Journal of Heart Valve Disease最新文献

Background: The study aim was to investigate the immediate and long-term results of balloon aortic valvuloplasty (BAV) in young patients (aged ≤20 years) with congenital bicuspid aortic valve presenting with severe aortic stenosis.

Methods: The study involved a single tertiary care center-based retrospective data analysis of immediate and long-term outcomes in patients following balloon valvuloplasty between 2000 and 2011. A total of 92 young patients (mean age 12.7 years; 95% CI 8.3-16.7 years) with aortic stenosis due to congenital bicuspid aortic valve and who underwent BAV were studied.

Results: The mean follow up period was 5.7 ± 1.3 years. Intervention resulted in successful BAV (≥50% reduction in baseline gradient) in 79 patients (85.9%; group A) and partially successful BAV (<50% reduction in baseline gradient) in eight patients (8.7%; group B). BAV failed in five patients (5.4%; group C). The mean left ventricular systolic pressure was decreased from 155.6 mmHg (95% CI 132.7-186.3 mmHg) to 100.9 mmHg (95% CI 82.1-119.6 mmHg; p <0.001), and the mean aortic valve gradient from 40.7 mmHg (95% CI 25.12-56.22 mmHg) to 17.2 mmHg (95% CI 15.83- 21.23 mmHg; p <0.001). Mean changes in aortic valve area and mean gradient were significantly different between successful BAV groups (A and B) and the failed BAV group (p = 0.001). Different grades of aortic regurgitation were noted in 32 patients (34.78%) after BAV (severe regurgitation in 2.18%). A post hoc analysis showed sustained gradient reductions at one- and five-year follow up investigations (p <0.05). The need for surgery was much lower in the successful BAV groups.

Conclusions: The success of BAV in bicuspid aortic valve stenosis in younger patients was approximately 85%. Although 10% of patients developed re-stenosis and required surgical intervention, the majority did well during the follow up period. It was concluded that BAV is a viable option in adolescents and young children with bicuspid aortic valve without severe calcification.

Osteogenesis imperfecta (OI) is a syndrome that is often associated with dysfunction of the aortic valve. Because of the resultant fragile vessels and impaired hemostasis, surgical therapy to treat OI is challenging. Previous reports have suggested that transcatheter aortic valve implantation (TAVI) might be a suitable treatment for this condition. To the best of the authors' knowledge, the present case is the first to describe a young patient who underwent successful TAVI to treat osteogenesis imperfecta. The proposal of transfemoral TAVI serving as first-line therapy for aortic valve stenosis in patients suffering from osteogenesis imperfect was confirmed.

Background: Currently, only limited data are available on the rate of hemodynamic progression with clinical outcome in patients receiving the latest Crown PRT aortic prosthesis. The study aim was to report clinical and hemodynamic outcomes in 55 consecutive patients for a follow up of up to one year after Crown PRT implantation.

Methods: Between February and September 2015, a total of 55 patients (34 males, 21 females; mean age 77.3 ± 1.2 years) underwent aortic valve replacement (AVR) with the latest LivaNova Crown PRT bioprosthesis at the authors' institution. Left ventricular function was preserved in 79% of patients. Data relating to the patients' clinical, echocardiographic and functional capacities were obtained prospectively.

Results: There were no in-hospital deaths. Significant perioperative complications included stroke (3.6%), atrial fibrillation (27%), and permanent pacemaker insertion (1.8%). Pre-discharge echocardiography demonstrated peak (PG) and mean (MG) transprosthetic gradients of 24.4 ± 10.4 mmHg and 12.9 ± 6.2 mmHg, respectively. The Doppler velocity index (DVI) was 0.49 ± 0.13, and the effective orifice area index (EOAi) 0.89 ± 0.12 cm2/m2. At a mean follow up of 1.3 ± 0.3 years, the transprosthetic gradients, DVI and EOAi were not significantly different from postoperative or pre-discharge values. The patients' NYHA status was I or II in 95% of cases, and the mean left ventricular mass had decreased by 36% at the end of follow up.

