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We describe the case of a 73-year-old woman presenting with heart failure, a degenerating bioprosthetic mitral valve, and severely dilated left atrium, and highlight the role of multimodality imaging in planning transseptal transcatheter mitral valve-in-valve implantation. (Level of Difficulty: Advanced.), Central Illustration

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Heart failure (HF) affects an estimated 90 000 people within the UK. As a consequence of ventricular remodelling, mitral regurgitation (MR) is common in patients with HF, further contributing to poor prognosis, frequent hospitalisation, and higher rates of mortality. Conventional treatment options include medical therapy, cardiac resynchronisation and conventional mitral valve surgery, with transcatheter mitral valve repair (TMVR) reserved for symptomatic patients with left ventricular dysfunction and multiple comorbidities, considered high surgical risk. Aim Our objectives were to determine: (1) the proportion of patients with an acute HF admission, ejection fraction (EF) of Method We performed a retrospective analysis of patients who presented with acute HF to two large tertiary centres over a five-year period. Based on a combination of electronic care records, and national registry and mortality data, we determined baseline symptoms, symptom progression, and co-morbidities. Echocardiography data was used to assess the degree of MR and EF. Where patients underwent a subsequent echocardiogram on OMT, the change in the degree of MR, EF and symptoms (NYHA class) was examined. Results Over a five-year period (Jan 2012–Dec 2017), 1884 patients presented with acute HF. Of this cohort, 302 (16%) had moderate or more MR and EF of Conclusions A large portion of patients who present with acute HF have moderate or more MR. Although medical therapy is effective in providing some relief from symptoms, the large majority of patients continue to have moderate or more MR. We propose a portion of these patients are potential candidates for TMVR, and should be considered for further intervention. Funding Acknowledgement Type of funding source: None

Heart failure (HF) affects an estimated 90 000 people within the UK and 26 million worldwide. As a consequence of ventricular remodelling, significant mitral regurgitation (MR) is common in patients with HF, further contributing to poor prognosis, frequent hospitalisation, and higher rates of mortality. Conventional treatment options for HF patients with MR include medical therapy, cardiac resynchronisation and conventional mitral valve surgery, with transcatheter mitral valve repair reserved for symptomatic patients with left ventricular dysfunction and multiple comorbidities, considered high surgical risk. Aim Our objectives were to determine: (1) the proportion of patients with an acute HF admission, an EF of Method We performed a retrospective analysis of all patients who presented with acute HF to two large London based tertiary centres over a five year period. Based on a combination of electronic care records, national registry data, and UK Office of National Statistics (ONS) mortality data, we determined baseline symptoms, symptom progression, and co-morbidities. Echocardiography data was used to assess the degree of MR and left ventricular systolic function (EF). Where patients underwent subsequent echocardiographic examinations on maximally tolerated medical therapy, the change in the degree of mitral regurgitation, ejection fraction and symptoms (NYHA class) was examined. Logistic regression was used to assess the impact of age, EF and comorbidities. Results Over a five-year period (Jan 2012 – Dec 2017), 1884 patients presented with acute HF. Of this cohort, 302 (16%) had moderate or more MR and an EF of Conclusions A large portion of patients who present with acute heart failure have moderate or more MR. Although medical therapy is effective in providing some relief from symptoms, the large majority of patients continue to have moderate or more mitral regurgitation. We propose a portion of these patients are potential candidates for transcatheter mitral valve repair according to current international guidelines, and should be considered for further intervention. Conflict of Interest Nil

Infective endocarditis (IE) is an uncommon, life-threatening systemic disorder with significant morbidity and persistently high mortality. The age of the peak incidence of IE has shifted from 45 years in the 1950s to 70 years at the present time, and elderly people have a five-fold higher risk of IE than the general adult population. Elderly IE patients demonstrate a higher prevalence of coagulase-negative staphylococci, enterococci and Streptococcus bovis, and lower rates of infection by viridans group streptococci. Methicillin resistance is more prevalent in elderly patients as a consequence of increased nosocomial acquisition. The elderly are a vulnerable group in whom diagnosis is often difficult on account of non-specific presenting features and where higher prevalence of comorbidities contributes to adverse outcomes. Treatment of older patients with IE presents specific challenges associated with prolonged antibiotic therapy, and access to surgery may be denied on account of advanced age and attendant comorbidities. This practical review covers all aspects of elderly IE, including clinical and microbiological diagnosis and appropriate diagnostic procedures, initial antibiotic selection, antibiotic prophylaxis, considerations about antibiotic therapy and surgery.

