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

TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and complex or multivessel coronary disease (TCW): an international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial

BACKGROUND

Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease.

METHODS

This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed.

FINDINGS

Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (pnon-inferiority<0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; psuperiority<0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010).

INTERPRETATION

The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment.

FUNDING

Isala Heart Centre and Medtronic.

Age, creatinine, and ejection fraction score is a risk factor for acute kidney injury after surgical aortic valve replacement

BACKGROUND

The incidence of acute kidney injury (AKI) increases after surgical aortic valve replacement (SAVR). This study aimed to characterize the risk factors of AKI after SAVR.

METHODS AND RESULTS

We conducted a retrospective registry study based on data from 299 consecutive patients undergoing SAVR. At 48 h after SAVR, 41 patients developed AKI. There was a significantly higher prevalence of older age, higher body mass index (BMI), and diabetes mellitus in the AKI group. Previous use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) and β-blocker, intake and output volumes within 24 h, mechanical ventilation time, length of intensive care unit and hospital stay, baseline creatinine, baseline, 24 h, and 48 h estimated glomerular filtration rate were strongly associated with the incidence of AKI. BMI >24, history of hypertension, use of ACEI/ARB and β-blocker, and mechanical ventilation time were associated with AKI. Univariate logistic regression indicated that overweight, hypertension, use of ACEI/ARB and β-blocker, and mechanical ventilation time were associated with AKI. Notably, the ACEF score was an independent predictor of AKI. The receiver operating characteristic curve was employed to assess the ACEF score for predicting AKI and the best cutoff was 1.1. After dividing ACEF into quartiles, each one-unit increment in ACEF led to a 2.27-fold risk in the incidence of AKI among patients.

CONCLUSIONS

AKI is a generalizable phenomenon occurring frequently after SAVR. The ACEF score is an independent predictor of AKI among patients undergoing SAVR.

Outcomes of mitral valve reoperation and first-time surgery for mitral regurgitation: A nationwide study

BACKGROUND

While mitral reoperation has been assumed to carry higher surgical risk than first-time mitral surgery, outcomes of this procedure remain uncertain.

AIMS

To examine characteristics and outcomes associated with mitral valve reoperation and first-time surgery for mitral regurgitation.

METHODS

Patients undergoing surgery for mitral regurgitation were identified using Danish nationwide registries. The population was categorized into 1) patients undergoing first-time mitral surgery, 2) patients undergoing mitral reoperation. Mortality rates were examined during 180-day follow-up using Reverse Kaplan-Meier and Multivariable Cox-analysis.

RESULTS

In total, 7734 patients underwent surgery for mitral regurgitation. Of these, 428 patients also underwent mitral reoperation. Compared to first-time surgery, reoperated patients were younger (median 64.9 and 66.7 years) and had more cardiovascular comorbidities including atrial fibrillation (61.6 % and 38.8 %) and heart failure (48.7 % and 29.9 %). Median time to reoperation was 2.3 years. Prosthetic replacement was performed in 34.0 % of first-time surgeries and 78.7 % of reoperations. Mortality was 7.1 % following first-time surgery and 10.1 % following reoperation. Following first-time surgery, factors associated with increased mortality rate was prior myocardial infarction (HR = 1.98, 95 %CI 1.62-2.41), heart failure (HR = 1.59, 95 %CI 1.33-1.90), concomitant aortic valve surgery (HR = 1.61-1.27, 95 % CI 1.27-2.02) and bypass grafting (HR = 1.58, 95 %CI 1.31-1.91). Following reoperation, heart failure was associated with increased mortality rate (HR = 2.23, 95 %CI 1.17-4.60).

CONCLUSIONS

Patients undergoing mitral reoperation are young but have developed high burden of comorbidities at the time of reoperation. In spite of this, outcomes of mitral reoperation were acceptable, reflecting that this procedure can be performed safely in selected patients.

Hemolytic Anemia Following SAPIEN 3 Ultra RESILIA Implantation (from the OCEAN-TAVI Registry)

