Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for high-risk aortic stenosis. Malposition of the prosthesis and severe residual aortic regurgitation are known complications of the procedure, which might require a second valve implantation. Although the implantation of a second valve seems to be an effective method, very few data are available describing this technique. Herein is reported a case of iatrogenic chordal rupture in a TAVI procedure which required a second valve implantation due to dislodgment of the first prosthesis.

How to cite: Cincin A, Tigen K, Sari I, Sunbul M, Kartal F, Basaran Y. A Case of Iatrogenic Chordal Rupture after Transcatheter Aortic Valve Implantation Procedure Requiring a Second Valve. J Heart Valve Dis. 2015 Jan;24(1):133-8. PMID: 26182632.

During the past few years, a new and attractive approach--transcatheter aortic valve implantation (TAVI)--has been developed for patients who are symptomatic of aortic stenosis and, due to the high expected operative risk, would not be otherwise treated. Unfortunately, TAVI can result in endocarditis of the percutaneously implanted valve that may present atypically and cause delays in diagnosis and treatment. Herein, the case is described of a 79-year-old female affected by endocarditis on aortic valve percutaneously implanted caused by Enterococcus faecium, complicated by iatrogenic pancytopenia and subacute disseminated intravascular coagulation, that proved fatal at six months after TAVI.

How to cite: Cimmino G, Ciccarelli G, Golino M, D'Amico C, Golino P. A Fatal Case of Endocarditis on CoreValve ReValving System Caused by Enterococcus faecium Complicated by Iatrogenic Pancytopenia and Subacute Disseminated Intravascular Coagulation. J Heart Valve Dis. 2015 Jan;24(1):130-2. PMID: 26182631.

Osteopetrosis is a heterogeneous group of heritable conditions in which there is a defect in bone resorption by osteoclasts. It is associated with an increased skeletal mass due to abnormally dense, but brittle, bones. Osteopetrosis varies greatly in severity, and fracture treatment remains a matter of controversy due to altered responses to fixation and the risk of osteomyelitis. The fate of sternotomy in this condition is unknown, and osteopetrosis could represent a situation of 'hostile chest'. Here, the case is described of a patient with osteopetrosis and concomitant symptomatic aortic valve stenosis and coronary artery disease.

How to cite: Villa E, Lauria G, Messina A, Rizzi A, D'Ambrosio A, Leonzi O, Sabatini T, Troise G. Osteopetrosis: a Case of 'Hostile Chest' Associated with Symptomatic Aortic Valve Stenosis. J Heart Valve Dis. 2015 Jan;24(1):126-9. PMID: 26182630.

Background and aim of the study: Calcific aortic valve disease (CAVD) is the most common valvular disorder. While fluid stresses are presumed to play a role in disease progression, the valvular hemodynamic changes experienced over the course of CAVD remain largely unknown. The study aim was to develop a laboratory protocol for the fabrication of tissue valve models mimicking mild and moderate calcific stenosis, for future use in flow studies.

Methods: Different hydroxyapatite (HA)-agarose mixtures were injected into porcine valve leaflets. Micro-computed tomography (micro-CT) was used to quantify HA deposition volume, area fraction and regional distribution, while von Kossa staining was performed to assess tissue mineralization. Particle image velocimetry measurements were carried out in intact and injected valves subjected to in vivo-like hemodynamics to characterize the degree of valvular stenosis in terms of geometric orifice area (GOA) and peak systolic velocity.

Results: The 5% HA-1% agarose solution (solution 1) and the 5% HA-0.5% agarose solution (solution 2) maximized the HA deposition volume. Leaflet injections with solution 1 resulted in a significant 1.9-fold increase in HA area fraction relative to solution 2 injections. While solution 1 injections generated multiple sites of high HA concentration, solution 2 injections produced smaller, discrete spots. Injections of both solution 1 and solution 2 into whole valves generated significant 47% and 32% reductions, respectively, in GOA and 1.8-fold and 1.5-fold increases, respectively, in peak systolic velocity, relative to untreated valves.

