Hemodynamic Performance of Two Current-Generation Transcatheter Heart Valve Prostheses in Severely Calcified Aortic Valve Stenosis.

BACKGROUND: Treatment of severely calcified aortic valve stenosis is associated with a higher rate of paravalvular leakage (PVL) and permanent pacemaker implantation (PPI). We hypothesized that the self-expanding transcatheter heart valve (THV) prostheses Evolut Pro (EPro) is comparable to the balloon-expandable Sapien 3 (S3) regarding hemodynamics, PPI, and clinical outcome in these patients. METHODS: From 2014 to 2019, all patients with very severe calcification of the aortic valve who received an EPro or an S3 THV were included. Propensity score matching was utilized to create two groups of 170 patients. RESULTS: At discharge, there was significant difference in transvalvular gradients (EPro vs. S3) (dPmean 8.1 vs. 11.1 mmHg, p ≤ 0.001) and indexed effective orifice area (EOAi) (1.1 vs. 0.9, p ≤ 0.001), as well as predicted EOAi (1 vs. 0.9, p ≤ 0.001). Moderate patient prosthesis mismatch (PPM) was significantly lower in the EPro group (17.7% vs. 38%, p ≤ 0.001), as well as severe PPM (2.9% vs. 8.8%, p = 0.03). PPI and the PVL rate as well as stroke, bleeding, vascular complication, and 30-day mortality were comparable. CONCLUSIONS: In patients with severely calcified aortic valves, both THVs performed similarly in terms of 30-day mortality, PPI rate, and PVL occurrence. However, patient prothesis mismatch was observed more often in the S3 group, which might be due to the intra-annular design.

Transcatheter Aortic Valve Implantation in Patients With Pre-Existing Mechanical Mitral Valve Prostheses.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has become standard therapy for aortic stenosis patients with intermediate or high operative risk. Treatment of patients with pre-existing mechanical mitral valve replacement (MVR) is challenging due to possible interference between the TAVI prosthesis and MVR. We present our single-center experience with this special patient cohort. METHODS: A total of 1960 patients underwent TAVI at our institution between 2009 and March 2018; of these, 16 patients had pre-existing mechanical MVR. Device success and adverse events were analyzed according to the Valve Academic Research Consortium (VARC)-2 criteria. Patients were followed for at least 12 months. RESULTS: Mean patient age was 81.5 ± 4.4 years. The patients had a mean logistic EuroScore of 37.1 ± 13.5% and STS score of 7.1 ± 3.2%. Successful valve deployment was achieved in all patients, peri-interventional stroke rate was 0.0%, and permanent pacemaker was implanted in 2 patients (12.5%). Two patients experienced major complications, with blockage of the MVR disc in 1 patient and annulus rupture in 1 patient. Hence, 30-day mortality was 12.5% and 1-year mortality was 25.0%. CONCLUSION: TAVI in patients with mechanical MVR is challenging and requires careful preparation and choice of TAVI device. Repositionable and retrievable devices seem to be a safer option.

Minimally invasive versus transapical versus transfemoral aortic valve implantation: A one-to-one-to-one propensity score-matched analysis.

