A guide to fluoroscopic identification and design of bioprosthetic valves: A reference for valve‐in‐valve procedure

Surgical aortic valve replacement remains the therapy of choice in majority of patients with aortic stenosis. Bioprosthetic heart valves are often preferred over mechanical valves as they preclude the need for anticoagulation with its associated risks of bleeding and thromboembolism. However, bioprosthetic heart valves undergo structural deterioration and eventually fail. Reoperation is the standard treatment for structural failure of the bioprosthetic valve, stenosis or regurgitation but can carry a significant risk, especially in elderly patients with multiple comorbidities. Transcatheter aortic valve implantation has recently been established as a feasible alternative to conventional valve surgery for the management of high‐risk elderly patients with aortic stenosis. This treatment modality has also been shown to be of benefit in the management of degenerated aortic bioprosthesis as a valve‐in‐valve procedure. The success of this procedure depends on a good understanding of the failing bioprostheses. This not only includes the device design but its radiological/fluoroscopic appearance and how it correlates with the implanted valve, as transcatheter aortic valve implantation is performed under fluoroscopic guidance. Here we illustrate the fluoroscopic appearance of 11 commercially available surgical bioprostheses and two commercially available transcatheter heart valves and discuss important aspects in their design which can influence outcome of a valve‐in‐valve procedure. We have also collated relevant information on the aspects of the design of a bioprosthetic valve, which are relevant to the valve‐in‐valve procedure. © 2012 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation in degenerative sutureless perceval aortic bioprosthesis

Sutureless aortic bioprostheses (SAB) are increasingly being used to provide shorter cross‐clamp time. Valve‐in‐valve transcatheter aortic valve replacement (VIV‐A) is shown to be effective and safe in the vast majority of patients with degenerated bioprosthetics, yet its' use in SAB failure is infrequent. We present a case of balloon‐expandable VIV‐A in an 80‐year‐old woman who suffered severe symptomatic aortic regurgitation in a failed Perceval S 21‐mm valve. Computed tomography scan demonstrated a deformed valve. Our heart team favored a percutaneous VIV‐A over reoperation due to the patients' high surgical risk. An Edwards‐Sapien XT 23 mm was successfully deployed with excellent results. The patient remained asymptomatic following 6 months. As other bioprosthesis, some sutureless valves are condemned to structural valve degeneration. Because VIV‐A is being established for managing degenerative bioprosthesis in high risk patients, it is cardinal to identify its role in novel degenerative sutureless valves. SAB were introduced to the clinical market only 5–7 years ago. The absence of sutures may theoretically impose risk for valve instability when adding a transcatheter sutureless valve inside the first one. Our successful experience was very reassuring. We report its feasibility because we believe it should provide support for further investigation on VIV‐A within novel SAV. © 2016 Wiley Periodicals, Inc.     

Fracturing a dysfunctional Edwards Perimount bioprosthetic valve to facilitate percutaneous valve‐in‐valve placement of SAPIEN 3 valve with modified delivery system

Pulmonary valve replacement via surgical implantation of a bioprosthetic valve (BPV) is a well‐established treatment for patients with dysfunctional RV outflow tracts. BPVs are prone to structural deterioration, and will eventually require replacement. Recently, percutaneous valve‐in‐valve (VIV) placement of transcatheter valves has established itself as a safe and effective alternative to surgical revision. Unfortunately, VIV therapy is inherently limited by the inner diameter of the BPV, which restricts the number of eligible patients. Other centers have reported on the feasibility of cracking certain BPVs with ultra high‐pressure balloons in bench testing. We now report cracking an Edwards Perimount BPV in the pulmonary position to facilitate VIV placement of an Edwards SAPIEN 3. The ability to crack the Perimount valve allowed placement of a larger valve than previously considered and minimized the final valve gradient. In an effort to avoid the morbidity and mortality of surgical pulmonary valve replacement, this new strategy will expand the number of patients eligible for percutaneous VIV therapy.     

Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture

Valve‐in‐valve transcatheter aortic valve replacement (VIV TAVR) has emerged as a preferable option for high surgical risk patients requiring redo aortic valve replacement. However, VIV TAVR may restrict flow, especially in small native aortic valves. To remedy this, bioprosthetic valve fracture has been utilized to increase the effective orifice area and improve hemodynamics. We present three cases in which bioprosthetic valve fracture was used to increase hemodynamic flow in VIV TAVR procedures.     

Chronic Kidney Disease and the Pathophysiology of Valvular Heart Disease

Valvular heart calcification is common in patients with chronic kidney disease (CKD), especially in those receiving hemodialysis therapy, and it is associated with poor prognosis. Furthermore, progression of valvular heart disease (VHD) and structural valve deterioration of bioprosthetic valves are faster in these patients. Mechanisms involved in the pathophysiology of VHD are similar between patients with and without impaired kidney function, but CKD is associated with a bone metabolism dysregulation, which might lead to a procalcifying phenotype within vessels and heart valves. CKD is also associated with left ventricular remodelling and dysfunction, which might contribute to increase the risk of heart failure and death in patients with VHD. Even if promising pharmacotherapeutic avenues are in development, no medical treatment can prevent or reduce the valvular calcific process. Patients with advanced CKD should undergo transthoracic echocardiography for detection of VHD, and if present, follow-up should be more frequent than what is recommended in the guidelines. Transcatheter valve replacement might be preferred over surgical replacement in patients with CKD and severe aortic valve stenosis.     

Impact of valvular calcification on the diagnostic accuracy of transesophageal echocardiography for the detection of congenital aortic valve malformation

BACKGROUND: Degeneration of congenital bicuspid or unicuspid aortic valves can progress more rapidly than that of tricuspid valves, and an early diagnosis significantly impacts decision making and outcome. We hypothesized that the extent of valvular calcification would negatively influence the diagnostic accuracy of multiplane transesophageal echocardiography (TEE) for the diagnosis of congenital aortic valve disease. METHODS: TEE was performed in 57 patients undergoing aortic valve replacement surgery for aortic stenosis (n = 46), pure regurgitation (n = 9), or significant regurgitation with less than severe aortic stenosis (n = 2). The degree of aortic valve calcification and the number of valve cusps were determined at surgery. RESULTS: Surgical inspection confirmed 14 bicuspid and 43 tricuspid aortic valves. Sensitivity and specificity of TEE for the diagnosis of congenital aortic valve malformation was 93% (13/14) and 91% (39/43) (P = 0.0001), respectively. In patients with no or mild aortic valve calcification (n = 13), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 100% (5/5) and 100% (8/8) (P = 0.001), respectively. In patients with moderate or marked aortic valve calcification (n = 44), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 89% (8/9) and 89% (31/35) (P<0.0001), respectively. In this subgroup of 44 patients, there were four false-positive and one false-negative diagnoses due to valvular calcification. CONCLUSIONS: Although TEE is highly sensitive and specific for the detection of congenital aortic valve malformations, presence of moderate or marked calcification of the aortic valve may result in false positive and false negative diagnoses.     

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well‐established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve‐in‐valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.     

Doppler echocardiography assessment of prosthetic heart valves

Transthoracic Doppler echocardiography is an accurate noninvasive method for the evaluation of prosthetic valve function. The flow characteristics and pressure gradients of normally functioning mechanical and bioprosthetic valves have been, in general established. Normal functioning mitral valve prostheses have a valve area > 1.8 cm² with the St. Jude valve having the largest effective valve area and normally functioning aortic prosthetic valves have a peak instantaneous gradient of < 45 mmHg, with the Starr-Edwards valves (Starr-Edwards, Irvine CA) showing the highest gradients. The incidence of minimal or mild regurgitation is approximately 15% to 30% in the mitral position and 25% to 50% in the aortic position, with the higher incidence of regurgitation seen with mechanical compared to bioprosthetic valves. Transthoracic Doppler echocardiography can accurately detect patients with prosthetic valvular stenosis. The presence of prosthetic aortic regurgitation can also generally be accurately assessed, except in the presence of both prosthetic aortic and mitral valves. Assessment of prosthetic mitral regurgitation remains limited due to significant attenuation of the ultrasound beam by the prosthesis and the frequent underestimation of severity of regurgitation. Other limitations of transthoracic studies include assessment of leaflet morphology, detection of vegetations and valve abscesses, and differentiation between valvular and paravalvular regurgitation.     

