Clinical considerations and challenges in TAV-in-TAV procedures

Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment for aortic valve disease, including low-risk patients. However, as TAVR usage increases, concerns about long-term durability and the potential for addition interventions have arisen. Transcatheter aortic valve (TAV)-in-TAV procedures have shown promise in selected patients in numerous registries, offering a less morbid alternative to TAVR explantation. In this review, the authors aimed to comprehensively review the experience surrounding TAV-in-TAV, summarize available data, discuss pre-procedural planning, highlight associated challenges, emphasize the importance of coronary obstruction assessment and provide insights into the future of this technique.

Rationale and Design of the Randomized Bayesian Multicenter COME-TAVI Trial in Patients With a New Onset Left Bundle Branch Block

Patients with new-onset left bundle branch block (LBBB) after transcatheter aortic valve implantation (TAVI) are at risk of developing delayed high-degree atrioventricular block. Management of new-onset LBBB post-TAVI remains controversial. In the Comparison of a Clinical Monitoring Strategy Versus Electrophysiology-Guided Algorithmic Approach in Patients With a New LBBB After TAVI (COME-TAVI) trial, consenting patients with new-onset LBBB that persists on day 2 after TAVI, meeting exclusion/inclusion criteria, are randomized to an electrophysiological study (EPS)-guided approach or 30-day electrocardiographic monitoring. In the EPS-guided approach, patients with a His to ventricle (HV) interval ≥ 65 ms undergo permanent pacemaker implantation. Patients randomized to noninvasive monitoring receive a wearable continuous electrocardiographic recording and transmitting device for 30 days. Follow-up will be performed at 3, 6, and 12 months. The primary endpoint is a composite outcome designed to capture net clinical benefit. The endpoint incorporates major consequences of both strategies in patients with new-onset LBBB after TAVI, as follows: (i) sudden cardiac death; (ii) syncope; (iii) atrioventricular conduction disorder requiring a pacemaker (for a class I or IIa indication); and (iv) complications related to the pacemaker or EPS. The trial incorporates a Bayesian design with a noninformative prior, outcome-adaptive randomization (initially 1:1), and 2 prespecified interim analyses once 25% and 50% of the anticipated number of primary endpoints are reached. The trial is event-driven, with an anticipated upper limit of 452 patients required to reach 77 primary outcome events over 12 months of follow-up. In summary, the aim of this Bayesian multicentre randomized trial is to compare 2 management strategies in patients with new-onset LBBB post-TAVI-an EPS-guided approach vs noninvasive 30-day monitoring. Trial registration number: NCT03303612.

Hybrid off-pump debranching and thoracic endovascular arch repair in a high-risk surgical patient

Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch-branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.

Bicuspid Aortic Valve Stenosis: From Pathophysiological Mechanism, Imaging Diagnosis, to Clinical Treatment Methods

Bicuspid aortic valve (BAV) is the most frequent congenital anomaly and has a natural evolution toward aortic regurgitation or stenosis due to the asymmetrical valve function associated with an evolutive ascending aortopathy. Several BAV classifications exist describing the presence and number of raphe, amount and location of calcium, and the symmetry of the functional cusps. The impact of BAV morphology on transcatheter aortic valve implantation (TAVI) outcomes still remains little investigated. Pivotal randomized trials comparing TAVI with surgery have excluded BAV until yet. However, data from registries and observational studies including highly selected patients have shown promising results of TAVI in BAV. With this review, we aimed at describing anatomical and pathophysiological characteristics of BAV, discussing the main aspects to assess diagnostic imaging modalities, and giving an overview of TAVI outcomes and technical considerations specific to BAV morphology.

Predictive value for paravalvular regurgitation of 3-dimensional anatomic aortic annulus shape assessed by multidetector computed tomography post-transcatheter aortic valve replacement

AIMS

Paravalvular regurgitation (PAR) remains a serious complication after trans-catheter aortic valve replacement (TAVR). Multidetector computed tomography (MDCT)-based measurements of the aortic basal virtual ring (BVR) are considered the gold standard for trans-catheter heart valve (THV) sizing. However, the real anatomic aortic annulus is a 3-dimensional structure. To compare measurement of 3D-anatomic annulus with BVR and secondly to assess independent predictive parameters that may impact on PAR > mild post-TAVR (PAR+).

