Previous Aortic Valve Surgery Research Articles

Long-term results of patients undergoing the Ross procedure after a previous aortic valve surgery

ObjectivesTo assess the long-term outcomes of patients undergoing a Ross procedure in the context of a redo aortic valve (AV) surgery. MethodsProspectively collected data in all consecutive adults who underwent a Ross procedure were analyzed to compare the Ross procedure performed as a first surgery (RF) or as a redo surgery (RP). ResultsBetween 1990 and 2021, 395 Ross procedures were performed at our center (RF, n = 345; RP, n = 50). A 2:1 propensity score matching was performed (RF, n = 100; RP, n = 50). The overall median follow-up was 11.6 years (interquartile range, 5.0-21.8 years) and 100% complete. Mean survival at 20 years was 87 ± 12% in the RF group and 87 ± 8% in the RP group (P = .30). The cumulative incidence of autograft reintervention at 10 years and 20 years was 6 ± 3% and 21 ± 6%, respectively, in the RF group and 9 ± 5% and 25 ± 8%, respectively, in the RP group (P = .74). The AV gradient remained stable up to 20 years in both groups (P = .42). The size of the sinuses of Valsalva tended to increase over time in the RF group but remained stable in the RP group (P = .03). ConclusionsThe ross procedure after a previous sternotomy for AV surgery is safe and offers good long-term results. Patients undergoing redo AV intervention have similar results as patients undergoing a primary Ross procedure, perhaps with a lower risk of autograft dilatation.

Impact of the use of cusp overlap projection technique in the incidence of post-TAVR permanent pacemaker implantation with self-expanding valves

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Current rates of new Permanent Pacemaker (PPM) Implantations in the context of Transcatheter Aortic Valve Replacement (TAVR) range from 2-36% and that necessity is related to worse prognosis. The use of self-expanding valves and a lower valve implantation depth are two factors associated with an increased risk of conduction disturbances post-TAVR. Theoretically, cusp overlap implantation technique has the potential to enable a higher valve deployment by eliminating parallax of the delivery catheter. Aim To compare the in-hospital incidence of PPM post-TARV using self-expandable valve according to the fluoroscopic guidance technique. Methods Retrospective, single-centre study, with evaluation of patients consecutively submitted to TAVR with self-expanding CoreValveTM between July 2020 and December 2021 dichotomized according to the use of cusp overlap implantation technique for fluoroscopic valve implantation guidance. Results 138 patients were included, predominantly women (57.2%), with a mean age of 78.4±8.0 years old, with severe aortic stenosis of the native valve being the most common indication for TAVI (85.5%). Cusp overlap view technique was applied in 50.7% of the patients (n=70). Frailty and co-morbidities were the most common cause for surgical refusal (54.3%). There was a significantly higher percentage of hypertensive patients (92.9% vs. 77.9%), lower previous aortic valve surgery (2.9% vs. 16.2%) and lower percentage of patients previously medicated with b-blockers in the group of patients in whom was used the cusp overlap technique; there were no other relevant differences related to the baseline characteristics. First degree atrioventricular block was present in 19.6% and complete right bundle block in 13.6% of the patients. Incidence of in-hospital post-TAVR PPM implantation wasn’t significantly different between the two cohorts of patients (cusp overlap vs. standard approach: 24.3% vs. 26.5%, p=0.77) (71.4% implanted in the context of complete heart block). Likewise, there were similar proportions of in-hospital new-onset of complete left bundle branch block (35.8% vs. 37.3%, p=0.86), volume of contrast used (140.6±37.5 mL vs. 145.2±51.5 mL, p=0.12), fluoroscopy time (15.6±8.8 min vs. 19.6±8.9 min, p=0.40) and radiation dose (556.3±320.6 mGy vs. 859.4±531.2 mGy, p=0.06). Conclusions This study shows that using the cusp overlap view for self-expanding valve implantation does not seem to achieve a significant reduction in in-hospital PPM implantation rate in comparison with the traditional 3 cusp co-planar fluoroscopic view. A larger and probably randomized clinical trial is needed to confirm these results.

Incidence and Predictors of Permanent Pacemaker Implantation after Transcatheter Aortic Valve Procedures: Data of The Netherlands Heart Registration (NHR).

