Moderate-severe Aortic Regurgitation Research Articles

Hemodynamic performance of the balloon-expandable SAPIEN 3 valve as assessed by cardiac magnetic resonance

BackgroundScarce data exist on transcatheter heart valve (THV) performance evaluated by cardiac magnetic resonance (CMR) in newer generation THV patients. Furthermore, it has been suggested that echocardiographic evaluation after TAVR may inaccurately assess residual AR in some patients. This study aimed to determine the incidence and severity of aortic regurgitation (AR) assessed by CMR in patients undergoing TAVR with the SAPIEN 3 valve, and evaluate the agreement between CMR and transthoracic echocardiography (TTE) on the assessment of AR severity in such patients. MethodsThis multicentric observational study included 146 SAPIEN 3 patients with TTE and CMR within the month following their procedure. According to the CMR regurgitation fraction (RF), AR was considered mild and moderate-severe if the RF was 15–<30% and ≥ 30%, respectively. TTE exams followed VARC-2 recommendations. ResultsBy CMR, SAPIEN 3 recipients displayed a mean RF of 5.0 ± 6.1%, and mild and moderate-severe AR rates of 3.4% and 0.7%, respectively. The agreement between CMR-TTE was modest (weighted κ = 0.2640, p<0.001), due to an overestimation of AR severity by TTE. A historical cohort of 139 SAPIEN XT patients with a post-procedure CMR, displayed a mean RF of 9.6 ± 10.7% and mild and moderate-severe AR rates of 18.7% and 3.6%, respectively (p < .001 vs. SAPIEN 3 group). ConclusionsSAPIEN 3 recipients exhibited very low rates of residual AR by CMR, suggesting a surgical-like performance regarding AR with this newer generation THV. TTE tended to overestimate the severity of AR, particularly among mild AR patients.

Sutureless and rapid deployment implantation in bicuspid aortic valve: results from the sutureless and rapid-deployment aortic valve replacement international registry

Benefits of sutureless and rapid deployment (SURD) bioprostheses in bicuspid aortic valves (BAV) are controversial. The aim of this study is to report the outcomes of patients undergoing aortic valve replacement (AVR) for BAV from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR). Of the 4,636 patients who received primary isolated SURD-AVR between 2007 and 2018, 191 (4.1%) BAV patients underwent AVR with SURD valve. Overall 30-day mortality was 1.6%. The Intuity valve was implanted in 53.9% of cases, whereas the Perceval was implanted in 46.1%. Rate of stroke for isolated AVR was 4.2%. No case of endocarditis, thromboembolism, myocardial infarction, valve dislocation or structural valve deterioration was reported in the early phase. Rate of pacemaker implantation and moderate-severe aortic regurgitation (AR) were 7.9% and 3.7%, respectively. BAV is not considered a contraindication for the implantation of SURD valves. However, detailed information of aortic root geometry as well as the knowledge of some technical considerations are mandatory for a good outcome.

Concomitant Mitral Regurgitation in Patients With Chronic Aortic Regurgitation

BackgroundEtiology, mechanisms, and survival of mitral regurgitation (MR) plus hemodynamically-significant chronic aortic regurgitation (AR) are mostly unknown. ObjectivesThe purpose of this study was to investigate the prevalence, mechanisms, etiologies, and survival impact of coexistent ≥ moderate MR in AR patients. MethodsConsecutive patients with ≥ moderate-severe AR were retrospectively identified between 2004 and 2019. ResultsOf 1,239 eligible patients (61 ± 18 years, 80% men), 1,072 (86%) had pure AR, and 167 (14%) had AR + MR (9% functional mitral regurgitation [FMR] [84% nonischemic] and 5% organic mitral regurgitation [OMR] [62% degenerative]). At baseline transthoracic echocardiogram, pure AR versus AR + OMR versus AR + FMR exhibited differences in age (59 ± 18, 62 ± 16, and 73 ± 14 years, respectively), female sex (18%, 27%, and 39%, respectively), symptoms (36%, 41%, and 64%, respectively), atrial fibrillation (5%, 17%, and 36%, respectively), left ventricular (LV) ejection fraction (59%, 58%, and 46%, respectively), LV end-systolic dimension and volume index, ≥ moderate tricuspid regurgitation (TR) (7%, 35%, and 53%, respectively), and right ventricular systolic pressure (32 ± 11, 45 ± 15, and 50 ± 14 mm Hg, respectively), all p < 0.0001. After a median follow-up of 5.2 years (interquartile range: 2.2 to 10.0 years) and adjusting for demographics, New York Heart Association functional class, aortic valve surgery, LV ejection fraction, LV end-systolic dimension and volume index, presence of FMR was independently associated with all-cause mortality (p ≤ 0.004). Compared with pure AR, AR + MR + TR exhibited the highest adjusted risk of death (2.4-fold; p < 0.0001). When compared with expected population survival, excess mortality risks of pure AR, AR + OMR, and AR + FMR were 1.25-fold, 1.76-fold, and 2.34-fold, respectively (all p ≤ 0.02). ConclusionsIn hemodynamically significant AR, coexistent MR is not uncommon (approximately 14%) and mostly comprises FMR and less commonly OMR. As compared with pure AR, AR + MR + TR exhibit the largest mortality risk. Both AR + OMR and AR + FMR carry a survival penalty compared with the general population, but AR + FMR is associated with the largest excess mortality and represents an advanced stage within the AR clinical spectrum.

