Sc Malaisrie

Successful Conversion of TandemHeart Left Ventricular Assist Device to Right Ventricular Assist Device After Implantation of a HeartMate XVE

A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted in cardiogenic shock, which was unresponsive to maximum inotropes and an intraaortic balloon pump. The TandemHeart (TH) left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA) was placed in the standard percutaneous transseptal configuration with improved hemodynamics. The HeartMate XVE (Thoratec Corp, Pleasanton, CA) implantation was performed as a bridge to transplant 5 days after TandemHeart insertion. The TandemHeart was converted to a temporary right ventricular assist device during the HeartMate XVE (Thoratec Corp) implantation due to right ventricular failure. The right ventricular assist device was weaned 3 days later. This strategy was useful, technically easy, and cost effective.

Biventricular Continuous Flow VADs Demonstrate Diurnal Flow Variation and Lead to End-Organ Recovery

HeartWare continuous flow ventricular assist devices (HVAD) configured as biventricular assist devices maintain diurnal flow variation, lead to end-organ recovery, and provide for a successful bridge-to-heart transplantation in the first successful North American use of continuous flow biventricular assist devices.

Improved semiautomated 4D flow MRI analysis in the aorta in patients with congenital aortic valve anomalies versus tricuspid aortic valves

Objective The aim of this study was to systematically investigate a newly developed semiautomated workflow for the analysis of aortic 4-dimensional flow MRI and its ability to detect hemodynamic differences in patients with congenitally altered aortic valve (bicuspid or quadricuspid valves) compared with tricuspid aortic valves. Methods Four-dimensional flow MRI data were acquired in 20 patients with aortic dilatation (9 tricuspid aortic valves, 11 congenitally altered aortic valves). A semiautomated workflow was evaluated regarding interobserver variability, accuracy of net flow, regurgitant fraction and peak systolic velocity, and the ability to detect differences between cohorts. Results were compared with manual segmentation of vessel contours. Results Despite the significantly reduced analysis time, a good interobserver agreement was found for net flow and peak systolic velocity, and a moderate agreement was found for regurgitation. Significant differences in peak velocities in the descending aorta (P = 0.014) could be detected. Conclusions Four-dimensional flow MRI-based semiautomated analysis of aortic hemodynamics can be performed with good reproducibility and accuracy.

Effect of aortic aneurysm replacement on outcomes after bicuspid aortic valve surgery: Validation of contemporary guidelines

OBJECTIVE Bicuspid aortic valve (BAV) disease is associated with aortic dilatation and aneurysm (AN) formation. The American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines recommend replacement of the ascending aorta for an aortic diameter (AD)> 45 mm in patients undergoing aortic valve replacement (AVR). We evaluated the outcomes of AVR and AVR with aortic replacement (AVR/AN). METHODS We retrospectively reviewed (2004-2011) the data from 456 patients with BAV and compared the morbidity and mortality between the AVR and AVR/AN groups and 3 subgroups: AVR with an AD<45 mm; AVR/AN with an AD of 45 to 49 mm; and AVR/AN with an AD of ≥50 mm. Propensity score matching was used to reduce bias. RESULTS Of the 456 patients, 250 (55%) underwent AVR and 206 (45%) AVR/AN, with 98% compliance with the current guidelines. The overall 30-day mortality was 0.9%. The AVR AD<45-mm group had adjusted short- and medium-term survival similar to that of the AVR/AN AD 45- to 49-mm and AVR/AN AD≥50-mm groups, with a 30-day mortality of 0.8%, 0%, and 1.9%, respectively (P=.41). The propensity score-matched AVR/AN AD≥50-mm group had significantly greater rates of reintubation than either the AVR AD<45-mm (P=.012) or AVR/AN AD 45- to 49-mm (P=.04) group and greater rates of prolonged ventilation (P=.022) than the AVR AD<45-mm group. No significant differences were found in reoperation or myocardial infarction among the subgroups. CONCLUSIONS In patients with undergoing AVR, no increase was seen in morbidity or mortality when adding aortic replacement with an AD of 45 to 49 mm, in accordance with the 2006 ACC/AHA guidelines, although the AVR/AN AD≥50-mm group had a greater risk of respiratory complications. Our findings indicate that compliance with the ACC/AHA guidelines is safe in select centers.

