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ObjectiveWe sought to determine the clinical outcomes of patients undergoing surgical aortic valve replacement with hemodynamically confirmed severe pulmonary hypertension and aortic stenosis and compare them with the outcomes of patients not undergoing aortic valve replacement and patients undergoing aortic valve replacement with mild-to-moderate pulmonary hypertension.MethodsA total of 317 patients with severe aortic stenosis (aortic valve area 35 mm Hg) was present in 81 patients, of whom 35 (43.2%) underwent surgical aortic valve replacement. We compared the clinical outcomes of these 35 patients with the 46 patients with severe pulmonary hypertension who did not undergo surgical aortic valve replacement.ResultsThirty-day mortality after aortic valve replacement was 2.85% in patients with severe pulmonary hypertension and 10.86% in patients not undergoing aortic valve replacement (P = .001). During a mean follow-up of 339.0 ± 343.7 days, overall mortality in patients undergoing aortic valve replacement was 14.2% in patients with severe pulmonary hypertension and 50% in patients with severe pulmonary hypertension who did not undergo aortic valve replacement (P

Objective Many high-risk patients with severe symptomatic aortic stenosis are not referred for surgical aortic valve replacement. Although this patient population remains ill-defined, many of these patients are now being referred for percutaneous aortic valve replacement. We sought to define the characteristics and outcomes of patients referred for percutaneous aortic valve replacement. Methods Between February 2006 and March 2007, 92 patients were screened for percutaneous aortic valve replacement. Clinical and echocardiographic characteristics of patients undergoing surgical aortic valve replacement, percutaneous aortic valve replacement, balloon aortic valvuloplasty, or no intervention were compared. The primary end point was all-cause mortality. Results Nineteen patients underwent successful surgical aortic valve replacement, 18 patients underwent percutaneous aortic valve replacement, and 36 patients had no intervention. Thirty patients underwent balloon aortic valvuloplasty, and of these, 8 patients were bridged to percutaneous aortic valve replacement and 3 were bridged to surgical aortic valve replacement. Of the remaining 19 patients undergoing balloon aortic valvuloplasty, bridging to percutaneous aortic valve replacement could not be accomplished because of death (n = 9 [47%)], exclusion from the percutaneous aortic valve replacement protocol (n = 6 [32%]), and some patients improved after balloon aortic valvuloplasty and declined percutaneous aortic valve replacement (n = 4 [21%]). The most common reasons for no intervention included death while awaiting definitive treatment (n = 10 [28%]), patient uninterested in percutaneous aortic valve replacement (n = 10 [28%]), and questionable severity of symptoms or aortic stenosis (n = 9 [25%]). Patients not undergoing aortic valve replacement had higher mortality compared with those undergoing aortic valve replacement (44% vs 14%) over a mean duration of 220 days. Conclusion Symptomatic patients with severe aortic stenosis have high mortality if timely aortic valve replacement is not feasible. Twenty percent of the patients referred for percutaneous aortic valve replacement underwent surgical aortic valve replacement with good outcome. Patients undergoing balloon aortic valvuloplasty alone or no intervention had unfavorable outcomes.

Objective Percutaneous aortic valve replacement is an emerging therapy for selected patients with severe aortic stenosis. Preoperative imaging of the aortic root facilitates sizing and deployment of the percutaneous aortic valve replacement device. We compared morphologic characteristics of the aortic root in patients with aortic stenosis versus elderly gender-matched controls using multidetector computed tomography. Methods Twenty-five consecutive subjects with severe calcific aortic stenosis referred for percutaneous aortic valve replacement and 25 elderly gender-matched controls were scanned on a Siemens Definition Dual Source (Siemens Medical, Forchheim, Germany) multidetector computed tomography scanner. Distances from the valve annulus to the coronary artery ostia and sinotubular junction, dimensions of the aortic root, and characteristics of the valve cusps were determined. Results Subjects with aortic stenosis had reduced distance from the aortic valve annulus to the inferior margins of the left and right coronary artery ostium and sinotubular junction compared with controls. There were no significant differences in cross-sectional dimensions of the aortic root. Conclusion The distance from the aortic valve annulus to the coronary artery ostia and sinotubular junction is reduced in patients with aortic stenosis compared with controls. This finding suggests that longitudinal remodeling of the aortic root occurs in calcific aortic stenosis and has implications for the design and deployment of percutaneous aortic valve replacement devices.

There has long been a need for a biologic valve that is easy to insert, safe, and durable, with low transvalvular pressure gradients and no anticoagulation requirement. Despite recent advances in biologic valve leaflet treatments with glutaraldehyde, alcohol, ethylene, and surfactant, biologic valves are not routinely recommended—particularly for younger patients—because of the risk of valve leaflet failure with time. This report describes a valve with an easy-toinsert base and exchangeable biologic leaflet set with low pressure gradients to allow the easier replacement of leaflets.

ObjectiveIn patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate.MethodsFrom January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs.ResultsPatients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P = .001) and postoperative (7.1 vs 6.1 days, P

Objectives Techniques employed today concomitantly with left-sided heart valve surgery address secondary tricuspid valve regurgitation at 3 anatomic levels—annulus, commissure, and leaflet—although success of these alone or in combination in eliminating tricuspid regurgitation is uncertain. Our objective was to assess the comparative effectiveness of these techniques in reducing or eliminating secondary tricuspid regurgitation. Methods From 1990 to 2008, 2277 patients underwent tricuspid valve procedures for secondary tricuspid regurgitation concomitantly with mitral (n = 1527, 67%), aortic (n = 180, 7.9%), or combined (n = 570, 25%) valve surgery. These included annulus (flexible prosthesis [n = 1052, 46%], rigid prosthesis [standard = 387, 3-dimensional = 197; 26%], Peri-Guard annuloplasty [Synovis Surgical Innovations, St Paul, Minn; n = 185, 8.1%], and De Vega suture [n = 129, 5.7%]), commissure (Kay [n = 248, 11%]), and leaflet (edge-to-edge suture [n = 79, 3.5%] ± annulus or commissural) procedures. A total of 4745 postoperative transthoracic echocardiograms in 1965 patients were analyzed. Results By 3 months after surgery, only 32% of patients overall had no tricuspid regurgitation. However, by 5 years, this had decreased to 22%, and 3+/4+ tricuspid regurgitation had increased from 11% at 3 months to 17%. Patients with rigid ring annuloplasty alone, either standard or 3-dimensional, had the least increase of 3+/4+ tricuspid regurgitation (to 12% at 5 years) compared with either a commissural or leaflet procedure. Conclusion Rigid prosthetic ring annuloplasty, standard or 3-dimensional, provides early and sustained reduction of tricuspid regurgitation secondary to left-sided valve disease without need for an additional leaflet procedure. However, results are imperfect, possibly because other anatomic levels (subvalvular, papillary muscle, and right ventricular) contributing to its pathophysiology are unaddressed.