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

Transapical Transcatheter Aortic Valve Replacement: A Real-World Early and Mid-Term Outcome of a Third-Level Centre

Background: Transapical transcatheter aortic valve replacement (TA-TAVR) is generally considered to be associated with higher morbidity compared with transfemoral-TAVR. However, TA-TAVR remains a feasible alternative for patients who are unsuitable for TF-TAVR. It has been shown that outcomes after TAVR are linked to the operator’s expertise. Therefore, the purpose of this study is to report short- and mid-term outcomes after TA-TAVR performed by an expert Heart-Team of a third-level centre. Methods: From 2015 to 2022, 154 consecutive patients underwent TA-TAVR. The outcomes were analysed according to the VARC-3 criteria. Kaplan–Meier curves were estimated for major clinical events at mid-term follow-up. Results: The mean age of the population was 79.3 years and the STS risk-score of mortality was 4.2 ± 3.6%. Periprocedural mortality was 1.9%. Acute kidney injury and prolonged ventilation occurred in 1.9%. Incidence of stroke was 0.6%. Pacemaker implantation rate was 1.9%. Freedom from cardiovascular mortality was 75.7%, and 60.2% at 3 and 5 years. Freedom from stroke was 92.3% and 88.9% at 3 and 5 years, respectively; freedom from endocarditis was 94.4% and 90.8% at 3 and 5 years, respectively. Conclusion: TA-TAVR may be considered a safe and effective alternative approach in patients unsuitable for TF-TAVR, especially when performed by a proficient Heart-Team.

Novel apical-to-femoral rail technique for horizontal aorta in transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment option for patients with severe aortic stenosis regardless of its surgical risk stratification (Otto et al., 2021). Aortic angulation is usually measured as the angle between the horizontal and the aortic annulus planes based on preproced‍ural multidetector computed tomography (MDCT) (Al-Lamee et al., 2011). Extremely horizontal aorta, defined as an aortic angulation greater than 70°, is an unfavorable anatomic structure that poses particular technical challenges for TAVR. Abramowitz et al. (2016) have proved that an extremely horizontal aorta increased the risk of procedural complications, such as lower device success rates, more moderate or even severe perivalvular leakage (PVL), and the need for second valve implantation. Because of the long stent frame, inflexibility, and non-steerability, it is challenging to pass the delivery system of self-expanding valves (SEVs) through an extremely horizontal aorta. As a result, patients with an extremely horizontal aorta have always been excluded from the clinical trials of TAVR, and transfemoral (TF)-TAVR with SEV is considered as an "off-label" use of TAVR (Adams et al., 2014; Kaneko et al., 2020). Herein, we present a technically difficult case, in which a patient with an extremely horizontal aorta underwent TF-TAVR with SEV by applying a unique apical-to-femoral rail strategy.

TAVR for All? The Surgical Perspective

In spite of the noninferiority of transcatheter aortic valve replacement (TAVR) in high- and intermediate-risk patients, there are still obstacles that need to be overcome before the procedure is further expanded and clinically integrated. The lack of evidence on the long-term durability of the bioprostheses used for TAVR remains of particular concern. In addition, surgery may be preferred over TAVR in patients with bicuspid aortic valve (BAV) or with concomitant pathologies such as other valve diseases (mitral regurgitation/tricuspid regurgitation), aortopathy, and coronary artery disease. In this review, we discuss and summarize relevant data from clinical trials, current trends, and remaining obstacles, and provide our perspective on the indications for the expansion of TAVR.

Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery

Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.

Impact of Managing Provider Type on Severe Aortic Stenosis Management and Mortality

Background Many patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow-up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS). Methods and Results We identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow-up, AVR, and mortality, as well as the independent association of cardiac specialist follow-up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate-adjusted cause-specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time-dependent covariates for follow-up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow-up (hazard ratio [HR], 0.47 [95% CI, 0.43-0.50], P<0.0001) and AVR (HR, 0.58 [95% CI, 0.53-0.64], P<0.0001) and with higher 1-year mortality (HR, 1.45 [95% CI, 1.26-1.66], P<0.0001). Cardiac specialist follow-up and AVR were independently associated with lower mortality (follow-up: HR, 0.55 [95% CI, 0.48-0.63], P<0.0001; AVR: HR, 0.70 [95% CI, 0.60-0.83], P<0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities. Conclusions For patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow-up and AVR and risk of mortality between primary care provider- versus cardiologist-managed patients with sAS. In addition, a lower likelihood of receiving follow-up and AVR was independently associated with higher mortality.

Management of patients with mitral regurgitation ineligible for standard therapy undergoing TMVI screening

BACKGROUND

Transcatheter mitral valve implantation (TMVI) represents a novel treatment alternative for patients with severe mitral regurgitation (MR) considered ineligible for standard therapies. Data on the management of patients after TMVI screening are scarce.

AIMS

We aimed to investigate outcomes of patients with severe MR undergoing TMVI evaluation treated with either TMVI, bailout-transcatheter edge-to-edge repair (bailout-TEER) or medical therapy (MT).

METHODS

Between May 2016 and February 2021, 121 patients with MR considered ineligible for standard therapy were screened for TMVI. Outcomes were assessed for the subgroups of patients treated with TMVI, bailout-TEER and MT. The primary composite endpoint was all-cause death or heart failure hospitalisation after one year.

RESULTS

The subgroups of TMVI (N=38), bailout-TEER (N=28) and MT (N=44) differed significantly with regard to MR aetiology (secondary MR: TMVI 68.4%, bailout-TEER 39.3%, MT 38.6%, p=0.014) and left ventricular ejection fraction (TMVI 37.0% [31.4-51.2], bailout-TEER 48.0% [35.3-58.3], MT 54.5% [40.8-60.0], p<0.001). At discharge and after one year, MR was reduced to ≤mild residual MR in all patients undergoing TMVI, while ≥moderate residual MR was present in 25.9% and 20.0% of patients, respectively, after bailout-TEER, and in 100.0% of patients on MT at one year. The primary endpoint occurred in 72.2% of patients remaining on MT, in 51.6% of patients undergoing TMVI and in 40.2% of those receiving bailout-TEER.

CONCLUSIONS

In MR patients considered ineligible for standard therapy, TMVI provided acceptable clinical outcomes and MR elimination in the majority of patients. In screen-failed patients, bailout-TEER represented a reasonable alternative while MT was associated with poor outcomes.

Three-year outcomes of transcatheter aortic valve implantation for bicuspid versus tricuspid aortic stenosis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) might be a feasible treatment option for more patients with bicuspid aortic valve (BAV) stenosis. However, long-term follow-up data in this population are scarce.

AIMS

The aim of this study was to evaluate three-year outcomes after TAVI in patients with BAV.

METHODS

A total of 246 consecutive patients who underwent TAVI at a single centre in China between March 2013 and February 2018 were enrolled in this study. Clinical outcomes, health status and echocardiography were followed and recorded for three years.

