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Frontiers in Cardiovascular Medicine 2024Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is... (Review)
Review
Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.
PubMed: 38665234
DOI: 10.3389/fcvm.2024.1381102 -
Annals of Cardiothoracic Surgery Jul 2023Debate still persists on whether valve-sparing root reimplantation (VSRR) of a very asymmetric bicuspid aortic valve (BAV) should be completed such that the asymmetry of...
BACKGROUND
Debate still persists on whether valve-sparing root reimplantation (VSRR) of a very asymmetric bicuspid aortic valve (BAV) should be completed such that the asymmetry of the native commissural orientation is retained, or if it should be made symmetric (180°-180°). Herein, we present our approach, in which the native asymmetry is preserved, and the valve is reimplanted in a 210°-150° orientation.
METHODS
A retrospective review was performed of 130 patients with BAV who underwent VSRR between January 1, 2004 and March 1, 2023 at a single institution. Of this total, 37 were reimplanted asymmetrically (210°-150°). The primary outcome was > moderate aortic insufficiency (AI). Secondary outcomes included severe aortic stenosis (AS), reintervention, and survival.
RESULTS
The included 37 patients were mostly male [94.6% (35/37)] with mean age of 46.3 years, and with low rates of comorbidities. At least moderate AI was present in 40.5% (15/37) prior to surgery. All BAV in this series were Sievers Type 1 with a mean commissural angle of 128.2°. Leaflet repair was required in 81.1% (30/37), most commonly involving central plication of the conjoined cusp [96.7% (29/30)] and raphe release [73.3% (22/30)]. There was no 30-day mortality or stroke. At 10 years, the cumulative incidences of > moderate AI, severe AS, and reintervention were 7.6% (0-17.2%), 7.1% (0-19.7%), and 5.3% (0.3-22%), respectively. There was no mortality for the entire duration of the study period.
CONCLUSIONS
This series demonstrates excellent 10-year outcomes of maintaining commissural orientation in asymmetric BAV reimplantation procedures. However, further study with additional patients, longer follow-up, and direct comparison to symmetric reimplantation for similar BAV morphology is required.
PubMed: 37554706
DOI: 10.21037/acs-2023-avs2-18 -
Circulation. Cardiovascular... May 2024Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying...
BACKGROUND
Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying Counter-Pulsation (TABERNACL), a simple, on-table temporary valve using commercially available equipment to temporize acute severe aortic regurgitation.
METHODS
We hypothesize that an appropriately sized commercial balloon dilatation catheter-straddling the aortic annulus and connected to a counterpulsation console-can serve as a temporizing valve to restore hemodynamic stability in acute aortic regurgitation. We performed benchtop testing of valvuloplasty, angioplasty, and sizing balloons as counterpulsation balloons. TABERNACL was assessed in vivo in a porcine model of acute aortic regurgitation (n=8). We also tested a static undersized, continuously inflated transvalvular balloon as a spacer intended physically to obstruct the regurgitant orifice.
RESULTS
Benchtop testing identified that Tyshak II and PTS sizing (NuMed Braun) balloon catheters performed adequately as temporary valves (ie, complete inflation and deflation with each cycle) and resisted fatigue, in contrast to others. When TABERNACL was used in the acute severe regurgitation animals, there was immediate hemodynamic improvement, with a significant 35% increase in diastolic aortic pressure by 16 mm Hg ([95% CI, 7-25] =0.0056), 34% reduction in left ventricular end-diastolic pressure by -7 mm Hg ([95% CI, -10 to -5] =0.0006), improvement in the aortic diastolic index by 0.28 ([95% CI, 0.18-0.39] =0.0009), and reversal of electrocardiographic myocardial ischemia. As an alternative, static balloon inflation across the aortic valve stabilized regurgitation hemodynamics at the expense of a new aortic gradient and caused excessive ectopy from balloon movement in the left ventricular outflow tract.
CONCLUSIONS
TABERNACL improves hemodynamics and reduces coronary ischemia by electrocardiography in animals with acute severe aortic regurgitation. TABERNACL valves obstruct the diastolic regurgitant orifice without systolic obstruction. This may prove a lifesaving bridge to definitive valve replacement therapy.
Topics: Animals; Hemodynamics; Aortic Valve Insufficiency; Disease Models, Animal; Balloon Valvuloplasty; Sus scrofa; Aortic Valve; Equipment Design; Recovery of Function; Acute Disease; Cardiac Catheters; Time Factors; Severity of Illness Index; Ventricular Function, Left
PubMed: 38533653
DOI: 10.1161/CIRCINTERVENTIONS.123.013898 -
Journal of Cardiothoracic Surgery Jul 2023Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this procedure might differ in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV).
DESIGN
Meta-analysis with meta-regression and systematic review.
SETTING
Systematic search in the following databases: PubMed, Cochrane Central Register of Controlled Trials, and Embase.
INTERVENTIONS
All observational studies of VSARR in patients with BAV or TAV were included in our study. Studies were included without any restrictions on language or publication date. A trial sequential analysis and a post-hoc meta-regression was performed on the main outcomes.
