Aortic Root abscess repair in a patient with previous mechanical aortic valve replacement, mitral regurgitation and ischemic heart disease

We present a complex case of aortic root abscess and fistula formation between the aorta and left ventricle, 20 years after aortic valve replacement with a mechanical prosthesis. The patient had concomitant severe rheumatic mitral valve regurgitation, significant left anterior descending and left circumflex coronary artery stenosis, with non-viable anterior wall and apex. In addition to replacing the mitral valve with a mechanical prosthesis, our decision was to treat the abscess and patch the fistula, while keeping the well functioning mechanical aortic valve to use its cuff to fix the patch. We have chosen to delay revascularization of the marginal branches with DES till after surgery to avoid extensive dissection under clopidogrel. We think that those decisions simplified the operative procedure and were essential to reach the positive outcome we had in this case

LOW INCIDENCE AND MINIMAL IMPACT OF PARAVALVULAR LEAK AFTER CONVENTIONAL AORTIC VALVE REPLACEMENT.

OBJECTIVES: To evaluate the incidence of paravalvular leaks (PVLs) after surgical aortic valve replacement (AVR) and assess its impact on postoperative outcomes.METHODS: A retrospective review of 460 consecutive isolated AVR from January 2008 to December 2014. Postoperative transthoracic echocardiograms (TTE) and clinical notes were reviewed.RESULTS: Thirty-five patients (7.6%) developed a PVL and formed the cohort of this report. TTE grading of PVL was trivial in 18 (51.4%), mild in 14 (40%), moderate in 2 (5.7%) and severe in 1 patient (2.9%), with an overall prevalence of developing moderate to severe PVL after AVR of 0.065%. Mean age was 63 years, 23 patients were males (65.7%) and mean logistic Euroscore was 8.35 + 15.8%. Valve lesions were mainly stenosis (24 patients; 68.6%), regurgitation (7 patients; 20%) and mixed aortic lesions (4 patients; 11.4%). Implanted prostheses were 19 bioprosthesis  (54.2%) and 16 mechanical valves  (45.8%). We had one 30-days mortality (2.8%), 13 postoperative new onset atrial fibrillation (37%), permanent pacemaker 2.8%, cerebrovascular stroke 2.8%, re sternotomy for bleeding 2.8% and two patients needed hemodialysis (5.7%). Patients were followed up for 0.9 + 1.2 years. When last seen, 27 patients were in NYHA class I (77.1%), six patients were in class II (17.1%) and two patients with moderate to severe PVL remained in NYHA class IV (5.7%). Peak aortic valve gradients ranged from 14 to 68 mmHg, with a mean gradient of 27.8 + 13.3 mm Hg. Three patients with trivial PVL (8.5%) developed prosthetic valve endocarditis, with 2 patients among them requiring intervention for prosthetic valve failure (5.7%). Demographics, preoperative risk profiles and hospital outcomes were comparable to those recorded in the remaining 425 patients without PVL.CONCLUSION: The incidence of PVL after conventional AVR is small and the development of moderate or greater leaks is negligible. Trivial to mild leaks had a benign course unless complicated by PVE. New percutaneous therapies for aortic valve disease must match these low rates.Key words: Paravalvular leak, prosthetic valve dysfunction, aortic valve

An unusual association of Hughes-Stovin syndrome and lung cancer in young age: a case report

We describe a rare case of bilateral Hughes-Stovin syndrome associated with non-small cell lung cancer in a 29-years old lady. Hughes-Stovin was diagnosed on the basis of pulmonary artery aneurysms, deep venous thrombosis and fever, without immunological evidence of Behçet’s disease. In absence of a radical cure for such a complicated pathology, the patient was effectively palliated for the last 12 months with a Cis-platinum based chemotherapy.

European real world transcatheter aortic valve implantation: Systematic review and meta-analysis of European national registries

AbstractObjective: Transcatheter aortic valve implantation (TAVI) has been adopted rapidly in Europe despite the paucity of randomized studies. TAVI registries represent a real-world scenario thus providing the evidence for the treatment of high-risk patients. We undertook a meta-analysis of published European national TAVI registries to assess current results of TAVI technologies in Europe.Methods: Electronic databases were searched. The review focused on the comparison of the following TAVI technologies: transfemoral (TF) and transapical (TA) SAPIEN and CoreValve implantation. Individual event rates for outcomes of interest were pooled using a mixed effect model.Results: A total of 7 European national TAVI registries (UK, Swiss, Belgium, Italy, Spain, France, Germany) were identified including a total of 9786 patients who received TF SAPIEN  (n=2885), TA SAPIEN  (n=2252) and CoreValve (n=4649) implantation. Pooled incidence of 30 day mortality was 0.08 [95%Confidence Interval (CI): 0.05-0.11], 0.12 [95%CI: 0.07-0.19] and 0.06 [95%CI: 0.03-0.11] for TF SAPIEN, TA SAPIEN and CoreValve respectively (test for subgroup difference P=0.18) and high heterogeneity across European country was found. Pooled incidence of stroke was comparable among the TAVI technologies (test for subgroup difference P=0.79) as well as the incidence of postprocedural paravalvular leak ≥ 2 (P=0.9). CoreValve increased the risk of pacemaker implantation requirement (test for subgroup difference P<0.0001).Conclusions: Trans-vascular TAVI approaches were associated with a lower early mortality regardless of the type of device used. There was a marked heterogeneity among European countries for early mortality

Accuracy and safety of low-dose dobutamine stress echocardiography early after acute anterior myocardial infarction

Objectives: We sought to explore the safety and prognostic accuracy of low-dose dobutamine stress echocardiography (DSE), performed early in the course of acute anterior ST elevation myocardial infarction (STEMI), in patients who received thrombolytic therapy.Methods: We enrolled 73 consecutive patients presenting with first acute anterior STEMI, who had significant coronary stenosis/occlusion of the culprit artery amenable for revascularization. Low-dose DSE was performed within 2-7 (3.8 ± 1.8) days of the index hospitalization. Patients underwent coronary revascularization. Follow-up echocardiography was performed 2-3 months after revascularization to assess regional wall motion abnormality. Predicted viability by low-dose DSE was compared with actual contractility improvement seen at follow-up echocardiography.Results: Considering a per-patient analysis, low-dose DSE early after anterior STEMI predicted viability with a sensitivity of 88.9%, specificity of 75.7%, PPV of 78%, NPV of 87.5%. Based on a per-segment analysis, low-dose DSE achieved a sensitivity of 86.9%, specificity of 92.5%, PPV of 73.2%, NPV of 96.8%. Based on a per-segment analysis performed individually for hypokinetic segments, low-dose DSE achieved a sensitivity of 88%, specificity of 85.4%, PPV of 74%, NPV of 93.8%. For akinetic segments, low-dose DSE achieved a sensitivity of 82.4%, specificity of 97%, PPV of 70%, NPV of 98.5%.Conclusion: Low-dose DSE performed early in patients presenting with acute anterior STEMI who received thrombolytic therapy, is safe with a high sensitivity but a modest specificity for predicting contractile improvement after revascularization, based on a per-patient analysis. However, based on a per-segment analysis, both sensitivity and specificity are high

Outcome of surgery in critically ill patients presenting with mechanical mitral valve thrombosis during pregnancy

Objectives: Prosthetic valve thrombosis during pregnancy is associated with serious maternal complications and considerable fetal loss. We report and analyze the outcome of surgery in critically ill patients referred to our tertiary center between January 2009 and January 2015.Methods: Twenty-eight pregnant patients with median age of 28 years (range: 20-40 years) presented with thrombosed bileaflet mechanical mitral valve prostheses, 48 (15-192) months after implantation. Twenty-two patients (78.6%) were on fixed dose LMWH (1 mg/kg twice daily) and six patients were on warfarin, with an INR <1.4 in four cases (66.6%).  Patients were reported as being critically ill since 4 (1-12) days and presented in NYHA class IV (III-IV), with median gestational age (GA) of 31 (8-40) weeks. We had six cases of confirmed stillbirth (21.4%) on admission. The remaining were 14 patients presenting with GA >28 weeks (Group 1) and 8 patients with GA <28 weeks (Group 2). Delivery was planned before bypass in Group 1. Measures of fetal protection during surgery included: >2.7 L/m2/min high flow normothermic bypass maintaining mean perfusion pressure > 70mm Hg and keeping hematocrit >28%.Results: All mitral prostheses were emergency replaced with same-sized mechanical valves. Median aortic cross clamp and bypass times were 57 (34-106) and 93 (48-140) minutes. We had two maternal mortalities (7.1%) and one preoperative regressive stroke (3.6%). Thirteen fetuses (59.1%) were successfully delivered before surgery (92.8% of Group 1) and nine were submitted to bypass: one rapidly deteriorating Group 1 patient and all eight patients in Group 2. Only three fetuses (GA =10, 21 and 31 weeks) survived bypass (33.3%) and were delivered at term. Outcome of the 22 live fetuses on admission was: 14 live births in Group 1 (100%; 9 healthy babies and 5 prematures) versus two in Group 2 (25%; P<0.001), with a total fetal loss of 27.3%.Conclusion: Maternal outcomes are comparable to those of non-pregnant subjects. Unless the fetus is delivered before bypass, the heavy fetal loss, especially in patients presenting with GA <28 weeks, calls for applying more safety bypass measures. Controlled randomized trials are equally needed to evaluate the alternative fibrinolytic therapy