Conventional versus modified delivery system technique in commissural alignment from the Evolut low-risk CT substudy.

OBJECTIVES: We assessed the impact of conventional delivery system (DS) insertion technique on "Hat-marker" orientation/commissural alignment in patients who underwent transcatheter aortic valve replacement (TAVR) in the Evolut Low Risk Trial CT substudy versus a modified technique. BACKGROUND: Unlike surgical aortic valve replacement, where alignment of the surgical valve commissures with native commissures can be achieved virtually 100% of the time, commissural alignment during TAVR is not achieved consistently. This may subsequently impact the feasibility of both coronary access and reintervention after TAVR. METHODS: "Hat-marker" orientations during deployment were characterized as outer curve (OC), center front (CF), inner curve, and center back. Severe commissure-to-CA overlap was 0-20°. "Hat-marker" orientations and CA overlap were compared to 240 patients from a single center using the modified 3-o'clock flush port DS technique. RESULTS: In the CT substudy in which conventional DS insertion was performed (flush port at 12 o'clock); 154/249 had both analyzable CT and procedural fluoroscopy to validate "Hat-marker" to C-tab/commissural orientation. On post-TAVR CT, Evolut valve commissural orientation and coronary artery (CA) ostia were identified. Compared to conventional DS technique in the CT substudy, the modified technique had higher rates of "Hat-marker" at OC/CF orientation, improved commissural alignment and reduced severe CA overlap; (left main, 14.2 vs. 27.9%; right coronary artery, 11.7 vs. 27.3% both, 5.0 vs. 13.6%; 1 or both CA, 20.8 vs. 41.6%, all p < 0.01). CONCLUSIONS: The modified technique improved initial "Hat-marker" orientation during Evolut deployment and resulted in better commissural alignment and reduced CA overlap.

Cusp Overlap Technique: Should It Become the Standard Implantation Technique for Self-expanding Valves?

PURPOSE OF REVIEW: Accurate imaging of the aortic root during valve implantation is crucial for proper prosthesis positioning during TAVR. The purpose of this review was to determine if routine use of the cusp-overlap view should be adopted for self-expanding valves. RECENT FINDINGS: The use of the cusp-overlap view with the Evolut, Portico, ACURATE neo/neo2, and JenaValve systems is associated with lower post-procedural new permanent pacemaker implantation rates when compared with the standard 3-cusp view, presumably due to more precise valve implantation relative to the conduction system by the non-coronary cusp. By elongating the left ventricular outflow tract and accentuating the right-non commissure in the center of the fluoroscopic view, the cusp-overlap technique allows operators to more precisely control the prosthesis implant depth during self-expanding valve deployment. While the early experience with this approach in Evolut TAVR has been promising, the results of larger studies with longer follow-up across multiple self-expanding systems are warranted.

Pulmonary artery aneurysm associated with a nonstenotic bicuspid pulmonic valve: A role for genetics?

BACKGROUND: Bicuspid pulmonic valves are quite uncommon, being described in only 0.1% of donor's hearts, while pulmonary artery aneurysms (PAAs) are even rarer, having been found in 8 out of 109,571 autopsies. This rarity makes it difficult to characterize the relationship between them. MATERIALS AND METHODS: We describe the case of a 66-year-old female who was found to have a bicuspid pulmonic valve and PAA (5.1 cm) on imaging by her cardiologist. DISCUSSION AND CONCLUSION: This case raises the question of whether the association between bicuspid semilunar valve disease and vascular wall anomalies is more genetic or hemodynamic. Even on the aortic side, despite the robust association between bicuspid aortic valves and thoracic aortic aneurysms, the mechanism still remains unclear. In our patient there was no significant gradient across the bicuspid pulmonic valve, suggesting that hemodynamics are not the primum mobile of this association.

Anatomic classification of mitral annular calcification for surgical and transcatheter mitral valve replacement.

