Long term follow up of percutaneous treatment for degenerated Mitroflow prosthesis with self-expanding transcatheter aortic valve implantation.

BACKGROUND: The durability of aortic valve bioprosthesis and the structural valve deterioration (SVD) are could be treated with valve-in-valve (VIV) transcatheter aortic valve implantation (TAVI). This technique has been proven to be a feasible procedure with good results in selected patients. The aim of this work was to assess the long-term results of this TAVI with an autoexpandable valve in patients with failed Mitroflow (MF) bioprosthetic aortic valves. METHODS: Single center, observational and prospective study that included 65 consecutive patients with symptomatic failed MF bioprosthetic aortic valve, treated with VIV-TAVI. The primary endpoints were clinical long-term events including all-cause mortality, cardiovascular mortality, re-hospitalization due to heart failure, stroke/transient ischemic attack (TIA) and endocarditis. Secondary endpoints were the absence of SVD or patient-prosthesis mismatch (PPM) and valve hemodynamics analysis at follow-up. RESULTS: Between March 2012 to July 2019, 65 symptomatic patients (age 80.4±5.9 years) with degenerated MF valves (numbers 19: 27.7%; 21: 38.5%; 23: 21.5%; 25: 12.3%) underwent CoreValve (n=11) or Evolut R (n=54) implantation (23, 26 and 29 mm sizes). The STS predicted risk of mortality was 6.39%±5.62%. The primary combined endpoint occurred in 32.3% of the cases. A total of 13 patients (20%) died during follow-up, but 4 (7.3%) from cardiovascular causes. Two patients were reported of having a stroke/TIA and 5 readmissions for cardiovascular causes were reported (2 of them within the first 30 days). Twenty-five patients (38.5%) presented PPM during follow-up, being PPM severe in 15 (23.1%). CONCLUSIONS: Self-expanding TAVI for degenerated MF bioprosthesis has favourable long-term outcomes. It is a good option in order to avoid the risks of redo surgery in selected patients.

Cerebral protection devices for transcatheter aortic valve replacement.

Aortic stenosis is the most prevalent primary valve disease in developed countries. Its prevalence is increasing due to population aging. Transcatheter aortic valve replacement (TAVR) is a sterling therapy for symptomatic patients with severe aortic stenosis and high or intermediate surgery risk. The number of procedures has increased exponentially expanding to younger and lower risk patients. Despite new-generation TAVR devices and enhanced operator skills, cerebrovascular events (CVEs) carry on being one of the most severe complications, increasing morbi-mortality. CVE might be under reported because there are few studies with rigorous neurological clinical assessment. Several imaging studies show most of CVE after TAVR has a probable embolic etiology. The risk of CVE ranges from 2.7% to 5.5% at 30 days. As TAVR expands to younger and lower risk patients, the prevention of stroke plays an increasingly important role. Cerebral protection devices (CPD) were designed to reduce the risk of CVE during TAVR. This review describes the scientific evidence on CVE after TAVR and summarizes the performance and results of the main CPDs.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

The Prevalence of Patient-Prosthesis Mismatch Can Be Reduced Using the Trifecta Aortic Prosthesis.

BACKGROUND: Some important studies have shown that patient-prosthesis mismatch is a frequent occurrence after surgical aortic valve replacement that impairs survival. The Trifecta valve (St. Jude Medical Inc, St. Paul, MN) has special architecture designed to achieve the best hemodynamic profile. The aim of this study was to determine the prevalence of mismatch when using this prosthesis. METHODS: This study included 1,302 patients at 3 months postoperatively, 339 patients with a Trifecta prosthesis and 963 patients (the control group) with a Mitroflow aortic valve (Sorin Group Inc, Mitroflow Division, Vancouver, Canada). Multinomial multivariate logistic regression was calculated to estimate the association between the Trifecta prosthesis and moderate or severe patient-prosthesis mismatch. RESULTS: Any degree of mismatch was present in 5.9% of the Trifecta group and in 42.4% in the Mitroflow group. Moderate patient-prosthesis mismatch was present in 3.8% of the patients with a Trifecta valve and in 32.6% in the Mitroflow group. Severe mismatch was present in 2.1% of the patients with a Trifecta prosthesis and in 9.8% of the patients with a Mitroflow valve. All differences were statistically significant (p < 0.001). The odds ratio of the Trifecta prosthesis as protector against mismatch was 16.9 (95% confidence interval, 9.5 to 30.4) and 11.9 (95% confidence interval, 5.3 to 26.7) for moderate or severe mismatch, respectively. CONCLUSIONS: The prevalence of patient-prosthesis mismatch using the Trifecta aortic prosthesis is extraordinary low. This finding may have great clinical repercussions in patients undergoing surgical aortic valve replacement.

Extracorporeal membrane oxygenation system as a bridge to reparative surgery in ventricular septal defect complicating acute inferoposterior myocardial infarction.

