Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock after valve replacement.

BACKGROUND: Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves. METHODS: This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups. RESULTS: There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years. CONCLUSIONS: Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.

Post-COVID-19 fatal Aspergillus endocarditis: A case report.

BACKGROUND: Aspergillus endocarditis (AE) is a rare fatal infection. The infection is often reported in patients with prosthetic heart valves, immunosuppressed, broad-spectrum antimicrobial use regimens, and drug abusers. METHODS: Herein, we report a rare case of native mitral valve AE in a 63-year-old man, with a probable COVID-19-associated invasive pulmonary aspergillosis nine months ago treated with antifungals. RESULTS: In the last admission, the lethargy, neurological deficit, and septic-embolic brain abscess in brain MRI led to suspicion of infective endocarditis. Transesophageal two-dimensional echocardiography and color Doppler flow velocity mapping showed a large highly mobile mass destroying leaflet and severe mitral regurgitation. The Surgical valve replacement is performed. The surgical valve replacement is performed. Direct microscopic examination and culture of the explanted and vegetative mass revealed Aspergillus section Fumiagati confirmed by molecular method. Despite the administration of voriconazole and transient improvement the patient expired. CONCLUSION: As AE is a late consequence of COVID-19-associated invasive pulmonary aspergillosis, therefore, long-term follow-up of invasive aspergillosis, and prompt diagnosis of surgical and systemic antifungal therapy treatment, are warranted to provide robust management.

Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis.

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.

Whats new in ESC Guidelines for the management of valvular heart disease?

The article summarize the most important changes regarding the management of valvular heart disease, which have been made in the ESC Guidelines 2021. Based on the randomized clinical study data, which were recently published, the most frequent changes were done in terms of the choice of mode of intervention in the aortic and mitral valves as well as in the management of the antithrombotic therapy.

Fully coupled dynamic simulations of bioprosthetic aortic valves based on an embedded strategy for fluid-structure interaction with contact.

AIMS: This work aims at presenting a fully coupled approach for the numerical solution of contact problems between multiple elastic structures immersed in a fluid flow. The key features of the computational model are (i) a fully coupled fluid-structure interaction with contact, (ii) the use of a fibre-reinforced material for the leaflets, (iii) a stent, and (iv) a compliant aortic root. METHODS AND RESULTS: The computational model takes inspiration from the immersed boundary techniques and allows the numerical simulation of the blood-tissue interaction of bioprosthetic heart valves (BHVs) as well as the contact among the leaflets. First, we present pure mechanical simulations, where blood is neglected, to assess the performance of different material properties and valve designs. Secondly, fully coupled fluid-structure interaction simulations are employed to analyse the combination of haemodynamic and mechanical characteristics. The isotropic leaflet tissue experiences high-stress values compared to the fibre-reinforced material model. Moreover, elongated leaflets show a stress concentration close to the base of the stent. We observe a fully developed flow at the systolic stage of the heartbeat. On the other hand, flow recirculation appears along the aortic wall during diastole. CONCLUSION: The presented FSI approach can be used for analysing the mechanical and haemodynamic performance of a BHV. Our study suggests that stresses concentrate in the regions where leaflets are attached to the stent and in the portion of the aortic root where the BHV is placed. The results from this study may inspire new BHV designs that can provide a better stress distribution.

Cine-Computed Tomography for the Evaluation of Prosthetic Heart Valve Function.

BACKGROUND: After aortic valve replacement (AVR), suspected prosthetic valve dysfunction (mechanical or biological) may arise based on echocardiographic transvalvular velocities and gradients, leading to reoperative surgical intervention being considered. Our experience has found that 4-dimensional (space and time) image reconstruction of ECG-gated computed tomography, termed cine-CT, may be helpful in such cases. We review and illustrate our experience. METHODS: Twenty-seven AVR patients operated previously by a single surgeon (who performs >100 AVRs/year) were referred for repeat evaluation of suspected aortic stenosis (AS) based on elevated transvalvular velocities and gradients. The patients were fully evaluated by cine-CT. RESULTS: In all but 2 cases, the cine-CT strikingly and visually confirmed normal leaflet function and excursion, with no valve thrombosis, restriction by pannus, or obstruction by clot. In only 2 cases did cine-CT reveal decreased mechanical valve leaflet excursion. Repeat surgery was required in only 1 case while all other patients continued clinically without cardiac events. CONCLUSIONS: Echocardiography is an extraordinarily useful tool for the evaluation of prosthetic valve function. Increased pressure recovery beyond the valve and other factors may occasionally lead to exaggerated gradients. Cine-CT is emerging as an extremely valuable tool for further evaluation of suspected prosthetic valve AS. Our experience has been extremely helpful, as is shown in the dramatically reassuring images.

