Cavernous hemangioma is a very rare benign primary cardiac tumor that commonly involves any part of the heart, having been found in the atria, ventricles, interventricular septum, pericardium, and epicardium. A predominant location in the avascular cardiac valves is extremely rare, however. The case is reported of a 48-year-old male with recurrent anginal chest pain who subsequently underwent coronary angiography that revealed a mobile, rounded mass at the mitral valve which was fed by the left circumflex artery. Echocardiography revealed a left atrial echogenic mass attached to the posterior leaflet of the mitral valve. Histopathology of the mass following its surgical resection was consistent with hemangioma of the cavernous type. The patient recovered uneventfully. To the present authors' knowledge, this is the first reported case of cavernous hemangioma of the mitral valve in an adult male to be successfully treated with surgical resection.

How to cite: Isbitan, A., Shaaban, H., Qaqa, A., Joshi, M., & Shamoon, F. (2014). Cavernous hemangioma of the mitral valve in an adult male patient successfully treated with surgical resection: a case report. The Journal of heart valve disease, 23(5), 662–664.

The case is described of a hybrid trans-aortic transcatheter aortic valve implantation and off-pump left internal mammary artery to left anterior descending artery bypass surgery in a man with a tight left main lesion and severe symptomatic aortic stenosis.

How to cite: Weich, H. S., van Wyk, J., Pecoraro, A. J., & Mabin, T. (2014). Hybrid internal mammary to left anterior descending bypass and transaortic transcatheter aortic valve implantation: a new treatment option for patients with complex disease. The Journal of heart valve disease, 23(5), 659–661.

Background and aim of the study: Transcatheter aortic valve implantation (TAVI) is a promising option to treat degenerated aortic valve bioprostheses, and may involve Valve-in-Valve (ViV) procedures. Unfortunately, the ViV technique may provide an inadequate relief of stenosis in small-diameter degenerated bioprostheses, especially in the 19 mm valve subgroup. The study aim was to determine the feasibility and reliability of reoperating 19 mm degenerated bioprostheses, using a minimally invasive sutureless valve implantation.

Methods: Between March and December 2012, three reoperative procedures for degenerated 19 mm conventional aortic bioprostheses were performed at the authors' unit. Stenosis was the main modality of structural deterioration. A partial upper ministernotomy approach was used, whereby part of the sewing ring of the previous bioprosthesis was left in place and a 19 mm Medtronic Enable sutureless valve was implanted in all cases.

Results: The average valve implantation time was 10.3 min. There were no cases of operative mortality or major morbidity. One permanent pacemaker was required. At discharge, transthoracic echocardiography showed no paravalvular leakages; the average transvalvular gradient was 16 mmHg. The one-year follow up showed no paravalvular leakages and unchanged gradients.

Conclusion: The use of a surgical sutureless valve after explanting a 19 mm degenerated bioprosthesis is feasible and effective for relieving stenosis However, larger series are needed to confirm these preliminary results.

How to cite: Vola, M., Campisi, S., Anselmi, A., Vaislic, C., & Fuzellier, J. F. (2014). Feasibility of sutureless valve implantation in reoperation for degenerated 19 mm aortic valvular bioprostheses. The Journal of heart valve disease, 23(5), 654–658.

A 31-year-old asymptomatic male was referred to hospital for an examination of right bundle brunch block. Both, transthoracic and transesophageal echocardiography revealed normal left ventricular function, and two different-sized papillary muscles; the anterolateral muscle was more pronounced, with almost major chordae tendineae inserted into this dominant muscle, whereas the immature, flat posteromedial papillary muscle had very short chordae tendineae and was located higher in the left ventricle, inserted directly into the mitral annulus. The mitral valve orifice was eccentrically located at the lateral side, but no significant mitral stenosis or regurgitation was observed. No other congenital heart anomalies were identified. Thus, the final diagnosis was isolated parachute-like asymmetric mitral valve (PLAMV), without any other congenital heart anomalies. The patient was followed up closely with periodic echocardiographic examinations. Parachute mitral valve is a rare congenital cardiac defect characterized by focalized attachment of the chordae tendineae of both leaflets to a single papillary muscle. In contrast to true parachute mitral valve, PLAMV has two separate papillary muscles, one of which is more pronounced and into which all chordae are inserted. PLAMV was highly associated with other congenital heart anomalies, and the involved dominant muscle was most frequently a posteromedial papillary muscle. Isolated PLAMV in an adult is even more rare, while the presence of an immature posteromedial papillary muscle--as in the present case--is extremely rare.

