2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Outcome of edge-to-edge vs. surgical repair in patients with functional mitral regurgitation and reduced left ventricular function

BACKGROUND

This study aims to compare the midterm outcome of percutaneous edge-to-edge repair (TEER) using the first-generation MitraClip system (Abbott Vascular, Santa Clara, CA) with surgical repair, in patients with severe functional mitral regurgitation (fMR) and reduced left ventricular function (LVEF).

METHODS

The data of consecutive patients with severe fMR and LVEF ≤ 45%, who underwent either isolated surgical repair or MitraClip implantation between January 2007 and December 2015, were retrospectively analyzed. Clinical and echocardiographic follow-up data after 12 and 24 months were obtained in both groups. A propensity score matching analysis was performed to adjust for intergroup differences in baseline characteristics.

RESULTS

A total of 167 patients with significant fMR and LVEF ≤ 45% were identified, who underwent either isolated surgical mitral valve repair (n = 83, 49.7%) or MitraClip (n = 84, 50.3%) implantation. Because the two groups had very different risk profiles, propensity scores were calculated for age, sex, EuroSCORE, LVEF, and coronary artery disease, which reduced the number of patients to 74 (38 in the clip group and 36 in the surgical group). There was no significant difference between the two groups in terms of survival, number of reinterventions, heart failure symptoms according to New York Heart Association (NYHA) class, degree of mitral regurgitation, and LVEF.

CONCLUSION

In this retrospective analysis of patients with severe fMR and LVEF ≤ 45%, the comparison between surgical repair, edge-to-edge repair and a first-generation MitraClip device showed similar midterm outcomes in terms of survival, number of reinterventions, NYHA class, degree of mitral regurgitation, and LVEF.

Impact of Continuation Versus Interruption of Oral Anticoagulation During TAVI on Health-Related Quality of Life

BACKGROUND

One-third of patients undergoing TAVR have a concomitant indication for oral anticoagulation. The impact of continuation as compared to interruption of oral anticoagulation during TAVR on health-related quality of life is unknown.

AIMS

To investigate the impact of continuation as compared to interruption of oral anticoagulation on health-related quality of life.

METHODS

The POPular PAUSE TAVI (Periprocedural Continuation vs. Interruption of Oral Anticoagulant Drugs during Transcatheter Aortic Valve Implantation) trial was an international, open-label, randomized, clinical trial performed at 22 European sites. Health-related quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-12 (SF-12) before, and at 1 and 3 months after TAVR.

RESULTS

A total of 8 patients were included: 431 were assigned to continuation and 427 to interruption of oral anticoagulation. Before TAVR, the mean overall KCCQ summary score was 53.6 (±26.0). At 1 month, the mean change in KCCQ summary score as compared to baseline was +11.4 points (95% confidence interval [CI] 8.0-14.8) in the continuation group and +12.2 points (95% CI 8.8-15.6) in the interruption group (difference -0.7 points; 95% CI -4.6 to 3.1). At 3 months, the mean change was +11.0 points (95% CI 7.3-14.6) versus +13.8 points (95% CI 10.2-17.4), respectively (difference -2.8 points; 95% CI -7.1 to 1.5). Mean changes in SF-12 physical and mental component summary scores showed no differences between both groups at 1 and 3 months after TAVR.

CONCLUSIONS

In patients undergoing TAVR with a concomitant indication for oral anticoagulation, continuation as compared to interruption of oral anticoagulation during TAVR did not significantly impact health-related quality of life up to 3 months after TAVR.

Barriers and facilitators to physical activity after transcatheter aortic valve replacement: A mixed-methods study

OBJECTIVE

To evaluate post-transcatheter aortic valve replacement (TAVR) physical activity and explore the factors influencing participation.

DESIGN

A quantitatively driven sequential explanatory mixed-methods study was performed from October 2021 to February 2022 in Shanghai, China.

PATIENTS

The study sample comprised 195 patients who underwent TAVR (58.46% men, mean age = 74.38 years.

METHODS

A cross-sectional survey was conducted to assess the extent of physical activity maintenance after TAVR via the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Preliminary factors were identified via Poisson regression. Subsequently, Fogg's behaviour model-guided targeted qualitative interviews were conducted to confirm and expand on barriers and facilitators to physical activity engagement.

RESULTS

93.33% of post-TAVR patients lacked regular physical activity. Fourteen barriers and facilitators were identified and grouped into motivation (health expectation, social belonging, feeling after physical activity, kinesiophobia), ability (complex forms of physical activity, misperceptions, scheduling conflicts, traffic and distance, self-regulation), and triggers (surroundings and environment, peer and family support, professional support, mobile health, internalization of exercise habits).

CONCLUSION

The study findings indicate low adherence to regular physical activity among patients post-TAVR. Intervention strategies that increase patients' motivation and ability to perform physical activity and provide appropriate triggers should be further developed.

Gadolinium-guided Transcatheter Aortic Valve Implantation in a Patient with Renal Impairment and a History of Severe Allergic Reaction to Iodinated Contrast Media

Iodinated contrast media is integral to the evaluation for transcatheter aortic valve implantation; however, some patients may have contraindications to the use of iodinated contrast media. The study reports successful use of a gadolinium-based contrast agent in a patient with severe symptomatic aortic stenosis, contrast allergy and post-contrast acute kidney injury.

Comparison of strategies for vascular ACCESS closure after Transcatheter Aortic Valve Implantation: the ACCESS-TAVI randomized trial

BACKGROUND AND AIMS

Data from randomized trials investigating different access closure strategies after transfemoral transcatheter aortic valve implantation (TF-TAVI) remain scarce. In this study, two vascular closure device (VCD) strategies to achieve haemostasis after TF-TAVI were compared.

METHODS

The ACCESS-TAVI (Comparison of Strategies for Vascular ACCESS Closure after Transcatheter Aortic Valve Implantation) is a prospective, multicentre trial in which patients undergoing TF-TAVI were randomly assigned to a strategy with a combined suture-/plug-based VCD strategy (suture/plug group) using one ProGlide™/ProStyle™ (Abbott Vascular) and one Angio-Seal® (Terumo) vs. a suture-based VCD strategy (suture-only group) using two ProGlides™/ProStyles™. The primary endpoint was a composite of major or minor access site-related vascular complications during index hospitalization according to Valve Academic Research Consortium 3 criteria. Key secondary endpoints included time to haemostasis, bleeding type ≥ 2, and all-cause mortality over 30 days.

RESULTS

Between September 2022 and April 2024, 454 patients were randomized. The primary endpoint occurred in 27% (62/230) in the suture/plug group and 54% (121/224) in the suture-only group [relative risk .55 (95% confidence interval: .44, .68); P < .001]. Time to haemostasis was significantly shorter in the suture/plug group compared with the suture-only group (108 ± 208 s vs. 206 ± 171 s; P < .001). At 30 days, bleeding type ≥ 2 occurred less often in the suture/plug group compared with the suture-only group [6.2% vs. 12.1%, relative risk .66 (.43, 1.02); P = .032], with no significant difference in mortality.

CONCLUSIONS

With regard to the composite of major or minor access site-related vascular complications, a combined suture-/plug-based VCD strategy was superior to a suture-based VCD strategy for vascular access closure in patients undergoing TF-TAVI.

Cardiovascular magnetic resonance imaging in mitral valve disease

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure episodes, and excess mortality. Cardiovascular magnetic resonance assessment is recommended for MR when routine ultrasound imaging information is insufficient or discordant. A well-planned CMR can provide an in-depth assessment of the mitral valve apparatus, leaflet morphology, and papillary muscles. In addition, it can precisely inform the impact of MR on left atrial and ventricular remodelling. The review aims to highlight established and emerging techniques for morphological assessment, flow assessment (including regurgitation and stenosis), myocardial assessment, and haemodynamic assessment of mitral valve disease by CMR. It also proposes a simplified clinical flow chart for CMR assessment of the mitral valve.

Shared Decision-Making in Severe Aortic Stenosis: Experiences and Needs of Older Patients

BACKGROUND

The experiences and preferences of older patients regarding shared decision-making (SDM) for managing severe aortic stenosis (AS) and its impact on health outcomes are not well known.

OBJECTIVE

The purpose of this study was to provide insight into the experiences, preferences, and needs for SDM of older patients with severe AS and the associations between perceived SDM levels and patients' quality of life, depression, and anxiety.

METHODS

A descriptive, exploratory multiple-methods study was conducted using a survey, focus groups, and individual interviews with patients 70 years and older with severe AS. Data were collected at baseline and at 3-month follow-up. Quantitative data were analyzed using multivariate linear regression and quantitative data using qualitative thematic analysis.

