The unique features of ischemic mitral regurgitation may necessitate attention to certain points during mitral valve replacement (MVR). A few simple but practical recommendations are offered for concomitant or isolated MVR in this high-risk population which is often burdened by an extremely limited myocardial reserve.

How to cite: Vural K. M. (2016). Recommendations for Valve Replacement in Ischemic Mitral Regurgitation with Compromised Ventricle. The Journal of heart valve disease, 25(5), 651–652.

Percutaneous pulmonary valve implantation (PPVI) has become a widely practiced treatment option for patients with right ventricular outflow tract (RVOT) dysfunction. For this procedure, the Melody transcatheter pulmonary valve has become the most widely used system. On-label indications are limited to the treatment of failing circumferential conduits. However, there is growing but still limited experience with the off-label treatment of native or patched RVOTs. Here, the case is reported of a 57-year-old patient in whom redo-surgery for a dysfunctional pulmonary valve could be avoided by PPVI into the patched RVOT at 51 years after tetralogy of Fallot repair.

How to cite: Grundmann, S., Hoehn, R., Kroll, J., & Grohmann, J. (2016). Percutaneous Pulmonary Valve Implantation in the Patched Right Ventricular Outflow Tract 51 Years after Surgical Repair for Tetralogy of Fallot. The Journal of heart valve disease, 25(5), 648–650.

Atrial septostomy is an infrequently used percutaneous technique to decompress either side of the heart. Here, a case is reported of atrial septostomy performed as an emergency 'bridge' procedure in a hemodynamically unstable 62-year-old man with acute mechanical prosthetic aortic valve thrombosis requiring peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO). ECMO was placed emergently as the patient suffered cardiac arrest during anesthesia induction for surgical replacement of the thrombosed prosthetic aortic valve. The increased afterload as a result of ECMO, in the setting of severe prosthetic valve dysfunction, led to a marked elevation of the left heart pressures, pulmonary edema and multiorgan dysfunction. A percutaneous atrial septostomy led to a rapid decompression of the left heart by shunting blood to the right atrium, allowing for a marked improvement in the patient's clinical condition. This facilitated the performance of re-do surgery to replace the dysfunctional thrombosed aortic prosthetic valve. Postoperatively, the pulmonary edema resolved completely and the patient achieved full recovery with no residual cardiac symptoms at three months. Video: Gated cardiac CT angiography demonstrating a large thrombus present between the St. Jude Medical mechanical aortic prosthetic leaflets, resulting in severe restriction of leaflet motion.

Situs inversus totalis and anomalous origin of the left coronary artery are rare conditions. An 87-year-old woman with both conditions presented to the authors' hospital with symptomatic aortic stenosis. She underwent aortic valve replacement (AVR) and coronary artery bypass grafting (CABG; saphenous vein graft to the left main trunk). The operator mainly stood on the left side of the patient and performed surgery without difficulty. Both, AVR and CABG were successfully performed despite these two rare conditions. Open-heart surgery in a very elderly patient with both of these rare conditions has not previously been reported.

How to cite: Kono, T., Takaseya, T., Shojima, T., Takagi, K., Akasu, K., & Tanaka, H. (2016). Aortic Valve Replacement in Dextrocardia and Anomalous Origin of the Coronary Artery. The Journal of heart valve disease, 25(5), 641–643.

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.

How to cite: Gualis, J., Castaño, M., Manuel Martínez-Comendador, J., Garrote, C., Otero, J., Martín, E., Maiorano, P., Miguel Marcos, J., & Estevez-Loureiro, R. (2016). A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma. The Journal of heart valve disease, 25(5), 638–640.

A 68-year-old woman with a history of previous double-valve replacement with On-X mechanical heart valves presented with clinical, echocardiographic and cardiac catheterization signs of obstruction of the On-X tricuspid heart valve prosthesis. The patient was successfully reoperated, but at surgery the valve was seen to be invaded by an abnormal overgrowth of pannus that blocked one of the leaflets. A small amount of non-obstructive fresh thrombus was also observed. The valve was successfully replaced with a biological heart valve prosthesis. The patient was discharged home, and is doing well four months after the operation, when echocardiography demonstrated normal function in the tricuspid valve. The present case represents the first ever report of pannus formation and subsequent dysfunction in an On-X heart valve, and also the first case of tricuspid valve malfunction and obstruction using this type of heart valve substitute.

