Moderate Aortic Insufficiency Research Articles

Aortic insufficiency in the patient on contemporary durable left ventricular assist device support: A state-of-the-art review on preoperative and postoperative assessment and management

The development of aortic insufficiency (AI) during HeartMate 3 durable left ventricular assist device support (dLVAD) can lead to ineffective pump output and recurrent heart failure symptoms. Progression of AI often comingles with the occurrence of other hemodynamic related events encountered during LVAD support, including right heart failure, arrhythmias, and cardiorenal syndrome. While data on AI burdens and clinical impact are still insufficient in patients on HeartMate 3 support, moderate or worse AI occurs in approximately 8% of patients by 1 year and studies suggest AI continues to progress over time and is associated with increased frequency of right heart failure. The first line intervention for AI management is prevention, undertaking surgical intervention on the insufficient valve at the time of dLVAD implant and avoiding excessive device flows and hypertension during long term support. Device speed augmentation may then be undertaken to try and overcome the insufficient lesion, but progression of AI should be anticipated over the long term. Surgical or transcatheter aortic valve interventions may be considered in dLVAD patients with significant persistent AI despite medical management, but neither intervention is without risk. It is imperative that future studies of dLVAD support capture AI in clinical endpoints using uniform assessment and grading of AI severity by individuals trained in AI assessment during dLVAD support.

Medium-Term Outcomes of Concomitant Aortic Valve Repair in Patients with Continuous-Flow Left Ventricular Assist Device

Our objective was to analyze the development of aortic insufficiency in patients who received central aortic valve repair when undergoing continuous-flow left ventricular assist device implantation. We conducted a retrospective review of patients who underwent HeartMate II or 3 (Abbott Lab) implantation between 2004 and 2022. Ninety-four patients were excluded from analysis for history of aortic valve procedures, a bicuspid aortic valve, baseline trace aortic insufficiency, or other concomitant aortic valve procedure. Patients who had ≥ mild aortic insufficiency had concomitant aortic valve repair. Clinical characteristics, serial echocardiograms, and outcomes were determined. Of the 656 patients who underwent HeartMate II or 3 implantation, 105 patients (59 HeartMate II and 46 HeartMate 3) met study criteria. Median age was 68 years [60-74 years], 91.4% [n=96] were male, 54.4% [n=56] were white, and 68.6% [n=72] received support as destination therapy. Preoperative aortic insufficiency degree was 54.3% (n=57) mild, 23.8% (n=25) mild-to-moderate, 20.0% (n=21) moderate, 1.0% (n=1) moderate-to-severe, 1.0% (n=1) severe. In hospital mortality was 5.7% [n=6]. Freedom from ≥ moderate aortic insufficiency was 96.4% (95%CI: 92.5%-100%), 93.3% (95%CI: 87.6%-99.2%), and 91.0% (95%CI: 84.1%-98.5%) at 1-year, 2-year, and 3-year post-implantation, respectively. One HeartMate II patient experienced severe aortic insufficiency and was treated with a heart transplant. Three-year survival was 63.4% [95%CI: 52.9%-75.9%]. Central aortic valve repair may be an effective technique to mitigate aortic insufficiency in HeartMate II and 3. A larger cohort study with longer duration of follow up is warranted to further investigate the clinical impact.

