Valve-in-valve implantation to seal post-dilation-induced annular rupture in transcatheter aortic valve replacement.

An 85-year-old woman was admitted to our hospital with severe symptomatic aortic stenosis. Preoperative computed tomography and transesophageal echocardiography (TEE) revealed a type I bicuspid aortic valve.

Single-Center Experience with the Balloon-Expandable Myval Transcatheter Aortic Valve System in Patients with Bicuspid Anatomy: Procedural and 30-Day Follow-Up.

Aims: To report our single-center data regarding the initial 52 consecutive patients with a bicuspid aortic valve who underwent a Transcatheter Aortic Valve Implantation (TAVI) procedure using the new balloon-expandable MYVAL system. The focus is on reporting procedural details and outcomes over the 30-day postoperative period. Methods: From December 2019 to July 2023, 52 consecutive patients underwent a TAVI procedure with bicuspid anatomy. All patients had moderate to-high surgical risk or were unsuitable for surgical aortic valve replacement based on the Heart Team's decision. Outcomes were analyzed according to the VARC-2 criteria. The results of bicuspid patients were compared to patients with tricuspid anatomy in the overall study group, and further analysis involved a comparison between 52 pairs after propensity score matching. The device performance was evaluated using transthoracic echocardiography. Data collection was allowed by the Local Ethical Committee. Results: The mean age was 71 ± 7.1 years, and 65.4% were male. The mean Euroscore II and STS score were 3.3 ± 3.2 and 5.2 ± 3.3, respectively. Baseline characteristics and echocardiographic parameters were well balanced even in the unmatched comparison. Procedures were significantly longer in the bicuspid group and resulted in a significantly higher ARI index. All relevant anatomic dimensions based on the CT scans were significantly higher in bicuspid anatomy, including a higher implantation angulation, a higher rate of horizontal aorta and a higher proportion of patients with aortopathy. In the unmatched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 1.4% (p = 0.394), device success 100% vs. 99.1% (p = 0.487), TIA 1.9% vs. 0% (p = 0.041), stroke 1.9% vs. 0.9% (p = 0.537), major vascular complication 3.8% vs. 2.3% (p = 0.530), permanent pacemaker implantation 34% vs. 30.4% (p = 0.429), and cardiac tamponade 0% vs. 0.5% (p = 0.624). In the propensity-matched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 0%, device success 100% vs. 100%, TIA 1.9% vs. 0% (p = 0.315), stroke 1.9% vs. 0.9% (p = 0.315), major vascular complication 3.8% vs. 0% (p = 0.475), permanent pacemaker implantation 34% vs. 24% (p = 0.274), and cardiac tamponade 0% vs. 0%. There was no annular rupture nor need for second valve or severe aortic regurgitation in both the unmatched and matched comparison. The peak and mean aortic gradients did not differ at discharge and at 30-day follow-up between the two groups regardless of whether the comparison was unmatched or matched. There were no paravalvular leakages (moderate or above) in the bicuspid patients. Intermediate and extra sizes of the Myval THV system used a significantly higher proportion in bicuspid anatomy with a significantly higher oversize percentage in tricuspid anatomy. Conclusions: The TAVI procedure using the Myval THV system in patients with significant aortic stenosis and bicuspid aortic valve anatomy is safe and effective. Hemodynamic parameters do not differ between tricuspid and bicuspid patients. However, the permanent pacemaker implantation rate is higher than expected; its relevance on long-term survival is controversial.

Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement.

Objective: Whereas transcatheter aortic valve replacement is widely implemented, annular rupture is a devastating complication and could be highly mortal. However, owing to its rare incidence, the optimal treatment algorithm has not been established. Thus, we evaluated the feasibility and effectiveness of a 3-step algorithm to treat annulus rupture. Methods: From 2009 to 2022, 8 patients of 1083 transcatheter aortic valve implantation (0.8%) developed annulus rupture and were treated with the three-step algorithm. The algorithm was composed of a first step (pericardial drainage and protamine neutralization with blood pressure control), second step (manual hemostatic compression via full/partial sternotomy), and a third step (conservative treatment or radical surgical correction). Results: The median age at the procedure was 85 (78-88) years and 7 female patients were included in this study. Two (25%) patients had end-stage renal failure under hemodialysis, and median Society of Thoracic Surgeons score was 8.9% (2.1%-23.2%). The implanted transcatheter heart valves (THVs) were 7 balloon-expandable THVs and 1 self-expandable THV with balloon postdilatation. Under this strategy, 8 (100%) patients underwent pericardial drainage as first step and 5 patients achieved hemostasis. Of these, patient 1 demonstrated bleeding from left sinus of Valsalva and required a Bentall procedure. Although the etiology of this phenomenon was not investigated by contrast-enhanced computed tomography, it might be derived from pseudoaneurysm rupture or delayed annular rupture. In 2 patients, the second step treatment was needed for hemostasis. Third-step treatment was conducted in 1 patient. Postoperatively, 6 patients could be discharged without critical complications whereas 2 patients died during the hospitalization. There were no other complications during the followed-up (584 [7-1614]) days. Conclusions: In accordance with the three-step algorithm, 6 patients, including those with high-risk or inoperative status, survived.

