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

Dynamic Imaging of Aortic Pathologies: Review of Clinical Applications and Imaging Protocols

The past decade has seen significant advances in dynamic imaging of the aorta. Today's vascular surgeons have the opportunity to choose from a wide array of imaging modalities to evaluate different aortic pathologies. While vascular ultrasound and aortography are considered to be the bread and butter imaging modalities, newer dynamic imaging techniques provide time-resolved information in various aortic pathologies. However, despite growing evidence of their advantages in the literature, they have not been routinely adopted. In order to understand the role of these emerging modalities, one must understand their principles, advantages, and limitations in the context of various clinical scenarios. In this review, we provide an overview of dynamic imaging techniques for aortic pathologies and describe various dynamic computed tomography and magnetic resonance imaging protocols, clinical applications, and potential future directions.

Comparison of Clinical and Economic Outcomes of an Optimized Lean Versus a Standard Transcatheter Aortic Valve Implantation Program (from SOLAR [Safe Outcomes Lean And Resourceful] Study)

The increasing prevalence of aortic stenosis (AS) and the increasing number of patients indicated for transcatheter aortic valve implantation (TAVI) can lead to increased hospital constraints. This study aimed to compare, from the hospital perspective, the costs, resource use, and 30-day clinical outcomes of patients who underwent TAVI under an optimized or standard clinical pathway. A single-center, retrospective study was conducted among patients with native AS who underwent TAVI between January 2018 and March 2021. Patients who underwent optimized lean TAVI were propensity-score matched 1:1 to those who underwent standard TAVI. In-hospital costs and 30-day clinical outcomes were compared between the 2 groups. A total of 182 patients (91 in each group) were included in the final analysis. Baseline covariates were well balanced after matching. Patients who underwent lean TAVI had shorter length of stay (median [interquartile range] 3.0 days [2.0 to 6.0] vs 6.0 days [5.0 to 9.0], p <0.001). Patients in the lean TAVI group incurred lower total costs than did those in the standard TAVI group (mean ± SD: $41,346 ± 10,062 vs $50,471 ± 15,115, p = 0.002). There was no between-group difference in 30-day all-cause mortality (2.2% vs 1.1%, p = 0.573) and pacemaker implantations (5.5% vs 6.6%, p = 0.788). Rates of procedural complications were comparable between groups. In conclusion, lean TAVI leads to hospital efficiencies without compromising patient safety. Efforts to streamline the TAVI procedure should be encouraged to improve access to TAVI for patients with AS, amid resource constraints.

Fatal infective endocarditis caused by Aerococcus sanguinicola: a case report and literature review

Aerococcus sanguinicola is a bacterium that can cause urinary tract infections and on rare occasions infective endocarditis (IE). The prognosis of IE caused by aerococci is generally favourable despite that the patients are typically old and have multiple comorbidities. Here we report a case of A. sanguinicola native valve aortic IE in a 68-year-old man with an underlying urinary tract condition. The infection led to severe aortic valve insufficiency and rapid death before the patient could be subjected to surgery. This demonstrates that IE caused by A. sanguinicola can be severe and cause valve destruction. In addition to the case report, we provide a review of the current literature on A. sanguinicola IE.

Outcomes of minimally invasive isolated tricuspid valve reoperation after left-side valve surgery: A single-center experience

BACKGROUND

Late severe tricuspid regurgitation (TR) after left-side valve surgery (LSVS) is not uncommon. However, the tricuspid valve has been deemed the forgotten valve because the isolated TR is well tolerated with medication, and reoperation has a higher rate of adverse events. With the advancement of minimally invasive techniques, isolated tricuspid valve reoperation (ITVR) via totally endoscopy or transcatheter approach brings the tricuspid valve into spotlight. Our aim is to report the safety and efficacy of minimally invasive ITVR using endoscopic and transcatheter approaches.

METHODS

From October 2020 to October 2021, 21 patients with LSVS history and secondary massive TR underwent minimally invasive ITVR in our institution. Baseline characteristics, surgical outcomes and follow-up results were analyzed, and data between the totally endoscopy approach and the transcatheter approach were compared.

RESULTS

Of the 21 cases, totally endoscopic isolated tricuspid valve surgery (EITVS) accounts for 16 (76.2%) cases, with 14 tricuspid valvuloplasty cases, and 2 tricuspid valve replacement cases; the remaining 5 (23.8%) cases underwent transcatheter tricuspid valve replacement (TTVR). The mean age was (60.0 ± 8.4) years, with 15 (71.4%) being female. Minimally invasive ITVR procedures were 100% successfully performed in all patients without any perioperative mortality, sternotomy conversion, or reoperation. During the median follow-up of 16.8 months (IQR, 13.0-20.6 months), New York Heart Association Class improved significantly from baseline (P = 0.004). TR severity was significantly improved during postoperative and follow-up period (both P < 0.001). Compared with the EITVS group, the TTVR group had a higher clinical risk score [8.00 (8.00, 9.00) vs. 5.00 (3.25, 5.00), P = 0.001], but a higher success rate in reducing TR to less than grade 1+ (100 vs. 43.8%, P = 0.045) at follow-up.

CONCLUSION

In our series, minimally invasive ITVR, including EITVS and TTVR, is a safe and feasible option for severe TR after LSVS, and presents excellent early outcomes in selected patients. TTVR is a reliable alternative for patients with high surgical risk. To improve the results of ITVR, it is necessary to improve patient's preoperative status or perform reoperation before the onset of significant right heart failure. Further studies with a larger sample size and a longer follow-up period are awaited.

Transcatheter Aortic Valve Implantation Two Decades of Evolution - TAVI From Current Perspective

Background

In the treatment of valvular heart diseases, transcatheter therapies have changed the rules of the game, especially in the case of aortic stenosis and mitral regurgitation. Since the first in man transcatheter aortic valve intervention (TAVI) performed by Dr. Alain Cribier in 2002 in a non-operable aortic stenosis (AS) patient, TAVI has changed the lives of so many patients for whom medical treatment was, up to then, the only option.

Objective

This article outlines patient selection and pre-procedure evaluation, current perspectives, recent advances, current and future devices, current guidelines informing the use of TAVI, expanding indications for TAVI, ongoing challenges and the future of TAVI.

Methods

The use of these percutaneous techniques has also increased significantly in the past few years with its first application in 2002, transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis and has become the standard of care for patients with AS at prohibitively high surgical risks, as well as a preferred treatment for elderly patients with intermediate and high-risk AS.

Results

Since the first pioneering procedure was performed 22 years ago, transcatheter aortic valve implantation (TAVI) has evolved into a routine procedure increasingly performed under conscious sedation via transfemoral access. On a global market worth $2 billion per year, over 300 000 patients have received a transcatheter aortic valve, demonstrating its clinical and market impact. TAVI may be used in lower risk, younger, asymptomatic populations with ongoing studies using an expanding portfolio of devices. Also, for patients deemed unsuitable for cardiac surgery, mitral transcatheter therapies represent the treatment of choice. Percutaneous repair techniques have had the most clinical experience to date.

Conclusion

During this 20-year period, the increased knowledge on pre-procedural planning, the important technological improvements in transcatheter valves, the increased experience and the numerous studies that have been carried out have permitted an expansion of the indications for TAVI, from inoperable patients to high- and intermediate-risk patients. This article outlines patient selection and pre-procedure evaluation, current perspectives, recent advances, current and future devices, current guidelines informing the use of TAVI, expanding indications for TAVI, ongoing challenges and the future of TAVI.

Valvular heart disease: shifting the focus to the myocardium

Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.

Beyond the 10-Year Horizon: Mitral Valve Repair Solely With Chordal Replacement and Annuloplasty

BACKGROUND

The long-term outcomes of mitral valve repair by nonresection techniques, such as annuloplasty and chordal replacement, for degenerative mitral valve regurgitation were investigated.

METHODS

All consecutive patients with degenerative mitral regurgitation who received solely chordal replacement and annuloplasty for mitral valve repair between 2003 and 2010 at the German Heart Center Munich were reviewed. The endpoints of this retrospective study were survival, cumulative incidence of reoperation on the mitral valve, and cumulative incidence of significant recurrent mitral regurgitation.

RESULTS

A total of 346 patients were evaluated. The median follow-up period was 10.86 (range, 0.01-15.86) years. The 30-day mortality rate was 0.58% (n = 2 of 346), whereas the 5-year survival was 92.97% ± 1.41%. At 5 years, cumulative incidence of recurrent mitral regurgitation was 6.87% ± 1.57% and cumulative incidence of reoperation on the mitral valve was 3.69% ± 1.05%. Survival at 10 years was 83.35% ± 2.15%. At 10 years, cumulative incidence of recurrent mitral regurgitation was 13.31% ± 2.22% and cumulative incidence of reoperation was 7.84% ± 1.55%. Cox regression analysis identified age, diabetes mellitus, and reduced left ventricular ejection fraction <55% as independent risk factors for death. Left ventricular ejection fraction <55% was revealed as independent risk factor for significant recurrent mitral regurgitation.

CONCLUSIONS

This study demonstrated excellent long-term outcomes with low incidence of reoperation after mitral valve repair using chordal replacement in a highly selected patient cohort. Our findings emphasized the importance of early intervention in severe degenerative mitral regurgitation, especially in patients with reduced left ventricular ejection fraction.

Readmission and In-Hospital Outcomes After Transcatheter Aortic Valve Replacement in Patients With Dementia

BACKGROUND/PURPOSE

The prevalence of dementia and aortic stenosis (AS) increases with each decade of age. Transcatheter aortic valve replacement (TAVR) is a definitive treatment for AS, but there are scarce data on morbidity, mortality, and readmission risk after TAVR in patients with dementia.

METHODS/MATERIALS

We identified all admissions for TAVR in patients with AS in the National Readmissions Database in 2017-2018 and stratified them according to the presence or absence of a secondary diagnosis of dementia. Inpatient outcomes were compared using logistic regression. Cox proportional-hazards models were used to compare 30-, 60-, and 90-day readmissions.

RESULTS

A total of 48,923 index hospitalizations for TAVR were identified, of which 2192 (4.5 %) had a secondary diagnosis of dementia. Presence of dementia was associated with higher odds of delirium, pacemaker placement, acute kidney injury, and fall in hospital. The hazard of 30-day readmission was not significantly different between patients with and without dementia, but patients with dementia experienced a higher hazard of 60-day readmission (HR 1.15, 95 % CI 1.03-1.26, p = 0.011) in the unadjusted model and higher hazard of 90-day readmission in both unadjusted (HR 1.18, 95 % CI 1.08-1.30, p < 0.001) and adjusted models (aHR 1.14, 95 % CI 1.04-1.25, p = 0.004).

CONCLUSIONS

Patients with dementia who undergo TAVR are at higher risk of in-hospital adverse outcomes and 60- and 90-day readmissions compared with patients without dementia. These estimates should be integrated into shared decision-making discussions with patients and families.

Toll-like receptor-3 contributes to the development of aortic valve stenosis

Aortic valve stenosis (AS) development is driven by distinct molecular and cellular mechanisms which include inflammatory pathways. Toll-like-receptor-3 (TLR3) is a lysosomal pattern-recognition receptor that binds double-stranded RNA and promotes pro-inflammatory cellular responses. In recent years, TLR3 has emerged as a major regulator of vascular inflammation. The exact role of TLR3 in the development of AS has not been investigated. Isolated human valvular interstitial cells (VICs) were stimulated with the TLR3-agonist polyIC and the resulting pro-inflammatory and pro-osteogenic response measured. Severe AS was induced in wildtype- and TLR3^-/- mice via mechanical injury of the aortic valve with a coronary springwire. TLR3 activation was achieved by polyIC injection every 24 h after wire injury, while TLR3 inhibition was realized using Compound 4a (C4a) every 48 h after surgery. Endothelial mesenchymal transition (EndoMT) of human valvular endothelial cells (VECs) was assessed after polyIC stimulation. Stimulation of human VICs with polyIC promoted a strong inflammatory and pro-osteogenic reaction. Similarly, injection of polyIC marginally increased AS development in mice after wire injury. AS induction was significantly decreased in TLR3^-/- mice, confirming the role of endogenous TLR3 ligands in AS pathology. Pharmacological inhibition of TLR3 with C4a not only prevented the upregulation of inflammatory cytokines and osteogenic markers in VICs, and EndoMT in VECs, but also significantly abolished the development of AS in vivo. Endogenous TLR3 activation significantly contributes to AS development in mice. Pharmacological inhibition of TLR3 with C4a prevented AS formation. Therefore, targeting TLR3 may be a viable treatment option.

New therapeutic approach for tricuspid regurgitation: Transcatheter tricuspid valve replacement or repair

The tricuspid valve is a complex structure with normal function dependent on the leaflet morphology, right atrial and annular dynamics, and right ventricular and chordal support. Thus, the pathophysiology of tricuspid regurgitation (TR) is equally complex and current medical and surgical management options are limited. Transcatheter devices are currently being investigated as possible treatment options with lower morbidity and mortality than open surgical procedures. These devices can be divided by their implant location/mechanism of action: leaflet approximation devices, annuloplasty devices, orthotopic valve implants, and heterotopic valve implants. The current review will discuss each class of transcatheter device therapy, and further delve into the current understanding of who and when to treat. Finally, we will include a brief discussion of the future of device and surgical therapy trials for TR and the remaining questions to answer about this complex disease process.

