Treatment Of Aortic Regurgitation Research Articles

Factors Impacting Leaflet Coaptation and Durability in Prosthetic Heart Valves

The treatment of Aortic regurgitation using TAVR has not met with excellent outcomes that TAVR did with Aortic stenosis treatment due to differences in patient anatomies, and manifestation of the disease at the native valve annulus. With exception of JenaValve device which relies on proprietary clipping mechanism to anchor the valve, off-label use of TAVR devices that are otherwise indicated for use only to treat AS disease, relied on valve-in-valve for anchoring to prevent paravalvular leakage and valve embolization. The under-expansion of the inside valve due to stiffness and geometry of the outside valve has an impact on leaflet coaptation leading to additional stresses on the leaflets and decreased durability. This article explores the stent frame and leaflet design considerations and their impact on valve durability in AR patient anatomies that rely predominantly on valve-in-valve configuration for anchoring.

TAVI en IA pura de válvula nativa: cuando indicaciones fuera de guías cumplen los requerimientos del paciente

In recent years, transcatheter aortic valve replace (TAVR) has revolutionized the interventional treatment of aortic stenosis, however, only scarce evidence considers it as treatment for Aortic Regurgitation (AR). At present, the treatment of Pure AR of Native Valve with TAVR does not fall within the recommendations of international guidelines, as it poses multiple challenges with immediate and long-term variable and unpredictable results. The objective of this paper is to present the case of a patient with prohibitive operative risk that benefited of TAVR treatment for AR. We present the case of a 79-year-old male patient who has severe Pure Native Aortic Valve Regurgitation, considered inoperable. Based on the heart team's decision, TAVR was planned with the use of an Edwards SAPIEN 3 valve. After TAVR, the patient developed complete heart block and a pacemaker was implanted. He improved to NYHA II functional class. At 15-month follow-up, he suffered intracranial hemorrhage and passed away. Management of patients with severe symptomatic AR with high surgical risk continues to be a special challenge. They have high mortality if left untreated with valvular change, despite medical treatment. Even though it is strictly off-label, TAVR might be a reasonable solution for a select type of patients who are considered inoperable due to surgical high mortality risk.

Abstract 14337: Cardiac Computed Tomography for Preoperative Assessment of Valve Morphology in Aortic Valve Repair

Introduction: A pre-operative assessment of aortic valve anatomy is important in valve repair for aortic regurgitation (AR). Although echocardiogram provides precise information, clear visualization of entire aortic valve and accurate quantification of valve geometry are limited even with 3D transesophageal echocardiography. In this study, usefulness of cardiac computed tomography (CT) in the evaluation of aortic valve pathology was investigated. Methods: A total of 119 patients who underwent surgical treatment for severe AR from May 2016 to July 2021 and had preoperative CT were studied. From the CT data set, volume rendering movie image was reconstructed to visualize valve anatomy. Effective height (EH) and geometric height (GH) were measured by CT in diastole and compared to intraoperative measurements. Results: The quality of CT image was satisfactory in 100 patients (84%), acceptable in 17 patients (14%) and suboptimal in 2 patients (2%). CT could visualize such detailed anatomy as shown in the Figure. EH in 41 patients and GH in 67 were measured by both CT and surgery. The measurements showed a correlation in EH (r=0.79, p<0.0001) and in GH (r=0.74, p<0.0001) with minimal bias of -1.6 mm in EH and 0.4 mm in GH and narrow limits of agreement from -5.9 to2.6 mm in EH and from -3.7 to 4.6 mm in GH. Inter- observer variabilities in CT measurement of EH and GH were 3.8±2.9% and 2.6±1.8%, with interclass correlation coefficients of 0.997 and 0.980, respectively. Conclusions: Reproducibility of CT measurement was excellent, while there was a little discrepancy between CT and surgical measurement. Not all cases underwent intraoperative measurement, and cases with structurally complexity tended to have surgical measurement. Some errors may be included in also intraoperative measurements. CT feasibly visualized aortic valve en-face view with showing the etiology of AR, which gave useful information to surgeons who perform aortic valve repair.

