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European Heart Journal Oct 2023
Topics: Humans; Endocarditis; Endocarditis, Bacterial; Heart Valve Prosthesis; Prosthesis-Related Infections; Positron Emission Tomography Computed Tomography; Fluorodeoxyglucose F18; Radiopharmaceuticals
PubMed: 37622656
DOI: 10.1093/eurheartj/ehad193 -
Journal of the American College of... May 2023Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can... (Review)
Review
Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can be caused by 4 main phenomena: 1) thrombosis; 2) fibrotic pannus ingrowth; 3) degeneration; and 4) endocarditis. Mechanical valve thrombosis (MVT) is a known complication with clinical presentation ranging from incidental imaging finding to cardiogenic shock. Thus, a high index of suspicion and expedited evaluation are essential. Multimodality imaging, including echocardiography, cine-fluoroscopy, and computed tomography, is commonly used to diagnose MVT and follow treatment response. Although surgery is oftentimes required for obstructive MVT, other guideline-recommended therapies include parenteral anticoagulation and thrombolysis. Transcatheter manipulation of stuck mechanical valve leaflet is another treatment option for those with contraindications to thrombolytic therapy or prohibitive surgical risk or as a bridge to surgery. The optimal strategy depends on degree of valve obstruction and the patient's comorbidities and hemodynamic status on presentation.
Topics: Humans; Thrombosis; Bioprosthesis; Heart Valve Prosthesis; Anticoagulants; Heart Valves
PubMed: 37225366
DOI: 10.1016/j.jacc.2023.03.412 -
Journal of the American College of... Jan 2023Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR... (Review)
Review
Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR procedure (less invasive) and its expansion to younger and healthier patients, the incidence of IE after TAVR remains stable, with incidence rates similar to those reported after surgical aortic valve replacement. Although IE after TAVR is recognized as a subtype of prosthetic valve endocarditis, this condition represents a particularly challenging scenario given its unique clinical and microbiological profile, the high incidence of IE-related complications, the uncertain role of cardiac surgery, and the dismal prognosis in most patients with TAVR-IE. The number of TAVR procedures is expected to grow exponentially in the coming years, increasing the number of patients at risk of developing this life-threatening complication. Therefore, a detailed understanding of this disease and its complications will be essential to improve clinical outcomes.
Topics: Humans; Transcatheter Aortic Valve Replacement; Endocarditis, Bacterial; Heart Valve Prosthesis; Endocarditis; Aortic Valve; Aortic Valve Stenosis; Risk Factors; Treatment Outcome
PubMed: 36697140
DOI: 10.1016/j.jacc.2022.11.028 -
Journal of the American College of... Feb 2021
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Topics: Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Pregnancy; Pregnancy Complications, Cardiovascular
PubMed: 33342586
DOI: 10.1016/j.jacc.2020.11.018 -
Journal of the American College of... Mar 2022There has recently been renewed interest in the Ross procedure in adults. (Comparative Study)
Comparative Study
BACKGROUND
There has recently been renewed interest in the Ross procedure in adults.
OBJECTIVES
The goal of this study was to compare long-term outcomes after the Ross procedure vs biological and mechanical aortic valve replacement (AVR) in adults (aged 18-50 years) undergoing aortic valve surgery.
METHODS
Mandatory California and New York databases were queried between 1997 and 2014. Exclusion criteria included: ≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, and out-of-state residency. Propensity matching (1:1:1) was used, resulting in 434 patients per group. The primary endpoint was all-cause mortality. Secondary endpoints were stroke, major bleeding, reoperation, and endocarditis. Median follow-up was 12.5 years (IQR: 9.3-15.7 years).