Decompensated hemolytic anemia after transcatheter aortic valve implantation (TAVI) requiring specific treatment is rarely encountered in actual clinical practice. Nevertheless, there have been several cases of clinically relevant hemolytic anemia following implantation of the recently launched SAPIEN 3 Ultra RESILIA (S3UR). This study aimed to elucidate the clinical features of hemolytic anemia following S3UR implantation. Patients who underwent TAVI using S3UR from the end of March 2023 to November 2023 were enrolled from the Japanese multicenter OCEAN (Optimized CathEter vAlvular iNtervention)-TAVI registry. Hemolytic anemia was defined as (1) a drop in hemoglobin level by >2.0 g/dL within 3 months after the index TAVI procedure and (2) the diagnosis of mechanical hemolysis as the cause of anemia made by the attending physician and hematologist based on the presence of any 2 of the following criteria: (1) serum lactate dehydrogenase level >220 IU/L; (2) haptoglobin level <0.5 g/L; and (3) reticulocyte count ≥2%. Of the 1,070 patients, 18 (1.7%) patients developed hemolytic anemia after TAVI. These patients had a significantly lower prosthesis oversizing relative to native annulus (-3.7% [-5.9% to 0.1%] vs 7.5% [0.6% to 14.0%], p <0.001) and a higher prevalence of paravalvular leakage (PVL) ≥mild (mild PVL: 61.1% vs 12.4%; moderate-to-severe PVL: 16.7% vs 0.2%; p <0.001) than those without hemolytic anemia. PVL ≥mild was associated with a higher incidence of hemolytic anemia particularly in patients with oversizing of <-5% (33.3% vs 1.3%, p <0.001) and in those with -5%≤ oversizing <10% (8.3% vs 0.7%, p <0.001). In conclusion, the incidence of decompensated hemolytic anemia after S3UR implantation was not negligible, and the results of the present study support the importance of selecting a prosthesis size with a sufficient oversizing relative to native annulus to minimize residual PVL ≥mild leading to hemolytic anemia after TAVI.

Therapeutical approach of tricuspid regurgitation and right heart failure

Significant tricuspid regurgitation (TR) is a relatively common condition, affecting approximately 4 % of the elderly population. However, there are currently no clear guidelines for its medical management due to a lack of sufficient data in the literature. This review examines the pathophysiology of TR, categorizes its etiologies, and evaluates therapeutic options, both pharmacological and non-pharmacological, to optimize intervention timing and hemodynamic management. Based on the etiology and severity of TR, we suggest a gradual, stage-based algorithm for diuretic therapy titration and a management approach derived from common clinical practices.

Early Aortic Valve Replacement in Asymptomatic Severe Aortic Stenosis: A Meta-Analysis of Randomized Controlled Trials

Determining the best time for aortic valve replacement (AVR) in asymptomatic severe aortic stenosis (AS) with preserved left ventricular function remains controversial, as current guidelines recommend waiting until symptoms appear. Recent evidence suggests that early AVR may improve outcomes for select patients. This meta-analysis of randomized controlled trials evaluated the efficacy of early AVR, including surgical and transcatheter approaches, versus conservative management in asymptomatic severe AS. We systematically searched PubMed, Embase, CENTRAL, and ClinicalTrials.gov to identify eligible trials. The outcomes of interest included all-cause mortality, unplanned hospitalization, stroke, as well as the composite endpoint of each trial, which was derived from combinations of these outcomes. Four trials involving 1,427 patients were included. Early AVR significantly reduced the risk of unplanned hospitalizations (HR 0.42, 95% CI 0.33 to 0.53, p <0.001, I² = 0%). Although there was a trend towards reduced all-cause mortality, it did not reach statistical significance (HR 0.76, 95% CI 0.48 to 1.21, I² = 42%). Stroke also trended lower with early AVR (HR 0.63, 95% CI 0.40 to 1.00, p = 0.05, I² = 0%). In conclusion, these findings indicate that early AVR may provide clinical benefits by reducing adverse events in asymptomatic severe AS, in particular unplanned rehospitalization, suggesting that early AVR could be beneficial and should be considered in future guideline revisions.

Outcomes of transcatheter aortic valve implantation in Africa: A systematic review and meta-analysis

BACKGROUND

Transcatheter Aortic Valve Implantation (TAVI) has become the routine standard of care in patients with severe aortic stenosis and prohibitive surgical risk worldwide. However, data on TAVI outcomes from Africa remain sparse. This study aimed to evaluate the outcomes of TAVI in Africa.

METHODS

We systematically searched PubMed, Scopus and Embase from inception to August 15th, 2024, in addition to the gray literature, and a single proportion meta-analysis was performed to pool proportions and means of categorical and continuous variables, respectively, with 95 % confidence interval (95 % CI). continuous variable reported as median (interquartile range) was converted into a mean (standard deviation). Inconsistency factor (I2) values greater than 50 % represent high heterogeneity. The analysis was performed by R software (RStudio).

