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Proceedings (Baylor University. Medical... 2024Among patients with bicuspid aortic valves (BAV) who are potential candidates for valve-sparing root replacement (VSRR), the long-term durability of this technique is...
BACKGROUND
Among patients with bicuspid aortic valves (BAV) who are potential candidates for valve-sparing root replacement (VSRR), the long-term durability of this technique is not well understood. This study aimed to compare the clinical and echocardiographic outcomes of VSRR in those with BAV and tricuspid aortic valve (TAV) morphology.
METHODS
This was a retrospective analysis of patients who underwent VSRR between 2007 and 2021 at a single center. Kaplan-Meier and log-rank analysis were used to estimate and compare freedom from mortality, progression to >2+ aortic insufficiency (AI), and reoperation between groups (BAV vs TAV). Preoperative and postoperative echocardiographic data were collected and assessed for temporal changes in mixed-effect models.
RESULTS
A total of 185 patients (BAV, n = 52, 28.1%; TAV, n = 133, 71.9%) underwent VSRR. At baseline, BAV patients were younger (42.4 ± 11.6 vs 52.3 ± 12.6 years; < 0.01) and had more severe AI (47.9% vs 27.0%; = 0.02). Average cardiopulmonary bypass and cross-clamp times were similar. There were no differences in rates of postoperative complications, intensive care unit or hospital days, or 30-day readmission. TAV patients' 1-, 5-, and 8-year survival rates were 99.2% [95% CI 97.8-100], 96.7% [93.5-99.9%], and 92.2% [85.6-99.3%], respectively. Overall, there were no differences between groups regarding freedom from mortality ( = 0.18), reoperation ( = 0.51), or recurrent >2+ AI ( = 0.97). .
CONCLUSIONS
VSRR can be safely performed on patients with BAV and TAV morphology, yielding similar midterm freedom from mortality, recurrent >2+ AI, and reoperation. This technique should be considered in carefully selected patients with aortic root pathology and BAV anatomy when performed at experienced centers.
PubMed: 38910820
DOI: 10.1080/08998280.2024.2346445 -
Journal of Clinical Medicine Mar 2024. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to...
. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to analyze the severity of TR before and after TAVR with regard to short- and long-term survival and to analyze the influencing factors. . In our retrospective analysis, TR before and after TAVR was examined and patients were classified into groups accordingly. Special attention was paid to patients with post-interventional changes in TR. Mortality after TAVR was considered the primary endpoint of the analysis and major complications according to the Valve Academic Research Consortium 3 (VARC3) were compared. Moreover, biomarkers and risk factors for worsening or improvement of TR through TAVR were analyzed. . Among 775 patients who underwent TAVR in our center between January 2009 and December 2019, 686 patients (89%) featured low- and 89 patients (11%) high-grade TR. High-grade pre-TAVR TR was associated with worse short- (30-day), mid- (2-year) and long-term survival up to 8 years. Even though in nearly half of the patients with high-grade TR the regurgitation improved within seven days after TAVR (n = 42/89), this did not result in a survival benefit for this subgroup. On the other hand, a worsening of low-grade TR was seen in more than 10% of the patients (n = 73/686), which was also associated with a worse prognosis. Predictors of worsening of TR after TAVR were adipositas, impaired right ventricular function and the presence of mild TR. Age, atrial fibrillation, COPD, impaired renal function and elevated cardiac biomarkers were risk factors for mortality after TAVR independent from the grade of TR. . Not only pre-interventional, but also post-TAVR high-grade TR is associated with a worse prognosis after TAVR. TAVR can change concomitant tricuspid regurgitation, but improvement does not have any impact on short- and long-term survival. Worsening of TR after TAVR is possible and impairs the prognosis.
