Rapid deployment versus trans-catheter aortic valve replacement in intermediate-risk patients: A propensity score analysis.

BACKGROUND: There are insufficient studies comparing rapid deployment aortic valve replacement (RDAVR) and trans-aortic valve replacement (TAVR) in intermediate-risk patients with severe aortic stenosis (AS). AIMS: We compared 2-year outcomes between RDAVR with INTUITY and TAVR with SAPIEN 3 in intermediate-risk patients with AS. METHODS: Inclusion criteria were patients with severe AS at a EuroSCORE II ≥ 4%, who received RDAVR or TAVR implantation and clinical evaluation by the Heart Team. Regression adjustment for the propensity score was used to compare RDAVR and TAVR. Primary outcome was the composite criterion of death, disabling stroke, or rehospitalization. SECONDARY OUTCOMES: major bleeding complications postoperation, paravalvular regurgitation ≥ 2, patient-prosthesis mismatch, and pacemaker implantation. RESULTS: A total of 152 patients were included from 2012 to 2018: 48 in the RDAVR group and 104 in the TAVR group. The mean age was 82.7 ± 6.0,51.3% patients were female, the mean EuroSCORE II was 6.03 ± 1.6%, mean baseline LVEF was 56 ± 13%, mean indexed effective orifice area was 0.41 ± 0.1 cm/m2 , and the mean gradient was 51.7 ± 14.7 mmHg. RDAVR patients were younger (79.5 ± 6 years vs. 82.6 ± 6 years; p = .01), and at higher risk (EuroSCORE II, 6.61 ± 1.8% vs. 5.63 ± 1.5%; p = .005), Twenty-two patients (45.99%) in the RDAVR group and 32 (66.67%) in the TAVR group met the composite criterion. Through the 1:1 propensity score matching analysis, there was a significant difference between the groups, favoring RDAVR (HR = 0.58 [95% CI: 0.34-1.00]; p = .04). No differences were observed in terms of patient-prosthesis mismatch (0.83 [0.35-1.94]; p = .67), major bleeding events (1.33 [0.47-3.93]; p = .59), paravalvular regurgitation ≥ 2 (0.33[0-6.28]; p = .46), or pacemaker implantation (0.84 [0.25-2.84]; p = .77) CONCLUSION: RDAVR was associated with better 2-year outcomes than TAVR in intermediate-risk patients with severe symptomatic AS.

[Reverse Takotsubo cardiomyopathy after iatrogenic epinephrine injection requiring percutaneous extracorporeal membrane oxygenation]. / « Reverse Tako-Tsubo ¼ après injection iatrogène d'adrénaline nécessitant l'intervention d'une équipe mobile d'assistance circulatoire: à propos d'un cas.

PURPOSE: Takotsubo cardiomyopathy is characterized by the sudden onset of reversible left ventricular dysfunction. Associated refractory cardiogenic shock is a rare occurrence and may require extracorporeal membrane oxygenation (ECMO). We report a case of a patient who, following the inadvertent injection of 1 mg of epinephrine, presented with reverse Takotsubo cardiomyopathy and refractory cardiogenic shock that required the implementation of a percutaneous ECMO. CLINICAL FEATURES: A 49-yr-old female patient presented with reverse Takotsubo cardiomyopathy in the operating room after an inadvertent injection of epinephrine. The development of refractory cardiogenic shock required emergent use of a mobile percutaneous ECMO system. It was possible to wean this support after four days, and the patient was later discharged without cardiac or neurological sequelae. The investigations performed confirmed the iatrogenic nature of this reverse Takotsubo cardiomyopathy. CONCLUSION: Takotsubo cardiomyopathy following an injection of epinephrine remains a rare but increasingly described occurrence. The severity of the symptoms appears to be patient dependent, but refractory cardiogenic shock may occur and require significant circulatory support. If this situation occurs in a hospital where this necessary equipment is lacking, a mobile ECMO unit appears to be a viable solution to optimize the patient's chances of survival.

