RESUMO
Takayasu arteriitis (TA) is a rare systemic vasculitis, affecting large vessels, cardiac valves and myocardium. Cardiac involvement is a major cause of morbidity and mortality in such patients. This publication presents a clinical case of a patient with severe aortic regurgitation combined with restrictive cardiomyopathy. It is emphasized that surgical treatment is associated with potential difficulties in patients with TA due to its inflammatory nature, disease activity and multiorgan involvement.
Assuntos
Insuficiência da Valva Aórtica , Arterite de Takayasu , Humanos , Arterite de Takayasu/complicações , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Feminino , AdultoRESUMO
BACKGROUND: Severe pure aortic regurgitation (AR) carries a high mortality and morbidity risk, and it is often undertreated because of the inherent surgical risk. Transcatheter heart valves (THVs) have been used off-label in this setting with overall suboptimal results. The dedicated "purpose-built" Jena Valve Trilogy (JVT, JenaValve Technology) showed an encouraging performance, although it has never been compared to other THVs. OBJECTIVES: The aim of our study was to assess the performance of the latest iteration of THVs used off-label in comparison to the purpose-built JVT in inoperable patients with severe AR. METHODS: We performed a multicenter, retrospective registry with 18 participating centers worldwide collecting data on inoperable patients with severe AR of the native valve. A bicuspid aortic valve was the main exclusion criterion. The primary endpoints were technical and device success, 1-year all-cause mortality, and the composite of 1-year mortality and the heart failure rehospitalization rate. RESULTS: Overall, 256 patients were enrolled. THVs used off-label were used in 168 cases (66%), whereas JVT was used in 88 (34%). JVT had higher technical (81% vs 98%; P < 0.001) and device success rates (73% vs 95%; P < 0.001), primarily driven by significantly lower incidences of THV embolization (15% vs 1.1%; P < 0.001), the need for a second valve (11% vs 1.1%; P = 0.004), and moderate residual AR (10% vs 1.1%; P = 0.007). The permanent pacemaker implantation rate was comparable and elevated for both groups (22% vs 24%; P = 0.70). Finally, no significant difference was observed at the 1-year follow-up in terms of mortality (HR: 0.99; P = 0.980) and the composite endpoint (HR: 1.5; P = 0.355). CONCLUSIONS: The JVT platform has a better acute performance than other THVs when used off-label for inoperable patients with severe AR. A longer follow-up is conceivably needed to detect a possible impact on prognosis.
Assuntos
Insuficiência da Valva Aórtica , Valva Aórtica , Próteses Valvulares Cardíacas , Desenho de Prótese , Sistema de Registros , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter , Humanos , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/mortalidade , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Feminino , Masculino , Estudos Retrospectivos , Idoso , Resultado do Tratamento , Idoso de 80 Anos ou mais , Fatores de Risco , Valva Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/instrumentação , Readmissão do Paciente , Recuperação de Função Fisiológica , Europa (Continente) , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/diagnóstico , HemodinâmicaAssuntos
Insuficiência da Valva Aórtica , Valva Aórtica , Cateterismo Cardíaco , Humanos , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Resultado do Tratamento , Valva Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco/instrumentação , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/efeitos adversos , Fatores de Risco , Hemodinâmica , Recuperação de Função Fisiológica , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversosRESUMO
Iatrogenic aortic regurgitation secondary to leaflet injury is a rare complication of mitral valve surgery. For the first time, we report a patient who had progressive aortic regurgitation due to non-coronary leaflet perforation after robotic mitral valve repair and required aortic valve repair 18 months after this initial surgery. As in our case, aortic regurgitation after mitral valve surgery may remain undiagnosed on intraoperative transesophageal echocardiography or undetected until the patient's discharge due to gradual enlargement of very small perforations over the postoperative course.