Fluid mechanics of aortic valve incompetence in the dilated left ventricle

Introduction: Aortic insufficiency (AI) occurs when the aortic valve fails to close completely, allowing backward blood flow into the left ventricle (LV). The progression of AI can lead to ventricular dysfunction and congestive heart failure, setting off a self-perpetuating cycle that worsens these conditions. This study employed models of repeatable and reversible AI within a simulated circulatory loop to analyze vortex dynamics, AI parameters, and gain insights into the efficiency of ventricular washout.Method: A transparent silicone model of an LV with an ejection fraction of 17% served as the baseline, simulating a condition without AI. Mild, moderate, and severe AI were induced using 3D-printed stents, obstructing the complete closure of the aortic valve while allowing unimpeded forward blood flow. Midplane velocity fields were analyzed to compute AI and vortex properties, energy dissipation rate, blood residence time, and shear activation potential.Results and discussion: With increasing AI severity, the regurgitant jet expanded, impeding the development and trajectory of mitral inflow. The inefficiency in fluid transport became apparent through a declining ratio of total kinetic energy rate to energy dissipation rate and an increasing residence time. Impaired ventricular washout resulted in the accumulation of fluid with elevated shear activation potential in the LV. These findings suggested that AI progressively induces abnormal intraventricular flow, heightening the thromboembolic risk in heart failure patients. The study also advocates for the potential application of mock circulatory system to explore the effects of various AI configurations, especially when combined with other cardiac implants like artificial heart valve or left ventricular assist device.

Abstract 16043: Impact of Left Ventricular Global Longitudinal Strain on the Outcomes of Patients With Moderate Aortic Stenosis and Moderate Aortic Insufficiency

Background: Reduced left ventricular global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis (AS). Its role in predicting outcomes in moderate AS is now being reported. We aim to investigate the prognostic value of GLS in patients with moderate AS and moderate aortic insufficiency (AI). Methods: We conducted a retrospective review of 1576 patients with a diagnosis of AS and AI at a community cardiology practice. We reviewed the echocardiographic data and included 254 patients with moderate AS and moderate AI. They were retrospectively followed for 1 year from the time they initially had the echocardiography findings to note the occurrence of shortness of breath (SOB), heart failure (HF) hospitalization, or mortality during the 1 year period. Results: Out of the 254 patients that were studied, 121 patients (47.64%) had GLS ≤16%. Demographics and comorbidities such as age, sex, hypertension, diabetes mellitus (DM), obesity, and atrial fibrillation were balanced in both arms. Patients with GLS ≤16% had significantly higher SOB (50.41% vs. 32.33%, p=0.003) and HF hospitalization (17.36% vs. 9.02%, p=0.049) during 1-year follow-up. 1-year mortality was higher in GLS ≤16% arm but not statistically significant (5.79% vs. 1.5%, p=0.065). After adjusting for patient characteristics using logistic regression, GLS ≤16% was independently associated with higher odds of SOB (aOR 2.139, 95CI 1.28-3.59, p=0.004) but not for HF hospitalization (aOR 2.022, 95CI 0.94-4.35, p=0.072) and 1-year mortality (aOR 4.165, 95CI 0.78-22.12, p=0.094). Conclusions: GLS ≤16% is associated with an increased likelihood of SOB in patients with moderate AS and moderate AI. HF hospitalization and 1-year mortality were not statistically significant, but there is a clear trend towards worse outcomes in patients with GLS ≤16%. If future studies reproduce similar results and outcomes, it may be time to rethink the timing of aortic valve intervention.

Aortic Root Thrombosis in patients with HeartMate 3 left ventricular assist device support

BackgroundAortic root thrombus (ART) formation is a complication of continuous flow left ventricular assist device (LVAD) therapy. However, the incidence and related complications of ART in HeartMate 3 (HM3) patients remains unknown. MethodsPatients who underwent HM3 implantation from November 2014 through August 2020 at a quaternary academic medical center were included. Demographics and outcomes were abstracted from the medical record. Echocardiograms and contrast-enhanced CT studies were reviewed to identify patients who developed ART and/or moderate or greater aortic insufficiency (AI) on HM3 support. ResultsThe study cohort included 197 HM3 patients with a median post-implant follow-up of 17.5 months. Nineteen patients (9.6%) developed ART during HM3 support, and 15 patients (7.6%) developed moderate or greater AI. Baseline age, gender, race, implantation strategy, and INTERMACS classification were similar between the ART and no-ART groups. ART was associated with an increased risk of death, stroke, or AV intervention (subhazard ratio [SHR] 3.60 [95% CI 1.71-7.56]; p=0.001) and moderate or greater AI (SHR 11.1 [CI 3.60-34.1]; p<0.001) but was not associated with a statistically significantly increased risk of death or stroke on HM3 support (2.12 [0.86-5.22]; p=0.10). Of the 19 patients with ART, 6 (31.6%) developed moderate or greater AI, necessitating more frequent AV interventions (ART: 5 AV interventions [3 surgical repairs, 1 surgical replacement, 1 transcatheter replacement; 26.3%]; no-ART: 0). ConclusionNearly 10% of HM3 patients developed ART during device support. ART was associated with increased risk of a composite endpoint of death, stroke, or AV intervention as well as moderate or greater AI.

Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome

BackgroundThe usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. ObjectivesThe purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. MethodsPatients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. ResultsThere were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. ConclusionsAortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.

Midterm Results of an Algorithmic 3-Pronged Approach to Bicuspid Aortic Valve Repair

BackgroundThis study evaluated midterm outcomes of a 3-pronged algorithm for bicuspid aortic valve (BAV) repair. Valve-sparing root reimplantation (VSRR) was performed for patients with aortic root dilatation. In those without a root aneurysm, external subannular ring (ESAR) was performed for annuli ≥28 mm and subcommissural annuloplasty (SCA) for annuli <28 mm. MethodsThis was a retrospective review of prospectively collected data of 242 patients undergoing primary BAV repair from April 29, 2004, to March 1, 2023, at a single institution. Primary end points were mortality, structural valve degeneration (SVD), which was defined as a composite of more than moderate aortic insufficiency or severe aortic stenosis, and reintervention. ResultsThe algorithm was used to treat 201 patients; of these, 130 underwent VSRR, 35 had ESAR, and 36 underwent SCA. Most were men with mean age of 43.8 years (SD, 12.0 years), which was similar between groups. Preoperative aortic insufficiency more than moderate was more common for ESAR compared with VSRR and SCA (74.3% vs 37.7% vs 44.4%, P < .001). At 30 days, mortality was 0.8% (n = 1) for VSRR and 0% for ESAR and SCA. At 6 years, overall Kaplan-Meier survival was 98.9% (95% CI, 97.3%-100%), with no differences between groups (P = .5). The cumulative incidence of SVD was 4.7% (95% CI, 0.1%-9.2%) for VSRR, 6.4% (95% CI, 0%-14.6%) for ESAR, and 0% for SCA (P = .4). Similarly, the cumulative incidence of reintervention with all-cause mortality as a competing risk was 2.2% (95% CI, 0.4%-6.9%), 6.1% (95% CI, 1%-17.9%), and 0% for VSRR, ESAR, and SCA, respectively (P = .506). ConclusionsA 3-pronged algorithmic approach to BAV repair results in excellent survival and freedom from reoperation at 6 years.

Trends in surgical management of anomalous aortic origin of the coronary artery over 2 decades

ObjectiveTo evaluate outcomes of patients undergoing surgery for anomalous aortic origin of the coronary artery (AAOCA) at a tertiary care center and determine the influences of a coronary artery program on management strategies and outcomes. MethodsThis retrospective review of consecutive surgical patients who had isolated AAOCA at a tertiary care center between August 1, 1999, and October 31, 2022, compared patient characteristics, interventional timing, and surgical strategies before and after program inception in 2018. Comparisons between time periods and anatomical subgroups were performed using Fisher exact and Wilcoxon rank-sum tests. ResultsOf 149 surgical AAOCA patients, 102 (69%) had AAO of the right coronary artery. Compared with AAO of the left coronary artery (AAOLCA), AAO of the right coronary artery (AAORCA) was associated with greater athletic participation (intramural, varsity, and college-level) (74% vs 43%; P < .001) and preoperative functional imaging (72% vs 49%; P = .01), but were less likely to have ischemic changes on functional imaging (5% vs 23%; P = .03) or any postoperative complications (7% vs 19%; P = .04). Moderate or greater aortic insufficiency occurred postoperatively in 1 (1%) of AAORCA and 1 (3%) of AAOLCA patients. After the coronary artery program inception, there was an increase among patients with AAOCA undergoing preoperative computed tomography angiography (pre-2018: 39 out of 98 [40%] vs post-2018: 48 out of 51 [94%]; P < .001) and a decrease in isolated AAOCA unroofing procedures performed (30 [31%] vs 5 [10%]; P = .004). ConclusionsSurgical management of AAOCA evolved over time, and can be achieved with low instance of postoperative aortic insufficiency. Establishment of a coronary artery program has streamlined care.

Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation.

During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00-1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00-1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.

Outcomes of aortic valve repair with the reimplantation technique and maintenance of commissural orientation.

Debate still persists on whether valve-sparing root reimplantation (VSRR) of a very asymmetric bicuspid aortic valve (BAV) should be completed such that the asymmetry of the native commissural orientation is retained, or if it should be made symmetric (180°-180°). Herein, we present our approach, in which the native asymmetry is preserved, and the valve is reimplanted in a 210°-150° orientation. A retrospective review was performed of 130 patients with BAV who underwent VSRR between January 1, 2004 and March 1, 2023 at a single institution. Of this total, 37 were reimplanted asymmetrically (210°-150°). The primary outcome was > moderate aortic insufficiency (AI). Secondary outcomes included severe aortic stenosis (AS), reintervention, and survival. The included 37 patients were mostly male [94.6% (35/37)] with mean age of 46.3 years, and with low rates of comorbidities. At least moderate AI was present in 40.5% (15/37) prior to surgery. All BAV in this series were Sievers Type 1 with a mean commissural angle of 128.2°. Leaflet repair was required in 81.1% (30/37), most commonly involving central plication of the conjoined cusp [96.7% (29/30)] and raphe release [73.3% (22/30)]. There was no 30-day mortality or stroke. At 10 years, the cumulative incidences of > moderate AI, severe AS, and reintervention were 7.6% (0-17.2%), 7.1% (0-19.7%), and 5.3% (0.3-22%), respectively. There was no mortality for the entire duration of the study period. This series demonstrates excellent 10-year outcomes of maintaining commissural orientation in asymmetric BAV reimplantation procedures. However, further study with additional patients, longer follow-up, and direct comparison to symmetric reimplantation for similar BAV morphology is required.

Valve-sparing aortic root replacement versus composite valve graft with bioprosthesis in patients under age 50

BackgroundAlthough the unique risks of implanting a prosthetic valve after aortic valve (AV) surgery in young patients are well established, studies of aortic root replacement (ARR) are lacking. We investigated long-term outcomes after valve-sparing root replacement (VSRR) versus the use of a composite valve graft with bioprosthesis (b-CVG) in patients age <50 years. MethodsA total of 543 patients age <50 years underwent VSRR (n = 335) or b-CVG (n = 208) between 2004 and 2021 from 2 aortic centers, excluding those with dissection or endocarditis. Endpoints included mortality over time, reoperative aortic valve replacement (AVR), and development of greater than moderate aortic insufficiency (AI) or aortic stenosis (AS). Fine and Gray competing risk regression was used to compare the risk of reintervention. Propensity score matching (PSM) balanced patient comorbidities, and landmark analysis isolated outcomes beginning 4 years postoperatively. ResultsCompared with VSRR, b-CVG was associated with lower 12-year survival (88.6% vs 92.9%; P = .036) and a higher rate of AV reintervention (37.6% vs 12.0%; P = .018). After PSM, survival was similar in the 2 arms (93.4% for b-CVG vs 93.0% for VSRR; P = .72). However, both Fine and Gray multivariable risk regression and PSM showed that b-CVG was independently associated with AV reintervention at >4 years postoperatively (Fine and Gray: subdistribution hazard ratio, 4.3 [95% confidence interval, 1.8-10.2; P = .001]; PSM: 35.7% for b-CVG versus 14.3% for VSRR; P = .024]). PSM rates of greater than moderate AI/AS at 10 years were more than 2-fold greater in the b-CVG arm compared with the VSRR arm (37.1% vs 15.9%; P = .571). Conclusionsb-CVG in young patients is associated with early valvular degeneration, with increasing rates of reoperative AVR occurring even within 10 years. In contrast, VSRR is durable with excellent survival. In eligible young patients, every effort should be made to retain the native AV.