Post-infarction ventricular septal defect (VSD) is a rare but potentially lethal complication of acute myocardial infarction. Medical management is usually futile, so definitive surgery remains the treatment of choice but the risk surgery is very high and the optimal timing for surgery is still under debate. A 55-year-old man with no previous medical history attended the emergency-room for 12 h evolution of oppressive chest pain and strong anginal pain 7 days ago. On physical examination, blood pressure was 96/70 mmHg, pansystolic murmur over left sternal border without pulmonary crackles. An electrocardiogram revealed sinus rhythm 110 bpm, elevation ST and Q in inferior-posterior leads. Transthoracic echocardiogram showed inferoposterior akinesia, posterior-basal septal rupture (2 cm × 2 cm) with left-right shunt. Suspecting VSD in inferior-posterior acute myocardial infarction evolved, we performed emergency coronarography with 3-vessels disease and complete subacute occlusion of the mid segment of the right coronary artery. Left ventriculography demonstrated shunting of contrast from the left ventricule to the right ventricule. He was rejected for heart transplantation because of his age. Considering the high surgical risk to early surgery and his hemodynamic and clinical stability, delayed surgical treatment is decided, and 4 days after admission the patient suffered hemodynamic instability so venoarterial extracorporeal membrane oxygenation system (ECMO) is implanted as a bridge to reparative surgery. The 9th day after admission double bypass, interventricular defect repair with pericardial two-patch exclusion technique, and ECMO decannulation were performed. The patient's postoperative course was free of complications and was discharged 10 days post VSD repair surgery. Follow-up 3-month later revealed the patient to be in good functional status and good image outcome with intact interventricular septal patch without shunt. ECMO as a bridge to reparative surgery in postinfarction VSD is an adequate option to stabilize patients until surgery.

Vascular approaches for transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving therapeutic modality currently available for patients with severe aortic stenosis (AS) that are unsuitable for surgery because of technical/anatomical issues or high-estimated surgical risk. Transfemoral approach is the preferred TAVI delivery route when possible. Alternative non-transfemoral access options include transaortic, trans-subclavian and transapical access. Other approaches are also feasible (transcarotid, transcaval, and antegrade aortic) but are restricted to operators and hospitals with experience. The peculiarities of each of the vascular approaches designed for TAVI delivery make it necessary to carefully assess patient's atherosclerotic load and location, arterial size and tortuosity, and presence of mural thrombus. Several clinical trials are currently ongoing and in the near future the indications for these approaches will likely be better defined and extended to a broader spectrum of TAVI candidates.

Predictive risk models for proximal aortic surgery.

Predictive risk models help improve decision making, information to our patients and quality control comparing results between surgeons and between institutions. The use of these models promotes competitiveness and led to increasingly better results. All these virtues are of utmost importance when the surgical operation entails high-risk. Although proximal aortic surgery is less frequent than other cardiac surgery operations, this procedure itself is more challenging and technically demanding than other common cardiac surgery techniques. The aim of this study is to review the current status of predictive risk models for patients who undergo proximal aortic surgery, which means aortic root replacement, supracoronary ascending aortic replacement or aortic arch surgery.

Double pseudoaneurysm, recurrent subvalvular aortic membrane and small left ventricular outflow tract in the same patient: who dares?

Patients with pseudoaneurysm in the left ventricular outflow tract (LVOT) commonly present vague and nonspecific symptoms making the diagnosis difficult. We present the case of a 37-year-old patient with two subvalvular pseudoaneurysms in whom a combined resection surgery, enlargement of the LVOT, aortic valve replacement (AVR) and aortic root replacement were performed using the technique of Cabrol.

Comparing American, European and Asian practice guidelines for aortic diseases.

The aortic disease comprises a group of different pathologies of high prevalence, seriousness and ever changing by the medical and surgical investigations. Therefore cardiovascular scientific societies in USA, Europe and Asia have created Task Force on practice guidelines (PG) to develop, update and revise PG for aortic diseases. These documents issue recommendations on the diagnosis and management of different aortic diseases. The three societies agree on the recommendations about diagnostic tests and on the value of computed tomography and magnetic resonance as the main tools for the diagnosis and follow-up of aortic disease. Concerning to acute aortic syndromes (AAS), American and European GPs recognize intramural hematoma (IMH) as a type of AAS with surgery indication; however Asian guidelines consider IMH a pathological process different from AAS and indicate medical treatment. In thoracic aortic aneurysms (TAA), all express the need for an adequate control of cardiovascular risk factors, emphasizing strict control of blood pressure, smoking cessation and recommend the use of beta-blockers and statins. The threshold for asymptomatic repair is 5.5 cm in European and American and 6 cm for Asian PG, with lower thresholds in Marfan and bicuspid aortic valve (BAV). As regards the abdominal aortic aneurysms (AAA), the PGs recognize the adequate control of cardiovascular risk factors, but there are differences in class of recommendation on statins, angiotensin-converting enzyme inhibitors or beta-blockers to prevent progression of AAA. For intervention, the threshold diameter in asymptomatic is 5.5 cm but can be reduced to 5 cm in women as recommended by Asian PG. Moreover the specific diseases such as Marfan, BAV, pregnancy or atherosclerosis aortic present specific recommendations with small differences between PGs. In conclusion, PGs are interesting and appropriate documents at present. They issue recommendations based on evidence that help the clinician and surgeon in their daily approach to aortic pathology.

Tomografía computarizada cardiaca: Nuevas aplicaciones de una técnica en evolución / Cardiac computed tomography: New applications of an evolving technique

En los últimos años hemos sido testigos del continuo desarrollo de las técnicas de imagen en cardiología. Entre ellas, la tomografía computarizada cardiaca, técnica emergente y en continua evolución. Con la posibilidad actual de realizar estudios con muy baja radiación se han ampliado sus indicaciones más allá de la coronariografía no invasiva. En el presente trabajo de revisión repasamos las novedades técnicas de la tomografía computarizada cardiaca así como sus nuevas aplicaciones.

During the last years we have witnessed an increasing development of imaging techniques applied in Cardiology. Among them, cardiac computed tomography is an emerging and evolving technique. With the current possibility of very low radiation studies, the applications have expanded and go further coronariography In the present article we review the technical developments of cardiac computed tomography and its new applications.