Changes in Mitral Annular Geometry after Aortic Valve Replacement: A Three-Dimensional Transesophageal Echocardiographic Study

PubMed Central

Mahmood, Feroze; Warraich, Haider J.; Gorman, Joseph H.; Gorman, Robert C.; Chen, Tzong-Huei; Panzica, Peter; Maslow, Andrew; Khabbaz, Kamal

2014-01-01

Background and aim of the study Intraoperative real-time three-dimensional transesophageal echocardiography (RT-3D TEE) was used to examine the geometric changes that occur in the mitral annulus immediately after aortic valve replacement (AVR). Methods A total of 35 patients undergoing elective surgical AVR under cardiopulmonary bypass was enrolled in the study. Intraoperative RT-3D TEE was used prospectively to acquire volumetric echocardiographic datasets immediately before and after AVR. The 3D echocardiographic data were analyzed offline using TomTec® Mitral Valve Assessment software to assess changes in specific mitral annular geometric parameters. Results Datasets were successfully acquired and analyzed for all patients. A significant reduction was noted in the mitral annular area (-16.3%, p <0.001), circumference (-8.9% p <0.001) and the anteroposterior (-6.3%, p = 0.019) and anterolateral-posteromedial (-10.5%, p <0.001) diameters. A greater reduction was noted in the anterior annulus length compared to the posterior annulus length (10.5% versus 62%, p <0.05) after AVR. No significant change was seen in the non-planarity angle, coaptation depth, and closure line length. During the period of data acquisition before and after AVR, no significant change was noted in the central venous pressure or left ventricular end-diastolic diameter. Conclusion The mitral annulus undergoes significant geometric changes immediately after AVR Notably, a 16.3% reduction was observed in the mitral annular area. The anterior annulus underwent a greater reduction in length compared to the posterior annulus, which suggested the existence of a mechanical compression by the prosthetic valve. PMID:23409347

Long-term results after aortic valve replacement with the Biocor PSB stentless xenograft in the elderly.

PubMed

Luciani, G B; Santini, F; Auriemma, S; Barozzi, L; Bertolini, P; Mazzucco, A

2001-05-01

This study seeks to define the long-term results after Biocor PSB stentless aortic valve replacement (AVR) in elderly patients, including the effects of No-React treatment. We reviewed the outcomes of 106 consecutive patients, aged 70+/-6 years, having Biocor PSB (93 standard, 13 No-React) AVR between October 1992 and October 1996. There were three early deaths (3%) and 15 late deaths (15%), during a mean follow-up of 5.8+/-1.6 years. At 8 years, survival was 82%+/-4% and freedom from cardiac death was 94%+/-3%. Freedom from valve failure was 92%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Replacement of the xenograft was required in 5 patients. Freedom from reoperation was 91%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Four bleeding and two embolic events were recorded: overall valve-related event-free survival was 81%+/-7% at 8 years (No-React: 76%+/-12% at 4 years). Age of long-term survivors averaged 77+/-5 years and their New York Heart Association status was 1.3+/-0.6 (versus 2.9+/-0.6 preoperatively, p = 0.01). Satisfactory freedom from cardiac events and from valve deterioration added to uniform improvement in functional status despite advanced age and high prevalence of comorbid conditions make AVR with the Biocor PSB xenograft a valid long-term therapy for the elderly. No-React treatment does not influence xenograft durability.

Society of Thoracic Surgeons Risk Score Predicts Hospital Charges and Resource Utilization After Aortic Valve Replacement

PubMed Central

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

2011-01-01

Context The impact of Society of Thoracic Surgeons (STS) predicted mortality risk score on resource utilization after aortic valve replacement (AVR) has not been previously studied. Objective We hypothesize that increasing STS risk scores in patients having AVR are associated with greater hospital charges. Design, Setting, and Patients Clinical and financial data for patients undergoing AVR at a tertiary care, university hospital over a ten-year period (1/2000–12/2009) were retrospectively reviewed. The current STS formula (v2.61) for in-hospital mortality was used for all patients. After stratification into risk quartiles (Q), index admission hospital charges were compared across risk strata with Rank-Sum tests. Linear regression and Spearman’s coefficient assessed correlation and goodness of fit. Multivariable analysis assessed relative contributions of individual variables on overall charges. Main Outcome Measures Inflation-adjusted index hospitalization total charges Results 553 patients had AVR during the study period. Average predicted mortality was 2.9% (±3.4) and actual mortality was 3.4% for AVR. Median charges were greater in the upper Q of AVR patients [Q1–3,$39,949 (IQR32,708–51,323) vs Q4,$62,301 (IQR45,952–97,103), p=<0.01]. On univariate linear regression, there was a positive correlation between STS risk score and log-transformed charges (coefficient: 0.06, 95%CI 0.05–0.07, p<0.01). Spearman’s correlation R-value was 0.51. This positive correlation persisted in risk-adjusted multivariable linear regression. Each 1% increase in STS risk score was associated with an added $3,000 in hospital charges. Conclusions This study showed increasing STS risk score predicts greater charges after AVR. As competing therapies such as percutaneous valve replacement emerge to treat high risk patients, these results serve as a benchmark to compare resource utilization. PMID:21497834

Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction

NASA Technical Reports Server (NTRS)

Pereira, Jeremy J.; Lauer, Michael S.; Bashir, Mohammad; Afridi, Imran; Blackstone, Eugene H.; Stewart, William J.; McCarthy, Patrick M.; Thomas, James D.; Asher, Craig R.

2002-01-01

OBJECTIVE: We sought to assess whether aortic valve replacement (AVR) among patients with severe aortic stenosis (AS), severe left ventricular (LV) dysfunction and a low transvalvular gradient (TVG) is associated with improved survival. BACKGROUND: The optimal management of patients with severe AS with severe LV dysfunction and a low TVG remains controversial. METHODS: Between 1990 and 1998, we evaluated 68 patients who underwent AVR at our institution (AVR group) and 89 patients who did not undergo AVR (control group), with an aortic valve area < or = 0.75 cm(2), LV ejection fraction < or = 35% and mean gradient < or = 30 mm Hg. Using propensity analysis, survival was compared between a cohort of 39 patients in the AVR group and 56 patients in the control group. RESULTS: Despite well-matched baseline characteristics among propensity-matched patients, the one- and four-year survival rates were markedly improved in patients in the AVR group (82% and 78%), as compared with patients in the control group (41% and 15%; p < 0.0001). By multivariable analysis, the main predictor of improved survival was AVR (adjusted risk ratio 0.19, 95% confidence interval 0.09 to 0.39; p < 0.0001). The only other predictors of mortality were age and the serum creatinine level. CONCLUSIONS: Among select patients with severe AS, severe LV dysfunction and a low TVG, AVR was associated with significantly improved survival.

Function of the Respiratory System in Elderly Patients After Aortic Valve Replacement.

PubMed

Stoliński, Jarosław; Plicner, Dariusz; Gawęda, Bogusław; Musiał, Robert; Fijorek, Kamil; Wąsowicz, Marcin; Andres, Janusz; Kapelak, Bogusław

2016-10-01

To compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients. Observational cohort study. University hospital. The study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR. Pulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed. Respiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patient's higher postoperative PFT parameter values. RAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

Valve-sparing aortic root replacement in patients with Marfan syndrome enrolled in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions.

PubMed

Song, Howard K; Preiss, Liliana R; Maslen, Cheryl L; Kroner, Barbara; Devereux, Richard B; Roman, Mary J; Holmes, Kathryn W; Tolunay, H Eser; Desvigne-Nickens, Patrice; Asch, Federico M; Milewski, Rita K; Bavaria, Joseph; LeMaire, Scott A

2014-05-01

The long-term outcomes of aortic valve-sparing (AVS) root replacement in Marfan syndrome (MFS) patients remain uncertain. The study aim was to determine the utilization and outcomes of AVS root replacement in MFS patients enrolled in the Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC). At the time of this analysis, 788 patients with MFS were enrolled in the GenTAC Registry, of whom 288 had undergone aortic root replacement. Patients who had undergone AVS procedures were compared to those who had undergone aortic valve replacement (AVR). AVS root replacement was performed in 43.5% of MFS patients, and the frequency of AVS was increased over the past five years. AVS patients were younger at the time of surgery (31.0 versus 36.3 years, p = 0.006) and more likely to have had elective rather than emergency surgery compared to AVR patients, in whom aortic valve dysfunction and aortic dissection was the more likely primary indication for surgery. After a mean follow up of 6.2 +/- 3.6 years, none of the 87 AVS patients had required reoperation; in contrast, after a mean follow up of 10.5 +/- 7.6 years, 11.5% of AVR patients required aortic root reoperation. Aortic valve function has been durable, with 95.8% of AVS patients having aortic insufficiency that was graded as mild or less. AVS root replacement is performed commonly among the MFS population, and the durability of the aortic repair and aortic valve function have been excellent to date. These results justify a continued use of the procedure in an elective setting. The GenTAC Registry will be a useful resource to assess the long-term durability of AVS root replacement in the future.

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.

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.

Efficacy of the Stonehenge Technique for Minimally Invasive Aortic Valve Replacement via Right Infraaxillary Thoracotomy.

PubMed

Yamazaki, Masataka; Kin, Hajime; Kitamoto, Shohei; Yamanaka, Shota; Nishida, Hidefumi; Nishigawa, Kosaku; Takanashi, Shuichiro

2017-02-20

Minimally invasive cardiac surgeries for aortic valve replacement (AVR) are still a technical challenge for surgeons because these procedures are undertaken through small incisions and deep surgical fields. Although AVR via vertical infraaxillary thoracotomy can be a cosmetically superior option, a disadvantage of this approach is the distance between the thoracotomy incision and the ascending aorta. Therefore, we devised a technique to perform all manipulations using the fingertips without the aid of a knot pusher or long-shafted surgical instruments. This was achieved by particular placement of several retracted sutures to the right chest wall. We named placement of these sutures the "Stonehenge technique." In conclusion, AVR via vertical infraaxillary thoracotomy with our Stonehenge technique can be safely and simply performed with superior cosmetic advantages.

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.

Multicenter Analysis of Clinical Follow-Ups in Patients with a Star GK Cardiac Valve Replacement for More than One Year.

PubMed

Li, Mingwen; Xiao, Yingbin; Chen, Daozhong; Liu, Liming; Ma, Liming; Wang, Pingfan; Jia, Kui; Yang, Kai; Chen, Lin

2016-05-18

Star GK valves were widely used in China, and we studied the clinical follow-up results of patients with Star GK valve implants for more than one year.  Clinical data were collected from those patients who had Star GK valve implants for over one year. Patients were divided into three groups: (1) AVR group: received aortic valve replacement surgery. Based on the valve model this group was further sub-divided into two groups: 21A group, and 23A group; (2) MVR group: received mitral valve replacement surgery. Based on the valve model this group was further sub-divided into three groups: 25M group, 27M group, and 29M group; (3) DVR group: received combined replacement surgeries including AVR + MVR. According to postoperative follow-up time these patients were divided into two groups: 1-year group and 3-year group. Follow-up data were collected by telephone, outpatient visits, or correspondence. Clinical data were aggregated by professional data scientists to conduct independent analyses.  959 patients were included in the study following Star GK valve implant. Follow-up after 1 year found that thrombosis occurred in 4 cases, hemorrhage in 15 cases, left heart failure in 13 cases, paravalvular leakage in 5 cases, and death due to cardiac causes in 2 cases.  The long-term efficacy of Star GK valve implants was satisfactory with low incidence of valve-related complications, and following Star GK valve implant, valve and blood were highly compatible and blood component damage was minor. Very low incidence rate of thrombosis was observed following Star GK valve implant, however, attention should be paid to adjust the anticoagulation intensity.

Mitral regurgitation after previous aortic valve surgery for bicuspid aortic valve insufficiency.

PubMed

Girdauskas, Evaldas; Disha, Kushtrim; Espinoza, Andres; Misfeld, Martin; Reichenspurner, Hermann; Borger, Michael A; Kuntze, Thomas

2017-06-01

Regurgitant bicuspid aortic valves (BAV) are reported to be associated with myxomatous degeneration of the anterior mitral leaflet. We examined the risk of late new-onset mitral regurgitation (MR) in patients who underwent aortic valve/aortic root surgery for BAV regurgitation and concomitant root dilatation. A total of 97 consecutive patients (47±11 years, 94% men) were identified from our institutional BAV database (N.=640) based on the following criteria: 1) BAV regurgitation; 2) aortic root diameter >40 mm; 3) no relevant mitral valve disease (i.e., MR<2+) and no simultaneous mitral intervention at the time of BAV surgery. All patients underwent isolated aortic valve replacement (AVR subgroup, N.=59) or aortic root replacement with a composite graft (i.e., for root aneurysm >50 mm) (ARR subgroup, N.=38) from 1995 through 2008. Echocardiographic follow-up (1009 patient-years) was obtained for all 96 (100%) hospital survivors. The primary endpoint was freedom from new-onset MR>2+ and redo mitral valve surgery. Nine patients (9.4%) showed new-onset MR>2+ after mean echocardiographic follow-up of 10.4±4.0 years postoperatively. Myxomatous degeneration and prolapse of the anterior mitral leaflet was found in all 9 patients, and the posterior leaflet was involved in 3 of them. Two patients (2%) in AVR subgroup underwent re-do mitral surgery. No MR>2+ occurred in ARR subgroup. Freedom from MR>2+ or mitral surgery at 15 years was significantly lower in AVR subgroup vs. ARR subgroup (i.e., 38% vs. 100%, P=0.01). The risk of new-onset MR is significantly increased in patients with BAV regurgitation and aortic root dilatation who undergo isolated AVR rather than root replacement. The mechanism by which aortic root replacement may prevent the occurrence of late MR in BAV root phenotype patients is to be determined.

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

Early Left and Right Ventricular Response to Aortic Valve Replacement.

PubMed

Duncan, Andra E; Sarwar, Sheryar; Kateby Kashy, Babak; Sonny, Abraham; Sale, Shiva; Alfirevic, Andrej; Yang, Dongsheng; Thomas, James D; Gillinov, Marc; Sessler, Daniel I

2017-02-01

The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function. In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons. LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1

Postoperative Reverse Remodeling and Symptomatic Improvement in Normal-Flow Low-Gradient Aortic Stenosis After Aortic Valve Replacement.

PubMed

Carter-Storch, Rasmus; Møller, Jacob E; Christensen, Nicolaj L; Irmukhadenov, Akhmadjon; Rasmussen, Lars M; Pecini, Redi; Øvrehus, Kristian A; Søndergård, Eva V; Marcussen, Niels; Dahl, Jordi S

2017-12-01

Severe aortic stenosis (AS) most often presents with reduced aortic valve area (<1 cm 2 ), normal stroke volume index (≥35 mL/m 2 ), and either high mean gradient (≥40 mm Hg; normal-flow high-gradient AS) or low mean gradient (normal-flow low-gradient [NFLG] AS). The benefit of aortic valve replacement (AVR) among NFLG patients is controversial. We compared the impact of NFLG condition on preoperative left ventricular (LV) remodeling and myocardial fibrosis and postoperative remodeling and symptomatic benefit. Eighty-seven consecutive patients with reduced aortic valve area and normal stroke volume index undergoing AVR underwent echocardiography, magnetic resonance imaging, a 6-minute walk test, and measurement of natriuretic peptides before and 1 year after AVR. Myocardial fibrosis was assessed from magnetic resonance imaging. Patients were stratified as NFLG or normal-flow high-gradient. In total, 33 patients (38%) had NFLG. Before AVR, they were characterized by similar symptom burden but less severe AS measured by aortic valve area index (0.50±0.09 versus 0.40±0.08 cm 2 /m 2 ; P <0.0001), lower LV mass index (74±18 versus 90±26 g/m 2 ; P =0.01), but the same degree of myocardial fibrosis. After AVR, NFLG had a smaller reduction in LV mass index (-3±10 versus -±18 g/m 2 ; P <0.0001) and a smaller reduction in natriuretic peptides. Both groups experienced similar symptomatic improvement. Normal-flow high-gradient condition independently predicted change in LV mass index. Patients with NFLG had less severe AS and LV remodeling than patients with normal-flow high-gradient. Furthermore, NFLG patients experienced less reverse remodeling but the same symptomatic benefit. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02316587. © 2017 American Heart Association, Inc.

Efficacy of the Stonehenge Technique for Minimally Invasive Aortic Valve Replacement via Right Infraaxillary Thoracotomy

PubMed Central

Kin, Hajime; Kitamoto, Shohei; Yamanaka, Shota; Nishida, Hidefumi; Nishigawa, Kosaku; Takanashi, Shuichiro

2017-01-01

Minimally invasive cardiac surgeries for aortic valve replacement (AVR) are still a technical challenge for surgeons because these procedures are undertaken through small incisions and deep surgical fields. Although AVR via vertical infraaxillary thoracotomy can be a cosmetically superior option, a disadvantage of this approach is the distance between the thoracotomy incision and the ascending aorta. Therefore, we devised a technique to perform all manipulations using the fingertips without the aid of a knot pusher or long-shafted surgical instruments. This was achieved by particular placement of several retracted sutures to the right chest wall. We named placement of these sutures the “Stonehenge technique.” In conclusion, AVR via vertical infraaxillary thoracotomy with our Stonehenge technique can be safely and simply performed with superior cosmetic advantages. PMID:28123153

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

Changes in Aortic Pulse Wave Velocity and the Predictors of Improvement in Arterial Stiffness Following Aortic Valve Replacement.

PubMed

Cantürk, Emir; Çakal, Beytullah; Karaca, Oğuz; Omaygenç, Onur; Salihi, Salih; Özyüksel, Arda; Akçevin, Atıf

2017-10-20

The interaction between valvular aortic stenosis (AS) and arterial stiffness, as well as the impact of aortic valve replacement (AVR) on arterial stiffness, remains unclear. In this study, we aimed to evaluate the degree of AS severity on non-invasive pulse wave velocity (PWV) measurements. We also searched whether the AVR procedure favorably affects PWV. In all, 38 patients undergoing AVR for chronic AS were included. The degree of aortic stiffness was measured with PWV at both baseline and 6 months after AVR. Improvement in aortic stiffness was defined as the absolute decrease in PWV at 6 months compared to the baseline value. The study population had a mean age of 59 ± 16 years, mean aortic gradient of 47.1 ± 6.4 mmHg, and mean aortic valve area (AVA) index of 0.45 ± 0.11 cm² /m² . Baseline PWV values correlated positively with the mean aortic gradient (r = 0.350, p = 0.031) and negatively with the AVA index (r = -0.512, p = 0.001). The mean PWV improved in 20 patients (53%) and worsened in 18 patients (47%). The baseline New York Heart Association (NYHA) class (odds ratio [OR] = 1.023, 95% confidence interval [CI] = 1.005-1.041, p = 0.041) and AVA index (OR = 1.040, 96% CI = 1.023-1.057, p = 0.028) emerged as the independent predictors of improvement in PWV following AVR. The severity of AS was significantly associated with baseline PWV. In general, the mean PWV did not change with AVR. Baseline NYHA class and the AVA index independently predicted PWV improvement following AVR. Since the change in PWV after AVR was polarized based on the patients' characteristics, such as preoperative NYHA functional class or AVA index, further studies are needed to confirm clinical significance of PWV change following AVR in severe AS patients.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement.

PubMed

Tokarek, Tomasz; Siudak, Zbigniew; Dziewierz, Artur; Sobczyński, Robert; Zasada, Wojciech; Sorysz, Danuta; Olszewska-Wityńska, Katarzyna; Bryniarski, Krzysztof; Krawczyk-Ożóg, Agata; Żabówka, Anna; Sadowski, Jerzy; Dudek, Dariusz

2016-09-01

Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini-thoracotomy, mini-sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high-risk patients. Aim of the study was to evaluate the quality of life (QoL) in patients with AS and treated with transfemoral TAVI, SAVR, mini-thoracotomy and mini-sternotomy. One hundred and seventy-three patients with symptomatic AS were enrolled in 2011-2013. TAVI group consisted of 39 patients (22.5%), mini-sternotomy was performed in 44 patients (25.5%), mini-thoracotomy in 50 (29%), and AVR in 40 patients (23%). QoL was assessed perioperatively, 12 and 24 months after aortic valve replacement (AVR) by Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-3L. Median follow-up was 583.5 (IQR: 298-736) days. Improvement of health status after procedure in comparison with pre-operative period was significantly more often reported after TAVI in perioperative period (90.3%; P = 0.004) and 12 months after procedure (100%, P = 0.02). Global MLHFQ, physical and emotional dimension score at 30-day from AVR presented significant improvement after TAVI in comparison with surgical methods (respectively: 8.3(±8.6), P = 0.003; 4.1(±5.9), P = 0.01; 1.5(±2.6), P = 0.005). Total MLHFQ score was significantly lower (better outcome) in TAVI patients 1 year after procedure (4.8(±6.8), P = 0.004), no differences in somatic and emotional component were found. No differences were found in MLHFQ score 24 months after AVR. Data from EQ-D5-3L questionnaire demonstrated significant improvement of QoL at 30-day follow-up after TAVI in comparison with surgical methods (1.2(±1.7), P = 0.0008). TAVI improves QoL in perioperative and 12 months observation in comparison with mini-thoracotomy, mini-sternotomy and SAVR. Improvement in QoL was obtained in both generic and disease specific

Comparison of four contemporary risk models at predicting mortality after aortic valve replacement.

PubMed

Wang, Tom Kai Ming; Choi, David H M; Stewart, Ralph; Gamble, Greg; Haydock, David; Ruygrok, Peter

2015-02-01

Risk stratification for aortic valve replacement (AVR) is desirable given the increased demand for intervention and the introduction of transcatheter aortic valve implantation. We compared the prognostic utility of the European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, Society of Thoracic Surgeons (STS) score, and an Australasian model (Aus-AVR score) for AVR. We retrospectively calculated the 4 risk scores for patients undergoing isolated AVR at Auckland City Hospital from 2005 to 2012 and assessed their discrimination and calibration for short- and long-term mortality. A total of 620 patients were followed up for 3.8 ± 2.4 years, with an operative mortality of 2.9% (n = 18). The mean EuroSCORE, EuroSCORE II, STS score, and Aus-AVR score was 8.7% ± 8.3%, 3.8% ± 4.7%, 2.8% ± 2.7%, and 3.2% ± 4.8%, respectively. The corresponding C-statistics for operative mortality were 0.752 (95% confidence interval [CI], 0.652-0.852), 0.711 (95% CI, 0.607-0.815), 0.716 (95% CI, 0.593-0.837), and 0.684 (95% CI, 0.557-0.811). The corresponding Hosmer-Lemeshow test P and chi-square values for calibration were .007 and 21.1, .125 and 12.6, .753 and 5.0, and .468 and 7.7. The corresponding Brier scores were 0.0348, 0.0278, 0.0276, and 0.0294. Independent predictors of operative mortality included critical preoperative state, atrial fibrillation, extracardiac arteriopathy, and mitral stenosis. The log-rank test P values were all <.001 for mortality during follow-up for all 4 scores, stratified by quintile. All 4 risk scores discriminated operative mortality after isolated AVR. The EuroSCORE had poor calibration, overestimating operative mortality, although the other 3 scores fitted well with contemporary outcomes. The STS score was the best calibrated in the highest quintile of operative risk. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Concomitant coronary artery bypass graft and aortic and mitral valve replacement for rheumatic heart disease: short- and mid-term outcomes.

PubMed

Davarpasand, Tahereh; Hosseinsabet, Ali; Jalali, Arash

2015-09-01

It has been reported that the short-term mortality of concomitant aortic and mitral valve replacement (AVR and MVR) is considerable and concomitant coronary artery bypass graft (CABG) has adverse effects on the survival of patients with valve replacement surgery. We summarize the short- and mid-term outcome after concomitant CABG, AVR and MVR in our centre. Between 2003 and 2013, 103 patients (68 males, 35 females, age: 60.1 ± 10.1 years) underwent CABG, AVR and MVR for rheumatic heart disease (RHD) and coronary artery disease (CAD). The median follow-up was 47.6 months. Most of the patients were asymptomatic at rest. We analysed demographic, clinical and operative data of patients to define independent predictors of overall survival, cardiac event-free survival as well as cardiac death. The rate of 30-day survival was 93% (n = 96). The corresponding rates of overall survival and cardiac event-free survival and the cumulative incidence rate of cardiac death at 1 year were 80.2, 77.3 and 10.9%; the same at 4 years were 73.7, 64.6 and 15.8%. The corresponding freedom rates from anticoagulation-associated major haemorrhage; a composite of major bleeding events, thromboemboli and valvular thrombosis; cardiac rehospitalization; major adverse valve-associated events; and significant malfunction of the prosthetic valve were 96.2, 95.3, 94.7, 81.6 and 97.7% at 1 year. The corresponding freedom rates from anticoagulation-associated major haemorrhage; a composite of major bleeding events, thromboemboli and valvular thrombosis; cardiac rehospitalization; major adverse valve-associated events; and significant malfunction of the prosthetic valve were 93.5, 91.0, 91.4, 73.5 and 95.5% at 4 years. The independent predictors of overall survival were age, cigarette smoking, chronic kidney diseases and balloon pump insertion. The independent predictors of cardiac event-free survival were age and previous myocardial infarction, while age, cigarette smoking, history of cerebrovascular

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.

[Cognitive and quality of life trajectory after either surgical or transcatheter aortic valve replacement in high-risk patients].

PubMed

Ciuca, Cristina; Fortuna, Daniela; Ferrari, Susy; Salizzoni, Stefano; Grisoglio, Enrica; Punta, Giuseppe; Del Ponte, Stefano; Aranzulla, Tiziana Claudia; Gabbieri, Davide; Gandolfo, Caterina; Dispensa, Flavia; Vecchio Verderame, Lavinia; Tamburino, Corrado; Caruso, Cinzia; Grossi, Claudio; Mikus, Elisa; Guiducci, Vincenzo; Violini, Roberto; Rongoni, Silvia; Pandolfi, Claudia; Moretti, Carolina; De Palma, Rossana; Chattat, Rabih; Savini, Carlo; Marzocchi, Antonio; Saia, Francesco

2016-12-01

The impact of transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (AVR) on cognitive status and quality of life in high-risk patients has been incompletely investigated. We conducted a prospective, multicenter study including all patients treated with TAVI and high-risk patients undergoing AVR (age ≥80 years or logistic EuroSCORE ≥15%) at participating centers. Multidimensional geriatric evaluation including Mini Mental State Examination (MMSE), EuroQol 5D (EQ5D) and Minnesota Living With Heart Failure Questionnaire (MLHFQ) were performed at baseline and at 3- and 12-month follow-up. A total of 518 patients (151 AVR and 367 TAVI) were enrolled in 10 Italian institutions. Patients receiving AVR were older (82.7 ± 2.4 years), with a lower logistic EuroSCORE (12.5 ± 7.1%) as compared with TAVI patients (81.5 ± 6.2 years and 19.6 ± 14.0%, respectively, p=0.001 and p<0.001). Overall, 35.5% of patients showed some degree of cognitive impairment at baseline, with no differences between groups. No significant changes in the cognitive status were observed between baseline and follow-up and between groups at any time point. TAVI patients had a lower quality of life at baseline as compared with AVR patients. Generic and heart failure-related quality of life improved significantly after either procedure. In high-risk patients, both TAVI and AVR are associated with a significant improvement of quality of life up to 1 year without a detrimental effect on cognitive function.

Outcome and Impact of Aortic Valve Replacement in Patients With Preserved LVEF and Low-Gradient Aortic Stenosis.

PubMed

Dayan, Victor; Vignolo, Gustavo; Magne, Julien; Clavel, Marie-Annick; Mohty, Dania; Pibarot, Philippe

2015-12-15

Low mean transvalvular gradient (<40 mm Hg) and small aortic valve area (<1.0 cm(2)) in patients with aortic stenosis (AS) and preserved left ventricular ejection fraction raises uncertainty about the actual severity of the stenosis and survival benefit of aortic valve replacement (AVR). This study analyzed studies of mortality and survival impact of AVR in patients with low-gradient (LG) AS and preserved left ventricular ejection fraction, including paradoxical low-flow (i.e., stroke volume index <35 ml/m(2)), low-gradient (LF-LG) and normal-flow, low-gradient (NF-LG), and those with high-gradient (≥ 40 mm Hg) AS or moderate AS. Studies published between 2005 and 2015 were analyzed. Primary outcome was the survival benefit associated with AVR. Secondary outcome was overall mortality regardless of treatment. Eighteen studies were included in the analysis. Patients with LF-LG AS have increased mortality compared with patients with moderate AS (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.31 to 2.17), NF-LG (HR: 1.80; 95% CI: 1.29 to 2.51), and high-gradient (HR: 1.67; 95% CI: 1.16 to 2.39) AS. AVR was associated with reduced mortality in patients with LF-LG (HR: 0.44; 95% CI: 0.25 to 0.77). Similar benefit occurred with AVR in patients with NF-LG (HR: 0.48; 95% CI: 0.28 to 0.83). Compared with patients with high-gradient AS, those with LF-LG were less likely to be referred to AVR (odds ratio: 0.32; 95% CI: 0.21 to 0.49). Patients with paradoxical LF-LG AS and NF-LG AS have increased risk of mortality compared with other subtypes of AS with preserved left ventricular ejection fraction, and improved outcome with AVR. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Minimally invasive aortic valve replacement in high risk patient groups

PubMed Central

Lewis, Harriet; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni; Vohra, Hunaid A.

2017-01-01

Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts. PMID:28740685

Changes in Aortic Pulse Wave Velocity and the Predictors of Improvement in Arterial Stiffness Following Aortic Valve Replacement

PubMed Central

Cantürk, Emir; Çakal, Beytullah; Karaca, Oğuz; Omaygenç, Onur; Salihi, Salih; Akçevin, Atıf

2017-01-01

Background: The interaction between valvular aortic stenosis (AS) and arterial stiffness, as well as the impact of aortic valve replacement (AVR) on arterial stiffness, remains unclear. In this study, we aimed to evaluate the degree of AS severity on non-invasive pulse wave velocity (PWV) measurements. We also searched whether the AVR procedure favorably affects PWV. Methods: In all, 38 patients undergoing AVR for chronic AS were included. The degree of aortic stiffness was measured with PWV at both baseline and 6 months after AVR. Improvement in aortic stiffness was defined as the absolute decrease in PWV at 6 months compared to the baseline value. Results: The study population had a mean age of 59 ± 16 years, mean aortic gradient of 47.1 ± 6.4 mmHg, and mean aortic valve area (AVA) index of 0.45 ± 0.11 cm2/m2. Baseline PWV values correlated positively with the mean aortic gradient (r = 0.350, p = 0.031) and negatively with the AVA index (r = −0.512, p = 0.001). The mean PWV improved in 20 patients (53%) and worsened in 18 patients (47%). The baseline New York Heart Association (NYHA) class (odds ratio [OR] = 1.023, 95% confidence interval [CI] = 1.005–1.041, p = 0.041) and AVA index (OR = 1.040, 96% CI = 1.023–1.057, p = 0.028) emerged as the independent predictors of improvement in PWV following AVR. Conclusion: The severity of AS was significantly associated with baseline PWV. In general, the mean PWV did not change with AVR. Baseline NYHA class and the AVA index independently predicted PWV improvement following AVR. Since the change in PWV after AVR was polarized based on the patients’ characteristics, such as preoperative NYHA functional class or AVA index, further studies are needed to confirm clinical significance of PWV change following AVR in severe AS patients. PMID:28890466

High- Versus Low-Gradient Severe Aortic Stenosis: Demographics, Clinical Outcomes, and Effects of the Initial Aortic Valve Replacement Strategy on Long-Term Prognosis.

PubMed

Taniguchi, Tomohiko; Morimoto, Takeshi; Shiomi, Hiroki; Ando, Kenji; Kanamori, Norio; Murata, Koichiro; Kitai, Takeshi; Kawase, Yuichi; Izumi, Chisato; Miyake, Makoto; Mitsuoka, Hirokazu; Kato, Masashi; Hirano, Yutaka; Matsuda, Shintaro; Inada, Tsukasa; Nagao, Kazuya; Murakami, Tomoyuki; Takeuchi, Yasuyo; Yamane, Keiichiro; Toyofuku, Mamoru; Ishii, Mitsuru; Minamino-Muta, Eri; Kato, Takao; Inoko, Moriaki; Ikeda, Tomoyuki; Komasa, Akihiro; Ishii, Katsuhisa; Hotta, Kozo; Higashitani, Nobuya; Kato, Yoshihiro; Inuzuka, Yasutaka; Maeda, Chiyo; Jinnai, Toshikazu; Morikami, Yuko; Saito, Naritatsu; Minatoya, Kenji; Kimura, Takeshi

2017-05-01

There is considerable debate on the management of patients with low-gradient severe aortic stenosis (LG-AS), defined as aortic valve area <1 cm 2 with peak aortic jet velocity ≤4.0 m/s, and mean aortic pressure gradient ≤40 mm Hg. In the CURRENT AS registry (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis), there were 2097 patients (initial aortic valve replacement [AVR] strategy: n=977, and conservative strategy: n=1120) with high-gradient severe aortic stenosis (HG-AS) and 1712 patients (initial AVR strategy: n=219, and conservative strategy: n=1493) with LG-AS. AVR was more frequently performed in HG-AS patients than in LG-AS patients (60% versus 28%) during the entire follow-up. In the comparison between the initial AVR and conservative groups, the propensity score-matched cohorts were developed in both HG-AS (n=887 for each group) and LG-AS (n=218 for each group) strata. The initial AVR strategy when compared with the conservative strategy was associated with markedly lower risk for a composite of aortic valve-related death or heart failure hospitalization in both HG-AS and LG-AS strata (hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P <0.001 and hazard ratio, 0.46; 95% confidence interval, 0.32-0.67; P <0.001, respectively). Among 1358 patients with LG-AS with preserved left ventricular ejection fraction, the initial AVR strategy was associated with a better outcome than the conservative strategy (adjusted hazard ratio, 0.37; 95% confidence interval, 0.23-0.59; P <0.001). The initial AVR strategy was associated with better outcomes than the conservative strategy in both HG-AS and LG-AS patients, although AVR was less frequently performed in LG-AS patients than in HG-AS patients. The favorable effect of initial AVR strategy was also seen in patients with LG-AS with preserved left ventricular ejection fraction. URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000012140. © 2017

The Ross operation: the autologous pulmonary valve in the aortic position.

PubMed

Gonzalez-Lavin, L; Robles, A; Graf, D

1988-03-01

Aortic valve replacement (AVR) with a pulmonary valve autograft (PVA) was first reported by Donald N. Ross (DNR) in 1967. The expectation of this procedure was to avoid degenerative changes seen in other biological tissue valves such as calcification, attenuation, and rupture of the leaflets. Recent reports by the original investigator's group have confirmed the lack of degenerative changes in PVA. To corroborate their conclusions, the fate of 12 patients undergoing AVR with PVA by one of us (LGL) has been ascertained. From March 1969 to June 1971, 12 patients underwent AVR with PVA. The right ventricular outflow tract (RVOT) was reconstructed with an aortic homograft valved conduit. The mean age was 42.7 years (range 21 to 52 years). The mean follow-up for 11 hospital survivors is 12.4 years. Three PVA have been replaced; one following infective endocarditis at 13 years, and two at 15 and 73 months due to technical malalignment. There was no evidence of PVA degeneration during histological examination of these explanted PVAs. Six patients are alive and retain the original PVA at 12 years (55%). This analysis corroborates the conclusions of the DNR report and strongly suggests an immunological mechanism in the process of calcification of other biological tissue valves. The Ross operation is advocated for AVR in young patients as valve durability is of paramount importance especially in this group.

Double-arterial cannulation for aortic valve replacement with porcelain aorta.

PubMed

De Paulis, Ruggero; Maselli, Daniele; Scaffa, Raffaele; Nardella, Saverio

2009-10-01

We describe a new technique of aortic valve replacement (AVR) in patients with porcelain aorta. Three patients (mean age 75 years) were treated. The cardiopulmonary bypass (CPB) was established after side-graft right axillary artery and direct femoral artery cannulation. Venous drainage was obtained by atrio-caval cannulation. The procedures were performed in mild hypothermia (30 degrees C). Cerebral perfusion was carried out by clamping the innominate artery and all epiaortic vessels. The aorta was endoclamped by a Foley balloon inserted into the isthmus. The aorta was then opened longitudinally for 10 cm to expose and replace the aortic valve. Near-infra-red spectroscopy (NIRS) and bilateral radial artery pressure were used to monitor effective cerebral perfusion. Operative mortality was absent. The mean time of CPB was 73 min. NIRS-derived tissue oxygenation was maintained above 55%. Postoperative course was uneventful. This technique has several advantages: first, the cannulation of right axillary and the common femoral artery allows simultaneous cerebral and systemic perfusion. Second, any form of cross-clamp is avoided and the aorta is occluded away from the epiaortic vessels. Third, there is an increased freedom to choose the best place for aortotomy.

Outcomes of Solo Smart valve in a single-center experience of 270 patients.

PubMed

Liu, Hao; Khani-Hanjani, Abbas; Yang, Siyuan; Wang, Wei; Sidhu, Surita; Mullen, John; Modry, Dennis; Wang, Shaohua

2018-04-03

The Solo Smart pericardial aortic valve has been widely used in Europe as an option for aortic valve replacement (AVR). We are reporting early and midterm clinical outcomes of AVR with the Solo Smart valve in a single North America center. This is a retrospective study of 270 consecutive patients who had AVR at Mazankowski Alberta Heart Institute from February 2011 to March 2015. Follow-up and echocardiographic data were collected retrospectively from electronic and paper charts. Univariate and multivariate analysis were performed to evaluate the results. The mean age was 71.2±10.0 years, 67.4% were male, and 79.3% had combined procedures. Mean STS Score was 4.18±3.91. Early mortality was 3.7% for the entire group and 0% for isolated aortic valve replacement group. Mean cross-clamp time for isolated AVR and AVR with concomitant procedure was 70.8±12.7min and 117.0±45.0min, respectively. Permanent pacemaker implantation was necessary in 2.2% of patients. Echocardiography demonstrated a reduction in mean gradients from 40.8±17.4mmHg to 7.6±3.7 mmHg and peak gradient from 72.5 ± 48.8 mmHg to 15.5±7.5 mmHg. The 1-, 3-, and 5- year overall survival was 93.0%, 86.5% and 75.9%, respectively. At 5 years, freedom from valve-related death was 92.4%, freedom from structural valve deterioration and freedom from aortic valve reoperation were 96.4% and 98%, respectively. The Solo Smart valve is safe and has excellent hemodynamic performance. Aortic valve reoperation and rates of valve-related adverse events during midterm follow-up were low.

Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis.

PubMed

Chaikriangkrai, Kongkiat; Jhun, Hye Yeon; Shantha, Ghanshyam Palamaner Subash; Abdulhak, Aref Bin; Tandon, Rudhir; Alqasrawi, Musab; Klappa, Anthony; Pancholy, Samir; Deshmukh, Abhishek; Bhama, Jay; Sigurdsson, Gardar

2018-07-01

In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

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

Transcatheter Aortic Valve Replacement for Native Aortic Valve Regurgitation

PubMed Central

Spina, Roberto; Anthony, Chris; Muller, David WM

2015-01-01

Transcatheter aortic valve replacement with either the balloon-expandable Edwards SAPIEN XT valve, or the self-expandable CoreValve prosthesis has become the established therapeutic modality for severe aortic valve stenosis in patients who are not deemed suitable for surgical intervention due to excessively high operative risk. Native aortic valve regurgitation, defined as primary aortic incompetence not associated with aortic stenosis or failed valve replacement, on the other hand, is still considered a relative contraindication for transcatheter aortic valve therapies, because of the absence of annular or leaflet calcification required for secure anchoring of the transcatheter heart valve. In addition, severe aortic regurgitation often coexists with aortic root or ascending aorta dilatation, the treatment of which mandates operative intervention. For these reasons, transcatheter aortic valve replacement has been only sporadically used to treat pure aortic incompetence, typically on a compassionate basis and in surgically inoperable patients. More recently, however, transcatheter aortic valve replacement for native aortic valve regurgitation has been trialled with newer-generation heart valves, with encouraging results, and new ancillary devices have emerged that are designed to stabilize the annulus–root complex. In this paper we review the clinical context, technical characteristics and outcomes associated with transcatheter treatment of native aortic valve regurgitation. PMID:29588674

Permanent pacemaker insertion following isolated aortic valve replacement before and after the introduction of TAVI.

