Different treatment options for Takayasu arteritis patients with moderate-to-severe aortic regurgitation: long-term outcomes.

OBJECTIVES: To determine the prognosis of Takayasu arteritis (TA) patients with moderate-to-severe aortic regurgitation treated with surgical vs conservative treatment and to identify independent prognostic factors of long-term outcomes. METHODS: Between January 2002 and January 2017, 101 consecutive TA patients with moderate-to-severe aortic regurgitation treated with either surgical (n = 38) or conservative (n = 63) treatments were investigated in this retrospective observational case-control study. The primary end point was all-cause mortality, and the secondary end point comprised the combined end points of death, non-fatal stroke and cardiac events (non-fatal myocardial infarction and congestive heart failure). Propensity score matching was used to reduce the bias of baseline risk factors. RESULTS: The unadjusted all-cause 10-year mortality in the conservative group was increased compared with the surgical group (28.2% vs 7.4%; log-rank P = 0.036), and the combined end points showed the same trend (52.1% vs 25.3%; log-rank P = 0.005). After an adjustment of baseline risk factors, the conservative treatment was associated with reduced survival rates of both all-cause mortality [hazard ratio (HR): 8.243; 95% CI: 1.069, 63.552; P = 0.007] and combined end points (HR: 6.341; 95% CI: 1.469, 27.375; P = 0.002). Conservative treatment (HR: 3.838, 95% CI: 1.333, 11.053; P = 0.013) and left ventricular end-diastolic diameter (HR: 1.036, 95% CI: 1.001, 1.071; P = 0.042) were risk factors for increased combined end points. CONCLUSION: Surgical treatment improves the outcomes of patients with moderate-to-severe aortic regurgitation due to TA. The dilated left ventricle indicated a worse prognosis.

Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation.

BACKGROUND: Valvular heart disease (VHD) in non-valvular atrial fibrillation (AF) is a puzzling clinical entity. The aim of this study was to evaluate the prognostic effect of significant VHD (sVHD) among patients with non-valvular AF. METHODS: This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction. RESULTS: In total, 983 patients with non-valvular AF (median age 76 [14] years) were analyzed over a median follow-up period of 32 [20] months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 6.5%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17-2.06; p = 0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR 1.70, 95% CI 1.09-2.66; p = 0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35-4.63; p = 0.02). The prognostic effect of sVHD was particularly evident in patients aged < 80 years and in those without history of heart failure (p for interaction < 0.05, in both subgroups). After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization. CONCLUSION: Among patients with non-valvular AF, sVHD was highly prevalent and beared high prognostic value across a wide spectrum of clinical outcomes, especially in patients aged < 80 years or in the absence of heart failure. Predominantly AS, as well as MR and TR, were associated with worse prognosis.

Case report describing late balloon dilatation as a treatment for paravalvular leak with intuity elite rapid deployment valve.

Use of sutureless bioprostheses for aortic valve replacement has increased in recent years as compared to conventional prostheses, though with the potential issue of paravalvular leak, which requires close follow-up. We present this case report describing the successful treatment of paravalvular leak in a 65 year old man, who had NYHA class III symptoms post implantation of a 21 mm Intuity Elite rapid deployment bioprosthesis (Edwards Lifesciences, Irvine, CA). Diagnosis was established using TTE, TOE, and Cardiac MRI. Performing balloon dilatation using an Atlas Gold balloon (BARD Peripheral Vascular Inc., Tempe, AZ) treated the likely inadequate expansion of the subvalvular stent, leading to significant reduction in the paravalvular leak. At one month follow-up patient reported complete resolution of his symptoms. Successful percutaneous treatment of paravalvular leak following implantation of rapid deployment sutureless bioprosthesis provides a new treatment strategy for these patients; this strategy requires further validation.

Early Detection of Subclinical Myocardial Damage in Chronic Aortic Regurgitation and Strategies for Timely Treatment of Asymptomatic Patients.

A series of hemodynamic and pathological responses occur in chronic aortic regurgitation, which eventually result in myocardial fibrosis and irreversible left ventricular dysfunction. According to guidelines, valvular surgery is recommended with the development of symptoms, left ventricular systolic dysfunction, or left ventricular dilatation. The optimal timing of surgical intervention has recently been questioned with documentation of irreversible myocardial damage resulting in incomplete left ventricular recovery and adverse clinical outcomes after surgery. Recognizing the shortcomings of the guidelines, we performed a comprehensive review on the novel diagnostic methods that have been shown to improve the detection of subclinical ventricular dysfunction in chronic aortic regurgitation and to improve prediction of outcomes.

