Amir-Ali Fassa

Transfemoral Implantation of Transcatheter Heart Valves After Deterioration of Mitral Bioprosthesis or Previous Ring Annuloplasty

OBJECTIVES This study sought to evaluate the feasibility of transfemoral transcatheter heart valve (THV) implantation in failed mitral bioprostheses and ring annuloplasties. BACKGROUND Redo mitral surgery may be high risk or contraindicated due to comorbidity. THV implantation has been recently reported in this setting. METHODS Transfemoral implantation of Edwards Sapien prosthesis was performed in 17 patients for degenerated mitral bioprosthesis or previous ring annuloplasty (6 bioprostheses, 11 ring annuloplasties). The procedure was elective for 14 patients and attempted as a rescue in 3 patients. Mean age was 61 ± 24 years. All patients were in New York Heart Association class ≥III, and the surgical risk was high (EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 37 ± 29%, Society of Thoracic Surgeons score: 18 ± 22%). RESULTS Procedure was successful in 14 patients (82%). Two complications occurred during rescue procedures: 1 procedural death and 1 THV migration. One patient had moderate paraprosthetic regurgitation following the procedure, whereas residual regurgitation was trace or less in 11 patients (69%) and mild in 4 patients (25%). Mean gradient decreased from 12 ± 6 mm Hg to 8 ± 3 mm Hg. During a mean follow-up of 22 months, 4 patients died, 3 from cardiac cause. The 18-month survival was 68 ± 14% in the overall population and 78 ± 14% for patients with elective procedure. One patient underwent mitral valve replacement due to periprosthetic mitral regurgitation. At last follow-up, 12 patients were in New York Heart Association class ≤II (75%) and 4 in class III (25%). CONCLUSIONS This single-center series suggests that transfemoral THV implantation for deterioration of mitral bioprosthesis or surgical repair is feasible in selected patients and improves early hemodynamic and midterm functional status.

Transcatheter valve replacement in patients with severe mitral valve disease and annular calcification.

Patients with extensive mitral annular calcification (MAC) may have an inoperable condition because of insurmountable technical issues. Four cases have suggested the feasibility of transcatheter mitral valve replacement (TMVR) in these patients [(1–4)][1]. We report here the first series of

Long-term outcome after transcatheter aortic valve implantation

Objective To assess late outcome after transcatheter aortic valve implantation (TAVI) up to 6 years and to analyse its predictive factors with a particular emphasis on functional status. Very few data exist on the long-term results of TAVI, and these data are crucial for decision making. Methods Between October 2006 and December 2009, 123 consecutive patients were discharged alive after TAVI in our institution. Mean age was 82±8 years, and 88% of patients were highly symptomatic in New York Heart Association (NYHA) class III–IV. Results Follow-up was complete in 122 patients (99%). The overall 6-year survival rate was 31%±5%, the majority of deaths being non-cardiac. Predictive factors of late mortality were the presence of lower limb arteritis (p=0.009), a higher Charlson comorbidity index (p=0.03) and post-TAVI paraprosthetic aortic regurgitation ≥2/4 (p=0.01). Late outcomes according to Valve Academic Research Consortium-2 criteria were analysed, and the 5-year event-free survival rate was 28%±4%. Finally, the rate of good functional results, defined as survival in NYHA class I or II, was 32%±5% at 5-year follow-up. In the survivors, the EQ-5D questionnaire further confirmed the benefit in terms of quality of life. Conclusions About one-third of patients discharged alive after TAVI were alive at 6-year follow-up, and the survivors exhibited good functional results assessed by NYHA class and quality-of-life standardised evaluation.

Transfemoral Tricuspid Valve-in-Ring Implantation Using the Edwards Sapien XT Valve One-Year Follow-Up

Between November 2012 and August 2013, after multidisciplinary evaluation, 3 high-risk patients underwent transfemoral tricuspid valve-in-ring implantation (TVIRI) for refractory congestive heart failure because of deterioration of their tricuspid surgery, using Sapien XT valves (Edwards Lifesciences Inc, Irvine, CA). Patient 1: 44-year-old man, drug abuse, 4 episodes of tricuspid endocarditis, 2 previous cardiac surgeries for mitral homograft in tricuspid position with 30-mm Classic Carpentier Edwards annuloplasty ring (2001), presenting with massive central tricuspid regurgitation (TR; Figure 1A). Figure 1. Color transesophageal echocardiography (TEE) image of tricuspid regurgitation (TR) before implantation on the left panels. A , Patient 1: severe TR with 2 jets, one emanating from the center of the homograft and the second from the medial part of the prosthetic annulus. B , Patient 2: severe central intraprosthetic jet. C , Patient 3: severe central intraprosthetic jet. Color TEE image of TR after valve-in-ring implantation on the right panels: A′ , Patient 1: mild residual TR with an excentric jet coming from the medial part of the prosthetic annulus. Mid-esophageal two-dimensional (2D) TEE view at 0°, compare black and white and color Doppler. B′ , Patient 2: trace TR coming from the medial part of the prosthetic annulus. Mid-esophageal 2D TEE view at 90°, compare black and white and color Doppler. C′ , Patient 3: moderate-to-severe residual paravalvular TR with a jet coming from …