Differential profile of the OPG/RANKL/RANK-system in degenerative aortic native and bioprosthetic valves

BACKGROUND AND AIM OF THE STUDY: Although degenerative calcific aortic valve stenosis is the most common valvular disease among the elderly, neither the etiology underlying the condition nor degeneration of the bioprostheses is yet fully understood. The study aim was to assess the expression profile of those OPG/RANKL/RANK-system determinants known to act as key regulators of bone metabolism and the immune system in calcific aortic valve stenosis and porcine aortic bioprostheses. METHODS: Valve probes from a total of 69 patients (41 with end-stage aortic stenosis, 11 with mild-to-moderate aortic sclerosis, 17 with degenerative porcine aortic bioprostheses) were explanted either during surgery or at autopsy. The presence and localization of OPG, RANKL, RANK and NF-kappaB were analyzed by immunostaining and morphometry. RESULTS: The majority of stenotic and sclerotic valves exhibited cell-bound signals of OPG, RANKL, RANK and NF-kappaB, while bioprostheses showed only sparse signaling. As key findings, the percentage of cells labeled by OPG, RANK and NF-kappaB was increased in sclerotic valves compared with stenotic valves (each p < 0.001), whereas the frequency of RANKL was higher in stenotic compared to sclerotic valves (p < 0.001). As a consequence, the OPG/RANKL ratio was decreased in stenotic (0.83) compared to sclerotic valves (20.2). CONCLUSION: The differential expression profile of specific members of the OPG/RANKL/RANK axis suggests an involvement of their determinants in native valve calcification, but not in the degeneration of porcine bioprostheses. Thus, these mediators of bone homeostasis may represent new targets for a more specified prevention and/or therapy of native aortic stenosis.     

Rescue “valve in valve” implantation after late onset corevalve cusp rupture leading to acute massive aortic insufficiency

Transcatheter aortic valve implantation (TAVI) has emerged as a feasible and effective alternative to aortic valve replacement in patients at high surgical risk, and is associated with a lower risk of death at 1 year follow‐up when compared with standard therapy. In a recent large study, enrolling 663 high risk patients with symptomatic severe aortic stenosis TAVI with the use of CoreValve system has been associated with early and sustained clinical and hemodynamic benefits, with a cumulative mortality of 15.0% at 1 year follow‐up. This study has shown that paravalvular aortic regurgitation after successful TAVI is a frequent finding, being of mild entity in the vast majority of cases, whereas valvular regurgitation is almost entirely absent or mild. Of note, no cases of structural valve deterioration were reported. We report a case of a successful implantation of a CoreValve that complicated with late onset massive intravalvular aortic regurgitation, due to CoreValve cusp rupture, leading to low output state with acute pulmonary edema, which was successfully treated with “valve in valve” implantation. © 2011 Wiley Periodicals, Inc.     

Transcatheter valve-in-valve implantation for failed surgical bioprosthetic valves

When bioprosthetic cardiac valves fail, reoperative valve replacement carries a higher risk of morbidity and mortality compared with initial valve replacement. Transcatheter heart valve implantation may be a viable alternative to surgical aortic valve replacement for high-risk patients with native aortic stenosis, and valve-in-valve (V-in-V) implantation has been successfully performed for failed surgical bioprostheses in the aortic, mitral, pulmonic, and tricuspid positions. Despite some core similarities to transcatheter therapy of native valve disease, V-in-V therapy poses unique clinical and anatomic challenges. In this paper, we review the challenges, selection criteria, techniques, and outcomes of V-in-V implantation.     

Simultaneous transapical transcatheter aortic valve replacement and transcatheter mitral valve replacement for native valvular stenosis

Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187–2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341–349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve‐in‐valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759–1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve‐in‐ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74–e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography. © 2015 Wiley Periodicals, Inc.     

