Despite significant technological advances, the diagnosis of infective endocarditis (IE) remains a major challenge, and the condition continues to be associated with significant morbidity and mortality. Valvular vegetations have long been the diagnostic and pathologic hallmarks of IE. However, IE can be diagnosed even in the absence of vegetations using the modified Duke criteria. Vegetation-negative endocarditis is rare, and to the present authors' knowledge no cases of septic emboli in the absence of valvular vegetations have been reported. Herein is reported a case of prosthetic aortic valve endocarditis associated with both clinical and radiologic evidence of septic emboli, but in the absence of vegetations on both repeated transesophageal echocardiography and pathologic evaluation. This case highlights the importance of maintaining a high clinical suspicion and a low threshold for the surgical replacement of a possibly infected valve, in patients that meet other clinical criteria for IE, even in the absence of detectable valvular vegetations.

How to cite: Katchi, T., Cooper, H. A., Yandrapalli, S. S., Khera, S., Fallon, J., Spielvogel, D., Aronow, W. S., & Panza, J. A. (2017). Prosthetic Aortic Valve Endocarditis Without Evidence of Vegetation. The Journal of heart valve disease, 26(3), 365–367.

The effect of a highly elevated level of right atrial filling pressure on fractional flow reserve (FFR) measurement remains unclear. Transcatheter tricuspid valve intervention, a recently introduced option for inoperable or high-risk patients, represents a unique model of in-vivo physiology to investigate the eventual influence of central venous pressure on coronary FFR measurements. The case is reported of a patient with a degenerated tricuspid surgical bioprosthesis who underwent transcatheter tricuspid valve-in-valve replacement and concomitant coronary functional assessment with FFR. In an experimental model, the significant fall in right atrial pressure did not influence FFR measurements in the presence of angiographically proven mild coronary artery disease.

How to cite: Scarsini, R., Pesarini, G., Castriota, F., Vassanelli, C., & Ribichini, F. (2017). Significant Drop in Right Atrial Pressure Does Not Influence Fractional Flow Reserve Coronary Assessment. The Journal of heart valve disease, 26(3), 361–364.

Fenestrated aortic valve is a frequent condition which is, for most of the time, asymptomatic and generally has no influence on aortic valve competence. However, aortic valve regurgitation could occur, especially in the case of fibrous strand rupture. In this situation, acute aortic regurgitation is poorly tolerated and requires urgent surgical correction. Herein is presented the case of a 70-year-old patient who was admitted as an emergency for acute heart failure after coital exertion. Echocardiography revealed severe acute aortic regurgitation due to leaflet prolapse. Intraoperative inspection of the valve showed a strand rupture of the isolated fenestration.

How to cite: Roumy, A., Jeanrenaud, X., Pretre, R., & Kirsch, M. (2017). Post-Coital Acute Rupture of a Fenestrated Aortic Valve. The Journal of heart valve disease, 26(3), 358–360.

Mitral valve repair is a feasible and preferable option for the treatment of Barlow's disease. Complex valve repair techniques, in contrast, often lead to increased cross-clamp times and low cardiac output syndrome. A simple, fast, and reproducible foldoplasty technique to reduce anterior and posterior mitral leaflet heights may improve coaptation and reduce mitral regurgitation. Accordingly, herein are described minimally invasive, successful trans-septal and robotic approaches for a bileaflet foldoplasty technique in two patients with Barlow's disease.

How to cite: Khalpey, Z., Rawashdeh, B., Kazui, T., & Lick, S. (2017). Bileaflet Foldoplasty in Barlow’s Disease. The Journal of heart valve disease, 26(3), 355–357.

Background and aim of the study: Prosthetic valve thrombosis (PVT) in metallic prosthetic cardiac valves is not an uncommon condition, and has high mortality and morbidity. Although surgery is the traditional choice for PVT therapy, thrombolysis with newer agents has achieved good success rates. Many studies described in the western literature have used tissue plasminogen activators, while studies from developing countries have been largely based on the use of streptokinase and urokinase. Data regarding the use of newer agents such as tenecteplase are scant. Hence, the study aim was to evaluate the safety and efficacy of tenecteplase in left-sided PVT.

