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Objective: Mechanical aortic valve replacement (AVR) is still the recommended valve substitute in young adults, although cultural reasons have popularized bioprostheses also in these patients. Inde...

Objective: Ascending aortic conduit with mechanical aortic valve prosthesis was the standard therapy for younger people suffering from severe aortic stenosis in combination with aortic aneurysm ove...

Escherichia coli is a rare cause of endocarditis. This article reports an 82-year-old male with a mechanical aortic valve replacement who was admitted for fever and fatigue. He was diagnosed with a tricuspid valve endocarditis caused by an extended spectrum beta lactamase producing Escherichia coli following positive blood cultures and echocardiography. He received six weeks of imipenem / cilastatin and subsequently improved and was discharged with ambulatory follow ups with his infectious disease specialist. Keywords: Tricuspid valve endocarditis, Infectious endocarditis, ESBL-producing E. coli, Case report, Imipenem

Mycobacterium chimaera is a rare infection associated with cardiopulmonary bypass. We describe a case of granulomatous interstitial nephritis caused by M. chimaera in a patient with prosthetic aortic valve endocarditis. A 63-year-old female with a mechanical aortic valve replacement developed fatigue, 20 lbs. weight loss, anemia, and an elevated creatinine. Fat pad aspirate at an outside hospital was suspicious for amyloidosis which prompted hematology referral at our institution. Bone marrow biopsy revealed a single granuloma, negative for amyloid or acid fast bacillus (AFB). She was admitted to our hospital for worsening kidney function refractory to intravenous fluid challenge. Transesophageal echocardiogram showed aortic root abscess and valve vegetation with negative blood cultures at seven days. Renal biopsy showed granulomatous interstitial nephritis and negative AFB stain. Prednisone 40 mg was started and renal function partially improved. Blood cultures obtained before biopsy subsequently grew M. chimaera. Three-drug antimicrobial therapy was initiated and prednisone discontinued. One month later, creatinine improved and follow up echocardiogram showed no lesion. Our case highlights this rare infection inducing granulomatous interstitial nephritis despite lack of positive AFB or gram stains on renal biopsy.

Summary Acute aortic valve obstruction is a medical and surgical emergency necessitating intensive care unit admission. The differential diagnosis includes thrombosis, pannus formation or vegetations. The diagnosis should be obtained as soon as possible, with possible orientation towards the cause. Different diagnostic modalities exist nowadays. Notably, the transesophageal echocardiography (TEE) offers a diagnosis and a guide for management. Surgical treatment remains of choice despite growing evidence about a benefit of combined thrombolytic and anticoagulation line of management. Learning points Acute management and resuscitation of acute valvular obstruction.Differential diagnosis and role of echo in the diagnosis.Management options.

Aortic stenosis (AS) is the third most common cardiovascular disease. Aortic valve replacement (AVR) is the only effective method of treatment in most AS patients. In some patients, AS leads to poststenotic dilatation of the ascending aorta – most commonly, this occurs in patients with concurrent aortic regurgitation or bicuspid aortic valve (BAV) and in patients after aortic valve replacement. Cardiac surgeons face the dilemma whether to perform concurrent replacement of the dilated ascending aorta in patients qualified for AVR, as it is associated with an increased risk of perioperative complications and mortality. We report a case of a patient with an ascending aortic aneurysm, who had been implanted with an aortic mechanical valve (Lillehei-Kaster 16 ECC) 37 years earlier.

A 48-year-old male with history of chronic arthritis and uveitis presented with 1 year of progressively reduced exercise capacity and nonexertional chest pain. Physical examination was consistent with severe aortic insufficiency. An electrocardiogram demonstrated sinus rhythm with first degree atrioventricular block. Transthoracic and transesophageal echocardiography demonstrated severe lone central aortic insufficiency of a trileaflet valve due to leaflet thickening, retraction of leaflet margins and mild aortic root dilation in the setting of left ventricular dilatation. In addition, computed tomographic angiography revealed a small focal aneurysm of the distal transverse arch. He was found to be positive for the immunogenetic marker HLA-B27. The patient subsequently underwent uncomplicated mechanical aortic valve replacement. The diagnosis of HLA-B27 associated cardiac disease should be entertained in any individual with lone aortic insufficiency, especially if accompanied by conduction disease.

Technical variations of the David reimplantation valve-sparing aortic root replacement (V-SARR) procedure have been proposed to be advantageous in patients with connective tissue disease, such as the Marfan syndrome (MFS). We report results of a Marfan cohort treated exclusively with the non-modified David I procedure.Forty-eight Marfan patients (25 males, mean age 33 ± 12 years, range 15-62 years) underwent the original variant of the David V-SARR (David I) between 1997 and 2013. Forty-two operations (88%) were performed as elective procedures for aortic root aneurysms and six for acute dissections (12%). Seventeen had aortic regurgitation (AR) grades ≥2+ preoperatively, and 3 had AR2+. No patients with severe AR (4+) were selected for V-SARR. Three full or hemi-arch replacements were performed. Patients who were operated on using a variation of the David I or David II procedure were excluded.Mean prosthesis size was 28 ± 3 mm (18-30 mm). Mean clinical and echocardiographic follow-up (98% complete) was 3.8 ± 3.7 years with a cumulative follow-up of 178 patient-years. The early mortality rate was 2% (one hospital death). The survival rate was 98% (95% confidence 84-99%) at 4 years and 90% (57-98%) at 8 years with 5 patients at risk at 10 years. The rate of freedom from root or valve reoperation was 97% (79-99%) and 97% (79-99%) at 4 and 8 years, respectively. Only one patient required mechanical aortic valve replacement for progression of AR.Despite potential theoretical drawbacks of the David I V-SARR technique without neo-sinuses or a neo-sinotubular junction, it results in a favourable mid-term outcome in Marfan patients and compares well with reported results of different modifications of David V-SARR.

