Background: The study aim was to evaluate the immune reaction, difference of degenerative calcification, and anti-calcification effect of decellularization with or without α-galactosidase in bovine pericardium and porcine heart valves, using an α1,3-galactosyltransferase (α-Gal) knockout (KO) mouse model.

Methods: In order to elucidate the anti-calcification effect of decellularization with or without α-galactosidase, bovine pericardium and porcine heart valve tissues were assigned to four groups according to the tissue preparation method: (i) glutaraldehyde (GA) fixation only; (ii) decellularization + GA fixation (Decell); (iii) α-galactosidase + GA fixation (α-galactosidase); and (iv) decellularization +α-galactosidase + GA fixation (Decell + α-galactosidase). Each prepared tissue was implanted subcutaneously into α-Gal KO mice. Anti-α-Gal immunoglobulin (Ig) G and IgM antibody titers were monitored prior to implantation and at four, eight and 12 weeks after implantation using an enzyme-linked immunosorbent assay. Calcium contents of explanted tissues were measured at 12 weeks after implantation.

Results: There were no significant differences in the anti-α-Gal IgG antibody titers according to the type of bioprosthetic material or tissue preparation method (p >0.05). The calcium content was significantly lower in porcine heart valves than in bovine pericardium when implanted in α-Gal-KO mice (p <0.001). Calcium contents in bovine pericardium and porcine heart valves were significantly lower in the Decell, α-galactosidase and Decell + α-galactosidase groups than in the GA group (all p <0.05).

Conclusions: The porcine heart valve induced lower levels of calcium deposition than did the bovine pericardium, but the anti-α-Gal IgG antibody titers did not differ significantly between the bioprosthetic tissues. Decellularization had significant anticalcification effects in both the bovine pericardium and porcine heart valves, though there was no significant difference in the anti-α-Gal IgG antibody titers among tissue preparation methods.

How to cite: Sung Jeong, W., Jin Kim, Y., Lim, H. G., Jung, S., & Ryul Lee, J. (2016). The Immune Responses and Calcification of Bioprostheses in the α1,3-Galactosyltransferase Knockout Mouse. The Journal of heart valve disease, 25(2), 253–261.

Background: Valvular disease is characterized in part by lipid deposition, but systematic analysis of the patterns of global lipid expression in healthy and diseased valve tissues are unknown. This is due in part to tissue limitations for lipidomic preparations and technologies for evaluating lipid distribution in tissues. The study aim was to examine the application of matrixassisted laser desorption ionization imaging mass spectrometry (MALDI IMS) to the aortic valve during development and disease, as an approach to detect and map lipids and ultimately better understand valve structure and function.

Methods: Established MALDI IMS strategies were applied to thin tissue sections of heart valves to map lipids to corresponding morphological features. Healthy prenatal and adult ovine aortic valve tissues were evaluated using the developed techniques. Lipid expression levels were compared between prenatal and adult valves using Wilcoxon rank sum testing and area under the receiver operating curves. A classification algorithm was used to determine distinct lipid signatures in adult extracellular matrix (ECM) substructures, including fibrosa and spongiosa layers. Lipid patterns were examined in heart valve tissue from pediatric patients with congenital aortic valve stenosis (CAVS).

Results: Lipid levels were decreased in adult ovine aortic valves when compared with prenatal valves. Classification algorithms applied to lipid signatures reported distinct lipid signatures mapping to ECM substructures in the adult aortic valve, but could not distinguish amorphous structures at pre-natal day 5. In CAVS, the in-situ lipid aggregation of distinct lipid species showed unique patterning both concurrent and divergent with ECM disarray. Fatty acid content varied between normal and diseased human aortic valves.

Conclusions: MALDI IMS provides a new and useful approach to evaluate lipid biology in heart valve tissue. These findings define a role for lipid regulation in aortic valve development and demonstrate patterns of lipid deregulation in congenital disease.

How to cite: Angel, P. M., Bayoumi, A. S., Hinton, R. B., Ru Su, Y., Bichell, D., Mayer, J. E., Scott Baldwin, H., & Caprioli, R. M. (2016). MALDI Imaging Mass Spectrometry as a Lipidomic Approach to Heart Valve Research. The Journal of heart valve disease, 25(2), 240–252.

