Valve Replacement For Aortic Insufficiency Research Articles

Long-term Outcomes Of Transcatheter Aortic Valve Replacement For Aortic Insufficiency In Patients With Left Ventricular Assist Devices

Long-term Outcomes Of Transcatheter Aortic Valve Replacement For Aortic Insufficiency In Patients With Left Ventricular Assist Devices

Outcomes of surgical bioprosthetic aortic valve replacement for aortic insufficiency

BackgroundResults and durability of aortic valve replacement in aortic stenosis are well known, but no study has focused on the results of aortic valve replacement in aortic insufficiency. AimThe aim of this retrospective study was to describe our mid-term outcomes after aortic valve replacement for aortic insufficiency. MethodsAll consecutive adult patients who underwent bioprosthetic aortic valve replacement for aortic insufficiency at two European centres (in France and Germany) between May 2005 and December 2020 were analysed. ResultsDuring the study period, 289 patients were included. Mean age was 56.9±12.5 years. Overall operative mortality was 1.5%, and the 10-year survival estimate rate was 75.0%, which was significantly lower than in the age- and sex-matched general population, with a standardized mortality ratio of 2.88 (95% confidence interval 1.96–4.08; P<0001). Freedom from aortic valve-related death was 87.6%, and from aortic valve-related reoperation was 87.4%. No patient aged>60 years was reoperated on during follow-up. Freedom from severe structural valve deterioration at 10 years was 73.3%, and freedom from moderate structural valve deterioration at 10 years was 50.3%. Freedom from major adverse valve-related events at 10 years was 69.7%. ConclusionsAlthough bioprosthetic aortic valve replacement for aortic insufficiency shows good early results, 10-year mortality and major adverse valve-related event rates in young patients may be a concern, with a reduction in life expectancy compared with the general population.

Surgical Aortic Valve Replacement for Aortic Insufficiency: Just Do It!

Surgical Aortic Valve Replacement for Aortic Insufficiency: Just Do It!

Reversal of fixed pulmonary hypertension with transcatheter valve replacement for aortic insufficiency on ventricular assist device support

We present a 43-year-old woman with a nonischemic cardiomyopathy implanted with a ventricular assist device (VAD) as bridge to transplant due to severe, “fixed” pulmonary hypertension (PH). Within three months of VAD implant, her “fixed” PH had resolved entirely. Nearly two years later, still supported with a VAD because of severe HLA allosensitization, she developed dyspnea and “moderate” aortic insufficiency (AI) by standard criteria. Invasive hemodynamics revealed recurrence of severe PH in the setting of elevated left-sided filling pressures. We concluded the AI was indeed severe and the cause of her symptoms and recurrent PH. Despite her noncalcified aortic valve and small body habitus, after a thorough assessment, including meticulous annular measurements and appropriate valve sizing, she underwent a transcatheter aortic valve replacement (TAVR) with complete resolution of both her AI and recurrent, severe PH. This case highlights, in a single patient, reversal of “fixed” PH with adequate left ventricular unloading, that “moderate” AI by standard criteria is often “severe” and must be considered in a VAD patient with recurrent PH, and the need for meticulous pre-procedural planning for TAVR in patients with VADs, including accurate measurements of the aortic annulus to ensure adequate oversizing of the valve.

Patients with anomalous aortic origin of the coronary artery remain at risk after surgical repair

ObjectivesAnomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare cardiac anomaly associated with sudden cardiac death (SCD). Single-center studies describe surgical repair as safe, although medium- and long-term effects on symptoms and risk of SCD remain unknown. We sought to describe outcomes of surgical repair of AAOCA. MethodsWe reviewed institutional records for patients who underwent AAOCA repair, from 2001 to 2016, at 2 affiliated institutions. Patients with associated heart disease were excluded. ResultsIn total, 60 patients underwent AAOCA repair. Half of the patients (n = 30) had an anomalous left coronary artery arising from the right sinus of Valsalva and half had an anomalous right. Median age at surgery was 15.4 years (interquartile range, 11.9-17.9 years; range, 4 months to 68 years). The most common presenting symptoms were chest pain (n = 38; 63%) and shortness of breath (n = 17; 28%); aborted SCD was the presenting symptom in 4 patients (7%). Follow-up data were available for 54 patients (90%) over a median of 1.6 years. Of 53 patients with symptoms at presentation, 34 (64%) had complete resolution postoperatively. Postoperative mild or greater aortic insufficiency was present in 8 patients (17%) and moderate supravalvar aortic stenosis in 1 (2%). One patient required aortic valve replacement for aortic insufficiency. Two patients required reoperation for coronary stenosis at 3 months and 6 years postoperatively. ConclusionsSurgical repair of AAOCA is generally safe and adverse events are rare. Restenosis, and even sudden cardiac events, can occur and long-term surveillance is critical. Multi-institutional collaboration is vital to identify at-risk subpopulations and refine current recommendations for long-term management.

