Background and aim of the study: Congenital abnormalities of the tricuspid valve (TV), including dysplasia, straddling, and those associated with other congenital heart disease, are rare causes of tricuspid regurgitation (TR). In congenital TV anomalies there can be varying levels of abnormalities of leaflet and subvalvular structures. Herein is reported a case of TV cleft with absent chordae, and a technique of TV repair.

Methods: A 14-year-old boy was found to have severe TR due to dysplasia of the anterior TV leaflet. Intraoperatively he was noted to have dysplasia of the TV with a cleft in the anterior leaflet of the TV and an absence of chordae supporting the anterior two-thirds of the anterior leaflet. The anterior papillary muscle was hypoplastic, with chordae to the posterior leaflet and small chordae partly to the anterior leaflet. The cleft was repaired and a neochordae placed onto the anterior leaflet with attachment to the papillary muscle, followed by an annuloplasty.

Results: Intraoperative and postoperative echocardiographic assessment showed good mobility of the anterior tricuspid leaflet at six months and two-year follow up.

Conclusion: Chordal replacement is a useful technique for repairing congenital dysplastic TV with absent chordae. The same technique for mitral valve repair with neochordae can be applied to chordal anomalies of the TV, with excellent outcome.

How to cite: Veerbhadran, S. P., Pillai, V. V., Sasidharan, B., & Karunakaran, J. (2015). Surgery for Congenital Tricuspid Valve Cleft: Tricuspid Valve Repair with Neochordae and Annuloplasty. The Journal of heart valve disease, 24(4), 525–527.

The case is described of an eight-year-old boy who required an operation for moderate mitral regurgitation due to a double-orifice mitral valve (DOMV). The DOMV, which was clearly demonstrated by transthoracic echocardiography, had a central fibrous bridge. Mitral valve repair using a 5/0 Prolene suture placed at the level of the superior commissure of each hole to stabilize the valve, and ring annuloplasty with Edwards Physio ring, was successfully performed. Intraoperative real-time transesophageal echocardiography showed the repaired DOMV to be without regurgitation or stenosis.

How to cite: Segreto, A., De Salvatore, S., Chiusaroli, A., Bizzarri, F., Van Wyk, C., & Congiu, S. (2015). Double-Orifice Mitral Valve in an Eight-Year-Old Boy. The Journal of heart valve disease, 24(4), 522–524.

A case is described of aortic stenosis that was initially treated with transcatheter aortic valve implantation (TAVI) due to a high-risk profile. Following dysfunction of the TAVI prosthesis, conventional aortic valve replacement (AVR) was successfully performed; the subsequent postoperative course was uneventful. In conclusion, the target population for TAVI must be more accurately specified, with further research helping to define whether AVR or TAVI is the best treatment option for 'intermediate-risk' patients.

How to cite: van der Straaten, E. P., van Straten, A. H., & Soliman Hamad, M. A. (2015). Conventional Aortic Valve Replacement after Displacement of a Percutaneously Implanted Aortic Prosthesis: Case Report. The Journal of heart valve disease, 24(4), 519–521.

Ascending-to-descending aortic bypass is a valuable technique for addressing coarctation of the aorta when additional cardiac procedures are indicated in adults. Among these, aortic valve replacement is one of the most commonly performed concomitant procedures, and there are instances in which aortic root enlargement is required. Herein, a novel technique is described for performing simultaneous ascending-to-descending aortic bypass in conjunction with aortic root enlargement which incorporates the bypass graft as part of the aortic root enlargement.

How to cite: Perry, P. A., & Young, N. (2015). Aortic Root Enlargement with Ascending-to-Descending Aortic Bypass in Repair of Coarctation. The Journal of heart valve disease, 24(4), 516–518.

Background and aim of the study: The study aim was to evaluate the effect of prophylactic tricuspid annuloplasty (TAP) on late tricuspid regurgitation (TR) after double valve (aortic and mitral) replacement (DVR).

Methods: Among 239 patients undergoing DVR at the authors' institution between 1994 and 2009, a total of 93 patients who had a less than moderate degree of preoperative TR was analyzed. Concomitant TAP was performed in 55 patients (TAP group). The mean follow up duration was 7.3 +/- 4.1 years (maximum 15.9 years). Serial echocardiographic data at one, three, five and more than seven years were analyzed.

