Among primary cardiac tumors, papillary fibroelastoma (PF) represents less than 10% of all such lesions. Of these tumors, 90% are solitary and multiple tumors have rarely been reported. More than 75% of PFs are attached to heart valves, while tumors that originate in the non-valvular endocardium are rare. We report a case of PF originating from the chordae of the mitral valve with two concomitant aortic valve Lambl's excrescences.

How to cite: Taha, A., Carr, S., Beckwith, L. G., & Berberian, G. (2015). Papillary fibroelastoma involving chordae of the mitral valve with two aortic valve excrescences. The Journal of heart valve disease, 24(2), 270–271.

Triple prosthetic valve operation carries a high peri-procedural risk and is associated with decreased long-term survival. Herein is reported the case of a 59-year-old female with a 30-year history of successful triple-valve replacement for rheumatic heart disease, who presented with symptomatic valvular dysfunction and rhythm disturbances. The patient was one of the few who had survived more than 30 years after triple-valve surgery. Illustrative echocardiograms and cinefluoroscopic images are provided, and issues regarding prosthetic valve dysfunction and rhythm disturbance management in operated patients are briefly discussed.

Transcatheter aortic valve implantation (TAVI) has been commonly used to treat patients with aortic stenosis who have a contraindication to, or a high risk of, corrective surgery. Anti-thrombotic treatment is an important part of the TAVI procedure to avoid thrombotic complications during both peri- and post-procedural periods. However, no specific data are available regarding the safety of TAVI with or without anti-thrombotic treatment, either during the surgical procedure or follow up period in patients with thrombocytopenia, such as myelofibrosis. Here, the case is reported of a patient with myelofibrosis and severe thrombocytopenia who underwent a TAVI procedure without anti-thrombotic treatment such as heparin, acetyl salicylic acid, or clopidogrel.

How to cite: Erkan, H., Korkmaz, L., Kiriş, G., & Celik, S. (2015). Transcatheter aortic valve implantation in a patient with myelofibrosis and severe thrombocytopenia. The Journal of heart valve disease, 24(2), 263–265.

Quadricuspid aortic valve (QAV) is a rare cardiac anomaly which can present with clinically significant regurgitation. The case is presented of a 38-year-old female patient with a regurgitant QAV managed surgically. A review of the current literature relating to QAV is also provided. The most common valve type that is operated on is type B, thus separating the surgical population from that of all QAVs, in which type A is most common. Moreover, aortic aneurysms were found to be a common and previously unrecognized significant characteristic among QAV patients. The majority of patients with a regurgitant QAV undergo replacement, although repairs have recently gained popularity. To date, the outcomes for both groups appear similar.

How to cite: Plaunova, A., Gulkarov, I., Tortolani, A. J., & Worku, B. (2015). Surgery for a quadricuspid aortic valve: case report and comprehensive review of the literature. The Journal of heart valve disease, 24(2), 260–262.

Background and aim of the study: Cardiac surgery during pregnancy is rarely required and potentially increases feto-maternal mortality. The study aim was to evaluate pregnancy outcomes in females who underwent open-heart surgery with cardiopulmonary bypass (CPB) during pregnancy.

Methods: Between 1999 and 2014, a total of 16 pregnant women (mean age 27 ± 7 years; mean gestational age 13 ± 7.7 weeks) underwent urgent cardiac surgery using CPB. The preoperative diagnosis included prosthetic valve dysfunction in 12 women (five aortic, seven mitral), native valve endocarditis and critical aortic stenosis each in one woman, and intracardiac masses in two women. Eleven patients were in the first trimester, three in the second trimester, and two in the third trimester. A retrospective analysis was conducted that included maternal variables of age, gestational age, cardiac diagnosis, prior operations, surgical details, maternal morbidity and mortality and type of delivery, while fetal variables included incidence of low birth weight, prematurity, and fetal malformation. Patients were allocated to two groups: Group A (n = 9) included pregnant women with living neonates, while group B (n = 7) included pregnant women with an aborted fetus or dead neonate. All data were compared between the groups.

Results: There was no in-hospital maternal mortality. There were no significant differences between the two groups regarding age, gestational age, previous cardiac operation, type of surgery, duration of operation, perfusion pressure and core temperature during CPB. The CPB time was longer in group B (110.3 ± 57.1 min) than in group A (62 ± 15.7 min) (p = 0.028), as was the aortic cross-clamp time (54.3 ± 27.2 min and 38.7 ± 9.3 min in groups A and B, respectively) (p = 0.014). Group B patients received higher doses of inotropes perioperatively. No congenital abnormalities were identified in any of the living neonates.