PubMed

Kogan, Alexander; Sternik, Leonid; Beinart, Roy; Shalabi, Amjad; Glikson, Michael; Spiegelstein, Danny; Levin, Shany; Raanani, Ehud

2015-04-01

Permanent pacemaker (PPM) implantation is required in 3-12% of all patients undergoing surgical aortic valve replacement (AVR). Our aim was to evaluate the contemporary incidence and impact of the introduction of transcatheter aortic valve implantation (TAVI) for PPM insertion after isolated AVR. Since 2004, during a 10-year period, a total of 858 patients underwent isolated AVR at our institution. Forty-one patients with PPM before operation were excluded from the study and 817 patients were included in the statistical analysis. Of these, 20 patients (2.45%) developed significant conduction disorders, leading to PPM implantation within 120 days postoperatively. Patients were further divided into two groups. Before (Group I: June 2004 to September 2008) and after (Group II: October 2008 to May 2014) the introduction of the TAVI program. There were 343 patients in Group I and 475 patients in Group II. The incidence of PPM implantation decreased from 3.79% (13 patients) in Group I to 1.47% (seven patients) in Group II (P < 0.001). Risk factors for permanent pacing identified by univariate analysis were: Group I (before introducing TAVI program), pulmonary hypertension, preoperative anemia, age older than 75 years, and previous myocardial infarction. Multivariate analysis identified Group I (before introducing TAVI program; P < 0.005; odds ratio [OR] 15.2, 95% confidence interval [CI] 6.3-19.9) and pulmonary hypertension (P < 0.005; OR 12.5, 95% CI 3.2-18.3) to be significant. Irreversible atrio-ventricular block or symptomatic bradycardia requiring PPM implantation is a relatively rare complication. The incidence of PPM implantation after isolated surgical AVR decreased in a contemporary setting after the introduction of the TAVI program. ©2015 Wiley Periodicals, Inc.

Comparison of Risk Scores for Prediction of Complications following Aortic Valve Replacement.

PubMed

Wang, Tom Kai Ming; Choi, David Hyun-Min; Haydock, David; Gamble, Greg; Stewart, Ralph; Ruygrok, Peter

2015-06-01

Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeon's (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context. We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications. Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications. The STS Score was best overall at discriminating post-operative complications and their composite for AVR. All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications. 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.

Coronary Artery Disease and Outcomes of Aortic Valve Replacement for Severe Aortic Stenosis

PubMed Central

Beach, Jocelyn M.; Mihaljevic, Tomislav; Svensson, Lars G.; Rajeswaran, Jeevanantham; Marwick, Thomas; Griffin, Brian; Johnston, Douglas R.; Sabik, Joseph F.; Blackstone, Eugene H.

2014-01-01

Objectives We contrast risk profiles and compare outcomes of patients with severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent aortic valve replacement (AVR) and coronary artery bypass grafting (AS+CABG) with those of patients with isolated AS who underwent AVR alone. Background In patients with severe AS, CAD is often an incidental finding with underappreciated survival implications. Methods From 10/1991–7/2010, 2,286 patients underwent AVR+CABG and 1,637 AVR alone. A propensity score was developed and used for matched comparisons of outcomes (1,082 patient pairs). Analyses of long-term mortality were performed for each group, then combined to identify common and unique risk factors. Results Patients with AS+CAD vs. isolated AS were older, more symptomatic, more likely to be hypertensive, had lower ejection fraction and greater arteriosclerotic burden, but less severe AS. Hospital morbidity and long-term survival were poorer (43% vs. 59% at 10 years). Both groups shared many mortality risk factors; however, early risk among AS+CAD patients reflected effects of CAD; late risk reflected diastolic left ventricular dysfunction expressed as ventricular hypertrophy and left atrial enlargement. Patients with isolated AS and few comorbidities had the best outcome, those with CAD without myocardial damage had intermediate outcome equivalent to propensity-matched isolated AS patients, and those with CAD, myocardial damage, and advanced comorbidities had the worst outcome. Conclusions Cardiovascular risk factors and comorbidities must be considered in managing patients with severe AS. Patients with severe AS and CAD risk factors should undergo early diagnostics and AVR+CABG before ischemic myocardial damage occurs. PMID:23428216

Endocarditis is not an Independent Predictor of Blood Transfusion in Aortic Valve Replacement Patients With Severe Aortic Regurgitation.

PubMed

Dahn, Hannah; Buth, Karen; Legare, Jean-Francois; Mingo, Heather; Kent, Blaine; Whynot, Sara; Scheffler, Matthias

2016-06-01

This study sought to evaluate if the presence of endocarditis was independently associated with increased perioperative blood transfusion in patients undergoing aortic valve replacements (AVR) with aortic regurgitation. This was a retrospective study. Large Canadian tertiary care hospital. Six hundred sixty-two consecutive patients with aortic regurgitation score of 3 or higher undergoing AVR from 1995 to 2012. No interventions were performed in this retrospective study. After REB approval, data were obtained from a center-specific database. Univariate analysis was performed to identify variables that may be associated with transfusion of any allogeneic blood product perioperatively. A multivariate logistic regression was generated to identify independent predictors of perioperative transfusion. Unadjusted transfusion rates in patients with no endocarditis and with endocarditis were 32% and 70% (p<0.001), respectively. Independent predictors of any transfusion were moderate-to-severe preoperative anemia, preoperative renal failure, non-isolated AVR, age>70, urgent/emergent surgery, BMI<25, and female sex. Endocarditis was not an independent predictor of transfusion (OR = 0.748; 95% CI = 0.35-1.601). In patients undergoing AVR, unadjusted perioperative transfusion rates were higher when endocarditis was present. However, after adjustment, aortic valve endocarditis was not independently associated with blood transfusion. The authors' observation could be explained by the higher prevalence of many independent predictors of transfusion, such as comorbidities or more complex surgery, within the endocarditis group. Thus, AV endocarditis, in the absence of other risk factors, was not associated with increased perioperative transfusion risk. Copyright © 2016 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

Comparison of 1-Year Outcome in Patients With Severe Aorta Stenosis Treated Conservatively or by Aortic Valve Replacement or by Percutaneous Transcatheter Aortic Valve Implantation (Data from a Multicenter Spanish Registry).

PubMed

González-Saldivar, Hugo; Rodriguez-Pascual, Carlos; de la Morena, Gonzalo; Fernández-Golfín, Covadonga; Amorós, Carmen; Alonso, Mario Baquero; Dolz, Luis Martínez; Solé, Albert Ariza; Guzmán-Martínez, Gabriela; Gómez-Doblas, Juan José; Jiménez, Antonio Arribas; Fuentes, María Eugenia; Gay, Laura Galian; Ortiz, Martin Ruiz; Avanzas, Pablo; Abu-Assi, Emad; Ripoll-Vera, Tomás; Díaz-Castro, Oscar; Osinalde, Eduardo P; Martínez-Sellés, Manuel

2016-07-15

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies. Copyright © 2016 Elsevier Inc. All rights reserved.

Late post-AVR progression of bicuspid aortopathy: link to hemodynamics.

PubMed

Naito, Shiho; Gross, Tatiana; Disha, Kushtrim; von Kodolitsch, Yskert; Reichenspurner, Hermann; Girdauskas, Evaldas

2017-05-01

The ascending aortic dilatation may progress after aortic valve replacement (AVR) in bicuspid aortic valve (BAV) patients. Our aim was to evaluate rheological flow patterns and histological characteristics of the aneurysmal aorta in BAV patients at the time of reoperative aortic surgery. 13 patients (mean age: 42 ± 9 years, 10 (77%) male) with significant progression of proximal aortopathy after isolated AVR surgery for BAV disease (i.e., 16.7 ± 8.1 years post-AVR) were identified by cardiac phase-contrast cine magnetic resonance imaging (MRI) in our hospital. A total of nine patients (69%) underwent redo aortic surgery. Based on the MRI data, the aortic area of the maximal flow-induced stress (jet sample) and the opposite site (control sample) were identified and corresponding samples were collected intraoperatively. Histological sum-score values [i.e. aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3)] were compared between these samples. Mean proximal aortic diameter at MRI follow-up was 55 ± 6 mm (range 47-66mm). Preoperative cardiac MRI demonstrated eccentric systolic flow pattern directed towards right-lateral/right posterior wall of the proximal aorta in 9/13 (69%) patients. Histological sum-score values were significantly higher in the jet sample vs control sample (i.e., 8.3 ± 3.8 vs 5.6 ± 2.4, respectively, p = 0.04). Hemodynamic factors may still be involved in the late progression of bicuspid aortopathy even after isolated AVR surgery for BAV disease.

Valve Repair or Replacement

MedlinePlus

... called anticoagulants) for the rest of their lives. Biological valves are made from animal tissue (called a ... for valve replacement (called an autograft). Patients with biological valves usually do not need to take blood- ...

Etiology and Risk Factors for Cerebral Infarct after Surgical Aortic Valve Replacement

PubMed Central

Massaro, Allie; Messé, Steven R.; Acker, Michael A.; Kasner, Scott E.; Torres, Jose; Fanning, Molly; Giovannetti, Tania; Ratcliffe, Sarah J.; Bilello, Michel; Szeto, Wilson Y.; Bavaria, Joseph E.; Mohler, Emile R.; Floyd, Thomas F.

2016-01-01

Background and Purpose Stroke is a potentially devastating complication of cardiac surgery. Identifying predictors of radiographic infarct may lead to improved stroke prevention for surgical patients. Methods We reviewed 129 post-operative brain MRIs from a prospective study of patients undergoing surgical aortic valve replacement (AVR). Acute infarcts were classified as watershed or embolic using pre-specified criteria. Results Acute infarct on MRI was seen in 79 of 129 patients (61%), interrater reliability for stroke etiology was high (κ =0.93). Embolic infarcts only were identified in 60 (46%), watershed only in 2 (2%), and both in 17 (13%). In multivariable logistic regression, embolic infarct was associated with aortic arch atheroma (OR=3.4, 95%CI 1.0-12.0, p=0.055), old subcortical infarcts (OR= 5.5, 95%CI 1.1-26.6, p=0.04), no history of PTCA or CABG (OR=4.0, 95%CI 1.2-13.7, p=0.03), and higher aortic valve gradient (OR=1.3 per 5mmHg, 95%CI 1.09-1.6, p=0.004). Watershed infarct was associated with internal carotid artery stenosis ≥70% (OR=11.7, 95%CI 1.8-76.8, p=0.01) and increased left ventricular ejection fraction (OR=1.6 per 5% increase, 95%CI 1.08-2.4, p=0.02). Conclusions The principal mechanism of acute cerebral infarction after AVR is embolism. There are distinct factors associated with watershed and embolic infarct, some of which may be modifiable. PMID:27382005

Outcome of bioprosthetic valve replacement in dogs with tricuspid valve dysplasia.

PubMed

Bristow, P; Sargent, J; Luis Fuentes, V; Brockman, D

2017-04-01

To describe the short-term and long-term outcome in dogs with tricuspid valve dysplasia undergoing tricuspid valve replacement under cardiopulmonary bypass. Data were collected from the hospital records of all dogs that had undergone tricuspid valve replacement under cardiopulmonary bypass between 2006 and 2012. Dogs were considered candidates for tricuspid valve replacement if they had severe tricuspid valve regurgitation associated with clinical signs of cardiac compromise. Nine dogs of six different breeds were presented. Median age was 13 months (range 7 to 61 months), median weight 26·5 kg (range 9·7 to 59 kg). Eight bovine pericardial valves and one porcine aortic valve were used. One non-fatal intraoperative complication occurred. Complications during hospitalisation occurred in six dogs, four of which were fatal. Of the five dogs discharged, one presented dead due to haemothorax after minor trauma seven days later. The four remaining dogs survived a median of 533 days; all of these dogs received a bovine pericardial valve. Based on our results, tricuspid valve replacement with bovine or porcine prosthetic valves is associated with a high incidence of complications. © 2017 British Small Animal Veterinary Association.

Association of Thoracic Aorta Calcium Score With Left Ventricular Hypertrophy and Clinical Outcomes in Patients With Severe Aortic Stenosis After Aortic Valve Replacement.

PubMed

Cho, In-Jeong; Chang, Hyuk-Jae; Heo, Ran; Kim, In-Cheol; Sung, Ji Min; Chang, Byung-Chul; Shim, Chi Young; Hong, Geu-Ru; Chung, Namsik

2017-01-01

Substantial aortic calcification is known to be associated with aortic stiffening and subsequent left ventricular (LV) hypertrophy. This study examined whether the thoracic aorta calcium score (TACS) is related to LV hypertrophy and whether it leads to an adverse prognosis in patients with severe aortic stenosis (AS) after aortic valve replacement (AVR). We retrospectively reviewed 47 patients (mean age, 64 ± 11 years) with isolated severe AS who underwent noncontrast computed tomography of the entire thoracic aorta and who received AVR. TACS was quantified using the volume method with values becoming log transformed ( log [TACS+1]). Transthoracic echocardiography was performed before and 1 year after the operation. Preoperative LV mass index (LVMI) displayed significant positive correlations with male gender (r = 0.430, p = 0.010) and log (TACS+1) (r = 0.556, p = 0.003). In multivariate linear regression analysis, only log (TACS+1) was independently associated with LVMI, even after adjusting for age, gender, transaortic mean pressure gradient, and coronary or valve calcium score. Independent determinants for postoperative LVMI included log (TACS+1) and preoperative LVMI after 1 year of follow-up echocardiography, adjusting for age, gender, indexed effective orifice area, and coronary or valve calcium score. During a median follow-up period of 54 months after AVR, there were 10 events (21%), which included 4 deaths from all-causes, 3 strokes, 2 inpatient admissions for heart failure, and 1 myocardial infarction. The event-free survival rate was significantly lower for patients with TACS of 2,257 mm 3 or higher compared with those whose TACS was lower than 2,257 mm 3 (log-rank p < 0.001). High TACS was associated with increased LVMI among patients with severe AS. Further, high TACS usefully predicted less regression of LVMI and poor clinical outcomes after AVR. TACS may serve as a useful proxy for predicting LV remodeling and adverse prognosis in patients

Influence of type of aortic valve prosthesis on coronary blood flow velocity.

PubMed

Jelenc, Matija; Juvan, Katja Ažman; Medvešček, Nadja Tatjana Ružič; Geršak, Borut

2013-02-01

Severe aortic valve stenosis is associated with high resting and reduced hyperemic coronary blood flow. Coronary blood flow increases after aortic valve replacement (AVR); however, the increase depends on the type of prosthesis used. The present study investigates the influence of type of aortic valve prosthesis on coronary blood flow velocity. The blood flow velocity in the left anterior descending coronary artery (LAD) and the right coronary artery (RCA) was measured intraoperatively before and after AVR with a stentless bioprosthesis (Sorin Freedom Solo; n = 11) or a bileaflet mechanical prosthesis (St. Jude Medical Regent; n = 11). Measurements were made with an X-Plore epicardial Doppler probe (Medistim, Oslo, Norway) following induction of hyperemia with an adenosine infusion. Preoperative and postoperative echocardiography evaluations were used to assess valvular and ventricular function. Velocity time integrals (VTI) were measured from the Doppler signals and used to calculate the proportion of systolic VTI (SF), diastolic VTI (DF), and normalized systolic coronary blood flow velocities (NSF) and normalized diastolic coronary blood flow velocities (NDF). The systolic proportion of the LAD VTI increased after AVR with the St. Jude Medical Regent prosthesis, which produced higher LAD SF and NSF values than the Sorin Freedom Solo prosthesis (SF, 0.41 ± 0.09 versus 0.29 ± 0.13 [P = .04]; NSF, 0.88 ± 0.24 versus 0.55 ± 0.17 [P = .01]). No significant changes in the LAD velocity profile were noted after valve replacement with the Sorin Freedom Solo, despite a significant reduction in transvalvular gradient and an increase in the effective orifice area. AVR had no effect on the RCA flow velocity profile. The coronary flow velocity profile in the LAD was significantly influenced by the type of aortic valve prosthesis used. The differences in the LAD velocity profile probably reflect differences in valve design and the systolic transvalvular flow pattern.

21 CFR 870.3925 - Replacement heart valve.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Replacement heart valve. 870.3925 Section 870.3925...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Prosthetic Devices § 870.3925 Replacement heart valve. (a) Identification. A replacement heart valve is a device intended to perform the function of any...

21 CFR 870.3925 - Replacement heart valve.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Replacement heart valve. 870.3925 Section 870.3925...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Prosthetic Devices § 870.3925 Replacement heart valve. (a) Identification. A replacement heart valve is a device intended to perform the function of any...

21 CFR 870.3925 - Replacement heart valve.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Replacement heart valve. 870.3925 Section 870.3925...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Prosthetic Devices § 870.3925 Replacement heart valve. (a) Identification. A replacement heart valve is a device intended to perform the function of any...

21 CFR 870.3925 - Replacement heart valve.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Replacement heart valve. 870.3925 Section 870.3925...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Prosthetic Devices § 870.3925 Replacement heart valve. (a) Identification. A replacement heart valve is a device intended to perform the function of any...

21 CFR 870.3925 - Replacement heart valve.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Replacement heart valve. 870.3925 Section 870.3925...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Prosthetic Devices § 870.3925 Replacement heart valve. (a) Identification. A replacement heart valve is a device intended to perform the function of any...

Blood flow characteristics in the ascending aorta after TAVI compared to surgical aortic valve replacement.

PubMed

Trauzeddel, Ralf Felix; Löbe, Ulrike; Barker, Alex J; Gelsinger, Carmen; Butter, Christian; Markl, Michael; Schulz-Menger, Jeanette; von Knobelsdorff-Brenkenhoff, Florian

2016-03-01

Ascending aortic blood flow characteristics are altered after aortic valve surgery, but the effect of transcatheter aortic valve implantation (TAVI) is unknown. Abnormal flow may be associated with aortic and cardiac remodeling. We analyzed blood flow characteristics in the ascending aorta after TAVI in comparison to conventional stented aortic bioprostheses (AVR) and healthy subjects using time-resolved three-dimensional flow-sensitive cardiovascular magnetic resonance imaging (4D-flow MRI). Seventeen patients with TAVI (Edwards Sapien XT), 12 with AVR and 9 healthy controls underwent 4D-flow MRI of the ascending aorta. Target parameters were: severity of vortical and helical flow pattern (semiquantitative grading from 0 = none to 3 = severe) and the local distribution of systolic wall shear stress (WSSsystole). AVR revealed significantly more extensive vortical and helical flow pattern than TAVI (p = 0.042 and p = 0.002) and controls (p < 0.001 and p = 0.001). TAVI showed significantly more extensive vortical flow than controls (p < 0.001). Both TAVI and AVR revealed marked blood flow eccentricity (64.7 and 66.7%, respectively), whereas controls showed central blood flow (88.9%). TAVI and AVR exhibited an asymmetric distribution of WSSsystole in the mid-ascending aorta with local maxima at the right anterior aortic wall and local minima at the left posterior wall. In contrast, controls showed a symmetric distribution of WSSsystole along the aortic circumference. Blood flow was significantly altered in the ascending aorta after TAVI and AVR. Changes were similar regarding WSSsystole distribution, while TAVI resulted in less helical and vortical blood flow.

Options for Heart Valve Replacement

MedlinePlus

... which may include human or animal donor tissue) Ross Procedure — “Borrowing” your healthy valve and moving it ... Considerations for Surgery Medications Valve Repair Valve Replacement - Ross Procedure - Newer Surgery Options - What is TAVR? - Types ...

Validity of standard gamble utilities in patients referred for aortic valve replacement.

PubMed

Hussain, Amjad I; Garratt, Andrew M; Beitnes, Jan Otto; Gullestad, Lars; Pettersen, Kjell I

2016-07-01

Standard gamble (SG) is the preferred method of assessing preferences in situations with uncertainty and risk, which makes it relevant to patients considered for aortic valve replacement (AVR). The present study assesses SG preferences in patients with severe aortic stenosis (AS). All patients >18 years old with severe AS referred for AVR to our institution were invited to enroll in the study. The SG was administered by a clinical research nurse. The SF-36, EQ-5D 3L, Hospital Anxiety and Depression Scale (HADS), and AS symptoms were administered by self-completed questionnaire. We hypothesized that SG utilities would have low-to-moderate correlations with physical and mental aspects of health based on our pathophysiological understanding of severe AS. No correlations were expected with echocardiographic measures of the aortic valve. The response rate for SG was 98 %. SG moderately correlated with physical aspects of SF-36 (PCS, role-physical, vitality), health transition, AS symptoms, and EQ-VAS (ρ S = 0.31-0.39, p < 0.001) and had low correlation with mental aspects of SF-36 and EQ-5D (ρ S = 0.17-0.28, p < 0.001). No correlation was found between SG and HADS, echocardiographic measures, age, gender, or education level (ρ S = 0.01-0.06). SG is an acceptable and feasible method of assessing preferences in patients with severe AS that has evidence for validity. The inclusion of uncertainty lends the SG face validity in this population as a direct approach to assessing preferences and basis for QALY calculations.

Hemodynamic outcomes of the Ross procedure versus other aortic valve replacement: a systematic review and meta-analysis.

PubMed

Um, Kevin J; Mcclure, Graham R; Belley-Cote, Emilie P; Gupta, Saurabh; Bouhout, Ismail; Lortie, Hugo; Alraddadi, Hatim; Alsagheir, Ali; Bossard, Matthias; Mcintyre, William F; Lengyel, Alexandra; Eikelboom, John W; Ouzounian, Maral; Chu, Michael W; Parry, Dominic; El-Hamamsy, Ismail; Whitlock, Richard P

2018-06-01

Life expectancy in young adults undergoing mechanical or bioprosthetic aortic valve replacement (AVR) may be reduced by up to 20 years compared to age matched controls. The Ross procedure is a durable, anticoagulation-sparing alternative. We performed a systematic review and meta-analysis to compare the valve hemodynamics of the Ross procedure versus other AVR. We searched Cochrane CENTRAL, MEDLINE and EMBASE from inception to February 2017 for randomized controlled trials (RCTs) and observational studies (n≥10 Ross). Independently and in duplicate, we performed title and abstract screening, full-text eligibility assessment, and data collection. We evaluated the risk of bias with the Cochrane and CLARITY tools, and the quality of evidence with the GRADE framework. We identified 2 RCTs and 13 observational studies that met eligibility criteria (N.=1412). In observational studies, the Ross procedure was associated with a lower mean aortic gradient at discharge (MD -9 mmHg, 95% CI: -13 to -5, P<0.0001, I2=97%) and latest follow-up (MD -5 mmHg, 95% CI: -7 to -3, P<0.0001, I2=92%). There was no significant difference in the incidence of severe aortic regurgitation at latest follow-up (RR 1.3, 95% CI: 0.3 to 5.8, P=0.70, I2=30%). In RCTs, the Ross procedure was associated with a lower mean gradient at latest follow-up (MD -15 mmHg, 95% CI: -32 to 2, P=0.08, I2=99%). The mean pulmonic gradient for the Ross procedure was 18.0 mmHg (95% CI: 16 to 20, P<0.0001) at latest follow-up. The evidence for all outcomes from observational studies was deemed to be of very low quality, while the evidence from RCTs was downgraded for imprecision and moderately serious risk of bias. Compared to conventional AVR, the Ross procedure was associated with better aortic valve hemodynamics. Future studies should evaluate the impact of the Ross procedure on exercise capacity and quality of life.

Valve assembly having remotely replaceable bearings

DOEpatents

Johnson, Evan R.; Tanner, David E.

1980-01-01

A valve assembly having remotely replaceable bearings is disclosed wherein a valve disc is supported within a flow duct for rotation about a pair of axially aligned bearings, one of which is carried by a spindle received within a diametral bore in the valve disc, and the other of which is carried by a bearing support block releasably mounted on the duct circumferentially of an annular collar on the valve disc coaxial with its diametrical bore. The spindle and bearing support block are adapted for remote removal to facilitate servicing or replacement of the valve disc support bearings.

[Longterm results of mitral valve replacement (author's transl)].

PubMed

Erhard, W; Reichmann, M; Delius, W; Sebening, H; Herrmann, G

1977-04-22

210 patients were followed up by the actuary method for over 5 years after isolated mitral valve replacement or a double valve replacement. After isolated valve replacement the one month survival including the operative mortality was 92+/-2%. The survival after one year was 83+/-3% and after 5 years 66+/-7%. The five year survival of patients in preoperative class III (according to the NYHA) was 73+/-8% and of class IV 57+/-8% (P less than or equal to 0.1). A comparison of valve replacements for pure mitral stenosis or mitral insufficiency showed no statistically significant differences. In the 37 patients who had a double valve replacement the survival risk was not increased in comparison with those patients who had had a single valve replacement. Age above 45 years and a preoperative markedly raised pulmonary arteriolar resistance reduced the chances of survival.

Utility of cardiac computed tomography for evaluation of pannus in mechanical aortic valve.

PubMed

Suh, Young Joo; Kim, Young Jin; Lee, Sak; Hong, Yoo Jin; Lee, Hye-Jeong; Hur, Jin; Choi, Byoung Wook; Chang, Byung-Chul

2015-08-01

The clinical significance of pannus detected on computed tomography (CT) has not yet been investigated. The purposes of this study were to investigate the clinical significance of pannus detected on cardiac CT in patients who underwent aortic valve replacement (AVR) with mechanical valves, and to determine predictors for pannus severity. A total of 92 patients who underwent cardiac CT and TTE and who had undergone mechanical AVR were included. The geometric orifice area (GOA), the presence of limitation of motion (LOM) and pannus were evaluated on CT. The GOA, presence of LOM, and presence and severity of pannus were compared with echocardiographic parameters. Logistic regression analysis was performed to determine the predictors for pannus severity. The GOA on CT positively correlated with effective orifice area on TTE (r = 0.733, P < 0.0001). Pannus was found in 77.2% and LOM in 14.0%. With increasing pannus severity, mean transvalvular pressure gradient (PG) was significantly higher (P < 0.0001). Patients with elevated PG showed a smaller GOA, a higher incidence of pannus, more severe pannus and LOM than patients with normal PG (P < 0.05). Small valve size (≤19 mm), Carbomedics valve, rheumatic etiology, and young age at AVR (<48.8 years) were independent predictors of moderate to severe pannus (P < 0.05). Cardiac CT is helpful in the evaluation of pannus formation in patients with mechanical aortic valves. Moderate to severe pannus formation frequently occurred in patients with small mechanical valve size, Carbomedics valves, rheumatic heart disease and young age at AVR.

Improved Survival After the Ross Procedure Compared With Mechanical Aortic Valve Replacement.

PubMed

Buratto, Edward; Shi, William Y; Wynne, Rochelle; Poh, Chin L; Larobina, Marco; O'Keefe, Michael; Goldblatt, John; Tatoulis, James; Skillington, Peter D

2018-03-27

It is unclear whether the Ross procedure offers superior survival compared with mechanical aortic valve replacement (AVR). This study evaluated experience and compared long-term survival between the Ross procedure and mechanical AVR. Between 1992 and 2016, a total of 392 Ross procedures were performed. These were compared with 1,928 isolated mechanical AVRs performed during the same time period as identified using the University of Melbourne and Australia and New Zealand Society of Cardiac and Thoracic Surgeons' Cardiac Surgery Databases. Only patients between 18 and 65 years of age were included. Propensity-score matching was performed for risk adjustment. Ross procedure patients were younger, and had fewer cardiovascular risk factors. The Ross procedure was associated with longer cardiopulmonary bypass and aortic cross-clamp times. Thirty-day mortality was similar (Ross, 0.3%; mechanical, 0.8%; p = 0.5). Ross procedure patients experienced superior unadjusted long-term survival at 20 years (Ross, 95%; mechanical, 68%; p < 0.001). Multivariable analysis showed the Ross procedure to be associated with a reduced risk of late mortality (hazard ratio: 0.34; 95% confidence internal: 0.17 to 0.67; p < 0.001). Among 275 propensity-score matched pairs, Ross procedure patients had superior survival at 20 years (Ross, 94%; mechanical, 84%; p = 0.018). In this Australian, propensity-score matched study, the Ross procedure was associated with better long-term survival compared with mechanical AVR. In younger patients, with a long life expectancy, the Ross procedure should be considered in centers with sufficient expertise. Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.

Impact of Prosthesis-Patient Mismatch on Long-term Functional Capacity After Mechanical Aortic Valve Replacement.

PubMed

Petit-Eisenmann, Hélène; Epailly, Eric; Velten, Michel; Radojevic, Jelena; Eisenmann, Bernard; Kremer, Hélène; Kindo, Michel

2016-12-01

The impact of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) for aortic stenosis on exercise capacity remains controversial. The aim of this study was to analyze the long-term impact of PPM after mechanical AVR on maximal oxygen uptake (VO 2max ). The study included 75 patients who had undergone isolated mechanical AVR for aortic stenosis with normal left ventricular (LV) function between 1994 and 2012. Their functional capacity was evaluated on average 4.6 years after AVR by exercise testing, including measurement of their VO 2max , and by determining their New York Heart Association functional class and Short Form-36 score. Two groups were defined by measuring the patients' indexed effective orifice area (iEOA) by transthoracic echocardiography: a PPM group (iEOA < 0.85 cm 2 /m 2 ) and a no-PPM group (iEOA ≥ 0.85 cm 2 /m 2 ). PPM was present in 37.0% of the patients. The percentage of the predicted VO 2max achieved was significantly lower in the PPM group (86.7 ± 19.5% vs 97.5 ± 23.0% in the no-PPM group; P = 0.04). Compared with the no-PPM group, the PPM group contained fewer patients in New York Heart Association functional class I and their mean Short Form-36 physical component summary score was significantly lower. The mean transvalvular gradient was significantly higher in the PPM group than in the no-PPM group (P < 0.001). Systolic and diastolic function and LV mass had normalized in both groups. PPM is associated in the long term with moderate but significant impairment of functional capacity, despite optimal LV reverse remodelling and normalization of LV systolic and diastolic function. Copyright © 2016 Canadian Cardiovascular Society. 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.

Effect of Hospital Volume on Prosthesis Use and Mortality in Aortic Valve Operations in the Elderly.

PubMed

McNeely, Christian; Markwell, Stephen; Filson, Kathryn; Hazelrigg, Stephen; Vassileva, Christina

2016-02-01

This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly. The study included 277,928 Medicare beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year. The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year--odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year--OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year--OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year--OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume (p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11-1.19). Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Mitral valve replacement with the Hancock stabilized glutaraldehyde valve. Clinical and laboratory evaluation.

PubMed

Buch, W S; Pipkin, R D; Hancock, W D; Fogarty, T J

1975-11-01

From March 1971 through April 1975, one hundred twenty patients underwent mitral valve replacement with a Hancock "stabilized glutaraldehyde process" porcine aortic xenograft. A simultaneous canine experimental series was also carried out. In the clinical series, the early mortality was 8.3%. Actuarial analyses of all patients predicts survival at two years of 81.0% and at four years of 70.0%. The predicted survival for patients without coronary disease or prior prosthetic valve replacement is 87.5% at two years and 77.5% at four years. There were four thromboembolic episodes, a rate of 2.4% per patient-year. None were fatal. No valve failure were noted. Histologic examination and shrink temperature analysis of recovered valves show excellent tissue preservation at 40 months. The data indicate that the Hancock valve is durable, enjoys a low incidence of thromboembolism, and may be the valve of choice for mitral valve replacement.

Effect of prior aortic valve intervention on results of the Ross operation.

PubMed

Sakaguchi, Hidehito; Elkins, Ronald C; Lane, Mary M; McCue, Carolyn

2003-07-01

Patient-related factors, aortic insufficiency, bicuspid aortic valve, aortic annulus dilatation, ascending aortic dilatation or aneurysm, and aortic valve endocarditis have been suggested as affecting the results of the Ross operation. The study aim was to assess the impact of prior aortic valve intervention on early and late results of a Ross operation. A total of 399 patients who underwent surgery between August 1986 and September 2000 were reviewed retrospectively. The patients were grouped as: no prior aortic valve intervention (NOAVI, n = 219); prior aortic valvuloplasty (AVP, n = 106); prior balloon aortic valvuloplasty (AVB, n = 40); and prior aortic valve replacement (AVR, n = 34). Details of operative and late mortality, autograft valve function, and homograft valve function were analyzed. Operative mortality was higher for AVB (10%; three deaths in neonates) than the other groups (from 2.3% to 5.9%) (p = 0.084). Freedom from autograft valve degeneration, defined as severe autograft valve insufficiency, non-endocarditis autograft valve reoperation or valve-related death, ranged from 93 +/- 3% for AVP to 76 +/- 8% for NOAVI at 10 years (p = 0.43). Freedom from homograft reoperation in the pulmonary position was 100% for AVB at six years, and 99 +/- 1% for AVP, 82 +/- 8% for NOAVI, and 70 +/- 13% for AVR at 10 years (p = 0.0026). There appears to be no significant difference between patients with and without prior aortic valve surgery, with respect to operative mortality or late autograft function. However, patients with prior AVR appear to have a significantly higher homograft reoperation rate after a Ross operation, the reasons for which are uncertain.

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

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

Leaving Moderate Tricuspid Valve Regurgitation Alone at the Time of Pulmonary Valve Replacement: A Worthwhile Approach.

PubMed

Kogon, Brian; Mori, Makoto; Alsoufi, Bahaaldin; Kanter, Kirk; Oster, Matt

2015-06-01

Pulmonary valve disruption in patients with tetralogy of Fallot and congenital pulmonary stenosis often results in pulmonary insufficiency, right ventricular dilation, and tricuspid valve regurgitation. Management of functional tricuspid regurgitation at the time of subsequent pulmonary valve replacement remains controversial. Our aims were to (1) analyze tricuspid valve function after pulmonary valve replacement through midterm follow-up and (2) determine the benefits, if any, of concomitant tricuspid annuloplasty. Thirty-five patients with tetralogy of Fallot or congenital pulmonary stenosis were analyzed. All patients had been palliated in childhood by disrupting the pulmonary valve, and all patients had at least moderate tricuspid valve regurgitation at the time of subsequent pulmonary valve replacement. Preoperative and serial postoperative echocardiograms were analyzed. Pulmonary and tricuspid regurgitation, along with right ventricular dilation and dysfunction were scored as 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Right ventricular volume and area were also calculated. Comparisons were made between patients who underwent pulmonary valve replacement alone and those who underwent concomitant tricuspid valve annuloplasty. At 1 month after pulmonary valve replacement, there were significant reductions in pulmonary valve regurgitation (mean 3 vs 0.39, p < 0.0001), tricuspid valve regurgitation (mean 2.33 vs 1.3, p < 0.0001), and in right ventricular dilation, volume, and area. There was no difference in the degree of tricuspid regurgitation 1 month postoperatively between patients who underwent concomitant tricuspid annuloplasty and those who underwent pulmonary valve replacement alone (mean 1.31 vs 1.29, p = 0.81). However, at latest follow-up (mean 7.0 ± 2.8 years), the degree of tricuspid regurgitation was significantly higher in the concomitant annuloplasty group (mean 1.87 vs 1.12, p = 0.005). In patients with at least moderate tricuspid valve

Factors associated with poor self-reported health status after aortic valve replacement with or without concomitant bypass surgery.

PubMed

Oterhals, Kjersti; Hanssen, Tove Aminda; Haaverstad, Rune; Nordrehaug, Jan Erik; Eide, Geir Egil; Norekvål, Tone M

2015-08-01

Improving patients' health status is a central goal for cardiac surgery. Knowledge remains sparse on how combined CABG or other factors influence long-term, self-reported health status after aortic valve replacement (AVR). The aims of this study were (i) to identify significant factors influencing self-reported health status of patients assessed up to 13 years after AVR; and (ii) to compare their health with the age- and gender-matched general population. A survey questionnaire was sent to 1191 patients who had undergone AVR with or without concomitant CABG between 2000 and 2012. Physical and mental sum scores of Short Form 12 were used as dependent variables and 34 independent variables including the Minnesota living with Heart Failure Questionnaire (MLHFQ) were evaluated by hierarchical linear regression. A comparison was made with the Norwegian general population. Clinical data were obtained from the local cardiac surgery database. In all, 912 patients (77%) responded (mean age: 73 years; 63% men). Of these, 59% had an isolated AVR. The mean assessment interval since surgery was 6 years. Several factors significantly predicted worse physical health: low education level (b: -2.8, P = 0.005), higher preoperative EuroSCORE (b: -0.88, P = 0.007), high NYHA class (b: -4.5, P < 0.001), depression (b: -5.62, P = 0.012), worse MLHFQ physical scores (b: -0.70, P < 0.001), arthritis (b: -5.13, P = 0.003), osteoporosis (b: -6.96, P = 0.010) and cancer (b: -4.48, P = 0.047) accounting for 60% of the variation (P < 0.001). Living alone (b: -3.60, P < 0.001), anxiety (b: -12.99, P < 0.001), depression (b: -6.82, P < 0.001) and worse MLHFQ emotional score (b: -0.50, P < 0.001) predicted poor mental health status, and explained 58% of the variation among AVR patients (P < 0.001). Both genders had poorer physical and mental health than their age-matched general population peers, particularly those in older age groups. AVR patients, regardless of gender, had worse physical and

Anterior mitral valve aneurysm: a rare sequelae of aortic valve endocarditis.

PubMed

Janardhanan, Rajesh; Kamal, Muhammad Umar; Riaz, Irbaz Bin; Smith, M Cristy

2016-03-01

SummaryIn intravenous drug abusers, infective endocarditis usually involves right-sided valves, with Staphylococcus aureus being the most common etiologic agent. We present a patient who is an intravenous drug abuser with left-sided (aortic valve) endocarditis caused by Enterococcus faecalis who subsequently developed an anterior mitral valve aneurysm, which is an exceedingly rare complication. A systematic literature search was conducted which identified only five reported cases in the literature of mitral valve aneurysmal rupture in the setting of E. faecalis endocarditis. Real-time 3D-transesophageal echocardiography was critical in making an accurate diagnosis leading to timely intervention. Early recognition of a mitral valve aneurysm (MVA) is important because it may rupture and produce catastrophic mitral regurgitation (MR) in an already seriously ill patient requiring emergency surgery, or it may be overlooked at the time of aortic valve replacement (AVR).Real-time 3D-transesophageal echocardiography (RT-3DTEE) is much more advanced and accurate than transthoracic echocardiography for the diagnosis and management of MVA. © 2016 The authors.

Transcatheter Mitral Valve Replacement for Native and Failed Bioprosthetic Mitral Valves

PubMed Central

Sarkar, Kunal; Reardon, Michael J.; Little, Stephen H.; Barker, Colin M.; Kleiman, Neal S.

2017-01-01

Transcatheter mitral valve replacement (TMVR) is a novel approach for treatment of severe mitral regurgitation. A number of TMVR devices are currently undergoing feasibility trials using both transseptal and transapical routes for device delivery. Overall experience worldwide is limited to fewer than 200 cases. At present, the 30-day mortality exceeds 30% and is attributable to both patient- and device-related factors. TMVR has been successfully used to treat patients with degenerative mitral stenosis (DMS) as well as failed mitral bioprosthesis and mitral repair using transcatheter mitral valve-in-valve (TMViV)/valve-in-ring (ViR) repair. These patients are currently treated with devices designed for transcatheter aortic valve replacement. Multicenter registries have been initiated to collect outcomes data on patients currently undergoing TMViV/ViR and TMVR for DMS and have confirmed the feasibility of TMVR in these patients. However, the high periprocedural and 30-day event rates underscore the need for further improvements in device design and multicenter randomized studies to delineate the role of these technologies in patients with mitral valve disease. PMID:29743999

Valve replacement in children: a challenge for a whole life.

PubMed

Henaine, Roland; Roubertie, François; Vergnat, Mathieu; Ninet, Jean

2012-10-01

Valvular pathology in infants and children poses numerous challenges to the paediatric cardiac surgeon. Without question, valvular repair is the goal of intervention because restoration of valvular anatomy and physiology using native tissue allows for growth and a potentially better long-term outcome. When reconstruction fails or is not feasible, valve replacement becomes inevitable. Which valve for which position is controversial. Homograft and bioprosthetic valves achieve superior haemodynamic results initially but at the cost of accelerated degeneration. Small patient size and the risk of thromboembolism limit the usefulness of mechanical valves, and somatic outgrowth is an universal problem with all available prostheses. The goal of this article is to address valve replacement options for all four valve positions within the paediatric population. We review current literature and our practice to support our preferences. To summarize, a multitude of opinions and surgical experiences exist. Today, the valve choices that seem without controversy are bioprosthetic replacement of the tricuspid valve and Ross or Ross-Konno procedures when necessary for the aortic valve. On the other hand, bioprostheses may be implanted when annular pulmonary diameter is adequate; if not or in case of right ventricular outflow tract discontinuity, it is better to use a pulmonary homograft with the Ross procedure. Otherwise, a valved conduit. Mitral valve replacement remains the most problematic; the mechanical prosthesis must be placed in the annular position, avoiding oversizing. Future advances with tissue-engineered heart valves for all positions and new anticoagulants may change the landscape for valve replacement in the paediatric population. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Anesthetic Considerations for Transcatheter Pulmonary Valve Replacement.

PubMed

Gregory, Stephen H; Zoller, Jonathan K; Shahanavaz, Shabana; Chilson, Kelly L; Ridley, Clare H

2018-02-01

The introduction of transcatheter therapy for valvular heart disease has revolutionized the care of patients with valvular disorders. Pathologic regurgitation or stenosis of the pulmonary valve, right ventricular outflow tract, or a right ventricle-to-pulmonary artery conduit represent emerging indications for transcatheter therapy. To date, minimal literature exists detailing the anesthetic management of patients undergoing transcatheter pulmonary valve replacement. In this review, the pathophysiology and indications for transcatheter pulmonary valve replacement and possible complications unique to this procedure are reviewed. Anesthetic management, including preoperative assessment, intraoperative considerations, and early postoperative monitoring, are discussed. Copyright © 2018 Elsevier Inc. All rights reserved.

