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Die transkatheter Aortenklappenimplantation (TAVI) ist ein relativ junges, jedoch nunmehr etabliertes Verfahren zur Behandlung von Patienten mit hochgradiger Aortenklappenstenose und hohem operativen Risiko. Ungeachtet der rasanten Fortschritte mit immer besser werdenden Resultaten, ist eine sorgfaltige Evaluation fur eine optimale Therapieplanung unverzichtbar. Sobald das Vorliegen einer hochgradigen, symptomatischen Aortenklappenstenose gesichert ist, sollte eine Einschatzung des individuellen Risikos erfolgen. Ist schlieslich die Indikation fur eine TAVI gestellt, wird im nachsten Schritt eine Computertomografie der Aortenwurzel und der Aorta einschlieslich der Femoralarterien durchgefuhrt. Hieraus entscheidet sich die technische Durchfuhrbarkeit einer TAVI, sowie die Wahl des Zugangsweges und der Klappenprothese. Die fortschrittliche Bildgebung tragt der zunehmenden Vielfalt an Klappenprothesen Rechnung, ermoglicht sie doch eine sehr differenzierte Therapie mit einer auf die individuelle Anatomie zugeschnittenen Selektion der Prothese. Voraussetzung hierfur ist allerdings ist eine ausreichende Erfahrung in der Verwendung der verschiedenen Klappensysteme.

Due to limited case numbers, severe Direct flow™ transcatheter device restenosis is, until now, a rare event with unknown long-term incidence, but challenging several treatment strategies. This case report gives an overview of possible interventional treatment considerations in this context that might occur more often in the future due to expected valve deterioration processes in the next years.

Uvod: Bolesti srčanih zalistaka rasprostranjene su diljem cijeloga svijeta te povezane s velikom stopom pobola i smrtnosti. Kirurška zamjena zalistaka najvažniji je način liječenja bolesti srčanih zalistaka. Jedna od najvažnijih komplikacija liječenja jest disfunkcija umjetnoga srčanog zalistka, što zahtijeva brzu dijagnozu i liječenje. U ovoj smo studiji istraživali etiologiju, strategije i ishode liječenja u seriji bolesnika s disfunkcijom umjetnoga srčanog zalistka. Bolesnici i metode: Ova je presječna, analitičko-opisno studija uključivala 63 slučaja u 52 bolesnika s disfunkcijom umjetnoga srčanog zalistka. Upitnikom su prikupljeni podatci o koagulacijskom statusu te demografski, klinički podatci. Zabilježeni su i podatci o liječenju, ishodima liječenja te o učestalosti ponovne hospitalizacije. Podatci su analizirani primjenom programa SPSS 20. Rezultati: U ovoj je populacijskoj studiji prosječna dob bila 49,98 ± 14,31, a 53,9 % bolesnika bile su žene. Od ukupno 63 slučaja, 57 ih je imalo disfunkciju mehaničkog zalistka, a 6 bolesnika disfunkciju na biološkom zalistku. Svi slučajevi disfunkcije bili su uzrokovani trombozom. Kirurški su zahvati bili najčešća metoda i bili su povezani s odličnim ishodima u usporedbi s drugim strategijama liječenja (p = 0,002). U ovoj smo studiji proučavali prihvatljive ishode za trombolitičku terapiju. Zaključak. Tromboza je bila najčešći uzrok disfunkcije umjetnoga srčanog zalistka, najvjerojatnije uzrokovana neadekvatnim antikoagulantnim liječenjem. Može se zaključiti da je za smanjenje disfunkcije nužna edukacija i praćenje bolesnika radi točnog utvrđivanja koagulacijskog statusa. Također smo zamijetili da su kirurški zahvati bili mnogo uspješniji od drugih oblika liječenja., Background: Valvular heart diseases are common worldwide and are associated with a high rate of mortality and morbidity. Surgical valve replacement is the most important treatment for valvular diseases. One of the most important complications of this treatment is prosthetic valve malfunction which requires rapid diagnosis and treatment. In this study, we examined the etiologies, treatment strategies, and treatment outcomes in a series of patients with prosthetic valve malfunction. Patients and Methods: In this cross-sectional, analytic-descriptive study, 63 cases in 52 patients with prosthetic valve malfunction were included. Their coagulation status, demographic, and clinical information was collected in a questionnaire. Patients treatment and their outcomes or rehospitalization rate was recorded as well. Data were analyzed using SPSS 20 software. Results: In our study population, average age was 49.98±14.31, and 53.9% of patients were women. Among 63 cases, 57 of them had mechanical valve malfunction and 6 of them had biological valve malfunction. All cases of mechanical valve malfunction were caused by thrombosis. Surgery was the most common treatment strategy and was associated with excellent outcomes compared with other strategies (p=0.002). In this study, we observed acceptable outcomes for thrombolytic therapy. Conclusion: Thrombosis was the most frequent cause of prosthetic valve malfunction in this study, which seems to be due to inadequate anticoagulant therapy. It can be concluded that educating and following patients for their accurate coagulation status is necessary for decreasing prosthetic valve malfunction. We also found surgical treatment to be significantly better than other treatments.

