Transapical aortic valve implantation in patients with severely depressed left ventricular function

ObjectivesTransapical aortic valve implantation significantly reduces operative risk in elderly patients with aortic valve stenosis and comorbidities. However, it is unknown whether this procedure is feasible in patients with advanced heart failure.MethodsBetween April 2008 and July 2010, 258 patients underwent transapical aortic valve implantation. Twenty-one patients had advanced heart failure with decompensation and a left ventricular ejection fraction of 10% to 25%. The mean age of these patients was 74 ± 11 years (range, 36-88 years). The mean left ventricular ejection fraction was 20% ± 5% (range, 10%-25%). Mean logistic EuroSCORE was 66% ± 21% (range, 27%-97%) and mean Society of Thoracic Surgeons score 33% ± 25% (range, 4%-90%). Nine patients were operated on using femorofemoral cardiopulmonary bypass and 12 without.ResultsTechnical success of the procedure was 100% with no conversion to conventional surgery. The mean time of cardiopulmonary bypass was 27 ± 25 minutes (range, 6-81 minutes). Postoperatively, the left ventricular ejection fraction increased to 38% ± 12% (range, 20%-60%). There were no postoperative neurologic complications. A new pacemaker implantation was needed in 2 (10%) patients. The 30-day mortality was 4.8%. Survival at 1, 3, 12, and 24 months was 95%, 81%, 76%, and 62%, respectively.ConclusionsTransapical aortic valve implantation can be performed safely in patients with decompensated heart failure or even in the presence of cardiogenic shock

Case Report: Successful endovascular treatment of acute type A aortic dissection

Introduction: Open surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach. Methods: We report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch. Results: Postoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course. Discussion: An individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable

Endovascular treatment of an anastomotic outflow graft pseudoaneurysm of the descending aorta after implantation of a left ventricular assist device

Introduction: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after the implantation of the left ventricular assist device (LVAD). Case Report: In this study, we describe the case of a 67‐year‐old patient on LVAD support who developed a late pseudoaneurysm of the OG anastomosis (to the descending aorta) causing OG stenosis at the level of the anastomosis. The patient was treated with a customized fenestrated endovascular stent graft placed into the descending aorta and stent implantation into the OG.ISSN:0886-0440ISSN:1540-819

Pseudoaneurysm of the outflow graft in a patient with novacor N100 LVAD system

Six months after implantation of a wearable Novacor N100 left ventricular assist device, a 47-year-old patient developed a swelling that overlay the body of sternum. Computed tomographic scan of the chest revealed a pseudoaneurysm of the Novacor outflow graft. The patient was taken back to surgery and the diagnosis was confirmed at operation. Repair was performed by direct sutures via right anterolateral thoracotomy, under deep hypothermia and low flow technique. The postoperative course was uneventful

Transapical aortic valve implantation in patients with poor left ventricular function and cardiogenic shock

ObjectivesIn line with our institutional no exclusion policy we accept patients with very poor left ventricular performance and cardiogenic shock for transcatheter aortic valve implantation (TAVI). The purpose of our study was to analyze outcome in these patients and to identify what happens to the left ventricular function after TAVI in patients with failing ventricles.MethodsBetween April 2008 and August 2013, 730 patients underwent transapical TAVI at our institution. The study group consisted of all 104 patients who presented with severely depressed left ventricular function, defined as left ventricular ejection fraction (LVEF) ≤ 30%. Based on the Society of Thoracic Surgeons predicted risk of mortality, the arithmetic risk for surgery in the study cohort was 23% ± 19% (2%-90%), and 23 patients (22%) were in cardiogenic shock.ResultsExcluding patients in cardiogenic shock, the survival rates in the study group at 1, 2, and 4 years were 81% ± 5%, 65% ± 6%, and 45% ± 8%, respectively. Patients in cardiogenic shock showed significantly worse outcome (P = .048). Improvement in LVEF of 50% or more was found in 74 patients (71%) and 100% or more improvement in 45 patients (43%). Early improvement in LVEF was significantly (P = .049) greater in patients with preoperative values of LVEF ≤ 20%.ConclusionsIn the majority of patients with failing ventricles, left ventricular function is quickly restored after TAVI and elimination of aortic stenosis. Without the additional trauma of cardioplegic arrest, TAVI is the potentially superior treatment option in patients with poor and very poor left ventricular performance

Outcomes and survival following thoracic endovascular repair in patients with aortic aneurysms limited to the descending thoracic aorta

Abstract Background Thoracic endovascular aortic repair (TEVAR) is a well-established therapy for descending aortic aneurysms (DTA). There is a paucity of large series reporting the mid- and long-term outcomes from this era. The main aim of this study was to evaluate the outcomes of TEVAR with regards to the effect of aortic morphology and procedure-related variables on survival, reintervention and freedom from endoleaks. Methods In this retrospective single center study, we evaluated the clinical outcomes among 158 consecutive patients with DTA than underwent TEVAR between 2006 and 2019 at our center. The cohort included 51% patients with device landing zones proximal to the subclavian artery and 25.9% patients undergoing an emergent or urgent TEVAR. The primary outcome was survival, and secondary outcomes were reintervention and occurrence of endoleaks. Results Median follow-up was 33 months [IQR 12 to 70] while 50 patients (30.6%) had longer than 5-year follow-up. With a median patient age of 74 years, post-operative Kaplan Meyer survival estimates were 94.3% (95%CI 90.8–98.0, SE 0.018%) at 30 days, 76.4% (95%CI 70.0–83.3, SE 0.034%) at one year and, 52.9% (95%CI 45.0–62.2, SE 0.043%) at five years. Freedom from reintervention at 30 days, one year, and five years was 92.9% (95%CI 89.0–97.1, SE 0.021%), 80.0% (95%CI 72.6–88.1, SE 0.039%), and 52.8% (95%CI 41.4–67.4, SE 0.065%), respectively. On cox regression analysis greater aneurysm diameter, and the use of device landing zones in aortic regions 0–1 were associated with an increased probability of all-cause mortality, and with reintervention during follow-up. Independent of aneurysm size undergoing urgent or emergent TEVAR was associated with higher mortality risk for the first three years post-operative but not on long-term follow-up. Conclusions Larger aneurysms and those requiring stent-graft landing in aortic zones 0 or 1, are associated with higher risk for mortality and reintervention. There remains a need to optimize clinical management and device design for larger proximal aneurysms

Transapical aortic valve implantation after previous aortic valve replacement: Clinical proof of the “valve-in-valve” concept

ObjectiveThe “valve-in-valve” concept may be applied in patients with previously implanted biological aortic valve prostheses. There are few reports of individual cases and as yet no clinical proof of safety and feasibility in a larger group of patients. We report the single-center outcome of transapical implantation of aortic valves into degenerated biological aortic valve prostheses (“valve-in-valve”) in very high-risk patients.MethodsSince October 2008, 14 patients were treated by transapical valve implantation into degenerated biological aortic valve prostheses. Edwards SAPIEN (Edwards Lifesciences, Irvine, Calif) transcatheter heart valves were used in all patients. Mean (± standard deviation) patient age was 73.3 ± 13.1 years. Mean (± standard deviation) Society of Thoracic Surgeons score was 21.9% ± 10.9% (range, 4.2%–42.2%), and logistic euroSCORE was 45.3% ± 22.2%. Preoperatively, all patients were in New York Heart Association functional class III or IV.ResultsThe procedural success was 100%. Preoperative transthoracic echocardiography mean transvalvular gradient was reduced from 37.1 ± 25.7 mm Hg to 13.1 ± 6.4 mm Hg, and mean aortic valve area increased from 0.68 ± 0.23 cm2 to 1.35 ± 0.48 cm2. There was no postoperative valve insufficiency. The postoperative course was short and uneventful in all but 1 patient. One patient underwent reoperation 3 months later because of endocarditis. Up to 20 months postoperatively, the patients were in New York Heart Association functional class I or II.ConclusionsTransapical aortic valve implantation after previous aortic valve replacement was feasible and safe in our patients. The results are excellent with improvements in hemodynamics, but longer follow-up with more patients is needed