Eric Brochet

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.

MRI and cine MRI of asymmetric septal hypertrophic cardiomyopathy.

Objective This study was designed to determine MR and cine MR characteristics of asymmetric septal hypertrophie cardiomyopathy and to correlate MR and cine MR features with the severity of left ventricular outflow tract obstruction. Materials and Methods Ten consecutive patients with asymmetric septal hypertrophie cardiomyopathy [resting obstructive (n = 3), latent obstructive (n = 4), nonobstructive hypertrophie (n = 3)] and five healthy volunteers underwent MRI and cine MRI. Oblique two chamber and four chamber views were obtained in all cases. Results In the 10 patients, the mean ± SD end-diastolic myocardial thickness was 22.7 ± 6.3 mm in the basal septum and 13 ± 3.9 mm in the posterolateral wall with a ratio of 1.76 ± 0.30; the corresponding values were 10.6 ± 1.1, 10.4 ±1.1, and 1.02 ± 0.08 mm, respectively, in five healthy volunteers. The mean systolic thickening of the basal septum was 22 ± 12%. This value was 49 ± 4% in the five healthy volunteers. In resting obstructive hypertrophie cardiomyopathy, septal wall thickness was ≥25 mm with a systolic thickening of 10%. A systolic anterior motion of the mitral valve was demonstrated in four patients with resting subaortic pressure gradients ranging from 28 to 120 mm Hg. A signal void area was demonstrated within the left ventricular outflow tract during systole in the seven patients with obstructive cardiomyopathy. This signal void area reached its maximum during early systole in the most severe obstructions and during midsystole in the less severe obstructions. Conclusion In patients with asymmetric septal hypertrophie cardiomyopathy, gross correlation was demonstrated between severity of obstruction and several MR and cine MR features including increased end-diastolic thickness of the septal wall, decreased systolic thickening of the septal wall, systolic anterior motion of the mitral valve, and signal void area within the left ventricular outflow tract during systole.

Partial Rupture of the Tricuspid Valve after Extraction of Permanent Pacemaker Leads: Detection by Transesophageal Echocardiography

Traumatic lesions of the tricuspid valve complicating pacemaker lead extractions appear to be rare. We report two cases of partial rupture of the tricuspid valve, following apparently uneventful extraction of permanent ventricular leads, resulting in severe regurgitation and. in one case, chronic heart failure. TEE was useful to identify the traumatic mechanism of tricuspid regurgitation (TR) and the extent of valvular lesions in these patients. Such etiology should be suspected, and TEE performed, in patients developing TR or heart failure late after lead extraction.

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 …

Cine MRI of mitral regurgitation in planes angled along the intrinsic cardiac axes.

Objective This prospective study was designed to evaluate the mechanism and severity of mitral regurgitation (MRG) by means of cine MRI using planes angled along the intrinsic cardiac axes. Materials and Methods In 25 patients with MRG, analysis of the direction, extent, and distribution of left atrial signal void area was performed on both two chamber and four chamber cine MRI views. Cine MRI features including qualitative grading, maximal length of regurgitant jet, and ratio of regurgitant jet area to left atrial area were compared with the results of color flow Doppler (CFD) mapping (n = 25), angiography (n = 20), and regurgitant fraction as determined at catheterization (n = 15). Results In the four chamber view, cine MRI demonstrated central extension of regurgitant jet (n = 8) in cases with dilatation of valve annulus or retraction of both mitral valve leaflets, anterior extension (n = 8) in cases with prolapse of the posterior leaflet, and posterior extension (n = 7) in cases with prolapse of the anterior leaflet or retraction of the posterior leaflet. In two cases of mild MRG with small signal void area, evaluation of mechanism was not feasible. The results of cine MRI and angiographic qualitative gradings were the same in 19 of the 20 patients and differed by one grade in the other patient. In the 25 patients, maximal length of the regurgitant jet was well correlated with both regurgitant jet area and ratio of the jet area to the left atrial area as determined by CFD mapping (r = 0.91, r = 0.85, p < 0.0001, respectively). In 15 patients the maximal length of regurgitant jet was correctly correlated with regurgitant fraction determined at catheterization (r = 0.76, p < 0.001). Conclusion Cine MRI by means of planes angled along the intrinsic cardiac axes allows assessment of both the mechanism and the severity of MRG.