Diuretic treatment before and after transcatheter aortic valve implantation: A Danish nationwide study

OBJECTIVES

We examined loop diuretic treatment before and 1-year after transcatheter aortic valve implantation (TAVI), as a proxy for changes in symptom severity and secondly assessed how changes in loop diuretics related to mortality risk.

BACKGROUND

Randomized clinical trials suggest that approximately one third of patients undergoing TAVI do not achieve symptom relief, but "all-comer" data are lacking.

METHODS

Using Danish nationwide registries, we identified all citizens, who underwent TAVI from 2008 to 2019 and were alive at 1-year post-discharge. Loop diuretic treatment pre-TAVI and at 1-year post-TAVI were assessed and grouped as receiving 1) no-loop diuretics; 2) low: 1-40 mg of furosemide (or equivalent bumetanide) daily; 3) intermediate: 41-120 mg of furosemide daily; or 4) high: >120 mg furosemide daily.

RESULTS

Among the 4431 patients undergoing TAVI, 2173 (49%) patients were not treated with loop diuretics at the time of TAVI, 918 (21%) had low-loop diuretics, 881 (20%) had intermediate-loop diuretics, and 459 (10%) had high-loop diuretics. At 1-year post-TAVI, 893 (20%) patients had increased, 1010 (23%) had reduced, and 2528 (57%) had unchanged loop diuretic treatment. The cumulative 5-year risk of death in patients surviving one year, was 61% (95% CI: 56.4% to 65.3%) in patients with increased and 47% (95% CI: 44.9% to 49.9%) in patients with reduced/unchanged loop diuretic treatment, respectively. In multivariable Cox proportional hazard analysis, increased loop diuretic treatment was associated with a higher risk of death compared with reduced/unchanged loop diuretic treatment (Hazard ratio: 1.4; 95% CI: 1.22 to 1.52).

CONCLUSIONS

Among patients undergoing TAVI, surviving one year, one fifth of patients had increased loop diuretic treatment, and a little over one fifth had reduced loop diuretic treatment 1-year post-procedure. In patients with increased diuretic treatment, the risk of death was higher compared to those with reduced/unchanged loop diuretic treatment.

A journey from resect to respect to restore: aiming at optimal physiological surgical mitral valve repair

The concept of 'repairing' a degenerated mitral valve in order to restore the native competence means achieving the best physiological result coupled with the least invasive approach: this represents an interesting challenge for cardiac surgeons. The evolution of cardiac surgery through the years has involved techniques and technologies in every field of interest. From 'resect', to 'respect', to 'restore': the micro-invasive approach based on Neochord implant implies a transapical beating heart surgery which is based on the concept of implanting artificial chordae, preserving the physiological dynamics of the mitral annulus and avoiding the disadvantages of cardiopulmonary bypass and cardioplegic arrest of the heart.

Spatiotemporal Complexity of Vena Contracta and Mitral Regurgitation Grading Using Three-Dimensional Echocardiographic Analysis

BACKGROUND

Spatiotemporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatiotemporal vena contracta complexity and its impact on MR severity grading.

METHODS

In 192 patients with suspected moderate or severe MR (100 primary MR [PMR]; 92 secondary MR [SMR]), we performed three-dimensional vena contracta area (VCA) quantification using single-frame (midsystolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns and with cardiac magnetic resonance (CMR) in a subset of cases (n = 20).

RESULTS

The vena contracta was noncircular (shape index > 1.5) in 90% of patients. Severe noncircularity (shape index > 3) was more prevalent in SMR than in PMR (32.4% vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high grading agreement with VCAmean (83.3%). Pulmonary vein flow systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (area under the curve, 0.88, 0.86, and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as nonsevere by CMR more frequently compared with VCAmid and VCAmean.

CONCLUSIONS

Highly prevalent spatiotemporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.

Exercise oscillatory ventilation in patients with advanced heart failure with and without left ventricular assist device

BACKGROUND

Exercise oscillatory ventilation (EOV), indicating pathological fluctuations on pulmonary arterial pressure, is associated with mortality in patients with heart failure (HF). Whether left ventricular assist device (LVAD)-induced ventricular unloading can reverse EOV and may prevent short-term rehospitalization has not been investigated.

METHODS

We performed a retrospective single-center in- and outpatient analysis of patients with (n = 20, LVAD) and without (n = 27, HF) circulatory support and reduced ejection fraction (EF, 22.8 ± 7.9%). The association of cardiopulmonary exercise testing (CPET) variables and 3 months-rehospitalization (3MR) as a primary outcome was analyzed. Furthermore, CPET variables were compared regarding the presence of EOV (+/-).

RESULTS

Lower VO_2peak (11.6 ± 4.9 ml/kg/min vs. 14.4 ± 4.3 ml/kg/min, p = 0.039), lower increase of PETCO₂ (CI = 0.049-1.127; p = 0.068), and higher VE/VCO₂ (43.8 ± 9.5 vs. 38.3 ± 10.6; p = 0.069) were associated with 3MR. Flattening of O₂ pulse (CI = 0.139-2.379; p = 0.487) had no impact on 3MR. EOV was present in 59.5% (n = 28/47) of patients, without a significant difference between LVAD and HF patients (p = 0.959). Patients with HF/EOV+ demonstrated significantly lower VO_2peak compared with HF/EOV- (p = 0.039). LVAD/EOV+ displayed significantly lower EF (p = 0.004) and fewer aortic valve opening than LVAD/EOV- (p = 0.027).

CONCLUSIONS

Lower VO_2peak , but not EOV, was associated with 3MR. EOV occurred at a similar rate in LVAD and HF patients, which may illustrate insufficient unloading during exercise in chronic LVAD therapy and may contribute to the limited exercise capacity following LVAD implantation. Simultaneous CPET and right heart catheterization studies are needed to elucidate whether EOV may serve as a non-invasive predictor of insufficient LV unloading necessitating LVAD reprograming.

Watchful surgery in asymptomatic mitral valve prolapse

The most common organic etiology of mitral regurgitation is degenerative and consists of mitral valve prolapse (MVP). Volume overload because of mitral regurgitation is the most common complication of MVP. Advocating surgery before the consequences of volume overload become irreparable restores life expectancy, but carries a risk of mortality in patients who are often asymptomatic. On the other hand, the post-surgical outcome of symptomatic patients is dismal and life expectancy is impaired. In the present article, we aim to bridge the gap between these two therapeutic approaches, unifying the concepts of watchful waiting and early surgery in a "watchful surgery approach".

Quantitative Echocardiographic Assessment and Optimal Criteria for Early Intervention in Asymptomatic Tricuspid Regurgitation

BACKGROUND

Significant tricuspid regurgitation (TR) is associated with poor outcome and high operative mortality resulting from late presentation. Yet, the optimal timing for intervention is unknown.

OBJECTIVES

The purpose of this study was to evaluate the prognostic value of echocardiographic parameters to inform early intervention in asymptomatic TR.

METHODS

Using the Cleveland Clinic echocardiography database 2004 to 2018, the authors identified a consecutive cohort of asymptomatic patients with moderate to severe (3+) or severe (4+) TR. Quantitative TR and right heart parameters were retrospectively determined, and their prognostic utility for all-cause mortality was assessed.

RESULTS

In 325 asymptomatic patients (mean age: 67.9 years; 79.4% female) with at least 3+ TR, there were 132 deaths (40.6%), with a median survival time of 9.9 years (95% CI: 7.9-12.7 years). By contrast, the median survival time in an age- and sex-matched cohort of symptomatic TR patients was 4.4 years (95% CI: 2.8-5.9 years). Among all the echocardiographic parameters evaluated, right ventricle free wall strain (RVFWS) and tricuspid regurgitant volume (RVol) were the strongest predictors of mortality in asymptomatic TR. The optimal discriminatory thresholds for these parameters were RVFWS <-19% and RVol >45 mL. The 5-year survival rates by number of risk factors (RF) were 93% (95% CI: 86%-96%), 65% (95% CI: 55%-74%), and 38% (95% CI: 26%-49%) for no RF, 1 RF, and both RFs, respectively. Compared with symptomatic TR, mortality was lower for asymptomatic TR with no RF (HR: 0.10; 95% CI: 0.04-0.29) or 1 RF (HR: 0.29; 95% CI: 0.14-0.58), but similar for asymptomatic TR with both RFs (HR: 1.11; 95% CI: 0.56-2.19).

CONCLUSIONS

RVFWS and RVol are key prognostic markers that can be serially monitored to inform optimal timing of intervention for severe asymptomatic TR.

Right ventricle to pulmonary artery coupling after transcatheter aortic valve implantation-Determinant factors and prognostic impact

Introduction

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI.

Methods

One hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67).

Results

A significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44-24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37-12.5, p = 0.012).

Conclusion

Our results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study

BACKGROUND

Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown.

METHODS

Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures.

RESULTS

There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85).

CONCLUSIONS

An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.

Myocardial Fibrosis at Cardiac MRI Helps Predict Adverse Clinical Outcome in Patients with Mitral Valve Prolapse

Background Patients with mitral valve prolapse (MVP) may develop adverse outcomes even in the absence of mitral regurgitation or left ventricular (LV) dysfunction. Purpose To investigate the prognostic value of mitral annulus disjunction (MAD) and myocardial fibrosis at late gadolinium enhancement (LGE) cardiac MRI in patients with MVP without moderate-to-severe mitral regurgitation or LV dysfunction. Materials and Methods In this longitudinal retrospective study, 118 144 cardiac MRI studies were evaluated between October 2007 and June 2020 at 15 European tertiary medical centers. Follow-up was from the date of cardiac MRI examination to June 2020; the minimum and maximum follow-up intervals were 6 months and 156 months, respectively. Patients were excluded if at least one of the following conditions was present: cardiomyopathy, LV ejection fraction less than 40%, ischemic heart disease, congenital heart disease, inflammatory heart disease, moderate or worse mitral regurgitation, participation in competitive sport, or electrocardiogram suggestive of channelopathies. In the remainder, cardiac MRI studies were reanalyzed, and patients were included if they were aged 18 years or older, MVP was diagnosed at cardiac MRI, and clinical information and electrocardiogram monitoring were available within 3 months from cardiac MRI examination. The end point was a composite of adverse outcomes: sustained ventricular tachycardia (VT), sudden cardiac death (SCD), or unexplained syncope. Multivariable Cox regression analysis was performed. Results A total of 474 patients (mean age, 47 years ± 16 [SD]; 244 women) were included. Over a median follow-up of 3.3 years, 18 patients (4%) reached the study end point. LGE presence (hazard ratio, 4.2 [95% CI: 1.5, 11.9]; P = .006) and extent (hazard ratio, 1.2 per 1% increase [95% CI: 1.1, 1.4]; P = .006), but not MAD presence (P = .89), were associated with clinical outcome. LGE presence had incremental prognostic value over MVP severity and sustained VT and aborted SCD at baseline (area under the receiver operating characteristic curve, 0.70 vs 0.62; P = .03). Conclusion In contrast to mitral annulus disjunction, myocardial fibrosis determined according to late gadolinium enhancement at cardiac MRI was associated with adverse outcome in patients with mitral valve prolapse without moderate-to-severe mitral regurgitation or left ventricular dysfunction. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gerber in this issue.

MitraClip: a review of its current status and future perspectives

Mitral regurgitation (MR), among the most common valvular heart diseases, is closely associated with heart failure and worse clinical outcomes. Surgical repair or replacement as an intervention for MR is deemed too high risk in patients who are elderly or have multiple comorbidities; thus, nearly half of all patients with severe symptomatic MR are not referred for surgical therapy. MitraClip, a transcatheter mitral valve repair system for MR that mimics the Alfieri surgical edge-to-edge technique for mitral valve repair, was developed in the late 1990s. After clinical trials demonstrated its safety and efficacy, it received approval for clinical use, particularly for aging and inoperable or high-risk patients for heart surgery in Europe, the US, and Japan. Since the start of its clinical use, randomized clinical trials (RCTs) have optimized patient selection, and the latest generation MitraClip can increase procedural success, even in patients with challenging mitral valve anatomy. Therefore, here, we review evidence from clinical trials and RCTs and discuss optical patient selection and future perspectives for the MitraClip.

Comparison of effective regurgitant orifice area by the PISA method and tricuspid coaptation gap measurement to identify very severe tricuspid regurgitation and stratify mortality risk

Introduction

Various definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes.

Materials and methods

In this French multicentre retrospective study, we included 606 patients with ≥moderate-to-severe isolated functional TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm²) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality.

Results

The relationship between the EROA and TCG was poor (R²=0.22), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA <60 mm² vs. ≥60 mm² (68 ± 3% vs. 64 ± 5%, p = 0.89). A TCG ≥10 mm was associated with lower four-year survival than a TCG <10 mm (53 ± 7% vs. 69 ± 3%, p < 0.001). After adjustment for covariates, including comorbidity, symptoms, dose of diuretics, and right ventricular dilatation and dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95% CI] = 1.47[1.13-2.21], p = 0.019) and cardiovascular mortality (adjusted HR[95% CI] = 2.12[1.33-3.25], p = 0.001), whereas an EROA ≥60 mm² was not associated with all-cause or cardiovascular mortality (adjusted HR[95% CI]: 1.16[0.81-1.64], p = 0.416, and adjusted HR[95% CI]: 1.07[0.68-1.68], p = 0.784, respectively).

Conclusion

The correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10 mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated significant functional TR.

Congenital aortic valve stenosis: from pathophysiology to molecular genetics and the need for novel therapeutics

Congenital aortic valve stenosis (AVS) is one of the most common valve anomalies and accounts for 3%-6% of cardiac malformations. As congenital AVS is often progressive, many patients, both children and adults, require transcatheter or surgical intervention throughout their lives. While the mechanisms of degenerative aortic valve disease in the adult population are partially described, the pathophysiology of adult AVS is different from congenital AVS in children as epigenetic and environmental risk factors play a significant role in manifestations of aortic valve disease in adults. Despite increased understanding of genetic basis of congenital aortic valve disease such as bicuspid aortic valve, the etiology and underlying mechanisms of congenital AVS in infants and children remain unknown. Herein, we review the pathophysiology of congenitally stenotic aortic valves and their natural history and disease course along with current management strategies. With the rapid expansion of knowledge of genetic origins of congenital heart defects, we also summarize the literature on the genetic contributors to congenital AVS. Further, this increased molecular understanding has led to the expansion of animal models with congenital aortic valve anomalies. Finally, we discuss the potential to develop novel therapeutics for congenital AVS that expand on integration of these molecular and genetic advances.

Prosthesis Tailoring for Patients Undergoing Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has risen over the past 20 years as a safe and effective alternative to surgical aortic valve replacement for treatment of severe aortic stenosis, and is now a well-established and recommended treatment option in suitable patients irrespective of predicted risk of mortality after surgery. Studies of numerous devices, either newly developed or reiterations of previous prostheses, have been accruing. We hereby review TAVI devices, with a focus on commercially available options, and aim to present a guide for prosthesis tailoring according to patient-related anatomical and clinical factors that may favor particular designs.

Multimodality imaging in aortic stenosis: new diagnostic and therapeutic frontiers

The advent of transcatheter aortic valve implantation has revolutionized the treatment of calcific aortic valve stenosis. Elderly patients who were previously considered inoperable have currently an efficacious and safe therapy that provides better survival. In addition, current practice guidelines tend to recommend earlier intervention to avoid the irreversible consequences of long-lasting pressure overload caused by the stenotic aortic valve. Appropriate timing of the intervention relies significantly on imaging techniques that provide information on the severity of the aortic stenosis as well as on the hemodynamic consequences and cardiac remodeling. While left ventricular ejection fraction remains one of the main functional parameters for risk stratification in patients with severe aortic stenosis, advances in imaging techniques have provided new structural and functional parameters that allow the identification of patients who will benefit from intervention before the occurrence of symptoms or irreversible cardiac damage. Furthermore, ongoing research aiming to identify the medical therapies that can effectively halt the progression of aortic stenosis relies heavily on imaging endpoints, and new imaging techniques that characterize the metabolic activity of calcific aortic stenosis have been proposed to monitor the effects of these therapies. The present review provides an up-to-date overview of the imaging advances that characterizes the pathophysiology and that have changed the management paradigm of aortic stenosis.

Predictors of Progression of Tricuspid Regurgitation in Patients with Persistent Atrial Fibrillation

Previous studies have shown that tricuspid regurgitation (TR) can be developed in patients with atrial fibrillation (AF) due to annular dilatation. This study aimed to investigate the incidence and predictors of the progression of TR in patients with persistent AF. A total of 397 patients (66.9±11.4 years, 247 men; 62.2%) with persistent AF were enrolled between 2006 and 2016 in a tertiary hospital, and 287 eligible patients with follow-up echocardiography were analyzed. They were divided into two groups according to TR progression (progression group [n=68, 70.1±10.7 years, 48.5% men] vs. non-progression group [n=219, 66.0±11.3 years, 64.8% men]). Among 287 patients in the analysis, 68 had worsening TR severity (23.7%). Patients in the TR progression group were older and more likely to be female. Patients with left ventricular ejection fraction <50% were less frequent in the progression group than those in the non-progression group (7.4% vs. 19.6%, p=0.018). Patients with mitral valve disease were more frequent in the progression group. Multivariate analysis with COX regression demonstrated independent predictors of TR progression, including left atrial (LA) diameter >54 mm (HR 4.85, 95%CI 2.23-10.57, p<0.001), E/e' (HR 1.05, 95%CI 1.01-1.10, p=0.027), and no use of antiarrhythmic agents (HR 2.20, 95%CI 1.03-4.72, p=0.041). In patients with persistent AF, worsening TR was not uncommon. The independent predictors of TR progression turned out to be greater LA diameter, higher E/e', and no use of antiarrhythmic agents.

Technical Success after Transcatheter Aortic Valve Replacement for Bicuspid versus Tricuspid Aortic Stenosis

Background: Comparative data of the Valve Academic Research Consortium (VARC-3)-defined technical success between bicuspid versus tricuspid aortic stenosis (AS) remain lacking. Aims: We sought to compare the technical success and other clinical outcomes between patients with bicuspid and tricuspid AS receiving transcatheter aortic valve replacement. Methods: A registration-based analysis was performed for 402 patients (211 and 191 cases of bicuspid and tricuspid AS, respectively). The primary outcome was VARC-3-defined technical success. Additional analysis was performed to assess outcomes for up to one year between the two groups. Results: Bicuspid AS patients tended to be younger (74 years vs. 77 years; p < 0.001) with a lower Society of Thoracic Surgeons score (4.4% vs. 5.4%; p = 0.003). Bicuspid AS patients showed a lower prevalence of hypertension and peripheral vascular diseases. Technical failure was encountered in 17.7% of these patients, driven primarily by the high incidence of second valve implantation. The technical success rates were comparable between the bicuspid and tricuspid AS groups (82.5% vs. 82.2%, p = 0.944). Chronic kidney disease (CKD) and larger sinotubular junctional diameter (STJ) were identified as predictors of technical failure, whereas CKD, impaired left ventricular ejection fraction (LVEF), along with larger STJ, were predictors of cardiac technical failure. Technical failure was associated with an increased risk of all-cause mortality at 30 days and 1 year, as evidenced by the Cox multivariable analysis. Conclusions: No significant differences were observed in the technical success rates and most clinical outcomes between the bicuspid and tricuspid AS groups. Technical failure conferred an increased risk for both 30-day and 1-year all-cause mortalities.

Derivation and Validation of a Clinical Risk Score for COAPT-Ineligible Patients Who Underwent Transcatheter Edge-to-Edge Repair

Up to half of real-world patients with secondary mitral regurgitation who underwent transcatheter edge-to-edge repair (TEER) do not meet the highly selective COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) criteria. No randomized trials or standardized and validated tools exist to evaluate the risk: benefit ratio of TEER in this specific population. We sought to derive and externally validate a clinical risk score to predict the risk of death or heart failure (HF) hospitalization for COAPT-ineligible patients who underwent TEER (CITE score). The study population consisted of patients with secondary mitral regurgitation having at least 1 exclusion criterion of the COAPT trial. The derivation cohort included 489 patients from the GIOTTO (GIse registry of Transcatheter treatment of Mitral Valve regurgitaTiOn) registry. Cox proportional hazards regression was used to identify predictors of 2-year death/HF hospitalization and develop a numerical risk score. The predictive performance was assessed in the derivation cohort and validated in 268 patients from the MiZüBr (Milan-Zürich-Brescia) registry. The CITE score (hemodynamic instability, left ventricular impairment, New York Heart Association class III/IV, peripheral artery disease, atrial fibrillation, brain natriuretic peptide, and hemoglobin) showed a c-index for 2-year death or HF hospitalization of 0.70 (95% confidence interval [CI] 0.67 to 0.73) in the derivation cohort, and 0.68 (95% CI 0.64 to 0.73) in the validation cohort. A cutoff of <12 points was selected to identify patients at lower risk of adverse outcomes, hazard ratio of 0.35 (95% CI 0.26 to 0.46). In conclusion, the CITE score is a simple 7-item tool for the prediction of death or HF hospitalization at 2 years after TEER in COAPT-ineligible patients. The score may support clinical decision-making by identifying those patients who, even if excluded from clinical trials, can still benefit from TEER.

Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization

Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.

Clinical and Echocardiographic Characteristics of Flow-Based Classification Following Balloon-Expandable Transcatheter Heart Valve in PARTNER Trials

BACKGROUND

Current expected normal echocardiographic measures of transcatheter heart valve (THV) function were derived from pooled cohorts of the randomized trials; however, THV function by flow state before or following transcatheter aortic valve replacement (TAVR) has not been previously reported.

OBJECTIVES

This study sought to assess the expected normal echocardiographic hemodynamics for the balloon-expandable THV grouped by stroke volume index (SVI).

METHODS

Patients with severe aortic stenosis enrolled in PARTNER (Placement of Aortic Transcatheter Valves) 1 (high/extreme surgical risk), PARTNER 2 (intermediate surgical risk), or PARTNER 3 (low surgical risk) trials with complete core laboratory echocardiography were included. Patients were grouped by low-flow (SVI_LOW <35 mL/m²) and normal-flow (SVI_NORMAL ≥35 mL/m²). Mean gradient, effective orifice area (EOA), and Doppler velocity index (DVI) were collected at baseline and at 30 days post-TAVR. Prosthesis-patient mismatch (PPM) was both calculated and predicted from normative data, using defined criteria.

RESULTS

In the entire population (N = 4,991), mean age was 81.8 years, 58% of patients were male, and 42% had low flow. Compared with patients with baseline SVI_NORMAL, those with SVI_LOW were more likely to be male; have more comorbidities; and lower left ventricular ejection fraction, mean gradient, and EOA. Post-TAVR, SVI_LOW increased to SVI_NORMAL in 17.3% and SVI_NORMAL decreased to SVI_LOW in 12.3% of patients. Using baseline SVI, follow-up EOA, mean gradient, and DVI for patients with SVI_LOW tended to be lower than for patients with SVI_NORMAL. Using the post-TAVR SVI, follow-up EOA, mean gradient, and DVI were significantly lower for patients with SVI_LOW than for those with SVI_NORMAL (P < 0.001 for all). The incidence of calculated, but not predicted, severe PPM was higher in patients with low flow than it was in patients with normal flow, suggesting pseudo-PPM in the presence of low flow.

CONCLUSIONS

This study demonstrates that flow affects THV hemodynamics and both baseline and follow-up SVI should be considered when predicting THV hemodynamics prior to TAVR, as well as assessing valve function following valve implantation.

Cardiovascular disease and kidney transplantation

Compared to general population, patients with chronic kidney disease (CKD) exhibit high prevalence of cardiovascular disease (CVD) that increases with a stage of CKD. Traditional and non-traditional risk factors associated with CKD contribute to accelerated atherosclerosis leading to CVD. CVD represents the main cause of morbidity and mortality in CKD population. Pretransplant examination is essential to evaluate and optimize the state of cardiovascular system prior transplantation, thus   to minimize risks that could have a negative impact on transplant outcome.

Temporal Trends and Contemporary Outcomes After Transcatheter Aortic Valve Replacement With Evolut PRO/PRO+ Self-Expanding Valves: Insights From the NEOPRO/NEOPRO-2 Registries

BACKGROUND

In recent years, transcatheter aortic valve replacement (TAVR) techniques and technology have continuously improved. Data regarding the impact of these advancements on outcomes in large real-world settings are still limited. The aim of this study was to investigate temporal trends and assess contemporary outcomes after TAVR with Evolut PRO/PRO+ supra-annular self-expanding valves.

METHODS

This study included patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries who underwent transfemoral TAVR with Evolut PRO/PRO+. Procedural dates (August 2017 through November 2021) were stratified in quartiles (Q) and used to investigate temporal trends in TAVR outcomes. Predischarge, 30-day Valve Academic Research Consortium-3 defined, and 1-year outcomes were evaluated.

RESULTS

In total, 1616 patients from 28 centers were included. Over time, patients had lower Society of Thoracic Surgeon-Predicted Risk of Mortality score (Q1-4, 4.1% [2.8-6.3%], 3.7% [2.6-5.3%], 3.3% [2.4-4.9%], 2.9% [2.2-4.3%]; P<0.001) and more moderate or heavy valve calcification (Q1-4, 80%, 80%, 82%, 88%; P=0.038). Overall Valve Academic Research Consortium-3 technical success was 94.1%, with 30-day and 1-year all-cause mortality of 2.4% and 10%, respectively. Throughout the study period, procedures were associated with higher rates of 30-day device success (Q1-4, 81.2%, 82.2%, 82.0%, 88.0%; Cochran-Armitage P=0.023) and early safety (Q1-4, 66.8%, 67.5%, 74.0%, 77.6%; Cochran-Armitage P<0.001), with fewer permanent pacemaker implantations (Q1-4: 15.3%, 20.0%, 12.1%, 11.6%; Cochran-Armitage P=0.023) and residual mild or greater paravalvular leaks (Q1-4, 50.4%, 42.1%, 36.5%, 35.8%; Cochran-Armitage P<0.001).

CONCLUSIONS

TAVR with Evolut PRO/PRO+ self-expanding valve is safe and effective. Despite the treatment of heavier calcified anatomies, procedural outcomes are improving over time with less need for pacemaker implantation and less significant paravalvular leaks.

Patients' motivation to undergo transcatheter aortic valve replacement. A phenomenological hermeneutic study

BACKGROUND

Aortic stenosis is the most common valvular disease, and its prevalence is increasing due to the ageing population. Transcatheter aortic valve replacement (TAVR) is the recommended method when treating frail, older patients. Knowledge of what motivates older patients to undergo TAVR is important, in order to meet patients' expectations.

OBJECTIVE

The study aimed to explore the meaning of older patients' motivation to undergo TAVR.

DESIGN AND METHODS

The design was a qualitative study, analysed using a phenomenological hermeneutic approach. In-depth, semi-structured interviews with open-ended questions were conducted. Participants were selected from a specialist cardiology clinic in Sweden. Eighteen patients, six women and twelve men, aged 66-92, were recruited.

RESULTS

The analysis showed that patients who had agreed to undergo TAVR were deeply affected by their body's failure. Before the TAVR procedure, the participants were limited in their daily activities and experienced that their life was on hold. They experienced that they were barely existing. They were aware of their life-threatening condition and were forced to confront death. Yet despite an advanced age, they still had considerable zest for life. It was very important to them to remain independent in everyday life, and fear of becoming dependent had a strong impact on their motivations for undergoing TAVR.

CONCLUSION

Older patients' motivations to undergo TAVR are strongly influenced by their fear of being dependent on others and their zest for life. Health care professionals need to support these patients in setting realistic and personalised goals.

IMPLICATION FOR PRACTICE

Person-centered care actions could facilitate patients' involvement in the decision about TAVR and strenghten patients' beliefs in their own capabilities, before and after TAVR.

Dexmedetomidine Sedation Combined With Remifentanil in MitraClip Procedures is Feasible and Improves Hemodynamics

OBJECTIVES

The objective of the study was to compare the overall feasibility, respiratory and hemodynamic stability, as well as process times of a dexmedetomidine-based sedative regimen compared with general anesthesia among patients undergoing MitraClip procedures.

DESIGN

A retrospective cohort study.

SETTING

A single tertiary care university center.

PARTICIPANTS

The study included 79 patients.

INTERVENTIONS

Dexmedetomidine sedation versus general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Seventy-nine MitraClip procedures in dexmedetomidine/remifentanil conscious sedation (DCS, n = 26) or general anesthesia (GA, n = 53), performed between 2018 and 2020 at Charité - Universitätsmedizin Berlin, were analyzed retrospectively. Patients' median age was 81 years in both groups without differences in preinterventional EuroScore I (DCS 6 [5; 8], GA 7 [6; 8]) or systolic function (left ventricular ejection fraction: DCS 50% [32; 60] v. GA 50% [36; 60]; tricuspid annular plane systolic excursion: DCS 19 mm [16; 22] v GA 19 mm [15; 22]). During MitraClip procedures, respiratory parameters revealed no differences between groups, whereas patients under DCS showed higher mean arterial pressures (DCS 64 mmHg [59; 74] v GA 58 mmHg [53; 66]) and needed less norepinephrine (DCS 0.0µg/kg/min [0.0; 0.2] v GA 0.08 µg/kg/min [0.05; 0.15]). Emergence from both anesthesia regimens to readiness for intensive care unit transfer was faster in DCS (8 min [4; 18] v GA 16 min [11; 23]); however, total process time was comparable between groups (DCS 128 min [104; 155] v GA 142 min [117; 190]). Two patients required a switch from DCS to GA due to oral bleeding or prolonged procedure time. Both were excluded from the analysis. There was no switch to open surgery and no differences in postoperative complications between DCS and GA.

CONCLUSION

Dexmedetomidine/remifentanil sedation appears to be feasible and a safe option for MitraClip procedures, and provides better hemodynamic stability with faster emergence times compared with general anesthesia.

Glycoprotein and Lipoprotein Profiles Assessed by 1H-NMR and Its Relation to Ascending Aortic Dilatation in Bicuspid Aortic Valve Disease

INTRODUCTION

The bicuspid aortic valve (BAV) confers a high risk of ascending aorta dilatation (AAoD), although its progression seems highly variable. Furthermore, the implication of lipoprotein metabolism and inflammation in the mechanisms that underlie AAoD is not fully established. The aim of this study consisted of evaluating the impact of the lipoprotein and glycoprotein profiles in AAOD as well as its progression in BAV aortopathy.

METHODS

Using 1H-nuclear magnetic resonance (1H-NMR), we analyzed and compared the lipoprotein and glycoprotein profiles of plasma samples from 152 BAV patients with dilated and nondilated ascending aorta. Additionally, these profiles were also compared for 119 of these patients who were prospectively followed-up clinically and by echocardiography in the long-term (5 years). Ascending aorta dilation velocity (mm/year) was calculated for this analysis.

RESULTS

Several parameters related to the lipoprotein profile including remnant cholesterol, small LDL and IDL-cholesterol were found to be significantly increased in the dilated group compared to those in the nondilated group. The glycoprotein A-nuclear magnetic resonance (NMR) signal, a novel inflammation biomarker, was also observed to be increased in the dilated group. After performing multivariate analysis, remnant cholesterol remained an independent variable related to AAoD. In the long-term follow-up, proatherogenic lipoprotein parameters were related to ascending aorta dilatation velocity ascending. After a lineal regression analysis, non-HDL particles remained as an independent predictor of ascending aorta dilation velocity.

CONCLUSIONS

Patients with BAV and AAoD presented a more pro-atherogenic profile assessed by 1H-NMR, especially related to triglyceride-rich lipoproteins. This pro-atherogenic profile seems to contribute to the higher growth rate of ascending aorta diameter.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

Emergency transcatheter aortic valve implantation for acute heart failure due to severe aortic stenosis in critically ill patients with or without cardiogenic shock

AIMS

Severe aortic stenosis can cause acute heart failure and cardiogenic shock (CS). Transcatheter aortic valve implantation (TAVI) is the standard therapy for aortic stenosis in inoperable patients. However, its role in this setting is poorly evaluated. The study purpose was to explore clinical characteristics of these patients and to assess predictors of mortality.

METHODS AND RESULTS

All 2930 patients undergoing transfemoral TAVI at our centre between 2013 and 2019 were screened for critically ill patients, receiving intensive care therapy and emergency TAVI. Selected patients were subdivided into two groups, according to the presence or absence of CS. Remaining patients undergoing elective TAVI served as a comparison. Primary outcome was 90-day mortality. Out of 179 critically ill patients, 47 fulfilled criteria of CS (shock group) and 132 did not despite a severe decompensation (no shock group). Shock patients were more often male and had higher Society of Thoracic Surgeons scores [15.6, interquartile range (8.0-32.1) vs. 5.5 (3.9-8.5), P < 0.01] compared with severely decompensated patients. Ninety-day mortality was: shock group, 42.6%, vs. no shock group, 15.9%, vs. elective group, 5.3% (P < 0.01). A landmark analysis from day 90 showed similar mortality (P = 0.29). Compared with elective patients, 30-day composite endpoint device failure was higher in critically ill groups [shock group, odds ratio, 2.86 (1.43-5.36), no shock group, odds ratio, 1.74 (1.09-2.69)]. Multivariable regression revealed mechanical ventilation, haemofiltration, elevated C-reactive protein or bilirubin, and hypotension before TAVI as 90-day mortality predictors.

CONCLUSION

Ninety-day mortality after TAVI in critically ill patients is increased but survivors have similar outcomes as elective patients.

Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores

BACKGROUND

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI.

METHODS

Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR₄EATME₃AD₃, and ACEF scores were calculated retrospectively.

RESULTS

The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value = 0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value < 0.05 for all) as independent risk factors for AKI.

CONCLUSIONS

Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.

Randomized Comparison of Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients

BACKGROUND

Severe symptomatic degenerative mitral regurgitation (DMR) has a poor prognosis in the absence of treatment, and new transcatheter options are emerging.

OBJECTIVES

The CLASP IID (Edwards PASCAL Transcatheter Valve Repair System Pivotal Clinical Trial) randomized trial (NCT03706833) is the first to evaluate the safety and effectiveness of the PASCAL system compared with the MitraClip system in patients with significant symptomatic DMR. This report presents the primary safety and effectiveness endpoints for the trial.

METHODS

Patients with 3+ or 4+ DMR at prohibitive surgical risk were assessed by a central screening committee and randomized 2:1 (PASCAL:MitraClip). Study oversight also included an echocardiography core laboratory and a clinical events committee. The primary safety endpoint was the composite major adverse event rate at 30 days. The primary effectiveness endpoint was the proportion of patients with mitral regurgitation (MR) ≤2+ at 6 months.

RESULTS

A prespecified interim analysis in 180 patients demonstrated noninferiority of the PASCAL system vs the MitraClip system for the primary safety and effectiveness endpoints of major adverse event rate (3.4% vs 4.8%) and MR ≤2+ (96.5% vs 96.8%), respectively. Functional and quality-of-life outcomes significantly improved in both groups (P < 0.05). The proportion of patients with MR ≤1+ was durable in the PASCAL group from discharge to 6 months (PASCAL, 87.2% and 83.7% [P = 0.317 vs discharge]; MitraClip, 88.5% and 71.2% [P = 0.003 vs discharge]).

CONCLUSIONS

The CLASP IID trial demonstrated safety and effectiveness of the PASCAL system and met noninferiority endpoints, expanding transcatheter treatment options for prohibitive surgical risk patients with significant symptomatic DMR.

Early Outcomes of 2 Mitral Valve Transcatheter Leaflet Approximation Devices: A Propensity Score-Matched Multicenter Comparison

BACKGROUND

In addition to the edge-to-edge MitraClip repair system, the edge-to-spacer PASCAL repair system was approved for percutaneous treatment of severe mitral regurgitation (MR). Comparative data are lacking.

OBJECTIVES

The aim of this study was to compare procedural and short-term safety and efficacy of 2 leaflet-based transcatheter mitral valve repair systems.

METHODS

Procedural and 30-day outcomes were investigated in a propensity score-matched cohort of 307 PASCAL and 307 MitraClip patients at 10 sites. Matching criteria included sex, age, left ventricular ejection fraction, New York Heart Association functional class, MR etiology, left ventricular end-diastolic diameter, left atrial volume index, and vena contracta width. The primary efficacy endpoints were technical success and degree of residual MR at discharge. The primary safety endpoint was the rate of major adverse events (MAE).

RESULTS

Technical success was 97.0% in the PASCAL group and 98.0% in the MitraClip group (P = 0.624). MR ≤2+ at discharge was comparable in both groups (PASCAL: 93.8% vs MitraClip: 92.4%; P = 0.527), with more patients exhibiting MR ≤1+ in the PASCAL group (70.5% vs 56.6%; P < 0.001). The postprocedural mean gradient was significantly higher in the MitraClip group (3.3 ± 1.5 mm Hg vs 3.9 ± 1.7 mm Hg; P < 0.001). At 30 days, all-cause mortality and MAE rates were similar (mortality: 1.7% vs 3.3%; P = 0.299; MAE: 3.9% vs 5.2%; P = 0.562).

CONCLUSIONS

In this first large propensity score-matched comparison, procedural success rates and MAE did not differ significantly between patients treated with the PASCAL or MitraClip valve repair system. Procedural results with less than moderate MR and no elevated transmitral gradient were more common in the PASCAL group, which might have an impact on long-term outcome.

Elevated Fasting Glucose and C-Reactive Protein Levels Predict Increased All-Cause Mortality after Elective Transcatheter Aortic Valve Implantation

Surgical aortic valve replacement in the elderly is now being supplanted by transcatheter aortic valve implantation (TAVI). Scoring systems to predict survival after catheter-based procedures are understudied. Both diabetes (DM) and underlying inflammatory conditions are common in patients undergoing TAVI, but their impact remains understudied in this patient group. We examined 560 consecutive TAVI procedures and identified eight pre-procedural factors: age, body mass index (BMI), DM, fasting blood glucose (BG), left-ventricular ejection fraction (EF), aortic valve (AV) mean gradient, C-reactive protein levels, and serum creatinine levels and studied their impact on survival. The overall mortality rate at 30 days, 1 year and 2 years were 5.2%, 16.6%, and 34.3%, respectively. All-cause mortality was higher in patients with DM (at 30 days: 8.9% vs. 3.1%, p = 0.008; at 1 year: 19.7% vs. 14.9%, p = 0.323; at 2 years: 37.9% vs. 32.2%, p = 0.304). The presence of DM was independently associated with increased 30-day mortality (hazard ratio [HR] 5.38, 95% confidence interval [CI], 1.24-23.25, p = 0.024). BG levels within 7-11, 1 mmol/L portended an increased risk for 30-day and 2-year mortality compared to normal BG (p = 0.001 and p = 0.027). For each 1 mmol/L increase in BG 30-day mortality increased (HR 1.21, 95% CI, 1.04-1.41, p = 0.015). Reduced EF and elevated CRP were each associated with increased 2-year mortality (p = 0.042 and p = 0.003). DM, elevated BG, reduced EF, and elevated baseline CRP levels each are independent predictors of short- and long-term mortality following TAVI. These easily accessible screening parameters should be integrated into risk-assessment tools for catheter-based aortic valve replacement candidates.