Bioprosthetic Aortic Valve Replacement Research Articles

Is This a Satellite Orbiting Unchartered Territory?

SummaryA 27-year old female i.v. drug user presented to our institution with chest pain. She had a history of bicuspid aortic valve endocarditis with aortic root abscess repaired with bioprosthetic aortic valve replacement and pericardial patch reconstruction of the left ventricular outflow tract and non-coronary sinus 6 weeks previously.Echocardiographic and cardiac CT imaging confirmed three foci of breakdown of the pericardial patch repair with active bleeding into a large posterior pseudoaneurysm (92 mm diameter) compressing the left atrium and pulmonary artery. Following multidisciplinary discussion, the consensus was to attempt urgent percutaneous closure of the defect, given the prohibitive surgical risks.The procedure was performed under fluoroscopic and 3D-transoesophageal guidance. TOE demonstrated the pericardial patch breaches and active bleeding into the large pseudoaneurysm (Figs 1 and 2). Initial deployment of an Amplatzer atrial septal defect occluder resulted in significant flow reduction, but there remained two small peri-device leaks (Fig. 3).During an attempt to implant an additional smaller Amplatzer vascular plug (AVP-2) to rectify this, the initial device dislodged and embolised into the pseudoaneurysm. This was felt irretrievable and unlikely to be clinically significant given its containment. The embolised device freely floated within the pseudoaneurysm, uniquely akin to a satellite orbiting in space (Video 1). The secondary device was removed and initial breach was satisfactorily closed with a 15-mm-sized Amplatzer atrial septal defect occluder (third device). This was confirmed to be well-seated on real-time 3D imaging (Video 2), with negligible residual leak on TOE (Fig. 4). This is the first published case of percutaneous cardiac device embolization into a pseudoaneurysm cavity that we are aware of.

EMBOLIC STEMI IN CANDIDEMIA

ST-Elevation Myocardial Infarction (STEMI) due to septic coronary embolism is a rare complication of fungemia that is associated with high morbidity and mortality compared to atherosclerotic STEMI. A 32-year-old female with a bioprosthetic aortic valve replacement secondary to aortic valve

Aortic Valve Repair Versus Replacement Associated With Durable Left Ventricular Assist Devices

Aortic valve (AV) repair (AVr) using a central coaptation stitch or bioprosthetic AV replacement (AVR) are most commonly performed at the time of durable left ventricular assist device implant to address AV insufficiency (AI). Prospective data collection on 46 patients undergoing left ventricular assist device implant from 2007 through 2018 who received concomitant AVr (n=40) or AVR (n= 6) was retrospectively analyzed to assess freedom from recurrent aortic insufficiency. Paired Wilcoxon rank-sum test was used to compare echocardiographic findings. Mantel-Cox statistics were used to analyze survival. For AVr, central coaptation led to a mean decrease in AI severity by 2.1 ± 1.0 grades (P < .001). Three patients (7.5%) had recurrence of at least moderate AI by 3 years. In comparison, all patients in the AVR group had mild or less AI on subsequent follow-up. Success of AVr in downgrading AI severity was associated with a smaller aortic root diameter (P= .011) and sinotubular junction diameter (P= .003). An aortic root diameter greater than 3.5 cm was predictive of less improvement in AI severity compared with 3.5 cm or less (1.83 ± 1.03 versus 2.47 ± 0.80 grades of improvement; P= .038). Duration of cardiopulmonary bypass was 32 minutes longer and duration of aortic cross-clamp was 38 minutes longer for AVR versus AVr cohorts. No difference in 30-day (P= .418) or overall survival (P= .572) between the AVr and AVR groups was seen. Aortic valve repair for addressing AI has a recurrence rate of 7.5% at 3 years. Success in downgrading AI is more likely with a smaller aortic root. No difference in survival was observed between AVr and AVR.

Long Term Outcomes of Freestyle Stentless Aortic Bioprosthesis: A Single Center Experience.

