Cirugía valvular

Diagnosis, imaging and clinical management of aortic coarctation.

Heart. 2017 Apr 04;:

Authors: Dijkema EJ, Leiner T, Grotenhuis HB

Abstract
Coarctation of the aorta (CoA) is a well-known congenital heart disease (CHD), which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV), ventricular septal defect, patent ductus arteriosus and aortic arch hypoplasia. Despite echocardiographic screening, prenatal diagnosis of CoA remains difficult. Most patients with CoA present in infancy with absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (>20 mm Hg), or a murmur due to rapid blood flow across the CoA or associated lesions (BAV). Transthoracic echocardiography is the primary imaging modality for suspected CoA. However, cardiac magnetic resonance imaging is the preferred advanced imaging modality for non-invasive diagnosis and follow-up of CoA. Adequate and timely diagnosis of CoA is crucial for good prognosis, as early treatment is associated with lower risks of long-term morbidity and mortality. Numerous surgical and transcatheter treatment strategies have been reported for CoA. Surgical resection is the treatment of choice in neonates, infants and young children. In older children (>25 kg) and adults, transcatheter treatment is the treatment of choice. In the current era, patients with CoA continue to have a reduced life expectancy and an increased risk of cardiovascular sequelae later in life, despite adequate relief of the aortic stenosis. Intensive and adequate follow-up of the left ventricular function, valvular function, blood pressure and the anatomy of the heart and the aorta are, therefore, critical in the management of CoA. This review provides an overview of the current state-of-the-art clinical diagnosis, diagnostic imaging algorithms, treatment and follow-up of patients with CoA.

PMID: 28377475 [PubMed - as supplied by publisher]

Evidence of apoptosis in right ventricular dysfunction in rheumatic mitral valve stenosis.

Indian J Med Res. 2016 Nov;144(5):718-724

Authors: Pande S, Tewari P, Agarwal SK, Agarwal V, Agrawal V, Chagtoo M, Majumdar G, Tewari S

Abstract
BACKGROUND & OBJECTIVES: Right ventricular (RV) dysfunction is one of the causes of morbidity and mortality in valvular heart disease. The phenomenon of apoptosis, though rare in cardiac muscle may contribute to loss of its function. Role of apoptosis in RV in patients with rheumatic valvular heart disease is investigated in this study.
METHODS: Patients with rheumatic mitral valve stenosis formed two groups based on RV systolic pressure (RVSP) as RVSP <40 mmHg (group I, n=9) and RVSP ≥40 mmHg (group II, n=30). Patients having atrial septal defect (ASD) with RVSP <40 mmHg served as control (group III, n=15). Myocardial performance index was assessed for RV function. Real-time polymerase chain reaction was performed on muscle biopsy procured from RV to assess expression of pro-apoptotic genes (Bax, cytochrome c, caspase 3 and Fas) and anti-apoptotic genes (Bcl-2). Apoptosis was confirmed by histopathology and terminal deoxynucleotide-transferase-mediated dUTP nick end labelling.
RESULTS: Group II had significant RV dysfunction compared to group I (P=0.05) while caspase 3 (P=0.01) and cytochrome c (P=0.03) were expressed excessively in group I. When group I was compared to group III (control), though there was no difference in RV function, a highly significant expression of pro-apoptotic genes was observed in group I (Bax, P=0.02, cytochrome c=0.001 and caspase 3=0.01). There was a positive correlation between pro-apoptotic genes. Nuclear degeneration was present conforming to apoptosis in valve disease patients (groups I and II) while it was absent in patients with ASD.
INTERPRETATION & CONCLUSION: Our findings showed evidence of apoptosis in RV of patients with valvular heart disease. Apoptosis was set early in the course of rheumatic valve disease even with lower RVSP, followed by RV dysfunction; however, expression of pro-apoptotic genes regressed.

