Aortic Conduit Research Articles

Factor V Leiden Mutation Is a Risk Factor for Hepatic Artery Thrombosis in Liver Transplantation

BackgroundHepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT) is associated with significant morbidity and mortality. Factor V Leiden (FVL) mutation is the most common genetic defect that predisposes to thrombosis. The reconstruction of hepatic artery with arterial graft is a documented risk factor for HAT. However, the relationship among FVL mutation, arterial graft, and HAT remains to be determined. MethodsWe randomly genotyped 485 patients who underwent OLT from April 2002 to January 2011 and studied the incidence of Hepatic artery thrombosis in the presence of FVL mutation. ResultsOf 485 patients, 21 patients (4.3%) developed HAT (13 male, 8 female); 10 patients (4 male, 6 female) were heterozygous for the FVL mutation. The incidences of HAT in patients without versus with the FVL mutation were 3.8% and 30% (P = .007). Of patients with HAT, 8 hepatic arteries were reconstructed with infrarenal aortic conduits. All 3 patients (100%) with vs 5 (28%) without FVL who received arterial grafts developed HAT (P = .042). ConclusionOur study suggested that the FVL mutation may be a risk factor for HAT in liver transplantation; the risk is augmented in the presence of an arterial graft.

Acceleration of autologous in vivo recellularization of decellularized aortic conduits by fibronectin surface coating

Decellularization is a promising option to diminish immune and inflammatory response against donor grafts. In order to accelerate the autologous in vivo recellularization of aortic conduits for an enhanced biocompatibility, we tested fibronectin surface coating in a standardized rat implantation model. Detergent-decellularized rat aortic conduits (n = 36) were surface-coated with covalently Alexa488-labeled fibronectin (50 μg/ml, 24 h) and implanted into the systemic circulation of Wistar rats for up to 8 weeks (group FN; n = 18). Uncoated implants served as controls (group C; n = 18). Fibronectin-bound fluorescence on both surfaces of the aortic conduits was persistent for at least 8 weeks. Cellular repopulation was examined by histology and immunofluorescence (n = 24). Luminal endothelialization was significantly accelerated in group FN (p = 0.006 after 8 weeks), however, local myofibroblast hyperplasia with significantly increased ratio of intima-to-media thickness occurred (p = 0.0002 after 8 weeks). Originating from the adventitial surface, alpha-smooth muscle actin and desmin positive cell invasion into the media of fibronectin-coated conduits was significantly increased as compared to group C (p < 0.0001). In these medial areas, in situ zymography revealed enhanced matrix metalloproteinase activity. In both groups, inflammatory cell markers (CD3 and CD68) and signs of thrombosis proved negative. With regard to several markers of cell adhesion, inflammation and calcification, quantitative real-time PCR (n = 12) revealed no significant inter-group differences. Fibronectin surface coating of decellularized cardiovascular implants proved feasible and persistent for at least 8 weeks in the systemic circulation. Biofunctional protein coating accelerated the autologous in vivo endothelialization and induced a significantly increased medial recellularization. Therefore, this strategy may contribute to the improvement of current clinically applied bioprostheses.

Further Experience with the “No-React” Bioprosthesis in Patients with Active Infective Endocarditis: 11-Year Single Center Results in 402 Patients