PROGRESSION OF AORTIC REGURGITATION IN BICUSPID AORTIC VALVE

Patients with bicuspid aortic valve (BAV) develop aortic regurgitation (AR) at younger age. Hemodynamically significant AR(≥moderate-severe) is associated with excess death. However, predictors and rate of progression from ≤moderate AR to ≥moderate-severe AR in BAV remain unknown. Our study

Transcatheter aortic valve replacement with the balloon-expandable SAPIEN 3 valve: Impact of calcium score on valve performance and clinical outcomes

BackgroundAortic valve calcification severity has been associated with higher rates of aortic regurgitation (AR) following TAVR, but scarce data exist on its impact with the use of newer generation transcatheter heart valves. MethodsThis was a multicenter study including 626 patients with severe aortic stenosis who underwent TAVR with the SAPIEN 3 valve. Patients were divided in 2 groups according to the median index calcium score (iCS) for each sex: high CS (HCS, iCS ≥ median), and low iCS (LCS, iCS < median). Another analysis was performed in those patients with extreme iCS (ECS, iCS >75th percentile for each sex). Clinical and echocardiographic data were collected prospectively in a dedicated database. ResultsThe mean CS was 3758 ± 1417 AU and 1616 ± 691 AU in the HCS and LCS groups, respectively (p < 0.001). There were no differences between groups in 30-day mortality (HCS:2.6%, LCS:1.0%, p = 0.13) and stroke (HCS:2.6%,LCS:2.6%, p = 1.0) rates, but all cases (n = 5) of annulus rupture occurred in the HCS group (1.6% vs. 0%, p = 0.061). The incidence of moderate-severe AR post-TAVR was low in both groups (HCS:1.6%,LCS:1.6%, p = 1.0), and valve gradient and area were similar between groups. The results remained similar in the ECS group (mean CS:4607 ± 1424 AU), but a mildly increased mean transvalvular gradient post-TAVR was observed in ECS patients (12.1 ± 5.6 vs 11.0 ± 4.3 mmHg; p = 0.015). ConclusionAortic valve calcification severity failed to impact mortality/stroke rates following TAVR with the SAPIEN 3 valve. Low rates of significant AR were observed irrespective of CS, and a mild increase in transvalvular gradient was observed in ECS patients.

Aortic valve neocuspidization in patients under 65years old.

We aimed to elucidate the surgical outcomes of aortic valve neocuspidization (AVNeo) in patients under 65years old. From December 2010 to February 2019, we performed AVNeo in a total of 168 patients. Of them, we evaluated 36 patients aged under 65years. Twenty-three patients had aortic regurgitation (AR) and 13 had aortic stenosis (AS). There were 20 patients who had isolated AVNeo, and the concomitant procedures were coronary artery bypass grafting in 5, mitral valve procedures in 4, ascending aorta replacement in 4, MAZE in 3, closure of atrial septum defect in 1, and tricuspid valve annuloplasty in 1. In the AS series, preoperative echocardiography revealed an average peak pressure gradient of 81 ± 33mmHg. In the AR series, preoperative echocardiography revealed 15 patients with severe AR and 8 patients with moderate-severe AR. There were no conversions to valve replacement. There were two in-hospital deaths owing to low output syndrome and sepsis in the emergent cases. In the AS series, postoperative echocardiography showed an average peak pressure gradient of 23 ± 15mmHg 1week post-procedure and 19 ± 9mmHg 26months post-procedure. In the AR series, postoperative echocardiography revealed no AR in 11, trivial in 9, and moderate in 1. Three patients underwent reoperation. The freedom from reoperation rates were 100% and 93% at 36 and 60months of follow-up, respectively. AVNeo in patients aged under 65years appears to be suitable considering its early and midterm outcomes. Verification and follow-up of its long-term outcomes and reliability are indispensable.