Fluid mechanics computation of heart valves with an interface-tracking (moving-mesh) method was one of the classes of computations targeted in introducing the space---time (ST) interface tracking method with topology change (ST-TC). The ST-TC method is a new version of the Deforming-Spatial-Domain/Stabilized ST (DSD/SST) method. It can deal with an actual contact between solid surfaces in flow problems with moving interfaces, while still possessing the desirable features of interface-tracking methods, such as better resolution of the boundary layers. The DSD/SST method with effective mesh update can already handle moving-interface problems when the solid surfaces are in near contact or create near TC, if the "nearness" is sufficiently "near" for the purpose of solving the problem. That, however, is not the case in fluid mechanics of heart valves, as the solid surfaces need to be brought into an actual contact when the flow has to be completely blocked. Here we extend the ST-TC method to 3D fluid mechanics computation of heart valve models. We present computations for two models: an aortic valve with coronary arteries and a mechanical aortic valve. These computations demonstrate that the ST-TC method can bring interface-tracking accuracy to fluid mechanics of heart valves, and can do that with computational practicality.

A 61-year-old man was diagnosed with aortic stenoinsufficiency with periannular abscess, which involved the aortic root of noncoronary sinus (NCS) that invaded down to the central fibrous body, whole membranous septum, mitral valve (MV), and tricuspid valve (TV). The open complete debridement was executed from the aortic annulus at NCS down to the central fibrous body and annulus of the MV and the TV, followed by the left ventricular outflow tract reconstruction with implantation of a mechanical aortic valve by using a leaflet of the half-folded elliptical bovine pericardial patch. Another leaflet of this patch was used for the repair of the right atrial wall with a defect and the TV.

Aims A shortcoming common to all existing designs of mechanical cardiac valve prostheses is an increased trombogenicity caused, among other factors, by the lack of hydrodynamic compatibility between the luminal part of the prosthesis and the patterned blood flow. The aim of the study is to design and test our new mechanical aortic valve prosthesis to exclude life-long anticoagulation treatment. Materials and methods Standard hydrodynamic tests of the new prosthetic valve have been carried out for comparing with the other existing valve designs. A new method for the heart valve prosthesis testing in a tornado-like flow has been developed. The valve function has been verified in a swine excluding the anticoagulation treatment during the period of time exceeding six months. Results The significant advantage of the new prosthesis in the standard hydrodynamic tests has been demonstrated. The tests in the tornado-like flow have shown that only this prosthesis allows maintaining the pattern, the head and flow rate characteristics of the tornado-like jet. Upon implanting the new prosthesis in the aortic position in a swine, the good performance of the valve without anticoagulation therapy has been confirmed in the course of more than six months. Conclusion Obtained has been the evidence of the merits of the new mechanical aortic valve owing to the due consideration of the hydrodynamic peculiarities of the aortic blood flow and the creation of the design providing the proper hydrodynamic compatibility.

Dr. Aimo and colleagues from Italy identify several important points and raise interesting questions regarding the anticoagulation management of patients after mechanical aortic valve replacement (MAVR). The PROACT (Prospective Randomized On-X Anticoagulation Trial) trial [(1)][1] was designed more

We present a unique complication occurring during cryoballoon pulmonary vein isolation [(1)][1]. A 51-year-old woman with a history of coronary artery bypass and mechanical aortic valve replacement was referred for cryoballoon (Arctic Front Advance Cardiac CryoAblation Catheter System, Medtronic Inc

Background Micra transcatheter pacing systems were first brought onto the market in 2016. Currently the Micra pacemaker is indicated for VVIR mode in patients that experience symptomatic high-grade AV block, tachy-brady syndrome and individuals considered high risk for right atrial lead dislodgement. Our institution has utilized Micra pacing successfully in various clinical applications: limited transvenous access due to superior vena cava syndrome, right ventricular pacemaker lead induced tricuspid regurgitation, pacemaker infection and as described below, atrial fibrillation ablation shortly after pacemaker insertion. Case We report a case of a 72-year-old male with a history of symptomatic paroxysmal atrial fibrillation, mechanical aortic valve and morbid obesity who presented to our outpatient clinic for evaluation of his symptomatic atrial fibrillation. Despite increased Sotalol dosing, the patient continued to have symptomatic paroxysmal atrial fibrillation with symptoms of dizziness and near syncope. Outpatient monitoring revealed greater than 5-6 second pauses during atrial fibrillation episodes and greater than 1 second pauses during sinus rhythm. Clinical Decision Making Due to the patient's need for both a pacemaker and an atrial fibrillation ablation, the electrophysiologist felt the patient would be high risk for atrial lead dislodgment. Another concern was the patient's long-term anticoagulation secondary to his mechanical aortic valve. After a multidisciplinary discussion, the consensus was for a Micra pacemaker to be inserted with atrial fibrillation ablation to be performed shortly after. This was performed successfully and in outpatient follow up, the patient has been free of any further syncope, dizziness or atrial fibrillation. Conclusions This case focuses on creating awareness that Micra transcatheter pacing can be utilized in high risk patients with excellent results in an ever-expanding list of clinical indications.