Correlative vibrational spectroscopy and immunohistochemistry reveal astroglial processes co-localised with the lipid-rich shell of Aβ plaques., Recent work using micro-Fourier transform infrared (μFTIR) imaging has revealed that a lipid-rich layer surrounds many plaques in post-mortem Alzheimer's brain. However, the origin of this lipid layer is not known, nor is its role in the pathogenesis of Alzheimer's disease (AD). Here, we studied the biochemistry of plaques in situ using a model of AD. We combined FTIR, Raman and immunofluorescence images, showing that astrocyte processes co-localise with the lipid ring surrounding many plaques. We used μFTIR imaging to rapidly measure chemical signatures of plaques over large fields of view, and selected plaques for higher resolution analysis with Raman microscopy. Raman maps showed similar lipid rings and dense protein cores as in FTIR images, but also revealed cell bodies. We confirmed the presence of plaques using amylo-glo staining, and detected astrocytes using immunohistochemistry, revealing astrocyte co-localisation with lipid rings. This work is important because it correlates biochemical changes surrounding the plaque with the biological process of astrogliosis.

We sought to evaluate the effects of significant coronary artery disease (CAD) upon outcome after transcatheter aortic valve implantation (TAVI).We performed a retrospective study of 271 consecutive patients undergoing TAVI using either the Edwards SAPIEN or Edwards SAPIEN XT valve. Pre-procedural coronary angiograms were analysed by quantitative coronary angiography (defining significant CAD as a stenosis of ≥70% or ≥50% if in the left main stem or a vein graft). Ninety-three out of 271 patients had significant CAD. There was no difference in mortality at 30 days or 12 months between the two groups (6.7% vs. 7.5% and 21.5% vs. 23.7%; log-rank p=0.805). A secondary analysis using the SYNTAX algorithm of coronary anatomy complexity was performed on 189 patients. Those in the high SYNTAX score (33) group had higher mortality at 30 days and 12 months (14.3% and 57.1%) than the low (5.2% and 23.3%) and intermediate-risk groups (11.1% and 22.2%; log-rank p=0.007). ROC analysis identified a SYNTAX score of9 at the time of TAVI as the optimal cut-off, with an independent association with mortality (HR 1.95 [95% CI: 1.21-3.13]; p=0.006). Patients with a SYNTAX score9 had greater 30-day, 12-month and overall mortalities than those with a SYNTAX score9 (3.7% vs. 11.3% and 20.7% vs. 34.3%; log-rank p=0.005).Significant CAD, as defined using "real-world" QCA margins, did not have a significant effect upon mortality after TAVI for severe aortic stenosis. However, higher-risk SYNTAX groups, including those with a score9, had increased mortality.

Proactive planning and managing moving from old to newly built hospitals, and the relocation process of patients for complex specialized units such as intensive care units, are necessary for both patient safety and staff well-being. This article provides an exemplar for how theory can be used to facilitate a positive relocation experience. Using change management theory, a systematic approach to cocreate implementation strategy among researchers and clinicians was critical to the success of this project.

Introduction Stent creep is an uncommon mode of structural deterioration of bioprosthetic heart valves defined by a permanent inward deflection of the stent posts. This may occur because of valve over-sizing and leads to intrinsic valve stenosis. It has been described in older generation of bioprosthesis and was thought not to occur in modern devices. Methods We describe three patients who were referred for bioprosthetic valve degeneration with presumed aortic stenosis. Investigations demonstrated mid valvular gradient predominantly because of stent creep. We performed valve-in-valve TAVI with Edward SAPIEN prosthesis. Results Median age was 84 and logistic EuroSCORE 34.4. All patients had degenerated bioprosthesis with mean implant duration of 5.6 years. Two patients had Carpentier Edwards Perimount prosthesis (19 and 23 mm) and one patient had a Mitroflow (21 mm). Mean gradients were 33, 54, and 22 mm Hg. About 23 mm Edward SAPIEN valve was implanted in all cases with immediate improvement in haemodynamics with mean gradient reduction to 10, 17, and 8 mm Hg, respectively. The mean aortic valve area increased from 0.63 to 1.76cm2. There were no serious adverse events. The patients improved from NYHA III/IV to I/II post procedure and remain well at median follow-up of 24-months. Discussion: Stent creep is an uncommon mode of structural deterioration in bioprosthetic heart valves. It has been described in the previous generation of bioprosthesis. It is important to distinguish leaflet dysfunction and stent creep. By forcing the stent posts outwards a balloon expandable TAVI device can be used to treat this condition. © 2014 Wiley Periodicals, Inc.

Objective Transcatheter valve-in-valve is an accepted treatment in high-risk patients with degenerative stented bioprostheses in the aortic position. Experience in treating stentless valves is, however, limited. Our aim was to determine the feasibility and single-center outcome of balloon expandable SAPIEN valve placement in degenerated stentless aortic valve bioprostheses. Methods From February 2010 to January 2014, 10 patients with failing stentless bioprostheses underwent transcatheter aortic valve implantation using the Edwards SAPIEN transcatheter heart valve (SAPIEN, SAPIEN XT, and SAPIEN 3) at our institution. Seven patients had valve failure due to regurgitation and three to stenosis. The mean age was 73.3 ± 15.0 years. The mean logistic EuroSCORE was 31.8 ± 20.3, and the Society of Thoracic Surgeons score was 7.6 ± 5.4. Results Technical success was achieved in 9 of 10 patients. One patient required immediate placement of a second valve owing to low placement of the first. Two intraoperative complications developed that needed additional procedures. One patient underwent immediate repair of a right ventricular perforation from a pacing lead, the other, reexploration for epicardial bleeding. No deaths occurred. The median length of stay was 8.5 days (range, 3-44). The mean follow-up was 8.1 months (range, 1-21). No late reoperations or reinterventions were required. Conclusions Transcatheter aortic valve implantation after previous stentless aortic valve replacement is technically demanding but a safe and feasible approach. The early results were excellent, with consistent improvement in hemodynamics. Prospective long-term follow-up in larger series is needed to evaluate this technique further.