Methods and results: Between 2013 and 2016, a total of 18 patients with PVT was treated with a 40 mg bolus dose of tenecteplase. Significantly, one patient was a pregnant lady in whom a lower dose (25 mg) was successfully and safely used. Thrombolysis was followed by enoxaparin and oral anticoagulation in patients, all of whom had complete lysis of thrombus and clinical improvement.

Conclusions: Tenecteplase is an effective and excellent therapeutic agent for PVT, with a good safety margin. Its safe use in pregnancy points to a possible optional therapy, but this requires confirmation.

How to cite: Kumar Jha, R., Bansal, S., S Issar, H., Chaudhary, M., & Sharma, S. (2017). Treatment of Prosthetic Valve Thrombosis with Bolus Dose Tenecteplase: An Experience from a Developing Country. The Journal of heart valve disease, 26(3), 349–354.

Background and aim of the study: Thrombosis of a mechanical prosthetic heart valve is a potentially life-threatening complication associated with a high mortality. Although thrombolytic therapy has been considered highly beneficial in this situation, very few studies have been conducted to monitor the effectiveness of such thrombolytic therapy among Asian populations. Hence, the study aim was to evaluate the clinical profile, efficacy and safety of the thrombolytic agent streptokinase (SK) in patients with obstructive thrombosis of a left-sided mechanical heart valve.

Methods: Patients (n = 30) with left-sided mechanical heart valve thrombosis (LSMHVT) who had been managed with SK during the past four years were included in this retrospective study. Clinical features such as presenting symptoms based on NYHA functional class, prosthetic valve position, oral anticoagulant compliance, International Normalized Ratio (INR) and imaging methods including fluoroscopy, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were evaluated. In addition, the effectiveness and complications of SK were analyzed.

Results: The majority of patients presented with advanced NYHA class (III and IV, each 40%). Obstructive thromboses were observed at the mitral prosthesis in 70% of cases, at the aortic prosthesis in 27%, and at both valves in 3%. All patients underwent TTE, but fluoroscopy was used more often than TEE. Despite compliance with oral anticoagulation therapy, a sub-therapeutic INR was observed in 40% of cases at the time of presentation. Overall, thrombolysis was successful in 80% of patients using intravenous SK, with 100% success in patients in NYHA classes I-III and 42% for NYHA class IV. Moreover, embolic complications occurred in only a small number of patients.

Conclusions: In patients with obstructive thrombosis of LSMHVT, intravenous SK was effective and should be considered as first choice in patients in NYHA classes I-III, and as an acceptable alternative in those in NYHA class IV.

How to cite: Chandrakasu, A., Jayachandran, A., Gopinath Nayar, P., Meyyappan, C., Narayan, G., Basha Abdul Bari, A., & Johnson Samuel, P. (2017). Obstructive Thrombosis of Left-Sided Mechanical Heart Valves: Clinical Profile and Thrombolytic Therapy. The Journal of heart valve disease, 26(3), 344–348.

Background and aim of the study: The study aim was to compare the tissular expression of microRNAs (miRs) in bicuspid and tricuspid valves, and to evaluate their use as potential novel biomarkers of aortic valve calcification in bicuspid valves.

Methods: A prospective single-center observational study was conducted on stenotic bicuspid and tricuspid human aortic valves. According to their potential role in valve vascular and valvular calcification, a decision was taken to include miR- 92a, miR-141, and miR-223 in this analysis. A real-time quantitative polymerase chain reaction was used to measure the expression of each miR, using U6 and Cel-miR-39 as endogenous and exogenous gene controls, respectively.

Results: Among a total of 47 human calcified aortic valves collected, 30 (63.8%) were tricuspid valves. The mean preoperative transvalvular gradient was 50.8 mmHg (range: 37-89 mmHg), with no significant difference between bicuspid and tricuspid valves (50 mmHg versus 51.2 mmHg; p = 0.729). The mean aortic valve area was 0.79 cm2 (range: 0.33-1.3 cm2), again with no significant difference between the two groups (p = 0.34). The level of miR-92a expression was twofold higher in bicuspid valves compared to tricuspid valves (0.38 versus 0.17; p = 0.016), but no significant difference in miR-141 and miR-223 expression was observed between the two groups (p = 0.68 and p = 0.35, respectively). A positive correlation was observed between miR-92a expression and mean preoperative transvalvular gradient (r = 0.3257, p = 0.04).

