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Objective We sought to investigate real-world outcomes of patients with degenerated biological aortic valve prostheses who had undergone valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) or reoperative surgical aortic valve replacement (redo-SAVR) in the Netherlands. Methods Patients who had undergone ViV-TAVI or redo-SAVR for a degenerated biological aortic valve prosthesis in the Netherlands between January 2014 and December 2018 were eligible for this retrospective study. Patients with a prior homograft, active endocarditis or mechanical aortic valve prosthesis were excluded. Patients were matched using the propensity score. The primary endpoint was a composite of 30-day all-cause mortality and in-hospital postoperative stroke. Secondary endpoints were all-cause mortality at different time points, in-hospital postoperative stroke, pacemaker implantation and redo procedures within one year. Baseline characteristics and outcome data were collected from the Netherlands Heart Registration. Results From 16 cardiac centres, 653 patients were included in the study (374 ViV-TAVI and 279 redo-SAVR). European System for Cardiac Operative Risk Evaluation I (EuroSCORE I) was higher in ViV-TAVI patients (19.4, interquartile range (IQR) 13.3–27.9 vs 13.8, IQR 8.3–21.9, p Conclusion Patients with degenerated aortic bioprostheses treated with ViV-TAVI or redo-SAVR have similar mortality and morbidity.

Background and aim of the study: A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supra- annular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Methods: Case report and literature review conserning subtle aortic dissection is provided. Results: Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. Conclusions: Our case along with the review of current literature emphasizes that current imaging techniques may be inadequate for diagnosis of this rare variant of aortic dissection.

The coexistence of pannus and thrombus is not uncommon. Accurate diagnosis of the etiology of prosthetic valve dysfunction (PVD) is of utmost importance in guiding adequate and rational therapy. We present a case of PVD in which computed tomography played a decisive role in guiding treatment. (Level of Difficulty: Intermediate.), Central Illustration

Purpose To present a novel technique to successfully cross a mechanical aortic valve prosthesis. Technique A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels. Conclusion Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

While the role of cardiovascular computed tomography angiography (CCTA) is evolving in low-intermediate risk patients with myocardial injury due to equivocal causes, this report highlights the added value of CCTA in evaluating the mechanism of acute ST-segment elevation myocardial infarction in a patient with aortic dissection and mechanical aortic valve replacement. CCTA provided accurate diagnosis and guided therapy without delay. A 51-year-old man with mechanical aortic valve replacement was admitted for severe chest pain. CCTA showed type A aortic dissection with an entry tear at the ostial left main coronary artery. Given the high surgical risk, he underwent fenestration of the false lumen. Twelve days postoperatively, he had chest pain with anterior STEMI. Urgent CCTA showed two left coronary thrombi with transmural extensive ischemia. Urgent thrombus aspiration and percutaneous coronary intervention were performed. A drug-eluting stent was placed on the proximal LAD. CCTA was crucial prior to PCI in order to define the etiology of STEMI and evaluate the vascular access.

The advent of transcatheter aortic valve replacement (TAVR) has fundamentally changed the way we think of aortic valve disease. Surgical considerations for an index aortic valve intervention are now informed by the feasibility and optimization of a future transcatheter valve-in-valve (ViV) procedure. Over the past decade the number of TAVRs has grown exponentially, and the expanded indication to younger patients promises that these numbers will continue to increase (1). While the long-term durability of transcatheter valves remains unknown, both patient and physician enthusiasm for this therapy has outpaced current guidelines. Despite these surging TAVR numbers, cardiac surgeons continue to perform high numbers of aortic valve replacements. Conditions such as bicuspid aortic valve disease, aortic regurgitation, and endocarditis remain within the realm of the surgeon, as do many cases of aortic stenosis. Therefore, the question remains, how should we as cardiac surgeons think about index surgical valve choice in the modern TAVR era? Clearly this question has taken on increased importance over the past decade. Traditionally, decisions regarding valve choice were limited to factors such as effective orifice area (EOA), durability and desire for anticoagulation; however, both patients and surgeons are now selecting valves with consideration as to the ease of future ViV TAVR. Although it seems intuitive that ViV TAVR will offer life-prolonging therapy without the risks inherent to reoperative cardiac surgery, the consequences of this strategy remain largely uninvestigated, especially in younger patients. Within the past decade, there has been a significant shift away from mechanical aortic valves in favor of bioprosthetic ones (2). Whereas mechanical valves made up one quarter of all implanted surgical aortic valves in 2002, that number had fallen to a mere 12.2% by 2016 (2). Interestingly, this trend appears to have gained traction prior to the introduction of TAVR and has actually slowed slightly during the height of the TAVR era (2). At the same time, the AHA consensus guidelines have decreased the age at which they feel choosing a bioprosthetic valve is reasonable, with the lower limit of that age cohort now set at 50 years instead of 60 (3). Despite this guideline shift, there is data demonstrating a small but persistent survival advantage for patients

Infective endocarditis (IE) is rarely seen in children, and it can cause significant morbidity and mortality. Congenital heart disease is a predisposing cardiac condition for IE and has an increasing prevalence. A mycotic aortic aneurysm is a rare disease due to infection and it has been reported that it may be a result of IE. We present a 10-year-old boy who was referred to our cardiovascular surgery department due to severe aortic stenosis (AS). Transthoracic echocardiography revealed calcific severe AS and computerized tomography (CT) angiography was performed to better evaluate the ascending aorta. CT angiography demonstrated a saccular aneurysm of the ascending aorta. The underlying pathology was considered as chronic IE on top of congenital AS with an unknown number of cusps. Histologic findings supported our diagnosis and accompanied by a saccular aneurysm. The patient underwent a successful aortic root enlargement, mechanical aortic valve replacement, and ascending aorta repair surgery.