RESULTS

Quantitative analysis (n = 120) showed that 29.6% of patients reported maximum scores for the perceived SDM level. In addition, the perceived SDM level was significantly associated with the quality of life category environment (B = 2.75; 95% confidence interval, 0.90-4.61; P = .004). Professionals' identification of discussion partners was reported by 41.3% of patients, and 52% of patients reported professionals' exploration of patients' daily lives. For future decision-making, 55.6% of patients preferred a collaborative role. Qualitative analysis of 2 focus groups (n = 10) and interviews (n = 7) revealed patients' preference for informal caregivers' support for decision-making. Patients expressed caution in sharing views on their daily lives and expectations and suggested better preparation and goal exploration for decision-making.

CONCLUSIONS

To align with SDM and personalize the decision-making process, healthcare professionals must foster patient input and engage informal caregivers. Patients must reflect on their daily activities to define their treatment goals.

Fifteen years of experience with the melody™ TPV for percutaneous pulmonary valve replacement

BACKGROUND

The Melody™ TPV has been used as an alternative to surgical pulmonary valve replacement; limited medium-term follow-up data are available.

AIMS

To report the follow-up data of all Melody™ TPVs implanted locally over a 15-year period (2006-2021).

METHODS

Single-centre non-randomised prospective observational study of all implanted Melody™ valves in the pulmonary position.

RESULTS

234 Melody™ valves were implanted at a mean age of 20.8 ± 24.6y. Indications for valve implantation included: pulmonary stenosis (47.2%,) regurgitation (30.9%), and mixed pathology (21.9%). The implant zone substrate consisted of homograft in 52.6%, patched right ventricular outflow tract in 33.8%, and bioprostheses in 13.6% of the cases. Valve survival at 10 years was 89% and 72% at 15 years follow-up. Pulmonary stenosis and pulmonary and tricuspid valve regurgitation demonstrated no significant evolution over the 15-year follow-up. Over the study period, there were 7 deaths at a mean age of 54.2 ± 21.1y; none was valve related. Valve failure was observed in 22 cases (9.4%), mainly due to endocarditis 13/22 (59.0%). The overall incidence of endocarditis was 1.5% per patient-year and occurred in 10.2% (n = 24) of patients 2.7 ± 1.6y after TPV, mostly in younger men (median 18.3, range 8.1 - 49.5 y). Balloon dilatation to accommodate for somatic growth was successful in all 17 (7.3%) attempted cases.

CONCLUSION

The Melody™ valve had a low risk for valve failure with overall well-preserved valve function over up to 15 years of follow-up. Endocarditis remains a concern. The Melody™ valve is competitive with other surgical and percutaneous conduits.

Case Report: Leaflet thrombosis after transcatheter valve-in-valve aortic valve replacement in prosthetic valve endocarditis

A 70-year-old female patient with a history of bioprosthetic aortic valve replacement and coronary artery bypass graft presented with bioprosthetic valve failure secondary to prosthetic valve endocarditis. The patient was deemed unsuitable for surgery by the heart team, following which she underwent transcatheter aortic valve-in-valve replacement. This resulted in early death due to myocardial infarction and acute heart failure. A computed tomography revealed subclinical leaflet thrombosis. This case highlights the importance of postoperative anticoagulation therapy.

Transcatheter Aortic Valve Replacement in Patients With Quadricuspid Aortic Valve: A Case Series and Systematic Review

Background: Quadricuspid aortic valve (QAV) is a rare congenital cardiac anomaly associated with symptomatic aortic regurgitation (AR) or aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) for QAV remains uncertain. Methods: We retrospectively reviewed prospectively collected data from patients with QAV undergoing TAVR in our center and conducted a systematic literature review for further investigation. Results: Five patients with QAV were treated with TAVR between April 2016 and December 2023. The median age was 67 years (range: 59-86), and the median Society of Thoracic Surgeons score (STS-score) was 3.750% (range: 0.916%-11.823%). Procedural success was achieved in all cases. The median follow-up period was 3 years (from 30 days to 7 years). Four of the patients exhibited no serious complications, while one experienced delayed coronary obstruction. Our systematic review included 31 cases from 21 publications and our center. The median age of patients was 79 years (range: 57-90), including 18 males. The median STS score was 7.835%. Severe AS was present in 64.5% of the patients and severe AR in 41.9%. The most common QAV subtype was type B (48.4%). Technical success was achieved in 100% of the cases, with two cases reporting coronary obstruction and one required a permanent pacemaker implantation. During a median follow-up period of 1 year (from 30 days to 7 years), one case experienced serious complications of delayed coronary obstruction. Conclusion: The TAVR may be an alternative treatment for patients with QAV, preliminarily demonstrating feasible early and long-term results from current experience. However, extra precautions regarding coronary artery obstruction complications are necessary due to the rarity and anatomical complexity of QAV.

Abiotrophia defectiva endocarditis implicated in antineutrophil cytoplasmic antibody-negative glomerulonephritis

We report a rare case of antineutrophil cytoplasmic antibody (ANCA)-negative pauci-immune necrotising glomerulonephritis (PING) in Abiotrophia defectiva (A. defectiva) endocarditis. A woman in her 50s presented to the hospital with acute kidney injury (AKI), pancytopenia, microscopic haematuria, proteinuria and maculopapular rash. She had A. defectiva sepsis and endocarditis. Serologies were positive for antinuclear antibody and low complement components 3 and 4 but negative for ANCA. A kidney biopsy revealed PING with minimal focal crescents, fibrinoid necrosis and tubulointerstitial fibrosis. She was managed with antibiotics and mitral valve replacement alone. Haemodialysis (HD) was initiated briefly until renal recovery. She remained in complete remission after 2 years. This case illustrates the complex immune response to bacterial endocarditis resulting in ANCA-negative PING. The appropriate use of antibiotics and surgical intervention without immunosuppression in A. defectiva endocarditis led to the resolution of AKI and maculopapular rash.

Integrated double redo percutaneous valve replacement: simultaneous transcatheter aortic and mitral valve management

OBJECTIVES

The growing elderly population contributes to an increasing prevalence of severe degenerative native aortic valve (AV) or mitral valve (MV) disease in combination with bio-prosthetic valve failure of prior implanted (aortic or mitral) bio-prostheses, as well as concomitant failure of both aortic and mitral bio-prosthetic valves. A combined surgical AV and MV replacement carries a markedly higher risk, especially in the redo setting. Transcatheter double-valve implantation (TDVI) is emerging as a promising alternative that may mitigate the risks of redo surgery. The evidence for TDVI is very limited. This study aims to address the current gap in the literature by analysing a large institutional series of single-stage TDVI.

METHODS

Single-centre retrospective analysis of all patients (n = 13) undergoing simultaneous transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve implantation (TMVI) from October 2018 until April 2024. Primary end-points were Valve Academic Research Consortium-3 (VARC-3) and Mitral Valve Academic Research Consortium (MVARC) technical success, 30-day device success and early safety (MVARC procedural success). Secondary end-points included echocardiographic TDVI performance, adverse events, symptom change and survival.

RESULTS

The median age of patients was 77 years, with 7/13 (53.8%) females. Median EuroSCORE II was 16.9%. All patients presented with structural valve degeneration with severe haemodynamic valve deterioration according to the VARC-3 definition. Procedural outcomes showed 100% technical success. There was absence of 30-day mortality (0%). Thirty-day device success and early safety/MVARC procedural success were 100%. No major adverse events occurred. After TDVI, the median New York Heart Association functional class improved from III to II.

CONCLUSIONS

TDVI appears to be a safe and effective alternative to surgical redo double-valve replacement for selected patients. Our findings support the feasibility of TDVI with excellent early outcomes. Further prospective multicentre studies with larger cohorts are needed to validate the long-term effects and to establish TDVI as a guideline consideration.

Long-term clinical outcomes in patients between the age of 50-70 years receiving biological versus mechanical aortic valve prostheses

OBJECTIVES

The last 2 decades have seen an incremental use of biological over mechanical prostheses. However, while short-term clinical outcomes are largely equivalent, there is still controversy about long-term outcomes.

METHODS

All patients between the ages of 50 and 70 years undergoing elective/urgent isolated aortic valve replacement at our institute between 1996 and 2023 were included. Trends, early, and long-term outcomes were investigated.

