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

Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve replacement: A network meta-analysis

BACKGROUND

The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) is uncertain.

OBJECTIVES

To compare different PCI timings in patients with CAD undergoing TAVR.

METHODS

MEDLINE, Embase, and Cochrane were systematically searched for studies comparing different timings of PCI in patients with aortic stenosis and coronary artery disease (CAD) undergoing TAVR. PCI in a staged procedure to TAVR and PCI concomitantly to TAVR were compared with TAVR alone without PCI. A frequentist random-effects network meta-analysis calculates the odds ratio (OR) with a 95 % confidence interval (CI). Treatments were ranked using P-score analysis.

RESULTS

Two randomized controlled trials and 24 observational studies comprising 10,901 patients with aortic stenosis and CAD were included. Compared with PCI and concomitant TAVR, staged PCI was associated with lower rates of stroke (OR 0.54; 95 % CI 0.37-0.78), myocardial infarction (OR 0.54; 95 % CI 0.31-0.91), and all-cause mortality at 30 days (OR 0.62; 95 % CI 0.41-0.95). In addition, a subgroup analysis showed that staged PCI performed after TAVR is associated with the lowest rates of all-cause mortality of all strategies. In P-score analysis, staged PCI presented the highest likelihood of preventing stroke and myocardial infarction.

CONCLUSION

In patients with aortic stenosis and CAD undergoing TAVR, staged PCI is associated with lower rates of stroke, myocardial infarction, and short-term mortality compared with other timings.

Epicardial adipose tissue, myocardial remodelling and adverse outcomes in asymptomatic aortic stenosis: a post hoc analysis of a randomised controlled trial

BACKGROUND

Epicardial adipose tissue represents a metabolically active visceral fat depot that is in direct contact with the left ventricular myocardium. While it is associated with coronary artery disease, little is known regarding its role in aortic stenosis. We sought to investigate the association of epicardial adipose tissue with aortic stenosis severity and progression, myocardial remodelling and function, and mortality in asymptomatic patients with aortic stenosis.

METHODS

In a post hoc analysis of 124 patients with asymptomatic mild-to-severe aortic stenosis participating in a prospective clinical trial, baseline epicardial adipose tissue was quantified on CT angiography using fully automated deep learning-enabled software. Aortic stenosis disease severity was assessed at baseline and 1 year. The primary endpoint was all-cause mortality.

RESULTS

Neither epicardial adipose tissue volume nor attenuation correlated with aortic stenosis severity or subsequent disease progression as assessed by echocardiography or CT (p>0.05 for all). Epicardial adipose tissue volume correlated with plasma cardiac troponin concentration (r=0.23, p=0.009), left ventricular mass (r=0.46, p<0.001), ejection fraction (r=-0.28, p=0.002), global longitudinal strain (r=0.28, p=0.017), and left atrial volume (r=0.39, p<0.001). During the median follow-up of 48 (IQR 26-73) months, a total of 23 (18%) patients died. In multivariable analysis, both epicardial adipose tissue volume (HR 1.82, 95% CI 1.10 to 3.03; p=0.021) and plasma cardiac troponin concentration (HR 1.47, 95% CI 1.13 to 1.90; p=0.004) were associated with all-cause mortality, after adjustment for age, body mass index and left ventricular ejection fraction. Patients with epicardial adipose tissue volume >90 mm3 had 3-4 times higher risk of death (adjusted HR 3.74, 95% CI 1.08 to 12.96; p=0.037).

CONCLUSIONS

Epicardial adipose tissue volume does not associate with aortic stenosis severity or its progression but does correlate with blood and imaging biomarkers of impaired myocardial health. The latter may explain the association of epicardial adipose tissue volume with an increased risk of all-cause mortality in patients with asymptomatic aortic stenosis.

CLINICALTRIALS

gov (NCT02132026).

Percutaneous Management of Left Ventricular Perforation Causing Late Cardiac Tamponade After Transcatheter Aortic Valve Implantation

BACKGROUND

We present a case of left ventricular perforation and delayed cardiac tamponade after transcatheter aortic valve implantation (TAVI) managed percutaneously. This report describes a novel technique for management of left ventricular perforation after TAVI.

CASE SUMMARY

We performed elective transfemoral TAVI in a frail 85-year-old lady. Anatomical challenges included tortuous and horizontal aorta and a small left ventricular cavity. A 23-mm Sapien valve was implanted. She developed cardiac tamponade the next day needing emergency pericardiocentesis. Left ventricular angiogram showed perforation of the lateral wall. SURGIFLO Hemostatic Matrix was injected into the pericardial space using Agilis steerable introducer with a good outcome.

DISCUSSION

Cardiac perforation and tamponade are serious and potentially fatal complications after TAVI. The outcomes in these patients remain poor with high mortality rate even with emergent cardiac surgery. This report describes a novel technique for management of left ventricular perforation after TAVI.

Aortic valve calcification across stages of dysglycemia in middle-aged individuals from the general population

BACKGROUND

Aortic valve calcification (AVC) is an underlying pathophysiological mechanism in aortic stenosis, which shares many risk factors with diabetes. However, the association between dysglycemia and early stages of AVC remains unclear. The aim was to examine the associations between stages of dysglycemia and signs of AVC among middle-aged individuals from the general population.

METHODS

This was a cross-sectional study from the Swedish CArdioPulmonary bioImage Study (SCAPIS) randomly enrolling 30,154 middle-aged men and women from six study sites in Sweden between 2013 and 2018. Glycemic status was based on the World Health Organization criteria (fasting blood glucose and/or HbA1c) and questionnaire-based answers on previous diseases and categorized as normoglycemia, prediabetes, newly detected diabetes and known diabetes. AVC was assessed on cardiac computed tomography (CT) and defined as evident or not.

RESULTS

Of 29,331 individuals with data on glycemic status and AVC available, mean age was 57.5 years and normoglycemia was present in 76%, prediabetes in 16%, newly detected diabetes in 3% and known diabetes in 5%. The prevalence of AVC increased progressively across glycemic categories, particularly in males (8%, 11%, 14% and 17%; P < 0.01) compared to females (5%, 6%, 8% and 9%; P < 0.01). There was an association with AVC already in the early stages of dysglycemia; prediabetes (OR 1.16, 95% CI 1.02-1.31), newly detected diabetes (1.34 [1.05-1.71]) and known diabetes (1.61 [1.34-1.93]) after adjusting for age, sex, smoking, study site, low density lipoprotein-cholesterol and hypertension.

CONCLUSIONS

In this large, contemporary, and randomly selected population of middle-aged individuals, prediabetes, newly detected diabetes and known diabetes were all associated with CT-detected AVC. Further studies are warranted to investigate if managing dysglycemia, even in its early stages, may help slow down AVC progression.

Exercise capacity in moderate aortic stenosis: a cardiopulmonary stress echocardiography study

BACKGROUND

Patients with moderate aortic stenosis (AS) may experience symptoms and adverse outcomes. The aim of this study was to determine whether patients with moderate AS exhibited objective evidence of exercise limitation, compared with age and sex matched controls and if so, to determine which echocardiographic parameters predicted exercise ability.

METHODS

This was a prospective case control study of patients with moderate AS (peak velocity (Vmax) 3.0-3.9 m/s, mean gradient (MG) 20-39mmHg, aortic valve area (AVA)1.1-1.5cm2 ) and left ventricular ejection fraction (LVEF) ≥ 55%. All patients underwent cardiopulmonary stress echocardiography.

RESULTS

25 patients with moderate AS (Vmax 3.5 ± 0.2mmHg, mean gradient 28 ± 5mmHg, AVA 1.2 ± 0.1cm2, LVEF 61 ± 4%) were compared with 25 controls. % predicted oxygen uptake efficiency slope (OUES), % predicted O2 pulse and VO2 at anaerobic threshold (AT) were significantly lower in patients compared with controls (OUES 79 ± 15 vs. 89 ± 15%, p = 0.013). VO2 did not significantly differ between cases and controls.

CONCLUSION

Objective measures of exercise capacity including OUES, O2 pulse and VO2 at AT are significantly lower in patients with moderate AS compared with controls, suggesting that these parameters may be more useful than VO2 where patients may be unable to complete a maximal exercise test. Risk stratification using cardiopulmonary exercise echocardiography may help to identify patients with moderate AS who are at increased risk of cardiovascular events and should be considered for more intensive surveillance and intervention.

TRIAL REGISTRATION

Clinical trial number MRC 0225 IRAS 207395.

Angiographic Microvascular Resistance Is an Independent Predictor of Adverse Clinical Outcomes After Transcatheter Aortic Valve Replacement

BACKGROUND

The coronary microcirculatory resistance index plays a crucial role in predicting patient prognosis. Coronary angiography-based methods for assessing coronary microcirculatory function offer advantages such as simplicity and cost-effectiveness. This study aimed to confirm the prognostic value of a novel angiographic microvascular resistance (AMR) index in patients undergoing transcatheter aortic valve replacement.

