Predischarge Echocardiogram Research Articles

Multiple aortic valve papillary fibroelastomas causing recurrent cerebrovascular events

IntroductionPapillary fibroelastomas (PFE) are benign, rare primary cardiac tumors often discovered incidentally during cardiac imaging or as part of a workup for thromboembolic or obstructive events. We present a case of multiple PFE on the aortic valve's right coronary and non-coronary leaflets, presenting as recurrent cerebrovascular events managed by resection with valve preservation. Case SummaryA 53-year-old male presented with an acute right frontal cerebrovascular accident and a history of recurrent transient ischemic attacks. A transesophageal echocardiogram (TEE) revealed a 10 × 8 mm mass on the right coronary cusp of the aortic valve. Differential diagnosis included PFE versus thrombus. Following a neurology evaluation, the patient was anticoagulated and scheduled for urgent cardiac surgery. During surgery, an 8 × 7 mm mass was sharply excised from the right coronary leaflet's anterior surface. Further examination revealed additional masses: a 3 mm mass on the underside of the right coronary leaflet, a 2 mm mass on the non-coronary leaflet, and another 2 mm mass on its underside. All masses were excised, and pathology confirmed the diagnosis of PFE. The patient's post-operative course was unremarkable, and a pre-discharge transthoracic echocardiogram (TTE) demonstrated complete removal of the aortic valve masses with normal ventricular and aortic valve function. DiscussionPFE are rare benign cardiac tumors with a significant risk of thromboembolic or obstructive events, including stroke. Grossly, they are attached to the endocardium by a short fibrous pedicle with multiple papillary fronds resembling a sea anemone. More than 95 % originate from the left heart, most commonly affecting the aortic valve. Diagnosis is primarily through echocardiography, with TEE being more sensitive than TTE. Surgical excision is curative, offering an excellent long-term prognosis. ConclusionAll patients with suspected embolic cerebrovascular events should undergo echocardiographic evaluation to assess for potential cardiac etiologies. Surgical resection of PFE results in uniformly excellent clinical outcomes, with aortic valve preservation achievable in over 98 % of cases.

Recovery of left ventricular ejection fraction in Takotsubo Syndrome

Abstract Introduction Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Left ventricular ejection fraction (LVEF) recovery in TTS occurs over a wide-range interval, varying from days to weeks. Purpose Our purpose was to access the prognostic impact of delayed recovery of LVEF in patients with TTS. Methods We performed a retrospective analysis of patients admitted in a single centre between 2008 and 2022 with the diagnosis of TTS, with a LVEF <50% at admission. Patients were divided into two groups: Group A- patients with the recovery of ejection fraction during hospitalization (LV EF ≥ 50% at the pre-discharge echocardiogram) and Group B- patients that had a delay in recovery, with LV EF <50% at the pre-discharge echocardiogram. Major adverse cardiovascular events (MACCE) included heart failure hospitalization, cardiovascular mortality, stroke and TTS recurrence. Results We included 63 pts, 88,9% females, mean age of 69,38 ±12,5 years. Group A included 27 pts, with a median LV EF of 37% (IQR 33-41) and group B included 36 pts with a median LV EF of 36% (IQR 33-38,8), with no statistically significant difference between the two groups (p= 0,347). The median pre-discharge LV EF was 60,0% (IQR 56-65,6) in group A and 42,0% (IQR 37-47) in group B (p<0,005). The hospitalization length (HL)was similar between the two groups (mean HL of 7,9 ±7,8 in group A versus 8,1 ±8,4 days in group B, p= 0,93). The two groups were similar in terms of basal characteristics, with more prevalence of psychiatric disease in group A (13,9% vs 33,3%, p= 0,066). We found no statistically differences in clinical presentation and evolution during hospitalization (Killip class, cardiogenic shock, ventricular arrhythmias) and in the rates of concomitant coronary artery disease (14,8% group A versus 26,5% group B, p= 0,270). Also, the in-hospital medication and at discharge (Angiotensin-converting enzyme inhibitors, beta blockers, spironolactone and aspirin) were identical between the two groups. There was a tendency for more prescription of anticoagulants at discharge in group B (45,7% versus 22,2%, p = 0,055). During a median follow-up of 41,0 months (IQR 14,0-54,5), group B had a higher rate of MACCE (34,4% versus 20,0%, log rank p= 0,033). In a multivariate analysis, after adjusting for possible confounders, delayed recovery of LV EF was an independent predictor of MACCE with a HR 6,1 (95% CI: 1,50-24,9, p= 0,012) (Fig.1). Conclusions In this population, delayed recovery of LV EF in TTS was an independent predictor of major adverse cardiovascular events. These findings suggest that this population should be targeted in clinical trials to investigate possible interventions and these patients should have a closer follow-up.

