Mild Aortic Valve Regurgitation Research Articles

Abstract 14776: Myopericarditis Mimicking Myocardial Infarction With Non-Obstructive Coronary Arteries

This is a case of a 76-year-old female with a past medical history of recurrent paroxysmal symptomatic supraventricular tachycardia (SVT), atherosclerotic heart disease, mild aortic and mitral valve regurgitation, mild-moderate tricuspid regurgitation, right bundle branch block, hypothyroidism and bronchiectasis who presented to her dermatology appointment with palpitations and dizziness. She visited the cardiologist's office and was found to have SVT on electrocardiogram which did not terminate with Valsalva maneuvers. She arrived at the emergency department with chest pain and converted to sinus rhythm after 6 mg of intravenous adenosine was administered. Her troponin peaked to 0.21 and she was admitted with concerns for non-ST segment elevation myocardial infarction. Transthoracic echocardiogram showed left ventricular ejection fractions of 61 percent with no wall motion abnormalities and left atrial and inferior vena cava dilation. She underwent left heart catheterization which only showed mild calcification and minimal luminal irregularities of the left anterior descending artery. Cardiac MRI showed myopericarditis and she was discharged with 0.6 mg of colchicine twice daily with plans for outpatient follow up. Discussion Patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) are discovered to have myocarditis on cardiac MRI 25-30% of time. However, this case uniquely demonstrates myopericarditis as the cause for MINOCA which may not have been previously specified. In addition, it is important to emphasize the utility of Cardiac MRI as a non-invasive modality to diagnose MINOCA “mimics”, especially in the female population.

The Arterial Switch Operation in the Developing World: Risk Factors and Current Outcomes

BackgroundPublished data on the outcomes of the arterial switch operation in the developing world are limited. We sought to identify the midterm outcomes of and risk factors for mortality and morbidity in patients undergoing the arterial switch operation at a high-volume center in Vietnam. MethodsA retrospective review was conducted of 608 patients who underwent an arterial switch operation for the treatment of transposition of the great arteries (TGA; n = 509) or double-outlet right ventricle TGA (DORV-TGA; n = 99) at a single center from 2010 to 2021. ResultsOverall early mortality was 5.9%, and late mortality was 1%. Multivariate Cox regression showed weight at operation of <3 kg (P < .001), prolonged aortic cross-clamp time (P < .001), and need for secondary aortic cross-clamp (P = .011) as risk factors for overall mortality. The actuarial 10-year survival rate was 93%. The overall cardiac reoperation rate was significantly higher in patients with DORV-TGA (hazard ratio [HR], 16.43; 95% CI, 4.70-57.43; P < .001). The rate of freedom from cardiac reoperation at 10 years was 94%. Risk factors for outflow tract reoperation were patients with DORV-TGA (HR, 23.28; 95% CI, 2.86-189.66; P = .003), single coronary artery (HR, 4.1; 95% CI, 1.16-14.46; P = .028), and mild aortic valve regurgitation observed in 3.7% of patients. ConclusionsThe outcomes of the arterial switch operation in a low- and middle-income country were satisfactory. Nevertheless, the complexity of the procedure and lower weight of patients are still challenges. Patients with DORV-TGA and single coronary artery need to be closely followed up.

P104 LASER BALLOON APPROACH FOR PULMONARY VEIN ISOLATION IN MARFAN SYNDROME

Abstract Background Marfan syndrome (MFS) is an autosomal dominant disorder of the connective tissue and it’s associated with an increased incidence of atrial fibrillation (AF), due to scar–mediated processes and sites of atrial ectopy. Limited data exist regarding ablation techniques in these patients. The frailty of atrial walls correlated to connective disease makes the ablation challenging with an increased risk of complications. Laser–balloon (LB) approach for pulmonary vein isolation (PVI) could be a promising strategy due to the possibility to ablate a large volume of tissue with a single application of energy, short procedure times, and real–time monitoring of balloon–tissue contact. We present a case in which LB technology was applied for PVI in an MFS patient Clinical case A 44–year–old woman with MFS and paroxysmal AF underwent PVI. The echocardiographic examination showed mild aortic and mitral valve regurgitation, the first due to a slight dilation of the aortic root, the latter associated with mitral valve prolapse. Atrial volume was normal. No other comorbidities were present. The procedure was executed in general anesthesia. A decapolar catheter was inserted in the coronary sinus and used later to stimulate the phrenic nerve during the ablation of the right pulmonary veins (Fig.1C). Left atria (LA) was reached after an ultrasound–guided transeptal puncture. High–density mapping of the LA was performed to assess the number and geometry of PVs (Fig.1A). A LB catheter was used to perform laser ablation at the level of PV antrum, delivering 13 W in automatic rapid mode in regions with optimal contact and 5.5 W in areas with more represented blood–tissue interface. LA mapping after ablation assessed the effective isolation of pulmonary veins (Fig.1B). No complications occurred during the procedure. Conclusion a laser–balloon approach for PVI in MFS patients seems feasible and safe. To our knowledge, this is the first application of this technology on MFS patients. Larger data are needed to confirm our findings.