We investigated early, midterm, and long-term results following valve replacement with the "No-React" bioprosthesis in patients with active infective endocarditis (AIE).Patients and Methods Between February 2000 and February 2011, a total of 402 patients (median 61 years, 17 to 91 years) received "No-React" bioprostheses due to single valve AIE in 315 (aortic valve replacement n = 158, aortic conduit n = 30, mitral valve replacement n = 116, tricuspid valve replacement n = 11) and double valve AIE in 87 cases. Prosthetic AIE was found in 105 patients (26.1%). Mean follow-up was 2.8 ± 3.2 years (1 month to 11.4 years) with 1,124 patient years, completed in 97.1%. This retrospective study analyzes both prospectively updated data (n = 255) and patients recently operated upon (n = 147). There was a highly significant difference in the survival between patients operated on urgently and patients operated on in an emergency (30-day, 1-, 5-, and 10-year survival were 80.9 ± 2.3%, 63.8 ± 2.9%, 48.3 ± 3.3%, and 39.7 ± 4.1% vs. 61.3 ± 4.5%, 45.0 ± 4.7%, 33.1 ± 4.6%, and 14.0 ± 5.1%, respectively, p < 0.001), due to native versus prosthetic AIE (p = 0.032), single versus double valve replacement (p = 0.005), and with or without abscess formation (p < 0.001). Thirty-day, 1-, 5-, and 10-year freedom from reoperation due to recurrent endocarditis were 100%, 95.1 ± 1.4%, 86.4 ± 2.6%, and 82.1 ± 3.6% and due to structural valve deterioration (SVD) were 100%, 100%, 98.9 ± 0.8%, and 91.4 ± 4.0%, respectively. There was no difference in prosthesis durability between the older (> 60 years) and the younger patients. Our experience in the use of "No-React" bioprostheses in patients with native and prosthetic AIE shows satisfactory early, midterm, and long-term results, in particular low rates of reoperation due to recurrent endocarditis and SVD. Because these prostheses are readily available and their implantation straightforward, we strongly recommend their use in patients with AIE. Patients' survival differed significantly depending on their surgical urgency. Early mortality was independently predicted by septic shock, abscess formation, and number of implanted valves besides age per 10 years.

Granulocyte Colony-Stimulating Factor Minimizes Negative Remodeling of Decellularized Small Diameter Vascular Graft Conduits but Not Medial Degeneration

Poor endothelialization and intimal hyperplasia are major causes of small diameter vascular conduit (SDVC) failure. The present study was aimed to investigate the influence of granulocyte colony-stimulating factor (G-CSF) on inhibiting adverse remodeling of decellularized SDVCs. Sprague-Dawley rats implanted with allograft infra renal abdominal aortic conduits were divided into 2 groups according to whether they were treated with G-CSF (+G-CSF group; n=6) or without (Decell group; n=6). The conduits were harvested at 8 weeks after surgery and examined for intimal hyperplasia, collagen deposition, and -actin-staining cells. The medial layer was also examined for signs of cellular repopulation and changes in the elastic fiber morphology. Intergroup comparison of the intimal composition showed relatively sparse collagen content and predominance of -actin-staining cells in the +G-CSF group. The medial layer in the 2 groups showed similar degrees of elastic fiber degeneration and wall thinning relative to the normal aortic wall. However, the enhanced staining for von Willebrand factor and CD31, along with transmission electron microscopy findings of superior cellular and ultrastructural preservation, suggested that the remodeling and endothelialization in the +G-CSF conduits were superior to those in the Decell conduits. This study suggests that G-CSF exerts a positive influence on inhibiting adverse vascular remodeling of decellularized vascular conduit implants. However, whether G-CSF administration may also effectuate an improved ability to preserve the medial structural integrity is unclear.

Hybrid Repair of a Thoraco-abdominal Aortic Aneurysm through an Anterograde Approach after Transposition of Supra-aortic and Visceral Arteries

Introduction: Retrograde access through femoral artery is usual for endovascular repair of the aorta. Some patients are not suitable to receive endovascular treatment because of poor anatomic access. Report: We report the hybrid treatment of a type 1 thoraco-abdominal aortic aneurysm, through an anterograde access by a temporary ascending aortic conduit after the transposition of supra-aortic and visceral arteries. Discussion: This approach was described in two precedent cases that reported good results. It seems to be an interesting alternative in the case of retrograde access failure. Hybrid Repair of a Thoraco-abdominal Aortic Aneurysm through an Anterograde Approach after Transposition of Supra-aortic and Visceral ArteriesEJVES ExtraVol. 25Issue 5PreviewRetrograde access through femoral artery is usual for endovascular repair of the aorta. Some patients are not suitable to receive endovascular treatment because of poor anatomic access. Full-Text PDF Open Access