How to cite: Abad, C., Urso, S., Gomez, E., & De la Vega, M. (2016). Dysfunction of an On-X Heart Valve by Pannus. The Journal of heart valve disease, 25(5), 634–637.

Background: The unique design of the Freestyle stentless aortic bioprosthesis has led to different mechanisms of failure, particularly leaflet tearing. The aim of this retrospective study was to review the clinical presentation and echocardiographic data of symptomatic patients with leaflet tears and significant aortic regurgitation (AR) following implantation of the Freestyle bioprosthesis.

Methods: Between January 1993 and May 2011, a total of 430 consecutive patients was identified at the authors' institution who had undergone primary aortic valve replacement with a Freestyle stentless aortic bioprosthesis. Clinical and echocardiographic data were collected prospectively for all patients. Structural valve deterioration was the major cause of bioprosthetic valve failure.

Results: Twenty symptomatic patients presented with significant AR due to leaflet tears in the absence of more than mild valvular calcification. At presentation, all patients complained of dyspnea. Some 50% of patients (n = 10) presented with acute pulmonary edema, and 10% (n = 2) with cardiogenic shock. A leaflet tear was initially diagnosed using transthoracic echocardiography in five cases (25%), using transesophageal echocardiography (TEE) in eight cases (40%), or at surgery in seven cases (35%). An appropriate diagnosis of leaflet tearing was recognized at surgery in more than one-third of patients. Consequently, clinicians must be aware of the variety of clinical presentations and should have a high degree of suspicion regarding leaflet tears in patients who have received a Freestyle stentless aortic bioprosthesis and present with moderate to severe AR.

Conclusions: For the optimal management of patients with Freestyle stentless aortic bioprosthesis and new moderate to severe AR, TEE should be considered in all patients.

How to cite: Rheault, P., Mohammadi, S., O'Connor, K., Dagenais, F., Voisine, P., Bergeron, S., Bernier, M., Couture, C., Poirier, P., Cinq-Mars, A., Dubois, M., & Sénéchal, M. (2016). Clinical Presentation and Value of Echocardiography in the Diagnosis of Freestyle Aortic Bioprosthesis Leaflet Tears: A Retrospective Study. The Journal of heart valve disease, 25(5), 628–633.

Background: Rheumatic fever and rheumatic heart disease (RHD) are important health problems in developing countries. The study aim was to provide a review and content analysis of the scientific literature on rheumatic fever and RHD over a 70-year period.

Methods: Medline was employed via the online PubMed service of the US National Library of Medicine, to search for all documents containing the MeSH terms 'rheumatic fever' or 'rheumatic heart disease' between January 1945 and December 2013.

Results: A total of 18,552 references was retrieved. Between 1945 and 1970 the number of annual publications containing the search terms increased, but decreased between 1971 and 2013. Between 1990 and 2013, national collaboration (co-authorship) was greatly increased, from 8.7% to 41.7% of the total reports. International collaboration also increased, from 2.5% to 14.8% (p = 0.001). The United States was the main collaborating country, sharing ties mainly with India, South Africa and Brazil. A content analysis led to the identification of three prominent core research topics, chief among which were heart diseases (rheumatic fever diseases, mitral valve diseases and endocarditis). Other areas of note included streptococcal infections and rheumatic diseases (which, in addition to rheumatic fever, also highlighted arthritis and juvenile arthritis).

Conclusions: Publications on rheumatic fever and RHD had a major impact during the 1960s, but research groups interest has since declined overall, in line with a decreasing interest in these diseases in developed countries. In contrast, national and international collaboration has increased, a phenomenon that should be encouraged for research into these and other diseases that affect developing countries.

