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A 70-year-old female heart failure patient could not be weaned from temporary left ventricular mechanical support with Impella CP (Abiomed Inc, Danvers, MA) after myocardial infarction; therefore, she underwent left ventricular assist device implantation (HeartMate 3; Abbott, Chicago, IL). After uneventful surgery, the patient had an early postoperative thrombus in the aortic root, and surgical thrombectomy on extracorporeal circulation was performed on the seventh postoperative day. The patient recovered well and presented in good condition with no neurologic symptoms at the 6-month follow-up visit. Surgical excision of aortic root thrombus is a feasible option even for frail patients with a left ventricular assist device. Résumé: Après un infarctus du myocarde, une patiente de 70 ans présentant une insuffisance cardiaque n'a pas pu être sevrée d'une assistance mécanique temporaire pour le ventricule gauche par dispositif Impella CP (Abiomed Inc, Danvers, MA); elle a donc subi l'implantation d'un dispositif d'assistance ventriculaire gauche (HeartMate 3; Abbott, Chicago, IL). Après une intervention sans incident, la patiente a présenté un thrombus postopératoire précoce dans l'anneau aortique, et une thrombectomie chirurgicale sous circulation extracorporelle a été réalisée le septième jour suivant l'intervention. La patiente s'est bien rétablie et semblait en bonne santé, sans symptômes neurologiques, au moment de la visite de suivi six mois plus tard. L'excision chirurgicale du thrombus de l'anneau aortique est une option réaliste même chez les patients fragiles ayant un dispositif d'assistance ventriculaire gauche.

Summary Introduction: The Valve Academic Research Consor- tium (VARC) consensus document on outcome report- ing in transcatheter valves has recently been revised. We used these VARC-2 standardised endpoint defini- tions to report transcatheter aortic valve implantation (TAVI) outcome at our institution. Methods: The study included 350 consecutive patients undergoing TAVI at the University Hospital Zurich be- tween May 2008 and November 2012. The Edwards SAPIEN (n = 158; 45%), the Medtronic CoreValve (n = 189, 54%), and the Medtronic Engager (n = 3, 1%) pros- theses were implanted via either the transfemoral (83%) or the transapical (17%) access. Mean follow-up was 389 ± 405 days. Results: Device success within 72 hours was achieved in 88% of patients without significant differences be- tween access sites (p = 0.89) and prosthesis types (p = 0.24). Device failure was due to procedural mortality in 12 (3.4%) patients. In survivors, implantation of more than one prosthesis or malpositioning of the prosthesis was observed in six (1.7%) patients, an increased trans- valvular pressure gradient >20 mm Hg in four (1.1%) patients, and moderate aortic re- gurgitation in 19 (5.4%) patients, respectively. Severe aortic regurgi- tation was observed in one (0.3%) patient. All-cause mortality was 9.1% at 30 days (12.0% in the first half of the patients vs 6.3% in the second half; p = 0.07), and 21.2% at 1 year. The composite endpoint "early safety" was met in 67 (19.1%) patients at 30 days (23% in the first half of the patients vs 15% in the second half; p = 0.04). Stroke was o bserved in 2.9%, life-threatening bleeding in 4.6%, vascular compli- cations in 7.4% and acute renal failure in 5.7% of patients. Coro- nary obstruction was rarely observed (0.9%). Valve-re- lated dysfunction requiring repeat procedure occurred in two (0.6%) patients. With multivariate regression analysis, major and life-threatening bleeding within 30 days (hazard ratio (HR) 4.74, 95% confidence interval (CI) 2.03-11.07, p

