Valve-in-valve transcatheter aortic valve implantation: the new playground for prosthesis-patient mismatch.

Transcatheter aortic valve implantation (TAVI) has become an established procedure for patients with aortic valve stenosis and significant comorbidities. One option offered by this technique is the implantation of a transcatheter valve inside a surgically implanted bioprosthesis. Many reports address the feasibility but also the pitfalls of these valve-in-valve (VIV) procedures. Review articles provide tables listing which valve sizes are appropriate based on the size of the initially implanted bioprosthesis. However, we previously argued that the hemodynamic performance of a prosthetic tissue valve is in large part a result of the dimensions of the bioprosthesis in relation to the patient's aortic outflow dimensions. Thus, the decision if a VIV TAVI procedure is likely to be associated with a favorable hemodynamic result cannot safely be made by looking at premade sizing tables that do not include patient dimensions and do not inquire about the primary cause for bioprosthetic valve stenosis. Prosthesis-patient mismatch (PPM) may therefore be more frequent than expected after conventional aortic valve replacement. Importantly, it may be masked by a potentially flawed method assessing its relevance. Such PPM may therefore impact significantly on hemodynamic outcome after VIV TAVI. Fifteen percent of currently published VIV procedures show only a minimal reduction of pressure gradients. We will address potential pitfalls in the current determination of PPM, outline the missing links for reliable determination of PPM, and present a simplified algorithm to guide decision making for VIV TAVI.

Long-term performance of the Hancock bioprosthetic valved conduit in the aortic root position.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess long-term morbidity and mortality with special regard to prosthesis durability after aortic root replacement with the Hancock bioprosthetic porcine conduit. METHODS: Between 1975 and 2004, a total of 81 patients (55 males, 26 females; mean age 58 +/- 18 years) underwent aortic root replacement with the Hancock conduit for aortic dissection (n = 22; 27%), ascending aortic aneurysm (n = 57; 70%), or porcelain aorta (n = 2; 3%). Twenty-five patients (31%) underwent an emergency operation, 12 (15%) presented with Marfan syndrome, and eight (10%) had undergone previous cardiac surgery. Concomitant procedures were performed in 26 cases (32%). The follow up was 98% complete; the mean follow up was 4.8 +/- 4.0 years (range: 1 day to 16.7 years), and the cumulative follow up was 403 patient-years. Actuarial event-free rates were calculated, and valve-related complications classified according to guidelines for reporting morbidity and mortality after cardiac valvular operations. RESULTS: There were seven (9%) operative deaths and four (5%) in-hospital deaths. Actuarial survival rates at five and 10 years (excluding operative deaths) were 77.0 +/- 5.3% and 54.0 +/- 7.5%, respectively. Actuarial freedom from aortic valve reoperation at five and 10 years was 98 +/- 1.6% and 64 +/- 10.2%, from structural valve deterioration 88.1 +/- 4.7% and 49.9 +/- 9.6%, from thromboembolic events 87.4 +/- 4.6% and 75.1 +/- 9.5%, and from major bleeding events 90.2 +/- 3.9% and 75.4 +/- 8.1%, respectively. Among redo procedures, the stentless Hancock valve could be excised without separating the synthetic graft from the left ventricular outflow tract, and a stented valve prosthesis thus implanted. Hence, it was possible to avoid a second Bentall operation. CONCLUSION: The long-term survival rates after aortic root replacement with the bioprosthetic Hancock conduit were reasonable for this demanding patient cohort. However, the durability of the prosthesis was inferior to that reported for the stented Hancock valve substitute. The key benefit of this bioprosthetic valved conduit was the simplified redo procedure.

The complete supraannular concept: in vivo hemodynamics of bovine and porcine aortic bioprostheses.

