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

Serum lipoprotein(a) and bioprosthetic aortic valve degeneration

AIMS

Bioprosthetic aortic valve degeneration demonstrates pathological similarities to aortic stenosis. Lipoprotein(a) [Lp(a)] is a well-recognized risk factor for incident aortic stenosis and disease progression. The aim of this study is to investigate whether serum Lp(a) concentrations are associated with bioprosthetic aortic valve degeneration.

METHODS AND RESULTS

In a post hoc analysis of a prospective multimodality imaging study (NCT02304276), serum Lp(a) concentrations, echocardiography, contrast-enhanced computed tomography (CT) angiography, and 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) were assessed in patients with bioprosthetic aortic valves. Patients were also followed up for 2 years with serial echocardiography. Serum Lp(a) concentrations [median 19.9 (8.4-76.4) mg/dL] were available in 97 participants (mean age 75 ± 7 years, 54% men). There were no baseline differences across the tertiles of serum Lp(a) concentrations for disease severity assessed by echocardiography [median peak aortic valve velocity: highest tertile 2.5 (2.3-2.9) m/s vs. lower tertiles 2.7 (2.4-3.0) m/s, P = 0.204], or valve degeneration on CT angiography (highest tertile n = 8 vs. lower tertiles n = 12, P = 0.552) and 18F-NaF PET (median tissue-to-background ratio: highest tertile 1.13 (1.05-1.41) vs. lower tertiles 1.17 (1.06-1.53), P = 0.889]. After 2 years of follow-up, there were no differences in annualized change in bioprosthetic hemodynamic progression [change in peak aortic valve velocity: highest tertile [0.0 (-0.1-0.2) m/s/year vs. lower tertiles 0.1 (0.0-0.2) m/s/year, P = 0.528] or the development of structural valve degeneration.

CONCLUSION

Serum lipoprotein(a) concentrations do not appear to be a major determinant or mediator of bioprosthetic aortic valve degeneration.

Management of Mechanical Prosthetic Heart Valve Thrombosis: JACC Review Topic of the Week

Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can be caused by 4 main phenomena: 1) thrombosis; 2) fibrotic pannus ingrowth; 3) degeneration; and 4) endocarditis. Mechanical valve thrombosis (MVT) is a known complication with clinical presentation ranging from incidental imaging finding to cardiogenic shock. Thus, a high index of suspicion and expedited evaluation are essential. Multimodality imaging, including echocardiography, cine-fluoroscopy, and computed tomography, is commonly used to diagnose MVT and follow treatment response. Although surgery is oftentimes required for obstructive MVT, other guideline-recommended therapies include parenteral anticoagulation and thrombolysis. Transcatheter manipulation of stuck mechanical valve leaflet is another treatment option for those with contraindications to thrombolytic therapy or prohibitive surgical risk or as a bridge to surgery. The optimal strategy depends on degree of valve obstruction and the patient's comorbidities and hemodynamic status on presentation.

Imaging of Bioprosthetic Valve Dysfunction after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has become the standard of care in elderly high-risk patients with symptomatic severe aortic stenosis. Recently, TAVI has been increasingly performed in younger-, intermediate- and lower-risk populations, which underlines the need to investigate the long-term durability of bioprosthetic aortic valves. However, diagnosing bioprosthetic valve dysfunction after TAVI is challenging and only limited evidence-based criteria exist to guide therapy. Bioprosthetic valve dysfunction encompasses structural valve deterioration (SVD) resulting from degenerative changes in the valve structure and function, non-SVD resulting from intrinsic paravalvular regurgitation or patient-prosthesis mismatch, valve thrombosis, and infective endocarditis. Overlapping phenotypes, confluent pathologies, and their shared end-stage bioprosthetic valve failure complicate the differentiation of these entities. In this review, we focus on the contemporary and future roles, advantages, and limitations of imaging modalities such as echocardiography, cardiac computed tomography angiography, cardiac magnetic resonance imaging, and positron emission tomography to monitor the integrity of transcatheter heart valves.

Increased Dead Space Ventilation as a Contributing Factor to Persistent Exercise Limitation in Patients with a Left Ventricular Assist Device

(1) Background: The exercise capacity of patients with a left ventricular assist device (LVAD) remains limited despite mechanical support. Higher dead space ventilation (VD/VT) may be a surrogate for right ventricular to pulmonary artery uncoupling (RV-PA) during cardiopulmonary exercise testing (CPET) to explain persistent exercise limitations. (2) Methods: We investigated 197 patients with heart failure and reduced ejection fraction with (n = 89) and without (HFrEF, n = 108) LVAD. As a primary outcome NTproBNP, CPET, and echocardiographic variables were analyzed for their potential to discriminate between HFrEF and LVAD. As a secondary outcome CPET variables were evaluated for a composite of hospitalization due to worsening heart failure and overall mortality over 22 months. (3) Results: NTproBNP (OR 0.6315, 0.5037-0.7647) and RV function (OR 0.45, 0.34-0.56) discriminated between LVAD and HFrEF. The rise of endtidal CO2 (OR 4.25, 1.31-15.81) and VD/VT (OR 1.23, 1.10-1.40) were higher in LVAD patients. Group (OR 2.01, 1.07-3.85), VE/VCO2 (OR 1.04, 1.00-1.08), and ventilatory power (OR 0.74, 0.55-0.98) were best associated with rehospitalization and mortality. (4) Conclusions: LVAD patients displayed higher VD/VT compared to HFrEF. Higher VD/VT as a surrogate for RV-PA uncoupling could be another marker of persistent exercise limitations in LVAD patients.

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

The Importance of Mehran Score to Predict Acute Kidney Injury in Patients with TAVI: A Large Multicenter Cohort Study

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has developed as an alternative to surgery for symptomatic high-risk patients with aortic stenosis (AS). An important complication of TAVI is acute kidney injury. The purpose of the study was to investigate if the Mehran Score (MS) could be used to predict acute kidney injury (AKI) in TAVI patients.

METHODS

This is a multicenter, retrospective, observational study including 1180 patients with severe AS. The MS comprised eight clinical and procedural variables: hypotension, congestive heart failure class, glomerular filtration rate, diabetes, age >75 years, anemia, need for intra-aortic balloon pump, and contrast agent volume use. We assessed the sensitivity and specificity of the MS in predicting AKI following TAVI, as well as the predictive value of MS with each AKI-related characteristic.

RESULTS

Patients were categorized into four risk groups based on MS: low (≤5), moderate (6-10), high (11-15), and very high (≥16). Post-procedural AKI was observed in 139 patients (11.8%). MS classes had a higher risk of AKI in the multivariate analysis (HR 1.38, 95% CI, 1.43-1.63, p < 0.01). The best cutoff for MS to predict the onset of AKI was 13.0 (AUC, 0.62; 95% CI, 0.57-0.67), whereas the best cutoff for eGFR was 42.0 mL/min/1.73 m2 (AUC, 0.61; 95% CI, 0.56-0.67).

CONCLUSIONS

MS was shown to be a predictor of AKI development in TAVI patients.

Robotic mitral valve repair surgery: where do we go from here?

Surgical mitral valve repair through median sternotomy has long presented the treatment of choice for degenerative mitral valve disease. In recent decades, minimal invasive surgical techniques have been developed and are now gaining widespread popularity. Robotic cardiac surgery presents an emerging field, initially adopted only by selected centres, mostly in the United States. In recent years, the number of centers interested in robotic mitral valve surgery has grown with an increasing adoption in Europe as well. Increasing interest and surgical experience gained are stimulating further developments in the field and the full potential of robotic mitral valve surgery remains to be developed.

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

Impact of Aortic Valve Regurgitation on Doppler Echocardiographic Parameters in Patients with Severe Aortic Valve Stenosis

BACKGROUND

Diagnosing severe aortic stenosis (AS) depends on flow and pressure conditions. It is suspected that concomitant aortic regurgitation (AR) has an impact on the assessment of AS severity. The aim of this study was to analyze the impact of concomitant AR on Doppler-derived guideline criteria. We hypothesized that both transvalvular flow velocity (maxVAV) and the mean pressure gradient (mPGAV) will be affected by AR, whereas the effective orifice area (EOA) and the ratio between maximum velocity of the left ventricular outflow tract and transvalvular flow velocity (maxVLVOT/maxVAV) will not. Furthermore, we hypothesized that EOA (by continuity equation), and the geometric orifice area (GOA) (by planimetry using 3D transesophageal echocardiography, TEE), will not be affected by AR.

METHODS AND RESULTS

In this retrospective study, 335 patients (mean age 75.9 ± 9.8 years, 44% male) with severe AS (defined by EOA < 1.0 cm2) who underwent a transthoracic and transesophageal echocardiography were analyzed. Patients with a reduced left ventricular ejection fraction (LVEF < 53%) were excluded (n = 97). The remaining 238 patients were divided into four subgroups depending on AR severity, and they were assessed using pressure half time (PHT) method: no, trace, mild (PHT 500-750 ms), and moderate AR (PHT 250-500 ms). maxVAV, mPGAV and maxVLVOT/maxVAV were assessed in all subgroups. Among the four subgroups (no (n = 101), trace (n = 49), mild (n = 61) and moderate AR (n = 27)), no differences were obtained for EOA (no AR: 0.75 cm2 ± 0.15; trace AR: 0.74 cm2 ± 0.14; mild AR: 0.75 cm2 ± 0.14; moderate AR: 0.75 cm2 ± 0.15, p = 0.998) and GOA (no AR: 0.78 cm2 ± 0.20; trace AR: 0.79 cm2 ± 0.15; mild AR: 0.82 cm2 ± 0.19; moderate AR: 0.83 cm2 ± 0.14, p = 0.424). In severe AS with moderate AR, compared with patients without AR, maxVAV (p = 0.005) and mPGAV (p = 0.022) were higher, whereas EOA (p = 0.998) and maxVLVOT/maxVAV (p = 0.243) did not differ. The EOA was smaller than the GOA in AS patients with trace (0.74 cm2 ± 0.14 vs. 0.79 cm2 ± 0.15, p = 0.024), mild (0.75 cm2 ± 0.14 vs. 0.82 cm2 ± 0.19, p = 0.021), and moderate AR (0.75 cm2 ± 0.15 vs. 0.83 cm2 ± 0.14, p = 0.024). In 40 (17%) patients with severe AS, according to an EOA < 1.0 cm2, the GOA was ≥ 1.0 cm2.

CONCLUSION

In severe AS with moderate AR, the maxVAV and mPGAV are significantly affected by AR, whereas the EOA and maxVLVOT/maxVAV are not. These results highlight the potential risk of overestimating AS severity in combined aortic valve disease by only assessing transvalvular flow velocity and the mean pressure gradient. Furthermore, in cases of borderline EOA, of approximately 1.0 cm2, AS severity should be verified by determining the GOA.

Computed tomography-based pericoronary adipose tissue attenuation in patients undergoing TAVR: a novel method for risk assessment

OBJECTIVES

This study aims to assess the attenuation of pericoronary adipose tissue (PCAT) surrounding the proximal right coronary artery (RCA) in patients with aortic stenosis (AS) and undergoing transcatheter aortic valve replacement (TAVR). RCA PCAT attenuation is a novel computed tomography (CT)-based marker for evaluating coronary inflammation. Coronary artery disease (CAD) in TAVR patients is common and usually evaluated prior to intervention. The most sensible screening method and consequential treatment approach are unclear and remain a matter of ceaseless discussion. Thus, interest remains for safe and low-demand predictive markers to identify patients at risk for adverse outcomes postaortic valve replacement.

METHODS

This single-center retrospective study included patients receiving a standard planning CT scan prior to TAVR. Conventional CAD diagnostic tools, such as coronary artery calcium score and significant stenosis via invasive coronary angiography and coronary computed tomography angiography, were determined in addition to RCA PCAT attenuation using semiautomated software. These were assessed for their relationship with major adverse cardiovascular events (MACE) during a 24-month follow-up period.

RESULTS

From a total of 62 patients (mean age: 82 ± 6.7 years), 15 (24.2%) patients experienced an event within the observation period, 10 of which were attributed to cardiovascular death. The mean RCA PCAT attenuation was higher in patients enduring MACE than that in those without an endpoint (-69.8 ± 7.5 vs. -74.6 ± 6.2, P = 0.02). Using a predefined cutoff of >-70.5 HU, 20 patients (32.3%) with high RCA PCAT attenuation were identified, nine (45%) of which met the endpoint within 2 years after TAVR. In a multivariate Cox regression model including conventional CAD diagnostic tools, RCA PCAT attenuation prevailed as the only marker with significant association with MACE (P = 0.02). After dichotomization of patients into high- and low-RCA PCAT attenuation groups, high attenuation was related to greater risk of MACE (hazard ration: 3.82, P = 0.011).

CONCLUSION

RCA PCAT attenuation appears to have predictive value also in a setting of concomitant AS in patients receiving TAVR. RCA PCAT attenuation was more reliable than conventional CAD diagnostic tools in identifying patients at risk for MACE .

Cardiovascular involvement in Epstein-Barr virus infection

Cardiovascular involvement is an uncommon but severe complication of Epstein-Barr virus (EBV) infection caused by direct damage and immune injury. Recently, it has drawn increasing attention due to its dismal prognosis. It can manifest in various ways, including coronary artery dilation (CAD), coronary artery aneurysm (CAA), myocarditis, arrhythmias, and heart failure, among others. If not treated promptly, cardiovascular damage can progress over time and even lead to death, which poses a challenge to clinicians. Early diagnosis and treatment can improve the prognosis and reduce mortality. However, there is a lack of reliable large-scale data and evidence-based guidance for the management of cardiovascular damage. Consequently, in this review, we attempt to synthesize the present knowledge of cardiovascular damage associated with EBV and to provide an overview of the pathogenesis, classification, treatment, and prognosis, which may enhance the recognition of cardiovascular complications related to EBV and may be valuable to their clinical management.

Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

BACKGROUND

The Valve Academic Research Consortium (VARC)-3 definition for myocardial injury after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

This study sought to determine the incidence, predictors, and clinical impact of periprocedural myocardial injury (PPMI) following TAVR as defined by recent VARC-3 criteria.

METHODS

We included 1,394 consecutive patients who underwent TAVR with a new-generation transcatheter heart valve. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs ≥15 times according to the VARC-2 definition). Baseline, procedural, and follow-up data were prospectively collected.

RESULTS

PPMI was diagnosed in 193 (14.0%) patients. Female sex and peripheral artery disease were independent predictors of PPMI (P < 0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.69, 95% CI: 1.50-4.82; P = 0.001) and 1-year (for all-cause mortality, HR: 1.54; 95% CI: 1.04-2.27; P = 0.032; for cardiovascular mortality, HR: 3.04; 95% CI: 1.68-5.50; P < 0.001) follow-up. PPMI according to VARC-2 criteria had no impact on mortality.

CONCLUSIONS

About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria, and baseline factors like female sex and peripheral artery disease determined an increased risk. PPMI had a negative impact on early and late survival. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.

Impact of Mitral Regurgitation Etiology on Mitral Surgery After Transcatheter Edge-to-Edge Repair: From the CUTTING-EDGE Registry

BACKGROUND

Although >150,000 mitral TEER procedures have been performed worldwide, the impact of MR etiology on MV surgery after TEER remains unknown.

OBJECTIVES

The authors sought to compare outcomes of mitral valve (MV) surgery after failed transcatheter edge-to-edge repair (TEER) stratified by mitral regurgitation (MR) etiology.

METHODS

Data from the CUTTING-EDGE registry were retrospectively analyzed. Surgeries were stratified by MR etiology: primary (PMR) and secondary (SMR). MVARC (Mitral Valve Academic Research Consortium) outcomes at 30 days and 1 year were evaluated. Median follow-up was 9.1 months (IQR: 1.1-25.8 months) after surgery.

RESULTS

From July 2009 to July 2020, 330 patients underwent MV surgery after TEER, of which 47% had PMR and 53.0% had SMR. Mean age was 73.8 ± 10.1 years, median STS risk at initial TEER was 4.0% (IQR: 2.2%-7.3%). Compared with PMR, SMR had a higher EuroSCORE, more comorbidities, lower LVEF pre-TEER and presurgery (all P < 0.05). SMR patients had more aborted TEER (25.7% vs 16.3%; P = 0.043), more surgery for mitral stenosis after TEER (19.4% vs 9.0%; P = 0.008), and fewer MV repairs (4.0% vs 11.0%; P = 0.019). Thirty-day mortality was numerically higher in SMR (20.4% vs 12.7%; P = 0.072), with an observed-to-expected ratio of 3.6 (95% CI: 1.9-5.3) overall, 2.6 (95% CI: 1.2-4.0) in PMR, and 4.6 (95% CI: 2.6-6.6) in SMR. SMR had significantly higher 1-year mortality (38.3% vs 23.2%; P = 0.019). On Kaplan-Meier analysis, the actuarial estimates of cumulative survival were significantly lower in SMR at 1 and 3 years.

CONCLUSIONS

The risk of MV surgery after TEER is nontrivial, with higher mortality after surgery, especially in SMR patients. These findings provide valuable data for further research to improve these outcomes.

Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience

AIMS

Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure.

METHODS AND RESULTS

All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence.

CONCLUSION

In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo.

A review of numerical simulation in transcatheter aortic valve replacement decision optimization

BACKGROUND

Recent trials indicated a further expansion of clinical indication of transcatheter aortic valve replacement to younger and low-risk patients. Factors related to longer-term complications are becoming more important for use in these patients. Accumulating evidence indicates that numerical simulation plays a significant role in improving the outcome of transcatheter aortic valve replacement. Understanding mechanical features' magnitude, pattern, and duration is a topic of ongoing relevance.

METHODS

We searched the PubMed database using keywords such as "transcatheter aortic valve replacement" and "numerical simulation" and reviewed and summarized relevant literature.

FINDINGS

This review integrated recently published evidence into three subtopics: 1) prediction of transcatheter aortic valve replacement outcomes through numerical simulation, 2) implications for surgeons, and 3) trends in transcatheter aortic valve replacement numerical simulation.

INTERPRETATIONS

Our study offers a comprehensive overview of the utilization of numerical simulation in the context of transcatheter aortic valve replacement, and highlights the advantages, potential challenges from a clinical standpoint. The convergence of medicine and engineering plays a pivotal role in enhancing the outcomes of transcatheter aortic valve replacement. Numerical simulation has provided evidence of potential utility for tailored treatments.

Transcatheter Repair for Patients with Tricuspid Regurgitation

BACKGROUND

Severe tricuspid regurgitation is a debilitating condition that is associated with substantial morbidity and often with poor quality of life. Decreasing tricuspid regurgitation may reduce symptoms and improve clinical outcomes in patients with this disease.

METHODS

We conducted a prospective randomized trial of percutaneous tricuspid transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation. Patients with symptomatic severe tricuspid regurgitation were enrolled at 65 centers in the United States, Canada, and Europe and were randomly assigned in a 1:1 ratio to receive either TEER or medical therapy (control). The primary end point was a hierarchical composite that included death from any cause or tricuspid-valve surgery; hospitalization for heart failure; and an improvement in quality of life as measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ), with an improvement defined as an increase of at least 15 points in the KCCQ score (range, 0 to 100, with higher scores indicating better quality of life) at the 1-year follow-up. The severity of tricuspid regurgitation and safety were also assessed.

RESULTS

A total of 350 patients were enrolled; 175 were assigned to each group. The mean age of the patients was 78 years, and 54.9% were women. The results for the primary end point favored the TEER group (win ratio, 1.48; 95% confidence interval, 1.06 to 2.13; P = 0.02). The incidence of death or tricuspid-valve surgery and the rate of hospitalization for heart failure did not appear to differ between the groups. The KCCQ quality-of-life score changed by a mean (±SD) of 12.3±1.8 points in the TEER group, as compared with 0.6±1.8 points in the control group (P<0.001). At 30 days, 87.0% of the patients in the TEER group and 4.8% of those in the control group had tricuspid regurgitation of no greater than moderate severity (P<0.001). TEER was found to be safe; 98.3% of the patients who underwent the procedure were free from major adverse events at 30 days.

CONCLUSIONS

Tricuspid TEER was safe for patients with severe tricuspid regurgitation, reduced the severity of tricuspid regurgitation, and was associated with an improvement in quality of life. (Funded by Abbott; TRILUMINATE Pivotal ClinicalTrials.gov number, NCT03904147.).

Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review

The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.

PAI-1 Overexpression in Valvular Interstitial Cells Contributes to Hypofibrinolysis in Aortic Stenosis

Aortic stenosis (AS) is associated with hypofibrinolysis, but its mechanism is poorly understood. We investigated whether LDL cholesterol affects plasminogen activator inhibitor 1 (PAI-1) expression, which may contribute to hypofibrinolysis in AS. Stenotic valves were obtained from 75 severe AS patients during valve replacement to assess lipids accumulation, together with PAI-1 and nuclear factor-κB (NF-κB) expression. Five control valves from autopsy healthy individuals served as controls. The expression of PAI-1 in valve interstitial cells (VICs) after LDL stimulation was assessed at protein and mRNA levels. PAI-1 activity inhibitor (TM5275) and NF-κB inhibitor (BAY 11-7082) were used to suppress PAI-1 activity or NF-κB pathway. Clot lysis time (CLT) was performed to assess fibrinolytic capacity in VICs cultures. Solely AS valves showed PAI-1 expression, the amount of which was correlated with lipid accumulation and AS severity and co-expressed with NF-κB. In vitro VICs showed abundant PAI-1 expression. LDL stimulation increased PAI-1 levels in VICs supernatants and prolonged CLT. PAI-1 activity inhibition shortened CLT, while NF-κB inhibition decreased PAI-1 and SERPINE1 expression in VICs, its level in supernatants and shortened CLT. In severe AS, valvular PAI-1 overexpression driven by lipids accumulation contributes to hypofibrinolysis and AS severity.

Medium-Term Outcomes of the Different Antithrombotic Regimens After Transcatheter Aortic Valve Implantation

Bioprosthetic valve thrombosis is associated with accelerated bioprosthesis degeneration and valve re-replacement. Whether 3-month warfarin use after transcatheter aortic valve implantation (TAVI) protects against such consequences is unknown. We aimed to investigate if 3-month warfarin treatment after TAVI is associated with better outcomes than dual antiplatelet therapy (DAPT) and single antiplatelet therapy (SAPT) at medium-term follow-up. Adults who underwent TAVI were identified retrospectively (n = 1,501) and classified into warfarin, DAPT, and SAPT groups based on antithrombotic regimen received. Patients with atrial fibrillation were excluded. Outcomes and valve hemodynamics were compared between the groups. Annualized change from baseline in mean gradients and effective orifice area at last follow-up echocardiography was calculated. Overall, 844 patients were included (mean age: 80 ± 9 years, 43% women; 633 receiving warfarin, 164 DAPT, and 47 SAPT). Median time to follow-up was 2.5 (interquartile range 1.2 to 3.9) years. There were no differences in the adjusted outcome end points of ischemic stroke, death, valve re-replacement/intervention, structural valve degeneration, or their composite end point at follow-up. Annualized change in aortic valve area was significantly higher in DAPT (-0.11 [0.19] cm²/year) than warfarin (-0.06 [0.25] cm²/y, p = 0.03), but annualized change in mean gradients was not different (p >0.05). In conclusion, antithrombotic regimen, including warfarin, after TAVI was associated with marginally lower decrease in aortic valve area but no difference in medium-term clinical outcomes compared with DAPT and SAPT.

Shifting from Left Ventricular Ejection Fraction to Strain Imaging in Aortic Stenosis

Adverse ventricular remodeling is an inflexion point of disease progression in aortic stenosis (AS) and a major determinant of prognosis. Intervention before irreversible myocardial damage is of paramount importance to sustain favorable post-operative outcomes. Current guidelines recommend a left ventricular ejection fraction (LVEF)-based strategy to determine the threshold for intervention in AS. However, LVEF has several pitfalls: it denotes the left ventricular cavity volumetric changes and it is not suited to detecting subtle signs of myocardial damage. Strain has emerged as a contemporary imaging biomarker that describes intramyocardial contractile force, providing information on subclinical myocardial dysfunction due to fibrosis. A large body of evidence advocates its use to determine the switch from adaptive to maladaptive myocardial changes in AS, and to refine thresholds for intervention. Although mainly studied in echocardiography, studies exploring the role of strain in multi-detector row computed tomography and cardiac magnetic resonance are emerging. This review, therefore, summarizes contemporary evidence on the role of LVEF and strain imaging in AS prognosis, aiming to move from an LVEF-based to a strain-based approach for risk stratification and therapeutic decision-making in AS.

Discrepancy between invasive and echocardiographic transvalvular gradient after TAVI: Insights from the LAPLACE-TAVI registry

BACKGROUND

Echocardiography-based transvalvular mean pressure gradient (ECHO-mPG) used to assess the forward valve function and structural valve deterioration could overestimate the true pressure gradient. This study evaluated the discrepancy between invasive and ECHO-mPG after transcatheter aortic valve implantation (TAVI) with respective valve type and size, its impact on a device success criterion, and predictors of a pressure discrepancy.

METHODS

We analyzed 645 patients registered in a multicenter TAVI registry (balloon-expandable valve [BEV]: 500; self-expandable valve [SEV]: 145). The invasive transvalvular mPG was measured after valve implantation using two Pigtail catheters (CATH-mPG), while the ECHO-mPG was measured within 48 h after TAVI. Pressure recovery (PR) was calculated using the following formula: ECHO-mPG × effective orifice area (EOA)/ascending aortic area (AoA) × (1 - EOA/AoA).

RESULTS

ECHO-mPG was weakly correlated with (r = 0.29, p < 0.0001), and consistently overestimated CATH-mPG in both BEV and SEV, and respective valve sizes. The magnitude of the discrepancy was larger for BEV than SEV (p < 0.001) and smaller valves (p < 0.001). After the correction of PR using the above formula, the pressure discrepancy remained for BEV (p < 0.001) but not SEV (p = 0.10). The proportion of patients with an ECHO-mPG > 20 mmHg decreased from 7.0% to 1.6% after correction (p < 0.0001). Among the baseline and procedural variables, post-procedural ejection fraction, BEV versus SEV, and smaller valves were associated with a larger discrepancy in mPG.

CONCLUSIONS

ECHO-mPG could be overestimated after TAVI, especially in patients with a smaller BEV. A higher ejection fraction, BEV, and smaller valves were predictors of a pressure discrepancy between CATH- and ECHO-mPG.

Diabetes Mellitus in Patients Undergoing Mitral Transcatheter Edge-to-Edge Repair-A Decade Experience in 1000+ Patients

BACKGROUND

Diabetes mellitus worsens outcomes in patients suffering from heart disease undergoing cardiac procedures.

OBJECTIVES

To investigate the impact of diabetes in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER).

METHODS

1118 patients treated with M-TEER for functional (FMR) and degenerative (DMR) mitral regurgitation (MR) between 2010 and 2021 were analyzed using the combined endpoint of death/rehospitalization for heart failure (HFH).

RESULTS

Among diabetics (N = 306; 27.4%), comorbidities such as coronary artery disease (75.2% vs. 62.7%; p < 0.001) and progressed (stage III/IV) chronic kidney disease (79.5% vs. 72.6%; p = 0.018) were more frequent. The rate of FMR was higher in diabetics (71.9% vs. 64.5%; p < 0.001). The combined endpoint occurred more frequently in diabetics (40.2% vs. 35.6%; log-rank = 0.035). While no difference was observed in FMR patients (36.8% vs. 37.6%; log-rank p = 0.710), rates of the combined endpoint differed significantly between diabetics and non-diabetics in DMR patients (48.8% vs. 31.9%; log-rank p = 0.001) only. However, diabetes did neither predict the combined endpoint in the overall (OR: 0.97; 95% CI 0.65-1.45; p = 0.890) nor in the DMR cohort (OR: 0.73; 95% CI 0.35-1.51; p = 0.389). Among diabetics treated with M-TEER, troponin (OR: 2.32; 95% CI 1.3-3.7; p = 0.002) and estimated glomerular filtration rate (OR: 0.52; 95% CI 0.3-0.88; p = 0.018) independently predicted the combined endpoint.

CONCLUSIONS

Diabetes is associated with adverse outcomes after M-TEER, particularly in DMR patients. However, diabetes does not predict the combined endpoint. In diabetics undergoing M-TEER, biochemical markers associated with organ function and damage independently predict the combined endpoint of death and rehospitalization.

Transcatheter Mitral Valve Replacement in Failed Bioprosthetic Valve, Ring, and Mitral Annular Calcification Associated Mitral Valve Disease Using Balloon Expandable Transcatheter Heart Valve

Transcatheter mitral valve replacement (TMVR) using the SAPIEN platform has been performed in failed bioprosthetic valves (valve-in-valve), surgical annuloplasty rings (valve-in-ring), and native valves with mitral annular calcification (MAC) (valve-in-MAC). Experience over the past decade has identified important challenges and solutions to improve clinical outcomes. In this review, we discuss the indication, trend in utilization, unique challenges, procedural planning, and clinical outcomes of valve-in-valve, valve-in-ring, and valve-in-MAC TMVR.

Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement

The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.

Transcatheter mitral and tricuspid interventions-the bigger picture: valvular disease as part of heart failure

The prevalence of mitral (MR) and tricuspid regurgitation (TR), especially in heart failure (HF) populations, is high. However, the distinct role of atrioventricular valve diseases in HF, whether they are merely indicators of disease status or rather independent contributors in a vicious disease cycle, is still not fully understood. For decades, tricuspid regurgitation (TR) was considered an innocent bystander subsequent to other heart or lung pathologies, thus, not needing dedicated treatment. Recent increasing awareness towards the role of atrioventricular valve diseases has revealed that MR and TR are, in fact, independent predictors of outcome in HF, thus, warranting attention in the HF treatment algorithm. This awareness arose, especially, with the development of minimally invasive transcatheter solutions providing new treatment options, which can also be used for patients considered as having increased surgical risk. However, outcomes of such transcatheter treatments have, in part, been sub-optimal and likely influenced by the status of the concomitant HF disease. Thus, this review aims to summarize data on the current understanding regarding the role of MR and TR in HF, how HF impacts outcomes of transcatheter MR and TR interventions, and how the understanding of this relationship might help to identify patients that benefit most from these therapies, which have proven to be lifesaving in properly selected candidates.

ABCDEG Stress Echocardiography in Aortic Stenosis

Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.

Is There Still a Role for Invasive Assessment of Aortic Gradient?

Advances in technology and imaging have expanded the range of tools for diagnosing aortic stenosis (AS). The accurate assessment of aortic valve area and mean pressure gradient is crucial to determine which patients are appropriate candidates for aortic valve replacement. Nowadays, these values can be obtained noninvasively or invasively, with similar results. Contrariwise, in the past, cardiac catheterization played a major role in the evaluation of AS severity. In this review, we will discuss the historical role of the invasive assessment of AS. Moreover, we will specifically focus on tips and tricks for properly performing cardiac catheterization in patients with AS. We will also elucidate the role of invasive methods in current clinical practice and their additional value to the information provided through non-invasive techniques.

1-Year Outcomes of Transcatheter Tricuspid Valve Repair

BACKGROUND

Surgical management of isolated tricuspid regurgitation (TR) is associated with high morbidity and mortality, thereby creating a significant need for a lower-risk transcatheter solution.

OBJECTIVES

The single-arm, multicenter, prospective CLASP TR (Edwards PASCAL TrAnScatheter Valve RePair System in Tricuspid Regurgitation [CLASP TR] Early Feasibility Study) evaluated 1-year outcomes of the PASCAL transcatheter valve repair system (Edwards Lifesciences) to treat TR.

METHODS

Study inclusion required a previous diagnosis of severe or greater TR and persistent symptoms despite medical treatment. An independent core laboratory evaluated echocardiographic results, and a clinical events committee adjudicated major adverse events. The study evaluated primary safety and performance outcomes, with echocardiographic, clinical, and functional endpoints. Study investigators report 1-year all-cause mortality and heart failure hospitalization rates.

RESULTS

Sixty-five patients were enrolled: mean age of 77.4 years; 55.4% female; and 97.0% with severe to torrential TR. At 30 days, cardiovascular mortality was 3.1%, the stroke rate was 1.5%, and no device-related reinterventions were reported. Between 30 days and 1 year, there were an additional 3 cardiovascular deaths (4.8%), 2 strokes (3.2%), and 1 unplanned or emergency reintervention (1.6%). One-year postprocedure, TR severity significantly reduced (P < 0.001), with 31 of 36 (86.0%) patients achieving moderate or less TR; 100% had at least 1 TR grade reduction. Freedom from all-cause mortality and heart failure hospitalization by Kaplan-Meier analyses were 87.9% and 78.5%, respectively. Their New York Heart Association functional class significantly improved (P < 0.001) with 92% in class I or II, 6-minute walk distance increased by 94 m (P = 0.014), and overall Kansas City Cardiomyopathy Questionnaire scores improved by 18 points (P < 0.001).

CONCLUSIONS

The PASCAL system demonstrated low complication and high survival rates, with significant and sustained improvements in TR, functional status, and quality of life at 1 year. (Edwards PASCAL TrAnScatheter Valve RePair System in Tricuspid Regurgitation [CLASP TR] Early Feasibility Study [CLASP TR EFS]; NCT03745313).

Long-Term Outcomes after Transcatheter Mitral Valve-in-Valve or Valve-in-Ring Procedures

BACKGROUND

Redo mitral valve surgery is the standard of care for failed mitral bioprostheses or recurrence of mitral regurgitation after repair. Nonetheless, catheter-based valve-in-valve (ViV) or valve-in-ring (ViR) procedures have increasingly become viable alternatives in high-risk subpopulations. Despite reported good initial results, little is known about longer-term outcomes. Here, we report the long-term outcomes of transcatheter mitral ViV and ViR procedures.

METHODS

All consecutive patients (n = 54) undergoing transcatheter mitral ViV or ViR procedures for failed bioprostheses or recurring regurgitation after mitral repair in the time period between 2011 and 2021 were retrospectively enrolled. The mean age was 76.5 ± 6.5 years, and 30 (55.6%) of the patients were male. The procedures were done using a commercially available balloon-expandable transcatheter heart valve. Clinical and echocardiographic follow-up data were obtained from the hospital's database and analyzed. Follow-up reached up to 9.9 years with a total of 164.3 patient-years.

RESULTS

A total 25 patients received a ViV and 29 patients a ViR procedure. Both groups were at high surgical risk with an STS-PROM of 5.9 ± 3.7% in ViV and 8.7 ± 9.0% in ViR patients (p < 0.01). The procedures themselves were mainly uneventful with no intraoperative deaths and a low conversion rate (n = 2/54; 3.7%). VARC-2 procedural success was low (ViV 20.0% and ViR 10.3%; p = 0.45), which was either driven by high rates of transvalvular pressure gradients ">5 mmHg" (ViV 92.0% and ViR 27.6%; p < 0.01) or residual regurgitation ">trace" (ViV 28.0% and ViR 82.7%; p < 0.01). ICU-stay was prolonged in both groups (ViV 3.8 ± 6.8 days and ViR 4.3 ± 6.3 days; p = 0.96) with acceptable hospital stay (ViV 9.9 ± 5.9 days and ViR 13.5 ± 8.0 days; p = 0.13). Despite 30-day mortality being acceptable (ViV 4.0% and ViR 6.9%; p = 1.00), the mean posthospital survival time was disappointingly low (ViV 3.9 ± 2.6 years and ViR 2.3 ± 2.7 years; p < 0.01). Overall survival in the entire group was 33.3%. Cardiac reasons for death were frequent in both groups (ViV 38.5% and ViR 52.2%). Cox-regression analysis identified ViR procedures as a predictor of mortality (HR 2.36, CI 1.19-4.67, p = 0.01).

CONCLUSIONS

Despite acceptable immediate outcomes in this high-risk subpopulation, long-term results are discouraging. Transvalvular pressure gradients as well as residual regurgitations remained drawbacks in this real-world population. The indication for catheter-based mitral ViV or ViR procedures rather than conventional redo-surgery or conservative treatment must be thoughtfully considered.

Sex Differences in Outcomes After Transcatheter Aortic Valve Replacement: A POPular TAVI Subanalysis

BACKGROUND

Stroke and bleeding are complications after transcatheter aortic valve replacement (TAVR). A higher incidence of bleeding and stroke has been reported in women, but the role of antithrombotic management pre- and post-TAVR has not been studied.

OBJECTIVES

The study sought to compare bleeding and ischemic complications after TAVR between women and men stratified by antiplatelet and oral anticoagulant (OAC) regimen.

METHODS

The POPular TAVI (Antiplatelet Therapy for Patients Undergoing Transcatheter Aortic Valve Implantation) trial was a randomized clinical trial to test the hypothesis that monotherapy with aspirin or OAC after TAVR is safer than the addition of clopidogrel. The primary endpoints of interest of this post hoc subanalysis were: 1) all bleeding; and 2) a composite of ischemic events consisting of stroke and myocardial infarction. Secondary endpoints were: 1) nonprocedural bleeding; 2) major or life-threatening bleeding; 3) minor bleeding; 4) stroke; 5) myocardial infarction; and 6) all-cause death.

RESULTS

A total of 978 patients (466 [47.6%] women) were included in this study. All bleeding and the composite of myocardial infarction and stroke rates were similar between sexes (all bleeding: 106 [22.8%] women vs 121 [23.6%] men; P = 0.815; ischemic events: 26 [5.6%] vs 36 [7.0%]; P = 0.429). However, major or life-threatening bleeding occurred more often in women (58 [12.5%]) vs men (38 [7.4%]) (P = 0.011), most of which were access site bleedings. The use of aspirin pre- and post-TAVR increased major or life-threatening bleeding in women but not in men.

CONCLUSIONS

After TAVR, overall bleeding and ischemic outcomes were similar between women and men. However, women had more major or life-threatening bleedings, especially those receiving aspirin pre- and post-TAVR.

Peak left atrial longitudinal strain is associated with all-cause mortality in patients with ventricular functional mitral regurgitation

PURPOSE

Chronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).

METHODS

Patients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.

RESULTS

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 - 40%) and median effective regurgitant orifice area (EROA) was 15mm² (IQR: 9 - 22mm²). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 - 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality (adjusted hazard ratio 1.052 per % decrease; 95% CI: 1.010 - 1.095; P = 0.016), even after adjustment for several (n = 14) clinical and echocardiographic confounders.

CONCLUSION

PALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.

Functional Mitral and Tricuspid Regurgitation across the Whole Spectrum of Left Ventricular Ejection Fraction: Recognizing the Elephant in the Room of Heart Failure

Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.

Investigating the unmet need for the treatment of tricuspid regurgitation

INTRODUCTION

Tricuspid regurgitation has been increasingly recognized as a clinically relevant entity with long-term prognostic impact on quality of life and survival. Despite this, there are still some unmet clinical needs regarding the management of tricuspid regurgitation that require further investigation.

AREAS COVERED

This review addresses current evidence for the treatment of tricuspid regurgitation, focusing primarily on new catheter-based technologies. In addition, we discuss recent registries and clinical trial results.

EXPERT OPINION

A multimodality and multiparametric integrative approach has been preconized to assess tricuspid regurgitation mechanism and severity, and new technologies have been developed to address the main causative factors of tricuspid regurgitation. Matching the right device to the right patient and deciding when is the best time for intervention are major challenges in the management of tricuspid regurgitation.

Treatment of pure aortic regurgitation using surgical or transcatheter aortic valve replacement between 2018 and 2020 in Germany

Background

In pure aortic regurgitation, transcatheter aortic valve replacement (TAVR) is not yet used on a regular base. Due to constant development of TAVR, it is necessary to analyze current data.

Methods

By use of health records, we analyzed all isolated TAVR or surgical aortic valve replacements (SAVR) for pure aortic regurgitation between 2018 and 2020 in Germany.

Results

4,861 procedures-4,025 SAVR and 836 TAVR-for aortic regurgitation were identified. Patients treated with TAVR were older, showed a higher logistic EuroSCORE, and had more pre-existing diseases. While results indicate a slightly higher unadjusted in-hospital mortality for transapical TAVR (6.00%) vs. SAVR (5.71%), transfemoral TAVR showed better outcomes, with self-expanding compared to balloon-expandable transfemoral TAVR having significantly lower in-hospital mortality (2.41% vs. 5.17%; p = 0.039). After risk adjustment, balloon-expandable as well as self-expanding transfemoral TAVR were associated with a significantly lower mortality vs. SAVR (balloon-expandable: risk adjusted OR = 0.50 [95% CI 0.27; 0.94], p = 0.031; self-expanding: OR = 0.20 [0.10; 0.41], p < 0.001). Furthermore, the observed in-hospital outcomes of stroke, major bleeding, delirium, and mechanical ventilation >48 h were significantly in favor of TAVR. In addition, TAVR showed a significantly shorter length of hospital stay compared to SAVR (transapical: risk adjusted Coefficient = -4.75d [-7.05d; -2.46d], p < 0.001; balloon-expandable: Coefficient = -6.88d [-9.06d; -4.69d], p < 0.001; self-expanding: Coefficient = -7.22 [-8.95; -5.49], p < 0.001).

Conclusions

TAVR is a viable alternative to SAVR in the treatment of pure aortic regurgitation for selected patients, showing overall low in-hospital mortality and complication rates, especially with regard to self-expanding transfemoral TAVR.

Medical therapy after surgical aortic valve replacement for aortic regurgitation

OBJECTIVES

Current clinical guidelines have no specific recommendations regarding medical therapy after surgical aortic valve replacement in patients with aortic regurgitation (AR). We studied the association between medical therapy with renin-angiotensin system (RAS) inhibitors, statins and β-blockers and long-term major adverse cardiovascular events.

METHODS

All patients undergoing valve replacement due to AR between 2006 and 2017 in Sweden and alive 6 months after discharge were included. Time-dependent multivariable Cox regression models adjusted for age, sex, patient characteristics, comorbidities, other medications and year of surgical aortic valve replacement were used. Primary outcome was a composite of all-cause mortality, myocardial infarction and stroke. Subgroup analyses based on age, sex, heart failure, low ejection fraction, hyperlipidaemia and hypertension were performed.

RESULTS

A total of 2204 patients were included [median follow-up 5.0 years (range 0.0-11.5)]. At baseline, 68% of the patients were dispensed RAS inhibitors, 80% β-blockers and 35% statins. Dispense of RAS inhibitors and β-blockers declined over time, especially during the first year after baseline, while dispense of statins remained stable. Treatment with RAS inhibitors or statins was associated with a reduced risk of the primary outcome [adjusted hazard ratio (aHR) 0.71, 95% confidence interval (CI) 0.57-0.87 and aHR 0.78, 95% CI 0.62-0.99, respectively]. The results were consistent in subgroups based on age, sex and comorbidities. β-Blocker treatment was associated with an increased risk for the primary outcome (aHR 1.35, 95% CI 1.07-1.70).

CONCLUSIONS

The results indicate a potential beneficial association of RAS inhibitors and statins as part of a secondary preventive treatment regime after aortic valve replacement in patients with AR. The role of β-blockers needs to be further investigated.

Contemporary treatment of mitral valve disease with transcatheter mitral valve implantation

BACKGROUND

Transcatheter mitral valve implantation (TMVI) with self-expanding (SAV) or balloon-expandable (BAV) valves are rising as promising treatment options for high-risk patients with symptomatic mitral valve (MVD) disease unsuitable for alternative treatment options.

AIMS

The aim of this study was to examine the clinical, procedural and outcome parameters of patients undergoing SAV or BAV for MVD.

METHODS

In this observational and single-center case series, fifteen consecutive patients treated with the Tendyne Mitral Valve System (SAV) and thirty-one patients treated with SAPIEN prosthesis (BAV) were included.

RESULTS

The patients (aged 78 years [interquartile range (IQR): 65.5 to 83.1 years], 41% women, EuroSCORE II 10.3% [IQR: 5.5 to 17.0%] were similar regarding baseline characteristics, despite a higher rate of prior heart valve surgery and prevalence of MV stenosis in the SAV-group. At discharge, the SAV-group had a mean transvalvular gradient of 4.2 mmHg, whereas the BAV-group had a mean transvalvular gradient of 6.2 mmHg. None or trace paravalvular leakage (PVL) was assessed in 85% in SAV-group and 80% in the BAV-group. 320 day all-cause and cardiac mortality rates were comparable in both groups (SAV: 26.7% vs BAV: 20%, p = 0.60). Four deaths occurred early in the SAV-group until 32 days of follow-up.

CONCLUSIONS

In high-risk patients with MVD, TMVI presents a promising treatment option with encouraging mid-term outcomes and good valve durability. TMVI either with BAV or SAV may be developed to an established treatment option.

Reduction of permanent pacemaker implantation by using the cusp overlap technique in transcatheter aortic valve replacement: a meta-analysis

BACKGROUND

The need for permanent pacemaker (PPM) implantation is a common complication after transcatheter aortic valve replacement (TAVR). Deep implantation position is a risk factor for PPM implantation. Thus, in the field of self-expandable (SE) transcatheter heart valves (THV) cusp overlap projection (COP) technique was implemented to reduce parallax, allowing a more precise guidance of implantation depth.

AIMS

This meta-analysis aims to report the outcome of patients undergoing TAVR with SE THV using COP versus conventional implantation technique (CIT).

METHODS

Systematical search in MEDLINE and EMBASE yielded five observational controlled studies comparing both implantation techniques for the SE Evolut prosthesis (Medtronic Intern. Ltd., CA, USA) and fulfilling the inclusion criteria for meta-analysis.

RESULTS

Totally, 1227 patients were included, comprising 641 who underwent COP and 586 CIT TAVR. Incidence of post-procedural need for PPM implantation was significantly lower in COP group (9.8% vs 20.6%; OR = 0.43; p < 0.00001). This was accompanied by significantly higher implantation position in COP group (mean difference distance from distal end of the intraventricular portion of the THV to the non-coronary cusp (NCC): - 1.03 mm; p = 0.00001). Incidence of new-onset left bundle branch block did not differ. Regarding procedural and 30-day mortality, technical success, post-procedural aortic regurgitation, and rates of multiple device implantation, no difference between COP and CIT was found.

CONCLUSION

COP is an effective and safe implantation technique to reduce the need for a permanent pacemaker implantation during TAVR with SE Evolut prosthesis.

The first reported case of embolic protection device implantation in a patient with prosthetic valve thrombosis treated with thrombolytic therapy: a case report

Background

Prosthetic valve thrombosis (PVT) is a rare but one of the most dreaded complications of implanted mechanical valves. Although surgery is the first-line treatment modality particularly in symptomatic obstructive mechanical valve thrombosis, it is associated with high rates of morbidity and mortality. Thrombolytic therapy has also been used as an alternative to surgical treatment. The risk for cerebral thromboembolism associated with thrombolytic therapy seems to be the main limitation for its use in left-sided mechanical valve thrombosis. To the best of our knowledge, this is the first case of implantation of embolic protection devices during thrombolytic therapy of PVT.

Case summary

Our report describes management of patient with obstructive PVT of the aortic valve. Fluoroscopy showed an immobile anterior disc of the aortic prosthesis. Transoesophageal echocardiography (TOE) detected the severely restricted prosthetic valve motions and a huge mass at the supravalvular site. A patient had very high surgical risks. Although, thrombolytic treatment was not without risk due to the large thrombus (>10 mm) increasing the risk of thromboembolism. We implanted embolic protection devices into both internal carotid arteries followed by the administration of a thrombolytic therapy with 50 mg Alteplase. After the procedure an embolized thrombus was detected at the apex at the left-sided placed device. There were no signs of transient ischaemic attack nor stroke, and the procedure was ended uneventful. The TOE performed on the next day confirmed successful resolution of the thrombus.

Discussion

Mechanical left-sided prosthetic valve obstruction is a serious complication with high mortality and morbidity and requires urgent therapy. The choice between surgery, thrombolysis, and escalation of anticoagulation is considered on an individual basis. In patients with high surgical risk and high risk of embolization, an embolic protection device may be used in conjunction with thrombolytic therapy to decrease the risk of embolic cerebral events.

Comparison of First-generation and Third-generation Dual-source Computed Tomography for Detecting Coronary Artery Disease in Patients Evaluated for Transcatheter Aortic Valve Replacement

PURPOSE

This study compared image quality and evaluability of coronary artery disease (CAD) in routine preparatory imaging for transcatheter aortic valve replacement using 64-slice (first-generation) to 192-slice (third-generation) dual-source computed tomography(DSCT).

MATERIALS AND METHODS

The CT data sets of 192 patients (122 women, median age 82 y) without severe renal dysfunction or known CAD were analyzed retrospectively. Half were examined using first-generation DSCT (June 2014 to February 2016) and the other half with third-generation DSCT (April 2016 to April 2017). Per protocol, contrast material (110 [110 to 120] vs. 70 [70 to 70] mL, P <0.001) and radiation dose of multiphasic retrospectively gated thoracic CT angiography (dose-length-product, 1001 [707 to 1312] vs. 727 [474 to 1369] mGy×cm, P <0.001) were significantly lower with third-generation DSCT. Significant CAD was defined as CAD-RADS ≥4 by CT. Invasive coronary angiography served as the reference standard (CAD is defined as ≥70% stenosis or fractional flow reserve ≤0.80).

RESULTS

In comparison with first-generation DSCT, third-generation DSCT showed significantly better subjective (3 [interquartile range 2 to 3] vs. 4 [3 to 4.25] on a 5-point scale, P <0.001) and objective image quality (signal-to-noise ratio of left coronary artery 12.8 [9.9 to 16.4] vs. 15.2 [12.4 to 19.0], P <0.001). Accuracy (72.9% vs. 91.7%, P =0.001), specificity (59.7% vs. 88.3%, P <0.001), positive (61.0% vs. 83.3%, P <0.001), and negative predictive value (91.9% vs. 98.2%, P =0.045) for detecting CAD per-patient were significantly better using third-generation DSCT, while sensitivity was similar (92.3% vs. 97.2%, P =0.129).

CONCLUSIONS

Coronary artery evaluation with CT angiography before TAVI is feasible in selected patients. Compared with first-generation DSCT, state-of-the-art third-generation DSCT technology is superior for this purpose, allowing for less contrast medium and radiation dose while providing better image quality and improved diagnostic performance.

LGE prevalence and patterns in severe aortic stenosis: When "junctional" means the same

BACKGROUND

Left ventricular (LV) remodeling in severe aortic valve stenosis (AS) is a complex process that goes beyond hypertrophic response. Reparative/replacement fibrosis is considered irreversible and has recognized value in both risk stratification and prognosis. Currently, cardiac magnetic resonance (CMR) is the gold-standard imaging technique for fibrosis identification through late gadolinium enhancement (LGE) assessment. However, its prevalence and distribution are quite variable among series. Our goal was to assess LGE prevalence and patterns in severe AS.

METHODOLOGY

Single-center prospective cohort of 140 patients with severe symptomatic high-gradient AS (mean age 72 ± 8 years; mean valvular transaortic gradient 61 ± 18 mmHg; mean LV ejection fraction by echocardiogram 58 ± 9%) undergoing surgical aortic valve replacement. Those with previous myocardial infarction and/or non-ischemic cardiomyopathy were excluded. All patients performed 1.5 T LGE-CMR prior to surgery.

RESULTS

Overall, 103 patients (74%) had non-ischemic LGE (median LGE mass 2.8 g [IQR 0.0-7.8] g), many of them with combined mid-wall and junctional enhancement pattern (36%). LGE was most frequently observed in the mid-basal segments of the interventricular septum. Seventy-four patients (53%) had non-exclusively junctional LGE. Contrary to those with junctional enhancement, patients with non-exclusively junctional LGE had higher LV volumes/mass, worse LV ejection fraction and worse global longitudinal strain.

CONCLUSION

Among patients with severe, symptomatic, high-gradient AS, LGE is frequent, primarily affecting the mid-basal interventricular septum. Contrary to junctional LGE, the presence of non-junctional LGE seems to correlate with adverse markers of LV remodeling.

Combining cardiopulmonary exercise testing with echocardiography: a multiparametric approach to the cardiovascular and cardiopulmonary systems

Exercise intolerance is a prominent feature of several cardiovascular conditions. However, the physical effort requires the intertwined adaptation of several factors, namely the cardiovascular system, the lungs, and peripheral muscles. Several abnormalities in each domain may be present in a given patient. Cardiopulmonary exercise testing (CPET) has been used to investigate metabolic and ventilatory alterations responsible for exercise intolerance but does not allow for direct evaluation of cardiovascular function. However, this can readily be obtained by concomitant exercise-stress echocardiography (ESE). The combined CPET-ESE approach allows for precise and thorough phenotyping of the pathophysiologic mechanisms underpinning exercise intolerance. Thus, it can be used to refine the diagnostic workup of patients with dyspnoea of unknown origin, as well as improve risk stratification and potentially guide the therapeutic approach in specific conditions, including left and right heart failure or valvular heart disease. However, given its hitherto sporadic use, both the conceptual and technical aspects of CPET-ESE are often poorly known by the clinician. Improving knowledge in this field could significantly aid in anticipating individual disease trajectories and tailoring treatment strategies accordingly. Therefore, we designed this review to revise the pathophysiologic correlates of exercise intolerance, the practical principles of the combined CPET-ESE examination, and its main applications according to current literature.

Temporal changes of patient characteristics over 12 years in a single-center transcatheter aortic valve implantation cohort

BACKGROUND

Beneficial results of transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR) in patients at all risk strata have led to substantial changes in guideline recommendations for valvular heart disease.

AIM

To examine influence of these guideline changes on a real-world TAVI cohort, we evaluated how risk profiles and outcomes of TAVI patients developed in our single-center patient cohort over a period of 12 years.

METHODS

Baseline, procedural and 30-day outcome parameters of TAVI patients were retrospectively compared between three time periods (period 1: 2008-2012, period 2: 2013-2017, period 3: 2018-2020).

RESULTS

Between 03/2008 and 12/2020, a total of 3678 patients underwent TAVI at our center. The median age was 81.1 years (25th, 75th percentile: 76.7, 84.9) with no significant change over time. The EuroSCORE II showed a continuous and significant decline from 5.3% (3.3, 8.6) in period 1 to 2.8% (1.7, 5.0) in period 3 (p < 0.001). Furthermore, rates of permanent pacemaker implantation, acute kidney injury, and paravalvular leakage ≥ moderate continuously declined over time. Accordingly, the 30-day mortality fell from 9.3% in period 1 to 4.3% in period 3 (p < 0.001).

CONCLUSION

Despite substantial guideline alterations, median patient age remained largely unchanged in our TAVI cohort over the past 12 years. Therefore, increased age still appears to be the main reason to choose TAVI over SAVR. However, risk profiles declined substantially. Significant improvements in early outcomes suggest favorable influence of less invasive access routes, improved device platforms and growing user experience.

Hemostatic protocol and risk-reduction surgery for treating coronary artery disease with aortic stenosis in a patient with combined coagulation factor VIII and XI deficiency: a case report

Background

Cardiac surgery remains a significant challenge in patients with coagulation factor VIII (FVIII) deficiency, especially in those with multiple factor deficiencies.

Case summary

A 79-year-old man with combined FVIII and factor XI (FXI) deficiency was admitted for heart failure treatment. Transthoracic echocardiography revealed aortic stenosis (AS) with decreased left ventricular ejection fraction (LVEF) of 40%, mean aortic pressure gradient of 21 mmHg, and aortic valve area of 0.58 cm2. Coronary angiography revealed significant triple-vessel disease. The patient had multiple comorbidities, including diabetic end-stage renal disease treated with hemodialysis and liver cirrhosis (Child-Pugh score of A). Considering the high surgical risk, a two-stage treatment strategy was developed: the first with off-pump coronary artery bypass grafting (CABG), and the second with transcatheter aortic valve implantation if AS symptoms were significant after CABG. A perioperative hemostatic protocol by the author's heart team was used to appropriately replenish recombinant FVIII concentrates and fresh frozen plasma. The target preoperative and postoperative FVIII coagulation activity values were set at 80-100% and 60-80%, respectively, whereas the target perioperative FXI coagulation activity value was set at 30-45%. Off-pump CABG without aortic manipulation was completed without bleeding events. Transthoracic echocardiography conducted 20 months postoperatively revealed LVEF of 65% and mean aortic pressure gradient of 31 mmHg. The patient leads a normal life 21 months after surgery.

Discussion

The hemostatic protocol and risk-reduction surgery provided satisfactory surgical results in a patient with significant coronary artery disease and AS, high-surgical-risks, and combined FVIII and FXI deficiency.

Multi-modality imaging for pre-procedural planning of transcatheter mitral valve interventions

Transcatheter mitral valve interventions (TMVI), either repair or replacement, are established alternative options for patients with mitral regurgitation (MR) deemed not suitable for conventional open-heart surgery. Multi-modality imaging plays a pivotal role in the selection of patients, gaining insights into the anatomy of the mitral valve the mechanism and the severity of MR, which are essential to predict the success of these procedures. The aim of this review is to provide an overview on the role of multi-modality imaging in the patient selection and pre-procedural planning of TMVI.

Evolution of interventional imaging in structural heart disease

Treatments for structural heart diseases (SHD) have been considerably evolved by the widespread of transcatheter approach in the last decades. The progression of transcatheter treatments for SHD was feasible due to the improvement of devices and the advances in imaging techniques. In this setting, the cardiovascular imaging is pivotal not only for the diagnosis but even for the treatment of SHD. With the aim of fulfilling these tasks, a multimodality imaging approach with new imaging tools for pre-procedural planning, intra-procedural guidance, and follow-up of SHD was developed. This review will describe the current state-of-the-art imaging techniques for the most common percutaneous interventions as well as the new imaging tools. The imaging approaches will be addressed describing the use in pre-procedural planning, intra-procedural guidance, and follow-up.