Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases

Short-term Outcomes of Urgent Transcatheter Aortic Valve Replacement in Symptomatic Aortic Stenosis That Requires Emergency Hospital Admission

Objective This study retrospectively compared the outcomes of emergently admitted patients with aortic stenosis (AS) with or without urgent transcatheter aortic valve replacement (TAVR). Methods Patients hospitalized between February 2015 and December 2019 for symptomatic AS were retrospectively analyzed by comparing the received conservative management [continued medical therapy with or without elective surgical transcatheter replacement (SAVR) or TAVR scheduled after the index hospitalization] and urgent TAVR (TAVR during the index hospitalization). Results The cohort comprised 114 patients with symptomatic AS who required emergency admission. Urgent TAVR was performed for 37 patients, while conservative management was provided for 77 patients, including 1 who received urgent SAVR. Urgent TAVR was more likely to be performed in patients with a history of hospitalization for heart failure, high New York Heart Association class scores, a lower clinical frailty scale at admission, and a high aortic valve peak velocity (p=0.01, p<0.001, p<0.01 and p=0.02, respectively). Kaplan-Meier analyses with log-rank test revealed favorable outcomes of urgent TAVR in all-cause mortality and cardiovascular events within 60 days of admission (p<0.01, p<0.01, respectively). Conclusion Urgent TAVR had better short-term outcomes in patients with symptomatic AS who required emergency hospital admission than conservative management. When considering urgent TAVR, patients with typical heart failure symptoms due to AS with a history of heart failure hospitalization and relatively little frailty can be selected.

Comparison of Outcomes of Mitral Valve Repair for Leaflet Prolapse with Advanced versus Mild/Moderate Myxomatous Degeneration

There is limited information on long-term outcomes of mitral valve repair for mitral regurgitation (MR) caused by different degrees of myxomatous degeneration. The aim of this study was to compare the surgical results of patients with advanced and mild/moderate myxomatous mitral valve degeneration (MVD). We identified 130 patients (25 advanced and 105 mild/moderate MVD patients) who underwent mitral valve repair for MR and were pathologically diagnosed as myxomatous degeneration. Follow-up was 100% complete (mean length, 5.1 ± 1.8 years). Survival differed significantly between the advanced and mild/moderate MVD groups (76.0 ± 9.7% versus 95.0 ± 5.4% at 8 years, P < 0.001). The univariate predictors of mortality were advanced myxomatous degeneration, recurrent MR, and early series (surgeries before 2011). The mild/moderate MVD group had higher freedom from a moderate or severe MR rate compared with the advanced MVD group (77.4 ± 4.5% versus 50.5 ± 10.2% at 7 years, P = 0.003). Multivariable Cox analysis revealed advanced myxomatous degeneration and residual MR as independent predictors of recurrent moderate or severe MR. A total of 25 patients (19.2%) had persistent atrial fibrillation (AF) after repair. In multivariate analysis, advanced myxomatous degeneration was found to be an independent predictor of postoperative persistent AF.In conclusion, the long-term outcomes of mitral valve repair in patients with advanced MVD are poorer than in those with mild/moderate MVD. Advanced myxomatous degeneration is an independent predictor of recurrent moderate or severe MR and postoperative persistent AF in MVD patients performing repair, which deserves more attention before and after surgery.

Observational Study of Infective Endocarditis at a Community-based Hospital: Dominance of Elderly Patients with Comorbidity

Objective The purpose of this study was to present the recent clinical profiles and the real-world management of infective endocarditis (IE). Methods All medical records of patients with IE were reviewed retrospectively for their clinical data, including clinical presentation, laboratory results, blood cultures, echocardiographic findings, treatments and complications. Using the clinical data collected, we calculated the EuroSCORE II, the European risk score for adult cardiac surgery, the Charlson Comorbidity Index as a surrogate of comordibity, and the Katz Index as a surrogate of frailty. Results Thirty-eight patients were identified as having IE (24 men, age: 71.8±13.1 years). Congestive heart failure occurred in 16 patients (42%), stroke in 14 (50%), and systemic embolism in 5 (13%). The EuroSCORE II and Charlson Comorbidity Index were high (7.7±5.8% and 5.5±2.8%, respectively). The Katz Index was fair (5.5±1.4) before the onset but deteriorated to 2.8±2.7 at the time of establishing the diagnosis of IE (p<0.001). Early surgery was performed in 22 cases (61%). In-hospital death occurred in 10 cases (26%). A EuroSCORE II ≥9%, Staphylococcus aureus etiology, and a Charlson Comorbidity Index were suggested as determinants of in-hospital death (hazard ratios: 173.60, 9.31, 1.57, respectively). In contrast, early surgery was suggested as a determinant of the survival (hazard ratio: 0.04). The Charlson Comorbidity Index was also suggested as a determinant for selecting conservative management (odds ratio: 1.40). Conclusion Comorbidity may influence the treatment selection and outcome of elderly patients with IE.

Left Ventricular Outflow Tract Migration of a Balloon-Expandable Prosthesis During Transcatheter Aortic Valve Implantation

Valve migration into the left ventricular outflow tract (LVOT) during transcatheter aortic valve implantation (TAVI) is a life-threatening complication. An 89-year-old female patient was admitted for TAVI due to severe symptomatic aortic stenosis. After deployment of a balloon-expandable prosthesis, the prosthesis had migrated into the LVOT. The prosthesis was reimpacted to the aortic annulus by a balloon-assisted recapture procedure. Immediately after recapturing the prosthesis with an oversized balloon, the patient's vital signs deteriorated due to acute aortic regurgitation (AR), and a prompt valve-in-valve (V-in-V) procedure allowed us to stabilize the patient's condition. This is the first reported case of a V-in-V procedure using an oversized balloon and a larger prosthesis to treat migration of the initial prosthesis into the LVOT. Balloon recapture and V-in-V procedure using an oversized balloon and larger prosthesis for a migrated balloonexpandable prosthesis into the LVOT is feasible, but hemodynamic support should be prepared before recapture and Vin-V because overdilatation of the first prosthesis might cause hemodynamic collapse due to severe AR.