Transcatheter closure of ventricular septal defect in aortic valve prolapse and aortic regurgitation

ObjectiveTo report intermediate follow-up result of transcatheter closure of ventricular septal defect (VSD) in presence of aortic valve prolapse (AVP) with or without aortic regurgitation (AR).MethodThis is a retrospective review of 19 patients with VSD with AVP with AR who underwent transcatheter closure in between September 2011–July 2014. Mean age was 8 years (1–16 years, standard deviation [SD] 4.08 years) and mean weight was 26.03 kg (9–81.5 kg, SD 16.57 kg). Among them 2 had subarterial VSD, 6 had subaortic VSD and 11 had perimembranous VSD. All of them had mild AVP and 13 of them had AR (trivial or mild). Median VSD size was 4.3 mm (4–6 mm). Transcatheter closure was done either by retrograde technique using the Amplatzer Duct Occluder-II in 17 patients or antegrade technique using the Duct Occluder-I in 2 cases. Mean follow-up period was 18 months (12–36 months).ResultImmediate major complications were encountered in 2 (10.5%) cases. Significant aggravation of device related AR was seen in one case & device embolised to right pulmonary artery in another case and both of them were managed surgically.During follow up, 1 child had significant additional VSD requiring device closure. One child developed moderate AR, requiring surgery. None of the other had shown any increase in severity of AR.ConclusionDevice closure of VSD in presence of mild AVP and mild AR appears to be safe. Longer follow-up is necessary to draw final conclusion.     

Long-Term Durability of Transcatheter Aortic Valve Prostheses

Background

Very little is known about long-term valve durability after transcatheter aortic valve replacement (TAVR).

Transfemoral Implantation of a Fully Repositionable and Retrievable Transcatheter Valve for Noncalcified Pure Aortic Regurgitation

ObjectivesThis study sought to evaluate the use of the Direct Flow Medical (DFM) transcatheter heart valve (Direct Flow Medical, Santa Rosa, California) for the treatment of noncalcific pure aortic regurgitation (AR).BackgroundThe treatment of noncalcific AR has remained a relative contraindication with transcatheter heart valves due to challenges in anchoring devices in the absence of calcium, concerns of valve embolization, and the high risk of significant residual paravalvular leak.MethodsThe study population consisted of patients treated for severe noncalcific pure AR with transfemoral implantation of a DFM transcatheter heart valve at 6 European centers. The primary endpoint was the composite endpoint of device success and the secondary endpoint was the composite early safety endpoint (according to the VARC-2 criteria).ResultsEleven high-risk (STS score 8.84 ± 8.9, Logistic EuroSCORE 19.9 ± 7.1) patients (mean age 74.7 ± 12.9 years) were included. Device success was achieved in all patients. In 1 patient, the initial valve prosthesis was retrieved after pull-through, and a second valve was successfully deployed. The early safety endpoint was reached in 91% of the patients, with 1 patient requiring surgical aortic valve replacement secondary to downward dislocation of the prosthesis that was successfully managed with surgical aortic valve replacement. DFM implantation resulted in excellent hemodynamics with none or trivial paravalvular regurgitation in 9 patients and a transprosthetic gradient of 7.7 ± 5.1 mm Hg at 30-day follow up. All patients derived symptomatic benefit following the procedure, with 72% in New York Heart Association functional class I or II.ConclusionsThis study reports the feasibility of treating severe noncalcific AR with the Direct Flow prosthesis via the transfemoral route.     

Quantitative Angiographic Assessment of Aortic Regurgitation after Transcatheter Aortic Valve Implantation among Three Balloon-Expandable Valves