RESULTS

A total of 1708 (61% male) patients with a median age of 63.60 (interquartile range: 58.28-67.0) years were included of which 1191 (69.7%) received a biological prosthesis. After inverse propensity score weighting, there were no short-term differences when comparing patients receiving biological and mechanical valves. However, patients who received mechanical prostheses had better long-term survival (P < 0.001). Sub-group analysis revealed that patients with biological size 19 mm prosthesis had the worst long-term survival. Patients with a size 21-mm mechanical prosthesis had better survival compared to both size 19-mm [hazard ratio (HR) 0.25, 95% confidence interval (CI) 0.17-0.37, P < 0.001], 21-mm (HR 0.33, 95% CI 0.23-0.48, P < 0.001) and 23-mm (HR 0.40, 95% CI 0.27-0.60, P < 0.001) biological prosthesis. Additionally, patients with severe patient-prosthesis mismatch exhibited the lowest survival rate compared to those with moderate or no (HR 1.56, 95% CI 1.21-2.00, P < 0.001).

CONCLUSIONS

Patients aged between 50 and 70 years with a mechanical aortic prosthesis had better long-term survival compared to those with a biological prosthesis. Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group.

Transcatheter Edge-to-Edge Repair Versus Annuloplasty in Functional Mitral Valve Regurgitation: A Comparison of Cardiovascular Outcomes

Background

The EVEREST trials established the MitraClip as a viable alternative to surgery in treating functional mitral valve regurgitation (FMVR). The MitraClip G4 offers a less invasive way of managing severe FMVR. We sought to compare in-patient mortality and cardiovascular complications in patients with heart failure with reduced ejection fraction (HFrEF) who developed severe FMVR requiring treatment with MitraClip G4 versus annuloplasty. Comparisons of outcomes to previous iterations of the MitraClip were included in the analysis.

Methods

Using the National Inpatient Sample, we included adult patients with FMVR and HFrEF between 2016 and 2020 who underwent percutaneous repair or annuloplasty. MitraClip G4 use was assumed for MitraClip performed in the third quarter of 2019 and afterward. To avoid overlap between the G4 and previous iterations, MitraClip data from 2019 were excluded. Mortality, stroke, and other complications were assessed. Survey-weighted logistic regression was used to adjust for selection bias in the treatment received based on age and comorbidities. The weighted analysis included 19,500 patients receiving either MitraClip G4 or annuloplasty.

Results

The MitraClip group was associated with a decreased risk of in-hospital mortality (odds ratio (OR): 0.38, confidence interval (CI): 0.18 - 0.77), ischemic stroke (OR: 0.29, CI: 0.13 - 0.61), and myocardial infarction (OR: 0.15, CI: 0.08 - 0.28). The MitraClip G4 cohort did not outperform earlier clip versions in reducing complications.

Conclusions

The MitraClip G4 was associated with lower in-hospital mortality and cardiovascular complications than annuloplasty but had outcomes similar to earlier clip versions. Additional studies comparing percutaneous therapies and surgical interventions are necessary to determine optimal treatment strategies for patients with FMVR.

Isolated tricuspid regurgitation: a new entity to face. Prevalence, prognosis and treatment of isolated tricuspid regurgitation

In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identified as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.

Residual Mitral Regurgitation Interacts With Transmitral Mean Pressure Gradient to Modify the Association With Mortality Following Transcatheter Edge-to-Edge Repair

BACKGROUND

The association, if any, between the transmitral mean pressure gradient (TMPG) after mitral transcatheter edge-to-edge repair and 1-year mortality is controversial in patients undergoing mitral transcatheter edge-to-edge repair with the MitraClip system. We sought to estimate the association between intraoperatively measured residual mitral regurgitation (rMR) and TMPG and 1-year mortality among patients undergoing mitral transcatheter edge-to-edge repair to facilitate decisions on additional devices.

METHODS

In patients with severe secondary (functional) MR, we analyzed registry data using generalized estimating equations. Both rMR and TMPG were nonlinearly transformed using fractional polynomials.

RESULTS

We studied 570 patients with secondary MR who underwent mitral transcatheter edge-to-edge repair in 11 centers. Most patients were men (61%) and averaged 72±12 years of age. Most (78%) patients had TMPG <5 mm Hg and 22% had TMPG ≥5 mm Hg. Postprocedural MR severity improved substantially, being ≤2+ in 95% (with ≤1+ in 76%), 3+ in 3%, and 4+ in 2%. 1-year mortality was 20%. After adjustment for confounders, rMR (odds ratio, 2.10 [95% CI, 1.88-2.35]; P<0.001 for rMR.5) and TMPG remained associated with mortality, with odds ratios of 1.26 (95% CI, 1.19-1.32), 1.84 (1.58-2.10), and 3.13 (2.31-3.98) for TMPG values of 4, 6, and 8, respectively, compared with TMPG=2 mm Hg at rMR=1+.

CONCLUSIONS

Both rMR and TMPG were nonlinearly associated with 1-year mortality. At low levels of rMR, changes in TMPG are associated with only small changes in the risk of death. Conversely, at higher levels of rMR, even small changes in TMPG are associated with larger changes in the absolute risk of death.

Pathology of Self-Expanding Transcatheter Aortic Bioprostheses and Hypoattenuated Leaflet Thickening

BACKGROUND

Hypoattenuated leaflet thickening (HALT) is believed to reflect leaflet thrombosis; however, no systematic histological examination of HALT has ever been performed. The aim of this study was to evaluate histological findings of explanted self-expanding transcatheter aortic bioprosthetic valves from clinical trials and to compare microCT findings of suspected HALT with histology findings of valve thrombosis and its characterization over time.

METHODS

A total of 123 self-expanding transcatheter aortic valves were collected through autopsy (n=89) or surgical explant (n=34) from 11 CoreValve/Evolut clinical trials. Histological findings in transcatheter aortic valve leaflets were evaluated. MicroCT imaging was used to evaluate HALT in histology. Cases with infective endocarditis (10/123) or transcatheter aortic valve-in-surgical aortic valve procedures (3/123) were excluded.

RESULTS

A total of 110 cases were divided into 3 groups based on implant duration: <30 days (n=42), 30 to 365 days (n=35), and >365 days (n=33). Thrombus and inflammation scores were consistent across groups, while scores for pannus, calcification, and structural change increased over time. The analysis of leaflet thickening by histology was performed on 320 leaflets and any degree of leaflet thickening was observed in 46.5% (149/320) of leaflets. Histologically, leaflet thickening was confirmed as an acute, organizing, and organized thrombus (ie, pannus). In the <30 days group, all leaflet thickening was due to acute thrombus, while most thrombi were organized >30 days. The types of thrombi could not be differentiated by microCT imaging.

CONCLUSIONS

HALT represents the presence of a thrombus and its progression. Our data suggest that treatment of HALT would likely be most effective in the early stages before the thrombus becomes organized and emphasizes the need for early detection.

Successful Valve-in-Valve-in-Valve Transcatheter Aortic Valve Implantation for Severe Bioprosthetic Valve Restenosis in a High-Risk Patient

Transcatheter aortic valve implantation (TAVI) has significantly improved in treating aortic valve disease in recent years, particularly in patients at high surgical risk. This case report describes an 80-year-old woman who had severe aortic stenosis previously treated with surgical aortic valve replacement (SAVR) and six years later had a valve-in-valve (ViV) TAVI who developed severe symptomatic restenosis of the bioprosthetic aortic valve five years later of the last procedure. A third valve-in-valve-in-valve (ViViV) TAVI using a 26-mm Sapien 3 valve was performed due to the high surgical risk. The procedure resulted in significant hemodynamic improvement, reducing the transvalvular gradient from 80-90 mmHg to 15-20 mmHg and increasing the effective orifice area from 0.4 cm² to 1.5 cm². The patient's symptoms improved to NYHA Class I. This case highlights the feasibility and safety of ViViV TAVI as a minimally invasive solution for recurrent bioprosthetic valve dysfunction in high-risk patients.

Evaluation of Expanded Mitral Regurgitation Grading in Patients Undergoing Transcatheter Edge-to-Edge Repair

Background

An expanded tricuspid regurgitation scale has been shown to be incrementally useful in understanding the response to transcatheter therapies. A similar approach to mitral regurgitation (MR) has not been evaluated. The purpose of this study was to investigate how an expanded MR grading system that includes categories of massive and torrential would regrade patients undergoing transcatheter edge-to-edge repair (TEER) for MR and evaluate procedural outcomes.

Methods

We retrospectively identified 142 consecutive patients with severe MR who underwent TEER. Transesophageal echocardiography was used to assess the quantitative severity of MR and reclassify regurgitation into severe, massive, and torrential grades. Similarly, residual MR was assessed postprocedurally.

