Significant Aortic Regurgitation Research Articles

Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock

AimsWe investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and resultsBetween June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. ConclusionsOur study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation

Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown. To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR. This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019). Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF. Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF. Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival. In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.

Totally endoscopic aortic valve replacement with stented biological and mechanical aortic prostheses

Abstract Background Endoscopic mitral valve surgery has become the gold standard of care in many expert centres around the globe. The aortic valve has not met the same popularity mainly due to the very confined space in the aortic root, and to the close proximity with the sternum which restricts the movement of the endoscopic instruments. When endoscopic aortic valve replacement is practiced in expert centres, is usually performed with the use of sutureless bioprostheses. We hereby present our experience of totally endoscopic aortic valve replacement (TEAVR) with conventional mechanical and biological prostheses. Methods Since January 2019, fifty-two consecutive patients with significant aortic stenosis and/or aortic regurgitation, who were operated with TEAVR with conventional prostheses were studied. 7,69% of the cases were REDOs. The prostheses used were either stented bovine pericardial in 84,6% of the patients and bileaflet mechanical in 15,4%. The operations were performed through a 3 to 4 cm working incision in the 3rd intercostal space (ICS) right parasternally (where an extra small soft tissue protector was deployed), a 10 mm port for the 3D, 30°, endoscope, and a 5 mm port for the left atrial vent. On full cardiopulmonary bypass, the heart was arrested with cardioplegia which was administered either in the aortic root or directly in the coronary ostia. A transverse aortotomy was performed 3 cm above the right coronary ostium. The native valve (tricuspid or bicuspid) was excised, the annulus was sized and the prostheses were inserted using twelve to fifteen annular sutures who were secured using an automated suture-fastening device. In order to facilitate exposure in the aortic root, a metal self-expandable net was used. Results The average age of the patients treated was 68,3 years (range 36–81, median 72). The mean EuroSCORE2 was 3,22 (0,9–12,01, SEM:0,71). The mean size of the prostheses inserted was 23,72 mm (21–27, median 23) and the mean postoperative peak gradient was 12,15 (5–19, SEM: 1,00). Mean cross clamp and CPB times were 75,38 min (SEM:5,87) and 116,30 (SEM:8,63). There was no case of paravalvular leak or pacemaker insertion. There was no mortality in this cohort of patients. There was one case of cerebrovascular accident. Conclusions TEAVR can be performed safely with conventional aortic prostheses. There are several advantages of the technique over the other aortic valve replacing approaches. Over the other surgical techniques has the advantage of not fracturing the sternum or spreading or dislodging the ribs and increased patient satisfaction. Over the TAVI has the advantages of fully removing the diseased native valve, securing the prosthesis at the exact annular level without any paravalvular leaks or need for pacemaker insertion and the ability of using mechanical prostheses. The main disadvantages of the technique are the relatively prolonged cross clamp and CPB times and the steep learning curve. TEAVR Funding Acknowledgement Type of funding source: None