CARC12: Surgical Correction of De Novo Aortic Valve Insufficiency after Left Ventricular Assist Device Implantation

Background: Development of significant aortic insufficiency (AI) is a common complication associated with prolonged support with continuous-flow left ventricular assist device (CF-LVAD). The aim of this study is to investigate the clinical outcomes after surgical correction of de novo AI after LVAD implantation. Methods: Between January 2013 and June 2022, 190 patients underwent CF-LVAD implantation. Of them, 24 had trivial or less AI before LVAD implantation and developed moderate or greater de novo AI after LVAD implantation. Those who had undergone aortic valve surgery before or concomitant with LVAD surgery were excluded. Among the 24 patients, surgeries were indicated for medically refractory de novo AI in 11 patients, who were included in the current study. Primary endpoint was post-operative improvement in hemodynamics as assessed with right heart catheter examination, and the secondary endpoint was 3-year survival and freedom from death and/or heart failure readmission rate. Results: Correction of de novo AI were accomplished with aortic valve closure with bovine pericardial patch in 10 patients and prosthetic valve replacement in one patient. After surgery, pulmonary artery wedge pressure (PAWP), and cardiac index (CI), mixed venous blood oxygen saturation (SvO2) significantly improved compared with preoperative baseline (Figure). The mean follow-up after LVAD implantation was 1413days, and the 3-year survival rate was 90.9%. The freedom from postoperative moderate or greater AI rate, and the freedom from heart failure readmission rate were both 90.9% at 3 years. Conclusion: In patients who were indicated for surgical correction of de novo AI after LVAD implantation, postoperative hemodynamic improvement and survival were considered favorable.Figure 1. Hemodynamic change in three states

P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.

P219 EXTRINSIC COMPRESSION OF THE RIGHT VENTRICLE CAUSING ISOLATED RIGHT HEART FAILURE

Abstract Isolated right heart failure (RHF) can be caused by right ventricular (RV) compression, mainly described in severe cases of pectus excavatum. Mediastinal masses can determine an extrinsic compression of the RV. A 62–year–old retired agricultural inspector from Sicily presented in our clinic with worsening signs of RHF. His medical history consisted of echinococcosis familiarity, surgically treated congenital subvalvular aortic stenosis, resulted in a residual moderate aortic insufficiency and permanent atrial fibrillation. Around January 2021 he developed isolated leg swelling. Aortic valvular dysfunction, heart failure and other cardiogenic explanations were excluded. A year later dyspnea (NYHA class II) appeared. High resolution CT demonstrated fluid collection with peripheric calcifications inside the anterior mediastinum. PET showed uptake in a limited zone of the anterior mediastinum. The patient slowly started developing ascites, hardly manageable with diuretics because of kidney failure. Transthoracic echocardiography (TTE) highlighted mild RV dysfunction (FAC 35%) and right ventricular free wall hypokinesia due to the mediastinal mass extrinsic compression. Transesophageal echocardiography showed a heterogeneous cystic aspect of the mediastinal mass, an oscillating intraventricular mass of the right aortic cuspid (6x4 mm) and a severe mitral annular calcification. In consideration of medical history, endocarditis was considered. Cardiac magnetic resonance recognized a mediastinal mass with echinococcosis features. Echinococcous serology and antibodies were negative but the Quantiferon tested positive. Laboratory tests showed an absolute eosinophilia and a high CD4/CD8 ratio. Because of the patient severely compromised hemodynamic balance the mass was surgically removed and identified as pseudocystic tuberculoma. After the excision, hemodynamic balance was improved and the TTE showed a restored RV function with persistent hypokinesia of the RV free wall and increased right atrium pressure. In this clinical case RHF was determined by an extracardiac mass which interfered with the hemodynamic balance and the function of the right heart in the absence of any signs of left heart failure. Because of the mass mechanical action on the reduction of RV ejected volumes, a surgical option was the only possible strategy to avoid a following worsening of the heart failure.

