aortic valve disease, and it may minimize surgical complications, as neither pledgets nor braided sutures are used.

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

PubMed

Paradis, Jean-Michel; George, Isaac; Kodali, Susheel

2013-09-01

We report the case of an 81-year-old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans-apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. Copyright © 2013 Wiley Periodicals, Inc.

One-year outcomes after rapid-deployment aortic valve replacement.

PubMed

Young, Christopher; Laufer, Günther; Kocher, Alfred; Solinas, Marco; Alamanni, Francesco; Polvani, Gianluca; Podesser, Bruno K; Aramendi, Jose Ignacio; Arribas, Jose; Bouchot, Olivier; Livi, Ugolino; Massetti, Massimo; Terp, Kim; Giot, Christophe; Glauber, Mattia

2018-02-01

The goals of rapid-deployment aortic valve replacement include facilitation of minimally invasive surgery and reduced aortic crossclamp time. We report the short-term outcomes of a series of 493 patients undergoing rapid-deployment aortic valve replacement with the EDWARDS INTUITY valve system (Edwards Lifesciences, LLC, Irvine, Calif). Assessing Standard oF Care and Clinical Outcomes UsiNg the EDWARDS INTUITY VAlve SysTem in a European multI-center, Active, pOst-market surveillaNce Study was a prospective, multicenter (n = 26) European registry designed to evaluate the safety and performance of the valve system. During rapid-deployment aortic valve replacement, device technical success and crossclamp time were assessed. Procedural outcomes, hemodynamic performance, and various adverse events and clinical outcomes were evaluated up to 2 years. Between 2012 and 2014, 493 of 517 enrolled patients successfully received implants with the study valve (95.4% technical success). Mean crossclamp times for 163 full sternotomies, 128 mini-upper sternotomies, and 36 right anterior thoracotomies isolated aortic valve replacements were 47.3, 52.0, and 73.3 minutes, respectively. Mean follow-up was 1.8 years, with 870 total patient-years of follow-up. Mean effective orifice area increased from 0.72 (baseline) to 1.88 cm 2 , and mean pressure gradient decreased from 47.6 to 9.6 mm Hg (1 year). Mean effective orifice area index increased (0.39-1.01 cm 2 /m 2 ), and 28 of 287 patients (9.8%) exhibited severe prosthesis-patient mismatch at 1 year. After 1 year, 68.1% and 21.7% of patients were in New York Heart Association class I and II, respectively. Freedom from death, major bleeding, major perivalvular leak, reoperation, and device explant at 1 year were 0.935, 0.939, 0.976, 0.975, and 0.983, respectively. These results demonstrate commendable safety and performance of the test valve system over the short term in a broad European setting. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

The effect of losartan on progressive aortic dilatation in patients with Marfan's syndrome: a meta-analysis of prospective randomized clinical trials.

PubMed

Gao, Linggen; Chen, Lei; Fan, Li; Gao, Dewei; Liang, Zhiru; Wang, Rong; Lu, Wenning

2016-08-15

To assess the effect of losartan therapy on progressive aortic dilatation and on clinical outcome in patients with Marfan's syndrome (MFS). The meta-analysis was instituted, which included studies identified by a systematic review of MEDLINE of peer-reviewed publications. Echocardiogram or MRI measurements of the aortic root dimension and outcome measures of death, cardiovascular surgery and aortic dissection or rupture were compared between patients who were treated and untreated with losartan therapy. Six randomized trials with 1398 subjects met all the inclusion criteria and were included in the meta-analysis. Compared with non-losartan treatment, losartan therapy significantly decreased the rate of aortic dilatation (SMD=-0.13 with 95% CI -0.25 to 0.00, p=0.04). The clinical outcome beneficial was not observed in the losartan treatment group when compared with no losartan treatment group (odds ratio=1.04 with 95% CI of 0.57-1.87). Given the current results of the meta-analysis and together with the lack of associated side effects, it would be reasonable to use losartan in MFS patients with aortic root dilatation. However, no clinical outcome benefits were observed in the losartan treatment group when compared with no losartan treatment group. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Pros and cons of transcatheter aortic valve implantation (TAVI)

PubMed Central

Terré, Juan A.; George, Isaac

2017-01-01

Transcatheter aortic valve implantation (TAVI) or replacement (TAVR) was recently approved by the FDA for intermediate risk patients with severe aortic stenosis (AS). This technique was already worldwide adopted for inoperable and high-risk patients. Improved device technology, imaging analysis and operator expertise has reduced the initial worrisome higher complications rate associated with TAVR, making it comparable to surgical aortic valve replacement (SAVR). However, many answers need to be addressed before adoption in lower risk patients. This paper highlights the pros and cons of TAVI based mostly on randomized clinical trials involving the two device platforms approved in the United States. We focused our analysis on metrics that will play a key role in expanding TAVR indication in healthier individuals. We review the significance and gave a perspective on paravalvular leak (PVL), valve performance, valve durability, leaflet thrombosis, stroke and pacemaker requirement. PMID:29062739

Contemporary results of open aortic arch surgery.

PubMed

Thomas, Mathew; Li, Zhuo; Cook, David J; Greason, Kevin L; Sundt, Thoralf M

2012-10-01

The success of endovascular therapies for descending thoracic aortic disease has turned attention toward stent graft options for repair of aortic arch aneurysms. Defining the role of such techniques demands understanding of contemporary results of open surgery. The outcomes of open arch procedures performed on a single surgical service from July 1, 2001 to August 30, 2010, were examined as defined per The Society of Thoracic Surgeons national database. During the study period, 209 patients (median age, 65 years; range, 26-88) underwent arch operations, of which 159 were elective procedures. In 65 the entire arch was replaced, 22 of whom had portions of the descending thoracic aorta simultaneously replaced via bilateral thoracosternotomy. Antegrade cerebral perfusion was used in 78 patients and retrograde cerebral perfusion in 1. Operative mortality was 2.5% in elective circumstances and 10% in emergency cases (P = .04). The stroke rate was 5.0% when procedures were performed electively and 11.8% when on an emergency basis (P = .11). Procedure-specific mortality rates were 5.5% for elective and 10% for emergency procedures with total arch replacement, and 1.0% for elective and 10% for emergency procedures with hemiarch replacement. Stratified by extent, neurologic event rates were 5.5% for elective and 10% for emergency procedures with total arch and 4.8% for elective and 12.5% for emergency procedures with hemiarch replacement. Open aortic arch replacement can be performed with low operative mortality and stroke rates, especially in elective circumstances, by a team with particular focus on the procedure. The results of novel endovascular therapies should be benchmarked against contemporary open series performed in such a setting. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Alkaptonuria-associated aortic stenosis.

PubMed

Lok, Zoe S Y; Goldstein, Jacob; Smith, Julian A

2013-07-01

Alkaptonuria is an autosomal recessive disorder of tyrosine metabolism, which results in accumulation of unmetabolized homogentisic acid and its oxidized product in various tissues, including the heart. Cardiovascular involvement is a rare but serious complication of the disease. We present two patients who have undergone successful aortic valve replacement for alkaptonuria-associated aortic stenosis along with a review of the literature. © 2013 Wiley Periodicals, Inc.

Costs of transcatheter versus surgical aortic valve replacement in intermediate-risk patients.

PubMed

Osnabrugge, Ruben L J; Head, Stuart J; Genders, Tessa S S; Van Mieghem, Nicolas M; De Jaegere, Peter P T; van der Boon, Robert M A; Kerkvliet, J Marco; Kalesan, Bindu; Bogers, Ad J J C; Kappetein, A Pieter; Hunink, M G Myriam

2012-12-01

Transcatheter aortic valve replacement (TAVR) offers a new treatment option for patients with aortic stenosis, but costs may play a decisive role in decision making. Current studies are evaluating TAVR in an intermediate-risk population. We assessed the in-hospital and 1-year follow-up costs of patients undergoing TAVR and surgical aortic valve replacement (SAVR) at intermediate operative risk and identified important cost components. We prospectively collected clinical data on 141 patients undergoing TAVR and 405 undergoing SAVR. Propensity score matching yielded 42 matched pairs at intermediate risk. Costs were assessed using a detailed resource-use approach and compared using bootstrap methods. In-hospital costs were higher in TAVR patients than in SAVR patients (€40802 vs €33354, respectively; p=0.010). The total costs at 1 year were €46217 vs €35511, respectively (p=0.009). The TAVR was less costly with regard to blood products, operating room use, and length-of-stay. For intermediate-risk patients with severe aortic stenosis the costs at 1 year are higher for TAVR than for SAVR. The difference was mainly caused by the higher costs of the transcatheter valve and was not compensated by the lower costs for blood products and hospital stay in TAVR patients. Therefore, SAVR remains a clinically and economically attractive treatment option. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Aortic valve replacement during acute rheumatic fever.

PubMed Central

Khan, A; Chi, S; Gonzalez-Lavin, L

1978-01-01

Emergency aortic valve replacement was performed during an attack of acute rheumatic fever in a 12-year-old black boy. He had an uneventful recovery and has remained asymptomatic 27 months after operation. In the light of this experience and that of others, one might conclude that the decision to operate on these patients should be based on the severity of the haemodynamic derangement rather than on the state of activity in the rheumatic process. Images PMID:687481

Surgical outcomes in native valve infectious endocarditis: the experience of the Cardiovascular Surgery Department – Cluj-Napoca Heart Institute

PubMed Central

MOLNAR, ADRIAN; MURESAN, IOAN; TRIFAN, CATALIN; POP, DANA; SACUI, DIANA

2015-01-01

Background and aims The introduction of Duke’s criteria and the improvement of imaging methods has lead to an earlier and a more accurate diagnosis of infectious endocarditis (IE). The options for the best therapeutic approach and the timing of surgery are still a matter of debate and require a close colaboration between the cardiologist, the infectionist and the cardiac surgeon. Methods We undertook a retrospective, descriptive study, spanning over a period of five years (from January 1st, 2007 to December 31st, 2012), on 100 patients who underwent surgery for native valve infectious endocarditis in our unit. Results The patients’ age varied between 13 and 77 years (with a mean of 54 years), of which 85 were males (85%). The main microorganisms responsible for IE were: Streptococcus Spp. (21 cases – 21%), Staphylococcus Spp. (15 cases – 15%), and Enterococcus Spp. (9 cases – 9%). The potential source of infection was identified in 26 patients (26%), with most cases being in the dental area (16 cases – 16%). The lesions caused by IE were situated in the left heart in 96 patients (96%), mostly on the aortic valve (50 cases – 50%). In most cases (82%) we found preexisting endocardial lesions which predisposed to the development of IE, most of them being degenerative valvular lesions (38 cases – 38%). We performed the following surgical procedures: surgery on a single valve - aortic valve replacement (40 cases), mitral valve replacement (19 cases), mitral valve repair (1 case), surgery on more than one valve – mitral and aortic valve replacement (20 cases), aortic and tricuspid valve replacement (1 case), aortic valve replacement with a mechanical valve associated with mitral valve repair (5 cases), aortic valve replacement with a biological valve associated with mitral valve repair (2 cases), and mitral valve replacement with a mechanical valve combined with De Vega procedure on the tricuspid valve (1 case). In 5 patients (5%) the bacteriological examination of valve pieces excised during surgery was positive. In 3 cases it matched the germ identified in the hemocultures, and in 2 cases it evidenced another bacterium. Conclusion The overall mortality of 5% is well between the limits presented in literature, being higher (30%) in patients who required emergency surgery. For the patients who return into our clinic with prosthetic valve endocarditis, the mortality after surgery was even higher (50%). PMID:26609267

Progression of Hypertrophy and Myocardial Fibrosis in Aortic Stenosis: A Multicenter Cardiac Magnetic Resonance Study.

PubMed

Everett, Russell J; Tastet, Lionel; Clavel, Marie-Annick; Chin, Calvin W L; Capoulade, Romain; Vassiliou, Vassilios S; Kwiecinski, Jacek; Gomez, Miquel; van Beek, Edwin J R; White, Audrey C; Prasad, Sanjay K; Larose, Eric; Tuck, Christopher; Semple, Scott; Newby, David E; Pibarot, Philippe; Dweck, Marc R

2018-06-01

Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis. We investigated the natural history of these processes in asymptomatic patients and their potential reversal post-aortic valve replacement (AVR). Asymptomatic and symptomatic patients with aortic stenosis underwent repeat echocardiography and magnetic resonance imaging. Changes in peak aortic-jet velocity, left ventricular mass index, diffuse fibrosis (indexed extracellular volume), and replacement fibrosis (late gadolinium enhancement [LGE]) were quantified. In 61 asymptomatic patients (43% mild, 34% moderate, and 23% severe aortic stenosis), significant increases in peak aortic-jet velocity, left ventricular mass index, indexed extracellular volume, and LGE mass were observed after 2.1±0.7 years, with the most rapid progression observed in patients with most severe stenosis. Patients with baseline midwall LGE (n=16 [26%]; LGE mass, 2.5 g [0.8-4.8 g]) demonstrated particularly rapid increases in scar burden (78% [50%-158%] increase in LGE mass per year). In 38 symptomatic patients (age, 66±8 years; 76% men) who underwent AVR, there was a 19% (11%-25%) reduction in left ventricular mass index ( P <0.0001) and an 11% (4%-16%) reduction in indexed extracellular volume ( P =0.003) 0.9±0.3 years after surgery. By contrast midwall LGE (n=10 [26%]; mass, 3.3 g [2.6-8.0 g]) did not change post-AVR (n=10; 3.5 g [2.1-8.0 g]; P =0.23), with no evidence of regression even out to 2 years. In patients with aortic stenosis, cellular hypertrophy and diffuse fibrosis progress in a rapid and balanced manner but are reversible after AVR. Once established, midwall LGE also accumulates rapidly but is irreversible post valve replacement. Given its adverse long-term prognosis, prompt AVR when midwall LGE is first identified may improve clinical outcomes. URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01755936 and NCT01679431. © 2018 The Authors.

Delayed Infective Endocarditis with Mycotic Aneurysm Rupture below the Mechanical Valved Conduit after the Bentall Procedure

PubMed Central

Chen, Mei-Ling; Chen, Michael Y.; Yin, Wei-Hsian; Wei, Jeng; Wang, Ji-Hung

2014-01-01

The Bentall procedure is the gold standard for treating aortic dissection complicated with valvular and ascending aorta disease. Recent results for this procedure have been excellent; nearly 100% of patients remain free of infective endocarditis in long-term follow-up. We report a case of delayed Streptococcus agalactiae infective endocarditis complicated by mycotic aneurysm in a man who had undergone the Bentall procedure with a mechanical valve conduit 15 years previously. The mycotic aneurysm was located in the remnant aortic root, below the mechanical valve conduit, and later ruptured into the right atrium. The patient was treated conservatively and survived the acute period. Later, the aortic root defect was repaired successfully by means of a hybrid technique using a Amplatzer duct occluder. PMID:27122809

[Emergency percutaneous valvuloplasty: Which patients, which results?

PubMed

Tron, Christophe; Bizios, Anna; Durand, Eric; Bouhzam, Najime; Bettinger, Nicolas; Eltchaninoff, Hélène

2016-10-01

Balloon aortic valvuloplasty is a relatively simple procedure with a low rate of complications despite patients' frailty. Urgent balloon aortic valvuloplasty is especially useful in patients with temporary contra-indication to TAVI or in case of difficult clinical scenario. It allows for a functional improvement for up to 6 months. This period should be used to bridge the patient to TAVI or surgical aortic valve replacement, stand-alone aortic valvuloplasty being without mid-term survival benefit. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Consequence of patient substitution of nattokinase for warfarin after aortic valve replacement with a mechanical prosthesis.

PubMed

Elahi, Maqsood M; Choi, Charles H; Konda, Subbareddy; Shake, Jay G

2015-01-01

This report describes a patient's self-substitution of nattokinase for the vitamin K antagonist warfarin after aortic valve replacement with a mechanical prosthesis. Nattokinase is an enzyme derived from a popular fermented soybean preparation in Japan (natto), which has fibrinolytic properties and is gaining popularity in nontraditional health journals and nonmedical health websites as an over-the-counter thrombolytic. After nearly a year of use of nattokinase without warfarin, the patient developed thrombus on the mechanical valve and underwent successful repeat valve replacement. We believe this is the first documented case of nattokinase being used as a substitute for warfarin after valve replacement, and we strongly discourage its use for this purpose.

