Bioprosthetic Replacement Research Articles

Incidence and factors associated with mitral valve reoperation in patients undergoing surgery for mitral regurgitation: A nationwide cohort study

BackgroundWhen patients undergo surgery for mitral regurgitation, risk of reoperation is of concern. AimsTo examine the incidence and factors associated with mitral reoperation following surgery for mitral regurgitation according to type of surgery. MethodsPatients undergoing first-time surgery for mitral regurgitation, 1996–2021, were identified from nationwide registries. According to index surgery, the population was categorized into 1) mitral repair; 2) mechanical prostheses; 3) bioprostheses. Patients were followed from discharge with a maximum of 15 years of follow-up and cumulative incidence of reoperation was examined. Multivariable Cox analysis was used to examine factors associated with reoperation. ResultsWe identified 6958 patients: 4624 with mitral repair (72 % male, median age 66), 1250 with mechanical prosthesis (52 % male, median age 59), and 1084 with bioprosthesis (57 % male, median age 74). Cumulative incidence of reoperation was 7.3 % for repair (median 7.2 years follow-up), 6.1 % for mechanical prostheses (median 10.9 years follow-up), and 7.1 % for bioprostheses (median 4.5 years follow-up). Within first year, 22.6 % of reoperations were preceded by infective endocarditis. In long-term follow-up, bioprosthetic replacement was associated with a higher reoperation rate, while increasing age, male sex and mechanical prosthesis were associated with lower reoperation rate. ConclusionsIn patients operated for mitral regurgitation, reoperation was infrequent at approximately 7 % for all intervention types during a maximum of 15-year follow-up. In adjusted analysis, bioprosthetic replacement was associated with a higher rate of reoperation, while increasing age, male sex and mechanical prosthesis was associated with a lower rate of reoperation.

Clinical characteristics and long-term outcome of patients with bioprosthetic mitral valve- Experience from a South Asian country.

Due to rheumatic heart disease, young people are more likely to develop valvular heart disease in developing countries. In countries like Pakistan, surgeons implant more bioprosthetic mitral valves (MVs) in younger patients. However, bioprosthetic valves degenerate rapidly in younger people, leading to bioprosthetic MV dysfunction (BMVD). This study aims to evaluate the clinical characteristics and long-term outcomes of patients with bioprosthetic MV replacement (MVR) at a tertiary care hospital in a South Asian country. This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bioprosthetic MVR from the year 2006 to 2020. Clinical and surgical characteristics along with transthoracic echocardiographic findings (pre-surgery and recent most follow-up studies) were noted. Follow-up data were also collected. Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. MVR was done as an elective procedure due to the New York Heart Association (NYHA) II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 ± 2.99 years, BMVD was observed in 183 (36.5%) patients. However, re-do MV surgery was done in only 49 (9.8%) patients. Patients were divided into two groups based on normal functioning bioprosthetic MV and BMVD. Comparing the two groups, individuals with normal functioning bioprosthetic MV had a mean age of 51.6 ± 14.27 years, while those with BMVD had a mean age of 45.639 ± 14.33 years at the time of index surgery (P = 0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%), and death (n = 6, 3.28%) in the BMVD group which were statistically significant. This study is distinct because it demonstrates the outcomes of bioprosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bioprosthetic valve in younger patients, significant number of patients developed BMVD along with poor long-term clinical outcomes, even at a short follow-up period of <10 years. These findings are similar to international data and signify that mechanical MVR may be a more reasonable alternative in younger patients.

