Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review.

BACKGROUND: To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE). METHODS: We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020). RESULTS: Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone. CONCLUSIONS: SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.

AIMS: Isolated tricuspid valve surgery (ITVS) is considered to be a high-risk procedure, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR). METHODS AND RESULTS: All consecutive adult patients who underwent ITVS for severe non-congenital TR at 12 French centres between 2007 and 2017 were included. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. The final risk score ranged from 0 to 12 points and included eight parameters: age ≥70 years, New York Heart Association Class III-IV, right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. Tricuspid regurgitation mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65%, respectively, as the score increased from 0 up to ≥9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75, respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63). CONCLUSION: We propose TRI-SCORE as a dedicated risk score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging (www.tri-score.com).

Diagnosis and staging of cardiac masses: additional value of CMR with 18F-FDG-PET compared to CMR with CECT.

PURPOSE: Characterization of malignant cardiac masses is usually performed with cardiac magnetic resonance (CMR) and staging with whole-body contrast-enhanced computed tomography (CECT). In this study, our objective was to evaluate the role of 18Fluor-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) with CMR for both characterization and staging of cardiac masses. METHODS: Patients with cardiac masses who underwent CMR, CECT, and 18F-FDG-PET were retrospectively identified. For the characterization of cardiac masses, we calculated the respective performances of CMR alone, 18F-FDG-PET alone, and the combination of 18F-FDG-PET and CMR. For staging, we compared head-to-head the respective performances of 18F-FDG-PET and CECT. Histology served as gold standard for malignancy, and response to anticoagulation for thrombus. RESULTS: In a total of 28 patients (median age 60.5 years, 60.7% women), CMR accurately distinguished malignant from benign masses with sensitivity (Se) of 86.7%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 86.7%, and accuracy of 92.9%. 18F-FDG-PET demonstrated 93.3% Se, 84.6% Sp, 87.5% PPV, 91.7% NPV, and 89.3% accuracy. Combining CMR with 18F-FDG-PET allowed to benefit from the high sensitivity of 18F-FDG-PET (92.9%) and the excellent specificity of CMR (100%) for malignant diseases. For staging, 18F-FDG-PET outperformed CECT on per-patient (66.7% vs 55.6% correct diagnosis, respectively), per-organ (10 vs 7 organs, respectively), and per-lesion basis (> 29 vs > 25 lesions, respectively). CONCLUSION: Combining 18F-FDG-PET with CMR improved the characterization of cardiac masses compared to each modality alone. Additionally, the diagnostic performance of 18F-FDG-PET was better than CECT for staging. This study suggests that the combination of CMR and 18F-FDG-PET is the most effective for the characterization of cardiac masses and the staging of these lesions.

Diagnostic performance of White Blood Cell SPECT imaging against intra-operative findings in patients with a suspicion of prosthetic valve endocarditis.

AIM: The objective of this study was to evaluate the diagnostic performance of white blood cells (WBC)-SPECT imaging in patients with suspicion of prosthetic valve endocarditis (PVE) against intra-operative findings. METHODS: 36 consecutive patients who underwent cardiac surgery 30 days after WBC-SPECT imaging were identified retrospectively. Clinical, imaging, and biological results were collected from reports. WBC-SPECT results were classified as positive or negative and, if positive, the intensity of signal graded as intense or mild. Lesions observed during cardiac surgery were collected from surgeons' reports. RESULTS: The 20 patients with positive WBC-SPECT study had confirmed PVE intra-operatively. Patients with intense signal on WBC-SPECT had high prevalence of abscesses (83%) compared to patients with only mild signal (12%). The three patients with negative WBC-SPECT but confirmed PVE had longer duration of antibiotic treatment before imaging and had no perivalvular abscess. Sensitivity, specificity, positive predictive and negative values, and accuracy of WBC-SPECT were measured at 87%, 100%, 100%, 81%, and 92%, respectively. Addition of WBC-SPECT results to the modified Duke score helped re-classify correctly 25% of patients from possible to definite PVE. CONCLUSION: In patients with suspicion of PVE, WBC-SPECT imaging provides excellent diagnostic performance against intra-operative findings.

Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes.

