Journal of Heart Valve Disease最新文献

Background: Transcatheter aortic valve replacement (TAVR) is a widely established alternative to surgery in intermediate- and high-risk patients. TAVR program development within the Veterans Affairs (VA) system has been previously described. However, national TAVR registries do not capture VA outcomes data, and few data have been reported regarding TAVR outcomes at lower-volume federal institutions. The study aim was to demonstrate the evolution of a successful VA TAVR program.

Methods: A retrospective analysis was performed of the first 100 TAVR patients at San Francisco VA Medical Center. Mortality and major complications were evaluated.

Results: Between 25th November 2013 and 31st August 2016, a total of 100 TAVR procedures was performed at the authors' institution. The mean patient age was 79.7 ± 8.7 years. Patients underwent TAVR via percutaneous-transfemoral (n = 90), surgical cutdown-transfemoral (n = 8), or transapical (n = 2) approaches. The valve systems employed were Edwards SAPIEN (n = 16), SAPIEN XT (n = 31), SAPIEN 3 (n = 23), and Medtronic CoreValve (n = 16) and CoreValve Evolut R (n = 14). The overall device success was 96%. TAVR-in-TAVR was required in the remaining 4% of patients, and was successful. All-cause procedural mortality was 1%. Complications included tamponade (1%), stroke (2%), temporary hemodialysis (1%), vascular injuries requiring intervention (4%), and permanent pacemaker implantation (14%). There were no conversions to surgical aortic valve replacement. Twenty-two (22%) patients had mild, two (2%) had moderate, and none (0%) had severe paravalvular leakage. The post-procedure aortic valve gradient by echocardiography was 8.6 ± 4.5 mmHg. Follow up was 100% complete and survival was 99%, 93%, and 89% at one, six, and 12 months, respectively.

Conclusions: Successful outcomes were demonstrated for a VA TAVR program that compared favorably with benchmarks established by the National Transcatheter Valve Therapies Registry. These results provide a necessary transparency of TAVR outcomes at a federal institution.

Background: Temporal three-dimensional (3D) analysis of the mitral valve biomechanics has prompted a re-evaluation of surgical approaches and repair device designs to accommodate the natural dynamics of the valve. Such new designs strive to obtain lower annulus restraining forces, resulting in more natural leaflet and chordal stresses. A new annuloplasty system was evaluated using 3D motion and out-of-plane force analysis. It was hypothesized that this system would not impact the valve with adverse motion restrictions or high systolic annular forces compared to conventional flat rigid ring designs.

Methods: In an acute porcine set-up, six 80 kg pigs were monitored before and after implantation of the new annuloplasty system consisting of two half-rings with a saddle-shaped outline. Valvular 3D dynamic geometry was obtained using sonomicrometry before and after annuloplasty system implantation. Strain gauges mounted on the commissural segments provided the annular restraining force distribution perpendicular to the annular plane.

Results: The change in annular height to commissural width ratio from diastole to systole did not alter following implantation (p >0.05). Out-of-plane systolic restraining forces were 0.2 ± 0.1 N and 0.8 ± 0.3 N (mean ± SEM) in the posterior and anterior commissural segments, respectively, without any difference in-between (p >0.1). Forces in both commissural segments were significantly lowered compared to previous measurements with a flat and stiff mitral annuloplasty ring (p <0.01). Mitral annular septal-lateral distance, area, and circumference in the commissural segments were decreased after implantation (p <0.05). The cross-annular distance between the commissural segments and the lengths of the anterior and posterior annular segments did not change following implantation (p >0.05).

Conclusions: The new annuloplasty system design maintained annular 3D dynamics and provided a minimized out-of-plane restraining force distribution compared to earlier studies on flat rigid rings. This may have important implications in the selection of annuloplasty devices in order to increase repair durability.

Background: Previous studies have reported an association between aortic valve sclerosis (AVS) and coronary atherosclerosis. However, the threshold of sclerosis used to identify high-risk patients has not yet been determined.

Methods: A total of 225 patients admitted with non- ST-elevation myocardial infarction (NSTEMI) or unstable angina was studied. Echocardiography was performed on all patients within 24 h of admission. Sclerosis scores were determined for each aortic cusp, and the average AVS score index (AVSSI) was calculated. The left ventricular ejection fraction (LVEF) and variables of left ventricular diastolic function and filling pressure, such as transmitral pulsed Doppler early diastolic velocities (E wave), early diastolic tissue Doppler mitral annular velocities (e'), and E/e', were also determined. These patients underwent coronary angiography, and SYNTAX scores were determined.

Results: Patients with an average AVSSI >1 were older, more hypertensive, and had higher rates of previous coronary artery bypass grafting. In addition, the prevalences of significant coronary artery disease (CAD) and three-vessel CAD were higher in these patients. Among the echocardiographic variables, LVEF and e' velocity were significantly lower and E/e' was significantly higher in patients with an AVSSI >1. These patients also had a higher prevalence of left ventricular hypertrophy, diastolic dysfunction, and ischemic mitral regurgitation than those with an average AVSSI ≤1. Regression analysis showed that AVS was independently associated with significant CAD and SYNTAX score.

