Search

Background: Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS)., Methods: Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke., Results: BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13-2.14, p = 0.006; HR 1.47, 95%CI 1.02-2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF., Conclusions: Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR., Competing Interests: Declaration of competing interest No disclosures to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: On-pump cardiac surgery provokes a predictable perioperative myocardial ischaemia-reperfusion injury which is associated with poor clinical outcomes. We determined the occurrence of time-of-the-day variation in perioperative myocardial injury in patients undergoing aortic valve replacement and its molecular mechanisms., Methods: We studied the incidence of major adverse cardiac events in a prospective observational single-centre cohort study of patients with severe aortic stenosis and preserved left ventricular ejection fraction (>50%) who were referred to our cardiovascular surgery department at Lille University Hospital (Lille, France) for aortic valve replacement and underwent surgery in the morning or afternoon. Patients were matched into pairs by propensity score. We also did a randomised study, in which we evaluated perioperative myocardial injury and myocardial samples of patients randomly assigned (1:1) via permuted block randomisation (block size of eight) to undergo isolated aortic valve replacement surgery either in the morning or afternoon. We also evaluated human and rodent myocardium in ex-vivo hypoxia-reoxygenation models and did a transcriptomic analysis in myocardial samples from the randomised patients to identify the signalling pathway(s) involved. The primary objective of the study was to assess whether myocardial tolerance of ischaemia-reperfusion differed depending on the timing of aortic valve replacement surgery (morning vs afternoon), as measured by the occurrence of major adverse cardiovascular events (cardiovascular death, myocardial infarction, and admission to hospital for acute heart failure). The randomised study is registered with ClinicalTrials.gov, number NCT02812901., Findings: In the cohort study (n=596 patients in matched pairs who underwent either morning surgery [n=298] or afternoon surgery [n=298]), during the 500 days following aortic valve replacement, the incidence of major adverse cardiac events was lower in the afternoon surgery group than in the morning group: hazard ratio 0·50 (95% CI 0·32-0·77; p=0·0021). In the randomised study, 88 patients were randomly assigned to undergo surgery in the morning (n=44) or afternoon (n=44); perioperative myocardial injury assessed with the geometric mean of perioperative cardiac troponin T release was significantly lower in the afternoon group than in the morning group (estimated ratio of geometric means for afternoon to morning of 0·79 [95% CI 0·68-0·93; p=0·0045]). Ex-vivo analysis of human myocardium revealed an intrinsic morning-afternoon variation in hypoxia-reoxygenation tolerance, concomitant with transcriptional alterations in circadian gene expression with the nuclear receptor Rev-Erbα being highest in the morning. In a mouse Langendorff model of hypoxia-reoxygenation myocardial injury, Rev-Erbα gene deletion or antagonist treatment reduced injury at the time of sleep-to-wake transition, through an increase in the expression of the ischaemia-reperfusion injury modulator CDKN1a/p21., Interpretation: Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery., Funding: Fondation de France, Fédération Française de Cardiologie, EU-FP7-Eurhythdia, Agence Nationale pour la Recherche ANR-10-LABX-46, and CPER-Centre Transdisciplinaire de Recherche sur la Longévité., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR)., Background: Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients., Methods: The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria., Results: Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium-defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%., Conclusions: Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: We compared the outcomes of transcatheter aortic valve implantation (TAVI) in three different aortic stenosis syndromes: paradoxical low-flow low-gradient aortic stenosis (PLFLG), high-gradient aortic stenosis (HGAS), and low ejection fraction low-gradient severe aortic stenosis (LEF-LG)., Background: Outcomes for PLFLG patients after TAVI procedure are not well known., Methods: Between 2010 and 2013, patients with severe (indexed aortic valve area iAVA≤0.6 cm(2)/m(2)) symptomatic aortic stenosis were consecutively referred to our institution for TAVI because of multiple comorbidities and excessive surgical risk. About 262 patients were split into three groups as following, PLFLG: mean gradient MG≤40 mm Hg, stroke volume index SVI≤35 mL/m(2), ejection fraction EF≥55%, valvuloarterial impedance Zva>4.5 mm Hg/mL/m(2), maximal aortic jet velocity MaxV<4 m/s;, Lef-Lg: MG≤40 mm Hg, MaxV<4 m/s, EF≤50%, SVI≤35 mL/m(2); and HGAS: MaxV>4 m/s, MG>40 mm Hg, EF>55%. The primary endpoint of our study was to evaluate mid-term global and cardiovascular mortalities; secondary endpoints included recommended VARC-2 variables., Results: PLFLG (n = 31) mid-term survival was similar to HGAS (n = 172) (mean follow-up = 13.2 months [4.6-26]). Conversely LEF-LG patients (n = 59) displayed significant higher rates of all-cause (P = 0.01) and cardiovascular mortalities (P = 0.05). Postprocedural outcomes (VARC-2 criteria) were similar in the PLFLG and HGAS groups except regarding major bleeding (P = 0.02), while the LEF-LG group had more congestive heart failure and a higher BNP before discharge (both P < 0.001) than the other groups. 30-days deaths were significantly more frequent in LEF-LG and PLFLG in comparison to HGAS (P = 0.03)., Conclusion: As opposed to LEF-LG patients, mid-term prognosis after TAVI procedure in PLFLG patients is similar to HGAS patients despite higher perioperative mortality., (© 2015 Wiley Periodicals, Inc.)