PubMed: 38592316
DOI: 10.3390/jcm13051474 -
Circulation Journal : Official Journal... Jul 2023
Topics: Humans; Aortic Valve; Takayasu Arteritis; Aortic Valve Insufficiency; Heart Valve Prosthesis Implantation; Thorax
PubMed: 37344405
DOI: 10.1253/circj.CJ-23-0256 -
Journal of Medical Case Reports Oct 2023Ventricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to...
INTRODUCTION
Ventricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.
CASE PRESENTATION
We present a case of 23-year-old White man with VSD, AR and ascending aortic aneurysm. The patient presented to outpatient clinic with weakness and gradual worsening shortness of breath for the past 5 years. Clinical examination revealed regular heart rhythm and loud continuous systolic-diastolic murmur (Lewin's grade 6/6), heard all over the precordium, associated with a palpable thrill. The ECG showed right axis deviation, fractionated QRS in V1 and signs of biventricular hypertrophy. The chest X-ray showed cardiomegaly. Transthoracic and transesophageal echocardiograms showed a perimembranous VSD with moderate restrictive shunt (Qp/Qs = 1.6), aortic regurgitation (AR), and ascending aortic aneurysm. Other clinical and laboratory findings were within normal limits.
CONCLUSIONS
Perimembranous VSD, may be associated with aortic regurgitation and ascending aortic aneurysm as secondary phenomenon if it is not early diagnosed and successfully treated.
Topics: Humans; Male; Young Adult; Aneurysm, Ascending Aorta; Aortic Valve Insufficiency; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Echocardiography
PubMed: 37880790
DOI: 10.1186/s13256-023-04167-7 -
Biomimetics (Basel, Switzerland) Oct 2023Heart failure is a global health concern with significant implications for healthcare systems. Left ventricular assist devices (LVADs) provide mechanical support for...
Heart failure is a global health concern with significant implications for healthcare systems. Left ventricular assist devices (LVADs) provide mechanical support for patients with severe heart failure. However, the placement of the LVAD outflow graft within the aorta has substantial implications for hemodynamics and can lead to aortic insufficiency during long-term support. This study employs computational fluid dynamics (CFD) simulations to investigate the impact of different LVAD outflow graft locations on aortic hemodynamics. The introduction of valve morphology within the aorta geometry allows for a more detailed analysis of hemodynamics at the aortic root. The results demonstrate that the formation of vortex rings and subsequent vortices during the high-velocity jet flow from the graft interacted with the aortic wall. Time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI) indicate that modification of the outflow graft location changes mechanical states within the aortic wall and aortic valve. Among the studied geometric factors, both the height and inclination angle of the LVAD outflow graft are important in controlling retrograde flow to the aortic root, while the azimuthal angle primarily determines the rotational direction of blood flow in the aortic arch. Thus, precise positioning of the LVAD outflow graft emerges as a critical factor in optimizing patient outcomes by improving the hemodynamic environment.
PubMed: 37887596
DOI: 10.3390/biomimetics8060465 -
Multimedia Manual of Cardiothoracic... Feb 2024Aortic valve repair has emerged as the treatment of choice for congenital aortic valvular disease, avoiding the need for a reoperation associated with stented prosthesis...
Aortic valve repair has emerged as the treatment of choice for congenital aortic valvular disease, avoiding the need for a reoperation associated with stented prosthesis overgrowth. The introduction of a leaflet implant represents a recent advancement in a field that originated early techniques, such as simple commissurotomies. In our experimental approach, we assessed two established leaflet-sizing techniques by analysing their resultant coaptation areas. Although both techniques produced competent valves, the large coaptation areas differed significantly from the native aortic valve. This observation prompted us to revisit the functional anatomy of the aortic valve, our goal being to refine leaflet design and implantation for enhanced efficacy and longevity in neo-leaflet procedures. We designed a novel aortic valvar neo-leaflet, utilizing porcine pericardium as our primary source material, and we implanted four tri-leaflet valves in four porcine hearts. All tri-leaflet valves were competent and closely resembled the coaptation area of the native aortic valve. This study serves as a pilot for further experimental aortic valve repair surgery using neo-leaflet implants.