Atrioventricular conduction disturbance leading to permanent pacemaker (PM) implantation is a frequent and relevant complication after transcatheter aortic valve implantation (TAVI). We aimed to evaluate the rate of post-TAVI permanent PM implantation over time and to identify the predictive factors for post-TAVI PM. The data were retrospectively collected by the Netherlands Heart Registration (NHR). In total, 7489 isolated TAVI patients between 2013 and 2019 were included in the final analysis. The primary endpoint was a permanent PM implantation within 30 days following TAVI. The incidence of the primary endpoint was 12%. Post-TAVI PM showed a stable rate over time. Using multivariable logistic regression analysis, age (OR 1.01, 95% CI 1.00–1.02), weight (OR 1.00, 95% CI 1.00–1.01), creatinine serum level (OR 1.15, 95% CI 1.01–1.31), transfemoral TAVI approach (OR 1.34, 95% CI 1.11–1.61), and TAVI post-dilatation (OR 1.58, 95% CI 1.33–1.89) were shown to be independent predictors of PM. Male sex (OR 0.80, 95% CI 0.68–0.93) and previous aortic valve surgery (OR 0.42, 95% CI 0.26–0.69) had a protective effect on post-TAVI PM. From a large national TAVI registry, some clinical and procedural factors have been identified as promoting or preventing post-TAVI PM. Further efforts are required to identify high-risk patients for post-TAVI PM and to reduce the incidence of this important issue.

Circumferential wall shear stress predicts co-localized progressive dilation in bicuspid aortic valve patients

Abstract Background Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta (AAo) dilation. Whether the high prevalence of dilation in BAV patients is related to alteration of aortic blood flow and thus in wall shear stress (WSS) [1,2], which have been associated with aortic wall degeneration [3], or intrinsic abnormalities of the aortic wall, such as altered aortic stiffness [4], has not been established. Recently, a technique for the semi-automatic quantification of progressive aortic dilation maps via image registration has been introduced [5]. Purpose To test whether ascending aorta WSS predicts co-localized progressive dilation in BAV patients. Methods Forty BAV patients free from moderate and severe aortic valve regurgitation (regurgitant fraction <16%) and stenosis (maximum velocity at the aortic valve <3m/s), with no previous aortic or aortic valve surgery or replacement and included in a double-blind clinical trial (BICATOR, NCT02679261) were enrolled. All patients underwent a baseline 4D flow CMR study to assess aortic hemodynamics, followed by two contrast-enhanced computed tomography angiographies to quantify progressive dilation. WSS was computed at 64 pre-specified standardized ascending aortic regions, automatically obtained dividing the ascending aorta into 8 equidistant longitudinal sections which were further divided along the circumference into 8 equal regions (I = inner, L = left, O = outer and R = right) [2]. WSS was also projected into axial and circumferential directions, as previously described [1,2]. Progressive dilation was assessed in terms of growth rate (GR), i.e. increase in diameter divided by follow-up duration [mm/year], following a previously described methodology [5], at the same 64 pre-specified ascending aortic locations. A two-tailed p-value <0.05 was considered statistically significant. Results Demographic and clinical characteristics of the patients are shown in Table 1. WSS and growth rate maps are shown in Figure 1. Follow-up duration was 44.8±2.6 months. Growth rate (Figure 1A) was heterogeneously distributed, being highest (up to 0.26 mm/year) in the outer region of the mid AAo and in the inner region of the proximal-mid AAo. Circumferential WSS showed highest values in the outer region of the mid AAo (Figure 1C) while WSS (magnitude) and its axial component (Figure 1B and D) presented maximum values in the right region of the mid AAo. Maps of statistically significant association between GR and WSS values showed circumferential WSS to be correlated with GR in regions where progressive dilation was fastest, while WSS magnitude and its axial component resulted in limited associations with GR maps. Conclusions Circumferential wall shear stress predicts location-matched progressive dilation in bicuspid aortic valve patients. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study has received funding from the Instituto de Salud Carlos III (PI17/00381). Guala A. has received funding from Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I). Table 1. DemographicsFigure 1. GR and WSS maps and correlations

Family screening in patients with isolated bicuspid aortic valve : Restriction to those with aortic dilatation is not justified.

AimTo determine the prevalence of undiagnosed bicuspid aortic valve (BAV) and isolated aortic dilatation in first-degree relatives (FDRs) of patients with isolated BAV and to explore the recurrence risk of BAV in different subgroups of probands with BAV. Recent American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines recommend family screening in patients with associated aortopathy only.MethodsDuring follow-up visits, patients with isolated BAV received a printed invitation for their FDRs advising cardiac screening.ResultsFrom 2012–2019, 257 FDRs of 118 adult BAV patients were screened, among whom 63 (53%) index patients had undergone aortic valve surgery (AVS), including concomitant aortic replacement in 25 (21%). Of the non-operated index patients, 31 (26%) had aortic dilatation (> 40 mm). Mean age of the FDRs was 48 years (range 4–83) and 42% were male. The FDR group comprised 20 parents, 103 siblings and 134 offspring. Among these FDRs, 12 (4.7%) had a previously undiagnosed BAV and 23 (8.9%) had an isolated aortic dilatation. FDRs of the probands with previous AVS (n = 147) had a risk ratio for BAV of 2.25 (95% confidence interval (CI) 0.62–8.10). FDRs of the probands with BAV and repaired or unrepaired aortic dilatation (n = 127) had a risk ratio for BAV of 0.51 (95% CI 0.16–1.66).ConclusionScreening FDRs of patients with isolated BAV resulted in a reasonable yield of 14% new cases of BAV or isolated aortic dilatation. A trend towards an increased risk of BAV in FDRs was observed in the probands with previous AVS, whereas this risk seemed to be diminished in the probands with associated aortic dilatation. This latter finding does not support the restrictive ACC/AHA recommendation.

