Mean Systolic Gradient Research Articles

One-Year Outcome of an Ongoing Pre-Clinical Growing Animal Model for a Tissue-Engineered Valved Pulmonary Conduit.

Objectives: A self-constructed valved pulmonary conduit made out of a de-cellularized porcine small intestinal submucosal extracellular matrix biological scaffold was tested in a chronic growing lamb model. Methods: The conduit was implanted in pulmonary valve position in 19 lambs. We monitored clinical, laboratory, and echocardiographic findings until 12 months after surgery. In two animals, euthanasia was planned at nine and twelve months. Pre-mortem chest computed tomography and post-mortem pathologic work up were performed. Data are presented as frequency and percentage, median and range, or mean and standard deviation. Results: Twelve (63.2%) animals survived the perioperative period. Three unexpected deaths occurred during the follow-up period: one due to aspiration pneumonia at 23 days after surgery, and two due to early and late infective endocarditis of the conduit at 18 and 256 days. In the two animals with planned scarification, the pre-mortem CT scan revealed mild or no calcification within the conduit or valve leaflets. In the echocardiographic examination at 12 months, peak and mean systolic pressure gradients across the conduit valve were 6.5 (3-21) mmHg and 3 (2-12) mmHg, while valve regurgitation was none (n = 2), trivial (n = 5), moderate (n = 1), or severe (n = 1). No clinical or laboratory signs of hemolysis were seen. After 12 months of follow-up, the animals' body weights had increased from 33 (27-38) kg to 53 (38-66) kg (p = 0.010). Conclusions: Implantation of a valved pulmonary conduit in our growing lamb model was feasible. Infective endocarditis of the implanted valved conduit remained a significant complication.

Mid-term Results of Double Chamber Right Ventricle in Association with Genetic Syndromes

Double chamber right ventricle (DCRV) is a congenital disease in which a hypertrophied muscle band divides the right ventricle chamber into two. The early-mid-term follow-up of 6 patients with DCRV and distant genetic syndromes is reported in this paper. A retrospective analysis was performed of 6 DRCV patients with a mean age of 3.9±1.4 years. Concomitant cardiac anomalies were perimembranous ventricular septal defect (n=3), atrial septal defect (n=1), mild aortic regurgitation (n=1), discrete subaortic membrane (n=1). Associated genetic syndromes were Costello (n=1), Seckel (n=1) and Down syndromes (n=4). The mean follow-up period was 4.86±4.6 years. Mean systolic pressure gradient in the right ventricle in the postoperative was 18.5±11.5 mmHg. No mortality occurred and there was no requirement for reintervention. To the best of our knowledge, this is the first report in literature of concomitant DCRV with Costello and Seckel syndromes.

ENDOVASCULAR TREATMENT OF AORTIC COARCTATION

Objectives: The aim of this study is to present our center’s experience with the endovascular treatment inaortic coarctation with a follow-up of 10 years. Background: Stent implantation has been evolved as an important therapeutic strategy for coarctation of the aorta. However, available data is frequently flawed by short follow up, retrospective data and disparity in the approach. Methods: Clinical data, imaging studies and angiographic outcomes of 24 patients treated for CoA were reviewed between january 2007 to december2018. We included native diagnosed aortic coarctation (NCO) and recurrent coarctation. Results: There were 57% male patients and 43% female with a mean age of 26+/- 11 years. 90% of patients had NCO and 10% had re-coarctation after surgical repair in childhood (21+/- 4years after initial repair). Endovascular treatment was performed using BMS (PalmazGenesis peripheral stent, Cordis) in 71% of cases. Covered stent (mounted covered CP stent; Numed) was placed in 2 patients. One patient was treated by balloon angioplasty. Acute procedural success had reached 92% in our series with a technical failure in 2 cases. Mean lesion length and diameter were respectively 15,3+/-11,9 mm and 7,2+/- 2,7mm. Mean systolic pressure gradient decreased from 51,4 +/- 20,4 mm Hg to 7,7±10 mmHg (P < 0,05). After a mean follow-up of 60 +/- 38 months, the blood pressure profile was evaluated. the CT scan showed a local aortic wallanevrysms in 1 patient (4.1%). Surgical intervention was needed in 2 patients forrecoarctationand aortic valve replacement. Conclusion: Percutaneous aortic coarctation treatment is effective with an acceptable safety and a good long-termoutcome. Therefore, patients require regular clinical and radiological monitoring tobalance blood pressure, look for local aortic wall complications and assess associated lesions such as aortic bicuspid valve and ascending aorta dimension.