AIMS: The aim of this study was to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery (ITVS) and more specifically the impact of tricuspid regurgitation (TR) mechanism and clinical presentation. METHODS AND RESULTS: Among 5661 consecutive adult patients who underwent a tricuspid valve (TV) surgery at 12 French tertiary centres in 2007-2017 collected from a mandatory administrative database, we identified 466 patients (8% of all tricuspid surgeries) who underwent an ITVS. Most patients presented with advanced disease [47% in New York Heart Association (NYHA) III/IV, 57% with right-sided heart failure (HF) signs]. Tricuspid regurgitation was functional in 49% (22% with prior left-sided heart valve surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%). In-hospital mortality and major complications rates were 10% and 31%, respectively. Rates of survival and survival free of HF readmission were 75% and 62% at 5 years. Patients with functional TR incurred a worse in-hospital mortality than those with organic TR (14% vs. 6%, P = 0.004), but presentation was more severe. Independent determinants of outcomes were NYHA Class III/IV [odd ratios (OR) = 2.7 (1.2-6.1), P = 0.01], moderate/severe right ventricular dysfunction [OR = 2.6 (1.2-5.8), P = 0.02], lower prothrombin time [OR = 0.98 (0.96-0.99), P = 0.008], and with borderline statistical significance, right-sided HF signs [OR = 2.4 (0.9-6.5), P = 0.06] while TR mechanism was not [OR = 0.7 (0.3-1.8), P = 0.88]. CONCLUSION: Isolated TV surgery was associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by TR mechanism. Our results suggest that TV intervention should be performed earlier in the course of the disease.

Optimising Aortic Endovascular Repair in Patients with Marfan Syndrome.

OBJECTIVE: In Marfan syndrome (MFS) patients, endovascular repair carries a risk of aortic wall injury, which may result in retrograde aortic dissection, dilatation, or false aneurysm at the landing zones. It was hypothesised that potentially these complications may be avoided using modified practices. This study aimed to describe experience of a specific protocol for endovascular aortic repair in patients with MFS. METHODS: All MFS patients treated by aortic endovascular repair between February 2015 and August 2018 were included prospectively. The following rules were applied: (i) excluding stent grafts with bare stents and barbs, (ii) proximal landing in a pre-existing graft, or (iii) minimising proximal oversizing when landing in the proximal native aorta (<10%), and (iv) distal undersizing for chronic dissection cases. RESULTS: In eighteen patients (55% men, mean age: 47 ± 17 years), the index procedures were initial endovascular aortic repair (n = 10), elephant trunk completion (n = 6), and anastomotic pseudo-aneurysm after thoracic open repair (n = 2). The technical success rate was 100%. Proximal landing was in the native aorta in 11 patients (61%), with a mean proximal oversizing of 2.4 mm (8% oversized). Distal landing in the native aorta was performed in 16 cases (89%), with a mean distal undersizing of 8.9 mm (- 23%). No mortality, spinal cord ischaemia, stroke, or retrograde aortic dissection occurred post-operatively. One type 1b endoleak was observed. The mean follow up was 21.4 months. Aortic aneurysm related mortality was 5% (n = 1) and occurred after distal thoraco-abdominal surgery planned from the outset (prior to endovascular repair). Another patient presented a proximal landing zone complication with aortic enlargement. The mean maximum aortic diameter decreased significantly from 59 mm to 45 mm (p = .0005) after treatment. CONCLUSION: The specific protocol described in this study seems to optimise the results of endovascular aortic repair in MFS patients with significant aortic remodelling.

Clinical and haemodynamic outcomes of balloon-expandable transcatheter mitral valve implantation: a 7-year experience.