Assuntos
Insuficiência da Valva Aórtica , Ecocardiografia Transesofagiana , Doença Iatrogênica , Insuficiência da Valva Mitral , Valva Mitral , Procedimentos Cirúrgicos Robóticos , Humanos , Valva Mitral/cirurgia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , FemininoRESUMO
BACKGROUND AND OBJECTIVE: The implantation of ventricular assist devices (VADs) has become an important treatment option for patients with heart failure. Aortic valve insufficiency is a common complication caused by VADs implantation. Currently, there is very little quantitative research on the effects of transcatheter micro VADs or the intervention pumps on the aortic valves. METHODS: In this study, the multi-component arbitrary Lagrange-Eulerian method is used to perform fluid-structure interaction simulations of the aortic valve model with and without intervention pumps. The effects of intervention pumps implantation on the opening area of the aortic valves, the stress distribution, and the flow characteristics are quantitatively analyzed. Statistical results are consistent with clinical guidelines and experiments. RESULTS: The implantation of intervention pumps leads to the valve insufficiency and causes weak valve regurgitation. In the short-term treatment, the valve regurgitation is within a controllable range. The distribution and variation of stress on the leaflets are also affected by intervention pumps. The whirling flow in the flow direction affects the closing speed of the aortic valves and optimizes the stress distribution of the valves. In the models with whirling flow, the effects of intervention pumps implantation on valve motion and stress distribution differ from those without whirling flow. However, the valve insufficiency and valve regurgitation caused by intervention pumps still exist in the models with whirling flow. Conventional artificial bioprosthetic valves have limited effectiveness in treating the valve diseases caused by intervention pumps implantation. CONCLUSIONS: This study quantitatively investigates the impact of intervention pumps on the aortic valves, and investigates the effect of blood rotation on the valve behavior, which is a gap in previous research. We suggest that in the short-term treatment, the implantation of intervention pumps has limited impact on aortic valves, caution should be exercised against valve regurgitation issues caused by intervention pumps.
Assuntos
Valva Aórtica , Simulação por Computador , Coração Auxiliar , Modelos Cardiovasculares , Humanos , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/etiologia , Estresse Mecânico , HemodinâmicaRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat severe aortic stenosis in younger patients. Accordingly, lifetime management regarding future reintervention and coronary access is a concern. AIMS: To assess the impact of commissural alignment on ACURATE neo2 transcatheter aortic valve (TAV) performance. METHODS: COMALIGN-neo2 was an observational, retrospective study enrolling consecutive TAVR patients treated with the ACURATE neo2 (October 2021 to October 2022). The degree of commissural (mis)-alignment (CMA) with the native aortic valve commissures was determined and transvalvular gradient, effective orifice area, patient-prosthesis mismatch (PPM), and aortic regurgitation (AR) were assessed. RESULTS: Among 825 patients, the mean age was 80.7 years and 42% were female. Commissural alignment was achieved in 60% of cases; mild (26%), moderate (9%), and severe misalignment (5%) were found less often. Severe PPM occurred more frequently in patients with severe CMA (14.7%) compared to aligned valves (p = 0.034). By multivariate analysis, severe CMA (odds ratio [OR]: 3.12, 95% confidence interval [CI] [1.09-8.90]; p = 0.033) and lack of postdilatation (OR: 3.85, [1.33-11.1]; p = 0.012) were associated with severe PPM. Higher rates of ≥mild AR (51.4%) were found in TAVs implanted with severe CMA compared to aligned (34.3%), mildly (38.1%) or moderately (36.0%) misaligned TAVs (p = 0.030). Multivariate analysis identified severe CMA (OR: 2.05, [1.05-4.02]; p = 0.037) to be an independent predictor of ≥mild AR. CONCLUSIONS: COMALIGN-neo2 is the largest study to date assessing the impact of commissural alignment on acute TAV performance. Severe CMA with the ACURATE neo2 platform was associated with worse valve hemodynamics and increased risk for mild AR.