Transcatheter aortic valve replacement during the COVID-19 pandemic-A Dutch single-center analysis.

BACKGROUND AND AIM OF THE STUDY: The coronavirus disease 2019 (COVID-19) pandemic has put an enormous strain on healthcare systems and intensive care unit (ICU) capacity, leading to suspension of most elective procedures, including transcatheter aortic valve replacement (TAVR). However, deferment of TAVR is associated with significant wait-time mortality in patients with severe aortic valve stenosis. Conversely, there is currently no data available regarding the safety and feasibility of a continued TAVR program during this unprecedented crisis. The aim of this study is to evaluate the safety and feasibility of patients undergoing TAVR during the COVID-19 pandemic in our center, with specific emphasis on COVID-19 related outcomes. METHODS: All patients who underwent TAVR in our center between February 27, 2020, and June 30, 2020, were evaluated. Clinical outcomes were described in terms of Valve Academic Research Consortium 2 definitions. Patient follow-up was done by chart review and telephone survey. RESULTS: A total of 71 patients have undergone TAVR during the study period. Median age was 80 years, 63% were men, and 25% were inpatients. Procedural success was 99%. After TAVR, 30% involved admission to the ICU, and 94% were ultimately discharged to the cardiac care unit on the same day. Two patients (3%) had confirmed COVID-19 a few days after TAVR, and both died of COVID-19 pneumonia within 2 weeks after hospital discharge. CONCLUSIONS: A continued TAVR program during the COVID-19 pandemic is feasible despite limited hospital resources. However, COVID-19 related mortality after TAVR is of concern.

Four-dimensional flow MRI of stented versus stentless aortic valve bioprostheses.

OBJECTIVES: To evaluate aortic velocity, wall shear stress (WSS) and viscous energy loss (EL) of stented and stentless bioprostheses using 4D flow MRI 1 year after surgical aortic valve replacement. METHODS: For this cross-sectional study 28 patients with stented (n = 14) or stentless (n = 14) bioprosthesis underwent non-contrast-enhanced 4D-flow MRI at 1.5 T. Analyses included a comparison of velocity, WSS and EL in the ascending aorta during peak systole for both spatially averaged values and a comparison of local differences using per-voxel analysis. RESULTS: No significant differences were found in peak and mean velocity (stented vs. stentless: 2.45 m/s vs. 2.11 m/s; p = 0.09 and 0.60 m/s vs. 0.62 m/s; p = 0.89), WSS (0.60 Pa vs. 0.59 Pa; p = 0.55) and EL (10.17 mW vs. 7.82 mW; p = 0.10). Per-voxel analysis revealed significantly higher central lumen velocity, and lower outer lumen velocity, WSS and EL for stentless versus stented prostheses. CONCLUSION: One year after aortic valve implantation with stented and stentless bioprostheses, velocity, WSS and EL were comparable when assessed for averaged values in the ascending aorta. However, the flow profile described with local analysis for stentless prosthesis is potentially favourable with a significantly higher central velocity profile and lower values for outer lumen velocity, WSS and EL. KEY POINTS: • Stentless bioprostheses can be implanted instead of stented aortic valve bioprostheses. • Haemodynamic performance of valve prosthesis can be assessed using 4D flow MRI. • Averaged ascending aorta PSV, WSS and EL are comparable 1 year post-implantation. • Centreline velocity is highest, WSS and EL is lowest for stentless prosthesis.

When Not to Go SOLO? Contraindications Based on Implant Experience.

BACKGROUND AND AIM OF THE STUDY: Because of the design and specific implantation technique of the stentless Freedom SOLO bioprosthesis, patient selection is crucial. The aim of the study was to discuss the contraindications to this prosthesis based on the authors' implant experience. METHODS: Between April 2005 and February 2015, one surgeon at the authors' center performed 292 aortic valve replacements using a bioprosthesis, with the initial intention of implanting a SOLO valve in every patient. A search was conducted for all of these patients and data collected on whether a SOLO valve was used, or not. RESULTS: A SOLO valve was implanted in 238 patients (82%), and a stented bioprosthesis in 54 (18%). The predominant reasons not to implant a SOLO valve were asymmetric commissures (26%) and a large aortic annulus (24%). Only one patient had structural valve deterioration, and none of the patients had to undergo reoperation because of aortic valve insufficiency or paravalvular leakage. CONCLUSIONS: Asymmetric commissures, large aortic annulus (>27 mm), calcified aortic sinuses, dilated sinotubular junction, aberrant location of coronary ostia and whenever the stent of a stented bioprosthesis is useful, were contraindications to implant a SOLO valve. When these contraindications were taken into account, a very good durability could be achieved with the SOLO valve during mid-term follow up.

