Does Transcatheter Aortic Valve Implantation Mean the End of Surgical Aortic Valve Replacement?

Although the results of the early TAVI experience are promising, longer-term follow-up is necessary before the procedure can be extended to lowerrisk patients. Many issues are not yet resolved, including the long-term effects of paravalvular leaks (which occur in most TAVI patients), the true stroke rate in TAVI patients (which is probably in the range of 5% to 6%), and the need for permanent pacemaker implantation (which ranges from 5% to 40% in TAVI patients, depending upon the device used). As the procedure is extended into the lower-risk population, these issues will assume greater import than they have in the population currently in treatment—very elderly, high-risk patients with limited life expectancy. As in the coronary-revascularization paradigm of percutaneous coronary intervention versus coronary artery bypass grafting, there will be increasing adoption of the transcatheter approach. Just as the rumors of the demise of surgical bypass were premature, conventional AVR will continue to be the predominant technique for the treatment of aortic stenosis during at least the next decade. Although the percentage of patients treated by a transcatheter approach will continue to increase, regulatory and reimbursement factors are likely to be the primary determinants of the rate of adoption.     

Transcatheter Pulmonary Valve Replacement With the Melody Valve in Small Diameter Expandable Right Ventricular Outflow Tract Conduits

Objectives

This study sought to evaluate the safety, feasibility, and outcomes of transcatheter pulmonary valve replacement (TPVR) in conduits ≤16 mm in diameter.

Bioprosthetic Valve Performance After Transcatheter Aortic Valve Replacement With Self-Expanding Versus Balloon-Expandable Valves in Large Versus Small Aortic Valve Annuli: Insights From the CHOICE Trial and the CHOICE-Extend Registry

Objectives

The aim of this study was to compare self-expanding and balloon-expandable transcatheter heart valves (THVs) in large versus small aortic valve annuli.

Is Bioprosthetic Valve Fracture Beneficial for Patients with Larger Surgical Valves Undergoing Valve in Valve TAVR?

Purpose of Review

This review aims to summarize data regarding bioprosthetic valve fracture (BVF), a novel technique that involves fracturing the surgical valve sewing ring to allow for further expansion of the transcatheter heart valve in patients undergoing valve in valve transcatheter aortic valve replacement (VIV TAVR).

Recent Findings

Bench testing and clinical experience have demonstrated that most, but not all, bioprosthetic surgical valves can be fractured. BVF in patients with small- and intermediate-sized surgical valves results in a lower residual valve gradient and larger final valve effective orifice area as compared with standard VIV TAVR. However, whether patients with larger bioprothetic valves benefit from BVF, and whether the hemodynamic benefits of BVF translate into improved clinical outcomes, is unknown.

Summary

BVF improves the hemodynamic results of VIV TAVR in small surgical valves. However, further research is needed to determine whether BVF is beneficial for patients with larger surgical valves, and whether the hemodynamic benefits of BVF result in improved clinical outcomes.

     

Sex-Specific Outcomes of Transcatheter Aortic Valve Replacement With the SAPIEN 3 Valve: Insights From the PARTNER II S3 High-Risk and Intermediate-Risk Cohorts

Objectives

The purpose of this study was to identify sex-specific outcomes of intermediate risk patients undergoing transcatheter aortic valve replacement with the SAPIEN 3 valve.

Significant Differences in Debris Captured by the Sentinel Dual-Filter Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement Among Different Valve Types

Objectives

The aim of this study was to evaluate the debris captured by the Claret Sentinel cerebral embolic dual-filter protection device during transfemoral transcatheter aortic valve replacement (TAVR) with different valve types.

Transcatheter Aortic Valve Implantation in the Elderly: Who to Refer?

In recent years, experience with transcatheter aortic valve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions.     

Does Minimal-Access Aortic Valve Replacement Reduce the Incidence of Postoperative Atrial Fibrillation?

