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Background: Echocardiographic predictors of redo-percutaneous balloon mitral valvuloplasty (redo-PBMV) have not been well studied, and indications are based mainly on Wilkins score. The study aim was to evaluate the immediate results of redo-PMBV and to introduce a simplified redo-score to predict the success of redo-PBMV., Methods: Two cohorts of symptomatic patients (derivation group, n = 218; validation group, n = 100) who had undergone redo-PBMV at a mean of 8.1 ± 2.9 years after a first successful PBMV were enrolled in the study. The mean Wilkins scores were 8.5 ± 1.7 in the derivation group and 8.4 ± 1.8 in the validation group. PBMV was performed using a multi-track technique. Independent echocardiographic predictors of outcome were assigned a points value: mitral valve area ≤1.0 cm2 (2 points), posterior mitral valve leaflet length (PMVL)/anterior mitral valve leaflet length (AMVL) ratio ≤1/2 (2 points), doming distance ≤12 mm (3 points), mitral annular calcification (mild = 1 point; moderate = 2 points; severe = 3 points), commissural status (no fusion = 0 points; uni-fusion = 2 points; bi-fusion = 3 points) and chordal length ≤10 mm (2 points)., Results: The minimum score was 5 and the maximum was 13. A receiver operating curve analysis showed the redo score to be highly significant in predicting redo-PBMV immediate results. The cut-off value of redo score to predict a favorable outcome was ≤8, with a sensitivity of 96% and specificity of 85% in the derivation cohort, and a sensitivity of 95% and specificity of 83% in the validation cohort. A Wilkins score ≤8 had a sensitivity of 71% and a specificity of 59% in the derivation cohort, while sensitivity was 70% and specificity 62% in the validation cohort., Conclusions: The described scoring system was significantly more predictive than the Wilkins score, and was particularly valuable in predicting outcome in patients with a prior PBMV. It may serve as a satisfactory scoring system for correctly selecting patients with mitral restenosis for PBMV.

Background: Sutureless aortic valve replacement (AVR) is an emerging alternative to standard AVR in elderly and high-risk patients. This procedure is associated with a high rate of postoperative permanent pacemaker implantation (PPI). The study aim was to assess the impact on the rate of PPI of implanting the Perceval prosthesis without using balloon inflation., Methods: A total of 159 patients who underwent sutureless AVR using the Perceval prosthesis was included. Balloon inflation was used in 132 patients (Balloon group) and not used in the remaining 27 (No-Balloon group). Clinical, echocardiographic and electrocardiographic outcomes were assessed., Results: There was no significant difference in PPI rate between the two groups (26% for Balloon group versus 22% in No-Balloon group; p = 0.700). Balloon inflation had no significant impact on the incidence of paravalvular leaks (p = 0.839), or on the need to return to cardiopulmonary bypass (CPB) intraoperatively due to paravalvular leak or unsatisfactory deployment (p >0.999). Mean and peak transaortic pressure gradients were similar between the two groups (p = 0.417 and p = 0.522, respectively). Cross-clamp and CPB times were shorter in the No-Balloon group (49.6 ± 15.9 min versus 61.1 ± 25.6 min and 64.1 ± 26.3 min versus 79.6 ± 35.4 min, respectively; p = 0.027 and p = 0.012, respectively)., Conclusions: The two groups had similar postoperative PPI rates. Implanting the Perceval prosthesis without balloon inflation is safe and had no impact on paravalvular leaks, intraoperative complications or hemodynamic results. Reductions in aortic cross-clamp time and CPB time were observed when the balloon was not used.

Background: Transcatheter aortic valve implantation (TAVI) is an effective treatment for severe aortic stenosis in high-risk patients. Several complications related to the TAVI procedure, including aortic regurgitation (AR), cerebrovascular accident (CVA) and the requirement for permanent pacemaker (PPM), are thought to be secondary to balloon aortic valvuloplasty (BAV) before TAVI. The aim of the present review was to evaluate any beneficial role of the direct TAVI approach over BAVTAVI., Methods: A comprehensive search of major databases was performed. Only studies comparing TAVI with and without BAV were included. A total of nine full length articles was included in the analysis., Results: Among 2,650 patients, 1,043 underwent 'direct TAVI' without pre-BAV, while 1,607 underwent TAVI following BAV. Overall, there was no difference between the 30-day all-cause mortality (OR 0.96, 95% CI 0.63-1.47, p = 0.86), CVA (OR 0.81, 95% CI 0.34-1.92, p = 0.63) and PPM implantation (OR 0.84, 95% CI 0.66- 1.05, p = 0.12) between the two approaches. The rate of moderate to severe AR was significantly lower with direct TAVI implantation (OR 0.44, 95% CI 0.20-0.96, p = 0.04). In the case of self-expandable valves, direct TAVI was associated with a lower device success (OR 5.15, 95% CI 1.33-19.9, p = 0.02)., Conclusions: No difference was identified in mortality between direct TAVI and BAV-TAVI. However, direct TAVI is associated with a lower incidence of AR, a finding that would only be confirmed by conducting further randomized studies.