OBJECTIVES: Although transcatheter aortic valve implantation was the treatment of choice in inoperable and high-risk patients, the effect of transcatheter aortic valve implantation relative to conventional aortic valve replacement via ministernotomy in patients with moderate surgical risk remains unclear. METHODS: We consecutively enrolled patients who underwent minimally invasive aortic valve replacements via ministernotomy (n = 1929), transapical (n = 607), and transfemoral (n = 1273) aortic valve implantations from a single center during the period from July 2009 to July 2017. Of those, we conducted a 1:1:1 propensity score matching according to 23 preoperative risk factors. RESULTS: We were able to find 177 triplets (n = 531). The median European System for Cardiac Operative Risk Evaluation II was 3.0% versus 3.4% versus 2.9%, and Society of Thoracic Surgeons Predicted Risk of Mortality was 3.2% versus 3.6% versus 3.4%, respectively. According to the Valve Academic Research Consortium 2 criteria, there were no significant periprocedural differences regarding 30-day mortality (2.3% minimally invasive aortic valve replacement vs 4.5% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .34), stroke (1.1% minimally invasive aortic valve replacement vs 0.6% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .84), or myocardial infarction (0.6% minimally invasive aortic valve replacement vs 0.0% transapical transcatheter aortic valve implantation vs 0.0% transfemoral transcatheter aortic valve implantation, P = .83). Both intensive care and hospitalization times were significantly longer in the transapical group. Regarding midterm survival, transapical transcatheter aortic valve implantation was associated with a tendency toward a less favorable outcome (hazard ratio, 1.48; 95% confidence interval, 0.95-2.31; P = .17) compared with minimally invasive aortic valve replacement. CONCLUSIONS: In this real-world propensity score-matched minimally invasive aortic valve replacement, transapical transcatheter aortic valve implantation, transfemoral transcatheter aortic valve implantation cohort of intermediate-risk patients, early mortality was not significantly different, whereas the rates of periprocedural complications were different depending on the approach. During follow-up, there was a tendency in the transapical transcatheter aortic valve implantation group toward a less favorable survival outcome, although there was no significant difference among the 3 groups.

Posterior papillary muscle rupture after transapical transcatheter aortic valve implantation.

Transapical transcatheter aortic valve implantation is a well-established alternative in patients at a high risk for conventional aortic valve replacement. We performed transapical transcatheter aortic valve implantation on an 83-year-old woman with symptomatic severe aortic stenosis. Intraoperative transoesophageal echocardiography (TOE) after transcatheter aortic valve implantation showed mild mitral regurgitation without intracardiac structural injury. In the intensive care unit, the patient gradually had haemodynamic instability; TOE revealed severe mitral regurgitation with A2 and A3 prolapse due to rupture of the posterior papillary muscle. To repair the mitral regurgitation, mitral valve replacement was performed. Preoperative TOE revealed posterior displacement of the left ventricle due to right ventricular dilatation. Computed tomography showed the insertion angle of the guidewire from the left ventricular apex to the aortic valve as 95.6° and a relatively sharp angle of guidewire through the aortic valve. In such a case, it is necessary to carefully perform the catheter procedures to prevent intracardiac structure injury; posterior papillary muscle is particularly crucial.

Anaortic off-pump versus clampless off-pump using the PAS-Port device versus conventional coronary artery bypass grafting: mid-term results from a matched propensity score analysis of 5422 unselected patients.

OBJECTIVES: Meta-analyses from observational and randomized studies have demonstrated benefits of off-pump surgery for hard and surrogate endpoints. In some of them, increased re-revascularization was noted in the off-pump groups, which could impact their long-term survival. Therefore, we analyzed the course of all patients undergoing isolated coronary surgery regarding the major cardiac and cerebrovascular event (MACCE) criteria. METHODS: A prospective register was taken from a high-volume off-pump center recording all anaortic off-pump (ANA), clampless off-pump (PAS-Port) and conventional (CONV) coronary artery bypass operations between July 2009 and June 2015. Propensity Score Matching was performed based on 28 preoperative risk variables. RESULTS: We identified 935 triplets (N = 2805). Compared with CONV, in-hospital mortality of both the ANA group (OR for ANA [95% CI] 0.25 [0.06; 0.83], P = 0.021), and the PAS-Port group was lower (OR for PAS-Port [95% CI] 0.50 [0.17; 1.32], P = 0.17). In the mid-term follow-up there were no significant differences between the groups regarding mortality (HR for ANA [95%-CI] 0.83 [0.55-1.26], P = 0.38; HR for PAS-Port [95%-CI] 1.06 [0.70-1.59], P = 0.79), incidence of stroke (HR for ANA 0.81 [0.43-1.53], P = 0.52; HR for PAS-Port 0.78 [0.41-1.50], P = 0.46), myocardial infarction (HR for ANA 0.53 [0.22-1.31], P = 0.17; HR for PAS-Port 0.78 [0.37-1.66], P = 0.52) or re-revascularization rate (HR for ANA 0.99 [0.67-1.44], P = 0.94; HR for PAS-Port 0.95 [0.65-1.38], P = 0.77). CONCLUSIONS: Both off-pump clampless techniques were associated with lower in-hospital mortality compared with conventional CABG. The mid-term course showed no difference with regard to the MACCE criteria between anaortic off-pump, clampless off-pump using PAS-Port and conventional CABG.