Single center experience with the balloon-expandable Myval transcatheter aortic valve system with the first 100 patients: 30-day and 1-year follow-up.

AIMS: To report our single-center data, regarding the first 100 patients who underwent TAVR procedure with the new balloon-expandable MYVAL system. We report 30-day and 1-year outcomes in low to high-risk TAVR patient population. METHODS: From November 2019 to July 2021, 100 consecutive patients underwent TAVR procedure. Patient outcome was classified according to the VARC-2 definitions. The device performance was assessed using transthoracic echocardiography. Data collection was allowed by the Local Ethical Committee. RESULTS: The mean age was 74.7 years, 63 (63%) were male. The mean Euroscore II and STS score were 4.8 ± 4.9 and 5.6 ± 3.9, respectively. Transfemoral access was the most frequent (surgical vs. percutaneous 2% vs. 97%) and in one patient surgical subclavian access was used. VARC-2 outcomes were as follows: device success 99%, STROKE 1%, major and minor vascular complication was 1% and 11%, respectively, the rate of new permanent pacemaker implantation was 30.7%. At discharge, the incidence of grade I, grade II aortic regurgitation was 39% and 1%, respectively, without relevant PVL. In-hospital mortality was only 1%. These results included a high proportion (17%) of patients with bicuspid aortic valves. At 1 year, the all-cause mortality rate was 7% (only two due to cardiac event) and only a single patient had valve-related dysfunction requiring surgical aortic replacement. CONCLUSIONS: TAVR procedure with MYVAL transcatheter heart valve system shows excellent 30-day and 1-year outcomes regarding patient survival, technical success, and valve-related adverse events. The limitations of our study comprise a single-center study with retrospective data collection.

Transannular rupture during transcatheter aortic valve replacement: management in a patient with prior cardiac surgery.

Annular rupture occurs in approximately 1% of transcatheter aortic valve replacement cases. Annular rupture often requires surgical management and is associated with high mortality. Repair of annular rupture in patients with previous coronary artery bypass grafting (CABG) is undercharacterized and poses a unique challenge given the increased difficulty and complexity from both an emergent and reoperative case. An 80-year-old male with previous CABG experienced annular rupture post-transcatheter aortic valve replacement requiring urgent surgical management. This case illustrates the successful repair of a rare and high-risk complication describing the approach utilized in correcting annular rupture in a patient with previous CABG.

Damage to the base of the main blood vessel supplying blood to the body (the aortic annulus) after transcatheter aortic valve replacement (TAVR), a minimally invasive procedure to replace a narrowed aortic valve that fails to open properly, is rare. Annular rupture, a term used for injuries that occur in the region of the base of the aorta during TAVR, often needs surgical management. It also carries a high risk of death. Repair of annular rupture in patients with previous coronary bypass surgery, a surgery used to treat coronary heart disease, a condition where blood vessels of the heart become narrowed due to a buildup of fatty material within their walls, is not well described and poses a unique challenge. An 80-year-old male with previous bypass surgery had an annular rupture after TAVR requiring urgent surgery. This case illustrates the successful repair of a rare and high-risk complication. This case report also describes the approach for correcting this complication in a patient with previous bypass surgery.

Biomechanical evaluation of a novel intervertebral disc repair technique for large box-shaped ruptures.

