Treatment Of Valvular Heart Disease Research Articles

Exploring the biology of valvular heart disease: Time to move into the twenty-first century.

[first paragraph of article] Valvular heart disease (VHD), when severe and prolonged, creates a hemodynamic overload, the consequences of which damage the myocardium - leading to heart failure and death if left uncorrected by mechanical intervention. In 1906 Sir William Osler wrote in the sixth edition of his famous textbook “The Principles and Practice of Medicine”, that the prognosis of valvular heart disease (VHD) depended upon the severity of disease, the presence or absence of symptoms, and upon heart size. Remarkably, 100 years later, the ACC/AHA Guidelines for the treatment of VHD essentially rely upon the same criteria, albeit heart size is measured more accurately than in Osler’s day and the outcome of VHD has been changed dramatically by valve surgery. And, because man has also been fascinated by the heart’s motion, quantification of this motion (today usually by ejection fraction (EF)) has been added to evaluate cardiac performance. Still, timing of mechanical therapy is largely based on disease severity, symptoms, heart size and heart motion . . . not much of an advance in over a century, especially considering the leaps of progress made in other fields of medicine.

Update of transcatheter valve treatment

Transcatheter valve implantation or repair has been a very promising approach for the treatment of valvular heart diseases since transcatheter aortic valve implantation (TAVI) was successfully performed in 2002. Great achievements have been made in this field (especially TAVI and transcatheter mitral valve repair--MitraClip system) in recent years. Evidence from clinical trials or registry studies has proved that transcatheter valve treatment for valvular heart diseases is safe and effective in surgical high-risk or inoperable patients. As the evidence accumulates, transcatheter valve treatment might be an alterative surgery for younger patients with surgically low or intermediate risk valvular heart diseases in the near future. In this paper, the updates on transcatheter valve treatment are reviewed.

Interview: From a pacemaker in a donkey to valve disease research in humans

Philippe Pibarot speaks to Caroline Telfer, Assistant Commissioning Editor Philippe Pibarot was born in Toulon, France in 1964. He obtained a doctorate in veterinary medicine in 1987 at the University Claude Bernard (Lyon, France). He obtained his PhD degree in biomedical sciences from the University of Montreal (Montreal, Canada) in April 1995. He is now a professor at the Department of Medicine of Laval University and he holds the Canada Research Chair in Valvular Heart Disease at the Quebec Heart & Lung Institute (Quebec, Canada). The objective of his research program is to develop and validate novel approaches to improve the diagnosis, prevention and treatment of valvular heart disease. He is currently the principal investigator of three multicenter studies funded by Canadian Institutes of Health Research and the Heart and Stroke Foundation of Quebec. He has published more than 250 articles in the course of his career. He recently received the Annual Achievement Award of the Canadian Society of Echoca...

Contemporary Drug Treatment of Infective Endocarditis

Infective endocarditis (IE) occurs at a rate of approximately 0.9-6.2 per 100,000 people per year and is associated with a high morbidity and mortality despite advancements in antibiotic and surgical treatments. The general approach to the treatment of IE is initial clinical stabilization, early acquisition of blood cultures, and definitive medical and/or surgical treatment. Surgical consultation should be obtained early when indicated in order to determine the best treatment approach for each individual patient. Surgery is indicated in most cases of prosthetic valve endocarditis, Staphylococcus aureus endocarditis, fungal endocarditis, and endocarditis associated with large vegetations (≥10mm). Initial antibiotic therapy for IE should be targeted to the culprit microorganism; however, in some cases, empiric therapy must be initiated prior to definitive culture diagnosis. Empiric antibiotics should be targeted toward the most likely pathogens, including staphylococci, streptococci, and enterococci species. Here we discuss the recommended antibiotic regimens for the most common causes of IE as indicated by the American Heart Association and European Society of Cardiology. In 2008, the ACC/AHA published guideline updates on the treatment of valvular heart disease, which included a focused update on endocarditis prophylaxis. According to the most recent guidelines, the number of patients who require antibiotic prophylaxis has decreased substantially. Treatment of IE should be targeted toward the causative microorganism and must be based on the type and location of valve involved (native, prosthetic, left or right sided), the clinical status of the patient, and the likelihood for clinical success. This requires a collaborative effort from multiple medical specialties including infectious disease specialists, cardiologists, and cardiothoracic surgeons.