The impact of annuloplasty ring or band implantation on post-repair mitral valve hemodynamic performance.

The clinical importance of optimal post-repair mitral valve diastolic performance is increasingly being recognized. The haemodynamic effect of a partial annuloplasty band implantation, in comparison to a full ring, remains insufficiently explored. Patients undergoing mitral valve repair for pure degenerative disease between 2011 and 2019 at two experienced heart valve centres were eligible for inclusion. Exclusion criteria were concomitant procedures other than tricuspid valve repair and ablation procedures for atrial fibrillation. Pre-discharge and follow-up echocardiograms (1-4 years after surgery) were analyzed to assess haemodynamic mitral valve performance. Of 535 patients meeting the inclusion criteria, 364 (68.0%) patients underwent full annuloplasty ring and 171 (31.0%) partial band implantation. On predischarge echocardiogram, post-repair mitral valve gradient and area did not differ between groups [2.89 mmHg (IQR 2.26-3.72) vs 2.60 mmHg (IQR 1.91-3.55), P = 0.19 and 1.98 cm2 (IQR 1.66-2.46) vs 2.03 cm2 (IQR 1.55-3.06), P = 0.15]. However, multivariable linear regression analysis demonstrated band annuloplasty as a determinant of larger valve area (coefficient 0.467 cm2, standard error 0.105, P < 0.001). On multivariable analysis, no significant impact on post-repair gradient was observed (-0.370 mmHg, standard error 0.167, P = 0.36). At follow-up, the differences between groups disappeared and multivariable regression analysis failed to demonstrate a significant impact of annuloplasty device type on mitral valve gradient (coefficient -0.095 mmHg, standard error 0.171, P = 1.00) or area (coefficient -0.085 cm2, standard error 0.120, P = 1.00). These results were confirmed with a linear mixed model analysis. Partial band annuloplasty was related to an improved haemodynamic profile directly after valve repair for degenerative disease but the effect was short-lived. Our results suggest that the type of annuloplasty device has no durable impact on diastolic valve performance.

P65 A STRANGE CASE OF ACUTE CORONARY SYNDROME WITH VESSEL SQUEEZING AND INTRAMURAL HEMATOMA

Abstract A 53–year–old woman presented herself at our center for the appearance of oppressive chest pain radiating to the upper limbs associated with cold sweat, which arose in resting conditions. The patient had as cardiovascular risk factors tobacco habits and an important family history of cardiovascular diseases (father died of AMI at a young age) and had entered menopause for some months. The ECG showed signs of anterior transmural ischemia (Figure 1a) with corresponding echocardiographic kinetic abnormalities of the cardiac apex (EF 40%). The patient underwent an emergency coronary angiography documenting an intramyocardial bridge with evident systolic squeezing of the vessel in the proximal–middle section of the anterior descending artery and normal appearance of the remaining coronary tree (Figure 2). She was subjected to infusion of intracoronary nitrates with improvement of the instrumental picture and on that occasion it was opted for medical therapy alone with double antiplatelet therapy and low–dose calcium antagonist. On the second day after the diagnostic procedure, there was a recurrence of anginal symptoms with evidence on the ECG of anterolaterally reversed T waves (figure 1b). The patient underwent a new coronary angiography, IVUS–guided, with documentation of probable intramural hematoma in the absence of non–flow–limiting dissection image with an area of 7 mm² (Figure 3). During the subsequent hospitalization, the patient remained asymptomatic with stable ECG tracing, but telemetry revealed ventricular tachyarrhythmias for which beta–blocker therapy was optimized with improvement of the arrhythmic burden. The pre–discharge echocardiogram showed improvement of cardiac kinesis with resumption of systolic function (EF 48%). The patient was discharged stable and asymptomatic with follow–up at our dedicated ischemic heart disease clinic. This case report is an example of an infrequent cause of acute coronary syndrome, of non–atherosclerotic origin, to be considered in clinical practice.

