Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center.

Objective: This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system. Methods: A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications. Results: The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients. Conclusions: TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.

Potential benefits of aortic valve opening in patients with left ventricular assist devices.

BACKGROUND: Aortic regurgitation (AR) is a well-known cause of impaired outcome in patients with centrifugal left ventricular assist devices (cfLVADs). The failure of the aortic valve (AV) to open at least intermittently is associated with cusp remodeling, commissural fusion, and ultimately developing AR. Our aim was to characterize patients in whom AV opening (AVO) was preserved 6 months after implantation and identify determinants related to it. METHODS AND RESULTS: We conducted standardized echocardiography and collected clinical and laboratory tests at the outpatient clinic 6 months after implantation. We classified patients into those showing intermittently opening of the AV, every 2-3 beats, or in every cycle (AVO) and those whose AV was continuously closed (NAVO). From the 219 cfLVAD implanted in our center between March 2018 and January 2020, 156 subjects were alive and on the device after 6 months. In 2 of the reviewed echocardiograms, we could not evaluate the AV. 99 patients (64%) showed AVO compared to 55 (36%) with NAVO. The first presented higher mean arterial pressure (84 ± 10 vs. 77 ± 13 mm Hg, p = 0.002), larger LV end-diastolic diameter (LVEDD 57.5 ± 12 vs. 52.7 ± 13 mm, p = 0.022), a better TAPSE (15 ± 4 vs. 13 ± 4 mm, p = 0.028), and less frequently significant AR than patients with NAVO (moderate/severe AR in 6% vs. in 20%, p = 0.042). In a multiple logistic regression, a lower NYHA Class, a larger LVEDD, and a better LV ejection fraction appeared as significant predictors of AVO. After a median follow-up of 3.2 years, we found no significant impact on survival stratifying patients by AVO (log-rank p = 0.53). CONCLUSION: AVO was associated with better RV function, lower NYHA Class, and a lower rate of significant AR. This could indicate that AVO should be pursued in LVAD patients.

Unmasking Rheumatic Heart Disease Decades Later in a Patient With a Remote History of Rheumatic Fever Despite Prolonged Antibiotic Prophylaxis.

Rheumatic heart disease (RHD) is one of the leading causes of valvular heart disease worldwide and still persists in the USA, particularly among vulnerable populations with limited healthcare. Depending on the risk, severity, and types of valve involvement, treatment includes guideline-directed medical therapy (GDMT) and surgical interventions like valve repair or replacement. Here, we present a unique case of a patient in his late fifties who presented with worsening heart failure symptoms and several heart murmurs. A transthoracic echocardiogram (TTE) revealed moderate to severe mitral regurgitation (MR), aortic regurgitation (AR), and mild aortic stenosis (AS) with a bicuspid aortic valve. However, coronary angiography and right heart catheterization showed no blockages, right ventricular dysfunction, or pulmonary hypertension. Furthermore, no valvular vegetation was noticed on the transesophageal echocardiogram. The patient had a history of acute rheumatic fever (RF) in adolescence and was treated until age 21. Despite potential alternative causes like myocardial infarction or endocarditis, the lack of ischemic findings, negative blood cultures, and absence of valvular vegetation suggested that RHD was the possible cause of his valvular issues. This case highlights the rare occurrence of RHD impacting multiple valves despite proper antibiotic prophylaxis and draws attention to the importance of considering RHD when diagnosing multiple valvular problems, as many patients are identified too late for surgical intervention.

Transapical Transcatheter Aortic Valve Replacement Under 3-Dimensional Guidance to Treat Pure Aortic Regurgitation in Patients with a Large Aortic Annulus.