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands.

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called 'endocarditis team' in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE).

Atrial fibrillation (AF) is a major worldwide public health problem, and AF in association with valvular heart disease (VHD) is also common. However, management strategies for this group of patients have been less informed by randomized trials, which have largely focused on 'non-valvular AF' patients. Thrombo-embolic risk also varies according to valve lesion and may also be associated with CHA2DS2VASc score risk factor components, rather than only the valve disease being causal. Given marked heterogeneity in the definition of valvular and non-valvular AF and variable management strategies, including non-vitamin K antagonist oral anticoagulants (NOACs) in patients with VHD other than prosthetic heart valves or haemodynamically significant mitral valve disease, there is a need to provide expert recommendations for professionals participating in the care of patients presenting with AF and associated VHD. To address this topic, a Task Force was convened by the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Thrombosis, with representation from the ESC Working Group on Valvular Heart Disease, Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) with the remit to comprehensively review the published evidence, and to publish a joint consensus document on the management of patients with AF and associated VHD, with up-to-date consensus recommendations for clinical practice for different forms of VHD. This consensus document proposes that the term 'valvular AF' is outdated and given that any definition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional Evaluated Heartvalves, Rheumatic or Artificial (EHRA) categorization in relation to the type of OAC use in patients with AF, as follows: (i) EHRA Type 1 VHD, which refers to AF patients with 'VHD needing therapy with a Vitamin K antagonist (VKA); and (ii) EHRA Type 2 VHD, which refers to AF patients with 'VHD needing therapy with a VKA or a Non-VKA oral anticoagulant (NOAC)', also taking into consideration CHA2DS2VASc score risk factor components. This consensus document also summarizes current developments in the field, and provides general recommendations for the management of these patients based on the principles of evidence-based medicine.

[The Integrated Approach to Improving Efficiency and Safety of Anticoagulation Therapy in Patients With Prosthetic Mitral Valve].

AIM: To assess advantages of integrated approach to improvement of efficiency and safety of warfarin therapy after heart valve replacement. MATERIALS AND METHODS: We included in this study 118 patients who had undergone simultaneous mitral valve replacement and maze procedure. Group 1 patients (n=37) underwent just sinus rhythm restoration, group 2 patients (n=54) underwent sinus rhythm restoration and participated in a patient education program, group 3 patients (n=27) underwent sinus rhythm restoration, participated in a patient education program, and were subjected to pharmacogenetic testing for warfarin sensitivity. In examination of patients we used clinical, demographic, and instrumental methods. Estimation of the time in the therapeutic range (TTR) of an international normalized ratio (INR) was used as a measure of warfarin therapy quality, and the Kaplan-Meier method was applied for analysis of hemorrhagic and thrombotic complications. RESULTS: TTR was 42 % in group 1, 68 % in group 2 (p=0.0327), and 82 % in group 3 (p=0.0019). Application of integrated approach was associated with absence of hemorrhagic and thrombotic complications within one year after heart valve replacement. CONCLUSION: The integrated approach comprising restoration of sinus rhythm, patient education, and pharmacogenetic testing for warfarin sensitivity was associated with improved anticoagulation control, and prevention of hemorrhagic and thrombotic complications.

[Effectiveness of a long-term education program in patients with prosthetic heart valves].

AIM: The current study was aimed at assessing the effectiveness and the impact of a long-term education program, in both inpatient and outpatient treatment settings, on adherence to treatment and the quality of life 5 years after heart valve replacement. MATERIALS AND METHODS: All the patients were randomly included into two study groups. The study group patients (n=176) underwent the long-term education program in both inpatient and outpatient treatment settings. The control group (n=108) consisted of patients who underwent only an inpatient education program. Adherence to treatment and the quality of life were assessed before education, at the end of the inpatient and outpatient education and 5 years after heart valve replacement. Patients' treatment adherence was estimated with the Davydov's questionnaire, and the quality of life - with the 36­Item Short Form Health Survey. RESULTS: After the completion of the education program, the integral index reflecting patients' adherence to treatment in the study group remained at the same level, but was 1.4­fold higher compared to the control group in the 5­year follow-up. The long-term education program is associated with improved quality of life, mainly due to emotional well-being. The study reported a correlation between physical functioning and emotional well-being and the integral index reflecting patients' adherence to treatment during the follow-up period. CONCLUSION: The long-term education program in both inpatient and outpatient treatment settings contributed to improved patients' adherence to treatment and the quality of life, mainly due to physical functioning. The inpatient education program was associated with poor patients' adherence to treatment and the quality of life 5 years after heart valve replacement.