Engineering a New Polymeric Heart Valve Using 3D Printing-TRISKELION.

Background and Objectives: Developing a prosthetic heart valve that combines the advantageous hemodynamic properties of its biological counterpart with the longevity of mechanical prostheses has been a major challenge for heart valve development. Anatomically inspired artificial polymeric heart valves have the potential to combine these beneficial properties, and innovations in 3D printing have given us the opportunity to rapidly test silicone prototypes of new designs to further the understanding of biophysical properties of artificial heart valves. TRISKELION is a promising prototype that we have developed, tested, and further improved in our institution. Materials and Methods: STL files of our prototypes were designed with FreeCad 0.19.2 and 3D printed with an Agilista 3200W (Keyence, Osaka, Japan) using silicones of Shore hardness 35 or 65. Depending on the valve type, the support structures were printed in AR-M2 plastics. The prototypes were then tested using a hemodynamic pulse duplicator (HKP 2.0) simulating an aortic valve cycle at 70 bpm with 70 mL stroke volume (cardiac output 4.9 L/min). Valve opening cycles were visualized with a high-speed camera (Phantom Miro C320). The resulting values led to further improvements of the prototype (TRISKELION) and were compared to a standard bioprosthesis (Edwards Perimount 23 mm) and a mechanical valve (Bileaflet valve, St. Jude Medical). Results: We improved the silicone prototype with currently used biological and mechanical valves measured in our setup as benchmarks. The regurgitation fractions were 22.26% ± 4.34% (TRISKELION) compared to 8.55% ± 0.22% (biological) and 13.23% ± 0.79% (mechanical). The mean systolic pressure gradient was 9.93 ± 3.22 mmHg (TRISKELION), 8.18 ± 0.65 mmHg (biological), and 10.15 ± 0.16 mmHg (mechanical). The cardiac output per minute was at 3.80 ± 0.21 L/min (TRISKELION), 4.46 ± 0.01 L/min (biological), and 4.21 ± 0.05 L/min (mechanical). Conclusions: The development of a heart valve with a central structure proves to be a promising concept. It offers another principle to address the problem of longevity in currently used heart valves. Using 3D printing to develop new prototypes provides a fast, effective, and accurate way to deepen understanding of its physical properties and requirements. This opens the door for translating and combining results into modern prototypes using highly biocompatible polymers, internal structures, and advanced valve layouts.

Abstract 12290: Effects of Hemodynamic Triggers and Genetic Predisposition on Endocardial Fibroelastosis Recurrence

Introduction: Endocardial fibroelastosis (EFE) can be the cause of diastolic dysfunction in congenital heart defects. It is derived through endothelial-to-mesenchymal transformation (EndMT), and flow disturbances have been associated with its development. Surgical resection is the only available treatment, but recurrence is often observed. We sought to determine hemodynamic predictors and genetic predisposition of EFE recurrence for preoperative risk stratification. Methods: In 93 patients undergoing LV-EFE resection from 01/2010-03/2021, univariate and multivariable competing risks analysis was applied to determine the effects of hemodynamic parameters on EFE recurrence. In 48 patients with EFE, we classified patient’s rare de novo , damaging missense, and loss of function variants from whole exome sequencing through gene ontology and pathway network enrichments analysis associated with EndMT and/or reduced myocardial contraction or conduction. Results: 51 patients (54.8%) had EFE recurrence with a median time to recurrence of 2.2 years (95% CI 1.3-3.0). We identified mitral valve area (<1 cm 2 ), LV filling pressures (≥9 mmHg), aortic valve (AoV) mean systolic gradient (≥25 mmHg), and AoV diameter (Z-score ≤ -1.6) as predictors of faster time to recurrence (Fig. 1A). In a scoring system, these predictors together achieved an area under the curve of 0.79. Rare variants in the cohort were found in genes enriched for functions related to EndMT and myocardial conduction/contraction, with 75% of patients possessing a variant in such a gene. The combination of both (n=16) was associated with a significantly higher yearly recurrence incidence (p<0.05, Fig. 1B). Conclusions: The degree of hemodynamic disturbances and genetic predisposition predict the time to recurrence in patients after EFE resection. Understanding mechanisms behind EFE progression might provide an opportunity to prevent recurrence and develop new treatment options.