The study is presenting our long-term clinical results after freestyle stentless aortic root bioprosthesis replacement in patients with severe aortic insufficiency with ascending aortic aneurysm. Seventy-seven patients with ascending aortic aneurysms and aortic valve insufficiency underwent a total root replacement procedure using a stentless "Freestyle" valve (Medtronic Inc., Minneapolis, Minnesota). There were 50 (64.9%) men and 27 (35.1%) women. Mean age was 68.7 ± 11.1 years. The surgical procedure used a complete root replacement. Concomitant procedures included coronary artery bypass grafting in 15 (19.5%) patients. The mean cardiopulmonary bypass time was 130.3 ± 26.4 minutes and total aortic cross clamp time was 99.5 ± 23.6 minutes. Hospital mortality was 2.6%. The median follow-up time was 11.2 years. The 5- and 10-years freedom from aortic valve reoperation were 97.4 ± 1.2% and 93.4 ± 4.9%, respectively. During 10 years follow up, there were 14 late deaths; 4 deaths were cardiac, and 10 deaths were noncardiac. Valve-related deaths were attributable to thromboembolism in 1 patient, endocarditis in 2 patients, and congestive heart failure in 1 patient. The freestyle stentless aortic root bioprosthesis offered good clinical outcomes, in terms of survival and structural valve deterioration. The Freestyle valve is a viable option for use in patients undergoing bioprosthetic aortic valve replacement and expected desire for long-term durability.

CRT-600.22 Incidence of Leaflet Thrombosis Amongst TAVR Valves: A Meta-analysis

Subclinical leaflet thrombosis (SLT) has been infrequently reported following bioprosthetic aortic valve replacement. Impact of different type of TVAR valves on SLT has not been well studied. Comprehensive search of PubMed, EMBASE, Google Scholar and Cochrane database were performed for all trials

Impact of leaflet thrombosis on hemodynamics and clinical outcomes after bioprosthetic aortic valve replacement: A meta-analysis.

BackgroundLeaflet thrombosis (LT, also called cusp thrombosis) detected by multidetector computed tomography (MDCT) is common in bioprosthetic aortic valve replacement (bAVR). However, it remains contradictory whether MDCT‐defined LT following bAVR is associated with hemodynamic deterioration and stroke. Thus, we performed the first meta‐analysis to assess hemodynamic outcomes and updated the latest researches on the clinical outcomes of MDCT‐defined LT after bAVR.HypothesisMDCT‐defined LT might be associated with worse hemodynamic and clinical outcomes after bAVR.MethodMEDLINE, EMBASE, Cochrane Library, and http://clinicaltrial.gov were searched from inception to 15th April 2019. The fix‐effect model was utilized to calculate odds ratio (OR) and 95% confidence interval (CI). The primary outcomes were hemodynamic stability indexes, including mean pressure gradient (MPG), left ventricular ejection fraction (LVEF), paravalvular leak (PVL), and clinical heart failure. The secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs), which consisted of myocardial infarction, all‐cause death, stroke, and transient ischemic attack (TIA).ResultsTwelve studies with 4820 patients were included. The total prevalence of MDCT‐defined LT was 9.7%. MDCT‐defined LT was associated with a significantly increased risk of MPG (inverse variance 0.43, 95% CI: [0.30, 0.57]), MACCEs (OR 2.43, 95% CI: [1.45, 4.06]), stroke (OR 1.79, 95% CI: [1.03, 3.11]), and TIA (OR 4.09, 95% CI: [1.59, 10.54]). There were no differences for other outcomes.ConclusionsMDCT‐defined LT after bAVR is associated with increased MPG and increased risk of adverse cerebrovascular events, including TIA and stroke. While LVEF, PVL, and clinical heart failure were similar between patient with and without LT.

Study Design of the Prospective Non-Randomized Single-Arm Multicenter Evaluation of the Durability of Aortic Bioprosthetic Valves with RESILIA Tissue in Subjects under 65 Years Old (RESILIENCE Trial)

ABSTRACT Background: Structural valve deterioration (SVD) is the Achilles heel of bioprosthetic valves used for aortic valve replacement (AVR). SVD has been traditionally defined based upon the requirement for valve reintervention. Recent expert consensus documents have proposed more granular and sensitive definitions of SVD based on the occurrence of morphological and hemodynamic valve deterioration measured by transthoracic echocardiography (TTE) and computed tomography (CT). RESILIA™ tissue is a new tissue technology incorporating a stable-capping process which permanently blocks residual aldehyde groups known to bind with calcium. Methods: Two clinical trials of RESILIA tissue valves have shown promising safety and effectiveness outcomes through early follow up. We here describe the design of the RESILIENCE trial (ClinicalTrials.gov: NCT03680040), which evaluates the long-term durability of RESILIA tissue bioprosthetic AVR in patients <65 years of age. Up to 250 patients implanted with a RESILIA tissue valve will prospectively undergo a TTE and non-contrast CT at 5, 7, 9, and 11 years; the echos and CTs will be analyzed by core laboratories. Results: The primary outcome is the occurrence of valve re-intervention or death related to structural valve failure. The secondary outcomes are the volume of valve leaflet calcification measured by CT and the occurrence of Stage 2 (moderate) or 3 (severe) hemodynamic SVD measured by TTE. Conclusion: The RESILIENCE trial is the first prospective study to associate both clinical and imaging definitions of SVD with long-term (11 years) bioprosthetic valve durability.