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Valva Aórtica , Próteses Valvulares Cardíacas , Hemodinâmica , Desenho de Prótese , Recuperação de Função Fisiológica , Substituição da Valva Aórtica Transcateter , Humanos , Feminino , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/efeitos adversos , Estudos Retrospectivos , Masculino , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Idoso de 80 Anos ou mais , Idoso , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Resultado do Tratamento , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Fatores de Risco , Índice de Gravidade de Doença , Fatores de TempoRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) stenosis is technically challenging and is burdened by an increased risk of paravalvular regurgitation (PVR). OBJECTIVES: The aim of this study was to identify the incidence, predictors, and clinical outcomes of PVR after TAVR in Sievers type 1 BAV stenosis. METHODS: Consecutive patients with Sievers type 1 BAV stenosis undergoing TAVR with current-generation transcatheter heart valves (THVs) in 24 international centers were enrolled. PVR was graded as none/trace, mild, moderate, and severe according to echocardiographic criteria. The endpoint of major adverse events (MAEs), defined as a composite of all-cause death, stroke, or hospitalization for heart failure, was assessed at the last available follow-up. RESULTS: A total of 946 patients were enrolled. PVR occurred in 423 patients (44.7%)-mild, moderate, and severe in 387 (40.9%), 32 (3.4%), and 4 (0.4%) patients, respectively. Independent predictors of moderate or severe PVR were a larger virtual raphe ring perimeter (adjusted OR: 1.07; 95% CI: 1.02-1.13), severe annular or left ventricular outflow tract calcification (adjusted OR: 5.21; 95% CI: 1.45-18.77), a self-expanding valve (adjusted OR: 9.01; 95% CI: 2.09-38.86), and intentional supra-annular THV positioning (adjusted OR: 3.31; 95% CI: 1.04-10.54). At a median follow-up of 1.3 years (Q1-Q3: 0.5-2.4 years), moderate or severe PVR was associated with an increased risk of MAEs (adjusted HR: 2.52; 95% CI: 1.24-5.09). CONCLUSIONS: After TAVR with current-generation THVs in Sievers type 1 BAV stenosis, moderate or severe PVR occurred in about 4% of cases and was associated with an increased risk of MAEs during follow-up.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Próteses Valvulares Cardíacas , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter , Humanos , Masculino , Feminino , Fatores de Risco , Idoso , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/mortalidade , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/mortalidade , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/anormalidades , Resultado do Tratamento , Idoso de 80 Anos ou mais , Incidência , Fatores de Tempo , Doença da Válvula Aórtica Bicúspide/cirurgia , Doença da Válvula Aórtica Bicúspide/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/cirurgia , Doenças das Valvas Cardíacas/fisiopatologia , Europa (Continente) , Medição de Risco , Desenho de Prótese , Razão de Chances , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/diagnóstico , Estudos RetrospectivosRESUMO
BACKGROUND: As compared to treatment of aortic stenosis (AS), transcatheter aortic valve replacement (TAVR) using the commercially available valves to treat pure aortic regurgitation (PAR) has a lower device success rate and higher complication rates. AIMS: The study compared the acute results between TAVR using a novel noncoronary sinus pivot implantation (NCPI) method and that using the conventional method, aiming to explore a more optimized and effective operation method for TAVR in PAR. METHODS: PAR patients who underwent TAVR with self-expanding valves in our center from September 2021 to September 2023 were enrolled were divided into the NCPI (group A, N = 16) and conventional method (group B, N = 39) groups. We analyzed the pre-operative evaluation parameters and procedural and postoperative data of the two subgroups. RESULTS: The total patients' mean age was 71.2 ± 8.7 years and most were male (61.8%), with a mean Society of Thoracic Surgeons score of 3.4 ± 1.9%. The device success rate of groups A and B was 100% and 71.8%, respectively. In group B, 48.7% had major adverse cardiac events (MACE); 46.2% patients had permanent pacemaker implantation or valve in valve implantation. None had MACE in group A. The noncoronary sinus implantation depth in NCPI was -1.1 + 1.0 and 4.2 + 3.7 mm in groups A and B (p < 0.001), respectively. CONCLUSIONS: TAVR with a self-expanding valve using the NCPI method had a higher procedure success rate and dramatically low complications than that using the conventional method in PAR patients.