Conclusion: The durations of CPB and aortic cross-clamping may not affect maternal outcome, but shorter CPB and aortic cross-clamp times led to better fetal outcomes. Increasing the perioperative dosage of inotropes may lead to a reduced fetal survival.

How to cite: Hosseini, S., Kashfi, F., Samiei, N., Khamoushi, A., Ghavidel, A. A., Yazdanian, F., Mirmesdagh, Y., & Mestres, C. A. (2015). Feto-maternal outcomes of urgent open-heart surgery during pregnancy. The Journal of heart valve disease, 24(2), 253–259.

Background and aim of the study: Reintervention after the Ross procedure (RP) remains a concern. Hence, the study aim was to assess the long-term results of the RP in adults and to identify predictors of reoperation.

Methods: Between 1995 and 2012, a total of 263 consecutive patients (189 males, 74 females; mean age 42 ± 14 years) underwent the RP, using the free-standing root technique. The mean follow up was 7.5 ± 5.0 years and was 94% complete. Survival, and freedom from autograft, homograft and Ross-related reoperation were analyzed using Kaplan-Meier analysis, while Cox proportional hazard regression was used to identify predictors of reoperation.

Results: Early mortality was 2.6% (n = 7) and late mortality 4.9% (n = 14). Survival at 13 years was 90% (95% CI 80-95%). Freedom from homograft, autograft and Ross-related reoperation at 13 years were 97% (95% CI 90-99%), 92% (95% CI 82-96%) and 90% (95% CI 81-95%), respectively. No predictors of homograft reoperation were identified. Freedom from autograft reoperation was not significantly different for patients with preoperative aortic insufficiency (AI) (88%; 95% CI 74-95% at 13 years) compared to those with aortic stenosis (96%; 95% CI 84-99% at 13 years), or both (86%; 95% CI 51-97% at 13 years) (p = 0.62). Other variables (gender, aortic/pulmonary mismatch and aortic annulus diameter) were not significantly associated with the need for autograft reoperation.

Conclusion: Despite its complexity and reoperation rate, RP should be considered as a valid surgical option for aortic valve disease treatment in selected patients. Among the present series, no predictors for homograft or autograft reoperation were identified.

How to cite: Escarain, M. C., Giunta, G., & Favaloro, R. R. (2015). Ross procedure in adults: is reoperation a real concern?. The Journal of heart valve disease, 24(2), 247–252.

Objectives: The long-term success of CoreValve stent prosthesis (Medtronic) implantation for severe aortic valve stenosis is limited in determination of correct aortic valve annulus.

Methods: We retrospectively investigated preinterventional cardiac 256-slice computed tomography (cardiac CT) scans and 3-dimensional transesophageal echocardiography (3D TEE) for assessment of aortic valve annulus to (i) compare both methods as well as (ii) to define predictors for annulus sizing.

Results: We investigated 200 consecutive patients with a mean aortic valve annulus (AA) of 24mm and a mean age of 81 years. Primarily we defined mean diameters of AA individually and grouped the different patients according to age, gender, body weight, length, surface area and body mass index. Thereby, we found statistical significant different annulus diameter in age (larger diameter when < 80 years of age), gender (male > femal), and body length (larger diameter when length > 165cm). Secondly, the multivariate analysis demonstrated that the age, the gender and the body length were additionally independent predictors for annulus size.

Conclusion: Our data demonstrate the feasibility of cardiac CT and 3D TEE with no difference in the quality of the aortic valve annulus diameter determination. We describe predictors for annulus size in age, gender and body length. Conclusive, we support patient dependent parameters as age, gender and body length as predictors that must go into selection of CoreValve stent prosthesis size individually prior to implantation procedure.

How to cite: Anger, T., Schmid, M., Geisler, T., Gawaz, M. P., Oberhoff, M., & Höher, M. (2015). Comparison of aortic valve annulus diameter determination through 3-dimensional transesophageal echo with cardiac MDCT and assessment of predictors for annulus sizing. The Journal of heart valve disease, 24(2), 239–246.

Libman-Sacks endocarditis is the most widely encountered aseptic endocarditis among patients with systemic lupus erythematosus. Due to the deformed cardiac valves, secondary infective endocarditis should be considered in lupus patients with acute refractory heart failure and fever of unknown origin. The case is reported of a woman with lupus and Libman-Sacks endocarditis who had concurrent coagulase-negative Staphylococcus infective endocarditis that resulted in cerebral septic emboli and acute pulmonary edema. She underwent valve replacement surgery for acute heart failure, and gradually recovered with antibiotic treatment.

How to cite: Lin, G. M., Chang, F. Y., & Wang, W. B. (2015). Coagulase-negative staphylococcus infective endocarditis in a lupus patient with Libman-Sacks endocarditis. The Journal of heart valve disease, 24(2), 236–238.