Aims: We analysed the early and long-term clinical and haemodynamic outcomes of balloon-expandable transcatheter mitral valve implantation (TMVI) in an experienced centre. Methods and results: All patients undergoing TMVI from July 2010 to July 2017 in our centre were prospectively included. Indication for TMVI relied on the judgement of the local heart team. Patients were followed at 1 month, 1 year, and yearly thereafter. A total of 91 patients underwent TMVI. The median age was 73 (57-81) years and 70% of patients were women. Patients were at high risk for surgery with a median EuroSCORE II of 9.6 (4.0-14.6) %. Indication for TMVI was bioprosthesis failure (valve-in-valve) in 37.3%, annuloplasty failure (valve-in-ring) in 33.0%, and severe mitral annulus calcification (MAC) in 29.7%. The transseptal approach was used in 92.3% of patients and balloon-expandable valves were used in all patients. Technical success was achieved in 84.6% of patients, one patient died during the procedure and haemodynamically significant left ventricular outflow tract obstruction occurred in three patients (3.3%). At 30 days, 7.7% of patients had died, without significant differences between groups, and a major stroke occurred in 2.2% of patients. The cumulative rates of all-cause mortality at 1-year and 2-year follow-up were 21.0% [95% confidence interval (CI) 9.9-38.8] and 35.7% (95% CI 19.2-56.5), respectively, with a higher late mortality in patients with MAC. The 2-year rates of re-intervention and valve thrombosis were 8.8% and 14.4%, respectively. At 6 months to 1 year, 68.9% of patients were in New York Heart Association Class I or II, and 90.7% of patients had mild or less mitral regurgitation. The mean transmitral gradient decreased from 9.3 ± 3.9 mmHg at baseline to 6.0 ± 2.3 mmHg at discharge (P < 0.001) without changes at 6-month to 1-year follow-up. Conclusion: Transcatheter mitral valve implantation using balloon-expandable valves in selected patients with bioprosthesis or annuloplasty failure or severe MAC was associated with a low rate of peri-procedural complications and acceptable long-term outcomes.

Multimodality Imaging in Rothia dentocariosa Infective Endocarditis and Internal Iliac Artery Infectious Aneurysm.

Background: Aneurysms of the internal iliac artery in infective endocarditis are extremely rare, with few cases reported in the literature, and Rothia dentocariosa infective endocarditis are rare. Analysis: We describe the case of a previously healthy 62-year-old male who presented a Rothia dentocariosa infective endocarditis. Results: Multi-modality imaging revealed an aneurysm of the left internal iliac artery, which was clinically silent. The patient was treated with antibiotics and semi-emergent bioprosthesis aortic valve replacement. Follow-up multi-modality imaging showed the regression of the aneurysm. Conclusion: This case shows that an aneurysm of the internal iliac artery in infective endocarditis can regress under antibiotherapy alone. This case also highlights the ability of PET/CT to identify and follow such an aneurysm.

Prophylactic epicardial pacemaker implantation in tricuspid valve replacement.

OBJECTIVES: Patients undergoing surgical tricuspid valve replacement (TVR) are at high risk of atrioventricular conduction disorders. Because implanting a lead through the tricuspid bioprosthesis is discouraged, the patients who undergo TVR in our centre are usually given a prophylactic epicardial pacemaker. Our aim was to assess the benefits and risks of this strategy. METHODS: Among the patients who underwent TVR with prophylactic epicardial pacemaker implantation, clinical evaluations and pacemaker reports were analysed retrospectively after surgery. The need for cardiac pacing were assessed by characterizing the atrioventricular conduction, while the risks were evaluated by listing and adjudicating post-operative events. RESULTS: A total of 80 patients were analysed (mean age was 57 ± 16 years old, 30% males). TVR was isolated in 28 (35%) patients, but most often associated with another valve surgery. In the postoperative period, heart rhythm was analysed in 59/80 patients during a median follow-up of 35 months. Cardiac pacing was needed in 46% patients: 14% had complete pacing dependency, 17% had high degree AV block, while 15% had a high ventricular pacing rate (>80%). No pre- or per-operative variables could predict cardiac pacing requirement. Post-operatively, a spontaneous heart rate >70 bpm (P = 0.02) and the presence of narrow QRS (P = 0.03) were significantly associated with a lower risk of cardiac pacing requirement. Complications related to epicardial pacemaker were documented in 2 (2.5%) patients. CONCLUSIONS: After TVR, cardiac pacing was needed in 46% of patients for post-operative atrioventricular conduction disorders. This high incidence associated with an acceptable safety profile supports a prophylactic epicardial pacing strategy for the patients undergoing TVR.

Predictive value of the TRI-SCORE for in-hospital mortality after redo isolated tricuspid valve surgery.

OBJECTIVES: The TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores. METHODS: Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated. RESULTS: We identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure. CONCLUSION: Redo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

Premier cas d'endocardite infectieuse sur valve aortique prosthétique dû à Prevotella Intermedia.