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.

Preoperative planning of left-sided valve surgery with 3D computed tomography reconstruction models: sternotomy or a minimally invasive approach?

PubMed

Heuts, Samuel; Maessen, Jos G; Sardari Nia, Peyman

2016-05-01

With the emergence of a new concept aimed at individualization of patient care, the focus will shift from whether a minimally invasive procedure is better than conventional treatment, to the question of which patients will benefit most from which technique? The superiority of minimally invasive valve surgery (MIVS) has not yet been proved. We believe that through better patient selection advantages of this technique can become more pronounced. In our current study, we evaluate the feasibility of 3D computed tomography (CT) imaging reconstruction in the preoperative planning of patients referred for MIVS. We retrospectively analysed all consecutive patients who were referred for minimally invasive mitral valve surgery (MIMVS) and minimally invasive aortic valve replacement (MIAVR) to a single surgeon in a tertiary referral centre for MIVS between March 2014 and 2015. Prospective preoperative planning was done for all patients and was based on evaluations by a multidisciplinary heart-team, an echocardiography, conventional CT images and 3D CT reconstruction models. A total of 39 patients were included in our study; 16 for mitral valve surgery (MVS) and 23 patients for aortic valve replacement (AVR). Eleven patients (69%) within the MVS group underwent MIMVS. Five patients (31%) underwent conventional MVS. Findings leading to exclusion for MIMVS were a tortuous or slender femoro-iliac tract, calcification of the aortic bifurcation, aortic elongation and pericardial calcifications. Furthermore, 2 patients had a change of operative strategy based on preoperative planning. Seventeen (74%) patients in the AVR group underwent MIAVR. Six patients (26%) underwent conventional AVR. Indications for conventional AVR instead of MIAVR were an elongated ascending aorta, ascending aortic calcification and ascending aortic dilatation. One patient (6%) in the MIAVR group was converted to a sternotomy due to excessive intraoperative bleeding. Two mortalities were reported during

Will Catheter Interventions Replace Surgery for Valve Abnormalities?

PubMed Central

O’Byrne, Michael L; Gillespie, Matthew J

2015-01-01

Purpose of Review Catheter-based valve technologies have evolved rapidly over the last decade. Transcatheter aortic valve replacement (TAVR) has become a routine procedure in high-risk adult patients with calcific aortic stenosis. In patients with congenital heart disease (CHD), transcatheter pulmonary valve replacement represents a transformative technology for right ventricular outflow tract dysfunction with the potential to expand to other indications. This review aims to summarize 1) the current state of the art for transcatheter valve replacement (TVR) in CHD, 2) the expanding indications for TVR, and 3) the technological obstacles to optimizing TVR. Recent findings Multiple case series have demonstrated that TVR with the Melody transcatheter pulmonary valve in properly selected patients is safe, effective, and durable in short-term follow-up. The Sapien transcatheter heart valve represents an alternative device with similar safety and efficacy in limited studies. Innovative use of current valves has demonstrated the flexibility of TVR, while highlighting the need for devices to address the broad range of post-operative anatomies either with a single device or strategies to prepare the outflow tract for subsequent device deployment. Summary The potential of TVR has not been fully realized, but holds promise in treatment of CHD. PMID:24281347

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

Should patients with Björk-Shiley valves undergo prophylactic replacement?

PubMed

Birkmeyer, J D; Marrin, C A; O'Connor, G T

1992-08-29

About 85,000 patients have undergone replacement of diseased heart valves with prosthetic Björk-Shiley convexo-concave (CC) valves. These valves are prone to fracture of the outlet strut, which leads to acute valve failure that is usually fatal. Should patients with these valves undergo prophylactic replacement to avoid fracture? The incidence of strut fracture varies between 0% and 1.5% per year, depending on valve opening angle (60 degrees or 70 degrees), diameter (less than 29 mm or greater than or equal to 29 mm), and location (aortic or mitral). Other factors include the patient's life expectancy and the expected morbidity and mortality associated with reoperation. We have used decision analysis to identify the patients most likely to benefit from prophylactic reoperation. The incidence of outlet strut fracture was estimated from the data of three large studies on CC valves, and stratified by opening angle, diameter, and location. A Markov decision analysis model was used to estimate life expectancy for patients undergoing prophylactic valve replacement and for those not undergoing reoperation. Prophylactic valve replacement does not benefit patients with CC valves that have low strut fracture risks (60 degrees aortic valves and less than 29 mm, 60 degrees mitral valves). For most patients with CC valves that have high strut fracture risks (greater than or equal to 29 mm, 70 degrees CC), prophylactic valve replacement increases life expectancy. However, elderly patients with such valves benefit from prophylactic reoperation only if the risk of operative mortality is low. Patient age and operative risk are most important in recommendations for patients with CC valves that have intermediate strut fracture risks (less than 29 mm, 70 degrees valves and greater than or equal to 29 mm, 60 degrees mitral valves). For all patients and their doctors facing the difficult decision on whether to replace CC valves, individual estimates of operative mortality risk that

Association of Nurse-to-Patient Ratio with mortality and preventable complications following aortic valve replacement.

PubMed

Arkin, Nicole; Lee, Peter H U; McDonald, Kathryn; Hernandez-Boussard, Tina

2014-03-01

To examine hospital resources associated with patient outcomes for aortic valve replacement (AVR), including inpatient adverse events and mortality. We used the Nationwide Inpatient Sample to identify AVR procedures from 1998 to 2010 and the American Hospital Association Annual Survey to augment hospital characteristics. Primary outcomes included mortality and the development of adverse events, identified using standardized patient safety indicators (PSI). Patient and hospital characteristics associated with PSI development were evaluated using univariate and multivariate analyses. An estimated 410,157 AVRs at 5009 hospitals were performed in the US between 1998 and 2010. The number of procedures grew annually by 4.72% (p=0.0003) in high volume hospitals, 4.48% in medium volume hospitals (p<0.0001), and 2.03% in low volume hospitals (p=0.154). Mortality was highest in low volume hospitals, 4.70%, decreased from 4.14% to 3.73% in medium and high volume hospitals, respectively (p=0.0002). Rates of PSIs did not vary significantly across volume terciles (p=0.254). Multivariate logistic regression analysis showed low volume hospitals had increased risk of mortality as compared with high volume hospitals (odds ratio [OR]: 1.42; 95% confidence interval [CI]: 1.01 to 2.00), while hospital volume was not associated with adverse events. PSI development was associated with small hospitals as compared with large (OR: 1.63, 95% CI: 1.16 to 2.28) and inversely associated with higher nurse-to-patient ratio (OR: 0.94, 95% CI: 0.90 to 0.99). The volume-outcomes relationship was associated with mortality outcomes but not postoperative complications. We identified structural differences in hospital size, nurses-to-patient ratio, and nursing skill level indicative of high quality outcomes. © 2014 Wiley Periodicals, Inc.

Mitral valve replacement with preservation of the subvalvular apparatus.

PubMed

Reardon, M J; David, T E

1999-03-01

The introduction of the Starr-Edwards valve allowed complete replacement of diseased left-sided heart valves. With improved cardiopulmonary bypass, myocardial protection, and surgical techniques the mortality rate from aortic valve replacement decreased substantially, whereas the mortality rate from mitral valve replacement remained high, largely because of low cardiac output syndrome. Increasing use of mitral valve repair techniques resulted in a marked decrease in short-term and long-term morbidity and mortality when treating patients with mitral regurgitation. Some believed that this resulted from maintenance of the mitral annular papillary muscle continuity during mitral valve repair. Subsequent experimental and clinical studies have validated the positive short-term and long-term effects of maintaining the integrity of the mitral valve subvalvular apparatus. This article considers the history of the clinical use of preservation of the subvalvular apparatus, the physiologic studies examining this concept, and the clinical data available on its use. It also examines the following: 1) mitral stenosis versus mitral regurgitation and the preservation of the subvalvular apparatus; 2) whether the anterior, posterior, or both areas of the subvalvular apparatus should be preserved; and 3) the surgical techniques for the preservation of the subvalvular apparatus and valve implantation.

Transcatheter aortic valve-in-valve implantation for severe bioprosthetic stenosis after Bentall operation using a homograft in a patient with Behçet's disease.

PubMed

Joo, Hyung Joon; Hong, Soon Jun; Yu, Cheol Woong

2015-03-01

A 43-year-old man presented with severe aortic stenosis. Eight years previously, he had undergone primary surgical aortic valve replacement (AVR) for severe aortic regurgitation, but one year later developed cardiac arrest and complete atrioventricular block as a result of non-bacterial thrombotic endocarditis with severe valvular dehiscence. Following the diagnosis of prosthetic valve failure caused by Behçet's disease, the patient underwent a Bentall operation using 23 mm aortic homograft with permanent pacemaker implantation and coronary artery bypass grafting. Subsequently, he was stable with steroid administration and azathioprine for seven years after the second operation, but recently suffered from severe dyspnea and chest pain. Echocardiography revealed the development of severe aortic stenosis. A preprocedural evaluation demonstrated a porcelain aorta with severe calcification in the previous homograft valve on computed tomography, and critical stenosis at the ostium of the left circumflex artery on coronary angiography. After percutaneous coronary intervention for the ostium of the left circumflex artery, a transcatheter AVR was successfully performed using a 26 mm Edwards SAPIEN XT valve. The patient recovered without any complications after the procedure. This is the first report of a successful transcatheter aortic valve-in valve implantation for severe homograft aortic stenosis after a Bentall operation, using a homograft, in a patient with Behçet's disease.

Left ventricular mass regression after aortic valve replacement with the new Mitroflow 12A pericardial bioprosthesis.

PubMed

García-Bengochea, José; Sierra, Juan; González-Juanatey, José R; Rubio, José; Vega, Marino; Fernández, Angel L; Sánchez, Daniel

2006-05-01

The study aim was to evaluate the durability of the new Mitroflow 12A pericardial bioprosthesis and to assess ventricular mass regression after aortic valve replacement (AVR) in patients with small valves. A total of 326 Mitroflow 12A pericardial bioprostheses was implanted without any other associated valve procedure. The mean patient age was 73.5 +/- 6.1 years; 252 patients (78.0%) were in NYHA class III/IV. Small valves (19 and 21 mm) were implanted in 212 patients (65.6%). The total follow up period was 837.1 patient-years (pt-yr). A subset of 61 patients with preoperative stenosis was selected and submitted to conventional echo-Doppler assessment at a mean period of 11.1 months after surgery. Hospital mortality was 8.6%. At eight years of follow up, survival was 57.1%. Freedom from structural valve deterioration (SVD) was 86.5% per pt-yr. Mean gradients were significantly reduced postoperatively for each valve size (to 18 +/- 8 mmHg for 19-mm valves and 12 +/- 4 mmHg for 25-mm valves). The effective orifice area (EOA) was also increased significantly for all valve sizes (to 1.1 +/- 0.1 cm2 for 19-mm valves and 1.8 +/- 0.2 cm2 for 25-mm valves). The left ventricular mass index (LVMI) decreased significantly, from 177 +/- 29 to 136 +/- 22 g/m2 for the 19-mm valve, and from 200 +/- 42 to 132 +/- 22 g/m2 for the 25-mm valve. The EOA index (EOAI) showed mismatch for the 19- and 21-mm valves (0.74 and 0.82 cm2/m2, respectively). The diagrammatic calculation between LVMI and relative wall thickness after surgery showed that 29.7% of patients achieved a normal pattern of remodeling (including 19- and 21-mm valves), despite various degrees of mismatch. The new Mitroflow 12A pericardial bioprosthesis showed an absence of mechanical failure after an eight-year follow up, with a satisfactory rate of SVD. Significant reductions in LVMI and improved ventricular geometry were observed, despite the small valve sizes implanted.

Short-term and mid-term results with the Sorin Freedom Solo aortic valve.

PubMed

Ustunsoy, Hasim; Yasim, Alptekin; Deniz, Hayati; Gokaslan, Gokhan; Ozcaliskan, Ozerdem

2013-03-01

The study aim was to present the short- and mid-term results for patients who underwent aortic valve replacement (AVR) with the Sorin Freedom Solo third-generation stentless prosthetic valve. AVR with a Sorin Freedom Solo valve was performed in 14 patients between March 2006 and March 2011. Patients aged > or = 60 years (male:female ratio 6:8; mean age 73.28 +/- 5.42 years) who required AVR with the Sorin Freedom Solo valve according to the surgeon's choice were included in the study. The valvular prosthesis was implanted in the supra-annular position, using a single suture line. Eight patients underwent an isolated AVR; combined interventions were carried out in the other patients due to concomitant cardiac disease. One patient died during the immediate perioperative period, and two more during the follow up, from non-cardiac causes. The mean maximum transvalvular gradient of patients with aortic stenosis was 88.1 +/- 20.2 mmHg, and this fell to 26.4 +/- 7.6 mmHg during the early postoperative period. The mean gradient at one year of follow up was further decreased to 19.4 +/- 5.3 mmHg. The left ventricular end-diastolic and end-systolic diameters were also significantly reduced, from 4.8 +/- 0.9 to 4.3 +/- 0.6 cm and from 3.2 +/- 0.6 to 2.8 +/- 5.3 cm, respectively. The average left ventricular ejection fraction was 60.2 +/- 4.9% preoperatively, and 63.2 +/- 2.1% at one year after surgery (p = NS). No paravalvular leakage, endocarditis, prosthesis failure or neurologic events were reported among patients. The Sorin Freedom Solo stentless valve has provided good early and intermediate-term results. Implantation of the prosthesis is straightforward, with low rates of morbidity and mortality. However, these data require further support from larger patient series and long-term follow up.

Cost-effectiveness of homograft heart valve replacement surgery: an introductory study.

PubMed

Yaghoubi, Mohsen; Aghayan, Hamid Reza; Arjmand, Babak; Emami-Razavi, Seyed Hassan

2011-05-01

The clinical effectiveness of heart valve replacement surgery has been well documented. Mechanical and homograft valves are used routinely for replacement of damaged heart valves. Homograft valves are produced in our country but we import the mechanical valves. To our knowledge the cost-effectiveness of homograft valve has not been assessed. The objective of the present study was to compare the cost-effectiveness of homograft valve replacement with mechanical valve replacement surgery. Our samples were selected from 200 patients that underwent homograft and mechanical heart valve replacement surgery in Imam-Khomeini hospital (2000-2005). In each group we enrolled 30 patients. Quality of life was measured using the SF-36 questionnaire and utility was measured in quality-adjusted life years (QALYs). For each group we calculated the price of heart valve and hospitalization charges. Finally the cost-effectiveness of each treatment modalities were summarized as costs per QALYs gained. Forty male and twenty female participated in the study. The mean score of quality of life was 66.06 (SD = 9.22) in homograft group and 57.85 (SD = 11.30) in mechanical group (P < 0.05). The mean QALYs gained in homograft group was 0.67 more than mechanical group. The incremental cost-effectiveness ratio (ICER) revealed a cost savings of 1,067 US$ for each QALY gained in homograft group. Despite limitation of this introductory study, we concluded that homograft valve replacement was more effective and less expensive than mechanical valve. These findings can encourage healthcare managers and policy makers to support the production of homograft valves and allocate more recourse for developing such activities.

Design of pneumatic proportional flow valve type 5/3

NASA Astrophysics Data System (ADS)

Laski, P. A.; Pietrala, D. S.; Zwierzchowski, J.; Czarnogorski, K.

2017-08-01

In this paper the 5/3-way pneumatic, proportional flow valve was designed and made. Stepper linear actuator was used to move the spool. The valve is controlled by the controlled based on a AVR microcontroller. Virtual model of the valve was created in CAD. The real element was made based on a standard 5/3-way manually actuated valve with hand lever, which was dismounted and replaced by linear stepper motor. All the elements was mounted in a specially made housing. The controller consists of microcontroller Atmega16, integrated circuit L293D, display, two potentiometers, three LEDs and six buttons. Series of research was also conducted. Simulation research were performed using CFD by the Flow Simulation addition to SolidWorks. During the experiments the valve characteristics of flow and pressure was determined.

Evaluation of mitral valve replacement anchoring in a phantom

NASA Astrophysics Data System (ADS)

McLeod, A. Jonathan; Moore, John; Lang, Pencilla; Bainbridge, Dan; Campbell, Gordon; Jones, Doug L.; Guiraudon, Gerard M.; Peters, Terry M.

2012-02-01

Conventional mitral valve replacement requires a median sternotomy and cardio-pulmonary bypass with aortic crossclamping and is associated with significant mortality and morbidity which could be reduced by performing the procedure off-pump. Replacing the mitral valve in the closed, off-pump, beating heart requires extensive development and validation of surgical and imaging techniques. Image guidance systems and surgical access for off-pump mitral valve replacement have been previously developed, allowing the prosthetic valve to be safely introduced into the left atrium and inserted into the mitral annulus. The major remaining challenge is to design a method of securely anchoring the prosthetic valve inside the beating heart. The development of anchoring techniques has been hampered by the expense and difficulty in conducting large animal studies. In this paper, we demonstrate how prosthetic valve anchoring may be evaluated in a dynamic phantom. The phantom provides a consistent testing environment where pressure measurements and Doppler ultrasound can be used to monitor and assess the valve anchoring procedures, detecting pararvalvular leak when valve anchoring is inadequate. Minimally invasive anchoring techniques may be directly compared to the current gold standard of valves sutured under direct vision, providing a useful tool for the validation of new surgical instruments.

Early Outcomes of Sutureless Aortic Valves.

PubMed

Hanedan, Muhammet Onur; Mataracı, İlker; Yürük, Mehmet Ali; Özer, Tanıl; Sayar, Ufuk; Arslan, Ali Kemal; Ziyrek, Uğur; Yücel, Murat

2016-06-01

In elderly high-risk surgical patients, sutureless aortic valve replacement (AVR) should be an alternative to standard AVR. The potential advantages of sutureless aortic prostheses include reducing cross-clamping and cardiopulmonary bypass (CPB) time and facilitating minimally invasive surgery and complex cardiac interventions, while maintaining satisfactory hemodynamic outcomes and low rates of paravalvular leakage. The current study reports our single-center experience regarding the early outcomes of sutureless aortic valve implantation. Between October 2012 and June 2015, 65 patients scheduled for surgical valve replacement with symptomatic aortic valve disease and New York Heart Association function of class II or higher were included to this study. Perceval S (Sorin Biomedica Cardio Srl, Sallugia, Italy) and Edwards Intuity (Edwards Lifesciences, Irvine, CA, USA) valves were used. The mean age of the patients was 71.15±8.60 years. Forty-four patients (67.7%) were female. The average preoperative left ventricular ejection fraction was 56.9±9.93. The CPB time was 96.51±41.27 minutes and the cross-clamping time was 60.85±27.08 minutes. The intubation time was 8.95±4.19 hours, and the intensive care unit and hospital stays were 2.89±1.42 days and 7.86±1.42 days, respectively. The mean quantity of drainage from chest tubes was 407.69±149.28 mL. The hospital mortality rate was 3.1%. A total of five patients (7.69%) died during follow-up. The mean follow-up time was 687.24±24.76 days. The one-year survival rate was over 90%. In the last few years, several models of valvular sutureless bioprostheses have been developed. The present study evaluating the single-center early outcomes of sutureless aortic valve implantation presents the results of an innovative surgical technique, finding that it resulted in appropriate hemodynamic conditions with acceptable ischemic time.

Early Outcomes of Sutureless Aortic Valves

PubMed Central

Hanedan, Muhammet Onur; Mataracı, İlker; Yürük, Mehmet Ali; Özer, Tanıl; Sayar, Ufuk; Arslan, Ali Kemal; Ziyrek, Uğur; Yücel, Murat

2016-01-01

Background In elderly high-risk surgical patients, sutureless aortic valve replacement (AVR) should be an alternative to standard AVR. The potential advantages of sutureless aortic prostheses include reducing cross-clamping and cardiopulmonary bypass (CPB) time and facilitating minimally invasive surgery and complex cardiac interventions, while maintaining satisfactory hemodynamic outcomes and low rates of paravalvular leakage. The current study reports our single-center experience regarding the early outcomes of sutureless aortic valve implantation. Methods Between October 2012 and June 2015, 65 patients scheduled for surgical valve replacement with symptomatic aortic valve disease and New York Heart Association function of class II or higher were included to this study. Perceval S (Sorin Biomedica Cardio Srl, Sallugia, Italy) and Edwards Intuity (Edwards Lifesciences, Irvine, CA, USA) valves were used. Results The mean age of the patients was 71.15±8.60 years. Forty-four patients (67.7%) were female. The average preoperative left ventricular ejection fraction was 56.9±9.93. The CPB time was 96.51±41.27 minutes and the cross-clamping time was 60.85±27.08 minutes. The intubation time was 8.95±4.19 hours, and the intensive care unit and hospital stays were 2.89±1.42 days and 7.86±1.42 days, respectively. The mean quantity of drainage from chest tubes was 407.69±149.28 mL. The hospital mortality rate was 3.1%. A total of five patients (7.69%) died during follow-up. The mean follow-up time was 687.24±24.76 days. The one-year survival rate was over 90%. Conclusion In the last few years, several models of valvular sutureless bioprostheses have been developed. The present study evaluating the single-center early outcomes of sutureless aortic valve implantation presents the results of an innovative surgical technique, finding that it resulted in appropriate hemodynamic conditions with acceptable ischemic time. PMID:27298793

[Transcatheter aortic valve replacement].

PubMed

Sawa, Yoshiki

2014-07-01

While transcatheter aortic valve replacement( TAVR) has spread rapidly all over the world for highrisk patients with severe aortic stenosis (AS), SAPIEN XT was approved in Japan in October 2013. Since that, approximately 400 TAVR cases were performed in Japan. In our institute, we have performed 164 cases since first case in Japan in 2009 and have achieved satisfactory early results(30-day mortality:1.2%). At the same time, however, simultaneously various TAVR-related complications including a paravalvular leak, stroke, vascular complications, and coronary obstruction were observed. A reduction in the incidence and severity of these complications had led technical improvements in various new devices(2nd generation TAVR device such as the SAPIEN 3, ACURATE, and JenaValve) and in implantation techniques including repositioning/recapturing features, paravalvular sealing technologies, and prevention of coronary obstruction. Furthermore, there is also increasing experience with special indications for TAVR such as pure aortic valve insufficiency or valve-in-valve techniques. Currently, an increasing number of publications of midterm results demonstrate good prosthetic valve function and durability, with good quality of life and low morbidity after TAVR. There are also some randomized trials such as PARTNER 2 or SURTAVI to investigate potential benefits of TAVR for intermediate-risk patients. These improvements in the TAVR devices promises the expansion of TAVR towards the treatment of lower-risk patients in the near future.

Reoperation for non-structural valvular dysfunction caused by pannus ingrowth in aortic valve prosthesis.

PubMed

Oh, Se Jin; Park, Samina; Kim, Jun Sung; Kim, Kyung-Hwan; Kim, Ki Bong; Ahn, Hyuk

2013-07-01

The authors' clinical experience is presented of non-structural valvular dysfunction of the prosthetic aortic valve caused by pannus ingrowth during the late postoperative period after previous heart valve surgery. Between January 1999 and April 2012, at the authors' institution, a total of 33 patients underwent reoperation for increased mean pressure gradient of the prosthetic aortic valve. All patients were shown to have pannus ingrowth. The mean interval from the previous operation was 16.7 +/- 4.3 years, and the most common etiology for the previous aortic valve replacement (AVR) was rheumatic valve disease. The mean effective orifice area index (EOAI) of the previous prosthetic valve was 0.97 +/- 0.11 cm2/m2, and the mean pressure gradient on the aortic prosthesis before reoperation was 39.1 +/- 10.7 mmHg. Two patients (6.1%) died in-hospital, and late death occurred in six patients (18.2%). At the first operation, 30 patients underwent mitral or tricuspid valve surgery as a concomitant procedure. Among these operations, mitral valve replacement (MVR) was combined in 24 of all 26 patients with rheumatic valve disease. Four patients underwent pannus removal only while the prosthetic aortic valve was left in place. The mean EOAI after reoperation was significantly increased to 1.16 +/- 0.16 cm2/m2 (p < 0.001), and the mean pressure gradient was decreased to 11.9 +/- 1.9 mmHg (p < 0.001). Non-structural valvular dysfunction caused by pannus ingrowth was shown in patients with a small EOAI of the prosthetic aortic valve and combined MVR for rheumatic disease. As reoperation for pannus overgrowth showed good clinical outcomes, an aggressive resection of pannus and repeated AVR should be considered in symptomatic patients to avoid the complications of other cardiac diseases.

A technique of snaring method for fitting a prosthetic valve into the annulus.

PubMed

Nagasaka, Shigeo; Kawata, Tetsuji; Matsuta, Masahiro; Taniguchi, Shigeki

2005-01-01

Tourniquetting technique to fit a prosthetic valve (PV) into the annulus in valve replacement surgery has been previously reported. We modified the previously reported method and designed a simpler tying technique. We performed 11 aortic (AVR: including four cases for calcified aortic stenosis (AS) with a small annulus and one cases for infective endocarditis with intramuscular abscess cavity), eight mitral valve replacements (MVR), and one tricuspid valve replacement (TVR: for corrected transposition of the great arteries). A PV was implanted using 2-0 polyester mattress sutures with a pledget. Each of the two tourniquets held a suture at the bottom of the annulus and at the opposite position to fit a PV. The sutures between each snare were tied down from the bottom to the top. In MVR, after seating of a PV with two tourniquets, we could make sure that no native tissue of any preserved mitral apparatus disturbed PV leaflet motion. In calcific AS, a PV had a good fitting into the annulus because of tourniquets applied to unseated part during tying sutures. In AVR for infective endocarditis, mattress sutures supported by a Teflon pledget were placed to close the abscess cavity. After snaring on one of these sutures, we tied down the sutures, ensuring that they did not cut through the friable tissues. In TVR, we found that native leaflets interfered with PV motion after seating down the prosthesis and those leaflets were resected before tying down the sutures. Postoperative transesophageal echocardiography showed no paravalvular leakage in any patients and excellent PV functions.

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.

Prosthetic valve endocarditis 7 months after transcatheter aortic valve implantation diagnosed with 3D TEE.

PubMed

Sarı, Cenk; Durmaz, Tahir; Karaduman, Bilge Duran; Keleş, Telat; Bayram, Hüseyin; Baştuğ, Serdal; Özen, Mehmet Burak; Bayram, Nihal Akar; Bilen, Emine; Ayhan, Hüseyin; Kasapkara, Hacı Ahmet; Bozkurt, Engin

2016-01-01

Transcatheter aortic valve implantation (TAVI) was introduced as an alternative treatment for patients with severe symptomatic aortic stenosis for whom surgery would be high-risk. Prosthetic aortic valve endocarditis is a serious complication of surgical AVR (SAVR) with high morbidity and mortality. According to recent cases, post-TAVI prosthetic valve endocarditis (PVE) seems to occur very rarely. We present the case of a 75-year-old woman who underwent TAVI (Edwards Saphien XT) with an uneventful postoperative stay. She was diagnosed with endocarditis using three dimensional (3D) echocardiography on the TAVI device 7 months later and she subsequently underwent surgical aortic valve replacement. Little experience of the interpretation of transoesophageal echocardiography (TEE) and the clinical course and effectiveness of treatment strategies in post-TAVI endocarditis exists. We report a case of PVE in a TAVI patient which was diagnosed with three-dimensional transoesophageal echocardiography (3DTEE). Copyright © 2016 Hellenic Cardiological Society. Published by Elsevier B.V. All rights reserved.

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

Telemedicine-guided, very low-dose international normalized ratio self-control in patients with mechanical heart valve implants.

PubMed

Koertke, Heinrich; Zittermann, Armin; Wagner, Otto; Secer, Songuel; Sciangula, Alfonso; Saggau, Werner; Sack, Falk-Udo; Ennker, Jürgen; Cremer, Jochen; Musumeci, Francesco; Gummert, Jan F

2015-06-01

To study in patients performing international normalized ratio (INR) self-control the efficacy and safety of an INR target range of 1.6-2.1 for aortic valve replacement (AVR) and 2.0-2.5 for mitral valve replacement (MVR) or double valve replacement (DVR). In total, 1304 patients undergoing AVR, 189 undergoing MVR and 78 undergoing DVR were randomly assigned to low-dose INR self-control (LOW group) (INR target range, AVR: 1.8-2.8; MVR/DVR: 2.5-3.5) or very low-dose INR self-control once a week (VLO group) and twice a week (VLT group) (INR target range, AVR: 1.6-2.1; MVR/DVR: 2.0-2.5), with electronically guided transfer of INR values. We compared grade III complications (major bleeding and thrombotic events; primary end-points) and overall mortality (secondary end-point) across the three treatment groups. Two-year freedom from bleedings in the LOW, VLO, and VLT groups was 96.3, 98.6, and 99.1%, respectively (P = 0.008). The corresponding values for thrombotic events were 99.0, 99.8, and 98.9%, respectively (P = 0.258). The risk-adjusted composite of grade III complications was in the per-protocol population (reference: LOW-dose group) as follows: hazard ratio = 0.307 (95% CI: 0.102-0.926; P = 0.036) for the VLO group and = 0.241 (95% CI: 0.070-0.836; P = 0.025) for the VLT group. The corresponding values of 2-year mortality were = 1.685 (95% CI: 0.473-5.996; P = 0.421) for the VLO group and = 4.70 (95% CI: 1.62-13.60; P = 0.004) for the VLT group. Telemedicine-guided very low-dose INR self-control is comparable with low-dose INR in thrombotic risk, and is superior in bleeding risk. Weekly testing is sufficient. Given the small number of MVR and DVR patients, results are only valid for AVR patients. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Do we have to operate on moderate functional mitral regurgitation during aortic valve replacement for aortic stenosis?

PubMed

Kowalówka, Adam R; Onyszczuk, Magdalena; Wańha, Wojciech; Deja, Marek A

2016-11-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Do we have to operate on moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) for aortic stenosis (AS)?' Altogether 325 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The current evidence obtained from these papers revealed that the significant predictors of improvement outcome include lower preoperative mitral regurgitation and lower preoperative left ventricle fractional area change. We also know that persistent atrial fibrillation, enlarged left atrium, increased indexed left ventricular mass, pulmonary hypertension and preoperative peak aortic valve gradient <60 mmHg are predictors of deterioration. Generally, we observed a trend towards improvement or non-progression of FMR following AVR for AS. In the six papers that suggest conservative treatment of FMR, the degree of mitral regurgitation (MR) improved in 45-95%, remained unchanged in 19-38% and deteriorated in 1-14%. In the three papers favoring surgical treatment of MR, the degree of MR improved in 46-69%, stay unchanged in 34-53% and deteriorated in 10%. The current evidence suggests that moderate or less grade of FMR without predictors of deterioration should be treated conservatively and moderate-severe and severe FMR warrants additional surgical procedure. A clearly randomized study, especially in patients with moderate and moderate-severe FMR for AS, seems appropriate to further elucidate surgical strategy. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Use of multidetector-row computed tomography scan to detect pannus formation in prosthetic mechanical aortic valves.

PubMed

Aladmawi, Mohamed A; Pragliola, Claudio; Vriz, Olga; Galzerano, Domenico

2017-04-01

Obstruction of a mechanical aortic valve by pannus formation at the subvalvular level is a major long-term complication of aortic valve replacement (AVR). In fact, pannus is sometime difficult to differentiate from patient-prosthesis mismatch or valve thrombosis. In most cases cine-angiography and echocardiography, either transthoracic or transesophageal, cannot correctly visualize the complication when the leaflets show a normal mobility. Recent technological refinements made this difficult diagnosis possible by ECG-gated computed tomography (CT) scan which shows adequate images in 90% of the cases and can differentiate pannus from fresh and organized thrombus.

Visualization of novel virulence activities of the Xanthomonas type III effectors AvrBs1, AvrBs3 and AvrBs4.

PubMed

Gürlebeck, Doreen; Jahn, Simone; Gürlebeck, Norman; Szczesny, Robert; Szurek, Boris; Hahn, Simone; Hause, Gerd; Bonas, Ulla

2009-03-01

Xanthomonas campestris pv. vesicatoria secretes at least 20 effector proteins through the type III secretion system directly into plant cells. In this study, we uncovered virulence activities of the effector proteins AvrBs1, AvrBs3 and AvrBs4 using Agrobacterium-mediated transient expression of the corresponding genes in Nicotiana benthamiana, followed by microscopic analyses. We showed that, in addition to the nuclear-localized AvrBs3, the effector AvrBs1, which localizes to the plant cell cytoplasm, also induces a morphological change in mesophyll cells. Comparative analyses revealed that avrBs3-expressing plant cells contain highly active nuclei. Furthermore, plant cells expressing avrBs3 or avrBs1 show a decrease in the starch content in chloroplasts and an increased number of vesicles, indicating an enlargement of the central vacuole and the cell wall. Both AvrBs1 and AvrBs3 cause an increased ion efflux when expressed in N. benthamiana. By contrast, expression of the avrBs3 homologue avrBs4 leads to large catalase crystals in peroxisomes, suggesting a possible virulence function of AvrBs4 in the suppression of the plant defence responses. Taken together, our data show that microscopic inspection can uncover subtle and novel virulence activities of type III effector proteins.

Bioprosthetic Valve Fracture Improves the Hemodynamic Results of Valve-in-Valve Transcatheter Aortic Valve Replacement.

PubMed

Chhatriwalla, Adnan K; Allen, Keith B; Saxon, John T; Cohen, David J; Aggarwal, Sanjeev; Hart, Anthony J; Baron, Suzanne J; Dvir, Danny; Borkon, A Michael

2017-07-01

Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) may be less effective in small surgical valves because of patient/prosthesis mismatch. Bioprosthetic valve fracture (BVF) using a high-pressure balloon can be performed to facilitate VIV TAVR. We report data from 20 consecutive clinical cases in which BVF was successfully performed before or after VIV TAVR by inflation of a high-pressure balloon positioned across the valve ring during rapid ventricular pacing. Hemodynamic measurements and calculation of the valve effective orifice area were performed at baseline, immediately after VIV TAVR, and after BVF. BVF was successfully performed in 20 patients undergoing VIV TAVR with balloon-expandable (n=8) or self-expanding (n=12) transcatheter valves in Mitroflow, Carpentier-Edwards Perimount, Magna and Magna Ease, Biocor Epic and Biocor Epic Supra, and Mosaic surgical valves. Successful fracture was noted fluoroscopically when the waist of the balloon released and by a sudden drop in inflation pressure, often accompanied by an audible snap. BVF resulted in a reduction in the mean transvalvular gradient (from 20.5±7.4 to 6.7±3.7 mm Hg, P <0.001) and an increase in valve effective orifice area (from 1.0±0.4 to 1.8±0.6 cm 2 , P <0.001). No procedural complications were reported. BVF can be performed safely in small surgical valves to facilitate VIV TAVR with either balloon-expandable or self-expanding transcatheter valves and results in reduced residual transvalvular gradients and increased valve effective orifice area. © 2017 American Heart Association, Inc.

Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option?

PubMed

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

2004-11-01

Aortic dilatation occurs in many patients with bicuspid aortic valves. We have added root replacement using the remodeling technique originally designed for tricuspid aortic valves to bicuspid aortic valve repair for treatment of the dilated root. We compared the results of remodeling in bicuspid aortic valves with those in tricuspid aortic valves. From October 1995 through January 2004, 60 patients underwent root remodeling for bicuspid aortic valves (group A), and 130 patients underwent root remodeling for tricuspid aortic valves (group B). Correction of cusp prolapse was more often performed in group A (group A, 50/60; group B, 47/130; P < .0001). Transthoracic echocardiography was performed at 1 week, 6 and 12 months, and every year thereafter. Cumulative follow-up was 527 patient-years (mean, 2.9 +/- 2 years). No patient died in group A. Hospital mortality in group B was 5% (5/100; 95% confidence interval,1.6%-11.3%) after elective operations and 10% (3/30; 95% confidence interval, 2.1%-26.5%) after emergency operations. Mean systolic gradients were identical at 1 year (group A, 4.8 +/- 2.1 mm Hg; group B, 4.0 +/- 2 mm Hg) and 5 years (group A, 4.5 +/- 2.3 mm Hg; group B, 3.9 +/- 2.2 mm Hg). Freedom from aortic regurgitation of grade 2 or higher at 5 years was 96% in group A and 83% in group B ( P = .07), and freedom from reoperation at 5 years was 98% in group A and 98% in group B ( P = .73). Valve-sparing aortic replacement with root remodeling can be applied to aortic dilatation and a regurgitant bicuspid aortic valve. Hemodynamic function and valve stability of a repaired bicuspid aortic valve are comparable with those seen in cases of tricuspid anatomy.

A contemporary cost analysis of postoperative morbidity after coronary artery bypass grafting with and without concomitant aortic valve replacement to improve patient quality and cost-effective care.

PubMed

LaPar, Damien J; Crosby, Ivan K; Rich, Jeffrey B; Fonner, Edwin; Kron, Irving L; Ailawadi, Gorav; Speir, Alan M

2013-11-01

The financial burden of postoperative morbidity after cardiac operations remains ill defined. This study evaluated the costs associated with the performance of coronary artery bypass grafting (CABG) with and without aortic valve replacement (AVR) and determined the incremental costs associated with major postoperative complications. A total of 65,534 regional patients undergoing CABG (n = 55,167) ± AVR (n = 10,367) were evaluated from 2001 to 2011. Patient-related, hospital-related, and procedure-related cost data were analyzed by use of Medicare-based cost reports. Hierarchical multivariable regression modeling was used to estimate risk-adjusted incremental cost differences in postoperative complications. The mean age was 64 years, and women accounted for 31% of patients. CABG + AVR patients had higher rates of overall complication (40% vs 35%, p < 0.001) and operative mortality (5% vs 3%, p < 0.001) than did CABG patients. CABG + AVR patients also accrued increased median postoperative lengths of stay (7 vs 5 days, p < 0.001) and total costs ($26,527 vs $24,475, p < 0.001). After mortality risk adjustment, significant positive relationships existed between total costs and major postoperative complications. Interestingly, the highest incremental costs among CABG patients included newly instituted hemodialysis ($71,833), deep sternal wound infection ($56,003), and pneumonia ($50,025). Among CABG + AVR patients, these complications along with perioperative myocardial infarction ($68,917) dominated costs. Postoperative complications after CABG ± AVR are associated with significantly increased incremental costs. The most costly complications include newly instituted hemodialysis, infectious complications, and perioperative myocardial infarction. Identification of the most common and the most costly complications provides opportunities to target improvement in patient quality and the delivery of cost-effective care. Copyright © 2013 The Society of Thoracic Surgeons

Aorta-atria-septum combined incision for aortic valve re-replacement

PubMed Central

Xu, Yiwei; Ye, Xiaofeng; Li, Zhaolong

2018-01-01

This case report illustrates a patient who underwent supra-annular mechanical aortic valve replacement then suffered from prosthesis dysfunction, increasing pressure gradient with aortic valve. She was successfully underwent aortic valve re-replacement, sub-annular pannus removing and aortic annulus enlargement procedures through combined cardiac incision passing through aortic root, right atrium (RA), and upper atrial septum. This incision provides optimal visual operative field and simplifies dissection. PMID:29850170

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.

Factors influencing mortality after bioprosthetic valve replacement; a midterm outcome.

PubMed

Javadzadegan, Hassan; Javadzadegan, Amir; Mehdizadeh Baghbani, Jafar

2013-01-01

Although valve repair is applied routinely nowadays, particularly for mitral regurgitation (MR) or tricuspid regurgitation (TR), valve replacement using prosthetic valves is also common especially in adults. Unfortunately the valve with ideal hemodynamic performance and long-term durability without increasing the risk of bleeding due to long-term anticoagulant therapy has not been introduced. Therefore, patients and physicians must choose either bioprosthetic or mechanical valves. Currently, there is an increasing clinical trend of using bioprosthetic valves instead of mechanical valves even in young patients apparently because of their advantages. Seventy patients undergone valvular replacement using bioprosthetic valves were evaluated by ECG and Echocardiography to assess the rhythm and ejection fracture. Mean follow-up time was 33 months (min 9, max 92). Mortality rate was 25.9% (n=18) within 8 years of follow-up. Statistical analysis showed a significant relation between atrial fibrillation rhythm and mortality (P=0.02). Morbidities occurred in 30 patients (42.8%). Significant statistical relation was found between the morbidities and age over 65 years old (P=0.005). In follow-up period, 4 cases (5.7%) underwent re-operation due to global valve dysfunction. Our study shows that using biprosthetic valve could reduce the risk of morbidity occurrence in patient who needs valve replacement. However, if medical treatments fail, patients should be referred for surgery. This would reduce the risk of mortality because of lower incident of complications such as atrial fibrillation and morbidities due to younger patients' population.

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.).

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.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes.

