Multiple Valve Research Articles

Abstract 13642: Post-Operative Bleeding Risk in TAVR Patients With Atrial Fibrillation

Introduction: Antithrombotic medications are the subject of multiple transcatheter aortic valve replacement (TAVR) randomized control trials. Pragmatically, decisions are complicated by conditions such as atrial fibrillation (AF) that also require lifetime anticoagulation. Our study examines antithrombotic medications in a real-world cohort to identify risk factors for bleeding by 1-year post-TAVR. Methods: This retrospective study includes 844 patients undergoing transfemoral TAVR between 2015 and 2020. Pre- and post-operative medications, comorbidities, and 1-year outcomes were recorded based on review of the medical record. Antithrombotic regiment decisions were made on a case-by-case basis. Bleeding classification followed VARC2 definitions. Patients were stratified into two groups based on history of AF. Multivariable logistic regression was used to determine independent predictors of bleeding. Results: Among the 844 patients, 290 had comorbid AF (34%). Patients with AF were older (80.3 vs 77.8 years; p<0.001), more frequently had cardiovascular comorbidities, and had lower LVEF (52.4% vs 56.8%; p<0.001). Patients with AF were more likely to experience major or life-threatening bleeding (10% vs 5%; p<0.001), but there were no differences in rates of myocardial infarction, cerebrovascular accident, nor death by 1-year follow-up. After controlling for risk factors including anticoagulation and increases to antithrombotic regiment post-operatively, the independent risk predictors of major or life-threatening bleed included female sex [OR 1.522 (1.118-1.741); p=0.018], severe baseline anemia [2.938 (1.146-7.533); p=0.025], and atrial fibrillation [2.195 (1.206-3.997); p=0.010]. Conclusions: Female sex, severe baseline anemia, and comorbid atrial fibrillation are predictors of major or life-threatening bleed by 1 year in patients undergoing transfemoral TAVR, independent of antithrombotic regiment.

Using multiple heart-cutting valves and stop-flow operation to enable variable second dimension gradient times in online comprehensive two-dimensional liquid chromatography

Online comprehensive two-dimensional liquid chromatography (LC×LC) is the preferred method currently for the separation of highly complex mixtures of non-volatile compounds. With fully automated commercial instrumentation and software making the method appealing to both researchers and industry, the demand for systems with improved separation capabilities for highly complex mixtures such as those found in natural products or proteomics has increased. In this study we report an approach that enables variable second dimension analysis times based on the use of multiple heart-cutting valves and stop-flow operation to circumvent the requirement for very fast second dimension (2D) analyses in online LC×LC. As application, the HILIC×RP-LC analysis of condensed tannins (proanthocyanidins) in cocoa, grape seed and quebracho extracts is used to demonstrate the performance on the proposed methodology. The method offers increased flexibility compared to conventional online LC×LC separations in that longer 2D gradients can be used to accommodate more complex portions of the chromatogram, while shorter 2D gradients can be used in sections containing fewer peaks, while largely maintaining the benefits of comprehensive separation. We present an evaluation of the performance of the variable gradient time stop-flow HILIC×RP-LC method compared to a comparable, conventional online HILIC×RP-LC system in terms of practical peak capacities using established 2D-LC theory. The improved separation of especially low-level intermediate molecular weight proanthocyanidin oligomers by the former method demonstrates the benefits of the developed approach.

Sutureless aortic valves in isolated and combined procedures: Thirteen years of experience in 784 patients

ObjectiveThe aim of this study was to evaluate the outcome and experience of the Perceval sutureless valve at our institution (UZ Leuven). MethodsBetween 2007 and 2019, 784 patients underwent sutureless aortic valve replacement using the Perceval valve (isolated or combined with other procedures). We performed a retrospective analysis of the postoperative and follow-up data. ResultsMean age was 78 years with a median European System for Cardiac Operative Risk Evaluation II score of 4.2% (interquartile range, 2.6%-7.2%). Isolated aortic valve replacement accounted for 45% of cases; 30% of cases were aortic valve replacement in combination with coronary artery bypass grafting and the remaining 25% were other combined procedures. The median crossclamp times were 38 minutes in single aortic valve replacement, 70 minutes in cases with coronary artery bypass grafting, and 89 minutes in multiple valve cases. Device success was 99.1% and in-hospital mortality was 3.3%. Postoperative stroke or transient ischemic attack occurred in 1.9% of patients and 1% of patients had a new need for dialysis after surgery and median survival time was 7.0 years with a cumulative follow-up of 2797.8 patient-years. The 1-, 5-, and 10-year freedom from reintervention were 99%, 97%, and 94%, respectively. ConclusionsThese data represent the longest follow-up available, to our knowledge, for the Perceval sutureless valve. We observed favorable early outcomes, and low rates of early mortality, stroke, and other major complications. Valve durability is promising with low rates of valve degeneration and a limited need for reintervention.

