Critical Aortic Stenosis Research Articles

Does Fetal Intervention Make a Difference of Postnatal Outcome?

The recent advance of fetal intervention for many disease including congenital heart disease(CHD) believes to improve the outcome of postnatal life. However the reality of postnatal outcome by fetal intervention remains diverse, especially in CHD. The target disease of FI for CHD at current era are critical aortic stenosis (AS) , hypoplastic left heart syndrome with intact atrial septum (HLHS+IAS), and pulmonary atresia with intact ventricular septum(PAIVS). Those FI underwent by ultrasound guide and in limited institute. To discuss the outcome of FI, we must consider case-selection and technical bias. There was no randomized case-control study of FI on postnatal outcome, yet. The large-volume institute of FI reported a promising result of FI on postnatal life, however those of the all institute but such a large-volume one undergoing FI could not demonstrate a clear difference of postnatal outcome, especially in cases with HHS-IAS or PAIVS , even in cases with AS. Some cases became even worse after FI in the light of survival rate or has no change. The answer to the title question is “unclear” at present, but may improve by accumulating the experience of FI institute via registry and by establishing the optimal protocol or FI.

651 - Long-term functional and myocardial assessment in patients with critical aortic valve stenosis

651 - Long-term functional and myocardial assessment in patients with critical aortic valve stenosis

ВОЗМОЖНОСТИ ИНТЕРВЕНЦИОННОЙ КОРРЕКЦИИ КРИТИЧЕСКОГО АОРТАЛЬНОГО СТЕНОЗА: СОВРЕМЕННОЕ СОСТОЯНИЕ ПРОБЛЕМЫ И ПЕРСПЕКТИВЫ

The paper studies the issues of aortic stenosis etiology and pathogenesis, clinical assessment of severity based on the distinct symptoms of decompensated aortic defect and echocardiographic measures, and modern methods of aortic stenosis correction. Valve replacement is well known as the «gold standard» in the treatment of aortic stenosis. However, the older-age-group patients with different attendant pathologies are likely to have re-operative complications during the valve replacement operation. The alternative methods of aortic stenosis treating are balloon valvuloplasty and transcatheter implantation of the aortic valve. Analyzing the experience of using the minimally invasive methods of critical aortic stenosis correction convincingly shows reduction of re-operative danger among older-age-group patients with different attendant pathologies and persuades to hospitalize old-aged comorbid patients with significant degrees of aortic valve stenosis and advanced degrees of heart failure to special medical centers. There patients can get an integrated approach to the treatment of this disease that leads to improving treatment results and favorable prognosis in this challenging group of patients.

Изучение непосредственных результатов хирургического лечения критического аортального стеноза у пациентов старше 70 лет в условиях искусственного кровообращения

Изучение непосредственных результатов хирургического лечения критического аортального стеноза у пациентов старше 70 лет в условиях искусственного кровообращения

Single Centre Experience With the Ross-Konno Procedure for Critical Aortic Stenosis in the Paediatric Population

Single Centre Experience With the Ross-Konno Procedure for Critical Aortic Stenosis in the Paediatric Population

Abstract 13178: A Novel, Data-Driven Approach to Classify Critical Left Ventricular Outflow Tract Obstruction Using Pre-Intervention Echocardiographic Measurements: A Report From The Congenital Heart Surgeons’ Society Data Center

Objective: Critical left ventricular outflow tract obstruction (LVOTO) has been traditionally classified by aortic and mitral valvar pathology. We aimed to determine if baseline qualitative and quantitative echocardiographic measures alone could define new groups of patients with greater clinical relevance. Methods: Pre-intervention transthoracic echocardiograms for 651 neonates with Critical LVOTO were interpreted by one pediatric cardiologist according to a standardized protocol. Cluster analysis, with 136 echocardiographic measures, was used to group the patients. Variables defining each group were identified by multinomial regression. Results: Cluster analysis categorized the 651 neonates into groups of 215 (Group 1), 338 (Group 2), and 98 (Group 3) patients (Panel A). Aortic valve atresia and left ventricular (LV) end diastolic volume were identified as significant discriminating variables. LV size was largest in Group 3 and smallest in Group 2. Aortic atresia was most prevalent in Group 2 and least prevalent in Group 3. The distribution of these and other variables is shown in Panel B. Balloon valvotomy was the first intervention in 9% (19/215), 2% (6/338), and 61% (60/98) (p<0.0001). In those with an initial operation, single ventricle palliation was performed in 90% (176/215), 98% (326/338), and 58% (22/38) (p<0.0001). Overall mortality in each group was 27% (59/215), 41% (138/338), and 12% (12/98) (p<0.0001). Conclusions: Using a completely data-driven approach, we identified three novel groups, primarily based on baseline LV size, that correlate with management strategy and overall mortality. These groups roughly correspond anatomically with multi-level LV hypoplasia, hypoplastic left heart syndrome, and critical aortic stenosis, respectively. Our analysis suggests that a more useful classification of critical LVOTO may require more detailed measurements, especially of LV size, than a simplistic scheme limited to valvar pathology.

