Over the years, the surgery of ventricular postinfarction aneurysm has evolved from linear resection to endoaneurysmorrhaphy using a patch. Technically, several aims that include the restoration of ventricular shape and function, exclusion of dead space, minimization of the risk of thrombus formation and restoration of valve function are pursued. Herein is reported the case of a 58-year-old male with a giant inferobasal aneurysm involving the mitral valve apparatus who underwent successful endoaneurysmorrhaphy. Correct sizing of the patch proved to be the 'road to success' in this patient. The present case is the second reported instance of a giant ventricular aneurysm involving the mitral valve, with favorable outcome.

How to Cite: Ramadani, B., Schurr, P., Möhlenkamp, S., & Lichtenberg, A. (2017). Endoaneurysmorrhaphy for a Giant Inferobasal Left Ventricular Aneurysm Restoring Mitral Function. The Journal of heart valve disease, 26(5), 613–615.

Mixed connective tissue disease (MCTD) syndrome in children may lead to large aortic aneurysms, which in turn pose a difficult surgical problem. Valve-sparing root replacement is not always a viable option as the disease process invariably affects the aortic valve leaflets. Among pediatric patients, the Ross procedure is contraindicated on account of weakness of the pulmonary root, while Bentall surgery is the 'gold standard' treatment of aortic aneurysm, with reproducible and excellent long-term results. The case is presented of a three-year-old girl with a large thoracic aortic aneurysm in whom Bentall's surgery was performed, with a good result. The present patient, with MCTD syndrome, was too young to have undergone aortic root replacement with a composite mechanical valved graft.

How to cite: Ramaprabhu, K., Prakash, O., Davidson, N., Bhalero, S., Radhakrishnan, S., & Coelho, R. (2017). Bentall’s Procedure in Pediatric Mixed Connective Tissue Disease Syndrome: Management of Pediatric Aortic Aneurysm - A Brief Review. The Journal of heart valve disease, 26(5), 610–612.

The case is reported of a 55 year-old woman, with a previously known congenital septal defect, who was admitted to the emergency department with a diagnosis of meningoencephalitis, septic shock, and rapid clinical deterioration. Echocardiography revealed a vegetation occupying the right-side heart. Endocarditis affectation of the septal defect, aortic and tricuspid valves was noted and blood cultures were positive for Staphylococcus aureus. Urgent surgical treatment was performed whereby the ventricular septal defect was closed, a meticulous debridement of the affected area was conducted, and the aortic and tricuspid valves were replaced.

How to cite: Varela Barca, L., López-Menéndez, J., Redondo Palacios, A., & Rodríguez-Roda Stuart, J. (2017). Septic Shock, Meningoencephalitis and Multiple Pulmonary Emboli: Case Report of an Uncommon Clinical Presentation of Ventricular Septal Defect Acute Infective Endocarditis. The Journal of heart valve disease, 26(5), 606–609.

A patient presented with a decompensated cardiomyopathy requiring invasive hemodynamic support with an Impella® heart pump. Extracorporeal life support (ECLS) became necessary during the further course and the patient was bridged to left ventricular assist device (LVAD) implantation. Postoperatively, the patient did not improve as expected due to new aortic regurgitation (AR) that was most likely caused by the previously placed Impella. A SAPIEN 3 transcatheter aortic valve was implanted as a bail-out strategy; an additional valve-in-valve rescue was required due to paravalvular regurgitation. This resulted in a restitution of valvular function and hemodynamic improvement. TAVI appears to be a valuable bail-out option for postoperative AR following LVAD implantation.

How to cite: M Herrmann, F. E., Wellmann, P., von Dossow, V., Massberg, S., Hagl, C., Schramm, R., & Pichlmaier, M. (2017). Rescue TAVI for Aortic Regurgitation after Left Ventricular Assist Device Implantation Following Preoperative Impella® Support. The Journal of heart valve disease, 26(5), 603–605.

A 36-year-old pregnant woman with a history of rheumatic heart disease and prior aortic valve replacement and mitral valve repair presented to an outside hospital with severe aortic stenosis. The patient had a cardiac arrest upon labor induction and underwent a transcatheter aortic valve replacement (TAVR), which dislodged two days later. Five months later, the patient underwent removal of the dislodged TAVR and a Ross procedure at the authors' institution. The patient was stable upon discharge, with minimal aortic and pulmonary regurgitation. To the authors' knowledge, the present report is the first of the Ross procedure being used under such circumstances. It is suggested that caution be taken when using bioprosthetic and transcatheter aortic valves in young patients, and primary use of the Ross procedure is encouraged at experienced centers.

