Outcomes of transfemoral TAVR using two new-generation devices in patients with horizontal aorta.

BACKGROUND: Challenging anatomies and comorbidities have impact on success in transcatheter aortic valve replacement (TAVR). There is controversy whether the extent of the aortic angle (AA) has an impact on procedural outcomes. Matched comparative outcome data of new generation transcatheter heart valves (THVs) in horizontal aorta (HA) are scarce. METHODS: A total of 1582 patients with severe native aortic stenosis (AS) treated with the SAPIEN3 Ultra (Ultra; n = 526) or ACURATE Neo2 (Neo2; n = 1056) THVs from January 2017 to January 2023 were analyzed. Patients with non-horizontal aortas (AA < 51.7°, n = 841) were excluded. The population was matched by 1-to-1 nearest-neighbor matching (Ultra, n = 246; Neo2, n = 246). Clinical and procedural outcome were evaluated according to VARC-3 recommendations. RESULTS: Technical success (93.1% vs. 94.7%, p = 0.572) was high after Ultra and Neo2. Device success (80.5% vs. 89.8%, p = 0.05) was inferior with Ultra. Neo2 reveals superior hemodynamic properties with lower rate of severe prosthesis patient mismatch (12.0% vs. 3.7%, p = 0.001) and elevated gradients ( ≥ $\ge $ 20 mmHg: 11.9% vs. 1.7%, p < 0.001). Ultra showed a lower rate of relevant paravalvular regurgitation ( > $\gt $ mild paravalvular regurgitation or Valve-in-Valve due to paravalvular regurgitation: 0.0% vs. 3.7%, p = 0.004). The rate of procedural bailout maneuvers (0.8% vs. 0.4%, p = 1.000) and thirty-day all-cause mortality (1.3% vs. 2.2%, p = 0.496) was similar. CONCLUSION: Transfemoral TAVR in patients with severe aortic stenosis and HA, using the balloon expandable Sapien3 Ultra and self-expanding ACURATE Neo2 prosthesis, is feasible and safe. Therefore, valve selection between these platforms should be made irrespective of the aortic angle by a team experienced with both valves based on their specific advantages. Large, randomized trials in this sub-group of patients would be necessary to compare long term outcomes.

Endovascular treatment for nontraumatic rupture of the descending thoracic aorta: long-term results.

BACKGROUND: This study evaluated the long-term results of thoracic endovascular aortic repair (TEVAR) of nontraumatic rupture of the descending thoracic aorta. METHODS: This was a retrospective and observational single-center study. During the 10-year study period, 21 patients (6 males) with an average age of 66.1 ± 12.4 (range 31-81) years underwent emergency TEVAR for nontraumatic rupture of the descending thoracic aorta. The underlying aortic pathologies causing the rupture were degenerative aneurysms in 11 patients, complicated type B dissection in nine, and erosion hemorrhage due to neoplasia in one patient. RESULTS: The 30-day mortality rate was 9.5% (2/21). Two patients died postoperatively: one from a repeat aortic rupture and the other from pneumonia. Two patients underwent early endovascular reintervention. After a median follow-up of 65.6 ± 50.4 (range 1.5-44) months, 10 patients died, resulting in a late mortality of 52.6% (10/19). Six patients (31.5%) developed major complications requiring late reintervention. There was no mortality with reintervention. CONCLUSIONS: Endovascular treatment of the descending thoracic aorta in patients with nontraumatic rupture is a promising treatment option in an emergency setting with a relatively low mortality rate. Despite encouraging early results, TEVAR is associated with a high reintervention rate and poor survival due to nonaortic or procedure-related mortality in the long term.

Secondary interventions after endovascular thoracic aortic repair.

