Aortic stenosis in chronic kidney disease: challenges in diagnosis and treatment

Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.

Long-Term Outcomes of Bioprosthetic or Mechanical Valve Replacement in End-Stage Renal Disease: A Nationwide Population-Based Retrospective Study

Background: Valve replacement is associated with worse outcomes in individuals who have end-stage renal disease (ESRD) and require a long-term renal replacement therapy. Prosthetic valve selection in patients with ESRD has remained controversial.Objective: We aimed to investigate long-term outcomes of mechanical and bioprosthetic valve replacement in individuals with ESRD.Methods: We conducted a population-based retrospective cohort study using data obtained from the Taiwan National Health Insurance Research Database. In total, 10,202 patients, including 912 ESRD and 9,290 non-ESRD patients, were selected after a 1:1 propensity-score matching based on the type of prosthetic valve used. The long-term mortality outcomes were then analyzed.Results: During a median follow-up period of 59.6 months, the Kaplan–Meier survival analysis revealed that ESRD patients who underwent mechanical valve replacement had higher rates of all-cause mortality and CV deaths than those who underwent bioprosthetic valve replacement (Log-rank test, p = 0.03 and 0.02, respectively). Multivariable regression analyses demonstrated that ESRD patients who underwent bioprosthetic valve replacement had lower rates of all-cause mortality (p < 0.001, hazard ratio: 0.88, 95% confidence interval: 0.82–0.93) and cardiovascular (CV) death (p < 0.001, hazard ratio: 0.83, 95% confidence interval: 0.76–0.90) than those who had mechanical valve replacement.Conclusion: Bioprosthetic valve replacement is significantly associated with lower rates of all-cause mortality and CV death in the ESRD population.

Aortic Valve Replacement in Patients with Small Aortic Annulus: New Pericardial Stented Valves vs Aortic Root Enlargement Procedures.

Objectives: Newer generations of stented pericardial valves may offer hemodynamic benefit in patients with small aortic annulus. The aim of this study was to determine the effectiveness of isolated aortic valve replacement with one such valve, the Trifecta valve, when compared to Aortic root enlargement surgery in reducing postoperative gradients and the severity of PPM in patients with small aortic annulus. Patients and methods: A prospective observational study of 100 patients with SAA who underwent AVR from March 2020 to October 2021 in Cairo university hospitals and other centers. The cohort was divided into two groups based on surgical technique: Isolated AVR using Trifecta valve or ARE and mechanical valve placement. Preoperative characteristics, intraoperative times and postoperative outcomes were recorded and compared in all patients, including a pre-discharge echocardiography. Results: Increased operative times, increased ICU stay and need for blood products were observed in the ARE group and operative time was determined as an independent risk factor. Higher rate of complications such as need for permanent pacemaker as well increased postoperative drainage was also recorded in ARE group, with no difference between groups in in-hospital mortality. Higher incidence of PPM was recorded in the Trifecta group (24%) compared to the ARE group (8%). but, the severity of PPM within the Trifecta group was reduced compared to the ARE group, and no degree of PPM was observed in Trifecta valves sized 21. Conclusion The Trifecta valve offers excellent postoperative hemodynamics and significant reduction in severity of PPM in patients with SAA undergoing AVR, with gradients and iEOA almost comparable to larger sized valves implanted after ARE, making the increased surgical burden of ARE unnecessary in most patients.

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

Early Outcomes of Emergency Surgery for Left-Sided Mechanical Valve Thrombosis

Background: Valve thrombosis is a potentially lethal complication of mechanical cardiac valves. We examined the clinical characteristics as well as the early outcomes of patients undergoing emergency surgery for left-sided mechanical valve thrombosis. Methods: Between January 2012 and May 2020, 104 consecutive patients were offered an emergency redo surgery for acute mechanical valve thrombosis. Ninety-seven of these patients were included in the current study. Results: The mean age was 34.2 ± 10.3 years. Most of the patients were females (61 patients), and 27 patients (27.8%) were pregnant. The mitral valve was the site of thrombosis in 81 patients. Inadequate anticoagulation was found in 60.8% of patients. The overall early mortality was 32.9% (32 patients) with an operative mortality of 25.7%. Outcomes in the pregnant subgroup tended to be worst with a maternal mortality in the range of 37%, and with fetal and neonatal survival as low as 33.3%. Conclusion: The overall mortality in cases of mechanical valve thrombosis warranting surgery remains high. Since inadequate anticoagulation seems to be one of the major precipitating factors, the current study highlights the need for improvements in anticoagulation practices. The use of tissue valves should also be contemplated more seriously in some younger patients, especially females expressing the desire for future pregnancies.

Case Report: Reconstruction of the Right Atrium With the Left Atrial Appendage

We herein present a case of infective endocarditis of the mitral valve and a paravalvular abscess around the tricuspid valve. Preoperative blood culture confirmed the presence of pathogenic diphtheroids. During the operation, an unexpected infection of the free wall of the right atrium (RA) near the tricuspid annulus was found. We harvested the left atrial appendage (LAA) en bloc. After resection of the infected and abnormal tissues, the resected LAA was used to reconstruct the RA. The infected mitral valve was replaced with a mechanical valve without any accident. Postoperative echocardiography showed that the RA had a supple shape, with no kinking.

Modified Manouguian Technique for Aortic Root Enlargement: A Case Series

Background: Manouguian aortic root enlargement (ARE) has been a standard root enlargement procedure to assist in patients with a small annular size. We describe a modification to the Manouguian ARE similar to Yang et al. This approach could serve as an alternate technique for performing ARE; to date only case reports have defined this approach and no studies have evaluated its efficacy or safety. Methods: A retrospective case series was performed on patients who underwent ARE for surgical aortic valve replacement via the modified Manouguian procedure at a single institution. Thirteen patients were identified between 2015-2021, and all surgeries were performed by a single operator. Data were collected via the Society of Thoracic Surgeons database and chart review. The primary outcome was difference in valve size after the procedure. Results: The most common indication for surgery was aortic stenosis (12, 92%), with the most common etiology being degenerative calcification (7, 54%). Congenital bicuspid or uni-cuspid valves were identified in 5 (38%) patients. The majority (10, 77%) of patients received a mechanical valve. This procedure was successfully performed in all 13 of the patients. Additionally, 13 of the 13 patients (100%) were upsized to a satisfactory valve size based on pre-operative echocardiography sizing. Conclusions: The modified Manouguian aortic enlargement technique can be safely and effectively used as an aortic enlargement procedure in a broad sample of patients.

Abstract 1122‐000097: Recurrent Carotid Cavernous Fistula Requiring Complex Repair of Ruptured Cavernous Carotid Aneurysm: A Case Report

Introduction : There are no studies investigating the safety and efficacy of covered stent grafts, particularly the newly developed stents such as the PK Papyrus stent, for endovascular treatment of direct carotid cavernous fistulas (CCFs). Methods : We present a case of a 75‐year‐old female who presented to the hospital with a three‐week history of worsening left eye vision, chemosis, proptosis, and partial third nerve palsy. Patient was found to have left direct Type A CCF secondary to ruptured cavernous segment carotid aneurysm. Results : The CCF was treated with coil embolization and pipeline Shield stent embolization devices with immediate stagnation and improvement of symptoms. Patient had history of an aortic mechanical valve and thus was started on warfarin and ASA. After achieving INR level of 2.5‐3.5, patient started to have recurrent swelling of the left eye associated and decreased visual acuity. Repeated diagnostic cerebral angiogram revealed residual CCF. Onyx liquid embolization and a Surpass Evolve Flow Diverter were attempted to slow the fistulization with no success. Multiple attempts for direct percutaneous superior ophthalmic vein cannulation were also unsuccessful. At this point, two coronary graft‐covered PK Papyrus stents were implanted across the fistula pouch, which resulted in immediate resolution of the CCF with evidence of persistent normal flow within left ophthalmic artery. Patient’s visual acuity and left eye movement improved. Conclusions : This case report highlights the effectiveness and safety of covered stent grafts, particularly more flexible stents such as the PK Papyrus stent, in navigating the carotid vasculature and closing direct CCFs and may be used as a first‐line technique. More large‐scale studies are warranted to investigate the safety and efficacy of using such stent grafts to treat direct CCFs in the setting of antithrombotic agents and anticoagulation.

Survival rate of patients undergoing aortic, mitral, and tricuspid valve replacement with prosthetic valves

Objectives: The burden of valvular heart disease (VHD) is high and increasing all around the world due to aging of the population. The etiologic factors of VHD are different among countries. There is little data about etiologic factors of VHD in Iran. The aim of present study was to determine the associated factors related to the 5-year survival and mortality rate of patients undergoing bileaflet mechanical valve replacement. Methods: In this retrospective cohort study, demographic, electrocardiographic and echocardiographic data of patients who had underwent aortic, mitral and tricuspid valve replacement with bileaflet valves in the Afshar Hospital in Yazd, Iran, between March 2008 to February 2015 were obtained from their records. Supplementary information like hemorrhagic or thromboembolic events, rehospitalization and death during follow-up were gathered through contact with patients. For analysis of the data, SPSS ver. 19 was used. Results: Four hundred and thirty eight patients entered the study. Male gender was slightly predominant (%53). Mean age of the patients was 51.6 ± 17.4 years. The rate of in-hospital mortality was 9.8% while the 5-year survival rate was 82.42%. The rate of major thromboembolic events was 0.97%/year and that of major hemorrhagic events was 0.5%/year. Patients with older age, lower cardiac ejection fraction (less than 30%) and with atrial fibrillation had a higher rate of mortality (P = 0.001). In-hospital mortalities were 3%, 9%, 12% and 15% for AVR, AVR+MVR, MVR and CABG+valvular surgery, respectively. Conclusions: Higher rate of mitral valve surgery in this study may be due to possible predominance of rheumatic valvular pathology similar to other developing countries. Rate of 5-year survival, thromboembolic and hemorrhagic rates were acceptable and comparable to global reports.

Point-of-Care Testing for Multiple Cardiac Markers Based on a Snail-Shaped Microfluidic Chip

Existing methods for detecting cardiac markers are difficult to be applied in point-of-care testing (POCT) due to complex operation, long time consumption, and low sensitivity. Here, we report a snail-shaped microfluidic chip (SMC) for the multiplex detection of cTnI, CK-MB, and Myo with high sensitivity and a short detection time. The SMC consists of a sandwich structure: a channel layer with a mixer and reaction zone, a reaction layer coated with capture antibodies, and a base layer. The opening or closing of the microchannels is realized by controlling the downward movement of the press-type mechanical valve. The chemiluminescence method was used as a signal readout, and the experimental conditions were optimized. SMC could detect cTnI, CK-MB, and Myo at concentrations as low as 1.02, 1.37, and 4.15. The SMC will be a promising platform for a simultaneous determination of multianalytes and shows a potential application in POCT.