Background— Endothelial dysfunction and injury are thought to play an important role in the progression of coronary artery disease (CAD). High-density lipoprotein from healthy subjects (HDL Healthy ) has been proposed to exert endothelial antiapoptotic effects that may represent an important antiatherogenic property of the lipoprotein. The present study therefore aimed to compare effects of HDL CAD and HDL Healthy on the activation of endothelial anti- and proapoptotic pathways and to determine which changes of the lipoprotein are relevant for these processes. Methods and Results— HDL was isolated from patients with stable CAD (HDL sCAD ), an acute coronary syndrome (HDL ACS ), and healthy subjects. HDL Healthy induced expression of the endothelial antiapoptotic Bcl-2 protein Bcl-xL and reduced endothelial cell apoptosis in vitro and in apolipoprotein E–deficient mice in vivo. In contrast, HDL sCAD and HDL ACS did not inhibit endothelial apoptosis, failed to activate endothelial Bcl-xL, and stimulated endothelial proapoptotic pathways, in particular, p38-mitogen-activated protein kinase–mediated activation of the proapoptotic Bcl-2 protein tBid. Endothelial antiapoptotic effects of HDL Healthy were observed after inhibition of endothelial nitric oxide synthase and after delipidation, but not completely mimicked by apolipoprotein A-I or reconstituted HDL, suggesting an important role of the HDL proteome. HDL proteomics analyses and subsequent validations and functional characterizations suggested a reduced clusterin and increased apolipoprotein C-III content of HDL sCAD and HDL ACS as mechanisms leading to altered effects on endothelial apoptosis. Conclusions— The present study demonstrates for the first time that HDL CAD does not activate endothelial antiapoptotic pathways, but rather stimulates potential endothelial proapoptotic pathways. HDL-proteome remodeling plays an important role for these altered functional properties of HDL. These findings provide novel insights into mechanisms leading to altered vascular effects of HDL in coronary disease.

ObjectivesThis study was undertaken to compare the hemodynamic performance of a percutaneous bioprosthesis to that of surgically implanted (stented and stentless) bioprostheses for the treatment of severe aortic stenosis.MethodsFifty patients who underwent percutaneous aortic valve implantation (PAVI) with the Cribier-Edwards or Edwards SAPIEN bioprosthetic valve (Edwards Lifesciences, Inc., Irvine, California) were matched 1:1 for sex, aortic annulus diameter, left ventricular ejection fraction, body surface area, and body mass index, with 2 groups of 50 patients who underwent surgical aortic valve replacement (SAVR) with a stented valve (Edwards Perimount Magna [SAVR-ST group]), or a stentless valve (Medtronic Freestyle, Medtronic, Minneapolis, Minnesota [SAVR-SL group]). Doppler echocardiographic data were prospectively obtained before the intervention, at discharge, and at 6- to 12-month follow-up.ResultsMean transprosthetic gradient at discharge was lower (p < 0.001) in the PAVI group (10 ± 4 mm Hg) compared with the SAVR-ST (13 ± 5 mm Hg) and SAVR-SL (14 ± 6 mm Hg) groups. Aortic regurgitation (AR) occurred more frequently in the PAVI group (mild: 42%, moderate: 8%) compared with the SAVR-ST (mild: 10%, moderate: 0%) and SAVR-SL (mild: 12%, moderate: 0%) groups (p < 0.0001). At follow-up, the mean gradient in the PAVI group remained lower (p < 0.001) than that of the SAVR-ST group, but was similar to that of the SAVR-SL group. The incidence of severe prosthesis-patient mismatch was significantly lower (p = 0.007) in the PAVI group (6%) compared with the SAVR-ST (28%) and SAVR-SL (20%) groups. However, the incidence of AR remained higher (p < 0.0001) in the PAVI group compared with the 2 other groups.ConclusionsPAVI provided superior hemodynamic performance compared with the surgical bioprostheses in terms of transprosthetic gradient and prevention of severe prosthesis-patient mismatch, but was associated with a higher incidence of AR.

