Severe Aortic Valve Insufficiency Research Articles

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review

SummaryBackgroundA fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention.Case presentationA 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4.ConclusionsThe clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient’s condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

Clover stitch technique for aortic valve in mitral valve repair.

In the case of mitral repair with severe aortic regurgitation, aortotomy and selective cardioplegia are necessary for myocardiac protection. In this situation, the saline test for mitral valve repair cannot be accomplished due to incomplete left ventricular filing. In patients undergoing mitral valve repair concomitant with severe aortic valve insufficiency, after cardiac stand still was achieved by selective cardioplegia. Each center of the aortic leaflet, termed the node of Arantius, was stitch up using a 5-0 polypropylene suture, forming a clover leaflet shape. This stitch inhibits aortic valve opening and reduces saline leakage thorough aortic valve. We have termed this procedure as the "Clover Stitch Technique". Upon completion of this technique, mitral valve repair can be undertaken via a right-side left atrial incision. This technique enables accurate evaluation of mitral valve morphology or the extent of regurgitation, repeatedly without complicated manipulations during and after mitral valve repair.

The prevalence and prognostic impact of aortic valve diseases in heart failure with mildly reduced ejection fraction

Abstract Objective This study aims to investigate the prevalence and prognostic value of aortic valve diseases in patients hospitalized with heart failure with mildly reduced ejection fraction (HFmrEF). Background Limited data regarding the prognostic impact of aortic valve diseases in patients with HFmrEF is available. Methods A large retrospective study was used including all consecutive hospitalized patients with HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41 – 49%) from 2016 to 2022 according to current European guidelines. The prognostic impact of moderate to severe aortic valve stenosis (AS) and aortic valve insufficiency (AI) was compared to patients without (i.e., non-AS and non-AI, respectively). The primary endpoint was the first heart-failure related re-hospitalization at 3 years. Secondary endpoints comprised amongst others in-hospital mortality. Kaplan-Meier, uni- and multivariable Cox regression analyses were applied for statistics. Results 800 consecutive patients with HFmrEF were included. The prevalence of AS was 10% (moderate 6% and severe 4%) and AI 8% (moderate 7% and severe 1%). The risk of first heart-failure related hospitalization was not significantly affected by the presence of AS (14% vs. 8%; log rank p=0.092; HR= 1.727; 95% CI 0.908 - 3.284; p=0.096), however, HFmrEF patients with moderate to severe AI were associated with an increased risk of heart-failure related re-hospitalization compared to patients without (18% vs. 8%; log rank p=0.010; HR= 2.270; 95% CI 1.193 - 4.317; p=0.012). Even after multivariable adjustment, the risk of heart failure related re-hospitalization was still significantly higher in patients with moderate to severe AI (HR= 2.022; 95% CI 1.030 - 3.969; p=0.041). Finally, patients with moderate or severe AS and patients with moderate or severe AI revealed no significant difference of in-hospital mortality (4% vs. 3%; p=0.807 and 3% vs. 3%; p=0.946). Conclusions In patients hospitalized with HFmrEF between 2016 and 2022, patients with moderate to severe AI – but not AS – had a higher risk of heart failure related re-hospitalization at 3 years.

Severe aortic valve insufficiency with a ‘normal’ appearing aortic root: reimplantation (David) procedure.

Severe aortic valve insufficiency with a ‘normal’ appearing aortic root: reimplantation (David) procedure.

Risk prediction of preoperative acute ischemic stroke in acute type A aortic dissection.