33-year follow-up after valvular surgery for carcinoid heart disease

Abstract Background Valvular surgery for carcinoid heart disease (CaHD) has been found to improve long-term prognosis. Experience is limited and questions about single versus double-valve surgery as well as selection of prosthetic valves remain under debate. Purpose We reviewed the surgical experience after valvular surgery for CaHD in our institution, which is a national referral center. Methods We reviewed clinical records and echocardiograms. Perioperative death was defined as mortality within 30 days of operation. Results Sixty consecutive patients (32 men, 62±9 years) underwent valve surgery between 1986 and 2019, of whom 59/60 had an intestinal carcinoid disease with hepatic metastases. Mean time from diagnosis to heart surgery was 3.8±3.7 years. Preoperatively, 6 patients were in NYHA class I/II, the others were in class III or IV. All 60 surgical procedures involved tricuspid valve replacement (TVR). In 47 cases, the pulmonary valve was treated surgically: Early in the series, five patients underwent pulmonary valvotomy or commissurotomy, and more recently, 42 patients received pulmonary valve replacement (PVR). All valves were replaced with bioprostheses, except for one pulmonary homograft. Concomitant significant aortic and mitral regurgitation occurred in 2 patients who received quadruple valve replacement. Two re-operations were performed due to degeneration of bioprostheses. Mean hospital stay was 13±9 days. Overall 30-day mortality was 11.6% (n=7) but was reduced to 8.3% in the last decade. The overall median survival was 2.2 years. Maximal survival free of reoperation was 18 years, and maximal survival for a single patient was 21 years. Median survival for combined TVR and PVR was significantly better than for single TVR or TVR combined with pulmonary valvotomy (3.0 years vs. 0.94 years, respectively, p=0.02; see Figure). Preoperatively, left ventricular ejection fraction (EF) was normal in 83%. Severe tricuspid regurgitation was always present. The right ventricle (RV) was dilated (RVD1 49 mm ± 5 mm) as well as the right atrium (60±16 ml/m2). The TAPSE was in normal range (17 to 29 mm). Pulmonary regurgitation was mild, moderate, severe, or indeterminate in 6%, 26%, 51%, and 17% respectively. In 17% the transpulmonary velocity was &amp;gt;2.5 m/s, indicating stenosis. On last available postoperative echo (mean time 2.1 years) EF was found unchanged. RV diameter was nearly normalized (RVD1 41 mm ± 5 mm). TAPSE was reduced (12 mm ± 4 mm). No significant regurgitation was detected in any TVR. There was significant stenosis (mean gradient &amp;gt;5 mmHg) in 23% of the TVR. No regurgitation of significance was detected in any PVR. A mean gradient &amp;gt;20 mmHg was found in 11% of the PVR. Conclusions While perioperative risk of valve replacement in CaHD remains substantial, this study shows relatively favourable outcomes of surgical valve replacement with bioprostheses. PVR together with TVR had better outcomes than those undergoing TVR only. Figure. Survival by Surgical Treatment. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Department of Medical Sciences, Uppsala University. Department of Surgical Sciences, Uppsala University

Aortic regurgitation is not created equal: outcomes of bicuspid versus tricuspid aortic valve regurgitation

Abstract Background Bicuspid aortic valve (BAV) is an important cause of AR; these patients belong to a young and male predominant population and are distinctively different from tricuspid aortic valve (TAV). However, the differences between BAV and TAV in AR have not been completely explored. Purpose To explore differences between patients with BAV and TAV in hemodynamically significant aortic regurgitation (AR). Methods Consecutive patients with ≥moderate-severe AR were retrospectively identified from 2006 to 2017. Results Of 798 patients (502 with TAV, mean age 67±14 years; 296 with BAV, mean age 46±14 years) followed for 6.1±3.6 years, 403 underwent AV surgery (AVS); 154 died during follow-up. BAV men (94%) tended to become symptomatic when left ventricle enlarged; TAV patients became symptomatic before left ventricular (LV) enlargement. During follow-up, BAV patients had lower mortality (hazard ratio [HR], 0.19; P&amp;lt;0.0001) and higher incidence of AVS (HR, 1.28; P=0.01) than TAV, which attenuated after adjusted on age, sex, comorbidities, LV ejection fraction (LVEF), functional class, and time-dependent AVS. In a propensity-matched cohort, differences of survival and incidence of AVS between BAV and TAV were not demonstrated. After a median of 6.3 (IQR: 3.3–9.3) years, 53 patients died post-AVS; TAV patients having class I surgical triggers had poor survival than TAV-non-class I patients and BAV patients with and without class I triggers (Figure). Class I triggers had no effect on BAV patients regarding post-AVS survival. LVEF&amp;lt;60% was associated with increased mortality in both TAV and BAV. Conclusions The correlation between larger LV size and symptomatic status only applied in BAV men. Patients with BAV and significant AR tended to have better survival and higher incidence of AVS, likely driven by inherent younger age and less comorbidity than patients with TAV. Class I surgical triggers had heavier negative impact on poor survival in TAV patients. The cutoff of LV dysfunction in AR may be LVEF 60%. Figure 1. Kaplan-Meier curves post-AVS Funding Acknowledgement Type of funding source: None

Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation

ObjectiveTo comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR).MethodsConsecutive patients with chronic ≥moderate-severe AR from a...