Objective To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system. Methods A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: ≥grade 3 were classed as significant and ≤grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms. Results 60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.7±16.6% vs 20.3±10.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p

A 21-year-old woman affected by a rare autosomal-dominant disorder called Singleton-Merten syndrome [(1)][1] with symptomatic severe aortic regurgitation in New York Heart Association functional class III was referred for consideration of aortic valve intervention. Her clinical history was

Background Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. Methods TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. Results Procedural success was achieved in 99% of 256 patients (mean age, 82.9 ± 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 ± 11.2%; mean aortic valve area, 0.63 ± 0.19 cm 2 ), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 ± 1.9 mm, 22.5 ± 2.2 mm ( P P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. Conclusions A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

This review describes the assessment of the aortic valve by echocardiography and also the roles that multidetector CT (MDCT) and cardiac magnetic resonance have to play as complimentary imaging modalities. It describes how to resolve apparent discrepancies in grading aortic stenosis and discusses the management of apparently moderate stenosis associated with cardiac symptoms or left ventricular dysfunction. The role of cardiac imaging including three-dimensional (3D) echocardiography and MDCT scanning in the preparation for transcatheter aortic valve implantation and during and after the procedure are described. While echocardiography remains the mainstay of imaging, 3D modalities, notably MDCT, are increasingly useful and a multimodality approach is likely to become established as routine clinical practice.

AIMS The aim of this study was to identify the incidence and risk factors for acute kidney injury (AKI) after TAVI, a potentially serious complication of transcatheter aortic valve implantation (TAVI) that has been redefined by the Valve Academic Research Consortium (VARC). METHODS AND RESULTS We performed a retrospective analysis of 248 patients undergoing TAVI. AKI was defined as a VARC-modified Risk, Injury, Failure, Loss, and End-stage (RIFLE) kidney disease score ≥ 2. Eighty-nine patients suffered AKI (35.9%) and demonstrated increased mortality at 30 days (13.5% vs. 3.8%) and one year (31.5% vs. 15.0%) (p

Separate event-related brain potential (ERP) components have been hypothesized to index familiarity and recollection processes that support recognition memory. A 300- to 500-ms mid-frontal FN400 old/new difference has been related to familiarity, whereas a 500- to 800-ms parietal old/new difference has been related to recollection. Other recent work has cast doubt on the FN400 familiarity hypothesis, especially its application to familiarity-based recognition of conceptually impoverished stimuli such as novel faces. Here we show that FN400 old/new differences can be observed with novel faces, and as predicted by the familiarity hypothesis, these differences are observed regardless of whether or not recognition is accompanied by the recollection of specific details from the study episode. Furthermore, FN400 differentiation between hits and misses is more consistent with an explicit familiarity process than an implicit memory process.

Mitral valve intervention in heavy mitral annular calcification (MAC) presents significant surgical challenges. Current dedicated transcatheter mitral valve therapy excludes patients with significant MAC. Transcatheter aortic valve implantation devices have been used for mitral valve-in-valve and valve-in-ring procedures.1 Balloon-expandable valves have been used with some success in the presence of MAC, but their use is limited by the inability to reposition if left ventricular outflow tract (LVOT) obstruction occurs.2 We describe 2 cases, where a self-expanding and repositionable transcatheter valve was implanted in the mitral position using MAC as an anchor. A 75-year-old woman presented with increasing breathlessness after her aortic valve replacement and mitral valve repair in 2014. Echocardiography demonstrated a functioning prosthetic aortic valve and severe mitral regurgitation. The mitral annulus had a measured perimeter of 77 mm and area of 400 mm2 (transesophageal echocardiography) with an aortomitral annular angle of 124° (computed tomography). A 62-year-old man presented with New York Heart Association III symptoms. Medical history included Alport syndrome, transcatheter aortic valve implantation (26 mm Sapien XT), and permanent pacemaker. Echocardiography demonstrated a functioning prosthetic aortic valve and severe mitral regurgitation. The mitral annulus had a measured perimeter of 82 mm …

Aims To demonstrate the feasibility of implanting the Lotus second-generation transcatheter heart valve (THV) (designed for a transfemoral procedure) via a transaortic approach. Methods and results We describe a case with severe aortic stenosis in the presence of small calibre and calcified femoral access and severe chronic obstructive pulmonary disease. The transaortic approach was the ideal approach for this patient and we successfully implanted a 25 mm Lotus valve without any complication. Conclusions The transaortic access is a feasible and safe alternative in patients who have suboptimal iliofemoral conduits and who will benefit from the unique features of the Lotus THV.