BACKGROUND: Endovascular stent grafting of the descending thoracic aorta has evolved rapidly and is now the standard of care for certain patient subsets. However, the durability of this technique is limited by the development of technique-specific complications at mid-term follow-up. The aim of this study was to evaluate the incidence, techniques, and outcomes of secondary intervention for complications after stent grafting of the descending thoracic aorta. METHODS: Between March 2001 and November 2011, 152 patients underwent endovascular thoracic aortic repair (TEVAR). We identified 19 (12.5%) patients from this cohort who required secondary interventions. RESULTS: The indications for TEVAR were type B aortic dissection in 12 patients, thoracic aortic aneurysm in six patients, and intramural hematoma in one patient. The mean time between TEVAR and secondary intervention was 20.49 ± 24.90 months (range, 1.2-83 months). A secondary endovascular intervention was required in eleven patient, six patients required secondary surgical therapy, and hybrid procedures were performed in two patients. Endoleaks were the most common indication for a secondary intervention. The 30-day mortality rate was 10.5% (2/19). Two perioperative deaths were observed following surgical therapy. During the mean follow-up of 78.06 ± 37.37 months (range, 23-142 months) after TEVAR, four unrelated deaths occurred, two patients were lost to follow-up, and four patients required a further intervention. CONCLUSIONS: Secondary intervention after endovascular stent grafting of the descending thoracic aorta was not infrequently required and can be performed with acceptable risks. However, serial, systematic follow-up is essential to detect late complications and to perform secondary procedures, preferably under elective circumstances.

ACURATE neo2 Versus SAPIEN 3 Ultra Transcatheter Heart Valve in Severe Aortic Valve Calcification: A Propensity-Matched Analysis.

BACKGROUND: Comparative data on transcatheter self-expanding ACURATE neo2 (NEO2) and balloon-expandable SAPIEN 3 Ultra prostheses in technically challenging anatomy of severe aortic valve calcified aortic annuli are scarce. METHODS: A total of 1987 patients with severe native aortic stenosis treated with the self-expanding NEO2 (n=1457) or balloon-expandable SAPIEN 3 Ultra (n=530) from January 2017 to April 2023 were evaluated. The primary end point was procedural outcome according to the Valve Academic Research Consortium 3 definitions. Propensity matching defined 219 pairs with severe calcification (calcium density cutoff, 758 AU/cm2) of the native aortic valve. RESULTS: Technical success (90.4% versus 91.8%; risk difference, 1.4% [95% CI, -4.4 to -7.2]; P=0.737) and device success at 30 days (80.8% versus 75.8%; risk difference, -5.0% [95% CI, -13.2 to 3.1]; P=0.246) were comparable between NEO2 and SAPIEN 3 Ultra. The rate of severe prosthesis-patient mismatch (1.1% versus 10.1%; risk difference, 10.0% [95% CI, 4.0-13.9]; P<0.001) and mean transvalvular gradient ≥20 mm Hg (2.8% versus 14.3%; risk difference, 11.5% [95% CI, 5.8-17.1]; P<0.001) was lower with NEO2. The rate of more-than-mild paravalvular leakage or valve-in-valve due to paravalvular leakage was significantly higher (6.2% versus 0.0%; risk difference, 6.2% [95% CI, -10.1 to -2.7]; P=0.002), and there was a tendency for a higher rate of device embolization or migration (1.8% versus 0.0%; risk difference, -1.8% [95% CI, -4.1 to 0.4]; P=0.123) with NEO2. Multivarate regression revealed no independent impact of transcatheter heart valve selection on device success (odds ratio, 0.93 [95% CI, 0.48-1.77]; P=0.817). CONCLUSIONS: In patients with severely calcified annuli, supraannular implantation of NEO2 showed hemodynamic advantages. Nevertheless, NEO2 was associated with a higher incidence of relevant paravalvular leakage and a numerically higher rate of device embolization than SAPIEN 3 Ultra in this particular patient group.