How to cite: Mochizuki, Y., Tanaka, H., Fukuda, Y., & Hirata, K. (2014). An uncommon case of isolated parachute-like asymmetric mitral valve in an adult. The Journal of heart valve disease, 23(5), 651–653.

Background and aim of the study: The effects of the implantation angle of bileaflet mechanical heart valves (BMHVs) on the sinus region and downstream flow profiles were investigated. Three-dimensional numerical simulations of BMHVs were performed under physiologic pulsatile flow conditions. The study aim was to examine how the flow fields of different aortic sinus shapes and the downstream aortic arch geometry would be affected by implantation angle.

Methods: Two geometric models of sinus were investigated: a simplified axisymmetric sinus; and a three-sinus aortic root model, with two different downstream geometries, namely a straight pipe and a simplified curved aortic arch. A 29 mm St. Jude Medical BMHV geometric model was used and positioned at four different angles (0 degrees, 30 degrees, 60 degrees and 90 degrees).

Results: The simulation results showed variation in downstream flow profiles at different implantation angles. Generally, at position Z = 1D along the centerline (where Z refers to the axis normal to the x-y plane and D is the inlet diameter), the triple-jet structures were observed with a slight shift of the center jet for three-sinus aortic cases. Apparent differences were observed at position Z = 2D and 4D, such as higher velocity profiles at the inner arch wall. The flow field downstream of the valve implanted at 0 degrees (anatomic position) showed the smallest overall asymmetry at peak systole, while the flow field downstream of the valve implanted at 90 degrees (anti-anatomic position) exhibited high regions of recirculation.

Conclusion: Valve orientation was found not to affect the shear stress distribution significantly in the downstream aorta, and this was in agreement with the findings of earlier studies.

Cite: Kuan, Y. H., Nguyen, V. T., Kabinejadian, F., Su, B., Kim, S., Yoganathan, A. P., & Leo, H. L. (2014). Numerical analysis of the hemodynamic performance of bileaflet mechanical heart valves at different implantation angles. The Journal of heart valve disease, 23(5), 642–650.

Background and aim of the study: Aortic valve replacement (AVR) in patients with a small aortic root is often associated with some degree of obstruction and residual gradients. Stentless valves display better hemodynamic performance than stented valves, and might be ideal in patients with a small aortic annulus. A new stented bioprosthesis, the Trifecta valve, has recently become available and has yielded interesting early results. The study aim was to compare the hemodynamic performance of the Trifecta valve with that of the Freestyle valve in patients with an aortic annulus ≤ 2.3 cm.

Methods: Between September 2011 and September 2013, a total of 40 patients with pure aortic stenosis and native aortic annulus diameter ≤ 2.3 cm was randomized to receive either a St. Jude Medical Trifecta stented prosthesis (n = 20) or a Medtronic Freestyle stentless prosthesis (n = 20). Hemodynamics results were compared between the two groups on discharge from hospital.

Results: The Trifecta valve showed slightly better hemodynamics, with peak gradients of 11 ± 5 mmHg and 17 ± 9 mmHg (p = 0.009), and mean gradients of 5.5 ± 3 mmHg and 7.5 ± 4 mmHg (p = 0.06) for the Trifecta and Freestyle valves, respectively. The average indexed effective orifice area (EOAi) was 1.14 ± 0.23 cm2/m2 and 1.09 ± 0.20 cm2/m2 (p = 0.520) for the Trifecta and Freestyle, respectively. Patient-prosthesis mismatch (PPM) occurred in two patients of the Freestyle group, and in three patients of the Trifecta group.

Conclusion: In the present study, the stentless and stented prostheses each yielded comparable and excellent early hemodynamics results. The data obtained suggest that Trifecta valve implantation is a valid means of avoiding PPM after AVR in patients with a small native aortic annulus.

How to cite: Tasca, G., Stefano, A., Giannico, F., Lobiati, E., Riva, B., Galanti, A., Triggiani, M., & Gamba, A. (2014). Early hemodynamic evaluation of Trifecta and Freestyle bioprostheses in patients with a small aortic root: preliminary results from a prospective randomized study. The Journal of heart valve disease, 23(5), 633–641.

Background and aim of the study: The aim of this prospective observational study was to evaluate the clinical, echocardiographic, microbiological profile and outcomes of patients with definitive infective endocarditis (IE) in tropical countries.

