2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Long-Term Clinical Outcomes in Patients With Severe Tricuspid Regurgitation

Background The natural history and optimal interventional timing in patients with isolated severe tricuspid regurgitation (TR) have not been well studied. This study aimed to investigate long-term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR. Methods and Results Consecutive transthoracic echocardiographic examinations in 2877 patients with isolated severe TR were retrospectively reviewed. Patients with significant left-sided valve disease or repeated examinations were excluded. Primary outcome was defined as a composite of all-cause death and hospitalization for heart failure. Among the 613 enrolled patients (mean age, 74±13 years; men, 38%), 141 died, and 62 were hospitalized for heart failure during the median follow-up period of 26.5 (interquartile range, 6.0-57.9) months. The 5-year event-free rate was 60.1%. TR pressure gradient (adjusted hazard ratio [HR], 1.03 [95% CI, 1.01-1.04]), blood urea nitrogen (adjusted HR, 1.02 [95% CI, 1.01-1.04]), left atrial volume index (adjusted HR, 1.01 [95% CI, 1.002-1.02]), and serum albumin (adjusted HR, 0.56 [95% CI, 0.36-0.95]) were identified as independent predictors of adverse events. A risk model based on the 4 clinical factors that included pulmonary hypertension (TR pressure gradient >40 mm Hg), elevated blood urea nitrogen levels (>25 mg/dL), decreased albumin levels (<3.7 g/dL), and left atrial enlargement (left atrial volume index <34 mL/m²) revealed a graded increase in the risk of adverse events (P<0.001). Conclusions The prognosis of isolated severe TR is not always favorable. Careful attention should be paid to patients with concomitant risk factors, such as pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement.

New-onset persistent left bundle branch block following sutureless aortic valve replacement

OBJECTIVE

To evaluate the incidence, predictive factors and prognostic value of new-onset persistent left bundle branch block (NOP-LBBB) in patients undergoing sutureless surgical aortic valve replacement (SU-SAVR).

METHODS

A total of 329 consecutive patients without baseline conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent SU-SAVR with the Perceval valve (LivaNova Group, Saluggia, Italy) in two centres from 2013 to 2019 were included. Patients were on continuous ECG monitoring during hospitalisation and 12-lead ECG was performed after the procedure and at hospital discharge. NOP-LBBB was defined as a new postprocedural LBBB that persisted at hospital discharge. Baseline, procedural and follow-up clinical and echocardiography data were collected in a dedicated database.

RESULTS

New-onset LBBB was observed in 115 (34.9%) patients, and in 76 (23.1%) persisted at hospital discharge. There were no differences in baseline and procedural characteristics between patients with (n=76) and without (n=253) NOP-LBBB. After a median follow-up of 3.3 years (2.3-4.4 years), patients with NOP-LBBB had a higher incidence of PPI (14.5% vs 6.3%, p=0.016), but exhibited similar rates of all-cause mortality (19.4% vs 19.2%, p=0.428), cardiac mortality (8.1% vs 9.4%, p=0.805) and heart failure readmission (21.0% vs 23.2%, p=0.648), compared with the no/transient LBBB group. NOP-LBBB was associated with a decrease in left ventricular ejection fraction (LVEF) at 1-year follow-up (delta: -5.7 vs +0.2, p<0.001).

CONCLUSIONS

NOP-LBBB occurred in approximately a quarter of patients without prior conduction disturbances who underwent SU-SAVR and was associated with a threefold increased risk of PPI along with a negative impact on LVEF at follow-up.

Radiomic analysis of enhanced CMR cine images predicts left ventricular remodeling after TAVR in patients with symptomatic severe aortic stenosis

Objective

This study aimed to develop enhanced cine image-based radiomic models for non-invasive prediction of left ventricular adverse remodeling following transcatheter aortic valve replacement (TAVR) in symptomatic severe aortic stenosis.

Methods

A total of 69 patients (male:female = 37:32, median age: 66 years, range: 47-83 years) were retrospectively recruited, and severe aortic stenosis was confirmed via transthoracic echocardiography detection. The enhanced cine images and clinical variables were collected, and three types of regions of interest (ROIs) containing the left ventricular (LV) myocardium from the short-axis view at the basal, middle, and apical LV levels were manually labeled, respectively. The radiomic features were extracted and further selected by using the least absolute shrinkage and selection operator (LASSO) regression analysis. Clinical variables were also selected through univariate regression analysis. The predictive models using logistic regression classifier were developed and validated through leave-one-out cross-validation. The model performance was evaluated with respect to discrimination, calibration, and clinical usefulness.

Results

Five basal levels, seven middle levels, eight apical level radiomic features, and three clinical factors were finally selected for model development. The radiomic models using features from basal level (Rad I), middle level (Rad II), and apical level (Rad III) had achieved areas under the curve (AUCs) of 0.761, 0.909, and 0.913 in the training dataset and 0.718, 0.836, and 0.845 in the validation dataset, respectively. The performance of these radiomic models was improved after integrating clinical factors, with AUCs of the Combined I, Combined II, and Combined III models increasing to 0.906, 0.956, and 0.959 in the training dataset and 0.784, 0.873, and 0.891 in the validation dataset, respectively. All models showed good calibration, and the decision curve analysis indicated that the Combined III model had a higher net benefit than other models across the majority of threshold probabilities.

Conclusion

Radiomic models and combined models at the mid and apical slices showed outstanding and comparable predictive effectiveness of adverse remodeling for patients with symptomatic severe aortic stenosis after TAVR, and both models were significantly better than the models of basal slice. The cardiac magnetic resonance radiomic analysis might serve as an effective tool for accurately predicting left ventricular adverse remodeling following TAVR in patients with symptomatic severe aortic stenosis.

Outcomes of transcatheter edge-to-edge mitral valve repair with percutaneous coronary intervention vs. surgical mitral valve repair with coronary artery bypass grafting

Aims

Patients with severe ischemic mitral regurgitation (IMR) may receive concurrent coronary artery bypass graft (CABG) with surgical mitral valve repair (SMVr) or percutaneous coronary stent implantation (PCI) with transcatheter edge-to-edge mitral valve repair (TMVr). However, there is no consensus on the management of severe IMR in this setting. We aimed to compare the outcomes of combined SMVr with CABG to concurrent TMVr with PCI among patients with IMR in the National Inpatient Sample (NIS) database.

