Background: The study aim was to identify factors affecting early mortality in valvular reoperations.

Methods: Between January 1993 and December 2011, a total of 693 patients who had undergone valvular reoperations due to problems with previously implanted mechanical and biological valves, new valve degeneration or valve failure after a reconstructive procedure was included in the study. Factors affecting early mortality were identified by the examination of preoperative and perioperative data, using multivariate analysis.

Results: The average age of the patients was 44.9 years. For all patients, overall hospital mortality was 15.9%, while hospital mortality rates were 12.9% and 35.3% for elective operation and urgent/emergency treatment, respectively. Factors affecting early mortality in the multivariate analysis were longer total perfusion time (>120 min, p = 0.001), emergency or urgent treatment (p = 0.001), and the presence of preoperative renal failure (p = 0.001).

Conclusions: Mortality for elective patients in valvular reoperations was within an acceptable range. Total mortality was dependent on a high mortality level of emergency/urgency of the cases. The use of a well-defined protocol in valvular reoperations may decrease hospital mortality.

How to cite: Erdem Toker, M., Çine, N., Taşar, M., Dedemoğlu, M., Yılmaz, E., Balkanay, M., & Yakut, C. (2016). Analysis of the Early Results of 693 Patients Undergoing Valvular Reoperation Between 1993 and 2011. The Journal of heart valve disease, 25(1), 123–129.

BACKGROUND AND AIM OF THE STUDY: Deformation of the left atrium during the reservoir phase may provide information regarding potential preclinical heart disease, but at present insufficient data are available concerning left atrial (LA) reservoir function in valvular heart disease. The study aim was to assess LA reservoir function in patients with moderate mitral stenosis (MS), and its relation to the patient’s clinical status. METHODS: A total of 40 patients (31 females, nine males; mean age 29.47 ± 19.1 years) with isolated moderate MS and in sinus rhythm were allocated to either symptomatic or asymptomatic groups (n = 20 in each group). All patients provided their complete medical history, were examined clinically and underwent transthoracic echocardiography to assess MS severity, systolic pulmonary artery pressure (SPAP), mean pulmonary artery pressure (MPAP), left atrial maximal volume (LAV(max)), left atrial minimal volume (LAV(min)), and indices of left atrial reservoir function, including total left atrial emptying volume Tot(empVol), indexed Tot(empVol), and total left atrial emptying fraction (LAEF). RESULTS: Symptomatic patients showed a significantly higher mean LAV(max) (79.25 ± 19.12 versus 70.65 ± 13.34 ml, p = 0.022), LAV(min) (54.63 ± 6.68 versus 47.1 ± 12.87 ml, p = 0.029), Tot(empVol) (23.83 ± 5.33 versus 18.4 ± 7.13 ml, p = 0.01), indexed Tot(empVol) (14.73 ± 2.49 versus 12.53 ± 3.18 ml/m2, p = 0.02), SPAP (44.35 ± 7.79 versus 32.65 ± 10.6 mmHg, p = 0.002), and MPAP (37.60 ± 10.78 versus 30.46 ± 7.55 mmHg, p = 0.02) and a significantly lower mean LAEF (30.40 ± 7.26 versus 36.13 ± 6.37%, p = 0.011). Significant negative correlations were noted between LAEF with SPAP, LAV(max) and LAV(min). Further significant associations were detected for the symptomatic group between LAEF (r = -0.43) and mitral valve area (r = -0.37). Similarly, multivariate linear regression analysis revealed a significant negative association between presence in the symptomatic group and LAEF (β = -4.78, SE = 2.22, p <0.05). Finally, Tot(empVol) was the strongest predictor of LAEF (β = 1.23). CONCLUSION: LA reservoir function is impaired in symptomatic patients with moderate MS.

How to cite: El Sebaie, M., El Fatah Ferer, A., El Shaer, H., & Hamed, P. (2016). Left Atrial Reservoir Function in Symptomatic Versus Asymptomatic Patients with Moderate Mitral Stenosis. The Journal of heart valve disease, 25(1), 116–122.

A 78-year-old man was admitted to the authors' hospital with a short history of shortness of breath and pyrexia. He had long-standing moderate mitral regurgitation and stable coronary artery disease. Blood cultures grew Abiotrophia defectiva coccobaccili. Transesophageal echocardiography confirmed the diagnosis of mitral valve endocarditis that necessitated treatment with intravenous benzylpenicillin and gentamicin for six weeks. At nine days after admission the patient developed several episodes of self-limiting monomorphic ventricular tachycardia, without ischemic cardiac pain, associated with hemodynamic compromise requiring treatment with intravenous amiodarone and inotropic support in the Intensive Care Unit. The patient made an uneventful recovery. This case report demonstrates that patients with A. defective endocarditis may be associated with life-threatening ventricular tachycardia, and more so if they have underlying coronary artery disease. Hence, these patients are better managed in the Coronary Care Unit with continuous electrocardiogram monitoring, especially in the early stages of the antibiotic treatment.