RESULTS

Of 177 articles, we identified seven observational studies in Africa (n = 704). The mean age was 79.18 years (95 % CI: 77.26-81.10; I2 = 97 %) and 52 % were male. Procedural success rate in Africa was 91 % (95 % CI: 86 %-94 %; I2 = 38 %), however, In-hospital all-cause mortality was 5.0 % (95 % CI: 3 %-8 %; I2 = 35 %) and all-cause mortality at 1-year follow-up was 11.0 % (95 % CI: 6 %-20 %; I2 = 61 %). In terms of adverse events, PPM was in 7.0 % (4.0-11.0, I2 = 14 %), major bleeding occurred in 8.0 % (4.0-14.0, I2 = 78 %), and stroke/TIA 2.0 % (1.0-4.0), I2 = 41 %).

CONCLUSION

The procedural success is high in Africa, however, the mortality rate and adverse events are notable. More national registries are required to accurately identify these outcomes to improve the healthcare system.

Periprocedural care for frail older patients with aortic stenosis undergoing transcatheter aortic valve replacement

Degenerative aortic stenosis (AS) is an aging-associated disease with alarmingly high mortality that has risen in prevalence in tandem with the global population aging. Treatment options for AS are currently limited to surgical or percutaneous valve intervention, which are associated with significant morbidity. It is increasingly recognized that the care of AS patients is frequently constrained by concomitant frailty, an under-recognized syndrome among older individuals. Many AS patients have concurrent aging-associated diseases, including atherosclerotic diseases, organ impairment, physical frailty, and nutritional deficiencies which limit functional improvement after valve intervention. It has become increasingly crucial for clinicians to address these concurrent issues in frail, older individuals with AS to achieve the best possible outcomes. We aim to review the well-studied relationship between frailty and AS, as well as possible strategies for periprocedural optimization and risk management.

Tricuspid regurgitation after heart transplantation: where innovation and intervention are in hibernation

Tricuspid regurgitation (TR) is a common valvular dysfunction following heart transplantation (HT), with reported prevalence rates ranging from 19 to 84%, primarily depending on the duration of follow-up. Its etiology is multifactorial and includes surgical technique, ischemic time, primary graft dysfunction, pulmonary hypertension, pacemaker leads, and endomyocardial biopsies. Severe TR can significantly impair graft function, exercise capacity, and patient survival. This mini-review explores current management strategies, including surgical techniques such as annuloplasty and tricuspid valve replacement. HT patients are often high-risk surgical candidates due to factors such as immunosuppressive therapy, prior surgeries, and various comorbidities. Therefore, we primarily focus on the evidence regarding emerging interventional methods, such as transcatheter edge-to-edge repair. Although these interventions show promising early results, they remain relatively novel in HT recipients, and the current evidence is based on case reports and small studies. Further research is essential to evaluate the long-term efficacy and safety of these management strategies to enhance outcomes for HT recipients with TR.

The role of the Prognostic Nutritional Index in predicting survival and rehospitalization after surgical aortic valve replacement

Purpose

The Prognostic Nutritional Index (PNI), calculated using serum albumin levels and blood lymphocyte count, reflects a patient's nutritional and immune status. It is commonly used as a prognostic tool following oncological surgery and in certain cardiovascular conditions. This study aims to assess whether the PNI can also serve as a prognostic indicator in patients undergoing surgical aortic valve replacement (SAVR).

Methods

A total of 471 low-risk patients with EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) of ≤4%, who underwent isolated SAVR, were retrospectively analysed. Patients were divided into two groups based on their PNI values (cut-off, 46.75). Outcomes such as length of hospital stay, 30-day mortality, 1-year survival, and rehospitalization rates were compared between the groups.

Results

The Low PNI group consisted of 116 patients, while the High PNI group included 355 patients. The latter were younger, but both groups had comparable comorbidities. All patients underwent SAVR with a bioprosthesis. There was no significant difference in 30-day mortality between the groups (Low PNI, 2.6% vs. High PNI, 0.9%, p = 0.162). However, the 1-year survival rate was significantly lower in the Low PNI group (Low PNI, 5.2 ± 4.1% vs. High PNI, 1.7 ± 1.3%, p = 0.039). Additionally, the 1-year rehospitalization rate was significantly higher in the Low PNI group (Low PNI, 13.8 ± 6.3% vs. High PNI, 7.7 ± 2.7%, p = 0.040). Multivariate analysis identified PNI as a protective factor, while mechanical ventilation was associated with increased risk of death or rehospitalization at 1-year after SAVR.

Conclusions

The PNI is an inexpensive, accessible, and reliable tool that can be easily integrated into existing risk stratification scores for SAVR.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01891-7.

