Biological Valve Replacement Research Articles

Transcatheter Aortic Valve Replacement in Aortic Stenosis: a Clinical Case

Background. Aortic valve stenosis is common with prevalence of about 0.5 %, peaking in people aged over 70 years mostly due to age-related valve calcification. The year 2002 was marked by the invention and use of the endovascular aortic replacement valve by an A. Cribier’s group of French surgeons. Russian endovascular surgery introduced transcatheter aortic valve replacement in 2009, having since built an extensive experience in this practice. Perioperative mortality in patients under 70 years with no serious comorbidity ranges from 1 to 3 %, however, reaching two-fold 4–8 % in elderly patients. The emergence of minimally invasive technologies offered cure to critical patients, who would merely not get over an open surgery.Materials and methods. This case study provides video recordings of transcatheter aortic valve replacement (Accurate Neo) in transfemoral approach performed for the first time in the Republic of Bashkortostan. Patient K., 70 yo, diagnosis: Atherosclerosis. Aortic valve stenosis. FC III. Complications: aortic valve calcification st. III, CHF II A, FC III, persistent atrial fibrillation, tachysystole. Comorbid: CHD. Exertional angina. FC III. CHF II A, FC III.Results and discussion. Improving the transcatheter valve type facilitates an optimal individual aortic valve selection. Pre-replacement valvuloplasty was performed in all patients. The valve replacement is followed by transoesophageal echocardiography to justify possible aortic valve post-dilatation upon marked paravalvular regurgitation. The implant positioning relative to the aortic valve fibrous crown and mitral valve flaps is precisely controlled with ultrasound.Conclusion. Interventional radiology currently provides high-quality, effective, minimally invasive medical aid even in aortic stenosis patients with multiple comorbidity. In the patient’s denial of open surgery, transcatheter aortic valve replacement represents a sole alternative treatment, also increasing the life expectancy and quality. A wider diversity of available transcatheter devices enables a better personalisation of the biological valve replacement procedure.

Transillumination Rendering of a Prosthetic Mitral Valve Endocarditis

A 61-year-old man presented in mid-2019 to the emergency department complaining of high-grade fever, chills, and malaise 4 days before his visit. He had a history of hypertension and a biological mitral valve replacement in 2016 as treatment for a severe mitral regurgitation. Cardiac auscultation and physical examination were noncontributory. A late endocarditis of the prosthetic mitral valve was suspected. Hemocultures taken in the first hour were positive for Streptococcus viridans and S. pneumoniae.

Massa Valvar Mitral em Paciente com Suspeita de Lúpus Sistêmico: Tumor, Endocardite ou Ambos?

ResumoApresentamos o relato de caso de uma paciente com mixoma valvar mitral infectado e uma revisão da literatura sobre o assunto. Uma mulher de 33 anos apresentou histórico de febre e dispneia com evolução de alguns dias. Na hospitalização, ela apresentava uma síndrome semelhante ao lúpus, com hemoculturas positivas para Haemophilus spp . O ecocardiograma revelou uma massa gigante envolvendo ambos os folhetos mitrais associada à regurgitação grave, necessitando de troca valvar mitral biológica. A microscopia revelou mixoma infectado e a paciente recebeu alta assintomática após o término da antibioticoterapia. Ela apresentou bons resultados no seguimento. Este é o sexto caso de mixoma valvar mitral infectado relatado na literatura e o terceiro caso de mixoma cardíaco infectado pelo grupo HACEK. Devido à alta incidência de eventos embólicos, a antibioticoterapia precoce aliada à pronta intervenção cirúrgica são decisivos para a redução da morbimortalidade. O tempo para o diagnóstico foi muito mais breve do que o geralmente relatado em casos de endocardite por HACEK. A troca valvar foi a intervenção mais comum e todos os pacientes em relatos de caso anteriores apresentaram bons resultados no seguimento.

Post-operative thrombocytopenia after sutureless biological aortic valve replacement: is it clinically relevant?