Results

In the expanded scale, 59% of patients were regraded as severe, 23% as massive, and 18% as torrential, with respective median effective regurgitant orifice area (cm2) of 0.45 [0.39, 0.50], 0.68 [0.65, 0.75], and 0.95 [0.85, 1.20]. Ninety-three percent of the entire cohort and 93% of severe, 94% of massive, and 96% of torrential patients, achieved moderate or less MR post-TEER (p = 0.850) with corresponding improvements in New York Heart Association Functional Classification and 12-item Kansas City Cardiomyopathy Questionnaire scores.

Conclusions

An expanded grading system demonstrated that patients with massive and torrential MR still achieve adequate procedural success with reduction in regurgitation and improvement in health status. Further evaluation of how an expanded MR grading scale may be useful is warranted.

Epicardial adipose tissue, cardiac damage, and mortality in patients undergoing TAVR for aortic stenosis

Computed tomography (CT)-derived Epicardial Adipose Tissue (EAT) is linked to cardiovascular disease outcomes. However, its role in patients undergoing Transcatheter Aortic Valve Replacement (TAVR) and the interplay with aortic stenosis (AS) cardiac damage (CD) remains unexplored. We aim to investigate the relationship between EAT characteristics, AS CD, and all-cause mortality. We retrospectively included consecutive patients who underwent CT-TAVR followed by TAVR. EAT volume and density were estimated using a deep-learning platform and CD was assessed using echocardiography. Patients were classified according to low/high EAT volume and density. All-cause mortality at 4 years was compared using Kaplan-Meier and Cox regression analyses. A total of 666 patients (median age 81 [74-86] years; 54% female) were included. After a median follow-up of 1.28 (IQR 0.53-2.57) years, 11.7% (n = 77) of patients died. The EAT volume (p = 0.017) decreased, and density increased (p < 0.001) with worsening AS CD. Patients with low EAT volume (< 49cm3) and high density (≥-86 HU) had higher all-cause mortality (log-rank p = 0.02 and p = 0.01, respectively), even when adjusted for age, sex, and clinical characteristics (HR 1.71, p = 0.02 and HR 1.73, p = 0.03, respectively). When CD was added to the model, low EAT volume (HR 1.67 p = 0.03) and CD stages 3 and 4 (HR 3.14, p = 0.03) remained associated with all-cause mortality. In patients with AS undergoing TAVR, CT-derived low EAT volume, and high density were independently associated with increased 4-year mortality and worse CD stage. Only EAT volume remained associated when adjusted for CD.

Percutaneous Management of Paravalvular Leak-Related Hemolytic Anemia After Transcatheter Aortic Valve Replacement

We present a case of a patient with severe intravascular hemolytic anemia from a paravalvular leak after transcatheter aortic valve replacement and describe a technique of percutaneous repair of the leak with a vascular plug that resolved the patient's transfusion-dependent hemolysis.

LEARNING POINTS

Paravalvular leak after transcatheter aortic valve replacement could lead to intractable hemolytic anemia.Percutaneous paravalvular leak repair with vascular plug implantation is a feasible treatment for aortic prosthesis leak-related hemolysis.

Evolution of Coagulation and Platelet Activation Markers After Transcatheter Edge-to-Edge Mitral Valve Repair

Background/Objectives: The recommendations for antithrombotic therapy after transcatheter edge-to-edge mitral valve repair (TEER) are empirical, and the benefit of antiplatelet (APT) or anticoagulation therapy (ACT) remains undetermined. The study sought to investigate the degree and the timing of coagulation and platelet marker activation after TEER. Methods: This was a prospective study including 46 patients undergoing TEER. The markers of coagulation activation, namely prothrombin fragment 1 + 2 (F1 + 2) and thrombin-antithrombin III (TAT), and the markers of platelet activation, namely soluble P-Selectin and soluble CD-40 ligand (sCD40L), were measured at baseline, 24 h, 1 month, and 1 year after TEER. Results: At discharge, 20 (43%) patients received APT (single: 16, dual: 4), 24 (52%) received ACT, and 2 (4%) had both single APT and ACT. Levels of F1 + 2 and TAT significantly increased at 24 h post TEER (both p < 0.001), rapidly returning to baseline levels at 1 month. However, levels of F1 + 2 and TAT remained higher at 1 month in patients without ACT compared to patients with ACT (respectively, 303.1 vs. 148.1 pmol/L; p < 0.001 and 4.6 vs. 3.0 µg/L; p = 0.020), with a similar trend at 1 year. Levels of soluble P-selectin and sCD40L remained stable at all times after TEER (respectively, p = 0.071 and p = 0.056), regardless of the APT. Conclusions: TEER is associated with an acute activation of the coagulation system, with no increase in platelet activation markers. Hence, the use of dual APT is questionable in this population. Our results raise the hypothesis that the optimal antithrombotic therapy after TEER could be short-term ACT over APT. Further larger studies are warranted.

Transcatheter Aortic Valve Implantation (TAVI) in Bicuspid Anatomy

Bicuspid aortic valve (BAV) stenosis, a common congenital condition, presents unique challenges for transcatheter aortic valve replacement (TAVI) due to anatomical variations like cusp morphology, coexisting aortopathy and calcification. TAVI offers a viable option for BAV patients with refinements in technique and technology, though ongoing research is essential to optimize patient-specific approaches and long-term results. Key considerations for TAVI in BAV include precise valve sizing, positioning, and the need for rigorous pre-procedural imaging to mitigate risks such as paravalvular leak and stroke. Early results show TAVI's safety and efficacy are comparable to surgery, though BAV patients undergoing TAVI often are exposed to higher rates of post-procedural pacemaker implantation. Emerging data on next-generation self-expandable (SE) and balloon-expandable (BE) valves reveal that while both offer success in this complex anatomical aortic valve variation, gaps remain in the long-term durability and management of BAV-related aortopathy. This review examines the latest advancements in TAVI for BAV, emphasizing how specialized approaches and device selection address BAV's complexities.

TAVI with the ACURATE neo2 in severe bicuspid aortic valve stenosis: the Neo2 BAV Registry

BACKGROUND

The ACURATE neo2 is a contemporary transcatheter aortic valve implantation (TAVI) system approved for the treatment of severe aortic stenosis in Europe. The ACURATE neo2 has not been evaluated in bicuspid aortic valve (BAV) stenosis.

AIMS

We sought to evaluate the safety and efficacy of ACURATE neo2 in patients with BAV stenosis.

METHODS

We retrospectively analysed consecutive severe BAV stenosis patients undergoing TAVI with ACURATE neo2 at 10 European centres. Imaging data from preprocedural multislice computed tomography, pre- and postprocedural echocardiography, and procedural cinefluoroscopy were evaluated by a core laboratory. Valve Academic Research Consortium 3 (VARC-3)-defined 30-day procedure safety and efficacy were the primary endpoints. Adverse events were site-reported according to VARC-3 criteria.

RESULTS

Among 181 patients with BAV stenosis treated with the ACURATE neo2, the mean age was 77.5±7.2 years, 58.0% were female, and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.3% (1.6-3.7%). Most procedures were transfemoral, and predilatation was performed in all cases. A second valve was required in 4 cases (2.2%). VARC-3-defined technical success was 95.6%. The primary endpoints of device success and early safety occurred in 90.6% and 82.3%, respectively. At 30 days, cardiovascular death occurred in 2.2% (N=4) and stroke in 1.6% (N=3). Core laboratory-adjudicated echocardiography reported an effective orifice area of 2.0 (1.7-2.5) cm2 and a mean transvalvular gradient of 6.5 (4.6-9.0) mmHg. Half of all cases (51.2%) had no paravalvular leak, while moderate leak occurred in 4.3%. A new permanent pacemaker was required in 11 patients (6.5%).

CONCLUSIONS

The ACURATE neo2 demonstrated favourable clinical outcomes and bioprosthetic valve performance at 30 days in selected patients with severe BAV stenosis.

Registries on transcatheter edge-to-edge repair in heart failure: Current evidence and future perspectives

AIMS

Secondary mitral regurgitation (SMR) and tricuspid regurgitation (TR) are the most common valvular heart diseases in patients with heart failure (HF). Transcatheter edge-to-edge repair (TEER) devices designed for treating MR and TR have been successfully tested in randomized controlled trials, but methodological issues have often challenged their interpretation. This manuscript aimed to provide an overview of TEER registries on SMR and TR in HF, highlighting their key features, describing clinical characteristics and outcomes of patients receiving these devices, and exploring the available data limitations.

