Laurens W. Wollersheim

Transapical JenaValve in a degenerated Freedom SOLO bioprosthesis.

Degeneration of an aortic bioprosthesis is a complication often requiring high-risk surgical reintervention. Transcatheter aortic valve implantation (TAVI) provides an alternative to high-risk surgery. However, TAVI for a degenerated stentless bioprosthesis becomes more perilous because of the lack of support of a stent and the changed landmarks of the aortic root. Furthermore, the supraannular implantation technique for the stentless Freedom SOLO (Sorin Group, Milan, Italy) bioprosthesis may increase the risk for coronary occlusion after deployment because of the reduced distance between the neoannulus and the coronary ostia. In this setting, the use of the JenaValve (JenaValve Technology, GmbH,M€unchen, Germany) could reduce the risk of coronary ostium obstruction because of the specific design of this device. To illustrate this clinical problem, we present the first reported case after successful transcatheter valve-in-valve implantation of a JenaValve in a degenerated Freedom SOLO.

Aortic Valve Replacement With the Stentless Freedom SOLO Bioprosthesis: A Systematic Review

This systematic review examined the clinical and hemodynamic performance of the stentless Freedom SOLO (Sorin Group, Milan, Italy) aortic bioprosthesis. The occurrence of postoperative thrombocytopenia was also analyzed. The Freedom SOLO is safe to use in everyday practice, with short cross-clamp times, and postoperative pacemaker implantation is notably lower. Valvular gradients are low and remain stable during short-term follow-up. Thrombocytopenia is more severe than in other aortic prostheses; however, this is without clinical consequences. Within a few years, the 15-year follow-up of this bioprosthesis will be known, which will be key to evaluating its long-term durability.

Stentless vs Stented Aortic Valve Bioprostheses in the Small Aortic Root.

In patients with a small aortic root undergoing aortic valve replacement (AVR), the Freedom SOLO bioprosthesis may be the ideal prosthesis because of its stentless design and supra-annular implantation. This study investigated if the stentless Freedom SOLO has an advantage when compared with a stented bioprosthesis in patients with a small aortic root. From April 2005-July 2014, 269 consecutive patients underwent AVR with either a Freedom SOLO (n = 76) or Mitroflow (n = 193) bioprosthesis size 19mm or 21mm, respectively. This retrospective comparison study presents clinical and echocardiographic follow-up data. In results, operative outcome and survival were similar. At 7 years, cumulative incidence of aortic valve reoperation and structural valve deterioration favor the Freedom SOLO (0% vs 7.1%, P = 0.03 and 0% vs 4.5%, P = 0.08, respectively). Additionally, the postoperative peak and mean valvular gradients favor the Freedom SOLO (21 ± 9mmHg vs 32 ± 12mmHg and 12 ± 5mmHg vs 19 ± 8mmHg, both P = <0.001, respectively). During mid-term follow-up this hemodynamic advantage continued in favor of the Freedom SOLO. Also prosthesis-patient mismatch occurred less frequently in the Freedom SOLO (28% vs 52%, P = 0.001). There were no differences in prosthetic valve endocarditis, thromboembolic, or bleeding events. In conclusion, the stentless Freedom SOLO has several significant advantages for AVR in patients with a small aortic root in comparison with a stented Mitroflow bioprosthesis. The Freedom SOLO shows superior hemodynamic performance with significantly lower valvular gradients that remained stable during mid-term follow-up. Additionally, significantly fewer prosthesis-patient mismatch occurred and the Freedom SOLO showed superior durability.

A 76-year old man with a torn Freedom SOLO bioprosthesis

We describe a case of a 76-year old male who presented with progressive dyspnoea. He underwent an aortic valve replacement with a Freedom SOLO bioprosthesis 6 years ago. Transthoracic echocardiography showed a moderate-to-severe leakage of the Freedom SOLO bioprosthesis. During surgical reintervention, a partial tear of the left coronary cusp was seen from the commissure of the right coronary cusp to its base. After radiographic and microscopic examination, no clear cause was found for the failure of this Freedom SOLO bioprosthesis. To our knowledge, this is the third failure of a Freedom SOLO bioprosthesis reported in the literature. When the long-term follow-up of the Freedom SOLO bioprosthesis is available, it has to be compared with other bioprosthesis for long-term durability.

Current Status of Surgical Treatment for Aortic Valve Stenosis

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve. doi: 10.1111/jocs.12384 (J Card Surg 2014;29:630–637)

Lost guidewire protrudes through the heart and chest

A 65-year-old woman was referred to our institution with an ‘iron wire’ that protruded through her chest ( Panel A ). She had no dyspnoea, pain, or fever. Her medical history included a mitral- and tricuspid valve repair 15 years ago and she was on permanent dialysis. Computed tomography scan ( Panel B ) showed a guidewire of ∼40 cm …

Transcatheter aortic valve replacement alters ascending aortic blood flow and wall shear stress patterns: A 4D flow MRI comparison with age-matched, elderly controls

BackgroundWith the implementation of transcatheter aortic valve replacement (TAVR) in lower-risk patients, evaluation of blood flow characteristics and the effect of TAVR on aortic dilatation becomes of considerable interest. We employed 4D flow MRI in the ascending aorta of patients after TAVR to assess wall shear stress (WSS) and compare blood flow patterns with surgical aortic valve replacement (SAVR) and age- and gender-matched controls.MethodsFourteen post-TAVR patients and ten age- and gender-matched controls underwent kt-PCA accelerated 4D flow MRI of the thoracic aorta at 3.0 Tesla. Velocity and wall shear stress was compared between the two groups. In addition, aortic flow eccentricity and displacement was assessed and compared between TAVR patients, controls and 14 SAVR patients recruited as part of an earlier study.ResultsCompared to controls, abnormally elevated WSS was present in 30±10% of the ascending aortic wall in TAVR patients. Increased WSS was present along the posterior mid-ascending aorta and the anterior distal-ascending aorta in all TAVR patients. TAVR results in eccentric and displaced flow in the mid- and distal-ascending aorta, whereas blood flow displacement in SAVR patients occurs only in the distal-ascending aorta.ConclusionThis study shows that TAVR results in increased blood flow velocity and WSS in the ascending aorta compared to age- and gender-matched elderly controls. This finding warrants longitudinal assessment of aortic dilatation after TAVR in the era of potential TAVR in lower-risk patients. Additionally, TAVR results in altered blood flow eccentricity and displacement in the mid- and distal-ascending aorta, whereas SAVR only results in altered blood flow eccentricity and displacement in the distal-ascending aorta.Key Points• TAVR results in increased blood flow velocity and WSS in the ascending aorta.• Longitudinal assessment of aortic dilatation after TAVR is warranted in the era of potential TAVR in lower-risk patients.• Both TAVR and SAVR result in altered blood flow patterns in the ascending aorta when compared to age-matched controls.