Surgical treatment for posteromedial talar process fractures.

PURPOSE: The first descriptions on medial talar tubercle fractures are attributed to Cedell. He described avulsion fractures of the insertion of the posterior talotibial ligament. However the true etiology has not been established. Since little is known about these fractures, they are easily misdiagnosed as simple ankle sprains. Untreated, these fractures may lead to chronic ankle pain. To improve the understanding of the etiology and outcome of these fractures a systematic review was conducted of all cases of isolated fractures of the medial tubercle of the posterior talar process. In addition we present the first series of competitive athletes treated by means of the two-portal hindfoot approach for isolated medial talar tubercle fractures. METHODS: A systematic search was performed to identify all cases of medial tubercle fractures. Data on trauma mechanism, clinical presentation, imaging and treatment were extracted. In addition we retrospectively report on the results of endoscopically treated patients in our institution over the last fifteen years. Of all patients Numeric Rating Scores (NRS) for Satisfaction, Pain and Function, Foot Ankle Outcome Scores (FAOS), return to sport and complications were reported. RESULTS: Eightteen articles were included reporting on 33 patients with an isolated fracture or avulsion of the posteromedial talar process. Most of the fractures occurred during sport activities (58%), followed by motor vehicle accidents (21%) and fall from height (12%). Of the activities during sport, 73% resulted following an ankle sprain. Reasonable to good outcomes are described in cases treated with immobilization, open reduction internal fixation or open excision. Of the nine patients treated in our institution, five were male and the median age was 29. All were participating in sports at a competitive level, with four of them being a professional athlete. In most patients the diagnosis was made more than a year after initial trauma. Ankle sprain was most common trauma mechanism. In some patients it was evident the avulsion was part or the deep portion of the deltoid ligament, however in two cases it was more likely an avulsion of the flexor hallucis longus (FHL) retinaculum. The median follow-up was 69 months (IQR 12.0-94.3). At final follow-up patients had little pain, NRS 1. Median NRS for satisfaction and function were 7 and 8, respectively. All patients did resume sport activities, however only four reached the preinjury level. Of the five patients that did not return to their pre-injury level of activity, two were professional athletes at the end of their career, and retired not due to ankle complaints. One complication was reported. CONCLUSION: Fractures of the medial tubercle are rare and based on the available literature there is not one distinct trauma mechanism. Based on literature no recommendation for treatment can be made. Our results show endoscopic excision of the fragment as a save alternative for open surgical treatment.

Two Cases of Endocarditis After MitraClip Procedure Necessitating Surgical Mitral Valve Replacement.

In the present report, we describe 2 cases of endocarditis after MitraClip (Abbott Vascular, Santa Clara, CA) procedures. In both patients, successful bailout surgical treatment was performed despite a high-risk constellation due to significant comorbidities. These cases highlight that surgical treatment may still be an option in patients initially declined for surgical therapy and that endocarditis after MitraClip procedure might be an underrecognized complication.

Incidence, Predictors, and Impact of Vascular Complications After Transfemoral Transcatheter Aortic Valve Implantation With the SAPIEN 3 Prosthesis.

Vascular complications (VCs) after transfemoral transcatheter aortic valve implantation (TAVI) have always been reported to occur frequently. Studies addressing VCs have been conducted with older-generation prostheses. We aimed to evaluate the incidence, predictors, and impact of VCs after transfemoral TAVI with the balloon-expandable SAPIEN 3. We report a single-center retrospective analysis of 400 consecutive patients of a prospectively acquired cohort. All patients underwent transfemoral TAVI with SAPIEN 3 between January 2014 and December 2016. VC was defined according to the Valve Academic Research Consortium. In this cohort 83 patients had VCs (20.8%), 5.8% major and 15.0% minor. Sheath-to-iliofemoral artery ratio was the only predictor of major VCs (odds ratio 7.51, 95% confidence interval 1.61 to 34.95, p = 0.010). The area under the receiver-operator characteristic curve for sheath-to-iliofemoral artery ratio was 0.63 (poor accuracy). Thirty-day mortality rates were 17.4%, 1.7%, and 0.6% for major, minor, and no VCs, respectively (log-rank p ≤0.001). After adjustment, only major VCs were associated with 30-day mortality (adjusted hazard ratio 48.31, 95% confidence interval 7.80 to 299.24). Mortality from 30 days until 1 year did not differ between patients with and without VCs (log-rank p = 0.61). In conclusion we report that VCs remain an issue of transfemoral TAVI with the SAPIEN 3, and their prediction continues to be difficult, albeit the low-incidence, major VCs were associated with higher 30-day mortality. However, after these first 30 days, they were not of influence on survival anymore.