Background: Transcatheter aortic valve replacement (TAVR) is a challenge for patients with aortic regurgitation (AR) and a large annulus. Our goal was to evaluate the clinical outcomes and predictors of transapical TAVR in AR patients with a large annulus and noncalcification and the feasibility and safety of 3-dimensional printing (3DP) in the preprocedural simulation. Methods: Patients with a large annulus (diameter >29 mm) were enrolled and divided into the simulation (n = 43) and the nonsimulation group (n = 82). Surgeons used the specific 3DP model of the simulation group to simulate the main steps before the procedure and to refit the transcatheter heart valve (THV) according to the simulated results. Results: The average annular diameter of the overall cohort was 29.8 ± 0.7 mm. Compared with the nonsimulation group, the simulation group used a higher proportion of extra oversizing for THVs (97.6% vs. 85.4%, p = 0.013), and the coaxiality performance was better (9.7 ± 3.9° vs. 12.7 ± 3.8°, p < 0.001). Both THV displacement and ≥ mild paravalvular leakage (PVL) occurred only in the nonsimulation group (9.8% vs. 0, p < 0.001; 9.8% vs. 0, p < 0.001). Multivariate regression analysis showed that extra oversizing, coaxial angle and annulus diameter were independent predictors of THV displacement and ≥ mild PVL, respectively. Conclusions: Based on 3DP guidance, transapical TAVR using extra oversizing was safe and feasible for patients with noncalcified AR with a large annulus. Extra oversizing and coaxial angle were predictors of postprocedural THV displacement and ≥ mild PVL in such patients.

Silent severe aortic regurgitation due to blunt chest trauma: ignore it at your peril-a case report.

Background: Blunt chest trauma (BCT) presenting to the emergency department is common and may cause life-threatening cardiac complications. Whilst complications causing haemodynamic instability are generally detected promptly, others may present late with long-term consequences. We describe a rare, serious complication of BCT presenting five years after a road traffic accident (RTA). Case summary: A 23-year-old man was incidentally found to have a murmur. Past history was notable only for BCT with rib fracture sustained in a RTA 5 years prior. Examination revealed a hyperdynamic pulse, loud decrescendo diastolic murmur, and Duroziez's sign over the femoral arteries. Echocardiography showed severe valvular aortic regurgitation (AR) from a hole in the left coronary cusp and holodiastolic flow reversal in the descending aorta. The left ventricle (LV) showed marked dilatation in diastole, mild dilatation in systole, and preserved systolic function. The aorta was normal. Severe AR was attributed to his previous BCT, with AR causing subsequent LV dilatation. He underwent aortic valve replacement (AVR) with rapid recovery. He remains well, and his echo shows a well-functioning AVR with normalization of LV dimensions. Discussion: Aortic regurgitation following BCT is rare but well-recognized, most often resulting from RTAs. Only a third of cases are diagnosed acutely. In others, lack of haemodynamic instability means that emergency echocardiography is not routinely performed, such that this may go unrecognized with long-term consequences. Clinicians should be aware of possible valve damage following BCT. Prompt echocardiography should be routinely performed for all BCT at initial presentation, even without haemodynamic instability.

The novel balloon-expandable Myval transcatheter heart valve: systematic review of aortic, mitral, tricuspid and pulmonary indications.

INTRODUCTION AND OBJECTIVES: Myval technology represents the first balloon-expandable alternative since the Edwards system became commercially available. Despite certain controversies, its use has rapidly expanded. We aimed to gather all the available literature regarding its indications and outcomes. METHODS: A comprehensive search of articles published between December 2016 and May 2024 was conducted using BioMedCentral, Google Scholar, and PubMed to evaluate the main outcomes of Myval for native aortic stenosis (AS) (meta-analysis) and off-label uses (systematic review). RESULTS: A total of 151 studies were identified, and 74 were included in the analysis, covering aortic (n = 51), mitral (n = 9), tricuspid (n = 6), and pulmonary (n = 8) valve positions. A meta-analysis of studies on native AS demonstrated that Myval is safe and effective, with a 30-day mortality rate of 1.3%, good hemodynamic performance, low rates of pacemaker implantation (8.8%), and ≥ moderate paravalvular regurgitation (1.3%). Compared with other contemporary devices, Myval was competitive and associated with lower rates of pacemaker implantation. In a systematic review of off-label indications, Myval was also found to be safe and effective. In bicuspid AS, pure regurgitation, and aortic valve-in-valve procedures, success rates were 100%, 92%, and 100%, respectively, with pacemaker rates of 9.9%, 22.2%, and 3%, respectively. For mitral valve-in-valve/in-ring procedures, the success rate was 96.9%, while in tricuspid and pulmonary positions, small case series reported 100% success rates for both, with minimal procedural complications. CONCLUSIONS: Myval technology is safe and effective for the treatment of native valvular disease and dysfunctional prostheses or rings in all heart valve positions, although larger scale studies are warranted.

TAVI complication: Prosthetic valve leaflet dislodgment after post-dilatation.