Two-year mortality after transcatheter aortic valve implantation versus medical therapy for high-surgical risk or inoperable aortic stenosis patients.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve implantation (TAVI) has become a therapeutic option for the treatment of high-risk or inoperable patients with symptomatic severe aortic stenosis. The study aim was to compare the two-year mortality of high-risk or inoperable patients treated by TAVI compared to medical therapy, in a single-center setting. METHODS: A total of 135 consecutive patients (58 males, 77 females; mean age 80 +/- 6 years; logistic EuroSCORE 21 +/- 13%) who had undergone TAVI was compared to 135 patients (60 males, 75 females; mean age 79 +/- 3 years; logistic EuroSCORE 21 +/- 19%) who had undergone medical treatment before TAVI became available. The one- and two-year follow up mortalities were recorded for each group. In the TAVI group, the patient characteristics were analyzed for predictors of mortality. RESULTS: Sixteen patients (12%) in the TAVI group and 10 (7%) in the medically treated group died within 30 days of intervention or presentation (p = 0.303). At the one-year follow up, 28 TAVI patients (21%) and 69 medically treated patients (41%) died (p < 0.001). At the two-year follow up, 41 TAVI patients (30%) and 80 medically treated patients (59%) died (p < 0.001). Log-rank analysis demonstrated a significant survival benefit after TAVI compared to medical treatment during the total follow up period. Univariate predictors of death at the two-year follow up included medical therapy, logistic EuroSCORE, and pulmonary hypertension. Medical therapy remained the only independent predictor of two-year mortality in a multivariate analysis (OR 3.343; 95% CI 2.021-6.234, p < 0.001). CONCLUSION: In high-surgical risk or inoperable symptomatic aortic stenosis patients, the one- and two-year follow up mortalities of patients treated with TAVI was significantly lower than after medical therapy. Predictors of mortality, in addition to treatment strategy, were pulmonary hypertension and EuroSCORE.

Sclerostin as a potential novel biomarker for aortic valve calcification: an in-vivo and ex-vivo study.

BACKGROUND AND AIM OF THE STUDY: Sclerostin is a key negative regulator of bone formation. It was hypothesized that sclerostin might also play a potential role in the development of aortic valve calcification (AVC). The study aim was to evaluate serum sclerostin levels in patients with different degrees of AVC compared to a healthy control group, and to investigate local sclerostin expression in explanted calcified and non-calcified aortic valves. METHODS: A prospective cross-sectional study was performed in 115 patients (mean age 74 +/- 7 years) with echocardiographically proven AVC. Sclerostin serum levels were measured using ELISA and compared to values obtained from a healthy control population. For quantification of AVC, all patients of the study cohort underwent non-contrast-enhanced dual-source computed tomography (DSCT). Immunohistochemistry (IHC) staining for sclerostin and mRNA sclerostin expression was analyzed in 10 calcified aortic valves and 10 non-calcified age-matched control valves. RESULTS: Patients with AVC showed significantly higher sclerostin serum levels as compared to healthy controls (0.94 +/- 0.45 versus 0.58 +/- 0.26 ng/ml, p < 0.001). A significant correlation between sclerostin serum levels and Agatston AVC scores as assessed by DSCT was observed (r = 0.62, p < 0.001) in the study cohort. IHC revealed positive sclerostin staining in nine calcified valves, in contrast to negative staining for sclerostin in all non-calcified valves. Quantitative real-time PCR confirmed the increased sclerostin expression on mRNA level, with a significant up-regulation of sclerostin mRNA (fold change 150 +/- 52, p < 0.001) expression being shown in calcified aortic valves compared to non-calcified control valves. Co-staining experiments revealed that sclerostin-expressing cells co-express the major osteogenic transcription factor Runx2 and the extracellular matrix protein osteocalcin. CONCLUSION: Patients with AVC showed increased sclerostin serum levels compared to a healthy reference population, and it was revealed that the severity of AVC may be linked to increased sclerostin serum levels. Moreover, the PCR and staining data demonstrated an increased sclerostin expression in parallel to prototypic markers of osteogenic transdifferentiation, indicating a role of sclerostin in the valvular calcification process.

Procedural Outcomes of a Self-Expanding Transcatheter Heart Valve in Patients with Porcelain Aorta.

