Transfemoral transcatheter aortic valve implantation in a patient with multiple endovascular aortic stents – a case report

Background: In patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents. Case Presentation: We report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique. Conclusions: The transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon

Constrictive pericarditis with a life-threatening giant pericardial cyst and pectus excavatum as unusual cause for malign cardiac arrhythmias

Pericardial cysts are rare, abnormal, benign and usually congenital anomalies with an estimated incidence of 1:100.000 and are caused by an incomplete coalescence of foetal lacunae of pericardium development. The size of pericardial cysts varies from 1 to 5 cm and generally do not cause any symptoms. Pectus excavatum is one of the most frequent chest wall abnormalities with a caved-in appearance of the chest and mostly of unknown pathogenesis. We present a rare case of constrictive pericarditis with a huge pericardial cyst (11.6 x 8.7 x 7.1 cm) and pectus excavatum which led to compression of the heart and life-threatening cardiac arrhythmias

Intracardiac Metastasis from a Large Cell Neuroendocrine Lung Carcinoma

Primary malignant tumors of the heart are rare; the biggest group is sarcomas. Cardiac metastases make up the biggest group of secondary cardiac tumors. We present a rare case of cardiac metastasis (3.1 x 3.2 x 2.8 cm) localized in the right atrium, originating from a large cell neuroendocrine lung carcinoma, with close contact to the tricuspid valve and inferior cava vein

Direct oral anticoagulation in atrial fibrillation and heart valve surgery - a meta-analysis and systematic review

Aims: Oral anticoagulation with direct oral anticoagulants (DOAC) could provide an alternative to vitamin K antagonists (VKA) for patients with atrial fibrillation (AF) undergoing bioprosthetic heart valve replacement or valve repair. Methods and results: The aim of this meta-analysis was to review the safety and efficacy of DOAC in patients with surgical implanted bioprosthetic heart valves or valve repairs and AF including data from six clinical trials with a total of 1,857 patients. The efficacy and safety data of DOAC and VKA were pooled to perform random-effects meta-analyses using the Mantel-Haenszel method with pooled risk ratios (RR) and 95% confidence interval (CI). A trial sequential analysis (TSA) was performed to assess statistical robustness. Death caused by cardiovascular cause or thromboembolic events were comparable (RR 0.67, 95% CI: 0.42-1.08; p= 0.101 as DOAC significantly reduced the risk for major bleeding (RR 0.55, 95% CI: 0.35-0.88; p = 0.01) and thromboembolic stroke or systemic embolism rates (RR 0.54, 95% CI: 0.32-0.90; p= 0.021. Rates for intracranial bleeding and hemorrhagic stroke (RR 0.27, 95% CI: 0.07-0.99; p= 0.051 show a trend toward fewer events in the DOAC group. Outcomes for major or minor bleeding events and all-cause mortality were comparable for DOAC and VKA. Conclusion: Cumulative data analysis reveals that DOAC may provide an effective and safe alternative to VKA in patients with AF after surgically implanted bioprosthetic heart valves or repair with AF. Within a relatively heterogeneous study population, this meta-analysis shows a risk reduction of major bleedings and thromboembolic stroke or systemic embolisms for DOAC

Impaired non-canonical transforming growth factor-beta signalling prevents profibrotic phenotypes in cultured peptidylarginine deiminase 4-deficient murine cardiac fibroblasts

Transforming growth factor-beta (TGF-beta) becomes rapidly activated in the infarcted heart. Hence, TGF-beta-mediated persistent activation of cardiac fibroblasts (CFs) and exaggerated fibrotic responses may result in adverse cardiac remodelling and heart failure. Additionally, peptidylarginine deiminase 4 (PAD4) was described to be implicated in organ fibrosis. Here, we investigated the impact of PAD4 on CF function and myofibroblast transdifferentiation in vitro. The expression of fibrosis-related genes was largely similar in cultured WT and PAD4(-/-) CFs of passage 3, although collagen III was reduced in PAD4(-/-) CFs. Exposure to TGF-beta inhibited proliferation and increased contractile activity and migration of WT CFs, but not of PAD4(-/-) CFs. However, under baseline conditions, PAD4(-/-) CFs showed comparable functional characteristics as TGF-beta-stimulated WT CFs. Although the SMAD-dependent TGF-beta pathway was not disturbed in PAD4(-/-) CFs, TGF-beta failed to activate protein kinase B (Akt) and signal transducer and activator of transcription 3 (STAT3) in these cells. Similar results were obtained in WT CFs treated with the PAD4 inhibitor Cl-amidine. Abrogated Akt activation was associated with diminished levels of phosphorylated, inactive glycogen synthase kinase-3 beta (GSK-3 beta). Consequently, PAD4(-/-) CFs did not upregulate collagen I and alpha-smooth muscle actin (alpha-SMA) expression after TGF-beta treatment. Thus, PAD4 is substantially involved in the regulation of non-canonical TGF-beta signalling and may represent a therapeutic target for the treatment of adverse cardiac remodelling

The outcome of patients with peripartum cardiomyopathy and consecutive implantation of a left ventricular assist device

Objectives Peripartum cardiomyopathy (PPCM) is a form of systolic heart failure occurring toward the end of pregnancy or in the period after delivery. Lack of myocardial recovery or therapy-refractory cardiogenic shock are rare complications and left ventricular assist device (LVAD) systems might be used as a life-saving option. The aim of this study was to investigate outcomes of PPCM patients supported with LVAD, registered in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). Methods All patients registered in EUROMACS with a primary diagnosis of PPCM were included in this study. Demographic, preoperative, intraoperative, postoperative, and follow-up data were collected and patients analysed concerning their outcome after initiation of LVAD therapy. Results Between May 2011 and September 2018, 16 patients with PPCM and consecutive LVAD implantation were enrolled into EUROMACS. The median age of the patient population was 31 (26;41) years with a mean left ventricular ejection fraction (LV-EF) of 15% +/- 6%. In-hospital mortality after LVAD implantation was 6% (n = 1). One-year mortality accounted for 13% (n = 2). Six patients (40%) were transplanted with a median support time of 769 (193;1529) days. Weaning of LVAD support due to ventricular recovery was feasible in 3 (20%) patients. Conclusion In patients with severe PPCM, LVAD therapy is associated with considerably low in-hospital mortality, potentially allowing bridging to heart transplantation, or left ventricular recovery. Therefore, durable mechanical support should be considered as a treatment option in this, by nature, young and often otherwise healthy patient population.European Association of Cardio-Thoracic Surgery (EACTS)To all colleagues and co-workers of the centers contributing data to the EUROMACS Registry of the EACTS. The European Association of Cardio-Thoracic Surgery (EACTS) supported this study

Rapid deployment and catheter-based aortic valve prostheses Comparative investigation of hemodynamic characteristics

The treatment of high-grade symptomatic aortic valve stenosis is currently undergoing innovative changes. Due to the exponentially growing expertise in the field of catheter-based procedures the gold standard, if still existing, is increasingly being called into question. Inspired by these developments conventional surgical valve prostheses are undergoing changes and enhancements so that they can be implanted with shorter operation times in order to improve the outcome of patients. This retrospective study compared a transcatheter-based aortic valve prosthesis with a surgical rapid deployment prosthesis with respect to postoperative hemodynamic characteristics. Transvalvular pressure gradients and the incidence of paravalvular regurgitation were evaluated as important surrogate parameters for the long-term survival of patients. Furthermore, both valve types were analyzed with respect to the hemodynamic profile in an in vitro model using 4D flow magnetic resonance imaging (MRI)

Multiple emboli caused by ascending aorta thrombus-Surgical approach

Embolizing aortic thrombus can be associated with severe complications. Here, we present images showing a rare presentation of an ascending aorta thrombus

Rapid Deployment Aortic Valve Replacement: Excellent Results and Increased Effective Orifice Areas

Background. The aim of this study was to evaluate the effects of rapid deployment aortic valve replacement (RDAVR) on surgical outcome and hemodynamics compared with standard aortic valve replacement (AVR). Methods. One hundred sixty- three RDAVR patients (isolated, n = 67; combined with coronary artery bypass graft surgery [CABG], n = 96) were compared with a propensity matched control group (n = 163). Primary endpoints included association between valve type and procedure times, prosthesis size, transvalvular gradient, and indexed effective orifice area. Secondary endpoints were postoperative mortality and morbidity. Results. Aortic cross-clamp and cardiopulmonary bypass times in the RDAVR group were 55 +/- 23 and 88 +/- 38 minutes, respectively, compared with 77 +/- 22 and 105 +/- 38 minutes in the control group (p < 0.001). In the subgroup of patients undergoing isolated RDAVR (n = 67 of 163), the aortic cross-clamp and cardiopulmonary bypass times were 38 +/- 13 and 66 +/- 22 minutes, respectively, compared with 55 +/- 14 and 81 +/- 18 minutes in the control group (n = 67 of 163; p < 0.001). The RDAVR patients received larger prostheses (23.3 +/- 1.8 mm) compared with standard AVR (22.8 +/- 1.5 mm; p = 0.002). Mean transvalvular gradients and indexed effective orifice areas were 9 +/- 5 mm Hg and 1.11 +/- 0.11, respectively, in the RDVAR group compared with 13 +/- 5 mm Hg and 0.95 +/- 0.08 in the control group (p < 0.001). Hospital mortality was similar in both groups (1.8%, n = 3 of 163; p = 1.000). Postoperative pacemaker rates were 3.5% (n = 3 of 67) for isolated RDAVR versus 3.0% (n = 2 of 67; p = 0.649) for isolated AVR and 12.5% (n = 12 of 96) for RDAVR/CABG versus 4.2% (n = 4 of 96; p = 0.032) for AVR/CABG. Conclusions. RDAVR facilitates reduced aortic crossclamp and cardiopulmonary bypass times compared with standard AVR, particularly in patients undergoing concomitant procedures, allowing the use of larger prostheses and resulting in lower transvalvular gradients and higher indexed effective orifice area compared with standard AVR. Therefore, RDAVR may help to overcome patient-prosthesis mismatch in some patients. (C) 2018 by The Society of Thoracic Surgeon