Management of a protruding right coronary artery stent during aortic valve replacement for aortic stenosis

ABSTRACT: We describe the successful management of a stent protruding from the right coronary ostium into the aortic root in the setting of aortic valve replacement for aortic stenosis. Due to advances in medical care more elderly patients present for aortic valve surgery after percutaneous coronary intervention. Therefore, with an aging population due to advances in medical care, more patients will present for aortic valve surgery after percutaneous coronary intervention. We suggest a degree of caution before valve deployment in transcatheter aortic valve intervention or during annular manipulation in patients undergoing traditional aortic valve replacement with coexisting patent proximal stents.     

Balloon aortic valvuloplasty as a bridge to aortic valve replacement in a patient with severe calcific aortic stenosis

This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aortic valve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aortic valve replacement when the risks for surgery are considered to be too high.     

Reduction of gaseous microembolism during aortic valve replacement using a dynamic bubble trap

Serious postoperative psycho-neurological dysfunction is at least partially attributed to the occurrence of gaseous microbubbles in the arterial line of extracorporeal circulation (ECC). Therefore, we investigated in a prospective randomized double blind study whether the usage of dynamic bubble trap (DBT) will reduce microbubble load of patients undergoing aortic valve replacement. Patients (n = 41) were divided into group I (GI, n = 22) with DBT introduced into the arterial line of ECC and group II (GII, n = 19) with placebo-DBT instead. Doppler ultrasonography was used for detection of microbubbles before and after DBT, and for detection of high intensity transient signals (HITS) within the middle cerebral artery. The recording time during ECC was divided into period 1 (P1, until aortic clamp removal) and period 2 (P2, clamp removal until the end of ECC). A significant reduction of microbubble load was found in GI only (p < 0.0001 for ECC; p < 0.0001 for P1; p < 0.0025 for P2). A significant difference in number of HITS between the groups was observed in P1 only (p < 0.002 left middle cerebral artery, p < 0.005 right middle cerebral artery), since in P2 the trapped air in left chamber can go to the supraaortal vessels without passing ECC. In conclusion the use of DBT cannot substitute careful venting after aortic declamping. Nevertheless, reduction of HITS in the cross-clamped period of ECC justifies the use of DBT in patients undergoing open chamber surgery.     

Sutureless aortic valve with supracoronary ascending aortic replacement as an alternative strategy for composite graft replacement in elderly patients

Netherlands Heart Journal - Aortic valve disease is frequently associated with ascending aorta dilatation and can be treated either by separate replacement of the aortic valve and ascending aorta...     

Undiagnosed hypertrophic obstructive cardiomyopathy during transcatheter aortic valve replacement: a case report

Background

Transcatheter aortic valve replacement is indicated for severe symptomatic aortic stenosis in patients who have a very high or prohibitive surgical risk as assessed pre-procedurally by the Society of Thoracic Surgery Risk Score, EuroSCORE (II), frailty testing, and other predictors. When combined with another left ventricular outflow tract obstruction, careful consideration must be taken prior to proceeding with transcatheter aortic valve replacement because an additional masked left ventricular outflow tract pathology can lead to challenging hemodynamics in the peri-deployment phase, as reported in this case.

Case presentation

A 56-year-old Caucasian man with multiple comorbidities and severe aortic stenosis underwent transcatheter aortic valve replacement under monitored anesthesia care. During the deployment phase, he developed dyspnea that progressed to pulmonary edema requiring emergent conversion to general anesthesia, orotracheal intubation, acute respiratory distress syndrome-type ventilation, and vasopressor medications. Intraoperative transesophageal echocardiography was performed and hypertrophic obstructive cardiomyopathy with systolic anterior motion of the mitral valve was discovered as an underlying pathology, undetected on preoperative imaging. After treatment with beta blockers, fluid resuscitation, and alpha-1 agonists, he stabilized and was eventually discharged from our hospital without any lasting sequelae.