Lower-extremity malperfusion syndrome in patients undergoing proximal aortic surgery for acute type A aortic dissection

ObjectiveData regarding management of lower-extremity malperfusion in the setting of type A aortic dissection are limited. This study aimed to compare acute type A aortic dissection with lower-extremity malperfusion outcomes in patients undergoing lower-extremity revascularization with no revascularization. MethodsConsecutive patients undergoing acute type A aortic dissection surgery were identified from a prospectively maintained database. Perioperative variables were compared between patients with and without lower-extremity malperfusion. Factors associated with lower-extremity malperfusion, revascularization, and mortality were determined using univariable Cox regression and Firth's penalized likelihood modeling. ResultsFrom January 2007 to December 2021, 601 patients underwent proximal aortic repair for acute type A aortic dissection at a quaternary care center. Of these, 85 of 601 patients (14%) presented with lower-extremity malperfusion and were more often male (P = .02), had concomitant moderate or greater aortic insufficiency (P = .05), had lower ejection fraction (P = .004), had preoperative dialysis dependence (P = .01), and had additional cerebral, visceral, and renal malperfusion syndromes (P < .001). Kaplan–Meier estimated survival fared worse with lower-extremity malperfusion compared with no lower-extremity malperfusion at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, respectively, P = .03). In the lower-extremity malperfusion group, 15 of 85 patients (18%) underwent lower-extremity revascularization without significant differences in postoperative morbidity and mortality compared with patients not undergoing revascularization. Need for peripheral revascularization was associated with peripheral vascular disease (hazard ratio, 3.7 [1.0-14.0], P = .05) and pulse deficit (hazard ratio, 5.6 [1.3-24.0], P = .02) at presentation. ConclusionsPatients presenting with type A aortic dissection and lower-extremity malperfusion have worse overall survival compared with those without lower-extremity malperfusion. However, not all patients with type A aortic dissection and lower-extremity malperfusion require revascularization.

Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Long-term durability of valve-sparing root replacement in patients with and without connective tissue disease

ObjectiveThe goal of this study was to evaluate the long-term outcomes of valve-sparing root replacement in patients with connective tissue disease (CTD) and compare them with patients without CTD who underwent valve-sparing root replacement for root aneurysm. MethodsOf 487 patients, 380 (78%) did not have CTD and 107 (22%) had CTD; 97 (91%) with Marfan syndrome, 8 (7%) with Loeys-Dietz syndrome, and 2 (2%) with Vascular Ehlers-Danlos syndrome. Operative and long-term outcomes were compared. ResultsThe CTD group was younger (36 ± 14 years vs 53 ± 12 years; P < .001), had more women (41% vs 10%; P < .001) and had less hypertension (28% vs 78%; P < .001) and bicuspid aortic valve (8% vs 28%; P < .001). Other baseline characteristics did not differ between the groups. Overall operative mortality was nil (P = 1.000); the incidence of major postoperative complications was 1.2% (0.9% vs 1.3%; P = 1.000) and did not differ between groups. Residual mild aortic insufficiency (AI) was more frequent in the CTD group (9.3% vs 1.3%, P < .001) with no difference in moderate or greater AI. Ten-year survival was 97.3% (97.2% vs 97.4%; log-rank P = .801). Of the 15 patients with residual AI, 1 had none, 11 remained mild, 2 had moderate, and 1 had severe AI on follow-up. Ten-year freedom from moderate/severe AI was 89.6% (hazard ratio, 1.05; 95% CI, 0.8-1.37; P = .750) and 10-year freedom from valve reoperation was 94.9% (hazard ratio, 1.21; 95% CI, 0.43-3.39; P = .717). ConclusionsThe operative outcomes as well as long-term durability of valve-sparing root replacement is excellent in patients with or without CTD. Valve function and durability are not influenced by CTD.

