Aortic Valve Repair Versus Replacement for Aortic Regurgitation: Effects on Left Ventricular Remodeling

Early outcomes of aortic valve repair versus replacement for aortic regurgitation: a single-center experience

Background

Aortic valve repair in rheumatic patients is not well-studied. We aimed to present our initial Egyptian experience in the aortic valve repair and compare it with the aortic valve replacement. The study included 85 patients who had an aortic valve surgery for aortic regurgitation (AR) in a single center from 2018 to 2020. We assigned the patients to either aortic valve repair (n= 39) or aortic valve replacement (n= 46). Fifty-nine patients (69.4%) had rheumatic heart disease. Study outcomes were hospital complications and the degree of aortic regurgitation after 6 months in patients who had aortic valve repair.

Results

Patients who had replacement were significantly older (49.6± 7.2 vs. 43.8± 8.6 years: P= 0.002) and had more advanced New York Heart Association (P<0.001) and Canadian Cardiovascular Scoring (P= 0.03) classes. Hypertension (31 (67.4%) vs. 17 (43.6%); P= 0.03) and hypercholesteremia (18 (40%) vs. 17 (18.9%); P= 0.04) were more common in the replacement group. Patients who had replacement had a significantly higher percentage of valve retraction (P<0.001). Cardiopulmonary bypass (54.5 (49.5–60) vs. 45 (41–49) min; P<0.001) and ischemic times (36.5 (31–40) vs. 30 (28–33) min; P<0.001) were longer in patients who had an aortic valve replacement. Blood transfusion (28 (60.9%) vs. 11 (282%); P= 0.003) and ICU stay (24.5 (24–48) vs 23 (20–31) h; P= 0.01) were higher in the replacement group. Hospital mortality was non-significantly different between groups. Four patients had trivial AR (10.3%), and six had mild AR (15.4%) in the repair group. There was no difference in valve pathology or outcomes in aortic valve repair patients for degenerative versus rheumatic pathologies. After a 6-month follow-up, four patients had trivial AR (10.3%), and six patients had mild AR (15.4%) in the repair group.

Conclusions

Aortic valve repair could be an alternative to replacement in selected patients with rheumatic heart disease. Shorter cardiopulmonary bypass and ischemic times may improve repair outcomes compared to replacement.

Combined Triple Transcatheter Aortic Procedure in a Patient With Aortic Stenosis, Coarctation, and Aneurysm

We present the case of a 71-year-old man admitted because of chest tightness, palpitations, and progressive shortness of breath. The diagnosis of severe aortic stenosis, coarctation, and aneurysm was established, as well as severely depressed left ventricular ejection fraction. Three consecutive transcatheter procedures were successfully performed in a single session. (Level of Difficulty: Advanced.).

Reduction of tethering distance by papillary muscle tugging approximation with mitral valve replacement for non-ischemic functional mitral regurgitation induces left ventricular reverse remodeling

BACKGROUND

Functional mitral regurgitation (FMR) is caused by left ventricular (LV) remodeling and subsequent tethering of the mitral valve (MV). If LV remodeling is irreversibly advanced, it could not be attenuated by the MV procedure alone, although the additional subvalvular procedure could induce LV reverse remodeling by forcibly reducing MV tethering. This study aimed to assess the anti-tethering effect of papillary muscle tugging approximation (PMTA) on LV reverse remodeling after mitral valve replacement (MVR) for non-ischemic FMR.

METHODS

The study subjects were 19 patients who underwent MVR with and without PMTA [MVR + PMTA (n = 11) and MVR alone (n = 8), respectively] for non-ischemic FMR. The tethering distance (TD) and LV end-systolic volume (ESV) at the preoperative, postoperative, and follow-up periods were assessed in terms of their correlation and time-dependent changes. The intra-LV energy efficiency was also evaluated through vector flow mapping analysis.

RESULTS

TD and ESV were comparable between both procedures preoperatively and did not change after MVR alone. In MVR + PMTA, however, a significant decrease was identified in TD and ESV at the early postoperative and follow-up periods, respectively [TD = 48, 30, and 31 mm (p < 0.001) and ESV = 159, 133, and 82 mL (p < 0.001) at the preoperative, postoperative, and follow-up periods, respectively]. Finally, at follow-up, the extent of change from the preoperative value in ESV significantly correlated with that in TD (ρ = 0.81, p < 0.001 for overall; ρ = 0.93, p < 0.001 for MVR + PMTA; ρ = 0.86, p = 0.011 for MVR alone). The ratio of TD to ESV was also significantly correlated with systolic energy loss to LV stroke work after MVR + PMTA (ρ = 0.81, p = 0.015).