Impact of Potentially Malignant Incidental Findings by Computed Tomographic Angiography on Long-Term Survival After Transcatheter Aortic Valve Implantation.

Computed tomography angiography (CTA) in workup for transcatheter aortic valve implantation (TAVI) frequently reveals potentially malignant incidental findings. Most incidental findings provoke discussions on their influence. We aimed to analyze if these findings were a predictor of long-term survival after TAVI. In a single-center retrospective analysis, all consecutive patients with pre-TAVI CTA were included (years 2009 to 2014). Patients were divided by presence or absence of incidental findings. We analyzed up to 5 years of all-cause, non-cardiovascular and cardiovascular mortality for all 553 patients who underwent TAVI; 113 had a potentially malignant incidental finding (20.4%). At 5 years, all-cause mortality risk was 64.5% in patients with versus 49.1% in patients without a finding (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.25 to 2.31). After adjustment, the findings remained an independent predictor of all-cause (adjusted HR 1.46, 95% CI 1.07 to 1.99) and non-cardiovascular mortality (adjusted subdistribution HR 1.84, 95% CI 1.06 to 3.20), but not of cardiovascular mortality. In conclusion, the presence of potentially malignant incidental findings on CTA is an independent predictor of long-term all-cause and noncardiovascular mortality but not of cardiovascular mortality.

Predicting hospitalisation duration after transcatheter aortic valve implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) is widely used as an alternative to conventional surgical aortic valve replacement. The aim of this study was to identify preprocedural predictors of duration of length of stay (LoS) after transfemoral TAVI (TF-TAVI). METHODS: We included all consecutive patients who underwent TF-TAVI at our centre between November 2010 and June 2013. Preprocedural, periprocedural and postprocedural variables were collected and evaluated to LoS. Linear regression was performed to find preprocedural predictors for total LoS. RESULTS: The population consisted of 114 patients (mean age: 79.6±8.7, 32.5% male). The median total LoS was 6.5 days (5-9 days). Multivariate analysis showed that the Metabolic Equivalent score (METs) (ß=-0.084, p=0.011) and diastolic blood pressure (ß=-0.011, p=0.016) independently contributed to the log-transformed LoS. CONCLUSION: Multivariate linear regression showed that lower METs and lower diastolic blood pressure were associated with prolonged LoS. Understanding patients' physical functionality can improve logistical planning of hospital stay and selecting patients eligible for early discharge.

Assessment of Cardiac Device Position on Supine Chest Radiograph in the ICU: Introduction and Applicability of the Aortic Valve Location Ratio.

OBJECTIVES: The use of intracardiac assist devices is expanding, and correct position of these devices is required for optimal functioning. The aortic valve is an important landmark for positioning of those devices. It would be of great value if the device position could be easily monitored on plain supine chest radiograph in the ICU. We introduce a ratio-based tool for determination of the aortic valve location on plain supine chest radiograph images, which can be used to evaluate intracardiac device position. DESIGN: Retrospective observational study. SETTING: Large academic medical center. PATIENTS: Patients admitted to the ICU and supported by an intracardiac assist device. INTERVENTIONS: We developed a ratio to determine the aortic valve location on supine chest radiograph images. This ratio is used to assess the position of a cardiac assist device and is compared with echocardiographic findings. MEASUREMENTS AND MAIN RESULTS: Supine anterior-posterior chest radiographs of patients with an aortic valve prosthesis (n = 473) were analyzed to determine the location of the aortic valve. We calculated several ratios with the potential to determine the position of the aortic valve. The aortic valve location ratio, defined as the distance between the carina and the aortic valve, divided by the thoracic width, was found to be the best performing ratio. The aortic valve location ratio determines the location of the aortic valve caudal to the carina, at a distance of 0.25 ± 0.05 times the thoracic width for male patients and 0.28 ± 0.05 times the thoracic width for female patients. The aortic valve location ratio was validated using CT images of patients with angina pectoris without known valvular disease (n = 95). There was a good correlation between cardiac device position (Impella) assessed with the aortic valve location ratio and with echocardiography (n = 53). CONCLUSIONS: The aortic valve location ratio enables accurate and reproducible localization of the aortic valve on supine chest radiograph. This tool is easily applicable and can be used for assessment of cardiac device position in patients on the ICU.