Long-term outcome of percutaneous balloon aortic valvuloplasty for children with congenital aortic valve stenosis

Objective: To assess the efficacy and long-term outcome of percutaneous balloon aortic valvuloplasty (PBAV) for children with congenital aortic stenosis (CAS) and to explore risk factors for significant aortic regurgitation (AR) and reintervention after PBAV during follow up. Methods: This was a retrospective study. Children (≤18 years old) with CAS, who underwent PBAV in Guangdong Provincial Hospital from January 2004 to December 2018, were included in this study. Demographic, preoperative transthoracic echocardiography (TTE) and surgical data were collected. Postoperative complications were closely observed, and the patients were followed up at 1, 6, 12 months after the operation, and then at one year interval thereafter. Endpoint events included significant AR and reintervention. Reintervention was defined as any intervention that needed to be performed on the valve for various reasons, including re-PBAV, surgical valvuloplasty and valve replacement. Significant AR was defined as AR grade≥3 by TTE criteria. The results of the last TTE examination before the end of the study were collected. The Kaplan-Meier curve for long-term AR-free and intervention-free survival was plotted. Cox regression model was used to further analyze the risk factors for significant AR and reintervention after PBAV in CAS patients. Results: A total of 55 patients were enrolled in this study, and the age was 4.6(1.6, 6.5) years, with 37(67.3%) males. The peak systolic valve gradient fell from (80.3±30.6)mmHg to (38.5±18.5)mmHg(P<0.001, 1 mmHg=0.133 kPa). Surgical success rate was 89% (49/55). Acute post-PBAV AR occurred in 18 patients, including 3 patients with RA≥3 grade. In-hospital complications occurred in 6 patients (2 deaths, 2 cases of transient arrhythmia, and 2 cases of femoral artery embolization). Fifty patients accomplished the follow-up and the follow-up time was 6.2(3.4, 8.5) years. Significant AR was found in 20 patients. Significant AR-free survival rate was 53% at 5 years and 19% at 10 years. Reintervention was performed in 11 patients (4 with valvuloplasty and 7 with valve replacement), and the 5-year and 10-year intervention-free survival rates were 87% and 62%, respectively. Multivariate Cox regression analysis showed that acute post-PBAV AR was a risk factor for long-term significant AR (HR=2.398, 95%CI 1.007-5.712, P=0.048). Post-PBAV residual pressure gradient ≥ 35 mmHg (HR=4.747, 95%CI 1.116-19.329, P=0.030)and acute post-PBAV AR (HR=5.104, 95%CI 1.083-24.065, P=0.039)were risk factors for re-intervention. Conclusions: PBAV is safe and effective in the treatment of CAS in children, but attention should be paid on significant AR post procedure. Acute post-PBAV AR is a risk factor for re-intervention and significant AR post PBAV, and high post-PBAV residual pressure gradient is a risk factor for re-intervention.

Clinical implications of exercise-induced regional wall motion abnormalities in significant aortic regurgitation.

Significant aortic regurgitation (AR) is sometimes accompanied by regional wall motion abnormalities (RWMA) during exercise stress echocardiography. The aim of this study was to estimate the association between RWMA after exercise and in the presence of significant AR in patients with coronary artery disease (CAD) or volume overload and to predict the eventual need for aortic valve replacement (AVR). We retrospectively reviewed 182 patients with significant AR who underwent exercise echocardiography. In addition, we investigated patients with AR who underwent coronary angiography (CAG) or coronary computed tomography angiography (CCTA) and were diagnosed with CAD. The presence of RWMA after exercise was defined as newly developed RWMA after exercise and included all changes in wall motion. Patients were divided into two groups according to the presence of RWMA after exercise: the RWMA group (n=42) and non-RWMA group (n=140). In the RWMA group, 31 patients (73.8%) underwent coronary artery evaluation by CAG or CCTA. Only two patients in the RWMA group were diagnosed with current CAD and underwent percutaneous coronary intervention. Patients with RWMA were older (61.6±10.8 vs 52.0±13.7years, P<.001), had more severe AR (54.8% vs 32.9%), and underwent AVR more frequently (40.5% vs 14.3%, P=.001) than patients without RWMA. METs (odds ratio [OR], 0.796; P=.019), difference between rest and postexercise left ventricular end-diastolic volume (OR, 0.967; P=.001), and the difference between pre- and postexercise left ventricular end-systolic volume (OR, 1.113; P<.001) were identified as independent factors associated with RWMA after exercise according to multivariable logistic regression analysis. The majority of wall motion changes were seen in the lateral and inferior segments, and the locations of wall motion changes were relatively consistent with the direction of the AR jet. The relationship between RWMA after exercise and time to AVR was investigated by simple linear regression (hazard ratio [HR], 3.402; P<.001). After adjusting for baseline parameters of diastolic blood pressure, left ventricular end-systolic dimension (LVESD), aorta size, deceleration time, and METs, the presence of RWMA after exercise was not predictive of time to AVR (HR, 1.106; P=.81). On the other hand, without forcible entry of RWMA after exercise, LVESD (HR, 1.119; P<.001) and METs (HR, 0.828; P=.006) independently predicted the eventual need for AVR as an outcome. The degree of change in wall motion from rest to exercise in those with significant AR was not correlated with CAD, but was correlated with the severity of volume overload and exercise-induced preload changes, as well as the direction of the AR jet. In addition, RWMA after exercise had no role in predicting the need for AVR.