El procedimiento de Manougian es una de las técnicas empleadas para la ampliación del anillo aórtico en los casos de anulus pequeño o discordancia válvulo-protésico-paciente, que se utiliza con el fin de implantar una válvula de mayor tamaño y así evitar las complicaciones derivadas de una prótesis pequeña para el área corporal del paciente. Se presenta el caso de una mujer adulta joven con antecedente de reemplazo valvular aórtico el cual se encuentra con estenosis severa, quien presenta en el intraoperatorio un anillo valvular estrecho que requiere de las técnicas de ampliación del anillo aórtico para la implantación de una prótesis adecuada.

Background Increasing attention has been given to patients with blood stream infection (BSI) and the concurrent prevalence of infective endocarditis (IE). However, there exist a gap in knowledge on the prevalence of IE among patients with a left-sided heart valve prosthesis and BSI. Purpose To examine the prevalence between different BSI and IE in patients with a left-sided heart valve prosthesis. Methods By linking Danish nationwide registries, we were able to identify patients with a left-sided prosthetic heart valve and first-time BSI of interest (Enterococcus faecalis, Staphylococcsus aureus, streptococci species (spp.), and coagulase negative staphylococci [CoNS]) in the period of 2010–2016. Concurrent admission for IE was identified from the Danish National Patient Registry in a period of up to 14 days after the BSI. Results A total of 1,465 patients with BSI were included (1,319 patients with an aortic valve prosthesis [82.6% bioprosthetic] and 146 patients with a mitral valve prosthesis [48.6% bioprosthetic]). Among the included patients, 244 had E. faecalis (median age: 78.3 years, 77.0% male), 301 had S. aureus (median age: 76.9 years, 69.1% male), 401 had streptococci spp. (median age: 78.0 years, 69.1% male) and 519 had CoNS (median age: 76.4 years, 64.2% male). The percentage of patients with a diagnosis of IE in relation to the BSI was 44.3%, 33.6%, 34.4%, and 7.9% for E. faecalis, S. aureus, streptococci spp., and CoNS, respectively. No difference in the overall results was seen by type of valve prosthesis, sex, or age group. Percentage of patients with endocarditis Conclusion In patients with a left-sided heart valve prosthesis, IE was diagnosed in almost half of the patients with E. faecalis, in 1/3 with S. aureus or streptococci spp. and in 1 in 12 with CoNS BSI. Future studies may try to explain why some microbes are more likely to cause prosthetic heart valve endocarditis, than others are.