Background and aim of the study: Systemic lupus erythematosus (SLE) and primary/secondary antiphospholipid syndrome (APLS) may cause early degenerative changes in cardiac valves, such as Libman-Sacks endocarditis, though few reports exist of this condition. Herein are presented the early and late clinical outcomes after cardiac valve surgery in patients diagnosed with SLE and APLS in a single-center experience.

Methods: A prospective analysis was conducted of the perioperative and follow up data acquired from patients with diagnosed SLE, and primary and secondary APLS, who underwent either single or combined valve surgery at the authors' department between 2002 and 2014.

Results: Fifteen patients (14 females, one male; mean age 53 ± 16 years; range: 16-77 years) were identified. The mean follow up time was 49 ± 32 months (range: 12.5-119 months). Thirteen patients (11 females, two males) were diagnosed with SLE; one of these patients had tricuspid Libman-Sacks endocarditis, while two female patients had primary APLS and four had secondary APLS. Besides bioprosthetic and mechanical valve replacements, mitral and tricuspid valve reconstruction were performed. The mean cross-clamp time was 112 ± 73 min (range: 55-294 min). Early major cardiovascular events occurred in two patients, and late non-fatal events in four patients, including one thromboembolic event. The 30-day and in-hospital mortalities were both 0%. Currently, 12 patients (80%) are alive at the end of follow up. Actuarial survival was 92 ± 7.4% at one year, 74 ± 18% at four years, and 49 ± 23% at ten years.

Conclusion: Despite general concerns, the present results confirmed that patients with SLE and APLS can be operated on for cardiac valve disease, with favorable early results and acceptable long-term outcome.

How to cite: Arif, R., Farag, M., Seppelt, P., Beller, C. J., Ruhparwar, A., Karck, M., & Kallenbach, K. (2015). Patients with systemic lupus erythematosus and antiphospholipid syndrome undergoing cardiac valve surgery. The Journal of heart valve disease, 24(2), 228–235.

Background and aim of the study: An increasing number of young adult patients are choosing bioprostheses for aortic valve replacement (AVR). In this context, the Ross operation deserves renewed consideration as an alternative biological substitute. After both the Ross procedure and bioprosthetic AVR, reoperation rates remain a concern and may be related to age at surgery. Herein are reported details of freedom from reoperation after the Ross procedure for different age groups.

Methods: The reoperation rates of 1,925 patients (1,444 males, 481 females; mean age 41.2 ± 15.3 years) from the German Ross registry with a mean follow up of 7.4 ± 4.7 years (range: 0.00-18.51 years; total 12,866.6 patient-years) were allocated to three age groups: group I < 40 years; group II 40-60 years; and group III > 60 years.

Results: At 10 years (respectively 15 years) of follow up, freedom from reoperation was 86% (76%) in group I, 93% (85%) in group II, and 89% (83%) in group III.

Conclusion: There is some evidence that, at least during the first 10 and 15 years after AVR, the Ross procedure provides a significantly lower reoperation rate in young adult and middle-aged patients aged < 60 years. This information may be of interest to the patients' or physicians' decision-making for aortic valve surgery.

How to cite: Richardt, D., Hemmer, W., Moritz, A., Hetzer, R., Gorski, A., Franke, U. F., Hörer, J., Lange, R., Sachweh, J. S., Riso, A., Dodge-Khatami, A., Hübler, M., Charitos, E. I., Stierle, U., & Sievers, H. H. (2015). Age-related reoperation rate after the Ross procedure: a report from the German Ross Registry. The Journal of heart valve disease, 24(2), 220–227.

A 43-year-old man presented with severe aortic stenosis. Eight years previously, he had undergone primary surgical aortic valve replacement (AVR) for severe aortic regurgitation, but one year later developed cardiac arrest and complete atrioventricular block as a result of non-bacterial thrombotic endocarditis with severe valvular dehiscence. Following the diagnosis of prosthetic valve failure caused by Behçet's disease, the patient underwent a Bentall operation using 23 mm aortic homograft with permanent pacemaker implantation and coronary artery bypass grafting. Subsequently, he was stable with steroid administration and azathioprine for seven years after the second operation, but recently suffered from severe dyspnea and chest pain. Echocardiography revealed the development of severe aortic stenosis. A preprocedural evaluation demonstrated a porcelain aorta with severe calcification in the previous homograft valve on computed tomography, and critical stenosis at the ostium of the left circumflex artery on coronary angiography. After percutaneous coronary intervention for the ostium of the left circumflex artery, a transcatheter AVR was successfully performed using a 26 mm Edwards SAPIEN XT valve. The patient recovered without any complications after the procedure. This is the first report of a successful transcatheter aortic valve-in valve implantation for severe homograft aortic stenosis after a Bentall operation, using a homograft, in a patient with Behçet's disease.

