Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future.

Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.

Early results of a modified biological valved conduit for the Bentall procedure.

INTRODUCTION: Few bioprosthetic valved conduits for aortic root surgery are commercially available. Long-term Warfarin therapy (mechanical), potential root calcification (xeno- or homograft valves), and the need for additional ascending aorta grafts are concerns associated with currently used valved conduits. A simplified, self-assembled bioroot conduit comprising currently available materials that facilitates future intervention and exhibits advantages of a bioprosthesis was used. METHODS: From November 2015 to January 2017, 17 consecutive patients underwent urgent or elective aortic root surgery. A bioroot conduit, constructed using 28 or 30 mm of sinus of Valsalva Gelweave tube graft and a 3 to 5 mm smaller bioprosthetic Trifecta valve sewn into the sinus of Valsalva base, was preconstructed in the operating room before sternotomy. The size of the valved conduit was based on the distal ascending aorta or proximal arch and not aortic annular dimension. The bioroot was sutured to the native aortic annulus at the level of the bottom skirt of the Valsalva graft without contacting the sewing cuff of the bioprosthetic valve. RESULTS: All patients survived the operation and were discharged home without long-term anticoagulation therapy. The mean age was 65 ± 12 years, and 13 patients were male. The cardiopulmonary bypass duration was 169 ± 84 minutes, and the cross-clamp (XC) duration was 110 ± 32 minutes. The operation was elective in 12 patients, urgent/emergent in five, and redo in three. CONCLUSION: A simplified self-assembled bioroot Bentall conduit is appropriate for aortic root reconstruction. Use of a patient-tailored valved conduit will not prolong the cardiac ischemic time and will facilitate future valve replacement.

Type A Aortic Dissection with Antegrade Intimointimal Intussusception.

We describe a 60-year-old man with a history of hypertension who presented to an outside emergency department with chest pain and left lower extremity numbness and weakness. Computed tomography (CT) revealed Stanford type A aortic dissection (TAAD), and he was transferred to our institution for emergent open surgical repair. Review of the outside CT showed no dissection flap in the ascending aorta and a complex flap in the proximal descending thoracic aorta consistent with complex intimal transection at the sinotubular junction and intimointimal intussusception. This case presents high-resolution diagnostic and intraoperative images and illustrates the importance of rapid diagnosis and recognition of the potentially complex nature of the aortic dissection to avoid impending hemodynamic deterioration.

Ventricular Septal Rupture Complicating Silent Myocardial Infarction.

A 55-year-old gentleman presented to the emergency department with shortness of breath for the past 3 days. Cardiac magnetic resonance imaging assessed intracardiac shunting and a mechanism of ventricular septal rupture (VSR), showing significant left-to-right shunting and Qp:Qs of 4:1. There was transmural myocardial infarction as well as an aneurysm at the diaphragmatic inferior wall of the left ventricle.

Renal Dysfunction in Patients with Left Ventricular Assist Device.

Late-stage heart failure and renal dysfunction are often seen in conjunction. Cardiorenal syndrome (CRS) describes the complex interaction between the two disease states. Early literature described the pathophysiology of CRS as related only to reduced cardiac output and decreased renal perfusion. Recent literature suggests a more multifaceted mechanism. Left ventricular assist devices (LVAD), used as bridge-to-transplant and destination therapy in patients with heart failure, impact not only cardiac function but also renal function, especially in those patients with preoperative renal dysfunction. The mechanism by which LVAD implantation affects renal function is complex and understated in early literature. In this review, we discuss the pathogenesis of CRS, the impact of preoperative renal dysfunction in patients undergoing LVAD implantation, and the effect of LVAD implantation on postoperative renal function.

Current considerations for heart-kidney transplantation.

Cardiorenal syndrome is a complex syndrome characterized by dysfunction of the heart and kidneys in an interdependent fashion and is further divided into different subtypes based on primary organ dysfunction. Simultaneous Heart-Kidney transplantation is the treatment of choice for end-stage irreversible dysfunction of both organs, however it may be avoided with determination of cardiorenal subtype and management of primary organ dysfunction. This article discusses types of cardiorenal syndrome, indications and concerns regarding the use of simultaneous heart-kidney transplantation, and outlines algorithms for determination of need for dual vs. single organ transplantation.

Atypical Presentation of Marantic Endocarditis.

We describe a 39-year-old man referred for surgical aortic valve replacement for severe symptomatic aortic stenosis. Intraoperative inspection was unexpectedly consistent with marantic endocarditis. Pathology confirmed nonbacterial thrombotic endocarditis. We present high-resolution intraoperative, diagnostic, and pathology images of nonbacterial thrombotic endocarditis in a patient with antiphospholipid syndrome with atypical presentation.

Acute mitral valve regurgitation secondary to papillary muscle rupture due to infective endocarditis.

BACKGROUND: Papillary muscle rupture due to infective endocarditis is a rare event and proper management of this condition has not been described in the literature. Our case aims to shed light on treatment strategies for these patients using the current guidelines. CASE PRESENTATION: This case presents a 58-year-old male with acute heart failure secondary to papillary muscle rupture. He underwent an en bloc resection of his mitral valve with a bioprosthetic valve replacement. Specimen pathology later showed necrotic papillary muscle due to infective endocarditis. The patient was further treated with antibiotic therapy. He recovered well post-operatively and continued to do well after discharge. CONCLUSION: In patients who present with papillary muscle rupture secondary to infective endocarditis, clinical symptoms should drive the treatment strategy. Despite the etiology, early mitral valve surgery remains treatment of choice for patients who have papillary muscle rupture leading to acute heart failure. Culture-guided prolonged antibiotic treatment is vital in this category of patients, especially those who have a prosthetic valve implanted.