Current trends in aortic valve-preserving surgery.

The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.

Risk factors for recurrence of aortic regurgitation after aortic valve repair.

In the past decade, the treatment of aortic regurgitation has evolved from a strategy focused mainly on valve replacement to one of valve repair (AVr). Nevertheless, AVr has yet to gain broad acceptance within the surgical community despite excellent reported results in selected centers. In fact, AVr failure due to recurrence of regurgitation remains a challenge. Thanks to sustained research efforts, the mechanisms underlying aortic valve repair failure are now better understood. The aim of this article is to discuss the risk factors for recurrent AR after valve repair, the technical strategies that can mitigate this risk and highlight the contemporary results associated with AVr.

Aortic Regurgitation.

Aortic regurgitation (AR) is a common form of valvular disease which is characterized by reflux of blood from the aorta into the left ventricle (LV) during diastole. AR results from various etiologies, affecting the aortic valve cusps or the aortic root. The clinical presentation of patients with AR depends on the severity of the regurgitation and differs whether AR develops acutely or if it progresses over a prolonged period, allowing the cardiac chambers to adapt. Echocardiography is the primary method to determine the etiology of AR and to define its severity. We review the current data regarding the diagnosis and treatment of AR. No single parameter is sufficient to determine AR severity; thus, an integrative, multi-parametric approach is required. Echocardiography is key for imaging the aortic valve morphology and flow as well as aortic root and ascending aorta. Determining LV ejection fraction and dimensions is essential for patient management and optimizing timing for intervention. Three-dimensional (3D) echocardiography is useful in the evaluation of AR etiology and severity. The use of Trasncatheter aortic valve replacement (TAVR) has emerged as an alternative to surgery in patients at high operative risk. The diagnosis and management of AR requires a comprehensive approach and routine clinical and echocardiographic follow-up. Surgical or percutaneous therapy is indicated when symptoms develop and in those who have LV dysfunction or LV dilation.

Aortic Valvuloplasty or Rootplasty for Aortic Regurgitation.

At present, aortic valvuloplasty is considered an effective procedure for treatment of aortic regurgitation in pediatric patients. It has encouraging mid- and long-term results. The improved outcome is primarily related to better understanding of the functional anatomy of the normal valve and the different factors that alter it. It is also related to the realization that outcome after valvuloplasty is dependent on comprehensive repair of all of the involved components of the aortic root. Refinement in preoperative diagnosis has helped identify these abnormal components and focus the surgical approach on the needed reconstruction. Although the technical aspects of valvuloplasty are well defined, suboptimal long-term results still occur in some cases because the patch material used for valve repair can become fibrotic or calcified. This review summarizes the surgical approach to and the management of the different abnormal root components in pediatric patients with significant aortic valve regurgitation.

Off-Pump Semicircular Annuloplasty: Effective Treatment of Concurrent Moderate Aortic Regurgitation

The treatment of aortic regurgitation (AR) in patients undergoing off-pump coronary artery bypass grafting (CABG) is a difficult problem. Aortic valve repair has become a promising therapy for AR. Various annuloplasty approaches have been used and have gained satisfactoryresults. Thus we adopted off-pump semicircular annuloplasty to treat concurrent moderate AR in 12 high-risk patients. Early follow-up results showed that this way is simple, safe, and effective.

Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation.