Methods: Between September 2010 and March 2013, a total of 109 patients with 111 episodes of definitive IE (as per the modified Duke's criteria) was enrolled in the study. The mean age at presentation was 32.7 ± 17.2 years (range: 2-70 years), and there was a male preponderance (3:1).

Results: Native valve disease was identified in 57 cases of IE, followed by congenital heart disease (n = 35), prosthetic valve disease (n = 11), normal valves (n = 5) and pacemaker lead infection (n = 1). Echocardiography was diagnostic in all patients except one. Positive blood cultures were obtained in 68 episodes, with streptococci (n = 34) and staphylococci (n = 11) the most common organisms. At least one major complication was identified in 60 patients. Ultimately, only 15 patients underwent surgery for IE, but 25 died during their hospital stay. On multivariate analysis, prosthetic valve involvement, combined mitral and aortic valve involvement, male gender, and leukocytosis were independent predictors of mortality.

Conclusion: IE in India is associated with a higher mortality and lower rates of culture positivity compared to the west; rates of surgery for IE in India are unacceptably low. Changing epidemiological trends may pose newer challenges in the near future.

How to cite: Gupta, K., Jagadeesan, N., Agrawal, N., Bhat, P., & Nanjappa, M. C. (2014). Clinical, echocardiographic and microbiological study, and analysis of outcomes of infective endocarditis in tropical countries: a prospective analysis from India. The Journal of heart valve disease, 23(5), 624–632.

Background and aim of the study: The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of poor prognosis in different clinical conditions such as infectious and cardiovascular diseases. It was hypothesized that a patient's admission NLR would be predictive of an adverse clinical outcome in cases of infective endocarditis (IE).

Methods: A total of 171 patients with IE was enrolled retrospectively, and allocated to two tertiles based on admission NLR values. The high-NLR group (n = 76) was defined as having an NLR value in the third tertile (> 5.46), and the low-NLR group (n = 95) as having a value in the lower two tertiles (≤ 5.46).

Results: Patients in the high-NLR group had a significantly higher incidence of in-hospital mortality than the low-NLR group (39.4% versus 18.9%, p = 0.003). A high NLR was found to be an independent predictor of in-hospital mortality (odds ratio 2.53, 95% confidence interval 1.19-5.3; p = 0.01). The mean follow up was 25.5 months, and long-term follow up mortality was similar in both groups (12.9% versus 19.5%; p = 0.33).

Conclusion: A high NLR at admission is associated with increased in-hospital mortality in patients with IE. During the long-term follow up, NLR showed no predictive indication of mortality.

How to cite: Bozbay, M., Ugur, M., Uyarel, H., Cicek, G., Koroglu, B., Tusun, E., Sunbul, M., Murat, A., Sari, I., & Eren, M. (2014). Neutrophil-to-lymphocyte ratio as a prognostic marker in infective endocarditis: in-hospital and long-term clinical results. The Journal of heart valve disease, 23(5), 617–623.

Background and aim of the study: While early valve surgery for active infective endocarditis (AIE) is recommended, surgeons have hesitated to operate on patients complicated by cerebral septic embolism resulting in cerebral bleeding when cardiopulmonary bypass is required intraoperatively. The study aim was to review the outcomes of operations for AIE, and to determine the risks of neurologic complications resulting from cerebral septic embolism.

Methods: Between 1994 and June 2011, among 278 patients who underwent heart valve surgery for AIE at the authors' institution, 39 (14%) had cerebral septic embolisms. Cerebral lesions were verified by imaging, and were predominantly multiple embolic infarctions (34 patients; 87.2%). Five patients had brain abscess, and 10 had hemorrhage with or without infarction. The mean interval between the recent onset of a stroke and surgery was 10.1 ± 10.1 days (range: 0-43 days).

Results: One patient died postoperatively of septic shock. New neurologic complications occurred in five patients, including secondary hemorrhagic transformation in the previous lesions (n = 2), newly developed subdural and subarachnoid hemorrhage (n = 2), and an increased degree of subarachnoid hemorrhage (n = 1). One patient needed a craniotomy, and the others were treated medically. There were five late deaths, including one cardiac death, and one redo valve surgery due to repaired valve failure during the follow up period of 46.3 ± 40.4 months (range: 1.9-127.4 months). The overall and event-free survival rates at five and 10 years were 84.3 ± 6.5% and 75.9 ± 9.9%, and 81.7 ± 6.8% and 73.6 ± 9.9%, respectively.