Aortic valve regurgitation following transaortic septal myectomy for obstructive hypertrophic cardiomyopathy: Incidence and influence on late outcomes

ObjectiveIn this study, we describe the incidence, sites of valve injury, and the influence of aortic valve regurgitation (AR) on outcomes of septal myectomy for obstructive hypertrophic cardiomyopathy. MethodsWe analyzed patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from 2001 to 2022. The primary study end point was incidence of procedure-related AR, defined as the need for an unplanned aortic valve (AV) procedure or new-onset moderate AR on early postoperative echocardiography. ResultsThere were 2807 patients who underwent transaortic septal myectomy for hypertrophic cardiomyopathy and had pre- and postoperative transthoracic echocardiograms. Procedure-related AR was observed in 55 (2%) patients; 27 (1%) required unplanned AV procedures at the time of myectomy, and 29 (1%) additional patients developed moderate AR postoperatively. During follow-up, 9 total patients underwent late AV reoperation, 1 patient who developed new moderate AR postoperatively required late AVR due to severe calcific AS, and none of the patients who had unplanned AV procedures required late reoperation. The overall cumulative incidence of AV reoperation at 10 and 15 years was 1% and 5%. The predicted probability of moderate or severe AR at 5 and 10 years was 1.4% and 1.8%, respectively. There was no difference in survival comparing patients with or without early postoperative mild or worse AR (P = .69). ConclusionsProcedure-related AR was observed in 2% of patients undergoing transaortic septal myectomy, and unplanned AV procedures were necessary for half of these patients. Intraoperative identification and valve repair mitigate the impact of cusp injury on late reintervention and survival.

898 ROLE OF 3D ECHOCARDIOGRAPHY IN AORTIC VALVE ABNORMALITIES: TWO CASES REPORT

Abstract Introduction Aortic valves with a number of cusps different from two or three are infrequent congenital anomalies that might manifest with valvular disease in young patients. We present two cases of unicuspid and quadricuspid aortic valve diagnosed in our Center. Clinical Cases Case 1. A 23-year-old asymptomatic male was admitted to our Hospital because of the necessity of bone marrow transplantation for Hodgkin lymphoma. He had a previous diagnosis of bicuspid aortic valve and presented a 5/6 mid-systolic harsh murmur, heard best at the right upper sternal border and radiating to the neck. ECG showed sinus rhythm with left ventricular hypertrophy. BNP was in normal range (31 pg/ml). At trans-thoracic echocardiography, there was severe aortic stenosis [peak/mean gradient of 100/67 mmHg with an aortic valve area of 1.04 cm2 (0.54 cm2/m2); V max was 5 m/s] without regurgitation and dilation of the ascending aorta (39 mm), however the morphology of the aortic valve remained undefined. Left ventricle showed hypertrophy (maximum wall thickness = 13 mm) with normal volumes and systolic function. Thus, the patient underwent to 3D-Transesophageal echocardiography, which demonstrated unicuspid aortic valve with a lone commissure between L-NC and anterior calcification. After multidisciplinary discussion, the patient underwent close follow-up and aortic valve replacement was planned after the bone marrow transplantation. Case 2. A 21-year-old male was referred by general practitioner to our outpatient clinic for palpitations. Cardiovascular physical examination and ECG were normal with no evidence of arrhyhtmia or cardiac murmurs. Transthoracic echocardiography revealed central mild aortic valve regurgitation in a suspected quadricuspid aortic valve (i.e., an X-shaped commissure pattern during diastole and a rectangular appearance during systole in the parasternal short-axis view). Left ventricular size and function and ascending aorta dimensions were normal. There was no associated congenital cardiovascular abnormality. 3D-Transesophageal echocardiography confirmed the evidence of a quadricuspid aortic valve. The cusps appeared to be of different size: two equal larger cusps and two equal smaller cusps (Type C, Hurwitz and Robert's classification), thin and mobile. The patient was advised to echocardiographic follow-up at intervals of 12 months. Conclusions We describe two cases of aortic valve congenital anomalies in two coetaneous patients with completely different impacts on hemodynamics. Severe aortic stenosis complicated unicuspid aortic valve whereas quadricuspid aortic valve was associated with mild aortic regurgitation. 3D-Transesophageal echocardiography was essential for accurate morphological characterization of the aortic valves.