Impact of atrial fibrillation in clinical outcomes of low gradient aortic stenosis

Abstract Introduction Aortic stenosis (AS) is the most common significant valvular heart disease in developed countries. A significant portion of the AS populations have low-gradient AS (LGAS), defined as aortic valve area ≤1.0 cm2 and a trans-aortic mean systolic gradient and peak velocity <40 mmHg and <4 m/s, respectively. LGAS has been shown previously to have worse mortality compared to high-gradient AS (HGAS). Atrial fibrillation (AF) is associated with LGAS and AF has been associated with worse outcomes compared to sinus rhythm (SR) in HGAS. The prognostic impact of AF in LGAS is not well described in previous literature. Hypothesis AF will be associated with worse clinical outcomes compared to SR in patients with LGAS. Methods 3400 patients diagnosed with LGAS from 2010–2020 were retrospectively identified and analyzed. Their electrical rhythm was analyzed at the time of their echocardiographic diagnosis of LGAS and patients were split into 3 separate groups: SR (n=2036), SR with history of AF (n=519), and AF (n=845). After adjustment for age, sex, and Charlson Comorbidity Index (CCI), primary endpoints of overall mortality and cardiac mortality were assessed for patients. Results Compared to those with SR, patients with AF and history of AF had significantly higher overall mortality (HR 1.52, p<0.0001 and HR 1.22, p=0.004, respectively) and cardiac mortality (HR 2.05, p<0.0001 and HR 1.37, p=0.03, respectfully) (Figure 1). On further sub group analysis, AF seemed to be most importantly associated with mortality and cardiac mortality in patients with preserved ejection fraction (EF >50%, normal flow LGAS) compared to those patients with reduced EF (classical low-flow LGAS), where there was no statistically significant difference in outcomes between AF and SR (Figure 2). Conclusions Atrial fibrillation, compared to sinus rhythm, is associated with worse overall mortality and cardiac mortality in patients with LGAS and preserved EF. Specifically, this association was strongest in patients with preserved EF >50%. Given these findings, the presence of AF should be factored into clinical decision making regarding LGAS management given the higher risk of age, sex, and CCI adjusted overall and cardiac mortality. Further research needs to be done to see if earlier aortic valve intervention in these patients would improve mortality compared to their SR counterparts. Funding Acknowledgement Type of funding sources: None.

Abstract 9294: Prognosis of Atrial Fibrillation in Low Gradient Aortic Stenosis

Introduction: A significant portion of patients with aortic stenosis (AS) have low-gradient AS (LGAS) defined as aortic valve area ≤ 1.0 cm 2 and a trans-aortic mean systolic gradient and peak velocity < 40 mmHg and < 4 m/s, respectively. LGAS has been shown previously to have worse mortality compared to high-gradient AS (HGAS). Etiologies for LGAS include diastolic dysfunction, heart failure, other significant valvular disease, and atrial fibrillation (AF). AF is associated with worse outcomes compared to sinus rhythm (SR) in HGAS. AF is common in LGAS, but whether AF is associated with worse outcomes versus SR in LGAS has not been elucidated. Hypothesis: We hypothesize that AF is associated with higher mortality compared to SR in patients with LGAS. Methods: We retrospectively identified and reviewed charts of patients who were diagnosed with LGAS on transthoracic echocardiogram (TTE) from 2010-2020 at Mayo Clinic. Patient were classified according to rhythm at the time of TTE and history of AF was ascertained among those in SR. Patents were divided into 3 groups; SR without history of AF (group 1), SR with history of AF (group 2), and AF during TTE (group 3). Primary endpoints of overall mortality and cardiac mortality were ascertained. Results: A total of 3400 patients were included: n=2036 in group 1, n=519 in group 2, and n=845 in group 3. After adjusting for age, sex, and the Charlson index, group 2 and group 3 patient had significantly higher overall mortality (HR 1.22 and HR 1.52, respectively, p<0.0001 for both) and cardiac mortality (HR 1.37 and HR 2.05, respectively, p<0.0001 for both), Figure . Conclusions: In LGAS, AF is a significant prognostic indicator of overall mortality and cardiac mortality. LAGS associated with AF may need different management strategies given the higher mortality associated with the presence of AF.

