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Concept: Aortic valve replacement

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OBJECTIVESThe Trifecta valve (St. Jude Medical) was introduced into clinical practice as a tri-leaflet stented pericardial valve designed for supra-annular placement in the aortic position. The present study aims to evaluate the preliminary results with this new bioprosthesis.METHODSSeventy patients underwent aortic valve replacement (AVR) with the Trifecta valve between August 2010 and December 2011. Thirty-three patients were male and 37 were female (52.9%). Mean age was 74.65 ± 7.63 (range 47-90 years). Prevalent cause of AVR was aortic stenosis in 64 (91.43%) patients. The mean preoperative pressure gradient was 50 ± 17 (range 20-84 mmHg), and the mean aortic valve area was 0.77 ± 0.33. Five (7.14%) patients were operated on due to aortic valve endocarditis. One patient was operated on due to isolated, severe aortic insufficiency. All patients were in New York Heart Association functional class III or IV. Twenty-eight (40%) patients underwent concomitant procedures.RESULTSConcomitant procedures were coronary artery bypass grafting (n = 25), mitral valve replacement (n = 1), ablation of atrial fibrillation (n = 1) and septal myomectomy (n = 1). There were no intraoperative deaths. The 30-day in-hospital mortality was 2.85% (2 of 70). One late death occurred during the in-hospital stay due to a multiorgan failure on postoperative day 60. There were 2 (2.85%) perioperative strokes. Mean pressure gradient decreased significantly from a preoperative value of 50 ± 17 mmHg to an intraoperative gradient of 9 ± 4 mmHg (Table 3). The mean gradients were 14, 11, 11, 8 and 6 mmHg for the 19, 21, 23, 25 and 27 mm valve size, respectively. No prosthesis dislocation, endocarditis, valve thrombosis or relevant aortic regurgitation was observed at discharge.CONCLUSIONSThe initial experience with the Trifecta valve bioprosthesis shows excellent outcomes with favourable early haemodynamics. Further studies with longer follow-up are needed to confirm those preliminary results.

Concepts: Cardiology, Heart, Mitral valve prolapse, Aortic valve, Valvular heart disease, Aortic valve stenosis, Aortic valve replacement, Aortic insufficiency

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Reoperation for failing stentless aortic valve replacement is a technically demanding procedure that has traditionally been tackled in one of two ways: either root replacement or the more conservative option of implanting a stented valve within the valve. We sought to determine the relative operative risks, follow-up status and medium to long-term survival of these two methods.

Concepts: Derivative, Left ventricle, Aortic valve, Valve, Valve Corporation, Aortic valve replacement, Aortic insufficiency

28

To evaluate factors associated with aortic enlargement in patients with a bicuspid aortic valve (BAV) and the impact of isolated aortic valve replacement (AVR).

Concepts: Aortic aneurysm, Aortic valve, Aortic valve replacement, Aortic insufficiency, Bicuspid aortic valve

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BACKGROUND: =0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts.Conclusions-Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.

Concepts: Myocardial infarction, Cardiology, Heart failure, Ejection fraction, Heart, Aortic valve, Aortic valve replacement, Aortic insufficiency

5

Left ventricular (LV) systolic dysfunction and moderate aortic stenosis (AS) are more frequent with advancing age and often coexist. Afterload reduction is the mainstay of pharmacological treatment of heart failure (HF). Aortic valve replacement (AVR) is only formally indicated for symptomatic severe AS.

Concepts: Cardiology, Heart, Aorta, Left ventricle, Aortic valve, Valvular heart disease, Aortic valve replacement, Aortic insufficiency

4

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are expanding towards treating younger patients with lower-risk profiles. Given the progressive nature of coronary artery disease and its high prevalence in those with severe aortic stenosis, coronary angiography and percutaneous coronary intervention will become increasingly necessary in patients after TAVR. There are some data suggesting that there are technical difficulties with coronary re-engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia. The authors review the challenges of coronary angiography and percutaneous coronary intervention post-TAVR and examine the geometric interactions between currently approved transcatheter aortic valves and coronary ostia, while providing a practical guide on how to manage these potentially complex situations.