Objectives:The aim of the present analysis is to compare the quantitative angiographic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) among three balloon-expandable valves.Background:Quantitative videodensitometric aortography is an objective, accurate, and reproducible tool for adjudication of AR following TAVI.Methods:This is a retrospective corelab analysis, independent from industry, of aortograms from patients treated with TAVI using the balloon-expandable Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd., India), Sapien 3, and XT THVs (Edwards Lifesciences, Irvine, CA, USA). The study comprised of 108 analyzable aortograms from consecutive patients in a multicenter European registry who underwent Myval THV implantation. The results of quantitative assessment of AR in the Sapien 3 THV (n = 397) and Sapien XT THV (n = 239) were retrieved from a published pooled database.Results:The Myval THV had the lowest proportion of patients with moderate or severe angiographic quantitative AR (2.8%) compared to the Sapien 3 THV (8.3%; p = 0.049) and Sapien XT THV (10.9%; p = 0.012). Furthermore, the Myval THV had the lowest mean angiographic quantitative AR (6.3 ± 6.3%), followed by Sapien 3 THV (7.6 ± 7.1%) and Sapien XT THV (8.8 ± 7.5%), and it was significantly lower than that of the Sapien XT THV (p = 0.006), but not significantly different from Sapien 3 THV (p = 0.246).Conclusion:The Myval THV, in comparison with other BEV’s analyzed in our database, showed a lower occurrence of moderate or severe AR after TAVI. These results should be confirmed in prospective cohorts of randomized patients with head-to-head THV comparisons.     

经导管主动脉瓣置换术时代慢性主动脉瓣反流诊治进展

慢性主动脉瓣反流无症状期长,晚期预后差,最佳干预时机尚不明确.目前干预指征主要依据于症状和超声心动图的左室功能和扩张程度,而新影像学评估(磁共振、超声心动图新参数和计算机断层扫描评估等)及生物标志物可优化治疗决策.主动脉瓣反流患者药物治疗效果有限,不能替代或延迟手术治疗.目前大多数主动脉瓣反流患者仍首选外科主动脉瓣置换...     

Ventricular septal defect in chinese with aortic valve prolapse and aortic regurgitation

Summary The incidence of aortic valve prolapse and aortic regurgitation (AR) among Chinese with ventricular septal defect (VSD) has not been studied, and controversies still exist regarding optimal surgical treatment and timing of operation for this condition. A prospective study of 332 consecutive patients with VSD showed that aortic valve prolapse and AR occurred in 43 (11.9%) patients. Valve lesions occurred more commonly among patients with subpulmonic VSD (28.0%) than with subaortic VSD (8.8%) (P<0.005). A retrospective study of another 306 patients revealed that 37 (12.1%) had valve complications. Of the 80 patients with valve lesions, 60 were males and 20 were females. The youngest ages of prolapse and AR in subpulmonic VSD were 7 months and 3 years 8 months, respectively; those in subaortic VSD were 2 years and 3 years 6 months, respectively. Valve prolapse occurred mostly before the age of 6–10 years, leading progressively to AR. The coronary cusps prolapsed in subpulmonic VSD were limited to the right cusp; and those in subaortic VSD were the right cusp, noncoronary cusp, or both. The magnitude of left-to-right shunts was small and the pulmonary artery pressure was normal in the majority of patients. Seventy-two patients underwent open-heart closure of the VSD, with additional valvuloplasty in 15 and valve replacement in three patients. It is concluded that Chinese with VSD are prone to develop aortic valve complications. Surgical closure of the subpulmonic VSD may restore the prolapsed valve to normal. Closure of the subaortic VSD has little effect. Valvuloplasty in subaortic VSD may palliate AR, but in all probability cannot restore valve competency.     

Outcomes of Transcatheter Aortic Valve Replacement in Mixed Aortic Valve Disease

ObjectivesThe aim of this study was to compare outcomes after transcatheter aortic valve replacement (TAVR) in patients with pure aortic stenosis (AS) (i.e., no or trivial associated aortic regurgitation [AR]) with those in patients with AS and mild or more severe AR (i.e., mixed aortic valve disease [MAVD]).BackgroundTAVR is indicated in treating patients with severe AS. Limited data exist regarding the outcomes of TAVR in patients with MAVD.MethodsA total of 1,133 patients who underwent TAVR between January 2014 and December 2017 were included. The primary outcome was all-cause mortality. The comparison was adjusted to account for post-TAVR AR development in both groups. The secondary outcomes included composite endpoints of early safety and clinical efficacy as specified in the Valve Academic Research Consortium-2 criteria. Variables were compared using Mann-Whitney, chi-square, and Fisher exact tests, while Kaplan-Meier analyses were used to compare survival.ResultsA total of 688 patients (61%) had MAVD (median age 83 years , 43% women). Among these, 17% developed mild, 2% moderate, and <1% severe post-TAVR AR. Overall, patients with MAVD had better survival compared with patients with pure AS (p = 0.03). Among patients who developed post-TAVR AR, those in the MAVD group had better survival (p = 0.04). In contrast, in patients who did not develop post-TAVR AR, pre-TAVR AR did not improve survival (p = 0.11).ConclusionsPatients with MAVD who underwent TAVR had better survival compared with patients with pure AS. This is explained by the better survival of patients with MAVD who developed post-TAVR AR, likely due to left ventricular adaptation to AR.     