Transcatheter Replacement of Stenotic Aortic Valve Normalizes Cardiac-Coronary Interaction by Restoration of Systolic Coronary Flow Dynamics as Assessed by Wave Intensity Analysis.

BACKGROUND: Aortic valve stenosis (AS) can cause angina despite unobstructed coronary arteries, which may be related to increased compression of the intramural microcirculation, especially at the subendocardium. We assessed coronary wave intensity and phasic flow velocity patterns to unravel changes in cardiac-coronary interaction because of transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: Intracoronary pressure and flow velocity were measured at rest and maximal hyperemia in undiseased vessels in 15 patients with AS before and after TAVI and in 12 control patients. Coronary flow reserve, systolic and diastolic velocity time integrals, and the energies of forward (aorta-originating) and backward (microcirculatory-originating) coronary waves were determined. Coronary flow reserve was 2.8±0.2 (mean±SEM) in control and 1.8±0.1 in AS (P<0.005) and was not restored by TAVI. Compared with control, the resting backward expansion wave was 45% higher in AS. The peak of the systolic forward compression wave was delayed in AS, consistent with a delayed peak aortic pressure, which was partially restored after TAVI. The energy of forward waves doubled after TAVI, whereas the backward expansion wave increased by >30%. The increase in forward compression wave with TAVI was related to an increase in systolic velocity time integral. AS or TAVI did not alter diastolic velocity time integral. CONCLUSIONS: Reduced coronary forward wave energy and systolic velocity time integral imply a compromised systolic flow velocity with AS that is restored after TAVI, suggesting an acute relief of excess compression in systole that likely benefits subendocardial perfusion. Vasodilation is observed to be a major determinant of backward waves.

An up-to-date overview of the most recent transcatheter implantable aortic valve prostheses.

Over the past decade transcatheter aortic valve implantation (TAVI) has evolved towards the routine therapy for high-risk patients with severe aortic valve stenosis. Technical refinements in TAVI are rapidly evolving with a simultaneous expansion of the number of available devices. This review will present an overview of the current status of development of TAVI-prostheses; describes the technical features and applicability of each device and the clinical data available.

Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms.

BACKGROUND: Current data about the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve implantation (TAVI) are conflicting. Our purpose was to analyze the clinical course of MR and to assess the influence of MR on survival and clinical status after TAVI. METHODS: We included 375 consecutive patients who underwent TAVI. MR grade and NYHA class were determined before TAVI and at follow-up. RESULTS: In total 171 patients (46%) had MR grade ≥ 2 at baseline and of these 29% improved to MR grade ≤ 1 after TAVI. MR grade ≤ 1 at baseline was present in 204 patients (54%) and of these 17% worsened to grade ≥ 2 after TAVI. Improvement of MR was associated with absence of atrial fibrillation (OR: 2.35, 95%CI: 1.17-4.71, p = 0.02). Worsening of MR was associated with moderate or more aortic valve regurgitation after TAVI (OR: 4.2, CI: 1.83-9.49, p = 0.001). NYHA class improved at follow-up. Baseline MR grade did not determine the degree of clinical improvement (MR grade ≤ 1: NYHA ≥ 3 from 67% to 17%; MR grade ≥ 2: NYHA ≥ 3 from 69% to 14%). Although patients with MR grade ≥ 2 at baseline improved symptomatically, this degree of MR was associated with reduced two year survival compared with patients with MR grade ≤ 1(mortality 37% vs 26%; HR 1.99; 95% CI 1.27-3.13; p = 0.003). CONCLUSION: In patients who undergo TAVI almost half have MR grade ≥ 2 prior to the procedure. TAVI had no influence on MR grade at follow-up. Although patients with MR grade ≥ 2 at baseline improved symptomatically after TAVI, concomitant MR at baseline significantly reduced two year survival.