Large, Hormonally Active Primary Cardiac Paraganglioma: Diagnosis and Management.

We describe a 26-year-old woman presenting with chest pain and evidence of coronary ischemia. Echocardiography revealed a large left ventricular mass initially deemed unresectable at her initial institution. Investigation revealed a dopamine-secreting primary cardiac paraganglioma encompassing vital cardiac architecture. This case discusses our heart team approach to complex cardiac masses and illustrates the feasibility of surgical resection in complex cases of hormonally active primary cardiac paragangliomas.

Papillary Fibroelastoma Incidentally Found on Left Atrial Wall During Minimally Invasive Aortic Valve Replacement.

A 60-year-old man was about to undergo minimally invasive aortic valve replacement when transesophageal echocardiography revealed an intracardiac mass on the left atrial free wall. Multimodal images from 5 months earlier had shown no mass. We converted the procedure to open surgery. The excised mass resembled a cardiac myxoma but was determined to be a papillary fibroelastoma. This case illustrates that papillary fibroelastomas can form and grow rapidly, warranting alertness for their unexpected discovery before and during cardiac surgical procedures.

Surgical Salvage of Annular Rupture After Transcatheter Aortic Valve Implantation by Conversion Into Annular Enlargement.

We describe an 88-year-old woman who experienced annular rupture during transcatheter aortic valve replacement despite preventative measures. She underwent Y incision and rectangular patch for the double purpose of repairing the rupture and enlarging the aortic root. We highlight the heart team's role in confronting this potentially catastrophic complication. (Level of Difficulty: Advanced.).

Late Transcatheter Aortic Valve Thrombosis Leading to Cardiogenic Shock.

A 67-year-old woman with prior transcatheter aortic valve replacement presented with worsening dyspnea. Imaging revealed transcatheter aortic valve thrombosis and aortic stenosis. Despite oral anticoagulation, she progressively deteriorated and developed cardiogenic shock. We highlight the Heart Team's role in treating this unusual late thrombosis. (Level of Difficulty: Intermediate.).

Atypical Presentation of Right Ventricular Cardiac Hamartoma in a Young Man.

Cardiac tumors in adults are exceedingly rare and usually benign. We describe a 29-year-old man with a previous diagnosis of interventricular septal hypertrophy who presented with increasing severity of dyspnea and fatigue. Work-up revealed a 4.9 × 3.7 cm mass at the base of the interventricular septum. Biopsy revealed a benign cardiac hamartoma atypically located in the right ventricle, and the mass was resected via right ventriculotomy.

Chronic Thromboembolic Pulmonary Hypertension: A Comprehensive Review and Multidisciplinary Approach to Surgical Treatment.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed and undertreated sequelae of acute pulmonary embolism. In this comprehensive review, we provide an introductory overview of CTEPH, highlight recent advances in its diagnostic imaging, and describe the surgical technique for pulmonary thromboendarterectomy (PTE), the only established curative treatment for CTEPH. We also discuss the emerging role of balloon pulmonary angioplasty, both independently and combined with PTE, for patients with inoperable, residual, or refractory pulmonary hypertension post PTE. Finally, we stress the importance of a specialized multidisciplinary team approach to CTEPH patient care and share our approach to optimizing care for these patients.

Ortner's syndrome: Cardiovocal syndrome caused by aortic arch pseudoaneurysm.

72-year-old hypertensive presented with two weeks history of left sided chest pain and hoarseness. Workup demonstrated a pseudoaneurysm in the lesser curvature of the distal aortic arch opposite the origin of the left subclavian artery from a penetrating atherosclerotic ulcer. Following a left carotid-subclavian bypass, endovascular stenting of the aorta was performed excluding the pseudoaneurysm. Patient had excellent angiographic results post-stenting. Follow up at 12 weeks demonstrated complete resolution of his symptoms and good stent position with no endo-leak. Ortner's syndrome describes vocal changes caused by cardiovascular pathology. It should be included in the differential diagnosis of patients with cardiovascular risk factors presenting with hoarseness. This case demonstrates the use of endovascular stents to treat the causative pathology with resolution of symptoms. In expert hands, it represents low risk, minimally invasive therapeutic strategy with excellent early results in patients who are high risk for open procedure.

Prevalence Pattern of Risk Factors for Coronary Artery Disease among Patients Presenting for Coronary Artery Bypass Grafting in Oman.

OBJECTIVES: To identify the pattern of prevalence of risk factors in patients presenting for coronary artery bypass grafting at a single center in Oman. METHODS: All patients who had coronary artery bypass grafting between March 2008 to March 2010 were included and data were obtained from history and laboratory investigations. The prevalence rates of eight conventional risk factors are presented as a retrospective single center observational study. RESULTS: Out of 146 total patients, 107 (73.29%) were male. The age ranged from 31 to 87 years old. The mean age was 58.18 ± 10.08 years (males = 56.81 ± 10.42, females = 61.95 ± 7.97). Hypertension was present in 119 patients (81.51%), 115 patients (78.77%) had dyslipidemia, 107 patients (73.29%) were male, 79 patients (54.11%) had diabetes mellitus, 70 patients (47.95%) were over the age of 60 years, 41 patients (28.08%) gave a history of smoking, 31 patients (21.23%) were obese, and 19 patients (13.01%) gave a positive family history. CONCLUSIONS: The most common risk factor was hypertension, followed by dyslipidemia, male gender, diabetes mellitus, old age, smoking, obesity and positive family history; 87.7% had three or more risk factors. The females in this study were older than the males and had more risk factors at presentation. The most common combination of factors seen together was diabetes, hypertension, dyslipidemia and male gender.