P866 Mitraaortic intervalvular fibrosa pseudoaneurysm with aortic paravalvular regurgitation in a marfan-like syndrome patient diagnosed with multimodality imaging

Abstract Introduction The fibrous area. between the mitral and aortic valves described as the mitral-aortic intervalvular fibrosa (MAIF). The MAIF can be damaged by endocarditis, degenerative calcification or mitral and aortic valve surgery . Damage caused by replacement of the aortic valve can lead to the formation of pseudoaneurysms (MAIF) or other complications Case A 64-year-old male admitted to our outpatient department with complaints of dyspnea fatique and atypical chest pain. He has Marfan like syndrome and had a history of mechanical aortic valve replacement 16 years ago and upon dysfunciton of the prosthetic valve and significant ascending aorta aneurysm he had undergone a second Bentall operation 6 years after the first operation. We performed a transthoracic echocardiography and a transesophageal echocariography to clarify the underlying pathology. Transesophageal echocardiography revealed a moderate to severe paravalvular regurgitation, a mitraaortic intervalvular fibrosa pseudoaneurysm and a functional moderate-severe mitral regurgitation. The echocardiographic appearence of MAIF pseudoaneurysm cavity demontrates marked pulsatilty with systolic expansion and diastolic collapse. In order to show the pathology truly and exclude a coronary artery disease, we decided to perform a cardiac CT (CCT). Cardiac CT confirmed mitraaortic intervalvular fibrosa pseudoaneurysm and paravalvular defect clearly with patent coronary arteries. After our heart team meeting, we decided to give the patient to the cardiovascular surgery for the complete treatment of aortic valve, pseudoaneurysm and mitral valve. The patient underwent his 3rd surgery succesfully with a new bioprosthetic aortic valve replacement, repair of the pseudoaneurysm and mitral valve and his potoperative course was uneventful. Conclusion Combination of MAIVF pseudoaneurysm and paravalvular leak together in a connective tissue disorder patient is quite rare. TEE is more sensitive than TTE in accurately predicting this complication but to combine TOE with cardiac CT facilitates the diagnosis and gives a more accurate anatomic description of the defects to cardiologists and cardiovascular surgeons which is very helpful in terms of orientation. Abstract P866 Figure. 2D,3D TOE and CCT images of MAFP and PVL

Bioprosthetic Transcatheter Aortic Valve Replacement Leading to Infective Endocarditis With Aortic Abscess and Vertebral Osteomyelitis

Bioprosthetic Transcatheter Aortic Valve Replacement Leading to Infective Endocarditis With Aortic Abscess and Vertebral Osteomyelitis

P1476 Percutaneous paravalvular leak closure after transcatheter aortic valve replacement expedited with multimodality imaging

