The role of surgical transcatheter valve implantation for the treatment of severe mitral annular calcification.

With a rise in the aging population, mitral annular calcification is increasingly encountered with an incidence of 10% in over 70 years old. This with increasing patient comorbidities presents a technical challenge due to the risk of atrioventricular disruption which is associated with high operative mortality of up to 75%. We describe two cases of severe mitral disease with marked annular calcification successfully treated with a balloon expandable transcatheter valve which was deployed on cardiopulmonary bypass via a trans-atrial approach.

A pathway to earlier discharge following TAVI: Assessment of safety and resource utilization.

INTRODUCTION: There is considerable variability within the population of patients treated with transcatheter aortic valve implantation (TAVI), the procedural approach and time to discharge. In Belfast, from the commencement of our program, our approach has been to perform TAVI by the least invasive approach, where feasible, utilizing a percutaneous transfemoral route and local anesthetic. By analyzing our Belfast TAVI database we identified factors that predicted shorter admission times without impacting adversely on patient safety. Following this, we developed an early discharge pathway. The aim of this current study was to perform a prospective analysis of outcomes in our unit since implementation of this pathway assessing discharge time, mortality, serious adverse events, readmission, and resource implications for patients according to time to discharge. METHODS: Consecutive patients who underwent TAVI and were successfully discharged from 2013 to 2014 over a 14 month period were included, and analyzed according to time to discharge. Baseline and procedural characteristics, mortality, serious adverse events, readmission, and cost were assessed. RESULTS: In total 120 patients were included, 26 (21.7%) were discharged the same/next day, 39 (32.5%) early (>1-4 days), and 55 (45.8%) discharged in the late group. There was no significant difference in baseline or preprocedural characteristics. The incidence of complications was low, and there was no difference in 30-day mortality (P = 0.167) or readmission rates between groups (P = 0.952). Resource analysis revealed the late discharge group cost £3,091.6 more per patient per TAVI than same/next day discharge group. CONCLUSION: Same/next day discharge can be performed safely in appropriately selected patients. Although this will be achieved in a minority of patients (21.7% in this study using an early discharge pathway) it has potential for resource and cost savings. © 2015 Wiley Periodicals, Inc.

Carotid-access transcatheter aortic valve replacement in a patient with a previous mitral valve replacement.

We describe a case of transcatheter aortic valve replacement (TAVR) using carotid artery access and regional anesthesia in a patient with rheumatic heart disease, previous mitral valve replacement, and multiple co-morbidities. It highlights the role of the multidisciplinary Heart Team and multimodality imaging in reaching and implementing an appropriate management plan in this complex patient group.

Early experience of implantation of the new CoreValve(®) Evolut(™) in degenerated bioprosthetic aortic valves.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis in high-risk patients. The PARTNER trial demonstrated equivalent 1-year survival rates between patients randomized to TAVI versus conventional surgery (Leon et al., N Engl J Med 2010;363:1597-1607), with sustained benefit up to 2 years (Makkar et al., NEJM 2012;366:1696-1704). Recently, the ADVANCE registry cited all-cause mortality rates of 4.5%, 12.8%, and 17.9% at 30-days, 6 months, and 1-year following TAVI in 1,015 high-risk patients (Linke, TCT 2012, 2012). In addition, TAVI was demonstrated to be a feasible treatment for severe native valve regurgitation in a series of 31 high-risk patients. The all-cause 30-day mortality rate was 6.4%, with a 30-day major stroke rate of 6.4%. At 1-year, the all-cause mortality rate was 12.5% (Roy et al., J Am Coll Cardiol 2012;60(17S):B264). We report the successful transcatheter implantation of the new CoreValve(®) Evolut(™) in two patients with regurgitant aortic bioprostheses.

Direct aortic TAVI via anterior right mini-thoracotomy using 32 mm myval for pure aortic regurgitation.