Mechanical heart valves have been used worldwide for more than 60 years. While the composition and design of the valves, and the surgical techniques employed to implant them, have changed and advanced over that time, some of the earlier mechanical heart valves showed such great durability that they are still functioning in patients today. One of the most often-used and long-lasting mechanical prostheses was the Björk-Shiley heart valve. While many versions of this valve were used during its 25 years of production, the most durable was the Björk-Shiley flat-disc valve. This valve was first implanted in 1971 and was the first successful tilting-disc valve. Here, the complex medical history is reported of an elderly patient with a well-functioning Björk-Shiley flat-disc valve in the aortic position that was placed over 42 years ago. The history of mechanical heart valves - in particular the Björk-Shiley heart valve, including the flat-disc mechanical valve - is also briefly reviewed.

How to cite: Shaikh, A., & Jamil Tajik, A. (2016). Excellence and Durability: A Normally Functioning Björk-Shiley Flat-Disc Prosthesis 42 Years Post Implantation. The Journal of heart valve disease, 25(2), 237–239.

Background: Although many mechanical heart valves are replaced worldwide each year, mechanical valve dysfunction (MVD) remains one of the most common complications following this surgery. In an attempt to improve the postoperative and surgical management of MVD, the study plan was to investigate a group of patients who had undergone redo mechanical valve replacement to treat MVD at the authors' institution.

Methods: A total of 52 consecutive patients diagnosed with MVD underwent redo mechanical valve replacement between January 2007 and December 2013. A retrospective analysis was made of the clinical data from patients with MVD, and to compare these data with that from patients who had undergone redo heart valve surgery for other reasons.

Results: Seven patients died in the early stage, with an overall mortality of 13.46%. All other patients were clinically cured and discharged. In total, nine patients died during this six-year review.

Conclusions: The surgical management of MVD has a high mortality and involves complex surgical procedures, but remains an effective means of treating MVD. Adequate surgery time, preoperative improvements in cardiac function, effective myocardial preservation during surgery and reasonable perioperative management may all help to improve the postoperative and mid-term outcomes of the surgical management of MVD.

How to cite: Li, M., Xiao, Y., & Chen, L. (2016). Surgical Management and Postoperative Outcomes of Mechanical Valve Dysfunction: A Six-Year, Single-Center Study. The Journal of heart valve disease, 25(2), 230–236.

'Sutureless' or rapid-deployment (RD) aortic valve replacement (AVR) is an emerging alternative to standard AVR in elderly high-risk surgical patients. Here, the authors describe their implantation technique for the newer-generation Edwards INTUITY-Elite® valve (Edwards Lifesciences, Irvine, CA, USA), a balloon-expandable stented trileaflet bovine pericardial bioprosthesis that received CE Mark European approval in April 2014.

How to cite: Prakash Patil, N., Falconieri, F., Pepper, J., & Bahrami, T. (2016). How to Do It - Implantation Technique for Newer-Generation Sutureless/Rapid-Deployment Aortic Valve Replacement. The Journal of heart valve disease, 25(2), 227–229.

Background and aim of the study: Infective endocarditis (IE) is diagnosed by blood and/or resected valve cultivation and echocardiographic findings, as defined by the Duke criteria. Unfortunately, cultures may be negative due to prior antibiotic therapy or fastidious or slow-growing microorganisms. The study aim was to investigate the value of the broad-range polymerase chain reaction (PCR) in addition to blood and valve culture for the detection of causative microorganisms.

Methods: Between February 2012 and March 2015, valve samples from 36 patients undergoing cardiac surgery were analyzed; of these patients, 26 had a preoperative diagnosis of IE and 10 served as controls. Multiple blood cultures were obtained from 34 patients before antibiotic therapy was commenced. Valve samples were inoculated on bacteriological media and underwent analysis using broad-range PCR (16S rDNA).

Results: IE was confirmed microbiologically in 21 of the 26 patients (80.7%); in 20 cases (76.9%) this was by positive blood cultures and in 16 (61.5%) by positive valves. Valves were positive in 15 blood culturepositive patients, and in one blood-culture negative patient. Broad-range PCR detected a microorganism in valves significantly more frequently (n = 14; 53.8%) compared to valve culture (n = 8; 30.7%) (chisquare 11.5, p <0.001). The predominant microorganisms were Staphylococcus aureus, Streptococcus of the viridans group, coagulasenegative staphylococci and Enterococcus faecalis. Blood, valve cultures and broad-range PCR were negative in five patients (19.3%) with IE, and in all 10 subjects of the control group.

Conclusions: Broad-range PCR on valves was more sensitive than valve culture. However, blood culture, if taken before the start of antibiotic therapy, was the best method for detecting IE.

How to cite: Müller Premru, M., Lejko Zupanc, T., Klokočovnik, T., Ruzić Sabljić, E., & Cerar, T. (2016). Broad-Range 16S rDNA PCR on Heart Valves in Infective Endocarditis. The Journal of heart valve disease, 25(2), 221–226.