Bioprosthetic Heart Valves: Impact of Implantation on Biomaterials

Prosthetic heart valves are commonly used in the treatment of valvular heart disease. Mechanical valves are more durable than the bioprosthetic valves; however, the need for long-term anticoagulant therapy renders them unsuitable for some patient groups. In this paper we discuss the different types and models of bioprosthesis, and in particular, pericardial bioprosthesis. We also discuss the preimplantation preparation processes, as well as their postimplantation changes and modes of failure.

Imaging of Valvular Heart Disease

Imaging plays a fundamental role in the current diagnosis and treatment of valvular heart disease (VHD) and in the preclinical and clinical research aiming at the development of novel pharmacologic or interventional therapies. Doppler echocardiography remains the primary imaging technique for the clinical management of VHD. However, the multifaceted and complex nature of VHD and the rapid development of transcatheter valve therapies has led to a spectacular increase in the use of multimodality imaging in the past decade. The purpose of this article is to review the current and emerging roles of the different imaging modalities in the diagnosis and treatment of VHD and to present the new directions for future research and clinical applications.

Towards an integrated approach to mitral valve disease: implementation of an interventional mitral valve programme and its impact on surgical activity†

Transcatheter-based treatment of valvular heart disease has increasingly been implemented for the treatment of high-risk patients. The impact of these new treatment modalities on surgical valve programmes is unclear at present. We sought to evaluate the impact of an interventional mitral valve programme on surgical mitral valve activity and to assess the risk profiles of the respective patient populations. Between 2007 and 2011, 1112 patients underwent mitral valve surgery for isolated or combined procedures. An interventional mitral valve programme was initiated in 2008, with 270 patients treated from 2008 to 2011. Data were prospectively entered into a database and retrospectively analysed. From 2007 to 2011, surgical mitral valve activity increased by 29.9% compared with a 9.8% increase nationwide (P = 0.09). Compared with the year before the introduction of a MitraClip programme, mean logistic EuroSCORE I of surgical patients was similar in 2011 (2007: 9.4 ± 10.4 vs 2011: 9.5 ± 10.5; P = 0.92), while overall 30-day mortality decreased from 7.2 to 4.4% (P = 0.22). The risk profile of surgical patients decreased significantly regarding several parameters. For isolated mitral valve repair, 30-day mortality was 1.5% (6 of 406) in all patients during the study period. Mean logistic EuroSCORE I of transcatheter patients was significantly higher when compared with that of surgical patients (28.8 ± 18.8 vs 9.5 ± 10.5%; P < 0.01). Since the implementation of an interventional mitral valve programme, surgical mitral valve activity has increased over the following years. The risk profile of surgical patients decreased regarding several important parameters, although the overall logistic EuroSCORE I remained unchanged. An integrated approach to mitral valve disease with complementary surgical and non-surgical treatment options may possibly help in relieving the undertreatment of patients with severe mitral regurgitation.

Transcatheter Valve-in-Valve Therapies: Patient Selection, Prosthesis Assessment and Selection, Results, and Future Directions

The development of transcatheter valve implantations (TAVI) has induced profound changes in the treatment of valvular heart disease over the past decade. At the same time, due to excellent clinical results, bioprostheses continuously outperformed mechanical prostheses. The increasing number of elderly patients has led to numerous patients presenting with deteriorated bioprostheses needing reoperation. In selected high-risk patients or patients with unreasonable surgical risk, valve-in-valve TAVI has advanced to a viable alternative to conventional redo surgery. High procedural success, good hemodynamics and acceptable clinical results were reported up until now. Valve-in-valve TAVI seems to be safe and effective in treatment of deteriorated valve prostheses in high-risk patients. The valve-in-valve concept presents the next step toward an individual treatment strategy for patients at prohibitive risk for conventional surgery. Present studies were reviewed with special concern to patient selection, prosthesis assessment, device selection, clinical outcome and technical challenging aspects as well.

