Access platform techniques for transcatheter aortic valve replacement.

BACKGROUND: One of the unique variables for successful implantation of transcatheter aortic valves involves the ability to secure an access route for deployment of the aortic valve. AIM OF STUDY: A large number of the high-risk patients with critical aortic stenosis referred for transcatheter valve implantation approach may not be candidates for the femoral approach due to peripheral vascular disease with the morbidity and mortality increased severalfold in patients who develop access related complications. METHOD & RESULTS: A thorough knowledge and review of various alternate access site techniques and trouble shooting are therefore important and required by the implanting cardiac surgeons involved in transcatheter aortic valve therapy. CONCLUSION: The article review highlights the various percutaneous, hybrid, and surgical access techniques platforms available as well as options for implantation of these devices.

Tricuspid valve disease.

The normal tricuspid valve anatomy and function have several dissimilarities to the corresponding mitral valve in the left heart, in part, based on lower pressures in the right heart chambers. The functional abnormalities resulting from tricuspid valve disease are classified as primary and secondary. Primary valve disease is any associated intrinsic valve pathology. The list of responsible conditions includes congenital, rheumatic, infective endocarditis, carcinoid heart disease, toxic effects of chemicals, tumors, blunt trauma, and myxomatous degeneration. The secondary tricuspid valve disease does not involve intrinsic anatomic abnormalities of the valve apparatus, aside from tricuspid annular dilation secondary to right ventricular dilation and dysfunction. The most common cause of tricuspid valve disease is secondary to left heart disease, either myocardial, valvular, or mixed. Although bedside diagnosis of advanced tricuspid valve disease is feasible, echocardiography provides valuable clues to the presence and severity of tricuspid valve stenosis and/or regurgitation with considerable accuracy. The tricuspid regurgitation signal using Doppler techniques is utilized for estimation of right ventricular systolic pressure, which, in the absence of right ventricular outflow obstruction, corresponds to pulmonary arterial systolic pressure. This is clinically useful since nearly 80 to 90% of patients exhibit some degree of tricuspid regurgitation. The treatment of tricuspid valve disease is guided by underlying etiology and pathology. Tricuspid valve repair is increasingly advocated for patients with advanced tricuspid regurgitation, especially when combined with surgery on the left heart pathology. Primary tricuspid valve disease is often treated by surgical approach specific to the underlying pathology.

Impact of intraoperative echocardiography/surgery team on successful mitral valve repair: a community hospital experience.

BACKGROUND AND AIM OF THE STUDY: Mitral valve (MV) repair is generally accepted as the preferred treatment of mitral regurgitation (MR) with MV prolapse secondary to myxomatous mitral valve disease (MMVD). However, the incidence of successful valve repair is variable between hospitals and among different surgeons at one hospital, and often results in needless MV replacement. The study aim was to measure the impact of a dedicated echocardiography/surgery team on MV repair at a community hospital. METHODS: The outcome was analyzed of a group of 116 consecutive patients with severe MR secondary to MMVD who underwent surgery by the same surgeon over a six-year period. A dedicated team approach, comprising one echocardiographer and one surgeon was established in January 1999. The results of MV repair between 1996 and 1998 (group I; n = 37) were compared to results obtained between 1999 and 2001 (group II; n = 79). RESULTS: In group I, MV repair was attempted in 25 patients (67.6%) and was successful in 21 (56.8%). In group II, MV repair was attempted in 68 patients (86.1%) and was successful in 67 (84.8%). The success rate between groups was significantly (p = 0.001) different. The rate of successful MV repair in patients with a diffusely redundant prolapsing valve involving both leaflets and multiple segments with chordae elongation was significantly higher in group II (14/20; 70%) than in group I (1/6; 14.3%) (p = 0.011). CONCLUSION: A greater incidence of successful MV repair, even with more diffuse pathology of MMVD, was realized following the institution of dedicated echocardiography/surgery team at a community hospital. It is proposed that a combination of dedicated intraoperative echocardiography and surgical expertise is required for optimal results in MV repair.