Abstract 121: Improvement in Functional Mitral Regurgitation After Isolated Aortic Valve Replacement for Aortic Insufficiency

Objective: Aortic insufficiency (AI) can lead to left ventricular (LV) remodeling characterized by dilation and increased LV mass. This remodeling can cause altered mitral valve coaptation and functional mitral regurgitation (FMR). While there is growing evidence that aortic valve replacement (AVR) for aortic stenosis promotes sufficient ventricular reverse remodeling that FMR improves or resolves, this effect is not well characterized for patients with AI. Methods: All cases of AVR for AI that were performed at a single center between January 2003 and December 2015 were reviewed. Cases with any concomitant procedures, any degree of aortic stenosis, any evidence of ischemic etiology, absence of mitral regurgitation, or significant primary mitral pathology were excluded from analysis. The primary outcome was change in FMR after isolated AVR. Secondary outcomes included change in LV ejection fraction (EF), left atrial (LA) dimension, and change in end-diastolic and –systolic LV dimensions. Two-tailed paired t-test was used to evaluate for difference between the two time points. Results: Over the course of 13.4 years, 31 cases of isolated aortic valve replacement for pure aortic insufficiency with concurrent functional mitral regurgitation were identified. 54.8% (17/31) of cases had some evidence of bacteremia or aortic vegetations at time of surgery, with 41.9% (13/31) of cases completed urgently. Postoperatively, FMR was improved in 74.2% (23/31) of the patients, and decreased by a mean 1.0 ± 0.8 grades (1.6 ± 0.8 vs 0.6 ± 0.7, p &lt; 0.001). There was no significant change in LV EF (50.5 ± 13.4 vs. 50.2 ± 12.9, p = 0.892) or LA dimension (42.5 ± 7.2 vs 40.7 ± 5.9, p = 0.341), but there were significant reductions in the dimension of the LV at end-diastole (56.7 ± 7.1 vs 47.7 ± 8.5, p &lt; 0.001) and end-systole (38.5 ± 9.7 vs 34.0 ± 8.3, p = 0.011). Conclusions: Significant reduction in ventricular size and subsequent improvement in functional mitral regurgitation is expected after isolated aortic valve replacement for pure aortic insufficiency.

MRI-based Multiparametric Strain Analysis Predicts Contractile Recovery after Aortic Valve Replacement for Aortic Insufficiency

Guidelines for referral of chronic aortic insufficiency (AI) patients for aortic valve replacement (AVR) suggest that surgery can be delayed until symptoms or reduction in left ventricular (LV) contractile function occur. The frequent occurrence of reduced LV contractile function after AVR for chronic AI suggests that new contractile metrics for surgical referral are needed. In 16 chronic AI patients, cardiac MRI tagged images were analyzed before and 21.5 ± 13.8 months after AVR to calculate LV systolic strain. Average measurements of three strain parameters were obtained for each of 72 LV regions, normalized using a normal human strain database (n = 63), and combined into a composite index (multiparametric strain z score [MSZ]) representing standard deviation from the normal regional average. Preoperative global MSZ (72-region average) correlated with post-AVR global MSZ (R(2) = 0.825, p < 0.001). Preoperative global MSZ also predicts improvement of impaired regions (N = 271 regions from 14 AI patients, R(2) = 0.392, p < 0.001). Preoperative MRI-based LV ejection fraction (LVEF) is also predictive (r = 0.410, p < 0.001). Although global preoperative MSZ had a significantly higher correlation than preoperative LVEF with improvement of injured regions (p < 0.001), both measures convey the same phenomenon. Global preoperative MRI-based multiparametric strain predicts global strain postoperatively, as well as improvement of regions (n = 72 per LV) with impaired contractile function. Global contractile function is an important correlate with improvement in regionally impaired contractile function, perhaps reflecting total AI volume-overload burden (severity/duration of AI).