Objective: The purpose of this study was to analyze the feasibility of repairing a ruptured intervertebral disc using a patch secured to the inner surface of the annulus fibrosus (AF). Different material properties and geometries for the patch were evaluated. Methods: Using finite element analysis, this study created a large box-shaped rupture in the posterior-lateral region of the AF and then repaired it with a circular and square inner patch. The elastic modulus of the patches ranged from 1 to 50 MPa to determine the effect on the nucleus pulposus (NP) pressure, vertical displacement, disc bulge, AF stress, segmental range of motion (ROM), patch stress, and suture stress. The results were compared against the intact spine to determine the most suitable shape and properties for the repair patch. Results: The intervertebral height and ROM of the repaired lumbar spine was similar to the intact spine and was independent of the patch material properties and geometry. The patches with a modulus of 2-3 MPa resulted in an NP pressure and AF stresses closest to the healthy disc, and produced minimal contact pressure on the cleft surfaces and minimal stress on the suture and patch of all models. Circular patches caused lower NP pressure, AF stress and patch stress than the square patch, but also caused greater stress on the suture. Conclusion: A circular patch with an elastic modulus of 2-3 MPa secured to the inner region of the ruptured annulus fibrosus was able to immediately close the rupture and maintain an NP pressure and AF stress similar to the intact intervertebral disc. This patch had the lowest risk of complications and produced the greatest restorative effect of all patches simulated in this study.

Annular Rupture Due to Calcified Nodule Located in Left Ventricular Outflow Tract (LVOT) During Transcatheter Aortic Valve Replacement (TAVR) Managed by Protamine Sulfate.

Annular rupture is a rare yet fatal complication of transcatheter aortic valve replacement (TAVR). The likelihood of annular rupture is increased by the presence of extensive subannular calcification, excessive balloon dilatation for valve expansion or aggressive valve oversizing to prevent paravalvular leakage during TAVR. Although extensive annular or aortic root calcification increases the likelihood of annular rupture, rupture due to the presence of a calcified nodule in the left ventricular outflow tract (LVOT) is not commonly reported. We present the case of an 84-year-old man who developed an annular rupture during TAVR, likely due to the presence of a calcified nodule located in LVOT, which was noted on a pre-procedural computed tomography (CT) scan. The rupture was identified early and was successfully reversed with the administration of protamine sulfate during the procedure.

Enterococcus faecalis endocarditis resulting in annular rupture: a case report.

Enterococcus faecalis is the third most common organism to cause infective endocarditis and is associated with high rates of morbidity and mortality. E. faecalis infective endocarditis often presents with a subacute course and with nonspecific constitutional symptoms. Complications related to E. faecalis infective endocarditis are common and include embolic events, abscess formation and pseudoaneurysm formation. Contained annular rupture is a complication of E. faecalis infective endocarditis that, to the authors knowledge, has not been previously described in the literature. Herein, we present an unusual case of a 62-year-old male presenting with classical symptoms of E. faecalis infective endocarditis which resulted in an unusual complication of this condition, a contained annular rupture and the surgical management undertaken to correct this condition.

Enterococcus faecalis is the third most common organism to cause infection of the heart and heart valves and is associated with high rates of complications and death. Complications related to E. faecalis heart infections are common and include dislodging of infected material, abscess formation and injury to blood vessel walls. Contained rupture of the aortic valve annulus is a complication of E. faecalis infections that, to the authors knowledge, has not been previously described in the literature. Herein, we present an unusual case of a 62-year-old male presenting with classical symptoms of E. faecalis infection of the heart which resulted in an unusual complication of this condition, a contained annular rupture and the surgical management undertaken to correct this condition.

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.).

Bespoke valve sizing avoids annular rupture in patients treated with a balloon-expandable transcatheter heart valve.

BACKGROUND: Annular and left ventricular outflow tract (LVOT) calcification increase the risk of annular rupture following transcatheter aortic valve replacement (TAVR). The outcomes of a strategy of routine use of a balloon-expandable valve (BEV) for all patients irrespective of annular or LVOT calcium is unknown. OBJECTIVES: We evaluated the impact of bespoke sizing on annular rupture in patients treated with a BEV. METHODS: All consecutive patients undergoing TAVR at a single centre (February 2020-February 2022) were treated only with a BEV. No other valve design was used. Annular/LVOT calcification was assessed using a standardized grading system. For each annular area, we determined the percentage valve oversizing with nominal deployment. The balloon deployment volume was then adjusted when required (over-/underfilled) to achieve over-sizing of approximately 5% in the presence of annular/LVOT calcium and 5%-10% in the absence of annular/LVOT calcium. Adjusted valve areas were assumed to change proportionately to the change in balloon deployment volume. RESULTS: Among 533 TAVR treated patients, annular/LVOT calcification was present in 166 (31.1%) and moderate or severe in 90 (16.9%). In patients with annular/LVOT calcification, the adjusted oversizing was 3.5 ± 3.6% and in patients without annular/LVOT calcification, the adjusted oversizing was 6.8 ± 4.7% (p < 0.001). There were no cases of annular rupture and no cases with more than mild paravalvular leak (PVL). Mild PVL was more frequent in patients with annular/LVOT calcium (10.8% vs 4.6%, p = 0.01). CONCLUSION: Bespoke BEV sizing by adjustment of balloon deployment volume avoided annular rupture in patients undergoing TAVR.

