Mm Hg Mean Gradient Research Articles

Hybrid, Transcatheter Aortic Valve Implantation (TAVI) and Total Arterial Off-Pump Coronary Artery Bypass (OPCAB) in a Patient with Severe Aortic Valve Regurgitation – A Case Report

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been shown to be an effective growing strategy for severe, symptomatic aortic valve stenosis (AS) in patients who are either not ideal candidates or who are at intermediate or high surgical risk for surgical aortic valve replacement. Hybrid TAVI and off-pump coronary artery bypass graft (OPCAB) have been previously reported in high-risk patients with severe AS and coronary artery disease (CAD). TAVI data for severe aortic valve regurgitation (AR) is limited and currently considered an off-label application. Reports on hybrid TAVI for severe AR and OPCAB in patients with severe co-morbid CAD are limited. We report a hybrid TAVI and OPCAB in a 64-year-old female, with severe AR, severe left ventricular systolic dysfunction and CAD with a low take-off of the left main (LM) and porcelain aorta. CASE REPORT: The patient is a 64-year-old morbidly obese Filipino female with porcelain aorta and post-percutaneous coronary intervention with drug-eluting stent implantation for multivessel CAD with LM involvement and was admitted for refractory heart failure. Her 2D echocardiography demonstrated a dilated left ventricle with 19% left ventricular ejection fraction (LVEF) and severe AR. Computed tomography angiography demonstrated porcelain aorta, a low take-off of the left main with good femoral access. Hybrid TAVI with 26 mm Corevalve was done via the transfemoral approach after OPCAB of the left internal mammary artery to left anterior descending artery. Valve-in-valve transcatheter aortic valve replacement was required due to low valve implantation and severe paravalvular leak (PVL). Follow-up echo at 22 months demonstrated no PVL, 1.6 cm2 effective orifice aortic valve area, 12.4 mmHg mean gradient and 50% LVEF. She remains asymptomatic and in functional class I. CONCLUSION: Hybrid TAVI and OPCAB in patients with severe valvar AR, porcelain aorta and CAD represents a feasible and effective option of care. There are few reports in the literature documenting the effectiveness or feasibility of this approach for such patients.

VD18 TRANSFEMORAL AORTIC VALVE REPLACEMENT IN A PATIENT WITH PREVIOUS TRANSCATHETER MITRAL VALVE-IN-VALVE: THE NEW ROLE OF THE “INTERVENTIONAL” CARDIAC SURGEON

On September 2014, a 76-year-old female patient presented with dyspnea. She underwent to mitral valve replacement with SJM 27 mm bioprosthesis valve in 2013. Other comorbidities included atrial fibrillation paroxysm and COPD. The echocardiography showed a degeneration of the bioprosthesis with severe regurgitation. Due to high surgical risk, we performed a transcatheter valve-in-valve replacement through left ventricular apical approach. Thus, we implanted an Edwards SAPIEN XT 26 mm into the bioprosthesis mitral valve. Echocardiography showed no MR and a 4 mmHg mean gradient. On February 2018, the patient was admitted with symptoms of progressive hearth failure. Echocardiography showed a severe aortic stenosis. Based on MDCT analysis, we proceeded with a TAVI (Edwards SAPIEN 3 23 mm) through transfemoral approach, with an optimal result. In the current scenario, we want to emphasize the growing role of the “interventional” cardiac surgeon in the treatment of all valve diseases.

Outcomes and Survival with Aortic Valve Replacement Compared with Medical Therapy in Patients with Low-, Moderate-, and Severe-Gradient Severe Aortic Stenosis and Normal Left Ventricular Ejection Fraction

This study determined outcomes and survival with aortic valve replacement (AVR) versus medical therapy in patients with normal left ventricular ejection fraction (LVEF) with severely reduced aortic valve areas (AVA) but nonsevere mean gradients. We identified 248 aortic stenosis (AS) patients with LVEF ≥ 50% and echocardiographic AVA < 1.0 cm(2). Group 1 had low-gradient: <30 mmHg mean gradient; group 2 (moderate: 30 to 40 mm Hg); and group 3 (severe: >40 mm). There were 94, 87, and 67 patients in groups 1, 2, and 3. Incidence of death in groups 1, 2, and 3 were 55%, 39%, and 39% (P not significant). Incidence of AVR in groups 1, 2, and 3 were 23%, 53%, and 49% (P < 0.0001 for group 1 vs. 2; P = 0.0003 for group 1 vs. group 3). Incidence of AVR or death was 71%, 77%, and 76% (P not significant). AVR (hazard ratio = 0.30; 95% CI, 0.18, 0.51; P < 0.0001) and mitral annular calcification (hazard ratio = 2.33; 95% CI, 1.40, 3.88; P = 0.001) were independently associated with time to mortality. Kaplan-Meier curves for time to death did not differ significantly among the three groups. Kaplan-Meier survival curves for patients with and without AVR showed patients in all three groups who underwent AVR had significantly greater survival. Among patients with normal LVEF and AVA < 1.0 cm(2), overall survival does not differ among those with low-, moderate-, or severe-aortic valve gradients. Survival is significantly improved with AVR, regardless of gradient.

Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion

A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4 x 1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large 'snake-like' thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.

The non-circular shape of FloWatch®-PAB prevents the need for pulmonary artery reconstruction after banding.Computational fluid dynamics and clinical correlations

To evaluate the differences between non-circular shape of FloWatch-PAB and conventional pulmonary artery (PA) banding. Geometrical analysis. Conventional banding and FloWatch-PAB perimeters were plotted against cross-sections. Computational fluid dynamics (CFD) model. CFD compared non-circular FloWatch-PAB cross-sections with conventional banding regarding pressure gradients. Clinical data. Seven children, median age 2 months (7 days to 3 years), median weight 4.2 kg (3.2-9.8 kg), with complex congenital heart defects underwent PA banding with FloWatch-PAB implantation. Geometrical analysis. Conventional banding: progressive reduction of cross-sections was accompanied by progressive reduction of PA perimeters. FloWatch-PAB: with equal reduction of cross-sections the PA perimeter remained constant. CFD model. Non-circular and circular banding provided same trans-banding pressure gradients for same cross-sections at any given flow. Clinical data. Mean PA internal diameter at banding was 13.3+/-4.5 mm. After a mean interval of 5.9+/-3.7 months, all children underwent intra-cardiac repair and simple FloWatch-PAB removal without PA reconstruction. Mean PA internal diameter with FloWatch-PAB removal increased from 3.0+/-0.8 to 12.4+/-4.5 mm (normal mean internal diameter for the age=9.9+/-1.6). No residual pressure gradient was recorded in correspondence of the site of the previous FloWatch-PAB implantation in 6/7 patients, 10 mmHg peak and 5 mmHg mean gradient in 1/7. The non-circular shape of FloWatch-PAB can replace conventional circular banding with the following advantages: (a) the pressure gradient will remain essentially the same as for conventional circular banding for any given cross-section, but with significantly smaller reduction of PA perimeter; and (b) PA reconstruction at the time of de-banding for intra-cardiac repair can be avoided.