Transcatheter aortic valve implantation for patient with non-calcified bicuspid aortic valve: a case report.

Background: Non-calcified aortic stenosis (AS) is rare and is associated with a high risk of transcatheter valve embolization and migration (TVEM) because aortic valve complex calcification is important for stable anchoring of the prosthesis. Therefore, transcatheter aortic valve implantation (TAVI) for non-calcified AS is not preferred. However, a universally accepted strategy for TAVI in such patients is not yet established. Case summary: A 69-year-old woman with symptomatic severe AS and a high surgical risk was admitted to our institution for TAVI. Pre-procedural computed tomography (CT) revealed a non-calcified bicuspid aortic valve. Implantation of a 23 mm self-expandable valve (SEV) was planned according to the manufacturer's recommended optimal size based on CT measurements. Intraoperatively, the 23 mm SEV did not snugly fit at the aortic apparatus level. Thus, we deployed a 26 mm SEV with stable anchoring because of the stronger radial force. She was discharged without any complication. Echocardiography at 3 months follow-up showed a well-functioning transcatheter heart valve (THV) without migration or paravalvular leakage. Discussion: In our patient with non-calcified bicuspid AS, an SEV that was one size larger than the optimal as measured on CT was successfully implanted without THV embolization. An upsized SEV may be considered when performing TAVI in patients with severe non-calcified AS.

Concomitant use of VA-ECMO and Impella with inhaled nitric oxide to treat cardiogenic shock after cardiac surgery: A case report.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to treat cardiogenic shock. However, a lack of left ventricle (LV) unloading and increased systemic afterload can cause pulmonary congestion. Impella (Abiomed, Danvers, MA, USA), a catheter-mounted micro-axial rotary pump, unloads the LV and provides hemodynamic support. However, Impella cannot support the right ventricle (RV), and RV dysfunction impedes weaning from VA-ECMO. A 50-year-old man with heart failure with reduced ejection fraction due to myocardial infarction developed moderate aortic stenosis and regurgitation, moderate mitral regurgitation, and tricuspid regurgitation. Aortic valve replacement, mitral valve replacement, and tricuspid valve replacement were performed. VA-ECMO with intra-aortic balloon pump (IABP) was initiated as he could not be weaned from cardiopulmonary bypass. The patient could not be weaned from IABP and VA-ECMO; therefore, Impella 5.0 was inserted instead of IABP on day 7. However, Impella 5.0 was ineffective due to RV dysfunction. Increased inhaled nitric oxide (iNO) dose lowered pulmonary vascular resistance, decreased RV afterload, and improved RV distension. He was weaned from VA-ECMO after increasing the flow from the Impella 5.0. Combining VA-ECMO with Impella and iNO improved hemodynamics in a patient with RV dysfunction, and Impella with iNO aided weaning from VA-ECMO. Learning objective: Combining venoarterial extracorporeal membrane oxygenation (VA-ECMO) with Impella (Abiomed, Danvers, MA, USA) and inhaled nitric oxide (iNO) can improve hemodynamics in a patient with right ventricular dysfunction, and iNO may aid weaning from VA-ECMO.

A Giant Left Coronary Button Aneurysm After Aortic Root Remodeling Procedure in a Patient With Marfan Syndrome: A Case Report.

Coronary button aneurysm is a well-known complication of aortic root surgery, especially in patients with Marfan syndrome. We present a case of a giant left coronary button aneurysm that occurred 20 years after an aortic root remodeling procedure was performed. A 32-year-old man with Marfan syndrome underwent the aortic root remodeling procedure for annuloaortic ectasia. Thirteen years later, an aortic aneurysm with chronic aortic dissection was diagnosed, and partial aortic arch replacement was performed. Twenty years after the first procedure, a 73-mm left coronary button aneurysm was observed. Due to dense adhesions from repeated surgeries, we approached the aneurysm through the artificial graft lumen, and the coronary artery was successfully reconstructed using Piehler's technique. When performing aortic root surgery for Marfan syndrome, the risk of coronary artery button aneurysm formation should be considered. Once an aneurysm is formed, a surgical strategy that assumes dense adhesions is essential.

Prognostic impact of electrocardiographic left ventricular hypertrophy following transcatheter aortic valve replacement.

