Search

With the expansion of the indication for transcatheter aortic valve implantation (TAVR), the value of access to on-site emergency heart surgery at performing centers needs to be assessed.To evaluate postoperative mortality after surgical rescue post-TAVR, in a population at high surgical risk.Retrospective analysis of a cohort of patients included in the France-TAVI registry who had undergone TAVR with the latest generation valves between January 2017 and February 2020.Among the 968 patients undergoing TAVR, 6 patients (0.62%) were identified as candidates for surgery: 3 in the peri-operative context and 3 during hospitalization. Four subjects were managed in a salvage situation, two due to tamponade, one due to aortic dissection, and one due to aortic annulus rupture. One patient died of a delayed aortic annulus rupture and one patient presented a right coronary occlusion which was medically treated. All patients who underwent emergency surgery were discharged alive from the hospital.In TAVR patients initially contraindicated for surgery, emergency bailout surgery could be performed successfully with all patients discharged alive. Access to on-site heart surgery represents a life-saving resource for TAVR centers.

In recent years, transcatheter aortic valve implantation (TAVI) without predilation (direct TAVI) has become the preferred method for implanting TAVI prostheses. Appropriate patient selection is important to avoid suboptimal outcomes and associated complications.To evaluate whether aortic valve calcification measured with computed tomography predicts suboptimal results from direct TAVI with a self-expanding prosthesis.Single-centre retrospective analysis of patients who received a CoreValve™ prosthesis (Medtronic, Minneapolis, MN, USA) in a direct TAVI procedure between January 2018 and March 2019. Aortic valve calcification assessment (aortic valve calcium score, calcium volume and calcium mass) was calculated from the computed tomography scan before TAVI. Procedural characteristics, need for postdilation and complications were analysed.Of 168 included patients, 18 were postdilated. Aortic valve calcium score (4259 vs. 2578; P0.001), calcium volume (1184 vs. 647mmA high aortic valvular calcium score, assessed by computed tomography scan, is an independent predictor of suboptimal prosthesis implantation outcomes in direct TAVI.

Summary Background Immediate improvement in kidney function has been reported after surgical aortic valve replacement or transcatheter aortic valve implantation. Long-term data, however, are not available. Aim To assess the evolution of kidney function in chronic kidney disease stage 3b–5, 1 year after surgical aortic valve replacement or transcatheter aortic valve implantation. Methods All patients with chronic kidney disease stage 3b–5 undergoing surgical aortic valve replacement or transcatheter aortic valve implantation for aortic stenosis in a single centre were included. Kidney function was assessed 1 year postprocedure. Improvement or deterioration in estimated glomerular filtration rate was defined by an increase or decrease of 5 mL/min/1.73 m2, respectively. Results Overall, 127 procedures were analysed (54 surgical aortic valve replacements and 73 transcatheter aortic valve implantations). Kidney function improved in 51% of patients at 1 year (45% of the surgical aortic valve replacement group versus 57% of the transcatheter aortic valve implantation group; P = 0.21), and deteriorated in only 14% of patients at 1 year (18% of the surgical aortic valve replacement group versus 10% of the transcatheter aortic valve implantation group; P = 0.22). Almost a quarter of patients (23%) had an improvement in estimated glomerular filtration rate of > 15 mL/min/1.73 m2, and this was consistent at later follow-up. Few patients went onto chronic dialysis at 1 year (three after surgical aortic valve replacement and one after transcatheter aortic valve implantation). Acute kidney injury was an independent prognostic factor for long-term deterioration in kidney function (odds ratio 2.1, 95% confidence interval 1.4–3.6; P = 0.006). Conclusion Aortic valve replacement, whether by surgical aortic valve replacement or transcatheter aortic valve implantation, improved estimated glomerular filtration rate at 1 year in more than half of patients with chronic kidney disease stage 3b–5.

BACKGROUND Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. OBJECTIVES This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. METHODS The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. RESULTS A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p = 2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in < 2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. CONCLUSIONS The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time. (J Am Coll Cardiol 2016; 68: 1637-47) (C) 2016 by the American College of Cardiology Foundation.

