Combined surgical and catheter‐based treatment of extensive thoracic aortic aneurysm and aortic valve stenosis

An extensive thoracic aortic aneurysm (TAA) is a potentially life‐threatening condition and remains a technical challenge to surgeons. Over the past decade, repair of aortic arch aneurysms has been accomplished using both hybrid (open and endovascular) and totally endovascular techniques. Thoracic endovascular aneurysm repair (TEVAR) has changed and extended management options in thoracic aorta disease, including in those patients deemed unfit or unsuitable for open surgery. Accordingly, transcatheter aortic valve replacement (TAVR) is increasingly used to treat patients with symptomatic severe aortic valve stenosis (AS) who are considered at high risk for surgical aortic valve replacement. In this report, we describe the combined surgical and catheter‐based treatment of an extensive TAA and AS. To our knowledge, this is the first report of hybrid TAA repair combined with TAVR. © 2014 Wiley Periodicals, Inc.     

主动脉瓣四叶瓣畸形合并主动脉瓣病变的外科处理

目的 探讨主动脉瓣四叶瓣畸形对主动脉瓣功能的影响及其外科治疗.方法 2000年1月至2013年1月,我院通过经胸超声心动图和术中病理诊断主动脉瓣四叶瓣畸形13例.其中4例主动脉瓣的功能基本正常,9例合并主动脉瓣病变：重度关闭不全7例,重度关闭不全伴狭窄2例,合并二尖瓣中度关闭不全2例,三尖瓣中重度关闭不全1例.结果 13例患者中4例主动脉瓣功能正常者,继续随访中.9例合并主动脉瓣病变者,均行主动脉瓣置换术,同期行二尖瓣成形术2例、三尖瓣成形术1例.围术期无严重并发症及早期死亡,均康复出院.术后平均随访（6.34±5.17）年,心彩超提示主动脉瓣功能良好,无远期死亡.结论 主动脉瓣四叶瓣畸形是一种少见的先天性畸形,超声心动图有助于早期诊断.主动脉瓣功能正常时,可以随访;当合并主动脉瓣功能障碍时,应及时行主动脉瓣置换或修复,手术后可获得良好的远期效果.     

First trans‐axillary implantation of Edwards Sapien valve to treat an incompetent aortic bioprosthesis

There exist case reports of using transcatheter aortic valves to treat dysfunctional surgically implanted aortic bioprosthesis. There are also case series reported of transaxillary implantation of the CoreValve device to treat Aortic Stenosis. In this article, we report the successful implantation an Edwards Sapien 23mm transcatheter aortic valve through the left axillary artery, in a patient with a functioning LIMA graft in order to treat a severely regurgitant Freestyle 23mm aortic bioprosthesis. © 2009 Wiley‐Liss, Inc.     

Intraoperative transesophageal echocardiographic imaging of double valve repair for aortic and mitral stenosis

An intraoperative echocardiographic evaluation to determine the feasibility and adequacy of the valve repair procedure is crucial for a successful repair. However, aortic valve repair in severe aortic stenosis (AS) is very limited and, consequently, its intraoperative echocardiographic evaluation has not been described well. Here, we describe an intraoperative transesophageal echocardiographic evaluation of a double-valve repair procedure for a patient with severe AS, moderate aortic insufficiency, and severe mitral stenosis.     

Transcatheter repair of aortic leaflet perforation in a patient with prior surgical bicuspid aortic valve repair

A 47‐year‐old male underwent surgery for functional bicuspid aortic valve severe regurgitation with a fused right and left coronary cusp. The patient presents nine years after surgical bicuspid aortic valve repair with symptomatic severe aortic regurgitation, diagnosed by TEE and MRI, caused primarily from a perforation located at the base of the surgically fused coronary cusps. The patient had a minimally dilated aortic root that did not yet necessitate surgical intervention. We present a novel percutaneous bicuspid aortic valve perforation repair that potentially decreases the number of surgical operations the patient must undergo during his lifetime. © 2015 Wiley Periodicals, Inc.     

