M004 In aortic stenosis, 2D speckle tracking differentiates left ventricular dysfunction load- to remodelling-dependant

BackgroundIn aortic stenosis, it is not known which between longitudinal, radial and circumferential contraction is influenced by loading conditions or remodelling. To test our hypothesis and to understand left ventricular function recovery, we investigated patients at early, i.e. 7 days (contractility enhancement load-dependant) and at late follow-up, i.e. 3 months (contractility enhancement remodelling-dependant) after transcutaneous aortic valve implantation (TAVI).Methods and ResultsTwenty-three subjects (AS: valve orifice < or =0.7cm2; 14 female; mean age, 84+/-6 years) were studied. All subjects of the study had conventional 2D-Doppler echocardiography and speckle tracking analysis (GE HealthCare). Speckle tracking was sampled in short-axis view for radial and circumferential strain and in apical 4, 3 and 2-chamber view for averaged longitudinal strain. Measurements were performed before, 7 days and 3 months after TAVI. Mean pressure gradient decreased from 41±20mmHg to 10±3mmHg (p<0.001) while aortic valve area increased from 0.6±0.1 to 1.7±0.2cm2 (p<0.001) after implantation. Biplane Simpson EF was 50±10 %, 51±13 and 58±11 % at baseline, 7-day and 3-month follow-up (p=0.01), respectively. Improvement of circumferential strain found 7 days after TAVI is sustained at 3 months. Radial strain increased shortly after TAVI, then decreased at 3 months and was compensated by improvement of longitudinal strain (see figure).ConclusionIn patients with aortic stenosis, radial contraction is load dependant, circumferential contraction is both load- and remodelling-dependant, whereas longitudinal contraction is remodeling-dependant

Sternal reentry in a patient with previous deep sternal wound infection managed with horizontal titanium plate fixation

Redo open-heart surgery and sternal reentry in patients with previous deep sternal wound infection (DSWI) and absence of sternal integrity can be a delicate and morbid task due the lack of a dissection plane between the heart and the surrounding soft tissues. Delayed sternal reconstruction and osteosynthesis with horizontal titanium plating fixation (Synthes) following vacuum assisted therapy (KCI) has recently been proposed and adopted for the treatment of DSWI. We present such a case of a patient who was successfully reoperated for valve replacement three years after coronary artery bypass grafting complicated by DSWI and initially treated with titanium plate fixation

Transcatheter or surgical aortic-valve replacement in intermediate-risk patients

BACKGROUND: Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aorticvalve replacement. We evaluated the two procedures in a randomized trial involving intermediate-risk patients. METHODS: We randomly assigned 2032 intermediate-risk patients with severe aortic stenosis, at 57 centers, to undergo either TAVR or surgical replacement. The primary end point was death from any cause or disabling stroke at 2 years. The primary hypothesis was that TAVR would not be inferior to surgical replacement. Before randomization, patients were entered into one of two cohorts on the basis of clinical and imaging findings; 76.3% of the patients were included in the transfemoral-access cohort and 23.7% in the transthoracic-access cohort. RESULTS: The rate of death from any cause or disabling stroke was similar in the TAVR group and the surgery group (P=0.001 for noninferiority). At 2 years, the Kaplan–Meier event rates were 19.3% in the TAVR group and 21.1% in the surgery group (hazard ratio in the TAVR group, 0.89; 95% confidence interval [CI], 0.73 to 1.09; P=0.25). In the transfemoralaccess cohort, TAVR resulted in a lower rate of death or disabling stroke than surgery (hazard ratio, 0.79; 95% CI, 0.62 to 1.00; P=0.05), whereas in the transthoracic-access cohort, outcomes were similar in the two groups. TAVR resulted in larger aortic-valve areas than did surgery and also resulted in lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation. CONCLUSIONS: In intermediate-risk patients, TAVR was similar to surgical aortic-valve replacement with respect to the primary end point of death or disabling stroke. (Funded by Edwards Lifesciences; PARTNER 2 ClinicalTrials.gov number, NCT01314313

Cardiovascular magnetic resonance for the assessment of patients undergoing transcatheter aortic valve implantation: a pilot study