Impact of Aortic Valve Stenosis on Coronary Hemodynamics and the Instantaneous Effect of Transcatheter Aortic Valve Implantation.

BACKGROUND: Aortic valve stenosis (AS) induces compensatory alterations in left ventricular hemodynamics, leading to physiological and pathological alterations in coronary hemodynamics. Relief of AS by transcatheter aortic valve implantation (TAVI) decreases ventricular afterload and is expected to improve microvascular function immediately. We evaluated the effect of AS on coronary hemodynamics and the immediate effect of TAVI. METHODS AND RESULTS: Intracoronary pressure and flow velocity were simultaneously assessed at rest and at maximal hyperemia in an unobstructed coronary artery in 27 patients with AS before and immediately after TAVI and in 28 patients without AS. Baseline flow velocity was higher and baseline microvascular resistance was lower in patients with AS as compared with controls, which remained unaltered post-TAVI. In patients with AS, hyperemic flow velocity was significantly lower as compared with controls (44.5±14.5 versus 54.3±18.6 cm/s; P=0.04). Hyperemic microvascular resistance (expressed in mm Hg·cm·s(-1)) was 2.10±0.69 in patients with AS as compared with 1.80±0.60 in controls (P=0.096). Coronary flow velocity reserve in patients with AS was lower, 1.9±0.5 versus 2.7±0.7 in controls (P<0.001). Improvement in coronary hemodynamics after TAVI was most pronounced in patients without post-TAVI aortic regurgitation. In these patients (n=20), hyperemic flow velocity increased significantly from 46.24±15.47 pre-TAVI to 56.56±17.44 cm/s post-TAVI (P=0.003). Hyperemic microvascular resistance decreased from 2.03±0.71 to 1.66±0.45 (P=0.050). Coronary flow velocity reserve increased significantly from 1.9±0.4 to 2.2±0.6 (P=0.009). CONCLUSIONS: The vasodilatory reserve capacity of the coronary circulation is reduced in AS. TAVI induces an immediate decrease in hyperemic microvascular resistance and a concomitant increase in hyperemic flow velocity, resulting in immediate improvement in coronary vasodilatory reserve.

Antiplatelet therapy following transcatheter aortic valve implantation.

OBJECTIVE: There is limited evidence to support decision making on antiplatelet therapy following transcatheter aortic valve implantation (TAVI). Our aim was to assess the efficacy and safety of aspirin-only (ASA) versus dual antiplatelet therapy (DAPT) following TAVI. METHODS: We performed a systematic review and pooled analysis of individual patient data from 672 participants comparing single versus DAPT following TAVI. Primary endpoint was defined as the composite of net adverse clinical and cerebral events (NACE) at 1 month, including all-cause mortality, acute coronary syndrome (ACS), stroke, life-threatening and major bleeding. RESULTS: At 30 days a NACE rate of 13% was observed in the ASA-only and in 15% of the DAPT group (OR 0.83, 95% CI 0.48 to 1.43, p=0.50). A tendency towards less life-threatening and major bleeding was observed in patients treated with ASA (OR 0.56, 95% CI 0.28 to 1.11, p=0.09). Also, ASA was not associated with an increased all-cause mortality (OR 0.91, 95% CI 0.36 to 2.27, p=0.83), ACS (OR 0.5, 95% CI 0.05 to 5.51, p=0.57) or stroke (OR 1.21; 95% CI 0.36 to 4.03, p=0.75). CONCLUSIONS: No difference in 30-day NACE rate was observed between ASA-only or DAPT following TAVI. Moreover, a trend towards less life-threatening and major bleeding was observed in favour of ASA. Consequently the additive value of clopidogrel warrants further investigation.

Predictors of outcome in patients undergoing MitraClip implantation: An aid to improve patient selection.