PMID: 28361825 [PubMed - in process]

Management of Traumatic Aortic and Splenic Rupture in a Patient With Ascending Aortic Aneurysm.

Ann Thorac Surg. 2016 Aug;102(2):e81-2

Authors: Topcu AC, Ciloglu U, Bolukcu A, Dagsali S

Abstract
Traumatic aortic rupture is rupture of all or part of the aortic wall, mostly resulting from blunt trauma to the chest. The most common site of rupture is the aortic isthmus. Traumatic rupture of the ascending aorta is rare. A 62-year-old man with a family history of ascending aortic aneurysm was referred to our hospital after a motor vehicle accident. He had symptoms of cardiogenic shock. A contrast-enhanced computed tomographic scan revealed rupture of the proximal ascending aorta and an ascending aortic aneurysm with a diameter of 55 mm at the level of the sinuses of Valsalva. Transthoracic echocardiography at the bedside revealed severe aortic valvular insufficiency. We performed a successful Bentall procedure. During postoperative recovery, the patient experienced a cerebrovascular accident. Transesophageal echocardiography did not reveal thrombosis of the mechanical prosthesis. The patient's symptoms resolved in time, and he was discharged from the hospital on postoperative day 47 without any sequelae. He has been symptom free during a 6-month follow-up period. We suggest that individuals who have experienced blunt trauma to the chest and have symptoms of traumatic aortic rupture and a known medical history of ascending aortic aneurysm should be evaluated for a rupture at the ascending aorta and the aortic isthmus.

PMID: 27449463 [PubMed - indexed for MEDLINE]

Valvular Cytomegalovirus Endocarditis.

Ann Thorac Surg. 2016 Aug;102(2):e105-7

Authors: Stear TJ, Shersher D, Kim GJ, Smego DR

Abstract
Endocarditis is a rare presentation for cytomegalovirus (CMV) infection. We present the case of a 49-year-old man who underwent mitral and tricuspid valve replacement for valvular CMV endocarditis. The patient's past medical history was significant for human immunodeficiency virus, intravenous drug abuse, and chronic hepatitis B. During his clinical course, he was found to have tricuspid and mitral valve vegetations. After progressive valvular destruction despite antibiotic therapy, he underwent successful mitral and tricuspid valve replacement. Pathologic analysis of the culture-negative valve specimens were found to contain inclusion bodies consistent with CMV, and quantitative serum polymerase chain reaction returned a highly elevated CMV DNA count.

PMID: 27449440 [PubMed - indexed for MEDLINE]

Concomitant Maze IV Ablation Procedure Performed Entirely by Bipolar Clamp Through Right Lateral Minithoracotomy.

Ann Thorac Surg. 2016 Nov;102(5):e473-e475

Authors: Mei J, Ma N, Jiang Z, Zhao D, Bao C, Ding F

Abstract
Atrial fibrillation ablation with bipolar clamp has proved to be effective for patients with valvular atrial fibrillation. However, left pulmonary vein ablation with bipolar clamp through right minithoracotomy was considered difficult or impossible. In this report, we described a novel technique of performing concomitant Maze IV ablation procedure entirely by bipolar clamp through right minithoracotomy. Left pulmonary vein ablation with bipolar clamp was performed through an established channel and a natural space. This technique has proved to be safe and feasible and to have good clinical outcomes that may deserve further use for patients with atrial fibrillation and mitral valve disease.

PMID: 27772614 [PubMed - indexed for MEDLINE]

Aortic Valve Stenosis in a Dialysis Patient Waitlisted for Kidney Transplantation.