Concepts: Atherosclerosis, Angina pectoris, Coronary artery disease, Cardiology, Atheroma, Cardiovascular system, Aortic valve, Aortic valve replacement

4

Use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis is growing rapidly. However, to our knowledge, the durability of these prostheses is incompletely defined.

Concepts: Left ventricle, Aortic valve, Valvular heart disease, Valve, Valve Corporation, Aortic valve stenosis, Aortic valve replacement, Aortic insufficiency

4

Background -Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods -The NCDR STS/ACC TVT Registry was used to characterize the anesthesia choice and clinical outcomes of all U.S. patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014 and June 30, 2015. Raw and inverse probability of treatment weighted (IPTW) analyses were performed to compare general anesthesia patients with conscious sedation patients on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, ICU and hospital length-of-stay, and rates of discharge to home. Post-hoc falsification endpoint analyses were performed to evaluate for residual confounding. Results -Conscious sedation was used in 1,737/10,997 (15.8%) cases with a significant trend of increasing usage over the time period studied (p for trend <0.001). In raw analyses, intraprocedural success with conscious sedation and general anesthesia was similar (98.2% versus 98.5%, p=.31). The conscious sedation group was less likely to suffer in-hospital (1.6% vs. 2.5%, p=0.03) and 30-day death (2.9% vs. 4.1%, p = 0.03). Conversion from conscious sedation to general anesthesia was noted in 102/1737 (5.9%) of conscious sedation cases. After IPTW adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% vs. 98.6%, p<0.001) and a reduced rate of mortality at the in-hospital (1.5% vs. 2.4%, p<0.001) and 30-day (2.3% vs. 4.0%, p<0.001) timepoints. Conscious sedation was associated with reductions in procedural inotrope requirement, ICU and hospital length of stay (6.0 vs. 6.5 days, p < 0.001), and combined 30-day death/stroke rates (4.8% vs. 6.4%, p <0.001). Falsification endpoint analyses of vascular complications, bleeding, and new pacemaker/defibrillator implantation demonstrated no significant differences between groups after adjustment. Conclusions -In U.S. practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality compared to TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, though comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.

Concepts: Scientific method, Surgery, Anesthesia, Confounding, Covariate, Aortic valve, Sedation, Aortic valve replacement

4

A 68 year-old man with a severe ischemic cardiomyopathy underwent left ventricular assist device (LVAD) implantation (Heart Mate II device) for destination therapy. He presented 49 months following LVAD implant with worsening heart failure symptoms and new severe aortic regurgitation. Given high risk for both surgical and transcatheter aortic valve replacement, he was admitted for transcatheter closure of the aortic valve under transesophageal echocardiographic (TEE) guidance. TEE imaging revealed severe aortic regurgitation (see Figure 1A and 1B, and multimedia files 1 and 2). Under TEE and fluoroscopic guidance, a 25 mm Amplatzer cribiform atrial septal defect closure device was advanced across the aortic valve (see figures 1C and 1D, and multimedia files 3 and 4). Immediately following device deployment, TEE revealed a well-seated device with complete aortic valve closure, and trivial aortic regurgitation (see figures 2A-D, and multimedia files 5-7). Subsequent transthoracic echocardiograms obtained from 74 to 172 days post-procedure revealed no residual aortic regurgitation. The patient awoke with diffuse urticaria 244 days following the procedure, and died en route to the emergency department, presumably secondary to a systemic allergic reaction. De novo aortic regurgitation is increasingly recognized in patients with LVADs (1). TEE guided transcatheter aortic valve closure is an option in these high-risk patients (2).

Concepts: Cardiology, Heart failure, Heart, Left ventricle, Ventricular assist device, Aortic valve, Aortic valve replacement, Aortic insufficiency

4

Cardiovascular Magnetic Resonance is often used to evaluate patients after heart valve replacement. This study systematically analyses the influence of heart valve prostheses on phase contrast measurements in a phantom trial.

Concepts: Heart, Nuclear magnetic resonance, Circulatory system, Valvular heart disease, Artificial heart valve, Aortic valve replacement