To predict preoperative acute ischemic stroke (AIS) in acute type A aortic dissection (ATAAD). In this multi-center retrospective study, 508 consecutive patients diagnosed as ATAAD between April 2020 and March 2021 were considered for inclusion. The patients were divided into a development cohort and two validation cohorts based on time periods and centers. Clinical data and imaging findings obtained were analyzed. Univariable and multivariable logistic regression analyses were performed to identify predictors associated with preoperative AIS. The performance of resulting nomogram was evaluated in discrimination and calibration on all cohorts. A total of 224 patients were in the development cohort, 94 in the temporal validation cohort, and 118 in the geographical validation cohort. Six predictors were identified: age, syncope, D-dimer, moderate to severe aortic valve insufficiency, diameter ratio of true lumen in ascending aorta < 0.33, and common carotid artery dissection. The nomogram established showed good discrimination (area under the receiver operating characteristic curve [AUC], 0.803; 95% CI: 0.742, 0.864) and calibration (Hosmer-Lemeshow test p = 0.300) in the development cohort. External validation showed good discrimination and calibration abilities in both temporal (AUC, 0.778; 95% CI: 0.671, 0.885; Hosmer-Lemeshow test p = 0.161) and geographical cohort (AUC, 0.806; 95% CI: 0.717, 0.895; Hosmer-Lemeshow test p = 0.100). A nomogram, based on simple imaging and clinical variables collected on admission, showed good discrimination and calibration abilities in predicting preoperative AIS for ATAAD patients. • A nomogram based on simple imaging and clinical findings may predict preoperative acute ischemic stroke in patients with acute type A aortic dissection in emergencies. • The nomogram showed good discrimination and calibration abilities in validation cohorts.

The dawn of surgical treatment of aortic insufficiency.

The dawn of surgical treatment of aortic insufficiency.

Minimally invasive aortic valve replacement with an expandable bioprosthesis after LVAD implantation as redo surgery.

Left Ventricular Assist Device (LVAD) is currently implanted not only as a bridge to transplant or recovery but also as destination therapy. One factor, affecting the device performance and treatment adequacy negatively is the development of aortic valve insufficiency (AI) after the implantation. Herein, we introduce a minimally invasive partial sternotomy aortic valve replacement with an expandable bio-prosthesis in a 74-year-old LVAD patient with severe AI.

Repair of insufficient aortic valve and single coronary artery with intramural course.

We report about a patient with severe bicuspid aortic valve insufficiency and a single coronary artery with an intramural course. Aortic valve repair with double plication and coronary translocation was satisfactory.

Can Antipsychotics and Antidepressants Affect the Formation or Chronicization of Aortic Dissections?

Acute Stanford type-A aortic dissections (STAAD) are life-threatening diseases which require&#x0D; emergency surgery to eliminate risks of aortic rupture, severe aortic valve insufficiency, pericardial&#x0D; tamponade and cerebral and/or coronary malperfusion. Only a small subset of patients go unnoticed&#x0D; and become chronic with unclear mechanism. These patients are usually diagnosed thru late symptoms&#x0D; or incidentally. Surgical techniques requiring cardiopulmonary bypass and sometimes deep hypothermia&#x0D; and circulatory arrest are first-line treatments with considerable mortality and complications. Herein,&#x0D; an incidentally diagnosed chronic STAAD patient who was receiving antipsychotic and antidepressant&#x0D; treatment and successfully repaired with total aortic arch replacement was presented.

P24: MANAGEMENT OF RHEUMATIC VALVE DISEASE OF THE AORTIC VALVE USING THE OZAKI PROCEDURE WITH AUTOLOGOUS PERICARDIUM

Abstract Case-Study A 15-year-old boy was referred to our tertiary centre from his local paediatric services with a background of rheumatic fever, severe aortic regurgitation (AR) and mild to moderate mitral regurgitation. He had a history of angina and dyspnoea on exertion, a 2/6 ejection systolic murmur and 2/4 end diastolic murmur. Transthoracic echocardiography showed severe aortic valve insufficiency (with flow reversal seen in the descending aorta and an LV end diastolic volume of 173 ml/m2) and trivial pulmonary valve regurgitation. Autograft failure following the favoured Ross procedure deemed the patient as a candidate for an Ozaki procedure. Autologous pericardium was used to replace the diseased aortic valve. Intraoperative transoesophageal echocardiography showed a deficient left coronary cusp leaflet and a retracted right coronary cusp leaflet. The patient was under cardiopulmonary bypass for 124 minutes and on cross-clamping for 99 minutes with no intraoperative complications. Histological examination of the aortic valve leaflets showed neovascularisation, myxoid changes and disarray of the fibrous stroma. Postoperative recovery was uneventful. The postoperative echocardiogram showed trivial AR, end diastolic volume 217ml, end systolic volume 12 ml and 40% ejection fraction. There was full resolution of the dyspnoea, angina and diastolic murmur on follow-up 4-months postoperatively as supported by healthy valve function on echocardiography. This case highlights that in those of risk of multiple valve pathology, such as in rheumatic valve disease, an Ozaki procedure using autologous pericardium is a viable surgical option for paediatric aortic valve repair with good outcomes. Take-home message In cases of systemic conditions affecting the heart valves where there is multiple valve pathology and risk of autograft failure, such as rheumatic valve disease, the use of autologous pericardium to replace these valves has shown to be a viable option in this paediatric case.

