Riccardo Cocchieri

Factors associated with cardiac conduction disorders and permanent pacemaker implantation after percutaneous aortic valve implantation with the CoreValve prosthesis

BACKGROUND Cardiac conduction disorders and requirement for permanent pacemaker implantation (PPI) are not uncommon after surgical aortic valve replacement and have important clinical implications. We aimed to investigate the incidence of cardiac conduction disorders after percutaneous aortic valve implantation (PAVI) and to identify possible clinical factors associated with their development. METHODS We studied 34 patients (mean age 80 +/- 8 years, 18 male) who underwent PAVI with the CoreValve bioprosthesis (Corevalve Inc, Irvine, CA). Electrocardiographic evaluation was performed pre- and postprocedurally, and at 1-week and 1-month follow-up. Other clinical variables were obtained from the medical history, echocardiography, and angiography. RESULTS After PAVI, 7 patients required PPI, all of whom developed total atrioventricular block within 3 days postprocedurally. A smaller left ventricular outflow tract diameter (20.3 +/- 0.5 vs 21.6 +/- 1.8 cm, P = .01), more left-sided heart axis (-20 degrees +/- 29 degrees vs 19 degrees +/- 36 degrees , P = .02), more mitral annular calcification (10 +/- 1 vs 5 +/- 4 mm, P = .008), and a smaller postimplantation indexed effective orifice area (0.86 +/- 0.20 vs 1.10 +/- 0.26 cm(2)/m(2), P = .04) were associated with PPI. The incidence of new left bundle-branch block (LBBB) was 65% and was associated with a deeper implantation of the prosthesis: 10.2 +/- 2.3 mm in the new-LBBB group versus 7.7 +/- 3.1 mm in the non-LBBB group (P = .02). CONCLUSIONS Percutaneous aortic valve implantation with the CoreValve prosthesis results in a high incidence of total atrioventricular block requiring PPI and new-onset LBBB. Preexisting disturbance of cardiac conduction, a narrow left ventricular outflow tract, and the severity of mitral annular calcification predict the need for permanent pacing, whereas the only factor shown to be predictive for new-onset LBBB is the depth of prosthesis implantation.

Predictors and Prognostic Value of Myocardial Injury During Transcatheter Aortic Valve Implantation

Background— Myocardial injury is a common complication during cardiac surgery and percutaneous coronary intervention and is associated with postprocedural cardiovascular morbidity and mortality. Limited data have been reported about the occurrence of myocardial damage associated with transcatheter aortic valve implantation (TAVI). Therefore, our purpose was to investigate the incidence, predictors, and prognostic value of myocardial injury during TAVI. Methods and Results— We studied 119 patients (aged 81±8 years; 47 male) who had undergone a TAVI with the Medtronic-CoreValve bioprosthesis. Serum creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were measured before and after the procedure. Myocardial injury was defined as a postprocedural increase of CK-MB and/or cTnT level >5 times the upper reference limit. After TAVI, the incidence of myocardial injury was 17%, which was independently predicted by procedural duration (in minutes) (odds ratio [OR], 1.04; 95% CI, 1.01–1.06), preprocedural &bgr;-blocker use (OR, 0.12; 95% CI, 0.03–0.45), peripheral arterial disease (OR, 6.36; 95% CI, 1.56–25.87), and prosthesis depth (in millimeters) (OR, 1.31; 95% CI, 1.08–1.59). The 30-day mortality after TAVI was 13% and was independently predicted by myocardial injury (OR, 8.54; 95% CI, 2.17–33.52), preprocedural hospitalization (OR, 9.36; 95% CI, 2.55–34.38), and left ventricular mass index (in g/m2) (OR, 1.02; 95% CI, 1.00–1.03). Conclusions— After transcatheter aortic valve implantation, serum levels of both CK-MB and cTnT increase, reflecting the occurrence of periprocedural myocardial injury. A longer procedural duration, the absence of &bgr;-blocker use, peripheral arterial disease, and a deeper prosthesis insertion are associated with myocardial injury. Together with preprocedural hospitalization and left ventricular mass, myocardial injury is an independent predictor for 30-day mortality after TAVI.

Hybrid coronary artery bypass grafting and transaortic transcatheter aortic valve implantation

Evolving less-invasive surgical techniques potentially minimize surgical trauma and reduce the risk of cardiac valve surgery. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative for patients facing high or even prohibitive risk with conventional aortic valve replacement (AVR). Concomitant coronary artery disease (CAD) is a well-known comorbidity in degenerative aortic valve stenosis and has been identified as an independent factor for increased mortality in patients undergoing AVR. The presence of CAD in patients undergoing TAVI is estimated to be as great as 75.6%. Simultaneous percutaneous coronary intervention (PCI) has been reported although TAVI is currently considered a stand-alone procedure. Significant coexisting CAD requires preprocedural PCI. In patients with significant complex CAD, rendering them ineligible for PCI, revascularization ideally consists of coronary artery bypass grafting (CABG). According to the current guidelines, patients undergoing CABG with at least moderate aortic stenosis should undergo concomitant AVR. Combining CABG and AVR increases procedural duration and is considered to increase operative mortality. High-risk patients with significant CAD who are ineligible for PCI could undergo surgical revascularization in a hybrid procedure with TAVI, reducing the duration of aortic crossclamping and cardiopulmonary bypass or even eliminating them entirely, thus decreasing surgical risk. Limited data are available regarding combined TAVI and surgical revascularization. We report TAVI through a transaortic approach during surgical revascularization in 5 high-risk patients with severe symptomatic aortic valve stenosis and significant CAD (Table 1).

Rationale and design of a proof-of-concept trial investigating the effect of uninterrupted perioperative (par)enteral nutrition on amino acid profile, cardiomyocytes structure, and cardiac perfusion and metabolism of patients undergoing coronary artery bypass grafting

BackgroundMalnutrition is very common in patients undergoing cardiac surgery. Malnutrition can change myocardial substrate utilization which can induce adverse effects on myocardial metabolism and function. We aim to investigate the hypothesis that there is a disturbed amino acids profile in the cardiac surgical patient which can be normalized by (par)enteral nutrition before, during and after surgery, subsequently improving cardiomyocyte structure, cardiac perfusion and glucose metabolism.Methods/DesignThis randomized controlled intervention study investigates the effect of uninterrupted perioperative (par)enteral nutrition on cardiac function in 48 patients undergoing coronary artery bypass grafting. Patients are given enteral nutrition (n = 16) or parenteral nutrition (n = 16), at least two days before, during, and two days after coronary artery bypass grafting, or are treated according to the standard guidelines (control) (n = 16). We will illustrate the effect of (par)enteral nutrition on differences in concentrations of amino acids and asymmetric dimethylarginine and in activity of dimethylarginine dimethylaminohydrolase and arginase in cardiac tissue and blood plasma. In addition, cardiomyocyte structure by histological, immuno-histochemical and ultrastructural analysis will be compared between the (par)enteral and control group. Furthermore, differences in cardiac perfusion and global left ventricular function and glucose metabolism, and their changes after coronary artery bypass grafting are evaluated by electrocardiography-gated myocardial perfusion scintigraphy and 18F-fluorodeoxy-glucose positron emission tomography respectively. Finally, fat free mass is measured before and after intervention with bioelectrical impedance spectrometry in order to evaluate nutritional status.Trial registrationNetherlands Trial Register (NTR): NTR2183

Aortic valve calcification as a predictor of location and severity of paravalvular regurgitation after transcatheter aortic valve implantation

OBJECTIVES To determine whether the location of aortic valve calcium (AVC) influences the location of paravalvular regurgitation (PR). PR is an adverse effect of transcatheter aortic valve implantation (TAVI) with a negative effect on long-term patient survival. The relationship between AVC and the occurrence of PR has been documented. However, the relationship between the distribution of AVC and the location of PR is still sparsely studied. The purpose of this study was to correlate severity and location of AVC with PR in patients treated with TAVI. METHODS Fifty-six consecutive patients who underwent transaortic or transapical TAVI and had preoperative computed tomography scans were included in this retrospective study. The volume, mass and location of AVC was determined and compared between patients with and without PR using a non-parametric t-test. Postoperative echocardiography was performed to determine the presence and location of PR, which was associated with the cusp with highest AVC using a χ(2) test. RESULTS Valve deployment was successful in all 56 patients. PR was present in 38 patients (68%) after TAVI. There was a non-significantly higher volume of AVC in the PR group [214 (70-418) vs 371 (254-606) cm(3), P = 0.15]. AVC mass was significantly higher in patients with PR than in patients without PR [282 (188-421) vs 142 (48-259) mg, respectively, P = 0.043]. The location of PR was determined in 36 of these patients. Of these 36 patients, PR occurred at the cusp with the highest AVC in 20 patients (56%, χ(2) P = 0.030). CONCLUSIONS In our population, PR was associated with greater AVC mass. Moreover, the location of PR was associated with the cusp with the highest amount of AVC.

Troubleshooting in transatrial tricuspid valve-in-valve implantation.