Ann Thorac Surg. 2016 Nov;102(5):e437-e438

Authors: Büttner S, Weiler H, Zöller C, Koch B, Zierer A, Zeiher AM, Geiger H, Vasa-Nicotera M, Hauser IA, Fichtlscherer S

Abstract
Management of dialysis patients with valvular heart disease waitlisted for kidney transplantation is challenging. Development of severe aortic valve stenosis can lead to the exclusion from the transplant program or even death while on the waiting list. In dialysis patients, surgical aortic valve replacement is associated with a high perioperative risk with increased morbidity and mortality. In contrast, transcatheter aortic valve implantation emerges as a viable option for dialysis patients. Herein, we present the long-term follow-up of successful kidney transplantation after TAVI in a diabetic patient receiving long-term hemodialysis.

PMID: 27772602 [PubMed - indexed for MEDLINE]

A Decade of Transapical Aortic Valve Implantation.

Ann Thorac Surg. 2016 Sep;102(3):759-65

Authors: Papadopoulos N, Wenzel R, Thudt M, Doss M, Wimmer-Greinecker G, Seeger F, El-Sayed Ahmad A, Fichtlscherer S, Moritz A, Zierer A

Abstract
BACKGROUND: Transcatheter-based aortic valve procedures have undergone tremendous evolution during the past decade and have led to great changes in the treatment of valvular heart disease. The Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany is one of the three pioneering centers that started performing transapical transcatheter aortic valve implantation (TA-TAVI) back in 2005, and this study reviews the 10-year institutional experience with this approach.
METHODS: From January 2005 through January 2015, 312 consecutive high-risk patients underwent TA-TAVI. Echocardiographic follow-up at discharge, at 6 and 12 months, and yearly thereafter was 100% complete. Structural behavior of the balloon-expandable valves in 11 patients with a mean follow-up time beyond 8 years was additionally evaluated at latest follow-up using computed tomography measurements.
RESULTS: The age of the patients in this study was 79.8 ± 5.8 years, and the mean logistic EuroSCORE II and The Society of Thoracic Surgeons score were 23.9% ± 17.2% and 9.8% ± 8.6%, respectively. Perioperative, 30-day, and in-hospital mortality rates were 1.3%, 8.2%, and 9.5%, respectively, with a decrease in 30-day mortality to 4.2% in 2014. The incidence of neurologic complications was 3.2%. Mean length of hospital stay was 8.7 ± 4.3 days. Echocardiographic results demonstrated a significant and persistent increase of effective aortic valve orifice area (preoperative: 0.69 ± 0.1 cm(2) vs. late-follow-up: 1.52 ± 0.2 cm(2); p = 0.04) and a decrease in mean transvalvular gradient (preoperative: 49.5 ± 8.2 mm Hg vs. late-follow-up: 13.8 ± 4.3 mm Hg; p = 0.03) after a mean follow-up time of 4.1 ± 2.3 years. Overall survival rates were 73% ± 2% and 56% ± 6% at 3 and 5 years, respectively. Computed tomography measurements have not shown any signs of stress fracture of balloon-expandable stents up to 8 years of follow-up.
CONCLUSIONS: A decade after clinical introduction of TA-TAVI, procedural and technical advances have made it an established alternative to classic aortic valve replacement in high-risk patients with aortic valve stenosis. Despite limited worldwide data on hemodynamic and structural valve behavior beyond 8 years, 11 patients from our early experience who were followed up for 8 years in the current report did not have any signs of structural valve dysfunction.

PMID: 27154146 [PubMed - indexed for MEDLINE]

Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient.

Neurourol Urodyn. 2017 Mar 27;:

Authors: Cameron AP, Campeau L, Brucker BM, Clemens JQ, Bales GT, Albo ME, Kennelly MJ

Abstract
AIMS: Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient.
METHODS: Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system.
RESULTS: All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification.
CONCLUSIONS: These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.

PMID: 28345769 [PubMed - as supplied by publisher]

Comparison of Clinical and Electrocardiographic Predictors of Ischemic and Nonischemic Cardiomyopathy During the Initial Evaluation of Patients With Reduced (≤40%) Left Ventricular Ejection Fraction.