How to cite: Salinas, A., González, G., & Manuel Ramos, J. (2016). Rheumatic Fever and Rheumatic Heart Disease: Collaboration Patterns and Research Core Topics. The Journal of heart valve disease, 25(5), 619–627.

Background: Rheumatic heart disease is a common reason for cardiovascular morbidity and mortality. Plasma levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are known to rise in patients with MS, but the role of this compound as a non-invasive marker of left atrial (LA) dysfunction is yet to be established. The study aim was to correlate levels of NT-proBNP in patients with rheumatic mitral stenosis (MS), with echocardiographic parameters of LA function including tissue Doppler-derived strain/strain rate (S/Sr) indices, hemodynamic parameters of LA function, before and after percutaneous balloon mitral valvotomy (PBMV) for a follow up of one year.

Methods: The study included 51 patients with severe MS and 10 age- and gender-matched controls. All patients and subjects underwent detailed clinical and echocardiographic evaluation (including LA S/Sr indices) prior to PBMV and at 12 h, one month and one year after PBMV. Venous blood samples were withdrawn to monitor NT-proBNP levels during the same period. LA functions were assessed echocardiographically, using conventional parameters, while S/Sr indices were calculated at mid-LA segments (septal, lateral, anterior and inferior) during ventricular systole, and at early and late diastole. The LA appendage contraction velocity was calculated using transesophageal echocardiography (TEE) and correlated with NT-proBNP levels. The cardiac output (CO) was calculated invasively. The pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure (PAP) and other parameters were correlated with NT-proBNP levels before and after PBMV.

Results: The mean NT-proBNP level before PBMV was 761.76 ± 213.6 pg/ml, and was 425 pg/ml, 300 pg/ml and 50 pg/ml at one day, one month and one year, respectively (p <0.01). The S/Sr indices at each mid-LA segment (septal, lateral, anterior, and inferior) during ventricular systole (LAs), at early (LAe) and late diastole (LAa) were each significantly lower in patients than in controls (p <0.001). The S/Sr values were improved significantly (p <0.05) in most segments at one day and at one month after PBMV, but after one year the values were increased by >50%, in relation to the NT-proBNP level. There were significant falls in mean PAP and PCWP and a rise in CO, each of which correlated significantly with NTproBNP levels.

Conclusions: NT-proBNP levels correlated significantly with LA dysfunction, and can predict improvements in LA function following PBMV in rheumatic MS for up to one year. Tissue Doppler-derived S/Sr indices may be used to detect fine variations over and above conventional echocardiography, and this may be clinically valuable in the prognosis of MS patients.

How to cite: Khare, R., & Dwivedi, S. (2016). NT-ProBNP as a Potential Marker of Left Atrial Dysfunction in Rheumatic Mitral Stenosis: Correlation with Left Atrial Function after PBMV. The Journal of heart valve disease, 25(5), 613–618.

Background and aim of study: Although the sheep is the most acceptable animal model for heart valve evaluation, it has severe limitations for detecting heart valve thrombosis during preclinical studies. While the pig offers an alternative model and is better for detecting prosthetic valve thrombogenicity, it is not often used because of inadvertent valve thrombosis or bleeding complications. The study aim was to develop an improved pig model which can be used reliably to evaluate mechanical heart valve thrombogenicity.

Methods: Mechanical heart valves were implanted in the mitral position of indigenous pigs administered aspirin-clopidogrel, and compared with similar valves implanted in control pigs to which no antiplatelet therapy had been administered. The pigs were observed for six months to study their overall survivability, inadvertent bleeding/valve thrombosis and pannus formation. The efficacy of aspirinclopidogrel on platelet aggregation and blood coagulation was also recorded and compared between test and control animals.

Results: In comparison to controls, pigs receiving anti-platelet therapy showed an overall better survivability, an absence of inadvertent valve thrombosis/ bleeding, and less obstructive pannus formation. Previously unreported inhibitory effects of aspirin-clopidogrel on the intrinsic pathway of blood coagulation were also observed in the pig model. Notably, with aspirin-clopidogrel therapy inadvertent thrombus formation or bleeding can be prevented.