We describe a 32-year-old pregnant woman at 31 + 6 weeks of gestation who presented to a tertiary-care hospital with headache and back pain. She was found to have a sign of tear about 1.3 cm away from the aortic valve, and the torn intima extended upward to the ascending aorta and the descending part of the aortic arch. She delivered a live male neonate via cesarean delivery. She had a history of hypertension with oral Labetalol 50 mg twice times daily. At the very beginning of the onset, physicians in the emergency room wouldn’t be aware of the symptoms of aortic dissections, as well as atypical presentations which include anterior chest pain or chest pain radiating to the back. She was only received anti-hypertension management, until her symptoms of back pain aggravated, and an aortic dissection was confirmed by ultrasound and CT angiography. Then she received a mechanical aortic valve replacement. After 51 days of treatment, she was discharged and recovered without any complications. Aortic dissection in pregnancy is a rare disease. We recommend transthoracic echocardiography every 1 to 2 months to monitor the diameter of the ascending aorta during pregnancy in which patients with hypertension problems or other risk factors of aneurysm and perform the CT angiography scan to confirm aortic dissection in a pregnant or postpartum woman with suspicious pain symptoms. It is essential that multidisciplinary approach in which teams must urgently collaborate to ensure the protection life of both mother and baby.

BACKGROUND Little is known about the ablation outcomes of premature ventricular contractions (PVCs) that originate from the periprosthetic aortic valve (PPAV) regions of patients with aortic valve replacement (AVR). METHODS AND RESULTS Our study had 11 patients who underwent catheter ablation for PVCs arising from the PPAV regions (bioprosthetic aortic valve, n = 5; mechanical aortic valve, n = 6). The PVC characteristics, procedure characteristics, and efficacy of ablation were compared with the control group (n = 33). At baseline, the PPAV group had a lower left ventricular ejection fraction (mean [SD], 41% [12%] vs. 51% [8%]; p = .002). The rate of acute ablation success was 90.9% in the PPAV group. Ablation sites were identified above the left coronary cusp (LCC) and right coronary cusp commissure (LRCC) in one PVC, below the prosthetic valve in eight PVCs (four below LCC and four below LRCC), and within the distal coronary sinus in two PVCs. The mean procedure time, fluoroscopy time, and radiation in the PPAV group were all significantly greater than those in the control group (all p

Leaflet escape from mechanical heart valves is a rare but potentially fatal complication of prosthetic valve replacement. Historically, the incompetent valve is replaced emergently and the escaped leaflet is subsequently retrieved from its settlement in a distal vessel. If it is not retrieved, the fragment can increase the risk of infection, thrombosis, and migration. We report a case of a mechanical aortic valve leaflet that embolized during valve reoperation and caused occlusive aortic disease found 2 years later. This case emphasizes the importance of locating leaflet fragments after they are noticed missing.

Transcatheter valvular interventions are established as an alternative for surgery in selected patients in symptomatic high surgical risk patients. Tricuspid valve replacement after failed repair ring had limited experience to date. We report this case to highlight the procedure details and results.

Background Scarce data are available on the long-term outcomes of different regimens of oral anticoagulation in an all comer population of patients undergoing aortic valve replacement with a bileaflet mechanical heart valve. Methods Outcomes of 88 patients discharged with a target INR of 2.0 (LOW-INR) were compared to 147 contemporary patients who have been recommended a target INR of 2.5 (CONV). Primary outcome was the composite of any thromboembolic or haemorrhagic events. Secondary outcomes were the individual components of the primary outcome, cardiovascular mortality and stroke. To reduce selection bias, a propensity weighted analysis was performed. Results After inverse probability of treatment weighting, the primary endpoint occurred in 0.7% of patient in the LOW-INR group and in 7.0% in the CONV group (p = .0255). Linearized event rate were significantly lower in the LOW-INR group (primary endpoint: rate difference − 12.0 per 1000 patient/years, p = .0052; haemorrhage: −5.8 per 1000 patient/years, p = .0330; neurological events: −7.6 per 1000 patient/years, p = .0140). Conventional target INR was associated with an increased hazard of the composite endpoint (HR 11.193, 95% CI 1.424–88.003, p = .0217). Conclusions Lowering the intensity of oral anticoagulation resulted in a relevant clinical benefit of reduced rates of haemorrhagic and neurological adverse events in the mid-term follow-up. This report confirms the safety profile of the low INR regimen in an all comer population undergoing aortic valve replacement with an Abbott mechanical valve.

Introduction: We describe a patient who developed severe aortic regurgitation following Impella left ventricular assist device implantation requiring aortic valve replacement. Case report: A previously healthy 34-year-old female presented with chest pain and flu-like symptoms. Electrocardiogram showed widespread ST elevation and serum troponin was raised, consistent with myocarditis. Coronary angiography was normal but the right coronary artery dissected. Subsequent cardiogenic shock required veno-arterial extracorporeal membrane oxygenation and Impella implantation. Myocardial function recovered, but upon removal of the Impella, severe aortic regurgitation was present and she underwent aortic valve replacement, making a full recovery. Discussion: Aortic regurgitation is a rare complication of Impella implantation, and to our knowledge, this is the first reported case successfully treated with aortic valve replacement. Veno-arterial extracorporeal membrane oxygenation and Impella used in tandem are relatively novel, and may add synergistic benefit to strategies for acute cardiogenic shock. Conclusion: Echocardiography must include frequent assessment of both valvular and myocardial function after Impella removal.