Conclusion: Tissue valve models were generated that recapitulated the structure and hemodynamics of mild and moderate valvular calcification. Those models may be used for future investigations of the native valvular hemodynamic alterations that occur during CAVD.

How to cite: Seaman C, McNally A, Biddle S, Jankowski L, Sucosky P. Generation of Simulated Calcific Lesions in Valve Leaflets for Flow Studies. J Heart Valve Dis. 2015 Jan;24(1):115-25. PMID: 26182629.

Background and aim of the study: Carcinoid heart valve disease (CHVD) occurs as the cardiac manifestation of carcinoid syndrome (also known as Hedinger's syndrome), which develops secondary to neuroendocrine tumor activity. CHVD almost exclusively affects right-sided heart valves, since circulating serotonin is metabolized by pulmonary endothelial cells, thus sparing left-sided valves. Replacement of the tricuspid and pulmonary valve is a well-established and feasible therapeutic option for these patients. Whether biological valve substitutes are subject to a continuous degenerative process is not entirely clear at present due to the rarity of the disease and inconclusive findings in the current literature.

Methods: Herein are presented the details of two patients suffering from advanced CHVD who had undergone previous combined tricuspid valve replacement (TVR) and pulmonary valve replacement (PVR) using biological xenografts, and had subsequently been readmitted with failure of the pulmonary valve substitute.

Results: Due to the increased risk for repeat surgical valve replacement, the patients were treated by percutaneous stent implantation into the pulmonary artery, followed by the implantation of a balloon- expandable transcatheter heart valve (THV). The procedures were feasible and safe through the intact TVR.

Conclusion: This strategy resulted in a favorable acute outcome in both patients, with adequate valve function and no PVL as documented by TTE, although the transvalvular gradients were elevated in both cases. The patients had an uneventful postoperative course and were discharged home in timely fashion. Whether the residual elevated transvalvular gradients following the valve-in-valve procedures, or an early degeneration of the implanted bioprostheses, will have a negative impact on the patients' further course will become clear in the future.

How to cite: Conradi L, Schaefer A, Mueller GC, Seiffert M, Gulbins H, Blankenberg S, Reichenspurner H, Treede H, Diemert P. Carcinoid Heart Valve Disease: Transcatheter Pulmonary Valve-In-Valve Implantation in Failing Biological Xenografts. J Heart Valve Dis. 2015 Jan;24(1):110-4. PMID: 26182628.

Background and aim of the study: Structural valve deterioration (SVD) is the leading failure mode of bioprosthetic heart valves. The Edwards Integrity-Preservation (EIP™) technology was developed to permanently block tissue calcium-binding sites and allow for non-aqueous valve storage. The study aim was to evaluate the efficacy of tissue anti-calcification, valve performance, durability, and safety.

Methods: Bovine pericardial tissue with EIP technology was compared to industry-standard Carpentier-Edwards ThermaFix® and Xenologix® treatments. Anti-calcification efficacy was evaluated in the rabbit model at 60 days, and tissue calcium contents were quantified using atomic absorption spectrophotometry. Valve performance was assessed using an in-vivo 20-week chronic ovine model, and in-vitro hydrodynamic testing (effective orifice area and regurgitation). Valve durability was evaluated by accelerated wear testing at 200 million cycles (equivalent to five years). Valve safety was characterized by biocompatibility testing as per ISO requirements.

Results: Calcification results showed that the control and EIP technology tissues had a mean Ca content of 104.95 ± 102.69 and 21.20 ± 38.46 µg/mg dry tissue, respectively; the median Ca contents were 81.15 and 0.43 µg/mg dry tissue, respectively (p < 0.0001). The overall valve performance in the sheep was comparable between control and test. In-vitro hydrodynamics and durability were similar between groups, across all sizes, and met ISO requirements. EIP technology was shown to be biocompatible for use as an implantable device.