Current status of surgical treatment for aortic valve stenosis.

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.

Stentless vs Stented Aortic Valve Bioprostheses in the Small Aortic Root.

In patients with a small aortic root undergoing aortic valve replacement (AVR), the Freedom SOLO bioprosthesis may be the ideal prosthesis because of its stentless design and supra-annular implantation. This study investigated if the stentless Freedom SOLO has an advantage when compared with a stented bioprosthesis in patients with a small aortic root. From April 2005-July 2014, 269 consecutive patients underwent AVR with either a Freedom SOLO (n = 76) or Mitroflow (n = 193) bioprosthesis size 19mm or 21mm, respectively. This retrospective comparison study presents clinical and echocardiographic follow-up data. In results, operative outcome and survival were similar. At 7 years, cumulative incidence of aortic valve reoperation and structural valve deterioration favor the Freedom SOLO (0% vs 7.1%, P = 0.03 and 0% vs 4.5%, P = 0.08, respectively). Additionally, the postoperative peak and mean valvular gradients favor the Freedom SOLO (21 ± 9mmHg vs 32 ± 12mmHg and 12 ± 5mmHg vs 19 ± 8mmHg, both P = <0.001, respectively). During mid-term follow-up this hemodynamic advantage continued in favor of the Freedom SOLO. Also prosthesis-patient mismatch occurred less frequently in the Freedom SOLO (28% vs 52%, P = 0.001). There were no differences in prosthetic valve endocarditis, thromboembolic, or bleeding events. In conclusion, the stentless Freedom SOLO has several significant advantages for AVR in patients with a small aortic root in comparison with a stented Mitroflow bioprosthesis. The Freedom SOLO shows superior hemodynamic performance with significantly lower valvular gradients that remained stable during mid-term follow-up. Additionally, significantly fewer prosthesis-patient mismatch occurred and the Freedom SOLO showed superior durability.

Transaortic Aortic Valve Implantation in 100 Patients: Follow-up to 3 Years.

OBJECTIVE: Transaortic aortic valve implantation (TAo-AVI) through the ascending aorta is a novel technique and is used as an alternative in patients with poor femoral access. Although early results have been promising, no midterm data have been published yet. To determine whether this approach is an acceptable treatment option, we analyzed the first 100 cases performed at our institution with a follow-up to 3 years. METHODS: Between July 2011 and January 2015, a total of 100 patients with high-risk or inoperable aortic valve stenosis were treated with TAo-AVI. Preoperative patient data were collected and analyzed retrospectively. All surviving patients were seen for clinical and echocardiographic examination for follow-up. RESULTS: Median follow-up was 15 months. Device success was accomplished in 94 patients (94%). There were no access site complications. The 30-day mortality rate was 9%. Stroke occurred in a total of six patients (6%). Survival at 1-, 2-, and 3 years was 75%, 62%, and 58%, respectively. CONCLUSIONS: Our results show that TAo-AVI is a promising alternative to transapical implantation for treating severe inoperable aortic valve stenosis.

Midterm Follow-Up of the Stentless Freedom Solo Bioprosthesis in 350 Patients.