BACKGROUND: Aortic regurgitation with dilated annulus presents a technical challenge for conventional transcatheter aortic valve implantation (TAVI) procedures. CASE PRESENTATION: We report a case of an 84-year-old frail patient with a history of breathlessness found to have severe aortic regurgitation and moderately impaired left ventricular systolic function. The patient underwent a successful TAVI procedure using the XL-Myval 32 mm transcatheter heart valve (THV) via an anterior right mini-thoracotomy with a direct aortic approach. The patient recovered well post-operatively with good hemodynamic resolution. CONCLUSIONS: This first in human case highlights the efficacy and potential of applying innovative approaches, such as the new sizes of Myval THV and direct aortic access via anterior right mini thoracotomy, in addressing challenging anatomical variations in TAVI procedures with good outcome.

A very rare case of incidental aortic valve fibrolipoma.

Cardiac valve fibrolipomas are extremely rare. We report a case of a 38-year-old female initially presenting with palpitations and moderate aortic incompetence who was found to have a lipomatous growth of the aortic valve. She underwent aortic valve repair with good postoperative results. Histopathogy verified the lesion as a fibrolipoma. This is the first reported case of fibrolipoma in the aortic valve, whilst aiming to consider repair as a surgical option in young patients with such growths.

Concomitant use of Sapien 3 transcatheter valve for severe MAC with Intuity Elite rapid deployment valve for aortic stenosis.

BACKGROUND: Concomitant double valve pathology in the presence of severe MAC poses significant technical challenges when planning surgical intervention. With continued evolution of valve prosthesis, innovative techniques can be considered with the potential for additional therapeutic benefit. CASE PRESENTATION: We present a novel technique of using a rapid deployment surgical aortic valve in combination with open surgical transcatheter mitral valve implantation (TMVI) for severe Mitral Annular Calcification (MAC). The Intuity Elite rapid deployment prosthesis (Edwards Lifesciences, Irvine, CA) was used concomitantly with the Sapien 3 (Edwards Lifesciences, Irvine, CA) transcatheter prosthesis trans-atrially on cardiopulmonary bypass in a patient with critical aortic stenosis and moderate-severe mixed mitral valve disease in the setting of severe MAC (off-label use). CONCLUSIONS: We demonstrate how both technologies can, not only be accommodated, but indeed complement each other achieving an excellent outcome in a high-risk patient.

The figure-of-8 aortic valve suturing technique optimizes the effective orifice area of a small aortic annulus-an ex vivo study.

OBJECTIVES: Surgical aortic valve replacement (SAVR) in small annuli carries an elevated risk for the patient-prosthesis mismatch. In this study, we systematically investigated the influence of different implantation techniques including annular enlargement (AE) on the functional result after SAVR in small annuli using a standardized ex vivo model. METHODS: SAVR using the PERIMOUNT Magna Ease® (PME) 21 mm was performed in small porcine aortic roots using 4 implantation techniques: non-everting pledgeted (NE) suture, single interrupted (SI) suture, continuous suture (CS), figure-of-8 (F8) suture, as well as the PME 23 mm after AE using the Nunez method and the NE suture technique (PME23 AE). The effective orifice area (EOA), mean pressure gradient and leakage volume were evaluated using a mock circulation loop in accordance with ISO regulations. RESULTS: Experiments were conducted on 31 porcine aortic roots. PME21 using F8 and PME23 after AE achieved a significantly larger EOA than using NE. PME23 after AE showed a larger EOA than the PME21 using any suture technique, except the F8 [for stroke volume of 74 ml: PME21 NE: 1.68 (1.63-1.72) cm2, PME21 SI: 1.76 (1.68-1.81) cm2 (P = 0.17), PME21 CS: 1.76 (1.65-1.79) cm2 (P = 0.14), PME21 F8: 1.81 (1.70-1.85) cm2 (P = 0.005); PME23 AE: 1.83 (1.73-1.92) cm2 (P < 0.001)]. SI and CS did not result in larger EOA compared with the NE technique. PME21 using SI had a significantly larger leakage volume than using NE and there was no significant difference between other techniques [for stroke volume of 74 ml: PME21 NE: 3.51 (1.85-4.53) ml/stroke, PME21 SI: 6.00 (4.02-7.06) ml/stroke (P < 0.001), PME21 CS: 4.04 (3.60-4.49) ml/stroke (P = 0.10), PME21 F8: 3.16 (1.99-3.62) ml/stroke (P = 0.74), PME23 NE: 2.89 (2.45-4.72) ml/stroke (P = 0.51)]. CONCLUSIONS: The F8 technique with the PME21 achieved a similar EOA as the 1 size larger PME23 using NE after AE. These results suggest that the F8 technique may be an effective surgical modification to improve the haemodynamic result in a small annulus without additional AE.