BACKGROUND: Left ventricular hypertrophy (LVH) develops with both structural and electrical remodeling in response to elevated afterload due to aortic stenosis (AS). This study evaluated the prognostic value of electrocardiographic LVH (ECG LVH) after transcatheter aortic valve replacement (TAVR). METHODS: A retrospective study including 157 consecutive patients who underwent TAVR was conducted. ECG LVH was defined as Sokolow-Lyon voltage (S in V1 + R in V5/6) before TAVR was ≥3.5mV. We investigated the association between ECG LVH and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. ECG and echocardiographic measurements at 1, 6, and 12 months after TAVR were assessed. RESULTS: The baseline characteristics were comparable between the ECG LVH (n = 74) and non-ECG LVH groups (n = 83). The ECG LVH was associated with a significantly greater reduction of Sokolow-Lyon voltage and LV mass index than the non-ECG LVH after TAVR. The absence of ECG LVH was an independent predictor of the 1-year composite outcome [adjusted hazard ratio (HR), 2.27; 95% confidence interval (CI), 1.01 - 5.60; p = 0.04]. Furthermore, a reduction of Sokolow-Lyon voltage from baseline to 1-month follow-up, but not a reduction of LV mass index, was associated with a lower cumulative composite outcome from 1 month to 1 year (adjusted HR, 0.36; 95% CI, 0.15 - 0.86; p = 0.02). CONCLUSIONS: ECG LVH was associated with a low incidence of adverse clinical outcomes and greater reverse LV remodeling after TAVR. Preprocedural and serial LVH assessment by ECG might be useful in AS patients undergoing TAVR.

Prognostic impact of arterial stiffness following transcatheter aortic valve replacement.

BACKGROUND: Increased left ventricular (LV) afterload in patients with aortic stenosis consists of valvular and vascular loads; however, the effects of vascular load induced by arterial stiffness on clinical outcomes after transcatheter aortic valve replacement (TAVR) remain unclear. This study evaluated the prognostic value of brachial-ankle pulse wave velocity (baPWV) after TAVR. METHODS: A retrospective study including 161 consecutive patients who underwent TAVR with a pre-procedural baPWV assessment was conducted. We investigated the association between baPWV and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. Echocardiographic measurements including the LV mass index (LVMi) and LV diastolic function at 1, 6, and 12 months after TAVR were assessed. RESULTS: Of the 161 patients, 31 patients experienced composite outcome within 1 year after TAVR. The receiver operating characteristic curve analysis revealed that the discriminating baPWV level to discern 1-year composite outcome was 1,639 cm/s, and all subjects were allocated to two groups based on the result. Baseline characteristics were comparable between the high baPWV (n = 72) and low baPWV groups (n = 89). The Kaplan-Meier curve revealed a significantly higher cumulative 1-year composite outcome in the high baPWV group than in the low baPWV group (31% vs. 10%; log-rank test, p<0.001). High baPWV was an independent predictor of the 1-year composite outcome (adjusted hazard ratio, 3.42; 95% confidence interval, 1.62-7.85; p = 0.002). Furthermore, post-procedural echocardiography revealed that the high baPWV group had less LVMi regression and higher E/e' after TAVR compared to the low baPWV group. The delayed reversal in LVMi and diastolic function attributable to arterial stiffness might be linked to impaired clinical outcomes after TAVR. CONCLUSIONS: Higher baPWV could be associated with adverse clinical outcomes and delayed reverse LV remodeling after TAVR.

Evaluation of objective nutritional indexes as predictors of one-year outcomes after transcatheter aortic valve implantation.