How to cite: Schnittman, S. R., Weiss, A. J., Varghese, R., & Stelzer, P. (2017). Ross Procedure Following a Dislodged Transcatheter Aortic Valve Replacement. The Journal of heart valve disease, 26(5), 600–602.

Paradoxical low-flow, low-gradient aortic stenosis (LFLG AS) is recognized as a subtype of aortic stenosis. A small left ventricular (LV) cavity with marked LV concentric remodeling leads to a reduced stroke volume in this condition. The case is reported of a paradoxical LFLG AS patient who was undergoing treatment for pulmonary hypertension (PH) and interstitial pneumonia associated with scleroderma. Echocardiography demonstrated enlargement of the right ventricle and a diminished LV cavity. Moreover, the aortic valve opening was restricted despite a preserved LV ejection fraction (61%). The patient's aortic valve area (obtained with the continuity equation) was 0.57 cm2 (indexed AVA was 0.39 cm2/m2), and the mean gradient was 16 mmHg. Multi-detector computed tomography findings confirmed that the aortic valve calcification was not severe. The main mechanism responsible for LFLG AS was considered to be a reduced LV cavity secondary to PH, rather than a sclerotic aortic valve. Thus, a decision was taken to treat the patient with additional medical management prior to performing any invasive procedures. It should be borne in mind that PH can lead to paradoxical LFLG AS, and that appropriate treatment should be contemplated depending on the underlying mechanisms. Video 1: Transthoracic echocardiography in the parasternal long-axis view showing right ventricular dilatation and a diminished left ventricular cavity. Video 2: Transthoracic echocardiography in the shortaxis view showing enlargement of the right ventricle and septal flattening due to pulmonary hypertension. Video 3: Transesophageal echocardiography clearly demonstrates an insufficient valve opening.

How to cite: Watanabe, Y., Higashi, H., Inoue, K., Aono, J., Okura, T., Higaki, J., & Ikeda, S. (2017). Pulmonary Hypertension as a Possible Cause of Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. The Journal of heart valve disease, 26(5), 597–599.

The case is described of a successful MitraClip procedure performed on an 88-year-old patient with severe mitral regurgitation (MR), five years after she had undergone mitral valve repair using the Alfieri surgical procedure. It is suggested that the MitraClip procedure is an option in patients with severe MR persisting after the Alfieri procedure. Video 1: Transesophageal echocardiography before the MitraClip procedure. Severe mitral regurgitation with preserved left ventricular systolic function. The main regurgitant jet originates from the medial commissure. Video 2: Transesophageal echocardiography: clip placement and jet reduction. A single clip placement on the medial portion of the mitral valve, resulting in elimination of the medial jet and reduction of the overall mitral regurgitant jet from grade 4+ to grade 2+.

How to cite: Tonchev, I. R., Turyan, A., Beeri, R., & Shuvy, M. (2017). MitraClip Technique Five Years after Alfieri Stitch Mitral Valve Repair. The Journal of heart valve disease, 26(5), 595–596.

Herein is presented the case of an 83-year-old male patient in cardiogenic shock with acute aortic regurgitation that occurred six years after aortic valve replacement (AVR) with a 23 mm Trifecta™ valve. Prosthesis endocarditis was initially suspected because of a floating structure attached to the aortic valve that was visible on echocardiography. Emergency redo-AVR surgery was performed, but no signs of endocarditis were found intraoperatively. Hence, cusp tearing of the implanted bioprosthesis was considered to be the reason for the severe aortic regurgitation.

How to cite: Schaefer, A. K., Kocher, A., Laufer, G., & Wiedemann, D. (2017). Cusp Tear of Trifecta™ Aortic Bioprosthesis Resulting in Acute Heart Failure. The Journal of heart valve disease, 26(5), 592–594.