Bicuspid aortic valve fusion length correlates with maximum aortic diameter and heamodynamic abnormalities: a 4D flow CMR study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities. Background Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta dilation, possibly via alteration of aortic blood flow [1]. In BAV abnormal flow condition have been associated with aortic extracellular matrix dysregulation and elastic fiber degeneration [2]. Current morphological classification of BAV patients with aortic valve with a single fusion between two adjacent leaflets does not allow for risk stratification. Purpose This research work tested whether the extent of fusion between leaflets is related to AAo diameter and flow alterations. Methods Ninety BAV patients free from moderate and severe aortic valve disease and with no previous aortic or aortic valve surgery or replacement were prospectively enrolled. A comprehensive magnetic resonance protocol comprised a stack of double-oblique 2D balanced steady-state free-precession (bSSFP) cine CMR of the aortic valve, which was used to measure the length of the fusion between leaflets, a cine CMR at the level of the pulmonary bifurcation to assess aortic diameter and 4D flow MRI sequence to assess flow characteristics and regional stiffness [3]. Jet angle and flow radial displacement, quantifying the extent of flow eccentricity, and systolic flow reversal ratio (SFRR), assessing the relative amount of backward flow during systole, were computed at 8 equidistant planes in the ascending aorta and 4 equidistant planes in the aortic arch [4]. A two-tailed p-value < 0.05 was considered statistically significant. Results The length of leaflet fusion varied widely (median 7.7 mm, inter-quartile range [5.5; 10.2]), Table 1). In bivariate analysis, fusion length was also associated to ascending aortic diameter (R = 0.391, p < 0.001), age (R = 0.313, p = 0.005) and body surface area (R = 0.396, p < 0.001). It was also positively related to flow abnormalities: like displacement in the proximal and distal ascending aorta, jet angle in the mid ascending aorta, and SFRR in the ascending aorta and the aortic arch (see Figure 1). The association between fusion length and ascending aorta diameter persisted in multivariate analysis after correction for age (p = 0.006). Conclusions Bicuspid aortic valve fusion extent varies greatly and it is associated with aortic diameter, possibly through flow alterations. Prospective longitudinal studies are needed to establish whether fusion length may allow for risk stratification in bicuspid aortic valve patients.

Bicuspid Aortic Valve in Infants, Children, and Adolescents: A Review for Primary Care Providers.

1. Talha Niaz, MBBS* 2. Jonathan N. Johnson, MD*,† 3. Frank Cetta, MD*,† 4. Timothy M. Olson, MD*,† 5. Donald J. Hagler, MD*,† 1. *Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and 2. †Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN * Abbreviations: AHA : : American Heart Association BAV : : bicuspid aortic valve TTE : : transthoracic echocardiography Bicuspid aortic valve is the most common congenital heart defect in children, adolescents, and adults. Primary care providers play an important role in screening, referral, and follow-up of these patients and should be aware of the family screening guidelines, sports participation recommendations, and periodic follow-up requirements for adequate surveillance of the complications that arise from bicuspid aortic valve. After reading this article, readers should be able to: 1. Describe the epidemiology and anatomy of bicuspid aortic valve (BAV). 2. Understand the clinical presentation and diagnosis of BAV in infants, children, and adolescents. 3. Identify the various complications of BAV disease. 4. Discuss the management and follow-up requirements for BAV. 5. Analyze the family screening and sports participation guidelines for patients with BAV. Bicuspid aortic valve (BAV) is the most common congenital heart defect in children, adolescents, and adults. (1) It is a heterogeneous disease that affects both the aortic valve and the aorta. It can lead to many complications, including aortic valve stenosis, regurgitation, or endocarditis. (2)(3) It also can lead to dilation of the aorta, predisposing individuals to a significantly higher risk of aortic aneurysm and dissection. (4) Although most individuals with BAV present with these long-term complications during adulthood, a considerable number of patients may also present during childhood and adolescence with early-onset disease; that may require interventions in up to 12% to 15% of the patients. (5)(6) Therefore, patients with BAV require lifelong follow-up and surveillance. BAV has multiple implications in terms of sports participation and family screening, making it an important subject for primary care providers. This article reviews the anatomy, genetics, presentation, diagnosis, …

Leaflets fusion length in bicuspid aortic valve is related to ascending and aortic root dilation and ascending aorta wall shear stress

