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Stinis CT, Abbas AE, Teirstein P, Makkar RR, Chung CJ, Iyer V, Généreux P, Kipperman RM, Harrison JK, Hughes GC, Lyons JM, Rahman A, Kakouros N, Walker J, Roberts DK, Huang PH, Kar B, Dhoble A, Logsdon DP, Khanna PK, Aragon J, McCabe JM. Real-World Outcomes for the Fifth-Generation Balloon Expandable Transcatheter Heart Valve in the United States. JACC Cardiovasc Interv 2024; 17:1032-1044. [PMID: 38456883 DOI: 10.1016/j.jcin.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The fifth-generation SAPIEN 3 Ultra Resilia valve (S3UR) incorporates several design changes as compared with its predecessors, the SAPIEN 3 (S3) and SAPIEN 3 Ultra (S3U) valves, including bovine leaflets treated with a novel process intended to reduce structural valve deterioration via calcification, as well as a taller external skirt on the 29-mm valve size to reduce paravalvular leak (PVL). The clinical performance of S3UR compared with S3 and S3U in a large patient population has not been previously reported. OBJECTIVES The aim of this study was to compare S3UR to S3/S3U for procedural, in-hospital, and 30-day clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR). METHODS Patients enrolled in the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) Registry between January 1, 2021, and June 30, 2023, who underwent TAVR with S3UR or S3U/S3 valve platforms were propensity-matched and evaluated for procedural, in-hospital, and 30-day clinical and echocardiographic outcomes. RESULTS 10,314 S3UR patients were propensity matched with 10,314 patients among 150,539 S3U/S3 patients. At 30 days, there were no statistically significant differences in death, stroke, or bleeding, but a numerically higher hospital readmission rate in the S3UR cohort (8.5% vs 7.7%; P = 0.04). At discharge, S3UR patients exhibited significantly lower mean gradients (9.2 ± 4.6 mm Hg vs 12.0 ± 5.7 mm Hg; P < 0.0001) and larger aortic valve area (2.1 ± 0.7 cm2 vs 1.9 ± 0.6 cm2; P < 0.0001) than patients treated with S3/S3U. The 29-mm valve size exhibited significant reduction in mild PVL (5.3% vs 9.4%; P < 0.0001). CONCLUSIONS S3UR TAVR is associated with lower mean gradients and lower rates of PVL than earlier generations of balloon expandable transcatheter heart valve platforms.
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Affiliation(s)
- Curtiss T Stinis
- Division of Cardiology, Scripps Clinic, La Jolla, California, USA.
| | - Amr E Abbas
- Corewell Health East, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Paul Teirstein
- Division of Cardiology, Scripps Clinic, La Jolla, California, USA
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christine J Chung
- University of Washington Medical Center, Department of Medicine, Division of Cardiology, Seattle, Washington, USA
| | - Vijay Iyer
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, New York, USA
| | - Philippe Généreux
- Gagnon Cardiovascular Institute at Morristown Medical Center, Morristown, New Jersey, USA
| | - Robert M Kipperman
- Atlantic Health System Morristown Medical Center, Morristown, New Jersey, USA
| | - John K Harrison
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - G Chad Hughes
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | | | - Ayaz Rahman
- Cardiology Associates of East Tennessee, Knoxville, Tennessee, USA
| | - Nikolaos Kakouros
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Jennifer Walker
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | | | | | - Biswajit Kar
- Division of Cardiology, Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Abhijeet Dhoble
- Division of Cardiology, Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - Joseph Aragon
- Santa Barbara Cottage Hospital, Santa Barbara, California, USA
| | - James M McCabe
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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Hutt E, Canosa FJM, Unai S, Jaber WA. Manifestations of Prosthetic Valve Endocarditis: Lessons From Multimodality Imaging and Pathological Correlation. Circ Cardiovasc Imaging 2024; 17:e016435. [PMID: 38626096 DOI: 10.1161/circimaging.123.016435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/28/2024] [Indexed: 04/18/2024]
Abstract
Heart valve replacement has steadily increased over the past decades due to improved surgical mortality, an aging population, and the increasing use of transcatheter valve technology. With these developments, prosthetic valve complications, including prosthetic valve endocarditis, are increasingly encountered. In this review, we aim to characterize the manifestations of prosthetic valve endocarditis using representative case studies from our institution to highlight the advances and contributions of modern multimodality imaging techniques.
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Affiliation(s)
- Erika Hutt
- Departments of Cardiovascular Imaging (E.H., W.A.J.), Cleveland Clinic Foundation, OH
| | | | - Shinya Unai
- Cardiothoracic Surgery (S.U.), Cleveland Clinic Foundation, OH
| | - Wael A Jaber
- Departments of Cardiovascular Imaging (E.H., W.A.J.), Cleveland Clinic Foundation, OH
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Herrmann HC, Desai ND. Incidence, Implications, and Treatment of Patients With Severe Aortic Stenosis and Small Aortic Annulus. Circulation 2024; 149:656-657. [PMID: 38408150 DOI: 10.1161/circulationaha.123.067816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Howard C Herrmann
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | - Nimesh D Desai
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia
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Tom S, Lisko J, Grubb KJ. How to Assess the Feasibility of a Second Transcatheter Aortic Valve Replacement When the First Valve Fails. Tex Heart Inst J 2024; 51:e238301. [PMID: 38349041 DOI: 10.14503/thij-23-8301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
- Stephanie Tom
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - John Lisko
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Al-Hashimi I, Qazi M, Hickerson S, Okon E. Late Recurrence of Prosthetic Valve Endocarditis Due to Candida albicans. Am J Case Rep 2024; 25:e942399. [PMID: 38297824 PMCID: PMC10846750 DOI: 10.12659/ajcr.942399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/23/2023] [Accepted: 12/14/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Candida prosthetic valve endocarditis is a rare disease that is increasing in incidence with the rising rates of fungemia and increased use of intracardiac devices. Chronic antifungal prophylaxis is used after primary treatment to prevent recurrence, but the optimal duration of prophylaxis is currently unknown. This case report is of a woman with a history of mitral valve replacement due to Candida endocarditis presenting 2 years later with prosthetic valve and native aortic valve Candida albicans endocarditis. CASE REPORT A 32-year-old woman with a history of intravenous drug abuse, Staphylococcus and Candida endocarditis, and 2 mitral valve replacements 2 years ago on long-term oral fluconazole presented with fevers, weight loss, and dyspnea. She had stopped taking her oral antifungals prior to presentation. She was found to have vegetations on her prosthetic mitral valve and on her native aortic valve. She was started on ceftriaxone, vancomycin, and micafungin, and blood cultures grew C. albicans. She also developed a C. albicans metatarsal abscess and a splenic infarct. She underwent redo mitral valve replacement and aortic valve debridement successfully and was continued on intravenous micafungin for 8 weeks. CONCLUSIONS This case highlights the association between prosthetic valve endocarditis, intravenous drug abuse, and opportunistic fungal infections. Lifelong oral fluconazole can be considered for all patients with C. albicans prosthetic valve endocarditis, especially in the setting of the presence of other risk factors, such as intravenous drug abuse, as demonstrated in our case. Further studies are needed to determine differences in outcomes.
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Affiliation(s)
- Ibrahim Al-Hashimi
- Office of Graduate Medical Education, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Mariam Qazi
- Department of Medicine, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Steven Hickerson
- Department of Infectious Diseases, UT Health East Texas, Tyler, TX, USA
| | - Emmanuel Okon
- Department of Infectious Diseases, Christus Trinity Clinic, Tyler, TX, USA
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Ueyama HA, Xie J, Hanzel GS, Byku I, Paone G, Grubb KJ, Devireddy CM, Greenbaum AB, Babaliaros VC, Gleason PT. Hemodynamic Comparison of Resilia and Sapien 3/Ultra Transcatheter Heart Valves in Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2024; 17:e013325. [PMID: 38047373 DOI: 10.1161/circinterventions.123.013325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Affiliation(s)
- Hiroki A Ueyama
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Joe Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - George S Hanzel
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Gaetano Paone
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (G.P., K.J.G.)
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (G.P., K.J.G.)
| | - Chandan M Devireddy
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Adam B Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
| | - Patrick T Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.)
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Hohmann C, Pfister R, Frerker C, Beckmann A, Walther T, Bleiziffer S, Ensminger S, Bekeredjian R, Seiffert M, Sinning JM, Möllmann H, Beyersdorf F, Baldus S, Böning A, Herrmann E, Balaban Ü, Kuhn E. Direct oral anticoagulants versus vitamin K antagonist after transcatheter aortic valve implantation. Heart 2023; 109:1706-1713. [PMID: 37407220 DOI: 10.1136/heartjnl-2023-322548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE After transcatheter aortic valve implantation (TAVI), the optimal regimen of anticoagulant therapy in patients with an additional indication for oral anticoagulation remains a matter of debate. This study investigates the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients after TAVI in a real-world population. METHODS The German Aortic Valve RegistrY (GARY) is a prospective, multicentre registry enrolling patients undergoing invasive treatment for aortic valve disease. From January 2011 to December 2019, 1 41 790 patients from 92 hospitals in Germany were enrolled. Anticoagulatory treatment regimens were assessed at hospital discharge for patients after TAVI procedures. All-cause mortality and the combined endpoint 'cardiac and cerebrovascular events' containing myocardial infarction, stroke, transient ischaemic attack, aortic prosthesis reintervention and all-cause mortality in the first year after TAVI were examined by treatment regimen. RESULTS Of 45 598 patients (mean age 80.7±5.7 years, 49.3% males) undergoing TAVI, 16 974 patients (37.2%) received an anticoagulant regimen that included VKA or DOAC. Hereof, the majority of patients were prescribed VKA (n=11 333, 66.8%) compared with DOAC (n=5641, 33.2%) with an increase of DOAC use from 9.4% in 2011 to 69.9% in 2019. During the 1-year follow-up, the absolute event rates per 100 person-years for all-cause mortality and the combined endpoint cardiac and cerebrovascular events were 1.9 and 1.3 for VKA-treated and 1.7 and 1.2 for DOAC-treated patients, respectively. After adjustment for baseline confounders, all-cause mortality (HR 0.95, 95% CI 0.88 to 1.01, p=0.114) and cardiac and cerebrovascular event-free survival (HR 0.93, 95% CI 0.86 to 1.01, p=0.071) did not differ significantly between VKA and DOAC groups. CONCLUSIONS This study supports evidence of the efficacy of DOAC use after TAVI in patients with an indication for oral anticoagulation.
