Global epidemiology of valvular heart disease

Purinergic ecto-enzymes in human and ovine aortic valves: indicators of bacterial nanocellulose scaffold cellularization

Purinergic signalling pathways play a vital role in the biological functions of the aortic valve (AV) through nucleotide and adenosine-dependent receptor effects. This study focused on characterizing a side-specific purinergic cascade in human non-stenotic and stenotic AVs, ovine native AVs and a novel bacterial nanocellulose (BNC) bio-prosthesis in an ovine model. Human stenotic AVs were collected during replacement surgeries, while non-stenotic AVs came from heart transplant patients. Ovine native AVs were sourced from domestic sheep, and the BNC prosthesis was implanted in the ovine aorta for six months, with hemodynamic monitoring throughout. Biochemical assessments revealed a beneficial ecto-enzyme pattern in non-stenotic and native AVs, contrasting with a detrimental pattern in stenotic valves. The BNC prosthesis demonstrated significantly lower nucleotide conversion activities than native valves and displayed increased peripheral blood mononuclear cell adhesion on its aortic surface. These findings suggest that nucleotide-converting ecto-enzymes could serve as markers for the biological activity of AV prostheses, highlighting the need for further studies to enhance the cellularization of BNC prostheses, potentially through adenosine-releasing scaffold modifications.

Early aortic valve replacement versus conservative management in asymptomatic severe aortic stenosis: Meta-analysis of time-to-event data of randomized controlled trials

BACKGROUND

Current guidelines recommend aortic valve replacement (AVR) for symptomatic patients with severe aortic stenosis (AS), but the optimal timing for intervention in asymptomatic patients is still debated. Recent randomized controlled trials (RCTs) have offered new insights, prompting a reevaluation of the potential benefits of early AVR.

METHODS

A systematic review and pooled meta-analysis of Kaplan-Meier-derived reconstructed time-to-event data of RCTs published by November 2024 was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Outcomes were derived from the primary endpoints of the included studies, with the main analysis focusing on all-cause mortality, cardiovascular mortality, and heart failure hospitalization.

RESULTS

Four randomized controlled trials, involving 1427 patients, were included. The early AVR group demonstrated a significant reduction in all-cause mortality (hazard ratio [HR] = 0.72, 95 % confidence interval [CI] 0.53-0.97, p = 0.031), cardiovascular mortality (HR = 0.56, 95 % CI 0.36-0.89, p = 0.014), and heart failure hospitalization (HR = 0.31, 95 % CI 0.18-0.53, p < 0.001). No significant interaction effects between surgical AVR and transcatheter AVR were observed. Additionally, in the conservative management group, the conversion to AVR was substantial, with a median time to conversion of 13.4 months. The cumulative conversion rates were 42.8 % (95 % CI 38.6 %-46.7 %) at 1 year, 82.3 % (95 % CI 78.6 %-85.3 %) at 3 years, and 94.9 % (95 % CI 91.4 %-96.9 %) at 5 years.

CONCLUSION

Early AVR in asymptomatic patients with severe AS is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and heart failure hospitalization compared to conservative management.

Engineering of Bioprosthetic Heart Valves with Synergistic Zwitterionic Surface Modification and Zirconium Cross-linking for Improved Biocompatibility and Durability

Bioprosthetic heart valves (BHVs) are frequently utilized in surgeries for heart valve replacement to address valvular heart disease (VHD). Despite their widespread use, BHVs still face challenges in clinical applications, such as thrombosis, calcification, immune responses, poor re-endothelialization, infection, component degradation, and mechanical failure, which are largely due to the heterogeneous cross-linking effects. To address these issues, we propose a synergistic engineering strategy based on sequential zwitterionic surface modification and zirconium cross-linking to improve the biocompatibility and durability of BHVs. After surface modification via ring-opening reactions of zwitterionic epoxy copolymers (PGSB) on collagen fibers of decellularized porcine pericardium (D-PP), the zwitterionic PGSB significantly promoted the uniform transfer of zirconium ions (Zr4+) and further coordinated with Zr4+ to achieve homogeneous cross-linking between collagen fibers. Compared to conventional glutaraldehyde (GA)-cross-linked PP, PGSB/Zr-PP showed enhanced anti-thrombotic performance, attenuated immune rejection, accelerated endothelialization, and over 95% reduction in calcification after 90 days of subcutaneous implantation, collectively indicating improved biocompatibility. Furthermore, this homogeneously cross-linked PGSB/Zr-PP exhibited undetectable component degradation and simultaneous improvements in both strength and toughness, all of which are essential for improving the durability of BHVs. Intriguingly, the zwitterionic sulfobetaine groups could be converted into bactericidal quaternary ammonium groups upon coordination with Zr4+, resulting in strong antibacterial and anti-biofilm activities beneficial for preventing life-threatening prosthetic valve endocarditis. More importantly, PGSB/Zr-PP met the ISO 5840-3 standards required for BHV applications in terms of hydrodynamic performance and 200-million-cycle durability. These results demonstrate that PGSB/Zr-PP would be a promising alternative to GA-cross-linked BHVs. STATEMENT OF SIGNIFICANCE: Mainstream glutaraldehyde-cross-linked BHV face persistent clinical challenges, including thrombosis, calcification, immune response, poor re-endothelialization, infection, component degradation, and mechanical failure. Although various non-glutaraldehyde cross-linkers have been investigated, few strategies effectively address these challenges due to the heterogeneous nature of cross-linking. Herein, we present a synergistic engineering strategy based on sequential zwitterionic surface modification and zirconium cross-linking. This strategy produces homogeneously cross-linked BHVs with comprehensive improvements in anti-thrombogenicity, immune compatibility, endothelialization, resistance to calcification and infection, enzymatic stability, and mechanical strength. Notably, the aortic BHV fabricated via this method met the ISO 5840-3 standards for hydrodynamic performance and durability, demonstrating its long-term clinical potential.

Porcine pericardium crosslinked with POSS-PEG-CHO possesses weakened immunogenicity and anti-calcification property

Valvular heart disease (VHD) poses a thorny problem in cardiovascular diseases. The most effective treatment for VHD is heart valve replacement. Biological heart valve (BHV) is more favored than mechanical heart valve due to the maturity of transcatheter heart valve replacement (THVR) and the absence of the need for lifelong anticoagulant use. However, traditional commercial BHV suffers degeneration within 10-15 years because of calcification caused by the cross-linking reagent, glutaraldehyde. Considering the remarkable properties of POSS, PEG, and the star-like eight-arm structure, we fabricated POSS-PEG-PP, which is a decellularized porcine pericardium (DPP) crosslinked by a star-like eight-arm cross-linker octafunctionalized POSS of benzaldehyde-terminated polyethylene glycol (POSS-PEG-CHO) based on the Schiff's base reaction. POSS-PEG-PP exhibits more intense fiber arrangement and better mechanical properties than GLUT-PP (glutaraldehyde crosslinked DPP). The results also show that the cytocompatibility, endothelialization, and hemocompatibility of POSS-PEG-PP are outstanding in vitro. Subsequently, in vivo assessments demonstrate that POSS-PEG-PP has anti-inflammatory and anti-calcification abilities. Furthermore, RNA sequencing analysis of subcutaneous implants suggests that the intervention of AMPK and IL-17 signaling pathways plays an important role in the inflammatory and immune responses regulation of POSS-PEG-PP. Therefore, POSS-PEG-PP is an excellent substitute material for BHVs and is expected to be clinically transformed.

DeepValve: The first automatic detection pipeline for the mitral valve in Cardiac Magnetic Resonance imaging

Mitral valve (MV) assessment is key to diagnosing valvular disease and to addressing its serious downstream complications. Cardiac magnetic resonance (CMR) has become an essential diagnostic tool in MV disease, offering detailed views of the valve structure and function, and overcoming the limitations of other imaging modalities. Automated detection of the MV leaflets in CMR could enable rapid and precise assessments that enhance diagnostic accuracy. To address this gap, we introduce DeepValve, the first deep learning (DL) pipeline for MV detection using CMR. Within DeepValve, we tested three valve detection models: a keypoint-regression model (UNET-REG), a segmentation model (UNET-SEG) and a hybrid model based on keypoint detection (DSNT-REG). We also propose metrics for evaluating the quality of MV detection, including Procrustes-based metrics (UNET-REG, DSNT-REG) and customized Dice-based metrics (UNET-SEG). We developed and tested our models on a clinical dataset comprising 120 CMR images from patients with confirmed MV disease (mitral valve prolapse and mitral annular disjunction). Our results show that DSNT-REG delivered the best regression performance, accurately locating landmark locations. UNET-SEG achieved satisfactory Dice and customized Dice scores, also accurately predicting valve location and topology. Overall, our work represents a critical first step towards automated MV assessment using DL in CMR and paving the way for improved clinical assessment in MV disease.