Conclusion: Preclinical in-vitro and in-vivo evaluations showed that EIP technology significantly reduced tissue calcification and preserved valve performance and safety compared to current standards of care. Future studies will determine whether these findings can be replicated in humans.

How to cite: De La Fuente AB, Wright GA, Olin JM, Duhay FG, Kapelak B, Bochenek M, Bartus K, Sadowski J. Advanced Integrity Preservation Technology Reduces Bioprosthesis Calcification While Preserving Performance and Safety. J Heart Valve Dis. 2015 Jan;24(1):101-9. PMID: 26182627.

Background and aim of the study: Currently, no effective crosslinking reagents are available to treat xenogenic decellularized heart valve matrices. The study aim was to evaluate the crosslinking effect of quercetin, catechin, caffeic acid and tannic acid on porcine aortic valve matrices.

Methods: Cytotoxicity of the different crosslinkers was evaluated. The mechanical properties of crosslinked porcine matrices and control matrices (non-fixed) were examined by tensile strength testing, as was the cytocompatibility of the fixed matrices. Crosslinked and control matrices were implanted subcutaneously in Wistar rats (n = 9) and, after two weeks, their calcium contents were determined using inductively coupled plasma-mass spectrometry. The antibody reaction against porcine tissue in rat serum was also determined.

Results: Cytotoxicity studies showed that crosslinkers, even at high concentrations, did not inhibit cell viability. All crosslinkers except tannic acid improved the mechanical strength of acellular porcine matrices. Moreover, the tensile strength of quercetin-fixed matrices was comparable with that of glutaraldehyde (GTA)-fixed leaflets. Light microscopic evaluation showed that crosslinked matrices caused only a mild lymphocytic inflammatory reaction. Furthermore, quercetin-fixed leaflets exhibited a well-preserved matrix without infiltration of CD3+ cells. After two weeks, calcium levels were 206.33 µg/mg for controls (non-fixed), and 151.33 µg/mg, 181 µg/mg and 163.66 µg/mg for quercetin-, catechin-, and caffeic acid-fixed matrices, respectively. At two weeks after implantation the quercetin-crosslinked matrices also elicited the lowest levels of IgG antibodies.

Conclusion: The study results identified quercetin as the most suitable crosslinker for heart valve tissue engineering, and a possible alternative to GTA. Further studies are essential to determine whether quercetin crosslinking will allow autologous cell repopulation in order to create a viable heart valve.

How to cite: Somers P, Roosens A, De Somer F, Cornelissen M, Van Nooten G. Non-Cytotoxic Crosslinkers for Heart Valve Tissue Engineering. J Heart Valve Dis. 2015 Jan;24(1):92-100. PMID: 26182626.

Transaortic septal myectomy, known as Morrow's procedure, is a standard treatment for hypertrophic obstructive cardiomyopathy (HOCM). The case is described of a 58-year-old male patient who suffered a repetition of syncope due to HOCM, in whom septal myectomy was performed. As resection of the hypertrophied septum using Morrow's procedure was considered insufficient by palpation to release mitral regurgitation (MR) and systolic anterior motion of the mitral valve, the surgical approach was changed such that the right ventricular outflow tract and ventricular septum was incised. The residual hypertrophied septum was successfully resected to the base of the anterior papillary muscle under direct vision. Postoperative echocardiography demonstrated a dramatic improvement in the MR and left ventricular outflow tract obstruction. The patient's postoperative course was good, with cibenzoline and calcium channel blocker therapy stopped and beta-blocker therapy reduced after surgery. If resection of the hypertrophied septum using Morrow's procedure is considered insufficient, a trans-septal approach represents an adequate option to treat HOCM.

