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

Electrical Remodeling and Low Voltage Areas in Atrial Fibrillation Patients with Functional Mitral Regurgitation: A Multicenter Evaluation

Background

Atrial fibrosis may act as a substrate for atrial fibrillation (AF) and atrial functional mitral regurgitation (MR); thus, recognition is required to select the optimal therapeutic intervention.

Methods

We examined clinical data from 1045 consecutive patients in three centers who underwent catheter ablation for persistent AF between 2020 and 2022. 75 patients met the moderate and severe MR criteria and completed a 1-year follow-up. Voltage mapping during the ablation procedure was reviewed to classify the extent of atrial fibrosis.

Results

Significant atrial fibrosis was found in 34 patients (45.3%), and these patients had a higher prevalence of congestive heart failure (New York Heart Association (NYHA) II-III: 76.5% vs. 36.6%, p < 0.001) and an increased incidence of biatrial enlargement at baseline than the mild fibrosis group. At the 1-year post-ablation period, the entire cohort exhibited a decrease in left atrial size (41.6 ± 6.5 mm vs. 45.5 ± 5.3 mm, p < 0.001), and a significant reduction in MR was achieved in 70.7% of patients. The significant fibrosis group had a higher recurrence rate of atrial arrhythmias (55.9% vs. 22.0%, log-rank p = 0.002) and no significant change in atria size compared with baseline diameters (left atrium, 44.4 ± 6.4 mm vs. 47.2 ± 5.6 mm, p = 0.068; right atrium, 44.7 ± 11.2 mm vs. 46.7 ± 6.2 mm, p = 0.427).

Conclusions

This study revealed a considerable proportion of significant fibrosis in patients with atrial functional MR and AF, leading to limited effectiveness in reducing atrial size following catheter ablation. Optimal intervention to reduce atrial size and recurrent arrhythmias in this population requires further investigation.

Should MitraClip also be used in less severe functional mitral regurgitation? The RESHAPE-HF2 study

Transcatheter edge-to-edge repair (TEER) is currently indicated in symptomatic patients with severe functional mitral regurgitation (MR) who are not eligible for surgery and who have a high likelihood of responding to treatment. This recommendation is based on two randomized trials suggesting that the benefits of TEER may be limited to patients with severe MR, defined by an effective regurgitant orifice area (EROA) ≥0.40 cm2, and a non-excessively remodelled left ventricle. The randomized RESHAPE-HF2 study recently showed that compared to medical therapy alone, treatment with TEER by MitraClip in patients with symptomatic heart failure and less severe functional MR, with lower EROA (mean 0.23 cm2), is associated with a significant reduction in hospitalizations for heart failure, and an improvement in symptoms and quality of life, without a clear benefit on mortality. However, within the cohort of patients with less severe MR enrolled in the RESHAPE-HF2 study, the benefits of MitraClip compared to medical therapy alone seem more significant in selected patients with characteristics associated with a higher risk of heart failure exacerbation, suggesting the importance of careful selection of patients with symptomatic heart failure and MR who could benefit from TEER.

Ten years of transcatheter aortic valve implantation in the NOTION study: the good and the bad

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis, becoming a preferred option for patients at high and moderate surgical risk and for individuals over 75 years of age. The NOTION study represents the first randomized clinical trial to reach a 10-year follow-up in patients at low surgical risk, comparing TAVI with surgical valve replacement (SAVR). The results show comparable clinical outcomes between TAVI and SAVR in terms of all-cause mortality, stroke, and myocardial infarction. TAVI demonstrated a better haemodynamic profile and a lower incidence of structural valve deterioration (SVD), but showed higher rates of pacemaker requirement and paravalvular leakage compared with surgical replacement. The trial highlights the excellent durability of transcatheter bioprostheses, although new-generation devices and advanced techniques could further reduce adverse events. The study confirms the increasing role of TAVI even in younger patients, but further long-term data will be needed to evaluate its full potential.

Even aortic insufficiency can be treated percutaneously: right?

Moderate or severe aortic insufficiency (AI) is a relatively rare condition but with significant clinical implications, especially in elderly patients at high surgical risk. Although surgical aortic valve replacement remains the gold standard for treatment, a significant proportion of patients are not eligible due to the high surgical risk. In recent years, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of aortic stenosis, but its application to AI has encountered significant challenges, mainly related to specific anatomical characteristics of this population. This review provides an overview of the evolution of the transcatheter treatment of AI, highlighting the critical issues of first-generation TAVI devices and the improvements achieved with new-generation and dedicated devices, such as JenaValve and J-Valve. Preliminary data demonstrate encouraging procedural results, including a reduction in residual insufficiency and improved safety in patients at high surgical risk. However, limitations remain, including the high incidence of pacemaker implantation and the lack of long-term randomized clinical trials. In light of technological advances, TAVI represents a promising therapeutic option for selected patients with AI, if performed in high-volume centres with extensive experience in the treatment of aortic disease.

MitraClip and repair surgery: comparable results?

Mitral regurgitation (MR) is the most common valvular disease in industrialized countries, with a significant impact on patient quality of life and survival, especially in an increasingly elderly and comorbid population. Repair surgery is considered the treatment of choice for primary MR, offering excellent long-term outcomes. However, the MitraClip system, a less invasive percutaneous option based on the edge-to-edge principle, has proved to be a valid alternative for patients at high surgical risk, showing initial benefits in terms of fewer post-operative complications. Surgery remains superior in terms of durability and prevention of residual regurgitation, but the MitraClip system offers advantages in selected patients, with improvements in quality of life and reductions in hospitalizations for heart failure. A multidisciplinary approach and careful patient selection are essential to optimize outcomes.

Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020).

Diagnosis and Management of Mitral Valve Disease in the Elderly

Calcific mitral stenosis, commonly seen in the elderly in developed countries, occurs primarily due to mitral annular calcification, and its prevalence is increasing secondary to an aging population. Mitral regurgitation, commonly seen across all age groups, occurs primarily due to anatomical or functional impairment of one or more components of the mitral apparatus or the left ventricle that are necessary for normal valve function, and its prevalence is increasing secondary to an increasing number of patients with heart failure. The current review discusses the diagnosis of and treatment options (medical, surgical, and transcatheter) for mitral valve disease, including the associated challenges, specifically in the elderly.

When should the tricuspid valve be repaired during mitral valve repair?

PURPOSE OF REVIEW

Management of tricuspid regurgitation and annular dilation during mitral valve repair remains controversial. We review the latest evidence on indications to repair the tricuspid valve during mitral valve repair and discuss surgical strategies and complications.

RECENT FINDINGS

Concomitant tricuspid valve repair of moderate tricuspid regurgitation is effective in reducing tricuspid regurgitation progression at 2 years, but has not shown benefit to late survival, quality of life, or functional benefit, and is associated with increased permanent pacemaker implantation (PPM) rates, which is associated with reduced late survival. Progression of less than moderate tricuspid regurgitation with annular dilation alone is uncommon, obviating the need for concomitant repair.

SUMMARY

Repairing concomitant moderate tricuspid regurgitation at the time of mitral repair reduces tricuspid regurgitation progression at 2 years, at the cost of a higher PPM implantation rate. However, repairing less than moderate tricuspid regurgitation for annular dilation alone has not been shown to reduce tricuspid regurgitation progression, bringing current guideline recommendations surrounding repair for annular dilation into question. Longer-term follow-up data, at 5 years, will shed further light on this topic.

Comparison of patients with occlusive or hemorrhagic access site complications requiring reintervention after percutaneous transfemoral transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) via transfemoral (TF) access is increasingly integral to aortic valve disease treatment, expanding beyond high-risk patients. Despite technical advancements, access-related vascular complications, occurring in approximately 10% of TAVI procedures, remain a substantial challenge. Objective: This study investigated the clinical and morphological characteristics of percutaneous TF-TAVI patients experiencing occlusive (OC) and hemorrhagic (HC) complications managed with surgical or endovascular reintervention. Methods: The cohort included patients from a Dutch and a German tertiary referral hospital, managed with TF-TAVI procedures between 2017 and 2021 that required reintervention for OC or HC. Demographics, comorbidities, procedural details, and preoperative imaging data were collected and compared between groups. Results: Among 109 TF-TAVI patients, 32 with OC and 77 with HC required reintervention. The OC group presented significantly smaller access arterial diameters (common femoral artery: OC 6.7 mm vs. HC 8.9 mm, p<.001; external iliac artery: OC 7.2 mm vs. HC 8.3 mm, p<.001; common iliac artery: OC 9.4 mm vs. HC 10.5 mm, p=.012) while the HC group presented higher tortuosity index (TI) (OC 1.24 vs. HC 1.30; p=.017). No differences were observed regarding baseline characteristics, vessel calcification or vascular closure device use. Conclusions: In patients requiring reintervention following TF-TAVI, smaller arterial diameters were associated with OC, while higher TI was linked to HC. These findings emphasize the importance of preoperative imaging in developing individualized prevention strategies.

Could SGLT2 inhibitors improve outcomes in patients with heart failure and significant valvular heart disease? Need for action

Delivering valvular intervention for all eligible patients with valvular heart disease (VHD) in a timely manner remains a challenge. Therefore, a high number of patients with heart failure (HF) and VHD receive pharmacotherapy while awaiting intervention or as destination therapy if they are deemed inoperable. The sodium-glucose co-transporter-2 inhibitors (SGLT2i) are recommended with a class I indication for patients with chronic HF throughout the spectrum of left ventricular ejection fraction. However, all randomized trials of SGLT2i in HF patients have consistently excluded patients with significant VHD. Considering the proven benefit of SGLT2i for stable outpatients and acutely hospitalized patients with HF, SGLT2i could potentially be used for patients with HF secondary to significant VHD. This article highlights the unmet need to produce robust clinical evidence for the pharmacological management of patients with HF and significant VHD while summarizing the potential benefit from SGLT2i in the management of these patients.

Clinical Characteristics, Outcomes, and Risk Stratification of Combined Mitral and Tricuspid Regurgitation: The China-VHD Study

BACKGROUND

Combined mitral regurgitation (MR) and tricuspid regurgitation (TR) is related to more complicated hemodynamic burdens than isolated atrioventricular valve regurgitation.

OBJECTIVES

This study aimed to investigate clinical characteristics and outcomes of combined MR and TR, as well as developing dedicated prognostic instruments.

METHODS

A total of 6,704 patients with ≥ moderate MR or TR from the China Valvular Heart Disease study were included in this analysis. The study outcomes included all-cause mortality, death or hospitalization for heart failure, and worsening functional status or death within 2 years.

RESULTS

Compared with those with isolated valvular regurgitation, patients with combined MR and TR more often experienced atrial fibrillation or flutter and pulmonary hypertension. During a median follow-up of 733 days (Q1, Q3: 706, 749 days), 624 (9.3%) deaths occurred. Combined MR and TR was related to poorer 2-year outcomes than isolated MR, and was independently associated with worse prognosis in symptomatic patients (all-cause mortality: MR vs MR+TR, HR: 0.776 [95% CI: 0.616-0.978]; P = 0.031) and those with normal left ventricular systolic function (composite endpoint: HR: 0.629 [95% CI: 0.400-0.990]; P = 0.045). Based on carefully evaluated predictors of mortality, a prognostic nomogram and a risk score were developed and externally validated for patients with combined MR and TR, with superior predictive performance than the MitraScore and comparable discrimination compared with artificial intelligence-derived models.

CONCLUSIONS

Patients with combined MR and TR displayed worse clinical profiles and poorer outcomes compared with those with isolated MR. The novel prognostic tools may improve personalized risk assessment of combined MR and TR.

Atrial Functional Tricuspid Regurgitation: Contemporary Characteristics, Outcomes, and Novel Risk Score

BACKGROUND

Despite increasing clinical recognition of atrial functional tricuspid regurgitation (AF-TR), there remains limited literature regarding the characteristics, outcomes, and adverse prognosticators for this valve lesion.

OBJECTIVES

This study aimed to elucidate clinical and echocardiographic characteristics and outcomes and to develop a novel risk model in a large cohort of patients with significant AF-TR.

METHODS

Consecutive patients with at least moderate-to-severe AF-TR seen between January 2004 and December 2018 were retrospectively studied. Univariable and multivariable logistic regression (OR) were conducted to determine the risk factors and develop novel risk scores for 1-year all-cause mortality.

RESULTS

Among 370 patients with AF-TR (mean age 73.9 ± 15.0 years, 82.2% female; mean follow-up 4.1 ± 3.6 years), 1-year and total mortality occurred in 81 (21.9%) and 219 (59.2%) of patients respectively, with a median survival of 2.5 and 8.5 years for patients with AF-TR effective regurgitant orifice area ≥0.40 and <0.40 cm2. Multivariable analyses identified right heart failure (OR: 2.40; 95% CI: 1.31-4.41), lower serum albumin (OR: 0.88; 95% CI: 0.85-0.92), higher right atrial volume indexed (OR: 1.25; 95% CI: 1.04-1.49), lower tricuspid annular plane systolic excursion/right ventricular systolic pressure ratio (OR: 0.82; 95% CI: 0.70-0.95), and higher TR-effective regurgitant orifice area (OR: 1.11; 95% CI: 1.02-1.21) to be independently associated with 1-year mortality, from which a risk model was derived with good discrimination (area under the curve: 0.87).

CONCLUSIONS

Patients with AF-TR had poor prognosis especially if tricuspid regurgitation effective regurgitant orifice area was ≥0.40 cm2, validating the guidelines threshold for severe tricuspid regurgitation. A novel risk score for 1-year mortality in patients with AF-TR was developed, offering potential utility for risk stratification and treatment guidance; however, external validation is needed.

Prognostic Implications of Guideline-Directed Medical Therapy for Heart Failure in Functional Mitral Regurgitation: A Systematic Review and Meta-Analysis

Objectives: Randomized evidence on the role of heart failure guideline-directed medical therapy for patients with functional mitral regurgitation (FMR) is lacking. The present meta-analysis sought to investigate the prognostic impact of different pharmacotherapy categories recommended in heart failure on subjects with FMR. Methods: A systematic literature review was conducted to identify studies reporting the association of renin angiotensin system inhibitors (RASi), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) with outcomes in FMR. A random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome in each medical category. Results: Twelve studies with 6,715 FMR patients were included. The use of RASi and BB was associated with a significantly lower risk of all-cause mortality (HR 0.52 [0.39-0.68]; p < 0.00001, I2 = 62% and HR 0.62 [0.49-0.77]; p < 0.0001, I2 = 44%, respectively) and the composite outcome (HR 0.54 [0.44-0.67]; p < 0.00001, I2 = 33% and HR 0.62 [0.52-0.75], p < 0.00001, I2 = 35%, respectively) in unadjusted models. Both RASi (aHR 0.73 [0.56-0.95], p = 0.02, I2 = 52%) and BB (aHR 0.60 [0.41-0.88], p = 0.009, I2 = 55%) retained their association with the composite outcome in pooled adjusted models. The prognostic benefit of using RASi or BB was retained in subgroup analyses including only (1) patients with moderate or severe FMR and (2) patients with reduced or mildly reduced left ventricular ejection fraction. MRA did not demonstrate a significant association with improved outcomes. Conclusions: RASi and BB administration appear to have a favorable prognostic impact on patients with FMR, regardless of the severity of regurgitation.

Incidence and predictors of continued ascending aortic dilatation after TAVI in patients with bicuspid aortic stenosis

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) for bicuspid aortic stenosis (AS) frequently present with ascending aortic (AAo) dilatation which is left untreated. The objective of this study was to study the natural progression and underlying mechanisms of AAo dilatation after TAVI for bicuspid AS.

METHODS

Patients with a native bicuspid AS and a baseline AAo maximum diameter > 40 mm treated by TAVI and in whom post-TAVI computed tomography (CT) scans beyond 1 year were available were included. AAo dilatation was deemed to be either continuous (≥ 2 mm increase) or stable (< 2 mm increase or decrease). Uni- and multivariate logistic regression analysis was utilized in order to identify factors associated with continuous AAo dilatation post-TAVI.

RESULTS

A total of 61 patients with a mean AAo maximum diameter of 45.6 ± 3.9 mm at baseline were evaluated. At a median follow-up of 2.9 years, AAo dimensions remained stable in 85% of patients. Continuous AAo dilatation was observed in 15% of patients at a rate of 1.4 mm/year. Factors associated with continuous AAo dilatation were raphe length/annulus mean diameter ratio (OR 4.09, 95% CI [1.40-16.7], p = 0.022), TAV eccentricity at the leaflet outflow level (OR 2.11, 95%CI [1.12-4.53], p = 0.031) and maximum transprosthetic gradient (OR 1.30, 95%CI [0.99-1.73], p = 0.058).

CONCLUSIONS

Ascending aortic dilatation in patients undergoing TAVI for bicuspid AS remains stable in the majority of patients. Factors influencing TAV stent frame geometry and function were identified to be associated with continuous AAo dilatation after TAVI; this should be confirmed in future larger cohort studies.

Concomitant interventions in mitral valve surgery - A European perspective

INTRODUCTION

In recent years, major findings on concomitant procedures and anticoagulation management have occurred in Mitral Valve (MV) surgery. Therefore, we sought to evaluate the current practices in MV interventions across Europe.

METHODS

In October 2021, all national cardio-thoracic societies in the European region were identified following an electronic search and sent an online survey of 14 questions to distribute among their member consultant/attending cardiac surgeons.

RESULTS

The survey was completed by 91 consultant/attending cardiac surgeons across 12 European countries, with 78% indicating MV repair as their specialty area. 57.1% performed >150 operations/year and 71.4% had 10+ years of experience.Concomitant tricuspid valve repair is performed for moderate tricuspid regurgitation (TR) by 69% of surgeons and for mild TR by 26.3%, both with annular diameter >40 mm. 50.6% indicated ischaemic MV surgery in patients undergoing CABG if moderate mitral regurgitation with ERO >20 mm2 and regurgitant volume >30 mL, and 45.1% perform it if severe MR with ERO >40 mm2 and regurgitant volume >60 mL. For these patients the preferred management was: MVR if predictors of repair failure identified (47.2%) and downsizing annuloplasty ring only (34.1%).For atrial fibrillation (AF) in cardiac surgery, 34.1% perform ablation with biatrial lesion and 20% with left sided only. 62.6% perform concomitant Left Atrial Appendage (LAA) Occlusion irrespective of AF ablation with a left atrial clip. A wide variability in anticoagulation strategies for MV repair and bioprosthetic MV valve was reported both for patients in sinus rhythm and AF.

CONCLUSION

These results demonstrate a variable practice for MV surgery, and a degree of lack of compliance with surgical intervention guidelines and anticoagulation strategy.

Non-femoral focused transaxillary access in TAVI: GARY data analysis and future trends

BACKGROUND

In patients not suitable for transfemoral transcatheter aortic valve implantation (TAVI), several access strategies can be chosen.

AIM

To evaluate the use and patient outcomes of transaxillary (TAx), transapical (TA), and transaortic (TAo) as alternative access for TAVI in Germany; to further evaluate surgical cutdown vs. percutaneous TAx access.

METHODS

All patients entered the German Aortic Valve Registry (GARY) between 2011 and 2019 who underwent non-transfemoral TAVI were included in this analysis. Patients with TA, TAo, or TAx TAVI were compared using a weighted propensity score model. Furthermore, a subgroup analysis was performed for TAx regarding the percutaneous or surgical cutdown approach.

RESULTS

Overall, 9686 patients received a non-transfemoral access. A total of 8918 patients (92.1%) underwent TA, 398 (4.1%) TAo, and 370 (3.8%) TAx approaches. Within the TAx subgroup, 141 patients (38.1%) received subclavian cutdown, while 200 (54.1%) underwent a percutaneous approach. The TA patients had a significantly lower 30-day survival than TAx patients (TA 90.92% vs. TAx 95.59%, p = 0.006; TAo 92.22% vs. TAx 95.59%, p = 0.102). Comparing percutaneous and cutdown TAx approaches, no significant differences were seen. However, more vascular complications occurred (TA 1.8%, TAo 2.4%, TAx 12.2%; p < .001), and the hospital length of stay was shorter (TA 12.9 days, TAo 14.1 days, TAx 12 days; p < .001) after TAx access.

CONCLUSION

It may be reasonable to consider TAx access first in patients not suitable for TF-TAVI, because the 30-day survival was higher compared with TA access and the 1-year survival was higher compared with TAo access. It remains important for the heart teams to offer alternative access modalities for patients not amenable to the standard TF-TAVI approaches.

Aortic and mitral structural interventions in the absence of cardiac surgery

Traditionally, structural heart interventions have been performed at heart valve centres with on-site heart surgery to maximize expertise and deal with complications requiring emergent cardiac surgery (ECS). However, at present, only transcatheter aortic-valve implantation (TAVI) must be performed at centres with on-site heart surgery according to current guidelines, while mitral transcatheter edge-to-edge repair, or left appendage atrial occlusion could be performed also in centres without on-site cardiac surgery. Today, ageing of the population and improved results of TAVI have increased the need for such procedures posing strong pressure to traditional heart valve centres, prolonging waiting times for TAVI and increasing access disparities. Fortunately, TAVI procedures have a very low rate of complications, including those necessitating ECS, and observational data suggest that TAVI can be safely performed in centres without on-site cardiac surgery. However, guideline recommendations need randomized clinical trials like the TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial to be updated. The TRACS trial randomizes high-risk symptomatic aortic stenosis patients to treatment by the same operators either at centres with or without on-site cardiac surgery and compares 1-year follow-up. Key issues for structural interventions, in particular TAVI, at centres without on-site surgery are shared indications through heart team evaluation, consistent experiences and competences of non-surgical centres, and strong networking with the Hub centre. The increasing demand for structural heart interventions highlights the need for innovative care models and the careful introduction of a 'Hub-and-Spoke' approach for high-volume heart valve networks could be a study option.

Impact of oncologic diseases on outcome in patients with severe isolated tricuspid regurgitation

BACKGROUND

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Isolated TR, defined as TR without overt heart disease, is typical and offers limited cardiac treatment options other than interventional repair or replacement. Survival history of cancer or active cancer treatment may lead to an unnecessary delay of TR treatment.

METHODS

We included all patients diagnosed with severe TR at the Medical University of Vienna between 2003 and 2016 who had normal left ventricular function and no other valvular lesions. Outcome analysis was performed on cancer type, status and the number of organs affected by cancer.

RESULTS

A total of 973 patients were included. 182 (19%) patients had cancer, 52 were active and 130 had a history of cancer at the time of TR diagnosis. Oncologic patients were divided into subgroups of gastrointestinal, skin, glands, gynaecological, breast, urogenital, lung and other cancers. Ten-year mortality of patients with cancer was higher than those without cancer (p < 0.001). Multivariate analysis adjusting for age did not reveal significantly higher mortality in patients with a history of cancer compared to patients without cancer (p = 0.59). Patients with lung, active, or multi-organ cancer showed the highest mortality.

CONCLUSIONS

Mortality in patients with severe isolated TR is high and increased by active or multi-organ cancer but not by a history of cancer. These patients should be discussed in interdisciplinary cardio-oncology teams to avoid delaying life-saving treatment of TR and cancer.

The Impact of Frailty on VARC-3 Integrated Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

TAVR is preferred over surgical aortic valve replacement in frail patients with aortic stenosis. The assessment of the treatment benefit of TAVR in this population is however equivocal.

OBJECTIVES

The purpose of this study was to investigate the impact of frailty on clinical and patient-reported outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients in the SCOPE I (Safety and Efficacy of the ACURATE Neo/TF Compared to the SAPIEN 3 Bioprosthesis) trial were stratified according to frailty, defined as a multicomponent index that included loss of independence criteria based on activities of daily living, lean body mass, serum albumin, and cognitive impairment or dementia. The outcomes of interest included an endpoint integrating vital and patient-reported disease-specific health status, as well as clinical efficacy according to the Valve Academic Research Consortium (VARC)-3 definition.

RESULTS

Among 739 randomized patients, 122 patients (16.5%) met the definition of frailty. Mean age, comorbidities, and surgical risk were comparable between groups. Patients with and without frailty had similar improvement in patient-reported health status measures after TAVR, while patients with frailty had an increased risk of VARC-3 unfavorable outcome (risk ratio: 1.38, 95% CI: towards reduced VARC-3 clinical efficacy (risk ratio: 0.82; 95% CI: 0.65-1.03) at 3 years after TAVR.

CONCLUSIONS

More than 1 in 6 patients with severe aortic stenosis undergoing TAVR were considered frail in the SCOPE I trial. Patients with frailty had a similar improvement in patient-reported health status measures after TAVR, but a higher risk of unfavorable outcomes throughout 3 years of follow-up.

Perioperative management and inflammatory marker monitoring in a cardiac surgery patient treated with tocilizumab: a case report of successful surgical aortic valve replacement

Background

Interleukin (IL)-6 is associated with wound healing and infection response. Tocilizumab (TCZ) is a monoclonal antibody against the IL-6 receptor, interfering with its signalling pathway. However, reports on patients treated with TCZ undergoing cardiac surgery are limited.

Case summary

A 73-year-old man with Castleman disease, treated with TCZ, underwent surgical aortic valve replacement via median sternotomy for aortic valve regurgitation with exertional shortness of breath. Comprehensive measures for preventing surgical site infection along with close examination were implemented during the perioperative period. Tocilizumab was discontinued 26 days before surgery and resumed 30 days after surgery, during which plasma IL-6 levels decreased. There was no evidence of infection or exacerbation of Castleman disease. Vascular endothelial growth factor levels increased before an increase in C-reactive protein levels following hospital discharge and prior to TCZ resumption.

Discussion

Meticulous perioperative management with a multi-disciplinary approach is crucial during the cessation of TCZ for cardiac surgery. Changes in vascular endothelial growth factor levels may serve as an early predictor of underlying disease exacerbation after TCZ cessation for surgery.

Cerebral blood flow and cognitive functioning in patients undergoing transcatheter aortic valve implantation

Background

Approximately one-third of patients with symptomatic severe aortic valve stenosis scheduled for transcatheter aortic valve implantation (TAVI) have some degree of cognitive impairment. The effect of TAVI on cardiac output, cerebral blood flow (CBF), and cognitive functioning has not been systematically studied.

Methods

CAPITA (NCT05481008) is a prospective longitudinal study assessing cerebral and cognitive outcomes in patients that underwent TAVI between August 2020 and October 2022. At baseline (<24 h before TAVI) and three-month follow-up, patients underwent echocardiography, brain magnetic resonance imaging (MRI), and multidomain neuropsychological assessment. Primary outcome measures were change in CBF (Δml/100 g/min on arterial spin labelling MRI) and change in global cognitive functioning (Δz-scores). Secondary outcomes included cardiac output (L/min), and white matter hyperintensities (mL, number). Differences were tested with paired t-test and associations were tested with linear mixed models.

Findings

A total of 148 patients (80.5 ± 5.7 years, 43% female) underwent TAVI. Three months after TAVI, cardiac output increased from 5.9 ± 1.4 L/min to 6.3 ± 1.4 L/min (mean difference 0.37, 95% CI 0.12-0.62, p = 0.004). CBF increased from 52.2 ± 14.5 mL/100 g/min to 55.9 ± 17.7 mL/100 g/min (mean difference 3.8, 95% CI 1.15-6.36, p = 0.005). Global cognitive functioning also increased from 0.02 ± 0.52 to 0.15 ± 0.49 (mean difference 0.13, 95% CI 0.06-0.20, p < 0.001) with most prominent increase in patients with worst baseline cognitive functioning. Patients with cognitive decline (22%), had a higher volume of new in white matter hyperintensities than patients with stable or improved cognition (78%): 1.26 ± 2.96, vs 0.29 ± 0.45, vs 0.31 ± 0.91 mL (p = 0.06).

Interpretation

In patients with severe symptomatic aortic valve stenosis undergoing TAVI, cardiac output, CBF, and cognitive functioning improved after three months.

Funding

The Heart-Brain Connection crossroad consortium of the Dutch Cardiovascular Alliance. The Netherlands CardioVascular Research Initiative: Dutch Heart Foundation (CVON 2018-28 & 2012-06 Heart Brain Connection).

Incidence, characteristics, and outcome of noncardiac surgery following transcatheter aortic valve implantation

BACKGROUND

Planning noncardiac surgery after transcatheter aortic valve implantation (TAVI) is challenging. We evaluated the incidence, characteristics, and outcome of noncardiac surgeries in patients who underwent TAVI.

METHODS

We retrieved data from the Prospective Segeberg TAVI registry of all patients who received TAVI between 2007 and 2020. Type, timing, urgency, and risk of noncardiac surgery were assessed. We evaluated the patients' clinical outcomes within 30 days following noncardiac surgery that included death, myocardial infarction, bleeding, stroke, and acute heart failure. A composite outcome of all adverse events was proposed to independently predict 30 day adverse events.

RESULTS

Among 1602 patients, 104 patients (mean age, 79.9 ± 7.14 years; 61 (58.7%) females) underwent 148 noncardiac surgeries after TAVI. More than half of the noncardiac surgeries were considered elective (n = 84, 56.7%). Procedures were categorized into low-risk (n = 27, 18.2%), intermediate-risk (n = 102, 68.9%), and high-risk (n = 19, 12.8%) surgery. The composite outcome of adverse events occurred after 57 noncardiac surgeries (38.5% of all procedures) and after more than half of the surgeries in the high-risk group (n = 11, 57.9%). Major or life-threatening bleeding occurred in 24 noncardiac surgeries (19.1%) and was more frequent in high-risk surgeries than in low- and intermediate-risk surgeries (36.8%, p < 0.047). High-risk category of surgery was independently associated with increased risk of the composite outcome (adjusted OR, 3.99; 95% CI 1.12-14.23; p = 0.033).

CONCLUSION

Noncardiac surgery after TAVI was performed in 6.5% patient of our study cohort. High-risk noncardiac surgeries were associated with increased risk of adverse events.

Stroke volume index (SVI) predicts all-cause mortality following transcatheter aortic valve replacement (TAVR)

BACKGROUND

Left ventricular systolic dysfunction in patients with severe aortic stenosis (AS) may result in low transvalvular gradients and underestimation of AS severity. A low-flow state may occur with reduced LVEF. Little is known about the implications of low compared to normal flow in patients with reduced LVEF undergoing transcatheter aortic valve replacement (TAVR).

OBJECTIVES

We compared survival rates with degree of flow across stenosed aortic valves and left ventricular dysfunction. We hypothesized that the stroke volume index (SVI) offers essential information regarding survival following TAVR.

METHODS

We retrospectively reviewed patients with LVEF <50 % undergoing TAVR at the Gates Vascular Institute in Buffalo, New York, from 2012 to 2017. We performed Receiver Operator Characteristics to examine the value of SVI in predicting the postoperative outcome of patients. Kaplan-Meier and Cox regression analyses were used to investigate the effect of a low-flow state on five-year survival in patients with systolic dysfunction undergoing TAVR.

RESULTS

Five-year survival following TAVR was decreased in patients with low-flow AS (SVI <35 mL/m2) compared to patients with normal flow. Seventy-four percent (n = 50) of patients with low-flow compared to 43 % (n = 22) of patients with normal flow were deceased five years post-TAVR (p ≤0.001). ROC curve indicated SVI to be a clinical predictor of five year survival (AUC 0.732, 95 % CI: 0.641-0.823, p < 0.001).

CONCLUSION

Patients with systolic dysfunction and low transvalvular flow AS had increased mortality five years following TAVR. These findings highlight a better prognosis in patients with normal flow and LV systolic dysfunction.

CONDENSED ABSTRACT

Low-flow aortic stenosis can occur with reduced left ventricular function. We compared survival rates of patients with known reduced left ventricular function in low-flow and normal flow aortic stenosis. This retrospective single-center study examined mortality rates following transcatheter aortic valve replacement. The mean gradient was not a predictor of mortality. This study shows patients with low-flow aortic stenosis have decreased five-year survival following valve replacement.

Incidence and Pathology of Aortic Regurgitation

Aortic regurgitation (AR) is the third most common valvular heart disease, with its prevalence and severity increasing with age. AR can arise from degenerative, congenital, inflammatory and infectious aetiologies, manifesting as primary AR with intrinsic leaflet disease, secondary AR due to aortopathy or annular dilatation, or a combination. Furthermore, AR can be acute, as observed in endocarditis and aortic dissection, or chronic, as seen in calcific aortic valve disease, connective tissue disorders, or bicuspid valve phenotypes. This review discusses the aetiopathology of these various AR manifestations (primary, secondary, acute and chronic AR), highlighting diagnostic challenges and implications for aortic valve replacement and transcatheter aortic valve implantation.

Mixed valvular heart disease: diagnosis and management

Mixed valvular diseases (MVDs) are common but have received little attention in the literature, especially regarding the mitral valve (MV) and the right-sided cardiac valves. Whereas echocardiography plays a pivotal diagnostic role, the diagnosis is made difficult due to haemodynamic interactions that may invalidate common indices of severity used in isolated stenosis or regurgitation. The diagnostic strategy should aim at initially separately assessing stenosis and regurgitation, taking into account the diagnostic pitfalls, with complementary use of multimodality imaging in cases of persisting diagnostic uncertainties. Unlike aortic stenosis, the calcium score cannot be used as a surrogate for haemodynamic severity of mixed MV disease. Severe stenosis and/or severe regurgitation are indicative of severe MVD, and management should follow recommendations on the predominant lesion. However, some patients with the combination of moderate stenosis and moderate regurgitation have a poor prognosis when left untreated. Concordant data suggest that, in patients with mixed aortic or MV disease, transvalvular velocities and pressure gradients are more powerful prognostic indicators than valve area or the severity of regurgitation. It is essential to consider the global repercussions that indicate poor outcomes in patients with MVD. However, whereas symptoms and/or ventricular dysfunction are considered as clear indication for intervention, imaging cut-offs have not been validated for balanced moderate regurgitation and stenosis. Although emerging evidence tends to support earlier management, further prospective studies are required, and pending the results of these studies, asymptomatic patients with MVD should be closely monitored.

Association of Cardiac Damage and Computed Tomography-Derived Extracellular Volume in Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

Extravalvular cardiac damage (EVCD) and extracellular volume (ECV) are key determinants of poor outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). We aimed to assess the association of ECV derived by means of cardiac computed tomography (CT) with EVCD before and after TAVI, its impact on left ventricular reverse remodelling, and functional improvements at 3-month follow-up in patients with severe AS undergoing TAVI.

METHODS

This was a prospective study of 73 consecutive patients undergoing TAVI, with CT-derived ECV assessment and baseline and follow-up echocardiographic evaluation of EVCD. After identifying the best ECV cutoff for predicting EVCD progression and advanced EVCD (stages 3-4) at follow-up according to the Youden index, patients were divided into low (n = 39) and high (n = 34) ECV groups. Predictors of EVCD progression, advanced EVCD, and functional improvements at follow-up were identified by means of logistic regression analysis.

RESULTS

At 3-month follow-up, 34.2% of patients showed EVCD progression. ECV ≥ 32% accurately predicted EVCD progression and stages 3-4 (area under the receiver operating characteristic curve 0.66, P < 0.001). At follow-up, patients with high ECV were more frequently in stages 3-4 (P = 0.011) and had a 50% progression rate (P = 0.012). Conversely, patients with low ECV exhibited greater LV reverse remodelling (P = 0.004) and improvement in New York Heart Association (NYHA) functional class at both 3-month (P = 0.020) and 6-month (P = 0.001) follow-ups compared with patients with high ECV. High ECV emerged as an independent predictor of EVCD progression (odds ratio [OR] 4.34, 95% CI 1.36-13.78, P = 0.013), stages 3-4 (OR 5.71, 95% CI 1.77-18.42, P = 0.004) and lack of improvement in NYHA functional class (OR 3.22, 95% CI 1.14-9.09, P = 0.027) at 3-month follow-up.

CONCLUSIONS

Elevated CT-derived ECV was associated with EVCD progression and reduced functional improvement after TAVI.

The efficiency of endocardial suture occlusion of the left atrial appendage at a single institution: MICs vs. sternotomy

BACKGROUND

Most thrombi originate from the left atrial appendage (LAA), preventing thromboembolic stroke is an important aspect of stroke prevention. Previous studies have found that LAA closure is beneficial for preventing thrombosis. Currently, surgical procedures can achieve LAA closure by closing the endocardium or epicardium. LAA endocardial suture technique is performed concomitantly during sternotomy cardiac surgery but can also be performed during right minimally invasive cardiac surgery (MICS).

AIMS

This study aims to evaluate the efficacy of left atrial appendage closure (LAAC) with MICS.

METHODS

A total number of 74 patients who underwent LAAC during valve operation between 2017 and 2021 were retrospectively analyzed in this study. LAA was closed by continuous suture through the endocardium of the left atrium during cardiac surgery. 42 patients performed LAA endocardial suture during MICS, while 32 patients performed with the same LAAC technique during sternotomy. Patients underwent cardiac computed tomography (CT) follow-up after surgery to verify the completeness of the LAAC. The heart structure and function were recorded by echocardiography Transthoracic echocardiography (TTE), and the heart rhythm was recorded by electrocardiogram.

RESULTS

The LAA closure procedure was successful in 26 cases (81%) in the sternotomy group and 20 cases (48%) in the right minimally invasive group. Residual shunting (failed LAA closure) was more common in the right minimally invasive group (p = 0.003), and no correlation was found between residual shunting and left atrial (LA), left ventricular end-diastolic diameter (LVDD), and left ventricular ejection fraction (LVEF). The incidence of leaks was not associated with mitral valve replacement or valvuloplasty.

CONCLUSIONS

Compared to sternotomy, residual shunting after MICS was more common. CT imaging analysis of 22 patients with failed closure in the MICS group showed that residual shunting was mainly concentrated on margins of the suture (anterior superior and posterior inferior) (86%), with a middle area accounting for 3 (14%). Based on this finding, reinforcing the suture margins may significantly reduce the incidence of incomplete closure.

THE CLINICAL TRIAL NUMBER

KY-2023-001.

A Chinese patient with cardiogenic stroke and warfarin resistance: a case report

BACKGROUND

Warfarin is the most commonly used oral anticoagulant drug in clinical practice due to its effective anticoagulant effect and low cost. Warfarin plays a crucial role in the anticoagulant treatment of patients with thrombotic diseases such as atrial fibrillation, heart valve replacement, and deep vein thrombosis. In general, low-dose warfarin can effectively achieve the optimal international normalized ratio (INR) for patients requiring anticoagulation therapy. In some cases, patients may require significantly higher doses of warfarin to achieve an INR in the desired range; failure to achieve this is commonly referred to as warfarin resistance. We report a rare case of cerebral infarction caused by atrial fibrillation and warfarin resistance in China.

CASE PRESENTATION

A Chinese patient with atrial fibrillation complicated by cerebral infarction had been taking warfarin for 2 years, and the dose was gradually increased to 12.5 mg per day; however, the INR remained below the standard. The patient was considered to be resistant to warfarin. The cause of warfarin resistance in this patient is unknown, but we speculate that pharmacodynamic and genetic factors may be involved. Finally, we chose to replace warfarin with rivaroxaban to avoid the risk of bleeding at high doses. To date, there has been no bleeding or infarcts since the patient was discharged. In cases where the cause of warfarin resistance cannot be determined, alternative drugs may be more appropriate.

CONCLUSIONS

When considering warfarin resistance, it is important to actively search for the cause of resistance early on. If the cause is determined, appropriate measures should be taken. If the cause is not determined or cannot be resolved, the dose can be gradually increased under close monitoring, alternatives can be actively adopted, and patients can be informed and educated.

Non-vitamin K antagonist oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR): a network meta-analysis

BACKGROUND

Balancing the risk of thromboembolism and bleeding after transcatheter aortic valve replacement (TAVR) remains clinically challenging. Questions regarding the efficacy and safety of non-vitamin K oral anticoagulants (NOACs) after TAVR still need to be definitively answered.

OBJECTIVES

To evaluate the efficacy and safety of NOACs after TAVR in individuals with and without indication for anticoagulation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, ClinicalTrials.gov, and WHO ICTRP on 7 October 2023 together with reference checking and citation searching to identify additional studies.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) that compared NOACs versus antiplatelet therapy or vitamin K antagonists (VKAs) after TAVR in adults with or without an indication for anticoagulation.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and conducted random-effects pair-wise analyses and network meta-analyses (NMAs). Our primary outcomes were all-cause mortality, cardiovascular mortality, stroke, and major bleeding. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included four RCTs with 4808 participants in the NMA. Of these, one compared rivaroxaban versus antiplatelet therapy in people without an indication for anticoagulation after TAVR; one compared apixaban versus antiplatelet therapy in people without an indication for anticoagulation or versus VKA in people with an indication for anticoagulation after TAVR; one compared edoxaban versus VKA in people with an indication for anticoagulation after TAVR; and one compared edoxaban with antiplatelet therapy in people without an indication for anticoagulation after TAVR. The mean age of trial participants was 81 years. Follow-up duration ranged from 6 to 18 months. Overall, we judged the risk of bias in the included trials to be low in all domains except for blinding, which was assessed as high in all four studies. No studies evaluated dabigatran. In people without an indication for anticoagulation, rivaroxaban and apixaban may increase all-cause mortality after TAVR as compared to antiplatelet therapy (rivaroxaban: risk ratio (RR) 1.67, 95% confidence interval (CI) 1.13 to 2.46; studies = 1, participants = 1644; moderate-certainty evidence; apixaban: RR 1.71, 95% CI 0.97 to 3.02; studies = 1, participants = 1049; low-certainty evidence), while edoxaban may result in little or no difference (RR 1.59, 95% CI 0.27 to 9.36; studies = 1, participants = 229; low-certainty evidence). Low-certainty evidence suggests little or no difference between rivaroxaban, apixaban, or edoxaban and antiplatelet therapy in cardiovascular mortality (rivaroxaban: RR 1.28, 95% CI 0.78 to 2.10; studies = 1, participants = 1644; apixaban: RR 1.30, 95% CI 0.64 to 2.65; studies = 1, participants = 1049; edoxaban: RR 7.44, 95% CI 0.39 to 142.38; studies = 1, participants = 229) and between rivaroxaban or edoxaban and antiplatelets in stroke (rivaroxaban: RR 1.19, 95% CI 0.71 to 2.00; studies = 1, participants = 1644; edoxaban: RR 1.06, 95% CI 0.15 to 7.42; studies = 1, participants = 229). While rivaroxaban versus antiplatelets probably increases major bleeding after TAVR (RR 1.98, 95% CI 1.07 to 3.65; studies = 1, participants = 1644; moderate-certainty evidence), there may be little or no difference between apixaban and antiplatelet therapy (RR 1.07, 95% CI 0.70 to 1.64; studies = 1, participants = 1049; low-certainty evidence). It is unclear if edoxaban has an effect on major bleeding, although the point estimate suggests increased bleeding (versus antiplatelets: RR 2.13, 95% CI 0.54 to 8.30; studies = 1, participants = 229; low-certainty evidence). In people with an indication for anticoagulation, low-certainty evidence suggests apixaban or edoxaban may result in little to no difference in our predefined primary efficacy outcomes after TAVR when compared to VKA (all-cause mortality: apixaban: RR 1.02, 95% CI 0.59 to 1.77; studies = 1, participants = 451; edoxaban: RR 0.91, 95% CI 0.69 to 1.20; studies = 1, participants = 1426; cardiovascular mortality: apixaban: RR 1.43, 95% CI 0.76 to 2.70; studies = 1, participants = 451; edoxaban: RR 1.07, 95% CI 0.72 to 1.57; studies = 1, participants = 1426; stroke: apixaban: RR 1.28, 95% CI 0.35 to 4.70; studies = 1, participants = 451; edoxaban: RR 0.83, 95% CI 0.51 to 1.34; studies = 1, participants = 1426). While apixaban may result in a similar rate of bleeding as VKA in this population, edoxaban probably increases major bleeding after TAVR in people with an indication for anticoagulation (apixaban: RR 0.90, 95% CI 0.53 to 1.54; studies = 1, participants = 451; low-certainty evidence; edoxaban: RR 1.44, 95% CI 1.08 to 1.93; studies = 1, participants = 1426; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

In people without an indication for oral anticoagulation, rivaroxaban and apixaban may increase all-cause mortality when compared to antiplatelet therapy, while edoxaban may result in little or no difference. There might be little or no difference between rivaroxaban, apixaban, or edoxaban and antiplatelet therapy in cardiovascular mortality, and between rivaroxaban or edoxaban and antiplatelets in stroke. While rivaroxaban probably increases major bleeding following TAVR, there might be little or no difference between apixaban and antiplatelet therapy, and the effect of edoxaban on major bleeding remains unclear. In people with an indication for anticoagulation, apixaban and edoxaban may be as effective as VKA in preventing all-cause mortality, cardiovascular death, and stroke. Apixaban may lead to a similar rate of major bleeding as VKA in this population. However, edoxaban probably increases major bleeding following TAVR when compared to VKA. Our NMA did not show superiority of one NOAC over another for any of the primary outcomes. Head-to-head trials directly comparing NOACs against each other are required to increase the certainty of the evidence.

Low-Gradient Severe Aortic Stenosis: Insights From the CURRENT AS Registry-2

BACKGROUND

Low-gradient (LG) aortic stenosis (AS) has not been fully characterized compared with high-gradient (HG) AS in terms of cardiac damage, frailty, aortic valve calcification, and clinical outcomes.

OBJECTIVES

The aim of this study was to compare the clinical characteristics and outcomes between each hemodynamic type of LG AS and HG AS.

METHODS

The current study included 3,363 patients in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) Registry-2 after excluding patients without indexed stroke volume or left ventricular ejection fraction (LVEF) data. Patients were divided into 4 groups (LG AS with reduced LVEF: n = 285; paradoxical low flow, low gradient [LFLG]: n = 220; normal flow, low gradient [NFLG]: n = 872; HG: n = 1,986).

RESULTS

Compared with HG AS, LG AS with reduced LVEF more often had cardiovascular comorbidities, advanced cardiac damage, and frailty with less severe valve calcification and paradoxical LFLG AS more often had atrial fibrillation, advanced cardiac damage, and frailty with less severe valve calcification, while NFLG AS had comparable cardiac damage and frailty with less severe valve calcification. Cumulative 3-year incidence of death or heart failure hospitalization was higher in LG AS with reduced LVEF and paradoxical LFLG than in HG AS. After adjusting for confounders, LG AS with reduced LVEF and paradoxical LFLG compared with HG AS were independently associated with higher risk for death or heart failure hospitalization (HR: 1.82; 95% CI: 1.49-2.23; P < 0.001; and HR: 1.43; 95% CI: 1.13-1.82; P = 0.003, respectively) but NFLG AS was not (HR: 1.03; 95% CI: 0.88-1.21; P = 0.68).

CONCLUSIONS

Clinical outcomes were significantly worse in LG AS with reduced LVEF and paradoxical LFLG AS and comparable in NFLG AS compared with HG AS.

Novel Circulating Biomarkers in Aortic Valve Stenosis

The underlying pathophysiology of aortic stenosis and factors affecting its clinical progression remain poorly understood. Apart from B-type natriuretic peptide (BNP), novel and emerging biomarkers have been described in association with aortic stenosis, emphasising the potential for these biomarkers to illuminate on yet unknown mechanisms of its pathogenesis. In this review, we aimed to summarise what is known about aortic stenosis biomarkers, highlight the emerging ones, and provide a roadmap for translating these insights into clinical applications. Among the biomarkers studied, lipoprotein(a) [Lp(a)] has emerged as the most promising for risk stratification. Elevated Lp(a) levels are often associated with more rapid aortic stenosis progression. This detrimental effect is attributed to its role in promoting valve calcification. While other emerging biomarkers such as matrix metalloproteinases, monocytes, and metabolites show promises, their specific roles in aortic stenosis pathophysiology remain less clear. This may be due to their relatively recent discovery. Ongoing research aims to elucidate their mechanisms of action.

Contemporary risk models for transcatheter aortic valve replacement: A narrative review

Aortic stenosis (AS) is the most common form of valvular heart disease in older adults requiring intervention. Severe symptomatic AS, if left untreated, is typically associated with a poor prognosis. Over the past two decades, there have been significant advances in the field of transcatheter aortic valve replacement (TAVR), leading to its emergence as an alternative to the well-established surgical aortic valve replacement (SAVR) for treating severe AS. Multiple randomized clinical trials have demonstrated comparable efficacy and safety outcomes of TAVR vs SAVR in high, intermediate, and low-risk surgical candidates. In the process, multiple risk scores, both traditional surgical and TAVR-specific, have been developed to better risk stratify patients as well as guide periprocedural management and patient counseling. This review aims to discuss the currently available risk models for risk prediction in TAVR patients, highlighting their strengths, limitations, and applicability to different patient populations.

Recent Advances on the Prevention and Management of Rheumatic Heart Disease

The global burden of rheumatic heart disease (RHD) remains substantial, particularly in low-income countries, despite advancements in prevention and management strategies. This article emphasizes the strategies related to primordial prevention, primary prevention, and secondary prevention, including recent advancements in vaccine development, and discusses current challenges in management and future research directions. For treatment, it evaluates percutaneous mitral commissurotomy, mitral valve repair, and replacement, noting the advantages of individualized approaches based on patient conditions. Addressing RHD's global burden requires equitable access to surgical treatments, robust healthcare systems, and sustainable strategies for prevention and care.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aortic Valve Replacement Versus Conservative Management in Patients With Asymptomatic Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aortic valve replacement (AVR) is recommended for symptomatic severe aortic stenosis (AS) patients. However, evidence of its role in asymptomatic patients with severe AS remains controversial. Hence, a systematic review and meta-analysis of randomized controlled trials comparing AVR to conservative management in patients with asymptomatic severe AS was conducted. A systematic literature search was performed on electronic databases including MEDLINE (via PubMed), Embase, and Cochrane CENTRAL Library until November 2024. A random effects model was used to pool individual risk ratios (RRs) with their corresponding 95% confidence intervals (CIs) using Review Manager Version 5.4.1 to calculate pooled effect estimates. Three randomized controlled trials with 1203 patients (42% females) were included. On pooled analysis, AVR significantly reduced the risk of hospitalization for heart failure (RR = 0.11, CI: 0.02-0.56, P = 0.008) compared with conservative care. However, there were no significant differences between the 2 groups in all-cause mortality (RR = 0.63, CI: 0.36-1.11, P = 0.11), stroke (RR = 0.59, CI: 0.35-1.01, P = 0.05), myocardial infarction (RR = 0.43, CI: 0.06-2.92, P = 0.38), or thromboembolic events (RR = 0.54, CI: 0.13-2.29, P = 0.40). In asymptomatic patients with severe AS, AVR significantly reduces the risk of hospitalization due to heart failure, with comparable risks in terms of all-cause mortality, myocardial infarction, stroke, and thromboembolic events compared with conservative management.

An Integrative Machine Learning Model for Predicting Early Safety Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation

Background: Early safety outcomes following transcatheter aortic valve implantation (TAVI) for severe aortic stenosis are critical for patient prognosis. Accurate prediction of adverse events can enhance patient management and improve outcomes. Aim: This study aimed to develop a machine learning model to predict early safety outcomes in patients with severe aortic stenosis undergoing TAVI. Methods: We conducted a retrospective single-centre study involving 224 patients with severe aortic stenosis who underwent TAVI. Seventy-seven clinical and biochemical variables were collected for analysis. To handle unbalanced classification problems, an adaptive synthetic (ADASYN) sampling approach was used. A fined-tuned random forest (RF) machine learning model was developed to predict early safety outcomes, defined as all-cause mortality, stroke, life-threatening bleeding, acute kidney injury (stage 2 or 3), coronary artery obstruction requiring intervention, major vascular complications, and valve-related dysfunction requiring repeat procedures. Shapley Additive Explanations (SHAPs) were used to explain the output of the machine learning model by attributing each variable's contribution to the final prediction of early safety outcomes. Results: The random forest model identified left femoral artery diameter and aortic valve calcification volume as the most influential predictors of early safety outcomes. SHAPs analysis demonstrated that smaller left femoral artery diameter and higher aortic valve calcification volume were associated with poorer early safety prognoses. Conclusions: The machine learning model highlights of early safety outcomes after TAVI. These findings suggest that incorporating these variables into pre-procedural assessments may improve risk stratification and inform clinical decision-making to enhance patient care.

Impact of Tricuspid Regurgitation on Atrial Fibrillation Recurrence After Pulmonary Vein Isolation

BACKGROUND

The impact of tricuspid regurgitation (TR) on the outcomes of pulmonary vein isolation (PVI) for atrial fibrillation (AF) remains unclear. While the effects of mitral regurgitation (MR) on PVI outcomes are well-documented, there are limited data on how moderate or greater TR influences PVI efficacy and recurrence rates.

OBJECTIVES

The aim of this study was to assess the impact of moderate or greater TR on the outcomes of PVI, particularly focusing on AF recurrence rates within the first year post-PVI.

METHODS

We conducted an observational cohort study involving 421 patients undergoing their first PVI. 96 patients with moderate or greater TR were propensity score-matched with 96 controls based on age, sex, body mass index, and MR severity. Procedural parameters, complication rates, and AF recurrence within 1-year post-PVI were analyzed.

RESULTS

Despite comparable procedural parameters and low overall complication rates between the groups, patients with moderate or greater TR experienced significantly higher AF recurrence rates within the first year after PVI. Right atrium (RA) area was notably larger in these patients, suggesting a potential link between RA remodeling and increased AF recurrence.

CONCLUSIONS

Our findings indicate that moderate or greater TR is associated with higher recurrence rates of AF after PVI, potentially due to RA enlargement and remodeling. This highlights the need for tailored ablation strategies that consider the RA substrate and/or TR treatment in patients with significant TR and AF. Further multicenter, prospective studies are required to validate these results and explore long-term outcomes.

Multiparametric Outcome Assessment After Transcatheter Aortic Valve Implantation-A Systematic Review

Backround/Objectives: Aortic stenosis (AS) is the most commonly acquired valvular disorder. Patient risk stratification and the development of an accurate and reliable tool are crucial in identifying suitable candidates for TAVI. The present review summarized the current state of knowledge on the influence of selected factors on the outcomes and course of patients with AS undergoing transcatheter aortic valve implantation (TAVI). Methods: The inclusion criteria for the present systematic review were as follows: (1) studies indexed in the medical databases PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus; (2) full-text articles available in English; (3) papers published between 2013 and 2023; and (4) addressing the topic of assessing the impact of factors on the outcomes of patients with aortic stenosis undergoing TAVI. This review used PRISMA 2020 reporting guidelines for systematic reviews and meta-analyses. Results: One hundred and thirty-two studies were eligible for this review. The available studies showed an association of psychosocial and socioeconomic factors, valve parameters, comorbidities, clinical factors, treatment-related factors, biomarkers, and treatment methods with the outcomes of patients with AS undergoing TAVI. Conclusions: Given the conflicting results obtained regarding the impact of right ventricular dysfunction, paravalvular leaks, and treatment method on the mortality of patients undergoing aortic valve implantation, further research in these areas is needed. In view of the researchers' differing views on some of the factors affecting patient outcomes after TAVI, further analysis is needed to develop a new tool for assessing predictive outcomes in AS patients. This study is registered at PROSPERO (CRD42024612752).

Association between periprocedural cerebral desaturation during transcatheter aortic valve implantation and postprocedural delirium: a prospective observational study

BACKGROUND

The aim of this study was to investigate whether the level of decrease in cerebral oxygen saturation during the valve placement phase of the transcatheter aortic valve implantation (TAVI) procedure under sedation has an effect on postoperative delirium (POD).

METHODS

The study initially assessed 50 patients between the ages of 50 and 90 years with an indication for TAVI by the cardiac team. Regional cerebral oxygen saturation (rScO2) was measured using Near-infrared spectroscopy (NIRS) before the procedure (T1), during surgical field sterilization (T2), catheter placement (T3), wire manipulation (T4), valve placement (T5) and access site artery repair (T6). Confusion Assessment Method for The Intensive Care Unit (ICU-CAM) test was performed on intensive care unit and the presence of POD was questioned. Patients were divided into two groups as those without POD (Group 1) and those with POD (Group 2).

RESULTS

The study was completed with 41 patients in total. While POD was present in 12 (29.3%) of the patients evaluated intensive care unit, POD was not observed in 29 (70.7%) patients. The rScO2 value measured at T5 was significantly lower in Group 2 compared to Group 1 (p < 0.001).

CONCLUSIONS

In our study, the rate of POD after TAVI was as high as 29.3%. Low rScO2 during valve placement was associated with delirium. Our findings indicate that NIRS devices could be a useful tool for assessing the risk of POD during the TAVI procedure; however, further research is needed to validate their routine clinical use.

Sex-Specific Association of Myocardial Fibrosis With Mortality in Patients With Aortic Stenosis

Importance

Myocardial fibrosis in aortic stenosis (AS) may exhibit sex differences. However, its prognostic significance in women with AS remains unclear.

Objective

To investigate sex differences in myocardial fibrosis assessed by cardiovascular magnetic resonance (CMR) and evaluate its prognostic value in women and men with AS.

Design, Setting, and Participants

Patients with severe AS who underwent CMR before aortic valve replacement (AVR) were prospectively enrolled from 13 international sites between March 2011 and September 2021. Myocardial fibrosis was evaluated using extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The main analysis was conducted on patients without obstructive coronary artery disease (CAD), defined as those with no history of myocardial infarction and no concomitant coronary artery bypass grafting. Data were analyzed from December 2023 to February 2024.

Exposures

Surgical or transcatheter AVR.

Main Outcomes and Measures

The primary outcome was post-AVR all-cause mortality and the secondary outcome was cardiovascular mortality.

Results

Of 822 patients, 670 were without obstructive CAD (368 men [55%] and 302 women [45%]). Among these, women and men had a similar age (median, 72 years vs 71 years, respectively), comorbidities, and AS severity. ECV% was similar between sexes; however, women had less LGE (both infarct and noninfarct LGE). After a median follow-up of 3.7 (IQR, 2.1-4.7) years, there were 76 deaths (11.3%), including 29 adjudicated cardiovascular deaths, in patients without obstructive CAD. Increasing ECV% and LGE were associated with higher all-cause and cardiovascular mortality in both sexes. Cox analyses demonstrated that both ECV% and LGE were associated with higher all-cause mortality without significant interaction by sex (women: adjusted hazard ratio [HR], 1.08 per 1% ECV% increase; 95% CI, 1.04-1.12; P < .001; men: adjusted HR, 1.01; 95% CI, 0.96-1.06; P = .66; P for interaction by sex = .09 and women: adjusted HR, 2.49 for the presence of LGE; 95% CI, 1.07-5.80; P = .03; men: adjusted HR, 1.82; 95% CI, 1.00-3.32; P = .04; P for interaction by sex = .68). In the entire population (n = 822), both noninfarct and infarct-related LGE were associated with increased mortality without significant interaction by sex.

Conclusions and Relevance

In this study, patients with severe AS who underwent AVR exhibited similar ECV% between sexes, while women had lower LGE. Increased myocardial fibrosis provided important prognostic value for both sexes.

Direct Oral Anticoagulants Compared With Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease Without Mechanical Valves

BACKGROUND

Despite proven efficacy and safety of direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), data on patients with AF and valvular heart disease remain scarce. We aimed to evaluate the DOACs compared with warfarin among patients with AF and valvular heart disease.

METHODS AND RESULTS

We conducted a retrospective cohort study of patients ≥18 years of age, who had AF and valvular heart disease, and were new users of DOACs or warfarin. The primary effectiveness outcomes were ischemic stroke or systemic embolism, and bleeding for safety. We used Cox proportional-hazards regression after propensity score matching to estimate hazard ratios (HRs) and 95% CIs. In the matched cohort, DOAC use (versus warfarin) was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.70 [95% CI, 0.61-0.81]) and bleeding (HR, 0.72 [95% CI, 0.65-0.80]). We found a lower rate of ischemic stroke or systemic embolism with rivaroxaban (HR, 0.74 [95% CI, 0.62-0.89]) and apixaban (HR, 0.62 [95% CI, 0.52-0.74]) but not dabigatran (HR, 0.89 [95% CI, 0.63-1.26]). We found a lower rate of bleeding with rivaroxaban (HR, 0.84 [95% CI, 0.74-0.95]), apixaban (HR, 0.60 [95% CI, 0.53-0.68]), dabigatran (HR, 0.75 [95% CI, 0.58-0.97]), and edoxaban (HR, 0.21 [95% CI, 0.05-0.83]). We were unable to obtain estimates for the effectiveness outcome with edoxaban due to the small number of events.

CONCLUSIONS

In this study of patients with AF and valvular heart disease, DOAC treatment was associated with a lower risk of ischemic stroke or systemic embolism and bleeding compared with warfarin.

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Practice Change in Surgical Treatment Strategies for Ischaemic Mitral Regurgitation and Late Outcomes

BACKGROUND

Ischaemic mitral regurgitation (IMR) results from dysfunctional myocardial remodelling, which portends a poor clinical prognosis. This study assessed the surgical treatment of IMR and its associations with clinical and echocardiographic outcomes in the context of 2014 reports suggesting non-surgical management of non-severe IMR.

METHOD

Patients who underwent mitral valve (MV) procedures for IMR at Liverpool Hospital (Sydney, Australia) between 2008 and 2020 were included based on coronary disease and echocardiographic criteria. Data were obtained from patient records and linkage with the Australian Institute of Health and Welfare National Death Index. The primary outcome was the type of MV surgery performed in 2008-2014 and 2015-2020. Secondary outcomes were survival and freedom from combination of mortality and congestive heart failure (CHF) readmission, comparing MV repair and MV replacement and the outcomes for two periods by MV procedure.

RESULTS

Of 106 patients treated surgically for IMR, 78 had MV repair (59 in 2008-2014, 19 in 2015-2020) and 28 had MV replacement (14 in 2008-2014, 14 in 2015-2020). Patients were followed up for 7.2 years (interquartile range 5.2-9.1). Compared to 2008-2014, there was a reduced proportion of MV procedures for IMR (4.2% and 2.0%; p<0.001) and MV repair for IMR (80.8% and 57.6%; p=0.012) post-2014. Freedom from a combination of mortality and CHF readmission over 10 years was significantly better in the MV repair than in the MV replacement group (log rank p<0.001). Over 5 years, freedom from mortality and the combination of mortality and CHF readmission were similar in both periods (log rank p=0.675 and p=0.433). In the earlier period, freedom from combined outcome was better in the MV repair group than the MV replacement group (log rank p<0.001) but not different in the second period (log rank p=0.149). Mitral regurgitation recurrence was less in the later period (25.8% and 3.6%; p=0.013).

CONCLUSIONS

The proportion of MV procedures and MV repairs performed for IMR declined significantly after 2014, indicating a significant change in practice towards conservative surgical correction of IMR. The combined long-term outcomes were unchanged after the change in practice, but the incidence of mitral regurgitation recurrence was significantly improved.

Cardiovascular magnetic resonance imaging in mitral valve disease

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

Combined Mitral and Aortic Valve Surgery Through a Right Minithoracotomy: A Single-Center Experience

OBJECTIVE

Minimally invasive combined mitral and aortic valve surgery is still uncommon. We report our experience performing multiple valve procedures through a right-sided minithoracotomy.

METHODS

We present an observational case series with a retrospective analysis of 38 patients who underwent double valve surgery through right anterior thoracotomy from November 2013 to November 2023.

RESULTS

The median age of our population was 72 years, and 61% were female patients. The median EuroSCORE II was 2.27. Three patients (7.9%) had redo operations. The median cardiopulmonary bypass (CPB) and cross-clamp times were 98 and 85 min, respectively. No conversion to full sternotomy was necessary. In-hospital mortality was 2.6% (1 patient); the patient died of septic shock and consequent multiorgan failure. Of the patients, 53% required transfusions with packed blood cells. Postoperative atrial fibrillation was observed in 12 patients (32%), and 2 patients (5.2%) required pacemaker implantation due to third-degree atrioventricular block. Also, 1 stroke (2.6%) and 1 rethoracotomy for bleeding were observed. The median ventilation time was 10 h. The median intensive care unit and postoperative length of stay were 2 days and 7.5 days, respectively. Survival at 1, 3, 5, and 10 years was 93.8%, 86.3%, 86.3%, and 77.2%, respectively, with a median follow-up time of 6.5 years. Freedom from reintervention at 1, 3, 5, and 10 years was 96.8%, 89.5%, 85.0%, and 69.5%, respectively, with a median follow-up time of 5.7 years.

CONCLUSIONS

In our experience, a minimally invasive approach for combined aortic and mitral valve surgery is safe and feasible, with acceptable CPB and cross-clamp times and good outcomes. Therefore, it can be an attractive option for patients with double valve diseases.

Diagnostic Challenges in the Management of Aortic Valve Stenosis and the Role of Imaging: A Narrative Review

Aortic valve stenosis (AS) is a prevalent and progressive valvular disease that poses significant diagnostic challenges, particularly in low-flow, low-gradient (LF-LG) states. Accurate assessment of AS severity is crucial for timely intervention and improved clinical outcomes. This narrative review critically evaluates the limitations of conventional echocardiographic techniques and explores the role of multimodal imaging-including advanced echocardiography, computed tomography (CT), and cardiac magnetic resonance (CMR)-in enhancing diagnostic accuracy. Special emphasis is placed on the unique challenges of LF-LG AS, where standard Doppler-derived assessments may misclassify disease severity, necessitating a more integrative diagnostic approach. By addressing these key diagnostic uncertainties and proposing a multimodal framework for improved assessment, this review provides a comprehensive update on best practices in AS evaluation, with the goal of optimizing clinical decision making and patient outcomes.