Hybrid Repair of a Thoraco-abdominal Aortic Aneurysm through an Anterograde Approach after Transposition of Supra-aortic and Visceral Arteries

Introduction Retrograde access through femoral artery is usual for endovascular repair of the aorta. Some patients are not suitable to receive endovascular treatment because of poor anatomic access. Report We report the hybrid treatment of a type 1 thoraco-abdominal aortic aneurysm, through an anterograde access by a temporary ascending aortic conduit after the transposition of supra-aortic and visceral arteries. Discussion This approach was described in two precedent cases that reported good results. It seems to be an interesting alternative in the case of retrograde access failure.

Incidental diagnosis of unicuspid aortic valve in an asymptomatic adult

A 38 year-old male with no cardiovascular history was referred for computed tomography (CT) of chest aorta due to prominence of the right cardiac contour in prophylactic chest X-ray examination required by his employer. Initially, transoesophageal echocardiography (TEE) was performed and revealed abnormal aortic valve morphology with a posteriorly positioned commissural attachment and ascending aorta aneurysm coupled by a moderate aortic regurgitation without valve orifice stenosis (Fig. 1A, B). With the suspicion of unicuspid aortic valve (UAV) and the diagnosis of ascending aorta aneurysm, he was referred for further cardiovascular evaluation. Physical examination revealed a regular heart rate with a mild diastolic murmur at the right upper sternal border, blood pressure of 125/83 mm Hg and heart rate 68 bpm. Scheduled 64-slice multi-detector CT (MDCT) confirmed dilatation of ascending aorta up to 53 mm and UAV with only one distinctive commissure (Fig. 1C). The Bentall de Bono procedure was performed and a size 29 ATS aortic valved conduit was implanted (ATS Medical, Minneapolis, MN, USA). During surgery, the valve was found to be unicommissural and unicuspid without significant calcification and thickening (Fig. 1D). There were no postoperative complications and the patient made a full recovery. UAV is mainly discovered during surgery or autopsy and can be easily mistaken for a more common bicuspid aortic valve. Morphologic similarities between unicuspid and bicuspid valves in TEE can often provide diagnostic difficulties. The incidental finding in TEE or MDCT substantially affects further management, including Bentall procedure, ascending aorta surgery and aortic valve replacement, with the need for endocarditis prophylaxis.

Aortic aneurysm in a Marfan’s syndrome patient

Presents a case of diagnosis and successful surgical treatment of youth of 15 years with Marfan syndrome. The patient was diagnosed with aortic sinus of Valsalva and the ascending aorta, atrioventricular valve prolapse, as well as severe funnel chest. After a thorough diagnosis was made simultaneous surgery including a prosthetic aortic valve-containing conduit, suture annuloplastics atrioventricular valves, and surgical correction of the funnel chest.

Aortic Conduit Valve Model With Controlled Moderate Aortic Regurgitation in Rats

The objective of this study was to describe a small animal aortic conduit model that could analyze long-term conduit valve (CV) function by echocardiography. Recipient Wistar rats (200-250g, n=20) underwent aortic leaflet injury of their native aortic valve under echocardiographic control. After 2 weeks, U-shaped decellularized CVs obtained from other rats were implanted onto the abdominal aorta. Implanted CVs were analyzed via pulsed-wave echocardiography at day 0, 4 and 12 weeks. CV stenosis was assessed as systolic flow velocity (post-pre CV)/flow velocity in the ascending aorta. CV regurgitation was assessed as the ratio of the amount of reversed diastolic flow to forward systolic flow in post-pre CV. The endpoint was set at 12 weeks. Three rats died immediately after aortic valve injury and all surviving rats received CV implantation (n=17, 85%). The survival rate after conduit implantation was 100% at 4 weeks and 88% (15/17) at 12 weeks. Regarding the CV function at 0, 4 and 12 weeks, the average observed value of CV stenosis was 3.8±7.9%, 3.1±4.1% and 14±10% (P<0.01), respectively. The average value of CV regurgitation was 0%, 12±27% and 52±43%, respectively (P<0.001). By using this model, the degeneration of implanted CV could be assessed not only qualitatively, but also quantitatively.