RESULTS

Among 109 (44.3%) BAV patients, 61.5% were Type 0 and 36.7% were Type 1 BAV patients. BAV patients were younger (75 vs 77 years, p=0.041) and had a lower Society of Thoracic Surgeons (STS) score (5.09 vs 6.00, p=0.026) compared to tricuspid aortic valve (TAV) patients. There were no differences in three-year survival rates between bicuspid and tricuspid patients (87.1% vs 79.5%, log-rank p=0.126). Multivariate Cox regression analysis adjusting for confounding factors revealed a similar risk of all-cause mortality in the BAV population (hazard ratio [HR] 0.86, 95% confidence interval [CI]: 0.44-1.70, p=0.666). Except for the rate of permanent pacemaker implantation that was lower in BAV patients (11.9% vs 21.9%, p=0.041), the incidence of other clinical adverse events was comparable between the two groups. Both BAV and TAV patients showed an obvious improvement in valve haemodynamics, which was sustained for three years. In addition, similar left ventricular reverse remodelling was found during follow-up.

CONCLUSIONS

BAV patients showed similar satisfactory three-year clinical outcomes, persistent valve haemodynamics improvement, and obvious cardiac reverse remodelling after TAVI compared to TAV patients.

A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke

Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20-30% of ischemic strokes are unknown, and thus are termed "cryptogenic strokes". About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in "cryptogenic strokes", is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended. Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state. We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.

Timing of Patient Management Decisions Relative to Echocardiography in Staphylococcus aureus Bacteremia; A Single-Center Retrospective Analysis

Background

In patients with Staphylococcus aureus bacteremia (SAB), endocarditis evaluation includes transthoracic echocardiography (TTE) and, in patients at increased risk of endocarditis, subsequent transesophageal echocardiography (TEE). In patients deemed to warrant TEE, it has not been well-studied whether performing TTE prior to TEE influences clinicians’ decision-making.

Methods

This retrospective case series studied clinician behavior at a large Veterans Affairs medical center regarding the care of adult patients diagnosed with SAB who completed both TTE and TEE (n = 206 episodes of SAB). The timing of key patient management decisions were compared to the timing of the patient’s TTE and TEE. It was inferred whether each management decision could have been informed by TTE alone versus TTE plus subsequent TEE. Management decisions included: documentation of antibiotic treatment duration, initiation of synergistic antibiotics, consultation of relevant specialists, ordering of relevant imaging studies, and performance of valve surgery or cardiac device explanation.

Results

The primary outcome (any of the above five management decisions taking place) occurred after completion of TTE but prior to TEE in 13 SAB episodes (6.3%). The primary outcome occurred after completion of both TTE and TEE in 178 SAB episodes (86.4%). Documentation of antibiotic treatment duration accounted for the large majority of observed management decisions.

Conclusion

Among patients with SAB who are deemed to warrant TEE for endocarditis evaluation, TTE results alone rarely prompt clinical management decisions.

Mechanisms and Drug Therapies of Bioprosthetic Heart Valve Calcification

Valve replacement is the main therapy for valvular heart disease, in which a diseased valve is replaced by mechanical heart valve (MHV) or bioprosthetic heart valve (BHV). Since the 2000s, BHV surpassed MHV as the leading option of prosthetic valve substitute because of its excellent hemocompatible and hemodynamic properties. However, BHV is apt to structural valve degeneration (SVD), resulting in limited durability. Calcification is the most frequent presentation and the core pathophysiological process of SVD. Understanding the basic mechanisms of BHV calcification is an essential prerequisite to address the limited-durability issues. In this narrative review, we provide a comprehensive summary about the mechanisms of BHV calcification on 1) composition and site of calcifications; 2) material-associated mechanisms; 3) host-associated mechanisms, including immune response and foreign body reaction, oxidative stress, metabolic disorder, and thrombosis. Strategies that target these mechanisms may be explored for novel drug therapy to prevent or delay BHV calcification.

Invasive Hemodynamic Assessment and Procedural Success of Transcatheter Tricuspid Valve Repair-Important Factors for Right Ventricular Remodeling and Outcome

Introduction

Severe tricuspid regurgitation (TR) is a common condition promoting right heart failure and is associated with a poor long-term prognosis. Transcatheter tricuspid valve repair (TTVR) emerged as a low-risk alternative to surgical repair techniques. However, patient selection remains controversial, particularly regarding the benefits of TTVR in patients with pulmonary hypertension (PH).

Aim

We aimed to investigate the impact of preprocedural invasive hemodynamic assessment and procedural success on right ventricular (RV) remodeling and outcome.

Methods

All patients undergoing TTVR with a TR reduction of ≥1 grade without precapillary or combined PH [mean pulmonary artery pressure (mPAP) ≥25 mmHg, mean pulmonary artery Wedge pressure ≤ 15 mmHg, pulmonary vascular resistance ≥3 Wood units] were assigned to the responder group. All patients with a TR reduction of ≥1 grade and precapillary or combined PH were classified as non-responders. Patients with a TR reduction ≥2 grade were directly classified as responders, and patients without TR reduction were directly assigned as non-responders.

Results

A total of 107 patients were enrolled, 75 were classified as responders and 32 as non-responders. We observed evidence of significant RV reverse remodeling in responders with a decrease in RV diameters (-2.9 mm, p = 0.001) at a mean follow-up of 229 days (±219 SD) after TTVR. RV function improved in responders [fractional area change (FAC) + 5.7%, p < 0.001, RV free wall strain +3.9%, p = 0.006], but interestingly further deteriorated in non-responders (FAC -4.5%, p = 0.003, RV free wall strain -3.9%, p = 0.007). Non-responders had more persistent symptoms than responders (NYHA ≥3, 72% vs. 11% at follow-up). Subsequently, non-response was associated with a poor long-term prognosis in terms of death, heart failure (HF) hospitalization, and re-intervention after 2 years (freedom of death, HF hospitalization, and reintervention at 2 years: 16% vs. 78%, log-rank: p < 0.001).

Conclusion

Hemodynamic assessment before TTVR and procedural success are significant factors for patient prognosis. The hemodynamic profiling prior to intervention is an essential component in patient selection for TTVR. The window for edge-to-edge TTVR might be limited, but timely intervention is an important factor for a better outcome and successful right ventricular reverse remodeling.