Rare or unusual causes of chronic, isolated, pure aortic regurgitation

Six patients undergoing aortic valve replacement had rare or unusual causes of isolated, pure aortic regurgitation. Two patients had congenitally bicuspid aortic valves with a false commissure (raphe) displaced to the aortic wall ("tethered bicuspid aortic valve"), two had floppy aortic valves, one had a congenital quadricuspid valve, and one had radiation-induced valve damage.     

Transfemoral implantation of CoreValve Evolut R in patient with functionally bicuspid aortic valve

Catheter based aortic valve replacement became largely adopted technique to treat patients with severe aortic stenosis in the setting of prohibitive risk and in high risk operation patients. Based on the positive clinical data from the Nordic Aortic Valve Intervention (NOTION) Trial [1] and from a subset analysis from the CoreValve U.S. High Risk Pivotal Trial Medtronic plc. announced CE mark for the self-expanding CoreValve™ Evolut™ R to obtain an expanded indication to treat aortic stenosis in patients who are at intermediate risk for open-heart surgery. Bicuspid aortic valve was deemed contraindicated for CoreValve implantation and nowadays is considered to be “off label” use even if multiple publications showed successful CoreValve implantation in patients with stenotic bicuspid aortic valve [2], [3]. Current case report tackles preprocedural evaluation of stenotic aortic valve anatomy and together with the relevant pictures illustrates recapurability and repositionability of abovementioned TAVI system in patient with funcionally bicuspid severely stenotic aortic valve.     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71‐year‐old gentleman developed life‐threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self‐expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon‐expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non‐calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow‐up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

Echocardiographic and hemodynamic features of severe aortic regurgitation with diastolic opening of the aortic valve

Severe aortic regurgitation may be associated with premature aortic valve opening. Several possible etiologies for this diastolic opening have been suggested. We present a patient with hemodynamic data, M-mode and 2-D echocardiography in the setting of severe aortic regurgitation and diastolic aortic valve opening. Our data lead us to conclude that aortic valve opening in this situation is neither from passive flotation nor dependent on atrial systole. We believe that active ventricular recoil mechanisms can facilitate increases in diastolic ventricular pressure which then can transiently exceed aortic pressure in the setting of severe aortic regurgitation. This hemodynamic observation suggests that the valve opening is an active process.     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

A safe,rapid method of transfemoral retrograde left ventricular catheterization in valvular aortic stenosis

We report our experience with the use of a standard left Amplatz coronary catheter and a guidewire to cross the aortic valve in 34 patients being evaluated for valvular aortic stenosis. A number 2 Amplatz left coronary catheter inserted via the femoral artery was positioned above the noncoronary aortic valve cusp with the tip aligned toward the aortic valve. This catheter allowed a soft-tipped, Teflon-coated guidewire to be guided through the aortic valve orifice. The catheter was then advanced over the guidewire into the left ventricle. This technique was successful within six minutes in 32 of 34 patients (94%). The stenotic aortic valve was crossed in less than two minutes in 15 patients (42%) and in less than four minutes in 31 (91%). The aortic valve was not crossed in two patients. Twenty-one patients (62%) had an aortic valve area area of less than 0.75 cm². There were no complications. We conclude that this technique provides a method for safe, rapid transaortic left ventricular catheterization in patients with aortic stenosis of all degrees of severity.     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。     

Transcatheter aortic valve implantation for treatment of failing homograft with preexisting mechanical mitral prosthesis

Transcatheter aortic valve implantation is increasingly used to treat bioprosthetic degeneration. Valve‐in‐valve technique has been performed successfully to treat homograft, stentless, and stented bioprosthetic dysfunction. The presence of a prosthesis in the mitral position can make the transcatheter aortic valve implantation procedure challenging due to proximity of the mitral and aortic annuli. We describe the case of a 66‐year‐old who underwent the first successful implantation of Edwards Sapien device in a failing homograft in the presence of a mechanical mitral valve prosthesis. © 2013 Wiley Periodicals, Inc.     

Retrograde percutaneous aortic valve implantation for critical aortic stenosis.