A New Transcatheter Aortic Valve Replacement System for Predominant Aortic Regurgitation Implantation of the J-Valve and Early Outcome

ObjectivesThis study introduces a newly designed transcatheter aortic valve system, the J-Valve system, and evaluates its application in patients with predominant aortic regurgitation without significant valve calcification. We also report the early results of one of the first series of transapical implantations of this device and aim to offer guidance on the technical aspects of the procedure.BackgroundTranscatheter aortic valve replacement (TAVR) has been widely used in high-risk patients for surgical aortic valve replacement. However, the majority of the TAVR devices were designed for aortic valve stenosis with significant valve calcification.MethodsSix patients with native aortic regurgitation without significant valve calcification (age, 61 to 83 years; mean age, 75.50 ± 8.14 years) underwent transapical implantation of the J-Valve prosthesis (JieCheng Medical Technology Co., Ltd., Suzhou, China), a self-expandable porcine valve, in the aortic position at our institution. All patients were considered to be prohibitive or high risk for surgical valve replacement (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation], 22.15% to 44.44%; mean, 29.32 ± 7.70%) after evaluation by an interdisciplinary heart team. Procedural and clinical outcomes were analyzed.ResultsImplantations were successful in all patients. During the follow-up period (from 31 days to 186 days, mean follow-up was 110.00 ± 77.944 days), only 1 patient had trivial prosthetic valve regurgitation, and none of these patients had paravalvular leak of more than mild grade. There were no major post-operative complications or mortality during the follow-up.ConclusionsOur study demonstrated the feasibility of transapical implantation of the J-Valve system in high-risk patients with predominant aortic regurgitation.     

Outcomes of Transcatheter Closure in Outlet-Type Ventricular Septal Defect after 1 Year

Background: Ventricular septal defect (VSD) is the most common congenital heart disease. Transcatheter VSD closure is an effective treatment for patients with muscular and perimembranous VSD. However, there is a limit data for outlet VSD, especially impact to the aortic valve leaflet after transcatheter closure. This study aims to assess the outcomes of transcatheter closure of the outlet-type ventricular septal defect (OVSD) after 1 postoperative year. Methods: A retrospective study was performed including 50 patients who underwent transcatheter (n = 25) and surgical (n = 25) OVSD closure during the exact time frame at two medical centres. Results: The median age and body weight of patients in the transcatheter group were significantly higher than those of patients in the surgical group (7.0 vs. 2.8 years; 27.0 vs. 11.4 kg; p < 0.01). The defect size in the surgical group was significantly larger than that in the transcatheter group (5.0 vs. 3.0 mm; p < 0.01). All OVSD patients have successful transcatheter closure (100%) as effective as surgical closure. Less than small residual shunt was present 20% and 8% immediately after the procedure in the transcatheter and surgical groups (p = 0.50), which decreased to 12% and 4% at the 1-year follow-up (p = 0.61), respectively. No incidence of complete atrioventricular block and other complications was observed in both groups, and no significant differences were noted in the new onset or worsening of the aortic regurgitation in both groups (p = 1.0). Conclusions: Transcatheter treatment could be effectively and safely achieved for OVSD closure at 1-year follow-up.     