Background: Recently, we have demonstrated that cyclic variation in ultrasonic integrated backscatter (IBS) can be used to predict patency of the infarct related artery (IRA) post-acute myocardial infarction (AMI). Second harmonic imaging has become widely available on ultrasound machines and enhances endocardial definition. The effect of harmonic imaging on the measurement and interpretation of cyclic IBS is unknown. Methods and results: Twenty-eight patients were studied post-AMI. Cyclic IBS was measured in myocardial segments supplied by the IRA as well as in remote segments with normal myocardial function in both fundamental and second harmonic modes. Harmonic imaging increased the measurement of cyclic IBS in IRA as well as normal myocardial territories. However, the difference in cyclic IBS between IRA and normal myocardial territories remained unchanged. Conclusion: Second harmonic imaging increases the measurement of cyclic IBS. However, the interpretation of these data is unchanged in the setting of AMI. It is important that repeated studies in the same patient are performed in the same mode (fundamental or harmonic) as the values are not interchangeable.

An 81-year-old man presented with sudden-onset slurred speech and right-sided weakness commencing 2 hours previously. Initial National Institute of Health Stroke Scale score was 13. Non-contrast CT brain scan excluded haemorrhage, and he received intravenous thrombolysis. Medical history included tissue aortic valve replacement. On arrival, his temperature was 38°C. Two hours after thrombolysis he had two seizures, and his Glasgow Coma Scale score dropped from 15/15 to 6/15 (breakdown: eyes 1, voice 1, motor 4). Repeat CT demonstrated a left middle cerebral artery territory infarct, and he was transferred to the intensive care unit (figure 1 …

Transcatheter aortic valve implantation (TAVI) has demonstrated the feasibility of treating valvular heart disease with transcatheter therapy. On the back of this success, various transcatheter concepts are being evaluated to treat other valvular disease, especially mitral regurgitation (MR). The concepts currently approved to treat MR replicate surgical mitral valve repair. However, most of them cannot eliminate MR completely. Similar to TAVI, a transcatheter mitral valve implantation may provide a valuable alternative. The FORTIS transcatheter mitral valve (Edwards Lifesciences, Irvine, CA, USA) is a self-expanding device implanted via a transapical approach. We describe our experience and early results in the first five patients treated on compassionate grounds. We also describe the details of the device, selection criteria and technical details of implantation.

Aims Transcatheter aortic valve implantation (TAVI) is now the therapy of choice for those patients with severe symptomatic aortic stenosis who are considered to be at too high risk for conventional surgery. Balloon aortic valvuloplasty (BAV) is routinely performed to allow placement of the balloon-expandable valve during the procedure. Instrumentation of the valve has been linked to procedural stroke risk, with the associated runs of rapid pacing risking haemodynamic compromise. We outline a novel technique to eliminate BAV prior to transcatheter valve placement. Methods and results We illustrate a clinical case that outlines the problems encountered in transcatheter valve placement despite a prior BAV. The solution used in this case involved the partial inflation of the distal section of the balloon allowing easy passage of the SAPIEN XT valve from the transaortic route. After bench testing, we report a series of patients who have undergone this "direct TAVI" procedure from both the transaortic and the transfemoral routes. Conclusions In a limited series within a single centre, "direct TAVI" has been shown to be effective in allowing accurate placement of a balloon-expandable device without the need for prior BAV.

AIMS To evaluate the effects of access route upon clinical results and quality of life (QoL) in patients undergoing either transfemoral (TF-TAVI) or transapical balloon-expandable transcatheter aortic valve implantation (TA-TAVI) in the real world. METHODS AND RESULTS A prospective analysis was performed upon 264 consecutive patients receiving TF-TAVI or TA-TAVI. QoL was assessed using the EQ-5D questionnaire. At baseline, TA-TAVI patients reported significantly more problems in mobility, self-care, usual activities and lower overall health status domains (p

Objective To evaluate changes in left ventricular mass and diastolic function during normal pregnancy. Methods This was a cross-sectional study of 125 pregnant women at 9–42 weeks of gestation and 19 non-pregnant female controls. Two-dimensional and M-mode echocardiography of the maternal left ventricle and left atrium was performed. Results During pregnancy left ventricular mass increased by 52%. There was an increase in left ventricular end-diastolic and end-systolic diameters (12% and 20%, respectively), left ventricular posterior wall diameter during diastole and systole (22% and 13%, respectively) and left intraventricular septum during diastole and systole (15% and 19%, respectively). Mitral valve A-wave maximum velocity increased during pregnancy by 19%, while mitral valve E-wave maximum velocity and the ratio of E-wave/A-wave velocities increased early in pregnancy by about 14% and 6%, respectively, with a subsequent decline to 4% and 10%, respectively, below non-pregnant levels. Conclusion Left ventricular mass increases during pregnancy, while left ventricular diastolic function, as demonstrated by the changes in mitral valve flow velocities, increases in the first two trimesters but declines in the third trimester.