METHODS AND RESULTS

We prospectively included 335 patients with severe aortic stenosis who underwent transcatheter aortic valve replacement at Fuwai Hospital. The AMR was calculated based on coronary angiography performed before prosthetic valve implantation. Patients were divided into 2 groups based on an AMR cutoff value of 250: AMR ≤250 and AMR >250. The primary end point was major adverse cardiovascular events, defined as a composite of all-cause mortality, readmission for heart failure, and myocardial infarction. At a median follow-up of 40 months (interquartile range [IQR], 25-50), AMR was significantly higher in patients who experienced the primary end point (257 [IQR, 186-299] versus 226 [IQR, 177-264]; P<0.001), identifying it as an independent risk factor for major adverse cardiovascular events, all-cause mortality, and new-onset atrial fibrillation. Kaplan-Meier analysis indicated that patients with AMR >250 had significantly lower event-free survival rates for major adverse cardiovascular events (62.9% versus 75.1%; hazard ratio, 1.94 [95% CI, 1.34-2.81]; log-rank P<0.001), mainly driven by all-cause death (75.7% versus 83.4%, log-rank P=0.018). Subgroup analyses supported these findings for major adverse cardiovascular events.

CONCLUSIONS

AMR is an independent predictor of adverse clinical outcomes after transcatheter aortic valve replacement. An AMR >250 can be used as a novel indicator for long-term prognostic management.

Intraoperative Transesophageal Echocardiographic Guidance in Cardiac Surgery

Transesophageal echocardiography (TEE) is a valuable tool for diagnosing structural heart diseases, offering superior resolution compared to transthoracic echocardiography. It allows for real-time evaluation of cardiac valves and both systolic and diastolic heart function. Additionally, TEE facilitates the prompt detection of potential complications during cardiac surgeries, such as paravalvular leaks, iatrogenic aortic dissections, and pericardial effusions. Advances in imaging, including 3D echocardiography, have further enhanced the visualization of complex structures like cardiac valves, providing "surgical views" that improve preoperative planning. These features have also made TEE indispensable for postoperative evaluation of cardiac valve repairs and for intraoperative guidance during minimally invasive procedures. This review article aims to summarize the indications for using TEE as an intraoperative tool in cardiac surgery.

Extracellular Matrix Proteins Improve Risk Prediction in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Cardiac fibrosis is common in patients with severe aortic stenosis and an independent predictor of death. Therefore, we examined the additional value of circulating fibrosis markers as a putative biomarker platform to identify patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) who are at a higher risk of death.

METHODS

In this study, 2-year survival analyses were conducted in 378 consecutive patients undergoing TAVR to evaluate the association between fibrosis marker and risk of adverse long-term outcome. Implementation of fibrosis marker into TAVR risk stratification was tested by a machine-learning algorithm.

RESULTS

Among 20 circulating fibrosis markers involved in pathological extracellular matrix remodeling, high tissue inhibitor of metalloproteinase-1 (TIMP-1) levels independently predicted risk of death in univariable (hazard ratio, 5.0 [95% CI, 2.6-9.7]; P<0.001) and multivariable (adjusted hazard ratio, 2.2 [95% CI, 1.0-4.7]; P=0.046) Cox regression analyses. Consequently, higher TIMP-1 levels offered a significantly higher overall prediction of reduced survival compared with the conventional Society of Thoracic Surgeons Predicted Risk of Mortality score (area under the curve, 0.753 [95% CI, 0.682-0.824] versus area under the curve, 0.656 [95% CI, 0.578-0.734]; P<0.05). Applying an independent machine-learning algorithm allowed identification of a simple combination of 2 biomarkers (TIMP-1 and high-sensitivity cardiac troponin T) with superior prognostic value compared with Society of Thoracic Surgeons Predicted Risk of Mortality alone (area under the curve, 0.757 [95% CI, 0.686-0.828] versus 0.656 [95% CI, 0.578-0.34]; P<0.05).

CONCLUSIONS

Circulating TIMP-1 is an independent predictor of reduced 2-year overall survival in patients undergoing TAVR. Combined with high-sensitivity cardiac troponin T, circulating TIMP-1 should be incorporated into risk stratification to identify patients undergoing TAVR who are at a higher risk of death.

Comparing Early Intervention to Watchful Waiting: A Review on Risk Stratification and Management in Asymptomatic Aortic Stenosis

Aortic stenosis is a progressive condition with substantial implications for morbidity and mortality. In recent years, attention has shifted toward risk stratification and the development of individualized management plans to optimize treatment outcomes. The management of asymptomatic patients has become a topic of significant controversy, as emerging studies challenge traditional watchful waiting guidelines and propose the potential benefits of early intervention. While early intervention may reduce overall morbidity and mortality in this patient population, the associated procedural risks remain a critical consideration. This review seeks to analyze the existing literature, offering an updated perspective on patient risk stratification and evidence evaluating both management approaches.

Long-Term Outcomes of Contemporary Surgical Repair for Degenerative Mitral Regurgitation

BACKGROUND

There are limited published reports about the long-term outcomes of contemporary surgical mitral repair series for degenerative mitral regurgitation performed at a high-volume center.

OBJECTIVES

The aim of this study is to report independently adjudicated long-term results of contemporary mitral repair surgery performed at a high-volume center.

METHODS

A retrospective study was conducted on 3,317 patients who underwent surgical mitral repair for degenerative mitral regurgitation at a tertiary care center between January 1, 2008 and December 31, 2017. Follow-up data, focusing on survival, reinterventions, and heart failure rehospitalizations were adjudicated and analyzed by the Italian National Agency for Regional Healthcare Services. Echocardiographic assessments during follow-up were not included. Complete (100%) data linkage was achieved.

RESULTS

The median age of the patients was 57 years, and 68.56% were men. The overall in-hospital mortality was 0.48% (16 of 3,317) for all cases and 0.21% (5 of 2,399) in isolated mitral valve repair. The 10-year survival was 89.65% (95% CI: 88.75%-90.55%), independently associated with preoperative symptoms and anterior leaflet disease. Freedom from reoperation was 96.63% (95% CI: 95.63%-97.63%) at 10 years. Anterior leaflet disease, a second run of cardiopulmonary bypass, and more than mild mitral regurgitation at discharge were associated with increased risk of reoperation. Finally, 10-year freedom from rehospitalization for heart failure was 92.24% (95% CI: 90.62%-93.86%), with age, prior hospitalization for heart failure, preoperative symptoms, and anterior leaflet disease identified as independent risk factors.

CONCLUSIONS

This contemporary series provides further data on the low in-hospital mortality and excellent long-term outcomes of surgical mitral repair when performed in a high-volume center. Preoperative symptoms are associated with worse outcomes. Isolated anterior leaflet disease increases the risk of reoperation, heart failure rehospitalization, and late mortality compared to posterior or bileaflets pathology.

Atrial and ventricular functional mitral regurgitation: prevalence, characteristics, outcomes, and disease progression

AIMS

Limited data exist on the natural history of functional mitral regurgitation (FMR), including atrial (AFMR), ventricular (VFMR), and dual FMR. This study examined the prevalence, characteristics, outcomes, and progression of these FMR subtypes.

METHODS AND RESULTS

Consecutive patients with ≥mild to moderate FMR were included and classified as AFMR, VFMR, or dual FMR. AFMR is characterized by left atrial enlargement, while VFMR involves left ventricular enlargement or reduced left ventricular ejection fraction. Dual FMR combines features of both. Clinical outcome was all-cause mortality and heart failure (HF) hospitalization. Echocardiographic outcome was the progression from mild-moderate/moderate to severe FMR and from AFMR/VFMR to dual FMR. Of 22 814 patients, AFMR, VFMR, and dual FMR were identified in 39%, 14%, and 47%, respectively. Most (84%) had mild-moderate to moderate FMR. Over a median clinical follow-up of 4.7 years, dual FMR has the highest risk of all-cause mortality and HF hospitalization. Compared with AFMR, patients with VFMR have a higher incidence of all-cause mortality (adjusted HR = 1.73, 95%CI 1.54-1.94, P < 0.001) and HF hospitalization (adjusted HR = 1.23, 95%CI 1.15-1.32, P < 0.001). In the serial cohort with 2.4 (1.0-4.9) years echocardiogram follow-up, VFMR was associated with a 1.51-fold and 3.08-fold increase in the risk of progressing to severe FMR and dual FMR than AFMR (both P < 0.001). Sensitivity analyses did not change these findings.

CONCLUSION

AFMR and VFMR have significant differences in survival and disease progression. Dual FMR is a common and distinct disease process that occurs in the progression of AFMR or VFMR and is associated with a poor prognosis.

Transcatheter aortic valve implantation in bicuspid aortic valves: present and future

The prevalence of bicuspid aortic valves (BAV) in patients undergoing transcatheter aortic valve implantation (TAVI) is expected to gradually increase over the coming years. However, in the absence of dedicated randomized trials, TAVI outcomes in BAV patients have failed to match those obtained in trileaflet anatomies. This discrepancy is mainly due to varying degrees of valve morphology and calcification, aortic angulation, concomitant aortopathy, and the difficulties of achieving optimal preprocedural anatomic sizing and device selection in the BAV setting. In this review, we aim to outline the current state of knowledge in the BAV and TAVI field, evaluate the main challenges faced by TAVI operators when dealing with these anatomies, summarize novel approaches for sizing and preprocedural evaluation, and provide a glimpse into the future of this interesting and evolving field.

Sex-Specific Association of Left Ventricular Function With Mortality in Severe Mitral Regurgitation

Importance

The association between left ventricular (LV) systolic dysfunction and adverse outcomes in patients with severe degenerative mitral regurgitation (MR) may vary by sex.

Objective

To investigate the sex-specific association of LV systolic function with mortality in patients with severe degenerative MR.

