Prosthetic Dysfunction Research Articles

Artificial aortic valve dysfunction due to pannus and thrombus - different methods of cardiac surgical management.

IntroductionApproximately 60 000 prosthetic valves are implanted annually in the USA. The risk of prosthesis dysfunction ranges from 0.1% to 4% per year. Prosthesis valve dysfunction is usually caused by a thrombus obstructing the prosthetic discs. However, 10% of prosthetic valves are dysfunctional due to pannus formation, and 12% of prostheses are damaged by both fibrinous and thrombotic components. The authors present two patients with dysfunctional aortic prostheses who were referred for cardiac surgery. Different surgical solutions were used in the treatment of each case.Case study 1The first patient was a 71-year-old woman whose medical history included arterial hypertension, stable coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia; she had previously undergone left-sided mastectomy and radiotherapy. The patient was admitted to the Cardiac Surgery Department due to aortic prosthesis dysfunction. Transthoracic echocardiography revealed complete obstruction of one disc and a severe reduction in the mobility of the second. The mean transvalvular gradient was very high. During the operation, pannus covering the discs’ surface was found. A biological aortic prosthesis was reimplanted without complications.Case study 2The second patient was an 87-year-old woman with arterial hypertension, persistent atrial fibrillation, and COPD, whose past medical history included gastric ulcer disease and ischemic stroke. As in the case of the first patient, she was admitted due to valvular prosthesis dysfunction. Preoperative transthoracic echocardiography revealed an obstruction of the posterior prosthetic disc and significant aortic regurgitation. Transesophageal echocardiography and fluoroscopy confirmed the prosthetic dysfunction. During the operation, a thrombus growing around a minor pannus was found. The thrombus and pannus were removed, and normal functionality of the prosthetic valve was restored.ConclusionsPrecise and modern diagnostic methods facilitated selection of the treatment method. However, the intraoperative view also seems to be crucial in individualizing the surgical approach.

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review.

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.

Valve-related complications after mechanical heart valve implantation.

The number of heart valve surgeries is increasing, and 19,164 patients underwent heart valve surgery in Japan in 2011. The early mortality rate has remained stable for more than 10 years. Many patients now survive for many years, with a reported 10-year survival rate of at least 60 %. However, unfavorable complications can occur after valve surgery. Valve-related complications include thromboembolisms, bleeding complications and prosthetic valve endocarditis, followed by structural and nonstructural prosthetic valve dysfunctions. Our review of studies published after 2000 revealed that the rate of all valve-related complications was 0.7–3.5 % per patient-year. Thromboembolisms occur at a rate of approximately 1 % per patient-year, and bleeding complications occur at almost 0.5 % per patient-year. Thromboembolic and hemorrhagic events related to anticoagulant therapy should be considered during life-long follow-up. The occurrence rate of endocarditis reaches 0.5 % per patient-year, with a poor postoperative survival. Structural dysfunctions have been largely overcome, and the nonstructural dysfunction rate is 0.4–1.2 % per patient-year. The nonstructural dysfunctions induced by paravalvular leaks and pannus ingrowth are also issues that need to be resolved.

Catheter ablation for atrial fibrillation after an unsuccessful surgical ablation and biological prosthetic mitral valve replacement: A pilot study

BackgroundPatients with mitral valve (MV) disease and atrial fibrillation (AF) undergo simultaneous prosthetic valve replacement and radiofrequency (RF) ablation procedure; however, this combinational procedure restores sinus rhythm (SR) in only 68–82% of the cases. In patients with ineffective surgical ablation, the use of a biological prosthetic valve might not only be a good choice to perform safe catheter ablation procedure in the left atrium (LA), but also provide a way to discontinue administration of oral anticoagulants. The objective of this study was to assess the efficacy of catheter ablation for AF after MV replacement with a biological prosthesis and an ineffective surgical ablation procedure. MethodsTen consecutive patients aged 48 ± 7 years were enrolled in this study. All patients had long-persistent AF associated with a rheumatic valve disease, which was treated by MV replacement with a biological prosthesis and a surgical RF ablation procedure. In the late postoperative period, all the patients had recurrent hemodynamically significant AF, which required repeated cardioversions. From 1 year to 3 years after the surgery, catheter ablation was performed, including reisolation of pulmonary veins (PVs) with the ablation of ganglionic plexi or linear lesions on the roof of the LA and mitral isthmus. The efficacy was assessed at 3 months, 6 months, and 12 months after the procedure. ResultsRestoration of SR during ablation was achieved in all of the cases. In 6–9 months, all the patients were free of arrhythmia. LA stunning manifested by the absence or decrease of the “A” wave in the transmitral flow and the retrograde wave in the PV flow was observed in nine patients with SR. In five of the patients, LA contractile function was restored in 1–6 months. Prosthetic valve dysfunction was not detected in any of the patients. ConclusionCatheter ablation is an effective method for AF treatment following an ineffective surgical RF ablation procedure and biological prosthetic MV replacement. The use of bioprosthetic MVs allows for performing safe catheter ablation without subsequent prosthetic dysfunction.

Clots and cardiac valve prostheses

Clots and cardiac valve prostheses

PT119 Evaluation of p53 polymorphism in patients with pannus-derived prosthetic dysfunction

PT119 Evaluation of p53 polymorphism in patients with pannus-derived prosthetic dysfunction

Limb-length Discrepancy After Total Hip Arthroplasty

Limb-length discrepancy, to one degree or another, is a problem that must be reckoned with after total hip arthroplasty (THA). It must be addressed as both a clinical issue for patients and, unfortunately, a potential medicolegal problem. Although a small limb-length discrepancy may cause no symptoms or may not be perceived, a large limb-length discrepancy may cause nerve palsy, low back pain, altered gait, hip instability, and patient dissatisfaction.1-4 Importantly, limb-length discrepancy is believed to be the leading cause of malpractice claims after THA.5-7 Despite deliberate attempts to equalize leg lengths using meticulous preoperative planning and intraoperative guides, landmarks, and navigation, limb-length discrepancy of 1 cm or more is common. Most often there is only minimal influence on function, but larger discrepancies are associated with inferior functional outcomes and lower patient satisfaction rates.8 In this issue of Orthopedics, Thakral et al describe a novel technique for correcting limb-length discrepancy after THA using distraction osteogenesis of the contralateral limb. Although this is an interesting study, it should be considered preliminary work, with its main limitation being its small sample. It is hoped that this will generate interest in this technique and additional, larger studies. It is encouraging that all patients were able to return to their activities of daily living and reported improved satisfaction once the limb-length discrepancy was corrected. In addition, Thakral et al provide a thorough discussion of all aspects of limb-length discrepancy along with a suggested treatment algorithm for surgeons performing THA. Symptomatic limb-length discrepancy after THA is a challenging condition to treat. Nonsurgical measures such as physical therapy or shoe lifts can treat discrepancies of less than 1 cm. Correcting larger discrepancies, such as those greater than 2 cm, typically requires invasive surgical procedures. Options include revision THA, ipsilateral limb shortening, or contralateral THA.9-11 Each of these techniques has drawbacks, such as low patient compliance with using shoe lifts. A small lift can be placed inside the shoe, but larger ones must be on the outside and may be unsightly. Obviously, when shoes are removed, the limb-length discrepancy returns. Revision of the ipsilateral hip to correct limb-length discrepancy is not desirable in cases where there is no evidence of prosthetic dysfunction and the lack of substantial arthritis in the contralateral hip may rule out primary THA to gain length. Thakral et al provide an option for patients who may not want to wear shoe lifts, who have well-fixed ipsilateral prostheses, and who have no evidence of advanced arthritis in the contralateral hip. Thakral et al correctly point out that not all patients may be candidates for their procedure to correct limb-length discrepancy after THA, and they offer a treatment algorithm for the problem. They propose a novel technique for the correction of limb-length discrepancy that has not been previously reported and are to be commended for their research and study.

Acute Myocardial Infarction and Severe Prosthetic Dysfunction after Bentall Procedure

Coronary artery anastomotic dehiscence is a rare complication following aortic procedures. A 59-year-old male previously underwent replacement of the ascending aorta and aortic valve because of ascending aorta aneurysm and severe aortic regurgitation. Eight years after the procedure, he presented with acute myocardial infarction. Transesophageal echocardiography (TEE) and coronary angiography revealed coronary artery dehiscence. This finding rarely occurs after a Bentall procedure; however, if it does, it usually occurs in the early postoperative period and is associated with an infectious etiology. In this case, coronary dehiscence presented with myocardial infarction years after the procedure and was first suspected after TEE.

Acute Obstruction by Pannus in Patients With Aortic Medtronic-Hall Valves: 30 years of Experience

Acute dysfunction of mechanical aorticvalve prostheses is a life-threatening adverse event. Pannus overgrowth, which is fibroelastic hyperplasia originating from the periannular area, is one cause of dysfunction. The aim of this study was to determine the annual incidence of readmittance resulting from acute obstruction caused by pannus during 30 years of observation in patients with Medtronic-Hall aortic valve prostheses and to analyzethe risk factors associated with pannus development. From 1982 to 2004, 1,187 patients in our department underwent aortic valve replacement with Medtronic-Hall mechanical monoleaflet valve prostheses. As of December 31, 2012, 27 of these patients (2.3%) had presented with acute valve dysfunction caused by pannus obstruction. The annual incidence of pannus was 0.7 per 1,000. The median time from the primary operation to prosthetic dysfunction was 11.1 years (range, 1.2 to 26.8 years). Of the 20 patients who underwent reoperation, 2 died. Seven patients died before reoperation. Women had a higher risk for the development of obstructing pannus, and patients with pannus obstruction were younger. Valve size was not an independent risk factor. Women and younger patients are at higher risk for pannus development. When acute dysfunction by pannus is suspected in a mechanical aortic valve, an immediate echocardiogram and an emergency aortic valve replacement should be carried out because of the potential of a fatal outcome.

Transapical Aortic Valve-in-Valve-in-Valve Implantation as a Procedural Rescue Option

Device malposition and dysfunction with resultant severe aortic insufficiency are known complications of transcatheter aortic valve implantation (TAVI). Fortunately, these complications can often be successfully treated with a transcatheter valve-in-valve (VinV) implantation. However, prosthetic leaflet dysfunction or immobility from the VinV configuration can lead to severe central aortic insufficiency. We report the first known case of implantation of a third SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA) during TAVI as a valuable bailout strategy to deal with severe aortic insufficiency after VinV implantation.

Prótesis Choostent como método de paliación de la disfagia secundaria a patología maligna

Use of Choostent prosthetic device for palliation of dysphagia secondary to esophageal cancer Background: Esophageal cancer causes disabling dysphagia and swallowing problems. Aim: To prospectively analyze the outcome of the insertion of a covered self-expanding metallic Choostent type prosthesis as a method of palliation of dysphagia, esophageal fistula or leak secondary to malignant disease of the esophagus or cardia. Material and Methods: A total of 30 consecutive patients aged 75 ± 8.8 years (63% males) with malignant disease of the esophagus or cardia were studied. Results: In 27 patients (90%) the stenosis was located in the esophagus, in two (6.7%) at the gastroesophageal junction and in one (3.3%) at the esophago - jejunal anastomosis due to tumor recurrence. In 24 cases (80%), the indication of the prosthesis was dysphagia, in three (10%) the presence of a tracheo-esophageal fistula and in the remaining three (10%), the suspicion of a perforation. Patients were followed until death. The prosthesis was inserted without incidents in 29 patients (96.6%). One patient had a pneumomediastinum, which evolved favorably. Dysphagia subsided in all patients. Early evolution was satisfactory in 12 patients (66.7%). The most common early complication was a transient chest pain in 3 cases (10%). Four patients (13.3%) died within 30 days post procedure. Of the remaining 26 patients, 14 (53.8%) had late complications (recurrence of dysphagia in 42% and hemorrhage in 11%). The mean interval between stent insertion and death was 169 ± 142.5 days. Conclusions: The Choostent esophageal prosthesis improves dysphagia immediately and safely. However, its use is associated with a high rate of late complications, directly related to prosthetic dysfunction.

EComment. Early surgery for patients with uncomplicated prosthetic valve endocarditis

Attaran et al. [1] are to be commended for trying to answer an important question that recurrently arises in clinical practice: do all patients with prosthetic valve endocarditis (PVE) need surgery? The authors concluded after reviewing the relevant literature that redo surgery is warranted especially in case of complicated PVE, or when the culprit organism is Staphylococcus aureus. We entirely agree with their opinion and would like to add a brief comment concerning the timing of surgery in patients with uncomplicated PVE. Despite advances in medical and surgical care interventions, PVE remains a diagnostic and therapeutic challenge. PVE accounts for 10-30% of all cases of infective endocarditis [2], with the International Collaboration on Endocarditis, the largest registry of patients with endocarditis, reporting a PVE incidence of 20% [3]. Furthermore, the proportion of infective endocarditis cases undergoing surgery ranges from 28-42% as shown in a recent meta-analysis [4]. Unfortunately, PVE still carries a high mortality risk ranging from 20-80% of affected patients [2]. Therapeutic strategies for PVE are not backed by evidence-based recommendations. Although several retrospective studies showed that surgical intervention is indicated in cases of PVE with severe prosthetic dysfunction, heart failure, abscess formation and early staphylococcal infection, no randomized trials have been performed to examine the role of valve surgery in the management of PVE. There are no clear recommendations regarding the indication for surgery in PVE patients with uncomplicated large vegetations. Indeed, a recently published study tried to find an answer, albeit in patients with native valve endocarditis. The EASE study (Early Surgery versus Conventional Treatment in Infective Endocarditis) is a randomized control trial involving patients with native infective endocarditis, who were candidates for both early surgery and conventional treatment at two Korean medical centres [5]. They randomized 76 patients with vegetations larger than 10 mm, and severe valve dysfunction and assigned them to surgery within 48 hours after enrolment (early surgery) or to antibiotic therapy (conventional treatment). The primary end point was a composite of embolic events or death within 6 weeks after randomization. Early surgery prevented additional embolic events without increasing mortality, whereas 20% in the conventional treatment group had additional embolic events. Postponing the surgery in this patient population on the assumption that operating on them is too risky and challenging, exposes these patients to the hazard of further destruction of cardiac tissue as well as to the potential development of heart failure and embolic events, and might also render those patients ineligible for surgery due to complications of the disease or its treatment. Further randomized trials are warranted to refine the indications for and timing of surgery especially in patients with uncomplicated PVE. Conflict of interest: none declared

Evaluation of Prosthetic Valve Function by Platelet Function Analysis and Von Willebrand Factor Indices

AbstractAbstract 1128 BackgroundDysfunctional or mismatched prosthetic heart valves can results in high shear stress related von Willebrand factor (VWF) impairment, and clinical bleeding. This mechanism is similar to that seen in aortic stenosis patients, where gastrointestinal bleeding related to VWF multimer loss is well described (Heyde syndrome). In this study, we compared the results of VWF testing of patients with normally functioning cardiac valve prostheses, dysfunctional prosthetic valves, severe native aortic stenosis, and normal controls. MethodsA total of 75 patients, 31 female and 44 male with a median age of 79.5 years were recruited to this study. Thirty patients had severe aortic stenosis (mean gradient > 40 mm Hg); 39 patients had normally functioning prosthetic valves, 21 aortic (AVR) and 18 mitral valves (MVR); and 6 patients had with dysfunctional valves (4 aortic and 2 mitral). Whole blood and plasma samples were drawn from patients and tested for platelet function analyzer-100 collagen ADP closure time (PFA-CADP), VWF antigen (VWF:Ag), VWF activity by latex immunoassay (VWF:Ltx), VWF multimer analysis and VWF multimer densitometry ratio of large vs medium to low molecular weight multimers (>15 mers/2–15 mers). ResultsThe 6 dysfunctional prosthetic valve patients included patient-prosthesis mismatch (2) and (one each), thrombosed mechanical aortic prosthesis, torn biological aortic prosthesis, severe tissue mitral prosthetic regurgitation, and post-mitral valve repair severe mitral regurgitation. Four of six patients had clinically significant bleeding. Most aortic stenosis and all 6 prosthetic dysfunction patients had abnormal VWF multimers which is rare in normally functioning prostheses and completely absent in normal donors. VWF:Ltx/Ag was lower in AS and MVR than normal. VWF:Ltx/Ag ratio, VWF:multimer ratio and PFA-CADP were all significantly abnormal in patients with dysfunctional prosthetic valve. VWF:multimer ratios in normally functioning prostheses tended to be intermediate between normals and than those of patients with severe AS or prosthetic valve dysfunction (Table).TableNormalsProsthetic DysfunctionAVRMVRSevere ASAbnormal VWF multimers0/216/62/211/1826/30Multimer ratio >15/2–15 mers0.24 ± 0.050.13 ± 0.01*,†0.17 ± 0.02*0.19 ± 0.04*0.13 ± 0.03*,†PFA-100 CADP89 ± 16141 ± 36*,†98 ± 2993 ± 31181 ± 69*,†Ltx/Ag0.96 ± 0.110.71 ± 0.06*,†0.93 ± 0.09‡0.87 ± 0.05*0.87 ± 0.16*,†*p<0.001 vs normals. † p<0.001 vs AVR+MVR. cm=NS vs normal, but p<0.02 vs mitral valve replacement. ConclusionsVWF testing including quantitative von Willebrand multimer analysis and PFA-CADP reliably separate dysfunctional from normally functioning cardiac prostheses, and should be considered in the evaluation of patients with cardiac prostheses, especially those who have clinically significant bleeding. Disclosures:No relevant conflicts of interest to declare.

High trans-prosthetic gradients and prosthetic aortic valve dysfunction: the need for an accurate and multimodality imaging approach

Abstract Introduction This report will review the role of echocardiography and other noninvasive methods in the differential diagnosis of high transprosthetic aortic gradients. New insights the pathophysiology of high transprosthetic gradients allowed more complete and accurate diagnosis of “functional” versus “organic” prosthetic “dysfunction indicating the strong potential of noninvasive methods. Specifically this report will review current applications of echocardiographic, Doppler and other noninvasive techniques in the evaluation of prosthetic valve mismatch and prosthetic obstruction. Moreover new insights the dynamics of discs and the Doppler characteristics of pathologic flows are discussed. Conclusions New insights the pathophysiology of prosthetic dysfunction, prosthesis mismatch and correlated prosthetic flows have significantly improved the understanding of the more correct diagnostic approach to patients with the suspicion of prosthetic dysfunction. In this regard transthoracic and transesophageal echo and Doppler echocardiography, cinefluoroscopy and other imaging modalities have a complementary diagnostic role.

Transcatheter Aortic Valve Replacement With the St. Jude Medical Portico Valve: First-in-Human Experience

The purpose of this study was to demonstrate the feasibility and procedural outcomes with a new self-expanding and repositionable transcatheter heart valve. Transcatheter aortic valve replacement is a viable option for selected patients with severe symptomatic aortic stenosis. However, suboptimal prosthesis positioning may contribute to paravalvular regurgitation, atrioventricular conduction block, and mitral or coronary compromise. The repositionable Portico valve (St. Jude Medical, Minneapolis, Minnesota) was implanted in 10 patients with severe aortic stenosis utilizing percutaneous femoral arterial access. Patients underwent transthoracic and transesophageal echocardiography and multidetector computed tomography before and after valve implantation. Clinical and echocardiographic follow-up was obtained at 30 days. Device implantation was successful in all patients. Prosthesis recapture and repositioning was performed in 4 patients. Intermittent prosthetic leaflet dysfunction in 1 patient required implantation of a second transcatheter valve. There was 1 minor stroke. At 30-day follow-up, echocardiographic mean transaortic gradient was reduced from 44.9 ± 16.7 mm Hg to 10.9 ± 3.8 mm Hg (p < 0.001), and valve area increased from 0.6 ± 0.1 cm 2 to 1.3 ± 0.2 cm 2 (p < 0.001). Paravalvular regurgitation was mild or less in 9 patients (90%) and moderate in 1 patient (10%). There were no major strokes, major vascular complications, major bleeds, or deaths. No patient required pacemaker implantation. All patients were in New York Heart Association functional class II or less. Transcatheter aortic valve replacement with the repositionable Portico transcatheter heart valve is feasible, with good short-term clinical and hemodynamic outcomes.

Transcatheter Valve-In-Valve Implantation for Failed Balloon-Expandable Transcatheter Aortic Valves

This study sought to evaluate outcomes after implantation of a second transcatheter heart valve (THV-in-THV) for acute THV failure. Aortic regurgitation after transcatheter aortic valve replacement (TAVR) may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. Patients undergoing aortic balloon-expandable TAVR at 3 centers were prospectively evaluated at baseline, intraprocedurally, at hospital discharge, and annually. Of 760 patients undergoing TAVR, 21 (2.8%) received a THV-in-THV implant due to acute, severe regurgitation. Aortic regurgitation was paravalvular in 18 patients and transvalvular in the remaining 3 patients. THV-in-THV implantation was technically successful in 19 patients (90%) and unsuccessful in 2 patients (10%), who subsequently underwent open heart surgery. Mortality at 30 days and 1 year was 14.3% and 24%, respectively. After successful THV-in-THV, mean aortic valve gradient fell from 37 ± 12 mm Hg to 13 ± 5 mm Hg (p < 0.01); aortic valve area increased from 0.64 ± 0.14 cm(2) to 1.55 ± 0.27 cm(2) (p < 0.01); and paravalvular aortic regurgitation was none in 4 patients, mild in 13 patients, and moderate in 2 patients. At 1-year follow-up, 1 patient had moderate and the others had mild or no paravalvular leaks. The mean transvalvular gradient was 15 ± 4 mm Hg, which was higher than in patients undergoing conventional TAVR (11 ± 4 mm Hg, p = 0.02). THV-in-THV implantation is feasible and results in satisfactory short- and mid-term outcomes.

142 Transcatheter valve-in-valve implantation for failed balloon expandable transcatheter aortic valves

BackgroundDevice malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal.Methods and results19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg).ConclusionsThis multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes. BackgroundDevice malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal. Device malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal. Methods and results19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg). 19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg). ConclusionsThis multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes. This multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes.

The Enemy of Good …

The Enemy of Good …

Transapical Transcatheter Aortic Valve Implantation in the Presence of a Mitral Prosthesis

We review our experience with transapical transcatheter aortic valve implantation (AVI) in patients with functioning mitral prostheses, and describe the technical considerations. Transcatheter AVI for aortic stenosis in patients with mitral prostheses is technically challenging. Ten patients (7 mechanical and 3 bioprosthetic mitral valves) received the Edwards SAPIEN balloon-expandable valve (Edwards Lifesciences, Irvine, California) during 2006 to 2010. All patients were declined conventional surgery and prospectively followed. The mean patient age was 77.6 ± 7.1 years (range: 67 to 88 years). The logistic EuroSCORE and the Society of Thoracic Surgeons-predicted operative mortality were 30.3 ± 18.6% (range: 11.4% to 70.4%), and 9.9 ± 4.8% (range: 4.6% to 18.7%), respectively. All valves were successfully implanted, with no 30-day mortality or mitral prosthetic dysfunction. Nine patients had none to mild residual aortic paravalvular leak. The overall survival was 60% at a mean follow-up of 12.2 ± 10.4 months (range: 2 to 33 months), with 4 nonvalve-related deaths. Seven patients improved to New York Heart Association functional class I to II. The mean transvalvular gradient and effective orifice area improved from 40.0 ± 17.4 mm Hg to 8.2 ± 2.1 mm Hg, and 0.6 ± 0.1 cm² to 1.3 ± 0.2 cm², respectively (p < 0.0001). The mitral bioprosthetic strut predisposes to device "shift" during deployment. An "unfavorable" mechanical mitral prosthetic cage or pivot strut can also cause shifts. Balloon shifts during valvuloplasty warn of a high likelihood of prosthesis shift. This report details the technical lessons learned thus far from our first 10 patients. Excellent procedural success and early outcomes in patients with functioning mitral prosthesis can be achieved.

Real-Time Three-Dimensional Echocardiography in Estimation of Prosthetic Valves

To investigate possibilities of real-time three-dimensional echocardiography (3DE) in comparison with two-dimensional echocardiography (2DE) for evaluation of prosthetic valves of the heart. 2DE and 3DE were performed using Vivid 7 Dimension (GE) with matrix transducers M4S, 3V. 3DE was taken using sector mode, full volume, 9 slices, color Doppler. Twenty patients with mechanical and biological prosthetic valves of the heart were examined. Ten had prosthetic valvule dysfunction. At volumetric reconstruction, it was possible to investigate more precisely the details of valves and framework of annulus. Using nine slices at different levels, the movement estimation of elements was possible at bicuspid prosthetic valves. In real time, we observed the absence of movement of leaflets of dysfunctional bioprosthetic or mechanical valves, thrombosis and pannus. In one case, the 3D sector views demonstrated the details of mechanical prosthetic aortic valve. On addition of full volume and nine slices, vegetations and valvular obstruction were found. Using sector 3DE, we diagnosed a thrombosis of the bioprosthetic valve in the tricuspid position in a patient with a burn sepsis. Color Doppler with 3D imaging has provided improved visualization of pathological regurgitated jet for assessment of convergence and vena contracta of dysfunctional bioprosthetic valve. Three-dimensional echocardiography in real time provides a better estimation of anatomical and functional details of prosthetic valves in comparison with 2D echo.