OBJECTIVE—To assess the feasibility of measuring left atrial (LA) function with acoustic quantification (AQ) and then assess the effects of age and sex on LA reservoir, conduit, and booster pump function. PATIENTS AND SETTING—165 subjects without cardiovascular disease, 3-79 years old, were enrolled by six tertiary hospital centres. INTERVENTIONS—Continuous LA AQ area data were acquired and signal averaged to form composite waveforms which were analysed off-line. MAIN OUTCOME MEASURES—Parameters of LA performance according to age and sex. RESULTS—Signal averaged LA waveforms were sufficiently stable and detailed to allow automated analysis in all cases. An age related increase in LA area was noted. LA reservoir function did not vary with age or sex. All parameters of LA passive and active emptying revealed a significant age dependency. Overall, the passive emptying phase accounted for 66% of total LA emptying ranging from 76% in the youngest to 44% in the oldest decade. LA contraction accounted for 34% of atrial emptying in all subjects combined with the older subjects being more dependent on atrial booster pump function. When adjusted for atrial size, there were no sex related differences in LA function. CONCLUSIONS—LA reservoir, conduit, and booster pump function can be assessed with automated analysis of signal averaged LA area waveforms. As LA performance varies with age, establishment of normal values should enhance the evaluation of pathologic states in which LA function is important. Keywords: aging; atrium; echocardiography

Trans-catheter aortic valve implantation is rapidly becoming an established modality of treatment for patients with critical aortic stenosis who are high risk for conventional aortic valve replacement. This approach also has its limitations; however, with growing experience and improvements in the delivery system, it may be possible to overcome these limitations. We describe a case where conventional trans-catheter approaches, that is, transfemoral or trans-apical using the Edwards THV system, were not possible but successful implantation was achieved through the trans-aortic route.

Background—The value of angioplasty in occluded coronary arteries is limited by a restenosis/reocclusion rate of 50-70%. In patients with subtotal occlusion, stent implantation has been shown to reduce clinical and angiographic restenosis. Retrospective observational studies have suggested that stenting could reduce restenosis in total occlusions. The value of sustained coronary patency on global and regional left ventricular function in this clinical setting has not been defined clearly. Objectives—To assess the medium term effect of elective intracoronary stent deployment after successful percutaneous transluminal coronary angioplasty (PTCA) of an occluded coronary artery. Methods—Sixty patients with a total coronary occlusion successfully treated by PTCA were randomised to receive an intracoronary stent or no stent. Patients underwent clinical and angiographic follow up at six months. Results—Thirty patients received a stent (group A) and 30 were treated by angioplasty alone (group B), all with initial success. One patient in group B required repeat angioplasty with stenting at 24 hours and one patient died after 10 days. Angiographic follow up was available for 57 patients. This showed a significantly reduced reocclusion rate in group A compared with group B (7% v 29%, p

Real-time imaging is required to guide minimally invasive catheter-based cardiac interventions. While transesophageal echocardiography allows for high-quality visualization of cardiac anatomy, X-ray fluoroscopy provides excellent visualization of devices. We have developed a novel image fusion system that allows real-time integration of 3-D echocardiography and the X-ray fluoroscopy. The system was validated in the following two stages: 1) preclinical to determine function and validate accuracy; and 2) in the clinical setting to assess clinical workflow feasibility and determine overall system accuracy. In the preclinical phase, the system was assessed using both phantom and porcine experimental studies. Median 2-D projection errors of 4.5 and 3.3 mm were found for the phantom and porcine studies, respectively. The clinical phase focused on extending the use of the system to interventions in patients undergoing either atrial fibrillation catheter ablation (CA) or transcatheter aortic valve implantation (TAVI). Eleven patients were studied with nine in the CA group and two in the TAVI group. Successful real-time view synchronization was achieved in all cases with a calculated median distance error of 2.2 mm in the CA group and 3.4 mm in the TAVI group. A standard clinical workflow was established using the image fusion system. These pilot data confirm the technical feasibility of accurate real-time echo-fluoroscopic image overlay in clinical practice, which may be a useful adjunct for real-time guidance during interventional cardiac procedures.

