Diabetes Mellitus Impairs Left Ventricular Mass Regression after Surgical or Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis

BACKGROUND

It is well-documented that persistent myocardial hypertrophy in patients with aortic stenosis is related to suboptimal postoperative outcomes after aortic valve replacement. Although diabetes is known to potentially exacerbate myocardial hypertrophy, it has yet to be examined if it affects postoperative left ventricular mass regression (LVMR).

METHODS

A single-centre, retrospective analysis was performed on 183 consecutive patients who underwent either surgical or transcatheter aortic valve replacement between 2010 and May 2013. Patient demographics, postoperative outcomes and echocardiographic data were obtained preoperatively and a year after surgery.

RESULTS

There were 42 diabetic and 141 non-diabetic patients. Preoperative characteristics of diabetic patients were statistically similar to those of non-diabetic patients, except for higher prevalence of hyperlipidaemia (p <0.001) and history of cerebrovascular disorder (p=0.046) in diabetic patients. Median value of postoperative LVMR of all patients was -36.5 g/m(2), and was significantly greater in the non-diabetics compared to the diabetics (-39.1 vs. -22.2 g/m(2), p=0.008). Univariate and multivariate analyses were performed on preoperative variables, and stepwise multiple regression analysis demonstrated that diabetes (standardised partial regression coefficient (SPRC)=-0.187, p=0.018), female gender (SPRC=0.245, p=0.026) and age (SPRC=0.203, p=0.018) were associated with poor postoperative LVMR.

CONCLUSIONS

Patients with diabetes showed suboptimal postoperative LVMR, and the disease was a prognostic factor that was associated with poor LVMR. These findings suggest that diabetes may predispose the particular group of patients to worse postoperative outcomes.

The lipid theory in the pathogenesis of calcific aortic stenosis

AIMS

Biologically active phenomena, triggered by atherogenesis and inflammation, lead to aortic valve (AV) calcification. Lipids play an important role in activating the cell signaling leading to AV bone deposition. This review, based on evidence from animal and human studies, mainly focused on the involvement of lipids and atherogenic phenomena in the pathogenesis of calcific aortic stenosis (AS).

DATA SYNTHESIS

The role of elevated low density lipoproteins for the risk of both vascular atherosclerosis and AS has been elucidated. Lipid disorders act synergistically with other risk factors to increase prevalence of calcific AS. Atherosclerosis is also involved in the pathogenesis of bone demineralization, a typical hallmark of aging, which is associated with ectopic calcification at vascular and valvular levels. Animal studies have recently contributed to demonstrate that lipids play an important role in AS pathogenesis through the activation of molecular cell signalings, such as Wnt/Lrp5 and RANK/RANKL/Osteprotegerin, which induce the transition of valvular myofibroblasts toward an osteogenic phenotype with consequent valvular bone deposition. Although all these evidence strongly support the lipid theory in AS pathogenesis, lipids lowering therapies failed to demonstrate in controlled trials a significant efficacy to slow AS progression. Encouraging results from animal studies indicate that physical activity may counteract the biological processes inducing AV degeneration.

CONCLUSIONS

This review indicates a robust interplay between lipids, inflammation, and calcific AS. This new pathophysiological scenario of such an emerging valvular disease paves the way to the next challenge of cardiovascular research: "prevent and care aortic valve stenosis".

Supravalvular aortic stenosis after arterial switch operation

Supravalvular aortic stenosis as a late complication of transposition of the great arteries is very rare, and only a few cases have been reported. We describe the case of a 14-year-old girl who developed supravalvular aortic stenosis as a late complication of the arterial switch operation for transposition of the great arteries. The narrowed ascending aorta was replaced with a graft. The right pulmonary artery was transected to approach the ascending aorta which adhered severely to the main pulmonary trunk, and we obtained a good operative field.

Aortic regurgitation after transcatheter aortic valve implantation (TAVI) - Angiographic, echocardiographic and hemodynamic assessment in relation to one year outcome

BACKGROUND

Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) remains a relatively frequent and life-limiting complication. However, the most prognostically discriminative (and therefore preferred) technique of AR evaluation after TAVI is not yet clearly defined. The aim of this study was to compare angiographic, echocardiographic and hemodynamic assessment of AR after TAVI in relation to one year outcome.

METHODS AND RESULTS

In this single center prospective cohort study, angiography (AR grading), echocardiography (AR quantification using color Doppler flow mapping) and invasive hemodynamics (AR index) were assessed before and after TAVI. All patients were followed up to at least one year. A total of 111 consecutive (very) high-risk patients with severe, symptomatic aortic valve stenosis underwent TAVI. No concordant relation could be demonstrated between angiographic, echocardiographic and invasive assessment of AR after TAVI. AR index <25 post TAVI was significantly influenced by left ventricular posterior wall thickness (odds ratio: 1.276, p=0.030) and AR index pre TAVI (odds ratio: 0.948, p=0.019). Neither angiographic nor hemodynamic AR assessments were able to discriminate between good or significantly decreased one year survival. In contrast, color Doppler flow mapping of AR after TAVI was highly reproducible, and able to differentiate between good or significantly decreased one year survival (AR grades 0-I: one year survival 87% vs. AR grades II-III-IV: one year survival 68%, p=0.035).

CONCLUSION

Echocardiography using color Doppler flow mapping is the preferred technique to assess prognostically relevant AR after TAVI.

High left ventricular outflow tract gradient: Aortic stenosis, obstructive hypertrophic cardiomyopathy or both?

The authors report the case of a patient diagnosed with both hypertrophic cardiomyopathy and aortic stenosis. Due to clinical deterioration, additional investigation was performed, and a high left ventricular outflow tract gradient was identified. Correct identification of the condition causing the symptoms was challenging, and involved several imaging techniques, the contribution of transesophageal echocardiography being crucial. The final diagnosis of severe aortic stenosis led to successful valve replacement surgery. The presence of these two conditions in the same patient has been documented, although it is uncommon. This association poses particular diagnostic and therapeutic challenges, which are discussed in this paper.

Hemodynamics of 17-mm vs. 19-mm St. Jude Medical Regent and annulus enlargement

OBJECTIVE

We aimed to compare early and midterm clinical and hemodynamic outcomes of 17-mm vs. 19-mm St. Jude Medical Regent valves with concomitant aortic annulus enlargement.

METHODS

Between 1999 and 2012, 20 patients (group 1) underwent first-time aortic valve replacement with a 17-mm St. Jude Medical Regent valve, and 35 patients (group 2) had a 19-mm valve and concomitant aortic annulus enlargement. The mean follow-up was 81 ± 37 months (range 20-110 months).

RESULTS

There was one death in group 1 vs. 4 in group 2 (p > 0.05). The mean postoperative transprosthetic gradient was 17.5 ± 4.5 in group 1 and 17 ± 6.4 mm Hg in group 2 (p = 0.83), and 37 ± 10.7 and 32 ± 13 mm Hg, respectively, under stress (p = 0.17). Left ventricular mass and left ventricular mass index were reduced and similar in both groups. Postoperative effective orifice area index was higher in group 2 (0.85 ± 0.17 cm(2 )m(-2)) than group 1 (0.76 ± 0.2 cm(2 )m(-2); p > 0.05). A multivariate Cox model identified a 19-mm valve with aortic annulus enlargement (p = 0.032), functional class (p = 0.025), reoperation (p = 0.04), ejection fraction < 35% (p = 0.042), and combined surgery (p = 0.04) as strong predictors of poorer overall event-free survival.

