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

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.

Shared Decision-Making in Severe Aortic Stenosis: Experiences and Needs of Older Patients

BACKGROUND

The experiences and preferences of older patients regarding shared decision-making (SDM) for managing severe aortic stenosis (AS) and its impact on health outcomes are not well known.

OBJECTIVE

The purpose of this study was to provide insight into the experiences, preferences, and needs for SDM of older patients with severe AS and the associations between perceived SDM levels and patients' quality of life, depression, and anxiety.

METHODS

A descriptive, exploratory multiple-methods study was conducted using a survey, focus groups, and individual interviews with patients 70 years and older with severe AS. Data were collected at baseline and at 3-month follow-up. Quantitative data were analyzed using multivariate linear regression and quantitative data using qualitative thematic analysis.

RESULTS

Quantitative analysis (n = 120) showed that 29.6% of patients reported maximum scores for the perceived SDM level. In addition, the perceived SDM level was significantly associated with the quality of life category environment (B = 2.75; 95% confidence interval, 0.90-4.61; P = .004). Professionals' identification of discussion partners was reported by 41.3% of patients, and 52% of patients reported professionals' exploration of patients' daily lives. For future decision-making, 55.6% of patients preferred a collaborative role. Qualitative analysis of 2 focus groups (n = 10) and interviews (n = 7) revealed patients' preference for informal caregivers' support for decision-making. Patients expressed caution in sharing views on their daily lives and expectations and suggested better preparation and goal exploration for decision-making.

CONCLUSIONS

To align with SDM and personalize the decision-making process, healthcare professionals must foster patient input and engage informal caregivers. Patients must reflect on their daily activities to define their treatment goals.

Transcatheter edge-to-edge repair for mitral regurgitation

Mitral valve transcatheter edge-to-edge repair (M-TEER) has emerged as a transformative therapy for mitral regurgitation (MR), addressing the unmet needs of patients unsuitable for surgery. Landmark trials such as EVEREST II, COAPT, and MITRA-FR have established the safety and efficacy of M-TEER, in both patients with primary (PMR) and secondary MR (SMR). Recent trials, including RESHAPE-HF2 and MATTERHORN, have expanded our understanding and refueled discussions regarding patient selection and appropriate treatment indications in SMR. These trials have also contributed to the discussion regarding SMR phenotypes most appropriate for M-TEER. This review summarizes the evidence from pivotal trials, discusses patient selection, device advancements, potential future directions, and outlines ongoing trials that may shape future clinical practice.

Transfemoral Transcatheter Aortic Valve Implantation at Hospitals Without On-Site Cardiac Surgery (TAVI at Home): A Multicenter Prospective Interventional Study

Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly patients with aortic stenosis. International guidelines recommend that TAVI should be performed only in centers with on-site cardiac surgery (CS). However, rapidly evolving TAVI technology and increasing operator expertise have significantly reduced peri-procedural complications, including those requiring rescue surgery, which occur in less than 0.5% of cases. Furthermore, only a minority of major complications are treated with CS, and the outcomes remain unfavorable. TAVI in centers without CS could represent a solution to reduce waiting times and ensure continuity of care for fragile patients. "TAVI at Home" is a single-arm prospective interventional study. According to sample size calculations based on literature data, the study aims to enroll a total of 200 patients, beginning with a run-in phase of 20 patients to establish safety. The primary endpoint is 30-day all-cause mortality. Secondary endpoints include technical success and the evaluation of single complications 30 days after the procedure. Hospitals without CS that are eligible to perform TAVI must have a high volume of coronary percutaneous interventions, operators with established TAVI experience, collaboration with vascular surgeons, and regular Heart Team meetings to ensure rigorous patient selection.

Transapical Transcatheter Mitral Valve Replacement After Failed Transcatheter Edge-to-Edge Repair: A Multicenter Experience

BACKGROUND

Management of recurrent mitral regurgitation (MR) or relevant iatrogenic mitral valve (MV) stenosis after mitral transcatheter edge-to-edge repair (M-TEER) emerges as an increasingly relevant clinical issue. Surgery after M-TEER is associated with higher morbidity and mortality. Electrosurgical leaflet laceration and stabilization of the implant (ELASTA-Clip) followed by transcatheter mitral valve replacement (TMVR) is an innovative, less-invasive treatment option for patients with TEER failure.

OBJECTIVES

The authors sought to evaluate the early results of ELASTA-Clip followed by transapical TMVR in patients with symptomatic failed M-TEER (defined as persistent or recurrent MR, or iatrogenic MV stenosis).

METHODS

Data from symptomatic patients with failed M-TEER who underwent ELASTA-Clip followed by compassionate use or commercial transapical TMVR using the Abbott Tendyne system were retrospectively collected from 8 tertiary care centers in 4 countries. Safety and efficacy of the procedure were assessed up to 1 year according to Mitral Valve Academic Research Consortium (MVARC) criteria.

RESULTS

A total of 22 patients (mean age 77.8 ± 9.2 years, 40.9% [9/22] female) at high surgical risk (EuroSCORE II 8.0 ± 0.4, STS score 7.2% ± 1.1%) with symptomatic residual MR ≥3+ (n = 21) or iatrogenic MV stenosis (n = 1) after failed M-TEER were followed for a median period of 8.5 [Q1-Q3: 2.6-11.6] months. The ELASTA-Clip procedure (90.9% [20/22] transseptal, 9.1% [2/22] transapical) followed by TMVR were successful in all patients (22/22). Technical success according to MVARC was achieved in 21 patients (21/22, 95.4%) without left ventricular outflow tract obstruction or conversion to sternotomy. At 30 days, 3 patients had paravalvular leak progression, ischemic stroke occurred in 3 patients (3/20, 15.0%). Baseline MR (≥3+ in 95.5% [21/22]) was reduced to grade 1+ or less in all patients with durable results in 89.5% (17/19) (P < 0.001). NYHA functional class significantly improved to ≤II in 81.3% (13/16) at discharge (P < 0.001) and 72.2% (13/18) at last follow-up (P < 0.001). At 30 days, all patients (20/20) were alive. Three patients (3/20, 15.0%) were rehospitalized for heart failure (uncontrolled atrial fibrillation in 2 cases) and 1 of them (1/22, 4.5%) underwent a reintervention (valve retensioning).

CONCLUSIONS

Transapical TMVR after ELASTA-Clip is a feasible and less invasive option for the management of failed M-TEER that can be performed with acceptable results in a carefully selected patient population. Particular attention is required to avoid paravalvular leakage and measures to minimize the risk of periprocedural cerebrovascular events need to be implemented in future larger-scale prospective studies with longer-term follow-up.

Tricuspid Regurgitation Disease Stages and Treatment Outcomes After Transcatheter Tricuspid Valve Repair

BACKGROUND

Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a treatment option for patients with severe tricuspid regurgitation (TR). However, randomized trials have not shown a survival benefit, possibly because of the inclusion of patients in an early or too advanced disease stage.

OBJECTIVES

The authors sought to investigate the association between disease stage and outcomes following T-TEER.

METHODS

In total, 1,885 patients with significant TR were analyzed, including 585 conservatively treated individuals and 1,300 patients who received T-TEER. Patients were evaluated as part of the prospective EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) registry and grouped into early, intermediate, and advanced disease stage. Disease stage was based on left and right ventricular function, renal function, and natriuretic peptide levels. The stratification was validated in an external cohort. The primary endpoint was 1-year mortality.

RESULTS

Overall, 395 patients (21% [395/1,885]) were categorized as early, 1,173 patients (62% [1,173/1,885]) as intermediate, and 317 patients (17% [317/1,885]) as advanced disease stage. In patients with early and advanced disease, mortality did not differ between interventional and conservative treatment (early-stage HR: 0.78; 95% CI: 0.34-1.80; P = 0.54; advanced stage HR: 1.06; 95% CI: 0.71-1.60; P = 0.78). However, mortality was significantly lower in patients undergoing percutaneous treatment with intermediate disease stage (HR: 0.73; 95% CI: 0.52-0.99; P = 0.03).

CONCLUSIONS

Compared to medically treated controls, T-TEER was associated with 1-year survival at intermediate stage disease but not at early or advanced disease stages. The timing of T-TEER with regard to disease stages might be crucial to optimize treatment benefits.

Transcatheter Aortic Valve Implantation in Patients at Intermediate and Low Risk Is Not (Yet) the Existential Threat That Surgeons Feared: A Retrospective Analysis of Medicare Claims Data

BACKGROUND

In Australia, the role of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in patients who are suitable for both procedures remains controversial. In 2022, new Items were added to the Medicare Benefits Schedule (MBS) to allow patients at intermediate and low risk with appropriate private health insurance to undergo TAVI. The Cardiac Society of Australia and New Zealand supported these changes whereas the Australian and New Zealand Society of Cardiac and Thoracic Surgeons opposed them. The aim of this study was to document subsequent private TAVI activity in patients at intermediate and low risk, relative to both private TAVI activity in patients at high risk and private SAVR activity.