666 Mechanisms of aortic insufficiency in patients presenting for aortic valve preservation and repair

Aortic valve repair is emerging as a feasible and attractive alternative to valve replacement for aortic insufficiency (AI). However, little is known about the etiology and mechanisms of AI in patients presenting for aortic valve preservation and repair. The objective of this study was to examine the mechanisms of AI and repair techniques required in an unselected cohort of patients.

Aortic Root Replacement in 372 Marfan Patients: Evolution of Operative Repair Over 30 Years

We reviewed the evolution of practice and late results of aortic root replacement (ARR) in Marfan syndrome patients at our institution. A retrospective clinical review of Marfan patients undergoing ARR at our institution was performed. Follow-up data were obtained from hospital and office records and from telephone contact with patients or their physicians. Between September 1976 and September 2006, 372 Marfan syndrome patients underwent ARR: 269 had a Bentall composite graft, 85 had valve-sparing ARR, 16 had ARR with homografts, and 2 had ARR with porcine xenografts. In the first 24 years of the study, 85% received a Bentall graft; during the last 8 years, 61% had a valve-sparing procedure. There was no operative or hospital mortality among the 327 patients who underwent elective repair; there were 2 deaths among the 45 patients (4.4%) who underwent emergent or urgent operative repair. There were 74 late deaths (70 Bentalls, 2 homograft, and 2 valve-sparing ARRs). The most frequent causes of late death were dissection or rupture of the residual aorta (10 of 74) and arrhythmia (9 of 74). Of the 85 patients who had a valve-sparing procedure, 40 had a David II remodeling operation; there was 1 late death in this group, and 5 patients required late aortic valve replacement for aortic insufficiency. A David I reimplantation procedure using the De Paulis Valsalva graft has been used exclusively since May 2002. All 44 patients in this last group have 0 to 1+ aortic insufficiency. Prophylactic surgical replacement of the ascending aorta in patients with Marfan syndrome has low operative risk and can prevent aortic catastrophe in most patients. Valve-sparing procedures, particularly using the reimplantation technique with the Valsalva graft, show promise but have not yet proven as durable as the Bentall.

Prosthesis–patient mismatch is less frequent and more clinically indolent in patients operated for aortic insufficiency

To date, no study has focused on the incidence and effects of prosthesis-patient mismatch in patients requiring aortic valve replacement for aortic insufficiency. We hypothesized that the incidence and implications of prosthesis-patient mismatch in patients with aortic insufficiency might be different than for aortic stenosis or mixed disease because the annulus is generally larger in aortic insufficiency and left ventricular remodeling might differ. Ninety-eight patients with lone aortic insufficiency (>or=3+ with a preoperative mean gradient <30 mm Hg) were followed over 7.7 +/- 4.3 years (maximum, 17.5 years) with clinical and echocardiographic assessments. They were compared with 707 patients who had aortic valve replacement for aortic stenosis or mixed disease. Prosthesis-patient mismatch was defined as an in vivo indexed effective orifice area of 0.85 cm(2)/m(2) or less. Compared with patients with aortic stenosis/mixed disease, patients with aortic insufficiency had approximately half the incidence of prosthesis-patient mismatch (P = .003). Patients with prosthesis-patient mismatch had significantly higher transprosthesis gradients postoperatively. An independent detrimental effect of prosthesis-patient mismatch on survival was observed in patients with aortic stenosis/mixed disease who had preoperative left ventricular dysfunction (hazard ratio, 2.3; P = .03) but not in patients with aortic insufficiency, irrespective of left ventricular function (hazard ratio, 0.7; P = .7). In patients with aortic stenosis/mixed disease with left ventricular dysfunction, prosthesis-patient mismatch predicted heart failure symptoms by 3 years after aortic valve replacement (odds ratio, 6.0; P = .002), but there was no such effect in patients with aortic insufficiency (P = .8). Indexed left ventricular mass regression occurred to a greater extent in patients with aortic insufficiency than in patients with aortic stenosis/mixed disease (by an additional 29 +/- 5 g/m(2), P < .001), and there was a trend for prosthesis-patient mismatch to impair regression in patients with aortic insufficiency (by 30 +/- 17 g/m(2), P = .1). The incidence and significance of prosthesis-patient mismatch differs in patients with aortic insufficiency compared with those with aortic stenosis or mixed disease. In patients with aortic insufficiency, prosthesis-patient mismatch is seen less frequently and has no significant effect on survival and freedom from heart failure but might have a negative effect on left ventricular mass regression.

