Large Field-of-View Intravascular Ultrasound for Mitral and Tricuspid Valve-in-Valve Guidance: A Pilot Study.

Background: Actual expansion of a transcatheter heart valve (THV) might differ from nominal, particularly during nonaortic valve-in-valve for a degenerated bioprosthetic surgical heart valve (SHV). This pilot study compared THV expansion measured using large-field-of-view intravascular ultrasound (IVUS) vs. multi-slice computed tomography (MSCT) and assessed the correlation between THV dimensions and transvalvular gradients. Methods: Fourteen patients were successfully treated with mitral/tricuspid valve-in-valve SAPIEN 3 implantation sized using the true SHV inner diameter; all 14 had baseline MSCT and transvalvular gradients measured at baseline, postprocedure, and at discharge. Periprocedural IVUS (in 6 patients using a Philips 10MHz Vision PV035) was compared with postprocedural MSCT (in 9 patients) with offline measurements performed at 1-mm steps along the THV height. Overall, 190 MSCT and paired 124 IVUS cross-sections were analyzed. Results: There was very good agreement between IVUS THV dimensions and corresponding MSCT measurements (intraclass correlation coefficient ≥0.986 and p < 0.001). IVUS measured THV expansion (percent of the nominal cross-sectional area) was smaller within the inflow and middle of the THV overlapping the ring (85.9% ± 11.3%, 83.8% ± 11.8%) than within the outflow (98.8% ± 12.7%). The residual mean transvalvular gradient increased from periprocedural to predischarge (3.5 ± 2.0 vs. 6.3 ± 1.7 mmHg, p < 0.001). The only independent predictor of predischarge maximal transvalvular gradient was the smallest minimal inner THV frame diameter (r2 = 0.67), predicted by true SHV internal diameter (Beta = 0.066, 95% CI = 0.015-0.117, r2 = 0.49, p = 0.037). Conclusions: This pilot study is the first to report the feasibility of a large field-of-view IVUS for periprocedural measurement of actual THV expansion when deployed valve-in-valve. Minimal inner THV stent frame dimensions correlate with increased postprocedural transvalvular gradients.

Evolut transcatheter aortic valve replacement explant and aortic root repair with an annular patch in the setting of endocarditis.

As a consequence of the growing number of implanted transcatheter aortic valve prostheses, the increasing incidence of early and late complications of biological valves requires in several cases surgical explantation of the transcatheter valve and subsequent aortic root or surgical aortic valve replacement. In this video tutorial, we show how to avoid aortic root damage in the surgical explantation of a transcatheter aortic valve bioprosthesis in a patient with a dysfunctional transcatheter aortic valve prosthesis affected by endocarditis 15 months after implantation. The infected prosthesis and all foreign materials, concomitant to the calcified native valve, were excised en bloc in preparation for the extensive debridement of infected tissue in the abscess cavity. The defect on the aortic annulus was reconstructed using a pericardial patch, followed by a surgical valve implant.

Predictors of permanent pacemaker implantation for transcatheter self-expandable aortic valve implant in the cusp overlap era.

BACKGROUND: Predictors of permanent pacemaker implantation (PPMI) after self-expanding transcatheter aortic valve implant (TAVI) were described. Is unknown if PPMI predictors remain in the era of high implants using the cusp overlap (COP). METHODS: Single-center, prospective, consecutive case series of patients undergoing self-expanding TAVI with the COP approach. The status of PPMI and other clinical events were ascertained at 30 days. RESULTS: A total of 261 patients were included (84% with Evolut, n = 219). Implant depth >4 mm was infrequent (13.8%). TAVI depth (OR 1.259; p = 0.005), first or second-degree auriculo-ventricular block (OR 3.406; p = 0.033), right-bundle (OR 15.477; p < 0.0001), and incomplete left-bundle branch block (OR 7.964; p = 0.036) were found to be independent predictors of PPMI. The risk of PPMI with deep implant and no electrical disturbances was 3%, and 0% with high implant and no prior electrical disturbances. Those who received PPMI had no statistically significant increased risk of death, myocardial infarction, stroke, bleeding events, or vascular complications at 30 days, but longer hospital stay (mean difference 1.43 days more, p = 0.003). CONCLUSIONS: Implant depth and prior conduction abnormalities remain the main predictors of PPMI using self-expanding TAVI in the COP era. Patients with high implants and no prior conduction abnormalities may be candidates for early discharge after uneventful self-expanding TAVI, while the rest may need inpatient monitoring regardless of achieving a high implant. The need for PPMI was associated with longer hospital stays.

Hybrid Interventions in Congenital Heart Disease.