Purpose In postcardiotomy shock patients with prosthetic valves , the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may induce prosthetic valve thrombosis due to blood stasis in cardiac chambers. Incidence and outcomes of prosthetic valve thrombosis during VA ECMO has not been previously described. Methods Between January 2007 and June 2018, a total of 171 patients underwent VA ECMO therapy after major cardiovascular surgery at our center. Of these patients, 89 had a prosthetic valve in place, and we conducted a retrospective review of this cohort. Results Of the 89 patients with prosthetic valves placed on VA ECMO, 37 (41.5%) had central VA ECMO cannulation , and the remaining 52 patients (58.5%) underwent peripheral VA ECMO cannulation. Median age was 66 years (interquartile range [IQR], 55-74) and 53 (59.6%) were men. Average duration of ECMO support was 5.1 days (IQR 3.0, 8.5). The majority of patients (76.4%, n = 68) were on therapeutic anticoagulation within 24 hours post-cardiotomy, and inotropes were used in all patients. A total of 8 patients (9%) developed prosthetic valve thrombosis: 5 involved the aortic valve (including one mechanical aortic valve prosthesis), 2 involved bioprosthetic mitral valves , and 1 involved a bioprosthetic pulmonary valve (Table). Overall cohort survival to discharge was 41.2% (n = 35), but was reduced to 9% (n = 1) amongst those patients that developed valve thrombosis. Conclusion Prosthetic valve thrombosis is relatively common complication while patients with prosthetic valves are placed on VA-ECMO, and it is almost uniformly fatal when it does develop.

The decision of which advanced therapies to implement can become challenging with a patient with mechanical aortic valve surgery and decompensated heart failure. Our case highlights a patient who was referred for advanced therapies however was not an ideal candidate for OHT or LVAD implantation. A

Valve-sparing root replacement (the David procedure) is a valuable alternative to conventional aortic root replacement with a composite graft, especially in patients whose aortic valve leaflets have not been altered. However, reintervention rates are higher than are those associated with composite graft implantation. In this report, we present the case of a patient who had undergone valve-sparing root replacement 2 years earlier and was admitted to our hospital with myocardial infarction and cardiogenic shock secondary to coronary ostial button dissection, aortic pseudoaneurysm formation, and severe left main coronary artery compression. To our knowledge, this case is exceedingly rare. Rather than attempt local reconstruction of the mouth of the pseudoaneurysm, we excised the lesion, the aortic valve, and the graft, and we successfully implanted a composite aortic graft with a mechanical aortic valve.

Obstruction of mechanical aortic valve is a rare but serious complication associated with a high mortality rate that frequently follows thrombosis – due to regional clotting or, less often, due to endocarditis. Thrombosis of mechanical heart valve depends on certain factors such as lifestyle, coagulation status, valve position, presence of atrial fibrillation and ventricular dysfunction. 70-year-old patient is admitted to the On-Call Department for moderate-severe dyspnea with progressive onset over the last month with a history of a prior aortic valve replacement. An echocardiogram reveals a dysfunctional metallic aortic prosthesis. He undergoes a surgical intervention for mechanical valve replacement with iterative median sternotomy and a meticulous dissection of the pleuro-pericardial adhesions. Post operative evolution in the ICU is followed by SIRS.The patient goes into a GCS 4 coma and the neurological examination presumes a recent stroke.

OBJECTIVES: The ideal prosthesis for young patients requiring aortic valve replacement has not been defined to date. Although the Ross procedure provides excellent survival, its application is still limited. We compared the long-term survival after the Ross procedure with mechanical aortic valve replacement. METHODS: All consecutive Ross procedures and mechanical aortic valve replacements performed between 1991 and 2008 at a single centre were analysed. Only adult patients between 18 and 50 years of age were included in the study. Survival and valve-related complications were evaluated. Furthermore, survival was compared with the age- and sex-matched Austrian population. RESULTS: A total of 159 Ross patients and 173 mechanical valve patients were included. The cumulative survival for the Ross procedure was significantly better, with survival rates of 96, 94 and 93% at 5, 10 and 15 years, respectively, in comparison to 90, 84 and 75% (P< 0.01) for patients with mechanical valves. A Cox regression analysis including patients’ age, gender and valve type revealed age and the type of aortic valve replacement as independent significant factors influencing survival (for age, hazard ratio = 1.1, 95% confidence interval = 1.0– 1.1, P= 0.03; and for valve type, hazard ratio = 2.6, 95% confidence interval = 1.2–5.8, P= 0.02). The observed survival was comparable to the expected standard survival for the Ross group but was significantly reduced in the mechanical valve group. CONCLUSIONS: In a real-world setting, the Ross procedure is associated with a long-term survival benefit in young adults in comparison to mechanical aortic valve replacement.

A 75-year old woman with a history of coronary disease status post 3-vessel coronary artery bypass grafting (CABG) 8 years ago and a repeat one-vessel CABG 2 years ago in the setting of aortic valve replacement with a #19 mm St. Jude bileaflet mechanical valve for severe aortic stenosis presented with two to three weeks of progressive dyspnea and increasing substernal chest discomfort. Echocardiography revealed a gradient to 31 mmHg across her aortic valve, increased from a baseline of 13 mmHg five months previously. Fluoroscopy revealed thrombosis of her mechanical aortic valve. She was not a candidate for surgery given her multiple comorbidities, and fibrinolysis was contraindicated given a recent subdural hematoma 1 year prior to presentation. She was treated with heparin and eptifibatide and subsequently demonstrated resolution of her aortic valve thrombosis. We report the first described successful use of eptifibatide in addition to unfractionated heparin for the management of subacute valve thrombosis in a patient at high risk for repeat surgery or fibrinolysis.

Aims: We present this case to raise awareness of this unusual presentation of a malignant anomalous right coronary artery arising from the left coronary cusp in a patient older than 50 years. We describe a useful imaging modality and discuss therapy. Presentation of the Case: We report a case of a 63-year-old male with an interarterial coursing right coronary artery arising from the left coronary cusp with a history of a mechanical aortic valve replacement. The patient presented to our emergency department after being resuscitated from a cardiac arrest and later had a normal coronary angiogram. High suspicion of his right coronary artery angulation, he underwent a computed tomography with angiogram that revealed his anomalous course and anatomy. Discussion: We discuss the importance of coronary artery anomaly detection in the young at risk population (athletics), pathophysiology, diagnostic modalities, and treatment recommendations. Surgical revascularization has been advocated in malignant coronary anomalies, however, the lack of large randomized clinical trials for patients older than 50year-old left this topic controversial. Medical therapy augmented with implanted cardioverter defibrillator (ICD) was utilized in this case. Medical management could be considered in centers that don’t have surgical experience or in adult patients who are a Case Study British Journal of Medicine & Medical Research, 4(1): 501-509, 2014 502 poor surgical candidate because of other comorbidities or life expectancy. Conclusion: Computed tomography with angiogram seems to be the best noninvasive modality to delineate coronary course and anatomy. There is a need for randomized clinical trials to determine the best management of anomalies arising from opposite sinus with an interarterial course in adults >50-year-old.

Introduction: In recent decades, new high-performance prostheses have been invented for use with small aortic annuli, and they have helped avoid patient prosthesis mismatch (PPM) without the need for aortic annular enlargement. The purpose of this study is to examine the trends in mechanical aortic valve replacement surgery in a large, multi-surgeon, single hospital practice. Material and methods: Between January 1999 and January 2008, 1337 consecutive patients underwent aortic valve replacement (AVR) with or without concomitant aortic annulus enlargement. Patients with aortic dissections and patients undergoing Bentall and Ross procedures were excluded from the analysis. Patients were grouped according to the used aortic valve size. The data were collected and analyzed retrospectively. Results: The mean age of the subjects was 54.37 ± 17.35 (range: 10-84), and 881 of them were men (65.8%). The number of aortic root enlargement procedures decreased over the years (p 0.05). Although the use of combined surgery increased in time, there was no statistical relationship with any increase in mortality rates (p > 0.05). Conclusions: This study showed that avoiding the procedure of aortic root enlargement and implanting high-performance

Background: The use of low molecular weight heparin for early anticoagulation after mechanical aortic valve replacement is still a matter of debate even more that the early postoperative phase is associated with maximum of thrombo-embolic and bleeding risks. The objective of this study is to verify the efficacy and the safety of low molecular weight heparin for the early anticoagulation after mechanical aortic valve replacement. Methods and Results: It is a prospective study conducted over 6 months and interested 40 consecutive patients (32 male and 8 female) with a mean age 53.83 ± 16.93 years (19-75 years) who underwent a mechanical aortic valve replacement and received enoxaparin as bridging therapy between continuous unfractionated heparin and fully effective vitamin K antagonist therapy. There was no in-hospital death and no in-hospital thromboembolic events. We report 2 major bleeding events (5%). Conclusion: The use of low molecular weight heparin should be an alternative to explore for early anticoagulation after valve heart surgery and the results of our study must be verified by large randomized studies before drawing any hasty conclusions.

A 71-year-old man initially presented with an asymptomatic, incidentally detected ascending aortic pseudoaneurysm 25 years following aortic root repair with mechanical aortic valve replacement. This pseudoaneurysm was previously treated with coil embolization but due to coil impaction it reopened 8 years later. Endovascular closure of the pseudoaneurysm was achieved with the off-label use of a type II Amplatzer vascular plug.

Objectives The primary aim of this retrospective study was to evaluate short-term (one-to-six months) and mid-term (six-to-forty-eight months) results of aortic valve-sparing procedures. The second endpoint was to compare the results with the group of patients undergoing mechanical aortic valve replacement during the same period. Methods Between April 2008 and May 2012 at our institution, we treated 76 patients either with ascending aorta/root aneurysm/dissection or with isolated aortic regurgitation. A total of seventy-six patients undergoing aortic valve surgery. Results Analyzed parameters were divided into two parts as function of time. In the first part, i.e. during hospitalization, the mortality, duration of hospitalization, duration of extra corporeal circulation (ECC), and duration of cardiac arrest (CA) were compared and assessed. In the second part, i.e. during monitoring of the patients after their discharge from hospital (one-to-six months, and six-to-forty-eight months), the grade of postoperative AR aimed mainly at the group of aortic valve-sparing operations (subgroups A1, A2, A3), postoperative peak gradient, presence of thromboembolic and bleeding complications, postoperative endocarditis and need for reoperation or hospitalization due to cardiac reasons were analyzed. Conclusion Based on our first experience, we believe that in spite of higher technical difficulty, the aortic valve-sparing operations can be possibly performed with the same or respectively lower rate of postoperative morbidity and mortality. Presented results show that compared with the aortic valve replacement, the aortic valve-sparing operation is a promising method, and an interesting therapeutic alternative for patients. After proper indications, we consider it to be a method of choice (Tab. 6, Fig. 7, Ref. 28).