BACKGROUND AND AIM OF THE STUDY: Emergency valve replacement has long been the treatment of choice in left-sided prosthetic valve thrombosis (PVT) for critically ill patients in NYHA classes III-IV. Thrombolytic therapy is recommended for NYHA class I/II patients with a small thrombotic burden. METHODS: The results of thrombolytic therapy to treat left-sided PVT (eight mitral, three aortic) with streptokinase (STK) in critically ill NYHA class III/IV patients were analyzed, where surgery was either refused due to financial constraints or by the surgical team. Results were assessed clinically, using fluoroscopy and transthoracic and transesophageal echocardiography. RESULTS: Mechanical bileaflet prosthetic valves (eight mitral, four aortic) were implanted between two and 10 years previously in 11 patients (four females, seven males; age range: 32-54 years). One patient had diabetes and had undergone prior percutaneous coronary intervention with drug-eluting stent implantation to the ostial left main artery. All had cardiomegaly with ejection fraction 24-63% and an increased mean gradient across the immobile prosthetic valve. Patients presented in a hemodynamically unstable state with pulmonary edema and/or hypotensive shock. The International Normalized Ratio was <2.5 in nine patients. Eight patients with mitral valve thrombosis responded to thrombolytic therapy and survived, with complete resolution of thrombus and return of full mobility of leaflets and resolution of valve gradients. To date, all responders have survived (up to five years) without any recurrence of re-thrombosis (PVT). CONCLUSION: Intravenous STK may be life-saving in critically ill NYHA class III/IV patients with left-sided PVT. Thrombolytic therapy is much cheaper and easier to administer than surgical replacement of the thrombosed prosthetic valve.

How to cite: Gupta S. (2016). Thrombolysis for Left-Sided Prosthetic Valve Thrombosis: Short- and Long-Term Outcomes. The Journal of heart valve disease, 25(2), 214–220.

Thrombosis of transcatheter aortic valve implantation (TAVI) is an uncommon complication that commonly occurs weeks to months following the procedure. Herein are described the details of a patient who presented with a recurrence of symptoms days after intervention with a bioprosthesis thrombosis that was successfully treated with direct oral anticoagulant (DOAC) therapy and resulted in hemodynamic improvement and resolution of symptoms. Whilst a previous trial of DOAC therapy with mechanical valves was stopped due to elevated events in comparison to warfarin, a TAVI valve may be different, and the rapid onset of action and reduced bleeding risk may be beneficial in this patient group.

How to cite: Ruparelia, N., Panoulas, V. F., Frame, A., Sutaria, N., Ariff, B., Gopalan, D., Chukwuemeka, A., Mikhail, G. W., & Malik, I. S. (2016). Successful Treatment of Very Early Thrombosis of SAPIEN 3 Valve with Direct Oral Anticoagulant Therapy. The Journal of heart valve disease, 25(2), 211–213.

Background: Tricuspid regurgitation (TR) accompanying severe left-sided valve disease occurs on a functional basis, secondary to pulmonary hypertension and tricuspid annular dilatation. In the context of endemic left-sided rheumatic heart disease, non-recognition of organic disease of the tricuspid valve may adversely influence surgical decision-making, resulting in suboptimal outcomes.

Methods: A retrospective analysis of the perioperative and follow up data of 30 patients who underwent tricuspid valve surgery with concomitant left-sided valve replacement was undertaken. Preoperative evaluation by two-dimensional transthoracic echocardiography was routinely employed. Outcomes were analyzed by evaluation of the perioperative and two-year follow up clinical and echocardiographic data.

Results: All subjects had severe TR. Mixed tricuspid valve disease occurred in 11 subjects (36.7%). Tricuspid valve repair was performed in 28 patients. A significant improvement (p <0.05) in the following parameters occurred at six weeks postoperatively: NYHA functional class, tricuspid annular diameter, systolic pulmonary artery pressure, severity of TR and tricuspid transvalvular gradient. Severe residual postoperative TR occurred in 26.7% of patients, but there were no identifiable predictors for this phenomenon. Severe residual postoperative TR was not associated with major adverse cardiovascular events. Preoperative (p = 0.013) and postoperative (p<0.002) pulmonary hypertension were associated with the development of major adverse cardiovascular events. The technique of tricuspid valve repair was not associated with the occurrence of major adverse cardiovascular events, nor with the development of severe residual postoperative TR. A satisfactory outcome was observed in only 40% of the study population.

Conclusions: The coexistence of mixed tricuspid valve disease in rheumatic heart disease patients undergoing left-sided valve surgery is an important determinant of outcome in tricuspid valve repair. The persistence of severe TR contributes to poor long-term outcomes, and its incidence may be lowered by the adoption of appropriate perioperative imaging techniques to delineate valve morphology.

