A Comprehensive Review of Management Strategies for Bicuspid Aortic Valve (BAV): Exploring Epidemiology, Aetiology, Aortopathy, and Interventions in Light of Recent Guidelines.

OBJECTIVE: bicuspid aortic valve (BAV) stands as the most prevalent congenital heart condition intricately linked to aortic pathologies encompassing aortic regurgitation (AR), aortic stenosis, aortic root dilation, and aortic dissection. The aetiology of BAV is notably intricate, involving a spectrum of genes and polymorphisms. Moreover, BAV lays the groundwork for an array of structural heart and aortic disorders, presenting varying degrees of severity. Establishing a tailored clinical approach amid this diverse range of BAV-related conditions is of utmost significance. In this comprehensive review, we delve into the epidemiology, aetiology, associated ailments, and clinical management of BAV, encompassing imaging to aortic surgery. Our exploration is guided by the perspectives of the aortic team, spanning six distinct guidelines. METHODS: We conducted an exhaustive search across databases like PubMed, Ovid, Scopus, and Embase to extract relevant studies. Our review incorporates 84 references and integrates insights from six different guidelines to create a comprehensive clinical management section. RESULTS: BAV presents complexities in its aetiology, with specific polymorphisms and gene disorders observed in groups with elevated BAV prevalence, contributing to increased susceptibility to other cardiovascular conditions. The altered hemodynamics inherent to BAV instigate adverse remodelling of the aorta and heart, thus fostering the development of epigenetically linked aortic and heart diseases. Employing TTE screening for first-degree relatives of BAV patients might be beneficial for disease tracking and enhancing clinical outcomes. While SAVR is the primary recommendation for indicated AVR in BAV, TAVR might be an option for certain patients endorsed by adept aortic teams. In addition, proficient teams can perform aortic valve repair for AR cases. Aortic surgery necessitates personalized evaluation, accounting for genetic makeup and risk factors. While the standard aortic replacement threshold stands at 55 mm, it may be tailored to 50 mm or even 45 mm based on patient-specific considerations. CONCLUSION: This review reiterates the significance of considering the multifactorial nature of BAV as well as the need for further research to be carried out in the field.

Graft flow assessment and early coronary artery bypass graft failure: a computed tomography analysis.

OBJECTIVES: We evaluated graft patency by computed tomography and explored the determinants of intraoperative mean graft flow (MGF) and its contribution to predict early graft occlusion. METHODS: One hundred and forty-eight patients under a single surgeon were prospectively enrolled. Arterial and endoscopically harvested venous conduits were used. Intraoperative graft characteristics and flows were collected. Graft patency was blindly evaluated by a follow-up computed tomography at 11.4 weeks (median). RESULTS: Graft occlusion rate was 5.2% (n = 22 of 422; 8% venous and 3% arterial). Thirteen were performed on non-significant proximal stenosis while 9 on occluded or >70% stenosed arteries. Arterial and venous graft MGF were lower in females (Parterial = 0.010, Pvenous = 0.009), with median differences of 10 and 13.5 ml/min, respectively. Arterial and venous MGF were associated positively with target vessel diameter ≥1.75 mm (Parterial = 0.025; Pvenous = 0.002) and negatively with pulsatility index (Parterial < 0.001; Pvenous < 0.001). MGF was an independent predictor of graft occlusion, adjusting for EuroSCORE-II, pulsatility index, graft size and graft type (arterial/venous). An MGF cut-off of 26.5 ml/min for arterial (sensitivity 83.3%, specificity 80%) and 36.5 ml/min for venous grafts (sensitivity 75%, specificity 62%) performed well in predicting early graft occlusion. CONCLUSIONS: We demonstrate that MGF absolute values are influenced by coronary size, gender and graft type. Intraoperative MGF of >26.5 ml/min for arterial and >36.5 ml/min for venous grafts is the most reliable independent predictor of early graft patency. Modern-era coronary artery bypass graft is associated with low early graft failure rates when transit time flow measurement is used to provide effective intraoperative quality assurance.

Tropheryma whipplei endocarditis: An uncommon infection with potentially fatal consequences.

We report a case of culture-negative aortic valve endocarditis secondary to Tropheryma whipplei infection. Our patient underwent aortic valve replacement after 4 weeks of antibiotic therapy with persistently negative blood culture results. Despite a technically uneventful operation, the patient showed continued sepsis and was unresponsive to a broad-spectrum of antibiotic therapy with subsequent multiorgan failure. He died on the 5th postoperative day, and diagnosis was established at postmortem examination. In this case report, we discuss the diagnosis and treatment of a rare type of endocarditis caused by T. whipplei.