How to cite: Mouyis, K., Metaxa, S., & Missouris, C. (2016). Abiotrophia defectiva Endocarditis Complicated by Ventricular Tachycardia. The Journal of heart valve disease, 25(1), 114–115.

Reoperations after the Ross procedure are rare, with autograft as well as homograft failure being the dominant causes for redo cardiac procedures. Due to increasing experience with valve-sparing aortic valve procedures, more valves can be preserved during redo surgery. Herein are reported the details of a patient who underwent quadruple valve reoperation comprising redo with a reconstructive approach after the short-term failure of pulmonary autograft and homograft with concomitant mitral and tricuspid regurgitation.

How to cite: Goebel, N., Albert, M., Stan, A., Ursulescu, A., & W Franke, U. F. (2016). Quadruple Valve Reoperation after the Ross Procedure. The Journal of heart valve disease, 25(1), 112–113.

Background: Prosthetic valve dysfunction due to pannus formation is a rare but serious complication. Currently, limited data are available concerning the pathogenesis and immunohistochemical properties of pannus. The study aim was to investigate the morphological, histopathological and immunohistochemical characteristics of pannus formation in patients with prosthetic valve dysfunction.

Methods: A total of 35 patients (10 males, 25 females; mean age 44 ± 16 years) who had undergone re-do valve surgery due to prosthetic valve obstruction was enrolled in the study. Immunohistochemical studies were aimed at evaluating the expression of alphasmooth muscle actin (α-SMA) and desmin in myofibroblasts and smooth muscle cells; epithelial membrane antigen (EMA) in epithelial cells; and CD34, Factor VIII and vascular endothelial growth factor (VEGF) in endothelial cells. Matrix metalloproteinases (MMPs) -2 and -9, and transforming growth factor-beta (TGF-β) were used to demonstrate cytokine release from macrophages, leukocytes, fibroblasts and myofibroblasts.

Results: Pannus appeared as a tough and thick tissue hyperplasia which began from outside the suture ring in the periannular region and extended to the inflow and outflow surfaces of the prosthetic valves. Histopathological analysis showed the pannus tissue to consist of chronic inflammatory cells (lymphocytes, plasma cells, macrophages and foreign body giant cells), spindle cells such as myofibroblasts, capillary blood vessels and endothelial cells laying down the lumens. Calcification was present in the pannus tissue of 19 explanted prostheses. Immunohistochemical studies revealed positive α-SMA expression in all patients, whereas 60.5% of patients were positive for desmin, 50% for EMA, 42.1% for VEGF, 39.5% for TBF-β, 42.1% for MMP-2, 86.8% for CD34, and 97.4% for Factor VIII. MMP-9 was negative in all patients.

Conclusions: Pannus tissue appears to be formed as the result of a neointimal response in periannular regions of prosthetic valves that consist of periannular tissue migration, myofibroblast and extracellular matrix proliferation with vascular components. It is a chronic active process in which mediators such as TGF-β, VEGF and MMP-2 play roles in both matrix formation and degradation.

How to cite: Karakoyun, S., Ozan Gürsoy, M., Yesin, M., Kalçık, M., Astarcıoğlu, M. A., Gündüz, S., Emrah Oğuz, A., Çoban Kökten, Ş., Nimet Karadayı, A., Tuncer, A., Köksal, C., Gökdeniz, T., & Özkan, M. (2016). Histopathological and Immunohistochemical Evaluation of Pannus Tissue in Patients with Prosthetic Valve Dysfunction. The Journal of heart valve disease, 25(1), 104–111.

BACKGROUND AND AIM OF THE STUDY: The study aims were to monitor the changes in tissue morphology, calcium content and CD40 expression in the in-vivo heterotopic transplantation of aortic valved homografts after de-endothelialization, and to seek better methods for preventing calcification and degeneration of the homograft valves. METHODS: Adult, healthy, inbred male Chinese rabbits were used as donors, and inbred adult female New Zealand White rabbits as recipients for the heterotopic transplantation of aortic valved homografts with abdominal aorta. Controls received aortic valved homografts without treatment, while the de-endothelialization group received aortic valved homografts after de-endothelialization. For the cryopreservation group, aortic valved homografts were treated with 10% dimethyl sulfoxide and cryopreserved in liquid nitrogen for 60 days. Recipients were randomly allocated to three groups (n = 20 per group). Grafts were removed after two, four, eight and 12 weeks of surgery and observed with light microscopy. Calcium concentrations were monitored using flame atomic absorption, and CD40 expressions with immunohistochemistry. RESULTS: At two weeks after transplantation, the calcium contents of the fresh, de-endothelialization and cryopreservation groups were similar (p >0.05). The calcium content at four, eight and 12 weeks in the fresh and cryopreservation groups was significantly higher than that in the de-endothelialization group (p <0.01), while at two, four and eight weeks after transplantation, CD40 expression in the fresh and cryopreservation groups was significantly different from that in the de-endothelialization group (p <0.01). CONCLUSION:The calcium content in valve homografts was found to correlate with immune rejection. De-endothelialization could reduce immune rejection reactions and prevent calcification of aortic homograft valve.