Whole blood viscosity in patients with aortic stenosis.

Whole blood viscosity (WBV) may promote endothelial shear stress, inflammation, and can accelerate the atherosclerotic process. We aimed to evaluate the relationship between WBV and aortic stenosis. The study included 209 participants of whom 49 patients had severe aortic stenosis, 98 patients had mild-to-moderate aortic stenosis and 62 patients served as control. WBV values were significantly higher for high shear rate (HSR) (P = 0.001) and for low shear rate (LSR) (P = 0.002) in severe aortic stenosis group. HSR and LSR were correlated with mean systolic transaortic gradient (P < 0.001 and P < 0.001, respectively). WBV for both LSR and HSR were found to be independent predictors for the aortic stenosis severity (P = 0.034 and P = 0.049, respectively). We found a significant relationship between WBV and aortic stenosis.

Multi-centre cross-sectional study on vascular remodelling in children following successful coarctation correction.

Coarctation of the aorta is an arteriopathy with life-long sequelae, with remarkably increased cardiovascular events in young adults even after successful repair and despite blood pressure status. There are data on arterial remodelling in adults after coarctation correction, however, these data are scarce in childhood. Thus, the aim of this cross-sectional study was to evaluate changes in arterial wall function and morphology in children following successful coarctation repair and to compare these changes among patients with different blood pressure status and coarctation correction modes. Blood pressure status, echocardiographic parameters, arterial wall structure and stiffness, endothelial function and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful coarctation repair with right arm blood pressure not exceeding leg blood pressure by ≥20 mmHg. The prevalence of arterial hypertension was 50%. The mean carotid intima-media thickness SDS was 3.1 ± 1.5 and above 1.65 SDS in 91 of 110 patients. Increased right carotid intima-media thickness was associated with left ventricular hypertrophy, office blood pressure difference between leg and right arm, recoarctation in the past and interventional coarctation correction. Increased local common carotid artery stiffness was associated with increased pulse pressure and central systolic blood pressure. Potentially decreased endothelial function was related to a slight increase of peak and mean systolic gradient in the descending aorta. After successful coarctation repair and with a low blood pressure gradient, children still have a high prevalence of arterial hypertension and significant arterial remodelling, indicating accelerated biological age and advanced arteriosclerosis.

The efficacy and safety of percutaneous balloon angioplasty for aortic coarctation in children. Acute and mid-term results in a single center experience.

Objectives:To assess the efficacy and safety of balloon angioplasty (BAP) procedure for treatment of coarctation of the aorta (CoA) in children.Methods:A retrospective study included 27 consecutive children, underwent BAP for either native-CoA (Na-CoA) or recoarctation (Re-CoA). Medical records, echocardiographic findings, angiographic and hemodynamic data were collected from the hospital database. Follow-up was scheduled at 1, 3, 6, 12 months after the procedure. The study took place over a period of 4.5 years, from April 2014 to January 2019, in Madinah Cardiac Center, Madinah, Northwest region, Saudi Arabia.Results:The mean age of patients was 11.86±8.96 months. Seven children had Na-CoA and 20 children had Re-CoA. The success rate of the procedure was achieved in 23 children (85%), as BAP reduced the mean systolic pressure gradient across the CoA (Na-CoA: from 45.28± 18.3 to 9.8± 6.57 mm Hg, p=0.0009), and in Re-CoA groups (from 42.48±16.7 to 10.9±8.5 mm Hg, p<0.0001). In mid-term follow-up, the need for re-intervention occurred in 8 children of the cohort (3 children [42.8%] from the Na-CoA group, and 5 children [25%] from the Re-CoA group).Conclusions:Balloon angioplasty is considered a safe procedure for the management of CoA, but its efficacy remains questionable especially for young infants with Na-CoA type. However, it is a reliable option for managing Re-CoA children, with a lower rate of future re-intervention.

