2021 ESC/EACTS Guidelines for the management of valvular heart disease

The Presence of Adipose Tissue in Aortic Valves Influences Inflammation and Extracellular Matrix Composition in Chronic Aortic Regurgitation

Adipose tissue is present in aortic valves (AVs). Valve interstitial cells (VICs) could differentiate into adipogenic lineages. We here characterize whether the presence of adipose tissue in the AV influences inflammation and extracellular matrix (ECM) composition in patients with aortic regurgitation (AR). A total of 144 AVs were analyzed by histological and molecular techniques. We performed discovery studies using Olink Proteomics® technology in 40 AVs (N = 16 without and N = 24 with adipose tissue). In vitro, human white adipocytes (HWAs) or VICs were cultured with adipogenic media and co-cultured with control VICs. Of Avs, 67% presented white-like adipocytes within the spongiosa. Discovery studies revealed increased levels of inflammatory and ECM molecules in AVs containing adipocytes. Interestingly, the presence of adipocytes was associated with greater AV thickness, higher inflammation, and ECM remodeling, which was characterized by increased proinflammatory molecules, collagen, fibronectin, proteoglycans, and metalloproteinases. AV thickness positively correlated with markers of adipose tissue, inflammation, and ECM. In vitro, adipocyte-like VICs expressed higher levels of adipocyte markers, increased cytokines, fibronectin, decorin, and MMP-13. Analyses of supernatants from co-cultured control VICs with HWA or adipocyte-like VICs showed higher expression of inflammatory mediators, collagen type I, proteoglycans, and metalloproteinases. AVs presenting adipocytes were thicker and exhibited changes characterized by increased inflammation accompanied by aberrant expression of collagen, proteoglycans, and metalloproteinases. VICs could differentiate into adipogenic pathway, affect neighbor VICs, and contribute to inflammation, collagen and proteoglycan accumulation, as well as to metalloproteinases secretion. In summary, the presence of adipose tissue in AV could modify its composition, favoring inflammation and remodeling with an impact on AV thickness.

The Prognostic Value of Pulmonary Hypertension in Patients with Mitral Regurgitation Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair: A Systematic Review and Meta-Analysis

Background: Pulmonary hypertension (PH) is associated with the outcomes of mitral valve transcatheter edge-to-edge repair (M-TEER) in patients with severe mitral regurgitation (MR). However, the prognosis of baseline PH on MR patients after M-TEER has been controversial. This meta-analysis aimed to determine the prognostic value of PH with early and late outcomes after M-TEER with MitraClip. Methods: We systematically searched PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science for studies. The results of the meta-analysis are summarized as the hazard ratio (HR), odds ratios (ORs) or mean difference (MD) and 95% confidence interval (CI). Results: A total of 20 publications were included in the systematic review, of which six were observational cohort studies including 5684 patients. The pooled incidence estimate of all-cause mortality was more common in severe PH than in patients who were non-PH. On pooled multivariate analysis, baseline PH was associated with late (≥1-year) all-cause mortality (HR = 1.61, 95% CI [1.23-2.11]) and the combined outcome of late HF rehospitalization and all-cause mortality (HR = 1.33, 95% CI [1.15-1.53]) after M-TEER. The level of SPAP significantly decreased after MitraClip in MR patients with PH (MD = -12.33 mmHg, 95% CI [-14.08--10.58]). Conclusions: Baseline PH had a worse prognosis of early (≥30-day) cardiac mortality, late all-cause mortality as well as the composite outcome of HF rehospitalization and all-cause mortality after M-TEER compared to non-PH patients. Future studies are needed to prove these findings.

Selecting the optimal candidates for percutaneous mitral valvuloplasty using multi-modality imaging

AIMS

This study compared echocardiography (echo) and cardiac computed tomography (CT) in measuring the Wilkins score and evaluated the potential added benefit of CT in predicting immediate percutaneous mitral valvuloplasty (PMV) outcomes in rheumatic mitral stenosis (MS) patients deemed eligible for PMV by echo.

METHODS AND RESULTS

From a multicentre registry of 3,140 patients with at least moderate MS, we included 96 patients (age 56.4 ± 11.5 years, 81% female) eligible for PMV based on echo Wilkins score (≤9) who underwent PMV and had measurable CT and echo images. We compared Wilkins scores from both modalities and analysed their relationship with unsuccessful procedural outcomes, defined as sub-optimal post-procedural mitral valve area (<1.5 cm2) or newly developed mitral regurgitation Grade ≥III. The mean CT score was higher than the echo score (8.0 ± 2.4 vs. 7.3 ± 1.2 points, P = 0.005). Procedural success was achieved in 65 (67.7%) patients. Unsuccessful results occurred in 31 patients, primarily in intermediate echo score (7-9 points) group. Among patients with intermediate echo scores, 90% had high CT scores (≥9), which were associated with significantly higher rates of unsuccessful PMV compared with lower CT scores (61.1 vs. 18.9%, P < 0.001).

CONCLUSION

CT-derived Wilkins scores were higher than echo-derived scores, with the most significant discrepancy in the intermediate echo score group. CT identified a subgroup of patients at higher risk for unsuccessful PMV among those with intermediate echo-based feasibility. Patients with intermediate echo-based PMV feasibility may benefit from CT-based reclassification, potentially improving patient selection and procedural outcomes.

Impact of valvulo-vascular haemodynamics on left ventricular remodelling and the prevalence of discordant moderate aortic stenosis

AIMS

This study aims to describe the prevalence of discordant mild/moderate aortic stenosis (AS) in a population-based study and to identify the mechanisms that lead to reduced stroke volume (SV) and discordant moderate AS.

METHODS AND RESULTS

Discordant high-gradient (HG)-mild AS, defined as AVA > 1.5 cm2 and mean pressure gradient (MG) of 20-40 mmHg, and discordant low-gradient (LG) moderate AS, defined as AVA 1.0-1.5 cm2 and MG < 20 mmHg, were assessed in 883 individuals from the DANCAVAS screening study with aortic valve calcification and 257 individuals form the PROGRESSA study excluding those with left ventricular (LV) ejection fraction < 50%. In the DANCAVAS cohort, 150 men had mild/moderate AS of which 34% had discordance between MG and AVA, representing 66% with moderate AS. Among 262 patients in the combined cohort, 39% had discordant LG-moderate AS and 6% discordant HG-mild AS. Compared with concordant mild and moderate AS, individuals with discordant LG-moderate AS were more likely to present with LV concentric remodelling geometry (26 vs. 33 vs. 45%, P < 0.001), increased valvulo-arterial impedance (3.3 ± 0.7 vs. 3.6 ± 0.5 vs. 4.1 ± 0.7 mmHg/mL/m2, P < 0.001), and reduced systemic arterial compliance (SAC) (0.74 ± 0.22 vs. 0.81 ± 0.22 vs. 0.64 ± 0.18 mL/m2/mmHg, P < 0.001). Factors associated with SV index were relative wall thickness, LV end-diastolic diameter index, SAC, and LV remodelling pattern.

CONCLUSION

Discordant moderate AS is common, accounting for two-thirds of patients with moderate AS in the general male population. Patients with discordant LG-moderate AS have predominantly a concentric remodelling pattern with reduced SV. Reduced SV index was associated with signs of reduced vascular compliance, suggesting that altered vascular properties drive differences in remodelling patterns and discordant moderate AS.

The role of multi-modality imaging in multiple valvular heart diseases: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

With this document, the European Association of Cardiovascular Imaging provides an Expert Consensus on the role of multi-modality imaging (MMI) in the management of patients with multiple valvular heart disease (MVD). Emphasis is given to the use of MMI to unravel the diagnostic challenges that characterize these patients and to improve risk stratification. Complementing the last European Society of Cardiology and European Association of Cardio-Thoracic Surgery guidelines on valvular heart disease, this Expert Consensus document also outlines how MMI assessment should form an integral part of the multi-disciplinary heart team discussion for patients with MVD to help with complex decision-making regarding the choice and timing of treatment.

Severity of tricuspid regurgitation predicts risk of recurrence of atrial fibrillation after pulmonary vein isolation

AIMS

Tricuspid regurgitation (TR) results in right atrial remodelling, thus promoting the formation of a substrate for atrial fibrillation (AF). In turn, AF may cause TR by annulus dilatation. We investigated whether the presence of TR affects the efficacy of pulmonary vein isolation (PVI) for AF.

METHODS AND RESULTS

In patients undergoing PVI, we compared the severity of TR before and 6 months after the procedure. Moderate to severe TR was defined as advanced. Moreover, we investigated whether the severity of TR, at baseline and 6 months after PVI, predicted the recurrence of AF. Out of 320 patients, advanced TR at baseline was documented in 13.1%. Six months after PVI, the proportion of patients with advanced TR (13.1% to 7.2%; P < 0.001) decreased significantly. Compared with patients with post-interventional improvement of advanced TR, right atrial (RA) dilatation at baseline was more pronounced in patients without TR improvement (RA area 20.2 ± 4.4 vs. 26.6 ± 8.3 cm). The presence of advanced TR, particularly without improvement during the follow-up, increased the risk of AF recurrences compared with patients without advanced TR. Even after propensity-score matching, TR at baseline remained an independent risk predictor regarding recurrent AF [hazard ratio 2.2 (95% confidence interval, 1.1-4.9); P = 0.045]. Advanced MR was not associated with increased risk of AF.

CONCLUSIONS

In AF patients undergoing PVI, the presence of advanced TR, particularly without improvement 6 months after the procedure, was associated with an increased risk of AF recurrences.

