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Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high‐risk surgical cohorts but also in low‐risk and intermediate‐risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the accuracy of predicted prosthesis‐patient mismatch (PPM) regarding actual PPM measured postoperatively. To assess the association between PPM and prosthetic valve dysfunction. Methods: Retrospective cohort study including adult patients after aortic valve replacement surgery with a biological prosthesis. Predicted PPM status was determined using mean reference effective orifice area indexed to total body surface (iEOA), without considering reference standard deviations. Postoperative PPM status was determined by measuring iEOA within the first 60 postoperative days. Prosthetic valve dysfunction was defined as thrombosis, pannus, valve degeneration, and/or disruption. Results: 205 patients were enrolled between January 2003 and June 2017: predicted PPM was absent in 52 patients (25.4%), moderate in 137 patients (66.8%), and severe in 16 patients (7.8%). After surgery, the actual postoperative iEOA was measured: 53 (25.9%) did not have PPM, 73 had moderate PPM (35.6%), and 79 had severe PPM (38.5%). Predicted PPM identified the presence of hemodynamically significant actual postoperative PPM (OR = 2.56; 95%CI 1.30–5.05; P =.006), though not its degree of severity. Prosthetic valve dysfunction was more frequent among patients with hemodynamically significant PPM (53.9% vs. 11.3%; P <.001), compared to those without PPM. The association between PPM and prosthetic valve dysfunction was maintained after adjusting for gender, age, and ever‐smoking (OR = 9.03; P <.001). The incidence of thrombosis or pannus was also nonsignificantly higher in patients with moderate or severe PPM. Conclusions: Predicted PPM identifies the presence, possibly not the severity, of actual postoperative PPM. Moderate or severe PPM is associated with prosthetic valve dysfunction. Actual postoperative prosthesis‐patient mismatch measured within 60 postoperative days showed a distinctive hemodynamic profile and presented a stronger association with prosthetic valve dysfunction than predicted prosthesis‐patient mismatch. A. Echocardiographic follow‐up in patients according to the actual postoperative PPM measured within 60 postoperative days. B. Prediction of prosthetic valve dysfunction based on preoperative predicted PPM or on actual postoperative PPM within 60 postoperative days. PPM: prosthesis‐patient mismatch. OR: Odds ratio. [ABSTRACT FROM AUTHOR]

Background: We investigated hospital and midterm outcome of patients operated for an aortic valve replacement (AVR) with a pericardial Perimount or a Porcine Hancock-II valve.Methods: We analyzed 353 patients with Perimount Magna (n = 189) or Hancock-II valves (n = 164). Echocardiographic data, hospital outcome, and follow-up were collected and compared. The role of the type of valve on perioperative and midterm outcome was investigated.Results: Mean age was 75.3 ± 6.8 and 74.3 ± 7.1 years (P = .17) for Perimount and Hancock-II group, respectively. Fifty-four Perimount (28.6%) and 24 patients with Hancock-II (14.6%) required urgent procedures (P = .002), including six type-A dissections and five endocarditis. EuroSCORE-II was 3.1 ± 2.7% (Perimount) and 2.7 ± 2.2% (Hancock-II). Combined procedures were performed in 115 Perimount (60.8%) and 71 patients with Hancock (43.3%); redo procedures counted for 1% and 2.4%, respectively (P = .42). Mean valve size was 23.2 ± 1.8 mm for pericardial and 23.6 ± 1.9 mm for porcine valves (P = .08). Hospital mortality (6.3% vs 2.4%; P = .05), kidney failure (11.6% vs 9.8%; P = .73), and new pacemaker implantation rates (6.3% vs 3.0%; P = .21) were higher in the Perimount group reflecting the fact that more urgent, combined, and critical procedures were implanted with a Perimount Magna. Overall, 51 patients died over 60 months (34 Perimount, 17 Hancock), corresponding to a mortality of 5.3 per 100-persons year (95% confidence interval [CI]: 3.8-7.4) and 3.0 (95% CI: 1.8-4.8), respectively. Survival at 5 years was 76% (95% CI: 68-82) and 83% (95% CI: 74-89) in the Perimount and Hancock groups (log-rank test; P = .099).Conclusions: We confirm a good clinical outcome of patients with AVR with modern pericardial or a porcine bioprosthesis. Despite better hemodynamic, the Perimount does not improve the midterm clinical outcome compared with the porcine valve. [ABSTRACT FROM AUTHOR]