Covered stent placement for treatment of coarctation of the aorta: immediate and long-term results

Objectives This study aimed to describe the safety and efficacy of covered stents in patients with coarctation of aorta (CoA) for immediate and long-term follow-up. Background Covered stents are increasingly being used in (re)CoA, mainly to reduce the risk of aortic wall injuries (AWI). However, limited data are available on intermediate and long-term outcome. Methods In 89 patients (67.4% male) with a mean age of 23.9 ± 15.8 (min max range 5.1–71.6) years were 102 covered stents implanted (January 2003 – December 2017). Short-term pre/post-implant hemodynamics and angiographic data were reported. Changes in blood pressure, the use of antihypertensive drugs and complications were recorded during follow-up. Results The procedural success rate was 100%. The mean invasive ascending-to-descending aorta systolic gradient under general anaesthesia decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After a mean follow-up time of 6.6 ± 3.7 years, there was a persistent improvement of the mean systolic blood pressure gradient between right arm and leg (−7 ± 18 vs 38 ± 24 mmHg; p < 0.001). A larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017) and needed ≥ 2 drugs (20.2% vs 27.4%, p = 0.066) to control blood pressure. Long-term adverse events were found in 4.5% of patients [covered stent fracture (n = 3), aneurysm formation (n = 2)]. Conclusions Covered stent implantation for CoA is highly successful, safe and results in a persistent hemodynamic improvement in the immediate and long-term outcome. Lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain favourable hemodynamic results after stenting. CONDENSED ABSTRACT Long-term follow-up data on covered stents in patients with coarctation of the aorta are scarce. A cohort of 89 patients was reviewed. The procedural implantation success rate was 100%. The invasive gradient decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After follow-up of 6.6 ± 3.7 years, there was a persistent improvement of the clinical systolic blood pressure gradient (−7 ± 18 vs 38 ± 24 mmHg; p < 0.001). However, a larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017). Covered stent implantation results in favourable hemodynamic effects, but lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain these results.

ATRIAL SEPTAL DEFECT AND VALVULAR PULMONARY STENOSIS IN THE ABSENCE OF NOONAN SYNDROME

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Atrial septal defects (ASD) is a common congenital abnormality discovered in adulthood but ostium primum ASDs are more rare with an incidence of ∼15% of ASDs.2 ASDs with coexisting pulmonary valve stenosis is rare but has been described in Noonan Syndrome.1 About 66% of Noonan Syndrome patients exhibit congenital heart defects.3,4 ASDs and coexisting valvular pulmonary stenosis in the absence of Noonan syndrome is very rare. CASE PRESENTATION: 62 year-old Hispanic male with CAD with prior PCI, hypertension, and hypothyroidism who presented with progressive dyspnea and palpitations. He was found to be in new-onset atrial fibrillation with ventricular rates in the 160’s BPM. Labs revealed normal electrolytes and TSH, elevated BNP (1226pg/ml), and negative troponin-I. CXR was unremarkable. He was rate controlled, anti-coagulated, and underwent successful TEE with 200J of DCCV with restoration of sinus rhythm. His TEE showed a normal EF but a RA measuring 5.1cm (ID) in end-systole along with a membrane in the posterior aspect of the RA (prominent eustachian valve versus cor triatriatum dextrum), mildly dilated RV, mild MR, and a large primum ASD measuring 4.91cm2 by planimetry. A TTE (in sinus rhythm) showed mild-mod pulmonary stenosis and mild pulmonary regurgitation by doppler (mean systolic gradient 17.00mmHg, peak systolic gradient 30.00mmHg) along with dilated pulmonary arteries with possible flow reversal in the right pulmonary artery. Left heart cath showed non-obstructive CAD. CTA of the pulmonary veins showed no anomalous pulmonary vein return but did show a 32mm main pulm vein, 42mm left pulm artery, 28mm right pulm artery, and known ASD measuring 24x30mm. He remained in sinus rhythm and was discharged. DISCUSSION: The natural progression of ASDs with left-to-right shunting leads to Eisenmenger syndrome. This case represents interesting hemodynamics, such that his valvular pulmonary stenosis served as a protective factor against significant left-to-right shunting due to the outflow obstruction. The patient presented with new AFib, which is common in patients with ASD due to the atrial dilation over time from the shunting. This patient likely presented with symptoms later in life due to his valvular pulmonary stenosis minimizing his left-to-right shunting through his ASD, and thereby delaying his right atrial dilation. This combination is seen with Noonan syndrome, but this case is unique in that the patient did not have any other known congenital syndrome.1,3 Although not formally genetically tested, he exhibited no phenotypic features associated with Noonan syndrome and did not have a family history of any chromosomal abnormalities, therefore the diagnosis is unlikely. CONCLUSIONS: We report a case of coexisting ostium primum ASD and valvular pulmonary stenosis (in absence of Noonan Syndrome) demonstrating valvular outflow obstruction preventing left-to-right shunting through the ASD. Reference #1: Ma LK, Ma PTS, Leung AKC. Pulmonary Valve Stenosis with Atrial Septal Defect. In: Lang F, ed. Encyclopedia of Molecular Mechanisms of Disease. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009:1779-80. Reference #2: Webb G, Gatzoulis MA. Atrial Septal Defects in the Adult. Circulation 2006;114:1645-53 Reference #3: Allanson JE. Noonan syndrome. Journal of medical genetics 1987;24:9. DISCLOSURES: No relevant relationships by Emmanuel Bassily, source=Web Response No relevant relationships by Fahad Hawk, source=Web Response no disclosure on file for Bibhu Mohanty