CONCLUSIONS

PMTA for non-ischemic FMR could induce LV reverse remodeling depending on the extent of postoperative TD reduction. A smaller TD to ESV was associated with a higher intra-LV energy efficiency after PMTA + MVR.

Autologous pericardial aortic valve reconstruction: early results and comparison with mechanical valve replacement

Introduction

Autologous pericardial aortic valve reconstruction is an attractive option compared with prosthetic valve replacement due to the absence of anticoagulation, lower pressure gradient across the valve and excellent valve haemodynamics.

Objective

We wanted to share the early results of autologous pericardial aortic valve reconstruction from our centre. The outcomes were compared with that of mechanical valve replacement.

Materials and methods

Between August 2016 to July 2018, 20 patients underwent autologous aortic valve reconstruction as per the techniques described by Ozaki et al. The surgery was done for aortic stenosis or regurgitation or a combination of both. All the surgeries were done by a single experienced surgeon. The results were compared to that of mechanical valve replacement. A comprehensive echocardiographic evaluation was done pre-discharge and at 6 months after surgery. The postoperative echocardiographic parameters that were evaluated include aortic valve pressure gradient, aortic valve orifice area, ejection fraction, left ventricular diameters etc. All the parameters were measured by a single expert. Other perioperative parameters were also evaluated like cardiopulmonary bypass and cross-clamp time, need for anticoagulation etc. Statistical analysis was done using chi-square test/Mann-Whitney U test/independent sample t test.

Results

Autologous pericardial aortic valve reconstruction had several favourable results including lower aortic valve pressure gradient, bigger aortic valve orifice area etc. None of the patients required anticoagulation. There were no conversions to prosthetic valve replacement or reinterventions in the follow-up period.

Conclusion

Autologous pericardial aortic valve reconstruction is a feasible alternative to prosthetic valve replacement with several advantages.

Simultaneous Transcatheter Aortic Valve Implantation and Infrarenal Aortic Aneurysm Repair for Severe Aortic Stenosis and Abdominal Aortic Aneurysm: Report of 2 Cases and Literature Review

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population. Both conditions have adverse outcomes, if not adequately managed. No clear recommendations are available in the literature until today, in regards of the management sequence making thus the decision-making challenging. We report 2 cases of AAA and significant AS treated with endovascular aortic repair (EVAR) and transcatheter aortic valve implantation (TAVI) during the same procedure and a review of the literature on this topic. Based on our experience, the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential.

Rate of reoperation at 1 year for aortic repair vs replacement in aortic regurgitation. A trial sequence analysis of published meta-analysis results

The pooled estimate of a recent meta-analysis concluded that rate of reoperation at 1 year was significantly higher in Aortic valve repair (8.82% vs 3.70%) as compared with aortic valve replacement in patients with aortic regurgitation (odds ratio = 2.67, 95% confidence interval [1.08, 3.62], P = .03). We performed a trial sequential analysis using the published data of the meta-analysis and found the evidence is not strong enough for the conclusion.

Aortic valve repair or replacement in patients with aortic regurgitation: A systematic review and meta-analysis

OBJECTIVE

To systematically compare clinical outcomes between aortic valve repair and replacement in patients with aortic regurgitation.

METHODS

A comprehensive literature search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing clinical outcomes of aortic valve repair vs replacement. Database searched from inception to November 2018.

RESULTS

A total of 1071 patients were analyzed in eight articles. Mean age was similar in both groups of patients (47.2 ± 12.8 vs 48.3 ± 12.7 years, P = 0.83, aortic valve repair and replacement, respectively). The preoperative left ventricular ejection fraction was better in the repair group (56.7% ± 4.8 vs 53.3% ± 4.2, P = 0.005). The rate of moderate-to-severe regurgitation and bicuspid aortic valve were similar in both cohorts (81% vs 78%, P = 0.90% and 58% vs 55%, P = 0.46). In-hospital and 1-year mortality was lower in repair cohort, although not reaching statistical significance (1.3% vs 3.6%, P = 0.12; 5.9% vs 9.3%, P = 0.77). Reoperation rate was higher in repair patients at 1 year (8.8% vs 3.7%, P = 0.03).

CONCLUSION

Aortic valve repair offers comparable perioperative outcomes to aortic valve replacement in aortic regurgitation patients at the expense of higher late reintervention rate. Larger trials with long-term follow-up are required to confirm the long-term benefits of aortic valve repair.

