Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

主动脉瓣置换术前合并中度功能性二尖瓣关闭不全治疗策略的回顾性队列研究

目的分析主动脉瓣置换术(aortic valve replacement,AVR)同期不同方式处理中度功能性二尖瓣关闭不全(functional mitral regurgitation,FMR)对患者预后的影响。方法回顾性纳入2014～2018年在本中心接受AVR且合并中度FMR的118例患者,其中男84例、女34例,年龄(58.1±12.4)岁。根据不同二尖瓣处理方式将患者分为三组:A组(未处理,11例)、B组(二尖瓣修复,51例)及C组(二尖瓣置换,56例)。研究主要终点为患者近中期生存情况,次要终点为FMR改善情况。结果中位随访时间为29.5个月。围术期死亡5例,均为C组患者;术后早期A、B两组FMR改善率分别为90.9%、94.1%(P=0.694)。A、B、C三组中期死亡率分别为0.0%、5.9%、3.9%(P=0.264),而主要心脑血管病事件发生率分别为0.0%、9.8%、17.7%(P=0.230)。A、B两组中期FMR改善率分别为100.0%、94.3%(P>0.05)。结论对于接受AVR合并中度FMR的患者,不处理或同期修复二尖瓣更为合理,而二尖瓣置换可能会...     

Atrial and ventricular flows across a transcatheter mitral valve

 Open in a separate windowOBJECTIVESThe objective of this study was to evaluate the haemodynamic performance of transcatheter mitral valve replacement (TMVR) Implant with a focus on turbulence and washout adjacent to the ventricular surface of the leaflets. TMVR holds the promise of treating a large spectrum of mitral valve diseases. However, the haemodynamic performance and flow dynamics of such replacements are not fully understood. METHODSA tri-leaflet biopsrosthetic TMVR represented by Caisson implant of size 36A was implanted in the mitral position of a left heart simulator pulse duplicating system under physiological conditions. The 36A implant covers an anterior–posterior range of 26–32 mm and a commissure-to-commissure range of 30–36 mm. Transmitral pressure gradient, effective orifice area and regurgitant fraction were calculated. Particle image velocimetry was performed to evaluate turbulence in 2 perpendicular planes (Reynolds and viscous shear stresses, respectively). Additionally, dye experiments were performed to visualize washout.RESULTSTransmitral pressure gradient was 1.29 ± 0.27 mmHg and effective orifice area was 2.96 ± 0.28 cm². Regurgitant fraction was 14.13 ± 0.08%. Total washout was 4.27 cardiac cycles. Largest viscous shear stress reaches 3.7 Pa and 2.4 Pa in ventricle and atrium, respectively. Reynolds shear stress in the atrial side was <10 Pa. In the ventricular side, the largest Reynolds shear stress reached ∼35 Pa.CONCLUSIONSTMVR leads to favourable haemodynamics with low degree of turbulence combined with fast washout around the leaflets indicating promising potential for freedom from blood damage potential and thrombosis corroborated by initial clinical studies as part of the valves’s Early Feasibility Study.     

使用J-ValveTM系统经心尖导管主动脉瓣置换术治疗高危主动脉瓣关闭不全患者:1年随访中期结果

目的分析使用J-Valve^TM系统行经心尖主动脉瓣置换术(transapical aortic valve implantation,TA-TAVI)治疗高危主动脉瓣关闭不全患者的中期临床预后。方法回顾性收集2016年9月至2020年6月在浙江大学医学院附属第二医院连续收治的25例使用J-Valve^TM系统经心尖TAVI治疗的主动脉瓣关闭不全患者资料,分析总结术后全因病死率,不良事件发生率及心功能改善情况。结果25例中男19例,年龄范围为59~83岁,平均年龄(72.3±27.11)岁。经胸超声心动图检查评估重度主动脉瓣反流比例达88%,心功能(NYHA分级)Ⅲ-Ⅳ级占92%。患者最常合并的基础病为高血压(占68%),合并冠心病5例,既往心脏手术史3例,术前胸外科医师协会(the Society of Thoracic Surgeons,STS)评分为1.511%~27.674%,中位STS评分为4.27(2.914~6.033)%。手术均成功置入J-Valve瓣膜,无中转开胸。术后置入永久起搏器2例,CRRT 1例,中度及以上瓣周漏1例。手术早期疗效可观,不良事件发生率低,中期随访心功能及心室逆重构也有持续改善表现。结论对于高危主动脉瓣关闭不全患者使用J-Valve^TM系统行经心尖TAVI可获得较好的围手术期安全性及中期预后。     