Valve implantation for successful sealing of a balloon predilatation-induced annular rupture during transcatheter aortic valve replacement.

Annular rupture is a rare and dreaded complication of transcatheter aortic valve replacement (TAVR) and even rarer when caused by predilatation balloon aortic valvuloplasty. This complication often presents as sudden cardiac tamponade with hypotension and requires urgent intervention. The traditional rescue strategy for patients with annular rupture is emergency surgical repair. However, the mortality rate is still high, considering that most patients who undergo TAVR are not candidates for conventional cardiac surgery. Therefore, there is a need for additional emergency treatment strategies to decrease mortality. This report describes a case of predilatation-induced annular rupture during TAVR that was successfully sealed at the rupture site by valve implantation. This case suggests that continuing with valve deployment may be a successful treatment for predilatation-induced annular rupture during TAVR.

Mechanical Complications of Transcatheter Aortic Valve Replacement.

Mechanical complications after transcatheter aortic valve replacement are fortunately rare with the current generation of devices. Unfortunately, life-threatening complications will occur and it is the responsibility of operators to be familiar with strategies to prevent and manage these challenging scenarios. Because these cases will not occur often, it is important for us to highlight and talk about those that do occur, to learn best practices in how to manage and prevent them going forward. We can learn much from each other's good crash landings.

Surgical Repair of a Transannular Rupture During Transfemoral Transcatheter Aortic Valve Replacement.

Annular rupture is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). Mortality rates are high if immediate intervention, most often necessitating surgical repair, is not performed. Herein, we describe an 87-year-old man who, after deployment of TAVR, experienced acute decompensation and required urgent conversion to a midline sternotomy to repair an aortic annular rupture. This case demonstrates an example of a rare but severe complication of TAVR. This report provides an in-depth description of the surgical approach to repair an aortic annular rupture and demonstrates the utility of performing minimally invasive procedures inside a hybrid operating room.

"Unlucky punch": unexpected annular rupture during TAVR and successful treatment.

Although rare, annular rupture in TAVR is a feared and often unpredictable complication with relevant impact on in-hospital prognosis. Severe annular calcification is a common risk factor for annular rupture. We report on a case of annular rupture during TAVR with a balloon-expanded prosthesis in the absence of any annular calcification in the planning CT scan and illustrate the proposed pathomechanism as well as its successful immediate surgical management.

Mitral prosthetic size predictor in minimally invasive mitral valve replacement.

BACKGROUND: Minimally invasive mitral valve replacement has become popular across the world. However, annular rupture and patient - prosthetic mismatch (PPM) are still problematic, particularly in the Asian population. To avoid this, a predictor model could be beneficial. Our study aimed to assess the value of mitral valve diameters measured on TTE and CT scan on predicting the actual mitral prostheses. METHODS: From January 2018 to December 2019, a total number of 96 patients underwent minimally invasive mitral valve replacement. The association between imaging measurements and the outcome was checked by scatter plot and Pearson's correlation coefficient. Univariable linear regression was used to build the prediction model. RESULTS: The three strongest correlations for the whole population are the following features: Mean TTE diameter (0.702), mean diameter on CT lowest plane through the mitral annulus (0.679), and area-derived diameter on CT highest plane through the mitral annulus (0.665). The prosthetic size of the tissue valve group was more correlated to the calculated annulus diameters than that of the mechanical valve group. Tissue valve size predictor models based on these calculated diameters were 16.19 + 0.27 × d (r = 0.744), 12.74 + 0.44 × d (r = 0.756) and 12.79 + 0.38 × d (r = 0.730), respectively. CONCLUSION: Mitral prosthetic size could be predicted based on the mitral diameters measured on TTE and CT scan. The overall correlation coefficient varied from 0.665 (CT Scan) to 0.702 (TTE). These models performed better when applied to bioprosthesis.

Percutaneous Management of a Contained Annular Rupture Occurring With Self-Expanding Transcatheter Aortic Valve Replacement.

Annular rupture is a rare catastrophic event during transcatheter aortic valve replacement, often life threatening and requiring emergent surgical repair. We describe, herein, a case of contained annular rupture successfully managed percutaneously with coiling and polymer injection. This is a novel technique to manage this complication. (Level of Difficulty: Advanced.).