Consequence of patient substitution of nattokinase for warfarin after aortic valve replacement with a mechanical prosthesis

PubMed Central

Elahi, Maqsood M.; Choi, Charles H.; Konda, Subbareddy

2015-01-01

This report describes a patient's self-substitution of nattokinase for the vitamin K antagonist warfarin after aortic valve replacement with a mechanical prosthesis. Nattokinase is an enzyme derived from a popular fermented soybean preparation in Japan (natto), which has fibrinolytic properties and is gaining popularity in nontraditional health journals and nonmedical health websites as an over-the-counter thrombolytic. After nearly a year of use of nattokinase without warfarin, the patient developed thrombus on the mechanical valve and underwent successful repeat valve replacement. We believe this is the first documented case of nattokinase being used as a substitute for warfarin after valve replacement, and we strongly discourage its use for this purpose. PMID:25552810

Multi-physics 3D computational study of leaflet thrombus formation following surgical and transcatheter aortic valve replacement

NASA Astrophysics Data System (ADS)

Vahidkhah, Koohyar; Abbasi, Mostafa; Barakat, Mohammed; Dvir, Danny; Azadani, Ali

2017-11-01

An increasingly recognized complication following surgical/transcatheter aortic valve replacement is thrombosis or blood clot formation on replacement valve leaflets. A predisposing factor in thrombus formation on biomaterial surfaces of a bioprosthetic heart valve is blood stasis. Longer residence time of blood provides an opportunity for platelets and agonists to accumulate to critical concentrations that leads to platelet activation and then thrombosis. In this study, we have developed a fluid-solid interaction (FSI) modeling approach, to quantify blood stasis on the leaflets of bioprosthetic aortic valves with different design operating in a patient-specific geometry. We have validated our FSI model against experimental measurements of valve opening/closing as well as in-vitro particle image velocimetry. We have also embedded in our method a model for transport of platelets and agonists (ADP, TxA2, and thrombin) and their interactions that result in platelets activation and adhesion to biomaterial bioprosthetic surfaces. We have provided quantitative evidence for the correlation between long residence of blood on bioprosthetic aortic valve leaflets and formation of high thrombogenicity risk regions on the leaflets that are characterized by accumulation of activated platelet.

Surgery for Young Adults With Aortic Valve Disease not Amenable to Repair.

PubMed

Zakkar, Mustafa; Bruno, Vito Domanico; Visan, Alexandru Ciprian; Curtis, Stephanie; Angelini, Gianni; Lansac, Emmanuel; Stoica, Serban

2018-01-01

Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair.

Elevation of B-Type Natriuretic Peptide at Discharge is Associated With 2-Year Mortality After Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis: Insights From a Multicenter Prospective OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) Registry.

PubMed

Mizutani, Kazuki; Hara, Masahiko; Iwata, Shinichi; Murakami, Takashi; Shibata, Toshihiko; Yoshiyama, Minoru; Naganuma, Toru; Yamanaka, Futoshi; Higashimori, Akihiro; Tada, Norio; Takagi, Kensuke; Araki, Motoharu; Ueno, Hiroshi; Tabata, Minoru; Shirai, Shinichi; Watanabe, Yusuke; Yamamoto, Masanori; Hayashida, Kentaro

2017-07-14

In this study, we sought to investigate the 2-year prognostic impact of B-type natriuretic peptide (BNP) levels at discharge, following transcatheter aortic valve replacement. We enrolled 1094 consecutive patients who underwent transcatheter aortic valve replacement between 2013 and 2016. Study patients were stratified into 2 groups according to survival classification and regression tree analysis (high versus low BNP groups). We evaluated the impact of high BNP on 2-year mortality compared with that of low BNP using a multivariable Cox model, and assessed whether this stratification would improve predictive accuracy for determining 2-year mortality by assessing time-dependent net reclassification improvement and integrated discrimination improvement. The median age of patients was 85 years (quartile 82-88), and 29.2% of the study population were men. The median Society of Thoracic Surgeons score was 6.8 (4.7-9.5), and BNP at discharge was 186 (93-378) pg/mL. All-cause mortality following discharge was 7.9% (95% CI, 5.8-9.9%) at 1 year and 15.4% (95% CI, 11.6-19.0%) at 2 years. The survival classification and regression tree analysis revealed that the discriminating BNP level to discern 2-year mortality was 202 pg/mL, and that elevated BNP had a statistically significant impact on outcomes, with an adjusted hazard ratio of 2.28 (1.36-3.82, P =0.002). The time-dependent net reclassification improvement ( P =0.047) and integrated discrimination improvement ( P =0.029) analysis revealed that the incorporation of BNP stratification with other clinical variables significantly improved predictive accuracy for 2-year mortality. Elevation of BNP at discharge is associated with 2-year mortality after transcatheter aortic valve replacement. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Suture technique does not affect hemodynamic performance of the small supra-annular Trifecta bioprosthesis.

PubMed

Ugur, Murat; Byrne, John G; Bavaria, Joseph E; Cheung, Anson; Petracek, Michael; Groh, Mark A; Suri, Rakesh M; Borger, Michael A; Schaff, Hartzell V

2014-10-01

The study objective was to evaluate whether aortic valve replacement with the Trifecta valve (St Jude Medical Inc, St Paul, Minn) using simple sutures produces better hemodynamic performance than valve replacement with noneverting pledget-reinforced sutures. We analyzed prospectively acquired 1-year hemodynamic data of patients with small aortic annulus sizes who were enrolled in a multicenter trial of the Trifecta aortic valve bioprosthesis and underwent aortic valve replacement with a 19-mm or 21-mm bioprosthesis between August 2007 and November 2009. We compared preoperative clinical information and 1-year postoperative hemodynamic data for noneverting pledget-reinforced sutures (group 1) versus everting mattress sutures or simple sutures (group 2). A total of 346 patients underwent aortic valve replacement: 269 in group 1 and 77 in group 2. Preoperative demographic characteristics for the 2 groups were similar. For groups 1 and 2, the mean gradient was 10.4±4.7 mm Hg and 11.1±4.4 mm Hg for 19-mm valves, respectively, and 8.4±3.5 mm Hg and 8.8±3.6 mm Hg for 21-mm valves, respectively; the effective orifice area was 1.40 cm2 and 1.25 cm2 for 19-mm valves, respectively, and 1.57 cm2 and 1.50 cm2 for 21-mm valves, respectively. The rate of severe prosthesis-patient mismatch (indexed effective orifice area≤0.65 cm2/m2) was 18.6% (n=11) and 25% (n=6) for 19-mm valves, respectively, and 10.9% (n=20) and 16.3% (n=8) for 21-mm valves, respectively. The suture method did not affect hemodynamic performance of supra-annular bioprostheses in patients with small aortic annulus sizes. Choice of suture technique should be determined by surgeon experience and local anatomic features. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Late outcomes for aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis: up to 17-year follow-up in 1,000 patients.

PubMed

McClure, R Scott; Narayanasamy, Narendren; Wiegerinck, Esther; Lipsitz, Stuart; Maloney, Ann; Byrne, John G; Aranki, Sary F; Couper, Gregory S; Cohn, Lawrence H

2010-05-01

This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 +/- 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure. Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The perceval S aortic valve implantation in patients with porcelain aorta; is this ideal option?

PubMed

Baikoussis, Nikolaos G; Dedeilias, Panagiotis; Prappa, Efstathia; Argiriou, Michalis

2017-01-01

We would like to present in this paper a patient with severe aortic valve stenosis referred to our department for surgical aortic valve replacement. In this patient, it was intraoperatively detected an unexpected heavily calcified porcelain ascending aorta. We present the treatment options in this situation, the difficulties affronted intraoperatively, the significance of the preoperative chest computed tomography scan and the use of the Perceval S aortic valve as ideal bioprosthesis implantation. This is a self-expanding, self-anchoring, and sutureless valve with a wide indication in all patients requiring aortic bioprosthesis.

Rapid Deployment Aortic Replacement (RADAR) Registry in Spain: a protocol.

PubMed

Bautista-Hernandez, Victor; Cal-Purriños, Natalia; Arribas-Leal, Jose M; Carnero-Alcazar, Manuel; Gutierrez-Diez, Jose F; Cuenca-Castillo, Jose J

2017-01-10

Rapid deployment valves (RDV) represent a newly introduced approach to aortic valve replacement which facilitates surgical implantation and minimally invasive techniques, shortens surgical times and shows excellent haemodynamic performance. However, evidence on their safety, efficacy and potential complications is mostly fitted with small-volume and retrospective studies. Moreover, no current guidelines exist. To improve our knowledge on this technology, The Rapid Deployment Aortic Replacement (RADAR) Registry will be established across Spain with the aim of assessing RDV outcomes in the real-world setting. The RADAR Registry is designed as a product registry that would provide information on its use and outcomes in clinical practice. This multicentre, prospective, national effort will initially involve 4 centres in Spain. Any patient undergoing cardiac surgery for aortic valve replacement and receiving an RDV as an isolated operation or in combination with other cardiac procedures may be included. Participation is voluntary. Data collection is equal to information obtained during standard care and is prospectively entered by the participating physicians perioperatively and during subsequent follow-up visits. The primary outcome assessed is in-hospital and up to 5 years of follow-up, prosthetic valve functioning and clinical status. Secondary outcomes are to perform subgroup analysis, to compare outcomes with other existing approaches and to develop future clinical guidelines. The follow-up assessments are timed with routine clinical appointments. Dissociated data will be extracted and collectively analysed. Initial target sample size for the registry is 500 participants entered with complete follow-up information. Different substudies will be implemented within the registry to investigate specific populations undergoing aortic valve replacement. The protocol is approved by all local institutional ethics committees. Findings will be shared by the participant hospitals, policymakers and the academic community to promote quality monitoring and efficient use of this technology. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures.

PubMed

Martin, Jacob A; Mayhew, Christopher R; Morris, Amanda J; Bader, Angela M; Tsai, Mitchell H; Urman, Richard D

2018-04-01

Time-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes for three different medical-surgical procedures. In each case, a multi-disciplinary team created process maps describing the care delivery cycle for a patient encounter using the TDABC methodology. Each step in a process map delineated an activity required for delivery of patient care. The resources (personnel, equipment and supplies) associated with each step were identified. A per minute cost for each resource expended was generated, known as the capacity cost rate, and multiplied by its time requirement. The total cost for an episode of care was obtained by adding the cost of each individual resource consumed as the patient moved along a clinical pathway. We built process maps for colonoscopy in the gastroenterology suite, calculated costs of an aortic valve replacement by comparing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) techniques, and determined the cost of carpal tunnel release in an operating room versus an ambulatory procedure room. TDABC is central to the value-based healthcare platform. Application of TDABC provides a framework to identify process improvements for health care delivery. The first case demonstrates cost-savings and improved wait times by shifting some of the colonoscopies scheduled with an anesthesiologist from the main hospital to the ambulatory facility. In the second case, we show that the deployment of an aortic valve via the transcatheter route front loads the costs compared to traditional, surgical replacement. The last case demonstrates significant cost savings to the healthcare system associated with re-organization of staff required to execute a carpal tunnel release.

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures

PubMed Central

Martin, Jacob A.; Mayhew, Christopher R.; Morris, Amanda J.; Bader, Angela M.; Tsai, Mitchell H.; Urman, Richard D.

2018-01-01

Background Time-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes for three different medical-surgical procedures. Methods In each case, a multi-disciplinary team created process maps describing the care delivery cycle for a patient encounter using the TDABC methodology. Each step in a process map delineated an activity required for delivery of patient care. The resources (personnel, equipment and supplies) associated with each step were identified. A per minute cost for each resource expended was generated, known as the capacity cost rate, and multiplied by its time requirement. The total cost for an episode of care was obtained by adding the cost of each individual resource consumed as the patient moved along a clinical pathway. Results We built process maps for colonoscopy in the gastroenterology suite, calculated costs of an aortic valve replacement by comparing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) techniques, and determined the cost of carpal tunnel release in an operating room versus an ambulatory procedure room. Conclusions TDABC is central to the value-based healthcare platform. Application of TDABC provides a framework to identify process improvements for health care delivery. The first case demonstrates cost-savings and improved wait times by shifting some of the colonoscopies scheduled with an anesthesiologist from the main hospital to the ambulatory facility. In the second case, we show that the deployment of an aortic valve via the transcatheter route front loads the costs compared to traditional, surgical replacement. The last case demonstrates significant cost savings to the healthcare system associated with re-organization of staff required to execute a carpal tunnel release. PMID:29511420

Preoperative Aspirin Use and Lung Injury After Aortic Valve Replacement Surgery: A Retrospective Cohort Study.

PubMed

Mazzeffi, Michael; Kassa, Woderyelesh; Gammie, James; Tanaka, Kenichi; Roman, Philip; Zhan, Min; Griffith, Bartley; Rock, Peter

2015-08-01

Acute respiratory distress syndrome (ARDS) occurs uncommonly after cardiac surgery but has a mortality rate as high as 80%. Aspirin may prevent lung injury in at-risk patients by reducing platelet-neutrophil aggregates in the lung. We hypothesized that preoperative aspirin use would be associated with a decreased risk of ARDS after aortic valve replacement surgery. We performed a retrospective single-center cohort study that included all adult patients who had aortic valve replacement surgery during a 5-year period. The primary outcome variable was postoperative ARDS. The secondary outcome variable was nadir PaO2/FIO2 ratio during the first 72 hours after surgery. Both crude and propensity score-adjusted logistic regression analyses were performed to estimate the odds ratio for developing ARDS in aspirin users. Subgroups were analyzed to determine whether preoperative aspirin use might be associated with improved oxygenation in patients with specific risk factors for lung injury. Of the 375 patients who had aortic valve replacement surgery during the study period, 181 patients took aspirin preoperatively (48.3%) with most taking a dose of 81 mg (72.0%). There were 22 cases of ARDS in the cohort (5.5%). There was no significant difference in the rate of ARDS between aspirin users and nonusers (5.0% vs 6.7%, P = 0.52). There was also no significant difference in the nadir PaO2/FIO2 ratio between aspirin users and nonusers (P = 0.12). The crude odds ratio for ARDS in aspirin users was 0.725 (99% confidence interval, 0.229-2.289; P = 0.47), and the propensity score-adjusted odds ratio was 0.457 (99% confidence interval, 0.120-1.730; P = 0.13). Within the constraints of this analysis that included only 22 affected patients, preoperative aspirin use was not associated with a decreased incidence of ARDS after aortic valve replacement surgery or improved oxygenation.

Acute gastrointestinal bleeding following aortic valve replacement in a patient with Heyde's sindrome. Case report.

PubMed

De Palma, G D; Salvatori, F; Masone, S; Simeoli, I; Rega, M; Celiento, M; Persico, G

2007-09-01

A 58-year old man was admitted to the hospital because of melena. He had a 1-year history of mechanical aortic valve replacement and coronary stent placement because of myocardial infarction and he was taking warfarin and clopidogrel. Esophagogastroduodenoscopy and colonoscopy were negative for bleeding. Capsule endoscopy showed bleeding diffuse angiodysplasia of the small bowel. The patient was treated with octreotide 20 mg, at monthly interval. After 25 months there had been no recurrence of gastrointestinal bleeding. The case suggests that mechanical valve replacement may not prevent gastrointestinal bleeding in Heyde syndrome and that octreotide treatment should be considered in these cases.

Life-threatening subdural hematoma after aortic valve replacement in a patient with Heyde syndrome: a case report.

PubMed

Uchida, Tetsuro; Hamasaki, Azumi; Ohba, Eiichi; Yamashita, Atsushi; Hayashi, Jun; Sadahiro, Mitsuaki

2017-08-08

Heyde syndrome is known as a triad of calcific aortic stenosis, anemia due to gastrointestinal bleeding from angiodysplasia, and acquired type 2A von Willebrand disease. This acquired hemorrhagic disorder is characterized by the loss of the large von Willebrand factor multimers due to the shear stress across the diseased aortic valve. The most frequently observed type of bleeding in these patients is mucosal or skin bleeding, such as epistaxis, followed by gastrointestinal bleeding. On the other hand, intracranial hemorrhage complicating Heyde syndrome is extremely rare. A 77-year-old woman presented to our hospital with severe aortic stenosis and severe anemia due to gastrointestinal bleeding and was diagnosed with Heyde syndrome. Although aortic valve replacement was performed without recurrent gastrointestinal bleeding, postoperative life-threatening acute subdural hematoma occurred with a marked midline shift. Despite prompt surgical evacuation of the hematoma, she did not recover consciousness and she died 1 month after the operation. Postoperative subdural hematoma is rare, but it should be kept in mind as a devastating hemorrhagic complication, especially in patients with Heyde syndrome.

Aortic root dilatation in young patients with cryptogenic stroke and patent foramen ovale.

PubMed

Keenan, Niall G; Brochet, Éric; Juliard, Jean-Michel; Malanca, Mihaela; Aubry, Pierre; Lepage, Laurent; Cueff, Caroline; Jondeau, Guillaume; Iung, Bernard; Vahanian, Alec; Messika-Zeitoun, David

2012-01-01

No previous study has looked for an association between aortic dilatation and the clinical sequelae of patent foramen ovale (PFO), although a possible relationship has been identified in case reports. To compare aortic dimensions in patients with symptomatic PFO and healthy controls. Forty-seven patients were identified who presented with cryptogenic cerebrovascular accident (CVA) assessed as most likely secondary to PFO (confirmed by contrast study), were aged less than 50 years and underwent percutaneous PFO closure. Forty-seven age-, sex- and body surface area-matched healthy controls were also identified. Aortic root diameters were greater in PFO patients. The difference was more marked at the levels of the sinuses of Valsalva (34±4 vs 31±3 mm, P<0.01) and the proximal ascending aorta (32±4 vs 29±3, P<0.01) and more modest at the level of the aortic annulus (23±3 vs 22±2 mm, P=0.20). In addition, patients with massive right-to-left shunting tended to have larger aortic diameters. In contrast, left ventricular end-systolic and end-diastolic diameters were not larger than in controls (30±4 vs 32±5 mm, P=0.10 and 48±5 vs 50±4 mm, P=0.04, respectively). The present study shows that aortic diameter is increased in young patients with cryptogenic CVA and PFO compared with in healthy subjects. Our results suggest that aortic dilatation may potentiate the risk of CVA in PFO patients and support further research in this area. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

The Ross operation: a Trojan horse?

