This paper discusses a female patient with severe aortic stenosis, who was preoperatively assessed to be at high risk of left coronary artery occlusion, but developed complete occlusion of the right coronary artery during the procedure of transcatheter aortic valve replacement, leading to hemodynamic disorder. Surgical treatment under emergency cardiopulmonary bypass played a critical role in rescuing the patient.
This case was a 58-year-old female patient with patent ductus arteriosus (PDA) and severe aortic stenosis. Upon admission, she had severe heart failure and severe edema of both lower extremities unable to lie flat. After cardiac function adjustment and under general anesthesia, she underwent a one-stop operation of PDA occlusion and transcarotid transcatheter aortic valve replacement due to the severe aortic arch stenosis which brought high risk in transfemoral artery approach. Her symptoms improved significantly, and she was discharged only 6 days after operation. At the follow-up 3 months after operation, the aortic valve transvalvular pressure gradient improved significantly, the ductus arteriosus murmur disappeared, and the patient recovered well.
ObjectiveTo analyze the characteristics and cardiac anatomy of patients with conduction block after transcatheter aortic valve replacement (TAVR) with Venus-A valve.MethodsRetrospective analysis was conducted on the clinical data of patients with severe aortic stenosis who underwent TAVR with Venus-A valve in the Second Affiliated Hospital of Army Military Medical University from October 2017 to May 2020. According to the occurrence of heart conduction block after TAVR, the patients were divided into the blocked group and the unblocked group, and the differences in characteristics and cardiac anatomy between the two groups were compared.ResultsForty-nine patients with severe aortic stenosis were included in the analysis, including 29 in the blocked group and 20 in the unblocked group. The incidence of atrial fibrillation in the blocked group was higher than that in the unblocked group (P=0.015), and there was no statistically significant difference in other preoperative indicators (P>0.05). There was no statistically significant difference in postoperative indicators between the blocked group and the unblocked group (P>0.05). Among bicuspid aortic valve, the ellipticity of left ventricular outflow tract and annulus in the blocked group were higher than those in the unblocked group (P<0.05), and the ratio of the short diameter of the left ventricular outflow tract to the bottom diameter of the implanted valve was smaller than that of the unblocked group (t=2.225, P=0.043). There was no significant difference in other cardiac anatomical indicators (P>0.05). As to tricuspid aortic valve cases, there was no significant difference in cardiac anatomic parameters between the blocked group and the unblocked group (P>0.05).ConclusionsFor bicuspid aortic valve patients with severe aortic stenosis and implanted with Venus-A valve, larger elliptic rate of annulus or left ventricular outflow tract, smaller proportion of left ventricular outflow tract diameter to the bottom diameter of implanted valve are associated with conduction block after TAVR. These anatomical patterns might be used as potential clinical indicators to predict postoperative conduction block.
Objective
To explore the safety and feasibility of general anesthesia with tracheal intubation in transcatheter aortic valve implantation (TAVI), and the key points in anesthetic management.
Methods
Twenty-five patients with aortic stenosis treated by TAVI in West China Hospital of Sichuan University between September 2012 and June 2013 were included in this study. General anesthesia with tracheal intubation was chosen. We recorded and analyzed the hemodynamics, blood gas, oxygen saturation data before and after anesthesia induction, before surgery, during rapid ventricular pacing, before and after aortic valve implantation. Besides, the incidence of perioperative complications and 30-day mortality were also recorded.
Results
All the 25 patients underwent the implantation surgery successfully. Two patients had the second implantation surgery due to moderate reflux. All the subjects in this study tolerated general anesthesia well without any anesthesia-related complications. There were 19 cases of newly developed or aggravated heart blocks, 7 of permanent pace maker, 2 of perioperative hemorrhage, 2 of cerebral vascular events, and 1 death case.
Conclusioins
General anesthesia with tracheal intubation can be utilized safely in patients undergoing TAVI. TAVI is a challenging technique in need of precise collaborations of multi-disciplines, in which anesthetists should play more as a leader in evaluation and decision-making during the surgery.
Objective To investigate the role and mechanism of peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α) in the activation of aortic valve interstitial cells (AVICs) in aortic stenosis. Methods Isolating primary AVICs and stimulating their activation with transforming growth factor β1 (TGF-β1, 30 ng/mL), the expression of PGC-1α was detected. The activation of AVICs induced by TGF-β1 was observed after overexpression of PGC-1α by adenovirus or inhibition of PGC-1α function by GW9662. The possible downstream molecular mechanism of PGC-1α in AVICs activation was screened. Finally, the phenotype was further verified in primary human AVICs. Results The expression of PGC-1α decreased after the activation of AVICs induced by TGF-β1 (control group: 1.00±0.18; 24 h: 0.31±0.10; 48 h: 0.32±0.06; 72 h: 0.20±0.07; P<0.05). Specific overexpression of PGC-1α by adenovirus inhibited the activation of AVICs induced by TGF-β1 stimulation (periostin: 3.17±0.64 vs. 1.45±0.54, P<0.05; α-smooth muscle actin: 0.77±0.11 vs. 0.28±0.06, P<0.05). On the contrary, inhibition of PGC-1α function by GW9662 promoted the activation of AVICs (periostin: 2.20±0.68 vs. 7.99±2.50, P<0.05). Subsequently, it was found that PGC-1α might inhibit the activation of AVICs through downregulating the expression of calcium/calmodulin-dependent protein kinase (CAMK1δ) (0.97±0.04 vs. 0.74±0.11, P<0.05), and downregulating the expression of CAMK1δ alleviated the activation of AVICs (periostin: 1.76±0.11 vs. 0.99±0.20, P<0.05). The possible mechanism was that the activation of mammalian target of rapamycin (mTOR) signaling pathway was inhibited by reducing the accumulation of reactive oxygen species (ROS) (778.3±139.4 vs. 159.3±43.2, P<0.05). Finally, the protective effect of PGC-1α overexpression was verified in the activated phenotype of human AVICs (periostin: 2.73±0.53 vs. 1.63±0.14, P<0.05; connective tissue growth factor: 1.27±0.04 vs. 0.48±0.09, P<0.05). Conclusions The expression of PGC-1α significantly decreases during the activation of AVICs induced by TGF-β1. The overexpression of PGC-1α significantly inhibites the activation of AVICs, suggesting that PGC-1α plays a protective role in the activation of AVICs. The possible mechanism is that PGC-1α can inhibit the activation of CAMK1δ-ROS-mTOR pathway. In conclusion, interventions based on PGC-1α expression levels are new potential therapeutic targets for aortic stenosis.