Unconventional methods of treatment critical aortic stenosis

Unconventional methods of treatment critical aortic stenosis

Operating the blues.

Key Clinical MessageA 63‐year‐old man bearing most signs and symptoms (facial pigmentation, degenerative arthritis, and dark urine) pertinent to his known history of alkaptonuria underwent aortic valve replacement for critical aortic stenosis. Although rare, aortic stenosis is the most common cardiac manifestation of alkaptonuric ochronosis.

OC15.05: Prenatal percutaneous valvuloplasty for critical aortic and pulmonary stenosis: 5 years' experience in a single centre

OC15.05: Prenatal percutaneous valvuloplasty for critical aortic and pulmonary stenosis: 5 years' experience in a single centre

The mid-term outcome of primary open valvotomy for critical aortic stenosis in early infancy - a retrospective single center study over 18years.

BackgroundThe objective of this study was to examine early and long-term results of surgical aortic valvotomy in neonates and infants aged less than four months and to identify predictors of outcome.MethodsBetween August 1994 and April 2012, 83 consecutive patients younger than 4 months of age underwent open heart valvotomy for critical aortic stenosis in our institution. Median age was 17 days (range 0-111 days). We examined clinical records to establish determinants of outcome and illustrate long-term results.ResultsFifty-six patients (67 %) were neonates. Associated cardiac malformations were found in 24 patients (29 %), including multilevel left heart obstruction in 5. The median follow-up was 4.2 years. The time-related survival rate was 87 and 85 % at 5 and 15 years, respectively. The time-related survival without reintervention was respectively 51, 35 and 18 % at 5, 10 and 15 years. The time-related survival without aortic valve replacement was respectively 67, 54 and 39 % at 5, 10 and 15 years. Ventricular dysfunction (p = 0.04), delayed sternal closure (p = 0.007), endocardial fibroelastosis (p = 0.02) and low z-score of the aortic annulus (p = 0.04) were found predictors of global mortality. Ventricular dysfunction (p = 0.01) and endocardial fibroelastosis (p = 0.04) were found predictors of reintervention.ConclusionsThe experience, in our center, on the management of critical aortic stenosis, shows a low early and late mortality, but the aortic valvotomy is a palliative procedure and we see unfortunately a high rate of reintervention among which the aortic valve replacement. These results suggest to reconsider the use of aortic balloon valvotomy, and particularly for the neonates with a low cardiac output in order to avoid the myocardial stress and the neurological injury due to the cardiopulmonary bypass.

Simultaneous Transcatheter Aortic Valve Implantation and Drive-By Endovascular Aortic Aneurysm Repair with the Lotus Valve System

A 79-year-old man with severe, but stable, long-standing chronic obstructive pulmonary disease (COPD; FEV1 22%) was recently found to have a 6cm infrarenal fusiform abdominal aortic aneurysm (AAA) (figure A). He presented with progressively worsening breathlessness, disproportionate to his COPD, and echocardiography demonstrated critical calcified aortic stenosis (AS; mean gradient 93mmHg, aortic valve area 0.6cm2) with normal ejection fraction. He was deemed to be at prohibitive surgical risk by the Heart Team and therefore simultaneous endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR) was recommended. CT revealed good calibre ileofemoral arteries and aortic annular dimensions suitable for a 25mm Lotus device (Boston Scientific, MA). Due to severe COPD, the procedure was performed under spontaneous ventilation general anaesthesia with laryngeal mask. The procedural strategy was to perform balloon valvuloplasty first (12x40mm Armada balloon), followed by EVAR (Cook Zenith Endovascular graft, figure B) and then TAVR. The 25mm Lotus valve adopted a barrel-shape suggestive of an undersised valve (figure C), so the decision was to replace it with a 27mm valve. The Lotus delivery system passed easily through the EVAR stents and deployment was successful. Post procedural transthoracic echo revealed no paravalvular regurgitation. Severe AS and AAA are increasingly prevalent and management of both simultaneously increases the complexity and risk of the procedure. We report here for the first time a successful simultaneous EVAR/TAVR procedure using the fully repositionable and retrievable Lotus Valve System.