BACKGROUND: Severe calcification of the ascending aorta increases the peri-operative risk for neurological complications in patients with severe aortic stenosis. Transcatheter aortic valve implantation (TAVI) seems to be an optimal treatment option in these patients. However, the impact of the extent of aortic calcification on procedural and neurological outcomes during TAVI is unclear. METHODS: Data from 3010 patients with severe native aortic valve stenosis treated with ACURATE neo/neo2 from May 2012 to July 2022 were evaluated and matched by 2-to-1 nearest-neighbor matching to identify one patient with porcelain aorta (PA) (n = 492) compared with two patients without PA (n = 984). PA was additionally subdivided into circumferential (classic PA) (n = 89; 3.0%) and non-circumferential (partial PA) (n = 403; 13.4%) calcification. We compared outcomes according to VARC-3 criteria among patients with and without PA and identified predictors for occurrence of stroke in the overall population. RESULTS: Technical success (88.5% vs. 87.4%, p = 0.589) and device success at 30 days (82.3% vs. 81.5%, p = 0.755) after transcatheter ACURATE neo/neo2 implantation according to VARC-3 definition was high and did not differ between non-calcified aortas or PA. The rate of in-hospital complications according to VARC-3-definitions was low in both groups. Rates of all stroke (3.2% (n = 31) vs. 2.6% (n = 13), p = 0.705) or transitory ischemic attacks (1.1% vs. 1.2%, p = 1.000) did not differ significantly. Thirty-day all-cause mortality did not differ (3.0% vs. 3.2%, RR 1.1; p = 0.775). Overall device migration/embolization (OR 5.0 [2.10;11.87]), severe bleeding (OR 1.79 [1.11;2.89]), and major structural cardiac complications (OR 3.37 [1.32;8.57]) were identified as independent predictors for in-hospital stroke in a multivariate analysis after implantation of ACURATE neo/neo2. CONCLUSION: A porcelain aorta does not increase the risk of neurological complications after transfemoral ACURATE neo/neo2 implantation. Based on these findings, transfemoral ACURATE neo/neo2 implantation is safe in these particularly vulnerable patients.

Comparison of the New-Generation Self-Expanding NAVITOR Transcatheter Heart Valve with Its Predecessor, the PORTICO, in Severe Native Aortic Valve Stenosis.

BACKGROUND: Third-generation transcatheter heart valves (THVs) are designed to improve outcomes. Data on the new intra-annular self-expanding NAVITOR are scarce. AIMS: The aim of this analysis was to compare outcomes between the PORTICO and the NAVITOR systems. METHODS: Data from 782 patients with severe native aortic stenosis treated with PORTICO (n = 645) or NAVITOR (n = 137) from 05/2012 to 09/2022 were evaluated. The clinical and hemodynamic outcomes of 276 patients (PORTICO, n = 139; NAVITOR, n = 137) were evaluated according to VARC-3 recommendations. RESULTS: Rates of postprocedural more-than-mild paravalvular leakage (PVL) were significantly lower for NAVITOR than for PORTICO (7.2% vs. 1.5%, p = 0.041). In addition, severe bleeding rates (27.3% vs. 13.1%, p = 0.005) and major vascular complications (5.8% vs. 0.7%, p = 0.036) were lower in the NAVITOR group. The mean gradients (7 vs. 8 mmHg, p = 0.121) and calculated aortic valve areas (1.90 cm2 vs. 1.99 cm2, p = 0.235) were comparable. Rates of PPI were similarly high in both groups (15.3 vs. 21.6, p = 0.299). CONCLUSIONS: The NAVITOR demonstrated favorable in-hospital procedural outcome data, with lower rates of relevant PVL, major vascular complications, and severe bleeding than its predecessor the PORTICO and preserved favorable hemodynamic outcomes.

Can cardiac surgery cause hypopituitarism?

Apoplexy of pituitary adenomas with subsequent hypopituitarism is a rare but well recognized complication following cardiac surgery. The nature of cardiac on-pump surgery provides a risk of damage to the pituitary because the vascular supply of the pituitary is not included in the cerebral autoregulation. Thus, pituitary tissue may exhibit an increased susceptibility to hypoperfusion, ischemia or intraoperative embolism. After on-pump procedures, patients often present with physical and psychosocial impairments which resemble symptoms of hypopituitarism. Therefore, we analyzed whether on-pump cardiac surgery may cause pituitary dysfunction also in the absence of pre-existing pituitary disease. Twenty-five patients were examined 3-12 months after on-pump cardiac surgery. Basal hormone levels for all four anterior pituitary hormone axes were measured and a short synacthen test and a growth hormone releasing hormone plus arginine (GHRH-ARG)-test were performed. Quality of life (QoL), depression, subjective distress for a specific life event, sleep quality and fatigue were assessed by means of self-rating questionnaires. Hormonal alterations were only slight and no signs of anterior hypopituitarism were found except for an insufficient growth hormone rise in two overweight patients in the GHRH-ARG-test. Psychosocial impairment was pronounced, including symptoms of moderate to severe depression in 9, reduced mental QoL in 8, dysfunctional coping in 6 and pronounced sleep disturbances in 16 patients. Hormone levels did not correlate with psychosocial impairment. On-pump cardiac surgery did not cause relevant hypopituitarism in our sample of patients and does not serve to explain the psychosocial symptoms of these patients.