Prosthetic Valve Escaping During Transcatheter Aortic Valve Implantation.

We performed transapical transcatheter aortic valve implantation on an 87-year-old woman with severe aortic valve stenosis. Because of the narrow left ventricular outflow tract, annular positioning of the prosthetic valve proved challenging. During positioning, the prosthetic valve was accidentally dislodged from the balloon catheter and dropped into the left ventricle. Attempted catheter retrieval was unsuccessful. We therefore converted to open surgery without delay. After aortotomy, to our surprise, the prosthesis could not be found, neither in the left ventricle nor in the ascending aorta. Transesophageal echocardiography failed to reveal the location of the missing prosthesis. Fluoroscopy finally displayed the prosthesis in the descending aorta at the level of the left atrium. We proceeded with aortic and mitral valve replacement and closed the sternum. Under fluoroscopic guidance, the prosthetic valve was secured to the wall of the abdominal aorta in an infrarenal position by dilatation with a balloon catheter. This case shows that we should be alert to septum hypertrophy or a narrow left ventricular outflow tract during transapical aortic valve implantation. In such anatomical situations, we recommend advancing the sheath of the application system directly below the annular plane and positioning the prosthesis from this point.

In-Graft Endovascular Stenting Repair for Supravalvular Stenosis From Aortic Rupture After Balloon-Expanding Transcatheter Aortic Valve Implantation.

An 81-year-old man with high-grade aortic valve stenosis and status post-coronary artery bypass grafting and supracoronary replacement of the ascending aorta was referred for transcatheter aortic valve implantation. He was in New York Heart Association class III and had dyspnea. After appropriate screening, we implanted a 29-mm SAPIEN XT valve (Edwards Lifesciences, Irvine, CA USA) through a transapical approach because of severe peripheral arterial occlusive disease. Postinterventional aortography revealed correct positioning and function of the valve and free coronary ostia but contrast extravasation in the vicinity of the interposed vascular prosthesis, resulting in severe luminal narrowing. We chose to manage the stenosis with an endovascular stent. After stenting, extravascular compression was markedly reduced, and the pressure gradient disappeared. The patient was discharged home on the 20th postoperative day. Three months later, computed tomography depicted correct positioning of both grafts. The patient's general health is good, and he is now in New York Heart Association class II. This case illustrates a complication of transcatheter aortic valve implantation specific for patients with an ascending aortic graft. Although stenting may be a good solution, as depicted by this case, self-expanding transcatheter aortic valves should be preferred in patients with ascending aortic grafts to avoid the described complication.

Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients.

OBJECTIVES: The proportion of minimally invasive approaches is rising in cardiac surgery, in part driven by increasing patient demand. This study aimed to perform a risk-adjusted comparison of mortality, rate of stroke and perioperative morbidity of aortic valve replacement (AVR) conducted through either partial mini-sternotomy or conventional sternotomy. METHODS: Between July 2009 and July 2012, data from 984 consecutive patients undergoing isolated AVR were prospectively recorded. In 44.3% (n = 436), the less invasive partial mini-sternotomy was used. Propensity score matching was performed based on 15 preoperative risk factors to correct for selection bias. In-hospital mortality, stroke rate as well as other major complications in the minimally invasive group and conventional sternotomy group were compared in 404 matched patient pairs (total 808). RESULTS: In-hospital mortality and rate of postoperative intra-aortic balloon pump use were identical for propensity-matched patients, 1.0% (4 in each group). The rate of stroke [OR (95% confidence interval (CI)): 0.80 (0.22-2.98)], perioperative myocardial infarction [OR (95% CI): 2.00 (0.18-22.06)], low-output syndrome [OR (95% CI): 0.90 (0.37-2.22)], new onset of dialysis [OR (95% CI): 1.25 (0.49-3.17)] and re-exploration for bleeding [OR (95% CI): 0.88 (0.50-1.56)] were similar. Likewise, resource utilization (operation time, duration of stay in the intensive care unit and in-hospital stay) and valve selection (type and size) was not affected by the surgical approach either. CONCLUSIONS: AVR can be safely conducted through a partial mini-sternotomy. This approach is not associated with an increased rate of complications. However, wide CIs reflect the still prevailing statistical uncertainty in estimates, not excluding patient-relevant differences between approaches. Large trials, which also address end points, such as postoperative pain, duration of postoperative recovery and quality of life, are needed to clarify the role of minimally invasive AVR.

