Aortic Prosthesis Dysfunction Research Articles

Redo aortic root surgery post-Ross procedure.

Despite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques. Between 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated. Overall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group. Redo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

Challenging cases of aortic prosthesis dysfunction, the importance of multimodality imaging. A case series.

Challenging cases of aortic prosthesis dysfunction, the importance of multimodality imaging. A case series.

P1266 Infectious endocarditis- still a diagnostic dilemma

Abstract INTRODUCTION Infectious endocarditis is still a challenge with a high mortality and complication rate despite the progress made in its management. DESCRIPTION OF CLINICAL CASE A 58 years old female, with a history of mitral and aortic mechanical prosthesis for rheumatic valvular disease and mitral infectious endocarditis with Aggregatibacter Actinomycetemcomita due to an apical abscess was referred to our service for persistent fever. The clinical examination revealed irregular mechanical prosthesis beats, with no heart murmurs and no signs of heart failure, but with a tender splenomegaly. The laboratory tests showed an inflammatory syndrome, but no positive blood cultures. An extensive panel for endocarditis was negative for Coxiella burnetii, Brucella Spp, Legionella Spp, Mycoplasma Spp and for the immunology markers (rheumatoid factor, antinuclear antibodies and anti-cardiolipin antibodies) ECG AF, 88 bpm, PVC bigeminy, LBBB. Infectious endocarditis was the most likely diagnosis considering the fever, the inflammatory syndrome, the presence of the mechanical valves and the history of endocarditis. An echocardiography was performed that showed a non-dilated left ventricle with a preserved EF, no aortic prosthesis dysfunction, nor mitral; a dilated RV with normal function, moderate tricuspid regurgitation, no intracardiac masses and no pericardial effusion. The TEE revealed no vegetation, no abscess or pseudoaneurysms and no dehiscence of the prosthetic valves. The Endocarditis Team was reunited and empirical antimicrobial therapies with Amoxiciline, Gentamicine and Cloxaciline for 6 weeks, as well as a PET scan were recommended. The PET-CT revealed abnormal fixation in the posterior-inferior part of the aortic valve. As we had only one major criterion and two minor criteria for the diagnosis of endocarditis a radiolabeled leukocytes SPECT CT that showed no pathological fixation was realised. The result was inconclusive as it was performed at the end of the antimicrobial treatment. A computed tomography of the brain, thorax, abdomen and pelvis didn’t reveal any vascular phenomena. The tender splenomegaly was secondary to two hemangiomas. Also a dental computed tomography revealed an apical abscess of 1.2 that was treated after discharge with antibiotic prophylaxis. DISCUSSION This clinical case confirms that the diagnosis on infectious endocarditis can be challenging in patients with prosthetic valves. The multimodality imaging is of major importance for the diagnosis of these patients. Additionally the microbiological criteria was not met in this case as it was a blood culture-negative endocarditis with a history of previous antibiotic therapy. CONCLUSION Our knowledge of infectious endocarditis is constantly evolving. Blood culture negative endocarditis accounts for one third of cases and is still a challenge. The Endocarditis Team and multimodality imaging play a central role in the diagnosis and treatment of these patients. Abstract P1266 Figure. PET-CT showing AV abnormal fixation

P5984Clinical results and predictors of long-term mortality after Transcatheter Aortic Valve Replacement in according to gender

Abstract Although it is well known, the differences between both sexes in cardiovascular disease, however, there is a lack of data in aortic valve, treated with Transcatheter Aortic Valve Replacement (TAVR). The purpose of our study was to analyze the long-term clinical results of patients treated with TAVR in the female and male population. Material Between April 2008 and December 2017, 647 patients with aortic stenosis and 20 patients with aortic prosthesis dysfunction, were treated with TAVR consecutively in our center. The primary objective was to analyze, by Cox regression, the predictors of long-term mortality in both sexes. Results 59.1% were women. Males had a higher number of comorbidities and after a mean follow-up of 2.87±2.2 years (range between 0 and 9 years), mortality was higher for male patients 40.7% vs. 32% (HR = 1.447 [95% CI 1.057–2.009], p=0.022) and there were no differences for the presence of threatening bleeding (HR = 1.654 [IC95% 0.719–3.808], p=0.237), myocardial infarction (HR = 1,768 [IC95% 0.753–4.132], p=0.191), stroke (HR = 0.992 [IC95% 0.564–1.743], p=0.976) and hospitalizations for heart failure (HR = 1.388 [IC95% 0.811–2.376], p=0.231). Among the predictors of long-term mortality, common to both sexes were: threatening bleeding, heart failure, Charlson index, Karnofsky, and STS score. Conclusion In our series, there was clinical differences between both sexes, which has an impact on survival, being worse for men due to comorbidities, however, in the population of patients with aortic stenosis treated with TAVI, we found predictors of late mortality similarities between in female and male.

