Percutaneous Valve Replacement Research Articles

Midterm Experience with the Self-Expandable Venus P-Valve™ for Percutaneous Pulmonary Valve Replacement in Large Right Ventricular Outflow Tracts

Background. Preliminary results with the recently certified self-expandable Venus P-Valve™ designed for percutaneous pulmonary valve implantation in patients with dilated right ventricular outflow tracts are encouraging, but experience is limited. We therefore assessed our early and midterm outcomes with the Venus P-Valve™. Methods. Twenty patients who underwent Venus P-Valve™ implantation in our institution were included in this retrospective study. Procedural data and clinical, imaging, and hemodynamic data at baseline and last follow-up were recorded and analyzed. Results. Mean patient age was 35.0 ± 16.8 years, and five patients were <18 years of age. Procedural success was 100%, and there was no major valve-related procedural complication. At last follow-up (median 0.5 (range 0.1–6.6) years), valve function was excellent in all patients. Two patients had mild regurgitation after 6.2 and 6.6 years, respectively, while all other patients had no or only trace regurgitation. Flow was unobstructed with a mean gradient estimated by echocardiography of 12 ± 4 mmHg. NYHA functional class improved significantly (p=0.009), and right ventricular dimensions significantly decreased (right ventricular end-diastolic diameter 56±9 mm vs. 44±8 mm) (p<0.001). Transient benign ventricular arrhythmias were frequent. One patient experienced a severe arrhythmia with sustained ventricular tachycardia during follow-up. Conclusions. Early and midterm results with the Venus P-Valve™ are excellent. It considerably extends the interventional options and offers a safe and effective alternative to surgery in patients with large right ventricular outflow tracts. Larger multi-institutional studies with longer follow-up duration are required to reliably assess the long-term performance and possible long-term complications of the Venus P-Valve™.

Butyrylcholinesterase activity in patients with postoperative delirium after cardiothoracic surgery or percutaneous valve replacement- an observational interdisciplinary cohort study

Background and objectivesPostoperative delirium is a frequent and severe complication after cardiac surgery. Activity of butyrylcholinesterase (BChE) has been discussed controversially regarding a possible role in its development. This study aimed to investigate the relevance of BChE activity as a biomarker for postoperative delirium after cardiac surgery or percutaneous valve replacement.MethodsA total of 237 patients who received elective cardiothoracic surgery or percutaneous valve replacement at a tertiary care centre were admitted preoperatively. These patients were tested with the Montreal Cognitive Assessment investigating cognitive deficits, and assessed for postoperative delirium twice daily for three days via the 3D-CAM or the CAM-ICU, depending on their level of consciousness. BChE activity was measured at three defined time points before and after surgery.ResultsPostoperative delirium occurred in 39.7% of patients (n = 94). Univariate analysis showed an association of pre- and postoperative BChE activity with its occurrence (p = 0.037, p = 0.001). There was no association of postoperative delirium and the decline in BChE activity (pre- to postoperative, p = 0.327). Multivariable analysis including either preoperative or postoperative BChE activity as well as age, MoCA, type 2 diabetes mellitus, coronary heart disease, type of surgery and intraoperative administration of red-cell concentrates was performed. Neither preoperative nor postoperative BChE activity was independently associated with the occurrence of postoperative delirium (p = 0.086, p = 0.484). Preoperative BChE activity was lower in older patients (B = -12.38 (95% CI: -21.94 to -2.83), p = 0.011), and in those with a history of stroke (B = -516.173 (95% CI: -893.927 to -138.420), p = 0.008) or alcohol abuse (B = -451.47 (95% CI: -868.38 to -34.55), p = 0.034). Lower postoperative BChE activity was independently associated with longer procedures (B = -461.90 (95% CI: -166.34 to -757.46), p = 0.002), use of cardiopulmonary bypass (B = -262.04 (95% CI: -485.68 to -38.39), p = 0.022), the number of administered red cell-concentrates (B = -40.99 (95% CI: -67.86 to -14.12), p = 0.003) and older age (B = -9.35 (95% CI: -16.04 to -2.66), p = 0.006).ConclusionBChE activity is not independently associated with the occurrence of postoperative delirium. Preoperative BChE values are related to patients’ morbidity and vulnerability, while postoperative activities reflect the severity, length and complications of surgery.