Three-dimensional transesophageal echocardiography assessment of a successful transcatheter mitral valve in valve implantation for degenerated bioprosthesis.

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off-label alternative for patients contra-indicated to surgery. We report a 46-year-old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra-prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three-dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.

Feasibility of Non-Invasive Coronary Artery Disease Screening with Coronary CT Angiography before Transcatheter Aortic Valve Implantation.

Coronary artery disease (CAD) screening is usually performed before transcatheter aortic valve implantation (TAVI) by invasive coronary angiography (ICA). Computed coronary tomography angiography (CCTA) has shown good diagnostic performance for CAD screening in patients with a low probability of CAD and is systematically performed before TAVI. CCTA could be an efficient alternative to ICA for CAD screening before TAVI. We sought to investigate the diagnostic performance of CCTA in a population of unselected patients without known CAD who were candidates for TAVI. All consecutive patients referred to our center for TAVI without known CAD were enrolled. All patients underwent CCTA and ICA, which were considered the gold standard. A statistical analysis of the diagnostic performance per patient and per artery was performed. 307 consecutive patients were enrolled. CCTA was non-analyzable in 25 patients (8.9%). In the per-patient analysis, CCTA had a sensitivity of 89.6%, a specificity of 90.2%, a positive predictive value of 65.15%, and a negative predictive value of 97.7%. Only five patients were classified as false negatives on the CCTA. Despite some limitations of the study, CCTA seems reliable for CAD screening in patients without known CAD who are candidates for TAVI. By using CCTA, ICA could be avoided in patients with a CAD-RADS score ≤ 2, which represents 74.8% of patients.

Reintervention of Residual Aortic Dissection after Type A Aortic Repair: Results of a Prospective Follow-Up at 5 Years.

Background After a type A aortic dissection repair, a patent false lumen in the descending aorta is the most common situation encountered, and is a well-known risk factor for aortic growth, reinterventions and mortality. The aim of this study was to analyze the long-term results of residual aortic dissection (RAD) at a high-volume aortic center with prospective follow-up. Methods In this prospective single-center study, all patients operated for type A aortic dissection between January 2017 and December 2022 were included. Patients without postoperative computed tomography scans or during follow-up at our center, and patients without RAD were excluded. The primary endpoint was all-cause mortality during follow-up for patients with RAD. The secondary endpoints were perioperative mortality, rate of distal aneurysmal evolution, location of distal aneurysmal evolution, rate of distal reinterventions, outcomes of distal reinterventions, and aortic-related death during follow-up. Results In total, 200 survivors of RAD comprised the study group. After a mean follow-up of 27.2 months (1-66), eight patients (4.0%) died and 107 (53.5%) had an aneurysmal progression. The rate of distal reintervention was 19.5% (39/200), for malperfusion syndrome in seven cases (3.5%) and aneurysmal evolution in 32 cases (16.0%). Most reinterventions occurred during the first 2 years (82.1%). Twenty-seven patients were treated for an aneurysmal evolution of RAD including aortic arch with hybrid repair in 21 cases and branched aortic arch endoprosthesis in six cases. In the hybrid repair group, there was no death, and the rate of morbidity was 28.6% (6/21) (one minor stroke, one pulmonary complication, one recurrent paralysis with complete recovery and three major bleeding events). In the branched endograft group, there was no death, no stroke, and no paraplegia. There was one case (16.7%) of carotid dissection. Complete aortic remodeling or complete FL thrombosis on the thoracic aorta was found in 18 cases (85.7%) and in five cases (83.3%) in the hybrid and branched endograft groups, respectively. Conclusions: Despite a critical course in most cases of RAD, with a high rate of aneurysmal evolution and reintervention, the long-term mortality rate remains low with a close follow-up and a multidisciplinary management in an expert center.

Percutaneous drainage of postoperative pericardial effusion in cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage. METHODS: This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view. RESULTS: No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007). CONCLUSIONS: Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.

Risk of reoperation for mitral bioprosthesis dysfunction.

