Prior Aortic Valve Replacement Research Articles

INFECTIVE VEGETATION IN THE INTERVALVULAR FIBROSA: 3D-TRANSESOPHAGEAL ECHO AIDS ACCURATE DIAGNOSIS AND TRACKS THE NATURAL HISTORY

A 75-year-old male with prior bioprosthetic aortic valve replacement (AVR) presented with chest pain and elevated troponins. Coronary angiogram was normal. A cardiac MRI revealed an inferolateral infarct, presumed embolic. CT-abdomen showed new splenic and renal infarcts. He endorsed recent fevers/

Haemodynamic flow abnormalities in bicuspid aortic valve disease improve with aortic valve replacement

Background Bicuspid aortic valve disease (BAV) is associated with dilatation of the proximal aorta and abnormal flow patterns, particularly increased helical flow and changes in the aortic wall shear stress. These altered flow patterns may be partly responsible for the aortic dilation, though the aetiology is still unclear. Aortic valve replacement can modify the flow pattern in the proximal aorta (potentially to normal) and could thus have an effect on future aortic dilation. In this study, we aimed to assess the effect of different types of aortic valve replacement (AVR) on aortic flow patterns. Methods We prospectively enrolled 69 participants: 23 BAV patients with prior AVR (10 mechanical, 6 bioprosthetic, 7 Ross procedure), 23 BAV patients with a native aortic valve and 23 healthy volunteers. All underwent 4D flow cardiovascular magnetic resonance. Results The majority of patients with mechanical AVR or Ross showed a normalised flow pattern (70% and 57% respectively) with near normal rotational flow values (7.4±3.9 and 11.0±12.0mm 2 /s respectively; normal range -5 to +11 mm 2 /s); and reduced in-plane wall shear stress compared to native BAV (0.13±0.18N/m 2 for mechanical AVR vs. 0.37±0.26N/m 2 for native BAV, p<0.05). In contrast, all subjects with bioprosthetic AVR showed abnormal flow patterns (mainly marked right-handed helical flow), with similar rotational flow values to native

Arteriovenous and Intercoronary Fistulae Presenting as Heart Failure in an Adult

A 79-year-old man with prior aortic valve replacement was admitted to our hospital due to exertional angina. Single-photon emission computed tomography revealed ischemia at the territory of the left anterior descending artery (LAD) and the right coronary artery (RCA) (Figures 1 A and B). Coronary arteriography (Figures 1 C and ​andD)D) and cardiac computed tomographic angiography (Figure 1 E), including volume rendering reconstruction (Figure 1 F), revealed an arteriovenous fistula between the proximal LAD and the pulmonary artery (PA). There was another fistula between the ostium of the RCA and the PA (Figures 1 G and ​andH).H). This vessel gave origin to a small branch to the middle part of the LAD, before reaching the PA, thus forming a third, intercoronary fistula (Figures C, ​,DD and ​andFF).

Treatment of a Failing St. Jude Medical Trifecta by Medtronic CoreValve Evolut Valve-in-Valve Implantation

A 70-year-old man with a prior aortic valve replacement was referred because of newly diagnosed, severe aortic regurgitation. Three years ago, he underwent a successful surgical aortic valve replacement with a 23-mm St. Jude Medical Trifecta valve (St. Jude Medical, St. Paul, Minnesota) because of

Transseptal Transcatheter Mitral Valve Implantation for Severely Calcified Mitral Stenosis

A 72-year-old woman, with prior aortic valve replacement and tricuspid annuloplasty, was referred for heart failure. Echocardiography showed mitral stenosis (mean gradient 12 mm Hg, area 0.8 cm2) with severe mitral annular calcification (MAC) ([Fig. 1][1]A). Computed tomography demonstrated a

Dynamic Left Ventricular Assist Device Inflow Obstruction

A 72-year-old man with a history of rheumatic heart disease, prior bioprosthetic mitral and aortic valve replacement, severe nonischemic dilated cardiomyopathy (left ventricular [LV] ejection fraction 5%), and a history of ventricular tachycardia (VT) underwent implantation of a continuous flow LV assist device (LVAD; HeartMate II; Thoratec Corporation) as destination therapy for severe heart failure. The early postoperative period was unremarkable and he had substantial functional improvement with minimal cardiovascular limiting symptoms after postoperative recovery. After ≈3 years on LVAD support, he experienced a series of appropriate implantable cardioverter-defibrillator shocks for sustained VT refractory to antiarrhythmic therapy. He underwent VT ablation targeting the basal LV inferoseptum, but he continued to have recurrent VT. Because VT seemed to originate from a deep septal substrate, he underwent an alcohol …