BACKGROUND: MitraClip implantation (MCI) reduces mitral regurgitation (MR) and symptoms in patients considered inoperable or with high-surgical risk. Data to determine the benefit from MCI for an individual patient are limited. The aim of this study is to determine predictors associated with the prognosis after MCI to improve the patient selection for this procedure. METHODS: We included 84 consecutive patients (age: 76 ± 10 years, 51% male) who underwent MCI in our institution for symptomatic severe MR. All patients underwent transthoracic echocardiography before MCI; clinical and echocardiographic follow-up was obtained after MCI. RESULTS: The 2-year survival was 81%. Predictors for two-year mortality in multi-variate analysis were baseline NT-proBNP ≥ 5000 µg/L (HR: 5.4, 95% CI: 1.8-16.2), previous valve surgery (HR: 4.5, 95% CI: 1.7-12.2), tricuspid regurgitation (TR)≥ grade 3 prior to MCI (HR: 2.8, 95% CI: 1.2-6.8) and absence of MR reduction after MCI (HR: 2.1, 95% CI: 1.2-3.8). The 2-year survival of patients with 0, 1 or ≥ 2 of these predictors was: 87%; 78% and 38% respectively (log-rank p < 0.001). The functional class at 1 month and mid-term follow-up was worse in patients with two or more of these predictors present at baseline compared to patients with zero or one of these predictors (1 month: p = 0.007 and mid-term: p < 0.001). CONCLUSION: Heart failure, previous valve surgery, co-presence of TR and the degree of MR reduction after MCI are the independent predictors of survival and functional status after MCI in high risk patients. The pre-procedural characteristics may be used to optimize patient selection, while maximal MR reduction should be attempted to optimize the outcome of MCI.

Predictors and permanency of cardiac conduction disorders and necessity of pacing after transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) with the Medtronic-CoreValve bioprosthesis (CoreValve Inc., Irvine, CA, USA) is associated with a high incidence of new-onset left bundle branch block (LBBB) and cardiac conduction disorders (CCDs) requiring permanent pacemaker (PPM) implantation. Our objective was to investigate the predictors and permanency of CCDs after TAVI and specifically to evaluate the necessity for pacing. METHODS: In this single-center study, we included patients who underwent TAVI with the Medtronic-CoreValve bioprosthesis. Electrocardiographic evaluation was performed pre- and post-TAVI and at follow-up. Pacemaker follow-up data were obtained and analyzed. RESULTS: We included 121 patients (age 81 ± 8 years). LBBB developed in 47 patients, for which prosthesis size (26 mm; odds ratio [OR]: 4.1, 95% confidence interval [CI]: 1.32-12.34, P = 0.01) and prosthesis depth (OR: 1.3, 95% CI: 1.09-1.57, P = 0.004) were independent predictors. In 19%, this new-onset LBBB was temporary. Requirement for a PPM occurred in 23 patients, for which mitral annular calcification (MAC; OR: 1.3, 95% CI: 1.05-1.56, P = 0.02) and preexisting right bundle branch block (RBBB; OR: 8.5, 95%CI: 1.61-44.91, P = 0.01) were independent predictors. At follow-up, 52% of the patients were continuously paced, but 22% of the patients had adequate atrioventricular conduction without the necessity for pacing. In the other 26% of the patients there was intermittent pacing. CONCLUSION: There is a high incidence of new-onset LBBB and PPM implantation following TAVI with a Medtronic-CoreValve bioprosthesis. Prosthesis depth and size were predictors for new LBBB, while MAC and preexistent RBBB were predictors for PPM implantation. In approximately one fifth of the patients, new-onset LBBB and the necessity for pacing are only temporary.

Mitral inflow patterns after MitraClip implantation at rest and during exercise.