Balloon-Expandable Prostheses for Transcatheter Aortic Valve Replacement

The implantation of a transcatheter heart valve (THV) through a balloon-expandable system played a major role in the early stages of transcatheter aortic valve replacement (TAVR). The technology consists of sewing a foldable biological cardiac valve inside a metallic stent frame, and then crimping the device into a balloon in order to implant the valve at the level of the aortic annulus through balloon inflation. The use of balloon-expandable valves underwent a rapid expansion in the years following the pioneering experience of 2002, and recent large multicenter trials and registries have confirmed the safety and efficacy of TAVR using balloon-expandable valves. The randomized Placement of Aortic Transcatheter Valves (PARTNER) trial showed both the superiority and non-inferiority of TAVR with the balloon-expandable Edwards-Sapien system compared to medical treatment (non-operable patients) and surgical aortic valve replacement (high risk patients), respectively. Balloon-expandable valves have been associated with excellent hemodynamic results (residual mean gradient < 15 mm Hg in most cases), though residual paravalvular aortic regurgitation is frequent (trivial or mild in the majority of patients, moderate or severe in < 10%). Valve durability studies with up to 5-year follow-up have shown maintained valve hemodynamics over time with only a minimal decrease in valve area and no increase in aortic regurgitation. Future improvements in the balloon-expandable THV technology such as implementing anti-paravalvular leak features (ex. Sapien 3 valve), and showing its efficacy for the treatment of non-high risk patients (ongoing PARTNER II trial) will probably lead to broader use in a lower risk population in the near future.     

Initial German Experience With Transapical Implantation of a Second-Generation Transcatheter Heart Valve for the Treatment of Aortic Regurgitation

ObjectivesThis analysis reports on the initial German multicenter experience with the JenaValve (JenaValve Technology GmbH, Munich, Germany) transcatheter heart valve for the treatment of pure aortic regurgitation.BackgroundExperience with transcatheter aortic valve implantation (TAVI) for severe aortic regurgitation is limited due to the risk of insufficient anchoring of the valve stent within the noncalcified aortic annulus.MethodsTransapical TAVI with a JenaValve for the treatment of severe aortic regurgitation was performed in 31 patients (age 73.8 ± 9.1 years) in 9 German centers. All patients were considered high risk for surgery (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 23.6 ± 14.5%) according to a local heart team consensus. Procedural results and clinical outcomes up to 6 months were analyzed.ResultsImplantation was successful in 30 of 31 cases (aortic annulus diameter 24.7 ± 1.5 mm); transcatheter heart valve dislodgement necessitated valve-in-valve implantation in 1 patient. Post-procedural aortic regurgitation was none/trace in 28 of 31 and mild in 3 of 31 patients. During follow-up, 2 patients underwent valvular reinterventions (surgical aortic valve replacement for endocarditis, valve-in-valve implantation for increasing paravalvular regurgitation). All-cause mortality was 12.9% and 19.3% at 30 days and 6 months, respectively. In the remaining patients, a significant improvement in New York Heart Association class was observed and persisted up to 6 months after TAVI.ConclusionsAortic regurgitation remains a challenging pathology for TAVI. After initial demonstration of feasibility, this multicenter study revealed the JenaValve transcatheter heart valve as a reasonable option in this subset of patients. However, a significant early noncardiac mortality related to the high-risk population emphasizes the need for careful patient selection.     

Transcatheter Ventricular Septal Defect Closure with Nit-Occlud Lê VSD Device—Five Years’ Experience and Literature Review

Introduction: Transcatheter closure is an alternative to ventricular septal defect (VSD) occlusion surgery. Nit-Occlud Lê VSD coil is a new device yet to be evaluated. The study aimed to evaluate immediate and midterm results after transcatheter closure with the Nit-Occlud Lê VSD device. Methods: The retrospective analysis included 30 patients with VSD referred for closure during the period from October 2015 to December 2020. Results: At the time of intervention, the patients’ mean age and body weights were 7.5 ± 5.6 years and 29.3 ± 19.1 kg. The majority of the defects had perimembranous location (24/30), four defects had muscular and two outlet subaortic position. The mean effective right-side diameter of the VSDs was 3.6 ± 1.3 mm. Single ventricular fibrillation, device embolization, and hemolysis developed in different patients and were successfully treated. None of the patients had a complete atrioventricular block. The coil was successfully placed in 25/30 (83.3%) patients. The majority of the devices were 10 mm × 6 mm (11/25) and 12 mm × 8 mm (8/25) in size. Two patients required the implantation of a second device. The follow-up period was 2.1 ± 1.4 years. Complete VSD closure was achieved in 48% of cases immediately after the intervention, 74% during 2.1 ± 1.6 months after the procedure, and 81% over follow-up. The remaining patients had a trivial residual defect. During the follow-up, approximately one-third of patients developed trivial aortic and mitral valve regurgitation, and half of the patients acquired trace/mild tricuspid regurgitation. Standardized (z-score) left ventricular end-diastolic diameter (0.15 ± 0.37 vs. 0.92 ± 0.82, p = 0.005) and left atrium dimension (0.47 ± 0.58 vs. 1.89 ± 1.11, p = 0.005), as well as the left atrium to aortic root ratio (1.2 ± 0.1 vs. 1.4 ± 0.2, p = 0.005) showed a significant decrease over follow-up related to the period before intervention. Conclusion: Intervention with Nit-Occlud® Lê VSD coil showed appropriate results regarding VSD closure rate, complications, and chamber remodeling. The introduction of this device into clinical practice is a significant step forward in transcatheter perimembranous VSD occlusion.     