BACKGROUND AND AIM OF THE STUDY: Today, when a mitral valve replacement is required, more patients and surgeons choose a bioprosthesis. Yet, the rationale of this choice is unclear in patients in whom age represents a predicting factor for reoperation. The study aim was to define the risk factors for reoperation after mitral bioprosthesis failure. METHODS: A total of 282 consecutive patients (202 women, 80 men; mean age at surgery 61 years; range: 28-88 years) who underwent reoperation for mitral bioprosthesis failure between 1990 and 2006 was reviewed. Surgery was undertaken because of bioprosthesis degeneration (91%), prosthetic valve infective endocarditis (6%), paravalvular leak (2%), or other causes (1%). Emergency procedures were performed in 7% of cases. Associated procedures included tricuspid valve surgery in 16% of patients (tricuspid valve repair in 11%, tricuspid valve replacement in 5%) and coronary artery bypass graft in 5%. Almost one-fifth of patients (18%) had undergone more than one previous mitral valve replacement. RESULTS: The overall operative mortality was 7.4% (n = 21). Factors identified (by multivariate analysis) as predictors of operative death included: presence of diabetes mellitus (odds ratio (OR) = 8.69, 95% CI 2.55-29.61; p = 0.001), chronic obstructive pulmonary disease (OR = 9.01, 95% CI 1.72-47.18; p = 0.009), NYHA class III/IV (OR 5.46, 95% CI 1.41-21.16; p = 0.01), and pulmonary artery pressure > 60 mmHg (OR = 3.13, 95% CI 1.10-8.94; p = 0.03). Associated procedures were not significant risk factors for mortality. New prostheses were mechanical in 68% of cases, and bioprostheses in 32%. CONCLUSION: One reoperation for mitral bioprosthesis dysfunction is acceptable if the patient can be expected to survive to reoperation while free from comorbidities and the severe effects of mitral disease. The application of strict selective criteria to recipients at the first valve replacement, combined with a close follow up, may allow this goal to be achieved.

Regional mechanical properties of human pulmonary root used for the Ross operation.

BACKGROUND AND AIM OF THE STUDY: Significant dilation of the pulmonary autograft after the Ross operation is problematic and requires reoperation. Autograft remodeling occurs in response to the immediate rise in pressure and consequent wall stress. The stress-strain response of the pulmonary root plays an important role in understanding the structural and functional changes of the autograft following the Ross procedure. At present, limited data are available on the mechanical properties of fresh human pulmonary roots; hence, the study aim was to determine the regional mechanical properties of human pulmonary roots. METHODS: Eighteen fresh healthy specimens of human pulmonary root were obtained from the California Transplant Donor Network (Oakland, CA, USA). Five regions of the pulmonary root--anterior and posterior pulmonary artery (PA), and each of the three sinuses--were subjected to displacement-controlled equibiaxial stretch testing within 24 h of cross-clamp time. Comparisons between the different regions of the pulmonary root were made based on tissue stiffness at physiologic stress. Histologic analyses were also performed of the fibrous structures of the PA and sinuses. RESULTS: Human PA and sinuses demonstrated a nonlinear response to loading, with no directional dependency to biaxial loading. The anterior PA was significantly more compliant than the posterior PA and the three sinuses in both circumferential and longitudinal directions (p < 0.04). However, there was no significant difference between the stiffness of the posterior PA and that of the three sinuses (p > 0.43), or among the three sinuses (p > 0.30) in the two directions. A tight, more dense weave of elastin was found in the anterior PA than in either the posterior PA or the sinuses. CONCLUSION: Significant inherent differences in compliance were demonstrated among different regions of the human pulmonary root. These regional differences may impact upon pulmonary autograft remodeling following the Ross operation, and also influence late autograft dilation.

Multisystem inflammatory syndrome-related refractory cardiogenic shock in adults after coronavirus disease 2019 infection: a case series.