Conclusions: The newly developed pig model can be successfully used to evaluate heart valve thrombosis following chronic orthotopic valve implantation. The model may also be utilized to evaluate other bloodcontacting implantable devices.

How to cite: Payanam Ramachandra, U., Shenoy, S. J., & Arumugham, S. (2016). Improved Pig Model to Evaluate Heart Valve Thrombosis. The Journal of heart valve disease, 25(5), 606–612.

Background: Tricuspid regurgitation may be a precursor for heart failure, reduced functional capacity, and poor survival. A human compatible experimental model is required to understand the pathophysiology of the tricuspid valve disease as a basis for validating novel tricuspid valve interventions before clinical use. The study aim was to evaluate and compare the tricuspid valve anatomy of porcine and human hearts.

Methods: The anatomy of the tricuspid valve and the surrounding structures that affect the valve during a cardiac cycle were examined in detail in 100 fresh and 19 formalin-fixed porcine hearts obtained from Danish Landrace pigs (body weight 80 kg). All valvular dimensions were compared with human data acquired from literature sources.

Results: No difference was seen in the tricuspid annulus circumference between porcine and human hearts (13.0 ± 1.2 cm versus 13.5 ± 1.5 cm; p = NS), or in valve area (5.7 ± 1.6 cm2 versus 5.6 ± 1.0 cm2; p = NS). The majority of chordae types exhibited a larger chordal length and thickness in human hearts compared to porcine hearts. In both species, the anterior papillary muscle (PM) was larger than other PMs in the right ventricle, but muscle length varied greatly (range: 5.2-40.3 mm) and was significantly different in pigs and in humans (12.2 ± 3.2 mm versus 19.2 mm; p <0.001).

Conclusions: The porcine tricuspid valve was determined to be a valid model for preclinical animal studies, despite various anatomic differences being noted between porcine and human hearts.

How to cite: Waziri, F., Lyager Nielsen, S., & Michael Hasenkam, J. (2016). Porcine Tricuspid Valve Anatomy and Human Compatibility: Relevance for Preclinical Validation of Novel Valve Interventions. The Journal of heart valve disease, 25(5), 596–605.

Background: A possible relationship between an obstructive prosthesis and suboptimal hemodynamic recovery, as reflected by unsatisfactory regression in systolic pulmonary artery pressure (sPAP) and functional tricuspid regurgitation (FTR) following mitral valve replacement (MVR), was investigated. A delineating effective orifice area index (EOAI) value was sought in order to define a patient-prosthesis mismatch.

Methods: A total of 128 patients undergoing isolated mechanical MVR were followed up for a mean of 46 ± 9 months. Patients were allocated to two groups. Group I comprised 83 patients (65%) exhibiting a satisfactory (≥30%) regression in sPAP and FTR, while group II comprised 45 patients with a <30% (suboptimal) decrease in these parameters. A cutoff value for the prosthetic mitral valve in-vivo EAOI was explored as a predictor of postoperative hemodynamic recovery.

Results: The mean in-vivo EOAI differed significantly between the groups (1.23 cm2/m2 in group I versus 1.11 cm2/m2 in group II; p <0.0001). The consequent receiver operating characteristic curve analysis revealed an EOAI of 1.19 cm2/m2 as the cut-off value, below which a suboptimal postoperative regression in pulmonary hypertension and FTR is predicted.

Conclusions: An in-vivo EOAI <1.19 cm2/m2 strongly suggests a suboptimal hemodynamic recovery following MVR with the bileaflet mechanical prosthesis used in the present study. Although no direct relationship between prosthesis size and in vivo EOAI was demonstrated, the logical approach is to implant a prosthesis of the largest possible size.

Background: Mitral chordae tendineae rupture (MCTR) is a progressive disorder which leads to severe mitral regurgitation. Despite its importance, the precise pathogenetic mechanism of MCTR remains unclear. The study aim was to investigate the expression profile of circulating microRNAs (miRNAs) as being potentially involved in the development of MCTR.