Does Preliminary Chest Shape Assessment Improve the Prognostic Risk Stratification of Individuals with Mitral Annular Disjunction? A Case Report and Narrative Review

Background: Mitral annular disjunction (MAD), a mitral annular abnormality involving the whole mitral valve annulus circumference, commonly detected in individuals with mitral valve prolapse (MVP), has been recently recognized as a potential risk factor for malignant ventricular arrhythmias (VAs) and sudden cardiac death. Recent evidence indicates that a multimodality imaging assessment comprehensive of echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography angiography (CCTA) may improve MAD detection. To date, no previous author has considered the potential influence of chest wall conformation on MAD presence. Considering the strong association between MVP and anterior chest wall deformities and the increased prevalence of MAD among MVP individuals, we have hypothesized that MAD presence might be more frequently detected among MVP individuals with a narrow anteroposterior (A-P) thoracic diameter and/or concave-shaped chest wall conformation, as noninvasively assessed by the modified Haller index (MHI). Methods: Herein, we present a case of MVP female with relevant MAD distance and moderate mitral regurgitation (MR) who underwent a diagnostic study comprehensive of transthoracic echocardiography, transesophageal echocardiography, CMR, CCTA, and exercise stress echocardiography. Results: The patient was found with a concave-shaped chest wall conformation (MHI > 2.5) and narrow A-P thoracic diameter (<13.5 cm), with a moderate and non-hemodynamically significant MR, without areas of LGE on CMR and with low arrhythmic profile. Conclusions: A preliminary chest shape assessment by the MHI might improve the prognostic risk stratification of MVP patients with MAD, potentially identifying a benign phenotype of MVP individuals, i.e., those with a narrow A-P thoracic diameter.

Cardiac evaluation in patients awaiting kidney transplant-position statement of the Cardiological Society of India and Indian Society of Nephrology

Cardiovascular diseases are a major cause of death after kidney transplantation. This statement addresses preoperative cardiac decision-making and management with the aim of assessing and reducing the risk of the kidney transplant surgery. Important issues from a clinician's perspective include the basic cardiovascular workup of these patients, coronary evaluation and management of coronary artery disease, valvular heart disease and left ventricular systolic dysfunction. Recovery left ventricular function after kidney transplant is discussed. In addition, the use of cardiovascular drugs in patients with special emphasis on antiplatelets and anticoagulants in patients planned for kidney transplant is also discussed.

Effect of Sodium-Glucose Cotransporter-2 Inhibitors on the Progression of Aortic Stenosis

BACKGROUND

Aortic stenosis (AS) is the leading cause of valvular heart disease-related morbidity and mortality, but there are no medical treatments to slow its progression. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have pleiotropic effects which could be disease modifying in AS.

OBJECTIVES

The purpose of this study was to determine if SGLT2i usage is associated with slower progression of AS.

METHODS

A target trial emulation comparing the effect of the initiation of SGLT2i compared with no SGLT2i in patients with nonsevere AS was performed using retrospective electronic medical record data from the Yale New Haven Health System from January 2016 to September 2022. Patients with native aortic valve sclerosis or nonsevere AS with at least 12 months of echocardiographic follow-up were included. Patients were excluded if they had an estimated glomerular filtration rate <30 mL/min/1.73 m2 or had initiated SGLT2i >1 year before the index echocardiogram. The prespecified primary outcome was progression to severe AS.

RESULTS

A total of 458 patients prescribed SGLT2i and 11,240 patients never prescribed SGLT2i were included. Patients were on SGLT2i for a median of 0.9 years. Patients on SGLT2i were younger and had higher rates of diabetes and chronic kidney disease. Patients on SGLT2i were more likely to have ejection fraction ≤40%. There were no differences between groups in baseline AS severity (66% sclerosis, 23% mild stenosis, and 11% moderate in overall cohort). Patients ever prescribed SGLT2i were less likely to progress to severe AS (HR: 0.61; 95% CI: 0.39-0.94; P = 0.03) with a progressively lower risk among patients on SGLT2i for >3, 6, and 12 months (HR: 0.54, 0.48, and 0.27, respectively).

CONCLUSIONS

This retrospective, multicenter, observational study suggests that SGLT2i may slow the progression of nonsevere AS.

Five-Year Results of Aortic Valve Replacement With a Novel Bioprosthesis: Real-World Data From a Large Multicenter Registry

BACKGROUND

The clinical performance and safety of a glutaraldehyde-free bioprosthetic valve using a novel tissue treatment in a large real-world patient population have not previously been reported.

METHODS

This is a prospective, multicenter, real-world registry of all patients undergoing surgical aortic valve replacement with a novel bioprosthesis at 7 European cardiac surgery centers. The primary end point was the 5-year freedom from structural valve deterioration per Valve Academic Research Consortium 3 criteria. Secondary end points included hemodynamic performance of the bioprosthesis and freedom from all-cause and cardiovascular mortality, prosthetic endocarditis, stroke, and reintervention at 5 years.

RESULTS

A total of 498 patients were included in the analysis; the mean age was 60.1 years, with a mean EuroSCORE II of 3.9% and 27.9% being female. The median follow-up was 4.8 years. Five-year freedom from structural valve deterioration stages 1, 2, and 3 was 95.7%, 98.6%, and 99.3%, respectively. The estimated 5-year overall survival was 93.2%; freedom from cardiovascular mortality was 97.2%. Event-free probabilities at 5 years for endocarditis, stroke, and reintervention were 98.6%, 98.1%, and 98.2%, respectively. Moderate-severe paravalvular leakage was infrequent (97.3% event-free probability at 5 years), and mean aortic valve pressure gradient was stable compared with discharge (median, 11.0 mm Hg at discharge vs 12.0 mm Hg at 5 years).

CONCLUSIONS

These real-world clinical data of a novel aortic bioprosthesis demonstrated good 5-year results for both durability and safety outcomes as well as stable hemodynamic valve performance.

Prognostic implications of functional tricuspid regurgitation in asymptomatic degenerative mitral regurgitation

AIMS

Functional tricuspid regurgitation (FTR) associated with degenerative mitral regurgitation (DMR) accentuates the severity of heart failure and is a marker of poor prognosis. Little is known about FTR associated with asymptomatic DMR.

METHODS AND RESULTS

The study included 1249 asymptomatic patients with moderate or severe DMR from the Mitral Regurgitation International Database-Quantitative (MIDA-Q) registry (mean age 64 ± 15 years, 25% female). Despite the asymptomatic status, absent/trivial FTR was noted in only 42%, mild in 34.5%, moderate in 11%, and severe FTR in 12.5%. Patients with higher FTR grades were older and more often female and had higher EuroScore II, larger left atrial volumes, and more atrial fibrillation (all P < 0.05). Patients with moderate or severe FTR had comparable 5-year survival (64 ± 4% and 65 ± 4%) and lower than patients with no/trivial FTR(96 ± 1%, P < 0.001). After adjustment for key prognostic factors, including age, left ventricular dilatation and dysfunction, DMR severity, left atrial dilatation, and pulmonary hypertension, ≥moderate FTR remained a strong predictor of mortality (HR = 2.08 [1.17-3.72], P = 0.013). Sensitivity analysis showed stable impact of ≥moderate FTR among patients with/without pulmonary hypertension, in women and men and for any other subset. For patients who underwent mitral valve surgery, post-operative survival rates were similar between those with no/trivial FTR and those with ≥moderate or severe FTR (P = 0.76), suggesting that surgery could reduce the excess mortality related to preoperative FTR.

CONCLUSIONS

Among asymptomatic patients with significant DMR, ≥moderate FTR is frequent and independently associated with higher mortality, independently of traditional guideline-based risk factors. These findings suggest that ≥moderate FTR should lead to consideration of early mitral surgery to improve outcomes.

Predicting the Need for Intensive Care Unit Treatment After Successful Transcatheter Edge-to-Edge Mitral Valve Repair

Background/Objectives: Transcatheter edge-to-edge mitral valve repair (M-TEER) has emerged as an efficacious treatment modality among patients at high perioperative risk. Given the steady increase in procedures and the limited capacity for intensive care, there is a need to identify patients at high risk for postinterventional intensive care. Methods: All patients who underwent M-TEER between 2014 and 2023 were investigated. The intensive care unit (ICU) stay ended when patients met all the following criteria: no further need for catecholamine support, no oxygen requirement > 6 L O2/min, no indication for renal replacement therapy, and no delirium or relevant bleeding. Uni- and multivariable logistic regression analyses were used to identify independent predictors of the need for ICU treatment. Results: In total, 33% of patients (62/183) had an indication for ICU treatment after M-TEER. Patients with an indication for ICU treatment had significantly lower survival rates three years after M-TEER (37.4% [23/62] vs. 61.6% [75/121], p < 0.001) than patients without an ICU indication. A EuroSCORE II of >10% (OR 2.6, 95% CI 1.3-5.4, p = 0.006), a MitraScore of >3 (OR 2.5, 95% CI 1.2-5.2, p = 0.02), and a hospital stay of >5 days before M-TEER (OR 3.2, 95% CI 1.6-6.4, p < 0.001) were independently associated with the need for ICU treatment. Conclusions: One-third of the patients were indicated for ICU treatment, which was associated with a high mortality rate. On the basis of these predictors of required ICU care, tailored treatment strategies can be developed to improve treatment outcomes.