INTRODUCTION: Prevotella species (i. e. P. intermedia, P. nigrescens, P. pallens, P. oris) are usually responsible for abscesses of head and neck spaces after dental procedures. P. intermedia - related infective endocarditis has never been reported. CASE REPORT: A 22-year-old man, with a history of aortic valve replacement 6 years ago, presented with fever and persistent retrosternal chest pain. An empirical antibiotic therapy was started on (cefotaxime, 2gx3 - gentamicin, 5mg/kilo). Five blood cultures were positive at Prevotella Intermedia. Metronidazole was introduced (500mg X 3 by day).The oro-pharyngeal spaces were normal. The evolution was marked by a hypotension, a third degree atrio-ventricular block, and a rapidly growing aortic root abscess complicated this case of Prevotella Intermedia infective endocarditis (IE). Aortic valve redux surgery was performed at day 5 of admission. Post-operative course was unremarkable. CONCLUSION: This first reported case of Prevotella Intermedia IE presented suggestive features of anaerobic IE as the patient developed both aortic-ring abscess, third degree atrio-ventricular block and hypotension.

Aortic Root Anatomy Is Related to the Bicuspid Aortic Valve Phenotype.

BACKGROUND: Bicuspid aortic valve (BAV) is associated with an asymmetric (not circular) aortic root, resulting in variability in the aortic root diameter measurements obtained using different techniques. The objective of this study was to describe aortic root asymmetry, including its orientation in the thorax, in relation to the various phenotypes of BAV and its impact on aortic root diameter measurements obtained using transthoracic echocardiography. METHODS: Aortic root asymmetry, orientation of the largest root diameter, and orientation of the valve opening were studied using computed tomographic scans of patients with BAV without significant aortic valve dysfunction referred for evaluation of a thoracic aortic aneurysm. Eighty-five patients with BAV were evaluated; BAV with fusion of the left and the right coronary cusps (L-R BAV), with or without raphe (n = 63), was compared with BAV with fusion of the right coronary and noncoronary cusps (N-R BAV), with or without raphe (n = 22). RESULTS: Asymmetry of the aortic root and its orientation in the thorax can be predicted from BAV phenotype: orientation of the valve opening differed from orientation of the largest root diameter by nearly 75° in both groups. The angle of the largest root diameter with the reference sagittal plane was 64.3° in the L-R BAV group versus 143.1° in the N-R BAV group (P < .0001). Therefore, using the parasternal long-axis view on transthoracic echocardiography, in N-R BAV, the ultrasound beam is roughly parallel to the valve opening orientation and almost orthogonal to the maximum diameter of the root. On the contrary, in L-R BAV, the ultrasound beam is roughly perpendicular to the valve opening orientation and almost parallel to the maximum diameter of the root. Consequently, the parasternal long-axis view on transthoracic echocardiography significantly underestimates maximal aortic root diameter in N-R BAV and modestly underestimates root diameter in L-R BAV (-6.1 ± 0.96 vs -2.3 ± 0.47 mm, P = .0008). CONCLUSIONS: Aortic root morphology in patients with BAV can be predicted by BAV phenotype: the largest root diameter is roughly perpendicular to the orientation of the valve opening. Therefore, echocardiographic measurements according to present recommendations (parasternal long-axis view) underestimate maximal diameter in patients with N-R BAV.

Diagnosis of early dysfunction of a tissue mitral valve replacement by three-dimensional transoesophageal echocardiography.

We present the case of a 42-year-old man who underwent tissue mitral valve replacement for symptomatic mitral stenosis. Post-operative course was unremarkable but three-dimensional transoesophageal echocardiography clearly indicated that one cusp had very restricted motion with incomplete opening and premature closure. The cause of this early single cusp failure is unclear. It was not related to flow effects. It is conceivable that cusp failure such as here might contribute towards the degeneration of tissue valve replacements.

Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome.

BACKGROUND: Aortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene. OBJECTIVES: This study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter. METHODS: Patients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up. RESULTS: A total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years. CONCLUSIONS: In patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.

A lesional classification to standardize surgical management of aortic insufficiency towards valve repair.

