778 Acute clinical valve thrombosis after transcatheter mitral valve-in-valve replacement

Aims Transcatheter heart valve (THV) thrombosis is a frequent and potentially life-threatening complication of transcatheter mitral valve replacement (TMVR), occurring in approximately 12% of patients (mainly within the first 3 months after the procedure). The majority of THV thromboses is non-obstructive and subclinical, and remains undetected until a routine echocardiogram is performed. Methods A 65 years old male was suffering from post-ischaemic dilated cardiomyopathy and severe left ventricle systolic dysfunction (LVEF 28%), secondary to a previous STEMI in 2010 treated with primary PCI on proximal LAD; after the STEMI he developed a left ventricle aneurysm and a subsequent severe secondary mitral regurgitation. In late 2020 he underwent a surgical valve replacement with a biologic valve (Perimount Magna Mitral Ease n. 27), alongside a left ventricle reshaping (Dor procedure). After a few months, the patient developed worsening dyspnoea and severe exercise intolerance; a transesophageal echocardiogram (TEE) showed an extensive valve degeneration with diffuse leaflet thickening determining severe valve stenosis and regurgitation. The patient was then admitted to the Cardiology department. A coronary angiography was performed, showing good result of previous PCI and excluding other critical stenoses. The patient then underwent a transcatheter valve-in-valve replacement with a Sapien S3 n. 29 in mitral position. The patient was already in chronic therapy with acetilsalicilic acid (ASA), and after the procedure anticoagulant therapy with Warfarin was started. In the post-procedural period the patient developed an acute worsening of the LVEF with severe hypotension, likely due to after-load mismatch; hence, supportive inotropic therapy with Adrenalin and Enoximone was required. A TEE performed 7 days after the procedure showed absence of diastolic excursion of posterior and lateral cusps and leaflet thickening with a 4 mm thrombotic apposition on the ventricular side, determining severe valve stenosis with markedly increased transvalvular gradients (peak gradient 20 mmHg, mean gradient 11 mmHg). A CT scan of the heart confirmed the valve thrombosis on the inferior and lateral leaflets. Results Unfractioned heparin (UFH) was then added to ASA and Warfarin (INR target of 3.0). After 11 days of aggressive antithrombotic therapy a new TEE was performed, showing marked reduction in transvalvular gradients (peak gradient 10 mmHg, mean gradient 5 mmHg) due to partial dissolution of the thrombotic formation. Warfarin was then stopped, and after switching from UFH to Enoxaparin the patient was discharged asymptomatic and in good general conditions, with indication of follow-up with TEE at 1 month. Conclusions Valve-in-valve TMVR is a relatively new and still infrequent procedure, therefore few evidences about its complications are currently available. Thrombosis on these valves is not rare (12%), but usually develops on the atrial side of the leaflets; interestingly, in this patient the thrombosis was on the ventricular side, likely due to an acute reduction in flow velocity caused by the after-load mismatch and the subsequent cardiogenic shock.

780 Rapid Deployment or Sutureless Valves as An Alternative to Conventional Bioprosthetic Aortic Valve Replacement

Aim Rapid deployment valves are being used widely. We wanted to compare outcomes for rapid-deployment valves and conventional bioprosthetic aortic valve replacements in order to assess if their use is justifiable. Method Outcomes of the last 120 patients who received a rapid-deployment AVR (RDAVR) between Sept 2014-Sept 2019 were compared to the last 120 patients who had conventional bioprosthetic aortic valve replacement (Conv AVR). Results Age of RDAVR 77.5±4.93 was compared to Conv AVR 67.9±11.9 years (p > 0.05). Other baseline characteristics were similar. RDAVR group included more elderly (>80 years; 40 vs 11, p < 0.05) and females (83 vs 36, p < 0.05). RDAVR group had shorter cross clamp time (68 vs 89 min, p < 0.05) and cardiopulmonary bypass time (97 vs 110 min, p < 0.05) for isolated AVR. Mortality was equal in both groups (1.7%). Post-operative pressure gradients were similar (mean gradient 10.4±4.44 vs 11±5.31 mmHg and peak gradient 20.32±8.64 vs 22.95±9.72 mmHg). Additionally, patients were divided into size matched subgroups and post-operative pressure gradients were comparable. Hospital length of stay and early post-operative results were similar between the two groups. Early permanent pacemaker rate was similar in both groups (9 vs 5, p > 0.05). Survival rates in group 1 and 2 were 97.5% vs 99.2% at 1 year, 95.8% vs 96.7% at 2 years. and 95% vs 96.7% at 3 years, respectively. Conclusions RDAVR had similar haemodynamic outcomes and survival. Where shorter cross clamp and pump times may be desirable RDAVR may be preferred in older high-risk patients.

