Facilitating right-sided axillary artery access for transcatheter aortic valve replacement using the Edwards Sapien 3 and ultra valves: Technical considerations.

Trans-Axillary Transcatheter Aortic Valve Replacement (TAVR) has become established as the safest arterial approach when femoral arterial anatomy is unfavorable. Although a left sided axillary approach is generally preferred, patient specific factors may require use of the right axillary artery. In this case series we describe procedural modifications that are required to overcome the challenge of restricted space in the ascending aorta for in situ valve preparation of balloon-expandable valve systems when a right sided trans-Axillary approach is taken. These steps permit implantation of both the Edwards LifeSciences Sapien 3 and Ultra prostheses via the right trans-Axillary approach, allowing patients a greater range of valve options when this arterial route is required for TAVR.

Successful Treatment of Very Early Thrombosis of SAPIEN 3 Valve with Direct Oral Anticoagulant Therapy.

Thrombosis of transcatheter aortic valve implantation (TAVI) is an uncommon complication that commonly occurs weeks to months following the procedure. Herein are described the details of a patient who presented with a recurrence of symptoms days after intervention with a bioprosthesis thrombosis that was successfully treated with direct oral anticoagulant (DOAC) therapy and resulted in hemodynamic improvement and resolution of symptoms. Whilst a previous trial of DOAC therapy with mechanical valves was stopped due to elevated events in comparison to warfarin, a TAVI valve may be different, and the rapid onset of action and reduced bleeding risk may be beneficial in this patient group.

Arterial pulse wave dynamics after percutaneous aortic valve replacement: fall in coronary diastolic suction with increasing heart rate as a basis for angina symptoms in aortic stenosis.

BACKGROUND: Aortic stenosis causes angina despite unobstructed arteries. Measurement of conventional coronary hemodynamic parameters in patients undergoing valvular surgery has failed to explain these symptoms. With the advent of percutaneous aortic valve replacement (PAVR) and developments in coronary pulse wave analysis, it is now possible to instantaneously abolish the valvular stenosis and to measure the resulting changes in waves that direct coronary flow. METHODS AND RESULTS: Intracoronary pressure and flow velocity were measured immediately before and after PAVR in 11 patients with unobstructed coronary arteries. Using coronary pulse wave analysis, we calculated the intracoronary diastolic suction wave (the principal accelerator of coronary blood flow). To test physiological reserve to increased myocardial demand, we measured at resting heart rate and during pacing at 90 and 120 bpm. Before PAVR, the basal myocardial suction wave intensity was 1.9±0.3×10(-5) W · m(-2) · s(-2), and this increased in magnitude with increasing severity of aortic stenosis (r=0.59, P=0.05). This wave decreased markedly with increasing heart rate (ß coefficient=-0.16×10(-4) W · m(-2) · s(-2); P<0.001). After PAVR, despite a fall in basal suction wave (1.9±0.3 versus 1.1±0.1×10(-5) W · m(-2) · s(-2); P=0.02), there was an immediate improvement in coronary physiological reserve with increasing heart rate (ß coefficient=0.9×10(-3) W · m(-2) · s(-2); P=0.014). CONCLUSIONS: In aortic stenosis, the coronary physiological reserve is impaired. Instead of increasing when heart rate rises, the coronary diastolic suction wave decreases. Immediately after PAVR, physiological reserve returns to a normal positive pattern. This may explain how aortic stenosis can induce anginal symptoms and their prompt relief after PAVR. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01118442.

Contribution of NOTCH1 genetic variants to bicuspid aortic valve and other congenital lesions.