Extra anatomic hepatic artery reconstruction in deceased donor liver transplantation – Feasibility and outcome

BackgroundHepatic arterial inflow to the liver graft following liver transplantation is critical to graft survival. When recipient hepatic artery is not available due to injury or recipient hepatic artery flow is inadequate extra anatomic hepatic arterial reconstruction during deceased donor liver transplantation is required to ensure adequate hepatic arterial blood flow to the graft. The outcome in such patients is analyzed and compared with patient with standard hepatic artery reconstruction. MethodsRetrospective analysis of 30 patients who underwent Deceased Donor Liver Transplantation (DDLT) from March 2007 to May 2010 was done to assess the outcome of extra anatomic arterial inflow reconstruction. DDLT with standard end to end Hepatic Artery anastomosis performed in 24 patients (n = 24) served as control. Extra anatomic hepatic arterial reconstruction (EAHAR) was performed in 6 patients. The preferred choice of EAHAR was to fashion an infrarenal aortic conduit using stored donor iliac artery graft routed through the base of the transverse mesocolon. ResultsExtra anatomic hepatic arterial reconstruction is not associated with increased morbidity, mortality, blood loss, operating room time or thrombosis. ConclusionExtra anatomic hepatic arterial reconstructions are associated with excellent long-term outcomes and provide acceptable alternatives for arterial reconstruction.

Apicoaortic Valved Conduit Bypass for Progressing Aortic Graft Stenosis Due to Malformation of Repeated Thoracic Endovascular Aortic Repairs

Since the first report by Cooley and colleagues in 1975 [Cooley DA, Norman JC, Mullins CE, Grace R. Left ventricle to abdominal aorta conduit for relief of aortic stenosis. Cardiovasc Dis 1975;2:376-83], an apicoaortic valved conduit bypass has been usually administrated to selected patients presenting with certain clinical conditions or complications such as aortic stenosis associated with porcelain aorta, unclampable atherosclerotic aorta, resternotomy, or previous coronary bypass surgery. On the other hand, thoracic endovascular aortic repair for various aortic lesions has become a promising and less invasive therapy. We encountered a critical case of a patient suffering from aortic graft stenosis due to malformation of a previous thoracic endovascular aortic repair procedure originally performed for acute type A aortic dissection. Because of a deep sternal wound infection, apicoaortic valved conduit bypass from the left ventricular apex to the abdominal aorta was successfully performed.

Use of the Recipient Celiac Trunk for Hepatic Artery Reconstruction in Orthotopic Liver Transplant