How to cite: Munasur, M., & Naidoo, D. (2016). Underlying Rheumatic Disease: An Important Determinant of Outcome in Tricuspid Valve Repair. The Journal of heart valve disease, 25(2), 203–210.

Background: Rheumatic mitral valve stenosis (RMVS)-induced left atrial thrombus (LAT) and embolic complications may have clinically devastating consequences. Stasis in the left atrium induced by valvular obstruction is a major factor in the development of thrombus. However, the development of thrombus may not be solely associated with stasis, as it is known that the inflammatory process increases the tendency for thrombosis. The study aim was to examine the relationship between the neutrophil-to-lymphocyte ratio (NLR), an indicator of inflammation, and the existence of LAT.

Methods: A total of 313 consecutive patients with RMVS and mitral valve area (MVA) <2 cm2 was included in this cross-sectional study. Patients were allocated to two groups with or without LAT using transthoracic and transesophageal echocardiography. Routine biochemical analyses and electrocardiographic examinations were also carried out. The NLR was calculated utilizing blood count analysis.

Results: The presence of LAT was identified in 78 RMVS patients (24.9%). No significant differences in terms of age, gender, body mass index were found between the groups with and without LAT. On echocardiographic examination, a higher mean gradient and left atrial diameter, as well as a smaller MVA, were determined in patients with LAT (p<0.001). In those patients with LAT, higher C-reactive protein levels and higher leukocyte and neutrophil counts (p <0.001) and lower lymphocyte counts were noted (p = 0.001). The NLR was shown to be higher in patients with LAT (p <0.001). Multivariate regression analysis showed that the relationship between LAT and a high NLR continued independently (OR 5.3; 95% CI 2.9-9.4; p <0.001).

Conclusions: The NLR is an easily obtained, low-cost and easily repeated parameter that seems effective for identifying RMVS patients who are at high risk of developing LAT.

How to cite: Ozal, E., Belen, E., Ozgun Cakmak, E., Durmus, G., & Pusuroglu, H. (2016). The Presence of Left Atrial Thrombus is Associated with the Neutrophil-to-Lymphocyte Ratio in Patients with Rheumatic Mitral Valve Stenosis. The Journal of heart valve disease, 25(2), 198–202.

Persistent pulmonary artery hypertension (PAH) after balloon mitral valvuloplasty (BMV) is not uncommon, and is generally associated with established pulmonary vascular disease, an inadequate result, or the development of mitral regurgitation. An unfavorable mitral valve morphology with a smaller post-procedural mitral valve area is among the most common causes of the condition. While routine cardiac catheterization is no longer recommended prior to intervention in valvular heart disease, patients with persistent PAH after BMV should undergo a thorough evaluation before they are considered for repeat BMV. Here, a rare case is reported of symptomatic persistent PAH in a patient referred for a third BMV, less than one year after the previous intervention, where a hypertensive patent ductus arteriosus was identified, the closure of which led to a regression of the PAH.

How to cite: Gopalakrishnan, A., Kumar Mohanan Nair, K., Harikrishnan, S., & Valaparambil, A. (2016). An Unusual Case of Persistent Severe Pulmonary Artery Hypertension Following Balloon Mitral Valvuloplasty. The Journal of heart valve disease, 25(2), 195–197.

Background: The repair of anterior mitral leaflet prolapse is known to be challenging. Hence, the study aim was to compare the mid-term results of anterior leaflet prolapse (ALP) using chordal transposition with results obtained using chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures.

Methods: Between 1999 and 2012, a total of 96 consecutive patients (mean age 62 years) with ALP underwent mitral valve repair at the authors' institution. Surgery involved either chordal transposition from the posterior to the anterior leaflet (n = 67), or chordal replacement using ePTFE sutures (n = 29). Clinical, operative and follow up data were recorded prospectively for each patient. The follow up was 100% complete (mean 3.4 years; range 0 to 12.9 years).

Results: Mitral valve repair was accomplished in all patients, with no operative mortality. The durations of cardiopulmonary bypass and aortic cross-clamp were significantly longer in the chordal replacement group. Actuarial overall survival at one, five and 10 years was 95 ± 3%, 87 ± 5% and 82 ± 7% versus 89 ± 6%, 89 ± 6% and 89 ± 6% in the chordal transposition and chordal replacement groups, respectively (p = 0.84). Freedom from reoperation in the two groups at five years was 95 ± 3% and 91 ± 7%, respectively (p = 0.24). The recurrence of moderate or severe mitral regurgitation (MR) (grade ≤2+) and of severe (grade ≤3+) MR was significantly higher in patients who underwent chordal replacement compared to chordal transposition (p = 0.04 and p = 0.01, respectively).