Background: A novel multisystem inflammatory syndrome in children (MIS-C) temporally associated with the coronavirus disease 2019 (COVID-19) infection has been reported, arising weeks after the peak incidence of COVID-19 infection in adults. Patients with MIS-C have been reported to have cardiac involvement and clinical features overlapping with other acute inflammatory syndromes such as Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. Multisystem inflammatory syndrome in children may follow COVID-19 infection, most of the time after its asymptomatic form, even though it can lead to serious and life-threatening illness. Case summary: In this case series, we discuss two cases of young adults with no former medical history who fit with the criteria defined in MIS-C. They both developed a refractory cardiogenic shock and required intensive care treatment including mechanical circulatory support, specifically the use of venous-arterial extracorporeal membrane oxygenation. They were both treated early with intravenous immune globulin and adjunctive high-dose steroids. They recovered ad integrum in less than 2 weeks. Discussion: Multisystem inflammatory syndrome in children occurs 2-4 weeks after infection with severe acute respiratory syndrome coronavirus 2. Patients with MIS-C should ideally be managed in an intensive care environment since rapid clinical deterioration may occur. It would be preferable to have a multidisciplinary care to improve outcomes. Patients should be monitored for shock. Elucidating the mechanism of this new entity may have importance for understanding COVID-19 far beyond the patients who have had MIS-C to date. The pathogenesis seems to involve post-infectious immune dysregulation so early administration intravenous immune globulin associated with corticosteroids appears appropriate. It implies early recognition of the syndrome even in young adults.

Prosthesis-Patient Mismatch in Small Aortic Annuli: Self-Expandable vs. Balloon-Expandable Transcatheter Aortic Valve Replacement.

Prosthesis−patient mismatch (PPM) is associated with worse outcomes following surgical aortic valve replacement (SAVR). PPM has been identified in a significant proportion of TAVR, particularly in patients with small aortic annuli. Our objective was to evaluate the hemodynamic performances of balloon-expandable (BE) (Sapiens 3TM) versus two different self-expandable (SE) (Evolut ProTM, Accurate NeoTM) TAVR devices in patients with small aortic annulus defined by a computed tomography aortic annulus area (AAA) between 330 and 440 mm2. We enrolled 131 consecutive patients corresponding to 76 Sapiens 3 23 mm (58.0%), 26 Evolut Pro (19.9%) and 29 Accurate Neo (22.1%). Mean age was 82.5 ± 7.06 years, 22.9% of patients were male and mean Euroscore was 4.0%. Mean AAA was 374 ± 27 mm2 for Sapiens 3, 383 ± 29 mm2 for Corevalve Evolut Pro and 389 ± 25 mm2 for Accurate Neo. BE devices were associated with significantly higher rates of PPM (39.5%) as compared to SE devices (15.4% for Corevalve Evolut Pro and 6.9% for Accurate Neo) (p < 0.0001). Paravalvular leaks ≥ 2/4 were more often observed in SE devices (15.4% for Corevalve Evolut Pro and 17.2% for Accurate Neo) than in BE devices (2.6%) (p = 0.007). In conclusion, SE TAVR devices did achieve better hemodynamic results despite higher rates of paravalvular leaks. Therefore, SE TAVI devices could be considered as first choice in small aortic anatomy.

Myocardial Revascularization Strategies in ST Elevation Myocardial Infarction Without Urgent Revascularization: Insight From a Nationwide Study.