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III Background Bicuspid aortic valve (BAV) is the most common congenital heart defect, consisting in the fusion of two aortic valve leaflets. Altered flow patterns have been related to aortic wall degeneration in BAV patients and may be responsible for the high prevalence of aortic disease in these patients. A number of studies on excised BAV or using advanced imaging modalities reported a wide variability of fusion extent between leaflet, but no previous study assessed whether leaflet fusion length may be used to stratify BAV patients. Purpose We aimed to test whether leaflet fusion extent can be quantified by cardiac magnetic resonance imaging (CMR) and whether it is related to aortic dilation and flow abnormalities in non-dysfunctional BAV. Methods One hundred and twenty BAV adults with no previous aortic or aortic valve surgery or significant valvular disease were consecutively enrolled. Patients with two sinuses of Valsalva (true BAV) or fusion of the left and non-coronary cusps, both being rare forms of BAV, were excluded. Twenty-eight healthy volunteers were also included for comparison. A 4D flow CMR sequence was acquired and circumferential wall shear stress and pulse wave velocity were assessed in the ascending aorta. A stack of double-oblique cine images of the aortic valve were used to quantify the length of the fusion between leaflets. Results The length of the fusion between leaflets was effectively measured in 112/120 patients (93%). Reproducibility was good (ICC = 0.826). Fusion length varied greatly (range 2.3 – 15.4 mm, 7.8 ± 3.2 mm, tertiles cut-off points were 6 and 9.3 mm). After correction for age, BSA, stroke volume and BAV fusion morphotype, fusion length was independently associated with diameter at the sinus of Valsalva (p = 0.002). Moreover, once corrected for age, stroke volume and ascending aorta pulse wave velocity, fusion length was positively related to ascending aorta diameter (p = 0.028). The comparison of maps of circumferential peak-systolic WSS in healthy volunteers (left) and BAV patients pertaining to the three leaflet fusion length tertiles is shown in Figure 1. Circumferential WSS progressively increase with larger fusion length. This trend was statistically significant (p < 0.05) in the right and outer regions of the proximal and mid ascending aorta. Conclusions Bicuspid aortic leaflet fusion length varies considerably and it is independently associated with ascending aorta and aortic root dilation, possibly through flow alterations. Abstract Figure 1

The length of the fusion between leaflets in bicuspid aortic valve is independently related to ascending aorta dilation and flow dynamics alterations assessed by 4D-flow CMR

Abstract Background Aortic dilation in bicuspid aortic valve (BAV) patients has been related to altered flow patterns, which contribute to aortic wall degeneration. However, preventive aortic replacement is currently based on a diameter threshold. Several studies on excised BAV reported wide variability of fusion extent. Purpose To unveil whether leaflet fusion extent can be quantified by CMR and is related to aortic dilation and flow abnormalities in non-dysfunctional BAV. Methods One hundred and twenty adults with non-dysfunctional BAV and no previous aortic or aortic valve surgery and 28 healthy volunteers underwent double-oblique cine and 4D flow CMR. BAV patients with two sinuses of Valsalva or left and non-coronary cusps fusion were excluded. Peak systolic circumferential wall shear stress (WSSc) and pulse wave velocity (PWV) in the ascending aorta (AAo) were assessed by 4D flow CMR. Fusion length between leaflets was measured using a stack of double-oblique cine CMR images of the aortic valve. Results The length of the fusion was effectively measured in 112/120 (93%) patients with good reproducibility (ICC = 0.826) and showed great variability (range 2.3–15.4 mm, 7.8±3.2 mm and tertiles cut-off points 6 and 9.3 mm). In multivariate analysis adjusted for clinical and demographic characteristics and PWV, fusion length was independently associated with the diameter at the sinus of Valsalva (p=0.002) and the AAo (p=0.02) (Table). WSSc progressively increased with larger fusion length (Figure), with statistical significance (p<0.05) in the right and outer regions of the proximal and mid AAo. Conclusions Bicuspid aortic leaflet fusion length varies considerably, and it is independently associated with AAo and aortic root dilation, possibly through flow alterations. Figure 1. Maps of circumferential WSS Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been partially funded by Instituto Carlos III, Spanish Ministry of Science and Innovation (PI17/00381). Guala A. has received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

Family screening in patients with isolated bicuspid aortic valve in a general hospital, yield and subgroup analysis

