A 76-year-old woman was admitted to the authors' hospital with pulmonary edema five months after the successful implantation of a Perceval sutureless aortic valve (Sorin Group Srl, Saluggia, Italy). Both echocardiography and computed tomography scanning demonstrated migration of the aortic valve into the left ventricle, causing severe aortic and mitral (secondary) insufficiency. Following heart team discussions, the sutureless valve was replaced with a standard bioprosthesis (Perimount, Magna Ease; Edwards Lifesciences, Irvine, California, USA) with spontaneous restoration of native mitral valve competence. The present case is the first of a new presentation of early Perceval sutureless aortic valve proximal migration, and highlights the importance of careful preoperative assessment and regular postoperative follow up after sutureless aortic valve implantation.

How to cite: Rossi, M., Cristodoro, L., Roger, D., Pennisi, V., Pisano, G., & Fratto, P. (2018). Double Valve Failure Due to Perceval Sutureless Aortic Valve Migration. The Journal of heart valve disease, 27(1), 124–126.

The use is reported of the AngioVac system to resolve a case of persistent bacteremia in the setting of MRSA tricuspid valve infective endocarditis. The infection was secondary to intravenous drug use in a patient who had failed multiple antibiotic regimens and was deemed a poor surgical candidate.

How to cite: Wallenhorst, P., Rutland, J., Gurley, J., & Guglin, M. (2018). Use of AngioVac for Removal of Tricuspid Valve Vegetation. The Journal of heart valve disease, 27(1), 120–123.

A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.

How to cite: Hernández-Enríquez, M., Freixa, X., Sanchis, L., Regueiro, A., Burgos, F., Navarro, R., Masotti, M., Sitges, M., & Sabaté, M. (2018). MitraClip® Repair in Cardiogenic Shock Due to Acute Mitral Regurgitation: From Near-Death to Walking. The Journal of heart valve disease, 27(1), 114–116.

Graves' disease is a common cause of hyperthyroidism that can lead to multiple cardiovascular complications. Herein is described the case of a 44-year-old male who presented with new-onset atrial fibrillation and mitral regurgitation secondary to flail anterior mitral leaflet with chordae tendineae rupture. This is a rare complication for Graves' disease, and has been reported only twice previously. It was hypothesized that this complication is secondary to Graves'-associated myxomatous degeneration of the mitral valve in the presence of a hyperdynamic circulation.

How to cite: Ghazal, S. N., & Alarfaj, M. K. (2018). Mitral Chordae Rupture as a Possible First-Time Presentation for Graves’ Disease. The Journal of heart valve disease, 27(1), 110–113.

Prosthetic heart valve thrombosis is a rare, difficult-to-treat condition that increases morbidity and mortality by leading to systemic embolism. Clinically, it presents mainly in the form of stroke, though an embolism be observed in many systems. Acute coronary syndrome, which is rarely observed in patients with a prosthetic heart valve, mostly occurs as non-ST segment elevation myocardial infarction (MI). There is no specific recommendation for the treatment of this condition. Revascularization success rates have been shown to be variable in cases wherein thrombolytic therapy, balloon angioplasty, stent implantation, and a combination of all of these techniques are used. Herein are presented details of the successful revascularization of a patient with ST segment elevation MI presenting with simultaneous right and left coronary system embolism, and without embolism in any other system. In cases of acute coronary syndrome in patients with a prosthetic heart valve with no known coronary artery disease, starting the procedure with thrombus aspiration may prevent unnecessary stent and balloon angioplasty procedures being required, by accelerating the revascularization process.

How to cite: Sığırcı, S., Keskin, K., Sezai Yıldız, S., Aksan, G., Bambul Sığırcı, B., & Orta Kılıçkesmez, K. (2018). Treatment of Simultaneous Thromboembolism of the Right and Left Coronary Arteries with Thrombus Aspiration in a Patient with a Prosthetic Mitral Valve. The Journal of heart valve disease, 27(1), 107–109.

Osteogenesis imperfecta (OI) is a syndrome that is often associated with dysfunction of the aortic valve. Because of the resultant fragile vessels and impaired hemostasis, surgical therapy to treat OI is challenging. Previous reports have suggested that transcatheter aortic valve implantation (TAVI) might be a suitable treatment for this condition. To the best of the authors' knowledge, the present case is the first to describe a young patient who underwent successful TAVI to treat osteogenesis imperfecta. The proposal of transfemoral TAVI serving as first-line therapy for aortic valve stenosis in patients suffering from osteogenesis imperfect was confirmed.

