A snare maneuver to reposition self-expandable aortic valve after transcatheter replacement of surgically implanted valve.

In this case, we successfully repositioned the transcatheter heart valve (THV) by pulling it with a snare inserted via the right brachial artery. Attempting to pull the THV via the femoral approach was not successful, due to the vector of the pulling force not being coaxial. Changing the direction of the force by switching to an approach from the right brachial artery successfully prevented perivalvular leakage. While there are previous case reports of repositioning an implanted transcatheter valve in a native valve using a gooseneck snare, to our knowledge, this is the first case of successfully repositioning an implanted transcatheter valve in a valve-in-valve procedure using the precise assessment that can be achieved with intra-procedural transesophageal echocardiography. Learning objective: Perivalvular leakage (PVL) is a major problem after transcatheter aortic valve replacement. In this case, we experienced PVL after implantation of self-expandable transcatheter heart valve (THV) inside the previously inserted Mosaic bioprosthetic valve. Depth of the implanted valve was too low into left ventricle accessed with transesophageal echocardiogram. It is barely known whether THV in surgical implanted aortic valve could be repositioned using snare maneuver, but we successfully pulled the valve via brachial artery and PVL was controlled.

Nephrotic syndrome induced by aortic regurgitation with Takayasu arteritis: an autopsy case with long-term clinical follow-up.

Takayasu arteritis is a rare, chronic, and large-vessel vasculitis involving the aorta and its branches in a complex autoimmune reaction. Takayasu arteritis sometimes complicates aortic regurgitation and chronic kidney disease, but rarely accompanies nephrotic syndrome. We had a patient with Takayasu arteritis and concomitant aortic regurgitation. She had nephrotic syndrome that was refractory to immunosuppressive therapy but was promptly improved after surgical aortic valve replacement. In her kidney biopsy, glomeruli had mild mesangial proliferative changes without immune complex deposition. Her proteinuria remained negative until the recurrence of aortic regurgitation due to perivalvular leakage. Seventeen years after the surgery, she died suddenly. In her kidney autopsy, the arteriolar showed severe hyalinosis and the glomerulus showed mesangial proliferative changes with segmental mesangiolysis. Severe aortic regurgitation may have altered renal hemodynamics and caused glomerular lesions, resulting in nephrotic syndrome. We should be aware of the rare but critical comorbidity of nephrotic syndrome in patients with Takayasu arteritis and concomitant aortic regurgitation.

Surgical management of aortic regurgitation secondary to Behcet's disease.

Background: Aortic regurgitation (AR) related to Behcet's disease (BD) is rare, but usually fatal. Perivalvular leakage (PVL) is high if AR related to BD treated with regular AVR. In this study, we report the surgical management of AR secondary to BD. Methods: Between September 2017 and April 2022, 38 patients with AR secondary to Behcet's disease had surgery in our center. 17 patients did not have a BD diagnosis before surgery, 2 of them were diagnosed during surgery and received Bentall procedure. The remaining 15 patients received conventional AVR. 21 patients were diagnosed as BD before surgery, all of them received modified Bentall procedures. All patients were followed up by regular outpatient visits, transthoracic echocardiogram and CT angiography were performed to evaluate the aorta and aortic valve. Results: Seventeen patients did not have a BD diagnosis at the time of surgery. Out of them, 15 patients received conventional AVR, and a total of 13 patients suffered PVL after surgery. Twenty-one patients had a BD diagnosis before surgery. They received modified Bentall procedures and IST and steroids were given both pre- and post-surgery. In this group treated with Bentall procedure no patient suffered PVL during follow up. Conclusions: PVL is a complex scenario after conventional AVR for AR in BD. Modified Bentall procedure seems superior to isolated AVR in these cases. The use of IST and steroids before and after surgery in combination with modified Bentall procedure could have a role in effectively reducing PVL.