We describe a case of a mass‐like echocardiographic density on a mechanical prosthetic aortic valve. We initially suspected a thrombus vs vegetation on transthoracic echocardiography, but after transesophageal echocardiography, the density was subsequently determined to be cavitation by reviewing the initial images in slow motion. [ABSTRACT FROM AUTHOR]

Aortic prosthetic valve endocarditis is often a challenging disease process that carries high morbidity and mortality. Echocardiography is widely used to identify infected valves and associated complications. One major complication of an infection involving the aortic annulus is dehiscence of the prosthetic valve from the aortic root and is usually associated with paravalvular regurgitation. Here, we present a rare case of complete prosthetic valve dehiscence without paravalvular regurgitation on transthoracic and transesophageal echocardiography. [ABSTRACT FROM AUTHOR]

Background: Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi‐detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high‐risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three‐dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT? Methods: A systematic literature search and meta‐analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included. Results: Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland–Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being −2.22 mm2 with 95% limits of agreement −12.79 to 8.36. Conclusion: Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure. [ABSTRACT FROM AUTHOR]

Background: Aortic prosthesis area (EOA) is computed by continuity equation from left ventricular (LV) stroke volume (SV) derived from LV outflow tract diameter (LVOTD) or, when unmeasurable, from LV volumes (SVV). There is evidence to suggest LVOT ellipticity and recommend 3D LVOT area (LVOTCSA) adoption in aortic stenosis. We sought to evaluate if the same concept applies to supra‐annular aortic prosthesis comparing SV and EOA derived from LVOTD (EOAD) and from LVOTCSA (EOACSA). EOA computed from SVV (EAOV) accuracy was evaluated in this setting. Patient‐prosthesis mismatch (PPM) was compared among different EOA computations. Methods: A consecutive series of 202 patients (aged 81 ± 4 years, 43% males) underwent St.Jude Trifecta aortic valve replacement (AVR) and were followed up with echocardiography at one‐year (335 ± 31 days). All measurements followed the EACVI or ASE guidelines, 3D X‐plane modality was used to compute SVv and measure LVOTCSA; SV was calculated from LVOTD (SVD) and LVOTCSA (SVCSA). PPM was indexed EOA <0.65 cm²/m². Results: LVOT showed a significant ellipticity index (1.17 ± .27), independent of prosthesis size. EOAD (1.70 ± 0.55 cm²) was less than EOACSA (1.95 ± 0.62 cm²) (P < .0001). SVV was significantly lower than SVD and SVCSA. Bland–Altman analysis showed a significant correlation between SVV and SVD or SVCSA although with large bias and imprecision. The correlations improved reducing bias and imprecision when LVOT time–velocity integral was <20 cm. PPM incidence was higher in EOAV (15.6%) compared to EOAD(P = .04) or EOACSA(P < .001). Conclusions: In supra‐annular AVR, LVOT retains its elliptical shape and LVOTCSA yielded larger prosthesis EOA with lower PPM incidence. PPM may be overestimated by EOAV. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the hemodynamic performance of a sutureless bioprosthesis under high workload at mid‐term follow‐up. Methods: Thirty‐two patients who underwent isolated aortic valve replacement with a Perceval sutureless bioprosthesis with a minimum follow‐up of 1 year were enrolled in this study. S size prosthesis was deployed in 10 patients (31.3%), M size in 9 (28.1%), L size in 8 (25%) and XL size in 5 (15.6%). Effective orifice area (EOA), EOA index (EOAi), and transvalvular gradients were assessed at rest and during dobutamine stress echocardiography (DSE) a median of 19.5 months after surgery. Results: Dobutamine stress echocardiography (DSE) significantly increased heart rate, stroke volume, ejection fraction, and transvalvular gradients (peak gradient, 24.0 ± 7.6 vs 38.7 ± 13.6 mm Hg, P < .001; mean gradient, 12.6 ± 4.2 vs 19.8 ± 8.3, P < .001). When compared to baseline, estimated valve areas significantly increased at follow‐up (EOA, 1.48 ± 0.46 vs 2.06 ± 0.67, P < .001; EOAi, 0.84 ± 0.26 vs 1.17 ± 0.37, P < .001). Mean percentage increase in EOAi was 40.3% ± 28.0%. S size prostheses had the highest increase in EOA1, but the difference was not significant (S 46.0% ± 27.5% vs M 45.4% ± 34.5% vs L 32.7% ± 26.4% vs XL 32.1% ± 20.5%, P = .66). Severe patient‐prosthesis mismatch (EOAi ≤ 0.65 cm2/m2) was present at rest in 8 patients (25%), but only in one patient (3.1%) during DSE. Conclusions: The Perceval sutureless bioprosthesis demonstrated good hemodynamics at rest and under high workload. The significant increase in EOAi during DSE suggests the potential advantages of Perceval sutureless bioprostheses in case of small aortic annulus or when patient‐prosthesis mismatch is anticipated. [ABSTRACT FROM AUTHOR]