RESULTS
At 15 years, actuarial survival after the Ross procedure was 93.1% (95% CI: 89.1%-95.7%), similar to that of the age-, sex-, and race-matched U.S. general population. It was significantly lower after biological AVR (HR: 0.42; 95% CI: 0.23-0.075; P = 0.003) and mechanical AVR (HR: 0.45; 95% CI: 0.26-0.79; P = 0.006). At 15 years, the Ross procedure was associated with a lower cumulative risk of reintervention (P = 0.008) and endocarditis (P = 0.01) than biological AVR. In contrast, at 15 years, the Ross procedure was associated with a higher cumulative incidence of reoperation (P < 0.001) but lower risks of stroke (P = 0.03) and major bleeding (P = 0.016) than mechanical AVR. Thirty-day mortality after valve-related complications was lowest after a reintervention.
CONCLUSIONS
In young adults, the Ross procedure is associated with better long-term survival and freedom from valve-related complications compared with prosthetic AVR. This confirms the notion that a living valve substitute in the aortic position translates into improved clinically relevant outcomes.
Topics: Adolescent; Adult; Aortic Valve Disease; Cardiac Surgical Procedures; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Propensity Score; Prosthesis Design; Retrospective Studies; Time Factors; Treatment Outcome; Young Adult
PubMed: 35210036
DOI: 10.1016/j.jacc.2021.11.057 -
Current Cardiology Reports Aug 2021Additional imaging modalities, such as FDG-PET/CT, have been included into the workup for patients with suspected infective endocarditis, according to major... (Review)
Review
PURPOSE OF REVIEW
Additional imaging modalities, such as FDG-PET/CT, have been included into the workup for patients with suspected infective endocarditis, according to major international guidelines published in 2015. The purpose of this review is to give an overview of FDG-PET/CT indications and standardized approaches in the setting of suspected infective endocarditis.
RECENT FINDINGS
There are two main indications for performing FDG-PET/CT in patients with suspected infective endocarditis: (i) detecting intracardiac infections and (ii) detection of (clinically silent) disseminated infectious disease. The diagnostic performance of FDG-PET/CT for intracardiac lesions depends on the presence of native valves, prosthetic valves, or implanted cardiac devices, with a sensitivity that is poor for native valve endocarditis and cardiac device-related lead infections, but much better for prosthetic valve endocarditis and cardiac device-related pocket infections. Specificity is high for all these indications. The detection of disseminated disease may also help establish the diagnosis and/or impact patient management. Based on current evidence, FDG-PET/CT should be considered for detection of disseminated disease in suspected endocarditis. Absence of intracardiac lesions on FDG-PET/CT cannot rule out native valve endocarditis, but positive findings strongly support the diagnosis. For prosthetic valve endocarditis, standard use of FDG-PET/CT is recommended because of its high sensitivity and specificity. For implanted cardiac devices, FDG-PET/CT is also recommended, but should be evaluated with careful attention to clinical context, because its sensitivity is high for pocket infections, but low for lead infections. In patients with prosthetic valves with or without additional aortic prosthesis, combination with CTA should be considered. Optimal timing of FDG-PET/CT is important, both during clinical workup and technically (i.e., post tracer injection). In addition, procedural standardization is key and encompasses patient preparation, scan acquisition, reconstruction, subsequent analysis, and clinical interpretation. The recommendations discussed here will hopefully contribute to improved standardization and enhanced performance of FDG-PET/CT in the clinical management of patients with suspected infective endocarditis.
Topics: Endocarditis; Endocarditis, Bacterial; Fluorodeoxyglucose F18; Heart Valve Prosthesis; Humans; Positron Emission Tomography Computed Tomography; Prosthesis-Related Infections; Radiopharmaceuticals; Reference Standards
PubMed: 34363148
DOI: 10.1007/s11886-021-01542-y -
Methodist DeBakey Cardiovascular Journal 2022Despite improvements and advancements in surgical technique, paravalvular leaks (PVL) continue to present a challenge when caring for patients with prosthetic valve...
