Gry Dahle

Transcatheter valve-in-ring implantation after failure of surgical mitral repair

OBJECTIVES Redo surgery after failed mitral valve repair may be high risk, or contraindicated in patients with comorbidities. Because of this high risk, other interventional possibilities like transcatheter valve implantation might be of benefit. We report our experience with transcatheter mitral valve-in-ring implantation (TVIR) in high-risk patients after failure of surgical ring annuloplasty. METHODS From January 2010 to February 2012, following a multidisciplinary discussion, 17 high-risk patients underwent TVIR using Edwards SAPIEN XT prostheses, via either a transvenous transseptal (n = 8), or a transapical approach (n = 9). RESULTS Patients were aged 70 ± 16 years, in New York Association classes III/IV. Their mean logistic EuroSCORE was 36 ± 17% and mean Society of Thoracic Surgeons risk score 13 ± 9%. The mean time interval between surgery and repair failure was 7 ± 3 years. Annuloplasty rings were semi-rigid in 14 cases, flexible in 2, and rigid in 1. Manufacturers ring diameters were 26 mm in 4 patients, 27 mm in 1, 28 mm in 9, 30 mm, 31 mm and 34 mm in 1. The predominant failure mode was regurgitation in 12 cases and stenosis in 5. SAPIEN XT diameters were 26 mm in 15 patients, 23 mm and 29 mm in 1. Procedural success rate was 88% (15/17). Emergency surgery was needed in 1 patient due to acute dislodgement of the ring. The degree of mitral regurgitation was reduced to none or mild in all but 2 patients; final mean gradient was 7 ± 3 mmHg. Thirty-day survival was 82% (14/17 patients). At last follow-up (13 ± 5 months), survival rate was 71% (12/17). CONCLUSIONS These preliminary results suggest that TVIR is feasible, with low operative risk, and may provide short-term clinical and haemodynamic improvement in selected high-risk patients with failure of mitral ring annuloplasty.

Concomitant transatrial valve-in-valve in pulmonal and tricuspid position.

Transcatheter valve implantation in the pulmonary valve has been established as a valuable treatment option for patients with conduit failure in the right ventricular outflow tract, most often with the use of the Melody valve. Transcatheter valve‐in‐valve (VIV) implantation in the tricuspid position is restricted to single case reports, most often with the implantation of the Edwards SAPIEN valve. A 67 years old male with carcionoid syndrome and previously implanted bioprosthesis in the pulmonary and tricuspid valve now presented with worsening symptoms due to degeneration of both bioprostheses. The risk of new open surgery was deemed to high. We report of the first transatrial double VIV implantation using the balloon expandable Edwards SAPIEN XT in pulmonary and tricuspid position.

Transcatheter Aortic Valve Implantation and Intraoperative Left Ventricular Function: A Myocardial Tissue Doppler Imaging Study

OBJECTIVE Transcatheter aortic valve implantation in patients turned down for surgical aortic valve replacement is a high-risk procedure. Severe aortic stenosis is associated with impaired left ventricular longitudinal motion, and myocardial peak systolic velocity is a measure of left ventricular function in these patients. The present study aimed to quantify the acute changes in left ventricular function during the procedure by using myocardial tissue Doppler imaging and transthoracic cardiac output measurements. DESIGN Prospective observational study. SETTING Tertiary care university hospital. PARTICIPANTS 40 patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation. INTERVENTIONS Transesophageal 4-chamber and 2-chamber echocardiograms were performed immediately before and ~15 minutes after valve implantation. Longitudinal myocardial peak systolic velocity was obtained by tissue Doppler imaging from 8 basal segments and averaged. Cardiac output was measured by the lithium dilution method, and systemic vascular resistance index and stroke volume were calculated. MEASUREMENTS AND MAIN RESULTS Longitudinal myocardial peak systolic velocity improved immediately after valve implantation, from -2.3±0.8 to -3.0±1.1 cm/sec (p<0.001); this represented an average increase of 31%±33%. Cardiac output increased from 3.2±0.8 L/min to 3.6±0.9 L/min (15%±33%; p = 0.04). This was due to increased heart rate (59±9 beats/min to 72±12 beats/min; p<0.001) and not to an improved stroke volume. Systemic vascular resistance index was reduced from 2,937±984 dynes*sec/cm(5)/m(2) to 2,436±730 dynes*sec/cm(5)/m(2) (p = 0.003). CONCLUSION Intraoperative echocardiography tissue Doppler imaging detected immediate improvement in left ventricular long-axis motion after transcatheter aortic valve implantation. The method provided detailed information not obtainable by routine hemodynamic monitoring.

Innovative technology-transcatheter aortic valve implantation: Cost and reimbursement issues

Abstract Objective. Transcatheter aortic valve implantation (TAVI) offers a new treatment option for patients with severe symptomatic aortic valve stenosis, classified as “inoperable”. The purpose of the study was to reveal the association between ascertained hospital costs with the actual patient Diagnosis-Related Group (DRG). Method. We examined 50 consecutive patients who underwent either transapical TAVI, (TAVI-TA) or transfemoral TAVI (TAVI-TF) with the Edwards SAPIEN valve and CoreValve® between September 2009 and August 2011. Results. Fourty-nine patients had successful valve deployment. Seven patients died within 30 days of the operation. The mean length of hospital stay for TAVI-TA was 199 hours (range 77–362), and the mean costs for TAVI-TA were 55,690 US

Intraoperative improvement in left ventricular peak systolic velocity predicts better short-term outcome after transcatheter aortic valve implantation

. For TAVI-TF the mean length of hospital stay was 170 hours (range 49–276) and the mean costs were 52,087 US

Reduced inflammatory response by transcatheter, as compared to surgical aortic valve replacement

. Conclusion. There was no significant difference between TAVI-TA and TAVI-TF patient characteristics. There was a significant discrepancy between actual hospital costs and the current Norwegian DRG reimbursement for the TAVI procedure. This discrepancy can be partly explained by excessive costs related to the introduction of a new program with new technology. Costly innovations should be considered in price-setting of reimbursement for novel technology.