CT annulus sizing prior to transcatheter aortic valve replacement (TAVR): evaluation of free-breathing versus breath-holding acquisition.

To assess feasibility and accuracy of aortic annulus measurements using cardiac computed tomography angiography (CTA) performed during free-breathing prior to transcatheter aortic valve replacement (TAVR). Sixty consecutive TAVR candidates underwent free-breathing wide-detector cardiac CTA, followed by a percutaneous valve replacement. For each, a theoretical valve size was suggested through CT measurements of the annulus, then compared to the size of the actual implanted transcatheter heart valve (THV). The procedural success and the 30-day outcomes were collected. Image quality of the annulus was also studied according to subjective and objective criteria. Data of a control group of 60 patients previously evaluated on breath-holding were also evaluated. A total of 120 patients (mean age, 83years ± 7, 60 men) were evaluated. All CT acquisitions provided sufficient image quality allowing precise annulus measurements. Mean attenuation (p < 0.001) and image noise (p = 0.01) were higher in the free-breathing group, while image quality was comparable (p = 0.36). The agreement rate between CT-suggested valve size and THV implanted size was comparable, estimated at 87% (κ = 0.79, 95%CI 0.566, 0.908) on free-breathing vs. 82% (κ = 0.78, 95%CI 0.634, 0.904) on breath-holding. The procedure was successful for all patients without increase in 30-day mortality or adverse events. Free-breathing cardiac CTA allows accurate aortic annulus measurements without compromising image quality or patients' outcome after TAVR. Elderly patients experiencing dyspnea, discomfort, or hearing loss that could prevent proper breath-holding should not be excluded from CT prior to TAVR. To decrease elderly patients' discomfort, MDCT evaluation prior to transcatheter aortic valve replacement (TAVR) may be performed on quiet breathing with no significant impact on the outcome. • Adhering to CT breathing commands can be challenging for patients with dyspnea, hearing impairment, agitation, or pulmonary diseases. • Free-breathing cardiac CT may be an alternative to breath-holding for patients unable to follow the breathing commands. • Wide-detector CT acquisition on free-breathing does not impair annulus measurements and prosthesis sizing in patients scheduled for TAVR.

Results of a heart team assessment of aortic stenosis candidates for percutaneous valve replacement in an upper-middle-income country

Abstract Objectives To analyze the results of patients with aortic stenosis (AS) who were evaluated by a heart team (HT) over a period of 10 years in a center in our city. Methods We designed a retrospective cohort study including consecutive patients with AS who were potential candidates for transcatheter aortic valve replacement (TAVI) between January 2012 and July 2021. Cases were discussed weekly by a HT consisting of at least one cardiovascular surgeon, one interventional cardiologist, one imaging specialist and one clinical cardiologist specializing in valve disease. The HT considered, among other things, the severity of AS, symptoms, surgical risk, suitability for the procedure, frailty using a 5-point scale, and access to high-cost technology. A final decision was made for all patients assessed, including TAVI, surgical aortic valve replacement (SAVR) or conservative medical treatment (CMT). The proposed treatment and the implementation of the interventions were compared. Follow-up was by personal or telephone contact. Actuarial survival analysis (Kaplan-Meier curves) included only patients who adhered to HT recommendations. Cox regression was used to identify predictors of survival. Results Of the 841 patients included in the study, 455 (53%) were assigned to TAVI (85% implanted), 213 (24%) to SAVR (86% operated) and 183 (23%) to CMT. The percentage of patients undergoing TAVI increased from 48 to 65% (p&amp;lt;0.05) over the last 4 years. Patients undergoing TAVI were slightly older (86±7 vs 83±7 years), with higher EUROSCORE II (6.2, 95%CI 5.7-6.6 vs 5.6, 95%CI 4.4-6.5) and frailer (1.62±1 vs 0.94±1, p&amp;lt;0.01) compared to SAVR. CMT patients were similar to TAVI patients, but frailer (1.74±1) and with a larger aortic valve area (0.70 cm2, 95%CI:0.5-0.8 vs. 0.65, 95%CI: 0.5-0.8). Survival at 1 year was 88% (95%CI: 84-91) for TAVI, 83% (95%CI: 76-88) for SAVR and 70% (95%CI: 60-87) for CMT. At 2 years, survival was 82% (95%CI: 77-86) for TAVI, 78% (95%CI: 70-84) for SAVR and 59% (95%CI: 48-68) for CMT (p&amp;lt;0.001). Significant independent predictors of actuarial mortality were CMT (HR 1.99), age (HR 1.04), left ventricular ejection fraction (HR:0.98), diabetes (HR:1.52) and renal impairment (1.58). Conclusions Ten years after the establishment of an aortic stenosis heart team in an upper-middle-income country, approximately half of patients have undergone transcatheter aortic valve replacement allocation, and this percentage has increased over time despite economic constraints. The remaining patients were equally divided between surgical and medical management. Survival was similar at two years in patients who underwent transcatheter aortic valve replacement or surgical aortic valve replacement, suggesting that the heart team made an appropriate recommendation. Conservative medical management was an independent predictor of higher mortality.interv 1=TAVI Interv 2=SAVR interv 3=CMT

Abstract 16711: Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement versus Percutaneous Mitral Valvuloplasty

Introduction: Mitral stenosis (MS) severity is determined by mitral valve area (MVA); the threshold for severe MS was raised from MVA of 1.0 cm 2 to 1.5 cm 2 in recent guidelines. Hypothesis: This study aimed to compare the clinical outcomes, according to percutaneous mitral valvuloplasty (PMV) versus mitral valve replacement (MVR) treatment strategy, of severe MS patients with the updated criteria for the subgroups categorized by MVA of 1.0 cm 2 and 1.5 cm 2 . Methods: From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included severe MS patients who underwent PMV or MVR between January 2000 and December 2021 except previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm 2 &lt;mva≤1.5 cm2 and MVA≤1.0 cm 2 , respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo-intervention. Results: Among 442 patients (mean 56.5±11.9 years, women 77.1%), the MVR group (n=260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n=182). During a mean follow-up of 6.9±5.2 years with inverse probability weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (p=0.010). In subgroup analysis of MS-MS and VS-MS patients, primary outcomes did not differ. However, the MVR group in VS-MS patients showed better secondary outcomes (p=0.012) (Figure). Conclusions: PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, due to increased early redo-intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Role of Computed Tomography before Transcatheter Pulmonary Valve Implantation in Patients with Dysfunctional Native Right Ventricular Outflow Tract.

The most performed percutaneous valve replacement procedure is for the aortic valve. In recent years, there have been developments in percutaneous valve replacement methods for other valves, including the pulmonary valve. Computed tomography plays a crucial role in various stages of procedure planning and provides essential information regarding potential complications after the procedure. We present images documenting step by step how to evaluate cardiac computed tomography in the qualification procedure for transcatheter pulmonary valve implantation in patients with dysfunctional native right ventricular outflow tract.

Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach.

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BackgroundThis study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2). MethodsFrom the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention. ResultsAmong 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012). ConclusionsPMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Technical Recommendations for Computed Tomography Guidance of Intervention in the Right Ventricular Outflow Tract: Native RVOT, Conduits, and Bioprosthetic Valves.

This consensus document for the performance of cardiovascular computed tomography (CCT) to guide intervention in the right ventricular outflow tract (RVOT) in patients with congenital heart disease (CHD) was developed collaboratively by pediatric and adult interventionalists, surgeons, and cardiac imagers with expertise specific to this patient subset. The document summarizes definitions of RVOT dysfunction as assessed by multimodality imaging techniques and reviews existing consensus statements and guideline documents pertaining to indications for intervention. In the context of this background information, recommendations for CCT scan acquisition and a standardized approach for reporting prior to surgical or transcatheter pulmonary valve replacement are proposed and presented. It is the first Imaging for Intervention collaboration for CHD patients and encompasses imaging and reporting recommendations prior to both surgical and percutaneous pulmonary valve replacement.

A Fully Percutaneous Transeptal Transcatheter Mitral Valve Replacement With a Novel Device

A Fully Percutaneous Transeptal Transcatheter Mitral Valve Replacement With a Novel Device

Simultaneous Aortic and Pulmonary Valve Replacement in Repaired Congenital Heart Disease.

Patients with congenital heart disease frequently require surgical or percutaneous interventional valve replacement after initial congenital heart defect (CHD) repair. In some of these patients, simultaneous replacement of both semilunar valves is necessary, resulting in increased procedural complexity, morbidity, and mortality. In this study, we analyze the outcomes of simultaneous aortic and pulmonary valve replacements following multiple surgical interventions for CHD. This was a retrospective study of 24 patients who after initial repair of CHD underwent single-stage aortic and pulmonary valve replacement at our institution between 2003 and 2021. The mean age of the patients was 28 ± 13 years; the mean time since the last surgery was 15 ± 11 years. Decellularized valved homografts (DVHs) were used in nine patients, and mechanical valves were implanted in seven others. In eight patients, DVHs, biological, and mechanical valves were implanted in various combinations. The mean cardiopulmonary bypass time was 303 ± 104 minutes, and aortic cross-clamp time was 152 ± 73 minutes. Two patients died at 12 and 16 days postoperatively. At a maximum follow-up time of 17 years (mean 7 ± 5 years), 95% of the surviving patients were categorized as New York Heart Association heart failure class I. Single-stage aortic and pulmonary valve replacement after initial repair of CHD remains challenging with substantial perioperative mortality (8.3%). Nevertheless, long-term survival and clinical status at the latest follow-up were excellent. The valve type had no relevant impact on the postoperative course. The selection of the valves for implantation should take into account operation-specific factors-in particular reoperability-as well as the patients' wishes.

A Novel Low-Profile Self-Expanding Biodegradable Percutaneous Heart Valve Frame That Grows with a Child

According to rough estimates, one in every 125 newborns born in the United States has a congenital cardiac abnormality that must be repaired. With the recent development of new biomaterials and innovative treatment methods, percutaneous cardiac valve replacement has been considered as an alternative to surgical procedures. While percutaneous heart valve replacement is a relatively new procedure with a few commercially available devices, the devices are not sufficiently low-profile, and do not grow with the child. To address this issue, a novel low-profile growing percutaneous pediatric heart valve frame made of two types of unique metallic biomaterials (supere lastic nitinol and biodegradable iron) has been developed through this study. The developed pediatric heart valve frame has an innovative mechanism that will expand its diameter by disconnecting biodegradable metals, enabling the growth of the device with the surrounding tissue in the cardiac space. The thermally treated iron wires show stable and gradual degradation characteristics, showing approximately 7.66% for both wires treated under 350 and 450 °C. Polymer-coated wires show a degradation range of 4.96 to 5.55% depending on the type of coating. Degradation test results show the predicted 9–23 months of degradation depending on the type of surface treatment (e.g., thermal treatment, polymer coating), which is a suitable range when compared with the theoretical arterial vessel remodeling process period in the human vascular system. Radial forces calculated by finite element analysis and measured by mechanical testing matched well, showing 5–6 N with a 20% diameter reduction considering the deployed valve frame in the heart. Biocompatibility study results demonstrated superior cell viability in thermally treated iron wires after 3 days of cell culture and showed rarely found platelets on the surface after 3-h blood exposure tests. Prototype devices were successfully fabricated using optimized advanced joining processes for dissimilar metallic materials such as nitinol and iron. This study represents the first demonstration of self-expanding and biodegradable percutaneous heart valve frames for pediatric patients that grow with a child.

Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand

This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed. The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant. A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained. One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up. Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.

Stroke, Seizures, Hallucinations and Postoperative Delirium as Neurological Complications after Cardiac Surgery and Percutaneous Valve Replacement.