Background Acute dysfunction of mechanical aortic valve prostheses is a life-threatening adverse event. Pannus overgrowth, which is fibroelastic hyperplasia originating from the periannular area, is one cause of dysfunction. The aim of this study was to determine the annual incidence of readmittance resulting from acute obstruction caused by pannus during 30 years of observation in patients with Medtronic-Hall aortic valve prostheses and to analyze the risk factors associated with pannus development. Methods From 1982 to 2004, 1,187 patients in our department underwent aortic valve replacement with Medtronic-Hall mechanical monoleaflet valve prostheses. As of December 31, 2012, 27 of these patients (2.3%) had presented with acute valve dysfunction caused by pannus obstruction. Results The annual incidence of pannus was 0.7 per 1,000. The median time from the primary operation to prosthetic dysfunction was 11.1 years (range, 1.2 to 26.8 years). Of the 20 patients who underwent reoperation, 2 died. Seven patients died before reoperation. Women had a higher risk for the development of obstructing pannus, and patients with pannus obstruction were younger. Valve size was not an independent risk factor. Conclusions Women and younger patients are at higher risk for pannus development. When acute dysfunction by pannus is suspected in a mechanical aortic valve, an immediate echocardiogram and an emergency aortic valve replacement should be carried out because of the potential of a fatal outcome.

Aim: This study analyzes the long-term outcomes of mechanical aortic valve replacement in octogenarian patients. Material and Method: A retrospective review was performed on 23 octogenarian patients who underwent mechanical aortic valve replacement. Hospital mortality, postoperative intensive care unit stay, hospital stay and long-term results was examined. Estimates of the cumulative event mortality rate were calculated by the Kaplan-Meier method. Results: The mean age of all patients was 82.9±2.3 years and most were men (65.22%). The median ejection fraction was 45%. 73.91% of patients were in New York Heart Association class III-IV. Thirteen patients (56.52%) in this study underwent combined procedure, the remaining 10 (43.48%) patients underwent isolated aortic valve replacement. The most common valve size was 23 mm. The mean intensive care unit stay was 1.76±1.14 days. The mean hospital stay was 9.33±5.06 days. No complications were observed in 56.52% patients during their hospital stay. The overall hospital mortality was 8.7%. Follow-up was completed for all 23 patients. Median follow-up time was 33 months (1-108 months). Actuarial survival among discharged from hospital was 59% at 5 years. Discussion: Mechanical aortic valve replacement is a safe procedure in octogenarian patients and can be performed safely even in combined procedure.

The Ross–Konno procedure has become a widely recognized surgical method for the treatment of complex left ventricular outflow tract obstruction (LVOTO) in patients of younger age. We applied this method in two young females who presented following mechanical aortic valve replacement with severe prosthesis-patient mismatch (PPM) resulting in significant gradient across the left ventricular outflow tract and congestive heart failure. In both cases the postoperative course was uneventful with immediate improvement in clinical symptoms. Both patients remain in excellent clinical and hemodynamic condition four and six years after the Ross–Konno procedure. doi: 10.1111/jocs.12210 (J Card Surg 2013;28:666–669)

We describe 2 cases of mechanical aortic valve endocarditis and the influence on clinical outcome and prostheses material integrity. One patient required extensive reconstruction due to active endocarditis leading to a “rocking valve”. The second case was caused by late aortic dissection following endocarditis. Both valve prostheses showed remarkable material quality and performance in functional assessment and high resolution scanning electron microscopic evaluation after 27 and 23 years of service.

The presence of a mechanical prosthesis has been regarded as an increased risk of thromboembolic complications and as a relative contraindication for a left ventricular assist device (LVAD). Five patients in our center had a mechanical aortic valve at the time of device implantation and were studied regarding thromboembolic complications.Five patients operated upon with an LVAD (1 HeartMate I™, 4 HeartMate II™) between 2002 and 2011 had a mechanical aortic valve at the time of implantation. The first patient had a patch closure of the aortic valve. In four patients, the prosthesis was left in place. Anticoagulants included aspirin, warfarin, and clopidogrel.The average and accumulated treatment times were 150 and 752 days, respectively. Three of the five patients showed early signs of valve thrombosis on echo with concomitant valve dysfunction. Four patients were transplanted without thromboembolic events during pump treatment. One patient died from a hemorrhagic stroke after 90 days on the LVAD.The strategy of leaving a mechanical heart valve in place at the time of LVAD implantation in five patients led to valvular thrombosis in three but did not provoke embolic events. It increased the complexity of postoperative anticoagulation.