Topics: Swine; Humans; Animals; Aortic Valve; Cardiac Surgical Procedures; Aortic Valve Insufficiency; Heart Valve Prosthesis; Aorta
PubMed: 38411164
DOI: 10.1510/mmcts.2024.004 -
ESC Heart Failure Dec 2023Conventional venoarterial extracorporeal membrane oxygenation (VA-ECMO) places a functional afterload burden on the left ventricle. In the setting of acute severe aortic...
Conventional venoarterial extracorporeal membrane oxygenation (VA-ECMO) places a functional afterload burden on the left ventricle. In the setting of acute severe aortic insufficiency-induced cardiogenic shock, the utility of VA-ECMO in combination with a failing valve may result in catastrophic haemodynamic consequences. This challenge is compounded when the culprit is a failing surgical bioprosthetic valve. We present a case of severe rapid-onset bioprosthetic aortic insufficiency-induced cardiogenic shock successfully resuscitated with left atrial VA-ECMO promptly followed by emergent percutaneous valve-in-valve transaortic valve replacement. We discuss the logistics, implications, and associated haemodynamic manifestations in utilizing this strategy for such disease processes.
Topics: Humans; Shock, Cardiogenic; Extracorporeal Membrane Oxygenation; Transcatheter Aortic Valve Replacement; Atrial Fibrillation; Aortic Valve Insufficiency
PubMed: 37890858
DOI: 10.1002/ehf2.14561 -
Journal of Cardiovascular Magnetic... Jul 2023When feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome...
BACKGROUND
When feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation.
METHODS
83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group).
RESULTS
72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; - 29 ± 21 ml/m vs - 37 ± 22 ml/m respectively, p = 0.584) and left atrial volumes (- 23 ± 30 ml/m and - 39 ± 26 ml/m respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR.
CONCLUSION
In primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.
Topics: Humans; Mitral Valve Insufficiency; Mitral Valve; Stroke Volume; Predictive Value of Tests; Ventricular Function, Right; Fibrosis
PubMed: 37496072
DOI: 10.1186/s12968-023-00946-9 -
Journal of the American Heart... Mar 2024Left atrial reservoir strain (LARS) is a novel imaging biomarker of left ventricular diastolic dysfunction. This study aimed to examine the prognostic implications of...
BACKGROUND
Left atrial reservoir strain (LARS) is a novel imaging biomarker of left ventricular diastolic dysfunction. This study aimed to examine the prognostic implications of LARS in patients with bicuspid aortic valve and significant (moderate-severe to severe) aortic regurgitation.
METHODS AND RESULTS
A total of 220 patients with bicuspid aortic valve and significant aortic regurgitation were prospectively enrolled in our study. LARS and left ventricular global longitudinal strain were derived from speckle-tracking echocardiography. The end point was a composite of all-cause mortality, heart failure hospitalization, and aortic valve repair or replacement. The threshold value of LARS <24% was used to identify impaired left atrial mechanics based on prior results. During a median follow-up of 364 (interquartile range, 294-752) days, 46 patients (20.9%) reached the composite end points. On multivariable Cox analysis, impaired LARS (adjusted hazard ratio, 2.08 [95% CI, 1.05-4.11]; =0.036) was a statistically significant predictor of composite end points after adjustment for other statistically significant predictors. Finally, adding impaired LARS to other statistically significant predictors (New York Heart Association functional class and left ventricular global longitudinal strain) significantly improved the global χ (from 32.19 to 36.56; =0.037) and reclassification (continuous net reclassification index=0.55; <0.001) of the prediction model.
CONCLUSIONS
In patients with bicuspid aortic valve and significant aortic regurgitation, the impairment of LARS is a strong independent prognostic predictor and confers incremental prognostic utility over clinical and other echocardiographic parameters. These findings suggest that LARS could be considered in risk stratification for such populations.