Observe the Unexpected: A Strange History of Bioprosthesis in a Patient in Dialytic Treatment

A 73-year-old male with a history of right nephrectomy due to cancer in 1996 was referred to our hospital for dyspnea and acute chest pain. In May 2007, the Shelhigh® No-React® valved bioconduit was implanted using the Bentall-De Bono procedure due to the finding of severe aortic valve insufficiency and acute type A aortic dissection. Nine months after discharge, he was placed on chronic renal dialysis. The patient’s condition was followed carefully after being placed on dialysis, and now, thirteen years later the implanted aortic valve is still moving freely without signs of calcification.

Staged Endovascular Repair of Aortic Coarctation followed by Double Valve Surgery.

We present a unique case of late diagnosis of coarctation of the aorta in an adult, presenting with congestive heart failure associated with severe aortic and mitral valve insufficiency. To minimize operative risk, staged endovascular repair of the coarctation was initially performed, followed by aortic valve replacement and mitral valve repair. Six months postoperatively, the 41-year-old patient remains completely asymptomatic.

Single Center Five Years’ Experience of Ozaki Procedure: Midterm Follow-up

The Ozaki procedure is an innovative surgical technique aiming at the reconstruction of the aortic valve with autologous pericardium to overcome the limitations of commercially available prostheses. We retrospectively analysed 71 patients who underwent Ozaki operation at our centre between October 2014 and February 2020. No in-hospital death occurred. Freedom from major adverse valve-related events (MAVRE) was 97%. The aortic gradients and transvalvular velocity are significantly lower at the 3-months echocardiographic control than at the pre-discharged echocardiography (10.93 ± 5.38, p= 0,0003 vs 16.24 ± 7.67 p= 0,0004 respectively). The median follow-up period was 20.7 months (range 2 to 47 months). Four patients showed mild/moderate aortic insufficiency (5.6%) and none showed severe aortic valve insufficiency. No patients underwent reoperation. Mid-term outcome follow-up of Ozaki procedure showed optimal results in term of mortality, transaortic valve gradients, freedom from MAVRE and recurrence of aortic valve insufficiency.

Successful extracorporeal membrane oxygenation assisted revascularisation in ahigh-risk elderly patient refused surgical treatment.

Management of high-risk elderly patients requiring revascularisation remains aclinical challenge. We report acase of extracorporeal membrane oxygenation (ECMO) assisted complex percutaneous coronary intervention in a high-risk octogenarian. An 83-year-old female with signs of worsening heart failure was admitted to theemergency department of atertiary care facility. Transthoracic echocardiography revealed a decreased left ventricular ejection fraction of 20% with severe mitral regurgitation and mild aortic and tricuspid valve insufficiency. Three-vessel disease was found during coronary angiography. Due to thepatient's frailty, ahigh-risk surgery decision to proceed with ECMO assisted percutaneous coronary intervention was made during aheart team meeting. Following initiation of mechanical support, coronary lesions were treated with three drug-eluting stents. After theprocedure, thepatient was transferred to theICU on ECMO support, where she was successfully weaned from thedevice 9h later. Her ICU stay was four days. She was successfully discharged from thehospital after uneventful recovery. At one-year's follow-up, thepatient was clinically stable in an overall state of general well-being and with complete participation in routine activities; she had good exercise tolerance and no signs of ischemia. This report highlights thepossibility of use of ECMO during PCI in high-risk elderly patients.

The Impact of Pump Speed and Blood Pressure Optimization on Severe Aortic Valve Insufficiency with Left Ventricular Assist Device: A Mock Loop Study