How to cite: Konishi Y, Shomura Y, Fukunaga N, Koyama T, Okada Y. Trans-Septal Approach for Hypertrophic Obstructive Cardiomyopathy. J Heart Valve Dis. 2015 Jan;24(1):89-91. PMID: 26182625.

Background and aim of the study: The study aim was to analyze the safety and longevity of cryopreserved homografts used for primary right ventricular outflow tract reconstruction (RVOTR), and to compare the outcome using either standard or bicuspidalized allografts.

Methods: Between February 2000 and September 2014, a total of 53 patients underwent primary RVOTR using either a standard (n = 40) or a bicuspidalized (n = 13) cryopreserved homograft. The median age at surgery was 15.5 months (range: 1-419.06 months), and bodyweight was 8.5 kg (range: 4.1-71 kg). The median standard homograft size was 17.5 mm (range: 10-25 mm), while the median bicuspidalized homograft size was 16 mm (range: 14-22 mm). Follow up was complete in 91.4% of patients, with a median duration of 30.11 months (range: 0.26-161.26 months). Data analysis included primary diagnosis, type of surgery, age at surgery, size of conduit, need for reintervention, and survival. Predetermined primary outcomes were represented by survival and freedom from conduit reintervention.

Results: Two patients with standard cryopreserved homograft died. during the early postoperative period (3.7%). No deaths were conduit-related. The five-year survival rate and ten-year freedom from reintervention were 91% (range: 74.7-97.2%) and 53.6% (range: 97-33.2%), respectively. RV-PA conduit replacement was performed in 14 patients (26.4%) at a median interval of 44.5 months (range: 14.93-162.46 months). Among these patients, four children (30.7%) received bicuspidalized homografts, and 10 (25%) received standard homografts. Causes of reintervention were conduit stenosis in six cases (43%), severe homograft valve regurgitation in two (14.2%), conduit stenosis and homograft valve regurgitation in two (14.2%), and stenosis of distal anastomosis involving pulmonary bifurcation in four (28.6%). Univariate analyses showed a longer freedom from reintervention for bicuspidalized compared to standard homograft (p = 0.03).

Conclusion: The results obtained suggested that bicuspidalized homograft performance compares well with that of standard allografts in terms of freedom from reintervention. Bicuspidalized homograft use is strongly indicated for primary RVOTR in small children, when a standard homograft of appropriate size is not available.

How to cite: Perri G, Polito A, Gandolfo F, Albanese SB, Carotti A. Outcome of Standard and Bicuspidalized Cryopreserved Homografts for Primary Right Ventricular Outflow Tract Reconstruction. J Heart Valve Dis. 2015 Jan;24(1):83-8. PMID: 26182624.

Background and aim of the study: Cryopreservation allows for the long-term storage of aortic homografts, but a high risk of calcification and degeneration is often observed following their transplantation. The study aim was to investigate the cryoprotective effect of trehalose on aortic valve homografts preserved in liquid nitrogen, and to determine the optimal trehalose concentration for such purpose.

Methods: Aortic valve homografts obtained from New Zealand White rabbits were processed using different protectants. Samples were assigned at random to four groups: a control group treated with dimethyl sulfoxide (DMSO; 0.1 mol/l), and test groups A, B and C, which were treated with 0.1 mol/l trehalose + 0.1 mol/l DMSO, 0.2 mol/l trehalose + 0.1 mol/l DMSO, or 0.3 mol/l trehalose + 0.1 mol/l DMSO, respectively, as protectant. Samples in each group were allocated randomly to three subgroups and cryopreserved for 12, 15, and 18 months, respectively. After thawing, apoptosis of the cryopreserved homograft samples was evaluated using immunohistochemistry, semi-quantitative RT-PCR and Western blotting methods. The viability of the tissue cells was assessed by monitoring glucose utilization capacity.

Results: The apoptosis assay showed that, among the four groups and at all time points, the expression of caspase-3 was lowest in test groups A and B and highest in the DMSO group. In comparison, the glucose metabolic rates of test groups A and B were highest, while rates for test group C and the control (DMSO) group ranked second and third.