How to cite: Minol, J. P., Zeus, T., Blehm, A., & Veulemans, V. (2018). TAVI as Therapy of Choice for Aortic Valve Disease in Osteogenesis Imperfecta. The Journal of heart valve disease, 27(1), 104–106.

Background: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades.

Methods: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0.

Results: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis.

Conclusions: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.

How to cite: Celiento, M., Ravenni, G., Tomei, L., Pratali, S., Milano, A. D., & Bortolotti, U. (2018). Excellent Durability of the Mosaic Porcine Aortic Bioprosthesis at Extended Follow Up. The Journal of heart valve disease, 27(1), 97–103.

Background: Currently, only limited data are available on the rate of hemodynamic progression with clinical outcome in patients receiving the latest Crown PRT aortic prosthesis. The study aim was to report clinical and hemodynamic outcomes in 55 consecutive patients for a follow up of up to one year after Crown PRT implantation.

Methods: Between February and September 2015, a total of 55 patients (34 males, 21 females; mean age 77.3 ± 1.2 years) underwent aortic valve replacement (AVR) with the latest LivaNova Crown PRT bioprosthesis at the authors' institution. Left ventricular function was preserved in 79% of patients. Data relating to the patients' clinical, echocardiographic and functional capacities were obtained prospectively.

Results: There were no in-hospital deaths. Significant perioperative complications included stroke (3.6%), atrial fibrillation (27%), and permanent pacemaker insertion (1.8%). Pre-discharge echocardiography demonstrated peak (PG) and mean (MG) transprosthetic gradients of 24.4 ± 10.4 mmHg and 12.9 ± 6.2 mmHg, respectively. The Doppler velocity index (DVI) was 0.49 ± 0.13, and the effective orifice area index (EOAi) 0.89 ± 0.12 cm2/m2. At a mean follow up of 1.3 ± 0.3 years, the transprosthetic gradients, DVI and EOAi were not significantly different from postoperative or pre-discharge values. The patients' NYHA status was I or II in 95% of cases, and the mean left ventricular mass had decreased by 36% at the end of follow up.

Conclusions: The Crown PRT is an effective bioprosthesis, with a low incidence of valve-related complications comparable to those of other current bioprostheses. The bioprosthesis demonstrated satisfactory results in terms of hemodynamics and freedom from reoperation.

How to cite: Duggan, S. M., Sadeque, S., Karamanou, D., Salhiyyah, K., Giritharan, S., Pousios, D., Miskolczi, S., & Barlow, C. W. (2018). Early Hemodynamic Performance of the Crown PRT Aortic Prosthesis: A Prospective Study. The Journal of heart valve disease, 27(1), 87–96.

Background: Readmissions after heart valve surgery represent a significant burden for both the patient and the healthcare system. The study aim was to identify independent predictors of readmission within 180 days after surgery in a population of patients undergoing heart valve surgery.

Methods: Demographic and clinical information was obtained from national registers. Patient-reported outcomes (PROs) including Short Form 12 (SF-12) and EuroQol 5D (EQ-5D) were measured at discharge as part of a national, cross-sectional study (DenHeart). Predictors of first readmission were investigated.

Results: Among a total of 1,084 patients (65% men; mean age 68 years; 354 responded to questionnaires), 534 (49%) were readmitted. Responding patients who were readmitted were younger and a greater proportion had undergone mitral valve surgery. A significantly higher proportion of non-responders was readmitted. No significant differences were found in PROs between patients readmitted and those not readmitted, and receiver operating characteristic (ROC) curves showed no predictive effect of SF-12 and EQ-5D. Survival analysis using Cox proportional hazard models showed that prior percutaneous coronary intervention (PCI) (HR 1.50, CI 1.10; 2.05, p = 0.010) and a history of heart failure (HR 1.37, CI 1.10; 1.72, p = 0.006) were predictive of readmission.

Conclusions: Readmission rates after heart valve surgery are high and often seen in patients who have undergone PCI and heart failure before surgery. Predictors for these high readmissions rates are difficult to establish based on medical history and type of surgery. PROs at discharge contribute information regarding a patient's perception of their often poor quality of life, but do not predict readmission.

How to cite: Borregaard, B., Sørensen, J., Ekholm, O., Møller, J. E., Riber, L. P., Thrysoee, L., Thorup, C. B., Vamosi, M., Christensen, A. V., Rasmussen, T. B., & Berg, S. K. (2018). Sociodemographic, Clinical and Patient-Reported Outcomes and Readmission After Heart Valve Surgery. The Journal of heart valve disease, 27(1), 78–86.

