Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery

PURPOSE: To assess whether there is survival benefit for patients with mild or moderate aortic stenosis if they undergo aortic valve replacement at the time of coronary artery bypass surgery. METHODS: From 1985 to 1995 we evaluated all patients at our institution who underwent coronary artery bypass surgery and who had the echocardiographic diagnosis of mild (mean gradient <0 mm Hg and/or valve area >1.5 cm(2)) or moderate (mean gradient > or =30 and < or =40 mm Hg and/or valve area >1.0 < or =1.5 cm(2)) aortic stenosis. Using propensity analysis, survival was compared between 129 patients who underwent coronary artery bypass surgery alone and 78 patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. RESULTS: Perioperative mortality was similar among patients who underwent coronary artery bypass surgery alone compared with patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. By Kaplan-Meier analysis, 1-year and 8-year survival were better at 90% and 55% for patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement compared with 85% and 39% for patients who underwent coronary artery bypass surgery alone (P <0.001). This benefit was limited to patients with moderate aortic stenosis (propensity-adjusted relative risk = 0.43; 95% confidence interval: 0.20 to 0.96; P = 0.04). CONCLUSION: Concomitant aortic valve replacement at the time of coronary artery bypass surgery for mild or moderate aortic stenosis appears to convey a survival advantage for patients with moderate aortic stenosis but not for those with mild aortic stenosis.     

Total arterial revascularization and concomitant aortic valve replacement

The safety of total arterial revascularization with a left internal thoracic artery-radial artery T-graft was evaluated in patients with at least two-vessel coronary artery disease and aortic valve stenosis requiring concomitant aortic valve replacement. From June 2001 to January 2005, 18 patients underwent aortic valve replacement and total arterial revascularization, while 101 had aortic valve replacement and conventional grafting. By matching age, sex, left ventricular ejection fraction, and number of distal anastomoses, 1:2 matched groups were generated: 15 patients with a left internal thoracic-radial artery T-graft, and 30 with left internal thoracic artery and additional vein grafts. Aortic cross clamp and cardiopulmonary bypass times were similar in both groups. There were no significant differences in postoperative data between the groups. Early mortality was 0% in the T-graft group and 2% in those with conventional grafts. Follow-up ranged from 2 to 50 months. Event-free survival was 100% in the T-graft group and 90% in the conventional graft group. Total arterial grafting with a left internal thoracic-radial artery T-graft can be performed in selected patients with aortic valve stenosis requiring simultaneous aortic valve replacement.     

Left ventricular mass regression following implantation of MIRA bileaflet valves in patients with severe aortic stenosis

The aim of this study was to evaluate the factors that determine the course of left ventricular mass regression in a homogeneous group of patients following aortic valve replacement by use of the mechanical Edwards MIRA bileaflet prosthesis. Furthermore, we examined if the 19-mm valve leads to an equally good outcome when compared with larger 21- and 23-mm valves. We included 79 patients (49 men) with a mean age of 65 ± 9 years operated on for isolated aortic valve replacement with the MIRA valve prosthesis. The analyses included preoperative and postoperative echocardiograms during a follow-up of at least 18 months (995 ± 439 days) after valve surgery. Indication for valve replacement was aortic stenosis in 59 and combined disease (aortic stenosis and regurgitation) in 20 patients. Concomitant coronary artery bypass grafting was performed in 28 patients. Left ventricular mass index declined from 155.6 ± 47 g/m² to 128.8 ± 35 g/m² (P < 0.001) at final visit and normalized in 49% of the patients. Female sex and a preoperatively highly elevated left ventricular mass index were identified as risk factors for residual hypertrophy. However, age and valve size did not have a predictive value for completeness of left ventricular mass regression. This study supports the evidence that an extensive preoperative left ventricular hypertrophy results in an incomplete postoperative mass regression in patients with aortic bileaflet valves. It shows that the slightly elevated pressure gradient in MIRA 19-mm valves does not affect left ventricular mass regression.     

Pre-operative use of levosimendan in two patients with severe aortic stenosis and left ventricular dysfunction

We describe two patients with severe aortic stenosis, coronary artery disease, severe left ventricular dysfunction and heart failure in which the calcium-sensitising agent, levosimendan was administered prior to aortic valve replacement and coronary artery bypass graft surgery. In both cases, drug infusion was well tolerated at the doses used, heart failure improved significantly prior to surgery and peri-operative management was relatively uncomplicated in cases that would traditionally be considered high risk. Further investigation of the use of levosimendan both for treating heart failure in the presence of severe aortic stenosis and as pre-operative therapy is warranted.     

Transcatheter aortic valve replacement in elderly patients

Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aortic valve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aortic valve replacement (TAVR) allows implantation of a prosthetic heart valve within the diseased native aortic valve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients.     

Simultaneous thoracic aortic endovascular graft and transfemoral transcatheter aortic valve replacement in a patient with a descending aortic thrombus

Severe descending thoracic and abdominal aortic pathology can deter consideration of transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) in adults with severe symptomatic aortic stenosis (AS) and may lead to utilization of alternative access sites. We report a case of an 88-year-old frail woman with severe symptomatic AS referred for TAVR with demonstration of a large thrombus in the descending thoracic aorta immediately distal to the left subclavian artery. Given concerns of thrombus embolization with femoral advancement of the transcatheter valve, coverage with a thoracic aortic endograft was planned immediately prior to the TAVR.     

Left Main Coronary Artery Obstruction by Dislodged Native-Valve Calculus after Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement can be an effective, reliable treatment for severe aortic stenosis in surgically high-risk or ineligible patients. However, various sequelae like coronary artery obstruction can occur, not only in the long term, but also immediately after the procedure. We present the case of a 78-year-old woman whose left main coronary artery became obstructed with calculus 2 hours after the transfemoral implantation of an Edwards Sapien XT aortic valve. Despite percutaneous coronary intervention in that artery, the patient died. This case reminds us that early recognition of acute coronary obstruction and prompt intervention are crucial in patients with aortic stenosis who have undergone transcatheter aortic valve replacement.     

Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable

IntroductionPatients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.Patients and methodsThis is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.ResultsThe introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.ConclusionSurgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.     

Endovascular repair of severe aortic coarctation,transcatheter aortic valve replacement for severe aortic stenosis,and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30?months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.     

Use of the SAPIEN 3 Transcatheter Heart Valve in High-Risk Scenarios

The transcatheter aortic valve replacement procedure is used in patients with aortic stenosis. Transcatheter aortic valve replacement devices are quite versatile; thus, they are increasingly being used for nonaortic applications, such as tricuspid valve-in-valve implantation. This case series describes a transcatheter aortic valve replacement procedure in 4 patients with anatomic challenges (eg, aortic tortuosity, high valvular calcium burden, highly calcified bicuspid valve, low coronary artery takeoff, left main coronary artery occlusion, and large aortic annulus) and a fifth patient who had a failed tricuspid bioprosthesis and underwent a tricuspid valve-in-valve implantation with the Edwards SAPIEN 3 transcatheter heart valve (Edwards Lifesciences). All procedures required adjustments to the standard protocol, and each procedure was successful. The critical, technical adjustments in the deployment technique and preprocedural planning of the procedures are detailed to provide a road map for other cardiologists who encounter similar challenges.     

冠状动脉旋磨及支架置入+TAVR“一站式”手术的可行性探讨

目的探讨合并冠状动脉重度钙化及狭窄的重度主动脉瓣狭窄(AS)患者行经导管冠状动脉旋磨及支架置入+经导管主动脉瓣置换(TAVR)“一站式”手术的可行性。方法本研究为回顾性研究,连续入选2019年4到10月于阜外医院接受冠状动脉旋磨及支架置入+TAVR“一站式”手术治疗的患者3例。收集患者的术前临床、影像学(包括超声心动图及主动脉根部及全主动脉CT)评估资料,及冠状动脉介入、TAVR手术资料和手术效果、术后6个月随访结果。结果本研究共纳入3例患者,其中2例为女性,年龄范围66~80岁,平均胸外科医师学会(STS)风险评分为7.8%,术前平均主动脉瓣最大流速为4.4 m/s,平均跨瓣压差为52.3 mmHg(1 mmHg=0.133 kPa),平均左心室射血分数为48.6%。2例患者需旋磨靶病变位于前降支中段,1例位于左主干到前降支,3例均合并非旋磨靶病变,平均SYNTAX积分为20分。术中均采用股动脉入路,先进行主动脉瓣跨瓣留置猪尾导管,然后行冠状动脉靶病变旋磨并置入药物洗脱支架,同期进行非旋磨靶病变的支架置入,冠状动脉介入术后予以主动脉瓣球囊扩张及自膨胀瓣膜置入,1例因瓣膜位置偏高予以“瓣中瓣”置入。3例患者均顺利完成手术,即刻效果满意,术中均无并发症。术后复查超声心动图示:平均主动脉瓣最大流速为2.1 m/s,平均跨瓣压差为9.3 mmHg,平均左心室射血分数为59%。随访6个月内无死亡,无冠状动脉再次血运重建。结论对于合并冠状动脉重度钙化及狭窄且外科风险较高的AS患者,行冠状动脉旋磨及支架置入+TAVR“一站式”手术治疗初步结果满意,该技术具有可行性。     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

Takayasu arteritis with multiple cardiovascular complications

A 60-year-old Japanese woman first presented in 1990 with effort angina. She underwent coronary angiography and was diagnosed with bilateral coronary ostial stenosis and Takayasu arteritis. Coronary artery bypass graft surgery (CABG) for multiple vessels was attempted, but the blood flow in the bilateral internal thoracic and gastroepiploic arteries was to poor for a donor artery, and the calcification of the ascending aortic wall was too severe for anastomosis of saphenous vein grafts. Therefore, the proper hepatic artery was connected to the left anterior descending artery using a vein graft. In April 2000, the patient's angina worsened. Occlusions of both subclavian arteries, bilateral coronary ostial stenosis and vein graft occlusion, aortic valve regurgitation, and two severe stenoses of the descending aorta were observed. Aortic valve replacement, and coronary and aorta revascularization were desirable, but the severe aortic wall calcification and thickening rendered these interventions impossible. Treatment with medication was chosen. The patient was discharged without severe angina. A combination of these serious cardiovascular complications which do not allow any surgical intervention is very rare. Received: May 21, 2001 / Accepted: August 24, 2001     

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.     

Minimally Invasive Repair of Left Ventricular Pseudoaneurysm after Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement is becoming a routine procedure to treat severe symptomatic aortic stenosis. At most transcatheter aortic valve replacement centers, transapical access is a frequent alternative for use in patients whose ileofemoral access is inadequate. Transapical access is increasingly applied to a variety of other structural heart and aortic procedures as well.There is a caveat, however. When performed in elderly patients with friable myocardium, transapical access is associated with such serious sequelae as bleeding and left ventricular apical pseudoaneurysmal formation.Here, we describe the case of a 70-year-old woman who developed a left ventricular apical pseudoaneurysm 3 weeks after transapical transcatheter aortic valve replacement. Our successful repair took a minimally invasive left lateral approach that involved peripheral cardiopulmonary bypass cannulation, Foley catheter occlusion and primary defect closure, and BioGlue reinforcement.     

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.     

When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization?

Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesisrelated complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.     

Transapical aortic valve implantation and 'off-pump' arterial coronary bypass in a patient with a porcelain aorta

A simple hybrid procedure, namely transapical aortic valve implantation combined with 'off-pump' coronary artery bypass using an internal thoracic artery, was performed in a patient with porcelain aorta, aortic valve stenosis and coronary artery disease. This approach does not require cardiopulmonary bypass, and avoids aortic or peripheral arterial cannulation and clamping of the aorta. This hybrid approach can be regarded as a 'new technique' being applied to an 'old idea'.     

Valve Replacement with a Sutureless Aortic Prosthesis in a Patient with Concomitant Mitral Valve Disease and Severe Aortic Root Calcification

Aortic valve replacement with concomitant mitral valve surgery in the presence of severe aortic root calcification is technically difficult, with long cardiopulmonary bypass and aortic cross-clamp times.We performed sutureless aortic valve replacement and mitral valve annuloplasty in a 68-year-old man who had severe aortic stenosis and moderate-to-severe mitral regurgitation. Intraoperatively, we found severe calcification of the aortic root. We approached the aortic valve through a transverse aortotomy, performed in a higher position than usual, and we replaced the valve with a Sorin Perceval S sutureless prosthesis. In addition, we performed mitral annuloplasty with use of an open rigid ring.The aortic cross-clamp time was 63 minutes, and the cardiopulmonary bypass time was 83 minutes. No paravalvular leakage of the aortic prosthesis was detected 30 days postoperatively.Our case shows that the Perceval S sutureless bioprosthesis can be safely implanted in patients with aortic root calcification, even when mitral valve disease needs surgical correction.     

Perioperative risk of aortic valve replacement after coronary artery bypass grafting

OBJECTIVE: To evaluate the operative risk of aortic valve replacement (AVR) after coronary artery bypass grafting (CABG). METHODS: Twenty patients (sixteen male, four female) underwent AVR 1.5-20 years (mean: 8.2) after CABG. RESULTS: Patients had received a mean number of four bypass grafts (2-5) with the use of the left internal thoracic artery in seventeen patients. Mean age at the time of AVR was 70.5 years (57-82). All patients suffered from an aortic stenosis with a mean orifice area of 0.74 cm (2) (0.34-1.1) and a mean pressure gradient of 52.4 mm Hg (22-78). Ten mechanical (mean diameter 23.6 mm, 21-27) and ten biological (22.1 mm, 19-25) prostheses were implanted. Mean duration of surgery, cardiopulmonary bypass (CPB) and cross-clamp time were 322.1 (205-645), 169.2 (87-411), and 77.1 (46-128) minutes, respectively. Fourteen patients had an uneventful postoperative course. A temporary neurological impairment, renal failure, and re-intubation for respiratory insufficiency for nine hours occurred in one patient each. Two patients died postoperatively (day 3 and 10) due to multiple cerebral infarctions. One patient required a replacement of the ascending aorta in deep hypothermia and re-implantation of the bypasses. He suffered from gastrointestinal bleeding on postoperative day 14 and expired on day 81 because of multi-organ failure. CONCLUSION: Aortic valve replacement after coronary artery bypass grafting is associated with an enhanced perioperative risk requiring meticulous decision-making and a sophisticated operative technique.