METHODS AND RESULTS

MDCT was performed in 92 patients before and after balloon or self-expandable TAVR. 3D-AA shape was obtained point by point following the semilunar attachment of aortic cusps (Osirix-MD 2.8.2). 3D-oversizing index (nominal THV area/3D-AA area - 1) × 100 was calculated as well as 2D-oversizing index using BVR area instead of 3D-AA area. PAR was quantified by planimetry of vena-contracta in transthoracic echocardiography short-axis view. Valvular calcium volume and annulus calcium area were measured using Hounsfield-intensity detection. ROC curves and logistic regression for PAR(+) were performed. BVR area overall underestimated 3D-AA area by 19 ± 9% (P< 0.001), significantly more in PAR(+) (26 ± 7%) vs. PAR(-) (17 ± 9%, P< 0.001). 3D-oversizing index had greater predictive value for PAR > mild (area under the curve, AUC = 0.88) with 88% sensibility (Se) and 82% specificity (Sp) than 2D-oversizing index (AUC = 0.68) with 84% Se, but only 41% Sp (P< 0.0001). Also, valvular calcium volume and annulus calcium area were less predictors for PAR > mild (AUC = 0.68, respectively, AUC = 0.75, P = 0.002). In a multivariate analysis, only 3D-oversizing index showed an independent value for PAR > mild (OR = 18.6, P< 0.001).

CONCLUSION

Basal ring CT measurement significantly underestimated the real 3D-anatomic aortic annulus area. This may impact on THV sizing and PAR incidence. 3D-oversizing index is the most predictive factor for PAR > mild.

Unilateral pulmonary edema after pulmonary embolism in a bilateral lung transplant patient

We report a case of unilateral pulmonary edema due to the decompensation of an asymptomatic ipsilateral pulmonary venous stenosis by a contralateral pulmonary embolism. Emergency surgery included pulmonary embolectomy and refashioning of the stenotic pulmonary venous anastomosis.

Rupture de l'artère pulmonaire par cathéter de Swan-Ganz au cours de la chirurgie cardiaque : conduite à tenir et stratégie

Pulmonary artery catheterization is almost uniformly used nowadays in cardiac surgery. Although rare, rupture of the pulmonary artery following catheterization is highly lethal. This review examines ways of avoiding its occurrence and means of improving outcomes in case of rupture.

Elective anterior and posterior thoracotomies

Surgical techniques, indications and pitfalls of the elective posterior thoracotomy are described. Discussion and an overview of the literature are developed.

Posterolateral thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe first the standard posterolateral thoracotomy, which has been the classic reference and then the muscle-sparing posterolateral thoracotomy. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.

Antero-lateral thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe the antero-lateral thoracotomy. Although these incisions are seldom used, it should be part of the surgeon's 'general culture'. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.

Modified lateral thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe the lateral muscle-sparing thoracotomy in the Weissmuller's position which is, according to us, the universal thoracotomy. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature for this incision are developed.

Clamshell and hemiclamshell incisions

Sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Transverse sternotomy with bilateral thoracotomy and combined approaches are developed. Surgical techniques, indications and pitfalls of these incisions are described.

Axillary thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. Axillary thoracotomy has increased the interest in muscle-sparing approaches. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.

Thoracic incisions - general considerations

Peri-operative management of thoracotomies is detailed. Discussions and an overview of the literature are developed.

Sternotomy

Median sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Surgical techniques, indications and pitfalls of this incision are described.

Aspergillus Endocarditis After Cardiac Surgery

Aspergillus species infections are an increasingly common occurrence in hospital wards. Aspergillus endocarditis constitutes one of the manifestations of the disease, which bears a poor prognosis in cardiac surgery patients. A review of the literature on fungal and Aspergillus endocarditis was undertaken. Valvular risk factors, indwelling intravenous catheters, prolonged antibiotics, malignancy, and intravenous drug use increase the risk. Clinical presentation is insidious, with embolic complications often representing the first manifestation of the disease. Blood cultures are typically negative. The mortality rate is almost 100%. Amphotericin B represents the mainstay of medical therapy with several possible adjuncts. Surgery is an essential part of therapy in Aspergillus endocarditis after cardiac surgery and should be undertaken as soon as the diagnosis is made. Aspergillus endocarditis is an ominous complication after cardiac surgery. A high suspicion index, early administration of appropriate antibiotics, and prompt surgical intervention should improve the prognosis, which remains dismal.

A cluster of cases of Aspergillus endocarditis after cardiac surgery

Aspergillus endocarditis is an ominous condition whose prevalence is increasing in the hospital population. Despite the life-threatening nature of the disease, detection of the source, establishment of the diagnosis, and treatment remain highly challenging. A cluster of three cases of Aspergillus endocarditis recently encountered at the Montreal Heart Institute are presented.