A 79-year-old woman with a history of ischemic dilated cardiomyopathy, severely depressed left ventricular ejection fraction and significant mitral regurgitation (MR) was admitted to the authors´ institution for percutaneous mitral valve repair. Transesophageal echocardiography (TEE) revealed the presence of a posterior mitral cleft at the P2 level, causing a trileaflet mitral valve that contributed significantly to the regurgitant jet. The procedure was performed under general anesthesia and guided by real-time three-dimensional TEE. Three MitraClip® devices (Abbott Vascular, Santa Clara, CA, USA) were implanted, which reduced the MR to grade 1+.

How to cite: Rodríguez-Santamarta, M., Estévez-Loureiro, R., Benito-González, T., Gualis, J., Garrote, C., Pérez de Prado, A., & Fernández-Vázquez, F. (2017). Trileaflet Mitral Valve Treated with the MitraClip® System. The Journal of heart valve disease, 26(5), 589–591.

Mitral annuloplasty ring thrombosis is an extremely infrequent pathology, for which no evidence-based antithrombotic management has yet been described. Herein is presented a case of heterozygous Factor V Leiden (FVL) and hyperhomocysteinemia with homozygous methylenetetrahydrofolate reductase (MTHFR) mutations that caused early thrombosis of the mitral annuloplasty ring. The clinical management and antithrombotic treatment of the patient, and the implications of hyperhomocysteinemia, are discussed. Video 1: Mobile 9-mm thrombus of mitral annuloplasty ring on two-dimensional (2D) transesophageal echocardiography. Video 2: Mitral annuloplasty ring thrombus on real time three-dimensional (RT-3D) transesophageal echocardiography. Video 3: 2D video showing the morphologic change of mitral annuloplasty ring thrombus after prolonged UFH infusion.

How to cite: Cerşit, S., Bayam, E., Gündüz, S., & Özkan, M. (2017). Early Thrombosis of a Mitral Annuloplasty Ring in a Patient with MTHFR and Factor V Leiden Mutations. The Journal of heart valve disease, 26(5), 585–588.

Pulmonary valve infections without the involvement of other valves account for only 1.5- 2% of all infective endocarditis cases. Isolated pulmonary valve endocarditis due to fungus is extremely rare. The case is presented of a 36-year-old male who was found to have isolated pulmonary valve endocarditis caused by a very rare organism, Candida parapsilosis, and that was solely managed with medical therapy. The patient was evaluated for three weeks of lowgrade fever, generalized rash and fatigue, and found to have C. parapsilosis in the blood. Transesophageal echocardiography (TEE) demonstrated a 4.5 cm vegetation on the pulmonary valve, without involvement of other valves. The patient was deemed not to be a surgical candidate and was subsequently started on intravenous liposomal amphotericin B and 5-flucytosine, with excellent clinical outcome. Based on these case details, it must be emphasized that in selective cases and if there are no known complications, fungal endocarditis can be managed successfully using anti-fungal agents.

How to cite: Guragai, N., Rampal, U., Vasudev, R., Shah, D., Patel, H., Salamera, J., Pullatt, R., & Shamoon, F. (2017). Isolated Pulmonary Valve Fungal Endocarditis with Candida parapsilosis: Management Considerations of a Rare Case. The Journal of heart valve disease, 26(5), 581–584.

Background: A genetic component to familial mitral valve prolapse (MVP) has been proposed for decades. Despite this, very few genes have been linked to MVP. Herein is described a four-generation pedigree with numerous individuals affected with severe MVP, some at strikingly young ages.

Methods: A detailed clinical evaluation performed on all affected family members demonstrated a spectrum of MVP morphologies and associated phenotypes.

Results: Linkage analysis failed to identify strong candidate loci, but revealed significant regions, which were investigated further using whole-exome sequencing of one of the severely affected family members. Whole-exome sequencing identified variants in this individual that fell within linkage analysis peak regions, but none was an obvious pathogenic candidate. Follow up segregation analysis of all exome-identified variants was performed to genotype other affected and unaffected individuals in the family, but no variants emerged as clear pathogenic candidates. Two notable variants of uncertain significance in candidate genes were identified: p.I1013S in PTPRJ at 11p11.2 and FLYWCH1 p.R540Q at 16p13.3. Neither gene has been previously linked to MVP in humans, although PTPRJ mutant mice display defects in endocardial cushions, which give rise to the cardiac valves. PTPRJ and FLYWCH1 expression was detected in adult human mitral valve cells, and in-silico analysis of these variants suggests they may be deleterious. However, neither variant segregated completely with all of the affected individuals in the family, particularly when 'affected' was broadly defined.

