Multiphase Assessment of Mitral Annular Dynamics in Consecutive Patients With Significant Mitral Valve Disease

ObjectivesThe aim of this study was to clarify the dynamics of the mitral annulus throughout the cardiac cycle and its relevance to transcatheter mitral valve replacement (TMVR) sizing and case selection.BackgroundLimited data are available regarding the relevance of mitral annular (MA) and neo–left ventricular outflow tract (LVOT) dynamics in the overall population presenting with significant mitral valve disease.MethodsPatients attending a combined surgical-transcatheter heart valve clinic for severe symptomatic mitral valve disease were assessed using multiphase computed tomography. The relative influence of MA and neo-LVOT dynamics to TMVR case selection was studied.ResultsA total of 476 patients with significant mitral valve disease were evaluated. In 99 consecutive patients with severe mitral regurgitation, a 10-phase assessment showed that the mitral annulus was on average largest in late systole. On comparing maximal MA dimension with late systolic dimension, TMVR size assignment changed in 24.2% of patients. If the average MA perimeter was used to determine sizing, 48.5% were excluded because of MA dimension being too large; in a multiphase assessment of the neo-LVOT, an additional 16.2% were excluded on the basis of neo-LVOT dimension. In an expanded series of 312 consecutive patients, selection protocol influenced anatomical exclusion: a manufacturer-proposed early systolic approach excluded 69.2% of patients, whereas a late systolic approach excluded 82.7% of patients, the vast majority because of large mitral annuli.ConclusionsContemporary TMVR can treat only a minority of patients with severe mitral regurgitation, principally because of limitations of large MA dimension.     

Minimally invasive insertion of an equine stented pulmonary valve with a built-in sinus portion in a sheep model

Objectives : This study evaluated the feasibility of inserting a new equine stented‐valve with a sinus portion in a lamb survival model, through a minimally invasive thoracotomy with right ventricular access without cardiopulmonary bypass. Background : Extant surgical or percutaneous methods for inserting biological valves in the right outflow tract have drawbacks and limitations. Methods : A decellularized equine valved jugular vein, sutured to a self‐expanding stent with a sinus portion, was placed through a minimal right thoracotomy using a newly developed flexible hydraulic release device in seven lambs. The approach through the right ventricle into the pulmonary valve position is achieved on a beating heart. Results : The stented valves were correctly positioned in the right outflow tract, were competent up to 6 months as confirmed by angiography and echocardiography, and were well‐tolerated by the animals, with endothelialization of the valve demonstrated at 6 months. Conclusions : The newly developed hydraulic release system allowed for safe and reliable insertion of an equine stented‐valve with a sinus portion, through a right transventricular approach on a beating heart, in a sheep survival model. © 2011 Wiley Periodicals, Inc.     

Mitral valve‐in‐valve replacement supported by a transapically snared guidewire via septostomy

We describe a 72‐year‐old woman, a known case of rheumatic heart disease with a history of mitral and aortic valve replacement 8 years previously, who underwent mitral valve‐in‐valve replacement supported by a transapically snared guidewire through septostomy.     

Fast-track anesthesia in lateral mini-thoracotomy for transapical transcatheter valve implantation

BackgroundPatients who undergo transapical transcatheter aortic/mitral valve implantation are at higher risk of morbidity and mortality than those undergoing transvascular procedures. In addition, these patients have prolonged intensive care and hospital courses. Fast-track anesthesia could reduce perioperative complications and admission stays in such patients.MethodsThis retrospective single-center study, evaluates six high-risk patients undergoing transapical valve implantation between 01/2020 till 01/2021. All patients received a paravertebral block (PVB) as part of a fast-track approach. The airway was secured with a Gastro-double-lumen laryngeal mask which includes one orifice was for ventilation and one for the transesophageal echocardiography probe. Anesthesia was maintained with a volatile anesthetic (Sevoflurane MAC 1%). Immediately post procedure, all patients were awakened and admitted to the intermediate/intensive-care unit.ResultsThree patients were females, mean age =71±6 years, patients’ risk profiles were high (mean Log. EuroSCORE-I 22% & STS-PROM 10%). No incidents of re-intubation, atelectasis/pneumonia, low output syndrome, stroke, dialysis, pacemaker implantation or operative mortality were reported. One patient (16.7%) underwent re-exploration for bleeding and developed a wound infection. Postoperative pain scores showed that no patient required additional analgesics after the initial eight hours post procedure. Mean postoperative intermediate/intensive-care stay was 13.8±3.2 hours and patients were mobilized early and discharged to the normal ward.ConclusionsFast-track anesthesia using paravertebral-blockade for transcatheter transapical valve replacement in high-risk patients is a possible anesthetic approach. An effective PVB, in addition to a double-lumen laryngeal mask, provide an alternative strategy to conventional general anesthesia. These promising results could encourage further consideration of this approach in similar cardiac surgery patients.     

A novel alternative: transapical transcatheter mitral valve-in-valve implantation using J-Valve for failed bioprosthesis

BackgroundFailed mitral bioprosthesis has conventionally been treated with redo surgical mitral valve replacement (SMVR). Transcatheter mitral valve-in-valve implantation (TM-VIVI) is emerging as an alternative to SMVR in high-risk patients. We report our experience with transapical TM-VIVI using the J-Valve system.MethodsFrom May 2020 to January 2021, 21 patients with a failed mitral bioprosthesis underwent transapical TM-VIVI without concomitant procedures at Guangdong Provincial People’s hospital. The mean age was 74.62 years. All patients were heavily symptomatic with severe mitral regurgitation and increased trans-prosthetic gradient. The Society of Thoracic Surgeons predicted risk of mortality (STS PROM) and European System for Cardiac Operative Risk Evaluation II (EuroScore II) scores were used and predicted high mortality (STS PROM, 12.91%±9.94%; EuroScore II, 12.04%±10.5%). All the procedures were performed in a hybrid room.ResultsThe success rate was 100% with no conversion to median sternotomy and no intraprocedural death. The mean ventilation time and intensive care unit (ICU) stay were 25±21.44 minutes and 4.14±7.08 days, respectively. No major postoperative complications were observed, except 1 patient suffered pneumonia and required tracheostomy. All patients recovered well. Postoperative echocardiography revealed excellent hemodynamics with no residual mitral regurgitation in 19 patients and mild regurgitation in 2 patients. In a subgroup analysis, no significant differences among procedural and postoperative outcomes were detected in patients with previous aortic-mitral double valve replacement (DVR) compared to other patients.ConclusionsOur results demonstrate the safety and feasibility of transapical TM-VIVI using the J-Valve system, even in patients following DVR.     

Transapical aortic valve implantation – a rescue procedure for patients with aortic stenosis and “porcelain aorta”

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta (“porcelain aorta”) is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and “porcelain aorta”, in whom the only available life-saving intervention was TAAVI.