Hybrid interventions in congenital heart disease (CHD) embody the inherent collaboration between congenital interventional cardiology and cardiothoracic surgery. Hybrid approaches to complex and common lesions provide the opportunity to circumvent the limitations of patient size, vascular access, severity of illness, and anatomy that would otherwise be prohibitive to surgical and percutaneous techniques alone. This review describes several important hybrid approaches to interventions in CHD.

Simplified balloon-BASILICA: A different perspective.

Nowadays, the long-life management of patients with aortic stenosis has emerged as one of the most debated issues. Transcatheter aortic valve replacement is more frequently performed in younger patients with lower surgical risk, and also the number of valve-in-valve (ViV) procedures has increased in the last few years. However, coronary obstruction is the most dreadful complication related to this procedure. To prevent coronary obstruction in the context of transcatheter aortic ViV implantation, the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) technique was developed. Although effective, BASILICA is complex and time-consuming. Hence, simpler, reproducible, and faster strategies are desirable. Here we present a promising simplified BASILICA technique employing an Armada Balloon to perform the leaflet laceration.

The PIGTAIL paradigm for a fast and safe transfemoral transcatheter aortic valve replacement.

Transfemoral transcatheter aortic valve replacement is the preferred primary access route whenever possible. Despite advancements in expertise and delivery system profiles, complications associated with the primary femoral access still significantly affect procedural morbidity and outcomes. The current standard for accurate main access planning involves proper preprocedural evaluation guided by computed tomography. Several baseline clinical and anatomical features serve as predictors for the risk of vascular injury occurring during or after transcatheter aortic valve replacement. In this paper, we aimed at reviewing the most up-to-date knowledge of the topic for a safe transfemoral access approach according to a paradigm we have called "PIGTAIL."

Health-related quality of life after minimal-invasive treatment of aortic valve stenosis in the elderly.

Background: Although transfemoral transcatheter aortic valve implantation (TF-TAVI) offers superior early outcome over open surgical aortic valve replacement (SAVR) in the elderly, a comparison of TF-TAVI with surgery performed through partial upper mini sternotomy (PUMS) hasn't yet been validated. The aim of the present study is to evaluate the clinical outcome and quality of life of patients subjected to TF-TAVI and open surgical aortic valve replacement through partial upper mini sternotomy (PUMS-SAVR). Methods: Baseline, procedural and post-treatment data of 197 consecutive patients: 137 TF-TAVI and 60 PUMS-SAVR treated at Philipps University of Marburg, were retrospectively collected. The propensity score method was used to create two groups in a 1:1 fashion. Questionnaire assessment (SF36_LQ) of quality of life of the matched patients was carried out at the ambulant routine control presentation. A competing risk regression model is used to evaluate the impact of the clinical outcome on health-related quality of life (HrQoL). Results: After propensity matching, TF-TAVI remained associated with lower procedural time (136±50 vs. 298±36 min, P<0.01), intensive care unit stay (2.68±2.70 vs. 4.29±2.43 days, P<0.01), transfusion of packed red cell units (0.46±2.05 vs. 1.60±2.00 U, P=0.02) and higher heart block (42.86% vs. 0%, P<0.01) and permanent pacemaker implantation rates (14.29% vs. 0%, P=0.05) compared to PUMS-SAVR. TF-TAVI is associated with less complains, superior HrQoL (excellent 40% and very good 60% vs. very good 100% in PUMS). Partial sternotomy is the main predictor of the inferior HrQoL, with the regression coefficient of -1.11 (95% confidential interval, -1.503 to -0.726; R2=0.324, P<0.0001). Transfusion (P=0.26), paravalvular leakage (0.618), pacemaker implantation (P=0.19) and delirium (P=0.92) did not influence HrQoL after the minimal-invasive treatment of aortic valve stenosis in elderly patients. Conclusions: Although PUMS-SAVR offers better technical outcomes with less permanent pacemaker implantation and less paravalvular leakage than TF-TAVI, it is still associated with more need for transfusion, longer ventilation-and intensive care unit-times, and prolonged hospital stay. In the elderly, PUMS-SAVR achieves inferior quality of life compared to TF-TAVI. Partial sternotomy reveals as the strongest risk factor of perceived health-level post-treatment. It remains to be revealed whether fast-track open heart surgery that maintains a fully intact sternum and allows immediate postoperative extubation-as performed through video-assisted mini-thoracotomy or thoracoscopic robotic procedures with percutaneous cannulation - should be favored against PUMS-SAVR.

Long-term function of a novel autologous transcatheter pulmonary heart valve implant in an adult animal model.