The Effect of Oral Ibuprofen on Closure of Patent Ductus Arteriosus in Term Neonates: A Clinical Trial Study

Background The function of ductus arteriosus closes within a few minutes to a few days after birth in term neonates. In some cases, the duct remains open after birth, a condition which is called patent ductus arteriosus (PDA). PDA is associated with high rates of neonatal mortality and morbidity. The present study aims to evaluate the effect of oral ibuprofen on closure of PDA in term neonates. Materials and Methods In this clinical trial, 40 neonates (at the gestational age of 37 weeks and more) aged 5 to 30 days, with confirmed PDA through echocardiography, were randomly divided into two groups (n= 20). One group received ibuprofen syrup (10 mg/kg body weight) in the first 24 hours, followed by 5 mg/kg body weight for the next four days. The other group received placebo in the same manner. On the seventh day after the beginning of intervention, neonates underwent echocardiography for examination of PDA closure. Side effects of ibuprofen were evaluated. Symptoms of kidney failure, such as oliguria, edema, and proteinuria and increased creatinine, as well as gastrointestinal side effects such as gastrointestinal bleeding and recurrent vomiting, were assessed for one month. Results According to the results, PDA diameter was not significantly different in ibuprofen compared to the placebo groups before (p>0.05) and after (p>0.05) intervention. Frequency of PDA closure was 13 (65%) in the ibuprofen group and 10 (50%) in the placebo group with no significant difference (p>0.05). There was no significant difference in the mean systolic and diastolic pressure gradient after intervention and in mean changes in pulmonary arterial hypertension between the two groups (p>0.05). No side effects were observed in any of the groups. Conclusion: Based on the results, oral ibuprofen did not significantly affect PDA closure in term neonates.

Unicuspid Aortic Valve Repair Using Geometric Ring Annuloplasty

Unicuspid aortic valves (Sievers type 2 bicuspid) are characterized by major fusion and clefting of the right-left coronary commissure, and minor fusion of the right-noncoronary commissure. Repair has been difficult because of two fusions, variable relative sinus sizes, and peripheral leaflet deficiencies or tears after balloon valvuloplasty. Twenty unicuspid aortic valves patients underwent valve repair in nine institutions. Right-left major fusion and right-noncoronary minorfusion occurred in 17 of 20 (85%). Commissurotomy was performed on the minor fusion, and a bicuspid annuloplasty ring with circular base geometry and two 180-degree subcommissural posts was sutured beneath the annulus, equalizing the annular circumferences of the fused and nonfused cusps. Thenonfused leaflet was plicated, and the cleft in the major fusion was closed linearly until leaflet effective heights and lengths became greater than 8 mm and equal, respectively. Average age (mean ± SD) was 22.3 ± 12.3 years (range, 13 to 58), 12 of 20 (60%) were symptomatic, 10 of 20 (50%) required aortic aneurysm resection. Pre-repair hemodynamic data included mean systolic valve gradient 25.8 ± 12.9 mm Hg, aortic insufficiency grade 2.9 ± 1.2, and annular diameter 24.7 ± 3.3 mm. No mortality or major complications occurred. Post-repair annular (ring) size was 20.5 ± 1.3 mm, mean gradient fell to 16.2 ± 5.9 mm Hg, and aortic insufficiency grade decreased to 0.1 ± 0.3 (P < .001). At an average follow-up of 11 months (range, 1 to 22), all 20 patients were asymptomatic and had returned to full activity. Aortic ring annuloplasty reduced annular diameter effectively, recruiting more leaflet to midline coaptation. Minor fusion commissurotomy and annular remodeling to 180-degree commissures converted UAV repair to a simple and reproducible procedure.