Introduction Postoperative thrombocytopenia (PTC) after aortic valve replacement by sutureless biological prosthesis (Perceval type) is described in the literature, however, its clinical relevance has not yet been established. • Primary objective: Description of platelet count after biological aortic valve replacement with Perceval® and Trifecta types. • Secondary objective: To compare need of transfusions (red blood cells (RBCs), Platelets, fibrinogen), re-explorations for bleeding in the first 48 hours, ICU stay, hospital stay and mortality at 30 days. Methods A retrospective comparative observational cohort study was conducted using data extracted from digital medical records, including data obtained by intraoperative thromboelastography (TEG) of patients undergoing aortic valve replacement with biological prosthesis Perceval and Trifecta, at our hospital. We performed consecutive non-randomized sampling from January 2018 to December 2018, including a total of 74 patients. 32 of them received Perceval®, 42 received Trifecta . Results We found a PTC after biological valve replacement that in both groups becomes severe, being in the Perceval group minimum values of 20 × 103 on the 4th postoperative day, while in the Trifecta group it was 50 × 103 also on the 4th postoperative day. We found no statistically significant differences in preoperative or postoperative platelet count except at hospital discharge, with Perceval presenting lower platelet count figures (median 133 × 103 interquartile range 108 - 203 × 103) than Trifecta® (median 230 × 103, interquartile range 167 - 220 × 103), (p = 0.018). Intraoperatively, we found statistically significant differences in the number of (RBCs) transfused, as follows in the Perceval group (mean: 1.06) versus Trifecta (mean: 0.31), (p = 0.005) We found no statistically significant differences in intra- or postoperative transfusion of blood products (platelets, fibrinogen), as well as in the need for re-explorations due to bleeding, ICU stay, hospital stay or mortality at 30 days. Discussion Biological valve replacement with Perceval and Trifecta causes postoperative thrombocytopenia, which, although it becomes severe on the fourth postoperative day in both groups, does not persist at hospital discharge. In our sample has not conditioned greater morbidity or mortality in patients. Larger sample studies will be necessary to corroborate the statistical significance.

Case report: A fatal case of aortic and mitral valve endocarditis caused by Streptobacillus moniliformis

BackgroundInfective endocarditis (IE) secondary to rat-bite fever (RBF) is rare but potentially lethal. Rapid diagnosis is of utmost prognostic importance. However, the diagnosis of RBF is challenging because Streptobacillus moniliformis does not grow under conventional culture conditions.Case summaryA 65-year-old male without previous cardiac history presented with sudden onset of balance problems and facial palsy. For 2 weeks, he had experienced intermittent fever and myalgia. Transoesophageal echocardiography (TOE) revealed severe mitral and aortic valve IE with aortic root abscess. The patient underwent a double biological valve replacement. Blood cultures remained negative after 9 days of incubation. However, sub-cultivation on solid media demonstrated the growth of pleomorphic Gram-negative rods, identified as S. moniliformis. After 4 weeks of antibiotic therapy, he was discharged. One month later, control TOE showed valve excrescences and aortic annular aneurysm. Despite comprehensive surgery, antibiotic treatment, and intensive care, the patient died 1 week after reoperation.DiscussionA fatal outcome of S. moniliformis IE is rare. The majority of previous cases describe underlying valvular abnormalities or death due to insufficient antimicrobial therapy. Here, the patient had no prehistory of valvular heart disease and despite appropriate antibiotics, the outcome was fatal. Rapid diagnosis of RBF IE has prognostic implications. Identification of S. moniliformis is, however, difficult, because the bacterium is fastidious and does not grow under standard laboratory conditions. Therefore, diagnosis often relies on clinical symptoms or a history of rodent exposure. Close attention to this disease by clinicians, in addition to, dialogue with clinical microbiologists is essential.