Am J Cardiol. 2017 Mar 01;:

Authors: Smilowitz NR, Devanabanda AR, Zakhem G, Iqbal SN, Slater W, Coppola JT

Abstract
Invasive coronary angiography is routinely performed during the initial evaluation of patients with suspected cardiomyopathy with reduced left ventricular function. Clinical and electrocardiographic (ECG) data may accurately predict ischemic cardiomyopathy (IC). Medical records of adults referred for coronary angiography for evaluation of left ventricular ejection fraction ≤40% from 2010 to 2014 were retrospectively reviewed. Patients with myocardial infarction (MI), previous coronary revascularization, cardiac surgery, or left-sided valvular disease were excluded. IC was defined as ≥70% diameter stenosis of the left main, proximal left anterior descending, or involvement of ≥2 epicardial coronary arteries. A risk model was developed from logistic regression coefficients, with a dichotomous cut-point based on the maximal Youden's index from the receiver-operating characteristic curve. A total of 273 patients met study inclusion criteria. Mean age was 56.8 ± 11.6 and 68.1% were men. IC was identified in 41 patients (15%). Patients with IC were more likely to have ECG evidence of Q-wave MI (34% vs 13%, p <0.001) and less likely to have left bundle branch block (2% vs 15%, p = 0.03) than non-IC. A model including age, hypertension, diabetes mellitus, tobacco use, ECG evidence of ST or T-wave abnormalities concerning for ischemia, and previous Q-wave MI, yielded a 95% negative predictive value for IC. In conclusion, at an urban referral hospital, the prevalence of IC was low. Left bundle branch block on electrocardiography was rarely associated with IC. A risk score incorporating clinical and ECG abnormalities identified patients at a low likelihood for IC.

PMID: 28341355 [PubMed - as supplied by publisher]

[Interventional left atrial appendage closure in a patient with GAVE syndrome].

Dtsch Med Wochenschr. 2016 Nov;141(24):1796-1799

Authors: Fastner C, Belle S, Akin I

Abstract
History and findings | A 56-year-old female with a gastric antral vascular ectasia (GAVE) suffered from recurrent episodes of upper gastrointestinal bleeding. Because of a history of a permanent atrial fibrillation (CHA2DS2-VASc score 3 points) an oral anticoagulation therapy with phenprocoumon was carried out which even worsened the bleeding frequency and intensity. A change of medication to low-molecular weight heparin did not lead to success. The frequent periods in hospital limited the patient's quality of life. Therapy and course | Two months after the initial diagnosis of the GAVE syndrome and after 5 hospital admissions together with several argon plasma coagulations an AmplatzerTM Cardiac Plug 2 was successfully implanted. With the postinterventional dual antiplatelet therapy with ASA and clopidogrel instead of an oral anticoagulation the bleedings stopped. Conclusion | The interventional left atrial appendage closure appears to be a feasible and safe alternative to oral anticoagulation in patients with a GAVE syndrome and non-valvular atrial fibrillation.

PMID: 27903032 [PubMed - indexed for MEDLINE]

Open Aortic Arch Reconstruction After Coronary Artery Bypass Surgery: Worth the Effort?

Semin Thorac Cardiovasc Surg. Spring 2016;28(1):26-35

Authors: Quintana E, Bajona P, Schaff HV, Dearani JA, Daly R, Greason K, Pochettino A

Abstract
Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6.8 ± 7.1 years. At reoperation, 33 (73%) patients had hemiarch replacement and 12 (27%) had a total arch replacement. The following were the indications for surgery: fusiform aneurysm in 20 (44%), pseudoaneurysm in 6 (13%), endocarditis in 4 (9%), valvular disease in 5 (11%), and acute aortic dissection in 10 (22%). There were 6 perioperative deaths (13%) and 1 stroke (2.2%). Selective antegrade cerebral perfusion was used in 13 patients (28.9%) and retrograde perfusion in 6 (13.3%). Survival was 74%, 65%, and 52% at 1, 3, and 5-year follow-up, respectively. Only predictors of early mortality were age (odds ratio = 1.20, CI: 1.01-1.44; P = 0.04) and nonuse of retrograde cardioplegia for myocardial protection (odds ratio = 6.80, CI: 1.06-43.48; P = 0.04). Intermediate survival of these patients was significantly lower than those of a sex-matched and age-matched population (P < 0.001). In conclusion, aortic arch surgery after previous CABG can be performed with acceptable early and midterm results and low risk of stroke. Perfusion strategies and myocardial protection contribute to successful outcomes.