Choledochoscope-guided treatment of pulmonary embolism caused by ventricular myxoma

A 33-year male patient presented with a 6-month history of cough and shortness of breath upon physical activity. Echocardiography demonstrated right ventricular space-occupying lesions. Contrast-enhanced computed tomography of the chest showed multiple emboli in the pulmonary artery and its branches. Right ventricle tumor (myxoma) resection, tricuspid valve replacement, and clearance of the pulmonary artery thrombus were performed under cardiopulmonary bypass. Minimally invasive forceps and balloon urinary catheters were used to clear the thrombus. Clearance was confirmed by direct visualization using a choledochoscope. The patient recovered well and was discharged. The patient was prescribed oral warfarin 3 mg/day, and the international normalized ratio for prothrombin time was maintained between 2.0 and 3.0. Pre-discharge echocardiogram showed no lesion in the right ventricle or pulmonary arteries. The 6-month follow-up echocardiography indicated that the tricuspid valve was functioning well and showed no thrombus in the pulmonary artery.

285 BIVENTRICULAR TAKO-TSUBOSYNDROME ASSOCIATED WITH SYNCOPE AND UNCONSCIOUSNESS

Abstract A 58-years old woman came to the emergency department due to syncope; she had been found lying on the ground in her residence. At the admission the patient was unconscious but had preserved blood pressure 120/80 mmHg. CT brain scan was negative for hemorrhage. Admission ECG showed a 52 b/m sinus bradycardia, elevated antero-septal ST segment and prolonged QT interval. Diagnosis of antero-septal STEMI was made and a coronary angiogram performed via right femoral access showed mild atheromasia in the absence of angiographically significant lesions. Bedside echocardiogram showed severe left ventricular dysfunction (LVEF 35%) with akinesia of apical and mid-ventricular segments. The right ventricle presented a marked hypocontractility of the apical region and a preserved kinetics of the basal portion (TAPSE 22 mm). There was also a moderate mitral regurgitation and a mild tricuspid regurgitation with a sPAP of 50 mmHg (40+10). On blood sampling, high-sensitivity troponin was slightly elevated (3950 pg/ml) and marked hyponatriemia (117 mmol/l) and slight hypokalemia (3.1 mmol/l) were noted. The echocardiogram on the third day showed an improvement in global and segmental kinetics of left ventricle with an estimated EF of 45% and persistence of a mild hypocontractility of the apex of right ventricle. During her hospital stay, her cognitive state gradually improved and she remained asymptomatic without evidence of arrhythmic events on monitoring. The ECG evolved on days with normalization of the ST-T tract, negative T wave in the anterior region and prolonged QTc interval. The pre-discharge echocardiogram showed a recovery of biventricular kinetics with an estimated EF of 50%. The presence of a transient abnormality in biventricular wall motion beyond a single epicardial coronary artery perfusion territory with new electrocardiographic change met the diagnostic criteria of Tako-tsubo Syndrome defined by Mayo Clinic criteria. The electrocardiogram on the day of discharge showed a 55 b/m sinus bradycardia with a negative T wave from V1 to V4. Tako-tsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction that improves spontaneously within days or weeks and is often preceded by emotional or physical stress. Biventricular involvement in TTS is typically identified on imaging studies such as echocardiography and MRI. TTS with RV involvement is associated with a higher rate of in-hospital mortality and long-term adverse clinical events than isolated LV TTS. In our clinical case, biventricular involvement was associated with a severe clinical presentation (syncope and unconsciousness). This case shows that biventricular Tako-tsubo is a clinical scenario that requires intensive care monitoring and strict cardiological evaluation.