BACKGROUND: Objective nutritional indexes have been shown to predict prognoses in some clinical settings. We aimed to investigate the prognostic values of these indexes in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: We retrospectively analyzed 95 consecutive patients who underwent TAVI at our institution from December 2013 to February 2017. As objective nutritional indexes, a controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) were calculated at baseline. The optimal cut-off values were determined using receiver operating characteristic curve analysis. According to the cut-off values, we investigated the association of these indexes with 1-year clinical outcomes including all-cause mortality and re-hospitalization due to heart failure. RESULTS: In the Kaplan-Meier analysis, patients with a higher CONUT score and lower PNI had significantly higher incidence rates of 1-year mortality (26.9% vs. 2.9%; p<0.001, 17.4% vs. 2.0%; p=0.011, respectively) and composite outcome of mortality and re-hospitalization due to heart failure (38.5% vs. 13.0%; p=0.006, 39.3% vs. 11.9%; p=0.002, respectively). On Cox hazard analysis, CONUT score and PNI were significantly associated with 1-year mortality [hazard ratio (HR): 1.91; 95% confidence interval (CI): 1.27-2.88; p=0.002, HR: 0.86; 95% CI: 0.75-0.99; p=0.031, respectively] and the composite outcome (HR: 1.49; 95% CI: 1.11-2.00; p=0.007, HR: 0.88; 95% CI: 0.80-0.97; p=0.011, respectively). CONCLUSIONS: The CONUT score and PNI are associated with 1-year clinical outcomes especially with 1-year all-cause mortality in patients undergoing TAVI. Moreover, the CONUT score and PNI might have better predictive values than GNRI.

The role of transcatheter aortic valve replacement in the patients with severe aortic stenosis requiring major non-cardiac surgery.

Severe aortic stenosis (AS) is considered as an independent risk factor for perioperative cardiac complications of non-cardiac surgery. Surgical aortic valve replacement should be considered before non-cardiac surgery in patients with symptomatic severe AS. However, recently, transcatheter aortic valve replacement (TAVR) has emerged as an alternative approach for selected AS patients. We sought to determine the safety and efficacy of TAVR in preparation for major non-cardiac surgery. From our retrospective database, seven patients who underwent TAVR in preparation for major non-cardiac surgery were identified, and their clinical and hemodynamic data were collected. After TAVR, a significant reduction in the mean transaortic pressure gradient from 54.0 (Interquartile range (IQR) 47.5-64.5) to 18.0 (IQR 12.5-19.0) mmHg (p = 0.016) and an increase in the calculated aortic valve area from 0.6 (IQR 0.6-0.7) to 1.3 (IQR 1.1-1.5) cm2 (p = 0.022) were noted. Non-cardiac surgery included lung segmentectomy and lymph node dissection, lung lobectomy, ileocecal resection, partial colectomy, partial nephrectomy, nephroureterectomy, laparoscopic nephrectomy, and laparoscopic nephroureterectomy. All the initial non-cardiac surgeries were performed without cardiac complications, under general anesthesia, 37 (IQR 32-74) days after TAVR. Two of the patients eventually needed additional non-cardiac surgery, which was performed uneventfully without the need for additional AS treatment. TAVR was an effective and safe procedure that might reduce the risk of general anesthesia and major non-cardiac surgery in severe AS.

Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction.

BACKGROUND: The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear. Methods and Results: We evaluated a consecutive series of 111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG: 63 underwent CR and 48 underwent incomplete revascularization (IR). At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and major adverse cardiac and cerebrovascular events (MACCE) were significantly greater in the IR group. After adjusting for propensity score, no significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75-2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68-3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08-3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34-11.44; P=0.013). CONCLUSIONS: Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.

Prognostic Impact of Computed Tomography-Derived Abdominal Fat Area on Transcatheter Aortic Valve Implantation.

BACKGROUND: Obesity has previously been identified as an indicator of good prognosis in patients undergoing transcatheter aortic valve implantation (TAVI), an association known as the "obesity paradox". We investigated whether abdominal total fat area (TFA), visceral fat area (VFA), or subcutaneous fat area (SFA) are prognostic indicators of long-term clinical outcome in patients undergoing TAVI. Methods and Results: We retrospectively analyzed 100 consecutive patients who underwent TAVI between December 2013 and April 2017. TFA, VFA, and SFA were measured from routine pre-procedural computed tomography (CT). Patients were divided into 2 groups according to median TFA, VFA, or SFA, and we investigated the association of abdominal fat area with adverse clinical events, including all-cause death and re-hospitalization due to worsening heart failure. At a median follow-up of 665 days, patients with higher SFA had significantly lower incidence of the composite outcome and all-cause death compared with patients with lower SFA (15.0% vs. 37.7%, P=0.025; and 8.9% vs. 23.7%, P=0.047, respectively). In contrast, patients with higher TFA or VFA did not show significant reduction in the incidences of the composite outcome or all-cause mortality. CONCLUSIONS: CT-derived SFA had prognostic value in patients undergoing TAVI.

Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair in a patient with very severe aortic stenosis with abdominal aortic aneurysm.

The safety of non-cardiac surgery is uncertain for asymptomatic patients with very severe aortic stenosis (AS). Herein, we describe a case involving an elderly and frail patient with asymptomatic, very severe AS. The patient was considered a high-risk candidate for aortic valve replacement (AVR); thus, transcatheter aortic valve implantation (TAVI) was planned. On perioperative examination, an abdominal aortic aneurysm (AAA) was observed, which required endovascular aneurysm repair (EVAR). To reduce the risks involved with sequential procedures, TAVI and EVAR were performed simultaneously. In patients with severe AS who are high-risk candidates for AVR, TAVI can be considered as an alternative therapy before non-cardiac surgery. In addition, the combined TAVI and EVAR procedure can reduce the risks associated with the perioperative period. .

Transcatheter aortic valve implantation in a patient with severe aortic valve stenosis, colon cancer, and obstructive ileus: A case report.

An 82-year-old woman with symptomatic severe aortic stenosis (AS) developed an obstructive ileus caused by colon cancer. Colectomy was considered a high-risk surgery due to both the severe AS and obstructive ileus. Therefore, we planned placement of a colonic stent for the obstructive ileus. After stenting, we performed transcatheter aortic valve implantation (TAVI) instead of surgical aortic valve replacement (SAVR), because of the risk of bleeding during extracorporeal circulation and the perioperative risk of AVR (Society of Thoracic Surgery predicted risk of mortality: 7.4%). Successful colonic stenting and TAVI allowed a safer colectomy. The period from TAVI to colectomy was 12 days. TAVI could be useful for symptomatic severe AS in high-risk patients prior to non-cardiac surgery, especially for malignant tumors. .

Transcatheter aortic valve implantation for patients with lung cancer and aortic valve stenosis.

Many patients who require lung resection have cardiovascular and cerebrovascular comorbidities. It has been recommended that surgical aortic valve replacement (SAVR) should precede lung resection in patients with severe aortic valve stenosis (AS). However, by first undergoing transcatheter aortic valve implantation (TAVI), the patient may undergo lung resection more safely. We present two patients with both severe AS and lung cancer who underwent TAVI and lung resection without any complications.

Coronary artery spasm following off-pump coronary artery bypass surgery.

Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.

Intraoperative assessment for mitral valve competency in a beating heart under retrograde coronary perfusion.

Intraoperative assessment of a repaired mitral valve is of paramount importance for reparative mitral surgery. From September 2010 through November 2012, 20 consecutive patients underwent mitral valve plasty for mitral regurgitation. The patients who underwent surgery after June 2012 received assessment of the repair with the heart beating (HB group, n = 10), and the patients who underwent the operation before May 2012 were assessed for the repair only under cardioplegic heart arrest (non-HB group, n = 10). Intermittent cold retrograde blood cardioplegia was used in all patients. In the HB-group, after completion of the procedures, pump blood without a crystalloid additive was delivered into the coronary sinus. The function of the mitral valve was assessed under beating conditions. There were no differences between the two groups in aortic cross clamp time and operation time, although operative and concomitant procedures were slightly more complicated in the HB group than in the non-HB group. Postoperative echocardiography revealed none or mild mitral regurgitation in all the patients in both groups. Reopening of the closed left atrium for additional repair was necessary only in one patient in the HB group and 3 patients in the non-HB group. In conclusion, the method of perfusing the myocardium retrogradely via the coronary sinus with warm blood is safe and effective for assessing the competency of the mitral valve in a beating heart.

Study Design of PROCEDURE Study. A Randomized Comparison of the Dose-Dependent Effects of Pitavastatin in Patients with Abdominal Aortic Aneurysm with Massive Aortic Atheroma: Prevention of Cholesterol Embolization during Endovascular and Open Aneurysm Repair with Pitavastatin (PROCEDURE) Study.

Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma (excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or 4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.