Aspergillus endocarditis (AE) accounts for a-quarter of all fungal endocarditis, mainly in immunocompromised hosts prior to heart-valve surgery with high mortality, even with treatment. Herein, we report a rare case of AE in a diabetic 60-year-old woman with a history of redo mitral valve prosthesis suspecious of acute endocarditis. She underwent second redo surgical mitral valve replacement in combination with mechanical aortic valve replacement. Blood cultures were negative. The explanted valve and vegetation were subjected to identification. Grown colonies were identified as Aspergillus flavus, based on conventional and molecular methods. Despite the administration of liposomal amphotericin B and improvement in her general condition shortly after initiation of therapy, the patient passed away. As AE is a late consequence of redo prosthetic valve replacement, extended follow-up, early diagnosis, repeating valve-replacement surgeries, and timely selective antifungal treatments are warranted.

Background Stuck mechanical heart valves had a debate about the management plan. There is debate regarding the type, dose, and rate of administration of various thrombolytic agents. We report a case with successful thrombolysis using an ultraslow regimen. Case summary A 43-year-old female with a history of aortic valve (AV) and mitral valve replacement (bi-leaflet metallic valves), and tricuspid valve repair (MINI band) at October 2017. Physical examination showed normal metallic first heart sound and weak metallic second heart sound. Laboratory investigations were normal except low INR, hematocrit, and hemoglobin level (9 gm/L due to iron deficiency anemia). Transthoracic echocardiogram (TTE) and Transoesophageal echocardiogram (TEE) confirmed stuck aortic valve leaflet, with a high mean pressure gradient across prosthetic AV (34 mmHg). The mechanical mitral valve was working well. Fluoroscopy showed stuck one of the AV leaflets in a closed position. The treating physician decided to give her the chance for thrombolytic therapy. This case was treated with ultraslow thrombolytic therapy (Alteplase, 1 mg, every hour) with follow up transthoracic echocardiogram every 24 h to check the pressure gradient on the AV. She was young, asymptomatic, and hemodynamically stable. After 48 h of Alteplase, the stuck leaflet was released. The mean pressure gradient dropped to 16 mmHg. Discussion Ultraslow thrombolytic regimen advised to be tried in stuck mechanical valves and hemodynamically stable patients.

Background We present a complex case of a failing tricuspid mechanical valve prosthesis in a patient with refractory cardiogenic shock at prohibitive risk for surgery in whom balloon ‘valvuloplasty’ resulted in immediate haemodynamic improvement in valve function. Case summary A 67-year-old woman with remote history of endocarditis s/p tricuspid valve repair and mechanical aortic valve replacement was referred for second opinion and management of new severe symptomatic tricuspid valve stenosis resulting in progressive debilitating congestive heart failure (HF). The patient was approved by the heart team to undergo redo open heart for surgical repair of the tricuspid valve. Intraoperative technical challenges were met to repair the tricuspid valve. In turn, the native valve was resected and a 33 mm On-X mechanical valve prosthesis. The patient’s post-operative course was complicated by recurrent haemoptysis, prolonged mechanical respiratory support, acute kidney injury, and cardiogenic shock. Surgical re-exploration to address the dysfunctional mechanical tricuspid valve was felt to be prohibitive. Structural heart team was consulted. Cardiac catheterization was recommended to ascertain and confirm findings. The patient was transferred to the cardiac catheterization laboratory. Initial fluoroscopic examination of the heart confirmed the echocardiographic results of an immobile septal leaflet of the recently implanted mechanical tricuspid valve. An 8 × 40 mm Mustang OTW angioplasty balloon was then advanced across the mechanical valve and inflated gradually at nominal pressure. A single inflation resulted in successful restoration of valve leaflet function. Discussion To the best of our knowledge, this is the first balloon ‘valvuloplasty’ on a mechanical On-X valve in the tricuspid position.

Background Haemolytic anaemia is a complication of paravalvular leak (PVL). The correlation between the size of the leak and the severity of haemolysis is unclear. Small leaks can cause severe haemolysis, whereas significant leaks may cause no haemolysis. Case summary We report the case of a 40-year-old male who underwent mechanical mitral and aortic valve replacement 20 years ago. In the last 3 years, the procedure was repeated three times due to infective endocarditis. He presented with severe shortness of breath. A transoesophageal echocardiogram with three-dimensional surgical view showed that both discs of the mechanical mitral valve opened sufficiently but a severe PVL had occurred at the 9–12 o’clock position. The location of the mitral valve was abnormal, the sewing ring was inserted high at the mid-interatrial septum. The mechanical aortic valve functioned well. Closure of the transcutaneous PVL was accomplished with two percutaneously implanted devices, leaving a small leak in between. After closure, he developed haemolytic anaemia (haemoglobin: 6 g/dL, lactate dehydrogenase: 1896 units/L, reticulocyte count: 4.6%). He then received 16 units of packed red blood cells. He developed acute kidney injury and was started on haemodialysis. We then installed two additional devices to completely close the mild residual leak and another device to resolve the bidirectional transseptal defect. After 2 days, his renal function returned to normal and anaemia improved (haemoglobin: 9.1 g/dL). Discussion Mild residual paravalvular leak can cause severe haemolytic anaemia that is correctable via percutaneous closure of the leak.

Introduction: The aim of this study was to investigate the effects of patient prosthesis mismatch on functional mitral regurgitation after mechanical aortic valve replacement. Patients and Methods: Total 59 patients were enrolled. All the echocardiographic assessments were performed by a single cardiologist. The patients were divided into two subgroups as per the presence of patient prosthesis mismatch. Group 1 comprised patients with mismatch, and group 2 included those without mismatch. Results: There were no significant differences between the two groups in terms of postoperative mitral regurgitation development, postoperative left ventricular mass regression, postoperative pulmonary arterial pressure, and postoperative functional capacity. Conclusion: Patient prosthesis mismatch is not a predictive factor for the development of functional mitral regurgitation after mechanical aortic valve replacement.