Conclusion: When aortic homografts are preserved in liquid nitrogen, the cryoprotective effect of trehalose combined with DMSO was superior to that of DMSO alone. The optimal trehalose concentration to cryoprotect rabbit aortic homografts was between 0.1 and 0.2 mol/l.

How to cite: Chang Q, Cheng CC, Jing H, Sheng CJ, Wang TY. Cryoprotective Effect and Optimal Concentration of Trehalose on Aortic Valve Homografts. J Heart Valve Dis. 2015 Jan;24(1):74-82. PMID: 26182623.

Background and aim of the study: Since the voluntary recall of St. Jude Medical (SJM) Silzone impregnated heart valves, no large-scale study has examined their long-term outcomes.

Methods: Using Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (1993-2004), the clinical outcomes were evaluated through eight years among those patients who received SJM mechanical heart valves during the Silzone era (March 1998 to December 1999; n = 3,775), relative to those in both the pre-Silzone era (January 1993 to February 1998; n = 13,570) and the post-Silzone era (January 2000 to December 2004; n = 6,882). An inverse probability weighting was used to balance the observed differences in case mix.

Results: During the Silzone era, 79% of all implanted mechanical heart valves were manufactured by SJM. By eight years post-implantation, the most common adverse events in this Medicare-linked cohort (median age 71 years) were death (43.5%) and thromboembolism (14.7%), while valve reoperation (1.7%) and endocarditis (1.4%) were less common. Patients treated during the Silzone era experienced a lower associated risk of mortality to eight years than those in both the pre-Silzone era (adjusted hazards ratio (HR) 0.93, 95% confidence interval (CI) 0.88-0.98) and post-Silzone era (adjusted HR 0.92, CI 0.67-0.98), while the adjusted eight-year risks of reoperation, thromboembolism and endocarditis were similar across the three eras for the overall cohort and among both aortic valve and mitral valve patients.

Conclusion: Medicare patients who received SJM mechanical heart valves during the Silzone era experienced similar clinical outcomes as those treated before or after the Silzone era. These data do not substantiate continued public health concerns associated with Silzone era valve prostheses among older individuals.

How to cite: Brennan JM, Zhao Y, Williams J, O'Brien S, Dokholyan R, Gammie J, Edwards F, Loyo-Berrios N, Canos D, Gross T, Marinac-Dabic D, Peterson E. Long-Term Clinical Outcomes of Silzone Era St. Jude Medical Mechanical Heart Valves. J Heart Valve Dis. 2015 Jan;24(1):66-73. PMID: 26182622.

The details are reported of a novel treatment strategy using two-clip delivery systems (2CDS) simultaneously, after double trans-septal puncture, for the treatment of severe functional mitral regurgitation. In five individual patients with complex mitral regurgitation, both CDSs were used successfully to titrate for an optimal result. The learning curve and limitations of this particular approach are described.

How to cite: Schaefer U, Frerker C, Kreidel F, Kuck KH. Simultaneous Double Clipping Delivery Guide Strategy in Complex Mitral Regurgitation. J Heart Valve Dis. 2015 Jan;24(1):57-65. PMID: 26182621.

Background and aim of the study: The study aim was to create a new form of mitral valve surgery with a novel stentless mitral valve (SMV) made from autologous pericardium, for use in patients with an unrepairable valve.

Methods: A newly designed two-leaflet SMV ('NORMO') was developed, the excellent hydrodynamic function of which had been evaluated previously using a pulsatile simulator (data reported elsewhere). The operation involved constructing the NORMO valve by using autologous pericardium and a flexible ring, before instituting cardiopulmonary bypass and implanting the valve. The new-style operation was performed successfully in seven patients with complicated mitral valve disease who had requested valve repair rather than replacement.