How to cite: Joo, H. J., Hong, S. J., & Yu, C. W. (2015). Transcatheter aortic valve-in-valve implantation for severe bioprosthetic stenosis after Bentall operation using a homograft in a patient with Behçet's disease. The Journal of heart valve disease, 24(2), 217–219.

A case is presented of the early degeneration of a 21 mm SOLO stentless valve concomitant with severe mitral regurgitation (MR). Transcatheter valve-in-valve implantation was considered in this high-risk case (logistic EuroSCORE 29.3%), but was dismissed because of the risk of coronary occlusion, an absence of visual landmarks, and the impossibility to treat the MR. Following the implantation of a 27 mm Medtronic Hancock II mitral bioprosthesis, the leaflets of the SOLO valve were removed, and a 19 mm 3f Enable sutureless bioprosthesis delivered into the remaining sewing belt of the stentless valve. The total cross-clamp time was 64 min. No aortic paravalvular leakage was detected at discharge and early follow up (four months); the mean and peak transvalvular aortic gradients were 13 and 23 mmHg, respectively, and the left ventricular ejection fraction 60%. A sutureless strategy simplified the management of this high-risk case.

How to cite: Vola, M., Gerbay, A., Campisi, S., Thulane, C., & Fuzellier, F. (2015). Aortic sutureless bioprosthesis implantation following degeneration of a SOLO stentless valve. The Journal of heart valve disease, 24(2), 214–216.

Background and aim of the study: Multi-detector computed tomography (MDCT), combined with retrospective electrocardiographic gating, permits cardiac imaging with high accuracy. Recent advances in MDCT have seemed to respond adequately to the need for a non-invasive and reliable assessment of the coronary artery lumen.

Methods: Two patients with prosthetic aortic valves (one bioprosthetic, one mechanical) presented at the authors' institution with dyspnea and syncopal episodes. MDCT was performed to evaluate thrombus characteristics and exclude coronary artery disease (CAD).

Results: Based on the MDCT coronary artery assessment, neither patient underwent preoperative invasive coronary angiography, abolishing the risk of any iatrogenic thrombus fragmentation and subsequent embolization. One patient underwent surgical treatment without complications, while medical therapy was successful in the other case.

Conclusion: MDCT can be used for the accurate imaging of thrombi on prosthetic aortic valves, and to correctly assess possible CAD.

How to cite: Tarzia, V., Bortolussi, G., Rubino, M., Gallo, M., Bottio, T., & Gerosa, G. (2015). Evaluation of prosthetic valve thrombosis by 64-row multi-detector computed tomography. . The Journal of heart valve disease, 24(2), 210–213.

Background and aim of the study: Percutaneous balloon mitral valvuloplasty (PMBV) has an established role in the treatment of rheumatic mitral stenosis. The study aim was to evaluate the effects of PMBV on left ventricular function in patients with rheumatic mitral stenosis (MS) by using strain and strain rate imaging modalities.

Methods: The study included 30 consecutive patients (21 women, nine men; mean age 44 ± 14 years) with moderate to severe MS. Left ventricular long-axis strain and strain rate color tissue Doppler imaging of the septal, lateral, inferior and anterior basal segments were performed one day before and seven days after PMBV.

Results: Compared with pretreatment findings, lateral systolic strain (-13.4 ± 2.9% versus -18.4 ± 3.9%; p = 0.024), inferior systolic strain (-14.7 ± 2.3% versus -17.6 ± 2.1%; p = 0.016), anterior systolic strain (-15.2 ± 2.4% versus -17.2 ± 2.2%; p = 0.02), and septal systolic strain (-15.7 ± 1.6% versus -18.1 ± 1.9%; p = 0.018) values were significantly increased after the procedure, but no significant change was observed in strain rate analysis.

Conclusion: A rapid improvement in strain values after PMBV in patients with isolated MS showed that the LV systolic dysfunction in isolated MS is strongly associated with impaired. hemodynamic parameters. Significantly increased strain values can be added to the criteria of successful PMBV.

How to cite: Bektaş, O., Günaydin, Z. Y., Karagöz, A., Vural, A., Kaya, A., Atmaca, H., & Sahin, O. (2015). Evaluation of the effect of percutaneous mitral balloon valvuloplasty on left ventricular systolic function via strain and strain rate in patients with isolated rheumatic mitral stenosis. The Journal of heart valve disease, 24(2), 204–209.