BACKGROUND: MitraClip implantation reduces mitral regurgitation effectively but decreases mitral valve area, creating iatrogenic mitral stenosis. Evaluation with transesophageal echocardiography intraprocedurally is necessary to measure mitral regurgitation and mitral valve pressure gradient (MVPG) to determine whether it is necessary and safe to place more clips. The aim of this study was to investigate whether these intraprocedural hemodynamics represent postprocedural measurements and whether exercise is affected by the stenosis. METHODS: In this retrospective single-center study, 51 patients who underwent MitraClip implantation were included. Measurements were performed intraprocedurally using transesophageal echocardiography and postprocedurally using transthoracic echocardiography. In 23 of these patients, exercise echocardiography was performed at follow-up. RESULTS: Intraprocedural mean MVPG was 3.0 ± 1.6 mm Hg and increased to 4.3 ± 2.2 mm Hg postprocedurally (P < .001). During exercise, mean MVPG increased significantly compared with rest conditions (from 3.6 ± 1.7 to 6.3 ± 2.7 mm Hg, P < .001). Six patients had mean resting MVPGs ≥ 5 mm Hg at follow-up and had higher systolic pulmonary artery pressure (sPAPs) than patients with mean MVPGs < 5 mm Hg (47 ± 7 vs 35 ± 12 mm Hg, P = .035). Higher MVPG and sPAP did not lead to more symptoms of heart failure. Receiver operating characteristic curve analysis showed an estimated cutoff point for intraprocedural pressure half-time of 91 msec to identify patients with mitral stenosis and sPAP ≥ 50 mm Hg postprocedurally. CONCLUSIONS: Mean MVPG during MitraClip implantation measured by TEE underestimates the hemodynamics in daily life, of which operators should be aware when deciding on placing one or more clips. Pressure half-time seems to be the most robust parameter compared with mean and maximum MVPG and may contribute to this decision. Patients with higher mean MVPGs after MitraClip implantation have higher sPAPs at follow-up. However, more symptoms of heart failure were not detected at follow-up.

Troubleshooting in transatrial tricuspid valve-in-valve implantation.

The established treatment for degenerated stenotic tricuspid bioprostheses is reoperation. Recently, transcatheter tricuspid valve implantation has been reported as an alternative option. This case report describes a complex transcatheter tricuspid valve implantation in a degenerated Medtronic intact 31 mm bioprosthesis. Implantation of a 26 mm Edwards Sapien valve failed, subsequent transcatheter implantation of a 29 mm Edwards Sapien valve was successful.

Predictors and prognostic value of myocardial injury during transcatheter aortic valve implantation.

BACKGROUND: Myocardial injury is a common complication during cardiac surgery and percutaneous coronary intervention and is associated with postprocedural cardiovascular morbidity and mortality. Limited data have been reported about the occurrence of myocardial damage associated with transcatheter aortic valve implantation (TAVI). Therefore, our purpose was to investigate the incidence, predictors, and prognostic value of myocardial injury during TAVI. METHODS AND RESULTS: We studied 119 patients (aged 81±8 years; 47 male) who had undergone a TAVI with the Medtronic-CoreValve bioprosthesis. Serum creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were measured before and after the procedure. Myocardial injury was defined as a postprocedural increase of CK-MB and/or cTnT level >5 times the upper reference limit. After TAVI, the incidence of myocardial injury was 17%, which was independently predicted by procedural duration (in minutes) (odds ratio [OR], 1.04; 95% CI, 1.01-1.06), preprocedural ß-blocker use (OR, 0.12; 95% CI, 0.03-0.45), peripheral arterial disease (OR, 6.36; 95% CI, 1.56-25.87), and prosthesis depth (in millimeters) (OR, 1.31; 95% CI, 1.08-1.59). The 30-day mortality after TAVI was 13% and was independently predicted by myocardial injury (OR, 8.54; 95% CI, 2.17-33.52), preprocedural hospitalization (OR, 9.36; 95% CI, 2.55-34.38), and left ventricular mass index (in g/m(2)) (OR, 1.02; 95% CI, 1.00-1.03). CONCLUSIONS: After transcatheter aortic valve implantation, serum levels of both CK-MB and cTnT increase, reflecting the occurrence of periprocedural myocardial injury. A longer procedural duration, the absence of ß-blocker use, peripheral arterial disease, and a deeper prosthesis insertion are associated with myocardial injury. Together with preprocedural hospitalization and left ventricular mass, myocardial injury is an independent predictor for 30-day mortality after TAVI.