RESULT
Eleven articles met the inclusion criteria. A total of 1138 patients in BAV group, and 2125 patients in TAV group. No significant differences in gender and age were observed between BAV and TAV patients. BAV and TAV patients showed no differences in in-hospital mortality rate [0.00% vs. 1.93%; RR (95% CI) 0.33 (0.09, 1.26), I = 0%, P = 0.11] and the rate of in-hospital reoperation [5.64% vs. 5.99%; RR (95% CI) 1.01(0.59, 1.73), I = 33%, P = 0.98]. The overall long-term mortality rate of BAV patients was better than that of TAV patients [1.63% vs. 8.15%; RR (95% CI) 0.34 (0.13, 0.86), I = 0%, P = 0.02]. During the follow-up observation period, patients in TAV group showed small but no statistic advantage in 3-year, 5-year, and over 10-year incidences of reintervention. Regarding the secondary endpoints, the two groups showed similar aortic cross-clamping time and total cardiopulmonary bypass time.
CONCLUSION
The VSARR techniques yielded similar clinical outcomes in both BAV and TAV patients. Although patients with BAV might have a higher incidence of reinterventions after initial VSARR, it is still a safe and effective approach to treat aortic root dilation with or without aortic valve insufficiency. TAV patients showed small but no statistic advantage in long-term (over 10 years) reintervention rate, which means, patients with BAV may face a higher risk of reintervention in the clinic.
Topics: Humans; Aortic Valve; Bicuspid Aortic Valve Disease; Heart Valve Diseases; Aorta; Tricuspid Valve; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Retrospective Studies; Treatment Outcome; Observational Studies as Topic
PubMed: 37400892
DOI: 10.1186/s13019-023-02329-8 -
Multimedia Manual of Cardiothoracic... Nov 2023The Ross-Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in...
The Ross-Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.
Topics: Humans; Autografts; Aorta, Thoracic; Transplantation, Autologous; Aortic Valve; Aorta; Aortic Valve Stenosis; Aortic Valve Insufficiency; Pulmonary Valve; Heart Valve Prosthesis Implantation; Reoperation
PubMed: 37942704
DOI: 10.1510/mmcts.2023.077 -
Alternative Therapies in Health and... Sep 2023This assessed the value of real-time three-dimensional echocardiography in patients with aortic valve lesions before and after transcatheter aortic valve implantation.
OBJECTIVE
This assessed the value of real-time three-dimensional echocardiography in patients with aortic valve lesions before and after transcatheter aortic valve implantation.
METHODS
A total of 61 patients were admitted for transcatheter aortic valve implantation due to aortic valve lesions between October 2021 and August 2022 (research group), and 55 patients who underwent a healthy physical examination during the same period (control group) were included. All participants underwent real-time three-dimensional echocardiography. Changes in left ventricular end-diastolic volume index, left ventricular end-systolic volume index, left ventricular ejection fraction, maximum velocity, and left ventricular mass index were observed at 1 week and 1 month after the surgery. Additionally, the research group was further divided based on the type of lesion to investigate the differences in real-time three-dimensional echocardiography findings between patients with moderate to severe aortic stenosis and moderate to severe aortic insufficiency. The occurrence of postoperative complications in the research group was also recorded to assess the role of real-time three-dimensional echocardiography in postoperative complication assessment after transcatheter aortic valve implantation.
RESULTS
Preoperative left ventricular ejection fraction did not differ significantly between the two groups (P > .05). However, the research group exhibited higher preoperative left ventricular end-diastolic volume index, left ventricular end-systolic volume index, left ventricular mass index, and maximum velocity compared to the control group (P < .05). At 1 week postoperatively, the research group showed significant reductions in left ventricular end-diastolic volume index, left ventricular end-systolic volume index, left ventricular mass index, and maximum velocity compared to preoperative values (P < .05). Furthermore, at 1 month postoperatively, the left ventricular mass index was further reduced (P < .05). Among the research group, patients with aortic stenosis had lower preoperative left ventricular end-diastolic volume index and left ventricular end-systolic volume index compared to patients with aortic insufficiency, while maximum velocity was higher (P < .05). Patients who experienced postoperative complications after transcatheter aortic valve implantation had lower left ventricular end-diastolic volume index, left ventricular end-systolic volume index and left ventricular mass index, and higher maximum velocity before and at 1 week after surgery (P < .05).
CONCLUSIONS
Real-time three-dimensional echocardiography demonstrated excellent assessment capabilities for aortic valve lesions and accurately guided the determination of left ventricular mass index, showcasing its significant clinical applications.
Topics: Humans; Transcatheter Aortic Valve Replacement; Stroke Volume; Ventricular Function, Left; Echocardiography, Three-Dimensional; Aortic Valve Stenosis; Postoperative Complications
PubMed: 37318894
DOI: No ID Found -
BMC Cardiovascular Disorders Jun 2023Evidence about safety and efficacy of transcatheter aortic valve replacement (TAVR) with the Venus A-Valve system (Venus Medtech, Hangzhou, China) remains limited for...