Clinical Impact of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: Insights Into the Degree and Acuteness of Presentation

ObjectivesThe aim of this study was to determine the impact of the degree of residual aortic regurgitation (AR) and acuteness of presentation of AR after transcatheter aortic valve replacement (TAVR) on outcomes.BackgroundThe degree of residual AR after TAVR leading to excess mortality remains controversial, and little evidence exists on the impact of the acuteness of presentation of AR.MethodsA total of 1,735 patients undergoing TAVR with balloon-expandable or self-expanding valves were included. The presence and degree of AR were evaluated by transthoracic echocardiography; acute AR was defined as an increase in AR severity of ≥1 degree compared with pre-procedural echocardiography.ResultsResidual AR was classified as mild in 761 patients (43.9%) and moderate to severe in 247 patients (14.2%). The presence of moderate to severe AR was an independent predictor of mortality at a mean follow-up of 21 ± 17 months compared with none to trace (adjusted hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.32 to 2.48; p < 0.001) and mild AR (adjusted HR: 1.68, 95% CI: 1.27 to 2.24; p < 0.001) groups. There was no increased risk in patients with mild AR compared with those with none to trace AR (p = 0.393). In patients with moderate to severe AR, acute AR was observed in 161 patients (65%) and chronic AR in 86 patients (35%). Acute moderate to severe AR was independently associated with increased risk of mortality compared with none/trace/mild AR (adjusted HR: 2.37, 95% CI: 1.53 to 3.66; p < 0.001) and chronic moderate to severe AR (adjusted HR: 2.24, 95% CI: 1.17 to 4.30; p = 0.015). No differences in survival rate were observed between patients with chronic moderate to severe and none/trace/mild AR (p > 0.50).ConclusionsAR occurred very frequently after TAVR, but an increased risk of mortality at ∼2-year follow-up was observed only in patients with acute moderate to severe AR.     

Long-term follow-up after aortic valvuloplasty and defect closure in ventricular septal defect with aortic regurgitation

The clinical course was studied in 25 patients with ventricular septal defect (VSD) and aortic regurgitation (AR) who had undergone aortic valvuloplasty and VSD closure. Twelve patients had a doubly committed subarterial VSD and 13 had a perimembranous type of VSD. Preoperatively, progressive hemodynamic disturbance after the onset of AR occurred in 11 patients (44%). The follow-up period extended from 6 months to 23 years (mean 10 years). Four patients required prosthetic valve replacement after valvuloplasty. One of these had had initial improvement of the AR but required valve replacement 20 years later; the condition of the other 3 did not improve initially and their valves were replaced 1 month to 8.5 years later. Four other patients had no initial improvement as a result of valvular reconstructive surgery, but the AR did not progress and remained hemodynamically well tolerated. Hence, the overall success rate of the valvuloplasty, defined as improving or preventing progressive AR, was 21 of 25 (84%). Since initial and long-term improvement in aortic valve function can be expected in most patients after valvuloplasty and closure of the VSD, early surgical intervention is recommended in patients with a VSD and AR.     

Usefulness of electromagnetic flowmetry in intraoperative evaluation of aortic regurgitation associated with ventricular septal defect