Background: The safety of next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) with a self-expandable valve is unknown. We investigated the safety of NDD after TAVR in patients who received a self-expandable valve or balloon-expandable valve. Methods and Results: We retrospectively evaluated consecutive patients who underwent elective minimalist TAVR between January 2017 and July 2018. We investigated the success rates and predictors of NDD after TAVR. Ninety-day and 1-year outcomes in patients managed with NDD after self-expandable ACURATE neo or balloon-expandable SAPIEN 3 replacement were compared. In 315 TAVRs, 249 patients received an ACURATE neo (n=146) or SAPIEN 3 (n=103) valve. There were no differences in baseline characteristics. In the ACURATE neo and SAPIEN 3 groups, NDD was achieved in 60% (n=87) and 55% (n=57) of patients, respectively ( P >0.50). Predictors of NDD included chronic obstructive pulmonary disease (odds ratio, 0.49; 95% CI, 0.25–0.94) and low pre-TAVR hemoglobin (odds ratio, 0.98; 95% CI, 0.96–0.99) but not type of valve (odds ratio, 1.20; 95% CI, 0.71–1.98 for ACURATE neo). After excluding non-NDD cases, there were no significant differences in 90-day mortality (0% versus 0%; P >0.90) or new pacemaker implantation (1% versus 0%; P >0.40) between ACURATE neo and SAPIEN3, respectively. No significant difference in 1-year mortality between ACURATE neo and SAPIEN 3 groups after NDD (8% versus 10%; log-rank, P >0.80) was observed. Conclusions: The safety of NDD using ACURATE neo was similar that using SAPIEN 3, with comparable 90-day and 1-year outcomes.

The orientation and design of bileaflet valve prosthesis in the mitral position affects the intraventricular blood flow and exposure to shear. The combination of the anatomic orientation and a small gap size of the St. Jude Medical valve produces an increase in shear exposure and blood residence time, which both predispose the formation of thrombus in the high shear gaps of the valve hinges.

Heart valve surgery is a leak reduction or repair operation or replacement of the infected valve. To alleviate the symptoms of valvular heart disease, it can prevent permanent damage to the heart. Heart valve surgery is normally open-heart surgery. This means cutting the sternum and to reach the heart. However, in response to the problems and other factors, there may be a procedure of other alternatives. Echocardiography and fluoroscopy is the main technique used for evaluation of the Prosthetic Heart Valve (PHV), for a particular cause restriction, they are the degree of morphological substrate or PHV pathology it cannot identify. Cardiac computed tomography or magnetic resonance imaging has become the new imaging modalities for the valve prosthesis. It propose the possibility of a systematic literature review based on all of the experiments and the patient's study. Pitfalls of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) provide an overview of the evaluation of the PHV. Metal artifacts might interfere with prosthetics analyzed directly in the MRI, provides information about the flow pattern and velocity associated with PHV. MRI shows an abnormal, asymmetric flow pattern of PHV barriers, enables the evaluation of repair reflux. Therefore, it offers great clinical relevance as a complementary imaging tool for diagnosing CT suspected PHV disorders and endocarditis. MRI is more research to enable a normal identification from pathological conditions required to provide a diagnostic reference value, to be used for functional PHV evaluation potential shows.

Transcatheter aortic valve implantation (TAVI) is a relatively new medical intervention. Research on dedicated TAVI devices is an exciting and dynamic field to be explored by professionals involved in technological innovation. The authors describe in this article the first engineering concept and part of the US Patent of a new valve prosthesis. Divided into two pieces to be separately implanted using a single catheter by means of an innovative technique, this device aims at reducing prosthesis and delivery catheter profile. Miniaturization of the valve and delivery system is probably the best solution to reduce the morbidity and mortality that derive from vascular complications associated with TAVI.

The Portico system (St. Jude Medical, Minneapolis, MN, USA) consists of a self-expanding valve prosthesis and a delivery system designed for transcatheter aortic valve replacement (TAVR). We describe this system, its 10-steps implantation procedure, and provide tips and tricks based on our personal experience with this system.

Coronary artery embolism (CE) should be considered as a nonatherosclerotic cause of acute myocardial infarction (AMI), especially in patients with conditions favouring the formation of intracardiac thrombi. The main aetiologies of CE have changed in recent decades. Currently, atrial fibrillation is the most common cause. Most studies on CE infarcts are case reports with small numbers of patients. There are still no clear guidelines for the management in embolic myocardial infarction. Depending on the aetiology, the treatment needs to be tailored individually. As long-term outcomes indicate, patients with CE causing AMI are at high-risk and therefore require close follow-up.