Quality of life in sexagenarians after aortic biological vs mechanical valve replacement: a single-center study in China

ObjectiveThis article aimed to study the quality of life and anxiety of sexagenarian patients who underwent aortic biological vs mechanical valve replacement in a single center in China.MethodsThe clinical data of 78 patients aged 60 to 70 years who underwent aortic prosthetic valve replacement were retrospectively analyzed in our hospital from June 2017 to February 2018. Patients were divided into two groups depending on the type of prosthetic valve they received (biological valve group vs mechanical valve group). The SF-36 was completed by all patients at discharge and at one-year follow-up, and the cardiac anxiety questionnaire (CAQ) was also completed at one-year follow-up.ResultsThere was no statistically significant difference between the two groups in general clinical data or SF-36 score at discharge. However, at one-year follow-up, the SF-36 scores were significantly higher in the biological valve group than in the mechanical valve group, and the CAQ scores in fear and anxiety, avoidance and attention in the mechanical valve group were significantly higher than those in the biological valve group.ConclusionsBased on the postoperative quality of life and anxiety scores of sexagenarian patients who underwent biological vs mechanical valve replacement in this study, a biological valve has more value than a mechanical valve for sexagenarians undergoing aortic valve replacement.

P1322 Role of echocardiography in the assessment of mechanical complications of acute myocardial infarction: case report series

Abstract INTRODUCTION The incidence of the mechanical complications of acute myocardial infarction (AMI) has noticeably decreased throughout the world after the era of primary percutaneous coronary intervention (PCI); nonetheless, when they present, the mortality rate continues being high, requiring for their diagnosis an adequate clinical suspicion, followed by intensive care therapy and in most cases, surgical treatment. In the current report we present 4 cases of mechanical complications using transthoracic echocardiography (TTE) as diagnostic tool: a ventricular septal defect, a papillary muscle rupture, a left ventricular (LV) free wall rupture and a ventricular aneurysm. PATIENT 1: A 71-year-old male who presented with inferior AMI and no reperfusion therapy, complicated with transitory AV block, ventricular fibrillation and severe mitral regurgitation secondary to posteromedial papillary muscle rupture (Panel A). He followed surgery with biological mitral valve replacement and PCI of the right coronary artery (RCA). PATIENT 2: A 71-year-old male who presented with anterior AMI and no reperfusion therapy, suddenly showed signs of cardiogenic shock. The TTE demonstrated pericardial effusion associated with an image of thrombus fixed to the antero-apical wall of the LV of 21 mm in dimension, apical segments akinesia and left ventricular ejection fraction (LVEF) of 40% (Panel B). These findings concluded LV free wall rupture, that required urgent surgical repair of the apical region with sphacelated myocardium. PATIENT 3: A68-year-old male, with history of hospitalization 2 months prior for an event of acute coronary syndrome. Admitted again for chest pain, with a TTE that demonstrated a ventricular septal defect associated with intramyocardial dissection, apical thrombus of 17x11 mm in dimension, apical dyskinesis and LVEF of 30% (Panel C). Coronary angiography documented critical obstruction of proximal left anterior descending coronary artery (LAD) and chronic total occlusion of the RCA. He was taken to surgical repair of the defect and coronary artery bypass (CABG). PATIENT 4: A 77-year-old male, with a history of PCI in 2009 (unknown coronary vessel), presented with inferior AMI and no reperfusion therapy. TTE demonstrated an aneurysm in the basal inferior segment of 55x44 mm in dimension, partially thrombosed, with a neck of 23 mm, severe mitral regurgitation and LVEF of 45% (Panel D). Coronary angiography documented multivessel disease with unsuitable coronary anatomy for CABG. CONCLUSIONS The incidence of AMI mechanical complications has decreased noticeably to less than 1% in the era of primary PCI. These include free wall rupture (0.17%), papillary muscle rupture (0.26%) and LV free wall rupture (0.17%). Immediate echocardiographic assessment is needed when clinical findings suggest such complications; urgent treatment is fundamental to improve short term prognosis. Abstract P1322 Figure. Bidimensional TTE images.

In vitro 4D Flow MRI evaluation of aortic valve replacements reveals disturbed flow distal to biological but not to mechanical valves.