Results: Postoperative echo-Doppler studies of the seven patients, performed at between six and 26 months (mean 18 months) after surgery, revealed mild mitral regurgitation (MR) in two cases and no or only trivial MR in the other five cases.

Conclusion: Although its long-term durability is unknown, this new surgery might represent an alternative for mitral valve repair, especially in those patients with a complicated valve pathology where the feasibility of repair is low.

How to cite: Kasegawa H, Tabata M, Shimizu A, Naito K, Fukui T, Takanashi S. A New Type of Mitral Valve Operation Using a Novel Stentless Mitral Valve made from Autologous Pericardium for Unrepairable Valve. J Heart Valve Dis. 2015 Jan;24(1):53-6. PMID: 26182620.

Background and aim of the study: Mitral annular calcification (MAC) represents a significant challenge in mitral valve (MV) surgery. Techniques to decalcify the mitral annulus significantly increase operative complexity and risk. MV repair can be particularly difficult in this setting. Mid-term outcomes following MV surgery with extensive annular decalcification were examined, with attention focused on the feasibility and outcomes of MV repair in this setting.

Methods: Among 1,485 patients undergoing MV surgery between 1999 and 2008 at the authors' institutions, 24 (1.6%) underwent complete posterior MV annular decalcification associated with either MV repair (n = 19) or replacement (n = 5). Extensive decalcification was performed from commissure to commissure in all patients. The annulus was reconstructed with pledgeted compression sutures in 17 patients, and with a bovine pericardial patch in seven.

Results: In-hospital mortality was 12.5%. One patient died in the operating room from atrioventricular groove rupture, and two patients died from low cardiac output postoperatively. During a mean follow up of 4.4 ± 2.7 years, eight patients died; five of these deaths were cardiovascular in nature. After five years the actuarial survival was 56 ± 11%, and freedom from cardiac death 63 ± 11%. Four patients underwent' reoperation because of failure of MV repair (n = 2), endocarditis (n = 1) or hemolysis (n = 1). All survivors were in NYHA class ≤ 2, with none to trivial mitral regurgitation in all MV repairs. The five-year freedom from MV reoperation was 82 ± 8%.

Conclusion: After aggressive decalcification of the posterior MV annulus, both MV repair and replacement were feasible, with acceptable procedure-related mortality. It was clear however, that decalcification increased both complexity and risk. In well-selected patients, an aggressive approach to MV repair might facilitate a high rate of repair with acceptable midterm outcome in this patient population.

How to cite: Price J, Glineur D, De Kerchove L, El Khoury G. Mitral Valve Repair is Feasible Following Extensive Decalcification and Reconstruction of the Atrioventricular Groove. J Heart Valve Dis. 2015 Jan;24(1):46-52. PMID: 26182619.

The case is reported of a symptomatic elderly patient with severe mitral regurgitation, severe aortic valve stenosis, and coronary heart disease. The coronary artery disease had been interventionally treated four years previously with stent implantation into the right coronary artery. Published studies have shown that a combination of mitral and aortic valve surgery is associated with a significantly increased risk of mortality and morbidity, particularly in elderly patients. In the present patient, both valvular malformations were successfully treated with a single-step interdisciplinary approach, namely an initial surgical mitral valve replacement followed by transfemoral transcatheter aortic valve replacement.

How to cite: Rustenbach C, Baumbach H, Hill S, Franke UF. Minimally Invasive Mitral Valve Replacement and Transfemoral Aortic Valve Implantation. J Heart Valve Dis. 2015 Jan;24(1):43-5. PMID: 26182618.