INTRODUCTION: Bicuspid aortic valve (BAV) affects 1% of the general population. NOTCH1 was the first gene associated with BAV. The proportion of familial and sporadic BAV disease attributed to NOTCH1 mutations has not been estimated. AIM: The aim of our study was to provide an estimate of familial and sporadic BAV disease attributable to NOTCH1 mutations. METHODS: The population of our study consisted of participants of the University of Leicester Bicuspid aoRtic vAlVe gEnetic research-8 pedigrees with multiple affected family members and 381 sporadic patients. All subjects underwent NOTCH1 sequencing. A systematic literature search was performed in the NCBI PubMed database to identify publications reporting NOTCH1 sequencing in context of congenital heart disease. RESULTS: NOTCH1 sequencing in 36 subjects from 8 pedigrees identified one variant c.873C>G/p.Tyr291* meeting the American College of Medical Genetics and Genomics criteria for pathogenicity. No pathogenic or likely pathogenic NOTCH1 variants were identified in 381 sporadic patients. Literature review identified 64 relevant publication reporting NOTCH1 sequencing in 528 pedigrees and 9449 sporadic subjects. After excluding families with syndromic disease pathogenic and likely pathogenic NOTCH1 variants were detected in 9/435 (2.1%; 95% CI: 0.7% to 3.4%) of pedigrees and between 0.05% (95% CI: 0.005% to 0.10%) and 0.08% (95% CI: 0.02% to 0.13%) of sporadic patients. Incomplete penetrance of definitely pathogenic NOTCH1 mutations was observed in almost half of reported pedigrees. CONCLUSIONS: Pathogenic and likely pathogenic NOTCH1 genetic variants explain 2% of familial and <0.1% of sporadic BAV disease and are more likely to associate with tetralogy of Fallot and hypoplastic left heart.

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study).

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. METHODS AND RESULTS: Our cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). CONCLUSIONS: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

COVID-19 and its impact on the cardiovascular system.

OBJECTIVES: The clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK. METHODS: We retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention. RESULTS: Mean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angiography, two underwent percutaneous coronary intervention and one required a permanent pacemaker implantation. 7.0% (n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39, 95% CI 1.31 to 4.40, p=0.005) and history of hypertension (OR 1.88, 95% CI 1.01 to 3.55, p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for. CONCLUSION: Hypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision.

BACKGROUND: Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms. METHOD: Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography. RESULTS: There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S' velocities 3% +/- 2% (P = not significant). Within the first 3 minutes of opening the pericardium, RV PW TD S' velocities had reduced by 43% +/- 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% +/- 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S' reduction being 61% +/- 11% (P < .0001). One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% +/- 12% (P < .0001) reduction in RV S' velocities compared with preoperative values. CONCLUSIONS: Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence.

BACKGROUND: Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue. METHODS: Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons. RESULTS: As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003]). CONCLUSION: In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out.

Rescue Valve-in-Valve-in-Valve TAVR for Acute Transvalvular Aortic Regurgitation.

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for severe symptomatic aortic stenosis (Leon et al., 2016), and recently has also been utilised for bioprosthetic surgical aortic valve (sAVR) failure (valve-in-valve TAVR (ViV-TAVR)) (Yoon et al., 2017; Nalluri et al., 2018). Data supporting ViV-TAVR are limited to observational studies but suggest similar outcomes to re-do sAVR in high risk patients (Barbanti et al., n.d.). Whilst bioprosthetic SAVR failure is well documented, TAVR failure is less well described (Barbanti et al., n.d.). Here, we describe a case of TAVR failure in a previous sAVR resulting in the need for emergent valve-in-valve-in-valve TAVR (ViViV-TAVR).

Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses: A Multicenter Study Using Intracoronary Pressure and Flow.

BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2). RESULTS: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74. CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.

Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: Insights from serial coronary wave intensity analysis.

AIM: Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous haemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary "suction" force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave intensity analysis (WIA) to separate and measure the sequential effects of outflow tract obstruction relief and then LVH regression following intervention for aortic stenosis. METHODS: Fifteen patients with unobstructed coronary arteries undergoing aortic valve intervention (11 surgical aortic valve replacement [SAVR], 4 TAVI) were successfully assessed before and after intervention, and at 6 and 12 months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial cuff system. RESULTS: Immediately following intervention, a decline in the backward decompression wave (BDW) was noted (9.7 ± 5.7 vs 5.1 ± 3.6 × 103  W/m2 /s, P < 0.01). Over 12 months, LV mass index fell from 114 ± 19 to 82 ± 17 kg/m2 . Accompanying this, the BDW fraction increased to 32.8 ± 7.2% at 6 months (P = 0.01 vs post-procedure) and 34.7 ± 6.7% at 12 months (P < 0.001 vs post-procedure). CONCLUSION: In aortic stenosis, both the outflow tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features.

Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity.

OBJECTIVES: In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve. BACKGROUND: A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied. METHODS: Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR. RESULTS: Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001). CONCLUSIONS: Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.

Female-specific survival advantage from transcatheter aortic valve implantation over surgical aortic valve replacement: Meta-analysis of the gender subgroups of randomised controlled trials including 3758 patients.

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is the first area of interventional cardiology where women are treated as often as men. In this analysis of the gender specific results of randomised controlled trials (RCTs) comparing TAVI with surgical aortic valve replacement (SAVR) we aimed to determine whether gender affects the survival comparison between TAVI and SAVR. We identified all RCTs comparing TAVI versus SAVR for severe AS and reporting 1 and/or 2year survival. Summary odds ratios (ORs) were obtained using a random-effects model. Heterogeneity was assessed using the Q statistic and I2. Four RCTs met the criteria, totalling 3758 patients, 1706 women and 2052 men. Amongst females, TAVI recipients had a significantly lower mortality than SAVR recipients, at 1year (OR 0.68; 95%CI 0.50 to 0.94) and at 2years (OR 0.74; 95%CI 0.58 to 0.95). Amongst males there was no difference in mortality between TAVI and SAVR, at 1year (OR 1.09; 95%CI 0.86 to 1.39) or 2years (OR 1.05; 95%CI 0.85 to 1.3). The difference in treatment effect between genders was significant at both 1year (pinteraction=0.02) and 2years (pinteraction=0.04). In women TAVI has a 26 to 31% lower mortality odds than SAVR. In men, there is no difference in mortality between TAVI and SAVR.

Valve surgery in octogenarians: a safe option with good medium-term results.

BACKGROUND AND AIM OF THE STUDY: The number of octogenarians is increasing in industrialized societies, and many patients aged over 80 years have heart valve disease which is amenable to surgical treatment. The perioperative outcomes and long-term results in very elderly patients undergoing valve surgery were evaluated. METHODS: A retrospective analysis was conducted of 2,791 patients with long-term follow up, who underwent valve surgery between 1990 and 2002. Of these patients, 132 (68 males, 64 females) were aged over 80 years (mean age 82 +/- 2 years; range: 80-94 years). RESULTS: Ninety-five patients (71.9%) underwent aortic valve replacement, 36 (27.3%) mitral surgery, and one patient had double-valve surgery. Sixty-five patients (49.2%) required concomitant coronary artery bypass grafting. There were 11 (8.3%) redo procedures. Patients aged over 80 years were significantly more symptomatic preoperatively than their younger counterparts (NYHA class III-IV 90.9% versus 69.0%, p < 0.001), with more congestive cardiac failure, hypertension, peripheral vascular disease, obstructive pulmonary disease, and renal failure (all p < 0.05). Perioperative mortality did not, however, differ significantly between groups (< 80 years versus > or = 80 years, 2.9% versus 4.6%, p = 0.10). There was also no difference in the composite end point of in-hospital death, renal failure, stroke, low output state, myocardial infarction, or sternal wound infection (< 80 years versus > or = 80 years, 10.5% versus 11.4%, p = 0.8). The mean follow up period was 66 +/- 44 months (< 80 years) versus 61 +/- 37 (> or = 80 years). Late mortality was higher in the elderly group (10-year survival 37.9% versus 68.2%, p < 0.001) and preoperative atrial fibrillation (RR 2.75; CI: 1.44-5.23), coronary artery disease (RR 1.98; CI 1.12-3.52) and congestive cardiac failure (RR 2.13; CI: 1.10-4.11) were independent predictors of late mortality. The groups did not differ with respect to long-term valve-related events, with the exception of fewer reoperations among elderly patients. CONCLUSION: Valve surgery in selected octogenarians is associated with low morbidity and mortality. The outlook after surgery is very good, and surgery should not be denied to this group on the basis of age alone.

Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function.

BACKGROUND: The natural history of aortic valve disease associated with ventricular dysfunction is dismal. Aortic valve replacement (AVR) is associated with increased mortality in patients with left ventricular dysfunction and the long-term outcome in these patients is not well-known. We evaluated perioperative outcomes and long-term results in patients with impaired left ventricular systolic function undergoing AVR. METHODS: Retrospective analysis identified 132 consecutive patients with a left ventricular ejection fraction (LVEF)<40% who underwent AVR with or without concomitant coronary artery bypass grafting (CABG) between 1990 and 2003. Patients with other valve pathology were excluded. RESULTS: Ages ranged from 29 to 94 years (mean 63+/-12), and 117 patients (89%) were male. Preoperatively, 82% were in NYHA III-IV. Sixty patients (45%) underwent AVR for severe aortic stenosis (AS) whilst 72 (55%) had aortic insufficiency (AI). In the AS group, the mean LVEF and aortic valve area were 26+/-4% and 0.8+/-0.4 cm(2), respectively. AI patients had a mean LVEF of 27+/-6% and a mean left ventricular end systolic diameter of 52+/-9 mm. Fifty-seven (43%) required concomitant CABG. There were only three perioperative deaths (2.3%) and no strokes. One patient (0.8%) had postoperative renal failure, and one suffered a myocardial infarct. Nine patients (6.9%) required a postoperative IABP. LVEF increased to 29+/-10% and 34+/-12% after six months in the AS and AI groups, respectively. The mean follow-up period was 6.1 years and no differences between the AS and AI groups were observed with respect to either perioperative or long-term outcomes. Overall survival was 96%, 79% and 55% at 1, 5 and 10 years, respectively. CONCLUSIONS: The long asymptomatic course of AS and AI means that many patients have impaired ventricular function at diagnosis. This study demonstrates that AVR in such patients can be performed with low perioperative morbidity and mortality. The outlook after surgery is excellent. A 10-year-survival of 55% compares favourably with heart transplantation and particularly with medical therapy. AVR is a safe, effective and durable option, which should not be denied to patients on the basis of low LVEF alone.

Transfemoral Valve-in-Valve Transcatheter Aortic Valve Implantation (TAVI) in a Patient With Previous Endovascular Aortic Repair (EVAR).

A 90-year-old man presented with increasing exertional breathlessness. He had previous implantation of a Perimount bioprosthetic aortic valve (Edwards Lifesciences) and coronary artery bypass graft surgery. Due to severe transvalvular bioprosthetic regurgitation with preserved left ventricular dimensions and ejection fraction, the heart team decided on valve-in- valve transcatheter aortic valve implantation via the transfemoral route in view of the patient's prohibitively high surgical and anesthetic risk. The patient had an uncomplicated recovery and was symptomatically much improved at 3-month follow-up.

Impact of clinical and procedural factors upon C reactive protein dynamics following transcatheter aortic valve implantation.