Background Homozygous familial hypercholesterolemia (hoFH) can cause severe atherosclerotic cardiovascular disease (ASCVD) in early infancy. Diagnosis and initiation of effective lipid-lowering therapy (LLT) are recommended as early as possible to prevent ASCVD-related morbidity and mortality. Methods The clinical courses of a pair of siblings with an identical hoFH genotype, who exhibited major similarities of their clinical phenotype were analyzed in a case-control fashion including the family. Results The older sibling was diagnosed with hoFH at the age of 4. Untreated LDL-cholesterol (LDL-C) was 17 mmol/L (660 mg/dL). LLT including lipoprotein apheresis (LA) was initiated and has been successful for 8 years now. A reduction of estimated cholesterol burden by 74% was achieved by LA and combined drug therapy including statins and ezetimibe. The efficacy of escalation of drug therapy was limited because the underlying LDL receptor (LDLR) mutation in the family resulted in substantially reduced receptor function. Treatment with proprotein convertase subtilisin-kexin type 9 (PCSK9)-antibodies failed. His younger brother died at the age of 2 years shortly after the hoFH diagnosis of the elder sibling. Postmortem examination revealed advanced aortic root atheroma and aortic valve stenosis. In the older sibling, aortic valve stenosis and insufficiency were treated at the age of 9 years with mechanical aortic valve replacement. Conclusions LLT including LA should be initiated as early as possible following the diagnosis of hoFH with very high LDL-C levels. With the same genotype, the phenotype of hoFH can exhibit similar patterns but outcome is substantially related to treatment.

Coronary embolism due to prosthetic valve thrombosis is a rare cause of acute coronary syndrome. We report the challenging case of a 66-year-old female patient with non-ST-elevation myocardial infarction caused by left main coronary artery bifurcation embolism in the setting of mechanical aortic valve thrombosis. The patient was treated with intravenous thrombolysis. Four hours later, she suffered an anterior ST-elevation myocardial infarction due to left anterior descending artery embolization. Repeat coronary angiogram showed complete disappearance of the LMCA embolus with only distal LAD occlusion. The patient was further treated medically with excellent outcome. (c) 2021 Elsevier Inc. All rights reserved.

A 20-year-old man with severe aortic insufficiency received a mechanical aortic valve replacement. Afterward he subsequently presented with an aortic root dissection, pseudoaneurysm, and prosthetic valve endocarditis requiring surgical reinterventions twice with a positive Mycobacterium chimaera tissue culture despite prolonged antimycobacterial therapy. This is the first reported clinical case of M chimaera in Western Canada and the first with M chimaera–associated aortic dissection and pseudoaneurysm.

Aortic valve neocuspidization with fixed autologous pericardium according to the Ozaki technique has been proven to be an effective therapy for the treatment of aortic valvulopathies of various entities (aortic stenosis, aortic regurgitation, aortic valve endocarditis) in both tricuspid and bicuspid aortic valves. Thus, aortic valve neocuspidization with fixed autologous pericardium represents a versatile alternative to complex aortic valve repair, with better hemodynamics compared to biological aortic valve replacement and without the need for lifelong anticoagulation, which characterizes mechanical aortic valve replacement. The authors meticulously describe all the technical steps of this highly reproducible, standardized procedure.

ObjectiveBioprosthetic aortic valves with an extended subannular component, such as transcatheter valves, exert increased compression on the cardiac conduction system and increase the risk for permanent pacemaker implantation. It is unknown if the On-X mechanical prosthetic valve, which has an elongated subannular valve housing, increases the risk of permanent pacemaker implantation following aortic valve replacement.DesignObservational nationwide cohort study.SettingSwedish population-based study.ParticipantsAll patients aged 18–65 years who underwent primary mechanical aortic valve replacement in Sweden between 2005 and 2018. We used the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register and other Swedish national health-data registers.ExposurePatients implanted with an On-X valve versus patients implanted with other bileaflet mechanical valves.Primary and secondary outcome measuresPrimary outcome measure was permanent pacemaker implantation within 30 days of surgery.ResultsA total of 2602 patients were included, and 581 patients received an On-X valve and 2021 patients received a St Jude Masters/Regent (n=945) or Carbomedics Reduced valve (n=1076). In the total study population, 115 (4.4%) permanent pacemaker implantations were performed within 30 days after aortic valve replacement. In the propensity score matched population, there was no significant difference in the rate of permanent pacemaker implantation in the On-X group compared with the control group: 3.6% (95% CI: 2.4% to 5.5%) vs 4.0% (95% CI: 2.7% to 5.9%), p=0.877.ConclusionsThe On-X prosthetic heart valve was associated with a similarly low risk for permanent pacemaker implantation after aortic valve replacement compared with other conventional bileaflet mechanical valves. The On-X elongated subannular valve housing does not interfere with the cardiac conduction system.

The use of left ventricular assist device (LVAD) in patients with mechanical aortic valves may result in thromboembolic events due to blood stasis around the valve and intermittent valve opening. Mechanical aortic valves encountered during LVAD implantation are managed by replacement with a tissue valve, or closure of the valve with a patch. Closure of the valve carries the risk of sudden death in cases of LVAD stoppage. Replacing the whole mechanical valve conduit is time consuming and carries a significant risk of bleeding and right ventricular (RV) failure. We describe an alternative technique of replacing a mechanical aortic valve by breaking its inner leaflets and sewing a tissue valve on top of the mechanical valve ring.