Laubry-Pezzi syndrome: three case reports and review of the literature.

We reported three cases of Laubry-Pezzi syndrome diagnosed in our department of cardiology on a cohort of more than 3000 cases of congenital heart disease. A 13-year-old patient presented a Laubry-Pezzi syndrome with severe AR and significant volumetric left ventricle overload and was operated on in time to allow a good evolution of his condition. A 43-year-old patient, followed for congenital cardiac pathology, presented with severe dyspnea. The echocardiogram found global dysfunction of the left ventricle with an ejection fraction of 35%, a perimembranous ventricular septal defect (VSD) almost completely closed by the prolapse of the noncoronary cusp, and severe eccentric aortic insufficiency due to the prolapse of the noncoronary cusp. Aortic valve replacement and VSD closure were indicated. The third patient is a 21-year-old patient with Down syndrome, in whom a grade 2/6 systolic murmur was detected. Transthoracic echocardiography revealed a perimembranous VSD measuring 4mm without any hemodynamic repercussions and a moderate aortic insufficiency due to the prolapse of the noncoronary cusp. Clinical and echocardiographic monitoring with Osler prevention was indicated as a modality of management. The pathophysiology is explained by the Venturi effect, the restrictive shunt of the VSD creates an area of low pressure that sucks the adjacent cusp resulting in aortic prolapse and regurgitation. The diagnosis is essentially based on transthoracic echocardiography; it must be conducted before the emergence of AR. The management of this rare syndrome still remains nonconsensual, whether it is through timing or operative techniques. Management must be early by closing the VSD with or without aortic valve intervention to prevent the onset or worsening of AR.

Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency

In minimally invasive aortic valve replacement via a right minithoracotomy for patients with significant aortic insufficiency, optimal cardioplegia delivery procedures remain controversial. This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive aortic valve replacement for aortic insufficiency. Between September 2015 and February 2022, 104 patients (mean age, 66.0±14.3 years) with moderate or greater aortic insufficiency underwent endoscopically assisted minimally invasive aortic valve replacement at our institutions. For myocardial protection, potassium chloride and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. The early clinical outcomes were also evaluated. Eighty-four patients (80.7%) had severe aortic insufficiency, and 13 patients (12.5%) had aortic stenosis and moderate or greater aortic insufficiency. A regular prosthesis was used in 97 cases (93.3%), and a sutureless prosthesis was used in 7 cases (6.7%). The mean operative, cardiopulmonary bypass, and aortic crossclamping times were 169.3±36.5, 102.4±25.4, and 72.5±21.8minutes, respectively. No patients underwent a conversion to full sternotomy or required mechanical circulatory support during or after surgery. No operative deaths or perioperative myocardial infarctions occurred. The median intensive care unit and hospital stays were 1 and 5 days, respectively. Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive aortic valve replacement in patients with significant aortic insufficiency.

Double-chambered left ventricle: diagnosis by CMR and review of the literature

BackgroundA double-chambered left ventricle (DCLV) is an extremely rare congenital malformation. The exact prevalence of DCLV is not known, although studies have reported prevalence of 0.04–0.42%. This abnormality is characterized by the sub-division of left ventricle into two chambers, the main left ventricular chamber (MLVC) and the accessory chamber (AC) by a septum or muscle band.Case presentationWe are reporting two cases of DCLV, one in an adult male and an infant, who were referred for undergoing cardiac magnetic resonance (CMR) imaging. The adult patient was asymptomatic, whereas the infant had the diagnosis of left ventricular aneurysm on fetal echocardiography. On CMR, we confirmed the diagnosis of DCLV in both patients, as well as moderate aortic insufficiency in the adult patient. Both patients were lost to follow-up.ConclusionsThe double-chambered left ventricle (DCLV) is commonly detected in infancy or childhood. Although echocardiography can help detect double-chambered ventricles, MRI provides a better knowledge of this problem and can also be used to diagnose other related heart disorders.