After myocardial infarction, functional ischemic mitral regurgitation (FIMR) is present in 21% of patients, and 3-13% have at least moderate FIMR. Currently, the 'gold-standard' treatment of FIMR is down-sized ring annuloplasty at the time of coronary artery bypass (CABG) surgery. However, this procedure has a failure rate of 20-30% in terms of recurrent FIMR after two to four years. In many ways, a cross-roads has been reached in terms of what constitutes optimal FIMR treatment: Is CABG combined with mitral valve ring annuloplasty better than CABG alone in moderate FIMR? Does mitral valve repair really produce better outcome than mitral valve replacement? And does adding an adjunct valvular repair or subvalvular left ventricular reverse remodeling procedure shift that balance? In order to shed further light on these questions and to help identify potential cornerstones in improving the 'gold standard' therapy, the present review addresses the current status and future perspectives of the surgical treatment of FIMR.

How to cite: Jensen H, Jensen MO, Nielsen SL. Surgical Treatment of Functional Ischemic Mitral Regurgitation. J Heart Valve Dis. 2015 Jan;24(1):30-42. PMID: 26182617.

Background and aim of the study: Transcatheter aortic valve replacements (TAVRs) are performed using fluoroscopic guidance, which makes precise positioning challenging. The aim of the present study was to investigate the effect of TAV positioning on flow characteristics in the ascending aorta and sinuses.

Methods: A commonly used TAV design with a supra-annular support section was investigated using particle image velocimetry (PIV) under physiological flow and pressure conditions. A bioprosthetic valve served as a control and mimicked the native aortic valve. The valve assembly was mounted in a custom-designed chamber with an axisymmetric sinus, the design of which was based on anatomic dimensions. The TAV was deployed in the supra-annular (high) and sub- annular (low) implantation positions and studied at two cardiac outputs (5.0 and 2.5 l/min).

Results: The TAV showed good systolic flow characteristics with wide forward flow jets in the ascending aorta (V = 1.5 m/s at 5.0 1/min; V = 1.0 m/s at 2.5 1/min). In the high implantation, the physical spacing between the leaflet free edge and sinotubular junction was reduced (< 10 mm), causing a weaker sinus vortex and a lower washout. A larger region of low velocity (< 0.1 m/s) in the sinus was observed at high implantation at all time points, particularly at a cardiac output of 2.5 l/min. In the low implantation, good sinus washout was observed.

Conclusion: For optimal sinus washout, sub- annular TAV deployment is recommended, particularly for patients with smaller sinuses. An impaired cardiac output may also require sub- annular deployment for adequate sinus washout. The study results confirmed the need for precise TAV deployment tailored to patient-specific annular and sinus dimensions, as sub-optimal positioning may inhibit coronary perfusion and cause potential regions of stasis near the aortic annulus.

How to cite: Kumar G, Raghav V, Lerakis S, Yoganathan AP. High Transcatheter Valve Replacement May Reduce Washout in the Aortic Sinuses: an In-Vitro Study. J Heart Valve Dis. 2015 Jan;24(1):22-9. PMID: 26182616.

Background and aim of the study: The study aim was to investigate prosthesis-specific predictors for paravalvular aortic regurgitation (PAR) in self-expandable versus balloon-expandable transcatheter heart valves (THVs). PAR is frequently observed after transcatheter aortic valve replacement (TAVR). As self-expandable and balloon-expandable THVs engage differently with the native aortic valve structures, factors that impact PAR may differ between the prosthesis types.

Methods: A total of 137 TAVR patients who underwent pre-procedural multidetector computed tomography and post-procedural transthoracic echocardiography were studied. Predictors for PAR, including annulus area oversizing and aortic valve calcification mass and volume, were analyzed in a multivariate model.

Results: The Medtronic CoreValve (MCV) prosthesis was utilized in 68 patients (50%), and the Edwards SAPIEN (ES) prosthesis in 69 (50%). More than mild PAR was observed in 43 patients (32%). Among MCV patients, aortic valve calcification volume and mass were higher in those with more than mild PAR than in those with none or mild PAR (p = 0.04, p = 0.03, respectively). Among ES patients, the annulus area and perimeter oversizing were lower in those with more than mild PAR compared to those with no or mild PAR (p = 0.001). By univariate and multivariate logistic regression analysis, aortic valve calcification mass was the only independent predictor for PAR in MCV patients (p = 0.02), whereas in ES patients it was THV undersizing (p = 0.002), irrespective of the calcific burden.