Early infectious endocarditis (IE) occurs in 3% of prosthesis in the first 12 months. Early IE is more aggressive than late prosthetic valve endocarditis. Mortality remains high, despite combined medical and surgical treatment. We present a case of early IE in aortic prosthetic valve complicated with paravalvular abscess, pseudoaneurysm and aorto‐ right atrial fistula. [ABSTRACT FROM AUTHOR]

The development of an aorto‐right ventricular fistula is a rare complication of cardiac surgery. The most common treatment is surgical closure of the fistula, but percutaneous closure of the fistula has become an attractive alternative option. We present a case of successful utilization of live/real time three/four‐dimensional transoesophageal echocardiography (3/4DTEE) to select the correct device size for percutaneous closure of an adult patient presenting with an aorto‐right ventricular (AO‐RV) fistula following aortic valve replacement. To the best of our knowledge, this is the first case in which 3/4DTEE was used to select the device size and guide percutaneous closure of an iatrogenic AO‐RV fistula. [ABSTRACT FROM AUTHOR]

Objective: This study aims to assess changes in mitral regurgitation ( MR) severity after transcatheter aortic valve implantation ( TAVI). Background: Existing data on MR after TAVI are contradictory. Methods: Thirty-five patients with MR graded ≥ 2+ were followed after undergoing TAVI with either the Edwards Sapien or CoreValve device. Echocardiography was performed the week before and 3 months after the procedure. MR was graded on a scale of 0 to 4+, classified as organic or functional, and the effective regurgitant orifice area ( EROA) and MR index were calculated. Results: At baseline, MR was graded 4+ in 4 (11.4%) patients, 3+ in 10 (28.6%), and 2+ in 21 (60%). At follow-up, MR was graded at 3+ in 4 (11.4%) patients, 2+ in 8 (22.9%), and 1+ in 19 (54.3%); 4 (11.4%) exhibited no MR. EROA (24.4 ± 11.5 mm2 pre- TAVI vs. 11.2 ± 10.3 mm2 post- TAVI, P < 0.001) and MR index (1.9 ± 0.3 pre- TAVI vs. 1.3 ± 0.7 post- TAVI, P < 0.001) were reduced with TAVI, independent of the etiology. MR decreased by at least 1 grade in 28 (80%) patients, with a reduction ≥2 grades in 10 (28.6%) patients; no patient showed a worsened condition. Subgroup analyses showed that the reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the Core Valve device. Conclusions: This multiparametric echocardiographic evaluation showed that MR improved significantly after TAVI and that this result may be related to the type of valve implanted. [ABSTRACT FROM AUTHOR]

