Aortic Valve Commissure Research Articles

Commissuralalignment and the ACURATE neo2 transcatheter aortic valve: Impact on valve performance.

Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat severe aortic stenosis in younger patients. Accordingly, lifetime management regarding future reintervention and coronary access is a concern. To assess the impact of commissural alignment on ACURATE neo2 transcatheter aortic valve (TAV) performance. COMALIGN-neo2 was an observational, retrospective study enrolling consecutive TAVR patients treated with the ACURATE neo2 (October 2021 to October 2022). The degree of commissural (mis)-alignment (CMA) with the native aortic valve commissures was determined and transvalvular gradient, effective orifice area, patient-prosthesis mismatch (PPM), and aortic regurgitation (AR) were assessed. Among 825 patients, the mean age was 80.7 years and 42% were female. Commissural alignment was achieved in 60% of cases; mild (26%), moderate (9%), and severe misalignment (5%) were found less often. Severe PPM occurred more frequently in patients with severe CMA (14.7%) compared to aligned valves (p = 0.034). By multivariate analysis, severe CMA (odds ratio [OR]: 3.12, 95% confidence interval [CI][1.09-8.90]; p = 0.033) and lack of postdilatation (OR: 3.85, [1.33-11.1]; p = 0.012) were associated with severe PPM. Higher rates of ≥mild AR (51.4%) were found in TAVs implanted with severe CMA compared to aligned (34.3%), mildly (38.1%) or moderately (36.0%) misaligned TAVs (p = 0.030). Multivariate analysis identified severe CMA (OR: 2.05, [1.05-4.02]; p = 0.037) to be an independent predictor of ≥mild AR. COMALIGN-neo2 is the largest study to date assessing the impact of commissural alignment on acute TAV performance. Severe CMA with the ACURATE neo2 platform was associated with worse valve hemodynamics and increased risk for mild AR.

Abstract 17322: Closing the Loop: Use of Amplatzer PFO Occluder Device in Case of LVAD-Associated Aortic Insufficiency

Description of Case: A 72-year-old woman with destination therapy Heartmate 3 left ventricular assist device (LVAD) presented with NYHA Class III symptoms. Review of her echocardiograms since LVAD implantation revealed progressive central aortic insufficiency (AI) with subsequent LV dilatation, managed with reduction in LVAD speed. Patient declined surgical aortic valve replacement and/or repair. After a multidisciplinary discussion, the patient opted to pursue percutaneous aortic valve closure. Cardiac CT demonstrated no aortic valve thrombus and identified appropriate anatomy for closure with an 18x25 mm Amplatzer PFO Occluder device (Graphic 1). Preoperative TEE revealed LV ejection fraction of 15% with moderate to severe AI and fibrosis of the aortic valve commissures with no aortic valve movement. The aortic valve was closed with the Amplatzer PFO Occluder with an 18mm disk that sat on the LV side of the aortic valve within the AV annulus and the 25mm disk sitting on the aortic side of the aortic valve within the sinus of Valsalva. TEE and intracardiac echocardiography demonstrated excellent device placement with two residual trace AI jets at the non-left and left-right commissure. Following LVAD speed increase, the degree of AI remained unchanged and she was discharged with improved symptoms. Discussion: Moderate-severe AI develops in about 15-25% of patients within 1 year of LVAD implantation. There are previous reports of LVAD-associated AI closure with an Amplatzer cribiform device. We describe the first known use of the Amplatzer PFO Occluder device for the management of LVAD-associated AI. While transcatheter aortic valve replacement (TAVR) is an attractive option to treat LVAD-associated AI, securing the transcatheter heart valve in the absence of calcifications remains a challenge.

Morphological analysis of ventricular septal defect by echocardiography for prediction of aortic regurgitation in pediatric population

Ventricular septal defects (VSD) are the most common congenital heart diseases in children. Among them, perimembranous VSD (pm-VSD) have a higher risk of complications, including aortic valve prolapse and aortic regurgitation (AR). The aim of our study was to assess echocardiographic criteria associated with AR during follow-up of pm-VSD. Forty children with restrictive pm-VSD, followed-up in our unit and who underwent a workable echocardiographic evaluation between 2015 and 2019 were included and retrospectively analyzed. The propensity score was used to match 15 patients with AR to 15 patients without AR. Median age was 2.2 year [1.4–5.7]. Median weight was 14 kg [9.9–20.3]. Aortic annulus z-score, Valsalva sinus z-score, sinotubular junction z-score, valve prolapse and commissure commitment were significantly different between the two groups (p = 0.047, p = 0.001, p = 0.010, p = 0.007, p < 0.001 respectively). Aortic root dilatation, aortic valve prolapse and commissure commitment to a perimembranous VSD are associated to aortic regurgitation.

Anatomical spatial distribution of the bilateral coronary ostia and aortic valve commissures relative to the aortic arch.

Previous studies have shown the importance of achieving commissural alignment during transcatheter aortic valve replacement (TAVR). However, the anatomical spatial distribution of the bilateral coronary ostia and aortic valve commissures relative to the aortic arch is still unknown. This study aimed to evaluate this anatomical relationship. A retrospective cross-sectional study was designed. Patients who underwent pre-procedural electrocardiographically gated computed tomography (CT) angiography with a second-generation dual-source CT scanner were enrolled in this study. Three-dimensional reconstruction was performed, and the inner curve (IC) of the aortic arch was defined. The angles between the coronary arteries or aortic valve commissures and the IC were measured. Ultimately, 80 patients were included in the analysis. The angle from the IC to the left main (LM) was 48.0°±17.5°, and the angle from the IC to the right coronary artery (RCA) was 172.6°±15.2°. The median angle from the IC to the non-coronary cusp (NCC)/left coronary cusp (LCC) commissure was -12.8° with an interquartile range (IQR) of -21.5° to -2.2°, the angle from the IC to the LCC/right coronary cusp (RCC) commissure was 102.4°±15.1°, and the angle from the IC to the RCC/NCC commissure was 219.9°±13.9°. This study found a fixed angular relationship between the coronary ostia or aortic valve commissures and the IC of the aortic arch. This relationship could help to establish an individualized implantation method that would enable commissural and coronary alignment to be achieved in TAVR.

Approach to the interventricular septum with transection and restoration of the fibrous ring of aortic valve (experimental study)

Septal myectomy is one of the most reliable methods of treating obstructive forms of hypertrophic cardiomyopathy. Most often, this operation is performed using a transaortic approach. Good immediate and long-term results of the operation are observed in more than 90% of cases. The limited visualization of interventricular septum through the aortic valve orifice is one of the reasons for myectomy ineffectiveness and some complications. This problem can be solved by using an extended transaortic approach to the interventricular septum, implying the intersection of the fibrous ring of aortic valve. Aim. To assess the effectiveness of extended transaortic approach to the interventricular septum by dissecting and restoring the fibrous ring of aortic valve in the commissural zone with subsequent assessment of its obturator function in the experiment. Material and Methods. Cadaveric porcine hearts were used as experimental models. The aortic root was exposed; the coronary arteries were ligated. A total of 30 experimental dissection operations were performed, followed by a restoration of one commissure of the native aortic valve. The effect of investigated method for the commissural restoration of the diameter to the fibrous ring of the aortic valve was evaluated. The obturator function of the aortic valve after the restoration of annulus fibrosus was studied using a special device by performing water test with a maximum pressure of 200 mm Hg and regurgitant volume estimation. Results . The aortic wall suture variant for the restoration of native aortic valve commissure was theoretically substantiated and studied in the experiment. When assessing the sufficiency of aortic valve after the dissection and restoration of commissure, no significant regurgitation on the aortic valve was observed in all cases. Direct measurements showed no significant decrease in the diameter of the annulus fibrosus of aortic valve after the reconstruction. The diameter of annulus fibrosus did not change in 26 (87%) cases; the diameter after correction decreased by 1 mm in 4 (13%) cases ( p = 0.570). Conclusion. The experiment showed a possibility of the dissection and successful restoration of the annulus fibrosus of aortic valve in the commissural zone without disrupting its function and significantly changing the diameter of annulus fibrosus. This technique can become a key one in the development of both extended transaortic approach to the interventricular septum and new options for the valve-sparing interventions at the aortic root.

Surgical repair for aortic regurgitation with left ventricular aneurysm just below the aortic valve commissure due to Takayasu arteritis：case report

Surgical repair for aortic regurgitation with left ventricular aneurysm just below the aortic valve commissure due to Takayasu arteritis：case report

Acute Aortic Regurgitation and Low Cardiac Output Syndrome due to Avulsion of the Aortic Valve Commissure: A Case Report

Acute Aortic Regurgitation and Low Cardiac Output Syndrome due to Avulsion of the Aortic Valve Commissure: A Case Report

Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator

ObjectiveThe optimal conduit for valve-sparing aortic root replacement is still debated, with several conduit variations available, ranging from straight tubular grafts to Valsalva grafts. Benefits of neosinus reconstruction include enhanced flow profiles and improved hemodynamics. Curiously, however, some clinical data suggest that straight grafts may have greater long-term durability. In this study, we hypothesized that straight tubular grafts may help maintain the native cylindrical position of the aortic valve commissures radially, resulting in preserved leaflet coaptation, reduced stresses, and potentially improved valve performance. MethodsUsing 3D printing, a left heart simulator with a valve-sparing root replacement model and a physiologic coronary circulation was constructed. Aortic valves were dissected from fresh porcine hearts and reimplanted into either straight tubular grafts (n = 6) or Valsalva grafts (n = 6). Conduits were mounted into the heart simulator and hemodynamic, echocardiographic, and high-speed videometric data were collected. ResultsHemodynamic parameters and coronary blood flow were similar between straight and Valsalva grafts, although the former were associated with lower regurgitant fractions, less peak intercommissural radial separation, preserved leaflet coaptation, decreased leaflet velocities, and lower relative leaflet forces compared with Valsalva grafts. ConclusionsValsalva grafts and straight grafts perform equally well in terms of gross hemodyanics and coronary blood flow. Interestingly, however, the biomechanics of these 2 conduits differ considerably, with straight grafts providing increased radial commissural stability and leaflet coaptation. Further investigation into how these parameters influence clinical outcomes is warranted.

Acute Aortic Regurgitation due to Rupture of an Aortic Valve Commissure

Acute Aortic Regurgitation due to Rupture of an Aortic Valve Commissure

A challenging case of aortic valve commissure detachment with fibrous strand ruptures mimicking infective endocarditis

A challenging case of aortic valve commissure detachment with fibrous strand ruptures mimicking infective endocarditis

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story

Surgical Treatment of Anomalous Aortic Origin of Coronary Arteries: The Reimplantation Technique and Its Modifications

Although anomalous aortic origin of a coronary artery has been described as a benign anomaly in the past, several reports suggest that such an anomaly may be the cause of sudden death in children and younger adults. Increased cardiac output during exercise may result in compression of the anomalous coronary artery when it runs between the aorta and the pulmonary artery or when its aortic origin is narrowed and its proximal course is intramural. It is unlikely that this rare anomaly would be identified during infancy, but once diagnosis has been made, indication to proceed with surgery is controversial. Nevertheless, if surgery is recommended, several operative techniques may be used, depending on the specific anatomy; unroofing, direct reimplantation, patch enlargement, and even coronary artery bypass grafting have been proposed. In this short report, we focus on different techniques of coronary reimplantation. As we already know from the arterial switch operation in neonates and from aortic root repair or replacement in adults, sufficient mobilization is necessary to allow direct reimplantation in the correct sinus to avoid kinking and other distortion.

AUGMENTED REALITY SYSTEM FOR ULTRASOUND GUIDANCE OF TRANSCATHETER AORTIC VALVE REPLACEMENT

Transcatheter aortic valve replacement (TAVR) relies on fluoroscopy and nephrotoxic contrast medium for valve deployment. We propose an alternative guidance system using augmented reality (AR) and transesophogeal echocardiography (TEE) to guide TAVR deployment. The goals of this study were to determine how consistently the aortic valve annulus is defined from TEE using different aortic valve landmarks, and to compare AR guidance to fluoroscopic guidance of TAVR deployment in an aortic root model. Magnetic tracking sensors were integrated into the TAVR catheter and TEE probe, allowing these tools to be displayed in an AR environment (Figure 1). Variability in identifying aortic valve commissures and cuspal nadirs was assessed using TEE aortic root images. To compare AR guidance of TAVR deployment to fluoroscopic guidance, a TAVR stent was deployed ten times in the aortic root model using each of the two guidance systems. Commissures and nadirs were both investigated as features for defining the valve annulus in the AR guidance system. The commissures were identified more consistently than the nadirs with an intraobserver variability of 2.2mm and 3.8mm respectively and an interobserver variability of 3.3 and 4.7mm respectively. The precision of TAVR deployment using fluoroscopic guidance was 3.4mm while the precision of AR guidance was 2.9mm and its overall accuracy was 3.4mm indicating similar performance. Aortic valve commissures can be identified more reliably than cuspal nadirs from TEE. The AR guidance system achieved similar deployment accuracy to fluoroscopy while eliminating the use and consequences of nephrotoxic contrast and radiation.

Two Dehiscences of the Aortic Valve Commissure and Cusp with Progressive Acute Aortic Regurgitation

A 54-year-old female with acute heart failure due to aortic regurgitation (AR) was admitted to our hospital. Following admission, her condition worsened progressively; thus, surgery was performed prematurely. During surgery, two dehiscences were visualized in the aortic valve commissure between the right and left cusps and the upper part of the left coronary artery ostium. However we scheduled aortic valve replacement (AVR) at first, we made the shift to perform the aortic root replacement for reinforcement of the aortic wall around the left coronary artery ostium. We describe a rare case of two dehiscences at the aortic root, which is the first report.

大動脈弁交連部の限局性解離から生じた心タンポナーデの1例

大動脈弁交連部の限局性解離から生じた心タンポナーデの1例

Acute Aortic Insufficiency due to Rupture of an Aortic Valve Commissure

Myxomatous degeneration generally involves the atrioventricular valves (mitral and tricuspid). Rarely, it may affect the aortic or pulmonary valve. We report a case of an acute severe aortic insufficiency due to a rupture of a commissure of the aortic valve in a patient who had previously undergone mitral valve surgery for myxomatous mitral valve prolapse.

Reverse Graft Placement in the Florida Sleeve Procedure for Aortic Root Aneurysm

Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta.

DynaCT-Guided Anatomical Rotation of the SAPIEN XT Valve during Transapical Aortic Valve Implantation: Proof of Concept

Transcatheter aortic valve implantation (T-AVI) by using the Edwards SAPIEN (Edwards Lifesciences LLC, Irvine, California, United States) prosthesis is currently being performed by the implantation of valved stent into the aortic annulus without respecting the native commissural (rotational) orientation. Anatomical orientation may, however, be beneficial regarding optimal physiological valve performance, optimal coronary flow, and avoidance of the fully covered commissural stent part in front of the coronary ostia. With the recently introduced SAPIEN XT, transcatheter valve identification of the commissures during fluoroscopy is feasible. The aim of this study was to evaluate the concept of Dynamic-CT (DynaCT)-guided anatomical rotation of the SAPIEN XT valve during transapical-AVI (TA-AVI). Intraoperatively, an automatically segmented DynaCT was performed using the Siemens Syngo Aortic ValveGuide (Siemens AG, Forchheim, Germany) software prototype. Commissures of SAPIEN XT could be identified with a high-quality fluoroscopic system. Before standard TA implantation, one radiopaque stent commissure of the crimped SAPIEN XT prosthesis was aligned with the native aortic valve commissure visualized by DynaCT. Resulting rotational orientation of the valve after implantation was assessed by transesophageal echocardiography. Feasibility of anatomical rotation was evaluated in 10 patients scheduled for TA-AVI by an interdisciplinary heart team. Mean logistic EuroSCOREs and Society of Thoracic Surgeons scores were 23.7 ± 4.9% and 8.6 ± 2.1%, mean aortic gradient improved from 46.0 ± 21.9 to 9.6 ± 3.1 mm Hg, and there was no death within 30 days. All valves were implanted successfully with none or trivial paravalvular regurgitation in seven patients, mild (1 + ) in two patients, and moderate (2 + ) in one patient. An optimal anatomical position could be achieved in six patients, minor rotational deviation (< 10 degrees) in three patients, and moderate deviation (10 to 20 degrees) in one patient only. DynaCT-guided anatomical rotation of the SAPIEN XT valve is feasible during TA-AVI, avoiding implantation of the fully covered commissural posts in front of the coronary ostia. This might reduce the risk of coronary obstruction. In addition, the technique provides the potential benefit of physiological valve position and performance.

Percutaneous Transcatheter Closure of the Aortic Valve to Treat Cardiogenic Shock in a Left Ventricular Assist Device Patient With Severe Aortic Insufficiency

In this case report, we present a patient status post left ventricular assist device implantation complicated by de novo aortic insufficiency. At 8 months postimplant, the patient underwent a reoperative aortic valve repair, without complete closure of the valve. Three months after reoperation, the patient developed cardiogenic shock secondary to recurrent, severe aortic insufficiency. Ultimately, the patient underwent percutaneous, transcatheter closure of the aortic valve with an Amplatzer Cribiform device (AGA Medical Corp, Plymouth, MN). Two months post procedure, the patient remains stable with improved symptoms and functional status, and without evidence of further aortic insufficiency or device migration.

Intraoperative 2D and 3D transoesophageal echocardiographic predictors of aortic regurgitation after transcatheter aortic valve implantation

BackgroundPost-procedural aortic regurgitation (AR) has been described in a large number of patients receiving transcatheter aortic valve implantation (TAVI).ObjectiveThe aim of this study was to examine the intraoperative 2-dimensional (2D)...