Predictors of Progression in Patients With Stage B Aortic Regurgitation

BackgroundThe natural history of stage B aortic regurgitation (AR) is unknown. ObjectivesThis study sought to examine determinants, rate, and consequences of progression of AR. MethodsConsecutive patients with ≤moderate chronic AR quantified by effective regurgitant orifice area (EROA) and regurgitant volume (RVol) from 2004 to 2017 who had ≥1 subsequent echocardiogram with quantitation were included. ResultsOf 1,077 patients (66 ± 15 years of age), baseline trivial/mild AR was noted in 196 (18%), mild-to-moderate AR in 465 (43%), and moderate AR in 416 (39%); 10-year incidence of progression to ≥moderate-severe AR (stage C/D; progressors) was 12%, 30%, and 53%, respectively. At 4.1-year follow-up (interquartile range: 2.1 to 7.2 years), there were 228 progressors (21%), whose annualized progression rates within 3 years before diagnosis of ≥moderate-severe AR were 4.2 mm2/year for EROA and 9.9 ml/year for RVol. Baseline AR severity and dimensions of sinotubular junction and annulus were associated with progression (all p ≤ 0.007); hypertension and systolic blood pressure were not. Progressors had faster chamber remodeling, functional class decline, and more aortic valve/aortic surgery. At medium-term follow-up, 242 patients (22%) died; poor survival was linked to age, comorbidities, functional class, resting heart rate, and left ventricular (LV) ejection fraction (p ≤ 0.003), not LV end-systolic dimension index. Survival after progression to stage C/D AR was associated with LV end-systolic dimension index (adjusted p = 0.02). ConclusionsProgression from stage B to stage C/D AR was observed in 21% patients. Repeat echocardiography for trivial/mild, mild-to-moderate, and moderate AR at every 5, 3, and 1 years, respectively, was reasonable. EROA, RVol, annulus, and sinotubular junction should be routinely measured to estimate progression rates and identify patients at high risk of progression, which was associated with adverse consequences.

Outcomes in Chronic Hemodynamically Significant Aortic Regurgitation and Limitations of Current Guidelines

BackgroundFew data exist on the contemporary profiles and outcomes of patients with significant aortic regurgitation (AR). ObjectivesThis study sought to assess the benefits of aortic valve repair or replacement (AVR) and the prognostic value of left ventricular (LV) dimensions in significant AR. MethodsFrom 2006 to 2017, consecutive patients with ≥moderate-severe chronic AR without prior heart surgery, myocardial infarction, or overt coronary artery disease were included. ResultsOf 748 participants (58 ± 17 years of age; 82% men), 387 (52%) were medically treated, and 361 (48%) had AVR. Of 361 patients having AVR, 334 (93%) met guideline criteria: Class I indications in 284 (79%) patients, which included symptoms in 236, and Class II indications in 50 (14%). The remaining 27 (7%) opted for surgery without Class I or II indications. At a median follow-up of 4.9 years (interquartile range: 2.3 to 8.3 years), 125 (17%) patients had died. Age, comorbidities, baseline symptoms, and higher LV end-systolic dimension index (LVESDi) were associated with all-cause mortality (all p ≤ 0.01). Compared with patients having LVESDi <20 mm/m2, those with LVESDi 20 to 25 mm/m2 (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.31) and ≥25 mm/m2 (HR: 2.23; 95% confidence interval: 1.32 to 3.77) had increased risks of death. AVR was associated with better survival (p < 0.0001). Patients with Class I indications for surgery had inferior post-operative survival (p < 0.003). ConclusionsClass I indications for surgery, mainly symptoms, are the most common triggers for AVR. Class II indications were associated with better post-operative outcome and thus merit more attention. LVESDi was the only LV parameter independently associated with all-cause mortality and the ideal cutoff seems to be lower than previously recommended.