Persistent pulmonary artery hypertension (PAH) after balloon mitral valvuloplasty (BMV) is not uncommon, and is generally associated with established pulmonary vascular disease, an inadequate result, or the development of mitral regurgitation. An unfavorable mitral valve morphology with a smaller post-procedural mitral valve area is among the most common causes of the condition. While routine cardiac catheterization is no longer recommended prior to intervention in valvular heart disease, patients with persistent PAH after BMV should undergo a thorough evaluation before they are considered for repeat BMV. Here, a rare case is reported of symptomatic persistent PAH in a patient referred for a third BMV, less than one year after the previous intervention, where a hypertensive patent ductus arteriosus was identified, the closure of which led to a regression of the PAH.

Transcatheter aortic valve replacement (TAVR) continues to garner considerable attention, especially as the commercial use of the procedure grows. Herein is highlighted an under-reported, underappreciated challenge in TAVR--that of a sigmoid septum. The two cases reported constitute the first discussion in the contemporary literature of this unique geometry in the setting of TAVR. Specifically, the report addresses how such a bulging septum may preclude safe TAVR with a balloon- expandable prosthesis, and also reinforces the importance of thoroughly evaluating all aspects of the subvalvular anatomy prior to valve deployment.

Background and Aim of the Study: Cardiac magnetic resonance (CMR) is the 'gold standard' for quantifying pulmonic regurgitation (PR) in adults with congenital heart disease, but remains costly and is less readily available than echocardiography. Qualitative echocardiographic assessment of PR is challenging, and guiding criteria are limited. It is unknown if echocardiography is sufficient to screen for significant PR. The study aim was to determine whether cardiac MRI provides additional benefit in the assessment of PR in adults with congenital heart disease., Methods: Patients with repaired tetralogy of Fallot or congenital pulmonic stenosis after valvotomy undergoing transthoracic echocardiography and CMR with no interval intervention were identified from a prospective registry. Patients with greater than mild pulmonic stenosis, residual ventricular septal defect or poor echocardiographic windows were excluded. Whole-cohort and subgroup (tetralogy of Fallot versus pulmonic stenosis) analyses for inter-modality agreement were performed., Results: A total of 48 patients (24 men, 24 women; mean age 43 +/- 12 years) was included in the analysis. The unweighted kappa value for the two modalities was 0.30, suggesting 'fair' agreement, though only 52% had matching PR assessments. The indexed right ventricular end-systolic volume (RVESVi) correlated closely with cardiac MRI-monitored PR (p = 0.011 by analysis of variance), but not with that monitored with echocardiography (p = 0.081). Subgroup analysis demonstrated less inter-modality agreement in the tetralogy of Fallot population (kappa 0.25) than in the pulmonic stenosis population (kappa 0.35)., Conclusion: CMR measurement of PR correlates closely with the RVESVi, and appears superior to echocardiography when assessing patients at risk for PR. The study results suggest a vital role for CMR whenever significant PR is suspected in the adult congenital heart disease population.

Background and Aim of the Study: The study aim was to investigate prosthesis-specific predictors for paravalvular aortic regurgitation (PAR) in self-expandable versus balloon-expandable transcatheter heart valves (THVs). PAR is frequently observed after transcatheter aortic valve replacement (TAVR). As self-expandable and balloon-expandable THVs engage differently with the native aortic valve structures, factors that impact PAR may differ between the prosthesis types., Methods: A total of 137 TAVR patients who underwent pre-procedural multidetector computed tomography and post-procedural transthoracic echocardiography were studied. Predictors for PAR, including annulus area oversizing and aortic valve calcification mass and volume, were analyzed in a multivariate model., Results: The Medtronic CoreValve (MCV) prosthesis was utilized in 68 patients (50%), and the Edwards SAPIEN (ES) prosthesis in 69 (50%). More than mild PAR was observed in 43 patients (32%). Among MCV patients, aortic valve calcification volume and mass were higher in those with more than mild PAR than in those with none or mild PAR (p = 0.04, p = 0.03, respectively). Among ES patients, the annulus area and perimeter oversizing were lower in those with more than mild PAR compared to those with no or mild PAR (p = 0.001). By univariate and multivariate logistic regression analysis, aortic valve calcification mass was the only independent predictor for PAR in MCV patients (p = 0.02), whereas in ES patients it was THV undersizing (p = 0.002), irrespective of the calcific burden., Conclusion: For self-expandable THVs, aortic valve calcification mass was the strongest predictor of PAR, whereas for balloon-expandable THVs it was prosthesis undersizing. Hence, in patients evaluated for TAVR these parameters should guide the selection of prosthesis type.