BACKGROUND: Current heart valve implants entail major disadvantages in the treatment for younger patients or those with congenital heart defects. AIM: Evaluation of novel transcatheter pulmonary valve implant made from autologous pericardium with natural crosslinking agent in an in vitro setup and in vivo animal model METHODS: Valves were tested in a pulse duplicator according to ISO-standard 5840. For in vivo studies computer tomography was performed to measure sheep's native pulmonary valve dimensions. Pericardium was harvested by thoracotomy, personalized implants were manufactured and deployed in pulmonary valve position of the same sheep. Every 3 months implant functionality was evaluated by intracardiac echocardiography, intracardiac pressure measurements and cardiac magnetic resonance imaging (cMRI). Implants were explanted for macroscopic and histological examination. RESULTS: In vitro experiments showed compliance with regulatory requirements in terms of valve opening and insufficiency. Five sheep successfully received an autologous valve implant. Two animals had to be euthanized due to trauma sustained in the stable. Long-term valve function was excellent in three out of four animals with median implant cMRI regurgitation fraction of 9% (n = 4) at 3 months, 8% (n = 3) at 6, 8% (n = 3) at 9, 12% (n = 3) at 13, 8% (n = 2) at 17% and 8% (n = 2) at 20.5 months after implantation. Despite good adherence to neighboring tissue and endothelization, histological assessment revealed some signs of degeneration. CONCLUSION: Transcatheter pulmonary valve implants showed promising function for up to 20.5 months encouraging research to further improve this approach.

Mitral re-valve-in-valve as a new perspective for high-risk patients with prosthetic valve dysfunction: case reports.

Background: Mitral valve diseases are a common medical condition, and surgery is the most used therapeutic approach. The need for less invasive interventions led to the development of transcatheter valve implantation in high-risk patients. However, the treatment to the dysfunctions of these prosthetic valves is still uncertain, and the yield and safety of repeated transcatheter valve implantations remain unclear. Cases summary: A 69-year-old Caucasian woman with three previous mitral valve procedures performed due to rheumatic valve disease (currently with a biological prosthetic mitral valve) and a 76-year-old Latin woman with previous liver transplantation (due to metabolic-associated fatty liver disease) and biological mitral prosthesis due to mitral valve prolapse with severe regurgitation underwent mitral valve-in-valve (ViV) transcatheter implantation at the time of dysfunction of their surgical prostheses. Later, these patients developed prosthetic valve dysfunction and clinical worsening, requiring another invasive procedure. Due to maintained high-risk status and unfavourable clinical conditions for surgery, re-valve-in-valve (re-ViV) was performed. Discussion: Valve-in-valve transcatheter mitral valve implantation was approved in 2017, and, since then, it has been used in several countries, mainly in high-risk patients. Nevertheless, these prosthetic valves may complicate with stenosis or regurgitation, demanding reinterventions. Although there are favourable data for mitral ViV, re-ViV still lacks robust data to support its performance, with only case reports in the literature so far. It is possible that in high-risk patients, there is a greater benefit from re-ViV when compared with the surgical strategy. However, this hypothesis must be studied in future controlled trials.

A novel high-risk aortic root anatomy for right coronary artery occlusion during TAVI.

Acute coronary occlusion during transcatheter aortic valve implantation (TAVI) is a rare but potentially lethal complication. Main mechanisms are sinus insufficiency or sinus sequestration with well-described risk factors. We present two cases of acute right coronary artery occlusion during TAVI with a self-expanding valve in the absence of classical risk factors and propose a novel mechanism.

Successful closure of transcatheter aortic valve replacement-induced Gerbode defect with valve-in-valve technique: A case report.

We present the first documented case of a successful closure of a transcatheter aortic valve replacement (TAVR)-induced Gerbode defect using a valve-in-valve approach. A 90-year-old female with severe aortic stenosis underwent TAVR. Following post-dilatation, the patient experienced hemodynamic deterioration and collapse due to tamponade and sub-annular rupture leading to hemodynamic deterioration and the development of a Gerbode defect with communication between the left ventricle and right atrium. Hemodynamic stabilization was achieved through pericardiocentesis, followed by the low implantation of a second valve, effectively sealing the rupture. This case showcases a valuable alternative for managing rare challenging complications during TAVR procedures.

Aortic Valve Stenosis and Cancer: Problems of Management.

Aortic valve stenosis and malignancy frequently coexist and share the same risk factors as atherosclerotic disease. Data reporting the prognosis of patients with severe aortic stenosis and cancer are limited. Tailoring the correct and optimal care for cancer patients with severe aortic stenosis is complex. Cancer patients may be further disadvantaged by aortic stenosis if it interferes with their treatment by increasing the risk associated with oncologic surgery and compounding the risks associated with cardiotoxicity and heart failure (HF). Surgical valve replacement, transcatheter valve implantation, balloon valvuloplasty, and medical therapy are possible treatments for aortic valve stenosis, but when malignancy is present, the choice between these options must take into account the stage of cancer and associated treatment, expected outcome, and comorbidities. Physical examination and Doppler echocardiography are critical in the diagnosis and evaluation of aortic stenosis. The current review considers the available data on the association between aortic stenosis and cancer and the therapeutic options.