Multi-Center Comparison of Two Self-Expanding Transcatheter Heart Valves: A Propensity Matched Analysis.

BACKGROUND: During the last years, several transcatheter aortic heart valves entered the clinical market and are commercially available. The prostheses differ regarding several technical and functional aspects. However, little is known regarding head-to-head comparative data of the ACURATE neo and the PORTICO valve prostheses. OBJECTIVES: The aim of this study was to compare two self-expanding transcatheter aortic heart valves (THV), the ACURATE neo and the PORTICO, with regard to in-hospital and 30-day outcomes, as well as early device failures. METHODS: A total of 1591 consecutive patients with severe native aortic valve stenosis from two centers were included in the analyses and matched by 1:1 nearest neighbor matching to identify one patient treated with PORTICO (n = 344) for each patient treated with ACURATE neo (n = 344). RESULTS: In-hospital complications were comparable between both valves, including any kind of stroke (ACURATE neo = 3.5% vs. PORTICO = 3.8%; p = 1.0), major vascular complications (ACURATE neo = 4.5% vs. PORTICO = 5.4%; p = 0.99) or life-threatening bleeding (ACURATE neo = 1% vs. PORTICO = 2%; p = 0.68). The rate of device failure defined by the VARC-2 criteria were comparable, including elevated gradients and moderate-to-severe paravalvular leakage (ACURATE neo = 7.3% vs. PORTICO = 7.6%; p = 1.0). However, the need for permanent pacemaker implantation (PPI) was significantly more frequent after the use of PORTICO THV (9.5% vs. 18.7%; p = 0.002). CONCLUSIONS: In this two-center case-matched comparison, short-term clinical and hemodynamic outcomes showed comparable results between PORTICO and ACURATE neo prostheses. However, PORTICO was associated with a significant higher incidence of PPI.

Procedural Outcomes of a Self-Expanding Transcatheter Heart Valve in Small Annuli.

BACKGROUND: Self-expanding transcatheter valves (THV) seem superior to balloon-expanding valves in regard to the incidence of prosthesis-patient mismatch (PPM). Data on the occurrence of PPM with the ACURATE neo/neo2 system as a representative of self-expanding prostheses in very small annuli, even below the applicable instructions for use (IFU), are scarce. METHODS: Data from 654 patients with severe native aortic stenosis treated with the smallest size ACURATE neo/neo2 valve (size S, 23 mm) at two German high-volume centers from 06/2012 to 12/2021 were evaluated. We compared clinical and hemodynamic outcomes among patients with implantation in adherence to the recommended sizing (on-label n = 529) and below the recommended sizing range (off-label n = 125) and identified predictors for PPM in the overall population. BMI-adjusted PPM was defined according to VARC-3 recommendations. RESULTS: Post-procedure, the mean gradient (10.0 mmHg vs. 9.0 mmHg, p = 0.834) and the rate of paravalvular leakage (PVL) ≥ moderate (3.2% vs. 2.8%, p = 0.770) were similar between on-label and off-label implantations. The rate of moderate to severe PPM (24%) was comparably low in ACURATE neo/neo2 S, with a very low proportion of severe PPM whether implanted off- or on-label (4.9% vs. 3.8%, p = 0.552). Thirty-day all-cause mortality was higher among patients with off-label implantations (6.5% vs. 2.3%, p = 0.036). In the subgroup of these patients, no device-related deaths occurred, and cardiac causes did not differ (each 5). Besides small annulus area and high BMI, a multivariate analysis identified a greater cover index (OR 3.26), deep implantation (OR 2.25) and severe calcification (OR 2.07) as independent predictors of PPM. CONCLUSIONS: The ACURATE neo/neo2 S subgroup shows a convincing hemodynamic outcome according to low mean gradient even outside the previous IFUs without a relevant increase in the rate of PVL or PPM. In addition to known factors such as annulus area and BMI, potential predictors for PPM are severe annulus calcification and implantation depth. Nevertheless, the ACURATE neo/neo2 system seems to be a reliable option in patients with very small annuli.