Long-Term Outcomes of Mitral Valve Repair Versus Replacement in Patients with Ischemic Mitral Regurgitation: A Retrospective Propensity-Matched Analysis

BACKGROUND

The optimal surgical management of ischemic mitral regurgitation (IMR)-mitral valve repair (MVr) versus mitral valve replacement (MVR)-remains controversial, with limited evidence on long-term outcomes. This study aimed to compare the outcomes of MVr and MVR in patients with IMR, focusing on survival and recurrence of mitral regurgitation. Additionally, survival was compared based on preoperative characteristics.

METHODS

A retrospective cohort analysis was conducted at a tertiary referral center and included 759 patients who underwent surgery for IMR between 2009 and 2021. Propensity score matching identified 140 matched pairs. The outcomes assessed included hospital mortality, long-term survival, recurrence of mitral regurgitation, mitral valve reintervention rates, and echocardiographic changes over time.

RESULTS

In the matched cohort, no significant differences were observed in hospital mortality (10% for MVr vs. 10.7% for MVR, p > 0.99) or long-term survival (p = 0.534). However, MVr was associated with a higher rate of recurrent moderate or higher mitral regurgitation (29.04% vs. 10.37%, p < 0.001) compared to MVR. The mitral valve reintervention rates did not differ significantly between the groups. Echocardiographic follow-up revealed significant improvements in left ventricular function and dimensions, with no significant differences between the groups. A subgroup analysis revealed no difference in survival according to the age, gender, ejection fraction, EuroSCORE category, or right ventricular function between the MVr and MVR patients.

CONCLUSIONS

MVr and MVR for IMR yielded comparable survival rates, but MVr was associated with a higher risk of recurrent MR. The efficacy of both surgical approaches across diverse patient populations was comparable, reinforcing the need for individualized decision-making based on other clinical and anatomical considerations.

Early experience with a novel transapical transcatheter aortic valve system in patients with severe aortic stenosis: a prospective, multicenter study

Objectives

Registered, prospective, multicenter study of the short-term clinical outcomes of a novel transcatheter aortic valve system (Xcor system, Saint Medical Technology, Inc., Nanjing) to evaluate its safety and efficacy.

Methods

130 high risk patients with symptomatic severe AS from 11 institutions were treated with the novel Xcor system. All patients were pre-TAVR assessed by transthoracic echocardiography and computed tomography of the aortic valve (AV) and relevant left cardiac and vascular anatomy. Procedural, in-hospital, and follow-up clinical outcomes were evaluated after procedures.

Results

The average age of the 130 patients was 71.2 ± 4.4 years old, 55.4% were male, and the STS score was 8.0 ± 3.9%. Device and procedural success were achieved in 98.5% and 97.7% of the patients, respectively. At 30-day follow-up, all-cause mortality, the incidence of major adverse cardiovascular events, major vascular complications, and new permanent pacemaker implantation were 3.8%, 4.6%, 0.8%, and 0.8%, respectively. 7.7% of patients showed ≥ mild paravalvular leakage, and all 125 (100%) patients were in New York Heart Association Class ≤ II. The procedural and clinical outcomes of bicuspid AV patients were similar to those of tricuspid AV patients.

Conclusions

Overall, the 30-day follow-up shows that the procedural outcomes with the novel Xcor system with self-centering support arms are comparable or superior to other contemporary TAVI devices, with a low all-cause mortality, low major adverse cardiovascular events, low PVL and similar clinical outcomes for BAV and TAV patients.

Investigating the results of transcatheter aortic valve implantation (TAVI) in non-diabetic and diabetic patients: a systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has emerged as an effective treatment option for patients with severe aortic stenosis, particularly in those who are not suitable candidates for open-heart surgery. While diabetes is known to be associated with a higher risk of cardiovascular diseases, the impact of diabetes on the outcomes of TAVI remains controversial.

METHODS

A systematic literature search was conducted across major databases, including PubMed, Web of Science (WOS), and Google Scholar, for studies published in English over the past 20 years, up until July 2024.

RESULTS

A total of 10 observational studies were analyzed, revealing that diabetic patients were generally younger than non-diabetic patients. The 30-day mortality rate was lower in non-diabetics (0.03 [0.02-0.04]) compared to diabetics (0.04 [0.03-0.05]). However, the hazard ratio for death beyond 30 days in diabetics was 2.05 (95% CI: 0.91-4.60, p = 0.08), and at one year, it was 1.04 (95% CI: 0.78-1.39, p = 0.77), with neither result reaching statistical significance. Meta-regression analysis showed that non-insulin-treated diabetes was significantly associated with an increased risk of acute kidney injury (AKI) compared to non-diabetics, with a log odds ratio (LogOR) of 0.3393 (p = 0.035) in one analysis and 0.3166 (p = 0.028) in another, confirming a statistically significant increase in AKI risk.

CONCLUSIONS

This review highlights that while diabetes slightly increases short-term mortality after TAVI, long-term survival remains comparable to non-diabetic patients. However, non-insulin-treated diabetes significantly raises the risk of acute kidney injury (AKI), emphasizing the need for enhanced renal protection and perioperative management.

CLINICAL TRIAL NUMBER

Not applicable.

Exploring sex differences in infective endocarditis - a prospective, observational study from Western Norway

BACKGROUND

We aimed to investigate sex-differences among patients with infective endocarditis (IE) in Western Norway, focusing on clinical presentation, treatment strategies, and outcomes.

METHODS

This prospective observational study included 131 females, and 366 males diagnosed with IE between 2016 and 2022. Clinical and microbiological characteristics were analysed using chi-squared or Fisher's exact tests, while survival data were assessed via Kaplan-Meier estimates and multiple Cox regression models.

RESULTS

The mean age was 69 years for females and 66 years for males (p = 0.317).

PRIMARY OUTCOMES

Mortality rates were significantly higher in females at 30 days (13% vs. 7%, p = 0.028), at 90 days (19% vs. 11%, p = 0.016), and overall (46% vs. 36%, p = 0.016), with a mean follow-up of 3.2 years (± 2.3 years).

SECONDARY OUTCOMES

The mitral valve was more frequently affected in females than in males (31% vs. 17%, p < 0.001), and Staphylococcus aureus more often the microbial cause (36% vs. 27%, p = 0.049). While surgical treatment rates were similar (26% of females and 34% of males, p = 0.075), females with aortic valve IE underwent surgery at a significantly lower rate (23% vs. 39%, p = 0.001) and experienced longer delays before surgery (median 25 vs. 21 days, p = 0.043). Multivariable analysis identified higher age (HR 1.02, 95% CI 1.00-1.04, p = 0.014) and mitral valve infection (HR 2.88, 95% CI 1.57-5.29, p < 0.001) as independent predictors of 90-day mortality, while surgery significantly improved survival (HR 0.38, 95% CI 0.17-0.81, p = 0.013).

CONCLUSIONS

Mitral valve IE was more common in females and strongly associated with higher mortality. Females with IE had higher mortality rates, more frequent mitral valve involvement, and a greater incidence of S. aureus infections. Despite the clear survival benefit of surgery, females with aortic valve IE underwent fewer and later surgeries. These findings highlight potential sex disparities in IE management and emphasize the need for further research into sex-based differences in treatment strategies and outcomes.

The PREVASC study: Prospective REgistry of Valve disease in Asymptomatic Italian elderly SubjeCts

AIMS

Valvular heart disease (VHD) is the third leading cause of cardiovascular morbidity, with its incidence and public health impact projected to increase significantly. This study adopts a novel perspective, focusing on elderly individuals residing in rural areas, highlighting the unique dynamics of small-town settings.

METHODS

This multicenter, observational study was conducted from May 2022 to September 2023, under the coordination of the AOU Careggi Echo Core-Lab, which managed the entire screening program. In 10 small Italian villages, each municipality facilitated the enrollment of asymptomatic individuals aged ≥ 65 years, with no prior VHD history, through voluntary participation. Participants were grouped into three age categories (65-69, 70-74, and ≥ 75 years) and underwent a thorough evaluation, including a Quality of Life (QoL) questionnaire and comprehensive echocardiographic assessment focusing on VHD detection and grading.

RESULTS

Among 1,113 participants, the prevalence and severity of VHD showed a significant increase with age (p < 0.0001). Remarkably, 94% of individuals aged ≥ 75 years had at least one valvular defect, with 22.5% presenting moderate or severe valvulopathy, including a prevalence of 4.8% for moderate or severe aortic valve stenosis and 7.5% for mitral regurgitation. Right-sided valvulopathies followed a similar trend, affecting 71.9% of elderly participants. QoL evaluations revealed a generally positive perceived health status, with a mean score of 77 ± 16.

CONCLUSIONS

Our registry highlights that the prevalence of VHD in asymptomatic individuals over 65 years living in small Italian communities is substantial, increases with age, and is predominantly degenerative in etiology. Notably, most individuals with undiagnosed VHD perceived themselves as healthy.

Dysglycaemia is associated with the pattern of valvular calcification in micro-computed tomography analysis: an observational study in patients with severe aortic stenosis

BACKGROUND

Diabetes mellitus (DM) has been shown to increase the rate of aortic stenosis (AS) progression. However, the impact of impaired plasma glucose on valvular calcification remains poorly understood. Using ex vivo micro-computed tomography (micro-CT), we aimed to determine whether plasma glucose, glycated haemoglobin (HbA1c), or concentrations of advanced glycation end products (AGEs) and their soluble receptor (sRAGE) are associated with a specific pattern of valvular calcification in severe AS.

METHODS

In this case-control study, 14 (48%) normoglycaemic patients with AS were compared to 15 individuals (52%) with elevated glucose levels (≥ 5.6 mmol/L), all with HbA1c ≤ 6.5%. Stenotic aortic valves obtained surgically were analysed using micro-CT to assess structure of tissue mineralization. Calcium volume (CV), surface volume (SV), CV/SV ratio, and trabecular thickness (TbTh) were evaluated. Plasma AGEs and sRAGE were assessed by ELISAs. DM patients or those using antidiabetic agents were excluded from the study.

