Mike Saji

Autopsy finding of the Sapien XT valve from a patient who died suddenly after transcatheter aortic valve replacement

An 89-year-old woman with severe aortic stenosis underwent transfemoral aortic valve replacement. The postoperative course was uneventful except transient bradycardia immediately after the procedure. Echocardiographic finding showed excellent valvular function. After discharge, the patient died suddenly. Autopsy findings showed compression of the atrioventricular conduction system region at the septum by the stent strut. Microscopic examination showed atrophy of the conduction fibers with eosinophilic degeneration of the cytoplasm or coagulation necrosis with pyknosis in the bundle of His and the left bundle branch. Compression by the stent strut triggering dysfunction of the conduction system could have caused fatal arrhythmic event.

Adjunctive intracardiac echocardiography imaging from the left ventricle to guide percutaneous mitral valve repair with the mitraclip in patients with failed prior surgical rings

We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings.

Transcatheter Aortic Valve Replacement in Lower Surgical Risk Patients: Review of Major Trials and Future Perspectives

Following the first successful transcatheter aortic valve replacement (TAVR) in 2002, TAVR has globally evolved to become a standard procedure in high-risk patients. Surgical aortic valve replacement in non-high-risk patients remains the gold standard for treatment of severe aortic stenosis. However, a paradigm shift appears to be occurring in the direction of treating lower-risk patients, and several studies have suggested its impact on clinical outcomes. In this review, we highlight the current status of TAVR in intermediate-risk patients and review major trials including Placement of AoRTic TraNscathetER (PARTNER) 2A randomized intermediate-risk trial using SAPIEN XT (Edwards Lifesciences Corp, Irvine, CA) recently presented with excellent outcomes and the lowest major complications rate at the American College of Cardiology’s 65th Annual Scientific Session in Chicago. Clinical trials in low-risk patients using SAPIEN 3 and CoreValve Evolut R have just been launched, and they are going to be important milestones in the TAVR field.

Current state of transcatheter mitral valve repair with the MitraClip

BACKGROUND Many patients affected with mitral valve regurgitation suffer from multiple comorbidities. The MitraClip device provides a safe means of transcatheter valve repair in patients with suitable mitral valve anatomy who are at prohibitive risk for surgery. We describe our early procedural outcomes and present a summary of the current state of MitraClip technology in the United States. METHODS We performed a retrospective chart review of initial high-risk or inoperable patients who underwent MitraClip placement at our institution after completion of the EVEREST II study. We examined the primary outcome of 30-day mortality, and secondary outcomes included extent of reduction of mitral regurgitation (MR), New York Heart Association (NYHA) functional class improvement, length of stay, and major complications. RESULTS A total of 115 high-risk patients (mean Society of Thoracic Surgeons predicted risk of mortality 9.4%±6.1%) underwent the MitraClip procedure at our institution between March 2009 and April 2014. Co-morbidities including coronary artery disease (67.8%), pulmonary disease (39.1%) and previous cardiac surgery (44.3%) were common. The device was placed successfully in all patients with a 30-day mortality of 2.6%. All patients demonstrated 3+ or 4+ MR on preoperative imaging, and 80.7% of patients had trace or 1+ MR at hospital discharge. NYHA class improved substantially, with 79% of patients exhibiting class III or IV symptoms pre-procedure and 81% reporting class I or II symptoms at one month follow-up. CONCLUSIONS The MitraClip procedure provides a safe alternative to surgical or medical management for high-risk patients with MR and suitable valve anatomy. A comprehensive heart team approach is essential, with surgeons providing critical assessment of patient suitability for surgery versus percutaneous therapy as well as performance of the valve procedure.

Impact of Frailty Markers for Unplanned Hospital Readmission Following Transcatheter Aortic Valve Implantation

BACKGROUND Various frailty markers have been developed to guide better patient selection for transcatheter aortic valve implantation (TAVI). This study aimed to investigate the frequency and specific causes of unplanned hospital readmission after TAVI, and to investigate which frailty markers better predicted outcomes.Methods and Results:We retrospectively reviewed 155 patients for whom we calculated their Short Physical-Performance Battery (SPPB), Placement of AoRTic TraNscathetER Valve (PARTNER) frailty scale, frailty index, clinical frailty scale, modified Fried scale, and gait speed. The primary endpoint was unplanned readmission following TAVI. The clinical model was established using variables that were identified as independent predictors in multivariate analysis. Incremental values were assessed after adding each frailty marker to the clinical model, and were compared between frailty markers. Although unplanned readmission <30 days was 1.9%, 23% of patients had an unplanned readmission following TAVI mainly because of heart failure and pneumonia within 1 year. Frailty markers other than the modified Fried scale were independently associated with unplanned readmission. The SPPB and the PARTNER frailty scale significantly increased discriminatory performance for predicting unplanned readmission. CONCLUSIONS Unplanned readmissions following TAVI in the present study were fewer than previously reported. There seems to be a difference between frailty markers in their predictive performance. Precise frailty assessment may result in reducing unplanned admissions after TAVI and therefore better quality of life.