Introduction: Arterial complications contribute to significant morbidity and mortality after liver transplant. If hepatic artery inflow to the graft is inadequate, alternative approaches can be considered, such as supraceliac or infrarenal aortic conduits and splenic artery for arterial inflow. Up to our knowledge we report the first series of cases using the recipient celiac trunk to provide arterial inflow to the donor liver allograft in orthotopic liver transplant (OLT). Methods: Between January-2005 and January-2012, we performed 928 OLTs, 850 cases are first transplant and 78 cases are retransplants, 143 cases are pediatric recipients and 785 cases are adult recipients. We used the recipient celiac trunk for arterial inflow in nine patients. Eight cases are first transplant and one case is a second transplant. Five cases are pediatric recipients and four cases are adult recipients. Male to female ratio is 3/6. Average follow up is 23 months. Retrospectively, we evaluated the indications, results and outcome of this technique. Doppler ultrasound of the liver (DUSL) was used to evaluate the arterial flow. Results: Indication are size mismatch between the donor and recipient common hepatic arteries (n= 5), and poor arterial inflow in the common hepatic artery (n=4). We used this technique in 1% of OLTs. We found that this technique was used more common in pediatric recipients with a p-value of 0.008 (3.4% of pediatric recipients and 0.5% of adult recipients). No hepatic artery thrombosis or arterial strictures were encountered. None of the patients developed ischemia of the stomach or duodenum, and none of them developed pancreatic or biliary complications related to poor arterial inflow. One patient had splenomegaly and splenic infarcts prior to transplant and this was not aggravated after the transplant. Another patient underwent spleenectomy at the time of the transplant due to associated autoimmune hemolytic anemia. DUSL on post-operative day 1 showed peak systolic flow ranging between (36-303 cm/sec) and resistive index ranging between (0.52-0.86). Arterial patency is 100 %. One, 3 & 5 year-patient and graft survival is 83%. One patient died 3 months after the transplant due to recurrent hepatoblastoma with a functioning graft and patent hepatic artery; all other patients are alive with a functioning graft and patent hepatic artery. Conclusion: The celiac trunk provides adequate arterial inflow in orthotopic liver transplant when the recipient's hepatic artery is not suitable to use, especially in pediatric patients. No complications were encountered as a result of sacrificing the branches of the celiac axis. We suggest that this technique might be considered as a viable option when an inadequate recipient hepatic artery is encountered.

Combined Heart Transplantation and Total Replacement of Thoracic Aorta in Marfan's Syndrome With Recurrent Aortic Dissection: A Case Report

It is extremely rare for a patient to need simultaneous heart transplantation (HTx) and replacement of the thoracic aorta. A 23-year-old woman with Marfan's syndrome underwent Bentall's operation and replacement of the ascending aorta (AsA) due to a type A aortic dissection (AD) in August 2001. In March 2005, she began to experience dyspnea on exertion and was found to have a huge pseudoaneurysm at the aortic root, which had caused dehiscence of the aortic conduit. In July 2009, she suffered acute chest pain followed by hypotension and cold sweating. The computed tomography (CT) scan showed a recurrent dissection with a long intimal tear extending from the arch to the mid-portion of the descending thoracic aorta (DTA). Due to technical difficulties in the repair of the aortic root, she was placed on the HTx waiting list. The next day, she received a donor heart and underwent combined HTx and total replacement of the thoracic aorta. Explantation of the heart improved the exposure of the DTA. With the use of a vascular ring connector (Vasoring), the operation was successfully performed without need for a blood transfusion. The patient was still well at 2 years after the operation. Simultaneous replacement of the heart and the whole segment of the thoracic aorta is technically possible in Marfan patients who are complicated with aortic dissection.

Editorial Comment: Reconstruction of the right ventricular outflow tract: short-term solutions, long-term problems