Low Incidence of Structural Valve Degeneration With the Trifecta Aortic Valve Bioprosthesis.

Objectives: An ideal bioprosthetic heart valve would have excellent haemodynamic performance and a low rate of Structural Valve Degeneration (SVD). The objective of this study was to investigate the haemodynamic performance and incidence of reintervention due to SVD of the Trifecta aortic valve.Methods:Between 2012 to 2019, 2934 valve surgeries were performed in which 2185 were biological valves. Out of 2185 patients, only 399 patients had undergone Trifecta biological Aortic Valve Replacement (AVR). Three surgeons performed all aortic Trifecta valve surgeries. Operative mortality, incidence of reintervention and overall survival figures was calculated. Results: A total of 399 patients were included of which 260 (65.2%) were male. The mean (± SD) age was 73.4 ± 8.0 with 41 patients (10.3%) aged under 65 with 222 patients (55.6%) had isolated AVR and 176 (44.1%) had AVR combined with coronary artery bypass grafting and a single patient underwent aortic and mitral valve replacement. The mean (±SD) logistic EuroSCORE was 7.4 (±2.7). The median valve size used was 23mm. A total of 21 patients (5.3%) required a permanent pacemaker to be implanted. The 30-day mortality rate was 2.8% (n=11). The rate of structural valve degeneration was 0.3% and median follow-up was 782 days. Neither peak nor mean valve gradients were significantly different between year 1 vs. year 3 (peak gradient: 18.3±8.0 vs. 17.1±8.5, p=0.34; mean gradient: 9.8±4.6 vs. 8.7±4.6, p=0.16). Conclusions: Mid-term echocardiographic data showed a low rate of significant regurgitation and excellent gradients. Larger multicentre studies are required to validate these findings.

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

<b><i>Background:</i></b> 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. <b><i>Method and Results:</i></b> 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, <i>p</i> &#x3c; 0.001), ventricular mass electrical criteria regression (Sokolow and Cornell products), and 1-year survival (90 vs. 93% and 97%, log rank <i>p</i> value = 0.04) in conventional, Perceval®, and Intuity® groups. <b><i>Conclusions:</i></b> 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.

Comparison of cardiovascular and psychological profile of young military men after COVID-19 with and without pneumonia

Aim. To compare the cardiovascular and psychological profile of young military population after coronavirus disease 2019 (COVID-19) with/without pneumonia.Material and methods. We examined 26 military men under 30 years of age (22,3±3,7 years/21,0 [19,8; 24,3] years) with documented COVID 19 (3 months±2 weeks after two virus-negative polymerase chain reaction tests). The participants were divided into 2 groups: experimental group (n=16) — those with COVID-19 pneumonia; comparison group (n=10) — those without pneumonia. All subjects underwent a complex of clinical and diagnostic tests.Results. Military men with COVID-19 pneumonia were significantly older (23,0 [20,5; 28,5] years vs 19,5 [19,0; 20,0] years, p=0,001). They had a prolonged PQ interval (154,5 [140,0; 163,5] ms vs 137,0 [134,0; 144,0] ms; p=0,014). According to echocardiography, the following parameters were significantly larger in experimental group: anteroposterior right ventricular dimension (26,0 [24,5; 27,5] mm vs 23,5 [22,0; 25,0] mm, p=0,012), right atrium length (48,0 [46,0; 51,5] mm and 45,5 [44,0; 47,0] mm, p=0,047), tricuspid regurgitation peak gradient (18,0 [15,5; 22,0] mm vs 14,0 [12,0; 20,0] mm, p=0,047), pulmonary artery systolic pressure (PASP) (30,3 [27,6; 34,0] mm Hg vs 23,0 [20,5; 30,5] mm Hg, p=0,038), mean pulmonary artery pressure (20,3 [18,9; 22,7] mm Hg vs 16,8 [14,5; 20,6] mm Hg, p=0,038). The estimated pulmonary vascular resistance was significantly higher in the study group (1,50 [1,2; 1,8] Wood units vs 1,17 [1,1; 1,2] Wood units, p<0,001). The groups did not differ significantly in terms of symptoms of stress (perceived stress scale score of 10) and anxiety and depression disorders (GAD7 and PHQ9 questionnaires), quality of life (SF-36 survey).Conclusion. In young military personnel, COVID-19 pneumonia in the long term after the disease is associated with longer PQ interval, older age and larger right heart sizes on echocardiography, as well as with a higher tricuspid regurgitation peak gradient, PASP, mean pulmonary artery pressure, and pulmonary vascular resistance. In this category of population, no association was found between the severity of COVID-19 and psychological status parameters.