It is cumbersome to medically optimize the RPM setup and afterload adjustment for patients with significant aortic valve insufficiency (AI) with left ventricular assist device (LVAD). Limited amount of information is available regarding the optimal RPM setting or afterload adjustment without adverse effect on the degree of AI. All measurements were performed using a mock circulatory system with a dilated silicone LV model attached to a HeartMateII LVAD (Abbott Labs). Baseline condition was established with 17% ejection fraction, 62 bpm heart rate, LVAD set at 8,800rpm pump flow and 90 mmHg systemic aortic pressure, followed by testing at 8,800 and 9,200 rpm, and two systemic aortic pressure conditions (90 and 80 mmHg at 8,800 rpm). Severe AI was created with a small 3-D printed stent which was nonobstructive to forward flow but prevented the leaflets from fully closing. LVAD, aortic valve and systemic flow were recorded in each situation. Q ratio was calculated with LVAD flow/systemic flow, which represented an efficiency of LVAD flow contribution to the systemic flow. With the constant circuit afterload at 90mmHg, an RPM increase from 8,800 RPM to 9,200 resulted in systemic flow increase by 21% (2.27 to 2.74 L/min) with a 16% increase in LVAD flow (3.09 to 3.58 L/min), similar aortic valve flow (-0.82 to -0.84 L/min) and improvement in Q ratio (1.36 to 1.31). The regurgitant flow was similar in 8,800 vs. 9,200 (-0.86 vs. -0.83 L/min) in the severe AI setting. With the constant RPM at 8,800, an afterload reduction by 10 mmHg resulted in an increase of the systemic flow by 28% (2.27 to 2.91 L/min) with a LVAD flow increase of 14% (3.09 to 3.52 L/min), aortic valve flow increase of 23% (-0.82 to -0.61 L/min) and improvement in Q ratio (1.36 to 1.21). The alteration in the regurgitant flow was minimal between 90mmHg vs. 80mmHg afterload (-0.86 to -0.81 L/min). Both RPM increase and afterload reduction increased systemic flow and LVAD flow with improved Q ratio. The regurgitant flow stayed constant either with RPM increase or afterload reduction with the fixed regurgitant valve area. This mock-loop study suggests that both afterload reduction and RPM increase should improve systemic flow without increasing the degree of AI after LVAD implant.

Significance of Aortic Valve Insufficiency with Left Ventricular Assist Device: Duration and Regurgitant Flow in a Mock Loop Study

In patients with left ventricular assist device (LVAD), aortic valve insufficiency (AI) could occur in longer period during the cardiac cycle, throughout the diastolic and part of the isovolumetric phases. As the result, the current echocardiographic evaluation of AI grade may underestimate the degree of AI in LVAD patients, especially those with significant AI. In this study, we investigated the differences in AI duration and regurgitant volume before and during LVAD supports (Off and On LVAD) using a mock circulatory loop. All measurements were performed using a mock circulatory system with a dilated silicone LV model attached to a HeartMate II LVAD (Abbott Lab), and pressure and flow measured in the LV, LVAD, and aorta. Baseline condition was established as no LVAD condition (Off LVAD setting) which has 17% ejection fraction, 62 bpm heart rate and 65 mmHg systemic pressure. LVAD condition (On LVAD setting) at 8,800 rpm with same ejection fraction, heart rate and systemic resistance (90 mmHg systemic pressure) was established, followed by testing at three AI severity conditions. AI severity was defined as mild, moderate, or severe based on effective regurgitant orifice area. AI conditions were created with small 3-D printed stents, which were nonobstructive to forward flow, but prevented the leaflets from fully closing. AI durations and regurgitant volumes were determined from the calculated backward flow through the aortic valve. With the constant systemic resistance in the On LVAD setting at 8,800 rpm, duration of AI increased by 8.3 % (75 to 83.3%) with mild AI, 5.6% (77.8 to 83.3%) with moderate AI, and 5.6% (77.8 to 83.3%) with severe AI compared to the Off LVAD setting. With the constant systemic resistance in the On LVAD setting at 8,800 rpm, regurgitant volume of AI increased by 0.11 L/min (0.12 to 0.23 L/min, 92%) in mild AI, 0.03 L/min (0.53 to 0.56 L/min, 5.7%) in moderate AI and 0.08L/min (0.78 to 0.86 L/min, 10.3%) with severe AI compared to the Off LVAD setting. This mock loop study demonstrated that AI duration was longer and regurgitant volume through the aortic valve was greater during LVAD support compared to same AI degree before LVAD. This suggests that clinical burden of AI may be underestimated in patients with LVAD.

TRANSCATHETER AORTIC VALVE REPLACEMENT OUTCOMES IN PATIENTS WITH NATIVE AORTIC VALVE INSUFFICENCY

Current treatment for severe Native Aortic Valve Insufficiency (NAVI) is surgical aortic valve replacement (SAVR). For inoperable patients, few treatment options are available and outcomes are poor. NAVI is considered a relative contraindication for Transcatheter Aortic Valve Replacement (TAVR),

Annuloaortic Ectasia and Arteritis: Clinical Features, Treatments of Choice, and Causative Relations.

The roles that aortitis plays in the development of annuloaortic ectasia (AAE) remain uncertain, while clinical features of AAE in arteritis are largely unknown. This study was designed to highlight the clinical features of AAE, the treatments of choice, and the causative relations between aortitis and AAE. The morphology of the aortic valve leaflets was normal in half of the patients, while the valves were thin and overstretched in the other half. Most patients had an aortic aneurysm. Half of the patients had severe aortic valve insufficiency, and one-quarter of them had dilation of the sinuses of Valsalva. Takayasu arteritis was prone to develop coronary artery lesions, whereas giant cell arteritis were not. Aortic branch lesions in Takayasu arteritis were stenotic or occlusive in 92.9% of the patients, while in giant cell arteritis, they were all dilated lesions. Most patients (94.7%) required surgical treatment with steroid therapy. However, long-term follow-up results showed a higher anastomotic dehiscence rate, particularly in patients with Takayasu arteritis. Further morphometric and pathological research on AAE in arteritis should be undertaken, and more feasible measures should be warranted for preventing postoperative anastomotic dehiscence.

Templates of flat pericardial patterns for precise aortic cusp extension

Background Aortic cusp extension is a subjective and operator-dependent technique. In order to facilitate surgical correction of aortic cusp retraction and reestablishment of adequate cusp coaptation, we sought to develop new templates that can be used to cut flat pericardial sheets into precise cusp extension patches. Methods Each template was designed as a two-dimensional unwrap of the natural geometry of a complete aortic cusp, and a series of templates were made available to correspond with all potential aortic cusp sizes. Based on these templates, aortic cusp extension was performed in 2 patients (aged 54 and 43 years) with significant retraction of the noncoronary aortic cusps and severe aortic valve insufficiency. In each patient, extension of the retracted native noncoronary cusp was undertaken using a bovine pericardial patch that matched the size of adjacent nondiseased native aortic cusps. Results Achieving geometrically perfect aortic cusp extensions was uncomplicated, and intraoperative transesophageal echocardiography confirmed satisfactory aortic valve repairs (aortic insufficiency < 1+ and low transvalvular gradients). Early follow-up transthoracic echocardiography confirmed that all valve cusps met at similar heights in the aortic root, and that their excursions were virtually identical. Conclusions The newly designed templates can be used to cut flat pericardial sheets into exact cusp extension patches, and initial clinical experience indicates that they are useful in performing precise aortic cusp extension procedures and restoring adequate aortic valve competence.

Management of aortic insufficiency in patients with left ventricular assist device ̶ a retrospective analysis

Background&#x0D; Aortic insufficiency is increasingly recognized as a complication of left ventricular assist device (LVAD) support and may lead to clinical decompensation requiring correction. This article describes experiences in managing patients presenting with concomitant aortic insufficiency and with de novo aortic insufficiency following left ventricular assist device implantations.&#x0D; Methods&#x0D; All patients undergoing LVAD implantation between 2012 and 2014 were included in this retrospective analysis if aortic valve insufficiency was present on implantation or newly developed (de novo) after implantation. Moderate to severe aortic valve insufficiency was corrected at implantation.&#x0D; Results&#x0D; The data of 39 patients were included. At the time of LVAD implantation, moderate to severe aortic valve insufficiency was present in 3 patients and was corrected by bioprosthetic valve replacement (2 patients) and by bioprosthetic valve replacement associated with ascending aorta with hemi arch replacement with a graft due to ascending aortic aneurysm (one patient). Four patients developed moderate to severe aortic insufficiency after LVAD surgery. Treatment with conservative medical management was successful in 3 patients. One patient underwent transcatheter aortic valve occlusion using an Amplatzer closure device after failure of medical management.&#x0D; Conclusions&#x0D; Concomitant aortic valve replacement with LVAD implantation is a safe and viable option in managing aortic valve insufficiency. De novo aortic insufficiency may lead to recurrent heart failure and presents a clinical treatment challenge following successful LVAD support; the most appropriate and effective treatment option awaits definition.