Aortic hemodynamics influence the integrity of the vessel wall and cardiac afterload. The aim of this study was to compare hemodynamics distal to biological (BV) and mechanical aortic valve (MV) replacements by in vitro 4D Flow MRI excluding confounding factors of in-vivo testing potentially influencing hemodynamics. Two BV (Perimount MagnaEase [Carpentier-Edwards], Trifecta [Abbott]) and two MV (On-X [CryoLife], prototype trileaflet valve) were scanned in a flexible aortic phantom at 3T using a recommended 4D Flow MR sequence. A triphasic aortic flow profile with blood-mimicking fluid was established. Using GTFlow (Gyrotools), area and velocity of the ejection jet were measured. Presence and extent of sinus vortices and secondary flow patterns were graded on a 0 to 3 scale. A narrow, accelerated central ejection jet (Area = 27 ± 7% of vessel area, Velocity = 166 ± 13 cm/s; measured at sinotubular junction) was observed in BV as compared to MV (Area = 53 ± 13%, Velocity = 109 ± 21 cm/s). As opposed to MV, the jet distal to BV impacted the outer curvature of the ascending aorta and resulted in large secondary flow patterns (BV: n = 4, grades 3, 3, 2, 1; MV: n = 1, grade 1). Sinus vortices only formed distal to MV. Although physiologically configured, they were larger than normal (grade 3). In contrast to mechanical valves, biological valve replacements induced accelerated and increased flow patterns deviating from physiological ones. While it remains speculative whether this increases the risk of aneurysm formation through wall shear stress changes, findings are contrasted by almost no secondary flow patterns and typical, near-physiological sinus vortex formation distal to mechanical valves.

Transcatheter mitral valve replacement: current status

After aortic valve stenosis, mitral regurgitation (MR) is the second most common valvular disease, particulary affecting older patients. Optimal medical treatment within the context of heart failure therapy is the favored first-line therapy for secondary MR. If symptoms persist despite optimal medical therapy, surgical or transcatheter mitral valve repair is indicated (recommendation class IIb). In contrast, surgical treatment is essential for patients with symptomatic primary MR and left-ventricular ejection fraction (LVEF) >30% and justifiable perioperative risk (repair preferred over replacement, recommendation classI); for high-risk patients, interventional transcatheter mitral valve repair (especially by "edge-to-edge-reconstruction") is aviable option (recommendation class IIb).Recently, transcatheter mitral valve replacement (TMVR) has come into focus as another attractive treatment option and is currently under intensive research. At first, the TMVR was used both for patients with symptomatic insufficiency or stenosis after biological mitral valve replacement (Bio-MKE) or after reconstruction as a"valve-in-valve" or "valve-in-ring" procedure. Therefore, transcatheter aortic valve prostheses were used.In the past few years several dedicated TMVR prostheses were developed for the treatment of native MR. So far, no TMVR prosthesis is CE-certified. All of the following TMVR methods are under clinical evaluation in the scope of pivotal trials. The interdisciplinary heart team, consisting of experienced cardiologists and heart surgeons develops apatient-specific, individual treatment concept considering the particular MR etiology, pre-existing comorbidities, age, clinical symptoms, and status.

Long-term outcome after mitral valve replacement using biological versus mechanical valves

BackgroundThis study compared long-term outcomes of biological and mechanical mitral valve replacement (MVR) in patients requiring replacement of the mitral valve where repair was not feasible.MethodsA single-centre registry of patients receiving MVR between 2005 and 2015 was established. Thirty-day mortality and long-term outcomes were analysed and compared.ResultsThree hundred twenty four patients underwent MVR (265 biological; 59 mechanical valves). Patients receiving biological valves were older (p < 0.001), had a higher log EuroSCORE (p < 0.001) and received less minimally invasive surgery (p < 0.001).Immediate procedural mortality was 1.9%, which only occurred in the biological valve group. At 30 days, 9.0% of patients had died, 4.0% experienced stroke, 8.0% received a pacemaker and 10.5% suffered an acute renal failure. The rate of re-thoracotomy (14.2%) was lower in the biological (12.5%) than in the mechanical valve group (22.0%; adjOR 0.45 [0.20–1.00]; p = 0.050). Frequent long-term complications were stroke (9.2%) and bleeding (4.8%), with bleeding complications being higher in the mechanical valve group (p = 0.009). During the follow-up period biological valves showed a numerically higher survival rate during the first years, which shifted after 3 years in favour of mechanical valves. At 10 years, survival rates were 62.4% vs. 77.1% in the biological and mechanical valve groups (p = 0.769). Hazard ratio after adjustment was 0.833 (95% CI 0.430–1.615).ConclusionThese data confirm that mechanical valve implantation is associated with an increased risk of bleeding. While there was a potential survival benefit during the first years after surgery for patients receiving a biological valves the difference became insignificant after a follow-up of 10 years.

Surgical valve selection in the era of transcatheter aortic valve replacement in the Society of Thoracic Surgeons Database

ObjectivesTime trends in surgical valve selection have not been explored in detail in the era of transcatheter aortic valve replacement (TAVR) in nationally representative data. Herein, we explore valve selection trends in the TAVR era using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. MethodsIsolated first-time biological or mechanical aortic valve replacements (AVR) from 2004 to 2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. Patient characteristics were examined in the pre-TAVR era (2004-2007) and the post-TAVR era (2008-2016) using the year 2007 as the cut-point. Using a piece-wise regression analysis to model the relationship between time and type of valve used, a change-point analysis was performed to empirically determine the time of change in practice, both overall and in age-specific subgroups (≤60 years and >60 years). ResultsIn total, 214,390 patients underwent isolated primary mechanical or biological AVR from 2004 to 2016. The patients' mean age increased slightly between the 2 eras (67.1 vs 68.6 years, P < .001), whereas the proportion of mechanical AVRs decreased (24.8% vs 12.2%, P < .001). Piece-wise regression demonstrated that the proportion of mechanical valves decreased over time. An empirically estimated slope change-point was found after the first quarter 2010; from 2004 to 2009, the overall proportion of mechanical valves was decreasing quickly (−2.81%/year, 95% confidence interval [95% CI], −3.03% to −2.60%), compared with 2010 to 2016. The early decline was steeper for younger patients (−4.21%/year, 95% CI, −4.74 to −3.69) compared with older patients (−1.44%/year, 95% CI −1.64 to −1.23). ConclusionsUse of mechanical AVR declined significantly from 2004 to 2016 and was decreasing before the introduction or the approval of TAVR in the United States.

Comparison of Early Results of Mechanical Valve and Sutureless Biological Valve Replacement in Patients with Symptomatic Aortic Stenosis

Amaç: Bu çalışmada ileri semptomatik aort darlığı bulunan yüksek riskli hastalarda dikişsiz biyoprotez aort kapak ve mekanik kapak replasmanı erken dönem sonuçlarının karşılaştırılması amaçlandı.Gereç ve Yöntemler: Ocak 2015 ve Eylül 2018 tarihleri arasında 34 (18 Erkek, 16 Kadın) dikişsiz biyoprotez aort kapak replasmanı (Edwards, Intuity) ve 50 (29 Erkek, 21 Kadın) mekanik aort kapak replasmanı (Medtronic, ATS) yapılan hasta çalışmaya alındı. Hastaların demografik verileri ve postoperatif 1. ay verilerinin karşılaştırılması amaçlandı.Bulgular: Mekanik kapak takılan hastalarda ejeksiyon fraksiyonu (EF) 60 (38-69), New York Kalp Cemiyeti (New York Heart Association, NYHA) sınıflaması 3 (2-4), EuroSCORE 3 (0-7) ve ortalama gradiyent 56 (40-75) mmHg iken, dikişsiz kapak kullanılan hastalarda ise EF 52 (33-68), NYHA 4 (2-4), EuroSCORE 5 (0-7) ve ortalama gradiyent 60 (40-95) mmHg olarak saptandı. Mekanik aort kapak replasmanı yapılan hastalarda eş zamanlı olarak 9 hastaya koroner bypass, 7 hastaya mitral kapak replasmanı ve 2 hastaya triküspid ring anüloplasti yapılmıştır. Dikişsiz kapak replasmanı yapılan grupta 8 hastaya koroner bypass, 1 hastaya mitral kapak replasmanı ve 1 hastaya mitral tamir işlemi uygulanmıştır. Her iki grupta da 1 hasta postoperatif ilk 30 gün içerisinde ex olmuştur.Sonuç: Aort darlığına bağlı operasyonlarda ileri yaş ve komorbiditelerin varlığı mortalite ve morbiditeyi arttırmaktadır. Dikişsiz aort kapağı replasmanı yüksek riskli hastalarda düşük mortalite ve morbidite, mükemmel hemodinami ve kısa implantasyon süresi ile güvenli bir biçimde kullanılabilir.

Conventional redo biological valve replacement over 20 years: Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy

ObjectivesAlthough primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. MethodsFrom January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). ResultsBiological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P = .03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P = .03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). ConclusionsIn a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.

Chronic graft-specific cell-mediated immune response toward candidate xenogeneic biomaterial.

Despite rabbits becoming an increasingly popular animal model, a flow cytometry panel that combines T cell markers (CD3, CD4, CD8, CD25, FOXP3) with a method for monitoring proliferation is lacking in this species. It has been shown that the rabbit model can be used to identify xenoantigens within bovine pericardium (BP), a common biological heart valve replacement material; however, these methods rely on monitoring the humoral immune response. The development of a rabbit T cell proliferation assay has utility in monitoring graft-specific cell-mediated immune responses toward bovine pericardium. Isolation and culture conditions were optimized to avoid cell death, red blood cell contamination, and non-specific proliferation. Effect of cell culture and stimulation on distribution and intensity of T cell markers was analyzed and compared between cells isolated from naïve and BP-immunized rabbits. Submaximal levels (0.25μg/mL) of concavalin A were used to stimulate proliferation toward BP extract, with resultant proliferation compared between naïve and BP-immunized rabbits. Density stratification followed by ammonium potassium chloride (ACK) lysis yielded the greatest number of viable peripheral blood mononuclear cells with the least amount of erythrocyte contamination. Flat-bottomed plates were necessary to reduce non-specific proliferation in culture. T cells responded appropriately to maximal mitogenic stimulation (5μg/mL concavalin A). Interestingly, immunization increased the intensity of FOXP3 in T regulatory cells compared to cells from naïve animals. With addition of submaximal levels of concavalin A, T cells from immunized rabbits proliferated in response to BP protein extract, while cells from naïve rabbits did not. In immunized rabbits, not only did more CD4+ T cells proliferate in response to BP re-stimulation, but the intensity of CD25 was increased indicating cell activation. This research provides a functional cell-mediated screening assay for assessment of BP-based biomaterials in rabbits, overcoming the limitations of previous humoral immune system-based assessments of biomaterial antigenicity in this important experimental animal species.

Is Surgical or Catheter-based Interventions an Option After an Unsuccessful Mitral Clip?

The objective of this study was to assess the results of catheter-based and surgical reinterventions in primary mitral regurgitation after failed MitraClip therapy. We report on 21 consecutive symptomatic patients with primary mitral regurgitation (median age 78 years) who underwent either repeat MitraClip therapy (n = 7) or mitral valve surgery (n = 14) after failure of the index procedure with 1-2 MitraClip implantations. At the time of reinterventions, 193 (interquartile range [IQR]: 32-622) days after the index procedure, patients had recurrent or persistent grade 3 mitral regurgitation. Early mortality at 30 days was 4.8%. Cardiac-related survival at 2 years was 85.4% (4 cardiac and 4 noncardiac deaths). Three of 7 patients with percutaneous reintervention were converted to surgery at 34, 52, and 56 days because repeat MitraClip therapy was ineffective because of pre-existing clip detachment or leaflet tear. Final therapy was biological mitral valve replacement in 14 of 21 patients (66.7%); 4 were treated with percutaneous repeat MitraClip repair (19%), and in 3 patients, surgical repairs were performed (14.3%). At follow-up with a median of 708 days, New York Heart Association class had improved significantly to class 2 (IQR: 1.0-2.5) (P = 0.0004), and the left ventricular end-diastolic diameter had decreased from 56 (IQR: 52-59) mm to 51 (48-58) mm (P = 0.0378), respectively. Recurrence of significant mitral regurgitation was absent in all but 1 patient with unsuccessful repeat MitraClip therapy who was deemed inoperable. Our data show that both repeat MitraClip and also mitral valve surgery are feasible and safe alternatives in patients without an excessively increased perioperative risk. We conclude that whenever leaflet insertion is not compromised, repeat catheter-based repair is a reasonable redo concept; in the remaining cases, surgery should be offered to the patient.

Flow structure in healthy and pathological left ventricles with natural and prosthetic mitral valves

In this paper, the structure and the dynamics of the flow in the left heart ventricle are studied for different pumping efficiencies and mitral valve types (natural, biological and mechanical prosthetic). The problem is investigated by direct numerical simulation of the Navier–Stokes equations, two-way coupled with a structural solver for the ventricle and mitral valve dynamics. The whole solver is preliminarily validated by comparisons with ad hoc experiments. It is found that the system works in a highly synergistic way and the left ventricular flow is heavily affected by the specific type of mitral valve, with effects that are more pronounced for ventricles with reduced pumping efficiency. When the ventricle ejection fraction (ratio of the ejected fluid volume to maximum ventricle volume over the cycle) is within the physiological range (50 %–70 %), regardless of the mitral valve geometry, the mitral jet sweeps the inner ventricle surface up to the apex, thus preventing undesired flow stagnation. In contrast, for pathological ejection fractions (⩽40 %), the flow disturbances introduced by the bileaflet mechanical valve reduce the penetration capability of the mitral jet and weaken the recirculation in the ventricular apex. Although in clinical practice the fatality rates in the five-year follow-ups for mechanical and biological mitral valve replacements are essentially the same, a breakdown of the deaths shows that the causes are very different for the two classes of prostheses and the present findings are consistent with the clinical data. This might have important clinical implications for the choice of prosthetic device in patients needing mitral valve replacement.

Interleukin-6 in cardiac surgery

Background and Purpose: Interleukin (IL)-6 is a multi-functional pro- and anti-inflammatory cytokine, and it has been a reliable biomarker of cardiac function status and myocardial damage. However, the characteristics of IL-6 expressions in the cardiac surgical patients have not been comprehensively described. The purpose of this review is to present the current knowledge on the role of IL-6 in the field of cardiac surgery. Materials and Methods: Medical literature of IL-6 in cardiac surgical disorders of recent 3 decades were carefully collected as studying materials, and comprehensively reviewed and analyzed. Results: Plasma IL-6 was significantly elevated 1 hour and peaked 3-6 hours after the start of cardiopulmonary bypass with a gradual decrease constant maintenance thereafter. No significant differences were found between patients with biological and mechanical heart valve replacements between on-poump and off-pump coronary artery bypass, or between cyanotic and acyanotic congental heart patients. The elevation of IL-6 was higher in mitral valve replacement than in coronary artery bypass grafting patients and in non-heart transplantation than heart transplantation patients. Il-6 was involved in the pathogenesis of pulmonary artery hypertension and infective endocarditis, and predicted adverse cardiac events, such as coronary graft occlusion, aortic dissection progression, and cardiac myxoma recurrence. Conclusions: In cardiac surgical patients, the expression of IL-6 reflects the inflammatory situation of the patients and also predicts their prognosis. The higher elevation of IL-6 in mitral valve replacement and in non-heart transplantation might be attributed to cardiotomy suction, and to lack of sterioid use. Early administrations with steroid, α 2 -adrenergic agonists, incretin hormones, or ischemic conditioning could reduce the inflammatory response and prevent from pertinent postoperative complications. Anesthetic agents and technique of choices may also reduce immune reactions and lower circulating cytokines. Extracorporeal IL-6 removal facilities have been successfully applied in clinical practice. The potential alternative therapies with IL-6 antibodies might be further developed and used in such patients for preventing myocardial apoptotic processes.

Stentless Bioprostheses for Aortic Valve Replacement in Octogenarians: The Influence of Coronary Artery Disease.

We sought to determine the long-term results of stentless biological heart valve replacement in octogenarians to find out whether coronary artery disease or the coronary artery bypass grafting (CABG) procedure itself influences survival in these aged patients. From 4,012 patients undergoing aortic valve replacement (AVR) with a stentless prosthesis (Freestyle, Medtronic) at a single center, 721 patients were older than 80 years. They had a mean age of 83 ± 2 (2,320 patient years), the male/female ratio was 42:58, NYHA (New York Heart Association) class I and II was prevalent in 22.8%, preoperative atrial fibrillation (AF) in 20.6%, coronary artery disease in 56.1%, mitral valve disease in 12.5%, and aortic disease in 3.5%. Follow-up included a total of 11,546 patient years (mean follow-up time: 74 ± 53 months); follow-up mortality data were 96.3% complete. In these aged patients, 30-day mortality in the isolated AVR group (10.3%) was similar to that in the AVR + CABG group (13.4%). Although long-term survival (15 years) in the octogenarian population is low (9% in the AVR group and 6% in the AVR + CABG group), it was not different (p = 0.191) between patients with and without coronary artery disease. The stroke rate and the myocardial infarction rate, respectively, in the AVR + CABG group (0.43%/100 patient years and 0.17%/100 patient years) were only insignificantly higher than that in the isolated AVR group (each 0.01%/100 patient years). The actuarial freedom from reoperation was 99% in both the groups. Use of the Freestyle stentless valve prosthesis for AVR is feasible also in octogenarians. The existence of coronary artery disease leads to concomitant bypass surgery, but not a higher level of perioperative or long-term mortality.

84 An assessment of the performance of three biological tricuspid valve replacements in patients with congenital heart disease

ObjectiveTo assess the performance of three Biological Tricuspid Valve replacements (St Jude Epic, Perimount and Hancock) in congenital heart disease patients. Currently, there is little comparative data on the long...

The Use of Rapid Deployment Valves in Combined Aortic and Mitral Valve Surgery: One-Year Clinical and Echocardiographic Outcomes.

Patients undergoing multiple valve surgery represent a high-risk group who could potentially benefit from a reduction of cross-clamp and cardiopulmonary bypass times because prolonged bypass and cross-clamp times are considered independent risk factors for increased morbidity and mortality after cardiac surgery. Between July 2013 and November 2014, 16 patients underwent rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in the setting of concomitant mitral disease. Fifteen patients showed mitral regurgitation, whereas one patient had severe mitral stenosis. Fourteen patients received mitral valve repair and two patients received biological mitral valve replacement. Tricuspid valve repair was performed additionally in two patients. The mean ± SD age was 72.8 ± 8.4 years, and the mean ± SD logistic EuroSCORE II is 8.7% ± 3.4%. Within a 30-day perioperative period, no patient was lost (n = 0). The mean ± SD follow-up time was 11 ± 2 months. At 1 year, the overall survival was 81% (n = 13). A mean ± SD transaortic gradient of 10.7 ± 2.3 mm Hg and a mean ± SD effective orifice area of 1.7 ± 0.3 cm were measured echocardiographically. No higher-grade paravalvular leak (aortic insufficiency > 1+) occurred. Eight patients (61%) had no residual mitral regurgitation, four patients (30%) showed trivial regurgitation (1/4), and one patient (7.3%) had moderate mitral regurgitation (2/4). No interference of the subannular stent frame with the reconstructed valve or the biological mitral prosthesis was seen. Rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in combined aortic and mitral valve surgery can be performed safely with reproducible results. One-year follow-up data of this small series shows encouraging results potentially justifying the extension of the indication for rapid deployment valves to patients with concomitant mitral disease. Especially elderly patients undergoing multiple valve surgery may benefit from a reduction of cardiopulmonary bypass and myocardial ischemic times.