There is no reliable, durable valve conduit for reconstruction of the right ventricular outflow tract in conditions such as Fallot’s tetralogy, pulmonary atresia, truncus arteriosus and for pulmonary valve replacement after the Ross procedure for aortic valve replacement. All the reconstructions available provide short-term unobstructed flow with no pulmonary incompetence but in the mediumto long-term there is the development of either right ventricular outflow tract obstruction and/or severe pulmonary incompetence. Currently, the answer to these problems is reoperation with pulmonary valve replacement, usually at an open operation or in some cases with a transcatheter-mounted valve placed in the right ventricular outflow tract. Historically pulmonary or aortic homografts have been the mainstay of valve replacement in the right ventricular outflow tract, either as valves or as conduits. Various animal-derived valves, usually glutaraldehyde-preserved valves from cows or pigs, have also been utilized. All of these conduits are dead tissue and are subject to degeneration. There is a variable availability of homografts, in particular, which are usually available in North America and Europe but may not be available in countries like Japan. Ethnic and social considerations also govern the availability of donated tissues. There are also certainly cost implications when homograft tissues in North America may cost in excess of 4000 dollars. In addition to cryopreserved or off-the-shelf products, individual centres have also developed their own techniques for reconstructing conduits and valves in the right ventricular outflow tract, reflecting the availability and cost of complete valve conduits in a particular country. The common conditions whereby a reconstruction is necessary are Fallot’s tetralogy and pulmonary atresia, and in these conditions the alternatives are a non-valved patch in the outflow tract, a monocusp, bicuspid or valved conduit reconstruction. Our own experience in Birmingham, with conduit reconstruction, utilizing new conduits, direct anastomosis without conduits or the use of small animal valve conduits has not been entirely satisfactory [1, 2]. Early competency of the outflow tract and recovery following surgical repair has been satisfactory, but shortterm follow-up has been very disappointing with early failure. We have not had experience of handmade bicuspid or monocuspid valves in the right ventricular outflow tract and have usually used, when necessary, a monocusp from either an aortic or pulmonary valve conduit. Again the short-term results of these have been satisfactory, we have yet to follow up in detail patients in the longer term. Other centres have been more adventurous in their development of tailor made pathways from the right ventricular to the pulmonary artery, and in this journal Oda et al. [3] report a tailor-made PTFE monocusp construction to replace the pulmonary valve in the Ross procedure. The posterior wall of the reconstruction is native pericardium with a 0.1-mm PTFE tailormade monocusp anteriorly roofed over by a 0.6-mm PTFE patch. They report 38 patients divided into two groups, the group with the PTFE patch and a PTFE monocusp had a freedom from pulmonary incompetence of 74.3% at 5 years and demonstrated satisfactory monocusp function in 79.2%. The group with the PTFE patch placed anteriorly instead of the pericardial patch faired better, probably due to a more rigid base for the PTFE monocusp. The monocusp reconstruction of the right ventricular outflow tract is quite a favoured method of tailor-made valve. There are a range of tissues that can be used, from aortic valve and pulmonary valve monocusps through to native pericardial monocusps, bovine pericardial monocusps and Gore-Tex monocusps. Other surgeons have also designed variations on the PTFE monocusp, varying from centre to centre in their techniques. Iemura et al. [4] describe 19 patients having a PTFE monocusp placed for reconstruction of the right ventricular outflow tract. In eight patients at 3-year follow up, two had distal stenoses, two had moderate pulmonary incompetence, however, five patients still had good cusp mobility. Vricella et al. [5] describe their experience with different types of PTFE in lamb models and showed that, at the time of lamb death, 50% had mobile leaflets but two-thirds had moderate or severe pulmonary incompetence. They felt, in this experiment, that the closed PTFE microstructure was better, with less inflammatory response. A 12-year experience with the PTFE monocusp outflow tract reconstruction was described by Brown et al. [6] and, before that, they had described the method of construction and early results, by Turrentine et al. [7, 8]. In the 12-year follow-up, there were 192 patients operated on up to 2006, freedom from pulmonary incompetence of greater than moderate was 86% at 1 year 68% at

Replacement of a Stented Biologic Prosthesis Within an Aortic Valved Conduit

A 68-year-old man was referred for severe aortic regurgitation 10 years after aortic root replacement with a valved conduit containing a stented bioprosthesis that had been sutured inside of the vascular tube graft, rather than at its extremity. Because of this simple modification of the Bentall concept, replacing the prosthetic valve within the aortic conduit was easy and uneventful.