Clinical, echocardiographic and prognostic outcomes of patients with concordant and discordant high-gradient aortic stenosis in an Asian cohort

Literature of patients with severe high-gradient aortic stenosis (HG AS) (mean pressure gradient [MPG] ≥ 40 mmHg and aortic valve area [AVA] ≥ 1.0 cm2) remains limited. This study seeks to compare the prognostic outcomes of patients with high-gradient concordant (HGCON-AS) and discordant AS (HGDIS-AS) in an Asian cohort. From 2010 to 2015, patients with moderate-to-severe AS with preserved left ventricular ejection fraction (LVEF ≥ 50%) were recruited and stratified into 3 groups based on index echocardiogram-(1) HGDIS-AS, (2) HGCON-AS and (3) moderate AS (MOD-AS). The primary study endpoints was all-cause mortality, with secondary endpoints of congestive heart failure (CHF) admissions and aortic valve replacement (AVR). Multivariable Cox regression was used and Kaplan-Meier curves were constructed to evaluate associations between HGDIS-AS, HGCON-AS and MOD-AS, and the study outcomes. A total of 467 patients were studied, comprising of 6.2% HGDIS-AS, 13.9% HGCON-AS and 79.9% MOD-AS patients. There was significantly higher AVR rates in the HGCON-AS group (58.5%), followed by HGDIS-AS (31.0%) and MOD-AS (4.6%), p < 0.001) groups. After adjusting for confounders, HGCON-AS was significantly associated with all-cause mortality (HR 3.082, 95% CI 1.479-6.420, p = 0.003) and CHF admissions (HR 12.728, 95% CI 2.922-55.440 p = 0.001) but not HGDIS-AS, with MOD-AS as the reference group. Both HGDIS-AS (HR 7.715, 95% CI 2.927-20.338; p < 0.001) and HGCON-AS (HR 21.960, 95% CI 10.833-44.515, p < 0.001) were independent predictors of AVR. After exclusion of reversible high-flow states, HGDIS-AS patients appear to have a more favourable prognostic profile compared to HGCON-AS patients. Large prospective interventional studies examining the prognostic differences between the two groups will be the next important step.

Transcatether Aortic Valve Implantation to Treat Degenerated Surgical Bioprosthesis: Focus on the Specific Procedural Challenges

Actually transcatheter aortic valve implantation within failed surgically bioprosthetic valves (VIV-TAVI) is an established procedure in patients at high risk for repeat surgical aortic valve intervention. Although less invasive than surgical reintervention, VIV-TAVI procedure offers potential challenges, such as higher rates of prosthesis-patient mismatch and coronary obstruction. Thus, optimal procedural planning plays an important role to minimize the risk of procedure complications. In this review, we describe the key points of a VIV-TAVI procedure to optimize outcomes and reduce the risk of procedure complications.

Association between Large Arteries Diameter and Heart Function in Subjects Free of Cardiovascular Diseases

To investigate the association between Aorta (Ao), pulmonary artery (PA) diameters and the PA/Ao ratio with right (RV) and left ventricle (LV) volumetric properties in subjects free of cardiovascular diseases. In the KORA-MRI study, 339 subjects (mean age 56.3 ± 9.1 years; 43.7% female) underwent whole-body 3T-MRI. Ao and PA were measured on DIXON sequences. Cvi42 quantified cardiac functional parameters from a SSFP sequence. The relationship between ascending (AAo), and descending aorta (DAo), as well as PA diameters, and RV and LV function were assessed using linear regression models adjusted for age, sex, and cardiovascular risk factors. AAo and DAo diameter were associated with LV end-diastolic volume (β = 4.52, p = 0.015; ß = 7.1, p ≤ 0.001), LV end-systolic volume (β = 2.37, p = 0.031; ß = 3.66, p = 0.002), while DAo associated with RV end-diastolic volume (β = 6.45, p = 0.006) and RV end-systolic volume (β = 3.9, p = 0.011). PA diameter was associated with LV end-diastolic volume (β = 4.81, p = 0.003). Interestingly, the PA/Ao ratio was only associated with RV end-diastolic and end-systolic volume (β = 4.48, p = 0.029; ß = 2.82, p = 0.037). Furthermore, we found different relationships between men and women. Ao and PA diameter were associated with LV and RV volumetric parameters in subjects free of cardiovascular diseases suggesting that ventricular volumetric performance directly relates to vascular diameter properties.

Same-Day Discharge After Transcatheter Aortic Valve Implantation: Insights from the Nationwide Readmission Database 2015 to 2019

Background There is a paucity of data on the feasibility of same-day discharge (SDD) following transcatheter aortic valve implantation (TAVI) at a national level. Methods and Results This study used data from the Nationwide Readmission Database from the fourth quarter of 2015 through 2019 and identified patients undergoing TAVI using the claim code 02RF3. A total of 158 591 weighted hospitalizations for TAVI were included in the analysis. Of the patients undergoing TAVI, 961 (0.6%) experienced SDD. Non-SDDs included 65 814 (41.5%) patients who underwent TAVI who were discharged the next day, and 91 816 (57.9%) discharged on the second or third day. The 30-day readmission rate for SDD after TAVI was similar to non-SDD TAVI (9.8% versus 8.9%, P=0.31). The cumulative incidence of 30-day readmissions for SDD was higher compared with next-day discharge (log-rank P=0.01) but comparable to second- or third-day discharge (log-rank P=0.66). At 30 days, no differences were observed in major or minor vascular complications, heart failure, or ischemic stroke for SDD compared with non-SDD. Acute kidney injury, pacemaker implantation, and bleeding complications were lower with SDD. Predictors associated with SDD included age <85 years, male sex, and prior pacemaker placement, whereas left bundle-branch block, right bundle-branch block, second-degree heart block, heart failure, prior percutaneous coronary intervention, and atrial fibrillation were negatively associated with SDD. Conclusions SDD following TAVI is associated with similar 30-day readmission and complication rates compared with non-SDD. Further prospective studies are needed to assess the safety and feasibility of SDD after TAVI.

Clinical Impact of Heart Team Decisions for Patients With Complex Valvular Heart Disease: A Large, Single-Center Experience

Background

A multidisciplinary approach might be pivotal for the management of patients with valvular heart disease (VHD), but clinical outcome data are lacking.

Methods and Results

At our institution, since 2014, internal guidelines recommended heart team consultations for patients with VHD. The clinical/echocardiographic characteristics, treatment recommendations, performed treatment, and early clinical outcomes of consecutive, hospitalized patients with VHD undergoing heart team evaluation were collected. Surgical risk was prospectively assessed by the EuroSCORE II and STS‐PROM. The primary end point of the study was early mortality. A total of 1004 patients with VHD with high clinical complexity (mean age, 75 years; mean EuroSCORE II, 9.4%; mean STS‐PROM, 5.6%; 48% ischemic heart disease; 29% chronic kidney disease, 9% oncologic/hematologic diseases) were enrolled. The heart team recommended an interventional treatment for 807 (80%) patients and conservative management for 197 (20%) patients. Management crossovers occurred in only 5% of patients. The recommended intervention was cardiac surgery for 230 (23%) patients, percutaneous treatment in 516 (51%) patients, and hybrid treatment in 61 (6%) patients. Early mortality occurred in 24 patients (2.4%) and was independently predicted by aortic stenosis, left ventricular ejection fraction, pulmonary artery systolic pressure, and conservative management recommendation. In patients referred to treatment, observed early mortality (1.7%) was significantly lower (P<0.001) than expected on the bases of both the STS‐PROM (5.2%) and EuroSCORE II (9.7%).

Conclusions

Within the limitations of its single‐center and observational design, the present study suggests that heart team–based management of patients with complex VHD is feasible and allows referral to a wide spectrum of interventions with promising early clinical results.

Infective Endocarditis Complicated With Septic Embolic Stroke After Transcatheter Aortic Valve Implantation: A Case Report

Transcatheter aortic valve implantation (TAVI) is a relatively novel procedure developed for aortic stenosis (AS) management in patients with moderate to high surgical risk, especially the elderly with multiple comorbidities. Infective endocarditis following transcatheter aortic valve implantation (post-TAVI-IE) is an uncommon complication that contributes to very high morbidity and mortality. Further complications from post-TAVI-IE include ischemic stroke from septic emboli. Here, we report a case of an 82-year-old man with severe symptomatic AS who underwent TAVI, presenting with fever and alteration of consciousness, which was diagnosed as post-TAVI-IE per Duke criteria complicated by acute hemiparesis from septic emboli stroke. He was treated successfully conservatively using antibiotics. We have reviewed the options of treatment and outcomes for post-TAVI-IE.

Transcriptome Sequencing Data Reveal LncRNA-miRNA-mRNA Regulatory Network in Calcified Aortic Valve Disease

Background

Calcified aortic valve disease (CAVD) is one of the most common valvular heart diseases in the elderly population. However, no effective medical treatments have been found to interfere with the progression of CAVD, and specific molecular mechanisms of CAVD remain unclear.

Materials and Methods

Transcriptome sequencing data of GSE55492 and GSE148219 were downloaded from the European Nucleotide Archive, and the microarray dataset, GSE12644 was acquired from the Gene Expression Omnibus database. Software, including FastQC, HISAT2, samtools, and featureCounts was applied to generate the read count matrix. The “Limma” package in R was utilized to analyze differentially expressed genes (DEGs). Thereafter, weighted gene co-expression network analysis, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, and the protein-protein interaction (PPI) network were used to identify hub genes associated with CAVD, which were further validated by receiver operating characteristic curve (ROC) analysis using GSE12644. The long non-coding RNA (LncRNA)-mediated regulatory network was established based on the differentially expressed LncRNAs and hub genes, which were detected using quantitative real-time PCR (qRT-PCR) in clinical samples and valve interstitial cells. Moreover, CIBERSORT was used to calculate the expression distribution of immune cell infiltration in CAVD.

Results

A total of 126 DEGs were included in the PPI network. PI3K-Akt signaling pathway, ECM-receptor interaction, hematopoietic cell lineage, cell adhesion molecules, and focal adhesion were the most enriched pathways revealed by KEGG. Four LncRNAs, including TRHDE-AS1, LINC00092, LINC01094, and LINC00702 were considered the differentially expressed LncRNA. SPP1, TREM1, GPM6A, CCL19, CR1, NCAM1, CNTN1, TLR8, SDC1, and COL6A6 were the 10 hub genes identified to be associated with CAVD. Moreover, the calcified aortic valve samples had a greater level of Tregs, naïve B cells, and M0 macrophages than the noncalcified ones, whereas CAVD samples had a lower M2 macrophage expression compared to the noncalcified valve tissues.

Conclusion

The current study identified SPP1, TREM1, TLR8, SDC1, GPM6A, and CNTN1 as hub genes that could potentially be associated with CAVD. The LINC00702–miR-181b-5p–SPP1 axis might participate in the development of CAVD. Additionally, M2 macrophages, Tregs, naïve B cells, and M0 macrophages might possibly play a role in the initiation of CAVD.

Structural Heart Valve Disease in the Era of Change and Innovation: The Crosstalk between Medical Sciences and Engineering

In recent years, both cardiology and cardiovascular surgery have witnessed an era of consistently evolving changes which have dramatically transformed the course and management of cardiovascular disease [...].

Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines

Antiplatelet therapy, mainly consisting of aspirin and P2Y₁₂ receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.

Concomitant Hepatorenal Dysfunction and Malnutrition in Valvular Heart Surgery: Long‐Term Prognostic Implications for Death and Heart Failure

Background

Strategies to improve long‐term prediction of heart failure and death in valvular surgery are urgently needed because of an increasing number of procedures globally. This study sought to report the prevalence, changes, and prognostic implications of concomitant hepatorenal dysfunction and malnutrition in valvular surgery.

Methods and Results

In 909 patients undergoing valvular surgery, 3 groups were defined based on hepatorenal function (the modified model for end‐stage liver disease excluding international normalized ratio score) and nutritional status (Controlling Nutritional Status score): normal hepatorenal function and nutrition (normal), hepatorenal dysfunction or malnutrition alone (mild), and concomitant hepatorenal dysfunction and malnutrition (severe). Overall, 32%, 46%, and 19% of patients were classified into normal, mild, and severe groups, respectively. Over a 4.1‐year median follow‐up, mild and severe groups incurred a higher risk of mortality (hazard ratio [HR], 3.17 [95% CI, 1.40–7.17] and HR, 9.30 [95% CI, 4.09–21.16], respectively), cardiovascular death (subdistribution HR, 3.29 [95% CI, 1.14–9.52] and subdistribution HR, 9.29 [95% CI, 3.09–27.99]), heart failure hospitalization (subdistribution HR, 2.11 [95% CI, 1.25–3.55] and subdistribution HR, 3.55 [95% CI, 2.04–6.16]), and adverse outcomes (HR, 2.11 [95% CI, 1.25–3.55] and HR, 3.55 [95% CI, 2.04–6.16]). Modified model for end‐stage liver disease excluding international normalized ratio and controlling nutritional status scores improved the predictive ability of European System for Cardiac Operative Risk Evaluation (area under the curve: 0.80 versus 0.73, P<0.001) and Society of Thoracic Surgeons score (area under the curve: 0.79 versus 0.72, P=0.004) for all‐cause mortality. One year following surgery (n=707), patients with persistent concomitant hepatorenal dysfunction and malnutrition (severe) experienced worse outcomes than those without.

Conclusions

Concomitant hepatorenal dysfunction and malnutrition was frequent and strongly linked to heart failure and mortality in valvular surgery.

Early outcomes of transcatheter versus surgical aortic valve implantation in patients with bicuspid aortic valve stenosis

BACKGROUND

Limited information is available on outcomes in patients with bicuspid aortic valve (BAV) stenosis undergoing transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR), as pivotal randomised trials excluded patients with BAV pathology due to anatomic complexity.

AIMS

The aim of the study was to compare early outcomes between TAVI and SAVR in patients with BAV stenosis.

METHODS

We queried the Nationwide Readmission Database (NRD) between 2016 and 2018 to identify adults who underwent TAVI or SAVR for BAV stenosis. The study's primary outcome was in-hospital mortality. Secondary outcomes were 30-day and six-month major adverse cardiovascular events (MACE). We matched both cohorts using propensity score matching, and applied logistic and Cox-proportional hazard regression to compute the odds ratio (OR), the hazard ratio (HR), and the 95% confidence interval (CI).

RESULTS

Out of 17,068 patients with BAV stenosis, 1,629 (9.5%) patients underwent TAVI and 15,439 (90.5%) underwent SAVR. After propensity score matching (PSM), we found 1,393 matched pairs. Of the matched pairs, 848 had complete six-month follow-ups. In the PSM cohort, TAVI was associated with reduced in-hospital mortality (0.7% vs 1.8%, OR: 0.35, 95% CI: 0.13-0.93; p=0.035), and a similar rate of MACE at 30 days (1% vs 1.5%, OR: 0.65, 95% CI: 0.27-1.58; p=0.343) and at six months (4.2% vs 4.9%, HR 0.86, 95% CI: 0.44-1.69; p=0.674), compared with SAVR.

CONCLUSIONS

In the propensity score-matched cohort, TAVI was associated with reduced odds of in-hospital mortality and a similar risk of 30-day and six-month MACE, supporting the feasibility of TAVI in BAV patients without a need for concurrent aortic root repair.

Tricuspid Structural Valve Deterioration Treated with a Transcatheter Valve-in-Valve Implantation: A Single-Center Prospective Registry

The valve-in-valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the tricuspid position. We report on the outcomes of patients treated by a transcatheter tricuspid valve-in-valve (TT-ViV) implantation for symptomatic SVD in the tricuspid position during the years 2010-2019 at our center. Three main outcomes were examined during the follow-up period: TT-ViV hemodynamic data per echocardiography, mortality and NYHA functional class. Our cohort consisted of 12 patients with a mean age 65.4 ± 11.9 years, 83.3% male. The mean time from initial valve intervention to TT-ViV was 17.4 ± 8.7 years. The indications for TT-ViV were varied (41.7% for predominant regurgitation, 33.3% for predominant stenosis and 25.0% with a mixed pathology). All patients were treated with a balloon-expandable device. The mean follow-up was 3.4 ± 1.3 years. Tricuspid regurgitation was ≥ moderate in 57.2% of patients prior to the procedure and this decreased to 0% following the procedure. The mean transtricuspid valve gradients mildly decreased from the mean pre-procedural values of 9.0 mmHg to 7.0 mmHg at one month following the procedure (p = 0.36). Mortality at one year was 8.0% (95% CI 0-23). At the baseline, 4 patients (33.3%) were in NYHA functional class III/IV; this was reduced to 2 patients (18.2%) at the one year follow-up and both were in NYHA III. The TT-ViV procedure offered a safe, feasible and less invasive treatment option for patients with SVD in our detailed cohort.

Clinical Impact of Computational Heart Valve Models

This paper provides a review of engineering applications and computational methods used to analyze the dynamics of heart valve closures in healthy and diseased states. Computational methods are a cost-effective tool that can be used to evaluate the flow parameters of heart valves. Valve repair and replacement have long-term stability and biocompatibility issues, highlighting the need for a more robust method for resolving valvular disease. For example, while fluid-structure interaction analyses are still scarcely utilized to study aortic valves, computational fluid dynamics is used to assess the effect of different aortic valve morphologies on velocity profiles, flow patterns, helicity, wall shear stress, and oscillatory shear index in the thoracic aorta. It has been analyzed that computational flow dynamic analyses can be integrated with other methods to create a superior, more compatible method of understanding risk and compatibility.

New Evidence About Aortic Valve Stenosis and Cardiovascular Hemodynamics

Aortic stenosis (AS) is the most common degenerative valvular disease in western word. In patients with severe AS, small changes in aortic valve area can lead to large changes in hemodynamics. The correct understanding of cardiac hemodynamics and its interaction with vascular function is of paramount importance for correct identification of severe AS and to plan effective strategies for its treatment. In the current review with highlight the importance of pressure recovery phenomenon and valvular arterial impedance as novel tools in the evaluation of patients with aortic stenosis.

ANMCO position paper: 2022 focused update of appropriate use criteria for multimodality imaging: aortic valve disease

This document addresses the evaluation of the Appropriate Use Criteria (AUC) of multimodality imaging in the diagnosis and management of aortic valve disease. The goal of this AUC document is to provide a comprehensive resource for multimodality imaging in the context of aortic valve disease, encompassing multiple imaging modalities. Clinical scenarios are developed in a simple way to illustrate patient presentations encountered in everyday practice.

Tricuspid Annulus Dilation in Patients With Combined Functional Tricuspid Regurgitation and Left-Heart Valvular Disease: Does Septal Annulus Not Dilate?

Background

This study aimed to investigate the course of tricuspid annulus dilation in functional tricuspid regurgitation with varied severities by direct intraoperative assessment.

Methods

A total of 317 patients who underwent left heart surgery and concomitant tricuspid repair were divided into three groups according to the severity of the functional tricuspid regurgitation (mild, moderate and severe). Demographic and echocardiographic data were collected. The length of each tricuspid annulus segment was measured intraoperatively. The risk factors for preoperative severe functional tricuspid regurgitation and its postoperative recurrence were identified, and the impact of each tricuspid annulus segment on postoperative recurrence was compared.

Results

In the course of tricuspid annulus dilation, the posterior annulus dilated 17% (group 1: 33.31 ± 6.94 mm vs. group 2: 35.56 ± 7.63 vs. group 3: 38.98 ± 8.70, p < 0.01), the anterior annulus dilated 13.4% (group 1: 36.71 ± 6.30 mm vs. group 2: 38.21 ± 8.35 vs. group 3: 41.63 ± 9.20, p < 0.01), and the septal annulus dilated 11.4% (group 1: 38.11 ± 5.28 mm vs. group 2: 39.76 ± 6.90 vs. group 3: 42.46 ± 7.50, p < 0.01). Tricuspid annulus circumference index (p < 0.01) independently correlated with preoperative severe tricuspid regurgitation and postoperative recurrence. When patients were grouped based on the length of each segment, the septal annulus demonstrated significantly higher sensitivity (p < 0.001) to postoperative recurrence than the anterior (p = 0.085) or posterior annulus (p = 0.262).

Conclusions

This study revealed that each segment of tricuspid annulus could dilate in functional tricuspid regurgitation and highlighted the potential benefits of septal annulus plication in tricuspid annuloplasty, which may aid in the development of a methodology for prosthetic ring annuloplasty.

Association Between Lipoprotein(a) and Calcific Aortic Valve Disease: A Systematic Review and Meta-Analysis

Background

Preliminary studies indicated that enhanced plasma levels of lipoprotein(a) [lp(a)] might link with the risk of calcific aortic valve disease (CAVD), but the clinical association between them remained inconclusive. This systematic review and meta-analysis were aimed to determine this association.

Methods

We comprehensively searched PubMed, Embase, Web of Science, and Scopus databases for studies reporting the incidence of CAVD and their plasma lp(a) concentrations. Pooled risk ratio (RR) and 95% confidence interval (95% CI) were calculated to evaluate the effect of lp(a) on CAVD using the random-effects model. Subgroup analyses by study types, countries, and the level of adjustment were also conducted. Funnel plots, Egger's test and Begg's test were conducted to evaluate the publication bias.

Results

Eight eligible studies with 52,931 participants were included in this systematic review and meta-analysis. Of these, four were cohort studies and four were case-control studies. Five studies were rated as high quality, three as moderate quality. The pooled results showed that plasma lp(a) levels ≥50 mg/dL were associated with a 1.76-fold increased risk of CAVD (RR, 1.76; 95% CI, 1.47–2.11), but lp(a) levels ≥30 mg/dL were not observed to be significantly related with CAVD (RR, 1.28; 95% CI, 0.98–1.68). We performed subgroup analyses by study type, the RRs of cohort studies revealed lp(a) levels ≥50 mg/dL and lp(a) levels ≥30 mg/dL have positive association with CAVD (RR, 1.70; 95% CI, 1.39–2.07; RR 1.38; 95% CI, 1.19–1.61).

Conclusion

High plasma lp(a) levels (≥50 mg/dL) are significantly associated with increased risk of CAVD.

Left Ventricular Remodeling in Non-syndromic Mitral Valve Prolapse: Volume Overload or Concomitant Cardiomyopathy?

Mitral valve prolapse (MVP) is a common valvular disorder that can be associated with mitral regurgitation (MR), heart failure, ventricular arrhythmias and sudden cardiac death. Given the prognostic impact of these conditions, it is important to evaluate not only mitral valve morphology and regurgitation, but also the presence of left ventricular (LV) function and remodeling. To date, several possible hypotheses have been proposed regarding the underlying mechanisms of LV remodeling in the context of non-syndromic MVP, but the exact pathophysiological explanation remains elusive. Overall, volume overload related to severe MR is considered the main cause of LV dilatation in MVP. However, significant LV remodeling has been observed in patients with MVP and no/mild MR, particularly in patients with bileaflet MVP or Barlow's disease, generating several new hypotheses. Recently, the concept of "prolapse volume" was introduced, adding a significant volume load to the LV on top of the transvalvular MR volume. Another possible hypothesis is the existence of a concomitant cardiomyopathy, supported by the link between MVP and myocardial fibrosis. The origin of this cardiomyopathy could be either genetic, a second hit (e.g., on top of genetic predisposition) and/or frequent ventricular ectopic beats. This review provides an overview of the different mechanisms and remaining questions regarding LV remodeling in non-syndromic MVP. Since technical specifications of imaging modalities impact the evaluation of MR severity and LV remodeling, and therefore might influence clinical decision making in these patients, this review will also discuss assessment of MVP using different imaging modalities.

Right-sided infective endocarditis and pulmonary embolism: a multicenter study

The incidence of right-sided infective endocarditis (RSIE) is steadily increasing and it has been reported to be associated with high risk of embolic events (EE). Aim of our study was to identify the clinical characteristics of patients with RSIE complicated by PE. Indeed, the identification of patients at high risk of significant PE who will benefit from a more aggressive therapeutic strategy may improve the prognosis. From January 2015 to September 2020, 176 patients (Pts) in 6 centers were found to have definite RSIE complicated by PE. Advanced imaging for PE including computed tomography pulmonary angiography (CTPA) was performed in 28 pts (16%) who represent our study group (24 male, mean age 50.6 ±18.29 years). They all underwent transesophageal echocardiography (TEE), in 12 cases (43%) also three-dimensional (3D) TEE, and 27 patients (99%) had both TEE and transthoracic echocardiography (TTE). A total of 53 vegetations (V) were detected. In 18 pts (64%) two or more vegetations were found. Native tricuspid valve was the most frequently involved valve (38 V, 71.7%), followed by catheter (5 V, 9.4%), tricuspid valve prosthesis (4 V, 7.5%), chordae and papillary muscle (2 V, 3.8%) and one vegetation (9%) in each of the following: pulmonic valve, inferior vena cava, eustachian valve, and right atrium. The most common location for vegetations was the anterior leaflet of the tricuspid valve (19 V, 35.8 %) followed by the posterior leaflet (11 V, 20.8%). The most common vegetations morphology was raceme-like shaped (35.8%). Staphylococcus aureus (S. aureus) was the most common causative pathogen (14 pts, 50%). The incidence of PE was very high in patients with vegetation length above 1.5 cm (median 17.6±6.5 mm by TEE). Our results suggest that a routine CTPA should be advised in the presence of vegetations larger than 1.5 cm and with S. aureus infection. This behavior would identify patients at high risk of PE who will benefit from a more aggressive therapeutic strategy, leading to an improvement in the prognosis. Further prospective studies are required to better confirm our hypothesis.

A Novel Thrombolytic Regimen for Mechanical Prosthetic Valve Thrombosis in a Patient With Antiphospholipid Syndrome

Management of mechanical prosthetic valve thrombosis (PVT) includes medical and surgical options. Standard medical treatment involves thrombolytic therapy with repeated slow infusions of low-dose IV tissue plasminogen activator (t-PA). The evidence for managing mechanical PVT that does not respond to the standard t-PA dosing is limited in the setting of an exacerbating hypercoagulable condition. We present a case of a patient with a history of antiphospholipid syndrome who presented with a probable thromboembolic myocardial infarction secondary to a mechanical mitral valve thrombosis that did not improve with systemic anticoagulation and repeated standard t-PA dosing but rapidly resolved with ultraslow, high-dose t-PA.

A Challenging Case of Mechanical Mitral Valve Obstruction

Prosthetic valve thrombosis (PVT) is a frequent complication with a mechanical valve that presents with symptoms of heart failure or thromboembolic episodes. A 45-year-old lady with antiphospholipid syndrome (APS) complicated by a previous history of native mitral valve thrombus and mechanical mitral valve replacement maintained on warfarin presented with complaints of chest pain and shortness of breath (NYHA class 2). The initial lab showed a subtherapeutic international normalized ratio (INR) of 1.8. Transthoracic echo (TTE) showed severe mitral stenosis with a normal ejection fraction of 65%, elevated peak gradient of 34.5 mmHg, mean gradient of 23.7 mmHg, and pressure half time of 214 ms. Cine-fluoroscopic images revealed an immobile posterior mitral valve leaflet. She failed two trials of low-dose alteplase therapy during the hospitalization. Hence cardiac CT with contrast was done, which showed a small degree of pannus formation on the ventricular surface of the mitral valve ring and a small thrombus. Due to persistent immobility of the post mitral valve after two doses of alteplase and a cardiac CT scan concerning pannus formation, a multi-departmental decision was made to proceed with mechanical mitral valve replacement, following which she had a good recovery. Our case report depicts the importance of imaging study, like cardiac CT scan that can help distinguish thrombus (which has a lower Hounsfield unit, HU of <90) vs. pannus (higher HU of more than 145).

Etiology, Risk Factors and Clinical Outcomes in Infective Endocarditis Patients Requiring Cardiac Surgery

Background: Infective endocarditis, which may be caused by various microbial agents, severely affects the innermost layer of the heart and often leads to poor clinical outcomes. The purpose of this study was to investigate the etiology, risk factors and short and long-term outcomes of infective endocarditis caused by various bacterial agents in patients requiring cardiac surgery. Methods: One hundred and forty-four patients aged 18 years or above with indications for cardiac surgery due to S. aureus, Streptococcus spp., E. faecalis or coagulase-negative staphylococci caused infective endocarditis were included in this study. Results: S. aureus, Streptococcus spp., E. faecalis and coagulase-negative staphylococci were the causative agents of infective endocarditis in 44 (30.6%), 35 (24.3%), 33 (22.9%) and 32 (22.2%) patients, respectively. The presence of bicuspid aortic valve was the most common predisposing factor confirmed in 19 (23.5%), whereas intravenous drug usage was the most common in 17 (11.8%) patients. No significant differences in intrahospital mortality due to infective endocarditis caused by various bacterial agents were found, however, the worsening of long-term prognosis of endocarditis caused by S. aureus when compared to E. faecalis was confirmed (p = 0.03). The presence of S. aureus was associated with significantly higher rates of embolic complications (p = 0.003). The presence of coagulase-negative staphylococci was associated with prosthetic valve endocarditis (p = 0.015) and perivalvular complications (p = 0.024). Conclusions: In contrast to E. faecalis, the presence of S. aureus determines the worsening of the long-term mortality from infective endocarditis. Perivalvular complications are associated with the presence of coagulase-negative staphylococci.

Patient Prosthesis Mismatch After SAVR and TAVR

Patient-prosthesis mismatch (PPM) remains one out of many factors to be considered during decision-making for the treatment of aortic valve pathologies. The idea of adequate sizing of a prosthetic heart valve was established by Rahimtoola already in 1978. In this article, the author described the phenomenon that the orifice area of a prosthetic heart valve may be too small for the individual patient. PPM is assessed by measurement or projection of the prosthetic effective orifice area indexed to body surface area (iEOA), while it is recommended to use different cut point values for non-obese and obese patients for the categorization of moderate and severe PPM. Several factors influence the accuracy of both the projected and the measured iEOA for PPM assessment, which leads to a certain number of false assignments to the PPM or no PPM group. Despite divergent findings on the impact of PPM on clinical outcomes, there is consensus that PPM should be avoided to prevent sequelae of increased prosthetic gradients after aortic valve replacement. To prevent PPM, it is required to anticipate the iEOA of the prosthesis prior to the procedure. The use of adequate reference tables, derived from echocardiographically measured mean effective orifice area (EOA) values from preferably large numbers of patients, is most appropriate to predict the iEOA. Such tables should be used also for transcatheter heart valves in the future. During the decision-making process, all available options should be taken into account for the individual patient. If the predicted size and type of a surgical prosthesis cannot be implanted, additional surgical procedures, such as annular enlargement with the Manougian technique, or alternative procedures, such as transcatheter aortic valve implantation (TAVI) can prevent PPM. PPM prevention for TAVI patients is a new field of interest and includes anticipation of the iEOA, prosthesis selection, and procedural strategies.

Wearable Smartwatch Facilitated Remote Health Management for Patients Undergoing Transcatheter Aortic Valve Replacement

Background

In the recent decades, the development of novel digital health technologies enables doctors to monitor ECG and vital signs remotely. But the data on applying the noninvasive wearable smartwatch on patients with transcatheter aortic valve replacement (TAVR) are unknown.

Methods and Results

We performed a prospective, observational cohort study to evaluate the feasibility of a novel, virtual, and remote health care strategy for patients with TAVR discharged to home with smart wearable devices. A total of 100 consecutive patients with severe aortic stenosis who underwent elective transfemoral TAVR were enrolled and received the Huawei smartwatch at least 1 day before TAVR. Vital signs, including heart rate, rhythm, oxygen saturation, and activity, were continuously recorded. Single‐lead ECG was recorded twice per day in the week following TAVR discharge and at least 2 days a week for the subsequent month after TAVR discharge. A designated heart team member provided remote health care with the data from the smartwatch when the patient had a need. Thirty‐eight cardiac events were reported in 34 patients after discharge, with most of the events (76.0%) detected and confirmed by the smartwatch. Six patients were advised and readmitted to the hospital for arrhythmia events detected by the smartwatch, of whom 4 patients received pacemaker implantation. The remaining 28 (82.4%) patients received telemedicine monitoring instead of face‐to‐face clinical visits, and 3 of them received new medication treatment under the online guidance of doctors. New‐onset left branch bundle block was found in 48 patients, with transient characteristics, and recovered spontaneously in 30 patients, and new‐onset atrial fibrillation was detected in 4 patients. There were no significant differences in the average weekly heart rates or the ratio of abnormal or low oxygen saturation when compared with the baseline. The average daily steps increased over time significantly (baseline, 870±1353 steps; first week, 1986±2406 steps; second week, 2707±2716 steps; third week, 3059±3036 steps; fourth week, 3678±3485 steps, P <0.001).

Conclusions

Smartwatches can facilitate remote health care for patients discharged to home after undergoing TAVR and enable a novel remote follow‐up strategy. The majority of cardiac clinical events that occurred within 30‐day follow‐up were detected by the smartwatch, mainly because of the record of conduction abnormality.

Registration

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04454177.

Left Atrial Remodeling and Dysfunction in Swine Models of Mitral Regurgitation

BACKGROUND

Left atrial (LA) dysfunction is one of the predictive factors of worse outcomes after mitral valve surgery for mitral regurgitation (MR). We aimed to investigate the effect of MR etiology on progression of LA remodeling in swine MR models.

METHODS

MR was induced in 14 Yorkshire pigs using catheter-based procedures. Seven pigs underwent simultaneous occlusions of the left circumflex artery and the diagonal branch, which resulted in ischemic MR (IMR group). The other seven pigs underwent chordal severing to induce leaflet prolapse simulating degenerative MR (DMR group). Changes in LA volume and function were assessed at baseline, 1 and 3 months using echocardiography and hemodynamic evaluations. Histopathological assessments were conducted to evaluate LA hypertrophy and fibrosis.

RESULTS

At 3 months, quantitative MR severity was comparable and severe in both groups. Despite the similar degree of MR, minimum LA volume index increased significantly more in the IMR group (IMR: 11.9±6.4 to 73.2±6.4, DMR: 10.7±6.4 to 29.5±6.4 ml/m², p_interaction=0.004). Meanwhile, increase in maximum LA volume index was similar between the groups, resulting in lower LA emptying function in the IMR group (IMR: 60.1±3.1 to 29.4±3.1, DMR: 62.4±3.1 to 58.2±3.1%, p_interaction=0.0003). LA reservoir strain assessed by echocardiography was also significantly lower in the IMR group. Histological analyses revealed increased LA cellular hypertrophy and fibrosis in the IMR group.

CONCLUSIONS

Ischemic MR is associated with aggressive remodeling and reduced emptying function compared to MR due to leaflet prolapse. Earlier intervention might be necessary for ischemic MR to prevent LA remodeling.

Diabetes Is Associated With Rapid Progression of Aortic Stenosis: A Single-Center Retrospective Cohort Study

Background

Mounting evidence indicates that rapid progression of aortic stenosis (AS) is significantly associated with poor prognosis. Whether diabetes accelerates the progression of AS remains controversial.

Objectives

The purpose of the present study was to investigate whether diabetes was associated with rapid progression of AS.

Methods

We retrospectively analyzed 276 AS patients who underwent transthoracic echocardiography at least twice with a maximum interval ≥ 180 days from January 2016 to June 2021. AS severity was defined by specific threshold values for peak aortic jet velocity (V_max) and/or mean pressure gradient. An increase of V_max ≥ 0.3 m/s/year was defined as rapid progression. The binary Logistic regression models were used to determine the association between diabetes and rapid progression of AS.

Results

At a median echocardiographic follow-up interval of 614 days, the annual increase of V_max was 0.16 (0.00–0.41) m/s. Compared with those without rapid progression, patients with rapid progression were older and more likely to have diabetes (P = 0.040 and P = 0.010, respectively). In the univariate binary Logistic regression analysis, diabetes was associated with rapid progression of AS (OR = 2.02, P = 0.011). This association remained significant in the multivariate analysis based on model 2 and model 3 (OR = 1.93, P = 0.018; OR = 1.93, P = 0.022). After propensity score-matching according to V_max, diabetes was also associated rapid progression of AS (OR = 2.57, P = 0.045).

Conclusions

Diabetes was strongly and independently associated with rapid progression of AS.

Transcatheter Aortic Valve Replacement with the Self-Expandable Core Valve Evolut Prosthesis Using the Cusp-Overlap vs. Tricusp-View

Despite the rapid increase in experience and technological improvement, the incidence of conduction disturbances in patients undergoing transcatheter aortic valve replacement (TAVR) with the self-expandable CoreValve Evolut valve remains high. Recently, a cusp-overlap view (COP) implantation technique has been proposed for TAVR with self-expandable valves offering an improved visualization during valve expansion compared to the three-cusp view (TCV). This study aims to systematically analyze procedural outcomes of TAVR patients treated with the CoreValve Evolut valve using a COP compared to TCV in a high-volume center. The primary endpoint was technical success according the 2021 VARC-3 criteria. A total of 122 consecutive patients (61 pts. TCV: April 2019 to November 2020; 61 pts. COP: December 2020 to October 2021) that underwent TAVR with the CoreValve Evolut prosthesis were included in this analysis. Although there was no difference in the primary endpoint technical success between TCV and COP patients (93.4% vs. 90.2%, OR 0.65, 95% CI 0.16, 2.4, p = 0.51), we observed a significantly lower risk for permanent pacemaker implantation (PPI) among COP patients (TCV: 27.9% vs. COP: 13.1%, OR 0.39, 95% CI 0.15, 0.97, p = 0.047). Implantation of the CoreValve Evolut prosthesis using the COP might help to reduce the rate of PPI following TAVR.

Transfemoral aortic valve replacement in a nonagenarian with aortic stenosis and cardiac amyloidosis: case report

BACKGROUND

Cardiac amyloidosis (CA) is diagnosed with increasing frequency in the elderly population with severe aortic stenosis (AS), especially with the low-flow, low- gradient phenotype. Prognosis is poor with no treatment.

CASE PRESENTATION

The patient is a 94-year-old active male who presented with a stroke that fully resolved. He was found to have low-flow, low-gradient severe AS, along with concomitant CA. Gradients across the aortic valve worsened with the dobutamine challenge test. He underwent successful transfemoral aortic valve replacement (TAVR) and did well postoperatively, where he remained in the hospital for only one day. Treatment of his CA with Tafamidis was recommended; however, the patient declined due to its cost and personal preference.

CONCLUSION

To our knowledge, we report on one of the oldest patients to undergo TAVR for low-flow, low-gradient AS with concurrent CA (AS-CA). It might be prudent to screen elderly patients with AS for CA, as prognosis is worse with medical management alone. TAVR has overall improved survival in patients with AS-CA and is considered the procedure of choice, as these patients are typically older and at higher risk for surgical intervention.

Impact of 3D Rigid Ring Annuloplasty for Tricuspid Regurgitation: A Systematic Review and Meta-Analysis

Background

Tricuspid annuloplasty (TAP) is accepted as the standard technique for correcting tricuspid regurgitation (TR). We conducted the present study to provide an overview of the contemporary results of 3D rigid ring annuloplasty for TR.

Methods

A systematic literature search was carried out in eight databases to collect all relevant studies on the three-dimensional (3D) rigid ring annuloplasty treatment of TR published before October 1, 2020. The main outcomes of interest were postoperative TR grade, perioperative mortality, and recurrent TR.

Results

A total of eight studies were included, all of which were retrospective observational studies. Rigid 3D rings were compared with flexible bands, and there was no difference in perioperative mortality [odds ratio (OR) = 1.02; 95% CI (0.52, 2.02); p = 0.95], late mortality [OR = 0.99; 95% CI (0.28, 3.50); p = 0.98], or recurrent TR [OR = 0.59; 95% CI (0.29, 1.21); p = 0.15]. The postoperative TR grade associated with 3D rigid rings was 0.12 lower [mean difference (MD) = −0.12; 95% CI (−0.22, −0.01); p = 0.03], which indicated that 3D rigid rings result in better postoperative outcomes than flexible bands. Compared with suture annuloplasty, the postoperative TR grade of the 3D rigid ring group was 0.51 lower [MD = −0.51; 95% CI (−0.59, −0.43); p &lt; 0.05]. Within the 5 years of follow-up, patients who underwent 3D rigid ring annuloplasty had lower TR recurrence [OR = 0.26; 95% CI (0.13, 0.50); p &lt; 0.05].

Conclusions

Compared with suture annuloplasty, 3D rigid rings present early advantages. The 3D rigid rings provide an acceptable short-term effect similar to that of the flexible bands, and a significant difference between these approaches was not discovered. However, the conclusion was based on the limited, short-term data available at the time of the study. Further research on the long-term effects of 3D rigid ring annuloplasty for TR is clearly needed.

Systematic Review Registration

https://inplasy.com/inplasy-2021-3-0105/, identifier: 202130105.

Expanding the Team: Optimizing the Multidisciplinary Management of Drug Use-Associated Infective Endocarditis

Amidst a substance use epidemic, hospitalizations and valve surgeries related to drug use-associated infective endocarditis (DU-IE) rose substantially in the last decade. Rates of reoperation and mortality remain high, yet in many hospitals patients are not offered valve surgery or evidence-based addiction treatment. A multidisciplinary team approach can improve outcomes in patients with infective endocarditis; however, the breadth of expertise that should be incorporated into this team is inadequately conceptualized. It is our opinion that incorporating addiction medicine services into the team may improve outcomes in DU-IE. Here, we describe our experience incorporating addiction medicine services into the multidisciplinary management of DU-IE and share implications for other hospitals and health systems looking to improve care for people with DU-IE.

Design Variation, Implantation, and Outcome of Transcatheter Mitral Valve Prosthesis: A Comprehensive Review

The transcatheter mitral valve prosthesis is ideally suited for patients with inoperable mitral etiology. The transcatheter mitral valve implantation (TMVI) procedure has closely followed the evolution of transcatheter aortic procedures. There are considerable design variations amongst the limited TMVI prostheses currently available, and the implantation profiles of the devices are notably different. This comprehensive review will provide an overview of the current clinically tried TMVI devices with a focused outcome analysis. In addition, we have discussed the various design characteristics of TMVI and its associated failure mode, implantation technology, delivery methods, first-in-man trials, and pivotal trial summary for the synthesis of recent evidence.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255241, identifier: CRD42021255241.