Characteristics of Patients with Ventricular Septal Defect that Had Been Closed with Transcatheter in Dr. Soetomo General Hospital from January 2019 to December 2021

VSD is the most common congenital heart disease in newborns. VSD can close spontaneously in the early years of life. However, VSD can not close spontaneously in a few patients and cause complications so that it is necessary to perform VSD closure earlier, one of all options is transcatheter. Transcatheter is a minimal invasive procedure with a high success rate and safety also the incidence of cardiorespiratory disturbances are less while using transcatheter devices making it an alternative intervention for VSD closure. This study aims to determine the outcome characteristics and complications of VSD closure with transcatheter intervention. This study was a descriptive observational study using a cross-sectional design with a retrospective approach, based on secondary data. Sampling was done by total sampling technique. A sample of 27 patients was obtained with a mean age of 4.48 ± 3,298 years, an average weight of 17.70 ± 10.5550 kg, and male sex dominated by 55.6%. The most common type of VSD that was closed with a transcatheter was the perimembranous type of 70.4% and the size of the VSD was dominated by the medium size of 85.2%. The transcatheter VSD closure was successful in 24 patients (88.9%) and failed in three (11.1%). Residual shunt developed in one of three patients who failed. The most common complication was arrhythmia with NSVT type of 62,96%. Other complications were PVC 7.4%, aortic valve regurgitation 3.7%, and hypotension 3.7%. Closure of VSD by transcatheterization has a high success rate, no death is found, and there are no major complications that require long-term or life-threatening therapy. All complications found only occurred during transcatheterization, i.e. arrhythmia, mild aortic valve regurgitation, and hypotension.

Abstract 14248: The Impact of Trastuzumab on the Pulmonary Artery Systolic Pressure in Patients With HER-2 Positive Breast Cancer

Introduction: Despite that trastuzumab (TZB) improves life expectancy and prognosis in patients with HER-2 positive breast cancer (BC), cardiotoxicity is a well-established complication. However, other potential cardiac complications of TZB such as pulmonary hypertension (PHTN) are poorly investigated. Aim: Evaluate the effect of TZB on pulmonary artery systolic pressure (PASP) and measure the predictors of developing elevated PASP. Methods: The medical records for all females who received TZB treatment for confirmed HER-2 positive BC at King Hussein Cancer Centre in Jordan between 2014 - 2019 who had a documented normal PASP of ≤35 mmHg before treatment were evaluated. Results: A total of 436 patients with a mean age of 53±11 years were included. The leading comorbidities were hypertension and diabetes mellitus affecting 26.2% and 15.4% of the patients, respectively. 15.6% of the study’s population were active smokers. Prior to initiating TZB, 22.3% had left ventricular hypertrophy (LVH), 14.3% had mild tricuspid valve regurgitation (TR), 11.5% had pericardial effusion, and 4.8% had mild aortic valve regurgitation (AR).Of alarming significance, 24.8% of the patients had their PASP increased after one year. Patients who developed elevated PASP tend to be older (56.9 vs 51.3, P&lt;0.001), had baseline mild TR (26.3% vs 10.3%, P&lt;0.001), LVH (39.4% vs 17.6%, P&lt;0.001), and mild AR (9.1% vs 3.7%, P=0.031).Multivariate analysis showed that the only predictors of elevated PASP are TR at baseline (OR 3.9; 95% CI 1.58-6.17, P=0.001), and age (OR 1.04; 95% CI 1.01-1.06, P=0.005). However, baseline LVH (OR 1.79; 95% CI 0.98-3.26, P=0.057), number of the TZB cycles (OR 0.93; 95% 0.85-1.02, P=0.152), and the total dose of TZB (OR 1; 95% CI 1-1, P=0.284) were non-significant predictors. At 1 year follow up, the mean total cumulative dose of TZB was 6.8±1.8 grams that were given at a mean of 15±3 cycles. Moreover, major events (heart failure exacerbation, pulmonary embolism, and acute coronary syndrome) were recorded in 3.9% of the patients and death occurred in 4.1%. Conclusions: Trastuzumab demonstrated an increase in the PASP in a considerable portion of the patients at 1-year interval with this elevation being substantially concerning due to being highly indicative of PHTN.