Development of mitral stenosis after single mitraclip insertion for severe mitral regurgitation

We report the first case of mitral stenosis following Mitra-Clip insertion in a patient with symptomatic NYHA IV heart failure, secondary to severe mitral regurgitation (MR). A 79-year-old female with a history of prior aortic valve replacement underwent percutaneous mitral valve (MV) repair. A single clip was advanced coaxially down onto the MV under TOE guidance, with the anterior and posterior leaflets clipped together between A2 and P2. TOE confirmed a significant reduction in MR (grade 4 to grade 1). Despite initial symptomatic relief, she represented 3 months later with similar symptoms. Repeat TOE confirmed a well positioned Mitra-Clip with mild residual MR. However, the possibility of significant mitral stenosis was raised due to the presence of significant turbulence through the bi-orifice valve, with a peak gradient of 25 mm Hg. In addition there was evidence of severe functional tricuspid valve (TV) regurgitation with elevated pulmonary artery pressures (PAP 90 mm Hg), confirmed on subsequent right heart catheterization. After repeated heart team discussions and a failure of optimal medical therapy, and despite a logistic EuroScore of 35.5, minimally invasive surgical replacement of the MV and simultaneous TV repair was undertaken via a right thoracotomy. Despite procedural success and initial good postoperative response, the patient died subsequently from a combination of hospital-acquired pneumonia and significant gastrointestinal bleeding (post operative day 35). Mitra-Clip is a promising novel approach to MV repair. The establishment of further clinical and echocardiographic based selection criteria will help identify the correct patients for this treatment.

Is there a rural gradient in the diagnosis of aortic stenosis? An analysis of a remote Scottish cohort

Calcific aortic stenosis is the most common cardiac valve lesion and is becoming increasingly prevalent as life expectancy rises. There is evidence that patients in remote and rural areas with certain diseases have worse outcomes and present to specialist services later than their urban counterparts. It is not known whether patients with aortic stenosis follow a similar pattern. The aim of this study was to investigate whether increasing rurality was associated with later presentation to healthcare services at a more advanced stage of aortic stenosis. This was a retrospective cohort study. Using ICD-10 discharge codes and local databases, 605 patients with aortic stenosis who presented between 31 November 1999 and 1 December 2008 were identified. Aortic stenosis was defined as a pressure gradient across the aortic valve of 25 mmHg or more. Patients with prior aortic valve replacement were excluded. Clinical notes were reviewed for all patients. Gender, age and pressure gradient across the aortic valve at presentation and patient GP-practice location were recorded. Patients were then assigned a Clinical Peripherality Index score based on the postcode of their GP's practice to define rurality. Patient data were compared across the six defined levels of clinical peripherality by ANOVA. Mean patient age was 73 ± 13 years, and 336 (54%) were male. The peak gradient across the valve was 41.1 ± 26.7 mmHg. There was no association between the level of clinical peripherality and the stage of aortic stenosis at presentation, age or gender (all p >0.05). There was no urban-rural gradient in the severity of aortic stenosis at presentation in this remote Scottish cohort. This suggests that patients with this condition in remote areas do not present later in their disease trajectory.

Prevalence of degenerative aortic valve stenosis in the elderly: results of a large community-based epidemiological study