Large left main coronary artery aneurysm following mitral and aortic valve replacement

Left main coronary artery aneurysm is an extremely uncommon coronary pathology that can present with angina, myocardial infarction, pericardial tamponade, or sudden death, and whose treatment still remains controversial. Here, we present a 64-year-old woman admitted due to angina with a previous mitral and aortic valve replacement. Transthoracic echocardiogram revealed an aortic prosthesis dysfunction and preoperative angiogram showed a large left main coronary artery aneurysm. Surgical aneurysm exclusion with concomitant coronary artery bypass grafting and aortic prosthesis replacement were performed after defining the aneurysm’s anatomical details and relationship using contrast-enhanced computed tomography.

A challenging case of transcatheter aortic prosthesis dysfunction: Endocarditis or thrombosis?

A challenging case of transcatheter aortic prosthesis dysfunction: Endocarditis or thrombosis?

Artificial aortic valve dysfunction due to pannus and thrombus - different methods of cardiac surgical management.

IntroductionApproximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case.Case study 1The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs’ surface was found. A biological aortic prosthesis was reimplanted without complications.Case study 2The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored.ConclusionsPrecise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Unsuspected Aortic Dissection in Patient with Diagnosis of Prosthesis Aortic Valve Dysfunction

or thrombus was seen on the prosthesis but an intimal flap on the aortic wall was found. So the diagnosis of chronic Stanford type A aortic dissection was done. The Aortic dissection involved only the ascending aorta and the proximal part of the aortic arch. We found two tears in this part of the ascending aorta and the descending was free of dissection. In the light of that we suppose Abstract On March 2012 a 74-year-old woman was admitted to our hospital for acute pulmonary oedema. In 1994 she had undergone aortic valve replacement with a Bicarbon 23A and mitral valve repair (commissurotomy) for mitral valve stenosis Auscultation revealed normal prosthetic valve opening and closing clicks and a grade 2/6 ejection systolic murmur. TTE showed an intermittent aortic prosthesis dysfunction with mean (24 mm Hg) and peak (100 mm Hg) aortic gradients. They were higher than previous values recorded one month before. While the diagnosis of an intermittent aortic prosthesis valve dysfunction was done, the patient was admitted to the operating theatre where she had an aortic and mitral valve replacement. An aortotomy was done and an intimal flap on the aortic wall was found. After the operation the patient had an uncomplicated recovery and she was discharged on her 7th postoperative day. Ten months later, on follow up, she was in good condition with no valve dysfunction.

Dysfunction of Bileaflet Aortic Prosthesis: Accuracy of Echocardiography Versus Fluoroscopy