PMID: 27568130 [PubMed - indexed for MEDLINE]

Transhepatic implant of a trimmed Melody™ valved stent in tricuspid position in a 1-year-old infant.

Catheter Cardiovasc Interv. 2017 Feb 15;89(3):E84-E89

Authors: Cools B, Rega F, Gewillig M

Abstract
Percutaneous valved stent implantation is precluded in small infants because large delivery sheaths and large devices. We describe a procedure in a 1-year-old boy in whom a 19 mm Epic™ valve in tricuspid position had become dysfunctional. As the internal diameter of the prosthetic valve was about 16 mm, the only available valve was the Melody™ valved stent. Technical modifications were required to address issues like venous access, the bulky delivery system, and the length of the valved stent. The Melody™ valved stent was surgically trimmed and mounted on a 16 mm Tyshak balloon, access was provided transhepatically through a short 18 Fr sheath. After deployment, the intrahepatic route was sealed with two vascular plugs (8 and 10 mm) in tandem. The procedure was uncomplicated with perfect valve function 18 months after implant. © 2016 Wiley Periodicals, Inc.

PMID: 27528537 [PubMed - indexed for MEDLINE]

Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease.

Congenit Heart Dis. 2016 Dec;11(6):751-755

Authors: Acheampong B, Johnson JN, Stulak JM, Dearani JA, Kushwaha SS, Daly RC, Haile DT, Schears GJ

Abstract
BACKGROUND: Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover.
METHODS: We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013.
RESULTS: During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors.
CONCLUSIONS: Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.

PMID: 27436116 [PubMed - indexed for MEDLINE]

Characteristics of Congenital Coronary Artery Fistulas Complicated with Infective Endocarditis: Analysis of 25 Reported Cases.

Congenit Heart Dis. 2016 Dec;11(6):756-765

Authors: Said SA

Abstract
Congenital coronary artery fistulas (CAFs) are infrequent congenital coronary artery anomalies. Complications such as left-to-right shunt, congestive heart failure, myocardial infarction, pericardial effusion, aneurysm formation, rupture, hemopericardium, pulmonary hypertension, infective endocarditis (IE), syncope, stroke, and sudden death may occur with a variable low frequency. To describe the clinical characteristics of patients with CAFs complicated by IE. A search was conducted through PubMed using the terms "CAFs" and "IE." Papers with a full description of the fistula characteristics and detailed data regarding bacterial endocarditis were included for evaluation. In the overall group of reviewed subjects (n = 25, 9 females), the mean patient age was 42.5 years (range: 16 and 87). The right coronary artery (RCA) and left coronary artery (LCA) contributed equally to fistula formation. Terminations into the right heart side occurred in 19 (76%) fistulas. The majority of the fistulas (92%) were unilateral. The cultured microorganism was Streptococcus in 14 (56%) and Staphylococcus in 4 (16%) of the reviewed subjects. Echocardiographic single or multiple valvular regurgitation was found in 8 (32%) of the reviewed subjects. Small and large intracardiac vegetations were detected in 18 patients (72%). Antibiotic therapy was initiated in 20 (80%) subjects and 16 fistulas were treated surgically. During surgery, spontaneous closure of the fistula was observed in one patient. Percutaneous therapeutic embolization (PTE) was successfully performed in two subjects. CAFs complicated by IE may affect all age groups with a slight male preponderance. Unilateral fistulas, either arising from the right or left coronary artery, are predominant, draining mainly into the right heart side. It is emphasized that antibiotic prophylaxis is strongly advised for pediatric and adult patients with congenital CAFs.