In 38 patients with aortic regurgitation (AR) associated with ventricular septal defect (VSD), indications for aortic valvuloplasty (AVP) or aortic valve replacement (AVR) were investigated by assessing AR ratio, which was measured by electromagnetic flowmetry of the ascending aorta during the operation. Residual AR was evaluated by auscultation postoperatively. Patients were assigned to group A if they underwent VSD closure alone and to group B if they underwent AVP in addition to VSD closure; patients who had no postoperative AR were assigned to group I and those with persistence of AR to group II. Thus, the patients were separated into 4 subgroups; A-I (9 patients), A-II (5 patients), B-I (20 patients) and B-II (4 patients). In subgroup A-I, mean AR ratio decreased from 9% to 7% postoperatively, in A-II from 19% to 16% (p less than 0.1), in B-I from 36% to 9% (p less than 0.01) and in B-II from 44% to 20% (p less than 0.05). An AR ratio of more than 25% should be regarded as an absolute indication for AVP or AVR. If the AR ratio is between 20 and 25%, the indication of AVP is determined by inspection of the aortic valve. A good correlation was found between AR ratio and the AR rate determined by the aortic angiographic findings (Sellers classification): grade I AR corresponded to an AR ratio of 5 to 15%, grade II to 20 to 35%, grade III to 25 to 50% and grade IV to 45% or higher (r = 0.87, p less than 0.01).     

Transcatheter Aortic Valve Replacement With Self-Expanding ACURATE neo2: Postprocedural Hemodynamic and Short-Term Clinical Outcomes

BackgroundThe first-generation ACURATE neo transcatheter heart valve (THV) (Boston Scientific) was associated with a non-negligible occurrence of moderate or greater paravalvular aortic regurgitation (AR) following transcatheter aortic valve replacement. To overcome this issue, the ACURATE neo2 iteration, which incorporates a taller outer skirt aimed at reducing the occurrence of paravalvular AR, has recently been developed.ObjectivesThe aim of this study was to assess the efficacy and safety of the ACURATE neo2 (Boston Scientific) THV in patients with severe aortic valve stenosis.MethodsITAL-neo was an observational, retrospective, multicenter registry enrolling consecutive patients with severe aortic valve stenosis, treated with first- and second-generation ACURATE neo THVs, via transfemoral and trans-subclavian access, in 13 Italian centers. One-to-one propensity score matching was applied to account for baseline characteristics unbalance. The primary endpoint was the occurrence of moderate or greater paravalvular AR on predischarge echocardiographic assessment. Secondary endpoints included postprocedural technical success and 90-day device success and safety.ResultsAmong 900 patients included in the registry, 220 received the ACURATE neo2 THV, whereas 680 were treated with the first-generation device. A total of 410 patients were compared after 1:1 propensity score matching. The ACURATE neo2 THV was associated with a 3-fold lower frequency of postprocedural moderate or greater paravalvular AR (11.2% vs 3.5%; P < 0.001). No other hemodynamic differences were observed. Postprocedural technical success was similar between the 2 cohorts. Fewer adverse events were observed in patients treated with the ACURATE neo2 at 90 days.ConclusionsTransfemoral transcatheter aortic valve replacement using the ACURATE neo2 was associated with a significant lower frequency of moderate or greater paravalvular AR compared with the earlier generation ACURATE neo device, with encouraging short-term safety and efficacy.     

TAVR for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device: 1-Year Results From the Prospective VIVA Postmarket Study

ObjectivesThe VIVA (Valve in Valve) trial was designed to systematically and prospectively collect data regarding the use of transcatheter aortic valve replacement in patients with failing surgical aortic bioprostheses at high-risk for reoperation.BackgroundSurgical aortic valve replacement has been the standard of care in symptomatic patients with aortic valve disease. However, bioprosthetic valves degenerate over time, requiring redo surgery.MethodsVIVA is an international, observational, single-arm, postmarket study conducted at 23 sites that enrolled 202 patients with symptomatic degeneration of an aortic bioprosthesis eligible for elective treatment with a CoreValve or Evolut R self-expanding transcatheter aortic valve.ResultsPatients were elderly (mean age 79.9 years), 47.5% were men, and they had a mean Society of Thoracic Surgeons score of 6.6%. Although 41.8% of patients had surgical bioprostheses with labeled size ≤21 mm, valve hemodynamic parameters were markedly improved from baseline (mean aortic valve gradient 35.0 ± 16.3 mm Hg) to discharge (17.5 ± 8.6 mm Hg) and were sustained at 1 year (15.5 ± 7.5 mm Hg). At 1 year, total aortic regurgitation greater than mild was measured in 1.1% of patients. Clinical outcomes at 30 days demonstrated low mortality (2.5%), no disabling strokes, a 0.5% rate of acute kidney injury, and an 8.0% rate of new pacemaker implantation. At 1 year, the mortality rate remained low (8.8%), with 1 disabling stroke (0.6%). Five patients (2.5%) experienced coronary artery obstructions, 3 during and 1 immediately after the procedure and 1 several months later.ConclusionsDegenerated surgical bioprostheses can be safely treated with the CoreValve or Evolut R platform using the catheter-based valve-in-valve procedure. Excellent 1-year clinical and hemodynamic outcomes were achieved in this real-world patient population. (CoreValve VIVA Study Evaluation of the Clinical Outcomes of CoreValve in Degenerative Surgical Aortic Bioprosthesis; NCT02209298)     