The aim of the investigation is to assess the possibility of predicting the outcome of transcatheter aortic valve prosthesis implantation in real clinical practice on the basis of patient-specific modeling. Material and Methods. Modeling of transcatheter bioprosthesis implantation was carried out based on clinical data of a patient aged 72 years. Multispiral computed tomography (CT) was performed before and after the operative intervention. Reconstruction of aorta and valvular apparatus geometry was done on the basis of obtained slices using computer-aided design (CAD). With the help of microcomputer tomography and a series of projection images and mathematical algorithms a 3D-model of the frame was reconstructed, on which a 3D-mesh from 17,000 cubic (C3D8)-elements was built. Simulation of the system component interaction was conducted using a finite element method involving a number of successive steps: preliminary balloon dilatation — frame compression in the catheter — releasing the frame from the catheter. To evaluate the accuracy of modeling results compared to the CT data of the patient with the implanted bioprosthesis a proprietary algorithm was developed using MATLAB R2014a software (The MathWorks, USA). Arrays of points corresponding to the center of the supporting frame beams, obtained in 11 orthogonal sections, were used as input data. Results. Peculiarities of patient-specific approach to modeling the implantation of transcatheter CoreValve bioprothesis by means of the developed bioinformation algorithm has been analyzed. We managed to achieve a high convergence of simulation and CT data for the frame inflow area (the difference of the simulation results for the first three layers did not exceed 4%). Comparison of the results in terms of the annulus area has also demonstrated a high convergence: the identity amounted to more than 90% for the inflow and middle zones of the supporting frame. Conclusion. The highest level of detail, including calcium conglomerates modeling, as well as a comprehensive description of nonlinear elements of the system under study accurately reproduces the process of implantation of the transcatheter aortic valve prosthesis.

Objectives: The aortic annulus diameter measured by transthoracic echocardiography yields lower values than by computed tomography, and echo-based selection of transcatheter aortic valve prosthesis size has been implied to result in more frequent paravalvular leakage. We investigated the relation of preoperative annulus diameter by echo with the ring size of the aortic prosthesis chosen by direct assessment during open-heart aortic valve replacement. Methods: Preoperative annulus diameter by echo (from parasternal long-axis cross-sections of the left ventricular outflow tract and aortic valve) and implanted prosthetic diameter (tissue annulus diameter, determined intraoperatively using a sizing instrument) were compared retrospectively in 285 consecutive patients undergoing open-heart aortic valve replacement. Results: A total of 285 prostheses (240 biologic and 45 mechanical) were implanted, with prosthetic diameter ranging between 19 and 27 mm. There was a significant linear correlation (P r = 0.51, between preoperative annulus diameter by echo (mean 21.8 ± 2.8 mm) and prosthetic diameter (22.9 ± 1.7 mm). Preoperative annulus diameter of patients receiving prostheses no. 21, 23 and 25 mm aortic prostheses (the most frequent prosthesis sizes) were significantly different (P Conclusion: Our data confirm that preoperative echo assessment of the aortic valve may slightly underestimates the optimal surgical prosthesis diameter for the aortic valve annulus.

Background Surgical treatment of infective aortic valve endocarditis (AVE) remains a therapeutic challenge, necessitating interdisciplinary approach to limit morbidity and mortality in this high-risk cohort. With a considerable spectrum of available laboratory testings, imaging techniques, as well as operative strategies developed in recent years, there is a lack of standardization across cardiac surgical departments in Germany. Thus, the optimal treatment strategy of AVE has yet to be defined. Methods A nationwide survey on infective AVE was conducted, including 64 cardiac surgical departments responding to a 41-item questionnaire. The evaluation included common surgical practice, routine diagnostic steps, surgical techniques, perioperative medical treatment, as well as postoperative management. Results Remarkable differences were observed among the participating institutions, including the following components of the treatment: (1) standardization and extent of the use of imaging techniques and (2) success rate in identification AVE-causing germs, (3) timing of operation in case of cerebral embolization, and (4) choice of valve prosthesis for aortic valve replacement for infective AVE. Conclusion The findings of this survey underline the need for a nationwide registry to further elucidate the nature and course of AVE in Germany, as well as to serve as a solid basis for prospective trials, addressing the most important clinical purposes in the diagnosis and treatment of AVE.