Stent creep is an uncommon mode of structural deterioration of bioprosthetic heart valves defined by a permanent inward deflection of the stent posts. This may occur because of valve over-sizing and leads to intrinsic valve stenosis. It has been described in older generation of bioprosthesis and was thought not to occur in modern devices.We describe three patients who were referred for bioprosthetic valve degeneration with presumed aortic stenosis. Investigations demonstrated mid valvular gradient predominantly because of stent creep. We performed valve-in-valve TAVI with Edward SAPIEN prosthesis.Median age was 84 and logistic EuroSCORE 34.4. All patients had degenerated bioprosthesis with mean implant duration of 5.6 years. Two patients had Carpentier Edwards Perimount prosthesis (19 and 23 mm) and one patient had a Mitroflow (21 mm). Mean gradients were 33, 54, and 22 mm Hg. About 23 mm Edward SAPIEN valve was implanted in all cases with immediate improvement in haemodynamics with mean gradient reduction to 10, 17, and 8 mm Hg, respectively. The mean aortic valve area increased from 0.63 to 1.76cm(2) . There were no serious adverse events. The patients improved from NYHA III/IV to I/II post procedure and remain well at median follow-up of 24-months.Stent creep is an uncommon mode of structural deterioration in bioprosthetic heart valves. It has been described in the previous generation of bioprosthesis. It is important to distinguish leaflet dysfunction and stent creep. By forcing the stent posts outwards a balloon expandable TAVI device can be used to treat this condition.

Objective Transcatheter aortic valve implantation has been used to treat high-risk patients with bioprosthetic valve degeneration (valve-in-valve). We report our experience with transcatheter aortic valve implantation in the treatment of degenerated biologic aortic valve prostheses and discuss factors that can influence the outcome. Methods From February 2009 to October 2011, 278 patients underwent transcatheter aortic valve implantation, of whom 23 underwent a valve-in-valve procedure with the Edwards Sapien valve to treat a failing bioprostheses in the aortic position. Eight of these valves were stentless bioprostheses. Thirteen patients had valve failure resulting predominantly from stenosis, and the remaining resulting from regurgitation. Results Mean age was 76.9 ± 14.4 years. The mean logistic EuroSCORE was 31.8% ± 20.3% and the Society of Thoracic Surgeons score was 7.6% ± 5.4%. All patients were New York Heart Association class III or IV. The majority of the operations (21/23) were performed via the transapical route. Procedural success was 100%, although 1 patient with a degenerated homograft needed immediate placement of a second valve because of low placement of the first. The reduction in the mean gradient was 31.2 ± 17.06 mm Hg to 9.13 ± 4.9 mm Hg. In those patients with predominant aortic regurgitation (9/23), reduction in aortic regurgitation was achieved in all. The median length of stay was 11.7 days (range, 3-44 days). In-hospital and/or 30-day mortality was 0%. Conclusions Valve-in-valve is a safe and feasible alternative to treat high-risk patients with failing aortic bioprostheses. The early results are excellent, with improvement seen in hemodynamics.

Minimally invasive cardiac surgery is made possible by image guidance technology. X-ray fluoroscopy provides high contrast images of catheters and devices, whereas 3D ultrasound is better for visualising cardiac anatomy. We present a system in which the two modalities are combined, with a trans-esophageal echo volume registered to and overlaid on an X-ray projection image in real-time. We evaluate the accuracy of the system in terms of both temporal synchronisation errors and overlay registration errors. The temporal synchronisation error was found to be 10% of the typical cardiac cycle length. In 11 clinical data sets, we found an average alignment error of 2.9 mm. We conclude that the accuracy result is very encouraging and sufficient for guiding many types of cardiac interventions. The combined information is clinically useful for placing the echo image in a familiar coordinate system and for more easily identifying catheters in the echo volume.

Objectives: To evaluate feasibility and outcome of Transoartic Transcatheter Sapien valve implantation. Background: Transcatheter Aortic valve implantation (TAVI) using the Edwards SAPIEN device (Edwards LifeScience, Irvine, CA) is usually performed via the transfemoral (TF) or transapical (TA) routes. Some patients are not suitable for these approaches. We report our experience with the novel transaortic (TAo) approach via a partial upper sternotomy and discuss the advantages and future applications. Methods: Between January 2008 to March 2011 193 patients with severe aortic stenosis underwent TAVI with the Edwards SAPIEN bioprosthesis at the St. Thomas' Hospital, London. 108 patients were unable to undergo a TF-TAVI and of those 17 were accepted for a TAo-TAVI on the basis of anatomy, risk, LV function, and significant respiratory disease. Results: The TAo-TAVI group (n = 17) had more prevalent respiratory disease than the TA-TAVI group (47.0% vs. 18.7%, P = 0.011). Otherwise the groups were similar in demographics and history. Despite this the 30 day mortalities were not significantly different between the groups (TAo-TAVI 4.3% at 30 days versus TA-TAVI 7.7%, P = 0.670). There were no significant differences in procedural complications. Conclusions: The TA-TAVI approach may not be desirable in patients with severe chest deformity, poor lung function or poor left ventricular function. TAo-TAVI via a partial sternotomy is safe and feasible in these patients. © 2011 Wiley Periodicals, Inc.

