A Hybrid Strategy for Geometrical Reshaping of the Main Pulmonary Artery and Transcatheter Pulmonary Valve Replacement.

Transcatheter pulmonary valve replacement has become an attractive alternative to surgical approach in patients with dysfunctional right ventricular outflow tract. However, in certain cases, an unfavorable anatomy might complicate optimal valve deployment and stability. Several techniques have been described to reshape the landing zone and allow proper implantation of the transcatheter valve. Among them, the hybrid approach has gained attention as an interesting method for off-pump pulmonary valve replacement in patients with dilated right ventricular outflow tract. But to date, there is no standardized method to resize and reshape the landing zone for the stented valve. Here, we describe a reproducible method based on simple geometric rules to allow adequate remodeling of the main pulmonary artery to the desired dimensions in a single attempt, followed by perventricular implantation of a Venus P-valve.

Transcatheter Valve-in-Valve Procedures for Bioprosthetic Valve Dysfunction in Patients With Rheumatic vs. Non-Rheumatic Valvular Heart Disease.

Background: Bioprosthetic heart valve has limited durability and lower long-term performance especially in rheumatic heart disease (RHD) patients that are often subject to multiple redo operations. Minimally invasive procedures, such as transcatheter valve-in-valve (ViV) implantation, may offer an attractive alternative, although data is lacking. The aim of this study was to evaluate the baseline characteristics and clinical outcomes in rheumatic vs. non-rheumatic patients undergoing ViV procedures for severe bioprosthetic valve dysfunction. Methods: Single center, prospective study, including consecutive patients undergoing transcatheter ViV implantation in aortic, mitral and tricuspid position, from May 2015 to September 2020. RHD was defined according to clinical history, previous echocardiographic and surgical findings. Results: Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9 vs. 43.2%, respectively; p = 0.004), atrial fibrillation (82.6 vs. 45.9%, respectively; p < 0.001), and 2 or more prior surgeries (68.1 vs. 32.4%, respectively; p = 0.001). Although, device success was similar between groups (75.4 vs. 89.2% in rheumatic vs. non-rheumatic, respectively; p = 0.148), there was a trend toward higher 30-day mortality rates in the rheumatic patients (21.7 vs. 5.4%, respectively; p = 0.057). Still, at median follow-up of 20.7 [5.1-30.4] months, cumulative mortality was similar between both groups (p = 0.779). Conclusion: Transcatheter ViV implantation is an acceptable alternative to redo operations in the treatment of patients with RHD and severe bioprosthetic valve dysfunction. Despite similar device success rates, rheumatic patients present higher 30-day mortality rates with good mid-term clinical outcomes. Future studies with a larger number of patients and follow-up are still warranted, to firmly conclude on the role transcatheter ViV procedures in the RHD population.

Transcatheter mitral valve-in-valve implantation: reports of the first 50 cases from a Latin American Centre.

OBJECTIVES: Our goal was to analyse the initial results of the first 50 transapical transcatheter mitral valve-in-valve procedures performed in a single Latin American centre. METHODS: A prospective, single centre, database analysis was conducted to evaluate immediate, 30-day and 1-year postoperative results of 50 consecutive patients who had a transcatheter mitral valve-in-valve procedure from May 2015 to June 2018. All patients were operated on in a hybrid operating room and received a balloon-expandable valve via the transapical approach. Preoperative and postoperative characteristics were analysed and compared between the first 25 and the second 25 patients to evaluate the impact of the learning curve. Twenty patients had a follow-up examination at 1 year. RESULTS: There was a 98% device success rate. The patients had a mean age of 64.8 years; 72% were women; 80% were in New York Heart Association functional class ≥III preoperatively; and 36% of the procedures were urgent. The mean Society of Thoracic Surgeons scores and EuroSCORE II were 8.3% and 12.4%, respectively. Patients had a median of 2 previous operations; valve durability was 12.1 years; and 64% mitral valve disease of rheumatic fever aetiology. Echocardiography showed decreases in the maximum and mean mitral gradients from 23.5 to 14.6 and 11.5 to 6.4 mmHg postoperatively; the overall mean hospitalization period was 15 days. The overall mortality rate at 30 days was 14%, with 1 intraprocedural death. Further subanalyses between the first and the second half of the cases showed a drop in the mortality rate from 20% to 8% (P < 0.01). CONCLUSION: The transcatheter mitral valve-in-valve procedure was shown to be a safe and effective procedure to treat bioprosthetic dysfunction, with potential benefits in patients with rheumatic disease.