Electrocardiographic and imaging predictors for permanent pacemaker requirement after transcatheter aortic valve implantation.

BACKGROUND AND AIM OF THE STUDY: Pacemaker (PM) implantation is a possible requirement after transcatheter aortic valve implantation (TAVI). The study aim was to evaluate the electrocardiographic and imaging predictors of the need for PM implantation after TAVI. METHODS: A total of 80 consecutive patients (mean age 82 +/- 6 years) who had been referred for TAVI were included in the study. Transfemoral TAVI was performed in 58 patients (CoreValve ReValving; 72%), while 22 patients (28%) underwent transapical TAVI using the Edwards SAPIEN valve. Patient characteristics, and the frequency of atrioventricular (AV) block, right bundle branch block (RBBB) and left bundle branch block (LBBB), were evaluated for the prediction of PM implantation after TAVI. In addition, the severity and distribution of aortic valve calcification (AVC) were assessed by calculating the Agatston AVC score for the total aortic valve, as well as for each cusp, using dual-source computed tomography. RESULTS: Pre-procedural RBBB was present in six patients (8%), while eight patients (10%) showed pre-procedural LBBB. In 20 of the 80 patients (25%), a new LBBB was observed after TAVI. In 17 TAVI patients (21%; only CoreValve patients) there was an indication for permanent PM implantation that was related to complete AV block (n = 13) or complete RBBB or LBBB with AV delay (n = 4). Four of six patients (67%) with pre-procedural RBBB received a PM after TAVI. Multivariate logistic regression analysis revealed that only prosthesis type (r = 0.30, p = 0.01) and pre-procedural RBBB (r = 0.4, p = 0.02) were significantly associated with the need for permanent PM implantation after TAVI. CONCLUSION: TAVI is frequently associated with new conduction disturbances. A higher incidence of new LBBB and of permanent PM requirement occurred with the CoreValve ReValving system. There was no relationship between the severity or distribution of AVC and the need for PM implantation after TAVI. Patients with pre-procedural RBBB are deemed to be at risk for PM implantation after TAVI.

Impact of transcutaneous aortic valve implantation on myocardial deformation.

AIMS: To define the impact of transcutaneous aortic valve implantation (TAVI) using the CoreValve prosthesis on myocardial deformation in a serial echocardiographic study with analysis of strain and strain rate. METHODS: In 36 patients (83 ± 6 years; EuroScore: 26 ± 13%) with severe aortic stenosis scheduled for CoreValve implantation serial echocardiographic studies pre- and postintervention (within 1 month) were performed. Midparasternal short-axis and three apical views were acquired. Using customized computer software which allows automatic frame-by-frame tracking of acoustic markers during the heart cycle circumferential, radial, and longitudinal strain (CS, RS, and LS) and strain rate (CSR, RSR, and LSR) were calculated for each segment in a 16 segment model of the left ventricle. RESULTS: Longitudinal strain, systolic, and early diastolic longitudinal strain rate increased significantly within 1 month after TAVI (LS from -15.8 ± 3.6% to -17.6 ± 3.1%; P < 0.001; LSR(S) from -1.03 ± 0.21 s(-1) to -1.21 ± 0.19 s(-1); P < 0.001 and LSR (E) from -1.15 ± 0.42 s(-1) to 1.51 ± 0.44 s(-1); P < 0.001). Circumferential strain and strain rate values remained unchanged after CoreValve implantation. RS (29.1 ± 17.1 to 34.0 ± 15.8%; ns), RSR (S) (1.56 ± 0.69 to 1.91 ± 0.87 s(-1); ns) and RSR(E) (-1.56 ± 0.78 to -1.81 ± 0.82 s(-1); ns) increased only nonsignificantly after TAVI. Analysis of covariance showed only chronic kidney disease to have a relevant impact on early diastolic LSR (P = 0.01). CONCLUSIONS: Mainly longitudinal mechanics respond to unloading of the left ventricle after TAVI for severe aortic stenosis while radial and circumferential deformation is substantially unchanged. Pacemaker implantation or onset of left bundle brunch block after TAVI do not influence early myocardial deformation parameters.

