Journal of Heart Valve Disease最新文献

Pulmonary venous flow (PVF) provides incremental information on left ventricular (LV) diastolic function, and can support the diagnosis of severe mitral regurgitation (MR). The suggestion has been made to combine the left atrial filling volume (LA Fill) and PVF for estimating the mitral regurgitant volume, but echocardiographic PVF evaluation is known to have many limitations. The present case report includes an example of how to assess PVF using cardiovascular magnetic resonance, and a new method is proposed for quantification of the mitral regurgitant volume.

Background and aim of the study: Although next-generation cardiac prostheses have shown favorable results in transcatheter aortic valve implantation (TAVI), these have mostly been documented in intermediate-risk patients. Whether this could be translated to high-risk patients is not known. Hence, the safety and clinical performance of the new, repositionable CoreValve Evolut R-System (ERS) was evaluated by comparison with a non-repositionable CoreValve-System (CVS), in 96 high-risk/inoperable (HRI) patients.

Methods: The primary safety end points were mortality and stroke, defined by VARC-2 criteria, at 30 days. Clinical performance end points were described by VARC-2 criteria, focusing on: (i) higher-grade atrioventricular conduction blocks with concomitant permanent pacemaker (PM) implantation; (ii) vascular complications (VCs); and (iii) aortic regurgitation (AR). The ERS and CVS patients underwent TAVI in equal proportions.

Results: In this study, 63% of patients in the CVS group and 82% in the ERS group were defined as HRI. One in-hospital death was documented after 30 days. With regards to the HRI cohort, no difference in rates of PM use were noted (ERS 20% versus CVS 20%; p >0.9999). ERS patients were characterized by a higher prevalence of peripheral vascular disease (PVD) (46% versus 21%; p <0.05), but fewer VCs (13% versus 41%; p <0.01). Both cohorts showed low rates of moderate-to-severe paravalvular AR (ERS 6% versus CVS 5%; p = 0.8639). However, ERS seemed to offer a favorable hemodynamic performance, with a significantly improved AR index (26.3 versus 22.3; p <0.05). TAVI with the ERS was associated with a higher stroke rate (3% versus 0%; p = 0.1232) after necessary postdilatation processes.

Conclusions: In comparison to last-generation CVS, the repositionable ERS is safe and effective in HRI patients. Similar rates of PM use were noted for each group. together with a favorable hemodynamic performance and fewer vascular complications.

Background and aim of the study: Aortic valve replacement (AVR) improves survival and quality of life in patients with severe aortic stenosis (AS), but despite clear indications for surgical treatment a significant proportion of patients do not undergo AVR. The study aim was to identify clinical variables associated with the decision to perform AVR, and to assess the prognostic effect of surgery versus medical treatment in patients with severe AS adjusted for significant confounders and effect modifiers.

Methods: A prospective observational study of consenting patients aged >18 years who were under consideration for AVR at the authors' tertiary teaching hospital was conducted. The main outcomes of the study were treatment decisions and survival.

Results: Among 480 patients with severe AS who were evaluated, 351 had surgical AVR, 38 had transcatheter AVR, and 91 were declined operative treatment. Typically, non-operated patients were older, were in a lower NYHA class, had fewer symptoms, a lower peak aortic jet velocity, a higher NT-proBNP level, and a lower physical summary score (SF-36). Higher age showed the strongest correlation against AVR (OR 0.91; 95% CI 0.87-0.94). One-, three-, and five-year cumulative survival rates, respectively, were 95%, 87%, and 73% among operated patients, and 82%, 47%, and 27% among non-operated patients. The median survival time was 1,604 days (95% CI 1,554-1,655) in operated patients versus 1,090 days (95% CI 954-1,226) in non-operated patients (p <0.001). The effect of operation on mortality was shown to depend on the interaction with diabetes, when adjusted for significant confounders (i.e., age, atrial fibrillation, NT-proBNP, hs-Troponin T, and NYHA class). An effect of AVR on mortality was found in patients without diabetes (HR 0.29; 95% CI 0.19-0.468; p <0.001), but not among patients with diabetes.

Conclusions: Supplemental and better parameters to improve patient selection are warranted. Surgical AVR shows a greater prognostic effect in patients without diabetes.

Coarctation of the aorta (CoA) is a relatively common congenital heart anomaly, and bicuspid aortic valve (BAV) is a common congenital heart disease that coexists with CoA. In larger children and adults with CoA, transcatheter intervention has gained acceptance, but for surgical high-risk patients with aortic stenosis, the use of transcatheter aortic valve implantation (TAVI) has been established. Recently, although favorable data have been reported for TAVI when treating BAV, simultaneous transcatheter intervention for CoA and BAV will prove to be a challenge because of the unique anatomy involved requires multiple procedural steps and also has problems of site access. Herein is reported a successful case of simultaneous thoracic endovascular repair (TEVAR) for CoA and transfemoral TAVI for congenital BAV dysfunction. A 62-year-old male with CoA and congenital BAV with severe aortic stenosis and aortic regurgitation had NYHA class IV heart failure symptoms. Because of the patient's extremely poor left ventricular function, the authors' heart team decided to perform simultaneous TEVAR for CoA and transfemoral TAVI. After deployment of a 32 mm stent graft, a 29 mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) was successfully deployed through the stent graft. This resulted in no significant pressure gradient within the aorta, and no aortic regurgitation. Video 1: Cineradiography showing delivery of the Edwards Commander delivery system through the stent graft. Video 2: Final aortography showing no residual aortic regurgitation.