BACKGROUND AND AIM OF THE STUDY: A systematic approach to quantify mitral annular calcification (MAC) in all-comers by multidetector computed tomography (MDCT) is essential to guide treatment, but lacking. METHODS: From September 2015 to July 2019, 82 patients with MAC underwent MDCT at two institutions to evaluate for surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management. Type 1 MAC was defined as <270° annular calcium and Type 2 as ≥270°. Absence/presence of predicted left ventricular outflow tract (LVOT) obstruction with virtual valve placement was used to further define Type 2 MAC into 2A/B for our treatment algorithm. RESULTS: Type 1 MAC was present in 51.2%, Type 2A in 18.3%, and Type 2B in 30.5%. Operable Type 1 patients (50.0%) underwent hybrid transatrial TMVR or SMVR. Type 2A underwent a variety of treatments, and Type 2B surgical candidates (40.0%) underwent hybrid transatrial TMVR secondary to difficult suture anchoring with significant MAC and predicted LVOT obstruction. At a follow-up of 29.6 ± 12.0 months, mortality was 42.7% with 46.3% in the intervention group and 39.0% in the medical group (p = 0.47). All percutaneous TMVR patients expired. This translated to a disproportionate number of Type 2A deaths (80.0% with intervention), but all were high/extreme surgical risk. The hybrid TMVR group consisted of 95.0% Type 1/2B patients and had a lower Society of Thoracic Surgeons predicted risk of operative mortality (7.4% vs. 9.2%, p = 0.43)/mortality. CONCLUSIONS: The highest mortality was seen in percutaneous TMVR Type 2A MAC patients, but they were at the greatest risk. Here we provide an objective MAC treatment algorithm for all-comers based on operability/anatomy.

Surgical management of mitral annular calcification.

PURPOSE OF REVIEW: The aim of the article is to discuss different therapeutic options for patients with severe mitral valve dysfunction because of mitral annular calcification (MAC), including mitral valve repair, conventional mitral valve replacement, percutaneous transcatheter mitral valve replacement (TMVR), and hybrid procedures. RECENT FINDINGS: Optimal management of severe mitral valve disease because of MAC remains challenging. Various 'resect' or 'respect' repair strategies have been standardized and are applicable in eligible patients. Mitral valve replacement with a standard surgical bioprosthesis is often possible in nonrepair candidates, especially with noncircumferential MAC. TMVR has evolved as a feasible option for anatomically and/or clinically prohibitive open-surgery cases, with the caveat of strict anatomic eligibility criteria. Hybrid TMVR provides the advantages of both open-surgery and TMVR and has emerged as a promising alternative in select patients. SUMMARY: Surgical management of MAC and severe mitral valve disease continues to evolve. The addition of transcatheter valve options may benefit many patients previously considered inoperable and are now candidates for intervention. This review will summarize state-of-the-art management options for patients with MAC.

Transcatheter Tricuspid and Pulmonary Valve Repair and Replacement.

Severe tricuspid regurgitation (TR) is associated with significant mortality and morbidities. Currently, surgical tricuspid repair with annuloplasty is the gold standard treatment. However, the prohibitive risks of open surgery and increasing evidence that severe TR should be intervened on early has led to an outburst in the development and evolution of transcatheter tricuspid valve interventions (TTVI). These technologies are broadly categorized into direct suture annuloplasty devices, minimally invasive annuloplasty, direct ring annuloplasty devices, coaptation-based strategies, edge-to-edge repair devices, and transcatheter valve replacement. Each has its own set of advantages and limitations and have been tried, to varying degrees of success, in a myriad of pathoanatomic scenarios. Challenges faced in TTVI device and trial designs include heterogeneous patient populations, the need for quality imaging, variations of imaging requirements and anatomic criteria by device, hard-to-define clinical endpoints, and the poor prognosis carried by significant residual TR. Similar to tricuspid valve disease, pulmonic valve (PV) disease can occur on its own or secondary to a congenital heart defect, most commonly tetralogy of Fallot. Many patients with pulmonic stenosis or insufficiency often require repeat surgical interventions for other cardiac problems, highlighting the importance of developing transcatheter approaches to reduce the number of repeat open-heart surgeries required. Transcatheter PV replacement (TPVR) is growing in use and is the procedure of choice in patients with failed bioprostheses via valve-in-valve implantation. The Melody (Medtronic Inc., Minneapolis, Minnesota) and SAPIEN XT (Edwards Lifesciences Inc., Irvine, California) devices are the currently available TPVR technologies. Current limitations here include device kinking, the risk of stent fracture, anatomic difficulties, such as asymmetric right ventricular outflow tracts leading to poor landing zones and procedural risks of coronary artery and aortic root compression.

Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification.

Objectives: Mitral annular calcification remains a formidable lesion in cardiac surgery with significant perioperative morbidity and mortality, particularly when en bloc annular decalcification is implemented. Respect strategies and hybrid approaches have provided safe alternatives. We report the short-term results of our institution's experience with mitral valve replacement in patients with extensive annular calcification. Methods: This is a retrospective review of 72 consecutive patients with extensive annular calcification who underwent open surgical mitral valve replacement from January 1, 2013, to September 31, 2022. Degree of annular calcification was graded as partial, horseshoe, or circumferential. We excluded patients with calcification involving less than one-third of the annulus and patients with rheumatic heart disease. Results: Mean patient age was 71.6 ± 10.9 years, and 50 (69.4%) were female. There were 51 patients (70.8%) with New York Heart Association class 3 or greater and 47 patients (65.3%) with pulmonary hypertension. There were 41 patients (56.9%) with partial, 12 patients (16.7%) with horseshoe, and 19 patients (26.4%) with circumferential calcification. Fifty-six patients (77.8%) underwent conventional valve replacement. Sixteen patients underwent a hybrid procedure using balloon-expandable devices. Concomitant procedures were performed in 61 patients (84.7%). In-hospital mortality and 1-year survival were 3.57% and 82.8% in the standard valve replacement cohort and 25.0% and 54.7% in the hybrid cohort, respectively. Conclusions: Conventional mitral valve replacement using respect strategies is safe and associated with good outcomes in patients with extensive annular calcification. Hybrid approaches using novel devices should remain as a bailout in select patients because of higher perioperative risks and poor short-term outcomes.

Transcatheter Mitral Valve Replacement: Procedural Planning, Utility, and Applicability.

Since the first native transcatheter mitral valve implantation in 2012, transcatheter mitral valve replacement (TMVR) has expanded its use to degenerated bioprostheses, failed annuloplasty ring repair, and mitral annular calcification. However, high-screen failure rates in trials have persisted due to predicted left ventricular outflow tract obstruction and unfavorable anatomy. Preprocedural planning in this patient population with multidetector computed tomography and transesophageal echocardiography is paramount to intraprocedural success. In patients with favorable left ventricular outflow tract anatomy who are not surgical candidates, the transseptal approach is preferred. In those who are surgical candidates, TMVR can be performed via a transapical or transatrial approach. Currently, a plethora of TMVR devices targeting the native mitral pathologies are undergoing clinical trials. Data have consistently shown the greatest benefit of this procedure in native mitral regurgitation and failed bioprostheses rather than failed annuloplasty rings or mitral annular calcification. With technological advancement and careful patient selection, this therapy will serve as a complement to surgical and TMV repair and will continue to expand to address MV diseases in a broader patient population.

Imaging the mitral valve: a primer for the interventional surgeon.

Transcatheter mitral valve interventions (TMVI) have evolved over the past decade as alternatives to open surgical repair for the therapeutic management of patients with severe mitral regurgitation (MR). Concurrent with the development of these technologies, quality multi-modality cardiac imaging has become essential in patient selection and procedural guidance. The former involves assessments of the pathophysiologic mechanisms of regurgitation, valvular anatomy and morphology, as well as objective quantification of the severity of MR. Both transthoracic and transesophageal echocardiography (TEE) are crucial and serve as the gateway to diagnosis and management of mitral valvular disease. Along with multi-detector computed tomography (CT) and cardiac magnetic resonance imaging (CMR), echocardiography plays an important role for preprocedural planning and evaluation of the spatial relationships of the mitral valvular complex with the coronary sinus, circumflex coronary artery and left ventricular (LV) outflow tract. Procedures that target mitral leaflets (e.g., MitraClip, PASCAL) or annulus (e.g., Cardioband, Carillon), or provide chordal (e.g., NeoChord, Harpoon) or valvular replacement, tend to be guided by TEE and assisted by fluoroscopy. As newer devices become available and outcomes of TMVI improve, cardiac imaging will undoubtedly continue to play an essential role in the success of percutaneous mitral valve repair (MVr) and replacement. The interventional surgeon of the future must therefore have a thorough understanding of the various imaging modalities while synthesizing and integrating novel concepts (e.g., neo-LV outflow tract) as applicable to assessing valvular function and pathology.