PMID: 27414233 [PubMed - indexed for MEDLINE]

Transcatheter aortic valve-in-valve treatment of degenerative stentless supra-annular Freedom Solo valves: A single centre experience.

Catheter Cardiovasc Interv. 2017 Feb 15;89(3):438-444

Authors: Cockburn J, Dooley M, Parker J, Hill A, Hutchinson N, de Belder A, Trivedi U, Hildick-Smith D

Abstract
BACKGROUND: Redo surgery for degenerative bioprosthetic aortic valves is associated with significant morbidity and mortality. Report results of valve-in-valve therapy (ViV-TAVI) in failed supra-annular stentless Freedom Solo (FS) bioprostheses, which are the highest risk for coronary occlusion.
METHODS: Six patients with FS valves (mean age 78.5 years, 50% males). Five had valvular restenosis (peak gradient 87.2 mm Hg, valve area 0.63 cm(2) ), one had severe regurgitation (AR). Median time to failure was 7 years.
RESULTS: Patients were high risk (mean STS/Logistic EuroScore 10.6 15.8, respectively). FS valves ranged from 21 to 25 mm. Successful ViV-TAVI was achieved in 4/6 patients (67%). Of the unsuccessful cases, (patient 1 and 2 of series) patient 1 underwent BAV with simultaneous aortography which revealed left main stem occlusion. The procedure was stopped and the patient went forward for repeat surgery. Patient 2 underwent successful ViV-TAVI with a 26-mm CoreValve with a guide catheter in the left main, but on removal coronary obstruction occurred, necessitating valve snaring into the aorta. Among the successful cases, (patients 3, 4, 5, 6) the TAVIs used were CoreValve Evolut R 23 mm (n = 3), and Lotus 23 mm (n = 1). In the successful cases the peak gradient fell from 83.0 to 38.3 mm Hg. No patient was left with >1+ AR. One patient had a stroke on Day 2, with full neurological recovery. Two patients underwent semi-elective pacing for LBBB and PR >280 ms.
CONCLUSIONS: ViV-TAVI in stentless Freedom Solo valves is high risk. The risk of coronary occlusion is high. The smallest possible prosthesis (1:1 sizing) should be used, and strategies to protect the coronary vessels must be considered. © 2016 Wiley Periodicals, Inc.

PMID: 27315455 [PubMed - indexed for MEDLINE]

Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature.

Catheter Cardiovasc Interv. 2017 Jan;89(1):78-92

Authors: Hiltrop N, Bennett J, Desmet W

Abstract
As the LCx is closely related to the mitral valve annulus, it is susceptible to perioperative injury. Various underlying mechanisms, predisposing factors, and therapeutic strategies have been suggested but disagreement exists. Using a MeSH terms-based PubMed search, 44 cases of mitral valve surgery-related LCx injury were detected, including our 4 cases. We provide a comprehensive review of current knowledge regarding mitral valve surgery-related left circumflex coronary artery (LCx) injury. Preoperative coronary angiography was performed in 55% (n = 24). Coronary abnormalities were present in 11% (n = 5). Coronary dominance was reported in 73% (n = 32), predominantly showing left (69%, n = 22) or balanced (19%, n = 6) circulations. Right coronary dominance was present in 12% (n = 4). Ischemia was detected in the perioperative or early postoperative phase in 86% (n = 30). Delayed symptoms were present in 14% (n = 5). Echocardiography demonstrated new regional wall motion abnormalities in 80% (n = 24), but was negative in 20% (n = 6) despite coronary compromise. Electrocardiography showed myocardial ischemia in 97% (n = 34), including regional ST-segment elevations in 68% (n = 23). Primary treatment was surgical in 42% (n = 15) and percutaneous in 58% (n = 21), reporting success ratios of 87% (n = 13) and 81% (n = 17), respectively. We confirm an augmented risk of mitral valve surgery-related LCx injury in balanced or left-dominant coronary circulations. Preoperative knowledge of coronary anatomy does not preclude LCx injury. An anomalous LCx arising from the right coronary cusp was identified as a possible specific high-risk entity. Electrocardiographic monitoring and intraoperative echocardiography remain paramount to ensure a timely diagnosis and treatment. © 2016 Wiley Periodicals, Inc.