CONCLUSIONS

The 17-mm St. Jude Medical Regent valve may be employed with satisfactory postoperative clinical and hemodynamic outcomes in patients with a small aortic annulus, as an alternative to a larger prothesis with aortic annulus enlargement.

Red cell distribution width improves the prediction of prognosis after transcatheter aortic valve implantation

OBJECTIVES

The aim of this study was to determine if red cell distribution width (RDW) could improve the prediction of prognosis after transcatheter aortic valve implantation (TAVI).

METHODS

In this single-centre study, 197 consecutive patients underwent TAVI (median age 82 (77-86), 46.2% men). Normal RDW at baseline was defined as ≤15.5%, elevated RDW at baseline was defined as >15.5%. Ouctomes according to the Valve Academic Research Consortium 2 and survival up to one year were compared between these groups.

RESULTS

Compared with the patients with RDW ≤15.5% (n = 168), those with RDW >15.5% (n = 29) had a higher Society of Thoracic Surgeon (STS) score (7.2 vs 5.0%, P = 0.041), higher systolic pulmonary arterial pressure (50 vs 41 mmHg, P = 0.021) and lower haemoglobin (11.5 vs 12.4 mg/dl, P = 0.003). Patients with RDW >15.5% developed significantly more adverse events after TAVI (major vascular complications: 10.3 vs 1.8%, P = 0.042; aortic regurgitation grade II-IV: 50.0 vs 18.0%, P = 0.001) and survival up to 1 year was significantly lower (85.6 vs 65.2%, log-rank: P = 0.007). In addition, RDW >15.5% at baseline was the most significant predictor for mortality (hazard ratio: 2.701 (1.279-5.704), P = 0.009), even when the STS score was added to the model [RDW >15.5%: hazard ratio: 2.276 (1.045-4.954), P = 0.038].

CONCLUSIONS

Elevated RDW is a significant predictor for adverse events and increased 1-year mortality after TAVI. Adding RDW to the classical STS score could be a valuable strategy to improve preoperative risk assessment in potential TAVI candidates.

Total endoscopic sutureless aortic valve replacement: rationale, development, perspectives

Transcatheter valve implantation is progressively becoming the first line option for high risk patients in the management of severe aortic valve stenosis. Surgery is likely to remain the gold standard treatment option for intermediate risk patients since it ensures ablation of the underlying pathology and the calcified aortic valvular tissue, which potentially can act as a nidus of chronic embolization and provoke neurocognitive dysfunction in this subset of active patients. The surgical approach is continually evolving, with sutureless technology having the potential to facilitate ministernotomy and minithoracotomy approaches. Furthermore, Nitinol stented models can be introduced through thoracoscopic trocars, enabling the evolution of totally endoscopic aortic valve replacement (TEAVR). We present herein the development of TEAVR, starting from the cadaver experience in our lab. We transitioned through a clinical minithoracotomy video-assisted experience until we finally could initiate a program of human sutureless TEAVR. The limitations of this approach, which is still in refinement, and possible innovative solutions in order to build up a quick and reproducible procedure are discussed.

A novel contribution towards coherent and reproducible intravalvular measurement of the aortic annulus by multidetector computed tomography ahead of transcatheter aortic valve implantation

BACKGROUND

As current multidetector computed tomography (MDCT) measurements underestimate the size of the aortic annulus ahead of transcatheter aortic valve implantation (TAVI), a strategy of approximate annulus area oversizing has been adopted recently.

AIMS

To measure the aortic annulus using a novel complementary intravalvular MDCT slice.

METHODS

Fifty-five patients with severe aortic stenosis were selected for MDCT ahead of and 1 month after CoreValve(®) TAVI. Two MDCT slices were analysed and compared: the current standard virtual basal ring (VBR) at the nadir of the aortic cusps; and a novel slice, defined as the basal (lowest) complete commissural coaptation (BCCC) plane.

RESULTS

BCCC is an intravalvular plane lying 5.2±0.8 mm above the VBR. The BCCC annulus is almost circular, unlike the VBR (mean eccentricity index 0.09±0.04 vs 0.3±0.1, respectively). The mean BCCC annulus diameter was 26.6±2.3 mm, 16% larger than that of the VBR (23.9±2.2 mm; P<0.001). The BCCC annulus area proved coherent with the orifice area measured after TAVI on the projection of the same slice (i.e. systematically equal to or greater than the latter [mean difference, +2.3±1.4 mm]), in contrast to the wider scatter found for the VBR (-1.3±2.0 mm). Once the sclerotic calcified valves have been pushed back by the implant, the aortic orifice after TAVI will inevitably be equal to or less than the diameter of the virtually unvalved annulus before TAVI.

CONCLUSION

Based on the present results, we recommend including a BCCC slice to complete aortic annulus sizing, in order to optimize implant calibration.

Valve thrombosis following transcatheter aortic valve implantation: a systematic review

INTRODUCTION AND OBJECTIVES

Despite the rapid global uptake of transcatheter aortic valve implantation, valve trombosis has yet to be systematically evaluated in this field. The aim of this study was to determine the clinical characteristics, diagnostic criteria, and treatment outcomes of patients diagnosed with valve thrombosis following transcatheter aortic valve implantation through a systematic review of published data.

METHODS

Literature published between 2002 and 2012 on valve thrombosis as a complication of transcatheter aortic valve implantation was identified through a systematic electronic search.

RESULTS

A total of 11 publications were identified, describing 16 patients (mean age, 80 [5] years, 65% men). All but 1 patient (94%) received a balloon-expandable valve. All patients received dual antiplatelet therapy immediately following the procedure and continued to take either mono- or dual antiplatelet therapy at the time of valve thrombosis diagnosis. Valve thrombosis was diagnosed at a median of 6 months post-procedure, with progressive dyspnea being the most common symptom. A significant increase in transvalvular gradient (from 10 [4] to 40 [12] mmHg) was the most common echocardiographic feature, in addition to leaflet thickening. Thrombus was not directly visualized with echocardiography. Three patients underwent valve explantation, and the remaining received warfarin, which effectively restored the mean transvalvular gradient to baseline within 2 months. Systemic embolism was not a feature of valve thrombosis post-transcatheter aortic valve implantation.

CONCLUSIONS

Although a rare, yet likely under-reported complication of post-transcatheter aortic valve implantation, progressive dyspnea coupled with an increasing transvalvular gradient on echocardiography within the months following the intervention likely signifies valve thrombosis. While direct thrombus visualization appears difficult, prompt initiation of oral anticoagulation therapy effectively restores baseline valve function.