Uncut Gemella Haemolysans: A Case of Bacteremia with No Clear Entry Site

Background: Gemella haemolysans is a gram-positive coccus that colonizes the genitourinary system, gastrointestinal system, and upper respiratory tract as an opportunistic pathogen. Berge et al. found that the frequency of Gemella species bacteremia was 4.5 and infective endocarditis was 0.31 per 1,000,000 inhabitants yearly. We report the first case of G. haemolysans bacteremia presenting as new-onset atrial fibrillation with rapid ventricular response (RVR) and acute respiratory failure and present a case series on G. haemolysans bacteremia and infective endocarditis. Case Presentation: A 58-year-old male with a past medical history including aortic valve bioprosthetic replacement, type 2 diabetes, hypertension, and coronary artery stenting and bypass surgery presented with shortness of breath and confusion. Examination and testing revealed a 40.4°C fever, acute respiratory failure, atrial fibrillation with RVR, congestive heart failure, lactic acidosis, and acute renal failure, with no drug use, dental wounds, or pneumonia. Diltiazem, metoprolol, aspirin, atorvastatin, insulin, heparin, and ceftriaxone were started. TTE and TEE revealed no clear vegetations. Blood cultures revealed Gemella haemolysans. He became stable after 4 days, was electrically cardioverted to sinus rhythm with first-degree AV block, progressed to complete heart block, then had a temporary pacer placed. A repeat TEE demonstrated an aortic root abscess. He underwent redo sternotomy and homograft placement with no complications and was discharged with instructions to complete a six-week course of ceftriaxone. Discussion: Our patient presented with multiple comorbidities at a younger age compared to the mean (66) and median (70) age of the 4 bacteremia cases in our 8-case series. Preemptive antibiotic treatment may be warranted for prosthetic heart valve patients, with the possibility of urgent valve replacement surgery. Several antibiotics were previously reported in case studies with varying results. The shortest course was 16 days, with most courses lasting 4 to 7 weeks. With no standard treatment, this case series suggests G. haemolysans tends to be susceptible to beta-lactam agents. Conclusion: Our case highlights the importance of a multidisciplinary approach in the diagnosis and management of Gemella haemolysans bacteremia, particularly in patients with complex medical histories and prosthetic heart valves.

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study

Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown. New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status. The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups. In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

Features of infective endocarditis in a contemporary cohort of persons who inject drugs: a matched comparison analysis of long-term prognostic factors.

The objective of the study was to assess the short- and long-term mortality of infective endocarditis (IE) among people who inject drugs (PWID). Using prospectively collected data on hospitalized patients (years 2000 through 2021) with IE, PWID were identified and included in this study. Survival analysis was performed to analyze short- and long-term mortality and study their risk factors among PWID and a matched group of non-intravenous drug users (N-IDU). In a study of 485 patients admitted for IE, 55 (11%) of them were PWID. These PWID patients were 1:1 age- and sex- matched to an N-IDU group (N = 55 per group). Both groups had similar baseline comorbid conditions, including congestive heart failure, type 2 diabetes, and neoplastic diseases. However, PWID were more likely to have HCV co-infection (62% vs 16%, respectively, p < 0.001) and advanced liver disease/cirrhosis (52% vs 7.9%, respectively, p < 0.001). IE in PWID more often affected the tricuspid valve (42% vs 22%, respectively, p = 0.024) and presented with more embolic events (66% vs 35%, respectively, p < 0.01). S. aureus was the primary cause of IE in PWID (44% vs 21%, respectively, p = 0.01). After adjusting for other variables, PWID (HR = 2.99, 95% CI [1.06, 8.43], p = 0.038) and valve bioprosthetic replacement (HR = 5.37, 95% CI [1.3, 22.1], p = 0.02) were independently associated with increased mortality risk, whereas IE caused by tricuspid valve infection was associated with reduced mortality risk (HR = 0.25, 95% CI [0.06, 0.97], p = 0.046). In this cohort, PWID had increased risk of long-term mortality after hospital discharge for IE, when compared to matched N-IDU with similar baseline characteristics. The reasons behind the significant increase in mortality warrant further investigation.

Prevalence and Predictive Factors of Early Degeneration of Bioprosthetic Mitral Valves: A Single-Center Cohort Study

Background. Bioprosthetic mitral valves (MV) have limited durability. Dysfunction and degeneration of these valves can lead to reoperation and progressive heart failure. We investigated the frequency and predictors of MV bioprosthesis early degeneration within three years following MV replacement surgery. Methods. In this retrospective cohort study, we retrieved the data of consecutive patients who underwent bioprosthetic MV replacement through midsternotomy at Tehran Heart Center between 2013 and 2019. Based on the reviewed parameters of the bioprosthetic MV in the follow-up echocardiography, the patients were divided into two groups to compare the variables respecting early degeneration. Finally, the predictors of early degeneration were recognized using the Cox regression hazards model. Results. We reviewed and analyzed data of 177 patients from our hospital database. The mean age of the patients was 63.9 ± 11.7 years and 100 (56.5%) were women. 39 (22.0%) patients had experienced early degeneration and two (1.1% of the total) had died during the follow-up period. Patients in the degeneration group tended to have a history of stroke and renal failure, although not statistically significant. The sole independent predictor of early degeneration of bioprosthetic MV was a high MV mean gradient in the first postoperative echocardiography study (HR = 11.01, 95% CI: 4.80–25.24; P &lt; 0.001 ). Conclusion. About 22.0% of our patients had echocardiographic criteria for early degeneration, and according to our results, increased MV gradients (without considering the reason) in the first postoperative echocardiography were the sole independent predictor for it. Careful valve selection can be essential in reducing early degeneration.

Severe Aneurysmal Degeneration of a Freestyle Aortic Root Bioprosthesis

Freestyle aortic roots are increasingly becoming popular as a means of bioprosthetic root replacement. We report a rare complication of Freestyle roots: severe aneurysmal degeneration of the prosthesis over time necessitating complex re-operative surgery.

Aortic root geometry following composite valve graft implantation: Implications for future valve-in-valve procedures

ObjectivesBiological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions. MethodsWe retrospectively identified 64 patients following bioprosthetic CVG replacement with pre- and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation. ResultsIn 64 patients (age, 67.6 ± 9.3 years; 76.6% men) the preoperative coronary height was 14.3 ± 6.8 mm for the left coronary artery (LCA) and 17.9 ± 5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7 ± 4.4 mm for the LCA and 11.3 ± 4.4 mm for the RCA (P < .001). The virtual valve-to-coronary distances measured 4.0 ± 1.3 mm (LCA) and 4.6 ± 1.4 mm (RCA). Overall, 59.4% (n = 38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n = 19) for LCA, 10.9% (n = 7) for RCA, and 18.8% (n = 12) for combined LCA and RCA. ConclusionsCoronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruction in future valve-in-valve procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population.

PO-03-084 EFFECT OF RIGHT VENTRICULAR ENDOCARDIAL VS EPICARDIAL LEADS ON CLINICAL OUTCOMES IN PATIENTS WITH TRICUSPID VALVE PROSTHESIS

Endocardial right ventricular (EnRV) leads are described as potential cause of native tricuspid valve regurgitation (TR). Need for cardiac pacing by EnRV or epicardial (EpiRV) lead after tricuspid valve repair (TVr) or bioprosthetic replacement (bTVR) is common, but little is known about their effects post-operatively. Assess clinical outcomes, such as TR, lead function, and risk of infection in patients with TV prosthesis followed by EnRV vs EpiRV lead implant. We retrospectively reviewed all patients with RV lead post-TVr or bTVR at our hospital between 1/2000-11/2022. These were divided in 2 groups: Grp 1 (patients with EnRV lead) and Grp 2 (patients with EpiRV lead). Primary outcome was change in TR and RV lead function at follow up. Level of TR was scored as 0 = none/trivial, 1 = mild, 2 = moderate, 3 = moderate-severe or severe. Pacing threshold change (Δ +/- SD V), need for revision/extraction, and death at follow up were noted. 64 patients were identified [Grp 1: n = 52 (56% female, 79% atrial fibrillation, 94% TVr, 6% bTVR) vs Grp 2: n = 12 (67% female, 42% atrial fibrillation, 42% TVr, 58% bTVR)]. In Grp 2, 58% had prior RV lead extracted intraoperatively due to lead-related TR vs 0% in Grp 1. In Grp 1, mean time from surgery to RV lead implant, last ECHO, and last device interrogation were 24, 77, and 83 months vs 0, 10.6, and 9 months for Grp2, respectively. TR worsened in Grp 1 only in 55% of TVr patients (mean 0.9 level). When compared to Grp 2, TR was significantly worse in Grp 1 vs Grp 2 (p = 0.029, FigA). This was particularly the case after TVr (FigB) and not bTVR (FigC). RV lead threshold significantly worsened in Grp 2 vs Grp 1 (55.5% vs 3.7%, p = 0.003); threshold increased significantly by Δ 1.18 +/- 2.05 V vs Δ 0.11 +/- 0.34 V (p = 0.026). Average threshold at follow up in Grp 2 was 2.02 +/- 2.13 V vs 0.737 +/- 0.27 V for Grp 1 (p = 0.05). Lead extraction occurred in 8% of patients in Grp 1 (25% endocarditis, 75% lead failure/malfunction) and 17% in Grp 2 (100% endocarditis). There were 28 deaths (Grp 1: 42%, mean follow up 97.9 months vs Grp2: 50%, mean follow up 14 months). In our study, presence of EnRV lead after TV surgery correlated with mild increase in TR after TVr but not bTVR. On the other hand, EpiRV lead threshold increased significantly over time compared to EnRV leads. EnRV lead is a suitable approach after TVr or bTVR.

Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement

ObjectiveDespite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. MethodsThis was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. ResultsA total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. ConclusionsOur results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.

Left Ventricular Outflow Tract Pseudoaneurysm Compresses Left Anterior Descending Artery: A Case Report and Review of Literature

A case of a 49-year-old man with a history of buprenorphine-substituted heroin was admitted for acute heart failure after three months of bioprosthetic aortic replacement to treat infective endocarditis. Transthoracic echocardiography (TTE) showed a left ventricular ejection fraction (EF) was 35% and a periprosthetic mass with an aorto-ventricular fistula. Thoracic computed tomography revealed a left ventricular outflow tract (LVOT) pseudoaneurysm measuring 69 x 45 mm that compressed left anterior descending (LAD) artery with downstream myocardial ischemia. Patient was treated by an urgent surgery, including an exclusion of the pseudoaneurysm, a left ventricular reconstruction surgery and a bioprosthetic aortic replacement. Patient went through a difficult postoperative period. Finally, he was safely discharged with a low EF (34%) from hospital to rehabilitation center with a Life vest. This case spotlights a rare devastating complication of a LVOT pseudoaneurysm compresses LAD artery and how surgery could decompress the false aneurysm and stabilize ischemia.

2-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Annular Calcification, Rings, and Bioprostheses

BackgroundThe MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study for valve-in-mitral annular calcification (ViMAC), mitral valve-in-ring (MViR), and mitral valve-in-valve (MViV) using balloon-expandable aortic transcatheter heart valves. Procedural outcomes beyond 1 year are not well described. ObjectivesThis study evaluated 2-year outcomes in ViMAC, MViR, and MViV in the MITRAL trial. MethodsThis multicenter prospective study enrolled patients with severe MAC, prior failed mitral annuloplasty ring repair, or prior failed bioprosthetic MV replacement who were at high surgical risk at 13 U.S. sites. ResultsBetween February 1, 2015, and December 31, 2017, 91 patients were enrolled (31 with ViMAC, 30 with MViR, and 30 with MViV). In the ViMAC group, 2-year all-cause mortality was 39.3%, 66.7% were New York Heart Association (NYHA) functional class I-II, and mean MV gradient was 5.6 ± 2.0 mm Hg. In the MViR group, 2-year all-cause mortality was 50%, 65% were NYHA functional class I-II, and mean MV gradient was 6.5 ± 2.7 mm Hg. In the MViV group, 2-year all-cause mortality was 6.7%, 85% were NYHA functional class I-II, and mean MV gradient was 6.9 ± 2.4 mm Hg. At 2 years, all patients had ≤mild mitral regurgitation and survivors in all 3 arms showed sustained improvement in Kansas City Cardiomyopathy Questionnaire scores compared to baseline. ConclusionsUse of balloon-expandable aortic transcatheter heart valves in selected patients with severe MAC, failed annuloplasty ring, and bioprosthetic MV dysfunction is associated with improvements in symptoms, quality of life, and stable prosthesis function at 2-year follow-up. Between 1 and 2 years, the MViR group experienced higher mortality rates than the MViV and ViMAC groups.

Abstract 14459: Case Report: Unusual Presentation of Cardiobacterium Hominis Bioprosthetic Valve Endocarditis

Introduction: Cardiobacterium hominis , part of the oropharyngeal flora, is a gram-negative bacteria reported to cause infection in less than 5% of patients with infective endocarditis (IE). In children, congenital heart disease (CHD) is a predominant risk factor for developing IE. Herein we describe an unusual presentation of C. hominis bioprosthetic valve endocarditis. Case Presentation: A 23-year-old woman with bicuspid aortic valve and aortic valve stenosis underwent aortic bioprosthetic valve placement in 2017. In March 2022, she presented to an emergency room with left lower abdominal pain. A CT scan demonstrated occlusion of the left iliac artery. Medications at that time included oral contraceptive pills and baby aspirin. No echocardiogram was obtained at that visit. She presented for a routine cardiology follow-up in May 2022 at which time she was asymptomatic. Transthoracic echocardiogram demonstrated moderate to severe aortic insufficiency, though the mechanism could not be delineated. There was concomitant development of mild mitral valve and tricuspid valve insufficiency. She denied dyspnea, chest pain, or fevers. Laboratory investigation showed mild elevation of CRP and a normal ESR. A transesophageal echocardiogram demonstrated that the severe aortic regurgitation was through a paravalvar leak (figure 1). There was no evidence of vegetations. Three separate blood cultures grew C. hominis . The patient was admitted for IV antibiotic therapy prior to bioprosthetic replacement. Conclusions: C. hominis is an infrequent cause of endocarditis and most cases present with fever and elevated ESR. This patient had an unusual presentation with left iliac thrombus, which in retrospect was likely due to embolism of a vegetation. She also developed aortic bioprosthetic paravalvar leak. This case highlights the need for a high degree of suspicion for endocarditis in patients with CHD and bioprosthetic valves.

Postoperative complications for the new Chinese and imported bioprosthetic surgical valves replacement

This study assessed structural valve degeneration (SVD) clinical difference of BalMedic and Edward bioprosthetic valves in Zhuzhou areas, Hunan province, China, in the past 6 years. From August 2016 to August 2022, Chinese bioprosthetic valves were implanted in 77 patients while imported valves were implanted in 64 patients, to compare their postoperative SVD. Results showed that, 4 patients (9.1%) underwent SVD after surgery for Chinese mitral valve replacement (MVR) group. In addition, 2 patients (6.3%) underwent SVD after procedure for the imported MVR group. Both of them showed no statistically significant difference (p &gt; 0.05). As for the Chinese AVR group, 3 patients (9.1%) underwent SVD after operation, and in contrast, as for the imported AVR group, 4 patients (12.5%) underwent SVD after surgery. Therefore, the short-term follow-up study in Zhuzhou area indicates good durability and efficiency of SVD, compared with its counterparts from Carpentier-Edwards PERIMOUNT Magna Ease, between mitral valve group and aortic valve group, (p&gt;0.05)

Risk factors and outcomes with surgical bioprosthetic mitral valve dysfunction

BackgroundThere are insufficient data regarding the risk factors associated with valve dysfunction of bioprosthetic valves in the mitral position This study aimed to investigate the factors associated with bioprosthetic mitral...

Periaortic scar-related ventricular tachycardia in patients with aortic valve replacement: transcatheter ablation is feasible and decisive

Abstract Funding Acknowledgements Type of funding sources: None. Background Aortic valve replacement (AVR) is a common procedure. While conduction disturbances are well-recognized complications, ventricular tachycardias (VTs) have not been widely reported neither described mainly because prosthetic valves represent a potential practical problem in the access to the ventricles, and this may limit the use of radiofrequency ablation (RF). Purpose and Methods We report three cases of periaortic scar-related VT in patients with AVR. Results The first case was a 85 years old (yo) man, with both aortic and mitral biological valve replacement. The left ventricular ejection fraction (LVEF) was normal and the clinical VT (left bundle branch block (BBB) and inferior axis, cycle length (CL) = 305 ms) was induced. Left ventricle (LV) was mapped with a retrograde transaortic approach: to cross safely the prosthesis, a 6-French (F) pigtail catheter was first placed in the ventricle; a 8.5-F Braided Guiding Introducer (SL1) was placed across the valve over a guidewire. The 8.5-F ablation catheter allowed to locate the VT origin underneath the septal portion of prosthetic aortic valve (PAV). The second case was a 85 yo man, with bioprosthetic AVR and replacement of the ascending aorta. LVEF was 40% with mild PAV degeneration. The clinical VT had left BBB morphology and inferior axis (CL = 352 ms). Transaortic approach was hampered by an unfavorable entry angle and by valve degeneration. Then we opted for the technique commonly used during transcatheter AVR: the access to the LV was obtained using a 6-F coronary catheter (AL1) and a stright tip 0.034" angiographic guidewire; subsequently a 8.5-F, 81 cm long, introducer sheath (SL0) was positioned across the PAV. The reentry circuit was mapped in the high anterior region, just below the PAV insertion. The third case was a 65 yo man, with mechanical PAV. LVEF was normal and the clinical VT had right BBB and left inferior axis (CL = 290 ms). After transseptal puncture, a steerable introducer was placed in left atrium. The mapping catheter allowed to identify early and fractional potentials in the anterior portion of PAV. In all cases, RF applications was delivered at the earliest ventricular activation site with termination of the VTs. Thereafter, no VTs could be induced. At 12 months follow-up, the patients are free of any VT relapses. Conclusions The most common origin of sustained monomorphic VT occurring after PAV is the surgical scar and catheter ablation is a feasible option. In case of mechanical PAV, the only practicable access is the transeptal one; on the contrary, with biological PAV the transaortic approach can also be used. In difficult cases, the access to the LV can be obtained with the technique routinely performed during transcatheter AVR.

PC-578-03 RIGHT ATRIAL ATYPICAL FLUTTER WITH 2:1 INTRA-ATRIAL BLOCK MIMICKING LEFT ATRIAL FOCAL AND LOCALISED REENTRANT TACHYCARDIA

Atrial-level blocks are known confounders for diagnosis of SVTs and commonly occur after previous linear ablation lesions. 1. To demonstrate importance of recognition of atrial-level block in SVT diagnosis and treatment. 2. To review underlying assumptions in using entrainment to localize SVT origins. 3. To discuss the importance of thorough biatrial mapping in determination of unclear SVT mechanisms. N/A A 74y M with a history of bioprosthetic MV replacement, atypical RA flutter ablation (2018), and permanent pacemaker (2020) for sick sinus syndrome presented with fatigue and 76% AF/AT burden. For index RA ablation, both an intercaval line using bridging scar near the atriotomy site anterior to the appendage and a cavotricuspid isthmus line were made. Tachycardia was induced via burst pacing. Initial entrainment from CS suggested a L-sided tachycardia. A Pentaray map of the tachycardia showed LA anteroseptal reentry with entrainment at the site giving a PPI-TCL < 30ms. PVI and anteroseptal line were performed which changed cycle length but not CS activation. LA re-mapping demonstrated focal breakout near RIPV; ablation lengthened cycle length to 290ms without rhythm cessation. After PVI confirmation, mapping of the RA showed 2:1 intra-atrial conduction in the lateral RA with 1:1 conduction in the septal RA (fig A). Mapping 1:1 areas of RA conduction showed a gap in previous IVC line with intact CTI block with the majority of the cycle length at the posteroseptal floor (fig B), immediately opposite the site of initial LA anteroseptal reentry (fig C). During ablation of IVC line gap, progressive lengthening of the TCL was noted followed by termination of rhythm without inducibility (fig D). Response to entrainment assumes 1:1 conduction through the entire circuit, and contributed to the appearance of a left sided tachycardia upon initial CS entrainment. The finding of a LA RIPV tachycardia upon remapping the LA after PVI is consistent with a separate focal tachycardia but could represent epicardial connections from the CS to the posterior LA.

Long-term outcomes of patients undergoing mechanical versus bioprosthetic aortic root replacement.

We evaluated the impact of valve type (mechanical vs. bioprosthetic) on survival after aortic root replacement (ARR). In a propensity-matched analysis, we evaluated consecutive operations from 2010 to 2018. Patients were identified using a prospectively maintained institutional database. Patients with infective endocarditis were excluded. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. Cox regression adjusted for age, sex, baseline comorbidities, and operative variables. Propensity score matching yielded 153 pairs of patients. A total of 893 patients were identified. We excluded 192 patients with endocarditis and evaluated 701 patients. Of these patients, 455 (64.9%) received a bioprosthetic valve, 246 (35.1%) received a mechanical valve. Median follow-up was 4.06 years. The proportion of aortic dissections and circulatory arrest as well as cardiopulmonary bypass and ischemic times were similar across groups (p = .207, p = .086, p = .668, p = .454, respectively). Operative mortality was significantly higher in the bioprosthetic valve group (7.9% vs. 2.4%, p = .004). Total length of hospital stay was longer (11.4 ± 11.0 vs. 9.5 ± 10.1, p < .001) and there was a higher proportion of prolonged postoperative ventilation >24 h (21.3% vs. 13.0%, p = .007) in the bioprosthetic group. Postoperative outcomes were similar, regarding stroke (p = .077), re-exploration for bleeding (p = .211), new dialysis requirement (p = .077), long-term bleeding complications (p = .561), and reoperations (p = .755). Mechanical valve replacement was associated with improved long-term survival (adjusted HR 0.42, 95% CI: 0.23-0.77, p = .005). These findings suggest that mechanical valves for ARRs may confer a survival benefit over bioprosthetic valves. Surgeon bias was likely to account for this survival advantage.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

First report of a percutaneous valve-in-Valve implantation of tricuspid valve in a systemic right ventricle.

Severe tricuspid regurgitation in corrected transposition of great arteries is treated with early bioprosthetic replacement to prevent right ventricular failure. When bioprosthesis degenerates, surgery on cardioplegic arrest further complicates right ventricular function. We report the first transcatheter valve-in-valve implantation of tricuspid valve in a systemic right ventricle in corrected transposition describing the modifications due to anatomical differences in these patients.