Transcatheter Aortic Valve Replacement for Residual Lesion of the Aortic Valve Following “Healed” Infective Endocarditis

ObjectivesThis study aimed to evaluate the safety and mid-term efficacy of transcatheter aortic valve replacement (TAVR) in the setting of aortic valve (AV) infective endocarditis (IE) with residual lesion despite successful antibiotic treatment. BackgroundPatients with AV-IE presenting residual lesion despite successful antibiotic treatment are often rejected for cardiac surgery due to high-risk. The use of TAVR following IE is not recommended. MethodsThis was a multicenter retrospective study across 10 centers, gathering baseline, in-hospital, and 1-year follow-up characteristics of patients with healed AV-IE treated with TAVR. Matched comparison according to sex, EuroSCORE, chronic kidney disease, left ventricular function, prosthesis type, and valve-in-valve procedure was performed with a cohort of patients free of prior IE treated with TAVR (46 pairs). ResultsAmong 2,920 patients treated with TAVR, 54 (1.8%) presented with prior AV-IE with residual valvular lesion and healed infection. They had a higher rate of multivalvular disease and greater surgical risk scores. A previous valvular prosthesis was more frequent than a native valve (50% vs. 7.5%; p < 0.001). The in-hospital and 1-year mortality rates were 5.6% and 11.1%, respectively, comparable to the control cohort. After matching, the 1-year III to IV aortic regurgitation rate was 27.9% (vs. 10%; p = 0.08) and was independently associated with higher mortality. There was only 1 case of IE relapse (1.8%); however, 18% of patients were complicated with sepsis, and 43% were readmitted due to heart failure. ConclusionsTAVR is a safe therapeutic alternative for residual valvular lesion after successfully healed AV-IE. At 1-year follow-up, the risk of IE relapse was low and mortality rate did not differ from TAVR patients free of prior IE, but one-fourth presented with significant aortic regurgitation and >50% required re-admission.

Determinants of clinical outcomes in patients with mixed mitral valve disease.

Although significant stenosis and regurgitation can be observed on a single heart valve, studies on the outcome predictors for mixed valve disease are limited. The purpose of the current study was to investigate the fate and determinants of clinical outcomes in patients with mixed single mitral valve disease who have concomitant mitral stenosis (MS) and mitral regurgitation (MR). We retrospectively reviewed 82 consecutive patients with rheumatic heart disease who had both significant MS (MVA≤1.5cm2 ) and at least moderate MR, excluding patients with significant aortic valve stenosis or regurgitation. The primary endpoint was a composite of all-cause mortality during follow-up, mitral valve replacement, heart failure admission, and stroke. There were 37 events (45.1%), 5 all-cause deaths (6.0%), and 32 mitral valve replacements (39.0%). In a multivariable Cox regression analysis, a transmitral mean pressure gradient (TMPG) over 6mmHg was the only independent echocardiographic predictor for events (hazard ratio 3.69, 95% confidential interval 1.31-10.44, P=.014), after adjusting for sex, age, symptoms, and the severity of MS and MR. The estimated 6-year event-free survival rate was significantly lower in patients with TMPG≥6mmHg than in those with TMPG<6mmHg (76.3% vs 22.9%, log-rank P<.001). Transmitral mean pressure gradient, which reflects the hemodynamic burden of the mitral valve lesion, appears to be the most important echocardiographic predictor of clinical outcomes in patients with mixed mitral valve disease.

Transthoracic echocardiography and cardiac biomarkers in healthy captive male and female squirrel monkeys (Saimiri spp.)