Conclusion: For self-expandable THVs, aortic valve calcification mass was the strongest predictor of PAR, whereas for balloon-expandable THVs it was prosthesis undersizing. Hence, in patients evaluated for TAVR these parameters should guide the selection of prosthesis type.

How to cite: aStähli BE, Nguyen-Kim TD, Gebhard C, Erhart L, Frauenfelder T, Tanner FC, Falk V, Landmesser U, Nietlispach F, Lüscher TF, Maier W, Binder RK. Prosthesis-Specific Predictors of Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: Impact of Calcification and Sizing on Balloon-Expandable versus Self-Expandable Transcatheter Heart Valves. J Heart Valve Dis. 2015 Jan;24(1):10-21. PMID: 26182615.

Background and aim of the study: The aortic valve-sparing reimplantation operation (David) is increasingly used in patients with aortic root aneurysm and intact cusps. David's procedure is also feasible in patients with bicuspid aortic valve (BA), though few long-term data are available.

Methods: An analysis was conducted of the long-term echocardiographic data from patients with BAV who had undergone David's procedure at early and long-term follow up (FU) examinations.

Results: Between 1994 and 2010, a total of 30 patients with BAV underwent David's procedure at the authors'institution. There were no in-hospital or late deaths, and the mean long-term FU was 6.64 ± 3.54 years (range: 3.2-20.1 years). The mean aortic regurgitation (AR) grade was increased from 0.26 ± 0.37 at early FU to 0.70 ± 0.80 at long-term FU (p = 0.013). Four patients (13%) had to be reoperated after 10.00 ± 4.74 years (range: 5.49-17.06 years) due to aortic stenosis (n = 1) and aortic insufficiency (n = 3); the latter three patients had a significant prolapse of both the fused and the non-coronary cusp of reconstruction.

Conclusion: The mean AR grade was increased significantly but was ≤ I-II in 59% of patients and ≤ II in 93% of patients after a mean FU of 6.6 years. Patients with prolapsing non-coronary leaflet at reconstruction seemed vulnerable to recurrent AR. Among patients, survival was excellent, and the reoperation rate and hemodynamics acceptable. Long-term follow up data are necessary to further refine the surgical techniques employed and to improve the results achieved.

How to cite: Richardt D, Stierle U, Sievers HH. Long-Term Results after Aortic Valve-Sparing-Reimplantation Operation (David) in Bicuspid Aortic Valve. J Heart Valve Dis. 2015 Jan;24(1):4-9. PMID: 26182614.

A case is reported of successful surgery using the Konno procedure seven years after the patient had undergone aortic valve replacement (AVR) with the Nicks procedure. A 79-year-old woman with aortic stenosis and a small aortic annulus had undergone previous AVR with a 17-mm mechanical prosthesis and aortic annular enlargement by the Nicks procedure. Redo surgery was performed using a 19-mm bioprosthesis with the Konno procedure, to replace a valve that had become stuck due to pannus formation. As intense adhesion was present around the heart, especially behind the posterior aortic wall where the Nicks procedure had been performed, the Konno procedure provided the advantage of a good field of vision at the aortic annulus. This procedure may be less invasive when applied to adults, because the septal incision in adults would be relatively smaller than in children. As well as being used in children, the Konno procedure could be an effective option for redo AVR in adults with a small aortic annulus.

How to cite: Matsuzakil K, Kudo Y, Ikeda A, Konishi T, Jikuyal T, Hiramatsu Y. The Konno Procedure in Redo Aortic Valve Replacement after the Nicks Procedure. J Heart Valve Dis. 2015 Jan;24(1):1-3. PMID: 26182613.