Design, Setting, and Participants

This retrospective cohort study included consecutive patients who underwent surgery for severe degenerative MR at 2 tertiary hospitals in South Korea from 2006 to 2020. Preoperative LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) were measured, with absolute LV-GLS values reported. Patients were stratified by LVEF (≤55%, >55% to ≤60%, and >60%) and LV-GLS (<19.9%, ≥19.9% to <23.4%, and ≥23.4%) tertiles. Mortality status was verified through December 2023, with a median (IQR) follow-up duration of 8.2 (5.3-12.2) years. Data analysis was conducted in March 2024.

Exposures

Surgical MV repair or replacement.

Main Outcomes and Measures

The primary outcome was all-cause mortality after MV surgery. Restricted cubic spline (RCS) curves visualized the association between LVEF, LV-GLS, and mortality for each sex.

Results

Among 1686 patients, 1088 (64.5%) were men and 598 (35.5%) were women. Women were older than men (median [IQR] age, 62 [51-70] vs 54 [45-63] years) and had higher LVEF and LV-GLS than men did. During the follow-up, 220 (13.0%) deaths occurred (117 men [10.8%]; 103 women [17.2%]). In Kaplan-Meier curves, mortality in men increased in the lowest LVEF (≤55%) and LV-GLS (<19.9%) groups, whereas women exhibited an earlier increase in mortality at higher LVEF (55%-60%) and LV-GLS (19.9%-23.4%) levels. Multivariable Cox analyses showed a higher mortality risk associated with LVEF less than or equal to 55% (adjusted hazard ratio [HR], 3.48; 95% CI, 1.84-6.58; P < .001) and 55% to 60% (adjusted HR, 2.21; 95% CI, 1.36-3.58; P = .001) compared with LVEF greater than 60% in women, but not in men (P for interaction by sex = .02). RCS curves showed an earlier increase in mortality risk at higher LVEF and LV-GLS levels in women. Similar trends were observed in asymptomatic patients.

Conclusions and Relevance

In this cohort study of patients with severe degenerative MR, women had an earlier increase in mortality risk associated with LV systolic dysfunction, suggesting the need to consider sex-specific criteria for early surgery in asymptomatic patients.

Hemodynamic Factors Driving Peripheral Chemoreceptor Hypersensitivity: Is Severe Aortic Stenosis Treated with Transcatheter Aortic Valve Implantation a Valuable Human Model?

Background: A reduction in carotid artery blood flow (CABF) and ultimately in wall shear stress (WSS) is a major driver of heightened peripheral chemoreceptor (PCh) activity in animal models of heart failure. However, it is yet to be translated to humans. To provide more insight into this matter, we considered severe aortic stenosis (AS) before and after transcatheter aortic valve implantation (TAVI) as a human model of carotid and aortic body function under dramatically different hemodynamic conditions. Materials and Methods: A total of 26 severe AS patients (aged 77 ± 6 y, body mass index: 29.1 ± 5.1 kg/m2, left ventricular ejection fraction (LVEF): 50 ± 15%) were subjected to a transient hypoxia test twice: immediately before vs. 1-4 months after TAVI (median follow-up: 95 days). PCh function was analyzed in terms of ventilatory (HVR, L/min/SpO2%) and heart rate responses to hypoxia (HR slope, bpm/SpO2%). Standard ultrasound (inc. aortic valve area [AVA], mean aortic valve gradient, peak aortic jet velocity, LVEF, and CABF), respiratory, hemodynamic, and blood parameters were collected at both visits. Pre- vs. post-TAVI data regarding HVR and HR slopes were available for N = 26 and N = 10 patients, respectively. Results: HVR did not change following TAVI (pre- vs. post-TAVI: 0.42 ± 0.29 vs. 0.39 ± 0.33 L/min/SpO2%, p = 0.523). The HR slope increased after TAVI (pre- vs. post-TAVI: 0.26 ± 0.23 vs. 0.37 ± 0.30 bpm/SpO2%, p = 0.019), and the magnitude of the increase was strongly associated with an increase in AVA (Spearman's R = 0.80, p = 0.006). No other significant relations between pre- vs. post-TAVI changes in PCh activity measures vs. hemodynamic parameters were found (all p > 0.12). Conclusions: The ventilatory component of the PCh reflex (defined as HVR) in severe AS patients is not affected by TAVI, and pre-TAVI values in this group are fairly comparable to those reported previously for healthy subjects. On the contrary, HR responses to hypoxia are increased after TAVI, and pre-TAVI values appear to be lower compared to the healthy population. An extraordinarily strong correlation between post-TAVI increases in HR slope and AVA may suggest that hemodynamic repercussions of the surgery in the aortic body area (most likely reduced WSS) play a critical role in determining aortic body function with a negligible effect on the carotid bodies. However, caution is needed when interpreting the results of the HR response to hypoxia in our study due to the small sample size (N = 10).

Association of aortic valve size with the degree of aortic valve calcification in severe high-gradient aortic stenosis

AIMS

Less pronounced calcification of the aortic valve (AVC) was observed in women with aortic stenosis (AS) when compared with men. Since women have smaller aortic valves (AVs), this could explain a lower calcium load. We aimed to analyse the association of AV size with AVC independent from sex.

METHODS AND RESULTS

Consecutive patients with high-gradient AS, who underwent cardiac computed tomography (CT), were assessed. AV annulus area and AVC with the Agatston score were measured on CT. In total, 601 patients (mean age 80 ± 7 years, 45% female) were included. Women had smaller AV annulus areas (4.12 ± 0.67 vs. 5.15 ± 0.78 cm2, P < 0.001) and lower Agatston scores [2018 (1456-3017) vs. 3394 (2562-4530), P < 0.001] than men. We found a significant correlation (r = 0.594, P < 0.001) and independent association (β = 926.20, P < 0.001) of AV annulus area with AVC. On separate regression analyses for men and women, AVC was independently associated with AV annulus area in both sexes (βmen = 887.77; βwomen = 863.48, both P < 0.001). When patients were stratified into AV size quartiles, patients in the lower quartiles were more likely to have AVC values below recommended sex-specific AVC thresholds. In the lowest quartile, 28% of female and 27% of male patients had Agatston scores below 1200 Agatston units (AU) (women) and 2000 AU (men), while this proportion decreased to 6 and 2%, respectively, in the quartiles with the largest annulus areas.

CONCLUSION

In high-gradient AS, AVC strongly depends on AV annulus area. This association is not dependent on sex. Thus, AVC should be indexed to AV size in addition to sex.

The role of multi-modality imaging for the assessment of left atrium and left atrial appendage: a clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

Structural, architectural, contractile, or electrophysiological alterations may occur in the left atrium (LA). The concept of LA cardiopathy is supported by accumulating scientific evidence demonstrating that LA remodelling has become a cornerstone diagnostic and prognostic marker. The structure and the function of the LA and left atrial appendage (LAA), which is an integral part of the LA, are key elements for a better understanding of multiple clinical conditions, most notably atrial fibrillation, cardioembolism, heart failure, and mitral valve diseases. Rational use of various imaging modalities is key to obtain the relevant clinical information. Accordingly, this clinical consensus document from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists and cardiac imagers for the best practice of imaging LA and LAA for the diagnosis, management, and prognostication of the patients.

Prognostic value of myocardial computed tomography-derived extracellular volume in severe aortic stenosis requiring aortic valve replacement: a systematic review and meta-analysis

Computed tomography (CT)-derived extracellular volume (ECV) fraction is a non-invasive method to quantify myocardial fibrosis. Evaluating CT-ECV during aortic valve replacement (AVR) planning CT in severe aortic stenosis (AS) may aid prognostic stratification. This meta-analysis evaluated the prognostic significance of CT-ECV in severe AS necessitating AVR. Electronic database searches of PubMed, Ovid MEDLINE, and Cochrane Library were performed. The primary outcome was to compare the occurrence of a composite of cardiovascular outcomes in patients with severe AS undergoing AVR with elevated myocardial CT-ECV values vs. patients with normal values. Secondary outcomes included all-cause mortality and heart failure (HF)-related hospitalization. A total of 1223 patients undergoing AVR for severe AS were included in 10 studies: 524 patients with high values of CT-ECV and 699 with normal values of CT-ECV. The pooled CT-ECV cut-off to define elevated values and predict prognosis was 30.7% [95% confidence interval (CI): 28.5-33.7%]. At a mean follow-up of 17.9 ± 2.3 months after AVR, patients with elevated CT-ECV experienced a significantly higher number of cardiovascular events [43.4 vs. 14.0%; odds ratio (OR): 4.3, 95% CI: 3.192-5.764, P < 0.001]. Regarding secondary outcomes, all-cause mortality occurred in 29.3% of patients with elevated CT-ECV vs. 11.6% with CT-ECV below the cut-off (OR: 3.5, 95% CI: 2.276-5.311, P < 0.001), whereas HF hospitalization was observed in 25.5% vs. 5.9% (OR: 4.9, 95% CI: 2.283-10.376, P < 0.001). Patients undergoing AVR for severe AS with elevated CT-ECV values experience a worse post-intervention prognosis. The implementation of CT-ECV evaluation in routine AVR planning protocols should be considered.

Diagnostic utility of velocity ratio for paradoxical low-flow/low-gradient aortic stenosis

BACKGROUND

Calcification score by cardiac computed tomography (CT) is required for diagnosis of paradoxical low-flow/low-gradient (PLFLG) aortic stenosis (AS). According to the guideline, velocity ratio (VR) < 0.25 by echocardiography is defined as severe AS, but utility of VR in patients with PLFLG AS remains unknown. This retrospective study was therefore conducted to investigate the utility of VR for a diagnosis of severe AS based on CT in patients with PLFLG AS.