[Photon-Counting Detector CT: Advances and Clinical Applications in Cardiovascular Imaging]

Since the approval of the first dual-source photon-counting detector CT (PCD-CT) in the fall of 2021, significant insights have been gained in its application for cardiovascular imaging. This review aims to provide a comprehensive overview of the current state of knowledge and the growing body of research literature, illustrating innovative applications and perspectives through case examples.We conducted a structured literature review, identifying relevant studies via Google Scholar and PubMed, using the keywords "photon-counting detector", "cardiovascular CT", "cardiac CT", and "ultra-high-resolution CT". We analyzed studies published since January 2015. Additionally, we integrated our own clinical experiences and case examples.In addition to the well-known benefit of increased temporal resolution offered by dual-source scanners, dual-source PCD-CT provides three key advantages: 1) Optimized geometric dose efficiency with an improved contrast-to-noise ratio, 2) intrinsic spectral sensitivity, and 3) the ability for ultrahigh-resolution CT. This technology enables improved image quality or radiation dose reduction in established cardiovascular protocols. Its use in non-invasive cardiac diagnostics for obese patients, those with a high plaque burden, or after stent implantation appears technically feasible, potentially expanding the scope of CT. The spectral sensitivity also allows tailored image acquisition, reducing metallic artifacts and contrast agent doses in patients with renal impairment. Early studies and clinical experience support these potential applications of PCD-CT in cardiovascular diagnostics, suggesting workflow optimization and improved patient management.However, challenges remain, including high costs, large data volumes, somewhat longer reconstruction times, and technical difficulties in combining spectral sensitivity with ultra-high resolution. Prospective randomized studies with clinical endpoints are lacking to confirm the clear advantage over conventional scanners. Future research should focus on endpoint-based studies and robust cost-benefit analyses to evaluate the potential of this technology and facilitate its evidence-based integration in clinical practice. · Photon-counting detector CT represents a technological advancement in computed tomography.. · Spectral sensitivity enhances iodine signal and minimizes artifacts.. · Ultra-high-resolution CT allows precise imaging, even in stents and advanced sclerosis.. · This technology must be validated through endpoint-based, randomized studies.. · Hagar MT, Schlett CL, Oechsner T et al. Photon-Counting Detector CT: Advances and Clinical Applications in Cardiovascular Imaging. Rofo 2025; 197: 509-516.

Comparative effectiveness of transcatheter vs surgical aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

The management of severe symptomatic aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), offering a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, the comparative safety and efficacy of these interventions remain subjects of ongoing investigation.

AIM

To compare the clinical outcomes and safety of TAVR vs SAVR in patients with severe symptomatic aortic stenosis.

METHODS

A systematic review and meta-analysis were conducted according to PRISMA guidelines. Randomized controlled trials (RCTs) comparing TAVR and SAVR were identified from databases including PubMed, Scopus, and Web of Science up to May 31, 2024. Data were extracted on clinical outcomes, including mortality, procedural complications, and post-procedure adverse events. Risk ratios (RRs) with 95%CIs were calculated using a random-effects model.

RESULTS

A total of 10 RCTs were included. TAVR demonstrated a significantly lower risk of acute kidney injury (RR: 0.33; 95%CI: 0.25–0.44), major bleeding (RR: 0.37; 95%CI: 0.30–0.46), and new-onset atrial fibrillation (RR: 0.44; 95%CI: 0.34–0.57) compared to SAVR. However, TAVR was associated with higher risks of new permanent pacemaker implantation (RR: 3.49; 95%CI: 2.77–4.39), major vascular complications (RR: 2.47; 95%CI: 1.91–3.21), and paravalvular leaks (RR: 4.15; 95%CI: 3.14–5.48). Mortality at 30 days was comparable (RR: 0.95; 95%CI: 0.78–1.15), but long-term mortality was slightly higher with TAVR in some analyses (RR: 1.23; 95%CI: 1.01–1.49). Rates of stroke (RR: 0.97; 95%CI: 0.81–1.17) and myocardial infarction (RR: 0.91; 95%CI: 0.67–1.24) were similar between the groups.

CONCLUSION

TAVR offers a less invasive option with significant benefits in reducing acute kidney injury, major bleeding, and new-onset atrial fibrillation, making it particularly advantageous for high-risk surgical candidates. However, higher risks of permanent pacemaker implantation, vascular complications, and paravalvular leaks highlight the need for individualized patient selection and shared decision-making to optimize outcomes.