METHODS AND RESULTS

PubMed, Web of Science, and EMBASE were searched for registries reporting on TEER in SMR or TR. Registries were excluded if single-centre and with <100 patients. Twenty-six registries (46% prospective, 12% ongoing), including a total cohort of 18 925 patients, were retrieved for TEER in SMR, and six registries (50% retrospective, 33% ongoing) reported on the use of TEER for TR in a total cohort of 1412 patients. Limited geographical representativity outside North America and Europe, high number of missing values, and inconsistency in data reporting were the main existing evidence limitations.

CONCLUSION

Registries on TEER represent a key data source in a setting where it is difficult to conduct randomized controlled trials. However, limitations in design, patient characterization, and outcomes reporting restrain their use. A novel conceptual framework for future prospective TEER registries, as proposed in this document, might inform current practice, address relevant clinical questions and future trial design.

Evolving perspectives on aortic stenosis: the increasing importance of evaluating the right ventricle before aortic valve intervention

Aortic stenosis (AS) was historically considered a disease of the left side of the heart, with the main pathophysiological impact being predominantly on the left ventricle (LV). However, progressive pressure overload in AS can initiate a cascade of extra-valvular myocardial remodeling that could also precipitate maladaptive alterations in the structure and function of the right ventricle (RV). The haemodynamic and clinical importance of these changes in patients with AS have been largely underappreciated in the past. Contemporary data indicates that RV dilatation or impairment identifies the AS patients who are at increased risk of adverse clinical outcomes after aortic valve replacement (AVR). It is now increasingly recognised that effective quantitative assessment of the RV plays a key role in delineating the late clinical stage of AS, which could improve patient risk stratification. Despite the increasing emphasis on the pathological significance of RV changes in AS, it remains to be established if earlier detection of these changes can improve the timing for intervention. This review will summarise the features of normal RV physiology and the mechanisms responsible for RV impairment in AS. In addition, we will discuss the multimodality approach to the comprehensive assessment of RV size, function and mechanics in AS patients. Finally, we will review the emerging evidence reinforcing the negative impact of RV dysfunction on clinical outcomes in AS patients treated with AVR.

Prognostic Implications of Right Ventricular Dysfunction in Severe Degenerative Mitral Regurgitation

BACKGROUND

The prevalence and impact of right ventricular dysfunction (RVD) in degenerative mitral regurgitation (DMR) is unknown. We aimed to determine whether RVD assessed by echocardiography in routine clinical practice is independently associated with mortality in patients with DMR.

METHODS AND RESULTS

We used data from the MIDA-Q (Mitral Regurgitation International DAtabase-Quantitative) registry, which included patients with isolated DMR due to mitral valve prolapse from January 2003 to January 2020 from 5 tertiary centers across North America, Europe, and the Middle East. A cohort of 2917 (mean age: 66 years, 70.8% male patients, follow-up: 5.2 [3.3-8.3] years) consecutive patients with severe DMR was included and long-term mortality was analyzed. RVD, identified in 426 (14.6%) patients, was associated with reduced 8-year survival (55%±3% versus 77%±1%; P <0.001), overall and in all subgroups of patients, even after comprehensive adjustment including left ventricular dilatation and dysfunction, DMR severity, pulmonary pressures, and surgery (adjusted hazard ratio, 1.44 [95% CI, 1.17-1.77]; P <0.001). This excess mortality was observed under medical management (adjusted hazard ratio, 1.57 [95% CI, 1.20-2.05]; P=0.001) and after surgical correction of mitral regurgitation (adjusted hazard ratio, 1.45 [95% CI, 1.02-2.05]; P=0.039). Patients with RVD undergoing surgery within 3 months of diagnosis experienced a better 8-year survival (73%±4% versus 43%±4%; P <0.001), even after adjustment (adjusted hazard ratio, 0.44 [95% CI, 0.29-0.67]; P <0.001) despite an increase of 1-month postoperative mortality (7.1% versus 0.5% for patients without RVD; P <0.001).

CONCLUSIONS

RVD is observed in 14.6% of severe DMR and exhibits a powerful and independent association with excess mortality partially attenuated by mitral surgery. Therefore, assessment of right ventricular systolic function should be included in routine DMR evaluation and in the clinical decision-making process.

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve Disease: A Review of the Existing Literature

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to replace a damaged aortic valve with a prosthetic valve. TAVR has exceeded surgical aortic valve replacement (SAVR) due to shorter procedures and recovery times. Though initially approved for patients with aortic stenosis at a high surgical risk, TAVR's indications have now broadened to include high, intermediate, and low-risk patients. This review focuses on the evolving role of TAVR in patients with bicuspid aortic valves (BAV). We examine the anatomical and hemodynamic differences between tricuspid aortic valve and BAV, highlighting the unique challenges TAVR faces in BAV patients.

FEBio FINESSE: An Open-Source Finite Element Simulation Approach to Estimate In Vivo Heart Valve Strains Using Shape Enforcement

PURPOSE

Finite element simulations are an enticing tool to evaluate heart valve function; however, patient-specific simulations derived from 3D echocardiography are hampered by several technical challenges. The objective of this work is to develop an open-source method to enforce matching between finite element simulations and in vivo image-derived heart valve geometry in the absence of patient-specific material properties, leaflet thickness, and chordae tendineae structures.

METHODS

We evaluate FEBio Finite Element Simulations with Shape Enforcement (FINESSE) using three synthetic test cases considering a range of model complexity. FINESSE is then used to estimate the in vivo valve behavior and leaflet strains for three pediatric patients.

RESULTS

Our results suggest that FINESSE can be used to enforce finite element simulations to match an image-derived surface and estimate the first principal leaflet strains within ± 0.03 strain. Key considerations include: (i) defining the user-defined penalty, (ii) omitting the leaflet commissures to improve simulation convergence, and (iii) emulating the chordae tendineae behavior via prescribed leaflet free edge motion or a chordae emulating force. In all patient-specific cases, FINESSE matched the target surface with median errors of approximately the smallest voxel dimension. Further analysis revealed valve-specific findings, such as the tricuspid valve leaflet strains of a 2-day old patient with HLHS being larger than those of two 13-year old patients.

CONCLUSIONS

FEBio FINESSE can be used to estimate patient-specific in vivo heart valve leaflet strains. The development of this open-source pipeline will enable future studies to begin linking in vivo leaflet mechanics with patient outcomes.

Validation of the Valve Academic Research Consortium High Bleeding Risk Definition in Patients Undergoing TAVR

BACKGROUND

The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) has recently introduced a consensus document that outlines risk factors to identify high bleeding risk in patients undergoing transcatheter aortic valve replacement. The objective of the present study was to evaluate the prevalence and predictive value of the VARC-HBR definition in a contemporary, large-scale transcatheter aortic valve replacement population.

METHODS

Multicenter study including 10 449 patients undergoing transcatheter aortic valve replacement. Based on consensus, 21 clinical and laboratory criteria were identified and classified as major or minor. Patients were stratified as at low, moderate, high, and very high bleeding risk according to the VARC-HBR definition. The primary end point was the rate of Bleeding Academic Research Consortium type 3 or 5 bleeding at 1 year, defined as the composite of periprocedural (within 30 days) or late (after 30 days) bleeding.

RESULTS

Patients with at least 1 VARC-HBR criterion (n=9267, 88.7%) had a higher risk of Bleeding Academic Research Consortium 3 or 5 bleeding, proportional to the severity of risk assessment (10.8%, 16.1%, and 24.6% for moderate, high, and very-high-risk groups, respectively). However, a comparable rate of bleeding events was observed in the low-risk and moderate-risk groups. The area under receiver operating characteristic curve was 0.58. Patients with VARC-HBR criteria also exhibited a gradual increase in 1-year all-cause mortality, with an up to 2-fold increased mortality risk for high and very-high-risk groups (hazard ratio, 1.33 [95% CI, 1.04-1.70] and 1.97 [95% CI, 1.53-2.53], respectively).

CONCLUSIONS

The VARC-HBR consensus offered a pragmatic approach to guide bleeding risk stratification in transcatheter aortic valve replacement. The results of the present study would support the predictive validity of the new definition and promote its application in clinical practice to minimize bleeding risk and improve patient outcomes.