METHOD

A retrospective population-level descriptive study was undertaken, using Medicare claims data obtained from Services Australia.

RESULTS

Among private patients who underwent TAVI, the groups at high, intermediate, and low risk all had a median age between 75 and 84 years. Only 1% were aged ≤64 years (86/6,586), and 80% of these were at high risk (69/86). Among private patients at intermediate and low risk who underwent TAVI and private patients who underwent SAVR, only 4% of patients aged 55-64 years chose private TAVI over private SAVR (8/211), and 63% of these were at intermediate risk (5/8).

CONCLUSIONS

The introduction of MBS Items for private TAVI in patients at intermediate and low risk without accompanying age exclusion criteria has not (yet) had a major impact on private SAVR activity. This suggests that the multidisciplinary heart team (TAVI case conference) approval process remains an effective mechanism for ensuring access to private TAVI is consistent with international guidelines.

Outcome Improvement with Last-Generation Devices in Mitral Transcatheter Edge-to-Edge Repair: Insights from the Real-World MitraClip Florence Registry

Background/Objectives: Over the past two decades, MitraClip™ therapy has proven to be an effective and safe treatment for severe mitral regurgitation (MR), with more than 200,000 patients treated globally through continuous advancements in device design and implantation techniques. This retrospective, observational, single-center study aimed to assess the safety and efficacy of the latest generation of MitraClip compared to earlier models in the Real-World MitraClip Florence Registry. The primary efficacy endpoint was a comparison in terms of the rate of successful procedures, the time to device deployment and the duration of the hospital stay. The secondary safety endpoint regarded long-term all-cause mortality and hospitalization for heart failure. Methods: Patients treated at our center from January 2016 to June 2022 were included. They were divided into two groups: those receiving early-generation devices (G1-G3) and those treated with the last-generation device (G4). All patients underwent a comprehensive preoperative echocardiographic assessment, with a re-evaluation before hospital discharge and after 12 months. A long-term follow-up focusing on all-cause mortality and hospitalization for heart failure was conducted. Results: Of 131 patients, 81 received the last-generation device. The mean age was 79.4 years. Both groups exhibited a high burden of comorbidities (overall mean n = 2.85). Procedural success was high (97%) across groups, with a significantly better MR reduction (Grade ≤ 1) in the G4 group (47% vs. 70%, p = 0.009). The time to device deployment was significantly shorter with the G4 system (72 vs. 135 min, p < 0.001), and there was a trend towards shorter hospital stays (6.1 vs. 7.9 days, p = 0.08). Kaplan-Meier analysis demonstrated better 5-year survival rates for the last-generation device group (p = 0.019), with no significant difference in rehospitalization rates (p = 0.186). Conclusions: The MitraClip G4 system in the real world for the treatment of severe MR is safe and effective, achieving immediate and durable procedural success, accompanied by an improved NYHA functional class. Moreover, a better long-term survival rate was observed, along with a comparable high rate of recurrent HF hospitalization, reflecting a high comorbidity burden in this frail population.

Shaping the Optimal Timing for Treatment of Isolated Asymptomatic Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction: The Role of Non-Invasive Diagnostics Focused on Strain Echocardiography and Future Perspectives

The optimal timing for treatment of patients with isolated asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction is still controversial and research is ongoing. Once a diagnosis has been performed and other cardiac comorbidities (e.g., concomitant significant valvulopathies or infiltrative cardiomyopathies) have reasonably been excluded, a hot topic is adequate myocardial characterization, which aims to prevent both myocardial dysfunction and subsequent adverse myocardial remodeling, and can potentially compromise the post-treatment outcomes. Another crucial subject of debate is the assessment of the real "preserved" left ventricular ejection fraction cut-off value in the presence of isolated asymptomatic severe aortic stenosis, in order to optimize the timing of aortic valve replacement as well. The aim of the present critical narrative review is highlighting the current role of non-invasive diagnostics in such a setting, focusing on strain echocardiography, and citing the main complementary cardiac imaging techniques, as well as suggesting potential implementation strategies in routine clinical practice in view of future developments.

Outcomes of aortic stenosis in patients with cardiac amyloidosis: A systematic review and meta-analysis

BACKGROUND

Cardiac amyloidosis (CA) results from the deposition of abnormally folded protein fibrils, leading to restrictive cardiomyopathy, valvular heart disease, and arrhythmias. Up to 15 % of patients with severe aortic stenosis (AS) have concomitant CA (AS-CA). We conducted this systematic review and meta-analysis to compare medical management, transcatheter aortic valve replacement (TAVR), and surgical AVR (SAVR) in AS-CA.

METHODS

A comprehensive literature search was conducted for relevant studies from inception through January 20, 2024. Studies exploring outcomes in adult AS patients with and without CA receiving medical therapy, TAVR, or SAVR were included in this analysis.

RESULTS

Fifteen studies including 253,334 patients (AS-CA 6704; AS alone 246,630) were identified. AS-CA patients had significantly higher all-cause mortality (RR = 2.60, 95 % CI 1.48-4.57, P = 0.0009) compared to AS alone. Among patients with AS-CA, TAVR was associated with lower all-cause mortality compared to both medical therapy (RR = 0.50, 95 % CI 0.29-0.89, P = 0.02) and SAVR (RR = 0.41, 95 % CI 0.22-0.78, P = 0.007). AS-CA patients undergoing TAVR were more likely to have paradoxical low-flow, low-gradient AS (RR = 1.56, 95 % CI 1.15-2.12, P = 0.04) at baseline and had a higher risk of post-TAVR acute kidney injury (RR = 1.95, 95 % CI 1.35-2.80, P = 0.0003) compared to patients undergoing TAVR for AS alone. There were similar risks of other post-TAVR complications, including major bleeding, vascular complications, stroke, and new pacemaker implantation between AS-CA and AS alone.

CONCLUSION

CA is associated with a higher mortality in patients with severe AS. In patients with concomitant AS and CA, TAVR is safe and associated with better survival than medical therapy or SAVR. SOCIAL MEDIA ABSTRACT: #Meta-Analysis: Cardiac amyloidosis is associated with increased mortality in severe AS. #TAVR is safe in amyloidosis & improves survival more than medical therapy or SAVR.

Evaluation of systemic inflammatory response following transcatheter aortic valve replacement: a pathway to rational antibiotic use

PURPOSE

Elevations in inflammatory markers after transcatheter aortic valve replacement (TAVR) often lead to preemptive antibiotic therapy (ABT). Distinguishing between physiological inflammatory reaction and true infection is crucial for rational ABT use.

METHODS

This retrospective study included 1275 consecutive TAVR patients from January 2020 to July 2022. Infectious foci, ABT administration, and inflammatory markers over seven days post-procedure were evaluated. Using multivariable logistic regression, predictors for infection were identified and integrated into the Risk of Infection After TAVR (RIAT) score.

RESULTS

An infectious focus was retrospectively identified in 2.6% of patients, while 11.4% received ABT. Distinct trends in body temperature (BT), white blood cells (WBC), and C-reactive protein (CRP) were noted, with BT and WBC peaking on day 1 and CRP on day 3. Significant predictors of infection included a rise in BT of ≥ 0.2 °C between day 1 and 3 (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.38-6.88, p = 0.006), elevated WBC counts ≥ 12 × 109/L (OR 3.77, 95% CI 1.67-8.48, p = 0.001), and CRP levels ≥ 80 mg/L (OR 5.72, 95% CI 2.59-12.64, p < 0.001) within three days after TAVR. Integrating these into the RIAT score revealed an infection probability of 1.5% for scores 0-3 points, 9.2% for scores 4-6 points, and 54.5% for scores 7-8 points.

CONCLUSION

Our findings indicate significant ABT overuse among TAVR recipients, likely due to misinterpretation of postoperative physiological reactions. Incorporating specific changes and thresholds of BT, WBC, and CRP post-TAVR into the RIAT score improved risk prediction for infection, underscoring its utility in enhancing antibiotic stewardship in this growing patient population.

Impact of amyloidosis on outcomes after transcatheter aortic valve implantation

INTRODUCTION AND OBJECTIVES

Data on the impact of amyloidosis on outcomes after transcatheter aortic valve implantation (TAVI) are limited. The objective of this study was to evaluate the 1-year risk of adverse events post-TAVI in patients with amyloidosis.