Abstract Background Bicuspid aortic valve (BAV) may frequently lead to aortic dilatation with risk of aortic dissection. In patients with BAV both familial clustering and aortic dilatation in first-degree relatives (FDR) without BAV has been demonstrated. Based on these findings the ESC Aortic Guidelines recommend to consider screening of FDR, while the ACC/AHA Guidelines on Valvular Heart Diseases consider screening of FDR only if the index patient has associated aortopathy. Currently, no data about the effectiveness of screening is available. Purpose To investigate the yield of screening FDR of patients with isolated BAV and to explore subgroups with FDR of patients who had needed surgery or of patients with aortic dilatation. We hypothesized that aortic dilatation (>40mm) in the index patient is not a risk factor for BAV in FDR. Methods From 2012, patients with BAV visiting the outpatient clinic of a teaching hospital, received information advising cardiac screening of FDR. FDR of patients with isolated BAV who were referred, were included. From the 10 index patients from other hospitals, information was retrieved. [Fig.1] Results Referred were FDR from 118 index patients (mean age 60 years, standard deviation [SD] 14, range 15–90 years, 82 males [70%]). Of all index patients 63 (53%) had undergone aortic valve replacement, including concomitant ascending aorta replacement in 25 (21%). In the non-operated index patients, 31 (26%) had dilatation (>40mm) of sinus of Valsalva and/or tubular ascending aorta. Screened were 257 FDR (median 2 per index patient) comprising 20 parents (8%), 103 siblings (40%) and 134 offspring (52%). Mean age of FDR was 48 years (SD16, range 4–83 years) and 89 subjects (42%) were male. The diagnostic imaging modality was echocardiography in 240 cases (93%) and MRI in 17 cases. Ten FDR had an already known BAV and were not included in the screening. Among the 257 FDR, we diagnosed 12 new BAV (4.7%, 95% confidence interval [CI]2.9–8.0%) (mean age 44 years, 50% male). Additionally, we diagnosed 23 new isolated aorta dilatations (8.9%; 95% CI 6.0–13%) at level of sinus of Valsalva and/or tubular ascending aorta (mean age 57 years, 18 [78%] were male) [Fig. 1]. Among them, 11 had hypertension. FDR (n=147) of index patients with BAV and previous aortic valve surgery (n=63), had a risk ratio (RR) of 2.25 (95% CI 0.62–8.10) of having a BAV. FDR (n=126) of index patients with BAV and repaired or unrepaired aortic dilatation (n=56) had RR 0.35 (95% CI 0.10–1.25) of having a BAV. Conclusions Screening FDR of patients with isolated BAV resulted in a reasonable yield of 14% new cases with BAV or isolated aortic dilatation. The RR of the subgroup with aorta dilatation did not justify the limitation of the FDR as suggested in the ACC/AHA Guidelines. Figure 1. Flowchart of screening and result Funding Acknowledgement Type of funding source: None

Ross Procedures in Children With Previous Aortic Valve Surgery

BackgroundThe Ross procedure in children is performed either as a primary operation, or a secondary operation after initial aortic valve surgery. ObjectivesThe study aimed to determine whether the outcomes of primary and secondary Ross procedure are similar. MethodsAll patients who underwent Ross procedure between 1995 and 2018 were included in the study. Outcomes were compared between those who had primary Ross procedure and those who had secondary Ross procedure, after aortic valve surgery. Propensity score matching for baseline characteristics and risk factors for death and reoperation was performed. ResultsOf 140 Ross procedures, 51.4% (n = 72 of 140) were primary operations, while 48.6% (n = 68 of 140) were secondary operations. Patients undergoing primary Ross procedure tended to be older (median age 8.6 years vs. 7.0 years; p = 0.10) and have a higher weight (28.9 kg vs. 19.4 kg; p = 0.07). There were no significant differences in survival or freedom from reoperation in the unmatched cohort. Propensity score matching resulted in 50 well-matched pairs. In the matched cohort, survival at 10 years was 90.0% (95% confidence interval [CI]: 77.5% to 95.7%) in the primary Ross group, compared with 96.8% (95% CI: 79.2% to 99.5%) in the secondary Ross group (p = 0.04). Freedom from autograft reoperation at 10 years was 82% (95% CI: 64.1% to 91.5%) in the primary Ross group, compared with 97.0% (95% CI: 80.4% to 99.6%) in the secondary Ross group (p = 0.03). ConclusionsSecondary Ross procedure performed after initial aortic valve surgery achieves superior long-term survival and freedom from autograft reoperation compared with primary Ross procedure. A strategy of initial aortic valve repair followed by delayed Ross procedure may provide better long-term survival and freedom from autograft reoperation.

Multiple left-sided stenotic lesions: outcomes after mitral valve surgery. Arguments for abandoning the eponym 'Shone syndrome'.

Management of patients with left ventricular inflow and outflow stenotic lesions can be challenging. Our purpose was to characterize such patients and review the long-term outcomes of those requiring mitral valve (MV) surgery. We performed a retrospective study of 40 patients with subaortic, aortic and/or arch stenotic lesion(s) who underwent MV surgery between 1985 and 2016. Associated left-sided stenotic lesions included aortic valve stenosis in 20 patients (50%), subaortic stenosis in 19 (47.5%) patients, coarctation in 23 (57.5%) patients and hypoplastic aortic arch in 16 (40%) patients. Nineteen patients (47.5%) had a supravalvular mitral ring and 15 (37.5%) patients had a parachute MV. The overall mortality rate was 32.5% (13 patients) with a mean follow-up of 16.3 ± 1.8 years. Being <6 months of age at the time of MV surgery (P = 0.02) and having had previous neonatal aortic valve and/or arch surgery (P = 0.01) were associated with death. The incidence of reoperation (95% confidence interval) at 1, 5, 10 and 15 years was 38% (23-53%), 54% (38-70%), 68% (53-84%) and 85% (72-98%), respectively. Results after MV surgery for children with associated left-sided stenotic lesions are closely age-related. The need for mitral intervention shortly after the initial aortic valve and/or arch intervention was a predictor of dismal outcomes.