Original technique for tricuspid valve replacement by mitral homograft: Step-by-step approach and initial results.

Severe tricuspid regurgitation is associated with the progression of heart failure symptoms and poor survival. Surgical treatment of infective and prosthetic tricuspid valve endocarditis using homografts gives promising early and midterm results. Tricuspid valve replacement with a mitral homograft is a reasonable procedure with a challenging technique. A total of 15 patients underwent tricuspid valve replacement by mitral homograft in two departments from October 2020 to May 2022. The mean age was 36 [31-40.5]. In this article, we describe our original step-by-step technique and initial experience of successful use of native or cryopreserved mitral homografts for surgical treatment of tricuspid valve disease. There were no in-hospital and 30-daymortality, no postoperative bleeding, myocardium infarction, stroke, or sternal wound infection. Only one patient required permanent pacemaker implantation after redo surgery before discharge. The predischarge echocardiogram showed no residual tricuspid regurgitation(TR) in 14 cases (93.3%) and mild TR in 1 (6.7%) patient. All patients were discharged from the hospital without symptoms of endocarditis, with negative blood culture samples. Satisfactory initial clinical and hemodynamic results were achieved utilizing our technique. Mid- and long-term results are required to understand the place of homografts in tricuspid valve surgery.

Abstract 9230: Intraoperative Residual Lesion Score Predicts Major Residua at Discharge and Early Unplanned Reinterventions Following Congenital Heart Surgery

Introduction: The Residual Lesion Score (RLS) has recently been validated as an important predictor of outcomes following congenital heart surgery. However, its reliance on the pre-discharge echocardiogram limits its utility. We assessed the intraoperative RLS (IO-RLS) as a predictor of outcomes following congenital cardiac surgery. Hypothesis: We hypothesized that IO-RLS would be an independent predictor of outcomes following congenital heart surgery. Methods: This was a single center, retrospective review of consecutive patients who underwent congenital cardiac surgery from 01/2011-12/2019. For each index operation, IO-RLS was assigned per the intraoperative echocardiogram using previously published criteria: Class 1, no residua; Class 2, minor residua; Class 3, major residua. Outcomes included major pre-discharge residua or in-hospital unplanned reintervention (primary) and unplanned reinterventions at 1-year post-surgery (secondary). Associations were evaluated using multivariable logistic regression, adjusting for age, prematurity, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) mortality category, and case complexity. Results: Of 6786 patients, 4743 (69.9%), 1903 (28.0%), and 140 (2.1%) patients had Class 1, 2, and 3 lesions, respectively. The primary outcome was observed in 988 (14.6%) patients. Both Class 2 and 3 patients had greater risk of the primary outcome ( Figure 1A ), compared to Class 1 patients. The predicted probability of major pre-discharge residua or in-hospital reintervention by STAT score and IO-RLS is shown in Figure 1B . At 1-year follow-up, 924 (13.6%) patients required reinterventions. IO-RLS Class 2 (OR 1.3, 95% CI 1.1-1.5, p=0.002) and Class 3 (OR 2.4, 95% CI 1.6-3.7, p&lt;0.001) patients had greater risk of the secondary outcome, versus Class 1 patients. Conclusions: IO-RLS may be an important adjunct for self-assessment and quality improvement in congenital heart surgery.

Mitral Valve Re-Repair Due to Chordal Pseudo-Elongation Through Repeated Right Anterior Minithoracotomy.