Abstract 11802: Evaluation of Family Risk of Rheumatic Heart Disease With Systematic Echocardiographic Screening: Data From the Provar+ Study

Introduction: Rheumatic Heart Disease (RHD) is determined by a complex interaction between socioeconomic environment and host susceptibility. Relatives of patients with advanced RHD share both, and may be at high-risk. We aimed to use echocardiographic (echo) family screening to evaluate the risk of RHD among 1 st degree relatives of patients with advanced RHD. Methods: From Feb 2020 - Jun 2021 patients with advanced RHD were consecutively enrolled in the University Hospital’s outpatient clinics. Consented 1 st degree relatives were invited for echo screening (2012 World Heart Federation Criteria) utilizing handheld devices (GE VSCAN) by non-physicians, with telemedicine interpretation by 2 experts. Matched controls (spouses, neighbors) living in the same household were also enrolled in a 1:5 fashion. A confirmatory full echo (GE Vivid IQ) was scheduled if abnormalities were observed, and all positive RHD cases were referred for follow-up. Results: In 16 months, 202 relatives and 42 controls of 117 patients were screened, including 114 children, 68 siblings and 20 parents. Mean age was 41±18 years, 62% were women and 214 (88%) lived with the index case for &gt;10 years. At total 51 (21%) individuals had hypertension, 17 (7%) diabetes, 5 reported a previous stroke and only 5 (all relatives) had personal history of RHD. Among index cases, 73% reported current or past prescription of Penicillin. Echo findings suggestive of RHD were observed in 0 controls and 14 (7%) relatives (p=0.08), being 11 with mitral valve (MV) disease and 3 with mixed (mitral and aortic valve (AV)) disease. Eleven patients had mild/moderate MV regurgitation, 4 with associated MV stenosis and abnormal morphology. Two patients had mild AV regurgitation and abnormal AV morphology, associated with mild AV and MV stenosis, and 1 patient had bioprostheses in the MV and AV. One case of mild left ventricular dysfunction was observed, and 1 patient had indication of commissurotomy for MV stenosis at the time of diagnosis. Conclusions: First-degree relatives of individuals with clinical RHD are at greater risk of having RHD and family screening should be considered. Genotyping studies are warranted to better understand individual and family susceptibility to RHD, in addition to socioeconomic conditions.

Developmental changes in bicuspid aortic valve and associated aortopathy in small children

Abstract Background The prevalence of bicuspid aortic valve (BAV) in newborns is 0.8%. BAV is associated with an increased risk of aortic valve dysfunction and aortopathy. Aortopathy with increased aortic diameters has recently been reported in newborns with BAV. As most patients with BAV are diagnosed in adulthood the development of BAV and associated aortopathy during early years of life is not well described. Purpose The purpose of the study was to assess changes in aortic valve function and aortic dimensions at two to four years of age in children diagnosed with BAV neonatally. Methods Children with BAV were included from a population-based cohort study, in which newborns (n≈25,000) underwent standardized transthoracic echocardiography (TTE). Follow-up TTE was performed and analyzed according to established guidelines. Neonatal (baseline) and follow-up data were compared. Diameters were indexed to body surface area (BSA). Z-scores were calculated using formulas from the Pediatric Heart Network Echocardiogram Database. Results At follow-up 101 newborns with BAV (mean age 2 years 5 months, SD 11 months), 75% male) were examined from May 2019 to April 2021. From baseline to follow-up there was an increase in the BSA-adjusted diameter of the aortic valve annulus (z-score −0.19 at baseline vs 0.95 at follow up, p&amp;lt;0.001), and of the sino-tubular junction (z-score 0.16 at baseline vs 0.43 at follow up, p&amp;lt;0.05). Conversely, there was a decrease in the Z-score for the diameter measured 1 cm from the valve annulus (z-score 1.31 at baseline vs 0.68 at follow up, p&amp;lt;0.001) and at the widest point of the visualized ascending aorta (z-score 2.44 at baseline vs 1.45 at follow up, p&amp;lt;0.001). There was no significant change in the diameter of the sinus of Valsalva (z-score 0.83 at baseline vs 0.80 at follow up, p=0.92). The number of children with at least one aortic z-score &amp;gt;3 was 31 (30.6%) at baseline and 17 (17.8%) at follow up. At baseline mild aortic valve regurgitation was observed in 18 children (17.8%) and in 23 children at follow up (23%). Mean maximum systolic velocities across the aortic valve were 1.03 m/s at baseline (SD 0.24) and 1.11 m/s at follow up (SD 0.27), p&amp;lt;0.05. Aortic stenosis, defined as flow velocity &amp;gt;2.5 m/s was seen in one child both at baseline and at follow-up. Conclusion In children diagnosed with BAV neonatally, re-examination at the age of 2.5 years showed significant increases in the diameter of the aortic valve annulus and the sino-tubular junction, but a significant decrease in the diameter of the ascending aorta. The maximum blood flow velocity across the aortic valve increased and more children had developed mild aortic valve regurgitation. Thus, the bicuspid aortic valve and the associated aortopathy seem to undergo remodeling during early childhood. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Children's Heart Foundation, Boernehjertefonden.