BARTONELLA ENDOCARDITIS INVOLVING THE MITRAL AND AORTIC VALVES COMPLICATED BY COMPLETE HEART BLOCK AND CEREBRAL MYCOTIC ANEURYSM

Bartonella endocarditis is a rare and potentially lethal infection characterized by a subacute course, severe valvulopathy and periannular complications. A 37-year-old male with known bicuspid aortic valve with moderate-severe aortic regurgitation presented with lightheadedness and syncope during

Aortic Dilatation Associated With Bicuspid Aortic Valve: Relation to Sex, Hemodynamics, and Valve Morphology (the National Heart Lung and Blood Institute-Sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions)

This study analyzed the impact of sex, hemodynamic profile, and valve fusion pattern on aortopathy associated with bicuspid aortic valve (BAV). The National Heart Lung and Blood Institute-sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) provided comprehensive information on a large population of well-characterized patients with BAV. Of 969 enrolled patients with BAV, 551 (57%, 77% male) had already undergone valvular and/or aortic surgery. Echocardiographic imaging data were available on 339 unoperated or preoperative participants who formed the basis of this study. BAV function was normal in 45 (14%), with a predominant aortic regurgitation (AR) in 127 (41%) and a predominant aortic stenosis (AS) in 76 (22%). Moderate-severe AR was associated with larger sinus of Valsalva (SOV) diameters compared with normal function and AS (all p <0.01). Moderate-severe AS was associated with a larger ascending aortic (AscAo) diameter compared with normal function (p = 0.003) but not with AR. The SOV diameter was larger in men than in women (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001), whereas AscAo diameters were comparable (3.9 ± 0.9 vs 3.7 ± 0.9 cm, p = 0.08). Right-left commissural fusion was associated with a larger SOV diameter (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001) compared with a right-noncoronary fusion pattern. Predominant AR was more common in men (45% vs 27%, p = 0.004), whereas AS was more common in women (29% vs 18%, p = 0.04). In conclusion, in the GenTAC Registry, AR was associated with diffuse (annular, SOV, and AscAo) enlargement, whereas moderate-severe AS was only associated with AscAo enlargement. Male sex and right-left cusp pattern of cusp fusion were associated with larger SOV diameters and a greater likelihood of AR, whereas women had a higher prevalence of AS.

Angiographic assessment of aortic regurgitation by video-densitometry in the setting of TAVI: Echocardiographic and clinical correlates.

We sought to investigate a new angiographic method for aortic regurgitation (AR) severity assessment in the setting of transcatheter aortic valve implantation (TAVI). AR after TAVI is common but challenging to quantitate, especially in the cath-lab. In 228 patients, AR was quantitated before and after TAVI by echocardiography and by video-densitometric analysis of aortograms. Contrast time-density curves for the aortic root (the reference region) and the left ventricular outflow tract, LVOT were generated. LVOT-AR was calculated as the area under the curve of the LVOT as a fraction of the area under the curve of the reference region. LVOT-AR was 0.10±0.08, 0.13±0.10 and 0.28±0.14 in none-trace, mild and moderate-severe post-TAVI AR as defined by echocardiography (P<0.001) and a cutpoint of >0.17 corresponded to moderate-severe AR on echocardiography (area under the curve=0.84). At follow-up (median, 496 days), patients with LVOT-AR ≤ 0.17 showed a significant reduction of LV mass index (LVMi; 121 [95-148] vs. 140 [112-169]g/m2 , P=0.009) and the prevalence of LV hypertrophy (LVH; 64 vs. 88%, P=0.001) compared to baseline. In patients with LVOT-AR>0.17, LVMi (149 [121-178] vs. 166 [144-188]g/m2 , P=0.14) and the prevalence of LVH (74 vs. 87%, P=0.23) did not show a significant change. Compared to patients with LVOT-AR ≤ 0.17, those with LVOT-AR>0.17 had an increased 30-day (16.4% vs. 7.1%, P=0.035) and one year mortality (32.9 vs. 14.2%, log rank P value=0.001; HR: 2.690 [1.461-4.953], P=0.001). LVOT-AR>0.17 corresponds to greater than mild AR as defined by echocardiography and predicts impaired LV reverse remodeling and increased early and midterm mortality after TAVI. © 2017 Wiley Periodicals, Inc.