INTRODUCTION AND IMPORTANCE: Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat severe aortic stenosis. While TAVI is generally safe and effective, it can be complicated by rare adverse events such as prosthetic leaflet dislodgment leading to acute free aortic regurgitation. CASE PRESENTATION: We report the case of a female patient who experienced acute free aortic regurgitation following elective TAVI. This complication arose due to prosthetic leaflet dislodgment after post-dilatation of the implanted valve. The timely identification and management of this rare complication are essential to prevent potentially fatal outcomes. CLINICAL DISCUSSION: The moderate paravalvular regurgitation (PVR) observed in this case was likely caused by the unsealing of heavily calcified aortic valve leaflets. While post-dilatation is a routine practice to optimize valve function, it poses the risk of serious complications, including leaflet dislodgment. Transoesophageal echocardiography (TEE) confirmed the loss of function of the prosthetic leaflet, which was likely exacerbated by aggressive post-dilatation techniques. The use of intravascular lithotripsy could be considered to mitigate the risk of significant PVR by effectively modifying the calcified valve structure. CONCLUSIONS: Acute prosthetic leaflet dislodgment leading to free aortic regurgitation is a very rare but serious complication of TAVI. Early recognition and immediate intervention are crucial to manage this life-threatening event and optimize patient outcomes.

Outcomes of Watchful Waiting Strategy and Predictors of Postoperative Prognosis in Asymptomatic or Equivocally Symptomatic Chronic Severe Aortic Regurgitation With Preserved Left Ventricular Function.

BACKGROUND: The optimal surgical timing for asymptomatic or equivocally symptomatic chronic severe aortic regurgitation with preserved left ventricular ejection fraction remains controversial. METHODS AND RESULTS: Two hundred ten consecutive patients (median age 65 years) with asymptomatic or equivocally symptomatic chronic severe aortic regurgitation and left ventricular ejection fraction ≥50% were registered. First, the treatment plans (aortic valve replacement or watchful waiting) after initial diagnosis were investigated. Then, 2 studies were set: Study A (n=144) investigated the prognosis of patients who were managed under the watchful waiting strategy after initial diagnosis; Study B (n=99) investigated the postoperative prognosis in patients who underwent aortic valve replacement at initial diagnosis or after watchful waiting. The primary outcomes were all-cause death in Study A and postoperative cardiovascular events in Study B. In Study A, 3 died of noncardiovascular causes during a median follow-up of 3.2 years. In Kaplan-Meier analysis, the survival curve was similar to that of an age-sex-matched general population in Japan. In Study B, 9 experienced the primary outcome during a median follow-up of 5.0 years. In Cox regression analysis, preoperative left ventricular end-systolic diameter enlargement (hazard ratio, 1.11; P=0.048) and left ventricular end-systolic diameter >45 mm (hazard ratio, 12.75; P=0.02) were significantly associated with poor postoperative prognosis. In Kaplan-Meier analysis, left ventricular end-systolic diameter >45 mm predicted a higher risk of the primary outcome (P <0.01). CONCLUSIONS: Watchful waiting was achieved safely in asymptomatic or equivocally symptomatic chronic severe aortic regurgitation with preserved left ventricular ejection fraction. Preoperative left ventricular end-systolic diameter >45 mm predicted a poor postoperative outcome and may be an optimal cut-off value for surgical indication.

Current Evidence of Unicuspid Aortic Valve in Young Adults: a Systematic Review and Metanalysis.

Unicuspid aortic valve (UAV) is a rare congenital valvular anomaly, often misdiagnosed as the more prevalent bicuspid aortic valve (BAV). The aim of this study was to explore demographic, clinical characteristics, diagnosis, surgical options, short and long term outcomes of young adults with UAV. A systematic review and meta-analysis of literature were conducted for studies (1971-2024) including patients (≥ 14 years old) with diagnosis of UAV. Among the 2953 studies retrieved, 67 case reports, 6 case series (n=130) and 13 retrospective studies (n=918), were included in the analysis. Data from retrospective studies were aggregated using a random effects model for estimating the pooled risk ratio and mean difference. UAV is mostly unicommissural in adults (mean age 36 years old at diagnosis, 76-79% males). The most common conditions associated in UAV patients were aortic coarctation (from 3.8 to 12%), ventricular septal defect (3%) and Turner syndrome (3%). In general, the diagnosis was performed with TTE and confirmed with TEE (+/- 3D-TEE). The most common types of surgery were AVR. Dilated ascending aorta was described in 44% and 35% of retrospective studies and case reports, respectively. Concomitant ascending aorta replacement/repair was reported 38% and 27% of retrospective studies and case reports, respectively. Overall survival was reported in 3 studies, ranging from 95 to 98% at 10 years. UAV should be considered a separate entity from BAV. Further investigations with regards to the possibility of a familial incidence, associated histopathological changes in the aorta, and ideal follow up and intervention are needed.