Long-Term Risk of Hospitalization and Death in Patients With Mechanical Prosthetic Heart Valves.

Mechanical prosthetic heart valves (MPHVs) are commonly used for valvular heart disease in patients with a long life expectancy. Few longitudinal data on the specific causes of hospitalization in patients with MPHV are available. We investigated the risk of all-cause hospitalization and mortality in patients with MPHV. We performed a prospective, observational, ongoing study including consecutive patients with MPHVs who were referred to the atherothrombosis outpatient clinic of the Policlinico Umberto I of Rome for the vitamin K antagonist management. Study end points were all-cause, cardiovascular hospitalization, and overall mortality. We included 305 patients with MPHV (38.4% women, median age 60.2 years). The site of MPHV was aortic in 53.5%, mitral in 29.5%, and mitroaortic in 17%. During a median follow-up of 57.3 months, 142 hospitalizations occurred (8.16 per 100 person-years). The most common causes of hospitalization were cardiovascular disease (3.62 per 100 person-years), infections, surgery, and bleeding. The predictors of cardiovascular hospitalization were atrial fibrillation (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.04 to 2.95, p = 0.035), previous stroke/transient ischemic attack (HR 2.96, 95% CI 1.59 to 5.48, p = 0.001), and peripheral artery disease (HR 2.42, 95% CI 1.09 to 5.36, p = 0.030). During a median follow-up of 97.2 months, 61 deaths occurred (2.43 per 100 person-years). Age was directly associated with the risk of death (HR 1.088, 95% CI 1.054 to 1.122, p <0.001), whereas the time in therapeutic range higher than the median was inversely associated (HR 0.436, 95% CI 0.242 to 0.786, p = 0.006). In conclusion, patients with MPHV had a high incidence of hospitalizations, especially cardiovascular-related. The incidence of death is high; however, it may be decreased by maintaining a good quality of anticoagulation.

Revisiting echocardiographic features of prosthetic heart valves: the necessity of correct differentiation of mono-leaflet vs. bileaflet mechanical heart valves in a case report.

BACKGROUND: Mechanical heart valve replacement is a standard treatment for severe valvular disorders. The use of mono-leaflet valves has decreased recently. Recognizing the echocardiographic features of mono-leaflet and bileaflet valves is crucial for accurate complication diagnosis and proper management. CASE PRESENTATION: A 65-year-old female with mono-leaflet mitral and bileaflet tricuspid valves underwent an echocardiographic assessment. This simple educational case provides a unique opportunity to compare the echocardiographic features of these valves within a single patient. CONCLUSION: There is a crucial need for clinicians, particularly those in training, to differentiate between mono-leaflet and bileaflet mechanical heart valves adeptly. With mono-leaflet valves decreasing in prevalence, proficiency in recognizing the echocardiographic nuances of each type is imperative. Failure to do so may result in misdiagnoses and inappropriate management. This underscores the significance of continuous education and vigilance in echocardiographic assessments to ensure optimal patient care.

Infective endocarditis after isolated aortic valve replacement: comparison between catheter-interventional and surgical valve replacement.

BACKGROUND AND AIMS: Prosthetic valve endocarditis (PVE) is the prognostically most unfavourable complication after aortic valve replacement. This study aims to contribute to a better understanding of the different pathological and therapeutical aspects between PVE following surgical (SAVR) and transcatheter aortic valve replacement (TAVI). METHODS: All patients who had undergone primary isolated SAVR (n = 3447) or TAVI (n = 2269) at our Centre between 01/2012 and 12/2018 were analysed. Diagnosis of PVE was based on Duke criteria modified in 2015. Incidence, risk factors, pathogens, impact of complications or therapy on mortality were analysed and compared between SAVR- and TAVI-PVE. RESULTS: PVE incidence did not differ significantly after SAVR with 4.9/100 patient-years and TAVI with 2.4/100 patient-years (p = 0.49), although TAVI patients were older (mean 80 vs. 67 years) and had more comorbidities (STS score mean 5.9 vs. 1.6) (p < 0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than without polymer (HR 4.3; p = 0.004). Most common pathogens were staphylococci and enterococci (p > 0.05). Propensity-score matching analysis showed that the type of aortic valve replacement had no effect on the development of post-procedural PVE (p = 0.997). One-year survival was higher in TAVI-PVE patients treated with antibiotics only compared to additional surgical therapy (90.9% vs. 33.3%; p = 0.005). In SAVR-PVE patients, both therapies were comparable in terms of survival (p = 0.861). However, SAVR-PVE patients who were not operated, despite ESC-guideline recommendation, had significantly poorer one-year survival (p = 0.004). CONCLUSION: TAVI patients did not have a significantly higher risk to develop PVE. Our data suggest that TAVI-PVE patients in contrast to SAVR-PVE patients can more often be treated with antibiotics only, presumably due to the lack of a polymeric suture ring.