PubMed

Klieverik, Loes M A; Takkenberg, Johanna J M; Bekkers, Jos A; Roos-Hesselink, Jolien W; Witsenburg, Maarten; Bogers, Ad J J C

2007-08-01

The Ross operation is the operation of choice for children who require aortic valve replacement (AVR) and may also provide a good option in selected adult patients. Although the autograft does not require anticoagulation and has a superior haemodynamic profile, concern regarding autograft and allograft longevity has risen. In this light, we report the 13-year results of our prospective autograft cohort study. Between 1988 and 2005, 146 consecutive patients underwent AVR with a pulmonary autograft at Erasmus Medical Center Rotterdam. Mean age was 22 years (SD 13; range 4 months-52 years), 66% were male. Hospital mortality was 2.7% (N = 4); during follow-up four more patients died. Thirteen-year survival was 94 +/- 2%. Over time, 22 patients required autograft reoperation for progressive neo-aortic root dilatation. In addition, eight patients required allograft reoperation. Freedom from autograft reoperation at 13 years was 69 +/- 7%. Freedom from allograft reoperation for structural failure at 13 years was 87 +/- 5%. Risk factors for autograft reoperation were previous AVR and adult patient age. Although survival of the Rotterdam autograft cohort is excellent, over time a worrisome increase in reoperation rate is observed. Given the progressive autograft dilatation, careful follow-up of these patients is warranted in the second decade after operation.

Current role of endovascular therapy in Marfan patients with previous aortic surgery

PubMed Central

Akin, Ibrahim; Kische, Stephan; Rehders, Tim C; Chatterjee, Tushar; Schneider, Henrik; Körber, Thomas; Nienaber, Christoph A; Ince, Hüseyin

2008-01-01

The Marfan syndrome is a heritable disorder of the connective tissue which affects the cardiovascular, ocular, and skeletal system. The cardiovascular manifestation with aortic root dilatation, aortic valve regurgitation, and aortic dissection has a prevalence of 60% to 90% and determines the premature death of these patients. Thirty-four percent of the patients with Marfan syndrome will have serious cardiovascular complications requiring surgery in the first 10 years after diagnosis. Before aortic surgery became available, the majority of the patients died by the age of 32 years. Introduction in the aortic surgery techniques caused an increase of the 10 year survival rate up to 97%. The purpose of this article is to give an overview about the feasibility and outcome of stent-graft placement in the descending thoracic aorta in Marfan patients with previous aortic surgery. PMID:18629349

Type of Valvular Heart Disease Requiring Surgery in the 21st Century: Mortality and Length-of-Stay Related to Surgery

PubMed Central

Boudoulas, Konstantinos Dean; Ravi, Yazhini; Garcia, Daniel; Saini, Uksha; Sofowora, Gbemiga G.; Gumina, Richard J.; Sai-Sudhakar, Chittoor B.

2013-01-01

Aim: While the incidence of rheumatic heart disease has declined dramatically over the last half-century, the number of valve surgeries has not changed. This study was undertaken to define the most common type of valvular heart disease requiring surgery today, and determine in-hospital surgical mortality and length-of-stay (LOS) for isolated aortic or mitral valve surgery in a United States tertiary-care hospital. Methods: Patients with valve surgery between January 2002 to June 2008 at The Ohio State University Medical Center were studied. Patients only with isolated aortic or mitral valve surgery were analyzed. Results: From 915 patients undergoing at least aortic or mitral valve surgery, the majority had concomitant cardiac proce-dures mostly coronary artery bypass grafting (CABG); only 340 patients had isolated aortic (n=204) or mitral (n=136) valve surgery. In-hospital surgical mortality for mitral regurgitation (n=119), aortic stenosis (n=151), aortic insufficiency (n=53) and mitral stenosis (n=17) was 2.5% (replacement 3.4%; repair 1.6%), 3.9%, 5.6% and 5.8%, respectively (p=NS). Median LOS for aortic insufficiency, aortic stenosis, mitral regurgitation, and mitral stenosis was 7, 8, 9 (replacement 11.5; repair 7) and 11 days, respectively (p<0.05 for group). In-hospital surgical mortality for single valve surgery plus CABG was 10.2% (p<0.005 compared to single valve surgery). Conclusions: Aortic stenosis and mitral regurgitation are the most common valvular lesions requiring surgery today. Surgery for isolated aortic or mitral valve disease has low in-hospital mortality with modest LOS. Concomitant CABG with valve surgery increases mortality substantially. Hospital analysis is needed to monitor quality and stimulate improvement among Institutions. PMID:24339838

[Preparation, storage, transportation and use of heart valves for allotransplantation].

PubMed

Spatenka, J; Kostelka, M; Kobylka, P; Hucín, B; Honĕk, T; Lochmann, O; Hájek, T; Tláskal, T; Povýsilová, V; Fiser, B

1997-03-01

Thanks to the co-operation with Czech and Slovak Transplant Centres and with some of the Departments of Pathology and Forensic Medicine 274 hearts were collected for allograft heart valves (AHV) processing during 1992-1995. The Cardiac surgeon dissected the aortic valve with the root and the pulmonary artery trunk with the valve. Tissues were antibiotically (ATB) sterilised in cultivation medium E 199 (24 hours at 37 degrees C). ATB concentrations (mg/ml): Cepharin 0.2, Azlocilin 0.2, Tobramycin 0.08 and Amphotericin B 0.1 for harvesting at post-mortem (P) or Miconazol 0.05 for sterile retrieval during multiorgan harvesting (MOH). After sterilisation AHV were stored at 4 degrees C. 49 AHV were infected even after ATB treatment-15 of 35 collected at P (43%) and 35 of 218 procured during MOH (16%)-(p < 0.01-ch2 test). After serological screening of the donor and microbiological testing the AHV were released for clinical use. Most AHV were programmed cooled to the temperature of liquid nitrogen (-196 degrees C), in which they were stored at the Allograft Heart Valves Cryobank. Cryoprotection was achieved by 10% dimethylsulphidoxide. A technology of harvesting, processing, storage and transportation of AHV, was introduced. It enabled the routine use in many cardiac surgical units. The AHV Cryobank was established. 131 AHV were used clinically between 1992 and 1995 (transportation as far as 1300 km). 108 AHV (82.4%) were used for repair of complex congenital heart defects, while 23 (17.6%) were used for aortic valve and/or root replacement.

Native valve endocarditis due to Corynebacterium group JK.

PubMed

Moffie, B G; Veenendaal, R A; Thompson, J

1990-12-01

We report a case of a 32-yr-old woman on chronic intermittent haemodialysis, who developed endocarditis due to a Corynebacterium group JK, involving both the native aortic and mitral valves. Despite a four-week treatment with vancomycin, an aortic root abscess developed. The diagnosis was confirmed on autopsy.

Left ventricular to left atrial communication secondary to a paraaortic abscess: color flow Doppler documentation.

PubMed

Fisher, E A; Estioko, M R; Stern, E H; Goldman, M E

1987-07-01

Aortic root abscess occurs frequently in aortic prosthetic valve infective endocarditis. The present echocardiographic report documents a ruptured abscess that led to a direct communication between the left ventricular outflow tract and the left atrium confirmed by real-time (color flow) Doppler imaging.

Unexpected embolization of Teflon pledget in the left main stem during: a Bentall operation.

PubMed

Rubino, Antonino S; Serraino, Giuseppe F; Marsico, Roberto; Renzulli, Attilio

2011-01-01

We report the case of an 83-year-old man in whom acute left ventricular failure with ventricular arrhythmic storm developed during a Bentall operation. During re-exploration of the annular and coronary ostial anastomoses, no abnormality was seen, and none of the common sequelae of aortic root replacement was evident. The application of retrograde cardioplegia yielded a Teflon pledget that had migrated into the distal part of the left main stem. The pledget was removed, the anastomoses were reestablished, and the patient recovered uneventfully. This case suggests that left ostial anastomosis re-exploration should be carefully considered when no other cause of coronary insufficiency is obvious, and that retrograde cardioplegia may be useful to detect embolization in the left coronary system.

Unexpected Embolization of Teflon Pledget in the Left Main Stem during a Bentall Operation

PubMed Central

Rubino, Antonino S.; Serraino, Giuseppe F.; Marsico, Roberto; Renzulli, Attilio

2011-01-01

We report the case of an 83-year-old man in whom acute left ventricular failure with ventricular arrhythmic storm developed during a Bentall operation. During re-exploration of the annular and coronary ostial anastomoses, no abnormality was seen, and none of the common sequelae of aortic root replacement was evident. The application of retrograde cardioplegia yielded a Teflon pledget that had migrated into the distal part of the left main stem. The pledget was removed, the anastomoses were reestablished, and the patient recovered uneventfully. This case suggests that left ostial anastomosis re-exploration should be carefully considered when no other cause of coronary insufficiency is obvious, and that retrograde cardioplegia may be useful to detect embolization in the left coronary system. PMID:22163143

Late outcome analysis of the Braile Biomédica® pericardial valve in the aortic position

PubMed Central

Azeredo, Lisandro Gonçalves; Veronese, Elinthon Tavares; Santiago, José Augusto Duncan; Brandão, Carlos Manuel de Almeida; Pomerantzeff, Pablo Maria Alberto; Jatene, Fabio Biscegli

2014-01-01

Objective Aortic valve replacement with Braile bovine pericardial prosthesis has been routinely done at the Heart Institute of the Universidade de São Paulo Medical School since 2006. The objective of this study is to analyze the results of Braile Biomédica® aortic bioprosthesis in patients with aortic valve disease. Methods We retrospectively evaluated 196 patients with aortic valve disease submitted to aortic valve replacement with Braile Biomédica® bovine pericardial prosthesis, between 2006 and 2010. Mean age was 59.41±16.34 years and 67.3% were male. Before surgery, 73.4% of patients were in NYHA functional class III or IV. Results Hospital mortality was 8.16% (16 patients). Linearized rates of mortality, endocarditis, reintervention, and structural dysfunction were 1.065%, 0.91%, 0.68% and 0.075% patients/year, respectively. Actuarial survival was 90.59±2.56% in 88 months. Freedom from reintervention, endocarditis and structural dysfunction was respectively 91.38±2.79%, 89.84±2.92% and 98.57±0.72% in 88 months. Conclusion The Braile Biomédica® pericardial aortic valve prosthesis demonstrated actuarial survival and durability similar to that described in the literature, but further follow up is required to assess the incidence of prosthetic valve endocarditis and structural dysfunction in the future. PMID:25372903

Three-dimensional thoracic aorta principal strain analysis from routine ECG-gated computerized tomography: feasibility in patients undergoing transcatheter aortic valve replacement.

PubMed

Satriano, Alessandro; Guenther, Zachary; White, James A; Merchant, Naeem; Di Martino, Elena S; Al-Qoofi, Faisal; Lydell, Carmen P; Fine, Nowell M

2018-05-02

Functional impairment of the aorta is a recognized complication of aortic and aortic valve disease. Aortic strain measurement provides effective quantification of mechanical aortic function, and 3-dimenional (3D) approaches may be desirable for serial evaluation. Computerized tomographic angiography (CTA) is routinely performed for various clinical indications, and offers the unique potential to study 3D aortic deformation. We sought to investigate the feasibility of performing 3D aortic strain analysis in a candidate population of patients undergoing transcatheter aortic valve replacement (TAVR). Twenty-one patients with severe aortic valve stenosis (AS) referred for TAVR underwent ECG-gated CTA and echocardiography. CTA images were analyzed using a 3D feature-tracking based technique to construct a dynamic aortic mesh model to perform peak principal strain amplitude (PPSA) analysis. Segmental strain values were correlated against clinical, hemodynamic and echocardiographic variables. Reproducibility analysis was performed. The mean patient age was 81±6 years. Mean left ventricular ejection fraction was 52±14%, aortic valve area (AVA) 0.6±0.3 cm 2 and mean AS pressure gradient (MG) 44±11 mmHg. CTA-based 3D PPSA analysis was feasible in all subjects. Mean PPSA values for the global thoracic aorta, ascending aorta, aortic arch and descending aorta segments were 6.5±3.0, 10.2±6.0, 6.1±2.9 and 3.3±1.7%, respectively. 3D PSSA values demonstrated significantly more impairment with measures of worsening AS severity, including AVA and MG for the global thoracic aorta and ascending segment (p<0.001 for all). 3D PSSA was independently associated with AVA by multivariable modelling. Coefficients of variation for intra- and inter-observer variability were 5.8 and 7.2%, respectively. Three-dimensional aortic PPSA analysis is clinically feasible from routine ECG-gated CTA. Appropriate reductions in PSSA were identified with increasing AS hemodynamic severity. Expanded study of 3D aortic PSSA for patients with various forms of aortic disease is warranted.

Beneficial Outcome of Losartan Therapy Depends on Type of FBN1 Mutation in Marfan Syndrome.

PubMed

Franken, Romy; den Hartog, Alexander W; Radonic, Teodora; Micha, Dimitra; Maugeri, Alessandra; van Dijk, Fleur S; Meijers-Heijboer, Hanne E; Timmermans, Janneke; Scholte, Arthur J; van den Berg, Maarten P; Groenink, Maarten; Mulder, Barbara J M; Zwinderman, Aeilko H; de Waard, Vivian; Pals, Gerard

2015-04-01

It has been shown that losartan reduces aortic dilatation in patients with Marfan syndrome. However, treatment response is highly variable. This study investigates losartan effectiveness in genetically classified subgroups. In this predefined substudy of COMPARE, Marfan patients were randomized to daily receive losartan 100 mg or no losartan. Aortic root dimensions were measured by MRI at baseline and after 3 years. FBN1 mutations were classified based on fibrillin-1 protein effect into (1) haploinsufficiency, decreased amount of normal fibrillin-1, or (2) dominant negative, normal fibrillin-1 abundance with mutant fibrillin-1 incorporated in the matrix. A pathogenic FBN1 mutation was found in 117 patients, of whom 79 patients were positive for a dominant negative mutation (67.5%) and 38 for a mutation causing haploinsufficiency (32.5%). Baseline characteristics between treatment groups were similar. Overall, losartan significantly reduced aortic root dilatation rate (no losartan, 1.3±1.5 mm/3 years, n=59 versus losartan, 0.8±1.4 mm/3 years, n=58; P=0.009). However, losartan reduced only aortic root dilatation rate in haploinsufficient patients (no losartan, 1.8±1.5 mm/3 years, n=21 versus losartan 0.5±0.8 mm/3 years, n=17; P=0.001) and not in dominant negative patients (no losartan, 1.2±1.7 mm/3 years, n=38 versus losartan 0.8±1.3 mm/3 years, n=41; P=0.197). Marfan patients with haploinsufficient FBN1 mutations seem to be more responsive to losartan therapy for inhibition of aortic root dilatation rate compared with dominant negative patients. Additional treatment strategies are needed in Marfan patients with dominant negative FBN1 mutations. http://www.trialregister.nl/trialreg/index.asp; Unique Identifier: NTR1423. © 2015 American Heart Association, Inc.

Low contrast media volume in pre-TAVI CT examinations.

PubMed

Kok, Madeleine; Turek, Jakub; Mihl, Casper; Reinartz, Sebastian D; Gohmann, Robin F; Nijssen, Estelle C; Kats, Suzanne; van Ommen, Vincent G; Kietselaer, Bas L J H; Wildberger, Joachim E; Das, Marco

2016-08-01

To evaluate image quality using reduced contrast media (CM) volume in pre-TAVI assessment. Forty-seven consecutive patients referred for pre-TAVI examination were evaluated. Patients were divided into two groups: group 1 BMI < 28 kg/m(2) (n = 29); and group 2 BMI > 28 kg/m(2) (n = 18). Patients received a combined scan protocol: retrospective ECG-gated helical CTA of the aortic root (80kVp) followed by a high-pitch spiral CTA (group 1: 70 kV; group 2: 80 kVp) from aortic arch to femoral arteries. All patients received one bolus of CM (300 mgI/ml): group 1: volume = 40 ml; flow rate = 3 ml/s, group 2: volume = 53 ml; flow rate = 4 ml/s. Attenuation values (HU) and contrast-to-noise ratio (CNR) were measured at the levels of the aortic root (helical) and peripheral arteries (high-pitch). Diagnostic image quality was considered sufficient at attenuation values > 250HU and CNR > 10. Diagnostic image quality for TAVI measurements was obtained in 46 patients. Mean attenuation values and CNR (HU ± SD) at the aortic root (helical) were: group 1: 381 ± 65HU and 13 ± 8; group 2: 442 ± 68HU and 10 ± 5. At the peripheral arteries (high-pitch), mean values were: group 1: 430 ± 117HU and 11 ± 6; group 2: 389 ± 102HU and 13 ± 6. CM volume can be substantially reduced using low kVp protocols, while maintaining sufficient image quality for the evaluation of aortic root and peripheral access sites. • Image quality could be maintained using low kVp scan protocols. • Low kVp protocols reduce contrast media volume by 34-67 %. • Less contrast media volume lowers the risk of contrast-induced nephropathy.