Background— There is a paucity of long-term data comparing biological versus mechanical aortic valve prostheses in older individuals. Methods and Results— We performed follow-up of patients aged 65 to 80 years undergoing aortic valve replacement with a biological (n=24 410) or mechanical (n=14 789) prosthesis from 1991 to 1999 at 605 centers within the Society of Thoracic Surgeons Adult Cardiac Surgery Database using Medicare inpatient claims (mean, 12.6 years; maximum, 17 years; minimum, 8 years), and outcomes were compared by propensity methods. Among Medicare-linked patients undergoing aortic valve replacement (mean age, 73 years), both reoperation (4.0%) and endocarditis (1.9%) were uncommon to 12 years; however, the risk for other adverse outcomes was high, including death (66.5%), stroke (14.1%), and bleeding (17.9%). Compared with those receiving a mechanical valve, patients given a bioprosthesis had a similar adjusted risk for death (hazard ratio, 1.04; 95% confidence interval, 1.01–1.07), higher risks for reoperation (hazard ratio, 2.55; 95% confidence interval, 2.14–3.03) and endocarditis (hazard ratio, 1.60; 95% confidence interval, 1.31–1.94), and lower risks for stroke (hazard ratio, 0.87; 95% confidence interval, 0.82–0.93) and bleeding (hazard ratio, 0.66; 95% confidence interval, 0.62–0.70). Although these results were generally consistent among patient subgroups, bioprosthesis patients aged 65 to 69 years had a substantially elevated 12-year absolute risk of reoperation (10.5%). Conclusions— Among patients undergoing aortic valve replacement, long-term mortality rates were similar for those who received bioprosthetic versus mechanical valves. Bioprostheses were associated with a higher long-term risk of reoperation and endocarditis but a lower risk of stroke and hemorrhage. These risks varied as a function of a patient’s age and comorbidities.

Background Haemodynamic performance of heart valve prosthesis can be defined as its ability to fully open and completely close during the cardiac cycle, neither overloading heart work nor damaging blood particles when passing through the valve. In this perspective, global and local flow parameters, valve dynamics and blood damage safety of the prosthesis, as well as their mutual interactions, have all to be accounted for when assessing the device functionality. Even though all these issues have been and continue to be widely investigated, they are not usually studied through an integrated approach yet, i.e. by analyzing them simultaneously and highlighting their connections. Results An in vitro test campaign of flow through a bileaflet mechanical heart valve (Sorin Slimline 25 mm) was performed in a suitably arranged pulsatile mock loop able to reproduce human systemic pressure and flow curves. The valve was placed in an elastic, transparent, and anatomically accurate model of healthy aorta, and tested under several pulsatile flow conditions. Global and local hydrodynamics measurements and leaflet dynamics were analysed focusing on correlations between flow characteristics and valve motion. The haemolysis index due to the valve was estimated according to a literature power law model and related to hydrodynamic conditions, and a correlation between the spatial distribution of experimental shear stress and pannus/thrombotic deposits on mechanical valves was suggested. As main and general result, this study validates the potential of the integrated strategy for performance assessment of any prosthetic valve thanks to its capability of highlighting the complex interaction between the different physical mechanisms that govern transvalvular haemodynamics. Conclusions We have defined an in vitro procedure for a comprehensive analysis of aortic valve prosthesis performance; the rationale for this study was the belief that a proper and overall characterization of the device should be based on the simultaneous measurement of all different quantities of interest for haemodynamic performance and the analysis of their mutual interactions. Electronic supplementary material The online version of this article (doi:10.1186/s12938-017-0314-2) contains supplementary material, which is available to authorized users.

Patients with mechanical aortic valves are generally contraindicated for left ventricular assist device (LVAD) insertion because the prosthetic valve often becomes fixed in closed position. A 41-year-old woman with mechanical aortic valve prosthesis experienced sudden chest pain and developed cardiogenic shock. A paracorporeal pulsatile LVAD and a monopivot centrifugal pump as a right VAD (RVAD) were implanted. The mechanical aortic valve was intentionally left in place. Soon after the operation, LVAD support was discontinued daily for few seconds to allow the mechanical aortic valve to open and to avoid thrombus formation. The patient was successfully weaned off RVAD and received anticoagulation therapy with warfarin. On postoperative day 141, she was transferred to a university hospital where a HeartMate II LVAD was implanted, and the aortic valve was successfully replaced with a bioprosthetic valve. The patient is currently awaiting heart transplantation.

Acute myocardial infarction (MI) in the setting of infective endocarditis (IE) of mechanical cardiac valve is a rare phenomenon. The most challenging aspect is the recognition between septic embolus versus thromboembolism from prosthesis in the setting of sub-therapeutic INR especially when the coronary vasculature is normal and etiology is not clear. We are presenting a case of 56-year-old patient who developed ST elevation MI during treatment of IE of mechanical aortic valve. Cardiac catheterization showed a very subtle blockade at most distal end of LAD therefore percutaneous coronary intervention (PCI) could not be carried out. Given the lack of clear etiology between septic embolus versus prosthesis associated thromboembolism, we opted for a successful conservative approach.

BACKGROUND: Cardiovascular Magnetic Resonance is often used to evaluate patients after heart valve replacement. This study systematically analyses the influence of heart valve prostheses on phase contrast measurements in a phantom trial. METHODS: Two biological and one mechanical aortic valve prostheses were integrated in a flow phantom. B0 maps and phase contrast measurements were acquired at a 1.5 T MR scanner using conventional gradient-echo sequences in predefined distances to the prostheses. Results were compared to measurements with a synthetic metal-free aortic valve. RESULTS: The flow results at the level of the prosthesis differed significantly from the reference flow acquired before the level of the prosthesis. The maximum flow miscalculation was 154 ml/s for one of the biological prostheses and 140 ml/s for the mechanical prosthesis. Measurements with the synthetic aortic valve did not show significant deviations. Flow values measured approximately 20 mm distal to the level of the prosthesis agreed with the reference flow for all tested all prostheses. CONCLUSIONS: The tested heart valve prostheses lead to a significant deviation of the measured flow rates compared to a reference. A distance of 20 mm was effective in our setting to avoid this influence.