The authors sought to investigate the accuracy of transthoracic echocardiography (TTE)-derived parameters in the identification of bileaflet aortic prosthesis dysfunction, compared with fluoroscopy (FL). Identification of bileaflet aortic prosthesis dysfunction is challenging, because high mean pressure gradient (MPG >20 mm Hg) is not proof of prosthetic obstruction (AVPO), and may be due to prosthesis-patient mismatch (PPM). Conversely, high gradients may not be manifest in AVPO and low cardiac output. TTE and FL were prospectively performed in 100 nonconsecutive patients with bileaflet aortic prosthesis. TTE included the estimation of MPG, indexed effective orifice area (EOAi), Doppler velocity index (DVI), intraprosthetic regurgitation, acceleration time (AT), ejection time (ET), AT/ET, and the difference (dA) between the expected prosthetic orifice area and EOA. FL allowed the calculation of opening and closing angles, and the discrimination of AVPO from normal (NL) and PPM. On the basis of FL examination and MPG and EOAi at TTE, patients were classified as NL (42%), PPM (32%), and AVPO (26%). High MPG (>20 mm Hg) was present in 65% of the patients, with higher values in PPM (36 ± 8 mm Hg) and AVPO (43 ± 16 mm Hg) than in NL (16 ± 6 mm Hg). DVI was reduced in PPM (0.30 ± 0.05) and AVPO (0.25 ± 0.04) compared with NL (0.42 ± 0.09). In AVPO, dA (0.59 ± 0.32 cm(2)), AT (108 ± 20 ms), and AT/ET (0.35 ± 0.05) significantly differed from NL (dA = -0.12 ± 0.43 cm(2), AT = 74 ± 15 ms, AT/ET = 0.25 ± 0.05) and PPM (dA = 0.15 ± 0.24 cm(2), AT = 78 ± 13 ms, AT/ET = 0.26 ± 0.04). Moderate or severe intraprosthetic regurgitation was observed only in AVPO. All considered TTE-derived parameters were found related to obstruction, and dA (accuracy = 87%), AT (94%), and AT/ET (89%) showed the highest accuracy in discriminating normofunctioning prostheses from AVPO. In the presence of high MPG, TTE parameters play a key role in aortic prosthesis examination. Especially time indices and dA add to the functional assessment of prosthetic aortic valves. However, the TTE discrimination between AVPO and PPM may be suboptimal, and fluoroscopy is a complementary and essential diagnostic step.

Intermittent, Non Cyclic Severe Mechanical Aortic Valve Regurgitation

Mechanical aortic prosthesis dysfunction can result from thrombosis or pannus formation. We describe an unusual case of intermittent, non cyclic mechanical aortic prosthesis dysfunction due to pannus formation with thrombus in the absence of systolic restriction of disk excursion, that presented with intermittent severe aortic regurgitation.

Near-Complete Obstruction of an Aortic Homograft

Aortic valve replacement in the setting of aortic valve endocarditis frequently is managed with an aortic homograft. However, late operation is not uncommon and may be very difficult because of calcification of the wall of the aortic homograft and the valve leaflets.1–3 We report a patient with a heretofore unreported complication with near-complete obstruction of his aortic homograft. A 38-year-old man was referred to the Bluhm Cardiovascular Institute at Northwestern University for surgical management of suspected aortic prosthesis dysfunction. He had undergone aortic valve replacements at 16 and 24 years of age, and at 25 years of age, he developed prosthetic valve endocarditis, which was treated with cryopreserved homograft aortic valve and root replacement. He required partial sternectomy for sternal osteomyelitis weeks later and an implantable cardioverter-defibrillator for perioperative ventricular arrhythmias. He recovered fully. In 2009, the patient developed weekly episodes of numbness, paresthesia, and weakness lasting from 15 minutes to several hours. In the fall of 2010, progressive fatigue and dyspnea on exertion progressed to near syncope. Echocardiographic (Figure 1) and computed tomography (Figure 2) scans suggested obstruction of the aortic homograft. At Northwestern, echocardiographic imaging from the apical transducer position demonstrated no aortic stenosis or regurgitation with a mean gradient of 6 mm Hg across the valve (Figure 1A). …

EComment: Early stentless aortic prosthesis dysfunction due to interlayer hematoma formation

eComment: Early stentless aortic prosthesis dysfunction due to interlayer hematoma formation

Intermittent, Noncyclic Dysfunction of a Mechanical Aortic Prosthesis by Pannus Formation

Mechanical aortic prosthesis dysfunction can result from thrombosis or pannus formation. Pannus formation usually restricts systolic excursion of the occluding disk, resulting in progressive stenosis of the aortic prosthesis. Intermittent dysfunction of a mechanical aortic prosthesis is usually ascribed to thrombus formation. We describe an unusual case of intermittent, noncyclic dysfunction of a mechanical aortic prosthesis due to pannus formation in the absence of systolic restriction of disk excursion that presented with intermittent massive aortic regurgitation, severe ischemia, and shock. Pannus formation should be considered as a potential cause of acute intermittent severe aortic regurgitation in a patient with a mechanical aortic prosthesis.