Abstract 17804: Echocardiographic and Radiologic Predictors of Atrial Fibrillation in Acute Ischemic Stroke

Introduction: Atrial fibrillation (AF) is an important risk factor for stroke. Approximately 15-25% of cryptogenic ischemic strokes (CIS) are due to AF. Hypothesis: Patients with echocardiographic markers including left atrial dilatation (LAD) and valvular disease and/or radiologic findings including a hyper-dense vessel sign (HDV sign), prior cortical or cerebellar stroke, and hemorrhagic transformation (HT) are more likely to have stroke due to AF. Methods: This is a single center, retrospective case control study of patients admitted with acute ischemic stroke (AIS) from 2008-2013. Patients with a new diagnosis of stroke and a defined stroke etiology (large vessel, cardio-embolic, small vessel and other, TOAST classification) were included. CIS patients or those without imaging/echocardiographic studies were excluded. Images were reviewed for prior stroke, HT, a HDV sign and stroke location (left or right anterior, posterior, multifocal). Echocardiograms were reviewed for LAD, ejection fraction&lt;35%, moderate-severe mitral regurgitation (MR), moderate-severe aortic regurgitation, mitral stenosis, aortic stenosis, left ventricular segmental akinesis, diastolic dysfunction, LVH and patent foramen ovale. Results: Charts of 600 patients were reviewed and 383 patients were included in the analysis. 185 patients had AF as the etiology of their stroke. The remainder had no known AF. Univariate and multivariate logistic regression was performed using SPSS. LAD, moderate to severe MR, HDV sign, and HT were found to accurately predict AF in patients with AIS. LAD had an OR of 6.9 (CI 4.4-10.8, p&lt;.0001) and HDV predicted AF with an OR of 2.2 (CI 1.2-4.2, p&lt;.016) even after controlling for LAD, MR, and HT. Conclusion: Echocardiographic and radiologic markers help predict AF as a stroke etiology in AIS patients. This is the first study, to the best of our knowledge, to show that HDV sign is a positive predictor of AF. Prospective studies with larger cohorts are needed to confirm these findings in CIS patients. These markers could be added to demographic information to enhance prediction of occult AF and the need for chronic cardiac monitoring.

Device-dependent association between paravalvar aortic regurgitation and outcome after TAVI

ObjectiveThe aim of the current study was to identify predictors of paraprosthetic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and examine its influence on short/medium-term mortality using the...

Partial Aortic Root Remodeling in Case of Ascending Aortic Aneurysms

In degenerative ascending aortic aneurysms (AAAs), the pathological process may extend into the aortic root, causing aortic regurgitation (AR). As often one or two sinuses are involved, ascending aorta replacement should be associated with selected sinus replacement. Thirty patients (21 men and 9 women; mean ± SD age, 70.0 ± 10.4) were operated on for ascending aorta and selected sinus replacement. All patients had degenerative AAA with sinotubular junction and partial root dilatation: one or two sinuses of Valsalva were involved. Mild to moderate-severe AR was present in all patients. The mean ± SD logistic EuroSCORE 1 was 15.4 ± 12.5. Twenty patients had ascending aorta replacement associated with noncoronary sinus replacement; 8 patients, associated with both right and noncoronary sinuses; 1 patient, associated with both left and noncoronary sinuses; and 1 patient, associated with left coronary sinus alone. There were no hospital or late deaths. No thromboembolic event or bleeding complications were reported. Postoperative echocardiography did not show significant AR, and computed tomographic scanning revealed a normal positioning of the vascular graft in the ascending aorta. Remodeling of the sinotubular junction with selected sinus replacement in degenerative AAA is a valuable approach for aortic root remodeling, leading to a significant reduction of AR when the aortic leaflets are normal.

Favorable Effects of Vasodilators on Left Ventricular Remodeling in Asymptomatic Patients With Chronic Moderate‐Severe Aortic Regurgitation and Normal Ejection Fraction: A Meta‐Analysis of Clinical Trials

The role of vasodilator therapy in asymptomatic patients with chronic moderate to severe aortic regurgitation (AR) and normal left ventricular (LV) function is uncertain. We assessed the effects of vasodilator therapy (hydralazine, calcium channel blockers, and angiotensin-converting enzyme inhibitors) in this subgroup of patient population. Vasodilators have favorable effects on LV remodelling in asymptomatic patients with chronic moderate to severe aortic regurgitation and normal LV function. We performed a systematic literature search for randomized clinical trials using long-term vasodilator therapy in asymptomatic patients with chronic severe AR and normal LV function. The magnitude of difference between the vasodilator and nonvasodilator groups was assessed by computing the mean difference (MD). Heterogeneity of the studies was analyzed by Cochran Q statistics. The MD for LV ejection fraction, LV end systolic volume index, and LV end diastolic volume index were computed by random effects model. The MD for LV end-systolic diameter and LV end-diastolic diameter were computed by fixed effects model. A 2-sided alpha error <0.05 was considered to be statistically significant. Seven studies with 460 patients were included. Meta-analysis of the studies revealed a significant increase in LVEF (MD: 5.32, 95% confidence interval [CI]: 0.37 to 10.26, P = 0.035), a significant decrease in LV end diastolic volume index (MD: -16.282, 95% CI: -23.684 to -8.881, P < 0.001), and a significant decrease in LV end diastolic diameter (MD: -2.343, 95% CI: -3.397 to -1.288, P < 0.001) in the vasodilator group compared with the nonvasodilator group. However, there was no significant decrease in LV end systolic volume index (MD: -6.105, 95% CI: -12.478 to 0.267, P = 0.060) or in LV end systolic diameter (MD: 0.00, 95% CI: -0.986 to 0.986, P = 1.0) in the vasodilator group compared with the nonvasodilator group. In asymptomatic patients with chronic severe AR and normal LV function, vasodilators have favorable effects on LV remodeling.