One-stage hybrid surgery for acute Stanford type A aortic dissection with David operation, aortic arch debranching, and endovascular graft: a case report

PubMed Central

Liu, Lulu; Qin, Chaoyi; Hou, Jianglong; Zhu, Da; Zhang, Bengui; Ma, Hao

2016-01-01

Acute Stanford type A aortic dissection requires an extremely complex surgical strategy and presents high risk of complications. Although many different procedures were reported to treat this aortic dissection, high mortality rate and incidences of complications still exist. This study presents a 59-year-old lady with acute Stanford type A aortic dissection, which originated from the aortic root to proximal part of right external iliac artery and involved the brachiocephalic trunk, left carotid artery, celiac trunk, and left renal artery. The patient underwent one-stage hybrid surgery of David procedures, debranching, and endovascular aortic repair under ultrasound-guided aortic arch cannulation cardiopulmonary bypass (CPB). The surgery was successfully performed, and the patient showed no post-operative complication. The one-staged hybrid surgery of David procedures, debranching, and endovascular aortic repair provides novel and well-designed combined techniques for treating complex acute Stanford type A aortic dissection. Our techniques significantly lowered the risks, thereby expanding the indications of surgical intervention for acute Stanford type A aortic dissection. PMID:28149590

One-stage hybrid surgery for acute Stanford type A aortic dissection with David operation, aortic arch debranching, and endovascular graft: a case report.

PubMed

Liu, Lulu; Qin, Chaoyi; Hou, Jianglong; Zhu, Da; Zhang, Bengui; Ma, Hao; Guo, Yingqiang

2016-12-01

Acute Stanford type A aortic dissection requires an extremely complex surgical strategy and presents high risk of complications. Although many different procedures were reported to treat this aortic dissection, high mortality rate and incidences of complications still exist. This study presents a 59-year-old lady with acute Stanford type A aortic dissection, which originated from the aortic root to proximal part of right external iliac artery and involved the brachiocephalic trunk, left carotid artery, celiac trunk, and left renal artery. The patient underwent one-stage hybrid surgery of David procedures, debranching, and endovascular aortic repair under ultrasound-guided aortic arch cannulation cardiopulmonary bypass (CPB). The surgery was successfully performed, and the patient showed no post-operative complication. The one-staged hybrid surgery of David procedures, debranching, and endovascular aortic repair provides novel and well-designed combined techniques for treating complex acute Stanford type A aortic dissection. Our techniques significantly lowered the risks, thereby expanding the indications of surgical intervention for acute Stanford type A aortic dissection.

A Migrated Aortic Stent Graft Causing Erosive Spondylopathy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gestrich, Christopher, E-mail: christopher.gestrich@ukb.uni-bonn.de; Probst, Chris, E-mail: chris.probst@ukb.uni-bonn.de; Wilhelm, Kai, E-mail: kai.wilhelm@ek-bonn.de

We report about a patient presenting with back pain 4 months after an uneventful endovascular implantation of an aortic stent graft. Computed tomography scan revealed a migration of the stent with consecutive endoleakage, kink formation, and movement of the stent toward the spine, which caused destruction of the aortic wall as well as vertebral necrosis. Explantation of the stent and replacement of the native aorta relieved the patient of his symptoms.

Echocardiographic versus histologic findings in Marfan syndrome.

PubMed

Gu, Xiaoyan; He, Yihua; Li, Zhian; Han, Jiancheng; Chen, Jian; Nixon, J V Ian

2015-02-01

This retrospective study attempted to establish the prevalence of multiple-valve involvement in Marfan syndrome and to compare echocardiographic with histopathologic findings in Marfan patients undergoing valvular or aortic surgery. We reviewed echocardiograms of 73 Marfan patients who underwent cardiovascular surgery from January 2004 through October 2009. Tissue histology was available for comparison in 29 patients. Among the 73 patients, 66 underwent aortic valve replacement or the Bentall procedure. Histologic findings were available in 29 patients, all of whom had myxomatous degeneration. Of 63 patients with moderate or severe aortic regurgitation as determined by echocardiography, 4 had thickened aortic valves. The echocardiographic findings in 18 patients with mitral involvement included mitral prolapse in 15. Of 11 patients with moderate or severe mitral regurgitation as determined by echocardiography, 4 underwent mitral valve repair and 7 mitral valve replacement. Histologic findings among mitral valve replacement patients showed thickened valve tissue and myxomatous degeneration. Tricuspid involvement was seen echocardiographically in 8 patients, all of whom had tricuspid prolapse. Two patients had severe tricuspid regurgitation, and both underwent repair. Both mitral and tricuspid involvement were seen echocardiographically in 7 patients. Among the 73 patients undergoing cardiac surgery for Marfan syndrome, 66 had moderate or severe aortic regurgitation, although their valves manifested few histologic changes. Eighteen patients had mitral involvement (moderate or severe mitral regurgitation, prolapse, or both), and 8 had tricuspid involvement. Mitral valves were most frequently found to have histologic changes, but the tricuspid valve was invariably involved.

Aortic biological valve thrombosis in an HIV positive patient.

PubMed

Achouh, Paul; Jemel, Amine; Chaudeurge, Aurélie; Redheuil, Alban; Zegdi, Rachid; Fabiani, Jean-Noël

2011-06-01

Biological aortic valve thrombosis is an exceptional complication. A 64-year-old patient positive for human immunodeficiency virus presented for syncope on exertion, 2 years after an aortic bioprosthetic valve replacement and double coronary artery bypass. Transvalvular aortic mean gradient was approximately 50 mm Hg on echocardiogram and catheterization. Cardiac computed tomography scan showed a limited opening of the bioprosthesis cusps. Surgical exploration revealed thrombosis of the three cusps on the aortic side, limiting the opening of the valve. No relation could be established between the patient's human immunodeficiency virus status and valve thrombosis. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Concomitant Reconstruction of Arch Vessels during Repair of Aortic Dissection

PubMed Central

Nezic, Dusko; Vukovic, Petar; Jovanovic, Marko; Lozuk, Branko; Jagodic, Sinisa; Djukanovic, Bosko

2014-01-01

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients. PMID:25120398

Concomitant reconstruction of arch vessels during repair of aortic dissection.

PubMed

Micovic, Slobodan; Nezic, Dusko; Vukovic, Petar; Jovanovic, Marko; Lozuk, Branko; Jagodic, Sinisa; Djukanovic, Bosko

2014-08-01

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.

Prevalence of pannus formation after aortic valve replacement: clinical aspects and surgical management.

PubMed

Sakamoto, Yoshimasa; Hashimoto, Kazuhiro; Okuyama, Hiroshi; Ishii, Shinichi; Shingo, Taguchi; Kagawa, Hiroshi

2006-01-01

Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated. We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk-Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used. Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk-Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus.

Impaired Left Atrial Strain as a Predictor of New-onset Atrial Fibrillation After Aortic Valve Replacement Independently of Left Atrial Size.

PubMed

Pessoa-Amorim, Guilherme; Mancio, Jennifer; Vouga, Luís; Ribeiro, José; Gama, Vasco; Bettencourt, Nuno; Fontes-Carvalho, Ricardo

2018-06-01

Left atrial dysfunction in aortic stenosis may precede atrial enlargement and predict the occurrence of atrial fibrillation (AF). To test this hypothesis, we assessed left atrial function and determined its impact on the incidence of AF after aortic valve replacement. A total of 149 severe aortic stenosis patients (74±8.6 years, 51% men) with no prior AF were assessed using speckle-tracking echocardiography. Left atrial function was evaluated using peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and phasic left atrial volumes. The occurrence of AF was monitored in 114 patients from surgery until hospital discharge. In multiple linear regression, PALS and PACS were inversely correlated with left atrial dilation, left ventricular hypertrophy, and diastolic function. Atrial fibrillation occurred in 36 patients within a median time of 3 days [interquartile range, 1-4] after aortic valve replacement. In multiple Cox regression, PALS and PACS were independently associated with the incidence of AF (HR, 0.946; 95%CI, 0.910-0.983; P=.005 and HR, 0.932; 95%CI, 0.883-0.984; P=.011, respectively), even after further adjustment for left atrial dimensions. Both reduced PALS and PACS were associated with the incidence of AF in patients with nondilated left atria (P value for the interaction of PALS with left atrial dimensions=.013). In severe aortic stenosis, left atrial dysfunction predicted the incidence of postoperative AF independently of left atrial dilation, suggesting that speckle-tracking echocardiography before surgery may help in risk stratification, particularly in patients with nondilated left atria. Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Five-year clinical and economic outcomes among patients with medically managed severe aortic stenosis: results from a Medicare claims analysis.

PubMed

Clark, Mary Ann; Arnold, Suzanne V; Duhay, Francis G; Thompson, Ann K; Keyes, Michelle J; Svensson, Lars G; Bonow, Robert O; Stockwell, Benjamin T; Cohen, David J

2012-09-01

Patients with severe, symptomatic aortic stenosis, who do not undergo valve replacement surgery have a poor long-term prognosis. Limited data exist on the medical resource utilization and costs during the final stages of the disease. We used data from the 2003 Medicare 5% standard analytic files to identify patients with aortic stenosis and a recent hospitalization for heart failure, who did not undergo valve replacement surgery within the ensuing 2 calendar quarters. These patients (n=2150) were considered to have medically managed severe aortic stenosis and were tracked over 5 years to measure clinical outcomes, medical resource use, and costs (from the perspective of the Medicare Program). The mean age of the cohort was 82 years, 64% were female, and the estimated logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (a measure of predicted mortality with cardiac surgery) was 17%. During 5 years of follow-up, overall mortality was 88.4% with a mean survival duration of 1.8 years. During this time period, patients experienced an average of 4.4 hospital admissions, 52% were admitted to skilled nursing care, and 28% were admitted to hospice care. The total 5-year costs were $63 844 per patient, whereas mean annual follow-up costs (excluding the index quarter) per year alive were $29 278. Elderly patients with severe aortic stenosis undergoing medical management have limited long-term survival and incur substantial costs to the Medicare Program. These results have important implications for policy makers interested in better understanding the cost-effectiveness of emerging treatment options such as transcatheter aortic valve replacement.

Seventeen-millimeter St. Jude Medical Regent valve in patients with small aortic annulus: dose moderate prosthesis-patient mismatch matter?

PubMed

Hu, Jia; Qian, Hong; Li, Ya-jiao; Gu, Jun; Zhao, Jing Janice; Zhang, Er-yong

2014-01-17

The study was designed to evaluate the effects of moderate prosthesis-patient mismatch (defined as 0.65 cm(2)/m(2) 

In-vivo assessment of the morphology and hemodynamic functions of the BioValsalva™ composite valve-conduit graft using cardiac magnetic resonance imaging and computational modelling technology.

PubMed

Kidher, Emaddin; Cheng, Zhuo; Jarral, Omar A; O'Regan, Declan P; Xu, Xiao Yun; Athanasiou, Thanos

2014-12-09

The evaluation of any new cardiac valvular prosthesis should go beyond the classical morbidity and mortality rates and involve hemodynamic assessment. As a proof of concept, the objective of this study was to characterise for the first time the hemodynamics and the blood flow profiles at the aortic root in patients implanted with BioValsalva™ composite valve-conduit using comprehensive MRI and computer technologies. Four male patients implanted with BioValsalva™ and 2 age-matched normal controls (NC) underwent cardiac magnetic resonance imaging (MRI). Phase-contrast imaging with velocity-mapping in 3 orthogonal directions was performed at the level of the aortic root and descending thoracic aorta. Computational fluid dynamic (CFD) simulations were performed for all the subjects with patient-specific flow information derived from phase-contrast MR data. The maximum and mean flow rates throughout the cardiac cycle at the aortic root level were very comparable between NC and BioValsalva™ patients (541 ± 199 vs. 567 ± 75 ml/s) and (95 ± 46 vs. 96 ± 10 ml/s), respectively. The maximum velocity (cm/s) was higher in patients (314 ± 49 vs. 223 ± 20; P = 0.06) due to relatively smaller effective orifice area (EOA), 2.99 ± 0.47 vs. 4.40 ± 0.24 cm2 (P = 0.06), however, the BioValsalva™ EOA was comparable to other reported prosthesis. The cross-sectional area and maximum diameter at the root were comparable between the two groups. BioValsalva™ conduit was stiffer than the native aortic wall, compliance (mm2 • mmHg(-1) • 10(-3)) values were (12.6 ± 4.2 vs 25.3 ± 0.4.; P = 0.06). The maximum time-averaged wall shear stress (Pa), at the ascending aorta was equivalent between the two groups, 17.17 ± 2.7 (NC) vs. 17.33 ± 4.7 (BioValsalva™ ). Flow streamlines at the root and ascending aorta were also similar between the two groups apart from a degree of helical flow that occurs at the outer curvature at the angle developed near the suture line. BioValsalva™ composite valve-conduit prosthesis is potentially comparable to native aortic root in structural design and in many hemodynamic parameters, although it is stiffer. Surgeons should pay more attention to the surgical technique to maximise the reestablishment of normal smooth aortic curvature geometry to prevent unfavourable flow characteristics.

Selective cerebro-myocardial perfusion in complex congenital aortic arch pathology: a novel technique.

PubMed

De Rita, Fabrizio; Lucchese, Gianluca; Barozzi, Luca; Menon, Tiziano; Faggian, Giuseppe; Mazzucco, Alessandro; Luciani, Giovanni Battista

2011-11-01

Simultaneous cerebro-myocardial perfusion has been described in neonatal and infant arch surgery, suggesting a reduction in cardiac morbidity. Here reported is a novel technique for selective cerebral perfusion combined with controlled and independent myocardial perfusion during surgery for complex or recurrent aortic arch lesions. From April 2008 to April 2011, 10 patients with arch pathology underwent surgery (two hypoplastic left heart syndrome [HLHS], four recurrent arch obstruction, two aortic arch hypoplasia + ventricular septal defect [VSD], one single ventricle + transposition of the great arteries + arch hypoplasia, one interrupted aortic arch type B + VSD). Median age was 63 days (6 days-36 years) and median weight 4.0 kg (1.6-52). Via midline sternotomy, an arterial cannula (6 or 8 Fr for infants) was directly inserted into the innominate artery or through a polytetrafluoroethylene (PTFE) graft (for neonates <2.0 kg). A cardioplegia delivery system was inserted into the aortic root. Under moderate hypothermia, ascending and descending aorta were cross-clamped, and "beating heart and brain" aortic arch repair was performed. Arch repair was composed of patch augmentation in five, end-to-side anastomosis in three, and replacement in two patients. Average cardiopulmonary bypass time was 163 ± 68 min (71-310). In two patients only (one HLHS, one complex single ventricle), a period of cardiac arrest was required to complete intracardiac repair. In such cases, antegrade blood cardioplegia was delivered directly via the same catheter used for selective myocardial perfusion. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 39 ± 18 min (17-69). Weaning from cardiopulmonary bypass was achieved without inotropic support in three and with low dose in seven patients. One patient required veno-arterial extracorporeal membrane oxygenation. Four patients, body weight <3.0 kg, needed delayed sternal closure. No neurologic dysfunction was noted. Renal function proved satisfactory in all, while liver function was adequate in all but one. The present experience suggests that selective and independent cerebro-myocardial perfusion is feasible in patients with complex or recurrent aortic arch disease, starting from premature newborn less than 2.0 kg of body weight to adults. The technique is as safe as previously reported methods of cerebro-myocardial perfusion and possibly more versatile. © 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Mid- to long-term outcome comparison of the Medtronic Hancock II and bi-leaflet mechanical aortic valve replacement in patients younger than 60 years of age: a propensity-matched analysis.