Background: Brachial-ankle pulse wave (ba-PW) analysis is an established technique for assessing arterial stiffness and cardiovascular risk. The peripheral arterial pulse wave configuration may be useful for valvular heart disease (VHD) detection because it is closely related to the physical signs of VHD; however, few reports have been made assessing the efficacy of ba-PW analysis for VHD screening.

Methods: Consecutive VHD patients scheduled for valve surgery were enrolled in the study. These included 58 patients with aortic stenosis (AS) (mean age 74 ± 1.1 years), 67 with aortic regurgitation (AR) (mean age 59 ± 1.9 years), and 65 with mitral regurgitation (MR) (mean age 62 ± 1.6 years). Ba-PW analysis was conducted using the VaSera VS-1500 screening system before and after surgery. Upstroke time (UT), ejection time (ET), pre-ejection period (PEP), PEP/ET ratio, mean arterial pressure (%MAP), and cardio-ankle vascular index (CAVI) were compared with a control group (n = 65; mean age 69 ± 1.5 years) without VHD.

Results: The UT was significantly shorter in the AR group (132.9 ± 4.0 ms) and MR group (134.5 ± 2.5 ms), but significantly longer in the AS group (178.2 ± 2.8 ms) compared to controls (149.6 ± 3.6 ms; all p <0.01). The ET was significantly longer in the AS group (318.5 ± 7.4 ms) and AR group (320.0 ± 4.6 ms), but significantly shorter in the MR group (289.0 ± 3.8 ms) compared to controls (305.3 ± 3.4 ms; all p <0.05). In ROC analyses of each group compared to controls, areas under the curve of UT, corrected (c)UT, ET and cET in the AS group, UT/ET ratio in the AR group, and PEP/UT ratio in the MR group were all >0.7.

Conclusions: Multiple pulse wave parameters reflect VHD hemodynamics and may be useful for screening for the condition.

How to cite: Kurimoto, R., Shiraishi, H., Taniguchi, T., Otakara, A., Nakanishi, N., Zen, K., Nakamura, T., Yamano, T., Shirayama, T., Yaku, H., & Matoba, S. (2018). Brachial-Ankle Pulse Waves Reflect the Hemodynamics of Valvular Heart Disease. The Journal of heart valve disease, 27(1), 71–77.

Background: Prosthetic valve thrombosis (PVT) may impair pulmonary venous flow (PVF) and left atrial appendage (LAA) functions. An investigation was conducted to determine the association between left superior PVF and LAA functions and mitral PVT.

Methods: This observational case-control study included 100 consecutive patients (87 females, 13 males; mean age 59 years; range 35-71 years) with mechanical mitral PVT, and 50 age- and gender-matched otherwise healthy controls with normally functioning mitral prostheses. All patients were included after comprehensive transesophageal echocardiography (TEE) examinations for the presence and quantification of PVT, the left atrial diameter, and LAA length. Peak systolic velocity (PSV), velocity-time integral of systolic flow (VTI-s), peak diastolic velocity (PDV), velocity-time integral of diastolic flow (VTI-d), systolic fraction (SFr) of the left upper PVF and the flow of the LAA orifice were each recorded using color-guided pulsed-wave Doppler imaging during TEE.

Results: The PSV [30 cm/s (range: 13-77 cm/s) versus 44 cm/s (range: 16-71 cm/s)], respectively (p = 0.002), VTI-s [(2.85 cm (range: 0.5-10.7 cm) versus 5 cm (range: 1.3-12.7 cm)], respectively (p <0.001), VTI-d [(3 cm (range: 0.6-9.7 cm) versus 4.2 cm (range: 1.5-8.3 cm)], respectively (p <0.001), SFr (45.5% (range: 15.66-67.44%) versus 50 % (range: 21.11-82.61%)], respectively (p = 0.008), and LAA orifice velocity [(23 cm/s (range: 11-75 cm/s) versus 34 cm/s (range: 10-112 cm/s)], respectively (p = 0.011) were each significantly lower in patients with PVT compared to controls. The PDV was similar between groups. Patients with obstructive PVT (n = 21) had a lower PDV and a higher VTI-d compared to those with non-obstructive PVT.

Conclusions: Mitral mechanical PVT is associated with decreased systolic PVF and LAA function. The presence of obstructive PVT is associated with further limitations of diastolic flow velocity, and a compensatory prolongation of diastolic flow of the left upper pulmonary vein.