RESULTS

Patients with impaired and high glucose, including 10 (67%) with glucose between 5.6 and 6.9 mmol/L and 5 (33%) ranging from 7 to 7.6 mmol/L, exhibited higher HbA1c (+ 17%) and AGEs levels (+ 44.6%), but not sRAGE compared to those with normal glucose. Patients with impaired and high glucose had also 19.2% higher maximal transvalvular pressure gradient (PGmax) and 9.3% higher peak transvalvular velocity (Vmax) compared to normoglycaemic individuals. Micro-CT indices correlated with fasting glucose, HbA1c, and AGEs levels (all p < 0.05), but not with sRAGE (p > 0.05). Valves extracted from patients with impaired and high glucose exhibited higher mineralization volume, folding, and structural integrity, as reflected by increased CV (+ 127.6%), CV/SV ratio (+ 59%) and calcium deposits microarchitecture as indicated by about 50% higher TbTh, compared to normoglycaemic patients. When patients with AS were divided into three groups based on their glucose levels (< 5.5 mmol/L, 5.6-6.9 mmol/L, and 7.0-7.6 mmol/L), micro-CT analysis showed more distinct structural differences among the groups. The valves in the highest glucose group were the most severely affected. Micro-CT parameters were also associated with both transvalvular pressure gradients (PGmean and PGmax), Vmax and aortic valve area (all p < 0.05).

CONCLUSIONS

Strict glycaemic control could potentially reduce the rate of valve mineralization and calcium deposit accumulation in patients with AS.

RESEARCH INSIGHTS

WHAT IS CURRENTLY KNOWN ABOUT THIS TOPIC?: Diabetes mellitus (DM) is a risk factor for the progression of aortic stenosis (AS). Accumulation of advanced glycation end products (AGEs) enhances glycation of valvular proteins. WHAT IS THE KEY RESEARCH QUESTION?: Is dysglycaemia associated with more severe aortic valve calcification in patients with severe AS? Is ex vivo micro-CT suitable for assessing differences in calcification pattern within stenoticvalves? WHAT IS NEW?: Pre-diabetic patients with AS show increased valvular calcium volume, surface corrugation, and calcium deposit integrity. Micro-CT parameters associate with glycaemic status and echocardiographic measures of AS severity. Micro-CT provides precise assessment of calcification, offering insights beyond traditional methods. HOW MIGHT THIS STUDY INFLUENCE CLINICAL PRACTICE?: Strict glycaemic control together with CT calcium scoring should be performed in patients with AS to monitor disease progression.

Antithrombotic strategy following valve-in-valve transcatheter aortic valve replacement. A German Statutory Health Claims data analysis

AIMS

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) procedures are increasingly used. Specific recommendations on antithrombotic strategies following ViV-TAVR are lacking. We aimed to assess the efficacy of different antithrombotic strategies following ViV-TAVR.

METHODS AND RESULTS

We performed a retrospective analysis of German Statutory Health Claims data following ViV-TAVR stratified by antithrombotic strategies according to prescription within 90 days. Antithrombotic regimens included antiplatelet therapy (APT), direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). The composite endpoint was all-cause mortality, stroke and/or systemic embolism (SSE) and mechanical complication of heart valve prosthesis at 12 months. Cox proportional hazard regression models were used to compare outcomes. In total, 908 patients between 2005 and 2022 were identified. Of these, 286 received DOACs, 99 received VKAs, 351 received APT exclusively and 172 had no prescription. The incidence of the composite endpoint was 20.8% in the APT group, 20.3% in the DOAC group and 25.3% in the VKA group which was not statistically significantly different. The rate of SSE in the acetylsalicylic acid (ASA) mono group was higher compared to the dual antiplatelet therapy (DAPT) group (27.3% vs. 12.4%, univariable HR 0.42, 95% CI [0.19, 0.95], p = 0.03).

CONCLUSION

In this analysis of German Health Claims data, DOACs seemed to be a safe alternative to VKAs and APT. ASA monotherapy was associated with higher rates of SSE compared to DAPT. Given the high risk of bias of this retrospective analysis and the growing use of valve-in-valve procedures, randomized controlled trials are needed to confirm these findings.

The Evolving Landscape of Infective Endocarditis: Difficult-to-Treat Resistance Bacteria and Novel Diagnostics at the Foreground

Infective endocarditis (IE) is a relatively rare but potentially life-threatening disease characterized by substantial mortality and long-term sequelae among the survivors. In recent decades, a dramatic change in the profile of patients diagnosed with IE has been observed primarily in developed countries, most likely due to an aging population and a recent increase in invasive medical procedures. Nowadays, the typical IE patient is usually older, with complex comorbidities, and a history significant for cardiac disease, including degenerative heart valve disease, prosthetic valves, or cardiovascular implantable electronic devices (CIEDs). Moreover, as patient risk factors change, predisposing them to more healthcare-associated IE, the microbiology of IE is also shifting; there are growing concerns regarding the rise in the incidence of IE caused by difficult-to-treat resistance (DTR) bacteria in at-risk patients with frequent healthcare contact. The present review aims to explore the evolving landscape of IE and summarize the current knowledge on novel diagnostics to ensure timely diagnosis and outline optimal therapy for DTR bacterial IE.

Severe Tricuspid Regurgitation in a Patient With a Cardiac Implantable Electronic Device: What We Have Learned

BACKGROUND

Cardiac implantable electronic devices (CIEDs) are associated with the occurrence of tricuspid regurgitation (TR) leading to poor outcomes. The distinction between CIED-induced TR and other etiologies is often challenging, making its optimal management difficult.

CLINICAL CONDITION

We describe a case of CIED-induced TR, discuss its common diagnostic/managements challenges, and analyze recent definitions/classifications and position statements.

KEY QUESTIONS

What are the most common challenges in diagnosing CIED-induced TR? What are the different causative mechanisms of CIED-inducing TR? How can CIED-induced TR be classified? What are the different management strategies for CIED-induced TR, and what are the main factors to consider?

OUTCOME

The patient underwent successful right ventricular lead extraction and placement of a right atrial lead and a coronary sinus lead. Repeat echocardiography showed reversed right ventricular remodeling with improvement of the TR.

Automated Aortic Regurgitation Detection and Quantification: A Deep Learning Approach Using Multi-View Echocardiography

Background

Accurate evaluation of aortic regurgitation (AR) severity is necessary for early detection and chronic disease management. AR is most commonly assessed by Doppler echocardiography, however limitations remain given variable image quality and need to integrate information from multiple views. This study developed and validated a deep learning model for automated AR severity assessment from multi-view color Doppler videos.

Methods

We developed a video-based convolutional neural network (R2+1D) to classify AR severity using color Doppler echocardiography videos from five standard views: parasternal long-axis (PLAX), PLAX-aortic valve focus, apical three-chamber (A3C), A3C-aortic valve focus, and apical five-chamber (A5C). The model was trained on 47,638 videos from 32,396 studies (23,240 unique patients) from Cedars-Sinai Medical Center (CSMC) and externally validated on 3369 videos from 1504 studies (1493 unique patients) from Stanford Healthcare Center (SHC).

Results

Combining assessments from multiple views, the EchoNet-AR model achieved excellent identification of both at least moderate AR (AUC 0.95, [95% CI 0.94-0.96]) and severe AR (AUC 0.97, [95% CI 0.96 - 0.98]). This performance was consistent in the external SHC validation cohort for both at least moderate AR (AUC 0.92, [95% CI 0.88-0.96]) and severe AR (AUC 0.94, [95% CI 0.89-0.98]). Subgroup analysis showed robust model performance across varying image quality, valve morphologies, and patient demographics. Saliency map visualizations demonstrated that the model focused on the proximal flow convergence zone and vena contracta, appropriately narrowing on hemodynamically significant regions.

Conclusion

The EchoNet-AR model accurately classifies AR severity and synthesizes information across multiple echocardiographic views with robust generalizability in an external cohort. The model shows potential as an automated clinical decision support tool for AR assessment, however clinical interpretation remains essential, particularly in complex cases with multiple valve pathologies or altered hemodynamics.

Predictors of Diagnostic Inaccuracy of Detecting Coronary Artery Stenosis by Preprocedural CT Angiography in Patients Prior to Transcatheter Aortic Valve Implantation

Background: The diagnostic performance of preprocedural CT angiography in detecting coronary artery disease (CAD) in patients scheduled for transcatheter aortic valve implantation (TAVI) has been reported. However, data on predictors of diagnostic inaccuracy are sparse. We sought to investigate clinical characteristics and imaging criteria that predict the inaccurate assessment of coronary artery stenosis based on pre-TAVI-CT. Methods: The patient- and vessel-level analysis of all CT datasets from 192 patients (mean age 82.1 ± 4.8 years; 63.5% female) without known CAD or severe renal dysfunction was performed retrospectively in a blinded fashion. Significant CAD was defined as a CAD-RADS™ 2.0 category ≥ 4 by CT. Invasive coronary angiography (ICA) served as the reference standard for relevant CAD (≥70% luminal diameter stenosis or fractional flow reserve ≤ 0.80). Pertinent clinical characteristics and imaging criteria of all true-positive (n = 71), false-positive (n = 30), false-negative (n = 4), and true-negative patient-level CT diagnoses (n = 87) for relevant stenosis according to ICA were assessed. Results: In the univariate per-patient analysis, the following parameters yielded discriminative power (p < 0.10) regarding inaccurate CAD assessment by pre-TAVI-CT: age, atrial fibrillation, scanner generation, and image quality. Factors independently associated with CT diagnostic inaccuracy were determined using multivariable logistic regression analysis: a younger age (odds ratio [OR] 0.87; 95% confidence interval [CI] 0.80 to 0.94; p < 0.01) and insufficient CT image quality (OR 0.6; CI 0.41 to 0.89; p < 0.01). Conclusions: Our results demonstrate younger age and poor CT image quality to predict less accurate CAD assessments by pre-TAVI-CT in comparison with ICA. Knowledge of these predictors may aid in more efficient coronary artery interpretations based on pre-TAVI-CT.

