Aortic annulus elevation for aortic valve and root replacement

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when peforming valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neo-aortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.

Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement

Aortic valve calcium scoring by cardiac computed tomographic (CT) has been recommended as an alternative to classify the AS severity, but it is unclear that whether CT findings can predict and have prognostic implication in low-flow, low-gradient aortic stenosis (LF-LG AS), which has fewer benefit from surgery among the AS subtypes. In this study, we examined the clinical and cardiac CT findings of LF-LG AS patients and evaluated factors affecting outcomes after surgical aortic valve replacement (AVR). This study included 511 (66.9±8.8 years, 55% men) consecutive patients with severe AS who underwent surgical AVR. Aortic valve area (AVA) was obtained by echocardiography (AVAecho) and by CT (AVACT) using each modalities measurement of the left ventricular outflow tract. Patients with AS were classified as 1) high-gradient severe (n=438), 2) classic LF-LG (n=18), and 3) paradoxical LF-LG (n=55) based on echocardiography. Classic LF-LG AS patients had higher end-systolic and end-diastolic volume indices, lower left ventricular ejection fraction, larger AVAecho and AVACT, and larger aortic annulus compared to high-gradient severe AS (P<0.05, for all). In classic LF-LG AS group, 27.8% of patients presented AVACT≥1.2 cm2. After multivariable adjustment, old age (hazard ratio [HR], 1.04, P=0.049), high B-type natriuretic peptide (BNP) (HR, 1.005; P<0.001), preoperative atrial fibrillation (HR, 2.75; P=0.003), classic LF-LG AS (HR, 5.53, P=0.004), and small aortic annulus (HR, 0.57; P=0.002) were independently associated with major adverse cardiac and cerebrovascular events (MACCE). The classic LF-LG AS group presented larger AVACT and aortic annulus than those in high-gradient severe AS group and one third of them had AVACT ≥1.2 cm2. Old age, high BNP, atrial fibrillation, classic LF-LG AS, and small aortic annulus were associated with MACCE in severe AS patients after surgical AVR.

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.

One-Year Hemodynamic Performance of Three Cardiac Aortic Bioprostheses: A Randomized Comparative Clinical Trial

Background: We aimed to compare 1 year the hemodynamic in-vivo performance of three biological aortic prostheses (Carpentier Perimount Magna EaseTM, Crown PRTTM, and TrifectaTM). Methods: The sample used in this study comes from the “BEST-VALVE” clinical trial, which is a phase IV single-blinded randomized clinical trial with the three above-mentioned prostheses. Results: 154 patients were included. Carpentier Perimount Magna EaseTM (n = 48, 31.2%), Crown PRTTM (n = 51, 32.1%) and TrifectaTM (n = 55, 35.7%). One year after the surgery, the mean aortic gradient and the peak aortic velocity was 17.5 (IQR 11.3–26) and 227.1 (IQR 202.0–268.8) for Carpentier Perimount Magna EaseTM, 21.4 (IQR 14.5–26.7) and 237.8 (IQR 195.9–261.9) for Crown PRTTM, and 13 (IQR 9.6–17.8) and 209.7 (IQR 176.5–241.4) for TrifectaTM, respectively. Pairwise comparisons demonstrated improved mean gradients and maximum velocity of TrifectaTM as compared to Crown PRTTM. Among patients with nominal prosthesis sizes ≤21, the mean and peak aortic gradient was higher for Crown PRTTM compared with TrifectaTM, and in patients with an aortic annulus measured with metric Hegar dilators less than or equal to 22 mm. Conclusions: One year after surgery, the three prostheses presented a different hemodynamic performance, being TrifectaTM superior to Crown PRTTM.

Early-Term Hemodynamic Performance And Clinical Results of 19-mm st. Jude Medical Regent Valve In Patients With Small Aortic Annulus Undergoing Dual Valve Replacement: A Retrospective Study

Background: The prosthesis selection in patients with small aortic annulus undergoing aortic valve replacement (AVR) has always been a challenge, especially in dual valve replacement (DVR, combined aortic and mitral valve replacement). The present study aimed to analyze early-term hemodynamic parameters of 19-mm St. Jude Medical Regent ( SJMR19 ) valve in patients with small aortic annulus undergoing DVR. Methods: Between January 2015 to December 2020, 54 patients with small aortic annulus who underwent DVR were divided into two groups: SJMR19 valve group (n=30) and 21-mm mechanical (M21) valve group (n=24). The perioperative and early-term hemodynamic data were collected and analyzed. Results: A significant difference in terms of maximum transaortic flow velocity (Vav max), maximum transaortic pressure gradient (PGav max), left ventricular mass index (LVMi) and left ventricular mass (LVM) was observed postoperatively in both groups. The postoperative left ventricular ejection fraction (LVEF) was significantly higher while the LVM and LVMi was evidently decreased in the SJMR19 group, compared with the M21 group. In order to confirm the influencing factors on postoperative LVEF, a multiple linear regression analysis model was established by including all candidate variables and the implanted valve type was identified in the multivariate analysis as an independent predictor for postoperative LVEF. Conclusions: The postoperative cardiac function and hemodynamic parameters was improved both in the SJMR19 and M21 groups. The postoperative LVEF, LVM and LVMi were better in the SJMR19 group compared with those of the M21 group. And the implanted valve type might possess the predictive value of postoperative LVEF in patients with small aortic annulus undergoing DVR.

Particle Image Velocimetry for in vitro characterization of Paravalvular Leakage of TAVR-sealing concepts

Paravalvular leakage (PVL), defined as the leakage between the aortic annulus and a transcatheter aortic valve replacement (TAVR), is verifiably associated with short- and long-term clinical outcome, especially with increased mortality. Therefore, with the ambition to reduce or even prevent PVL of next generation TAVR, it is necessary to extend the hemodynamic understanding of PVL. This study presents an in vitro flow measurement method to localize PVL during hydrodynamic characterization of TAVR and furthermore presents different design features, socalled outer skirt, to reduce PVL. Particle image velocimetry (PIV) measurements were performed for flow field assessment during hydrodynamic characterization of TAVR. Additionally, two different sealing concepts were developed to reduce PVL. The skirts were manufactured from polymeric-nonwoven and sued to pericardium-based TAVR-prototype. The prepared TAVR-prototypes were then deployed in a pathophysiological model of the aortic root with a calcification nodule of 2 mm according to ISO 5840:2021. To assess PVL, the flow field and the regurgitation volume was measured. The PIV measurements showed a clearly visible leakage jet between the TAVR-prototypes without skirt and the pathophysiological aortic annulus model. Jet velocities of up to 0.5 m/s were measured depending on presence or configuration of a PVL-preventing skirt. When implanted in the physiological annulus model without calcification nodule, PVL was hardly recognizable. The regurgitation volume of a TAVR-prototype without skirt at 5 l/min was 36.26±1.89 ml (n = 10). The developed and manufactured polymeric-nonwoven skirts reduced PVL from 37.67±1.17 ml to 18.36±1.8 ml (n = 10, TAVR-skirt-design1) and from 46.97±1.07 ml to 17.85±1.29 ml (n = 10, TAVR-skirt-design2) at 5 l/min. The localization of PVL during hydrodynamic characterization by means of PIV was successful. The sealing concepts developed in this work were very effective and led to a PVL-reduction of the tested TAVR prototypes of about 50% to 70%.