How to cite: Cerşit, S., Gündüz, S., Ozan Gürsoy, M., Karakoyun, S., Kalçık, M., Bayam, E., Yesin, M., & Özkan, M. (2018). Relationship Between Pulmonary Venous Flow and Prosthetic Mitral Valve Thrombosis. The Journal of heart valve disease, 27(1), 65–70.

Background: Despite considerations of its therapeutic range and multiple drug-food interactions, warfarin is the mainstay of oral anticoagulation in patients with mechanical heart valves (MHVs). The quality of anticoagulation demonstrates variations, with 'time in therapeutic range' (TTR) values usually lower than expected. It has been hypothesized that warfarin adherence is among the modifiable causes of suboptimal coagulation. The aim of the study was to demonstrate the ability of the 8-Item Morisky Medication Adherence Scale (MMAS-8©) to identify patients with non-adherence to warfarin, and to define the predictors of optimal coagulation when a TTR value ≥65% is used as the surrogate.

Methods: In a cross-sectional survey of 112 patients, TTR6 months and TTR12 months were calculated using the Rosendaal method. A questionnaire was used to assess the patients' warfarin knowledge, bleeding complications, and adherence. Patients were categorized into low-adherence (LA), moderate adherence (MA) and high-adherence (HA) groups based on MMAS-8 values. The target INR was 2.5-3.5, and an effective TTR was defined as ≥65%.

Results: TTR6 months, TTR12 months and warfarin knowledge were significantly lower in the LA group than in the MA and HA groups. In addition, the bleeding score of HA patients was significantly lower than that of LA and MA patients. The MMAS-8 was the single independent predictor of effective TTR for six and 12 months on multivariate regression analysis (B = 0.506, p <0.001 and B = 0.469, p <0.001, respectively).

Conclusions: Warfarin adherence accounted for poor TTR values in patients with MHV, and MMAS-8 was used effectively to identify those expected to have a low TTR, to suffer more complications, and to require robust education.

How to cite: Ozkaramanli Gur, D., Baykız, D., Akyuz, A., Alpsoy, S., & Fidan, C. (2018). The Influence of Warfarin Adherence on Time in Therapeutic Range Among Patients with Mechanical Heart Valves. The Journal of heart valve disease, 27(1), 55–64.

Background: Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring.

Methods: Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete.

Results: In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%.

Conclusions: Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

How to cite: Saitto, G., Lio, A., Russo, M., Nicolò, F., Bassano, C., Scafuri, A., Nardi, P., & Ruvolo, G. (2018). Mitral Valve Repair with a Semi-Rigid C-Band Annuloplasty Ring in Ischemic Mitral Regurgitation: Still a Viable Surgical Option?. The Journal of heart valve disease, 27(1), 47–54.

Background: Temporal three-dimensional (3D) analysis of the mitral valve biomechanics has prompted a re-evaluation of surgical approaches and repair device designs to accommodate the natural dynamics of the valve. Such new designs strive to obtain lower annulus restraining forces, resulting in more natural leaflet and chordal stresses. A new annuloplasty system was evaluated using 3D motion and out-of-plane force analysis. It was hypothesized that this system would not impact the valve with adverse motion restrictions or high systolic annular forces compared to conventional flat rigid ring designs.

Methods: In an acute porcine set-up, six 80 kg pigs were monitored before and after implantation of the new annuloplasty system consisting of two half-rings with a saddle-shaped outline. Valvular 3D dynamic geometry was obtained using sonomicrometry before and after annuloplasty system implantation. Strain gauges mounted on the commissural segments provided the annular restraining force distribution perpendicular to the annular plane.

Results: The change in annular height to commissural width ratio from diastole to systole did not alter following implantation (p >0.05). Out-of-plane systolic restraining forces were 0.2 ± 0.1 N and 0.8 ± 0.3 N (mean ± SEM) in the posterior and anterior commissural segments, respectively, without any difference in-between (p >0.1). Forces in both commissural segments were significantly lowered compared to previous measurements with a flat and stiff mitral annuloplasty ring (p <0.01). Mitral annular septal-lateral distance, area, and circumference in the commissural segments were decreased after implantation (p <0.05). The cross-annular distance between the commissural segments and the lengths of the anterior and posterior annular segments did not change following implantation (p >0.05).

Conclusions: The new annuloplasty system design maintained annular 3D dynamics and provided a minimized out-of-plane restraining force distribution compared to earlier studies on flat rigid rings. This may have important implications in the selection of annuloplasty devices in order to increase repair durability.