Transcatheter aortic valve replacement (TAVR) has become a well-established therapy for inoperable and high-risk patients of Aortic Stenosis in most of the part of the world. The technological advancements in the hemodynamic performance and design of valve prosthesis and also the data provided by various trials regarding the safety and efficacy of TAVR have widened the scope of TAVR in intermediate and low-risk groups also. The main focus of this review is to discuss the feasibility of TAVR in developing countries. Along with this review, it also gives a detailed outlook of the pros and cons of TAVR along with insight into the future of TAVR and its adoption into the low-risk group.

Aims We compared thromboembolic (TE) and bleeding risks in patients with atrial fibrillation (AF) according to the new ‘Evaluated Heartvalves, Rheumatic or Artificial' (EHRA) valve classification. Methods Patients were divided into 3 categories: (i) EHRA type 1 corresponds to the previous ‘valvular' AF patients, with either rheumatic mitral valve stenosis or mechanical prosthetic heart valves; (ii) EHRA type 2 includes AF patients with other valvular heart disease (VHD) and valve bioprosthesis or repair; and (iii) ‘non-VHD controls' i.e. all AF patients with neither VHD nor post-surgical valve disease. Results Among 8962 AF patients seen between 2000 and 2010, 357 (4%) were EHRA type 1, 1754 (20%) were EHRA type 2 and 6851 (76%) non-VHD controls. EHRA type 2 patients were older and had a higher CHA 2 DS 2 -VASc and HAS-BLED scores than either type 1 and non-VHD patients. After a mean follow-up of 1264 ± 1160 days, the occurrence of TE events was higher in EHRA type 2 than non-VHD patients (HR (95%CI): 1.30 1.09–1.54), p = 0.003; also, p = 0.31 for type 1 vs 2, p = 0.68 for type 1 vs non-VHD controls). The rate of major BARC bleeding events for AF patients was higher in either EHRA type 1 (HR (95%CI): 3.16(2.11–4.72), p p Conclusion The EHRA valve classification of AF patients with VHD appears useful in categorizing these patients, in terms of TE and bleeding risks. This classification can be used in clinical practice for appropriate choices of oral anticoagulation therapy and follow-up.

Isolated valve surgery is associated with a small incidence of postoperative PCI. PCI after single-valve surgery is associated with elevated mortality and morbidity risk. Possible mechanisms for cardiac ischemia include iatrogenic causes (such as suture-related or air embolism), intimal hyperplasia, and immunologic reaction to the valve prosthesis.

Transcatheter aortic valve replacement (TAVR) has become the treatment of choice for patients with severe, symptomatic aortic stenosis with prohibitive risk for valve replacement surgery (SAVR) and is now considered a favourable alternative to surgical management for patients considered to be high risk (1). Recently published results of the PARTNER 2 trial have demonstrated that TAVR is an acceptable treatment option for patients with intermediate surgical risk and may hold an advantage over surgery if feasible via transfemoral approach (2). As we continue to explore the possibility of TAVR for lower risk patients who are typically younger and good candidates for surgical therapy, the durability of the prosthesis becomes an important consideration. Bioprosthetic valve failure after surgical aortic valve replacement (SAVR) is well described and well investigated. Structural valve deterioration is the most common noted cause with incidence of