The Starr–Edwards ball and cage valves were among the first and most commonly used mechanical valve devices. These valves offered a novel design that would become one of the mainstays for replacement of severely diseased heart valves in the early second half of the twentieth century. We describe the case of a patient with a Starr–Edwards ball and cage valve in the aortic position that was replaced 40 years earlier who was admitted with concerns for symptoms of new volume overload. Transthoracic and transesophageal echocardiography demonstrated a functional mechanical aortic valve with no evidence of compromise. The patient was treated with diuretics for congestive heart failure exacerbation and on 3 years follow-up was doing well. This is one of the few cases reported of a patient with Starr–Edwards ball and cage aortic valve functioning normally extending into the fifth decade without signs of significant instability.

Thromboembolism related to a mechanical heart valve (MHV) is a major complication after surgical valve replacement. Warfarin remains as guideline-endorsed thromboprophylaxis in patients with MHVs. Alternative anticoagulation therapy for patients who do not tolerate or who fail warfarin is not adequately covered in the current guidelines. We report a case of successful long-term anticoagulation with enoxaparin in a patient with a mechanical aortic valve who had a contraindication to warfarin. The patient developed a left thigh hematoma requiring surgical evacuation 1 month after initiation of weight-based dosing of enoxaparin. His dose was then titrated based on peak anti-factor Xa levels (goal 0.6-1.0 IU/ml). He remained free of signs and symptoms of thromboembolic events, valve dysfunction, bleeding complications, or major adverse effects from long-term enoxaparin use for the next 13 years. Our case provides promising evidence of the potential role of enoxaparin in patients with MHVs in whom warfarin thromboprophylaxis is not possible. Meticulous monitoring of anti-factor Xa levels and dosage adjustments are crucial to treatment success.

Background This study aimed to confirm the safety and feasibility of simple pannus removal in patients with mechanical aortic valve dysfunction for pannus overgrowth by evaluating its early clinical outcomes. Methods From March 2015 to April 2019, 24 consecutive patients with mechanical aortic valve dysfunction due to subaortic pannus underwent reoperation. In 12 patients the repeat aortic valve replacement (AVR) was performed, and 12 received the simple pannus removal to preserve the previously implanted prosthesis. Results There was only 1 in-hospital death in simple pannus removal group. Significant differences were obtained between procedures in cardiopulmonary bypass (CPB) and aortic cross-clamp time (128.7 vs 179.7 and 74.2 vs 132.7 mins, respectively, P P > 0.05) in echocardiography 1 week after operation. In addition, the aortic transvalvular peak velocity and TMPG in echocardiography 1 week after operation in pannus removal group between the repeat and initial surgery were not statistically significant (2.6 ± 0.4 vs. 2.5 ± 0.3 m/s, 13.2 ± 3.6 vs. 13.0 ± 3.5 mmHg, P > 0.05). Conclusions Simple pannus removal was a safe and effective procedure with satisfied early clinical outcomes for pannus overgrowth in mechanical aortic valve. However, further randomized and long-term follow-up studies were warranted to determine the clinical effects of the simple aortic pannus removal.

Background Biologic prostheses are preferred for surgical aortic valve replacement (SAVR) in patients more than 70 years of age in clinical practice. This study investigated differences in long-term outcomes between SAVR-treated patients more than 70 years of age who received mechanical or biologic prosthetic valves. Methods All patients (excluding those with endocarditis) who were more than 70 years of age and who underwent isolated first-time SAVR (with or without coronary artery bypass grafting) in Finland between 2004 and 2014 were retrospectively studied (n = 4227). Propensity score matching (1:3) was used to account for baseline differences (n = 296 with mechanical prostheses and n = 888 with biologic prostheses). Outcomes were 10-year survival, major bleeding (all, gastrointestinal, intracranial), ischemic stroke, infective endocarditis, and aortic valve reoperation. Mean age was 75.8 years, and mean follow-up was 8.3 years. Results Survival at 10 years was 46.1% with mechanical prostheses and 57.8% with biologic prostheses (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.21 to 1.80; P Conclusions Mechanical aortic valve prosthesis is associated with worse long-term survival and increased bleeding after SAVR in patients more than 70 years old. The study results suggest caution when considering mechanical aortic valve prostheses in elderly patients.

Background Prosthetic valve endocarditis (PVE) is a life-threatening systemic infection involving a high mortality rate and severe complications, including perivalvular abscess. Early diagnosis and detection of PVE continue to be challenging in clinical settings. Case summary A 64-year-old man with a history of mechanical aortic valve implantation 12 years prior was referred to our hospital with a major complaint of high fever and was admitted. Although results of three blood culture tests at admission were negative, transthoracic echocardiography, and transoesophageal echocardiography (TOE) were performed to exclude the possibility of PVE; both, however, were inconclusive. Subsequently, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was performed; revealing intense hyper-metabolism above the aortic valve prosthesis with a greater intensity at the posterior end, confirming a diagnosis of aortic PVE complicated with perivalvular abscess. Discussion Considering the intermediate suspicion of PVE despite negative TOE and negative blood culture tests, 18F-FDG PET/CT can play a central role in diagnosing PVE. However, this new imaging modality often fails to differentiate thrombi, soft atherosclerotic plaques, or foreign body reactions on the surface of prosthetic valves. In this report, we have successfully enhanced the diagnostic accuracy of 18F-FDG PET/CT by focusing on perivalvular involvement, which could be a key finding, because intense 18F-FDG uptake surrounding the aortic annulus was consistent with the thickened area within the aortic annular region observed in the TOE examinations.