Implementation of Multicenter Records in the Therapeutic Cardiovascular Assessment in Brazil

Clinical research finds, in controlled clinical trials, its main instrument to establish the therapeutic effectiveness of drug or interventional therapies. On the other hand, the evaluation of demographic, clinical and prognostic characteristics of patients under treatment in the real world depends on comprehensive multicenter observational studies, whose results vary according to countries or regions involved. In the field of cardiology, we have, in our country, few records that represent the national reality. In this vein, recent experiences have been conducted by the Brazilian Society of Cardiology and by specific groups or institutions in recording some specific conditions or therapies. These studies include the evaluation of epidemiological aspects, prognostic results and the factors involved in the care of patients with acute coronary syndromes1-3, decompensated heart failure4 or disorders at high risk of cardiovascular events5. In parallel, the evaluation of the characteristics and outcomes of interventional procedures such as the use of stents in the treatment of heart failure6 and cardiac surgeries in the treatment of valvular heart diseases or heart failure7 have also been the subject of specific records. The initial publications of clinical records related to acute coronary syndromes suggest the inclusion of more than six thousand patients treated in centers based in different regions of Brazil. These records have become major documents that show the demography of the disorders involved2, 3, 8. The initial results of these records demonstrate the diversity of treatments conducted at a national level, including the regional inequality in the employment of reperfusion therapies2. The use of these therapies relates, on the other hand, to lower mortality and lower rates of complications in the immediate follow-up of patients3,8. Besides this, recent data show lower rates of mortality that are consistent with the international experience in the treatment of unstable angina and acute myocardial infarction with or without ST-segment elevation8. Records focusing on the evolution of patients with heart failure and disorders at high risk of cardiovascular events are still at an initial stage of including patients4,5. However, important issues on the application of confirmedly beneficial therapies can be found in the preliminary data of the REACT study9. As for interventional procedures, publications of the CENIC registry, which includes patients undergoing percutaneous coronary intervention in several Brazilian regions, suggest a progressive improvement of results6,10, including the reduction of vascular complications promoted by the technique of access through the radial artery10. Finally, the constitution of the SP-SCORE-SUS registry to evaluate the results of cardiac surgeries in the State of Sao Paulo, based on previous publications of a national reference center11,12, fills an important gap with respect to the employment and results of cardiovascular surgical therapy, expected to be expanded at a national level13. The scenario presented shows the growing concern of researchers and our scientific societies to better characterize the therapeutic profile of cardiovascular disorders in our country. The analysis of the results of a number of multicenter records opens new perspectives for better planning of financial, personal and technological resources used in cardiovascular health, and contributes with insights to deepening scientific knowledge on the events under study.

Management of Prosthetic Heart Valve Complications

With greater awareness and treatment of valvular heart disease, there are now an increasing number of patients with prosthetic heart valves. However, replacement of a diseased valve with a prosthetic valve creates the opportunity for new and unique complications that once diagnosed require specific treatments. Complications which may occur depend not only on the type of prosthesis but also are influenced by clinical factors that are important to understand and may affect treatment strategies. Tissue prostheses tend to deteriorate over time while mechanical prostheses require anticoagulation with its attendant risks. The rate of serious prosthetic heart valve complications is approximately 3% per year. They include bleeding, systemic embolization, obstruction due to thrombus or pannus formation, patient-prosthesis mismatch, infective endocarditis, structural deterioration, prosthetic and peri-prosthetic regurgitation, and hemolysis. Importantly, the risk of prosthetic heart valve complications can be reduced by appropriate choices made at the time of surgery such as utilization of the correct prosthesis size and type. In addition, adherence to current guidelines for anticoagulation, endocarditis prophylaxis, and the timing of clinical and echocardiographic surveillance is also important to prevent complications. Should complications occur, rapid diagnosis, usually with echocardiography, is pivotal and can provide important hemodynamic as well as anatomic information critical to determining appropriate treatment and timing of surgical re-intervention if necessary. Optimal treatment of prosthetic heart valve complications remains a challenge and new treatment strategies continue to evolve.

TCT-816 Anticipated Utilization of Transcatheter Aortic Valve Replacement Reflects Cautious Optimism of the U.S. Interventional Cardiology Community

Transcatheter aortic valve replacement (TAVR) is the first major addition to the treatment of valvular heart disease in more than a decade, and the number of patients eligible for valve replacement is likely to increase significantly. As a consequence, little is known about expectations within the

Percutaneous treatment of valvular heart diseases

Surgical valve replacement represents the treatment of choice for symptomatic and severe valvular heart disease. However, the operative risk is increased in presence of advanced age and comorbidities, therefore such patients are often not deemed suitable for surgical treatment. Recently, percutaneous valve replacement has emerged as an optional treatment for such patients, particularly for treating severe aortic stenosis and severe mitral regurgitation.