Aortic valve calcifications on chest films: how much calcium do I need?

OBJECTIVE: Aortic valve calcifications (AVC) as seen on conventional chest films or on CT are associated with aortic valve stenosis (AVS). The absence of AVC on chest films does not exclude high grade AVS. The aim of this study was to analyse if there is a threshold for the detection of AVC from conventional chest films in patients suffering from high grade AVS. METHODS AND RESULTS: The explanted aortic valves of 29 patients (16 male, mean age 72.3 +/- 11.5 years) with high grade AVS were examined by dual-source CT. AVC were quantified using the Agatston AVC score. In all patients conventional chest films obtained the day before surgery were evaluated for the presence of AVC. Results were analysed with students t-test, Spearman's rank correlation and ROC analysis. On conventional chest films AVC were visible in 18 patients. On CT all specimen presented with AVC with an Agatston AVC score ranging from 40.7 to 1870 (mean 991.3 +/- 463.1). In patients with AVC visible on chest films the AVC score was significantly higher (1264.0 +/- 318.2) when compared with patients without visible calcifications (544.9 +/- 274.4; P < 0.0001). There was a strong correlation between the AVC score and the visibility of AVC on chest films (r = 0.781). ROC analysis identified an ideal threshold of 718 for AVC score to separate conventional chest films with and without visible AVC. CONCLUSION: Unlike in coronary calcifications, there is a threshold for identifying AVC from conventional chest films. This finding may be of diagnostic value, as conventional chest films may be used to semiquantitatively evaluate the extent of AVC.

Chronic augmentation of the parasympathetic tone to the atrioventricular node: a nonthoracotomy neurostimulation technique for ventricular rate control during atrial fibrillation.

INTRODUCTION: The right inferior ganglionated plexus (RIGP) selectively innervates the atrioventricular node. Temporary electrical stimulation of this plexus reduces the ventricular rate during atrial fibrillation (AF). We sought to assess the feasibility of chronic parasympathetic stimulation for ventricular rate control during AF with a nonthoracotomy intracardiac neurostimulation approach. METHODS AND RESULTS: In 9 mongrel dogs, the small endocardial area inside the right atrium, which overlies the RIGP, was identified by 20 Hz stimulation over a guiding catheter with integrated electrodes. Once identified, an active-fixation lead was implanted. The lead was connected to a subcutaneous neurostimulator. An additional dual-chamber pacemaker was implanted for AF induction by rapid atrial pacing and ventricular rate monitoring. Continuous neurostimulation was delivered for 1-2 years to decrease the ventricular rate during AF to a range of 100-140 bpm. Implantation of a neurostimulation lead was achieved within 37 +/- 12 min. The latency of the negative dromotropic response after on/offset or modulation of neurostimulation was <1 s. Continuous neurostimulation was effective and well tolerated during a 1-2 year follow-up with a stimulation voltage <5 V. The neurostimulation effect displayed a chronaxie-rheobase behavior (chronaxie time of 0.07 +/- 0.02 ms for a 50% decrease of the ventricular rate during AF). CONCLUSION: Chronic parasympathetic stimulation can be achieved via a cardiac neurostimulator. The approach is safe, effective, and well tolerated in the long term. The atrioventricular nodal selectivity and the opportunity to adjust the negative dromotropic effect within seconds may represent an advantage over pharmacological rate control.

Comparison of the Carpentier-Edwards Perimount and St. Jude Medical Epic bioprostheses for aortic valve replacement--a retrospective echocardiographic short-term study.