A modern approach to aortic valve insufficiency: Aortic root restoration via HAART 300 internal annuloplasty ring.

HAART 300 is an internal geometric annuloplasty ring. The safety and efficacy of this novel device in aortic valve (AV) repair in a single referral center are reported. Twenty patients with trileaflet AV insufficiency with ascending aorta and/or aortic root enlargement were included. Subannular implantation was performed to correct annular dilatation, whereas concomitant leaflet repair was performed whenever required. All but two patients also received ascending aorta replacement, whereas selective sinus replacement was performed in all but five patients. Follow-up was for a maximum of 3.8 years and a mean of 2.2 years. Mean age was 54.2 years old. Moderate to severe preoperative AV insufficiency was noted in 75% of patients, whereas 70% of them had an ascending aorta over 45 mm. One patient was lost from follow-up. Overall mortality as well as major complication rates were zero. Early postoperatively, no more than mild AV regurgitation was detected, whereas only one patient appeared with moderate AV regurgitation during our 2.2-year follow-up. New York Heart Association class was also significantly lower compared to preoperative values and valve gradients remained low at last follow-up. Geometric ring annuloplasty is a safe and effective valve sparing approach to deal with AV insufficiency contributing to overall root reconstruction. Short-term results are excellent rendering this easily reproducible and versatile method very attractive.

Impaction of regurgitation jet on anterior mitral leaflet is associated with diastolic dysfunction in patients with bicuspid aortic valve and mild insufficiency: a cardiovascular magnetic resonance study

To assess the impact of regurgitant jet direction on left ventricular function and intraventricular hemodynamics in asymptomatic patients with bicuspid aortic valve (BAV) and mild aortic valve regurgitation (AR), using cardiac magnetic resonance (CMR) feature tracking and 4D flow imaging. Fifty BAV individuals were retrospectively selected: 15 with mild AR and posterior regurgitation jet (Group-PJ), 15 with regurgitant jet in other directions (Group-nPJ) and 20 with no regurgitation (Controls). CMR protocol included cine steady state free precession (SSFP) sequences and 4D Flow imaging covering the entire left ventricle (LV) cavity and the aortic root. Cine-SSFP images were analyzed to assess LV volumes, longitudinal and circumferential myocardial strain. Circumferential and longitudinal peak diastolic strain rate (PDSR) and peak diastolic velocity (PDV) were reduced in group PJ if compared to group nPJ and control group (PDSR = 1.10 ± 0.2 1/s vs. 1.34 ± 0.5 1/s vs. 1.53 ± 0.3 1/s, p:0.001 and 0.68 ± 0.2 1/s vs. 1.17 ± 0.2 1/s vs. 1.05 ± 0.4 1/s ; p < 0.001, PDV = − 101.6 ± 28.1 deg/s vs. − 201.4 ± 85.9 deg/s vs. − 221.6 ± 67.1 deg/s; p < 0.001 and − 28.1 ± 8 mm/s vs. − 38.9 ± 11.1 mm/s vs. − 43.6 ± 14.3 mm/s, p < 0.001, respectively), whereas no differences have been found in systolic strain values. 4D Flow images (available only in 9 patients) showed deformation of diastolic transmitral streamlines direction in group PJ compared to other groups. In BAV patients with mild AR, the posterior direction of the regurgitant jet may hamper the complete mitral valve opening, disturbing transmitral flow and slowing the LV diastolic filling.

The First 100 Cases of Two Innovations Combined: Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Mini-Thoracotomy Using a Novel Aortic Prosthesis.

IntroductionAortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT. MethodsBetween April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database.ResultsCardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm2, peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg.ConclusionOur preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

Outcomes of transfemoral transcatheter aortic valve implantation (TAVI) and predictors of thirty-day major adverse cardiovascular events (MACE) and one-year mortality

ObjectiveTAVI is more frequently used to treat aortic stenosis with the mandate to have a low as possible rate of adverse events. We present our 30-day outcomes and one-year mortality and examine the factors associated with them. MethodsA prospective evaluation was performed of all patients who underwent transfemoral TAVI in Nicosia General Hospital from January 2015 until March 2020. MACE were defined as cardiac death, disabling stroke, and/or major vascular complications (VC). Multiple logistic and Cox regression analyses were used to identify the factors associated with 30-day MACE and one-year mortality, respectively. ResultsA total of 235 TAVI procedures were performed (178 balloon-expandable, 57 self-expandable). Thirty-day outcomes were MACE: 4.3%, cardiovascular death: 2.1%, disabling stroke: 1.3%, major VC: 1.7%, and contrast induced nephropathy (CIN): 4.3%. There was a rate of 6.2% new pacemaker implantations and 0.9% of more than mild aortic valve regurgitation (AR) at 30 days. Mortality at one year was 15.1%. The balloon-expandable valves appear to have less new pacemakers, less mild AR, lower contrast volume used, and less days of hospitalization, while the self-expandable valves have lower post-procedural gradients. Low hemoglobulin, history of atrial fibrillation (AF), and lower BMI were predictors of 30-day MACE. Serum creatinine >2 mg/dL, history of AF, RVSP >60 mmHg and major VC are predictors of one-year mortality. ConclusionWe have shown excellent 30-day results with low incidence of adverse events for both the balloon-expandable and self-expandable valves. Clinical factors are the main predictors of both 30-day MACE and one-year mortality; major VC is a strong predictor of one-year mortality.