Post/preprocedural ratio of hemodynamically assessed aortic regurgitation index as a marker for the need for corrective measures during transcatheter valve replacement: A first confirmatory study in patients receiving a new generation transcatheter self-expandable prosthesis.

OBJECTIVES: We aimed to investigate the value of post/preprocedural aortic regurgitation index (ARI) ratio as a marker for more-than-mild aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) and as an indication of the need for corrective measures, provided that the implantation depth was acceptable. BACKGROUND: Post/preprocedural ARI increases accuracy of residual AR assessment by considering hemodynamic status prior to TAVR. METHODS: ARI ratio was calculated in 70 patients undergoing TAVR. ARI ratios were defined as post/preprocedural ARI (ARI ratio 1), and as postcorrective measure/preprocedural ARI (ARI ratio 2). Intraprocedurally, corrective measures use was decided based on angiographically assessed AR severity. The relationship of such decisions to ARI ratios based on a recently proposed threshold (ARI ratio < 0.6) was evaluated. ARI ratios in corrected versus noncorrected patients and precorrection versus postcorrection values were assessed. RESULTS: Overall, mean (±SD) ARI ratio 1 (n = 70) was 0.81 (±0.36). Corrective measures were used in 22 patients (31.4%). Mean ARI ratio 1 in such patients was 0.55 (±0.25) versus 0.93 (±0.34) in the 48 noncorrected patients (P < 0.0001). Mean ARI ratio 1 in 21 patients requiring postdilation was 0.56 (±0.25), which was below the previously suggested 0.6 threshold. After postdilation, ARI ratio 2 increased to 0.85 (±0.16) (P < 0.0001), with all patients showing an ARI ratio 2 ≥ 0.6. CONCLUSIONS: ARI ratio is closely related to intraprocedural decisions to perform corrective measures based on angiography. Routine use of intraprocedural ARI ratio could be useful as a complementary quantitative marker for residual AR and for the need for corrective measures.

A word of caution using self-expanding transcatheter aortic valve-frame infolding.

Transcatheter aortic valve replacement has become a mainstay alternative to surgical aortic valve replacement in patients with severe aortic stenosis at high and intermediate surgical risk. Two commercially approved valves are available in the United States: balloon-expandable and self-expanding. We report here a rare complication of a self-expanding Evolut PRO (Medtronic, Minneapolis, Minnesota) valve failing to expand due to nitinol frame infolding. This results in a malopposed valve with a severe paravalvular leak, even though treated successfully with balloon valvuloplasty. It is important to recognize the characteristic angiographic signature of this complication-the "straight line" sign-and how to avoid this potentially serious complication by balloon valvuloplasty or by recapture and deployment of a new valve.

Effect of percutaneous paravalvular leak closure on hemolysis.

OBJECTIVE: To study the effect of percutaneous paravalvular leak closure on hemolysis. BACKGROUND: Although transcatheter PVL closure reduces heart failure and mortality in symptomatic patients with paravalvular leaks (PVL), little is known about its effect on hemolysis. METHODS: We retrospectively analyzed patients undergoing transcatheter mitral or aortic PVL closure (January 2005-December 2016) at Mayo Clinic. Patients with anemia or abnormal hemolysis markers (LDH, haptoglobin) were included in the analysis. The primary outcome was defined as hemoglobin increase ≥ 1.5 mg/dL, decrease in LDH above median or improvement in haptoglobin. Univariate and multivariate binary logistic regression modeling were used to determine predictors of successful treatment of hemolysis. RESULTS: Final study population included 168 patients (130 [77%] mitral, 38 [23%] aortic PVL). Primary outcome occurred in 70 patients (42%). Hemoglobin increased by 1.74 ± 1.69 mg/dL in patients who reached primary outcome. 57/168 (34%) patients required blood transfusion prior to PVL closure compared to 35/168 (21%) postprocedure. The mean reduction in LDH was 403 U/L. Multivariate regression showed that patients with mechanical valves were more likely to have successful outcome (P = 0.044). CONCLUSION: Percutaneous PVL closure is associated with modest improvement in hemolysis markers, increase in hemoglobin levels and reduction in blood transfusion requirements. This benefit is most significant in patients with mechanical valves.