OBJECTIVE: Stented biological prostheses show different performance related to their design and ultrastructure. Therefore, we compared the Carpentier-Edwards Perimount (Edwards Lifesciences, Irvine, CA, USA) and the St. Jude Medical Epic (SJM Epic; St. Jude Medical Inc., St. Paul, MN, USA) prostheses with respect to their hemodynamic features. METHODS: Eighty-six patients underwent aortic valve replacement for severe aortic stenosis (50 patients), aortic regurgitation (seven patients), or mixed lesion (29 patients) with these randomly assigned bioprostheses (Perimount: 39 patients; SJM Epic: 47 patients). Following informed consent, patients were examined postoperatively (mean 9.7 +/- 4 months after surgery) with a detailed echocardiographic study, quality of life was determined by a standardized questionnaire. RESULTS: Comparing the indexed effective orifice area (0.77 cm(2)/m(2) vs. 0.64 cm(2)/m(2); p = 0.019), the mean pressure gradient (11.15 mmHg vs. 14.80 mmHg; p = 0.004) and the stroke-work loss (6.95% vs. 8.49%; p = 0.025), the Carpentier-Edwards Perimount demonstrated significantly better hemodynamic features than the SJM Epic prosthesis. These effects were more pronounced in the smaller prosthetic sizes. CONCLUSION: The Carpentier-Edwards Perimount prosthesis was less obstructive than the SJM Epic in echocardiographic controls. Patient-prosthesis mismatch as determined by indexed effective orifice area showed no impact on functional recovery.

Hemodynamics of high-performance bileaflet valves: comparison to simulated clinical Doppler measurements.

BACKGROUND AND AIM OF THE STUDY: The newly designed, so-called 'high performance' bileaflet heart valve prostheses are suggested to be especially beneficial in small sizes. Herein, valvular energy loss and transvalvular gradients were evaluated using an in-vitro pulsatile flow model for aortic prostheses (St. Jude Medical Regent and On-X, sizes 19-23 mm). Gradients were compared with simulated clinically derived Doppler gradients to determine the extent of pressure recovery. METHODS: Valves were analyzed using a pulsatile circulatory mock loop simulator at heart rates of 70 and 110 bpm, and at cardiac outputs of 2, 4, 5, and 7 l/min, respectively (FDA requirements). Measurements consisted of computed calculation of energy loss and determination of mean pressure gradient by pressure transducers. A Doppler probe was mounted into the device for simultaneous measurement of Doppler gradient according to the Bernoulli equation. RESULTS: The systolic energy loss of the SJM Regent valve averaged 5.0 +/- 4.6% (range: 0.2 to 14.9%) of the effective forward energy, while that for the On-X valve was 6.5% (range: 0.7-22.8%). Total energy loss was 9.9% (range: 4.8-22.1%) for the SJM Regent valve, and 12.7% (range: 6.5-27.7%) for the On-X valve. The average extent of pressure recovery was 64% for both valve types. CONCLUSION: All tested valves were characterized by excellent hemodynamic performance, with overall low systolic and total energy losses, but results were slightly favorable for the SJM Regent valve. Valve performance was concluded to be much better than expected by clinical routine Doppler measurements, which significantly overestimates transvalvular gradients; this effect was explained by pressure recovery. Nevertheless, Doppler gradient remains a valuable follow up technique for patients with heart valve prostheses.

Improved Assessment of Pathological Regurgitation in Patients with Prosthetic Heart Valves by Multiplane Transesophageal Echocardiography.

The aim of this study was to evaluate the diagnostic increment of individually optimized axes in the assessment of pathological prosthetic valve regurgitation. Forty-two patients with pathologically regurgitant prostheses in the aortic (n = 21), mitral (n = 15), and tricuspid (n = 6) positions were examined by multiplane transesophageal echocardiography. The investigation was performed utilizing the transverse axis first, the longitudinal axis second, and the intermediate axes afterwards. The presence of regurgitation, the differentiation between trans- and perivalvular origin, and the localization of perivalvular leakages at the sewing ring were evaluated. Findings in the biplane and intermediate axes were compared to surgery or autopsy in all patients. There was slightly higher detection rate for aortic prosthetic regurgitation using the intermediate axes than the biplane axes. The intermediate axes revealed significantly fewer differences to the morphological control than the biplane axes with regard to the differentiation of peri- and transprosthetic aortic regurgitation and to the localization of a periprosthetic aortic regurgitant origin. The intermediate axes provided significantly better agreement to surgery/autopsy than the biplane axes regarding the localization of the origin of mitral periprosthetic regurgitation. Morphological visualization of the perivalvular gap adds important information on the precise localization of the regurgitant origin. The pathological gap was visualized significantly more often using the intermediate than the biplane axes in all types of prostheses. The data in this study therefore suggest that multiplane transesophageal echocardiography is superior to biplane transesophageal echocardiography in the assessment of pathologic prosthetic regurgitation.