OBJECTIVE: To analyze the outcomes of patients presenting with ST-segment elevation myocardial infarction (STEMI) without early (<48 hours) revascularization, according to percutaneous versus surgical revascularization. PATIENTS AND METHODS: Based on the French administrative hospital discharge database, the study collected information for all consecutive patients seen for a STEMI in France between January 1, 2010, to June 31, 2019, who underwent either a first percutaneous coronary intervention (PCI) or a first coronary artery bypass graft between 48 hours and 90 days after the index hospitalization. Propensity score matching was used for the analysis of outcomes. RESULTS: Of 71,365 patients with STEMI in the analysis, 59,340 patients underwent PCI and 12,025 patients underwent coronary artery bypass graft. In a matched analysis of 12,012 patients by arm, surgical revascularization was associated with lower rates of all cause (5.1% vs 7.1%; hazard ratio [HR], 0.70; 95% CI, 0.66 to 0.75) and cardiovascular (2.6% vs 3.1%; HR, 0.83; 95% CI, 0.76 to 0.91) death. Rehospitalization for heart failure was less often reported after surgery (5.5% vs 7.5%; HR, 0.76; 95% CI, 0.71 to 0.81) whereas stroke incidence was not statistically different between the two arms (2.1% vs 2.3%; HR, 0.90; 95% CI, 0.80 to 1.00). Major bleeding was less often reported in the PCI arm (4.6% vs 6.1%; HR, 1.31; 95% CI, 1.22 to 1.41). CONCLUSION: In patients with STEMI who did not undergo urgent revascularization (ie, within 48 hours after presentation), surgical revascularization was associated with better outcomes and should be individually considered as an alternative to PCI.

Long-Term Prognosis Value of Paravalvular Leak and Patient-Prosthesis Mismatch following Transcatheter Aortic Valve Implantation: Insight from the France-TAVI Registry.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the preferred treatment for symptomatic severe aortic stenosis (AS) in a majority of patients across all surgical risks. PATIENTS AND METHODS: Paravalvular leak (PVL) and patient-prosthesis mismatch (PPM) are two frequent complications of TAVI. Therefore, based on the large France-TAVI registry, we planned to report the incidence of both complications following TAVI, evaluate their respective risk factors, and study their respective impacts on long-term clinical outcomes, including mortality. RESULTS: We identified 47,494 patients in the database who underwent a TAVI in France between 1 January 2010 and 31 December 2019. Within this population, 17,742 patients had information regarding PPM status (5138 with moderate-to-severe PPM, 29.0%) and 20,878 had information regarding PVL (4056 with PVL ≥ 2, 19.4%). After adjustment, the risk factors for PVL ≥ 2 were a lower body mass index (BMI), a high baseline mean aortic gradient, a higher body surface area, a lower ejection fraction, a smaller diameter of TAVI, and a self-expandable TAVI device, while for moderate-to-severe PPM we identified a younger age, a lower BMI, a larger body surface area, a low aortic annulus area, a low ejection fraction, and a smaller diameter TAVI device (OR 0.85; 95% CI, 0.83-0.86) as predictors. At 6.5 years, PVL ≥ 2 was an independent predictor of mortality and was associated with higher mortality risk. PPM was not associated with increased risk of mortality. CONCLUSIONS: Our analysis from the France-TAVI registry showed that both moderate-to-severe PPM and PVL ≥ 2 continue to be frequently observed after the TAVI procedure. Different risk factors, mostly related to the patient's anatomy and TAVI device selection, for both complications have been identified. Only PVL ≥ 2 was associated with higher mortality during follow-up.

Prosthesis-patient mismatch is an independent predictor of congestive heart failure after transcatheter aortic valve replacement.