Methods: Twenty-one patients with 'primary' MCTR, and 30 age- and gender-matched controls, were enrolled in the study. Comparisons were made between the expression levels of circulating miRNAs in MCTR patients and controls. Four target gene databases were used to predict target genes and pathways of differentially expressed miRNAs.

Results: Compared to controls, the expression of 22 miRNAs (hsa-miR-106b-5p, hsa-miR-126-3p, hsa-miR-150-5p, hsa-miR-17-5p, hsa-miR-195-5p, hsa-miR-19a-3p, hsa-miR-19b-3p, hsa-miR-20a-5p, hsa-miR-21-5p, hsa-miR-222-3p, hsa-miR-223-3p, hsa-miR-23a-3p, hsa-miR-25-3p, hsa-miR-92a-3p, hsa-miR-93-5p, hsa-miR-26b-5p, hsa-miR-30e-5p, hsa-miR-373-3p, hsa-miR-15b-5p, hsa-miR-16-5p, hsa-miR-191-5p, hsa-miR-26a-5p) were significantly down-regulated in the MCTR group. Bioinformatic analysis indicated that the following potential miRNA targets and pathways are commonly related to the development of MCTR: MMPs, TIMP-2,TGFBR2, VEGFA, PIK3R2, NRAS, PPP3CA, PPP3R1, PTGS 2 were predicted as putative targets of 13 of these miRNAs.

Conclusions: The present study is the first to describe altered miRNA expression in patients with MCTR. Bioinformatic analysis has revealed that target genes involved in MCTR development were regulated by miRNAs.

How to cite: Bulent Vatan, M., Kalaycı Yigin, A., Akdemir, R., Tarik Agac, M., Akif Cakar, M., Aksoy, M., Tatli, E., Kilic, H., Gunduz, H., Guzel, D., & Karacan, K. (2016). Altered Plasma MicroRNA Expression in Patients with Mitral Chordae Tendineae Rupture. The Journal of heart valve disease, 25(5), 580–588.

Background: Re-entrant atrial arrhythmias are common in patients after cardiac surgery. To date, however, no studies have reported the safety and efficacy of radiofrequency (RF) ablation of macro-re-entrant atrial arrhythmias in a unique, homogeneous group of patients after surgical replacement of the aortic valve and single right atriotomy.

Methods: Among over 4,000 RF catheter ablations performed at the authors' center between 2008 and 2014, eight patients (seven males, one female; mean age 55.1 ± 19.9 years) after aortic valve replacement (AVR) and without history of any other cardiosurgical procedures were identified with documented macro-re-entrant atrial arrhythmia. The mechanism of macro-re-entrant arrhythmia was analyzed, as well as the safety and efficacy of RF ablation in a group of patients after AVR and single right atrial free wall atriotomy.

Results: The average time from surgery to RF catheter ablation was 11.3 ± 11.3 years (range: 4-35 years). In five patients with permanent arrhythmia, entrainment mapping proved these arrhythmias to be cavotricuspid isthmus- dependent, in three patients with paroxysmal atrial arrhythmia cavotricuspid isthmus-dependent atrial flutter was induced during the electrophysiological study. Intra-atrial re-entrant tachycardia was neither recorded nor induced in any patient. Successful ablation of cavotricuspid isthmus is defined as the termination of arrhythmia, and bidirectional block in cavotricuspid isthmus was achieved in all patients. A long-term follow up, based on a seven-day Holter monitoring, was conducted in all patients, with a mean observation time of 40.1 ± 28.6 months after the procedure. Among the patients, ablated arrhythmia (cavotricuspid isthmusdependent atrial flutter) recurred in one patient, atrial fibrillation occurred in three patients, and an atrial tachycardia in one patient.

Conclusions: In the presented series of patients, cavotricuspid isthmus-dependent atrial flutter was shown to be the mechanism of post-cardiosurgical macro-re-entrant clinical arrhythmia in all subjects. Atrial fibrillation was frequently observed among those patients during follow up.

How to cite: Orczykowski, M., Derejko, P., Urbanek, P., Bodalski, R., Kodziszewska, K., Sierpiński, R., Baranowski, R., Bilińska, M., & Szumowski, Ł. (2016). Ablation of Macro-Re-Entrant Atrial Arrhythmia Late after Surgical Aortic Valve Replacement. The Journal of heart valve disease, 25(5), 574–579.