Severe aortic valve regurgitation in patient with Takayasu arteritis: a case report.

Background: Takayasu arteritis (TAK) is a systemic non-inflammatory vasculitis that primarily affects large- and medium-sized arteries. Case summary: We report the case of a 57-year-old woman with a history of coronary artery bypass grafting (CABG) 7 years prior, who was referred for a stress echo due to chest pain. Transthoracic echocardiography revealed the left ventricle at the upper limits of normal with preserved contractility, as well as circumferential thickening of the aortic root, causing severe aortic regurgitation (AR). Cardiac computed tomography and angiography demonstrated diffuse thickening of the aortic wall from the aortic root to the descending thoracic aorta, extending to the left carotid artery and significant stenosis of the left subclavian artery. Coronary angiography showed severe narrowing of the left main coronary ostium with ostial stenosis and total occlusion of the right coronary and left internal mammary arteries. Magnetic angiography highlighted thickening of the aortic wall, while no active inflammation was detected on positron emission tomography. These findings suggested Takayasu aortitis with chronic inflammation. Discussion: In young patients, particularly women, who present with angina and coronary ostial stenosis, Takayasu arteritis should be considered in the differential diagnosis. Aortic regurgitation (AR) is a serious complication, and its surgical management can be challenging.

Outcome of Transcatheter Aortic Valve Replacement for Pure Native Aortic Regurgitation in Patients with Pulmonary Hypertension.

Background: In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a pivotal treatment for pure native aortic regurgitation (PNAR). Given patients with severe aortic regurgitation (AR) are prone to suffer from pulmonary hypertension (PH), understanding TAVR's efficacy in this context is crucial. This study aims to explore the short-term prognosis of TAVR in PNAR patients with concurrent PH. Methods: Patients with PNAR undergoing TAVR at Zhongshan Hospital, Affiliated with Fudan University, were enrolled between June 2018 to June 2023. They were categorized based on pulmonary artery systolic pressure (PASP) into groups with or without PH. The baseline characteristics, imaging records, and follow-up data were collected. Results: Among the 103 patients recruited, 48 were afflicted with PH. In comparison to PNAR patients without PH, the PH group exhibited higher rates of renal dysfunction (10.4% vs. 0.0%, p = 0.014), increased Society of Thoracic Surgeons scores (6.4 ± 1.9 vs. 4.7 ± 1.6, p < 0.001), and elevated Nterminal fragment of pro-brain natriuretic peptide (NT-proBNP). Transthoracic ultrasound examination revealed that patients with PH displayed lower left ventricular ejection fraction, larger left ventricle dimension, and more frequent moderate to severe tcuspid regurgitation (TR). Following TAVR, both groups experienced significant reductions in PASP, mitral regurgitation (MR) and TR. There were no significant differences in the incidence of postoperative adverse events in patients with or without PH. Conclusions: We found TAVR to be a safe and effective treatment for patients with PNAR and PH, reducing the degree of aortic regurgitation and PH without increasing the risk of postoperative adverse events.