Analysis of the causes, outcomes, and mortality of patients with severe symptomatic aortic stenosis requiring the implantation of 2 valves during transcatheter aortic valve implantation was conducted from the French Aortic National CoreValve and Edwards 2 (FRANCE2) registry. Pre- and postprocedural data from 3,919 patients from January 2010 to December 2011 (CoreValve or Edwards) were collated and analyzed. Characteristics of patients requiring immediate second valve procedures were compared with those of the other patients. The 72 patients (1.8%) who underwent implantation of a second valve were studied. Indications were device malpositioning (72%) and embolization (28%). Clinical and echocardiographic characteristics of patients receiving 2 valves were comparable with those of the other patients. The 2-year survival rate was 51.7% for patients with 2 valves as opposed to 62.3% for those with 1 valve (p0.001). The need for a second valve was an independent predictor of all-cause (hazard ratio 2.32, 95% confidence interval 1.50 to 3.60, p0.001) and cardiovascular (hazard ratio 2.64, 95% confidence interval 1.35 to 5.15, p0.001) mortality at 2 years. During follow-up, clinical and echocardiographic data remained similar between the 2 groups. In conclusion, in the FRANCE2 study, the main causes for second valve implantation during the same procedure were malpositioning and embolization. Although the procedure was feasible, it was accompanied by excess mortality. Valve hemodynamic status was preserved during the course of follow-up.

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.

Bioprosthetic thromboses are rarely reported in post-transcatheter aortic valve implantation (TAVI). We describe herein the case of bioprosthetic valve thrombosis in an 82-year-old patient which resolved completely after anticoagulant therapy.

Phasic blood flow dynamics and wall shear stress (WSS) have the potential to directly modulate endothelial responses, playing an important role in the development of bypass graft occlusion. This study compares phasic blood flow velocity patterns and WSS of the left internal thoracic artery (LITA) used as a composite Y-graft (27 patients, Y-group) and as a single graft (24 patients, S-group) on the left anterior descending (LAD) coronary artery.An intravascular Doppler-tipped guide wire was used for postoperative analysis of phasic blood flow velocity. Flow velocities were recorded proximally and distally into the LITA in both groups. Digitalized spectral velocities were acquired to compute systolic peak velocity, diastolic peak velocity, and average peak velocity. The ratio of diastolic to systolic peak velocity was computed (DSVR). WSS was calculated from graft flow velocity and vessel diameter.Proximal LITA in Y-group had greater average peak velocity (APV) (p=0.000), DSVR (p=0.026), flow volume (p=0.000), WSS (p=0.02), and diameter (0.019) than S-group. There were not significant differences for the distal LITA between the two groups.The LITA shows a marked adaptability to flow dynamics. The proximal tract of the LITA in Y-group is able to match increased flow requirements, probably through the release of endothelial vasoactive mediators. Flow velocity spectra acquired in the proximal LITA in Y-group resemble the biphasic coronary artery pattern with a clear diastolic predominance. This pattern is probably consequence of the increase of blood flow due to the lower vascular resistance of the Y-graft system and to the active dilatation of the LITA.

