A novel calcium scoring system accurately predicts likelihood and location of post-TAVI paravalvular leak

AIM

Sclerosis distribution, topography and morphology in aortic stenosis may have an impact on the localisation of post-procedural paravalvular leakage (PVL) following transcatheter aortic valve implantation (TAVI).

METHODS

Between 05/2005 and 03/2011 a total of 208 patients underwent either transapical (TA) or transvascular (TV) TAVI using the Edwards-SAPIEN(TM), or CoreValve(TM) system. Aortic cusp and annular sclerosis distribution and aortic valve sclerosis symmetry were evaluated by preoperative transesophageal echocardiography (TOE). Mild, moderate and severe PVL after TAVI (group 1, N.=117) were analysed and compared to those patients with no signs of postprocedural PVL (group 2, N.=91). Commercial available image processing and analysing software were used to evaluate all relevant calcific sections (aortic sclerosis score 0-66; symmetry score 0-5) and were matched with the localization of the PVLs.

RESULTS

A total of 117 patients (83±6 years, mean logistic EuroSCORE 20.1±12.7%) were identified with a mild-moderate PVL (TV, N.=102; TA, N.=15). Mean aortic sclerosis score was 38.7±7.6 in group 1 compared to 33.7±8.3 in group 2 (P<0.001) showing highest calcification in the non-coronary part for both groups. The mean symmetry score was 1.9±1.0 group 1 compared to 1.7±1.0 in group 2 (P=0.12). Regression analysis showed a significant relation of preoperative cusp localisation to the corresponding paravalvular leakage (P<0.001).

CONCLUSION

The present study shows that a aortic sclerosis score constructed by TOE enables prediction of postoperative PVL and moreover, the localisation of PVL after TAVI correlates with the corresponding preoperative amount of sclerosis for each cusp.

[Angioscopy: a new intraoperative diagnostic and interventional tool for thoracic aortic treatment]

In complex thoracic aortic disease endovascular techniques and the use of hybrid stent grafts enables a combination therapy of the aortic arch and the descending aorta through a median sternotomy. This emphasizes the importance of intraoperative visualization of the descending aorta and its pathologies. Intraoperative angioscopy is a new diagnostic method for the assessment of distal aortic disease and assists in therapeutic decision-making and navigation of endovascular techniques in the descending aorta. This study presents the angioscopic results of 62 patients (mean age 60±12 years, 73% male, 54 aortic dissections, eight aortic aneurysms) during surgery of the thoracic aorta. Visualization of the extent of pathology along the downstream aorta was feasible in all patients. The implantation of a hybrid stent graft prosthesis was assisted by angioscopy in 34 patients and endovascular balloon dilatation of the stent graft was navigated by angioscopy in 11 patients. Angioscopy has become an indispensable tool in the intraoperative treatment of complex thoracic aortic disease in our clinic, particularly in the navigation of endovascular interventions in the distal thoracic aorta through the aortic arch.

Towards trends in minimal invasive cardiac surgery

While various minimally invasive techniques have been established in many other surgical specialties during the last decades, cardiac surgery has been one of the last domains to adopt the principles of minimally invasive techniques. This was mainly based on the reduced surgical exposure in highly complex cardiac operations and the missing technical requirements in the beginning of the modern cardiac era. Nowadays, technical conditions have continuously improved and have become routine also in cardiac surgery. Most of these novel minimal-invasive concepts have been developed in order to treat high-risk or inoperable patients by reducing operative trauma. Actually, since more high-risk and multimorbid patients were referred for surgery, these initial extraordinary procedures have been adopted into daily clinical routine. Currently, many promising innovations aim to reduce the operative trauma and perioperative morbidity, and furthermore, to increase patients' satisfaction and security. It is anticipated that in the future this current trend towards minimal invasiveness will increase further due to an increased demand, and therefore, such minimal-invasive procedures will become less complex and straightforward.

On-line monitoring of oxygen as a non-destructive method to quantify cells in engineered 3D tissue constructs

Regulatory guidelines have established the importance of introducing quantitative quality controls during the production and/or at the time of release of cellular grafts for clinical applications. In this study we aimed to determine whether on-line measurements of oxygen can be used as a non-destructive method to estimate the number of chondrocytes within an engineered cartilage graft. Human chondrocytes were seeded and cultured in a perfusion bioreactor, and oxygen levels in the culture medium were continuously monitored at the inlet and outlet of the bioreactor chamber throughout the culture period. We found that the drop in oxygen across the perfused construct was linearly correlated with the number of cells per construct (R(2)  = 0.82, p < 0.0001). The method was valid for a wide range of cell numbers, including cell densities currently used in the manufacture of cartilage grafts for clinical applications. Given that few or no non-destructive assays that quantitatively characterize an engineered construct currently exist, this non-invasive method could represent a relevant instrument in regulatory compliant manufacturing of engineered grafts meeting specific quality criteria.