BackgroundEchocardiography is the most frequently used non -invasive diagnostic tool to evaluate cardiac anatomy and function in domestic species but increasingly also in non -domestic species, especially since cardiac disease is being recognized as an important cause of death in captive primates. The purpose of this cross -sectional study was to investigate the feasibility of transthoracic echocardiography in healthy squirrel monkeys as well as to provide species specific normal values for standard echocardiographic measurements. A secondary aim was to determine plasma and serum levels of the cardiac biomarkers, N -terminal pro -brain natriuretic peptide (NT -proBNP) and cardiac troponin T (cTnT). Furthermore, a commercial, non -invasive, smartphone -based ECG (AliveCor Vet TM) monitoring device was used to evaluate the heart rate and rhythm and to diagnose possible arrhythmias.ResultsIn this study, transthoracic echocardiography of 14 squirrel monkeys was performed in right and left lateral recumbency. Similar standard right parasternal and left apical images were obtained as in dogs and cats and normal values for routine two -dimensional, time motion mode and Doppler mode measurements were generated. Thirteen animals were considered healthy and one squirrel monkey was identified with significant aortic dilation and regurgitation and consequently values obtained from this animal were not used when species specific normal values were calculated. NT -ProBNP and cTnT concentrations were available for 7 of the 13 healthy monkeys with NT -proBNP concentrations below detection limit in all animals and a mean cTnT concentration of 0.049 ng/mL. Electrocardiography was performed in all squirrel monkeys. The mean heart rate was 172 bpm. Frequent supraventricular premature beats were diagnosed in the squirrel monkey suffering from significant aortic dilation and regurgitation.ConclusionThis study presents echocardiographic normal values and additional cardiovascular data in anaesthetised Saimiri monkeys, fundamental from both the perspective of zoo animal health care as well as scientific research, since the squirrel monkey is often used as an animal model for human disease.

VENTRICULAR SEPTAL DEFECT WITH SEVERE AORTIC REGURGITATION, SUB AORTIC STENOSIS, AORTIC AND PULMONARY ROOTS DILATION IN AN ADULT: A CASE REPORT

A case of 30 years’ male, a farmer by occupation who was a diagnosed case of a ventricular septal defect (VSD) since the age of seven, but refused for surgical closure back then, came in the emergency room (ER) with decompensated congestive cardiac failure and peripheral edema. After initial stabilization, he underwent transthoracic echocardiography (TTE) that showed small perimembranous VSD with the left to right shunt, a subaortic membrane with severe left ventricular outflow tract (LVOT) obstruction and moderate aortic and mitral regurgitation. TTE was followed by Computed Tomography (CT) thoracic aortogram that revealed small VSD with significant aortic regurgitation (AR). Subaortic membrane, aneurysmal dilated aortic root and ascending aorta and aneurysmal dilated pulmonary arteries. Cardiac surgeons were taken onboard and advised for VSD closure with aortic valve replacement, subaortic membrane resection and aortic root replacement. Patient and family were counseled regarding the procedure but refused again for surgical closure. Key Words: ​Ventricular Septal Defect, Aortic Regurgitation, Subaortic Membrane, Pulmonary Roots Dilation, Adult

Thromboembolic Events in Patients with Concomitant Aortic Valve Surgery and Left Ventricular Assist Device Implantation, an IMACS Database Analysis

Patients with significant aortic regurgitation at time of left ventricular assist device (LVAD) implantation, frequently need concomitant aortic valve (AV) replacement (AVR) or AV repair. The aim of this study was to investigate the risk for thromboembolic events (TE) in patients with concomitant continuous-flow LVAD and AV surgery. We used the international multicenter registry data from the International Society of Heart and Lung Transplantation Mechanically Assisted Circulation Support (IMACS) registry of LVAD patients, implanted between January 2013 until September 2017. Differences between AVR, AV repair and non-AVR/repair patients were analyzed. In total, 785 (5.1%) out of the total 15267 patients (mean age 56±13 years, 79% male) received concomitant AVR/repair during LVAD surgery (mean age 60±11 years, 89% male); 386(2.5%) patients had biological prosthesis, 71 (0.5%) mechanical prosthesis and 328 (2.1%) AV repair. Follow-up was complete in 644 out of 785 (82%) patients, with a median follow-up of 11.8 months [IQR 4.8-23.4]. In total, TE occurred in 3135 cases; 2976 out of 12317 (24%) in patients without AV surgery, 73 out of 316 (23%) with a biological prosthesis, 73 out of 267 (27%) with an AV repair, and 13 out of 61 (21%) with mechanical prosthesis. The Figure shows that early (90-day) post LVAD, TE rate was significantly higher in the mechanical prosthesis group compared to the remaining cohort. However, at 2-years of follow-up, none of the concomitant surgery modalities were associated with higher TE rates. In patients treated with concomitant AVR or AV repair during LVAD surgery, a significant higher rate of early TE's was found in the mechanical prosthesis group. However, after 2-year follow-up, this differences was no longer significant. Caution in the early postoperative period is warranted when concomitant mechanical prosthesis is scheduled.