Computed tomography-based coronary lumen volume to myocardial mass ratio in patients undergoing transcatheter aortic valve replacement: a novel method for risk assessment

BACKGROUND

The coronary lumen volume to myocardial mass (V/M) ratio has been suggested as a quantitative metric of potential imbalance between coronary blood supply and myocardial oxygen demand. This study was designed to assess the prognostic value of the V/M ratio for predicting major adverse cardiovascular events (MACE) in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

This study enrolled patients who received a standard planning computed tomography (CT) scan before TAVR and dichotomized at the median of 33.31 mm³/g of V/M ratio into groups with low V/M ratio and high V/M ratio. The V/M ratio was calculated by coronary computed tomography angiography (CTA). The endpoint was a composite of all-cause mortality, stroke, and hospitalization for heart failure. The cumulative incidence of the MACE was compared using Kaplan-Meyer plots and uni- and multivariate Cox proportional hazards regression analysis.

RESULTS

In total, 139 patients were enrolled in this study finally (mean age 71.7 ± 6.7 years, 41.7% female). The mean V/M ratio was considerably lower in patients with MACE than in those without MACE (26.5 ± 4.9mm3/g vs. 34.0 ± 3.8mm3/g, P<0.001). Multivariate Cox proportional hazards regression showed that the low V/M ratio group (≤ 33.31 mm³/g) had a higher risk of MACE after TAVR (HR: 6.14, 95%CI: 1.37-27.54; P = 0.018).

CONCLUSIONS

The lower V/M ratio could serve as an independent predictor of MACE in patients undergoing TAVR.

CLINICAL TRIAL NUMBER

Not applicable.

Associations between new-onset postoperative atrial fibrillation and changes in left ventricular mass index in patients undergoing transcatheter aortic valve replacement

BACKGROUND

New-onset postoperative atrial fibrillation (POAF) is common after transcatheter aortic valve replacement (TAVR). At present, the impact of POAF on cardiac remodeling after TAVR has not been thoroughly studied.

OBJECTIVES

To investigate the impact of POAF on cardiac remodeling and its association with clinical outcomes after TAVR.

METHODS

601 patients undergoing TAVR for severe aortic stenosis were evaluated. Of these, 253 patients were identified to have POAF, which was categorized as normal left ventricular mass index (LVMI) in 54 (21%) and high LVMI in 199 (79%). The primary endpoint was a composite of all-cause death, heart failure rehospitalization and disabling stroke. Reverse remodeling was assessed by transthoracic echocardiography.

RESULTS

In POAF patients, the 3-year cumulative incidence of primary composite outcome in the high LVMI subgroup was significantly higher than that in the normal LVMI subgroup (9.3 ± 3.3% vs. 13.5 ± 3.9%; p = 0.02). The incidence of LVMI regression after TAVR was lower in patients with POAF than in those without (65.6 ± 3.0% vs. 82.6 ± 2.7% at 3 years; p = 0.029). Furthermore, the 3-year cumulative incidence of the primary composite outcome and cardiovascular death was highest in the group of POAF without LVMI regression. Baseline LVMI (β = -1.73, p < 0.001) and POAF (β = -1.46, p < 0.001) were independent predictors of change in LVMI at one year.

CONCLUSIONS

Patients with POAF had less LVMI regression and impaired cardiac reverse remodeling after TAVR, which increased the incidence of all-cause death and heart failure rehospitalization. Therefore, clinicians should be more proactive in monitoring and treating POAF after TAVR.

Blood biomarkers in left-sided valvular heart disease

Valvular heart disease (VHD) is a common condition that poses several challenges from the standpoints of diagnosis and therapeutic management. While several studies have explored the role of blood biomarkers in assessing the severity and risk of progression of VHD, as well as in evaluating related cardiac damage and predicting the occurrence of adverse events, blood biomarkers are generally not considered criteria to trigger valve intervention in the latest European and American guidelines for VHD management. This review article provides an up-to-date overview of the utility of blood biomarkers to (i) assess the presence, severity, and progression of left-sided VHD; (ii) establish the presence and extent of cardiovascular damage; (iii) predict clinical outcomes before and after valve interventions; and (iv) identify patients at risk for early structural valve deterioration, valve thrombosis, and paravalvular leak.

The implementation of a streamlined TAVI patient pathway across five European countries: BENCHMARK registry

BACKGROUND

Benchmark best practices have been shown to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI), but the impact in diverse health systems is unknown.

AIMS

We evaluated the impact of Benchmark best practices implementation in Germany, Austria, France, Spain, and Italy.

METHODS

International, multicentre registry of severe symptomatic aortic stenosis (AS) patients undergoing TAVI with a balloon-expandable valve, before and after Benchmark best practices implementation. Objectives were to reduce overall and intensive care unit (ICU) length of stay (LoS), and to document 30-day safety.

RESULTS

A total of 890 patients were analysed in France, 454 in Spain, 362 in Germany, 300 in Italy, and 176 in Austria. Patients had the highest surgical risk in Germany (EuroSCORE II 6.8 ± 7.3%) and lowest in Spain (3.8 ± 2.6%). Austrian patients reported higher rates of prior myocardial infarction, severe pulmonary hypertension, and aortic valve-related symptoms at baseline. After the implementation of Benchmark best practices, the median hospital LoS was significantly reduced in France (5 vs. 3 days, p < 0.001), Spain (6 vs. 4, p < 0.001), Germany (9 vs. 6, p < 0.001), and Italy (7 vs. 5, p < 0.001); reductions in median ICU LoS were reported in France (1.1 vs. 0 days, p < 0.001), Spain (1.9 vs. 1, p < 0.001), and Germany (1 vs. 0.9, p = 0.004). Across all countries, 30-day safety outcomes were uncompromised and reduced rates of major vascular complications rates were observed in Germany (5.9 vs. 0.0%, p < 0.001).

CONCLUSION

The implementation of Benchmark best practices in diverse European healthcare systems resulted in reduced hospital and ICU LoS without compromising patient safety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04579445, September 28th, 2020.

Interventional strategies to unload the right ventricle: a systematic review

INTRODUCTION

The function of the right ventricle (RV) is dependent on preload, end-systolic elastance (afterload) and intrinsic RV contractility. RV dysfunction comprises dilatation and hypertrophy leading to RV failure and commonly death despite advances in medical treatments. This systematic review summarizes current and future interventional treatments to mechanically unload the RV. First, this review focuses on targeting pulmonary vascular afterload by addressing 1. Catheter-directed treatment for acute pulmonary embolism, 2. Balloon Pulmonary Angioplasty for chronic thromboembolic pulmonary hypertension, and 3. Pulmonary Artery Denervation for pulmonary hypertension. Second, mechanical support systems for enhancing RV contractility, and interventions targeting tricuspid regurgitation as a cause of RV failure are discussed.

METHODS

On 2nd December 2024, a systematic search for publications between 2022 and 2025 was performed, using MEDLINE, EMBASE, Cochrane and SCOPUS. The primary outcome was improvement in hemodynamic measurements. Secondary outcomes included In-hospital mortality and complications. Meta-analyses, randomized controlled trials and for newer devices, observational studies and case series were included.

RESULTS

Of 32,852 screened studies, 80 were included. All treatments demonstrated various degrees of RV unloading.

CONCLUSION

Novel treatments directed at mechanical RV unloading may improve survival, but further research is needed to examine long-term effects.

PROSPERO REGISTRATION

;(CRD42024616310).

Diagnosing Severe Low-Gradient vs Moderate Aortic Stenosis with Artificial Intelligence Based on Echocardiography Images

Diagnosis of aortic valve stenosis (AS) is performed manually by a physician experienced in echocardiography imaging. A specific subtype of AS, a severe low-gradient AS, is the most challenging one in terms of differentiating it from the moderate AS. In this study, an artificial intelligence (AI)-based model was used to diagnose the severe low-gradient AS in a fully automatic manner. Data from 158 consecutive patients undergoing echocardiography examination to assess AS severity were used. The obtained performance of our fully automatic approach was AUC = 0.719, 95% confidence interval, 0.640-0.798. It is an important step towards a comprehensive and automatic, image-only-based clinical decision support system for determining the presence of AS and its severity, especially in AS subtypes, such as low-gradient AS.

Severe pulmonary hypertension in weaning from cardiopulmonary bypass following double Ozaki procedure: a case report

BACKGROUND

Ozaki surgery, which reconstructs cardiac valves using autologous pericardium, is commonly performed for aortic valve replacement and offers benefits such as avoiding anticoagulation and reducing valve degeneration. However, its application to pulmonary valve replacement remains rare, and anesthetic management for such cases is not well documented.

CASE PRESENTATION

A 71-year-old woman with severe aortic and pulmonary valve stenosis underwent double valve replacement using the Ozaki procedure and coronary artery bypass grafting. Post-cardiopulmonary bypass, she developed severe pulmonary hypertension and systemic hypotension. Norepinephrine exacerbated pulmonary hypertension, while arginine vasopressin effectively stabilized systemic pressure without worsening pulmonary pressure.

CONCLUSIONS

This is the first reported case of anesthetic management for double valve replacement using the Ozaki procedure. Adequate use of vasopressin led to ameliorating pulmonary hypertension after cardiopulmonary bypass. Assessing preoperative right ventricular pressure and selecting appropriate vasopressors are crucial in mitigating perioperative pulmonary hypertension.

Impact of Mitral Regurgitation on Outcomes of Catheter Ablation for AF With Left Ventricular Systolic Dysfunction

BACKGROUND

Atrial fibrillation (AF) and left ventricular (LV) systolic dysfunction (LVSD) may be associated with function mitral and tricuspid regurgitation (FMR/FTR). Prior studies have largely assessed impact of MR on AF ablation outcomes in the presence of preserved LV ejection fraction.

OBJECTIVES

This study sought to determine the impact of FMR on the outcomes of catheter ablation (CA) in patients with AF and LVSD.

METHODS

We examined baseline clinical characteristics, CA outcomes, and change in echocardiographic parameters (FMR and FTR severity, LV and left atrial [LA] dimensions, LVEF) at baseline and 12 months in individuals with AF and LVSD with at least mild FMR undergoing CA. Patients with primary mitral valve disease were excluded.

RESULTS

235 patients (age 62.8 years,16.2% female, NYHA functional class III (Q1-Q3: II-III)) underwent CA and were categorized by FMR severity at baseline (mild n = 117; moderate/severe n = 118). Baseline characteristics were comparable irrespective of degree of FMR, other than lower LVEF (LVEF 29% [Q1-Q3: 22.8%-35.0%] vs 35% [Q1-Q3: 30.0%-41.0%]; P < 0.001) and increased tricuspid regurgitation in moderate/severe MR (22%) vs mild MR (8%, P < 0.001). LA size did not differ significantly across FMR groups (P = 0.233). At 12 months following CA, recurrent atrial arrhythmia occurred in 101 of 235 (43.0%) including 42.7% in mild vs 43.2% in moderate-to-severe MR (P = 0.940). The severity of FMR did not influence arrhythmia recurrence (OR: 1.15; 95% CI: 0.54-1.86; P = 0.601) nor LV recovery (OR: 1.07; 95% CI: 0.67-1.25; P = 0.153). After CA, 89% of those with significant FMR and 85% with significant FTR exhibited ≥1 grade reduction at 12 months. Change in LV dimensions was associated with MR responders (OR: 0.93; 95% CI: 0.87-0.99; P = 0.022) with a greater reduction in LV size at 12 months in MR improvement (-5.0 (Q1-Q3: -9.3 to -1.0) vs non-improvement -1.0 (Q1-Q3: -5.0 to 2.5), P = 0.004) whereas change in LA size was not (OR: 0.98; 95% CI: 0.97-1.03; P = 0.984).

CONCLUSIONS

In patients with AF and LVSD, the degree of FMR did not impact the success of ablation. There was a significant reduction in FMR and FTR at 12 months following CA. Patients with AF and LVSD should be strongly considered for AF ablation irrespective of the degree of mitral regurgitation.

Management of TAVR in asymptomatic or minimally symptomatic patients: Insights from resting angiographic microvascular resistance

BACKGROUND

The optimal timing of transcatheter aortic valve replacement (TAVR) for asymptomatic or minimally symptomatic patients with severe aortic stenosis (AS) remains controversial. Microvascular dysfunction and increased microcirculatory resistance have been linked to adverse outcomes in AS, suggesting that resting angiographic microvascular resistance (AMRr) may aid in identifying higher-risk patients.

METHOD

We conducted a retrospective study of 180 severe AS patients who underwent TAVR at Fuwai Hospital between 2012 and 2021. Patients were grouped based on an AMRr cutoff value of 490, identified through receiver operating characteristic (ROC) analysis. The primary endpoint was the incidence of major adverse cardiovascular events (MACE), including all-cause mortality, heart failure, and myocardial infarction. Kaplan-Meier and Cox regression analyses were used to compare outcomes between groups.

RESULTS

A total of 180 asymptomatic or minimally symptomatic AS patients undergoing TAVR were enrolled. After a 40-month follow-up, the AMRr >490 group had a higher MACE risk, mainly driven by readmission for heart failure. Additionally, continuous analysis indicated that every 100-unit increase in AMRr was associated with an 18 %, 17 %, and 1.58-fold increased risk of MACE, all-cause mortality, and NOAF, respectively. Moreover, the addition of AMRr to a clinical model significantly improved the prediction of MACE (AUC 0.678 vs. 0.582, p = 0.023).

CONCLUSION

Asymptomatic or minimally symptomatic AS patients with AMRr >490 had a significantly higher incidence of MACE and heart failure rehospitalization than those with AMRr ≤490 after TAVR. The inclusion of AMRr in a predictive model improved the accuracy for long-term MACE, demonstrating an incremental prognostic value.