Aorto–Atrial Fistula: An Important Complication of Aortic Prosthetic Valve Endocarditis

Aorto–Atrial Fistula: An Important Complication of Aortic Prosthetic Valve Endocarditis

Systolic Anterior Motion of the Mitral Valve After Aortic Valve Replacement for Aortic Insufficiency

INTRAOPERATIVE SYSTOLIC ANTERIOR motion of the mitral valve (SAM) after aortic valve replacement (AVR) for aortic stenosis has been previously described.1,2 The presence of concentric left ventricular hypertrophy (LVH), a relatively narrow left ventricular outflow tract (LVOT), and increased blood flow velocity in the LVOT when coupled with perioperative hypovolemia and/or vasodilatation place patients with aortic stenosis at risk for SAM. Alternatively, patients with aortic insufficiency (AI) are much less likely to develop SAM because this regurgitant lesion is most often associated with a dilated left ventricle (LV) and the LVOT widens during systole preventing apposition of the anterior leaflet.

Management of Aortic Insufficiency With Continuous Flow Left Ventricular Assist Devices: Bioprosthetic Valve Replacement

There are several methods for surgical management of aortic insufficiency in patients with end-stage congestive heart failure who are undergoing implantation of a left ventricular assist device (LVAD). To date, little is known about the long-term outcome of bioprosthetic valves for aortic insufficiency in patients with continuous flow LVADs. We report on two patients with bioprosthetic aortic valve replacement for aortic insufficiency at the time of HeartMate II LVAD insertion.

Aortic Valve Replacement for Aortic Insufficiency: Valve Type as a Determinant of Systolic Strain Recovery

Left ventricular (LV) 3D systolic strain decreases in absolute value postoperatively and does not recover in patients who undergo aortic valve replacement (AVR) for chronic aortic insufficiency (AI). We investigated whether choice of valve prosthesis (mechanical [St. Jude], bioprosthetic [bovine pericardial], Ross procedure) had a significant impact on strain recovery in this surgical population. MRI with tissue-tagging was performed on 14 patients with chronic AI both before and 28 +/- 13 months after AVR. Average values of LV systolic strain and end-systolic stress (ESS) were computed from MRI data for the LV. Three types of prosthetic valve were examined (Ross procedure n = 4, bovine pericardial n = 5, and St. Jude n = 5). Overall, systolic strain, ESS, LV volumes, ejection fraction, and LV mass all changed significantly following AVR. Comparisons between individual valve types revealed no differences in any of these measurements. Patients who received a mechanical valve had a greater decrease in the absolute value of systolic strain following surgery compared to patients from the nonmechanical group (Ross procedure and bioprosthetic valve). Comparisons between the Ross group and the prosthetic group (St. Jude and bioprosthetic) produced no significant differences in strain, ESS, LV volume, and mass. These early results suggest that valve prosthetic type may be a factor in efforts to improve strain recovery after AVR for AI, although further investigation is warranted. MRI with tissue-tagging may be a useful tool for comparing the impact of prosthetic valve choice on incompletely recovered systolic strain following AVR for chronic AI.

Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction characterized by thrombocytopenia and a high risk for venous or arterial thrombosis.1 It is caused by heparin-dependent, platelet-activating antibodies that recognize a “self” protein, platelet factor 4 (PF4), bound to heparin. The resulting platelet activation is associated with increased thrombin generation (Figure).2 Typically, the platelet count fall begins 5 to 10 days after starting heparin, although a rapid platelet count fall can occur in a patient who has antibodies from recent heparin use.3 Remarkably, transience of HIT antibodies permits safe heparin reexposure in selected patients (for example, heart surgery patients) despite a history of HIT.3,4 Pathogenesis of HIT. HIT antibodies of IgG class bind to multimolecular complexes of platelet factor 4 (PF4) and heparin on platelet surfaces, resulting in platelet activation when the IgG molecules interact with the platelet Fc receptors. Platelet-derived microparticles are generated, which enhance coagulation reactions. In addition, HIT antibodies can activate endothelium and monocytes, exacerbating the procoagulant response. Activation of platelets and increased production of thrombin could explain the high risk of arterial and venous thrombosis in HIT. Reprinted with permission from Greinacher and Warkentin.2 A 61-year-old woman5 with Ray-naud’s phenomenon underwent mechanical aortic valve replacement for aortic insufficiency. She developed persistent vasospasm of fingers and toes after surgery that responded to warming measures. Unfractionated heparin (UFH) prophylaxis was given until postoperative day 4, and warfarin (5, 5, and 2.5 mg) was given from days 2 to 4. On day 8, the patient developed ischemic necrosis of multiple fingers and toes. The platelet count had fallen by 44% from 221×109/L (day 4) to 124×109/L (day 8), and the international normalized ratio (INR) rose to 4.3. The diagnosis of delayed-onset HIT complicated by warfarin-induced digital necrosis was supported …