Conclusion: Surgery for AIE with cerebral septic embolisms can be performed safely, with good early and mid-term follow-up results. When urgent or emergent surgery for AIE is needed, neurologic complications should not be a reason for delay.

How to cite: Wan, S., Sung, K., Park, P. W., Kim, W. S., Lee, Y. T., Jun, T. G., Yang, J. H., Jeong, D. S., & Cho, Y. H. (2014). Stroke is not a treatment dilemma for early valve surgery in active infective endocarditis. The Journal of heart valve disease, 23(5), 609–616.

Background and aim of the study: The study aim was to investigate the mid-term outcome of tricuspid annuloplasty (TAP) in the repair of functional tricuspid regurgitation (TR), using the three-dimensional (3D) MC3 ring with 'aggressive' stitches.

Methods: Between May 2007 and December 2012, a total of 165 patients (104 women, 61 men; mean age 68.0 ± 9.0 years) underwent TAP using the MC3 ring. Horizontal mattress sutures were placed on the annulus beyond the anteroseptal commissure and away from the deemed atrioventricular node artery/vein, which could be detected in the triangle of Koch. Transthoracic echocardiography was performed preoperatively and postoperatively. The severity of TR was graded from 0 to 4. The mean follow up was 30.3 ± 20.4 months.

Results: Both, TR grade and pulmonary artery systolic pressure (PASP) were significantly improved postoperatively. After a median of 24 months, the mean TR grade and PASP remained satisfactory. The overall survival rates were 97.6% and 94.8% at one and four years, respectively. The rates of freedom from recurrent TR (grade > 2) were 97.3% and 90.5% at one and four years, respectively. There were neither impulse conduction disorders requiring new pacemaker implantation, nor reoperations for recurrent TR. Multivariate analysis showed that recurrent TR during the follow up period was significantly related to severe preoperative TR.

Conclusion: The clinical and echocardiographic results of TAP with the MC3 ring and 'aggressive' stitches were excellent, though further follow up is mandatory to confirm the safety and durability of this technique. Detection of the prominent vessel in the triangle of Koch can be helpful in avoiding impulse conduction disorders after TAP.

How to cite: Hata, H., Fujita, T., Shimahara, Y., Sato, S., & Kobayashi, J. (2014). Early and mid-term outcomes of aggressive tricuspid annuloplasty with the MC3 ring. The Journal of heart valve disease, 23(5), 601–608.

Standardized techniques of mitral valve repair (MVR) have recently witnessed the introduction of a 'respect rather than resect' concept, the strategy of which involves the use of artificial chordae. MVR displays several advantages over mitral valve replacement in degenerative mitral regurgitation (MR), but the risk of reoperation for MVR failure must be taken into account. Different mechanisms could be advocated as the leading cause of MVR failure; procedure-related mechanisms are usually involved in early MVR failure, while valve-related mechanisms are common in late failure. Here, the case is reported of an early failure of MVR using artificial chordae that could be explained by an unusual procedure-related mechanism, namely anterior papillary muscle necrosis. MVR failure is a well-known complication after surgical repair of degenerative MR, but anterior papillary muscle partial necrosis might also be considered a possible mechanism of procedure-related MVR failure, especially when considering the increasing use of artificial chordae. Owing to the encouraging results obtained, mitral valve re-repair might be considered a viable solution, but must be selected after only a meticulous evaluation of the underlying mechanism of MVR failure.

How to cite: Pozzi, M., Generali, T., Henaine, R., Mitchell, J., Lemaire, A., Chiari, P., Fran, J., & Obadia, J. F. (2014). Could anterior papillary muscle partial necrosis explain early mitral valve repair failure?. The Journal of heart valve disease, 23(5), 598–600.

Background and aim of the study: Previous case reports have described patients with left ventricular noncompaction cardiomyopathy (LVNC) with significant mitral regurgitation (MR). The study aim was to determine if LVNC is associated with MR, as assessed by cardiac magnetic resonance imaging (cMRI).

Methods: LVNC, assessed with cMRI, was observed retrospectively among 122 consecutive cases, 31 of whom had an end-systolic noncompacted-to-compacted ratio (ESNCCR) ≥ 2. In addition, 40 normal subjects undergoing cMRI and 40 with moderate to severe MR were included as controls. Using cine images, the ESNCCR and left ventricular (LV) and right ventricular (RV) stroke volumes were measured. The mitral regurgitant fraction (MRF) was calculated by dividing the difference between the RV and LV stroke volumes by the LV stroke volume. The total papillary muscle (TPM) area was measured from the mid short-axis view. Adjusting for age, race, gender and body surface area, an analysis of covariance was conducted to determine whether MRF and TPM were associated with ESNCCR ≥ 2. Adjusted means were presented with 95% confidence intervals.

