Background and aim of the study: Atrial fibrillation (AF) is common in patients submitted for transcatheter aortic valve implantation (TAVI), and these patients are at higher risk of developing conduction system disturbances requiring pacemaker (PM) implantation. Conventional predictors for PM use in this population have limited applicability. It was hypothesized that a post-procedural heart rate reduction could gauge the degree of atrioventricular (AV) node injury, and that this would be a clinically useful predictor of a need for PM.

Methods: All consecutive patients submitted for TAVI between December 2009 and August 2015 were included prospectively in a local registry. Clinical and electrocardiographic data and procedural details were recorded, and patients in sinus rhythm or with pre-existing PM were excluded. Heart rate (HR) at the start and end of the procedure were used to assess post-procedural HR reduction by calculating the HR ratio (HRratio = HRend/HRstart). The relationship between previously described predictors of PM, HRratio and implantation of a permanent PM during the 30 days after TAVI were analyzed using the Wilcoxon ranksum test and receiver operating characteristic (ROC) curve.

Results: A total of 102 patients was submitted for TAVI, 24 of whom had AF and no previous PM. Of the latter 24 patients, 10 (41.6%) received a PM during the 30 days after TAVI. Conventional predictors of permanent PM such as male gender, left anterior hemiblock and right bundle branch block were not significantly associated with PM implantation. The HRratio was significantly lower in patients submitted for PM implantation (median 0.76, IQR 0.68-0.86 versus 1.18, IQR 1.10-1.26; p <0.001; Wilcoxon ranksum test). ROC curve analysis of the HRratio showed a good discrimination for the need of PPM with a c-statistic of 0.93. An optimal cut-off value of 0.9 predicted the need for PM implantation with a sensitivity of 90% and specificity of 92.8% CONCLUSIONS: Conventional predictors of PM after TAVI were not associated with PM implantation in patients with AF. The fall in post-procedural HR was significantly associated with PM implantation, with an HRratio cut-off value of 0.9 accurately predicting a need for PM within 30 days.

How to cite: Portugal, G., Patrício, L., Abreu, A., Cacela, D., Oliveira, M., & Ferreira, R. (2016). Conventional and Novel Predictors of Permanent Pacemaker after TAVI in Atrial Fibrillation Patients. The Journal of heart valve disease, 25(3), 397–402.

Background and aim of the study: The neutrophil-tolymphocyte ratio (NLR) was found to be a predictor of adverse outcome in patients with coronary artery disease (CAD). The ratio may also be a useful marker to predict mortality following valve replacement surgery.

Methods: A total of 932 patients was enrolled retrospectively. Patients were allocated to three tertiles based on their NLR (group 1, NLR ≤1.90; group 2, 1.90 < NLR ≤2.93; group 3, NLR >2.93).

Results: Patients in the highest tertile were older (p = 0.049, 95% CI 0.09-5.98), tended to have chronic renal failure (p = 0.028, OR: 2.6, 95% CI 1.08-6.35), and had more frequent critical CAD on preoperative angiography (p <0.001, OR 2.1, 95% CI 1.38-3.21). Postoperatively, patients in the highest NLR tertile had a higher in-hospital mortality rate than those in the first tertile (p <0.001, OR 4.67, 95% CI 2.37-9.20) and second tertile (p = 0.002, OR 2.26, 95% CI 1.32-3.86). Patients in the third tertile had the highest mortality at day 300 (log-rank p <0.001). The hazard ratio (HR) for the second tertile was 1.8 (p = 0.11, 95% CI 0.88-3.79), and for the third tertile was 2.8 (p = 0.003, 95% CI 1.40-5.59).

Conclusions: The NLR is a useful parameter to assess postoperative in-hospital mortality risk after valvular surgery.

How to cite: Sinan Guvenc, T., Ekmekci, A., Uluganyan, M., Ertas, G., Betul Erer, H., Ozpamuk Karadeniz, F., Tanik, O., Oz, A., Kocogullari, C., Velibey, Y., Karaca, G., & Eren, M. (2016). Prognostic Value of Neutrophil-to-Lymphocyte Ratio for Patients Undergoing Heart Valve Replacement. The Journal of heart valve disease, 25(3), 389–396.

Background and aim of the study: Bioengineered living autologous valves with remodeling and growth capacity represent a promising concept for future cardiac and venous valve repair. A meticulous understanding of the mechanisms involved in recellularization and remodeling is essential for the safe and efficient clinical translation of this technology. In this context, the first investigations of bioengineered vascular grafts in immune-incompetent or transgenic rodents represented an important step. However, the in-vivo assessment of bioengineered synthetic scaffold-based (biodegradable) valve replacements in rodent models has not been achieved to date.

Methods: Miniaturized monocuspid PGA (polyglycolic acid)-P4HB (poly-4-hydroxybutyrate)-based valves were created, incorporated into metallic stents (length 2.0 mm, diameter 1.1 mm) and introduced into catheter-based implantation devices. Wistar outbred rats (n = 8) underwent a laparotomy, abdominal aorta arteriotomy and valve delivery into the abdominal aorta. Valve placement and function were evaluated following deployment using ultrasound (Doppler- and M-mode). Explanted tissues were analyzed both macroscopically and histopathologically.

Results: No significant physiological or hemodynamic changes were observed, including heart rate, pressure gradients, velocity values and cardiac output before and after valve implantation. The cross-sectional area at the level of the stented valve was reduced by 22%. Valvular leaflet oscillation was observed in two animals, and thrombus formation in the stent was observed in one animal. Histological evaluation revealed cellular infiltration within 3 h in vivo, and no signs of thrombus deposition on the valvular surface.

Conclusions: This study demonstrated the technical feasibility of the transcatheter implantation of bioengineered stented miniaturized valves into the infrarenal rat aorta, without affecting the animal's physiological and hemodynamic variables and with valvular oscillation in part of the implants. These results could serve as a basis for the implementation of a chronic rat in-vivo model for mechanistic studies in bioengineered valvular tissues under systemic hemodynamic conditions. Video 1: 2D ultrasonographic projection revealing graft's leaflet oscillation.

How to cite: Książek, A. A., Mitchell, K. J., Cesarovic, N., Schwarzwald, C. C., Hoerstrup, S. P., & Weber, B. (2016). PGA (polyglycolic acid)-P4HB (poly-4-hydroxybutyrate)-Based Bioengineered Valves in the Rat Aortic Circulation. The Journal of heart valve disease, 25(3), 380–388.

Background and aim of the study: Q fever, caused by the rickettsia Coxiella burnetii, is a worldwide zoonotic disease with both acute and chronic manifestations. Endocarditis is the principal chronic manifestation. Q fever can easily be mistaken for degenerative valve disease due to its indolent presentation, the fastidious nature of the organism (routine cultures are negative), and the absence of a typical echocardiographic and macroscopic appearance for endocarditis. Prosthetic valve failure, with associated morbidity and mortality, have been described following unrecognized infections.

Methods: Previous studies have documented the value of screening strategies in areas of high prevalence. Hence, a pilot study was conducted in a low-prevalence setting, in which 139 patients at two tertiary cardiac centers attending for elective valve replacement for degenerative valvular disease underwent testing for chronic Q fever infection by serological and molecular methods on blood and valve tissue.

Results: Five patients (3.7%) had serological evidence of past exposure to Q fever (consistent with rates in the literature). None had evidence of chronic Q fever endocarditis. The cost of adopting a universal screening strategy is around £40,000 per case (if serology is used to screen patients prior to surgery).

Conclusions: Alternative and more cost-effective methods for identifying clinically quiet cases of chronic Q fever endocarditis are required.

How to cite: Seddon, O., Ashrafi, R., Duggan, J., Rees, R., Tan, C., Williams, J., Carson, G., & Healy, B. (2016). Seroprevalence of Q Fever in Patients Undergoing Heart Valve Replacement Surgery. The Journal of heart valve disease, 25(3), 375–379.

Background and aim of the study: Infective endocarditis (IE) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The study aim was to evaluate the demographic, clinical, microbiological and inpatient mortality data of IE in hemodialysis patients.

Methods: Data were analyzed for all IE patients admitted to the authors' 800-bed tertiary care hospital between January 2001 and December 2014. These data included demographics, comorbidities, clinical and microbiological characteristics, echocardiographic findings, complications, outcomes, and in-patient mortality.

Results: A total of 296 patients, including 52 on hemodialysis, was admitted with a diagnosis of IE. The median age of patients with ESRD (28 females, 24 males) was 55.9 ± 15.47 years. The prevalences of comorbidities such as hypertension (80%) and diabetes mellitus (46%) were significantly higher in ESRD patients, whereas other comorbidities were similarly distributed in both groups. The mitral valve was the most commonly involved (55.8%), followed by aortic (21.7%), tricuspid (21.2%) and pulmonary (1.9%) valves. Staphylococcus aureus was the most common organism (40%), followed by Enterococcus sp. (13.7%), Gram-negative staphylococci (13.7%), coagulase-negative staphylococci (11.5%), and Streptococcus sp. (5.7%). Polymicrobes were found in 11.5% of patients and cultures were negative in 19%. The mean ejection fraction in these patients was 42 ± 4.19% and the mean area of vegetation was 63.5 ± 40 mm2. The in-hospital course of 11 patients was complicated by embolic events, while three patients had acute heart failure and one patient had heart block secondary to IE. A total of four patients (7.7%) died during the index hospitalization.

Conclusions: IE in patients receiving chronic hemodialysis is a very frequent occurrence. Its diagnosis is complex and its presence should be considered in all hemodialysis patients with bacteremia. In the present study the etiology was shown to be multifactorial, with the mitral valve being the most commonly involved and S. aureus the most common organism.

How to cite: Vasudev, R., Shah, P., Kaur, S., Chitturi, C., Yamini, S., Mechineni, A., Chandran, C., Bikkina, M., & Shamoon, F. (2016). Infective Endocarditis in Hemodialysis Patients. The Journal of heart valve disease, 25(3), 369–374.

Propionibacterium acnes is known to be a causative microorganism in low-grade and late prosthetic valve endocarditis. Here, the case is reported of a late, apparently culture-negative endocarditis of an aortic mechanical prosthesis, diagnosed to be caused by P. acnes after pan-bacterial polymerase chain reaction (PCR) on the explanted mechanical prosthetic valve. This endocarditis was complicated by an aortic root abscess; after surgical resection a ventricular septal defect (VSD) with overt right ventricular and multiple organ failure occurred. Low suspicion, the failure of routine blood culture to grow P. acnes and erroneous interpretation of P. acnes as contamination, frequently delay the correct diagnosis and treatment of this condition. Hence, although infection with P. acnes is usually indolent, abscess formation and a need for surgery are common.

How to cite: De Caluwé, E., & Verwerft, J. (2016). Complicated Infective Endocarditis of a Mechanical Aortic Valve due to Propionibacterium acnes. The Journal of heart valve disease, 25(3), 364–368.

Background: Carcinoid tumor is a slow-growing type of neuroendocrine tumor, originating from enterochromaffin cells and secreting mainly serotonin. The diagnosis is based on clinical symptoms, hormone blood levels, radiological and nuclear imaging, and histological confirmation. However, most patients have metastases at the time of diagnosis because the clinical signs often remain unnoticed or are attributed to other abdominal conditions. In up to 50% of patients the endocardium is affected due to a hormonally active tumor profile. The study aim was to report the outcome of surgical treatment in patients with carcinoid heart disease, including the data of radiological and nuclear imaging, histological diagnosis, and follow up information.

Methods: Between 2008 and 2014, a total of 39 consecutive patients (28 males, 11 females; mean age 66 years; range: 28-84 years) with carcinoid heart syndrome were operated on at the authors' institution. Valvular heart disease was diagnosed with two-dimensional echocardiography. The study population included 26 patients (67%) with severe metastatic disease, who underwent radiotherapy preoperatively, and 13 patients (33%) who were metastasis-free and did not receive preoperative systemic therapy. Follow up was available for all hospital survivors, all of whom underwent serial echocardiographic follow up postoperatively. Adverse cardiac events were defined as cardiac-related death, a need for valvular reintervention, the occurrence of valve prosthesis-related complications, or echocardiographic evidence of new, high-degree valvular dysfunction during follow up.

Results: The majority of patients (n = 34; 87%) underwent isolated tricuspid valve replacement, while simultaneous pulmonary valve replacement was performed in five patients (13%). Postoperative complications included reoperation for bleeding in five patients (13%) and new heart block requiring pacemaker implantation in 10 (25%). The in-hospital mortality was 5% (n = 2). The overall survival was 43% at six years postoperatively. At the latest follow up, 12 of the 17 survivors were in NYHA class I, and five in NYHA class II. The adverse cardiac event rate was 71%. Echocardiographically, 46% of patients (6/13) showed at least stationary or mild improvement in the right ventricular ejection fraction at follow up, with no evidence of paravalvular leak, infective endocarditis, or progressive other native valvular carcinoid affection. Postoperatively, the right atrial dimensions were preserved as normal in 23 patients (59%), mildly dilated in six (15%), moderately dilated in three (8%), and severely dilated in seven (18%). Valve-in-valve transcatheter aortic valve implantation was performed in two patients (12%) due to structural degeneration of the valve bioprosthesis and native valve disease progression.

Conclusions: Despite advanced systemic disease, the surgical treatment of patients with carcinoid heart syndrome is associated with an acceptable perioperative risk and satisfactory mid-term survival. Those patients who survived valve surgery benefited from a significant improvement in their functional capacity. Percutaneous procedures may represent a useful tool to reduce the risk of late valvular reinterventions.

How to cite: Kuntze, T., Owais, T., Secknus, M. A., Kaemmerer, D., Baum, R., & Girdauskas, E. (2016). Results of Contemporary Valve Surgery in Patients with Carcinoid Heart Disease. The Journal of heart valve disease, 25(3), 356–363.

Background and aim of the study: The prosthetic valve of choice in patients with carcinoid valve disease (CVD) remains controversial due to the limited life expectancy of patients with advanced-stage neuroendocrine tumors (NETs) on the one hand, and concerns regarding structural valve deterioration (SVD) on the other hand.

Methods: The records of 17 patients (11 females, seven males; mean age 65 ± 11 years; undergoing 18 operations) with primarily right heart failure due to CVD were reviewed. All patients received somatostatin analogs perioperatively. Hospital and follow up data (acquired via direct patient contact and echocardiography) collected included baseline characteristics, procedural details, and clinical outcomes.

Results: The primary NET site was the ileum (n = 11), lungs (n = 2) and stomach, colon and appendix (n = 1 each). In one patient the primary tumor location could not be identified. Preoperative urinary levels of 5-hydroxyindole acetic acid (5-HIAA; 61 ± 36 mg/24 h) and serum levels of chromogranin A (2926 ± 4057 ng/ml) were 10- and 50-fold greater than normal, respectively. A total of 23 valves was implanted: five tricuspid valve replacements (TVR; four tissue and one mechanical), TVR and pulmonary valve replacements (PVR; three tissue and one mechanical), and TVR and mitral valve replacements (MVR; one tissue and two mechanical). The 30-day mortality was 11% (n = 2). No patient experienced a carcinoid crisis. The mean follow up was 24 ± 21 months (range: 4-85 months). Four patients (receiving seven valves) developed SVD at 12, 14, 15, and 20 months after surgery, and all of these patients died. The actuarial four-year survival and freedom from SVD were 23 ± 14% and 43 ± 15%, respectively.

Conclusions: The data acquired suggested that the main advantage of tissue valve prostheses, namely to avoid lifelong, intense anticoagulation, might be offset by accelerated SVD. The use of mechanical valves should be considered in CVD patients with a large primary tumor mass and persistent high urinary levels of 5-HIAA, and who are unresponsive to therapy.

How to cite: Korach, A., Grozinsky-Glasberg, S., Atlan, J., Dabah, A., Atlan, K., Rudis, E., Elami, A., Gross, D. J., Reardon, M. J., & Shapira, O. M. (2016). Valve Replacement in Patients with Carcinoid Heart Disease: Choosing the Right Valve at the Right Time. The Journal of heart valve disease, 25(3), 349–355.

Background: The outcomes of re-repair of the tricuspid valve to treat recurrent tricuspid regurgitation (TR) after tricuspid valve suture surgery were analyzed.

Methods: Thirty-six patients (mean age 65.3 ± 9.3 years) who underwent re-repair of the tricuspid valve to treat recurrent TR between January 1990 and November 2014 were reviewed retrospectively. All patients underwent suture annuloplasty for TR. Of these 36 patients, 15 (41.7%) underwent ring annuloplasty and 21 (58.3%) underwent re-suture annuloplasty. The mean follow up period was 5.8 ± 6.1 years.