Background: Currently, the use of transcatheter aortic valve implantation (TAVI) is constantly increasing, whilst cardiosurgical back-up varies substantially. Besides immediate conversion to surgical aortic valve replacement (SAVR) for periprocedural complications, SAVR for TAV failure may be necessary within the early or late post-implant course. The etiology, incidence, risk-stratification, management and outcome for both scenarios are largely unclear. The study aim was to provide details of the authors' experience of SAVR after the failure of TAVI at a single institution.

Methods: Nineteen patients (14 males, five females) underwent SAVR after TAVI at the authors' institution between June 2008 and December 2015. The patients' initial EuroSCORE II was 8.54 ± 9.81. In eight cases (42%; 50% transfemoral) an immediate conversion was necessary due to paravalvular leakage and insufficiency (n = 1), valve-malpositioning (n = 1), valve dislocation (n = 3), valve-trapping in mitral chordae (n = 1), and annular rupture (n = 2). The 50% transfemoral EuroSCORE II was 19.06 ± 8.61. In 11 patients transcatheter valve failure occurred at a mean of 18 ± 17 months after TAVI (two patients with structural valve failure and one with severe paravalvular leakage, seven with prosthetic valve endocarditis, and one patient with aortic aneurysm); the mean EuroSCORE II was 13.42 ± 13.06.

Results: For immediate conversion, the cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 104 ± 40 min and 60 ± 16 min, respectively. Concomitant procedures were necessary in two patients, one patient required hypothermic circulatory arrest (HCA) and one died intraoperatively. For early and late failure, the CPB and cross-clamp times were 115 ± 32 min and 82 ± 20 min, respectively. HCA was necessary in one patient, and concomitant procedures in seven patients. The 30-day survival was 63% for immediate SAVR and 100% for early and late SAVR, even though one more patient died on postoperative day 31 after immediate SAVR. Besides, the longest follow up periods were 29 ± 15 months and 19 ± 14 months for immediate and early/late failure, respectively. In both groups, one patient died from cardiovascular-related causes, and one from non-valve-related causes.

Conclusions: SAVR after previous TAVI will become increasingly relevant. Due to the increasing use of TAVI in medium- or lower-risk patients, adequate strategies must be established since, in comparison to multimorbid patients, not taking action in these patients is not an option. Due to potentially high-risk patients and unique technical implications, SAVR after TAVI differs from conventional (redo) AVR. Under optimal conditions, acceptable survival rates can be achieved, but effective interdisciplinary approaches are essential.

How to cite: Guenther, S. P. W., Pichlmaier, M. A., Bagaev, E., Herrmann, F., Schramm, R., Massberg, S., Hagl, C., & Khaladj, N. (2016). Immediate, Early and Late Failure after Transcatheter Aortic Valve Implantation: How to Deal with the Inoperable?. The Journal of heart valve disease, 25(5), 557–567.

Transcatheter aortic valve implantation (TAVI) is currently the treatment of choice for patients with severe aortic stenosis (AS) who are unsuitable for surgical aortic valve replacement (SAVR), and is an acceptable alternative for those at high and intermediate surgical risk. In published TAVI registries and meta-analyses, whilst women are significantly older they present with fewer comorbidities compared to men (including coronary artery disease, peripheral vascular disease, diabetes and chronic obstructive pulmonary disease). In response to chronic pressure overload from AS, women have been shown to develop greater levels of left ventricular hypertrophy than men, as well as having a greater preservation of LV ejection fraction (LVEF) and less fibrosis. Following aortic valve replacement, women have been shown to have a faster regression of myocardial hypertrophy, with a significant improvement in LVEF. Following TAVI, female gender seems to be associated with a significantly lower one-year mortality. In the current viewpoint, it is discussed whether these findings reflect a true differential treatment response to TAVI among women, or simply the higher comorbidity burden among males undergoing TAVI.