Conclusions: While a contributory role for PTPRJ and FLYWCH1 in this family cannot be excluded, the study results underscored the difficulties involved in uncovering the genomic contribution to MVP, even in apparently Mendelian families.

How to cite: Haskell, G. T., Jensen, B. C., Skrzynia, C., Pulikkotil, T., Tilley, C. R., Lu, Y., Marchuk, D. S., Ann Samsa, L., Wilhelmsen, K. C., Lange, E., Patterson, C., Evans, J. P., & Berg, J. S. (2017). Genetic Complexity of Mitral Valve Prolapse Revealed by Clinical and Genetic Evaluation of a Large Family. The Journal of heart valve disease, 26(5), 569–580.

Background: Myxomatous mitral valve disease (MMVD) is one of the most prevalent valvular heart diseases, while back pain, neck pain and upper-extremity numbness are some of the most common complaints in outpatient settings. Decreased thoracic kyphosis (straight back) is a known cause of hastening back or neck problems, radiculopathy, or even myelopathy. The study aim was to examine the relationship between MMVD, straight back, and the need for cervical fusion.

Methods: In this single-center retrospective study, patients who underwent mitral valve repair or replacement due to MMVD (cases) based on age, gender and body mass index (BMI), were matched with patients who underwent coronary artery bypass grafting (CABG) surgery and had no history of mitral valve disease (controls). The number of patients in each group who required cervical fusion was also noted. Patients included were aged <65 years at the time of surgery, which was performed between January 2014 and December 2015. Thoracic kyphosis curvature was measured from the length of a perpendicular line drawn from the middle of the anterior border of T8 vertebral body to a vertical line connecting anterior superior T4 and anterior inferior T12 on a lateral chest radiograph (AP distance). An AP distance <12 mm was defined as straight back. A Wilcoxon rank-sum test was used to compare the AP distance between cases and controls, and a chi-square test was used to compare the prevalence of straight back in the two groups.

Results: The study cohort included 75 patients in the MMVD group and 225 patients in the CABG group. Straight back was present in 27% of the MMVD group versus only 6.7% of the CABG group (p <0.0001) (Odds ratio 5.1; 95% CI 2.4-10.6). The mean AP distance in the MMVD group was 19.8 ± 8 mm, compared to 22.4 ± 6 mm for CABG cohort (p = 0.017). Of those patients with MMVD who had straight back, 10% required cervical fusion, compared to none in the CABG group.

Conclusions: MMVD is associated with straight back and a relatively high requirement for cervical fusion. Patients with MMVD should be screened for straight back and, if the condition is identified, should consider preventive measures to obviate the need for cervical fusion.

How to cite: Movahed, A., Majdalany, D., Gillinov, M., & Schiavone, W. (2017). Association Between Myxomatous Mitral Valve Disease and Skeletal Back Abnormalities. The Journal of heart valve disease, 26(5), 564–568.

Background: The study aim was to investigate factors affecting the improvement of mitral regurgitation (MR) severity within 48 hours after cardiac resynchronization therapy (CRT) in patients with cardiomyopathy.

Methods: Sixty-nine cardiomyopathy patients (48 males, 21 females; mean age 59.12 ± 9.66 years) in NYHA functional class ≥III, with left ventricular ejection fraction (LVEF) ≤35%, and QRS duration >120 ms, with MR ≥moderate, were included in the study. Conventional echocardiography was performed before and within 48 h after CRT, and all patients underwent tissue Doppler imaging prior to CRT. Improved MR was defined as a reduction of at least one grade in MR severity.

Results: After CRT, 49 patients (71%) showed MR improvement but 20 (29%) had no MR improvement. The mean MR severity grade was reduced significantly, from 2.70 ± 0.77 before CRT to 1.90 ± 0.94 after CRT (p<0.001). The group with improved MR had a significantly higher rate of left bundle branch block (75.5% versus 45%; p = 0.015), a higher QRS duration (172.00 ± 31.98 versus 147.25 ± 28.75 ms; p = 0.001), a higher median septal lateral delay (70 versus 35 ms, p = 0.035), and a higher median anteroseptal to posterior-wall delay by M mode (200 versus 130 ms, p = 0.041). Older age, longer QRS duration, and septallateral delay remained significant independent predictors of MR improvement. A greater proportion of patients with improved MR showed ≥5% increase in LVEF (55.1% versus 30.0%, p = 0.058).