Abstract A 75-year-old male admitted to our hospital with decompansated heart failure symptoms. He had a history of 3 vessel coronary artery bypass grafting 10 years ago and a 29 mm Evolut R bioprosthetic transcatheter aortic valve replacement (TAVR) history 2 months ago. His physical examination revealed a 3/6 diastolic murmur on the aortic valve area. We performed a transeosophagel echocardiography (TOE) as the transthoracic echocardiography (TTE) images were not so clear and didn’t guide enough for the procedure . TOE showed a severe paravalvular leak . After we found out from his medical reports that postprocedural ad-hoc post dilatation was performed but didn’t work, we decided to close this paravalvular leak percutanaously . According to TOE, the paravalvular leak was at 12 o’clock position. We identified the corresponding location of the leak on previous CT images which was scanned pre-TAVR for selection of the valve size and planning of the procedure. We recognized that the leak location was corresponding to a very calcified part of the aortic annulus and the reason of the severe PVL seemed to be due to this nodular extensive calcification. We planned the procedure according to TOE-CT integrated analysis and selected the optimal flouroscopic viewing angle.The defect was found and crossed in 20 seconds after the wire passed through arcus aorta.The selected VSD Occluder(No:12) was deployed precisely by extending the device throughout the defect. Succesful complete closure was confirmed with TOE. In the past 1o years, TAVR has become the treatment of choice for patients with severe aortic stenosis with a higher operative risk. Different studies have depicted a higher incidence of PVR in patients who undergo TAVR compared to SAVR. Percutaneous postTAVR PVL closure is a technically challenging procedure. Echocardiography remains the primary imaging modality for assessing PVR immediately following TAVR. Finding and crossing the PVL defect is one of the most difficult and time-consuming parts of the procedure. The reason of this difficulty can be different anatomies, bad quality imaging and lack of common language between interventional cardiologist and cardiac imaging expert. To facilitate this part of the procedure integration of echocardiograohy and CT and finding the best angulation for flouroscopy seems to be quite promising. Abstract P1476 Figure. Step by step approach to PostTAVR

P1712 How the speed and high-level data acquisition of 3D Echocardiography benefitted surgical planning in a complex aortic root abscess case

Abstract Introduction Despite 3D echocardiography (3DE) obtaining significantly greater data than 2D echocardiography (2DE), its underutilised in assessing cardiac anatomy and dynamics. It eliminates the need for geometric modelling and assumptions about cardiac shape and permits high levels of post processing, with a single 3DE volumetric image allowing (a) generation of unlimited multiplanar reconstruction (MPR) 2D images, (b) reconstruction of volume-rendered 3D images and (c) real-time live 3D imaging. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia, but diagnosed using rapid 3DE-TOE under sedation. Case A 25-year-old-female intravenous drug user presented to our institution with collapse after a 1-month history of constitutional symptoms. Her background included bicuspid aortic valve disease with severe aortic stenosis. On admission, leucophilia (WCC 18x109/L), anaemia (Hb 70g/L) and Staphylococcus Aureus bacteraemia were present. Bedside transthoracic echocardiography (TTE) revaled a likely aortic root abscess. Cardiac surgeons recommended urgent surgery. The patient was highly anxious however and refused pre-operative TOE under general anaesthesia. She reluctantly agreed to a ‘fast’ TOE under sedation. She tolerated a study of only 7 minutes with only single 3D image acquisitions of the mitral and aortic valves and aortic root being necessary for post-processed generation of highly detailed anatomical assessment of endocarditis, permitting surgical planning (Figs 1-4). These demonstrated severe infection of both aortic valve leaflets, perforation of the major leaflet, severe mixed aortic valve disease and infection throughout the aortic root with multiple abscess cavities. She subsequently underwent urgent bioprosthetic aortic valve replacement and root reconstruction and made an excellent recovery. Discussion Valve endocarditis with leaflet destruction and aortic root abscesses are potentially fatal, requiring urgent surgery. The preferred standard for diagnosing aortic root abscesses is TOE over TTE. This is because of the greater anatomical resolution of intracardiac structures, crucial in pre-operative surgical planning. Due to the need for a diagnostic TOE study here in this complex case rapidly, the ability to obtain such a vast amount of post processed data using two rapidly acquired TOE 3D images under sedation rather than anaesthesia was crucial in guiding the cardiac surgeon and benefitting her clinical outcome. Conclusion We encourage clinicians to use 3DE routinely in patients needing detailed and accurate anatomical and functional assessment, and in those that are complex or technically difficult given its ability to rapidly produce unrivalled echocardiographic data through unlimited post-processed MPR images including volume-rendered and colour-doppler. Abstract P1712 Figure. 4 MPR 2D images from single 3DE image

P249 Iatrogenic aortic cusp laceration causing severe acute traumatic aortic regurgitation secondary to complex percutaneous coronary intervention using rotablator;3DTEE-anatomic correlates