Paravalvular leak closure under intracardiac echocardiographic guidance.

OBJECTIVES: The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure. BACKGROUND: PVL following surgical valve replacement occurs in 2%-15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention. METHODS: All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed. RESULTS: Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%. CONCLUSIONS: Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

The Hemodynamic Effects of Aortic Insufficiency in Patients Supported With Continuous-Flow Left Ventricular Assist Devices.

BACKGROUND: The impact of aortic insufficiency (AI) on the morbidity and mortality of left ventricular assist device (LVAD) patients remains controversial. This study's aim was to assess the hemodynamics of LVAD patients with at least mild AI, at baseline and in response to device speed changes. METHODS AND RESULTS: Asymptomatic LVAD patients were prospectively enrolled and underwent a hemodynamic and echocardiographic ramp study. Hemodynamics at rest and in response to device speed changes were compared between patients with at least mild AI at their baseline speed and patients without AI. Fift-five patients were enrolled in the study, and 42% had AI. The AI group had higher baseline central venous pressure (11 ± 5 vs 8 ± 5 mm Hg; P = .03), higher pulmonary capillary wedge pressure (PCWP) (16 ± 6 vs 12 ± 6 mm Hg; P = .02) and lower pulmonary artery pulsatility index (PAPI) (2.3 ± 1.3 vs 3.6 ± 2.4; P = .01). Cardiac index (CI) increased and PCWP decreased in both groups by similar degrees during the ramp study. AI worsened in 78% of patients during the ramp study. CONCLUSIONS: LVAD patients with at least mild AI have increased filling pressures and reduced PAPI. Normalization of filling pressures can be achieved by increasing LVAD speed; however, this concomitantly worsens AI severity. The long-term hemodynamic consequences of this approach are unknown.

Long-term outcomes and re-interventions following balloon aortic valvuloplasty in pediatric patients with congenital aortic stenosis: A single-center study.

OBJECTIVES: To describe long-term risk of mortality, aortic insufficiency (AI), and re-intervention following balloon aortic valvuloplasty (BAV) in pediatric patients and to identify risk factors for re-intervention. BACKGROUND: Few studies report long-term outcomes following BAV in infants and children. METHODS: Kaplan-Meier estimates and proportional hazards regression were used in a retrospective study of 154 patients undergoing BAV from 1993 to 2013. RESULTS: Seventy-six (49%) patients were neonates. Aortic stenosis (AS) gradients were reduced by 38 ± 19 mm Hg. Moderate or severe AI developed acutely in 19 (12%) patients. Estimates of fifteen-year transplant-free survival were 85% (95%CI: 73-92%) in neonates, 94% (95%CI: 80-96%) in infants, and 100% in older patients. Neonates had an elevated long-term risk of AI (P < 0.001) and left heart re-interventions (P = 0.02). At 15 years, an estimated 32% (95%CI: 15-50%) of neonates and 44% (95%CI: 20-65%) of non-neonates remained free from re-intervention; an estimated 45% (95% CI: 26-63%) of neonates and 62% (95% CI: 40-77%) of non-neonates remained free of aortic valve replacement (AVR). Neonatal age, additional left heart lesions, higher pre- and post-dilation gradients, and acute AI were associated with LVOT re-interventions. Post-dilation gradient ≥30 mm Hg and acute AI were associated with AVR. Patients with moderate or severe acute AI but a residual AS gradient <30 mm Hg had a greater risk of AVR compared to patients with a residual AS gradient ≥30 mm Hg but mild or less AI (HR: 2.98 [95% CI: 1.01-8.77]). CONCLUSIONS: While post-BAV survival is excellent, long-term risks of AI and re-intervention are significant. Acute AI is a more strongly associated with AVR than residual AS. © 2016 Wiley Periodicals, Inc.

Techniques and outcomes of paravalvular leak repair after transcatheter aortic valve replacement.