The reimplantation technique for valve-sparing aortic root replacement is increasingly used to treat aortic root pathology. The systematic approach described by El Khoury in 2009 and modified in 2011 using the Valsava graft is simple and reproducible. However, in-conduit suturing of the aortic valve annulus and small rim of sinus remnant to the graft sinuses is time-consuming and may lead to bleeding or distortion of the prosthetic root. We describe a simple technique to facilitate the native valve reimplantation., (© 2014 Wiley Periodicals, Inc.)

Transcatheter aortic valve implantation (TAVI) is still under active investigation. When the femoral route is impossible for anatomic reasons, the transapical, transaxillary and direct aortic approaches have demonstrated their effectiveness. We report the successful implantation of a Sapien XT bioprosthesis with the NovaFlex catheter through a left carotid approach., (© 2014 Wiley Periodicals, Inc.)

Acute valve-sparing procedures are effective in the treatment of aortic root dilation when there is no valve pathology. In this review, we discuss the role of aortic valve-sparing procedures in the presence of connective tissue disorders such as scleroderma., (© 2013 Wiley Periodicals, Inc.)

Objective: Both retrograde femoral and subclavian artery catheterization techniques have been described as the most common methods for the implantation of the Medtronic CoreValve percutaneous aortic valve (Medtronic Inc, Minneapolis, Minn). The subclavian artery has been shown to be a safe and effective alternative access route in patients with unfavorable femoral access. Of the patients who are identified as candidates for subclavian artery access, a subset possess a patent left internal thoracic artery to left anterior descending artery. This patent left internal thoracic artery presents an additional anatomic and clinical variable that must be taken into consideration to ensure procedural safety and efficacy. We describe the Medtronic CoreValve percutaneous aortic valve implantation using the subclavian arterial approach in patients with a patent left internal thoracic artery and report our study's findings., Methods: The CoreValve percutaneous aortic valve is a self-expandable nitinol-based frame with a porcine pericardial valve. The subclavian access was created by a small infraclavicular surgical incision to expose the artery. Rapid ventricular pacing was used to reduce cardiac output to perform the balloon aortic valvuloplasty via a 12F sheath inserted into the subclavian artery. An 18F sheath was then inserted into the artery down into the ascending aorta and used for introduction of the delivery catheter and implantation of the percutaneous aortic valve., Results: With the use of this method, 19 patients (76 ± 13 years) whose surgical risk was deemed excessive because of severe comorbidity and in whom transfemoral catheterization was considered unfeasible or at risk of severe complications have received implants. Subclavian artery or left internal thoracic artery injury did not occur in any patient. Two deaths occurred. One patient died of right coronary artery occlusion during the procedure, and one patient died 48 hours after the procedure as the result of a tamponade after the temporary pacemaker wire ablation., Conclusions: This initial experience suggests that subclavian transarterial aortic valve implantation in patients with a patent left internal thoracic artery to left anterior descending artery is feasible and safe with satisfactory short-term outcomes., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Aims: High rates of permanent pacemaker (PPM) implantation are reported after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve® system. The Accutrak™ catheter is designed to allow a more predictable landing zone. Little is known about the real clinical impact of this catheter. The aims of this paper were to describe the potential impact of the Accutrak™ catheter on the accuracy of positioning a 26 or 29 mm CoreValve® across the aortic annulus and its impact on the need for a pacemaker., Methods and Results: A total of 134 patients were treated with the CoreValve® Accutrak™ system at two French centres (Lille and Toulouse). Mean age was 82.4 ± 4.7 years; logistic EuroSCORE was 24.3 ± 9.5%. Procedural success rate was 99.2%; mean depth of implantation was 4.9 mm. A final position between 0 and 6 mm was achieved in 85.8% of the patients. All-cause mortality at 30 days was 6%. The PPM implantation rate was 10.6%. Due to a limited number of events, we could not identify any predictor of need for a PPM: pre-existing right bundle branch block (RBBB) (OR 2.72 [0.63-11.87], p=ns), use of a 29 mm prosthesis (OR 2.73 [0.33-22.90], p=ns) and left ventricular septal hypertrophy (OR 2.63 [0.08-83.32], p=ns)., Conclusions: In this cohort of patients treated with the CoreValve® Accutrak™ system, the incidence of permanent pacemaker implantation was low, which may be a consequence of an average small implantation depth. The Accutrak™ catheter seems to be helpful in achieving higher and more predictable implants. Operators could standardise their technique to place the CoreValve® prostheses less than 6 mm below the aortic annulus.