PubMed

Wang, Yin; Chen, Si; Shi, Jiawei; Li, Geng; Dong, Nianguo

2016-03-01

This study aims to compare mid-long-term clinical outcomes between patients younger than 60 years of age undergoing bioprosthetic and mechanical aortic valve replacement. From January 2002 to December 2009, patients younger than 60 years of age who received Medtronic Hancock II porcine bioprostheses were selected and compared with those who received mechanical bi-leaflet valves in the aortic position. A stepwise logistic regression propensity score identified a subset of 112 evenly matched patient-pairs. Mid-long-term outcomes of survival, valve-related reoperations, thromboembolic events and bleeding events were assessed. The follow-up was only 95.1% complete. Fourteen measurable variables were statistically similar for the matched cohort. Postoperative in-hospital mortality was 3.6% (bioprosthetic valves) and 2.7% (mechanical valves) (P = 0.700). Survival at 5 and 10 years was 96.3 and 88.7% for patients receiving bioprosthetic valve replacement versus 96.3 and 87.9% for patients receiving mechanical valve replacement (P = 0.860), respectively. At 5 and 10 years after operations, freedom from valve-related reoperation was 97.2 and 94.8% for patients receiving mechanical valve replacement, and 96.3 and 90.2% for patients receiving bioprosthetic valve replacement (P = 0.296), respectively. There was no difference between freedom from thromboembolic events (P = 0.528) and bleeding events (P = 0.128) between the matched groups during the postoperative 10 years. In patients younger than 60 years of age undergoing aortic valve replacement, mid-long-term survival rate was similar for patients receiving bioprosthetic versus mechanical valve replacement. Bioprosthetic valves were associated with a trend for a lower risk of anticoagulation treatment and did not have significantly greater likelihood of a reoperation. These findings suggest that a bioprosthetic valve may be a reasonable choice for AVR in patients younger than 60 years of age. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Identification of Aortic Arch-Specific Quantitative Trait Loci for Atherosclerosis by an Intercross of DBA/2J and 129S6 Apolipoprotein E-Deficient Mice

PubMed Central

Kayashima, Yukako; Makhanova, Natalia A.; Matsuki, Kota; Tomita, Hirofumi; Bennett, Brian J.; Maeda, Nobuyo

2015-01-01

The genetic background of apolipoprotein E (apoE) deficient mice influences atherosclerotic plaque development. We previously reported three quantitative trait loci (QTL), Aath1–Aath3, that affect aortic arch atherosclerosis independently of those in the aortic root in a cross between C57BL6 apoEKO mice (B6-apoE) and 129S6 apoEKO mice (129-apoE). To gain further insight into genetic factors that influence atherosclerosis at different vascular locations, we analyzed 335 F2 mice from an intercross between 129-apoE and apoEKO mice on a DBA/2J genetic background (DBA-apoE). The extent of atherosclerosis in the aortic arch was very similar in the two parental strains. Nevertheless, a genome-wide scan identified two significant QTL for plaque size in the aortic arch: Aath4 on Chromosome (Chr) 2 at 137 Mb and Aath5 on Chr 10 at 51 Mb. The DBA alleles of Aath4 and Aath5 respectively confer susceptibility and resistance to aortic arch atherosclerosis over 129 alleles. Both QTL are also independent of those affecting plaque size at the aortic root. Genome analysis suggests that athero-susceptibility of Aath4 in DBA may be contributed by multiple genes, including Mertk and Cd93, that play roles in phagocytosis of apoptotic cells and modulate inflammation. A candidate gene for Aath5 is Stab2, the DBA allele of which is associated with 10 times higher plasma hyaluronan than the 129 allele. Overall, our identification of two new QTL that affect atherosclerosis in an aortic arch-specific manner further supports the involvement of distinct pathological processes at different vascular locations. PMID:25689165

A Case of an Aortic Abscess around the Elephant Trunk.

PubMed

Fujii, Takeshiro; Kawasaki, Muneyasu; Katayanagi, Tomoyuki; Okuma, Shinnosuke; Masuhara, Hiroshi; Shiono, Noritsugu; Watanabe, Yoshinori

2015-01-01

A 52-year-old male patient with a history of total arch replacement using the elephant trunk technique for acute aortic dissection 4 years before visited our hospital with the chief complaint of persistent fever. Chest computed tomography (CT) suggested prosthetic vascular graft infection, which was treated surgically after chemotherapy. The first surgery consisted of debridement of an abscess around the vascular graft and in the aorta around the elephant trunk, and thoracic descending aorta replacement and vacuum-assisted closure (VAC) in view of the risk of bleeding from the peripheral region of the elephant trunk. One week later, omental filling was performed as the second step. This is a very rare case of aortic abscess around the elephant trunk that could successfully be managed by graft-conserving treatment.

Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry.

PubMed

Charitos, Efstratios I; Takkenberg, Johanna J M; Hanke, Thorsten; Gorski, Armin; Botha, Cornelius; Franke, Ulrich; Dodge-Khatami, Ali; Hoerer, Juergen; Lange, Rudiger; Moritz, Anton; Ferrari-Kuehne, Katharina; Hetzer, Roland; Huebler, Michael; Bogers, Ad J J C; Stierle, Ulrich; Sievers, Hans-Hinrich; Hemmer, Wolfgang

2012-10-01

Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry. From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years). In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P < .001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P < .001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation. The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Latest evidence on transcatheter aortic valve implantation vs. surgical aortic valve replacement for the treatment of aortic stenosis in high and intermediate-risk patients.

PubMed

Praz, Fabien; Siontis, George C M; Verma, Subodh; Windecker, Stephan; Jüni, Peter

2017-03-01

The goal of this review is to summarize the current evidence supporting the use of transcatheter aortic valve implantation (TAVI) in high and intermediate-risk patients. The focus is on the five randomized controlled trials comparing TAVI with surgical aortic valve replacement (SAVR) published to date, as well as two recent meta-analyses. TAVI has profoundly transformed the treatment of elderly patients presenting with symptomatic severe aortic stenosis. In experienced hands, the procedure has become well tolerated and the results more predictable. So far, two trials using two different devices [Placement of Aortic Transcatheter Valve (PARTNER) 1A and US CoreValve High Risk] have shown that TAVI is able to compete in terms of mortality with SAVR in high-risk patients. These findings have been extended to the intermediate-risk population in two recently published randomized controlled trials [PARTNER 2 and Nordic Aortic Valve Intervention (NOTION)]. The two meta-analyses suggested improved survival in both high and intermediate-risk patients during the first 2 years following the intervention. The survival benefit was only found in patients treated via the transfemoral access, and appeared more pronounced in women. Individual randomized trials enrolling high and intermediate-risk patients have established the noninferiority of TAVI in comparison with SAVR, whereas subsequent meta-analyses suggest superiority of transfemoral TAVI in terms of a sustained survival benefit 2 years after valve implantation irrespective of the surgical risk category. The benefit of TAVI appears more pronounced in women than in men.

[Intravascular Hemolysis Caused by Stenosis of an Elephant Trunk;Report of a Case].

PubMed

Takamaru, Rikako; Kawahito, Koji; Aizawa, Kei; Misawa, Yoshio

2017-07-01

Symptomatic intravascular hemolysis after prosthetic aortic graft replacement is rare. It is primarily attributed to mechanical injury of red blood cells caused by stenosis of the vascular graft. A 50-year-old man presented with hemolytic anemia, 5 years after total arch replacement with an elephant trunk for type A aortic dissection. The hemolysis was caused by graft stenosis of the elephant trunk. Endovascular treatment for the stenotic elephant trunk was successfully performed. The postoperative course was uneventful, and the hemolysis was resolved immediately after operation.

Aortic valve replacement in a patient with severe nickel allergy.

PubMed

Lusini, Mario; Barbato, Raffaele; Spadaccio, Cristiano; Chello, Massimo

2011-11-01

Nickel allergy can raise clinical problems in patients undergoing cardiac surgery who require sternal closure with stainless steel wire. We describe the case of a 51-year-old woman with severe nickel allergy who underwent aortic valve replacement with a nickel-free ON-X prosthesis and sternal closure by Fiberwire # 2 suture without complications. Considering its biocompatibility and its mechanical characteristics including optimal strength and knot resistance, this suture might be a viable alternative in patients in which the use of stainless steel wire is contraindicated. © 2011 Wiley Periodicals, Inc.

Ventricular Tacyhcardia in A Patient with A Previous History of Endocarditis and Ankylosan Spondylitis: A Challenging Case.

PubMed

Koza, Yavuzer; Taş, Muhammed Hakan; Şimşek, Ziya; Gündoğdu, Fuat

2016-10-01

Cardiac conduction defects are commonly observed in patients with ankylosing spondylitis, infective endocarditis, and aortic valve replacement. Each of these clinical situations can also present with ventricular tacyhcardia by different mechanisms. Here we report the case of a 53-year-old man with a medical history of untreated ankylosing spondylitis and aortic valve replacement who presented with ventricular tachycardia and underwent successful catheter ablation. Most ventricular tachycardia episodes were intermittent and drug resistant, which could have been caused by abnormal automaticity rather than re-entry.

Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy.

PubMed

Ross, J

1985-04-01

In the management of patients with valvular heart disease, an understanding of the effects of altered loading conditions on the left ventricle is important in reaching a proper decision concerning the timing of corrective operation. In acquired valvular aortic stenosis, concentric hypertrophy generally maintains left ventricular chamber size and ejection fraction within normal limits, but in late stage disease function can deteriorate as preload reserve is lost and aortic stenosis progresses. In this setting, even when the ejection fraction is markedly reduced (less than 25%), it can improve to normal after aortic valve replacement, suggesting that afterload mismatch rather than irreversibly depressed myocardial contractility was responsible for left ventricular failure. Therefore, patients with severe aortic stenosis and symptoms should not be denied operation because of impaired cardiac function. In chronic severe aortic and mitral regurgitation, operation is generally recommended when symptoms are present, but whether to recommend operation to prevent irreversible myocardial damage in patients with few or no symptoms has remained controversial. In aortic regurgitation, left ventricular function generally improves postoperatively, even if it is moderately impaired preoperatively, indicating correction of afterload mismatch. Most such patients can be carefully followed by echocardiography. However, in some patients, severe left ventricular dysfunction fails to improve postoperatively. Therefore, when echocardiographic studies in the patient with severe aortic regurgitation show an ejection fraction of less than 40% (fractional shortening less than 25%) plus enlarging left ventricular end-diastolic diameter (approaching 38 mm/m2 body surface area) and end-systolic diameter (approaching 50 mm or 26 mm/m2), confirmation of these findings by cardiac catheterization and consideration of operation are advisable even in patients with minimal symptoms. In chronic mitral regurgitation, maintenance of a normal ejection fraction can mask depressed myocardial contractility. Pre- and postoperative studies in such patients have shown a poor clinical result after mitral valve replacement, associated with a sharp decrease in the ejection fraction after operation. This response appears to reflect unmasking of decreased myocardial contractility by mitral valve replacement, with ejection of the total stroke volume into the high impedance of the aorta (afterload mismatch produced by operation).(ABSTRACT TRUNCATED AT 400 WORDS)

Sex, Aging, and Preexisting Cerebral Ischemic Disease in Patients With Aortic Stenosis

PubMed Central

Wang, Ping; Acker, Michael A.; Bilello, Michel; Melhem, Elias R.; Stambrook, Elizabeth; Ratcliffe, Sarah J.; Floyd, Thomas F.

2011-01-01

Background Patients undergoing cardiac surgery have a high frequency of preexisting cerebral ischemic lesions, the presence of which appears to predict cognitive sequelae. Patients undergoing aortic valve replacement for aortic stenosis (AS) incur an exceptionally high risk for perioperative cerebral ischemia. The extreme risk in this subgroup may arise from the preexisting burden of cerebral ischemic disease. We tested the hypotheses that increasing age, female sex, coronary artery disease, and the severity of AS are predictive of the severity of preexisting cerebral ischemic lesions. Methods A total of 95 subjects were included in this study. Subjects were imaged on 1.5 Tesla magnetic resonance imaging scanners to obtain multimodal image sets which were used for the automatic segmentation of cerebral lesion volume. The dependence of lesion volume upon age, sex, coronary artery disease, and the severity of AS were tested. Results The results demonstrate a strong correlation between aging, female sex, and white matter and ischemia-like lesion volume in patients with aortic stenosis. Conclusions Women and those of advanced age presenting for aortic valve replacement for AS may incur a particularly high risk for postoperative neurologic sequelae due to an exceptional preexisting burden of cerebral ischemic disease. PMID:20868818

Interventional valve surgery: building a team and working together.

PubMed

Ruel, Marc; Dickie, Sean; Chow, Benjamin J W; Labinaz, Marino

2010-01-01

Transcatheter aortic valve implantation (TAVI) is a new modality that may change the therapeutic landscape in the management of aortic valve stenosis. Despite the excellent results of surgical aortic valve replacement, TAVI has the potential to revolutionize the treatment of elderly and high-risk patients with aortic stenosis. It therefore constitutes a new reality that cardiac surgeons have to acknowledge. As TAVI indications and techniques become better defined, the importance of a team approach to the implementation and performance of TAVI is becoming increasingly evident. The surgeon has a crucial role to play in the introduction, development, and sustainability of TAVI at any institution. In this article, we discuss the procedural technique involved in TAVI, as well as the cardiologist and heart surgeon individualities and team dynamics. We make a case for judicious team-based adoption of TAVI technologies, considering that evidence-based and health economics data are not yet available. We also illustrate how a team approach may lead to improved outcomes, better patient and institutional acceptance, and a better definition of the therapeutic niche of TAVI modalities, amid the excellent results of conventional aortic valve replacement surgery. Copyright © 2010 Elsevier Inc. All rights reserved.

Aortic valve replacement in elderly patients.

PubMed

Glock, Y; Pecoul, R; Cerene, A; Laguerre, J; Puel, P

1984-01-01

The results for 62 consecutive patients aged 70 or more given aortic valve replacement (A.V.R.) between 1970 and 1982 are reported. All the patients were in the New York Heart Association (N.Y.H.A.) functional class III (29%) or IV (71%); 54.8% had angina and 30.6% had experienced syncope. Forty patients had aortic stenosis (A.S.), 10 had aortic regurgitation and 12 had mixed aortic valve disease. The operative myocardial infarction rate was 6.4%. Tilting disk valves were used. Eighty percent of the patients were anticoagulated with Warfarin whilst twenty percent received only antiplatelet drugs. All the patients were followed up for a mean period of 26 months; late mortality was 22.6% with 4.8% cardiac deaths. The thromboembolic rate was 1.6% and the disinsertion rate was 3.2%. Cerebral stroke was fatal in 3 cases in anticoagulated patients but the mechanism of the accident was not known. At the termination of the study 93% of surviving patients were in N.Y.H.A. class I or II. No patient was in class IV. The probability of five year survival is 71% for the entire group.

A laboratory model of the aortic root flow including the coronary arteries

NASA Astrophysics Data System (ADS)

Querzoli, Giorgio; Fortini, Stefania; Espa, Stefania; Melchionna, Simone

2016-08-01

Cardiovascular flows have been extensively investigated by means of in vitro models to assess the prosthetic valve performances and to provide insight into the fluid dynamics of the heart and proximal aorta. In particular, the models for the study of the flow past the aortic valve have been continuously improved by including, among other things, the compliance of the vessel and more realistic geometries. The flow within the sinuses of Valsalva is known to play a fundamental role in the dynamics of the aortic valve since they host a recirculation region that interacts with the leaflets. The coronary arteries originate from the ostia located within two of the three sinuses, and their presence may significantly affect the fluid dynamics of the aortic root. In spite of their importance, to the extent of the authors' knowledge, coronary arteries were not included so far when modeling in vitro the transvalvular aortic flow. We present a pulse duplicator consisting of a passively pulsing ventricle, a compliant proximal aorta, and coronary arteries connected to the sinuses of Valsalva. The coronary flow is modulated by a self-regulating device mimicking the physiological mechanism, which is based on the contraction and relaxation of the heart muscle during the cardiac cycle. Results show that the model reproduces satisfyingly the coronary flow. The analysis of the time evolution of the velocity and vorticity fields within the aortic root reveals the main characteristics of the backflow generated through the aorta in order to feed the coronaries during the diastole. Experiments without coronary flow have been run for comparison. Interestingly, the lifetime of the vortex forming in the sinus of Valsalva during the systole is reduced by the presence of the coronaries. As a matter of fact, at the end of the systole, that vortex is washed out because of the suction generated by the coronary flow. Correspondingly, the valve closure is delayed and faster compared to the case with no coronary flow.

Hemodynamic Correlates of Abnormal Aortic Root Dimension in an Adult Population: The Strong Heart Study.

PubMed

de Simone, Giovanni; Roman, Mary J; De Marco, Marina; Bella, Jonathan N; Izzo, Raffaele; Lee, Elisa T; Devereux, Richard B

2015-09-28

We evaluated the relationship of aortic root dimension (ARD) with flow output and both peripheral and central blood pressure, using multivariable equations predicting ideal sex-specific ARD at a given age and body height. We measured echocardiographic diastolic ARD at the sinuses of Valsalva in 3160 adults (aged 42±16 years, 61% women) from the fourth examination of the Strong Heart Study who were free of prevalent coronary heart disease, and we compared measured data with the theoretical predicted value to calculate a z score. Central blood pressure was estimated by applanation tonometry of the radial artery in 2319 participants. ARD z scores were divided into tertiles representing small, normal, and large ARD. Participants with large ARD exhibited greater prevalence of central obesity and higher levels of inflammatory markers and lipids (0.05

Fisics-Incor bovine pericardial bioprostheses: 15 year results.

PubMed

Pomerantzeff, P M; Brandao, C M; Cauduro, P; Puig, L B; Grinberg, M; Tarasoutchi, F; Cardoso, L F; Lerner, A; Stolf, N A; Verginelli, G; Jatene, A D

1998-01-01

From March 1982 to December 1995, 2,607 Fisics-Incor bovine pericardial bioprostheses were implanted in 2,259 patients. Mean age was 47.2 +/- 17.5 years, and 55% were male. Rheumatic fever was present in 1,301 (45.7%) patients. One thousand and seventy-three aortic valve replacements, 1,085 mitral replacements, 27 tricuspid replacements, 195 mitral-aortic replacements, and 16 other combined valve replacements were carried out. Combined procedures were performed in 788 (32.9%) patients, the most frequent being tricuspid valve repair (9.2%) and coronary artery bypass grafting (7.7%). Hospital mortality was 8.6% (194 patients), 8.6% for the mitral group, 4.7% for the aortic group, and 12.8% for double-valve replacements. The linear rates for calcification, thromboembolism, rupture, leak and endocarditis were, respectively, 1.1%, 0.2%, 0.9%, 0.1% and 0.5% patient-year. The actuarial survival curve was 56.7 +/- 5.4% in 15 years. Survival free from endocarditis was 91.92%, survival free from thromboembolism was 95 +/- 1.7%, survival free from rupture was 43.7 +/- 9.8%, survival free from leak was 98.9 +/- 4.5%, and survival free from calcification was 48.8 +/- 7.9% in 15 years. In the late postoperative period, 1,614 (80.6%) patients were in New York Heart Association functional Class I. We conclude that the results with the Fisics-Incor bovine pericardial prostheses were satisfactory in our group of patients.