The management of patients with asymptomatic severe aortic regurgitation (AR) remains controversial. The aim of the present study was to assess and compare the clinical results between early surgery and conventional treatment for asymptomatic severe AR in patients with normal left ventricular (LV) systolic function and LV dilatation. This retrospective cohort study included 230 consecutive patients with severe AR with left ventricular ejection function (LVEF ≥50%) and left ventricular end-diastolic dimension (LVEDD >70 mm) from 2003 to 2014. A total of 154 patients received early aortic valve replacement (AVR), whereas 76 patients received conventional treatment at the discretion of the surgeon. Overall and cardiovascular survival rates were evaluated between 2 groups with propensity score analysis. The patients had a mean age of 54.3 ± 14.1 years; 60.4% were men. Mean LVEF and LVEDD were 58.3 ± 7.7% and 75.3 ± 5.2 mm, respectively. Kaplan-Meier analysis revealed that early AVR was associated with better 10-year cardiovascular ( P = 0.037) survivals in the overall population. In the 62 propensity score-matched pairs, early AVR was still associated with a significantly better 10-year overall survival ( P = 0.018). Furthermore, patients who underwent early AVR had significantly improved 3-, 5- and 10-year cardiovascular survival rates of 98.3, 96.2 and 93.6%, respectively, compared with 93.5, 88.3 and 80.0% for those in the conventional treatment group ( P = 0.008). Compared with conservative management, early AVR is associated with an improved long-term outcome in patients with asymptomatic severe AR with LVEF ≥50% and LVEDD >70 mm. These data provide new evidence to strongly support current guidelines, which recommend a strategy of early operative intervention.

Transcatheter Aortic Valve Replacement for the Treatment of Pure Native AorticValve Regurgitation: A Systematic Review.

This study sought to summarize available evidence on transcatheter aortic valve replacement (TAVR) for the treatment of native pure aortic regurgitation (AR). Surgical aortic valve replacement (SAVR) is the gold standard for the treatment of AR. However, case series of high-risk patients undergoing TAVR for native pure AR were reported. We systematically searched Medline, Embase, and Scopus for reports of at least 5 patients with native pure AR undergoing TAVR. Patients' and procedural characteristics were summarized. The primary outcome of interest was all-cause mortality. Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO (CRD42016038422). Thirteen reports including 237 patients were included in the analysis. Self-expandable prostheses were used in 79% of patients, whereas 21% of the patients were treated with a balloon-expandable valve. Device success ranged between 74% and 100%. Seventeen patients (7%) required the implantation of a second valve. Conversion to SAVR wasreported in 6 (2.5%) cases. The rate of all-cause mortality at 30 days amounted to 7% (95% confidence interval [CI]: 3%to13%; I2= 37%). Cerebrovascular events were rare (0%, 95% CI: 0% to 1%; I2= 0); major bleeding and vascular complications occurred in 2% (95% CI: 0% to 7%; I2= 41%), and 3% (95% CI: 1% to 7%; I2= 0%), respectively. Permanent pacemaker implantation was required in 11% of patients (95% CI: 5% to 19%; I2= 50%). The rate of moderate or severe post-procedural ARamounted to 9% (95% CI: 0% to 28%; I2= 90%). Among selected patients with native pure AR deemed at high risk for SAVR, TAVR is technically feasibleand associated with an acceptable risk of early mortality.

Severity of Preoperative Aortic Regurgitation Does Not Impact Valve Durability of Aortic Valve Repair Following the David V Valve Sparing Aortic Root Replacement

The David V valve-sparing aortic root replacement (VSRR) is an established and durable method of root reconstruction for varying pathologies. However, the impact of the severity of preoperative aortic regurgitation (AR) on long-term durability remains unclear. The purpose of this research was to investigate the impact of the degree of preoperative AR on midterm durability following VSRR. A retrospective review of the adult cardiac surgical database at a single academic center was undertaken from 2005 to 2015 for 223 adult patients who underwent VSRR. Patients were followed annually with echocardiograms, and a prospectively maintained database kept track of patient data. Follow-up was 97.7% complete, and the median echocardiographic follow-up was 25.5 months (range, 1 to 123 months). Patients with preoperative AR less than or equal to 2 were compared with patients with AR greater than 2 to determine the impact of preoperative AR upon valve repair durability. There were 223 patients who underwent VSRR during the study period, including 114 (51.1%) who required concomitant cusp repair. The operative mortality was 5 (2.2%). Ninety-seven patients (43.5%) had preoperative AR greater than 2. A total of 213 patients (95.5%) were available for long-term follow-up; of these patients, 7(3.3%) had AR greater than 2. Fifty-two patients had a bicuspid aortic valve (22 AR ≤2 and 30 AR >2; p= 0.02). Patients with preoperative AR greater than 2 experienced greater reverse left ventricular remodeling and increases in left ventricular ejection fraction than did patients with preoperative AR less than or equal to 2 (p < 0.01). The midterm freedom from AR greater than 2 was similar for both preoperative AR groups (p= 0.57). The 8-year freedom from AR greater than 2 was 89.1% (95% confidence interval, 55.3% to 97.8%) for patients with preoperative AR less than or equal to 2 and 92.7% (95% confidence interval, 78.8% to 97.6%) for preoperative AR greater than 2. Five patients (2.4%) required aortic valve replacement during the follow-up period (3 preoperative AR ≤2, 2 preoperative AR >2). VSRR remains an effective and durable treatment for severe AR and preserved leaflet architecture. The severity of preoperative AR does not appear to impact midterm freedom from moderate to severe AR. VSRR results in significant left ventricular remodeling in patients with preoperative AR greater than2.