Remodeling+Ring(改良Yacoub)技术治疗二叶式主动脉瓣反流合并升主动脉瘤一例

二叶式主动脉瓣患者常合并主动脉扩张,若主动脉瓣质量良好,可行保留主动脉瓣的主动脉根部置换术.本文报道了1例35岁二叶式主动脉瓣反流合并升主动脉瘤男性患者行Remodeling+Ring(改良Yacoub)手术.患者术后第3d复查心脏彩色超声提示主动脉瓣无反流,术后第6d顺利出院.Remodeling+Ring手术保证了...     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

Combined aortic root replacement and mitral valve surgery: The quest to preserve both valves

Objectives

Coexisting aortic root and mitral valve pathology is increasingly recognized among patients undergoing surgery. We characterized the pathology and surgical outcomes of patients with combined aortic root and mitral disease.

Accessory mitral valve associated with aortic regurgitation in an elderly patient: report of a case

We encountered a 75-year-old man who complained of exertional dyspnea. An echocardiographic examination showed aortic regurgitation and a tumor in the left ventricular outflow tract. Under complete extracorporeal circulation, we surgically made an incision of the ascending aorta with a slight thickening of the aortic valve and an enlarged annulus. After excising the aortic valve, an examination of the subvalvular region revealed mitral valve-like tissue extending from the annular region of the right coronary cusp to the ventricular septum, while the chordae tendinae was attached to the septum. This issue was excised, and the aortic valve was replaced with a 27-mm SJM valve. The postoperative course was uneventful, and the patient was discharged in good condition on postoperative day 30. An accessory mitral valve is extremely rare. Since this indication for surgical treatment is associated with congenital heart disease or a left ventricular outflow tract obstruction, most patients are young. Our patient had no associated cardiac anomalies and no pressure gradient attributable to a left ventricular outflow tract obstruction. This accessory mitral valve was discovered during aortic valve replacement surgery. To our knowledge, our patient is the oldest reported with an accessory mitral valve to have undergone a surgical resection.     

Surgically treated aortic root aneurysm following aortic valve replacement

A 65-year-old man with aortic regurgitation underwent aortic valve replacement with a St. Jude Medical prosthetic valve about 6 years ago. At that time, the aortic root was slightly dilated at about 40 mm in diameter and the ascending aorta was within the normal range. This year, the man was diagnosed with an aortic root aneurysm in regular follow-up echocardiography. Chest-enhanced computed tomography and chest aortography at our hospital demonstrated a pear-like aortic root aneurysm about 60 mm in diameter. Elective operation for the aortic root aneurysm was conducted September 29, 1999, based on the Bentall procedure. Composite graft replacement with coronary reconstruction was conducted using a 28-mm Hemashield prosthetic graft and a 23-mm St. Jude Medical prosthetic valve under cardiopulmonary bypass. An 8-mm Hemashield graft was interposed on the left main coronary artery and the right coronary artery was directly anastomosed using a Carrel patch method. The postoperative course was uneventful and post-operative examination demonstrated good surgical results. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. Surgical cases of aortic root aneurysm after aortic valve replacement are rare, but serious complications with the possibility of rupture or dissection warrant surgical intervention.     

Transcatheter aortic valve replacement in patients with severe mitral or tricuspid regurgitation at extreme risk for surgery

Objectives

Patients with symptomatic severe aortic stenosis and severe mitral regurgitation or severe tricuspid regurgitation were excluded from the major transcatheter aortic valve replacement trials. We studied these 2 subgroups in patients at extreme risk for surgery in the prospective, nonrandomized, single-arm CoreValve US Expanded Use Study.

Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants

 Open in a separate windowOBJECTIVESThis study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation.METHODSBetween November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated.RESULTSThe prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm.CONCLUSIONSExtensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks.Subj collection122, 125     

Outcomes of Liu’s aortic root repair and valve preservation in patients with type A dissection and aortic regurgitation

 Open in a separate windowOBJECTIVESTo evaluate short- and medium-term outcomes following Liu’s aortic root repair and valve preservation in patients with acute type A aortic dissection complicated by moderate-to-severe aortic regurgitation (AR). METHODSFrom October 2011 to July 2018, a total of 324 consecutive patients underwent emergency surgery for acute type A aortic dissection. There were 122 patients (38%) with moderate-to-severe AR, of whom 82 (67%) underwent Liu’s aortic root repair and valve preservation. Aortic computed tomography angiography and echocardiography were performed at discharge, 6 and 12 months postoperatively, and annually thereafter. We focused on assessing the survival and aortic root and valve durability in the 82 patients.RESULTSThe 30-day, 1-year, 3-year and 6-year survival estimates were 94%, 90%, 85% and 81%, respectively. At a median follow-up of 36.5 (interquartile range 24.9–50.9) months, all patients were free from reoperation. No residual false lumens in the aortic root, recurrent aortic root dissections or aortic root pseudoaneurysms were observed during the follow-up period. Only 1 patient (1%) presented with moderate AR at 6 months, which remained asymptomatic with no significant changes over a 3-year period. The remaining patients showed satisfactory valve function with an AR grade of mild (27%) or trace or none (72%). In the competing risk analysis, the incidence of recurrence of AR was 2% at 8 years.CONCLUSIONSLiu’s aortic root repair and valve preservation is a safe and effective operative strategy that achieves favourable short- and medium-term outcomes for acute type A aortic dissection with moderate-to-severe AR.     