BACKGROUND: The stentless Freedom Solo aortic bioprosthesis is implanted supraannularly using one running suture line in the sinuses of Valsalva. We report our 9-year experience with this bioprosthesis. METHODS: From April 2005 to July 2014, 350 consecutive patients at our institution underwent aortic valve replacement with the Freedom Solo bioprosthesis. Follow-up and echocardiographic data were collected retrospectively from referring cardiology centers. RESULTS: The mean age was 76 ± 6 years, 48% were male, and 46% underwent a concomitant procedure. Median EuroSCORE II was 3.0 (interquartile range, 1.9 to 4.9). Operative mortality was 5.1% for all procedures and 2.1% for isolated aortic valve replacement. The 1-, 5-, and 9-year overall survival was 92%, 74%, and 47%, respectively. At 6 years, freedom from structural valve deterioration and freedom from aortic valve reoperation were 98% and 96%, respectively. Prosthetic valve endocarditis occurred at a rate of 0.8% per patient-year. Permanent pacemaker implantation was necessary in 2.3% (n = 8), and moderate and severe prosthesis-patient mismatch occurred in 30 patients overall (9.6%). Postoperative maximum and mean valvular gradients were 17 mm Hg and 10 mm Hg, respectively, and remained stable during follow-up. CONCLUSIONS: Aortic valve replacement with the Freedom Solo is safe and has a low rate of permanent pacemaker implantations and prosthesis-patient mismatch. Survival is comparable to that with other aortic bioprostheses, and structural valve deterioration and aortic valve reoperation are infrequent during midterm follow-up. Hemodynamic performance is excellent, with low valvular gradients that remain stable during follow-up.

Aortic Valve Replacement With the Stentless Freedom SOLO Bioprosthesis: A Systematic Review.

This systematic review examined the clinical and hemodynamic performance of the stentless Freedom SOLO (Sorin Group, Milan, Italy) aortic bioprosthesis. The occurrence of postoperative thrombocytopenia was also analyzed. The Freedom SOLO is safe to use in everyday practice, with short cross-clamp times, and postoperative pacemaker implantation is notably lower. Valvular gradients are low and remain stable during short-term follow-up. Thrombocytopenia is more severe than in other aortic prostheses; however, this is without clinical consequences. Within a few years, the 15-year follow-up of this bioprosthesis will be known, which will be key to evaluating its long-term durability.

A 76-year old man with a torn Freedom SOLO bioprosthesis.

We describe a case of a 76-year old male who presented with progressive dyspnoea. He underwent an aortic valve replacement with a Freedom SOLO bioprosthesis 6 years ago. Transthoracic echocardiography showed a moderate-to-severe leakage of the Freedom SOLO bioprosthesis. During surgical reintervention, a partial tear of the left coronary cusp was seen from the commissure of the right coronary cusp to its base. After radiographic and microscopic examination, no clear cause was found for the failure of this Freedom SOLO bioprosthesis. To our knowledge, this is the third failure of a Freedom SOLO bioprosthesis reported in the literature. When the long-term follow-up of the Freedom SOLO bioprosthesis is available, it has to be compared with other bioprosthesis for long-term durability.

Usefulness of preoperative cardiac dimensions to predict success of reverse cardiac remodeling in patients undergoing repair for mitral valve prolapse.

Mitral valve repair for mitral regurgitation (MR) is currently recommended based on the degree of MR and left ventricular (LV) function. The present study examines predictors of reverse remodeling after repair for degenerative disease. We retrospectively identified 439 patients who underwent repair for myxomatous mitral valve degeneration and had both pre- and postoperative echocardiographic data available. Patients were categorized based on left atrial (LA) diameter and LV diameter standards of the American Society of Echocardiography. The outcome of interest was the degree of reverse remodeling on all heart dimensions at follow-up. Mean age was 57 ± 12 years, and 37% of patients were women. Mean preoperative LV end-diastolic diameter was 5.8 ± 0.7 cm, LV end-systolic diameter 3.5 ± 0.6 cm, LA 4.7 ± 0.7 cm, and median ejection fraction 60%. Median observation time was 81 months, and time to postoperative echocardiography was 38 months. Overall, 95% of patients had normal LV diastolic dimensions postoperatively, 93% normal LV systolic dimensions, and 37% normal LA dimensions. A Cox regression analysis showed that moderate (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3 to 3.4) or severe preoperative LA dilatation (OR 2.7, 95% CI 1.7 to 4.4), abnormal preoperative LV end-systolic dimensions (OR 1.3, 95% CI 1.1 to 1.5), and age in years (OR 1.02, 95% CI 1.01 to 1.03) were predictive of less reverse remodeling on follow-up. In conclusion, preoperative LV end-systolic dimensions and LA dilatation substantially affect the likelihood of successful LA remodeling and normalization of all heart dimensions after mitral valve repair for MR. These findings support early operation for MR before the increase in heart dimensions is nonreversible.