Successful Endovascular Stroke Rescue With Retrieval of an Embolized Calcium Fragment After Transcatheter Aortic Valve Replacement

A 90-year-old symptomatic woman with a critical aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). The procedure was performed under locoregional anesthesia from a right femoral approach, with the successful implantation of a 23-mm CoreValve (Medtronic Inc, Minneapolis, MN). Echocardiographic assessment after TAVR showed a mean transprosthetic gradient of 16 mm Hg and trace paravalvular regurgitation. After percutaneous closure of the right femoral artery, the patient suddenly became unresponsive. After prompt intubation, emergency cerebral MRI was performed to assess the presence of reversible ischemia and exclude parenchymal hemorrhage, showing partial occlusion of the right middle cerebral artery with ischemia in the corresponding territory (Figure 1). Conventional cerebral angiography confirmed partial M1-M2 occlusion of the right middle cerebral artery (Figure 2A; Movie I in the Data Supplement). Complete revascularization …

Clinical outcomes in patients with stable coronary artery disease with vs. without a history of myocardial revascularization

Aims The aim was to describe outcomes among patients with stable coronary artery disease (CAD) with or without a history of myocardial revascularization in a large contemporary cohort. Methods and results Patients with stable CAD were selected from the Reduction of Atherothrombosis for Continued Health (REACH) registry. The cohort was divided into patients with ( n = 25 583) and without ( n = 13 133) a history of myocardial revascularization. Crude outcomes were described according to the use and type of revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). The primary outcome was cardiovascular (CV) death. At baseline, the non-revascularized group was older and had more CV risk factors. At 36-month median follow-up, previous revascularization was associated with a lower risk of CV death [crude incidence rate (CIR): 6.82 vs. 9.08%, hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.66-0.80]; P < 0.01]. This association was seen for patients with a history of PCI (CIR 5.78 vs. 8.88%, HR 0.64 [0.58-0.71]; P ≤ 0.01), but not with CABG (HR 1.26 [1.14-1.49]; P < 0.01), and was consistent regardless of prior MI and the timing of prior revascularization. Conclusion Among patients with stable CAD, a history of myocardial revascularization was associated with lower CV mortality, particularly when PCI was the mode of revascularization. Coronary artery disease patients managed non-invasively represent a high-risk group.

TRANSFEMORAL TRICUSPID VALVE-IN-VALVE AND VALVE-IN-RING IMPLANTATION USING THE EDWARDS SAPIEN XT VALVE: ONE-YEAR FOLLOW-UP

Redo tricuspid surgery may be high risk or even contraindicated due to comorbidity. Transcatheter valve implantation (TVI) has been recently reported in this setting. We aimed to evaluate the feasibility of transfemoral implantation of Edwards SAPIEN prosthesis in failed tricuspid bioprostheses (BP

0026 : Transfemoral tricuspid valve-in-valve and valve-in-ring implantation using the Edwards SAPIEN XT valve: one-year follow-up

Background Redo tricuspid surgery may be at high risk or even contraindicated in patients with comorbidities. Transcatheter valve implantation (TVI) has been recently reported in this setting. The aim of this study was to evaluate the early and 1-year outcomes of TVI with Edwards SAPIEN XT valves in failed tricuspid bioprostheses (BP) and ring annuloplasty (RA). Methods and Results TVI was performed in 6 patients for failed tricuspid surgical valves (3 BP, 3 RA). Median patient age was 58 years, all were in New York Heart Association (NYHA) class≥III and 5 out of 6 had previously undergone at least 2 cardiac interventions. The procedure was successful in the 3 patients with BP and 2 with RA; one patient had a moderate paravalvular regurgitation at the level of the open portion of a rigid incomplete ring. Otherwise, regurgitation was absent in 3 patients, trace in 1 and mild in 1. The transvalvular gradient decreased from 8 mmHg at baseline to 4 mmHg at day 7. At 1-year follow-up, survival was 100%. Tricuspid gradients remained stable in all but 1 patient, as well as regurgitation grades. Only 1 patient was in NYHA class III, 2 were in class II and 3 in class I. Conclusions Transfemoral TVI with SAPIEN XT valves after failed tricuspid surgery is feasible in selected high-risk patients, with good early and 1-year hemodynamic and clinical results. However, RA may raise issues due to their oval shape and open configuration.