Edition 2022/04

Background. The most common forms of congenital and acquired obstructions of the left ventricular outflow tract (LVOT) are the valvular aortic stenosis, the congenital tunnel-like obstruction, the hypertrophic obstructive cardiomyopathy and finally the prosthetic-patient mismatch (PPM) following aortic valve replacement. The last one is most probably under-estimated and under-treated. Here, we report our experience with the Konno anterior aorto-ventriculoplasty in adult patients suffering from prothesis-patient mismatch.

Patients. Between 2005 and 2020, 8 patients received a classical Konno anterior enlargement of the aortic anulus to treat a typical PPM (n=5) or another complex obstructing pathology of the LVOT (n=3). Median age was 42.5 years and 5 patients were female. All patients suffered from exercise dyspnea NYHA functional class III or IV. In addition to the Konno procedure, 3 patients underwent mitral valve replacement (n=2) or repair (n=1). Two patients received tricuspid anuloplasty to treat severe concomitant tricuspid regurgitation. All patients had undergone at least one previous operation, 3 patients had 2 prior procedures in their medical history and 1 patient was operated for the fifth time.

Results. All patients survived the operation. One younger patient suffering from Werners' type of progeria died in-hospital on postoperative day 45 following prolonged hemodynamic failure. She also had developed thrombosis of the mechanical mitral prosthesis, underwent thrombectomy and extracorporeal membrane oxygenation support (ECMO) but did not recover. One patient required a double chamber pacemaker implantation because of persistent atrio-ventricular block III. All surviving patients had very satisfactory postoperative hemodynamic patterns across the LVOT.

Conclusion. The Konno anterior aorto-ventriculoplasty is a very efficient method to adequately enlarge the LVOT, independently from the initial pathology. This technique is only rarely used because it is considered as a complex intervention. However, this type of enlargement usually allows the insertion of a larger prosthesis than after a simpler Manougian or Nicks posterior anulus enlargement. For adult patients with severe PPM or other forms of complex LVOT obstruction, the Konno intervention is a valuable option that should be offered to these patients.

We present the case of an atrial thrombus that developed under established anticoagulation in a patient with a giant left atrial appendage aneurysm and persistent atrial fibrillation. The management of patients with left atrial appendage aneurysm is challenging and might include surgical resection of the aneurysm and antithrombotic treatment tailored according to surgical risk, comorbidities, and patient preferences.

In the light of possible restriction of the number of pacemaker implantations in Switzerland and missing local data on this topic, we aimed to evaluate if the pacemaker indications in a tertiary Swiss hospital are in accordance with current guidelines of the European Society of Cardiology (ESC).

We included all 309 pacemakers implanted between the 1st of January 2018 and the 15th of March 2019. CRT pacemakers were excluded. Mean age of the patients was 78.3 years (standard deviation 10.2 years). Class I indication was present in 90.6%, class IIa in 3.6%, class IIb in 3.6%, and class III in 2.2%.

Based on these results, it is unlikely that a prespecified restriction of annual pacemaker implantations will prevent volume expansion. On the contrary, these measures may even result in withholding indicated therapy for symptomatic patients.

We report a series of 31 patients after surgically aortic valve implantation of a bovine Sorin Mitroflow bioprosthesis with early severe structural valve degeneration (SVD) despite absence of known risk factors. Half of the patients underwent re-intervention and more than one third died without re-intervention, mostly prematurely due to heart failure caused by SVD. The Sorin Mitroflow valve was prone to early SVD even in very old patients, which may be at least in part due to a lack of anti-calcification treatment and its peculiar design. This led to additional suffering of the patients and added healthcare expense. The inferior durability was largely undetected for almost 2 decades, which in retrospect was mainly because earlier studies relied on SVD diagnosis only at reoperation, reported no regular echocardiographic monitoring and did not consider the competing risk of death despite high mortality rates. To avoid a similar delay in the recognition of specific problems with new surgical valves analogue to the already ongoing TAVR-registries the introduction of mandatory SAVR-registries with regular echocardiographic monitoring and uniform definition of SVD as well as broad training of all cardiologists and echocardiographers involved in SVD screening and treatment seems reasonable.

In fetuses with complex type of congenital heart disease (CHD), impaired brain growth and brain development starts in utero. A complex interplay between heart, brain, and placenta takes place within the second and third trimester of pregnancy. Altered fetal cardiovascular hemodynamics due to the type of CHD leads to an altered cerebral and placental perfusion, both factors contributing to maturational delay of body and brain development. Impaired cerebral perfusion, oxygenation, and nutritive energy supply affects brain growth and leads to brain developmental delay of 3-4 weeks until birth. Comparable to the altered brain development in pre-terms, pathogenic mechanisms lead to an encephalopathy of CHD on a micro- and macrostructural level. After birth palliative or corrective cardiac surgery is needed, which further contributes to the brain maturational delay with consequences on the neurodevelopmental outcome.