Transcatheter Aortic Valve Implantation

Percutaneous catheter-based interventions are an emerging area in the treatment of valvular heart disease. Percutaneous aortic balloon valvuloplasty was initially introduced by Cribier et al1 in 1985 for patients with severe calcific aortic stenosis. This technique results in moderate hemodynamic improvement and significant clinical improvement, but it is associated with significant periprocedural morbidity and mortality and with a very high hemodynamic and clinical restenosis within 6 to 12 months after the procedure.2 Today, this technique is used mainly as a bridging technique to surgical aortic valve replacement (AVR) or to transcatheter aortic valve implantation (TAVI).2–4 The early results of percutaneous catheter-based valve replacement are promising. The first percutaneous heart valve replacement was performed by Bonhoeffer in 2002 in the pulmonary position5,6 and by Cribier in 2002 in the aortic position.7,8 Nowadays, TAVI has evolved to become a valid therapeutic option for patients with severe aortic stenosis who are inoperable or are at very high risk for surgical AVR.7–10 Recently, TAVI has been offered to select patients with good results. In Europe, TAVI is now an established, evidence-based alternative to open AVR in patients with aortic stenosis who are unsuitable for conventional cardiac surgery. Recent reported studies from the United States have demonstrated that for patients with severe aortic stenosis who are not candidates for surgery, TAVI with the Edwards SAPIEN valve significantly reduced mortality compared with standard treatment (Placement of Aortic Transcatheter Valves [PARTNER] trial, cohort B).9,10 Currently, there are 2 first-generation percutaneous valves in clinical application, a balloon-expandable Edwards SAPIEN and a self-expandable valve (CoreValve), with several other second-generation new players achieving first-in-human application. Since 2002 when the first TAVI in a human was reported by Cribier et al,7 percutaneous heart …

Noninvasive cerebral oxygenation monitoring during rapid ventricular pacing in transcutaneous aortic valve implant

Most recent attention in interventional cardiology is now directed towards treatment of valvular heart disease. In patients with high-risk cardiac surgery, transcutaneous aortic valve implantation (TAVI) could offer a therapeutic solution. Near-infrared spectroscopy (NIRS) has been introduced as a useful noninvasive cerebral monitoring technique assessing cerebral oxygenation. As of today, no reports have been published on the use of any NIRS technology during TAVI procedures. During valve prosthesis implantation, a cardiac standstill by rapid ventricular pacing (RVP) is induced to minimize cardiac motion. While RVP is advantageous for valve positioning, a combination of rapid heart rate and ventricular hypertrophy can induce a complete loss of cardiac output. In most cases, this hemodynamic deficit is well tolerated, due to the brief duration of RVP. But as of today no data are available on cerebral oxygenation during these critical periods of RVP.

A17 NIRS Cerebral Oxygenation Monitoring during Transcutaneous Aortic Valve Implant (TAVI)

Introduction: Most recent attention in interventional cardiology is directed towards treatment of valvular heart disease. In high risk pts, transcutaneous aortic valve implantation (TAVI) offers a therapeutic solution. Near Infrared Spectroscopy (NIRS) has been introduced as a useful non-invasive cerebral monitoring technique assessing cerebral oxygenation. During TAVI procedure, transient cardiac standstill by rapid ventricular pacing (RVP) is induced to minimize cardiac motion. In most cases, this hemodynamic deficit is well tolerated, due to the brief duration of RVP. But as far as today no data are available on cerebral oxygenation during these critical periods of RVP. Methods: We report on 10 consecutive pts (>75yrs, major comorbidities) suffering from severe aortic stenosis. Bilateral ForeSight sensors were applied after induction of anesthesia. We studied the changes in cerebral oxygenation (SctO2 monitoring) occurred during these RVP periods. Results: In all pts, procedure was technically successful. Mean SctO2 before RVP was 67% (59–71%) with immediate decrease during RVP to m54% (37–70%). In 7 pts, RVP resulted in SctO2 decreases below 55% (m44%; range 37–52%), lasting for m20 min (14sec-87 min). Systolic blood pressure before RVP was m135mmHg (95–165mmHg) and decreased to m74mmHg (112–42mmHg) during RVP. In 6 pts, RVP resulted in systolic blood pressure below 90mmHg, immediately countered by vasoactive drugs. In 2 pts, extensive hypotension persisted despite vasoactive support and CPR had to be initiated. In 1 pt, SctO2 values remained below 55% for 87 min and pt was declared brain dead 48 h later. Conclusion: Transcutaneous cardiac interventions, with transient cardiac standstill, can induce longlasting inadequacy of cerebral perfusion, despite immediate restoration of normal hemodynamics. Future strategies should focus on optimalizing cerebral oxygenation before RVP.