Reframing Optimal Implantation of the Sapien 3 Transcatheter Heart Valve.

OBJECTIVES: To define the optimal implantation of the Sapien 3 (Edwards Lifesciences) transcatheter heart valve (THV), this study systematically analyzed the predeployment fluoroscopic THV position and correlated this to clinical outcomes. METHODS: This was an observational study of 279 patients treated with the Sapien 3 THV. Fluoroscopic imaging was used to categorize patients into low (n = 147), intermediate (n = 86), and high (n = 46) implantation zones. These zones were based on the relationship of the balloon marker and radiolucent line of the valve frame (line of lucency) to the annular plane at deployment. The primary outcome was the rate of permanent pacemaker implantation (PPI) at 30 days. The secondary outcomes were the rates of new left bundle-branch block (LBBB) in-hospital and all-cause mortality at 1 year. RESULTS: In the high, intermediate, and low groups, 30-day PPI rates were 4.3%, 8.1%, and 8.8% (P=.62); in-hospital LBBB rates were 10.9%, 26.7%, and 32.0% (P=.02); and all-cause mortality rates at 1 year were 3.1%, 7.3%, and 12.5% (P=.14), respectively. No differences were observed with respect to procedural success/complications or THV performance between the groups. CONCLUSION: This study demonstrates fewer conduction abnormalities for Sapien 3 valves positioned within a higher zone defined fluoroscopically by the line of lucency and balloon marker.

A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic.

OBJECTIVES: During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN: A multi-centre prospective cohort study. SETTING: The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS: Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES: Primary outcome was surgery, percutaneous therapy or death at one year. METHODS: Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS: On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS: This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.

Open transcatheter valve implantation for mitral annular calcification: One-year outcomes.

BACKGROUND: Transcatheter mitral valve implantation (TMVI) for native mitral valve pathology with severe mitral annular calcification has emerged as an alternative treatment option to conventional mitral valve surgery. The objective of this study was to evaluate patients who were referred for TMVI with severe mitral annular calcification and their procedural outcomes. METHODS: Retrospective analysis of patients from 2017 to 2020 referred for TMVI was carried out. Demographic characteristic details; surgical strategy; perioperative complications; and hospital stay, including 30-day and 1-year mortality, were analyzed. RESULTS: Eleven patients were referred for consideration of TMVI. The 8 patients who underwent TMVI had a median age of 74 years (range, 57-80 years), the median Society of Thoracic Surgeons score was 4.6 (range, 2.4-10.9), and European System for Cardiac Operative Risk Evaluation II score was 5.2% (2%-10.1%). The median cardiopulmonary bypass time and crossclamp times were 170 minutes (range, 150-248 minutes) and 152 minutes (range, 118-214 minutes), respectively. The median hospital stay was 29 days (range, 2-40 days). Thirty-day in hospital mortality was 12%, whereas 1-year mortality was 25%. There was symptomatic improvement with downgrade of New York Heart Association functional class from III or IV to I or II. The 3 patients who were turned down had a median age of 73 years, median Society of Thoracic Surgeons score was 13.4, and median European System for Cardiac Operative Risk Evaluation II score was 5.72%. They were alive at 12 months follow-up from the date of surgical assessment; however, all with New York Heart Association functional class III or IV symptoms. CONCLUSIONS: We describe a series demonstrating the technical consideration and capability of transatrial TMVI to treat mitral annular calcification and native mitral valve disease. Our results are favorable when compared with TMVI global registry data for transseptal or transapical approach.

Cardiac surgery outcome during the COVID-19 pandemic: a retrospective review of the early experience in nine UK centres.

BACKGROUND: Early studies conclude patients with Covid-19 have a high risk of death, but no studies specifically explore cardiac surgery outcome. We investigate UK cardiac surgery outcomes during the early phase of the Covid-19 pandemic. METHODS: This retrospective observational study included all adult patients undergoing cardiac surgery between 1st March and 30th April 2020 in nine UK centres. Data was obtained and linked locally from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery database, the Intensive Care National Audit and Research Centre database and local electronic systems. The anonymised datasets were analysed by the lead centre. Statistical analysis included descriptive statistics, propensity score matching (PSM), conditional logistic regression and hierarchical quantile regression. RESULTS: Of 755 included individuals, 53 (7.0%) had Covid-19. Comparing those with and without Covid-19, those with Covid-19 had increased mortality (24.5% v 3.5%, p < 0.0001) and longer post-operative stay (11 days v 6 days, p = 0.001), both of which remained significant after PSM. Patients with a pre-operative Covid-19 diagnosis recovered in a similar way to non-Covid-19 patients. However, those with a post-operative Covid-19 diagnosis remained in hospital for an additional 5 days (12 days v 7 days, p = 0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% v 0.0%, p = 0.005). CONCLUSIONS: To mitigate against the risks of Covid-19, particularly the post-operative burden, robust and effective pre-surgery diagnosis protocols alongside effective strategies to maintain a Covid-19 free environment are needed. Dedicated cardiac surgery hubs could be valuable in achieving safe and continual delivery of cardiac surgery.

Flow, Reflected by Stroke Volume Index, Is a Risk Marker in High-Gradient Aortic Stenosis Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Tools are needed to identify patients at increased risk after transcatheter aortic valve replacement (TAVR). Indexed stroke volume (SVi) is an echocardiographic measurement that is used for low-gradient aortic stenosis. We studied whether low SVi is a high-risk marker in patients with high-gradient aortic stenosis (HG-AS) and assessed the relationship between SVi and left ventricle (LV) systolic function in contributing to this risk. METHODS: A total of 816 consecutive patients who underwent TAVR were screened, and only patients with HG-AS were included. Low flow (LF) was defined as SVi ≤ 35 mL/m2. The primary endpoint was defined as a combination of all-cause mortality and readmission with heart failure at 1 year. RESULTS: Of the 476 patients with HG-AS, 215 (45%) had LF. They had higher N-terminal pro b-type natriuretic peptide (NTproBNP) (2565 [1037-5492] vs 1730 [818-3575], P = 0.006) and smaller indexed valve area (0.30 ± 0.10 vs 0.37 ± 0.10 cm2/m2, P < 0.001) when compared with normal flow patients. The primary endpoint was higher in LF patients (hazard ratio, 1.49; 95% confidence interval, 1.01-2.21; P = 0.045). There were no statistical differences in the individual components of death (13.0% vs 8.9%, P = 0.16) or heart failure (14.9% vs 10.1%, P = 0.12). When stratified according to LV function, low SVi was associated with future adverse events in patients with reduced function (hazard ratio, 3.37; 95% confidence interval, 1.26-8.98; P = 0.015) with comparable clinical outcomes in those with preserved function. LF was an independent predictor of adverse events in the reduced LV function subgroup. CONCLUSIONS: SVi can further characterize patients with HG-AS and may help to identify those who are at increased risk after TAVR.

Sarcoidosis or acute coronary syndrome: Easily distinguishable?

Sinus of Valsalva aneurysm is a rare presenting feature of ST-elevation myocardial infarction. We describe such a case which resolved with thrombolysis, and on further investigation, the patient was found to have a large sinus of Valsalva aneurysm. Abnormal gross pathology at the time of surgery was suspected to be aortitis which was only confirmed on postmortem examination 6 months later. We highlight the importance of working closely with a pathologist when aortitis is suspected, because failure to treat it medically results in a poor outcome.