Prosthetic valve thrombosis: twenty-year experience at the montreal heart institute

BACKGROUND

Prosthetic valve thrombosis is a life-threatening complication. We reviewed the incidence, risk factors, and treatment strategies of this rare complication.

METHODS

From February 1981 through January 2001, 5430 valve operations were performed in 4924 patients at the Montreal Heart Institute. Of this cohort, 39 patients presented with prosthetic valve thrombosis and had complete follow-up data obtained from our prospective valve clinic database.

RESULTS

In this series 82% of patients were women, and the mean age was 58 +/- 11 years. The underlying pathology involved the mitral valve in 75% of cases. Most prosthetic valve thromboses occurred with mechanical prostheses (95%). The time interval from first valve replacement to prosthetic valve thrombosis was 39 +/- 42 months. The most frequent clinical presentation was severe congestive heart failure (44%). On prosthetic valve thrombosis presentation, the international normalized ratio was less than 2.5 in 54%, with inadequate anticoagulation management in 26% and poor compliance in 26%. Eighty-two percent of patients underwent a surgical procedure, consisting of thrombectomy in 47%, mitral valve replacement in 47%, and aortic valve replacement in 6% of patients. The 30-day operative mortality and total in-hospital mortality after prosthetic valve thrombosis were 25% and 41%, respectively. The 10-year actuarial survival after prosthetic valve thrombosis was 46% +/- 10%.

CONCLUSION

Inadequate level of anticoagulation is the most important factor involved in the pathogenesis of prosthetic valve thrombosis. The overall mortality rate despite surgical treatment remains high. This study underscores the importance of meticulous surveillance of anticoagulation therapy in patients with prosthetic valves.

Incidence and outcome of radial artery infections following cardiac surgery

BACKGROUND

Radial artery infections secondary to catheterization for blood pressure monitoring are rare but potentially serious complications. The objective of the study was to evaluate the incidence, the risk factors and the evolution of radial artery infections following cardiac surgery.

METHODS

A retrospective review of 8300 patients undergoing cardiac surgery between 1998 and 2002 at the Montreal Heart Institute (MHI) was undertaken. All patients with superficial radial artery infections, infected radial artery pseudoaneurysms, and arterial catheter-related bacteremia were considered using prospective global surveillance of all nosocomial infections over the study period by an infection control nurse.

RESULTS

Thirteen patients with radial infections were encountered (0.2%) with bacteremia occurring in 9 patients (0.15%). Five patients developed infected radial artery pseudoaneurysms (0.05%) and 5 patients developed subsequent sternal wound infections. Two patients died in their early postoperative evolution. Mean patient age was 67 years old and mean duration of cannulation was 5.8 days. Only 1 patient had diabetes. Seven of 13 patients were positive for Staphylococcus aureus (54%). All patients had undergone cardiopulmonary bypass (CPB) for various procedures. All superficial infections responded well to antibiotic therapy. Early surgical intervention is essential in cases of infected radial artery pseudoaneurysms.

CONCLUSIONS

The postoperative state and cardiopulmonary bypass put patients at risk for infectious complications. Strict systematic changing of arterial lines on a timely basis is unwarranted in our opinion. A high suspicion index, aggressive surgical treatment of bacterial arteritis and appropriate intravenous antibiotics are essential to improve the prognosis.

[Chronic constrictive pericarditis in African children: report of a case]

The chronic constrictive pericarditis is a rare affection, with multiple etiologies and concerning especially the adult. We report a case of chronic constrictive pericarditis in an African child in whom no etiology was found. A review of the literature raises the characteristics of chronic constrictive pericarditis for a better therapeutic management.

Aspergillus flavus mitral valve endocarditis after lung abscess

A 16-year-old male with bone marrow failure due to chemotherapy for recurrent acute lymphoblastic leukemia developed an abscess in the lower lobe of the left lung draining through a bronchogastric fistula, as well as mitral valve endocarditis with large vegetations. After a course of antifungal therapy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, double-leaflet prosthesis. Microscopy of the lung and heart specimens disclosed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fungus, which was identified by culturing on Czapek's medium as Aspergillus flavus. Despite further antifungal therapy, fatal embolism developed. The emboli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunocompromised patients, and suggests that delayed surgical treatment and the presence of another focus of Aspergillus infection may increase the risk of death.