Can mechanical heart valves perform similarly to tissue valves? An in vitro study.

Current surgical aortic valve (AV) replacement options include bioprosthetic and mechanical heart valves (MHVs), each with inherent limitations. Bioprosthetic valves offer superior hemodynamics but suffer from durability issues, typically initiating deterioration within 7-8 years. MHVs, while durable, necessitate lifelong anticoagulation therapy, presenting risks such as severe bleeding and thromboembolic events. The need for anticoagulants is caused by non-physiological flow through the hinge area during the closed phase and large spikes of regional backflow velocity (RBV) during the closing phase that produces high shear events. This study introduces the iValve, a novel MHV designed to combine the hemodynamic benefits of bioprosthetic valves with the durability of MHVs without requiring anticoagulation. The iValve features eye-like leaflets, a saddle-shaped housing, and an optimized hinge design to enhance blood flow and minimize thrombotic risk. Fabricated using 6061-T6 aluminum and polyether ether ketone (PEEK), twelve iValve iterations were evaluated for their opening and closing dynamics. The reported top-performing prototypes demonstrated competitive performance against industry standards. The proposed iValve prototype exhibited a mean RBV of -4.34 m/s with no spikes in RBV, performing similarly to bioprosthetic valves and significantly outperforming existing MHVs. The iValve's optimized design showed a 7-10% reduction in closing time and a substantial decrease in RBV spikes, potentially reducing the need for anticoagulation therapy. This study highlights the iValve's potential to revolutionize prosthetic heart valve technology by offering a durable, hemodynamically superior solution that mitigates the drawbacks of current MHVs.

Conduction system pacing in prosthetic heart valves.

BACKGROUND: There has been increasing interest in physiologic pacing techniques that directly activate the specialized conduction system. We aimed to assess outcomes of conduction system pacing (CSP) in patients with prosthetic heart valves. METHODS: This systematic review was performed according to PRISMA guidelines. Freeman-Tukey double arcsine transformation with the random-effect model was used to summarize the data. Outcomes studied were 1) implant success (defined as ability to recruit the His-Purkinje system or the distal Purkinje system); (2) lead parameters at implant and follow-up; and (3) procedure-related complications. RESULTS: This systematic review of 7 studies included 267 unique patients in whom CSP was attempted with either HBP or LBBAP for pacing indications after a prosthetic valve. HBP was attempted in 38% (n = 108), while LBBAP in 62% (n = 175) patients. The overall success rate of CSP was 87%, while in patients post-TAVR, the overall success rate was 83.2%. In the subgroup analysis, LBBAP had a significant higher overall success rate compared to HBP (94.3% vs. 76.5%, p interaction = 0.02) and post-TAVR patients (94.3 vs. 66.9%, p interaction < 0.01), respectively. The LBBAP thresholds were significantly lower compared to HBP both at implant (0.67 ± 0.4 @ 0.44 ms vs. 1.35 ± 1 @ 0.85 ms, p interaction < 0.01) and at a mean follow-up of 12.4 ± 8 months (0.73 ± 0.1 @ 0.44 ms vs. 1.39 ± 1 @ 0.85 ms, p interaction < 0.01), respectively. CONCLUSION: CSP is safe and feasible in patients with a prosthetic valve, with a significantly higher success rate and superior lead parameters with LBBAP than HBP, especially in patients post-TAVR.

Cardiac Surgeons Highlight the Need for Innovation Stewardship: Noteworthy in 2022.

Modern cardiac surgery has rapidly evolved to treat complex cardiovascular disease. This past year boasted noteworthy advances in xenotransplantation, prosthetic cardiac valves, and endovascular thoracic aortic repair. Newer devices often offer incremental design changes while demanding significant cost increases that leave surgeons to decide if the benefit to patients justifies the increased cost. As innovations are introduced, surgeons must continuously aim to harmonize short- and long-term benefits with financial costs). We must also ensure quality patient outcomes while embracing innovations that will advance equitable cardiovascular care.