Ultrasound guided vascular access site management and left ventricular pacing are associated with improved outcomes in contemporary transcatheter aortic valve replacement: Insights from the OxTAVI registry.

OBJECTIVES: To identify clinical and procedural practice predictors of avoidable complications during transcatheter aortic valve replacement (TAVR). BACKGROUND: TAVR is evolving as a viable strategy for treatment of aortic stenosis (AS). Vascular complications, major bleeding, or pericardial tamponade may be influenced by procedural practice. METHODS: The Oxford TAVR (OxTAVI) prospective registry was retrospectively analyzed to identify predictors of avoidable procedural complications in a contemporary cohort of transfemoral TAVR between January 2015 and September 2018. The primary endpoint was defined as a hierarchic composite of in-hospital mortality, pericardial effusion/cardiac tamponade, major bleeding, and vascular access complications. Individual components of the primary endpoint have been analyzed separately. RESULTS: Five-hundred-twenty-nine patients underwent transfemoral TAVR using contemporary techniques during the study period and were enrolled in the OxTAVI registry. Female sex and high frailty were associated with a higher risk of death, major bleeding, vascular complication or pericardial tamponade. The use of ultrasound (US) guidance for vascular access management was independently associated with a reduced composite primary endpoint (OR = 0.35, CI:0.14-0.86, p = .02) after adjustment for clinical confounders, largely driven by a threefold reduction in vascular access complication (OR = 0.29, CI:0.15-0.55, p < .001). Performing rapid pacing via the left ventricle guidewire (LV-GW) was associated with a significant decrease in the risk of cardiac tamponade/pericardial effusion (OR = 0.19, CI:0.05-0.66, p = .009). CONCLUSION: US-guided vascular access management and rapid pacing via the LV-GW are important determinants of reduced procedural complications during TAVR.

Beyond patency: Functional assessment of adequacy using internal mammary artery grafting to the left anterior descending artery.

INTRODUCTION: Arterial graft physiology influences the long-term outcome of coronary artery bypass grafting (CABG). We studied factors that can affect the overall resistance to flow using internal mammary artery grafting to the left anterior descending artery. METHODS: This was a prospective, nonrandomized observational study of 100 consecutive patients who underwent elective on-pump isolated or combined valve surgery and CABG. Coronary stenoses were assessed using conventional and quantitative coronary angiography assessment. The flow and pulsatility index (PI) of the grafts were assessed by transit-time flowmetry during cardioplegic arrest and at the end of the operation. Fractional polynomials were used to explore linearity, followed by multivariable regression analysis. RESULTS: Univariate analysis demonstrated higher flows at the end of the operation in patients who had higher flows with the cross-clamp on (P < .001), in males (P = .004), in patients with a low PI at the end of the operation (P = .04), and in patients with a larger size of the recipient artery (P = .005). Multivariable regression analysis showed that the graft flow at the end of the operation was significantly associated with the mean flow with the cross-clamp on (P < .001), sex (P = .003), and PI at the end of the operation (P = .003). Concomitant valve surgery did not influence flows. Male patients had 18 mL/min higher flow. CONCLUSIONS: The graft flow at the end of the operation can be determined by the flow with the cross-clamp on, the PI with the cross-clamp off and coronary artery. We reported differences in the graft flows between sexes, and for first the time, we introduced the concepts of "adequate flow" and "resistance-to-forward-flow" for patent coronary grafts.

Thrombotic Thrombocytopenic Purpura Following Aortic Valve Replacement with St. Jude Medical Trifecta Bio-Prosthesis.

Thrombocytopenia is a recognized complication following aortic valve replacement (AVR). While post-operative thrombotic thrombocytopenic purpura (TTP) is less common than heparin-induced thrombocytopenia (HIT), it is associated with high mortality and morbidity and prompt diagnosis and treatment is vital. In this case report, we describe the first reported case of TTP after AVR using the trifecta bio-prosthesis. We recommend that patients with severe and progressive thrombocytopenia following biological AVR should have early screening for both HIT and TTP, to shorten the decision-making process and provide the appropriate therapy.

Procedural and thirty-day outcomes following transfemoral implantation of the fully repositionable and retrievable Lotus valve without routine pre-dilatation in a consecutive patient cohort: a single-center experience.