Conclusions: miR-92a is overexpressed in calcified bicuspid aortic valves, and may serve as a potential biomarker of rapid aortic valve calcification. Further studies based on these results may be designed to correlate the relative expression of miR-92a in the serum with its tissular expression in AS.

How to cite: Nader, J., Metzinger-Le Meuth, V., Maitrias, P., Humbert, J. R., Brigant, B., Tribouilloy, C., Metzinger, L., & Caus, T. (2017). miR-92a: A Novel Potential Biomarker of Rapid Aortic Valve Calcification. The Journal of heart valve disease, 26(3), 327–333.

In patients with carcinoid syndrome, the development of carcinoid valve disease typically carries an unfavorable prognosis. We present the case of a patient with significant valvular dysfunction secondary to carcinoid valve disease. Valve replacement surgery was complicated by the development of prosthetic valve degeneration, ultimately requiring percutaneous valve implantation in a valve-in-valve fashion. The technical details of the case, as well as a review of carcinoid valve disease, including its pathophysiology, clinical manifestations, diagnostic features and management considerations, are presented.

How to cite: Heikali, D., Chang, N., & Tabibiazar, R. (2017). Carcinoid Valve Disease: A Case Report and Review. The Journal of heart valve disease, 26(3), 321–326.

Background and aim of the study: A subset of patients requiring coronary revascularization of the proximal left anterior descending coronary artery (LAD) and valve surgery may benefit from a staged approach, rather than combined median sternotomy coronary artery bypass graft (CABG) and valve surgery.

Methods: A retrospective evaluation was made of the outcomes of patients with significant proximal LAD and valvular heart disease undergoing a staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) at the authors' institution between February 2009 and April 2014. A Kaplan-Meier analysis was performed to estimate mid-term survival.

Results: A total of 68 consecutive patients (mean age 75.2 ± 8.9 years) was identified. PCI was performed for one- or two-vessel disease in 76.5% and 23.5% of the patients, respectively. Within a median of 39 days (IQR 11-62 days), 91.2% of patients underwent primary MIVS, and 8.8% underwent re-operative MIVS, of which 58 (85.3%) were single-valve and 10 (14.7%) were double-valve operations. At the time of surgery, 72.1% of the patients were receiving dual anti-platelet therapy. The 30-day mortality was 2.9%. At a mean follow up of 26 ± 16 months, 7.4% of the patients had a non-target vessel acute coronary syndrome, and the survival rate was 88.2%.

Conclusions: Among a select group of patients with proximal LAD and valvular disease, a staged approach of PCI followed by MIVS can be safely performed for primary or re-operative surgery, with excellent mid-term outcomes.

How to cite: Pineda, A. M., Mihos, C. G., Rodriguez-Escudero, J. P., Lamelas, J., Beohar, N., & Santana, O. (2017). A Staged Approach of Proximal Left Anterior Descending Coronary Artery Percutaneous Intervention Followed by Minimally Invasive Valve Surgery. The Journal of heart valve disease, 26(3), 314–320.

Except for bleeding complications, vitamin K antagonists (VKAs) are known to have few undesirable side effects. Herein is presented the case of a 45-year-old woman in whom liver damage was induced by fluindione and warfarin after mitral valve replacement. Hepatotoxicity is a rare complication of VKAs, both in the French National and Drug Safety registry and the medical literature. A diagnosis of VKA-induced drug damage was confirmed by the absence of other etiologies, the chronological sequence, recurrence after re-exposure to VKA, and rapid improvements after discontinuation of the drug. Despite possible cross-reactions between VKAs, the re-introduction of acenocoumarol was successfully achieved, with no recurrence of biological disturbances.

How to cite: Marchandot, B., Messas, N., Jesel, L., Trinh, A., Kibler, M., Reydel, A., Ohlmann, P., & Morel, O. (2017). Unexpected Problems of Antithrombotic Therapy with An Unusual Side Effect of Vitamin K Antagonists after Mitral Valve Replacement. The Journal of heart valve disease, 26(3), 309–313.