Conclusions: Provided that chordal quality is preserved, chordal transposition is easier and quicker to achieve for ALP repair, and is also durable in the mid term. Chordal replacement offers a satisfying durability even if the recurrence of severe MR appears to be higher. Preferably, both surgical techniques should be mastered to allow valve repair when anatomic conditions prevent chordal transposition.

How to cite: Bourguignon, T., Mazine, A., Laurin, C., Bouchard, D., Demers, P., & Pellerin, M. (2016). Repair of Anterior Mitral Leaflet Prolapse: Comparison of Mid-Term Outcomes with Chordal Transposition and Chordal Replacement Techniques. The Journal of heart valve disease, 25(2), 187–194.

An 83-year-old man with a previous mitral valve repair using a semi-rigid annuloplasty ring was found to have severe mitral stenosis. A transcatheter approach for mitral valve-in-ring replacement was selected due to the patient's high surgical risk. Pre-procedural computed tomography scans for transcatheter valve size selection were inconsistent with previously published recommendations. To determine the appropriate valve size, a 25 mm compliant balloon was inflated intraoperatively within the stenotic mitral ring, but yielded no resistance to movement and no 'waist'. Thus, a 29 mm balloon-expandable prosthetic valve was selected and deployed with no paravalvular leak. This novel balloon sizing technique helped lead to a successful outcome in this case. Video 1: Angiographic video displaying mitral valve-in-ring balloon sizing technique. The 25 mm compliant balloon was inflated within a stenotic mitral ring to determine which prosthetic transcatheter valve size was appropriate. As shown, this technique yielded no 'waist' and no resistance to movement, suggesting that a 29 mm valve was necessary.

How to cite: Sola, M., Caranasos, T. G., Yeung, M., Ramm, C. J., Sell, K., & Vavalle, J. P. (2016). Transcatheter Mitral Valve-in-Ring for Progressive Mitral Stenosis after Prior Repair with Annuloplasty: A Novel Balloon Sizing Technique. The Journal of heart valve disease, 25(2), 185–186.

Transcatheter aortic valve replacement (TAVR) is a valuable alternative in surgical high-risk patients with symptomatic aortic valve stenosis. Here, the case is presented of very early transcatheter heart valve degeneration, probably caused by a 'Venturi effect' of a severe paravalvular regurgitant jet. This ultimately led to a leaflet being in the open position, creating severe valvular regurgitation that necessitated classical surgical revision. The occurrence of paravalvular regurgitation, and its known relationship with an adverse prognosis after TAVR, demonstrates the clear need for innovative alterations in valve design to prevent this complication. Video 1: Angiography immediately after implantation of an Edwards SAPIEN 23 mm transcatheter heart valve, showing severe paravalvular aortic valve regurgitation. The implantation position is rather low. Video 2: Transesophageal echocardiography with 2-D color imaging showing aortic valve long-axis view at 131°, three days after implantation of an Edwards SAPIEN 23 mm transcatheter heart valve. Severe eccentric paravalvular aortic valve regurgitation is shown without a significant valvular component. The implantation position is rather low. Video 3: Transesophageal echocardiography with 2-D color imaging showing aortic valve long-axis view at 120°, one month after implantation of an Edwards SAPIEN 23 mm transcatheter heart valve. Severe combined valvular and paravalvular aortic valve regurgitation (grade 4/4) is shown.

How to cite: Hiltrop, N., Adriaenssens, T., Herijgers, P., & Dubois, C. (2016). Aortic Regurgitation after TAVR: From Bad to Worse. The Journal of heart valve disease, 25(2), 182–184.

Background: Although the efficacy and safety of transfemoral transcatheter aortic valve implantation (TAVI) have been improved with new devices, careful patient selection is essential and awkward complications associated with the procedure persist. Despite a gradual reduction in the delivery system size and the development of access site arterial closure devices, vascular complications remain one of the main challenges of TAVI. The aim of this single-center study was to prospectively evaluate the incidence and predictors of vascular complications in transfemoral TAVI.

Methods: A total of 211 patients (mean age 77.98 ± 8.20 years) who underwent transfemoral TAVI between 2011 and 2014 at the authors' institution, using two different commercially available devices, was included in the study. Technical success, vascular complications, predictors of vascular complications and mortality were each assessed. Vascular complications were defined by the current Valve Academic Research Consortium-2 (VARC-2) criteria.