Association of Right Ventricular-Pulmonary Arterial Coupling and Progression of Tricuspid Regurgitation in Patients With Atrial Fibrillation

BACKGROUND

Tricuspid regurgitation (TR) severity is associated with poor prognosis in patients with atrial fibrillation (AF). Recently, right ventricular-pulmonary arterial (RV-PA) coupling has been shown to be related to clinical outcomes in patients with TR. However, data on the relationship of RV-PA coupling to the progression of significant TR are limited. This study aimed to investigate whether RV-PA coupling affects the progression of significant TR in patients with AF.

METHODS

Among 664 patients with AF who underwent follow-up echocardiography at least 6 months after the initial assessment, 484 consecutive patients with AF (mean age 68±12 years, 38% women) with insignificant TR were included. RV-PA coupling was assessed by the ratio of RV 4-chamber strain measured through speckle tracking echocardiography to pulmonary artery systolic pressure (PASP).

RESULTS

Over a mean 3.6±2.7 years of follow-up, 46 (9.5%) patients have progressed to significant TR, at least a moderate degree. Patients who progressed to significant TR were older, more likely to be women, had higher E/eꞋ and PASP, lower RV4CSL and RV 4-chamber strain /PASP compared with patients without TR progression. RV-PA coupling, reflected by RV 4-chamber strain/PASP, was independently associated with the progression of TR even after adjusting for age, sex, and E/eꞋ (P <0.001). It remained significant for predicting TR progression even after further adjustment for PASP or RV strain (all P <0.001).

CONCLUSIONS

In patients with AF, RV-PA coupling was independently associated with the progression of TR, suggesting that it may be helpful in monitoring this population.

Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients With Cardiogenic Shock: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with severe mitral regurgitation and cardiogenic shock demonstrate a poor prognosis. Mitral transcatheter edge-to-edge repair could alter patient management.

METHODS AND RESULTS

We systematically reviewed PubMed/Medline, Scopus, and Cochrane Library until January 2023, including studies assessing transcatheter edge-to-edge repair in patients with severe mitral regurgitation and cardiogenic shock. Studies with <5 patients were excluded. The primary outcome was device success and all-cause death, while secondary outcomes included myocardial infarction, stroke, and heart failure hospitalization rates at 30-day and intermediate-term follow-up. A fixed-effects meta-analysis was used to estimate pooled rates. Risk of bias was assessed with the Newcastle-Ottawa Scale. A total of 24 studies and 5428 patients were included, with a mean age of 71.2±3.3 years and a high mean Society of Thoracic Surgery score (15.2±8.9). Device success was achieved in 86% (95% CI, 85%-87%) and mitral regurgitation ≤2+ in 89% (95% CI: 88%-90%). The 30-day all-cause mortality rate was 14% (95% CI, 13%-15%). Stroke, myocardial infarction, and heart failure hospitalization rates were 2% (95% CI, 1%-2%), 15% (95% CI, 13%-18%), and 9% (95% CI, 8%-10%), respectively. Patients with acute myocardial infarction had similar device success (81% [95% CI, 74%-87%]), a 30-day mortality rate of 20% (95% CI, 16%-25%), and intermediate-term mortality rate of 14% (95% CI, 9%-19%). In non-myocardial infarction populations, the 30-day mortality rate was 13% (95% CI, 13%-14%), and the intermediate-term mortality rate was 35% (95% CI, 34%-36%).

CONCLUSIONS

In patients with mitral regurgitation and cardiogenic shock, transcatheter edge-to-edge repair is associated with favorable 30-day and intermediate-term outcomes. Limitations, including the observational design of included studies and considerable heterogeneity, necessitate further research in this setting.

Atrial fibrillation's role in MitraClip patient outcomes: a retrospective analysis of mortality and heart failure hospitalization in a single-centre cohort

OBJECTIVE

Atrial fibrillation (AF) is common in patients with mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) with MitraClip; however, its impact on procedural hemodynamics and clinical outcomes remains inadequately characterized.

METHODS

This retrospective single-center study analyzed 226 high-risk patients who underwent MitraClip implantation between 2010 and 2022. The primary endpoint was time to first heart failure hospitalization. Secondary endpoints included procedural hemodynamics and long-term mortality.

RESULTS

AF was observed in 46.9% of the patients and was associated with distinct hemodynamic features, including significantly elevated right (11 vs. 9 mmHg, P = 0.008) and left atrial pressures (17 vs. 15 mmHg, P = 0.023). Despite similar procedural success rates, patients with AF experienced markedly accelerated time to first HF hospitalization (median 48 vs. 106 weeks, P = 0.005). Tricuspid regurgitation at discharge emerged as the strongest predictor of early heart failure hospitalization (HR 1.393, 95% CI: 1.009-1.924, P = 0.044). One-year mortality (16.0% vs. 16.7%, P = 0.899) and long-term survival remained comparable between groups.

CONCLUSION

AF in TEER patients is characterized by elevated atrial filling pressures and substantially accelerated time to heart failure hospitalization, with tricuspid regurgitation at discharge predicting early events. Although these findings indicate the need for more intensive monitoring of patients with AF during the first post-procedural year, comparable survival rates suggest that AF alone should not preclude TEER in otherwise suitable candidates.

Long-Term Complications Related to Cardiac Implantable Electronic Devices

Cardiac implantable electronic devices (CIEDs) are commonly used for a number of cardiac-related conditions, and it is estimated that over 300,000 CIEDs are placed annually in the US. With advances in technology surrounding these devices and expanding indications, CIEDs can remain implanted in patients for long periods of time. Although the safety profile of these devices has improved over time, both the incidence and prevalence of long-term complications are expected to increase. This review highlights pertinent long-term complications of CIEDs, including lead-related issues, device-related arrhythmias, inappropriate device therapies, and device-related infections. We also explore key clinical aspects of each complication, including common presentations, patient-specific and non-modifiable risk factors, diagnostic evaluation, and recommended management strategies. Our goal is to help spread awareness of CIED-related complications and to empower physicians to manage them effectively.

Calculation of Regurgitant Volume Using Echocardiographic Volumetric Method for Accurate Diagnosis of Severe Mitral Regurgitation

BACKGROUND

Recent studies have shown suboptimal results of the proximal isovelocity surface area (PISA) method and the American Society of Echocardiography (ASE) algorithm for diagnosing severe primary mitral regurgitation (MR). The aim of this study was to evaluate the accuracy of regurgitant volume (RegVol) calculated using volumetric transthoracic echocardiography (TTE) for diagnosing severe primary MR.

METHODS

A total of 74 patients with primary MR due to prolapse or flail leaflet were prospectively recruited for both TTE and cardiac magnetic resonance (CMR) imaging. RegVol was calculated using PISA (RegVol_PISA) or the volumetric method (left ventricular total stroke volume - systolic forward outflow volume; RegVol_TTE). According to the ASE algorithm, patients with four or more parameters were diagnosed with severe MR. RegVol_CMR ≥ 60 mL was used as the gold standard for diagnosing severe MR.

RESULTS

All subjects had at least moderate to severe MR according to ASE guidelines. CMR imaging confirmed that 30 patients (41%) had severe MR. The concordance correlation coefficient between RegVol_TTE and RegVol_CMR (0.809; 95% CI, 0.715-0.893) was higher than that between RegVol_PISA and RegVol_CMR (0.468; 95% CI, 0.323-0.576). The overall accuracy of RegVol_TTE for the diagnosis of severe MR was 90.5% (95% CI, 81.5-96.1), which was significantly higher than that of RegVol_PISA (64.9%; 95% CI, 52.9-75.6; P < .001) and the ASE algorithm (77.0%; 95% CI, 65.8-86.0; P = .004). The area under the curve for RegVol_TTE (0.95; 95% CI, 0.90-1.00) was significantly larger than that for RegVol_PISA (0.88; 95% CI, 0.80-0.96; P = .028).

CONCLUSIONS

RegVol_TTE showed better diagnostic performance than the PISA method and the ASE algorithm in diagnosing severe MR. Further investigations are necessary to evaluate the clinical usefulness of the routine use of RegVol_TTE.

Bridging Disciplines: Comprehensive Approaches to Cardiovascular Disease Treatment

Cardiovascular disease (CVD) remains one of the leading causes of death worldwide [...].

Tricuspid regurgitation: Innovation, current landscape, and future perspective of transcatheter tricuspid valve interventions

Tricuspid regurgitation (TR) is a prevalent cardiovascular disease necessitating innovative treatments. Assessing comorbidities, such as right ventricular dysfunction, is pivotal for the therapeutic strategy. Preprocedural echocardiographic assessments are crucial for achieving optimal TR reduction. Transcatheter interventions have emerged as less invasive therapies. Tricuspid transcatheter edge-to-edge repair is the predominant technology, proven safe and effective in reducing TR. Additionally, transcatheter tricuspid valve replacement and direct annuloplasty technologies have been developed and recognized as attractive alternatives, each with unique advantages. This review discusses the innovation, current landscape, and future perspective of transcatheter tricuspid valve interventions for treating TR.

