This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access.

How to cite: Hun Kim, J., Hwa Kim, K., Bum Choi, J., & Hong Kuh, J. (2016). Chordal Shortening for Anterior Mitral Leaflet Prolapse and the Maze Procedure for Persistent Atrial Fibrillation. The Journal of heart valve disease, 25(4), 525–526.

This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access.

How to cite: Banzato, A., Denas, G., Lombardi, G., Pambuku, A., Bianchi, A., & Pengo, V. (2016). The Three Players of Mechanical Valve Thrombosis: Cancer, Anticancer Therapy, and Thromboprophylaxis. The Journal of heart valve disease, 25(4), 522–524.

The case is presented of a non-infectious anterior mitral valve leaflet diverticulum, which appeared as symptomatic mitral stenosis. Unlike previous reports, there was no histological myxomatous degeneration of the valve. To the authors' knowledge, this is the first time a mitral valve diverticulum resulting in severe mitral stenosis has been reported in the literature.

How to cite: Green, P. G., French, A. E., Petrou, M., Manghat, N. E., Lyen, S. M., & Chandrasekaran, B. (2016). Mitral Valve Diverticulum Presenting with Severe Mitral Stenosis: Case Report. The Journal of heart valve disease, 25(4), 515–518.

The case is presented of a 72-year-old male patient suffering from active infective aortic prosthetic endocarditis two months after emergency surgery with aortic valve implantation, and who underwent aortic arch reconstruction using a Dacron patch, due to the spontaneous post-procedural migration of a transcatheter-implanted aortic valve. The heart team considered transcatheter valve implantation (TAVI) due to the increased operative risk demonstrated by a EuroSCORE II of 10.9%, including chronic obstructive pulmonary disease (GOLD 3), cirrhosis (Child-B), esophageal varicose stage 2, chronic renal failure stage 3, and reduced left ventricular ejection fraction. Subsequently, the EuroSCORE II was extremely high (76%) due to active infective prosthetic endocarditis and the aortic arch reoperation. A sutureless aortic valve was implanted and a pericardial patch repair of the aortic ascending and arch completed. Sternal re-stabilization was required postoperatively. The patient was discharged home after 42 days, and no recurrent endocarditis was diagnosed during follow up.

How to cite: Konertz, J., Kastrup, M., Treskatsch, S., & Dohmen, P. M. (2016). A Perceval Valve in Active Infective Bioprosthetic Valve Endocarditis: Case Report. The Journal of heart valve disease, 25(4), 512–514.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

How to cite: Mitsos, S., Attaran, S., & De Souza, A. C. (2016). Right Coronary Artery and Left Anterior Descending Artery Occlusion after Aortic Valve Replacement. The Journal of heart valve disease, 25(4), 504–507.

Transcatheter aortic valve implantation (TAVI) is an emerging treatment for high-risk patients with aortic stenosis. Aortic regurgitation is considered to be a relative contraindication for transcatheter procedures, as a non-calcified aortic annulus poses the risk of an insufficient anchoring of the transcatheter aortic valve prosthesis. Herein is described the case of a patient who suffered from recurrent aortic valve regurgitation after valve-sparing repair, and which was successfully treated by the transcatheter implantation of an Edwards SAPIEN 3™ prosthesis. This case report demonstrated the suitability of this prosthesis to treat pure aortic valve regurgitation, without excessive oversizing of the valve.

How to Cite: Minol, J. P., Veulemans, V., Zeus, T., & Blehm, A. (2016). Implantation of a SAPIEN 3 Valve in a Patient with Pure Aortic Regurgitation. The Journal of heart valve disease, 25(4), 498–500

Transcatheter aortic valve replacement (TAVR) is used for the treatment of aortic stenosis (AS). Besides major bleeding, conduction blocks, stroke or atrial fibrillation, complications include cardiac perforation with possible left-to-right-shunts. Herein is reported the sixth case of a left-to-right shunt in an 87-year-old man who underwent TAVR using a 29 mm Edwards SAPIEN S3 prosthesis to treat AS. Soon after the procedure, a small channel evolving from the right coronary cusp could be detected on echocardiography. The patient was managed medically.

How to cite: Steffen, J., Köhler, A., Schwarz, F., Sadoni, S., Hagl, C., Massberg, S., & Greif, M. (2016). A Left-to-Right Shunt After Transfemoral TAVR Using Edwards SAPIEN 3. The Journal of heart valve disease, 25(4), 491–493.

Background: The study aim was to evaluate the outcomes of minimally invasive valve surgery, performed via a right anterior thoracotomy approach, in patients with a history of multiple (more than two) prior cardiac surgeries.

Methods: A retrospective review was conducted of all minimally invasive valve operations performed in patients with a prior history of two or more cardiac surgeries, including coronary artery bypass grafting (CABG) and/or valve surgery, at the authors' institution between January 2008 and November 2014.

