A comprehensive description of transcatheter heart valve (THV) failure has not been performed. We undertook a systematic review to investigate the aetiology, diagnosis, management, and outcomes of ...THV failure.
The systematic review was performed in accordance with the PRISMA guidelines using EMBASE, MEDLINE, and Scopus. Between December 2002 and March 2014, 70 publications reported 87 individual cases of transcatheter aortic valve implantation (TAVI) failure. Similar to surgical bioprosthetic heart valve failure, we observed cases of prosthetic valve endocarditis (PVE) (n = 34), structural valve failure (n = 13), and THV thrombosis (n = 15). The microbiological profile of THV PVE was similar to surgical PVE, though one-quarter had satellite mitral valve endocarditis, and surgical intervention was required in 40% (75% survival). Structural valve failure occurred most frequently due to leaflet calcification and was predominantly treated by redo-THV (60%). Transcatheter heart valve thrombosis occurred at a mean 9 ± 7 months post-implantation and was successfully treated by prolonged anticoagulation in three-quarters of cases. Two novel causes of THV failure were identified: late THV embolization (n = 18); and THV compression (n = 7) following cardiopulmonary resuscitation (CPR). These failure modes have not been reported in the surgical literature. Potential risk factors for late THV embolization include low prosthesis implantation, THV undersizing/underexpansion, bicuspid, and non-calcified anatomy. Transcatheter heart valve embolization mandated surgery in 80% of patients. Transcatheter heart valve compression was noted at post-mortem in most cases.
Transcatheter heart valves are susceptible to failure modes typical to those of surgical bioprostheses and unique to their specific design. Transcatheter heart valve compression and late embolization represent complications previously unreported in the surgical literature.
Patients with homozygous familial hypercholesterolemia (hmzFH) attributable to LDL receptor gene mutations have shown a remarkable increase in survival over the last 20 years. Early onset coronary ...heart disease (CHD) and calcific aortic valve stenosis are the major complications of this disorder. We now report extensive premature calcification of the aorta in patients with hmzFH.
We examined 25 hmzFH patients from Canada; mean age was 32 years (range 5 to 54), and mean baseline cholesterol before treatment was 19+/-5 mmol/L (737+/-206 mg/dL). Aortic calcification was quantified using computed tomography (CT). An elevated mean calcium score was found in patients by age 20 and correlated with age (r(2)=0.53, P=0.001). One quarter (24%) of patients underwent aortic valve surgery.
We document premature severe aortic calcifications in all adult hmzFH patients studied. These presented considerable surgical management challenges. Strategies to identify and monitor aortic calcification in hmzFH by noninvasive techniques are required, as are clinical trials to determine whether additional or more intensive therapies will prevent the progression of such calcifications. Whether vascular calcifications in hmzFH subjects are related to sustained increases in LDL-C levels or to other mechanisms, such as abnormal osteoblast activity, remains to be determined.
Abstract
Introduction
Intra-operative predictors of mid-to-late mitral valve dysfunction after surgical repair of mitral regurgitation (MR) caused by prolapse remain poorly characterized. This study ...aims to evaluate the effect of annuloplasty prosthesis size on post-operative MV hemodynamics at rest and during exercise, and to identify perioperative predictors of MV dysfunction.
Methods
104 patients were randomly assigned to resection and preservation for surgical treatment of posterior leaflet prolapse in the Canadian Mitral Research Alliance CardioLink-2 study. Echocardiograms were performed at baseline and 1 year postoperatively. Intraoperative TEE was performed to assess immediate MV gradients. Exercise TTE was performed 1 year after repair. Linear regression analysis was used to identify associations between MV indices (rest and peak exercise gradients) at 12 months, and perioperative echocardiographic and clinical factors.
Results
Mean age of participants was 65±10 years, and 83% were male. Larger annuloplasty size was associated with lower transmitral gradients at rest and during peak exercise. In multivariable analysis, annuloplasty size ≥34mm was associated with lower mean and peak rest and exercise gradients at 12 months, after adjustment for repair type, age, sex, and BSA (p<0.001). Higher pre-operative pulmonary artery pressures were associated with reduced functional capacity post-operatively. Intra-operative TEE gradients predict resting and exercise MV hemodynamics at 1 year.
Conclusion
Annuloplasty size ≥34mm is associated with improved MV hemodynamics at rest and during peak exercise 1 year post MV repair. MV repair prior to onset of pulmonary hypertension confers favourable post operative functional capacity. Finally, intra-operative TEE can be used to identify patients at risk of mitral valve dysfunction within 1 year of repair.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The Heart and StrokeFoundation of Ontario (GIA 16-00014666)
The Institut national d'excellence en santé et en services sociaux (INESSS) has collaborated with Québec's transcatheter aortic valve implantation (TAVI) programs since 2013 to evaluate processes of ...care and outcomes. In 2018-2019, data were also collected on surgical aortic valve replacement (SAVR). Herein, we describe real-world volume and outcome trends for these two patient groups, as well as processes of care and clinical characteristics over a 6-month period.
Volume and mortality have been ascertained for TAVI since 2013 in collaboration with all Québec programs, and from the Canadian Institute for Health Information (CIHI) for SAVR. From October 1, 2018 to March 31, 2019, patient characteristics and process of care data were also collected, in collaboration with clinical teams, for all TAVI and SAVR performed in patients aged ≥ 75 years. Rates of TAVI doubled between 2013-2014 and 2018-2019 (9.4 to 19.6 / 100,000 population), whereas rates of isolated SAVR (iSAVR) remained stable (19.8 to 21.5 / 100,000 population). Thirty-day mortality post-TAVI decreased from 4.8% in 2013-2016 to 2.4% in 2016-2019 amongst patients ≥ 75 years, and from 3.7% to 2.3% in younger patients. For iSAVR, 30-day mortality during the same periods decreased in patients ≥ 75 years, from 3.2% to 1.0%, but remained stable (at 1.0%) in younger patients. During the 6-month 2018-2019 period, 300 TAVI and 129 iSAVR in patients ≥ 75 years were examined. TAVI patients had a higher median age than iSAVR (84 vs. 78) and more comorbidities. For TAVI, median delay from referral to treatment decision was 72 days (inter-quartile range, IQR: 11-138) and 28 days (IQR: 7-75) from decision to procedure; for iSAVR, these were 17 (IQR: 1-49) and 63 days (IQR: 16-109), respectively. Median length of hospital stay was 3 days (IQR: 1-5) for TAVI, and 7 days (IQR: 6-10) for iSAVR. Incidence of in-hospital stroke, new pacemaker and 30-day mortality was 3.3%, 17.7% and 2.3% for TAVI, respectively, and 1.6%, 6.2% and 0% for iSAVR.
From 2013-2019, use of TAVI increased and a decrease in overall 30-day mortality associated with treatment for severe and symptomatic aortic stenosis was observed. Amongst elderly patients in 2018-2019, TAVI and SAVR patients had different characteristics, evaluation processes and wait times. Broadening of TAVI to patients at low surgical risk raises organizational and long-term clinical issues and may favour a shift from procedure-focused to disease-centred evaluation processes.
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