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Background: Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access., Objectives: This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR., Methods: Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups. Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centers were performed., Results: Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure. After matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access. The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centers., Conclusions: n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Aortopathy is common in patients with bicuspid aortic valve (BAV)., Aim: To evaluate the fate of unreplaced Valsalva sinuses in patients with BAV, 10 years after aortic valve replacement (AVR) with or without replacement of the ascending aorta (RAA)., Methods: We retrospectively reviewed all surgical patients with BAV who were operated on between January 2005 and December 2007. Patients who underwent AVR with or without RAA were included. Surgical data were entered prospectively. Ten-year clinical and echocardiographic follow-up data as well as survival data were collected by contacting the patients and their personal cardiologists, and by consulting the French national mortality registry. Overall, 25% of the patients had computed tomography angiographic assessment of the aortic root at follow-up., Results: A total of 133 patients with BAV were operated on within the selected period. Thirty-two patients did not meet the inclusion criteria, and had primary Valsalva sinus surgery. Twenty-four patients underwent AVR with RAA and 77 patients had isolated AVR; all of these 101 patients were included in the study. The median follow-up was 9 years (up to 12 years). During follow-up, eight patients (7.9%) underwent late reoperation; two of them (2.0%) required root surgery. Ten-year freedom from reoperation was 86.2±4.7%. Ten-year freedom from dilatation of the Valsalva sinuses (>45mm) was 86.6±5.2%. Ten-year cumulative survival was 83.5±4%., Conclusions: Ascending aorta and Valsalva sinuses seem to have different fates after AVR in BAV disease. When the Valsalva sinuses are not dilated at the initial surgery, the risk of secondary dilatation at 10 years is low. Preservation of the sinuses is therefore justified in patients with BAV with a non-dilated root. In BAV with isolated aortic insufficiency, a more aggressive approach may be justified, especially in young patients., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Aims: To compare the stiffness index in patients with bicuspid aortic valve (BAV) with first-degree relatives at each segment of the thoracic ascending aorta and to compare segmental analysis of aortic stiffness in association with BAV morphotype and function., Methods: 219 patients with BAV and 148 first-degree relatives (without BAV) were consecutively included at a reference centre for BAV. Ultrasound assessment of aortic and carotid stiffness was based on the variation of the segmental arterial diameters during the cardiac cycle and on blood pressure., Results: Without adjustment, the ascending aorta of patients with BAV seemed stiffer at each segment compared with controls (stiffness index at the sinus of Valsalva: 17.0±10.9 vs 8.9±6.1, p<0.001; tubular aorta: 20.4±31.3 vs 12.7±4.8, p=0.04). However, after adjustment on aortic diameter and age, only the sinus of Valsalva remained stiffer (p<0.001), whereas the tubular aorta no longer differed (p=0.610). In patients with BAV, aortic diameters were not influenced by the valve morphotype, except for the arch, which was more dilated in the case of 1- Non coronary sinus-Right subtype of BAV : 36.1 vs 27.6 mm, p<0.001. Aortic regurgitation was associated with an increase in aortic diameters at the sinus of Valsalva (p<0.001) and the tubular aortic levels (p=0.04)., Conclusion: Stiffness increase at the sinus of Valsalva level is independent of aortic dilatation in patients with BAV, contrary to the classic relationship between stiffness and dilatation found on the other segments. The relationship between stiffness and clinical impact needs to be assessed at each aortic segment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Surgical mortality and long-term outcomes are important considerations when determining strategies for multiple reoperations on the aortic valve (AV). With the rise of percutaneous valve-in-valve, we sought to evaluate the current outcomes of conventional surgery for AV reoperation, focusing first on the effect of the number of previous AV interventions with a subsequent analysis of the risk factors for adverse outcomes., Methods: From January 2007 to December 2016, 316 consecutive patients underwent an open redo operation (replacement) on their AV at a single centre. It was the first AV reintervention in 263 patients (Group 1), second in 42 patients (Group 2) and third or more in 11 patients (Group 3)., Results: There were 230 men and 86 women, with a median age of 58 (Q1-Q3: 46-70) years. Structural valve deterioration (SVD) of the bioprosthesis (n = 136, 44%), endocarditis (n = 57, 18%) and prosthetic valve dehiscence (n = 41, 13%) were the most common reasons for reintervention. Overall, in-hospital mortality was 7.3%: 7.2% in Group 1, 4.76% in Group 2 and 18.2% in Group 3 (P = 0.233) and ranged from 3.7% for SVD to 14.0% when endocarditis was the reason for reintervention. Higher preoperative New York Heart Association (NYHA) class (III/IV) [odds ratio (OR) 15.9, P = 0.011], injury during re-entry (OR 16.9, P = 0.015), endocarditis (OR 3.7, P = 0.038) and concomitant mitral valve replacement (OR 5.6, P = 0.006) were independent risk factors for in-hospital mortality. Survival at 8 years was 79.0 ± 3.0% for the entire cohort and 88.4 ± 3.2% for re-replacement after SVD., Conclusions: Multiple AV reoperations carry an acceptable risk of early postoperative mortality, particularly for isolated valve replacements of SVD.

Biological aortic valve thrombosis is an exceptional complication. A 64-year-old patient positive for human immunodeficiency virus presented for syncope on exertion, 2 years after an aortic bioprosthetic valve replacement and double coronary artery bypass. Transvalvular aortic mean gradient was approximately 50 mm Hg on echocardiogram and catheterization. Cardiac computed tomography scan showed a limited opening of the bioprosthesis cusps. Surgical exploration revealed thrombosis of the three cusps on the aortic side, limiting the opening of the valve. No relation could be established between the patient's human immunodeficiency virus status and valve thrombosis., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Stent deployment within stenotic native aortic valves has been shown to depend on valve anatomy (presence of bicuspid valve or not). This study investigated the influence of stent stiffness on stent expansion., Methods: The study included 88 patients with severe aortic stenosis, and 36 (41%) had bicuspid aortic valves. Two self-expandable stents with different radial force were deployed intraoperatively inside stenotic aortic valves before surgical aortic valve replacement. Patients in group B received a stent stiffer than that in group A. Effect of stent radial force on stent shape and incidence of paraprosthetic gaps was determined., Results: Noncircular stent deployment was more frequent in bicuspid (81%) than in tricuspid aortic valves (33%; p < 0.0001). Increasing stent radial force significantly improved stent shape in tricuspid valves (circular shape: 60% in group A vs 93% in group B; p = 0.005) but had no significant effect in bicuspid valves (12.5% in group A vs 27% in group B;p = 0.394). Likewise, incidence of paraprosthetic gaps was significantly reduced with the stiff stent in tricuspid valves (64% in group A vs 30% in group B, p = 0.025) but not in bicuspid valves (50% in group A vs 60% in group B; p= 0.722)., Conclusions: Increased stent radial force had a favorable effect on stent deployment in tricuspid but not in bicuspid valves. In bicuspid valves, stent maldeployment was constant. Leaflet distortion of implanted valved stent might be a concern in this setting., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background/introductionCurrently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure.PurposeTo assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD.MethodsPatients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age.ResultsWe considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p