Death on waiting list for transcatheter aortic valve implantation: Current incidence, clinical characteristics and predictive factors

BACKGROUND

The rapid and exponential growth in demand for transcatheter aortic valve implantation (TAVI) tends to overwhelm current capacity, leading to prolonged waiting times for TAVI.

AIMS

To investigate current waiting times for TAVI, the incidence of death on waiting list for TAVI, clinical characteristics and factors predictive of death before TAVI.

METHODS

A total of 1495 patients referred for TAVI in two French centres (TAVI centre, n=790; and non-TAVI centre, n=705) were included for analysis.

RESULTS

The mean age of the population was 82years. The median waiting time was 79 (interquartile range: 49-119) days, and was longer in the non-TAVI centre than in the TAVI centre (105 vs. 64days; P<0.001). The overall rate of death on waiting list was 5.8% (n=86), with the majority of deaths related to cardiovascular causes. Most patients (63%) died within the first 2months on the waiting list, with a linear occurrence of death without clear threshold. Impaired renal function (odds ratio: 2.12, 95% confidence interval: 1.30-3.45; P=0.003) and left ventricular ejection fraction<50% (odds ratio: 2.90, 95% confidence interval: 1.83-4.62; P<0.001) were identified as independent predictors of death on waiting list.

CONCLUSIONS

The delay between patient referral and TAVI procedure is longer than 2.5months in half of cases, with a steady increase over the years and longer delays in centres without on-site TAVI facilities. One in 20 patients dies while on the waiting list for TAVI, with two thirds of deaths occurring within the first 2months on the waiting list. Impaired renal function and left ventricular ejection fraction<50% determine an increased risk of death.

Australian Cardiac Outcomes Registry of Transcatheter Aortic Valve Implantation: Report and Update of Transcatheter Aortic Valve Implantation in Australia

BACKGROUND

Transcatheter aortic valve implantation (TAVI) procedures performed in Australia are recorded in the national Australian Cardiac Outcomes Registry (ACOR) TAVI Registry. Characteristics of patients and operators are prospectively collected with reference to patient demographics, procedural factors as well as outcomes related to both efficacy and safety metrics.

METHODS

Patient level data reported to the ACOR TAVI Registry from enrolled sites from registry inception up until 31 December 2021 were analysed. Key safety and efficacy metrics were identified and used to assess TAVI performance and outcomes in the Australian setting.

RESULTS

From 10 April 2018 to 31 December 2021, 9,881 consecutive patients underwent a TAVI procedure in Australia across 42 TAVI hospitals. The mean age of patients treated was 81.8 years (± standard deviation [SD] 7.1 years), 40.6% were female and the mean STS (Society for Thoracic Surgeons) score was 5.3% (±SD 4.4%). Overall, 0.3% of the cohort identified as Australian Aboriginal or Torres Strait Islander peoples. All-cause mortality at 30 days and 12 months was 1.37% and 5.57% respectively. The 30-day rates of stroke, major vascular complications and newly implanted permanent pacemaker were 2.19%, 1.23% and 10.68% respectively. There were 181 unique primary operators who performed TAVI during this time with an annualised median number of 19 procedures per operator per year (interquartile range [IQR] 42.5) and 63% of operators performed <30 cases per year.

CONCLUSIONS

TAVI is being performed in Australia with the encouraging outcomes described. These would appear to compare favourably with other international datasets.

Diastolic Stress Echocardiography Using the Six-Minute Walk Test in Asymptomatic Patients With Aortic Stenosis

Diastolic stress echocardiography is useful in patients with heart failure with preserved ejection fraction (EF); however, its utility in asymptomatic patients with aortic stenosis (AS) remains unexplored. We investigated the value of diastolic stress echocardiography using a 6-minute walk test (6-MWT) in elderly AS patients. This retrospective observational study included 96 consecutive asymptomatic patients (82 years, 39.6% male) with at least moderate AS (mean pressure gradient (MPG) ≥ 20 mm Hg or aortic valve area < 1.5 cm2) and preserved left ventricular EF. All underwent diastolic stress echocardiography using the 6-MWT. Patients were classified into a post-exercise impaired relaxation pattern (pIR) and a post-exercise pseudo-normalised/restrictive pattern (pPN) groups, based on transmitral flow velocity post-6-MWT. The primary endpoint was the time to first occurrence of the composite endpoint (all-cause mortality, aortic valve replacement due to AS-related symptoms, and hospitalization for heart failure).22 patients (23%) changed from baseline IR pattern at rest to the pPN pattern after the 6-MWT.The pPN group demonstrated lower %predicted walking distance than the pIR group. Additionally, the pPN group exhibited greater dyspnea after the 6-MWT. During a median follow-up of 536 days (interquartile range, 106-720 days), 46 patients experienced AS-related events. Multivariable Cox regression analysis indicated that the pPN group was independently associated with increased event risk (hazard ratio: 5.37, p < 0.001). In conclusion, this study suggests that the diastolic stress echocardiography using the 6-MWT is useful for risk stratification in asymptomatic elderly AS patients.

Comparative assessment of left and right atrial deformation using 2D and 3D speckle-tracking echocardiography in healthy individuals and rheumatic mitral stenosis patients with/without atrial fibrillation

BACKGROUND

Rheumatic mitral stenosis continues to be a significant public health issue in developing countries. Advances in echocardiography have made it possible to non-invasively assess atrial physiomechanics. In our study, we aimed to evaluate the changes in left and right atrial phasic functions in patients with have mitral stenosis and to investigate the relationship of these changes with clinical signs, symptoms, and intervention decisions.

METHODS

Patients with rheumatic mitral stenosis who did not have comorbidities affecting cardiac function were included in this single-center, prospective study. The study population consisted of 122 subjects: 30 healthy controls with no chronic diseases and normal cardiac function confirmed by clinical and echocardiographic evaluations, 31 patients with moderate mitral stenosis, 31 patients with severe mitral stenosis and 30 patients with severe mitral stenosis with valvular atrial fibrillation. In addition to conventional echocardiographic parameters, biventricular deformation analyses were assessed using 2D-STE. Right and left atrial phasic functions were evaluated using both 2D and 3D-STE analysis and compared with clinical findings.

RESULTS

In the patient group with severe mitral stenosis in sinus rhythm, the contractile left atrial strain values were significantly higher. The left atrial peak longitudinal (reservoir) strain values were found to be significantly lowest in the group with severe mitral stenosis accompanied by atrial fibrillation. Similarly, in the group with severe mitral stenosis accompanied by atrial fibrillation, the right atrial phasic strain values were significantly lower in both 2D and 3D measurements.

CONCLUSION

Mitral stenosis, the increased left atrial afterload in patients with sinus rhythm is compensated by an increase in contractile function. However, this compensatory increase is insufficient to preserve left atrial reservoir function. Patients with mitral stenosis who develop atrial fibrillation lack the compensatory contractile function, and this deficiency underlies the increased clinical deterioration associated with the development of atrial fibrillation.

Comparison of cardiac computed tomography recommendations in recent ESC vs. ACC/AHA guidelines

Cardiac computed tomography (CCT) continues to expand with increasing applications and technological advancements. Growing evidence on the clinical utility of CCT necessitates evaluating how this knowledge is incorporated into European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. We aimed to provide a comprehensive comparison of CCT indications between ESC and ACC/AHA guidelines to identify areas of consensus and divergence in the current landscape of CCT utilization. ESC and ACC/AHA guidelines were systematically reviewed for CCT recommendations. The class of recommendation (COR) and level of evidence (LOE) were compared using χ2 or Fisher exact tests. The latest ESC guidelines included 40 recommendations regarding CCT: 18 (45%) COR-I, 14 (35%) COR-IIa, 6 (15%) COR-IIb, and 2 (5%) COR-III. Two (5%) recommendation had LOE-A, 20 (50%) had LOE-B, and 18 (45%) had LOE-C. The latest ACC/AHA guidelines consisted of 54 recommendations: 18 (33.3%) COR-I, 28 (51.9%) COR-IIa, 6 (11.1%) COR-IIb, and 2 (3.7%) COR-III. Two recommendations were assigned LOE-A (3.7%), 30 (55.6%) were classified as LOE-B, and 22 (40.7%) as LOE-C. ACC/AHA guidelines had a significantly higher proportion of COR-IIa recommendations (P = 0.04) and similar proportions of COR-I and COR-IIb recommendations (P = 0.28; P = 0.76), compared to ESC guidelines. The proportion of LOE-B and LOE-C recommendations weren't statistically different (P = 0.54; P = 0.84). ACC/AHA guidelines included more CCT recommendations with a higher COR and LOE than ESC guidelines. These findings highlight the need for continued research and consensus-building to establish standardized, evidence-based CCT recommendations in clinical practice.

Trends and outcomes of concomitant tricuspid valve surgery with mitral valve surgery: A National Readmission Database study

BACKGROUND

Clinically significant tricuspid regurgitation (TR) affects nearly one-third of patients with mitral valve (MV) disease and portends higher morbidity and mortality. Concomitant tricuspid valve repair (TVr) is recommended during MV surgery (MVS) for patients with severe TR or moderate TR with tricuspid annular dilation or right-sided heart failure. This study assessed the frequency, trends, and outcomes of concomitant tricuspid valve surgery (TVS) in MVS patients in the United States.