How to cite: Jensen, M. O., Jensen, H., Skov, S. N., Levine, R. A., Nygaard, H., M Hasenkam, J., & Nielsen, S. L. (2018). New Mitral Valve Annuloplasty Concept: Optimizing Annular Dynamics and Force Distribution. The Journal of heart valve disease, 27(1), 38–46.

Background: Currently, several different flexible mitral annuloplasty rings are available, and their efficacy for surgical repair of the mitral valve is, in general, considered equal. However, clinical experience indicates differences in remodeling capacity that have not yet been quantitatively assessed. The study aim was to compare the biomechanical properties of two commonly used flexible mitral annuloplasty rings in an acute pig model.

Methods: Medtronic Simulus Flex (n = 5) and Medtronic Duran AnCore (n = 7) flexible mitral annuloplasty rings were implanted in pigs (bodyweight 80 kg). The native mitral valve was used as a reference (n = 7). Mitral annular dynamics and dimensions were assessed using 11 sonomicrometry crystals placed in the mitral apparatus. A dedicated force transducer was used to detect deformational force transmission between the annuloplasty ring and the mitral annulus.

Results: Cyclic changes in mitral annular circumference and commissure-commissure distance were significantly reduced in the Simulus Flex group compared to the Duran AnCore group (p = 0.025 and p <0.01, respectively). In the Simulus Flex group, smaller deformational forces were recorded compared to the Duran AnCore group, but the difference was not statistically significant (p = 0.52 and p = 0.06 for the septal-lateral and the commissure-commissure force measurements, respectively).

Conclusions: The Simulus Flex ring showed significantly more remodeling capacity than the Duran AnCore ring, but the latter ring preserved the natural dynamics of the mitral valve to a greater degree. Insights into these biomechanical differences may facilitate strategies for surgical reconstruction in degenerative mitral valve disease, especially in patients with excessive amounts of tissue and who are at risk of systolic anterior motion of the mitral valve.

How to cite: Rasmussen, J., Nielsen Skov, S., Ropcke, D. M., Juan Tjoernild, M., Ilkjaer, C., & Lyager Nielsen, S. (2018). In-Vivo Evaluation of Flexible Mitral Annuloplasty Rings: Are They All the Same?. The Journal of heart valve disease, 27(1), 32–37.

Background: The study aim was to investigate the immediate and long-term results of balloon aortic valvuloplasty (BAV) in young patients (aged ≤20 years) with congenital bicuspid aortic valve presenting with severe aortic stenosis.

Methods: The study involved a single tertiary care center-based retrospective data analysis of immediate and long-term outcomes in patients following balloon valvuloplasty between 2000 and 2011. A total of 92 young patients (mean age 12.7 years; 95% CI 8.3-16.7 years) with aortic stenosis due to congenital bicuspid aortic valve and who underwent BAV were studied.

Results: The mean follow up period was 5.7 ± 1.3 years. Intervention resulted in successful BAV (≥50% reduction in baseline gradient) in 79 patients (85.9%; group A) and partially successful BAV (<50% reduction in baseline gradient) in eight patients (8.7%; group B). BAV failed in five patients (5.4%; group C). The mean left ventricular systolic pressure was decreased from 155.6 mmHg (95% CI 132.7-186.3 mmHg) to 100.9 mmHg (95% CI 82.1-119.6 mmHg; p <0.001), and the mean aortic valve gradient from 40.7 mmHg (95% CI 25.12-56.22 mmHg) to 17.2 mmHg (95% CI 15.83- 21.23 mmHg; p <0.001). Mean changes in aortic valve area and mean gradient were significantly different between successful BAV groups (A and B) and the failed BAV group (p = 0.001). Different grades of aortic regurgitation were noted in 32 patients (34.78%) after BAV (severe regurgitation in 2.18%). A post hoc analysis showed sustained gradient reductions at one- and five-year follow up investigations (p <0.05). The need for surgery was much lower in the successful BAV groups.

Conclusions: The success of BAV in bicuspid aortic valve stenosis in younger patients was approximately 85%. Although 10% of patients developed re-stenosis and required surgical intervention, the majority did well during the follow up period. It was concluded that BAV is a viable option in adolescents and young children with bicuspid aortic valve without severe calcification.

How to cite: Ananthakrishna Pillai, A., Rangaswamy Balasubramanian, V., & Kanshilal Sharma, D. (2018). Immediate and Long-Term Follow Up Results of Balloon Aortic Valvuloplasty in Congenital Bicuspid Aortic Valve Stenosis Among Young Patients. The Journal of heart valve disease, 27(1), 17–23.