Conclusions

Patients with aortic stenosis most often develop symmetric hypertrophy; however, a small subset has asymmetric septal hypertrophy leading to left ventricular outflow tract obstruction. In cases of severe aortic stenosis, however, evidence of left ventricular outflow tract obstruction via both symptoms and echocardiographic findings may be minimized due to extremely high afterload on the left ventricle. Diagnosing a left ventricular outflow tract obstruction as the cause of hemodynamic instability during transcatheter aortic valve replacement, in the absence of abnormal findings on echocardiogram preoperatively, requires a high index of clinical suspicion. The management of acute onset left ventricular outflow tract obstruction intraoperatively consists primarily of medical therapy, including rate control, adequate volume resuscitation, and avoidance of inotropes. With persistently elevated gradients, interventional treatments may be considered.

     

Successful aortic valve replacement in a patient with AIDS

In trying to assess the benefit of cardiac surgery in AIDS patients, the question arises whether a patient with a deficient immune system can tolerate open heart surgery well enough to make the operation worthwhile. Surgical procedures and cardiopulmonary bypass have been noted to alter immune function (Diettrich et al., Ide et al.). Therefore, the presence of clinical AIDS is often still regarded as a contraindication to cardiac surgery. In this report we describe an AIDS patient who developed endocarditis of the native aortic valve. The endocarditis was successfully treated with antibiotic drugs, but the patient was left with damaged valves. Over the months he developed a massive aortic insufficiency and underwent aortic valve replacement. The patient did well after surgery, and is alive and well 18 months after the operation, suggesting that cardiac surgery might be a good and valuable treatment option in AIDS patients.     

Patient-specific MRI-based 3D FSI RV/LV/patch models for pulmonary valve replacement surgery and patch optimization

A patient-specific right/left ventricle and patch (RV/LV/patch) combination model with fluid-structure interactions (FSIs) was introduced to evaluate and optimize human pulmonary valve replacement/insertion (PVR) surgical procedure and patch design. Cardiac magnetic resonance (CMR) imaging studies were performed to acquire ventricle geometry, flow velocity, and flow rate for healthy volunteers and patients needing RV remodeling and PVR before and after scheduled surgeries. CMR-based RV/LV/patch FSI models were constructed to perform mechanical analysis and assess RV cardiac functions. Both pre- and postoperation CMR data were used to adjust and validate the model so that predicted RV volumes reached good agreement with CMR measurements (error <3%). Two RV/LV/patch models were made based on preoperation data to evaluate and compare two PVR surgical procedures: (i) conventional patch with little or no scar tissue trimming, and (ii) small patch with aggressive scar trimming and RV volume reduction. Our modeling results indicated that (a) patient-specific CMR-based computational modeling can provide accurate assessment of RV cardiac functions, and (b) PVR with a smaller patch and more aggressive scar removal led to reduced stress/strain conditions in the patch area and may lead to improved recovery of RV functions. More patient studies are needed to validate our findings.     

Report on outcomes of valve-in-valve transcatheter aortic valve implantation and redo surgical aortic valve replacement in the Netherlands

Netherlands Heart Journal - We sought to investigate real-world outcomes of patients with degenerated biological aortic valve prostheses who had undergone valve-in-valve transcatheter aortic valve...     

Tryptase as a marker of severity of aortic valve stenosis

Background

Severe aortic valve stenosis is one of the most common cause of mortality in adult patients affected with metabolic syndrome, a condition associated with an active inflammatory process involving also mast cells and their mediators, in particular tryptase. The aim of this study was to characterize the possible long-term prognostic role of tryptase in severe aortic valve stenosis.

Case presentation

The baseline serum tryptase was measured in 5 consecutive patients admitted to our Hospital to undergo aortic valve replacement for severe acquired stenosis. Within 2 years after, the patients were evaluated for the occurrence of major cardiovascular events (MACE). The tryptase measurements were higher in patients experiencing MACE (10.9, 11.7 and 9.32 ng/ml) than in non-MACE ones (5.69 and 5.58 ng/ml).