Objectives To clarify the prevalence and risk factors of ascending aortic (AA) dilatation according to ESC 2014 guidelines. Methods This study included 1000 consecutive patients scheduled for diagnostic coronary artery computed tomographic angiography. AA diameter was retrospectively measured in 3 planes: sinus valsalva, sinotubular junction, and tubular part. The threshold for AA dilatation was set to > 40 mm which has been suggested as an upper normal limit for AA diameter in ESC 2014 guidelines on aortic diseases. Aortic size index (ASI) using the ratio between aortic diameter and body surface area (BSA) was applied as a comparative measurement. The threshold for AA dilatation was set to the upper limit of normal distribution exceeding two standard deviations (95%). Risk factors for AA dilatation were collected from medical records. Results The patients’ mean age was 52.9 ± 9.8 years (66.5% women). The prevalence of AA dilatation was 23.0% in the overall study population (52.5% males) and 15.1% in the subgroup of patients with no coronary artery disease or bicuspid (BAV)/mechanical aortic valve (n = 365). According to the normal-distributed ASI values, the threshold for sinus valsalva was defined as 23.2 mm/m2 and for tubular part 22.2 mm/m2 in the subgroup. Higher BSA was associated with larger AA dimensions (r = 0.407, p p p p = 0.009) in males, and smoking (p Conclusions The prevalence of AA dilatation is high with current ESC guidelines for normal AA dimension, especially in males. Body size is strongly associated with AA dimensions; it would be more reliable to use BSA-adjusted AA diameters for the definition of AA dilatation. Key Points • The prevalence of AA dilatation is high in patients who are candidates for coronary CT angiography. • Body size is strongly associated with AA dimensions.

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.

Sinus of Valsalva aneurysm, a rare cardiac anomaly, can be life-threatening if it ruptures. Transcatheter closure has emerged as an effective alternative to surgical management; however, it has rarely been reported in patients with previous mechanical aortic valve replacements. We describe the case of a 45-year-old man who presented with a ruptured aneurysm of the noncoronary sinus of Valsalva 14 years after the implantation of a mechanical aortic valve. The ruptured aneurysm was closed by transcatheter means with use of a double-disc perimembranous ventricular septal defect occluder. The patient remained asymptomatic one year after the procedure. Our case suggests that transcatheter closure with use of this type of occluder is a viable method for successfully repairing ruptured sinus of Valsalva aneurysms in patients who have mechanical aortic valves.

Graphical abstract, Highlights • The authors describe culture-negative endocarditis causing mechanical AV dehiscence. • Early diagnosis and prompt surgical treatment are necessary. • TEE is useful in identifying the etiology of AR in this instance. • Pseudoaneurysm involving aortic homograft is rare and can occur without reinfection.

Objective Although the results of aortic valve replacement are well documented for industrialized countries, the outcome in patients with rheumatic aortic valve disease in low- to middle-income countries is less well explored. The aim of this study was to determine the long-term survival and clinical outcomes after isolated aortic valve replacement in patients with rheumatic heart disease in a Sub-Saharan country where follow-up of indigent patients is often challenging. Methods A retrospective review of 969 aortic valve replacements performed between 2003 and 2013 was conducted at Cape Town's Groote Schuur Hospital. Patients who underwent concomitant procedures (n = 664) or had nonrheumatic valve pathology (n = 185) were excluded. The mean age of the rheumatic cohort (n = 121) was 43.1 ± 11.6 years with a mean follow-up period of 6.14 ± 3.44 years. The primary end points were survival and valve-related complications. Results A 15% cardiac- or valve-related 10-year mortality after receiving a mechanical prosthesis corresponded with a significantly higher mortality rate than that of a matched population. Overall cumulative survival at 1, 5, and 10 years was 93.5% (87.0-96.9), 86.4% (78.4-91.8), and 78.1% (67.5-86.0), respectively, and the corresponding cumulative freedom from combined thromboembolism and bleeding was 94.4% (88.2-97.5), 87.4% (79.4-92.5), and 86.1% (77.9-91.6), respectively. Conclusions In low- to middle-income countries, with their unique mix of indigent and “First World” patients, rheumatic heart disease still accounts for a significant proportion of patients requiring isolated aortic valve replacement. Although mechanical prostheses are often selected in these young adults, survival remains suboptimal. Major bleeding and thromboembolic events account for the majority (77%) of the reported valve-related complications.

Background Prosthetic valve endocarditis (PVE) is a rare but severe complication of valve replacement surgery, with an incidence rate of 0.3–1.2% per patient-year. At present, staphylococci are the predominant causative microorganism of PVE. Herein, we report a confirmed case of late PVE in a mechanical aortic valve caused by Mycobacterium tuberculosis. Case presentation A 32-year-old immunocompetent man with recurrent fever and 5-kg weight loss had a history of having undergone the Bentall procedure due to congenital heart disease. Nine years after the operation, he developed a paravalvular abscess in the mechanical aortic valve, presented with evidence of pulmonary tuberculosis on CT scan and was diagnosed with tuberculous endocarditis. This case report highlights a rare and non-negligible example of tuberculous endocarditis involving a mechanical valve. Conclusions Tuberculous PVE should be considered in patients with a history of valve replacement, recurrent fever, unexplained weight loss, pulmonary tuberculosis and meaningful valvular findings on echocardiogram.

Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.