Complete resection of undifferentiated cardiac sarcoma and reconstruction of the atria and the superior vena cava: case report.

Primary cardiac tumors are rare with an incidence ranging from 0.001% to 0.03% in autopsy series. The prognosis of cardiac sarcomas remains poor because it proliferates rapidly and distant metastases are often found at diagnosis. A 47-year-old male complained of persistent cough. The chest roentgenogram was normal. Subsequent computed tomography revealed a mass in the right atrium. Echocardiography and magnetic resonance imaging confirmed also a right atrial mass (34 x 35 mm) infiltrating the atrial septum. The tumor was completely resected en bloc, including the anterior and lateral right atrial walls, the left atrial dome, and a large segment of the superior vena cava, and reconstructed the atria and superior vena cava with bovine pericardium. The tumor was histologically and immunohistochemically diagnosed as undifferentiated pleomorphic sarcoma. This type of cardiac sarcoma is very rare and usually found in the left atrium. Twenty-seven months after surgery, the patient is doing well without metastasis or local tumor recurrence.

A silent gigantic solitary fibrous tumor of the pleura: case report.

Solitary fibrous tumor of the pleura is a rare mesenchymal tumor, representing less than 5% of all neoplasms associated with the pleura. A 57-year-old man had general malaise without chest symptoms for 1 month. A chest roentgenogram and computed tomography showed a giant mass in the left thorax. Although the tumor compressed the descending aorta and other mediastinal structures strongly, thereby shifting them to the right side, the patient had no symptoms except malaise. The tumor was successfully resected via two separate thoracotomies. The tumor was measured (20 cm × 19 cm × 15 cm) and weighed (2150 g). The tumor was histologically and immunohistochemically diagnosed as benign. Although SFT is benign, a long follow-up period is essential as even patients with complete resection are at risk of recurrence many years after surgery.

Mitral regurgitation caused by an isolated mitral leaflet cleft.

An isolated cleft of the mitral valve leaflet is rare cause of mitral regurgitation in adults. We report a successful minimally invasive mitral valve repair for severe mitral regurgitation caused by an isolated cleft of the anterior mitral leaflet. During the operation, we found a large cleft measuring 5×8 mm in the center of the anterior mitral leaflet. We closed the cleft directly and performed annuloplasty with a 30-mm Carpenter-Edwards Physio Ring (Edwards Lifesciences, Irvine, CA). The mitral valve is very well visualized with the video-assisted minimally invasive approach through the right chest.

Reoperation for aortic valve stenosis due to severe calcification of the bioprosthetic valve after modified Bentall operation in Takayasu arteritis.

Takayasu arteritis is an inflammatory disease that affects the aorta and its main branches. The dilation of the aortic root would cause aortic regurgitation (AR). We would demonstrate the dramatic change of the bioprosthesis implanted in the young woman with Takayasu arteritis, which has not been reported previously, and we believe that bioprosthesis should not be implanted easily in Takayasu arteritis.

Less invasive quick replacement for octogenarians with type A acute aortic dissection.