How to cite: Panoulas, V. F., Ruparelia, N., Franks, R., Sen, S., Ariff, B., Sutaria, N., Frame, A., Nihoyannopoulos, P., Malik, I. S., & Mikhail, G. W. (2016). The Impact of Gender on Outcomes Following Transcatheter Aortic Valve Implantation: True Effect or Bias?. The Journal of heart valve disease, 25(5), 552–556.

Background: Prosthesis-patient mismatch (PPM) is highly prevalent among patients undergoing aortic valve replacement (AVR) to treat aortic stenosis. Data regarding the prevalence and impact of PPM on left ventricular remodeling and outcomes in patients who have undergone surgical AVR to treat pure severe aortic regurgitation (AR) are, however, scarce.

Methods: A retrospective analysis was conducted of clinical and echocardiographic data acquired from 50 consecutive patients with pure severe AR, without evidence of significant coronary artery disease, who underwent AVR between 2004 and 2010 at the authors' institution. PPM was defined as a projected in vivo effective orifice area (EOA) 0.85 cm2/m2.

Results: The incidence of PPM was 16%, but no severe mismatch occurred. At a mean follow up of 52 ± 39 months, event-free survival (a composite of all-cause mortality and hospitalization for cardiovascular causes) was similar between patients with and without PPM (p = 0.73). Within seven days after surgery, mean reductions in indexed left ventricular end-diastolic diameter (LVEDD) and indexed left ventricular end-systolic diameter (LVESD) were similar between patients with and without PPM [4.4 mm/m2 versus 5.0 mm/m2; p = 0.67 and 1.6 mm/m2 versus 2.2 mm/m2; p = 0.35, respectively]. At follow up, no difference was observed for mean reductions in indexed LVEDD and indexed LVESD [6.9 mm/m2 versus 7.1 mm/m2; p = 0.91 and 4.1 mm/m2 versus 5.1 mm/m2; p = 0.57, respectively], and mean improvement in left ventricular ejection fraction (4.4% versus 5.1%; p = 0.87).

Conclusions: PPM occurs less frequently in patients undergoing AVR for pure severe AR than for aortic stenosis, and seems to have a less significant impact on ventricular remodeling and outcomes.

How to cite: Auffret, V., Voisine, P., Cinq-Mars, A., Charbonneau, É., Le Ven, F., Dubois-Sénéchal, S. M., Brenna, E., Dagenais, F., Dubois, M., Ridard, C., & Sénéchal, M. (2016). Prevalence and Impact of Prosthesis-Patient Mismatch Following Surgical Aortic Valve Replacement for Pure Aortic Regurgitation. The Journal of heart valve disease, 25(5), 543–551.

Background: Controversy exists regarding the potential effects of lipid metabolism on the expression of proximal aortopathy. The study aim was to compare the association between markers of lipid metabolism and the expression of proximal aortopathy in patients with either bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) disease.

Methods: A total of 458 consecutive patients (68% males) underwent aortic valve replacement (AVR) with or without concomitant aortic surgery between January 2008 and December 2014 at the authors' institution. All patients undergoing combined procedures were excluded. Attention was focused only on those patients who had aortic dimensions quantified by preoperative computed tomography/magnetic resonance imaging and/or transesophageal echocardiography. A correlation analysis was performed between markers of lipid metabolism (e.g., cholesterol, LDL, HDL, and triglyceride) and cross-sectional aortic diameters in BAV patients (n = 273) versus TAV patients (n = 185). Comparisons were also made of correlation patterns between markers of lipid metabolism and proximal aortic diameter in BAV regurgitation (n = 48) versus BAV stenosis (n = 225) cohorts. A logistic regression was performed to analyze predictors of proximal aortic diameter ≥40 mm in BAV and TAV subgroups.