Objective: We sought to evaluate whether the radial artery (RA) provides the same clinical and angiographic results when proximally anastomosed to the aorta or to the left internal thoracic artery (ITA) as a composite Y-graft. Methods: From February 1999 to December 2002, 512 patients underwent myocardial revascularization using the RA, the left ITA and, when required, the saphenous vein. According to the surgeons’ preference the RA was proximally anastomosed to the aorta [336 patients (65.6%), Ao-Cor group] or to the left ITA as a composite Y-graft [176 patients (34.4%), Y-graft group]. There was a significant prevalence of three-vessel disease (86.8 versus 73.2%, P ¼ 0:000) and elderly age (60 ^ 9 versus 58 ^ 8 years, P ¼ 0:014) in the Y-graft group. Results: Patients in Y-graft group had longer aortic cross clamp time ðP ¼ 0:001Þ; more bypass grafts per patient ðP # 0:001Þ; more arterial bypass grafts per patient ðP # 0:001Þ and more bypass grafts per patient with the RA ðP # 0:001Þ: There were no differences in terms of perioperative outcome. Mean follow-up time was 27.1 ^ 11.7 months in 322/333 (96.7%) patients of the Ao-Cor group and 14.9 ^ 10.2 in 165/172 (95.9%) patients of the Y-graft group. There was no difference in terms of overall survival ðP ¼ 0:75Þ; cardiac event-free survival ðP ¼ 0:65Þ; RA patency rate at postoperative angiography ðP ¼ 0:59Þ and during follow-up ðP ¼ 0:93Þ: A preoperative coronary artery stenosis #70% was related with competitive flow ðP ¼ 0:000Þ at postoperative angiography and with RA occlusion ðP ¼ 0:001Þ at follow-up angiography. Conclusions: The RA provides the same clinical and angiographic results both as aorto-coronary and composite Y-graft with the left ITA. When the RA is used as Y-graft the procedure is more technically demanding and a greater number of distal coronary anastomoses is possible. RA grafts to targets with stenosis # 70% appear to be at risk of failure. q 2004 Elsevier B.V. All rights reserved.

Objective: It is not well established whether the blood flow of arterial composite Y-grafts can efficiently respond to the flow demand of the coronary system early postoperatively. The aim of this study was to evaluate if soon after the operation, arterial composite Y-grafts can increase blood flow in response to an increase in myocardial oxygen consumption (MVO2). Methods: Twenty-seven patients who received complete arterial myocardial revascularization using the left internal thoracic artery (LITA) and the radial artery (RA) as composite Y-graft gave their consent to a pre-discharge coronary angiography and intravascular flow velocity measurements using a Doppler guide wire. Flow measurements were performed in the LITA main stem, the distal LITA and the RA, both at rest and during atrial pacing at the 85% of the patient age-predicted maximum. The heart rate‐ systolic blood pressure product was considered as an indirect index of MVO2. Hyperemic flow was determined after injection of adenosine. The flow reserve (FR) was defined as the ratio of blood flow during maximal hyperemia (Qmax) to baseline flow (Qbasal). Results: Atrial pacing increased MVO2 significantly ðP , 0:000Þ. None of the patients developed ischemic S-T segment modifications or complained of chest pain. Qbasal increased significantly in the LITA main stem ðP ¼ 0:001Þ, distal LITA ðP ¼ 0:041Þ and RA ðP ¼ 0:004Þ while Qmax did not change significantly. As a consequence, the FR decreased in the LITA main stem ðP ¼ 0:002Þ, distal LITA ðP , 0:000Þ and RA ðP , 0:000Þ but was not completely exhausted. Conclusions: Soon after the operation, arterial composite Y-grafts can significantly increase blood flow in response to conditions of increased MVO2, keeping normal the myocardial O2 supply-to-demand ratio. q 2003 Elsevier Science B.V. All rights reserved.

It is not well established whether early following surgery the blood flow of arterial composite Y-grafts may efficiently meet the flow demand of the coronary system. The aim of this study was to evaluate whether early after surgery arterial composite Y-grafts may increase the blood flow in response to an increase in myocardial oxygen consumption (MVO2).Twenty-seven patients who received complete arterial myocardial revascularization using the left internal thoracic artery (LITA) and the radial artery (RA) as composite Y-graft gave their consent to a pre-discharge coronary angiography and intravascular flow velocity measurements using a Doppler guidewire. Flow measurements were performed in the LITA main stem, the distal LITA and the RA, both at rest and during atrial pacing at 85% of the patient age-predicted maximum heart rate. The heart rate-systolic blood pressure product was considered as an indirect index of MVO2. Hyperemic flow was determined after injection of adenosine. The flow reserve was defined as the ratio of blood flow during maximal hyperemia (Qmax) to baseline flow (Qbasal).Atrial pacing significantly increased MVO2 (p0.000). None of the patients developed ischemic ST-segment modifications or complained of chest pain. Qbasal increased significantly in the LITA main stem (p = 0.001), distal LITA (p = 0.041) and RA (p = 0.004) while Qmax did not change significantly. As a consequence the flow reserve decreased in the LITA main stem (p = 0.002), distal LITA (p = 0.000) and RA (p = 0.000) but was not completely exhausted.Early after surgery arterial composite Y-grafts may significantly increase blood flow in response to conditions of increased MVO2 and maintain a normal myocardial oxygen supply-to-demand ratio.

