Transcatheter Aortic Valve Implantation in the Descending Aorta: History Revisited!

An elderly patient with significant aortic regurgitation presented with heart failure. Dilation of the aortic root precluded a transcatheter anatomic site valve implantation, and prohibitive operative risk ruled against surgical implantation. A bail-out transcatheter implantation of the aortic valve in the descending aorta was successfully carried out with satisfactory outcomes.

Characterization of dysfunctional remote myocardium in left ventricular anterior aneurysms and improvements following surgical ventricular restoration using cardiac magnetic resonance imaging: preliminary results.

OBJECTIVES: In patients with previous myocardial infarction, the remote uninfarcted regions, although contractile, demonstrate dysfunctional wall kinetics because of increased afterload, which improves after surgical ventricular restoration (SVR). We characterized left ventricular (LV) mean myocardial velocity (MMV) through an analysis of endocardial motion and wall thickening (WT) over the cardiac cycle using standard cardiac magnetic resonance (cMR). METHODS: LV endocardial motion and WT from cMR data in 7 heart failure (HF) patients with postinfarction antero apical aneurysm were compared against normal controls to establish a baseline for the mean myocardial velocity during phases of the cardiac cycle. The HF patients' MMV and WT curves were compared with post-SVR data. RESULTS: Global MMV showed significant postoperative improvements in the ejection phase of systole and the early filling phase of diastole. The aneurysmal wall was dyskinetic in both systole and diastole. The remote myocardium preoperatively had a delayed peak velocity during the ejection phase of systole and diminished velocity during early filling in diastole. After SVR, the remote myocardium had an increased MMV with an earlier peaking during the ejection phase and slightly improved early diastolic velocity. WT increased cumulatively during systole and decreased during diastole with improved end-systolic and end-diastolic wall thickness after SVR. The end-systolic wall thickness showed a significant correlation with left ventricular ejection fraction (r(2) = 0.89, P = 0.001) and stroke volume (r(2) = 0.80, P = 0.02). The MMV had a significant correlation with WT over the phases of the cardiac cycle (r(2) = 0.953, P ≤ 0.0001). CONCLUSIONS: In patients with chronic ischaemic heart disease with LV aneurysms/large areas of scar, improvements in the remote myocardial MMV and WT underline LV systolic function improvements after SVR. The persistence of myocardial WT in early diastole is the likely mechanism for incomplete or absence of relief of LV diastolic dysfunction by SVR.

Ventricular restoration by linear endoventricular patchplasty and linear repair.

Surgical ventricular restoration improves cardiac function in patients with large left ventricular aneurysms. Aneurysm repair techniques have evolved to geometric repair by exclusion of the aneurysmal area with a circular patch. But even circular endoventricular patchplasty may result in a less elliptical ventricle. We modified the techniques of both linear and geometric repair. The early and intermediate outcomes in 102 patients with post-infarction left ventricular aneurysm, treated between 2001 and 2004, were analyzed. Concomitant procedures included coronary artery bypass grafting in 73 patients, mitral valve repair in 29, cryoablation in 3, and post-infarction ventricular septal rupture repair in 3. Overall mortality was 12.7%. Left ventricular ejection fraction increased significantly postoperatively, from 31.5% +/- 6.5% to 34.2% +/- 5.9%. There were significant decreases in end-diastolic volumes from 140.3 +/- 38.3 to 100.8 +/- 33.5 mL, and end-systolic volumes from 95.1 +/- 26.1 to 66.0 +/- 21.7 mL. These benefits continued at the 12- to 52-month follow-up. Our modified technique restores a near physiological left ventricular geometry and has a favorable clinical outcome.

Mitral valve repair in infants and children.

A number of children are born with myxomatous deformity of the mitral valve, causing mitral regurgitation. Traditional techniques of repair may be daunting in these children because apart from their small size, their valves appear grossly deformed and the tissues are friable. Techniques to circumvent these problems and ensure a predictable and satisfactory outcome are described.