BACKGROUND: Complete supraannular placement of an aortic bioprosthesis is one approach to optimize the hemodynamic result of an aortic valve replacement. It is achieved with the combination of a special valve design and the supraannular sewing technique with noneverted mattress sutures. We evaluated 5 bioprostheses designed for complete supraannular placement to assess potential hemodynamic differences caused by factors (eg, valve material) other than implantation position. METHODS AND RESULTS: In 336 patients (mean age, 72.0+/-7.1 years; 143 women), hemodynamics including mean pressure gradients, effective orifice areas, and indices and incidence of patient-prosthesis mismatch were evaluated 6 months after surgery. Annulus diameter was measured during surgery. Patients received the Carpentier Edwards Perimount Magna (Magna, n=169), the Medtronic Mosaic (Mosaic, n=46), the Mosaic Ultra (Ultra, n=17), the SJM Epic Supra (Epic, n=46), and the Sorin Soprano (Soprano, n=58). For small annulus sizes (<23 mm), the mean pressure gradients of the Magna (11.82+/-4.8 mm Hg) were significantly lower than the Mosaic (16.04+/-6.1 mm Hg) and the Ultra (22.0+/-4.1 mm Hg), and the Soprano (13.3+/-5.2 mm Hg) was hemodynamically superior to the Ultra. For medium (23 to 24 mm) and large (>24 mm) annulus sizes, the mean pressure gradients of the Magna were lower than the Epic (10.0+/-3.5 mm Hg versus 14.9+/-6.4 mm Hg; 9.9+/-4.0 mm Hg versus 18.6+/-12.7 mm Hg). Furthermore, in patients with large annulus size, the mean pressure gradients of the Soprano (11.4+/-3.8 mm Hg) were lower compared with the Epic (18.5+/-12.7 mm Hg). Severe patient-prosthesis mismatch was observed more frequently in patients with the Mosaic (12/46; 26.1%) and the Ultra (3/17; 17.6%) prostheses. CONCLUSIONS: Complete supraannular placement cannot prevent high pressure gradients or patient-prosthesis mismatch thoroughly, but the choice of a bovine prosthesis can optimize hemodynamic performance.

Aortic root replacement with re-implantation technique in an infant with Loeys-Dietz syndrome and a bicuspid aortic valve.

We report on an infant with a Loeys-Dietz Syndrome and a bicuspid aortic valve, who presented with rapid dilatation of the aortic root. We performed a valve-sparing aortic root replacement with re-implantation technique using a Dacron graft with pseudo-sinuses (Gelweave Valsalva conduit, Vascutek Terumo, Glasgow, Scotland).

Hemodynamic characterization of the Sorin Mitroflow pericardial bioprosthesis at rest and exercise.

BACKGROUND AND AIM OF THE STUDY: Although the long-term clinical outcome after aortic valve replacement (AVR) with the Sorin Mitroflow pericardial bioprosthesis has been well described, few data are available with regards to hemodynamic performance. On the basis of its specialized design, with the pericardium mounted on the outside of the stent, the Mitroflow valve is considered to provide optimal opening and orifice areas. METHODS: Between February 2006 and April 2007, a total of 127 patients (66 females, 61 males; mean age 77.6 +/- 5.2 years) underwent AVR with the Mitroflow valve at the authors' institution. Echocardiography was performed at discharge in 91 patients, while a six-month follow up examination was conducted in 78 (including ergometer hemodynamics in 25 cases). RESULTS: The mean systolic pressure gradient (MPG) ranged from 19.7 +/- 3.3 mmHg (size 19 valve) to 12.4 +/- 2.4 mmHg (size 27 valve), and the mean effective orifice area (EOA) from 0.96 +/- 0.0 cm2 (size 19 valve) to 2.36 +/- 0.4 cm2 (size 27 valve). The incidence of mild-to-moderate and severe prosthesis-patient mismatch (PPM) was 33% and 10% at the six-month follow up. During exercise (25 W-100 W), the MPG increased from 17.1 +/- 3.6 mmHg to 23.6 mmHg in valve sizes 19 to 21, and from 12.2 +/- 3.6 mmHg to 15.9 +/- 2.5 mmHg in valve sizes 23 to 27. The effective orifice fraction (EOF = EOA/annulus area) was 38 +/- 7%. CONCLUSION: The Mitroflow valve exhibits an adequate MPG and EOA, as might be expected for a pericardial bioprosthesis. Of note, the gradient increase during exercise was low, especially for the larger valve sizes. Due to its special design, the Mitroflow prosthesis shows a large opening, as demonstrated by the high EOF. These data relating to the EOA of all prosthesis sizes may help surgeons to select the minimum prosthesis size in order to prevent PPM.