We aim to show the step-by-step surgical technique of mitral valve re-repair by means of a repeated right anterior minithoracotomy in a case of a procedure-related early mitral valve repair failure due to left ventricular positive remodeling and chordal pseudo-elongation. The patient was readdressed to our institution for an early severe mitral valve regurgitation, less than a year after performing a right minithoracotomy mitral valve repair (42-mm annular ring implantation, P2 triangular resection, and P2 neochord positioning). The mechanism was attributed to a positive left ventricle remodeling and neochordal pseudo-elongation. Therefore, we decided to perform a mitral valve re-repair in a redo minimally invasive cardiac surgery. We describe in a video-guided step-by-step fashion the surgical procedure, from the reopening of the right anterior minithoracotomy to the surgical strategy chosen to address the re-repair, guided by the mechanism of the previous repair failure. We replaced the previously implanted ring with a smaller one and positioned a new polytetrafluoroethylene 4-0 neochord at the P2 level. The patient was discharged home on the fifth postoperative day after an uneventful hospital stay. Predischarge echocardiogram demonstrated undetectable residual mitral valve regurgitation. At 3-month follow-up, echocardiographic and clinical data were encouraging. At 9-month follow-up, the patient endorsed no recurrence of cardiologic symptoms. Redo minimally invasive cardiac surgery is a viable option even in case of a mitral valve re-repair due to previous repair failure, especially when procedure related in degenerative mitral disease. Combining the benefits of mitral valve re-repair with those of a minimally invasive surgery may optimize short-term and long-term outcomes.

Factors associated with discontinuation of pulmonary vasodilator therapy in children with bronchopulmonary dysplasia-associated pulmonary hypertension.

To evaluate factors associated with discontinuation of pulmonary vasodilator therapy in bronchopulmonary dysplasia-related pulmonary hypertension (BPD-PH). Retrospective study of neonatal, echocardiographic, and cardiac catheterization data in 121 infants with BPD-PH discharged on pulmonary vasodilator therapy from 2009-2020 and followed into childhood. After median 4.4 years, medications were discontinued in 58%. Those in whom medications were discontinued had fewer days of invasive support, less severe BPD, lower incidence of PDA closure or cardiac catheterization, and higher incidence of fundoplication or tracheostomy decannulation (p < 0.05). On multivariable analysis, likelihood of medication discontinuation was lower with longer period of invasive respiratory support [HR 0.95 (CI:0.91-0.99), p = 0.01] and worse RV dilation on pre-discharge echocardiogram [HR 0.13 (CI:0.03-0.70), p = 0.017]. In those with tracheostomy, likelihood of medication discontinuation was higher with decannulation [HR 10.78 (CI:1.98-58.59), p < 0.001]. In BPD-PH, childhood discontinuation of pulmonary vasodilator therapy is associated with markers of disease severity.

Device Failure in Bicuspid Aortic Stenosis Following Transcatheter Aortic Valve Implantation

Recent studies showed the favorable outcomes of transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve (BAV) stenosis. However, data on the relation between BAV morphology and optimal transcatheter heart valve (THV) selection are limited. This study sought to evaluate the determinants of device performance in patients with BAV who underwent TAVI. Consecutive patients with BAV who underwent TAVI with the SAPIEN 3 from multicenters were evaluated. Outcomes were the incidence and predictors of device failure. Device failure was defined as peak aortic velocity >3.0 m/s, mean pressure gradient >20 mm Hg, moderate or severe paravalvular leakage and/or procedure mortality. A total of 187 patients with BAV were identified, aged 77 years, and 38.0% were women. A total of 37 patients (19.8%) were treated with 23-mm valve, 58 (31.0%) with 26-mm valve, and 92 (49.2%) with 29-mm valve. Predischarge echocardiogram demonstrated 37 patients (19.8%) with device failure. BAV with excessive leaflet calcification plus calcified raphe (EC-BAV) (OR 16.7, 95% CI 1.99 to 39.6) and smaller THV (OR 4.41, 95% CI 1.43 to 13.6) were independently associated with increased risk of device failure. In addition, 4.0%, 5.1%, and 11.1% of device failures were observed in patients without EC-BAV who underwent TAVI with 23-, 26- and 29-mm THV (p=0.47), respectively, and 91.7%, 31.6% and 23.2% in those with EC-BAV, respectively (p <0.001). In conclusion, EC-BAV morphology was the major determinant of a device failure after TAVI. Moreover, TAVI in patients with EC-BAV requiring small SAPIEN 3 could be challenging. Further data on device and treatment selection in patients with BAV are still warranted.

