Sleeve valve-sparing procedure in bicuspid aortic valve: early and midterm clinical results.

BACKGROUND: Patients with aortic root ectasia and bicuspid aortic valve benefit of the treatment with aortic valve sparing procedure, with excellent long-term results. The Sleeve-procedure is one of the options in patients with aortic root diseases and it might be suitable for patients with a bicuspid valve. METHODS: From October 2006 to December 2018, 42 consecutive patients with bicuspid aortic valve and aortic root ectasia/aneurysm, with or without aortic regurgitation, were surgically treated with the Sleeve-procedure. RESULTS: In 20 patients (48%) leaflets surgery was necessary and consisted of raphe mobilization/resection in 17 patients, plication of both leaflets in 2 patients and a two-commissures resuspension in 1 patient. During a mean clinical follow-up time of 4.4±3.1 years, the survival rate was 100%, 1 patient required a reoperation at 6.1 years postoperatively, with an overall freedom from reoperation of 94±5%. The rest of the patients (41/42), had no more than mild residual aortic valve regurgitation. With a mean follow-up of 4.3±1.7 years the magnetic resonance imaging performed in 26 patients, did not show signs of aortic wall herniation through the key-holes or persisting creases of the aortic wall inside the prosthesis. CONCLUSIONS: Patients with aortic root disease and bicuspid aortic valve may be treated with Sleeve technique with excellent midterm results. However, a longer follow-up is required before drawing any solid conclusion.

Aortic Root Dynamics in Sleeve Aortic Sparing Procedure: Echocardiographic and Computational Studies.

In Sleeve procedure, the leaflets-sinus unit is maintained. We hypothesized that this feature partially preserves aortic root (AR) dynamics and leaflets kinematics and limits tensions in the leaflets. We tested our hypothesis based on in vivo and computational assessment of leaflets and AR dynamics. AR and aortic leaflet kinematics was assessed by transthoracic echocardiography in 10 patients treated with the Sleeve procedure and in 10 healthy patients. Numerical calculations with the Finite Element Method were performed to support the analysis of the clinical results and provide a better understanding of the behavior of the AR treated via the Sleeve procedure. Echocardiographic evidence showed that AR expansion in the Sleeve group was partially preserved as compared to the Control group (2.9 ± 2.5% vs 7.7 ± 6.3%, P = 0.038) and of the sinotubular junction (2.9 ± 1.5% vs 7.3 ± 3.8%, P = 0.003), and significantly preserved at the Valsalva sinuses level (6.7 ± 2.6% vs 9.5 ± 4.3%) with not statistically significant differences (P = 0.11). In none of the cardiac phases, differences in aortic valve leaflets kinematics were measured between the 2 groups; computational results were rather consistent with this evidence. Computational results well matched echocardiographic evidences, allowing for their mechanistic interpretation. Near-normal opening and closing characteristics can be accomplished by a technique that preserves the shape and the dynamics of the Valsalva sinuses. Whether the substantial preservation of the AR distensibility and leaflets kinematics observed in this study will favorably affect long-term valve durability it remains to be ascertained.

Opening/closing pattern of Trifecta and Freestyle valves versus native aortic valve: Are stentless valves more physiologic than a stented valve?

BACKGROUND: Stentless valves have long been considered the ideal valves in terms of hemodynamics. Recently, the Trifecta valve, a stented bioprosthesis with excellent fluid dynamic characteristics, has become available. The aim of the study was to compare the opening/closing pattern of the Freestyle stentless valve and the Trifecta valve with that of the native aortic valve. METHODS: A total of 12 patients with a Freestyle and 10 with a Trifecta valve were compared to normal native aortic valves in 12 control patients. Leaflet kinematics and hemodynamic parameters were obtained by echocardiographic M-mode and Doppler measurements. RESULTS: The control group displayed significantly longer Rapid Valve Opening Time (45 ± 7 ms) and Rapid Valve Closing Time (42 ± 9 ms) than Freestyle patients (Rapid Valve Opening Time: 32 ± 7 ms; Rapid Valve Closing Time: 31 ± 8 ms) and Trifecta patients (Rapid Valve Opening Time: 31 ± 7 ms; Rapid Valve Closing Time: 30 ± 8 ms) (P < 0.0001). The maximal leaflet displacement reached at the end of rapid valve opening was 16.7 ± 3.2 mm, 17.7 ± 2.3 mm, and 17.7 ± 5.3 mm (P = 0.42) in the Freestyle, Trifecta, and control groups, respectively. The total opening time was shorter in the control group (223 ± 25 ms) than in Freestyle (319 ± 61 ms) and Trifecta (324 ± 46 ms) patients (P < 0.0001). CONCLUSIONS: The Freestyle stentless valve was not superior to the Trifecta valve in terms of kinematics and functions more like a stented bioprosthesis.