Transcatheter aortic valve implantation for severe aortic regurgitation using the J-Valve system: A midterm follow-up study.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a well-established intervention for severe aortic valve stenosis. However, its application for severe aortic regurgitation (AR) is still under evaluation. This study aims to present the 3-year follow-up outcomes of the J-Valve system in managing severe AR. AIMS: The aim of this study was to evaluate the mid-term efficacy and durability of the J-Valve system in the treatment of severe AR and to provide new information on this intervention. METHODS: In this retrospective, single-center study, we evaluated the prognostic outcomes of patients with AR, who underwent treatment with the J-Valve system at Nanjing Drum Tower Hospital. Consecutive patients who were treated with the J-Valve were included in the analysis. The study focused on the echocardiographic follow-up to assess the effectiveness and durability of the J-Valve system in managing AR. RESULTS: From January 2018 to December 2022, 36 high-risk AR patients treated with the J-Valve system had a procedural success rate of 97.2%, with one case requiring open-heart surgery due to valve displacement. Significant improvements were observed in left ventricular diameter (from 63.50 [58.75-69.50] mm to 56.50 [53.00-60.50] mm, p < 0.001) and left atrial diameter (from 44.00 [40.00-45.25] mm to 39.00 [36.75-41.00] mm, p = 0.003) postsurgery. All patients completed the 1-year follow-up, with an overall mortality rate of 2 out of 36 (5.6%). Among the surviving patients, there was one case of III° atrioventricular block and one case of stroke, both occurring within 90 days postsurgery. After a 3-year follow-up, 15.0% of patients had mild or moderate valvular regurgitation, with no cases of moderate or severe paravalvular leak. Additionally, 89.5% of patients were classified as New York Heart Association class I or II, showing significantly enhanced cardiac function. CONCLUSION: The J-Valve system has shown positive therapeutic outcomes in treating AR, with notable effectiveness in managing the condition and significant improvements in heart failure symptoms and cardiac remodeling. However, due to the limited sample size and partial follow-up data, it is important to emphasize the need for further research with comprehensive long-term follow-up, to fully validate these results.

Cardiac Magnetic Resonance for Structural Aortic Valve Stenosis Procedures.

The number of structural aortic valve procedures has increased significantly in recent years. Pre-procedural planning and follow-up with noninvasive testing are essential. Although cardiac magnetic resonance (CMR) is the gold standard for assessing left ventricular mass, volume, and function, it is not performed routinely in patients undergoing structural interventions. CMR can provide useful information for pre- and post-procedural assessment, including quantification of cardiac function, myocardial assessment, grading of the severity of valvular heart disease, and evaluation of extracardiac anatomy while avoiding the limitations of other non-invasive modalities. Here, we review the use cases, future perspectives, and limitations of CMR for patients undergoing structural aortic valve procedures.

A Coronary-Friendly Device Mitigating Risk of Coronary Obstruction in Transcatheter Aortic Valve Replacement.

Purpose: Transcatheter aortic valve replacement (TAVR) induced coronary artery obstruction (CAO) is a rare but devastating complication. Current preventive strategies need additional procedures and may be associated with adverse events. This study aimed to evaluate the early safety and efficacy of stand-alone TAVR using the J-Valve (Jianshi JieCheng Medical Technology Co. Ltd, Shanghai, China) in patients at potential high risk for CAO. Patients and Methods: CAO was defined as coronary ostia obstruction requiring intervention. Patients at potential high risk for CAO were identified retrospectively from 673 consecutive patients who underwent TAVR from January 2015 to July 2021 at Zhongshan Hospital, Fudan University. Procedural results and early outcomes were evaluated according to Valve Academic Research Consortium-3 definitions. Results: A total of 20 consecutive patients (age 72 ± 9 years; 85% female;) were included. The Society of Thoracic Surgeons-Predicted Risk of Mortality was 5% (interquartile range, 4 to 10%). All patients (100%) had at least 2 classical risk factors for CAO by pre-procedural computed tomography analysis, and 90% patients had native aortic valve diseases. TAVR was successful in 95% of cases, with only 1 patient requiring second device implantation. Early safety at 30 days was achieved in all cases without death. All patients were free from CAO, stroke or emergency reintervention. Post-procedural mean aortic valve gradient was 7 (interquartile range, 4, 12) mmHg, and none/trace or mild aortic regurgitation was present in all patients. Conclusion: Stand-alone TAVR using the J-Valve may mitigate the risk of TAVR-induced CAO.

Aortic regurgitation in left ventricular assist device patients - Does aortic root dilatation contribute to valve incompetence?