BACKGROUND: Little is known about the effect of prosthesis-patient mismatch (PPM) on outcomes after transcatheter aortic valve replacement. We reported previously an increased risk of PPM with the SAPIEN 3 transcatheter heart valve (S3-THV). AIMS: To investigate the association of PPM with 1-year outcomes in patients with severe aortic stenosis (AS) implanted with S3-THV. METHODS: Moderate PPM was defined by an indexed effective orifice area (iEOA)≤0.85cm2/m2, and severe PPM by an iEOA<0.65cm2/m2. Inclusion criteria were severe symptomatic AS and implantation with S3-THV. The primary endpoint was hospitalization for congestive heart failure (CHF) at 1 year; the secondary endpoint was all-cause mortality. RESULTS: A total of 208 consecutive patients were included between 2016 and 2018. Male sex was prevalent (53.8%), mean age was 81.9±6.2 years, mean EuroSCORE II was 4.35±3.37, mean LVEF was 57.9±13%. Moderate and severe PPM were observed in 69 (33.2%) and 10 (4.8%) patients. Patients with PPM were younger (80.4±7 vs 82.8±5.41 years; P=0.006), had a larger BSA (1.84±0.19 vs 1.77±0.19 m2; P=0.01), a lower iEOA (0.73±0.08 vs 1.11±0.22 cm2/m2; P<0.001) and a higher mean gradient (14±4.6 vs 11.9±3.9mmHg; P<0.001). CHF occurred in 16.5% vs 7% (P=0.03). By multivariable analysis, PPM was independently associated with CHF (hazard ratio [HR] 3.17, 95% confidence interval [CI] 1.17 to 8.55; P=0.032), especially in patients with mitral regurgitation≥2/4 (HR>100, 95%CI>100 to>1000; P<0.01). PPM did not correlate with all-cause mortality (HR 0.90, 95%CI 0.22 to 3.03; P=0.86). CONCLUSIONS: PPM after S3-THV implantation is strongly associated with CHF at 1 year, but is not correlated with overall mortality.

Valve-in-valve transcatheter aortic valve implantation after failed surgically implanted aortic bioprosthesis versus native transcatheter aortic valve implantation for aortic stenosis: Data from a nationwide analysis.

BACKGROUND: Valve-in-valve transcatheter aortic valve implantation (TAVI) has emerged as a treatment for aortic bioprosthesis failure in case of prohibitive risk for redo surgery. However, clinical evaluation of valve-in-valve TAVI remains limited by the number of patients analysed. AIM: To evaluate outcomes of valve-in-valve TAVI compared with native aortic valve TAVI at a nationwide level in France. METHODS: Based on the French administrative hospital discharge database, the study collected information for all consecutive patients treated with TAVI for aortic stenosis or with isolated valve-in-valve TAVI for aortic bioprosthesis failure between 2010 and 2019. Propensity score matching was used for the analysis of outcomes. RESULTS: A total of 44,218 patients were found in the database. After matching on baseline characteristics, 2749 patients were analysed in each arm. At 30 days, no significant differences were observed regarding the occurrence of major clinical events (composite of cardiovascular mortality, all-cause stroke, myocardial infarction, major or life-threatening bleeding and conversion to open heart surgery) (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.68-1.01; P=0.32). During follow-up (mean 516 days), the combined endpoint of cardiovascular death, all-cause stroke or rehospitalization for heart failure was not different between the valve-in-valve TAVI and native TAVI groups (RR 1.03, 95% CI 0.94-1.13; P=1.00). CONCLUSION: We observed that valve-in-valve TAVI was associated with good short- and long-term outcomes. No significant differences were observed compared with native valve TAVI regarding clinical follow-up.

Outcomes Following Aortic Stenosis Treatment (Transcatheter vs Surgical Replacement) in Women vs Men (From a Nationwide Analysis).

Gender-differences in survival following transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have been suggested. The objective of this study was to analyze outcomes following TAVR according to gender and to compare outcomes between TAVR and SAVR in women, at a nationwide level. Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with TAVR and SAVR between 2010 and 2019. Outcomes were analyzed according to gender and propensity score matching was used for the analysis of outcomes. In total 71,794 patients were identified in the database. After matching on baseline characteristics, we analyzed 12,336 women and 12,336 men treated with TAVR. In a second matched analysis, we compared 9,297 women treated with TAVR and 9,297 women treated with SAVR. Long term follow-up showed lower risk of all-cause death (12.7% vs 14.8%, hazard ratio (HR) 0.85, 95% CI 0.81 to 0.90) in women than men. Although the difference in cardiovascular death remained non-significant (5.8% vs 6.0%, HR 0.96, 95% CI 0.88 to 1.05), non-cardiovascular death was less frequent in women than in men following TAVR (6.9% vs 8.8% HR 0.78, 95%CI 0.72 to 0.84).When TAVR was compared with SAVR in women, long-term follow-up with TAVR showed higher rates of all-cause death (11.2% vs 6.5%, HR 1.91, 95%CI 1.78 to 2.05), cardiovascular death (5.0% vs 3.2%, HR 1.44, 95%CI 1.30 to 1.59), and non-cardiovascular death (6.2% vs 3.3%, HR 2.48, 95% CI 2.25 to 2.72). In conclusion, we observed that women undergoing TAVR have lower long-term all-cause mortality as compared with TAVR in men, driven by non-cardiovascular mortality. SAVR was associated with lower rates of long-term cardiovascular adverse events in women as compared with TAVR.

