Impact of a tailored surgical approach on autograft root dimensions in patients undergoing the Ross procedure for aortic regurgitation†

Abstract OBJECTIVES The Ross procedure in patients with aortic regurgitation (AR) has been associated with increased autograft dilatation and late reintervention. The aim of this study was to evaluate the impact of a tailored approach aimed at mitigating that risk on early changes in autograft root dimensions following the Ross procedure in patients with AR. METHODS From 2011 to 2018, 241 consecutive patients underwent a Ross procedure with >1 year of follow-up [46 (7) years]. Aortic root dimensions were prospectively measured on serial echocardiograms. Patients with aortic stenosis group (n = 171; 71%) were compared to those with AR or mixed aortic disease (AR group) (n = 70; 29%). Mean length of follow-up was 29 ± 11 months (100% complete). Changes in aortic dimensions were analysed using mixed-effect models. RESULTS At 4 years, mean indexed diameters of the annulus, sinuses of Valsalva and the sinotubular junction in the AR group were 12.3 (0.2) mm/m2, 20.0 (0.4) mm/m2 and 16.3 (0.9) mm/m2, respectively, vs 11.9 (0.2), 18.4 (0.3) and 15.5 (0.5) in the aortic stenosis group. Overall, there were no significant differences in the rates of autograft annulus, sinuses of Valsalva and sinotubular junction dimension changes between the aortic stenosis and AR groups up to 4 years after surgery (P = 0.55, P = 0.12, P = 0.59 and P = 0.48, respectively). CONCLUSIONS Use of a tailored surgical approach, combined with a strict blood pressure control, appears to mitigate clinically significant early dilatation of the autograft root following a Ross procedure in patients with AR. Further follow-up is needed to determine if this will translate into a lower incidence of long-term reintervention.

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Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension

Current Vascular Pharmacology ◽

10.2174/1570161116666180101165306 ◽

2019 ◽

Vol 17 (2) ◽

pp. 180-190 ◽

Cited By ~ 3

Author(s):

V. Katsi ◽

G. Georgiopoulos ◽

D. Oikonomou ◽

C. Aggeli ◽

C. Grassos ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Regurgitation ◽

Antihypertensive Agents ◽

Renin Angiotensin System ◽

Aortic Disease ◽

Review Of The Literature ◽

Angiotensin System ◽

The Impact ◽

Worse Prognosis

Background: Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve. Objective: To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease. Methods: We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease. Results: Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis. Conclusion: Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

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Comparison of Aortic Gradient and Ventricular Mass after Valve Replacement for Aortic Stenosis with Rapid Deployment, Sutureless, and Conventional Bioprostheses

Cardiology ◽

10.1159/000516465 ◽

2021 ◽

pp. 1-11

Author(s):

Rubén Taboada-Martín ◽

José María Arribas-Leal ◽

María Asunción Esteve-Pastor ◽

José Abellán Alemán ◽

Francisco Marín ◽

...

Keyword(s):

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Ventricular Mass ◽

Risk Of Mortality ◽

Echocardiographic Parameters ◽

Rapid Deployment ◽

The Impact ◽

Peak Gradient

Background: The use of rapid deployment and sutureless aortic prostheses is increasing. Previous reports have shown promising results on haemodynamic performance and mortality rates. However, the impact of these bioprostheses on left ventricular mass (LVM) regression remains unknown. We decided to study the changes in remodelling and LVM regression in isolated severe aortic stenosis treated with conventional or Perceval® or Intuity® valves. Method and Results: From January 2011 to January 2016, 324 bioprostheses were implanted in our centre. The collected characteristics were divided into 3 groups: conventional valves, Perceval®, and Intuity®, and they were analysed after 12 months. There were 183 conventional valves (56%), 72 Perceval® (22%), and 69 Intuity® (21.2%). The statistical analysis showed significant differences in transprosthetic postoperative peak gradient (23 [18–29] mm Hg vs. 21 [16–29] mm Hg and 18 [14–24] mm Hg, p < 0.001), ventricular mass electrical criteria regression (Sokolow and Cornell products), and 1-year survival (90 vs. 93% and 97%, log rank p value = 0.04) in conventional, Perceval®, and Intuity® groups. Conclusions: We observed differences in haemodynamic, electrocardiographic, and echocardiographic parameters related to the different types of prosthesis. Patients with the Intuity® prosthesis had the highest reduction in peak aortic gradient and the higher ventricular mass regression. Besides, patients with the Intuity® prosthesis had less risk of mortality during follow-up than the other two groups. Further studies are needed to confirm these findings.

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Comparative adherence between DOAC and VKA in patients with atrial fibrillation: a 23-year retrospective observational study in Canada

European Heart Journal ◽

10.1093/eurheartj/ehab724.0563 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S Salmasi ◽

A Safari ◽

M.A De Vera ◽

L Lynd ◽

M Koehoorn ◽

...

Keyword(s):

Atrial Fibrillation ◽

Drug Class ◽

Oral Anticoagulants ◽

Current Evidence ◽

Mixed Effect ◽

Medication Discontinuation ◽

The Impact ◽

Rolling Windows ◽

Over Time

Abstract Background A recent systematic review highlighted significant gaps in the evidence on atrial fibrillation (AF) patients' adherence to oral anticoagulants (OAC). Current evidence suffers from short follow-up times, focuses on the first OAC and does not take switching into account. There is also lack of observational data on adherence to warfarin due to its varying dose that complicates the calculations. As such there is lack of evidence on comparative adherence between VKAs and DOACs and whether the convenience of DOACs translates into better adherence in AF patients. Purpose Our objective was to measure AF patients' long-term OAC adherence and compare the impact of taking direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) on adherence, while accounting for switching. Methods Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996–2019), incident adult cases of AF were identified. The primary measure of adherence was proportion of days covered (PDC). Consecutive rolling 90-day windows were created for each patient starting from their first OAC prescription fill date until the end of their follow-up. The PDC for each 90-day rolling window was calculated and averaged to yield mean adherence over the follow-up period for each patient. Permanent medication discontinuation resulted in a PDC of 0 for all subsequent rolling windows after their supply ran out. As such, both poor execution and non-persistence were measured simultaneously. The association between drug class and adherence was assessed using generalized mixed effect linear regression models with drug class treated as time-varying covariate to account for switching. Results The study cohort was 30,264 AF patients [mean age 72.2 years (SD11.0), 44.6% female, mean CHA2DS2-VASc 2.94 (SD1.4)] with mean follow-up of 7.7 (SD 4.8) years. The mean PDC was 0.71 (SD 0.27) with 51% of the cohort having mean PDC values below the conventional threshold of adherence (PDC<0.8). Adherence dropped over time with the greatest decline in the first two years after therapy initiation. After controlling for all other confounders and accounting for switching, taking VKA compared to DOAC was, on average, associated with a 1-day decrease in number of days of medication-taking per year. Conclusion AF patients' OAC adherence was below the conventional threshold of 0.8, and dropped over time, particularly in the first two years. Drug class had no clinically meaningful impact on medication adherence. Our study highlights the need for effective adherence interventions particularly early in OAC therapy. Our findings also emphasizes that prescribers should not assume inherently better adherence for DOACs and should instead choose OAC in conversation with the patient and in accordance with their values and preferences. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research grant

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Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience

Frontiers in Neurology ◽

10.3389/fneur.2020.598619 ◽

2020 ◽

Vol 11 ◽

Author(s):

Fabio Cofano ◽

Carlotta Giambra ◽

Paolo Costa ◽

Pietro Zeppa ◽

Andrea Bianconi ◽

...

Keyword(s):

Clinical Outcomes ◽

Surgical Approach ◽

Spinal Canal ◽

Clinical Status ◽

Extent Of Resection ◽

Intraoperative Neurophysiological Monitoring ◽

Neurophysiological Monitoring ◽

Surgical Access ◽

The Impact

Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications.Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up.Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19).Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.

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The carotid arterial approach for balloon dilation of critical aortic stenosis in neonates—immediate results and follow-up

Cardiology in the Young ◽

10.1017/s1047951100011732 ◽

1995 ◽

Vol 5 (2) ◽

pp. 155-160 ◽

Cited By ~ 10

Author(s):

Sandra Giusti ◽

Adele Borghi ◽

Sofia Redaelli ◽

Philipp Bonhoeffer ◽

Isabella Spadoni ◽

...

Keyword(s):

Carotid Artery ◽

Aortic Stenosis ◽

Aortic Regurgitation ◽

Balloon Dilation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Critical Aortic Stenosis ◽

The Right

SummaryBalloon dilation of the aortic valve was performed in 20 consecutive neonates with critical aortic stenosis using an approach achieved by cutting down on the right carotid artery. The age of the patients ranged from one to 25 days (mean seven days) and their weight from 2.1 to 4.0 kg (mean 3.16 kg). All patients were evaluated before cardiac catheterization with cross-sectional and Doppler echocardiography so as to keep the catheterization procedure as short as possible. Balloon dilation was accomplished in all patients. The only complication was an apical perforation by the guide wire in two cases. The ensuing pericardial effusion was immediately drained with pericardiocentesis and the subsequent course of the procedure was uneventful. Immediate results showed dramatic improvement in cardiovascular conditions. The transvalvar pressure gradient fell from 80±40 to 27±20 mm Hg (p<0.001). Left ventricular ejection fraction evaluated by echocardiography increased from 30±21% before dilation to 54±18% 24-48 hours after the procedure (p<0.001). In all patients, the procedure was free from vascular complications. Aortic regurgitation was documented after the procedure in 11 patients, being severe in one, moderate in five and trivial in five. Seven patients died, although in only one was the death related directly to the procedure itself. Six patients died because of associated lesions despite an immediate satisfactory result of the balloon valvoplasty. The 13 surviving patients are doing well, and are receiving no medications. During a mean follow-up of 25 months (range 2-54 months), four patients have developed restenosis. One underwent surgical valvotomy at one year of age. The second was successfully redilated through the same approach at two months of age. The other two have a significant gradient, as assessed by Doppler measurements (60 and 70 mm Hg), with normal systolic ventricular function. Two patients have moderate aortic regurgitation. Balloon dilation achieved through cutdown on the right carotid artery is a safe and effective alternative to surgery in neonates with isolated aortic stenosis. The unfavorable results are mainly due to associated anomalies.

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Long-term outcomes of the Ross procedure in adults with severe aortic stenosis: single-centre experience with 20 years of follow-up†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezu038 ◽

2014 ◽

Vol 47 (1) ◽

pp. 159-167 ◽

Cited By ~ 17

Author(s):

David Kalfa ◽

Siamak Mohammadi ◽

Dimitri Kalavrouziotis ◽

Mounir Kharroubi ◽

Daniel Doyle ◽

...

Keyword(s):

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Ross Procedure ◽

Long Term Outcomes ◽

Single Centre ◽

Single Centre Experience

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The Immediate And Intermediate Results Of Percutaneous Balloon Aortic Valvuloplasty In Patients With Congenital Valvular Aortic Stenosis

AL-Kindy College Medical Journal ◽

10.47723/kcmj.v13i2.94 ◽

2019 ◽

Vol 13 (2) ◽

pp. 51-55

Author(s):

Hussein A. Alwahab

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Pressure Gradient ◽

Aortic Regurgitation ◽

Balloon Aortic Valvuloplasty ◽

Maximum Peak ◽

Percutaneous Balloon ◽

Aortic Valvuloplasty ◽

Valvular Aortic Stenosis

Background: Aortic valve stenosis results from minor to severe degrees of aortic valve maldevelopment. This stenosis causes mild to severe obstruction of the left ventricular outflow . Objectives : to study the immediate and intermediate results of percutaneous balloon aortic valvuloplasty in patients with congenital valvular aortic stenosis . Type of the study: A prospective study. Methods: The study was done on thirty five patients with congenital valvular aortic stenosis who had percutaneous balloon aortic valvuloplasty in Ibn Al- Bitar Center for Cardiac Surgery from May 2009 to February 2011. Results: Twenty seven patients were male (77.2%) and 8 patients were female (22.8%), male to female ratio 3.5/ 1, . The aortic valve was bicuspid in 18 patients (51.4%) while 17 patients ( 48.6%) had tricuspid aortic valve. Balloon aortic valvuloplasty was successful in 30 patients (85.7%),. Maximum peak instantaneous Doppler pressure gradient across the aortic valve 24 hours postprocedural echocardiography showed reduction which is statistically significant. New aortic regurgitation had occurred in 15 patients ( 42.8%), it was mild in 9 patients ( 25.6%), moderate in 5 patients ( 14.3%) and severe in 1 patient( 2.9%) which is statistically significant. The follow up of 12.57 ± 3.88 ( 3- 22) months after intervention was done for all patients using echocardiography Doppler study, reveal the maximum peak instantaneous Doppler pressure gradient across the aortic valve was raised which is statistically significant. The aortic regurgitation was present in 18 patients (51.4%) , it was mild in 9 patients (25.7%) , moderate in 6 patients (17.1%) and severe in 3 patients ( 8.6%). No mortality had been reported during the procedure or on follow up. Conclusion: Aortic balloon valvuloplasty is safe and effective procedure in the treatment of congenital valvular aortic stenosis but mild aortic regurgitation is the most common immediate complication of aortic balloon dilatation and progressive aortic regurgitation is a major problem during the intermediate follow up.

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Balloon Valvuloplasty for Congenital Aortic Stenosis: Experience at a Tertiary Center in a Developing Country

Journal of Interventional Cardiology ◽

10.1155/2021/6681693 ◽

2021 ◽

Vol 2021 ◽

pp. 1-7

Author(s):

Fatme A. Charafeddine ◽

Haytham Bou Houssein ◽

Nadine B. Kibbi ◽

Issam M. El-Rassi ◽

Anas M. Tabbakh ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Developing Country ◽

Aortic Regurgitation ◽

Developed Countries ◽

Left Ventricular ◽

Complication Rates ◽

Congenital Aortic Stenosis ◽

Tertiary Center

Background. Aortic valve stenosis accounts for 3–6% of congenital heart disease. Balloon aortic valvuloplasty (BAV) is the preferred therapeutic intervention in many centers. However, most of the reported data are from developed countries. Materials and Methods. We performed a retrospective single-center study involving consecutive eligible neonates and infants with congenital aortic stenosis admitted for percutaneous BAV between January 2005 and January 2016 to our tertiary center. We evaluated the short- and mid-term outcomes associated with the use of BAV as a treatment for congenital aortic stenosis (CAS) at a tertiary center in a developing country. Similarly, we compared these outcomes to those reported in developed countries. Results. During the study period, a total of thirty patients, newborns (n = 15) and infants/children (n = 15), underwent BAV. Left ventricular systolic dysfunction was present in 56% of the patients. Isolated AS was present in 19 patients (63%). Associated anomalies were present in 11 patients (37%): seven (21%) had coarctation of the aorta, two (6%) had restrictive ventricular septal defects, one had mild Ebstein anomaly, one had Shone’s syndrome, and one had cleft mitral valve. BAV was not associated with perioperative or immediate postoperative mortality. Immediately following the valvuloplasty, a more than mild aortic regurgitation was noted only in two patients (7%). A none-to-mild aortic regurgitation was noted in the remaining 93%. One patient died three months after the procedure. At a mean follow-up of 7 years, twenty patients (69%) had more than mild aortic regurgitation, and four patients (13%) required surgical intervention. Kaplan–Meier freedom from aortic valve reintervention was 97% at 1 year and 87% at 10 years of follow-up. Conclusion. Based on outcomes encountered at a tertiary center in a developing country, BAV is an effective and safe modality associated with low complication rates comparable to those reported in developed countries.

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1161 Baseline echocardiographic parameters associated with reintervention in children with aortic valve stenosis following balloon aortic valvuloplasty

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.665 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

K Papneja ◽

Z Blatman ◽

I D Kawpeng ◽

J Wheatley ◽

H Osce ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Circumferential Strain ◽

Ventricular Outflow Tract ◽

Aortic Insufficiency ◽

Left Ventricular ◽

Balloon Aortic Valvuloplasty ◽

Aortic Valvuloplasty ◽

The Impact

Abstract Introduction Aortic valve (AV) stenosis is the most common type of congenital left ventricular outflow tract obstruction. Short-term outcomes following balloon aortic valvuloplasty (BAV) including residual aortic stenosis, aortic insufficiency, and procedural complications have been established. The impact of pre-intervention AV characteristics on long-term outcomes has not been well studied. Purpose The aim of this study was to determine the relationship between the initial parameters on baseline echocardiogram and the time to reintervention in children with AV stenosis following BAV. Methods Children from the newborn period to 18 years of age with AV stenosis who underwent BAV from 2004-2012 were included. Patients with aortic insufficiency prior to BAV, complex congenital heart lesions, or less than two accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function was retrospectively collected until December 2017 or until the first reintervention. Time to reintervention or death was evaluated. Results Among the 98 enrolled patients, the median [IQR] age at BAV was 2.8 months [0.2-75]. The median [IQR] duration of follow-up was 6.8 [1.9-9.0] years. Eighty-nine (83%) patients had bicuspid valve morphology and the median [IQR] peak-to-peak catheterization gradient prior to BAV was 49 [34-65] mmHg. The cumulative proportion [95% CI] of reintervention at 5 years following BAV was 33.7% [23.6%, 42.4%]. Primary indications for reintervention were aortic stenosis (57%), aortic insufficiency (14%), or mixed valve disease (30%). Reinterventions included repeat BAV (49%), AV repair (15%), and AV replacement (36%). Increased LVEF at baseline as well as increased mean LV circumferential strain at baseline were associated with decreased risk of reintervention (HR [95% CI] (1 unit increments): 0.974 [0.959-0.989], p < 0.001; 0.939 [0.884-0.997], p = 0.041 respectively). Increased AV annulus z-score was also associated with decreased risk of reintervention (HR [95% CI] (1 unit increments): 0.806 [0.698-0.93], p = 0.003). Conclusions Our results demonstrate that better left ventricular function at baseline, measured by LVEF and mean LV circumferential strain, is associated with a decreased risk of reintervention in neonates and children following BAV. We have also shown that a bigger AV annulus prior to BAV is associated with a decreased risk of reintervention.

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