METHODS

We studied 58 patients with PLFLG AS. Severity of AS was defined as calcium score derived from cardiac CT.

RESULTS

Of the 58 patients, 28 (48.3%) were diagnosed with severe AS based on CT, while 23 of them (82.1%) had VR < 0.25. It was noteworthy that receiver operating characteristic curve analysis showed that the optimal VR cutoff value for a diagnosis of severe AS was 0.25, with an area under the curve of 0.870 (P < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of VR < 0.25 for a diagnosis of severe AS were 82.1%, 86.7%, 85.2% and 83.9%, respectively. Furthermore, patients who match the value of VR and severity of AS based on CT had higher prevalence of atrial fibrillation, higher serum brain natriuretic peptide concentration, larger left ventricular end-diastolic volume, and left ventricular stroke volume index.

CONCLUSION

The measurement of VR is simple, and VR < 0.25 can be used for diagnosis of patients with PLFLG AS as severe. Our findings may thus have clinical implications for routine clinical practice.

The Role of 4D Flow MRI-derived Wall Shear Stress in Aortic Disease: A Comprehensive Review

Aortic diseases, such as aortic dissection and aortic rupture, often lead to catastrophic complications, significantly increasing morbidity and mortality. Population-based screening for early detection in asymptomatic individuals is not feasible due to high costs and practical challenges. However, recent advancements in four dimensions (4D) Flow magnetic resonance imaging (MRI) offer a comprehensive tool for evaluating hemodynamic changes within the aortic lumen. This technology allows for the quantification and visualization of flow patterns and the calculation of advanced hemodynamic parameters, such as wall shear stress (WSS). WSS is crucial in the development, risk stratification, and surgical outcomes of aortic diseases and their complications, enabling noninvasive and quantitative screening of high-risk populations. This review explores the current status and limitations of 4D flow MRI-derived WSS imaging for aortic disease.

Isolated Tricuspid Valve Surgery for Functional Tricuspid Regurgitation

BACKGROUND

 Severe tricuspid regurgitation (TR) adversely affects long-term survival; however, isolated tricuspid valve (TV) surgery has been rarely performed due to high operative mortality. In addition, the previous literature included heterogeneous TR etiologies. Therefore, we aimed to elucidate early and long-term outcomes of isolated TV surgery for functional TR.

METHODS

 An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis.

RESULTS

 This meta-analysis included seven studies. Pooled analyses showed that 68% (35, 89) of patients had preoperative atrial fibrillation or flutter, and 58% (11, 94) had a history of left-sided valve surgery. Seventy-three percent (65, 80) of patients had at least one physical exam finding of right-sided heart failure, and 57% (44, 69) were in New York Heart Association class III or IV. TV replacement was more common than repair. In TV replacement, bioprosthetic valve (39%, 13, 74) was more common than mechanical prosthesis (22%, 18, 26). The early mortality rate was 7%. Twenty percent of patients required a permanent pacemaker postoperatively. The overall 1- and 5-year survival rates were 84.5 and 69.1%, respectively.

CONCLUSION

 More than half of the patients who underwent isolated TV surgery for functional TR had undergone left-sided valve surgery and had significant heart failure symptoms at the time of surgery. Further studies on the surgical indication for concomitant TV surgery at the time of left-sided valve surgery and the appropriate timing of surgery for isolated functional TR are needed to improve survival.

Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves

OBJECTIVE

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

METHODS

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

RESULTS

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

CONCLUSION

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

EchoNavigator®-guided transcatheter mitral valve-in-valve procedure to treat a degenerated radiolucent surgical bioprosthetic valve: a case report

Background

Radiolucent valves present unique clinical challenges since interventions often depend on multiple imaging modalities to perform such procedures successfully. EchoNavigator® is novel imaging software that specializes in real-time merging ultrasound and fluoroscopy images. It addresses these limitations by simultaneously integrating the benefits of two imaging modalities.

Case summary

An 85-year-old man with a history of bioprosthetic valve disease developed life-limiting symptoms. Transesophageal echocardiogram (TEE) showed severe bioprosthetic mitral stenosis, prompting plans to perform a transcatheter mitral valve-in-valve (TMVIV) replacement. Using EchoNavigator® to mark the annulus on TEE, we were able to successfully deploy the valve using fluoroscopy to guide the successful deployment of the valve.

Discussion

The treatment of degenerated valves using transcatheter valve-in-valve procedures has increased in frequency recently due to increasing age and comorbidities associated with patients. Identifying the true annulus plays an integral role in ensuring the valve is deployed in the ideal location. However, the radiolucent nature of the valve prohibits performing a TMVIV under conventional methods. Utilization of fusion imaging, such as EchoNavigator®, provides an opportunity to visualize such valves using the strengths of both modalities simultaneously, simplifying such procedures. To our knowledge, this is the first report of using such fusion technology to facilitate the placement of a bioprosthesis within a failed radiolucent surgical valve. Application of such technologies can help improve the performance and outcomes of such procedures by allowing operators to use the advantages of both imaging for improved outcomes.

Prognostic Implication of Preprocedural Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis

Pulmonary hypertension (PH) is a common comorbidity in patients with aortic stenosis (AS) who are candidates for transcatheter aortic valve implantation (TAVI). Herein, we sought to elucidate the prognostic value of preprocedural PH on the early and late mortality after TAVI. The Cochrane Library, Scopus, PubMed, Web of Science, Embase, and ProQuest were screened using a predefined search query. We considered odds ratios (ORs) as the measure of effect. Meta-regression analysis was applied to investigate the potential impact of baseline characteristics on the outcomes. Egger's and Begg's tests were used to assess the publication bias. Thirty-three studies comprising 34 datasets representing 68,435 patients were included in the analysis. Regardless of the definition and severity of PH, pooled data analysis indicated that preprocedural PH was associated with higher cardiac and overall 30-day [OR, 1.45 (1.15-1.82) and OR, 1.75 (1.42-2.17), respectively], and 1-year mortality [OR, 1.63 (1.35-1.96) and OR, 1.59 (1.38-1.82), respectively]. Meta-regression analysis demonstrated that older age, higher New York Heart Association function class, history of hypertension, diabetes, and lower left ventricular ejection fraction were predictors of higher mortality rate following TAVI. Moreover, we found that preprocedural PH is significantly associated with higher in-hospital mortality and 30-day acute kidney injury. Our results demonstrated that preprocedural PH is associated with higher early and late cardiac and overall mortality following TAVI; however, this finding is limited regarding the considerable inconsistency in the definition of PH and PH severity among studies.

Dynamic Response of Heart Rate Variability to Active Standing in Aortic Valve Disease: Insights from Recurrence Quantification Analysis

INTRODUCTION

Aortic valve disease (AVD) is an inflammatory, lipid infiltration and calcification disease that has been associated with changes in the conventional linear heart rate variability (HRV) indices showing a marked shift towards sympathetic predominance and a deterioration of the autonomic control.

OBJECTIVE

To explore the HRV dynamics in AVD patients through nonlinear methods by recurrence quantification analysis (RQA).

METHODS

In total, 127 subjects participated in a cross-sectional study categorized into three groups: healthy valve (HV), aortic valve sclerosis (AVSc), and aortic valve stenosis (AVS), as determined by echocardiographic assessment. HRV data were collected from five-minute ECG recordings at both a supine position and active standing. RQA indices were calculated using the Cross Recurrence Plot Toolbox.

RESULTS

In the supine position, patients with AVS exhibited larger determinism and trapping time than those with AVSc and HV. The analysis of these differences revealed that determinism and laminarity increased progressively from HV to AVS. In the same way, the magnitude of change (Δ) between positions decreased and presented the lowest values in AVS in most of the nonlinear indices.

CONCLUSION

RQA indices of HRV in AVD patients indicate a rigidizing dynamic characterized by larger determinism and extended trapping times in fewer system states in relation to the severity of AVD. These findings establish a precedent for future perspective assessments for the implementation of these methods in medical software or devices.

Deferral of routine percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation: Rationale and design of the PRO-TAVI trial

BACKGROUND

Concomitant coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The optimal treatment strategy for CAD is a topic of debate. An initial conservative strategy for CAD in patients undergoing TAVI may be favorable as multiple studies have failed to show an evident beneficial effect of percutaneous coronary intervention (PCI) on mortality after TAVI. However, more randomized, controlled trials are warranted.

METHODS

The PeRcutaneous cOronary Intervention before Transcatheter Aortic Valve Implantation (PRO-TAVI) trial is an investigator-initiated, multicenter, open-label, randomized controlled trial comparing TAVI with or without routine preprocedural PCI. A total of 466 patients undergoing TAVI will be randomized in a 1:1 ratio to PCI (reference group) or no PCI (index group). Concomitant CAD is defined as at least 1 stenosis of 70% to 99%, or at least 1 stenosis between 40% and 70% combined with positive physiological measurement in a coronary artery with a minimal diameter of 2.5 mm or bypass graft. The primary endpoint is a composite of all-cause mortality, myocardial infarction, stroke, or type 2 - 4 bleeding at 12 months after randomization, in accordance with Valve Academic Research Consortium-3 criteria. Key secondary endpoints include the individual components of the primary endpoint, revascularization, quality of life and cost-effectiveness. The primary endpoint will be analyzed to assess non-inferiority of deferral of routine PCI in patients undergoing TAVI against the prespecified margin of 11 percentage points.