Results: The mean logistic EuroSCORE of the patients was 21.04 ± 7.51. An Edwards SAPIEN XT valve was used in 69.7% of cases, and a Medtronic CoreValve in 30.3%. Completely percutaneous transfemoral TAVI was successful in 81.6% of patients. Procedural and 30-day mortalities were 1.4% and 8.5%, respectively. Vascular complications occurred in 16.1% of patients (minor 10.4%, major 5.7%), and necessitated surgical repair in 25 cases (11.8%). Major vascular complications were predictive of 30-day mortality (58.3% versus 5.6% (p = 0.000). Predicted major vascular complications (by multivariate analysis) were female gender (hazard ratio (HR) 5.45; 95% confidence interval (CI) 0.91-32.5, p = 0.063), arterial calcification (HR 2,88; 95% CI 1.14-7.30, p = 0.025) and sheath to iliofemoral artery ratio (SIFAR) (HR 1.91, 95% CI 1.27-2.87, p = 0.001).

Conclusions: Although vascular preclosure devices have revolutionized transfemoral TAVI, and offer a simple but effective percutaneous procedure, vascular complications are still observed in a considerable number of patients. The major vascular complications were predictive of 30-day mortality, and included female gender, iliofemoral calcification and SIFAR. Further technological and procedural developments are required to reduce vascular complication rates and related mortality.

How to cite: Uguz, E., Gokcimen, M., Ali, S., Alsancak, Y., Bastug, S., Ahmet Kasapkara, H., Canyigit, M., Hıdıroglu, M., & Sener, E. (2016). Predictability and Outcome of Vascular Complications after Transfemoral Transcatheter Aortic Valve Implantation. The Journal of heart valve disease, 25(2), 173–181.

Background: Aortic stenosis imposes a chronic pressure overload on the left ventricle, with attendant adaptations in hemodynamics, muscle mass and performance. The hemodynamic changes that occur during the initial 24 h following abrupt removal of the impediment to left ventricular outflow have not been previously examined.

Methods: A total of 52 patients with right heart catheterization was evaluated before, within 6 h and at 24 h after successful transcatheter aortic valve replacement (TAVR). Echocardiographic data were examined before and within 30 days of the procedure.

Results: TAVR was successful in all 52 patients, and at 24 h after the procedure resulted in: (i) an increase in cardiac index (CI) (from 2.0 ± 0.6 to 3.1 ± 0.7 l/min/ m2, p <0.001) and stroke volume (SV) (from 62.3 ± 18.7 to 76.6 ± 21.3 ml, p <0.001); (ii) reductions in systemic vascular resistance (from 1555 ± 458 to 1021 ± 280 dyne·s/cm5, p <0.001) and pulmonary vascular resistance (from 174 ± 150 to 112 ± 76 dyne·s/cm5, p = 0.001); (iii) reductions in pulmonary capillary wedge pressure (from 24.2 ± 6.7 to 19.7 ± 7.3 mmHg, p <0.001), mean pulmonary artery pressure (from 32.2 ± 9.9 to 27.5 ± 8.8 mmHg, p = 0.002) and in central venous pressure (from 13.5 ± 4.8 to 9.4 ± 3.9 mmHg, p <0.001); and (iv) an increase in systolic arterial pressure (from 127 ± 25 to 135 ± 14 mmHg, p = 0.04), along with a decrease in diastolic arterial pressure (from 58 ± 11 to 53 ± 9 mmHg, p = 0.009).

Conclusions: Successful TAVR results in immediate and sizeable improvements in SV and CI, reductions in left and right ventricular filling pressures, and marked reductions in systemic and pulmonary vascular resistances.

How to cite: Chrissoheris, M., Ziakas, A., Chalapas, A., Chadjimiltiades, S., Styliades, I., Karvounis, C., Nikolaou, I., & Spargias, K. (2016). Acute Invasive Hemodynamic Effects of Transcatheter Aortic Valve Replacement. The Journal of heart valve disease, 25(2), 162–172.

Background: Although significant late tricuspid regurgitation (TR) may develop after surgery for degenerative mitral regurgitation (MR), the use of routine tricuspid annuloplasty is debatable. The study aim was to determine the prevalence and predictors of significant late TR after surgery for degenerative MR.

Methods: A total of 112 patients who had undergone surgery for degenerative MR without concomitant tricuspid valve repair (average follow up 7.7 ± 4.0 years) was studied retrospectively. The prevalence of post-surgical TR and predictors of progression were determined.