Minimally Invasive Redo Aortic Valve Replacement: Results From a Multicentric Registry (SURD-IR)

Reoperation for aortic valve replacement can be challenging and is usually associated with an increased risk for complications and mortality. The study aim was to report the results of a multicenter cohort of patients who underwent minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis. From 2007 to 2018 data from 3651 patients were retrospectively collected from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry. Of them, 63 patients who had previously undergone cardiac surgery represented the study population. In-hospital clinical and echocardiographic outcomes were recorded. Mean age of the selected 63 patients was 75.3 ± 7.8 years and logistic EuroSCORE 10.1. Surgery was performed by ministernotomy in 43 patients (68.3%) and by anterior right thoracotomy in 20 (31.7%); 31 patients (49.2%) received the Perceval valve (Livanova PLC, London, UK) and 32 (50.8%) the Intuity valve (Edwards Lifesciences, Irvine, CA). Mean cross-clamp time was 57.8± 23.2 minutes and cardiopulmonary bypass time 95.0±34.3 minutes. Neither conversion to full sternotomy nor in-hospital deaths occurred. Postoperative events were ischemic cerebral events in 3 patients (4.8%), need for pacemaker implantation in 2 (3.6%), bleeding requiring reoperation in 5(8.9%), and dialysis in 1 (1.6%). Median intensive care unitstay was 1 day, and median length of hospital stay was 10 days. On echocardiographic evaluation 1 patient showed a significant postoperative aortic regurgitation. Minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis is a safe and feasible treatment strategy, resulting in fast recovery and improved postoperative outcome with no mortality and an acceptable complication rate.

P1598 Ruptured Sinus of Valsalva: clinical and echocardiographic features at presentation and long-term results after surgical and percutaneous repair

Abstract Background Rupture of Sinus of Valsalva (rSOV) is a rare and potentially life-threatening condition often misdiagnosed. Percutaneous device closure has been replacing surgical repair as a treatment of choice. However, long-term outcome is poorly documented. Methods Echo database (2001-2019) was searched for patients &amp;gt;16y with rSOV. Clinical data were collected from ACHD database. Marfan Syndrome patients were excluded. Results Fifteen patients (42.2y, 10M) were diagnosed with rSOVbetween 1979 and 2019. HF symptoms at initial presentation were reported in 50%. All cases were diagnosed by TTE with finding of high velocity continuous flow from SOV to right heart. Two were initially misdiagnosed as VSD. Digital imaging recordings of 10/15 were available. The aortic root was dilated in 8/10. Four had asymmetrical SOV dilatation. LV and LA were dilated in 7/10 and 9/10. Significant aortic regurgitation was in 4. Two had RVOTO. RVSP was always raised. Echo findings are summarised in the Table. Mean FU after repair was 10,7y (0,9-39). Ten patients had surgical repair and 5 device closure. Seven had repair of concomitant lesions (4 VSD closure and 3 AVR) at the time of the procedure. One redo device closure was performed. During FU 1 died from Cardiomyopathy. At the latest FU significant improvement in functional class, LV and LA size and RVSP was found. Conclusion Patients with rSOV may present with acute HF. High velocity continuous flow from SOV to right heart on TTE is characteristic feature for diagnosis. Percutaneous closure is an attractive alternative to surgery in patients with isolated lesion. Significant haemodynamic improvement can be achieved with good long-term haemodynamic results Tot = 15 Initial findings Latest FU NYHA class 4 class I 2 class II 2 class III 4 class IV 3 unknown 11 class I 2 class II 1 class III 0 class IV* SOV (mm) 38.2 (33-44) STJ (mm) 36.2 (26-42 Asc Ao (mm) 30.3 (25-34) rupture site 8 RC sinus, 2 NC sinus Shunt to 8 RVOT, 1 RA, 1 RVOT + RA LVEDV (ml) 169.7 (114-330) 120 (67-230)* LVESV (ml) 66(42-130) 46 (28-80)* LAVi (ml/m2) 53.1 (30-129) 35 (24-53)* LV EF% 61.2 (57-65) 60.4 (50-70) RVSP (mmHg) 53.2 (37-130) 24.06 (15-32)** Pre VS post procedure p-value: * P &amp;lt; 0,05 **P &amp;lt; 0,01 Abstract P1598 Figure. PLAX in patient with ruptured RC sinus