A Review of "Access to Care" Issues in Aortic Stenosis Patients: A Negative Report Card

The identification and management of patients with aortic stenosis exist along a continuum that includes healthy living, latent progression, diagnosis, treatment, and posttreatment recovery. Barriers to the provision of appropriate care for these patients can occur at any stage along this continuum. Despite the presence of diagnostic echocardiograms, many patients with aortic stenosis are never clinically recognized, and the rate of mismanagement worsens among underrepresented minority groups and women. Regarding the treatment of clinically recognized aortic stenosis, only about half of patients with symptomatic severe aortic stenosis actually undergo aortic valve replacement within 2 ​years of diagnosis. Treatment rates are even lower among patients with symptomatic low-gradient severe aortic stenosis. Although several strategies have been raised by experts within the field to help and improve the diagnosis and treatment of patients with aortic valve disease, timely referral to a heart valve team specialist whenever aortic valve replacement is being considered likely remains the most pertinent intervention. Connecting these patients with fully informed aortic valve disease experts helps facilitate shared decision-making discussions, thus ensuring that patients have the opportunity to learn about and potentially receive the lifesaving interventions available to them.

Usefulness of Aortic Valve Calcification in Patients With Low-Flow Aortic Stenosis

BACKGROUND

Aortic valve calcification (AVC) has been shown to be a powerful assessment of aortic stenosis (AS) severity and a predictor of adverse outcomes. However, its accuracy in patients with low-flow AS has not yet been proven. The objective of the study was to assess the predictive value of AVC in patients with classical low-flow (CLF, that is, low-flow reduced left ventricular ejection fraction) or paradoxical low-flow (PLF, that is, low-flow preserved left ventricular ejection fraction) AS.

METHODS

We prospectively included 641 patients, 319 (49.8%) with CLF-AS and 322 (50.2%) with PLF-AS, who underwent Doppler echocardiography and multidetector computed tomography. AVC ratio (AVCratio) was calculated as AVC divided by the sex-specific AVC threshold for AS severity; AVC score ≥2000 Agatston units in male patients and ≥1200 Agatston units in female patients. The primary end point of the study was all-cause mortality regardless of treatment.

RESULTS

Sex-specific AVC thresholds identified AS severity correctly in 137 (87%) of the patients. During a median follow-up of 4.9 (4.3-5.9) years, there were 265 deaths. After comprehensive adjustment, AVCratio was associated with all-cause mortality in patients with CLF-AS (adjusted hazard ratio, 1.25 [95% CI, 1.01-1.56]; P=0.046) and PLF-AS (adjusted hazard ratio, 1.51 [95% CI, 1.14-2.00]; P=0.004). There was an interaction (P=0.001) between AVC and AS flow patterns (ie, CLF versus PLF) with regard to the prediction of mortality. The best AVCratio threshold to predict mortality was different in patients with CLF-AS (AVCratio ≥0.7) and PLF-AS (AVCratio ≥1). After a comprehensive analysis, AVCratio as a dichotomic variable was associated with all-cause mortality in all groups (P≤0.001). The addition of AVCratio to the models improved all models' predictive value (all net reclassification index >18%; all P≤0.05).

CONCLUSIONS

In patients with CLF-AS or PLF-AS, AVC is a major predictor of mortality. Thus, AVC should be used in low-flow patients to assess AS severity and stratify risk. Importantly, in patients with reduced left ventricular ejection fraction, a nonsevere AS (ie, AVC 70% of severe) could be associated with reduced survival.

Dental Instrumentation Leading to Multivalvular Vegetation Endocarditis in an Otherwise Healthy Immunocompetent Patient Requiring Double Valve Replacement

Infective endocarditis (IE) is a severe condition associated with significant morbidity and mortality, often caused by bacterial seeding. Dental procedures are a well-known and well-documented risk factor for this disease. The authors present a case involving an otherwise healthy 58-year-old male with no cardiac risk factors who developed IE following a dental crown preparation. The patient's dental-induced IE could not be managed medically due to bacterial abscess formation in the mitral and aortic valves. As a result, he developed both mitral and aortic valvopathies, characterized by mild mitral and severe aortic regurgitation, ultimately necessitating mitral valve and aortic valve replacement under cardiopulmonary bypass. This case report highlights the appropriate identification of IE, perioperative evaluation, intraoperative anesthetic management, and a review of echocardiographic findings. A heightened level of clinical awareness was critical for identifying this high-morbidity and high-mortality disease process. The report also reviews the full spectrum of diagnostic and therapeutic interventions in managing an otherwise healthy individual.

Multi-modality artificial intelligence-based transthyretin amyloid cardiomyopathy detection in patients with severe aortic stenosis

PURPOSE

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a frequent concomitant condition in patients with severe aortic stenosis (AS), yet it often remains undetected. This study aims to comprehensively evaluate artificial intelligence-based models developed based on preprocedural and routinely collected data to detect ATTR-CM in patients with severe AS planned for transcatheter aortic valve implantation (TAVI).

METHODS

In this prospective, single-center study, consecutive patients with AS were screened with [99mTc]-3,3-diphosphono-1,2-propanodicarboxylic acid ([99mTc]-DPD) for the presence of ATTR-CM. Clinical, laboratory, electrocardiogram, echocardiography, invasive measurements, 4-dimensional cardiac CT (4D-CCT) strain data, and CT-radiomic features were used for machine learning modeling of ATTR-CM detection and for outcome prediction. Feature selection and classifier algorithms were applied in single- and multi-modality classification scenarios. We split the dataset into training (70%) and testing (30%) samples. Performance was assessed using various metrics across 100 random seeds.

RESULTS

Out of 263 patients with severe AS (57% males, age 83 ± 4.6years) enrolled, ATTR-CM was confirmed in 27 (10.3%). The lowest performances for detection of concomitant ATTR-CM were observed in invasive measurements and ECG data with area under the curve (AUC) < 0.68. Individual clinical, laboratory, interventional imaging, and CT-radiomics-based features showed moderate performances (AUC 0.70-0.76, sensitivity 0.79-0.82, specificity 0.63-0.72), echocardiography demonstrated good performance (AUC 0.79, sensitivity 0.80, specificity 0.78), and 4D-CT-strain showed the highest performance (AUC 0.85, sensitivity 0.90, specificity 0.74). The multi-modality model (AUC 0.84, sensitivity 0.87, specificity 0.76) did not outperform the model performance based on 4D-CT-strain only data (p-value > 0.05). The multi-modality model adequately discriminated low and high-risk individuals for all-cause mortality at a mean follow-up of 13 months.

CONCLUSION

Artificial intelligence-based models using collected pre-TAVI evaluation data can effectively detect ATTR-CM in patients with severe AS, offering an alternative diagnostic strategy to scintigraphy and myocardial biopsy.

Predictive Value of Preoperative Hypersensitive C-Reactive Protein in the Incidence of Postoperative Cognitive Impairment in Valvular Disease Patients: A Retrospective Study

Objective

Postoperative cognitive dysfunction (POCD) is associated with adverse outcomes of cardiac surgery. This study investigated the potential of pre-operative hypersensitive C-reactive protein (Hs-CRP) as a prognostic indicator of POCD in valvular disease (VHD).

Methods

This study retrospectively analyzed 372 VHD patients admitted to the Department of Cardiac Surgery, Fujian Medical University Union Hospital from January 2024 to July 2024. POCD was evaluated by neuropsychological examination before and one month after surgery. Demographics, disease history, blood biochemical parameters, and perioperative data were collected. Patients were divided into a POCD group (N = 103) and a non-POCD group (N = 269) according to the occurrence of POCD. A logistic regression model was used to analyze the relationship between Hs-CPR and POCD in VHD patients.

Results

The 1-month incidence of POCD in VHD patients was 27.6%. There was statistical significance in age and years of education between the two groups (P = 0.047, P = 0.001). The red blood cell count in the POCD group was lower than that in the non-POCD group (P = 0.025), and the Hs-CRP and mechanical ventilation duration in the POCD group was higher than that in the non-POCD group, with statistical significance (P < 0.001). No significant differences were observed in the results of demographic characteristics and other laboratory measures. The incidence of hospitalization days, ICU stay time, acute renal insufficiency, and new cerebral infarction in the POCD group were higher than those in the non-POCD group (P < 0.001, P < 0.001, P = 0.001, P = 0.029). Univariate and multivariate analysis showed that Hs-CRP was an independent risk factor for POCD in patients undergoing surgery for VHD disease.

Conclusion

Our study shows that preoperative Hs-CRP is significantly elevated in POCD patients undergoing VHD surgery, and preoperative Hs-CRP is an independent predictor of POCD.