Inter-operative determination of the aortic root and cusp geometry associated with the aortic regurgitation grade.

To perform successful aortic valve plasty (AVP) and valve-sparing root replacement (VSRR), a sufficient understanding of the aortic root and cusp geometry is required. Several key parameters of the aortic root and cusp geometry were, therefore, measured intraoperatively. Forty-nine patients (63.1 ± 16.6 y.o., 40 males) were measured during the surgeries. The patients were divided into 3 groups; including patients with no or mild aortic valve regurgitation (AR) (n = 13), moderate AR (n = 18), and severe AR (n = 18). There were no significant differences in the body surface area (1.72 ± 0.19m2) among the 3 groups (p = 0.858). The effective height (EH) and geometric height (GH) of right coronary cusp were smaller than those of the others (EH: p = 0.068, GH: p < 0.01). The insertion line length (ILL) and free margin length (FML) of each leaflet tended to be significantly longer according to the AR grade(ILL: p < 0.01, FML: p < 0.01). The FML/AVJ ratios were significantly different (p < 0.01). The FML/ILL ratios were constant with the ratio of 0.88 ± 0.1(p = 0.624). Although the ILL and FML tended to increase with the AR grade, the FML/ILL ratio remained constant. For successful AVP and VSRR, adequately maintaining the FML/ILL ratio is necessary to prevent remarkable cusp prolapse while also preserving its favorable cusp motion.

Efficacy and safety of transcatheter aortic valve implantation in patients with severe bicuspid aortic stenosis.

Bicuspid aortic valve (BAV) is common congenital malformation, bicuspid aortic stenosis accounts for a substantial proportion of patients with aortic valve stenosis (AS). Bicuspid AS are more likely to have aortic dilatation with slightly less elliptical annuli, which might lead to paravalvular aortic valve regurgitation (AR) and permanent pacemaker implantation (PPM) after TAVI with higher mortality. Our study aims to understand the therapeutic efficacy and safety of transcatheter aortic valve implantation (TAVI) with a supra-annular structure-based sizing strategy in Chinese AS patients with BAV versus tricuspid aortic valve (TAV). Seventy-four consecutive tricuspid AS patients and 44 bicuspid AS patients were included and enrolled in the study for analysis. Both groups underwent TAVI performed using balloon sizing less than mild paravalvular AR to assess the proper prosthesis size. The myocardial function within 1 year postoperative were sequentially evaluated using the New York Heart Association (NYHA) class, and echocardiography measurements. The incidence rates of complications at 30 days and 1 year were analyzed. During the 1-year follow-up, the time of death from any cause or complications in both groups was recorded. The study found that the percentage of patients with class III-IV of NYHA dropped after TAVI in both groups, and no significant difference between both groups at 1 year. Compared with the tricuspid AS group patients, Bicuspid group patients had more improvement in mean aortic valve gradient from baseline to 1year (-47.47±13.38 vs. -50.22±19.25 mmHg, P<0.05). There were no significant differences in 30-day and one-year compliance outcomes except a lower incidence of AR at post-procedure and 30 days in the tricuspid AS group as the Bicuspid AS group. There were no statistically significant differences in the time of death from any cause or significant complications between groups. TAVI has acceptable therapeutic efficacy and safety and is feasible for AS patients with BAV in China.

What Is the Optimal Post-Transplant Cardiac Screening for Transplant Recipients with a Non-Malignant Disease?