A 37‐year‐old man with prosthetic aortic valve and composite aortic graft was admitted to our emergency department with syncope and dyspnea. A transesophageal echocardiography revealed a vegetative mass on the aortic mechanic valve and a flow that originates from the left ventricle into the periaortic echogenic free space. There were a partial dehiscence of the mechanical valve conduit from the base of the heart and a periaortic root abscess/hematoma. Real time three‐dimensional TEE revealed complete disarticulation of the aortic graft that was totally collapsing during systole. We herein report a case who presented with syncope secondary to entire aortic graft collapse and periaortic annular abscess. [ABSTRACT FROM AUTHOR]

A 38-year-old male presented with heart failure symptoms and was diagnosed with aortic valve endocarditis and underlying aortic stenosis in the absence of concentric hypertrophy or bicuspid aortic valve and underwent aortic valve replacement but continued to have symptoms which were then attributed to hypertrophic cardiomyopathy with dynamic left ventricular outflow tract obstruction. He was determined to be unsuitable for myomectomy and underwent successful alcohol septal ablation using transthoracic echocardiographic Doppler and continuous wave velocity monitoring without requiring to cross the aortic valve or to perform transatrial septostomy and left ventricular pressure monitoring. When crossing the aortic valve is a relative or absolute contraindication like in our index case, continuous Doppler velocity recording is a safe and effective alternative approach to monitor the outflow gradient while performing alcohol septal ablation. [ABSTRACT FROM AUTHOR]

Background: Echocardiographic imaging of a stented valve bioprosthesis can reveal apparent inward deflection of one or more struts. It could be assumed that this finding is related to actual strut distortion as opposed to an artifact of off-axis imaging. Objective: To determine whether normal (nondistorted) bioprosthetic struts can appear by artifact to be bent inward on two-dimensional echocardiographic imaging. Methods: A production-quality porcine bioprosthetic aortic valve was imaged in vitro using standard two-dimensional echocardiographic techniques. Apparent strut distortion on echocardiographic imaging was investigated relative to prosthesis orientation to the transducer. Results: The appearance of inward strut distortion was produced when two of three struts were simultaneously imaged, including imaging in an off-axis long axis orientation and from above or below the prosthesis. Conclusion: Apparent inward distortion of bioprosthetic struts can be simulated in vitro using a normal, nondistorted valve, and is common if two struts are simultaneously imaged. A finding of inward distortion of strut tips on in vivo imaging should be used with caution, since the finding may not be representative of actual strut anatomy. [ABSTRACT FROM AUTHOR]

Percutaneous aortic valve replacement (PAVR) is an emerging therapy for nonsurgical patients with severe aortic stenosis (AS). We examined the role of transesophageal echocardiography (TEE) in PAVR. TEE was used initially to assess the native valve and aortic root, and served as a guide during PAVR. Following prosthetic valve deployment, TEE was used to assess valve function. Eleven patients aged 82 ± 10 years with NYHA III–IV underwent PAVR. Periprocedural TEE gave immediate information on prosthetic position and function, LV function, mitral regurgitation, pericardium, and thoracic aorta anatomy. There was excellent visual agreement between fluoroscopic and TEE images of prosthetic positioning and deployment. TEE facilitated the detection and management of procedure-related complications. Compared with pre-PAVR, AV area (0.56 ± 0.19 cm2 vs. 1.3 ± 0.4 cm2; P < 0.001) and LVEF (49 ± 17% vs. 56 ± 11%; P < 0.001) increased. TEE provides key anatomical and functional information, and serves as a diagnostic guide for complications, which may arise during PAVR. [ABSTRACT FROM AUTHOR]