(1) Background: Neurological complications such as acute ischemic stroke or postoperative delirium are frequent after cardiac surgery or percutaneous valve replacement. This study aimed to identify corresponding risk factors. (2) Methods: 297 patients with percutaneous valve replacement or cardiac surgery were postoperatively screened for neurological complications such as delirium, stroke, seizures and hallucinations twice daily for three days. Pre- and perioperative risk factors were evaluated in a multivariate model. (3) Results: Neurological complications occurred in 43.8% (n = 130) as composed of delirium (43.43%, n = 129), stroke (2.7%, n = 8), seizures (1.35%, n = 4) and real hallucinations (3.36%, n = 10). Multiple logistic regression revealed an association of neurological complications with lower Montreal Cognitive Assessment scores (Exp(B) 2.042; 95% CI, 1.183-3.525, p = 0.010), older age (Exp(B) 1.071; 95% CI, 1.036-1.107, p &lt; 0.001), red blood cell transfusions until postoperative day 3 (Exp(B) 1.157; 95% CI, 1.030-1.300, p = 0.014), history of heart failure (Exp(B) 1.985; 95% CI, 1.130-3.487, p = 0.017) and increased CRP levels (Exp(B) 1.004; 95% CI, 1.000-1.008, p = 0.037). (4) Conclusions: Postoperative delirium remains a frequent complication after cardiac surgery, while stroke and seizures occur rarely. A preoperative risk profile including older age, history of heart failure and cognitive impairment was identified for a complicated postoperative course. However, the impact of an intense inflammatory response must not be neglected.

Valves, Vegetations, and Valves.

We present a novel method for the treatment of right-sided bioprosthetic valve endocarditis with AngioVac debulking followed by percutaneous pulmonic and tricuspid valve replacement for residual transcatheter valve degeneration and right ventricular dysfunction.

Long-term outcomes of severe rheumatic mitral stenosis after undergoing percutaneous mitral commissurotomy and mitral valve replacement: A 10-year experience.

Introduction: Percutaneous mitral commissurotomy (PTMC) and mitral valve replacement (MVR) are treatments of choice for severe rheumatic mitral stenosis (MS). Data regarding the long-term outcomes of patients who underwent PTMC and MVR are limited. Methods: A retrospective cohort study was conducted to evaluate the long-term outcomes of patients with severe rheumatic MS who underwent PTMC or MVR between 2010 to 2020. The primary outcome comprised of all-cause death, stroke or systemic embolism, heart failure hospitalization and re-intervention. Cox regression was used to investigate predictors of the primary outcome. Results: 264 patients were included in analysis, 164 patients (62.1%) in PTMC group and 100 patients in MVR group (37.9%). The majority were females (80.7%) and had atrial fibrillation (68.6%). The mean age was 49.52 (SD: 13.03) years old. MVR group had more age and AF, higher Wilkins’ score with smaller MVA. Primary outcome occurred significantly higher in PTMC group (37.2% vs 22%, P=0.002), as well as, re-intervention (18.3% vs 0%, P<0.001). However, all-cause mortality, stroke or systemic embolism and heart failure hospitalization were not significantly different. In multivariate Cox regression analysis, PTMC (HR 1.94; 95%CI 1.14, 3.32; P=0.015), older age (HR 1.03; 95%CI 1.01, 1.06; P=0.009) and SPAP > 50 mmHg (HR 2.99; 95%CI 1.01, 8.84; P=0.047) were the only predictors of primary outcome. Conclusion: Primary outcome occurred in PTMC group more than MVR group which was driven by re-intervention. However, all-cause mortality, stroke or systemic embolism and heart failure hospitalization were not significantly different.

Effect of percutaneous pulmonary valve replacement on ventricular electrophysiological remodeling in a porcine model of repaired tetralogy of Fallot