PubMed

Gupta, Tanush; Khera, Sahil; Kolte, Dhaval; Goel, Kashish; Kalra, Ankur; Villablanca, Pedro A; Aronow, Herbert D; Abbott, J Dawn; Fonarow, Gregg C; Taub, Cynthia C; Kleiman, Neal S; Weisz, Giora; Inglessis, Ignacio; Elmariah, Sammy; Rihal, Charanjit S; Garcia, Mario J; Bhatt, Deepak L

2018-04-01

A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 ( P trend <0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P =0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P <0.001), stroke (1.4% versus 2.7%; P <0.001), bleeding complications (10.6% versus 24.6%; P <0.001), and acute kidney injury (16.2% versus 19.3%; P <0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR. TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients. © 2018 American Heart Association, 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

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

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

Factors Influencing Mortality after Bioprosthetic Valve Replacement; A Midterm Outcome

PubMed Central

Javadzadegan, Hassan; Javadzadegan, Amir; Mehdizadeh Baghbani, Jafar

2013-01-01

Introduction: Although valve repair is applied routinely nowadays, particularly for mitral regurgitation (MR) or tricuspid regurgitation (TR), valve replacement using prosthetic valves is also common especially in adults. Unfortunately the valve with ideal hemodynamic performance and long-term durability without increasing the risk of bleeding due to long-term anticoagulant therapy has not been introduced. Therefore, patients and physicians must choose either bioprosthetic or mechanical valves. Currently, there is an increasing clinical trend of using bioprosthetic valves instead of mechanical valves even in young patients apparently because of their advantages. Methods: Seventy patients undergone valvular replacement using bioprosthetic valves were evaluated by ECG and Echocardiography to assess the rhythm and ejection fracture. Mean follow-up time was 33 months (min 9, max 92). Results: Mortality rate was 25.9% (n=18) within 8 years of follow-up. Statistical analysis showed a significant relation between atrial fibrillation rhythm and mortality (P=0.02). Morbidities occurred in 30 patients (42.8%). Significant statistical relation was found between the morbidities and age over 65 years old (P=0.005). In follow-up period, 4 cases (5.7%) underwent re-operation due to global valve dysfunction. Conclusion: Our study shows that using biprosthetic valve could reduce the risk of morbidity occurrence in patient who needs valve replacement. However, if medical treatments fail, patients should be referred for surgery. This would reduce the risk of mortality because of lower incident of complications such as atrial fibrillation and morbidities due to younger patients' population. PMID:24404348

Early beneficial effect of preservation of papillo-annular continuity in mitral valve replacement on left ventricular function.

PubMed

Dilip, D; Chandra, A; Rajashekhar, D; Padmanabhan, M

2001-05-01

Impairment of left ventricular (LV) function after mitral valve replacement (MVR) has been the most important factor to determine morbidity and mortality. With this in mind, LV performance in the postoperative period was assessed with and without preservation of papillo-annular continuity in MVR. Between March 1994 and August 1998, a total of 383 valve prostheses (202 MVR, 65 AVR, 58 MVR+AVR) were implanted in 325 patients, 177 of whom underwent MVR with Starr Edwards ball cage prostheses (the study group). Of these 177 patients, 105 had MVR with preservation of the posterior mitral leaflet (group I), and 72 had conventional MVR (group II). Predominant lesions were mitral stenosis in 81, mitral regurgitation in 42, and mixed mitral lesion (MS/MR) in 54. Concomitant tricuspid valve annuloplasty was performed in 13, and atrial septal defect repair in five. Sixteen patients underwent MVR for mitral restenosis. In-vivo performance of the prostheses and LV function was evaluated by M-mode and Doppler echocardiography. At 3-6 months clinical improvement was seen in NYHA class, with reduction in cardiothoracic ratio among patients with preserved papillo-annular continuity, irrespective of lesion type. Significant reductions (p <0.05) were seen in left atrial dimensions (54.10 +/- 8.79 preop. versus 44.64 +/- 8.54 postop.; p <0.05), left ventricular end-diastolic dimensions (LVEDD) (50.84 +/- 10.42 preop. versus 41.21 +/- 7.16 postop.; p <0.05) and end-systolic dimensions (LVESD) (34.76 +/- 7.94 preop. versus 28.81 +/- 5.79 postop.; p <0.05) in patients who had their posterior mitral leaflet preserved with significant improvement in ejection fraction (60.31 +/- 8.22 versus 64.47 +/- 7.93; p <0.05). Further analysis of data in group I patients showed significant reductions in left atrial dimensions, LVESD and peak gradient, along with improved ejection fraction compared with conventional (group II) patients. Deterioration in LV function in patients undergoing conventional

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

Use of multidetector-row computed tomography scan to detect pannus formation in prosthetic mechanical aortic valves

PubMed Central

Aladmawi, Mohamed A.; Vriz, Olga; Galzerano, Domenico

2017-01-01

Obstruction of a mechanical aortic valve by pannus formation at the subvalvular level is a major long-term complication of aortic valve replacement (AVR). In fact, pannus is sometime difficult to differentiate from patient-prosthesis mismatch or valve thrombosis. In most cases cine-angiography and echocardiography, either transthoracic or transesophageal, cannot correctly visualize the complication when the leaflets show a normal mobility. Recent technological refinements made this difficult diagnosis possible by ECG-gated computed tomography (CT) scan which shows adequate images in 90% of the cases and can differentiate pannus from fresh and organized thrombus. PMID:28540078

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.

Early and 1-year outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study.

PubMed

Coselli, Joseph S; Volguina, Irina V; LeMaire, Scott A; Sundt, Thoralf M; Connolly, Heidi M; Stephens, Elizabeth H; Schaff, Hartzell V; Milewicz, Dianna M; Vricella, Luca A; Dietz, Harry C; Minard, Charles G; Miller, D Craig

2014-06-01

To compare the 1-year results after aortic valve-sparing (AVS) or valve-replacing (AVR) aortic root replacement from a prospective, international registry of 316 patients with Marfan syndrome (MFS). Patients underwent AVS (n = 239, 76%) or AVR (n = 77, 24%) aortic root replacement at 19 participating centers from 2005 to 2010. One-year follow-up data were complete for 312 patients (99%), with imaging findings available for 293 (94%). The time-to-events were compared between groups using Kaplan-Meier curves and Cox proportional hazards models. Two patients (0.6%)--1 in each group--died within 30 days. No significant differences were found in early major adverse valve-related events (MAVRE; P = .6). Two AVS patients required early reoperation for coronary artery complications. The 1-year survival rates were similar in the AVR (97%) and AVS (98%) groups; the procedure type was not significantly associated with any valve-related events. At 1 year and beyond, aortic regurgitation of at least moderate severity (≥2+) was present in 16 patients in the AVS group (7%) but in no patients in the AVR group (P = .02). One AVS patient required late AVR. AVS aortic root replacement was not associated with greater 30-day mortality or morbidity rates than AVR root replacement. At 1 year, no differences were found in survival, valve-related morbidity, or MAVRE between the AVS and AVR groups. Of concern, 7% of AVS patients developed grade ≥2+ aortic regurgitation, emphasizing the importance of 5 to 10 years of follow-up to learn the long-term durability of AVS versus AVR root replacement in patients with MFS. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases.

PubMed

Javadikasgari, Hoda; Gillinov, A Marc; Idrees, Jay J; Mihaljevic, Tomislav; Suri, Rakesh M; Raza, Sajjad; Houghtaling, Penny L; Svensson, Lars G; Navia, José L; Mick, Stephanie L; Desai, Milind Y; Sabik, Joseph F; Blackstone, Eugene H

2017-06-01

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial. From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis. Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more postoperative renal failure (7.0% vs 3.2%, p = .01), reexplorations for bleeding (6.0% vs 3.1%, p = .05), and respiratory failure (14% vs 4.7%, p < .0001). Of matched patients undergoing repair, 18% had MR above 3+ by 5 years. Mitral valve durability was similar between matched groups, but survival at 15 years was 18% after replacement versus 52% after repair. Nomograms from the multivariable equation revealed that in 94% of cases, 10-year survival was calculated to be higher after repair than after replacement. In patients with coexisting degenerative mitral valve and coronary artery diseases, mitral valve repair is expected to confer a long-term survival advantage over replacement despite some recurrence of MR. When feasible, it is the procedure of choice for these patients. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Intraoperative echocardiographic detection of regurgitant jets after valve replacement

NASA Technical Reports Server (NTRS)

Morehead, A. J.; Firstenberg, M. S.; Shiota, T.; Qin, J.; Armstrong, G.; Cosgrove, D. M. 3rd; Thomas, J. D.

2000-01-01

BACKGROUND: Paravalvular jets, documented by intraoperative transesophageal echocardiography, have prompted immediate valve explantation by others, yet the significance of these jets is unknown. METHODS: Twenty-seven patients had intraoperative transesophageal two-dimensional color Doppler echocardiography, performed to assess the number and area of regurgitant jets after valve replacement, before and after protamine. Patients were grouped by first time versus redo operation, valve position and type. RESULTS: Before protamine, 55 jets were identified (2.04+/-1.4 per patient) versus 29 jets after (1.07+/-1.2 per patient, p = 0.0002). Total jet area improved from 2.0+/-2.2 cm2 to 0.86+/-1.7 cm2 with protamine (p<0.0001). In all patients jet area decreased (average decrease, 70.7%+/-27.0%). First time and redo operations had similar improvements in jet number and area (both p>0.6). Furthermore, mitral and mechanical valves each had more jets and overall greater jet area when compared to aortic and tissue valves, respectively. CONCLUSIONS: Following valve replacement, multiple jets are detected by intraoperative transesophageal echocardiography. They are more common and larger in the mitral position and with mechanical valves. Improvement occurs with reversal of anticoagulation.

Acquired discrete subaortic stenosis late after mitral valve replacement.

PubMed

Mohan, Jagdish C; Shukla, Madhu; Mohan, Vishwas; Sethi, Arvind

2016-09-01

Although acquired left ventricular outflow obstruction has been reported in a variety of conditions, there are scant reports of its occurrence following mitral valve replacement (MVR). This study describes two female patients, who developed severe discrete subaortic stenosis, five years following MVR. In both cases, the mitral valve was replaced by a porcine Carpentier-Edwards 27-mm bioprosthesis with preservation of mitral valve leaflets. The risk of very late left ventricular outflow tract obstruction after bio-prosthetic MVR with preservation of subvalvular apparatus needs to be kept in mind in symptomatic patients. Copyright © 2016 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Pannus Formation Leads to Valve Malfunction in the Tricuspid Position 19 Years after Triple Valve Replacement.

PubMed

Alskaf, Ebraham; McConkey, Hannah; Laskar, Nabila; Kardos, Attila

2016-06-20

The Medtronic ATS Open Pivot mechanical valve has been successfully used in heart valve surgery for more than two decades. We present the case of a patient who, 19 years following a tricuspid valve replacement with an ATS prosthesis as part of a triple valve operation following infective endocarditis, developed severe tricuspid regurgitation due to pannus formation.

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

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

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.

Optimal Elastomeric Scaffold Leaflet Shape for Pulmonary Heart Valve Leaflet Replacement

PubMed Central

Fan, Rong; Bayoumi, Ahmed S.; Chen, Peter; Hobson, Christopher M.; Wagner, William R.; Mayer, John E.; Sacks, Michael S.

2012-01-01

Surgical replacement of the pulmonary valve (PV) is a common treatment option for congenital pulmonary valve defects. Engineered tissue approaches to develop novel PV replacements are intrinsically complex, and will require methodical approaches for their development. Single leaflet replacement utilizing an ovine model is an attractive approach in that candidate materials can be evaluated under valve level stresses in blood contact without the confounding effects of a particular valve design. In the present study an approach for optimal leaflet shape design based on finite element (FE) simulation of a mechanically anisotropic, elastomeric scaffold for PV replacement is presented. The scaffold was modeled as an orthotropic hyperelastic material using a generalized Fung-type constitutive model. The optimal shape of the fully loaded PV replacement leaflet was systematically determined by minimizing the difference between the deformed shape obtained from FE simulation and an ex-vivo microCT scan of a native ovine PV leaflet. Effects of material anisotropy, dimensional changes of PV root, and fiber orientation on the resulting leaflet deformation were investigated. In-situ validation demonstrated that the approach could guide the design of the leaflet shape for PV replacement surgery. PMID:23294966

MANAGEMENT OF FAILED MITRAL VALVE REPLACEMENT. THE DURBAN EXPERIENCE.

PubMed

Kistan, D; Booysen, M; Alexander, G; Madiba, T E

2017-06-01

Mitral valve replacement is the procedure of choice in patients with severe mitral valve disease. However, these patients are surviving longer and are thus at an increased risk of prosthesis failure or valve-related complications. Study setting: Inkosi Albert Luthuli Central Hospital, a tertiary referral Hospital in Durban. Study population: All patients undergoing redo mechanical mitral valve replacement surgery between January 2005 and December 2014. Study design: Retrospective analysis of patients undergoing redo mitral valve replacement. Patients were identified from theatre record books, their files were electronically accessed and pertinent information extracted onto a data capture sheet. Information documented included demographics, duration to failure, INR, Albumin, HIV status, clinical findings and outcome. The data was stored on an Excel datasheet. Fifty-eight patients were documented (mean age 32 ± 15.81 years; M:F 1:3). Ten patients (17%) were HIV positive (median CD4 count 478). Mean duration between first surgery and redo was 8.8 years. Thirty-five patients (60%) had no co-morbidities. Presenting features at redo surgery were congestive cardiac failure (27), chest pain (11) and palpitations (17). Mean preoperative Ejection Fraction was 51.65 %. Twenty-nine patients (55%) had emergency redo surgery. Twenty-two patients (75%) had acute prosthetic valve thrombosis. Thirty-two patients had tricuspid regurgitation. Original pathology was documented in 23 patients (40%) as Rheumatic valve disease. Prosthetic valve thrombosis was documented in 31 patients (54%). The most commonly used valve was the On-X. Mean presenting INR was 1.96 + 1.2 and mean presenting serum albumin was 36.7 + 7.8 g/l. Forty-one patients (71%) were found to be compliant to Warfarin therapy prior to redo surgery. Mean ICU stay was 6 +9 days. Two patients died postoperatively. Mean followup was 32 + 26.6 months. Twelve patients (20.7%) developed postoperative complications. Patients

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.

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

[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.

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.

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.

Lipid binding activities of flax rust AvrM and AvrL567 effectors.

PubMed

Gan, Pamela H P; Rafiqi, Maryam; Ellis, Jeffrey G; Jones, David A; Hardham, Adrienne R; Dodds, Peter N

2010-10-01

Effectors are pathogen-encoded proteins that are thought to facilitate infection by manipulation of host cells. Evidence showing that the effectors of some eukaryotic plant pathogens are able to interact directly with cytoplasmic host proteins indicates that translocation of these proteins into host cells is an important part of infection. Recently, we showed that the flax rust effectors AvrM and AvrL567 are able to internalize into plant cells in the absence of the pathogen. Further, N-terminal sequences that were sufficient for uptake were identified for both these proteins. In light of the possibility that the internalization of fungal and oomycete effectors may require binding to specific phospholipids, the lipid binding activities of AvrM and AvrL567 mutants with different abilities to enter cells were tested. While AvrL567 was not found to bind to phospholipids, AvrM bound strongly to phosphatidyl inositol, phosphatidyl inositol monophosphates and phosphatidyl serine. However, a fragment of AvrM sufficient to direct uptake of a fusion protein into plant cells did not bind to these phospholipids. Thus, our results do not support the role of specific binding of AvrM and AvrL567 to phospholipids for uptake into the plant cytoplasm. © 2010 Landes Bioscience

Tricuspid valve replacement with mechanical prostheses: Short and long-term outcomes.

PubMed

Rossello, Xavier; Muñoz-Guijosa, Christian; Mena, Elisabet; Camprecios, Marta; Mendez, Ana B; Borras, Xavier; Padro, Josep M

2017-09-01

Tricuspid valve replacement has been associated with high mortality and poor long-term outcomes. We report the preoperative risk factors associated with short and long-term outcomes following tricuspid valve replacement with mechanical prostheses. In 62 patients who underwent mechanical tricuspid valve replacement, clinical, laboratory, and echocardiographic findings were analyzed using both univariate and multivariate analyses to describe operative and long-term mortality. In our population (mean age 59 ± 9.7 years, 82.3% female), most common causes of tricuspid valve disease were rheumatic fever (69.4%) and functional regurgitation (19.4%). Operative and long-term mortality were 17.7 and 33.9%, respectively. Age, diabetes mellitus, and coronary artery disease were independently associated with increased long-term mortality. New York Heart Association (NYHA) class and right heart failure symptoms significantly improved during follow-up. In this series of mechanical tricuspid valve replacements in patients with predominately rheumatic heart disease, operative and long-term mortality were increased; however, survivors had significant improvement in their NYHA class and freedom from right heart failure symptoms. Three preoperative factors (age, diabetes mellitus, and coronary artery disease) were independently associated with long-term mortality. © 2017 Wiley Periodicals, Inc.

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.

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

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.

Dissection of the atrial wall after mitral valve replacement.

PubMed Central

Lukács, L; Kassai, I; Lengyel, M

1996-01-01

We describe an unusual sequela of mitral valve replacement in a 50-year-old woman who had undergone a closed mitral commissurotomy in 1975. She was admitted to our hospital because of mitral restenosis in November 1993, at which time her mitral valve was replaced with a mechanical prosthesis. On the 8th postoperative day, the patient developed symptoms of heart failure; transesophageal echocardiography revealed dissection and rupture of the left atrial wall. At prompt reoperation, we found an interlayer dissection and rupture of the atrial wall into the left atrium. We repaired the ruptured atrial wall with a prosthetic patch. The postoperative course was uneventful, and postoperative transesophageal echocardiography showed normal prosthetic valve function and no dissection. Images PMID:8680278

[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

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.

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

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.

Prosthetic Aortic Valve Fixation Study: 48 Replacement Valves Analyzed Using Digital Pressure Mapping.

PubMed

Lee, Candice Y; Wong, Joshua K; Ross, Ronald E; Liu, David C; Khabbaz, Kamal R; Martellaro, Angelo J; Gorea, Heather R; Sauer, Jude S; Knight, Peter A

Prostheses attachment is critical in aortic valve replacement surgery, yet reliable prosthetic security remains a challenge. Accurate techniques to analyze prosthetic fixation pressures may enable the use of fewer sutures while reducing the risk of paravalvular leaks (PVL). Customized digital thin film pressure transducers were sutured between aortic annulus models and 21-mm bioprosthetic valves with 15 × 4-mm, 12 × 4-mm, or 9 × 6-mm-wide pledgeted mattress sutures. Simulating open and minimally invasive access, 4 surgeons, blinded to data acquisition, each secured 12 valves using manual knot-tying (hand-tied [HT] or knot-pusher [KP]) or automated titanium fasteners (TFs). Real-time pressure measurements and times were recorded. Two-dimensional (2D) and 3D pressure maps were generated for all valves. Pressures less than 80 mm Hg were considered at risk for PVL. Pressures under each knot (intrasuture) fell less than 80 mm Hg for 12 of 144 manual knots (5/144 HT, 7/144 KP) versus 0 of 288 TF (P < 0.001). Pressures outside adjacent sutures (extrasuture) were less than 80 mm Hg in 10 of 60 HT, zero of 60 KP, and zero of 120 TF sites for 15 × 4-mm valves; 17 of 48 HT, 25 of 48 KP, and 12 of 96 TF for 12 × 4-mm valves; and 15 of 36 HT, 17 of 36 KP, and 9 and 72 TF for 9 × 6-mm valves; P < 0.001 all manual versus TF. Annular areas with pressures less than 80 mm Hg ranged from 0% of the sewing-ring area (all open TF) to 31% (12 × 4 mm, KP). The average time per manual knot, 46 seconds (HT, 31 seconds; KP, 61 seconds), was greater than TF, 14 seconds (P < 0.005). Reduced operative times and PVL risk would fortify the advantages of surgical aortic valve replacement. This research encourages continued exploration of technical factors in optimizing prosthetic valve security.

Valve-sparing aortic root replacement in Loeys-Dietz syndrome.

PubMed

Patel, Nishant D; Arnaoutakis, George J; George, Timothy J; Allen, Jeremiah G; Alejo, Diane E; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A

2011-08-01

Loeys-Dietz syndrome (LDS) is a recently recognized aggressive aortic disorder characterized by root aneurysm, arterial tortuosity, hypertelorism, and bifid uvula or cleft palate. The results of prophylactic root replacement using valve-sparing procedures (valve-sparing root replacement [VSRR]) in patients with LDS is not known. We reviewed all patients with clinical and genetic (transforming growth factor-β receptor mutations) evidence of LDS who underwent VSRR at our institution. Echocardiographic and clinical data were obtained from hospital and follow-up clinic records. From 2002 to 2009, 31 patients with a firm diagnosis of LDS underwent VSRR for aortic root aneurysm. Mean age was 15 years, and 24 (77%) were children. One (3%) patient had a bicuspid aortic valve. Preoperative sinus diameter was 3.9±0.8 cm (z score 7.0±2.9) and 2 (6%) had greater than 2+ aortic insufficiency. Thirty patients (97%) underwent reimplantation procedures using a Valsalva graft. There were no operative deaths. Mean follow-up was 3.6 years (range, 0 to 7 years). One patient required late repair of a pseudoaneurysm at the distal aortic anastomosis, and 1 had a conversion to a David reimplantation procedure after a Florida sleeve operation. No patient suffered thromboembolism or endocarditis, and 1 (3%) patient experienced greater than 2+ late aortic insufficiency. No patient required late aortic valve repair or replacement. Loeys-Dietz syndrome is an aggressive aortic aneurysm syndrome that can be addressed by prophylactic aortic root replacement with low operative risk. Valve-sparing procedures have encouraging early and midterm results, similar to those in Marfan syndrome, and are an attractive option for young patients. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Role of diastolic function indices in the risk stratification of patients with mixed aortic valve disease.

PubMed

Egbe, Alexander C; Khan, Arooj R; Boler, Amber; Said, Sameh M; Geske, Jeffrey B; Miranda, William R; Akintoye, Emmanuel; Connolly, Heidi M; Warnes, Carole A; Oh, Jae K

2018-06-01

Determine the role of diastolic function indices in pre-operative and post-operative risk stratification in patients with moderate mixed aortic valve disease (MAVD). A retrospective study was conducted of asymptomatic patients with moderate MAVD (a combination of moderate aortic stenosis and moderate aortic regurgitation) and an ejection fraction of 50% or more who were followed up at Mayo Clinic from 1 January 2004, to 31 December 2013. A pre-requisite for inclusion in the study was assessment of diastolic function involving at least three of the following indices: tissue Doppler early diastolic velocity (e'), mitral inflow early velocity (E), tricuspid regurgitation velocity, and left atrial volume index. Primary endpoints were aortic valve replacement (AVR) or cardiac death while secondary endpoints were cardiovascular adverse events (CAEs) after AVR. We defined CAEs as stroke, heart failure hospitalization, severe left ventricular dysfunction, and cardiac death. There were 214 patients (age 61 ± 8 years, men 146 [68%]) followed for 6.1 ± 2.3 years during which 162 (76%) AVRs and 11 (5%) cardiac deaths occurred. The multivariable risk factors for cardiac death or AVR were relative wall thickness (RWT) > 0.42 [hazard ratio (HR), 1.88 [95% CI, 1.28-2.59]; P = 0.001] and average E/e' >14 (HR, 1.94 [95% CI, 1.29-3.01]; P = 0.02). Freedom from CAE after AVR was significantly lower in the patients with baseline RWT >0.42 or mean E/e' >14 than the other patients: 79% (95% CI 74-83%) vs. 94% (95% CI 89-98%) at 3 years (P = 0.03). The presence of RWT >0.42 or E/e' >14 identifies a high-risk patient subset whose risk for cardiovascular morbidities persists even after AVR.

Earlier Pulmonary Valve Replacement in Down Syndrome Patients Following Tetralogy of Fallot Repair.

PubMed

Sullivan, Rachel T; Frommelt, Peter C; Hill, Garick D

2017-08-01

The association between Down syndrome and pulmonary hypertension could contribute to more severe pulmonary regurgitation after tetralogy of Fallot repair and possibly earlier pulmonary valve replacement. We compared cardiac magnetic resonance measures of pulmonary regurgitation and right ventricular dilation as well as timing of pulmonary valve replacement between those with and without Down syndrome after tetralogy of Fallot repair. Review of our surgical database from 2000 to 2015 identified patients with tetralogy of Fallot with pulmonary stenosis. Those with Down syndrome were compared to those without. The primary outcome of interest was time from repair to pulmonary valve replacement. Secondary outcomes included pulmonary regurgitation and indexed right ventricular volume on cardiac magnetic resonance imaging. The cohort of 284 patients included 35 (12%) with Down syndrome. Transannular patch repair was performed in 210 (74%). Down syndrome showed greater degree of pulmonary regurgitation (55 ± 14 vs. 37 ± 16%, p = 0.01) without a significantly greater rate of right ventricular dilation (p = 0.09). In multivariable analysis, Down syndrome (HR 2.3, 95% CI 1.2-4.5, p = 0.02) and transannular patch repair (HR 5.5, 95% CI 1.7-17.6, p = 0.004) were significant risk factors for valve replacement. Those with Down syndrome had significantly lower freedom from valve replacement (p = 0.03). Down syndrome is associated with an increased degree of pulmonary regurgitation and earlier pulmonary valve replacement after tetralogy of Fallot repair. These patients require earlier assessment by cardiac magnetic resonance imaging to determine timing of pulmonary valve replacement and evaluation for and treatment of preventable causes of pulmonary hypertension.

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.

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.

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.

Impact of pannus formation on hemodynamic dysfunction of prosthetic aortic valve: pannus extent and its relationship to prosthetic valve motion and degree of stenosis.

PubMed

Koo, Hyun Jung; Ha, Hojin; Kang, Joon-Won; Kim, Jeong A; Song, Jae-Kwan; Kim, Hwa Jung; Lim, Tae-Hwan; Yang, Dong Hyun

2018-02-19

Although pannus is an important cause of prosthetic valve dysfunction, the minimum pannus size that can induce hemodynamic dysfunction has not yet been determined. This study investigated the correlation between the limitation of motion (LOM) of the prosthetic valve and pannus extent and determined the pannus extent that could induce severe aortic stenosis. This study included 49 patients who underwent mechanical aortic valve replacement (AVR) and showed pannus on cardiac computed tomography (CT). Pannus width, ratio of pannus width to valve diameter, pannus area, effective orifice area, encroachment ratio by pannus, pannus involvement angle and percent LOM of mechanical valves were evaluated on CT. Transvalvular peak velocity (TPV) and transvalvular pressure gradient (TPG) were measured by transesophageal echocardiography to determine the degree of aortic stenosis. The relationship between percent LOM of the prosthetic valve and pannus extent and the cut-off of pannus extent required to induce severe aortic stenosis were evaluated. The mean interval between AVR and pannus formation was 11 years and was longer in patients with than without severe aortic stenosis (14.0 vs. 7.3 years). On CT, the percent LOM of the prosthetic valve was significantly associated with the extent of pannus only in patients with pannus involvement angle > 180° (r = 0.55-0.68, P < 0.01). Pannus width, effective orifice area, and encroachment ratio were significantly associated with increased TPV and TPG (r = 0.51-0.62, P < 0.01). Pannus width > 3.5 mm, pannus width/valve inner diameter > 0.15, and encroachment ratio > 0.14 were significantly associated with severe aortic stenosis (TPV > 4 m/s; mean TPG ≥ 35 mmHg), with c-indices of 0.74-079 (P < 0.005). CT-derived pannus extent parameters are good indicators of significant hemodynamic changes with increased TPV and mean TPG.

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

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.

The Freedom Solo pericardial stentless valve: Single-center experience, outcomes, and long-term durability.

PubMed

Stanger, Olaf; Bleuel, Irina; Gisler, Fabian; Göber, Volkhard; Reineke, Sylvia; Gahl, Brigitta; Aymard, Thierry; Englberger, Lars; Carrel, Thierry; Tevaearai, Hendrik

2015-07-01

To report our institutional experience and long-term results with the Freedom Solo bovine pericardial stentless bioprosthesis (Sorin Group, Saluggia, Italy). Between January 2005 and November 2009, 149 patients (mean age, 73.6 ± 8.7 years; 68 [45.6%] female) underwent isolated (n = 75) or combined (n = 74) aortic valve replacement (AVR) using the Solo in our institution. Follow-up was 100% complete with an average follow-up time of 5.9 ± 2.6 years (maximum, 9.6 years) and a total of 885.3 patient years. Operative (30-day) mortality was 2.7% (1.3% for isolated AVR [n = 1] and 4.0% for combined procedures [n = 3]). All causes of death were not valve-related. Preoperative peak (mean) gradients of 74.2 ± 23.0 mm Hg (48.6 ± 16.3 mm Hg) decreased to 15.6 ± 5.4 mm Hg (8.8 ± 3.0 mm Hg) after AVR, and remained low for up to 9 years. The postoperative effective orifice area was 1.6 ± 0.57 cm(2), 1.90 ± 0.45 cm(2), 2.12 ± 0.48 cm(2), and 2.20 ± 0.66 cm(2) for the valve sizes 21, 23, 25, and 27, respectively, with absence of severe prosthesis-patient mismatch and 0.7% (n = 1) experienced moderate prosthesis-patient mismatch. During follow-up, 26 patients experienced structural valve deterioration (SVD) and 14 patients underwent explantation. Kaplan-Meier estimates for freedom from death, explantation, and SVD at 9 years averaged 0.57 (range, 0.47-0.66), 0.82 (range, 0.69-0.90), and 0.70 (range, 0.57-0.79), respectively. The Freedom Solo stentless aortic valve is safe to implant and shows excellent early and midterm hemodynamic performance. However, SVD was observed in a substantial number of patients after only 5-6 years and the need for explantation increased markedly, suggesting low durability. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Identification of a host 14-3-3 Protein that Interacts with Xanthomonas effector AvrRxv

PubMed Central

Whalen, Maureen; Richter, Todd; Zakhareyvich, Kseniya; Yoshikawa, Masayasu; Al-Azzeh, Dana; Adefioye, Adeshola; Spicer, Greg; Mendoza, Laura L.; Morales, Christine Q.; Klassen, Vicki; Perez-Baron, Gina; Toebe, Carole S.; Tzovolous, Ageliki; Gerstman, Emily; Evans, Erika; Thompson, Cheryl; Lopez, Mary; Ronald, Pamela C.

2009-01-01

AvrRxv is a member of a family of pathogen effectors present in pathogens of both plant and mammalian species. Xanthomonas campestris pv. vesicatoria strains carrying AvrRxv induce a hypersensitive response (HR) in the tomato cultivar Hawaii 7998. Using a yeast two-hybrid screen, we identified a 14-3-3 protein from tomato that interacts with AvrRxv called AvrRxv Interactor 1 (ARI1). The interaction was confirmed in vitro with affinity chromatography. Using mutagenesis, we identified a 14-3-3-binding domain in AvrRxv and demonstrated that a mutant in that domain showed concomitant loss of interaction with ARI1 and HR-inducing activity in tomato. These results demonstrate that the AvrRxv bacterial effector recruits 14-3-3 proteins for its function within host cells. AvrRxv homologues YopP and YopJ from Yersinia do not have AvrRxv-specific HR-inducing activity when delivered into tomato host cells by Agrobacterium. Although YopP itself cannot induce HR, its C-terminal domain containing the catalytic residues can replace that of AvrRxv in an AvrRxv-YopP chimera for HR-inducing activity. Phylogenetic analysis indicates that the sequences encoding the C-termini of family members are evolving independently from those encoding the N-termini. Our results support a model in which there are three functional domains in proteins of the family, translocation, interaction, and catalytic. PMID:21796232

Real-time magnetic resonance imaging-guided transcatheter aortic valve replacement.

PubMed

Miller, Justin G; Li, Ming; Mazilu, Dumitru; Hunt, Tim; Horvath, Keith A

2016-05-01

To demonstrate the feasibility of Real-time magnetic resonance imaging (rtMRI) guided transcatheter aortic valve replacement (TAVR) with an active guidewire and an MRI compatible valve delivery catheter system in a swine model. The CoreValve system was minimally modified to be MRI-compatible by replacing the stainless steel components with fluoroplastic resin and high-density polyethylene components. Eight swine weighing 60-90 kg underwent rtMRI-guided TAVR with an active guidewire through a left subclavian approach. Two imaging planes (long-axis view and short-axis view) were used simultaneously for real-time imaging during implantation. Successful deployment was performed without rapid ventricular pacing or cardiopulmonary bypass. Postdeployment images were acquired to evaluate the final valve position in addition to valvular and cardiac function. Our results show that the CoreValve can be easily and effectively deployed through a left subclavian approach using rtMRI guidance, a minimally modified valve delivery catheter system, and an active guidewire. This method allows superior visualization before deployment, thereby allowing placement of the valve with pinpoint accuracy. rtMRI has the added benefit of the ability to perform immediate postprocedural functional assessment, while eliminating the morbidity associated with radiation exposure, rapid ventricular pacing, contrast media renal toxicity, and a more invasive procedure. Use of a commercially available device brings this rtMRI-guided approach closer to clinical reality. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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.

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.

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.

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

Neurocognitive functions after beating heart mitral valve replacement without cross-clamping the aorta.

PubMed

Cicekcioglu, Ferit; Ozen, Anil; Tuluce, Hicran; Tutun, Ufuk; Parlar, Ali Ihsan; Kervan, Umit; Karakas, Sirel; Katircioglu, Salih Fehmi

2008-01-01

Although neurologic outcome after cardiac surgery is well-established, neurocognitive functions after beating heart mitral valve replacement still needs to be elucidated. The aim of this study was to compare preoperative and postoperative neurocognitive functions in patients who underwent beating heart mitral valve replacement on cardiopulmonary bypass without cross-clamping the aorta. The prospective study included 25 consecutive patients who underwent mitral valve replacement. The operations were carried out on a beating heart method using normothermic cardiopulmonary bypass without cross-clamping the aorta. All patients were evaluated preoperatively (E1) and postoperatively (at sixth day [E2] and second month [E3]) for neurocognitive functions. Neurologic deficit was not observed in the postoperative period. Comparison of the neurocognitive test results, between the preoperative and postoperative assessment for both hemispheric cognitive functions, demonstrated that no deterioration occurred. In the three subsets of left hemispheric cognitive function test evaluation, total verbal learning, delayed recall, and recognition, significant improvements were detected at the postoperative second month (E3) compared to the preoperative results (p = 0.005, 0.01, and 0.047, respectively). Immediate recall and retention were significantly improved within the first postoperative week (E2) when compared to the preoperative results (p = 0.05 and 0.05, respectively). The technique of mitral valve replacement with normothermic cardiopulmonary bypass without cross-clamping of the aorta may be safely used for majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.

Impact of closed minimal extracorporeal circulation on microvascular tissue perfusion during surgical aortic valve replacement: intravital imaging in a prospective randomized study.

PubMed

Donndorf, Peter; Park, Hannah; Vollmar, Brigitte; Alms, Angela; Gierer, Philipp; Steinhoff, Gustav; Kaminski, Alexander

2014-08-01

Closed minimal extracorporeal circulation (MECC) systems currently do not represent the standard of surgical care for open-heart surgery. Yet, considering the beneficial results reported for coronary artery bypass graft (CABG) surgery, we used an MECC system in aortic valve replacement (AVR) and analysed the effects on intraoperative microvascular perfusion in comparison with conventional open extracorporeal circulation (CECC). In the current study, we analysed alterations in microvascular perfusion at 4 predefined time points (T1-T4) during surgical AVR utilizing orthogonal polarization spectral (OPS) imaging. Twenty patients were randomized for being operated on utilizing either MECC or CECC. Changes in functional capillary density (FCD, cm/cm(2)), mircovascular blood flow velocity (mm/s) and vessel diameter (μm) were analysed by a blinded investigator. After the start of extracorporeal circulation and aortic cross-clamping (T2), both groups showed a significant drop in FCD, but with a significantly higher FCD in the MECC group (153.1 ± 15.0 cm/cm² in the CECC group vs 160.8 ± 12.2 cm/cm² in the MECC group, P = 0.034). During the late phase of the cardiopulmonary bypass (CPB) (T3), the FCD was still significantly depressed in both treatment groups (153.5 ± 14.6 cm/cm² in the CECC group, P <0.05 vs 'T1'; 159.5 ± 12.4 cm/cm² in the MECC group, P <0.05 versus 'T1'). After termination of CPB (T4), the FCD recovered in both groups to baseline values. Microvascular blood flow velocity tended to remain at a higher level in the MECC group, whereas haemodilution during CPB was significantly reduced in the MECC group. The use of MECC in AVR did not affect procedural safety and, resulted in beneficial preservation of microvascular blood flow velocity and significantly reduced haemodilution during CPB. In contrast to CABG surgery, the use of MECC did not improve FCD during surgical AVR. Clinical advantages possibly resulting from attenuated haemodilution and

The importance of echocardiography in transcatheter aortic valve implantation.

PubMed

Bilen, Emine; Sari, Cenk; Durmaz, Tahir; Keleş, Telat; Bayram, Nihal A; Akçay, Murat; Ayhan, Hüseyin M; Bozkurt, Engin

2014-01-01

Valvular heart diseases cause serious health problems in Turkey as well as in Western countries. According to a study conducted in Turkey, aortic stenosis (AS) is second after mitral valve disease among all valvular heart diseases. AS is frequently observed in elderly patients who have several cardiovascular risk factors and comorbidities. In symptomatic severe AS, surgical aortic valve replacement (AVR) is a definitive treatment. However, in elderly patients with left ventricular dysfunction and comorbidities, the risk of operative morbidity and mortality increases and outweighs the gain obtained from AVR surgery. As a result, almost one-third of the patients with serious AS are considered ineligible for surgery. Transcatheter aortic valve implantation (TAVI) is an effective treatment in patients with symptomatic severe AS who have high risk for conventional surgery. Since being performed for the first time in 2002, with a procedure success rate reported as 95% and a mortality rate of 5%, TAVI has become a promising method. Assessment of vascular anatomy, aortic annular diameter, and left ventricular function may be useful for the appropriate selection of patients and may reduce the risk of complications. Cardiac imaging methods including 2D and 3D echocardiography and multidetector computed tomography are critical during the evaluation of suitable patients for TAVI as well as during and after the procedure. In this review, we describe the role of echocardiography methods in clinical practice for TAVI procedure in its entirety, i.e. from patient selection to guidance during the procedure, and subsequent monitoring. © 2013, Wiley Periodicals, Inc.

The German Aortic Valve Registry (GARY): a nationwide registry for patients undergoing invasive therapy for severe aortic valve stenosis.

PubMed

Beckmann, A; Hamm, C; Figulla, H R; Cremer, J; Kuck, K H; Lange, R; Zahn, R; Sack, S; Schuler, G C; Walther, T; Beyersdorf, F; Böhm, M; Heusch, G; Funkat, A K; Meinertz, T; Neumann, T; Papoutsis, K; Schneider, S; Welz, A; Mohr, F W

2012-07-01

Background The increasing prevalence of severe aortic valve defects correlates with the increase of life expectancy. For decades, surgical aortic valve replacement (AVR), under the use of extracorporeal circulation, has been the gold standard for treatment of severe aortic valve diseases. In Germany ~12,000 patients receive isolated aortic valve surgery per year. For some time, percutaneous balloon valvuloplasty has been used as a palliative therapeutic option for very few patients. Currently, alternatives for the established surgical procedures such as transcatheter aortic valve implantation (TAVI) have become available, but there are only limited data from randomized studies or low-volume registries concerning long-time outcome. In Germany, the implementation of this new technology into hospital care increased rapidly in the past few years. Therefore, the German Aortic Valve Registry (GARY) was founded in July 2010 including all available therapeutic options and providing data from a large quantity of patients.Methods The GARY is assembled as a complete survey for all invasive therapies in patients with relevant aortic valve diseases. It evaluates the new therapeutic options and compares them to surgical AVR. The model for data acquisition is based on three data sources: source I, the mandatory German database for external performance measurement; source II, a specific registry dataset; and source III, a follow-up data sheet (generated by phone interview). Various procedures will be compared concerning observed complications, mortality, and quality of life up to 5 years after the initial procedure. Furthermore, the registry will enable a compilation of evidence-based indication criteria and, in addition, also a comparison of all approved operative procedures, such as Ross or David procedures, and the use of different mechanical or biological aortic valve prostheses.Results Since the launch of data acquisition in July 2010, almost all institutions performing

Successful replacement of the systemic tricuspid valve with a mechanical valve in a 3-month-old boy with congenitally corrected transposition of the great arteries having a dysplastic tricuspid valve.

PubMed

Asada, Dai; Ikeda, Kazuyuki; Yamagishi, Masaaki

2017-04-01

There are a few reports of successful replacement of the left-sided systemic tricuspid valve with a mechanical valve in small infants with congenitally corrected transposition of the great arteries having Ebstein's anomaly. Tricuspid valve replacement is the preferred option when pulmonary artery banding, performed as a prelude to performing the double-switch operation, is not feasible because of severe heart failure caused by tricuspid regurgitation.