Background and aim of the study: Cardiac amyloidosis (CA) is a rare condition characterized by the extracellular deposition of amyloidogenic proteins in the heart. The aim of the present study was to compare the size and function of the mitral annulus (MA) between CA patients and age- and gender-matched controls, using three-dimensional speckle-tracking echocardiography (3-D STE).

Methods: The study included 17 patients (mean age 64.2 ± 9.8 years) with CA, whose results were compared to 26 age- and gender-matched healthy controls (mean age 59.0 ± 8.2 years). Complete two-dimensional (2-D) Doppler echocardiography and 3-D STE were performed in all cases.

Results: Significantly enlarged end-diastolic and end-systolic MA diameters (3.09 ± 0.56 cm versus 2.70 ± 0.37 cm, p = 0.01 and 2.71 ± 0.68 cm versus 1.87 ± 0.31 cm, p <0.001) and MA area (11.22 ± 3.56 cm2 versus 8.60 ± 1.92 cm2, p = 0.004 and 8.57 ± 3.35 cm2 versus 4.55 ± 1.05 cm2, p <0.001) were demonstrated in CA. MA fractional area change (24.10 ± 13.97% versus 46.06 ± 14.37%, p <0.001) and MA fractional shortening (12.92 ± 9.55% versus 30.98 ± 11.65%, p <0.001) were also impaired in CA patients as compared to matched controls.

Conclusions: CA is associated with MA enlargement and functional impairment represented by MA fractional shortening and MA fractional area change, as assessed using 3-D STE.

How to cite: Nemes, A., Földeák, D., Kormányos, Á., Domsik, P., Kalapos, A., Borbényi, Z., & Forster, T. (2017). Cardiac Amyloidosis Associated with Enlargement and Functional Impairment of the Mitral Annulus: Insights from the Three-Dimensional Speckle Tracking Echocardiographic MAGYAR-Path Study. The Journal of heart valve disease, 26(3), 304–308.

Background and aim of the study: Mitral leaflet enlargement in patients with chronic aortic regurgitation (AR) has been identified as an adaptive mechanism potentially able to prevent functional mitral regurgitation (FMR) in response to left ventricular (LV) dilatation. The timing of valve enlargement is not known, and the related mechanisms are largely unexplored.

Methods: AR was induced in 58 rats, and another 54 were used as sham controls. Animals were euthanized at different time points after AR creation (48 h, one week, and three months), and AR severity, FMR and LV dilatation were assessed using echocardiography. Mitral valves were harvested to document the reactivation of embryonic growth pathways.

Results: AR animals had increased LV dimensions and mitral annulus size. No animal developed FMR. No change in leaflet length or thickness was seen at 48 h; however, anterior mitral leaflets were longer and thicker in AR animals at one week and three months. Molecular changes were present early (at 48 h and at one week), with positive staining for transforming growth factor-b1 (TGF-b1), Alpha-smooth muscle actin (α-SMA) and matrix metalloproteinase-2 (MMP-2), which suggested active matrix remodeling. Increased gene expression for collagen 1, TGF-β1, α-SMA and MMP-2 was found in the mitral valve at 48 h and at one week, but after three months their expression had returned to normal.

Conclusions: This model of AR induces active expansion and thickening of the mitral leaflets. Growth signals are expressed acutely, but not at three months, which suggests that most of this enlargement occurs at an early stage. The stimulation of valvular growth could represent a new strategy for the prevention of FMR.

How to cite: Marsit, O., Royer, O., Drolet, M. C., Arsenault, M., Couet, J., Morin, S., Levine, R. A., Pibarot, P., & Beaudoin, J. (2017). Early Activation of Growth Pathways in Mitral Leaflets Exposed to Aortic Regurgitation: New Insights from an Animal Model. The Journal of heart valve disease, 26(3), 281–289.

Background and aim of the study: The aim of this systematic review was to assess the incidence of bicuspid aortic valve (BAV) in Chinese patients with aortic valve disease.

Methods: Articles published between January 2000 and January 2015 were retrieved, and those reporting numbers of BAVs were selected. Data relating to congenital BAV and rheumatic lesions with functional BAV that were available for analysis were also collected.

Results: A total of 4,070 articles (3,538 in Chinese, 532 in English) was retrieved, among which 3,954 were excluded and 116 were selected. Ultimately, 20 articles remained for further analysis, and these revealed that the prevalence of confirmed BAVs in aortic valves was 10.92% (133/1,218). The long-term follow up survival rate of patients undergoing surgical procedures to treat BAVs ranged from 76.7% to 91.7%.