There is a paucity of epidemiological data on the prevalence of degenerative aortic stenosis (AS) after the recent demographic changes and in the present therapeutic era. We sought to assess the prevalence of AS in an elderly population of an Italian urban area and to derive an epidemiological estimate of AS prevalence on a larger scale. Elderly people (aged 75-95 years) of a 26 000 inhabitants town were clinically screened by general practitioners and classified into four groups: (1) no signs of AS; (2) known AS; (3) suspected AS (on the basis of the presence of a systolic murmur); (4) prior aortic valve replacement (AVR). Group 2 and 3 patients underwent physical examination and transthoracic echocardiography to confirm or rule out the diagnosis of AS, and to assess main comorbidities. Among the eligible patients, 2203 (93.7%) had no sign of AS; 49 (2.1%) had known AS; in 74 (3.1%) there was a systolic murmur suggesting AS, and 26 (1.1%) had previous AVR because of AS. Ten patients refused further screening, therefore 113 patients underwent transthoracic echocardiography. Among them, degenerative aortic disease without stenosis was observed in 22, and 63 had confirmed AS (severe in 21). Important comorbidities were frequently diagnosed in these patients. Including patients with previous AVR, AS was confirmed in 89/2350 patients (3.8%). On a regional scale, based on the demographics of this area, we estimated a prevalence of severe AS of 2248 cases per million inhabitants. The prevalence of AS in a population aged 75-95 years was 3.8%, and it was not previously diagnosed in a sizable proportion. More attention for early diagnosis of AS in the elderly is warranted.

Pseudoaneurysms of the Heart

Case 1 : An 85-year-old man with a history of ischemic cardiomyopathy and recent reoperation coronary bypass surgery was noted on a routine follow-up echocardiogram to have a 25×25-mm fluid-filled extracardiac mass adjacent to the basal inferolateral wall of the left ventricle (Figure 1). Cardiac computed tomography (CT) identified the structure to be a pseudoaneurysm of a saphenous vein graft to an obtuse marginal branch of the left circumflex coronary artery. How should this patient be managed? Figure 1. Saphenous vein graft (SVG) pseudoaneurysm in an 85-year-old man after recent reoperation coronary artery bypass surgery. The pseudoaneurysm was visible as a mass (arrow) in the left atrioventricular (AV) groove on the chest x-ray ( A ). Transthoracic echocardiography ( B ) demonstrated a vascular mass (arrow) adjacent to the basal lateral wall. Cardiac computed tomographic angiography ( C ) demonstrated the pseudoaneurysm (arrow) connecting to the SVG by a narrow neck with contrast enhancement (light gray) and some thrombus (dark gray). Four-chamber view ( D ) demonstrating the pseudoaneurysm (arrow) in the left AV groove; a magnified view ( D , inset) demonstrates the pseudoaneurysm connected to the SVG via a narrow neck (arrow) with active contrast extravasation (red outline) contained by thrombus (white outline). Invasive angiography showing contrast extravasation ( E ) into the pseudoaneurysm (arrow) and postintervention angiogram demonstrated successful occlusion of the pseudoaneurysm ( F ). LA indicates left atrium; LV, left ventricle. Case 2 : A 27-year old man with prior homograft aortic valve replacement developed recurrent endocarditis (Figure 2). Echocardiography noted a periaortic valvular fluid collection concerning for abscess or valvular dehiscence. However, Doppler signal to and from the fluid collection connecting to the left ventricular outflow tract also raised concern for pseudoaneurysm. Cardiac CT confirmed the structure to be a 37×32-mm pseudoaneurysm involving the left coronary cusp of a trileaflet homograft prosthetic aortic valve just below the takeoff of …

Transcatheter Aortic Valve-in-Valve-in-Valve Implantation for a Failed Xenograft

A 78-year-old gentleman with a diagnosis of symptomatic severe xenograft aortic stenosis with multiple comorbidities was referred for transcatheter aortic valve implantation, that is, a "valve-in-valve" procedure. Transcatheter aortic valve implantation was performed by transapical approach using a balloon-expandable bioprosthesis. During valve deployment, the prosthesis moved toward the left ventricle and a second balloon-expandable valve was implanted within the first one-a "valve-in-valve-in-valve" to avoid further ventricular embolization of the first bioprosthesis. Echocardiography at hospital discharge showed a residual mean transvalvular gradient of 17 mm Hg and trivial paravalvular aortic regurgitation. At 1 year follow-up, the patient was in New York Heart Association functional class II.