Exploratory Study of the Measurement of Geometric Height in 3D Transesophageal Echocardiography as a Predictor of Valve-Sparing Root Replacement for Aortic Regurgitation

Background: Valve-sparing root replacement surgery is an alternative strategy for patients with aortic regurgitation with or without aortic root enlargement. A detailed understanding of the mechanisms of regurgitation and the morphology of the aortic root would be beneficial for predicting the feasibility and success of valve-sparing surgery. This is an exploratory study of the measurement of geometric height in 3D transesophageal echocardiography as a predictor of valve-sparing root replacement for aortic regurgitation. Methods: Transesophageal echocardiographic findings and long-term outcomes were compared in 124 patients undergoing either valve-sparing root replacement (VSRR group) or composite valve graft replacement (Bentall group) from September 2014 to March 2019. Results: The VSRR group was younger and had better left ventricular function than the Bentall group. Three-dimensional transesophageal echocardiography showed that geometric height was significantly larger in the VSRR group. In receiver-operating curve analysis, the cutoff values of geometric height for the feasibility of valve-sparing surgery were 15.9 mm and 19.8 mm in the tricuspid and bicuspid aortic valve, respectively. The overall survival was 98.6% and the freedom from reoperation rate was 89.7% at 5 years in the VSRR group. Conclusions: Appropriate patient selection and adequate GH may contribute to the success of VSSR and improve long-term outcomes.

Research on rheumatic heart disease from 2013 to early 2024: a bibliometric analysis

OBJECTIVES

The aim of this bibliometric analysis was to highlight potential future areas for the practical application of research on rheumatic heart disease (RHD), considering past and current research efforts.

METHODS

A systematic search was conducted in the WoSCC to find articles and reviews focused on RHD published between 2013 and 2024. Microsoft Excel 2019 was used to chart the annual productivity of research relevant to RHD, while ArcGIS (version 10.8) was employed to visualize the global distribution of publications. Analysis tools such as CiteSpace (version 6.1.R6) and VOSviewer (version 1.6.18) were utilized to identify the most prolific countries or regions, authors, journals, and resource-, intellectual-, and knowledge-sharing in RHD research, and to perform co-citation analysis of references and keywords. Additionally, the Bibliometrix R Package was used to analyze topic dynamics.

RESULTS

From the search, a total of 2,428 publications were retrieved. In terms of countries or regions, the United States was the most productive country (566, 23.31%). As for institutions, most publications have been contributed by the University of Cape Town (149, 6.14%). Regarding authors, Jonathan R. Carapetis produced the most published works, and he received the most co-citations. The most prolific journal was identified as the International Journal of Cardiology (70, 2.88%). The study published in Circulation received the most co-citations. Keywords with ongoing strong citation bursts included "surgical treatment" and "valvular heart disease".

CONCLUSION

Despite the rapid advancements in the field of RHD research, future efforts should prioritize strengthening collaboration among national institutions to facilitate information dissemination. Current research on RHD mainly focuses on prognosis of patients. While, the emerging research trends in RHD encompass treatment strategies for complications, including atrial fibrillation (AF), heart failure (HF), and infective endocarditis, as well as screening strategies for RHD and surgical interventions for patients with rheumatic mitral valve disease.

Global, Regional, and National Burden of Valvular Heart Disease, 1990 to 2021

BACKGROUND

Valvular heart disease poses an escalating global health challenge with an increasing impact on mortality and disability. This study aims to comprehensively analyze the global burden of valvular heart disease.

METHODS AND RESULTS

Using the Global Burden of Disease 2021 data, we analyzed the prevalence and disability-adjusted life years, examining implications across demographics and geographic regions. In 2021, an estimated 54.8 million (95% uncertainty interval [UI], 43.3-67.6) cases of rheumatic heart disease, 13.3 million (95% UI, 11.4-15.2) cases of nonrheumatic calcific aortic valve disease (CAVD), and 15.5 million (95% UI, 14.5-16.7) cases of nonrheumatic degenerative mitral valve disease (DMVD) were reported globally. Despite the rising prevalence, disability-adjusted life years declined between 1991 and 2021. Among individuals aged 70 years or older, the age-standardized prevalences were 1803.6 per 100 000 (95% UI, 1535.5-2055.7) for CAVD and 2148.9 per 100 000 (95% UI, 2001.4-2310.1) for DMVD. Sub-Saharan Africa had the highest age-standardized prevalence for rheumatic heart disease; Conversely, high-income regions led in CAVD and DMVD prevalence. Rheumatic heart disease had the highest age-standardized prevalence of 1184.2 per 100 000 (95% UI, 932.4-1478.2) in low Socio-Demographic Index (SDI) regions, whereas CAVD peaked at 349.8 per 100 000 (95% UI, 303.6-395.8) in high SDI regions. The most substantial increases in age-standardized prevalences of CAVD from 1990 to 2021 occurred in the middle SDI and low-middle SDI regions. A parallel trend was noted for DMVD.

CONCLUSIONS

Rheumatic heart disease remains a significant burden in low SDI regions, whereas CAVD and DMVD pose challenges in high SDI regions with aging populations.

Lifetime management considerations to optimise transcatheter aortic valve implantation: a practical guide

Transcatheter aortic valve implantation (TAVI) is a safe and effective procedure for the treatment of aortic stenosis. With the recently broadened indications, there is a larger cohort of patients likely to outlive their first transcatheter heart valve (THV). This review discusses relevant lifetime planning considerations, focusing on the utility of preprocedural computed tomography imaging to help implanters future-proof their patients who are likely to outlive their first valve. The initial priority is to optimise the index procedure by maximising THV haemodynamic function and durability. This involves maximising the effective orifice area, minimising the risk of new pacemaker implantation, reducing paravalvular regurgitation, and preventing coronary obstruction and annular rupture. In patients requiring a second valve procedure, a significant proportion will require a TAVI-in-TAVI, and implanters should consider the key priorities for a redo procedure, including the increased risks of patient-prosthesis mismatch and conduction abnormalities, promoting coronary reaccessibility, and preventing coronary obstruction and sinus sequestration. Careful planning can identify potential hurdles as well as predict the feasibility and likely outcomes of redo-TAVI, to help individualise care over the lifetime of each patient.

Strategic Management of Valve Infolding in Evolut TAVR Procedures: Enhancing Outcomes and Ensuring Patient Safety

Transcatheter aortic valve repair (TAVR) presents a minimally invasive alternative to traditional surgical valve replacement, albeit not without its own set of complications. A rare complication is the infolding of the self-expanding valve, which can precipitate cardiac arrest. The estimated incidence rate of this complication stands at 1.6%. The management of this complication hinges on either balloon dilation or valve replacement. This article discusses a case involving a 78-year-old man with symptomatic severe aortic valve stenosis. Following TAVR, the patient experienced asystole due to valve infolding, highlighting the need for heightened vigilance and refined intervention strategies in the management of TAVR complications.

Five-year outcomes of mitral valve repair for leaflet prolapse at a medium-sized Norwegian university hospital

Objective. To evaluate patient characteristics and 5-year outcomes after surgical mitral valve (MV) repair for leaflet prolapse at a medium-sized cardiothoracic center. Background. Contemporary reports on the outcome of MV repair at medium-sized cardiothoracic centers are sparse. Methods. Patients receiving open-heart surgery with MV repair due to primary mitral regurgitation caused by leaflet prolapse between 2015 and 2021, without active endocarditis, were included. Clinical data, complications, re-interventions, mortality, and echocardiographic data were retrospectively registered from electronical patient charts, both pre-operatively and from post-operative follow-ups. Results. One hundred and three patients were included, 83% male, with a mean age of 62 years. All-cause mortality was 9% during a median follow-up time of 4.9 years. Re-intervention rate on the MV was 4%. Post-operative complications before last available follow-up visit at median 3.0 years were infrequent, with new-onset atrial fibrillation/flutter in 16%, post-operative MV regurgitation grade II or above in 17% and post-operative tricuspid regurgitation grade II or above in 14%. Conclusions. These data demonstrate that surgical MV repair for leaflet prolapse at a medium-sized cardiothoracic center was associated with low re-intervention rate and few severe complications. The presented results are comparable to data from surgical high-volume centers, indicating that surgical MV repair can be safely performed at selected medium-sized cardiothoracic centers.

Severe acute recoil following transcatheter aortic valve replacement with a self-expanding prosthesis in a heavily calcified bicuspid aortic valve

Bicuspid aortic valve (BAV) is one of the most common congenital valvular heart diseases occurring in 0.5-2% of the general population, in 2-6% of patients with severe aortic stenosis (AS) and up to 20% of octo/nonagenarians undergoing surgery. In this regard, Transcatheter aortic valve replacement (TAVR) has emerged as a therapeutic alternative. At the present time, there is not enough evidence to determine which is the best therapeutic approach for AS in BAV. We report a severe acute recoil following TAVR with a self-expanding prosthesis in heavily calcified BAV. In addition, we provide an updated review of the clinical significance of prosthesis underexpansion in the medium-term.