BACKGROUND
Evidence about safety and efficacy of transcatheter aortic valve replacement (TAVR) with the Venus A-Valve system (Venus Medtech, Hangzhou, China) remains limited for patients with pure native aortic regurgitation (PNAR).
OBJECTIVES
The single-center study sought to report the one-year clinical outcomes of the Venus A-Valve in the treatment of PNAR.
METHODS
This study was a retrospective analysis of prospectively collected data. Data was from all consecutive patients who had PNAR and underwent TAVR with the Venus A-Valve system at our center from July 2020 and June 2021. Procedural and clinical outcomes up to one year were analyzed using Valve Academic Research Consortium-2 criteria.
RESULTS
A total of 45 consecutive patients with PNAR underwent transfemoral TAVR with the Venus A-Valve system. The Mean age was 73.5 ± 5.5 years and 26.7% were female. All the TAVR procedures were performed via transfemoral access. Implantations were successful in 44 cases (97.8%). Only one patient was converted to surgical aortic valve replacement. No patient died intraoperatively. No second valve was implanted. In-hospital mortality rate was 2.3%. The one-year all-cause mortality rate was 4.7% without cardiovascular related death. No patient had moderate or severe paravalvular leakage during follow-up. At one year, the mean pressure gradient was 8.8 ± 0.9 mmHg, and left ventricular ejection fraction increased to 61.5 ± 3.6%.
CONCLUSIONS
This single-center study demonstrated the safety and efficacy of transfemoral TAVR with the Venus A-Valve in the treatment of patients with PNAR.
Topics: Humans; Female; Aged; Male; Aortic Valve Insufficiency; Transcatheter Aortic Valve Replacement; Retrospective Studies; Stroke Volume; Ventricular Function, Left
PubMed: 37386379
DOI: 10.1186/s12872-023-03329-1 -
Circulation. Cardiovascular Imaging Apr 2024
Topics: Humans; Echocardiography; Echocardiography, Doppler; Echocardiography, Transesophageal; Mitral Valve Insufficiency; Mitral Valve Stenosis
PubMed: 38516797
DOI: 10.1161/CIRCIMAGING.124.016517 -
Multimedia Manual of Cardiothoracic... Aug 2023Valve-sparing root reimplantation has become an attractive alternative to conventional aortic root replacement in young patients as a means to avoid the anticoagulation...
Valve-sparing root reimplantation has become an attractive alternative to conventional aortic root replacement in young patients as a means to avoid the anticoagulation required for mechanical roots while improving the durability compared to bioprosthetic valved conduits. In this video tutorial, we present our step-by-step process for performing a valve-sparing root reimplantation with a Valsalva graft for a patient with an aortic root aneurysm and a trileaflet aortic valve.
Topics: Humans; Aortic Valve; Treatment Outcome; Aortic Valve Insufficiency; Aorta; Replantation
PubMed: 37584335
DOI: 10.1510/mmcts.2023.052 -
European Journal of Cardio-thoracic... Nov 2023Aortic valve repair procedures are technically challenging, and current intraoperative evaluation methods often fail to predict the final echocardiographic result. We...
OBJECTIVES
Aortic valve repair procedures are technically challenging, and current intraoperative evaluation methods often fail to predict the final echocardiographic result. We have developed a novel intraoperative aortic valve visualization and pressurization (AVP) device, enabling valve inspection under physiological conditions, and measuring aortic valve insufficiency (AI) during cardioplegic arrest.
METHODS
The AVP device is attached to the (neo)aorta, after any type of aortic valve repair, while the heart is arrested. The root is pressurized (60-80 mmHg) using a saline solution and an endoscope is introduced. The valve is inspected, and the amount of valvular leakage is measured. Postoperative 'gold standard' transesophageal echocardiogram measurements of AI are performed and compared against regurgitation volume measured.
RESULTS
In 24 patients undergoing valve-sparing root replacement, the AVP device was used. In 22 patients, postoperative echocardiographic AI was ≤ grade 1. The median leakage was 90 ml/min, IQR 60-120 ml/min. In 3 patients, additional adjustments after visual inspection was performed. In 2 patients, with complex anatomy, the valve was replaced. In one, after evaluation with the device, there was undesirable result visually and residual AI of 330 ml/min, and in another, 260 ml/min residual AI was measured and valve restriction on visual inspection.
CONCLUSIONS
The novel AVP device enables intraoperative evaluation of the valve under physiological conditions, while still on arrested heart, and allows for targeted adjustments. The AVP device can be an important aid for intraoperative evaluation of the aortic valve, during valve repair and valve-sparing procedures, thereby making the operative result more predictable and the operation more efficient.
Topics: Humans; Aortic Valve; Cardiac Surgical Procedures; Aortic Valve Insufficiency; Aorta; Echocardiography; Treatment Outcome
PubMed: 37610333
DOI: 10.1093/ejcts/ezad291