The experience in reoperation of Behcet's disease patient with perivalvular leakage after aortic valve replacement / 中华胸心血管外科杂志

Objective:To introduce the application of sleeve reconstruction with bovine pericardium in the reoperation of Behcet's disease with advanced aortic annulus invasion, and to report our experience and the early outcomes.Methods:From August 2012 to May 2022, 19 patients with Behcet's disease developed perivalvular leakage after previous surgery underwent aortic root replacement. They were analyzed retrospectively. Fifteen out of 19 cases underwent conventional aortic root replacement, 4 cases with advanced aortic annulus invasion underwent sleeve reconstruction with bovine pericardium. The medical records were reviewed. Demographic and perioperative data were collected, which included the aortic crossclamp time, intraoperative RBC consumption, length of ICU stay, and major postoperative complications.Postoperative follow-up was accomplished through telephone visit.Results:The median age was 39(36, 42) years old. Five were female. The median interval of diagnosis of perivalvular leak from index surgery was 5(3, 14)months. There was no perioperative death. Fifteen patients underwent conventional aortic root replacement. One patient had intraoperative ECMO impant due to low cardiac output as well as another one had IABP support. CABG was performed in 5 patients. One patient underwent permanent pacemaker implantation after surgery. The median follow-up time for the 15 patients was 55.00(29.25, 71.25)months. Two patients were lost during follow-up. One patient died of infection 3 years after surgery. One patient developed perivalvular leak. Two patient developed distal anastomotic pseudoaneurysm which need reintervention. The median follow-up time for the 4 patients with sleeve reconstruction was 5.5(5, 11.25)months. One patient underwent tracheotomy. Perivalvular leakage and pseudoaneurysm were not appreciated. Four patients were in NYHA class Ⅰ-Ⅱ.Conclusion:The sleeve reconstruction with bovine pericardium is safe and effective in reoperation treating patients with Behcet's disease and advanced aortic annulus invasion.

Clinical Outcome of Reoperation for Mechanical Prosthesis at Aortic Position.

AIM: Redo aortic valve surgery is usually associated with a high risk of mortality and complications. The aim of this study was to investigate the perioperative and long-term outcomes of reoperation after prior mechanical prosthesis implantation at the aortic position. METHOD: The clinical data of 146 consecutive patients who underwent reoperation at the aortic position between 2003 and 2019 were analysed. RESULTS: Mean age was 51.5±12.7 years and 69 (47.3%) were female. The median interval from prior surgery to redo aortic valve surgery was 6 years. The aetiologies were pannus formation with prosthetic aortic stenosis in 62 cases (42.5%), prosthetic valve endocarditis (PVE) in five (3.4%), PVE with perivalvular leakage (PVL) in 16 (11.0%), PVL in 45 (30.8%), thrombosis in seven (4.8%), and aortic disease in 11 (7.5%). As for surgical procedure, aortic valve replacement was performed in 81 cases (55.5%), Bentall in 34 (23.3%), PVL repair in six (4.1%), and pannus debridement in 25 (17.1%). Fourteen (14) (9.6%) patients expired perioperatively. Prolonged ventilation time and postoperative renal failure were proved to be significant independent predictors of mortality according to multivariate analysis. Overall survival was 87.8%±7.4% and 76.4%±15.1% at 5 and 10 years, respectively. Survival was 87.7%±13.7% and 84.2%±15.6% in the pannus group, and 84.5%±12.6% and 74.6%±19.4% in the non-pannus group at 5 and 10 years, respectively (p=0.951). Survival was 87.5%±14.2% and 75.8%±22.7% in the PVL group and 84.7%±11.9% and 81.6%±13.5% in the non-PVL group at 5 and 10 years, respectively (p=0.365). CONCLUSIONS: Pannus formation and PVL are two major indications for reoperation of mechanical prosthesis at the aortic position. Redo aortic valve surgery has a satisfactory outcome but with a high risk of complications. Long-term survival of patients seems not to be related to the aetiology. Final decision-making of redo aortic valve surgery should be based on aetiology.

Clinical and Surgical Evaluations of Reoperation After Mechanical Mitral Valve Replacement Due to Different Etiologies.