Conclusions

In patients affected with severe aortic stenosis, baseline serum tryptase may predict occurence of MACE. Further studies are needed to demonstrate the long-term prognostic role of this biomarker.

     

Rapid novel aortic arch replacement for thoracic aortic aneurysm using three continuous sutures and a felt cylindrical collar

This report describes the novel parachute technique of open distal anastomosis at the aortic arch replacement. Two Teflon felt cylindrical collars were initially placed on the anastomotic site of the descending aorta. All four to five outer loops of the stitches used in the parachute technique were tracked by the gathering suture. The anastomotic sutures and three gathering sutures were finally pulled simultaneously. The prosthetic graft and the aortic stump with Teflon felt were safely and completely anastomosed. Surgical or hospital death and serious complications were not found. The mean anastomotic duration (circulatory arrest duration) in 16 patients was 23 minutes. Our novel technique using a Teflon felt cylindrical collar and modified continuous suturing was not only safe but also reduced the duration of anastomosis and minimized blood loss. This technique is simple and can be applied to aortic valve replacement.     

Left ventricular function early after aortic valve replacement for aortic regurgitation: Assessment by gated radionuclide ventriculography

This study characterizes left ventricular performance early after aortic valve replacement for severe isolated aortic regurgitation. Gated radionuclide ventriculography studies in 13 patients showed that left ventricular end-diastolic volume was reduced after surgery and that ejection fraction dropped significantly. Despite the fall in ejection fraction, the postoperative cardiac index was significantly greater than the preoperative value. Radionuclide ventriculography is a useful and reliable means of noninvasively assessing left ventricular function soon after aortic valve replacement for aortic regurgitation.     

Incidence and outcome of prosthetic valve endocarditis after transcatheter aortic valve replacement in the Netherlands

Background

Transcatheter aortic valve replacement (TAVR) is increasingly being used as an alternative to conventional surgical valve replacement. Prosthetic valve endocarditis (PVE) is a rare but feared complication after TAVR, with reported first-year incidences varying from 0.57 to 3.1%. This study was performed to gain insight into the incidence and outcome of PVE after TAVR in the Netherlands.

Methods

A multicentre retrospective registry study was performed. All patients who underwent TAVR in the period 2010–2017 were screened for the diagnosis of infective endocarditis in the insurance database and checked for the presence of PVE before analysis of general characteristics, PVE parameters and outcome.

Results

A total of 3968 patients who underwent TAVR were screened for PVE. During a median follow-up of 33.5 months (interquartile range (IQR) 22.8–45.8), 16 patients suffered from PVE (0.4%), with a median time to onset of 177 days (IQR 67.8–721.3). First-year incidence was 0.24%, and the overall incidence rate was 0.14 events per 1000 person-years. Overall mortality during follow-up in our study was 31%, of which 25% occurred in hospital. All patients were treated conservatively with intravenous antibiotics alone, and none underwent a re-intervention. Other complications of PVE occurred in 5 patients (31%) and included aortic abscess (2), decompensated heart failure (2) and cerebral embolisation (1).

Conclusion

PVE in patients receiving TAVR is a relatively rare complication and has a high mortality rate.

     

The geometry of the aortic root in health, at valve disease and after valve replacement

For the design of aortic valve prostheses with a separation-free flow field and minimum pressure drop the geometry of the aortic root is of high importance, since an appropriate adjustment of the prostheses to the surrounding geometry could largely reduce the risk of thromboembolic complications. For the investigation of the geometry of the aortic root 604 angiographic films out of a total stock of 15,000 of the Medical Clinic I were evaluated. The film material was preclassified into five clinical categories according to the patient's data. For each category characteristic geometries could be derived in non-dimensional form.