Evaluation of Left Ventricular Outflow Gradients During Staged Exercise Stress Echocardiography Helps Differentiate Pediatric Patients With Hypertrophic Cardiomyopathy From Athletes and Normal Subjects

Background: Elevated left ventricular outflow tract (LVOT) gradients during exercise can occur in patients with hypertrophic cardiomyopathy (HCM) as well as in athletes and normal controls. The authors’ staged exercise protocol calls for imaging at rest and during each stage of exercise to evaluate the mechanism of LVOT obstruction at each stage. They investigated whether this staged approach helps differentiate HCM from athletes and normal controls. Methods: They reviewed pediatric exercise stress echocardiograms completed between January 2009 and October 2017 at their center and identified those with gene-positive HCM, athlete’s heart, and normal controls. Children with inducible obstruction (those with no LVOT gradient at rest who developed a LVOT peak gradient > 25 mm Hg during exercise) were included. LVOT peak gradient, velocity time integral, acceleration time, and deceleration time were measured at rest, submaximal stages, and peak exercise. Results: Compared with athletes, HCM patients had significantly higher LVOT peak gradients at rest (P = .019), stage 1 of exercise (P = .002), and peak exercise (P = .051), as well as a significantly higher change in LVOT peak gradient from rest to stage 1 (P = .016) and from rest to peak (P = .038). The acceleration time/deceleration time ratio of the LVOT Doppler was significantly lower in HCM patients compared with normal controls at peak exercise. Conclusions: The HCM patients who develop elevated LVOT gradients at peak exercise typically manifest early obstruction in the submaximal stages of exercise, which helps to differentiate them from athletes and normal controls.