METHODS

We analyzed index hospitalizations of patients undergoing MVS from the 2016-2020 Nationwide Readmissions Database (NRD), stratified by whether concomitant TVS was performed. Outcomes included inpatient mortality, length of stay (LOS), post-operative complications, and 30-day and 90-day all-cause readmissions. Inverse probability of treatment weighting (IPTW) controlled for selection bias. Outcomes were assessed using logistic regression and lognormal models.

RESULTS

Out of 63,047 weighted hospitalizations for MVS, 2627 (4.17 %) underwent concomitant TVS. TVS was associated with 67 % higher adjusted odds of in-hospital mortality (8.29 % vs. 5.14 %, aOR 1.67; 95 % CI: 1.33-2.10; p < 0.001) and 61 % higher odds of complications (40.94 % vs. 30.08 %, aOR 1.61; 95 % CI: 1.42-1.83; p < 0.001) compared to MVS alone. TVS was associated with 18 % longer hospital stay (12.17 days vs. 10.27 days, aOR 1.18; 95 % CI: 1.13-1.24) and higher odds of 90-day readmission (30.26 % vs. 25.58 %, aOR:1.26;95 % CI: 1.06-1.50).

CONCLUSIONS

Concomitant tricuspid valve surgery in patients undergoing mitral valve surgery is associated with higher in-hospital mortality, complications, and readmissions. This early excess risk has to be weighed against potential long-term benefits.

Age and Sex-Related Outcomes in CMR Versus CT-Guided TAVR: A Secondary Analysis of a Randomized Clinical Trial

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is the preferred treatment for older patients with severe aortic stenosis with outcomes influenced by age and sex. Computed tomography (CT) is the reference imaging modality for TAVR planning, while cardiac magnetic resonance (CMR) is an emerging alternative for this indication. The aim of this study was to evaluate the impact of age and sex on implantation success in patients undergoing CT- or CMR-guided TAVR.

METHODS

This was a secondary analysis of the randomized TAVR-CMR trial comparing TAVR planning by CT or CMR (NCT03831087). Patients were categorized according to the median age (82 years) and sex. Implantation success, defined using the Valve Academic Research Consortium-2 definition (absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance), was compared at hospital discharge between age groups and sex for each imaging strategy. All-cause mortality at 6 months was compared between imaging strategies across age groups and sex.

RESULTS

A total of 267 patients (median age 82 [IQR 80-85] years, 50% female) underwent TAVR at two heart centers in Austria between September 2017 and December 2022. Implantation success did not differ significantly between imaging strategies across age and sex subgroups. For patients ≤82 years, success rates were 92.1% (CT) vs. 94.7% (CMR) (p=0.524), and for those >82 years, 89.4% (CT) vs. 91.9% (CMR) (p=0.622). Among female patients, success rates were 84.7% (CT) vs. 93.2% (CMR) (p=0.113), and among male patients, 95.7% (CT) vs. 93.8% (CMR) (p=0.610). All-cause mortality at 6 months did not differ significantly between imaging strategies across age and sex subgroups. Mortality rates for patients ≤82 and >82 years were 4.8% vs. 5.3% (p=0.839) and 9.1% vs. 12.9% (p=0.490) for CT and CMR, respectively. Similarly, female and male patients had comparable mortality rates (10.2% vs. 8.1%, p=0.680; 4.3% vs. 9.4%, p=0.240).

CONCLUSIONS

In this secondary analysis of the TAVR-CMR trial, CMR-guided TAVR was associated with similar outcomes compared with CT-guided TAVR irrespective of age and sex.

Outcomes of tricuspid valve surgery in patients with significant tricuspid regurgitation and low to intermediate risk

BACKGROUND

In patients with tricuspid regurgitation (TR), delayed surgical intervention is associated with poor outcomes, particularly in advanced stages. This study aimed to assess whether earlier tricuspid valve (TV) surgery provides a survival benefit in patients with moderate to severe TR who are considered at low to intermediate risk of adverse clinical or surgical outcomes.

METHODS

This retrospective cohort study included 10 016 patients diagnosed with moderate to severe TR between 2008 and 2020. Patients were stratified using the the Tricuspid Regurgitation Impact on Outcomes (TRIO) Score (for general health risk) and TRI-SCORE (for perioperative risk). We focused on patients deemed at low or intermediate risk by these scores, comparing the all-cause mortality of those who underwent TV surgery to those managed medically.

RESULTS

Among 8874 patients categorised as low or intermediate risk, 871 (9.8%) underwent TV surgery. Patients in the surgical group were younger and had a higher prevalence of RV enlargement and RV dysfunction compared to those in the medical treatment group. During a mean follow-up of 5.2 years, surgical patients had a lower risk of death (HR 0.38, 95% CI 0.29 to 0.50) compared with medically managed patients after adjusting for confounders. This association persisted in patients who underwent isolated TV surgery. However, the potential for residual confounding in this non-randomised analysis should be considered.

CONCLUSIONS

TV surgery was associated with higher survival rates in patients with moderate to severe TR and low to intermediate prognostic risk. However, the observational nature of the study means that uncontrolled confounding cannot be excluded. These findings warrant further investigation in randomised studies.

Predictors of Outcomes of Reintervention After Transcatheter Aortic Valve Replacement: FRANCE 2 and FRANCE TAVI Registries

BACKGROUND

In a context of extending transcatheter aortic valve replacement (TAVR) to patients with a longer life expectancy, it is important to better document the incidence and outcomes of reintervention.

OBJECTIVES

The authors sought to evaluate the incidence, predictive factors, and long-term outcomes of surgical (explant TAVR) or transcatheter (redo TAVR) reintervention after TAVR.

METHODS

Patients who had a TAVR between 2010 and 2022 recorded in the FRANCE 2 and FRANCE TAVI registries were included in the analysis. Cumulative incidence of early (≤1 year) and late (>1 year) reintervention was assessed using the Kalbfleisch and Prentice method to account for all-cause death as a competing risk. Patients who had reintervention for infective endocarditis were excluded. Long-term mortality was evaluated using Kaplan-Meier analysis.

RESULTS

Among 72,850 patients included, the cumulative incidence of overall reintervention at 8 years was 1.7% including 591 patients who had redo TAVR and 111 patients who required explant TAVR with a low incidence of Bentall intervention. Reintervention occurred mostly early in 62.1% of cases and was more frequent in patients who had a mean aortic gradient >20 mm Hg immediately after index TAVR. Age and mean aortic gradient before TAVR and mean aortic gradient >20 mm Hg, aortic regurgitation ≥ grade 2, and percutaneous coronary intervention after TAVR were predictive of reintervention. Six-year mortality was high but was similar in patients who had early and late reintervention (76.2% vs 64.0%; P = 0.77).

CONCLUSIONS

Reintervention after TAVR remains rare and was mostly performed early after the procedure and by redo TAVR. Further studies are warranted, particularly in younger patients with longer life expectancy.

Transcatheter Aortic Valve Replacement in Patients With Systolic Heart Failure and Moderate Aortic Stenosis: TAVR UNLOAD

BACKGROUND

Neurohormonal modulation and afterload reduction are key for treatment of heart failure with reduced ejection fraction (HFrEF). In HFrEF patients with concomitant moderate aortic stenosis (AS), treatment with transcatheter aortic valve replacement (TAVR) may be complementary to guideline-directed medical therapy (GDMT).

OBJECTIVES

This study sought to determine whether TAVR for moderate AS provides clinical benefit in patients with HFrEF on top of GDMT.

METHODS

We performed an investigator-initiated, international, randomized controlled trial in patients with HFrEF on GDMT with moderate AS who were suitable for transfemoral TAVR with a balloon-expandable valve. Patients were randomized 1:1 to TAVR or clinical aortic stenosis surveillance (CASS) with aortic valve replacement upon progression to severe AS. The primary endpoint was the hierarchical occurrence of: 1) all-cause death; 2) disabling stroke; 3) disease-related hospitalizations and heart failure equivalents; and 4) change from baseline in the Kansas City Cardiomyopathy Questionnaire Overall Summary Score analyzed using the win ratio.

RESULTS

From January 2017 to December 2022, 178 patients were randomized to TAVR (n = 89) or AS surveillance (n = 89). The mean age was 77 years, 20.8% were female, and 55.6% were in NYHA functional class III or IV. The median follow-up duration was 23 months (Q1-Q3: 12-33 months). A total of 38 (43%) patients in the CASS group (of whom 35 had progressed to severe AS) underwent TAVR at a median of 12 months postrandomization. TAVR was associated with wins in 47.6% of pairs, compared with 36.6% in the CASS group, resulting in a win ratio of 1.31 (95% CI: 0.91-1.88; P = 0.14). At 1 year, TAVR resulted in a greater improvement in the Kansas City Cardiomyopathy Questionnaire Overall Summary Score compared with the CASS group (12.8 ± 21.9 points vs 3.2 ± 22.8 points; P = 0.018).

CONCLUSIONS

TAVR was not superior to AS surveillance for the primary hierarchical composite endpoint in patients with moderate AS and HFrEF on GDMT. Preemptive TAVR for moderate AS was safe and may provide clinically meaningful quality-of-life benefits.