P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS

Abstract A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.

C17 SIMPLIFIED MINIMALLY INVASIVE MITRAL VALVE SURGERY THROUGH A DIRECT VISION TRANSAXILLARY APPROACH: PROCEDURAL AND 30–DAYS OUTCOMES

Abstract Background Minimally invasive cardiac surgery through right mini–thoracotomy access is nowadays an established approach for the treatment of mitral valve pathologies. Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure. Aim of this study is to review our early results with a minimally invasive approach characterized by a lateral right trans–axillary (TAx) approach and direct vision. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2018 and 2021 were reviewed. Among them, 245 patients underwent minimally invasive mitral valve surgery through TAx access. A single incision at the fourth right intercostal space on the anterior axillary line, 3–to–5 cm in length (Fig 1), allowed a 90° direct view exposure of the mitral valve (Fig 2) and the subvalvular apparatus (Fig 3). A transthoracic clamp was invariably used to achieve the cardioplegic arrest. Results Mean age of the patients was 63 years and the mean EuroSCORE II was 1.6. Regurgitation was the prevalent mitral valve dysfunction (91%). Mitral valve repair was performed in 87% of the cases using several techniques including a combination of annuloplasty, leaflet resection and sliding, placement of neochordae and repair of the commissures. In patients with degenerative disease, the rate of valve repair was 92%. Tricuspid annuloplasty was associated in 10% of the cases. There was no in–hospital death; the rates of postoperative stroke and TIA were 0.4% and 1.2%, respectively. Median mechanical ventilation time was 3 [0–6] hours with 40% of the patients extubated in theatre at the end of the procedure. Median ICU stay was 24 [21–46] hours. Three patients had superficial complications of the thoracic wound and in 7 cases of the groin incision. After a median time of 7 [6–8] days, all the patients were successfully discharged from the hospital. The pre–discharge echocardiogram revealed none or trace residual mitral regurgitation in up to 96% of the patients who underwent mitral valve repair with a mean gradient across the valve of 3 [2–4] mmHg. Conclusions The TAx approach for minimally invasive mitral valve surgery is safe and allows a quick functional recovery. A superb direct view of the mitral apparatus and the ascending aorta, facilitates the exposure and the surgical repair of the valve with no need of any endoscopic nor an endoaortic balloon occlusion system support.

Early- and mid-term outcomes of reinterventions for aortic bioprosthesis failure.

The aim of this study was to evaluate early- and mid-term results of our actual practice embedding redo aortic valve replacement and transcatheter procedures for aortic bioprosthetic failure. Data for aortic valve reinterventions (redo surgical aortic valve replacement, isolated redo aortic valve replacement, and valve-in-valve transcatheter aortic valve implantation, transcatheter valve-in-valve procedure) were collected (2010-2019). Logistic regression analysis was performed to identify predictors favouring the choice of transcatheter against redo surgery. Cox analysis was used to study the association of preoperative variables with survival. Survival probabilities were calculated with Kaplan-Meier analysis and compared using a log-rank test. A total of 125 patients were included (redo surgical aortic valve replacement: 84 patients, valve-in-valve transcatheter aortic valve implantation: 41 patients). Median age was 74 [63-80] years, 58% of the patients were male and the median logistic EuroSCORE was 15 [8-26] %. There was no early mortality. Eighteen patients (redo surgical aortic valve replacement: 15, valve-in-valve transcatheter aortic valve implantation: 3) sustained at least one postoperative complication. At pre-discharge transthoracic echocardiogram, valve-in-valve transcatheter aortic valve implantation had significantly higher trans-prosthetic gradients (mean gradient: valve-in-valve transcatheter aortic valve implantation 18 mmHg vs. redo surgical aortic valve replacement 14 mmHg, p < 0.001). Overall survival probabilities were 94% and 73% at 1 year and 5 years, respectively. Previous coronary artery bypass surgery operation and age were independently associated with lower survival probabilities during the follow-up. Redo surgical aortic valve replacement and valve-in-valve transcatheter aortic valve implantation are both safe and effective for aortic bioprosthetic failure. Further valve-in-valve data are needed to determine the haemodynamic performance of transcatheter prostheses and its impact on long-term outcomes.