The established treatment for degenerated stenotic tricuspid bioprostheses is reoperation. Recently, transcatheter tricuspid valve implantation has been reported as an alternative option. This case report describes a complex transcatheter tricuspid valve implantation in a degenerated Medtronic intact 31 mm bioprosthesis. Implantation of a 26 mm Edwards Sapien valve failed, subsequent transcatheter implantation of a 29 mm Edwards Sapien valve was successful.

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.

Nutrition before and during Surgery and the Inflammatory Response of the Heart: A Randomized Controlled Trial

Major surgery induces a long fasting time and provokes an inflammatory response which increases the risk of infections. Nutrition given before and during surgery can avoid fasting and has been shown to increase the arginine/asymmetric dimetlhylarginine ratio, a marker of nitric oxide availability, in cardiac tissue and increased concentrations of branched chain amino acids in blood plasma. However, the effect of this new nutritional strategy on organ inflammatory response is unknown. Therefore, we studied the effect of nutrition before and during cardiac surgery on myocardial inflammatory response. In this trial, 32 patients were randomised between enteral, parenteral, and no nutrition supplementation (control) from 2 days before, during, up to 2 days after coronary artery bypass grafting. Both solutions included proteins or amino acids, glucose, vitamins, and minerals. Myocardial atrial tissue was sampled before and after revascularization and was analysed immunohistochemically, subdivided into cardiomyocytic, fatty, and fibrotic areas. Inflammatory cells, especially leukocytes, were present in cardiac tissue in all study groups. No significant differences were found in the myocardial inflammatory response between the enteral, parenteral, and control groups. In conclusion, nutrition given before and during surgery neither stimulates nor diminishes the myocardial inflammatory response in patients undergoing coronary artery bypass grafting. The trial was registered in Netherlands Trial Register (NTR): NTR2183.

Balloon-expandable transaortic transcatheter aortic valve implantation with or without predilation

Objective: It has been reported that balloon aortic valvuloplasty immediately before transfemoral or transapical transcatheter aortic valve implantation has mostly little to no clinical value. We aimed to provide data on the need for balloon aortic valvuloplasty in patients undergoing transaortic transcatheter aortic valve implantation. Methods: Patients undergoing transaortic transcatheter aortic valve implantation with the Edwards SAPIEN XT (Nyon, Switzerland) or 3 transcatheter heart valve were prospectively included at 18 sites across Europe. In the present analysis, we compare the periprocedural and 30‐day outcomes of patients undergoing conventional (+ balloon aortic valvuloplasty) versus direct (− balloon aortic valvuloplasty) transaortic transcatheter aortic valve implantation. Results: Of the 300 patients enrolled, 222 underwent conventional and 78 underwent direct transaortic transcatheter aortic valve implantation. Peak and mean transvalvular gradients were improved in both groups with no significant difference between groups. Procedural duration, contrast agent volume, and requirement for postdilation were also comparable. A trend toward fewer periprocedural complications was evident in the direct group (3.9% vs 11.3%; P = .053), with significantly lower rates of permanent pacemaker implantation (0% vs 5.0%; P = .034). Balloon aortic valvuloplasty omission had no significant effect on any of the 30‐day safety and efficacy outcomes, including Valve Academic Research Consortium‐2 composite end points (early safety events: 22.7% vs 17.4%, odds ratio, 1.17, 95% confidence interval, 0.53‐2.62; clinical efficacy events: 20.5% vs 18.7%, odds ratio, 1.14, 95% confidence interval, 0.51‐2.55). Conclusions: For many patients, balloon aortic valvuloplasty predilation seems to have little clinical value in transaortic transcatheter aortic valve implantation using a balloon expandable transcatheter valve and may result in a higher rate of periprocedural complications, particularly in terms of permanent pacemaker implantation.

Automated CTA based measurements for planning support of minimally invasive aortic valve replacement surgery

Minimally invasive aortic valve replacement (mini-AVR) procedures are a valuable alternative to conventional open heart surgery. Currently, planning of mini-AVR consists of selection of the intercostal space closest to the sinotubular junction on preoperative computer tomography images. We developed an automated algorithm detecting the sinotubular junction (STJ) and intercostal spaces for finding the optimal incision location. The accuracy of the STJ detection was assessed by comparison with manual delineation by measuring the Euclidean distance between the manually and automatically detected points. In all 20 patients, the intercostal spaces were accurately detected. The median distance between automated and manually detected STJ locations was 1.4 [IQR= 0.91-4.7] mm compared to the interobserver variation of 1.0 [IQR= 0.54-1.3] mm. For 60% of patients, the fourth intercostal space was the closest to the STJ. The proposed algorithm is the first automated approach for detecting optimal incision location and has the potential to be implemented in clinical practice for planning of various mini-AVR procedures.