Hemodynamic comparison between Trifecta and freestyle aortic valve during exercise in patients with small aortic root.

BACKGROUND: Patients with a small aortic annulus, that is ≤ 23 mm, constitute a challenge for the surgeon, because they are at high risk of patient-prosthesis mismatch. Stentless valves provide better hemodynamic performance at rest and during exercise than stented valves, and are advocated in this group of patients. A new-generation stented valve, the Trifecta (St. Jude), has recently become available with improved hemodynamics. The aim of this study was to compare the hemodynamic performance of Freestyle (Medtronic) and Trifecta at rest and during exercise in patients with a small aortic annulus. METHODS: From September 2012 to September 2014, 22 patients with a native aortic annulus ≤ 23 mm underwent ergometric stress testing one year after aortic valve replacement with either a Trifecta (12 patients) or a Freestyle (10 patients) bioprosthesis as part of a randomized study. RESULTS: The mean gradient at rest was 6.0 ± 2.3 mmHg for Trifecta and 4.3 ± 3.5 for Freestyle (p = 0.213). The mean gradient at peak of exercise was 9.7 ± 3.4 mmHg for Trifecta and 7.4 ± 5 mmHg for Freestyle (p = 0.243). No significant differences were found between the two prostheses regarding other hemodynamic parameters: effective orifice area, velocity index, and performance indexes. CONCLUSION: Both the stented Trifecta and stentless Freestyle prostheses provide excellent hemodynamic results during physical stress in patients with a small aortic annulus. Our study confirms that Trifecta implantation results in low gradients at rest and during exercise and that the performance of Trifecta is similar to that of a stentless valve.

Early and medium term results of the sleeve valve-sparing procedure for aortic root ectasia.

BACKGROUND: The aim of this retrospective study was to evaluate our experience of using a simplified aortic valve sleeve procedure to treat aortic root ectasia and aneurysms with or without aortic regurgitation. In experienced hands, 2 aortic valve-sparing procedures, ie, Yacoub and David, have yielded excellent long-term results in the treatment of aortic root aneurysms, with or without aortic regurgitation. However, these techniques are demanding and not widely used. Recently, a new and simplified valve-sparing technique, named "sleeve procedure," has been proposed, and has yielded encouraging early results. METHODS: Ninety consecutive patients with aortic root aneurysms underwent sleeve procedures from October 2006 to October 2012. Follow-up data (clinical 100% complete and echocardiographic 93% complete) were acquired from our outpatient clinic or from the referring cardiologist. RESULTS: The mean age of the patients was 61.5 ± 12.5 years, 79% were male, 16 (18%) had a bicuspid valve, 3 had Marfan syndrome, and 2 had aortic dissection. Over a mean clinical follow-up of 34 ± 19 months, 2 patients died from noncardiac causes and 1 was reoperated on for the recurrence of aortic regurgitation. On follow-up echocardiography after a mean of 18 ± 9 months, aortic regurgitation was absent/negligible, mild or moderate in 62%, 37%, and 1% of patients, respectively, and the diameters of the annulus, Valsalva sinuses, and sinotubular junction were 27.3 + 2.2, 37.0 + 3.4, and 30.6 + 3.1 mm, respectively. CONCLUSIONS: Our encouraging early and medium term results suggest that the sleeve procedure is a safe and effective aortic valve-sparing technique for the treatment of aortic root ectasia and aneurysm. However, longer follow-up is needed in order to draw definitive conclusions.

Hemodynamic comparison between Trifecta and Freestyle valves implanted in small aortic roots. One-year echocardiographic results from a prospective randomized study.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement in patients with a small aortic root may be associated to high residual gradients. In such patients, both stentless valves and aortic annulus enlargement can reduce these residual gradients. Several studies have reported that Trifecta valves yield very good hemodynamic results. The aim of the present study was to compare the hemodynamic performance of Trifecta vs. Freestyle valves at one year in patients with an aortic annulus ≤ 2.3 cm. METHODS: Between September 2011 and September 2013, 40 patients with a native aortic annulus diameter ≤ 2.3 cm and average age of 81 ± 4 years, were randomized to receive either a St-Jude Trifecta stented prosthesis (20 patients) or a Medtronic Freestyle stentless prosthesis (20 patients). RESULTS: No differences between Trifecta and Freestyle were found at one year in mean gradient s: 6.1 ± 3 mmHg and 6.6 ± 3 mmHg (p = 0.796); effective ori fice area: 1.82 ± 0.3 mmHg and 1.76 ± 0.4 mmHg (p = 0.676) or regression of left ventricular mass: - 25% ± 14 vs. -19% ± 16 (p = 0.204), respectively. Only moderate patient -pro sthesis mismatch was found, which affected 3 patient s in each group. CONCLUSION: At one year both stentless and stented prostheses yielded comparable hemodynamic results. These data suggest that Trifecta implantation is a valid means of avoiding patient -prosthesis mismatch in aortic valve replacement in elderly patients with a small native aortic annulus.

Early hemodynamic evaluation of Trifecta and Freestyle bioprostheses in patients with a small aortic root: preliminary results from a prospective randomized study.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with a small aortic root is often associated with some degree of obstruction and residual gradients. Stentless valves display better hemodynamic performance than stented valves, and might be ideal in patients with a small aortic annulus. A new stented bioprosthesis, the Trifecta valve, has recently become available and has yielded interesting early results. The study aim was to compare the hemodynamic performance of the Trifecta valve with that of the Freestyle valve in patients with an aortic annulus ≤ 2.3 cm. METHODS: Between September 2011 and September 2013, a total of 40 patients with pure aortic stenosis and native aortic annulus diameter ≤ 2.3 cm was randomized to receive either a St. Jude Medical Trifecta stented prosthesis (n = 20) or a Medtronic Freestyle stentless prosthesis (n = 20). Hemodynamics results were compared between the two groups on discharge from hospital. RESULTS: The Trifecta valve showed slightly better hemodynamics, with peak gradients of 11 ± 5 mmHg and 17 ± 9 mmHg (p = 0.009), and mean gradients of 5.5 ± 3 mmHg and 7.5 ± 4 mmHg (p = 0.06) for the Trifecta and Freestyle valves, respectively. The average indexed effective orifice area (EOAi) was 1.14 ± 0.23 cm2/m2 and 1.09 ± 0.20 cm2/m2 (p = 0.520) for the Trifecta and Freestyle, respectively. Patient-prosthesis mismatch (PPM) occurred in two patients of the Freestyle group, and in three patients of the Trifecta group. CONCLUSION: In the present study, the stentless and stented prostheses each yielded comparable and excellent early hemodynamics results. The data obtained suggest that Trifecta valve implantation is a valid means of avoiding PPM after AVR in patients with a small native aortic annulus.

Influence of CoreValve ReValving System implantation on mitral valve function: an echocardiographic study in selected patients.

OBJECTIVES: The purpose of this study is to verify whether transcatheter aortic valve implantation (TAVI) determined changes in mitral valve (MV) function, in terms of mitral regurgitation (MR) and stenosis. BACKGROUND: Little data is available regarding the effects of TAVI on global MV function, often derived from analysis primarily focused on clinical and aortic related outcomes. METHODS: From May 2008 to March 2010, 73 patients with severe symptomatic aortic stenosis underwent TAVI with the CoreValve ReValving System. The study population consisted of 58 patients (27 males, mean age 82 ± 7 years) who underwent transthoracic echocardiography at least ≥1 month after implantation (mean follow-up 7.8 ± 5.4 months). RESULTS: In patients with a left ventricular dysfunction (ejection fraction, EF, <45%) at the baseline, EF significantly increased from 37 ± 6% to 48 ± 7% after TAVI (P = 0.003). Before TAVI, 42 patients had no or mild MR, 13 mild-to-moderate, and 3 moderate or moderate-to-severe. During follow-up, the MR degree was unchanged in the majority of patients (55%), 12% reduced, and 33% worsened. Variables associated with worsening in MR were depth of aortic prosthesis (P = 0.02 for the distance between the ventricular end and the right coronary cusp; P = 0.04 for mean distance right-left coronary cusps) and left atrium area at the baseline (P = 0.02). After TAVI, six patients (10%) developed mild or moderate mitral stenosis, often in a native valve with anterior calcifications. CONCLUSIONS: In the majority of patients no significant changes occurred in the degree of MR in native valve, but we found that if the aortic valve was deeply implanted in the left ventricle outflow tract, a worsening in MR can be observed. A mitral stenosis development must be sought in patients with heavy calcifications of the anterior leaflet.

