Valve Injury Research Articles

Early Clinical Experience with Impella 5.5 at a Large Tertiary Care Center

<h3>Purpose</h3> The Impella 5.5 system is the newest temporary left ventricular assist device (LVAD) for the treatment of cardiogenic shock (CS). Impella 5.5 aims to improve deliverability and durability over Impella 5.0, but real-world experience with this device is limited. We aimed to report our clinical experience with Impella 5.5. <h3>Methods</h3> Clinical and outcome data of all patients treated with Impella 5.5 at our center between Feb and Oct 2020 were collected. AKI was defined as per KDIGO criteria, vascular complications as per VARC-2 criteria and severe thrombocytopenia as <50k. <h3>Results</h3> 13 patients with Impella 5.5 were managed at our center (9 (69%) male, median age 58y (IQR 52, 67). 5 patients were transitioned to Impella 5.5 from VA-ECMO, 2 from Impella CP, 2 from IABP, and 4 from inotropes. Etiology of CS was AMI in 6 cases, decompensated chronic HF in 5, suspected acute myocarditis in 1 and post-cardiotomy CS in 1 case. Median duration of Impella 5.5 support was 12 days (IQR 7-28). 2 patients required device removal due to complications: 1 with entanglement in the mitral subvalvular apparatus, 1 with migration into the ascending aorta. Device-related complications were hemolysis in 4 (30%) patients, severe thrombocytopenia in 1, axillary hematoma (minor as per VARC-2 criteria) in 3 (23%), and AKI in 2 patients (15%). No stroke, valve injury or limb complications occurred. Survival to device explant was 85%. 2 patients who were not candidates for durable LVAD or transplant died on support of refractory CS. Of the survivors, 2 required surgically implanted biventricular support for refractory ventricular arrhythmia, 4 were bridged to durable VAD, 2 were bridged to OHT, and 3 achieved ventricular recovery. At the time of analysis, 3 patients remain hospitalized (1 surgical BIVAD, 1 early post-durable LVAD, 1 recovered after device explant). <h3>Conclusion</h3> All patients supported with Impella 5.5 were critically ill in profound CS. Rates of procedural and device-related complications were favorable, and survival was high in this critically ill cohort.

Tip-to-Base LAMPOON for Transcatheter Mitral Valve Replacement With a Protected Mitral Annulus.

The purpose of this study was to evaluate tip-to-base intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (LAMPOON) in patients undergoing transcatheter mitral valve replacement (TMVR) in annuloplasty rings or surgical mitral valves. LAMPOON is an effective adjunct to TMVR that prevents left ventricular outflow tract obstruction (LVOTO). Laceration is typically performed from the base to the tip of the anterior mitral leaflet. A modified laceration technique from leaflet tip to base may be effective in patients with a prosthesis that protects the aortomitral curtain. This is a multicenter, 21-patient, consecutive retrospective observational cohort. Patients underwent tip-to-base LAMPOON to prevent LVOTO and leaflet overhang, or therapeutically to lacerate a long anterior mitral leaflet risking or causing LVOTO. Outcomes were compared with findings from patients in the LAMPOON investigational device exemption trial with a prior mitral annuloplasty. Twenty-one patients with a annuloplasty or valve prosthesis-protected mitral annulus underwent tip-to-base LAMPOON (19 preventive, 2 rescue). Leaflet laceration was successful in all and successfully prevented or treated LVOTO in all patients. No patients had significant LVOTO upon discharge. There were 2 cases of unintentional aortic valve injury (1 patient underwent emergency transcatheter aortic valve replacement and 1 patient underwent urgent surgical aortic valve replacement). In both cases, the patients had a supra-annular ring annuloplasty, and the retrograde aortic guiding catheter failed to insulate the guidewire lacerating surface from the aortic root. All patients survived to 30days. Compared with classic retrograde LAMPOON, there was a trend toward shorter procedure time. Tip-to-base laceration is a simple, effective, and safe LAMPOON variant applicable to patients with an appropriately positioned mitral annular ring or bioprosthetic valve. Operators should take care to insulate the lacerating surface from adjacent structures.

Balloon versus self-expandable transcatheter aortic valve implantation for bicuspid aortic valve stenosis: A meta-analysis of observational studies.