Assuntos
Insuficiência da Valva Aórtica , Valva Aórtica , Próteses Valvulares Cardíacas , Desenho de Prótese , Recuperação de Função Fisiológica , Substituição da Valva Aórtica Transcateter , Humanos , Masculino , Feminino , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/efeitos adversos , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Idoso , Resultado do Tratamento , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Tempo , Fatores de Risco , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , HemodinâmicaRESUMO
Transcatheter aortic valve implantation (TAVI) has traditionally been indicated for the treatment of aortic stenosis. However, in this case report, we describe a successful TAVI procedure in a 46-year-old male patient who had previously undergone David aortic valve-sparing aortic root replacement for type 1 aortic dissection. The patient presented with aortic valve insufficiency 4 years after the initial surgery and was subsequently treated with a 34 mm Medtronic CoreValve Evolut R prosthesis via TAVI. This case highlights the feasibility of TAVI as a viable treatment option for postoperative aortic valve insufficiency in patients with prior ascending aortic or aortic arch surgery.
Assuntos
Dissecção Aórtica , Insuficiência da Valva Aórtica , Valva Aórtica , Implante de Prótese Vascular , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Masculino , Dissecção Aórtica/cirurgia , Dissecção Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/fisiopatologia , Pessoa de Meia-Idade , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Resultado do Tratamento , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/efeitos adversos , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Desenho de Prótese , Prótese Vascular , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Aneurisma Aórtico/diagnóstico por imagem , AortografiaRESUMO
Quadricuspid aortic valve is a rare congenital cardiac anomaly with an incidence of 0.008% to 0.043%. Its clinical course varies depending on cusp anatomy, function, and associated cardiac malformations. It frequently progresses to aortic valve regurgitation that may require surgical valve replacement. Detection has shifted from incidental discovery during autopsies or cardiac surgeries in the early 20th century to various cardiac imaging methods in recent decades. In addition to contributing to the literature, this report supports the use of transesophageal echocardiography more liberally to detect aortic valve abnormalities. The case presents a 48-year-old female patient with an incidentally discovered quadricuspid aortic valve.
Assuntos
Insuficiência da Valva Aórtica , Valva Aórtica , Ecocardiografia Transesofagiana , Cardiopatias Congênitas , Achados Incidentais , Humanos , Feminino , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Pessoa de Meia-Idade , Ecocardiografia Transesofagiana/métodos , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/etiologia , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Cardiopatias Congênitas/diagnóstico por imagem , Valor Preditivo dos Testes , Implante de Prótese de Valva Cardíaca , Ecocardiografia Doppler em CoresRESUMO
BACKGROUND: Previous studies have documented a high rate of implantation success with the ACURATE neo2 valve, as well as a reduction in paravalvular leak (PVL) compared to its predecessor, the ACURATE neo. However, there are no studies that have reviewed and compared the long-term clinical and hemodynamic outcomes of these patients. AIMS: This study aimed to evaluate the results of the ACURATE neo transcatheter aortic valve in a real-world context, and to compare the results of the outcomes of both generations of this device (ACURATE neo and ACURATE neo2), with a specific focus on procedural success, safety, and long-term effectiveness. METHODS: A prospective study including all consecutive patients treated with the ACURATE neo device in seven hospitals was conducted (Clinical Trials Identification Number: NCT03846557). The primary endpoint consisted of a composite of adverse events, including mortality, aortic insufficiency, and other procedural complications. As the second-generation device (ACURATE neo2) replaced the ACURATE neo during the study period, hemodynamic and clinical results before admission, at 30 days, and at 1 year of follow-up were compared between the two generations. RESULTS: A total of 296 patients underwent transcatheter aortic valve implantation with the ACURATE device, with 178 patients receiving the ACURATE neo and 118 patients receiving the ACURATE neo2. In the overall population, the absence of device success occurred in 14.5%. The primary reason for the absence of device success was the presence of para-valvular regurgitation ≥ 2. There were no instances of coronary occlusions, valve embolization, annulus rupture, or procedural deaths. ACURATE neo2 was associated with a significantly higher device success rate (91.7% vs. 82%, p = 0.04), primarily due to a significantly lower rate of para-valvular regurgitation, which remained significant at 1 year. CONCLUSION: The use of ACURATE neo and neo2 transcatheter aortic valves is associated with satisfactory clinical results and an extremely low rate of complications. The ACURATE neo2 enables a significantly higher device success rate, primarily attributed to a significant reduction in the rate of PVL.
Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Próteses Valvulares Cardíacas , Hemodinâmica , Desenho de Prótese , Sistema de Registros , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Valva Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Complicações Pós-Operatórias , Estudos Prospectivos , Recuperação de Função Fisiológica , Fatores de Risco , Espanha , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
This case report presents a 20-year-old male patient initially diagnosed with infective endocarditis, later correctly identified as Behçet's syndrome. The patient's complex clinical presentation, including chest pain, aortic dilation, severe aortic regurgitation, and aortic root abscess, posed significant diagnostic and therapeutic challenges. Despite initial misdiagnosis and treatment difficulties, the patient's condition significantly improved with appropriate immunosuppressive therapy, underscoring the potential for successful management of this complex condition. This case serves as a valuable reminder of the diagnostic challenges posed by Behçet's syndrome and the importance of considering this condition in patients presenting with symptoms suggestive of infective endocarditis.
Assuntos
Síndrome de Behçet , Erros de Diagnóstico , Imunossupressores , Humanos , Síndrome de Behçet/diagnóstico , Síndrome de Behçet/tratamento farmacológico , Masculino , Adulto Jovem , Imunossupressores/uso terapêutico , Endocardite/diagnóstico , Endocardite/terapia , Endocardite/tratamento farmacológico , Resultado do Tratamento , Diagnóstico Diferencial , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/etiologia , Valor Preditivo dos TestesAssuntos
Insuficiência da Valva Aórtica , Próteses Valvulares Cardíacas , Falha de Prótese , Humanos , Próteses Valvulares Cardíacas/efeitos adversos , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/diagnóstico , Masculino , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Idoso , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Estenose da Valva Aórtica/cirurgiaRESUMO
We report the case of an 80-year-old woman with known quadricuspid aortic valve (QAV), severe aortic stenosis, and moderate-to-severe regurgitation who recently underwent a transcatheter aortic valve replacement (TAVR).
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Valva Aórtica , Substituição da Valva Aórtica Transcateter , Humanos , Idoso de 80 Anos ou mais , Feminino , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/complicações , Substituição da Valva Aórtica Transcateter/métodos , Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/etiologia , Ecocardiografia Transesofagiana/métodos , Índice de Gravidade de Doença , Resultado do Tratamento , Próteses Valvulares CardíacasRESUMO
Structural valve deterioration after aortic root replacement (ARR) surgery may be treated by transcatheter valve-in-valve (ViV-TAVI) intervention. However, several technical challenges and outcomes are not well described. The aim of the present review was to analyze the outcomes of ViV-TAVI in deteriorated ARR. This review included studies reporting any form of transcatheter valvular intervention in patients with a previous ARR. All forms of ARR were considered, as long as the entire root was replaced. Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases were searched until September 2023. Overall, 86 patients were included from 31 articles that met our inclusion criteria out of 741 potentially eligible studies. In the entire population, the mean time from ARR to reintervention was 11.0 years (range: 0.33-22). The most frequently performed techniques/grafts for ARR was homograft (67.4%) and the main indication for intervention was aortic regurgitation (69.7%). Twenty-three articles reported no postoperative complications. Six (7.0%) patients required permanent pacemaker implantation (PPI) after the ViV-TAVI procedure, and 4 (4.7%) patients had a second ViV-TAVI implant. There were three device migrations (3.5%) and 1 stroke (1.2%). Patients with previous ARR present a high surgical risk. ViV-TAVI can be considered in selected patients, despite unique technical challenges that need to be carefully addressed according to the characteristics of the previous surgery and on computed tomography analysis.