Determinants of Type II and Type III Aortic Arch in Humans

Introduction: Based on the level of the great arch vessels take:off, three types of aortic arches (AA) have been described in humans, namely Type I, II and III. There are no definitive studies identifying the potential causation of these anatomical variations. We hypothesized that a continual downward drag of a vigorously beating hypertrophied heavier heart over time causes rightward aspect of aortic arch to shift caudad resulting in type II and III arches. Methods: We reviewed 111 consecutive CT scans of the chest with contrast in patients who also happened to have a 2D echocardiogram performed within the preceding year. AA type was determined by CT scan and then patients’ baseline characteristics and echocardiographic parameters including, but not limited to LV ejection fraction (LVEF), LV mass, LV mass index, LV weight (LV mass plus mass of blood contained in LV cavity) and relative wall thickness were analyzed. After the exclusion of bovine AA, complete data was available in 61 patients. The relationship between these variables and AA type was then tested in univariate and multivariate statistical models. Results: Univariate analysis revealed increased age, LV mass, LV weight, and LVPWd had significant correlation with Type II and III AAs. However, after multivariate analysis only increased age and LV weight remained independent predictors of AA type. Incidentally, 10 of 11 elderly patients with critical aortic stenosis being evaluated for TAVR had a Type III arch. Conclusion: Advanced age and LV weight (LV mass plus mass of blood contained in LV cavity) are the most powerful predictors of Type II/III AAs.

Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

Tissue Doppler imaging in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome before and after fetal aortic valvuloplasty.

Fetal aortic valvuloplasty can improve filling and reduce afterload of the left ventricle in critical aortic stenosis. Success of an intrauterine intervention is currently measured by technical success, clinical survival and eventual postnatal biventricular physiology. In the present study we investigated the use of tissue Doppler imaging (TDI) to evaluate changes in ventricular function assessed before and after prenatal aortic valvuloplasty. Between October 2008 and December 2012, cardiac function was assessed by TDI before and after intervention in 23 fetuses that underwent technically successful valvuloplasty for critical aortic stenosis and in which postnatal outcome was known. The measurements were transformed into gestational age-independent Z-scores where appropriate. Mean ± SD gestational age at intervention was 27.5 ± 3.1 weeks. Of the 23 fetuses, 14 had biventricular outcome. Before intervention all left ventricular (LV) TDI-derived parameters and mitral annular plane systolic excursion (MAPSE) were severely abnormal. It was possible to demonstrate considerably improved cardiac function after technically successful valvuloplasty. Among fetuses with postnatal biventricular outcome, TDI-derived LV myocardial peak velocity during early diastole (E') and myocardial peak velocity during systole in the ejection phase (S') significantly increased, E'/myocardial peak velocity during late diastole with atrial contraction (A') increased towards normal values, and LV transmitral-to-mitral-annular diastolic velocity ratio (E/E') and myocardial performance index (MPI') decreased but remained abnormally elevated. In addition, right ventricular A', S' and MPI' significantly improved after intervention. Technically successful fetal aortic valvuloplasty led to significantly improved myocardial performance. It was possible to use TDI to detect distinct changes in ventricular function and TDI-derived parameters correlated with a biventricular outcome after birth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Balancing the Risks of Thrombosis and Bleeding Following Transcatheter Aortic Valve Implantation: Current State-of-Evidence.

While transcatheter aortic valve implantation (TAVI) has rapidly evolved as an acceptable alternative to conventional surgical aortic valve replacement in elderly, high-risk surgical candidates with critical aortic stenosis, thrombotic and bleeding complications remain relatively frequent and potentially life-threatening. Thrombotic events during and following TAVI relate to the dynamic interplay between the systemic burden of atherosclerotic disease, atrial arrhythmias, device and native aortic valve interactions, as well as platelet and coagulation cascade activation. Bleeding in the acute setting relates primarily to access site vascular complications, but also appears related to pre-existing renal impairment and anemia. Current pre-, peri- and post-procedural anti-thrombotic regimens are empirical, based on expert consensus following extrapolation from the wealth of experience gleaned following percutaneous coronary intervention. However the complexities of the TAVI procedure, the high-risk clinical substrate and competing effects of anti-thrombotic regimens and bleeding risk are yet to be prospectively assessed in randomized clinical trials for defining evidence-based anti-thrombotic strategies.

TRANSCATHETER AORTIC VALVE IMPLANTATION IN PATIENTS WITH PREVIOUS EXTERNAL BEAM RADIOTHERAPY

Exposing the heart to external beam radiotherapy (EBRT) increases the risk of heart disease sevenfold. We report 23 patients with previous EBRT and critical aortic stenosis (AS) who were treated with transcatheter aortic valve implantation (TAVI). Of the 424 consecutive patients who underwent TAVI

Registry report of structural and functional cardiac abnormalities diagnosed by echocardiography in an asymptomatic population

BackgroundThe epidemiology of heart disease is changing, with rheumatic heart disease becoming less common but degenerative valve disorders, heart failure and atrial fibrillation (AF) increasing.ObjectiveWe sought to determine the prevalence...