Introduction There are no published cardiac screening guidelines specific to nonmalignant hematopoietic cell transplant (HCT) recipients. Historically, our program has performed cardiac screening on all transplant recipients, regardless of transplant indication. We performed a quality improvement audit to determine the utility of this practice. Objective Assess the utility of routine cardiac screening post HCT for nonmalignant patients. Methods We performed a retrospective chart review to determine the new pathologies detected by post-HCT ECHO and EKG performed on patients with nonmalignant disorders who underwent HCT at our center from January 1, 2008 – December 31, 2016. Patients were included if they had a nonmalignant disease and an electrocardiogram (EKG) and echocardiogram (ECHO) prior to transplant and at either three months post-transplant, one year and/or yearly thereafter. Results The mean follow-up for the cohort (n=88) was 25 months (range 3-93 mo). Average age was 97 months and transplant indications included: 37% bone marrow failure, 5% metabolic, 22% immune deficiency and 36% other. For these patients, a total of 632 EKGs and 501 ECHOs were reviewed. On average each patient received 2 screening ECHO's and EKGs, post-transplant. Only 1 patient had new cardiac finding on post-transplant cardiac screening. Prior to HCT, this patient, with I cell disease, had right bundle branch block. On post-transplant screening, he was noted to develop mild aortic valve regurgitation, with normal systolic function. Three patients developed new cardiac dysfunction detected on additional screening due to clinical symptoms. One patient developed pericardial effusion and ultimately required the placement of a window. Subsequently, his pericardial effusion resolved, and his cardiac function was normal at last check two years post HCT. Another developed left ventricle enlargement and decreased function secondary to a fungemia. This subsequently resolved following resolution of her infection and cardiac function was normal on her last evaluation. The third died of pulmonary hypertension and decreased ventricular function 22 months post HCT. His Day 100- and 1-year screenings were normal. His dysfunction was detected on additional scans due to clinical symptoms. Conclusion In patients with nonmalignant disorders and a normal pre-transplant cardiac evaluation, the development of post-transplant cardiac complications is rare. This is likely explained by the lack of cardiac toxic medications prior to transplantation or high dose cardiac irradiation during the preparative regimen. Disease specific prospective studies including assessing individual risk factors are needed to guide post-transplant cardiac screening in this widely diverse patient population.

Aortic Valve Replacement with Bovine Pericardium in Patients with Aortic Valve Regurgitation.

This study aimed to analyze the early and mid-term outcomes of aortic valve replacement with bovine pericardium in the treatment of aortic valve regurgitation.From January 2015 to March 2018, 36 patients (19 men; mean ± standard deviation [SD] age, 46.70 ± 16.60 years) underwent aortic valve replacement with bovine pericardium. The bovine pericardium was intraoperatively measured and shaped using an Ozaki template, according to the shape and size of the individual patient's aortic valve leaflets. Additional procedures were performed, including ventricular septal defect repair in 5 cases, mitral valve reconstruction in 6 cases, tricuspid valve reconstruction in 6 cases, and coronary artery bypass grafting in 3 cases.There were no perioperative deaths. One elderly patient with postoperative respiratory failure recovered after symptomatic treatment. One patient with frequent ventricular tachycardia after intraoperative cardiac re-jump underwent intra-aortic balloon counterpulsation (IABP), and the IABP device was successfully removed on the second postoperative day. Within the first 6 months of follow-up, there were no death events, no reoperation events, and no additional thromboembolic events. Follow-up echocardiography was performed for 6 months, with average left ventricular ejection fraction of 62.01 ± 3.21%, mean transvalvular pressure gradient of 11.17 ± 4.90 mmHg, and mean aortic valve velocity of 1.60 ± 0.58 m/s. Compared with the preoperative transthoracic echocardiography findings, the results at the six-month follow-up were statistically significant (P < 0.05). Mild aortic valve regurgitation occurred in 2 patients (5.56%), whereas other patients had no or only minimal aortic valve regurgitation (n = 34, 94.44%). Moderate aortic valve regurgitation occurred in one patient at 9 months after the initial operation. This was found to be due to infective endocarditis, and a biological valve was finally implanted.Aortic valve replacement with bovine pericardium in the treatment of aortic valve regurgitation is feasible, and good early and mid-term results are achieved. Long-term results need to be followed up in the future.

Long-term outcomes and predictors of recurrent aortic regurgitation after aortic valve-sparing and reconstructive cusp surgery: a single centre experience