BACKGROUND / PURPOSE: The Lotus valve (Boston Scientific, Natick, MA, USA) is a contemporary transcatheter aortic valve implantation (TAVI) device that is fully repositionable and retrievable to aid implantation and optimise procedural results. The ability to implant the device without routine pre-dilatation is another possible advantage reducing associated risks and procedure times. The aim of this study is to report procedural and 30-day outcomes following TAVI in a consecutive patient group presenting with severe symptomatic aortic stenosis with the Lotus valve system without routine pre-dilatation. METHODS / MATERIALS: 146 consecutive patients that underwent TAVI at the John Radcliffe Hospital, Oxford between January 2015 - December 2016 were retrospectively analysed. RESULTS: The mean age was 81.1±7.4 years and the mean logistic EuroSCORE was 14.6±10. 134 (91.8%) of patients were treated under conscious sedation. 144 (98.6%) of procedures were successful. Two patients (1.4%) died during the follow-up period. None or mild residual aortic regurgitation was achieved in 98.6% of patients. The mean and peak transvalvular gradients were 8.6±3.6mmHg and 16.6±6.6mmHg respectively. Eight patients (5.5%) suffered a stroke. Over time, there was a reduction in major vascular complications (14.3% vs. 2.2%, p=0.03) and a trend toward shorter procedure times (97.6±44.3 vs. 86.8±31.4 minutes, p=0.14) and the administration of less contrast (104.4±45.2 vs. 91.7±37.6 millilitres, p=0.16). The overall new pacemaker implantation rate was 36.3%. CONCLUSIONS: The use of the Lotus valve as a 'workhorse' device without routine pre-dilatation is safe and efficacious and is associated with a very low incidence of residual aortic regurgitation and acceptable transvalvular haemodynamics.

Transfemoral Transcatheter Aortic Valve-in-Valve Implantation for Aortic Valve Bioprosthesis Failure With the Fully Repositionable and Retrievable Lotus Valve: A Single-Center Experience.

OBJECTIVE: To report a first case series of the Lotus valve (Boston Scientific) for the treatment of surgical aortic bioprosthesis failure. BACKGROUND: Valve-in-valve (VIV) transcatheter aortic valve implantation (TAVI) is an established management option for surgical aortic bioprosthesis failure. Although TAVI has proven efficacious, complications relating to suboptimal valve implantation have been reported in approximately 5% of patients. The Lotus valve is fully repositionable and retrievable, and therefore enables complete assessment of valve function prior to definitive deployment. However, data supporting its use for this indication are limited. METHODS: Consecutive patients who underwent transfemoral VIV-TAVI at John Radcliffe Hospital between January 2015 and December 2016 were retrospectively analyzed. Procedural and 30-day outcomes were reported in accordance with Valve Academic Research Consortium-2 (VARC-2) definitions. RESULTS: Seven patients underwent VIV-TAVI with the Lotus valve. Device success according to VARC-2 criteria was achieved in 6 of the 7 patients. Following implantation, transvalvular hemodynamics were acceptable, with a mean gradient of 11.9 ± 6.6 mm Hg. All patients had mild or no residual aortic regurgitation. Specifically, no patient required further valve-related intervention, or suffered myocardial infarction, stroke, or acute kidney injury stage 2 or 3. There were no deaths during the follow-up period. CONCLUSIONS: Transfemoral VIV-TAVI for the treatment of surgical aortic bioprosthesis failure with the Lotus device appears to be safe and is associated with no significant residual aortic regurgitation, and offers favorable transvalvular hemodynamics at 30-day follow-up.

Extracorporeal membrane oxygenation in burn and smoke inhalation injury.

A systematic review and meta-analysis was conducted to assess the level of evidence for the use of extracorporeal membrane oxygenation (ECMO) in hypoxemic respiratory failure resulting from burn and smoke inhalation injury. We searched any article published before March 01, 2012. Available studies published in any language were included. Five authors rated each article and assessed the methodological quality of studies using the recommendation of the Oxford Centre for Evidence Based Medicine (OCEBM). Our search yielded 66 total citations but only 29 met the inclusion criteria of burn and/or smoke inhalation injury. There are no available systematic reviews/meta-analyses published that met our inclusion criteria. Only a small number of clinical trials, all with a limited number of patients, were available. The overall data suggests that there is no improvement in survival for burn patients suffering acute hypoxemic respiratory failure, with the use of ECMO. ECMO run times of less than 200 h correlate with higher survival compared to 200 h or more. Scald burns show a tendency of higher survival than flame burns. In conclusion, the presently available literature is based on insufficient patient numbers; the data obtained and level of evidence generated are limited. The role of ECMO in burn and smoke inhalation injury is therefore unclear. However, ECMO technology and expertise have improved over the last decades. Further research on ECMO in burn and smoke inhalation injury is warranted.