Conclusions: CRT acutely reduced the severity of functional MR in the majority of cardiomyopathy patients. Those patients with improved MR showed a higher frequency of ≥5% increase in LVEF after CRT. Older age, longer QRS duration, and septallateral delay were independent predictors of MR improvement after CRT.

How to cite: Sadeghian, H., Lotfi-Tokaldany, M., Montazeri, M., Kazemi Saeed, A., Sahebjam, M., Sardari, A., & Ejmalian, G. (2017). Early Improvement in Mitral Regurgitation after Cardiac Resynchronization Therapy in Cardiomyopathy Patients. The Journal of heart valve disease, 26(5), 557–563.

Background: Segmental analysis of diseased mitral valves is important to predict a successful surgical valve repair. An assessment was made of the comparative accuracy of intraoperative three-dimensional (3D) and two-dimensional (2D) transesophageal echocardiography (TEE) in the evaluation of mitral valve lesions when compared with intraoperative surgical segmental analysis.

Methods: A total of 42 consecutive patients (12 females, 30 males; mean age 70.5 ± 14 years) with severe mitral valve regurgitation due to degenerative disease and who underwent mitral valve repair was enrolled in the study. Complete 2D- and 3D-TEE were performed before surgery. The findings obtained using the different echocardiographic techniques were compared with intraoperative segmental analysis performed by a single operator who was blinded to the 2D- and 3D-TEE findings until the end of the inspection. The sensitivity and specificity of echocardiographic evaluations of involved scallops were compared with surgical inspection.

Results: 3D-TEE allowed an accurate identification of all mitral lesions. Thirty-three patients had simple lesions at 3D-TEE and underwent a simple surgical procedure, while nine patients had complex lesions; in these latter cases complex surgical procedures were performed. 3D-TEE showed more sensitivity than 2D-TEE in the analysis of the anterior leaflet (A), in particular for A3 lesion (100% versus 25%, p <0.001) and for complex lesion (100% versus 33.3%, p <0.009).

Conclusions: 3D-TEE allowed a more accurate identification of mitral valve lesions compared with 2D-TEE. The greatest accuracy was achieved for analysis of the anterior leaflet. 3D-TEE should be regarded as an important adjunct to standard 2D-TEE in decisions regarding mitral valve repair.

How to cite: Pisano, C., Calia, C., Ricasoli, A., Fabio Triolo, O., & Argano, V. (2017). Intraoperative Transesophageal Echocardiography for Surgical Repair of Degenerative Mitral Regurgitation. The Journal of heart valve disease, 26(5), 547–556.

Background: Echocardiographic predictors of redo-percutaneous balloon mitral valvuloplasty (redo-PBMV) have not been well studied, and indications are based mainly on Wilkins score. The study aim was to evaluate the immediate results of redo-PMBV and to introduce a simplified redo-score to predict the success of redo-PBMV.

Methods: Two cohorts of symptomatic patients (derivation group, n = 218; validation group, n = 100) who had undergone redo-PBMV at a mean of 8.1 ± 2.9 years after a first successful PBMV were enrolled in the study. The mean Wilkins scores were 8.5 ± 1.7 in the derivation group and 8.4 ± 1.8 in the validation group. PBMV was performed using a multi-track technique. Independent echocardiographic predictors of outcome were assigned a points value: mitral valve area ≤1.0 cm2 (2 points), posterior mitral valve leaflet length (PMVL)/anterior mitral valve leaflet length (AMVL) ratio ≤1/2 (2 points), doming distance ≤12 mm (3 points), mitral annular calcification (mild = 1 point; moderate = 2 points; severe = 3 points), commissural status (no fusion = 0 points; uni-fusion = 2 points; bi-fusion = 3 points) and chordal length ≤10 mm (2 points).