[Quality of life after transcatheter aortic valve implantation: a Comprehensive literature review and critical appraisal].

PubMed

Ferrari, Susy; Ciuca, Cristina; Grisoglio, Enrica; Aranzulla, Tiziana Claudia; Gabbieri, Davide; Vecchio Verderame, Lavinia; Dispensa, Flavia; Caruso, Cinzia; Di Mauro, Alda Carmela; Di Gregorio, Omar; Pandolfi, Claudia; Rongoni, Silvia; Ottoboni, Giovanni; Moretti, Carolina; De Palma, Rossana; Marzocchi, Antonio; Chattat, Rabih; Saia, Francesco

2016-12-01

Transcatheter aortic valve implantation (TAVI) is a very effective treatment option for patients with severe aortic stenosis who are either not suitable candidates or at high risk for surgical aortic valve replacement (AVR). Patients undergoing TAVI are often very elderly and their clinical status is burdened with multiple comorbidities, therefore evaluation of quality of life (QoL) might be challenging. We sought to provide an overview of available data on QoL changes after TAVI and critical insights on the instruments used to detect these changes. This analysis focuses on studies that evaluated QoL after TAVI with standardized questionnaires. Out of 706 items identified through literature search, 23 studies were included in the final review: 2 randomized controlled trials (one comparing QoL pre- vs post-TAVI, one TAVI vs AVR vs medical therapy) and 21 observational studies (19 studies comparing QoL pre- and post-TAVI and 2 studies TAVI vs AVR). The instruments used in all studies were not specific for TAVI patients. Most studies reported a significant improvement in QoL after TAVI, greater for physical aspects compared with psychological components, which persisted at mid and long-term follow-up. A short-term benefit was found for transfemoral TAVI patients as compared with transapical TAVI and AVR; however, these differences tended to disappear over time. The study highlights an improvement in QoL after TAVI that persists over time. As different instruments resulted to be more sensitive to detect different aspects, multidimensional assessments - capable of combining disease-specific and disease-non-specific measures - should foster clinical research in order to have a more complete picture of QoL of TAVI patients.

Mitral valve replacement for mitral stenosis: A 15-year single center experience.

PubMed

Al Mosa, Alqasem F; Omair, Aamir; Arifi, Ahmed A; Najm, Hani K

2016-10-01

Mitral valve replacement with either a bioprosthetic or a mechanical valve is the treatment of choice for severe mitral stenosis. However, choosing a valve implant type is still a subject of debate. This study aimed to evaluate and compare the early and late outcomes of mitral valve replacement [mechanical (MMV) vs. bioprosthetic (BMV)] for severe mitral stenosis. A retrospective cohort study was performed on data involving mitral stenosis patients who have undergone mitral valve replacement with either BMV (n = 50) or MMV (n = 145) valves from 1999 to 2012. Data were collected from the patients' records and follow-up through telephone calls. Data were analyzed for early and late mortality, New York Heart Association (NYHA) functional classes, stroke, pre- and postoperative echocardiographic findings, early and late valve-related complications, and survival. Chi-square test, logistic regression, Kaplan-Meier curve, and dependent proportions tests were some of the tests employed in the analysis. A total of 195 patients were included in the study with a 30-day follow-up echocardiogram available for 190 patients (97.5%), while 103 (53%) were available for follow-up over the telephone. One patient died early postoperatively; twelve patients died late in the postoperative period, six in the bioprosthesis group and six in the mechanical group. The late mortality had a significant association with postoperative stroke (p < 0.001) and postoperative NYHA Classes III and IV (p = 0.002). Postoperative NYHA class was significantly associated with age (p = 0.003), pulmonary disease (p = 0.02), mitral valve implant type (p = 0.01), and postoperative stroke (p = 0.02); 14 patients had strokes in the mechanical (9) and in the bioprosthetic (5) groups. NYHA classes were significantly better after the replacement surgeries (p < 0.001). BMV were significantly associated with worse survival (p = 0.03), worse NYHA postoperatively (p = 0.01), and more reoperations

Performance of EuroSCORE II in a large US database: implications for transcatheter aortic valve implantation.

PubMed

Osnabrugge, Ruben L; Speir, Alan M; Head, Stuart J; Fonner, Clifford E; Fonner, Edwin; Kappetein, A Pieter; Rich, Jeffrey B

2014-09-01

Validation studies of European system for cardiac operative risk evaluation II (EuroSCORE II) have been limited to European datasets. Therefore, the aims of this study were to assess the performance of EuroSCORE II in a large multicentre US database, and compare it with the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM). In addition, implications for patient selection for transcatheter aortic valve implantation (TAVI) were explored. EuroSCORE II and the STS-PROM were calculated for 50 588 patients from a multi-institutional statewide database of all cardiac surgeries performed since 2003. Model performance was assessed using the area under the receiver operator curve (AUC), observed vs expected (O:E) ratios and calibration plots. Analyses were performed for isolated coronary artery bypass grafting (CABG) (n = 40 871), aortic valve replacement (AVR) (n = 4107), AVR + CABG (n = 3480), mitral valve (MV) replacement (n = 1071) and MV repair (n = 1059). The overall in-hospital mortality rate was 2.1%. EuroSCORE II was outperformed by the STS-PROM in the overall cohort with regard to discrimination (AUC = 0.77 vs 0.81, respectively; P < 0.001) and calibration (O:E = 0.68 vs 0.80, respectively). Discrimination for CABG was worse with EuroSCORE II (AUC = 0.77 vs STS-PROM: 0.81, P < 0.001). For other procedures discrimination was similar: AVR (AUC = 0.71 vs STS-PROM: 0.74, P = 0.40), AVR + CABG (AUC = 0.72 vs STS-PROM: 0.74, P = 0.47), MV repair (AUC = 0.82 vs STS-PROM: 0.86, P = 0.55) and MV replacement (AUC = 0.78 vs STS-PROM: 0.79, P = 0.69). Calibration of EuroSCORE II was worse for CABG (O:E = 0.68 vs STS-PROM: 0.80), similar in AVR + CABG (O:E = 0.76 vs STS-PROM: 0.70) and MV repair (O:E = 0.64 vs STS-PROM: 0.67), while EuroSCORE II may be more accurate in AVR (O:E = 0.96 vs STS-PROM: 0.76). Performance of both models improved when only recent cases (after 1 January 2008) were used. Ongoing TAVI trials aimed at patients with an estimated 4

Long-term Outcomes of Mitral Valve Repair Versus Replacement for Degenerative Disease: A Systematic Review

PubMed Central

McNeely, Christian A; Vassileva, Christina M

2015-01-01

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data. PMID:25158683

Early outcome of patients undergoing transcatheter aortic valve implantation (TAVI): The Auckland City Hospital experience 2011-2015.

PubMed

Wu, Sylvia S Y; Wang, Tom Kai Ming; Nand, Parma; Ramanathan, Tharumenthiran; Webster, Mark; Stewart, Jim

2016-01-08

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR) in high-risk patients. We report the initial TAVI experience at Auckland City Hospital. The records of patients undergoing TAVI between 2011 and 2015 at Auckland City Hospital were reviewed. We report the procedural success and outcome, including major adverse events (death, stroke, myocardial infarction, bleeding, vascular complications and rehospitalisations), degree of aortic regurgitation and symptom status up to 1-year follow-up. Mean age was 80.7 years and mean Euroscore II and Society of Thoracic Surgeons' scores were 8.2% and 6.3% respectively; 50% had undergone previous cardiac surgery. Successful deployment of the valve was achieved in all patients. The cumulative mortality rates at 30 days, 6 months and 1 year were 2.4%, 6.1% and 12.2% and cumulative stroke rates 1.2%, 3% and 8.2% respectively. Severe aortic regurgitation occurred in 2.3% TAVI is available in the New Zealand public hospital system for patients who are high-risk candidates for AVR. Early results are excellent and indicate that the technology is being used appropriately, according to current access criteria. If the early cost effectiveness data are confirmed, the indications for TAVI may widen.

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.

Investigating the effect of remote ischaemic preconditioning on biomarkers of stress and injury-related signalling in patients having isolated coronary artery bypass grafting or aortic valve replacement using cardiopulmonary bypass: study protocol for a randomized controlled trial.

PubMed

Fiorentino, Francesca; Angelini, Gianni D; Suleiman, M-Saadeh; Rahman, Alima; Anderson, Jon; Bryan, Alan J; Culliford, Lucy A; Moscarelli, Marco; Punjabi, Prakash P; Reeves, Barnaby C

2015-04-23

Ischaemia-reperfusion injury occurs during heart surgery that uses cardiopulmonary bypass (CPB) and cardioplegic arrest. It is hypothesised that remote ischaemic preconditioning (RIPC) protects the heart against such injury. Despite the numerous studies investigating the protective effects of RIPC, there is still uncertainty about the interpretation of the findings as well as conflicting results between studies. The objective of this trial is to investigate the cardioprotective effect of RIPC in patients having coronary artery bypass grafting (CABG) or aortic valve replacement surgery. This will be achieved by estimating the effect of the intervention in the two groups of pathologies and by investigating the signalling mechanisms that may underpin the cardioprotective effect. A two-centre randomised controlled trial will be used to investigate the effects of RIPC in two pathologies: patients having isolated CABG and those having aortic valve replacement surgery (AVR) with CPB. Participants will be randomised to RIPC or control (sham RIPC), stratified by surgical stratum. The intervention will be delivered by a research nurse. Data will be collected by a research nurse blinded to the intervention. The patient and the theatre staff are also blinded to the allocation. Markers of myocardial injury and inflammation will be measured in myocardial biopsies and in blood samples at different times. This trial is designed to investigate whether RIPC will reduce myocardial injury and inflammation following heart surgery and whether there is a difference in effect between participants having CABG or AVR. This trial is a unique opportunity to study the mechanisms associated with RIPC using human myocardial tissue and blood, and to relate these to the extent of myocardial injury/protection. Current Controlled Trials ISRCTN33084113 (25 March 2013).

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

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

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.).

Beating heart mitral valve replacement with a bovine pericardial bioprosthesis for treatment of mitral valve dysplasia in a Bull Terrier.

PubMed

Behr, Luc; Chetboul, Valérie; Sampedrano, Carolina Carlos; Vassiliki, Gouni; Pouchelon, Jean-Louis; Laborde, François; Borenstein, Nicolas

2007-04-01

To describe an open, beating heart surgical technique and use of a bovine pericardial prosthetic valve for mitral valve replacement (MVR) in the dog. Clinical case report. Male Bull Terrier (17-month-old, 26 kg) with mitral valve dysplasia and severe regurgitation. A bovine pericardial bioprosthesis was used to replace the mitral valve using an open beating heart surgical technique and cardiopulmonary bypass. Successful MVR was achieved using a beating heart technique. Mitral regurgitation resolved and cardiac performances improved (left ventricular end-diastolic diameter decreased from 57.6 to 48.7 mm, and left atrium/aorta ratio returned to almost normal, from 1.62 to 1.19). Cardiopulmonary by-pass time and total surgical duration were decreased compared with standard cardioplegic techniques. Surgical recovery was uneventful and on echocardiography 6 months later valve function was excellent. Considering the technique advantages (no cardiac arrest, ischemic reperfusion injury, and hypothermia, or the need for aortic dissection and cannulation for administration of cardioplegic solution), short-term mortality and morbidity may be reduced compared with standard cardioplegic techniques. Based on experience in this dog, beating heart mitral valvular replacement is a seemingly safe and viable option for the dog and bovine pericardial prosthesis may provide better long-term survival than mechanical prostheses.

Stroke after Aortic Valve Surgery: Results from a Prospective Cohort

PubMed Central

Messé, Steven R.; Acker, Michael A.; Kasner, Scott E.; Fanning, Molly; Giovannetti, Tania; Ratcliffe, Sarah J.; Bilello, Michel; Szeto, Wilson Y.; Bavaria, Joseph E.; Hargrove, W. Clark; Mohler, Emile R.; Floyd, Thomas F.

2014-01-01

Background The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results We performed a prospective cohort study of subjects ≥ 65 years of age undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists pre-operatively and post-operatively, and underwent post-operative magnetic resonance imaging (MRI). Over a 4 year period, 196 subjects were enrolled at 2 sites. Mean age = 75.8 ± 6.2 years, 36% female, 6% non-white. Clinical strokes were detected in 17%, Transient Ischemic Attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery (STS) database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale (NIHSS) was 3 (interquartile range 1 – 9). Clinical stroke was associated with increased length of stay, median 12 vs 10 days, p = 0.02. Moderate or severe stroke (NIHSS ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality, 38% vs 4%, p = 0.005. Of the 109 stroke-free subjects with post-operative MRI, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions Clinical stroke after AVR was more common than previously reported, more than double for this same cohort in the STS database, and silent cerebral infarctions were detected in over half of patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality. PMID:24690611

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

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

Tackling the Issue of High Postoperative Pacemaker Implantation Rates in Sutureless Aortic Valve Replacement: Should Balloon Inflation be Removed from the Implantation Method of the Perceval Prosthesis?

PubMed

Charles Blouin, Mathieu; Bouhout, Ismail; Demers, Philippe; Carrier, Michel; Perrault, Louis; Lamarche, Yoan; El-Hamamsy, Ismail; Bouchard, Denis

2017-05-01

Sutureless aortic valve replacement (AVR) is an emerging alternative to standard AVR in elderly and high-risk patients. This procedure is associated with a high rate of postoperative permanent pacemaker implantation (PPI). The study aim was to assess the impact on the rate of PPI of implanting the Perceval prosthesis without using balloon inflation. A total of 159 patients who underwent sutureless AVR using the Perceval prosthesis was included. Balloon inflation was used in 132 patients (Balloon group) and not used in the remaining 27 (No-Balloon group). Clinical, echocardiographic and electrocardiographic outcomes were assessed. There was no significant difference in PPI rate between the two groups (26% for Balloon group versus 22% in No-Balloon group; p = 0.700). Balloon inflation had no significant impact on the incidence of paravalvular leaks (p = 0.839), or on the need to return to cardiopulmonary bypass (CPB) intraoperatively due to paravalvular leak or unsatisfactory deployment (p >0.999). Mean and peak transaortic pressure gradients were similar between the two groups (p = 0.417 and p = 0.522, respectively). Cross-clamp and CPB times were shorter in the No-Balloon group (49.6 ± 15.9 min versus 61.1 ± 25.6 min and 64.1 ± 26.3 min versus 79.6 ± 35.4 min, respectively; p = 0.027 and p = 0.012, respectively). The two groups had similar postoperative PPI rates. Implanting the Perceval prosthesis without balloon inflation is safe and had no impact on paravalvular leaks, intraoperative complications or hemodynamic results. Reductions in aortic cross-clamp time and CPB time were observed when the balloon was not used.

One-year outcome following biological or mechanical valve replacement for infective endocarditis.

PubMed

Delahaye, F; Chu, V H; Altclas, J; Barsic, B; Delahaye, A; Freiberger, T; Gordon, D L; Hannan, M M; Hoen, B; Kanj, S S; Lejko-Zupanc, T; Mestres, C A; Pachirat, O; Pappas, P; Lamas, C; Selton-Suty, C; Tan, R; Tattevin, P; Wang, A

2015-01-15

Nearly half of patients require cardiac surgery during the acute phase of infective endocarditis (IE). We describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and examine whether the type of prosthesis was associated with in-hospital and 1-year mortality. Among 5591 patients included in the International Collaboration on Endocarditis Prospective Cohort Study, 1467 patients with definite IE were operated on during the active phase and had a biological (37%) or mechanical (63%) valve replacement. Patients who received bioprostheses were older (62 vs 54years), more often had a history of cancer (9% vs 6%), and had moderate or severe renal disease (9% vs 4%); proportion of health care-associated IE was higher (26% vs 17%); intracardiac abscesses were more frequent (30% vs 23%). In-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p=0.0009) and 25.3% vs 16.6% (p<.0001), respectively. In multivariable analysis, mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10years), and in patients with a history of cancer (0.72), but were more commonly implanted in mitral position (1.60). Bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298). Patients with IE who receive a biological valve replacement have significant differences in clinical characteristics compared to patients who receive a mechanical prosthesis. Biological valve replacement is independently associated with a higher in-hospital and 1-year mortality, a result which is possibly related to patient characteristics rather than valve dysfunction. Copyright © 2014 Elsevier Ireland Ltd. 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

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.

Root replacement using stentless valves in the small aortic root: a propensity score analysis.

PubMed

Kunihara, Takashi; Schmidt, Kathrin; Glombitza, Petra; Dzindzibadze, Vachtang; Lausberg, Henning; Schäfers, Hans-Joachim

2006-10-01

Root replacement using a stentless bioprosthesis may be the optimal approach to avoid patient-prosthesis mismatch in patients with a small aortic root. Primary root replacement, however, is considered to be associated with increased surgical risk. We compared early outcome of full root replacement with a stentless bioprosthesis with that of aortic valve replacement with a stented bioprosthesis using propensity score-matching analysis. Of 231 patients undergoing elective, first-time aortic valve replacement with a small root (< or = 22 mm), 120 patients were selected using propensity score-matching analysis. They underwent either root replacement using a 23-mm stentless bioprosthesis (stentless group, n = 60) or supra-annular aortic valve replacement using a 21-mm stented bioprosthesis (stented group, n = 60). Preoperative characteristics and frequency of concomitant operations were identical. Duration of operation (196 +/- 54 versus 174 +/- 49 minutes), cardiopulmonary bypass (112 +/- 36 versus 91 +/- 33 minutes), and aortic cross-clamping (76 +/- 21 versus 61 +/- 21 minutes) were significantly longer in the stentless group. However, the need for perioperative transfusion and the incidence of postoperative reexploration for bleeding (3% versus 8%) was lower, and ventilation time was shorter. Mean duration of intensive care and hospital stay were also significantly shorter (2.3 +/- 1.7 versus 4.0 +/- 3.9 days, 8.9 +/- 3.1 versus 12.4 +/- 5.7 days). In-hospital mortality was identical (5% each). No independent predictor for in-hospital mortality was identified. Full root replacement using a stentless bioprosthesis does not increase postoperative morbidity or mortality of aortic valve replacement and may be advantageous in patients with a small aortic root.

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.

Minimally Invasive Aortic Valve Replacement Following Root Enlargement on too Narrow Annulus to Perform Transcatheter Aortic Valve Implantation.

PubMed

Sakamoto, Kosuke; Totsugawa, Toshinori; Hiraoka, Arudo; Tamura, Kentaro; Yoshitaka, Hidenori; Sakaguchi, Taichi

2018-05-30

An 88-year-old woman was diagnosed with aortic stenosis and an aortic annulus that was too narrow to perform transcatheter aortic valve implantation. Surgery was performed through a 7-cm right mini-thoracotomy at the fourth intercostal space. A 19-mm aortic valve bioprosthesis was implanted after root enlargement. The fourth intercostal space was a suitable site for aortic root enlargement because of the shorter skin-to-root distance and the detailed exposure of the aortic valve after cutting the aortic wall. This study concluded that minimally-invasive aortic valve replacement following root enlargement can be an option for the treatment of elderly patients with aortic stenosis accompanied by an annulus that is too small to perform transcatheter aortic valve implantation.

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

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.

Specific resistances against Pseudomonas syringae effectors AvrB and AvrRpm1 have evolved differently in common bean, soybean, and Arabidopsis

PubMed Central

Chen, Nicolas W. G.; Sévignac, Mireille; Thareau, Vincent; Magdelenat, Ghislaine; David, Perrine; Ashfield, Tom; Innes, Roger W.; Geffroy, Valérie

2010-01-01

Summary In plants, the evolution of specific resistance is poorly understood. Pseudomonas syringae effectors AvrB and AvrRpm1 are recognized by phylogenetically distinct resistance (R) proteins in Arabidopsis (Brassicaceae) and soybean (Glycine max, Fabaceae). In soybean, these resistances are encoded by two tightly linked R genes Rpg1-b and Rpg1-r. To study the evolution of these specific resistances, we investigated AvrB- and AvrRpm1-induced responses in common bean (Phaseolus vulgaris, Fabaceae).Common bean genotypes of various geographical origins were inoculated with P. syringae strains expressing AvrB or AvrRpm1. A common bean recombinant-inbred-line (RIL) population was used to map R genes to AvrRpm1.No common bean genotypes recognized AvrB. By contrast, multiple genotypes responded to AvrRpm1, and two independent R genes conferring AvrRpm1-specific resistance were mapped to the ends of linkage group B11 (Rpsar-1) and B8 (Rpsar-2). Rpsar-1 is located in a region syntenic with the soybean Rpg1 cluster. However, mapping of specific Rpg1 homologous genes suggests that AvrRpm1 recognition evolved independently in common bean and soybean.The conservation of genomic position of AvrRpm1-specific genes between soybean and common bean suggests a model whereby specific clusters of R genes are predisposed to evolve recognition of the same effector molecules. PMID:20561214

Criteria for determining the need for surgical treatment of tricuspid regurgitation during mitral valve replacement

PubMed Central

2012-01-01

Background Tricuspid regurgitation (TR) is common in patients with mitral valve disease; however, there are no straightforward, rapidly determinably criteria available for deciding whether TR repair should be performed during mitral valve replacement. The aim of our retrospective study was to identify a simple and fast criterion for determining whether TR repair should be performed in patients undergoing mitral valve replacement. Methods We reviewed the records of patients who underwent mitral valve replacement with or without (control) TR repair (DeVega or Kay procedure) from January 2005 to December 2008. Preoperative and 2-year postoperative echocardiographic measurements included right ventricular and atrial diameter, interventricular septum size, TR severity, ejection fraction, and pulmonary artery pressure. Results A total of 89 patients were included (control, n = 50; DeVega, n = 27; Kay, n = 12). Demographic and clinical characteristics were similar between groups. Cardiac variables were similar between the DeVega and Kay groups. Right atrium and ventricular diameter and ejection fraction were significantly decreased postoperatively both in the control and operation (DeVega + Kay) group (P < 0.05). Pulmonary artery pressure was significantly decreased postoperatively in-operation groups (P < 0.05). Our findings indicate that surgical intervention for TR should be considered during mitral valve replacement if any of the following preoperative criteria are met: right atrial transverse diameter > 57 mm; right ventricular end-diastolic diameter > 55 mm; pulmonary artery pressure > 58 mmHg. Conclusions Our findings suggest echocardiography may be used as a rapid and simple means of determining which patients require TR repair during mitral valve replacement. PMID:22443513

Long-term outcome in dogs undergoing mitral valve repair with suture annuloplasty and chordae tendinae replacement.

PubMed

Mizuno, T; Mizukoshi, T; Uechi, M

2013-02-01

Mitral valve repair under cardiopulmonary bypass was performed in three dogs with clinical signs associated with mitral regurgitation that were not controlled by medication. Mitral valve repair comprised circumferential annuloplasty and chordal replacement with expanded polytetrafluoroethylene. One dog died 2 years after surgery because of severe mitral regurgitation resulting from partial circumferential suture detachment. The others survived for over 5 years, but mild mitral valve stenosis persisted in one. The replaced chordae did not rupture in any dog. Mitral valve repair appears to be an effective treatment for mitral regurgitation in dogs. Chordal replacement with expanded polytetrafluoroethylene is a feasible technique, demonstrating long-term durability in dogs. However, mitral annuloplasty techniques need improvement. © 2012 British Small Animal Veterinary Association.

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

Mitral valve disease in patients with Marfan syndrome undergoing aortic root replacement.

PubMed

Kunkala, Meghana R; Schaff, Hartzell V; Li, Zhuo; Volguina, Irina; Dietz, Harry C; LeMaire, Scott A; Coselli, Joseph S; Connolly, Heidi

2013-09-10

Cardiac manifestations of Marfan syndrome include aortic root dilation and mitral valve prolapse (MVP). Only scant data exist describing MVP in patients with Marfan syndrome undergoing aortic root replacement. We retrospectively analyzed data from 166 MFS patients with MVP who were enrolled in a prospective multicenter registry of patients who underwent aortic root aneurysm repair. Of these 166 patients, 9% had mitral regurgitation (MR) grade >2, and 10% had MR grade 2. The severity of MVP and MR was evaluated by echocardiography preoperatively and ≤ 3 years postoperatively. Forty-one patients (25%) underwent composite graft aortic valve replacement, and 125 patients (75%) underwent aortic valve-sparing procedures; both groups had similar prevalences of MR grade >2 (P=0.7). Thirty-three patients (20%) underwent concomitant mitral valve (MV) intervention (repair, n=29; replacement, n=4), including all 15 patients with MR grade >2. Only 1 patient required MV reintervention during follow-up (mean clinical follow-up, 31 ± 10 months). Echocardiography performed 21 ± 13 months postoperatively revealed MR >2 in only 3 patients (2%). One early death and 2 late deaths occurred. Although the majority of patients with Marfan syndrome who undergo elective aortic root replacement have MVP, only 20% have concomitant MV procedures. These concomitant procedures do not seem to increase operative risk. In patients with MR grade ≤ 2 who do not undergo a concomitant MV procedure, the short-term incidence of progressive MR is low; however, more follow-up is needed to determine whether patients with MVP and MR grade ≤ 2 would benefit from prophylactic MV intervention.

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.

Current Management of Calcific Aortic Stenosis

PubMed Central

Lindman, Brian R.; Bonow, Robert O.; Otto, Catherine M.

2014-01-01

Calcific aortic stenosis (AS) is a progressive disease with no effective medical therapy that ultimately requires aortic valve replacement (AVR) for severe valve obstruction. Echocardiography is the primary diagnostic approach to define valve anatomy, measure AS severity and evaluate the left ventricular (LV) response to chronic pressure overload. In asymptomatic patients, markers of disease progression include the degree of leaflet calcification, hemodynamic severity of stenosis, adverse LV remodeling, reduced LV longitudinal strain, myocardial fibrosis and pulmonary hypertension. The onset of symptoms portends a predictably high mortality rate unless AVR is performed. In symptomatic patients, AVR improves symptoms, improves survival and, in patients with LV dysfunction, improves systolic function. Poor outcomes after AVR are associated with low-flow low-gradient AS, severe ventricular fibrosis, oxygen dependent lung disease, frailty, advanced renal dysfunction and a high comorbidity score. However, in most patients with severe symptoms, AVR is lifesaving. Bioprosthetic valves are recommended for patients over the age of 65 years. Transcatheter AVR is now available for patients with severe comorbidities, is recommended in patients who are deemed inoperable and is a reasonable alternative to surgical AVR in high risk patients. PMID:23833296

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

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

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.

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.

The AvrE superfamily: ancestral type III effectors involved in suppression of pathogen-associated molecular pattern-triggered immunity.

PubMed

Degrave, Alexandre; Siamer, Sabrina; Boureau, Tristan; Barny, Marie-Anne

2015-10-01

The AvrE superfamily of type III effectors (T3Es) is widespread among type III-dependent phytobacteria and plays a crucial role during bacterial pathogenesis. Members of the AvrE superfamily are vertically inherited core effectors, indicating an ancestral acquisition of these effectors in bacterial plant pathogens. AvrE-T3Es contribute significantly to virulence by suppressing pathogen-associated molecular pattern (PAMP)-triggered immunity. They inhibit salicylic acid-mediated plant defences, interfere with vesicular trafficking and promote bacterial growth in planta. AvrE-T3Es elicit cell death in both host and non-host plants independent of any known plant resistance protein, suggesting an original interaction with the plant immune system. Recent studies in yeast have indicated that they activate protein phosphatase 2A and inhibit serine palmitoyl transferase, the first enzyme of the sphingolipid biosynthesis pathway. In this review, we describe the current picture that has emerged from studies of the different members of this fascinating large family. © 2015 BSPP AND JOHN WILEY & SONS LTD.

Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.

PubMed

Acker, Michael A; Parides, Michael K; Perrault, Louis P; Moskowitz, Alan J; Gelijns, Annetine C; Voisine, Pierre; Smith, Peter K; Hung, Judy W; Blackstone, Eugene H; Puskas, John D; Argenziano, Michael; Gammie, James S; Mack, Michael; Ascheim, Deborah D; Bagiella, Emilia; Moquete, Ellen G; Ferguson, T Bruce; Horvath, Keith A; Geller, Nancy L; Miller, Marissa A; Woo, Y Joseph; D'Alessandro, David A; Ailawadi, Gorav; Dagenais, Francois; Gardner, Timothy J; O'Gara, Patrick T; Michler, Robert E; Kron, Irving L

2014-01-02

Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of

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

[Periodontal microbiota and microorganisms isolated from heart valves in patients undergoing valve replacement surgery in a clinic in Cali, Colombia].

PubMed

Moreno, Sandra; Parra, Beatriz; Botero, Javier E; Moreno, Freddy; Vásquez, Daniel; Fernández, Hugo; Alba, Sandra; Gallego, Sara; Castillo, Gilberto; Contreras, Adolfo

2017-12-01

Periodontitis is an infectious disease that affects the support tissue of the teeth and it is associated with different systemic diseases, including cardiovascular disease. Microbiological studies facilitate the detection of microorganisms from subgingival and cardiovascular samples. To describe the cultivable periodontal microbiota and the presence of microorganisms in heart valves from patients undergoing valve replacement surgery in a clinic in Cali. We analyzed 30 subgingival and valvular tissue samples by means of two-phase culture medium, supplemented blood agar and trypticase soy agar with antibiotics. Conventional PCR was performed on samples of valve tissue. The periodontal pathogens isolated from periodontal pockets were: Fusobacterium nucleatum (50%), Prevotella intermedia/ nigrescens (40%), Campylobacter rectus (40%), Eikenella corrodens (36.7%), Gram negative enteric bacilli (36.7%), Porphyromonas gingivalis (33.3%), and Eubacterium spp. (33.3%). The pathogens isolated from the aortic valve were Propionibacterium acnes (12%), Gram negative enteric bacilli (8%), Bacteroides merdae (4%), and Clostridium bifermentans (4%), and from the mitral valve we isolated P. acnes and Clostridium beijerinckii. Conventional PCR did not return positive results for oral pathogens and bacterial DNA was detected only in two samples. Periodontal microbiota of patients undergoing surgery for heart valve replacement consisted of species of Gram-negative bacteria that have been associated with infections in extraoral tissues. However, there is no evidence of the presence of periodontal pathogens in valve tissue, because even though there were valve and subgingival samples positive for Gram-negative enteric bacilli, it is not possible to maintain they corresponded to the same phylogenetic origin.

Aortic valve repair with autologous pericardial patch.

PubMed

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

2006-08-01

Isolated aortic valve repair (AVR) has been gaining increasing interest in recent times. Results of isolated aortic valve repair have been reported to be variable. Various techniques have been utilized. We analyzed our experience with isolated valve repair using autologous pericardial patch plasty and compared the results to an age-matched collective with aortic valve repair without the use of additional material. Between January 1997 and June 2005, pericardial patch plasty of the aortic valve was performed in 42 patients (PATCH). During the same period, 42 patients after AVR without the use of additional material were age matched (NO-PATCH). Mean age in both groups was 52 years with a majority of male patients (PATCH ratio, 3.7:1; NO-PATCH ratio, 5:1). Valve anatomy was similar in both groups. All patients were followed by echocardiography for a cumulative follow-up of 2341 patient months (mean 28+/-23 months). No patient died in the hospital in neither group. The average systolic gradient was 5.9+/-2.2 mmHg in PATCH and 4.8+/-2.1 mmHg in NO-PATCH; p=0.17). Freedom from aortic regurgitation > or = II degrees was 87.8% in PATCH and 95.0% in NO-PATCH after 5 years (p=0.21). Freedom from reoperation was 97.6% in PATCH and 97.4% in NO-PATCH (p=0.96). Aortic regurgitation can be treated effectively by aortic valve repair using pericardial patch plasty. The functional results are satisfactory. With the application of this technique also more complex pathologies of the aortic valve can be addressed adequately thus extending the concept of valve preservation in patients with aortic regurgitation.

Determining the impact of 24/7 phone support on hospital readmissions after aortic valve replacement surgery (the AVRre study): study protocol for a randomised controlled trial.

PubMed

Lie, Irene; Danielsen, Stein Ove; Tønnessen, Theis; Solheim, Svein; Leegaard, Marit; Sandvik, Leiv; Wisløff, Torbjørn; Vangen, Jonny; Røsstad, Tor Henning; Moons, Philip

2017-05-30

Patients undergoing surgical aortic valve replacement (sAVR) have high rates of 30-day readmissions. They also report a low health-related quality of life (HRQOL) and elevated anxiety and depression. The aim of the AVRre study is to determine the efficacy and cost of a 24/7 phone-support intervention in reducing post-discharge readmissions after sAVR. The nature of the support is to help patients better understand and self-manage non-urgent symptoms at home. AVRre is a prospective, randomised controlled study comprising 30 days of continuous phone-support intervention and then intermittent follow-up for the first 12 months. Phone call data from and to patients are evaluated qualitatively; thus, the study has a mixed-method design. Two hundred and eighty-six patients, aged >18 years, scheduled for a sAVR - singly or in combination with another procedure - are recruited from locations in southeast Norway. Patients are randomly assigned to the intervention group, who are purposively phone-called individually 2 and 9 days after discharge and offered on-demand 24/7 (around-the-clock) telephone support for 30 days post-discharge. The primary outcome variable is the number of 30-day hospital readmissions. Secondary outcomes are anxiety and depression symptoms, as measured by the Hospital Anxiety and Depression Scale, HRQOL and quality-adjusted life years, measured by the EuroQol (EQ-5D). Intervention and hospital readmission (diagnosis-related groups (DRGs)/length of stay) for the first year after initial discharge from hospital are used for a cost-utility analysis. Standard parametric and non-parametric tests are used for evaluations over time. Analysis of covariance is used to control for possible differences at baseline. Narratives from phone calls are transcribed verbatim and analysed using systematic text condensation. A complex 'around-the-clock' intervention within a university hospital-based setting could be an effective strategy to reduce the high

Comparison of acute elastic recoil between the SAPIEN-XT and SAPIEN valves in transfemoral-transcatheter aortic valve replacement.

PubMed

Garg, Aatish; Parashar, Akhil; Agarwal, Shikhar; Aksoy, Olcay; Hammadah, Muhammad; Poddar, Kanhaiya Lal; Puri, Rishi; Svensson, Lars G; Krishnaswamy, Amar; Tuzcu, E Murat; Kapadia, Samir R

2015-02-15

The SAPIEN-XT is a newer generation balloon-expandable valve created of cobalt chromium frame, as opposed to the stainless steel frame used in the older generation SAPIEN valve. We sought to determine if there was difference in acute recoil between the two valves. All patients who underwent transfemoral-transcatheter aortic valve replacement using the SAPIEN-XT valve at the Cleveland Clinic were included. Recoil was measured using biplane cine-angiographic image analysis of valve deployment. Acute recoil was defined as [(valve diameter at maximal balloon inflation) - (valve diameter after deflation)]/valve diameter at maximal balloon inflation (reported as percentage). Patients undergoing SAPIEN valve implantation were used as the comparison group. Among the 23 mm valves, the mean (standard deviation-SD) acute recoil was 2.77% (1.14) for the SAPIEN valve as compared to 3.75% (1.52) for the SAPIEN XT valve (P = 0.04). Among the 26 mm valves, the mean (SD) acute recoil was 2.85% (1.4) for the SAPIEN valve as compared to 4.32% (1.63) for the SAPIEN XT valve (P = 0.01). Multivariable linear regression analysis demonstrated significantly greater adjusted recoil in the SAPIEN XT valves as compared to the SAPIEN valves by 1.43% [(95% CI: 0.69-2.17), P < 0.001]. However, the residual peak gradient was less for SAPIEN XT compared to SAPIEN valves [18.86 mm Hg versus 23.53 mm Hg (P = 0.01)]. Additionally, no difference in paravalvular leak was noted between the two valve types (P = 0.78). The SAPIEN XT valves had significantly greater acute recoil after deployment compared to the SAPIEN valves. Implications of this difference in acute recoil on valve performance need to be investigated in future studies. © 2014 Wiley Periodicals, Inc.

Repair or Replacement for Isolated Tricuspid Valve Pathology? Insights from a Surgical Analysis on Long-Term Survival

PubMed Central

Farag, Mina; Arif, Rawa; Sabashnikov, Anton; Zeriouh, Mohamed; Popov, Aron-Frederik; Ruhparwar, Arjang; Schmack, Bastian; Dohmen, Pascal M.; Szabó, Gábor; Karck, Matthias; Weymann, Alexander

2017-01-01

Background Long-term follow-up data concerning isolated tricuspid valve pathology after replacement or reconstruction is limited. Current American Heart Association guidelines equally recommend repair and replacement when surgical intervention is indicated. Our aim was to investigate and compare operative mortality and long-term survival in patients undergoing isolated tricuspid valve repair surgery versus replacement. Material/Methods Between 1995 and 2011, 109 consecutive patients underwent surgical correction of tricuspid valve pathology at our institution for varying structural pathologies. A total of 41 (37.6%) patients underwent tricuspid annuloplasty/repair (TAP) with or without ring implantation, while 68 (62.3%) patients received tricuspid valve replacement (TVR) of whom 36 (53%) were mechanical and 32 (47%) were biological prostheses. Results Early survival at 30 days after surgery was 97.6% in the TAP group and 91.1% in the TVR group. After 6 months, 89.1% in the TAP group and 87.8% in the TVR group were alive. In terms of long-term survival, there was no further mortality observed after one year post surgery in both groups (Log Rank p=0.919, Breslow p=0.834, Tarone-Ware p=0.880) in the Kaplan-Meier Survival analysis. The 1-, 5-, and 8-year survival rates were 85.8% for TAP and 87.8% for TVR group. Conclusions Surgical repair of the tricuspid valve does not show survival benefit when compared to replacement. Hence valve replacement should be considered generously in patients with reasonable suspicion that regurgitation after repair will reoccur. PMID:28236633

Reoperations after tricuspid valve repair: re-repair versus replacement

PubMed Central

Hwang, Ho Young; Kim, Kyung-Hwan; Kim, Ki-Bong

2016-01-01

Background Data demonstrating results of reoperation after initial tricuspid valve repair are scarce. We evaluated outcomes of tricuspid reoperations after tricuspid valve repair and compared the results of tricuspid re-repair with those of tricuspid valve replacement (TVR). Methods From 1994 to 2012, 53 patients (56±15 years, male:female =14:39) underwent tricuspid reoperations due to recurrent tricuspid regurgitation (TR) after initial repair. Twenty-two patients underwent tricuspid re-repair (TAP group) and 31 patients underwent TVR (TVR group). Results Early mortality occurred in 6 patients (11%). Early mortality and incidence of postoperative complications were similar between the 2 groups. There were 14 cases of late mortality including 9 cardiac deaths. Five- and 10-year free from cardiac death rates were 82% and 67%, respectively, without any intergroup difference. Recurrent TR (> moderate) developed in 6 TAP group patients and structural valve deterioration occurred in 1 TVR group patient (P=0.002). Isolated tricuspid valve surgery (P=0.044) and presence of atrial fibrillation during the follow-up (P=0.051) were associated with recurrent TR after re-repair. However, the overall tricuspid valve-related event rates were similar between the 2 groups with 5- and 10-year rates of 61% and 41%, respectively. Conclusions Tricuspid valve reoperation after initial repair resulted in high rates of operative mortality and complications. Long-term event-free rate was similar regardless of the type of surgery. However, great care might be needed when performing re-repair in patients with atrial fibrillation and those who had isolated tricuspid valve disease due to high recurrence of TR after re-repair. PMID:26904221

Prosthetic valve sparing aortic root replacement: an improved technique.

PubMed

Leacche, Marzia; Balaguer, Jorge M; Umakanthan, Ramanan; Byrne, John G

2008-10-01

We describe a modified surgical technique to treat patients with a previous history of isolated aortic valve replacement who now require aortic root replacement for an aneurysmal or dissected aorta. This technique consists of replacing the aortic root with a Dacron conduit, leaving intact the previously implanted prosthesis, and re-implanting the coronary arteries in the Dacron graft. Our technique differs from other techniques in that we do not leave behind any aortic tissue remnant and also in that we use a felt strip to obliterate any gap between the old sewing ring and the newly implanted graft. In our opinion, this promotes better hemostasis. We demonstrate that this technique is safe, feasible, and results in acceptable outcomes.

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

Incidence, Timing, and Predictors of Valve Hemodynamic Deterioration After Transcatheter Aortic Valve Replacement: Multicenter Registry.

PubMed

Del Trigo, Maria; Muñoz-Garcia, Antonio J; Wijeysundera, Harindra C; Nombela-Franco, Luis; Cheema, Asim N; Gutierrez, Enrique; Serra, Vicenç; Kefer, Joelle; Amat-Santos, Ignacio J; Benitez, Luis M; Mewa, Jumana; Jiménez-Quevedo, Pilar; Alnasser, Sami; Garcia Del Blanco, Bruno; Dager, Antonio; Abdul-Jawad Altisent, Omar; Puri, Rishi; Campelo-Parada, Francisco; Dahou, Abdellaziz; Paradis, Jean-Michel; Dumont, Eric; Pibarot, Philippe; Rodés-Cabau, Josep

2016-02-16

Scarce data exist on the incidence of and factors associated with valve hemodynamic deterioration (VHD) after transcatheter aortic valve replacement (TAVR). This study sought to determine the incidence, timing, and predictors of VHD in a large cohort of patients undergoing TAVR. This multicenter registry included 1,521 patients (48% male; 80 ± 7 years of age) who underwent TAVR. Mean echocardiographic follow-up was 20 ± 13 months (minimum: 6 months). Echocardiographic examinations were performed at discharge, at 6 to 12 months, and yearly thereafter. Annualized changes in mean gradient (mm Hg/year) were calculated by dividing the difference between the mean gradient at last follow-up and the gradient at discharge by the time between examinations. VHD was defined as a ≥10 mm Hg increase in transprosthetic mean gradient during follow-up compared with discharge assessment. The overall mean annualized rate of transprosthetic gradient progression during follow-up was 0.30 ± 4.99 mm Hg/year. A total of 68 patients met criteria of VHD (incidence: 4.5% during follow-up). The absence of anticoagulation therapy at hospital discharge (p = 0.002), a valve-in-valve (TAVR in a surgical valve) procedure (p = 0.032), the use of a 23-mm valve (p = 0.016), and a greater body mass index (p = 0.001) were independent predictors of VHD. There was a mild but significant increase in transvalvular gradients over time after TAVR. The lack of anticoagulation therapy, a valve-in-valve procedure, a greater body mass index, and the use of a 23-mm transcatheter valve were associated with higher rates of VHD post-TAVR. Further prospective studies are required to determine whether a specific antithrombotic therapy post-TAVR may reduce the risk of VHD. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Dynamic Course of Serratia marcescens Pulmonic Valve Endocarditis Resulting in Submassive PE and Valve Replacement.

PubMed

Meyer, Chloe Grace; Vacek, Thomas Paul; Bansal, Amit; Gurujal, Ravi; Parikh, Analkumar

2018-01-01

This report illustrates a case of a 42-year-old male with a history of intravenous drug abuse who presented with septic shock. Diagnostic studies, including a transthoracic echocardiogram, chest computed tomography angiography, transesophageal echocardiogram, and blood cultures ultimately revealed Serratia marcescens pulmonic valve infective endocarditis that was treated with intravenous antibiotics. In addition to the rare form of endocarditis and bacterium involved, this case brings into awareness the dynamic nature of the hospital course that requires vigilance in responding to hypotensive episodes for consideration of pulmonary embolism. Surgical valve replacement was opted for due to such a complication in addition to the large size of the vegetation, 2.5 cm.

Pseudomonas syringae effector avrB confers soybean cultivar-specific avirulence on Soybean mosaic virus adapted for transgene expression but effector avrPto does not.

PubMed

Wang, Li; Eggenberger, Alan; Hill, John; Bogdanove, Adam J

2006-03-01

Soybean mosaic virus (SMV) was adapted for transgene expression in soybean and used to examine the function of avirulence genes avrB and avrPto of Pseudomonas syringae pvs. glycinea and tomato, respectively. A cloning site was introduced between the P1 and HC-Pro genes in 35S-driven infectious cDNAs of strains SMV-N and SMV-G7. Insertion of the uidA gene or the green fluorescent protein gene into either modified cDNA and bombardment into primary leaves resulted in systemic expression that reflected the pattern of viral movement into uninoculated leaves. Insertion of avrB blocked symptom development and detectable viral movement in cv. Harosoy, which carries the Rpg1-b resistance gene corresponding to avrB, but not in cvs. Keburi or Hurrelbrink, which lack Rpg1-b. In Keburi and Hurrelbrink, symptoms caused by SMV carrying avrB appeared more quickly and were more severe than those caused by the virus without avrB. Insertion of avrPto enhanced symptoms in Harosoy, Hurrelbrink, and Keburi. This result was unexpected because avrPto was reported to confer avirulence on P. syringae pv. glycinea inoculated to Harosoy. We inoculated Harosoy with P syringae pv. glycinea expressing avrPto, but observed no hypersensitive reaction, avrPto-dependent induction of pathogenesis-related protein la, or limitation of bacterial population growth. In Hurrelbrink, avrPto enhanced bacterial multiplication and exacerbated symptoms. Our results establish SMV as an expression vector for soybean. They demonstrate that resistance triggered by avrB is effective against SMV, and that avrB and avrPto have general virulence effects in soybean. The results also led to a reevaluation of the reported avirulence activity of avrPto in this plant.

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

Is mitral valve repair superior to replacement for chronic ischemic mitral regurgitation with left ventricular dysfunction?

PubMed Central

2010-01-01

Background This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation (IMR) with left ventricular dysfunction (LVD). Specifically, we sought to determine whether the choice of mitral valve procedure affected survival, and discover which patients were predicted to benefit from mitral valve repair and which from replacement. Methods A total of 218 consecutive patients underwent either mitral valve repair (MVP, n = 112) or mitral valve replacement (MVR, n = 106). We retrospectively reviewed the clinical material, operation methods, echocardiography check during operation and follow-up. Patients details and follow-up outcomes were compared using multivariate and Kaplan-Meier analyses. Results No statistical difference was found between the two groups in term of intraoperative data. Early mortality was 3.2% (MVP 2.7% and MVR 3.8%). At discharge, Left ventricular end-systolic and end-diastolic diameter and left ventricular ejection fraction (LVEF) were improved more in the MVP group than MVR group (P < 0.05), however, in follow-up no statistically significant difference was observed between the MVR and MVP group (P > 0.05). Follow-up mitral regurgitation grade was significantly improved in the MVR group compared with the MVP group (P < 0.05). The Kaplan-Meier survival estimates at 1, 3, and 5 years were simlar between MVP and MVR group. Logistic regression revealed poor survival was associated with old age(#75), preoperative renal insufficiency and low left ventricular ejection fraction (< 30%). Conclusion Mitral valve repair is the procedure of choice in the majority of patients having surgery for severe ischemic mitral regurgitation with left ventricular dysfunction. Early results of MVP treatment seem to be satisfactory, but several lines of data indicate that mitral valve repair provided less long-term benefit than mitral valve replacement in the LVD patients. PMID:21059216

Posterior leaflet preservation during mitral valve replacement for rheumatic mitral stenosis.

PubMed

Djukić, P L; Obrenović-Kirćanski, B B; Vranes, M R; Kocica, M J; Mikić, A Dj; Velinović, M M; Kacar, S M; Kovacević, N S; Parapid, B J

2006-01-01

Mitral valve replacement with posterior leaflet preservation was shown beneficial for postoperative left vetricular (LV) performance in patients with mitral regurgitation. Some authors find it beneficial even for the long term LV function. We investigated a long term effect of this technique in patients with rheumatic mitral stenosis. We studied 20 patents with mitral valve replacement due to rheumatic mitral stenosis, in the period from January 1988 to December 1989. In group A (10 patients) both leaflets and coresponding chordal excision was performed, while in group B (10 patients) the posterior leaflet was preserved. In all patients a Carbomedics valve was inserted. We compared clinical pre and postoperative status, as well as hemodynamic characteristics of the valve and left ventricle in both groups. Control echocardiographyc analysis included: maximal (PG) and mean (MG) gradients; effective valve area (AREA); telediastolic (TDV) and telesystolic (TSV) LV volume; stroke volume (SV); ejection fraction (EF); fractional shortening (FS) and segmental LV motion. The mean size of inserted valve was 26.6 in group A and 27.2 in group B. Hemodynamic data: PG (10.12 vs 11.1); MG (3.57 vs 3.87); AREA (2.35 vs 2.30); TDV 126.0 vs 114.5); TSV (42.2 vs 36.62); SV (83.7 vs 77.75); EF (63.66 vs 67.12); FS (32.66 vs 38.25). Diaphragmal segmental hypokinesis was evident in one patient from group A and in two patients from group B. In patients with rheumatic stenosis, posterior leaflet preservation did not have increased beneficial effect on left ventricular performance during long-term follow-up. An adequate posterior leaflet preservation does not change hemodynamic valvular characteristics even after long-term follow-up.

Morbidity following the Ross operation.

PubMed

Gonzalez-Lavin, L; Robles, A; Graf, D

1988-09-01

Aortic valve replacement (AVR) with a pulmonary valve autograft (PVA) was first reported by Donald N. Ross in 1967. The expectation of this procedure was to avoid degenerative changes seen in other biological tissue valves such as calcification, attenuation, and rupture of the leaflets. Recent reports by the original investigator's group have confirmed the lack of degenerative changes in PVA. To corroborate their conclusions, the fate of 12 patients undergoing AVR with PVA by Dr. Gonzalez-Lavin has been ascertained. From March 1969 to June 1971, 12 patients underwent AVR with PVA. The right ventricular outflow tract (RVOT) was reconstructed with an aortic homograft valved conduit. The mean age was 42.7 years (range 21 to 52 years). The mean follow-up for 11 hospital survivors is 12.4 years. Three PVAs have been replaced; one following infective endocarditis at 13 years, and two at 15 and 73 months due to technical malalignment. There was no evidence of PVA degeneration during histologic examination of these explanted PVA. Six patients are alive and retain the original PVA at 12 years (55%). This analysis corroborates the conclusions of Dr. Ross and strongly suggests an immunological mechanism in the process of calcification of other biological tissue valves. The Ross operation is believed to be the preferred method of AVR in young patients.

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.

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.

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.

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.

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

Illness Perception Profiles and Their Association with 10-Year Survival Following Cardiac Valve Replacement.

PubMed

Crawshaw, Jacob; Rimington, Helen; Weinman, John; Chilcot, Joseph

2015-10-01

The aim of the present study was to examine whether profiles of illness perceptions are associated with 10-year survival following cardiac valve replacement surgery. Illness perceptions were evaluated in 204 cardiac patients awaiting first-time valve replacement and again 1 year post-operatively using cluster analysis. All-cause mortality was recorded over a 10-year period. At 1 year, 136 patients were grouped into one of four profiles (stable positive, stable negative, changed from positive to negative, changed from negative to positive). The median follow-up was 3063 days (78 deaths). After controlling for clinical covariates, including markers of function, patients who changed illness perceptions from positive to negative beliefs 1 year post-surgery had an increased mortality risk (hazard ratio (HR) = 3.2, 95% confidence interval (CI) 1.2-8.3, p = .02) compared to patients who held positive stable perceptions. Following cardiac valve replacement, developing negative illness perceptions over the first post-operative year predicts long-term mortality. Early screening and intervention to alter this pattern of beliefs may be beneficial.

Twin Valve Caval Stent for Functional Replacement of Incompetent Tricuspid Valve: A Feasibility Animal Study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sochman, Jan, E-mail: jan.sochman@medicon.cz; Peregrin, Jan H., E-mail: jape@medicon.cz; Pavcnik, Dusan, E-mail: pavcnikd@ohsu.edu

Objective: To evaluate feasibility of a twin valve caval stent (TVCS) for functional replacement of an incompetent tricuspid valve (TV) in an acute animal study. Methods: One swine and three sheep were used in the study. TVCS placement was tested in a swine with a normal TV. TVCS function was tested in three sheep with TV regurgitation created by papillary muscle avulsion. Cardiac angiograms and pressure measurements were used to evaluate TVCS function. Two sheep were studied after fluid overload. Results: TVCS was percutaneously placed properly at the central portions of the superior vena cava (SVC) and inferior vena cavamore » (IVC) in the swine. Papillary muscle avulsion in three sheep caused significant tricuspid regurgitation with massive reflux into the right atrium (RA) and partial reflux into the SVC and IVC. TVCS placement eliminated reflux into the SVC and IVC. After fluid overload, there was enlargement of the right ventricle and RA and significant increase in right ventricle, RA, SVC, and IVC pressures, but no reflux into the IVC and SVC. Conclusion: The results of this feasibility study justify detailed evaluation of TVCS insertion for functional chronic replacement of incompetent TV.« less

The valve choice in tricuspid valve replacement: 25 years of experience.

PubMed

Van Nooten, G J; Caes, F L; François, K J; Taeymans, Y; Primo, G; Wellens, F; Leclerq, J L; Deuvaert, F E

1995-01-01

This study reviews 146 consecutive patients who underwent tricuspid valve replacement (TVR) with 69 bioprostheses (porcine and bovine pericardial) and 77 mechanical ball, disc or bileaflet valves between 1967 and 1987. The mean age was 51.4 +/- 12.1 years. Preoperatively, 97% were in New York Heart Association (NYHA) functional class III or more and over 40% had undergone previous cardiac surgery. Hospital mortality was high (16.1%). Incremental risk factors for hospital death were preoperative icterus (P < 0.01), hepatomegaly (P = 0.02), NYHA functional class IV (P = 0.02) and male sex (P = 0.04) (univariate analysis). Ninety-eight percent of the hospital survivors were followed up for a mean of 92 months. Cumulative follow-up added up to 955 patient-years. There were 70 late deaths. The actuarial survival rate was 74% at 60 months and less than 25% at 14 years. Incremental risk factors for late death indicated by univariate analysis were the type of tricuspid prosthesis (Smel-off-Cutter and Kay-Shiley prostheses) (P = 0.04), the type of operative myocardial protection (normothermia and coronary perfusion) (P = 0.05) and preoperative NYHA functional class IV (P = 0.05). We conclude that TVR carries a high operative risk and poor long-term survival, both influenced by preoperative and perioperative variables. Bearing in mind the poor prognosis for TVR, we prefer a large-sized bioprosthesis, in view of its initial good durability and low risk of valve-related events. However, in patients with good life expectancy, a bileaflet mechanical prosthesis may be an acceptable alternative.

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.

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

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

Outcomes of De Vega versus biodegradable ring annuloplasty in the surgical treatment of tricuspid regurgitation (mid-term results).

PubMed

Basel, Halil; Aydin, Unal; Kutlu, Hakan; Dostbil, Aysenur; Karadag, Melike; Odabasi, Dolunay; Aydin, Cemalettin

2010-08-01

The aim of this study was to compare De Vega semicircular annuloplasty and a new biodegradable ring annuloplasty technique in patients requiring surgical intervention for tricuspid valve disease with concomitant disease of the mitral valve. Between January 2004 and May 2008, 129 consecutive patients underwent annuloplasty procedures to correct tricuspid valve regurgitation during a concomitant mitral valve operation requiring replacement. Additionally, 24 patients underwent aortic valve replacement (AVR), 11 underwent coronary artery bypass grafting (CABG), 5 underwent AVR plus CABG, 3 underwent mitral valve replacement plus atrial septal defect (ASD) closure, and 2 underwent ASD closure. The patients in this study were assigned to 2 groups: Kalangos ring annuloplasty was performed in 67 patients (group 1), and De Vega semicircular annuloplasty was performed in the remaining 62 patients (group 2). Both tricuspid valve repair techniques produced a low rate of complications; however, the number of patients who developed residual tricuspid regurgitation was significantly lower in group 1. The biodegradable ring annuloplasty technique may be used easily and safely in moderate and severe cases of tricuspid regurgitation; however, larger clinical series are necessary to confirm our promising results.

Percutaneous Transcatheter Mitral Valve Replacement: Patient-specific Three-dimensional Computer-based Heart Model and Prototyping.

PubMed

Vaquerizo, Beatriz; Theriault-Lauzier, Pascal; Piazza, Nicolo

2015-12-01

Mitral regurgitation is the most prevalent valvular heart disease worldwide. Despite the widespread availability of curative surgical intervention, a considerable proportion of patients with severe mitral regurgitation are not referred for treatment, largely due to the presence of left ventricular dysfunction, advanced age, and comorbid illnesses. Transcatheter mitral valve replacement is a promising therapeutic alternative to traditional surgical valve replacement. The complex anatomical and pathophysiological nature of the mitral valvular complex, however, presents significant challenges to the successful design and implementation of novel transcatheter mitral replacement devices. Patient-specific 3-dimensional computer-based models enable accurate assessment of the mitral valve anatomy and preprocedural simulations for transcatheter therapies. Such information may help refine the design features of novel transcatheter mitral devices and enhance procedural planning. Herein, we describe a novel medical image-based processing tool that facilitates accurate, noninvasive assessment of the mitral valvular complex, by creating precise three-dimensional heart models. The 3-dimensional computer reconstructions are then converted to a physical model using 3-dimensional printing technology, thereby enabling patient-specific assessment of the interaction between device and patient. It may provide new opportunities for a better understanding of the mitral anatomy-pathophysiology-device interaction, which is of critical importance for the advancement of transcatheter mitral valve replacement. Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

[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.

Midterm results after aortic valve replacement with freehand stentless xenografts: a comparison of three prostheses.

PubMed

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

1998-06-01

The ideal substitute for the diseased aortic valve is yet to be found. For the assessment and comparison of the midterm results after aortic valve replacement with three different types of freehand stentless xenografts, all patients who underwent the operation between October 1992 and April 1997 were reviewed. Of 231 patients undergoing aortic valve replacement, 106 patients (group 1) were given the Biocor PSB (Biocor Industria e Pesquisa Ltda, Belo Horizonte, MG, Brazil); 76 patients (group 2) were given the Toronto SPV (St. Jude Medical, Inc., St. Paul, Minn.), and 49 patients (group 3) were given the O'Brien-Angell valve (Bravo Cardiovascular model 300, Cryolife, Inc., Marietta, Ga.). The first two xenografts require inflow and outflow suturelines; the third xenograft needs a single-sutureline implantation. Mean age (70 +/- 6 years; 70 +/- 7 years; 72 +/- 9 years; p = 0.6), prevalence of male sex (56 patients, 53%; 37 patients, 49%; 22 patients, 45%; p = 0.7), of aortic stenosis (72 patients, 68%; 54 patients, 71%; 37 patients, 73%; p = 0.6), and need for associated procedures (51 patients, 48%; 30 patients, 40%; 21 patients, 43%; p = 0.1) were comparable among groups. Mean aortic crossclamp time was shorter in group 3 (96 +/- 24 minutes; 100 +/- 23 minutes; 88 +/- 25 minutes;p = 0.01). Early deaths were 3 of 106 (3%) in group 1, 2 of 76 (3%) in group 2, and 2 of 49 (4%) in group 3. Follow-up of survivors ranged from 1 to 54 months (mean 32 +/- 13 months). Survival at 4 years was 90% +/- 3% in group 1, 95% +/- 3% in group 2, 85% +/- 8% in group 3 (p = 0.3). At 4 years, freedom from valve-related events was 95% +/- 6%, 100%, 70% +/- 8% (p = 0.004), while freedom from valve deterioration was 99% +/- 1%, 100%, 73% +/- 8% (p = 0.001), in group 1, 2, and 3, respectively (p = 0.001). At follow-up, reintervention on the xenograft was necessary in one patient (endocarditis) in group 1, none in group 2, and six in group 3 (technical cause, group 3; valve tear, group 2

Computerized system for the follow-up of patients with heart valve replacements.

PubMed

Bain, W H; Fyfe, I C; Rodger, R A

1985-04-01

A system is described which will accept, store, retrieve and analyze information on large numbers of patients who undergo valve replacement surgery. The purpose of the database is to yield readily available facts concerning the patient's clinical course, prosthetic valve function, length of survival, and incidence of complications. The system uses the Apple Macintosh computer, which is one of the current examples of small, desk-top microprocessors. The software for the input, editing and analysis programs has been written by a professional software writer in close collaboration with a cardiac surgeon. Its content is based on 8 years' experience of computer-based valve follow-up. The system is inexpensive and has proved easy to use in practice.

Added value of cardiac computed tomography for evaluation of mechanical aortic valve: Emphasis on evaluation of pannus with surgical findings as standard reference.

PubMed

Suh, Young Joo; Lee, Sak; Im, Dong Jin; Chang, Suyon; Hong, Yoo Jin; Lee, Hye-Jeong; Hur, Jin; Choi, Byoung Wook; Chang, Byung-Chul; Shim, Chi Young; Hong, Geu-Ru; Kim, Young Jin

2016-07-01

The added value of cardiac computed tomography (CT) with transesophageal echocardiography (TEE) for evaluating mechanical aortic valve (AV) dysfunction has not yet been investigated. The purposes of this study were to investigate the added value of cardiac CT for evaluation of mechanical AVs and diagnoses of pannus compared to TEE, with surgical findings of redo-aortic valve replacement (AVR) used as a standard reference. 25 patients who underwent redo-AVR due to mechanical AV dysfunction and cardiac CT before redo-AVR were included. The presence of pannus, encroachment ratio by pannus, and limitation of motion (LOM) were evaluated on CT. The diagnostic performance of pannus detection was compared using TEE, CT, and CT+TEE, with surgical findings as a standard reference. The added value of CT for diagnosing the cause of mechanical AV dysfunction was assessed compared to TTE+TEE. In two patients, CT analysis was not feasible due to severe metallic artifacts. On CT, pannus and LOM were found in 100% (23/23) and 60.9% (14/23). TEE identified pannus in 48.0% of patients (12/25). CT, TEE, and CT+TEE correctly identified pannus with sensitivity of 92.0%, 48.0%, and 92.0%, respectively (P=0.002 for CT vs. TEE). In 11 of 13 cases (84.6%) with inconclusive or negative TEE results for pannus, CT detected the pannus. Among 13 inconclusive cases of TTE+TEE for the cause of mechanical AV dysfunction, CT suggested 6 prosthetic valve obstruction (PVO) by pannus, 4 low-flow low-gradient PVO, and one LOM without significant PVO. Cardiac CT showed added diagnostic value with TEE in the detection of pannus as the cause of mechanical AV dysfunction. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Correlation between systolic transvalvular flow and proximal aortic wall changes in bicuspid aortic valve stenosis.

PubMed

Girdauskas, Evaldas; Rouman, Mina; Disha, Kushtrim; Scholle, Thorsten; Fey, Beatrix; Theis, Bernhard; Petersen, Iver; Borger, Michael A; Kuntze, Thomas

2014-08-01

The purpose of this study was to analyse the correlation between preoperative systolic transvalvular flow patterns and proximal aortic wall lesions in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis. A total of 48 consecutive patients with BAV stenosis (mean age 58 ± 9 years, 65% male) underwent aortic valve replacement (AVR) ± proximal aortic surgery from January 2012 through February 2013. Preoperative cardiac phase-contrast cine magnetic resonance imaging (MRI) assessment was performed in all patients in order to detect the area of maximal flow-induced stress in the proximal aorta. Based on these MRI data, two aortic wall samples (i.e. area of the maximal stress (jet sample) and the opposite aortic wall (control sample)) were collected during AVR surgery. Aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3). Histological sum score (0-21) was separately calculated and compared between the two aortic samples (i.e. jet sample vs control sample). An eccentric transvalvular flow jet hitting the proximal aortic wall could be identified in all 48 (100%) patients. The mean histological sum score was significantly higher in the jet sample vs control sample areas of the aorta (i.e. 4.1 ± 1.8 vs 2.2 ± 1.5, respectively) (P = 0.02). None of the patients had a higher sum score value in the control sample. Our study demonstrates a strong correlation between the systolic pattern of the transvalvular flow jet and asymmetric proximal aortic wall changes in patients undergoing AVR for BAV stenosis. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Cardiac Imaging for Assessing Low-Gradient Severe Aortic Stenosis.

PubMed

Clavel, Marie-Annick; Burwash, Ian G; Pibarot, Philippe

2017-02-01

Up to 40% of patients with aortic stenosis (AS) harbor discordant Doppler-echocardiographic findings, the most common of which is the presence of a small aortic valve area (≤1.0 cm 2 ) suggesting severe AS, but a low gradient (<40 mm Hg) suggesting nonsevere AS. The purpose of this paper is to present the role of multimodality imaging in the diagnostic and therapeutic management of this challenging entity referred to as low-gradient AS. Doppler-echocardiography is critical to determine the subtype of low-gradient AS: that is, classical low-flow, paradoxical low-flow, or normal-flow. Patients with low-flow, low-gradient AS generally have a worse prognosis compared with patients with high-gradient or with normal-flow, low-gradient AS. Patients with low-gradient AS and evidence of severe AS benefit from aortic valve replacement (AVR). However, confirmation of the presence of severe AS is particularly challenging in these patients and requires a multimodality imaging approach including low-dose dobutamine stress echocardiography and aortic valve calcium scoring by multidetector computed tomography. Transcatheter AVR using a transfemoral approach may be superior to surgical AVR in patients with low-flow, low-gradient AS. Further studies are needed to confirm the best valve replacement procedure and prosthetic valve for each category of low-gradient AS and to identify patients with low-gradient AS in whom AVR is likely to be futile. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Thrombocytopenia following implantation of the stentless biological sorin freedom SOLO valve.

PubMed

Gersak, Borut; Gartner, Urska; Antonic, Miha

2011-07-01

Stentless biological valves have proven advantages in hemodynamic performance and left ventricular function compared to stented biological valves. Following a marked postoperative fall in the platelet count of patients after implantation of the Freedom SOLO valve, the study aim was to confirm clinical observations that this effect was more severe in patients receiving Freedom SOLO valves than in those receiving St. Jude Medical (SJM) mechanical aortic valves. Preoperative and postoperative platelet counts were compared in two groups of patients who underwent aortic valve replacement (AVR) without any concomitant procedures between January and December 2007. Patients received either a Freedom SOLO valve (n = 28) or a SJM mechanical valve (n = 41). Mean values of platelet counts were compared using three multiple linear regression models. Platelet counts were significantly lower in the Freedom SOLO group than in the SJM group from the first postoperative day (POD 1) up to POD 6 (p <0.001). In three patients of the Freedom SOLO group the platelet count fell below 30x10(9)/l, while the lowest level in the SJM group was 75x10(9)/l. Based on multiple linear regression models, the type of valve implanted had a statistically significant influence on postoperative platelet counts on POD 1, POD 3, and POD 5 (p <0.001). Whilst the reason for this phenomenon is unknown, the use of consistent monitoring should prevent severe falls in platelet count from becoming dangerous for the patient. Further studies are required to investigate the phenomenon since, despite a shorter cardiopulmonary bypass time, the fall in platelet count was more profound in the Freedom SOLO group.

Late-term results of mitral valve replacement with St. Jude Medical mechanical valve prosthesis: Samsun experience.

PubMed

Demirag, Mustafa Kemal; Keceligil, Hasan Tahsin; Kolbakir, Fersat

2006-10-01

We have reported the short- and long-term results of mitral valve replacement in this article. Mitral valve replacement was conducted in 276 patients in our clinic between January 1989 and March 2005. The youngest patient was 4 years old and the oldest patient was 74 years old. Mean age was 40.08 +/- 1.06 y. Of these patients, 41.3% were men and 58.7% were women. The reason for operation was mitral stenosis in 96 patients (34.78%), mitral insufficiency in 78 patients (29.26%) and mitral stenosis plus mitral insufficiency in 102 patients (36.96%). The aetiology of mitral valve lesions was acute rheumatic fever in 208 patients (75.36%). The aetiology of mitral valve lesions was degenerative in 37 patients (13.41%), ischaemic in 23 patients (8.33%) and congenital in 8 patients (2.9%). In the 5, 10 and 15-year periods, the actual survival rates were 87.64% +/- 2.02%, 83.35% +/- 2.38% and 68.19% +/- 5.63%, respectively. Thromboembolism was observed in 38 patients (13.77%). The rates of actual freedom from thromboembolism in the 5, 10 and 15-year periods were 93.08% +/- 1.53%, 88.48% +/- 1.99% and 81.06% +/- 3.43%, respectively. Of the 276 patients who had been observed for 15 years, 5 had (1.81%) valvular thrombosis. The rates of actual freedom from valvular thrombosis in the 5, 10 and 15-year periods were 98.89% +/- 0.64%, 98.04% +/- 0.87% and 98.04% +/- 0.87%, respectively. In the 15-year period, 23 patients (8.33%) had haemorrhage due to anti-coagulation. The rates of actual freedom from haemorrhage due to anti-coagulation in the 5, 10 and 15-year periods were 95.64% +/- 1.23%, 93.40% +/- 1.56% and 87.73% +/- 2.96%, respectively. Seven patients (2.54%) had prosthetic valvular endocarditis. The rates of actual freedom from endocarditis in the 5, 10 and 15-year periods were 98.51% +/- 0.74%, 97.60% +/- 0.97% and 97.01% +/- 1.13%, respectively. Nine patients (3.27%) were re-operated. The rates of actual freedom from re-operation in the 5, 10 and 15-year periods were 97

Transcatheter Pulmonary Valve Replacement by Hybrid Approach Using a Novel Polymeric Prosthetic Heart Valve: Proof of Concept in Sheep

PubMed Central

Xu, Tong-yi; Zhang, Zhi-gang; Li, Xin; Han, Lin; Xu, Zhi-yun

2014-01-01

Background Since 2000, transcatheter pulmonary valve replacement has steadily advanced. However, the available prosthetic valves are restricted to bioprosthesis which have defects like poor durability. Polymeric heart valve is thought as a promising alternative to bioprosthesis. In this study, we introduced a novel polymeric transcatheter pulmonary valve and evaluated its feasibility and safety in sheep by a hybrid approach. Methods We designed a novel polymeric trileaflet transcatheter pulmonary valve with a balloon-expandable stent, and the valve leaflets were made of 0.1-mm expanded polytetrafluoroethylene (ePTFE) coated with phosphorylcholine. We chose glutaraldehyde-treated bovine pericardium valves as control. Pulmonary valve stents were implanted in situ by a hybrid transapical approach in 10 healthy sheep (8 for polymeric valve and 2 for bovine pericardium valve), weighing an average of 22.5±2.0 kg. Angiography and cardiac catheter examination were performed after implantation to assess immediate valvular functionality. After 4-week follow-up, angiography, echocardiography, computed tomography, and cardiac catheter examination were used to assess early valvular function. One randomly selected sheep with polymeric valve was euthanized and the explanted valved stent was analyzed macroscopically and microscopically. Findings Implantation was successful in 9 sheep. Angiography at implantation showed all 9 prosthetic valves demonstrated orthotopic position and normal functionality. All 9 sheep survived at 4-week follow-up. Four-week follow-up revealed no evidence of valve stent dislocation or deformation and normal valvular and cardiac functionality. The cardiac catheter examination showed the peak-peak transvalvular pressure gradient of the polymeric valves was 11.9±5.0 mmHg, while that of two bovine pericardium valves were 11 and 17 mmHg. Gross morphology demonstrated good opening and closure characteristics. No thrombus or calcification was seen

The management of patients with aortic regurgitation and severe left ventricular dysfunction: a systematic review.

PubMed

Badar, Athar A; Brunton, Alan P T; Mahmood, Ammad H; Dobbin, Stephen; Pozzi, Andrea; McMinn, Jenna F; Sinclair, Andrew J E; Gardner, Roy S; Petrie, Mark C; Curry, Phil A; Al-Attar, Nawwar H K; Pettit, Stephen J

2015-01-01

A systematic search of Medline, EMBASE and CINAHL electronic databases was performed. Original research articles reporting all-cause mortality following surgery in patients with aortic regurgitation and severe left ventricular systolic dysfunction (LVSD) were identified. Nine of the 10 eligible studies were observational, single-center, retrospective analyses. Survival ranged from 86 to 100% at 30 days; 81 to 100% at 1 year and 68 to 84% at 5 years. Three studies described an improvement in mean left ventricular ejection fraction (LVEF) following aortic valve replacement (AVR) of 5-14%; a fourth study reported an increase in mean left ventricular ejection fraction (LVEF) of 9% in patients undergoing isolated AVR but not when AVR was combined with coronary artery bypass graft and/or mitral valve surgery. Three studies demonstrated improvements in functional New York Heart Association (NYHA) class following AVR. Additional studies are needed to clarify the benefits of AVR in patients with more extreme degrees of left ventricular systolic dysfunction (LVSD) and the potential roles of cardiac transplantation and transaortic valve implantation.

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).

Evolutionary Relationship of Disease Resistance Genes in Soybean and Arabidopsis Specific for the Pseudomonas syringae Effectors AvrB and AvrRpm11[W][OPEN

PubMed Central

Ashfield, Tom; Redditt, Thomas; Russell, Andrew; Kessens, Ryan; Rodibaugh, Natalie; Galloway, Lauren; Kang, Qing; Podicheti, Ram; Innes, Roger W.

2014-01-01

In Arabidopsis (Arabidopsis thaliana), the Pseudomonas syringae effector proteins AvrB and AvrRpm1 are both detected by the RESISTANCE TO PSEUDOMONAS MACULICOLA1 (RPM1) disease resistance (R) protein. By contrast, soybean (Glycine max) can distinguish between these effectors, with AvrB and AvrRpm1 being detected by the Resistance to Pseudomonas glycinea 1b (Rpg1b) and Rpg1r R proteins, respectively. We have been using these genes to investigate the evolution of R gene specificity and have previously identified RPM1 and Rpg1b. Here, we report the cloning of Rpg1r, which, like RPM1 and Rpg1b, encodes a coiled-coil (CC)-nucleotide-binding (NB)-leucine-rich repeat (LRR) protein. As previously found for Rpg1b, we determined that Rpg1r is not orthologous with RPM1, indicating that the ability to detect both AvrB and AvrRpm1 evolved independently in soybean and Arabidopsis. The tightly linked soybean Rpg1b and Rpg1r genes share a close evolutionary relationship, with Rpg1b containing a recombination event that combined a NB domain closely related to Rpg1r with CC and LRR domains from a more distantly related CC-NB-LRR gene. Using structural modeling, we mapped polymorphisms between Rpg1b and Rpg1r onto the predicted tertiary structure of Rpg1b, which revealed highly polymorphic surfaces within both the CC and LRR domains. Assessment of chimeras between Rpg1b and Rpg1r using a transient expression system revealed that AvrB versus AvrRpm1 specificity is determined by the C-terminal portion of the LRR domain. The P. syringae effector AvrRpt2, which targets RPM1 INTERACTOR4 (RIN4) proteins in both Arabidopsis and soybean, partially blocked recognition of both AvrB and AvrRpm1 in soybean, suggesting that both Rpg1b and Rpg1r may detect these effectors via modification of a RIN4 homolog. PMID:25034017

A 20-year study on treating childhood infective endocarditis with valve replacement in a single cardiac center in China.

PubMed

Xiao, Jian; Yin, Liang; Lin, Yiyun; Zhang, Yufeng; Wu, Lihui; Wang, Zhinong

2016-07-01

Children with infective endocarditis (IE) have to undergo valve replacement instead of valve repair in China due to severe valve damage. The present study is to review our experience on surgical treatment of children with IE in reference to the incidence, pathologic status, diagnosis, surgical strategies and outcomes. We reviewed 35 patients with a mean age of 13.7±2.2 years who were underwent valve replacement surgery for IE during the period from January 1993 to December 2013. Preoperative transthoracic echocardiographic (TTE) evaluation and transesophageal echocardiography during operation were performed in all patients. All the children underwent chart review and retrospective risk-hazard analysis. Among the patients surveyed congenital cardiac lesions were present in 15 (42.8%), rheumatic heart valve disease in 2 (5.7%) and previous heart surgery in 2 (5.7%). The median stay of intensive care unit was 6 days. Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (88.5%). Triple or quadruple valve involvement was found in one patient each. Ten-year freedom from IE-related death and re-intervention was 94.2% and 91.6%, respectively. Children undergoing surgery for IE frequently have advanced disease with embolic complications. Although valve replacement is not the primary option for pediatric IE, the rate of 5-year survival and freedom from re-operation was optimal prognostically. Pediatric physicians should pay attention to the common clinical features of IE so that the native valve is preserved well.

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.

The Rice Resistance Protein Pair RGA4/RGA5 Recognizes the Magnaporthe oryzae Effectors AVR-Pia and AVR1-CO39 by Direct Binding[W][OA

PubMed Central

Cesari, Stella; Thilliez, Gaëtan; Ribot, Cécile; Chalvon, Véronique; Michel, Corinne; Jauneau, Alain; Rivas, Susana; Alaux, Ludovic; Kanzaki, Hiroyuki; Okuyama, Yudai; Morel, Jean-Benoit; Fournier, Elisabeth; Tharreau, Didier; Terauchi, Ryohei; Kroj, Thomas

2013-01-01

Resistance (R) proteins recognize pathogen avirulence (Avr) proteins by direct or indirect binding and are multidomain proteins generally carrying a nucleotide binding (NB) and a leucine-rich repeat (LRR) domain. Two NB-LRR protein-coding genes from rice (Oryza sativa), RGA4 and RGA5, were found to be required for the recognition of the Magnaporthe oryzae effector AVR1-CO39. RGA4 and RGA5 also mediate recognition of the unrelated M. oryzae effector AVR-Pia, indicating that the corresponding R proteins possess dual recognition specificity. For RGA5, two alternative transcripts, RGA5-A and RGA5-B, were identified. Genetic analysis showed that only RGA5-A confers resistance, while RGA5-B is inactive. Yeast two-hybrid, coimmunoprecipitation, and fluorescence resonance energy transfer–fluorescence lifetime imaging experiments revealed direct binding of AVR-Pia and AVR1-CO39 to RGA5-A, providing evidence for the recognition of multiple Avr proteins by direct binding to a single R protein. Direct binding seems to be required for resistance as an inactive AVR-Pia allele did not bind RGA5-A. A small Avr interaction domain with homology to the Avr recognition domain in the rice R protein Pik-1 was identified in the C terminus of RGA5-A. This reveals a mode of Avr protein recognition through direct binding to a novel, non-LRR interaction domain. PMID:23548743

Novel valve replacement with an extracellular matrix scaffold in an infant with single ventricle physiology.

PubMed

Guariento, Alvise; Burke, Redmond; Fedrigo, Marny; Angelini, Annalisa; Maschietto, Nicola; Vida, Vladimiro; Thiene, Gaetano; Stellin, Giovanni; Padalino, Massimo

2016-01-01

Valve replacement in children with functionally univentricular hearts remains challenging. The absence of small prostheses, the lack of growth, and the need for anticoagulation limit these procedures. We describe a 1-year follow-up of an extracellular matrix scaffold tube used as systemic atrio-ventricular valve in an infant. Copyright © 2015 Elsevier Inc. All rights reserved.

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.

The bacterial type III-secreted protein AvrRps4 is a bipartite effector

PubMed Central

Spears, Benjamin J.; Garner, Christopher M.; Rogan, Conner J.; Su, Jianbin; Bhattacharjee, Saikat

2018-01-01

Bacterial effector proteins secreted into host plant cells manipulate those cells to the benefit of the pathogen, but effector-triggered immunity (ETI) occurs when effectors are recognized by host resistance proteins. The RPS4/RRS1 pair recognizes the Pseudomonas syringae pv. pisi effector AvrRps4. AvrRps4 is processed in planta into AvrRps4N (133 amino acids), homologous to the N-termini of other effectors including the native P. syringae pv. tomato strain DC3000 effector HopK1, and AvrRps4C (88 amino acids). Previous data suggested that AvrRps4C alone is necessary and sufficient for resistance when overexpressed in heterologous systems. We show that delivering AvrRps4C from DC3000, but not from a DC3000 hopK1- strain, triggers resistance in the Arabidopsis accession Col-0. Delivering AvrRps4C in tandem with AvrRps4N, or as a chimera with HopK1N, fully complements AvrRps4-triggered immunity. AvrRps4N in the absence of AvrRps4C enhances virulence in Col-0. In addition, AvrRps4N triggers a hypersensitive response in lettuce that is attenuated by coexpression of AvrRps4C, further supporting the role of AvrRps4N as a bona fide effector domain. Based on these results we propose that evolutionarily, fusion of AvrRps4C to AvrRps4N may have counteracted recognition of AvrRps4N, and that the plant RPS4/RRS1 resistance gene pair was selected as a countermeasure. We conclude that AvrRps4 represents an unusual chimeric effector, with recognition in Arabidopsis by RPS4/RRS1 requiring the presence of both processed effector moieties. PMID:29601603

The bacterial type III-secreted protein AvrRps4 is a bipartite effector.

PubMed

Halane, Morgan K; Kim, Sang Hee; Spears, Benjamin J; Garner, Christopher M; Rogan, Conner J; Okafor, Elizabeth C; Su, Jianbin; Bhattacharjee, Saikat; Gassmann, Walter

2018-03-01

Bacterial effector proteins secreted into host plant cells manipulate those cells to the benefit of the pathogen, but effector-triggered immunity (ETI) occurs when effectors are recognized by host resistance proteins. The RPS4/RRS1 pair recognizes the Pseudomonas syringae pv. pisi effector AvrRps4. AvrRps4 is processed in planta into AvrRps4N (133 amino acids), homologous to the N-termini of other effectors including the native P. syringae pv. tomato strain DC3000 effector HopK1, and AvrRps4C (88 amino acids). Previous data suggested that AvrRps4C alone is necessary and sufficient for resistance when overexpressed in heterologous systems. We show that delivering AvrRps4C from DC3000, but not from a DC3000 hopK1- strain, triggers resistance in the Arabidopsis accession Col-0. Delivering AvrRps4C in tandem with AvrRps4N, or as a chimera with HopK1N, fully complements AvrRps4-triggered immunity. AvrRps4N in the absence of AvrRps4C enhances virulence in Col-0. In addition, AvrRps4N triggers a hypersensitive response in lettuce that is attenuated by coexpression of AvrRps4C, further supporting the role of AvrRps4N as a bona fide effector domain. Based on these results we propose that evolutionarily, fusion of AvrRps4C to AvrRps4N may have counteracted recognition of AvrRps4N, and that the plant RPS4/RRS1 resistance gene pair was selected as a countermeasure. We conclude that AvrRps4 represents an unusual chimeric effector, with recognition in Arabidopsis by RPS4/RRS1 requiring the presence of both processed effector moieties.

Rice Exo70 interacts with a fungal effector, AVR-Pii, and is required for AVR-Pii-triggered immunity.

PubMed

Fujisaki, Koki; Abe, Yoshiko; Ito, Akiko; Saitoh, Hiromasa; Yoshida, Kentaro; Kanzaki, Hiroyuki; Kanzaki, Eiko; Utsushi, Hiroe; Yamashita, Tetsuro; Kamoun, Sophien; Terauchi, Ryohei

2015-09-01

Vesicle trafficking including the exocytosis pathway is intimately associated with host immunity against pathogens. However, we still have insufficient knowledge about how it contributes to immunity, and how pathogen factors affect it. In this study, we explore host factors that interact with the Magnaporthe oryzae effector AVR-Pii. Gel filtration chromatography and co-immunoprecipitation assays identified a 150 kDa complex of proteins in the soluble fraction comprising AVR-Pii and OsExo70-F2 and OsExo70-F3, two rice Exo70 proteins presumably involved in exocytosis. Simultaneous knockdown of OsExo70-F2 and F3 totally abrogated Pii immune receptor-dependent resistance, but had no effect on Pia- and Pik-dependent resistance. Knockdown levels of OsExo70-F3 but not OsExo70-F2 correlated with reduction of Pii function, suggesting that OsExo70-F3 is specifically involved in Pii-dependent resistance. Under our current experimental conditions, over-expression of AVR-Pii or knockdown of OsExo70-F2 and -F3 genes in rice did not affect the virulence of compatible isolates of M. oryzae. AVR-Pii interaction with OsExo70-F3 appears to play a crucial role in immunity triggered by Pii, suggesting a role for OsExo70 as a decoy or helper in Pii/AVR-Pii interactions. © 2015 The Authors The Plant Journal © 2015 John Wiley & Sons Ltd.

[Experience of Mitral Valve Replacement Using a Pulmonary Autograft (Ross II Operation) in an Infant;Report of a Case].

PubMed

Kawahito, Tomohisa; Egawa, Yoshiyasu; Yoshida, Homare; Shimoe, Yasushi; Onishi, Tatsuya; Miyagi, Yuhichi; Terada, Kazuya; Ohta, Akira

2015-07-01

A 24-day-old boy suddenly developed progressive heart failure and was transported to our hospital. Echocardiography showed massive mitral regurgitation due to chordal rupture. Mitral valve repair was performed at 28 days of life, but postoperative valvular function was not satisfactory. A mechanical valve was implanted in the supra-annular position at 37 days of life. Two months after valve replacement, the mechanical valve was suddenly stuck. Emergent redo valve replacement was performed, but the prosthetic valve became stuck again 2 months after the 3rd operation, despite sufficient anti-coagulation therapy. At the 4th operation (6 months after birth), we implanted a pulmonary autograft in the mitral position instead of another mechanical valve in an emergent operation. The right ventricular outflow tract was reconstructed with a valved conduit. A postoperative catheter examination, which was performed 1 year after the Ross II operation, showed mild mitral stenosis with no regurgitation. Previous reports of Ross II operations in infants are rare and long-term results are unknown. However, we advocate that this procedure should be a rescue operation for mitral valve dysfunction in the early period of infants.

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.

Salmonella enteritidis Effector AvrA Stabilizes Intestinal Tight Junctions via the JNK Pathway.

PubMed

Lin, Zhijie; Zhang, Yong-Guo; Xia, Yinglin; Xu, Xiulong; Jiao, Xinan; Sun, Jun

2016-12-23

Salmonella pathogenesis studies to date have focused on Salmonella typhimurium, and the pathogenesis of a second major serotype, Salmonella enteritidis, is poorly understood. Salmonella spp. possess effector proteins that display biochemical activities and modulate host functions. Here, we generated a deletion mutant of the effector AvrA, S.E-AvrA - , and a plasmid-mediated complementary strain, S.E-AvrA - /pAvrA + (S.E-AvrA + ), in S. Enteritidis. Using in vitro and in vivo infection models, we showed that AvrA stabilizes epithelial tight junction (TJ) proteins, such as ZO-1, in human intestinal epithelial cells. Transepithelial electrical resistance was significantly higher in cells infected with S.E-AvrA + than in cells infected with S.E-AvrA - Inhibition of the JNK pathway suppresses the disassembly of TJ proteins; we found that enteritidis AvrA inhibited JNK activity in cells infected with wild type or S.E-AvrA + strains. Therefore, Enteritidis AvrA-induced ZO-1 stability is achieved via suppression of the JNK pathway. Furthermore, the S.E-AvrA - strain led to enhanced bacterial invasion, both in vitro and in vivo Taken together, our data reveal a novel role for AvrA in S. Enteritidis: Enteritidis AvrA stabilizes intestinal TJs and attenuates bacterial invasion. The manipulation of JNK activity and TJs in microbial-epithelial interactions may be a novel therapeutic approach for the treatment of infectious diseases. © 2016 by The American Society for Biochemistry and Molecular Biology, Inc.

Salmonella enteritidis Effector AvrA Stabilizes Intestinal Tight Junctions via the JNK Pathway*

PubMed Central

Lin, Zhijie; Zhang, Yong-Guo; Xia, Yinglin; Xu, Xiulong; Jiao, Xinan

2016-01-01

Salmonella pathogenesis studies to date have focused on Salmonella typhimurium, and the pathogenesis of a second major serotype, Salmonella enteritidis, is poorly understood. Salmonella spp. possess effector proteins that display biochemical activities and modulate host functions. Here, we generated a deletion mutant of the effector AvrA, S.E-AvrA−, and a plasmid-mediated complementary strain, S.E-AvrA−/pAvrA+ (S.E-AvrA+), in S. Enteritidis. Using in vitro and in vivo infection models, we showed that AvrA stabilizes epithelial tight junction (TJ) proteins, such as ZO-1, in human intestinal epithelial cells. Transepithelial electrical resistance was significantly higher in cells infected with S.E-AvrA+ than in cells infected with S.E-AvrA−. Inhibition of the JNK pathway suppresses the disassembly of TJ proteins; we found that enteritidis AvrA inhibited JNK activity in cells infected with wild type or S.E-AvrA+ strains. Therefore, Enteritidis AvrA-induced ZO-1 stability is achieved via suppression of the JNK pathway. Furthermore, the S.E-AvrA− strain led to enhanced bacterial invasion, both in vitro and in vivo. Taken together, our data reveal a novel role for AvrA in S. Enteritidis: Enteritidis AvrA stabilizes intestinal TJs and attenuates bacterial invasion. The manipulation of JNK activity and TJs in microbial-epithelial interactions may be a novel therapeutic approach for the treatment of infectious diseases. PMID:27875307

Impact of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mechanical mitral valve replacement for rheumatic mitral valve disease.

PubMed

Wang, Bin; Xu, Zhi-yun; Han, Lin; Zhang, Guan-xin; Lu, Fang-lin; Song, Zhi-gang

2013-03-01

The prognostic significance of preoperative atrial fibrillation on mitral valve replacement remains unclear. The aim of this study was to explore the effects of the presence of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mitral valve replacement for rheumatic valve disease. A retrospective analysis was performed on a total of 793 patients who underwent mitral valve replacement with or without tricuspid valve repair in our hospital. The patients selected were divided into two groups according to preoperative rhythm status. Patients with preoperative atrial fibrillation were assigned to the AF group, while patients in preoperative sinus rhythm were assigned to the SR group. Postoperative follow-up was performed by outpatient visits, as well as by telephone and written correspondence. Data gathered included survivorship, postoperative complications, left ventricular function and tricuspid regurgitation. For patients with atrial fibrillation vs those in sinus rhythm, there was no difference in postoperative mortality and morbidity. Follow-up was a mean of 8.6 ± 2.4 years. For patients with preoperative atrial fibrillation, 10-year survival from a Kaplan-Meier curve was 88.7%, compared with 96.6% in patients with preoperative sinus rhythm (P = 0.002). Multivariate analysis identified low left ventricular ejection fraction, older age, large left atrium and preoperative atrial fibrillation as significant adverse predictors for overall survival. Freedom from thromboembolism complications at 13 years was lower for patients with preoperative atrial fibrillation without maze procedure and left atrial appendage ligation, compared with that for patients with preoperative sinus rhythm without maze procedure and left atrial appendage ligation, and patients with concomitant maze procedure and left atrial appendage ligation (76.3 vs 94.8 vs 94.0%, respectively; P = 0.001). On echocardiography, the proportion of patients with significant tricuspid

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.

Percutaneous Closure of 2 Paravalvular Leaks and a Gerbode Defect after Mitral Valve Replacement for Infective Endocarditis.

PubMed

Peñalver, Jorge; Shatila, Wassim; Silva, Guilherme V

2017-04-01

Surgical valve replacement after infective endocarditis can result in local destructive paravalvular lesions. A 30-year-old woman with infective endocarditis underwent mitral valve replacement that was complicated postoperatively by 2 paravalvular leaks. During percutaneous closure of the leaks, a Gerbode defect was also found and closed. We discuss our patient's case and its relation to others in the relevant medical literature. To our knowledge, we are the first to describe the use of a percutaneous approach to close concomitant paravalvular leaks and a Gerbode defect.

Implementation of transcatheter aortic valve replacement in California: Influence on aortic valve surgery.

PubMed

Maximus, Steven; Milliken, Jeffrey C; Danielsen, Beate; Shemin, Richard; Khan, Junaid; Carey, Joseph S

2018-04-01

Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high-risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown. The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the years 2009 through 2014. isolated surgical aortic valve and aortic valve/coronary artery bypass graft (SAVR) and TAVR procedures were identified by International Classification of Diseases-9th revision clinical modification procedure codes. Seven TAVR programs were introduced in 2011, 12 in 2012, 3 in 2013, and 6 in 2014. SAVR procedure volumes were compared from the 2 years before institution with SAVR volumes during the year(s) after institution of the TAVR program in these 28 hospitals. Overall, surgical volumes increased during the first, second, and third years after implementation of TAVR procedures. Among 7 hospitals with 4-year programs, surgical volumes increased to a maximum of 15.5% during the third year, then began to decrease. The hospital performing the largest number of TAVR procedures showed a marked decrease in SAVR volume by the fourth year, suggesting a shift of SAVR candidates to TAVR. Among all hospitals with 4-year programs, TAVR exceeded SAVR procedures by the fourth year. In California overall, SAVR increased during 2011 through 2013, due primarily to increasing volume of isolated SAVR procedures. Statewide, isolated SAVR increased from a yearly average of 3111 procedures during 2009-2010 to 3592 (+15.5%) in 2013, then decreased slightly in 2014. SAVR plus coronary artery bypass graft procedures decreased during the same time period. After implementation of TAVR, hospital SAVR volumes increased moderately, then began to decrease by the fourth year, when TAVR volume exceeded SAVR. Surgical candidates may be identified

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.

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

Regional Systems of Care to Optimize Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

PubMed

Stub, Dion; Lauck, Sandra; Lee, May; Gao, Min; Humphries, Karin; Chan, Albert; Cheung, Anson; Cook, Richard; Della Siega, Anthony; Leipsic, Jonathon; Charania, Jay; Dvir, Danny; Latham, Tim; Polderman, Jopie; Robinson, Simon; Wong, Daniel; Thompson, Christopher R; Wood, David; Ye, Jian; Webb, John

2015-12-28

This study sought to describe the development of a multicenter, transcatheter aortic valve replacement program and regional systems of care intended to optimize coordinated, efficient, and appropriate delivery of this new therapy. Transcatheter aortic valve replacement (TAVR) has become an accepted treatment option for patients with severe aortic stenosis who are at high surgical risk. Regional systems of care have led to improvements in outcomes for patients undergoing intervention for myocardial infarction, cardiac arrest, and stroke. We implemented a regional system of care for patients undergoing TAVR in British Columbia, Canada. We describe a prospective observational cohort of 583 patients who underwent TAVR in British Columbia between 2012 and 2014. Regionalization of TAVR care in British Columbia refers to a centrally coordinated, funded, and evaluated program led by a medical director and a multidisciplinary advisory group that oversees planning, access to care, and quality of outcomes at the 4 provincial sites. Risk-stratified case selection for transfemoral TAVR is performed by heart teams at each site on the basis of consensus provincial indications. Referrals for lower volume and more complicated TAVR, including nontransfemoral access and valve-in-valve procedures, are concentrated at a single site. In-hospital and 30-day outcomes are reported. The median age was 83 years (interquartile range [IQR]: 78 to 87 years) and median STS score was 6% (IQR: 4% to 8%). Transfemoral access was performed in 499 (85.6%) cases and nontransfemoral in 84 (14.4%). Transcatheter valve-in-valve procedures in for failed bioprosthetic valves were performed in 43 patients (7.4%). A balloon-expandable valve was inserted in 386 (66.2%) and a self-expanding valve in 189 (32.4%). All-cause 30-day mortality was 3.5%. All-cause in-hospital mortality and disabling stroke occurred in 3.1% and 1.9%, respectively. Median length of stay was 3 days (IQR: 3 to 6 days), with 92.8% of

[Electroacupuncture intervention combined with general anesthesia for 80 cases of heart valve replacement surgery under cardiopulmonary bypass].

PubMed

Chi, Hao; Zhou, Wen-Xiong; Wu, Yao-Yao; Chen, Tong-Yu; Ge, Wen; Yuan, Lan; Shen, Wei-Dong; Zhou, Jia

2014-02-01

To determine whether electroacupuncture (EA) intervention combined with general anesthesia (GA) strategy can reduce early post-operative morbidity and medical costs in patients undergoing heart valve replacement operation under cardiopulmonary bypass. A total of 160 heart valve replacement surgery patients undergoing cardiopulmonary bypass were randomly divided into GA and EA + GA groups (n = 80 in each group). Patients of the GA group were given with intravenous injection of Fentanyl, Midazolam, Vecuronium Bromide, etc. and routine tracheal intubation. EA (3-4 Hz, 2.0-2.2 mA) was applied to bilateral Zhongfu (LU 1), Chize (LU 5) and Ximen (PC 4) beginning about 20 mm before the surgery in the EA + GA group. Endotracheal intubation was not employed but only prepared as a standby for patients of the EA + GA group. The dosage of narcotic drugs, duration of surgery, duration of aertic blockage, rate of cardiac re-beating, volumes of post-operative blood transfusion, discharge volume, cases of post-operative pulmonary infection, vocal cord injury, and the time of first bed-off, first eating and duration in intensive care unit (IOU) residence. etc. were recorded. The successful rates of heart valve replacement surgery were similar in both GA and EA + GA groups. Compared with the GA group, the dosages of Fentanyl, Midazolam and Vecuronium of the EA + GA group were significantly lower (P < 0.05, P < 0.01), the numbers of patients needing blood-transfusion, antibiotics treatment, and suffering from pulmonary infection were fewer, the time of first bed-off and duration of hospitalizetion and IOU residence were considerably shorter (P < 0.05, P < 0.01) and the total medical cost was obviously lower (P < 0.05) in the EA + GA group. EA combined with general anesthesia strategy for heart valve replacement surgery without endotracheal intubation is safe and can reduce post-operative morbidity and medical costs in patients undergoing heart valve replacement surgery under

Comparison of the Long-Term Outcomes of Mechanical and Bioprosthetic Aortic Valves　- A Propensity Score Analysis.

PubMed

Minakata, Kenji; Tanaka, Shiro; Tamura, Nobushige; Yanagi, Shigeki; Ohkawa, Yohei; Okonogi, Shuichi; Kaneko, Tatsuo; Usui, Akihiko; Abe, Tomonobu; Shimamoto, Mitsuomi; Takahara, Yoshiharu; Yamanaka, Kazuo; Yaku, Hitoshi; Sakata, Ryuzo

2017-07-25

The aim of this study was to assess the long-term outcomes of aortic valve replacement (AVR) with either mechanical or bioprosthetic valves according to age at operation.Methods and Results:A total of 1,002 patients (527 mechanical valves and 475 bioprosthetic valves) undergoing first-time AVR were categorized according to age at operation: group Y, age <60 years; group M, age 60-69 years; and group O, age ≥70 years). Outcomes were compared on propensity score analysis (adjusted for 28 variables). Hazard ratio (HR) was calculated using the Cox regression model with adjustment for propensity score with bioprosthetic valve as a reference (HR=1). There were no significant differences in overall mortality between mechanical and bioprosthetic valves for all age groups. Valve-related mortality was significantly higher for mechanical valves in group O (HR, 2.53; P=0.02). Reoperation rate was significantly lower for mechanical valves in group Y (HR, 0.16; P<0.01) and group M (no events for mechanical valves). Although the rate of thromboembolic events was higher in mechanical valves in group Y (no events for tissue valves) and group M (HR, 9.05; P=0.03), there were no significant differences in bleeding events between all age groups. The type of prosthetic valve used in AVR does not significantly influence overall mortality.

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

Contemporary Costs Associated With Transcatheter Aortic Valve Replacement: A Propensity-Matched Cost Analysis.

PubMed

Ailawadi, Gorav; LaPar, Damien J; Speir, Alan M; Ghanta, Ravi K; Yarboro, Leora T; Crosby, Ivan K; Lim, D Scott; Quader, Mohammed A; Rich, Jeffrey B

2016-01-01

The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the "real world" by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients. A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts. Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR. TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc

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.

Impact of Annular Size on Outcomes After Surgical or Transcatheter Aortic Valve Replacement.

PubMed

Deeb, G Michael; Chetcuti, Stanley J; Yakubov, Steven J; Patel, Himanshu J; Grossman, P Michael; Kleiman, Neal S; Heiser, John; Merhi, William; Zorn, George L; Tadros, Peter N; Petrossian, George; Robinson, Newell; Mumtaz, Mubashir; Gleason, Thomas G; Huang, Jian; Conte, John V; Popma, Jeffrey J; Reardon, Michael J

2018-04-01

This analysis evaluates the relationship of annular size to hemodynamics and the incidence of prosthesis-patient mismatch (PPM) in surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) patients. The CoreValve US Pivotal High Risk Trial, described previously, compared TAVR using a self-expanding valve with SAVR. Multislice computed tomography was used to categorize TAVR and SAVR subjects according to annular perimeter-derived diameter: large (≥26 mm), medium (23 to <26 mm), and small (<23 mm). Hemodynamics, PPM, and clinical outcomes were assessed. At all postprocedure visits, mean gradients were significantly lower for TAVR compared with SAVR in small and medium size annuli (p < 0.001). Annular size was significantly associated with mean gradient after SAVR, with small annuli having the highest gradients (p < 0.05 at all timepoints); gradients were similar across all annular sizes after TAVR. In subjects receiving SAVR, the frequency of PPM was significantly associated with annular size, with small annuli having the greatest incidence. No difference in PPM incidence by annular sizing was observed with TAVR. In addition, TAVR subjects had significantly less PPM than SAVR subjects in small and medium annuli (p < 0.001), with no difference in the incidence of PPM between TAVR and SAVR in large annuli (p = 0.10). Annular size has a significant effect on hemodynamics and the incidence of PPM in SAVR subjects, not observed in TAVR subjects. With respect to annular size, TAVR results in better hemodynamics and less PPM for annuli less than 26 mm and should be strongly considered when choosing a tissue valve for small and medium size annuli. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Clinical Outcomes Following Transcatheter Aortic Valve Replacement in Asian Population.

PubMed

Yoon, Sung-Han; Ahn, Jung-Min; Hayashida, Kentaro; Watanabe, Yusuke; Shirai, Shinichi; Kao, Hsien-Li; Yin, Wei-Hsian; Lee, Michael Kang-Yin; Tay, Edgar; Araki, Motoharu; Yamanaka, Futoshi; Arai, Takahide; Lin, Mao-Shin; Park, Jun-Bean; Park, Duk-Woo; Kang, Soo-Jin; Lee, Seung-Whan; Kim, Young-Hak; Lee, Cheol Whan; Park, Seong-Wook; Muramatsu, Toshiya; Hanyu, Michiya; Kozuma, Ken; Kim, Hyo-Soo; Saito, Shigeru; Park, Seung-Jung

2016-05-09

This study describes the characteristics of a real-world Asian patient population treated with transcatheter aortic valve replacement (TAVR) and evaluates their clinical outcomes. No previously reported randomized or observational studies adequately assess the safety and efficacy of TAVR in an Asian population. The Asian TAVR registry is an international multicenter study that enrolled patients with aortic stenosis who underwent TAVR in Asian countries. In total, 848 patients with mean STS score of 5.2 ± 3.8% were enrolled between March 2010 and September 2014 at 11 centers in 5 countries. The Edwards Sapien or Medtronic CoreValve was implanted in 64.7% and 35.3% of patients, respectively. The procedural success rate was 97.5%. The 30-day and 1-year mortality rates were 2.5% and 10.8%, respectively. There was no difference in 1-year mortality between devices (Sapien: 9.4%; CoreValve: 12.2%; log-rank p = 0.40). The rates of stroke, life-threatening bleeding, major vascular complications and acute kidney injury (stage 2 to 3) were 3.8%, 6.4%, 5.0% and 3.3%, respectively. Moderate or severe paravalvular leakage was significantly more common with the CoreValve than Sapien (14.4% vs. 7.3%; p = 0.001). According to the multivariate model, a higher STS score, lower body mass index, New York Heart Association functional class III-IV symptoms, diabetes mellitus, prior cerebrovascular accident, low mean gradient at baseline, and moderate or severe paravalvular leakage were significantly associated with reduced survival. Despite anatomical features of concern, the clinical outcomes of TAVR in our Asian population were favorable in comparison with those of previously published trials and observational studies. (The Asian Transcatheter Aortic Valve Replacement Registry [Asian TAVR]; NCT02308150). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Bioprosthetic mitral valve replacement in patients aged 65 years or younger: long-term outcomes with the Carpentier-Edwards PERIMOUNT pericardial valve.

PubMed

Bourguignon, Thierry; Espitalier, Fabien; Pantaleon, Clémence; Vermes, Emmanuelle; El-Arid, Jean Marc; Loardi, Claudia; Karam, Elias; Candolfi, Pascal; Ivanes, Fabrice; Aupart, Michel

2018-02-12

Mitral valve replacement using a bioprosthesis remains controversial in young patients because data on long-term outcomes are missing. This study evaluated the long-term results of the PERIMOUNT pericardial mitral bioprosthesis in patients aged 65 years or younger. From 1984 to 2010, 148 Carpentier-Edwards PERIMOUNT mitral bioprostheses were implanted in 148 patients aged 65 years or younger. Baseline clinical, perioperative and follow-up data were recorded prospectively. Structural valve deterioration (SVD) was defined by strict echocardiographic assessment. The mean follow-up period was 8.6 ± 5.5 years, for a total of 1269 valve-years. Operative mortality rate was 2.0%. Fifty-one late deaths occurred (linearized rate 4.0% per valve-year). Actuarial survival rates averaged 70 ± 4%, 53 ± 6% and 31 ± 7% after 10, 15 and 20 years of follow-up, respectively. Actuarial freedom from SVD at 10, 15 and 20 years was 78 ± 5%, 47 ± 7% and 19 ± 7%, respectively. Reoperation was associated with no operative mortality. Actuarial freedom from reoperation due to SVD at 10, 15 and 20 years was 82 ± 4%, 50 ± 6% and 25 ± 8%, respectively. Competing risk analysis demonstrated an actual risk of explantation secondary to SVD at 20 years of 44 ± 5%. Expected valve durability was 14.2 years for this age group. In the selected patients aged 65 years or younger undergoing mitral valve replacement with a pericardial bioprosthesis, the expected valve durability was 14.2 years. Reoperation for SVD was associated with a low risk of mortality. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Thrombocytopenia after aortic valve replacement with freedom solo bioprosthesis: a propensity study.

PubMed

Piccardo, Alessandro; Rusinaru, Dan; Petitprez, Benoit; Marticho, Paul; Vaida, Ioana; Tribouilloy, Christophe; Caus, Thierry

2010-05-01

The incidence of postoperative thrombocytopenia after aortic valve replacement with the Freedom Solo bioprosthesis remains unclear. This propensity-matched study was carried out to evaluate the incidence and clinical impact of thrombocytopenia in patients receiving the Freedom Solo bioprosthesis. Patients who underwent aortic valve replacement with a Freedom Solo or Carpentier-Edwards Perimount pericardial prosthesis at our institution between 2006 and 2008 were screened retrospectively. Exclusion criteria included double valve replacement, redo surgery, and active endocarditis. Two hundred six patients were considered eligible for this analysis. Using propensity scores 36 matched pairs of patients with a Freedom Solo or Perimount bioprosthesis were obtained. The primary end point was the occurrence of postoperative thrombocytopenia. Secondary end points were postoperative thromboembolic or hemorrhagic events and 30-day mortality. Before matching, severe thrombocytopenia (<30 x 10(9) platelets/L) occurred in 22% of patients with a Freedom Solo bioprosthesis and 1% with a Perimount bioprosthesis (p < 0.0001), thromboembolic or hemorrhagic events occurred in 3% and 2%, respectively (p = 0.37), and 30-day mortality was 4% and 6%, respectively (p = 0.48). Multivariate analysis identified preoperative platelet count (p = 0.01) and Freedom Solo (p < 0.0001) as independent risk factors for severe postoperative thrombocytopenia. After matching, severe thrombocytopenia occurred in 25% and 3% of patients with Freedom Solo and Perimount bioprostheses, respectively (p < 0.0001), thromboembolic or hemorrhagic events occurred in 0%, and 30-day mortality was 3% and 6%, respectively (p = 0.99). The risk of thrombocytopenia was high after Freedom Solo implantation. However, this complication was not related to any deleterious events in our study population. Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Quality of life following heart valve replacement in the elderly.

PubMed

Spaziano, Marco; Carrier, Michel; Pellerin, Michel; Choinière, Manon

2010-07-01

The purpose of this investigation was to evaluate both long-term functional status and quality of life (QoL) following valvular replacement surgery in octogenarians. The influence of gender and discharge location was also examined. A total of 133 patients (age range: 80-89 years) who underwent surgical valve replacement between January 2003 and December 2006 was identified. Two questionnaires evaluating QoL (SF-12v2 and MLHFQ), as well as a demographic questionnaire, were sent to these patients. The response rate was 64.4%. Among the participants, the mean NYHA functional class improved from 2.7 to 1.4 after surgery. Men showed results similar to those of the age-matched general Canadian population on the mental and physical component scales of the SF-12v2. The data on women were similar to those of the general population on the physical component scale, but their scores were significantly lower on the mental component scale of the SF-12v2. Further analysis of the results comparing discharge location for each gender revealed that women discharged to a convalescence resource had significantly better QoL scores than those discharged to home with regards to the physical component scale of the SF-12v2, the total score of the MLHFQ, and the physical dimension score of the MLHFQ. Patients aged > or = 80 years benefit from heart valve replacement surgery in terms of both QoL and functional status. Women may be at increased risk of a decline in their emotional well-being and, postoperatively, may benefit more from convalescence than from discharge to home.

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

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.

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.

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

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.

Multiple activities of the plant pathogen type III effector proteins WtsE and AvrE require WxxxE motifs.

PubMed

Ham, Jong Hyun; Majerczak, Doris R; Nomura, Kinya; Mecey, Christy; Uribe, Francisco; He, Sheng-Yang; Mackey, David; Coplin, David L

2009-06-01

The broadly conserved AvrE-family of type III effectors from gram-negative plant-pathogenic bacteria includes important virulence factors, yet little is known about the mechanisms by which these effectors function inside plant cells to promote disease. We have identified two conserved motifs in AvrE-family effectors: a WxxxE motif and a putative C-terminal endoplasmic reticulum membrane retention/retrieval signal (ERMRS). The WxxxE and ERMRS motifs are both required for the virulence activities of WtsE and AvrE, which are major virulence factors of the corn pathogen Pantoea stewartii subsp. stewartii and the tomato or Arabidopsis pathogen Pseudomonas syringae pv. tomato, respectively. The WxxxE and the predicted ERMRS motifs are also required for other biological activities of WtsE, including elicitation of the hypersensitive response in nonhost plants and suppression of defense responses in Arabidopsis. A family of type III effectors from mammalian bacterial pathogens requires WxxxE and subcellular targeting motifs for virulence functions that involve their ability to mimic activated G-proteins. The conservation of related motifs and their necessity for the function of type III effectors from plant pathogens indicates that disturbing host pathways by mimicking activated host G-proteins may be a virulence mechanism employed by plant pathogens as well.

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.

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.

1-Year Outcomes After Transcatheter Aortic Valve Replacement With Balloon-Expandable Versus Self-Expandable Valves: Results From the CHOICE Randomized Clinical Trial.

PubMed

Abdel-Wahab, Mohamed; Neumann, Franz-Josef; Mehilli, Julinda; Frerker, Christian; Richardt, Doreen; Landt, Martin; Jose, John; Toelg, Ralph; Kuck, Karl-Heinz; Massberg, Steffen; Robinson, Derek R; El-Mawardy, Mohamed; Richardt, Gert

2015-08-18

The use of a balloon-expandable transcatheter heart valve previously resulted in a greater rate of device success compared with a self-expandable transcatheter heart valve. The aim of this study was to evaluate clinical and echocardiographic outcome data at longer term follow-up. The investigator-initiated trial randomized 241 high-risk patients with symptomatic severe aortic stenosis and anatomy suitable for treatment with both balloon- and self-expandable transcatheter heart valves to transfemoral transcatheter aortic valve replacement with either device. Patients were followed-up for 1 year, with assessment of clinical outcomes and echocardiographic evaluation of valve function. At 1 year, the rates of death of any cause (17.4% vs. 12.8%; relative risk [RR]: 1.35; 95% confidence interval [CI]: 0.73 to 2.50; p = 0.37) and of cardiovascular causes (12.4% vs. 9.4%; RR: 1.32; 95% CI: 0.63 to 2.75; p = 0.54) were not statistically significantly different in the balloon- and self-expandable groups, respectively. The frequencies of all strokes (9.1% vs. 3.4%; RR: 2.66; 95% CI: 0.87 to 8.12; p = 0.11) and repeat hospitalization for heart failure (7.4% vs. 12.8%; RR: 0.58; 95% CI: 0.26 to 1.27; p = 0.19) did not statistically significantly differ between the 2 groups. Elevated transvalvular gradients during follow-up were observed in 4 patients in the balloon-expandable group (3.4% vs. 0%; p = 0.12); all were resolved with anticoagulant therapy, suggesting a thrombotic etiology. More than mild paravalvular regurgitation was more frequent in the self-expandable group (1.1% vs. 12.1%; p = 0.005). Despite the higher device success rate with the balloon-expandable valve, 1-year follow-up of patients in CHOICE (Randomized Comparison of Transcatheter Heart Valves in High Risk Patients With Severe Aortic Stenosis: Medtronic CoreValve Versus Edwards SAPIEN XT Trial), with limited statistical power, revealed clinical outcomes after transfemoral transcatheter aortic valve

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.

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.

Robotic artificial chordal replacement for repair of mitral valve prolapse.

PubMed

Brunsting, Louis A; Rankin, J Scott; Braly, Kimberly C; Binford, Robert S

2009-07-01

Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then "adjusted" by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The "adjustable" ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner.

Mid-term haemodynamic and clinical results after aortic valve replacement using the Freedom Solo stentless bioprosthesis versus the Carpentier Edwards Perimount stented bioprosthesis.

PubMed

van der Straaten, Ellen P J; Rademakers, Leonard M; van Straten, Albert H M; Houterman, Saskia; Tan, M Erwin S H; Soliman Hamad, Mohamed A

2016-04-01

The aim of this study was to investigate the mid-term haemodynamic and clinical results after aortic valve replacement (AVR) using the Sorin Freedom Solo (SFS) stentless bioprosthesis, compared with the standard Carpentier Edwards Perimount (CEP) stented bioprosthesis. In this retrospective cohort study of prospectively collected data, 116 patients were included in the SFS group (53 males; median age 74 years, range 56-85 years), and 122 patients in the CEP group (85 males; median age 73 years, range 43-88 years) between July 2007 and January 2013. Echocardiography was performed at 6 weeks after surgery in our centre, and the most recent echocardiography (in our centre or in referring cardiology departments) was requested. Between September 2013 and April 2014, all patients were called by the same researcher to gain clinical follow-up data. Mid-term mortality was 16.4% in the SFS group (19 patients) and 21.3% in the CEP group (26 patients); (P = 0.3). The mean transvalvular gradient was 7.4 ± 3.1 mmHg in the SFS group, and 11.6 ± 3.2 mmHg in the CEP group at 6 weeks postoperatively (P < 0.001). When stratified by labelled valve size, mean gradients were significantly lower in the SFS group for every size (P ≤ 0.03). After 3.3 ± 1.4 years of follow-up, the mean gradient was still significantly lower in the SFS group than that in the CEP group (P < 0.001). Clinical follow-up showed relatively low complication rates. These data suggest that the Sorin Freedom Solo stentless bioprosthesis is as safe as the Carpentier Edwards bioprosthesis, and provides better short- and mid-term haemodynamic performance than the Carpentier Edwards bioprosthesis. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The effect of postoperative medical treatment on left ventricular mass regression after aortic valve replacement.

PubMed

Helder, Meghana R K; Ugur, Murat; Bavaria, Joseph E; Kshettry, Vibhu R; Groh, Mark A; Petracek, Michael R; Jones, Kent W; Suri, Rakesh M; Schaff, Hartzell V

2015-03-01

The study objective was to analyze factors associated with left ventricular mass regression in patients undergoing aortic valve replacement with a newer bioprosthesis, the Trifecta valve pericardial bioprosthesis (St Jude Medical Inc, St Paul, Minn). A total of 444 patients underwent aortic valve replacement with the Trifecta bioprosthesis from 2007 to 2009 at 6 US institutions. The clinical and echocardiographic data of 200 of these patients who had left ventricular hypertrophy and follow-up studies 1 year postoperatively were reviewed and compared to analyze factors affecting left ventricular mass regression. Mean (standard deviation) age of the 200 study patients was 73 (9) years, 66% were men, and 92% had pure or predominant aortic valve stenosis. Complete left ventricular mass regression was observed in 102 patients (51%) by 1 year postoperatively. In univariate analysis, male sex, implantation of larger valves, larger left ventricular end-diastolic volume, and beta-blocker or calcium-channel blocker treatment at dismissal were significantly associated with complete mass regression. In the multivariate model, odds ratios (95% confidence intervals) indicated that male sex (3.38 [1.39-8.26]) and beta-blocker or calcium-channel blocker treatment at dismissal (3.41 [1.40-8.34]) were associated with increased probability of complete left ventricular mass regression. Patients with higher preoperative systolic blood pressure were less likely to have complete left ventricular mass regression (0.98 [0.97-0.99]). Among patients with left ventricular hypertrophy, postoperative treatment with beta-blockers or calcium-channel blockers may enhance mass regression. This highlights the need for close medical follow-up after operation. Labeled valve size was not predictive of left ventricular mass regression. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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.

Outcomes following transcatheter aortic valve replacement in patients with native aortic valve regurgitation

PubMed Central

Bob-Manuel, Tamunoinemi; Kadire, Siri; Heckle, Mark R.; Wang, Jiajing

2018-01-01

Due to the absence of annular calcification for device anchoring, it is presumed that transcatheter aortic valve replacement (TAVR) is not suitable for the treatment of native aortic valve regurgitation (NAVR) resulting in very limited data and experience concerning its safety and efficacy. We sought to review published data on the safety and efficacy of TAVR in high-risk patients with NAVR. Studies including case reports, case series and original articles published between 2002 and 2016 on TAVR in patients with NAVR were identified with a systematic electronic search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Only studies reporting data on demographic and procedural characteristics, management and follow up outcomes were analyzed. A total of 30 publications describing 182 patients were identified. Most patients (54%) were men, with a mean age of 70.1±2.6 years, mean logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE) of 21.8%±4.5% and mean Society of Thoracic Surgeons (STS) score of 8%±1.8% for mortality. The majority (87%) of patients had severe NAVR with no valvular calcification. TAVR was mostly performed through the femoral (58.8%) and apical (33.1%) approach. Device success, defined by VARC-2, was achieved in 86.3% of our study population. A second valve was required in 17 patients (9.3%) during the index procedure for residual aortic regurgitation or malposition. Post-procedure aortic regurgitation of grade 1 or less was present in 80 patients (81%). Pacemaker implantation was required post procedure in 17 patients (9.3%). The 30-day and 1-year mortality was 11.9% and 16.2%, respectively. TAVR is associated with favorable pacemaker implantation and 1-year mortality rates with a high 30-day mortality among selected patients with NAVR. PMID:29404354

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

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.

Recent Development in Pulmonary Valve Replacement after Tetralogy of Fallot Repair: The Emergence of Hybrid Approaches

PubMed Central

Suleiman, Tariq; Kavinsky, Clifford J.; Skerritt, Clare; Kenny, Damien; Ilbawi, Michael N.; Caputo, Massimo

2015-01-01

An increasing number of patients with tetralogy of Fallot require repeat surgical intervention for pulmonary valve replacement secondary to pulmonary regurgitation. Catheter-based interventions have emerged as an attractive alternative to surgery in this patient population but it is limited by patient size or the anatomy of the right ventricular outflow tract. Hybrid approaches involving both cardiac interventionists and surgeons are being developed to overcome these limitations. The purpose of this review is to highlight the recent advances in the hybrid field of pulmonary valve replacement, summarizing the advantages and disadvantages of the “traditional” surgical and the new catheter-based techniques and discuss the direction future research should take to determine the optimal management for individual patients. PMID:26082929

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.

Gene-for-genes interactions between cotton R genes and Xanthomonas campestris pv. malvacearum avr genes.

PubMed

De Feyter, R; Yang, Y; Gabriel, D W

1993-01-01

Six plasmid-borne avirulence (avr) genes were previously cloned from strain XcmH of the cotton pathogen, Xanthomonas campestris pv. malvacearum. We have now localized all six avr genes on the cloned fragments by subcloning and Tn5-gusA insertional mutagenesis. None of these avr genes appeared to exhibit exclusively gene-for-gene patterns of interactions with cotton R genes, and avrB4 was demonstrated to confer avr gene-for-R genes (plural) avirulence to X. c. pv. malvacearum on congenic cotton lines carrying either of two different resistance loci, B1 or B4. Furthermore, the B1 locus appeared to confer R gene-for-avr genes resistance to cotton against isogenic X. c. pv. malvacearum strains carrying any one of three avr genes: avrB4, avrb6, or avrB102. Restriction enzyme, Southern blot hybridization, and DNA sequence analyses showed that the XcmH avr genes are all highly similar to each other, to avrBs3 and avrBsP from the pepper pathogen X. c. pv. vesicatoria, and to the host-specific virulence gene pthA from the citrus pathogen X. citri. The XcmH avr genes differed primarily in the multiplicity of a tandemly repeated 102-base pair motif within the central portions of the genes, repeated from 14 to 23 times in members of this gene family. The complete nucleotide sequence of avrb6 revealed that it is 97% identical in DNA sequence to avrB4, avrBs3, avrBsP, and pthA and that 62-bp inverted terminal repeats mark the boundaries of homology between avrb6 and all members of this Xanthomonas virulence/avirulence gene family sequenced to date. The terminal 38 bp of both inverted repeats are highly similar to the 38-bp consensus terminal sequence of the Tn3 family of transposons. Up to 11 members of the avr gene family appear to be present in North American strains of X. c. pv. malvacearum, including XcmH. The high level of homology observed among these avr genes and their presence in multiple copies may explain the gene-for-genes interactions and also the observed high

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.

Planar biaxial testing of heart valve cusp replacement biomaterials: Experiments, theory and material constants.

PubMed

Labrosse, Michel R; Jafar, Reza; Ngu, Janet; Boodhwani, Munir

2016-11-01

Aortic valve (AV) repair has become an attractive option to correct aortic insufficiency. Yet, cusp reconstruction with various cusp replacement materials has been associated with greater long-term repair failures, and it is still unknown how such materials mechanically compare with native leaflets. We used planar biaxial testing to characterize six clinically relevant cusp replacement materials, along with native porcine AV leaflets, to ascertain which materials would be best suited for valve repair. We tested at least six samples of: 1) fresh autologous porcine pericardium (APP), 2) glutaraldehyde fixed porcine pericardium (GPP), 3) St Jude Medical pericardial patch (SJM), 4) CardioCel patch (CC), 5) PeriGuard (PG), 6) Supple PeriGuard (SPG) and 7) fresh porcine AV leaflets (PC). We introduced efficient displacement-controlled testing protocols and processing, as well as advanced convexity requirements on the strain energy functions used to describe the mechanical response of the materials under loading. The proposed experimental and data processing pipeline allowed for a robust in-plane characterization of all the materials tested, with constants determined for two Fung-like hyperelastic, anisotropic strain energy models. Overall, CC and SPG (respectively PG) patches ranked as the closest mechanical equivalents to young (respectively aged) AV leaflets. Because the native leaflets as well as CC, PG and SPG patches exhibit significant anisotropic behaviors, it is suggested that the fiber and cross-fiber directions of these replacement biomaterials be matched with those of the host AV leaflets. The long-term performance of cusp replacement materials would ideally be evaluated in large animal models for AV disease and cusp repair, and over several months or more. Given the unavailability and impracticality of such models, detailed information on stress-strain behavior, as studied herein, and investigations of durability and valve dynamics will be the best surrogates

[Papillary muscle rupture complicating acute myocardial infarction--treatment with mitral valve replacement and coronary bypass surgery in acute phase].

PubMed

Kyo, S; Miyamoto, N; Yokote, Y; Ueda, K; Takamoto, S; Omoto, R

1996-06-01

Complete rupture of a papillary muscle following acute myocardial infarction is a severe complication that is typically associated with acute left ventricular failure, pulmonary edema, and relentless clinical deterioration. The reported mortality rates without surgical intervention is almost 90%, therefore, prompt operation without prolonged attempts at medical stabilization is the key to decrease operative mortality. Although the complete coronary revascularization in conjunction with mitral valve replacement is advocated in the western medical academic society, there is only a few case of conjunct surgery has been reported in Japan. Three successful cases of conjunct surgery of mitral valve replacement and coronary complete revascularization in acute phase within one week from the onset of acute myocardial infarction (AMI) are described. There were one male and two female patients with an average age of 60-year-old (range 48-67), who developed cardiogenic shock and admitted to our hospital. The average interval between onset of AMI and the appearance of mitral regurgitation (MR) was 38 hours, and that of the appearance of MR and admission was 40 hours. Surgeries were performed within 26 hours (average 13 hours) after admission. The mitral valve was replaced with a mechanical valve (St. Jude Medical Valve) and a complete coronary revasculatization was done using saphenous vein graft. The average period of operation time and aortic cross clamping time were 6 hours 22 minutes and 109 minutes respectively. The average number of coronary grafting was 2.3 (range 1-3). Postoperative recovery from cardiogenic shock was uneventful in all three patients. The average periods of ICU stay and hospital stay were 5 days and 43 days respectively. All patients have regained their social activities with mean follow up period of 52 months. Since ischemic heart disease remains the leading cause of death in such patients, it is suggested that complete coronary revascularization

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

Lead aVR: beyond 'No man's land'.

PubMed

Singh, Bhupinder; Ali, Amjad; Singla, Vivek; Gowda, Sadananda K

2014-04-25

Coronary artery disease (CAD) is one of the leading causes of mortality in the world. Treadmill test is a very useful non-invasive test to diagnose and stratify the risk of CAD. Lead aVR is usually a neglected lead while reading the ECG. We describe a case demonstrating the importance of subtle changes in lead aVR that has got a direct angiographic correlation with left main CAD. Therefore picking up the subtle clues on ECG may help in stratifying the risk and optimal treatment of the patient in a timely fashion.

Pannus overgrowth after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis.

PubMed

Oda, Takeshi; Kato, Seiya; Tayama, Eiki; Fukunaga, Shuji; Akashi, Hidetoshi; Aoyagi, Shigeaki

2009-01-01

A Carpentier-Edwards pericardial (CEP) bioprosthesis was explanted from an 81-year-old woman due to nonstructural dysfunction 9 years after mitral valve replacement. The nonstructural dysfunction produced severe regurgitation in the mitral position. During the surgery, excessive pannus overgrowth was seen on the left ventricular side of the CEP bioprosthesis. Pannus overgrowth was prominent on one leaflet. That leaflet was stiff and shortened due to the excessive overgrowth of pannus. In this patient, the distortion of one leaflet was the main reason for transvalvular leakage of the CEP bioprosthesis in the mitral position. A new CEP bioprosthesis was implanted in the mitral position. Pathological analysis revealed fibrotic pannus with a small amount of cellular material over the leaflets of the resected CEP valve. This change was marked on the distorted leaflet.

Effects of tranexamic acid on coagulation indexes of patients undergoing heart valve replacement surgery under cardiopulmonary bypass

PubMed Central

Liu, Fei; Xu, Dong; Zhang, Kefeng; Zhang, Jian

2016-01-01

This study aims to explore the effects of tranexamic acid on the coagulation indexes of patients undergoing heart valve replacement surgery under the condition of cardiopulmonary bypass (CPB). One hundred patients who conformed to the inclusive criteria were selected and divided into a tranexamic acid group and a non-tranexamic acid group. They all underwent heart valve replacement surgery under CPB. Patients in the tranexamic acid group were intravenously injected with 1 g of tranexamic acid (100 mL) at the time point after anesthesia induction and before skin incision and at the time point after the neutralization of heparin. Patients in the non-tranexamic acid group were given 100 mL of normal saline at corresponding time points, respectively. Then the coagulation indexes of the two groups were analyzed. The activated blood clotting time (ACT) of the two groups was within normal scope before CPB, while four coagulation indexes including prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), and fibrinogen (FIB) had significant increases after surgery; the PT and INR of the tranexamic acid group had a remarkable decline after surgery. All the findings suggest that the application of tranexamic acid in heart valve replacement surgery under CPB can effectively reduce intraoperative and postoperative blood loss. PMID:27694613

[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.

[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 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

[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.

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

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.

Perturbation of Maize Phenylpropanoid Metabolism by an AvrE Family Type III Effector from Pantoea stewartii1[OPEN

PubMed Central

Asselin, Jo Ann E.; Lin, Jinshan; Perez-Quintero, Alvaro L.; Gentzel, Irene; Majerczak, Doris; Opiyo, Stephen O.; Zhao, Wanying; Paek, Seung-Mann; Kim, Min Gab; Coplin, David L.; Blakeslee, Joshua J.; Mackey, David

2015-01-01

AvrE family type III effector proteins share the ability to suppress host defenses, induce disease-associated cell death, and promote bacterial growth. However, despite widespread contributions to numerous bacterial diseases in agriculturally important plants, the mode of action of these effectors remains largely unknown. WtsE is an AvrE family member required for the ability of Pantoea stewartii ssp. stewartii (Pnss) to proliferate efficiently and cause wilt and leaf blight symptoms in maize (Zea mays) plants. Notably, when WtsE is delivered by a heterologous system into the leaf cells of susceptible maize seedlings, it alone produces water-soaked disease symptoms reminiscent of those produced by Pnss. Thus, WtsE is a pathogenicity and virulence factor in maize, and an Escherichia coli heterologous delivery system can be used to study the activity of WtsE in isolation from other factors produced by Pnss. Transcriptional profiling of maize revealed the effects of WtsE, including induction of genes involved in secondary metabolism and suppression of genes involved in photosynthesis. Targeted metabolite quantification revealed that WtsE perturbs maize metabolism, including the induction of coumaroyl tyramine. The ability of mutant WtsE derivatives to elicit transcriptional and metabolic changes in susceptible maize seedlings correlated with their ability to promote disease. Furthermore, chemical inhibitors that block metabolic flux into the phenylpropanoid pathways targeted by WtsE also disrupted the pathogenicity and virulence activity of WtsE. While numerous metabolites produced downstream of the shikimate pathway are known to promote plant defense, our results indicate that misregulated induction of phenylpropanoid metabolism also can be used to promote pathogen virulence. PMID:25635112

Triple valve surgery: a 25-year experience.

PubMed

Yilmaz, Mustafa; Ozkan, Murat; Böke, Erkmen

2004-09-01

Surgical treatment of rheumatic valvular disease still constitutes a significant number of cardiac operations in developing countries. Despite improvements in myocardial protection and cardiopulmonary bypass techniques, triple valve operations (aortic, mitral and tricuspid valves) are still challenging because of longer duration of cardiopulmonary bypass and higher degree of myocardial decompensation. This study was instituted in order to assess results of triple valve surgery. Between 1977 and 2002, 34 patients underwent triple valve surgery in our clinic by the same surgeon (EB). Eleven patients underwent triple valve replacement (32.4%) and 23 underwent tricuspid valve annuloplasty with aortic and mitral valve replacements (67.6%). There was no significant difference between the two groups of patients who underwent triple valve replacement and aortic and mitral valve replacement with tricuspid valve annuloplasty. There were 4 hospital deaths (11.8%) occurring within 30 days. The duration of follow-up for 30 survivors ranged from 6 to 202 months (mean 97 months). The actuarial survival rates were 85%, 72%, and 48% at 5, 10, and 15 years respectively. Actuarial freedom from reoperation rates at 5, 10, and 15 years was 86.3%, 71.9%, and 51.2%, respectively. Freedom from cerebral thromboembolism and anticoagulation-related hemorrhage rates, expressed in actuarial terms was 75.9% and 62.9% at 5 and 10 years. Major cerebral complications occurred in 10 of the 30 patients. We prefer replacing, if repairing is not possible, the tricuspid valve, with a bileaflet mechanical prosthesis in a patient with valve replacement of the left heart who will be anticoagulated in order to avoid unfavorable properties of bioprosthesis like degeneration and of old generation mechanical prosthesis like thrombosis and poor hemodynamic function. In recent years, results of triple valve surgery either with tricuspid valve conservation or valve replacement in suitable cases have become

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 ...

Effects of tranexamic acid on coagulation indexes of patients undergoing heart valve replacement surgery under cardiopulmonary bypass.

PubMed

Liu, Fei; Xu, Dong; Zhang, Kefeng; Zhang, Jian

2016-12-01

This study aims to explore the effects of tranexamic acid on the coagulation indexes of patients undergoing heart valve replacement surgery under the condition of cardiopulmonary bypass (CPB). One hundred patients who conformed to the inclusive criteria were selected and divided into a tranexamic acid group and a non-tranexamic acid group. They all underwent heart valve replacement surgery under CPB. Patients in the tranexamic acid group were intravenously injected with 1 g of tranexamic acid (100 mL) at the time point after anesthesia induction and before skin incision and at the time point after the neutralization of heparin. Patients in the non-tranexamic acid group were given 100 mL of normal saline at corresponding time points, respectively. Then the coagulation indexes of the two groups were analyzed. The activated blood clotting time (ACT) of the two groups was within normal scope before CPB, while four coagulation indexes including prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), and fibrinogen (FIB) had significant increases after surgery; the PT and INR of the tranexamic acid group had a remarkable decline after surgery. All the findings suggest that the application of tranexamic acid in heart valve replacement surgery under CPB can effectively reduce intraoperative and postoperative blood loss. © The Author(s) 2016.

Robot-assisted real-time magnetic resonance image-guided transcatheter aortic valve replacement.

PubMed

Miller, Justin G; Li, Ming; Mazilu, Dumitru; Hunt, Tim; Horvath, Keith A

2016-05-01

Real-time magnetic resonance imaging (rtMRI)-guided transcatheter aortic valve replacement (TAVR) offers improved visualization, real-time imaging, and pinpoint accuracy with device delivery. Unfortunately, performing a TAVR in a MRI scanner can be a difficult task owing to limited space and an awkward working environment. Our solution was to design a MRI-compatible robot-assisted device to insert and deploy a self-expanding valve from a remote computer console. We present our preliminary results in a swine model. We used an MRI-compatible robotic arm and developed a valve delivery module. A 12-mm trocar was inserted in the apex of the heart via a subxiphoid incision. The delivery device and nitinol stented prosthesis were mounted on the robot. Two continuous real-time imaging planes provided a virtual real-time 3-dimensional reconstruction. The valve was deployed remotely by the surgeon via a graphic user interface. In this acute nonsurvival study, 8 swine underwent robot-assisted rtMRI TAVR for evaluation of feasibility. Device deployment took a mean of 61 ± 5 seconds. Postdeployment necropsy was performed to confirm correlations between imaging and actual valve positions. These results demonstrate the feasibility of robotic-assisted TAVR using rtMRI guidance. This approach may eliminate some of the challenges of performing a procedure while working inside of an MRI scanner, and may improve the success of TAVR. It provides superior visualization during the insertion process, pinpoint accuracy of deployment, and, potentially, communication between the imaging device and the robotic module to prevent incorrect or misaligned deployment. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. 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.

Pericardial tissue valves and Gore-Tex conduits as an alternative for right ventricular outflow tract replacement in children.

PubMed

Allen, Bradley S; El-Zein, Chawki; Cuneo, Betina; Cava, Joseph P; Barth, Mary Jane; Ilbawi, Michel N

2002-09-01

There is still no perfect conduit for reconstruction of the right ventricular outflow tract (RVOT) in children. Homografts are not always available in the appropriate size, and degenerate in a few years. This study evaluates the pericardial valve with Gore-Tex conduit as an alternative for RVOT construction. From January 1, 1993, to September 30, 1999, a pericardial tissue valve was inserted in all patients undergoing RVOT reconstruction or pulmonary valve replacement (PVR) who were large enough to accommodate a tissue valve. In patients without a native main pulmonary artery, a new technique was used to construct an RV-PA conduit out of a flat sheet of Gore-Tex, as Dacron frequently leads to stenosis. Data were collected by retrospective review, follow-up echocardiograms, and assessment by a single cardiologist. There were 48 patients, 22 undergoing a PVR alone and 26 a RV-PA valved Gore-Tex conduit. Diagnosis included tetralogy of Fallot (n = 25); truncus arteriosis (n = 9); ventricular septal defect with PA (n = 5); DORV (n = 4); D-TGA with PS (n = 2); and 1 each IAA with sub AS, VSD with PI, and PS s/p Ross procedure. Patient age ranged from 3 to 33 years and 98% were reoperations. The valve sizes ranged from 19 to 33 mm and the median hospital length of stay was 4 days. There were 2 (4.2%) perioperative and 1 (2.1%) late deaths, none related to the valve or Gore-Tex conduit. At a follow-up of 15 to 86 months (mean 43 +/- 16 months), all remaining 45 patients are New York Heart Association class I, all valves are functional, and no patient has required valve or conduit replacement or revision; more importantly, echocardiogram revealed no significant valve or conduit stenosis (mean gradient 16 +/- 8 mm Hg) and no evidence of regurgitation or structural degeneration. A pericardial tissue valve and Gore-Tex conduit provides a reliable alternative for RVOT reconstruction in pediatric patients. It is readily available, molds in the limited retrosternal space, and

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.

Transcatheter Aortic Valve Replacement by a Novel Suprasternal Approach.

PubMed

Codner, Pablo; Pugliese, Daniel; Kouz, Rémi; Patel, Amisha; Chen, Cheng-Han; Terre, Juan; Eudailey, Kyle W; Nazif, Tamim; Vahl, Torsten P; George, Isaac; Khalique, Omar K; Hahn, Rebecca T; Leon, Martin B; Kodali, Susheel; Borger, Michael

2018-04-01

Transcatheter aortic valve replacement (TAVR) provides therapy for patients with severe aortic stenosis at extreme, high, or intermediate surgical risk. Transfemoral access has been the preferred access route; however, this approach is not suitable for many TAVR candidates. A suprasternal approach may allow for earlier ambulation and shorter hospital stay as compared with other, nontransfemoral approaches. A total of 11 patients with unsuitable transfemoral access underwent suprasternal TAVR. Propensity matching was used to compare suprasternal patients to patients undergoing transaortic, transapical, and trans-subclavian TAVR. Groups were well matched for baseline characteristics. A self-expanding valve device was used in 6 (54.5%) and a balloon-expandable valve in 5 (45.5%) of the 11 patients treated by the suprasternal route. Suprasternal and trans-subclavian patients were able to ambulate earlier than patients treated by the transaortic route, a median 1.6 days (interquartile range [IQR]: 0.9 to 1.8), 1.6 days (IQR: 0.9 to 2.7), and 3.9 days (IQR: 1.9 to 4.5) after the procedure for suprasternal, trans-subclavian, and transaortic patients, respectively (p = 0.001). Length of hospitalization was shorter for patients treated by suprasternal or trans-subclavian access in comparison with patients treated by the transaortic or transapical approach: median 4 days (IQR: 3 to 8) and 4 days (IQR: 4 to 8) versus 8 days (IQR: 6 to 14) and 6 days (IQR: 7 to 11) for suprasternal and trans-subclavian versus transaortic and transapical, respectively (p = 0.01). Suprasternal and trans-subclavian access are associated with earlier ambulation and shorter hospitalization than other nontransfemoral TAVR routes, without an increase in complications. Further study is required to determine if suprasternal is the alternative access of choice for TAVR patients with poor transfemoral vasculature. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights

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

The Melody® valve and Ensemble® delivery system for transcatheter pulmonary valve replacement

PubMed Central

McElhinney, Doff B; Hennesen, Jill T

2013-01-01

The Melody® transcatheter pulmonary valve (TPV) is a percutaneous valve system designed for the treatment of obstruction and/or regurgitation of prosthetic conduits placed between the right ventricle and pulmonary arteries in patients with congenital heart disease. In 2000, Melody TPV became the first transcatheter valve implanted in a human; in 2006 it became the first transcatheter valve commercially available anywhere in the world; and in 2010 it was launched as the first commercially available transcatheter valve in the United States. In this review, we present the clinical background against which the Melody valve was developed and implemented, introduce the rationale for and challenges of transcatheter valve technology for this population, outline the history and technical details of its development and use, and summarize currently available data concerning the performance of the device. PMID:23834411

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 ...

What Is Heart Valve Disease?

MedlinePlus

... and replacing it with a man-made or biological valve. Biological valves are made from pig, cow, or human ... the valve. Man-made valves last longer than biological valves and usually don’t have to be ...

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.

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. �

Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement.

PubMed

Wang, Jian-tang; Dong, Ming-feng; Song, Guang-min; Ma, Zeng-shan; Ma, Sheng-jun

2014-12-01

The safety and efficacy of combined low dose aspirin and warfarin therapy in patients with atrial fibrillation after mechanical heart valve replacement were evaluated. A total of 1016 patients (620 females, mean age of 36.8±7.7 years) admitted for cardiac valve replacement and complicated with atrial fibrillation after surgery were randomly divided into study (warfarin plus 75-100 mg aspirin) or control (warfarin only) groups. International normalized ratio (INR) and prothrombin time were maintained at 1.8-2.5 and 1.5-2.0 times the normal values, respectively. Thromboembolic events and major bleedings were registered during the follow-up period. Patients were followed up for 24±9 months. The average dose of warfarin in the study and control groups was 2.91±0.83 mg and 2.88±0.76 mg, respectively (P>0.05). The incidence of overall thromboembolic events in study group was lower than that in control group (2.16% vs. 4.35%, P=0.049). No statistically significant differences were found in hemorrhage events (3.53% vs. 3.95%, P=0.722) or mortality (0.20% vs. 0.40%, P=0.559) between the two groups. Combined low dose aspirin and warfarin therapy in the patients with atrial fibrillation following mechanical heart valve replacement significantly decreased thromboembolic events as compared with warfarin therapy alone. This combined treatment was not associated with an increase in the risk of major bleeding or mortality.

Profiling illness perceptions to identify patients at-risk for decline in health status after heart valve replacement.

PubMed

Kohlmann, Sebastian; Rimington, Helen; Weinman, John

2012-06-01

Identification of risk factors for decline in health status by profiling illness perceptions before and one year after heart valve replacement surgery. Prospective data from N=225 consecutively admitted first time valve replacement patients was assessed before and one year after surgery. Patients were asked about their illness perceptions (Illness Perception Questionnaire-Revised) and mood state (Hospital Anxiety and Depression Scale). Health status was defined by quality of life (Short-Form 36) and New York Heart Association (NYHA) class. Cluster analyses were conducted to identify illness perception profiles over time. Predictors of health status after surgery were analyzed with multivariate methods. Patients were grouped according to the stability and nature (positive, negative) of their illness perception profile over one year. One year after surgery patients holding a negative illness perception profile showed a lower physical quality of life and were diagnosed in a higher New York Heart Association class than patients changing to positive and patients with stable positive illness perceptions (P<.001). Over and above biological determinants, post-surgery physical quality of life and NYHA class were both predicted by pre-surgery illness perception profiles (P<.05). Patients going for heart valve replacement surgery can be easily categorized into illness perception profiles that predict health status one year after surgery. These patients could benefit from early screening as negative illness perceptions are modifiable risk factors. Copyright © 2012 Elsevier Inc. All rights reserved.

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.

Subprosthetic Pannus after Aortic Valve Replacement Surgery: Cardiac CT Findings and Clinical Features.

PubMed

Han, Kichang; Yang, Dong Hyun; Shin, So Youn; Kim, Namkug; Kang, Joon-Won; Kim, Dae-Hee; Song, Jong-Min; Kang, Duk-Hyun; Song, Jae-Kwan; Kim, Joon Bum; Jung, Sung-Ho; Choo, Suk Jung; Chung, Cheol Hyun; Lee, Jae Won; Lim, Tae-Hwan

2015-09-01

To investigate the cardiac computed tomographic (CT) findings and clinical implications of subprosthetic pannus in patients who have undergone aortic valve replacement. The institutional review board approved this retrospective study, and the need to obtain written informed consent was waived. From April 2011 to March 2012, 88 patients (mean age, 63 years; 45 men) with a prosthetic aortic valve who underwent cardiac CT were retrospectively selected. Dynamic cardiac CT images were analyzed by using a multiplanar reformatted technique. The presence or absence of subprosthetic pannus and its extent were evaluated at cardiac CT. The geometric orifice area and the effective orifice area of each prosthetic valve were measured to enable analysis of the pannus encroachment ratio in the systolic phase. Hemodynamic parameters at echocardiography, including mean transprosthetic pressure gradient (MTPG), were compared between patients with and those without pannus. The encroachment ratio and the MTPG were correlated by using the Spearman test to evaluate the relationship between the two variables. Seventeen patients (19%) had subprosthetic pannus at cardiac CT. In patients with subprosthetic pannus, MTPG, peak pressure gradient, transvalvular peak velocity, and left ventricular ejection fraction (LVEF) were significantly higher than in patients without pannus (MTPG: 28.1 mm Hg ± 19.8 [standard deviation] vs 14.0 mm Hg ± 6.5, P = .004; peak pressure gradient: 53.1 mm Hg ± 38.4 vs 26.1 mm Hg ± 11.4, P = .004; transvalvular peak velocity: 3.3 m/sec ± 1.3 vs 2.5 m/sec ± 0.5; and LVEF: 64.7% ± 7.4 vs 56.8% ± 10.5, P = .004). A high MTPG (≥40 mm Hg) was observed in four patients at echocardiography, and subprosthetic panni were identified at CT in all four patients. In patients with increased MTPGs, the encroachment ratio by subprosthetic pannus at CT was significantly higher than that in patients with MTPGs of less than 40 mm Hg (42.7 ± 13.3 vs 7.6 ± 3, P = .012

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

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.

Computed Tomography Helps to Plan Minimally Invasive Aortic Valve Replacement Operations.

PubMed

Stoliński, Jarosław; Plicner, Dariusz; Grudzień, Grzegorz; Kruszec, Paweł; Fijorek, Kamil; Musiał, Robert; Andres, Janusz

2016-05-01

This study evaluated the role of multidetector computed tomography (MDCT) in preparation for minimally invasive aortic valve replacement (MIAVR). An analysis of 187 patients scheduled for MIAVR between June 2009 and December 2014 was conducted. In the study group (n = 86), MDCT of the thorax, aorta, and femoral arteries was performed before the operation. In the control group (n = 101), patients qualified for MIAVR without receiving preoperative MDCT. The surgical strategy was changed preoperatively in 12.8% of patients from the study group and in 2.0% of patients from the control group (p = 0.010) and intraoperatively in 9.9% of patients from the control group and in none from the study group (p = 0.002). No conversion to median sternotomy was necessary in the study group; among the controls, there were 4.0% conversions. On the basis of the MDCT measurements, optimal access to the aortic valve was achieved when the angle between the aortic valve plane and the line to the second intercostal space was 91.9 ± 10.0 degrees and to the third intercostal space was 94.0 ± 1.4 degrees, with the distance to the valve being 94.8 ± 13.8 mm and 84.5 ± 9.9 mm for the second and third intercostal spaces, respectively. The right atrium covering the site of the aortotomy was present in 42.9% of cases when MIAVR had been performed through the third intercostal space and in 1.3% when through the second intercostal space (p = 0.001). Preoperative MDCT of the thorax, aorta, and femoral arteries makes it possible to plan MIAVR operations. Copyright © 2016 The Society of Thoracic Surgeons. 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.

The Midterm Outcomes of Bioprosthetic Pulmonary Valve Replacement in Children.

PubMed

Shinkawa, Takeshi; Lu, Chiajung K; Chipman, Carl; Tang, Xinyu; Gossett, Jeffrey M; Imamura, Michiaki

2015-01-01

The purpose of this study was to assess the outcomes of bioprosthetic pulmonary valve replacement (PVR) in children. This is a retrospective review of all bioprosthetic PVR in children (≤ 20-year old) between 1992 and 2013 at a single institution. Most outcomes studied included pulmonary valve reintervention and bioprosthetic valve function. A total of 136 bioprosthetic PVRs were identified for 123 patients. The median age and body weight at the time of operation were 13.2 years and 48.4 kg. There were 1 early death and 3 late deaths during the median follow-up of 7.2 years (0-22.0 years). The actuarial transplant-free survival was 97.6% at 10 years. There were 43 bioprosthesis reinterventions with 29 reoperations and 14 catheter-based interventions. The freedom from bioprosthesis reintervention was 89.6% and 55.0% at 5 and 10 years, respectively. Echocardiographic bioprosthesis dysfunction (≥ moderate bioprosthesis insufficiency, ≥ 50 mmHg peak gradient through bioprosthesis, or bioprosthesis endocarditis with vegetation) was found in 57 bioprostheses. The freedom from bioprosthesis dysfunction was 74.0% and 32.8% at 5 and 10 years, respectively. Results from the Cox proportional hazards models showed that age had significant association with freedom from bioprosthesis reintervention and freedom from bioprosthesis dysfunction (P < 0.001 and P = 0.03), whereas bioprosthesis type had nonsignificant association with freedom from bioprosthesis dysfunction (P = 0.068). Bioprosthetic PVR in children had excellent early outcomes but rapidly deteriorating midterm outcomes. Careful and close follow-up are necessary for children with bioprosthesis in the pulmonary position. Copyright © 2015 Elsevier Inc. All rights reserved.

Transapical JenaValve in a patient with mechanical mitral valve prosthesis.

PubMed

O' Sullivan, Katie E; Casserly, Ivan; Hurley, John

2015-04-01

We report the first case of transcatheter aortic valve replacement implantation using JenaValve™ in a patient with mechanical mitral valve prosthesis. We believe that the design features of this valve may be particularly suited for use in this setting. © 2014 Wiley Periodicals, Inc.

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.

3D Printed Cardiac Phantom for Procedural Planning of a Transcatheter Native Mitral Valve Replacement

PubMed Central

Izzo, Richard L.; O’Hara, Ryan P.; Iyer, Vijay; Hansen, Rose; Meess, Karen M.; Nagesh, S.V. Setlur; Rudin, Stephen; Siddiqui, Adnan H.; Springer, Michael; Ionita, Ciprian N.

2017-01-01

3D printing an anatomically accurate, functional flow loop phantom of a patient’s cardiac vasculature was used to assist in the surgical planning of one of the first native transcatheter mitral valve replacement (TMVR) procedures. CTA scans were acquired from a patient about to undergo the first minimally-invasive native TMVR procedure at the Gates Vascular Institute in Buffalo, NY. A python scripting library, the Vascular Modeling Toolkit (VMTK), was used to segment the 3D geometry of the patient’s cardiac chambers and mitral valve with severe stenosis, calcific in nature. A stereolithographic (STL) mesh was generated and AutoDesk Meshmixer was used to transform the vascular surface into a functioning closed flow loop. A Stratasys Objet 500 Connex3 multi-material printer was used to fabricate the phantom with distinguishable material features of the vasculature and calcified valve. The interventional team performed a mock procedure on the phantom, embedding valve cages in the model and imaging the phantom with a Toshiba Infinix INFX-8000V 5-axis C-arm bi-Plane angiography system. Results After performing the mock-procedure on the cardiac phantom, the cardiologists optimized their transapical surgical approach. The mitral valve stenosis and calcification were clearly visible. The phantom was used to inform the sizing of the valve to be implanted. Conclusion With advances in image processing and 3D printing technology, it is possible to create realistic patient-specific phantoms which can act as a guide for the interventional team. Using 3D printed phantoms as a valve sizing method shows potential as a more informative technique than typical CTA reconstruction alone. PMID:28615797

3D Printed Cardiac Phantom for Procedural Planning of a Transcatheter Native Mitral Valve Replacement.

PubMed

Izzo, Richard L; O'Hara, Ryan P; Iyer, Vijay; Hansen, Rose; Meess, Karen M; Nagesh, S V Setlur; Rudin, Stephen; Siddiqui, Adnan H; Springer, Michael; Ionita, Ciprian N

2016-02-27

3D printing an anatomically accurate, functional flow loop phantom of a patient's cardiac vasculature was used to assist in the surgical planning of one of the first native transcatheter mitral valve replacement (TMVR) procedures. CTA scans were acquired from a patient about to undergo the first minimally-invasive native TMVR procedure at the Gates Vascular Institute in Buffalo, NY. A python scripting library, the Vascular Modeling Toolkit (VMTK), was used to segment the 3D geometry of the patient's cardiac chambers and mitral valve with severe stenosis, calcific in nature. A stereolithographic (STL) mesh was generated and AutoDesk Meshmixer was used to transform the vascular surface into a functioning closed flow loop. A Stratasys Objet 500 Connex3 multi-material printer was used to fabricate the phantom with distinguishable material features of the vasculature and calcified valve. The interventional team performed a mock procedure on the phantom, embedding valve cages in the model and imaging the phantom with a Toshiba Infinix INFX-8000V 5-axis C-arm bi-Plane angiography system. After performing the mock-procedure on the cardiac phantom, the cardiologists optimized their transapical surgical approach. The mitral valve stenosis and calcification were clearly visible. The phantom was used to inform the sizing of the valve to be implanted. With advances in image processing and 3D printing technology, it is possible to create realistic patient-specific phantoms which can act as a guide for the interventional team. Using 3D printed phantoms as a valve sizing method shows potential as a more informative technique than typical CTA reconstruction alone.

3D printed cardiac phantom for procedural planning of a transcatheter native mitral valve replacement

NASA Astrophysics Data System (ADS)

Izzo, Richard L.; O'Hara, Ryan P.; Iyer, Vijay; Hansen, Rose; Meess, Karen M.; Nagesh, S. V. Setlur; Rudin, Stephen; Siddiqui, Adnan H.; Springer, Michael; Ionita, Ciprian N.

2016-03-01

3D printing an anatomically accurate, functional flow loop phantom of a patient's cardiac vasculature was used to assist in the surgical planning of one of the first native transcatheter mitral valve replacement (TMVR) procedures. CTA scans were acquired from a patient about to undergo the first minimally-invasive native TMVR procedure at the Gates Vascular Institute in Buffalo, NY. A python scripting library, the Vascular Modeling Toolkit (VMTK), was used to segment the 3D geometry of the patient's cardiac chambers and mitral valve with severe stenosis, calcific in nature. A stereolithographic (STL) mesh was generated and AutoDesk Meshmixer was used to transform the vascular surface into a functioning closed flow loop. A Stratasys Objet 500 Connex3 multi-material printer was used to fabricate the phantom with distinguishable material features of the vasculature and calcified valve. The interventional team performed a mock procedure on the phantom, embedding valve cages in the model and imaging the phantom with a Toshiba Infinix INFX-8000V 5-axis Carm bi-Plane angiography system. Results: After performing the mock-procedure on the cardiac phantom, the cardiologists optimized their transapical surgical approach. The mitral valve stenosis and calcification were clearly visible. The phantom was used to inform the sizing of the valve to be implanted. Conclusion: With advances in image processing and 3D printing technology, it is possible to create realistic patientspecific phantoms which can act as a guide for the interventional team. Using 3D printed phantoms as a valve sizing method shows potential as a more informative technique than typical CTA reconstruction alone.

Mitral valve replacement complicated by iatrogenic left ventricular outflow obstruction and paravalvular leak: case report and review of literature.

PubMed

Lee, Justin Z; Tey, Kai R; Mizyed, Ahmad; Hennemeyer, Charles T; Janardhanan, Rajesh; Lotun, Kapildeo

2015-10-09

Left ventricular outflow tract (LVOT) obstruction and paravalvular leak (PVL) are relatively uncommon, but are serious complications of prosthetic valve replacement. We present a case that displays the unique therapeutic challenges of treating a patient who developed both LVOT obstruction and mitral PVL after undergoing surgical aortic and mitral valve replacement (MVR). We also describe the use of alcohol septal ablation and albumin-glutaraldehyde (BioGlue) for septal ablation to percutaneously treat the patient's LVOT obstruction, followed by use of an Amplatzer vascular plug for percutaneous closure of an antero-medial mitral PVL associated with severe regurgitation. Percutaneous interventional management of these entities may be considered as an initial therapeutic option, especially in high-risk patients with significant morbidity and mortality of repeat surgical operations.

Dimerization of the bacterial effector protein AvrBs3 in the plant cell cytoplasm prior to nuclear import.

PubMed

Gürlebeck, Doreen; Szurek, Boris; Bonas, Ulla

2005-04-01

The effector protein AvrBs3 from the bacterial phytopathogen Xanthomonas campestris pv. vesicatoria is translocated into the plant cell where it specifically induces hypertrophy symptoms or the hypersensitive reaction. Activity of AvrBs3 depends on nuclear localization signals (NLSs) and an acidic activation domain, suggesting a role in regulation of plant transcription. Here, we show that AvrBs3 dimerizes in the plant cell prior to its nuclear import. AvrBs3 deletion derivatives were tested in the yeast two-hybrid system revealing that the repeat region, which confers specific recognition in resistant plants and is crucial for virulence function, is also essential for the self-interaction. GST pull-down assays showed that the AvrBs3-AvrBs3 interaction occurs independent of plant proteins. Coexpression of two different inactive mutant AvrBs3 derivatives in Bs3-resistant pepper plants resulted in 'trans-complementation', i.e., the induction of a hypersensitive reaction. This clearly indicates that AvrBs3-dimerization occurs in planta. Interestingly, 'trans-complementation' was not observed in susceptible plants suggesting that wild-type homodimers are needed for the AvrBs3 virulence function in plants. Furthermore, a green fluorescent protein (GFP) fusion of AvrBs3 deleted in the NLSs (AvrBs3DeltaNLS-GFP), normally localized in the cytoplasm, was imported into the nucleus upon coexpression with wild-type AvrBs3 in Nicotiana benthamiana. Thus, AvrBs3 dimerization takes place in the cytoplasm of the plant cell prior to nuclear import. Given the fact that dimerization is a common feature of transcriptional regulators, our data are consistent with the idea that AvrBs3 manipulates expression of plant genes involved in the establishment of compatible and incompatible interactions.

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.

Intermediate results of isolated mitral valve replacement with a Biocor porcine valve.

PubMed

Rizzoli, Giulio; Bottio, Tomaso; Vida, Vladimiro; Nesseris, Georgios; Caprili, Luca; Thiene, Gaetano; Gerosa, Gino

2005-02-01

We analyzed the intermediate experience, survival, and prosthetic complications of patients who received the Biocor valve, a new-generation porcine valve, in the mitral position. At the University of Padua, between May 1992 and January 2004, 154 consecutive patients (102 female and 52 male patients; mean age, 72.3 +/- 6 years; age range, 37-86 years) received 158 mitral Biocor prostheses (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil). Thirty-five percent of the patients had previous mitral operations, 24% had coronary artery bypass grafting, and 34.6% had other procedures. Median preoperative New York Heart Association class was III. Echocardiography was performed in 75% of the long-term survivors. Follow-up included 609.4 patient-years and was 100% complete, with a median time of 4 patient-years (range, 0.02-11.3 years). At 8 years, 20 (14%) of 142 operative survivors were still at risk. Early mortality was 13.6%. According to univariate analysis, New York Heart Association class III to IV, ejection fraction of less than 40%, urgency, male sex, and coronary artery bypass grafting were significant perioperative risk factors. Eight- and 10-year actuarial survival was 51.1% +/- 5.6% (40 deaths). Eight-year actuarial freedom from valve-related death, thromboembolism, anticoagulant-related hemorrhage, endocarditis, paravalvular leak, and valve-related complications were 85.2% +/- 5%, 85.7% +/- 4.4%, 92.6% +/- 3.7%, 94.1% +/- 3%, 91.8% +/- 3%, and 70.2% +/- 5.7%, respectively. Freedom from structural valve deterioration was 100%. Actual freedom from reoperation was 93.2% +/- 2.2%. By Doppler echocardiography, the peak and mean transprosthetic gradients were 15 +/- 5 mm Hg and 6.3 +/- 3 mm Hg, respectively (mean follow-up, 4.2 +/- 2.7 years). At intermediate follow-up, the Biocor prosthesis in the mitral position showed excellent results in terms of valve durability when compared with other second-generation tissue valves.

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.

Quality of life in high-risk patients: comparison of transcatheter aortic valve implantation with surgical aortic valve replacement.

PubMed

Amonn, Kathrin; Stortecky, Stefan; Brinks, Henriette; Gahl, Brigitta; Windecker, Stephan; Wenaweser, Peter; Carrel, Thierry; Huber, Christoph

2013-01-01

To compare health-related quality of life (QoL) in patients undergoing transcatheter aortic valve implantation via transapical access (TA TAVI) with patients undergoing surgical aortic valve replacement (SAVR). One hundred and forty-four high-risk patients referred for aortic valve replacement underwent TAVI screening and were assigned to either TA TAVI (n = 51, age 79.7 ± 9.2 years, logistic EuroSCORE 26.5 ± 16.1%, 51% males) or SAVR (n = 93, age 81.1 ± 5.3 years, logistic EuroSCORE 12.1 ± 9.3%, 42% males) by the interdisciplinary heart team. QoL was assessed using the Short Form 36 (SF-36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale. Furthermore, current living conditions and the degree of independence at home were evaluated. Patients undergoing TA TAVI were at higher risk as assessed by EuroSCORE (26.5 ± 16 vs. 12.1 ± 9, P < 0.001) and STS score (6.7 ± 4 vs. 4.4 ± 3, P < 0.001) compared with SAVR patients. At the 30-day follow-up, the rate of mortality was similar and amounted to 7.8% for TA TAVI and 7.5% for SAVR patients and raised to 25.5% in TA TAVI and 18.3% in SAVR patients after a follow-up period of 15 ± 10 months. Assessment of QoL revealed no differences in terms of anxiety and depression between TA TAVI and SAVR patients. The SF-36 mental health metascore was similar in both groups (65.6 ± 19 vs. 68.8 ± 22, P = 0.29), while a significant difference was observed in the physical health metascore (49.7 ± 21 vs. 62.0 ± 21, P = 0.015). After adjustment for baseline characteristics, this difference disappeared. However, every added point in the preoperative risk assessment with the STS score decreased the SF-36 physical health dimension by two raw points at the follow-up assessment. Selected high-risk patients undergoing TAVI by using a transapical access achieve similar clinical outcomes and QoL compared with patients undergoing SAVR. Increased STS scores predict worse QoL outcomes.

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

Preservation of the bicuspid aortic valve.

PubMed

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

2007-02-01

Bicuspid anatomy of the aortic valve is a common reason for aortic regurgitation and is associated with aortic dilatation in more than 50% of patients. We have observed different patterns of aortic dilatation and used different approaches preserving the valve. Between October 1995 and February 2006, a regurgitant bicuspid valve was repaired in 173 patients. The aorta was normal in 57 patients who underwent isolated repair. Aortic dilatation mainly above commissural level (n = 38) was treated by separate valve repair plus supracommissural aortic replacement. In 78 patients, aortic dilatation involved the root and was treated by root remodeling. Hospital mortality and perioperative morbidity were low in all three groups. Myocardial ischemia was significantly shorter in repair plus aortic replacement than remodeling (p < 0.001). Freedom from aortic regurgitation II or greater at 5 years varied between 91% and 96%. Freedom from reoperation at 5 years was 97% after remodeling, but only 53% after repair plus aortic replacement (p = 0.33). Symmetric prolapse was the most frequent cause for reoperation. The long-term stability of bicuspid aortic valve repair is excellent in the absence of aortic pathology. In the presence of aortic dilatation, root remodeling leads to equally stable valve durability. In patients with less pronounced root dilatation, separate valve repair plus aortic replacement may be a less complex alternative. Symmetric prolapse should be avoided if the ascending aorta is replaced.

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

Structural valve deterioration in a starr-edwards mitral caged-disk valve prosthesis.

PubMed

Aoyagi, Shigeaki; Tayama, Kei-Ichiro; Okazaki, Teiji; Shintani, Yusuke; Kono, Michitaka; Wada, Kumiko; Kosuga, Ken-Ichi; Mori, Ryusuke; Tanaka, Hiroyuki