Results: There was no early mortality, but eight late cardiac-related mortalities occurred (8.6%). In the aortic position, the transprosthetic mean pressure gradient (TMPG) was increased during follow up (13.5 +/- 5.3 mmHg versus 16.4 +/- 10.2 mmHg, p = 0.006). However, the mitral TMPG did not change significantly (3.7 +/- 1.4 mmHg versus 3.8 +/- 1.6 mmHg, p = 0.677). Freedom from valve-related events at 10 years was higher in the TAP group than in the non-TAP group (85.2 +/- 5.9% versus 63.3 +/- 0.9%; p = 0.05). Freedom from more than moderate TR at 10 years was also higher in the TAP group (93.6 +/- 4.7% versus 66.3 +/- 10.3%; p = 0.03). The transmitral pressure gradient was associated with valve-related events (p = 0.025; HR, 1.367). An absence of TAP was predictive of late TR (p = 0.020; HR, 4.4).

Conclusion: The study results suggested that TAP can be considered in patients who require DVR, even if the TR grade is less than moderate, in order to prevent the late occurrence of TR.

How to cite: Jeong, D. S., Shim, M. S., Sung, K., Kim, W. S., Lee, Y. T., & Park, P. W. (2015). Prophylactic Tricuspid Annuloplasty in Patients Undergoing Double Valve Revlacement. The Journal of heart valve disease, 24(4), 508–515.

Background and aim of the study: Cardiac magnetic resonance (CMR) is the 'gold standard' for quantifying pulmonic regurgitation (PR) in adults with congenital heart disease, but remains costly and is less readily available than echocardiography. Qualitative echocardiographic assessment of PR is challenging, and guiding criteria are limited. It is unknown if echocardiography is sufficient to screen for significant PR. The study aim was to determine whether cardiac MRI provides additional benefit in the assessment of PR in adults with congenital heart disease.

Methods: Patients with repaired tetralogy of Fallot or congenital pulmonic stenosis after valvotomy undergoing transthoracic echocardiography and CMR with no interval intervention were identified from a prospective registry. Patients with greater than mild pulmonic stenosis, residual ventricular septal defect or poor echocardiographic windows were excluded. Whole-cohort and subgroup (tetralogy of Fallot versus pulmonic stenosis) analyses for inter-modality agreement were performed.

Results: A total of 48 patients (24 men, 24 women; mean age 43 +/- 12 years) was included in the analysis. The unweighted kappa value for the two modalities was 0.30, suggesting 'fair' agreement, though only 52% had matching PR assessments. The indexed right ventricular end-systolic volume (RVESVi) correlated closely with cardiac MRI-monitored PR (p = 0.011 by analysis of variance), but not with that monitored with echocardiography (p = 0.081). Subgroup analysis demonstrated less inter-modality agreement in the tetralogy of Fallot population (kappa 0.25) than in the pulmonic stenosis population (kappa 0.35).

Conclusion: CMR measurement of PR correlates closely with the RVESVi, and appears superior to echocardiography when assessing patients at risk for PR. The study results suggest a vital role for CMR whenever significant PR is suspected in the adult congenital heart disease population.

How to cite: Zdradzinski, M., Elkin, R., Flamm, S., & Krasuski, R. (2015). Incremenal Value of Cardiac Magnetic Resonance for Assessing Pulmonic Valve Regurgitation. The Journal of heart valve disease, 24(4), 502–507.

Background and aim of the study: Interleukin (IL)-13 is a major inducer of fibrosis in many chronic infectious diseases, yet few studies have reported its role in valvular fibrosis in patients with rheumatic heart disease (RHD). The study aim was to investigate the role of IL-13 in mitral valvular fibrosis in patients with RHD.

Methods: Peripheral blood samples were collected from surgical patients with RHD (n = 18) and from healthy controls (n = 9). Serum levels of IL-13 and interferon (IFN)-gamma were analyzed using ELISA. Rheumatic mitral valves removed from surgical patients with RHD, and normal mitral valves, were obtained at autopsy. The expression and distribution of collagen I, collagen III, and IL-13Ralpha1 were examined by immunohistochemical staining, the degree of which was measured using computed imaging analysis.

Results: Higher IL-13 levels were observed in RHD patients (15.16 +/- 9.62 pg/ml; p < 0.05) than in healthy controls (7.78 +/- 3.87 pg/ml). RHD patients had high levels of IFN-gamma (9.95 +/- 0.77 pg/ml; p <0.05) compared to healthy controls (5.95 +/- 0.69 pg/ml). Immunohistochemistry showed that, compared to normal valves, rheumatic mitral valves expressed high levels of collagen I (0.01931 +/- 0.00159 versus 0.01183 +/- 0.00207; p < 0.05), collagen III (0.00726 +/- 0.00078 versus 0.00342 +/- 0.00124; p <0.05), and IL-13Rcxl (0.00454 +/- 0.00086 versus 0.00017 +/- 0.00008; p <0.01). Collagens I and III were each expressed in heart interstitial cells, while IL-13Ralpha1 was expressed in the endothelial cells and smooth muscle cells of the blood vessels, and in interstitial cells.