Optimal antithrombotic therapy after transcatheter aortic valve replacement: a comprehensive review

Transcatheter aortic valve replacement (TAVR) has become a leading treatment for aortic stenosis, but managing thromboembolic and bleeding risks post-procedure remains challenging. This review examines current evidence on antithrombotic therapy after TAVR. Subclinical leaflet thrombosis is observed in 10%-20% of patients, though its clinical significance remains uncertain. Clinical valve thrombosis is rare. Current guidelines favor single antiplatelet therapy for patients without indications for long-term anticoagulation, as dual antiplatelet therapy increases bleeding risk without improving outcomes. For patients requiring long-term anticoagulation, monotherapy with direct oral anticoagulants or vitamin K antagonists is recommended to minimize bleeding. Ongoing trials aim to clarify optimal antithrombotic regimens and strategies for preventing subclinical leaflet thrombosis. Individualized therapy based on patient risk profiles is likely needed to improve the efficacy and safety of antithrombotic treatment post-TAVR.

Impact of hypotonic hyponatremia on outcomes in patients undergoing transcatheter aortic valve replacement: a national inpatient sample

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has emerged as a major therapeutic option for treating aortic stenosis. Hyponatremia is a common electrolyte disorder closely associated with adverse cardiovascular outcomes. However, large-scale studies investigating the impact of hypotonic hyponatremia on outcomes among TAVR patients are lacking.

METHODS

We queried patients who underwent TAVR with concomitant hypo-osmolar hyponatremia (defined as a serum sodium concentration < 135 mEq/L with a serum osmolality < 280 mOsm/kg) using the National Inpatient Sample (2016-2021). Multivariate regression analysis and 1:1 propensity score matching (PSM) were performed to assess the associations between hypo-osmolar hyponatremia and in-hospital mortality and major adverse events (including acute kidney injury [AKI], acute myocardial infarction [AMI], and cardiogenic shock [CS]). Furthermore, sensitivity analysis was performed to assess the robustness of the findings.

RESULTS

Among the total weighted national estimate of 370,680 patients who underwent TAVR, 13,865 (3.7%) had concomitant hypo-osmolar hyponatremia. These patients had a significantly increased risk of in-hospital mortality (aOR: 1.37; 95% CI: 1.08-1.74) and a greater likelihood of developing AKI (aOR: 3.39; 95% CI: 3.07-3.74), AMI (aOR: 3.20; 95% CI: 2.77-3.70), and CS (aOR: 2.96; 95% CI: 2.52-3.47). After PSM and sensitivity analysis, these associations remained significant.

CONCLUSION

In TAVR patients, hypo-osmolar hyponatremia is associated with increased in-hospital mortality and adverse events, including AKI, AMI, and CS.

MicroRNA-143-3p and miR-452-5p: A Fingerprint for the Diagnosis of Aortic Stenosis in the Geriatric Population

Background/Objectives: Aortic stenosis (AS) is the most common valvular pathology in the geriatric population and is the primary cause of valve replacement. However, misdiagnoses and delays in treatment are common due to comorbidities, frailty, and sedentary lifestyles among elderly individuals. MicroRNAs (miRNAs) are highly conserved molecular regulators involved in various cellular processes and have gained recognition as reliable biomarkers in cardiovascular diseases. In the present study, we evaluated plasma miRNAs as potential biomarkers for the early diagnosis of AS in the geriatric population to identify early therapeutic strategies. Methods: This prospective, case-control study included 87 individuals over 75 years of age. The participants were divided into AS (n = 58) and control (n = 29) groups. Results: Fifty-four miRNAs were differentially expressed between patients with AS and controls. Among those genes, 29 were upregulated and 25 were downregulated in patients with AS relative to controls. We selected seven candidate genes (miR-185-5p, miR-143-3p, miR-370-3p, let-7d-3p, miR-452-5p, miR-6787-3p, and miR-21-3p) for experimental validation by qRT-PCR. Only miR-143-3p and miR-452-5p were significantly upregulated in the plasma of patients with AS compared with controls. We developed a multiparametric model by combining the two-miRNA signature with echocardiographic parameters (left ventricular ejection fraction, stroke volume, and global longitudinal strain) to increase diagnostic power; this model yielded sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) values of 78.2%, 70.7%, and 0.837, respectively. Conclusions: In clinical practice, the use of a multiparametric model involving this set of miRNAs combined with echocardiographic variables may improve the accuracy of AS diagnosis and risk stratification.

Outcomes and Impact of Device Iterations in Mitral Valve Transcatheter Edge-to-Edge Repair: The REPAIR Study

BACKGROUND

The PASCAL P10 system for mitral valve transcatheter edge-to-edge repair has undergone iterations, including introduction of the narrower Ace implant and the Precision delivery system.

OBJECTIVES

This study sought to evaluate outcomes and the impact of PASCAL mitral valve transcatheter edge-to-edge repair device iterations.

METHODS

The REPAIR (REgistry of PAscal for mltral Regurgitation) study is an investigator-initiated, multicenter registry including consecutive patients with mitral regurgitation (MR) treated from 2019 to 2024. Patients were stratified by device iteration: P10only, P10/AceGen1 (introduction of Ace), and P10/AcePrec (introduction of Precision). The primary endpoint was MR ≤1+ at discharge; secondary endpoints included technical success and MR durability (discharge vs 30 days, 1 year, and 2 years).

RESULTS

A total of 2,165 patients (mean age 78 ± 10 years, 44% female, 85% in NYHA functional class ≥III, EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 4.9% [Q1-Q3: 3.0% to 8.1%]) were included: 660 P10only, 945 P10/AceGen1, and 560 P10/AcePrec. Median follow-up was 510 days (Q1-Q3: 369-874 days). Primary (47% [n = 1,019 of 2,142]) and secondary (52% [n = 1,123 of 2,142]) MR etiology did not change across device iterations (P = 0.547). Technical success was achieved in 97.0% (n = 2,099 of 2,165) with similar rates across device iterations (P = 0.290). MR ≤1+ was achieved in 72% (n = 1,397 of 2,085), improving with device iterations (P10only: 66% [n = 422 of 638], P10/AceGen1: 73% [n = 661 of 906], P10/AcePrec: 77% [n = 414 of 541]; P < 0.001). MR grades of ≤1+ and ≤2+ slightly worsened at 30 days, 1 year, and 2 years, primarily in patients with primary MR, with no differences across iterations.

CONCLUSIONS

Device iterations of the PASCAL system resulted in increasing rates of achieving MR reduction to ≤1+ at discharge, with stable and high technical success rates. A slight deterioration of the initial result warrants further investigation.

Transcatheter Aortic Valve Implantation and Replacement: The Latest Advances and Prospects

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, particularly in patients at high risk of adverse events for traditional open-heart surgery. Since the early 2000s, TAVR has evolved rapidly with advancements in device technology, procedural techniques, and patient selection criteria. Over the past 20 years, this catheter-based procedure has significantly improved patient survival and quality of life, demonstrating both the safety and efficacy of TAVR, even in patients at low surgical risk. This paper reviews the latest advances in valve design and strategies for treating aortic stenosis. It explores the challenges with long-term outcomes given the younger age of patients undergoing TAVR and the prospects of emerging technologies to improve long-term outcomes.

Comparative analysis of percutaneous vs. surgical access in transfemoral TAVR: a propensity-matched cohort study

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) is a proven treatment for severe aortic stenosis. Transfemoral access is the most prevalent method, achieved either surgically or percutaneously. This study compared in-hospital outcomes and length of stay between surgical cut-down and fully percutaneous approaches.

METHODS

This retrospective, propensity-matched study analyzed medical records of all patients who underwent transfemoral TAVR at our center from January 2019 to December 2023. Outcomes were assessed based on Valve Academic Research Consortium-2 (VARC-2) consensus criteria.

RESULTS

A total of 251 TAVR patients (77 propensity score-matched pairs) were included (55% female) with a median (IQR) age of 80 (11) years. Surgical cut-down showed fewer vascular complications, bleeding, and transfusions. No death was reported in this group. Fewer mean hospitalization days were observed in the total cohort over the years (p < 0.001). This reduction was more pronounced after 2021 when the surgical approach was adopted. Mean hospitalization days were 6.40 ± 6.46 for percutaneous and 4.34 ± 1.61 for surgical groups (p < 0.001).

CONCLUSION

Surgical cut-down for TAVR femoral access yields superior outcomes and shorter hospital stays compared to fully percutaneous methods.

Contemporary Diagnosis, Management, and Early Outcomes in Children with Kawasaki Disease in Romania: A Single-Center Experience

Background: Kawasaki disease (KD) is an acute inflammatory vasculitis with a particularly high incidence of coronary artery complications and constitutes a significant cause of acquired heart disease in children and young adults. Methods: We conducted a retrospective analysis of consecutive patients aged 0-18 years hospitalized at the "Prof. Dr. Matei Balş" National Institute of Infectious Diseases in Bucharest with Kawasaki disease over a period of 6 years (2018-2023). Results: A total of 25 children were discharged from hospital with this diagnosis during the analyzed period. The mean age was 2.9 years, and 56% were boys. Fever ≥5 days was present in all cases, and the most frequent additional sign was the presence of oral changes. Patients were treated according to in-effect guidelines with intravenous immunoglobulin (IVIG) (100%) and acetylsalicylic acid (68%). Only two cases were considered IVIG resistant and received a second IVIG infusion. Only mild cardiovascular changes were noted in echocardiography: mild coronary artery dilatation (21.7% of cases), mild valvular regurgitation, and small pericardial effusion. Infants displayed less inflammation and higher percentages of leukocytosis, developed an increase in platelet count sooner, received IVIG faster, and had longer hospital stays. Outcomes were generally favorable, and 92% of children were discharged, while the two remaining patients were transferred to other centers. No deaths were recorded. Conclusions: To our knowledge, this is the largest contemporary Romanian cohort of Kawasaki disease published to date, outlining the local diagnostic process, therapeutic strategies, and early outcomes of Kawasaki disease.