Results: No significant correlation was found between maximal cross-sectional aortic diameters and parameters of lipid metabolism in the whole study population (n = 458). Only preoperative statin therapy was significantly associated with the proximal aortic diameter (OR = 0.64, p = 0.046). Neither was any significant correlation found between markers of lipid metabolism and proximal aortic diameter, separately in BAV and TAV cohorts. Logistic regression revealed a significant association between triglyceride levels and proximal aortic diameter ≥40 mm in the TAV-aortic stenosis (AS) subgroup (OR = 1.4, p = 0.026). Moreover, HDL levels were significantly associated with proximal aortic diameter ≥40 mm in the BAV-AS subgroup (OR = 0.5, p = 0.037).

Conclusions: No significant correlation was identified between markers of lipid metabolism and proximal aortic diameter in surgical BAV and TAV cohorts. The observed correlation between statin use and proximal aortopathy must be addressed in subsequent studies.

How to cite: Sequeira Gross, T. M., Kuntze, T., Bernhardt, A., Reichenspurner, H., von Kodolitsch, Y., & Girdauskas, E. (2016). Markers of Lipid Metabolism Do Not Correlate with the Expression of Aortopathy in Patients with Bicuspid Aortic Valve Disease. The Journal of heart valve disease, 25(5), 534–542.

Background: Continuous pressure overload may lead to subclinical myocardial tissue changes in patients with hypertensive heart disease (HHD) and aortic stenosis (AS). The study aim was to detect interstitial fibrosis using quantitative cardiovascular magnetic resonance.

Methods: Fifteen patients with HHD (arterial hypertension + septal wall thickness ≥13 mm), 33 with AS (eight mild, 15 moderate, 10 severe), and 60 healthy controls were enrolled. Native T1 maps (modified Look-Locker inversion recovery) were obtained in a basal, mid-ventricular, and apical shortaxis slice of the left ventricle to assess cardiac fibrosis. Focal fibrosis was assessed with late gadolinium enhancement (LGE).

Results: Patients with HHD and controls did not differ regarding the native myocardial T1 values, both per slice and per segment. In AS patients, apical native T1 values were lower than in controls, and there was a trend towards higher T1 values in the septum in severe AS (1172.6 ± 62.0 ms versus 1152.9 ± 43.9 ms). Five HHD patients and 11 AS patients had non-ischemic fibrosis in LGE images. Native T1 times did not differ between LGE-positive and LGEnegative groups (both with inclusion and exclusion of segments with LGE).

Conclusions: T1 mapping did not reveal any evidence of abnormal interstitial fibrosis in HHD subjects with mild hypertrophy. In severe AS, a trend towards more interstitial fibrosis was present, but absolute differences were small for decision making.

Hoow to cite: von Knobelsdorff-Brenkenhoff, F., Mueller, A. K., Prothmann, M., Hennig, P., Dieringer, M. A., Schmacht, L., Greiser, A., & Schulz-Menger, J. (2016). Cardiac Fibrosis in Aortic Stenosis and Hypertensive Heart Disease Assessed by Magnetic Resonance T1 Mapping. The Journal of heart valve disease, 25(5), 527–533.

The aim of this review was to describe recent advancements in the understanding of bicuspid aortic valve (BAV). BAV is the most common congenital cardiac anomaly, and affects between 0.46% and 1.37% of the population. There is a male predominance of approximately 3:1.While isolated BAV is found in certain patients, it is often associated with other congenital cardiac lesions, including dilatation of the thoracic aorta, coarctation of the aorta and abnormalities of the coronary anatomy. In most cases, it remains undetected until the patient contracts infective endocarditis, or calcification occurs. Alternatively, the BAV may remain functional for the entirety of the subjects' life, or it may develop progressive calcification, stenosis and regurgitation, with or without infection. Additionally, BAV is associated with aortic aneurysm formation and aortic dissection. Because BAV is a disease of both the valve and the aorta, surgical decision-making is complicated and remains an important challenge to the surgeon. Although recent reports have improved the current knowledge of the disease, many questions remain unresolved. The present review summarizes the current knowledge regarding the genetic basis of BAV and highlights some of the recent findings that have shed a light on the complications of this disease.

How to cite: Wang, L., Ming Wang, L., Chen, W., & Chen, X. (2016). Bicuspid Aortic Valve: A Review of its Genetics and Clinical Significance. The Journal of heart valve disease, 25(5), 568–573.