Background and aim of the study: Most valve repair techniques require resection and multiple sutures. In the present study, a novel technique without resection for correction of posterior leaflet prolapse due to chordal elongation or rupture was employed, the aim being to evaluate the outcomes of a non-resecting valve repair technique in patients with posterior leaflet prolapse that caused significant mitral regurgitation (MR).

Methods: Between May 2008 and December 2010, a total of 90 consecutive patients with posterior leaflet prolapse (55 males, 35 females; mean age 51.5 ± 14.6 years) underwent patch valvuloplasty. The procedure involved suturing the free margin of the prolapsed leaflet, invagination of the folded leaflet tissue into the left ventricular side, coverage of the dimpled portion with a round bovine pericardial patch using a continuous suture technique, and reshaping of the posterior annulus using a 53- to 61-mm strip. All patients underwent postoperative echocardiography after a mean follow up of 41.9 ± 10.4 months.

Results: No early death occurred, but there was one late death due to a non-cardiac cause. At the last echocardiographic follow up, 81 patients (90%) showed none or trace MR, seven (7.8%) had mild MR, and two (2.2%) moderate MR. The mean mitral valve area was 2.4 ± 0.5 cm2 and the mean pressure gradient 2.8 ± 1.2 mmHg. No patient required reoperation due to recurrent or aggravated MR.

Conclusion: In patients with posterior leaflet prolapse, the applied patch valvuloplasty technique was useful and reliable, showing excellent clinical and echocardiographic outcomes. Additional long-term evaluations with close follow up should be performed.

How to cite: Song, M. G., Shin, J. K., Chee, H. K., Kim, J. S., Yang, H. S., & Choi, J. B. (2015). Mid-term results for a patch valvuloplasty technique to correct posterior leaflet prolapse. The Journal of heart valve disease, 24(2), 197–203.

Background and aim of the study: Calcific aortic valve disease (CAVD) is a commonly acquired valvular disease. Although previous studies have shown valve calcification to be mediated by a chronic inflammatory disease process, with many similarities to atherosclerosis that included inflammatory cell infiltrates, lipoproteins, lipids, extracellular bone-matrix proteins, and bone minerals, little is known of the mechanisms of the cellular and molecular components and processes. It has recently been hypothesized that the calcific aortic valve is a product of active inflammation, similar to the atherosclerosis pathological process. Thus, the cessation of statin therapy should, in theory, have an effect on the treatment of CAVD and on aortic valve myofibroblasts (AVMFs), which play an important role in aortic valvular calcification. The study aim was to determine if oxidized low-density lipoprotein (oxLDL) could stimulate the apoptosis of AVMFs and the calcific-related pathway, and whether atorvastatin could inhibit the effects of AVMFs induced by oxLDL. The Wnt/GSK-3β/β-catenin signaling pathway may play a key role in this process, thereby making a major contribution to aortic valve calcification.

Methods: AVMFs were successfully acquired using a combination of trypsin and collagenase enzyme digestion, and made phenotypic for the identification for alpha-smooth muscle actin (α-SMA). Cell apoptosis was monitored using flow cytometry, bone protein expression by Western blot, and related gene expression by reverse transcription polymerase chain reaction (RT-PCR).

Results: A positive identification of α-SMA, a myofibroblast marker, confirmed the successful harvesting of myofibroblasts. OxLDL significantly induced cell apoptosis (p < 0.05), and this became even more obvious after 48 h (p < 0.01). OxLDL also significantly increased the protein expression of all differentiation markers (p < 0.05), as confirmed through Western blotting and RT-PCR, while atorvastatin significantly reduced the effects of oxLDL (p < 0.05).

Conclusion: Among the mechanisms of the cellular and molecular components and processes, oxLDL increased the valve calcification-related signaling pathway by increasing extracellular bone-matrix protein that produces osteoblastic gene markers via the Wnt/GSK-3β/β-catenin pathway. And atorvastatin also prevented any oxLDL-induced effects through the same pathway, this may represent a new therapeutic target for CAVD, as an alternative to traditional valve replacement surgery.

How to cite: Gao, X., Zhang, L., Gu, G., Wu, P. H., Jin, S., Hu, W., Zhan, C., Li, J., & Li, Y. (2015). The effect of oxLDL on aortic valve calcification via the Wnt/ β-catenin signaling pathway: an important molecular mechanism. The Journal of heart valve disease, 24(2), 190–196.