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Affiliation(s)
- Christopher Hohmann
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Christian Frerker
- Department of Cardiology, Vascular Medicine and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andreas Beckmann
- Department of Cardiac Surgery, Heart Centre Duisburg, Evangelisches Krankenhaus Niederrhein, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Germany
| | - Thomas Walther
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Department of Cardiothoracic Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Sabine Bleiziffer
- Department of Cardiothoracic Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital SchleswigHolstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Moritz Seiffert
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jan-Malte Sinning
- Department of Cardiology, St. Vinzenz-Hospital Cologne, Cologne, Germany
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Andreas Böning
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Eva Herrmann
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Ümniye Balaban
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
- Department of Cardiothoracic Surgery, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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Wang A, Wang Y, Liu W, Liu L, Zhou J. Effect of valve leaflet surface patterning on valve hydrodynamic performance. Int J Artif Organs 2023; 46:569-573. [PMID: 37698036 DOI: 10.1177/03913988231192118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE We aimed to elucidate the effects of the micro-structure of the pyrolytic carbon for artificial heart valves on its hydrodynamic performance. METHODS Bileaflet mechanical valves of GKS 23 and 29 A were randomly selected. According to ISO5840, mean transvalvular pressure (MPG), regurgitation fraction (RF), and effective orifice area (EOA) of valve were assessed. Then, parallel-groove pattern was constructed by laser etching on leaflet surface, and the valves were subjected again to the same test. RESULTS Compared with before patterning at 2, 3.5, 5, and 7 L/min, the MPG of the valves in two specifications were higher, the EOA was larger in 23 A, but smaller in 29 A, and the RF was contrary to EOA. At 5 L/min, the RF in both specifications was lower after etching at 45 bpm. At 70 bpm however, the RF in 23 A decreased, in 29 A increased. CONCLUSION The parallel-groove pattern on leaflet surface affected the hemodynamic performance of the valve prostheses.
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Affiliation(s)
- Aili Wang
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Yumiao Wang
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Wanbing Liu
- Beijing Star Medical Devices Co., Ltd., Beijing, PR China
| | - Li Liu
- Center for Medical Devices Testing, National Institutes for Food and Drug Control, Beijing, PR China
| | - Jianye Zhou
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
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Abstract
The prevalence of concurrent cancer and severe aortic stenosis (AS) is increasing due to an ageing population. In addition to shared traditional risk factors for AS and cancer, patients with cancer may be at increased risk for AS due to off-target effects of cancer-related therapy, such as mediastinal radiation therapy (XRT), as well as shared non-traditional pathophysiological mechanisms. Compared with surgical aortic valve replacement, major adverse events are generally lower in patients with cancer undergoing transcatheter aortic valve intervention (TAVI), especially in those with history of mediastinal XRT. Similar procedural and short-to-intermediate TAVI outcomes have been observed in patients with cancer as compared with no cancer, whereas long-term outcomes are dependent on cancer survival. Considerable heterogeneity exists between cancer subtypes and stage, with worse outcomes observed in those with active and advanced-stage disease as well as specific cancer subtypes. Procedural management in patients with cancer poses unique challenges and thus requires periprocedural expertise and close collaboration with the referring oncology team. The decision to ultimately pursue TAVI involves a multidisciplinary and holistic approach in assessing the appropriateness of intervention. Further clinical trial and registry studies are needed to better appreciate outcomes in this population.
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Affiliation(s)
- Douglas Leedy
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - David M Elison
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Francisco Farias
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Richard Cheng
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - James M McCabe
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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Danilov VV, Klyshnikov KY, Onishenko PS, Proutski A, Gankin Y, Melgani F, Ovcharenko EA. Perfect prosthetic heart valve: generative design with machine learning, modeling, and optimization. Front Bioeng Biotechnol 2023; 11:1238130. [PMID: 37781537 PMCID: PMC10541217 DOI: 10.3389/fbioe.2023.1238130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Majority of modern techniques for creating and optimizing the geometry of medical devices are based on a combination of computer-aided designs and the utility of the finite element method This approach, however, is limited by the number of geometries that can be investigated and by the time required for design optimization. To address this issue, we propose a generative design approach that combines machine learning (ML) methods and optimization algorithms. We evaluate eight different machine learning methods, including decision tree-based and boosting algorithms, neural networks, and ensembles. For optimal design, we investigate six state-of-the-art optimization algorithms, including Random Search, Tree-structured Parzen Estimator, CMA-ES-based algorithm, Nondominated Sorting Genetic Algorithm, Multiobjective Tree-structured Parzen Estimator, and Quasi-Monte Carlo Algorithm. In our study, we apply the proposed approach to study the generative design of a prosthetic heart valve (PHV). The design constraints of the prosthetic heart valve, including spatial requirements, materials, and manufacturing methods, are used as inputs, and the proposed approach produces a final design and a corresponding score to determine if the design is effective. Extensive testing leads to the conclusion that utilizing a combination of ensemble methods in conjunction with a Tree-structured Parzen Estimator or a Nondominated Sorting Genetic Algorithm is the most effective method in generating new designs with a relatively low error rate. Specifically, the Mean Absolute Percentage Error was found to be 11.8% and 10.2% for lumen and peak stress prediction respectively. Furthermore, it was observed that both optimization techniques result in design scores of approximately 95%. From both a scientific and applied perspective, this approach aims to select the most efficient geometry with given input parameters, which can then be prototyped and used for subsequent in vitro experiments. By proposing this approach, we believe it will replace or complement CAD-FEM-based modeling, thereby accelerating the design process and finding better designs within given constraints. The repository, which contains the essential components of the study, including curated source code, dataset, and trained models, is publicly available at https://github.com/ViacheslavDanilov/generative_design.
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Affiliation(s)
| | - Kirill Y. Klyshnikov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Pavel S. Onishenko
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | | | | | | | - Evgeny A. Ovcharenko
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
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Prieto-Lobato A, Nuche J, Avvedimento M, Paradis JM, Dumont E, Kalavrouziotis D, Mohammadi S, Rodés-Cabau J. Managing the challenge of a small aortic annulus in patients with severe aortic stenosis. Expert Rev Cardiovasc Ther 2023; 21:747-761. [PMID: 37869793 DOI: 10.1080/14779072.2023.2271395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Small aortic annulus (SAA) poses a challenge in the management of patients with severe aortic stenosis requiring aortic valve replacement - both surgical and transcatheter - since it has been associated with worse clinical outcomes. AREAS COVERED This review aims to comprehensively summarize the available evidence regarding the management of aortic stenosis in patients with SAA and discuss the current controversies as well as future perspectives in this field. EXPERT OPINION It is paramount to agree in a common definition for diagnosing and properly treating SAA patients, and for that purpose, multidetector computer tomography is essential. The results of recent trials led to the expansion of transcatheter aortic valve replacement among patients of all the surgical-risk spectrum, and the choice of treatment (transcatheter, surgical) should be based on patient comorbidities, anatomical characteristics, and patient preferences.
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Affiliation(s)
- Alicia Prieto-Lobato
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
- Hospital del Mar, Barcelona, Spain
| | - Jorge Nuche
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Marisa Avvedimento
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | | | - Eric Dumont
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | | | - Siamak Mohammadi
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
- Clínic Barcelona, Barcelona, Spain
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Kherallah RY, Silva G. Cutting-Edge Trials in Structural Heart Disease at The Texas Heart Institute. Tex Heart Inst J 2023; 50:e238123. [PMID: 37339087 DOI: 10.14503/thij-23-8123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Riyad Yazan Kherallah
- Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Guilherme Silva
- Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
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13
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Kim SE, Parekh D, Lam W. A Novel Approach to Diagnostic Left and Right Heart Catheterization in a Patient With a Mechanical Prosthetic Tricuspid Valve. Tex Heart Inst J 2023; 50:493515. [PMID: 37302148 DOI: 10.14503/thij-22-8039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A 47-year-old patient was experiencing dyspnea and fatigue concerning for right ventricular hypertension and new heart failure. Because of the risks associated with catheter entrapment, prosthetic valve leaflet damage, and valve thrombosis associated with crossing a mechanical valve, a novel technique was used for diagnostic left and right heart catheterization in a patient with mechanical tricuspid valve replacement and tortuous pulmonary arteries. Using a percutaneous subxiphoid approach to avoid traversing the mechanical valve without discontinuing anticoagulation, a Volcano fractional flow reserve pressure wire (Philips Volcano) was advanced for distal measurements of pressures and saturations.
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Affiliation(s)
- Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dhaval Parekh
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics/Pediatric Cardiology, Texas Children's Hospital, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Wilson Lam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics/Pediatric Cardiology, Texas Children's Hospital, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
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14
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Cercenelli L, Gironi C, Bortolani B, Marcelli E. First Ex Vivo Animal Study of a Biological Heart Valve Prosthesis Sensorized with Intravalvular Impedance. Sensors (Basel) 2023; 23:3829. [PMID: 37112167 PMCID: PMC10141024 DOI: 10.3390/s23083829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 06/19/2023]
Abstract
IntraValvular Impedance (IVI) sensing is an innovative concept for monitoring heart valve prostheses after implant. We recently demonstrated IVI sensing feasible in vitro for biological heart valves (BHVs). In this study, for the first time, we investigate ex vivo the IVI sensing applied to a BHV when it is surrounded by biological tissue, similar to a real implant condition. A commercial model of BHV was sensorized with three miniaturized electrodes embedded in the commissures of the valve leaflets and connected to an external impedance measurement unit. To perform ex vivo animal tests, the sensorized BHV was implanted in the aortic position of an explanted porcine heart, which was connected to a cardiac BioSimulator platform. The IVI signal was recorded in different dynamic cardiac conditions reproduced with the BioSimulator, varying the cardiac cycle rate and the stroke volume. For each condition, the maximum percent variation in the IVI signal was evaluated and compared. The IVI signal was also processed to calculate its first derivative (dIVI/dt), which should reflect the rate of the valve leaflets opening/closing. The results demonstrated that the IVI signal is well detectable when the sensorized BHV is surrounded by biological tissue, maintaining the similar increasing/decreasing trend that was found during in vitro experiments. The signal can also be informative on the rate of valve opening/closing, as indicated by the changes in dIVI/dt in different dynamic cardiac conditions.
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15
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Mack MJ, Adams DH. Avoidance of Patient Prosthesis Mismatch After Aortic Valve Replacement: Have We Been Too Aggressive? J Am Coll Cardiol 2023; 81:976-978. [PMID: 36889876 DOI: 10.1016/j.jacc.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Michael J Mack
- Baylor Scott & White Research Institute, Plano, Texas, USA.
| | - David H Adams
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
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16
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Dismorr M, Glaser N, Franco-Cereceda A, Sartipy U. Effect of Prosthesis-Patient Mismatch on Long-Term Clinical Outcomes After Bioprosthetic Aortic Valve Replacement. J Am Coll Cardiol 2023; 81:964-975. [PMID: 36889875 DOI: 10.1016/j.jacc.2022.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/29/2022] [Accepted: 12/21/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Prosthesis-patient mismatch (PPM) is common following surgical aortic valve replacement (SAVR). OBJECTIVES The purpose of this study was to quantify the impact of PPM on all-cause mortality, heart failure hospitalization, and reintervention following bioprosthetic SAVR. METHODS This observational nationwide cohort study from SWEDEHEART (Swedish Web system for Enhancement and Development of Evidence based care in Heart disease Evaluated According to Recommended Therapies) and other national registers included all patients who underwent primary bioprosthetic SAVR in Sweden from 2003 to 2018. PPM was defined according to the Valve Academic Research Consortium 3 criteria. Outcomes were all-cause mortality, heart failure hospitalization, and aortic valve reintervention. Regression standardization was used to account for intergroup differences and to estimate cumulative incidence differences. RESULTS We included 16,423 patients (no PPM: 7,377 [45%]; moderate PPM: 8,502 [52%]; and severe PPM: 544 [3%]). After regression standardization, the cumulative incidence of all-cause mortality at 10 years was 43% (95% CI: 24%-44%) in the no PPM group compared with 45% (95% CI: 43%-46%) and 48% (95% CI: 44%-51%) in the moderate and severe PPM groups, respectively. The survival difference at 10 years was 4.6% (95% CI: 0.7%-8.5%) and 1.7% (95% CI: 0.1%-3.3%) in no vs severe PPM and no vs moderate PPM, respectively. The difference in heart failure hospitalization at 10 years was 6.0% (95% CI: 2.2%-9.7%) in severe vs no PPM. There was no difference in aortic valve reintervention in patients with or without PPM. CONCLUSIONS Increasing grades of PPM were associated with long-term mortality, and severe PPM was associated with increased heart failure. Moderate PPM was common, but the clinical significance may be negligible because the absolute risk differences in clinical outcomes were small.
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Affiliation(s)
- Michael Dismorr
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Natalie Glaser
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden. https://twitter.com/NatalieGlaser10
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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17
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Beneduce A, Ancona MB, Russo F, Ferri LA, Bellini B, Vella C, Romano V, Ancona F, Agricola E, Montorfano M. Transcatheter Mitral Paravalvular Leak Closure Using Arteriovenous Rail Across Aortic Bileaflet Mechanical Prosthesis: Multimodality Imaging Approach. Circ Cardiovasc Imaging 2023; 16:e014267. [PMID: 36330808 DOI: 10.1161/circimaging.122.014267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Marco Bruno Ancona
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Filippo Russo
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Luca Angelo Ferri
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Barbara Bellini
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Ciro Vella
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Vittorio Romano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
| | - Francesco Ancona
- Echocardiography Laboratory, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.A., E.A.)
| | - Eustachio Agricola
- Echocardiography Laboratory, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.A., E.A.)
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (A.B., M.B.A., F.R., L.A.F., B.B., C.V., V.R., M.M.)
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18
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Hong JC, Orozco-Sevilla V, Diez JG, Coselli JS. Transcatheter Aortic Valve-in-Valve-in-Valve Replacement in a Young Woman With Transcatheter Structural Valve Deterioration Within a Degenerated Aortic Root Homograft. Tex Heart Inst J 2023; 50:491500. [PMID: 36917101 PMCID: PMC10178646 DOI: 10.14503/thij-22-7874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Transcatheter aortic valve replacement is a well-established procedure for older patients with symptomatic, severe aortic stenosis. However, data are lacking on its durability and long-term complications, particularly in young patients and patients treated for aortic valve regurgitation. This article describes the case of a 27-year-old woman with complex congenital cardiovascular disease who, after 4 previous aortic valve replacement procedures, presented with structural deterioration of her most recent replacement valve, which had been placed by transcatheter aortic valve replacement inside a failed aortic root homograft 6 years earlier. After the patient had undergone this transcatheter aortic valve replacement procedure to treat aortic valve regurgitation related to her degenerated aortic root homograft, she became pregnant and successfully carried her high-risk pregnancy to term. However, the replacement valve deteriorated during the late stages of pregnancy, resulting in substantial hemodynamic changes between the first trimester and the postpartum period. To avoid repeat sternotomy, a redo transcatheter valve-in-valve replacement procedure procedure was performed through the right carotid artery. Because the patient wanted to have more children and therefore avoid anticoagulation, a SAPIEN 3 transcatheter valve (Edwards Lifesciences) was placed as a bridge to a future, more-durable aortic root replacement. The result in this case suggests that in patients with complex adult congenital pathology, transcatheter aortic valve replacement can be used as a temporizing bridge to subsequent, definitive aortic valve repair.
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Affiliation(s)
- Jonathan C Hong
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Jose G Diez
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.,Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
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19
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Stoica S, Beard C, Takkenberg JJM, Mokhles MM, Turner M, Pepper J, Hopewell-Kelly N, Benedetto U, Nashef SAM, El-Hamamsy I, Skillington P, Glauber M, De Paulis R, Tseng E, Meuris B, Sitges M, Delgado V, Krane M, Kostolny M, Pufulete M. Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years. Heart 2023; 109:857-865. [PMID: 36849232 DOI: 10.1136/heartjnl-2022-321740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/12/2022] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. METHODS A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). RESULTS There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). CONCLUSIONS Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection.
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Affiliation(s)
- Serban Stoica
- Cardiothoracic Surgery, Bristol Heart Institute, Bristol, UK
| | - Chloe Beard
- Cardiothoracic Surgery, Bristol Heart Institute, Bristol, UK
| | | | - Mostafa M Mokhles
- Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mark Turner
- Department of Cardiology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - John Pepper
- Surgery, Royal Brompton Hospital, London, UK
| | - Noreen Hopewell-Kelly
- Health and Social Sciences, University of the West of England-Frenchay Campus, Bristol, UK
| | | | - Samer A M Nashef
- Cardiac Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | | | | | - Elaine Tseng
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Bart Meuris
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Marta Sitges
- Cardiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Markus Krane
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Martin Kostolny
- Cardiothoracic Unit, Great Ormond Street Hospital and Institute of Cardiovascular Science, University College London, London, UK
| | - Maria Pufulete
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, UK
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20
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Scotti A, Baggio S, Pagnesi M, Barbanti M, Adamo M, Eitan A, Estévez-Loureiro R, Veulemans V, Toggweiler S, Mylotte D, De Marco F, Giannini F, Ferlini M, Naber CK, Buono A, Schofer J, Rottbauer W, Van Mieghem NM, Khogali S, Taramasso M, Pilgrim T, Sinning JM, Zweiker D, Montorfano M, Van der Heyden JAS, Brugaletta S, Ielasi A, Hamm CW, Vanhaverbeke M, Costa G, Massussi M, Alarcón R, Zeus T, Lunardi M, Testa L, Di Ienno L, Lanzillo G, Wolf A, Maffeo D, Ziviello F, Saccocci M, Windecker S, Sedaghat A, Schmidt A, Brouwer J, Regueiro A, Reimers B, Kim WK, Sondergaard L, Colombo A, Mangieri A, Latib A. Temporal Trends and Contemporary Outcomes After Transcatheter Aortic Valve Replacement With Evolut PRO/PRO+ Self-Expanding Valves: Insights From the NEOPRO/NEOPRO-2 Registries. Circ Cardiovasc Interv 2023; 16:e012538. [PMID: 36649387 DOI: 10.1161/circinterventions.122.012538] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND In recent years, transcatheter aortic valve replacement (TAVR) techniques and technology have continuously improved. Data regarding the impact of these advancements on outcomes in large real-world settings are still limited. The aim of this study was to investigate temporal trends and assess contemporary outcomes after TAVR with Evolut PRO/PRO+ supra-annular self-expanding valves. METHODS This study included patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries who underwent transfemoral TAVR with Evolut PRO/PRO+. Procedural dates (August 2017 through November 2021) were stratified in quartiles (Q) and used to investigate temporal trends in TAVR outcomes. Predischarge, 30-day Valve Academic Research Consortium-3 defined, and 1-year outcomes were evaluated. RESULTS In total, 1616 patients from 28 centers were included. Over time, patients had lower Society of Thoracic Surgeon-Predicted Risk of Mortality score (Q1-4, 4.1% [2.8-6.3%], 3.7% [2.6-5.3%], 3.3% [2.4-4.9%], 2.9% [2.2-4.3%]; P<0.001) and more moderate or heavy valve calcification (Q1-4, 80%, 80%, 82%, 88%; P=0.038). Overall Valve Academic Research Consortium-3 technical success was 94.1%, with 30-day and 1-year all-cause mortality of 2.4% and 10%, respectively. Throughout the study period, procedures were associated with higher rates of 30-day device success (Q1-4, 81.2%, 82.2%, 82.0%, 88.0%; Cochran-Armitage P=0.023) and early safety (Q1-4, 66.8%, 67.5%, 74.0%, 77.6%; Cochran-Armitage P<0.001), with fewer permanent pacemaker implantations (Q1-4: 15.3%, 20.0%, 12.1%, 11.6%; Cochran-Armitage P=0.023) and residual mild or greater paravalvular leaks (Q1-4, 50.4%, 42.1%, 36.5%, 35.8%; Cochran-Armitage P<0.001). CONCLUSIONS TAVR with Evolut PRO/PRO+ self-expanding valve is safe and effective. Despite the treatment of heavier calcified anatomies, procedural outcomes are improving over time with less need for pacemaker implantation and less significant paravalvular leaks.
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Affiliation(s)
- Andrea Scotti
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.S., A.L.)
| | - Sara Baggio
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (S.B., B.R., A.C., A.M.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (S.B., B.R., A.C., A.M.)
| | - Matteo Pagnesi
- Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Italy (M.P., M.A., M. Massussi).,Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.P., M.A., M. Massussi)
| | - Marco Barbanti
- Department of Cardiology, C.A.S.T. Policlinico G. Rodolico, Catania, Italy (M.B., G.C.)
| | - Marianna Adamo
- Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Italy (M.P., M.A., M. Massussi).,Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.P., M.A., M. Massussi)
| | - Amnon Eitan
- Department of Cardiology, Carmel Medical Center, Haifa, Israel (A.E.)
| | - Rodrigo Estévez-Loureiro
- Cardiology Department, University Hospital Alvaro Cunqueiro, Galicia Sur Health Research Institute, Vigo, Spain (R.E.-L., R.A.)
| | - Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Germany (V.V., T.Z.)
| | - Stefan Toggweiler
- Heart Center Lucerne, Department of Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland (S.T.)
| | - Darren Mylotte
- Department of Cardiology, Galway University Hospitals, Ireland (D.M., M.L.)
| | | | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy (F.G., L.D.I.)
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (M.F., G.L.)
| | - Christoph K Naber
- Contilia Heart and Vascular Centre, Elisabeth-Krankenhaus Essen, Germany (C.K.N., A.W.)
| | - Andrea Buono
- Interventional Cardiology Unit, Fondazione Poliambulanza, Brescia, Italy (A.B., D.M.)
| | - Joachim Schofer
- Department for Percutaneous Treatment of Structural Heart Disease, Albertinen Heart Center, Hamburg, Germany (J.S.).,MVZ Department Structural Heart Disease, Asklepios St Georg Clinic, Hamburg, Germany (J.S.)
| | - Wolfgang Rottbauer
- Department of Internal Medicine II, University Hospital Ulm, Germany (W.R., S.W.)
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (N.M.V.M., F.Z.)
| | - Saib Khogali
- Heart and Lung Center, New Cross Hospital, Wolverhampton, UK (S.K.)
| | - Maurizio Taramasso
- Division of Cardiothoracic Surgery, HerzZentrum Hirslanden Zürich, Switzerland (M.T., M.S.)
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.P.)
| | - Jan-Malte Sinning
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Germany (J.-M.S., A. Sedaghat)
| | - David Zweiker
- Division of Cardiology, Medical University of Graz, Austria (D.Z., A. Schmidt)
| | - Matteo Montorfano
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (M. Montorfano)
| | - Jan A S Van der Heyden
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands (J.A.S.V.d.H., J.B.).,Interventional Cardiology Unit, AZ Sint-Jan Hospital, Bruges, Belgium (J.A.S.V.d.H.)
| | - Salvatore Brugaletta
- Clinic Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (S.B., A.R.)
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Milan, Italy (A.I.)
| | - Christian W Hamm
- Department of Cardiology and Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany (C.W.H., W.-K.K.)
| | - Maarten Vanhaverbeke
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Denmark (M.V., L.S.)
| | - Giuliano Costa
- Department of Cardiology, C.A.S.T. Policlinico G. Rodolico, Catania, Italy (M.B., G.C.)
| | - Mauro Massussi
- Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Italy (M.P., M.A., M. Massussi).,Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.P., M.A., M. Massussi)
| | - Robert Alarcón
- Cardiology Department, University Hospital Alvaro Cunqueiro, Galicia Sur Health Research Institute, Vigo, Spain (R.E.-L., R.A.)
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Germany (V.V., T.Z.)
| | - Mattia Lunardi
- Department of Cardiology, Galway University Hospitals, Ireland (D.M., M.L.)
| | - Luca Testa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy (L.T.)
| | - Luca Di Ienno
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy (F.G., L.D.I.)
| | - Giuseppe Lanzillo
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (M.F., G.L.)
| | - Alexander Wolf
- Contilia Heart and Vascular Centre, Elisabeth-Krankenhaus Essen, Germany (C.K.N., A.W.)
| | - Diego Maffeo
- Interventional Cardiology Unit, Fondazione Poliambulanza, Brescia, Italy (A.B., D.M.)
| | - Francesca Ziviello
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (N.M.V.M., F.Z.)
| | - Matteo Saccocci
- Division of Cardiothoracic Surgery, HerzZentrum Hirslanden Zürich, Switzerland (M.T., M.S.)
| | - Stephan Windecker
- Department of Internal Medicine II, University Hospital Ulm, Germany (W.R., S.W.)
| | - Alexander Sedaghat
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Germany (J.-M.S., A. Sedaghat)
| | - Albrecht Schmidt
- Division of Cardiology, Medical University of Graz, Austria (D.Z., A. Schmidt)
| | - Jorn Brouwer
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands (J.A.S.V.d.H., J.B.)
| | - Ander Regueiro
- Clinic Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (S.B., A.R.)
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (S.B., B.R., A.C., A.M.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (S.B., B.R., A.C., A.M.)
| | - Won-Keun Kim
- Department of Cardiology and Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany (C.W.H., W.-K.K.)
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Denmark (M.V., L.S.)
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (S.B., B.R., A.C., A.M.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (S.B., B.R., A.C., A.M.)
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (S.B., B.R., A.C., A.M.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (S.B., B.R., A.C., A.M.)
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.S., A.L.)
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21
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Kachel M, Buszman PP, Milewski KP, Michalak M, Domaradzki W, Pruski M, Sobota M, Fernandez C, Konopko M, Nożyński J, Kaźmierczak P, Włodarczyk J, Stojko M, Bochenek A, Buszman PE. Temporal, biomechanical evaluation of a novel, transcatheter polymeric aortic valve in ovine aortic banding model. Front Cardiovasc Med 2022; 9:977006. [PMID: 36606288 PMCID: PMC9810075 DOI: 10.3389/fcvm.2022.977006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives The aim of the study is to evaluate the functionality, durability, and temporal biocompatibility of a novel, balloon-expandable polymeric transcatheter heart valve (ATHV) system (InFlow, CardValve Consortium, Poland). Along with expanding TAVI indications, the demand for new transcatheter valves is increasing. Methods A surgical ascending aortic banding model was created in 20 sheep. Two weeks later, 16 sheep were implanted with ATHV systems (15-16F). Three animals were euthanized after a 30-day follow-up, four animals after a 90-day follow-up, and six animals after a 180-day follow-up. A follow-up transthoracic echocardiography (TTE) was performed. Results There was one procedure-related (6,25%) and two model-related deaths (12,5%; banding site calcification with subsequent infection originating externally from banding). TTE revealed the flow gradients (max/average) of 30,75/17,91; 32,57/19,21; and 21,34/10,63 mmHg at 30, 90, and 180 days, respectively. There were two cases of low-degree regurgitation after 180 days with no perivalvular leak observed. Histopathological analysis showed no valve degeneration at terminal follow-up with optimal healing. Small thrombi were present at the aortic wall adjacent to the base of the leaflets, and between the aortic wall and the stent in most of the valves; however, leaflets remained free from thrombi in all cases. Scanty calcifications of leaflets were reported in three animals evaluated 180 days after implantation. Conclusion This preclinical study in the aortic banding model showed good hemodynamic performance, durability, and biocompatibility of the novel ATHV. Furthermore, regulatory studies with longer follow-ups are warranted.
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Affiliation(s)
- Mateusz Kachel
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland,Department of Cardiology, Andrzej Frycz Modrzewski Kraków University, Bielsko-Biała, Poland
| | - Piotr P. Buszman
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland,Department of Cardiology, Andrzej Frycz Modrzewski Kraków University, Bielsko-Biała, Poland,*Correspondence: Piotr P. Buszman,
| | - Krzysztof P. Milewski
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland,Faculty of Medicine, University of Technology, Katowice, Poland
| | - Magdalena Michalak
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland
| | - Wojciech Domaradzki
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland
| | - Maciej Pruski
- Department of Epidemiology, Medical University of Silesia, Katowice, Poland
| | - Michał Sobota
- Centre of Polymer and Carbon Materials, Polish Academy of Sciences, Zabrze, Poland
| | - Carlos Fernandez
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland
| | - Marta Konopko
- Department of Cardiology, Andrzej Frycz Modrzewski Kraków University, Bielsko-Biała, Poland
| | | | - Paweł Kaźmierczak
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland
| | - Jakub Włodarczyk
- Centre of Polymer and Carbon Materials, Polish Academy of Sciences, Zabrze, Poland
| | - Mateusz Stojko
- Centre of Polymer and Carbon Materials, Polish Academy of Sciences, Zabrze, Poland
| | - Andrzej Bochenek
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland,Faculty of Medicine, University of Technology, Katowice, Poland
| | - Paweł E. Buszman
- American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland,Department of Epidemiology, Medical University of Silesia, Katowice, Poland
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22
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Tanaka I, Morioka S, Honda A, Miyazaki R, Wajima T, Nakaminami H, Kato T. Prosthetic valve endocarditis due to highly beta-lactam-resistant Streptococcus oralis: a case report. Access Microbiol 2022; 4:acmi000437. [PMID: 36644435 PMCID: PMC9833417 DOI: 10.1099/acmi.0.000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
There are limited reports of patients with prosthetic valve infective endocarditis (IE) or recurrent IE due to highly beta-lactam-resistant viridans group streptococci. We present a case in which a patient with native valve IE due to beta-lactam-susceptible Streptococcus oralis developed prosthetic valve IE due to highly beta-lactam-resistant S. oralis . A 79-year-old man with a history of native aortic valve IE caused by beta-lactam-susceptible S. oralis 21 months prior to admission and aortic valve replacement was admitted to our hospital with a 2-week history of general malaise and low-grade fever. Transesophageal echocardiography showed a 20 mm vegetation on the prosthetic aortic valve, and emergency cardiovascular surgery was performed on admission day 2. Three sets of blood cultures on admission were positive for highly beta-lactam-resistant S. oralis . Vancomycin and cefazolin were administered as initial treatment. After the surgery, the patient was given vancomycin and gentamicin for 2 weeks, followed by vancomycin for 4 weeks. He was relapse-free at the 6-month follow-up. For patients with native valve IE due to S. oralis who have undergone valve replacement more than 1 year earlier, given the possibility of methicillin-resistant Staphylococcus aureus as well as S. oralis resistance to beta-lactams, it may be advisable to start vancomycin as an initial treatment and continue it until the infecting micro-organism has been proven to be susceptible to beta-lactams.
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Affiliation(s)
- Ippei Tanaka
- Department of Pharmacy, Japanese Red Cross Musashino Hospital, Tokyo, Japan,Department of Clinical Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Shinichiro Morioka
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan,*Correspondence: Shinichiro Morioka,
| | - Arisa Honda
- Department of Pharmacy, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Takeaki Wajima
- Department of Clinical Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan,Department of Microbiology, Faculty of Pharmacy, Meijo University, Nagoya, Japan
| | - Hidemasa Nakaminami
- Department of Clinical Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Tomoyuki Kato
- Department of Pharmacy, Japanese Red Cross Musashino Hospital, Tokyo, Japan,Department of Infection Control, Japanese Red Cross Musashino Hospital, Tokyo, Japan
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23
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Chan KYE, Tai-Leung Chan D, Lam CCS, Shu-Yue Sze M, Un KC, Tam CCF, Lam YM, Wong CK. First-in-Human Undermining Iatrogenic Coronary Obstruction With Radiofrequency Needle (UNICORN) Procedure During Valve-in-Valve Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2022; 15:928-931. [PMID: 36268707 DOI: 10.1161/circinterventions.122.012399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kwong-Yue Eric Chan
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Daniel Tai-Leung Chan
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, China (D.T.-L.C.)
| | - Cheung-Chi Simon Lam
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Michael Shu-Yue Sze
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Ka-Chun Un
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Chor-Cheung Frankie Tam
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Yui-Ming Lam
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
| | - Chun-Ka Wong
- Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China (K.-Y.E.C., C.-C.S.L., M.S.-Y.S., K.-C.U., C.-C.F.T., Y.-M.L., C.-K.W.)
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24
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Gironi C, Cercenelli L, Bortolani B, Emiliani N, Tartarini L, Marcelli E. Innovative IntraValvular Impedance Sensing Applied to Biological Heart Valve Prostheses: Design and In Vitro Evaluation. Sensors (Basel) 2022; 22:s22218297. [PMID: 36365997 PMCID: PMC9656368 DOI: 10.3390/s22218297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 05/14/2023]
Abstract
Subclinical valve thrombosis in heart valve prostheses is characterized by the progressive reduction in leaflet motion detectable with advanced imaging diagnostics. However, without routine imaging surveillance, this subclinical thrombosis may be underdiagnosed. We recently proposed the novel concept of a sensorized heart valve prosthesis based on electrical impedance measurement (IntraValvular Impedance, IVI) using miniaturized electrodes embedded in the valve structure to generate a local electric field that is altered by the cyclic movement of the leaflets. In this study, we investigated the feasibility of the novel IVI-sensing concept applied to biological heart valves (BHVs). Three proof-of-concept prototypes of sensorized BHVs were assembled with different size, geometry and positioning of the electrodes to identify the optimal IVI-measurement configuration. Each prototype was tested in vitro on a hydrodynamic heart valve assessment platform. IVI signal was closely related to the electrodes' positioning in the valve structure and showed greater sensitivity in the prototype with small electrodes embedded in the valve commissures. The novel concept of IVI sensing is feasible on BHVs and has great potential for monitoring the valve condition after implant, allowing for early detection of subclinical valve thrombosis and timely selection of an appropriate anticoagulation therapy.
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25
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Sapapsap B, Srisawat C, Suthumpoung P, luengrungkiat O, Leelakanok N, Saokaew S, Kanchanasurakit S. Safety of Vitamin K in mechanical heart valve patients with supratherapeutic INR: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30388. [PMID: 36086772 PMCID: PMC10980458 DOI: 10.1097/md.0000000000030388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/22/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients who had mechanical heart valves and an international normalized ratio (INR) of >5.0 should be managed by temporary cessation of vitamin K antagonist. This study aimed to investigate the safety of low-dose vitamin K1 in patients with mechanical heart valves who have supratherapeutic INR. METHODS CINAHL, Cochran Library, Clinical trial.gov, OpenGrey, PubMed, ScienceDirect, and Scopus were systematically searched from the inception up to October 2021 without language restriction. Studies comparing the safety of low-dose vitamin K1 treatment in patients with placebo or other anticoagulant reversal agents were included. We used a random-effect model for the meta-analysis. Publication bias was determined by a funnel plot with subsequent Begg's test and Egger's test. RESULTS From 7529 retrieved studies, 3 randomized control trials were included in the meta-analysis. Pooled data demonstrated that low-dose vitamin K was not associated with thromboembolism rate (risk ratio [RR] = 0.94; 95% CI: 0.19-4.55) major bleeding rate (RR = 0.58; 95% CI: 0.07-4.82), and minor bleeding rate (RR = 0.60; 95% CI: 0.07-5.09). Subgroup and sensitivity analysis demonstrated the nonsignificant effect of low-dose vitamin K on the risk of thromboembolism. Publication bias was not apparent, according to Begg's test and Egger's test (P = .090 and 0.134, respectively). CONCLUSION The current evidence does not support the role of low-dose vitamin K as a trigger of thromboembolism in supratherapeutic INR patients with mechanical heart valves. Nevertheless, more well-designed studies with larger sample sizes are required to justify this research question.
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Affiliation(s)
- Bannawich Sapapsap
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Chansinee Srisawat
- Division of Pharmaceutical care, Department of Pharmacy, Banphaeo General Hospital, Samut Sakhon, Thailand
| | - Pornsinee Suthumpoung
- Division of Pharmaceutical care, Department of Pharmacy, Fort Khuncheangthammikkarat Hospital, Phayao, Thailand
| | - Onjira luengrungkiat
- Division of Pharmaceutical Care, Department of Pharmacy, Wichaivej International Omnoi Hospital, Samutsakhon, Thailand
| | - Nattawut Leelakanok
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Surasak Saokaew
- Division of Social and Administration Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia
| | - Sukrit Kanchanasurakit
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Division of Pharmaceutical care, Department of Pharmacy, Phrae Hospital, Phrae, Thailand
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26
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Farmer DM, Díez JG, Orozco-Sevilla V, Coselli JS. Use of a self-expanding transcatheter valve for a degenerated INTUITY valve. J Card Surg 2022; 37:3413-3416. [PMID: 35811483 DOI: 10.1111/jocs.16746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 11/28/2022]
Abstract
Valve-in-valve transcatheter aortic valve replacement for degenerated surgical bioprosthesis is becoming a more common therapeutic option. Rapid-deployment valves are novel, have distinct structural differences from standard surgical valves, and are increasingly used in minimal-access surgery. We report the case of a 61-year-old man who developed severe stenosis of an Edwards INTUITY Elite rapid-deployment valve and who subsequently underwent successful valve-in-valve placement of a self-expanding transcatheter valve. To our knowledge, this is the first description of the technical aspects of and considerations for using the self-expanding transcatheter platform in the Edwards INTUITY Elite valve.
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Affiliation(s)
- Douglas M Farmer
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Texas Heart Institute, Houston, Texas, USA
| | - Jose G Díez
- Texas Heart Institute, Houston, Texas, USA.,Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Texas Heart Institute, Houston, Texas, USA
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Texas Heart Institute, Houston, Texas, USA
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27
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Affiliation(s)
- Jason H Anderson
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Division of Structural Heart Diseases, Mayo Clinic, Rochester, Minnesota, USA.
| | - Nathaniel W Taggart
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Division of Structural Heart Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald Hagler
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Division of Structural Heart Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Allison Cabalka
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Division of Structural Heart Diseases, Mayo Clinic, Rochester, Minnesota, USA
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28
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Almeida AS, Ceron RO, Anschau F, de Oliveira JB, Leão Neto TC, Rode J, Rey RAW, Lira KB, Delvaux RS, de Souza RORR. Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression. Innovations (Phila) 2022; 17:3-13. [PMID: 35044253 DOI: 10.1177/15569845211060039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: To assess the potential benefits of minimally invasive aortic valve replacement (MIAVR) compared with conventional AVR (CAVR) by examining short-term outcomes. Methods: A systematic search identified randomized trials comparing MIAVR with CAVR. To assess study limitations and quality of evidence, we used the Cochrane Risk of Bias tool and GRADE and performed random-effects meta-analysis. We used meta-regression and sensitivity analysis to explore reasons for diversity. Results: Thirteen studies (1,303 patients) were included. For the comparison of MIAVR and CAVR, the risk of bias was judged low or unclear and the quality of evidence ranged from very low to moderate. No significant difference was observed in mortality, stroke, acute kidney failure, infectious outcomes, cardiac events, intubation time, intensive care unit stay, reoperation for bleeding, and blood transfusions. Blood loss (mean difference [MD] = -130.58 mL, 95% confidence interval [CI] = -216.34 to -44.82, I2 = 89%) and hospital stay (MD = -0.93 days, 95% CI = -1.62 to -0.23, I2 = 81%) were lower with MIAVR. There were shorter aortic cross-clamp (MD = 5.99 min, 95% CI = 0.99 to 10.98, I2 = 93%) and cardiopulmonary bypass (CPB) times (MD = 7.75 min, 95% CI = 0.27 to 15.24, I2 = 94%) in the CAVR group. In meta-regression analysis, we found that age was the variable with the greatest influence on heterogeneity. Conclusions: MIAVR seems to be an excellent alternative to CAVR, reducing hospital stay and incidence of hemorrhagic events. Despite significantly greater aortic cross-clamp and CPB times with MIAVR, this did not translate into adverse effects, with no changes in the results found with CAVR.
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Affiliation(s)
- Adriana Silveira Almeida
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Oliveira Ceron
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Fernando Anschau
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Postgraduate Program in Technology Assessment for SUS (PPGATSUS/GHC), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Jeffchandler Belém de Oliveira
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Tércio Campos Leão Neto
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Juarez Rode
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Antonio Widholzer Rey
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Kathize Betti Lira
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Renan Senandes Delvaux
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rodrigo Oliveira Rosa Ribeiro de Souza
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
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29
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Wilde N, Rogmann M, Mauri V, Piayda K, Schmitz MT, Al-Kassou B, Shamekhi J, Maier O, Sugiura A, Weber M, Zimmer S, Zeus T, Kelm M, Adam M, Baldus S, Nickenig G, Veulemans V, Sedaghat A. Haemodynamic differences between two generations of a balloon-expandable transcatheter heart valve. Heart 2022; 108:1479-1485. [PMID: 35039329 DOI: 10.1136/heartjnl-2021-320084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/07/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to investigate early haemodynamic and clinical performance of the SAPIEN 3 Ultra (S3 Ultra) transcatheter heart valve (THV) system in comparison to its precursor, the SAPIEN 3 (S3). Previous studies have indicated potential haemodynamic differences between the S3 Ultra and S3. Such differences may impact clinical outcome after transcatheter aortic valve implantation (TAVI). METHODS Postprocedural haemodynamic performance and 30-day clinical outcome were compared in patients who underwent TAVI receiving either the S3 or the new S3 Ultra prostheses. Multivariable analysis and propensity score matching (PSM) were used to identify factors associated with higher mean transvalvular gradients. RESULTS We included 697 patients (S3 Ultra: n=314, S3: n=383) from the multicentre RhineHeart TAVI Registry. Patients receiving the S3 Ultra prosthesis showed significantly higher postprocedural mean transvalvular gradients (14.2±4.8 vs 10.2±4.4 mm Hg; p<0.01). Multivariable logistic regression analyses and additional PSM revealed the use of the S3 Ultra to be associated with higher postprocedural mean transvalvular gradients (p<0.01). 30-day clinical outcomes, such as mortality, myocardial infarction, permanent pacemaker implantation and vascular complications were comparable between the groups. CONCLUSIONS The new S3 Ultra THV was associated with a higher postprocedural mean transvalvular gradient compared with the S3 system, while there was no difference in mortality or adverse clinical outcomes at 30 days. These echocardiographic differences will require long-term studies to assess the clinical relevance of this finding.
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Affiliation(s)
- Nihal Wilde
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marc Rogmann
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Victor Mauri
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Kerstin Piayda
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marie-Therese Schmitz
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Baravan Al-Kassou
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Jasmin Shamekhi
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Oliver Maier
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Atsushi Sugiura
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Matti Adam
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Stephan Baldus
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Georg Nickenig
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Verena Veulemans
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alexander Sedaghat
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
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30
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Lunardi M, Kennedy C, Prabhakar A, Mylotte D. Transcatheter aortic valve replacement: when should we say no? Open Heart 2022; 9:openhrt-2021-001837. [PMID: 34987074 PMCID: PMC8734017 DOI: 10.1136/openhrt-2021-001837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
| | - Ciara Kennedy
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
| | - Akul Prabhakar
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
| | - Darren Mylotte
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
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Abstract
Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.
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Affiliation(s)
- Jessica I Gupta
- Internal Medicine, Division of Cardiology, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA .,Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah K Gualano
- Internal Medicine, Division of Cardiology, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA.,Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole Bhave
- Internal Medicine, Division of Cardiology, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA.,Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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32
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Cordeiro ALL, Reis JRD, Cruz HBD, Guimarães AR, Gardenghi G. Impact of early ambulation on functionality in patients undergoing valve replacement surgery. J Clin Transl Res 2021; 7:754-758. [PMID: 34988326 PMCID: PMC8710356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/21/2021] [Accepted: 10/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac surgery is a highly complex procedure that aims to increase and prolong the quality of life of patients. The role of physiotherapy in early mobilization after cardiac surgery has shown several benefits to the patient when he presents impairments in terms of functionality. AIM To evaluate the impact of early ambulation on the functionality of patients undergoing cardiac valve replacement surgery. MATERIALS AND METHODS Prospective cohort study in patients undergoing cardiac valve replacement surgery. Patients had their functionality assessed preoperatively using the Functional Independence Measurement (FIM) and Perme Intensive Care Unit (ICU) Mobility Score scales. At ICU discharge, they were divided into two groups: walking group (WG) and non-WG (NWG). At discharge, the two functional scales were reapplied in these patients. Pre- and postoperative values were assessed using the independent Student's t-test. It was considered statistically significant when P<0.05. RESULTS One hundred and seventy patients were evaluated, 110 (65%) male, with a mean age of 48±2 years. In relation to Perme Score, the WG had a decrease of 11±2 and the NWG had a decrease of 13±2 (P=0.34). Regarding FIM, those who walked had a decrease of 27±3 against those who did not walk, which showed a reduction of 36±5, with a significance level of P<0.001. CONCLUSION Based on the FIM data found, patients undergoing cardiac valve replacement surgery who underwent early mobilization had less decrease of functionality compared to patients who did not ambulate. RELEVANCE FOR PATIENTS Based on this article, we can demonstrate that walking while still in the ICU environment favors less loss of functionality for patients after valve replacement surgery.
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Affiliation(s)
- André Luiz Lisboa Cordeiro
- 1Centro Universitário Nobre, Feira de Santana, Bahia, Brazil,2Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil,Corresponding author: André Luiz Lisboa Cordeiro Rua Pássaro Vermelho, Sem Número, Condomínio Salvador Dali, House 47, Feira de Santana, Bahia, Brazil. E-mail:
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33
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Giblett JP, Williams LK, Moorjani N, Calvert PA. Percutaneous management of paravalvular leaks. Heart 2021; 108:1005-1011. [PMID: 34686568 DOI: 10.1136/heartjnl-2021-319159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/09/2021] [Indexed: 11/04/2022] Open
Abstract
Paravalvular leak (PVL) is a challenging complication of valve replacement surgery that can cause heart failure and haemolysis. Surgical repair is the traditional treatment for severe, symptomatic PVL, but many patients with PVL fall into high-risk categories for redo surgery. Percutaneous techniques for closure of PVL have been increasingly refined over the last decade with availability of approved purpose-specific devices for closure. Percutaneous closure requires a heart team approach, with attention paid to appropriate preprocedural and periprocedural imaging to ensure a successful closure with minimal residual leak or complication. There are limited studies addressing the selection of a percutaneous approach to PVL. No randomised trials comparing surgical and percutaneous repair have been conducted. Large national registries from the UK and Ireland and from Spain have demonstrated that high rates of technical success can be achieved, with mortality comparable with surgical repair. Six retrospective studies comparing surgical and percutaneous approaches have been published. These broadly show comparable technical success between the interventions, with reduced short-term mortality among patients treated percutaneously. Long-term outcomes were similar between both treatment options. Percutaneous repair is an attractive treatment option in many patients due to its reduced invasiveness and quicker recovery period. However, more prospective studies are needed to validate its place in the armamentarium of the heart team.
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Affiliation(s)
- Joel P Giblett
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Lynne K Williams
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK .,Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
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Romaguera R, Roura G, Ruiz-Majoral A, Sánchez-Recalde Á, Díez-López C, Fontes-Caramé D, Comin-Colet J, Gómez-Hospital JA. First Bicaval Valve Implantation in a Heart Transplant Patient to Treat Severe Symptomatic Tricuspid Regurgitation. Circ Heart Fail 2021; 14:e008491. [PMID: 34657439 DOI: 10.1161/circheartfailure.121.008491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rafael Romaguera
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
| | - Gerard Roura
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
| | - Alex Ruiz-Majoral
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
| | | | - Carles Díez-López
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
| | | | - Josep Comin-Colet
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
| | - Joan A Gómez-Hospital
- Cardiology Department, Bellvitge University Hospital-Bellvitge Biomedical Research Institute, University of Barcelona, Spain (R.R., G.R., A.R.-M., C.D.-L., J.C.-C., J.A.G.-H.)
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35
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Knight JH, Sarvestani AL, Ibezim C, Turk E, McCracken CE, Alsoufi B, St Louis J, Moller JH, Raghuveer G, Kochilas LK. Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children. Heart 2021; 108:940-947. [PMID: 34611043 DOI: 10.1136/heartjnl-2021-319597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/09/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10-15 years after valve replacement are limited but important for evaluating substitute longevity. We aimed to describe up to 25-year death/cardiac transplant by type of valve substitute and assess the potential impact of treatment centre. Our hypothesis was that patients with pulmonic valve autograft would have better survival than mechanical prosthetic. METHODS This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional US-based registry of paediatric cardiac interventions, linked with the National Death Index and United Network for Organ Sharing through 2019. Children (0-20 years old) receiving aortic valve replacement (AVR) from 1982 to 2003 were identified. Kaplan-Meier transplant-free survival was calculated, and Cox proportional hazard models estimated hazard ratios for mechanical AVR (M-AVR) versus pulmonic valve autograft. RESULTS Among 911 children, the median age at AVR was 13.4 years (IQR=8.4-16.5) and 73% were male. There were 10 cardiac transplants and 153 deaths, 5 after transplant. The 25-year transplant-free survival post AVR was 87.1% for autograft vs 76.2% for M-AVR and 72.0% for tissue (bioprosthetic or homograft). After adjustment, M-AVR remained related to increased mortality/transplant versus autograft (HR=1.9, 95% CI=1.1 to 3.4). Surprisingly, survival for patients with M-AVR, but not autograft, was lower for those treated in centres with higher in-hospital mortality. CONCLUSION Pulmonic valve autograft provides the best long-term outcomes for children with aortic valve disease, but AVR results may depend on a centre's experience or patient selection.
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Affiliation(s)
- Jessica H Knight
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Amber Leila Sarvestani
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Chizitam Ibezim
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Elizabeth Turk
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - James St Louis
- Department of Surgery, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - James H Moller
- School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Geetha Raghuveer
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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36
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Jannasch A, Rix J, Welzel C, Schackert G, Kirsch M, König U, Koch E, Matschke K, Tugtekin SM, Dittfeld C, Galli R. Brillouin confocal microscopy to determine biomechanical properties of SULEEI-treated bovine pericardium for application in cardiac surgery. Clin Hemorheol Microcirc 2021; 79:179-192. [PMID: 34487036 DOI: 10.3233/ch-219119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Heart valves are exposed to a highly dynamic environment and underlie high tensile and shear forces during opening and closing. Therefore, analysis of mechanical performance of novel heart valve bioprostheses materials, like SULEEI-treated bovine pericardium, is essential and usually carried out by uniaxial tensile tests. Nevertheless, major drawbacks are the unidirectional strain, which does not reflect the in vivo condition and the deformation of the sample material. An alternative approach for measurement of biomechanical properties is offered by Brillouin confocal microscopy (BCM), a novel, non-invasive and three-dimensional method based on the interaction of light with acoustic waves. OBJECTIVE BCM is a powerful tool to determine viscoelastic tissue properties and is, for the first time, applied to characterize novel biological graft materials, such as SULEEI-treated bovine pericardium. Therefore, the method has to be validated as a non-invasive alternative to conventional uniaxial tensile tests. METHODS Vibratome sections of SULEEI-treated bovine pericardium (decellularized, riboflavin/UV-cross-linked and low-energy electron irradiated) as well as native and GA-fixed controls (n = 3) were analyzed by BCM. In addition, uniaxial tensile tests were performed on equivalent tissue samples and Young's modulus as well as length of toe region were analyzed from stress-strain diagrams. The structure of the extracellular matrix (ECM), especially collagen and elastin, was investigated by multiphoton microscopy (MPM). RESULTS SULEEI-treated pericardium exhibited a significantly higher Brillouin shift and hence higher tissue stiffness in comparison to native and GA-fixed controls (native: 5.6±0.2 GHz; GA: 5.5±0.1 GHz; SULEEI: 6.3±0.1 GHz; n = 3, p < 0.0001). Similarly, a significantly higher Young's modulus was detected in SULEEI-treated pericardia in comparison to native tissue (native: 30.0±10.4 MPa; GA: 31.8±10.7 MPa; SULEEI: 42.1±7.0 MPa; n = 3, p = 0.027). Native pericardia showed wavy and non-directional collagen fibers as well as thin, linear elastin fibers generating a loose matrix. The fibers of GA-fixed and SULEEI-treated pericardium were aligned in one direction, whereat the SULEEI-sample exhibited a much denser matrix. CONCLUSION BCM is an innovative and non-invasive method to analyze elastic properties of novel pericardial graft materials with special mechanical requirements, like heart valve bioprostheses.
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Affiliation(s)
- Anett Jannasch
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Jan Rix
- Clinical Sensoring and Monitoring, Department of Anesthesiology and Intensive Care Medicine, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Cindy Welzel
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Gabriele Schackert
- Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Kirsch
- Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Klinik für Neurochirurgie, Asklepios Kliniken Schildautal, Seesen, Germany
| | - Ulla König
- Department of Medical and Biotechnological Applications, Fraunhofer Institute for Organic Electronics, Electron Beam and Plasma Technology, Dresden, Germany
| | - Edmund Koch
- Clinical Sensoring and Monitoring, Department of Anesthesiology and Intensive Care Medicine, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Sems Malte Tugtekin
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Claudia Dittfeld
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Roberta Galli
- Department of Medical Physics and Biomedical Technology, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
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37
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Kim W, Hwang HY, Kang Y, Kim JS, Sohn SH, Choi JW, Kim KH. Comparative analysis of structural valve deterioration and long-term clinical outcomes after bovine pericardial versus porcine bioprosthetic mitral valve replacement. J Thorac Dis 2021; 13:3969-3978. [PMID: 34422327 PMCID: PMC8339742 DOI: 10.21037/jtd-21-281] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022]
Abstract
Background This study aimed to compare long-term outcomes, including durability, after bovine pericardial valve replacement with those after porcine mitral valve replacement (MVR). Methods We enrolled 309 patients who underwent MV replacement (mean age: 65.8±11.5 years; 68.9% females) with Carpentier-Edwards PERIMOUNT bovine pericardial valves (bovine MVR group, n=241) or Hancock II porcine bioprosthesis (porcine MVR group, n=68). The mean clinical and echocardiographic follow-up durations were 81.4±60.0 and 57.8±53.3 months, respectively. Structural valve deterioration (SVD) was defined as prosthetic mitral valve (MV) regurgitation or stenosis of greater than moderate degree combined with a motion limitation, tear, or perforation of prosthetic valve leaflet on follow-up echocardiography. Propensity score (PS)-adjusted multivariable analyses were performed. Results Thirty-day mortality rate was 6.4% (20/309 patients). SVD occurred in 50 patients (33 and 17 patients in the bovine and porcine MV replacement groups, respectively). Cumulative incidences of SVD at 5, 10, and 15 years were 3.2%, 15.9%, and 32.4%, respectively, in the bovine MVR group and 1.9%, 15.3%, and 41.7%, respectively, in the porcine MVR group. Cumulative incidences of SVD in the two groups were not different in competing risk analysis (P=0.23). Other clinical outcomes including overall survival and cumulative incidences of cardiac death and MV-related events were not statistically significantly different between the groups in PS-adjusted multivariable analyses. Conclusions Long-term clinical outcomes including SVD were not different between the bovine and porcine bioprosthesis MVR groups during average 7 years of clinical follow-up after MVR.
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Affiliation(s)
- Woojung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Seong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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38
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Lopes MP, Rosa VEE, Palma JH, Vieira MLC, Fernandes JRC, de Santis A, Spina GS, Fonseca RDJ, de Sá Marchi MF, Abizaid A, de Brito FS, Tarasoutchi F, Sampaio RO, Ribeiro HB. Transcatheter Valve-in-Valve Procedures for Bioprosthetic Valve Dysfunction in Patients With Rheumatic vs. Non-Rheumatic Valvular Heart Disease. Front Cardiovasc Med 2021; 8:694339. [PMID: 34422923 PMCID: PMC8373457 DOI: 10.3389/fcvm.2021.694339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Bioprosthetic heart valve has limited durability and lower long-term performance especially in rheumatic heart disease (RHD) patients that are often subject to multiple redo operations. Minimally invasive procedures, such as transcatheter valve-in-valve (ViV) implantation, may offer an attractive alternative, although data is lacking. The aim of this study was to evaluate the baseline characteristics and clinical outcomes in rheumatic vs. non-rheumatic patients undergoing ViV procedures for severe bioprosthetic valve dysfunction. Methods: Single center, prospective study, including consecutive patients undergoing transcatheter ViV implantation in aortic, mitral and tricuspid position, from May 2015 to September 2020. RHD was defined according to clinical history, previous echocardiographic and surgical findings. Results: Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9 vs. 43.2%, respectively; p = 0.004), atrial fibrillation (82.6 vs. 45.9%, respectively; p < 0.001), and 2 or more prior surgeries (68.1 vs. 32.4%, respectively; p = 0.001). Although, device success was similar between groups (75.4 vs. 89.2% in rheumatic vs. non-rheumatic, respectively; p = 0.148), there was a trend toward higher 30-day mortality rates in the rheumatic patients (21.7 vs. 5.4%, respectively; p = 0.057). Still, at median follow-up of 20.7 [5.1–30.4] months, cumulative mortality was similar between both groups (p = 0.779). Conclusion: Transcatheter ViV implantation is an acceptable alternative to redo operations in the treatment of patients with RHD and severe bioprosthetic valve dysfunction. Despite similar device success rates, rheumatic patients present higher 30-day mortality rates with good mid-term clinical outcomes. Future studies with a larger number of patients and follow-up are still warranted, to firmly conclude on the role transcatheter ViV procedures in the RHD population.
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Affiliation(s)
- Mariana Pezzute Lopes
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
| | | | - José Honório Palma
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
| | | | | | - Antonio de Santis
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
| | | | | | | | - Alexandre Abizaid
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
| | | | - Flavio Tarasoutchi
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
| | - Roney Orismar Sampaio
- Heart Institute (InCor) Clinical Hospital, University of Sáo Paulo, Sáo Paulo, Brazil
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Kim EJ, Gerstenfeld EP, Pellegrini CN. Use of Adenosine to Release an Entrapped Catheter During Ablation of Premature Ventricular Complexes. JACC Case Rep 2021; 3:610-613. [PMID: 34317587 PMCID: PMC8302799 DOI: 10.1016/j.jaccas.2021.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/25/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
Catheter entrapment is a rare complication during catheter ablation that may require surgical intervention. Use of adenosine to prolong diastole can be a safe and effective strategy to free the catheter and avoid significant morbidity. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Eun-Jeong Kim
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Cara N Pellegrini
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.,Cardiology Division, Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
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40
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Bavry AA, Kumbhani DJ. As Patients Live Longer, Are We on the Cusp of a New Valve Epidemic? J Am Coll Cardiol 2021; 77:15-17. [PMID: 33413935 DOI: 10.1016/j.jacc.2020.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/24/2022]
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41
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Aitaliyev S, Rumbinaitė E, Mėlinytė-Ankudavičė K, Nekrošius R, Keturakis V, Benetis R. Early outcomes of patient-prosthesis mismatch following aortic valve replacement. Perfusion 2021; 37:692-699. [PMID: 34080457 PMCID: PMC9500169 DOI: 10.1177/02676591211023286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patient-prosthesis mismatch (PPM) has been associated with numerous short- and long-term adverse events. This study aimed to evaluate the effect of PPM on early postoperative results after aortic valve replacement (AVR) in daily practice. METHODS In this single-centre retrospective study, 150 non-consecutive patients from March 2019 to January 2020 with clinically indicated AVR with/without concomitant surgery were analysed. The study protocol included operative mortality, complication rate, and pre- and postoperative echocardiographic data. PPM was considered severe with indexed effective orifice area at <0.65 cm2/m2, moderate at 0.65-0.85 cm2/m2 and none at >0.85 cm2/m2. RESULTS Moderate PPM was observed in 16 patients (10.6%). No patient had severe PPM. PPM was not related to early mortality (r = 0.40, p = 0.630), intra- (r = -0.076, p = 0.352) and postoperative (r = -0.0134, p = 0.102) events. CONCLUSION In this study, moderate PPM was a frequent finding after AVR, whereas severe PPM was not observed. PPM did not affect the early results after AVR. A long-term follow-up study in a large patient population is required to assess the actual influence of residual PPM.
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Affiliation(s)
- Serik Aitaliyev
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Egle Rumbinaitė
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Rokas Nekrošius
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytenis Keturakis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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42
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Naser JA, Petrescu I, Ionescu F, Nkomo VT, Pislaru C, Schaff HV, Pellikka PA, Connolly HM, Egbe AC, Pislaru SV. Gradient changes in bioprosthetic valve thrombosis: duration of anticoagulation and strategies to improve detection. Open Heart 2021; 8:openhrt-2021-001608. [PMID: 34031215 PMCID: PMC8149431 DOI: 10.1136/openhrt-2021-001608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/14/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Bioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. How early abnormal gradients can be detected prior to diagnosis and how fast they normalise with anticoagulant therapy is unknown. We set forth to (1) evaluate patterns of increase in gradients prior to BPVT diagnosis and (2) characterise time-course of response to anticoagulation. Methods Patients treated with warfarin for BPVT (1999–2019) with clinically significant reduction of mean gradients (≥25%) were identified retrospectively. Recovery was defined as gradient decrease ≥50%, to postimplantation or to normal-range gradients per position, model and size. Time-to-BPVT (implantation—BPVT diagnosis), potential diagnostic delay (first abnormal gradient by position, model and size—BPVT diagnosis) and time-to-recovery (BPVT diagnosis—complete resolution) were recorded. Results 77 patients were identified; 32 (42%) aortic (23 surgical—12 porcine, 11 pericardial; 9 transcatheter); 24 (31%) mitral; 21 (27%) tricuspid. Median time-to-BPVT was 24, 21 and 10 months, respectively. Potential diagnostic delay was median 21 months for aortic, 4 months for mitral, but 0 for tricuspid. Recovery was significantly faster in mitral than aortic (median 2.5 vs 4.8 months, p=0.038) and tricuspid (median 5.9 months, p=0.025) positions. Porcine aortic valves responded faster than pericardial aortic valves (median 2.9 vs 20.3 months, p=0.004). Conclusion Gradients start to increase months before the clinical BPVT diagnosis. Recovery is faster in mitral and surgical aortic porcine valves; a longer warfarin trial seems indicated in tricuspid and surgical aortic pericardial valves.
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Affiliation(s)
- Jwan A Naser
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Ioana Petrescu
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA.,Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - Filip Ionescu
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA.,Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - Vuyisile T Nkomo
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Cristina Pislaru
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | | | - Patricia A Pellikka
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Cardiovascular Medicine, Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
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43
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Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
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Desai ND, O'Brien SM, Cohen DJ, Carroll J, Vemulapalli S, Arnold SV, Forrest JK, Thourani VH, Kirtane AJ, O'Neil B, Manandhar P, Shahian DM, Badhwar V, Bavaria JE. Composite Metric for Benchmarking Site Performance in Transcatheter Aortic Valve Replacement: Results From the STS/ACC TVT Registry. Circulation 2021; 144:186-194. [PMID: 33947202 DOI: 10.1161/circulationaha.120.051456] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is a transformative therapy for aortic stenosis. Despite rapid improvements in technology and techniques, serious complications remain relatively common and are not well described by single outcome measures. The purpose of this study was to determine whether there is site-level variation in TAVR outcomes in the United States using a novel 30-day composite measure. METHODS We performed a retrospective cohort study using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry to develop a novel ranked composite performance measure that incorporates mortality and serious complications. The selection and rank order of the complications for the composite was determined by their adjusted association with 1-year outcomes. Sites with risk-adjusted outcomes significantly more or less frequent than the national average based on a 95% probability interval were classified as performing worse or better than expected. RESULTS The development cohort consisted of 52 561 patients who underwent TAVR between January 1, 2015, and December 31, 2017. Based on associations with 1-year risk-adjusted mortality and health status, we identified 4 periprocedural complications to include in the composite risk model in addition to mortality. Ranked empirically according to severity, these included stroke, major, life-threatening or disabling bleeding, stage III acute kidney injury, and moderate or severe perivalvular regurgitation. Based on these ranked outcomes, we found that there was significant site-level variation in quality of care in TAVR in the United States. Overall, better than expected site performance was observed in 25/301 (8%) sites, performance as expected was observed in 242/301 sites (80%), and worse than expected performance was observed in 34/301 (11%) sites. Thirty-day mortality; stroke; major, life-threatening, or disabling bleeding; and moderate or severe perivalvular leak were each substantially more common in sites with worse than expected performance as compared with other sites. There was good aggregate reliability of the model. CONCLUSIONS There are substantial variations in the quality of TAVR care received in the United States and 11% of sites were identified as providing care below the average level of performance. Further study is necessary to determine structural, process-related, and technical factors associated with high- and low-performing sites.
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Affiliation(s)
- Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (N.D.D., J.E.B.).,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, PA (N.D.D., J.E.B.)
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University, Durham, NC (S.M.O., S.V., P.M.)
| | - David J Cohen
- St Francis Hospital, Roslyn, NY (D.J.C.).,Cardiovascular Research Foundation, New York (D.J.C.)
| | - John Carroll
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (J.C.)
| | | | - Suzanne V Arnold
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A.)
| | - John K Forrest
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.K.F.)
| | | | - Ajay J Kirtane
- Department of Medicine, Columbia University, New York (A.J.K.)
| | - Brian O'Neil
- Division of Cardiology, Henry Ford Hospital, Detroit, MI (B.O.)
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University, Durham, NC (S.M.O., S.V., P.M.)
| | - David M Shahian
- Division of Cardiac Surgery and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston (D.M.S.)
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown (V.B.)
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (N.D.D., J.E.B.).,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, PA (N.D.D., J.E.B.)
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45
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Cannata A, Cantoni S, Sciortino A, Bruschi G, Russo CF. Mechanical Hemolysis Complicating Transcatheter Interventions for Valvular Heart Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:2323-2334. [PMID: 33958130 DOI: 10.1016/j.jacc.2021.03.295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
Mechanical intravascular hemolysis is frequently observed following procedures on heart valves and uncommonly observed in native valvular disease. In most cases, its severity is mild. Nevertheless, it can be clinically significant and even life threatening, requiring multiple blood transfusions and renal replacement therapy. This paper reviews the current knowledge on mechanical intravascular hemolysis in valvular disease, before and after correction, focusing on pathophysiology, approach to diagnosis, and impact of other hematological conditions on the resultant anemia. The importance of a multidisciplinary management is underscored. Laboratory data are provided about subclinical hemolysis that is commonly observed following the implantation of surgical and transcatheter valve prostheses and devices. Finally, clinical scenarios are reviewed and current medical and surgical treatments are discussed, including alternative options for inoperable patients.
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Affiliation(s)
- Aldo Cannata
- Department of Cardiac Surgery, Niguarda Hospital, Milan, Italy.
| | - Silvia Cantoni
- Department of Hematology, Niguarda Hospital, Milan, Italy
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Fanning J, Roberts S, Merza M, Anstey C, Poon K, Incani A, Natani S, Fraser J. Evaluation of latest viscoelastic coagulation assays in the transcatheter aortic valve implantation setting. Open Heart 2021; 8:openhrt-2020-001565. [PMID: 33879508 PMCID: PMC8061803 DOI: 10.1136/openhrt-2020-001565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/22/2021] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
Background Point of care viscoelastic measures with thromboelastography (TEG; Haemonetics Corporation, Switzerland) and thromboelastometry (ROTEM, Tem Innovations GmbH, Germany) now supersede laboratory assays in the perioperative assessment and management of coagulation. To the best of our knowledge, this sophisticated coagulation assessment has not been performed to characterise thrombotic changes in the transcatheter aortic valve implantation (TAVI) setting, nor have the two latest iteration cartridge-based systems been directly compared in the elective perioperative period. Methods Patients undergoing TAVI were prospectively recruited. Samples (n=44) were obtained at four timepoints (postinduction of anaesthesia, postheparin (100 IU/kg), postprotamine (1 mg/100 IU heparin) and 6 hours postoperatively). Each sample was concurrently assessed with standard laboratory tests (prothrombin time/international normalised ratio, activated partial thromboplastin time, thrombin clotting time, platelet count and direct fibrinogen, ROTEMSigma and TEG6s). Results Clot strength showed a statistically significant increase postheparin/TAVI deployment. When considering the subgroup of samples taken following the administration heparin, the heparinase channel of the TEG6s did not yield clotting strength results in 55% of samples and clotting time exceeded the upper limit of normal in 70% of samples. It was retrospectively recognised that the arachidonic acid channel of the TEG6s Platelet Mapping Cartridge had been decommissioned prohibiting assessment of aspirin effect. Conclusions This study demonstrated a small intraprocedural prothrombotic change of uncertain clinical importance during the transcatheter aortic valve procedure. Further comparison with percutaneous coronary intervention and aortic valve replacement cohorts are needed to assess the merits of current antithrombotic guidelines, which are extrapolated from the PCI setting. The heparin effect was more consistently quantified by ROTEM.
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Affiliation(s)
- Jonathon Fanning
- Wesley Medical Research Limited, Auchenflower, Queensland, Australia .,St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.,The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Shaun Roberts
- The Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Megan Merza
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Karl Poon
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Alexander Incani
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Sarvesh Natani
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia.,The Prince Charles Hospital, Chermside, Queensland, Australia
| | - John Fraser
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.,The Prince Charles Hospital, Chermside, Queensland, Australia
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Glaser N, Jackson V, Eriksson P, Sartipy U, Franco-Cereceda A. Relative survival after aortic valve surgery in patients with bicuspid aortic valves. Heart 2021; 107:1167-1172. [PMID: 33622679 PMCID: PMC8257557 DOI: 10.1136/heartjnl-2020-318733] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The objective of this cohort study was to analyse long-term relative survival in patients with bicuspid aortic valve (BAV) who underwent aortic valve surgery. METHODS We studied 865 patients with BAVs who participated in three prospective cohort studies of elective, open-heart, aortic valve surgery at the Karolinska University Hospital, Stockholm, Sweden, between 2007 and 2020. The expected survival for the age, sex and calendar year-matched general Swedish population was obtained from the Human Mortality Database. The Ederer II method was used to calculate relative survival, which was used as an estimate of cause-specific survival. RESULTS No differences were found in the observed versus expected survival at 1, 5, 10 or 12 years: 99%, 94%, 83% and 76% vs 99%, 93%, 84% and 80%, respectively. The relative survival at 1, 5, 10 and 12 years was 100% (95% CI 99% to 100%), 101% (95% CI 99% to 103%), 99% (95% CI 95% to 103%) and 95% (95% CI 87% to 102%), respectively. The relative survival at the end of follow-up tended to be lower for women than men (86% vs 95%). The mean follow-up was 6.3 years (maximum 13.3 years). CONCLUSIONS The survival of patients with BAV following aortic valve surgery was excellent and similar to that of the general population. Our results suggest that the timing of surgery according to current guidelines is correct and provide robust long-term survival rates, as well as important information about the natural history of BAV in patients following aortic valve surgery.
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Affiliation(s)
- Natalie Glaser
- Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden .,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Jackson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Per Eriksson
- Cardiovascular Medicine Unit, Centre for Molecular Medicine, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Abstract
The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The 12839Jikei University School of Medicine, Tokyo, Japan
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49
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Malvindi PG, Olevano C, Luthra S, Tsang G, Barlow C, Ohri S. Outcomes of patients with acute prosthetic aortic valve endocarditis. Asian Cardiovasc Thorac Ann 2020; 29:268-277. [PMID: 33167670 DOI: 10.1177/0218492320974112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prosthetic valve endocarditis is burdened by high mortality and morbidity. We reviewed our experience in the management of patients with acute prosthetic aortic valve infection and studied the implications and outcomes associated with surgical treatment and medical therapy. METHODS Data of 118 consecutive patients admitted during the period 2008-2018 with definite acute prosthetic aortic valve endocarditis, and presenting a surgical indication, were retrieved from the hospital database. Univariate and multivariate analysis were undertaken to study the association of preoperative characteristics with hospital mortality and the probability of undergoing a reoperation. Survival was assessed with Kaplan-Meier analysis. RESULTS In the overall population, prosthesis dehiscence was independently associated with the possibility of undergoing surgical reoperation, while presentation with embolic stroke was associated with medical treatment. Hospital mortality was 24%, medical treatment was found to be independently associated with early death. One hundred (85%) patients underwent redo procedures; aortic valve replacement was performed in 53 and full root replacement in 47. Postoperative hospital mortality was 17%. Survival at 1-, 5-, and 8-years was 78%, 74%, and 66%, respectively. Freedom from reoperation and recurrent endocarditis was 95% at 8-year follow-up.Hospital mortality in patients who did not receive a redo operation was 61% with a survival rate of 17% at 1-year follow-up. CONCLUSIONS Surgical mortality after reoperation for prosthetic aortic valve endocarditis is still high but mid-term outcomes are satisfactory. Failure to undertake surgery when indicated is an independent risk factor for early death.
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Affiliation(s)
| | - Carlo Olevano
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Suvitesh Luthra
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Geoffrey Tsang
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Clifford Barlow
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Sunil Ohri
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
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50
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Arar Y, Hong J, Veeram Reddy S. Transcatheter mechanical manipulation of obstructed prosthetic mitral valve in an infant. Cardiol Young 2020; 30:1747-9. [PMID: 32880248 DOI: 10.1017/S104795112000270X] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prosthetic valve thrombosis is a serious complication of prosthetic heart valves that typically requires either surgical intervention or systemic thrombolysis. In patients with contraindications to both treatment modalities, options can be limited. We describe an alternative approach to managing prosthetic valve thrombosis in an infant presenting in extremis with pulmonary haemorrhage. Using transoesophageal echocardiography and fluoroscopic guidance, we restored function to the infant's obstructed St. Jude prosthetic mitral valve through percutaneous transcatheter manipulation of the valve's leaflets.
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