Results: The majority of patients (97%) had non-significant TR (less than moderate) prior to surgery, although an overall trend of progression towards significant TR (grades 2 or 3) was noted in 17 patients (p = 0.0006). Of the 18 patients (16%) with late postoperative significant TR, only nine (8%) had severe TR with only a single referral to surgery. New-onset post-surgical atrial fibrillation was more common in patients who developed late significant TR (p = 0.002). Multivariate analysis of the pre-surgery variables, age >65 years and left ventricular dysfunction were shown to be independent predictors of late functional TR.

Conclusions: Significant progression in TR after surgery for degenerative MR was rare in this patient cohort. The impact of older age and left ventricular dysfunction at the time of surgery showed a strong association with post-surgical atrial fibrillation.

How to cite: Vaturi, M., Kotler, T., Shapira, Y., Weisenberg, D., Monakier, D., & Sagie, A. (2016). Prevalence of Late Functional Tricuspid Regurgitation in Degenerative Mitral Regurgitation Surgery. The Journal of heart valve disease, 25(2), 157–161.

Transcatheter aortic valve replacement (TAVR) has become an acceptable alternative to surgical aortic valve replacement in high-risk and inoperable patients. Several technical and anatomical considerations can increase the complexity and risk of the procedure, and therefore are considered as contraindications to TAVR. Patients with significant aortic disease such as aortic dissection are not usually considered for TAVR due to risk of aortic rupture or retrograde extension of the dissection. Herein is presented a report of the first successful TAVR in a patient with extensive type B dissection.

How to cite: Gulkarov, I., Da-Wariboko, A., Afzal, A., Salemi, A., & Worku, B. (2016). Transcatheter Aortic Valve Replacement in Type B Aortic Dissection. The Journal of heart valve disease, 25(2), 153–155.

Aortic valve infective endocarditis (IE) can be complicated with severe aortic regurgitation (AR) jet-related lesions such as vegetations, pseudoaneurysms, aneurysms or perforations on the anterior mitral leaflet. Herein is reported the case of a 69-year-old male with culture-negative aortic valve endocarditis complicated with aortic valve perforations resulting in severe and eccentric AR and an AR jet-related ventricular septal defect (VSD). Neither transthoracic echocardiography (TTE) nor two-dimensional transesophageal echocardiography (2D-TEE) were unable to clearly discriminate an aorto-right ventricular fistula from a VSD. By contrast, three-dimensional TEE (3D-TEE) demonstrated multiple aortic valve vegetations, aortic valve perforations, severe AR, and an AR jet-related VSD. The 3D-TEE findings were confirmed at surgery, the aortic valve was replaced with a bioprosthetic valve, and the VSD was repaired with a pericardial patch. To the authors' knowledge, this is the first case of a VSD resulting from an AR jet lesion to be detected and characterized using 3D-TEE. The accurate preoperative diagnosis and characterization of the VSD with 3D-TEE contributed to successful surgery and the patient's short- and long-term survival. Video 1A: This four-chamber transthoracic echocardiography (TTE) view with color Doppler shows a color-Doppler jet traversing the basal interventricular septum (IVS) into the right ventricle, predominantly during systole. However, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. A mild to moderate degree of tricuspid regurgitation is also noted. Video 1B: Close-up view of the basal IVS demonstrates a color Doppler jet traversing the IVS, predominantly during systole and apparently originating in the left ventricular outflow tract side, as illustrated by a color Doppler acceleration zone. However, and as in Fig. 1A, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. Video 1C: Color Doppler two-dimensional TEE view longitudinal to the aortic valve and aortic root, showing a predominantly systolic color Doppler jet originating in the left ventricular outflow tract and/or aorta and crossing the anterior and basal IVS defect into the right ventricle. Videos 1D: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1E: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1F: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D.

How to cite: Darabant, S., Oberton, S. B., Roldan, L. P., & Roldan, C. A. (2016). Ventricular Septal Defect from Aortic Regurgitation Jet Lesion in Aortic Valve Infective Endocarditis. The Journal of heart valve disease, 25(2), 150–152.

An anomalous origin of the left circumflex coronary artery (LCx) from the right sinus of Valsalva is a frequent coronary problem. This particular condition, though usually silent, is associated with an increased incidence of serious complications during surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation. Here, the cases are described of four patients with an anomalous origin of the LCx from the right sinus of Valsalva who underwent sutureless AVR with the Sorin Perceval S prosthesis. The possible advantages of this approach are also discussed.

How to cite: Giuseppe Cerillo, A., Haxhiademi, D., Berti, S., & Solinas, M. (2016). Sutureless Aortic Valve Replacement: An Easy and Safe Approach for Patients with Anomalous Left Circumflex Coronary Artery. The Journal of heart valve disease, 25(2), 145–148.