Association of Yeo's index with clinical outcomes in rheumatic mitral stenosis

Yeo's index, the product of the mitral leaflet separation index and dimensionless index of mitral valve (MV), was recently described to accurately identify severe rheumatic mitral stenosis (MS). We assess the association between Yeo's index and clinical outcomes in patients with rheumatic MS. We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo's index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, MV intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. The median follow up was 6.3 years; 145 patients (48.8%) developed the composite outcome. Yeo's index (p < 0.001), mitral valve area (MVA) by pressure half-time (PHT) (p = 0.028) and planimetry (p < 0.001), age (p = 0.016), history of diabetes mellitus (p = 0.029), previous HF (p = 0.021), left ventricular ejection fraction (p = 0.022), and pulmonary artery systolic pressure (p = 0.007) were univariately associated with the composite outcome. Yeo's index remained independently associated with the composite outcome in multivariate analysis (p < 0.001, HR 0.094, 95% CI 0.260-0.340). This was primarily driven by MV intervention. In a subgroup analysis of patients without pre-existing AF, Yeo's index was independently associated with new onset AF (p = 0.024, HR 0.354, 95% CI 0.143-0.874). This demonstrated that Yeo's index was independently associated with clinical outcomes in patients with rheumatic MS which was mainly driven by MV intervention.

Heart valve clinics: an expanding role for the clinical scientists - validation of a framework for competency and certification

BACKGROUND

Valvular heart disease (VHD) represents a significant burden on healthcare systems worldwide, necessitating specialised care through multidisciplinary valve clinics. However, there is a lack of a standardised training and certification framework for clinical scientists and specialist physiologists (CSSPs) working within specialist valve clinics (SVCs). This study aimed to design, implement and validate a competency framework dedicated to training and certifying valve CSSPs to enhance patient outcomes and establish standardised care.

METHODS

A comprehensive competency framework was developed and implemented, consisting of two levels: Enhanced Valve Clinic Training (EVCT) and Advanced Valve Clinic Training (AVCT). The programme was trialled at Guy's Valve Clinic, London, over a 12-month period. Validation was undertaken through trainee and patient feedback, including multiple-choice questions, clinical skills assessments, and patient satisfaction surveys.

RESULTS

Nine CSSPs completed the EVCT and four the AVCT. All participants passed their certification examinations with scores ranging from 80% to 95%. The time to complete each programme averaged 6 months. After certification, clinical queries raised by EVCT trainees averaged 1.2 per session but dropped by 75% to 0.3 per session in the AVCT group, indicating greater confidence and independence in managing cases. Physician review of trainee-led cases led to additional tests or treatment changes in 23% of cases and referrals to physician clinics in 11%. Patient feedback was positive: 95% felt confident in the clinical scientists' knowledge, and 100% were satisfied with the clarity of their care plans and follow-up.

CONCLUSIONS

The implementation of this training and certification framework demonstrated enhanced clinical outcomes and care delivery in SVCs. By advocating for formal recognition and accreditation of valve clinic training, this framework could serve as a model for national and international standardisation in valve care and clinical training.

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations

BACKGROUND

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.

METHODS AND RESULTS

Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men.

CONCLUSIONS

Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Transcatheter mitral valve replacement - a new option for a selected group of patients?

Mitral regurgitation (MR) is the second most common valvular disease. Symptomatic MR is associated with a poor prognosis. Cardiac surgery is recommended in the severe form of the disease. If the surgical risk is high or functional mitral regurgitation repair/replacement cannot be combined with aorto-coronary bypass graft surgery, a transcatheter edge-to-edge valve repair should be considered. Currently, there is no recommended procedure in patients with severe symptomatic MR, high cardiac surgical risk, and low probability of success or contraindications to the percutaneous edge-to-edge treatment. A recent alternative is the mitral valve implantation using a transapical approach or through the interatrial septum. Currently, the only CE-marked transcatheter bioprothesis valve using transapical approach and implanted without extracorporeal circulation support is the Tendyne valve. This paper discusses the safety, clinical efficacy and cost effectiveness of this valve and the size of the target population in Poland. The clinical efficacy was evaluated in a study of 100 patients with severe symptomatic MR. The total 2-year mortality was 39%. The hospitalisation rate due to heart failure decreased from 1.3 events/year prior to the surgery to 0.51. MR was not recorded in 93.2% of the survivors. An economic analysis accounting for the survival, health-related quality of life, and the risk of hospitalisation due to heart failure showed that the Tendyne system is cost-effective compared to pharmacological treatment: the incremental cost-utility ratio equalled 93,324-110,696 PLN, depending on the approach, clearly below the official threshold in Poland. The annual number of eligible patients was estimated at 60.

Clinical Outcomes According to Aortic Stenosis Management: Insights From Real-World Practice

BACKGROUND

Real-world data regarding clinical outcomes according to aortic stenosis (AS) management are scarce. Therefore, we aimed to investigate long-term management across the spectrum of outpatients with AS.

METHODS AND RESULTS

Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (3-3.9 m/s), and severe AS (≥4 m/s) were included by 117 cardiologists in the VALVENOR (Follow-Up of a Cohort of Patients With Valvular Aortic Stenosis in the Nord-pas-de-Calais Region) study and followed-up for aortic valve replacement (AVR) and modes of death. Among 2704 patients included, 1156 (42.7%) had mild, 1121 (41.5%) moderate, and 427 (15.8%) severe AS. After a median follow-up of 5 years, 993 AVRs (488 surgical and 505 transcatheter) and 1098 deaths occurred. The 5-year cumulative incidence of AVR or of the composite of death or AVR was 13.3% and 45.2% in mild AS, 45.5% and 75.3% in moderate AS, and 62.8% and 90.6% in severe AS, respectively. Of the 292 patients who met the criteria for AVR but were not treated, AVR was considered futile in 137 patients and 155 patients refused AVR. Mortality rates after 3 years were high: 86% for anticipated futility and 72.3% for refusal. While patients at anticipated futility showed a well-balanced proportion of cardiovascular and noncardiovascular deaths, cardiovascular deaths predominated among those who refused AVR.

CONCLUSIONS

At 5-year follow-up, only two thirds of patients with severe AS underwent AVR. Patients with untreated severe AS experienced high mortality rates, mostly cardiovascular for patients who declined AVR. This advocates for better patient education based on shared decision making and for optimizing AS quality of care, from diagnosis to treatment.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in Chinese patients with intermediate and high surgical risk for aortic stenosis: a decision analysis on effect, affordability and cost-effectiveness

OBJECTIVE

Examine the cost-effectiveness of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) for Chinese patients with severe aortic stenosis (AS) at intermediate and high surgical risk.

DESIGN

A two-phase model, comprising a 1-month decision tree to simulate perioperative outcomes and a 5-year Markov model with monthly cycles to simulate long-term outcomes, has been developed to evaluate the cost-effectiveness of TAVI compared with SAVR for Chinese patients with AS at intermediate and high risk. The event rates for both phases are sourced from the Placement of Aortic Transcatheter Valves IA and IIA trials, while the cost inputs and utility values are sourced from local sources or published literature. Adjustments for inflation were made using consumer price indexes for healthcare to enhance precision. To ensure the reliability and robustness of the model, sensitivity analyses were conducted to assess their impact on outcomes.

SETTING

China healthcare system perspective.

PARTICIPANTS

A hypothetical cohort of Chinese patients with AS in intermediate and high surgical risk.

INTERVENTIONS

TAVI versus SAVR.

OUTCOME MEASURES

Cost, quality-adjusted life-years (QALYs), life-years gained and incremental cost-effectiveness Ratio (ICER).

RESULT

For both intermediate- and high-risk AS patients, offering TAVR resulted in high healthcare costs but moderate benefits compared with SAVR. Specifically, in the intermediate-risk population, TAVR led to a 0.34 QALY increase over SAVR, with an incremental cost of $16 707.58, resulting in an ICER of $49 176.60/QALY. Similarly, in the high-risk population, TAVR showed a 0.15 QALY increase over SAVR, with an incremental cost of $18 093.52, leading to an ICER of $122 696.37/QALY. However, both ICERs exceeded the willingness-to-pay threshold of $37 654.50/QALY. Sensitivity analyses confirmed the model's stability under parameter uncertainty.

CONCLUSION

TAVI was deemed not cost-effective compared with SAVR for patients with AS at intermediate or high surgical risk in the Chinese healthcare system. Lowering valve costs was considered an effective approach to improve the cost-effectiveness of TAVI.