Recently, a prosthetic aortic valve has been implanted percutaneously in several patients using an antegrade transseptal approach. This has been shown to be feasible and associated with dramatic hemodynamic improvement. We report a retrograde implantation of a percutaneous heart valve (PHV) in an 84-year-old man with critical aortic stenosis and refractory congestive heart failure after difficulties encountered with an initial antegrade approach. While attempting antegrade transseptal implantation of a PHV, the anterior leaflet of the mitral valve was tethered by the guidewire resulting in severe mitral regurgitation and pulseless electrical activity. Cardiac resuscitation was successful. Utilizing a retrograde approach, the PHV was successfully implanted in a stable position below the coronary ostia and well above the mitral valve leaflets. The aortic valve area increased from 0.55 to 1.7 cm2 with only mild paravalvular aortic regurgitation. Despite marked improvement in aortic valve function, the patient died secondary to guidewire-induced mitral valve anterior leaflet laceration, severe mitral regurgitation, and cardiogenic shock. Retrograde implantation of a PHV can be successfully performed with substantial increase in aortic valve area and an acceptable degree of aortic regurgitation. Although the retrograde approach may be associated with greater risk of vascular access site complications, it may be considerably safer by avoiding potential guidewire injury to the mitral valve. Further refinements in technique may establish the retrograde approach as the preferred means of PHV implantation in nonsurgical patients with critical aortic stenosis.     

Massive aortic regurgitation following paravalvular balloon valvuloplasty of an edwards sapien valve treated by emergent corevalve implantation: Never cross a transcatheter aortic valve without a pigtail

A 72‐year‐old patient, with a history of coronary artery bypass and aorto‐bifemoral graft, was diagnosed with a symptomatic severe aortic valve stenosis in the presence of moderately decreased left ventricular function. The Heart team decision was to implant an Edwards SAPIEN XT 26 mm valve by transapical approach, therefore avoiding access through the aorto‐bifemoral graft. At the end of the procedure, grades 2–3 aortic regurgitation was observed. Since each run of rapid pacing ended in ventricular fibrillation, it was decided to treat the aortic regurgitation conservatively with the option of post‐dilation in a second procedure if hemodynamic deterioration was observed. Six days later balloon valvuloplasty was performed because of heart failure requiring endotracheal intubation. Despite transesophageal echocardiography guidance the balloon was inadvertently advanced through the paravalvular space. As a consequence, balloon valvuloplasty was complicated by massive aortic regurgitation and severe hemodynamic instability which was resolved after emergency transfemoral implantation of a CoreValve. Without any further complications, the patient was discharged eight days later. © 2013 Wiley Periodicals, Inc.     

Transfemoral transcatheter aortic valve implantation after aortic valve repair with HAART 300 device

We report the first successful case, to our knowledge, of CoreValve Evolut R (Medtronic, Minneapolis, MN) implantation into a failed HAART 300 aortic annuloplasty device (BioStable Science & Engineering, TX). An 81‐year‐old man presented with severe symptomatic aortic regurgitation secondary to failure of the 21 mm HAART 300 device, which had been implanted 45 days previously. Transthoracic echocardiography (TTE) revealed grade 3 aortic regurgitation with central jet, without aortic valve stenosis. Because of the high risk for redo surgery, the heart team proceeded with femoral transcatheter aortic valve implantation. The 26 mm CoreValve Evolut R was deployed into the 21 mm HAART 300 device without difficulty or complications. There were no intraoperative or postoperative complications. The patient was discharged after 5 days. TTE showed a mean aortic valve gradient of 18 mmHg, with minimal paravalvular leak. Our experience suggests that CoreValve Evolut R implantation may be an attractive option in patients with failed HAART 300 aortic annuloplasty.     

二瓣化畸形加速主动脉瓣钙化的机制研究进展

主动脉二瓣化畸形是最常见的先天性主动脉瓣发育异常,发病率约0.5%-2%,易并发主动脉瓣钙化、主动脉夹层、主动脉瘤等疾病。几乎所有的该类患者在成年期后都会出现主动脉瓣钙化,且发病年龄比三瓣化主动脉瓣者提前20年。为何二瓣化畸形容易出现主动脉瓣钙化加速,其机制仍存在许多争议。目前研究认为目前研究认为异常的遗传学表达、血流动力学、炎症反应及内皮功能障碍之间的相互作用可能是重要原因,本综述将从以上几个方面对其进行讨论。     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.