Impact of aortic valve replacement for aortic stenosis on dynamic mitral annular motion and geometry

The effect of balloon-expandable stent and self-expanding stent on changes in mitral annular motion after aortic valve replacement in patients with aortic stenosis

OBJECTIVES

The purpose of this study was to evaluate the effect of decalcification and existence of stent at the aortic annulus on mitral annular motion after surgery.

METHODS

Patients receiving Inspiris (Edwards, CA, USA, n = 117), Intuity (Edwards, n = 36), Perceval (Corcym, London, UK, n = 36), Evolut (Medtronics, MN, USA, n = 81) and Sapien 3 (Edwards, n = 250) were included in the study. Mitral annular motion was evaluated by E', using tissue doppler imaging.

RESULTS

After surgery, a significant increase in E' was observed in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Discharge: 5.0 ± 1.23 cm/s, p < 0.001). Mid-term echocardiogram performed at 11.8 ± 2.2 months after the surgery, showed a significant increase in E' in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Mid-term: 5.2 ± 1.20 cm/s, p < 0.001) and Perceval (Before: 3.9 ± 1.34 cm/s vs. Mid-term: 4.5 ± 1.24 cm/s, p = 0.008). Univariable analysis showed a higher increase in E' in patients with decalcified annulus compared to those without decalcified annulus (Decalcification: 0.15 ± 1.321 cm/s vs. No Decalcification: 0.66 ± 1.420 cm/s, p < 0.001). Multivariable analysis showed that balloon-expandable stent (β = - 0.6960, p < 0.001) and self-expanding stent (r = - 0.3592, p = 0.042) were independent limiting factors for an increase in E' at discharge. However, balloon-expandable stent (β = - 0.8382, p < 0.001), and not self-expanding stent (β = - 0.3682, p = 0.089), was a remaining independent factor associated with E' at mid-term follow-up.

CONCLUSIONS

Decalcification was associated with improvement in E' after surgery. Balloon-expandable stent was an independent limiting factor for improvement in E' up to 1 year after the surgery, while self-expanding stent was not a significant factor after 1 year.

Morphometry and topography of the coronary ostia in the dog

Introduction

The purpose of this study was to perform a morphometric examination of the coronary ostia, including their location in the area of the aortic sinuses, and to describe variations in ostia structure in the domestic dog.

Material and Methods

The study was conducted on the hearts of 91 pedigree dogs of both sexes, aged 1 to 18 years (median 9 years), with a body weight from 1.2 to 65 kg (median 20.7 kg). Morphometric examinations of the coronary ostia were performed in the studied individuals, and the location of the structures in relation to the intercommissural lines was determined.

Results

Three types of location of the coronary ostia were distinguished, i.e. below the intercommissural line (type I), on the intercommissural line (type II), and above the intercommissural line (type III). In the studied dogs, the most common location of the ostia was type I - found in the left coronary artery of 74/91 dogs (81%) and in the right coronary artery of 42/91 dogs (46%). Morphological variations were shown in 36/91 dogs (40%) in the structure of the coronary ostia, including the presence of accessory ostia. The most common variation was the presence of an accessory ostium near the ostium of the right coronary artery, which was found in 28/91 dogs (31%).

Conclusion

The results may be useful in developing standards for procedures to replace the whole or part of the aortic valve and repair the coronary artery.

Mitral Annulus Geometry and Dynamic Motion Changes in Patients With Aortic Regurgitation: A Three-Dimensional Transesophageal Echocardiographic Study

OBJECTIVE

The aim of the present study was to investigate the mitral annulus (MA) geometry and dynamic motion changes in patients with aortic regurgitation (AR) before and after aortic valve replacement (AVR). Moreover, the difference in the effect of the type of prosthetic aortic valve on MA was compared.

DESIGN

Prospective observational study.

SETTING

Cardiac operating room at a single hospital.