Due to the lack of calcification of the aortic valve, it is difficult to provide effective support for the fixation of artificial valve in aortic stenosis characterized by leaflet thickening. There is a risk of postoperative perivalvular leakage and secondary valve implantation, which is widely regarded as a relative contraindication for transcatheter aortic valve replacement (TAVR). But aortic valvuloplasty and self-expanding transcatheter aortic valve has showed its safety and efficacy. This paper reports a patient with bicuspid aortic valve characterized by leaflet thickening treated with TAVR. After the operation, the patient’s symptom of exertional dyspnea was significantly improved, New York Heart Association class increased to Ⅱ, no perivalvular leakage was found, and the mean transaortic pressure gradient and the maximum aortic valve velocity decreased significantly.
Aortic stenosis (AS) is the most common primary valve lesion requiring surgery or transcatheter intervention in modern era. Its prevalence is rising rapidly as a consequence of the aging population. Transcatheter aortic valve replacement (TAVR) as a therapy option for older high-risk symptomatic severe AS patients has emerged and is currently extending its indications towards surgery intermediate- and low-risk subjects. Considering the common characteristics of frailty and high comorbidity among AS patients, cardiac rehabilitation (CR) has been proven to improve not only survival but also quality of life in previous reports. CR as a classⅠ recommendation in guidelines for the prevention and treatment of cardiovascular disease has been widely used in clinical practice. The purpose of this article is to sort out the current CR programs for TAVR patients in global medical management, and explore the CR optimization program fit for China medical model in post COVID-19 pandemic era.
Transcatheter aortic valve replacement (TAVR) has become a common theraputic option for aortic stenosis, but the evidence for precise anatomy for TAVR is accumulating. This paper presents the case of an 71-year-old female patient who had an extremely high risk of coronary obstruction due to both coronary ostia lying too low. The patient underwent TAVR with the help of coronary protection successfully. During the procedure, the patient was protected with wires only for both coronaries. After deployment, angiofluoroscopy suggested that chimney stenting should be applied for left coronary. The whole procedure was unenventful and both coronaries were seen.
Nowadays, aortic bioprostheses are used more and more widely in clinical practice, but the valve will experience structural valve degradation over time, and eventually lose its function, which is valve failure. Valve failure has become a significant challenge for aortic valve replacement and especially limits the expansion of indications for transcatheter aortic valve replacement. This review focuses on the current status and relevant evidence on the definition, risk factors, epidemiological characteristics, diagnosis and evaluation, treatment strategies of aortic bioprostheses failure. The purpose is to provide a basis for a more comprehensive understanding of aortic bioprostheses failure, finding better coping strategies and further improving the long-term durability of the valve.
ObjectiveTo systematically review the efficiency and safety of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis at intermediate-low risk compared with surgical aortic valve replacement (SAVR).MethodsTwo researchers searched literatures independently in databases including PubMed, Embase, Scopus, Cochrane Library, China Biology Medicine disc, China National Knowledge Internet, VIP database for studies published from January 2012 to October 2017, then screened for propriate studies, collected information from different follow-up period all on the principle of Cocharan handbook. At last statistal analysis was performed in RevMan 5.3 to calculate relative risk (RR) and its 95% confidence interval (CI).ResultsThirteen studies were enrolled in this Meta-analysis with 10 753 patients, including 5 263 cases in TAVR group and 5 490 cases in SAVR group. Meta-analysis showed that there were no statistically significant differences in all-cause mortality between TAVR group and SAVR group in 30 days, 1 year or 2 years after operation [RR=0.96, 95%CI (0.75, 1.24), P=0.78; RR=0.84, 95%CI (0.68, 1.03), P=0.09; RR=0.97, 95%CI (0.84, 1.14), P=0.75]; while stroke more preferred SAVR no matter 30 days or 1 year [RR=0.64, 95%CI (0.51, 0.80), P<0.000 1;RR=0.76, 95%CI (0.63, 0.92), P=0.004].ConclusionThere is no significant difference in all-cause mortality of intermediate-low risk patients undergoing TAVR and SAVR, but TAVR perfoms better in terms of srtoke.