Risk of reoperation for aortic bioprosthesis dysfunction.

BACKGROUND AND AIM OF THE STUDY: The risk of reoperative valve replacement for failed aortic bioprosthesis may be overestimated, this being a dominant factor when selecting an initial prosthesis to be implanted in patients aged <70 years. The study aims were, first, to analyze the mortality and morbidity of redo aortic bioprosthesis replacement in the current era, and second, to identify preoperative risk factors and evaluate the EuroSCORE. METHODS: A total of 156 consecutive patients (111 men, 45 women; mean age 60.9 years; range: 23-87 years) who underwent reoperation for failed aortic bioprosthesis between 1990 and 2006 was reviewed in this retrospective, single-center study. Surgery was undertaken due to bioprosthesis degeneration (82.7%), bacterial prosthetic endocarditis (14.1%), paravalvular leak (1.3%) and other causes (1.9%). Emergency procedures were performed in 9% of patients. Associated procedures were coronary artery bypass grafting in 7.7% of patients, ascending aortic graft in 7%, and complete aortic root replacement in 6.4%. The predictive mortality was 8% according to the Additive EuroSCORE, and 15% according to the Logistic EuroSCORE. RESULTS: Overall, the operative mortality was 3.8% (n = 6), and postoperative morbidity was low. The only multivariable predictor was emergency surgery (OR = 15.22, 95% CI = 1.68-86.43; p = 0.02). A mortality trend was associated with atrial fibrillation and NYHA class III/IV, but this was not statistically significant (p = 0.09 and p = 0.06, respectively). Associated procedures were not significant risk factors for mortality. CONCLUSION: Reoperation for aortic bioprosthesis dysfunction can be performed with a low risk of mortality. It appears that this risk is overestimated by the EuroSCORE. Those patients who wish to avoid postoperative anticoagulant therapy may choose to receive this type of valve, even if reoperation is foreseeable.

Aortic valve-in-valve implantation: impact of transcatheter- bioprosthesis size mismatch.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valves (TAVs) provide minimally invasive treatment for high-risk patients with severe native aortic stenosis. While the off-label application of TAV for degenerative bioprosthetic stenosis (valve-in-valve therapy) is attractive, few cases have been reported. If the rigid annulus and stent posts of bioprostheses prevent full expansion of the TAV, the hemodynamic performance may be compromised. The study aim was to evaluate the use of a 23 mm TAV within normal bioprostheses of equivalent or smaller orifice sizes. METHODS: Twelve TAVs designed to mimic the 23 mm Edwards SAPIEN valve were created using stainless steel stents and trileaflet pericardial valves. A custom-built pulse duplicator was used to measure the hemodynamic performance of the TAV within 19, 21 and 23 mm Edwards pericardial bioprostlieses. The transvalvular gradient, effective orifice area (EOA) and regurgitant volume were used to evaluate valve-in-valve therapy for each valve size. RESULTS: The TAV demonstrated similar hemodynamics to the Edwards SAPIEN valve (mean pressure gradient 6.68 +/- 2.11 mmHg and EOA 2.07 +/- 0.35 cm2). Acceptable valve-in-valve hemodynamics were achieved only in the 23 mm bioprosthesis after TAV implantation, with no significant change in mean pressure gradient (5.93 +/- 0.87 to 8.27 +/- 1.19 mmHg, p = 0.052) and EOA (2.13 +/- 0.15 to 1.79 +/- 0.15 cm2, p = 0.053). In 19 and 21 mm valves, the excess pericardial tissue relative to the stent EOA resulted in severe and moderate stenosis, respectively. The mean pressure gradient increased from 16.18 +/- 2.20 mmHg to 45.53 +/- 12.54 mmHg (p = 0.004) in 19 mm bioprostheses, and from 11.84 +/- 1.88 mmHg to 28.18 +/- 9.03 mmHg (p = 0.004) in 21 mm bioprostheses. Furthermore, the EOA was reduced from 1.28 +/- 0.1 to 0.78 +/- 0.11 cm2 (p < 0.001) in 19 mm valves, and from 1.51 +/- 0.15 to 1.01 +/- 0.19 cm2 (p < 0.001) in 21 mm bioprostheses. The TAV resulted in an increased regurgitant volume for all valve sizes. CONCLUSION: Oversized TAVs are constrained by rigid bioprostheses, creating hemodynamic complications. Patients with 19 and 21 mm Edwards pericardial bioprostheses may be poor candidates for valve-in-valve therapy with the currently available technology.