Results: The overall hospital mortality rate was 13.9% (5/36). Pre-discharge TR grades were 1.2 ± 0.7 in the ring group and 1.4 ± 0.8 in the re-suture group (p = 0.7353). There were no significant differences in survival, freedom from late TR and freedom from valve-related events between the two groups. At the final follow up, TR >mild was present in four patients (36.4%) in the ring group, and in 12 patients (75%) in the re-suture group (p = 0.0447). Severe TR was present in five patients (31.3%) in the re-suture group, but none was present in the ring group (p = 0.2445).

Conclusions: In the present study cohort, the durability of re-repair of the tricuspid valve using a flexible prosthesis appeared to be superior to the durability following re-suture annuloplasty.

How to cite: Fukunaga, N., Okada, Y., & Koyama, T. (2016). Re-Repair of Tricuspid Valve after Tricuspid Suture Annuloplasty: An Analysis of the Causes for Reoperation and its Durability. The Journal of heart valve disease, 25(3), 341–348.

Background: The study aim was to investigate the mechanism of mitral regurgitation (MR) in lone atrial fibrillation (AF) patients using three-dimensional (3D) transesophageal echocardiography (TEE).

Methods: A retrospective analysis was conducted of 64 patients with AF and a normal left ventricle, and without prolapse of the mitral valve. Among these patients, significant MR was not identified in 33 cases (AF+MR- group) but was present in 31 cases (AF+MR+ group). The distance from the coaptation to the bending point of the anterior mitral leaflet (AML), where the chorda was attached, was termed the 'bending length'. The ratio of the bending length to the distance from coaptation to anterior mitral annulus was termed the 'bending ratio' (= bending length/coaptation-annulus length). The mitral annular area (MAA) fractional change was defined as follows: (MAA at late systole - MAA at early systole)/MAA at late systole × 100%). Other parameters relating to mitral valve morphology obtained using 3D TEE were measured with commercial software (QLAB, Phillips).

Results: The coaptation length (CL) was smaller in the AF+MR+ group than in the AF+MR- group (p<0.001), and correlated significantly with the anteriorposterior diameter of the mitral annulus (R = 0.286, p = -0.022), MAA at mid-systole (R = -0.269, p = 0.032), MAA fractional change (R = 0.434, p <0.001), and the bending ratio (R = -0.603, p <0.001). With a multivariable analysis, the correlating factors of significant MR in lone AF patients were a decrease in MAA fractional change (p = 0.022) and an increase of the bending ratio (p = 0.009).

Conclusions: Small MAA fractional changes and the distant position of the chordae tendineae on the AML from the coaptation correlated with significant MR in AF patients with normal left ventricular systolic function.

How to cite: Itabashi, Y., Mihara, H., Berdejo, J., Utsunomiya, H., & Shiota, T. (2016). Distant Position of Chordae from Coaptation Causes Mitral Regurgitation in Patients with Atrial Fibrillation. The Journal of heart valve disease, 25(3), 323–331.

A 73-year-old male received a percutaneous mitral valve repair with a MitraClip to treat severe (grade IV) symptomatic mitral regurgitation (MR). The MitraClip® procedure reduced the MR to grade I, but the patient died 14 days post-procedurally due to a pneumosepsis. Histological analysis of the MitraClip mesh covering showed a chronic inflammatory reaction with an abundance of multinucleated giant cells. Remarkably, signs of early onset clip-coverage were found, indicated by the presence of a few scattered myofibroblasts.

How to cite: Velu, J. F., de Boer, H. H., Bouma, B. J., & Baan, J., Jr (2016). MitraClip®: Two Weeks after Implantation. The Journal of heart valve disease, 25(3), 320–322.

Background: Mitral regurgitation causes left atrial (LA) and left ventricular (LV) dysfunction, dilatation, and remodeling. Following percutaneous mitral valve repair (PMVR) using the MitraClip® approach, reverse cardiac remodeling is desirable. To date, the influence of PMVR on LA and segmental LV function and remodeling has not been investigated in detail.

Methods: Twenty-six patients who received the MitraClip device were enrolled in an open-label, single-center observational study. Patients underwent clinical assessment, conventional echocardiography and global and segmental longitudinal strain analysis of the left atrium and left ventricle by speckle tracking echocardiography at baseline and at a three-month follow up.

Results: PMVR improved both LV systolic function (from 40.5 ± 2.5% to 45.0 ± 2.5%, p = 0.04) and LV global longitudinal strain (from -8.9 ± 0.7% to -10.7 ± 0.9%, p = 0.004). Segmental analysis revealed improved myocardial deformation mainly in the basal (basalseptal -8.9 ± 0.8% to -12.9 ± 0.8%, p = 0.0002; basallateral -7.9 ± 1.1% to -13.9 ± 1.4%, p = 0.0005) and midventricular segments (mid-septal -12.7 ± 0.9% to -14.5 ± 1.1%, p = 0.02; mid-lateral -7.5 ± 0.8% to -10.8 ± 1.2%, p = 0.006). In patients with pre-procedural preserved LA function with sinus rhythm the impact of PMVR revealed an improvement in LA global conduit function (from 10.6 ± 1.2% to 13.9 ± 1.6%, p = 0.003) and global contractile function (from -2.1 ± 0.47% to -3.5 ± 0.5%, p = 0.03). The reversed remodeling was not associated with altered levels of the cardiac biomarkers matrix metalloproteinase 2 (MMP-2) and MMP-9, tissue-inhibitors of MMPs (TIMP-2 and ST-2).

Conclusions: PMVR improves global segmental LV and LA function and leads to a reverse remodeling.

How to cite: Rammos, C., Zeus, T., Balzer, J., Veulemans, V., Hellhammer, K., Niebel, S., Kelm, M., & Rassaf, T. (2016). Left Atrial and Left Ventricular Function and Remodeling Following Percutaneous Mitral Valve Repair. The Journal of heart valve disease, 25(3), 309–319.

Background: Paravalvular aortic regurgitation (PAR) remains a common complication following transcatheter aortic valve replacement (TAVR), and has been associated with increased mortality. Adverse left ventricular (LV) remodelling has been reported in patients with post-TAVR PAR, but the association between adverse LV remodeling and increased mortality remains unclear. The aim of the present study was to examine the association between PAR, LV remodeling and mortality following TAVR in a non-PARTNER (Placement of Aortic Transcatheter Valves) trial population.

Methods: A total of 195 patients that underwent TAVR was included in the study. The LV ejection fraction (LVEF), LV mass index (LVMI), LV internal dimension at systole (LVIDs) and diastole (LVIDd) were compared between patients with different degrees of PAR at baseline, and at one month and one year after TAVR. Survival analysis was performed for different degrees of PAR and LV remodeling.

Results: PAR ≥moderate was associated with increased mortality (HR 4.58 [1.80-11.63], p = 0.001), but PAR >mild was not. The LVIDd and LVIDs were persistently increased at one year after TAVR in patients with PAR >mild compared to those with PAR ≤mild (5.9 ± 0.8 cm versus 5.4 ± 0.7 cm, p = 0.02 and 4.4 ± 0.8 cm versus 3.9 ± 0.8, p = 0.03, respectively). The LVEF was improved similarly between the two groups at one year after TAVR (p = 0.1). Patients with PAR ≥moderate had significantly more adverse LV remodeling at one month after TAVR in terms of LVIDd, LVIDs, and LVMI. The degree of remodeling as expressed in terms of LVIDd, LVIDs, LVMI and LVEF changes from baseline did not have a direct impact on mortality.

Conclusions: A worse PAR was associated with more adverse LV remodeling and a higher mortality after TAVR in a non-PARTNER patient population.

How to cite: Kampaktsis, P. N., Ullal, A. V., Minutello, R. M., Feldman, D. N., Swaminathan, R. V., Voudris, K., Baduashvili, A., Pastella, K., Pawar, S., Kaple, R. K., Vavuranakis, M., Bergman, G. S., Skubas, N. J., Lin, F., Salemi, A., Devereux, R. B., & Chiu Wong, S. (2016). Impact of Paravalvular Aortic Insufficiency on Left Ventricular Remodeling and Mortality after Transcatheter Aortic Valve Replacement. The Journal of heart valve disease, 25(3), 301–308.