Assessment of mitral prosthetic valve thrombosis by live three-dimensional echocardiography: comparison with transesophageal echocardiography.

We report the feasibility of transthoracic live three-dimensional echocardiography in the diagnosis of a thrombus attached to the mitral bioprosthetic valve.

[Prognostic value of serial measurements of left ventricular function and exercise performance in chronic heart failure]. / Valor pronóstico de las medidas seriadas de la función ventricular izquierda y del rendimiento en el ejercicio en la insuficiencia cardiaca crónica.

INTRODUCTION AND OBJECTIVES: The prognostic value of a single measurement of ejection fraction and peak oxygen uptake in chronic heart failure has been extensively investigated. The aim of our study was to evaluate the prognostic significance of serial changes in ejection fraction and exercise performance in moderate to severe chronic heart failure. METHODS: 182 patients (156 men, 53 [47-58] years) underwent echocardiography and cardiopulmonary exercise testing at baseline and after 10 [8-12] months. Most patients had idiopathic dilated cardiomyopathy (69%) and all patients presented left ventricular ejection fraction <45%. Median follow-up was 21 [14-34] months; cardiac death and heart transplantation were the end-points. Hazard ratio (HR, per unit) is presented with its 95% confidence interval (CI). RESULTS: During follow-up 18 patients (9.9%) died and 14 (7.7%) underwent heart transplantation. Baseline ejection fraction (HR, 0.94, 95% CI, 0.89-0.98 P=.006) and mitral regurgitation (HR, 4.22, 95% CI, 1.63-10.92, P=.003), and delta (second examination-baseline) ejection fraction (HR, 0.93, 95% CI, 0.88-0.98, P=.01) were the only significant variables at univariate analysis. Both ejection fraction and delta ejection fraction remained independently associated with events at multivariate analysis. The prognostic power significantly increased between a model including ejection fraction alone and another one including ejection fraction plus delta ejection fraction. CONCLUSIONS: In clinically stable patients with chronic heart failure, ejection fraction and its changes were independently associated with outcome; on the contrary, serial cardiopulmonary exercise testing did not provide significant prognostic value. Baseline plus changes in ejection fraction showed better prognostic performance than baseline ejection fraction alone.

Valor pronóstico de las medidas seriadas de la función ventricular izquierda y del rendimiento en el ejercicio en la insuficiencia cardiaca crónica / Prognostic value of serial measurements of left ventricular function and exercise performance in chronic heart failure