Results: A total of 38 consecutive patients (23 males, 15 females; mean age 65.8 ± 14.6 years) were identified. Nine patients (24%) had two prior CABG operations, 18 (47%) had more than two prior valve surgeries, and 11 (29%) had a cardiac operative history that included both CABG and valve surgery. A total of 34 (89.5%) isolated valve procedures was identified; these consisted of 24 (64%) mitral valve operations, nine (23.7%) aortic valve replacements, and one (0.3%) tricuspid valve repair. Four patients (10.5%) underwent combined mitral and tricuspid valve surgery. Postoperatively, two patients (5.3%) had cerebrovascular accidents, three (7.9%) required reoperation for bleeding, and three (7.9%) had acute kidney injury. The median hospital length of stay was 9.5 days (IQR: 7-16 days). The 30-day mortality was 7.9%. The cumulative survival at one year was 82%, and was 72% at five years.

Conclusions: Minimally invasive reoperative valve surgery after multiple prior cardiac operations is safe and feasible, with good perioperative outcomes and mid-term survival.

How to cite: Santana, O., Krishna, R., Kherada, N., & Mihos, C. G. (2016). Outcomes of Minimally Invasive Valve Surgery in Patients with Multiple Previous Cardiac Operations. The Journal of heart valve disease, 25(4), 487–490.

In adult patients who have undergone mitral annuloplasty with a rigid ring at a young age, the mitral valve may ultimately deform and demonstrate insufficient growth because the valve annulus is fixed to the ring. Mitral valve re-repair, following this scenario, was performed for mitral stenoinsufficiency in a 26-year-old female patient who had undergone mitral annuloplasty with a rigid ring at the age of five years. The valve re-repair procedure consisted of decalcification and stripping of the anterior leaflet and annulus, posterior leaflet augmentation using an elliptical autologous pericardial patch, and a posterior strip annuloplasty sparing the anterior annulus and commissures. Using this procedure, the mitral valve recovered sufficient coaptation area for valve competence, and anterior annular motion was resumed with resultant dynamic changes of the septolateral annular dimension.

How to cite: Hun Kim, J., Youn Kim, T., Bum Choi, J., & Hong Kuh, J. (2016). Mitral Valve Re-Repair in an Adult Patient Having Undergone Mitral Ring Annuloplasty at Five Years of Age. The Journal of heart valve disease, 25(4), 483–486.

Background: Functional mitral regurgitation (FMR) is common in patients with advanced heart failure and impaired left ventricular function. The study aim was to examine functional and hemodynamic effects at three months after MitraClip® implantation in high-risk surgical patients with FMR.

Methods: A group of 93 patients was rejected for surgical treatment by heart-team decisions due to an inacceptable risk for conventional mitral valve surgery. Between October 2011 and May 2015, 89 of these patients (96%) were treated successfully with MitraClip implantation. A subsequent complete follow up was performed over three months in 32 patients with FMR, including pro-brain natriuretic peptide (pro-BNP) measurements, six-minute walk test, echocardiography, and right heart catheterization.

Results: The patients (mean age 73 ± 7 years) presented with a mean left ventricular ejection fraction (LVEF) of 32 ± 13%, and mitral regurgitation (MR) grade ≥3 in 30 of 32 cases (93%). All patients suffered from severe FMR and were highly symptomatic (NYHA functional class III or IV). The mean logistic EuroSCORE was 33%. MitraClip implantation resulted in a significant clinical improvement and reverse cardiac remodelling with a decrease in LV end-diastolic and LV endsystolic diameters, while LVEF was unchanged. In addition, a statistically relevant reduction of systolic, diastolic and mean pulmonary artery pressures (PAPsystolic -7.2 mmHg, p = 0.011; PAPdiastolic -4.5 mmHg, p = 0.003; and PAPmean -5.3 mmHg, p = 0.007) were measured, while the cardiac index (+0.3 l/min/m2, p <0.001) and cardiac output (+0.5 l/min, p <0.001) were increased significantly. The 30-day mortality was 8.6% (n = 8).

Conclusions: Among the study population, MitraClip implantation led to clinical improvement, reverse cardiac remodeling, and a sustained hemodynamic benefit during the three-month follow up period.

How to cite: Barth, S., Hautmann, M. B., Kerber, S., Gietzen, F., Zacher, M., Halbfass, P., Müller, P., Schade, A., Deneke, T., Diegeler, A., Schieffer, B., & Hamm, K. (2016). Hemodynamic Improvement at Three Months after MitraClip® Treatment in End-Stage Heart Failure Patients with Functional Mitral Regurgitation. The Journal of heart valve disease, 25(4), 475–482.