Background and Aim of the Study: The study aim was to determine the immediate and long-term outcomes of balloon pulmonary valvuloplasty (BPV) in a large cohort of adult patients (aged ≥ 18 years) with congenital valvular pulmonic stenosis., Methods: A retrospective data analysis was conducted of the immediate and long-term outcomes of adult patients who had undergone BPV between 2000 and 2012 at a single tertiary care center., Results: A total of 132 patients (mean age 27.7 years; 95% CI 21.12-34.76) underwent BPV, with a mean follow up period of 5.7 years (95% CI 4.37-6.98). Intervention resulted in successful BPV (> 50% reduction in baseline gradient) in 124 patients (94%), and a partially successful BPV (20-50% reduction in baseline gradient) in eight patients (6%). The mean right ventricular (RV) systolic pressure was decreased from 90.6 mmHg (95% CI 84.90-96.33) to 50.9 mmHg (95% CI 47.17-54.61) (p < 0.001), and the pulmonary valve (PV) gradient was reduced from 70.7 mmHg (95% CI 65.12-76.22) to 29.0 mmHg (95% CI 25.83-32.23) (p < 0.001). The mean percentage difference in PV gradient in both genders was 60.23% in males and 57.44% in females (95% CI 55.33-65.12 and 55.32-61.56, respectively) (p > 0.05). Pulmonary valve regurgitation was reported in 17.4% of patients, and was not related to either successful outcome or balloon size. The gradient reductions were maintained after five and 10 years of follow up. Two patients (1.5%) developed restenosis that required repeat BPV. There was no referral for urgent surgery., Conclusion: BPV in adults produced excellent long-term clinical results, there being no gender-related difference in outcome. In addition, the need for reintervention was very low.

Transcatheter aortic valve implantation (TAVI) is sometimes associated with severe complications due to the unpredictability of such closed-chest procedures. Reported complications include atrioventricular blocks, vascular complications, aortic root rupture, aorto-right ventricular fistulas, and aortic dissections. Herein is presented the case of an 88-year-old female with a late atrioventricular septal defect that developed after TAVI.

Background and Aim of the Study: The study aim was to define the timing of cerebral embolization events during transcatheter aortic valve implantation (TAVI), and to determine if events were more closely associated with valve implantation or with balloon inflation., Methods: Between January 2008 and November 2011, a total of 114 patients underwent TAVI at the author's institution. Of these patients, 44 had previously undergone imaging before and after TAVI, and were included in the study (26 transfemoral (TF); 18 transapical (TA)). Eleven patients who had only balloon valvuloplasty (BV) during the same period were included, as were 22 patients who had open aortic valve replacement (AVR), as controls. All 77 patients underwent neurological examination, and all had cerebral MRIs before and after their procedures., Results: Fifty of the 77 patients who underwent postprocedural MRI had new cerebral lesions, as follows: 24/26 (92%) in TF patients; 17/18 (94%) in TA patients; 3/11 (27%) in BV patients; and 6/22 (27%) in AVR patients (TF and TA versus BV and AVR, p < 0.0001). The mean number and volume of embolic lesions per patient were respectively 5.4/438 mm3 for TF, 11.6/3414 mm3 for TA, 0.7/46 mm3 for BV, and 0.4/48 mm3 for AVR (TF versus TA and BV versus AVR, p = NS; TF and TA versus BV and AVR, p < 0.0001). No association was found between either the EuroSCORE or patient age and the number of events., Conclusion: In the present study, an incidence of silent cerebral embolic lesions after TAVI was identified which was significantly higher than that for BV or AVR. This indicated an association of embolism with valve implantation rather than with balloon inflation.

Background and Aim of the Study: Severe aortic regurgitation (AR) is a contraindication for balloon aortic valvuloplasty (BAV). As the effects of mild and moderate AR are unknown, the study aim was to determine the effects of BAV in patients with mild and moderate AR., Methods: A total of 263 consecutive patients with symptomatic severe aortic stenosis (AS) who underwent BAV was included in the study. The patients were stratified into three groups according to their pre-procedural degree of AR, as assessed echocardiographically., Results: The study groups included pre-BAV with no AR (n = 76; 28.9%), mild AR (n = 180; 68.4%), and moderate AR (n = 7; 2.7%). There were no differences in the baseline characteristics of the groups, with a mean age of 81.9 +/- 9.0 years and a Society of Thoracic Surgeons score of 12.9 +/- 6.0. Among patients with no AR pre-BAV, 48.7% developed mild AR post-BAV, while 4.5% of those with mild AR pre-BAV developed moderate AR (p < 0.001). The majority of patients (93%) had mild AR both pre- and post-BAV. Only two patients developed severe AR post-BAV. A good agreement existed between the categories of AR pre- and post-BAV (weighted kappa = 0.54, 95% CI, 0.43-0.65). The degree of AR post-BAV did not impact on the mortality rates of mild AR (41.1%), moderate AR (46.9%), or severe AR (63.6%) (p = 0.31)., Conclusion: It is safe to perform BAV in patients with mild and moderate AR. About half of all patients with no AR may develop mild AR, the majority will remain in mild AR, and a small percentage will develop moderate or severe AR.