OBJECTIVES: To investigate the feasibility, procedural success, and outcomes of paravalvular leak (PVL) closure in patients with prior transcatheter aortic valve replacement (TAVR). BACKGROUND: PVL after TAVR is associated with adverse patient outcomes and increased mortality. Percutaneous PVL closure has emerged as a therapeutic strategy for addressing this issue, but data for transcatheter PVL repair after TAVR remains limited. METHODS: This is a single center retrospective review of PVL closure after TAVR. Patients with balloon-expandable or self-expanding prostheses were included. Baseline patient demographics, procedural characteristics, complications, and clinical outcomes were reviewed. RESULTS: A total of 18 patients with clinically significant PVL after TAVR referred for PVL closure were identified during the study period. Procedural success resulting in successful transcatheter occluder plug delivery was 78% (14 cases). Balloon postdilatation (2/4) and valve-in-valve (2/4) were used effectively in the remaining patients after an unsuccessful PVL closure attempt. PVL grading by echocardiography decreased from moderate or severe to < moderate in 13 patients (72%). Adverse events including cardiac tamponade and acute kidney injury occurred in 1 case each. One-month all-cause mortality was 11%. CONCLUSION: In selected patients, percutaneous PVL repair following TAVR is feasible and effective for both balloon-expandable and self-expanding prostheses. Most patients undergoing PVL closure after TAVR require a single occluder plug placement for reduction in PVL to mild or less.

Transcatheter aortic valve-in-valve treatment of degenerative stentless supra-annular Freedom Solo valves: A single centre experience.

BACKGROUND: Redo surgery for degenerative bioprosthetic aortic valves is associated with significant morbidity and mortality. Report results of valve-in-valve therapy (ViV-TAVI) in failed supra-annular stentless Freedom Solo (FS) bioprostheses, which are the highest risk for coronary occlusion. METHODS: Six patients with FS valves (mean age 78.5 years, 50% males). Five had valvular restenosis (peak gradient 87.2 mm Hg, valve area 0.63 cm2 ), one had severe regurgitation (AR). Median time to failure was 7 years. RESULTS: Patients were high risk (mean STS/Logistic EuroScore 10.6 15.8, respectively). FS valves ranged from 21 to 25 mm. Successful ViV-TAVI was achieved in 4/6 patients (67%). Of the unsuccessful cases, (patient 1 and 2 of series) patient 1 underwent BAV with simultaneous aortography which revealed left main stem occlusion. The procedure was stopped and the patient went forward for repeat surgery. Patient 2 underwent successful ViV-TAVI with a 26-mm CoreValve with a guide catheter in the left main, but on removal coronary obstruction occurred, necessitating valve snaring into the aorta. Among the successful cases, (patients 3, 4, 5, 6) the TAVIs used were CoreValve Evolut R 23 mm (n = 3), and Lotus 23 mm (n = 1). In the successful cases the peak gradient fell from 83.0 to 38.3 mm Hg. No patient was left with >1+ AR. One patient had a stroke on Day 2, with full neurological recovery. Two patients underwent semi-elective pacing for LBBB and PR >280 ms. CONCLUSIONS: ViV-TAVI in stentless Freedom Solo valves is high risk. The risk of coronary occlusion is high. The smallest possible prosthesis (1:1 sizing) should be used, and strategies to protect the coronary vessels must be considered. © 2016 Wiley Periodicals, Inc.

Outcome of paravalvular leak repair after transcatheter aortic valve replacement with a balloon-expandable prosthesis.

BACKGROUND: Significant paravalvular leak (PVL) occurs in up to 13% of patients after transcatheter aortic valve replacement (TAVR) with a balloon-expandable bioprosthesis. Transcatheter PVL repair has emerged as a less invasive alternative for this problem. OBJECTIVES: The aim of this study was to evaluate the safety, feasibility, and clinical outcomes of transcatheter PVL repair after TAVR with balloon-expandable valve. METHODS: We retrospectively identified 15 patients who underwent 16 PVL repair procedures after the TAVR at our center. Procedural characteristics, results, and clinical outcomes were analyzed. The association of PVL repairs with subsequent hospitalizations and mortality was assessed and compared to 57 patients who did not undergo repair for at least moderate PVL after TAVR. RESULTS: The PVL repair was successful in 13 (87%) patients, without significant procedure or device related complications. In patients with successful PVL repair, there was an improvement in symptom status, subsequent hospitalizations, and B-type natriuretic peptide levels. There was 1 (out of 13, 8%) death in the group of patients who successfully underwent PVL repair whereas 24 (out of 57, 42%) patients died during follow up in the group that did not undergo repair of their PVL. Similarly, there was significant reduction in the subsequent heart failure related hospitalization after the PVL repair, compared with the patients who did not undergo PVL repair (P = 0.03). CONCLUSION: Transcatheter repair of PVL after TAVR can be safely and effectively accomplished in carefully selected patients, and may lead to reduction in hospitalizations, improvement in symptoms, and long-term survival. © 2016 Wiley Periodicals, Inc.