Applicability and Durability of Valve-Sparing Tetralogy of Fallot Repair.

Although valve-sparing repair remains ideal for patients with tetralogy of Fallot, the durability of valve-sparing repair and which patients may have been better served with a transannular patch remain unclear. Retrospective review was performed of tetralogy of Fallot operations at our institution from January 2008 to December 2018. Standard demographic data were collected, including echocardiographic parameters, operative details, and clinical outcomes. Statistical analysis was performed comparing the transannular patch and valve-sparing repair groups. Sixty-seven patients underwent tetralogy of Fallot repair with a median age of 4.5 (3.2-6.0) months and weight of 5.8 (5.2, 6.7) kg. Seventeen (25%) patients underwent transannular patch repair and 50 (75%) patients underwent valve-sparing repair. There was no difference in age or weight between patients who underwent a transannular patch repair and those who underwent a valve-sparing repair. At last follow-up (median 42 months), there was a trend of a higher peak pulmonary valve/right ventricular outflow tract gradient (P = .06) in the valve-sparing group, but no difference in the pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from -2.3 ± 1.0 on predischarge echocardiogram of to -1.2 ± 1.6 on last follow-up, with the peak gradient on predischarge 23 (0-37) mm Hg remaining stable on last follow-up at 18 (0-29) mm Hg. There was one reoperation: pulmonary valve replacement six years after a transannular patch. Obtaining a postrepair pulmonary valve z-score of -2 yields satisfactory, stable valve-sparing repair with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from reintervention during follow-up.

Mitral repair with leaflet preservation versus leaflet resection and ventricular reverse remodeling from a randomized trial

ObjectivesIn the Canadian Mitral Research Alliance (CAMRA) Trial CardioLink-2 leaflet resection versus preservation techniques for posterior leaflet prolapse was investigated and no difference was shown in their effect on mean mitral gradient at peak exercise at 12 months postoperatively. The purpose of this subanalysis was to evaluate the effect of the 2 strategies on left ventricular (LV) reverse remodeling after repair. MethodsA total of 104 patients were randomized to either a leaflet resection or leaflet preservation strategy. Echocardiograms, performed at baseline (preoperative), predischarge, and 12 months postoperatively, were analyzed in a blinded fashion at a core laboratory. ResultsAll patients underwent successful mitral repair. At discharge, 3 patients showed moderate mitral regurgitation, whereas the remainder showed mild or less regurgitation. Compared with the baseline echocardiogram, the indexed end diastolic volume was reduced at the discharge echocardiogram (P < .0001) and was further reduced at the 12-month echocardiogram (P = .01). In contrast, the indexed end systolic volume did not significantly change from baseline assessed at the predischarge echocardiogram (P = .32) but improved at 12 months postoperatively (P < .0001), resulting in a corresponding improvement in ejection fraction at 12 months (P < .0001). The type of mitral repair strategy had no significant effect on LV reverse remodeling trends. ConclusionsThe mitral repair strategies used did not influence postoperative LV reverse remodeling, which occurred in stages. Although LV end diastolic dimensions recovered before discharge, improvements in LV end systolic dimension were evident 12 months after repair.

Effect of eliminating pre-discharge transthoracic echocardiogram on outcomes after TAVR.