Assuntos
Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/efeitos adversos , Estimulação Cardíaca Artificial , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Falha de Prótese , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Surgery remains the only recommended intervention for patients with native aortic regurgitation. A transcatheter therapy to treat patients at high risk for mortality and complications with surgical aortic valve replacement represents an unmet need. Commercial transcatheter heart valves in pure aortic regurgitation are hampered by unacceptable rates of embolisation and paravalvular regurgitation. The Trilogy transcatheter heart valve (JenaValve Technology, Irvine, CA, USA) provides a treatment option for these patients. We report outcomes with transfemoral transcatheter aortic valve implantation (TAVI) in patients with pure aortic regurgitation using this dedicated transcatheter heart valve. METHODS: The ALIGN-AR trial is a prospective, multicentre, single-arm study. We recruited symptomatic patients (aged ≥18 years) with moderate-to-severe or severe aortic regurgitation at high risk for mortality and complications after surgical aortic valve replacement at 20 US sites for treatment with the Trilogy transcatheter heart valve. The 30-day composite primary safety endpoint was compared for non-inferiority with a prespecified performance goal of 40·5%. The primary efficacy endpoint was 1-year all-cause mortality compared for non-inferiority with a performance goal of 25%. This trial is registered with ClinicalTrials.gov, NCT04415047, and is ongoing. FINDINGS: Between June 8, 2018, and Aug 29, 2022, we screened 346 patients. We excluded 166 (48%) patients and enrolled 180 (52%) patients with symptomatic aortic regurgitation deemed high risk by the heart team and independent screening committee assessments. The mean age of the study population was 75·5 years (SD 10·8), and 85 (47%) were female, 95 (53%) were male, and 131 (73%) were White. Technical success was achieved in 171 (95%) patients. At 30 days, four (2%) deaths, two (1%) disabling strokes, and two (1%) non-disabling strokes occurred. Using standard Valve Academic Research Consortium-2 definitions, the primary safety endpoint was achieved, with events occurring in 48 (27% [97·5% CI 19·2-34·0]) patients (pnon-inferiority<0·0001), with new pacemaker implantation in 36 (24%) patients. The primary efficacy endpoint was achieved, with mortality in 14 (7·8% [3·3-12·3]) patients at 1 year (pnon-inferiority<0·0001). INTERPRETATION: This study shows the safety and effectiveness of treating native aortic regurgitation using a dedicated transcatheter heart valve to treat patients with symptomatic moderate-to-severe or severe aortic regurgitation who are at high risk for mortality or complications after surgical aortic valve replacement. The observed short-term clinical and haemodynamic outcomes are promising as are signs of left ventricular remodelling, but long-term follow-up is necessary. FUNDING: JenaValve Technology.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying Counter-Pulsation (TABERNACL), a simple, on-table temporary valve using commercially available equipment to temporize acute severe aortic regurgitation. METHODS: We hypothesize that an appropriately sized commercial balloon dilatation catheter-straddling the aortic annulus and connected to a counterpulsation console-can serve as a temporizing valve to restore hemodynamic stability in acute aortic regurgitation. We performed benchtop testing of valvuloplasty, angioplasty, and sizing balloons as counterpulsation balloons. TABERNACL was assessed in vivo in a porcine model of acute aortic regurgitation (n=8). We also tested a static undersized, continuously inflated transvalvular balloon as a spacer intended physically to obstruct the regurgitant orifice. RESULTS: Benchtop testing identified that Tyshak II and PTS sizing (NuMed Braun) balloon catheters performed adequately as temporary valves (ie, complete inflation and deflation with each cycle) and resisted fatigue, in contrast to others. When TABERNACL was used in the acute severe regurgitation animals, there was immediate hemodynamic improvement, with a significant 35% increase in diastolic aortic pressure by 16 mmâ Hg ([95% CI, 7-25] P=0.0056), 34% reduction in left ventricular end-diastolic pressure by -7 mmâ Hg ([95% CI, -10 to -5] P=0.0006), improvement in the aortic diastolic index by 0.28 ([95% CI, 0.18-0.39] P=0.0009), and reversal of electrocardiographic myocardial ischemia. As an alternative, static balloon inflation across the aortic valve stabilized regurgitation hemodynamics at the expense of a new aortic gradient and caused excessive ectopy from balloon movement in the left ventricular outflow tract. CONCLUSIONS: TABERNACL improves hemodynamics and reduces coronary ischemia by electrocardiography in animals with acute severe aortic regurgitation. TABERNACL valves obstruct the diastolic regurgitant orifice without systolic obstruction. This may prove a lifesaving bridge to definitive valve replacement therapy.