Mitral valve diseases (MVD)s, comprising congenital and acquired forms, are characterized by a diverse etiology, pathophysiology, prevalence, and incidence. In industrialized countries, the acquired forms represent 2.5% of all cardiovascular diseases, with a marked augmentation after the age of 65 years. In addition, all forms of MVDs (i.e., degenerative forms) have a difficult clinical management. The major challenge is 'the early diagnosis', and echocardiographic analysis has been shown inappropriate for diagnosing MVD in moderate forms. Thus, there is a strong need to identify more appropriate biomarker tools to diagnose MVDs at early clinical stage before complications occur and worsen the prognosis. Innovative biomarker tools may particularly be appropriate for the complex treatment of elderly patients, the clinical management of which is very difficult due to the high risk of surgical interventions and no clear benefits in terms of life expectancy or quality of life compared to younger patients. These biomarker tools may be identified as genetic factors and/or components of cellular and molecular pathways related to the mechanisms of MDV pathophysiology. In this review, emphasis is placed on the possibility of proposing matrix metalloproteinase (MMP) pathways, their genetic variants and microRNA as promising predictive, diagnostic and prognostic biomarkers and targets for personalized treatments. Evidence is also provided of the lack of any consistent evidence which actually hampers their clinical application. Thus, criticisms and concerns are underlined, as well as suggestions to close the existing gaps.

How to cite: Rita Balistreri, C., Allegra, A., Crapanzano, F., Pisano, C., & Ruvolo, G. (2016). Matrix Metalloproteinases (MMPs), Their Genetic Variants and miRNA in Mitral Valve Diseases: Potential Biomarker Tools and Targets for Personalized Treatments. The Journal of heart valve disease, 25(4), 463–474.

Background: Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis in intermediate, high-risk, and inoperable patients. TAVR has multiple access routes, including transfemoral (TF), transapical (TA), direct aortic (DA), axillary, transcarotid, and transcaval. The most commonly applied algorithm is a TF-first approach, where only when patients are unsuitable for TF are alternatives such as TA considered. An infrequent - but dreaded - risk is left ventricular (LV) apical bleeding from tearing or rupture with the TA approach. With burgeoning transcatheter mitral technology that requires a TA approach, the study aim was to develop a mathematical model to determine suture forces for TA closure.

Methods: Preoperative cine-cardiac magnetic resonance imaging (MRI) was used to acquire three-dimensional (3D) LV geometry at end-systole and end-diastole. Endocardial and epicardial boundaries were manually contoured using MeVisLab, a surface reconstruction software. 3D surfaces of endocardium and epicardium were reconstructed, and surfaces at end-systole were used to create a 3D LV finite element (FE) mesh. TA access was mimicked by developing a 10-mm defect within the LV FE model. The LV apex was closed using a virtual suture technique in FE analysis with the application of two virtual sutures. After virtual closure, a FE analysis was performed of LV model diastolic filling and systolic contraction.

Results: Proof of concept was achieved to develop an LV transapical access site and perform FE analysis to achieve closure. The FE method of virtual suture technique successfully approximated the LV apical defect. The peak axial forces on virtual sutures at end-diastole and end-systole were 0.445N and 0.736N, respectively.

Conclusions: A LV TA access model was mathematically developed that could be used to evaluate the suture tension of the TA closure process. Further development of this approach may be useful to risk-stratify patients in the future for LV apical tearing. Video 1: Cine cardiac magnetic resonance imaging of the left ventricle. Video 2: Slow motion animation of left ventricular baseline simulation. Video 3: Animation of the virtual suturing process.

How to cite: Ge, L., Haraldsson, H., Hope, M. D., Saloner, D., Guccione, J. M., Ratcliffe, M. B., & Tseng, E. E. (2016). Suture Forces for Closure of Transapical Transcatheter Aortic Valve Replacement: A Mathematical Model. The Journal of heart valve disease, 25(4), 424–429.

Background and aim of the study: A major drawback of the transcatheter aortic valve replacement (TAVR) procedure using the self-expandable Medtronic CoreValve (MCV) prosthesis is the high incidence of conduction disturbances and the need for postprocedural permanent pacemaker (PPM) implantation. The depth of prosthesis implantation may be an important contributing factor. The study aim was to determine the relationship between angiographic measurements of the MCV prosthesis depth and the occurrence of new conduction disturbances and need for PPM after TAVR.

Methods: A retrospective analysis was conducted of 157 consecutive patients who had undergone TAVR procedures with the MCV between 2009 and 2013. Patients with pre-existing pacemakers (n = 27) were excluded. Prosthesis depth was defined as the angiographic distance from the lowest part of the prosthesis to the base of the non-coronary cusp (NCcD) and the base of the left coronary cusp (LCcD).