Results: After adjustment, the MRF in patients with ESNCCR ≥ 2 was higher than in controls, but did not differ from that in patients with significant MR (21 ± 6.5% versus 2.7 ± 12% versus 29.2 ± 11%, p = 0.039 and p = 0.3, respectively). Further, patients with ESNCCR ≥ 2 had a lower TPM than normal controls or those with moderate to severe MR (1.89 ± 0.28 cm2 versus 3.6 ± 0.26 cm2 versus 3.7 ± 0.24 cm2; p < 0.001 and p < 0.001, respectively).

Conclusion: LVNC is associated with increased MR, as assessed using cMRI. LVNC is also associated with abnormalities in the papillary muscle anatomy, which may predispose to MR.

How to cite: Stacey, R. B., Haag, J., Hall, M. E., McLeod, G., Upadhya, B., Hundley, W. G., & Thohan, V. (2014). Mitral regurgitation in left ventricular noncompaction cardiomyopathy assessed by cardiac MRI. The Journal of heart valve disease, 23(5), 591–597.

Background and aim of the study: Despite advances in mitral valve repair techniques, including robotic surgeries, few studies are available on predicting mitral annuloplasty ring size using echocardiography. Furthermore, these studies either had limited accuracy or else required the use of three-dimensional transesophageal echocardiography (3D-TEE), an expensive and semi-invasive tool. The study aim was to predict the mitral annuloplasty ring size preoperatively using real-time, three-dimensional transthoracic echocardiography (RT3D-TTE), which is a cheaper, non-invasive technique.

Methods: This prospective study included 47 consecutive patients scheduled for elective mitral valve surgery. All participants underwent preoperative RT3D-TTE. The mitral annular transverse diameter during early systole and the maximum height of the A2 scallop were measured in the multiplanar reconstruction mode. The surgeon, who was blinded to the echocardiographic measurements, also measured these two variables intraoperatively. A Pearson correlation coefficient was used to assess the association between the echocardiographic and operative measurements. A linear regression analysis was used to predict the annuloplasty ring size.

Results: A total of 34 patients (72.3%) underwent mitral valve repair. The echocardiographic measurements of the mitral annular transverse diameter were well correlated with the operative measurements (r = 0.64, p < 0.001). A moderate correlation was observed between the echocardiographic and operative measurements of A2 height (r = 0.59, p < 0.001). Linear regression analysis yielded an equation that predicted the annuloplasty ring size (R = 0.828, p < 0.001).

Conclusion: RT3D-TTE was used successfully to predict the mitral annuloplasty ring size. This technique may potentially aid surgical planning, particularly before robotic procedures are performed.

How to cite: Labib, D. O., Heshmat, H., Gaafar, A. H., Salah, M., & Mahdy, S. G. (2014). Real-time three-dimensional transthoracic echocardiography for predicting mitral annuloplasty ring size. The Journal of heart valve disease, 23(5), 583–590.

Background and aim of the study: Mitral regurgitation (MR) is an important complication after prosthetic mitral valve (PMV) implantation. Transthoracic echocardiography is widely used to screen for native MR, but can be limited with PMV. Cine-cardiac magnetic resonance (CMR) holds the potential for the non-invasive assessment of regurgitant severity based on MR-induced inter-voxel dephasing. The study aim was to evaluate routine cine-CMR for the visual assessment of PMV-associated MR.

Methods: Routine cine-CMR was performed at nine sites. A uniform protocol was used to grade MR based on jet size in relation to the left atrium (mild < 1/3, moderate 1/3-2/3, severe > 2/3). MR was graded in each long-axis orientation, with overall severity based on cumulative grade. Cine-CMR was also scored for MR density and pulmonary vein systolic flow reversal (PVSFR). Visual interpretation was compared to quantitative analysis in a single-center (derivation) cohort, and to transesophageal echocardiography (TEE) in a multicenter (validation) cohort.