Conclusions: The prevalence of BAVs in aortic valve disease remains high among the Chinese population. Rheumatic lesions with functional BAV have frequently been described in the Chinese population. More epidemiological data are required to better characterize and understand aortic valve disease, especially in the context of transcatheter aortic valve implantation.

How to cite: Wang, X., & Wang, W. (2017). Prevalence of Bicuspid Aortic Valve in Chinese Patients with Aortic Valve Disease: A Systematic Review. The Journal of heart valve disease, 26(3), 274–280.

Background and aim of the study: Although transcatheter aortic valve implantation (TAVI) is a steadily expanding treatment for the pathology of the aortic valve, its role in the replacement of native aortic valves following valve-sparing surgery has not been investigated.

Methods: Among 150 patients who underwent TAVI at the authors' institution, three (2%) had a failed valve-sparing operation. The in-hospital outcome, mid-term mortality, and valvular function of the three patients were evaluated retrospectively. These patients, who were deemed at high surgical risk by the heart team, underwent TAVI for predominant severe aortic stenosis (n = 2) or pure severe aortic regurgitation (AR) (n = 1).

Results: A self-expandable CoreValve prosthesis was inserted via femoral access in all three patients. Based on the Valve Academic Research Consortium 2 criteria (VARC-2), implantation was successful in all cases, with only one major access site complication and no more than mild residual AR. At a follow up of 13 ± 6 months there were no deaths and the mean transvalvular gradient remained low (7 ± 6 mmHg at discharge; 7 ± 4 mmHg at follow up), without any echocardiographic signs of valve deterioration.

Conclusions: The results obtained with this small patient cohort demonstrated the feasibility, safety, and favorable mid-term outcomes of TAVI for failed valve-sparing operations in high surgical risk patients. However, these findings must be validated in larger cohorts before extending such treatment routinely to this subset of patients.

How to cite: Notaristefano, F., Notaristefano, S., Sclafani, R., Reccia, M. R., Annunziata, R., Da Col, U., Ambrosio, G., & Cavallini, C. (2017). TAVI for Failed Valve-Sparing Operations: In-Hospital and Mid-Term Outcome. The Journal of heart valve disease, 26(3), 268–273.

Background and aim of the study: Epicardial fat tissue (EAT) is associated with coronary as well as aortic valve calcification. The study aim was to determine whether EAT thickness is different in patients with and without aortic valve stenosis (AVS).

Methods: A cohort of 200 consecutive patients with severe AVS and 200 matched patients without AVS were included retrospectively in the study. EAT thickness was quantified, using transthoracic echocardiography, as the space between the epicardial wall of the myocardium and the visceral layer of the pericardium. Unadjusted and risk factor-adjusted logistic regression analysis was used to determine the association of EAT thickness with the presence of AVS.

Results: Overall, 400 patients (182 males, 218 females; mean age 79.6 ± 6.5 years) were included in the study. EAT thickness was significantly higher in patients with severe AVS (7.4 ± 0.3 mm versus 5.8 ± 0.2 mm; p <0.0001 for patients with and without AVS, respectively). In logistic regression analysis, an increase in EAT by one standard deviation was associated with a two-fold increased occurrence of AVS (OR [95%CI]: 2.10 [1.65-2.68]; p <0.0001). Associations remained stable upon adjustment for age, gender and traditional cardiovascular risk factors (2.08 [1.59-2.72]; p <0.0001). Body mass index (BMI) -specific subgroup analysis showed that the link between EAT and AVS was independent of BMI (1.78 [1.15-2.75], 2.62 [1.71- 4.02], and 2.22 [1.36- 3.62], for BMI <25 kg/m2, 25-30 kg/m2, and >30kg/ m2, respectively). EAT, in addition to traditional cardiovascular risk factors, significantly improved the area under the receiver operating characteristic curve (from 0.70 to 0.76; p = 0.003).

Conclusions: EAT thickness is significantly associated with severe AVS, independent of traditional risk factors. While further studies are needed to confirm these results, the present findings support the hypothesis that EAT may influence sclerosis of the aortic valve.