PARTICIPANTS

Eighty-two patients with isolated moderate-to-severe AR who underwent AVR. Forty patients with normal valves were enrolled as controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The MA geometry and dynamic motion throughout the cardiac cycle were evaluated semiautomatically by three-dimensional transesophageal echocardiography. The severity of functional mitral regurgitation was intraoperatively evaluated. All patients were divided into 2 groups depending on the type of prosthetic valve (mechanical valve and bioprosthetic valve groups). Before AVR, compared with the control group without AR, the AR group demonstrated larger MA dimensions and the MA geometry was flatter. The contraction fraction of the MA area, perimeter, and height during the whole cardiac cycle were larger in the AR group (p < 0.05 for all). After AVR, most MA geometric and dynamic parameters decreased and functional mitral regurgitation also improved. In the postoperative subset analyses, the mechanical valve group showed a larger contraction fraction of the MA area and perimeter than the bioprosthetic valve group (p < 0.05 for both).

CONCLUSIONS

The MA geometry and dynamic motion changed markedly in patients with AR. These spatial and dynamic changes were restored to a certain extent after surgical correction of the aortic valve. However, the effects produced by mechanical and bioprosthetic valves on MA were different.

The effect of stent and decalcification on mitral annular motion after aortic valve replacement

OBJECTIVE

The purpose of this study was to evaluate the changes in mitral annular motion after surgery in patients with aortic stenosis.

METHODS

Patients receiving Edwards (Edwards) valves were included in the study. Echocardiographic findings were compared among the three treatments postoperatively, at discharge, and at 1 year after the surgery. Mitral annular motion was evaluated by e prime, using tissue doppler imaging.

RESULTS

There were 111 patients receiving Inspiris, 30 patients receiving Intuity and 241 patients receiving Sapien 3. The patients receiving Sapien 3 were significantly older, (Inspiris: 71 ± 6.7 years vs. Intuity: 75 ± 5.2 years vs. Sapien 3: 84 ± 5.1 years, p < .001), and prevalence of hemodialysis were significantly higher in patients receiving Intuity (Inspiris: 11.7% vs. Intuity: 46.7% vs. Sapien 3: 0.0%, p < .001). There was a significant improvement in mean pressure gradient in all groups (Inspiris: 55 ± 21.2-13 ± 5.2 mmHg, p < .001; Intuity: 48 ± 17.6-12 ± 4.9 mmHg, p < .001, Sapien 3: 55 ± 16.6-14 ± 5.2 mmHg, p < .001). Decalcification was associated with increase in e prime after surgery (no decalcification: 0.10 ± 1.280 cm/s vs. decalcification: 0.68 ± 1.405 cm/s, p < .001) Further, existence of stent was associated with less increase in e prime after surgery (no stent: 0.83 ± 1.210 cm/s vs. stent: 0.10 ± 1.356; p < .001). Multivariate analysis showed that existence of stent but not decalcification of the aortic valve was independently associated with changes in e prime after surgery (β: -.4679, 95% confidence interval: -0.93389 to -0.00200, p = .049).

CONCLUSIONS

Although improvement in pressure gradient was achieved in all treatments, existence of stent inhibited mitral annular motion after surgery.

The Prospects of Secondary Moderate Mitral Regurgitation after Aortic Valve Replacement -Meta-Analysis

Aortic valve replacement for aortic stenosis represents one of the most frequent surgical procedures on heart valves. These patients often have concomitant mitral regurgitation. To reveal whether the moderate mitral regurgitation will improve after aortic valve replacement alone, we performed a systematic review and meta-analysis. We identified 27 studies with 4452 patients that underwent aortic valve replacement for aortic stenosis and had co-existent mitral regurgitation. Primary end point was the impact of aortic valve replacement on the concomitant mitral regurgitation. Secondary end points were the analysis of the left ventricle reverse remodeling and long-term survival. Our results showed that there was significant improvement in mitral regurgitation postoperatively (RR, 1.65; 95% CI 1.36–2.00; p < 0.00001) with the average decrease of 0.46 (WMD; 95% CI 0.35–0.57; p < 0.00001). The effect is more pronounced in the elderly population. Perioperative mortality was higher (p < 0.0001) and long-term survival significantly worse (p < 0.00001) in patients that had moderate/severe mitral regurgitation preoperatively. We conclude that after aortic valve replacement alone there are fair chances but for only slight improvement in concomitant mitral regurgitation. The secondary moderate mitral regurgitation should be addressed at the time of aortic valve replacement. A more conservative approach should be followed for elderly and high-risk patients.

Transcatheter aortic valve implantation and its impact on mitral valve geometry and function

BACKGROUND

The aim of this study was to evaluate the impact of transcatheter aortic valve implantation (TAVI) on mitral valve geometry and function.

METHODS

Eighty-four patients underwent TAVI. Forty-four (52%) patients received a balloon-expandable valve and 40 (48%) were implanted with a self-expandable valve. All patients underwent three-dimensional-volumetric transesophageal echocardiography of the mitral valve before and immediately after TAVI. A dedicated software was used for assisted semiautomatic measurement of mitral annular geometry.

RESULTS

During systole, the anterior to posterior (AP) diameter was significantly reduced after the procedure (3.4 ± 0.5 cm vs 3.2 ± 0.5 cm; P < .05). The mitral annular area (10.8 ± 2.8cm² vs 9.9 ± 2.6cm² ; P < .05) as well as the tenting area (1.6 ± 0.7 cm² vs 1.2 ± 0.6 cm² ; P < .001) measured at mid-systole were reduced after TAVI. Diastolic measures were similar. Patients treated with balloon-expandable valves showed a significantly larger reduction in the AP diameter compared to self-expandable valves (-0.25 cm vs -0.11 cm; P < .05). The reduction of the annular area was higher in the balloon-expandable group (-1.2 ± 1.59 vs -0.22 ± 1.41; P < .05). Grade of mitral regurgitation did improve or remained stable after TAVI.

CONCLUSION

TAVI significantly impacts the mitral valve and mitral annular geometry and morphology. The choice of the prosthesis (balloon- vs self-expandable) may be relevant for those changes.

Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement

BACKGROUND

Severe mitral regurgitation (MR) after aortic valve replacement (AVR) is a serious complication. Although several causes of MR after AVR have been reported, severe MR due to geometric changes in the mitral valve imposed by an aortic valve prosthesis has not been reported. We here report a case of severe MR after AVR that was improved after re-AVR.

CASE PRESENTATION

A 77-year-old male underwent elective total aortic arch replacement and AVR. Mild MR was preoperatively identified. After surgery and separation from cardiopulmonary bypass, transesophageal echocardiography (TEE) demonstrated restriction and distortion of the anterior mitral leaflet and severe MR. Displacement of the anterior mitral annulus by the prosthetic aortic valve was strongly suspected to be the cause of MR, which should be surgically restored. Re-AVR using a small-sized valve was then performed. Consequently, the structural changes in the mitral valve were reverted and the MR was reduced.

CONCLUSIONS

Geometric changes in the mitral valve induced by an aortic valve prosthesis can cause massive increment of MR. Intraoperative TEE examination of the mitral apparatus is important when severe MR occurs after AVR.

Mitral Valve Stenosis after Transcatheter Aortic Valve Replacement: Case Report and Review of the Literature

Mitral stenosis is a rare and potentially severe complication of transcatheter aortic valve replacement (TAVR). Given the anatomic coupling and interdependence of the aortic and mitral valves, it comes by itself that procedures (either surgical or percutaneous) involving the aortic valve imply the risk of altering mitral valve function. Indeed, transcatheter aortic prostheses may impair adequate anterior mitral leaflet (AML) opening, especially when implanted in a "low" position, thus resulting in high transvalvular gradients. Hereby, we report the case of a 71-year-old male with symptomatic severe aortic stenosis and a history of previous surgical mitral valve repair who underwent TAVR with a self-expandable prosthesis. Notwithstanding an acceptable angiographic position, the prosthetic frame was shown to interfere with the AML, as evidenced by augmented transmitral gradients; nonetheless, pulmonary artery pressures remained unchanged, and the patient experienced symptomatic improvement. Therefore, a conservative approach was chosen and the patient was discharged home after medical therapy optimization. Moreover, we provide a review of the available literature regarding the incidence, predictors and possible management of this infrequent complication.