Recovery of Kidney Dysfunction After Transcatheter Aortic Valve Implantation (from the Northern New England Cardiovascular Disease Study Group)

Acute Kidney Recovery (AKR) is a potential benefit of transcatheter aortic valve implantation (TAVI). We determined the incidence and predictors of AKR in a multicenter prospective registry of TAVI. After excluding patients on dialysis or who died within 48 hours postprocedure, we reviewed 1,502 consecutive patients underwent TAVI in Northern New England from 2012 to 2017. Patients were categorized into 3 groups based on the change in postprocedure estimated glomerular filtration rate (eGFR): Acute Kidney Injury (AKI, decrease in eGFR >25%), AKR (increase in eGFR >25%) or no change in kidney function on discharge creatinine following TAVI. We then focused in patients with baseline chronic kidney disease (CKD defined as eGFR ≤60 ml/min; n = 755) and developed multivariate predictor models to determine the clinical and procedural variables associated with AKR. For the TAVI cohort (n = 1,502), the overall incidence of AKR was 17.8%. AKR was threefold higher in patients with eGFR ≤60 ml/min as compared to those with eGFR >60 ml/min (26.6% vs 8.9%, p < 0.001). In the CKD population, hospital complications were similar among patients with no change in renal function and AKR; patients with AKI had a higher rate of hospital mortality, pacemaker implantation, length of hospitalization, and transfusions. Using multivariable logistic regression, moderate to severe lung disease, eGFR < 50 ml/min and previous aortic valve surgery were found to be independent predictors of AKR. Patients with diabetes mellitus, baseline anemia, and Society of thoracic surgeons score >6.1 were less likely to develop AKR. In conclusion, AKR occurred in 1 of 4 of all TAVI patients with baseline CKD and was a more frequent phenomena than AKI. Patients with decreased lung function, previous aortic valve surgery and worse baseline renal function were more likely to demonstrate AKR, whereas patients with diabetes mellitus, baseline anemia, and higher Society of thoracic risk scores were less likely to see improvements in renal function after TAVI.

Does Mitral Valve Calcium in Patients Undergoing Mitral Valve Replacement Portend Worse Survival?

Mitral annular calcification (MAC) is associated with worse outcomes after mitral valve replacement (MVR). With limited data available on long-term outcomes, we reviewed our experience of MVR in presence of MAC. A retrospective review of 1,710 consecutive patients who underwent MVR between January 2000 and December 2015 was performed. Patients with isolated primary MVR (n= 496) were included, whereas patients with concomitant cardiac surgery (n= 1,068), previous MVR (n= 110), and mitral valve (MV) endocarditis (n= 36) were excluded. MV calcification was classified as MAC present in anterior/posterior annulus and vertically at the level of leaflets/subvalvular apparatus. A conservative approach towards annular debridement was followed. Our sample's mean age was 64.4 ± 14.1 years, and included 279 (56%) women. MV calcification was observed in 169 (34%) patients with MAC in 115 (23%). Older age, higher ejection fraction, peripheral vascular disease, diabetes, dialysis, and previous aortic valve surgery were associated with increased prevalence of MAC. Patients with MV calcification had higher stroke rate (p= 0.040), patients with anterior leaflet and commissural calcification had higher pacemaker implantation (p= 0.010, p= 0.001, respectively), and patients with circumferential MAC had higher postoperative dialysis (p= 0.006). Operative mortality was not significantly different (p= 0.466) between MAC (n= 1, 1%) and non-MAC (n= 9, 2%) patients. MAC was associated with late mortality (unadjusted hazard ratio, 1.62; 95% confidence interval, 1.20 to 2.18), though on multivariable analysis age, diabetes, dialysis, hypertension, previous aortic valve surgery, previous coronary artery bypass grafting, and MVR with a bioprosthetic valve were found to be independent risk factors for mortality whereas MAC was not. A conservative approach to treat MAC achieves satisfactory results. Patients with MAC have significant comorbidities contributing to a worse survival, though MAC in itself is not a risk factor for mortality.

Mitral regurgitation after previous aortic valve surgery for bicuspid aortic valve insufficiency.