Transcatheter Aortic Valve Implantation (TAVI) in Patients With Bicuspid Aortic Valve Stenosis--Systematic Review and Meta-Analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a feasible interventional technique for severe aortic stenosis in patients who are deemed inoperable or at high surgical risk. There is limited evidence for the safety and efficacy of TAVI in patients with bicuspid aortic valves (BAV), the most common congenital valve abnormality. In many TAVI trials, patients with BAV have been contraindicated due to concerns surrounding abnormal valve geometry, leading to malfunction or malpositioning. A systematic review and meta-analysis was conducted in order to assess the current evidence and relative merits of TAVI in aortic stenosis patients with BAV.

METHOD

From six electronic databases, seven articles including 149 BAV and 2096 non-BAV patients undergoing TAVI were analysed.

RESULTS

Between the BAV and no-BAV cohorts, there was no difference in 30-day mortality (8.3% vs 9.0%; P=0.68), post-TAVI mean peak gradients (weighted mean difference, 0.36 mmHg; P=0.55), moderate or severe paravalvular leak (25.7% vs 19.9%; P=0.29), pacemaker implantations (18.5% vs 27.9%; P=0.52), life-threatening bleeding (8.2% vs 13.9%; P=0.33), major bleeding (20% vs 16.8%; P=0.88), conversion to conventional surgery (1.9% vs 1.2%; P=0.18) and vascular complications (8.6% vs 10.1%; P=0.32).

CONCLUSIONS

Preliminary short and mid-term pooled data from observation studies suggest that TAVI is feasible and safe in older patients with BAV. While future randomised trials are not likely, larger adequately-powered multi-institutional studies are warranted to assess the long-term durability and complications associated with TAVI in older BAV patients with severe aortic stenosis.

Management of Coronary Disease in the Era of Transcatheter Aortic Valve Replacement: Comprehensive Review of the Literature

Among the cohort of complex and multifaceted patients undergoing transcatheter aortic valve replacement (TAVR), the prevalence of coronary artery disease (CAD) ranges from 48% to 75%. However, optimal management of CAD in this setting has not been established. This article provides a comprehensive review of the literature to depict the actual knowledge on the subject of aortic stenosis and concomitant CAD. This article also aids heart teams in their decision-making process to appropriately manage these challenging patients with aortic stenosis and CAD. Upcoming randomized studies will clarify the influence of CAD, the best timing for percutaneous coronary intervention, and its impact on TAVR results.

Resting heart rate and risk of adverse cardiovascular outcomes in asymptomatic aortic stenosis: the SEAS study

BACKGROUND

An elevated resting heart rate (RHR) may be an early sign of cardiac failure, but its prognostic value during watchful waiting in asymptomatic aortic stenosis (AS) is largely unknown.

METHODS

RHR was determined by annual ECGs in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study of asymptomatic mild-to-moderate AS patients. Primary endpoint in this substudy was major cardiovascular events (MCEs) and secondary outcomes its individual components. Multivariable Cox-models using serially-measured RHR were used to examine the prognostic impact of RHR per se.

RESULTS

1563 patients were followed for a mean of 4.3years (6751 patient-years of follow-up), 553 (35%) MCEs occurred, 10% (n=151) died, including 75 cardiovascular deaths. In multivariable analysis, baseline RHR was independently associated with MCEs (HR 1.1 per 10min(-1) faster, 95% CI: 1.0-1.3) and cardiovascular mortality (HR 1.3 per 10min(-1) faster, 95% CI: 1.0-1.7, both p≤0.03). Updating RHR with annual in-study reexaminations, time-varying RHR was highly associated with excess MCEs (HR 1.1 per 10min(-1) faster, 95% CI: 1.1-1.3) and cardiovascular mortality (HR 1.4 per 10min(-1) faster, 95% CI: 1.2-1.7, both p≤0.006). The association of RHR with MCEs and cardiovascular mortality was not dependent on atrial fibrillation status (both p≥0.06 for interaction).

CONCLUSIONS

RHR is independently associated with MCEs and cardiovascular death in asymptomatic AS (Clinicaltrials.gov; unique identifier NCT00092677).

One problem two issues! Left ventricular systolic and diastolic dysfunction in aortic stenosis

Reports suggested that immediate post-aortic valve replacement (AVR); left ventricular (LV) dysfunction may be an important risk for morbidity and mortality in patients requiring positive inotropic support. Several factors have been identified as significant prognostic factors i.e., LV systolic dysfunction, LV diastolic dysfunction (LV-DD), heart failure and myocardial infarction (MI). Specific to pathophysiological changes associated with AS, markers of systolic LV function (e.g., LVEF) have been extensively studied in management, yet only a few studies have analysed the association between LV-DD and immediate post-operative LV dysfunction This review brings together the current body of evidence on this issue.

Transcatheter aortic valve implantation in a patient with previous mitral valve replacement

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or are unsuitable candidates for open heart surgery. However, concerns exist over treating patients who have previously undergone mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement who was successfully treated with TAVI using a CoreValve.

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy in infants with severe congenital valvular aortic stenosis: feasibility of a new method†

OBJECTIVES

To evaluate a novel hybrid balloon valvuloplasty procedure for severe congenital valvular aortic stenosis in low-weight infants, performed through the ascending aorta via median sternotomy.

METHODS

Eighteen infants (<90 days of age) with severe congenital aortic stenosis were included in this study. Hybrid balloon valvuloplasty procedures were performed in a hybrid operating room. Patients were followed up at 3 months, 6 months, 1 year and then annually following the procedure.

RESULTS

The hybrid balloon valvuloplasty procedure was successful in all patients. Eight patients were successfully rescued from left ventricular systolic dysfunction by cardiac compression under direct vision. The aortic valve pressure gradient decreased from 80.3 ± 20.8 mmHg preoperatively to 16.0 ± 3.6 mmHg immediately postoperatively (P < 0.001). None of the patients developed significant aortic insufficiency. The fluoroscopy time was 6.2 ± 2.9 min. Intraoperative blood transfusions and pacing were not required. The patients were all alive and healthy at the end of the follow-up period (mean 21.3 months; range 3-41 months), and the aortic valve pressure gradient remained low (21.7 ± 5.3 mmHg). Reintervention was not required in any of the patients.

CONCLUSIONS

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy is an effective and safe procedure for infants with severe congenital aortic stenosis.

Cardiac taurine and principal amino acids in right and left ventricles of patients with either aortic valve stenosis or coronary artery disease: the importance of diabetes and gender

Free intracellular taurine and principal α-amino acids (glutamate, glutamine, aspartate, asparagine and alanine) are abundant in human heart. They are cellular regulators and their concentration can change in response to disease and cardiac insults and have been shown to differ between hypertrophic left ventricle (LV) and the relatively "normal" right ventricle (RV) in patients with aortic valve stenosis (AVS). This difference has not been shown for coronary artery disease (CAD) and there are no studies that have simultaneously compared amino acid content in LV and RV from different pathologies. In this study we investigated the effect of disease on taurine and principal amino acids in both LV and RV, measured in myocardial biopsies collected from patients with either AVS (n = 22) or CAD (n = 36). Amino acids were extracted and measured using HPLC. Intra- and inter-group analysis was performed as well as subgroup analysis focusing on gender in AVS and type 2 diabetes in CAD. LV of both groups has significantly higher levels of taurine compared to RV. This difference disappears in both diabetic CAD patients and in male AVS patients. Alanine was the only α-amino acid to be altered by diabetes. LV of female AVS patients had significantly more glutamate, aspartate and asparagine than corresponding RV, whilst no difference was seen between LV and RV in males. LV of females has higher glutamate and glutamine and less metabolic stress than LV of males. This work shows that in contrast to LV, RV responds differently to disease which can be modulated by gender and diabetes.

Transcatheter aortic valve implantation combined with elective coronary artery stenting: a simultaneous approach†

OBJECTIVES

Many patients referred for transcatheter aortic valve implantation (TAVI) also require percutaneous coronary intervention (PCI). The aim of the study was to identify whether combined treatment of patients with aortic stenosis and coronary artery disease (CAD) with TAVI and PCI has comparable results to treatment of patients with no CAD or with CAD with non-significant lesions who receive only TAVI.

METHODS

Between April 2008 and August 2013, 730 consecutive patients underwent transapical TAVI at our institution. In our study population of 593 patients, 285 (48.1%) had no CAD and received TAVI only (Group I); 232 (39.1%) presented with CAD but no highly significant coronary artery lesion(s) and also received TAVI only (Group II), and 76 (12.8%) had CAD and highly significant coronary lesion(s) and underwent combined, single-staged TAVI and PCI (Group III). Three transapical TAVI patients who received PCI because of iatrogenic coronary artery obstruction during TAVI and 134 transapical TAVI patients with previous CABG were excluded from this study.

RESULTS

Group II showed a calculated mean SYNTAX score of 5.7 ± 7.4. However, Group III showed a statistically significantly higher mean SYNTAX score of 8.0 ± 5.7 than Group II (P < 0.001) before the combined procedure. Combined TAVI and PCI reduced the mean SYNTAX score significantly from 8.0 ± 5.7 to 3.0 ± 4.9 (P < 0.001) in those patients presenting with severe aortic stenosis and highly significant CAD (Group III). The thirty-day all-cause mortality rate was 5.3, 3.9 and 2.6% for Group I, II and III, respectively (P = 0.609). Patients with highly significant CAD undergoing TAVI and PCI had similar survival up to 3 years as patients without CAD undergoing TAVI only. Radiation time and amount of contrast agent were higher during combined treatment in Group III (P < 0.05). However, no difference in acute kidney injury post-procedurally was observed.

CONCLUSIONS

Single-stage combined treatment of severe aortic stenosis and highly relevant coronary lesions is a safe and feasible procedure. Early survival and survival up to 3 years are comparable to that observed in patients presenting without CAD who received TAVI only. PCI effectively reduces the complexity of coronary lesions. Although more contrast agent is applied during the combined treatment, the rate of acute kidney injury was not higher.

The effect of disease on human cardiac protein expression profiles in paired samples from right and left ventricles

BACKGROUND

Cardiac diseases (e.g. coronary and valve) are associated with ventricular cellular remodeling. However, ventricular biopsies from left and right ventricles from patients with different pathologies are rare and thus little is known about disease-induced cellular remodeling in both sides of the heart and between different diseases. We hypothesized that the protein expression profiles between right and left ventricles of patients with aortic valve stenosis (AVS) and patients with coronary artery disease (CAD) are different and that the protein profile is different between the two diseases. Left and right ventricular biopsies were collected from patients with either CAD or AVS. The biopsies were processed for proteomic analysis using isobaric tandem mass tagging and analyzed by reverse phase nano-LC-MS/MS. Western blot for selected proteins showed strong correlation with proteomic analysis.

RESULTS

Proteomic analysis between ventricles of the same disease (intra-disease) and between ventricles of different diseases (inter-disease) identified more than 500 proteins detected in all relevant ventricular biopsies. Comparison between ventricles and disease state was focused on proteins with relatively high fold (±1.2 fold difference) and significant (P < 0.05) differences. Intra-disease protein expression differences between left and right ventricles were largely structural for AVS patients and largely signaling/metabolism for CAD. Proteins commonly associated with hypertrophy were also different in the AVS group but with lower fold difference. Inter-disease differences between left ventricles of AVS and CAD were detected in 9 proteins. However, inter-disease differences between the right ventricles of CAD and AVS patients were associated with differences in 73 proteins. The majority of proteins which had a significant difference in one ventricle compared to the other pathology also had a similar trend in the adjacent ventricle.

CONCLUSIONS

This work demonstrates for the first time that left and right ventricles have a different proteome and that the difference is dependent on the type of disease. Inter-disease differential expression was more prominent for right ventricles. The finding that a protein change in one ventricle was often associated with a similar trend in the adjacent ventricle for a large number of proteins suggests cross-talk proteome remodeling between adjacent ventricles.

The prevalence of aortic stenosis in the elderly in Iceland and predictions for the coming decades: the AGES-Reykjavík study

AIMS

To evaluate the prevalence of significant aortic valve stenosis (AS) in a randomly selected study population of elderly individuals representing the general population of Iceland. Furthermore, to predict the number of individuals likely to have severe AS in the future.

METHODS AND RESULTS

Echocardiography and computed tomography (CT) data from individuals who participated in the AGES-Reykjavik study were used. Echocardiography data from 685 individuals (58% females) aged 67-95 years were available. In both sexes combined, the prevalence for severe AS, defined as an aortic valve area index of <0.6 cm2/m2, in the age groups<70, 70-79 and ≥80 years was 0.92%, 2.4% and 7.3%, respectively. A ROC analysis on the relation between the echocardiography data and the aortic valve calcium score on CT defined a score≥500 to be indicative of severe AS. Subsequently, in a CT study cohort of 5256 individuals the prevalence of severe AS in the same age groups was 0.80%, 4.0% and 9.5%, respectively. Overall, the prevalence of severe AS by echocardiography and CT in individuals≥70 years was 4.3% and 5.9%, respectively. A prediction on the number of elderly≥70 years for the coming decades demonstrated that patients with severe AS will have increased 2.4 fold by the year 2040 and will more than triple by the year 2060.

CONCLUSION

This study, in a cohort of elderly individuals representative of the general population in a Nordic country, predicts that AS will be a large health problem in the coming decades.

A prospective, non-randomized comparison of SAPIEN XT and CoreValve implantation in two sequential cohorts of patients with severe aortic stenosis

OBJECTIVES

Few data is available comparing Edwards SAPIEN XT - SXT (Edwards Lifesciences, Irvine, California) with Medtronic CoreValve - CoV (Medtronic Inc., Minneapolis, Minnesota) in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).

METHODS

We selected consecutive patients undergoing transfemoral TAVR with SXT or CoV at our Institution. Main outcomes were Valve Academic Research Consortium (VARC)-combined safety endpoints.

RESULTS

A total of 100 patients (SXT, n=50 versus CoV, n=50) were analyzed. Both SXT and CoV showed good device success rates (98% versus 90%, p=0.20). SXT versus CoV reduced the occurrence of paravalvular regurgitation after TAVR (26% versus 90%, p<0.0001) though not affecting the rate of moderate/severe regurgitation (p=0.20). SXT versus CoV required less frequently a permanent pacemaker after TAVR (8% versus 38%, p<0.0001). In-hospital major vascular complications (8% versus 4%, p>0.99), life-threatening bleedings (2% versus 4%, p>0.99), stroke (4% versus 6%, p>0.99) and death (6% versus 2%, p>0.99) did not differ between SXT and CoV. However, safety endpoints favored SXT (17% versus 34.6%, p=0.01), due to a numerically higher incidence of ischemic stroke and Acute Kidney Injury Stage 3 after CoV. At multivariate analysis, TAVR with SXT (odds ratio=0.21, 95% confidence intervals [0.05-0.84], p=0.03) was predictive of fewer adverse events.

CONCLUSIONS

Transcatheter valve implantation with Edwards SAPIEN XT was associated with lower VARC-combined safety endpoints as compared with Medtronic CoreValve. More extensive cohorts are needed to confirm these results.

Natural progression of low-gradient severe aortic stenosis with preserved ejection fraction

Because the natural progression of low-gradient aortic stenosis (LGAS) has not been well defined, we performed a retrospective study of 116 consecutive patients with aortic stenosis who had undergone follow-up echocardiography at a median interval of 698 days (range, 371-1,020 d). All patients had preserved left ventricular ejection fraction (>0.50) during and after follow-up. At baseline, patients were classified by aortic valve area (AVA) as having mild stenosis (≥1.5 cm(2)), moderate stenosis (≥1 to <1.5 cm(2)), or severe stenosis (<1 cm(2)). Severe aortic stenosis was further classified by mean gradient (LGAS, mean <40 mmHg; high-gradient aortic stenosis [HGAS], mean ≥40 mmHg). We compared baseline and follow-up values among 4 groups: patients with mild stenosis, moderate stenosis, LGAS, and HGAS. At baseline, 30 patients had mild stenosis, 54 had moderate stenosis, 24 had LGAS, and 8 had HGAS. Compared with the moderate group, the LGAS group had lower AVA but similar mean gradient. Yet the actuarial curves for progressing to HGAS were significantly different: 25% of patients in LGAS reached HGAS status significantly earlier than did 25% of patients in the moderate-AS group (713 vs 881 d; P=0.035). Because LGAS has a high propensity to progress to HGAS, we propose that low-gradient aortic stenosis patients be closely monitored as a distinct subgroup that warrants more frequent echocardiographic follow-up.

Regional left ventricular function after transapical vs. transfemoral transcatheter aortic valve implantation analysed by cardiac magnetic resonance feature tracking

AIMS

This study analysed the impact of transapical (TA) vs. transfemoral (TF) access site transcatheter aortic valve implantation (TAVI) on post-procedural regional left ventricular (LV) function using cardiac magnetic resonance (CMR) feature tracking (FT).

METHODS AND RESULTS

CMR was performed 3 months after TAVI on 44 consecutive patients with normal LV ejection fraction prior to TAVI. Twenty patients had TA-TAVI, and 24 had TF-TAVI. Standard cine imaging was performed in three standard cardiac long-axis views (two-, four- and three-chamber views). Myocardial peak systolic radial strain (PSRS) and peak systolic longitudinal strain (PSLS) were analysed based on CMR-FT considering 49 segments in each of the three views. There were no differences in PSRS and PSLS for the basal and mid-ventricular segments between TA- and TF-TAVI groups. In contrast, PSRS and PSLS of apical segments and apical cap were reduced in the TA- compared with the TF-TAVI group (PSRS: 15.7 ± 6.4 vs. 35.9 ± 15.7%, respectively, P < 0.001; PSLS: -8.9 ± 5.3 vs. -16.9 ± 4.3%, respectively, P < 0.001). Comparison of all non-apical segments vs. apical segments and apical cap demonstrated no difference in the TF group (PSRS: 34.6 ± 9.0 vs. 35.9 ± 15.7%; respectively, P = 0.702; PSLS: -17.8 ± 4.6 vs. -16.9 ± 4.3%; respectively, P = 0.802). After TA-TAVI, PSRS and PSLS of the apical segments were reduced compared with the non-apical segments (PSRS: 15.7 ± 6.4 vs. 33.5 ± 7.0%, respectively, P < 0.001; PSLS: -8.9 ± 5.3 vs. -15.5 ± 3.5%, respectively, P < 0.001).

CONCLUSION

Apical LV function abnormalities can be detected at 3-month follow-up in all TA-TAVI patients using CMR-FT. TA-TAVI results in significant impairment of apical LV function compared with TF-TAVI.

A rare case of biventricular outflow obstruction with intact ventricular septum

We report a case of pulmonary atresia with intact ventricular septum and aortic valve stenosis in a neonate. This combination is extremely rare. Cardiac catheterization was performed at 2 days of age, which confirmed the prenatal echocardiographic diagnosis and identified associated moderate aortic valve stenosis. Soon after the examination, an urgent surgical intervention was required due to uncontrollable circulatory instability. The baby underwent a successful Fontan-type repair achieved by surgical management only.

Left ventricular functional recovery and remodeling in low-flow low-gradient severe aortic stenosis after transcatheter aortic valve implantation

BACKGROUND

Speckle-tracking-derived global longitudinal strain (GLS) is a more sensitive method of detecting left ventricular (LV) functional recovery after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis. However, it remains unknown whether LV function improves in patients with low-flow, low-gradient severe aortic stenosis (LFLGSAS) after TAVI. The aim of the present was to evaluate LV functional recovery and remodeling after TAVI in patients with LFLGSAS.

METHODS

Sixty-eight patients (57% men; mean age, 79.1 ± 7.1 years) with LFLGSAS treated with TAVI were evaluated. LV function and remodeling were investigated before TAVI and at 6 and 12 months after TAVI. All echocardiographic data were prospectively collected, and GLS was retrospectively analyzed.

RESULTS

Among patients with LFLGSAS, 35 (52%) had low LV ejection fraction (LVEF) (<50%), and 33 (48%) had preserved LVEF (≥50%). The low-LVEF group had significantly more impaired GLS than the group with preserved LVEF (-8.3 ± 2.6% vs -13.3 ± 3.5%, P < .001). LV systolic function improved after TAVI in both groups. Although in the group of patients with low LVEF, all functional parameters improved, in the group of patients with preserved LVEF, only strain-derived parameters significantly improved. There were significant decreases in absolute LV wall thickness and relative wall thickness and a trend toward decreased LV mass index in both LVEF groups. LV volumes decreased significantly in those with low LVEF but not in those with preserved LVEF. Baseline GLS but not LVEF group was independently associated to GLS improvement at 12 months after TAVI.

CONCLUSIONS

Patients with LFLGSAS with low and preserved LVEF had a significant improvement in LV function after TAVI, as assessed by GLS. Absolute and relative LV wall thickness decreased in both groups of patients, but only those with low LVEF had reductions in LV volumes.

Perioperative predictors of midterm survival after aortic valve replacement

BACKGROUND

Elderly patients with aortic stenosis are under-referred for aortic valve replacement surgery. This study investigated the perioperative factors associated with midterm outcomes in a consecutive series of patients undergoing aortic valve replacement with or without coronary artery bypass graft surgery.

METHODS

From 2006 to 2010, 509 patients having aortic valve replacement or aortic valve replacement with coronary artery bypass were grouped according to age (<80 years and ≥80 years) and procedure (aortic valve replacement ± coronary artery bypass). Patient survival was followed up for 5 years (mean 2.6 years). Midterm survival was evaluated using Kaplan-Meier and Cox proportional hazards regression model statistics.

RESULTS AND CONCLUSIONS

5-year survival among octogenarians was 59.2% with an observed 30-day mortality of 1% for aortic valve replacement and 3% for aortic valve replacement with coronary artery bypass. Kaplan-Meier survival analysis showed that age ≥80 years, New York Heart Association functional class III/IV, and left ventricular ejection fraction <35% were significantly associated with increased midterm mortality. Cox regression modeling demonstrated that age ≥80 years was the only significant independent factor associated with midterm mortality; older patients had a 3-fold increase in mortality (adjusted hazard ratio = 3.231, 95% confidence interval: 1.764-5.920, p < 0.0001). While hospital and 30-day mortality were not statistically different between age groups, age ≥80 years was the most powerful predictor of midterm death. These results support early aortic valve replacement with or without coronary artery bypass in aortic stenosis management.

Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation

OBJECTIVES

Significant coronary artery disease (CAD) is common among patients currently evaluated for transcatheter aortic valve implantation (TAVI). Limited data exist on the outcome of patients undergoing combined transcatheter treatment of aortic valve disease and CAD. The aim of the study was to analyse the impact of concomitant percutaneous coronary intervention (PCI) on early and late clinical outcomes of patients receiving TAVI.

METHODS

TAVIs were performed through either transfemoral or transapical access using SAPIEN (XT), CoreValve or AcurateTA valves. PCI was decided by the interdisciplinary heart team and performed synchronously or as a staged procedure upfront. Standardized valve academic research consortium (VARC)-2 endpoints were used. In case of a staged approach, TAVI was defined as the index procedure. Thirty-day outcomes and Kaplan-Meier 2-year survival were analysed.

RESULTS

Of 411 TAVIs, 65 (16%) received PCI. Mean age was 82 years (P = 0.92) and mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.7% (TAVI + PCI) and 20.3% (TAVI; P = 0.47). PCI was performed as staged procedure upfront (74%) or synchronously (26%). In 95% of PCIs, a single coronary artery was treated, and 71% received bare metal stents. Incidence of myocardial infarction (6 vs 1%; P = 0.01) and 30-day mortality (15 vs 5%; P = 0.01) were higher in the TAVI + PCI group, compared with the TAVI group. Synchronous (18%) vs staged (15%) approach for PCI had comparable early mortality (P = 1.0). Kaplan-Meier 2-year survival was poorer in the TAVI + PCI group (P = 0.03) with an odds ratio of 1.66 (P = 0.04).

CONCLUSIONS

Concomitant PCI is--when based on current heart team practice--associated with increased early and late mortality in selected elderly patients undergoing TAVI.

"Killer coronary artery" and aortic valve stenosis: A tricky case

Anomalous origin of the left main coronary artery from the right coronary sinus is rarely diagnosed in elderly patients. We report such an anomaly in a 75-year-old lady presenting with chest pain and syncope. Preoperative screening revealed that her aortic valve was moderately stenotic. The patient underwent a successful unroofing procedure combined with aortic valve replacement. The outcome was uncomplicated and the patient remained asymptomatic at one year postoperatively.

Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report

We present a 55-year-old female patient who underwent burr-hole drainage due to chronic subdural hematoma, with obstructive prosthetic aortic valve dysfunction. Anesthetic management of a patient with severe obstructive prosthetic aortic valve dysfunction can be challenging. Similar considerations should be given to patients with aortic stenosis with an additional emphasis on thrombotic complication due to discontinuation of anticoagulation, which may further jeopardize the valve dysfunction. This case emphasizes the importance of a comprehensive understanding of the etiology and hemodynamic consequences of obstructive prosthetic valve dysfunction and the adequacy of anticoagulation for patients undergoing noncardiac surgery even after a successful valve replacement.

Partial anomalous pulmonary venous connection with acquired valve disease

We describe the rare case of a 76-year-old man with left partial anomalous pulmonary venous connection with intact atrial septum. He experienced dyspnea due to significant aortic stenosis and mitral regurgitation, and required valve repair. Preoperative computed tomography revealed connection of the left upper pulmonary vein to the innominate vein. Although right heart overload was not recognized, we repaired the left partial anomalous pulmonary venous connection with concomitant aortic valve replacement and mitral annuloplasty, because of the potential for unpredictable harmful effects of a residual left-to-right shunt. The patient recovered well with no signs of left upper lung congestion.

Kinking of the aorta with calcified aortic valve stenosis: A case report

Congenital kinking of the aorta is an uncommon anomaly consisting of elongation of the aortic arch with kinking at the level of the ductal ligament. Herein we report a case of congenital kinking of the aorta with calcified aortic valve stenosis. The combination of a kinked aorta with severe calcified valve stenosis is very unusual.

Enhanced expression of hemoglobin scavenger receptor and heme oxygenase-1 is associated with aortic valve stenosis in patients undergoing hemodialysis

A high prevalence and a rapid progression of aortic valve stenosis (AS) in patients undergoing hemodialysis (HD) has been reported. In these circumstances, intraleaflet hemorrhage of aortic valve may be related to the development of AS in HD patients. We immunohistochemically examined the relationship among intraleaflet hemorrhage, neovascularization, hemoglobin scavenger receptor (CD163), and heme oxygenase-1 (HO-1) using surgically resected aortic valve specimens from AS patients undergoing HD. The study population consisted of 26 HD patients and 25 non-HD patients with severe AS who had undergone aortic valve replacement. Frozen aortic valve samples surgically obtained from AS patients were stained immunohistochemically with antibodies against smooth muscle cells, macrophages, glycophorin-A (a protein specific to erythrocyte membranes), CD31, CD163, and HO-1. Morphometric analysis demonstrated that the CD163-positive macrophage score, the number of CD31-positive microvessels, and the percentage of glycophorin-A and HO-1-positive area were significantly higher in HD patients than in non-HD patients (CD163-positive macrophage score, P < 0.0001; CD31-positive microvessels, P < 0.0001; glycophorin-A, P < 0.0001; HO-1, P < 0.0001). Double immunostaining for CD163 or HO-1 and macrophages revealed that the majority of CD163- or HO-1-positive cells were macrophages. Furthermore, CD163-positive macrophage score was positively correlated with glycophorin-A, HO-1-positive area, and the number of CD31-positive microvessels (glycophorin-A, R = 0.66, P < 0.0001; HO-1, R = 0.50, P < 0.0005; microvessels, R = 0.38, P < 0.01). These findings suggest a positive association among intraleaflet hemorrhage, neovascularization, and enhanced expression of CD163 and HO-1 as a response to intraleaflet hemorrhage in stenotic aortic valves in AS patients undergoing HD.

Right origin of the circumflex artery and posterior aortic annulus enlargement

We present the case of a patient who required posterior enlargement of the aortic annulus during aortic valve replacement in the presence of abnormal origin of the circumflex artery from the right coronary artery, with a retroaortic course.

Immediate post-operative responses to transcatheter aortic valve implantation: An observational study

BACKGROUND

Conventional treatment for patients with severe symptomatic aortic stenosis is surgical aortic valve replacement (SAVR), but transcatheter aortic valve implantation (TAVI) has become a reliable alternative in high-risk patients.

AIMS

The aim of our study was to describe the post-operative patient response to TAVI on the evening of the procedure and the following day before discharge from the coronary care unit. A secondary aim was to compare responses of patients younger and older than 80 years of age.

METHODS

A prospective, comparative observational study triangulating nurse assessment and structured interviews on a cohort of 54 Danish patients: 28/26 male/female, 26/28 younger/older than 80. Mean age in the younger/older group was 73/85 years.

RESULTS

After TAVI pain was experienced by 47 (87%) patients; 29 (62%) were restricted by pain, and 24 (44%) had discomfort at the femoral insertion site. Disturbed sleep/rest were reported by 34 (63%)/29 (55%) patients; nausea/vomiting by 14 (26%)/5 (9%) patients, restricting eating/drinking in 11 (21%)/8 (15%) patients. Sinus rhythm/atrial fibrillation/paced rhythm were observed in 35 (65%)/8 (15%)/21 (39%) patients; bleeding/haematoma/oozing from femoral insertion site in 23 (45%)/10 (19%)/23 (43%) patients.

CONCLUSION

Patients older than 80 years did as well as the younger patients in our study; the main complaints were post-operative pain and disrupted sleep. Our numbers are small, but most patients experienced considerable pain, predominantly continuous and at rest. We recommend the development of an evidence-based pathway to address the immediate post-operative issues in TAVI patients. Non-pharmacological interventions to prevent pain and promote sleep need to be explored.

Surgical treatment of valvular and supravalvular aortic stenosis in homozygous familial hypercholesterolemia

A 61-year-old male with homozygous familial hypercholesterolemia presented with dyspnea and syncope. He had been treated with low-density lipoprotein apheresis for 26 years. Echocardiography and computed tomography showed severe valvular and supravalvular aortic stenosis. Computed tomography and cardiac catheterization revealed a severely calcified narrowed aortic root and an occlusion in the proximal right coronary artery. During surgery, the ascending aorta was replaced under deep hypothermic circulatory arrest without aortic cross-clamping. After that, the aortic root from the annulus to the sino-tubular junction was enlarged with a two-ply bovine pericardial patch. An aortic valve replacement with a 17 mm mechanical valve and coronary artery bypass grafting to the right coronary artery were performed. The patient recovered from the surgery without any cerebrovascular complications.

In vitro assessment of the influence of aortic annulus ovality on the hydrodynamic performance of self-expanding transcatheter heart valve prostheses

BACKGROUND

Although CT-studies as well as intraoperative analyses have described broad anatomic variations of the aortic annulus, which is predominantly found non-circular, commercially available transcatheter aortic heart valve prostheses are circular. In this study, we hypothesize that the in vitro hydrodynamic function of a self-expanding transcatheter heart valve (Medtronic CoreValve) assessed in an oval compartment representing the aortic annulus will differ from the conventionally used circular compartment.

METHODS

Medtronic CoreValve prostheses were tested in specifically designed and fabricated silicone compartments with three degrees of defined ovalities. The measurements were performed in a left heart simulator at three different flow rates. In this setting, regurgitation flow, effective orifice area, and systolic pressure gradient across the valve were determined. In addition, high speed video recordings were taken to investigate leaflet kinematics.

RESULTS

The pressure difference across the prosthesis increased with rising ovality. The effective orifice areas were only slightly impacted. The analyses of the regurgitation showed minor changes and partially lower regurgitation when switching from round to slightly oval settings, followed by strong increases for further ovalization. The high speed videos show minor central leakage and impaired leaflet apposition for strong ovalities, but no leaflet/stentframe contact in any setting.

CONCLUSION

This study quantifies the influence of oval expansion of transcatheter heart valve prostheses on their hydrodynamic performance. While slight ovalities were well tolerated by a self-expanding prosthesis, more significant ovality led to worsening of prosthesis function and regurgitation.

Quantitative Analysis of Aortic Valve Stenosis and Aortic Root Dimensions by Three-Dimensional Echocardiography in Patients Scheduled for Transcutaneous Aortic Valve Implantation

Accurate assessment of the aortic valve area (AVA) and evaluation of the aortic root are important for clinical decision-making in patients being considered for transcatheter aortic valve implantation (TAVI). Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) provides accurate and reliable quantitative assessment of aortic valve stenosis and the aortic root. We performed two-dimensional transthoracic echocardiography (2D-TTE), real-time 2D transesophageal echocardiography (RT2D-TEE) and RT3D-TEE in 71 consecutive patients referred for TAVI. RT3D-TEE multiplanar reconstruction was used to measure aortic root parameters, including left ventricular outflow tract (LVOT) diameter and area, aortic annulus diameter, aortic annulus area, and AVA. RT3D-TEE methods for planimetry and the LVOT-derived continuity equation for the estimation of AVA showed a good correlation. As iatrogenic coronary ostium occlusion is a potentially life-threatening complication, we evaluated the distances from the aortic annulus to the coronary ostia using RT3D-TEE. Based on our findings, we conclude that the geometry of the aortic root and aortic valve can be reliably and feasibly evaluated using RT3D-TEE, which is important for protecting against potential complications of TAVI, such as underestimation of the size of the aortic annulus that can result in aortic regurgitation and dislocation of the valve, or overestimation can lead to annulus rupture.

Mini-Konno procedure using a 10 mm handmade valve for pulmonary atresia with intact ventricular septum and severe aortic stenosis

We herein report the case of a neonate with pulmonary atresia with intact ventricular septum, right ventricular hypoplasia and severe aortic stenosis. Repetitive aortic valve surgeries in early infancy resulted in early relapse of the aortic stenosis due to the small aortic annulus, bicuspid configuration and duct-dependent pulmonary circulation. The infant underwent a successful mini-Konno procedure using a 10 mm handmade valve and bidirectional Glenn shunt at 6 months of age.

Floating mass in the aortic arch: An interesting case report

The finding of a floating mass in the aortic arch is rare and the management remains controversial. The gold standard for visualization of atheromatic plaque is computed tomography scanning. However, in some patients transthoracic harmonic imaging from a suprasternal window can reliably visualize protruding aortic arch atheromas, thus making an excellent screening test. We report a case of a ruptured floating atheromatous aortic plaque in a 77-year-old man with severe aortic valve stenosis and known coronary artery disease presenting with progressing dyspnea. Both procedures, atheromatic plaque removal and aortic valve replacement, were undertaken during the same surgical operation, which was completed with success and the patient was discharged in a good state of health. <Learning objective: The management of a patient suffering from both aortic valve stenosis and a pedunculated aortic plaque remains a challenge. It seems to be the only way to remove the plaque before replacing the aortic valve in order to avoid a possible embolism. A strong association between aortic stenosis and aortic atherosclerosis has recently been established. Finally, this case emphasizes the importance of suprasternal echocardiographic view in the diagnosis of a pedunculated mass in the aortic arch.>.

Transcatheter aortic valve implantation in nonagenarians: effective and safe

BACKGROUND

The number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients.

METHODS

Between August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12 months and then annually post TAVI.

RESULTS

Patients were male in 52% with a mean age of 90.3 ± 2.3 years. Mean logistic EuroSCORE and STS score were 26.6 ± 14.5% and 8.7 ± 2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30 days was 8.7% overall and 4.8% for transfemoral approach. At 30 days the rate of stroke was 4.3%, paravalvular leak grade ≥ 2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417 days.

CONCLUSIONS

TAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates.

Extensive vascular and valvular involvement in Gaucher disease

A 17-year-old patient with type III Gaucher disease was hospitalized for recurrent syncope. Echocardiography showed calcified aortic and mitral stenosis. Three-dimensional computed tomography showed severely calcified plaques on the ascending aorta, arcus, and abdominal aorta. On follow-up, palpitations and syncope were triggered by emotional stress, followed by severe bradycardia that was resulted in cardiogenic shock; the patient died after 8 h despite all efforts. Gaucher disease should be kept in mind in the differential diagnosis of a young patient with extensive vascular and valvular calcification. Patients with symptomatic severe valvular disease must be referred for early surgery.

Isolated left ventricular apical hypoplasia with infundibular pulmonary and aortic stenosis: a rare combination

Isolated left ventricular (LV) apical hypoplasia is a rare congenital cardiac anomaly which is not accompanied by other cardiac abnormalities, with the exception of two cases. We report a case of a 33-year-old male patient with isolated LV apical hypoplasia combined with infundibular pulmonary stenosis and aortic stenosis. We review a literature focusing on the characteristic magnetic resonance features and combined cardiac abnormalities.

Prognostic value of NT-proBNP and an adapted monin score in patients with asymptomatic aortic stenosis

INTRODUCTION AND OBJECTIVES

Our objective was to assess the prognostic value of NT-proBNP in patients with asymptomatic moderate/severe aortic stenosis and to validate an adapted Monin score using natriuretic peptide levels in our setting.

METHODS

Prospective study of 237 patients with degenerative asymptomatic moderate/severe aortic stenosis. NT-proBNP was determined in all patients, who were then followed up clinically. The adapted Monin score was defined as follows: (peak velocity [m/s]×2)+(logn NT-proBNP×1.5)(+1.5 if woman). A clinical event was defined as surgery, hospital admission due to angina, heart failure or syncope, or death.

RESULTS

A total of 51% were women, and the mean age was 74 years. Mean (SD) echocardiographic values were as follows: peak velocity 4.14 (0.87) m/s; mean gradient, 43.2 (16.0) mmHg; aortic valve area, 0.87 (0.72) cm(2), and aortic valve area index, 0.49 (0.14) cm(2)/m(2). The median NT-pro-BNP value was 490.0 [198.0-1312.0] pg/mL. There were 153 events during follow-up (median 18 months). The optimum NT-proBNP cut-point was 515 pg/mL, giving event-free survival rates at 1 and 2 years of 93% and 57%, respectively, in patients with NT-proBNP <515 pg/mL compared with 50% and 31% in those with NT-proBNP >515 pg/mL. Patients were divided into quartiles based on the Monin score. Event-free survival at 1 and 2 years was 87% and 79% in the first quartile, compared with 45% and 28% in the fourth quartile, respectively.

CONCLUSIONS

NT-proBNP determination provides prognostic information in patients with asymptomatic moderate/severe aortic stenosis. The adapted Monin score is useful in our setting and allows a more precise prognosis than does the use of NT-proBNP alone.

Comparison of Early Clinical Results of Transcatheter versus Surgical Aortic Valve Replacement in Symptomatic High Risk Severe Aortic Stenosis Patients

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been an alternative to conventional aortic valve replacement (AVR) in old and high risk patients. The goal of this study is to compare the early outcomes of conventional AVR vs. TAVI in high risk severe AS patients.

METHODS

From January 2008 to July 2012, 44 high risk severe aortic stenosis patients underwent conventional AVR, and 15 patients underwent TAVI. We compared echocardiographic data, periprocedural complication, and survival. The mean follow-up duration was 14.5±10 months (AVR), and 6.8±3.5 months (TAVI), respectively.

RESULTS

AVR group was younger (78.2±2.4 years vs. 82.2±3.0 years, p<0.001) and had lower operative risk (Euroscore: 9.4±2.7 vs. 11.0±2.0, p=0.044) than TAVI group. There was no significant difference in early mortality (11.4% vs. 13.3%, p=0.839), and 1 year survival (87.4%±5.3% vs. 83.1%±1.1%, p=0.805). There was no significant difference in postoperative functional class. There was no significant difference in periprocedural complication except vascular complication (0% [AVR] vs. 13.3% [TAVI], p=0.014). TAVI group had more moderate and severe paravalvular leakage.

CONCLUSION

In this study, both groups had similar periprocedural morbidity, and mortality. However, TAVI group had more greater than moderate paravalvular leakage, which can influence long-term outcome. Since more patients are treated with TAVI even in moderate risk, careful selection of the patients and appropriate guideline need to be established.

Oxidative stress and nitric oxide pathway in adult patients who are candidates for cardiac surgery: patterns and differences

OBJECTIVES

We investigated whether oxidative stress and the arginine/nitric oxide pathway differ in control subjects and in adult patients who are candidates for the three most common cardiac surgical operations: coronary bypass surgery, aortic valve replacement for calcific non-rheumatic aortic stenosis or mitral valve repair for degenerative mitral insufficiency.

METHODS

In this prospective observational study, we studied 165 consecutive patients undergoing surgery from January to June 2011 (coronary bypass surgery, n = 63; aortic valve replacement for calcific non-rheumatic aortic stenosis, n = 51; mitral valve repair for degenerative mitral insufficiency, n = 51). Thirty-three healthy subjects with cardiovascular risk factors similar to surgery patients were also studied (Controls). Oxidative stress (the ratio of reduced and oxidized glutathione and urinary isoprostane), antioxidants (alpha- and gamma tocopherol) and factors involved in nitric oxide synthesis (arginine, symmetric and asymmetric dimethylarginine) were measured before surgery. Analysis of variance general linear models and principal component analysis were used for statistical analysis.

RESULTS

Surgical patients had increased levels of oxidative stress and decreased levels of antioxidants. Increased levels of nitric oxide inhibitor asymmetric dimethylarginine were detected in surgical candidates, suggesting arginine/nitric oxide pathway impairment. Concerning the differences among surgical procedures, higher oxidative stress and a major imbalance of the ratio between substrate and inhibitors of nitric oxide synthesis were evidenced in patients who were candidates for mitral valve repair with respect to coronary bypass surgery patients and patients with calcific non-rheumatic aortic stenosis.

CONCLUSIONS

Patients undergoing cardiac surgery have increased oxidative stress and a trend towards an impaired arginine/nitric oxide pathway with respect to Controls. Patients affected by mitral valve regurgitation show more pronounced perturbations in these pathways. The clinical implications of these findings need to be investigated.