Contemporary Results Following Surgical Repair of Acute Type A Aortic Dissection (AAAD): A Single Centre Experience

The study aims to define predictors of neurological dysfunction, 30-day mortality, long-term survival and quality of life following repair of acute type A aortic dissection (AAAD). Between 2000 and 2008, 65 patients underwent repair of AAAD. Sixty-four pre-, intra- and post-operative variables were studied. Mean follow-up was 26.6 months. The mean age was 61years; 60% were male and five had Marfan's syndrome. At presentation, ischaemic ECG changes were seen in 45%, malperfusion syndrome in 59%, moderate-severe aortic regurgitation in 48% and tamponade in 16%. EF was <40% in 17%. There was a delay of >12hours between diagnosis and operation in 64%. Axillary cannulation was performed in 37%. Cerebral protection was by hypothermic arrest (HCA) alone (19%), HCA with retrograde cerebral perfusion (RCP) (11%), or HCA with antegrade cerebral perfusion (ACP) (46%). The procedure was performed on cross-clamp in 24%. Full arch replacement was performed in 14% and concomitant coronary artery grafting was performed in 11%. Post-operative neurological dysfunction was present in 33.8%. The only significant predictor of poor neurological outcome was full arch replacement (p=0.04) on univariate analysis. In-hospital OR 30 mortality was 23.53%. Significant predictors of mortality were low ejection fraction (p=0.017) and post-operative renal failure (p=0.012). Long-term survival was 70% at two years, 50% at five years and 25% at nine years. Functional outcomes and long-term quality of life were assessed in 69% of patients who were alive at last follow-up. Ninety percent of patients reported minimal limitation on functional scores. Quality of life was assessed using the EQ-5D questionnaire. Forty-eight percent of patients recorded full health with an overall mean index of 0.854 (where the best possible score is 1) using the US preference weighted index score. Discharged patients have reasonable long-term survival and good quality of life.

Adherence to patient selection criteria in patients undergoing transcatheter aortic valve implantation with the 18F CoreValve ReValving System

Background:Anecdotal evidence suggests that transcatheter aortic valve implantation (TAVI) is being used beyond pre-market label indications.Methods:To assess the frequency and outcomes associated with “off-label” use of TAVI, we conducted a...

Subaortic membrane excision: Mid-term results

Background: Subaortic membrane (SAM) is a form of fixed subaortic obstruction in which a fibrous membrane is located below the aortic valve. Aim: To determine the role of surgical treatment for patients with a discrete SAM. Patients and Methods: The hospital records of 45 patients (age range: 2–23 years; median 8 years) undergoing surgery for SAM between 1990 and 1998 at the All India Institute of Medical Sciences, New Delhi, India, were analysed. Preoperative echocardiographically calculated gradients across the left ventricular outflow tract ranged from 50 to 154 mmHg (mean: 86.5 ± 33.2 mmHg). Nine patients had trivial aortic regurgitation (AR), 10 had mild AR and five had moderate-severe AR. The left ventricular ejection fraction (LVEF) ranged from 20 to 68% (mean 48 ± 15%). Nineteen patients had significant left ventricular dysfunction (LVEF <50%). Transaortic resection of SAM was done in all patients along with excision of a wedge-shaped segment of septal muscle underlying the membrane. Results: There were no early or late postoperative deaths. On follow up (up to 113 months), only four patients had gradients >30 mmHg. LVEF improved to 45–70% (mean 58 ± 7.7%). AR reduced to mild in four patients and trivial in four patients, and did not progress further. Conclusion: Resection of SAM carries long-term benefits. Routine septal myectomy appears to be associated with a low risk of recurrence.