We sought to evaluate whether the radial artery (RA) provides the same clinical and angiographic results when proximally anastomosed to the aorta or to the left internal thoracic artery (ITA) as a composite Y-graft.From February 1999 to December 2002, 512 patients underwent myocardial revascularization using the RA, the left ITA and, when required, the saphenous vein. According to the surgeons' preference the RA was proximally anastomosed to the aorta [336 patients (65.6%), Ao-Cor group] or to the left ITA as a composite Y-graft [176 patients (34.4%), Y-graft group]. There was a significant prevalence of three-vessel disease (86.8 versus 73.2%, (P = 0.000) and elderly age (60+/-9 versus 58+/-8 years, (P = 0.014) in the Y-graft group.Patients in Y-graft group had longer aortic cross clamp time (P = 0.001), more bypass grafts per patient (Por = 0.001) more arterial bypass grafts per patient (Por = 0.001) and more bypass grafts per patient with the RA (Por = 0.001). There were no differences in terms of perioperative outcome. Mean follow-up time was 27.1+/-11.7 months in 322/333 (96.7%) patients of the Ao-Cor group and 14.9+/-10.2 in 165/172 (95.9%) patients of the Y-graft group. There was no difference in terms of overall survival (P = 0.75) cardiac event-free survival (P = 0.65) RA patency rate at postoperative angiography (P = 0.59) and during follow-up (P = 0.93). A preoperative coronary artery stenosisor = 70% was related with competitive flow (P = 0.000) at postoperative angiography and with RA occlusion (P = 0.001) at follow-up angiography.The RA provides the same clinical and angiographic results both as aorto-coronary and composite Y-graft with the left ITA. When the RA is used as Y-graft the procedure is more technically demanding and a greater number of distal coronary anastomoses is possible. RA grafts to targets with stenosisor = 70% appear to be at risk of failure.

The combination of an acute ventricular septal defect (VSD) and left ventricular aneurysm (LVA) is a rare, life-threatening complication which usually occurs within the first week following acute myocardial infarct- tion (AMI). We describe the case of an apical VSD and LVA in a 77-year-old diabetic and dyslipidemic male patient after anterior AMI. The patient was an active smoker and had a history of chronic obstructive pulmonary disease, arterial hypertension and atrial fibrillation. The patient underwent ventriculotomy for VSD repair using a large equine pericardial patch followed by intraventricular patch remodelling of the LVA. He was discharged 2 months after surgery and underwent a successful hip replacement 10 months later.

International audience; BackgroundAortic valve stenosis is one of the most common heart diseases in older patients. Nowadays, surgical aortic valve replacement is the 'gold standard' treatment for this pathology and the most implanted prostheses are biological ones. The three most implanted bovine bioprostheses are the Trifecta valve (St. Jude Medical, Minneapolis, MN, USA), the Mitroflow valve (Sorin Group, Saluggia, Italy), and the Carpentier-Edwards Magna Ease valve (Edwards Lifesciences, Irvine, CA, USA). We propose a randomized trial to objectively assess the hemodynamic performances of these bioprostheses.Methods and designFirst, we will measure the aortic annulus diameter using CT-scan, echocardiography and by direct sizing in the operating room after native aortic valve resection. The accuracy of information, in terms of size and spatial dimensions of each bioprosthesis provided by manufacturers, will be checked. Their hemodynamic performances will be assessed postoperatively at the seventh day and the sixth month after surgery.DiscussionThis prospective controlled randomized trial aims to verify and compare the hemodynamic performances and the sizing of these three bioprostheses. The data obtained may help surgeons to choose the best suitable bioprosthesis according to each patient's morphological characteristics.Trial registrationClinicalTrials.gov Identifier: NCT01522352

IntroductionAortic valve replacement is the definitive therapy for severe aortic stenosis (valve area