CONCLUSION

The PeRcutaneous cOronary intervention before Transcatheter Aortic Valve Implantation (PRO-TAVI) trial is designed to investigate the hypothesis that deferral of routine PCI in patients undergoing TAVI is non-inferior to TAVI with preceding PCI.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov. Unique identifier NCT05078619.

Anticoagulants: From chance discovery to structure-based design

Taking a historical perspective, we review the discovery, pharmacology, and clinical evaluation of the old and new anticoagulants that have been approved for clinical use. The drugs are discussed chronologically, starting in the 1880s, and progressing through to 2024. The innovations in technology used to develop novel anticoagulants came in fits and starts and reflected the advances in science and technology over these decades, whereas the shift from anecdote to evidence-based use of anticoagulants was delayed until the principles of epidemiology and biostatistics were introduced into clinical trial design and to the approval process. Hirudin, heparin, and vitamin K antagonists were discovered by chance, and were used clinically before their mechanism of action was elucidated and before their net clinical benefits were evaluated in randomized clinical trials. Subsequent anticoagulants were designed based on a better understanding of the structure and function of coagulation proteins, including antithrombin, thrombin, and factor Xa, and underwent more rigorous preclinical and clinical evaluation before regulatory approval. By simplifying oral anticoagulation, the direct oral anticoagulants have revolutionized anticoagulation care and have enhanced the uptake of anticoagulation, but bleeding has not been eliminated and there is a need for more effective and convenient anticoagulants for thrombosis triggered by the contact pathway of coagulation. The newly developed factor XIa and XIIa inhibitors have the potential to address these unmet clinical needs and are undergoing clinical evaluation for several indications. SIGNIFICANCE STATEMENT: Anticoagulant therapy is the cornerstone of treatment and prevention of thrombosis, which remains a leading cause of morbidity and mortality worldwide. Elucidation of the structure and function of coagulation enzymes, their cofactors, and inhibitors, coupled with advances in structure-based design led to the discovery of more convenient, safer, and more effective anticoagulants that have revolutionized the management of thrombotic disorders.

A murine model of aortic regurgitation generated by trans-apical wire destruction of the aortic valve

BACKGROUND

The mechanisms underlying cardiac remodeling in aortic valvular (AoV) disease remain poorly understood, partially due to the insufficiency of appropriate preclinical animal models. Here, we present a novel murine model of aortic regurgitation (AR) generated by trans-apical wire destruction of the AoV.

METHODS

Directed by echocardiography, apical puncture of the left ventricle (LV) was performed in adult male C57BL/6 mice, and a metal guidewire was used to induce AoV destruction. Echocardiography, invasive LV hemodynamic and histological examination were conducted to assess the degree of AR, LV function and remodeling.

RESULTS

AR mice exhibited rapid aortic regurgitation velocity (424 ± 15.22 mm/s) immediately following successful surgery. Four weeks post-surgery, echocardiography revealed a 54.6% increase in LV diastolic diameter and a 55.1% decrease in LV ejection fraction in AR mice compared to sham mice. Pressure-volume catheterization indicated that AR mice had significantly larger LV end-diastolic volumes (66.2 ± 1.5 μL vs. 41.8 ± 3.4 μL), reduced LV contractility (lower dP/dtmax and Ees), and diminished LV compliance (smaller dP/dtmin and longer Tau) compared to sham mice. Histological examination demonstrated that AR mice had significantly larger cardiomyocyte area and more myocardial fibrosis in LV tissue, as well as a 107% and a 122% increase of heart weight/tibial length and lung weight/tibial length, respectively, relative to sham mice.

CONCLUSIONS

The trans-apex wire-induced destruction of the AoV establishes a novel and efficient murine model to develop AR, characterized by significant eccentric LV hypertrophy, heart failure, and pulmonary congestion.

Pacemaker implantation after surgical aortic valve replacement and balloon-expandable transcatheter aortic valve implantation: Incidence, predictors, and prognosis

Background

Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) remains a significant challenge despite new-generation devices.

Objectives

This study aimed to identify predictors of PPI during preoperative evaluation and assess its mid-term impact in a single-center, real-world setting.

Methods

From 2010 to 2020, 1486 patients with aortic stenosis underwent surgical aortic valve replacement or TAVI using balloon-expandable transcatheter heart valves. The PPI rate was estimated using the hospital discharge record for each patient in the Emilia-Romagna region.

Results

The 30-day incidence of PPI in the TAVI group was 3.4%. While 30-day PPI did not affect overall survival (log-rank, P = .494 NS), it predicted rehospitalization due to cardiac causes (hazard ratio 10.28; 95% confidence interval [CI] 95% 3.41-31.00; P <.001). Calcifications in the leaflet (odds ratio [OR] 4.66; 95% CI 1.41-15.47; P = .012), left ventricular outflow tract (OR 4.51; 95% CI 1.48-13.76; P = .008), and device landing zone (OR 2.52; 9% CI 0.86-7.40; P = .093) were associated with a higher risk of PPI.

Conclusion

A low 30-day PPI incidence was observed, primarily because of the exclusive use of balloon-expandable SAPIEN transcatheter heart valves and high implantation techniques. Baseline factors such as leaflet, left ventricular outflow tract, and device landing zone calcifications, as well as right bundle branch block, highlight the need for comprehensive preoperative analysis to reduce PPI incidence and mitigate its associated longer hospital stays and rehospitalizations due to cardiac causes.

SCAI Expert Consensus Statement on Alternative Access for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has become a widely accepted procedure for treating patients with symptomatic aortic stenosis. While transfemoral access remains the primary route due to its lower complication rates and favorable outcomes, a subset of patients have anatomical or clinical factors precluding this approach. For these patients, alternative access routes such as transaxillary, transcarotid, and transcaval provide viable options. This expert consensus statement aims to provide a comprehensive review of case selection, technical considerations, and outcomes associated with these alternative access routes in TAVR. Additionally, this document highlights the advancements in device technology and imaging guidance that have contributed to improving the safety and efficacy of alternative access TAVR. This consensus statement serves as a practical guide on best practices for interventional cardiologists, cardiothoracic surgeons, and heart teams in selecting patients and performing alternative access TAVR.

Transapical transcatheter mitral valve replacement for mitral valve disease: an Iberian experience

INTRODUCTION AND OBJECTIVES

Transcatheter mitral valve replacement (TMVR) is an emerging treatment alternative for mitral valve (MV) disease in patients who were ineligible for surgical intervention or edge-to-edge repair. This study aimed to assess the short- and mid-term outcomes of this procedure.

METHODS

We conducted a prospective registry to include the initial experience with symptomatic, consecutive patients who underwent TMVR using the transapical Tendyne system at 7 centers in the Iberian Peninsula. Baseline clinical and imaging data, periprocedural information, and follow-up assessments were collected at 1 month and 1 year.

RESULTS

A total of 40 patients (mean age 78.5 years [76-82], 47,5% males) underwent TMVR. The majority had significant surgical risk, comorbidities, and advanced functional class. All patients had significant mitral regurgitation (MR), except for 2 with severe stenosis. Previous MV intervention and off-label indication for the procedure were present in 4 (10.0%) and 8 (20.0%) patients, respectively. Technical success was recorded in 100%, device success in 95.0%, and procedural success in 85.0% at 30-day. All-cause mortality was 2.5% and 17.5% at the 1-month and 1-year follow-up, respectively. MR reduction (≤ 1) and functional class improvement (NYHA I-II) were observed at 1 year in 93.9% and 87.9% of survivors, respectively.

CONCLUSIONS

Treatment with TMVR produced enduring resolution of MV disease and notable functional enhancement at 1 year of follow-up. The procedure demonstrated a satisfactory early safety profile, although 1-year mortality remained relatively high in this high-risk population.

The influence of lipoprotein(a) on aortic valve calcification in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Elevated levels of lipoprotein(a) (Lp[a]) have been recognized as substantial risk factors for cardiovascular disease and aortic stenosis (AS). However, the specific role of Lp(a) in promoting aortic valve calcification (AVC) and influencing mortality in elderly, multimorbid patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear and warrants further investigation.

METHODS

A retrospective analysis was conducted on all consecutive patients who underwent TAVR between August 2019 and June 2020 at our clinic. Patients with missing data or prior aortic valve replacement were excluded. The study cohort was stratified based on an Lp(a) threshold of 60 mg/dl according to guidelines for lipoprotein apheresis in UK and Germany.1,2 RESULTS: In total, 454 patients were included into the analysis. Mean age was 81 ± 6 years and patients presented with a notable cardiovascular risk profile. Lp(a) values ≥ 60 mg/dl were detected in 102 (22.5%) patients, while 352 (77.5%) had Lp(a) values < 60 mg/dl. The median calcium volume of the total cohort was 894.5 [570.8; 1,382.8] mm2. No significant difference was observed between the groups (p = 0.83). Furthermore, Lp(a) did not emerge as a statistically significant predictor of calcium levels before TAVR. Notably, male gender (B = 404.11, p < 0.001) and mean trans-valvular pressure gradient (B = 15.64, p < 0.001) were identified as the strongest coefficients within the robust regression analysis. Log-rank tests indicated no prognostic utility of Lp(a) for 30-day all-cause mortality (p = 0.30) or 40 months long-term all-cause mortality (p = 0.60).