Results: A 26 mm MCV was implanted in 50% of patients, and a 29 mm MCV in 38%. The rate of new ≥2nd degree atrioventricular block (AVB) after TAVR was 5%, and the incidence of new left ventricular bundle branch block (LBBB) was 23%. PPMs were implanted in 13 patients (10%) within 30 days after the procedure. Freedom from new ≥2nd degree AVB, LBBB and the need for PPM after TAVR was significantly higher among patients with NCcD <6 mm or LCcD <8 mm (90% and 89%, respectively) compared to patients with NCcD ≥6 mm or LCcD ≥8 mm (53% and 54%, respectively) (p <0.0001).

Conclusions: Prosthesis depth, measured relative to either the NCcD or LCcD, strongly predicted the occurrence of conduction disturbances and the need for PPM following TAVR with the MCV prosthesis.

How to cite: Wolff, R., Radhakrishnan, S., Mitsuhashi, H., Zavodni, A., Roifman, I., Sparkes, J. D., Fremes, S. E., Bakar-Irwin, S., Hansen, M. S., & Strauss, B. H. (2016). CoreValve Prosthesis Depth: What is the Optimal Measurement Target?. The Journal of heart valve disease, 25(4), 417–423.

Background and aim of the study: Aortic regurgitation (AR) is a frequent and life-limiting complication after transcatheter aortic valve implantation (TAVI). The study aim was to relate post-TAVI AR, using a self-expandable stent, to detailed baseline anatomical and morphological characteristics of the native aortic valve.

Methods: A total of 82 patients (40 males, 42 females; mean age 80 ± 7 years) who received a Medtronic CoreValve implant was included. Aortic root morphology, aortic annulus and implant size mismatch, implant position, extent of aortic annulus and leaflet calcification, the connected sub-annular calcification volume, and their distribution were quantified based on computed tomography scan analysis. AR following TAVI was quantified using standardized angiography and echocardiography.

Results: The mean logistic EuroSCORE of all patients was 16.9 ± 11.1%. According to angiography and echocardiography, 41% and 39% respectively, of the patients had AR grade ≥2. The two methods correlated moderately (Spearman's ρ = 0.51, p <0.001). The maximal diameter of the native annulus was larger in patients with significant AR after TAVI based on echocardiography (28.0 mm versus 26.8 mm, p = 0.059). Excessive calcification, especially on the left coronary cusp, was present in patients with significant AR, based on angiography (AR ≥II 71.0 mm3 versus AR <II 26.3 mm3, p = 0.001) as well as on echocardiography (AR ≥II 59.9 mm3 versus AR <II 34.0 mm3, p = 0.016).

Conclusions: Of the evaluated characteristics, a larger volume of calcification (especially on the left coronary cusp) is most related to the development of significant AR (grade II-IV) following implantation, when quantified by both angiography and echocardiography.

How to cite: Bosmans, B., Collas, V., Verhoelst, E., Paelinck, B., Vander Sloten, J., & Bosmans, J. (2016). Morphological Characteristics and Calcification of the Native Aortic Valve and the Relation to Significant Aortic Regurgitation after CoreValve TAVI. The Journal of heart valve disease, 25(4), 410–416.

Background and aim of the study: Paravalvular leakage (PVL) remains an unavoidable complication of heart valve surgery and in its severe forms may lead to heart failure and hemolysis. The study aim was to evaluate the echocardiographic, clinical, surgical and laboratory characteristics of patients with aortic PVL.

Methods: A total of 77 aortic PVL patients underwent transthoracic and transesophageal echocardiography examinations. Clinical, echocardiographical and surgical findings were also recorded.

Results: Among the 77 patients, 21 (27.3%) had mild, 33 (42.8%) had moderate and 23 (29.9%) had severe aortic PVL. Seventeen patients (22.1%) had moderate-to-severe hemolysis and had a higher incidence of multiple PVL compared to those with no or mild hemolysis. Moderate- to-severe PVL was more frequent between the non-coronary and the left coronary sinus annuli, especially adjacent to the left main coronary artery ostium. Percutaneous closure was performed in five patients. Eleven patients underwent surgical repair, and the localizations of PVL were in accordance with echocardiographic findings.

Conclusions: Aortic PVL occurs more frequently between the non-coronary sinus and the left coronary sinus annuli, which may be associated with multiple factors. Difficulties in seating the prosthesis due to the steep angulation of the commissure and annulus, the avoidance of deep sutures, and focal annular calcification may make this region prone to injury and leakage.

How to cite: Ozan Gürsoy, M., Kalçık, M., Özkan, M., Ali Astarcıoğlu, M., Karakoyun, S., Gündüz, S., Gökdeniz, T., Yesin, M., Altuğ Tuncer, M., & Köksal, C. (2016). Evaluation of Aortic Paravalvular Leak: A Special Reference for Anatomical Localization. The Journal of heart valve disease, 25(4), 403–409.