Background: A lower rate of permanent pacemaker (PPM) has been linked to a target aortic implantation height (AIH) >0.70, following transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve. Based on clinical experience, it was hypothesized that a higher AIH (≥0.85) would lower the rate of PPM implantation.

Methods: A total of 127 patients (66 females, 61 males; mean age 82 ± 8 years) underwent TAVR with the SAPIEN 3 valve between May 2015 and July 2016. AIH was defined as the proportion of the valve frame above the aortic annulus in the post-deployment aortogram. A target AIH (≥0.70) was achieved in 113 patients (89%). Cases were stratified into a High Implantation (HI) group (AIH ≥0.85; 33 patients) or a Standard Implantation (SI) group (AIH <0.85; 94 patients).

Results: The mean Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of all patients was 6.4 ± 3.5%. Preoperative right bundle branch block (RBBB) was prevalent in 13% of SI patients, and in 18% of HI patients (p = 0.56). There were no significant differences in operative mortality (3.2% versus 0%), median length of stay (2 days versus 3 days) and incidence of moderate-to-severe paravalvular leak (3.2% versus 0%; all p >0.410) between SI and HI patients, respectively. Likewise, the incidence of new PPM did not differ between the two groups (12% in HI versus 13% in SI; p ≥0.99). The mean AIH was similar for patients with PPM implantation (0.80 ± 0.08) compared to those without (0.78 ± 0.06; p = 0.520). Preoperative RBBB was significantly associated with PPM implantation (odds ratio (OR) 10.1; p = 0.002), and patients who underwent PPM implantation had a higher operative mortality (12.5% versus 1%; p = 0.040).

Conclusions: Among TAVR patients who received the SAPIEN 3 heart valve, a higher AIH (≥0.85) was not associated with a lower rate of PPM implantation or increased operative mortality. Prior RBBB was the only independent risk factor for new PPM implantation. Long-term follow up is crucial in determining the clinical significance of PPM implantation.

How to cite: Ramirez Del Val, F., Hirji, S. A., Carreras, E. T., Kolkailah, A. A., Chowdhury, R., McGurk, S., Lee, J., Nyman, C. B., Shook, D. C., Sobieszczyk, P. S., Pelletier, M. P., Shah, P. B., & Kaneko, T. (2018). Clinical Significance of Greater Implantation Height with SAPIEN 3 Transcatheter Heart Valve. The Journal of heart valve disease, 27(1), 9–16.

Background: Previous studies have reported an association between aortic valve sclerosis (AVS) and coronary atherosclerosis. However, the threshold of sclerosis used to identify high-risk patients has not yet been determined.

Methods: A total of 225 patients admitted with non- ST-elevation myocardial infarction (NSTEMI) or unstable angina was studied. Echocardiography was performed on all patients within 24 h of admission. Sclerosis scores were determined for each aortic cusp, and the average AVS score index (AVSSI) was calculated. The left ventricular ejection fraction (LVEF) and variables of left ventricular diastolic function and filling pressure, such as transmitral pulsed Doppler early diastolic velocities (E wave), early diastolic tissue Doppler mitral annular velocities (e'), and E/e', were also determined. These patients underwent coronary angiography, and SYNTAX scores were determined.

Results: Patients with an average AVSSI >1 were older, more hypertensive, and had higher rates of previous coronary artery bypass grafting. In addition, the prevalences of significant coronary artery disease (CAD) and three-vessel CAD were higher in these patients. Among the echocardiographic variables, LVEF and e' velocity were significantly lower and E/e' was significantly higher in patients with an AVSSI >1. These patients also had a higher prevalence of left ventricular hypertrophy, diastolic dysfunction, and ischemic mitral regurgitation than those with an average AVSSI ≤1. Regression analysis showed that AVS was independently associated with significant CAD and SYNTAX score.

Conclusions: The average AVSSI may be a useful marker in the risk stratification of acute coronary syndrome patients, and is consistent with other high-risk echocardiographic variables, the presence of significant CAD, and more complex coronary artery lesions.

How to cite: Nabati, M., & Favaedi, M. (2018). Average Aortic Valve Sclerosis Score Index as a Marker for Significant Coronary Artery Disease in Patients with Non-ST-Elevation Myocardial Infarction or Unstable Angina. The Journal of heart valve disease, 27(1), 1–8.