Regurgitant bicuspid aortic valves (BAV) are reported to be associated with myxomatous degeneration of the anterior mitral leaflet. We examined the risk of late new-onset mitral regurgitation (MR) in patients who underwent aortic valve/aortic root surgery for BAV regurgitation and concomitant root dilatation. A total of 97 consecutive patients (47±11 years, 94% men) were identified from our institutional BAV database (N.=640) based on the following criteria: 1) BAV regurgitation; 2) aortic root diameter >40 mm; 3) no relevant mitral valve disease (i.e., MR<2+) and no simultaneous mitral intervention at the time of BAV surgery. All patients underwent isolated aortic valve replacement (AVR subgroup, N.=59) or aortic root replacement with a composite graft (i.e., for root aneurysm >50 mm) (ARR subgroup, N.=38) from 1995 through 2008. Echocardiographic follow-up (1009 patient-years) was obtained for all 96 (100%) hospital survivors. The primary endpoint was freedom from new-onset MR>2+ and redo mitral valve surgery. Nine patients (9.4%) showed new-onset MR>2+ after mean echocardiographic follow-up of 10.4±4.0 years postoperatively. Myxomatous degeneration and prolapse of the anterior mitral leaflet was found in all 9 patients, and the posterior leaflet was involved in 3 of them. Two patients (2%) in AVR subgroup underwent re-do mitral surgery. No MR>2+ occurred in ARR subgroup. Freedom from MR>2+ or mitral surgery at 15 years was significantly lower in AVR subgroup vs. ARR subgroup (i.e., 38% vs. 100%, P=0.01). The risk of new-onset MR is significantly increased in patients with BAV regurgitation and aortic root dilatation who undergo isolated AVR rather than root replacement. The mechanism by which aortic root replacement may prevent the occurrence of late MR in BAV root phenotype patients is to be determined.

Minimally Invasive Mitral Valve Surgery Utilizing Heart Port Technology

To determine operative outcomes of right mini-thoracotomy mitral valve surgery utilizing port access technology in first-time and reoperative cardiac surgery patients. From 2002 to 2011, 881 patients underwent minimally invasive mitral valve surgery. Of these, 154 patients had previous cardiac operations via sternotomy (Group 1), of which 18 (12%) had two previous operations. Seven hundred and twenty-seven patients had no previous cardiac operations (Group 2). Patient demographics were similar in both groups. In Group 1, 76 (49%) patients had previous coronary artery bypass grafting, 13 (8%) had previous aortic valve surgery, and 57 (37%) had previous mitral valve surgery. Preoperative echo findings for Groups 1 and 2 included severe mitral regurgitation (MR) (88%, n = 135; 94%, n = 687), mitral stenosis (MS) (4%, n = 6; 2%, n = 12), MS + MR (8%, n = 13; 4%, n = 28), and ejection fraction (48%, 56%). Operative procedures in Groups 1 and 2 were MV repair (54%, n = 84; 89%, n = 645) and MV replacement (46%, n = 70; 11%, n = 82). Circulatory management techniques for Groups 1 and 2 included endoballoon (75%, n = 116; 79%, n = 576), Chitwood clamp (8%, n = 12; 20%, n = 147), and fibrillatory arrest (17%, n = 30; 0.5%, n = 4). Perioperative outcomes were: stroke: 2.5%, 1.6%; reoperation for bleeding: 5%, 6%; valvular reoperation rate: 0.6%, 2%; aortic dissection: 2.5%, 1%; and wound infection: 0%, 0%. Transfusion requirement was 49% (n = 76) and 31% (n = 232), respectively. Median hospital stay was seven and seven days, respectively. On postoperative echocardiography, 98% (n = 151) and 99% (n = 718) of patients had zero or trace MR (1+) with 100% freedom from MR > 2+. In-hospital mortality was 3% (n = 5) and 1% (n = 8). Operative outcomes with minimally invasive mitral valve surgery utilizing port access technology can be performed safely. Stroke rate was higher in the reoperative cases (p = NS) although similar to reports evaluating redo sternotomy in mitral valve cases.

Reoperation on aortic disease in patients with previous aortic valve surgery

Background Aortic valve replacement (AVR) is a safe and effective method in the treatment of aortic valve diseases. This study aimed to increase the understanding on re-treatment of aortic diseases after aortic valve surgery through a retrospective analysis of 47 related cases. Methods Forty-seven patients (38 males and 9 females) with previous aortic valve surgery have received reoperation on aorta from January 2003 to June 2012, and the mean interval time of re-intervention to aortic disease was 6 years ((6.0± 3.8) years). The secondary aortic surgery included aortic root replacement (14 cases), ascending aorta replacement (10 cases), aortic root/ascending aorta plus total arch replacement with stented elephant trunk implantation (21 cases), and total thoracoabdominal aorta replacement (2 cases). All these patients have received outpatient re-exams or follow-up by phone calls. Results After the initial aortic valve replacement, patients suffered from aortic dissection (25 cases, 53%), ascending aortic aneurysm (12 cases, 26%) or aortic root aneurysm (10 cases, 21%). Diameter in ascending aorta increased (5.2±7.1) mm per year and aortic sinus (3.3±3.1) mm per year. The annual growth value of diameter in ascending aorta was higher in patients with rheumatic heart disease than that in Marfan syndrome (P&lt;0.05). All 47 patients have received reoperation on aorta. One patient died in operating room because aortic dissection seriously involved right coronary artery. Seven patients had renal insufficiency after operation; neurological complications occurred in 14 patients including 7 patients with stroke and the others with transient brain dysfunction. All patients were followed up, the mean survival time was (97.25±17.63) months, 95% confidence interval was 55.24–73.33 months. Eight cases were died during follow-up and five-year survival rate was 83%. Conclusion To reduce the aortic adverse events after first aortic valve surgery, it is necessary to actively treat and strictly follow-up patients with previous aortic operation especially patients with Marfan syndrome and rheumatic heart disease.

Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation

Aortic valve regurgitation reduces left ventricular assist device mechanical efficiency. Evidence has also suggested that left ventricular assist device implantation can induce or exacerbate aortic valve regurgitation. However, this has not been compared with aortic valve regurgitation progression in a nonsurgical end-stage heart failure population. Furthermore, its clinical effect is unclear. We sought to characterize the development and progression of aortic valve regurgitation in left ventricular assist device recipients and to identify its clinical effect. A review of all consecutive patients who received an intracorporeal left ventricular assist device at Duke University Medical Center from January 2004 to January 2011 was conducted. Cases of previous or concomitant aortic valve surgery were excluded. Data from the remaining implants (n=184) and a control group of contemporaneous nonsurgical patients with end-stage heart failure (n=132) were analyzed. Serial transthoracic echocardiography was used to characterize aortic valve regurgitation as a function of time. Left ventricular assist device implantation was associated with worsening aortic valve regurgitation, defined as an increase in aortic valve regurgitation grade, relative to the nonsurgical patients with end-stage heart failure (P<.0001). The recipients of continuous flow left ventricular assist devices were more likely than recipients of pulsatile left ventricular assist devices to develop worsening aortic valve regurgitation (P=.0348). Moderate or severe aortic valve regurgitation developed in 21 left ventricular assist device recipients; this was unrelated to the type of device implanted (continuous vs pulsatile; P=.754) or aortic valve regurgitation grade before left ventricular assist device implantation (P=.42). Five patients developed severe aortic valve regurgitation; all of whom underwent aortic valve procedures. Native aortic valve regurgitation developed and/or progressed after left ventricular assist device implantation, with this effect being more pronounced in continuous flow left ventricular assist device recipients. However, the preoperative aortic valve regurgitation grade failed to correlate with the development of substantial aortic valve regurgitation after left ventricular assist device implantation. After left ventricular assist device implantation, aortic valve regurgitation had a small, but discernible, clinical effect, with some patients developing severe aortic valve regurgitation and requiring aortic valve procedures. These data have implications for the long-term management of left ventricular assist device recipients, in particular as the durability of implantable continuous flow left ventricular assist device therapy improves.

Nonanatomical Mitral Valve Replacement in the Pulmonary Venous Confluence for Heavily Calcified Aortic or Mitral Annulus

Mitral valve replacement surgery after previous aortic valve surgery can be extremely challenging. The presence of heavy calcification and scarring in the aortic and/or mitral annulus can make suture placement nearly impossible. Although novel techniques have been described, even these alternatives might not be feasible. We present a case of nonanatomical mitral valve replacement in the pulmonary venous confluence as a salvage operation. This can provide adequate hemodynamics and survival until a subsequent care plan can be established.

Results of Reoperation on the Aortic Root and the Ascending Aorta

Reoperations on the aortic root and the ascending aorta after previous aortic valve and proximal aortic surgery are increasingly frequent and highly demanding. The scarce comparability of the published series and the heterogeneity of clinical pictures contribute to the challenges of this subgroup. Forty-one patients (2004 to 2010) who were reoperated on the aortic root and the ascending aorta for aneurysmal, pseudoaneurysmal, or infectious disease were retrospectively analyzed from a prospectively filled-in database. Mean logistic European system for cardiac operative risk evaluation was 29.8%. At index reoperation, procedures were classic Bentall (51%), prosthesis-sparing operation (17%), supracoronary ascending aortic replacement plus aortic valve replacement-repair (22%), and root replacement using valved homografts (9.7%). Distally, the operation involved the arch in 51% of cases (17 hemiarch replacement, 4 total transverse arch, 3 elephant trunk). Operative mortality was 12% and rate of major operative morbidity was 17%. At a mean 26-months follow-up, the patients surviving the operation had a good survival and functional class. The rate of adverse events during the follow-up was acceptable. Reoperations on the aortic root-ascending aorta in the elective patients have respectable operative mortality-morbidity despite the high-risk profile, and are justified by the excellent follow-up survival. The mortality can be diminished by integrated surgical strategies and optimal myocardial protection. Our findings encourage complete resection of borderline dilated ascending aortic-root tissue at primary and redo operation.