Piggyback mounting for stent and valve deployment during percutaneous pulmonary valve implantation

We report our experience in simultaneously implanting multiple stents and valves mounted on a single balloon before and during transcatheter pulmonary valve placement. Heterogeneity and complexity of the right ventricular outflow tract(RVOT) may complicate stent deployment when preparing a landing zone for transcatheter pulmonary valve implantation. Retrospective analysis of patients from Children's Hospital of Colorado, USA; and Oslo University Hospital, Norway, undergoing transcatheter pulmonary valve replacement that had at least twostents mounted on a single balloon, deployed in the RVOT. Over a 42-month period, a total of 50 subjects from the two centers met inclusion criteria for the study. Subjects were predominantly male (58%), and the median age was 17 years (4-78 years). In six subjects (12%), there was need for prestenting with use of the double or triple stent piggyback technique. Forty subjects (80%) had a Melody ™ TPV implanted. In 45 cases (90%),one or more stents were mounted over the pulmonary valve using its delivery system, either the Ensemble for the Melody™ TPV or the Edwards Commander for the SAPIEN 3 THV. Thirty-sevensubjects (74%) had one stent mounted and eight subjects (16%) had two stents mounted over the pulmonary valve for simultaneous deployment. No complications related to this technique were reported. The piggyback technique aims to simplify and facilitate adequate conduit preparation and valve insertion by minimizing manipulation across the outflow tract and decreasing the risk of stent distortion, misalignment, and embolization.

Fuzzy Dynamic Output Feedback Force Security Control for Hysteretic Leaf Spring Hydro-Suspension With Servo Valve Opening Predictive Management Under Deception Attack

This article addresses the hierarchical resilient event triggered sampled-data security control and valve opening management problem for networked hysteretic leaf spring hydro-suspension with asymmetric actuator under false injected deception attack. For the derived Takagi–Sugeno (T–S) fuzzy model employed to tackle hysteresis nonlinearity, a new full-order dynamic output feedback top control with improved error and threshold functions for resilient event triggered mechanism is proposed to generate the target force so as to suppress the body and tire vibration under limited suspension chatter space. For the asymmetric cylinder hydraulic actuator over actuated by multiple servo valves, optimal servo valve openings are dynamic regulated to track the target force with weight adaptive nonlinear model predictive lower control. Benefiting from saved communication resource while more sparsely generating piecewise target force, as well as precise regulation by reasonably allocating over actuated valve openings to produce required force, the obtained results indicating more comfortable ride performance and less tire dynamic loads within smaller suspension chatter space favorably demonstrate the effectiveness of the proposed control strategy.

Sex Differences in In-Hospital Mortality After Open Cardiac Valve Surgery.

Cardiac valvular disease affects millions of people worldwide and is a major cause of morbidity and mortality. Female patients have been shown to experience inferior clinical outcomes after nonvalvular cardiac surgery, but recent data are limited regarding open valve surgical cohorts. The primary objective of our study was to assess whether female sex is associated with increased in-hospital mortality after open cardiac valve operations. Utilizing the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), we conducted a retrospective cohort study of patients who underwent open cardiac valve surgery from 2007 to 2018 in Washington, Maryland, Kentucky, and Florida; from 2007 to 2011 in California; and from 2007 to 2016 in New York. The primary objective of this study was to estimate the confounder-adjusted association between sex and in-hospital mortality (as recorded and coded by SID HCUP) after open cardiac valve surgery. We used multilevel multivariable models to account for potential confounders, including intrahospital practice patterns. A total of 272,954 patients (108,443 women; 39.73% of sample population with mean age of 67.6 ± 14.3 years) were included in our analysis. The overall mortality rates were 3.8% for male patients and 5.1% for female patients. The confounder-adjusted odds ratio (OR) for in-hospital mortality for female patients compared to male patients was 1.41 (95% confidence interval [CI], 1.35-1.47; P < .001). When stratifying by surgical type, female patients were also at increased odds of in-hospital mortality ( P < .001) in populations undergoing aortic valve replacement (adjusted OR [aOR], 1.38; 95% CI, 1.25-1.52); multiple valve surgery (aOR, 1.38; 95% CI, 1.22-1.57); mitral valve replacement (aOR, 1.22; 95% CI, 1.12 - 1.34); and valve surgery with coronary artery bypass grafting (aOR, 1.64; 95% CI, 1.54 - 1.74; all P < .001). Female patients did not have increased odds of in-hospital mortality in populations undergoing mitral valve repair (aOR, 1.26; 95% CI, 0.98 - 1.64; P = .075); aortic valve repair (aOR, 0.87; 95% CI, 0.67 - 1.14; P = .32); or any other single valve repair (aOR, 1.10; 95% CI, 0.82 - 1.46; P = .53). We found an association between female patients and increased confounder-adjusted odds of in-hospital mortality after open cardiac valve surgery. More research is needed to better understand and categorize these important outcome differences. Future research should include observational analysis containing granular and complete patient- and surgery-specific data.

Redundant Robot with Pneumatic Artificial Muscles for Rehabilitation Works Using Iterative Learning Control

This study aims to develop a multi-functional robotic arm with a multi-degree of freedom using a pneumatic artificial muscle cylinder as the main actuator, with a wearable function. While wearing the robotic arm, it has four degrees of freedom and can be used as an upper limb rehabilitation aid to perform rehabilitation exercise tasks. The rotating axes are driven by pneumatic artificial muscle cylinders to ensure the safety and flexibility of the robot interaction. By integrating multiple pneumatic control valves and sensors with embedded interface cards, the control of pneumatic artificial muscle cylinders is performed, and the rehabilitation trajectory commands are planned through the kinematics of the robotic arm, and a closed-loop control system is established to enable the robotic arm to achieve the task of rehabilitation trajectory tracking. In the single-axis robotic arm controller experiment, it was found that the LMS-PID is superior to the conventional PID control method. In the control experiment of the robotic arm under the multi-axis recovery trajectory, the result showed that the training of drawing a circle on the wall could be successfully planned. In the multi-axis robotic tracking experiment under the rehabilitation trajectory, the result showed that the RMSE of the tracking trajectory decreased to 0.2444 and 0.2853. In the robotic arm joining/loading experiment, it was shown that the method of this study can withstand some loading effects. Moreover, this study introduces iterative learning control to improve the non-linear compensation and phase lag problems of the PID controller so that the robot arm can have a certain tracking accuracy under the round-trip robust trajectory.

Diaphragmless shock tube with multiple air-operated valves

Diaphragmless shock tube with multiple air-operated valves

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Implante de la prótesis Edwards Intuity Elite en cirugía plurivalvular y en cirugía de revascularización coronaria concomitante

IntroductionConcomitant use of rapid deployment valves is not widespread. A EDWARDS INTUITY Elite valve replacement and concomitant mitral valve replacementent or coronary artery bypass grafting (CABG) were performed. Patients and methodsWe implanted 15 consecutive EDWARDS INTUITY Elite in patients with mitral valve replacement or concomitant CABG. Patients were divided in two groups: Intuity + mitral (8 patients), and Intuity + CC (7 patients). We registered aortic cross-clamp and cardio-pulmonary bypass (CPB) times, and ICU and Hospital length of stay. Two control groups were selected: control + mitral (43 consecutive patients submitted to multiple valve surgery) and control + CC group (48 consecutive patients with aortic replacement and concomitant CABG). Mean and peak intra-prosthesis gradients were calculated before discharge by means trans-thoracic echocardiogram. ResultsThere were no intraoperative complications. Cross-clamp times in Intuity + mitral and Intuity + CC groups were 84,3 ± 10,1 and 67,1 ± 20,7, significantly lower than control groups (117 ± 36,1 y 102,7 ± 27,3) respectively. CPB times in Intuity + mitral were 112 ± 11,6 significantly lower than control group (138,1 ± 43,7). No paravalvular leaks or prosthesis dysfunction were observed. Two patients death during the follow-up. ConclusionsEDWARDS INTUITY Elite prosthesis significantly reduces CPB and cross clamp time when used in multiple valve surgery and cross clamp time in patients with concomitant CABG. The implantation is safe and feasible, and the postoperative intra-prosthetic gradients are adequate.

Triple-valve replacement for Rhizobium radiobacter endocarditis with septic shock in an adult with ventricular septal defect. A case report.

Introduction and importanceTriple-valve replacement in active infective endocarditis has rarely been reported. This paper is the first report of a triple-valve replacement performed in endocarditis with septic shock and the first presentation of multivalvular endocarditis due to Rhizobium radiobacter.Case presentationA 26-year-old patient with a neglected ventricular septal defect referred to us in septic shock, with multiple organ failure, severe biventricular dysfunction, and pulmonary hypertension, due to Rhizobium radiobacter infective endocarditis affecting the aortic, tricuspid and pulmonary valves. Initially, he was deemed unfit for surgery. However, after clinical stabilization, triple-valve replacement, aortic annular abscess repair, membranous septum aneurysm resection, and ventricular septal defect patch closure were performed. The postoperative evolution was good; both ventricles showed functional recovery after six months.Clinical discussionAlthough surgery provides the best chances of survival in endocarditis with septic shock, reportedly, most cases are considered inoperable. Clinical stabilization under intensive care using specific therapies to manage septic shock, myocardial dysfunction, and pulmonary hypertension was crucial for surgery success. Custodiol® cardioplegia, and replacement of the right-sided valves using a beating-heart technique were used to reduce the myocardial ischemic time.ConclusionRhizobium radiobacter, an opportunistic gram-negative bacterium, potentially may cause multiple valve endocarditis. Patients with endocarditis and septic shock initially considered inoperable can still benefit from surgery after tenacious intensive care (cytokine hemoadsorption and levosimendan are helpful in this process). In complex multivalvular procedures, a beating heart technique to replace the right-sided valves should be considered to minimize the duration of myocardial ischemia.

Mechanical Complications of Sophysa SM8 Shunt in Adult Hydrocephalus: A Monocentric Experience.

Sophysa SM8 is widely used by neurosurgeons in France. Published studies report shunt malfunction rates in adults between 18% and 29%. However, these studies included multiple valve types and thus entailed a serious confounding factor. To ascertain the incidence the Sophysa SM8 cerebrospinal fluid (CSF) shunt malfunctions in adults. We present a retrospective series of adult patients who underwent CSF shunt placement between 2000 and 2013 with Sophysa SM8. In total, 599 patients (329 males and 270 females) were included. The mean age at surgery was 64.15 years (19-90) (SD 16.17; median 68.0). The causes of hydrocephalus were normal pressure hydrocephalus (49%), traumatic hemorrhages (26.5%), tumors (15.7%), cerebral aqueduct stenoses (3%), and arachnoid cysts (2%). The mean follow-up was 3.9 years (0-16) (SD 4.10; median 3 years). The rate of complications was 22.04% (132 of 599). Most frequent causes of complications were disconnection (25%), migration (12.9%), overdrainage (9.1%), and proximal obstruction (6.8%). In 17 cases (12.9%), no failure was diagnosed during revision. Seven infections (5.3%) were reported. The mean delay for the first revision was 1.70 years (0-13.93) (SD 2.67, median 0.35). The risk of shunt failure was 36% at 10 years. Seventeen percent of revisions occurred during the first year after shunt placement. Disconnections are a very frequent complication of Sophysa SM8 valve. They are related to the 2-connector system of this valve. Based on these results, we recommend using 1-piece valves.

A fluidic relaxation oscillator for reprogrammable sequential actuation in soft robots

A fluidic relaxation oscillator for reprogrammable sequential actuation in soft robots

Controlled Comparison of Simulated Hemodynamics Across Tricuspid and Bicuspid Aortic Valves.

Bicuspid aortic valve is the most common congenital heart defect, affecting 1-2% of the global population. Patients with bicuspid valves frequently develop dilation and aneurysms of the ascending aorta. Both hemodynamic and genetic factors are believed to contribute to dilation, yet the precise mechanism underlying this progression remains under debate. Controlled comparisons of hemodynamics in patients with different forms of bicuspid valve disease are challenging because of confounding factors, and simulations offer the opportunity for direct and systematic comparisons. Using fluid-structure interaction simulations, we simulate flows through multiple aortic valve models in a patient-specific geometry. The aortic geometry is based on a healthy patient with no known aortic or valvular disease, which allows us to isolate the hemodynamic consequences of changes to the valve alone. Four fully-passive, elastic model valves are studied: a tricuspid valve and bicuspid valves with fusion of the left- and right-, right- and non-, and non- and left-coronary cusps. The resulting tricuspid flow is relatively uniform, with little secondary or reverse flow, and little to no pressure gradient across the valve. The bicuspid cases show localized jets of forward flow, excess streamwise momentum, elevated secondary and reverse flow, and clinically significant levels of stenosis. Localized high flow rates correspond to locations of dilation observed in patients, with the location related to which valve cusps are fused. Thus, the simulations support the hypothesis that chronic exposure to high local flow contributes to localized dilation and aneurysm formation.

Principlist approach to multiple heart valve replacements for patients with intravenous drug use-induced endocarditis

Medical professionals often deny patients who inject opioids a second or third heart valve replacement, even if such a surgery is medically indicated. However, such a position is not well...

Clinical significance and change in the degree of mitral insufficiency after TAVI

Introduction: Hemodynamically signifi cant mitral regurgitation (MR) occurs in up to 20-30% of patients with high-grade aortic stenosis (AC) indicated for transcatheter aortic valve implantation (TAVI). Despite the establishment of the method as a standard in the treatment of high-risk patients for surgery worldwide and the growing number of patients treated interventionally, behavior in concomitant signifi cant MR continues to be a diagnostic and therapeutic challenge. The decision to intervene on multiple valves must take into account the additional surgical risk of the combined procedures. Signifi cant MR is associated with a worse prognosis in both surgical and interventional treatment. With high operative risk and signifi cant MR, TAVI is a possible solution due to the proven reduction in severity in a signifi cant proportion of patients.&amp;nbsp;The aim of this paper is to evaluate the impact of signifi cant secondary MR on mortality and rate change after TAVI. Material and methods: The article is a retrospective analysis of 50 patients with high-grade symptomatic aortic stenosis who underwent successful TAVI. Patients were followed for a period of 1 year and were divided into two major groups &amp;ndash; no signifi cant MR (0.1 degree) and those with signifi cant secondary MR (&amp;ge; grade 2). Overall mortality, cardiovascular mortality, functional class of heart failure according to the NYHA classifi cation, ejection fraction and need for rehospitalizations weremonitored. Conclusions: Hemodynamically signifi cant secondary MR, concomitant high-grade AC before TAVI undergoes positive dynamics in a signifi cant proportion of patients postprocedurally and should be considered when deciding on a therapeutic strategy by the Heart team. The worsening of signifi cant secondary MI in the studied patients is associated with 30-day and one-year cardiovascular mortality and the need for rehospitalization, which is consistent with data that the prognosis is important not only the presence of signifi cant secondary MR, but its dynamics after TAVI.

Wielonarządowe powikłania odległe po radioterapii i chemioterapii chłoniaka Hodgkina

Forty-nine-year-old woman with a history of long-term complications after radiotherapy and chemotherapy including coronary artery disease and pulmonary fibrosis was admitted to our center. Further complications — pulmonary hypertension, heart failure, and multiple heart valves insufficiency — were diagnosed. Here we present images from diagnostic procedures that allowed us to visualize those disturbances.

Machine Learning-Based Risk Model for Predicting Early Mortality After Surgery for Infective Endocarditis.

BackgroundThe early mortality after surgery for infective endocarditis is high. Although risk models help identify patients at high risk, most current scoring systems are inaccurate or inconvenient. The objective of this study was to construct an accurate and easy‐to‐use prediction model to identify patients at high risk of early mortality after surgery for infective endocarditis.Methods and ResultsA total of 476 consecutive patients with infective endocarditis who underwent surgery at 2 centers were included. The development cohort consisted of 276 patients. Eight variables were selected from 89 potential predictors as input of the XGBoost model to train the prediction model, including platelet count, serum albumin, current heart failure, urine occult blood ≥(++), diastolic dysfunction, multiple valve involvement, tricuspid valve involvement, and vegetation >10 mm. The completed prediction model was tested in 2 separate cohorts for internal and external validation. The internal test cohort consisted of 125 patients independent of the development cohort, and the external test cohort consisted of 75 patients from another center. In the internal test cohort, the area under the curve was 0.813 (95% CI, 0.670–0.933) and in the external test cohort the area under the curve was 0.812 (95% CI, 0.606–0.956). The area under the curve was significantly higher than that of other ensemble learning models, logistic regression model, and European System for Cardiac Operative Risk Evaluation II (all, P<0.01). This model was used to develop an online, open‐access calculator (http://42.240.140.58:1808/).ConclusionsWe constructed and validated an accurate and robust machine learning–based risk model to predict early mortality after surgery for infective endocarditis, which may help clinical decision‐making and improve outcomes.

Priority flow divider valve and its dynamic analysis using various hydraulic drive systems: a bond graph approach

Abstract. The priority flow divider valve (PFDV) is used in power hydraulic system to split the supply flow in dual paths, i.e., primary path and secondary path. The flow ratio in each path is either predetermined or can be adjustable as per the loading conditions. The stated properties of the valve can be applied in a steering mechanism in automobile and a hydrostatic power transmission unit in a wind turbine. In a steering mechanism, it helps the system to perform two different functions against two different loads simultaneously, whereas, in a wind turbine, it can be used in hydrostatic power transmission unit to reduce the power fluctuation obtained from it. The hydrostatic power transmission system with PFDV (SMHPTSPFDV) used in a steering mechanism and the hydrostatic power transmission system with PFDV (WTHPTSPFDV) used in a wind turbine are modeled using the bond graph technique, and simulated in SYMBOLS Shakti software to analyze the steady and dynamic performance of the PFDV. The user-defined rectangular and sinusoidal variable pump speed has been used as inputs for system performance analysis. It is found that the PFDV may handle dual loads simultaneously, and it eliminates the use of multiple control valves to operate the same dual loads. Hence, it not only improves the system stability but also reduces the maintenance cost of the system. Moreover, the power and energy loss through the PFDV have been analyzed for both applications. It has been found that the power loss through the PFDV is higher when it is connected with SMHPTSPFDV. Also, the influences on the power and energy loss through PFDV are analyzed under various loading conditions.

P81 SIMULTANEOUS TRANS–APICAL AORTIC AND MITRAL VALVE IMPLANTATION IN A PATIENT WITH A DEGENERATED MITRAL BIOPROSTHESIS AND SEVERE AORTIC STENOSIS

Abstract Transcatheter Valve–in–Valve implantation has shown promising results in high–risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. This is a case of a 82–year–old man, with history of multiple previous mitral valve replacement, admitted to the hospital for heart failure. During diagnostic work out he was diagnosed with a severe aortic stenosis and structural degeneration of a mitral valve bioprostheses Epic 29mm, St Jude Medical, (Inc, St Paul, Minn, USA). The heart team defined the patient at high surgical risk profile and was therefore scheduled for a simultaneous mitral and aortic transcatheter valve implantation. Through a double trans–apical approach (Figure A and B), the patient underwent two balloon expandable valves (Sapien 3, Edwards Lifesciences, Irvine, CA, USA) deployment in native aortic (Figure C) and mitral bioprosthesis (Figure D), respectively. Final angiography showed lack of aortic (Figure E) and left atrial (Figure E) regurgitation. The procedure was uneventful as well as the following hospital stay. Post–procedural transesophageal echocardiography confirmed the absence of paravalvular leakage nor aortic or mitral regurgitation. The patient was discharged at home on day 7. Simultaneous transapical transcatheter aortic and mitral valve replacement is technically feasible with the current available technology and can be a possible alternative in patients with high surgical risk.