Early and late outcomes of surgical repair of double-chambered right ventricle: a single-centre experience.

Double-chambered right ventricle is characterised by division of the outlet portion of the right ventricle by hypertrophy of the septoparietal trabeculations into two parts. We aim to report our experiences regarding the presenting symptoms of double-chambered right ventricle, long-term prognosis, including the recurrence rate and incidence of arrhythmias after surgery. We retrospectively investigated 89 consecutive patients who were diagnosed to have double-chambered right ventricle and underwent a surgical intervention from 1995 to 2016. The data obtained by echocardiography, cardiac catheterisation, and surgical findings as well as post-operative follow-up, surgical approaches, post-operative morbidity, mortality, and cardiac events were evaluated. Median age at the time of diagnosis was 2 months and mean age at the time of operation was 5.3 years. Concomitant cardiac anomalies were as follows: perimembranous ventricular septal defect (78 patients), atrial septal defect (9 patients), discrete subaortic membrane (32 patients), right aortic arch (3 patients), aortic valve prolapse and/or mild aortic regurgitation (14 patients), and left superior caval vein (2 patients). The mean follow-up period was 4.86 ± 4.6 years. In these patients, mean systolic pressure gradient in the right ventricle by echocardiography before, immediately, and long-term after surgical intervention was 66.3, 11.8, and 10.4 mmHg, respectively. There were no deaths during the long-term follow-up period. Surgical reinterventions were performed for residual ventricular septal defect (2), residual pulmonary stenosis (1), and severe tricuspid insufficiency (1). The surgical outcomes and prognosis of double-chambered right ventricle are favourable, recurrence and fatal arrhythmias are unlikely in long-term follow-up.

Bicuspid aortic valve repair using geometric ring annuloplasty: A first-in-humans pilot trial.

ObjectiveAs bicuspid aortic valve (BAV) repair evolves, more effective annular reduction and stabilization could be advantageous. A geometric annuloplasty ring has been developed, and 2-year regulatory outcomes of a first-in-humans pilot trial are reported.MethodsA prospective first-in-humans trial of BAV ring annuloplasty was completed in 16 patients. Patient age was 44.4 ± 11.3 (mean ± standard deviation) years, preoperative aortic insufficiency grade was 2.5 ± 1.0, New York Heart Association class 1.8 ± 0.4, and mean systolic gradient 13.4 ± 12.9 mm Hg. Three patients had Sievers type 0 BAV, 11 had type 1, and 2 were type 2. The Dacron-covered titanium rings had circular base geometry with 180° subcommissural posts and were implanted subannularly. Leaflets were reconstructed using plication/cleft closure, creating an effective height of ≥8 mm, even if modest gradients were induced.ResultsMean pre-repair annular diameter was 28.6 ± 3.3 mm, and the average ring diameter was 22.3 ± 1.6 mm. All valves required leaflet plication/reconstruction; pericardium was avoided; and 7 patients had aortic replacement for aneurysms. No early mortalities or major complications occurred. Two patients required early prosthetic valve replacement for technical errors, and all were between 24-38 months’ postoperative at follow-up. No late mortalities or valve-related complications occurred, and all patients reverted to New York Heart Association class I. Aortic insufficiency reduction was significant to grade 0.9 ± 0.5 at 2-years (P < .0001). Mean valve gradients were acceptable (13.3 ± 5.0 mm Hg at 2 years; overall P = .11) and tended to fall over time (P < .0001).ConclusionsGeometric ring annuloplasty was safe and effective for BAV repair. AI reduction was significant, valve gradients were satisfactory, and clinical outcomes were excellent. Geometric ring annuloplasty could simplify and standardize BAV repair.

