Journal and News Scan

Hamandi and colleagues reviewed outcomes for 95 patients who underwent isolated tricuspid valve (TV) surgery between 2007 and 2017 at their institution. For 41% of patients, the procedure was reoperative, following either prior coronary artery bypass grafting or prior valve surgery. Valve repair was performed in over 70% of patients. Operative mortality was low, being 3.2% overall and with no mortality in the last 6 years studied (73 patients). The authors conclude that careful patient selection and current periprocedural management have improved morbidity and mortality of isolated TV surgery, and they suggest that these outcomes can serve as a benchmark for catheter-based TV interventions.

Transcatheter aortic valve replacement (TAVR) is expanding to younger patients, but the feasibility of TAVR in failing transcatheter aortic valves (TAV) remains unknown. Dr Tang and colleagues demonstrate in a retrospective review of 551 TAVR procedures by evaluating the postdeployment aortogram using a novel aortic root anatomic classification that TAV-in-TAV after Edwards SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, California) TAVR may not be feasible in >20% of S3 TAVR procedures and in >50% among patients with type 3 roots.

Unique challenges for TAV-in-TAV compared to surgical aortic valve replacement: (1) the native aortic valve leaflets remain in situ after the initial TAVR, acting as a barrier facing the LM orifice; (2) there is currently no predictable way to align the TAV neocommissures with native commissures; (3) often the only way to engage the left main coronary artery is from the TAV stent frame.

This is particularly important given the potential expansion of TAVR to low-risk and/or younger patients who may need redo TAVR. The ascertainment of aortic root type, STJ and SH relative to TVH is essential to guide valve selection and positioning for TAV-in-TAV feasibility on the basis of left main coronary artery obstruction risk.

Bauser-Heaton and colleagues evaluated outcomes for patients with complex tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries (MAPCAs), focusing on those patients who underwent unifocalization with placement of a shut rather than simultaneous intracardiac repair. Between 2001 and 2017, 57 patients underwent this type of procedure at the authors’ center. In this high-risk cohort, complete repair was achieved in 67% of patients within 3 years. The median right ventricle to systemic pressure ratio for patients with complete repair was 0.4.

This keynote lecture highlights the need for a standardized prepump intraoperative echocardiology protocol in order to provide a surgeon and their team with a roadmap as to what techniques may be applied for an effective repair of the aortic valve. The authors conclude that such a protocol is essential in enhancing the heart team’s approach by providing a common language between surgeons and echocardiologists, which they hope will ultimately increase aortic valve repairs for select patients in expert centers.