Conclusion: Patients with RHD showed increased serum levels of IL-13 compared to healthy controls. IFN-gamma levels were clearly different among RHD patients and healthy controls. The expression of collagens I and III and IL-13Ralpha1 was higher in rheumatic mitral valves compared to normal mitral valves. IL-13 may induce mitral valvular fibrosis in RHD.

How to cite: Liu, Q., Qiao, W. H., Li, F. F., Deng, P., & Hu, Z. W. (2015). The Role of Interleukin-13 in Patients with Rheumatic Valvular Fibrosis: A Clinical and Histological Study. The Journal of heart valve disease, 24(4), 496–501.

Background and aim of the study: Current cohort studies comparing the Trifecta valve to alternative pericardial bioprostheses are limited by selection bias. The study aim was to determine if hemodynamics are improved after the aortic valve implantation of a Trifecta valve as compared to a standard pericardial valve, when evaluated using strict paired matching for specific key relevant confounders.

Methods: Valve hemodynamics were compared in patients undergoing implantation with a Trifecta or Perimount valve matched for left ventricular outflow tract (LVOT) diameter, gender, age, body size, and days since surgery, using a 1:1 matched-paired cohort analysis (n = 20 per group).

Results: Patients receiving a Trifecta valve had a larger increase in indexed stroke volume (SVi) relative to baseline compared to the Perimount patients (p = 0.013), in whom SVi was decreased. The mean transvalvular pressure gradient was lower in Trifecta patients despite the larger SVi (p = 0.02). The effective orifice area (EOA) and indexed EOA (EOAi) were significantly larger in Trifecta patients compared to Perimount patients (2.04 +/- 0.46 versus 1.77 +/- 0.45 cm2, p = 0.049; 1.10 +/- 0.22 versus 0.95 +/- 0.06 cm2/m2, p = 0.027, respectively), and there was a greater increase in EOA and EOAi from baseline (p = 0.010 for both). Severe prosthesis-patient mismatch (PPM) (EOAi < or = 0.65 cm2/m2) was seen in two (10%) of the Perimount cases, but in none of the patients with the Trifecta valve (p = 0.072).

Conclusion: Trifecta valve implantation is associated with a significant improvement in EOA and a decreased incidence of PPM as compared to the Perimount valve. The superior hemodynamic outcomes observed support consideration of this valve for aortic valve replacement, particularly in patients with a small LVOT at risk for PPM.

How to cite: Rubens, F. D., Rao, R. V., Chan, V., & Burwash, I. G. (2015). A Matched-Paired Comparative Analysis of the Hemodynamics of the Trifecta and Perimount Aortic Bioprostheses. The Journal of heart valve disease, 24(4), 487–495.

The valve-in-valve (ViV) procedure is an option for patients with symptomatic structural degeneration of a bioprosthesis and excessive reoperative risk. The risk of coronary obstruction appears to be increased if ViV is performed for certain pericardial prostheses in which the leaflets are mounted outside the stent posts. Herein is described a successful ViV for a degenerated Trifecta aortic bioprosthesis, and the technical considerations for performing a ViV procedure within such types of prosthesis are considered. Emphasis is placed on the importance of preoperative investigations (computed tomography scan-based measurements of coronary ostial height and of sinus of Valsalva diameters), and on the precise deployment of the valve (transapical approach with transesophageal echocardiography control) to minimize the risk of major complications. The presence of a failing Trifecta bioprosthesis should not be considered an absolute contraindication to ViV on the basis of the risk of coronary obstruction.

How to cite: Verhoye, J. P., Harmouche, M., Soulami, R. B., Thebault, C., Boulmier, D., Leguerrier, A., & Anselmi, A. (2015). Feasibility of Valve-in-Valve Procedure for Degenerated St. Jude Medical Trifecta Bioprosthesis. The Journal of heart valve disease, 24(4), 484–486.

Background and aim of the study: In patients undergoing the Ross procedure, the right ventricular outflow tract (RVOT) conduit is inserted in an orthotopic position rather than in the more heterotopic position used in the repair of complex congenital RVOT obstruction. The study aim was to compare the authors' institutional mid-term experience of large-sized homografts (>19 mm) in patients with Ross and non-Ross RVOT reconstructions.

Methods: The outcome was reviewed of all homografts implanted for Ross (n = 72) or non-Ross (n = 64) RVOT reconstruction at a single center between 1993 and 2012. Echocardiographic data were reviewed to evaluate valve performance. Homograft dysfunction was defined as RVOT obstruction with peak echo-Doppler gradient >40 mmHg and/or grade >III/IV conduit valve regurgitation. Homograft failure was defined as the need for conduit replacement or catheter or surgical reintervention.

Results: The age, body weight, conduit diameter and previous surgery were significantly higher in patients with Ross compared to the non-Ross group (p = 0.002, 0.003 and <0.001, respectively). The mean follow up duration was similar in both groups. There were 35 re-interventions (Ross, n = 17; non-Ross, n = 18). The data acquired showed actuarial survival, freedom from conduit dysfunction and conduit failure to be similar in both cohorts. Freedom from any type of reoperation was worse for the Ross group (58%) than for the non-Ross group (72%) (p = 0.05).

Conclusion: During the first 15 years after Ross or non-Ross pulmonary homograft implantation, the survival rate, freedom from failure and dysfunction, and RVOT gradient were statistically similar. Freedom from any type of reoperation was significantly higher in the non-Ross group, however.

How to cite: Ruzmetov, M., Geiss, D. M., Shah, J. J., Fortuna, R. S., & Welke, K. F. (2015). Does the Homograft for RVOT Reconstruction in Ross: Patients Fare Better than for Non-Ross Patients? A Single-Center Experience. The Journal of heart valve disease, 24(4), 478–483.

Background and aim of the study: The practice of thoracoscopic assisted minimally invasive mitral valve repair surgery is less common in the United Kingdom than in Europe or the USA. The main reasons for this are concerns around increased operative risk, feasibility and durability of valve repair. The study aim was to report the early and late outcomes of minimally invasive mitral valve repair surgery at a single U.K. center.

Methods: Patients undergoing isolated minimally invasive mitral valve repair between 2003 and 2013 were reviewed retrospectively. Data were obtained from a prospectively maintained institutional database, a comprehensive review of individual case notes, echocardiograms, intensive care charts, clinic letters, discharge summaries, and the authors' follow up database (based on data supplied by the UK Office for National Statistics).

Results: A total of 190 patients (mean age 61 years; mean EuroSCORE 3.9) underwent the procedure. The mean cardiopulmonary bypass and aortic cross-clamp times were 153 and 108 min, respectively. Rates of major postoperative complications were: reoperation for bleeding 3.7%, stroke 1.6%, intra-aortic balloon pump 2.1%, and venovenous hemofiltration 2.6%. The median intensive care stay was one day, and the median hospital stay five days (21.8% of patients were discharged by day 3). The 30-day mortality was 1.1% (n = 2). Echocardiography performed at discharge or six weeks postoperatively showed less than mild mitral regurgitation (MR) in 91.3%. The median duration of follow up was 57 months. During the entire follow up period, four patients (2.1%) underwent repeat surgery for recurrent MR (between 15 months and five years). Of 188 patients discharged from hospital, nine (4.8%) died during follow up: median 5.3 years (range 1.3- 10.7 years) post surgery.

Conclusion: These data are the first from the U.K. demonstrating early and late outcomes after thoracoscopic assisted minimally invasive mitral valve repair surgery. The data establish the safety and efficacy of the technique and, importantly, lend further support towards a prospective randomized comparison of minimally invasive versus conventional mitral valve repair surgery.

How to cite: Akowuah, E., Burdett, C., Khan, K., Goodwin, A., Lage, I. B., El-Saegh, M., Smailes, T., & Hunter, S. (2015). Early and Late Outcomes After Minimally Invasive Mitral Valve Repair Surgery. The Journal of heart valve disease, 24(4), 470–477.

An 89-year-old female was referred to the authors' institution for repeating pulmonary edema. Recent transthoracic echocardiography (TTE) showed only a mild mitral regurgitation (MR), but a transient severe reversible functional MR was observed during an episode of respiratory distress. TTE demonstrated the functional nature of the regurgitation with a transient tenting of the mitral leaflets, resulting in a total absence of coaptation.

How to cite: Schouver, E. D., Moceri, P., Chiche, O., Doyen, D., Gibelin, P., & Ferrari, E. (2015). The So-Called 'Eclipsed' Mitral Regurgitation. The Journal of heart valve disease, 24(4), 468–469.

Transcatheter aortic valve replacement (TAVR) continues to garner considerable attention, especially as the commercial use of the procedure grows. Herein is highlighted an under-reported, underappreciated challenge in TAVR--that of a sigmoid septum. The two cases reported constitute the first discussion in the contemporary literature of this unique geometry in the setting of TAVR. Specifically, the report addresses how such a bulging septum may preclude safe TAVR with a balloon- expandable prosthesis, and also reinforces the importance of thoroughly evaluating all aspects of the subvalvular anatomy prior to valve deployment.