Results: The population comprised 85 PMV patients (59% mechanical valves, 41% bioprostheses). Among the derivation cohort (n = 25), quantitative indices paralleled visual scores, with stepwise increases in jet size and density in relation to visually graded MR severity (both p = 0.001). Patients with severe MR had an almost three-fold increase in quantitative jet area (p = 0.002), and a two-fold increase in density (p = 0.04) than did other patients. Among the multicenter cohort, cine-CMR and TEE (Δ =. 2 ± 3 days) demonstrated moderate agreement (κ = 0.44); 64% of discordances differed by ≤ 1 grade (Δ = 1.2 ± 0.5). Using a TEE reference, cine-CMR yielded excellent diagnostic performance for severe MR (sensitivity, negative predictive value = 100%). Patients with visually graded severe MR also had more frequent PVSFR (p < 0.001), denser jets (p < 0.001), and larger left atria (p = 0.01) on cine-CMR.

Conclusion: Cine-CMR is useful for the assessment of PMV-associated MR, which manifests concordant quantitative and qualitative changes in size and density of inter-voxel dephasing. Visual MR assessment based on jet size provides an accurate non-invasive means of screening for TEE-evidenced severe MR.

How to cite: Simprini, L. A., Afroz, A., Cooper, M. A., Klem, I., Jensen, C., Kim, R. J., Srichai, M. B., Heitner, J. F., Sood, M., Chandy, E., Shah, D. J., Lopez-Mattei, J., Biederman, R. W., Grizzard, J. D., Fuisz, A., Ghafourian, K., Farzaneh-Far, A., & Weinsaft, J. (2014). Routine cine-CMR for prosthesis-associated mitral regurgitation: a multicenter comparison to echocardiography. The Journal of heart valve disease, 23(5), 575–582.

Background and aim of the study: The logistic EuroSCORE and STS score have been used for the selection of suitable TAVI patients, but their predictive ability is unsatisfactory. The study aim was to evaluate the performance of the EuroSCORE II in predicting 30-day mortality after TAVI in comparison to the logistic EuroSCORE and STS scoring systems.

Methods: Between January 2008 and April 2013, a total of 123 consecutive patients underwent TAVI (transapical, n = 85; transfemoral, n = 38) at the authors' institution. Calibration and discriminatory ability was evaluated for three risk scores models (logistic EuroSCORE, STS score, and EuroSCORE II), and compared for the prediction of 30-day mortality using the Hosmer-Lemeshow test for goodness-of-fit and receiver operating characteristics curve analysis.

Results: The overall 30-day mortality was 4.1% (5/123). Predicted mortality was 25.0 ± 15.7% by logistic EuroSCORE, 7.3 ± 6.9% by STS score, and 7.8 ± 8.7% by EuroSCORE II. The observed/expected mortality ratio was 0.16 for logistic EuroSCORE, 0.56 for STS score, and 0.52 for EuroSCORE II. The area under the curve was 0.69 (95% CI 0.54-0.84) for the logistic EuroSCORE, 0.60 (95% CI 0.38-0.82) for the STS score, and 0.66 (95% CI 0.46-0.86) for the EuroSCORE II.

Conclusion: In the present study, the EuroSCORE II was found to predict 30-day mortality more accurately for the TAVI cohort than did the more established logistic EuroSCORE, and also to compare (at present) on a par with the STS score. However, there were no differences in discriminatory power between the models. It is believed that, in the absence of a more TAVI-oriented risk stratification system, the EuroSCORE II may be a valuable adjunct in the clinical setting.

How to cite: Johansson M, Nozohoor S, Zindovic I, Nilsson J, Kimblad PO, Sjögren J. Prediction of 30-day mortality after transcatheter aortic valve implantation: a comparison of logistic EuroSCORE, STS score, and EuroSCORE II. J Heart Valve Dis. 2014 Sep;23(5):567-74. PMID: 25799705.

Background and aim of the study: Valvular calcification is a prominent feature of aortic valve stenosis (AS), and calcified aortic valves share several features with bone tissue. Hypoxia-inducible factor-2 (HIF-2) is activated by nuclear factor-κB (NF-κB) and plays a critical role in an osteoblastic differentiation. The study aim was to determine whether the NF-κB-HIF-2 pathway is involved in the pathophysiology of calcified aortic valve disease.

Methods: A total of 50 specimens of aortic valve leaflets obtained from patients who had undergone aortic valve replacement for AS was examined. The aortic valve leaflets from 10 patients with annulo-aortic ectasia (AAE) served as controls. The stenotic valve leaflets were examined using immunohistochemistry to detect NF-κB, HIF-2α, vascular endothelial growth factor (VEGF), vascular endothelial cells, and collagen X. The calcification area was measured and any correlation between the calcification area and NF-κB-HIF-2 pathway was assessed.

Results: NF-κB and HIF-2α were expressed in the leaflets from patients with AS, but not in those from AAE controls. Both factors were expressed around massive calcified lesions, and HIF-2α was co-localized with NF-κB. VEGF, neoangiogenesis and collagen X were located in the area where HIF-2α was expressed, and correlated positively with HIF-2α expression. The calcification area correlated positively with collagen X expression.

Conclusion: The NF-κB-HIF-2 pathway was expressed in calcified aortic valves and associated with an increased expression of VEGF and collagen X. This signaling pathway may play important roles in the pathophysiology of AS.

How to cite: Akahori H, Tsujino T, Naito Y, Sawada H, Sugahara M, Fukui M, Ohyanagi M, Mitsuno M, Miyamoto Y, Masuyama T. Nuclear factor-κB-hypoxia-inducible factor-2 pathway in aortic valve stenosis. J Heart Valve Dis. 2014 Sep;23(5):558-66. PMID: 25799704.

Background and aim of the study: Aortic valve repair is an attractive alternative to valve replacement. Herein is presented the authors' single-center experience and lessons learned from 508 patients undergoing AVR, in three different groups.

Methods: Between 1993 and 2010, a total of 508 patients (148 females, 360 males; mean age 54 ± 17 years) underwent aortic valve repair. Operations included valve-sparing surgery (n = 253), isolated leaflet intervention (n = 158), and sinotubular junction (STJ) remodeling (n = 97). Aortic valve repair was defined as any primary or concomitant procedure performed at the level of the aortic valve or root for the restoration of function and/or anatomy of the valve. The mean follow up was 6.9 ± 3.8 years (range: 0-18 years; median: 6.3 years; total: 3,477 patient-years). The completeness of clinical follow up was 95%.

Results: The 30-day mortality with and without dissection was 4.4% (8/180) and 1.8% (6/328), respectively. Late survival without dissection, although statistically inferior, followed closely the expected general population. In total, 53 patients required a cardiac, valve-related reoperation. Among the valve-sparing group, no significant difference in freedom from reoperation at 10 years was observed between the David and Yacoub types (n = 147 (89%) versus n = 113 (79%); p = 0.373, respectively). Among patients who underwent isolated leaflet interventions, the number required to restore valve function (repair score) significantly affected the durability and incidence of reoperations (hazard ratio 1.47; 95% CI 1.1-2.0; p = 0.01), with the risk for failure being higher early after the operation. Patients with functional aortic insufficiency (AI) requiring only STJ remodeling resulted in the most durable outcome (freedom from reoperation 97.5% at 10 years). At the latest echocardiographic follow up (448 patients; total: 2,755 pt-yr; mean: 6.4 ± 3.7 years; completeness 88%), 97% of patients had AI of grade ≤ 2.

Conclusion: Aortic valve repair is an attractive alternative to conventional replacement in many patients and pathologies. In particular, pathologies requiring multiple leaflet interventions and repair techniques may lead to suboptimal results. Leaflet quality and leaflet-adjusted root stabilization/reconstruction are key elements for durable results.

How to cite: Charitos EI, Stierle U, Tietze C, Hanke T, Karluss A, Misfeld M, Sievers HH. Clinical outcomes and lessons learned with aortic valve repair in 508 patients. J Heart Valve Dis. 2014 Sep;23(5):550-7. PMID: 25799703.

Background and aim of the study: The study aim was to develop an in-vitro model of human aortic valve homograft (AVH) mineralization, as a basis for further research on the subject of calcific aortic valve disease (CAVD).

Methods: Human aortic valves were excised during autopsy (12-24 h post-mortem) from donors who had died due to accident or suicide. The mean (±SD) donor age was 32.5 ± 11.4 years. Under sterile conditions each aortic cusp (three cusps per valve) was cut in half to provide a total of 240 tissue samples. AVH mineralization was assessed in solutions with different Ca and P concentrations and CaxPO4 ionic product values. The impact of time on aortic valve mineralization rate was assessed using energy-dispersive X-ray fluorescence (ED-XRF).

Results: The model showed that human AVH mineralization can be best observed in a solution with a CaxPO4 ionic product of 2.2 mmol2/l2. The optimum incubation time for observing AVH mineralization was 21 days.

Conclusion: A novel in-vitro AVH mineralization model was developed for use in future studies.

How to cite: Goncerz G, Tomaszewski KA, Pasternak A, Głowacki R, Wróbel A, Rokita E, Podolec P. A novel in-vitro model of human aortic valve mineralization. J Heart Valve Dis. 2014 Sep;23(5):545-9. PMID: 25799702.

Background and aim of the study: The aim of this prospective study was to determine the impact of plasma B-type natriuretic peptide (BNP) on long-term outcome in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods: TAVI was performed either transfemorally or transaxillary using either the CoreValve prosthesis or Edwards SAPIEN prosthesis in 226 patients with symptomatic severe aortic valve stenosis and at high surgical risk. The examinations included measurements of plasma BNP and echocardiography before and at 30 days after TAVI. The primary study end-point was death from any cause after TAVI; the secondary end-point was defined as cardiovascular death.

Results: During a mean follow up of 728 ± 549 days, 72 patients died; 52 deaths were cardiovascular-related. Those patients who died had higher preprocedural plasma BNP levels compared to those who survived (1,305 ± 1,238 pg/ml versus 716 ± 954 pg/ml; p < 0.001). Plasma BNP was the strongest independent predictor of all-cause mortality (BNP > 475 pg/ml, hazard risk [HR] 3.049; 95% confidence interval [CI] 1.804-5.151; p < 0.001) and cardiovascular mortality (BNP > 475 pg/ml, HR 3.479; 95% CI 1.817-6.662; p < 0.001). In surviving patients, plasma BNP levels were decreased by 30 days after TAVI (pre-TAVI 874 ± 1,122 pg/ml; post TAVI 471 ± 569 pg/ml; p < 0.001). A plasma BNP level > 328 pg/ml at 30 days postoperatively was also associated with all-cause mortality (HR 8.125; 95% CI 3.097-21.318; p < 0.001).

Conclusion: In patients undergoing TAVI, plasma BNP is the strongest independent predictor of all-cause mortality and cardiovascular mortality. Plasma BNP levels at 30 days after TAVI may provide prognostic information that should, potentially, lead to a more intensive therapy of these patients.

How to cite: Gotzmann M, Czauderna A, Aweimer A, Hehnen T, Bösche L, Lind A, Kloppe A, Mügge A, Ewers A. B-type natriuretic peptide is a strong independent predictor of long-term outcome after transcatheter aortic valve implantation. J Heart Valve Dis. 2014 Sep;23(5):537-44. PMID: 25799701.

During recent years, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option for patients with severe symptomatic aortic stenosis who are at high surgical risk. Although infective endocarditis (IE) is a potential and serious complication in this group of patients, the best therapeutic approach for IE in patients with TAVI has not been well established. Here, the case is reported of a patient with a giant vegetation after TAVI infection that was successfully treated without surgery. The hope is to provide some clinical insight into this new group of patients with IE.

How to cite: Olmos C, Vilacosta I, Ferrera C, Vivas D, Sánchez-Enrique C, Nogales T, Tirado G. Transcatheter aortic valve implantation with a giant vegetation successfully treated with antibiotics: insights into a new group of patients with endocarditis. J Heart Valve Dis. 2014 Sep;23(5):534-6. PMID: 25799700.

Patients with asymptomatic severe aortic stenosis (AS) constitute a heterogeneous group which includes not only certain cases who are at high risk of sudden death and valve-related heart failure, but also those at low risk for these events. Degenerative AS, which includes a majority of patients with AS, is characterized by stricture of the valve, increased arterial stiffness, and diverse left ventricular response to the valvular plus arterial vascular load. In addition to using traditional primary parameters, the severity of AS and the total left ventricular load should be assessed using new measures such as energy loss index and valvulo-arterial impedance. Natriuretic peptide levels and global longitudinal strain imaging may also be used as secondary parameters to obtain information about left ventricular systolic function, although these parameters do not correlate with the severity of AS. Exercise stress testing and exercise echocardiography are also beneficial when assessing the patient if they are symptomatic, and for determining valvular and left ventricular contractile reserves. The aim of this review was to emphasize the importance of risk stratifications in asymptomatic severe AS cases, and to assess the severity of AS using not only conventional methods but also new methods on which much emphasis has been placed during recent years.

How to cite: Bilen E, Ipek G, Ayhan H, Nacar AB, Kasapkara HA, Sani C, Basbug S, Kurt M, Bozkurt E. Optimal timing of valve replacement in asymptomatic severe aortic stenosis. J Heart Valve Dis. 2014 Sep;23(5):524-33. PMID: 25799699.