PMID: 26892943 [PubMed - indexed for MEDLINE]

Percutaneous Therapy for Tricuspid Regurgitation: A New Frontier for Interventional Cardiology.

Circulation. 2017 Mar 23;:

Authors: Kapadia SR, Krishnaswamy A, Tuzcu EM

Abstract
Functional tricuspid regurgitation (FTR) is common, whether in association with mitral or aortic valve disease or presenting as an isolated valvular disease. Several studies have shown that TR is associated with poor patient outcomes, though a cause-and-effect relationship of TR to mortality has not been proven. Similarly the impact of surgical treatment of TR on outcomes needs well-controlled randomized trials that are under planning. The current professional society guidelines for treatment of TR are based on expert opinions with a level of evidence C for all indications. Transcatheter therapies for valvular heart disease are often based on established surgical techniques. When surgical therapy has well studied benefits including a reduction in mortality (e.g. aortic valve replacement for aortic stenosis), percutaneous therapies can be compared to surgery with survival as an endpoint. Similarly, the safety of surgical therapies (e.g. surgical aortic valve replacement) can serve as a benchmark for the safety of percutaneous treatment. In establishing percutaneous treatments for TR, on the other hand, there are several challenges: 1) the severity of TR and RV dysfunction are often difficult to determine; 2) the impact of TR on mortality or heart failure outcomes is not as clearly defined; and 3) surgical treatments are multiple without robust data for indications and outcomes. Importantly, the US Food and Drug Administration (FDA) is interested in providing expedited access for devices that fill an unmet clinical need by demonstrating appropriate intermediate and surrogate endpoints. Therefore, the aforementioned challenges also present opportunities to better define how trials for percutaneous treatments of TR can be conducted as we move forward (Table).

PMID: 28336789 [PubMed - as supplied by publisher]

The influence of surgical technique on early posttransplant atrial fibrillation - comparison of biatrial, bicaval, and total orthotopic heart transplantation.

Ther Clin Risk Manag. 2017;13:287-297

Authors: Rivinius R, Helmschrott M, Ruhparwar A, Erbel C, Gleissner CA, Darche FF, Thomas D, Bruckner T, Katus HA, Doesch AO

Abstract
PURPOSE: Early posttransplant atrial fibrillation (AF) has been associated with worse clinical outcomes after heart transplantation (HTX). The type of surgical technique may constitute a relevant risk factor for AF.
PATIENTS AND METHODS: This retrospective single-center study included 530 adult patients. Patients were stratified by surgical technique (biatrial, bicaval, or total orthotopic HTX) and early posttransplant heart rhythm (AF or sinus rhythm). Univariate and multivariate analyses were performed to evaluate risk factors for AF.
RESULTS: A total of 161 patients received biatrial HTX (30.4%), 115 bicaval HTX (21.7%), and 254 total orthotopic HTX (47.9%). Sixty-one of 530 patients developed early posttransplant AF (11.5%). Patients with AF showed a statistically inferior 5-year survival compared to those with sinus rhythm (P<0.0001). Total orthotopic HTX had the lowest rate of AF (total orthotopic HTX [6.3%], bicaval HTX [14.8%], biatrial HTX [17.4%], P=0.0012). Multivariate analysis showed pretransplant valvular heart disease (P=0.0372), posttransplant enlarged left atrium (P=0.0066), posttransplant mitral regurgitation (P=0.0370), and non-total orthotopic HTX (P=0.0112) as risk factors for AF.
CONCLUSION: Early posttransplant AF was associated with increased mortality (P<0.0001). Total orthotopic HTX showed the lowest rate of AF compared to biatrial or bicaval HTX (P=0.0012).