P705 Is chest wall deformity a serious issue? A rare case of TGFBR1 mutation in the paediatric population

Abstract INTRODUCTION Mutations in the genes encoding transforming growth factor β receptors 1 and 2 (TGFBR1 and TGFBR2) have recently been found in association with a continuum of clinical features. Mild association – a presentation similar to that of Marfan"s syndrome. Severe association – a complex phenotype in which aortic dissection or rupture commonly occurs in childhood and at aortic diameters, that ordinarily would not be predictive of these events. Classified as the Loeys–Dietz syndrome. Is chest wall asymmetry a serious issue? A study of 71 patients with Loeys-Dietz – 9% died from aneurysm rupture or dissection with aortic diameters of less than 4.5cm and as early as 6 months of age. Genetic variants of unknown clinical significance - how should they be managed? CASE History 3-year old girl seen in general paediatric clinic with 5 months history of worsening chest wall deformity. Examination Asymmetrical pectus deformity. Spinal asymmetry and soft systolic murmur at the lower left sternal edge. INVESTIGATION Chest x-ray: Grossly enlarged and distorted cardiac/mediastinal silhouette. Echocardiogram Massive ascending aortic root dilatation (5.5cm) with significant aortic regurgitation. MRI whole body angiogram Massively dilated aortic root and ascending aorta to the proximal arch, hugely tortuous and ectatic cerebral vessels, diffuse marked dural ectasia, asymmetrical pectus deformity and a diaphragmatic morgagni hernia in the lower right hemi thorax. Genetic analysis Heterozygous missense variant of unknown clinical significance in exon 3 of TGFBR1 gene. The first heterozygous missense variant of its kind in the paediatric population for which its clinical significance remains unknown. TREATMENT As risk of dissection, a Bentall procedure was performed. Family screening - Father has a dilated proximal ascending aorta. LEARNING POINTS Chest wall deformity should prompt clinicians to expedite investigations for aortic root dilatation/aneurysm and connective tissue disorders. The continuum of clinical features of these genetic associations emphasises the importance of early recognition of the phenotype, prophylactic intervention and meticulous surveillance of the distal aorta and vascular tree for optimal management. A genetic variant of uncertain significance (VUS) should not be used in clinical decision making. Efforts to resolve the classification of the variant as pathogenic or benign should be undertaken with good working relationships with clinical geneticists. A VUS is difficult for patients and parents to understand and may also cause psychological distress. The importance of careful clinical and molecular characterisation to identify patients and families at risk cannot be overemphasised. This allows the use of a structured approach to intervention, informed counselling regarding the risk of recurrence, concerns related to pregnancy, and guidelines for clinical management. Abstract P705 Figure. Case Photography and Imaging

P700 TEE guidance of percutaneous closure the inlet and exit of ascending aorta pseudoaneurysm in a patient had triple valve replacement

Abstract Funding Acknowledgements none OnBehalf none Introduction Surgical treatment of ascending aortic pseudoaneurysms (AAPA) that develop following cardiac surgery carries significant morbidity and mortality. However, there are emerging reports of transcatheter closure of AAPA. To the best of our knowledge, this is the first reported case where the APA communicates with the left ventricle (LV) cavity with significant diastolic volume overload mimic severe aortic regurgitation. We added to the complications of APA, a fistulous communication with LV causing severe volume overload and heart failure. Case description: Thirty-two years old female underwent mechanical aortic and mitral valve replacement and bioprosthetic tricuspid valve replacement in April 2013. At October 2016, she started to have progressive shortness of breath. TEE revealed large ascending aorta pseudoaneurysm that communicates with LV cavity. Cardiac computed tomography (CT) with contrast revealed a sizeable noncoronary sinus of Valsalva pseudoaneurysm 47mm x 39mm. Surgical excision of the aneurysm decided, but the patient refused any surgical procedure. Percutaneous closure of the inlet and exit of the aneurysm discussed and accepted by the patient. The procedure of transcatheter aneurysm device closure performed successfully with TEE guidance (Figure). A: showed the aneurysm exit to the LV while D: showed its inlet from the aorta. The wire passed the aneurysm inlet at ascending aorta to its outlet in the LV (B). Six mm VSD device deployed closing the aneurysm exit to LV (C). Another 6mm VSD device deployed closing the aneurysm inlet (E). Transgastric long axis aorta view showed no more flow to LV. Midessophageal Short axis view showed no flow between ascending aorta and the aneurysm. Fluoroscopy injection inside the aneurysm (F), another two devices left inside the aneurysm (G). The patient was observed in the cardiac care unit (CCU) for two days, then discharged home in good condition. She was followed in the outpatient clinic after two weeks, and she is doing well with no more shortness of breath. Follow up echo after one year of the procedure showed a small remaining flow from the aneurysmal cavity to the left ventricle. (H and K) compares apical three-chamber view before and one year after closure. Discussion: Preprocedural CT and Intraprocedural TEE are mandatory in determining the size and location of AAPA. Also, the type and size of suitable devices for closure. Overall, the success rate for percutaneous closure is 80%, with a 12% device embolization rate and an 8% failure rate of the transcatheter technique to close the pseudoaneurysm, necessitating conversion to surgical closure. In most reported cases the AAPA had only communication with the aorta. In our case, the AAPA also communicates with the LV cavity that requires the closure of both communications. Conclusion: Percutaneous closure of the inlet and exit of AAPA with TEE guidance is feasible. Long term follow up is required in a large number of patients. Abstract P700 Figure: AAPA device closure