Pulsed-wave doppler echocardiographic cardiac dimensions of Muzaffarnagari sheep

With the aim to determine reference pulsed-wave Doppler echocardiographic cardiac dimensions in sheep, transthoracic echocardiographic examination in right lateral position was performed in 20 healthy adult female Muzaffarnagari sheep. The study was conducted between August, 2014 and March, 2015 at ICAR-Indian Veterinary Research Institute, Izatnagar. The peak early (Emax) and late (Amax) transmitral filling velocities were 61.75±2.93 and 42.17±2.52 cm/s, respectively. The mean early (Emean) and late (Amean) transmitral filling velocities were 31.67±1.45 and 21.86±1.26 cm/s, respectively. The velocity time integrals of transmitral filling during early ventricular filling (VTIE) and atrial contraction (VTIA) were 8.22±0.29 and 4.52±0.39 cm, respectively. The peak early (PPGE) and late (PPGA) transmitral filling pressure gradients were 1.58±0.15 and 0.75±0.08 mmHg, respectively. The mean early (MPGE) and late (MPGA) transmitral filling pressure gradients were 0.42±0.04 and 0.20±0.02 mmHg, respectively. Early (ETE)andlate (ETA) transmitral filling ejection time were 0.27±0.01 and 0.21±0.02 s, respectively. Emax/Amax, VTIE: VTIA ETE: ETA and PPGE: PPGA ratios were 1.50±0.05, 2.11±0.23, 1.43±0.15 and 2.30±0.17, respectively. The peak (AOVmax), mean (AOVmean), velocity time integral (VTIAO), peak systolic pressure gradient (PPGAO), mean systolic pressure gradient (MPGAO), and ejection time (ETAO) of the aortic flow were 87.59±5.54 cm/s, 43.68±2.87 cm/s, 10.94±0.80 cm, 3.19±0.39 AO mmHg, 0.80±0.10 mmHg and 0.25±0.01s, respectively. These pulsed-wave Doppler echocardiographic cardiac dimension reference values in Muzaffarnagari sheep could serve as a reference for physiological and cardiovascular studies in this breed.

Incidence, Mechanisms, and Predictors of Mean Systolic Gradients ≥20 mm Hg after Transcatheter Aortic Valve Implantation

There is a significant increase in transvalvular gradients after transcatheter aortic valve implantation (TAVI) in some patients; however, mechanisms underlying the greater than expected gradients are unknown. We sought to determine the incidence and mechanisms of greater than expected gradients post-TAVI. A total of 424 patients who underwent TAVI at our institution between November 2008 and August 2015 and had at least 1 follow-up echocardiogram were included in the study. Greater than expected gradients were defined as mean systolic Doppler gradients ≥20 mm Hg. The primary end-point was incidence and mechanisms of mean systolic Doppler gradients ≥20 mm Hg. A total of 36 (8%) patients had mean systolic Doppler gradients ≥20 mm Hg. The mechanisms of mean systolic Doppler gradients ≥20 mm Hg were: patient prosthesis mismatch in 15 (42%) patients, high cardiac output in 13 (36%), prosthetic and periprosthetic regurgitation in 11 (31%), stenosis in 5 (14%), and multiple mechanisms in 8 (22%). Patients with mean systolic Doppler gradients ≥20 mm Hg had higher cardiac re-hospitalization rate, but no difference in mortality or major cardiovascular events when compared with the normal gradient group. Smaller prosthetic valve size (p <0.0001) and larger body mass index (p = 0.02) were associated with mean systolic Doppler gradients ≥20 mm Hg; warfarin therapy at discharge had no effect on gradients. In conclusion, about 8% patients had mean systolic Doppler gradients ≥20 mm Hg following TAVI, and patient-prosthesis mismatch was the most common mechanism. The mean systolic Doppler gradients ≥20 mm Hg after TAVI are not benign and warrant careful surveillance.

Pulmonary Valve Function Late After Ross Procedure in 443 Adult Patients

Limited data exist on long-term pulmonary valve function after the Ross procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross procedure. All 443 patients who underwent a Ross procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study's outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n= 4), severe pulmonary stenosis (n= 4), or severe pulmonary regurgitation (n= 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.

Multicenter experience with endovascular treatment of aortic coarctation in adults

ObjectiveThe objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults. MethodsClinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention. ResultsThere were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%. ConclusionsEndovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success.