Die Kardiovaskuläre Magnetresonanztomographie (CMR) ist eine etablierte Methode zur Evaluation von Patienten mit Herzklappenerkrankungen und nach Herzklappenersatz. Diese Studie analysiert systematisch den Einfluss von Herzklappenprothesen auf Phasenkontrast (PC)- Flussmessungen in der CMR im Flussmodell [1]. Zwei biologische und eine mechanische Aortenklappenprothese wurden in ein Flussphantom eingesetzt. B0-Maps und Phasenkontrast- Flussmessungen wurden am 1.5 und 3 Tesla (T) CMR in definierten Abständen von der Prothese durchgeführt. Die Resultate wurden mit Messungen eines Kunststoff-Inlays verglichen. Zudem wurde exemplarisch für jede Prothese jeweils ein Patient untersucht und die Resultate mit einem herzgesunden Probanden verglichen [1]. Die Resultate der Flussmessungen in Höhe der Prothese unterschieden sich signifikant von Referenzmessungen proximal der Prothese. Die maximale Fehlkalkulation sowohl im 1.5T als auch im 3T CMR betrug etwa 150 ml/s in einer der beiden biologischen Prothesen und 140 ml/s in der mechanischen Prothese im 1.5T CMR. Messungen mit eingesetztem Kunststoff-Inlay zeigten demgegenüber keine signifikanten Abweichungen. Die Ergebnisse der Flussmessungen circa 20 mm in-vitro und 30 mm in-vivo distal der Prothese entsprachen den Referenzflussmessungen in allen getesteten Prothesen und Feldstärken [1]. Die untersuchten Herzklappenprothesen zeigten eine signifikante Abweichung der gemessenen Flussraten verglichen mit einem Referenzpunkt. Mit einem Abstand 20 mm in-vitro und 30 mm in-vivo distal zur Prothese war diese Abweichung nicht mehr zu verzeichnen [1]., Cardiovascular Magnetic Resonance is established in patients with heart valve diseases before and after surgery. This study analyses systematically the influence of heart valve prostheses on phase contrast measurements in a phantom [1]. Two biological and one mechanical aortic valve prostheses were placed in a flow phantom. B0 maps and phase contrast flow measurements were acquired at a 1.5T and 3T CMR scanner using in predefined distances to the prostheses. Results were compared to measurements with a synthetic metal-free aortic valve. Additionally for each prosthesis a patient was examined and the results were compared to a hearth- healthy volunteer [1]. The flow results at the level of the prosthesis differed significantly from the reference flow acquired before the level of the prosthesis. The maximum flow miscalculation was around 150 ml/s in 1.5.T and 3T CMR for one of the biological prostheses and 140 ml/s in 1.5T CMR for the mechanical prosthesis. Measurements with the synthetic aortic valve did not show significant deviations. Flow values measured approximately 20 mm in-vitro and 30 mm in-vivo distal to the level of the prosthesis agreed with the reference flow for all tested all prostheses [1]. The tested heart valve prostheses lead to a significant deviation of the measured flow rates compared to a reference. A distance of 20 mm in-vitro and 30mm in-vivo was effective in our setting to avoid this influence [1].

Cardiovascular diseases are the leading causes of mortality worldwide. There is the only method to treat the severe heart valve defects is heart valve prosthetics. Nowadays, there is an active introduction of artificial materials into medicine. The use of polymeric materials to make a leaflet for the valve prostheses can solve the problems of biological prostheses by providing greater durability with the keeping of positive properties as low risk of thrombosis and the absence of the need for continuous anticoagulants administration. Firstly, it needs to find the most suitable polymer for heart prosthesis. The investigation of the elastic characteristics of artificial materials in comparison with the biomaterial used in the valve prosthesis manufacture is presented in the article. Tests for polymers aortic heart valve prosthesis were performed.

Transcatheter aortic valve implantation (TAVI) is a highly effective procedure in selected patients with severe degenerative aortic valve stenosis at high risk for conventional surgery. Coronary occlusion is a periprocedural life-threatening complication that despite its low frequency (˂1%) is poorly predictable and requires immediate diagnosis and treatment. Herein, we report a coronary obstruction after transcatheter implantation of valve prosthesis, followed by coronary intervention with successful recanalization.