P838 Accessory Mitral Valve Tissue in a 35-year-ol female with Significant Left Ventricular Outflow Tract Obstruction and Aortic regurgitation

Abstract Accessory mitral valve tissue (AMVT) causing left ventricular outflow tract (LVOT) obstruction and aortic regurgitation is a rare congenital cardiac malformation.The true prevalence is not well known but latest literature review identified 104 cases of AMVT from 1963 to 2013. We present a case of asymptomatic 35-year-old female who came in due to heart murmur. Chest X-ray showed a right-sided aorta and a dilated ascending aorta. An echocardiographic finding of a mobile serpiginous AMVT that parachutes into LVOT with significant gradient of 74 mmhg. There was mild restriction of the aortic right coronary cusp with moderate aortic regurgitation and other finding noted of persistent left superior vena cava. The patient underwent open heart surgery and had an excision of the AMVT and subcommissuroplasty of the right coronary cusp. Histological analysis of the excised specimen showed fragments of valvular tissue with fibrosis. There was no obstruction on repeat echo with mild aortic regurgitation. No postoperative complication noted and was discharged stable. AMVT usually seen among young patients and it is uncommon among female adult population. LVOT obstruction and aortic regurgitation may caused by the AMVT. Echocardiography is an important modality in diagnosing and recognising such anomaly and the optimal treatment is surgery in the presence of significant LVOT obstruction. Abstract P838 Figure. Intraoperative findings

Diastolic Blood Pressure and Heart Rate Are Independently Associated With Mortality in Chronic Aortic Regurgitation

BackgroundThe prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown. ObjectivesThis study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR. MethodsConsecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined. ResultsOf 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm. ConclusionsIn patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients.

Factors determining the nature of progression of discrete fixed subaortic stenosis

In discrete fixed subaortic stenosis, surgery is indicated when the systolic gradient (Gmax) between the left ventricle (LV) and the aorta exceed 50 mmHg or in the presence of significant aortic regurgitation (AR). The aim of this study was to determine the factors that influence the progression of the obstruction and the appearance of AR. Retrospective serial echocardiographic review of 19 patients, mean age 16 years (2 years–38 years), with fixed discrete subaortic stenosis that did not require surgery (initial Gmax at inclusion < 50 mmHg and without any symptom). The mean follow up was 5.42 years. The progression of gradient is defined by the formula (Gmax at follow up–initial Gmax). The mean velocity of increasing of Gmax was 2 mmHg/year. This progression was correlated to the patient's age (cut off = 15 years, r = −0.5 P = 0.02), and the initial value of the Gmax (cut off = 40 mmHg, r = 0.43, P = 0.04). The appearance or the aggravation of aortic regurgitation was determined by: the initial grade of AR ( r = 0.64; P = 0.003), initial Gmax ( r = 0.65; P = 0.002), progression's velocity of G max ( r = 0.47; P = 0.04), and distance between the membrane and the aortic cusps (cut off = 5 mm, r = 0.49; P = 0.03). LV hypertrophy was influenced by the velocity of progression of obstruction (> 2 mmHg/year). The identification of factors determining the evolution of discrete subaortic stenosis (age < 15 years, initial Gmax > 40 mmHg, distance membrane- cusps > 5 mm) allow an adequate screening of patients that will require early operation.