The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR. Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR. A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P=0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P=0.71). Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization.

EFFECT OF ELIMINATING PRE-DISCHARGE TRANSTHORACIC ECHOCARDIOGRAM ON OUTCOMES AFTER TAVR

OBJECTIVES The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR. METHODS Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR. RESULTS A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71). CONCLUSIONS Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization.

Short Term Outcomes of Aortic Valve Replacement Using a New Stented Pericardial Bioprosthesis

Objective: Development of stented bioprostheses have been evolving through several decades to improve performance and durability. A new pericardial bovine valve has been recently approved and released. This was introduced in our institution in December 2018. We report our single institution early results in 45 patients. Methods: The hospital cardiac surgery database (PATS & EPR) was retrospectively reviewed. Characteristics and outcomes, including mortality, post-operative complications together with echocardiographic findings are reported. Results: Between December 2018 and October 2020, n=45 patients underwent aortic valve replacements and had an Avalus tissue valve implanted. 28 of 45 patients had aortic valve stenosis, 6 had aortic regurgitation and 11 mixed aortic valve disease. Median age was 75yrs (range=49-83yrs), ventricular function was good in n=40 patients, moderate in n=3 patients, poor in n=2 patients. Aortic valve replacement was first time surgery in all of our patients, with one case of urgent infective endocarditis. 19 patients out of 45 had concomitant procedures: n=9 CABG, n=1 MVR, n=2 ascending aorta replacement, n=5 AF ablation, n=1 AF ablation + MVR, n=1 AF ablation + CABG. Valve sizes were: n=2 21mm, n=13 23mm, n=19 25mm, n=10 27mm, n=1 29mm. We had one in-hospital mortality not valve related, one case of re-exploration for bleeding and no valve related complications (thromboembolism, thrombosis, significant paravalvular leak, endocarditis, haemolysis, structural valve deterioration). All the patients had a pre-discharge echocardiogram which showed a mean gradient range=2-18mmHg (median=10mmHg) and peak gradient range=5-31mmHg (median 19.05mmHg). At 30 days follow up (41/45) all the patients reviewed were classified on NYHA class < 2, except one readmission for fast AF in an 80yrs of age female patient. Conclusions: Our short-term experience with Avalus bioprosthesis demonstrated it to be safe, with low mortality or valve related complications and good haemodynamic performance.

Abstract 14576: Durability of Valve-sparing Tetralogy of Fallot Repair

Introduction: While valve-sparing repair is ideal for Tetralogy of Fallot (TOF), it’s durability and which patients may benefit from a transannular patch remains unclear. To this end, we reviewed our experience with valve-sparing TOF repair. Methods: Retrospective review was performed of all primary TOF operations at our institution from 1/2008 to 12/2018. Standard demographic, operative, and echo data were collected, along with clinical outcomes. Transannular patch and valve-sparing repair groups were then compared. Results: Sixty-eight patients underwent TOF repair with a mean age of 4.1±2.2 months and weight of 5.7±1.8 kg. There was no difference in age or weight between patients who underwent a transannular patch repair and valve-sparing repair (Table). There was also no difference in the frequency of hypercyanotic spells or beta-blocker use. As expected the pre-operative pulmonary valve size and z-score were significantly different between groups. Bypass times were longer in the transannular patch group (176±40 vs. 144±40 minutes, p=0.005). There were no differences in post-operative complications. At last follow-up (median 41.5 months) there was a trend of a higher peak pulmonary valve gradient (p=0.07) in the valve-sparing group, but no difference in pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from -2.3±1.0 on pre-discharge echocardiogram to -1.2±1.6 on last follow-up, with the peak gradient on pre-discharge 20 (33) mmHg stable on last follow-up at 18 (29) mmHg and degree of pulmonary regurgitation stable. There was one reoperation in the cohort: a pulmonary valve replacement in a patient who had undergone a transannular patch repair 6 years prior. Conclusions: Valve-sparing TOF patients demonstrated stable repairs with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from re-intervention during follow-up.