Methods and results

The National Inpatient Sample was queried for all patients diagnosed with IMR who underwent SMVr with CABG or TMVr with PCI during the years 2016-2018. Study outcomes included all-cause in-hospital mortality, periprocedural complications, and resources used. A total of 1,360 potentially eligible patients were included in the study. After 1:5 propensity score matching, 133 patients were classified in the SMVr + CABG group and 29 patients in the TMVr + PCI group. Adjusted mortality was higher in the TMVr + PCI group compared with the SMVr + CABG group (13.8% vs. 4.5%, P = 0.034). Perioperative complications were higher among patients who underwent SMVr + CABG including blood transfusions (29.3% vs. 6.9%, P = 0.01) and post-procedural cardiogenic shock (11.3% vs. 0%, P = 0.044). The cost of care was higher (USD$783548.80 vs. USD$331846.523, P = 0.001) and the length of stay was longer (17.9 vs. 15.44 days, P < 0.001) in the TMVr + PCI group. On multivariable analysis, age (OR, 1.039 [95% CI, 1.006-1.072]; P = 0.032), renal failure (OR, 3.465 [95% CI, 1.867-6.433]; P < 0.001), and liver disease (OR, 5.012 [95% CI, 2.578-9.686]; P < 0.001) were associated with in-hospital mortality.

Conclusion

TMVr + PCI was associated with higher resource use and in-hospital mortality but with improved perioperative complications compared with SMVr + CABG.

Multimodality Imaging to Explore Sex Differences in Aortic Stenosis

The aim of this article is to review sex differences in aortic stenosis (AS) assessed with multimodality imaging. Echocardiography remains the mainstay imaging technique to diagnose AS and provides important insights into the differences between men and women in relation to valve haemodynamic and left-ventricular response. However, echocardiography does not have adequate resolution to provide important insights into sex differences in the degenerative, calcific pathophysiological process of the aortic valve. CT shows that women with AS have more fibrotic changes of the aortic valve whereas men show more calcific deposits. Cardiac magnetic resonance shows that women have left ventricles that are less hypertrophic and smaller compared with those of men, while men have more replacement myocardial fibrosis. These differences may lead to different responses to aortic valve replacement because myocardial diffuse fibrosis but not replacement myocardial fibrosis may regress after the procedure. Sex differences in the pathophysiological process of AS can be assessed using multimodality imaging, assisting in decisionmaking in these patients.

Assessment of aortic valve area on cardiac computed tomography in symptomatic bicuspid aortic stenosis: Utility and differences from Doppler echocardiography

Background

In this study, we investigate the utility of geometric orifice area (GOA) on cardiac computed tomography (CT) and differences from effective orifice area (EOA) on Doppler echocardiography in patients with bicuspid aortic stenosis (AS).

Methods

A total of 163 patients (age 64 ± 10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. To calculate the aortic valve area, GOACT was measured by multiplanar CT planimetry, and EOAEcho was calculated by the continuity equation with Doppler echocardiography. The relationships between GOACT and EOAEcho and patient symptom scale, biomarkers, and left ventricular (LV) functional variables were analyzed.

Results

There was a significant but modest correlation between EOAEcho and GOACT (r = 0.604, p < 0.001). Both EOAEcho and GOACT revealed significant correlations with mean pressure gradient and peak transaortic velocity, and the coefficients were higher in EOAEcho than in GOACT. EOAEcho of 1.05 cm2 and GOACT of 1.25 cm2 corresponds to hemodynamic cutoff values for diagnosing severe AS. EOAEcho was well correlated with the patient symptom scale and log NT-pro BNP, but GOACT was not. In addition, EOAEcho had a higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOACT.

Conclusion

GOACT can be used to evaluate the severity of bicuspid AS. The threshold for GOACT for diagnosing severe AS should be higher than that for EOAEcho. However, EOAEcho is still the method of choice because EOAEcho showed better correlations with clinical and functional variables than GOACT.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement for Failed Surgical Aortic Bioprostheses: A Systematic Review and Meta-Analysis

Background In the absence of randomized controlled trials, reports from nonrandomized studies comparing valve-in-valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results. Methods and Results PubMed/MEDLINE, Google Scholar, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched through December 2021. Meta-Analysis of Observational Studies in Epidemiology guidelines were followed. The protocol was registered at the International Prospective Register of Systematic Reviews. Random effects models were applied. The primary outcomes of interest were short-term and midterm mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis-patient mismatch. Of 8881 patients included in 15 studies, 4458 (50.2%) underwent ViV and 4423 (49.8%) rAVR. Short-term mortality was 2.8% in patients undergoing ViV compared with 5.0% in patients undergoing rAVR (risk ratio [RR] 0.55 [95% CI, 0.34-0.91], P=0.02). Midterm mortality did not differ in patients undergoing ViV compared with patients undergoing rAVR (hazard ratio, 1.27 [95% CI, 0.72-2.25]). The rate of acute kidney failure was lower following ViV, (RR, 0.54 [95% CI, 0.33-0.88], P=0.02), whereas prosthetic aortic valve regurgitation (RR, 4.18 [95% CI, 1.88-9.3], P=0.003) as well as severe patient-prothesis mismatch (RR, 3.12 [95% CI, 2.35-4.1], P<0.001) occurred more frequently. The mean transvalvular gradient was higher following ViV (standard mean difference, 0.44 [95% CI, 0.15-0.72], P=0.008). There were no significant differences between groups with respect to stroke (P=0.26), myocardial infarction (P=0.93), or pacemaker implantation (P=0.21). Conclusions Results of this meta-analysis demonstrate better short-term mortality after ViV compared with rAVR. Midterm mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow-up in patients with low-to-intermediate surgical risk is warranted. Registration URL: crd.york.ac.uk/prospero/. Unique identifier: CRD42021228752.

Patient-specific fluid simulation of transcatheter mitral valve replacement in mitral annulus calcification

Introduction

Transcatheter mitral valve replacement is a promising alternative to open-heart surgery in elderly patients. Patients with severe mitral annulus calcification (MAC) are a particularly high-risk population, where postprocedural complications can have catastrophic effects. Amongst these, obstruction of the left ventricular outflow tract can lead to ventricular hypertrophic remodeling and subsequent heart failure, while subclinical valve thrombosis can result in early bioprosthetic valve failure.

Methods

To elucidate the mechanisms of left ventricular outflow tract obstruction and valve thrombosis following valve-in-MAC procedures, we used image processing and Computational Fluid Dynamics (CFD) software to generate patient- and device-specific models based on preprocedural CT data. Personalized computer simulations were performed to predict the left ventricular haemodynamics after implantation in three patients with severe MAC.

Results

The simulations have successfully captured the increased pressure gradient in the left ventricular outflow tract as a result of the partial obstruction due to the implanted valve. Regions of wall shear stress above the threshold value for platelet activation were also observed on the bioprosthetic frame as a result of the reduced outflow tract area, which led to increases in flow resistance and blood residence time inside the ventricle. Consistent with these findings, areas of slow recirculating flow and blood stasis formed near the valve frame, creating potential pro-thrombotic conditions.