BACKGROUND: This study aimed to evaluate the clinical and surgical characteristics of patients who required reoperation after mechanical mitral valve replacement (MVR). METHODS: We retrospectively identified 204 consecutive patients who underwent reoperation after mechanical MVR between 2009 and 2018. Patients were categorized according the reason for reoperation (perivalvular leakage, thrombus formation, or pannus formation). The patients' medical and surgical records were studied carefully and the rates of in-hospital complications were calculated. RESULTS: The mean age was 51±12 years and 44% of the patients were male. The reasons for reoperation were perivalvular leakage (117 patients), thrombus formation (35 patients), and pannus formation (52 patients). The most common positions for perivalvular leakage were at the 6-10 o'clock positions (proportions of ≥25% for each hour position). Most patients had an interval of >10 years between the original MVR and reoperation. The most common reoperation procedure was re-do MVR (157 patients), and 155 of these patients underwent concomitant cardiac procedures. There were 10 in-hospital deaths and 32 patients experienced complications. The 10-year survival rate was 82.2 ± 3.9% in general, and the group of lowest rate was patients with PVL (77.5 ± 5.2%). The independent risk factors were "male" (4.62, 95% CI 1.57-13.58, P = 0.005) and "Hb <9g/dL before redo MV operation" (3.45, 95% CI 1.13-10.49, P = 0.029). CONCLUSION: Perivalvular leakage was the most common reason for reoperation after mechanical MVR, with a low survival rate in long term follow-up relatively.

The 1-year follow-up results of intraprocedural valve-in-valve deployment for treatment of aortic regurgitation following transcatheter aortic valve replacement (TAVR) in a single center / 中国胸心血管外科临床杂志

@#Objective    To evaluate the efficiency and safety of intraprocedural valve-in-valve deployment for treatment of aortic regurgitation following transcatheter aortic valve replacement (TAVR). Methods    Consecutive patients (n=333) who diagnosed with severe aortic stenosis and underwent TAVR in Zhongshan Hospital affiliated to Fudan University from October 3rd, 2010 to April 21st, 2021 were included. There were 208 males and 125 females aged 76.0±7.0 years. There were 316 patients underwent simple TAVR (simple TAVR group) and 17 patients underwent intraprocedural valve-in-valve deployment following TAVR (valve-in-valve group). Their clinical and echocardiographic outcomes were evaluated and compared. Results    There was no significant difference between the two groups of patients at postoperative 30 d and 1 year in all-cause mortality (4.4% vs. 0, P=1.000; 6.3% vs. 0, P=1.000), incidence of pacemaker implantation (10.4% vs. 17.6%, P=1.000; 11.8% vs. 17.6%, P=1.000), incidence of ischemic stroke (1.3% vs. 0, P=1.000; 1.3%  vs. 0, P=1.000), mean trans-aortic pressure gradient (11.4±6.4 mm Hg vs. 8.9±4.9 mm Hg, P=0.099; 10.5±7.6 mm Hg vs. 11.2±5.2 mm Hg, P=0.432), left ventricular ejection fraction (62.0%±9.0% vs. 57.0%±12.0%, P=0.189; 63.0%±7.0% vs. 60.0%±8.0%, P=0.170), and incidence of mitral valve dysfunction (0.6% vs. 5.9%, P=1.000; 0.6% vs. 5.9%, P=1.000). Conclusion    It is feasible to treat perivalvular leakage with valve-in-valve technology in the procedure of TAVR, and the short and medium-term effects are satisfied.

Specific Treatment Technique of Perivalvular Aortic Regurgitation in a Patient with Takayasu Arteritis / 日本心臓血管外科学会雑誌