CONCLUSION

Lp(a) might not exert a significant effect on calcification levels or all-cause mortality in patients undergoing TAVR. Despite the study's highly selected population, these results align with current research, supporting the assumption that the influence of Lp(a) may be confined to the early stages of AS and its progression.

Global burden of non-rheumatic valvular heart disease in older adults (60-89 years old), 1990-2019: Systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

Understanding the global burden and risk factors of non-rheumatic valvular heart disease (NRVHD) in older adults is important for effective disease control. We wanted to analyze the prevalence, incidence, disability-adjusted life years (DALY) rate, mortality rate, and risk factors of NRVHD in older adults aged 60-89 years.

METHODS

Global Burden of Disease Study (GBD) 2019 was used as the data source. Age standardized incidence rate, prevalence, DALY rate, and mortality rate of NRVHD among older adults aged 60-89 years from 1990 to 2019. We analyzed different age groups, genders, regions, sociodemographic index (SDI) across 204 countries/territories. Proportional DALY and mortality attributable to risk factors were calculated.

RESULTS

Globally, age-standardized DALY rate (per 100,000 population) for NRVHD in older adults decreased significantly from 44.46 (95 % confidence interval 39.95 to 49.18) in 1990 to 35.94 (32.32 to 40.19) in 2019 with an average annual percent change (AAPC) of -0.19 % (-0.24 % to -0.14 %), and the mortality rate also decreased significantly from 2.48 (2.21 to 2.64) to 2.25 (1.89 to 2.47) with an AAPC of -0.09 % (-0.16 % to -0.03 %,). However, the age-standardized incidence rate (per 100,000 population) increased from 18.37 (17.41 to 19.35) in 1990 to 19.77(18.62 to 20.95) in 2019 with an AAPC of 0.08 % (0.05 % to 0.10 %), and the age-standardized prevalence rate significantly increased from 391.40 (372.71 to 411.20) to 399.50 (378.31 to 420.75) with an AAPC of 0.02 % (0.00 % to 0.05 %). At the regional level, the greatest burden of NRVHD was seen in parts of high-income North America. At the national level, the highest age standardized incidence rate, age standardized DALY rate, and age standardized mortality rate in 2019 were all from Niger, Philippines and Belarus, making it the region with the greatest burden of NRVHD. The age standardized incidence and DALY rate were higher in women 20.83 (19.68 to 22.02) than in men 18.64 (17.39 to 19.88) globally, while the mortality rate was similar in different genders. The differences between men and women in incidence, DALY and mortality were mainly found in age groups of 80-84 and 85-89 years. A significant negative association was found between estimated annual percentage change (EAPCs) and age standardized rate (q=-0.19, p = 0.00). A significant positive relation was detected between EAPCs and human development index (q = 0.17, p = 0.02). The main attributable risk factor for DALY was high body mass index in all regions by SDI.

CONCLUSION

There is a substantial global burden of NRVHD in older adults in 2019, which is varied by age, gender, SDI and region. NRVHD in older people should be paid attention to. Risk factors described here should provide more evidence and clues for disease prevention in the future.

Sex differences in aortic valve inflammation and remodeling in chronic severe aortic regurgitation

Aortic regurgitation (AR) is more prevalent in males, although cellular and molecular mechanisms underlying the sex differences in prevalence and pathophysiology are unknown. This study evaluates the impact of sex on aortic valve (AV) inflammation and remodeling and the cellular differences in valvular interstitial cells (VICs) and valvular endothelial cells (VECs) in patients with AR. A total of 144 patients (27.5% female) with severe chronic AR were included. AVs were analyzed by imaging, histological, and molecular biology techniques (ELISA, RT-PCR). VICs and VECs isolated from patients with AR were characterized and further treated with transforming growth factor (TGF)-β. Anatomically, male had smaller index aortic dimensions and greater AV thickness. Proteome profiler analyzes in AVs (n = 40/sex) evidenced higher expression of inflammatory markers in male and that was further validated (interleukins, chemokines). Histological composition showed higher expression of inflammatory mediators and collagen thick fibers in AVs from male. Male VICs and VECs secreted higher levels of inflammatory markers than female cells. Interestingly, male VICs produced higher amounts of collagen type I and lower fibronectin and aggrecan, whereas male VECs secreted lower decorin. TGF-β exclusively enhanced inflammation in male VICs and decorin and aggrecan in female VICs. Compared with male, AVs from female were thinner, less inflamed, and fibrotic. VICs seem to be the key cell type responsible for the sex-differences. Valvular inflammation associated with an active remodeling process could be a key pathophysiological process involved in AR.NEW & NOTEWORTHY The pathogenesis of chronic aortic regurgitation (AR) is different in male and female. Female patients with AR showed less aortic valve inflammation and collagen accumulation as compared with male. Valvular cells from female patients secreted less inflammatory molecules and collagen and higher levels of proteoglycans. Valvular interstitial cells from females were more sensitive to transforming growth factor (TGF)-β-induced proteoglycans secretion. Our study opens a new perspective oriented toward sex-specific molecular pathways and therapeutic targets in chronic severe AR.

New nosologies: atriogenic valvular regurgitation

Functional mitral regurgitation and functional tricuspid regurgitation occur due to cardiac remodelling in the presence of macroscopically normal valve apparatus. Two main mechanisms are involved: a ventricular phenotype (when ventricular remodelling and dysfunction are predominant) and an atrial phenotype (when annulus dilatation and atrial remodelling are predominant). Both phenotypes are frequent in patients with heart failure and are associated with a significant increase in morbidity and mortality, representing a relevant therapeutic target. This work focuses on the epidemiology, pathophysiology, prognosis, and therapy of atrial functional regurgitation.

Transcatheter edge-to-edge repair in functional tricuspid regurgitation

Tricuspid edge-to-edge repair (T-TEER) has emerged as a promising treatment option for severe functional tricuspid regurgitation (TR) in patients unsuitable for surgery. Recent findings from randomized clinical trials consistently demonstrated a reduction in TR severity and significant symptomatic improvement with T-TEER, particularly in terms of quality of life and functional status. However, no significant differences in mortality or hospitalizations were observed compared to guideline-directed medical therapy. In this complex scenario, careful patient selection and a comprehensive evaluation of the tricuspid valve remain critical for optimizing outcomes. Patients with preserved right ventricular (RV) function, absence of pulmonary hypertension (PH), and no significant organ dysfunction are more likely to benefit from T-TEER. Conversely, in patients with severe RV dysfunction, lack of contractile reserve, pre-capillary or severe combined post-capillary PH, end-stage organ failure, and significant impairment in daily activities and self-care, the procedure may be futile. Patients in the grey zone should be evaluated by a dedicated heart team, with a tailored decision-making approach.

Myocardial Strain Imaging: Theory, Current Practice, and the Future

Myocardial strain imaging by echocardiography or cardiac magnetic resonance (CMR) is a powerful method to diagnose cardiac disease. Strain imaging provides measures of myocardial shortening, thickening, and lengthening and can be applied to any cardiac chamber. Left ventricular (LV) global longitudinal strain by speckle-tracking echocardiography is the most widely used clinical strain parameter. Several CMR-based modalities are available and are ready to be implemented clinically. Clinical applications of strain include global longitudinal strain as a more sensitive method than ejection fraction for diagnosing mild systolic dysfunction. This applies to patients suspected of having heart failure with normal LV ejection fraction, to early systolic dysfunction in valvular disease, and when monitoring myocardial function during cancer chemotherapy. Segmental LV strain maps provide diagnostic clues in specific cardiomyopathies, when evaluating LV dyssynchrony and ischemic dysfunction. Strain imaging is a promising modality to quantify right ventricular function. Left atrial strain may be used to evaluate LV diastolic function and filling pressure.

Association With Outcomes of Correcting the Proximal Isovelocity Surface Area Method to Quantitate Secondary Tricuspid Regurgitation

BACKGROUND

Although the correction of the proximal isovelocity surface area (PISA) method has been shown to improve the accuracy of assessing the severity of secondary tricuspid regurgitation (STR), its clinical impact remains to be investigated. The aim of this study was to compare the association of the quantitative parameters of STR severity obtained from the corrected and conventional PISA methods with outcomes.

METHODS

Both conventional and corrected effective regurgitant orifice area (EROA) (EROA vs corrected EROA [EROAc]), regurgitant volume (RegVol) (RegVol vs corrected RegVol [RegVolc]), and regurgitant fraction (RegFr) (RegFr vs corrected RegFr [RegFrc]) were measured in 519 consecutive patients (mean age, 75 ± 12 years; 44% men; 74% with ventricular STR) with moderate and severe STR. The end point was a composite of heart failure hospitalization and death.

RESULTS

EROAc, RegVolc, and RegFrc were significantly larger than EROA, RegVol, and RegFr (P < .001 for all). After a mean follow-up period of 19 ± 15 months, 210 patients reached the end point. Using time-dependent receiver operating characteristic curves, the parameters obtained from the corrected PISA method were more closely associated with outcomes at 2 years than those obtained with the conventional PISA method: EROAc vs EROA (P < .001), RegVolc vs RegVol (P = .001), and RegFrc vs RegFr (P < .001) for ventricular STR. Conversely, no significant differences were detected for atrial STR. After multivariable adjustment, both uncorrected and corrected EROA, RegVol, and RegFr were independently associated with the end point. Using the new five-grade severity scheme, patients reclassified using the corrected PISA method had a significantly higher rate of events compared with those not reclassified among those with ventricular STR (P = .0086). Conversely, this relationship was not statistically significant in patients with atrial STR (P = .061).