Transfemoral Implantation of a Fully Repositionable and Retrievable Transcatheter Valve for Noncalcified Pure Aortic Regurgitation

This study sought to evaluate the use of the Direct Flow Medical (DFM) transcatheter heart valve (Direct Flow Medical, Santa Rosa, California) for the treatment of noncalcific pure aortic regurgitation (AR). The treatment of noncalcific AR has remained a relative contraindication with transcatheter heart valves due to challenges in anchoring devices in the absence of calcium, concerns of valve embolization, and the high risk of significant residual paravalvular leak. The study population consisted of patients treated for severe noncalcific pure AR with transfemoral implantation of a DFM transcatheter heart valve at 6 European centers. The primary endpoint was the composite endpoint of device success and the secondary endpoint was the composite early safety endpoint (according to the VARC-2 criteria). Eleven high-risk (STS score 8.84 ± 8.9, Logistic EuroSCORE 19.9 ± 7.1) patients (mean age 74.7 ± 12.9 years) were included. Device success was achieved in all patients. In 1 patient, the initial valve prosthesis was retrieved after pull-through, and a second valve was successfully deployed. The early safety endpoint was reached in 91% of the patients, with 1 patient requiring surgical aortic valve replacement secondary to downward dislocation of the prosthesis that was successfully managed with surgical aortic valve replacement. DFM implantation resulted in excellent hemodynamics with none or trivial paravalvular regurgitation in 9 patients and a transprosthetic gradient of 7.7 ± 5.1 mm Hg at 30-day follow up. All patients derived symptomatic benefit following the procedure, with 72% in New York Heart Association functional class I or II. This study reports the feasibility of treating severe noncalcific AR with the Direct Flow prosthesis via the transfemoral route.

Transcatheter aortic valve implantation of a second-generation valve for pure aortic regurgitation: procedural outcome, haemodynamic data and follow-up

The second-generation Jenavalve prosthesis (Jenavalve Technology, Inc., Munich, Germany) is the first transcatheter valve Conformité Européene (CE) marked for treatment of both aortic stenosis (AS) and pure aortic regurgitation (AR). Although the feasibility of the Jenavalve transcatheter aortic valve implantation (TAVI) in patients with pure AR has been described, haemodynamic and follow-up data are lacking. We report on a series of 10 transapical Jenavalve implantations for pure AR between December 2012 and September 2013. The patients were determined for TAVI by heart team decision at high surgical risk [log EuroSCORE (European System for Cardiac Operative Risk Evaluation) >20%], frailty or Charlson Comorbidity Index (CCI). Transaortic gradients and right heart haemodynamics were measured invasively before and after TAVI. Ventriculography and transoesophageal echocardiography were used to determine paravalvular regurgitation. All-cause mortality, NYHA functional class and echocardiographic measurements were followed up at 30 days and at 3, 9 and 12 months postoperatively. Overall, mean age was 79 ± 9 years, mean left ventricular ejection fraction 50 ± 17% and mean log EuroSCORE 28.3 ± 17.1%. There were no perioperative complications. Paravalvular regurgitation immediately after implantation was graded none (n = 6), trace (n = 3) or mild (n = 1). Overall 30-day mortality was 30% (3/10). Three patients refused further treatment, such as haemodialysis or treatment of mitral regurgitation. Rate for pacemaker implantation was 2/10 (20%). Intraprocedural success and haemodynamic data in our cases were good. The mortality in our group highlighted the importance of careful patient selection, especially for this pathology. The Jenavalve prosthesis proved to be suitable for treatment of AR in surgical high-risk patients.

Current Treatment of Aortic Regurgitation. 1st ed. by Hans-Joachim Schäfers (ed.). London/Boston: UNI-MED Verlag Bremen; 2013. ISBN: 978–3-8374–1406–6 (Germany)/978–1-84815–196–3 (ROW)

Current Treatment of Aortic Regurgitation. 1st ed. by Hans-Joachim Schäfers (ed.). London/Boston: UNI-MED Verlag Bremen; 2013. ISBN: 978–3-8374–1406–6 (Germany)/978–1-84815–196–3 (ROW)

P47 FEATURES OF INFECTIVE ENDOCARDITIS CAUSED BY AEROCOCCI

P47 FEATURES OF INFECTIVE ENDOCARDITIS CAUSED BY AEROCOCCI

ACS Book Review.

Historically, the treatment of aortic regurgitation has undergone several changes. First attempts at repair were undertaken in the 1950s. At that time understanding of normal valve and root anatomy and physiology was limited by the lack of imaging techniques; consequently, the results of repair were unpredictable and suboptimal. Valve replacement, initially with mechanical and later with biologic prostheses, has revolutionized treatment of aortic regurgitation by making it reproducible. Replacement with a pulmonary autograft was developed as an option for young individuals who could not or would not take long-term anticoagulation. In the past 2 decades increasing evidence has been collected that prostheses are associated with a significant incidence of valve-related complications. Patients have become more educated and expect surgical options that address their specific needs; quality of life rather than mere life expectancy has increased in importance. In the past 20 years better imaging techniques and improved understanding of normal aortic valve anatomy and function have resulted in the development of repair techniques that today allow repair in many instances of aortic regurgitation, either with or without aortic dilatation. Aortic valve repair is evolving similar to mitral repair 30 years ago, and repair has been shown to result in fewer valve-related complications that would be expected from aortic valve replacement. The possibility of reconstruction has raised new questions regarding preoperative imaging, forced surgeons to change their approaches to aortic valve disease, and raise questions over traditional criteria in decision making for surgery. Treatment of aortic regurgitation has thus become the subject of interdisciplinary efforts similar to other areas of heart valve disease. Current textbooks have difficulty in keeping track with the dynamic changes. They often provide information with an isolated focus on pathology, cardiology, or surgery, rather than integrated knowledge of all involved specialties. In addition, aortic valve repair is not yet widely established and there is uncertainty regarding its options and limitations as well as exact the techniques that can be applied. This book tries to accommodate both traditional knowledge and recent developments (1). A group of internationally-renowned authors from a variety of specialties have made a collaborative effort to provide a state-of-the-art overview of all aspects of the disease. Anatomy, pathology, cardiological aspects and current guidelines are presented by European leaders in their fields. Surgical techniques and results are likewise summarized by an international team of individuals with a strong track record in their respective areas. The topics are presented precisely, comprehensively, and with the facility of quick reference in mind. Detailed description of surgical techniques and their long-term results allows cardiologists to judge their relative importance. Surgeons can use the technical descriptions before choosing or performing specific reconstructive operations. As such, this book is unique and can be a reference to all health care professionals seeking information on the latest developments. Aortic Regurgitation

Surgical Treatment of Aortic Valve Regurgitation Secondary to Ascending Aorta Aneurysm: Is Adjunctive Subcommissural Annuloplasty Necessary?

Subcommissural aortic annuloplasty (SCA) has been recommended for treatment of functional aortic regurgitation (AR), but its association with sinotubular junction adjustment is still controversial. Sixty patients with moderate or severe functional AR secondary to proximal ascending aorta aneurysm operated on between May 2004 and December 2010 were reviewed. Forty patients underwent SCA and ascending aorta repair (SCA group; mean age, 65 ± 9 years) and 20 underwent ascending aorta repair alone (non-SCA group; mean age, 69 ± 8 years). Preoperative AR grades were comparable between groups (p = 0.9). Echocardiographic data at discharge and during follow-up (SCA group, 41 ± 13 months; non-SCA group, 46 ± 13 months) were analyzed. Improvement of mean AR grade was better in the SCA group than in the non-SCA group at discharge (0.78 ± 0.9 vs 1.8 ± 0.1/4+, p = 0.0001) and at follow-up (0.44 ± 0.8 vs 2.4 ± 0.7/4+, p = 0.0001). Cox-regression analysis (odds ratio [95% confidence interval]) identified a higher residual AR at discharge (0.14 [0.012-0.37], p = 0.02) and the surgical technique, SCA or not (0.5 [0.03-0.899], p = 0.04), as predictors of more than grade 2/4+ AR at follow-up. Five-year freedom from more than grade 2/4+ AR was 94.4% ± 5.4% vs 58% ± 16% in SCA vs non-SCA (p = 0.02), respectively, and the survival rate was 95% ± 5% vs 89% ± 7.5% (p = 0.7). No valve stenosis was observed in the SCA group. SCA is effective for treatment of functional AR, providing stable results even for significant AR. Our results suggest that it should be possibly associated to sinotubular junction adjustment. SCA seems to not impair normal aortic valve opening.

Transcatheter aortic valve implantation for severe regurgitation in native and degenerated bioprosthetic aortic valves

We evaluated transcatheter aortic valve Implantation (TAVI) in high-risk patients with severe aortic regurgitation (AR) in native or degenerated bioprosthetic valves. TAVI has emerged as a viable treatment modality for severe aortic stenosis in inoperable or high-risk patients. The use of TAVI for treatment of severe AR has remained largely unexplored. Eight patients (age 79.6 years ± 5.75 years) with severe AR underwent TAVI at six tertiary hospitals between April 2010 and May 2011. All patients were considered to be at prohibitive risk for surgical aortic valve replacement (SAVR).TAVI with the nitinol based Core Valve bioprosthesis (CRS) (Medtronic) was performed in all patients. Transfemoral access was used in all cases. Procedural success was obtained in all cases without any intraprocedural complications. There was no in hospital or 30-day mortality. There were no cases of atrioventricular blocks requiring permanent pacemaker implantation. At a mean follow up of 15.5 ± 15 months; all patients had improvement in New York Heart Association functional class. Follow up echocardiography revealed improved or stable left ventricular ejection fraction and optimal device function in all cases. TAVI with the CRS bioprosthesis is feasible and effective in appropriately selected cases of severe aortic regurgitation in native and bioprosthetic aortic valves.

Treatment and prevention of aortic regurgitation after transcatheter aortic valve implantation

Significant aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) has been shown to be associated with worse mid-term outcome. The two-year follow-up results of the PARTNER US trial showed that not only ≥3/4 AR grade, but also grade 2 had a significant impact on mortality. Thus, prevention and treatment of significant AR after TAVI is of great importance. Usually, AR after TAVI consists mostly of paravalvular leak and significant central AR is uncommon. Here we describe measures to decrease the risk of AR after TAVI which are currently available.

A Novel Method for Repairing Aortic Regurgitation Due to Commissural Detachment

Currently, aortic valve replacement is the mainstay treatment for aortic regurgitation due to commissural detachment. Herein, we report a novel technique of aortic root and commissural repair and its intermediate clinical outcome in patients with significant aortic regurgitation caused by commissural detachment. The detached commissure and aortic root were treated concomitantly by en bloc reattachment of the detached commissure and aortic wall by using multiple pledgeted sutures, in addition to aortic root reimplantation.