Prognostic factors associated with optimal surgical outcome after valve replacement for aortic insufficiency in children Suzie Lee, Kyong-Jin Lee, Brian W. McCrindle. The Hospital for Sick Children, Toronto, ON, Canada

Prognostic factors associated with optimal surgical outcome after valve replacement for aortic insufficiency in children Suzie Lee, Kyong-Jin Lee, Brian W. McCrindle. The Hospital for Sick Children, Toronto, ON, Canada

Restrictive-type hemodynamics following valve surgery for rheumatic heart disease

Over a six-year period three patients with rheumatic valvular disease presented with congestive heart failure due to abnormalities in myocardial diastolic function. Each patient previously had been operated for mitral stenosis; one patient had additional aortic valve replacement for aortic insufficiency. The mean time for the development of symptoms following surgery was 4.7 years. In all patients, left ventricular systolic function was normal (radionuclide or angiographic ejection fraction greater than 0.50). Abnormalities in diastolic function involved the left ventricle in all patients. Biopsy material from right (one patient) and left (one patient) ventricles was nonspecific in its histologic appearance. Other disease processes, such as constrictive pericarditis and diabetic cardiomyopathy were considered to be clinically unimportant in these patients. Restrictive-type hemodynamics in patients with postoperative rheumatic heart disease may comprise a newly recognized entity.

Coronary Sinus Blood Flow and Myocardial Oxygen Consumption after Valve Replacement for Aortic Insufficiency

Seven cases are reviewed in which the aortic valve was replaced with a Bjö;rk-Shiley tilting disk valve to treat aortic insufficiency. Comparative studies were made to determine coronary sinus blood flow (CSF) and myocardial oxygen consumption ( ▪o 2) by using a continuous thermodilution method both before and after the operation. Additionally, indexes of left ventricular function were obtained by catheterization of the right and left heart and by left ventriculography. Postoperative total CSF decreased significantly compared with the preoperative value ( p < 0.02). However, in all cases, the postoperative CSF per 100 g of left ventricle (LV) increased compared with the preoperative measurement ( p < 0.001). The CSF per beat per 100 g LV also increased postoperatively ( p < 0.001). Total M ▪o 2 decreased postoperatively ( p < 0.02). However, the M ▪o 2 per unit mass tended to increase postoperatively; these increases were not significant. Postoperatively the left ventricular mass and left ventricular wall stress decreased considerably. The left ventricular ejection fraction (EF) and the mean velocity of circumferential fiber shortening (mVCF) remained at normal levels, whereas the left ventricular function improved markedly. In short, the total CSF decreased, along with LVM and left ventricular wall stress. However, because CSF per unit mass increased and EF and mVCF remained at normal values, it is assumed that the increase in CSF is associated with improvement in postoperative contractility.

Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency

A group of 80 patients were studied retrospectively to determine whether preoperative echocardiography is useful in predicting operative results in patients with aortic valve replacement for chronic aortic insufficiency. One year after operation, percent change of left ventricular dimension (%delta D) and ejection fraction (EF) were higher and end-systolic left-ventricular internal dimension was smaller in patients with good results than in those who had poor results (p less than 0.05). Regarding probability of 5 year survival, patients with a %delta D of more than 35% had good prognosis, those with 31% to 35% had a fairly good prognosis, and those with 30% or less had increased risk of death, especially if they were in New York Heart Association (NYHA) Functional Class III or IV. All deaths occurred in patients with preoperative values of 31% or less. Patients with EF of 60% or more had a better prognosis than those with a value of less than 60%. In addition, 10 early postoperative echocardiographic studies showed no correlation between early regression of end-diastolic left ventricular internal dimension and long-term operative results; 18 late postoperative studies showed reduction in this dimension in patients with good surgical results, and the only one with a poor result had an enlarged dimension. Thus echocardiographic indices of left ventricular function (%delta D) and EF) may be useful as prognostic indicators in patients undergoing aortic valve replacement for aortic insufficiency.

Syndrome of acute hemorrhagic intestinal infarction and renal insufficiency following aortic valve replacement for aortic insufficiency

Syndrome of acute hemorrhagic intestinal infarction and renal insufficiency following aortic valve replacement for aortic insufficiency