How to cite: Mahabadi, A. A., Kahlert, H. A., Dykun, I., Balcer, B., Kahlert, P., & Rassaf, T. (2017). Epicardial Adipose Tissue Thickness Independently Predicts Severe Aortic Valve Stenosis. The Journal of heart valve disease, 26(3), 262–267.

Background and aim of the study: Transcatheter aortic valve implantation (TAVI), especially via the transfemoral (TF) route, is increasingly performed in patients considered in the 'gray zone' between TAVI and surgery. However, the best treatment option in this patient population remains to be established.

Methods: Since 2010, a total of 923 patients underwent either TAVI (n = 538) or sutureless aortic valve replacement (AVR) (n = 385) at the authors' institutions. Among these patients, 79 treated with TF-TAVI were compared with 79 propensity score-matched patients who had undergone elective isolated AVR with the sutureless Perceval bioprosthesis.

Results: In-hospital mortality did not differ significantly between patients who underwent sutureless AVR or TF-TAVI (none versus three; 3.8%; p = 0.123). Similarly, postoperative complications were comparable between groups. Atrioventricular block requiring postoperative pacemaker implantation occurred in seven patients (9.2%) of the sutureless group and in eight patients (11.1%) of the TF-TAVI group (p = 0.455). The use of blood products varied between groups in terms of red blood cell transfusions (1.7 ± 2 versus 0.3 ± 0.9 units for the sutureless group versus TF-TAVI group; p <0.001). Paravalvular leakage at discharge was present in three patients (3.8%) in the sutureless group and in 26 patients (32.9%) in the TF-TAVI group (p <0.001). The mean follow up was longer for sutureless AVR (36 ± 21 versus 27 ± 20 months; p = 0.003). Survival rates were 97.5% and 84.8% in the sutureless and TF-TAVI groups, respectively (p = 0.001).

Conclusions: Both, TF-TAVI and sutureless AVR are well-standardized, safe and effective procedures. TF-TAVI seems to be a valuable alternative to surgical AVR for frail patients, reducing the need for perioperative blood transfusion. In contrast, in patients with a favorable long-term survival outcome, minimally invasive AVR remains the procedure of choice as it is associated with better long-term results.

How to cite: Santarpino, G., Vogt, F., Pfeiffer, S., Dell'Aquila, A. M., Jessl, J., Cuomo, F., von Wardenburg, C., Fischlein, T., Pauschinger, M., & Schwab, J. (2017). Sutureless versus Transfemoral Transcatheter Aortic Valve Implant: A Propensity Score Matching Study. The Journal of heart valve disease, 26(3), 255–261.

Background: Sutureless aortic valve replacement (AVR) is an emerging alternative to standard AVR in elderly and high-risk patients. This procedure is associated with a high rate of postoperative permanent pacemaker implantation (PPI). The study aim was to assess the impact on the rate of PPI of implanting the Perceval prosthesis without using balloon inflation.

Methods: A total of 159 patients who underwent sutureless AVR using the Perceval prosthesis was included. Balloon inflation was used in 132 patients (Balloon group) and not used in the remaining 27 (No-Balloon group). Clinical, echocardiographic and electrocardiographic outcomes were assessed.

Results: There was no significant difference in PPI rate between the two groups (26% for Balloon group versus 22% in No-Balloon group; p = 0.700). Balloon inflation had no significant impact on the incidence of paravalvular leaks (p = 0.839), or on the need to return to cardiopulmonary bypass (CPB) intraoperatively due to paravalvular leak or unsatisfactory deployment (p >0.999). Mean and peak transaortic pressure gradients were similar between the two groups (p = 0.417 and p = 0.522, respectively). Cross-clamp and CPB times were shorter in the No-Balloon group (49.6 ± 15.9 min versus 61.1 ± 25.6 min and 64.1 ± 26.3 min versus 79.6 ± 35.4 min, respectively; p = 0.027 and p = 0.012, respectively).

Conclusions: The two groups had similar postoperative PPI rates. Implanting the Perceval prosthesis without balloon inflation is safe and had no impact on paravalvular leaks, intraoperative complications or hemodynamic results. Reductions in aortic cross-clamp time and CPB time were observed when the balloon was not used.