Background: The anticoagulation of biological heart valves remains a 'hot spot' of discussion in various domains due to the risk of developing valve thrombosis and arterial thromboembolism. The situation has always been controversial, especially during the early postoperative phase. The American College of Cardiology/ American Heart Association and European Society of Cardiology guidelines recommend the use of warfarin for the first three months after biological aortic valve replacement (BAVR), although the American College of Chest Physicians guidelines suggest that these recommendations are experience-based and that the risk/benefit is unclear. The aim of the present study was to compare the efficacy of aspirin and warfarin in patients after BAVR.

Methods: A total of 863 patients who underwent BAVR between 2008 and 2015 was allocated to two groups. Each group was managed with a specific anticoagulation regimen, with 430 patients receiving warfarin during the first three postoperative months, and 433 receiving aspirin. The major study end points were bleeding, cerebral ischemic events, and survival.

Results: In total, 10 and 15 postoperative cerebral ischemic events occurred between 24 h and three months after surgery in patients treated with aspirin and warfarin, respectively. After three months the incidence of cerebral ischemic events did not differ greatly between the two groups. The rate of major bleeding events and rates of stroke-free survival and overall survival were not statistically significant between the warfarin and aspirin groups.

Conclusions: Plasma anticoagulation with warfarin during the early postoperative phase was shown statistically to be inferior to platelet aggregation inhibition by aspirin with regards to postoperative bleeding risk, cerebral ischemic events, and survival.

How to cite: Owais, T., Rouman, M., Breuer, M., Hüter, L., Fuchs, J., Lauer, B., & Kuntze, T. (2016). Anticoagulation After Biological Aortic Valve Replacement: Is There An Optimal Regimen?. The Journal of heart valve disease, 25(2), 139–144.

Background: Aortic valve replacement (AVR) is the treatment of choice in patients with severe symptomatic aortic stenosis (AS). Patients with a low left ventricular ejection fraction (LVEF) represent a challenge for evaluation and therapeutic decision. Dobutamine stress echocardiography (DSE) allows the distinction to be made between fixed low-flow/low-gradient (LF/LG) AS and pseudosevere AS.

Methods: Between 2001 and 2014 a retrospective analysis was conducted of patients who underwent DSE to investigate severe AS. DSE was performed in 3- to 5-min steps up to a maximum dose of 20 μg/kg/min. Parameters evaluated at baseline and at each step of DSE included: left ventricular enddiastolic volume (LVEDV) and left ventricular endsystolic volume (LVESV), maximum gradient (MaxG), mean gradient (MG) and aortic valve area (AVA). AS was considered to be severe if the AVA at peak dose was ≤1 cm2. Patients were allocated to two groups according to their therapy: group 1 received only medical treatment, while group 2 underwent AVR. The average follow up was 51.5 ± 4.4 months.

Results: A total of 41 patients (28 males, 13 females; mean age 71.7 ± 8.3 years) was analyzed. Severe AS was diagnosed in 34 patients (83%). Baseline echocardiographic characteristics were: AVA 0.7 ± 0.2 cm2, MaxG 42.0 ± 9.1 mmHg, MG 25.6 ± 6.4 mmHg, LVEF 33.1 ± 8.4%, LVEDV 149.6 ± 44.5 ml, and LVESV 104.0 ± 42.6 ml. At peak DSE, AVA was 0.8 ± 0.2 cm2, MaxG 62.7 ± 18.2 mmHg, MG 38.1 ± 11.6 mmHg, LVEF 42.2 ± 9.9%, LVEDV 142.6 ± 43.85 ml, and LVESV 89.7 ± 37.4 ml. Nineteen patients were allocated to group 1, and 22 to group 2. In group 2, two patients underwent transcatheter aortic valve implantation (TAVI) and 20 had surgery. Mortality in group 1 was significantly higher than in group 2 (78.9% versus 27.3%). A Cox proportional hazard model analysis showed that no-intervention was the only predictor of mortality (unadjusted to age; hazard ratio (HR) 5.13, 95% confidence interval (CI) 1.96-13.44, p = 0.001; adjusted to age - HR 4.01, 95% CI 1.46-11.01, p = 0.007).

Conclusions: LF/LG AS has a poor prognosis without intervention. DSE allows the lesion severity to be established. In the present study intervention was a predictor of survival during follow up.

How to cite: Aguiar Rosa, S., Moura Branco, L., Galrinho, A., Portugal, G., Abreu, J., Cacela, D., Fragata, J., & Cruz Ferreira, R. (2016). Contribution of Dobutamine Stress Echocardiography to the Diagnosis and Prognosis of Low-Flow/Low-Gradient Aortic Stenosis. The Journal of heart valve disease, 25(2), 130–138.