EFFICACY AND SAFETY OF SINGLE STAGE ENDOVASCULAR INTERVENTIONS WITH TRANSCATHETER IMPLANTING OF AORTIC VALVE

Transcatheter implanting of aortic valve (TIAV) in critical aortic stenosis is a separate manipulation requiring thorough preparation. Among patients with critical aortic stenosis from a group of endovascular correction, there is a high prevalence of comorbid atherosclerotic lesions in coronary, carotid arteries, and other pathologies, manageable only interventionally. Aim . To assess the efficacy and safety of single-moment performing of TIAV and additional endovascular interventions. Material and methods. From the year 2011, in our clinic endovascular implanting of aortic valve was done for 125 patients with aortic valve dysfunction, in 51% (64 patients) had coronary, renal and carotid arteries lesion, aneurysmatic dilation of abdominal aorta. In 31 (48%) cases together with endovascular valve placement additionally endovascular interventions were done. Results. Technical success was reached in all 125 cases. In-patient mortality from all causes was 7.2% (9 patients), with no significant difference between combination treatment group and other patients. In 2 cases there was stenting done, of coronary and carotid arteries (with 1 case of coronary, carotid and renal arteries), as single step. In one patient there was endovascular prevention done of ischemic complications of permanent atrial fibrillation by implanting of the system Watchman (Boston Scientific, USA) and stenting of coronary arteries; in one case a single step endoprosthesing of abdominal aorta was done and coronary stenting. In concomitant interventions group there was no myocardial infarction and no significant difference in cerebrovascular events between groups. Conclusion. TIAV can be followed by single step addition of endovascular procedures if the surgical team and clinics has good experience, and with thorough planning of operation and post-surgery period.

THE PROGNOSIS IN TRANSCATHETER AORTIC VALVE IMPLANTATION

Aim. To study the effect of transcatheter aortic valve implantation (TAVI), performed by different types of prostheses and various surgical access, on the prognosis of patients with critical aortic stenosis and comorbidities. Material and methods. Patients (n=130) that had consistently performed 80 TAVI by Edwards valve transfemoral (n=50) and transapical (n=30) access, as well as 50 transcatheter aortic valve replacement by CoreValve system were included into the study. Complications including perioperative mortality, total 30-day mortality, as well as post-hospital mortality were registered during aortic valve replacement, immediately after surgery, before the expiry of 30 days. Mean follow-up was 2.2 years (range 0.2 to 5.2 years). Results. Hospital mortality was on average 6.9%. 121 patients had been discharged from the department after the surgery. The number of deaths in the post-hospital period was 14.8%. Valve type and the type of access had no effect on post-hospital mortality. Men died more than 2.5 times often than women, regardless of age. Atrioventricular block, pacemaker implantation, and history of chronic obstructive pulmonary disease were the most significant prognostic factors. An important role of minor stroke and renal failure should be noted. Mortality did not depend on the surgical access or valve type. All parameters characterizing the intervention were significantly associated with mortality, both during and after surgery. The proportion of survivors at the end of the first year of observation using Corvalve system was 86.9%, Edwards valve by transfemoral access - 88% and Edwards valve by transapical access – 85.4% (insignificant differences for all groups, p>0.05). Two-year survival was 77.5%, 82.5% and 82.7%, respectively (also insignificant differences for all groups, p>0.05). Conclusion. TAVI is the method of choice, reasonable alternative approach for surgical valve replacement in patients with high surgical risk, although mortality after TAVI is still quite high and amounted to 6.9% in our study. It makes it possible to extend life and improve its quality that is of great social importance in the global trend of an aging population.

Fetal Cardiac Intervention：過去・現在・未来

Fetal cardiac intervention has developed over the last two decades in Europe and North America to prevent irreversible deterioration in the fetal heart caused by morphological cardiac malformation. Technique, patient selection, and effects of the intervention have been clarified through challenges faced by fetal cardiologists worldwide. The intervention is performed by direct puncture of the fetal heart through the maternal abdomen. The procedure is significantly invasive for the fetus and requires a high level of surgical skill. Severe congenital heart diseases, including critical aortic stenosis, pulmonary atresia with intact ventricular septum, and hypoplastic left heart syndrome with highly restrictive foramen ovale, are targets for the intervention. Fetal cardiac intervention is an important treatment for severe congenital heart disease in utero and is desired early introduction into clinical practice in Japan.