Reoperative Mitral Surgery Versus Transcatheter Mitral Valve Replacement: A Systematic Review.

Bioprosthetic mitral structural valve degeneration and failed mitral valve repair (MVr) have traditionally been treated with reoperative mitral valve surgery. Transcatheter mitral valve-in-valve (MVIV) and valve-in-ring (MVIR) replacement are now feasible, but data comparing these approaches are lacking. We sought to compare the outcomes of (1) reoperative mitral valve replacement (redo-MVR) and MVIV for structural valve degeneration, and (2) reoperative mitral valve repair (redo-MVr) or MVR and MVIR for failed MVr. A literature search of PubMed, Embase, and the Cochrane Library was conducted up to July 31, 2020. Thirty-two studies involving 25 832 patients were included. Redo-MVR was required in ≈35% of patients after index surgery at 10 years, with 5% to 15% 30-day mortality. MVIV resulted in >95% procedural success with 30-day and 1-year mortality of 0% to 8% and 11% to 16%, respectively. Recognized complications included left ventricular outflow tract obstruction (0%-6%), valve migration (0%-9%), and residual regurgitation (0%-6%). Comparisons of redo-MVR and MVIV showed no statistically significant differences in mortality (11.3% versus 11.9% at 1 year, P=0.92), albeit higher rates of major bleeding and arrhythmias with redo-MVR. MVIR resulted in 0% to 34% mortality at 1 year, whereas both redo-MVr and MVR for failed repairs were performed with minimal mortality and durable long-term results. MVIV is therefore a viable alternative to redo-MVR for structural valve degeneration, whereas redo-MVr or redo-MVR is preferred for failed MVr given the suboptimal results with MVIR. However, not all patients will be candidates for MVIV/MVIR because anatomical restrictions may preclude transcatheter options from adequately addressing the underlying pathology.

Outcomes of Prosthesis-Patient Mismatch Following Supra-Annular Transcatheter Aortic Valve Replacement: From the STS/ACC TVT Registry.

OBJECTIVES: The aim of this study was to assess the outcomes of severe prosthesis-patient mismatch (PPM) in the TVT (Transcatheter Valve Therapy) Registry in patients undergoing supra-annular transcatheter aortic valve replacement (TAVR) for de novo stenosis or failed surgical bioprostheses (transcatheter aortic valve [TAV]-in-surgical aortic valve [SAV]). BACKGROUND: Severe PPM has been associated with adverse outcomes following TAVR, yet the clinical outcome of severe PPM after supra-annular TAVR is largely unknown. METHODS: Supra-annular TAVR was performed in patients enrolled in the TVT Registry with de novo stenosis (n = 42,174) or TAV-in-SAV (n = 5,446). Valve Academic Research Consortium-3 criteria were used to define severe PPM. The clinical impact of severe PPM on 1-year mortality and valve-related readmission was assessed using multivariate regression. A generalized linear mixed model was used to evaluate predictors of severe PPM. RESULTS: Severe PPM was found in 5.3% of patients undergoing de novo TAVR and 27.0% of patients undergoing TAV-in-SAV. The presence of severe PPM was not significantly associated with 1-year mortality or valve-related readmissions in both groups. Mean aortic gradients were higher in patients with severe PPM than in those without severe PPM at 1 month (9.7 ± 5.7 mm Hg vs. 7.3 ± 4.0 mm Hg; p < 0.001) and 1 year (10.2 ± 6.4 mm Hg vs. 8.0 ± 4.3 mm Hg; p < 0.001). Pre-procedural factors, including a <20-mm aortic annulus, were positive predictors of severe PPM in patients undergoing de novo TAVR (area under the curve = 0.795) and TAV-in-SAV (area under the curve = 0.764). CONCLUSIONS: Severe PPM after supra-annular TAVR was not associated with increased 1-year mortality or valve-related readmissions. Longer-term follow-up is needed to determine if higher residual gradients in patients with severe PPM predict long-term outcomes. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).

Surgical and Transcatheter Mitral Valve Replacement in Mitral Annular Calcification: A Systematic Review.