Changes in left ventricular function in patients with aortic regurgitation 12 months after transapical transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is an established treatment for high surgical risk aortic stenosis patients; in recent years, it has also been used in patients with pure/dominant aortic regurgitation (AR). This study aimed to determine the impact of transapical TAVI on left ventricle myocardial mechanics in AR patients. Thirty AR patients (70% men; mean age, 72.8 ± 4.3 years) were enrolled. Conventional echocardiography was performed on all patients before and 12 months after TAVI. Three-dimensional speckle tracking was accomplished in 20 AR patients for the evaluation of global longitudinal strain, global circumferential strain, twist, torsion, apical rotation and basal rotation. Preoperative left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global circumferential strain (GCS), twist, torsion and apical rotation were impaired in AR patients compared with controls. Mean left ventricular (LV) end-diastolic diameter (from 62.9 ± 7.3 to 52.0 ± 6.8 mm, p < 0.001), LV end-diastolic volume (from 199.4 ± 55.0 to 130.1 ± 48.9 mL, p < 0.001), and LV mass index (179.8 ± 52.2-134.4 ± 42.5 g/m², p = 0.001) decreased 12 months after TAVI. Interestingly, GLS (from - 17.2 ± 3.2 to - 18.9 ± 3.7, p = 0.007) and GCS (from - 23.9 ± 4.9 to - 25.7 ± 5.0, p = 0.008) improved significantly, but LVEF did not significantly improve. In terms of the rotational mechanics, twist, rotation and basal rotation remained almost unchanged, whereas apical rotation (from 7.4 ± 4.0 to 5.5 ± 3.9, p = 0.009) was significantly impaired after transapical TAVI. Our results indicate that LV function was improved in terms of myocardial deformation but worsened in terms of apical rotation 12 months after TAVI in AR patients. Three-dimensional speckle tracking echocardiography appears to be a sensitive method for detecting subtle cardiac remodeling after TAVI.

Left ventricular reverse remodeling after aortic valve surgery for acute versus chronic aortic regurgitation

AIMS

Extent of left ventricular (LV) reverse remodeling after aortic valve repair or replacement (AVR) may differ between patients operated for acute aortic regurgitation (AR) and chronic AR. The aim of this study was to compare changes in LV volumes and function between patients with acute and chronic AR who underwent AVR.

METHODS AND RESULTS

A total of 98 patients (54±15 years, 61% men) with acute (n=21) or chronic AR (n=77) were included in the present retrospective evaluation. LV volumes, LV ejection fraction, and global longitudinal strain indexed for LV end-diastolic volume (GLSi) were assessed preoperatively and after a median follow-up of 28 months (interquartile range: 17-66 months). Patients with acute AR tended to have smaller preoperative LV end-diastolic volume compared with chronic AR (156±15 vs 183±6 mL; P=.070). Both in patients with acute and chronic AR, significant LV reverse remodeling with sustained reduction in LV volumes occurred during follow-up with a significant smaller LV end-diastolic volume in acute AR compared with chronic AR (106±8 vs 128±5 mL; P=.032). Preoperative and postoperative LV ejection fractions were not significantly different between groups. In contrast, GLSi was better in patients with acute AR compared with chronic AR before AVR (-1.34±0.20 vs -0.96±0.07%/10 mL; P=.042) and during follow-up (-1.65±0.16 vs -1.29±0.07%/10 mL; P=.017).

CONCLUSIONS

After AVR, LV reverse remodeling occurs both in patients with acute and chronic AR. However, LV end-diastolic volume was more reduced and GLSi was more preserved during follow-up in acute AR than in chronic AR.

Simultaneous percutaneous transcatheter aortic valve replacement and endovascular abdominal aortic aneurysm repair in a high risk patient with hostile aortic neck, a case report

BACKGROUND

Abdominal aortic aneurysm (AAA) can be a potential life threatening condition if left untreated. Total endovascular techniques to approach aortic aneurysms have extended management options and enabled patients who are unfit for open surgery to undergo repair. Transcatheter aortic valve replacement is increasingly used to treat patients with severe symptomatic aortic stenosis, who once were considered high risk for traditional open aortic valve replacement.

RESULTS

Herein we report the complete simultaneous treatment of an infrarenal AAA with hostile neck and severe aortic stenosis in a patient deemed high risk for surgical repair.

CONCLUSION

Advances in catheter based endovascular technology have enabled physicians to approach patients with AAA and valvular pathology even with multiple comorbidities that otherwise would be poor surgical candidates, even in the presence of challenging anatomic considerations and various comorbidities.