Background We reported the first case of successful transapical transcatheter aortic valve implantation in a human subject in 2005 and have now completed a 12-month follow-up on our first 26 patients. This is, to date, the longest follow-up of patients undergoing transapical aortic valve implantation. Methods Between October 2005 and January 2007, 26 patients (13 female) underwent transcatheter transapical aortic valve implantation with either 23- or 26-mm Edwards Lifesciences transcatheter bioprostheses. All patients with symptomatic aortic stenosis were declined for conventional aortic valve replacement because of unacceptable operative risks and were not candidates for transfemoral aortic valve implantation because of poor arterial access. Clinical and echocardiographic follow-up was performed before discharge and at 1, 6, and 12 months. Data from the 17 patients who survived over 12 months were used for comparisons of the baseline and follow-up results. Results The mean age was 80 ± 9 years, and the predicted operative mortality was 37% ± 20% by using logistic EuroSCORE and 11% ± 6% by using the Society of Thoracic Surgeons Risk Calculator. Valves were successfully implanted in all patients. Six patients died within 30 days (30-day mortality, 23%), and 3 patients died from noncardiovascular causes after 30 days (late mortality, 12%). Among patients who survived at least 30 days, 12-month survival was 85%. There were no late valve-related complications. New York Heart Association functional class improved significantly. The aortic valve area and mean gradient remained stable at 12 months (1.6 ± 0.3 cm 2 and 9.6 ± 4.8 mm Hg, respectively). Conclusion Our 1-year clinical and echocardiographic outcomes suggest that transapical transcatheter aortic valve implantation is a viable alternative to conventional aortic valve replacement in selected high-risk patients.

Objectives: Early clinical outcomes in selected high-risk patients undergoing catheter-based aortic valve replacement (AVR) compare favorably with conventional surgical AVR. Improved understanding of the mechanisms of success and failure of transcatheter AVR will likely improve outcomes further. To this end, we examined our experience during the developmental phases of transcatheter AVR and describe the causes and management of prosthetic valve malposition. Methods: Transcatheter balloon-expandable AVR was performed in 170 patients at two centers. Malposition was defined as prosthetic valve implantation in a location other than within the native valve. Patients were prospectively identified and followed as part of an ongoing database. Results: Valve malposition occurred in 9 of 170 patients (5.3%). Final position was supravalvular in eight of nine cases. In all cases, embolization to the ascending aorta occurred within a few cardiac cycles following deployment. Importantly, late embolization was not observed. In most cases, the prosthesis was uneventfully repositioned in the more distal aorta. Positioning was subvalvular in one patient (0.6%), resulting in a severe regurgitation with residual native valve stenosis. Implantation of a second transcatheter valve was attempted in six patients and was successful in all. Conventional AVR was performed in two patients, with early mortality in one. At late follow-up (mean 412 days), seven of nine patients remain alive (78%) with a functioning prosthesis and relief of aortic stenosis. Conclusions: Malposition of current balloon-expandable aortic valves is a largely preventable complication. An improved understanding of the procedure will likely minimize this possibility and mitigate the consequences should malposition occur. © 2008 Wiley-Liss, Inc.

Objectives Transcatheter aortic valve replacement (AVR) is a promising approach to aortic valve disease. The implications of this new therapy are not entirely known. We describe the potential for the development of new atrioventricular (AV) block. Background Atrioventricular block is a known complication of conventional surgical AVR. Block is presumed to occur as a consequence of surgical trauma to the cardiac conduction tissue during excision of the diseased aortic valve and debridement of the calcified annulus. Whether AV block might occur as a consequence of nonsurgical implantation of an aortic stent valve is unknown. Methods We reviewed our experience with patients undergoing transcatheter AVR using both the percutaneous transarterial and the open-chest direct left ventricular apical ventriculotomy approaches. Patients were considered at high risk for conventional surgery because of comorbidities. Continuous arrhythmia monitoring was performed for at least 48 h after the valve implantation procedure. Patients who developed apparently new, clinically significant AV block were identified. Results Transcatheter AVR was successfully performed in 123 patients. Seventeen of these patients (13.8%) had pre-existing permanent pacemakers. Two patients (1.6%) required pacemaker implantation because of pre-existing intermittent bradycardia. Seven patients (5.7%) developed new and sustained complete AV block requiring pacemaker implantation. An additional 4 patients (3.3%) developed new and sustained left bundle branch block but did not require pacemaker implantation. Conclusions As with conventional AVR surgery, transcatheter AVR may result in impaired atrioventricular conduction. Physicians and patients should be aware of the potential for AV block and pacemaker dependence.

Background— Percutaneous aortic valve replacement represents an endovascular alternative to conventional open heart surgery without the need for sternotomy, aortotomy, or cardiopulmonary bypass. Methods and Results— Transcatheter implantation of a balloon-expandable stent valve using a femoral arterial approach was attempted in 50 symptomatic patients with severe aortic stenosis in whom there was a consensus that the risks of conventional open heart surgery were very high. Valve implantation was successful in 86% of patients. Intraprocedural mortality was 2%. Discharge home occurred at a median of 5 days (interquartile range, 4 to 13). Mortality at 30 days was 12% in patients in whom the logistic European System for Cardiac Operative Risk Evaluation risk score was 28%. With experience, procedural success increased from 76% in the first 25 patients to 96% in the second 25 ( P =0.10), and 30-day mortality fell from 16% to 8% ( P =0.67). Successful valve replacement was associated with an increase in echocardiographic valve area from 0.6±0.2 to 1.7±0.4 cm 2 . Mild paravalvular regurgitation was common but was well tolerated. After valve insertion, there was a significant improvement in left ventricular ejection fraction ( P P =0.01), and functional class ( P Conclusion— Percutaneous valve replacement may be an alternative to conventional open heart surgery in selected high-risk patients with severe symptomatic aortic stenosis.

OBJECTIVES: Aortic valve calcification and changes after transcatheter aortic valve implantation (TAVI) were specifically assessed by computed tomography (CT). The main difference between TAVI and the conventional technique is the compression of the cusps of the calcified native valve against the aortic wall before implantation. The objective of this study was to quantify the segmented calcification in the area of the basal annular plane before and after TAVI. METHODS: The CT scans of 20 patients (13 male and 7 female; mean age: 82.9±8.1 years) were assessed. The aortic valve calcification was segmented; derived from this segmentation volume, mass and Hounsfield units (HU)/density of the calcifications on the annulus and cusps before and after TAVI were evaluated. Pre- and postoperative data were compared regarding potential calcification loss and calcification distances to the left and right coronary ostia. RESULTS: Significantly lower postprocedural mean volumes and masses for all cusps (P< 0.001) were found. The mean differences in the volume for the non-coronary, right-coronary and left-coronary cusp were �156.8 ± 53.73, �155.5 ± 62.54 and �115 ± 57.53 mm 3 , respectively, and differences in mass were �88.78 ± 29.48, �95.2 ± 39.27 and �71.56 ± 35.62 mg, respectively. Over all cusps, mean HU increased after intervention [784.41 ± 92.5 HU (pre) and 818.63 ± 78.71 HU (post); P< 0.004]. In 80.03% of all cusps, calcification loss was found; all patients were affected. Significantly lower (P< 0.047) postprocedural mean distances were found from the left and right coronary ostia to the next calcification point. CONCLUSIONS: Our results show a significant loss of calcification in all patients after TAVI, with a reduction in the calcification distances to the coronary ostia and the compression of calcification in the area of the device landing zone. The clinical implications of this finding need to be investigated further.

Objectives: Transcatheter aortic valve implantation (TAVI) has become an established therapy for severe aortic stenosis (AS) in high-risk elderly individuals. Concomitant coronary artery disease (CAD) is frequently encountered in this patient population and may have an impact on outcomes. Hence, in patients with both severe AS and CAD, a bespoke therapy of both AS and/or CAD appears mandatory. Methods: We report a series of 5 patients with severe AS and concomitant CAD considered for TAVI who underwent fractional flow reserve (FFR) for hemodynamic assessment of coronary lesions. Results: In 3 patients, a 2-staged procedure was undertaken with FFR measurements at the time of invasive assessment and TAVI thereafter. In the remaining 2 patients, FFR measurements were performed immediately prior to the TAVI procedure with deferral of percutaneous coronary intervention (PCI) in one and ad hoc PCI in the other patient. All 5 patients had uneventful FFR measurements and procedural TAVI outcomes. One patient with a staged approach noted a significant improvement in symptoms already after PCI. Conclusions: FFR provides an effective and safe strategy to assess hemodynamic significance of coronary lesions in patients with severe AS and concomitant CAD considered for TAVI.

Transcatheter aortic valve implantation (T-AVI) has shown good results in high-risk patients with severe aortic stenosis. Throughout the whole process of T-AVI, different imaging modalities are indispensable. Preoperatively, multislice computed tomography, angiography and transesophageal echo (TEE) are utilized for patient selection, valve selection, approach selection and the planning of implant placement. Intraoperatively, angiography and TEE are used for controlling placement of the guidewire and valve positioning. Quality control and follow-up require TEE imaging and can require additional CT or angiography studies. In the first half of this paper, we discuss the applicability of different imaging modalities for T-AVI in the light of the current best practice. In the second half of this paper, we present an overview on research projects in medical engineering which aim at development of image-based methods for increasing patient safety during T-AVI. Template-based implantation planning, as it is applied in dental, orthopedic and other surgical disciplines, is proposed as an aid during implant selection in order to help reduce the incidence of complications such as atrioventricular node block and paravalvular leaks. Current research tries to apply state-of-the-art engineering techniques, such as computational fluid dynamics to optimize valve selection and positioning. For intraoperative assistance during valve positioning, real-time image processing methods are proposed to track target landmarks and the stented valve., Aswan Heart Centre Science & Practice Series, 2011 (1), ISSN:2220-2730

An 81-year-old woman was referred for NSTEMI complicated by cardiogenic shock. Urgent invasive assessment revealed a subtotal left anterior descending artery (LAD) stenosis, severe aortic stenosis (mean gradient 60 mmHg, aortic valve area 0.5 cm2), decreased left ventricular (LV) function [left ventricular ejection fraction (LVEF) 49%], grade 3+ mitral regurgitation (MR), and severe pulmonary hypertension. In view of her critical situation, acute LAD–percutaneous coronary intervention and aortic valvuloplasty were performed with …

Aims Inflammation plays a key role in acute coronary syndromes (ACS). Toll-like receptors (TLR) on leucocytes mediate inflammation and immune responses. We characterized leucocytes and TLR expression within coronary thrombi and compared cytokine levels from the site of coronary occlusion with aortic blood (AB) in ACS patients. Methods and results In 18 ACS patients, thrombi were collected by aspiration during primary percutaneous coronary intervention. Thrombi and AB from these patients as well as AB from 10 age-matched controls without coronary artery disease were assessed by FACS analysis for cellular distribution and TLR expression. For further discrimination of ACS specificity, seven non-coronary intravascular thrombi and eight thrombi generated in vitro were analysed. In 17 additional patients, cytokine levels were determined in blood samples from the site of coronary occlusion under distal occlusion and compared with AB. In coronary thrombi from ACS, the percentage of monocytes related to the total leucocyte count was greater than in AB (47 vs. 20%, P = 0.0002). In thrombi, TLR-4 and TLR-2 were overexpressed on CD14-labelled monocytes, and TLR-2 was increased on CD66b-labelled granulocytes, in comparison with leucocytes in AB. In contrast, in vitro and non-coronary thrombi exhibited no overexpression of TLR-4. Local blood samples taken under distal occlusion revealed elevated concentrations of chemokines (IL-8, MCP-1, eotaxin, MIP-1α, and IP-10) and cytokines (IL-1ra, IL-6, IL-7, IL-12, IL-17, IFN-α, and granulocyte-macrophage colony-stimulating factor) regulating both innate and adaptive immunity (all P < 0.05). Conclusion In ACS patients, monocytes accumulate within thrombi and specifically overexpress TLR-4. Together with the local expression patterns of chemokines and cytokines, the increase of TLR-4 reflects a concerted activation of this inflammatory pathway at the site of coronary occlusion in ACS.