Atrioventricular Conduction After Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement

AV Conduction After TAVI and SAVR . Introduction: Atrioventricular conduction abnormalities (AVCA) may complicate transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). The aim of this study was to prospectively evaluate AVCA after TAVI and SAVR. Methods and Results: Among 50 patients undergoing TAVI and 25 patients undergoing SAVR a continuous 7‐day Holter electrocardiogram (ECG) was recorded after the procedure. ECGs during TAVI and 12‐lead ECGs before and 1 and 7 days after TAVI and SAVR were analyzed. At baseline, TAVI patients were older (mean 82.1 vs 75.4, P < 0.001), had a longer PR interval (median 200 milliseconds vs 175 milliseconds, P = 0.004) and broader QRS width (median 100 milliseconds vs 80 milliseconds, P = 0.007) than SAVR patients. New AVCA were observed among 29 TAVI patients (58%), mostly new left bundle branch block (76%). Predilatation induced new AVCA in 14 TAVI patients (28%). New AVCA resolved within 24 hours in 15 TAVI patients (30%), and persisted in 14 TAVI (28%) and 3 SAVR patients (12%, P = 0.12). Among patients with persistent QRS width <120 milliseconds during the first 24 hours after TAVI, QRS width remained stable during the remainder of the observation period. During Holter monitoring complete AV block was observed in 4 TAVI patients (8%) and 3 SAVR patients (12%; P = 0.68). Conclusions: Almost half of AVCA during TAVI are induced by predilatation, but half of them resolve within 24 hours. Persistent AVCA are more frequently observed after TAVI than SAVR. If QRS width is below 120 milliseconds the first day after TAVI, the risk of late AVCA seems low. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1115‐1122, October 2012)     

Ventricular septal defect closure in right coronary cusp prolapse and aortic regurgitation complicating VSD in the outlet septum: which treatment is most appropriate?

BACKGROUND: There is currently not a standardized technique for the sizing and shaping of surgical closure of the ventricular septal defect (VSD) patch in patients with right coronary aortic cusp prolapse and aortic regurgitation (AR) complicating VSD in the outlet septum. METHODS: Forty-six VSD patients who had aortic valve prolapse were divided into groups DC (direct closure, n=19), and SPC (small patch closure, n=27). Preoperative and postoperative echocardiography with Doppler color flow interrogation was performed on all patients. RESULTS: In the DC group, among seven patients who had aortic valve prolapse but no AR preoperative, one patient developed AR during postoperative follow-up period. In the remaining 12 patients who had mild AR associated with aortic valve prolapse prior to the procedure, AR was diminished in four and unchanged in six patients. However, AR was aggravated in two patients who required further operations for AV repair or replacement. In the SPC group, among the eight patients who had no preoperative AR, AR progressed in one patient postoperatively. In the remaining 19 patients who had mild AR, AR was diminished in 15 and unchanged in four. The outcome from the operative procedure was significantly better in the SPC group than DC group with mild preoperative AR (chi(2)=7.82; P<0.05). CONCLUSIONS: Small patch closure for this type of VSD is safer and more reliable in improving mild AR than that of direct closure, especially in patients with mild AR.     

Transcatheter membranous ventricular septal defect closure through a mechanical aortic prosthesis using the Amplatzer membranous ventricular septal defect occluder

An iatrogenic ventricular septal defect (VSD) after aortic valve replacement is rare, but represents a significant complication. Repeat surgery to repair such a defect carries a high surgical risk. The transcatheter approach (either transvascular or transapical) could be considered as an alternative to open chest surgery. We describe the successful transcatheter closure of an iatrogenic VSD with an Amplatzer Membranous VSD Occluder in a patient with previous combined mitral and aortic mechanical valve replacements. The device was implanted through a CarboMedics mechanical valve in the aortic position. © 2008 Wiley‐Liss, Inc.