Four-Dimensional Magnetic Resonance Flow Analysis Clarifies Paradoxical Symptoms in a Patient With Aortic Bypass and Retrograde Flow Mimicking Subclavian Steal

We present the case of a 39-year-old physically active male amateur hockey player with a history of preductal coarctation of the aorta repaired at the age of 10 years with an ascending-to-descending aortic conduit. He presented with neurological symptoms, which were present at rest but paradoxically resolved with physical exertion, including left upper extremity weakness, dizziness, visual changes, and facial tingling. A 2008 echocardiogram demonstrated a bicuspid aortic valve with moderate regurgitation and a mildly to moderately dilated and hypertrophied left ventricle with ejection fraction of 50%. A 2009 carotid Doppler ultrasound examination demonstrated high-velocity retrograde flow in the left vertebral artery, which reduced on exertion. Stenosis of the subclavian artery, and thus subclavian steal, which has been shown to cause neurological symptoms, was ruled out by a 2010 arteriogram.1 A recent magnetic resonance imaging (MRI) evaluation (in 2011) demonstrated worsening (moderate to severe) aortic insufficiency with a clearly visible asymmetrical diastolic flow jet (Figure 1, white arrows), mild decrease of left ventricular ejection fraction, and a patent aortic bypass conduit. Figure 1. Cardiac magnetic resonance angiography demonstrating aortic valve insufficiency and a clearly visible asymmetrical flow jet (white arrows, regions with signal void in the left ventricle). The individual images represent …

Development of a growing rat model for broad in vivo assessment of bioengineered aortic conduits

Objectives: Alternative heart valve prostheses are warranted to overcome numerous limitations of implants currently used in pediatric patients. In order to determine the fate of decellularized aortic conduit transplants beyond histological measures, including detailed functional evaluation, we created a growing rodent model as described below.

Total circumferential separation of a valved aortic conduit from the left ventricular outflow tract

A 48-year old man who underwent prior aortic root replacement was referred for prosthetic valve endocarditis. Echocardiography showed circumferential detachment of the valved aortic conduit from the left ventricular outflow tract (Fig. 1 and Supplementary material, Movie 1). Intraoperatively, complete uncoupling of the mechanical valve from its anchorage was clearly visualized (Fig. 2 and Supplementary material, Movie 2).

Short-Term Performance of the Transcatheter Melody Valve in High-Pressure Hemodynamic Environments in the Pulmonary and Systemic Circulations

The Melody valve is approved for percutaneous pulmonary valve replacement in dysfunctional right ventricular outflow tracts. The function of this valve when subjected to high-pressure loads in humans is unknown. The aim of this study was to describe the immediate and short-term results of Melody valves implanted in a high-pressure environment. Definitions of a high-pressure system were established for Melody valves implanted in the systemic (ie, aortic or mitral position) and pulmonary (ie, right ventricular outflow tract conduit or tricuspid valve annulus) circulations. Implants in these environments were ascertained from databases of the 5 centers that participated in the US Investigational Device Exemption trial. Thirty implants met the inclusion criteria: 23 pulmonary circulation implants (all in the pulmonary position) systemic circulation implants (5 in the native aortic position, 1 in a left ventricle-to-descending aorta conduit, and 1 in the mitral annulus). All pulmonary circulation implants were performed percutaneously in the catheterization laboratory. A hybrid approach (surgical exposure for transcatheter implant) was used for 4 of the aortic implants. There were no procedure-related deaths. Three patients died of nonprocedure- and nonvalve-related causes. At 1 year, freedom from moderate to severe regurgitation was 100%, and freedom from mild regurgitation was 90%. Freedom from moderate to severe stenosis was 86% at 1 year. Short-term performance of the Melody valve in high-pressure environments is encouraging, with good valve function in all patients.

Multi-modality imaging of apical aortic conduit

An 82-year-old lady with prior coronary artery bypass grafting presented with syncope. Echocardiography revealed severe aortic stenosis (peak gradient 165 mmHg, mean gradient 77 mmHg). The patient was at high risk for surgical aortic valve replacement in view of her ‘porcelain’ calcified aorta identified by CT ( Panel A ). Trans-catheter aortic valve implantation techniques were discounted …