BackgroundAortic valve sparing surgery (AVS), in combination with aortic cusp repair (ACR), still raises many questions about the increased surgical complexity and applicability for patients with pure aortic valve regurgitation (AR). The aim of this study was to investigate our long-term outcomes and predictors of recurrent AR (> 2+) after AVS and reconstructive cusp surgery.MethodsWe reviewed data of 81 patients who underwent AVS (a reimplantation technique) with concomitant ACR for AR and or dilatation of the aortic root at our institution during the period from April 2004 to October 2016. On preoperative echocardiography, the majority of the patients, 70 (86.4%) presented with severe AR grade (> 3+) and 28 (34.5%) of the patients had the bicuspid phenotype. Time to event analysis (long-term survival, freedom from reoperation, and recurrence of AR > 2+) was performed with the Kaplan–Meier method. Multivariate Cox regression risk analysis was performed to identify independent predictors of recurrent AR (> 2+). The mean follow-up was 5.3 ± 3.3 years and 100% complete.ResultsThe in-hospital (30-day) mortality rate after elective surgery was 1.2%. The overall actuarial survival rates were 92.9 ± 3.1% and 90.4 ± 3.9% at five and 10 years, respectively. Actuarial freedom from recurrent AR (> 2+) was 83.7 ± 4.5% within the cohort at five and 10 years. The cumulative freedom from all causes of cardiac reoperation was 94.2 ± 2.8% within the cohort at 10 years. Neither bleeding nor thromboembolic or permanent neurologic events were reported during follow-up. By multivariate analysis, independent predictors of reccurent AR (> 2+) were an effective height lower than 9 mm (p= 0.02) and intraoperative residual mild AR (p= 0.0001).ConclusionsAVS with ACR, combined in a systematic fashion, is a safe and reproducible option with low risk of long-term valve related events and normal life expectancy for patients with pure aortic regurgitation.The competent aortic valve and effective height, not lower than 9 mm intraoperatively, are mandatory to achieve long-lasting AV competency.

Does Coronary Reimplantation After Neoaortic Reconstruction Increase Aortic Regurgitation?

Coronary reimplantation after neoaortic reconstruction (CRANR) in the arterial switch operation (ASO) allows easy selection of accurate coronary transfer sites in the distended neoaorta. However, neoaortic valve injury may occur during coronary reimplantation. We determined whether the CRANR procedure increased the incidence of aortic valve regurgitation (AR) after ASO. Between March 1994 and August 2017, 227 patients underwent ASO. Since September 2000 CRANR has been performed on 155 patients and open coronary reimplantation (OCR) on 72. Patients who had undergone aortocoronary flaps procedures (n = 13), had early or late mortality (n = 27), or lacked data (n = 11) were excluded. We enrolled and retrospectively reviewed the medical records of 176 patients who were followed up for postoperative AR: 38 underwent OCR and 138 underwent CRANR. We compared the incidences of early and late postoperative AR in both groups. We defined mild or greater AR as "significant AR." The groups did not differ in body weight at operation, great artery relationship, and coronary artery anatomy. The incidences of significant AR at discharge were 21.1% (8/38) in the OCR group and 16.6% (23/138) in the CRANR group (p = 0.53). The freedom from significant AR at 5years was 59.9% in the OCR group and 62.4% in the CRANR group with no difference between the two groups (p = 0.73). Moderate AR occurred in one patient in the CRANR group. No surgical intervention was required for the aortic valve in either group. ASO using the CRANR technique did not increase the incidence of postoperative early and late AR.

Voxel-by-voxel 4D flow MRI-based assessment of regional reverse flow in the aorta.

Complex and reverse flow in the aorta has been implicated in aneurysm development and stroke via retrograde embolization. To evaluate global and regional differences between standard 2D plane-based and volumetric voxel-based quantification of regional forward/reverse flow, and reverse flow fraction (RFF) in the aorta. Retrospective. In all, 35 subjects: 10 healthy controls (age: 57 ± 7 years, nine male), nine patients without aortic valve regurgitation (AR) (age: 63 ± 10 years, seven male), six patients with mild AR (age: 66 ± 6 years, five male), and 10 with moderate or severe AR (age: 60 ± 16 years, eight male). 4D flow MRI (3T and 1.5T) was employed to acquire 3D blood flow velocities with entire thoracic aorta in all subjects. Data analysis included standard 2D plane-based quantification of forward/reverse flow, and RFF-plane. In addition, a new semiautomatic workflow based on 3D segmentation and extraction of an aorta centerline was developed for voxel-by-voxel visualization (forward/reverse flow and RFF-voxel maps) and quantification of regional voxel-by-voxel forward/reverse flow in the entire thoracic aorta. Kruskal-Wallis tests were performed to test for differences between groups. A two-sample t-test or Wilcoxon rank sum test was used to compare voxel-based and plane-based results. Semiautomatic plane-based analysis showed excellent agreement with standard manual plane-based analysis for net flow and RFF-plane (RFF-plane: y = 0.99x-0.0, net flow: y = 1.00x-0.21, R > 0.99, P < 0.0001). Voxel-by-voxel maps demonstrated marked regional flow reversal in the ascending aorta in all patients and RFF-voxel was significantly increased (P < 0.001) compared to RFF-plane for all four groups, with the most pronounced differences for mild AR (18.0 ± 15.2% vs. 4.7 ± 5.4%). Voxel-based flow and RFF-voxel along the aorta showed areas with marked regional flow reversal (eg, vortex flow) compared to plane-based analysis. Voxel-based analysis demonstrated regional flow reversal that was not detected by plane-based analysis. 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:1276-1286.