Conclusions: The Crown PRT is an effective bioprosthesis, with a low incidence of valve-related complications comparable to those of other current bioprostheses. The bioprosthesis demonstrated satisfactory results in terms of hemodynamics and freedom from reoperation.

Background: Currently, several different flexible mitral annuloplasty rings are available, and their efficacy for surgical repair of the mitral valve is, in general, considered equal. However, clinical experience indicates differences in remodeling capacity that have not yet been quantitatively assessed. The study aim was to compare the biomechanical properties of two commonly used flexible mitral annuloplasty rings in an acute pig model.

Methods: Medtronic Simulus Flex (n = 5) and Medtronic Duran AnCore (n = 7) flexible mitral annuloplasty rings were implanted in pigs (bodyweight 80 kg). The native mitral valve was used as a reference (n = 7). Mitral annular dynamics and dimensions were assessed using 11 sonomicrometry crystals placed in the mitral apparatus. A dedicated force transducer was used to detect deformational force transmission between the annuloplasty ring and the mitral annulus.

Results: Cyclic changes in mitral annular circumference and commissure-commissure distance were significantly reduced in the Simulus Flex group compared to the Duran AnCore group (p = 0.025 and p <0.01, respectively). In the Simulus Flex group, smaller deformational forces were recorded compared to the Duran AnCore group, but the difference was not statistically significant (p = 0.52 and p = 0.06 for the septal-lateral and the commissure-commissure force measurements, respectively).

Conclusions: The Simulus Flex ring showed significantly more remodeling capacity than the Duran AnCore ring, but the latter ring preserved the natural dynamics of the mitral valve to a greater degree. Insights into these biomechanical differences may facilitate strategies for surgical reconstruction in degenerative mitral valve disease, especially in patients with excessive amounts of tissue and who are at risk of systolic anterior motion of the mitral valve.

Background: Prosthetic valve thrombosis (PVT) may impair pulmonary venous flow (PVF) and left atrial appendage (LAA) functions. An investigation was conducted to determine the association between left superior PVF and LAA functions and mitral PVT.

Methods: This observational case-control study included 100 consecutive patients (87 females, 13 males; mean age 59 years; range 35-71 years) with mechanical mitral PVT, and 50 age- and gender-matched otherwise healthy controls with normally functioning mitral prostheses. All patients were included after comprehensive transesophageal echocardiography (TEE) examinations for the presence and quantification of PVT, the left atrial diameter, and LAA length. Peak systolic velocity (PSV), velocity-time integral of systolic flow (VTI-s), peak diastolic velocity (PDV), velocity-time integral of diastolic flow (VTI-d), systolic fraction (SFr) of the left upper PVF and the flow of the LAA orifice were each recorded using color-guided pulsed-wave Doppler imaging during TEE.

Results: The PSV [30 cm/s (range: 13-77 cm/s) versus 44 cm/s (range: 16-71 cm/s)], respectively (p = 0.002), VTI-s [(2.85 cm (range: 0.5-10.7 cm) versus 5 cm (range: 1.3-12.7 cm)], respectively (p <0.001), VTI-d [(3 cm (range: 0.6-9.7 cm) versus 4.2 cm (range: 1.5-8.3 cm)], respectively (p <0.001), SFr (45.5% (range: 15.66-67.44%) versus 50 % (range: 21.11-82.61%)], respectively (p = 0.008), and LAA orifice velocity [(23 cm/s (range: 11-75 cm/s) versus 34 cm/s (range: 10-112 cm/s)], respectively (p = 0.011) were each significantly lower in patients with PVT compared to controls. The PDV was similar between groups. Patients with obstructive PVT (n = 21) had a lower PDV and a higher VTI-d compared to those with non-obstructive PVT.

Conclusions: Mitral mechanical PVT is associated with decreased systolic PVF and LAA function. The presence of obstructive PVT is associated with further limitations of diastolic flow velocity, and a compensatory prolongation of diastolic flow of the left upper pulmonary vein.

Background: Finite element analysis (FEA) can be used to determine ascending thoracic aortic aneurysm (aTAA) wall stress as a potential biomechanical predictor of dissection. FEA is dependent upon zero-pressure three-dimensional geometry, patient-specific material properties, wall thickness, and hemodynamic loading conditions. Unfortunately, determining material properties on unoperated patients using non-invasive means is challenging; and we have previously demonstrated significant material property differences among aTAA patients. Our study objective was to determine the impact of patient-specific material properties on aTAA wall stress. Using FEA, we investigated if patient-specific wall stress could be reasonably predicted using population-averaged material properties, which would greatly simplify dissection prediction.

Methods: ATAA patients (n=15) with both computed tomography (CT) imaging and surgical aTAA specimens were recruited. Patient-specific aTAA CT geometries were meshed and pre-stress geometries determined as previously described. Patient-specific material properties were derived from biaxial stretch testing of aTAA tissue and incorporated into a fiber-enforced hyper-elastic model, while group-averaged material properties were estimated using mean values of each parameter. Population-averaged material properties were also calculated from literature and studied. Wall stress distribution and its magnitude were determined using LS-DYNA FEA software. Peak and averaged stresses and stress distributions were compared between patient-specific and both group- and population-averaged material property models.

Results: Patient-specific material properties had minimal influence on either peak or averaged wall stress compared to use of group- or population-averaged material properties. Stress distribution was also nearly superimposed among models with patient-specific vs. group- or population-averaged material properties and provided similar prediction of sites most prone to rupture.

Conclusions: FEA using population-averaged material properties likely provides reliable stress prediction to indicate sites most prone to rupture. Population-averaged material properties may be reliably used in computational models to assess wall stress and significantly simplify risk prediction of aTAA dissection.

Prosthetic heart valve thrombosis is a rare, difficult-to-treat condition that increases morbidity and mortality by leading to systemic embolism. Clinically, it presents mainly in the form of stroke, though an embolism be observed in many systems. Acute coronary syndrome, which is rarely observed in patients with a prosthetic heart valve, mostly occurs as non-ST segment elevation myocardial infarction (MI). There is no specific recommendation for the treatment of this condition. Revascularization success rates have been shown to be variable in cases wherein thrombolytic therapy, balloon angioplasty, stent implantation, and a combination of all of these techniques are used. Herein are presented details of the successful revascularization of a patient with ST segment elevation MI presenting with simultaneous right and left coronary system embolism, and without embolism in any other system. In cases of acute coronary syndrome in patients with a prosthetic heart valve with no known coronary artery disease, starting the procedure with thrombus aspiration may prevent unnecessary stent and balloon angioplasty procedures being required, by accelerating the revascularization process.

Background: Despite considerations of its therapeutic range and multiple drug-food interactions, warfarin is the mainstay of oral anticoagulation in patients with mechanical heart valves (MHVs). The quality of anticoagulation demonstrates variations, with 'time in therapeutic range' (TTR) values usually lower than expected. It has been hypothesized that warfarin adherence is among the modifiable causes of suboptimal coagulation. The aim of the study was to demonstrate the ability of the 8-Item Morisky Medication Adherence Scale (MMAS-8©) to identify patients with non-adherence to warfarin, and to define the predictors of optimal coagulation when a TTR value ≥65% is used as the surrogate.

Methods: In a cross-sectional survey of 112 patients, TTR6 months and TTR12 months were calculated using the Rosendaal method. A questionnaire was used to assess the patients' warfarin knowledge, bleeding complications, and adherence. Patients were categorized into low-adherence (LA), moderate adherence (MA) and high-adherence (HA) groups based on MMAS-8 values. The target INR was 2.5-3.5, and an effective TTR was defined as ≥65%.

Results: TTR6 months, TTR12 months and warfarin knowledge were significantly lower in the LA group than in the MA and HA groups. In addition, the bleeding score of HA patients was significantly lower than that of LA and MA patients. The MMAS-8 was the single independent predictor of effective TTR for six and 12 months on multivariate regression analysis (B = 0.506, p <0.001 and B = 0.469, p <0.001, respectively).

Conclusions: Warfarin adherence accounted for poor TTR values in patients with MHV, and MMAS-8 was used effectively to identify those expected to have a low TTR, to suffer more complications, and to require robust education.