METHODS

Patients undergoing TAVI (between 2005 and 2023) were categorized into 2 groups based on the presence of amyloidosis. The primary outcome was the 1-year risk of a composite endpoint: heart failure (HF), ischemic stroke, pacemaker implantation, acute kidney injury, and all-cause death. Secondary outcomes assessed the individual components of the composite. Propensity score matching was used to balance the groups, and Cox regression was used to assess the risk of adverse outcomes associated with amyloidosis. Composite outcomes were analyzed for early (30-days) and long-term (30-days to 1 year) follow-up.

RESULTS

Data from 589 TAVI patients with amyloidosis (mean age 78.9±8.2 years, 31.9% female) were compared with 52 296 individuals without amyloidosis (mean age 78.1±8.8 years, 40.3% female). After propensity score matching, patients with amyloidosis had a significantly higher 1-year risk of adverse events (HR, 1.27; 95%CI, 1.08-1.49). Specifically, patients with amyloidosis showed an increased risk of HF (HR, 1.37; 95%CI, 1.10-1.70). Stroke risk (HR, 1.67; 95%CI, 1.16-2.40) and pacemaker implantation (HR, 2.25; 95%CI, 1.15-4.41) were higher during long-term follow-up, while no differences were found for acute kidney injury or all-cause mortality between the 2 groups.

CONCLUSIONS

Among patients undergoing TAVI, those with amyloidosis are at a higher risk of adverse events, particularly HF, and have an increased risk of pacemaker implantation and stroke in the long-term.

Prothrombotic States in Transcatheter Heart Valve Leaflet Thrombosis (PROSTHESIS): Rationale and Early Results of the Observational Cohort Study

Subclinical leaflet thrombosis is an imaging phenomenon observed after transcatheter aortic valve implantation (TAVI) and characterized by hypoattenuating leaflet thickening (HALT) on computed tomography angiography. The clinical implications and underlying causes remain uncertain. Hypercoagulability, a component of Virchow's triad, may contribute to thrombus formation on bioprosthetic leaflets, but data on hypercoagulable disorders in TAVI patients and their impact on HALT are limited. The PROSTHESIS study (Prothrombotic States in Transcatheter Heart Valve Subclinical Leaflet Thrombosis) is a single-center observational cohort study aiming to include 130 TAVI patients. This pilot study aimed to (i) assess the effect of hypercoagulable disorders on HALT prevalence and (ii) evaluate their impact on the natural history of HALT. Patients were screened for common hypercoagulable disorders using genetic and functional assays and underwent multimodal imaging one year after TAVI to detect HALT. In patients with HALT, post-implant imaging was repeated after three months to assess its progression. Early results comparing 52 TAVI patients with 52 matched controls undergoing coronary angiography showed similar thrombophilia prevalence between the groups (16% vs. 12%, p = 0.565). HALT occurred in 15% of TAVI patients, more extensively in those with thrombophilia (712 mm3 vs. 135 mm3, p = 0.036). However, thrombophilia was not an independent predictor of HALT. One-year follow-up CTA revealed spontaneous HALT resolution in 63%, stability in 25%, and progression in 12%. This study aims to provide insights into HALT and its mechanisms, which may help prevent complications and improve bioprosthesis durability.

Case Report: Leaflet thrombosis after transcatheter valve-in-valve aortic valve replacement in prosthetic valve endocarditis

A 70-year-old female patient with a history of bioprosthetic aortic valve replacement and coronary artery bypass graft presented with bioprosthetic valve failure secondary to prosthetic valve endocarditis. The patient was deemed unsuitable for surgery by the heart team, following which she underwent transcatheter aortic valve-in-valve replacement. This resulted in early death due to myocardial infarction and acute heart failure. A computed tomography revealed subclinical leaflet thrombosis. This case highlights the importance of postoperative anticoagulation therapy.

Association between echocardiographic parameters of cardiac structure and function and mild cognitive impairment

BACKGROUND

Cardiovascular diseases (CVDs) marked with cardiac morphological or hemodynamical abnormalities are associated with mild cognitive impairment (MCI). The links between cardiac structure and function and MCI are not well understood. We aimed to explore the association between echocardiographic parameters of cardiac structure and function and MCI in CVD patients.

METHODS

We conducted an age-, gender-, and education level-matched case-control study in general CVD participants with a 1:3 ratio of MCI (Montreal Cognitive Assessment [MoCA] score < 26 and Mini-Mental State Examination [MMSE] score ≥ 24) and cognitively normal participants at a tertiary hospital in Beijing, China. The echocardiographic cardiac parameters and cognitive status were retrieved through the clinical electronic database from May 2021 to August 2023. Principal component analysis (PCA), negative binomial, and conditional multivariate regression were performed.

RESULTS

A total of 1136 CVD participants (mean age, 61.2 ± 8.3 years) were included in the study, comprising 289 (25.3%) MCI and 847 cognitively normal participants. Compared to cognitively normal participants, MCI participants had a higher prevalence of left ventricular (LV) diastolic dysfunction (54.0% vs. 40.3%; P < 0.001) and greater interventricular septal thickness (IVST) (1.04 ± 0.20 cm vs. 1.00 ± 0.17 cm; P = 0.002). LV diastolic dysfunction (Beta [SE], 0.234 [0.045]; P < 0.001) and IVST (Beta [SE], 0.034 [0.016]; P = 0.036) were negatively correlated with the MoCA score of global cognitive function. LV diastolic dysfunction (OR, 2.03; 95% CI, 1.48-2.79; P < 0.001) and IVST (OR, 1.14; 95% CI, 1.03-1.27; P = 0.014) were positively associated with MCI, independent of diagnosed CVDs and the conventional MCI risk factors.

CONCLUSIONS

General CVD patients with abnormal echocardiographic LV diastolic dysfunction and IVST were associated with cognitive decline, suggesting further cognitive assessment for MCI.

TRIAL REGISTRATION

Retrospectively registered.

Integrated double redo percutaneous valve replacement: simultaneous transcatheter aortic and mitral valve management

OBJECTIVES

The growing elderly population contributes to an increasing prevalence of severe degenerative native aortic valve (AV) or mitral valve (MV) disease in combination with bio-prosthetic valve failure of prior implanted (aortic or mitral) bio-prostheses, as well as concomitant failure of both aortic and mitral bio-prosthetic valves. A combined surgical AV and MV replacement carries a markedly higher risk, especially in the redo setting. Transcatheter double-valve implantation (TDVI) is emerging as a promising alternative that may mitigate the risks of redo surgery. The evidence for TDVI is very limited. This study aims to address the current gap in the literature by analysing a large institutional series of single-stage TDVI.

METHODS

Single-centre retrospective analysis of all patients (n = 13) undergoing simultaneous transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve implantation (TMVI) from October 2018 until April 2024. Primary end-points were Valve Academic Research Consortium-3 (VARC-3) and Mitral Valve Academic Research Consortium (MVARC) technical success, 30-day device success and early safety (MVARC procedural success). Secondary end-points included echocardiographic TDVI performance, adverse events, symptom change and survival.

RESULTS

The median age of patients was 77 years, with 7/13 (53.8%) females. Median EuroSCORE II was 16.9%. All patients presented with structural valve degeneration with severe haemodynamic valve deterioration according to the VARC-3 definition. Procedural outcomes showed 100% technical success. There was absence of 30-day mortality (0%). Thirty-day device success and early safety/MVARC procedural success were 100%. No major adverse events occurred. After TDVI, the median New York Heart Association functional class improved from III to II.

CONCLUSIONS

TDVI appears to be a safe and effective alternative to surgical redo double-valve replacement for selected patients. Our findings support the feasibility of TDVI with excellent early outcomes. Further prospective multicentre studies with larger cohorts are needed to validate the long-term effects and to establish TDVI as a guideline consideration.

Long-term clinical outcomes in patients between the age of 50-70 years receiving biological versus mechanical aortic valve prostheses

OBJECTIVES

The last 2 decades have seen an incremental use of biological over mechanical prostheses. However, while short-term clinical outcomes are largely equivalent, there is still controversy about long-term outcomes.

METHODS

All patients between the ages of 50 and 70 years undergoing elective/urgent isolated aortic valve replacement at our institute between 1996 and 2023 were included. Trends, early, and long-term outcomes were investigated.

RESULTS

A total of 1708 (61% male) patients with a median age of 63.60 (interquartile range: 58.28-67.0) years were included of which 1191 (69.7%) received a biological prosthesis. After inverse propensity score weighting, there were no short-term differences when comparing patients receiving biological and mechanical valves. However, patients who received mechanical prostheses had better long-term survival (P < 0.001). Sub-group analysis revealed that patients with biological size 19 mm prosthesis had the worst long-term survival. Patients with a size 21-mm mechanical prosthesis had better survival compared to both size 19-mm [hazard ratio (HR) 0.25, 95% confidence interval (CI) 0.17-0.37, P < 0.001], 21-mm (HR 0.33, 95% CI 0.23-0.48, P < 0.001) and 23-mm (HR 0.40, 95% CI 0.27-0.60, P < 0.001) biological prosthesis. Additionally, patients with severe patient-prosthesis mismatch exhibited the lowest survival rate compared to those with moderate or no (HR 1.56, 95% CI 1.21-2.00, P < 0.001).

CONCLUSIONS

Patients aged between 50 and 70 years with a mechanical aortic prosthesis had better long-term survival compared to those with a biological prosthesis. Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group.

Direct Oral Anticoagulants Versus Vitamin K Antagonists After Mitral Valve Transcatheter Edge-to-Edge Repair in Patients With Atrial Fibrillation: A Single-Center Observational Study

BACKGROUND

Mitral valve transcatheter edge-to-edge repair (M-TEER) has emerged as a viable therapy option in patients with severe mitral regurgitation and high surgical risk. Although atrial fibrillation is common among patients undergoing M-TEER, the optimal anticoagulatory treatment after the intervention is unknown.

METHODS

A single-center retrospective observational analysis was conducted using data from the M-TEER registry at the University Hospital Cologne collected from 2019 untill 2021 including patients undergoing M-TEER between November 2012 and April 2019. Patients with atrial fibrillation receiving consistent anticoagulation following M-TEER were categorized into a direct oral anticoagulant or a vitamin K antagonist (VKA) group. The primary end point was a composite of ischemic cerebrovascular and bleeding events. Additionally, overall survival was assessed.

RESULTS

Among 613 patients undergoing M-TEER, 206 met the inclusion criteria, with 61 receiving direct oral anticoagulants and 145 receiving VKAs. After a median follow-up of 833 (interquartile range, 355-1271) days, the incidence of the composite primary end point did not differ between direct oral anticoagulant and VKA groups (hazard ratio [HR], 0.51 [95% CI, 0.23-1.12]; P=0.07). Similarly, rates of ischemic cerebrovascular events and bleeding events were similar between groups. However, the overall mortality rate was higher in the VKA group (HR, 2.56 [95% CI, 1.54-4.26]; P=0.002). In the multivariable analysis, oral anticoagulation with a VKA was an independent predictor for death (adjusted HR, 2.23 [95% CI, 1.08-5.06]; P=0.03).

CONCLUSIONS

Our findings suggest that direct oral anticoagulants may offer comparable efficacy and safety to VKAs in preventing thromboembolic events following M-TEER in patients with atrial fibrillation. Further randomized trials are needed to confirm these results and establish optimal anticoagulation strategies in this patient population.

Outcomes of K-Clip Implantation for Functional Tricuspid Regurgitation Accompanied with Persistent Atrial Fibrillation

Background: Atrial fibrillation (AF) has been identified as a risk factor for functional tricuspid regurgitation (FTR) in the absence of other known etiologies, although limited interventional options are available. K-Clip™, a novel transcatheter tricuspid annuloplasty device, is a clip-based annular plication approach for FTR. To date, no studies have investigated the short-term outcomes of K-Clip™ for patients with severe FTR associated with AF. Therefore, the aim of this study was to explore the feasibility and effectiveness of transcatheter annular repair with K-Clip™ for FTR in patients with persistent AF. Methods: Patients with FTR and persistent AF who underwent transcatheter annular repair with K-Clip™ at nine centers in China during the inclusion period were included (This study derived from Confirmatory Clinical Study of Treating Tricuspid Regurgitation With K-Clip™ Transcatheter Annuloplasty System [TriStar study}). Baseline data, imaging results, and follow-up data were collected. Results: All 52 patients (23 men, 74.02 ± 7.03 years) received successful intervention, and the mean operation time and radian exposure were 2.64 ± 1.09 h and 133.33 ± 743.06 mGy, respectively. No death cases and a low major adverse event occurrence rate were reported in 30 days. A significant decrease in FTR was documented, and TR remained severe in only two patients (3.8%). The regurgitation volume decreased significantly, accompanied by a notable reduction in the effective regurgitation orifice area and tricuspid annulus diameter, which subsequently led to the reversal of right heart remodeling. Furthermore, a decrease in pulmonary artery systolic pressure and an increase in cardiac output were documented. Conclusions: Transcatheter annular repair with K-Clip™ showed favorable short-term prognosis and significant improvement in FTR in patients with severe FTR associated with persistent AF. K-Clip™ could be a novel option for that group of patients.

[Résultats chirurgicaux prometteurs à long terme du remplacement valvulaire aortique chez les patients présentant une régurgitation aortique isolée importante et une dysfonction ventriculaire gauche sévère]

BACKGROUND

Surgical management of patients with severe aortic regurgitation (AR) in the setting of significantly impaired left ventricle (LV) function generally carries very high operative risk. The aim of this study is to assess the short and long-term outcomes of aortic valve replacement (AVR) in a selected young Moroccan population.

MATERIEL AND METHODS

This is a retrospective study between January 2008 and June 2022 including all patients who underwent AVR for massive isolated AR with an LV ejection fraction EF ≤35%.

RESULTS

In this center, a total of 3820 patients were operated for valvular disease, from which 110 had important AR. Overall, 42 patients of 110 patients had an LV ejection fraction≤35%, and benefited from AVR. Rheumatic cause was predominant (50%). Preoperative characteristics find an average age of 46.3 ±14.4 years with male prevalence. Only two deaths are noted in the immediate postoperative period. At the 15 years follow-up, the survival was 86.8%. Clinical improvement was present in the majority of patients. The mean LVEF post-AVR has increased by an average of 16% with proof of reverse remodeling.

CONCLUSIONS

In this series, patients benefited largely from AVR with good postoperative outcomes. The global operative mortality was acceptable (4.7%). The long-term survival (86.8%) was better than that described in the western series. Therefore, our results should encourage a surgical approach for those patients.

Prognostic value of left atrial stiffness in patients undergoing transcatheter aortic valve implantation

Aim

This study was performed to evaluate the association between left atrial (LA) stiffness and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and Results

This study involved 279 patients with aortic stenosis (AS) who underwent TAVI at Kumamoto University Hospital between 2015 and 2023. During a median follow-up of 468 days (interquartile range: 258-825 days), 42 deaths occurred. Pre-TAVI echocardiography showed that the LA stiffness index (E/e' ratio/LA strain during the reservoir phase [LASr]) was significantly higher in the all-cause death group than in the survival group (2.80 ± 2.56 vs. 1.70 ± 1.23, p < 0.01). Multivariate Cox proportional hazard analysis identified LA stiffness as significantly and independently associated with all-cause death after adjusting for body mass index, trans-aortic valve velocity, atrial fibrillation, log-transformed high-sensitivity cardiac troponin T (hazard ratio [HR]: 1.31, 95 % confidence interval [CI]: 1.14-1.51, p < 0.01), tricuspid regurgitation, left ventricular global longitudinal strain (HR: 1.24, 95 % CI: 1.06-1.44, p < 0.05), and LASr (HR: 1.27, 95 % CI: 1.05-1.60, p < 0.05). Receiver operating characteristic analysis showed that the optimal cutoff value of the LA stiffness index for predicting all-cause mortality was 1.69 (sensitivity: 60 %, specificity: 62 %, area under the curve: 0.64). Kaplan-Meier analysis demonstrated that patients with a high LA stiffness index (≥1.69) had a significantly higher probability of all-cause death (p < 0.05).

Conclusion

Estimation of LA stiffness provides significant prognostic value in patients with AS undergoing TAVI, even after adjusting for multiple predictive factors.

Diffuse Interstitial Fibrosis of the Myocardium Predicts Outcome in Moderate and Asymptomatic Severe Aortic Stenosis

BACKGROUND

Patients with moderate or asymptomatic severe aortic stenosis (AS) are at risk of cardiovascular events.

OBJECTIVES

The authors investigated the utility of cardiac magnetic resonance (CMR) to identify drivers of outcome in patients with moderate or asymptomatic severe AS.

METHODS

A prospective, international, multicenter cohort (n = 457) of patients with moderate (aortic valve area [AVA]: 1.0-1.5 cm2) or asymptomatic severe AS (AVA ≤1.0 cm2 and NYHA functional class I-II) patients underwent CMR. Diffuse interstitial fibrosis and scar in the myocardium were analyzed with extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The outcome was a composite of mortality and heart failure admission.

RESULTS

Median ECV% was 26.6% (IQR: 24.4%-29.9%), and LGE was present in 31.5% (median 0.8%; IQR: 0.1%-1.7%). Greater AS severity was associated with greater left ventricular mass and diastolic dysfunction, but not with ECV% or LGE. During a median 5.7 years of follow-up, 83 events occurred. Patients with events had higher ECV% (median ECV% 26.3% vs 28.2%; P = 0.003). Patients in the highest ECV% tertiles (ECV% >28.6%) had worse outcomes both in the entire cohort and in those with NYHA functional class I moderate or severe AS, and ECV% was independently associated with outcome (adjusted HR: 1.05; P = 0.039). The ECV% had significant incremental prognostic value when added to parameters of AS severity and cardiac function, comorbidities, aortic valve replacement, and LGE (P < 0.05).

CONCLUSIONS

Increased diffuse interstitial fibrosis of the myocardium is associated with poor outcomes in patients with moderate and asymptomatic severe AS and can help identify those who require closer surveillance for adverse outcomes.

Informal caregivers' roles and needs regarding shared decision-making in severe aortic stenosis

OBJECTIVE

To provide insight into experiences, preferences and needs of informal caregivers (ICs) regarding shared decision-making (SDM) in severe aortic stenosis (AS) of patients ≥ 70 years, and the effect of the level of perceived SDM on ICs' quality of life (QOL) and distress.

METHODS

Multiple methods study consisting of a questionnaire at baseline and 3-month follow-up and focus groups.

RESULTS

Ninety-nine ICs (67.6 ± 11.7 years) completed the baseline questionnaire, eighty-two ICs the follow-up questionnaire, ten ICs (70.6 ± 12.6 years) participated in two focus groups. ICs perceived that identifying them as discussion partners and addressing patients' daily lives were least discussed with professionals (26.3 %; 59.6 %). Most ICs (63.9 %) preferred a collaborative decision-making (DM) role. The level of perceived SDM was positively associated with baseline QOL social relations (p = .038), and follow-up QOL psychological health (p = .048) and environment (p = .024). ICs experienced three roles in SDM: supporters in DM, stimulators in clarifying patient's personal context, and DM partners.

CONCLUSION

ICs play valuable roles in SDM for severe AS, but feel professionals do not consistently identify them as discussion partners.

PRACTICE IMPLICATIONS

Professionals should involve ICs in SDM for discussing older patient's QOL and personal context, which can inform personalized decisions regarding severe AS treatment.

Transcatheter aortic-valve implantation with or without on-site cardiac surgery: The TRACS trial

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has emerged as an effective and safe treatment for patients with symptomatic aortic stenosis. The indication to TAVI should be agreed upon by a Heart Team, and the procedure should be performed in centers with on-site cardiac surgery. However, TAVI complications requiring emergent cardiac surgery (ECS) have become very rare. Concurrently, access disparities and prolonged waiting times are pressing issues due to increasing clinical demand of TAVI. Many solutions have been proposed and one of them is the possibility of performing TAVI in centers without on-site cardiac surgery.

METHODS AND DESIGN

The Transcatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with symptomatic severe aortic stenosis and deemed inoperable, at high surgical risk, or presenting with at least 1 clinical factor compromising the benefit/risk ratio for ECS, will be randomized to undergo TAVI either in centers with or without on-site cardiac surgery. The primary endpoint will be the composite occurrence of all-cause death, stroke, and hospital readmission for cardiovascular causes at one year. The safety endpoint will include death attributable to periprocedural complications actionable by ECS. The study aims to enroll 566 patients.

IMPLICATIONS

The TRACS trial aims to address critical gaps in knowledge regarding the safety and efficacy of TAVI procedures performed in centers without on-site cardiac surgery, potentially improving access and outcomes for high-risk patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05751577.

Right ventricular to pulmonary artery coupling in patients with different types of aortic stenosis undergoing TAVI

BACKGROUND

Right ventricular (RV) dysfunction in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) has long been disregarded. We aimed to assess the predictive value of RV to pulmonary artery coupling (RV/PAc), defined as tricuspid annular plane systolic excursion to systolic pulmonary artery pressure, on mortality in different flow types of AS after TAVI.

METHODS

All patients undergoing TAVI for AS at our centre between 2018 and 2020 were assessed; 862 patients were analysed. The cohort was dichotomized using a ROC analysis (cut-off 0.512 mm/mmHg), into 429 patients with preserved and 433 patients with reduced RV/PAc.

RESULTS

Reduced RV/PAc was associated with male sex and a higher rate of comorbidities. Short-term VARC-3 endpoints and NYHA classes at follow-up were comparable. Reduced RV/PAc was associated with higher 2-year all-cause mortality (35.0% [30.3-39.3%] vs. 15.4% [11.9-18.7%], hazard ratio 2.5 [1.9-3.4], p < 0.001). Cardiovascular mortality was almost tripled. Results were consistent after statistical adjustment and in a multivariate model. Sub-analyses of AS flow types revealed lower RV/PAc in classical and paradoxical low-flow low-gradient AS, with the majority having reduced RV/PAc (74% and 59%). RV/PAc retained its predictive value in these subgroups.

CONCLUSIONS

RV dysfunction defined by low RV/PAc is a strong mortality predictor after TAVI independent of flow group. It should be incorporated in future TAVI risk assessment.

Assessment of the GLIDE Score for Prediction of Mild Tricuspid Regurgitation following Tricuspid Transcatheter Edge-to-Edge Repair

BACKGROUND

The GLIDE Score is an anatomical scoring system designed to predict moderate residual tricuspid regurgitation (TR) immediately following transcatheter tricuspid edge-to-edge repair (T-TEER).

OBJECTIVES

The purpose of this study was to evaluate the GLIDE Score's predictive capability for achieving a postprocedural TR grade of mild or better.

METHODS

This retrospective analysis included 336 patients from a multicenter registry who underwent T-TEER between January 2017 and November 2022. Anatomical features were assessed using transesophageal echocardiography to calculate the GLIDE Score, which ranges from 0 to 5. The primary endpoint was a postprocedural TR grade of mild or better, assessed via periprocedural imaging. Outcomes were compared between patients with GLIDE Scores of 0 to 1 and those with scores ≥2 using logistic regression and ROC curve analysis.

RESULTS

Median age was 81 years, with no significant differences in BMI, EuroScore II, or NYHA Class across GLIDE Score cohorts. The GLIDE Score ≥2 cohort had a larger median RV basal diameter (48 mm vs 45 mm, P < 0.001) and more torrential TR cases (35.9% vs 3.1%, P < 0.001). Postprocedural mild TR was achieved in 74.7% of patients with a GLIDE Score of 0 to 1, versus 13.4% in the ≥2 cohort (P < 0.001). Ordinal regression analysis found a strong correlation between the GLIDE Score and postprocedural TR severity (coefficient = 1.41, t = 12.92), with an AUC to predict mild TR of 0.87 (95% CI: 0.83-0.90).

CONCLUSIONS

The GLIDE Score is a valuable tool for predicting postprocedural TR severity in T-TEER patients, guiding patient selection and refining treatment strategies.

Validation of the Kansas City Cardiomyopathy Questionnaire in Patients With Tricuspid Regurgitation

Importance

Improving patients' health status is a key goal of treating tricuspid regurgitation (TR). The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a heart failure disease-specific health status measure used to capture the health status impact of TR and the benefit of transcatheter tricuspid valve intervention (TTVI), but its validity in this clinical setting is unknown.

Objective

To evaluate the psychometric properties of the KCCQ in patients with TR.

Design, Setting, and Participants

Data were pooled from patients with severe TR enrolled in 11 manufacturer-sponsored trials of TTVI. The data were transferred to the US Food and Drug Administration to harmonize and anonymize prior to analysis by an independent center. Data were collected from December 2015 to April 2023, and data analysis was performed from July to October 2023.

Main Outcomes and Measures

Prespecified analyses included evaluation of internal consistency, reproducibility, responsiveness, construct validity, and predictive validity. Outcomes were determined using Cronbach α, score comparisons, intraclass correlation, Cohen d, Spearman correlations with best available reference measures, and association of scores and changes in scores with risk of subsequent clinical events.

Results

The study cohort was composed of 2693 patients enrolled in either single-arm (n = 1517) or randomized (n = 1176) investigations of TTVI. Mean (SD) patient age was 78.6 (8.0) years, 1658 of 2693 patients (61.6%) were female, and the mean (SD) baseline KCCQ Overall Summary (KCCQ-OS) score was 50 (23). There was strong internal consistency within individual domains (Cronbach α, .77-.83). Among clinically stable patients between 1 and 6 months, there were small mean changes in KCCQ domain and summary scores (differences of -0.1 to 1.9 points), demonstrating reproducibility. In contrast, domain and summary scores of patients who underwent TTVI showed large improvements at 1 month after treatment (mean changes, 12.1-21.4 points), indicating excellent perceived responsiveness. Construct validity was moderately strong when domains were compared with best available reference measures (Spearman correlations, 0.47-0.69). In both cross-sectional and longitudinal analyses, the KCCQ-OS was associated with clinical events, with lower scores associated with an increased risk of mortality (hazard ratio, 1.34 per 10-point decrement; 95% CI, 1.22-1.47) and heart failure hospitalization (hazard ratio, 1.24 per 10-point decrement; 95% CI, 1.17-1.31).

Conclusions and Relevance

In this cohort study, the KCCQ had strong psychometric properties in patients with severe TR, including reliability, responsiveness, and validity. These data support use of the KCCQ in patients with severe TR as a measure of their symptoms, function, and quality of life and also for assessing the impact of interventions, such as TTVI, in rigorously controlled trials.

Assessment of bystander coronary artery disease in transcatheter aortic valve replacement (TAVR) patients using noncoronary-dedicated planning computed tomography angiography (CTA): diagnostic accuracy in a retrospective real-world cohort

AIM

To assess the diagnostic potential of a noncoronary-dedicated pre-TAVR CT angiography (CTA) conducted as a prospective ECG-gated scan without premedication and standard cardiac reconstructions in evaluating bystander coronary artery disease (CAD) against invasive coronary angiography (ICA) as the gold standard.

MATERIALS AND METHODS

This retrospective study included 232 patients who underwent both CTA and ICA as part of their pre-TAVR evaluation. Exclusion criteria included prior stent, pacemaker, coronary artery bypass, or valve surgery. Coronary arteries were analysed solely through thin-slice axial reconstructions, with observers blinded to ICA results. Stenosis was categorised as mild (< 50%), moderate (50%-69%), or severe (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for 50% and 70% diameter stenosis (DS) thresholds.

RESULTS

At the 50% DS threshold, CTA demonstrated 71% sensitivity, 74% specificity, 92% NPV, and 38% PPV. At the 70% DS threshold, results included 46% sensitivity, 91% specificity, 93% NPV, and 41% PPV. The highest vessel-specific NPV at 50% DS was for the left main (98%) and left anterior descending (LAD) (91%); at 70% DS, left main (LM) (98%) and left circumflex (LCX) (94%) showed the highest NPV. Image quality impacted NPV, with excellent or very good image quality linked to higher diagnostic performance.

CONCLUSION

Noncoronary-dedicated pre-TAVR CTA shows promise for ruling out significant CAD effectively and may act as a gatekeeper for ICA, aligning with typical coronary CT angiography (CCTA) outcomes.

Cardiovascular MRI-derived Right Atrial Strain for Improved Risk Stratification in Patients with Severe Aortic Stenosis

Purpose To assess the prognostic implications of cardiac MRI-derived imaging markers in individuals with severe aortic stenosis (AS). Materials and Methods This prospective study (German Clinical Trials Register, DRKS00024479) enrolled individuals with severe AS who underwent cardiac MRI before transcatheter aortic valve replacement (TAVR) from January 2017 to March 2022. Image analyses included myocardial volumes, cardiac MRI feature tracking-derived left atrial (LA) and right atrial (RA) as well as left ventricular (LV) and right ventricular (RV) strain, myocardial T1 mapping, and late gadolinium enhancement analyses. Cardiovascular (CV) mortality was defined as primary clinical end point. Cox proportional hazards models were used to determine the association between cardiac MRI-derived parameters and CV mortality. Results The final analysis included 145 participants (median age, 80 years [IQR, 75-83 years]; 91 male). Participants who experienced CV death during follow-up had significantly enlarged RV end-diastolic volumes (median, 82.9 [IQR, 70.8-96.0] mL/m2 vs 62.8 [54.7-76.0] mL/m2; P < .001) and impaired strain values of all cardiac chambers compared with those who survived (LV global longitudinal strain [GLS], -18.1% [-13.1% to -20.4%] vs -22.5% [-16.1% to -27.3%], P = .02; RV GLS, -22.9% [-18.6% to -25.4%] vs -27.9% [-22.9% to -32.0%], P = .002; LA atrial reservoir strain [Es], 9.5% [7.2%-15.4%] vs 14.3% [9.0%-18.1%], P = .04; RA Es, 12.4% [6.8%-14.4%] vs 16.2% [11.2%-22.1%], P < .001). RA reservoir strain independently helped predict CV mortality after adjustment for other cardiac MRI markers and clinical parameters of heart failure (hazard ratio, 0.82 [95% CI: 0.71, 0.95]; P = .008). Within the subgroup of participants with high extracellular volume values, RA strain further identified participants with AS at high risk for CV mortality (P = .001 on log-rank testing). Conclusion In individuals with AS undergoing TAVR, several cardiac MRI parameters were significantly associated with CV mortality. RA strain was an independent predictor of CV mortality and may provide more optimized patient management. Keywords: Cardiac MRI, Aortic Stenosis, TAVR, Risk Assessment, Strain Analyses German Clinical Trials Register no. DRKS00024479 Supplemental material is available for this article. © RSNA, 2025.

Hemodynamic response of the aortic valve during dobutamine onset then progressive aortic banding

An increasing number of procedures over the past two decades for aortic stenosis (AS) reflects the combination of an aging population and less invasive transcatheter options. As a result, the hemodynamics of the aortic valve (AV) have gained renewed interest to understand its behavior and to optimize patient selection. We studied the hemodynamic relationship between pressure loss (ΔP) and transvalvular flow (Q) of the normal AV as well as the impact of a variable supravalvular stenosis. Our mechanistic study included 11 healthy swine monitored during dobutamine stress and followed by acute aortic banding to simulate AS. Hemodynamics were continuously recorded, and transvalvular ΔP versus Q were analyzed using proportional and linear models. During dobutamine infusion, normal valves exhibited a highly linear relationship between ΔP and Q (median R2 of 0.93). Progressive aortic banding eventually displayed a highly linear relationship between an increasing ΔP and the decreasing Q, characterized by a constant systemic circulatory resistance (median R2 of 0.91). Consequently, a normal AV can be described by a single parameter: its resistance, median 0.37 Wood units (WU) in swine. During dobutamine stress and aortic banding, the systemic bed behaves like a constant and stable resistance, median of 11.9 WU in swine. These findings carry significant implications for quantifying normal and diseased AV behavior and potentially might improve patient selection and treatment outcomes.NEW & NOTEWORTHY This study demonstrates that the normal aortic valve functions like a resistor with a proportional pressure loss ΔP versus transvalvular flow Q relationship. During dobutamine stress and progressive aortic banding, a "load line" of constant resistance characterizes the systemic circulation. Consequently, during stress conditions, the relative pressure loss over a stenotic aortic valve (the stress aortic valve index, SAVI) quantifies the relative reduction in maximal flow. Potentially, SAVI might optimize patient selection for procedures to treat aortic stenosis.

Multiorgan Dysfunction and its Association With Congestion and Outcome in Aortic Stenosis Treated With TAVI

Background

Degenerative severe aortic stenosis (AS) is treated by valve replacement to improve outcome. Despite diagnostic advancements, many AS patients are still diagnosed late with advanced heart failure.

Objectives

The aim of the study was to assess multiorgan dysfunction in severe AS using blood biomarkers and their association with quantitative fluid levels and clinical outcomes after transcatheter aortic valve implantation (TAVI).

Methods

Consecutive AS patients undergoing TAVI received comprehensive preinterventional assessment with serum biomarker profiles reflecting organ dysfunction and quantitative fluid overload (FO) using bioelectrical impedance spectroscopy. FO by bioelectrical impedance spectroscopy was defined according to a previously established cut-off (≥1.0 L). Time to first heart failure hospitalization or death served as composite primary endpoint.

Results

Among 880 patients (age 81 ± 7 years, 47% female), 41% had FO and 89% had biomarker abnormalities of at least one domain. Ascending fluid levels were independently associated with distorted biomarkers across domains of myocyte stress, hepatic dysfunction, renal dysfunction, inflammation, and anemia. After 2.4 ± 1.0 years of follow-up, 27% had reached the primary endpoint (29 heart failure hospitalization, 194 deaths, 13 both). Biomarkers across all domains were individually and independently associated with outcomes. In a multidomain approach, every affected extra-cardiac domain was associated with a 71% increase in event hazard (adjusted HR: 1.71; 95% CI: 1.39-2.11). Also, for each domain, the combination of distorted biomarkers and FO had the highest event risk.

Conclusions

Biomarker abnormalities are highly prevalent in severe AS, influenced by congestion, and associated with impaired prognosis post-TAVI. Multiorgan dysfunction faces a particularly dismal outcome.

Silent brain infarctions in patients with rheumatic mitral stenosis

BACKGROUND

Silent brain infarctions (SBI) are commonly detected in brain imaging. The association of SBI with rheumatic mitral stenosis (MS) is not clearly relevant. Based on magnetic resonance imaging, we aimed to describe the prevalence of SBI in patients with rheumatic MS and the cardiac abnormalities related to their occurrence.

METHODS

This was a bicentric, cross-sectional study, conducted in Fez, Morocco which enrolled neurologically asymptomatic patients with rheumatic MS. The presence of SBI was scored on brain MRI. Age, sex, cardiac rhythm and oral anticoagulation (OAC) statement were recorded. We obtained mitral valve area and left atrium (LA) size through transthoracic echocardiography. Univariate and multivariate analysis were used to assess associations between presence of SBI and the explanatory variables.

RESULTS

Among the 100 patients with MS (mean age 47.08 ± 9.89 years, 72 % female, sex ratio: 0.38), 56 patients had SBI (56 %), including 7 with lacunar pattern. Patients with SBI were significantly older, had more frequently moderate/severe MS, and poorer control of INR when under OAC. Enlarged LA was strongly associated with SBI, either in patients with atrial fibrillation (AF) or in patients with sinus rhythm. Multivariate analysis revealed that enlarged LA (OR 20.15, [95 % CI 2.35-172.33]; p = 0.006) and labile INR (OR 3.86, [95 % CI 1.36-10.98]; p = 0.01) were independent predictors of SBI in patients with MS.

CONCLUSIONS

Patients with MS are at high risk of SBI. This risk increases with age, the severity of MS and above all the dilatation of LA, even without AF.

Robustness of tricuspid regurgitation reduction at 1 year following edge-to-edge repair for primary tricuspid regurgitation

BACKGROUND AND OBJECTIVE

Within recent years, transcatheter tricuspid edge-to-edge repair (T-TEER) has emerged as a safe and effective treatment option in patients with secondary tricuspid regurgitation (TR). However, for primary TR, data on the robustness and durability of TR reduction 1 year following T-TEER is limited.

METHODS

All consecutive patients treated with T-TEER for TR at two high-volume centers between September 2018 and December 2022 were enrolled in a registry. Primary TR was defined as tricuspid valve (TV) prolapse or flail TV leaflets as assessed by pre- and peri-interventional transesophageal echocardiography (TEE).

RESULTS

201 patients were included in this analysis, of whom 27 (13.4%) were classified as primary TR and 174 (86.6%) as TR of secondary origin. All-cause mortality during 1-year follow-up was reached by 50 patients (24.9%) [primary: 7 (25.9%), secondary: 43 (24.7%)], and 151 (75.1%) completed follow-up with transthoracic echocardiography (TTE). Patients' median age was 80 (76-83) years, 112 (55.7%) were female and 181 (90.1%) reported a New-York heart association functional class (NYHA-FC) of III or IV. The remaining baseline clinical and echocardiographic parameters were comparable between the groups, but secondary TR patients had a significantly higher TRI-SCORE (5 (4-8) vs. 7 (5-14), P = 0.010). In both groups, an immediate reduction of TR-Grade post-intervention was observed. This reduction was sustained at follow-up with 80.0% of the primary TR patients classified as moderate or less and 61.8% of the secondary TR patients. This translated to a significant improvement of NHYA-FC in both groups. Kaplan-Meier analysis revealed no differences regarding rates for all-cause mortality between the groups (P < 0.99).

CONCLUSION

T-TEER achieves a robust TR reduction in primary TR patients 1 year after intervention with noninferior clinical results to treatment for secondary TR with regards to mortality, re-hospitalization, and NYHA-FC.

Clinical outcomes, hemodynamics, and leaflet thrombosis following transcatheter aortic valve replacement with novel intra-annular devices

Background

The indication of transcatheter aortic valve replacement (TAVR) is becoming more prevalent among younger and lower-risk patients. However, data on the latest intra-annular TAVR devices are limited. This study aims to compare the short-term clinical outcomes of two intra-annular transcatheter aortic valve replacement (TAVR) devices in Japan: SAPIEN 3 Ultra RESILIA (S3UR) and Navitor.

Methods

Of the 286 patients who underwent TAVR between May 2022 and October 2023 at our center, we enrolled 97 consecutive patients who received either S3UR or Navitor. We compared the intraprocedural invasive and echocardiographic hemodynamic assessment and post-procedural multidetector computed tomography (MDCT).

Results

The basic characteristics of the 97 patients (median age, 86 years [interquartile range, 81-89 years]) were similar. Technical success, defined by the Valve Academic Research Consortium, was achieved in all cases. Despite a smaller annulus, Navitor demonstrated decreased mean pressure gradient by TTE, 9.2 [7.3-13.6] mmHg versus 7.5 [5.9-9.5] mmHg, p = 0.006; but not by invasive measurement 5.1 [3.4-7.7] mmHg versus 5.3 [3.2-7.9] mmHg, p = 0.986). Discordance between echocardiographic and invasive assessment was more prominent with S3UR. However, severe prosthesis-patient mismatch was similarly noted between the two devices. Mild paravalvular leak (PVL) (24.5% vs. 54.5%, p = 0.002) was more frequent with the Navitor, despite no moderate-severe PVL in each group. The incidence of hypoattenuated leaflet thickening (HALT) detected by MDCT was similar between the two groups.

Conclusions

Both intra-annular valves demonstrated excellent hemodynamic performance with minimal PVL after TAVR. The incidence of HALT in both devices was comparable.

Successful implantation of an EVOQUE-tricuspid valve replacement system in a patient with two right ventricular implantable cardioverter-defibrillator leads: a case report

Background

Tricuspid regurgitation (TR) is a disease with significant morbidity and mortality rates. Besides surgery and transcatheter edge-to-edge repair (TEER), transcatheter tricuspid valve replacement has evolved as a possible treatment option in high-risk patients with an unfavourable anatomy for TEER.

Case summary

We present a case of an 82-year-old patient with torrential TR due to an annulus dilation and subsequent central gap of >8 mm. Echocardiographic guiding was impeded by the presence of two permanent right ventricular implantable cardioverter-defibrillator (ICD) leads and previous surgical aortic valve implantation and mitral valve reconstruction. An EVOQUE prosthesis (Edwards Lifesciences; Irvine, USA) was successfully implanted without impairment of the ICD function or significant paravalvular leakage.

Conclusion

Transcatheter tricuspid valve replacement with the EVOQUE-tricuspid valve replacement system is feasible even in patients with two right ventricular ICD leads and limited echocardiographic visibility.

The relationship between symptoms and regurgitant severity in primary mitral regurgitation: a cardiovascular magnetic resonance study

In the ACC/AHA guidelines, the presence of symptoms plays a central role in determining timing surgery in primary mitral regurgitation (MR). Studies have shown a disconnect between the severity of MR and symptoms. The purpose of this study is to assess risk factors for symptoms in patients with chronic primary MR. There were 430 patients with degenerative MR and preserved left ventricular function who underwent cardiovascular magnetic resonance (CMR). MR volume (MRV) and MR fraction (MRF) were categorized as per the ACC/AHA guidelines. Patients were divided into three groups based on category of MRV and MRF: (1) MRV category > MRF category (V > F), (2) MRV = MRF category (V = F), and (3) MRV < MRF category (V < F). Symptoms were defined as shortness of breath, fatigue, and decreased exercise capacity and extracted from chart review. There were 134 (38%) patients who reported symptoms. Based on MRV, 236 (55%), 125 (29%), and 69 (16%) patients had mild moderate, and severe MR respectively. Based on MRF, 257 (60%), 130 (30%), and 43 (10%) patients had mild moderate, and severe MR respectively. There was no increase in the prevalence of symptoms with worsening MRV severity (39%, 40% and 30% for mild, moderate and severe MRV respectively, p = 0.4). There was a trend for increase in the prevalence of symptoms in patients with severe MRF (35%, 40% and 54% for mild, moderate and severe MRF respectively, p = 0.054). There was a significant increase in the prevalence of symptoms when comparing V > F, V = F, and V < F (20%, 40%, and 72% respectively, p < 0.0001). On multivariable analysis, risk factors for symptoms were age, female sex, MRF, and having a V < F. In patients undergoing CMR with degenerative MR the prevalence of symptoms do not increase with worsening MRV. MRV and MRF were not risk factors for symptoms but having V < F was a risk factors for the presence of symptoms. These findings suggest that symptomatic patients with MR may have other pathology which may be responsible for their symptoms. Further studies are needed to better characterize the relationship between MR severity and symptoms.

Validation of a hand-held ultrasound device in the evaluation of aortic stenosis

Hand-held ultrasound devices (HHUD) are increasingly used in routine clinical practice, though they lacked continuous (CW) Doppler capability until recent times. There is limited evidence on the utility of HHUD in assessing aortic stenosis (AS) in real-world settings. Our goal was to validate a new HHUD with CW Doppler assessing AS hemodynamic severity. An observational, single-center study at the Valdecilla University Hospital, Santander, Spain between October 2022 and August 2023 was conducted. Patients previously diagnosed with AS were consecutively recruited. Following a reference echocardiographic examination in the cardiac imaging laboratory by an experienced operator (American Society of Echocardiography, level III), a HHUD with CW Doppler (Kosmos, EchoNous™) was used by an operator with intermediate echocardiography experience (American Society of Echocardiography, level II). The focus was on measuring aortic transvalvular Doppler velocities. Agreement between the mean trans-aortic gradient (mAG) was assessed using the intraclass correlation coefficient (ICC) test. A total of 101 patients were included. The reference test obtained a mAG of 29 mmHg [19.8-42.2], while the HHUD test showed 27.2 mmHg [16.2-43.9]. A strong correlation was observed (r = 0.89), with an ICC value of 0.87 and no significant bias (1.61 ± 0.9). The HHUD demonstrated very good ability to identify severe AS (kappa = 0.81, 95% CI 0.68-0.94; global agreement 92.1%) and good agreement for moderate (kappa = 0.58; global agreement = 80.2%) and mild (kappa = 0.73; global agreement = 88.1%) AS. Agreement was lower in patients with obesity (ICC = 0.63), poor acoustic windows (ICC = 0.74), or atrial fibrillation (ICC = 0.74). The HHUD showed good agreement with standard echocardiography in assessing AS. While it slightly underestimated mAG, it was accurate enough to reliably quantify AS severity.

Wild-type transthyretin cardiac amyloidosis and aortic stenosis: Can carpal tunnel syndrome help distinguish the chicken from the egg?

BACKGROUND

The frequent association between transthyretin wild-type (TTRwt) cardiac amyloidosis (CA) and aortic stenosis (AS) suggests a bidirectional relationship: TTRwt-CA could induce AS and vice versa. Systemic manifestations may highlight this interaction: systemic amyloidogenesis would lead to systemic symptoms, CA, and AS, whereas the myocardial stresses induced by degenerative AS might promote local amyloidogenesis without systemic symptoms. Carpal tunnel syndrome (CTS) is the most frequently reported extracardiac symptom. Through a comparison of TTRwt-CA patients with and without CTS, we sought to determine whether CTS serves as a reliable indicator of systemic involvement and its impact on cardiac and valvular characteristics.

METHODS AND RESULTS

A total of 411 consecutive patients with TTRwt-CA were included. CTS, present in 70.3%, was associated with a younger age (80 vs. 84 years, p < 0.001), more extracardiac symptoms, and advanced CA, with greater cardiac remodeling and a higher heart-to-mediastinum ratio (1.63 vs. 1.54; p = 0.012) compared to patients without CTS. AS was present in 21% and 31% of patients with and without CTS, respectively (p = 0.024). Except for AS, these associations remained significant after adjusting for confounding factors. In severe AS, patients with CTS exclusively exhibited low-flow low-gradient (LFLG) AS and less severe class of aortic valvular calcium score (5.6% vs. 60%; p = 0.006) compared to those without CTS.

CONCLUSION

Our findings suggest that CTS may delineate two phenotypes in TTRwt-CA: a systemic phenotype associated with advanced CA and poorly calcified LFLG AS, and a cardiac phenotype characterized by less severe CA and a mixed pattern of highly calcified AS, suggesting disparate pathophysiologies.

Long-term outcomes with medical therapy, transcatheter repair, or surgery for isolated tricuspid regurgitation: a systematic review and network meta-analysis

BACKGROUND

Several transcatheter tricuspid valve (TV) repair devices for tricuspid regurgitation (TR) have emerged. However, few studies have compared transcatheter TV repair with medical therapy (MT) alone or isolated TV surgery.

METHODS

PubMed and EMBASE were searched in February 2024. Studies comparing at least any of the following 2 were included: MT, surgical TV repair, surgical TV replacement, or transcatheter TV repair. The primary outcome was long-term mortality (≧ 1 year). The secondary outcomes were short-term mortality (30-day or in-hospital mortality) and periprocedural complications. We performed a network meta-analysis using a random effects model.

RESULTS

A total of 25,831 patients from 22 studies (one randomized trial and 21 observational studies) were included. MT alone was associated with higher long-term mortality compared to surgical TV repair (HR [95% CI] 1.72 [1.34-2.23]), surgical TV replacement (HR [95% CI] 1.49 [1.14-1.96]), and transcatheter TV repair (HR [95% CI] 1.52 [1.30-1.78]). Long-term mortality was comparable between transcatheter and surgical interventions. Transcatheter TV repair had a lower risk of short-term mortality (versus surgical TV repair; RR [95% CI] 0.40 [0.22-0.72], versus surgical TV replacement; RR [95% CI] 0.35 [0.19-0.66]) and lower rates of periprocedural complications, including new pacemaker implantation, renal complications, cardiogenic shock than surgical interventions.

CONCLUSIONS

MT alone for TR was associated with higher long-term mortality compared to surgical or transcatheter TV interventions. Transcatheter TV repair had better periprocedural outcomes compared to surgical interventions with similar long-term mortality. Despite the possibility of selection bias, transcatheter TV repair appears to be an attractive option for TR treatment.

Unilateral-access vs. bilateral-access in transfemoral transcatheter aortic valve replacement: A slim fit approach

BACKGROUND

Vascular complications remain prevalent on transfemoral transcatheter aortic valve replacement (TF-TAVR) with a significant proportion related to the secondary arterial access. We hypothesized that placing the second sheath ipsilateral and distal to the delivery sheath could reduce vascular complications with similar safety and efficacy.

OBJECTIVES

Comparing vascular complications and clinical outcomes when placing the secondary arterial sheath in the ipsilateral (unilateral-access) versus in the contralateral (bilateral-access) femoral artery during TF-TAVR.

METHODS

Patients who underwent TF-TAVR using unilateral-access as first-choice approach were retrospectively compared with a contemporaneous bilateral-access group. The primary endpoint was the incidence of vascular complications related to femoral access according to the VARC-3 criteria. A propensity-score analysis was performed accounting for the differences in clinical, vascular, and procedural characteristics.

RESULTS

A total of 217 patients were included, of whom 150 (69.1 %) underwent TF-TAVR through bilateral- and 67 (30.9 %) through unilateral-access. Vascular complications occurred in 16.0 % of the bilateral-access group and 10.4 % of the unilateral-access group (p = 0.280). The unilateral-access group achieved high procedural success with normalization of peak aortic velocity and low rates of paravalvular leaks, valve migration and pacemaker requirement. After propensity-score matching, the overall complications rate was superior in the bilateral-access group (54.4 % vs 35.1 %, p = 0.038) due to a trend of higher vascular complications (26.3 % vs 12.3 %, p = 0.058) and a significant higher occurrence of bleeding complications (17.5 % vs 1.8 %, p = 0.008).

CONCLUSIONS

Unilateral-access TF-TAVR is feasible, safe, and potentially enhances procedural efficiency and patient satisfaction while maintaining the capacity for bailout interventions in managing vascular complications.

What Are the Implications of Choosing a TAVR-First Strategy in the Lifetime Management of Aortic Stenosis?: A Critical Review of TAVR-Explant- and Redo-TAVR

Some patients with aortic stenosis may require multiple valve interventions in their lifetime, and choosing transcatheter aortic valve replacement (TAVR) as the initial intervention may be appealing to many. If their transcatheter heart valve degenerates later in life, most will hope to undergo redo-TAVR. However, if redo-TAVR is not feasible, some may have to undergo surgical explantation of their transcatheter heart valve (TAVR-explant). With rising numbers of TAVR in younger patients, we address the practical implications of choosing a TAVR-first strategy. In this review we explore potential factors contributing to higher-than-expected mortality after TAVR-explant, synthesize available outcomes data for TAVR-explant for structurally degenerated valves, and describe strategies to standardize and optimize surgical techniques for TAVR-explant. We also discuss clinical outcomes of redo-TAVR within the context of limitations in currently published series and highlight the potential benefit of virtual planning to assess the feasibility of future redo-TAVR before implanting the first valve. Finally, we highlight areas for future investigation to inform management strategies in patients who may require multiple aortic valve interventions.