Corevalve dislocation has been reported to significantly increase the perioperative risk for severe complications and poor outcomes. We describe the case of an 87-year-old man who was referred to our center for transcatheter aortic valve implantation and who experienced an original complication after Corevalve dislocation by subclavian approach. Indeed, during the attempt to retrieve the partially expanded and dislocated valve through the subclavian introducer sheath, we experienced a dislodgment of the valve from the housing sheath that led to a delivery catheter cone separation and systemic embolization., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: In some patients, transfemoral, transaxillary, or transapical aortic valve implantation is not possible. Thus, carotid artery access may represent a safe alternative to those accesses, and even offers certain advantages. In this article, we describe aortic valve implantation using the left carotid arterial approach and report our initial experience., Methods: Using a self-expandable nitinol based device (CoreValve ReValving system, Medtronic Ltd, Luxembourg), we exposed the left carotid artery through a small incision. Arterial puncture and initial 6F sheath introduction were achieved through a contraincision. The same implantation technique as for transaxillary implantation was used. Progressive artery dilatation was achieved using sheaths of increasing diameter. Rapid ventricular pacing was used to reduce cardiac output while performing a routine aortic balloon valvuloplasty. Only then, an 18F sheath was inserted into the carotid artery and pushed down into the ascending aorta. The patients were monitored using cerebral oxymetry to assess cerebral perfusion., Results: Twelve consecutive patients, at high surgical risk, were implanted and studied prospectively. Transfemoral and subclavian catheterization were considered unfeasible or at risk of severe complications. Carotid arterial injury did not occur in any patient. A transient ischemic attack occurred in 1 patient, contralateral to the carotid access. There were no deaths in either intraprocedural or during the 30-day follow-up period., Conclusions: This initial experience suggests that left carotid transarterial aortic valve implantation, in selected high-risk patients, is feasible and safe with satisfactory short-term outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim of the Study: The study aim was to describe the characteristics and operative mortality of patients requiring valve surgery during active infective endocarditis (IE)., Methods: This retrospective analysis involved 141 surgically treated patients with active IE. All cardiac operations were performed by the same surgical team between January 1998 and July 2009. All patients had definite (n = 128) or possible (n = 13) endocarditis according to modified Duke criteria. The IE was considered active if surgery was required before completion of a standard course of antimicrobial therapy. Operative mortality included any death occurring within the same hospital admission as surgery., Results: Among the patients (108 males, 33 females; mean age 56.3 +/- 14.9 years), native valve endocarditis was present in 122 cases (87%). Multiple valve involvement was observed in 27 patients. The infected valves were the aortic (n = 81), mitral (n = 70), tricuspid (n = 15), or pulmonary (n = 2). The most common pathogens were staphylococci (n = 49), streptococci (n = 46) and enterococci (n = 27). The operative mortality was 16%. In univariate analysis, factors linked to operative mortality were age, prosthetic valve endocarditis (PVE) and inadequate antimicrobial therapy. In multivariate analysis, only PVE was an independent adverse predictor (adjusted Odds Ratio = 4.16; 95% confidence intervals 1.14-12.2; p = 0.01)., Conclusion: Surgery for active IE is associated with a high mortality rate. The prognosis is impaired in patients with PVE, but might be improved by adequate antimicrobial therapy.