Open-heart transcatheter aortic valve replacement in complex aortic valve reoperation: about a case series.

INTRODUCTION: Aortic homograft and stentless aortic root are helpful in acute infective endocarditis of the aortic valve as biological conduit when total root replacement is required. Reoperation for failure of aortic homograft and stentless aortic root remains challenging for the surgeon as the entire root can be heavily calcified. CASE PRESENTATION: Here, are reported, three cases of patients successfully treated with open-heart transcatheter aortic valve replacement (TAVR) whereas no other prosthesis was implantable due to a massively calcified homograft or stentless prosthesis. DISCUSSION: Open-heart TAVR avoided the risk of complete root replacement which is higher than redo aortic valve replacement (AVR). This rescue technique facilitated risky surgical procedure by combining the strengths of both TAVR and conventional AVR.

Patient-prosthesis mismatch in new generation trans-catheter heart valves: a propensity score analysis.

Aims: When compared with the former Sapien XT (XT-THV), the Sapien 3 trans-catheter heart valve (S3-THV) embeds an outer annular sealing cuff to prevent para-valvular regurgitation (PVR). The consequences of this new feature on valve haemodynamics have never been evaluated. We aimed to compare both types of prostheses regarding patient-prosthesis mismatch (PPM). Methods and results: Patients who underwent a TAVR for aortic stenosis were retrospectively included. Regression adjustment for the propensity score was used to compare 50 XT-THV patients with 71 S3-THV. At the 1-month follow-up, the mean indexed effective orifice area (iEOA) was 1.12 ± 0.34 cm2/m2 with XT-THV and 0.96 ± 0.27 cm2/m2 with S3-THV. The mean gradient was 11 ± 5 mmHg and 13 ± 5 mmHg, respectively. Nine patients had moderate PPM, and two exhibited severe PPM with XT-THV. Nineteen patients had moderate PPM, and seven demonstrated severe PPM with S3-THV. There was a five-fold increased risk of PPM with S3-THV (OR = 4.98; [1.38-20.94], P = 0.019). S3-THV decreased the iEOA by 0.21 cm2/m2 [-0.21; (-0.38 to - 0.05); P = 0.012] and increased the mean gradient by 4.95 mmHg [4.95; (2.27-7.64); P < 0.001]. The risk of PPM was increased 15.24-fold with 23 mm S3-THV [15.24; (2.92-101.52); P = 0.002] in comparison with the 23 mm XT-THV. PVR were reduced by 98% with S3-THV. Conclusion: There is an increased risk of PPM with 23mm S3-THV in comparison with 23 mm XT-THV. This may be attributable to the additional sub-annular cuff that avoids the risk of PVR. Regarding the increased vulnerability of younger patients to PPM, we provide essential information on the extension of TAVR indication to the younger population.