Conventional valves have a sewing ring that reduces the effective orifice area for a given valve size. In patients with small aortic roots, the implantation of a stented conventional prosthesis can be very difficult or may lead to patient-prosthesis mismatch. In the case of the Sorin Perceval sutureless aortic valve, concomitant mitral valve replacement (MVR) is an exclusion criterion because the latter valve's rigid ring may interfere with the self-expandable stent anchorage of the Sorin Perceval sutureless valve, or cause it to become distorted. The case is reported of very small, 77-year-old woman with severe aortic valve stenosis, severe mitral regurgitation and asymmetric hypertrophy of the left ventricle with systolic anterior motion. The patient underwent MVR and concomitant off-label implantation of the Sorin Perceval S sutureless valve due to the extremely small size of the aortic annulus. Echocardiography performed on completion of surgery, at discharge from hospital and at after a four-month follow up, documented a normal mitral prosthesis position and function, a normal aortic prosthesis position, and mild central regurgitation in both valves.

How to cite: Moriggia, S., Trumello, C., Buzzatti, N., Iaci, G., Di Giannuario, G., & Alfieri, O. (2015). Aortic sutureless Perceval valve for small root in concomitant mitral valve replacement. The Journal of heart valve disease, 24(2), 187–189.

Background and aim of the study: The advantages of minimally invasive aortic valve replacement (AVR) are well documented, but whether the benefits extend to subsequent reoperative aortic valve surgery and beyond is unknown. The study aim was to compare in-hospital outcomes and long-term survival following reoperative AVR between patients who had previous undergone either minimally invasive AVR (mini-AVR) or full sternotomy AVR (sAVR).

Methods: All reoperative, isolated AVRs performed between July 1997 and September 2013 at the authors' institution, with or without non-complex aortic surgery, were identified. Patients were excluded if AVR was not isolated, had occurred prior to July 1997, or if the initial AVR was performed before the patient was aged 18 years. All reoperations were performed through a full sternotomy. The main outcomes of interest were operative results and long-term survival.

Results: A total of 101 patients was identified, of which 34 had undergone previous mini-AVR and 67 previous sAVR. The time from the previous AVR was similar in both groups (median 7.6 years overall). Of previous valve implants, 57 were bioprostheses and 44 mechanical; structural valve degeneration was the most common indication for surgery (43/101). Mini-AVR and sAVR patients did not differ significantly with regards to patient demographics and preoperative risk factors. A strong trend towards shorter skin-to-skin operative times was observed for mini-AVR (330 min versus 356 min; p = 0.053). Postoperatively, mini-AVR patients had a shorter ventilation time (5.7 h versus 8.4 h; p = 0.005), intensive care unit stay (37 h versus 63 h; p ≤ 0.001) and hospital length of stay (6.5 days versus 8.0 days; p = 0.038). There was one operative mortality in the sAVR, and none in the mini-AVR group. Mid-term survival at one and five years for mini-AVR was 100% (95% CI 100-100) and 100% (95% CI 100-100), and for sAVR was 93.9% (95% CI 88.2-99.7) and 85.0% (95% CI 75.1-94.9), respectively (p = 0.041).

Conclusion: Mini-AVR confers benefits during subsequent reoperative AVR, with shorter hospital stays and improved long-term survival. These findings suggest that mini-AVR should be considered for patients at risk for aortic valve reoperation, and describes a previously unreported advantage of this well-established technique.

How to cite: Gosev, I., Neely, R. C., Leacche, M., McGurk, S., Kaneko, T., Zeljko, D., Loberman, D., Javed, Q., Cohn, L. H., & Aranki, S. F. (2015). The impact of a minimally invasive approach on reoperative aortic valve replacement. The Journal of heart valve disease, 24(2), 181–186.

Patients with severe aortic stenosis (AS) and left ventricular dysfunction are susceptible to hemodynamic decompensation due to limited myocardial reserve. Recent reports have suggested a role for hemodynamic assist devices such as the Impella or TandemHeart for improved in-hospital outcomes. However, the use of iodinated contrast during this vulnerable period poses a high risk for the development of contrast-induced nephropathy. A strategic approach is described for the treatment of high-risk patients with severe AS and cardiogenic shock, utilizing Impella-assisted balloon aortic valvuloplasty (BAV), without the administration of iodinated contrast as a bridge to transcatheter aortic valve replacement.

How to cite: Singh, V., Yarkoni, A., Gallegos, C., & O'Neill, W. W. (2015). Impella-assisted balloon aortic valvuloplasty as a bridge to transcatheter aortic valve replacement: non-contrast approach. The Journal of heart valve disease, 24(2), 177–180.

Transaortic interventions on the mitral valve are rarely performed, but offer advantages over traditional approaches in certain circumstances, including either extensive involvement of the aortomitral junction with endocarditis or the patient requiring reoperation for aortic and mitral disease. Herein is presented a case of recurrent endocarditis involving aortomitral continuity, reconstructed using a transaortic mitral valve repair and reconstruction of the aortic and mitral annuli with a pericardial patch, followed by aortic root replacement.

How to cite: Chiu, P., Allen, J. G., & Woo, Y. J. (2015). Transaortic aortomitral junction reconstruction and mitral valve leaflet repair for recurrent endocarditis. The Journal of heart valve disease, 24(2), 173–176.

A case is reported of iatrogenic mitral valve chordal rupture occurring during transcatheter aortic valve implantation (TAVI) with an inflatable and repositionable valve (Direct Flow; Direct Flow Medical, Santa Rosa, CA, USA). The specific implantation technique requires initial valve advancement into the left ventricular cavity, valve inflation within the ventricular cavity, and a final finely tuned valve upward pulling through the left ventricular outflow tract until contact with the aortic annulus is achieved. During this phase of the procedure, entangling with the mitral subvalvular apparatus should be excluded, to avoid inadvertent tissue tearing and consequent mitral valve malfunction. The present patient underwent TAVI but then developed symptomatic severe mitral valve regurgitation resulting from chordal rupture. The condition was successfully treated percutaneously by implanting a Mitra-Clip.

How to cite: D'Ancona, G., Ince, H., Ortak, J., Stoeckicht, Y., & Kische, S. (2015). Iatrogenic mitral valve chordal rupture during placement of an inflatable and repositionable percutaneous aortic valve prosthesis. The Journal of heart valve disease, 24(2), 169–172.

Background and aim of the study: The study aim was to assess the prevalence and clinical value of the pathological ankle-brachial index (ABI) in asymptomatic aortic stenosis (AS) patients.

Methods: This prospective study included 203 asymptomatic AS patients, with a mean follow up of 18 ± 10.6 months. Six-minute walk tests (6MWT) and ABI measurements were performed when patients were included in the study. Study events were defined as death, hospital admission due to related symptoms, or a need for surgery.

Results: A total of 198 patients (95 females, 103 males; mean age 74.6 ± 9.5 years) completed the study. An abnormal ABI was found in 35.8%. Mean (± SD) values were: peak velocity Vmax 4.1 ± 0.8 m/s; maximum/mean gradient 70.5 ± 25.1/43.3 ± 16.3 mmHg; aortic valve area 0.8 ± 0.7 cm2; indexed aortic valve area 0.4 ± 0.1 cm2/m2. A pathological ABI was associated with diabetes (p = 0.01), previous peripheral vascular disease (p = 0.04) and previous stroke (p = 0.04). In multivariate analyses, diabetes was an independent factor related to pathological ABI (relative risk 1.71, 95% CI 1.22-2.19). Patients with a pathological ABI walked less in the 6MWT (263.9 m versus 328.3; p = 0.002), but did not present a worse prognosis at follow up (p = NS).

Conclusion: Among asymptomatic AS patients, 35.8% had an abnormal ABI and this was related to previous diabetes. These patients walked less in the 6MWT but did not have a worse prognosis at follow up.

How to cite: Gomez, M., Roqueta, C., Molina, L., Cladellas, M., Ble, M., Comin-Colet, J., Soler, C., & Bruguera, J. (2015). Clinical value of ankle-brachial index in asymptomatic aortic stenosis patients. The Journal of heart valve disease, 24(2), 164–168.

Background and aim of the study: Risk stratification is particularly complex in asymptomatic patients with significant aortic stenosis (AS). The study aim was to assess which hemodynamic/Doppler-echocardiographic parameter best predicts mortality in asymptomatic patients with severe AS and a normal left ventricular ejection fraction (LVEF).

Methods: This prospective study included 128 consecutive asymptomatic patients (75 males, 53 females; mean age 66.35 ± 10.51 years) with severe AS (aortic valve area (AVA) ± 1.0 cm2) and a normal LVEF (55%). The patients were followed up for 47 months (median 35.5 months, IQR 7 months). Clinical data at follow up were obtained from all patients by either direct examination or telephone interview.

Results: During the follow up, 55 patients (43.0%) underwent aortic valve replacement (AVR) surgery due to AS-related symptoms. Of the 12 patients that died (9.4%), eight deaths occurred before surgery (four patients refused operation), and one patient died after surgery due to postoperative infection. Those patients who died had a significantly higher valvulo-arterial impedance (Z(va)) (7.81 versus 4.86 mmHg x ml/m2, p < 0.001), a higher N-terminal pro-brain natriuretic peptide (NT-proBNP) level (1708.5 versus 376.5 pg/ml, p = 0.003) and a lower AVA (0.65 versus 0.86 cm2, p = 0.002), but there were no differences in LVEF, P(mean) or age between the groups (69.68% versus 72.24%, p = 0.206; 44.95 versus 41.75 mmHg; and 69 versus 66 years, p = 0.332, respectively). When parameters that were predictors of mortality according to univariate analysis were further analyzed with Cox multivariate analysis, Z(va) was found to be the best independent predictor (B = 0.460, HR = 1.584, 95% CI = 1.064-2.359, p = 0.024). A Z(va) value of 6.1 mmHg x ml/m2 was identified as the best (cut-off) predictive value for the occurrence of death, with a sensitivity 61.1% and a specificity 86.0%.