AIM: To determine the effect of procedural and clinical factors upon C reactive protein (CRP) dynamics following transcatheter aortic valve implantation (TAVI). METHODS: Two hundred and eight consecutive patients that underwent transfemoral TAVI at two hospitals (Imperial, College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom and San Raffaele Scientific Institute, Milan, Italy) were included. Daily venous plasma CRP levels were measured for up to 7 d following the procedure (or up to discharge). Procedural factors and 30-d safety outcomes according to the Valve Academic Research Consortium 2 definition were collected. RESULTS: Following TAVI, CRP significantly increased reaching a peak on day 3 of 87.6 ± 5.5 mg/dL, P < 0.001. Patients who developed clinical signs and symptoms of sepsis had significantly increased levels of CRP (P < 0.001). The presence of diabetes mellitus was associated with a significantly higher peak CRP level at day 3 (78.4 ± 3.2 vs 92.2 ± 4.4, P < 0.001). There was no difference in peak CRP release following balloon-expandable or self-expandable TAVI implantation (94.8 ± 9.1 vs 81.9 ± 6.9, P = 0.34) or if post-dilatation was required (86.9 ± 6.3 vs 96.6 ± 5.3, P = 0.42), however, when pre-TAVI balloon aortic valvuloplasty was performed this resulted in a significant increase in the peak CRP (110.1 ± 8.9 vs 51.6 ± 3.7, P < 0.001). The development of a major vascular complication did result in a significantly increased maximal CRP release (153.7 ± 11.9 vs 83.3 ± 7.4, P = 0.02) and there was a trend toward a higher peak CRP following major/life-threatening bleeding (113.2 ± 9.3 vs 82.7 ± 7.5, P = 0.12) although this did not reach statistical significance. CRP was not found to be a predictor of 30-d mortality on univariate analysis. CONCLUSION: Careful attention should be paid to baseline clinical characteristics and procedural factors when interpreting CRP following TAVI to determine their future management.

NR2 antibody is associated with quality of life in aortic valve replacement.

BACKGROUND: The relationship between the potential brain injury biomarker N-methyl-D-aspartate receptor antibody and quality of life has never been assessed. METHODS: We measured serum N-methyl-D-aspartate receptor antibody levels preoperatively in patients undergoing aortic valve replacement. Quality of life was scored using the Short Form-36 and European Quality of Life 5-Dimensions questionnaires pre- and postoperatively. We analyzed the antibody levels as a continuous variable and as a dichotomous variable with 1.8 ng mL(-1) as the cutoff. RESULTS: Fifty-two patients (15 females) with a mean age of 71 ± 8.4 years were recruited for this study. Forty-eight (92%) patients attended the follow-up visit (405 ± 161 days). No mortality or severe neurological event was recorded. In both quality-of-life instruments, the low antibody level group (n = 35) had significantly better scores than the high antibody level group (n = 17) preoperatively. Postoperatively, the scores for both groups improved; however, the low antibody level group continued to score significantly better in most of the physical and mental health domains (p = 0.04 to <0.001). Multiple regression analyses revealed that antibody level and the 1.8 ng mL(-1) cutoff were independently related to quality of life (pre- and postoperatively). CONCLUSIONS: Higher N-methyl-D-aspartate receptor antibody levels in aortic valve replacement patients are independently related to poorer quality of life pre- and postoperatively.

Aortic Stiffness Is Related to the Ischemic Brain Injury Biomarker N-Methyl-D-aspartate Receptor Antibody Levels in Aortic Valve Replacement.

Background. Aortic stiffness changes the flow pattern of circulating blood causing microvascular damage to different end-organ tissues, such as brain cells. The relationship between aortic stiffness measured by pulse wave velocity (PWV) and serum ischemic brain injury biomarker N-methyl-D-aspartate receptor antibody (NR2Ab) levels in aortic valve replacement has not been assessed. Methods. Patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS) had their PWV and NR2Ab serum levels measured preoperatively. We analyzed PWV and NR2Ab in two ways: (1) as continuous variables using the actual value and (2) as dichotomous variables (PWV-norm and PWV-high groups) and (NR2Ab-low and NR2Ab-high groups). Results. Fifty-six patients (71 ± 8.4 years) were included in this study. The NR2Ab level (ng/mL) was significantly higher in the PWV-high group (n = 21) than in PWV-norm group (n = 35; median 1.8 ± 1.2 versus 1.2 ± 0.7, resp., P = 0.003). NR2Ab level was positively associated with PWV and negatively associated with male gender. Multiple regression revealed PWV independently related to NR2Ab level, and PWV cut-off was associated with a 7.23 times increase in the likelihood of having high NR2Ab (>1.8 ng/mL). Conclusion. Higher PWV in patients with surgical aortic stenosis is associated with higher levels of the ischemic brain biomarker NR2Ab.