CONCLUSIONS

Correcting the PISA method provides larger quantitative parameters of STR severity that are more closely associated with outcomes in patients with ventricular STR.

Transcatheter aortic valve replacement in heavily calcified aortic valve stenosis: a multicenter comparison

BACKGROUND

Heavy calcifications in severe aortic stenosis (AS) pose a major challenge in patients undergoing transcatheter aortic valve replacement (TAVR). Only a few studies have addressed the performance of different transcatheter heart valves (THV) in this subgroup of patients.

OBJECTIVES

We aimed to investigate the outcomes of the self-expanding Medtronic CoreValve Evolut valve frame and the balloon-expandable Edwards SAPIEN-3/3 Ultra THV in this challenging patient population.

MATERIALS AND METHODS

This was a multicenter registry including a total of 1513 patients with heavily calcified AS undergoing TAVR. The primary endpoint was the incidence and degree of paravalvular leak (PVL) after TAVR. Secondary endpoints were post-implant hemodynamics as well as clinical endpoints according to the VARC-3 definitions.

RESULTS

The CoreValve Evolut R but not the Evolut PRO showed significantly higher rates of PVL compared to the SAPIEN-3/3 Ultra (44.8% vs. 29.5% for mild PVL, p < 0.001), while there was no significant difference in ≥ moderate PVL between both groups (p = 0.399). The CoreValve Evolut R and Evolut PRO showed superior THV hemodynamics compared to the SAPIEN-3/3 Ultra group. These findings were confirmed in a propensity score-matched analysis. There were no significant differences regarding short-term outcomes including permanent pacemaker implantation and all-cause mortality between the three groups.

CONCLUSION

In patients with severely calcified AS, both CoreValve Evolut PRO and SAPIEN-3/3 Ultra THV showed lower rates of PVL than the CoreValve Evolut R. The self-expanding CoreValve platform had superior post-implant hemodynamics than the SAPIEN-3/3 Ultra system.

Computed tomography derived predictors of left ventricular obstruction after TAVR

BACKGROUND

Left ventricular obstruction (LVO) is an infrequent complication following transcatheter aortic valve replacement (TAVR) that can lead to severe hemodynamic decompensation. Previous studies have analyzed the pathophysiology of this clinical entity; however, little is known about the anatomical characteristics as assessed by computational tomography (CT) of patients at risk.

METHODS

Data from 349 patients were retrospectively analyzed from a single center registry of patients undergoing TAVR at San Raffaele Hospital, Milan, Italy, between January 2020 and December 2021. All patients with aortic valve stenosis and available pre-procedural CT data were included. Patients with previous heart valve surgery/interventions were excluded.

RESULTS

Post-procedurally, a total of 57 patients (16.3 %) developed LVO. They were more frequently older (83.2 vs 81.4, p = 0.04), females (67 % vs. 47 %, p < 0.05) and had smaller body surface areas and weight. CT analysis between the two groups demonstrated an acuter aorto-mitral angle (107 vs 114°, p < 0.001), shorter interventricular septum to leaflet coaptation distance (SLCL, 22.1 vs 28.1 mm, p < 0.001), smaller telo-systolic left ventricular areas (267 vs 714 mm2) and smaller LVOT area (404 vs 470 mm2, p < 0.001) in patients with LVO. Multivariate regression analysis identified as parameters able to predict the occurrence of LVO the telo-systolic LV area (OR, 0.998; 95 % CI 0.996-0.999; p = 0.001) and the anatomical distance between the interventricular septum and the point of leaflet coaptation (OR, 0.92; 95 % CI 0.86-0.99; p = 0.02).

CONCLUSION

This is the first study identifying pre-procedural CT imaging predictors of patients at risk for LVO following TAVR. Further multicenter studies with systematic follow up will be needed to confirm these findings.

Discordance between aortic valve gradient and area: do I trust the significant gradient?

Aortic stenosis is an increasingly relevant pathology not only for its high prevalence in the population (especially elderly), but also because in recent decades traditional surgery has been accompanied by transcatheter aortic valve implantation, a technique that has allowed a significant increase in effective therapeutic procedures, even in patients previously considered at high surgical risk. It has become essential to make precise diagnoses, based mainly on echo-Doppler that allows to identify the aetiology and severity of the valvular disease. A stenosis is considered severe when the area is <1 cm2, the mean gradient exceeds 40 mmHg and the peak velocity is >4 m/s. Although in many cases these cut-offs are decisive, in others a discrepancy between area (<1 cm2) and gradient (<40 mmHg) is observed, requiring the inclusion of other variables such as ejection fraction (EF > or <50%) and the systolic volume index (normal SVi >35 mL/m2 or reduced <35 mL/m2) to define the severity of the stenosis. This article describes the reasons for this discrepancy, identifies echo-Doppler parameters that further improve the classification of stenosis severity, and defines the indications for second-level examinations such as computed tomography and transoesophageal echocardiography.

Transcatheter aortic valve implantation in patients with significant septal hypertrophy

BACKGROUND

Previous reports suggest septal hypertrophy with an interventricular septum depth (IVSD) ≥ 14 mm may adversely affect outcomes after transcatheter aortic valve implantation (TAVI) due to suboptimal valve placement, valve migration, or residual increased LVOT pressure gradients.

AIMS

This analysis investigates the impact of interventricular septal hypertrophy on acute outcomes after TAVI.

METHODS

Between 2009 and 2021, 1033 consecutive patients (55.8% male, 80.5 ± 6.7 years, EuroSCORE II 6.3 ± 6.5%) with documented IVSD underwent TAVI at our center and were included for analysis. Baseline, periprocedural, and 30-day outcome parameters of patients with normal IVSD (< 14 mm; group 1) and increased IVSD (≥ 14 mm; group 2) were compared. Data were retrospectively analyzed according to updated Valve Academic Research Consortium-3 (VARC-3) definitions. Comparison of outcome parameters was adjusted for baseline differences between groups using logistic and linear regression analyses.

RESULTS

Of 1033 patients, 585 and 448 patients were allocated to groups 1 and 2, respectively. There was no significant difference between groups regarding transfemoral access rate (82.6% (n = 478) vs. 86.0% (n = 381), p = 0.157). Postprocedural mean transvalvular pressure gradient was significantly increased in group 2 (group 1, 7.8 ± 4.1 mmHg, vs. group 2, 8.9 ± 4.9 mmHg, p = 0.046). Despite this finding, there was no significant difference between groups regarding the rates of VARC-3 adjudicated composite endpoint device success (90.0% (n = 522) vs. 87.6% (n = 388), p = 0.538) or technical success (92.6% (n = 542) vs. 92.6% (n = 415), p = 0.639). Moreover, the groups showed no significant differences regarding the rates of paravalvular leakage ≥ moderate (3.1% (n = 14) vs. 2.6% (n = 9), p = 0.993), postprocedural permanent pacemaker implantation (13.4% (n = 77) vs. 13.8% (n = 61), p = 0.778), or 30-day mortality (5.1% (n = 30) vs. 4.5% (n = 20), p = 0.758).

CONCLUSION

Although transvalvular mean pressure gradients were significantly higher in patients with increased IVSD after TAVI, acute outcomes were comparable between groups suggesting no early impact of adverse hemodynamics due to elevated IVSD. However, how these differences in hemodynamic findings may affect mid- and long-term outcomes, especially in terms of valve durability, needs to be evaluated in further investigations.

Effect of chronic total occlusion of coronary arteries on cardiovascular outcomes in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has significantly advanced the treatment of severe aortic stenosis (AS), particularly in elderly patients who often have coexisting coronary artery disease (CAD). Chronic total occlusion (CTO), a severe form of CAD, may negatively impact outcomes in TAVR patients, though data are limited. This meta-analysis aims to evaluate the impact of CTO on TAVR outcomes.

METHODS

A comprehensive literature search was conducted across multiple electronic databases to identify studies comparing TAVR outcomes in patients with and without CTO. Pooled risk ratios (RR) with 95 % confidence intervals (CIs) were calculated using a random-effects model. The primary outcome was all-cause mortality, with several secondary endpoints also assessed.

RESULTS

Six studies involving a total of 331,159 TAVR patients were included in this meta-analysis. CTO was associated with a significantly increased risk of in-hospital mortality (RR: 1.24; 95 % CI: 1.01, 1.52; p = 0.04), acute myocardial infarction (RR: 1.67; 95 % CI: 1.48, 1.89; p < 0.00001), acute kidney injury (RR: 1.46; 95 % CI: 1.37, 1.56; p < 0.00001), and vascular complications (RR: 1.47; 95 % CI: 1.28, 1.69; p < 0.00001). No significant differences were observed in all-cause mortality (RR: 1.21; 95 % CI: 0.76, 1.93; p = 0.42), stroke (RR: 1.09; 95 % CI: 0.91, 1.30; p = 0.37), or bleeding events (RR: 1.19; 95 % CI: 1.00, 1.41; p = 0.06).

CONCLUSION

CTO poses a significant risk in TAVR patients, particularly for in-hospital mortality and acute myocardial infarction. A multidisciplinary approach is recommended for these patients, with consideration given to revascularization before TAVR. Further studies are needed to evaluate the potential benefits of prior CTO-PCI.