Transcatheter aortic valve implantation (TAVI) is an alternative treatment option for patients with aortic stenosis deemed high risk or unsuitable for aortic valve replacement. The aim of this study was to assess the feasibility of TAVI in elderly patients, the delivery of this technology with a multidisciplinary approach, and the use of traditional surgical scoring systems.One hundred fifty-one consecutive patients (mean age 82.6 +/- 7.3 years) with severe aortic stenosis underwent TAVI with the Edwards Lifesciences (Irvine, CA) Sapien bioprosthesis using the transapical (n = 84; 56%) or transfemoral (n = 67; 44%) approach from August 2007 to September 2009 at King's Health Partners, London, United Kingdom. We analyzed procedural outcome, complications, functional status, and midterm outcome of patients.The multidisciplinary team comprised interventional cardiologists, cardiothoracic surgeons, imaging specialists, cardiac anesthetists, and specialist nurses. Seventy percent of patients were in New York Heart Association class III/IV, and logistic EuroSCORE was 21.6 +/- 11.9. Procedural success was achieved in 98%. Postoperative complications included stroke (6%), complete atrioventricular block (5.3%), renal failure requiring hemofiltration (9.3%), and vascular injury (8.6%). Overall 30-day mortality was 9.9% (n = 15). The logistic EuroSCORE was a predictor of short-term mortality (logistic regression model, P.05). Thirty-day mortality post-TAVI for patients with logistic EuroSCORE20, 20 to 40, and40 was 5.4%, 13.2%, and 22.2%, respectively.Transcatheter aortic valve implantation is a feasible treatment option in this patient group with promising short/medium-term results. Renal failure is the commonest short-term complication, and the incidence of vascular complications remains high. Risk prediction/case selection remains challenging, and a multidisciplinary team approach appears to be helpful in appropriate patient selection.

A 53-year-old man was admitted to our institute with chest pain and palpitation. Using contrast echocardiography, left ventriculography and cardiac MRI, a subsequent diagnosis of mid-ventricular hypertrophic obstructive cardiomyopathy with an apical aneurysm was made. The current case highlights the benefits of multimodality imaging in not only achieving a diagnosis but also in comprehending the pathophysiological origins of this unusual phenomenon.

Kawasaki disease (KD) is characterized by persistent fever, mucous membrane hyperaemia, cervical lymph node enlargement, exanthema and periungual desquamation. It is seen mainly in children, with

Automated border-detection techniques such as acoustic quantification have proven accurate and useful for quantifying left ventricular (LV) function. We acquired LV acoustic quantification waveforms from the parasternal short-axis window in 140 healthy patients in the age range of 16 to 78 years. Signal-averaged waveforms were analyzed for parameters of systolic and diastolic performance. The average fractional area change was 54 +/- 12%, and there were no significant changes in LV systolic function in the age range studied. There were significant changes in diastolic parameters with aging. The percentage of contribution to total LV filling occurring during atrial filling nearly tripled during the 6 decades studied, from 13% in the youngest cohort to 36% in the eighth decade of life. This study provides normal reference values for systolic and diastolic parameters of LV function determined from signal-averaged acoustic quantification waveforms acquired from the parasternal short-axis view in adult and adolescent patients over a wide age range.

Background — The aim of the present study was to determine the use of cyclic variation in ultrasonic integrated backscatter (IBS), which is reduced in ischemic myocardium, to predict an occluded infarct-related artery (IRA) after thrombolysis for acute myocardial infarction (AMI). This is important, because patency of the IRA 90 minutes after thrombolysis has been shown to predict outcome. Methods and Results — One hundred thirteen patients with AMI had peak-to-peak cyclic IBS measured in the myocardial territory supplied by their IRA as well as a remote territory with normal function from the parasternal long- or short-axis view. This analysis took 5 to 10 minutes. Wall motion score index was assessed, and coronary angiography, to determine patency of the IRA, was performed in all patients. Cyclic IBS in the IRA territory was much lower in segments supplied by an occluded IRA (3.3 versus 4.6 dB, P Conclusions — The difference in cyclic IBS between IRA and remote normal segments, which can be analyzed rapidly, can be used to predict patency of the IRA in patients with AMI. This provides a noninvasive method to determine those patients who may require urgent invasive investigation.