Conclusion: Z(va) is the best mortality predictor in asymptomatic patients with severe AS and a normal LVEF. Future studies are required to focus further on predictors of outcome, the aim being to achieve an optimal selection of asymptomatic patients considered to be at risk and who would benefit from early AVR.

How to cite: Banovic, M., Brkovic, V., Vujisic-Tesic, B., Nedeljkovic, I., Trifunovic, D., Ristic, A., & Nikolic, S. (2015). Valvulo-arterial impedance is the best mortality predictor in asymptomatic aortic stenosis patients. The Journal of heart valve disease, 24(2), 156–163.

Background and aim of the study: Quadricuspid aortic valve (QAV) is a rare congenital anomaly. Aortic regurgitation (AR) has been suggested to be the major functional abnormality of QAV. The study aim was to define the clinical characteristics of patients with QAV through echocardiography, thereby identifying factors related to the severity of AR.

Methods: Patients diagnosed with QAV by echocardiography were enrolled from electronic medical records obtained between November 1994 and May 2012.

Results: Twenty-six patients diagnosed with QAV were identified. AR was present in 20 of these patients (77%), among which 12 (46%) exhibited significant AR. Aortic stenosis was rare (n = 1; 4%). Patient age and severity of AR were weakly correlated. The most frequent valve morphology type was three equally sized cusps and one smaller cusp (n = 12; 46%), followed by two larger, equally sized cusps and two smaller, equally sized cusps (n = 6; 23%). The latter morphology type was accompanied by a high prevalence of significant AR (5/6; 83%). The initial clinical symptoms of the patients included dyspnea and chest pain (n = 14; 54%), other congenital abnormalities (n = 4; 15%), and arrhythmias (n = 4; 15%). Among the patients with significant AR, 10 were symptomatic.

Conclusion: Approximately half of the patients with QAV had significant AR at the time of initial diagnosis by echocardiography. The severity of AR appeared to be correlated with patient age and valve morphology. These factors should be considered during echocardiographic assessment and follow up treatment for QAV.

How to cite: Cho, E. J., Son, M. K., Park, S. J., Park, S. W., Chang, S. A., Lee, S. C., & Kang, I. S. (2015). Aggravating factors associated with the severity of aortic regurgitation and clinical characteristics of patients with quadricuspid aortic valve. The Journal of heart valve disease, 24(2), 148–155.

Background and aim of the study: Balloon-expandable (BE) and self-expanding (SE) prostheses are both used for transcatheter aortic valve replacement (TAVR), but differences in long-term outcome using these types of device are unknown. The study aim was to monitor the histopathology, echocardiographic findings and structural integrity of BE and SE stents in a preclinical model for up to six months after TAVR.

Methods: Real-time magnetic resonance imaging (rtMRI)-guided TAVR was performed in 22 Yucatan pigs using either a BE (n = 10) or a SE (n = 12) prosthesis. Follow up echocardiography and MRI studies were performed at one-, three-, and six-month intervals. Additionally, high-contrast radiography was used to assess for strut fractures. The pigs were sacrificed after six months and tissues taken for histopathologic analysis.

Results: Stent malapposition was found in seven BE prostheses (70%), and in three SE prostheses (25%) (p = 0.046). Three of the SE group (25%) had a partial left coronary artery obstruction. The incidence and severity of aortic regurgitation were similar between the BE and SE groups. Three BE prostheses (30%) and one SE prosthesis (8.3%) had a gap between the stent frame and aorta. The mean (±SD) number of strut fractures was 6.1 ± 3.45 and 1.17 ± 2.32 in the BE and SE groups, respectively (p = 0.002). In addition, two implanted BE prostheses (20%) had a consequential compressed stent frame appearance.

Conclusion: Long-term pathologic examination of necropsy specimens from a preclinical model of rtMRI-guided TAVR showed SE stent prostheses to be superior to their BE counterparts in terms of correct valve apposition and durability. These results may be attributed to the differing deployment methods and associated expansion forces employed by the BE and SE stents.

How to cite: Kindzelski, B. A., Li, M., Mazilu, D., & Horvath, K. A. (2015). Pathology of balloon-expandable and self-expanding stents following MRI-guided transapical aortic valve replacement. The Journal of heart valve disease, 24(2), 139–147.