How to cite: Lou, Y., Jing, H., Wang, T., & Wu, H. (2016). Experimental Study on the In-Vivo Heterotopic Transplantation of Aortic Valved Homografts after De-Endothelialization. The Journal of heart valve disease, 25(1), 96–103.

Transcatheter aortic valve implantation (TAVI) is an alternative treatment method in high-risk patients with severe aortic stenosis (AS). Although TAVI is a minimally invasive procedure it is not free from complications. Here, the case is presented of a 61-year-old woman who underwent trans-subclavian aortic valve implantation to treat severe symptomatic rheumatic AS. The procedure was complicated by the ventricular embolization of two Edwards SAPIEN XT valves during the procedure, but was successfully managed with emergency open-heart surgery.

How to cite: Baştuğ, S., Nabi Aslan, A., Sarı, C., Ahmet Kasapkara, H., Ayhan, H., & Bozkurt, E. (2016). Ventricular Embolization of Two Edwards SAPIEN XT Prosthetic Valves During Trans-Subclavian Aortic Valve Implantation. The Journal of heart valve disease, 25(1), 93–95.

Degenerated and dysfunctional prosthetic valves are usually replaced surgically. However, repeated cardiac surgery can cause prohibitive risk, especially in patients with many associated co-morbidities. Transcatheter valve-in-valve implantation (TVIV) is a novel, technically very challenging, but less invasive alternative treatment for patients with unacceptably high surgical risk of degenerated prosthetic valves. The method is attractive because it takes advantage of the presence of the degenerated prosthesis, which serves as an anchoring zone. Here, the case is presented of TVIV in an 82-year-old female with significant stenosis of a biological mitral prosthesis. In 2011, Himbert et al. were the first to successfully insert a transcatheter heart valve in the mitral ring using a transfemoral approach. To date, only a small case series has been reported on the effectiveness of TVIV using a transfemoral venous access and a trans-septal anterograde approach. The present patient was the first in which TVIV was performed in Poland and Eastern Europe.

How to cite: Rudzinski, P. N., Dzielinska, Z., Witkowski, A., Konka, M., Katarzyna, K. L., & Demkow, M. (2016). Transcatheter Valve-in-Valve Implantation in a Degenerated Mitral Bioprosthesis Using a Trans-Septal Anterograde Approach and 3-D Transesophageal Echocardiography Guidance. The Journal of heart valve disease, 25(1), 90–92.

BACKGROUND AND AIM OF THE STUDY: Aortic valve leaflets have a complex, anisotropic structure that likely plays an important role in their biomechanical function. The larger scale (bulk) biomechanical properties of the valve have been well documented. However, limited data are available regarding the biomechanical properties of individual fiber bundles and membranes that connect the bundles. The study aim was to characterize these intermediate-scale ‘mesostructures’ and explore biomechanical variability across the three leaflets of the aortic valve. Methods: A custom uniaxial micro-testing system was developed to test mesostructures of the aortic valve leaflet. This system uses elliptically polarized light to enhance collagen features, providing ‘texture’ for image correlation-based strain measurements. Porcine aortic valve membrane and fiber bundle specimens were subjected to controlled stretch-and-hold tests. Synchronized video and load data were used to measure strain, elastic modulus, relaxation time, and degree of relaxation (among other parameters). These metrics were then compared between specimen types and across the three leaflets. METHODS: A custom uniaxial micro-testing system was developed to test mesostructures of the aortic valve leaflet. This system uses elliptically polarized light to enhance collagen features, providing ‘texture’ for image correlation-based strain measurements. Porcine aortic valve membrane and fiber bundle specimens were subjected to controlled stretch-and-hold tests. Synchronized video and load data were used to measure strain, elastic modulus, relaxation time, and degree of relaxation (among other parameters). These metrics were then compared between specimen types and across the three leaflets. RESULTS: Fiber bundles were found to have a significantly higher elastic modulus (13.87 ± 2.81 MPa) than the membranes (2.27± 0.36 MPa). Both specimen types had similar relaxation time constants (6.75 ± 0.73 s) and degrees of relaxation (0.223 ± 0.016). The elastic modulus of the fiber bundles from the left coronary and non-coronary leaflets was significantly higher than that of the right coronary leaflet. The fiber bundle elastic modulus also negatively correlated with the fiber bundle width. CONCLUSION: The resulting differences in biomechanical properties of mesostructures are likely related to their biomechanical and hemodynamic requirements. The study findings highlight the importance of considering aortic valve leaflets as inhomogeneous. Further studies are required to characterize the morphologies, nonaffine deformations, and biomechanical properties of the valve’s complex fiber-membrane mesostructures, potentially enabling the development of improved models and designs for durable replacement/repair strategies.

How to cite: Rock, C. A., & Doehring, T. C. (2016). Biomechanical Properties of Fiber Bundle and Membrane Mesostructures of the Porcine Aortic Valve. The Journal of heart valve disease, 25(1), 82–89.

BACKGROUND AND AIM OF THE STUDY: Sutureless aortic bioprosthetic valves have become an alternative to conventional bioprostheses in high surgical risk cases. A significant decline in platelet count during the immediate postoperative period was observed in cases of Perceval S sutureless aortic valve implantation. The study aim was to determine how the reduction in platelet count after Perceval S prosthesis implantation compared to that after other bioprosthesis implants. METHODS: Between July 2011 and July 2014, a total of 77 isolated biological aortic valve replacements (AVRs) was performed at the authors’ institution. These included 27 Perceval S prostheses (35.1%) and 50 Mitroflow prostheses (64.9%). Platelet counts and mean platelet volumes (MPVs) were determined on the day before surgery (T0) and at 24 h (T1), 48 h (T2) and 72 h (T3) after surgery. RESULTS: There were no significant differences in inhospital mortality (three Perceval S (11.1%) versus four Mitroflow 8%); p = 0.65), nor in morbidity between groups. A total of 16 patients (20.8%) had severe postoperative thrombocytopenia (<50×103/mm3). The incidence of severe thrombocytopenia was significantly higher (p = 0.046) in Perceval S patients (n = 9; 33.3%) than in Mitroflow patients (n = 7; 14%). The platelet count recovered in all patients with severe thrombocytopenia. In an adjusted-propensity multivariate logistic regression analysis, the Perceval S prosthesis was the major independent predictor of severe thrombocytopenia after AVR (OR 0.06, 95% CI: 0008-0.5, p = 0.009). CONCLUSION: Aortic bioprosthesis implantation with the Perceval S sutureless bioprosthesis appears to be associated with the occurrence of postoperative thrombocytopenia, though without any clinical implication for the patients. Prospective randomized trials are required to confirm these data.

How to cite: Sánchez, E., Corrales, J. A., Fantidis, P., Tarhini, I. S., Khan, I., Pineda, T., & González, J. R. (2016). Thrombocytopenia after Aortic Valve Replacement with Perceval S Sutureless Bioprosthesis. The Journal of heart valve disease, 25(1), 75–81.

Infective endocarditis (IE) has historically caused significant morbidity and mortality. Valve surgery reduces systemic embolization and mortality, but the optimal timing is controversial. The EASE (Early Surgery Versus Conventional Treatment for Infective Endocarditis) trial, which employed strict inclusion and exclusion criteria, showed that early surgery could reduce the risk of embolic events for a subset of patients. The aim of the present study was to determine the proportion of adult IE patients seen in usual clinical practice at a single tertiary medical center that would meet EASE enrollment criteria. Over a four-year period, only 10 of 88 patients (11.3%) were found to meet EASE enrollment criteria. These results have important research implications, and highlight the differences between populations of patients used in clinical trials and patients seen in practice.

How to cite: Amin Kashef, M., Atreya, A. R., Hernandez-Montfort, J., Frideric, J., & Lagu, T. (2016). Not So EASE-Y: How Often do Hospitalized Infective Endocarditis Patients Meet Criteria for Early Surgery?. The Journal of heart valve disease, 25(1), 72–74.

Background: A straightforward tricuspid valve (TV) repair technique was used to treat either moderate or severe functional (normal valve with dilated annulus) or for primary/organic (Ebstein's anomaly, leaflet retraction/tethering and chordal malposition/tethering, with annular dilatation) TV incompetence, and its long-term outcome assessed.

Methods: A double-orifice valve technique was employed in 91 patients (mean age 52.6 ± 23.2 years; median age 56 years; range: 0.6-82 years) with severe tricuspid regurgitation. Among the patients, three had post-transplant iatrogenic chordal rupture, five had infective endocarditis, 11 had mitral valve insufficiency, 23 had Ebstein's anomaly, and 47 had isolated severe TV incompetence. The basic principle was to reduce the distance between the coapting leaflets, wherein the most mobile leaflet could coapt to the opposite leaflet, by creating two orifices, ensuring valve competence. The TV repair was performed through a median sternotomy or right anterior thoracotomy in the fifth intercostal space under cardiopulmonary bypass. The degree and extent of creating a double-valve orifice was determined by considering the minimal body surface area (BSA)-related acceptable TV diameter. Repair was accomplished by passing pledgeted mattress sutures from the middle of the true anterior annulus to a spot on the opposite septal annulus, located approximately two-thirds of the length of the septal annulus to avoid injury to the bundle of His. The annular apposition divides the TV into a larger anterior and a smaller posterior orifices, enabling valve closure, on both sides. In adults, the diameter of the anterior valve orifice should be 23-25 mm, and the posterior orifice 15-18 mm; thus, the total valve orifice area is 5-6 cm2. In children, the total valve orifice should be a standard deviation of 1.7 mm for a BSA of <1. 0m2, and 1.5 mm for a BSA of >1.0m2.

Results: During a mean follow up of 8.7 ± 1.34 years (median 10 years; range: 1.5-25.9 years) there have been no reoperations for TV insufficiency or stenosis. Reoperations on three patients (mean age 42.5 ± 8.7 years) were indicated for aortic valve replacement at 14 months postoperatively (n = 1) and for assist device implantation (n = 2) who eventually underwent heart transplant at 18 and 20 months after TV repair, respectively. The cumulative 12-year survival rate was 86.9%.

Conclusions: This double-orifice technique is technically a straightforward repair to abolish TV incompetence with highly satisfactory results, particularly in patients with severe annular dilatation or with leaflet and chordal tethering. In the present series, the technique provided no pitfalls (if the location of the conduction system was borne in mind), requiring only a gentle placement of sutures. It also led to no residual regurgitation or reoperation during the follow up period.

How to cite: Hetzer, R., Javier, M., & Delmo Walter, E. M. (2016). The Double-Orifice Valve Technique to Treat Tricuspid Valve Incompetence. The Journal of heart valve disease, 25(1), 66–71.

Background: A third percutaneous mitral balloon valvuloplasty (PMBV) may provide a means of treating symptomatic patients with re-restenosis after successful initial and second valvuloplasties, though data related to the long-term safety and efficacy of a third PMBV are lacking. The study aim was to determine the immediate and long-term clinical outcome in patients who underwent a third PMBV to treat recurrent mitral stenosis.

Methods: Among a total of 1,849 patients who underwent PMBV at the authors' institution, seven females (mean age 38.5 ± 12.2 years at the first procedure) required repeat second and third PMBVs. The mean interval between the first and second valvuloplasties was 6.4 ± 2.5 years, and between the first and third valvuloplasties was 12.5 ± 6.5 years. All procedures were performed using the Inoue balloon system.

Results: Second and third PMBVs resulted in a significant increase in mitral valve area (MVA), from 1.1 ± 0.1 cm2 to 1.6 ± 0.2 cm2, and from 1.0 ± 0.2 cm2 to 1.6 ± 0.4 cm2, respectively. However, as mitral degeneration progressed, four patients required mitral valve replacement (MVR) at 9.2 ± 5.8 years (range: 6-18 years) after the third PMBV. The preoperative MVA of these patients was 0.97 ± 0.1 cm2. One patient died due to surgical complications, while the fifth and sixth patients remain under clinical observation. If patients have a fourth recurrence of mitral stenosis they are no longer considered to be suitable candidates for re-PMBV. The seventh patient died at the age of 84 years.

Conclusions: A repeat, third PMBV is a safe and feasible procedure in selected patients with recurrent stenosis after successful first and second valvuloplasties. Although the third procedure provides good immediate results, the long-term outcome is not satisfactory. Nonetheless, a third PMBV would allow MVR surgery to be postponed for a few years.

How to cite: Tyczyński, P., Chmielak, Z., Rużyłło, W., Fronczak, A., Kłopotowski, M., Szymański, P., Konka, M., & Witkowski, A. (2016). Triple Percutaneous Mitral Balloon Valvuloplasty for Patients with Recurrent Mitral Valve Stenosis: Long-Term Observations. The Journal of heart valve disease, 25(1), 62–65.

BACKGROUND AND AIM OF THE STUDY: The best timing for mitral valve surgery remains controversial. Decreased left ventricular function (LVF) is considered to be a predictor for increased mortality and is therefore an indication for surgery. The study aim was to investigate the independent effect of preoperative LVF on early and late mortality after mitral valve surgery. METHODS: Patients undergoing isolated mitral valve surgery between January 1998 and December 2010 at a single center were included for the analysis. Patients without recorded LVF, with active endocarditis, or patients lost to follow up were excluded. Patients were allocated to three groups based on their left ventricular ejection fraction (LVEF) measured using echocardiography as good (>50%), moderate (35-50%) or poor (<35%). A Cox regression analysis was performed to identify independent risk factors for late survival. RESULTS: A total of 549 patients underwent isolated mitral valve surgery. The 30-day mortality was not statistically different between groups (p = 0.579), and late survival was similar in all groups (log-rank, p = 0.130). A moderate or poor LVF was not identified as a risk factor for late mortality (HR 1.4 [0.9-2.2], p = 0.179; HR 1.8 [0.7-4.4], respectively, p = 0.213). The difference remained insignificant after correction for other risk factors (HR 1.4 [0.8-2.3], p = 0.192; HR 2.4 [0.9-6.7], respectively, p = 0.09). CONCLUSION: A reduced LVF is not an independent risk factor for short- and long-term all-cause mortality in patients undergoing isolated mitral valve surgery for non-ischemic mitral valve disease.

How to cite: Verstraeten, S. E., & Soliman Hamad, M. A. (2016). Impaired Left Ventricular Function Does Not Predict Worse Late Outcome after Isolated Mitral Valve Surgery. The Journal of heart valve disease, 25(1), 55–61.

BACKGROUND AND AIM OF STUDY: Rheumatic valvular heart disease, which remains a common health problem in developing countries, has numerous consequences on the heart chambers and circulation. The study aim was to investigate the effects of chronic rheumatic valve disease on the diameters of the descending aorta (DA) and inferior vena cava (IVC). METHODS: A total of 88 patients with echocardiographically documented rheumatic valvular heart disease and 112 healthy controls were enrolled into the study. All patients underwent detailed echocardiographic examinations, while their height and body weight were recorded and adjusted to their body surface area. RESULTS: The most common involvement was mitral valve disease, followed by aortic valve disease and tricuspid valve disease. The mean diameter of the DA (indexed to BSA) was 1.79 ± 0.49 cm for patients and 1.53 ± 0.41 for controls (p <0.001). The mean diameter of the IVC (indexed to BSA) was 1.69 ± 0.73 for patients and 1.38 ± 0.35 cm for controls (p <0.001). There was a significant positive correlation between mitral valve mean gradient and IVC diameter (p = 0.01, r = 0.18). There were also strong associations between the mitral valve area and the diameters of the DA (p = 0.001, r = -0.239) and IVC (p <0.001, r = -0.246). CONCLUSION: Rheumatic valve disease, especially mitral stenosis, was closely related to remodeling of the great vessels.

How to cite: Altunbas, G., Yuce, M., Ozer, H. O., Davutoglu, V., Ercan, S., Kizilkan, N., & Bilici, M. (2016). Impact of Chronic Rheumatic Valve Diseases on Large Vessels. The Journal of heart valve disease, 25(1), 51–54.

Background: The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation (TAVI). TAVI has become an acceptable mode of treatment for high-surgical risk patients with aortic stenosis (AS) requiring valve replacement. A significant number of patients have concomitant MR which cannot be addressed by TAVI alone, and therefore may not be considered candidates for this procedure. A comparison was conducted of results obtained from patients undergoing TAVI with or without MR.

Methods: Between 2008 and 2013, a total of 164 patients (mean age 81 ± 8 years) underwent TAVI at the authors' institution. Of these patients, 87 (53%) had MR of moderate or greater degree. The groups were similar with respect to age, gender, presence of congestive heart failure, left ventricular function and co-morbid conditions. The logistic EuroSCORE was higher in the MR group (p = 0.02).

Results: Procedural (30-day) mortality was 12% (n = 19) and similar between groups. Kaplan-Meier estimates showed the overall survival at three years to be 68% and 76% for the MR and non-MR groups, respectively (p = 0.6). By Cox regression, age (p = 0.007) and peripheral vascular disease (p = 0.03) were the only predictors of late survival. Regression of MR was seen in patients with functional MR. Neither the presence of MR nor residual MR emerged as predictors of late mortality.

Conclusions: In elderly patients undergoing TAVI the presence of MR does not impact survival. TAVI should not be withheld from this group of patients because of concomitant MR.

How to cite: Silberman, S., Fink, D., Butnaru, A., Balkin, J., Almagor, Y., Tauber, R., & Merin, O. (2016). Untreated Mitral Regurgitation Does Not Affect Survival of Elderly Patients Undergoing TAVI. The Journal of heart valve disease, 25(1), 46–50.

Background: The study aim was to determine the impact of prosthesis-patient mismatch (PPM) on early and late clinical outcomes, left atrial and ventricular remodeling, late tricuspid valve regurgitation and pulmonary hypertension (PH) in patients after mitral valve replacement (MVR).

Methods: A total of 46 patients (mean age 66 ± 9.3 years) with mitral valve diseases and undergoing isolated MVR was enrolled in the study. The mitral valve effective orifice area (EOA) was determined using the continuity equation and indexed for the patient's body surface area (EOAi). PPM was defined as EOAi ≤1.2 cm2/m2. PH was defined as a systolic pulmonary artery pressure (sPAP) >40 mmHg. Both, clinical and echocardiographic follow up were performed.

Results: PPM was identified in 25% of patients, but no significant differences were observed in baseline and operative characteristics when comparing patients with and without PPM. The NYHA class was improved in most cases after surgery. Indeed, significant decreases in mean transvalvular gradient (from 8.6 ± 2.8 mmHg to 5 ± 1.3 mmHg, p = 0.001), left atrial dimension (LAD) (from 31.9 ±9.8 mm to 29.5 ± 7 mm, p = 0.011), left ventricular end-systolic diameter (from 42.6 ± 18.1 mm to 35.5 ± 6.6 mm, p = 0.044) and left ventricular end-diastolic diameter (from 55.8 ± 19.2 mm to 48.7 ± 6.1 mm, p = 0.024) were observed over time when comparing preoperative and postoperative echocardiographic data. In addition, at follow up (mean 6.9 ± 1.8 years) there were significant decreases in LAD (from 31.9 ± 9.8 mm to 28 ± 11.1 mm, p = 0.001), left ventricular enddiastolic volume (from 106.9 ± 32.9 ml to 92.3 ± 21.9 ml, p = 0.024), tricuspid regurgitation (TR) (from 87% to 27%, p = 0.002) and PH (from 78.3% to 58.7%, p = 0.043) in all patients. No significant differences were observed in hemodynamic, clinical outcome and atrial natriuretic peptide levels of patients with and without PPM.

Conclusions: Mitral PPM does not appear to have any negative effect on ventricular and atrial remodeling, TR and PH during the early and late postoperative periods.

How to cite: Pisano, C., Rita Balistreri, C., Fabio Triolo, O., Franchino, R., Allegra, A., Capuccio, V., Argano, V., & Ruvolo, G. (2016). Impact of Prosthesis-Patient Mismatch after Mitral Valve Replacement. The Journal of heart valve disease, 25(1), 39–45.

BACKGROUND AND AIM OF THE STUDY: Patients with asymptomatic aortic stenosis (AS) may have left ventricular systolic dysfunction (LVSD) defined as an impairment of the circumferential and/or longitudinal (C&L) myocardial fibers, despite a preserved left ventricular ejection fraction (LVEF). An assessment was made as to whether the combined LVSD of C&L fibers has a prognostic impact in asymptomatic AS. METHODS: A total of 200 asymptomatic AS patients was analyzed. Midwall shortening and mitral annular peak systolic velocity were considered as indices of C&L function and classified as low if <16.5% and <8.5 cm/s, respectively. The primary outcome was a composite of major cardiovascular events (MACE), including aortic valve-related and ischemic cardiovascular-related events. RESULTS: During a 25-month follow up period, MACE occurred in 69 patients (35%),while 46 of 72 patients (64%) had C&L LVSD and 23 of 128 patients (18%) had not (p <0.001). Cox analysis identified C&L LVSD as an independent MACE predictor, together with aortic transvalvular peak gradient, E/E′ ratio and excessive left ventricular mass. C&L-LVSD also predicted the occurrence of aortic valve-related events and ischemic cardiovascular-related events analyzed separately. A receiver operating characteristic curve analysis showed that the area under the curve (AUC) for C&L LVSD in predicting MACE was 0.77, significantly higher (p = 0.002, z-statistic) than the AUCs of C&L fibers considered individually (0.64 and 0.63, respectively). CONCLUSION: C&L-LVSD provides additional prognostic information into traditional risk factors for patients with asymptomatic AS.

How to cite: Cioffi, G., Mazzone, C., Barbati, G., Rossi, A., Nistri, S., Ognibeni, F., Tarantini, L., Di Lenarda, A., Faggiano, P., Pulignano, G., Stefenelli, C., & de Simone, G. (2016). Value of Combined Circumferential and Longitudinal Left Ventricular Systolic Dysfunction to Predict Adverse Outcome in Patients with Asymptomatic Aortic Stenosis. The Journal of heart valve disease, 25(1), 28–38.

Background: Aortic valve replacement (AVR) with a sutureless valve is an innovative therapy in high-risk elderly patients. The study aim was to compare the early results of AVR using sutureless aortic valves or stentless aortic bioprostheses.

Methods: A retrospective analysis was conducted of 55 patients who underwent AVR with either a sutureless valve (Perceval S; n = 24 or Edwards Intuity; n = 9) or a stentless valve (Sorin Freedom SOLO™; n = 22).

Results: Baseline patient characteristics were similar in both groups, except for NYHA class. Concomitant procedures were performed in 17 patients (51.5%) of the sutureless group and in nine patients (40.9%) of the stentless group (p = 0.44). The aortic cross-clamp time was 55 ± 23 min in the sutureless group and 102 ± 36 min in the stentless group (p <0.0001), while the postoperative peak aortic gradient was 19.5 ± 5.0 mmHg and 29.3 ± 15.4 mmHg for the sutureless group and stentless group, respectively (p = 0.037). The postoperative mean gradient was 9.3 ± 3.4 mmHg for the sutureless group and 15.1 ± 10.5 mmHg for the stentless group (p = 0.06). Blood product transfusion was required less frequently by the sutureless group, but drainage and bleeding was similar in both groups. The intensive care unit and hospital stays were significantly shorter in favor of the sutureless group. One sutureless patient (3.0%) and two stentless patients (9.1%) died in hospital (p = 0.557).

Conclusions: Early results of the present study suggested that surgical AVR with a sutureless valve is associated with a good hemodynamic performance and an improved early outcome.

How to cite: Ihsan Parlar, A., Onur Hanedan, M., Mataraci, I., Ali Yuruk, M., Sayar, U., Kemal Arslan, A., & Ozer, T. (2016). Immediate Outcomes of Aortic Valve Replacement with Sutureless versus Stentless Bioprosthesis. The Journal of heart valve disease, 25(1), 21–27.

Bilateral coronary ostial stenosis without additional coronary artery involvement is a rare presentation of syphilitic aortitis, with most cases being identified post-mortem. Herein is presented a case of bilateral coronary ostial stenosis and aortic valve insufficiency caused by syphilitic aortitis without aneurysmal dilatation of the aorta. The patient underwent aortic root replacement and coronary artery bypass grafting. The intraoperative macroscopic findings raised the suspicion of an aortitis that was later confirmed to syphilitic aortitis on histological examination. It is of note that syphilis can be a cause of bilateral ostial stenosis in young adults with no predisposition to atherosclerosis, especially if combined with aortic insufficiency resulting from an isolated leaflet dysfunction.

How to cite: Jadeed, R., Paarmann, R., Harringer, W., & El-Essawi, A. (2016). Syphilitic Aortitis Presenting with Coronary Ostial Stenosis and Aortic Regurgitation. The Journal of heart valve disease, 25(1), 18–20.

Transcatheter aortic valve implantation (TAVI) can now be considered a standard of care for inoperable and high-risk surgical patients with severe aortic stenosis, and its uptake worldwide is rapidly increasing. Indeed, many centers performing the procedure have now moved towards treating intermediate-risk patients with TAVI rather than referring them for surgical aortic valve replacement. Although the incidence of peri-procedural acute and subacute stroke following TAVI has fallen to 2-5%, its occurrence can be life-threatening and life-changing, and every effort must be made to improve patient outcome should stroke occur. Many cardiologists would not instinctively consider the use of thrombolytic therapy for post-transfemoral TAVI ischemic stroke because of concern about the risk of major bleeding from the access site, despite it being a standard of care for ischemic stroke in other circumstances. The present case highlights the benefit of using intravenous thrombolytic therapy for an acute basilar artery thrombotic stroke after transfemoral TAVI (TF-TAVI) that would otherwise have almost certainly resulted in the patient's death. The case may also prompt interventional cardiologists to consider performing TF-TAVI under conscious sedation rather than general anesthesia, as this can result in an earlier detection of acute stroke and allow an earlier intervention with thrombolytic agents, with an improved outcome.

How to cite: Montarello, N. J., Nelson, A. J., Sidharta, S. L., & Worthley, S. G. (2016). Intravenous Recombinant Tissue Plasminogen Activator Therapy for Acute Basilar Artery Ischemic Stroke Following Transfemoral Transcatheter Aortic Valve Implantation. The Journal of heart valve disease, 25(1), 14–17.

Background: A comparison was made between the long-term survival of patients undergoing aortic valve replacement (AVR) for aortic stenosis and of the general Icelandic population, using centralized registries.

Methods: A total of 366 AVR patients (231 males, 135 females; mean age 70.1 years) operated on for aortic stenosis in Iceland between 2002 and 2011 was included in the study. Concomitant coronary artery bypass grafting was performed in 54% of cases. Short-term complications and 30-day mortality were analyzed. The patients' overall survival was compared with the survival of Icelanders of the same age and gender. The median follow up was 4.7 years.

Results: A bioprosthesis was used in 81% of the patients; the median prosthesis size was 25 mm. Atrial fibrillation (68%) and acute kidney injury (23%) were the most common complications, and the 30-day operative mortality was 6%. Overall survival at one year and five years was 92% and 82%, respectively. There was no difference in survival between the surgical cohorts and expected survival of Icelanders of the same age and gender (p = 0.08), except for the first 30 postoperative days.

Conclusions: Despite the significant rate of short-term complications, the long-term survival of patients undergoing AVR for aortic stenosis was good compared to the general population of the same age and gender. These results confirmed the value of AVR as an excellent treatment option for aortic stenosis, as it offers a normalization of the patients' life expectancy.

How to cite: Viktorsson, S. A., Helgason, D., Orrason, A. W., Aspelund, T., Sigurdsson, M. I., Geirsson, A., & Gudbjartsson, T. (2016). Favorable Survival after Aortic Valve Replacement Compared to the General Population. The Journal of heart valve disease, 25(1), 8–13.

BACKGROUND AIM OF THE STUDY: The real burden of valvular heart disease (VHD) is scarcely known, as several factors may potentially lead to its increased prevalence. The study aim was to assess the prevalence of VHD and its treatment in the authors' environment to plan the healthcare requisites for optimal management of the condition. METHODS: A retrospective analysis was conducted of data acquired from patients who had been assessed at different consultation levels for cardiovascular disorders during a six-month period between January and June 2014 in public health referral area of 500,00 inhabitants. Patients included were those admitted to hospital cardiology, cardiac surgery and geriatric care units (n = 1,083), as well as ambulatory patients attending cardiology-specific outpatient clinics at the authors' hospital or at two ascribed primary care centers (n = 852). Data were registered regarding the epidemiology, etiology, echocardiography and treatment of patients in whom VHD was detected. RESULTS: Among a total of 1,935 adult patients, moderate or severe valve disease was identified in 453 cases (23.4%) who were evaluated for cardiovascular disease. The prevalence of VHD increased with age. Multivalvular moderate-severe dysfunction was present in two valves in 33% and in three valves in 5.7% of patients. Significant mitral valve disease was present in 39% and aortic valve disease in 48% of patients. The etiology of the valvular lesions was degenerative in 60%, functional in 15.5%, rheumatic in almost 10%, congenital in 6%, due to endocarditis in only 3%. Patients with VHD represented up to 24.2% of the in-hospital admissions. An interventional treatment was required in 55% of the patients (mostly surgical valve procedures). CONCLUSION: The present study results showed that VHD is a frequent occurrence and is increasingly prevalent with age, constituting up to one-fourth of all in-hospital admissions for cardiovascular disease. VHD is a growing public health problem that should be addressed with appropriate resources to improve research into its nature, diagnosis and treatment.

How to cite: Domenech, B., Pomar, J. L., Prat-González, S., Vidal, B., López-Soto, A., Castella, M., & Sitges, M. (2016). Valvular Heart Disease Epidemics. The Journal of heart valve disease, 25(1), 1–7.