OBJECTIVE: We assessed the efficacy of our newly modified technique, namely, less invasive quick replacement with rapid rewarming, for octogenarians undergoing emergency surgery for type A acute aortic dissection. METHODS: Forty-two patients with acute aortic dissection, whose average age was 81.7 +/- 2.3 years, were divided into two groups: group I consisted of 25 patients undergoing surgery with deep hypothermic circulatory arrest and selective cerebral perfusion; group II consisted of 17 recent patients who underwent less invasive quick replacement. In the latter technique, during open distal anastomosis with a rectal temperature of 28 degrees C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40 degrees C accompanied by warming of the patient's body by a heating mat. As soon as the distal anastomosis was completed, rapid rewarming was initiated by 40 degrees C blood perfusion. RESULTS: The durations of cerebral protection (group I, 75.8 minutes, vs group II, 18.8 minutes), cardiopulmonary bypass (I, 201.2, vs II, 84.4 minutes), and overall operation (I, 425.6, vs II, 148.6 minutes) were significantly shorter in group II. In group I, 5 patients had complications of cerebral damage and 5 required re-exploration for bleeding, 7 had pneumonia, 6 required hemodialysis for renal failure, and the hospital mortality rate was 24% (6 patients). On the other hand, no such complications or mortality were observed in group II (P < .0291). Postoperative hospital stay was significantly shorter for the patients in group II than in group I (13.2 days vs 33.7 days; P < .0001). CONCLUSION: Less invasive quick replacement is safe and effective. It should be a standard surgical technique for octogenarians with type A acute aortic dissection.

Should emergency surgical intervention be performed for an octogenarian with type A acute aortic dissection?

OBJECTIVE: The number of octogenarians undergoing emergency surgery is increasing and may negate the impact of the beneficial advances. The aim of this study was to review octogenarians with type A acute aortic dissection and assess the prognosis. METHODS: Fifty-eight patients with acute aortic dissection, whose average age was 83.2 years, were divided into 2 groups: Group I comprised 30 patients who underwent emergency surgery, and group II comprised 28 patients who were treated conservatively. We compared the 2 groups in terms of mortality and morbidity. RESULTS: In group I, postoperative hospital mortality was 13.3% (4 patients). In group II, 17 patients (60.7%) died in the hospital. In group I, although emergency aortic replacement was successfully completed, 5 patients became bedridden after surgery and 2 patients died of pneumonia or stroke in the early stages of institutional care. Thirteen patients in group I died of malignancies, abdominal aortic rupture, traffic accident, heart failure, or late-stage senility in later phase. There was no difference in actuarial survivals at 5 years, which were 48.5% in group I and 35.4% in group II. CONCLUSION: Emergency surgery for octogenarians with acute aortic dissection showed acceptable mortality. However, families had to take responsibility for patients who experienced unconsciousness, had dementia, or became bedridden. It is important to have consensus between the family and surgeons about emergency surgical treatment for octogenarians.

First report of Bartonella quintana endocarditis in Japan.

Bartonella (Rochalimaea) species are increasingly recognized as a cause of endocarditis, but the total number of cases remains low. Especially, Bartonella quintana endocarditis is very rare and there have been no reports in Japan. A 66-year-old man was hospitalized because of dyspnea and fever. An echocardiogram showed severe mitral valve regurgitation, mild aortic valve regurgitation, and echogenic masses on the mitral and aortic valve. Six sets of blood cultures were negative. Replacement of the mitral- and aortic-valve with a mechanical valve was performed. However, due to symptomatic para-valvular leakage a re-mitral valve replacement was later performed. Unfortunately, the patient died 1 month after the operation owing to multiple organ failure. Four weeks after the second operation, blood culture yielded a Gram-negative bacillus. DNA was extracted from the colony and subjected to polymerase chain reaction amplification. Nucleotide sequence analysis (1,500 nucleotide positions) and a BLAST search of the EMBL/GENBANK database revealed 99.9% homology with the Bartonella quintana 16S rRNA gene. This is the first report of Bartonella quintana endocarditis in Japan, and should be considered with the view of culture negative endocarditis.

A simple and safe operation method for brachiocephalic artery aneurysms.

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.

Successful treatment of fulminant myocarditis with mechanical circulatory support.

A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.