Aortic root dilation is nearly universal among patients with Marfan syndrome (MFS) and many patients require aortic root replacement to prevent devastating aortic catastrophe. This has traditionally entailed placement of a composite-valved graft, often with a mechanical aortic valve, necessitating lifelong anticoagulation. In the 1990s, a significant development within the field of cardiac surgery occurred, and valve sparing root replacement (VSRR) techniques were developed and refined. These allow prophylactic replacement of aortic root aneurysms while sparing a healthy, functioning aortic valve. These techniques have been shown to be safe and durable in patients with MFS.1 2 However, VSRR is a technically demanding procedure that is not available in all cardiac centres. This has led some to investigate alternatives to VSRR, in an effort to make these repairs both safer and more generalisable within the cardiac surgical community. Van Hoof and colleagues3 report outcomes on the first 200 consecutive patients undergoing the personalized external aortic root support (PEARS) procedure. The results of this innovative procedure are very encouraging, with a 0.5% perioperative mortality. Late reoperations were only performed in three patients, and no type A dissections occurred during the follow-up period. Further, the PEARS procedure seems to have a positive impact on aortic regurgitation and medium-term valve outcomes seem promising. These results are remarkable and the authors and surgeons dedicated to pioneering this innovative approach …

A 74-year-old male with a past medical history of mechanical aortic valve replacement presented with abdominal pain and fever. Blood cultures revealed methicillin-resistant Staphylococcus aureus (MRSA) and the patient was started on target antibiotics. Initial transthoracic echocardiogram and transesophageal echocardiogram (TEE) did not show any vegetations or significant valvular regurgitation. No other sources of infection were identified. Five days after the initial TEE, a repeat TEE revealed new areas of thickening and echolucency seen anterior to the mechanical aortic valve, suggestive of aortic root abscess (AoRA). It also extended down the mitral-aortic intervalvular fibrosa and was associated with mitral valvular vegetation. Due to worsening clinical status and persistent bacteremia on appropriate antibiotics, a high index of suspicion for infective endocarditis (IE) remained after the initial TEE. As such, the repeat TEE was obtained only five days after and demonstrated clear evidence of rapidly growing endocarditis and abscess formation. This case uniquely demonstrates how rapid MRSA endocarditis may progress and emphasizes its high mortality. This case highlights the importance of a low threshold for repeat imaging when the index of suspicion for endocarditis remains high despite negative imaging.

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Background This study was conducted to evaluate the occurrence rate and risk factors of subaortic pannus (SAP) after bileaflet mechanical aortic valve (AV) replacement. Methods Between 1990 and 2014, 862 patients underwent primary AV replacement with bileaflet mechanical prosthesis. SAP was defined as (1) gradual increase in mean pressure gradient through mechanical AV without any evidence of motion limitation of the leaflets on echocardiography and (2) AV mean pressure gradient >40 mm Hg or AV peak velocity >4 m/s on echocardiography, and (3) any visible subaortic tissue ingrowth beneath the mechanical AV on echocardiography or computed tomography. Clinical and echocardiographic follow-up durations were 13.8 ± 8.0 and 10.7 ± 7.9 years, respectively. Results Mean age was 51.1 ± 12.1 years and concomitant surgeries were performed in 503 patients (58.4%). Overall survival at 10 and 20 years was 84.2 and 67.1%, respectively. SAP occurred in 33 patients, and in only 2 patients during the first 10 years after surgery. The cumulative incidence of SAP formation at 10, 20, and 25 years were 0.3, 5.0, and 9.9%, respectively. The Fine and Gray model demonstrated that small prosthetic valve size (hazard ratio [HR] [95% confidence interval, CI] = 0.738 [0.575–0.946]), young age (HR [95% CI] = 0.944 [0.909–0.981]), and concomitant mitral valve replacement (MVR) (HR [95% CI] = 3.863 [1.358–10.988]) were significant risk factors for the SAP formation. Conclusions SAP occurred gradually over time with 10- and 20-year cumulative incidence of 0.3 and 5.0%, respectively. Young age, small prosthetic valve size, and concomitant MVR were risk factors for SAP formation. Therefore, we recommend efforts to select large prostheses for young patients requiring concomitant MVR.

We presented a case of severe aortic regurgitation and moderate mitral regurgitation s/p aortic valve replacement and mitral valve repair. Deterioration of tachyarrhythmia attacks was noted. In EP study, left lateral accessory pathway with orthodromic atrioventricular reentrant tachycardia was identified. We successfully ablated the accessory pathway by trans‐septal approach. Even though trans‐septal approach currently is a daily routine of invasive interventional electrophysiologists, in this case, we want to emphasize and illustrate the distance between true mitral annulus and coronary sinus. Unrecognizing this concept could result in efficacy and safety of catheter‐based therapy.

Current guidelines recommend targeting an international normalized ratio (INR) of 2.5 to 3.5 for patients with mechanical aortic valve replacement (AVR) and additional risk factors for thromboembolic events. Available literature supporting the higher intensity (INR) goal is lacking. We aimed to evaluate the association of standard and higher intensity anticoagulation on outcomes in this patient population. The Michigan Anticoagulation Quality Improvement Initiative database was used to identify patients with mechanical AVR and at least one additional risk factor. Patients were classified into 2 groups based on INR goal: standard-intensity (INR goal 2.5) or higher-intensity (INR goal 3.0). Cox-proportional hazard model was used to calculate adjusted hazard ratios. One hundred and forty-six patients were identified of whom 110 (75.3%) received standard-intensity anticoagulation and 36 (24.7%) received higher intensity anticoagulation. Standard-intensity patients were older and more likely to be on aspirin. Atrial fibrillation was the most common additional risk factor for inclusion. The primary outcome of thromboembolic events, bleeding, or all-cause death was 13.9 and 19.5/100-person-years in the standard-intensity and higher intensity groups, respectively (adjusted HR 2.58, 95% confidence interval 1.28 to 5.18). Higher-intensity anticoagulation was significantly associated with any bleeding (adjusted HR 2.52, 95% confidence interval 1.27 to 5.00) and there were few thromboembolic events across both groups (5 events total). These results challenge current guideline recommendations for anticoagulation management of mechanical AVR in patients with additional risk factors.