Incremental Value of the Tissue Motion of Annular Displacement Derived From Speckle-Tracking Echocardiography for Differentiating Chronic Constrictive Pericarditis From Restrictive Cardiomyopathy

OBJECTIVES

The tissue motion of annular displacement provides an accurate and rapid assessment of left ventricular (LV) systolic function. However, it has rarely been used in patients with chronic constrictive pericarditis and restrictive cardiomyopathy. This study aimed to assess the differences in LV systolic function in patients with constrictive pericarditis and restrictive cardiomyopathy using tissue motion of annular displacement derived from speckle-tracking echocardiography.

METHODS

Twenty-four patients with constrictive pericarditis, 24 with restrictive cardiomyopathy, and 25 healthy volunteers (controls) were enrolled. The septal and lateral mitral annular longitudinal displacements, displacement at the midpoint, and normalized midpoint displacement of the mitral ring were calculated.

RESULTS

Mitral annular tracking and quantification of the tissue motion of annular displacement were achieved within 10 seconds. In patients with constrictive pericarditis, the lateral mitral annular longitudinal displacement, displacement at the midpoint, and midpoint displacement of the mitral ring were decreased, whereas the septal mitral annular longitudinal displacement was preserved compared to controls, indicating that the reduction of systolic function in constrictive pericarditis was caused by pericardial adhesion and calcium. In patients with restrictive cardiomyopathy, tissue motion of annular displacement was more reduced compared to patients with constrictive pericarditis and controls. The correlation between the septal mitral annular longitudinal displacement and left ventricular ejection fraction was 0.67 (P < .001). A cutoff value of 8.45 mm for the septal mitral annular longitudinal displacement could effectively differentiate constrictive pericarditis from restrictive cardiomyopathy with 95.2% sensitivity and 91.7% specificity.

CONCLUSIONS

The tissue motion of annular displacement was decreased in patients with constrictive pericarditis, which indicated early impairment of longitudinal function in constrictive pericarditis; adhesion and calcium in the pericardium might account for the reduction. The septal mitral annular longitudinal displacement provides a fast and effective method for the assessment of LV systolic function in patients with constrictive pericarditis and restrictive cardiomyopathy.

Morphometry of the coronary ostia and the structure of coronary arteries in the shorthair domestic cat

The aim of this study was to measure the area of the coronary ostia, assess their localization in the coronary sinuses and to determine the morphology of the stem of the left and right coronary arteries in the domestic shorthair cat. The study was conducted on 100 hearts of domestic shorthair cats of both sexes, aged 2-18 years, with an average body weight of 4.05 kg. A morphometric analysis of the coronary ostia was carried out on 52 hearts. The remaining 48 hearts were injected with a casting material in order to carry out a morphological assessment of the left and right coronary arteries. In all the studied animals, the surface of the left coronary artery ostium was larger than the surface of the right coronary artery ostium. There were four types of the left main coronary artery: type I (23 animals, 49%)-double-branched left main stem (giving off the left circumflex branch and the interventricular paraconal branch, which in turn gave off the septal branch), type II (12 animals, 26%)-double-branched left main stem (giving off the left circumflex branch and the interventricular paraconal branch without the septal branch), type III (11 animals, 23%)-triple-branched left main stem (giving off the left circumflex branch, interventricular branch and the septal branch, type IV (1 animal, 2%)-double-branched left main stem (giving off the interventricular paraconal branch and the left circumflex branch, which in turn gave off the septal branch). The left coronary artery ostium is greater than the right one. There is considerable diversity in the branches of proximal segment of the left coronary artery, while the right coronary artery is more conservative. These results can be useful in defining the optimal strategies in the endovascular procedures involving the coronary arteries or the aortic valve in the domestic shorthair cat.