The German Aortic Valve Registry (GARY): in-hospital outcome

PubMed Central

Hamm, Christian W.; Möllmann, Helge; Holzhey, David; Beckmann, Andreas; Veit, Christof; Figulla, Hans-Reiner; Cremer, J.; Kuck, Karl-Heinz; Lange, Rüdiger; Zahn, Ralf; Sack, Stefan; Schuler, Gerhard; Walther, Thomas; Beyersdorf, Friedhelm; Böhm, Michael; Heusch, Gerd; Funkat, Anne-Kathrin; Meinertz, Thomas; Neumann, Till; Papoutsis, Konstantinos; Schneider, Steffen; Welz, Armin; Mohr, Friedrich W.

2014-01-01

Background Aortic stenosis is a frequent valvular disease especially in elderly patients. Catheter-based valve implantation has emerged as a valuable treatment approach for these patients being either at very high risk for conventional surgery or even deemed inoperable. The German Aortic Valve Registry (GARY) provides data on conventional and catheter-based aortic procedures on an all-comers basis. Methods and results A total of 13 860 consecutive patients undergoing repair for aortic valve disease [conventional surgery and transvascular (TV) or transapical (TA) catheter-based techniques] have been enrolled in this registry during 2011 and baseline, procedural, and outcome data have been acquired. The registry summarizes the results of 6523 conventional aortic valve replacements without (AVR) and 3464 with concomitant coronary bypass surgery (AVR + CABG) as well as 2695 TV AVI and 1181 TA interventions (TA AVI). Patients undergoing catheter-based techniques were significantly older and had higher risk profiles. The stroke rate was low in all groups with 1.3% (AVR), 1.9% (AVR + CABG), 1.7% (TV AVI), and 2.3% (TA AVI). The in-hospital mortality was 2.1% (AVR) and 4.5% (AVR + CABG) for patients undergoing conventional surgery, and 5.1% (TV AVI) and AVI 7.7% (TA AVI). Conclusion The in-hospital outcome results of this registry show that conventional surgery yields excellent results in all risk groups and that catheter-based aortic valve replacements is an alternative to conventional surgery in high risk and elderly patients. PMID:24022003

A Simple Device for Morphofunctional Evaluation During Aortic Valve-Sparing Surgery.

PubMed

Leone, Alessandro; Bruno, Piergiorgio; Cammertoni, Federico; Massetti, Massimo

2015-07-01

Valve-sparing operations for the treatment of aortic root disease with a structurally normal aortic valve are increasingly performed as they avoid prosthesis-related complications. Short- and long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. Residual aortic regurgitation is the main cause of early failure, and it is the most common motive for reoperation. However, intraoperative morphofunctional valve assessment requires expertise, and only transesophageal echocardiography can provide reliable information. We describe a simple, economic, reproducible hydrostatic test to intraoperatively evaluate valve competency under direct visualization. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: The German Aortic Valve Registry.

PubMed

Husser, Oliver; Fujita, Buntaro; Hengstenberg, Christian; Frerker, Christian; Beckmann, Andreas; Möllmann, Helge; Walther, Thomas; Bekeredjian, Raffi; Böhm, Michael; Pellegrini, Costanza; Bleiziffer, Sabine; Lange, Rüdiger; Mohr, Friedrich; Hamm, Christian W; Bauer, Timm; Ensminger, Stephan

2018-03-26

The aims of this study were to report on the use of local anesthesia or conscious sedation (LACS) and general anesthesia in transcatheter aortic valve replacement and to analyze the impact on outcome. Transcatheter aortic valve replacement can be performed in LACS or general anesthesia. Potential benefits of LACS, such as faster procedures and shorter hospital stays, need to be balanced with safety. A total of 16,543 patients from the German Aortic Valve Registry from 2011 to 2014 were analyzed, and propensity-matched analyses were performed to correct for potential selection bias. LACS was used in 49% of patients (8,121 of 16,543). In hospital, LACS was associated with lower rates of low-output syndrome, respiratory failure, delirium, cardiopulmonary resuscitation, and death. There was no difference in paravalvular leakage (II+) between LACS and general anesthesia in the entire population (5% vs. 4.8%; p = 0.76) or in the matched population (3.9% vs. 4.9%, p = 0.13). The risk for prolonged intensive care unit stay (≥3 days) was significantly reduced with LACS (odds ratio: 0.82; 95% confidence interval [CI]: 0.73 to 0.92; p = 0.001). Thirty-day mortality was lower with LACS in the entire population (3.5% vs. 4.9%; hazard ratio [HR]: 0.72; 95% CI: 0.60 to 0.86; p < 0.001) and in the matched population (2.8% vs. 4.6%; HR: 0.6; 95% CI: 0.45 to 0.8; p < 0.001). However, no differences in 1-year mortality between both groups in the entire population (16.5% vs. 16.9%; HR: 0.93; 95% CI: 0.85 to 1.02; p = 0.140) and in the propensity-matched population (14.1% vs. 15.5%; HR: 0.90; 95% CI: 0.78 to 1.03; p = 0.130) were observed. Use of LACS in transcatheter aortic valve replacement is safe, with fewer post-procedural complications and lower early mortality, suggesting its broad application. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement.

PubMed

Nardi, Paolo; Vacirca, Sara R; Russo, Marco; Colella, Dionisio F; Bassano, Carlo; Scafuri, Antonio; Pellegrino, Antonio; Melino, Gerry; Ruvolo, Giovanni

2018-03-01

Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

[Progress and challenge of Stanford type A aortic dissection in China].

PubMed

Sun, L Z; Li, J R

2017-04-01

In recent 20 years, the rapid development of acute Stanford type A aortic dissection in China has been mainly due to three aspects: (1) the refined classification of aortic dissection based on Stanford classification, (2) right axillary artery canal and selective cerebral perfusion technology become basic cardiopulmonary bypass strategy for Stanford type A aortic dissection, and (3) total aortic arch replacement and descending aortic stent graft surgery (Sun's surgery) become the standard treatment of Stanford type A aortic dissection. However, there are still many problems in the diagnosis and treatment of aortic dissection in China, such as: (1) unstandardized, lack of comprehensive guidelines of aortic dissection, (2) immature, perioperative organ protection and intraoperative blood protection technology remains a big flaw, and (3) it takes a long time to get patient prepared for surgery. In conclusion, as to the issue of the management of acute Stanford type A aortic dissection, there will be a long way for Chinese doctors to go. Peers should pay more attention to this problem and take more efforts, so that the outcome of acute Stanford type A aortic dissection surgical patients can be improved.

Open heart surgery after renal transplantation.

PubMed

Yamamura, Mitsuhiro; Miyamoto, Yuji; Mitsuno, Masataka; Tanaka, Hiroe; Ryomoto, Masaaki; Fukui, Shinya; Tsujiya, Noriko; Kajiyama, Tetsuya; Nojima, Michio

2014-09-01

to evaluate the strategy for open heart surgery after renal transplantation performed in a single institution in Japan. we reviewed 6 open heart surgeries after renal transplantation in 5 patients, performed between January 1992 and December 2012. The patients were 3 men and 2 women with a mean age of 60 ± 11 years (range 46-68 years). They had old myocardial infarction and unstable angina, aortic and mitral stenosis, left arterial myxoma, aortic stenosis, and native valve endocarditis followed by prosthetic valve endocarditis. Operative procedures included coronary artery bypass grafting, double-valve replacement, resection of left arterial myxoma, 2 aortic valve replacements, and a double-valve replacement. Renal protection consisted of steroid cover (hydrocortisone 100-500 mg or methylprednisolone 1000 mg) and intravenous immunosuppressant infusion (cyclosporine 30-40 mg day(-1) or tacrolimus 1.0 mg day(-1)). 5 cases were uneventful and good renal graft function was maintained at discharge (serum creatinine 2.1 ± 0.5 mg dL(-1)). There was one operative death after emergency double-valve replacement for methicillin-resistant Staphylococcus aureus-associated prosthetic valve endocarditis. Although the endocarditis improved after valve replacement, the patient died of postoperative pneumonia on postoperative day 45. careful perioperative management can allow successful open heart surgery after renal transplantation. However, severe complications, especially methicillin-resistant Staphylococcus aureus infection, may cause renal graft loss. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Comparative outcomes of transcatheter aortic valve replacement in African American and Caucasian patients with severe aortic stenosis.

PubMed

Alqahtani, Fahad; Aljohani, Sami; Almustafa, Ahmad; Alhijji, Mohammed; Ali, Oluseun; Holmes, David R; Alkhouli, Mohamad

2018-04-01

Racial disparities in cardiovascular care have been extensively investigated. The introduction of transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis (AS) in the last decade. Whether a racial disparity in the utilization and outcome of TAVR exists is unknown. We utilized the nationwide inpatient sample (NIS) to compare utilization rates, and in-hospital outcomes of Caucasians and African American (AA) patients who underwent TAVR between August 2011 and December 2014. A total of 7,176 patients (6870 Caucasians, 95.7%) and (306 AAs, 4.3%) were included in this analysis. Among patients who underwent aortic valve replacement between 2011 and 2014, the rates of TAVR utilization increased from 0.32% to 7.6% in AAs and from 0.4% to 8.8% in Caucasians. In propensity-matched cohorts of patients (n = 300 Caucasians and n = 300 AAs), in-hospital mortality was similar (3.7% and 3.3%, respectively, P = 0.99). Also, rates of key complications including stroke, permanent pacemaker implantation (PPMI), vascular complications, acute kidney injury, new dialysis, blood transfusion, and tamponade were similar in both races. There was also no significant difference between Caucasians and AAs with regards to length of stay, cost of hospitalization, and intermediate care facility utilization. There was no significant difference in the utilization rates, in-hospital outcomes, and cost of TAVR between Caucasians and AA patients in contemporary US practice. Further comparative studies of surgical and TAVR in AAs and other racial minorities are warranted. © 2017 Wiley Periodicals, Inc.

Bioprosthetic Valve Fracture to Facilitate Transcatheter Valve-in-Valve Implantation.

PubMed

Allen, Keith B; Chhatriwalla, Adnan K; Cohen, David J; Saxon, John T; Aggarwal, Sanjeev; Hart, Anthony; Baron, Suzanne; Davis, J Russell; Pak, Alex F; Dvir, Danny; Borkon, A Michael

2017-11-01

Valve-in-valve transcatheter aortic valve replacement is less effective in small surgical bioprostheses. We evaluated the feasibility of bioprosthetic valve fracture with a high-pressure balloon to facilitate valve-in-valve transcatheter aortic valve replacement. In vitro bench testing on aortic tissue valves was performed on 19-mm and 21-mm Mitroflow (Sorin, Milan, Italy), Magna and Magna Ease (Edwards Lifesciences, Irvine, CA), Trifecta and Biocor Epic (St. Jude Medical, Minneapolis, MN), and Hancock II and Mosaic (Medtronic, Minneapolis, MN). High-pressure balloons Tru Dilation, Atlas Gold, and Dorado (C.R. Bard, Murray Hill, NJ) were used to determine which valves could be fractured and at what pressure fracture occurred. Mitroflow, Magna, Magna Ease, Mosaic, and Biocor Epic surgical valves were successfully fractured using high-pressures balloon 1 mm larger than the labeled valve size whereas Trifecta and Hancock II surgical valves could not be fractured. Only the internal valve frame was fractured, and the sewing cuff was never disrupted. Manufacturer's rated burst pressures for balloons were exceeded, with fracture pressures ranging from 8 to 24 atmospheres depending on the surgical valve. Testing further demonstrated that fracture facilitated the expansion of previously constrained, underexpanded transcatheter valves (both balloon and self-expanding) to the manufacturer's recommended size. Bench testing demonstrates that the frame of most, but not all, bioprosthetic surgical aortic valves can be fractured using high-pressure balloons. The safety of bioprosthetic valve fracture to optimize valve-in-valve transcatheter aortic valve replacement in small surgical valves requires further clinical investigation. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Combined repair of adult coarctation of the aorta and aortic valvular stenosis.

PubMed

Ivert, T; Busund, R; Avenarius, D; Dahi, P E

2000-06-01

A 57-year-old man with a high-grade aortic stenosis and aortic coarctation was treated with concomitant valve replacement and insertion of a conduit from the ascending aorta to the retrocardiac descending aorta via the left pleura. Because heart failure has been reported shortly after cardiopulmonary bypass using this technique, the conduit was initially clamped until the postrepair haemodynamics was stable. Computed tomography after 14 months verified patency of the shunt.

Aortic valve replacement in a Jehovah’s Witness: a case of multi-disciplinary clinical management for bloodless surgery

PubMed Central

Park, John Jungpa; Lang, Christopher C; Manson, Lynn; Brackenbury, Edward T

2012-01-01

An 81-year-old female Jehovah’s Witness (JW) patient with severe aortic stenosis required aortic valve replacement (AVR). However, the patient’s religious beliefs precluded the use of primary blood components. Since the definitive treatment of AVR required bloodless open heart surgery, careful peri-operative plans were set forth by a multi-disciplinary team involving the cardiothoracic surgeon, haematologist and anaesthetist. The patient went on to successfully recover postoperatively. This case highlights: 1) The importance of carefully navigating through the most recent clinical and ethical protocol involved in the surgical management of JW’s. 2) The importance of preparing individually tailored pre, intra and postoperative plans that are delivered through a multi-disciplinary clinical team to ensure the best and safest possible outcomes. PMID:22665474

Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement

PubMed Central

Reynolds, Matthew R.; Lei, Yang; Wang, Kaijun; Chinnakondepalli, Khaja; Vilain, Katherine A.; Magnuson, Elizabeth A.; Galper, Benjamin Z.; Meduri, Christopher U.; Arnold, Suzanne V.; Baron, Suzanne J.; Reardon, Michael J.; Adams, David H.; Popma, Jeffrey J.; Cohen, David J.

2016-01-01

Background Prior studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system. Objectives The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk. Methods We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk pivotal trial. Empirical data regarding survival and quality of life (QOL) over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S. perspective. Results Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month QOL. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years (QALYs; 0.41 life-years [LYs]) with 3% discounting. Lifetime incremental cost-effectiveness ratios (ICERs) were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ~$1,650 would lead to an ICER <$50,000/QALY gained. Conclusions In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S. standards. With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. PMID:26764063

Gait Speed Predicts 30-Day Mortality After Transcatheter Aortic Valve Replacement: Results From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

PubMed

Alfredsson, Joakim; Stebbins, Amanda; Brennan, J Matthew; Matsouaka, Roland; Afilalo, Jonathan; Peterson, Eric D; Vemulapalli, Sreekanth; Rumsfeld, John S; Shahian, David; Mack, Michael J; Alexander, Karen P

2016-04-05

Surgical risk scores do not include frailty assessments (eg, gait speed), which are of particular importance for patients with severe aortic stenosis considering transcatheter aortic valve replacement. We assessed the association of 5-m gait speed with outcomes in a cohort of 8039 patients who underwent transcatheter aortic valve replacement (November 2011-June 2014) and were included in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. We evaluated the association between continuous and categorical gait speed and 30-day all-cause mortality before and after adjustment for Society of Thoracic Surgeons-predicted risk of mortality score and key variables. Secondary outcomes included in-hospital mortality, bleeding, acute kidney injury, and stroke. The overall median gait speed was 0.63 m/s (25th-75th percentile, 0.47-0.79 m/s), with the slowest walkers (<0.5 m/s) constituting 28%, slow walkers (0.5-0.83 m/s) making up 48%, and normal walkers (>0.83 m/s) constituting 24% of the population. Thirty-day all-cause mortality rates were 8.4%, 6.6%, and 5.4% for the slowest, slow, and normal walkers, respectively (P<0.001). Each 0.2-m/s decrease in gait speed corresponded to an 11% increase in 30-day mortality (adjusted odds ratio, 1.11; 95% confidence interval, 1.01-1.22). The slowest walkers had 35% higher 30-day mortality than normal walkers (adjusted odds ratio, 1.35; 95% confidence interval, 1.01-1.80), significantly longer hospital stays, and a lower probability of being discharged to home. Gait speed is independently associated with 30-day mortality after transcatheter aortic valve replacement. Identification of frail patients with the slowest gait speeds facilitates preprocedural evaluation and anticipation of a higher level of postprocedural care. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01737528. © 2016 American Heart Association, Inc.

McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology.

PubMed

Longo, S A; Echegaray, A; Acosta, C M; Rinaldi, L I; Cabrera Schulmeyer, M C; Olavide Goya, I

2016-11-01

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

[The long term (15 years) evolution after valvular replacement with mechanical prosthesis or bioprosthesis between the age of 60 and 70 years].

PubMed

Hanania, G; Michel, P L; Montély, J M; Warembourg, H; Nardi, O; Leguerrier, A; Agnino, A; Despins, P; Legault, B; Petit, H; Bouraindeloup, M

2004-01-01

the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life. a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis. the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p<0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3). the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

Intimal re-layering technique for type A acute aortic dissection-reconstructing the intimal layer continuity to induce remodeling of the false channel.