PMID: 28331331 [PubMed - in process]

An uncommon cause of tricuspid regurgitation: three-dimensional echocardiographic incremental value, surgical and genetic insights.

Eur J Cardiothorac Surg. 2016 Jul;50(1):180-2

Authors: Theron A, Pinard A, Riberi A, Zaffran S

Abstract
Congenital tricuspid valve disease is a rare defect that includes regurgitation, stenosis and Ebstein's anomaly. We report a case of severe tricuspid regurgitation associated with functional mitral regurgitation in a 47-year-old man with congestive heart failure. Transthoracic echocardiography (TTE) ruled out any Ebstein's anomaly. Three-dimensional TTE revealed a 'tricuspid hole' into the anterior leaflet that was only attached to the tricuspid annulus next to both anteroseptal and anteroposterior commissures. There was no sign of leaflet tear or perforation. The surgical repair of the tricuspid and mitral valves was performed with an optimal result. No sign of endocarditis or rheumatic disease was observed during the intervention. Sequence analysis of GATA4, HEY2 and ZFPM2 genes was performed, but no causative mutation was identified.

PMID: 26670804 [PubMed - indexed for MEDLINE]

Patient-prosthesis mismatch in new generation trans-catheter heart valves: a propensity score analysis.

Eur Heart J Cardiovasc Imaging. 2017 Feb 27;:

Authors: Theron A, Pinto J, Grisoli D, Griffiths K, Salaun E, Jaussaud N, Ravis E, Lambert M, Messous L, Amanatiou C, Cuisset T, Gariboldi V, Giorgi R, Habib G, Collart F

Abstract
Aims: When compared with the former Sapien XT (XT-THV), the Sapien 3 trans-catheter heart valve (S3-THV) embeds an outer annular sealing cuff to prevent para-valvular regurgitation (PVR). The consequences of this new feature on valve haemodynamics have never been evaluated. We aimed to compare both types of prostheses regarding patient-prosthesis mismatch (PPM).
Methods and results: Patients who underwent a TAVR for aortic stenosis were retrospectively included. Regression adjustment for the propensity score was used to compare 50 XT-THV patients with 71 S3-THV. At the 1-month follow-up, the mean indexed effective orifice area (iEOA) was 1.12 ± 0.34 cm2/m2 with XT-THV and 0.96 ± 0.27 cm2/m2 with S3-THV. The mean gradient was 11 ± 5 mmHg and 13 ± 5 mmHg, respectively. Nine patients had moderate PPM, and two exhibited severe PPM with XT-THV. Nineteen patients had moderate PPM, and seven demonstrated severe PPM with S3-THV. There was a five-fold increased risk of PPM with S3-THV (OR = 4.98; [1.38-20.94], P = 0.019). S3-THV decreased the iEOA by 0.21 cm2/m2 [-0.21; (-0.38 to - 0.05); P = 0.012] and increased the mean gradient by 4.95 mmHg [4.95; (2.27-7.64); P < 0.001]. The risk of PPM was increased 15.24-fold with 23 mm S3-THV [15.24; (2.92-101.52); P = 0.002] in comparison with the 23 mm XT-THV. PVR were reduced by 98% with S3-THV.
Conclusion: There is an increased risk of PPM with 23mm S3-THV in comparison with 23 mm XT-THV. This may be attributable to the additional sub-annular cuff that avoids the risk of PVR. Regarding the increased vulnerability of younger patients to PPM, we provide essential information on the extension of TAVR indication to the younger population.

PMID: 28329317 [PubMed - as supplied by publisher]