Background Deciding which prosthetic aortic valve to choose is difficult in adolescents who have not yet met their full growth potential. The aim of this study was to assess long-term outcomes following mechanical aortic valve replacement with aortic root enlargement in adolescents. Methods Between September 1997 and December 2006, 58 consecutive adolescents (49 male, 9 female, median age 15.5, range 13 to 17 years) underwent mechanical aortic valve replacement with aortic root enlargement. All patients received long-term anticoagulation treatment with warfarin, aiming to maintain an international normalized ratio between 2.0 and 2.5. Follow-up of all patients was closed in December 2015. Results The mean size of implanted valves was 20.1 ± 1.3 mm. There were two operative deaths (3.4%) and one late death (1.7%). Mean follow-up was 11.6 ± 3.3 years (range, 8.5 to 15.8 years). Actuarial survival at 15 years was 94.7 ± 3.2%. No patient required a redo procedure. At the latest clinical evaluation, 47 patients (81.0%) were in New York Heart Association functional class I and 8 (13.8%) were in functional class II. Actuarial freedom from valve-related complication was 88.1 ± 2.8% at four years. The mean gradient across the aortic mechanical valve on echocardiography was 13.2 ± 6.3 mmHg (range 6 to 38 mmHg). Conclusions Mechanical aortic valve replacement with aortic root enlargement remains an excellent treatment option in adolescents with full growth potential. The mortality is very low and all surviving patients resumed normal lifestyles. It represents a good alternative to allografts and bioprostheses in adolescent patients with aortic valve disease.

Background The management of Dengue virus infection can be challenging. Varied presentations and numerous complications intrinsic to dengue by itself increase the complexity of treatment and potential mortality. When burdened with the presence of additional comorbidities and the need to continue compulsory medications, clear stepwise definitive guidance is lacking and patients tend to have more complex complications and outcomes calling to question the clinical decisions that may have been taken. The use and continuation of warfarin in dengue virus infection is one such example. Case presentation We report a 65 year old South Asian female who presented with dengue fever. She had a history bronchial asthma, a prior abdominal surgery, and was on warfarin and maintained a therapeutically appropriate internationalized normalized ratio for a mechanical aortic valve replacement. Though preemptive decision to stop warfarin was taken with decreasing platelet counts, her clinical course was complicated with the development of bilateral rectus sheath haematoma’s requiring resuscitation with blood transfusions. Conclusion Though management of dengue viral fever has seen drastic evolution with recent updated guidance, clinical scenarios seen in the course of the illness still pose challenges to the managing physician. The need to continue obligatory anticoagulation which may seem counterintuitive during a complex disease such as dengue virus infection must be considered after understanding the potential risks versus that of its benefits. Though case by case decisions maybe warranted, a clear protocol would be very helpful in making clinical decisions, as the correct preemptive decision may potentially avert catastrophic and unpredictable bleeding events.

BACKGROUND: Infective endocarditis is a rare disease associated with high morbidity and mortality. As a result, early diagnosis, prompt antibiotic treatment with or without surgical intervention is crucial in the management of such a condition. CASE REPORT: We report a case of missed infective endocarditis of the aortic valve. The patient underwent mechanical aortic valve replacement, with the native valve sent for histopathological analysis. On re-admission with syncope and shortness of breath he was noted to have complete heart block and severe aortic regurgitation and paravalvular leak. DISCUSSION: On review of the histopathology, endocarditis was identified which had not been acted upon at the original operation. The patient underwent redo aortic valve replacement with insertion of a permanent pacemaker and treatment with appropriate antibiotics. CONCLUSION: We highlight the importance of following up histopathological results as well as the need for multidisciplinary treatment of endocarditis with a combination of surgical and antibiotic therapy.

We present a case of a 50 year-old woman who was referred to our department with severe symptomatic aortic stenosis and systemic mastocytosis. Conventional mechanical aortic valve replacement was performed successfully with the use of perioperative protocol based on dexamethasone, cetirizine and ranitidine. The only postoperative event was an onset of atrial fibrillation which was treated with amiodarone infusion. 8 days after surgery the patient was discharged home. JRCD 2017; 3 (2): 54–55

Invasive hemodynamic evaluation in the patient with a mechanical aortic valve has in the past required transseptal or apical left ventricular puncture in order to obtain left ventricular pressure measurements. Over the last few years, several case reports have described the feasibility of using a coronary pressure-sensing guidewire to cross mechanical prosthetic aortic valves. In the current manuscript, we report four cases in which the use of a pressure-sensing guidewire was utilized for invasive hemodynamic diagnostic evaluation in patients with mechanical aortic valves. Furthermore, we present a detailed description of the technical approach to this technique and the limitations of this approach. © 2013 Wiley Periodicals, Inc.

Identifying the pathogen responsible for culture-negative valve endocarditis often depends on molecular studies performed on surgical specimens. A patient with Ehlers-Danlos syndrome who had an aortic graft, a mechanical aortic valve, and a mitral anulloplasty ring presented with culture-negative prosthetic valve endocarditis and aortic graft infection. Research-based polymerase chain reaction (PCR)/electrospray ionization mass spectrometry on peripheral blood samples identified Bartonella henselae. Quantitative PCR targeting the16S-23S ribonucleic acid intergenic region and Western immunoblotting confirmed this result. This, in turn, permitted early initiation of pathogen-directed therapy and subsequent successful medical management of B henselae prosthetic valve endocarditis and aortic graft infection.