We describe our experience of surgical treatment in a patient with Takayasu's arteritis who required aortic root replacement because of perivalvular aortic regurgitation, developing 2 years after aortic valve replacement. A 65-year-old man underwent aortic valve replacement with a mechanical valve 3 years previously because of serious aortic insufficiency associated with Takayasu's arteritis. No steroids were given postoperatively. Three years after surgery, perivalvular aortic regurgitation developed. Reoperation was scheduled because of increased regurgitation and valve dehiscence. The sinus of Valsalva and the ascending aorta were enlarged, and a false aneurysm was found at the suture line of the aortotomy. Moderate mitral insufficiency was also present. The patient underwent aortic root replacement with a mechanical valve (J-graft Shield^®, 24 mm ; and SJM Regent^®, 21 mm), hemiarch replacement (J-graft Shield^®, 24 mm), and mitral annuloplasty (IMR ET Logix^® ring, 28 mm). Intraoperative examination showed very severe adhesion around the ascending aorta and marked wall thickening extending from the aortic root to the ascending aorta. The annulus was recognized to be very fragile after the mechanical valve was removed. The annulus was reinforced with autologous pericardium patch, furthermore, the subannulus was reinforced with a shortly cut artificial vessel graft. Aortic root replacement was then performed. After surgery, the patient received steroids. Inflammation was improved by steroids and the patient is being followed up on an outpatient basis. In patients with a fragile annulus and severe inflammation associated with aortitis, tissue reinforcement and postoperative management of inflammation are essential.

A Perivalvular Leakage 25 Years after Mitral Valve Replacement by the Omnicarbon Valve Prosthesis / 日本心臓血管外科学会雑誌

A 79-year-old woman had undergone mitral valve replacement (Omnicarbon (OC) valve : 31 mm) due to rheumatic mitral stenosis with regurgitation and tricuspid annuloplasty at the age of 54. The patient developed anemia and congestive heart failure with pleural effusion and an elevated LDH level in 25 years late up without any valve-related cardiac event. Echocardiography revealed perivalvular leakage near the anterolateral commissure. The patient received re-mitral valve replacement (CEP valve : 25 mm) and a tricuspid valve ring annuloplasty (MC³ Tricuspid ring : 28 mm). The annulus was covered with marked calcification and fibrosis with a partial deficit at the anterior part of antero-lateral commissure. Despite the thorough pathological examination, we could not clarify the etiology of sudden onset of hemolysis.The patient was discharged uneventfully on the 28th day after operation. In general, the OC valve can work without serious complications for a long time. We report a rare case of perivalvular leakage 25 years after mitral valve replacement with hemolysis and congestive heart failure.

Aortic Valve Repair for an Aortic Valve Periprosthetic Leakage / 日本心臓血管外科学会雑誌

A 77-year-old man underwent aortic valve replacement with a Carpentier-Edwards Pericardial Magna (19 mm) for aortic stenosis. He presented with a low grade fever and congestive heart failure 6 months after the initial valve replacement. <i>Staphylococcus aureus </i>was detected in blood culture, and peri-valvular leakage was revealed by echocardiography. Prosthetic valve endocarditis was diagnosed and underwent re-aortic valve replacement with Medtronic Mosaic 21 mm bioprothesis. Six months after the re-do operation, perivalvular leakage was newly observed between the right and non-coronary cusps, which was opposite to endocarditis affected cusps. The peri-valvular leakage was considered to have resulted from the fragile valve annulus because he did not have fever, and repeated blood culture showed no bacterial growth. We performed a third surgery and repaired the leakage by adding sutures through the right atrium and the interventricular septum to avoid directly suturing the fragile annulus. The post-operative course was uncomplicated, and no sign of endocarditis nor perivalvular leakage was observed during 9-months of observation. It is considered that the aortic valve fixation sutures through the right atrium and inter-ventricular septum are useful alternatives for fragile aortic annulus after prosthetic valve endocarditis.

Aortic Root Replacement for Perivalvular Leakage after Aortic Valve Replacement for Marfan Syndrome with Severe Thoracic Deformity / 日本心臓血管外科学会雑誌

The number of operations performed for cardiovascular disease has increased since recent improvements in diagnostic and the therapeutic technology have led to a remarkable increase in the life expectancy of patients with Marfan syndrome. On the other hand, operative procedures can be difficult when patients have complications of connective tissue abnormalities such as thoracic deformities, lung diseases and ophthalmic lesions. Although recent surgical outcomes have improved, those of secondary surgery are more difficult. We describe aortic root replacement to treat perivalvular leakage after aortic valve replacement in a patient with Marfan syndrome with a severe thoracic deformity.