Discussion

This study provides insight into the relationship between size and shape of the outflow tract post-implantation, pressure gradients and pro-thrombotic flow metrics such as wall shear stress and blood residence time. Results show the potential of CFD modeling to bring key functional metrics into preprocedural assessment for a comprehensive evaluation of post-procedural risks beyond anatomical factors. Following further validation and extension to the atrial chamber, this approach can provide an in-depth analysis of the likelihood of valvular thrombosis.

Bridging therapy according to new clinical guidelines: A review

In modern world it is really important to know how to manage patients taking anticoagulant or antiplatelet therapy. There is an increasing number of patients, who have gone through PCI or any other cardiac intervention and who also need another surgery which cannot be postponed till the end of dual antiplatelet therapy. The number of patients who take oral anticoagulant has also increased last years. Algorithms of perioperative bridging therapy and antiplatelet therapy discontinuation can help to decrease both ischemic and hemorrhagic complications. Multidisciplinary risk assessment remains a critical component of perioperative care.

The Echocardiographic Evaluation of Aortic Aneurysm

PURPOSE OF REVIEW

Aortic aneurysm is the second most common aortic disease associated with significant morbidity and mortality. We summarize the role of echocardiography in the evaluation of aortic aneurysms in assessing the different etiologies, associated complications, and the role in serial follow-up. In addition, we discuss the limitations of echocardiographic evaluation and the role of multimodality imaging.

RECENT FINDINGS

Echocardiographic tools such as 2D/3D and Doppler imaging have helped improve the quality of aortic evaluation in acute and long-term follow-up. Moreover, multimodality imaging (CT and MR angiography) has advanced the field of aortic imaging. Echocardiography is an essential and critical tool for the evaluation of normal aorta and various aortic pathologies. It provides valuable information with its diverse modalities such as TTE and TEE. Echocardiography along with complimentary multimodality imaging is critical to identify the acute aortic syndromes and other associated complications of aortic aneurysms, and in long-term follow-up.

Thrombolysis for Cardiogenic Shock Secondary to Aortic Bioprosthetic Valve-in-Valve Thrombosis

Valvular obstruction and thromboembolism are feared complications of bioprosthetic valve thrombosis. We describe the case of an 81-year-old man with a prior aortic valve-in-valve bioprosthesis who presented in cardiogenic shock, requiring mechanical circulatory support. He was found to have acute bioprosthetic valve thrombosis and was treated with systemic thrombolysis. This case highlights the overall uncertainty regarding the optimal treatment of acute bioprosthetic valve thrombosis. Society guidelines and the current evidence behind prophylaxis and treatment are reviewed. Although the data remain sparse, systemic thrombolysis may be an effective strategy in critically ill patients who are poor surgical candidates.

Let's make a plan for when to reinstate do not resuscitate orders following TAVR

This editorial comments on the article by Bernacki et al. in this issue.

Real-World Multiple Comparison of Transcatheter Aortic Valves: Insights From the Multicenter OBSERVANT II Study

BACKGROUND

Head-to-head comparisons of devices for transcatheter aortic valve implantation (TAVI) are mostly limited to 2-arm studies so far. The aim of this study was to compare simultaneously outcomes of the most used, second- and third-generation transcatheter aortic valves in a real-world population.

METHODS

A total of 2728 patients undergoing TAVI with different second- and third-generation devices, and enrolled in the multicenter, prospective OBSERVANT II study (Observational Study of Effectiveness of TAVI With New Generation Devices for Severe Aortic Stenosis Treatment) from December 2016 to September 2018 were compared according to the transcatheter aortic valve received. Outcomes were adjudicated through a linkage with administrative databases, and adjusted using inverse propensity of treatment weighting. The primary end point was the composite of all-cause death, stroke and rehospitalization for heart failure at 1-year. Rates were reported consecutively for Evolut R, Evolut PRO, SAPIEN 3, ACURATE neo, and Portico groups.

RESULTS

The primary end point did not differ among groups (23.9% versus 24.7% versus 21.5% versus 23.7% versus 27.4%, respectively, P=0.56). Permanent pacemaker implantation was significantly lower for patients receiving SAPIEN 3 (19.9% versus 19.3% versus 12.5% versus 14.7% versus 22.1%, respectively, P<0.01) at 1 year. The SAPIEN 3 had lower rates of paravalvular regurgitation (moderate-to-severe grade 10.1% versus 5.0% versus 2.1% versus 13.1% versus 10.8%, respectively, P<0.01) but higher transprosthetic gradients (median mean gradients 7.0 versus 6.0 versus 10.0 versus 7.0 versus 8.0 mm Hg, respectively, P<0.01) after TAVI.

CONCLUSIONS

Data from real-world practice showed low and comparable rates of complications after TAVI considering all the available devices. Patients receiving SAPIEN 3 valve had lower rates of paravalvular regurgitation and permanent pacemaker implantation, but higher transprosthetic gradients.

Utilization of Two- and Three-Dimensional Transesophageal Echocardiography in Successfully Guiding Transcatheter Mitral Valve in Bioprosthetic Mitral Valve/Mitral Ring Implantation without Complications in Patients with Thrombus in Left Atrium/Left Atrial Appendage

BACKGROUND

The aim of this study is to describe, for the first time to our knowledge, the utilization of both two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) in successfully performing transcatheter mitral valve (MV) in bioprosthetic MV/MV annulopasty ring implantation using the apical approach in 12 patients (pts) with co-existing left atrial appendage (LAA) and/or LA (left atrium) body thrombus, which is considered a contraindication for this procedure.

METHODS AND RESULTS

All pts were severely symptomatic with severe bioprosthetic MV stenosis/regurgitation except one with a previous MV annuloplasty ring and severe native MV stenosis. Thrombus in LAA and/or LA body was noted in all by 2D and 3DTEE. All were at high/prohibitive risk for redo operation and all refused surgery. Utilizing both 2D and 3DTEE, especially 3DTEE, guidewires and the prosthesis deployment system could be manipulated under direct vision into the LA avoiding any contact with the thrombus. The procedure was successful in all with amelioration of symptoms and no embolic or other complications over a mean follow-up of 21 months.

CONCLUSION

Our study demonstrates the feasibility of successfully performing this procedure in pts with thrombus in LAA and/or LA body without any complications.

Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation

Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.

Tricuspid surgery at the time of LVAD implant: A critique

Tricuspid regurgitation (TR) is a common finding in patients with end stage heart failure referred for implantation of left ventricular assist devices. While functional TR frequently resolves after left ventricular unloading, patients with residual and progressive TR demonstrate increased rates of RV dysfunction and poor survival. Criteria for intervention on the tricuspid valve have focused on the degree of tricuspid annular dilatation and the severity of tricuspid regurgitant volume. The surgical decision making regarding intervention on the tricuspid valve remains obscure and historical cohort data cannot distinguish cause from effect.