Introduction. For pulmonary vein isolation in patients with atrial fibrillation (AF), some centers use the double transseptal puncture technique for catheter access in order to facilitate catheter manipulation within the left atrium. However, no safety data has so far been published using this approach.Method. 269 ablation procedures were performed in 243 patients (mean age years, 75% men) using the double transseptal puncture for catheter access in all cases. Patients were considered for ablation of paroxysmal (80%), persistent (19%), and permanent (1%) AF. 230 procedures were performed on an outpatient basis (85.5%), and 26 were repeat procedures (9.7%).Results. The double transseptal puncture catheter access was successfully achieved in all patients. The procedural success with the endpoint of pulmonary vein isolation was reached in 255 procedures (95%). A total of 1048 out of 1062 pulmonary veins (99%) were successfully isolated. Major complications occurred in eight patients (3.0%). Of these, seven patients (2.6%) had pericardial effusion requiring percutaneous drainage, and one patient (0.4%) suffered a minor reversible stroke. One patient (0.4%) had a minor air embolism with transient symptoms.Conclusion. The double transseptal puncture catheterization technique allows easy catheter manipulation within the left atrium to reach the goal of acute procedural success in AF ablation. Procedure-related complications are rare, and the technique can be used safely for AF ablation in the outpatient setting.

Background— Transcatheter aortic valve implantation is an alternative to open heart surgery in patients with aortic stenosis. However, long-term data on a programmatic approach to aortic valve implantation remain sparse. Methods and Results— Transcatheter aortic valve implantation was performed in 168 patients (median age, 84 years) in the setting of severe aortic stenosis and high surgical risk. Access was transarterial (n=113) or, in the presence of small iliofemoral artery diameter, transapical (n=55). The overall success rate was 94.1% in this early experience. Intraprocedural mortality was 1.2%. Operative (30-day) mortality was 11.3%, lower in the transarterial group than the transapical group (8.0% versus 18.2%; P =0.07). Overall mortality fell from 14.3% in the initial half to 8.3% in the second half of the experience, from 12.3% to 3.6% ( P =0.16) in transarterial patients and from 25% to 11.1% ( P =0.30) in transapical patients. Functional class improved over the 1-year postprocedure period ( P 3 years and a median of 221 days, structural valve failure was not observed. Conclusions— Transcatheter aortic valve implantation can result in early and sustained functional improvement in high-risk aortic stenosis patients. Late outcome is determined primarily by comorbidities unrelated to aortic valve disease.

Objectives: We describe the outcome of 168 patients with severe symptomatic aortic stenosis treated with transcatheter aortic valve implantation (TAVI). This cohort includes the first in man transarterial and off-pump transapical patients. Methods: The balloon-expandable aortic prosthesis was implanted via the femoral artery or left ventricular apex in 113 and 58 patients respectively. Data are described as 1–57, 58 –114 femoral and 1–58 apical procedures, respectively. Clinical and echocardiographic follow-up occurred at 1, 6, 12, and 24 months. Unsuccessful cases were censored at 30 days. Results: Mean age was 82.5 years (range 50 –97) with 57% males. Procedural success was 94.2% [88%, 96%, & 98%] with no unsuccessful procedures in the last 46 cases. One patient had a successful transfemoral procedure after a prior failure, and 3 patients had successful transapical procedures following failed transfemoral attempts. Logistic EuroSCORE and STS predicted 30-day surgical mortality was 31% [28.4%, 29.1% & 36%], and 10.4% [8.9%, 9.6% & 12.6%] respectively. Observed 30-day mortality was 10.5% [10.5%, 3.5%, & 17.2%], and 0% in the last 39 trans-femoral cases. Intra-procedural mortality was 1.1% [1.8%, 0% & 1.7%]. Peri-procedural stroke occurred in 4% [3.5%, 7%, & 1.7%]. Median hospital stay was 5 days [4, 5, & 7]. Survival at 1, 6, 12 and 24 months was 88%, 80%, 74% [73.9%, 84%, & 65.6%] and 61%. AVA, MG, LVEF and MR significantly improved post TAVI (Table 1 ), and MR, EF, and NYHA class significantly improved during follow-up. MG did not increase during follow-up, but AVA decreased slightly at 1 year (mean difference: 0.2±0.54cm 2 , p=0.04). Mild paravalvular AR was common but severe AR was not observed post-implant or at follow-up. Conclusion: TAVI provides sustained clinical benefit for up to 2 years in patients with symptomatic severe AS and high operative risk. Procedural outcome continues to improve with experience and device development. Table 1: Echocardiographic follow-up

CLINICAL SUMMARY An 88-year-old man with symptomatic severe aortic stenosis underwent percutaneous TAVI with a 26-mm SAPIEN valve (Edwards Lifesciences LLC, Irvine, Calif). Comorbid conditions included coronary artery bypass with patent retrosternal grafts, transient ischemic attacks, bilateral carotid endarterectomies, atrial fibrillation, repaired abdominal aneurysm, prostate cancer, and renal failure. Estimated 30day mortality for AVR was 35% by means of logistic EuroSCORE and 11.1% by means of the Society of Thoracic Surgeons National Database Risk Calculator. The procedure was performed without difficulty, but the final valve position was suboptimal, being slightly low (ventricularly), with the ventricular aspect of the stent abutting the anterior leaflet of the mitral valve (MV). Moderate paravalvular aortic regurgitation (AR) was treated with repeated balloon redilation without altering the valve position. Six-month transthoracic echocardiographic analysis showed trivial AR and mitral regurgitation. The patient presented 11 months after implantation with fever and Streptococcus angiosus in blood cultures. Also noted were a dental visit 6 weeks before and lack of compliance with endocarditis prophylaxis. Transesophageal echocardiographic analysis demonstrated mild-to-moderate paravalvular AR, a 13 3 8–mm ruptured anterior mitral leaflet aneurysm contiguous with the aortic prosthesis, and severe mitral regurgitation (Figure 1). Redo sternotomy was performed during cardiopulmonary bypass after cannulating the right axillary artery and right internal jugular vein. The bioprosthesis was well-seated below the coronary arteries with incomplete endothelialization of the uppermost struts and covered with nodular excrescences (Figure 2). It withstood extraction while fully expanded but was removable when grasped with forceps, which were

Ageing is an independent risk factor for the development of cardiovascular disease. The ageing process is known to be associated with increased oxidative stress and an increased risk for cardiovascular and other diseases, such as cancer. To delay this process, therapeutic strategies involving the use of naturally occurring antioxidants, such as vitamin A, have gained considerable interest. Therefore, we wanted to investigate in a model of mammalian ageing whether changes in tissue and plasma levels of vitamin A occur with increasing age. This would constitute a prime rationale for its dietary supplementation. Experiments were performed in three different age groups (4-6 months old, 19 months old, 32-35 months old) of F1 (F344 x BN) healthy male rats that were fed a normal diet without any additional supplementation. Vitamin A and carotenoids in plasma and major organs were measured by reverse-phase high-performance liquid chromatography. In 3-year-old rats, vitamin A levels were found to be decreased in plasma (P < 0.0001) as compared with young and middle-aged animals. However, they were markedly increased in the main storage organ (ie, the liver) (P < 0.01-0.0001), and also in the aortic vessel wall. They were undetectable in the heart, irrespective of age. Increased tissue levels of vitamin A, especially in the vasculature, may be part of an age-associated self-regulatory process of adaptation, possibly as a counter-regulation against oxidative tissue damage. Based upon the assumption that in elderly humans, as in our animal model, a similar demand-regulated mechanism may work independently of additional dietary vitamin A supplementation, one may question the strategy of large clinical interventional trials using vitamin A or its derivatives beyond normal dietary intake.