Abstract Clinical case 59 years old male known case of long standing diabetes and dyslipidemia presented to our institute with Non-STEMI.His past history was significant for multiple admissions with acute coronary syndromes and percutaneous coronary interventions(PCI). Echocardiogram in this presentation showed preserved biventricular systolic function with no valvulopathies. He was taken up for coronary angiogram which showed significant calcified angulated lesion in LAD/LCX(Left anterior descending and circumflex) with diffuse disease in Ramus/RCA. Mode of revascularisation was discussed in detail with the patient for Rotablation-guided PCI to LAD/LCX vs CABG.He preferred and underwent complex PCI to LAD. During the procedure he developed acute heart failure which was managed conservatively. Immediate TTE showed new severe aortic regurgitation(AR) with probable left coronary cusp(LCC) perforation and preserved LVEF.After stabilization, he was scheduled for TEE which showed tear in the LCC with complex fragmented jet of holodiastolic AR filling the entire LVOT.There was new late diastolic to early systolic MR.3DTEE Enface view of the aortic valve was evident of ovoid shaped laceration in LCC extending till the free margin (Fig 1C). There were additional tears in Non-coronary cusp(NCC) extending till the free margin of right coronary cusp(RCC).3DTEE colour was notable for regurgitant jet origin from LCC/NCC (Fig 2B). Based on above findings,He was offered aortic valve intervention but was reluctant initially.He presented 2 months later with exertional dyspnoea, mild LV dilatation and drop in LVEF to 50%.He consented for surgery and underwent bioprosthetic Aortic valve replacement because of extensive cusp tear and deformation of the valve along with complete revascularisation of the remaining diseased coronaries.Post-operative course was complicated by vasoplegic arrest and acute renal failure which was successfully managed conservatively. Discussion We report this case for the rarity of this post-PCI iatrogenic complication and the incremental role of 3DTEE in identifying the exact pathology.It was proposed that during PCI multiple stalling of rotatbur in calcified LAD caused traction and eventually disengagement of guide causing rotabur to freely hang in ascending aorta close to the cusps.Possibly this rotablator with very high speed(180000rpm) would have momentarily come in contact with the aortic cusps causing cuspal perforation and heart failure in Cath lab.3DTEE correlated very well with the anatomo-pathology and matched with intraoperative finding as shown in figures 2A &amp; 2C.These findings prior to aortic cross clamp could significantly reduce time of surgery as he had an additional CABG procedure to be performed.There are few isolated case reports of post PCI aortic valve perforation but probably ours is the first one secondary to the use of rotablator with near involvement of all the cusps and reasonably accurate 3DTEE-anatomic characterisation. Abstract P249 Figure.

Use of Suture tightening automated device COR-KNOT® for minimally invasive heart valve surgery: Our initial experience in Bangladesh

Background: COR-KNOT® (LSI Solutions, New York, NY, USA) is an automated suture securing device has not been well known. We report a case series for first automated knotting device used for minimally invasive heart valve surgery in Bangladesh. Method and&#x0D; Results: To overcome the challenge of knot securing via a Key-Hole surgery we have used CORKNOT ®. The newest device is capable of remotely and automatically secure sutures and simultaneously can cut and remove the excess suture tails. We covered the spectrum of heart valve surgery: There was one case of bioprosthetic aortic valve replacement, one case of mitral valve repair, one case of bioprosthetic mitral valve replacement, one case of failed mitral valve repair with COR-KNOT® explantation followed by mechanical mitral valve replacement and one case of redo-mitral valve replacement. Average length of hospital stays was 5 ± 1days. There was one reopening, one post-operative atrial fibrillation. No wound infection and no 30day mortality.&#x0D; Conclusion: We conclude, COR-KNOT® is a safe and effective tool to reduce the duration of operation. Clinical outcome of heart valve surgery with COR-KNOT® is comparable with other methods of suture tying methods.&#x0D; Bangladesh Heart Journal 2019; 34(2) : 127-131

Successful PCI for Left Main Stem Thrombus on an Open Chest and VA-ECMO

A 66-year-old woman underwent elective re-do aortic valve replacement, having previously undergone a Mitroflow bioprosthetic aortic valve replacement (Sorin Group USA, Arvada, Colorado), which had become severely stenosed. A 21-mm mechanical Carbomedics supra-annular Top Hat valve (Carbomedics,

Comparison of warfarin versus antiplatelet therapy after surgical bioprosthetic aortic valve replacement

ObjectivesTo compare effectiveness of warfarin and antiplatelet exposure regarding both thrombotic and bleeding events, following surgical aortic valve replacement with a biological prosthesis(bioSAVR).MethodsThe study included all patients in Sweden undergoing...

The Role of Monitoring Complement Levels in Catastrophic Antiphospholipid Syndrome: A Case Series of 4 Patients

Introduction: Catastrophic antiphospholipid syndrome (CAPS) is characterized by multiple intravascular thrombotic events occurring over a short time period in the presence of persistently detectable antiphospholipid antibodies (APLA). Despite its clinical significance with mortality rate of 40-50%, the underlying pathophysiology remains somewhat enigmatic. More recent focus on the complement system as it interacts with the coagulation cascade has led to off-label use of eculizumab, a humanized monoclonal antibody against C5, in the treatment of CAPS. Consequently, monitoring of disease status with complement levels is an area of interest. We report complement levels in four patients with CAPS who had various clinical outcomes. Methods: Four patients admitted to SUNY Upstate Medical University with CAPS between February and May 2019 were included in this case series. All patients had APS with prior history of refractory CAPS (persistent disease despite standard therapy with steroids, rituximab, and therapeutic plasma exchange [TPEX]). Antiphospholipid antibodies (APLA) and complement (C3 and C4) levels were monitored during admission until discharge or death. Results: Patient characteristics are summarized in Table 1. Patient 1 was a 42-year-old female with antiphospholipid syndrome (APS) on warfarin, ischemic stroke, and aortic valve replacement admitted on March 2019 with shortness of breath, hemoptysis and menorrhagia. She was found to have elevated APLA, thrombocytopenia, and acute renal failure with renal biopsy confirming APS nephropathy. Despite therapy with ongoing anticoagulation, steroids, rituximab, IVIG, and TPEX her clinical course continued to deteriorate. Hypocomplementemia was present (both low C3 and C4), with lowest C3 level on admission at 31 (Graph 1A). Decision was made to pursue eculizumab on 4/16/19 with continued clinical decline and no improvement in complement levels. She ultimately died on 4/24/19. Patient 2 was a 35-year-old male with systemic lupus erythematosus (SLE), APS, end-stage renal disease, and Libman-Sacks endocarditis status post bioprosthetic aortic valve replacement admitted in February 2019 for worsening digital ischemia. Workup showed presence of lupus anticoagulant, thrombocytopenia, low C3 levels (Graph 1B), normal C4 levels, and arterial thrombi in the upper and lower extremities. Prior to initiation of treatment, respiratory status declined due to massive pulmonary embolus. He died after PEA arrest shortly thereafter. Patient 3 is a 63-year-old male with chronic ITP and APS on warfarin, maintenance rituximab and intermittent apheresis admitted with worsening renal dysfunction in April 2019. Workup demonstrated acute on chronic thrombocytopenia, elevated APLA, and normal C3 and C4 levels (Graph 1C). Renal replacement therapy was commenced and he was discharged to receive ongoing outpatient therapy. Patient 4 is a 35-year-old male with history of SLE and APS admitted in April 2019 with renal failure, anemia and thrombocytopenia. Workup showed presence of APLA. Despite therapy with steroids, IVIG, rituximab and TPEX he became anuric with renal biopsy showing thrombotic microangiopathy. He was also bacteremic with a mitral valve vegetation for which he underwent valve replacement. Hospital course was complicated by need respiratory failure necessitating intubation and ECMO. C3 levels were consistently low, but varied throughout his long admission (Graph 1D) and were not necessarily related to his clinical course (sepsis, ECMO, etc.). C4 levels were normal. Conclusions: Complement levels were variable among the patients in this case series. Three out of four patient had low C3, while only one patient had low C4. Further, complement levels did not improve in one patient after administration of eculizumab. Routine laboratory testing for C3 and C4 may not be optimal assays for monitoring disease status in CAPS. More specialized complement testing, such a C5 a/b, may be more appropriate especially in the setting of eculizumab use. While eculizumab is typically used in refractory disease, it may be pertinent to move this therapy into early line treatment to achieve better outcomes in certain clinical scenarios. Identification of a more specific biomarker to recognize cases in need of early therapy is warranted. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Eculizumab, a humanized monoclonal IgG antibody that binds to complement protein C5, is discussed for its off-label use in the treatment of catastrophic antiphospholipid antibody syndrome.

Echocardiographic Parameters Continue to Improve in Patients with Self-Expandable Transcatheter Aortic Valve for Failing Bioprosthetic Aortic Valve Replacement

Since the initial TAVR in a degenerated surgical aortic bioprosthesis (ViV TAVR) in 2007, 1 ViV TAVR has grown in prominence in treating degenerative aortic bioprosthetic valves. Coupled with the c...

Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Left-Sided Heart Valve Surgery

New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are conflicting. In addition, data on stroke prophylaxis in this setting are lacking. To assess the long-term risk of thromboembolism in patients developing new-onset POAF after isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF). This observational cohort study was conducted from January 1, 2000, through December 31, 2015, using Danish nationwide registries and the Eastern Danish Heart Surgery Database. Patients who developed POAF after isolated left-sided heart valve surgery (bioprosthetic aortic or mitral valve replacement and/or aortic or mitral valve repair) from 2000 through 2015 were included. These patients were matched with patients with nonsurgical NVAF in a 1:3 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Data analyses took place from January to March 2019. Rates of thromboembolism. Of the 1587 patients who underwent isolated left-sided heart valve surgery, 741 patients (46.7%) developed POAF during admission. Of the 712 patients with POAF who were eligible for matching, 675 patients were matched with 2025 patients with NVAF and made up the study population. In the matched study population, the median age was 71 (interquartile range, 65-77) years, and 1600 (59.3%) were men. Oral anticoagulation therapy was initiated within 30 days postdischarge in 420 patients with POAF (62.9%) and in 1030 patients with NVAF (51.4%). The crude incidence rates of thromboembolism were 21.9 (95% CI, 17.4-27.6) and 17.7 (95% CI, 15.2-20.6) events per 1000 person-years for patients with POAF and patients with NVAF, respectively. In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio, 1.22 [95% CI, 0.88-1.68]). Oral anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (hazard ratio, 0.45 [95% CI, 0.22-0.90]) as well as patients with NVAF (hazard ratio, 0.63 [95% CI, 0.45-0.87]) compared with no anticoagulation therapy. New-onset POAF after isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism as NVAF. These data warrant studies addressing the role of anticoagulation therapy in POAF after left-sided heart valve surgery.

AUTOIMMUNITY TRIGGERED BY IMMUNOTHERAPY: A CASE OF AUTOIMMUNE HEPATITIS-INDUCED BY NINTEDANIB TREATMENT FOR IPF

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease characterized by progressive loss of lung function, dyspnea and impairment in quality of life.1 Nintedanib is a tyrosine kinase inhibitor approved for treatment of IPF which can reduce the annual rate of decline in forced vital capacity.2 Nintedanib’s adverse effects are managed symptomatically, by dose reduction or treatment interruption.3 We present a case of drug induced autoimmune hepatitis associated with Nintedanib. CASE PRESENTATION: A 59-year-old male with 19 pack year smoking history, COPD GOLD group B, GERD and CAD who initially presented to his PCP 2 years prior with dyspnea. Patient underwent CABG and bio-prosthetic aortic valve replacement, but dyspnea persisted. PFTs showed a restrictive pattern and reduced DLCO. Chest CT showed mild centrilobular emphysema, coarse interstitial markings and bilateral pleural-parenchymal scarring with early honeycombing in the lung bases, highly suggestive of pulmonary fibrosis. Workup for secondary causes of fibrotic lung disease including connective tissue diseases and barium swallow test were negative. He was diagnosed with IPF and was started on Nintedanib within a month. Pretreatment liver function tests (LFTs) were normal. Three months into treatment, Nintedanib was discontinued due severe nausea, vomiting and diarrhea. LFTs at this time were significant for ALP 471, AST 139 and ALT 189. Liver ultrasound showed fatty infiltration and chronic liver disease workup was negative except for gamma-globulin elevation. Repeat LFTs 4 weeks after stopping Nintedanib were persistently elevated while liver biopsy showed active lobular, portal hepatitis and mild focal fibrosis. Patient was diagnosed with drug-induced autoimmune hepatitis and started on Prednisone which led to normalization of liver enzymes. Liver panel worsened when prednisone was tapered, and therefore Azathioprine was started as a steroid sparing agent. Patient continues to be on Prednisone and Azathioprine and is undergoing workup for lung transplant. LFTs improved to normal limits on current treatment. DISCUSSION: Hepatitis is a potential complication associated with Nintedanib use 4. Mechanism of hepatocellular injury remains unclear but is thought to be due to epidemiologic variances in tolerability.5 Current recommendations are to monitor LFTs every 3 months while on Nintedanib. CONCLUSIONS: A literature review did not yield other cases of Nintedanib causing drug induced autoimmune hepatitis. Nintedanib’s adverse events are still not well known, making the documentation of cases such as this one important to aid in the monitoring of patients undergoing therapy. Reference #1: Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011;183:788–824.https://doi.org/10.1164/rccm.2009-040G. Reference #2: Richeldi L , Cottin V , du Bois RM , et al . Nintedanib in patients with idiopathic pulmonary fibrosis: Combined evidence from the TOMORROW and INPULSIS(®) trials. Respir Med 2016;:74–9.https://doi.org/10.1016/j.rmed.2016.02.001 Reference #3: Richeldi L , du Bois RM , Raghu G , et al . Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. N Engl J Med 2014 2071;370 82:2071–82.https://doi.org/10.1056/NEJMoa1402584 DISCLOSURES: Speaker/Speaker's Bureau relationship with boehringer ingleheim Please note: $20001 - $100000 Added 03/13/2019 by Tariq Cheema, source=Web Response, value=Honoraria No relevant relationships by Muhammad Asad Faruqi, source=Web Response No relevant relationships by Ayla Gordon, source=Web Response No relevant relationships by Melissa Mosley, source=Web Response No relevant relationships by Erica Rabold, source=Web Response

CONTEMPORARY OUTCOMES OF AORTIC AND MITRAL VALVE SURGERY FOR RHEUMATIC HEART DISEASE IN SUB-SAHARAN AFRICA

There is a paucity of data on outcomes of valvular surgery for end-stage rheumatic heart disease (RHD) in the developing world. The objective of this study was to evaluate the outcomes of aortic and mitral valve surgery for RHD in Ethiopia. From 2009 to 2016, 193 patients with end-stage RHD underwent aortic and/or mitral surgery at a single center in Ethiopia. These surgeries were performed in the context of 22 international humanitarian missions. Median follow-up was 2.6 (IQR: 0.5–3.8) years and 96% complete. The primary outcome was all- cause mortality. The secondary outcome was a composite of major adverse valve-related events (MAVRE): death, reoperation, stroke, major bleeding, endocarditis or structural valve deterioration. Median age was 16 (IQR: 13–22) years and 107 (55%) patients were female. Ten (5%) patients had undergone at least one previous cardiac operation. Surgery consisted of aortic valve (AV) surgery (n=24, 12%), mitral valve (MV) surgery (n=120, 62%), or double valve (aortic and mitral) surgery (n=49, 25%). Concomitant interventions included tricuspid valve repair (n=57, 30%), tricuspid valve replacement (n=3, 2%), and left atrial appendage closure (n=17, 9%). Of the 73 patients who underwent AV surgery, 22 (30%) underwent AV repair, 23 (32%) bioprosthetic AV replacement, and 28 (38%) mechanical AV replacement. Of the 169 patients who underwent MV surgery, 78 (46%) underwent MV repair, 37 (22%) bioprosthetic MV replacement, and 54 (32%) mechanical MV replacement. Mitral repair techniques included annuloplasty (n=63, 80%), commissurotomy (n=46, 58%), papillary muscle splitting (n=36, 46%), leaflet patch enlargement (n=28, 35%), and neo-chordae (n=19, 24%). In-hospital mortality occurred in 5 (2.6%) patients. Other complications included stroke (n=3, 2%), myocardial infarction (n=3, 2%), and re-exploration for bleeding (n=7, 4%). Freedom from all-cause mortality (panel A) and MAVRE (panel B) are presented in the Figure, stratified by the type of prosthesis implanted (no prosthetic valve, n=70; ≥ 1 bioprosthesis, n=55; ≥ 1 mechanical valve, n=68). Patients who received ≥ 1 bioprosthetic valve had a lower 5-year survival compared with those who received ≥ 1 mechanical valve or no prosthetic valve. At 5 years, freedom from MAVRE was significantly better for patients who received ≥ 1 mechanical valve, compared with those who received ≥ 1 bioprosthetic valve or no prosthetic valve. Left-sided valve surgery for end-stage RHD in sub-Saharan Africa is associated with a high incidence of MAVRE at follow-up. The use of bioprosthetic valves is associated with poor outcomes in this population.