Valve in Valve mitral por vía transapical en el Hospital México, reporte de dos casos y revisión de la literatura / Transapical mitral Valve in Valve in Hospital México, report of two cases and literatura review

Resumen La reoperación en pacientes con cirugía cardiaca previa en bioprótesis disfuncionantes representa una situación de alto riesgo quirúrgico, con elevada morbi-mortalidad perioperatoria. En la actualidad en casos seleccionados, el tratamiento percutáneo transcateter permite reemplazar la válvula mitral con acceso transapical o transeptal. El reemplazo percutáneo de la válvula mitral, tiene menor morbilidad y mortalidad comparado con la cirugía convencio nal, representando una alternativa terapéutica, la cual representa la única opción en pacientes de alto riesgo quirúrgico. Se presentan dos casos tratados de forma exitosa en nuestro centro con acceso transapical y válvula percutánea balón expandible Sapien XT.

Abstract Transapical mitral Valve in Valve in Hospital México, report of two cases and literatura review Surgical reintervention in patients with previous open heart surgery represents a high risk condition, with high morbidity and mortality in the perioperative period. Nowdays in selected clinical situations of patiens with failing bioprosthesis in mitral position, transcatheter percutaneous treatment allows the replacement of the mitral valve with transapical or transseptal access. The transcatheter percutaneous mitral valve replacement has lower morbidity and mortality in comparison with conventional surgery, representing a therapeutic alternative, wich migth be the only option in high risk patients. We present two cases done at our center with success using apical access and the ballon expandable device Sapien XT.

Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population.

OBJECTIVE: To comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR). METHODS: All Medicare fee-for-service patients undergoing TF (n = 4065), TA (n = 691), or TAO (n = 274) TAVR between January 1, 2011, and November 30, 2012, were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. RESULTS: TA and TAO patients were similar in age, race, and common comorbidities. Compared with TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA, 9.6%; TAO, 8.0%; TF, 5.0%; P < .001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03). CONCLUSIONS: For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.

Predictors and impact of myocardial injury after transcatheter aortic valve replacement: a multicenter registry.

BACKGROUND: Cardiac biomarker release signifying myocardial injury post-transcatheter aortic valve replacement (TAVR) is common, yet its clinical impact within a large TAVR cohort receiving differing types of valve and procedural approaches is unknown. OBJECTIVES: This study sought to determine the incidence, clinical impact, and factors associated with cardiac biomarker elevation post TAVR. METHODS: This multicenter study included 1,131 consecutive patients undergoing TAVR with balloon-expandable (58%) or self-expandable (42%) valves. Transfemoral and transapical (TA) approaches were selected in 73.1% and 20.3% of patients, respectively. Creatine kinase-myocardial band (CK-MB) measurements were obtained at baseline and at several time points within the initial 72 h post TAVR. Echocardiography was performed at baseline and at 6- to 12-month follow-up. RESULTS: Overall, 66% of the TAVR population demonstrated some degree of myocardial injury as determined by a rise in CK-MB levels (peak value: 1.6-fold [interquartile range (IQR): 0.9 to 2.8-fold]). A TA approach and major procedural complications were independently associated with higher peak of CK-MB levels (p < 0.01 for all), which translated into impaired systolic left ventricular function at 6 to 12 months post TAVR (p < 0.01). A greater rise in CK-MB levels independently associated with an increased 30-day, late (median of 21 [IQR: 8 to 36] months) overall and cardiovascular mortality (p < 0.001 for all). Any increase in CK-MB levels was associated with poorer clinical outcomes, and there was a stepwise rise in late mortality according to the various degrees of CK-MB increase after TAVR (p < 0.001). CONCLUSIONS: Some degree of myocardial injury was detected in two-thirds of patients post TAVR, especially in those undergoing TA-TAVR or presenting with major procedural complications. A greater rise in CK-MB levels associated with greater acute and late mortality, imparting a negative impact on left ventricular function.

Off-pump transapical closure of a mitral periprosthetic leak: a new approach to a difficult problem.

A 60-year old male patient with multiple risk factors and two previous interventions over the mitral valve was admitted to the emergency unit with symptoms of cardiac failure. Initial examination revealed a competent mitral bioprosthesis with severe perivalvular mitral insufficiency. Based on previous experiences with transapical procedures, a transapical transcatheter closure of the perivalvular leak was performed. The apex was punctured with a 7 French introducer sheath, and a hydrophilic guidewire was advanced with the aid of a right Judkins catheter and positioned across the defect in the left atrium. Fluoroscopic and tridimensional transoesophageal echocardiography was used to guide the manoeuvre. Next, a long introducer sheath was advanced through the guidewire and positioned inside the left atrium. Two Amplatzer Vascular Plug II (St Jude Medical) were deployed, resulting in a significant reduction in the perivalvular leak. The procedure was considered to be successful. The patient regained consciousness, and the orotracheal tube was removed in the operating theatre. No neurological deficits were detected, and the patient was transferred to the intensive care unit. The patient recovered well and was transferred to the ward after 1 day. Discharge was accomplished after 4 days.

Implantación transapical de la válvula aórtica / Transapical Aortic Valve Implantation

El reemplazo valvular aórtico por estenosis es notoriamente alto, hasta un 30% en poblaciones estudiadas, lo cual implica en determinados grupos un riesgo quirúrgico elevado. En este artículo se describe la implantación transapical de la válvula, un procedimiento miniinvasivo y en principio sin circulación extracorpórea. Se indica preferentemente en pacientes ancianos con alto riesgo operatorio, en aquellos con aortas gravemente calcificadas y en otros con revascularizaciones coronarias previas. El estudio de la geometría aórtica es esencial: la ecocardiografía transesofágica da la mejor medida del diámetro de la raíz aórtica y la tomografía computarizada determina exactamente el diámetro del anillo y tiene la posibilidad agregada de medir la distancia desde el anillo a los ostia coronarios. Se debe contar con la posibilidad de circulación extracorpórea en carácter de stand-by. Por una pequeña toracotomía anterolateral se accede a la punta del corazón donde se cateteriza el ventrículo hacia la posición aórtica con control radioscópico. La valvuloplastia, la inserción de la vaina transapical y el posicionamiento de la prótesis son las maniobras siguientes. El posicionamiento de la válvula constituye el paso más crítico, pero con esta técnica es más eficaz. En los últimos casos, mediante el software denominado DYNA CT, se han logrado mejores perspectivas en un punto crucial para el desarrollo definitivo. Desde febrero de 2006 hasta diciembre 2008 se implantaron 192 válvulas por vía transapical en pacientes con una edad media de 82,5 ± 5,7 años. La mortalidad a los 30 días fue del 8,9% y en el seguimiento alejado a 256 ± 213 días fue del 12,8%. Esta técnica debe ser realizada en un quirófano híbrido por un equipo especializado y debidamente entrenado de cirujanos, cardiólogos y anestesistas para obtener resultados óptimos.

Almost 30% of aortic valve replacements are due to aortic stenosis; therefore, certain groups of patients present high operative risk. This article describes transapical aortic valve implantation, a minimally invasive off-pump procedure. This technique represents a new alternative for patients with advanced age and increased operative risk, severe calcifications of the aorta, or previous coronary revascularization. Delineation of the aortic root geometry is essential. Transesophageal echocardiography is the most reliable tool to measure the diameter of the aortic root. Computerized tomography is another method of determining the width of the aortic annulus and it has the added ability of measuring the distance from the aortic annulus to the coronary ostia. Cardiopulmonary bypass should be available as a stand-by during all the procedure, which consists of an anterolateral mini-thoracotomy for direct antegrade surgical access through the apex of the left ventricle; then a catheter is inserted and placed in the aortic position under fluoroscopic guidance. Balloon valvuloplasty is performed thereafter, followed by transapical sheath insertion and prosthetic valve positioning. Exact valve positioning is the most critical step. The use of DYNA CT imaging software has improved the perspectives for the definite development of this technique. From February 2006 to December 2008, 192 aortic valves have been implanted transapically; mean age of patients was 82.5±5.7 years. Mortality 30 days after the procedure was 8.9% and 12.8% at long-term follow-up (256±213 days). Implantations are optimally performed in a hybrid operating room by an experienced team of cardiac surgeons, cardiologists, and anesthetists.