Assuntos
Insuficiência da Valva Aórtica , Valvuloplastia com Balão , Modelos Animais de Doenças , Hemodinâmica , Animais , Hemodinâmica/efeitos dos fármacos , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Sus scrofa , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Desenho de Equipamento , Recuperação de Função Fisiológica , Doença Aguda , Cateteres Cardíacos , Fatores de Tempo , Índice de Gravidade de Doença , Função Ventricular Esquerda/efeitos dos fármacosRESUMO
BACKGROUND: There is a lack of comparative data on transcatheter aortic valve implantation (TAVI) in degenerated surgical prostheses (valve-in-valve [ViV]). AIMS: We sought to compare outcomes of using two self-expanding transcatheter heart valve (THV) systems for ViV. METHODS: In this retrospective multicentre registry, we included consecutive patients undergoing transfemoral ViV using either the ACURATE neo/neo2 (ACURATE group) or the Evolut R/PRO/PRO+ (EVOLUT group). The primary outcome measure was technical success according to Valve Academic Research Consortium (VARC)-3. Secondary outcomes were 30-day all-cause mortality, device success (VARC-3), coronary obstruction (CO) requiring intervention, rates of severe prosthesis-patient mismatch (PPM), and aortic regurgitation (AR) ≥moderate. Comparisons were made after 1:1 propensity score matching. RESULTS: The study cohort comprised 835 patients from 20 centres (ACURATE n=251; EVOLUT n=584). In the matched cohort (n=468), technical success (ACURATE 92.7% vs EVOLUT 88.9%; p=0.20) and device success (69.7% vs 73.9%; p=0.36) as well as 30-day mortality (2.8% vs 1.6%; p=0.392) were similar between the two groups. The mean gradients and rates of severe PPM, AR ≥moderate, or CO did not differ between the groups. Technical and device success were higher for the ACURATE platform among patients with a true inner diameter (ID) >19 mm, whereas a true ID ≤19 mm was associated with higher device success - but not technical success - among Evolut recipients. CONCLUSIONS: ViV TAVI using either ACURATE or Evolut THVs showed similar procedural outcomes. However, a true ID >19 mm was associated with higher device success among ACURATE recipients, whereas in patients with a true ID ≤19 mm, device success was higher when using Evolut.
Assuntos
Insuficiência da Valva Aórtica , Bioprótese , Oclusão Coronária , Substituição da Valva Aórtica Transcateter , Humanos , Catéteres , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Valvas Cardíacas , Sistema de Registros , Substituição da Valva Aórtica Transcateter/efeitos adversosRESUMO
We report a case of bioprosthetic valve dysfunction and acute aortic valve regurgitation. The case was a 75-year-old female who had sudden onset chest pain. ST-segment depression in several leads on electrocardiogram( ECG) suggested acute coronary syndrome. Coronary angiography showed no significant stenosis in coronary arteries. Transesophageal echocardiography revealed severe aortic regurgitation, suggesting that angina was caused by myocardial ischemia associated with acute aortic regurgitation. She was diagnosed as having bioprosthetic valve dysfunction, and underwent redo aortic valve replacement. One leaflet of the bioprosthetic valve was torn along the stent post and caused bioprosthetic valve dysfunction. Failed bioprosthetic valve was removed and replaced by a mechanical valve.
Assuntos
Insuficiência da Valva Aórtica , Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Feminino , Humanos , Idoso , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Tórax , Próteses Valvulares Cardíacas/efeitos adversos , Dor no Peito/etiologia , Bioprótese/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversosRESUMO
Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus.