Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation: Challenging Pathology Awaiting Specialized Devices

Patients with aortic incompetence frequently present with anatomical and pathological challenges such as elliptical dilated annulus, dilated aortic root, dilated ascending aorta, and with no calcification in the aortic cusps or annulus. Patients are commonly in graver clinical condition as a result of a long silent clinical course before overt congestive heart failure. All of the above make transcatheter therapies for native aortic valve regurgitation more challenging with poorer outcomes, escalating the risk of insufficient anchoring, prosthesis migration, and residual paravalvular leak compared with current transcatheter aortic valve replacement (TAVR) outcomes for aortic stenosis. There is a need for specialized TAVR devices to address this complex pathology. Surgical aortic valve replacement is the current treatment option and the gold standard for patients with aortic incompetence (AR). Currently, the specific off-label indication for TAVR in pure native AR could be a feasible and reasonable option, as a compassionate treatment is limited to inoperable patients and agreed on by the heart team.

Outcomes of Ruptured Sinus of Valsalva Aneurysm -A 20-year experience

Background: Ruptured aneurysms of sinus of Valsalva are defects of the aortic media, which are uncommon yet present concomitantly with either ventricular septal defect, aortic insufficiency or both. Here, we analyse retrospectively outcomes of patients operated on in the last two decades. Patients and Methods: 151 cases of ruptured aneurysms of sinuses of Valsalva were treated here between January 2000 and December 2020. The majority (96%) arose from the right coronary sinus. The right ventricular outflow was the most common site of rupture (56.2%). Ventricular septal defect was associated in 24 patients (16%) all of whom had ruptured right sinus, of which 8 (33%) were of subpulmonic subtype. Aortic incompetence was found in 45 patients (43.3%). Elective surgery was offered to 78 patients (51.6%), while the rest had defects closed by interventional devices. Surgical conversion for device embolization occurred in 12 patients (7.94 %). The defect was closed through the aortic root in 13 patients (14.4% of 90) and employing the bicameral technique (root and ruptured chamber) in the remaining 87 patients. 18 patients (20%) underwent aortic valve repair while 5 (5.5%) underwent aortic valve replacement. Results: We had no hospital deaths, however 4 operated patients (2.6%) had comorbidities. Follow‐up ranged from 1 to 20 years (mean 13 ± 5). There were 3 deaths in this period, and among the majority, quality of life was uneventful. Conclusion: Surgical correction for ruptured aneurysms of Valsalva provides prudent results and must be the preferred modality of treatment in acute and chronic presentation.

Undiagnosed Bicuspid Aortic Valve: A Silent Danger

The normal aortic valve has three leaflets, which are almost equal in size. A bicuspid aortic valve developed as a result of abnormal aortic cusp formation during early embryogenesis. Complications such as valvular stenosis or incompetence are well known. Delayed in identifying the congenital abnormality or the complications may cause morbidity and mortality. We report two cases of congestive cardiac failure as the results of undiagnosed bicuspid aortic valve with severe aortic incompetence. Both young men in their productive age without cardiac risk factors, were unfortunate to present too late. Although one of them was lucky to survive the ordeal, most late presentation ends up gravely. Aortic valve replacement can be offered if early detection is made. Those with severe disease at diagnosis may require a heart transplant.

Emergency treatment of acute decompensated critical aortic stenosis with transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is relatively contraindicated in the bicuspid aortic valve, and to our knowledge has not been tried where the true native annulus is of a size far in excess of current device capabilities. We present here a case of a successful emergency TAVI of a 73-year-old previously healthy man, who presented with cardiogenic shock, ventricular tachycardia storm and severe left ventricular dysfunction because of the underlying critical bicuspid aortic stenosis with aortic annulus area of 991.9 mm2 and associated moderate aortic incompetence (the Society of Thoracic Surgeons (STS) risk score; score mortality of 40.9%). Despite the critical condition of the patient and technically challenging anatomy, successful TAVI was performed and the patient remains well with near-normal left ventricle (LV) function at 6 months follow-up.

A case report: a rare case of severe aortic incompetence

Background Aneurysms of the sinus of Valsalva (SOV) are thin-walled outpouchings most commonly involving the right or non-coronary sinuses. Because they are asymptomatic, they are rarely discovered before they rupture and form an aorto-cardiac fistula. We present a rare case of unruptured aneurysm of the right coronary SOV burrowing into the interventricular septum with severe aortic incompetence and left ventricular dysfunction. To our knowledge, burrowing of the SOV aneurysm (SVA) into the interventricular septum and its large sac-like appearance has never been described using three dimensional (3D) echocardiography before. Case summary A 37-year-old man presented to the cardiology outpatient department with complaints of dyspnoea and palpitations (New York Heart Association Class II–III) for the last 6 months. He was evaluated with transthoracic echocardiography which showed a large mobile sac-like structure with irregular borders bulging and prolapsing into the left ventricular cavity with each cardiac cycle along with severe aortic incompetence. On transoesophageal echocardiogram, the right coronary cusp showed malcoaptation with deformed aortic sinus causing severe aortic incompetence. Cardiac computed tomography showed sparing of right coronary artery at the origin. A diagnosis of SVA was made. The patient underwent aortic valve replacement along with partial resection of the aneurysm. The patient had an uneventful postoperative course. Follow-up echocardiography after 4 weeks showed well-seated aortic valve prosthesis with residual SVA. The ejection fraction decreased from 46–48% to 36–38%. Discussion Comprehensive multimodality imaging can be used for management strategy of SVA.

Auf den Spuren des Erb’schen Auskultationspunkts: Rätsel gelöst

Abstract“Erb’s point” is the fifth point of auscultation for the heart exam, located in the third intercostal space close to the sternum. It has sometimes been attributed to famous German neurologist Wilhelm Heinrich Erb (1840 – 1921), but without historical evidence. Erb’s focus on neurology suggested that the auscultation point may have been confused with other points in the neck named after Erb. As Erb was a specialist for neurological manifestations of syphilis, we speculated that the heart murmur of aortic incompetence produced by syphilitic aortitis, best heard at Erb’s point, linked Erb’s name to the auscultation point. However, we eventually found a publication by an American physician who visited Erb’s lectures in Heidelberg and reported that Erb explicitly introduced this “fifth point” in his case presentations in the late 1890 s. After all, Erb was chair of general medicine, with the first German chair of neurology only being established in 1919.

56-year-old lady with transaortic gradient

Clinical introductionA 56-year-old lady with a background of hypertension was admitted to our institution with acute pulmonary oedema. She reported gradual and increasingly severe dyspnoea on exertion over the preceding 12 months and, prior to presentation, her exercise tolerance was restricted to one flight of stairs. On transthoracic echocardiography during the index admission, left ventricular size and systolic function were normal, and peak and mean transaortic gradients were 67 mm Hg and 33 mm Hg, respectively, with a peak velocity of 3.9 m/s. No aortic incompetence or other significant valvular abnormality was noted. A transoesophageal echocardiogram was performed. Figure 1 depicts the mid-oesophageal parasternal long-axis view. What is the explanation behind the significant transaortic gradient?Figure 1Transoesophageal echocardiogram, mid-oesophageal long-axis view at 135 degrees.QuestionWhat is the explanation behind the significant transaortic gradient?Ventricular septal defect Supravalvular aortic stenosisAortic valvular stenosisSubaortic membraneHypertrophic obstructive cardiomyopathy