Peri-aortic hematoma has been recently described as a potentially life-threatening complication following transcatheter aortic valve replacement (TAVR). Patient- and procedure-related factors exist that predispose to peri-aortic hematoma formation, which can progress to myocardial rupture at the aortic root-myocardial junction. While conservative therapy with blood pressure control is the expectant management following peri-aortic hematoma formation, myocardial rupture can occur at the site of the aortic annulus. Hence, interventionists and echocardiologists must be prepared for emergent intervention to salvage the patient once the complication is recognized. The present report highlights the patho-histological findings related to left ventricular outflow tract calcification following TAVR.

How to cite: Kalra, A., Pedersen, W. R., Mackey-Bojack, S. M., Duncanson, E. R., & Harris, K. M. (2016). Patho-Histological Findings of Annular Rupture Related to Left Ventricular Outflow Tract (LVOT) Calcification Following Transcatheter Aortic Valve Replacement (TAVR). The Journal of heart valve disease, 25(3), 296–300.

Background: The echocardiographic grading of paravalvular aortic leakage (PVL) after transcatheter aortic valve implantation (TAVI) severity is challenging. The study aim was to assess the value of quantitative Doppler echocardiography to monitor PVL severity.

Methods: A total of 100 subjects was enrolled in the study, including 65 consecutive patients who had undergone TAVI with a CoreValve prosthesis and without valvular aortic regurgitation, and 35 normal controls. The PVL volume was calculated using the quantitative Doppler method as the difference of left and right ventricular stroke volume (SV). PVL severity was assessed both visually and quantitatively as the circumferential extent on a short-axis view (SAX).

Results: The inter-observer variabilities for SVs in TAVI patients were disappointing: 14 ± 11% for the left ventricular SV and 18 ± 14% for right ventricular SV. The correlation (r2) between the averaged regurgitant PVL volume and circumferential SAX extent of PVL was 0.02 (p = NS). The relationship between PVL volumes and categories, defined quantitatively by the circumferential SAX extent of PVL and qualitatively by visual assessment of severity of PVL were poor. The results improved when only patients with optimal quality images were included but were still statistically non-significant.

Conclusions: The relationship between calculated PVL volume in TAVI patients and other estimates of PVL severity was poor, most likely due to intrinsic errors made in the quantitative Doppler method. Therefore, one should be prudent to include the quantitative Doppler method in TAVI patients in clinical trials and clinical decision-making, in particular in patients with reduced image quality.

How to cite: M Di Martino, L. F., I Soliman, O. I., Vletter, W. B., Ren, B., de Vries, T., Galema, T. W., Van Mieghem, N. M., de Jaegere, P. P., & Geleijnse, M. L. (2016). Quantitative Doppler for Estimation of Paravalvular Leakage after Transcatheter Aortic Valve Implantation. The Journal of heart valve disease, 25(3), 289–295.

Background: The Direct Flow Medical (DFM) valve is a new non-metallic and repositionable bioprosthesis used for transcatheter aortic valve implantation (TAVI). The study aim was to investigate procedural and post-implant valve data in patients receiving differently sized DFM bioprostheses.

Methods: Procedural, echocardiographic and computed tomography findings of 28 patients receiving either a 25, 27 or 29 mm DFM bioprosthesis were analyzed.

Results: Implantation of a 29 mm bioprosthesis was associated with longer procedure (p <0.05) and radiation (p <0.05) times, and a higher dose-area product (p <0.01) compared to the 25 mm valve. A high mean post-interventional aortic gradient indicating a suboptimal result was found in 44% patients receiving a 29 mm bioprosthesis, whereas none of the patients with a 25 or 27 mm valve had a high gradient (p <0.05). Aortic valve calcification was greatest in the 29 mm group and correlated with a higher dose-area product (p <0.01).

Conclusions: DFM bioprosthesis size significantly influences the TAVI procedure and post-implant valve function. Valve calcification and use of the 29 mm DFM bioprosthesis per se possibly predict a more complicated procedure. Therefore, annulus size and valve calcification severity should be taken into consideration when deciding which bioprosthesis type might be best suited for individual patients.