PubMed

Neri, Eugenio; Tucci, Enrico; Tommasino, Giulio; Guaccio, Giulia; Ricci, Carmelo; Lucatelli, Pierleone; Cini, Marco; Ceresa, Roberto; Benvenuti, Antonio; Muzzi, Luigi

2018-01-01

Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

Early outcomes of transcatheter aortic valve replacement in patients with severe aortic stenosis: single center experience

PubMed Central

Bozkurt, Engin; Keleş, Telat; Durmaz, Tahir; Akçay, Murat; Ayhan, Hüseyin; Bayram, Nihal Akar; Aslan, Abdullah Nabi; Baştuğ, Serdal; Bilen, Emine

2014-01-01

Introduction Transcatheter aortic valve implantation is a promising alternative to high risk surgical aortic valve replacement. The procedure is mainly indicated in patients with severe symptomatic aortic stenosis who cannot undergo surgery or who are at very high surgical risk. Aim Description early results of our single-center experience with balloon expandable aortic valve implantation. Material and methods Between July 2011 and August 2012, we screened in total 75 consecutive patients with severe aortic stenosis and high risk for surgery. Twenty-one of them were found ineligible for transcatheter aortic valve implantation (TAVI) because of various reasons, and finally we treated a total of 54 patients with symptomatic severe aortic stenosis (AS) who could not be treated by open heart surgery (inoperable) because of high-risk criteria. The average age of the patients was 77.4 ±7.1; 27.8% were male and 72.2% were female. The number of patients in NYHA class II was 7 while the number of patients in class III and class IV was 47. Results The average mortality score of patients according to the STS scoring system was 8.5%. Pre-implantation mean and maximal aortic valve gradients were measured as 53.2 ±14.1 mm Hg and 85.5 ±18.9 mm Hg, respectively. Post-implantation mean and maximal aortic valve gradients were 9.0 ±3.0 and 18.2 ±5.6, respectively (p < 0.0001). The left ventricular ejection fraction was calculated as 54.7 ±14.4% before the operation and 58.0 ±11.1% after the operation (p < 0.0001). The duration of discharge after the operation was 5.29 days, and a statistically significant correlation between the duration of discharge after the operation and STS was found (r = 0385, p = 0.004). Conclusions We consider that with decreasing cost and increasing treatment experience, TAVI will be used more frequently in broader indications. Our experience with TAVI using the Edwards-Sapien XT (Edwards Lifesciences, Irvine, CA) devices suggests that this is an effective and relatively safe procedure for the treatment of severe aortic stenosis in suitable patients. PMID:25061453

Lissajous figures: an engineering tool for root cause analysis of individual cases--a preliminary concept.

PubMed

Palmer, Kenneth; Ridgway, Tim; Al-Rawi, Omar; Johnson, Ian; Poullis, Michael

2011-09-01

Some patients have short intensive care stay periods and little or no organ dysfunction after cardiac surgery and others do not despite seemingly faultless surgery, perfusion, and anesthesia. These "unknown" reasons for death and morbidity usually relate to organ ischemia and inflammation, but are obviously mutlifactorial. A Lissajous figure is a technique in electrical engineering to compare two different electrical signals. We utilize this basic concept in a very simple manner to potentially identify why some of these unknown deaths or morbidities occur. Utilizing an electronic perfusion database, we retrospectively analyzed 43 patients undergoing aortic surgery with regard to central venous saturations during cooling and rewarming. Isolated aortic valve replacement patients were excluded. Central venous saturation, time, and temperature were plotted to create a Lissajous figure for the whole operation, and during cooling and rewarming separately. Temperature and saturations were analyzed every 20 seconds. Perfusion related variables were registered and uploaded to www.perfsort.net. Lissajous figures during cooling add little to patient care due to their similarity. Isolated rewarming revealed startling differences. It is immediately visually obvious who had short and long periods of tissue ischemia and reperfusion during rewarming in a seemingly uneventful operation. The periods of ischemia can be semi quantified into: none, mild, moderate, and severe. Creation of simple Lissajous figures during rewarming for bypass runs may be an additional helpful tool in root cause analysis of patient death/morbidity when surgery, perfusion, and anesthesia seemed faultless. Low central venous saturations at hypothermic temperatures mean significant metabolic activity, indicating tissue ischemia is occurring. Further work is needed to correlate this concept to outcomes.

Mitral valve repair under cardiopulmonary bypass in small-breed dogs: 48 cases (2006-2009).

PubMed

Uechi, Masami; Mizukoshi, Takahiro; Mizuno, Takeshi; Mizuno, Masashi; Harada, Kayoko; Ebisawa, Takashi; Takeuchi, Junichirou; Sawada, Tamotsu; Uchida, Shuhei; Shinoda, Asako; Kasuya, Arane; Endo, Masaaki; Nishida, Miki; Kono, Shota; Fujiwara, Megumi; Nakamura, Takashi

2012-05-15

To determine whether mitral valve repair (MVR) under cardiopulmonary bypass would be an effective treatment for mitral regurgitation in small-breed dogs. Retrospective case series. 48 small-breed dogs (body weight, 1.88 to 4.65 kg [4.11 to 10.25 lb]; age, 5 to 15 years) with mitral regurgitation that underwent surgery between August 2006 and August 2009. Cardiopulmonary bypass was performed with a cardiopulmonary bypass circuit. After induction of cardiac arrest, a mitral annuloplasty was performed, and the chordae tendineae were replaced with expanded polytetrafluoroethylene chordal prostheses. After closure of the left atrium and declamping to restart the heart, the thorax was closed. Preoperatively, cardiac murmur was grade 3 of 6 to 6 of 6, thoracic radiography showed cardiac enlargement (median vertebral heart size, 12.0 vertebrae; range, 9.5 to 14.5 vertebrae), and echocardiography showed severe mitral regurgitation and left atrial enlargement (median left atrium-to-aortic root ratio, 2.6; range, 1.7 to 4.0). 45 of 48 dogs survived to discharge. Three months after surgery, cardiac murmur grade was reduced to 0/6 to 3/6, and the heart shadow was reduced (median vertebral heart size, 11.1 vertebrae, range, 9.2 to 13.0 vertebrae) on thoracic radiographs. Echocardiography confirmed a marked reduction in mitral regurgitation and left atrium-to-aortic root ratio (median, 1.7; range, 1.0 to 3.0). We successfully performed MVR under cardiopulmonary bypass in small-breed dogs, suggesting this may be an effective surgical treatment for dogs with mitral regurgitation. Mitral valve repair with cardiopulmonary bypass can be beneficial for the treatment of mitral regurgitation in small-breed dogs.

Impact of bendopnea on postoperative outcomes in patients with severe aortic stenosis undergoing aortic valve replacement.

PubMed

Dominguez-Rodriguez, Alberto; Thibodeau, Jennifer T; Ayers, Colby R; Jimenez-Sosa, Alejandro; Garrido, Pilar; Montoto, Javier; Prada-Arrondo, Pablo C; Abreu-Gonzalez, Pedro; Drazner, Mark H

2018-06-02

Bendopnea is a recently described symptom of advanced heart failure. Its prevalence and prognostic utility in other cardiac conditions are unknown. We prospectively enrolled 108 consecutive patients (75 ± 3 years, 68% men) with severe symptomatic aortic stenosis referred for surgical aortic valve replacement (SAVR). Preoperatively, patients were tested for bendopnea, which was considered to be present when dyspnoea occurred within 30 s of bending forward. Univariable and stepwise multivariable analyses tested the association of bendopnea with preoperative echocardiographic parameters and postoperative clinical outcomes. Bendopnea was present in 46 of 108 (42%) patients. The mean time of onset was 10.5 ± 3.4 s. Bendopnea was associated with higher estimated pulmonary artery systolic pressures [51 (11) mmHg vs 40 (11) mmHg), P < 0.0001], smaller aortic valve area [0.66 (0.16) cm2 vs 0.76 (0.13) cm2, P = 0.0006] and longer duration of mechanical ventilation (P = 0.002) and length of stay in the hospital (P = 0.007). Following SAVR, in-hospital mortality in those with bendopnea versus those without bendopnea was 13% vs 3% (P = 0.07). In multivariable analysis, bendopnea was associated with duration of mechanical ventilation (parameter estimate 2.4, P < 0.0001) and length of stay in the hospital (parameter estimate 10.2, P ≤ 0.0001). Bendopnea was present in a sizeable minority of patients (42%) with severe aortic stenosis referred for SAVR. Bendopnea was associated with higher pulmonary artery systolic pressure and smaller aortic valve area preoperatively and with longer duration of mechanical ventilation and length of hospitalization postoperatively. These data suggest that bendopnea provides prognostic information in patients with severe aortic stenosis undergoing SAVR.

Quantitative assessment of paravalvular leakage after transcatheter aortic valve replacement using a patient-specific pulsatile flow model.

PubMed

Tanaka, Yutaka; Saito, Shigeru; Sasuga, Saeko; Takahashi, Azuma; Aoyama, Yusuke; Obama, Kazuto; Umezu, Mitsuo; Iwasaki, Kiyotaka

2018-05-01

Quantitative assessment of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR) remains challenging. We developed patient-specific anatomical models with pulsatile flow circuit and investigated factors associated with AR after TAVR. Based on pre-procedural computed tomography (CT) data of the six patients who underwent transfemoral TAVR using a 23-mm SAPIEN XT, anatomically and mechanically equivalent aortic valve models were developed. Forward flow and heart rate of each patient in two days after TAVR were duplicated under mean aortic pressure of 80mmHg. Paravalvular leakage (PVL) volume in basal and additional conditions was measured for each model using an electromagnetic flow sensor. Incompletely apposed tract between the transcatheter and aortic valves was examined using a micro-CT. PVL volume in each patient-specific model was consistent with each patient's PVL grade, and was affected by hemodynamic conditions. PVL and total regurgitation volume increased with the mean aortic pressure, whereas closing volume did not change. In contrast, closing volume increased proportionately with heart rate, but PVL did not change. The minimal cross-sectional gap had a positive correlation with the PVL volumes (r=0.89, P=0.02). The gap areas typically occurred in the vicinity of the bulky calcified nodules under the native commissure. PVL volume, which could be affected by hemodynamic conditions, was significantly associated with the minimal cross-sectional gap area between the aortic annulus and the stent frame. These data may improve our understanding of the mechanism of the occurrence of post-TAVR PVL. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

PubMed Central

Pivatto Júnior, Fernando; Teixeira Filho, Guaracy Fernandes; Sant'anna, João Ricardo Michelin; Py, Pablo Mondim; Prates, Paulo Roberto; Nesralla, Ivo Abrahão; Kalil, Renato Abdala Karam

2014-01-01

Objective This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. Methods Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. Results 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. Conclusion Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup. PMID:24896162

Recurrent pannus formation causing prosthetic aortic valve dysfunction: Is excision without valve re-replacement applicable?

PubMed Central

2012-01-01

Prosthetic valve dysfunction at aortic position is commonly caused by pannus formation. The exact etiology is not known. It arises from ventricular aspect of the prosthesis encroaching its leaflets causing stenosis or it may remain localized causing left ventricular outflow tract obstruction without affecting valve function. The difference in location entails different approaches in management. Such a pathology requires surgical excision of the pannus with or without valve re-replacement. A recurrent pannus was observed in a female patient who needed repeated surgical intervention to excise a localized pannus without re-replacement of a well functioning prosthetic valve. Management of our case presents several questions, whether recurrence of pannus is caused by sparing the prosthetic valve, is it simply an exaggeration of an inflammatory healing process in certain individuals or is it ideal to re-replace the valve despite a well preserved function. PMID:22747790

Recurrent pannus formation causing prosthetic aortic valve dysfunction: is excision without valve re-replacement applicable?

PubMed

Darwazah, Ahmad K

2012-06-29

Prosthetic valve dysfunction at aortic position is commonly caused by pannus formation. The exact etiology is not known. It arises from ventricular aspect of the prosthesis encroaching its leaflets causing stenosis or it may remain localized causing left ventricular outflow tract obstruction without affecting valve function.The difference in location entails different approaches in management. Such a pathology requires surgical excision of the pannus with or without valve re-replacement.A recurrent pannus was observed in a female patient who needed repeated surgical intervention to excise a localized pannus without re-replacement of a well functioning prosthetic valve.Management of our case presents several questions, whether recurrence of pannus is caused by sparing the prosthetic valve, is it simply an exaggeration of an inflammatory healing process in certain individuals or is it ideal to re-replace the valve despite a well preserved function.

Ascending aortic injuries following blunt trauma.

PubMed

Sun, Xiumei; Hong, Jenny; Lowery, Robert; Goldstein, Steven; Wang, Zuyue; Lindsay, Joseph; Hill, Peter C; Corso, Paul J

2013-11-01

The diagnosis and the management of traumatic thoracic aortic injuries have undergone significant changes due to new technology and improved prehospital care. Most of the discussions have focused on descending aortic injuries. In this review, we discuss the recent management of ascending aortic injuries. We found 5 cohort studies on traumatic aortic injuries and 11 case reports describing ascending aortic injuries between 1998 to the present through Medline research. Among case reports, 78.9% of cases were caused by motor vehicle accidents (MVA). 42.1% of patients underwent emergent open repair and the operative mortality was 12.5%. 36.8% underwent delayed repair. Associated injuries occurred in 84.2% of patients. Aortic valve injury was concurrent in 26.3% of patients. The incidence of ascending aortic injury ranged 1.9-20% in cohort studies. Traumatic injuries to the ascending aorta are relatively uncommon among survivors following blunt trauma. Aortography has been replaced by computed tomography and echocardiography as a diagnostic tool. Open repair, either emergent or delayed, remains the treatment of choice. © 2013 Wiley Periodicals, Inc.

"Bail out" procedures for malpositioning of aortic valve prosthesis (CoreValve).

PubMed

Vavouranakis, Manolis; Vrachatis, Dimitrios A; Toutouzas, Konstantinos P; Chrysohoou, Christina; Stefanadis, Christodoulos

2010-11-05

Two techniques for correcting malpositioning occurring during percutaneous aortic valve 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 aortic valve prosthesis was successfully re-implanted. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

Exertional Angina Due To Fused Aortic Bioprosthesis During Left Ventricular Assist Device Support: Two Cases and Review of the Literature.

PubMed

Bonios, Michael J; Selzman, Craig H; Gilbert, Edward M; McKellar, Stephen H; Koliopoulou, Antigoni; Strege, Jennifer L; Nativi, Jose N; Fang, James C; Stehlik, Josef; Drakos, Stavros G

We present the case of two patients with idiopathic dilated cardiomyopathy and moderate aortic valve regurgitation that were treated with a bioprosthetic valve at the time of the left ventricular assist device (LVAD) implantation. A few months later, patients revealed partial recovery in the left ventricle systolic function. Both patients, during the LVAD turndown protocol, reported the onset of chest pain. The transthoracic echocardiography revealed the presence of a new transaortic pressure gradient. We confirmed the presence of a fused bioprosthetic valve by further performing a transesophageal echocardiogram and a left and right heart catheterization. Replacement of aortic valve at the time of an LVAD implantation constitutes a challenging case. Although a mechanical valve is contraindicated due to the increased thromboembolic risk, selecting a bioprosthetic valve increases the risk of valve leaflets fusion. The consequences of this phenomenon should be acknowledged in LVAD patients undergoing aortic valve replacement with a bioprosthetic, especially under the view of LVAD explantation for those revealing myocardial recovery under mechanical unloading.

Impact of electrocardiogram-gated multi-slice computed tomography-based aortic annular measurement in the evaluation of paravalvular leakage following transcatheter aortic valve replacement: the efficacy of the OverSized AortiC Annular ratio (OSACA ratio) in TAVR.

PubMed

Maeda, Koichi; Kuratani, Toru; Torikai, Kei; Shimamura, Kazuo; Mizote, Isamu; Ichibori, Yasuhiro; Takeda, Yasuharu; Daimon, Takashi; Nakatani, Satoshi; Nanto, Shinsuke; Sawa, Yoshiki

2013-07-01

Even mild paravalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) is associated with increased late mortality. Electrocardiogram-gated multi-slice computed tomography (MSCT) enables detailed aortic annulus assessment. We describe the impact of MSCT for PVL following TAVR. Congruence between the prosthesis and annulus diameters affects PVL; therefore, we calculated the OverSized AortiC Annular ratio (OSACA ratio) and OSACA (transesophageal echocardiography, TEE) ratio as prosthesis diameter/annulus diameter on MSCT or TEE, respectively, and compared their relationship with PVL ≤ trace following TAVR. Of 36 consecutive patients undergoing TAVR (Group A), the occurrence of PVL ≤ trace (33.3%) was significantly related to the OSACA ratio (p = 0.00020). In receiver-operating characteristics analysis, the cutoff value of 1.03 for the OSACA ratio had the highest sum of sensitivity (75.0%) and specificity (91.7%; AUC = 0.87) with significantly higher discriminatory performance for PVL as compared to the OSACA (TEE) ratio (AUC = 0.69, p = 0.028). In nine consecutive patients (Group B) undergoing TAVR based on guidelines formulated from our experience with Group A, PVL ≤ trace was significantly more frequent (88.9%) than that in Group A (p = 0.0060). The OSACA ratio has a significantly higher discriminatory performance for PVL ≤ trace than the OSACA (TEE) ratio, and aortic annular measurement from MSCT is more accurate than that from TEE. © 2013 Wiley Periodicals, Inc.