Progressive Mitral Stenosis After MitraClip Implantation in a Patient With Systemic Inflammatory Disease.

We describe a patient at high surgical risk who was successfully treated with a MitraClip (Abbott Vascular, Menlo Park, CA) without transmitral gradient. She received corticosteroid therapy for systemic lupus erythematosus, and progressive mitral stenosis developed late after MitraClip implantation. It gradually increased and reached 23 mm Hg at 28 months after the procedure; during the same period, her dose of prednisone had to be increased owing to lupus flare. Systemic inflammatory disease has the potential to result in mitral valve inflammation and fibrosis, ultimately causing thickening of the tissue bridge and worsening of the mitral valve obstruction. Preprocedural counseling regarding durability may help in this population.

Pre-Procedural 6-Min Walk Test as a Mortality Predictor in Patients Undergoing Transcatheter Mitral Valve Repair

The simple, functional 6-min walk test (6MWT) can predict exercise capacity and is widely used to assess treatment outcomes [(1)][1]. Transcatheter mitral valve repair (TMVR) (MitraClip, Abbott Vascular, Menlo Park, California) has become widely adopted for clinical use in high-risk or prohibitive-

Transcatheter Aortic Valve Replacement in a Young Adult Patient with a Failed Homograft.

To the Editor, Repeat surgical aortic valve replacement (SAVR) in patients with congenital aortic valve disease is common. Approximately one third of the patients have a second SAVR within 10 years after their initial SAVR [1]. Implantation of the bioprosthetic valve is an independent predictor of re-operation, which increases the risk of complication and mortality [2]. Transcatheter aortic valve replacement (TAVR) has been successfully performed as an alternative to SAVR in elderly patients with high operative risk, and the transcatheter aortic valve in surgical aortic valve [valve-invalve (VIV)] procedure is also considered clinically effective in structurally degenerated stenotic or regurgitant bioprosthetic valves [3]. However, there is lack of information about the VIV procedure in young adult patients [4]. Recently, we had a 23-year-old male who received a surgical homograft in the aortic position in his preadolescence. He subsequently had valve failure, and underwent the VIV procedure to the degenerated homograft in our institute. He was considered high risk for open heart surgery despite his age by the multidisciplinary heart team due to the history of multiple re-operative surgeries with cardiac arrest as well as psychological comorbidities (emotional distress and behavior problem) which would have hampered his recovery, and TAVR was decided as the optimal approach for him. The CoreValve Evolut R (Medtronic, Minneapolis, MN) was deployed via transfemoral approach under general anesthesia with fluoroscopic guidance (Fig. 1). The patient had an improvement in symptoms following the procedure, and he was discharged on third post-operative day without complication. This indicates that TAVR is feasible and effective in a young patient with a deteriorated homograft. TAVR was initially applied to elderly patients with significant comorbidities considered extreme surgical risk. However, there is a trend recently to treat lower risk and younger patients with considerable benefit of an advanced technology (e.g. well-designed valve, small delivery systems profile, established aortic annular assessment using imaging modalities, embolic protection device), which has reduced complications during TAVR [5–9]. Although a conventional TAVR risk evaluation tool such as Society of Thoracic Surgeons score / EuroSCORE cannot be well applied to this young patient, he was considered high & D. Scott Lim sl9pc@virginia.edu

Use of intracardiac echocardiography to guide percutaneous transluminal mitral commissurotomy: A 20‐patient case series

To report the efficacy and safety of the use adjunctive intracardiac echocardiography (ICE) during percutaneous transluminal mitral commissurotomy (PTMC) in patients without transesophageal echocardiography (TEE).

Transcatheter aortic valve replacement requiring staged percutaneous coronary intervention in Japanese patients with severely calcified ascending aorta: a case report and institution series analysis

Transcatheter aortic valve replacement (TAVR) has emerged as a less invasive therapeutic option for high-risk patients with aortic stenosis (AS) in Europe and US. Data on TAVR are relatively limited in Japan. We report a first TAVR case in Japan of successful TAVR following percutaneous coronary intervention (PCI). A 75-year-old man with stable angina pectoris and severe AS was considered to be at high risk for surgical AVR because of severely calcified ascending aorta. He underwent transfemoral TAVR after undergoing PCI of left circumflex artery. The procedure was successful and the patient was discharged on the 10th postoperative day.