Mitral Valve Plasty During Correction of Combined Mitral-Aortic Valve Diseases

The aim. To study reconstructive operations on the mitral valve (MV) combined with aortic valve replacement (AVR) for combined mitral-aortic valve defects (CMAVD). Materials and methods. The study included 1690 patients with CMAVD who underwent surgical treatment at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine for the period from 01/01/2006 to 01/01/2020. Of these, 429 (23.4%) patients underwent MV reconstruction with AVR. The following valve-sparing procedures were performed: – application of annuloplasty ring: 123 (28.7%); – MV suture annuloplasty: 137 (31.9%); – open mitral commissurotomy: 47 (11.0%); – open mitral commissurotomy + leaflet plication: 4 (0.9%); – application of autopericardial patch on the MV leaflet: 7 (1.6%); – alfieri procedure (MV bicuspidalization): 34 (7.9%); – mitral valve debridgment 12: (2.8%); – plasty with autopericardial patch: 18 (4.2%); – removal of vegetation from MV structures : 7 (1.6%); – resection of MV leaflets with addition of suture annuloplasty: 19 (4.4%); – resection of MV leaflets with addition of an annuloplasty ring: 21 (4.9%). Results. Fatal complications occurred in 4 cases due to heart failure (n = 2) and multiple organ failure (n = 2). Hospital mortality in AVR with MK plasticity MV plasty was 0.9%, which once again emphasizes the importance of traumatic intervention compared with combined mitral-aortic prosthetics, where mortality is 3 times higher. It decreased from 2.9% (2006–2012, n = 128) to 0.3% (2013–2019, n = 301), which indicates the effectiveness of the method with a significant increase in the number of operated patients. After correction, MV regurgitation decreased from +2.4 ± 0.3 to +0.4 ± 0.03. Coaptation of the sash Mk MV leaflets after correction was 7.4 ± 0.6 mm. At the hospital stage there was a decrease in the diastolic peak gradient on the MV from 19.4 ± 4.8 mm Hg to 6.4 ± 0.8 mm Hg. In the remote period, 82.6% of the discharged patients (n = 351) in the period of were followed for 9.3 ± 2.4 years. Better indicators were noted in group of patients with functional class III than those with functional class IV (p <0.05). Fatal outcomes due to thromboembolic complications (n = 29) were caused by the presence of a mechanical aortic prosthesis and partial non-compliance with the protocol of anticoagulant therapy. Unsatisfactory result in the group with changes in the MV was due to the activity of the rheumatic process and progressive heart failure with prolonged atrial fibrillation (n = 37). The etiology of the defect affected the long-term outcome. The activity of the rheumatic process in patients with functional class IV determined changes in the MV leaflets in the long term and worsened the result. MV regurgitation increased from +0.08 ± 0.03 (5 years after surgery) to +1.2 ± 0.3 (10 years after surgery). In the long term there was an increase in the diastolic peak gradient on the MV from 9.4 ± 0.4 mm Hg (5 years after surgery) to 13.4 ± 3.2 mm Hg (10 years after surgery). MV replacement was performed in 4 patients 6, 9, 10, 11 years after surgery. Conclusions. Given the available clinical experience, it is advisable to recommend reconstructive interventions on the MV to correct CMAVD and improve the level of survival and stability of good results.

Abstract 15172: Murf1 Inhibitor Embl205 is a New Approach for Treatment of Heart Failure With Preserved Ejection Fraction in an Animal Model

Background: The novel MuRF1 inhibitor EMBL205 attenuates effectively developing skeletal muscle atrophy and dysfunction in animals with heart failure with preserved ejection fraction (HFpEF, ZSF1 rat model). The impact of EMBL205 on myocardial function in the HFpEF setting is currently unknown and was evaluated in ZSF1 rats. Methods: 20 wks-old female obese ZSF1 rats received EMBL205 (12 wks, conc. of 0.1% in chow; HFpEF-EMBL205). Age-matched untreated lean (con) and obese (HFpEF) ZSF1 rats served as controls. At 32 wks of age left ventricular (LV)-, aortic valve (AV) function and LV end diastolic pressure (LVEDP) was determined by echocardiography and invasive hemodynamic measurements. LV expression of collagen 1A (Col1A) and 3A (Col3A) was assessed by qRT-PCR, MMP2 expression was obtained by zymography and perivascular fibrosis was quantified in histological sections. Results: Development of HFpEF in ZSF1 obese animals is associated with cardiac enlargement and hypertrophy, as evident by increased myocardial weight, an increase in end diastolic volume (EDV) and LV anterior and posterior wall diameters. Diastolic LV-function is disturbed with elevation of E/é, an increased LVEDP and a preserved LV ejection fraction. AV peak velocity and peak gradient are significantly increased and AV opening area (AVA) significantly decreased. Col1A and Col3A expression are increased in HFpEF animals. EMBL205 treatment results in a significant reduction of myocardial weight and a trend towards lower EDV compared to HFpEF group. EMBL205 attenuates the increase in E/é, LVEDP, AV peak gradient and the decrease of AVA. EMBL205 significantly reduces Col3A expression and a trend for Col1A expression is seen. Increased perivascular fibrosis and MMP2 expression in HFpEF is extenuated by EMBL205 treatment (table 1). Conclusions: Application of EMBL205 attenuated the development of pathological myocardial alterations associated with HFpEF in ZSF1rats due to antifibrotic effects.