BACKGROUND: Aortic regurgitation (AR) is a known complication after left ventricular assist device (LVAD) implantation potentially leading to recurrent heart failure. Possible pathomechanisms include valvular pathologies and aortic root dilatation. We assessed aortic root dimensions in a group of consecutive LVAD patients who received HeartMate 3. METHODS: Since 11/2015, we identified 68 patients with no or mild AR at the time of HeartMate 3 implantation who underwent serial echocardiography to assess AR and aortic root dimensions (annulus, sinus, and sinotubular junction). Median follow-up was 40 months (2-94 months). Results were correlated with clinical outcomes. RESULTS: Patients were 60 ± 10 years old, predominantly male (88%) and 35% presented in preoperative critical condition as defined by INTERMACS levels 1 and 2. During follow-up, 23 patients developed AR ≥ II (34%). Actuarial incidence was 8% at 1 year, 29% at 3 years and 41% at 5 years. Echocardiography revealed practically stable root dimensions at the latest follow-up compared to the preoperative state (annulus: 23 ± 3 mm vs. 23 ± 2 mm, sinus: 32 ± 4 mm vs. 33 ± 3 mm, sinotubular junction: 27 ± 3 mm vs. 28 ± 3 mm), irrespective of the development of AR. Serial CT angiograms were performed in 13 patients to confirm echocardiographic findings. Twenty-one patients died during LVAD support leading to a 5-year survival of 71%, showing no difference between patients with and without AR ≥ II (p = 0.573). CONCLUSIONS: At least moderate AR develops over time in a substantial fraction of patients (one-third over 3 years). The mechanism does not seem to be related to dilatation of the aortic annulus or root.

Recovery of left ventricular function after surgery for aortic and mitral regurgitation with heart failure.

Background: Severe aortic regurgitation (AR) and mitral regurgitation (MR) can lead to left ventricular (LV) systolic dysfunction; however, there are limited data about recovery of LV after surgery for AR or MR. Little is known to guide the management of combined AR and MR (mixed valvular heart disease [VHD]). This study is sought to investigate the predictors of postoperative LV function recovery in left-sided regurgitant VHD with reduced left ventricular ejection fraction (LVEF), especially for mixed VHD. Methods: From 2010 to 2020, 2053 adult patients underwent aortic or mitral valve surgery at our center. The patients with valvular stenosis, infective endocarditis, concomitant revascularization, and preoperative LVEF ≥40 % were excluded. A total of 127 patients were included in this study: 22 patients with predominant AR (AR group), 64 with predominant MR (MR group), and 41 with combined AR and MR (AMR group). Results: The mean preoperative LVEF was 32.4 %, 30.7 %, and 30.2 % (p = 0.44) in the AR, MR, and AMR groups, respectively. The AR group was more likely to have postoperative LVEF recovery. The cut-point of left ventricular end-systolic diameter (LVESD) for better recovery was 49 mm for the MR group and 58 mm for the AMR group. Conclusion: LV dysfunction due to combined AR and MR has similar remodeling reserve as AR, and better recoverability than MR. Thus, double-valve surgery is recommended before the LVESD is > 58 mm.

Quantitative Aortography Analysis of JenaValve's Trilogy Transcatheter Aortic Valve Implantation System in Patients With Aortic Regurgitation or Stenosis.

Background: JenaValve's Trilogy transcatheter heart valve (THV) (JenaValve Inc, Irvine, CA) is the only conformité européenne-marked THV system for the treatment of aortic regurgitation (AR) or aortic stenosis (AS). However, its efficacy has not been quantitatively investigated pre- and post-implantation using video-densitometric analysis. Methods: Using the CAAS-A-Valve 2.1.2 software (Pie Medical Imaging, Maastricht, the Netherlands), an independent core lab retrospectively analyzed the aortograms of 88 consecutive patients (68 severe AR; 20 severe AS) receiving the JenaValve THV in three European centers. Video-densitometric AR was categorized by the regurgitant fraction (RF) as none/trace AR (RF ≤ 6%), mild (6% < RF ≤ 17%), and moderate/severe AR (RF > 17%). Results: Pre- and post-THV aortograms were analyzable in 17 (22.4%) and 47 (54.0%) patients, respectively. The main reasons preventing analysis were the descending aorta overlap of the outflow tract (30%) and insufficient frame count (6%). The median RF pre- and post-THV implant was 31.0% (interquartile range 21.5-38.6%) and 5.0% (interquartile range 1.0-7.0%, p < 0.001), respectively. The post-THV incidence of none/trace AR was 72.3%, and of mild AR, 27.7%, with no cases of moderate/severe AR. Video-densitometry analysis of the 12 AR cases with paired pre- and post-THV showed a reduction in the RF of 21.8% ± 8.1%. Conclusions: Quantitative aortography confirms the low rates of AR and the large reduction in RF following the implantation of Jenavalve's Trilogy THV, irrespective of implant indication. However, these limited data need corroborating in prospective studies using standardized acquisition protocols.