Background and aim of the study: Worldwide, there is increased use of bioprosthetic valves in the aortic position. Part of this increase has been patient-driven for quality of life reasons. More recently, bioprosthetic valves have been chosen by progressively younger patients, with a strategy of performing a valve-in-valve TAVI if the prosthesis should wear out. Thus, a review was undertaken of the present authors' experience with patients whose first two aortic valve replacements (AVRs) were with bioprosthetic valves.

Methods: Patients receiving consecutive bioprosthetic AVRs at the Green Lane Cardiothoracic Surgical Unit were identified from a departmental database. Data were retrieved from prospective databases, electronic and archived clinical records. Outcomes of interest were overall survival and freedom from a third or more AVR.

Results: A total of 267 patients met the inclusion criteria, with a mean follow up of 22.3 years. Concurrent procedures (e.g., coronary artery bypass grafting) were performed in 65.2% of patients that underwent two bioprosthetic AVRs, and in 79.8% of patients undergoing three or more bioprosthetic AVRs. Median survival of the cohort was 31.7 years. Age at operation was the best predictor of needing a third or more AVR. Receiver operating characteristic curve analysis identified that age <45 years at the first operation and <56 years at the second operation were the optimal cut-off point for the likelihood of needing a third or more aortic valve intervention.

Conclusions: Overall survival for consecutive bioprosthetic AVRs was remarkably good. Data relating to consecutive bioprosthetic AVRs is of particular interest in the context of TAVI and valve-in-valve TAVI, which will likely significantly increase the number of patients receiving consecutive bioprosthetic valves. However, it must be noted that the majority of patients in this cohort required concurrent cardiac surgical procedures. The study results provided encouraging data for consecutive bioprosthetic AVRs, as well as data that may be of interest in the setting of TAVI being performed in younger cohorts of patients.

Background and aim of the study: Tricuspid valve regurgitation (TR) is often not taken into consideration in the prognostication of patients undergoing transcatheter aortic valve replacement (TAVR). Accordingly, its impact on such patients remains relatively poorly defined. The study aim was to explore the effect of TR and parameters of right ventricular (RV) function on outcomes in patients undergoing TAVR.

Methods: Baseline demographic and echocardiographic data were collected for 460 consecutive patients undergoing TAVR at the authors' institution between 2012 and 2015. A retrospective analysis was performed to determine the association of TR with all-cause mortality in these patients. The primary endpoint was 30-day rate of all-cause mortality and/or hospital re-admission.

Results: Among 460 patients included in the study analysis there were 25 deaths and 40 re-admissions. Univariate analysis showed that a higher Society of Thoracic Surgeons (STS) score, severe preoperative mitral and tricuspid regurgitation were associated with statistically significant higher 30-day mortality and/or re-admission rates. On multivariate analysis, STS score (OR 1.07, 95% CI 1.012-1.126), moderate TR (OR 3.24, 95% CI 1.52-6.87) and severe TR (OR 2.5, 95% CI 1.04-6.04) were identified as significant independent predictors of all-cause mortality.

Conclusions: The severity of TR is a strong independent parameter predictive of death at 30 days. Therefore, parameters of RV function such as TR should be incorporated into predictive models for patients undergoing TAVR.

Background and aim of the study: The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation.

Methods: Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29).

Results: No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33).

Conclusions: The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

Despite the limited clinical relevance of thrombocytopenia after bioprosthetic aortic valve replacement (AVR), the postoperative depletion of platelet count continues to attract the attention of many authors. The development of thrombocytopenia has been evaluated either in patients receiving a sutureless bioprosthesis (1,2) or in those undergoing transcatheter aortic valve implantation, where cardiopulmonary bypass bears little or no relation to this phenomenon (3). Recently, Sánchez et al. (1) have published their findings on this topic, but their limited experience with the devices used makes their study of doubtful interest. Over three years, 27 patients were implanted with a sutureless bioprosthetic valve and were compared with 50 patients receiving a stented aortic valve. No risk factors that may have predisposed to platelet dysfunction were described in either group.Mortality and number of units of transfused red blood cells also seems to be extremely high for a patient population undergoing elective isolated AVR: it is not clear whether bleeding complications occurred in any patients and re-thoracotomy could not be performed, or whether more liberal transfusion protocols were used. In addition, platelet transfusions in patients from the sutureless group could represent a bias that renders the comparison of postoperative mean platelet volume and platelet distribution width between groups unreliable. It would have been more appropriate to consider postoperative echocardiographic findings because, in case of suboptimal placement of the prosthesis, paravalvular leakage may cause severe hemolysis and thrombocytopenia. At present, clinical data can be derived from other case series (4). At our Center, over a six-year period, AVR was performed using a sutureless, stentless, or stented bioprosthesis in 432, 193, and 180 patients, respectively, with all devices being supplied by the same manufacturer. Perioperative trends in platelet count after sutureless AVR did not show progression towards thrombocytopenia as occurs after stentless AVR (5), but compared favourably with conventional stented AVR (Fig. 1), where platelet depletion has no clinical relevance. Figure 1: Perioperative trends in platelet count after aorticvalve replacement with the sutureless Perceval, stentlessSolo, and stented Crown bioprosthetic valves.References1. Sánchez E, Corrales JA, Fantidis P, Tarhini IS, Khan I, Pineda T, González JR. Thrombocytopenia after aortic valve replacement with Perceval S sutureless bioprosthesis. J Heart Valve Dis 2016;25:75-812. Jiritano F, Cristodoro L, Malta E, Mastroroberto P. Thrombocytopenia after sutureless aortic valve implantation: Comparison between Intuity and Perceval bioprostheses. J Thorac Cardiovasc Surg 2016;152:1631-16333. McCabe JM, Huang PH, Riedl LA, et al. Incidence and implications of idiopathic thrombocytopenia following transcatheter aortic valve replacement with the Edwards Sapien® valves: A single center experience. C

Background and aim of the study: The impact of adding papillary muscle approximation (PMA) to restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) function is unknown. Changes in LV function parameters and clinical outcome were evaluated following RMA with and without PMA in patients with clinically relevant functional mitral regurgitation (FMR).

Methods: A total of 176 patients with advanced cardiomyopathy underwent RMA either with (n = 59) or without (n = 117) PMA. Propensity score analysis was used to adjust for group differences in several baseline characteristics, such as age, gender and LV ejection fraction (LVEF) (C-statistic = 0.80, goodness-of-fit value = 0.58).

Results: Serial echocardiography in 30 propensity score-matched pairs demonstrated decreases in LV end-systolic dimension (RMA alone: 57 ± 9 mm at baseline versus 54 ±11 mm at one month versus 56 ± 13 mm at latest examination; RMA + PMA: 56 ± 8 mm versus 53 ± 9 mm versus 48 ± 11 mm, respectively) and improvement in LVEF (RMA alone: 28 ± 8% versus 28 ± 11% versus 29 ± 10%; RMA + PMA: 30 ± 8% versus 30 ± 9% versus 36 ± 13%, respectively) in both groups. Greater degrees of changes in value were noted for patients receiving RMA + PMA (group effect p <0.05 for both). The two-year survival of both groups was similar (73 ± 8% versus 77 ± 23%, p = 0.7), but the RMA + PMA group showed a trend towards a greater freedom from composite events, defined as mortality and/or unscheduled heart failure re-admission (48 ± 9% versus 63 ± 9%, p = 0.1).

Conclusions: RMA + PMA induced greater long-term effects on unloading of the left ventricle and improvements in LV systolic function than did RMA alone. PMA may be a useful adjunct repair in combination with RMA, although its clinical benefits remain to be determined.

Background and aim of the study: Xenograft conduits have been used successfully to repair congenital heart defects, but are prone to failure over time. Hence, in order to improve patient outcomes, better xenografts are being developed. When evaluating a conduit's performance and safety it must first be compared against a clinically available control in a large animal model. The study aim was to evaluate a clinically available xenograft conduit used in right ventricular outflow tract (RVOT) reconstruction in a sheep model.

Methods: RVOT reconstruction was performed in 13 adult and juvenile sheep, using the Medtronic Hancock® Bioprosthetic Valved Conduit (Hancock conduit). The method had previously been used on patients, and a newly modified variant termed 'RVOT Extraction' was employed to facilitate the surgical procedure. Animals were monitored over predetermined terms of 70 to 140 days. Serial transthoracic echocardiography, intracardiac pressure measurements and angiography were performed. On study completion the animals were euthanized and necropsies performed.

Results: Two animals died prior to their designated study term due to severe valvular stenosis and distal conduit narrowing, respectively. Thus, 11 animals survived the study term, with few or no complications. Generally, maximal and mean transvalvular pressure gradients across the implanted conduits were increased throughout the postoperative course. Among 11 full-term animals, seven conduits were patent with mild or no pseudointimal proliferation and with flexible leaflets maintaining the hemodynamic integrity of the valve.

Conclusions: RVOT reconstruction using the Hancock conduit was shown to be successful in sheep, with durable and efficient performances. With its extensive clinical use in patients, and ability for long-term use in sheep (as described in the present study) it can be concluded that the Hancock conduit is an excellent control device for the evaluation of new xenografts in future preclinical studies.