Introduction Patients undergoing surgical aortic valve replacement (sAVR) routinely undergo simultaneous coronary artery bypass grafting (CABG) for significant coronary artery disease (CAD) due to adverse prognostic impact. While manufacturers advise percutaneous intervention (PCI) of significant CAD prior to transcatheter aortic valve implantation (TAVI) there is considerable variation among operators. Methods We performed a retrospective analysis of 168 patients who underwent TAVI using the Edwards bioprosthesis from March 2008 to October 2010 at St. Thomas Hospital, London. They were divided into two groups according to the results of the pre-TAVI coronary angiogram: (Group 1) patients with ≥1 coronary stenosis of ≥70% severity and those without (Group 2). The end-point was all-cause mortality. Results In total, 70 patients (41.7%) had significant CAD prior to TAVI, with 10 (6.0%) undergoing PCI prior to their procedure. There were no significant differences in either the baseline characteristics or access approach between the two groups (Abstract 26 tables 1 and 2). At a mean follow-up of 335±277 days (mean±SD), the overall mortality was 22.6%; Group 1 mortality was 30% and in group 2 was 17.3% (p=0.124) (see Abstract 26 figure 1) There was no difference seen in the length of stay in the intensive care unit (2.7±6.2 vs 4.1±14.9 days, p=0.462) nor in the number of days to discharge (12.6±10.1 vs 12.8±13, p=0.928). Among those patients who underwent PCI in Group 1, 8 had single vessel intervention and 2 had PCI to 2 vessels. The target vessels were left main stem (LMS) (n=2), proximal left anterior descending artery (LAD) (n=5), circumflex (n=1), right coronary artery (RCA) (n=2), saphenous vein graft (SVG) to LAD (n=1) and SVG to circumflex (n=1). Mortality in this sub-group was not significantly different from the CAD patients who did not receive PCI (50% vs 26.7%, p=0.272). Conclusion The presence of significant CAD had no significant impact upon the all-cause mortality of patients after TAVI in our study. As yet, the impact of PCI to significant CAD upon outcome after TAVI is not known and will be assessed in a prospective, randomised controlled trial currently underway.

OBJECTIVE—To assess the potential of intravenous Optison, a second generation ultrasound contrast agent, and various ultrasound imaging modes to determine myocardial, kidney, and liver perfusion in normal subjects and patients with left ventricular dysfunction or chronic pulmonary disease together with renal or hepatic dysfunction. METHODS—Five normal subjects and 20 patients underwent grey scale echocardiographic imaging of myocardium, kidney, and liver during 505 intravenous injections of Optison. Images were assessed qualitatively by two independent observers and quantitatively using video densitometry to determine the peak contrast enhancement effect. RESULTS—Qualitative analysis showed that intermittent harmonic imaging was superior to either conventional fundamental or continuous harmonic imaging for all organs. Quantitative analysis showed that the peak change in echocardiographic intensity v baseline during continuous harmonic imaging was 11 units for myocardium (p

Introduction: Circulatory collapse during transfemoral transcatheter aortic valve implantation (TF-TAVI) procedure is a life-threatening complication. We present an important and poorly described cause. Case report description: An 82 year old male was accepted by the TAVI multi-disciplinary team for TF-TAVI. He had severely impaired left ventricular (LV) function (LVEF 25%), normal LV wall thickness and severe aortic stenosis (PG 63 mmHg, AVA 0.9cm2). Coronary angiography revealed significant disease in the proximal-mid LAD, mid-OM1 and an occluded RCA. His logistic EuroScore was 17.45%. It was felt that since his primary complaint was dyspnoea and he reported no anginal symptoms, in the absence of prognostic coronary disease, he did not require pre-TAVI revascularisation. The procedure was performed under a general anaesthetic with peri-operative tranoesophageal echocardiography (TOE) using a 29 mm Edwards SAPIEN XT with a good final position, no AR and good antegrade haemodynamics. He suffered a rapid loss of blood pressure and ventricular tachycardia, which reverted to asystole after defibrillation. CPR was performed according to guidelines. TOE was used to exclude annular or root injury, iatrogenic disruption of the mitral valve apparatus and prosthesis structural failure or malposition. Angiography confirmed patency of the coronary arteries and ilio-femoral integrity. A "suicide ventricle" was diagnosed and the decision was made to initiate femoral-femoral cardiopulmonary bypass to stabilise the patient. This was gradually weaned over 30 minutes with successful return of intrinsic cardiac function. Initial post-procedural transthoracic echocardiography demonstrated improvement of LV function (LVEF 45%) with normal prosthetic forward flow and only trivial regurgitation. This echocardiographic improvement was maintained at 60 day follow up with marked symptomatic improvement. Discussion and conclusion: A "suicide ventricle" is important cause of peri-procedural hypotension and circulatory collapse in TAVI patients. Immediately available fluoroscopic and TOE imaging can help to exclude the other major causes. A perfusionist and a primed CPB machine in the room can allow a desperate situation to be recovered and provide effective bridging for return of myocardial function. The mechanism and aetiology of this difficult complication is not yet known; revascularisation of large areas of at-risk myocardium may be protective. The effects of treatment of coronary artery disease prior to TAVI will be addressed in ongoing the ACTIVATION trial ([ISRCTN75836930][1]). [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN75836930

OP-023 EXPANDED EXPERIENCE USING THE TRANSAORTIC APPROACH (TAo) FOR TRANSCATHETER VALVE IMPLANTATION USING THE EDWARD SAPIEN VALVE R.Q. Attia, M. Sabetai, M. Thomas, S. Redwood, J. Hancock, K. Wilson, K. Macgillivray, C. Young, V. Bapat. Department of Cardiovascular Surgery, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom; Department of Cardiology, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom