How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle?

BACKGROUND: Despite the technical advancements of the transcatheter aortic valve implantation (TAVI) procedure, valve embolisation into the left ventricle remains a challenging situation requiring expedited management through the Heart Team. INVESTIGATION: The advantages and pitfalls of an interventional transfemoral approach, a transapical extraction of the dislocated prosthesis or the conversion to open heart surgery have to be balanced depending on the overall situation and the specific characteristics of the patient. DIAGNOSIS: A transfemoral approach would be the first choice for most TAVI implanters. We discuss the different options and present an elegant solution solving this challenging situation, leading to a good immediate and long-term outcome. MANAGEMENT: Attempts at pulling the prosthesis out of the ventricle using a balloon remained unsuccessful. After grasping of the prosthesis with a goose-neck snare, the valve was pulled into the annulus. A second SAPIEN XT prosthesis was implanted and fixed the first prosthesis within the annulus. After post-dilatation, there was a good result without relevant gradient and minimal aortic regurgitation.

Transcatheter aortic valve implantation in patients with severely reduced left ventricular systolic function: a single-center experience.

AIMS: Current guidelines consider severe systolic left ventricular dysfunction [ejection fraction (EF) ≤20 %; left ventricular dysfunction (LVD)] a contraindication for transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the efficacy and safety of TAVI in this extreme risk subset of patients. METHODS AND RESULTS: The study population (253 patients) was divided into two groups; the LVD group [21 patients with left ventricular ejection fraction (LVEF) ≤20 %] and the control group (232 patients with LVEF >20 %). TAVI was generally performed transfemorally under analgosedation without mechanical circulatory support. Clinical and hemodynamic variables, as well as procedural and follow-up outcomes, were compared, and all events were defined according to the Valve Academic Research Consortium criteria for event definition. Mean EF in the LVD group was 18.3 ± 2.9 % compared to 50.9 ± 11.3 % in the control group. Patients in the LVD group were younger, more commonly males, had higher logistic EuroSCORE and lower mean aortic pressure gradients. Immediate procedural mortality was low and similar in both groups (0 vs. 2.2 % in the LVD and control group, respectively, p = 0.49). At 30 days, post-procedural vascular and bleeding complications as well as strokes were similar, but all-cause mortality was higher in the LVD group (14.3 vs. 3.4 %, p = 0.05). In the survivors of the LVD group, New York Heart Association functional class and LVEF significantly improved at 30 days and 6 months. Survival at 1 and 2 years was 70.2 vs. 86.0 % and 56.1 vs. 78.3 % in the LVD and control group, respectively (log-rank p = 0.03). CONCLUSIONS: TAVI without mechanical circulatory support appears feasible, safe and effective in patients with severe aortic stenosis and severe LVD, but short- and long-term mortality remain high. TAVI should be considered a viable treatment option in this subset of extremely compromised patients.

Mid-term results of different aortic valve-sparing procedures in Marfan syndrome.

BACKGROUND AND AIM OF THE STUDY: Marfan patients with aortic root aneurysm are typically treated with the Bentall procedure, though aortic valve-sparing procedures (AVSPs) are also possible. The study aim was to compare the authors' experience with two such techniques performed at their institution, namely a reimplantation according to David (David I) and remodeling according to Yacoub. METHODS: Between 1996 and 2009, a total of 37 Marfan patients underwent an AVSP at the authors' institution. Of these patients, 25 (mean age 32 +/- 14.9 years) underwent surgery according to David (group D), and 12 (mean age 35 +/- 10.9 years) according to Yacoub (group Y). The patients underwent both clinical and echocardiographic follow up examinations at a mean of 42.0 +/- 36.4 months after surgery. RESULTS: One patient from each group had moved abroad and was lost to follow up. The remaining 35 patients were alive at follow up, and none presented with any major neurological or bleeding complications. In addition, no significant differences were noted between the groups in terms of NYHA classification, left ventricular function, or left ventricular diameter. At follow up, aortic valve function was also comparable between groups, with a peak/mean gradient of 9.4 +/- 6.4/5.3 +/- 3.5 mmHg and 5.1 +/- 3.3/2.8 +/- 1.5 mmHg for groups D and Y, respectively (p = 0.081/0.058). The measured mean grades of aortic valve regurgitation were comparable in groups D and Y (0.6 +/- 0.7 and 1.1 +/- 0.6, respectively; p = 0.055). However, aortic root dimensions obtained via M-mode were smaller in group D patients (29.6 +/- 2.3 mm) than in group Y patients (36.1 +/- 6.6 mm) (p = 0.027). Only three patients from group Y required reoperation on the aortic valve due to valvular regurgitation (p = 0.028); two of these had presented with aortic dissection at the first operation. CONCLUSION: Both types of AVSP can be performed with comparably good interim clinical results, and also low mortality and morbidity, in patients with Marfan syndrome.

Non-invasive cerebral oxygenation reflects mixed venous oxygen saturation during the varying haemodynamic conditions in patients undergoing transapical transcatheter aortic valve implantation.