Coronary Artery Complications in Infective Endocarditis

a v O FE A T U R E A R T IC LE S 52-year-old man with a prior bioprosthetic aortic valve replacement (Carpentier-Edwards valve; Edwards ifesciences, Irvine, CA) for Staphylococcus aureus endocaritis 2 years earlier was admitted with sudden onset of ever, headache, vomiting, and confusion. Blood cultures ere positive for S aureus. He was transferred to University of Ottawa Heart Instiute 9 days later because of a persistent fever despite ntibiotic therapy and new-onset chest pain associated with iffuse ST segment depression on the day of transfer. On resentation, he was in respiratory distress, his heart rate as 130 beats/min, and his blood pressure was 95/38 mm Hg. echanical ventilation and inotropic support were initiated. An urgent transesophageal echocardiogram (TEE) demnstrated multiple vegetations on the aortic bioprosthesis ausing severe stenosis but no insufficiency. A periaortic bscess (Fig 1A, arrowheads) extended laterally and comressed the left main coronary artery (arrow). Pulsed wave oppler (Fig 1B) showed high velocity coronary flow conistent with significant stenosis. The right coronary artery as aneurysmally dilated. There was severe left ventricular ystolic dysfunction with akinesis of the anterior wall. The atient was assessed for emergency aortic valve surgery, ut his condition deteriorated rapidly and he died within 12 ours of onset of chest pain. Autopsy confirmed the TEE findings. There were multiple egetations on the aortic bioprosthesis, extensive abscess foration of the periaortic area, and an aneurysmally dilated ight coronary artery (Fig 2A) with saccular mycotic aneuysms demonstrated in multiple transverse sections (Fig 2B). Coronary artery involvement with infective endocarditis an occur by several mechanisms. Aortic root abscess can ead to extrinsic compression and distortion. Coronary

Mitral valve repair in redo cardiac surgery.

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.

The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults

The purpose of this study was to describe the relationship between neo-aortic root size, neo-aortic insufficiency (AI), and reintervention at mid-term follow-up. Data on neo-aortic valve function and growth after the Ross procedure in children are limited. A total of 74 of 119 Ross patients from January 1995 to December 2003 had > or =2 follow-up echocardiograms at our institution and were included. Neo-aortic dimensions were converted to z-scores and modeled over time. Kaplan-Meier analysis was used to assess freedom from neo-aortic outcomes, and predictors were identified through multivariate analysis. Median age at Ross was 9 years (range 3 days to 34 years). Over 4.7 years (range 3 months to 9.3 years) follow-up, there was disproportionate enlargement of the neo-aortic root (z-score increase of 0.75/year [p < 0.0001]). Neo-AI progressed > or =1 grade in 36% of patients and > or =2 grades in 15%. Nine patients (12%) had neo-aortic reintervention at 2.0 years (range 1.1 to 9.5 years) after the Ross procedure owing to severe neo-AI (n = 7), neo-aortic root dilation (n = 1), and neo-aortic pseudoaneurysm (n = 1). At 6 years after the Ross procedure, freedom from neo-aortic reintervention was 88%. Freedom from neo-aortic root z-score >4 was only 3% and from moderate or greater neo-AI was 60%. Longer follow-up time was associated with neo-aortic root dilation (p < 0.0001). Prior ventricular septal defect (VSD) repair predicted neo-AI (p = 0.02) and reintervention (p = 0.03). Prior aortic valve replacement (p = 0.002) also predicted neo-AI. Neo-aortic root dilation was not associated with neo-AI or reintervention. At mid-term follow-up after the Ross procedure, neo-aortic root size increases significantly out of proportion to somatic growth, and neo-AI is progressive. Prior VSD repair and aortic valve replacement were associated with neo-AI and reintervention.

Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults

This study assessed the type, time course, and risk factors for right and left ventricular outflow tract reinterventions after the Ross procedure in a population of infants, children, and young adults. Patients who underwent the Ross procedure between January 1995 and June 2004 were included (n = 121 consecutive patients). Kaplan-Meier and hazard analyses of right and left ventricular outflow tract reinterventions were performed, and predictors of reintervention were identified through multivariate analysis. The median age at the Ross procedure was 8.2 years (4 days to 34 years); 20% were aged less than 1 year. Half of the patients had isolated aortic valve disease; the other half had complex left-sided heart disease. Early mortality (<30 days) was 2.5% (n = 3). There were 2 late deaths (1.7%). Follow-up (median 6.5 years [2.5 months to 10.4 years]) was available for 96% of survivors (n = 111). Right ventricular outflow tract reintervention (n = 22 in 15 patients) was performed 2.0 years (2.0 weeks to 9.8 years) after the Ross procedure because of stenosis in 19 of 22 cases. Freedom from right ventricular outflow tract reintervention at 8 years was 81%. Smaller homograft size was the strongest predictor (P < .001) of right ventricular outflow tract reintervention. Left ventricular outflow tract reintervention (n = 15 in 15 patients) was performed 2.8 years (1.0 months to 11.6 years) after the Ross procedure because of severe neoaortic insufficiency in 10 of 15 patients. Freedom from left ventricular outflow tract reintervention at 8 years was 83%. Native pulmonary valve abnormalities (P < .01), original diagnosis of aortic insufficiency (P < .01), prior aortic valve replacement (P = .01), and prior ventricular septal defect repair (P = .04) predicted left ventricular outflow tract reintervention. At midterm follow-up after the Ross procedure, interim mortality is rare. Neoaortic insufficiency and right ventricle to pulmonary artery conduit obstruction are common postoperative sequelae, requiring reintervention in one quarter of patients.

Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair

OBJECTIVESThe purpose of this study was to use transesophageal echocardiography (TEE) to define the mechanisms of aortic regurgitation (AR) in acute type A aortic dissection so as to assist the surgeon in identifying patients with mechanisms of AR suitable for valve preservation.BACKGROUNDSignificant AR frequently complicates acute type A aortic dissection necessitating either aortic valve repair or replacement at the time of aortic surgery. Although direct surgical inspection can identify intrinsically normal leaflets suitable for repair, it is preferable for the surgeon to correlate aortic valve function with the anatomy prior to thoracotomy.METHODSWe studied 50 consecutive patients with acute type A aortic dissection in whom preoperative TEE findings were considered by the surgeons in planning aortic valve surgery. Six patients did not undergo surgery (noncandidacy or refusal) and one patient had had a prior aortic valve replacement and therefore was excluded from the analysis.RESULTSTwenty-seven patients had no or minimal AR and 22 had moderate or severe AR. In all, there were 16 with intrinsically normal leaflets who had AR due to one or more correctable aortic valve lesion: incomplete leaflet closure due to leaflet tethering in a dilated aortic root in 7; leaflet prolapse due to disrupted leaflet attachments in 8; and dissection flap prolapse through the aortic valve orifice in 5. Of these 16 patients, 15 had successful aortic valve repair whereas just 1 underwent aortic valve replacement after a complicated intraoperative course (unrelated to the aortic valve). Nine patients underwent aortic valve replacement for nonrepairable abnormalities, including Marfan’s syndrome in four, bicuspid aortic valve in four, and aortitis in one. In patients undergoing aortic valve repair, follow-up transthoracic echocardiography at a median of three months revealed no or minimal residual AR, and clinical follow-up at a median of 23 months showed that none required aortic valve replacement.CONCLUSIONSWhen significant AR complicates acute type A aortic dissection, TEE can define the severity and mechanisms of AR and can assist the surgeon in identifying patients in whom valve repair is likely to be successful.

Predicting outcome after reoperative procedures on the aortic root and ascending aorta.

Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed. Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively. Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications. Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.

Aortoventriculoplasty in children

Aortoventriculoplasty was performed in 16 children between July, 1980, and July, 1984. Indications for the procedure were 1) aortic stenosis or insufficiency, or both, necessitating replacement of an aortic valve whose anulus would not accept a 19 mm diameter valve, (2) replacement of a small valve prosthesis, or (3) recurrent tunnel subaortic stenosis. Patients were 5 months to 17 years old at operation, 14 had previous repairs, and four had prior aortic valve replacement. There were 13 long-term survivors followed up for 14 to 38 months; 12 are asymptomatic with normal exercise tolerance. Three had residual ventricular septal defects, two requiring repair. All patients were given warfarin with or without antiplatelet agents. There have been no thromboembolic episodes and no hemorrhagic complications. Aortoventriculoplasty is well tolerated in children and appears to be a viable surgical option in the management of young patients with a hypoplastic left ventricular outflow tract.