Results: The minimum score was 5 and the maximum was 13. A receiver operating curve analysis showed the redo score to be highly significant in predicting redo-PBMV immediate results. The cut-off value of redo score to predict a favorable outcome was ≤8, with a sensitivity of 96% and specificity of 85% in the derivation cohort, and a sensitivity of 95% and specificity of 83% in the validation cohort. A Wilkins score ≤8 had a sensitivity of 71% and a specificity of 59% in the derivation cohort, while sensitivity was 70% and specificity 62% in the validation cohort.

Conclusions: The described scoring system was significantly more predictive than the Wilkins score, and was particularly valuable in predicting outcome in patients with a prior PBMV. It may serve as a satisfactory scoring system for correctly selecting patients with mitral restenosis for PBMV.

How to cite: Mahfouz, R. A., Elawady, W., Goda, M., & Moustafa, T. (2017). Redo Scoring for Prediction of Success of Redo-Percutaneous Balloon Mitral Valvuloplasty in Patients with Mitral Restenosis. The Journal of heart valve disease, 26(5), 537–546.

Background: Despite the limited durability of biological aortic valves, increasing numbers of younger patients are choosing to receive them, due mainly to the lack of a need for permanent anticoagulation. Few data exist, however, regarding the outcomes of valve replacement in patients aged <55 years, and additional data are required in this patient population.

Methods: Between 1993 and 2014, at the authors' institution, a total of 448 patients (237 males, 101 females; mean age 45.8 ± 8.0 years) underwent aortic valve replacement (AVR) with either a mechanical prosthesis (M1 group, n = 318) or a biological prosthesis (B1 group, n = 130). The mean follow up was 8.5 ± 5.8 years (range: 4 days to 20.8 years) in the M1 group, and 4.9 ± 4.6 years (range: 2 days to 21 years) in the B1 group. The entire collective (EC) (n = 448 patients) was compared and analyzed with a selective collective (SC) (n = 109 patients) after exclusion of patients with concomitant procedures or comorbidities (M2 group, n = 74; B2 group, n = 35).

Results: Early mortality was greater after biological AVR in the EC (6.1% versus 1.9%), but in the SC no early deaths were observed after both primary and redo procedures. The reoperation rate was greater after biological AVR in both collectives. The late mortality, survival and endocarditis rates were comparable in both collectives. Bleeding occurred more often in the EC after mechanical AVR.

Conclusions: Biological AVR in patients aged <55 years provides satisfactory outcomes, whereas reoperations were performed less commonly in patients with mechanical valve substitutes. In selective patients, AVR can be performed with zero mortality.

How to cite: Tsvelodub, S., Pieper, B., Stock, S., Sievers, H. H., & Richardt, D. (2017). Long-Term (up to 21 Years) Follow Up after Biological and Mechanical Aortic Valve Replacement in Younger Patients. The Journal of heart valve disease, 26(5), 528–536.

Background: The study aim was to investigate the hemodynamic behavior over time and ease of implant and durability of the Sorin Pericarbon Freedom (SPF)® stentless pericardial aortic xenograft.

Methods: Between March 2003 and April 2010, a total of 251 consecutive, non-selected patients (mean age 70.1 years; range: 17-89 years; 17.1% aged >80 years) received a SPF bioprosthesis as an aortic valve substitute at the authors' institution. All implantations were performed by a single surgeon using a classical, double-line, subcoronary implant technique. Of these patients. 108 (43%) underwent a concomitant procedure. The mean logistic EuroSCORE was 8.3. Patients were followed for complications and hemodynamic evaluation. Echocardiographic controls and clinical data were obtained at discharge, and at six months' and eight years' follow up.

Results: The in-hospital/30-day mortality was 1.2% for the entire group, but 0% for patients with isolated valve replacement. A total of 27 deaths had occurred at the time of the last follow up (22 were due to non-cardiac causes). At follow up (mean 3.7 years; range: 0-7.8 years), 91.1% of survivors were in NYHA classes I or II. Freedom from reoperation and from structural valve deterioration was 96.0% and 96.8%, respectively, at 7.8 years. The mean pressure gradient of the series (measured using echocardiography) was 10.3 ± 4.5 mmHg at discharge, and 8.3 ± 4.5mmHg at the time of the last follow up. The mean effective orifice area was 1.85 ± 0.70 cm2 for the entire series, and there was an absence of prosthesis-patient mismatch in 90% of patients.