Quadricuspid aortic valve associated with aortic stenosis and regurgitation

A 75-year-old man with moderate aortic stenosis and regurgitation admitted due to heart failure underwent uneventful aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis valve. A quadricuspid aortic valve discovered incidentally during surgery consisted of 4 of different sizes and a supernumerary cusp between the right and noncoronary cusps. No coronary abnormality was involved. Resected cusps showed fibrotic thickening with calcification and no sign of previous inflammatory disease. Although quadricuspid aortic valve is a very rare anomaly, its potential for severe valve failure in adulthood should not be neglected.     

Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

 Open in a separate windowOBJECTIVESWe investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).METHODSPatients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan–Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.RESULTSOut of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77–2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15–1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm²/year and that of its perimeter 0.43 mm/year.CONCLUSIONSWhen stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.     

经主动脉切口治疗主动脉根部瘤合并二尖瓣病变

目的 总结经主动脉切口治疗主动脉根部瘤合并二尖瓣病变的初步经验。方法 2009年3月至2010年12月,经主动脉瓣口行二尖瓣手术16例中男13例,女3例;年龄18～ 75岁,平均(40±10)岁。16例中Bentall+ MVR术12例,Bentall+ MVP术1例,Bentall+全弓置换+支架象鼻+MVP术1例,...     

Pseudoaneurysm in the mitral-aortic intervalvular fibrosa. A cause of mitral regurgitation

Left ventricular outflow tract pseudoaneurysm is an uncommon but potentially catastrophic complication of aortic valve surgery, aortic valve endocarditis or chest trauma. We describe a case of a left ventricular outflow tract pseudoaneurysm 1 month after an aortic valve replacement that caused a systolic compression of mitral valve and a severe regurgitation. The diagnosis was confirmed using transoesophageal echocardiography, magnetic resonance image and intraoperative endoscopy. Surgical repair of the pseudoaneurysm corrected the mitral regurgitation.     

Early commercial experience with a newly designed balloon-expandable transcatheter heart valve: 30-day outcomes and implications of preprocedural computed tomography

OBJECTIVESWe herein report a single-centre experience with the SAPIEN 3 Ultra balloon-expandable transcatheter aortic valve implantation (TAVI) system.METHODSBetween March 2019 and January 2020, a total of 79 consecutive patients received transfemoral TAVI using the SAPIEN 3 Ultra device. Data were retrospectively analysed according to updated Valve Academic Research Consortium-2 definitions. Detailed analysis of multislice computed tomography data was conducted to identify potential predictors for permanent pacemaker (PPM) implantation and residual paravalvular leakage (PVL) post TAVI.Open in a separate windowGraphical AbstractRESULTSDevice success and early safety were 97.5% (77/79) and 94.9% (75/79) with resulting transvalvular peak/mean pressure gradients of 21.1 ± 8.2/10.9 ± 4.4 and PVL >mild in 0/79 patients (0%). Mild PVL was seen in 18.9% (15/79) of cases. Thirty-day mortality was 2.5% (2/79). The Valve Academic Research Consortium-2 adjudicated clinical end points disabling stroke, acute kidney injury and myocardial infarction occurred in 1.3% (1/79), 5.1% (4/79) and 0% (0/79) of patients. Postprocedural PPM implantation was necessary in 7.6% (6/79) of patients. Multislice computed tomography analysis revealed significantly higher calcium amounts of the right coronary cusp in patients in need for postprocedural PPM implantation and a higher eccentricity index in patients with postinterventional mild PVL.CONCLUSIONSFirst experience with this newly designed balloon-expandable-transcatheter heart valve demonstrates adequate 30-day outcomes and haemodynamic results with low mortality, low rates of PPM implantation and no residual PVL >mild. The herein-presented multislice computed tomography values with an elevated risk for PPM implantation and residual mild PVL may help to further improve outcomes with this particular transcatheter heart valve in TAVI procedures.