Fluorescence in situ hybridization for identification and visualization of microorganisms in infected heart valve tissue as addition to standard diagnostic tests improves diagnosis of endocarditis.

OBJECTIVES: In infective endocarditis (IE), identification of the causative organism and consecutive treatment are crucial for patient survival. Although the macroscopic aspect resembles infected tissue, standard diagnostic tests often fail to allow one to identify bacteria. Fluorescence in situ hybridization (FISH) is a molecular, culture-independent technique that allows one to identify and visualize microorganisms within tissue and to recognize their morphology, number and activity. We analysed the diagnostic benefit of FISH/polymerase chain reaction (PCR) by comparing its results to those of standard diagnostic tests. METHODS: From September 2015 to April 2018, 128 patients underwent first-time or redo valve surgery to treat IE. Patients were designated according to the modified Duke criteria as definite (n = 61), possible (n = 34) or rejected (n = 33) IE. Tissue specimens obtained intraoperatively were analysed using FISH/PCR in addition to undergoing standard diagnostic testing and PCR alone. RESULTS: We used blood cultures to detect microorganisms in 67/128 patients; valve cultures, in 34/128; PCR, in 67/128; histopathological diagnosis showed IE in 72/128 cases. We were able to detect microorganisms in 103/128 cases using FISH/PCR, with 55/61 in definite IE. Furthermore, we were able to identify 26 cases of bacterial biofilm using FISH/PCR, despite antibiotic treatment of 61 in the definite, 13 in the possible and 1 in the rejected group, including 8/33 patients in the rejected group with active bacteria. In all cases, the patient's therapy was altered. CONCLUSIONS: FISH/PCR was used to identify microorganisms in cases in which standard diagnostic tests failed to provide sufficient results for various reasons. Furthermore, FISH/PCR enabled us to identify bacterial biofilms and to differentiate between active versus degraded bacteria, thus indicating the impact of treatment. Therefore, we suggest FISH/PCR as an additional diagnostic tool in IE alongside standard diagnostic tests.

Hemodynamic performance of the new St. Jude Medical Epic Supra porcine bioprosthesis in comparison to the Medtronic Mosaic on the basis of patient annulus diameter.

BACKGROUND AND AIM OF THE STUDY: The St. Jude Medical Epic Supra (ES) valve is a new porcine bioprosthesis designed for complete supra-annular implantation. To date, no in-vivo data regarding the hemodynamic and clinical performance of this valve are available. The study aim was to compare the hemodynamic performance of the ES valve with the completely supra-annular Medtronic Mosaic (MM) porcine valve. METHODS: Between July 2000 and April 2006, 83 patients (39 males, 44 females) underwent aortic valve replacement with either the ES (n = 44) or MM (n = 39) bioprosthesis. Hemodynamic performance was evaluated echocardiographically at six months postoperatively. Comparison between the valves was performed by dividing the patient groups according to their intraoperatively measured tissue annulus diameter rather than the labeled valve size. RESULTS: The internal diameter and sewing ring diameter differed in ES and MM valves with the same labeled size. For example, in valves labeled '23' the internal diameter/sewing ring diameters were 21.5 and 29.3 mm in the ES valve versus 20.5 and 30 mm in the MM. The mean pressure gradients (MPG) for patients with ES or MM valves were 15.5 +/- 4.5 or 14.8 +/- 5.1 mmHg for annulus diameter < or =22 mm, 14.6 +/- 6.4 or 13.9 +/- 3.6 for annulus diameter 23-24 mm, and 15.3 +/- 3.8 or 13.4 +/- 4.2 mmHg for annulus diameter > or =25 mm. No significant differences were identified in the hemodynamic data, including MPG, effective orifice area (EOA) and effective orifice area index (EOAI). The incidence of moderate or severe patient-prosthesis mismatch (PPM) was 40% (n = 18) and 5% (n = 1) in patients with ES valves, and 26% (n = 10) or 23% (n = 9) in patients with MM valves (p = 0.01). In patients with an annulus size < or =22 mm, severe PPM occurred in 29% (n =5) of patients with MM valves but in none of those with ES valves. CONCLUSION: The hemodynamic performance of the ES valve was comparable to that of the well-established MM valve. The incidence of severe PPM was lower in patients with ES valves than MM valves, presumably due to the somewhat larger EOA values in patients with a small aortic annulus (<25 mm).

Early Degeneration Caused by Cusp Tear of First-Generation Trifecta Bioprosthesis.

The Trifecta aortic valve has excellent hemodynamic performance as result of an expansive valve design with a bovine pericardial sheet externally mounted on a titanium stent. We report 2 cases of early Trifecta valve degeneration, both caused by partial rupture of one of the leaflet cusps 3 and 4 years post-implant. Post discharge, both patients had routinely performed echocardiography check-ups, without signs of valve failure. Transesophageal echocardiography performed during emergency hospital readmission due to severe dyspnea revealed transvalvular aortic regurgitation without signs of endocarditis. Urgent redo-surgery was successful in both cases, replacing the Trifecta prosthesis with a different bovine bioprosthesis.

Valvular chondromodulin-1 expression is downregulated in a rabbit model of infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Tissue neovascularization is a major event in the development and dissemination of inflammatory diseases, such as infective endocarditis (IE). Although the molecular triggers which allow vascular ingrowth in the aforementioned avascular regions are not well understood, they may represent potential prophylactic or therapeutic targets. Thus, an investigation was conducted to determine whether the expression of chondromodulin-1 (Chm-1), an anti-angiogenic protein, is dysregulated in mitral valves in a rabbit model of IE, and whether Chm-1 transcripts are differentially expressed in various heart tissues. METHODS: Five groups of animals (seven per group) were studied: group I was untreated controls; group II received (intravenously) 6x10(6) colony-forming units of Staphylococcus aureus; group III underwent mitral valve surgery; and groups IV and V underwent surgery and received S. aureus (as per group II), with tissues sampled at 6 and 12 h after surgery, respectively). Mitral valve surgery was performed by sewing a Dacron patch onto the valve, thereby creating a lesion and causing valve insufficiency. Explanted hearts were dissected and Chm-1 expression was determined using both conventional and real-time RT-PCR. RESULTS: Chm-1 transcripts were found in all cardiac regions, with strong expression in the heart valves, aorta, and pulmonary artery, and lowest expression in the ventricles. Both RT-PCR methods led to similar results; however, the down-regulation of Chm-1 expression in groups III, IV and V compared to controls was more pronounced in the real-time RT-PCR experiments (89 +/- 28% versus 40 +/- 28%; 63 +/- 22% versus 29 +/- 19%; and 51 +/- 11% versus 13 +/- 7.4%; Chm-1/GAPDH ratio levels relative to the control group in conventional versus real-time RT-PCRs in groups III, IV and V, respectively). Only the decrease in group V was significantly different from group I with both methods (p < 0.05 and p = 0.001). Bacteremia alone resulted only in minor changes compared to controls. CONCLUSION: It is concluded that valvular Chm-1 expression is down-regulated in the early phase of IE, which is likely to promote leaflet vascularization and progression of the disease.

Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.

OBJECTIVES: The present study evaluates complete supra-annular bioprostheses in patients with an aortic annulus of 18 to 23 mm in diameter. BACKGROUND: Aortic valve replacement in patients with small aortic annulus using stented bioprostheses is often associated with unsatisfactory hemodynamic results and high incidence of patient-prosthesis mismatch. METHODS: Between February 2000 and January 2004, 156 patients with aortic valve disease and an aortic annulus of 18 to 23 mm in diameter received the stented bovine Soprano (Sorin Biomedica Cardio, Saluggia, Italy) (n = 18), Perimount (Edwards Lifesciences, Irvine, California) (n = 52), Perimount Magna (Edwards Lifesciences) (n = 42), or the stented porcine Mosaic (Medtronic Inc., Minneapolis, Minnesota) (n = 44) bioprostheses. Intraoperatively, the surgeon measured the aortic annulus diameter by inserting a hegar dilator. Thus, postoperative hemodynamic results could be referred to the patient's aortic annulus diameter instead of referring the results to the labeled valve size. This allows for objective comparisons between different valve types. RESULTS: There was no significant difference in hemodynamic results between the different valve types in patients with an aortic annulus 18 to 20 mm. In patients with an annulus 21 to 23 mm, the Magna was significantly superior to the other investigated devices in mean pressure gradient, effective orifice area, and incidence of patient-prosthesis mismatch. There was no significant difference between the complete supra-annular bioprostheses Mosaic and Soprano and the intra-supra-annular Perimount valve. CONCLUSIONS: In patients with an aortic annulus of 18 to 20 mm in diameter, hemodynamic performance is independent of the implanted stented valve type and the annular position. Root enlargement or stentless valves may be beneficial alternatives. Patients with annulus diameter 21 to 23 mm benefit from the Magna in complete supra-annular position leading to superior hemodynamic results.

Exercise hemodynamics of bovine versus porcine bioprostheses: a prospective randomized comparison of the mosaic and perimount aortic valves.

OBJECTIVE: This prospective randomized study compares a porcine with a bovine bioprosthesis in the aortic position with regard to hemodynamic performance during exercise. METHODS: Between August of 2000 and December of 2002, 136 patients underwent aortic valve replacement with the porcine Medtronic Mosaic (n = 66) or the bovine Carpentier-Edwards Perimount (n = 70) bioprosthesis. Transthoracic echocardiography was performed to assess hemodynamic and dimensional data preoperatively and 10 months postoperatively; the latter follow-up included stress echocardiography with treadmill exercise. RESULTS: At rest and during exercise (25 and 50 W), there was a significant difference in mean pressure gradient between the bovine and the porcine valves with labeled sizes 21 and 23, with superiority of the Perimount prosthesis. There was no difference in effective orifice area and incidence of patient-prosthesis mismatch among all sizes. The left ventricular mass index decreased significantly within 10 months postoperatively in the size 23 bovine group and the size 25 porcine group. CONCLUSIONS: Our data show a significant superiority of pressure gradients for the bovine bioprosthesis, especially with small valve sizes, when compared with the porcine device, which is more distinctive during exercise.

The Toronto root stentless valve in the subcoronary position is hemodynamically superior to the mosaic stented completely supra-annular bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Stentless valves are considered to exhibit better hemodynamics after aortic valve replacement (AVR) compared to stented valves. However, a new generation of stented bioprostheses for completely supra-annular implantation has been designed to optimize the ratio of the effective orifice area (EOA) of the prosthesis and aortic annulus area. The study aim was to determine whether a stentless valve implanted in the subcoronary technique renders larger orifice areas and lower transvalvular pressure gradients at rest and exercise compared to a completely supra-annular stented device. METHODS: Twenty patients underwent AVR for aortic stenosis with the St. Jude Medical (SJM) Toronto Root stentless porcine bioprosthesis, using a subcoronary implantation technique. Through the authors' institutional database, 20 additional patients were identified who had undergone AVR with the Medtronic Mosaic stented completely supra-annular porcine bioprosthesis. The patient groups were not matched for labeled valve size, but for annulus diameter measured intraoperatively using Hegar's dilators. Hemodynamic performance was assessed by transthoracic echocardiography at discharge (early) and by rest and stress echocardiography at six months postoperatively (mid-term). RESULTS: Transvalvular mean pressure gradients (MPG) at rest were significantly lower in the stentless group, but cardiac output was similar in both groups. Stress echocardiography also revealed significantly lower gradients at 25 W and 50 W exercise in the stentless group. The EOA index (EOAI), grouped by annulus diameter, tended to be larger in the stentless group and showed no severe patient-prosthesis mismatch (PPM; EOAI <0.65 cm2/m2) which, in contrast, occurred in three patients (15%) in the stented group (p = 0.072). CONCLUSION: In summary, the SJM Toronto Root porcine stentless bioprosthesis in the subcoronary position showed lower MPGs and larger EOAs at rest and during exercise compared to the Medtronic Mosaic porcine stented bioprosthesis. Therefore, physically active patients in particular may benefit from use of the stentless valve. Because of its larger EOA, a stentless valve should be implanted if severe PPM is expected.

Hemodynamic evaluation of the Sorin Soprano bioprosthesis in the completely supra-annular aortic position.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the clinical and hemodynamic performance of the Sorin Soprano bioprosthesis in the aortic position. METHODS: Rest and stress echocardiography were performed at six months after surgery in 57 patients who underwent aortic valve replacement with the stented Soprano bioprosthesis. The exercise protocol included workloads of 25, 50, 75 and 100 W, each of 2 min duration. RESULTS: Thirty-day mortality was 1.8% (n = 1). Due to malperfusion of the coronary arteries, two Soprano prostheses had to be replaced by a different prosthesis, and one patient received coronary artery bypass grafts. One patient developed bacterial endocarditis of his prosthesis at seven months postoperatively and died as a result of a fulminant sepsis. There were no other prosthesis-related adverse events. Mean pressure gradients (MPG) ranged from 7.8 to 15.9 mmHg, effective orifice areas (EOA) from 1.25 to 2.98 cm2, EOA index (EOAI) from 0.79 to 1.43 cm2/m2, and EOA fraction from 34 to 45%. Stress echocardiography showed no significant increase in MPG up to 50 W, and MPGs did not exceed 35 mmHg at 75 and 100 W. CONCLUSION: Initial hemodynamic results showed low MPGs during rest and exercise. The EOAI was large due to completely supra-annular placement of the Soprano valve. The difficulty of complete supraannular placement is that the prosthesis is positioned relatively high, especially in narrow aortic roots, and this may handicap coronary artery perfusion. Patient selection with suitable aortic root anatomy is crucial to achieve the benefit of completely supra-annular implantation without coronary ostium deterioration.

The effective orifice area/patient aortic annulus area ratio: a better way to compare different bioprostheses? A prospective randomized comparison of the Mosaic and Perimount bioprostheses in the aortic position.

BACKGROUND AND AIM OF THE STUDY: The aim of this prospective, randomized study was to compare the hemodynamic performance of the Medtronic Mosaic and Edwards Perimount bioprostheses in the aortic position, and to evaluate prosthesis-specific differences in valve sizing and valve-size labeling. METHODS: Between August 2000 and September 2002, 139 patients underwent isolated aortic valve replacement (AVR) with the Mosaic (n = 67) or Perimount (n = 72) bioprosthesis. Intraoperatively, the internal aortic annulus diameter was measured by insertion of a gauge (Hegar dilator), while prosthesis size was determined by using the original sizers. Transthoracic echocardiography was performed to determine hemodynamic and dimensional data. As the aim of AVR is to achieve a maximal effective orifice area (EOA) within a given aortic annulus, the ratio of EOA to patient aortic annulus area was calculated, the latter being based on annulus diameter measured intraoperatively. RESULTS: Operative mortality was 2.2% (Mosaic 3.0%; Perimount 1.4%; p = NS). Upsizing (using a prosthesis larger in labeled valve size than the patient's measured internal aortic annulus diameter) was possible in 28.4% of Mosaic patients and 8.3% of Perimount patients. The postoperative mean systolic pressure gradient ranged from 10.5 to 22.2 mmHg in the Mosaic group, and from 9.4 to 12.6 mmHg in the Perimount group; it was significantly lower for 21 and 23 Perimount valves than for 21 and 23 Mosaic valves. The EOA ranged from 0.78 to 2.37 cm2 in Mosaic patients, and from 0.95 to 2.12 cm2 in Perimount patients. When indexing EOA by calculating the ratio of EOA to patient aortic annulus area to adjust for variables such as patient anatomy and valve dimensions, there was no significant difference between the two bioprostheses. CONCLUSION: Comparisons of absolute EOA values grouped by the manufacturers' valve sizes are misleading because of specific differences in geometric dimensions. The EOA:patient aortic annulus area ratio provides a new hemodynamic index which may facilitate objective comparisons between different valve types.

Left ventricular mass regression after aortic valve replacement with the mosaic bioprosthesis.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to evaluate the hemodynamic performance and extent of left ventricular (LV) mass regression after aortic valve replacement (AVR) with the Mosaic bioprosthesis within the first postoperative year. METHODS: Between 1994 and 1999, 366 patients (203 males, 163 females) underwent AVR with the Mosaic bioprosthesis at five centers in Europe. Mean age at implant was 71.1 years (range: 34.5-86.8 years). LV mass assessment and hemodynamic evaluation were performed using transthoracic echocardiography within six days postoperatively, after six months, and at annual intervals thereafter. RESULTS: LV mass index decreased significantly in patients with valve sizes 21 to 27 mm, from 184.4+/-56.2 g/m2 postoperatively to 157.3+/-45.5 g/m2 after one year (14.7% decrease). The 19-mm valve group did not show significant LV mass index reduction (from 210.4+/-39.4 to 195.0+/-59.4 g/m2; 7.3%). Patients with significant LV mass index regression had survival benefits after seven years. Mean pressure gradients after one year were 16.0+/-4.3, 14.2+/-5.4, 12.8+/-5.3, 11.1+/-4.0 and 10.5+/-3.7 mmHg for 19, 21, 23, 25 and 27 mm valves, respectively. CONCLUSION: Implantation of the Mosaic bioprosthesis resulted in a significant regression of LV mass for the valves sizes 21 to 27 mm, corresponding to very low pressure gradients for a stented bioprosthesis.

Successful transapical implantation of an Edwards Sapien valve within an insufficient aortic CoreValve prosthesis: an initial experience.

Transcatheter aortic valve implantation (TAVI) has become an emerging alternative for high-risk patients with aortic stenosis unsuitable for surgical intervention. We report the case of a 26-mm Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) implanted into an insufficient 29-mm CoreValve prosthesis (Medtronic Inc, Minneapolis, MN) 1 year after implantation using the transapical approach in a 59-year-old man. Transesophageal echocardiography showed severe paravalvular regurgitation and computed tomography revealed the CoreValve to be located slightly below the aortic annulus with evidence of underdeployment. The balloon-expandable Sapien system caused a better expansion of the underdeployed CoreValve and the pericardial skirt adequately covered the leakage. The paravalvular regurgitation disappeared and the patient recovered.

A primary pulmonary artery chondrosarcoma manifesting as acute pulmonary embolism.

Primary cardiac malignancies are rare, and the majority are benign. Malignant tumors are often found to be sarcomas arising from structural cells such as muscle, connective tissue, and blood vessels. We report a case of a 62-year-old woman who presented with pulmonary embolism secondary to a primary pulmonary artery chondrosarcoma. Radical resection with curative intent was impossible, but partial resection and reconstruction of the pulmonary main stem was performed. The remaining tumor was treated with adjuvant chemotherapy. A positron emission tomography-computed tomography scan 6 months postoperatively showed a nearly complete remission.

Are bicuspid aortic valves a limitation for aortic valve repair?

OBJECTIVE: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. METHODS: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. RESULTS: Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97). CONCLUSIONS: The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.

Intermittent regurgitation caused by incomplete leaflet closure of the Medtronic ADVANTAGE bileaflet heart valve: analysis of the underlying mechanism.

OBJECTIVE: Clinical echocardiographic assessments of the Medtronic ADVANTAGE (Medtronic Inc, Minneapolis, Minn) prosthesis in the aortic position revealed a phenomenon identified as "intermittent regurgitation." An in vitro investigation was initiated to identify the underlying mechanism. METHODS: In a pulse duplicator environment, 6 ADVANTAGE size 23 aortic valves were analyzed. Leaflet motion and flow through the valves were documented using echocardiography with color Doppler flow, digital high speed imaging, and flow meter assessment. RESULTS: Intermittent regurgitation could be reproduced in all 6 of the tested valves within limited ranges of flow, pressure, and valve orientation. By virtue of high-speed imaging, the mechanism underlying intermittent regurgitation was identified. During intermittent regurgitation, the leading edge of the second-to-close leaflet makes contact with the chamfer on the leading edge of the first-to-close leaflet. The fluid closing forces working on the first-to-close leaflet prevent it from shifting back so that the leading edge of the second-to-close leaflet remains positioned against the chamfer of the first-to-close leaflet. In this position, the major radius of the second-to-close leaflet does not reach the housing's major radius. Therefore, a crescent-shaped gap remains between the leaflet tip of the second-to-close leaflet and the housing major radius during all or part of diastole. The regurgitant fraction can increase from a normal range of 6% to 25% during an intermittent regurgitation beat. CONCLUSIONS: In vitro intermittent regurgitation can be induced in the size 23 aortic ADVANTAGE valve under a limited range of conditions. To avoid possible misinterpretations, the phenomenon must be known in detail by all physicians dealing with patients with an ADVANTAGE valve.

Twenty-year experience with the St. Jude medical Biocor bioprosthesis in the aortic position.

BACKGROUND: The purpose of this study was to evaluate the long-term performance of the St. Jude Medical Biocor stented porcine prosthesis in the aortic position. METHODS: From January 1985 to December 1996, 455 patients admitted for aortic valve replacement were consecutively enrolled in this study. The mean age was 72.5 +/- 9 years, 18 patients (3.5%) had had previous cardiac surgery, and coronary artery bypass grafting was performed in 171 patients (37.6%). Follow-up was complete in 99.6%; up to 21 years were covered. Actuarial event-free rates are given as mean +/- standard error and adverse events were classified according to the guidelines for reporting morbidity and mortality after cardiac valvular operations. RESULTS: Cumulative follow-up time was 3,321 patient-years with a mean follow-up of 8.2 years. The actuarial survival rate after 20 years was 9.4% +/- 2.8%. The actuarial rates for freedom from structural valve deterioration were 93.1% +/- 1.7% at 10 years, 88.4% +/- 3.5% at 15 years, and 70.3% +/- 10.9% at 20 years. The actuarial rates for freedom from reoperation due to structural valve deterioration were 91.9% +/- 1.6% at 10 years, 90.6% +/- 2.1% at 15 years, and 86.5% +/- 4.5% at 20 years. CONCLUSIONS: This study presents one of the largest series of St. Jude Medical Biocor aortic valves in the world. Results indicate an age-dependent risk of structural valve degeneration beginning as soon as 7 years postoperatively for patients below the age of 65 years, but show a low overall incidence of valve-related complications and excellent durability.