Lack of definite indication criteria for choosing between transcatheter implantation and surgical replacement of the aortic valve.

AIMS: Age over 75 years and logistic Euroscore over 20% have been jointly proposed by European scientific associations as the criteria for aortic valve stenosis patients to be considered 'high-risk' for surgical aortic valve replacement (AVR) and candidates for transcatheter aortic valve implantation (TAVI). We aimed to verify traditional AVR outcomes in the presence of the above criteria. METHODS: Between January 2001 and January 2011, 180 patients with severe aortic valve stenosis (mean aortic valve area = 0.4±0.1 cm/m), with age range 75-88 years (mean 78.2±3), logistic Euroscore between 4.5 and 40% (mean 12.6±7.4%), underwent surgical AVR. The patient population was divided into group A (118 patients between 75 and 79 years of age), further divided into subgroups A1 (76 patients) and A2 (42 patients) with logistic Euroscore, respectively, less than 20% and at least 20%; and group B (62 patients between 80 and 88 years of age), subdivided into B1 (34 patients) and B2 (28 patients) with logistic Euroscore, respectively, less than 20% and at least 20%. Hospital outcomes were retrospectively evaluated. Univariate and multivariate analyses, including age and logistic Euroscore, were performed to individuate predictors of hospital mortality. RESULTS: Overall observed/expected mortality ratio was 0.4. Hospital mortality was 5.3% in group A1, 4.8% in A2, 5.9% in B1, 3.6% in B2 (P=NS). Mortality with age over 75 and Euroscore at least 20% was 4.3%. As regards postoperative morbidity, atrio-ventricular bock indicating pacemaker implantation occurred in four patients, pneumonia in three, stroke in two, perioperative myocardial infarction in one. Age and Euroscore were not independent predictors of mortality, morbidity or composite endpoint in multivariable analysis. CONCLUSION: Age and logistic Euroscore might be inadequate criteria for the identification of patients with severe aortic stenosis unsuitable for AVR and addressable to TAVI.

Apico-aortic conduit for severe hypertrophic cardiomyopathy: sudden death despite conduit patency 31 years postoperatively.

Although small experiences have been described with the use of apico-aortic valved conduit in the treatment of hypertrophic cardiomyopathy (HCM), the long-term follow-up has never been previously reported. In a young female patient with symptomatic HCM and a prognostically unfavorable phenotype, apico-aortic conduit was chosen instead of conventional myectomy because severe ventricular hypertrophy involved the whole ventricle, making outflow tract cavity virtually absent in systole. Close clinical and imaging follow-up was postoperatively performed. The patient remained asymptomatic, without cardioactive drug therapy for 30 years, also experiencing 2 successful pregnancies. A striking finding was the perfect patency of the conduit at the last follow-up control (31 years), with computed tomography and echocardiography showing no calcification of the porcine Hancock bioprosthesis inside the graft. Nevertheless, the disease slowly evolved towards the dilative phase and the patient experienced sudden death while scheduled for implantation of defibrillator in waiting list for heart transplant.The present case could suggest that, in selected cases of HCM not treatable by myectomy, apico-aortic conduit may be an option. The relief of the obstruction can provide even long-term freedom from symptoms, however, late evolution to end-stage cannot be prevented.

Early cell changes and TGFß pathway alterations in the aortopathy associated with bicuspid aortic valve stenosis.

Previous studies on BAV (bicuspid aortic valve)-related aortopathy, whose aetiology is still debated, have focused mainly on severe dilatations. In the present study, we aimed to detect earlier signs of aortopathy. Specimens were collected from the 'concavity' (lesser curvature) and the 'convexity' (greater curvature) of mildly dilated AAs (ascending aortas; diameter ≤4 cm) with stenotic TAV (tricuspid aortic valve) or BAV and from donor normal aortas. Specimens were submitted to morphometry, immunohistochemistry and differential gene-expression analysis, focusing on SMC (smooth muscle cell) phenotype, remodelling, MF (myofibroblast) differentiation and TGFß (transforming growth factor ß) pathway. Smoothelin and myocardin mRNAs decreased in all the samples from patients, with the exception of those from BAV convexity, where a change in orientation of smoothelin-positive SMCs and an increase of α-SMA (α-smooth muscle actin) mRNA occurred. Dilated aortas from BAV and TAV patients showed both shared and distinct alterations concerning the TGFß pathway, including an increased TGFß and TGFßR2 (TGFß receptor 2) expression in both groups and a decreased TGFßR1 expression in BAV samples only. Despite a decrease of the mRNA coding for the ED-A (extra domain-A) isoform of FN (fibronectin) in the BAV convexity, the onset of the expression of the corresponding protein in the media was observed in dilated aortas, whereas the normal media from donors was negative for this isoform. This discrepancy could be related to modifications in the intima, normally expressing ED-A FN and showing an altered structure in mild aortic dilatations in comparison with donor aorta. Our results suggest that changes in SMC phenotype and, likely, MF differentiation, occur early in the aortopathy associated with valve stenosis. The defective expression of TGFßR1 in BAV might be a constitutive feature, while other changes we reported could be influenced by haemodynamics.

Long-term follow-up of reduction ascending aortoplasty with autologous partial wrapping: for which patient is waistcoat aortoplasty best suited?

OBJECTIVES: The aim of this study was to assess the early and long-term outcomes of a previously introduced technique of reduction aortoplasty for asymmetric ascending aortic dilatation. Different indication criteria for reduction ascending aortoplasty have been previously adopted by others, thus another purpose was to identify the patient profile for whom this approach may be best suited. METHODS: Between January 2001 and December 2010, reduction ascending aortoplasty with "waistcoat technique" was performed in 156 patients (mean age 62 ± 12 years, 61% male) with asymmetric dilatation of the ascending aorta (prevailing at the convexity of the supracoronary tract). Eighty-seven patients had a tricuspid aortic valve (TAV), 69 a bicuspid aortic valve (BAV). Aortoplasty was associated to aortic valve replacement in 60% cases. Preoperative, intraoperative, early postoperative and follow-up data were analysed. Comparisons were performed between groups of valve morphology (TAV versus BAV) and subgroups of baseline valve function. In patients with a follow-up time >1 year the annual growth of the ascending tract was calculated and compared between subgroups. The independent predictors of growth velocity were assessed by multivariable linear regression analysis. RESULTS: Mean cross-clamp and cardiopulmonary bypass times were 39 ± 18 and 69 ± 29 min, respectively. Hospital death was 1.9%. In no case, postoperative death or any early complication was causally related to the aortoplasty procedure. The mean postoperative ascending diameter was 3.1 ± 0.3 (versus preoperative 5.2 ± 0.8 cm, P < 0.001). Mean follow-up time was 4 ± 2.5 years (maximum 10 years): 7-year survival was 95 ± 2%; 7-year freedom from aortic events 94 ± 4%. Redilatation (ascending diameter exceeding 4.5 cm) occurred in two patients, acute dissection in one: all three preoperatively had significant aortic regurgitation. The mean ascending aortic diameter at last follow-up was 3.4 ± 0.5 cm; median diameter progression was 0.4 mm/year, with no significant difference between TAV and BAV and no patient reaching 0.5 cm/year. With TAV, the only determinant of aortic growth rate was normal preoperative valve function (P = 0.04); with BAV, the degree of regurgitation at preoperative echocardiography (P = 0.001). CONCLUSIONS: Waistcoat aortoplasty proved a safe and durable treatment for patients with asymmetric non-syndromic non-familial ascending aorta dilatation. The technique showed its best durability in aortic stenosis patients and in patients with normofunctional BAV.