No disponibleIntroducción y objetivos. Se ha investigado extensamente el valor pronóstico de una determinación aislada de la fracción de eyección y del consumo máximo de oxígeno en la insuficiencia cardiaca crónica. El objetivo del presente estudio fue valorar el significado pronóstico de los cambios seriados en la fracción de eyección y en el rendimiento del ejercicio en la insuficiencia cardiaca crónica moderada o severa. Métodos. En la situación basal y después de 10 (8-12) meses, se realizaron una ecocardiografía y pruebas de esfuerzo cardiopulmonar a 182 pacientes (156 varones, 53 [47-58] años de edad). La mayor parte de los pacientes presentaba una miocardiopatía dilatada idiopática (69%), y todos tenían una fracción de eyección inferior al 45%. La mediana del seguimiento fue de 21 (14-34) meses; los criterios principales de valoración fueron la muerte cardiaca y la necesidad de trasplante cardiaco. Se presenta el cociente de riesgo (CR, por unidad) con sus intervalos de confianza (IC) del 95%. Resultados. Durante el seguimiento fallecieron 18 pacientes (9,9%) y 14 (7,7%) recibieron un trasplante cardiaco. En el análisis univariado las únicas variables significativamente asociadas con la evolución fueron la fracción de eyección basal (CR = 0,94; IC del 95%, 0,89-0,98; p = 0,006), la regurgitación mitral (CR = 4,22; IC del 95%, 1,63-10,92; p = 0,003), y el cambio de la fracción de eyección (segundo examen basal) (CR = 0,93; IC del 95%; 0,88-0,98; p = 0,01). En el análisis multivariado la fracción de eyección y el cambio de la fracción de eyección siguieron asociándose independientemente con los acontecimientos adversos en el seguimiento. La potencia pronóstica aumentó significativamente entre el modelo que sólo incluyó la fracción de eyección y otro modelo que incluyó la fracción de eyección más el cambio de la fracción de eyección. Conclusiones. En pacientes con insuficiencia cardiaca crónica estables desde un punto de vista clínico, la fracción de eyección y sus cambios se asociaron independientemente con el pronóstico. Por el contrario, las pruebas de esfuerzo cardiopulmonar seriadas no tuvieron un valor pronóstico significativo. La fracción de eyección aislada más sus cambios demostraron un mayor rendimiento pronóstico que la fracción de eyección aislada determinada en el período basal (AU)

Introduction and objectives. The prognostic value of a single measurement of ejection fraction and peak oxygen uptake in chronic heart failure has been extensively investigated. The aim of our study was to evaluate the prognostic significance of serial changes in ejection fraction and exercise performance in moderate to severe chronic heart failure. Methods. 182 patients (156 men, 53 [47-58] years) underwent echocardiography and cardiopulmonary exercise testing at baseline and after 10 [8-12] months. Most patients had idiopathic dilated cardiomyopathy (69%) and all patients presented left ventricular ejection fraction <45%. Median follow-up was 21 [14-34] months; cardiac death and heart transplantation were the end-points. Hazard ratio (HR, per unit) is presented with its 95% confidence interval (CI). Results. During follow-up 18 patients (9.9%) died and 14 (7.7%) underwent heart transplantation. Baseline ejection fraction (HR, 0.94, 95% CI, 0.89-0.98 P=.006) and mitral regurgitation (HR, 4.22, 95% CI, 1.63-10.92, P=.003), and delta (second examination-baseline) ejection fraction (HR, 0.93, 95% CI, 0.88-0.98, P=.01) were the only significant variables at univariate analysis. Both ejection fraction and delta ejection fraction remained independently associated with events at multivariate analysis. The prognostic power significantly increased between a model including ejection fraction alone and another one including ejection fraction plus delta ejection fraction. Conclusions. In clinically stable patients with chronic heart failure, ejection fraction and its changes were independently associated with outcome; on the contrary, serial cardiopulmonary exercise testing did not provide significant prognostic value. Baseline plus changes in ejection fraction showed better prognostic performance than baseline ejection fraction alone (AU)

Tako-tsubo: a transitory impairment of microcirculation? A case report.

The tako-tsubo syndrome, or transient left ventricular apical ballooning, has been widely described in Japan as a cardiomyopathy which resembles acute myocardial infarction on presentation, but characterized by a normal coronary tree and a favorable outcome. Conversely few series have been described in Europe and etiology and mechanism are still unknown. We describe the case of a 74-year-old Italian woman with tako-tsubo cardiomyopathy, one of the first Italian cases reported to our knowledge. In the acute phase, echocardiography and ventriculography showed the typical mid-apical systolic left ventricular dysfunction, with an angiographically normal coronary tree. A few days after, technetium-99m single-photon emission computed tomography disclosed a large mid-apical perfusion defect and dobutamine stress echocardiography showed a typical "biphasic" response. Three months later, all of these tests normalized with normal left ventricular function. In conclusion, the results of functional tests, during the acute and subacute phases, suggest that, in the absence of evident coronary spasm, a transitory reduction of the coronary reserve played a role in the pathogenesis. In the absence of epicardial coronary obstruction this could be due to a transient microcircle dysfunction, and may be attributed to a spasm followed by impaired vasodilation capability.