“Current Status und Future Perspective of Interventional Treatment of Valvular Heart Disease”

Article “Current Status und Future Perspective of Interventional Treatment of Valvular Heart Disease” was published on September 6, 2012 in the journal Biomedical Engineering / Biomedizinische Technik (volume 57, issue SI-1-Track-S).

Tratamento percutâneo das doenças cardíacas valvares: procedimentos consagrados e abordagens inovadoras

(RBCI) includes two articles that portray the results of well-established techniques as well as innovations in the percutaneous treatment of valvular heart disease in Brazuk. Aguiar Filho et al., from the Instituto de Cardiologia Dante Pazzanese (Sao Paulo, SP, Brazil), show the evolution of the first 200 patients with mitral stenosis treated by balloon valvotomy from 1987 to 1990, their management over time, the probability of being free of restenosis after 20 years of evolution, and predictors of lesion recurrence. In a corresponding editorial, Palacios and Silva, from the Massachusetts General Hospital (Boston, USA), draw attention to the importance of the accurate analysis of valve morphology and function to obtain the best procedural results, the differences in clinical profile and outcome in different published series, and the different techniques available. At the end of their article, they reaffirm its role as a first-line treatment for rheumatic mitral stenosis.Additionally, Brito Jr., from Hospital Albert Einstein (Sao Paulo, SP, Brazil), and other physicians from the Brazilian Registry of Transcatheter Aortic Valve Im-plantation share their experience with an alternative route for CoreValve

Preface

The 2011 Pediatric Cardiac Surgery Annual of the Seminars in Thoracic and Cardiovascular Surgery includes topics from the 2011 AATS Congenital Post-Graduate Course and Post-Graduate Skills Sessions. This year's guest editor, Dr. Pedro del Nido from Boston Children's Hospital, has collected an outstanding group of authors to focus on treatment of valvular heart disease. Techniques for valve repair in many forms of complex congenital heart disease are becoming increasingly important as efforts to avoid prosthetic valve replacement in children continue. The increasing number of patients with single-ventricle malformations and heterotaxy syndrome with common AV valves bring a large population who require valvular reparative techniques for optimum palliation with the Fontan operation. Aortic and mitral valve reparative techniques in adults have progressed rapidly and these techniques are becoming increasingly utilized in the pediatric population. This year's Pediatric Cardiac Surgery Annual will be a valuable resource for all congenital heart surgeons who are continuing to develop their techniques for valve repair in children.

Percutaneous Treatment of Valvular Heart Disease: Well-known Procedures and Innovative Approaches

Percutaneous Treatment of Valvular Heart Disease: Well-known Procedures and Innovative Approaches

Cardiac imaging of prosthetic valve dysfunction by transesophageal echocardiography

Surgical implantation of a mechanical or biological prosthetic heart valve (PHV) with original structure and hemodynamics is conventional treatment of valvular heart disease. All kinds of prosthetic valves are stenotic comparing with native valves. They should be imagined by being aware of their specific properties. PHV diseases (PHVD) describes situations like obstruction, thromboembolism and regurgitation which also have characteristic images. Determining the cause and severity of PHVD is mandatory for selection of treatment method. Knowledge about PHVD and correct usage of cardiac imaging methods facilitate diagnosis. Most helpful diagnostic test for PHVD is transesophageal echocardiography (TEE). The aim of this review is to describe TEE in PHVD, TEE imaging characteristics of some special PHVD and clinical guidance of TEE in PHV problems.