Transcatheter Aortic Valve Implantation for Degenerated 19-mm Aortic Bioprosthetic Valve.

BACKGROUND: The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted over a prosthetic valve, has been shown to be safe and therapeutically effective, depending on the size of the replacement valve.Methods and Results:We report 3 cases of successful valve-in-valve procedure to replace a degenerated 19-mm stented prosthetic aortic valve. Balloon-expanding THVs were implanted: 20-mm in the 1st case and 23-mm in the next 2. Aortic stenosis was almost completely resolved in all patients, who recovered promptly and without cardiac adverse events. CONCLUSIONS: Using the valve-in-valve procedure for a 19-mm degenerated bioprosthesis was feasible and safe.

Quadricuspid Aortic Valve Associated with Aortic Regurgitation, Mitral Regurgitation, and Aortic Dilatation.

The quadricuspid aortic valve (QAV) is a very uncommon congenital malformation with an estimated incidence of 0.003% to 0.043% of all congenital heart diseases. Combinations of QAV with several different congenital malformations have been described. The case is reported of a type A QAV associated with moderate aortic regurgitation, mild mitral regurgitation, and ascending aorta dilatation. This interesting case was referred for close follow up.

Transfemoral transcatheter aortic valve replacement with a self-expanding valve for severe aortic regurgitation in a patient with left ventricular assist device.

Aortic insufficiency following left ventricular assist device implantation (LVAD) has been reported in up to 40% of patients and is associated with a worse prognosis. We describe the case of a successful transfemoral transcatheter aortic valve replacement with a self-expanding bioprosthesis for aortic insufficiency following destination LVAD implantation.

[Thoughts about valvular abnormalities yesterday and today]. / Zamyslení nad chlopenními vadami vcera a dnes.

The article deals with the problems of acquired valvular disorders. It mainly focuses on the new findings regarding ethiopathogenesis, diagnostics, evaluation and treatment, especially catheterization. In advanced countries, post-rheumatic abnormalities have almost disappeared, their current etiology has substantially changed (mitral stenosis). The earlier relatively rare degenerative changes now predominate, mainly affecting older patients (aortic stenosis). Also the treatment methods for acquired abnormalities have substantially changed - currently catheterization approaches are used more frequently in their correction.Key words: aortic regurgitation - aortic stenosis - echocardiography for valvular abnormalities - magnetic resonance abnormalities - mitral regurgitation - mitral stenosis - valve replacement.

Percutaneous aortic valve closure for patients with left ventricular assist device-associated aortic insufficiency.

The development of de novo aortic insufficiency (AI) is a significant complication of long-term LVAD support, which can lead to ineffective support, decreased device durability, end organ malperfusion, and increased mortality. Surgical aortic valve (AV) closure has been the standard treatment for symptomatic patients, but is associated with high mortality and recurrence of AI. Percutaneous AV closure using the Amplatzer cribriform device is a feasible and may be the preferable option to treat LVAD-associated severe AI in high-surgical risk patients. Certain technical issues with this procedure should be taken into consideration to achieve optimal results. © 2015 Wiley Periodicals, Inc.

Transcatheter aortic valve replacement for native aortic valve regurgitation as a bridge to liver transplantation.

Coexistence of end-stage liver disease (ESLD) and severe valvular heart disease conveyed substantial risk for patients, oftentimes leading to exclusion from liver transplantation candidacy due to inability to safely offer cardiac surgery prior to transplantation. Several approaches have been described, including performing transplantation and valve surgery concurrently, or in sequence. Both options, however, have associated complications: catastrophic repercussion of peri-operative coagulopathy and organ dysfunction post-transplantation, respectively. The introduction of transcatheter procedures offered a safer alternative for high-risk patients; however, its recognized indications remained limited. A novel approach to this surgical dilemma by performing transcatheter aortic valve replacement (TAVR) for severe native aortic valve regurgitation in a patient on the liver transplant list has been presented. The procedure proved to be an effective management for the aortic valve insufficiency, improving our patient's hemodynamics in preparation for the subsequent orthotopic liver transplantation (OLT). © 2015 Wiley Periodicals, Inc.