Faculty Bibliography

Mitral annular calcifications have been known to increase complexity during mitral valve replacement (MVR). Standard procedure requires decalcification followed by reconstruction of the mitral annulus prior to placing the prosthesis. While this is the ideal technique, it is not feasible in every patient due to the associated risks. The mere attempt at valve replacement without proper annular decalcification has been associated with a high incidence of periprosthetic leak which complicates the postoperative course and has been associated with increased morbidity and mortality. With the advances in transcatheter therapy, postoperative periprosthetic regurgitation can be managed with devices and primary transcatheter valve implantation could be alternative to standard valve replacement; however, these alternate strategies are not without its own limitations and drawbacks. In the current report, we present a novel strategy to be used in a select group of patients with severe but non-circumferential annular calcifications to prevent/minimize periprosthetic regurgitation during MVR. This involves placing a patch over the posteriorly located calcium bar, thus minimizing tension on the posterior suture line and contain any periprosthetic regurgitation if to develop. This modification has been performed in a total of nine cases with acceptable early results.

Background: B-type natriuretic peptide (BNP) has been established as a predictor of outcomes in patients who undergo surgical aortic valve replacement (SAVR). Studies on the prognostic value of BNP in high-risk patients undergoing transcatheter aortic valve replacement (TAVR) have yielded conflicting results. Additionally, BNP has not been well-studied in low- and intermediate-risk patients undergoing TAVR. The purpose of this study was to clarify the prognostic utility of baseline BNP in low-, intermediate-, and high-risk patients with severe aortic stenosis (AS) undergoing TAVR.
Method(s): This was a retrospective observational study of 1544 low-, intermediate-, and high-risk patients who underwent TAVR at our institution from 2012-2019. Included were patients who had a BNP <7 days prior to TAVR. Patients were then trichotomized into those with a pre-TAVR BNP <250 pg/mL (cohort 1), between 250-500 pg/mL (cohort 2), and >500 pg/mL (cohort 3). Outcomes of interest were inpatient and 30-day mortality. Statistical analyses of outcomes were performed using multivariate binary logistic regression.
Result(s): Of the 1544 patients screened, 1487 patients had a BNP level <7 days prior to TAVR and thus were included in the study. Patients in cohort 3 with a baseline BNP >500 pg/mL were 3.31 times more likely to have inpatient death (CI 0.142, 0.643; P=0.0019), 2.70 times more likely to have death within 30 days (CI 0.192, 0.711; P=0.0029) and 1.81 times more likely to have death within 1 year (CI 0.348, 0.880, p=0.0152).
Conclusion(s): Our study of 1487 low-, intermediate-, and high-risk patients demonstrates a baseline BNP greater than 500 pg/mL is an independent predictor of inpatient, 30-day and 1-year mortality. BNP has prognostic implications in TAVR patients across all risk groups and can help identify the subset of patients who may warrant closer follow up following TAVR.
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Transcatheter mitral valve implantation (TMVI) is at various levels of preclinical investigation and has proven to be more challenging than transcatheter aortic valve implantation due to more complex anatomy. The purpose of this study is to evaluate the short-term and long-term outcomes of high-risk patients who underwent TMVI for degenerated mitral bioprostheses. In this retrospective, observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement or repair with annular ring that underwent TMVI using the balloon-expandable heart-valve system at our institution from 2014 to 2019. We reviewed pre/postprocedure echocardiographic data, in-hospital, 30-day data and 1-year outcomes. The indication for TMVI was mitral regurgitation (MR) in 9 patients, mitral stenosis in 9 patients and mixed mitral disease in 8 patients. There was a 100% device implantation success rate and a 96% in-hospital survival rate. Survival was 96% at 30 days and 85% at 1 year. Mean mitral gradient (MMG) improved postprocedure (13.3 mm Hg to 6.8 mm Hg, p <0.0001) and was sustained at 1 year (13.3 mm Hg to 7.2 mm Hg, p <0.0001). MR grade improved postprocedure (3+ to 1+, p <0.0001) and was sustained at 1 year (3+ to 0, p <0.0001). Additionally there was significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score after TMVI (47.8 to 75.7 to 84.0, p = <0.0001). In conclusion, our early experience with treatment of degenerated mitral bioprostheses using TMVI in high-risk patients resulted in significant short-term and sustained long-term improvements in mean mitral gradient, MR and heart failure symptoms.

B-type natriuretic peptide (BNP) levels have been shown to predict outcomes in surgical aortic valve replacement patients. BNP levels have not been well studied in patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study is to define the utility of baseline BNP levels in predicting short-term outcomes after TAVI. In this retrospective, observational, study from 2012 to 2019, we reviewed data on 1297 low-risk, intermediate-risk and high-risk patients who underwent TAVI. Patients were dichotomized into those with baseline BNP levels above or below 500 pg/ml. Our primary outcome was a composite of inpatient stroke and death. Our secondary outcome was a composite of 30-day stroke, death and readmission. There were 975 patients with a baseline BNP level of <500 pg/ml and of those, 2% had our primary composite outcome and 13% of patients had our secondary composite outcome. There were 322 patients with a baseline BNP level of ≥500 pg/ml and of those, 6% had our primary composite outcome and 19% of patients had our secondary composite outcome. Those with a baseline BNP level ≥500 pg/ml were 3.47 times more likely (confidence of interval [CI] 1.727, 6.993, p = 0.0005) to have our primary composite outcome and were 1.72 times more likely (CI 1.186, 2.506, p = 0.0043) to have our secondary composite outcome. In conclusion, after adjustments for discrepant baseline characteristics, baseline BNP levels were independently predictive of a composite of inpatient stroke or death and a composite of 30-day stroke, death or readmission after TAVI. Those low, intermediate and high-risk patients whose baseline BNP is ≥500 pg/ml may ultimately require closer post-TAVI monitoring.

We report a rare case of a 30-year-old female who had a long-standing history of middle aortic syndrome that was being managed nonsurgically. She presented with hypertension and buttock pain with plans to become pregnant. She underwent an aortoiliac bypass.