Five- Year Outcomes in Low-Risk Patients Undergoing Surgery in the PARTNER 3 Trial

BACKGROUND

Surgery remains an important treatment for low-risk patients with severe symptomatic aortic stenosis (AS). This study evaluated 5-year outcomes in low-risk patients undergoing isolated surgical aortic valve replacement (SAVR) or SAVR with concomitant procedures within the randomized Placement of Aortic Transcatheter Valves (PARTNER) 3 trial.

METHODS

In the PARTNER 3 trial, 454 patients underwent surgery for severe, symptomatic, trileaflet AS and were followed up for 5 years. Patients were stratified into those undergoing isolated SAVR (n = 334; 73.6%) vs concomitant SAVR (n = 120; 26.4%). Short- and long-term morbidity was adjudicated by a Clinical Events Committee. Hemodynamic valve performance was evaluated by an echocardiographic core laboratory. Patient-reported health status was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ).

RESULTS

The mean age of participants was 73.6 ± 6.1 years; 71.1% of these patients were male. The median SAVR implant size was 23 mm overall. Five-year all-cause mortality (with vital status sweep) was 9.0% for all patients (8.5% isolated SAVR; 10.2% concomitant SAVR; P = .58), comparable to a recent analysis of low-risk isolated SAVR-treated patients in the STS database (overall mortality, 7.1%). The average 5-year mean gradient was 11.7 ± 5.6 mm Hg overall. Reintervention rates were low in both groups (isolated SAVR, 2.3% vs concomitant SAVR, 5.0%; P = .21), and most patients (isolated SAVR, 87.9%; concomitant SAVR, 86.1%) were alive with no evidence of bioprosthetic valve failure at 5 years.

CONCLUSIONS

SAVR in low-risk patients in the PARTNER 3 trial demonstrated excellent 5-year outcomes. Five-year mortality was similar in patients undergoing isolated SAVR vs concomitant SAVR. This result was comparable to recently published national SAVR outcomes, thus demonstrating the generalizability of these findings.

Mitral Valve Repair: Optimal Annual Case Volume for Surgery

BACKGROUND

Despite strong recommendations from multiple societies to pursue durable mitral valve repair (MVr), repair rates and outcomes remain inconsistent across the world. This is partly due to limited surgeon and center experience and lack of centralization of care for this technically challenging operation.

OBJECTIVES

The authors evaluate the association between annual case volume and contemporary long-term outcomes of patients undergoing isolated MVr.

METHODS

A systematic literature search was performed to identify contemporary studies on isolated MVr in adults from January 2013 to November 2023. The primary outcomes were long-term survival, freedom from reoperation, and freedom from recurrent mitral regurgitation (moderate-severe). A novel meta-analytic volume-outcome approach using reconstructed Kaplan-Meier-derived individual patient data from the original studies was used. A frailty Cox model was applied to study volume-outcome relationships. Studies were pooled for each reported outcome and divided into 3 tertiles (T1-3) based on the annual case volume and number of patients of each center.

RESULTS

A total of 14,070 patients from 60 studies were pooled. Sixteen studies (n = 6,099) reported long-term survival. The overall pooled 10-year survival was 70.8% (95% CI: 68.9%-72.8%). Compared to lower volume centers, centers performing >38 cases/y were associated with significantly improved long-term survival (HR: 0.42; 95% CI: 0.36-0.49; P < 0.001). For degenerative mitral valve disease, a volume cutoff of >45 cases/y was associated with significantly improved long-term survival (HR: 0.40; 95% CI: 0.32-0.49; P < 0.001). Twelve studies (n = 4,230) reported long-term freedom from reoperation and 10 studies (n = 2,470) reported Kaplan-Meier-derived long-term freedom from recurrent mitral regurgitation data, respectively. The overall pooled 10-year freedom from reoperation was 90.2% (95% CI: 88.1%-92.4%), while the overall pooled 10-year freedom from recurrent mitral regurgitation was 72.7% (95% CI: 68.9%-76.8%). Centers performing >45 cases/y (HR: 0.61; 95% CI: 0.44-0.84; P = 0.003) and >70 cases/y (HR: 0.64; 95% CI: 0.42-0.98; P = 0.042) were associated with significantly improved long-term freedom from recurrent mitral regurgitation and freedom from reoperation, respectively. For degenerative mitral disease, >45 cases/y was associated with significantly improved freedom from recurrent mitral regurgitation (HR: 0.51; 95% CI: 0.36-0.72; P < 0.001); the volume outcome association for freedom from reoperation was not statistically significant (P = 0.58).

CONCLUSIONS

Our study validates volume cutoffs associated with optimal long-term outcomes following isolated MVr. We found MVr volumes of >38 cases/y, 45 cases/y, and >70 cases/y to be associated with significantly improved long-term survival, durability of repair, and freedom from reoperation, respectively. These findings may define experienced centers and surgeons for patients requiring MVr for primary/degenerative mitral valve disease.

Clinical value of aortic arch morphology in transfemoral TAVR: artificial intelligence evaluation

BACKGROUND

The impact of aortic arch (AA) morphology on the management of the procedural details and the clinical outcomes of the transfemoral artery (TF)-transcatheter aortic valve replacement (TAVR) has not been evaluated. The goal of this study was to evaluate the AA morphology of patients who had TF-TAVR using an artificial intelligence algorithm and then to evaluate its predictive value for clinical outcomes.

MATERIALS AND METHODS

A total of 1480 consecutive patients undergoing TF-TAVR using a new-generation transcatheter heart valve at 12 institutes were included in this retrospective study. The AA measurements were evaluated by deep learning, and then the approach index (I A ) was determined. The machine learning algorithm was used to construct the predictive model and was validated externally.

RESULTS

The area under the curve of the I A model using random forest and logistic regression was 0.675 [95% confidence interval (CI): 0.586-0.764] and 0.757 (95% CI: 0.665-0.849), respectively. The I A model was validated externally, and consistent distinctions were obtained. After we used a generalized propensity score matching method for continuous exposure, the I A was the strongest correlation factor for major procedural events (odds ratio: 3.87; 95% CI: 2.13-7.59, P < 0.001). When leaflet morphology or transcatheter heart valve type was an interactive item with I A , neither of them was statistically significant in terms of clinical outcomes.

CONCLUSION

I A may be used to identify the impact of AA morphology on procedural and clinical outcomes in patients having TF-TAVR and to help to predict the procedural complications.

Valve Thrombosis Following Transcatheter Aortic Valve Replacement: State-of-the-Art Review

Transcatheter aortic valve replacement (TAVR) is a well-established treatment for severe aortic stenosis, especially in patients over 75 or those at high surgical risk. While these prosthetic valves have a lower thrombogenic profile than mechanical heart valves, leaflet thrombosis in transcatheter aortic valves (TAV) occurs in an estimated 5%-40% of cases. Most TAV thromboses are subclinical and can be detected via cardiac computed tomography (CCT), which reveals hypo-attenuating leaflet thickening and reduced leaflet motion in asymptomatic patients without elevated transprosthetic gradients on echocardiography. The mechanisms behind TAV thrombosis involve local mechanical triggers, patient predisposing factors, and device and procedure-related aspects. The ideal antithrombotic therapy post-TAVR depends on individual patient characteristics, balancing bleeding risks with the need for oral anticoagulants. Data on the optimal management of TAV thrombosis and the routine use of CT post-TAVR are limited. While anticoagulation effectively resolves clinically significant prosthesis thrombosis, its benefit in subclinical cases is unclear. There is an ongoing debate about whether subclinical leaflet thrombosis precedes clinical valve thrombosis, making the ideal follow-up after valve implantation uncertain. This article aims to provide a comprehensive review, summarizing current data on the incidence of TAVR thrombosis, underlying mechanisms, clinical and imaging diagnosis, management strategies, preventive measures, and long-term follow-up.

Clinical Outcomes According to the Extent of Atherosclerotic Disease in Female Patients Undergoing Transcatheter Aortic Valve Replacement: An Analysis From the WIN-TAVI Registry

BACKGROUND

Limited data exist on the impact of polyvascular disease (PolyVD) on clinical outcomes in female patients undergoing transcatheter aortic valve replacement (TAVR). We therefore sought to investigate clinical outcomes in women with versus without PolyVD undergoing TAVR.

METHODS

Female participants from the multicentre Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized based on the presence or absence of PolyVD. The PolyVD population was defined as the presence of atherosclerotic disease affecting ≥ 2 arterial systems from coronary, cerebral, or lower limb peripheral vessels, whilst patients with either no atherosclerosis or atherosclerotic disease in one vascular system were included in the non-PolyVD population. The primary endpoint was the Valve Academic Research Consortium-2 consensus (VARC-2) efficacy endpoint at 1 year, whilst secondary endpoints included VARC-2 safety events, VARC-2 major bleeding and major vascular complications. Cox regression analysis were computed adjusting for various cofounders.

RESULTS

Among 996 participants, 543 (54.5%) had PolyVD, while 453 (45.5%) did not. Across the subgroups no differences in age was noted, whilst patients with PolyVD were more likely to have a history of hypercholesterolemia and a previous cardiac surgery. The incidence of the primary endpoint was higher in the PolyVD group (19.4%) compared to the non-PolyVD group (13.3%, plog-rank = 0.014), though the difference was attenuated after multivariable adjustments (p = 0.093). Of note, no statistically significant differences concerning incident VARC-2 safety events, VARC-2 major bleeding and major vascular complications were noted according to PolyVD status.

CONCLUSION

PolyVD is a common comorbidity and is associated with elevated rates of adverse clinical events, but no increase in safety events, vascular complications, or bleeding among women undergoing TAVR.