As the most common sequela of cardiac valvular surgery, atrial fibrillation (AF) has an important impact on postoperative morbidity. Minimal-access aortic valve replacement (AVR), with purported benefits on operative outcomes, has emerged as an alternative to conventional AVR. We used meta-analysis to determine whether minimal access influences the incidence of postoperative AF after AVR. Further, we sought first to evaluate via sensitivity analysis the impact of any differences and to identify the sources of possible heterogeneity between studies; second, we sought to evaluate any indirect effect of minimal-access AVR on other surrogate outcomes related to postoperative AF. We identified 10 studies from 26 comparative randomized and nonrandomized reports that documented the primary outcome of interest: new-onset AF. Overall meta-analysis showed no significant difference between minimal-access and conventional AVR in the incidence of postoperative AF (odds ratio, 0.85; 2,262 patients; P=0.24; 95% confidence interval, 0.66–1.11). Nor were there any apparent differences in surrogate outcome measures of intensive care unit stay, total length of stay, or stroke among studies that displayed a notable difference in AF incidence between groups. Sensitivity analysis that included only high-quality studies similarly showed no significant difference in the incidence of AF and further showed several intraoperative variables as potential sources of heterogeneity between studies. Therefore, minimal access may not have a significant effect on postoperative AF. Future randomized studies must take into account the potential sources of heterogeneity identified here to better demonstrate any differences between the 2 approaches in the onset of AF.Key words: Aortic valve/surgery, aortic valve stenosis/surgery, atrial fibrillation/etiology/prevention & control, postoperative complications, surgical procedures, minimally invasiveAtrial fibrillation (AF) is an important complication of valvular heart surgery: the reported incidence is as high as 60%.^1–3 Postoperative AF can result in hemodynamic compromise, thromboembolic phenomena, and anxiety. Other sequelae include prolonged length of stay (LoS) and increased cost. Controversy exists concerning the benefits of a minimal-access approach for aortic valve replacement (AVR); it is important, therefore, to evaluate whether the minimal-access approach carries a different incidence of AF than does the conventional approach.Preoperative, intraoperative, and postoperative variables all affect the incidence of postoperative AF.^1,3–7 Therefore, the array of contributory pathophysiologic factors implicated in postoperative AF is diverse. It includes age- and hypertension-related structural changes in the atria, the effects of surgical manipulation of the heart or pericardium, the duration of myocardial ischemia, and the effects of systemic influences such as electrolyte imbalance, drug administration, and cardiopulmonary bypass (CPB)-related inflammatory effects.^8,9Minimal-access AVR (mAVR) offers apparent benefits in terms of postoperative morbidity, such as fewer respiratory complications and fewer patients transfused.^10–16 On the other hand, mAVR has been associated with longer CPB and aortic cross-clamp (CC) times and with a greater propensity for pleural and pericardial effusions.^14,15,17 We hypothesized that the incidence of AF after mAVR would relate to factors other than the technique of surgical access itself. To investigate this, we analyzed all studies in the surgical literature published in English that compared mAVR and conventional AVR (cAVR) with regard to the incidence of postoperative AF. We used a meta-analytical synthesis of data to examine the effects of minimal access on the incidence of AF, and we focused on the variables associated with AF, including the established preoperative predictors of postoperative AF and predictors that are related to intraoperative manipulation of the heart.     

Infective Endocarditis in Patients With Bicuspid Aortic Valve or Mitral Valve Prolapse

Background

There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not recommended for these conditions.

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.     

Valve repair at the level of the sub-inguinal deep venous plexus. Gadget technique or efficacious surgery?]

Between 1988 and 1990, the authors performed 35 valvuloplasties for major reflux syndrome involving the sub-inguinal deep venous system. Twenty two patients with a mean follow-up period of 23 months (1 year--3 years) were reviewed clinically and hemodynamically. Only one of the 10 patients with a chronic ulcer had developed a recurrence. This concerned the only postoperative thrombosis seen in this series. Results from a hemodynamic standpoint were as follows: Reflux evaluated preoperatively was Kistner type 4 with a popliteal venous reflux index (VRI) with a mean grade of 1.1. Postoperative evaluation (Duplex-Scan) showed the absence of reflux below the valvuloplasty in 86 p. cent of cases and VRI was normalised (less than 0.50) to the same extent. Mean venous filling time (PPG, peripheral pressure gradient measurement) after application of a supra-malleolar tourniquet was 8" (-8n + 4) preoperatively. It became normal in 13 patients and improved in 8 (mean of 82 p. cent). The results of valvuloplasty in this series confirm those published by other teams. They are notably superior to those offered by transposition and transplantation procedures. Unfortunately, this effective technique can only rarely be used in post-thrombotic syndromes and is useful essentially in Primary Deep Valve Insufficiency.