Conclusions: The average AVSSI may be a useful marker in the risk stratification of acute coronary syndrome patients, and is consistent with other high-risk echocardiographic variables, the presence of significant CAD, and more complex coronary artery lesions.

A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.

Background: Brachial-ankle pulse wave (ba-PW) analysis is an established technique for assessing arterial stiffness and cardiovascular risk. The peripheral arterial pulse wave configuration may be useful for valvular heart disease (VHD) detection because it is closely related to the physical signs of VHD; however, few reports have been made assessing the efficacy of ba-PW analysis for VHD screening.

Methods: Consecutive VHD patients scheduled for valve surgery were enrolled in the study. These included 58 patients with aortic stenosis (AS) (mean age 74 ± 1.1 years), 67 with aortic regurgitation (AR) (mean age 59 ± 1.9 years), and 65 with mitral regurgitation (MR) (mean age 62 ± 1.6 years). Ba-PW analysis was conducted using the VaSera VS-1500 screening system before and after surgery. Upstroke time (UT), ejection time (ET), pre-ejection period (PEP), PEP/ET ratio, mean arterial pressure (%MAP), and cardio-ankle vascular index (CAVI) were compared with a control group (n = 65; mean age 69 ± 1.5 years) without VHD.

Results: The UT was significantly shorter in the AR group (132.9 ± 4.0 ms) and MR group (134.5 ± 2.5 ms), but significantly longer in the AS group (178.2 ± 2.8 ms) compared to controls (149.6 ± 3.6 ms; all p <0.01). The ET was significantly longer in the AS group (318.5 ± 7.4 ms) and AR group (320.0 ± 4.6 ms), but significantly shorter in the MR group (289.0 ± 3.8 ms) compared to controls (305.3 ± 3.4 ms; all p <0.05). In ROC analyses of each group compared to controls, areas under the curve of UT, corrected (c)UT, ET and cET in the AS group, UT/ET ratio in the AR group, and PEP/UT ratio in the MR group were all >0.7.

Conclusions: Multiple pulse wave parameters reflect VHD hemodynamics and may be useful for screening for the condition.

Background: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades.

Methods: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0.

Results: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis.

Conclusions: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.

Background: Readmissions after heart valve surgery represent a significant burden for both the patient and the healthcare system. The study aim was to identify independent predictors of readmission within 180 days after surgery in a population of patients undergoing heart valve surgery.

Methods: Demographic and clinical information was obtained from national registers. Patient-reported outcomes (PROs) including Short Form 12 (SF-12) and EuroQol 5D (EQ-5D) were measured at discharge as part of a national, cross-sectional study (DenHeart). Predictors of first readmission were investigated.

Results: Among a total of 1,084 patients (65% men; mean age 68 years; 354 responded to questionnaires), 534 (49%) were readmitted. Responding patients who were readmitted were younger and a greater proportion had undergone mitral valve surgery. A significantly higher proportion of non-responders was readmitted. No significant differences were found in PROs between patients readmitted and those not readmitted, and receiver operating characteristic (ROC) curves showed no predictive effect of SF-12 and EQ-5D. Survival analysis using Cox proportional hazard models showed that prior percutaneous coronary intervention (PCI) (HR 1.50, CI 1.10; 2.05, p = 0.010) and a history of heart failure (HR 1.37, CI 1.10; 1.72, p = 0.006) were predictive of readmission.

Conclusions: Readmission rates after heart valve surgery are high and often seen in patients who have undergone PCI and heart failure before surgery. Predictors for these high readmissions rates are difficult to establish based on medical history and type of surgery. PROs at discharge contribute information regarding a patient's perception of their often poor quality of life, but do not predict readmission.

Graves' disease is a common cause of hyperthyroidism that can lead to multiple cardiovascular complications. Herein is described the case of a 44-year-old male who presented with new-onset atrial fibrillation and mitral regurgitation secondary to flail anterior mitral leaflet with chordae tendineae rupture. This is a rare complication for Graves' disease, and has been reported only twice previously. It was hypothesized that this complication is secondary to Graves'-associated myxomatous degeneration of the mitral valve in the presence of a hyperdynamic circulation.

A 76-year-old woman was admitted to the authors' hospital with pulmonary edema five months after the successful implantation of a Perceval sutureless aortic valve (Sorin Group Srl, Saluggia, Italy). Both echocardiography and computed tomography scanning demonstrated migration of the aortic valve into the left ventricle, causing severe aortic and mitral (secondary) insufficiency. Following heart team discussions, the sutureless valve was replaced with a standard bioprosthesis (Perimount, Magna Ease; Edwards Lifesciences, Irvine, California, USA) with spontaneous restoration of native mitral valve competence. The present case is the first of a new presentation of early Perceval sutureless aortic valve proximal migration, and highlights the importance of careful preoperative assessment and regular postoperative follow up after sutureless aortic valve implantation.

Background: Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring.

Methods: Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete.

Results: In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%.

Conclusions: Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.