Adapting to living with a mechanical aortic heart valve: a phenomenographic study.

PubMed

Oterhals, Kjersti; Fridlund, Bengt; Nordrehaug, Jan Erik; Haaverstad, Rune; Norekvål, Tone M

2013-09-01

To describe how patients adapt to living with a mechanical aortic heart valve. Aortic valve replacement with a mechanical prosthesis is preferred for patients with life expectancy of more than 10 years as they are more durable than bioprosthetic valves. Mechanical valves have some disadvantages, such as higher risk of thrombosis and embolism, increased risk of bleeding related to lifelong oral anticoagulation treatment and noise from the valve. An explorative design with a phenomenographic approach was employed. An explorative design with a phenomenographic approach was applied. Interviews were conducted over 4 months during 2010-2011 with 20 strategically sampled patients, aged 24-74 years having undergone aortic valve replacement with mechanical prosthesis during the last 10 years. Patients adapted to living with a mechanical aortic heart valve in four ways: 'The competent patient' wanted to stay in control of his/her life. 'The adjusted patient' considered the implications of having a mechanical aortic valve as part of his/her daily life. 'The unaware patient' was not aware of warfarin-diet-medication interactions. 'The worried patient' was bothered with the oral anticoagulation and annoyed by the sound of the valve. Patients moved between the different ways of adapting. The oral anticoagulation therapy was considered the most troublesome consequence, but also the sound of the valve was difficult to accept. Patient counselling and adequate follow-up can make patients with mechanical aortic heart valves more confident and competent to manage their own health. We recommend that patients should participate in a rehabilitation programme following cardiac surgery. © 2013 Blackwell Publishing Ltd.

Study of phenotype evolution during childhood in Marfan syndrome to improve clinical recognition.

PubMed

Stheneur, Chantal; Tubach, Florence; Jouneaux, Marlène; Roy, Carine; Benoist, Gregoire; Chevallier, Bertrand; Boileau, Catherine; Jondeau, Guillaume

2014-03-01

Because diagnosis of Marfan syndrome is difficult during infancy, we used a large cohort of children to describe the evolution of the Marfan syndrome phenotype with age. Two hundred and fifty-nine children carrying an FBN1 gene mutation and fulfilling Ghent criteria were compared with 474 non-Marfan syndrome children. Prevalence of skeletal features changed with aging: prevalence of pectus deformity increased from 43% at 0-6 years to 62% at 15-17 years, wrist signs increased from 28 to 67%, and scoliosis increased from 16 to 59%. Hypermobility decreased from 67 to 47% and pes planus decreased from 73 to 65%. Striae increased from 2 to 84%. Prevalence of ectopia lentis remained stable, varying from 66 to 72%, similar to aortic root dilatation (varying from 75 to 80%). Aortic root dilatation remained stable during follow-up in this population receiving β-blocker therapy. When comparing Marfan syndrome children with non-Marfan syndrome children, height appeared to be a simple and discriminant criterion when it was >3.3 SD above the mean. Ectopia lentis and aortic dilatation were both similarly discriminating. Ectopia lentis and aortic dilatation are the best-discriminating features, but height remains a simple discriminating variable for general practitioners when >3.3 SD above the mean. Mean aortic dilatation remains stable in infancy when children receive a β-blocker.

[Is the estimation of the progression of valvular aortic stenosis possible?].

PubMed

Piper, C; Bergemann, R; Schulte, H D; Körfer, R; Horstkotte, D

2000-04-20

It is of great importance to assess progression of aortic valvar stenosis (AVS) when cardiac surgery is planned for other indications when established criteria for aortic valve replacement are not fulfilled at that moment. These considerations have often been ignored in prospective planning of treatment, necessitating a second cardiac surgical intervention just a few years later. The aim of this study was to establish criteria for estimating the rate of progression of AVS. Clinical, echocardiographic and haemodynamic data were analysed for 169 patients with aortic valvar stenosis (169 men, 88 women; mean age at first cardiac catheterization [CC] 55.2 +/- 15.7 years, at second CC 63.4 +/- 15.6 years. The degree of AVS increases exponentially in relation to the extent of calcification (graded 0-3) and the fall in transaortic gradient (TG), from a TG > 0.6 mmHg/ml stroke volume and can be sufficiently predictable for clinical purposes. But neither age, sex nor the aetiology/pathology of the valvar defect have a sustained influence on the progression of AVS. These data indicate that knowing the current reduction in TG and the degree of calcification makes it possible to assess the likely progression of previously asymptomatic AVS and thus greatly facilitate the decision of whether or not to combine aortic valve replacement with another indicated cardiac operation.

Analysis of Outcomes of the Nutritional Status in Patients Qualified for Aortic Valve Replacement in Comparison to Healthy Elderly

PubMed Central

Jagielak, Dariusz; Dardzińska, Jolanta Anna; Aleksandrowicz-Wrona, Ewa; Rogowski, Jan; Gruszecka, Agnieszka; Małgorzewicz, Sylwia

2018-01-01

Severe aortic stenosis (AS) is associated with the reduction of muscle mass and may be associated with deterioration of nutritional status. Furthermore, malnourished cardiac patients are characterized by a higher risk of postoperative complications and mortality. The aim of this study was the evaluation and comparison of nutritional status, appetite and body composition in older people with severe aortic stenosis before aortic valve replacement and healthy elderly volunteers. One hundred and one patients, aged >65 years old with severe AS were included in the study. Nutritional status was assessed. Body composition was estimated using bioelectrical impedance analysis. Concentrations of albumin, prealbumin, triglycerides, total cholesterol and C-reactive protein were measured, and a complete blood count was done. About 40% of AS patients were at risk of malnutrition. They had decreased hand grip strength and they lost more body mass than the control group. Malnourished AS patients were older, had lower body mass indexes (BMIs) and lower aortic valve areas in comparison to well-nourished patients. Older AS patients, like their peers, show excessive body mass and, at the same time, the features of malnutrition. They have additional factors such as unintentional weight lost and decreased muscle strength which may be associated with worse outcomes. PMID:29510548

An augmented magnetic navigation system for Transcatheter Aortic Valve Implantation.

PubMed

Luo, Zhe; Cai, Junfeng; Nie, Yuanyuan; Wang, Guotai; Gu, Lixu

2013-01-01

This research proposes an augmented magnetic navigation system for Transcatheter Aortic Valve 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 aortic valve 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 aortic valve prosthesis to target. The system was validated by animal studies on three porcine subjects, the deployment and tilting errors of which are 3.17 ± 0.91 mm and 7.40 ± 2.89° respectively.

A meta-analysis and meta-regression of long-term outcomes of transcatheter versus surgical aortic valve replacement for severe aortic stenosis.

PubMed

Villablanca, Pedro A; Mathew, Verghese; Thourani, Vinod H; Rodés-Cabau, Josep; Bangalore, Sripal; Makkiya, Mohammed; Vlismas, Peter; Briceno, David F; Slovut, David P; Taub, Cynthia C; McCarthy, Patrick M; Augoustides, John G; Ramakrishna, Harish

2016-12-15

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic-valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) who are at high operative risk. We sought to determine the long-term (≥1year follow-up) safety and efficacy TAVR compared with SAVR in patients with severe AS. A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference proceedings, and relevant Web sites from inception through 10 April 2016. Fifty studies enrolling 44,247 patients met the inclusion criteria. The mean duration follow-up was 21.4months. No difference was found in long-term all-cause mortality (risk ratios (RR), 1.06; 95% confidence interval (CI) 0.91-1.22). There was a significant difference favoring TAVR in the incidence of stroke (RR, 0.82; 95% CI 0.71-0.94), atrial fibrillation (RR, 0.43; 95% CI 0.33-0.54), acute kidney injury (RR, 0.70; 95% CI 0.53-0.92), and major bleeding (RR, 0.57; 95% CI 0.40-0.81). TAVR had significant higher incidence of vascular complications (RR, 2.90; 95% CI 1.87-4.49), aortic regurgitation (RR, 7.00; 95% CI 5.27-9.30), and pacemaker implantation (PPM) (RR, 2.02; 95% CI 1.51-2.68). TAVR demonstrated significantly lower stroke risk compared to SAVR in high-risk patients (RR, 1.49; 95% CI 1.06-2.10); no differences in PPM implantation were observed in intermediate-risk patients (RR, 1.68; 95% CI 0.94-3.00). In a meta-regression analysis, the effect of TAVR baseline clinical features did not affect the long-term all-cause mortality outcome. TAVR and SAVR showed similar long-term survival in patients with severe AS; with important differences in treatment-associated morbidity. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Transcatheter vs Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Intermediate Risk Patients: A Meta-analysis.

PubMed

Tam, Derrick Y; Vo, Thin Xuan; Wijeysundera, Harindra C; Ko, Dennis T; Rocha, Rodolfo Vigil; Friedrich, Jan; Fremes, Stephen E

2017-09-01

Transcatheter aortic valve replacement (TAVR) has emerged as the treatment of choice for patients with severe aortic stenosis at high surgical risk; the role of TAVR compared with surgical aortic valve replacement (SAVR) in the low-intermediate surgical risk population remains uncertain. Our primary objective was to determine differences in 30-day and late mortality in patients treated with TAVR compared with SAVR at low-intermediate risk (Society of Thoracic Surgeons Predicted Risk of Mortality < 10%). Medline and Embase were searched from 2010 to March 2017 for studies that compared TAVR with SAVR in the low-intermediate surgical risk population, restricted to randomized clinical trials and matched observational studies. Two investigators independently abstracted the data and a random effects meta-analysis was performed. Four randomized clinical trials (n = 4042) and 9 propensity score-matched observational studies (n = 4192) were included in the meta-analysis (n = 8234). There was no difference in 30-day mortality between TAVR and SAVR (3.2% vs 3.1%, pooled risk ratio: 1.02; 95% confidence interval, 0.80-1.30; P = 0.89; I 2  = 0%) or mortality at a median of 1.5-year follow-up (incident rate ratio: 1.01; 95% confidence interval, 0.90-1.15; P = 0.83; I 2  = 0%). There was a higher risk of pacemaker implantation and greater than trace aortic insufficiency in the TAVR group whereas the risk of early stroke, atrial fibrillation, acute kidney injury, cardiogenic shock, and major bleeding was higher in the SAVR group. Although there was no difference in 30-day and late mortality, the rate of complications differed between TAVR and SAVR in the low-intermediate surgical risk population. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum.

PubMed

Tice, Jeffrey A; Sellke, Frank W; Schaff, Hartzell V

2014-08-01

The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications. In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence. TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and postoperative care to preserve and improve on the results attained in the Placement of Aortic Transcatheter Valve trial. Specialty societies are collaborating to ensure that this happens in a rational and comprehensive manner. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Five-year results after valve replacement with the Björk-Shiley 70 degrees convexo-concave prosthesis.

PubMed

Koldsland, S; Svennevig, J L; Abdelnoor, M; Aas, H; Semb, G

1992-01-01

In the 18 months up to July 1983, 120 Björk-Shiley convexo-concave prostheses with 70 degrees opening angle were implanted in 47 women and 61 men aged 19-78 (mean 58.6) years. The prosthetic valves were aortic in 65 cases, mitral in 23 and both aortic and mitral in 20 cases. Emergency operation was required in ten cases, and concomitant surgery was performed in 43 (39.8%). The early mortality was 5.5%. A follow-up study, comprising 498 patient years, revealed 73.1% 5-year survival. There were three mechanical failures of prosthesis, in one of which re-replacement was successful. Elective prosthesis replacement was performed in four other cases judged to be at high risk of strut fracture.

Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement.

PubMed

Goel, Sachin S; Agarwal, Shikhar; Tuzcu, E Murat; Ellis, Stephen G; Svensson, Lars G; Zaman, Tarique; Bajaj, Navkaranbir; Joseph, Lee; Patel, Neil S; Aksoy, Olcay; Stewart, William J; Griffin, Brian P; Kapadia, Samir R

2012-02-28

With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51-1.69; P=0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P<0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P<0.001). PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.

Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement.

PubMed

Deutsch, Marcus-Andre; Bleiziffer, Sabine; Elhmidi, Yacine; Piazza, Nicolo; Voss, Bernhard; Lange, Ruediger; Krane, Markus

2013-11-01

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR. Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Low permanent pacemaker rates following Lotus device implantation for transcatheter aortic valve replacement due to modified implantation protocol.

PubMed

Krackhardt, Florian; Kherad, Behrouz; Krisper, Maximilian; Pieske, Burkert; Laule, Michael; Tschöpe, Carsten

2017-01-01

Conduction disturbances requiring permanent pacemaker implantation following transcatheter aortic valve replacement (TAVR) are a common problem. Pacemaker implantation rates after TAVR appear to be higher compared to conventional aortic valve replacement. The aim of this study was to analyze whether a high annulus implantation conveys the benefit of a decreased rate of permanent pacemaker implantation while being safe and successful according to Valve Academic Research Consortium 2 (VARC2)-criteria. A total of 23 patients with symptomatic severe aortic valve stenosis, an aortic annulus of 19-27 mm and at high risk for surgery were treated with the Lotus valve. In all patients the valve was implanted in a high annulus position via femoral access. The primary device performance endpoint was VARC2-defined device success after 30 days and the primary safety endpoint was the need for permanent pacemaker implantation. The mean age was 73.23 ± 7.65 years, 46% were female, 38% were New York Heart Association class III/IV at baseline. Thirty-day follow-up data were available for all patients. The VARC2-defined device success rate after 30 days was 22/23 (96%). 2/21 (10%) patients required a newly implanted pacemaker due to 3rd degree atrioventricular block. 25% of the patients developed a new left bundle branch block after valvuloplasty or device implantation. 21 of the 23 patients (96%) had no other signs of conduction disturbances after 30 days. The approach of the modified implantation technique of Lotus TAVR device was safe and effective. The incidence of need for a permanent pacemaker following TAVR could be significantly reduced due to adopted implantation protocol.

Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: a propensity-matched comparison

PubMed Central

Del Giglio, Mauro; Mikus, Elisa; Micari, Antonio; Calvi, Simone; Tripodi, Alberto; Campo, Gianluca; Maietti, Elisa; Castriota, Fausto; Cremonesi, Alberto

2018-01-01

Background Right anterior mini-thoracotomy (MIAVR) is a promising technique for aortic valve replacement. We aimed at comparing its outcomes with those obtained in a propensity-matched group of patients undergoing sternotomy at our two high-volume centers. Methods Main clinical and operative data of patients undergoing aortic valve replacement between January 2010 and May 2016 were retrospectively collected. A total of 678 patients were treated with a standard full sternotomy approach, while MIAVR was performed in 502. Propensity score matching identified 363 patients per each group. Results In-hospital mortality was not significantly different between the propensity-matched groups (1.7% in MIAVR patients vs. 2.2% in conventional sternotomy patients; P=0.79). No significant difference in the incidence of major post-operative complications was observed. Post-operative ventilation times (median 7, range 5–12 hours in MIAVR patients vs. median 7, range 5–12 in conventional sternotomy patients; P=0.72) were not significantly different between the two groups. Cardiopulmonary bypass time (61.0±21.0 vs. 65.9±24.7 min in conventional sternotomy group; P<0.01) and aortic cross-clamping time (48.3±16.7 vs. 53.2±19.6 min in full sternotomy group; P<0.01) were shorter in MIAVR group. EuroSCORE (OR 1.52, 95% CI, 1.12–2.06; P<0.01) was found to be the only independent predictor of intra-hospital mortality in the whole propensity-matched population. Conclusions Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe and effective procedure with similar outcomes and no longer operative times compared to conventional sternotomy. PMID:29707310

[Feasibility Study of Dual-source Computed Tomography High-pitch Scan Mode in Preoperative Evaluation of Aortic Stenosis Referred to Transcatheter Aortic Valve Implantation].

PubMed

Peng, Liqing; Yu, Jianqun; Li, Zhenlin; Li, Wanjiang; Cheng, Wei

2016-10-01

The purpose of this study was to explore the feasibility of dual-source computed tomography(DSCT)highpitch scan mode in the preoperative evaluation of severe aortic stenosis(AS)referred to transcatheter aortic valve implantation(TAVI).Thirty patients with severe AS referred for TAVI underwent cervico-femoral artery joint DSCT angiography.Measurement and calculation of contrast,contrast noise ratio(CNR)and noise of aorta and access vessels were performed.The intra-and inter-observer reproducibilities for assessing aortic root and access vessels were evaluated.Evaluation of shape and plagues of aorta and access vessels was performed.The contrast,CNR and noise of aorta and access vessels were 348.2~457.9HU,12.2~30.3HU and 19.1~48.1 HU,respectively.There were good intra-and inter-observer reproducibilities in assessing aortic root and access vessels by DSCT(mean difference:-0.73~0.79 mm,r=0.90~0.98,P<0.001;mean difference:-0.70~0.73 mm,r=0.90~0.96,P<0.001).In the 30 patients,the diameters of external iliac artery,femeral artery or subclavian artery were less than 7mm in 5cases(16.7%),marked calcification in bilateral common iliac arteries in 1case(3.3%)and marked soft plaque in left common iliac artery in 1case(3.3%).DSCT high-pitch scan mode was feasible in the preoperative evaluation of aorta and access vessels in patients with AS referred for TAVI.