Conclusions: The study results confirmed the favourable hemodynamic behavior, low risk of implantation and acceptable durability of the pericardial stentless SPF aortic prosthesis. The data also endorsed use of the SPF as an aortic valve substitute, even in a young and active population, and particularly in the presence of a small aortic annulus. The accuracy of implantation remains a crucial factor for durability and subsequent satisfactory hemodynamic performance. A longer follow up would provide further information with regards to complications and durability of the SPF prosthesis.

How to cite: Stefanelli, G., Pirro, F., Danniballe, G., Olaru, A., Meli, M., & Weltert, L. (2017). Outcomes of a New-Generation Stentless Aortic Valve: A Single-Center Experience with 251 Consecutive Implants. The Journal of heart valve disease, 26(5), 518–527.

Background: Transthoracic echocardiography (TTE) is the standard method for evaluating the severity of aortic stenosis (AS), while transesophageal echocardiography (TEE) is useful for morphologic characterization. The study aim was to assess the impact of complementary TEE to TTE in refining hemodynamic assessment of AS severity.

Methods: A retrospective analysis was conducted of sequential TTE and TEE studies performed in 100 patients with moderate or severe AS confirmed on prior TTE. The left ventricular outflow tract (LVOT) velocity-time-integral (VTI1) and the aortic valve velocity-time integral (VTI2) were measured for both modalities. The highest values of VTI1 and VTI2 and mean gradients and peak velocities were selected from the sequential TTE/TEE study for indexed aortic valve area (AVAi) calculation and AS severity determination through an integrated assessment.

Results: AVAi determined by TTE was not significantly different from that determined by TEE (mean difference -0.008 cm2; p = 0.38). The dimensionless velocity index (DVI) was higher when assessed by TTE than by TEE (mean difference 0.0126 ± 0.04; p = 0.003). Using the integrated AS assessment, six of 13 patients with a TTE-based diagnosis of moderate AS were re-classified as severe AS. A slight lowering of the recommended TTE-derived DVI threshold for severe AS, from 0.25 to 0.24, improved the ability to discriminate moderate versus severe AS, as determined by the integrated assessment.

Conclusions: TEE integrated with TTE may improve the detection of severe AS, particularly in patients with moderate AS criteria assessed by TTE, but with a DVI ratio ≤0.24.

How to cite: Schwartzenberg, S., Vaturi, M., Kazum, S., Monakier, D., Sagie, A., Kornowski, R., & Shapira, Y. (2017). Incremental Value of Transesophageal Echocardiography Integrated with Transthoracic Echocardiography in the Assessment of Aortic Stenosis Severity. The Journal of heart valve disease, 26(5), 509–517.

Background: Flow measurements using cardiac magnetic resonance imaging (CMRI) enable quantification of the stroke volume, regurgitant volume (RV) and regurgitant fraction (RF) in patients with aortic regurgitation (AR). These variables are used to assess the severity of the valve disease and for the timing of surgery. The aim of the study was to investigate the impact of an increased heart rate on measurement of the RV and RF in patients with AR.

Methods: Among 13 patients with known moderate or severe AR, regurgitant flow measurements, using phase-contrast cine magnetic resonance imaging, were obtained in the ascending aorta. Flow measurements were obtained at rest and at increased heart rates after intravenous administration of atropine.

Results: The mean heart rate was 61 beats per min at rest and 91 beats per min after atropine administration. The RV and RF were 52 ml and 35% at rest, respectively, and 34 ml (p <0.001) and 30% (p = 0.065) at increased heart rate, respectively.

Conclusions: An increased heart rate leads to a decreased RV. The RF is more stable and may therefore be preferable for severity grading in AR.

How to cite: Lidén, M., Wodecki, M., Thunberg, P., & Rask, P. (2017). Impact of Heart Rate on Flow Measurements in Aortic Regurgitation. The Journal of heart valve disease, 26(5), 502–508.

Background: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ).

Methods: The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores <10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days.

Results: A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p <0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p <0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009).

Conclusions: TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.

How to cite: Kofi Okoh, A., Kang, N., Chauhan, D., Haik, N., Hanos, D., Cohen, M., Chen, C., Haik, B., & Russo, M. J. (2017). Association of Change in Patient-Reported Health Status after Transcatheter Aortic Valve Replacement, and Postoperative Outcomes. The Journal of heart valve disease, 26(5), 493–501.