Long-term outcomes after transcatheter aortic valve implantation: the impact of intraoperative tissue Doppler echocardiography

OBJECTIVES Left ventricular function is expected to improve after transcatheter aortic valve implantation due to the acute reduction in afterload, but does not occur in all patients. We hypothesized that the immediate intraoperative response in systolic left ventricular longitudinal motion during the procedure could be a predictor of short-term outcome. METHODS Sixty-four patients treated with transcatheter aortic valve implantation for severe aortic stenosis were included. Transoesophageal 4- and 2-chamber echocardiograms were obtained immediately prior to and ∼15 min after valve implantation. Patients were defined as responders if their average left ventricular longitudinal peak systolic velocity increased by ≥20% from the preimplantation value and was related to the 3-month outcome. RESULTS Thirty-five patients were classified as responders, with an increase in the intraoperative longitudinal peak systolic velocity from an average of 2.2 ± 0.8 to 3.1 ± 1.1 cm/s (P < 0.001); the velocity was unchanged in the remaining 29 patients, who averaged 2.4 ± 1.1 cm/s. There were significantly fewer adverse cardiac events in the responder group at the 3-month follow-up (20 vs 45%, P = 0.03) and the New York Heart Association class was significantly better in the responders compared with non-responders. Responders had a significant reduction in N-terminal probrain natriuretic peptide levels [243 (113-361) vs 163 (64-273), P = 0.004] at the 3-month follow-up, whereas non-responders did not [469 (130-858) vs 289 (157-921), P = 0.48]. CONCLUSIONS An immediate improvement in the longitudinal peak systolic velocity during the transcatheter aortic valve implantation procedure predicted a better short-term outcome and may be useful in identifying patients who are at risk of a less favourable outcome after transcatheter aortic valve implantation.

Functional Mitral Regurgitation with a Wide Extension of the Central Regurgitant Jet

Abstract Objectives. The inflammatory response to on-pump cardiac surgery is well known. Systemic inflammatory response syndrome after transcatheter valve implantation (TAVI) has been reported. The objective of this study was to study the inflammatory response during TAVI, and compare with the response during surgical aortic valve replacement. Methods. Eighteen patients undergoing transcatheter implantation, either by a transfemoral (n = 9) or transaortal (n = 9) approach were compared with eighteen patients admitted for surgical replacement. Blood samples per- and postoperatively were analysed for C3bc, terminal complement complex, myeloperoxidase, macrophage inflammatory protein-1β, monocyte chemo-attractant peptide-1, eotaxin, IL-6 and troponin-T. All markers were measured at defined time points and the areas under the curve were compared. Results. Activation of complement, granulocytes, monocytes and eosinophils were significantly lower in the transcatheter group as compared to the surgical group (<0.01). There was no difference in generation of troponin T and IL-6. A small difference in complement activation was observed between the transfemoral and transaortal placement of TAVI. There was no significant difference in clinical outcomes between the TAVI and surgical groups. Discussion. Activation and release of inflammatory markers was significantly less during with TAVI as compared to SAVR, particularly for markers associated with extracorporeal circulation. TAVI and SAVR generated the same degree of IL-6 and troponin T, indicating that the burden on the myocardial tissue was the same. Clinical Trials: Gov ID: NCT03074838 Unique protocol ID: 2012/7919

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation: A Global Feasibility Trial

OBJECTIVES Transcatheter aortic valve implantation improves survival in patients with severe aortic stenosis who are ineligible for surgical valve replacement; however, not all patients benefit from the procedure. We endeavoured to identify these patients using intraoperative echocardiography and hypothesized that intraoperative left ventricular function in response to the acute afterload reduction during the procedure was related to long-term outcomes. METHODS We prospectively included 64 patients who were scheduled for transcatheter aortic valve implantation and divided them into responders and non-responders based on their left ventricular intraoperative responses to the acute afterload reduction after valve deployment. Responders were defined by increases of ≥20% in left ventricular longitudinal peak systolic velocities determined by tissue Doppler echocardiography. All patients were assessed for the following outcomes at 12 months: cardiac mortality, adverse cardiac events, quality of life, New York Heart Association class, N-terminal pro-brain natriuretic peptide (NT-proBNP) and echocardiography. RESULTS Thirty-five patients (55%) were classified as responders and 29 patients (45%) as non-responders. Compared with responders, non-responders had higher risks of death (28 vs 9%, respectively, P = 0.04) and cardiac events (66 vs 26%, respectively, P < 0.01) during the 12-month follow-up. Significant long-term improvements in quality of life, NT-proBNP and left ventricular function were observed only in the responders. Preoperative risk stratification, intraoperative handling, aortic gradient and valve area were similar between groups. CONCLUSIONS Intraoperative assessment of left ventricular function by tissue Doppler echocardiography predicted long-term outcomes after transcatheter aortic valve implantation. Our results suggest that a preoperative test of myocardial contractile reserve might improve risk stratification and patient selection prior to the procedure.

Transapical 29-mm Edwards SAPIEN-XT aortic valve in a 34-mm mitral annuloplasty ring.

In this case, a patient with severe and extensive functional MR was treated with two MitraClips® with dramatic improvement in the MR severity and functional status. The two MitraClips® were placed some distance from each other because of the wide and extensive nature of the regurgitation, creating a three-orifice mitral valve.