<p>Abstract</p> <p>Background</p> <p>Before trans-catheter aortic valve implantation (TAVI), assessment of cardiac function and accurate measurement of the aortic root are key to determine the correct size and type of the prosthesis. The aim of this study was to compare cardiovascular magnetic resonance (CMR) and trans-thoracic echocardiography (TTE) for the assessment of aortic valve measurements and left ventricular function in high-risk elderly patients submitted to TAVI.</p> <p>Methods</p> <p>Consecutive patients with severe aortic stenosis and contraindications for surgical aortic valve replacement were screened from April 2009 to January 2011 and imaged with TTE and CMR.</p> <p>Results</p> <p>Patients who underwent both TTE and CMR (n = 49) had a mean age of 80.8 ± 4.8 years and a mean logistic EuroSCORE of 14.9 ± 9.3%. There was a good correlation between TTE and CMR in terms of annulus size (R²= 0.48, p < 0.001), left ventricular outflow tract (LVOT) diameter (R²= 0.62, p < 0.001) and left ventricular ejection fraction (LVEF) (R²= 0.47, p < 0.001) and a moderate correlation in terms of aortic valve area (AVA) (R²= 0.24, p < 0.001). CMR generally tended to report larger values than TTE for all measurements. The Bland-Altman test indicated that the 95% limits of agreement between TTE and CMR ranged from -5.6 mm to + 1.0 mm for annulus size, from -0.45 mm to + 0.25 mm for LVOT, from -0.45 mm²to + 0.25 mm²for AVA and from -29.2% to 13.2% for LVEF.</p> <p>Conclusions</p> <p>In elderly patients candidates to TAVI, CMR represents a viable complement to transthoracic echocardiography.</p

Procedural and 30-Day Outcomes of Patients Undergoing Transcatheter Aortic and Mitral Valve Replacements

Background: Transcatheter aortic valve replacement was originally described for the treatment of severe single-valve disease. Advances in technology have opened treatment options for patients with multivalvular pathology (aortic and mitral) with the SAPIEN XT and SAPIEN 3 prostheses. This study describes the procedural and 30-day outcomes of patients that underwent transcatheter aortic valve replacement and transcatheter mitral valve procedures (valve in valve [ViV], valve in ring [ViR]), and valve in mitral annulus calcification [MAC]) in a staged or concomitant fashion using the SAPIEN 3 and SAPIEN XT prosthetic valves. Methods: A retrospective analysis of TVT Registry including patients undergoing transcatheter aortic valve replacement for severe native aortic stenosis and bioprosthetic valve degeneration who also underwent therapy for the mitral valve (ViR, ViV, and valve in MAC) using the SAPIEN 3 and SAPIEN XT valves from August 6, 2014, to November 30, 2018, were included in the analysis. Procedural and 30-day outcomes were analyzed. Results: A total of 135 patients were included in the registry. They were primarily female (81 of 135) with a mean age of 73 ± 11 years and were all considered symptomatic and high risk due to their comorbidities. The type of procedure performed is described in Table 1. Device success was seen in 95.5% (127 of 133) with no surgical conversions. Procedures were performed in a staged 32% (43 of 135) or concomitant manner 68% (92 of 135), with median time between procedures of 183 days. The 30-day mortality was observed in 12.2%, stroke in 3.2%, life-threatening bleeding in 0.9%, and VARC safety events were seen in 18.3% (Table). [Figure presented] Conclusion: Transcatheter treatment of aortic and mitral valve disease is feasible in high-risk patients. Patient selection and procedural timing may influence survival. A direct comparison to surgical treatment of a similar population is warranted to determine patient outcomes

Transcatheter aortic valve implantation: technical aspects, results and indications

SummaryThe development of the percutaneous heart valve (PHV) may become a primary therapeutic modality for the high risk and inoperable patients with critical symptomatic aortic stenosis. The first human percutaneous aortic valve implant was performed by our group in April 2002. To date, more than 500 Cribier-Edwards-PHV have been implanted worldwide using arterial trans-femoral or trans-apical approach. Data on the retrograde transfemoral approach is growing with more than 270 patients implanted as of October 2007. Procedural success rate is high (86%) and the 30-day mortality is 12%. Today, 2 patients are alive at a follow-up of more than 4 years. The same Cribier-Edwards-PHV can be implanted using trans-apical approach. In this procedure, PHV is introduced under direct vision into the left ventricle via a mini-thoracotomy. This obviates the concerns regarding vascular access in the presence of small caliber vessels and/or vascular occlusive disease. More than 200 patients have been treated with this approach. In the European experience 30-day mortality is 14%.There is intense interest in PHV technology, and there are multiple devices at various stages of development in animals and humans. The most developed is the CoreValve Revalving® Technology. More than 350 patients have been treated with this technique. The immediate and mid-term results with this device are promising with a procedural success of 92% and a 30-day mortality of 15%.The future of this technology and its application is dependent on the continued collaboration between general internists, cardiologists, surgeons, engineers, and industry