OBJECTIVE: Aortic valve repair is an alternative to valve replacement for treatment of chronic aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echocardiographic and operative analysis of valvular lesions. METHODS: Classification was based on the retrospective analysis of chronic AI mechanisms of 781 adults operated on electively between 1997 and 2003. RESULTS: AI was isolated (406 patients (52%)), associated with supra-coronary aneurysm (97 cases (12.4%)), or with aortic root aneurysm (278 patients (35.6%)). Etiologies of valvular or aortic lesions were respectively rheumatic, dystrophic and atheromatous in 17%, 73.6% and 9.4% of cases. Lesional classification is based on the analysis of chronic AI mechanisms defining type I with central jet (354 cases, 45.3%) and type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (47 supra-coronary aneurysms), and type Ib as dilation of both sino-tubular junction and aortic annular base (233 root aneurysms, 74 isolated AI). The type II associates dilation of sino-tubular junction and annular base to a valvular lesion: IIa cusp prolapse (95 aneurysms, 200 isolated AI); IIb cusp retraction (132 rheumatic AI), IIc cusp tear (endocarditis, traumatic). CONCLUSION: A lesional classification aims to standardize the surgical management of aortic valve repair: type Ia, by supra-coronary graft; type Ib, by subvalvular aortic annuloplasty associated with the aortic root replacement with a remodelling technique (root aneurysm) or double sub- and supravalvular annuloplasty (isolated AI). For chronic AI type II, aortic annuloplasty associated a remodelling technique or double sub- and supravalvular annuloplasty is combined with the treatment of the cusp lesion (cusp resuspension, cusp reconstruction with autologous pericardium).

Redo aortic root surgery for failure of an aortic homograft is a major technical challenge.

OBJECTIVE: Aortic homografts offer many advantages over prosthetic valves. However, homograft dysfunction due to degeneration or infection may lead to reoperation. Aortic valve replacement in patients who have undergone previous aortic root replacement with an aortic homograft remains a technical challenge. To assess reoperation events a retrospective review was conducted. MATERIALS AND METHODS: From January 2000 to October 2006, 20 consecutive patients (38.8+/-14.9 years old) underwent repeat surgery for aortic homograft failure. RESULTS: Reoperation was performed 7.2+/-3.5 years after implantation of the aortic homograft as a root. Indication was homograft degeneration (n=18 [90%]) and endocarditis (n=2 [10%]). In patients with major homograft wall calcifications or endocarditis, nine aortic root reconstructions were performed (Bentall procedure n=7; homograft implantation n=2). Each homograft was dissected with electrical cauterization and removed 'en-bloc' sparing the coronary buttons. In case of flexible homograft wall, stented prostheses (mechanical n=10, bioprosthesis n=1) were implanted along the homograft annulus. Additional procedures consisted of mitral valve replacements (n=8), tricuspid repairs (n=4), Konno procedure (n=1) and coronary bypass (n=5). Perioperative complications occurred in seven (35%) patients: sternal re-entry accident (n=2); reoperations for mediastinitis (n=1) or bleeding (n=2); renal insufficiency (n=1); total heart block (n=1). No association was found between operative procedures and postoperative complications (Fisher's exact test). Two patients (10%) died from multiorgan failure in the early postoperative period. In total, 94.4% of the survivors remained free from reoperation at 74 months. CONCLUSION: Reoperation on patients with an aortic homograft as a root presents a relatively high perioperative morbidity. The surgical strategy depends on the degree of homograft wall calcification.

Is tricuspid annuloplasty increasing surgical mortality and morbidity during mitral valve replacement? A single-centre experience.