Topics: Humans; Prognosis; Aortic Valve Insufficiency; Bicuspid Aortic Valve Disease; Ventricular Dysfunction, Left; Heart Atria; Aortic Valve; Ventricular Function, Left; Aortic Valve Stenosis
PubMed: 38497457
DOI: 10.1161/JAHA.123.032770 -
The Lancet. Digital Health Aug 2023Chest radiography is a common and widely available examination. Although cardiovascular structures-such as cardiac shadows and vessels-are visible on chest radiographs,...
BACKGROUND
Chest radiography is a common and widely available examination. Although cardiovascular structures-such as cardiac shadows and vessels-are visible on chest radiographs, the ability of these radiographs to estimate cardiac function and valvular disease is poorly understood. Using datasets from multiple institutions, we aimed to develop and validate a deep-learning model to simultaneously detect valvular disease and cardiac functions from chest radiographs.
METHODS
In this model development and validation study, we trained, validated, and externally tested a deep learning-based model to classify left ventricular ejection fraction, tricuspid regurgitant velocity, mitral regurgitation, aortic stenosis, aortic regurgitation, mitral stenosis, tricuspid regurgitation, pulmonary regurgitation, and inferior vena cava dilation from chest radiographs. The chest radiographs and associated echocardiograms were collected from four institutions between April 1, 2013, and Dec 31, 2021: we used data from three sites (Osaka Metropolitan University Hospital, Osaka, Japan; Habikino Medical Center, Habikino, Japan; and Morimoto Hospital, Osaka, Japan) for training, validation, and internal testing, and data from one site (Kashiwara Municipal Hospital, Kashiwara, Japan) for external testing. We evaluated the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy.
FINDINGS
We included 22 551 radiographs associated with 22 551 echocardiograms obtained from 16 946 patients. The external test dataset featured 3311 radiographs from 2617 patients with a mean age of 72 years [SD 15], of whom 49·8% were male and 50·2% were female. The AUCs, accuracy, sensitivity, and specificity for this dataset were 0·92 (95% CI 0·90-0·95), 86% (85-87), 82% (75-87), and 86% (85-88) for classifying the left ventricular ejection fraction at a 40% cutoff, 0·85 (0·83-0·87), 75% (73-76), 83% (80-87), and 73% (71-75) for classifying the tricuspid regurgitant velocity at a 2·8 m/s cutoff, 0·89 (0·86-0·92), 85% (84-86), 82% (76-87), and 85% (84-86) for classifying mitral regurgitation at the none-mild versus moderate-severe cutoff, 0·83 (0·78-0·88), 73% (71-74), 79% (69-87), and 72% (71-74) for classifying aortic stenosis, 0·83 (0·79-0·87), 68% (67-70), 88% (81-92), and 67% (66-69) for classifying aortic regurgitation, 0·86 (0·67-1·00), 90% (89-91), 83% (36-100), and 90% (89-91) for classifying mitral stenosis, 0·92 (0·89-0·94), 83% (82-85), 87% (83-91), and 83% (82-84) for classifying tricuspid regurgitation, 0·86 (0·82-0·90), 69% (68-71), 91% (84-95), and 68% (67-70) for classifying pulmonary regurgitation, and 0·85 (0·81-0·89), 86% (85-88), 73% (65-81), and 87% (86-88) for classifying inferior vena cava dilation.
INTERPRETATION
The deep learning-based model can accurately classify cardiac functions and valvular heart diseases using information from digital chest radiographs. This model can classify values typically obtained from echocardiography in a fraction of the time, with low system requirements and the potential to be continuously available in areas where echocardiography specialists are scarce or absent.
FUNDING
None.
Topics: Humans; Male; Female; Aged; Retrospective Studies; Artificial Intelligence; Stroke Volume; Ventricular Function, Left; Heart Valve Diseases; Mitral Valve Insufficiency; Radiography
PubMed: 37422342
DOI: 10.1016/S2589-7500(23)00107-3