Anticoagulation therapy and related outcomes among Asian patients after bioprosthetic valve replacement

IMPORTANCE

An inadequate number of studies focused on Asian populations have investigated the safety of warfarin usage among Asian patients with tissue valve aortic valve replacement (AVR) or mitral valve replacement (MVR).

OBJECTIVE

This study aimed to identify the optimal international normalized ratio (INR) range for Asian patients during a 1-year follow-up after tissue valve replacement.

DESIGN, SETTING, PARTICIPANTS

We conducted a retrospective cohort study of patients who underwent tissue valve AVR, MVR, and double valve replacement (DVR) between January 1, 2001, and December 31, 2018. Data were sourced from the Chang Gung Research Database, an electronic structured medical database covering 4 regional hospitals and 3 medical centers. The exposure of interest was INR level.

MAIN OUTCOMES AND MEASURES

The outcomes of primary and secondary interest were composite thromboembolic events and bleeding events during the 1-year follow-up, respectively. The relationship between INR level and the risk of thromboembolic events was explored using a logistic regression model in which the INR value was treated as a flexible restricted cubic spline. Because having atrial fibrillation (AF) greatly would greatly affect the INR control result, the analysis was stratified by AF status.

RESULTS

A total of 1059 participants were eligible for this study. The mean patient age was 65.5 (11.9) years; 592 (55.9%) participants were men, and 467 (44.1%) were women. A total of 447 had AF and 612 did not. The lowest bleeding risk was observed at an INR level around 1.9 to 2.0. An INR level of 1.84 (hazard ratio [HR], 0.49; 95% confidence interval [CI]: 0.36-0.67) and 1.7 (HR, 0.78; 95% CI: 0.62-0.99) corresponded to the lowest risk of thromboembolic events in patients with pre-existing AF and those without, respectively. The INR level corresponding to the lowest risk of thromboembolic events was approximately 1.7 in patients without AF but with MVR, DVR, or isolated AVR.

CONCLUSIONS AND RELEVANCE

For patients who underwent tissue valve replacement, the bleeding risk was elevated when the INR was greater than 2.0, but the risk of thromboembolic event increased only when the INR was lower than 1.84 in the AF group and 1.7 in the non-AF group, regardless of whether the patient received AVR, MVR, or DVR.

Degeneration mechanisms and advancements in optimization for preparation and crosslinking strategy of pericardium-based bioprosthetic heart valves

Valvular heart disease (VHD), clinically manifested as the malfunction of heart valves, greatly threatens public health worldwide. The morbidity and mortality of VHD increase significantly with age, and the high prevalence of VHD in aging society has prompted the urgency for effective treatment. Prosthetic heart valve replacement is currently recognized as the gold standard for VHD treatment. Bioprosthetic heart valves (BHVs), generally manufactured from glutaraldehyde crosslinked xenogeneic tissue, exhibited better hemodynamics and lower thrombogenicity than mechanical heart valves (MHVs) and could be implanted by transcatheter valve replacement systems, which markedly improved the efficiency of VHD therapy, especially for the elderly patients. However, BHVs degenerate within 10-15 years after implantation, which is greatly associated with their defects including cytotoxicity, calcification, immune response, matrix degradation, mechanical damage, and thrombosis. To prolong the service life of BHVs, recent studies have developed a series of innovative modification strategies to improve the biocompatibility, mechanical performance, matrix components stability, anticalcification, and antithrombotic properties of conventional glutaraldehyde crosslinked BHVs. Moreover, a series of new crosslinking and modification strategies have been proposed and developed to fabricate non-glutaraldehyde crosslinked BHVs with good stability, biocompatibility, hemocompatibility, anticalcification property, durability, and hydrodynamics. In this review, we first summarized the defects of BHVs and the related reasons from the perspective of biomaterials, and then comprehensively detailed the functional modification strategies for BHVs based on glutaraldehyde crosslinking. We provided detailed insights into novel non-glutaraldehyde crosslinking and modification strategies for BHVs. Finally, the current challenges and prospects of BHVs were also discussed. STATEMENT OF SIGNIFICANCE: Bioprosthetic heart valves (BHVs) currently face challenges such as cytotoxicity, thrombosis, calcification, and immunoinflammatory responses, which contribute to structural valve degeneration and reduce the longevity of BHVs. This review provides a comprehensive introduction to the detailed defects associated with glutaraldehyde crosslinked BHVs from the perspective of biomaterials. It then thoroughly elaborates on the modification strategies based on glutaraldehyde crosslinking, as well as detailed insights into novel non-glutaraldehyde crosslinking strategies for BHVs. Finally, the challenges and prospects facing BHVs are discussed.

Sex-Associated Disparities in Surgical and Percutaneous Management of Aortic Stenosis With Severe Features: Retrospective Analysis From the National Readmission Database

BACKGROUND

Referral for valve intervention for severe aortic stenosis (AS) may exhibit sex-associated disparities independent of the growth of transcatheter interventions. This study aimed to determine whether there were sex-associated differences in the use of aortic valve replacement (AVR), either surgical or transcatheter, in patients with aortic stenosis and severe features from a national cohort of patients.

METHODS

Using the National Readmission Database, all patients with an index diagnosis of AS between January 2015 and December 2019 were included and stratified by their 90-day readmission status and sex. AS with severe features was defined as the combination of primary- or secondary-coded diagnosis of AS in combination with heart failure, syncope, angina pectoris, cardiac arrest, or cardiogenic shock. A 1:1 nested case-control matching was performed to account for competing risk. The main investigated outcome was the sex-associated rate of AVR in the 90 days after index hospitalization.

RESULTS

A total of 31 712 matched weighted discharges were included in the analysis, 16 597 men (52.3%) and 15 116 women (47.7%). At 90 days, the rate of AVR was significantly lower in women (45.7% versus 53.6%, P<0.001) with significant difference for both surgical (P<0.001) and transcatheter (P=0.010) interventions. After multivariable adjustment, these differences persisted with women significantly less likely to receive AVR (adjusted odds ratio [aOR], 0.67 [95% CI, 0.63-0.71], P<0.001), either surgical AVR (aOR, 0.48 [95% CI, 0.43-0.54], P<0.001) or transcatheter aortic valve implantation (aOR, 0.79 [95% CI, 0.75-0.84], P<0.001).

CONCLUSIONS

The use of surgical AVR and transcatheter aortic valve implantation was significantly lower in female patients with AS and severe features independent from patient- and hospital-level characteristics.

Current Landscape in the Management of Aortic Stenosis

Aortic stenosis (AS) poses significant risks to patient survival and quality of life. The management of AS extends beyond restoring valve function to encompass lifelong disease management. While curative treatments exist, advancements in therapeutic approaches and prosthetic valve technology continue to evolve. This review synthesizes recent developments in AS treatment modalities, prosthetic valve innovations, and their clinical implications, delineating the current therapeutic landscape.

A pH-responsive fluorescence nanosystem for imaging lipid deposition in diseased aortic valves

Lipid deposition is closely related to the pathogenesis of valvular heart disease (VHD), which is a potential target for the early diagnosis of VHD. However, early diagnosis of VHD and heart valve-specific delivery of imaging or therapeutic agents remain challenging. In this work, we hypothesized that lipid droplet-specific probe-loaded nanoparticles simultaneously responsive to the acidic pH of the lysosomes could be used as an effective nanosystem for the precise delivery of probes to the diseased aortic valves in which the endothelial layer was damaged. A lipid droplet-specific probe, namely, ECNBD, was synthesized and it showed great lipid-enhanced emission and great cellular and tissular lipid droplet-specific imaging capacity. Meanwhile, lysosome acid pH-responsive amphiphilic PEG-P (AEMA-co-PMA) was synthesized to serve as a nanocarrier for delivery of ECNBD. ECNBD-loaded nanoparticles exhibited good stability under physiological conditions, while the loaded probe was quickly released at pH 6.5. In addition, ECNBD-loaded nanoparticles could be internalized by cells, and the probe was quickly released because the acidic lysosome environment results in the lighting of intracellular lipid droplets. Impressively, ECNBD-loaded nanoparticles could accumulate in the diseased aortic valves of ApoE-/- mice after tail vein injection and specifically stained the deposited lipid. Thus, our results demonstrated that ECNBD-loaded nanoparticles could serve as a potential nanoplatform for the diagnosis of VHD and the feasibility of diseased heart valve-targeted delivery of imaging or therapeutic agents.

Associations between sweetened beverage consumption, degenerative valvular heart disease, and related events: a prospective study from UK Biobank

AIMS

There are no effective medications to prevent the onset of degenerative valvular heart disease (VHD). Sweetened beverage consumption may contribute to the development of VHD by affecting metabolic disorders, systemic inflammation, and calcification processes. This study aimed to prospectively assess the association between sweetened beverage consumption and the risk of degenerative VHD.

METHODS AND RESULTS

This prospective study included 167,801 participants from the UK Biobank who completed at least one dietary questionnaire. During a median follow-up of 14.53 years, 1,464 cases of aortic valve stenosis (AS) events, 584 cases of aortic valve regurgitation (AR) events, and 1,744 cases of mitral valve regurgitation (MR) events were recorded. Compared with non-consumers, participants consuming more than one drink per day of artificially sweetened beverages (ASBs) had a higher risk of AS (HR: 1.36, 95% CI: 1.10-1.68), AR (HR: 1.42, 95% CI: 1.02-2.00), MR (HR: 1.35, 95% CI: 1.10-1.64). Similarly, the consumption of more than one drink of sugar-sweetened beverages (SSBs) was associated with an increased incidence of MR (HR: 1.47, 95% CI: 1.22-1.77). In contrast, no significant association was observed between the consumption of natural juices (NJs) and VHD risk. Results for VHD-related interventions, deaths, or cardiovascular events were largely consistent. Substituting SSBs or ASBs per day with NJs was associated with a reduced risk of MR (HR: 0.83, 95% CI: 0.72-0.94) events or AS (HR: 0.81, 95% CI: 0.69-0.94) events, respectively.

CONCLUSIONS

Lower consumption of SSBs or ASBs may reduce the risk of degenerative VHD and VHD-related events.

Age-associated methionine sulfoxide reductase A protects against valvular interstitial cell senescence and valvular calcification

Calcific aortic valve disease (CAVD) is a cardiovascular disease prevalent in the aging population, resulting in high morbidity and mortality rates. However, the molecular mechanisms underlying CAVD remain unclear. We initially conducted an RNA sequencing analysis of aortic valve leaflets from rats of different ages to identify key genes involved in valvular aging and calcification. Bioinformatics analysis demonstrated that methionine sulfoxide reductase A (MSRA) was crucial to valvular calcification and senescence. To further investigate whether and how MSRA influences CAVD pathogenesis, we utilized two in vitro models: a human valvular interstitial cell (VIC) calcification model induced by osteogenic medium, and a VIC senescence model induced by hydrogen peroxide. Western blotting, immunofluorescence, flow cytometry, and alkaline phosphatase staining were conducted to evaluate the changes in calcific nodule formation and senescent markers. In vivo, ApoE-/- mice were treated either a normal chow or a high-cholesterol chow to determine the effects of MSRA overexpression on aortic valve calcification and senescence. MSRA silencing increased the osteogenic differentiation and senescence of VIC, whereas its overexpression produced the opposite effects. Similarly, we found that MSRA overexpression reduced calcium deposition and decreased the levels of senescent markers in ApoE-/- mice. Further mechanism experiments showed that MSRA suppressed osteoblastic differentiation via inhibiting the toll-like receptor (TLR2)/nuclear factor-κB (NF-κB) pathway. Our findings demonstrate that MSRA ameliorates valvular calcification and senescence by inhibiting TLR2/NF-κB pathway, highlighting MSRA as a promising target for treating age-associated CAVD.

High afterload rather than myocardial fibrosis predicts reduced ejection fraction in severe aortic stenosis with afterload mismatch

BACKGROUND

Afterload mismatch (AM) refers to high-gradient (mean gradient ≥40 mm Hg) severe aortic stenosis (AS) with reduced left ventricular ejection fraction (LVEF <50%) that is hypothesised to arise from mechanisms other than true contractile impairment. The extent, pattern and functional impact of myocardial fibrosis (MF), which is associated with systolic impairment, is poorly understood in the context of AM.

METHODS

High-gradient severe AS patients with (n=25; low ejection fraction high-gradient, LEF-HG) and without (n=33; normal ejection fraction high-gradient (NEF-HG)) reduced LVEF underwent cardiovascular MRI. Using T1 mapping, extracellular volume (ECV) fraction and late gadolinium enhancement (LGE), the extent and pattern of MF was compared between the two groups. End-systolic wall stress (ESWS) as a measure of afterload was estimated, and its relationship with LVEF was compared with that of MF and LVEF.

RESULTS

Stenosis severity was worse in the LEF-HG group (aortic valve area 0.5±0.2 vs 0.7±0.2 cm2, mean gradient 55 (46-66) vs 48 (41-69) mm Hg). In the LEF-HG group, high ESWS with cavity dilation and significant hypertrophy were observed compared with the NEF-HG group. MF was present in both groups with a significantly higher burden in the LEF-HG group (T1 time 1061±22 vs 1041±33 ms, ECV 26%±3% vs 24%±3%, LGE mass 4.3 (1.7-9.3) vs 0.1 (0.06-3.39) g). The association between MF and LVEF was weak, while ESWS was strongly associated with LVEF (r -0.8, p<0.0001) and was the best predictor of LVEF in multivariate prediction analysis.

CONCLUSIONS

MF was present in both groups with a higher burden in those with LEF-HG AS. High ESWS, that is, afterload, rather than MF, was the strongest predictor of LVEF. While MF may not directly impact systolic function in AM, it is still an important factor to account for in AS given its association with increased mortality.

In Silico Trials of Prosthetic Valves Replicate Methodologies for Evaluating the Fatigue Life of Artificial Leaflets to Expand Beyond In Vitro Tests and Conventional Clinical Trials

Background: Fatigue failure of artificial leaflets significantly limits the durability of prosthetic valves. However, the costs and complexities associated with in vitro testing and conventional clinical trials to investigate the fatigue life of leaflets are progressively escalating. In silico trials offer an alternative solution and validation pathway. This study presents in silico trials of prosthetic valves, along with methodologies incorporating nonlinear behaviors to evaluate the fatigue life of artificial leaflets. Methods: Three virtual patient models were established based on in vitro test and clinical trial data, and virtual surgeries and physiological homeostasis maintenance simulations were performed. These simulations modeled the hemodynamics of three virtual patients following transcatheter valve therapy to predict the service life and crack propagation of leaflets based on the fatigue damage assessment. Results and Conclusions: Compared to traditional trials, in silico trials enable a broader and more rapid investigation into factors related to leaflet damage. The fatigue life of the leaflets in two virtual patients with good implantation morphology exceeded 400 million cycles, meeting the requirements, while the fatigue life of a virtual patient with a shape fold in the leaflet was only 440,000 cycles. The fatigue life of the leaflets varied considerably with different implant morphologies. Postoperative balloon dilation positively enhanced fatigue life. Importantly, in silico trials yielded insights that are difficult or impossible to uncover through conventional experiments, such as the increased susceptibility of leaflets to fatigue damage under compressive loading.

Fluid-structure interaction analysis of bioinspired polymeric heart valves with experimental validation

BACKGROUND AND OBJECTIVES

Valvular heart disease, when not addressed adequately, can result in heart failure, serious heart-related health problems, and in some cases, death. Polymeric heart valves (PHVs) are promising valve replacement technologies that may offer improved durability and better biological performance. Notably, PHVs have the potential to accommodate highly innovative valve designs. Given this feature of PHVs, it is important to shortlist the best performing valve designs prior to committing to extensive in vitro hemodynamic validation prototypes.

METHODS

This study presents a computational fluid-structure interaction (FSI) workflow, which integrates computational fluid dynamics (CFD) and finite element analysis (FEA), to simulate the hemodynamic performance of PHVs with two different valve designs under physiological conditions.

RESULTS

The model accurately predicts cardiac output (CO), effective orifice area (EOA) and regurgitant fraction (RF) and these predictions have been successfully validated using experimental data. Consistent with experimental findings, increasing valve thickness results in a decrease in EOA, with RF trends varying between different valve designs. The fully opened and unfolded valve exhibited the lowest WSS on the leaflet surfaces. Both valve design and thickness significantly influence stress distribution along the leaflets with the thinnest valves showing lower von Mises stresses during opening and higher stresses during closing. Detailed analysis of flow patterns, wall shear stress (WSS), valve opening and closing behaviors, and mechanical stress distribution are presented.

CONCLUSIONS

This work demonstrates the potential of FSI simulations in predicting the hydrodynamic and mechanical behavior of PHVs, offering valuable insights into valve durability and design optimization for improved patient outcomes. This approach can significantly accelerate valve development by reducing reliance on extensive in vitro and in vivo testing.

Evidence Generation and Implementation of Transcatheter Interventions for Atrioventricular Valvular Heart Disease in Heart Failure: Current Status and Future Directions

Mitral regurgitation and tricuspid regurgitation are the most common valvular heart diseases in patients with heart failure and have independent prognostic value. Transcatheter interventions are now available for the treatment of valvular heart disease, and their efficacy and safety have been tested in randomized controlled trials. However, evidence is still limited and sometimes inconclusive because several aspects of these trials limit their interpretation or consistency. These include heterogeneity in the pathogenesis and clinical characteristics of patients, the dynamic nature of secondary atrioventricular valve disease severity, the role of heart failure medications and devices, dependency on procedural results and operators' skills, smaller number of patients enrolled and the power to detect differences in trials, and limitations to use patients' reported outcomes with unblinded study protocols. These specific aspects of trials in patients with atrioventricular valve disease are reviewed in this article with a focus on possible solutions to generate further evidence for the efficacy and safety for transcatheter treatments of atrioventricular valve disease in patients with heart failure.

Epidemiology of Valvular Heart Disease in Asia Pacific Region

Valvular heart disease poses a significant health burden in the Asia-Pacific region, with its epidemiology varying widely across countries caused by diverse socioeconomic and health care situations. Rheumatic heart disease remains prevalent, especially in low- to middle-income areas, while degenerative valvular diseases are emerging in developed regions caused by an aging population. Significant disparities in access to health care and intervention result in variable clinical outcomes. In the past decade, transcatheter interventions have revolutionized the management of patients with valvular heart disease globally. In the Asia-Pacific region, the uptake and development of transcatheter valvular interventions has been slow until recent years. Continued collaboration across the Asia-Pacific region is essential to mitigate the impact of the upcoming surge of valvular heart disease in this diverse and rapidly changing area.

A New Benchmark for Modern Management of Valvular Heart Disease: The Whole-Life Cycle Management System

Valvular heart disease (VHD) is rapidly increasing in prevalence worldwide, affecting millions and significantly impacting global health care systems. Despite notable advancements in understanding VHD progression, perioperative management, imaging techniques, and transcatheter therapies over the past 2 decades, the condition has not received the attention it deserves from the public and policymakers. Many patients with VHD in low- and middle-income countries continue to experience low detection, intervention, and follow-up rates. Systematic care for elderly patients and those with severe comorbidities, as well as postoperative patients, remains insufficient, leading to higher mortality and morbidity rates. This review focuses on the deficiencies in VHD treatment within the Chinese health care system and discusses the modern management program, known as the whole-life cycle management system, that has been implemented to enhance the survival prognosis of VHD patients.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

Surgical or transcatheter AVR.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Utility of Serum Biomarkers of Myocardial Fibrosis in High-Gradient Severe Aortic Stenosis: An Explorative Cardiovascular Magnetic Resonance Imaging-Based Study

Background: Myocardial fibrosis in aortic stenosis (AS) is associated with a significant risk of poor clinical outcomes. Myocardial fibrosis can be evaluated using cardiovascular magnetic resonance (CMR) imaging and may be useful for risk-stratifying patients at high risk for poorer outcomes. A circulating biomarker of fibrosis may be a cheaper, more accessible alternative to CMR in lower-to-middle-income countries. This study evaluated the correlation between serum biomarkers of myocardial fibrosis (TGF-β1, PICP, and PIIINP) with CMR markers of myocardial fibrosis (T1 mapping, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE)). Methods: Twenty-one high-gradient (mean gradient ≥ 40 mmHg) severe AS (aortic valve area < 1.0 cm2) participants underwent T1 mapping and LGE imaging using CMR. Blood serum was collected for enzyme-linked immunosorbent assays of the listed biomarkers. Results: Serum TGF-β1 was associated significantly with the global T1 relaxation time on CMR (r = 0.46 with 95% CI 0.03 to 0.74, p = 0.04). In the high T1 time group (1056 vs. 1023 ms), trends toward elevated serum TGF-β1 concentration (13,044 vs. 10,341 pg/mL, p = 0.08) and ECV (26% vs. 24%, p = 0.07) were observed. The high T1 and trend towards elevated TGF-β1 concentration in this group tracked adverse LV remodeling and systolic dysfunction. There were no significant associations between PICP/PIIINP and T1 mapping or between the biomarkers and LGE quantity. Conclusions: Serum TGF-β1 is a potential surrogate for diffuse interstitial fibrosis measured by T1 mapping and ECV on CMR. Serum PICP and PIIINP may be less appropriate as surrogate markers of fibrosis in view of their temporal trends over the course of AS. Larger studies are needed to validate the utility of TGF-β1 as a marker of diffuse fibrosis and to evaluate the utility of serial PICP/PIIINP measurements to predict decompensation.

Antimicrobial suppressive therapy in prosthetic valve endocarditis rejected from surgery despite indication

BACKGROUND

Prosthetic valve endocarditis (PVE) incidence is rising in older patients, often rejected for surgery, leading them to a poor prognosis. Optimal antibiotic management is unknown for these patients. We compared the efficacy and safety of suppressive (SAT) versus conventional antimicrobial therapy (CAT) in this setting.

METHODS

We conducted a prospective, multicentric, cohort study in southwest France including patients with PVE rejected from surgery despite indication, and surviving the initial 6 weeks of intravenous therapy. Beyond this period, patients could or not receive SAT, according to endocarditis team decision. Primary outcome was a composite endpoint of one-year all-cause mortality and PVE-related hospitalization. Secondary outcome was the incidence and nature of SAT-related adverse events.

RESULTS

Between 2012 and 2022, 88 patients were included in the study, 42 receiving SAT and 46 CAT. Mean age was 69.4 ± 16.4 years and patients were highly comorbid (mean Charlson Comorbidity Index 5.6 ± 2.7). Main organisms included Streptococcus spp. (26/88, 29.5%) and Staphylococcus aureus (25/88, 28.4%). The primary composite outcome occurred in 7/42 (16.7%) patients in the SAT group, and 16/46 (34.8%) in the CAT group. Using a Cox model, SAT was significantly and independently associated with a lower incidence of one-year primary outcome (Hazard ratio 0.23, 95% CI 0.08-0.67, P = 0.007). Adverse effects in the SAT group were reported for 6/42 patients (14.3%). These effects were limited, causing only one treatment discontinuation.

CONCLUSION

In patients with PVE rejected from surgery despite indication, SAT may be safe and associated with better outcomes than CAT.

Diabetes and calcific aortic valve disease: implications of glucose-lowering medication as potential therapy

Calcific aortic valve disease (CAVD) is a progressive disease, of which the 2-year mortality is >50% for symptomatic disease. However, there are currently no pharmacotherapies to prevent the progression of CAVD unless transcatheter or surgical aortic valve replacement is performed. The prevalence of diabetes among CAVD has increased rapidly in recent decades, especially among those undergoing aortic valve replacement. Diabetes and its comorbidities, such as hypertension, hyperlipidemia, chronic kidney disease and ageing, participated jointly in the initiation and progression of CAVD, which increased the management complexity in patients with CAVD. Except from hyperglycemia, the molecular links between diabetes and CAVD included inflammation, oxidative stress and endothelial dysfunction. Traditional cardiovascular drugs like lipid-lowering agents and renin-angiotensin system blocking drugs have proven to be unsuccessful in retarding the progression of CAVD in clinical trials. In recent years, almost all kinds of glucose-lowering medications have been specifically assessed for decelerating the development of CAVD. Based on the efficacy for atherosclerotic cardiovascular disease and CAVD, this review summarized current knowledge about glucose-lowering medications as promising treatment options with the potential to retard CAVD.

Effects of a Cloud-Based Synchronous Telehealth Program on Valvular Regurgitation Regression: Retrospective Study

BACKGROUND

Telemedicine has been associated with better cardiovascular outcomes, but its effects on the regression of mitral regurgitation (MR) and tricuspid regurgitation (TR) remain unknown.

OBJECTIVE

This study aimed to evaluate whether telemedicine could facilitate the regression of MR and TR compared to usual care and whether it was associated with better survival.

METHODS

This retrospective cohort study enrolled consecutive patients with moderate or greater MR or TR from 2010 through 2020, excluding those with concomitant aortic stenosis, aortic regurgitation, or mitral stenosis greater than mild severity. All patients underwent follow-up transthoracic echocardiography (TTE) at least 3 months apart. Patients receiving telehealth services for at least two weeks within 90 days of baseline TTE were categorized as the telehealth group; the remainder constituted the nontelehealth group. Telemedicine participants transmitted daily biometric data-blood pressure, pulse rate, blood glucose, electrocardiogram, and oxygen saturation-to a cloud-based platform for timely monitoring. Experienced case managers regularly contacted patients and initiated immediate action for concerning measurements. The primary endpoint was MR or TR regression from ≥moderate to

RESULTS

The MR cohorts consisted of 264 patients (mean age 67 years), including 97 regressors and 74 telehealth participants. Telehealth participation (hazard ratio 2.20, 95% CI 1.35-3.58; P=.001) was robustly associated with MR regression; MR regressors were linked to reverse cardiac remodeling, indicated by improved left ventricular ejection fraction (LVEF), and reduced left ventricular (LV) and left atrial (LA) dimensions (all P≤.005). Determinants of ACD were age (P<.001), LVEF (P<.001), percutaneous coronary intervention (P<.001), and MR regressors (P=.02). The TR cohort consisted of 245 patients (mean age 68 years), including 87 TR regressors and 61 telehealth participants. Telehealth (P=.05) was one of the univariable determinants of TR regression, while beta-blocker use (P=.048) and baseline TR severity (P=.01) remained strong predictors of TR regression in multivariable analysis.

CONCLUSIONS

Patients in the telehealth group were 2.2 times more likely to experience MR regression. Moreover, MR regressors had better survival and reverse cardiac remodeling compared to nonregressors. These findings may have important implications for future guidelines.

Collapse

Key Words

• cardiac remodeling
• mitral regurgitation
• telehealth
• telemedicine
• tricuspid regurgitation

Collapse

MESH Headings

• Humans
• Retrospective Studies
• Male
• Telemedicine
• Female
• Aged
• Mitral Valve Insufficiency/therapy
• Mitral Valve Insufficiency/mortality
• Cloud Computing
• Middle Aged
• Tricuspid Valve Insufficiency/therapy
• Tricuspid Valve Insufficiency/mortality
• Echocardiography

Collapse

Grants Collapse

Affiliation(s)

Li-Tan Yang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Han Wu Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Wei-Jyun Wang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Ying-Hsien Chen Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Ching-Chang Huang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Sheng Hung Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Kuang-Chien Chiang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Yi-Lwun Ho Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Hui-Wen Wu Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan

Collapse

Collaborators Collapse

Primary regional disparities in clinical characteristics, treatments, and outcomes of a typically designed study of valvular heart disease at 46 tertiary hospitals in China: Insights from the China-VHD Study

BACKGROUND

Valvular heart disease (VHD) has become increasingly common with the aging in China. This study aimed to evaluate regional differences in the clinical features, management strategies, and outcomes of patients with VHD across different regions in China.

METHODS

Data were collected from the China-VHD Study. From April 2018 to June 2018, 12,347 patients who presented with moderate or severe native VHD with a median of 2 years of follow-up from 46 centers at certified tertiary hospitals across 31 provinces, autonomous regions, and municipalities in Chinese mainland were included in this study. According to the locations of the research centers, patients were divided into five regional groups: eastern, southern, western, northern, and central China. The clinical features of VHD patients were compared among the five geographical regions. The primary outcome was all-cause mortality or rehospitalization for heart failure. Kaplan-Meier survival analysis was used to compare the cumulative incidence rate.

RESULTS

Among the enrolled patients (mean age, 61.96 years; 6877 [55.70%] male), multiple VHD was the most frequent type (4042, 32.74%), which was mainly found in eastern China, followed by isolated mitral regurgitation (3044, 24.65%), which was mainly found in northern China. The etiology of VHD varied significantly across different regions of China. The overall rate of valve interventions was 32.67% (4008/12,268), with the highest rate in southern China at 48.46% (205/423). In terms of procedure, the proportion of transcatheter valve intervention was relatively low compared to that of surgical treatment. Patients with VHD in western China had the highest incidence of all-cause mortality or rehospitalization for heart failure. Valve intervention significantly improved the outcome of patients with VHD in all five regions (all P  <0.05).

CONCLUSIONS

This study revealed that patients with VHD in China are characterized by significant geographic disparities in clinical features, treatment, and clinical outcomes. Targeted efforts are needed to improve the management and prognosis of patients with VHD in China according to differences in geographical characteristics.

REGISTRATION

ClinicalTrials.gov , NCT03484806.

Short- and mid-term outcomes after redo surgical valve replacement

BACKGROUND

While previous studies have indicated comparable outcomes for redo surgical valve replacement (SVR) and primary SVR, there is limited information regarding the long-term follow-up of these patients. Providing prognostic data on redo SVR is crucial for enhancing decision-making and medical care, as well as for identifying low-risk subsets of patients eligible for redo SVR. This study aimed to evaluate the short- and mid-term outcomes of patients who underwent their first and second redo SVR of a previously replaced valve.

METHODS

We included 118 consecutive patients with a history of first or second redo SVR. The participants had a mean age of 57.5 ± 14.4 years, with 71 (60%) being female. The median follow-up period was 69 months. Clinical, intraoperative, and laboratory data were analyzed to assess all-cause mortality, major adverse events (MAE), and a composite of prosthetic valve thrombosis, embolic events, and major hemorrhage (TEH), along with their predictors. Bayesian model averaging was used for statistical analysis.

RESULTS

The 30-day mortality rate was 11 patients (9.3%). Chronic kidney disease was identified as an independent predictor of 30-day mortality. The overall survival rates at one and five years were 86% (95% CI 80% to 93%) and 76% (95% CI 68% to 85%), respectively. Dyslipidemia, a history of major bleeding, chronic kidney disease, stroke, and transvalvular leakage in biological prostheses were all associated with all-cause mortality as independent predictors. The TEH-free survival rates at one and five years were 91% (95% CI 86% to 97%) and 79% (95% CI 71% to 88%), respectively. Diabetes, sex, a history of percutaneous coronary intervention, and baseline functional capacity were identified as independent predictors for the occurrence of TEH. The MAE-free survival rates at one and five years were 82% (95% CI 73% to 92%) and 61% (95% CI 49% to 75%), respectively. Hypertension and baseline functional class were independent predictors of MAE occurrence. The type and anatomical position of the valve were not predictors of mortality, THE, and MAE.

CONCLUSIONS

Our study demonstrated acceptable short- and mid-term outcomes for redo SVR, especially in patients without significant risk factors. Several potential predictors of adverse outcomes were identified.

Materials Advances in Devices for Heart Disease Interventions

Heart disease encompasses a range of conditions that affect the heart, including coronary artery disease, arrhythmias, congenital heart defects, heart valve disease, and conditions that affect the heart muscle. Intervention strategies can be categorized according to when they are administered and include: 1) Monitoring cardiac function using sensor technology to inform diagnosis and treatment, 2) Managing symptoms by restoring cardiac output, electrophysiology, and hemodynamics, and often serving as bridge-to-recovery or bridge-to-transplantation strategies, and 3) Repairing damaged tissue, including myocardium and heart valves, when management strategies are insufficient. Each intervention approach and technology require specific material properties to function optimally, relying on materials that support their action and interface with the body, with new technologies increasingly depending on advances in materials science and engineering. This review explores material properties and requirements driving innovation in advanced intervention strategies for heart disease and highlights key examples of recent progress in the field driven by advances in materials research.

Burden of cardiovascular hospitalizations and in-hospital mortality in Greece: national trends over five years

OBJECTIVE

Nationwide epidemiological studies provide crucial insights into the burden of prevalent and emerging diseases, guiding the development of targeted health policies. This study analyzes trends in cardiovascular disease (CVD) hospitalizations and in-hospital mortality in Greece.

METHODS

Anonymized data were retrieved from the Hellenic Statistical Authority to calculate hospitalization rates (HRs) per 100,000 population and in-hospital mortality for cardiovascular (CV) sub-causes from 2013 to 2017. The statistical significance of temporal trends was assessed using generalized linear models in Python.

RESULTS

From 2013 to 2017, HRs increased by 9.2% for myocardial infarctions (MIs), 34.5% for heart failure (HF), 12.3% for stroke, 62.7% for cardiac arrest, and 36.6% for pulmonary embolism. In 2017, CVDs were the leading cause of hospitalization (14%) with a HR of 1942.4 per 100,000 population, with HF being the leading CV sub-cause of hospitalization (12%). HF together with stroke, atrial fibrillation/flutter (AF/Af), and coronary artery disease represented over 60% of all CV hospitalizations. While coronary artery disease was more prevalent in the male population, HF, strokes, and AF/Af were the primary CV sub-causes in the female population. HRs were higher in the male population for most CV sub-causes. Higher in-hospital mortality was found in the female population across all major CV sub-causes.

CONCLUSION

This study demonstrated significant shifts in the burden of CV sub-causes in Greece, with increasing HRs for MIs and HF. These findings highlight the need for optimization of guideline implementation, and development of specialized CV units and cardiogeriatric centers to address the challenges posed by the aging population.

Advanced Silicon Modeling of Native Mitral Valve Physiology: A New Standard for Device and Procedure Testing

Mitral valve regurgitation is among the most prevalent valvular heart diseases and increases with age. Percutaneous therapy has emerged for the management of mitral regurgitation in high surgical risk patients. However, the long-term consequences of these interventions are still not fully understood due to their novelty and the difficulty of developing a strategy specific to the patient's anatomy and/or pathology. To optimize these outcomes, an in vitro patient-specific approach could provide important insights for the most suitable strategy to use according to the patient profile. To ensure the reliability of this in vitro approach, the aim of this study was to reproduce the physiological behavior of the healthy native mitral valve for future applications. To do so, different silicon combinations reproducing the physiological anatomy of a healthy mitral valve were developed and tested under physiological hemodynamic conditions in a cardiac simulator. The hemodynamic and biomechanical behaviors of each mitral valve model were analyzed and compared to the physiological values provided in the literature. This study identified EcoFlex 00-50 and DragonSkin 10 (Smooth-On Inc., Easton, PA, USA) as the optimal silicon combination resulting in physiological strain values and hemodynamic parameters. These findings could be useful for future patient-specific applications, helping in the optimization of percutaneous mitral valve therapy.

Biomimetic multilayered polymeric heart valve featuring ultra-thin thickness and exceptional durability

The transcatheter aortic valve replacement technique has rapidly developed in clinical practice, with its indications expanding to low-risk populations and younger patients. The durability of valve materials has emerged as a critical requirement from a clinical perspective and a research focus in interventional valves. Polymeric heart valves exhibit a promising future because of their enhanced durability and reduced cost. Herein, we developed biomimetic multilayered polymeric heart valves (BMPHVs) utilizing thermoplastic silicone-polycarbonate polyurethane and ultra-high molecular weight polyethylene fibers, selected to replicate the fibrosa, spongiosa, and ventricular layers in natural heart valves. The construction process involved the fabrication of ultra-strong, ultra-fine fiber textiles and leaflet laser cutting utilizing edge-sealing technology. BMPHVs exhibit superior durability than bovine pericardial valves. These findings facilitate the development of a new category of advanced synthetic materials characterized by long-term durability for valve replacement.

Analysis of potential categories of quality of life of transcatheter aortic valve replacement patients and discussion of their influencing factors

BACKGROUND

The prevalence of aortic valve stenosis is on the rise, primarily due to an aging population. Transcatheter Aortic Valve Replacement (TAVR) has emerged as an effective treatment option, especially for patients at high surgical risk. However, the variation in post-TAVR quality of life across patient groups warrants further examination to understand the contributing factors.

OBJECTIVE

This study aims to evaluate the quality of life in patients post-TAVR, characterize distinct patient group profiles, and identify key factors that influence their quality of life.

METHODS

From July 2023 to September 2024, 215 TAVR patients were recruited via convenience sampling. Data on sociodemographics and quality of life were gathered using the TAVR-specific quality of life scale. Latent variable growth modeling helped identify quality of life categories and predict influencing factors.

RESULTS

Three categories of TAVR patients were identified based on quality of life: the "High quality of life-high health status" group, the "Medium quality of life-intermediate health" group, and the "Low quality of life-low health status" group. Logistic regression analysis revealed that sleep quality, self-efficacy, and performance on the 30-s chair sit-to-stand test were significant predictors of quality of life.

CONCLUSION

There is considerable variability in the quality of life among TAVR patients. Tailored health management strategies based on specific patient profiles can potentially improve outcomes in these populations.

Independent risk factors and outcomes for ventilator-associated pneumonia due to multidrug-resistant organisms after cardiac valvular surgery

Background

Although numerous studies have documented the risk factors for ventilator-associated pneumonia (VAP) after cardiac surgery, most of these studies included heterogeneous patient populations. This study aimed to explore the risk factors for VAP caused by multidrug-resistant organisms (MDRO) in patients admitted to the cardiosurgery intensive care unit (CSICU) following cardiac valvular surgery.

Methods

This was a single-center, retrospective study. The clinical data of adult VAP patients following cardiac valvular surgery from January 2021 to December 2023 were analyzed. Patients were divided into MDRO VAP and non-MDRO VAP groups. Perioperative clinical data and postoperative follow-up results were collected for both groups. Univariable and multivariable logistic regression analyses were performed to identify risk factors for MDRO VAP, and the outcomes of MDRO VAP patients were analyzed. The species of pathogens isolated from the VAP patients were also investigated.

Results

A total of 109 VAP patients were included in this study, including 47 patients with MDRO VAP and 62 patients with non-MDRO VAP. Multivariable logistic regression analysis identified that independent risk factors for MDRO VAP included preoperative hypoalbuminemia (OR, 0.838; CI, 0.733-0.957; p = 0.009), prolonged mechanical ventilation (OR, 1.173; CI, 1.005-1.369; p = 0.043), and extended broad-spectrum antibiotic therapy (OR, 1.112; CI, 1.019-1.213; p = 0.018). Patients with MDRO VAP had significantly longer ICU stays, total hospital stays, and higher hospitalization costs than non-MDRO VAP patients. The in-hospital mortality rate of the MDRO VAP group was significantly higher than that of the non-MDRO VAP group (29.79% vs. 1.61%, p < 0.001). Gram-negative bacilli were the predominant pathogens in MDRO VAP patients (97.87%), with the highest rate of Pseudomonas aeruginosa (29.79%).

Conclusion

Postoperative MDRO VAP in patients undergoing cardiac valvular surgery is linked to severe clinical outcomes. Greater attention should be given to patients with prolonged mechanical ventilation, extended broad-spectrum antibiotic therapy, and preoperative hypoalbuminemia to prevent MDRO VAP infections.

Precision medicine in the management of valvular heart disease

The management of valvular heart disease has undergone a remarkable transformation over the past two decades, which was driven by the advent of catheter-based treatment methods. Whereas medical therapy was the only available treatment option for many older patients deemed unsuitable for conventional surgery until the early 2000s, a wide range of interventional therapies is now available. Transcatheter aortic valve replacement and mitral valve transcatheter edge-to-edge repair evidently provide prognostic advantages over medical therapy for inoperable patients with severe aortic stenosis and secondary mitral regurgitation, and they have been demonstrated to be non-inferior to conventional surgery in certain operable patient groups. Although catheter-based therapies of aortic and tricuspid regurgitation have not yet been proven to provide prognostic benefits, these approaches enable substantial and sustainable improvements in symptoms as well as quality of life while demonstrating a favorable safety profile. Given the multitude of available options for the treatment of valvular heart diseases, determining the appropriate indication and selecting the optimal therapeutic approach often pose significant challenges. This review article highlights the latest advancements in valvular heart disease management and explores the patient-centered application of available therapies within the framework of an approach toward precision medicine.

Association between Stroke History and Clinical Events in Atrial Fibrillation Patients after Valve Replacement

Background

The association between stroke history and clinical events after valve replacement in patients with atrial fibrillation (AF) combined with valvular heart disease (VHD) is unclear. Thus, we sought to investigate the relationship between stroke history and clinical events in patients with AF after valve replacement.

Methods

This retrospective cohort study enrolled 746 patients with AF who underwent valve replacement between January 2018 and December 2019 at the Wuhan Asia Heart Hospital. Patient information was collected from the hospital's electronic medical record system. Patients were categorized based on their stroke history and followed through outpatient visits or by telephone until the occurrence of an endpoint event; the maximum follow-up period was 24 months. Endpoint events included thrombotic events, bleeding, and all-cause mortality. The frequency of thrombotic, hemorrhagic, and fatal events during the follow-up period was compared between the two groups. Independent risk factors for endpoint events were analyzed using multifactorial Cox regression.

Results

The analysis included 746 patients. Over a 24-month follow-up period, there were more total adverse events (hazard ratio (HR) = 2.08, 95% confidence interval (CI) 1.06-4.08, p = 0.018), thrombotic events (HR = 10.28, 95% CI 2.85-37.11, p < 0.001), and increased all-cause mortality (HR = 5.74, 95% CI 1.84-17.93, p < 0.001) in the stroke history group than in the non-stroke history group. Fewer bleeding events were observed in the group with a history of stroke (HR = 0.87, 95% CI 0.37-2.04, p = 0.757). A multifactorial Cox regression analysis revealed that a personal history of stroke was an independent risk factor for total adverse events, thrombotic events, and all-cause mortality.

Conclusions

Previous stroke history is significantly associated with adverse events in AF patients following valve replacement.

Regulatory roles of PIWI-interacting RNAs in cardiovascular disease

Cardiovascular disease remains the number one cause of death worldwide. Across the spectrum of cardiovascular pathologies, all are accompanied by changes in gene expression profiles spanning a variety of cellular components of the myocardium. Alterations in gene expression are regulated by small noncoding RNAs (sncRNAs), with P-element-induced WImpy testis (PIWI)-interacting RNAs (piRNAs) being the most abundant of the sncRNAs in the human genome. Composed of 21-35 nucleotides in length with a protective methyl group at the 3' end, piRNAs complex with highly conserved RNA-binding proteins termed PIWI proteins to recruit enzymes used for histone, DNA, RNA, and protein modifications. Thus, specific piRNA expression patterns can be exploited for early clinical diagnosis of cardiovascular disease and the development of novel RNA therapeutics that may improve cardiac health outcomes. This review summarizes the latest progress made on understanding how piRNAs regulate cardiovascular health and disease progression, including a discussion of their potential in the development of biomarkers and therapeutics.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes: Developed by a multisociety taskforce coordinated by the Heart Valve Society (HVS) including the American Heart Association (AHA), the American College of Cardiology (ACC), the European Association for Cardio-Thoracic Surgery (EACTS), the European Society of Cardiology (ESC), The Society of Thoracic Surgeons (STS), the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS), the International Society for Applied Cardiovascular Biology (ISACB), the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), the South African Heart Association (SHA), Heart Valve Voice, and Global Heart Hub

BACKGROUND

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Advances in Pathophysiological Mechanisms of Degenerative Aortic Valve Disease

Degenerative aortic valve disease (DAVD) represents the most prevalent valvular ailment among the elderly population, which significantly impacts their physical well-being and potentially poses a lethal risk. Currently, the underlying mechanisms of DAVD remain incompletely understood. While the progression of this disease has traditionally been attributed to degenerative processes associated with aging, numerous recent studies have revealed that heart valve calcification may represent a response of valve tissue to a specific initiating factor, involving the interaction of various genes and signaling pathways. This calcification process is further influenced by a range of factors, including genetic predispositions, environmental exposures, metabolic factors, and hemodynamic considerations. Based on the identification of its biomarkers, potential innovative therapeutic targets are proposed for the treatment of this complex condition. The present article primarily delves into the underlying pathophysiological mechanisms and advancements in diagnostic and therapeutic modalities pertaining to this malady.

Navigating the Landscape of Translational Medicine of Calcific Aortic Valve Disease: Bridging Bench to Bedside

Calcific aortic valve disease (CAVD) is a prevalent condition characterized by pathological thickening and calcification of the aortic valve, leading to increased pressure overload and cardiac remodeling, particularly in individuals aged 65 and older. This review synthesizes recent advances in understanding the pathogenesis of CAVD, focusing on key mechanisms including hemodynamic alterations, endothelial dysfunction, lipid deposition, inflammation, and fibrotic calcification. We evaluate emerging therapeutic targets based on pivotal basic research and clinical trials, highlighting the potential for mechanism-oriented interventions. Furthermore, we explore the implications of lipid-lowering therapies, anti-inflammatory strategies, and antifibrocalcific agents, as well as novel bioprosthetic designs aimed at enhancing patient outcomes. Additionally, we discuss the inherent genetic and molecular backgrounds influencing individual susceptibility to CAVD, emphasizing the promise of personalized therapy. By bridging the gap between basic science and clinical application, this review aims to guide future research efforts toward more effective prevention and treatment strategies for CAVD.

Global, Regional, and National Burden of Non-Rheumatic Valvular Heart Diseases in Women: A Systematic Analysis of Global Burden of Disease 1990-2021

Background

The incidence of non-rheumatic valvular heart diseases (NRVHD) has shown an increasing trend. However, most studies have overlooked the impact of gender on the disease. Female patients, as a specific subgroup, have rarely been discussed independently. It is essential to conduct separate epidemiological studies to understand the latest epidemiological data for female NRVHD patients and to raise awareness among researchers and clinicians.

Methods

Data from the Global Burden of Disease (GBD) 2021 database were retrieved to obtain epidemiological data on female NRVHD from both global and regional perspectives, covering 204 countries and territories. Joinpoint regression, age-period-cohort analysis, decomposition, and predictive analyses were employed to further examine the epidemiological data.

Results

The incidence of female NRVHD patients has shown a continuous upward trend and is expected to persist in the future, particularly in regions with high and high-middle Socio-Demographic Index (SDI). However, in low and lower-middle SDI regions, patients experience relatively higher Disability-Adjusted Life Years (DALYs) and Years Lived with Disability (YLDs), with a greater number of heart failure cases attributed to NRVHD. Decomposition analysis indicates that the increase in the incidence of NRVHD and its subtypes is primarily driven by population growth and aging.

Conclusions

With economic development and population aging, female NRVHD remains a significant healthcare burden for countries worldwide. Low- and middle-SDI regions should implement tertiary prevention strategies to address the impending shift in the spectrum of valvular heart diseases. Further clinical research should focus on female patients as a distinct subgroup of NRVHD, exploring the unique aspects of the disease in this population.

[Short-term clinical efficacy of transcatheter edge-to-edge repair for moderate to severe mitral regurgitation]

OBJECTIVES

To evaluate the short-term clinical efficacy of transcatheter edge-to-edge repair (TEER) in patients with moderate to severe mitral regurgitation.

METHODS

Clinical data of patients with moderate to severe mitral regurgitation who underwent TEER in the Department of Cardiology, the First Affiliated Hospital of Xi'an Jiaotong University from April 2021 to May 2024, were retrospectively analyzed, including preoperative baseline clinical and echocardiography data, intraoperative data and 6-month postoperative follow-up data.

RESULTS

A total of 67 patients' (47 males and 20 females) data were included, of whom 62 completed 6-month follow-up. The immediately postoperative success rate was 88.1% (59/67), and 83.9% (52/62) patients exhibited mitral regurgitation ≤2+ at 6 months postoperatively, showing significant improvement compared with preoperative (P<0.05). The proportion of patients with mitral regurgitation ≤2+ at 6 months was significantly higher in the degenerative mitral regurgitation (DMR) group than that in the functional mitral regurgitation (FMR) group (P<0.05). The mean mitral valve gradient (MVG) in DMR group was increased from (3.1±1.2) mmHg (1 mmHg=0.133 kPa) to (3.7±1.2) mmHg 6 months after operation (P<0.05), while there was no significant change in FMR group (P>0.05). Compared with those before operation, the N-terminal pro-B-type natriuretic peptide levels in both FMR and DMR groups were significantly lower at 6 months postoperatively (all P<0.05), and the left atrial volume index and left atrial anteroposterior diameter were also significantly lower (all P<0.05). The left ventricular end-diastolic diameter and left ventricular end-systolic diameter were significantly reduced 6 months after operation in the FMR group (all P<0.05), but no significant changes were observed in the DMR group (all P>0.05). The ejection fraction was not significantly changed before and after operation in both groups (all P>0.05). The mitral regurgitation, tricuspid regurgitant, and pulmonary artery pressure were significantly reduced in both groups at 6 months postoperatively (all P<0.05).

CONCLUSIONS

TEER is effective for moderate to severe mitral regurgitation. The improve-ments in left ventricular remodeling are more pronounced in patients with FMR while the degree of mitral regurgitation is more significant in DMR patients. However, MVG elevation is more common during the follow-up.

[The association between biological aging markers and valvular heart diseases]

OBJECTIVES

To analyze the association between biological aging markers (phenotypic age and phenotypic age acceleration) and valvular heart diseases.

METHODS

Research subjects who met the inclusion and exclusion criteria were selected from the UK Biobank from 2006 to 2010. The phenotypic age and phenotypic age acceleration were calculated. Cox multivariate analysis was used to examine the relationship between the aging markers and valvular heart diseases. Sensitivity analysis was conducted by removing missing values and subgroup analysis. The predictive accuracy of phenotypic age and phenotypic age acceleration for valvular heart diseases was analyzed using receiver operating characteristic (ROC) curves, and a clinical decision curve was generated based on logistic regression.

RESULTS

A total of 411 687 subjects were included in the study, among whom there were 14 258 patients with valvular heart diseases. The overall median follow-up time was 12.80 years, the median follow-up time for patients with non-rheumatic aortic valve diseases (n=5238), non-rheumatic mitral valve diseases (n=4558), and non-rheumatic tricuspid valve diseases (n=411) were 12.82 years, 12.83 years and 12.84 years, respectively. After adjusting for demographic factors (gender, race, education, Townsend deprivation index), anthropometric factors (body mass index), lifestyle factors (smoking, alcohol consumption, Dietary Approaches to Stop Hypertension score), hypertension and hyperlipidemia, Cox multivariate analysis showed phenotypic age and phenotypic age acceleration were independent risk factors for valvular heart diseases, including non-rheumatic aortic valve diseases, non-rheumatic mitral valve diseases, and non-rheumatic tricuspid valve diseases (phenotypic age: corrected HR=1.04, P<0.01; phenotypic age acceleration: corrected HR=1.03, P<0.01), which was also confirmed by sensitivity analysis. ROC curves and clinical decision curves demonstrated that compared with the phenotypic age acceleration, phenotypic age had higher accuracy (the areas and the curves were 0.721 and 0.599) and higher net benefit in predicting valvular heart diseases. Moreover, compared with a single indicator, the combination of the two indicators had higher accuracy (the area under the curve was 0.725) and higher net benefit.

CONCLUSIONS

Phenotypic age and phenotypic age acceleration,as markers of biological aging, are independent risk factors for valvular heart diseases. Compared with phenotypic age acceleration, phenotypic age has a greater advantage in predicting valvular heart diseases. Overall, the combination of the two indicators offers a more effective approach for predicting valvular heart diseases.

Intraoperative Transesophageal Echocardiographic Guidance in Cardiac Surgery

Transesophageal echocardiography (TEE) is a valuable tool for diagnosing structural heart diseases, offering superior resolution compared to transthoracic echocardiography. It allows for real-time evaluation of cardiac valves and both systolic and diastolic heart function. Additionally, TEE facilitates the prompt detection of potential complications during cardiac surgeries, such as paravalvular leaks, iatrogenic aortic dissections, and pericardial effusions. Advances in imaging, including 3D echocardiography, have further enhanced the visualization of complex structures like cardiac valves, providing "surgical views" that improve preoperative planning. These features have also made TEE indispensable for postoperative evaluation of cardiac valve repairs and for intraoperative guidance during minimally invasive procedures. This review article aims to summarize the indications for using TEE as an intraoperative tool in cardiac surgery.

Atrial and ventricular functional mitral regurgitation: prevalence, characteristics, outcomes, and disease progression

AIMS

Limited data exist on the natural history of functional mitral regurgitation (FMR), including atrial (AFMR), ventricular (VFMR), and dual FMR. This study examined the prevalence, characteristics, outcomes, and progression of these FMR subtypes.

METHODS AND RESULTS

Consecutive patients with ≥mild to moderate FMR were included and classified as AFMR, VFMR, or dual FMR. AFMR is characterized by left atrial enlargement, while VFMR involves left ventricular enlargement or reduced left ventricular ejection fraction. Dual FMR combines features of both. Clinical outcome was all-cause mortality and heart failure (HF) hospitalization. Echocardiographic outcome was the progression from mild-moderate/moderate to severe FMR and from AFMR/VFMR to dual FMR. Of 22 814 patients, AFMR, VFMR, and dual FMR were identified in 39%, 14%, and 47%, respectively. Most (84%) had mild-moderate to moderate FMR. Over a median clinical follow-up of 4.7 years, dual FMR has the highest risk of all-cause mortality and HF hospitalization. Compared with AFMR, patients with VFMR have a higher incidence of all-cause mortality (adjusted HR = 1.73, 95%CI 1.54-1.94, P < 0.001) and HF hospitalization (adjusted HR = 1.23, 95%CI 1.15-1.32, P < 0.001). In the serial cohort with 2.4 (1.0-4.9) years echocardiogram follow-up, VFMR was associated with a 1.51-fold and 3.08-fold increase in the risk of progressing to severe FMR and dual FMR than AFMR (both P < 0.001). Sensitivity analyses did not change these findings.

CONCLUSION

AFMR and VFMR have significant differences in survival and disease progression. Dual FMR is a common and distinct disease process that occurs in the progression of AFMR or VFMR and is associated with a poor prognosis.

Prevalence, spectrum and aetiology of valvular heart disease based on community echocardiographic screening transition from different altitudes in Yunnan, China

BACKGROUND

The burden of valvular heart disease (VHD) is rising rapidly globally, accompanied by substantial geographical disparities. Although altitude may influence cardiovascular system, no community-based studies have yet explored altitudinal differences in VHD epidemiology.

OBJECTIVE

This study aims to investigate the prevalence, spectrum and aetiology of VHD in different altitude areas.

METHODS

We conducted two sequential community-based echocardiography screening programmes in Yunnan Province of China and included 5059 eligible participants aged 35 years and older. The multivariable Poisson regression models with robust variance were performed to assess the association of different altitude groups with VHD and its subtypes.

RESULTS

The prevalence of overall VHD, clinically significant VHD and clinically significant regurgitant VHD was 36.7%, 2.5% and 2.4%, respectively. After stratification by altitude, the prevalence of any VHD among participants in the <2000 m, 2000-2499 m, 2500-2999 m and ≥3000 m groups was 30.4%, 40.9%, 35.0% and 44.3%, respectively. The fully adjusted models showed that the prevalence ratios for VHD in the 2000-2499 m, 2500-2999 m and ≥3000 m groups were 1.28 (95% CI 1.15 to 1.42), 1.20 (95% CI 1.02 to 1.41) and 1.34 (95% CI 1.04 to 1.72), compared with the <2000 m group. Clinically significant VHD in the <3000 m altitude group was predominantly degenerative in aetiology, whereas functionality was most prevalent in the ≥3000 m altitude group. Subgroup analysis identified some high-risk populations, including male, minority ethnicity, 60 years and older and high systolic blood pressure.

CONCLUSIONS

Adults living at high altitudes have a higher prevalence risk of VHD; significant altitudinal differences exist in the characteristics and aetiology of VHD. The findings could provide insights into primary prevention and early screening for VHD in low- and middle-income countries where a majority of the population lives at high altitudes.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes: Developed by a multisociety taskforce coordinated by the Heart Valve Society (HVS) including the American Heart Association (AHA), the American College of Cardiology (ACC), the European Association for Cardio-Thoracic Surgery (EACTS), the European Society of Cardiology (ESC), The Society of Thoracic Surgeons (STS), the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS), the International Society for Applied Cardiovascular Biology (ISACB), the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), the South African Heart Association (SHA), Heart Valve Voice, and Global Heart Hub

Background

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

Methods

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

Results

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

Conclusions

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Patients with Age-related Macular Degeneration Have Increased Susceptibility to Valvular Heart Disease

Purpose

Valvular heart disease (VHD) contributes significantly to cardiovascular-related morbidity worldwide. Aortic valve stenosis is the third most common cardiovascular disease in the Western world, after hypertension and coronary artery disease. Recent studies have reported an association between VHD and the presence of subretinal drusenoid deposits (SDDs), a distinct manifestation of age-related macular degeneration (AMD). However, these findings were based on self-reported questionnaires and relatively modest cohort sizes. Our goal was therefore to investigate the putative associations between AMD and VHD and between the presence of SDDs and VHD.

Design

Retrospective case-control study.

Subjects

A total of 945 with AMD and 8275 control patients without AMD from a single tertiary center.

Methods

All patients with AMD underwent spectral-domain OCT (SD-OCT). The SD-OCT scans were annotated by 2 experienced graders. Among the patients with AMD, 547 had drusen and SDDs, and 398 had drusen only with no SDDs. We also extracted data from all 9220 patients' electronic medical records, including demographics and previous heart valve procedures based on International Classification of Diseases, ninth revision codes.

Main Outcome Measures

Heart valve-related diagnoses and procedures performed in both patient groups.

Results

Patients with AMD had a higher prevalence of various VHDs compared with the control group, including increased rates of aortic stenosis (odds ratio [OR], 2.00; 95% confidence interval (CI), 1.40-2.86; P < 0.001), aortic regurgitation (OR, 2.41; 95% CI, 1.49-3.91; P < 0.001), and mitral valve regurgitation (OR, 1.51; 95% CI, 1.13-2.01; P = 0.004). Heart valve procedures were also more prevalent among AMD patients including aortic valve replacement (OR, 1.70; 95% CI, 1.08-2.66; P = 0.019) and tricuspid valve replacement (OR, 3.99; 95% CI, 1.03-15.46; P = 0.03). Moreover, a supervised machine learning model successfully detected the presence of AMD based solemnly on the patient's history of VHD. In the AMD cohort, we found no significant difference in VHD prevalence between patients with nonneovascular AMD and patients with neovascular AMD, or between patients with SDDs and patients without SDDs.

Conclusions

Patients with AMD have a higher prevalence of VHD and are more likely to undergo a heart valve-related procedure compared with patients without AMD, with no difference between patients with SDDs and patients without SDDs in the AMD cohort.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Analysis of the haemodynamic changes caused by surgical and transcatheter aortic valve replacements by means fluid-structure interaction simulations

Aortic valve replacements, both surgical and transcatheter, are nowadays widely employed treatments. Although clinically effective, these procedures are correlated with potentially severe clinical complications which can be associated with the non-physiological haemodynamics that they establish. In this work, the fluid dynamics changes produced by surgical and transcatheter aortic valve replacements are analysed and compared with an ideal healthy native valve configuration, employing advanced fluid-structure interaction (FSI) simulations. The aim of the study is to investigate how existing treatments may affect the aortic valve function, and giving indications about how to improve current therapies. Simulations were performed using the commercial software LS-DYNA, where the FSI strategy is based on the coupling of a Lagrangian approach for the structures and a Eulerian approach for the fluid, whilst the coupling between the two domains is reached through a hybrid arbitrary-Lagrangian-Eulerian algorithm. Idealised geometries are used for the aortic root and leaflets. The aortic wall was modelled as linear elastic material, whilst leaflets were modelled as hyperelastic incompressible, using an Ogden's constitutive model. A combination of physiological flow velocity and pressure differences are applied as boundary conditions to model realistically the whole cardiac cycle. Results are analysed throughout the cardiac cycle in terms of leaflets kinematics, flow dynamics, pressure and valve performance parameters. Globally, surgical valves presented worse performance than transcatheter counterparts (reduced effective orifice area, increased transvalvular pressure drop and increased opening and closing times). The clinical parameters of transcatheter devices were improved and closer to those of the healthy native valve, although the vortical activity within the Valsalva's sinuses was substantially altered. Here, the presence of the partition obstructed the washing out, resulting in higher degree of blood stasis and potential blood damage. The implantation of prosthetic devices produces major haemodynamic changes which alters the valve dynamics and leads to diminished performance. Currently, the design of these substitutes is not optimised to mimic realistic native conditions, particularly in terms of valve opening behaviour. Although transcatheter devices provide systolic performance similar to that estimated for the healthy native aortic model, none of the prosthetic solutions appeared to be able to fully restore healthy physiological conditions.