There is a rising trend for transcatheter aortic valve implantation (TAVI) in bicuspid aortic stenosis patients. Data on the use of self-expandable (SEV) vs. balloon-expandable (BEV) valves in these patients are scarce. Therefore, we systematically compared clinical outcomes in bicuspid aortic stenosis patients treated with SEV and BEV. Data were extracted from PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, Google Scholar and reference lists of relevant articles. Eight studies published from 2013 to 2020 including a total of 1,080 patients (BEV: n=620; SEV: n=460) were selected. Primary endpoints were procedural, 30-day and 1-year mortality. Secondary endpoints were new pacemaker implantation, annular rupture, coronary obstruction, moderate-to-severe paravalvular leak, need of second valve, stroke and acute kidney injury. We found no statistically significant difference in mortality between patients treated with BEV vs. SEV during index procedure, at 30 days and at 1year. BEVs showed a statistically significant higher risk of annulus rupture (2.5%) in comparison with SEV (0%) (OR 5.81 [95% CI, 3.78-8.92], p < .001). New generation BEVs were also associated with significantly less paravalvular leak when compared to new generation SEVs (OR 0.08 [95% CI, 0.02-0.35], p=.001). This meta-analysis of observational studies of TAVI for bicuspid valves, showed no difference in short- and mid-term TAVI mortality with BEVs and SEVs. BEVs presented a higher risk of annular rupture in comparison with SEV.

Results of two different echocardiography-guided approaches to closure of perimembranous ventricular septal defects

The feasibility of mini-invasive closure of perimembranous ventricular septal defects has been proven, but can cause surgical incision or sternum injury. A relevant but, to date, unanswered question is whether there exists a treatment without surgical trauma, radiation exposure and arterial complications. From May 2017 to January 2020, a total of 449 patients with perimembranous ventricular septal defect [mean age 5.0 ± 6.1 years (range 0.8-52.0 years)] were involved in this study and underwent 2 different echocardiography-guided operative procedures [percutaneous device closure (group A) or percardiac device closure (group B)] based on the patients' or their parents' choice. The clinical data were collected and a retrospective analysis was performed. Fifty-five (96.5%) cases were successfully occluded in group A, and 2 (3.5%) patients were converted to percardiac device closure; 379 (96.7%) patients in group B underwent percardiac device closure, and 13 patients (3.3%) were turned to open-heart surgery after occlusion procedure failure. There were statistically significant differences (P < 0.05) between the 2 groups in operation time, postoperative hospitalization time and blood transfusion requirement. No acute complications or severe adverse events (death, valve injury, complete atrioventricular block and embolism) occurred either in the early period or during the follow-up. Percutaneous device closure can achieve the same validity and safety as percardiac device closure for treating perimembranous ventricular septal defects with a more rapid recovery and less trauma.

Correlation Between Cardiac Computed Tomography and Histopathology for Evaluating Patients with Aortic Valve Disease

The use of cardiac computed tomography (cardiac CT) and the quantification of the Agatston score for the evaluation of calcium of the aortic valve (AVC) has increased in different clinical contexts for diagnostic and prognostic purposes. This study aims to evaluate the correlation between cardiac CT and histopathology for the quantification of AVC. Ninety patients diagnosed with severe aortic valve dysfunction, of any etiology and regardless of the predominant type of injury, were included. Before the surgical event, a Cardiac CT were performed with Agatston Score measurement. The removed native valve was evaluated by a Pathologist, who provided a qualitative and quantitative evaluation of valve calcium. Calcium density was also analyzed by quantifying the area in pixel units obtained from photomicrographs. Follow-up was performed for four years after the aortic valve replacement. Ninety patients were analyzed. The degenerative etiology predominated 63.3% (57 patients). The calcium load was different for the gender (p = 0.01) and type of valve injury (p = 0.0013). There was a positive correlation between the Agatston score, and the percentage of calcium reported by the pathologist in a conventional qualitative way (rs = 0.75, p < 0.001) and between the AVC and the Cote etal. score (rs = 0.77, p < 0.001). There was no difference in survival after aortic valve replacement concerning valve calcium load. Left ventricular dysfunction showed a significant difference in survival (p = 0.003, Log-rank). There is a moderately high correlation between the Agatston score quantified by Cardiac CT and the histopathological evaluation. The severity of the calcification did not prove to be a predictor of death in the postsurgical follow-up.

Valvular complications following the Impella device implantation

Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.

P16 Management of Traumatic Injury of the Aortic Valve

Aortic valve injury following blunt chest trauma is an uncommon outcome [1]. The resulting aortic insufficiency is hard to detect unless sought out and investigated [2]. Echocardiographic assessment is the modality of choice for diagnosis [2].

Cholesterol crystal induced inflammation and mechanical cardiac valve injury: Implications for transcatheter aortic-valve replacement

The process of cardiac valve sclerosis and stenosis in non-rheumatic disease is related to inflammation via the innate immune system similar to atherosclerosis. Cardiac valve composition shares many features with arterial tissue. Cholesterol infiltration in the valve matrix results in cholesterol crystal formation and deposition that causes mechanical injury and triggers inflammation. Sclerotic human valve specimens as well as valves from atherosclerotic rabbit models reveal presence of cholesterol crystals and macrophage infiltration as seen in atherosclerosis. Lipid lowering by combination of simvastatin and ezetimibe demonstrates cholesterol reduction in valves only if used in a preventive manner. However, once the valve is infiltrated by cholesterol and crystals form in the tissue matrix, these become very difficult to extract and lipid lowering is no longer very effective. Furthermore, cholesterol crystals serve as a nidus for calcium phosphate deposition that distorts and stiffens the valve tissue leading to valve dysfunction. During Transcatheter Aortic Valve Replacement (TAVR) procedures, crystals can complicate the procedure by release of crystalline particles causing ischemic cerebral events and rupturing balloons.

Tricuspid valve injury after heart transplantation: how to monitor for rejection?

Tricuspid valve injury after heart transplantation: how to monitor for rejection?

Transcatheter Pulmonary Valve Replacement With the Sapien Prosthesis

BackgroundThere are limited published data focused on outcomes of transcatheter pulmonary valve replacement (TPVR) with either a Sapien XT or Sapien 3 (S3) valve. ObjectivesThis study sought to report short-term outcomes in a large cohort of patients who underwent TPVR with either a Sapien XT or S3 valve. MethodsData were entered retrospectively into a multicenter registry for patients who underwent attempted TPVR with a Sapien XT or S3 valve. Patient-related, procedural, and short-term outcomes data were characterized overall and according to type of right ventricular outflow tract (RVOT) anatomy. ResultsTwenty-three centers enrolled a total of 774 patients: 397 (51%) with a native/patched RVOT; 183 (24%) with a conduit; and 194 (25%) with a bioprosthetic valve. The S3 was used in 78% of patients, and the XT was used in 22%, with most patients receiving a 29-mm (39%) or 26-mm (34%) valve. The implant was technically successful in 754 (97.4%) patients. Serious adverse events were reported in 67 patients (10%), with no difference between RVOT anatomy groups. Fourteen patients underwent urgent surgery. Nine patients had a second valve implanted. Among patients with available data, tricuspid valve injury was documented in 11 (1.7%), and 9 others (1.3%) had new moderate or severe regurgitation 2 grades higher than pre-implantation, for 20 (3.0%) total patients with tricuspid valve complications. Valve function at discharge was excellent in most patients, but 58 (8.5%) had moderate or greater pulmonary regurgitation or maximum Doppler gradients >40 mm Hg. During limited follow-up (n = 349; median: 12 months), 9 patients were diagnosed with endocarditis, and 17 additional patients underwent surgical valve replacement or valve-in-valve TPVR. ConclusionsAcute outcomes after TPVR with balloon-expandable valves were generally excellent in all types of RVOT. Additional data and longer follow-up will be necessary to gain insight into these issues.

Mitral valve surgery after a failed MitraClip procedure.

Among patients undergoing transcatheter mitral valve repair with the MitraClip device, a relevant proportion (2-6%) requires open mitral valve surgery within 1 year after unsuccessful clip implantation. The goal of this review is to pool data from different reports to provide a comprehensive overview of mitral valve surgery outcomes after the MitraClip procedure and estimate in-hospital and follow-up mortality. All published clinical studies reporting on surgical intervention for a failed MitraClip procedure were evaluated for inclusion in this meta-analysis. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital adverse events and follow-up mortality. Pooled estimate rates and 95% confidence intervals (CIs) of study outcomes were calculated using a DerSimionian-Laird binary random-effects model. To assess heterogeneity across studies, we used the Cochrane Q statistic to compute I2 values. Overall, 20 reports were included, comprising 172 patients. Mean age was 70.5 years (95% CI 67.2-73.7 years). The underlying mitral valve disease was functional mitral regurgitation in 50% and degenerative mitral regurgitation in 49% of cases. The indication for surgery was persistent or recurrent mitral regurgitation (grade >2) in 93% of patients, whereas 6% of patients presented with mitral stenosis. At the time of the operation, 80% of patients presented in New York Heart Association functional class III-IV. Despite favourable intraoperative results, in-hospital mortality was 15%. The rate of periprocedural cerebrovascular accidents was 6%. At a mean follow-up of 12 months, all-cause death was 26.5%. Mitral valve replacement was most commonly required because the possibility of valve repair was jeopardized, likely due to severe valve injury after clip implantation. Surgical intervention after failed transcatheter mitral valve intervention is burdened by high in-hospital and 1-year mortality, which reflects reflecting the high-risk baseline profile of the patients. Mitral valve replacement is usually required due to leaflet injury.

Case Report: - Aortic Valve Replacement due to Aortic Valve Leaflet Perforation after PCI

- Percutaneous Coronary Intervention (PCI) is widely recognized as an effective treatment for Acute Coronary Syndrome (ACS). Inspite of advances in equipment and experience of interventional cardiologist, still there are rare complications occurred [1]. Iatrogenic injury of the aortic valve leaflet is a rare. Aortic insufficiency (AI) after a PCI suggests an iatrogenic valve injury. Aortic leaflet injury is not common but possible complication of PCI. Because of the serious consequences, it should be mentioned in the informed consent. Aortic repair of iatrogenic injury is possible, and it can be performed with excellent clinical and functional midterm results. So, Aortic valve replacement (AVR) is the last option [2].

Rare Case of Traumatic Tricuspid Valve Injury in Patient With Sinus Venosus Atrial Septal Defect (ASD)

Rare Case of Traumatic Tricuspid Valve Injury in Patient With Sinus Venosus Atrial Septal Defect (ASD)

Balloon Filling Algorithm for Optimal Size of Balloon Expandable Prosthesis During Transcatheter Aortic Valve Replacement

Aim is to report on the results of an optimized balloon filling algorithm and suggest a refinement of the implantation approach to maximize safety. Appropriate sizing of balloon expandable valves during transcatheter aortic valve implantation is crucial. Study comprised 370 consecutive patients receiving SAPIEN 3 valve between 2015 and 2018. Valve expansion/recoil measurement in the inflow area, annular area, and outflow area was performed previously and postimplantation. Nominal balloon filling resulted in underexpansion-23 mm (20.96 mm), 26 mm (23.88 mm), and 29 mm (27.56 mm) SAPIEN 3 valves at the annular level. Increased balloon filling by 2 cc resulted in a gradual increase in valve diameter reaching 97.35% (23 mm), 96.50% (26 mm), and 96.11% (29 mm) of the nominal valve diameter. Final diameters were usually higher in the valvular inflow and outflow tracts. The 29 mm valve did not reach its nominal diameter with 2 cc overfilling and in none of inflow area (95.48%), annular area (96.11%), or outflow area (96.86%). Device success (by VARC II) was 96.2%. No root or septal rupture, device migration, mitral valve injury, coronary obstruction, or dissection occurred. Rate of new permanent pacemaker implantation was 8.3%. Paravalvular leakage was none or trace in most patients. Mean valve gradient was 10.77 mm Hg postprocedure. 1.9% of the patients had a maximum gradient of >40 mm Hg, 2.2% >20 mm Hg. In conclusion, an optimized balloon filling algorithm resulted in appropriate valve gradients, low levels of paravalvular leakage, low rates of permanent pacemaker implantation and no annular rupture.

Traumatic tricuspid valve injury following pacemaker lead extraction: A case report

Traumatic tricuspid valve injury following pacemaker lead extraction: A case report

Cholesterol induced heart valve inflammation and injury: efficacy of cholesterol lowering treatment

BackgroundHeart valves often undergo a degenerative process leading to mechanical dysfunction that requires valve replacement. This process has been compared with atherosclerosis because of shared pathology and risk factors. In...

SAPIEN S3 valve deployment in the pulmonary position using the gore DrySeal sheath to protect the tricuspid valve.

Tricuspid valve injury can occur during implantation of a SAPIEN valve in the pulmonary position. We describe our experience using a long Gore DrySeal (GDS) sheath to protect the tricuspid valve during advancement of the Commander delivery system. Retrospective single center review of all patients who underwent placement of a SAPIEN valve in the right ventricular outflow tract between January 2016 and April 2020. Patients were divided into two groups: delivery of the valve using standard technique (Group I), and with the use of a GDS (Group II), for comparison. There were 48 patients in total: 25 in Group I and 23 in Group II. In Group II, the first 10 patients had a 29 mm S3 placed through a 26 French (Fr), 65 cm GDS. We then performed additional crimping of the S3 onto the balloon after the balloon catheter was withdrawn to position the valve on the balloon outside the body. Subsequently, seven had a 29 mm S3 placed through a 24 Fr GDS, and four had a 26 mm S3 placed through a 22 Fr GDS including one weighing 16 kg. Two had a 23 mm S3 placed through a 22Fr GDS as the 20Fr GDS was not available in our lab. Severe tricuspid valve injury occurred in 2/25 (8%) of Group I patients and 0/23 of Group II patients. Use of a long GDS may protect the tricuspid valve from injury during implantation of the S3 valve in the pulmonary position, and is technically feasible in smaller patients.

Contribution of Severe Dental Caries Induced by Streptococcus mutans to the Pathogenicity of Infective Endocarditis.

Streptococcus mutans, a major pathogen of dental caries, is regarded as a causative agent of infective endocarditis (IE), which mainly occurs in patients with underlying heart disease. However, it remains unknown whether severe dental caries that extend to pulp space represent a possible route of infection. In the present study, we evaluated the virulence of S. mutans for IE development using rats with concurrent severe dental caries and heart valve injury. Dental caries was induced in rats through the combination of a caries-inducing diet and the administration of S. mutans into the oral cavity. Then, the heart valves of a subset of rats were injured using a sterile catheter and wire under general anesthesia. The rats were euthanized at various times with various stages of dental caries. The number of teeth affected by dental caries with pulp exposure was increased in the rats in a time-dependent manner. S. mutans was recovered from injured heart tissue, which was mainly observed in rats with higher number of S. mutans bacteria in mandibular bone and a larger number of teeth in which caries extended to pulp. Dental caries was more severe in rats with heart injury than in rats without heart injury. Sequencing analysis targeting 16S rRNA revealed that specific oral bacteria appeared only in rats with heart injury, which may be related to the development of dental caries. Our findings suggest that dental caries caused by the combination of S. mutans infection and sucrose intake may contribute to S. mutans colonization in injured heart tissue.

Utility of the long DrySeal sheath in facilitating transcatheter pulmonary valve implantation with the Edwards Sapien 3 valve

To assess the utility of the 65-cm-long Gore DrySeal sheath when compared to the standard 36-cm-long Edwards expandable sheath (e-sheath) for transcatheter pulmonary valve implantation (TPVI) with the Edwards Sapien 3 valve. All patients who underwent TPVI with the Sapien 3 valve, excluding those performed via hybrid approach, at our center between September 2015 and November 2019 were retrospectively reviewed and compared between two groups. A total of 94 patients were enrolled; 29 patients underwent TPVI with the Sapien valve using the DrySeal sheath and 65 underwent TPVI using the e-sheath. The height and body weight of patients implanted using the DrySeal sheath ranged from 137 to 193 cm and from 33 to 129 kg, respectively. Valve delivery time was significantly shorter in the DrySeal group (median time 4 min 33 s vs. 9 min 6 s, p = .002). There were no complications in the DrySeal group (0/27). Nine procedural complications occurred in the e-sheath group (9/65), five of which were potentially directly related to sheath choice, including tricuspid valve injury in four and embolization of the tip of the e-sheath during retrieval of a ruptured balloon in one patient. TPVI with the Sapien 3 valve using the 65-cm-long DrySeal sheath facilitates faster and safer valve implantation when compared to the e-sheath.

Percutaneous Puncture Closure of Postoperative Residual Ventricular Septal Defects Without Radiation

A redo surgical approach to residual ventricular septal defect (VSD) is technically demanding. Sternum reentry has to be performed very carefully to avoid any uncontrolled bleeding, and preparation of the adhesions must be made to expose the most important structures (ascending aorta, caval veins). However, percutaneous transcatheter device closure of the residual VSD with radiation exposure can cause arrhythmia, valve injury, and vascular complications. This report presents a less invasive technique to treat residual VSD, without arterial access, radiation exposure, or cardiopulmonary bypass.