BACKGROUND: Performance of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery is recommended based on the degree of tricuspid regurgitation and tricuspid annulus size, but is often underused. AIM: To evaluate the impact of combined TA on in-hospital outcome in patients undergoing mitral valve replacement (MVR). METHODS: We selected all consecutive patients who underwent MVR for native valve disease. Clinical, echocardiographic and in-hospital complications were obtained from chart review. RESULTS: We identified 287 patients (mean age 62±17 years; 44% men). Combined TA was performed in 165 patients (57%), who had more rheumatic disease (71% vs. 24%; P<0.0001) and mitral stenosis (55% vs. 22%; P<0.0001), but less endocarditis (4% vs. 31%; P<0.0001), were more often in atrial fibrillation (54% vs. 22%; P<0.0001), were more severely symptomatic (80% vs. 57%; P<0.0001), presented with a higher systolic pulmonary artery pressure (SPAP) (53±16 vs. 45±15mmHg; P=0.0002) and were less likely to have required emergency surgery (17% vs. 38%; P<0.0001). Despite this higher risk profile, in-hospital mortality was slightly lower (5% vs. 13%; P=0.02) and complication rates were similar (redo surgery 22% vs. 16% [P=0.18] and tamponade 20% vs. 15% [P=0.15]). After adjustment for age, sex, functional class, SPAP, emergency surgery and concomitant coronary artery bypass graft or aortic valve replacement surgery, combined TA was not associated with an increased rate of in-hospital death (P=0.08) or major complications (P=0.89). CONCLUSIONS: In a consecutive series of patients who underwent MVR, TA did not seem to have a negative impact on immediate outcome. Hence, additional performance of TA at the time of MVR should not be declined on the basis of an increased surgical risk.

Systematic transoesophageal echocardiography after mitral valve replacement: Rates and determinants of paravalvular regurgitation.

BACKGROUND: With the emergence of transcatheter mitral valve replacement, it appears crucial to provide contemporary references with which this new technology can be compared. At our institution, transoesophageal echocardiography is systematically performed before discharge after surgical mitral valve replacement. AIM: To evaluate the rate and determinants of paravalvular regurgitation after surgical mitral valve replacement. METHODS: We collected medical history, indication, type of surgery and in-hospital outcome in all consecutive patients who underwent a mitral valve replacement in the past 2 years at our institution. Paravalvular regurgitation was assessed semiquantitatively using transoesophageal echocardiography before discharge. RESULTS: We enrolled 399 patients (mean age 61±16 years; 58% women; 27% with a history of cardiac surgery). Mitral valve replacement was performed mainly for rheumatic disease (44%). Most patients were severely symptomatic (70% in New York Heart Association class III/IV). A mechanical prosthesis was implanted in 60% and a bioprosthesis in 40%. In-hospital mortality was 10%. Transoesophageal echocardiography was performed in 310 patients (77%); the main reasons for not performing transoesophageal echocardiography were frailty (n=40, 10%), early death (n=19, 5%) and contraindication for transoesophageal echocardiography (n=10, 3%). The overall rate of paravalvular regurgitation was 8% (n=25); a grade ≥2 was observed in five patients (2%), and two patients had to be reoperated on. Mitral annular calcification was the main factor associated with paravalvular regurgitation (P=0.01). CONCLUSIONS: Surgical mitral valve replacement was associated with significant in-hospital mortality and morbidity. Using systematic transoesophageal echocardiography assessment, paravalvular regurgitation was not uncommon (8%), and was significantly linked to mitral annulus calcification. However, clinically significant leakage (≥grade 2) was rare (2%).

Suprasternal brachiocephalic approach as an alternative route for transcatheter aortic valve implantation: a single-centre experience.

AIMS: The aim of this study was to evaluate the feasibility, safety and outcomes of TAVI performed via the suprasternal brachiocephalic approach in selected patients at high or prohibitive surgical risk who are not eligible for transfemoral or subclavian TAVI. METHODS AND RESULTS: From March 2014 to March 2016, 26 high-risk patients without transfemoral or subclavian access options were considered for TAVI via a suprasternal brachiocephalic approach. The feasibility of the suprasternal brachiocephalic approach was determined according to computed tomography findings. In 23 (88.4%) patients the procedure was performed as intended, whereas in three (11.5%) patients the approach was converted to a right carotid access. Both self-expanding (n=20, 76.9%) and balloon-expandable prostheses (n=6, 23.1%) were used. At 30 days, no patient had died; there was one major stroke (3.8%) and there were three major vascular access site-related complications (11.5%). After a median follow-up of 317 days (57-705), two patients had died, both from cardiovascular causes, and 19 out of 24 survivors (79.2%) were in New York Heart Association functional Class I or II. CONCLUSIONS: This single-centre case series suggests that TAVI using the suprasternal brachiocephalic approach is feasible in selected patients and may represent an additional alternative route in patients who are not eligible for other approaches.