Transcatheter aortic valve implantation for the treatment of degenerated mitroflow bioprosthesis

Introduction The leading cause of valvular heart replacement therapy is symptomatic aortic stenosis (AS). The Mitroflow (MF) bovine pericardial prosthesis is prone to early structural valve deterioration (SVD) and has been used in over 100,000 patients for the treatment of symptomatic AS. The standard of care for degenerated bioprosthesis is surgical aortic valve replacement. However, valve-in-valve transcatheter aortic valve replacement (VIV-TAVI) is an interesting therapeutic modality currently being evaluated to avoid redo surgery. Purpose The purpose of this study was to evaluate the clinical outcomes of patients with SVD MF bioprosthesis treated with VIV-TAVI. Methods Data was collected from all the patients undergoing TAVI in a single center from March 2012 to July 2019. All the cases remitted for VIV-TAVI were prospectively included and followed. All events were classified according to the VARC-2 definitions. The primary endpoints were a combination of clinical events at the end of the follow-up which included all-cause mortality, cardiovascular mortality, hospitalizations due to heart failure and stroke/transient ischemic attack. Secondary endpoints were absence of SVD and valve hemodynamics at the end of the follow-up. Results Between march 2012 and July 2019, 65 patients were derived for VIV-TAVI. The mean age was 80,4±5.93 years. 50,8% were male. The average STS score was 6.39±5,62 and Euroscore II 8.86±5.17. All the patients were diagnosed with SVD with a mixed mechanism (stenosis/regurgitation) being the most frequent form of disfunction (38,5%) followed by regurgitation (33,9%) and stenosis (27,7%). Procedural success was achieved in 98,5% of the cases, there were 2 deaths of cardiovascular origin, 1 stroke, and 2 hospitalizations due to heart failure. The mean gradient, peak gradient and valve area at discharge were 13,3mmHg, 27,2mmHg and 1,14cm2, respectively. After 28,8 months (17,4–60,9) of follow-up the combined endpoint occurred in 21 patients (32,3%). There was a total of 13 deaths (20%) and only 4 (7.3%) from cardiovascular causes. 2 patients were reported of having a stroke/TIA and there were 5 readmissions from heart failure (2 of them within the first 30 days). The mean gradient, peak gradient and valve area remained steady when comparing post-TAVI vs follow-up, 20.3mmHg vs 18.8mmHg (p=0.2), 39.6mmHg vs 35.2mmHg (p=0.01) and 1.3cm2 vs 1.3cm2 (p=0.7), respectively. The same tendency was observed in aortic regurgitation. There were no significant changes in the LVEF over time. There were only 2 patients (3.1%) presenting with valve deterioration during follow-up. Conclusions VIV-TAVI for SVD MF bioprosthesis is a safe procedure and a valid alternative to surgery in this group patients, with a high rate of success and low intraprocedural complications. At 28 months of follow-up, 68% of patients were free of late clinical events and valve hemodynamics maintain over time. Figure 1 Funding Acknowledgement Type of funding source: None

Quantification of Severity of Unilateral Coronal Synostosis

Objectives: Severity of unilateral coronal synostosis (UCS) can vary. Quantification is important for treatment, expectations of treatment and natural outcome, and education of the patient and parents. Design: Retrospective study. Setting: Primary craniofacial center. Patients, Participants: Twenty-three preoperative patients with unilateral coronal craniosynostosis (age < 2 years). Intervention: Utrecht Cranial Shape Quantifier (UCSQ) was used to quantify severity using the variables: asymmetry ratio of frontal peak and ratio of frontal peak gradient. Main Outcome Measures(s): The UCSQ variables were combined and related to visual score using Pearson correlation coefficient; UCSQ and visual score were additionally compared to Di Rocco classification by one-way analysis of variance or Kruskal-Wallis test. All measurements were made on computed tomography scans. Results: Good correlation between UCSQ and visual score was found ( r = 0.67). No statistically significant differences were found between group means of UCSQ in the 3 categories of Di Rocco classification ( F 2,20 = 0.047; P > .05). Kruskal-Wallis test showed no significant differences between group means of visual score in the 3 categories of Di Rocco classification (Kruskal-Wallis H (2) = 0.871; P > .05). Conclusions: Using UCSQ, we can quantify UCS according to severity using characteristics, it outperforms traditional methods and captures the whole skull shape. In future research, we can apply UCSQ to 3D-photogrammetry due to the utilization of external landmarks.