Transapical transcatheter aortic valve implantation (TA-TAVI) is increasingly used to treat aortic valve stenosis in high-risk patients. Mixed venous oxygen saturation (SvO(2)) is still the 'gold standard' for the determination of the systemic oxygen delivery to consumption ratio in cardiac surgery patients. Recent data suggest that regional cerebral oxygen saturation (rScO(2)) determined by near-infrared spectroscopy is closely related to SvO(2). The present study compares rScO(2) and SvO(2) in patients undergoing TA-TAVI. n = 20 cardiac surgery patients scheduled for TA-TAVI were enrolled in this prospective observational study. SvO(2) and rScO(2) were determined at predefined time points during the procedure. Correlation and Bland-Altman analysis of the complete data set showed a correlation coefficient of r(2 )= 0.7 between rScO(2) and SvO(2) (P < 0.0001), a mean difference (bias) of 5.8 with limits of agreement (1.96 SD) of -6.8 to 18.3% and a percentage error of 17.5%. At all predefined time points correlation was moderate (r(2 )= 0.50) to close (r = 0.84), and the percentage error was <24%. RScO(2) determined by near-infrared spectroscopy is correlated to SvO(2) during varying haemodynamic conditions in patients undergoing TA-TAVI. This suggests that rScO(2) is reflective not only of the cerebral, but also of the systemic oxygen balance.

Altered microRNAs in bicuspid aortic valve: a comparison between stenotic and insufficient valves.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV), the most common form of congenital heart disease, is a leading cause of aortic stenosis (AS) and aortic insufficiency (AI). AS is typically caused by calcific valve disease. Recently, microRNAs (miRNAs) have been shown to modulate gene expression. The study aim was to examine the miRNAs that were altered in the aortic valve leaflets of patients with AS compared to those in patients with AI. In-vitro experiments were also carried out to determine if these miRNAs could modulate calcification-related genes. METHODS: Aortic valve samples (fused and unfused leaflets) were collected from nine male patients (mean age 44.9 +/- 13.8 years) undergoing aortic valve replacement (AVR). PIQOR miRXplore Microarrays containing 1,421 miRNAs were used and hybridized to fused leaflet samples labeled with Cy5; unfused samples were used as controls and labeled with Cy3. A quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed to validate the miRNA array results. Cultured human aortic valve interstitial cells (AVICs) were treated with miRNA mimics, and qRT-PCR was carried out to determine any changes in mRNAs. RESULTS: By microarray analysis, seven miRNAs were shown to be statistically different between the AS and AI patients. In the stenotic samples, the MiR-26a and miR-195 levels were shown (by qRT-PCR) to be reduced by 65% and 59%, respectively (p < 0.05), and MiR-30b to be reduced by 62% (p < 0.06). Human AVICs treated with miR-26a or miR-30b mimics showed decreased mRNA levels of calcification-related genes. MiR-26a repressed BMP2 by 36%, alkaline phosphatase (ALPL) by 38%, and SMAD1 by 26%, while MiR-30b reduced the expression of SMAD1 by 18% and of SMAD3 by 12%. In contrast, miR-195-treated AVICs had increased mRNA levels of calcification-related genes, such as BMP2 by 68% and RUNX2 by 11%. CONCLUSION: MiR-26a, miR-30b, and miR-195 were each decreased in the aortic valves of patients requiring AVR due to AS, compared to those requiring replacement due to AI. These miRNAs appear to modulate calcification-related genes in vitro.

Percutaneous aortic valve replacement: overview and suggestions for anesthestic management.

Transcutaneous aortic valve replacement (AVR) is increasingly used for high-risk patients with severe aortic stenosis, who have high operative mortality for surgical placement during cardiopulmonary bypass (CPB). Retrograde transfemoral AVR is usually performed during sedation, whereas antegrade transapical AVR is done with general anesthesia. Both procedures can be carried out without CPB. Extended hemodynamic monitoring, including pulmonary artery catheterization and transesophageal echocardiography, may be useful. Transfemoral AVR requires placement of a transvenous right ventricular pacing lead. Typical complications include local bleeding, obstruction of the coronary ostia, and neurological insult due to embolization of sclerotic material. Aortic regurgitation due to paravalvular leakage or inadequate device expansion also may occur. Renal function may deteriorate on excessive application of contrast medium. Atrioventricular blocks may occur later rather than after conventional AVR which tend to occur immediately.

The association of non-invasive cerebral and mixed venous oxygen saturation during cardiopulmonary resuscitation.

Mixed venous oxygen saturation (SvO(2)) is an accepted surrogate parameter for the ratio between oxygen delivery and demand and may thus be used to determine the adequacy of the function of the cardiopulmonary system. Cerebral oxygen saturation monitoring by near infrared spectroscopy is a non-invasive method for the determination of the cerebral oxygen delivery to demand ratio that is applicable outside the operating room or the intensive care unit and does not require calibration. The present case highlights the agreement of non-invasive cerebral and SvO(2) in an 87-year-old female cardiac surgery patient with severe aortic stenosis scheduled for transapical aortic valve replacement during prolonged cardiopulmonary resuscitation.