BACKGROUND: An 80-year-old man with symptomatic severe aortic valve stenosis, haemodynamic instability, important comorbidities and a high surgical risk. Following bridgeballoon aortic valvuloplasty to recover from the unstable haemodynamics he was deemed suitable for transcatheter aortic valve implantation (TAVI) via the femoral access route. INVESTIGATION: Fluoroscopy. DIAGNOSIS: During TAVI, while the operators were preparing for prosthesis deployment (Edwards SAPIEN 3), the extra-stiff guidewire was accidentally withdrawn from the left ventricle (LV) to the ascending aorta. MANAGEMENT: Valve orifice was re-crossed from the contralateral access, a snare was introduced through the AL1 catheter and pushed anterogradely through the valve. The extra-stiff wire was then captured in the ascending aorta and pulled back into the LV to complete the procedure.

Over the last 50 years medicine and technology have progressed to the point where it has become commonplace to safely replace damaged or diseased heart valves with mechanical and biological prostheses. Despite the advancements in technology current valve substitutes continue to have significant limitations with regards to thrombogenicity, durability, and inability to grow or remodel. In an attempt to overcome the limitations of currently available valve prosthesis, heart valve tissue engineering has emerged as a promising technique to produce biological valve substitutes. Currently, the field of tissue engineering is focused on delivering complex matrices which include scaffolds and cells separately or together to the damaged site. Additional functional enhancement of the matrices by exposing encoded biological signals to their residing cells in a controlled manner has the potential to augment the tissue engineering approach. This review provides an overview of the delivery of biological reagents to guide and regulate heart valve tissue engineering.

Summary Background Prosthetic heart valve thrombosis is a life-threatening condition for which treatment has not been evaluated by randomized trials. Objectives To compare surgery with thrombolytic therapy for the treatment of prosthetic valve thrombosis. Methods A comprehensive systematic review was carried out by independent researchers using PubMed, Web of Knowledge, HINARI, LILACS and EMBASE, including papers indexed up to 23 October 2013 with at least 10 patients, evaluating one or both treatment options. Outcomes of interest were death, stroke, bleeding, embolic events and success. Study quality was assessed by the Newcastle-Ottawa Scale (ranges from 0 to 9). Comprehensive Meta Analysis Software was used to pool study results, for publication bias analysis and for meta-regression. Results Forty-eight studies were included (2302 patients). No randomized study was identified, and all were observational in design. Study quality varied from 4 to 6 stars using the Newcastle-Ottawa Scale. Mortality for surgery was 18.1% (95%CI, 14.6–22.1; I2, 62% [42–75]), while mortality for thrombolytic therapy was 6.6% (95% CI, 4.8–8.9; I2, 0% [0–13]). Surgical mortality appeared to increase with NYHA-class, according to meta-regression. Other results related to surgery and thrombolytic therapy, respectively, were: embolic events, 4.6% (2.9–7.3) and 12.8% (10.8–15.2); stroke, 4.3%,(2.7–6.6%) and 5.6%,(4.3–7.4%); success rate, 81.9% (77.2–85.8) and 80.7% (75.6–85.0); bleeding, 4.6% (2.9–7.1) and 6.8% (5.4–8.6); and death or stroke, 19.0% (14.8–24.2) and 11.4% (8.7–14.7). Conclusion Mortality in patients treated by thrombolytic therapy for valve prosthesis thrombosis is significantly lower than in patients treated surgically. As we cannot yet ascertain whether this difference is due to the treatment alone, more studies are now necessary to further clarify these findings.

Visualizing the anatomy of the atrioventricular (AV) conduction axis substantiates that there is remarkable inter-individual variation at the macro- and microscopic levels, and that the atrioventricular bundle and left bundle branch are located more anteriorly, distally, and cranially and much closer to the aortic root complex than previously thought. The AV conduction system may therefore be compromised during implantation of a transcatheter aortic valve prosthesis, which may account for the relatively high incidence of new cardiac conduction abnormalities when conventional prosthetic valves are used. The design of the newer JenaValve® may afford advantages over more conventional valves by avoiding the high-risk implantation area and the potential for coronary ostia obstruction.