Study of Coronary Artery Disease in Single Aortic Valvular Disease

Objectives To analyze the results of coronary angiographies (CAG) in patients with single aortic valvular heart disease; To study the relationship between aortic valve diseases and coronary artery disease (CAD). Methods 105 patients with single aortic valvular heart disease before surgery underwent angiography. The data of clinical characteristics and angiographies were analyzed. Results 51 patients had symptoms of angina pectoris among 105 patients with single aortic valvular heart disease. Seven of them were confirmed coronary artery disease by angiographies. Although the incidence of angina in aortic valve stenosis group was significantly higher than that in aortic valve regurgitation, the probability of combination of CAD in aortic valve stenosis group was similar to the later. However, the probability of combination of CAD in degenerative aortic valve group was significantly higher than the groups of rheumatic, congenitally bicuspid aortic valves, and other causes (p < 0.01 ). Conclusions Angina pe     

Unicuspid aortic valve: Case series and review

A unicuspid aortic valve is a very rare valvular lesion. Its physical manifestations vary and are associated with other cardiovascular abnormalities such as aortic stenosis/insufficiency and aortopathy. Echocardiography remains the modality of choice, with computerized tomography or cardiac magnetic resonance used as adjunctive imaging. Herein, we present a case series of three patients with unicuspid aortic valves treated at our institution, with a focus on 2D and 3D echocardiographic imaging.     

Incidental Left Atrial Blood Cyst in a Patient Undergoing Transcatheter Aortic Valve Replacement

Blood cysts of the heart are benign cardiovascular tumors found incidentally in approximately 50% of infants who undergo autopsy at less than 2 months of age. These congenital cysts, frequently present on the atrioventricular valves of infants, are exceedingly rare in adults. Nonetheless, in adults, cardiac blood cysts have been found on the mitral valve, papillary muscles, right atrium, right ventricle, left ventricle, and aortic, pulmonic, and tricuspid valves. Reported complications include left ventricular outflow obstruction, occlusion of the coronary arteries, valvular stenosis or regurgitation, and embolic stroke.In high-risk patients with severe aortic stenosis, transcatheter aortic valve replacement has emerged as an alternative to surgical replacement. Transesophageal echocardiography plays a fundamental role in evaluating the feasibility of intraprocedural transcatheter aortic valve replacement, in measuring aortic annular size, in guiding placement of the prosthetic device, and in looking for possible complications. The embolic risk of rapid pacing and transcatheter aortic valve replacement in a patient with an intracardiac blood cyst is unknown, and such a case has not, to our knowledge, been reported heretofore. We present the case of a 78-year-old woman with severe aortic stenosis, in whom a blood cyst was incidentally found in the left atrium upon transesophageal echocardiography. She underwent successful transcatheter aortic valve replacement without embolic complication.     

Combined severe valvular aortic and valvular pulmonary stenosis and its management – A case report and literature review

Isolated congenital valvular stenosis of either aortic or pulmonary valve is commonly seen yet the presence of both these lesions in the same patient is rare. This combination presents unusual diagnostic as well as management problems. Apart from a few case reports, there is little in the literature on the combined stenosis of both semilunar valves. We present here a case report of a three and half year old boy diagnosed as a combined congenital severe valvular aortic stenosis with valvular pulmonary stenosis. The patient underwent successful balloon dilatation of both these valves in the same sitting.     

Bicuspid aortic valve morphology when associated with coarctation of the aorta

Thirteen children and young adults with coarctation of the aorta as their principal cardiovascular abnormality, 11 with bicuspid aortic valves, were evaluated by orifice-view aortography to evaluate their aortic valvular morphology. For comparison 30 individuals with aortic valvular deformities but without coarctation of the aorta were similarly studied. Two distinct forms of bicuspid valves could be identified characterized by either the appearance of gross inequality of size of the two valve leaflets or an appearance wherein each leaflet closely approximated the size of the other, thus equally bicuspid. Excepting two individuals with normal, tricuspid, aortic valves, all of the patients with coarctation of the aorta had equally bicuspid aortic valves which contrasted to the group without coarctation in which the unequally bicuspid type predominated. This difference in bicuspid aortic valve morphology associated with coarctation of the aorta suggests a different developmental process involving the aortic valve as opposed to the situation in individuals without coarctation.     

Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis: Results in six cases

Six patients with severe combined aortic and mitral valve stenosis underwent double valve balloon dilation as an alternative to surgical valve replacement. Cardiac catheterization in all patients before valve dilation revealed heavily calcified aortic and mitral valves with severe stenosis and minimal regurgitation. Balloon aortic valvuloplasty was performed in each patient with a 20 mm balloon dilation catheter passed retrograde through the aortic valve whereas mitral valvuloplasty was performed transseptally with either a single or double balloon technique.After dilation, the mean aortic and mitral gradients decreased in all patients, with the area of the aortic and the mitral valve increasing from 0.5 ± 0.3 to 0.9 ± 0.3 cm²and from 0.7 ± 0.1 to 1.5 ± 0.7 cm², respectively. The procedures were well tolerated, with no embolic events and no significant increase in valvular regurgitation, and resulted in a reduction in symptoms of dyspnea on exertion and weakness in all patients that has persisted for an average of 5.7 months of follow-up in five of the six patients.It is concluded that combined dilation of stenotic aortic and mitral valves can be accomplished percutaneously and may be considered for patients with combined valvular stenosis who refuse or are deferred from surgical intervention.     

Clinical and echocardiographic assessment of pregnant women with valvular heart diseases--maternal and fetal outcome

The study aimed to compare the outcome of pregnancy in women with valvular heart diseases. MATERIAL: Two hundred and fifty-nine pregnant women with cardiac diseases, aged 18-42, were observed. Group I-158 patients with mitral valve disease: 30 patients with mitral stenosis; 44 patients with mitral regurgitation, 33 patients with combined mitral valve disease, 51 patients with mitral valve prolapse; Group II-54 patients with aortic valve disease: 32 patients with aortic stenosis, 22 with aortic regurgitation; Group III-47 patients after valve replacement (36 mechanical; 11 homograft valves). Medical history and physical examination, NYHA class assessment, ECG, and echocardiography were performed during consecutive trimesters of pregnancy and after delivery. RESULTS: Clinical deterioration was observed in 38 patients-in 25 women of Group I, 6 women of Group II, and 7 women of Group III. Newborns outcome : 250 healthy (10 prematures, 12 with intrauterine growth retardation), 6 aborted, 2 stillbirths, 1 neonatal death. Method of delivery : 200 vaginally, 53 cesarean sections. CONCLUSIONS: (1). Pregnants with critical mitral valve stenosis form a high-risk group of life-threatening complications. (2) In women with severe aortic stenosis, pregnancy could lead to sudden clinical status deterioration. (3) Cardiac complications can be expected in patients with left ventricular enlargement and its depressed function. (4) Key factors influencing successful course of pregnancy and labour in patients with prosthetic valves: adequate left ventricular function, properly functioning valves, and effective anticoagulation.     

Advances in percutaneous treatment for adult valvular heart disease

Valvular heart disease occurs in 2–3% of the general population with an increase in prevalence with advancing age. The aetiology of valvular heart disease has evolved in recent decades with degenerative aortic and mitral valve disease supplanting rheumatic heart disease as a primary cause. The common valve lesions to be discussed in this article are aortic stenosis and mitral regurgitation. The traditional approach to calcific aortic stenosis when either symptoms or left ventricular impairment develops is surgical aortic valve replacement and it remains a treatment with excellent outcomes. In recent years there has been interest in less invasive approaches, including percutaneous and transapical aortic valve implantation. With refinements in technology these approaches are becoming a potential treatment option, primarily for high-risk patients who may otherwise be unsuitable for traditional open surgical treatment. Catheter-based approaches for mitral valve disease are also evolving. Mitral regurgitation may often be the result of mitral annular dilatation seen in patients with an enlarged left ventricle or left atrium. Percutaneous implantation of a constricting device in the coronary sinus, which lies in close proximity to the mitral annulus, results in a change to the geometry of the mitral valve and reduced regurgitation. Another technique in patients with degenerative mitral regurgitation is the endovascular edge-to-edge repair in which coaptation of the mitral valve leaflets can be improved with a percutaneously deployed clip. Small patient series indicate that these new techniques are promising. As such, advances in percutaneous interventional and surgical approaches have the potential to further improve outcomes for selected patients with valvular heart disease.