From unicuspid to quadricuspid: the impact of aortic valve morphology on 3D hemodynamics

Background The purpose of this study was to assess the impact of aortic valve morphology on aortic 3D blood flow dynamics and wall shear stress (WSS) in normal and a wide range of congenitally altered aortic valves ranging from unicuspid to quadricuspid morphology. Methods In-vivo aortic 3D hemodynamics were evaluated by MRI in 17 patients with unicuspid (n=3), bicuspid (n=9, 3 true bicuspid, 3 right-left (RL) coronary leaflet fusion, and 3 right-non (RN) coronary leaflet fusion), trileaflet (n=3), and quadricuspid aortic valves (n=2). Valve morphology and dynamics were assessed using 2D CINE MRI. Aortic blood flow was measured using ECG and respiration synchronized 4D flow MRI with full volumetric coverage of the aorta. Data analysis included co-registered visualization of aortic valve morphology with systolic 3D blood flow and grading of valve-specific aortic out-flow patterns. The influence of valve geometry on aortic hemodynamics was quantified by calculation of valve flow angle and segmental distribution of ascending aorta WSS. Results All congenitally altered valves showed marked flow derangement, elevated velocity jets along the aortic wall and distinct flow impingement locations. While all RLBAV valves were associated with flow jets directed towards the right anterior aortic wall, RN-fusion and unicuspid valves showed jet patterns towards the right-posterior wall. Quantitative analysis revealed higher flow angles for unicuspid, true BAV, RN-BAV, RL-BAV, and quadricuspid

Successful implantation of HeartWare HVAD left ventricular assist device with concomitant ascending and sinus of valsalva aneurysms repair

Coexistence of aortic disease is an uncommon finding in end-stage heart failure patients requiring left ventricular assist device (LVAD) placement. A 38-year-old man with non-ischemic dilated cardiomyopathy was admitted in stage D heart failure. Preoperative computed tomography demonstrated multiple saccular aneurysms of the ascending aorta and sinus of valsalva. We successfully performed complex aortic surgery and the implantation of a continuous-flow LVAD (HeartWare HVAD) (HeartWare International, Framingham, MA). The postoperative course was uneventful. The patient is currently listed for heart transplantation.

Transcatheter Aortic Valve Implantation

Severe aortic stenosis (AS) is a life-threatening condition when left untreated. Aortic valve replacement (AVR) is the gold standard treatment for the majority of patients; however, transcatheter aortic valve implantation/replacement (TAVI/TAVR) has emerged as the preferred treatment for high-risk or inoperable patients. The concept of transcatheter heart valves originated in the 1960s and has evolved into the current Edwards Sapien and Medtronic CoreValve platforms available for clinical use. Complications following TAVI, including cerebrovascular events, perivalvular regurgitation, vascular injury, and heart block have decreased with experience and evolving technology, such that ongoing trials studying TAVI in lower risk patients have become tenable. The multidisciplinary team involving the cardiac surgeon and cardiologist plays an essential role in patient selection, procedural conduct, and perioperative care.

Tricuspid valve annuloplasty for functional regurgitation

Functional tricuspid regurgitation (TR) is present in many patients with advanced heart failure. The following manuscript and videos describe our approach to its correction.

Thoracic aortic wall shear stress atlases in patients with bicuspid aortic valves

Background Wall shear stress (WSS) may be associated with the onset and development of aortopathy in the presence of bicuspid aortic valve (BAV) [Michelena, JAMA (2011)]. The use of ‘aortic atlases’ of 3D WSS vectors allows for systematic analysis of WSS differences between large patient cohorts. In this study, a comparison is performed between WSS atlases of BAV patients, BAV patients with aortic dilation, patients with BAV stenosis, and healthy controls with tricuspid valves. The aim is to test the hypothesis that WSS atlases can identify regions of significantly altered WSS that are associated with different expression of BAV and aortopathy.

Comprehensive 4-stage categorization of bicuspid aortic valve leaflet morphology by cardiac MRI in 386 patients

Bicuspid aortic valve (BAV) disease is heterogeneous and related to valve dysfunction and aortopathy. Appropriate follow up and surveillance of patients with BAV may depend on correct phenotypic categorization. There are multiple classification schemes, however a need exists to comprehensively capture commissure fusion, leaflet asymmetry, and valve orifice orientation. Our aim was to develop a BAV classification scheme for use at MRI to ascertain the frequency of different phenotypes and the consistency of BAV classification. The BAV classification scheme builds on the Sievers surgical BAV classification, adding valve orifice orientation, partial leaflet fusion and leaflet asymmetry. A single observer successfully applied this classification to 386 of 398 Cardiac MRI studies. Repeatability of categorization was ascertained with intraobserver and interobserver kappa scores. Sensitivity and specificity of MRI findings was determined from operative reports, where available. Fusion of the right and left leaflets accounted for over half of all cases. Partial leaflet fusion was seen in 46% of patients. Good interobserver agreement was seen for orientation of the valve opening (κ = 0.90), type (κ = 0.72) and presence of partial fusion (κ = 0.83, p < 0.0001). Retrospective review of operative notes showed sensitivity and specificity for orientation (90, 93%) and for Sievers type (73, 87%). The proposed BAV classification schema was assessed by MRI for its reliability to classify valve morphology in addition to illustrating the wide heterogeneity of leaflet size, orifice orientation, and commissural fusion. The classification may be helpful in further understanding the relationship between valve morphology, flow derangement and aortopathy.