Tetralogy of Fallot is the most common cyanotic congenital heart disease. Late after corrective surgery, patients are at risk of developing right ventricular (RV) failure due to pulmonary valve regurgitation and arrhythmias related to surgical scars and ventricular electrophysiological remodeling. Pulmonary valve replacement has been identified as an interesting strategy to reduce RV dilatation but its impact on the arrhythmic risk remains uncertain. We sought to determine whether percutaneous pulmonary valve implantation (PPVI) at an early pathological stage leads to benefical effects on right and left ventricular electrophysiological remodeling in a porcine model of repaired tetralogy of Fallot (rTOF). Piglets (<10 kg) underwent pulmonary artery banding, pulmonary valve disruption to induce RV hypertrophy and dilatation and a PTFE patch was sewn across the pulmonary annulus. Two-months later, PPVI was performed in a sub-group of rTOF pigs. At 3 months post-surgery, cardiac function was assessed by MRI in rTOF, rTOF-PPVI and Sham-operated pigs. Animals were euthanized and optical mapping of isolated left and right ventricles electrical activity was performed using the voltage-sensitive dye Di-4-ANEPPS. Expression of selected genes was assessed by quantitative RT-PCR. At 3 months post-surgery, pulmonary artery regurgitation, RV end-diastolic and end-systolic volumes normalized to body surface area were significantly increased in rTOF pigs compared to Sham animals. In rTOF-PPVI animals these parameters were partially reversed and not statistically different from Sham pigs. An action potential prolongation was observed in both the left ventricle and the RV epicardium but not in the endocardium of rTOF pigs. Within the RV epicardium, this prolongation was mainly confined to the anterior side. Interestingly, rTOF-PPVI pigs action potential durations were similar to Sham animals. In line with functional investigations, a large increase in BNP expression was found in rTOF RV compared to Sham pigs (fold change = 34) which was not as pronounced in rTOF-PPVi pigs (fold change = 3) while a lower expression of KCND3 and KCNJ2 was found in rTOF pigs. In our rTOF porcine model, PPVI at an early pathological stage reversed RV dilatation. It also successfully reversed action potential prolongation in the left ventricle and the anterior RV epicardium, and may thus have beneficial effects on the arrhythmic risk.

P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT

Abstract Background Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities. Case Report A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset. Discussion We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.

PO-717-05 PROPHYLACTIC AND PREVENTIVE RADIOFREQUENCY SEPTAL ABLATION TO REDUCE THE POSSIBILITY OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION POST-MITRAL VALVE REPLACEMENT

The patients who have severe mitral annulus calcification leading severe mitral stenosis often are eldery and have comorbidities which increase surgical risk of stroke, embolization, and bleeding complications. Radiofrequency ablation is another prophylactic and preventive option for reducing the possibility of left ventricular outflow tract obstruction (LVOTO) post-mitral valve replacement patients who are not suitable for surgical myomectomy or alcohol septal ablation. N/A We report on a 78-year-old woman with a history of symptomatic severe mitral valve stenosis with a mean gradient of 20 mmHg. She was not a surgical candidate for mitral valve and preparing for a valve-in-valve percutaneous mitral valve replacement. Computer tomography revealed left ventricular septal bulge appeared to have a significant LVOTO post-valve replacement. However she was not a candidate for surgical myomectomy due to her age and comorbidities, and she also had no anatomical option to consider for alcohol septal ablation. Heart team discussion decided to do radiofrequency ablation (RFA) to reduce the possibility of LVOTO post-valve replacement. RFA was performed in the left ventricular outflow tract (LVOT) using an irrigated-tip ablation catheter; the target site was identified along the LV septal hypertrophy using intracardiac echocardiography (ICE) and electroanatomical CARTO mapping. ICE demonstrated thinning of the ablated regions. The LV electrograms were noted during ablation and the size was decreasing from 0.63 mV to 0.15 mV. After RFA, she underwent minimally invasive open left-atrial transcatheter mitral valve replacement-in-MAC via right minithoracotomy with a 29-mm Edwards Sapien 3 bioprosthetic valve. Transthoracic echocardiography after surgery showed normal left ventricular systolic function with a mean mitral valve pressure gradient of 5.63 mmHg and no paravalvular leakage. The LVOT resting gradient of 17 mmHg. LVOTO could be one of the complications after valve replacement. Radiofrequency septal ablation is a novel prophylactic and preventive procedure in reducing the possibility of the left ventricular outflow tract obstruction post-mitral valve replacement and decreasing the risk of morbid and mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Tailoring the therapy to the patient with mitral and tricuspid regurgitation to avoid adverse long-term outcomes.

Key Points Tricuspid regurgitation may depend on pulmonary hypertension and may improve after left heart valve replacement or repair Retrospective studies indicate inferior clinical outcomes with severe untreated/residual tricuspid insufficiency in mutli‐valvular heart disease patients Early hemodynamic and imaging evaluation of the tricuspid valve insufficiency and evaluation for possible valve repair should be planned after percutaneous left heart valve replacement or repair