How to cite: de Biasi, A. R., Worku, B., Skubas, N. J., & Salemi, A. (2015). Sigmoid Septum and Balloon-Expandable Transcatheter Aortic Valve Replacement: A Cautionary Tale. The Journal of heart valve disease, 24(4), 465–467.

Background and aim of the study: Managing patients with asymptomatic severe aortic stenosis (AS) remains a major challenge. Myocardial as well as cardiocirculatory reserve have been hypothesized to predict outcome in patients with asymptomatic AS.

Methods: A total of 48 patients (indexed aortic valve area 0.39 +/- 0.12 cm2/m2; ejection fraction (EF) 67 +/- 7%) underwent spiroergometry and dobutamine stress echocardiography. Death or valve surgery served as a combined endpoint for follow up.

Results: Thirty-seven patients reached the endpoint after a mean of 756 days (range: 100-2146 days). Age- and gender-corrected univariate Cox proportional analysis revealed the presence of mild obstructive lung disease, stroke work loss (SWL), end-systolic diameter index, and E/Flow propagation velocity as the best predictive clinical, valvular, cardiostructural, and left ventricular filling pressure parameters, respectively. After inclusion of these parameters into a baseline multivariable Cox proportional hazard model, SWL (HR 1.21 per rise of 1 unit, CI 1.08-1.35, p = 0.0005) and female gender (HR 3.37, CI 1.50-7.59, p = 0.0044) were independently predictive. Similarly, the best-performing myocardial parameter, EF after dobutamine, was independently predictive (HR 0.75 per 5 units, CI 0.57-0.99, p = 0.035) after inclusion. The best-performing exercise capacity parameter, Watt(max), was of borderline significance (HR 0.93 per 5 units, CI 0.86-1.00, p = 0.0505). For each parameter, cut-off values were determined by time-dependent receiver-operator characteristics. The Kaplan-Meier curves of the patients above versus below the cut-offs differed significantly for SWL (p = 0.001), Wattm (p = 0.001), and gender (p = 0.013).

Conclusion: Besides SWL and female gender, the EF after dobutamine as well as highest exercise stress intensity reached are helpful in determining the prognosis of asymptomatic patients with moderate-severe AS.

How to cite: Schulz, O., Brala, D., Allison, T. G., & Schimke, I. (2015). Myocardial and Cardiocirculatory Reserve in Asymptomatic Aortic Stenosis and Preserved Ejection Fraction. The Journal of heart valve disease, 24(4), 457–464.

Background and aim of the study: It has been found recently that activated complement is more widespread in diseased aortic valves compared to the endogenous complement inhibitors C1-inhibitor and clusterin. Previously, another endogenous inhibitor of complement, C4b-binding protein (C4BP) has been described in atherosclerotic diseased coronary arteries. The study aim was to analyze C4BP levels in diseased aortic valves.

Methods: Aortic valve tissue was derived from surgical procedures and classified as 'degenerative', 'atherosclerotic' or 'atherosclerotic with bacterial infection'. Valves were stained with specific antibodies against C4BP, C3d and caspase-3. Areas of positivity were then quantified using computer- assisted morphometry.

Results: In atherosclerotic valves, the areas of C4BP and C3d positivity (38.8 +/- 0.4% versus 32.7 +/- 1.0%, respectively) were significantly higher compared to the degenerative and control groups. In atherosclerotic valves with bacterial infection, the area of positivity for C4BP was even further increased compared to atherosclerotic valves (65.1 +/- 1.2%; 70.1 +/- 1.9% for C3d). The areas of C4BP and C3d positivity were not significantly different in all groups. Caspase-3 was only present in <10% of endothelial cells in the atherosclerotic valves without bacterial infection and in neutrophilic granulocytes in atherosclerotic valves, with and without bacterial infection.

Conclusion: It has been shown for the first time that C4BP is deposited in the diseased aortic valve, coinciding with C3d. The area of C4BP positivity was more extensive compared to the areas of other endogenous complement inhibitors (C1-inhibitor and clusterin).

How to cite: Dikhoff, M. J., ter Weeme, M., Vonk, A. B., Kupreishvili, K., Blom, A. M., Krijnen, P. A., Stooker, W., & Niessen, H. W. (2015). C4b-Binding Protein Deposition is Induced in Diseased Aortic Heart Valves, Coinciding with C3d. The Journal of heart valve disease, 24(4), 451–456.

Background and aim of the study: Calcific and degenerative aortic diseases (CDADs) are a group of disorders that mostly affect the elderly population and may progress and warrant aortic valve replacement. It is believed that oxidative stress plays a role in the progression of the diseases. Several markers of oxidative stress were evaluated in a small cohort of patients with CDADs, and a control group with similar characteristics.

Methods: Thirty patients with aortic stenosis (AS) and 30 healthy subjects were included in the study. The activities of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) in both groups were studied as markers of oxidative stress. All patients and control subjects were evaluated echocardiographically for CDAD, and enzyme levels monitored biochemically.

Results: The risk factors were similar in both groups, but levels of low-density lipoprotein (LDL) were higher in the CDAD group compared to controls (123.6 +/- 37.0 mg/dl versus 99.3 +/- 38.0 mg/dl, p < 0.01). The GSH-Px activity was significantly higher in the CDAD group than in controls (0.19 +/- 0.03 IU/ml versus 0.16 +/- 0.03 IU/ml, p < 0.01). A GSH-Px level > 0.18 IU/ml was found to be an indicator of CDAD, with a sensitivity of 70% and specificity of 73.3% on ROC analysis [AUC = 0.721, p < 0.05, 95% CI: 0.685 +/- 0.773]. SOD and CAT activities were similar in both groups (p > 0.05).

Conclusion: The study results showed that the activity of GSH-Px, a marker of oxidative stress, is increased in patients with degenerative AS. The increase in GSH-Px activity may be a protective response to remove reactive oxygen derivatives (RODs) from the body.

How to cite: Memet, C., Gerede, D. M., Ozenci, M., Akbulut, I. M., Acibuca, A., Kiliçkap, M., & Erol, C. (2015). Evaluation of the Role of Oxidative Stress in Degenerative Aortic Stenosis. The Journal of heart valve disease, 24(4), 445–450.

Background and aim of the study: In patients with aortic stenosis, mitral regurgitation (MR) is a common finding. Little is known regarding outcomes of MR in patients undergoing transcatheter aortic valve implantation (TAVI). The study aim was to characterize the short- and mid-term impact of the TAVI procedure on MR grade.

Methods: A total of 261 patients (59% females; mean age 82.1 +/- 6.9 years) undergoing TAVI was assessed for rates of significant MR and the severity of MR at baseline, and at one month and six months after the procedure.

Results: In patients with moderate MR or above at baseline (n = 26, 10% of the cohort), there was a mean reduction in grade of 1.5 +/- 1.1 and 1.8 +/- 1.4 after one and six months, respectively (p < 0.01). Reduction in MR grade (1+) at six months was identified in 54.1% (40/74) of patients with mild-moderate MR or greater, and in 88.5% (23/26) of those with moderate MR or above, and was associated with an improved NYHA functional class (correlation coefficient r = -0.294, p < 0.001). Multivariate analysis identified low pulmonary pressure and tricuspid regurgitation as independent predictors of improvements in MR.

Conclusion: Among the present cohort of patients undergoing TAVI, those with MR at baseline showed an improvement in the severity of their MR. Patients with moderate MR regurgitation or above demonstrated the greatest improvement.

How to cite: Perl, L., Vaturi, M., Assali, A., Sagie, A., Weissler-Snir, A., Codner, P., Orvin, K., Vaknin-Assa, H., Shapira, Y., & Kornowski, R. (2015). The Impact of Transcatheter Aortic Valve Implantation on Mitral Regurgitation Regression in High-Risk Patients with Aortic Stenosis. The Journal of heart valve disease, 24(4), 439–444.

Aortic annulus rupture is a rare complication of transcatheter aortic valve implantation (TAVI), related to relative valve oversizing or eccentric calcification. A case is reported of periprocedural cardiac tamponade caused by aortic annulus rupture. Optimal management of periprocedural aortic annulus rupture and pseudoaneurysm formation in patients considered too frail for surgery should be discussed in a multidisciplinary setting.

How to cite: Hiltrop, N., Adriaenssens, T., Dymarkowski, S., Herijgers, P., & Dubois, C. (2015). Aortic Annulus Rupture During TAVI: A Therapeutic Dilemma in the Inoperable Patient. The Journal of heart valve disease, 24(4), 436–438.

Patients with severe aortic stenosis (AS) and left ventricular systolic dysfunction pose a significant challenge to the managing physician. Conventional pharmacological therapy for systolic heart failure has not been proven beneficial in this setting. Ivabradine, a selective current inhibitor, decreases the spontaneous firing rate of sinoatrial nodal cells, thereby reducing the heart rate, and has been shown to reduce a composite end-point of heart failure hospitalization and mortality in patients with impaired left ventricular function. Herein are reported details of the hemodynamic effects and clinical outcome of ivabradine treatment in an 86-year-old man with severe AS and severe left ventricular systolic function.

How to cite: Huang, D., Chan, P. H., Lam, C. C., Shea, P. C., Yiu, K. H., Tse, H. F., & Siu, C. W. (2015). Ivabradine in Severe Aortic Stenosis with Poor Left Ventricular Ejection Fraction. The Journal of heart valve disease, 24(4), 433–435.

Background and aim of the study: Transcatheter aortic valve replacement (TAVR) requires a safe route of access to the aortic valve. A direct aortic route has been used as alternate access approach in patients where ileo-femoral access is unsafe due to size, calcification and/or tortuosity. The study aim was to review the authors' results obtained with a direct aortic (DA) TAVR, examining in particular the safety and effectiveness of this approach.

Methods: A retrospective analysis was performed of all prospectively collected TAVR data from January 2011 to March 2015 at the authors' institution. DA-TAVRs were performed using either an upper mini- sternotomy (MST) into the second right intercostal space, or via a right anterior mini-thoracotomy (RAT) at the second intercostal space. The choice between MST and RAT approaches was made by the surgeon, based on aortic imaging, patent bypass grafts and pulmonary function. Both, Medtronic CoreValve and Edwards SAPIEN devices were used. All relevant perioperative and clinical outcomes were collected based on Valve Academic Research Consortium 2 (VARC-2) definitions. Median numerical values were used.

Results: Seventy-eight consecutive patients underwent DA-TAVR with 100% intraoperative survival and 92% 30-day survival. The procedural success was 97%. The majority of patients (79%) underwent DA-TAVR with the Medtronic CoreValve, via MST (92%). All patients were classified either as extreme (74%) or high risk (26%) for surgical aortic valve replacement.

Conclusion: DA-TAVR provides a safe and viable alternate access approach for patients with inadequate ileo-femoral access. The clinical outcomes were acceptable in this very high-risk group of patients.

How to cite: Ramlawi, B., Abu Saleh, W. K., Jabbari, O. A., Barker, C., Lin, C., Reyes, M., Kleiman, N. S., & Reardon, M. T. (2015). Short-Term Outcomes with Direct Aortic Access for Transcatheter Aortic Valve Replacement. The Journal of heart valve disease, 24(4), 426–432.

Background and aim of the study: Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alternative approach in patients with hostile ileo-femoral vessels. Planning the transaortic puncture site and an 'ideal' trajectory towards the annulus plane is important for safe and successful valve implantation. The feasibility of three-dimensional (3D) planning and real-time fluoroscopic image guidance for DA-TAVR was evaluated using pre-procedural multi-detector computed tomography (MDCT) and intra-procedural Dyna CT co-registration approaches.

Methods: Between May 2012 and August 2014, a total of 44 patients (40 mini-sternotomies, four mini-thoracotomies) was selected for DA-TAVR using the authors' MDCT-Dyna CT co-registration approach (32 CoreValve, 12 SAPIEN). Pre-procedural contrast-enhanced multi-slice CT (MSCT) and intra- procedural non-contrast Dyna CT images were co-registered based on cardiac outline and aortic root calcifications. Using a prototype software, the aortic root was segmented and relevant landmarks identified automatically. The intersection of a virtual perpendicular trajectory from the annulus with the greater curvature of the aorta was marked as the planned DA puncture site. The planned DA puncture site, trajectory and relevant landmarks were overlaid onto real-time fluoroscopic images for image guidance during DA-TAVR.

Results: Real-time fluoroscopic overlay of planned trajectory was feasible in all 44 cases of DA-TAVR. The mean 2D projection distance error between the actual and planned aortic puncture sites was 1.60 +/- 1.1 cm. The mean angular difference error (measure of co-axiality) between actual and planned DA trajectory was 11.86 +/- 9.3. Errors in distance and co-axiality were lower with the mini-thoracotomy than with the mini-sternotomy approach. The Multi-Slice CT (MSCT)-Dyna CT co-registration technique resulted in significantly less contrast usage, and trended towards shorter fluoroscopy and operative times. There was also a trend towards a reduction in acute kidney injury, but no difference was identified in the degree of paravalvular regurgitation or mortality.

Conclusion: 3D access planning and real-time image guidance for DA-TAVR is feasible using an MDCT/non-contrast Dyna CT image co-registration-based approach. Such image co-registration strategies improve the accuracy of case planning and safety of valve deployment with a direct aortic approach. Further studies are necessary to determine if these enhancements translate into an improvement in clinical outcomes.

How to cite: Abu Saleh, W. K., Goswami, R., Chinnadurai, P., Al Jabbari, O., Barker, C. M., Lin, C. H., Kleiman, N., Reardon, M. J., & Ramlawi, B. (2015). Direct Aortic Access Transcatheter Aortic Valve Replacement: Three-Dimensional Computed Tomography Planning and Real-Time Fluoroscopic Image Guidance. The Journal of heart valve disease, 24(4), 420–425.

Background and aim of the study: An investigation was made as to whether the preoperative aortic annular diameter affects the durability of bicuspid aortic valve (BAV) repair in patients who had undergone concomitant root stabilization with subcommissural annuloplasty (SCA) compared to valve-sparing root reimplantation (VSRR).

Methods: Among a retrospective review of 74 patients who underwent BAV repair between 2005 and 2012,42 had SCA and 32 had VSRR.

Results: The preoperative annulus was similar in the two groups (29 +/- 3 mm for SCA; 30 +/- 4 mm for VSRR, p = 0.3). Postoperative aortic insufficiency (AI) grade > or = 1+ was 100%, but five-year freedom from Al grade >1+ was lower in the SCA group (62 +/- 10% versus 92 +/- 6%, p = 0.02). On univariate analysis, a preoperative annulus 28 mm was predictive of recurrent Al grade >1+ in the SCA group (odds ratio 17.1, p = 0.05), but not in the VSRR group (3.31, p = 0.1). Consequently, SCA patients were evaluated by annular diameter 28 mm (n = 26) versus < or = 27 mm (n = 16). Five-year freedom from AI grade >1+ was lower for the 28 mm SCA subgroup (52 +/- 10% versus +/-3 +/- 6%, p = 0.02). Given this difference between the SCA subgroups, Al grade >1+ in the 28 mm SCA subgroup was compared to VSRR patients with annulus 28 mm ( 28 mm VSRR subgroup, n = 23). The five-year freedom from AI grade >1+ was significantly higher in the 28 mm VSRR subgrou+/- (86 +/- 10% versus 52 +/- 10%, p = 0.02), but simila < or = Sr in the 27 27 m< or = SCA and 527 mm VSRR subgroups (93 +/- 6% versus 100%, p = 0.4).

Conclusion: For BAV patients with a preoperative aortic annulus 28 mm, SCA results in inferior midterm outcomes. VSRR or alternative annular stabilization techniques should be considered

How to cite: Vallabhajosyula, P., Komlo, C. M., Szeto, W. Y., Rhode, T., Menon, R., Desai, N. D., & Bavaria, J. E. (2015). Aortic Annulus Diameter Affects Durability of the Repaired Bicuspid Aortic Valve. The Journal of heart valve disease, 24(4), 412–419.

Background and aim of the study: The study aim was to determine if the 'prophylactic' replacement of the aortic valve to treat moderate aortic valve stenosis (AS) in octogenarians undergoing cardiac surgery for coronary disease can influence outcome, and is also justified.

Methods: In a retrospective analysis of octogenarians operated on at the authors' center between 1998 and 2012, the patients were allocated to: Group I, isolated coronary artery bypass graft surgery (CABG; n = 159); Group II, combined CABG and aortic valve replacement (AVR) with the primary indication for surgery being severe AS (n = 156); and Group III, combined AVR +CABG with coronary disease being the primary indication and concomitant 'prophylactic' AVR (n = 34).

Results: The hospital mortality for octogenarians undergoing CABG+AVR was 8% compared to 2% for isolated CABG (p = 0.02). Survival at one year was higher in the isolated CABG group (94%) than in the CABG+AVR group (86%) (p = 0.01), but was no different at five years. Mortality according to AVR indication was similar (Group II 8% versus Group III 9%), as was one- and five-year survival. Group III had a higher preoperative co-morbid risk profile, including logistic EuroSCORE 21.7% versus 18% in Group II (p = 0.05), more recent myocardial infarctions, previous percutaneous interventions, peripheral vascular disease, and poor left ventricular function. Long-term symptomatic relief was excellent in Group III. Patients whose predominant disease profile was ischemic (Groups I and III) had a higher long-term risk of recurrent angina and stroke.

Conclusion: In-hospital mortality is higher for octogenarians undergoing CABG+AVR compared to those undergoing isolated CABG. In the present study, a 'prophylactic' AVR was justified in patients with moderate AS, and their increased mortality (versus isolated CABG) was congruent with a higher preoperative co-morbid risk profile. Excellent long- term symptom-free survival further justifies 'prophylactic' AVR in octogenarians undergoing CABG with coexistent moderate AS.

How to cite: Lopez-Marco, A., Tymko, R., & Von Oppell, U. (2015). Valve Replacement for Moderate Aortic Stenosis in Octogenarians Undergoing Revascularization. The Journal of heart valve disease, 24(4), 405–411.