Mitral annular calcification with mitral valve disease is a challenging problem that could necessitate surgical mitral valve replacement (SMVR). Transcatheter mitral valve replacement (TMVR) is emerging as a feasible alternative in high-risk patients with appropriate anatomy. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to December 25, 2019 for studies discussing SMVR or TMVR in patients with mitral annular calcification; 27 of 1539 articles were selected for final review. TMVR was used in 15 studies. Relevant data were available on 82 patients who underwent hybrid transatrial TMVR, and 354 patients who underwent transapical or transseptal TMVR. Outcomes on SMVR were generally reported as small case series (447 patients from 11 studies); however, 1 large study recently reported outcomes in 9551 patients. Patients who underwent TMVR had a shorter median follow-up of 9 to 12 months (range, in-hospital‒19 months) compared with patients with SMVR (54 months; range, in-hospital‒120 months). Overall, those undergoing TMVR were older and had higher Society of Thoracic Surgeons risk scores. SMVR showed a wide range of early (0%-27%; median 6.3%) and long-term mortality (0%-65%; median at 1 year, 15.8%; 5 years, 38.8%, 10 years, 62.4%). The median in-hospital, 30-day, and 1-year mortality rates were 16.7%, 22.7%, and 43%, respectively, for transseptal/transapical TMVR, and 9.5%, 20.0%, and 40%, respectively, for transatrial TMVR. Mitral annular calcification is a complex disease and TMVR, with a versatile option of transatrial approach in patients with challenging anatomy, offers a promising alternative to SMVR in high-risk patients. However, further studies are needed to improve technology, patient selection, operative expertise, and long-term outcomes.

Current challenges in TAVI: neo-commissural alignment to mimic more physiologic valve implantation.

Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinical implications as TAVI expands to younger patients in whom lifetime treatment of aortic valve disease and coronary artery disease is of particular importance. Numerous studies have shown that lack of commissural alignment may adversely affect coronary reaccess and the feasibility of redo-TAVI in this patient population. To assess the risk of commissural misalignment more accurately, we have pioneered and validated the use of a preprocedural imaging protocol that determines valve orientation using multi-detector computed tomography-fluoroscopy co-registration. Furthermore, we have shown that a modified delivery system insertion technique during initial valve deployment results in improved commissural alignment and reduced coronary artery overlap following TAVI with a self-expanding device. However, numerous unanswered questions remain about the impact of commissural misalignment on balloon-expandable valve-in-valve TAVI, especially in patients with unfavorable aortic root anatomy. It is imperative that clinicians consider these anatomic, device-related, and procedure factors, among others, when evaluating patients for transcatheter therapies.

Infective Endocarditis After Surgical and Transcatheter Aortic Valve Replacement: A State of the Art Review.

Prosthetic valve endocarditis (PVE) after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) carries significant morbidity/mortality. Our review aims to compare incidence, predisposing factors, microbiology, diagnosis, management, and outcomes of PVE in surgical aortic valve replacement/TAVR patients. We searched PubMed and Embase to identify published studies from January 1, 2015 to March 13, 2020. Key words were indexed for original reports, clinical studies, and reviews. Reports were evaluated by 2 authors against a priori inclusion/exclusion criteria. Studies were included if they reported incidence and outcomes related to surgical aortic valve replacement/TAVR PVE and excluded if they were published pre-2015 or included a small population. We followed the Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all stages of the design and implementation. Study quality was based on the Newcastle-Ottawa Scale. Thirty-three studies with 311 to 41 025 patients contained relevant information. The majority found no significant difference in incidence of surgical aortic valve replacement/TAVR PVE (reported as 0.3%-1.2% per patient-year versus 0.6%-3.4%), but there were key differences in pathogenesis. TAVR has a specific set of infection risks related to entry site, procedure, and device, including nonstandardized protocols for infection control, valve crimping injury, paravalvular leak, neo-leaflet stress, intact/calcified native leaflets, and intracardiac hardware. With the expansion of TAVR to lower risk and younger patients, a better understanding of pathogenesis, patient presentation, and guideline-directed treatment is paramount. When operative intervention is necessary, mortality remains high at 20% to 30%. Unique TAVR infection risks present opportunities for PVE prevention, therefore, further investigation is imperative.