A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supraannular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. As current data is limited, a literature review concerning subtle aortic dissection is provided.

Background Aortic valve myxoma is the rarest location of the most common primary tumour of cardiac origin. Because of the paucity of data, there is little known about their clinical presentation, diagnosis and complications. Methods PUBMED, EMBASE, SCOPUS and WEB OF SCIENCE were systematically searched to identify all published cases of aortic valve myxoma through October 2020. Descriptive statistics were used to report the data. Results Aortic valve myxomas were more prevalent in young (mean age 41 years) male (75%) patients. It most commonly involved the right coronary cusp (50%). Cerebrovascular events (25%), dyspnoea (18.8%), and distal embolisation (18.8%) were found to be the most frequent complications. Echocardiography remains the diagnostic modality of choice in all cases, histopathology is used for confirmation. Most cases were treated with surgical excision (94%); concomitant aortic valve repair and mechanical aortic valve replacement were performed in 25% and 37.5% cases respectively. Sudden cardiac death was noted in one patient. Conclusion Aortic valve myxomas are more often than not discovered in the context of embolic phenomenon or dyspnoea. The most feared complication is stroke, although mortality remains low in surgically managed cases.

For a fifth-time redo aortic valve replacement, a Y incision was made through the left-noncommissure post into the aortomitral curtain above the mitral annulus, undermining the aortic annulus below the nadirs of left coronary and noncoronary cusps without violating the left atrium or mitral valve. A rectangular Hemashield (Maquet Cardiovascular, San Jose, CA) patch was used to extensively enlarge the aortomitral curtain. The aortic annulus was increased from 21 mm to 27 mm for a mechanical aortic valve replacement. The patient was discharged without blood transfusion or any complications. Our enlargement technique was simple and effective to enlarge the aortic annulus for mechanical aortic valve replacement.

Prosthetic valve thrombosis is a rare phenomenon with limited treatment options. Current management choices include anticoagulation with or without fibrinolysis or surgical valve replacement for appropriate candidates. We report an alternative fibrinolytic and anticoagulation regimen resulting in successful treatment of a patient presenting with mechanical aortic valve thrombosis.

The presence of a mechanical aortic valve prosthesis is considered a relative contraindication for left ventricular assist device implantation (LVAD) due to the occurrence of thromboembolic events. Five patients were operated on for LVAD implantation with status post mechanical aortic valve implantation (n = 3 with status post Bentall procedure). After removal of the leaflets, a transcatheter balloon-expandable valve was placed within the mechanical ring in all patients. Three patients were discharged from hospital with a maximum follow-up of 3.3 years. Transaortic transcatheter valve implantation into a mechanical aortic valve during LVAD implantation is a feasible option. It reduces operative times and might also prevent thromboembolic events., Rarely patients selected for left ventricular assist device (LVAD) implantation have had prior mechanical aortic valve implantation.

BACKGROUND >We illustrate the steps for a Ross procedure in a 24-years old patient who presented with an unicuspid aortic valve with mixed aortic stenosis/aortic regurgitation and who was intraoperatively found to have a bicuspid pulmonary autograft, warranting the need for concurrent repair of the autograft. Without repair of the bicuspid pulmonary autograft, this patient would likely have had cusp prolapse and residual aortic insufficiency, compromising early and late valve function, and ultimately the patient's outcome. METHODS AND RESULTS Although it could be argued to have simply replaced our patient's aortic valve with a standard valve prosthesis, his young age posed a challenge with his longer anticipated life expectancy and higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike standard bioprosthetic or mechanical aortic valve replacement, restores expected survival equivalent to that of age and gender-matched general population. A bicuspid pulmonary valve is considered a rare congenital anomaly with an estimated incidence of 0.1% and may be considered a relative contraindication for the Ross procedure. However, our patient had favourable bicuspid anatomic characteristics with pliable cusps, good commissural orientation, and geometric height of 20 mm, and we applied all the principles of bicuspid aortic valve repair with symmetric commissural implantation, a tailored aortic annuloplasty and achieving an effective height of 10 mm with central cusp plication to ensure a well functioning bicuspid pulmonary autograft. At 1 year follow-up, the patient was completely asymptomatic and ambulating without limitations. Repeat transthoracic echocardiography revealed a normal functioning pulmonary autograft with no aortic insufficiency, normally functioning pulmonary homograft, and preserved left ventricular function and dimensions. We have employed this technique successfully in two patients. To our knowledge, only one previous paper presented a repair of a bicuspid pulmonary autograft valve, but this was for moderate aortic insufficiency noted 5 days after the Ross procedure. CONCLUSION In this report, we present the concomitant repair of a bicuspid pulmonary autograft at the time of the index operation. We aim at drawing on the advantages of the Ross procedure for young patients while restoring the function of the bicuspid pulmonary autograft using common bicuspid aortic valve repair techniques, thus extending the use of the Ross procedure to more patients who would otherwise be considered ineligible.

Patients with a true porcelain aorta and a failed mechanical aortic valve prosthesis have limited treatment options. Using a hybrid of an open trans-ventricular approach with peripheral cardiopulmonary bypass and integration of transcatheter techniques this challenge can be overcome. Trans-ventricular mechanical valve extraction (with transcatheter endovascular occlusion and cardioplegia) followed by direct ante-grade transcatheter heart valve implantation offers a potential solution to this conundrum. The procedure described is a novel technique that allows for the effective treatment of patients with failed mechanical surgical aortic valve prostheses in the setting of an inoperable porcelain aorta. In addition, a collaborative integrated multi-disciplinary heart team environment is required for the management of these complex patients.