How to cite: Czepluch, F. S., Schwarz, A., Tichelbäcker, T., Lotz, J., Hasenfuss, G., Schillinger, W., & Jacobshagen, C. (2016). Predictors of High Post-Procedural Gradients after Catheter-Based Aortic Valve Implantation Using Direct Flow Medical Bioprostheses. The Journal of heart valve disease, 25(3), 281–288.

Background: Bicuspid aortic valve (BAV)-related aortopathy is characterized by histological abnormalities that result in aortic wall stiffening and aortic dilation. The study aim was to determine the range of ascending aortic stiffness seen in a clinical cohort of patients with BAV, and to identify the association of aortic stiffness with standard clinical and imaging parameters.

Methods: Patients with BAV (n = 65) and normal subjects (n = 10) were studied using conventional phase-contrast magnetic resonance imaging through the ascending aorta. Local aortic stiffness was estimated by measuring pulse wave velocity (PWV) using the flow-area (QA) method. Correlations between PWV and other imaging and clinical variables were assessed, and multiple linear regression models were used to examine independent predictors of PWV.

Results: BAV patients demonstrated a significantly higher mean PWV compared to normal subjects (6.53 ± 5.88 versus 3.51 ± 0.92 m/s; p <0.01) with a considerably wider range of values noted in the BAV group. Significant associations were found between PWV and age (r = 0.4, p <0.001) and history of hypertension (r = 0.36, p = 0.005) in the overall BAV cohort. The correlation between age and PWV was significantly strengthened above 40 years of age. In a subgroup of BAV patients aged <40 years (n = 37) there were no significant predictors of PWV identified by multiple linear regression models.

Conclusions: BAV patients demonstrated an increased average ascending aortic stiffness and a dramatically higher range of stiffness values compared to normal subjects. Increased stiffness is not predicted by standard clinical or imaging parameters in patients aged <40 years. Ascending aortic stiffness may be a unique marker of early aortic dysfunction in young BAV patients.

How to cite: Burris, N. S., Dyverfeldt, P., & Hope, M. D. (2016). Ascending Aortic Stiffness with Bicuspid Aortic Valve is Variable and Not Predicted by Conventional Parameters in Young Patients. The Journal of heart valve disease, 25(3), 270–280.

Background: The study aim was to prospectively analyze the impact of cusp fusion pattern on aortopathy severity in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis.

Methods: A total of 137 consecutive patients with BAV stenosis (93 males, 44 females; mean age 61 ± 9 years) underwent aortic valve replacement with or without concomitant aortic surgery between January 2012 and March 2015. All patients underwent preoperative cardiac magnetic resonance imaging (cMRI) in order to evaluate morphological/functional parameters of the aortic root. Fusion of the right-left coronary cusps was identified in 99 patients (72%) (R/L group), while the remaining 38 patients (28%) had right-noncoronary cusp fusion (R/N group). cMRI data were used to guide sampling of the proximal aorta during surgery. The expression/severity of aortopathy was quantified by means of proximal aortic phenotype, indexed aortic diameter, and a histological sum-score.

Results: There were no significant differences in proximal aortic diameter between the R/L and R/N groups. Moreover, there was no significant difference in the prevalence of distinct aortic phenotypes between the study subgroups. The histological sumscore was comparable between the R/L and R/N groups (2.9 ± 1.5 versus 2.5 ± 1.1, p = 0.2). The angle LV/aorta was significantly larger in the R/L group than in the R/N group (52.1 ± 10.6° versus 45.1 ± 8.5°, p = 0.001). Logistic regression analysis demonstrated the angle LV/aorta and the angle jet/aorta to be predictive of a mid-ascending phenotype. The cusp fusion pattern had no significant impact on the occurrence of aortic phenotype.

Conclusions: The study results demonstrated that cusp fusion morphotype has no significant impact on the expression and severity of bicuspid aortopathy in patients undergoing surgery for BAV stenosis.

How to cite: Girdauskas, E., Rouman, M., Disha, K., Dubslaff, G., Fey, B., Theis, B., Petersen, I., Borger, M. A., von Kodolitsch, Y., Kuntze, T., & Reichenspurner, H. (2016). Aortopathy in Bicuspid Aortic Valve Stenosis with Fusion of Right-Left versus Right-Non-Coronary Cusps: Are These Different Diseases?. The Journal of heart valve disease, 25(3), 262–269.