Stress echocardiography is a safe and valuable test to aid in the diagnosis and management of patients with aortic valve disorders. In patients with suspected severe aortic stenosis (AS) and low aortic gradients secondary to low cardiac output, dobutamine echocardiography distinguishes those patients with contractile reserve (CR) from those without it. By increasing the stroke volume in subjects with CR, true severe AS patients have an increase in transaortic gradients without a significant change in the valve area, whereas patients with pseudostenosis have an increase in the gradients with concomitant increase in the aortic valve area to >1 cm2. Patients without CR are indeterminate in their AS status and have a poor prognosis. The presence of CR is also important in patients suffering from aortic insufficiency, as it may predict the development of symptoms, myocardial dysfunction, or death in the asymptomatic phase of the disease, and the potential for left ventricular functional recovery after valve replacement. Finally, both exercise and dobutamine echocardiography can help in the assessment of valve malfunction or mismatch in patients with aortic valve prostheses experiencing exercise intolerance by correlating the symptoms with the change in the aortic gradients induced during stress testing. (ECHOCARDIOGRAPHY, Volume 21, July 2004) [ABSTRACT FROM AUTHOR]

Aortic valve bypass (AVB)—a conduit from the apex of the left ventricle to the descending aorta containing a bioprosthetic valve—is a treatment option in severe aortic stenosis unsuitable for both surgical aortic valve replacement and transcatheter aortic valve replacement. An 82‐year‐old woman with severe aortic stenosis, porcelain aorta, and limited vascular access had an AVB inserted successfully. Imaging 3 months after implantation revealed a pseudoaneurysm at the AVB insertion site. Due to comorbidity and advanced age, the patient has been treated conservatively. Procedures with transapical insertions such as TAVI or AVB can lead to pseudoaneurysms, and the diagnosis often requires multiple imaging modalities. [ABSTRACT FROM AUTHOR]

A 47-year-old man presented with chest pain and was found to have an ascending aortic dissection. He underwent aortic arch resection and replacement with a hemishield tube graft with a valve conduit, better known as the Bentall technique. Five months later he presented with shortness of breath. A transesophageal echocardiogram revealed near-complete dehiscence of the mechanical valve conduit and a periaortic root abscess. He underwent removal of the conduit and placement of a homograft aortic root and valve. One month later he developed rigors. A transthoracic echocardiogram showed worsening systolic function and a periaortic hematoma or abscess. Serial transthoracic echocardiograms revealed increasing size in the periaortic echogenic free space and subsequent evidence of flow from the left ventricle into the periaortic space. He was determined not to be a surgical candidate and discharged to hospice in fair condition. He subsequently expired. (Echocardiography 2010;27:E27-E29) [ABSTRACT FROM AUTHOR]

Key Clinical Message: Fluoroscopy permits rapid and straightforward assessment of mechanical valve function and allows a distinction between normal and malfunctional prostheses, acting as a complementary diagnostic step. [ABSTRACT FROM AUTHOR]

We present a case of a 61‐year‐old man with a history of an ascending aortic aneurysm repair who was found to have prosthetic valve endocarditis. On transthoracic and transesophageal echocardiography, we show a devastating complication of prosthetic valve endocarditis: valve dehiscence with paravalvular flow compressing the tube graft during systole and distal dehiscence of the graft as blood from outside the graft reenters the native aorta. These echocardiographic images highlight the virulent nature of prosthetic valve endocarditis and the value of echocardiography in the diagnosis and management of prosthetic valve endocarditis. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 30-year-old male patient with congestive heart failure. The patient had a medical history significant for aortic valve replacement (AVR), aortic regurgitation (AR) and endocarditis. An echocardiogram showed an aortic aneurysm and right ventricular dysfunction. Echocardiogram results are explained in detail.

A 26-year-old man presented to emergency department with fever associated with night sweating and weight loss since 2 months prior to admission. He was an intravenous heroin user admitted for infective endocarditis of aortic valve 1 year ago. Transthoracic echocardiography followed by the transesophageal study showed bileaflet aortic prosthesis with normal transvalvular gradient and severe paravalvular aortic insufficiency. A pseudoaneurysm of intervalvular fibrosa connecting left ventricular outflow tract (LVOT) to noncoronary sinus of valsalva was detected. [ABSTRACT FROM AUTHOR]