Despite improvements and advancements in surgical technique, paravalvular leaks (PVL) continue to present a challenge when caring for patients with prosthetic valve disease. Paravalvular leaks result from dehiscence of the surgical ring from the mitral annulus. Some theories suggest that uneven distribution of collagen fibers in the mitral annulus leaves the posterior mitral annulus without a well-formed fibrous structure, which may predispose it to recurrent mechanical injury that leads to PVL. The reported incidence of PVL is 2.2%. Risk factors associated with PVL include the presence of mitral annular calcification, infective endocarditis, active steroid use, and continuous surgical suturing, which poses a greater risk than an interrupted surgical approach. Risk of PVL varies by prosthesis type, with mechanical prostheses carrying a higher risk of PVL than bioprosthetic valves. Below are images of a 70-year-old male with severe mitral stenosis and pulmonary hypertension who had previously undergone mitral valve commissurotomy and subsequent mitral valve replacement with a bioprosthetic mitral valve. He presented to the hospital with pulmonary edema. Initial transthoracic echocardiogram showed depressed biventricular function with a dehiscence of the bioprosthetic mitral valve and a large eccentric posterior PVL, severe tricuspid regurgitation, and severe pulmonary hypertension. Transesophageal images in illustrate a significant posterior PVL with dehiscence of the prosthetic valve from the mitral annulus. The patient underwent closure of the paravalvular leak with two 18-mm Amplatzer ventricular septal defect occluders (Abbott) with excellent results and trace residual mitral regurgitation post closure ( ).
Topics: Aged; Cardiac Catheterization; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Hypertension, Pulmonary; Male; Mitral Valve; Mitral Valve Insufficiency; Prosthesis Failure; Treatment Outcome
PubMed: 35432730
DOI: 10.14797/mdcvj.1096 -
JACC. Cardiovascular Imaging May 2022The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the... (Review)
Review
The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting.
Topics: Defibrillators, Implantable; Endocarditis; Fluorodeoxyglucose F18; Heart Valve Prosthesis; Humans; Positron Emission Tomography Computed Tomography; Predictive Value of Tests; Prosthesis-Related Infections; Radiopharmaceuticals
PubMed: 34922877
DOI: 10.1016/j.jcmg.2021.09.029 -
The American Journal of Cardiology Apr 2023Recent guidelines on valvular heart disease in Europe and the United States have expanded the indications for transcatheter aortic valve implantation (TAVI) to younger...
Recent guidelines on valvular heart disease in Europe and the United States have expanded the indications for transcatheter aortic valve implantation (TAVI) to younger patients and those at lower surgical risk with severe symptomatic aortic stenosis. Consequently, the number of TAVI procedures will significantly increase worldwide. Patients with longer life expectancies will outlive their transcatheter heart valves (THVs) and require established treatment strategies for re-intervention. Current data have shown encouraging outcomes, including low mortality, with redo-TAVI; in contrast, surgical explantation of THVs is associated with high mortality. Redo-TAVI, therefore, is likely to be the treatment of choice for THV failure. The expected increase in the number of redo-TAVIs stands in contrast to the current lack of evidence on how this procedure should be planned and performed, including the risks and pitfalls operators need to consider. Preliminary reports stress the importance of preprocedural planning, understanding of THV skirt and leaflet characteristics, and implantation guidelines specific to different THVs. Currently, SAPIEN 3/Ultra is the only THV approved in Europe and the United States for redo-TAVI. Therefore, we gathered a panel of experts in TAVI procedures with the aim of providing operative guidance on redo-TAVI, using the SAPIEN 3/Ultra THV. This consensus article presents a step-by-step approach encompassing clinical, anatomical, and technical aspects in preprocedural planning, procedural techniques, and postprocedural care. In conclusion, the recommendations aim to improve the feasibility, safety, and long-term outcomes of redo-TAVI, including the durability of implanted THVs.
Topics: Humans; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Consensus; Treatment Outcome; Heart Valve Prosthesis; Aortic Valve; Prosthesis Design
PubMed: 36710143
DOI: 10.1016/j.amjcard.2023.01.010 -
The Journal of Thoracic and... Aug 2021
Review
2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Topics: Consensus; Evidence-Based Medicine; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Heart Valves; Hemodynamics; Humans; Prosthesis Design; Recovery of Function; Risk Factors; Treatment Outcome
PubMed: 33972115
DOI: 10.1016/j.jtcvs.2021.04.002