The wall of a true aneurysm is composed of all histologic layers of the aorta. A false aneurysm represents a small, contained rupture of aorta followed by bulging of the corresponding area that is usually sustained by a fibrous peel. Aortic dissection is defined as a separation of the lamellae of the aortic wall. Herein, we describe an unusual clinical presentation of aortic dissection in a 37-year-old male patient that presented severe aortic regurgitation and unusual bulges with linear intimal fissures in ascending aorta underwent mechanical aortic valve replacement and interposition of tubular vascular graft in ascending aorta.

Complete dehiscence of a composite aortic valve graft with pseudoaneurysm formation is a rare complication following aortic root replacement. This complication often takes place in the setting of acute graft infection and accompanies symptoms of heart failure, valve insufficiency or sepsis. We present a delayed, asymptomatic presentation of this complication in a young man with distant history of aortic root replacement and medically treated prosthetic valve endocarditis a year postoperatively. He had been non-adherent to warfarin over 10 years, but otherwise maintained a healthy life. After being lost to follow-up, he re-presented 12 years after the initial operation with new-onset seizures. Echocardiogram revealed complete dehiscence of a composite valved conduit at the proximal anastomosis site with a resultant large pseudoaneurysm. The patient underwent an urgent re-operation with resection of the pseudoaneurysm and insertion of a tissue valved conduit. He had an uncomplicated postoperative recovery and promised close follow-up on discharge.

We present the cases of two patients with bioprosthetic aortic valves who developed an allergy to alpha-gal. Each had premature degeneration of their bioprosthesis and demonstrated rapidly increasing transvalvular gradients after development of their allergy. Each underwent successful replacement with a mechanical aortic valve within 1-2 years of symptom onset. doi: 10.1111/jocs.12764 (J Card Surg 2016;31:446-448).

Background the last 30 years have been associated with increased survival of 30 years in patients with Marfan syndrome. AWe thought to assess cause of death in patients with Marfan syndrome who were seen in the CNMR Syndrome de Marfan and related Methods patients who came at least once in CNMR, had a diagnosis of MFS with a FBN1 gene mutation were identified; patients who died where selected. Results 53 deaths were reported among the 1253 patients. Median age at death was 41 years and 35% were women. Three deaths occurred in children affected by a neonatal form of MFS: cause of death was 1) acute respiratory failure in a 2 years old boy with severe mitral regurgitation and severe restrictive respiratory failure, 2) post-operative death after planned surgery for MR and aortic aneurysm in a 4 years old boy and 3) sudden death in a 6 years old boy with aortic root diameter at 42mm;Thirteen deaths occurred after planned aortic surgery.Surgery has been performed for isolated aortic root dilatation or with mitral valve repair, Redo surgery, aortic root dilatation after supracoronary tube implantation, false aneurysm after a Bentall, dilatation of dissected thoracic descending aorta or mitral valve repair. Ten deaths were related to acute aortic events: Dissection of ascending aorta in 8, descending aorta in 1 and abdominal aorta in 1. Six patients died after myocardial infarction, Stroke, heart failure, aortic mechanical prosthesis thrombosis, ruptured mitral. Nine sudden cardiac deaths without autopsy performed were reported.Three deaths were related a mechanical aortic valve endocarditis in 2 patients and one patient died of a hemorrhagic shock complicating anticoagulation. Lastly, 9 deaths were non cardiac. Conclusion In MFS patients with a FBN1 gene mutation, cardiovascular deaths remains the leading cause of death despite increase in life expectancy associated with the modern care of the patients. Notably, post-operative mortality is high in this population. The author hereby declares no conflict of interest

This work focuses on the comparison between Newtonian and non-Newtonian blood flows through a bileaflet mechanical heart valve in the aortic root. The blood, in fact, is a concentrated suspension of cells, mainly red blood cells, in a Newtonian matrix, the plasma, and consequently its overall behavior is that of a non-Newtonian fluid owing to the action of the cells’ membrane on the fluid part. The common practice, however, assumes the blood in large vessels as a Newtonian fluid since the shear rate is generally high and the effective viscosity becomes independent of the former. In this paper, we show that this is not always the case even in the aorta, the largest artery of the systemic circulation, owing to the pulsatile and transitional nature of the flow. Unexpectedly, for most of the pulsating cycle and in a large part of the fluid volume, the shear rate is smaller than the threshold level for the blood to display a constant effective viscosity and its shear thinning character might affect the system dynamics. A direct inspection of the various flow features has shown that the valve dynamics, the transvalvular pressure drop and the large-scale features of the flow are very similar for the Newtonian and non-Newtonian fluid models. On the other hand, the mechanical damage of the red blood cells (hemolysis), induced by the altered stress values in the flow, is larger for the non-Newtonian fluid model than for the Newtonian one.

The presence of a mechanical aortic valve prosthesis has been considered a contraindication to retrograde percutaneous closure of mitral paravalvular leaks, because passing a catheter through the mechanical aortic valve can affect the function of a mechanical valve and thereby lead to severe hemodynamic deterioration. We report what we believe are the first 2 cases of retrograde transcatheter closure of mitral paravalvular leaks through a mechanical aortic valve prosthesis without transseptal or transapical puncture. Our experience shows that retrograde transcatheter closure of mitral paravalvular leaks in this manner can be an optional approach for transcatheter closure of such leaks, especially when a transapical or transseptal puncture approach is not feasible. This technique might also be applied to other transcatheter procedures in which there is a need to pass a catheter through a mechanical aortic valve prosthesis.