The Efficacy and Safety of Direct Oral Anticoagulants versus Standard of Care in Patients without an Indication of Anti-Coagulants after Transcatheter Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials

Transcatheter aortic valve replacement (TAVR) is now considered the mainstay of aortic stenosis management; however, the optimal antithrombotic therapy in patent without indications for an oral anticoagulant (OAC) is yet to be identified. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of direct oral anticoagulant (DOAC) treatment versus the standard of care in patients without indications of OACs after TAVR. We synthesized randomized controlled trials (RCTs) from Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane until 18 August 2022. We used the risk ratio (RR) for dichotomous outcomes with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022357027. Three RCTs with 2922 patients were identified. DOACs were significantly associated with higher incidence of all-cause mortality (RR: 1.68 with 95% CI [1.22, 2.30], p = 0.001), mortality due to non-cardiovascular causes (RR: 2.34 with 95% CI [1.36, 4.02], p = 0.002), and the composite outcome of death, myocardial infarction, or stroke (RR: 1.41 with 95% CI [1.13, 1.76], p = 0.002). However, DOACs were associated with decreased incidence of reduced leaflet motion (RLM) (RR: 0.19 with 95% CI [0.09, 0.41], p = 0.0001) and hypoattenuated leaflet thickening (HALT) (RR: 0.50 with 95% CI [0.36, 0.70], p = 0.0001). DOACs were effective to reduce RLM and HALT; however, the clinical effect of this is still controversial. DOACs were associated with worse efficacy and safety outcomes, including all-cause mortality. Further RCTs investigating the optimal antithrombotic regimen after TAVR.

Systematic review and meta-analysis of mid-term survival, reoperation, and recurrent mitral regurgitation for robotic-assisted mitral valve repair

BACKGROUND

Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr.

METHODS

Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) at five years or more post-RMVr. A meta-analysis of proportions or means was performed, utilizing a random effects model, to present the data. Kaplan-Meier curves were aggregated using reconstructed individual patient data.

RESULTS

Nine studies totaling 3,300 patients undergoing RMVr were identified. Rates of overall survival at 1-, 5- and 10-year were 99.2%, 97.4% and 92.3%, respectively. Freedom from MV reoperation at eight-years post RMVr was 95.0%. Freedom from moderate or worse MR at seven years was 86.0%. Rates of early post-operative complications were low with only 0.2% all-cause mortality and 1.0% cerebrovascular accident. Reoperation for bleeding was low at 2.2% and successful RMVr was 99.8%. Mean intensive care unit and hospital stay were 22.4 hours and 5.2 days, respectively.

CONCLUSIONS

RMVr is a safe procedure with low rates of early mortality and other complications. It can be performed with low complication rates in high volume, experienced centers. Evaluation of available mid-term data post-RMVr suggests favorable rates of overall survival, freedom from MV reoperation and from moderate or worse MR recurrence.

Multimodality Imaging of Progressive Aortic Valve Endocarditis: From Endophthalmitis to Aorto-Atrial Fistula

Our case highlights an atypical presentation of aortic valve endocarditis after initial presentation with endophthalmitis. This case demonstrates the rapidity of evolution of aortic valve endocarditis through sequential, multimodal imaging, and features the importance of a multidisciplinary approach required for the management of complicated aortic valve endocarditis. A male in his mid-thirties was admitted to the hospital with left endophthalmitis and diabetic ketoacidosis. He was found to have aortic valve endocarditis and severe aortic insufficiency, which progressed to aortic root pseudoaneurysm and subsequently to aorto-atrial fistula in less than 72 hours, as demonstrated by consecutive multimodality imaging studies. After extensive surgical repair, post-operative recovery, and rehabilitation, he was discharged home with a good functional outcome. Sequential and multimodal imaging can be beneficial in diagnosing paravalvular infection early in its evolution, which is crucial for decision-making regarding medical and surgical treatment strategies.

Effect of TAVR Approach and Other Baseline Factors on the Incidence of Acute Kidney Injury: A Systematic Review and Meta-Analysis

Background

Acute kidney injury (AKI) is a well-known complication following a transcatheter aortic valve replacement (TAVR) and is associated with higher morbidity and mortality.

Objective

We aim to compare the risk of developing AKI after transfemoral (TF), transapical (TA), and transaortic (TAo) approaches following TAVR.

Methods

We searched Medline and EMBASE databases from January 2009 to January 2021. We included studies that evaluated the risk of AKI based on different TAVR approaches. After extracting each study's data, we calculated the risk ratio and 95% confidence intervals using RevMan software 5.4. Publication bias was assessed by the forest plot.

Results

Thirty-six (36) studies, consisting of 70,406 patients undergoing TAVR were included. Thirty-five studies compared TF to TA, and only seven investigations compared TF to TAo. AKI was documented in 4,857 out of 50,395 (9.6%) patients that underwent TF TAVR compared to 3,155 out of 19,721 (16%) patients who underwent TA-TAVR, with a risk ratio of 0.49 (95% CI, 0.36–0.66; p < 0.00001). Likewise, 273 patients developed AKI out of the 1,840 patients (14.8%) that underwent TF-TAVR in contrast to 67 patients out of the 421 patients (15.9%) that underwent TAo-TAVR, with a risk ratio of 0.51 (95% CI, 0.27–0.98; p = 0.04). There was no significant risk when we compared TA to TAo approaches, with a risk ratio of 0.89 (95% CI, 0.29–2.75; p = 0.84).

Conclusion

The risk of post-TAVR AKI is significantly lower in patients who underwent TF-TAVR than those who underwent TA-TAVR or TAo-TAVR.

Comparison of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and an Aortic Bioprosthetic Valve

BACKGROUND

Current guidelines equally recommend direct oral anticoagulants (DOACs) and warfarin for atrial fibrillation (AF) patients with a bioprosthetic valve (BPV); however, there are limited data comparing DOACs and warfarin in AF patients with an aortic BPV.

METHODS AND RESULTS

This post-hoc subgroup analysis of a multicenter, prospective, observational registry (BPV-AF Registry) aimed to compare DOACs and warfarin in AF patients with an aortic BPV. The primary outcome was a composite of stroke, systemic embolism, major bleeding, heart failure requiring hospitalization, all-cause death, or BPV reoperation. The analysis included 479 patients (warfarin group, n=258; DOAC group, n=221). Surgical aortic valve replacement was performed in 74.4% and 36.7% of patients in the warfarin and DOAC groups, respectively. During a mean follow up of 15.5 months, the primary outcome occurred in 45 (17.4%) and 32 (14.5%) patients in the warfarin and DOAC groups, respectively. No significant difference was found in the primary outcome between the 2 groups (adjusted hazard ratio: 0.88, 95% confidence interval: 0.51-1.50). No significant multiplicative interaction was observed between the anticoagulant effects and type of aortic valve procedure (P=0.577).

CONCLUSIONS

Among AF patients with an aortic BPV, no significant difference was observed in the composite outcome of adverse clinical events between patients treated with warfarin and those treated with DOACs, suggesting that DOACs can be used as alternatives to warfarin in these patients.

Transcatheter mitral valve replacement in native mitral valve with severe mitral annular calcification: Skirting the Sapien 3 to reduce the risk of paravalvular leaks

BACKGROUND

Mitral annular calcification (MAC) may represent a significant challenge for heart surgeons with an extremely high perioperative risk during mitral valve (MV) surgery. The risk is further increased when patients fail to be eligible for any percutaneous treatment, particularly because circumferential calcifications involving the anterior leaflet suggest a critical obstruction of the left ventricular outflow tract (LVOT).

OBJECTIVES

The objective of this study was to evaluate residual mitral regurgitation (MR) after surgical mitral valve replacement using a Sapien 3 Ultra (Edwards Lifesciences, CA, USA) transcatheter aortic valve implantation (TAVI) prosthesis, reinforced with a pericardial skirt, in high-risk selected patients with severe MAC.

METHODS

Since 2020, five high-risk patients (mean age 70 years; 63-76; four women) with severe mitral disease in the context of severe MAC (computed tomography-based mean MAC Score 8.2 ± 1.1) were operated on after we adopted this novel technique. The operations were performed under general anesthesia, using a transapical TAVI delivery system to position the Sapien 3 in the mitral position under direct vision. To reinforce and avoid paravalvular leakages, a pericardial skirt was previously sewn around the prosthesis, securing it to the annulus and perivalvular atrial surface.

RESULTS

Sapien 3 Ultra implantation was successful without residual MR in all five patients (mild paravalvular leak in one case). Four patients had a 29-mm valve implanted, while one had a 26-mm valve implanted. Predilatation of the native annulus was never performed. Perfusion and clamping times were 134 ± 53 mins and 108 ± 43 mins, respectively. The presence of the pericardial skirt reduced the risk of leakage between the prosthesis and the rigid calcium surface, with final mean and maximal gradients of the TAVI prosthesis of 4.1 and 10.8 mmHg, respectively. There were no left ventricular outflow tract obstructions (mean LVOT gradient of 8 ± 1 mmHg). All patients were discharged, and neither mortality nor prosthetic dysfunction, nor residual mitral regurgitation was recorded. During follow-up, the last patient treated (MAC Score 10, severe calcification of the mitro-aortic junction) returned to our attention with a significant recurrent jet originating from the anterolateral commissure, currently medically treated, given the prohibitive redo risk.

CONCLUSION

Direct open surgical implantation of the Sapien 3 valve can be safely done in patients with severe MAC in dedicated centers. Reinforcing the TAVI prosthesis by sewing a pericardial skirt led to satisfactory perioperative and early postoperative results, reducing paravalvular leakages. Complex anatomies have a CERTAIN risk of recurrence.

Effect of mitral valve transcatheter edge-to-edge repair on indices of left atrial performance in chronic mitral regurgitation

INTRODUCTION

Effect of transcatheter edge-to-edge repair (TEER) using MitraClip in patients with mitral regurgitation (MR) on left atrial (LA) kinetic energy (LAKE), an index of LA work, and LA strain, a measure of LA performance, have not been well defined.

METHODS

Patients with chronic primary or secondary 3+ or 4+ MR were analyzed pre- and post-TEER using MitraClip. LAKE was determined by echocardiography using LA stroke volume and A-wave velocity. Peak atrial longitudinal strain (PALS), peak atrial strain in early diastole, and peak atrial contraction strain (PACS) were obtained by speckle tracking echocardiography.

RESULTS

Thirty-nine patients undergoing TEER with MitraClip were screened, 12 met criteria for analysis (9 primary and 3 secondary MR). Compared to pre-TEER, there was a significant increase post-TEER in LAKE (71.0 ± 64.1 vs. 177.5 ± 167.9 dyne·cm·10³ , respectively; p = .008) and Doppler transmitral A-wave velocity (87.8 ± 41.4 vs. 138.5 ± 43.7 cm/s, respectively; p < .001); LA stroke volume did not change significantly. Mitral valve mean gradient significantly increased post-TEER compared to pre-TEER (5.7 ± 2.1 vs. 3.3 ± 2.1 mmHg, respectively; p = .01). There was a trend toward decrease in PALS post-TEER compared to pre-TEER (16.2 ± 4.8 vs. 20.7 ± 9.9%, respectively; p = .05). Peak atrial strain in early diastole significantly decreased post-TEER compared to pre-TEER (7.2 ± 3.0 vs. 14.1 ± 7.2%; respectively, p < .001), while PACS did not significantly change (9.1 ± 3.5 vs. 6.7 ± 5.2%, respectively; p = .07).

CONCLUSION

In patients with chronic MR, LAKE increases after TEER with MitraClip driven by an increase in LA emptying velocities. Changes were also seen in LA strain with MitraClip. These procedurally induced changes due to mild mitral stenosis may have clinical implications.

Mitral Valve Surgery for Persistent or Recurrent Mitral Regurgitation After Transcatheter Edge-to-Edge Repair Is Associated With Improved Survival

Background

The management of severe mitral regurgitation (MR) after transcatheter edge‐to‐edge repair (TEER) remains a clinical conundrum. Considering the growing volume of TEER, more outcomes data for mitral surgery in this cohort are needed.

Methods and Results

Symptomatic patients with persistent or recurrent severe MR after TEER evaluated between May 2014 and June 2021 were included. The primary outcome was all‐cause mortality in patients who were treated with surgery versus medical therapy. The Kaplan–Meier and Cox regression methods were used to report risk‐adjusted survival analyses. Among the 142 included patients, 44 (31.0%) underwent mitral surgery. Patients who underwent surgery were younger than those treated medically (74.1±8.9 versus 78.6±10.5 years, P=0.01). Major comorbidities were similar except obesity, sleep apnea, left ventricular dimensions, and ejection fraction. Society of Thoracic Surgeons Predicted Risk of Operative Mortality was 9.0±4.7 versus 7.9±4.9 in the surgical versus medical therapy groups, respectively, P=0.22. Time from TEER to detection of severe MR was similar in both groups (median [interquartile range] 97.5 [39.5–384] versus 93.5 [40–389] days in the surgical versus medical groups, respectively [P>0.05]). In the surgical group, valve replacement was performed in all patients. Operative mortality was 4.5% (observed/expected ratio 0.55), and major complications were uncommon. After risk‐adjustment, surgery was associated with significantly lower all‐cause mortality (adjusted hazard ratio, 0.33 [95% CI, 0.12–0.92], P=0.001) compared with medial therapy.

Conclusions

Compared with medical therapy, mitral surgery in patients with severe persistent or recurrent MR after TEER is associated with lower mortality despite the high‐risk profile of these patients. Patients with severe MR after TEER should be considered for surgery at a referral mitral surgical center.

Mechanical Aortic Valve Thrombosis Successfully Treated With Intravenous Thrombolytic Therapy: A Case Report

Mechanical prosthetic valves, like all foreign bodies, are thrombogenic, requiring anticoagulation to avoid thrombosis and reduce the risk of catastrophic stroke. We reported a case of a 42-year-old female that developed mechanical valve thrombosis and was successfully treated with low infusion thrombolytic therapy using alteplase (tPA, tissue plasminogen activator).

Aerococcus Urinae Endocarditis: A Case Report and Literature Review

A 75-year-old male, with a past medical history of chronic kidney disease stage 3 (CKD3) and a recent diagnosis of bilateral hydronephrosis and Foley catheter placement, presented to the emergency department for fever. Blood cultures grew Aerococcus urinae. Transthoracic echo (TTE) demonstrated thickened aortic valve leaflets with perforation, multiple echo densities, and severe aortic regurgitation. The patient developed decompensated congestive heart failure and cardiogenic shock. En route to surgery for emergent aortic valve replacement, the patient lost pulse and was resuscitated. The patient was subsequently transferred to the ICU where the family decided to initiate comfort care measures. This case highlights the importance and necessity of the prompt diagnosis and treatment of infective endocarditis and makes the reader aware of uncommon and rare organisms, such as Aerococcus urinae, as potential etiologies.

Serial changes in cardiac sympathetic nervous function after transcatheter aortic valve replacement: A prospective observational study using 123I-meta-iodobenzylguanidine imaging

BACKGROUND

Transcatheter aortic valve replacement (TAVR) can rapidly improve cardiac sympathetic nervous function (CSNF) within 2 weeks in patients with aortic stenosis (AS). However, whether such short-term improvements will be sustained thereafter remains unclear.

METHODS

Patients with severe AS who underwent TAVR between October 2017 and June 2019 were enrolled in this single-center, prospective, observational study. 123I-meta-iodobenzylguanidine imaging was performed at baseline, within 2 weeks after TAVR, and at 6 to 12 months post-TAVR to evaluate the heart-mediastinum ratio (H/M) and washout rate.

RESULTS

Of 183 consecutive patients, 75 (19 men; median age: 86 years) were evaluated. The late H/M significantly improved within 2 weeks after TAVR (P = .041) and further improved over 6 to 12 months after TAVR (P = .041). Multivariate analysis revealed that the baseline mean aortic valve pressure gradient (mPG) was an independent predictor of mid-term improvement in the late H/M (> 0.1) (P = .037). Patients with a high baseline mPG (≥ 58 mmHg) exhibited a significantly greater increase in the late H/M than those with a low baseline mPG (< 42 mmHg) (0.24 vs 0.01; P = .029).

CONCLUSION

CSNF demonstrated sustained improvement from within 2 weeks after TAVR until 6 to 12 months later. Such improvement was related to baseline hemodynamic AS severity.

Prosthesis-patient mismatch after transcatheter aortic valve implantation

Prosthesis-patient mismatch (PPM), first described in 1978, occurs when a prosthetic valve functions normally, but has an effective orifice area that is too small relative to the patient's body surface area. It results in residual left ventricular afterload and higher transvalvular pressure gradient, which has been considered to impair prognosis. PPM following surgical aortic replacement is reportedly associated with worse clinical outcomes, such as high mortality. However, the impact of PPM on clinical outcomes after transcatheter aortic valve implantation (TAVI) remains unclear. There is conflicting evidence on the impact of PPM following TAVI due to differences across studies in terms of follow-up period, methods, patient populations, and type of bioprosthetic valve. The present review summarizes the most recent evidence on PPM after TAVI.

Bicuspid Aortic Valve and Premature Ventricular Beats in Athletes

BACKGROUND

The aim of this study was to identify a possible link between bicuspid aortic valve (BAV) and premature ventricular beats (PVBs), particularly from left and right ventricular outflow tracts, and to investigate possible associations between these arrhythmias and echocardiographic abnormalities.

METHODS

A comparison of sportspeople with and without BAV was performed to identify PVBs' occurrence in these two series. Then, subdividing the BAV group on the presence of cardiovascular complications due to BAV, we compared arrhythmic features between these two subgroups and echocardiographic findings between athletes with and without left and right outflow tract PVBs.

RESULTS

PVBs in 343 athletes with BAV were compared with 309 athletes without BAV, showing an increased frequency (29% vs. 11.8%, p < 0.001; OR 3.1; CI 2.1-4.7) and origin from the left (18.4% vs. 3.2%, p < 0.001, OR 6.7; CI 3.4-13.4) and right (15.2% vs. 3.6%, p < 0.001, OR 4.8; CI 2.5-9.5) outflow tracts compared to other ventricular areas (fascicular PVBs p = 0.81, other morphologies p = 0.58). No difference in PVBs' occurrence was found between near normal valve BAV and pathological BAV, nor was a difference in echocardiographic characteristics found between patients with and without outflow tract arrhythmias.

CONCLUSIONS

A possible causal link between BAV and PVBs was highlighted, but no association between PVBs and complicated BAV was emphasized.

Substitute parameters of exercise-induced pulmonary hypertension and usefulness of low workload exercise stress echocardiography in mitral regurgitation

In asymptomatic patients with mitral regurgitation (MR), data of exercise-induced pulmonary hypertension (EIPH) are limited, and feasibility of evaluating EIPH is not high. We aimed to investigate prognostic impact of EIPH and its substitute parameters. Exercise stress echocardiography (ESE) were performed in 123 consecutive patients with moderate to severe degenerative MR. The endpoint was a composite of death, hospitalization for heart failure, and worsening of symptoms. EIPH [tricuspid regurgitation peak gradient (TRPG) at peak workload ≥ 50 mmHg] was shown in 57 patients (46%). TRPG at low workload was independently associated with TRPG at peak workload (β = 0.67, p < 0.001). Early surgical intervention (within 6 months after ESE) was performed in 65 patients. Of the remaining 58 patients with the watchful waiting strategy, the event free survival was lower in patients with EIPH than in patients without EIPH (48.1 vs. 97.0% at 1-year, p < 0.001). TRPG at low workload ≥ 35.0 mmHg as well as EIPH were associated with poor prognosis in patients with the watchful waiting strategy. In conclusion, the importance of ESE and evaluating EIPH in patients with MR was re-acknowledged. TRPG at peak workload can be predicted by TRPG at low workload, and TRPG at low workload may be useful in real-world clinical settings.

The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis

Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. 

An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.

Identification of MMP9 as a Novel Biomarker to Mitochondrial Metabolism Disorder and Oxidative Stress in Calcific Aortic Valve Stenosis

Calcific aortic valve stenosis (CAVS) is the most common heart valve disorder among humans. To date, no effective method has been identified to prevent this disease. Herein, we aimed to identify novel diagnostic and mitochondria-related biomarkers of CAVS, based on two machine learning algorithms. We further explored their association with infiltrating immune cells and studied their potential function in CAVS. The GSE12644, GSE51472, and GSE83453 expression profiles were downloaded from the Gene Expression Omnibus (GEO) repository. The GSE12644 and GSE51472 datasets were integrated to identify differentially expressed genes (DEGs). GSE12644 contains 10 normal and 10 CAVS samples, whereas GSE51472 contains 5 normal and 10 CAVS samples. GO and KEGG assays of DEGs were conducted, and the correlation between matrix metalloproteinase 9 (MMP9) expression and immune cell infiltration was explored, using CIBERSORT. The LASSO regression model and SVM-RFE analysis were used to identify diagnostic genes. The expression of MMP9 in CAVS and non-CAVS samples was measured using RT-PCR, western blotting and immunohistochemistry. A series of functional experiments were performed to explore the potential role of MMP9 in mitochondrial metabolism and oxidative stress during CAVS progression. Twenty-two DEGs were identified, of which six genes (SCG2, PPBP, TREM1, CCL19, WIF1, and MMP9) were ultimately distinguished as diagnostic genes in CAVS. Of these, MMP9 was indicated as a mitochondria-related gene, the expression and diagnostic value of which were further confirmed in the GSE83453 dataset. Correlation analysis revealed a positive correlation between MMP9 and infiltrating immune cells. In our cohort, MMP9 expression was distinctly increased in CAVS samples, and its inhibition attenuated the calcification of valve interstitial cells (VICs) by suppressing mitochondrial damage and oxidative stress. Taken together, our findings suggest MMP9 as a novel mitochondrial dysfunction biomarker and therapeutic target for CAVS.

Iatrogenic ventricular septal defects following transcatheter aortic valve implantation

Ventricular septal defect (VSD) rarely occurs following transcatheter aortic valve implantation (TAVI). We report two patients who developed VSD following TAVI. One case was a Gerbode defect treated by percutaneous closure, and the second was a restrictive perimembranous VSD managed conservatively.

Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Valve Replacement or Repair

Background We sought to examine outcomes of direct oral anticoagulants (DOACs) versus warfarin in atrial fibrillation with valve repair/replacement. Methods and Results Two atrial fibrillation cohorts from Medicare were identified from 2015 to 2019. They comprised patients who underwent surgical or transcatheter mitral valve repair (MV repair cohort) and surgical aortic or mitral bioprosthetic or transcatheter aortic valve replacement (bioprosthetic cohort). Each cohort was divided into warfarin and DOACs (apixaban, rivaroxaban, and dabigatran) groups. Study outcomes included mortality, stroke, and major bleeding. Inverse probability weighting was used for adjustment between the 2 groups in each cohort. The MV repair cohort included 1178 patients. After a median of 468 days, DOACs were associated with lower risk of mortality (hazard ratio [HR], 0.67 [95% CI, 0.55-0.82], P<0.001), ischemic stroke (HR, 0.72 [95% CI, 0.52-1.00], P=0.05) and bleeding (HR, 0.79 [95% CI, 0.63-0.99], P=0.04) compared with warfarin. The bioprosthetic cohort included 8089 patients. After a median follow-up of 413 days, DOACs were associated with similar risk of mortality (adjusted HR, 0.93 [95% CI, 0.86-1.01], P=0.08), higher risk of ischemic stroke (adjusted HR, 1.27 [95% CI, 1.13-1.43], P<0.001), and lower risk of bleeding (adjusted HR, 0.86 [95% CI, 0.80-0.93], P<0.001) compared with warfarin. Conclusions In patients with atrial fibrillation, DOACs are associated with similar mortality, lower bleeding, but higher stroke with bioprosthetic valve replacement and lower risk of all 3 outcomes with MV repair compared with warfarin.

Impact of machine-learning-based coronary computed tomography angiography-derived fractional flow reserve on decision-making in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

OBJECTIVES

To evaluate feasibility and diagnostic performance of coronary CT angiography (CCTA)-derived fractional flow reserve (CT-FFR) for detection of significant coronary artery disease (CAD) and decision-making in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) to potentially avoid additional pre-TAVR invasive coronary angiography (ICA).

METHODS

Consecutive patients with severe AS (n = 95, 78.6 ± 8.8 years, 53% female) undergoing pre-procedural TAVR-CT followed by ICA with quantitative coronary angiography were retrospectively analyzed. CCTA datasets were evaluated using CAD Reporting and Data System (CAD-RADS) classification. CT-FFR measurements were computed using an on-site machine-learning algorithm. A combined algorithm was developed for decision-making to determine if ICA is needed based on pre-TAVR CCTA: [1] all patients with CAD-RADS ≥ 4 are referred for ICA; [2] patients with CAD-RADS 2 and 3 are evaluated utilizing CT-FFR and sent to ICA if CT-FFR ≤ 0.80; [3] patients with CAD-RADS < 2 or CAD-RADS 2-3 and normal CT-FFR are not referred for ICA.

RESULTS

Twelve patients (13%) had significant CAD (≥ 70% stenosis) on ICA and were treated with PCI. Twenty-eight patients (30%) showed CT-FFR ≤ 0.80 and 24 (86%) of those were reported to have a maximum stenosis ≥ 50% during ICA. Using the proposed algorithm, significant CAD could be identified with a sensitivity, specificity, and positive and negative predictive value of 100%, 78%, 40%, and 100%, respectively, potentially decreasing the number of necessary ICAs by 65 (68%).

CONCLUSION

Combination of CT-FFR and CAD-RADS is able to identify significant CAD pre-TAVR and bears potential to significantly reduce the number of needed ICAs.

KEY POINTS

• Coronary CT angiography-derived fractional flow reserve (CT-FFR) using machine learning together with the CAD Reporting and Data System (CAD-RADS) classification safely identifies significant coronary artery disease based on quantitative coronary angiography in patients prior to transcatheter aortic valve replacement. • The combination of CT-FFR and CAD-RADS enables decision-making and bears the potential to significantly reduce the number of needed invasive coronary angiographies.

Transcatheter Aortic Valve Implantation for Pure Native Aortic Regurgitation: The Last Frontier

Transcatheter aortic valve implantation (TAVI) to treat patients with severe symptomatic aortic stenosis is a well-established procedure. Even though cases series have reported TAVI use in high-risk patients with pure native aortic regurgitation, this is still considered an off-label intervention, especially when the aortic annulus dimensions are beyond the recommended by prosthesis manufacturers. Herein, we provide an updated review regarding the transcatheter treatment of pure native aortic regurgitation and illustrate this issue by presenting a clinical case of a patient with pure aortic regurgitation and a large aortic annulus who received a self-expanding non-dedicated transcatheter heart valve.

Bleeding risk differences after TAVR according to the ARC-HBR criteria: insights from SCOPE 2

BACKGROUND

The Academic Research Consortium - High Bleeding Risk (ARC-HBR) initiative defined conditions associated with percutaneous coronary intervention (PCI)-related bleeding.

AIMS

We sought to further explore these HBR conditions in the setting of transcatheter aortic valve replacement (TAVR).

METHODS

Patients from the SCOPE 2 trial were stratified by their bleeding risk status based on the ARC-HBR definitions. Baseline and procedural characteristics, as well as key clinical outcomes including Bleeding Academic Research Consortium (BARC) 3-5 bleeding, were compared in ARC-HBR positive (HBR+) and ARC-HBR negative (HBR-) patients.

RESULTS

Of 787 patients randomised in SCOPE 2 and included in this study, 633 were HBR+ (80.4%). Compared with HBR- patients, those HBR+ were older and more frequently presented with diabetes, a history of coronary artery disease, atrial fibrillation, prior cerebrovascular accident, and a Society of Thoracic Surgeons predicted risk of 30-day mortality (STS-PROM) (4.9±2.9% vs 3.3%±2.1%; p<0.0001). In addition, HBR+ patients were more frequently on oral anticoagulation therapy. At 1 year, HBR+ patients had higher rates of all-cause death (12.4% vs 4.3%, respectively, risk difference 8.09%; 95% confidence interval [CI]: 3.76-12.41; p=0.0002); the rates of BARC 3-5 type bleeding were relatively high but not statistically different compared with HBR- patients (7.7% vs 6.1%, risk difference 1.67%; 95% CI: -2.72 to 6.06; p=0.46). Subgroup analyses for bleeding events showed no significant interaction in terms of STS-PROM score, age, or medications.

CONCLUSIONS

The ARC-HBR criteria failed to isolate a subgroup of patients at higher bleeding risk in TAVR patients from a randomised trial. These findings have potential implications, especially for the selection of post-TAVR antithrombotic regimens based on individual bleeding-risk profiles. Specific HBR criteria should be defined for TAVR patients.

Percutaneous Closure of Mitral Paravalvular Leak: Long-Term Results in a Single-Center Experience

Background: Paravalvular leak occurs in 5–17% of patients following surgical valve replacement, more often in mitral position. The prognosis without treatment is poor. Percutaneous device closure represents an alternative to repeat surgery. The objective of this work is to evaluate the medium and long-term results in the percutaneous closure of PVL in mitral prosthesis. Methods: This observational study is based on a retrospective registry including consecutive mitral PVL cases undergoing percutaneous closure at a single tertiary-care center from April 2010 to December 2020. The safety and efficacy results of the procedure, at 90 days and in the long term, were analyzed. Also, predictors of procedure failure and long-term events were identified. Results: A total of 128 consecutive mitral paravalvular leak closure procedures were included. Technical success was achieved in 115 (89.8%) procedures. The presence of multiple PVLs was the sole factor that independently predicted procedural failure. Median follow-up of our sample was 41.8 months (mean 47.7 ± 35.7 months). Underlying hemolytic anemia as the indication for PVL closure, a recent admission for decompensated HF, and lack of improvement in functional class emerged as consistent predictors of MACE and death during long-term follow-up, while lack of procedural success during the first PVL procedure and chronic kidney disease were also associated with MACE during follow-up. Conclusions: Percutaneous mitral PVL closure displayed high technical and procedural success rates, with an acceptable safety profile, in a high-risk population. Percutaneous mitral PVL closure achieved an improvement in short- and long-term functional class and a reduction of hemolysis in the vast majority of patients. In addition, long-term survival in our study was good, in particular for patients undergoing successful PVL closure procedures.

Procedural Safety and Device Performance of the Portico™ Valve from Experienced TAVI Centers: 30-Day Outcomes in the Multicenter CONFIDENCE Registry

A total of 1001 subjects (82.0 years, 62.5% female, 63.7% NYHA III/IV at baseline) with severe aortic stenosis at high surgical risk were enrolled in the prospective CONFIDENCE registry and treated with a Portico™ transcatheter heart valve (THV) using either a first-generation delivery system (DS) or the FlexNav™ DS. The objective of this registry is to characterize the procedural safety and device performance of the Portico™ THV at 30 days. The study collected ‘standard-of-care’ clinical and device performance data, with adverse events adjudicated by an independent clinical event committee according to the Valve Academic Research Consortium-2 criteria. The implantation of a single Portico™ THV was successful in 97.5% of subjects. The 30-day all-cause mortality, cardiovascular mortality, and disabling stroke rates were 2.6%, 2.1%, and 1.8%, respectively. A new pacemaker was implanted in 19.0% of subjects at 30 days. At 30 days, the effective orifice area and mean gradient values were 1.82 cm2 and 7.1 mmHg, respectively. The 30-day rate of moderate paravalvular leak (PVL) was 2.1%, with no occurrence of severe PVL. The Portico™ THV demonstrated improved hemodynamic performance and low rates of safety events at 30 days in a large cohort of subjects implanted with the Portico™ THV with either the first-generation DS or FlexNav™ DS.

Expanding utility of cardiac computed tomography in infective endocarditis: A contemporary review

There is increasing evidence on the utility of cardiac computed tomography (CCT) in infective endocarditis (IE) to investigate the valvular pathology, the extra-cardiac manifestations of IE and pre-operative planning. CCT can assist in the diagnosis of perivalvular complications, such as pseudoaneurysms and abscesses, and can help identify embolic events to the lungs or systemic vasculature. CCT has also been shown to be beneficial in the pre-operative planning of patients by delineating the coronary artery anatomy and the major cardiovascular structures in relation to the sternum. Finally, hybrid nuclear/computed tomography techniques have been shown to increase the diagnostic accuracy in prosthetic valve endocarditis. This manuscript aims to provide a contemporary update of the existing evidence base for the use of CCT in IE.