Heart Failure With Preserved Ejection Fraction Phenotype Is Associated With Early Symptom Onset in Aortic Stenosis and Residual Symptoms After Transcatheter Aortic Valve Implantation

BACKGROUND

Aortic stenosis can lead to cardiac adaptations and symptoms similar to heart failure with preserved ejection fraction. We hypothesized that a heart failure with preserved ejection fraction phenotype in aortic stenosis is associated with earlier onset of symptoms and reduced symptomatic response after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

This retrospective cohort study included 469 patients with moderate aortic stenosis. We determined heavy, hypertension, atrial fibrillation, pulmonary, elder, filling pressure (H2FPEF) score at diagnosis and compared aortic peak jet velocity at onset of dyspnea in patients with low (<6) and high (≥6) H2FPEF score. In a separate cohort of 601 patients undergoing TAVI, we compared New York Heart Association class, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and cardiovascular mortality post-TAVI between patients with low and high H2FPEF scores. In patients with aortic stenosis and a high H2FPEF score (n=43, 9.2%), the median peak jet velocity at onset of dyspnea was 4.2 versus 4.4 m/s in patients with a low H2FPEF score (P<0.001). After TAVI, a high H2FPEF score (n=123, 20%) was associated with a lower proportion of New York Heart Association class I at 30 days (49% versus 61%; P=0.04), persistently elevated NT-proBNP, and higher 5-year rate of cardiovascular mortality (36% versus 30%; P=0.012), compared with a low H2FPEF score.

CONCLUSIONS

Patients with aortic stenosis with a heart failure with preserved ejection fraction phenotype are more likely to develop symptoms at lower gradients and have worse outcomes post-TAVI. Randomized trials are warranted to investigate whether medical therapy targeted at heart failure with preserved ejection fraction delays onset of symptoms and improves symptomatic response after TAVI.

Right atrial remodelling and prognosis in patients with severe atrial functional tricuspid regurgitation

AIMS

Atrial functional tricuspid regurgitation (AFTR) is increasingly recognized as a distinct cause of tricuspid regurgitation, yet data on outcomes and their determinants are limited. This study examines the prognostic role of right atrial (RA) remodelling in patients with severe AFTR.

METHODS AND RESULTS

This retrospective study included consecutive patients with severe AFTR. The primary outcome was all-cause mortality. Cutoff values for RA and right ventricular (RV) sizes related to mortality were identified using receiver operating characteristic curves and maximally selected rank statistics. The cohort included 155 patients with severe AFTR, 96.1% of whom had atrial fibrillation. Of these, 121 received medical treatment, and 34 underwent surgery during follow-up. In the medical management group, 42 deaths (34.7%) occurred over a median of 3.3 years. Patients with high RV end-diastolic area and RA area indices (>14.5 cm2/m2 and >22 cm2/m2) had significantly lower survival compared to their counterparts (P = 0.012 and P = 0.001, respectively). Cox analyses demonstrated that increased RV end-diastolic area and RA area indices were associated with higher mortality (RV end-diastolic area index, per 1 cm2/m2 increase: adjusted hazard ratio 1.11, 95% confidence interval 1.02-1.22, P = 0.019; RA area index, per 1 cm2/m2 increase: adjusted hazard ratio 1.06, 95% confidence interval 1.02-1.10, P = 0.006). Mortality was highest in patients with both high RV end-diastolic area index (>14.5 cm2/m2) and RA area index (>22 cm2/m2) and lowest in those with low values for both indices (P = 0.001). In the surgical intervention group, four post-surgical deaths (11.8%) occurred exclusively in patients with both high RA area and RV end-diastolic area indices.

CONCLUSIONS

RA and RV enlargement are poor prognostic factors in patients with severe AFTR. These findings underscore the importance of assessing RA and RV remodelling to optimize the timing of intervention in this population.

MANAGEMENT OF ASYMPTOMATIC SEVERE AORTIC STENOSIS: A CRITICAL REVIEW OF GUIDELINES AND CLINICAL OUTCOMES

BACKGROUND

Asymptomatic severe aortic stenosis (AS) poses a clinical challenge with variations in recommendations for management.

OBJECTIVES

We sought to compare contemporary guidelines focusing on asymptomatic AS management and present a summary of contemporary studies on early intervention in these patients.

METHODS

Systematic search of electronic databases was conducted with guidelines analyzed using a comparative matrix. A pooled random-effects meta-analysis of randomized controlled trial (RCT) data comparing intervention versus clinical surveillance in asymptomatic severe AS was also performed.

RESULTS

Four guidelines from ACC/AHA, ESC/EACTS, JCS/JSCS/JATS/JSVS, and NICE were included encompassing 108 recommendations. Consensus was found for intervention thresholds including left ventricular dysfunction and very severe AS while discrepancies existed in the utility of biomarkers, myocardial fibrosis, exercise stress testing and choice of intervention. Despite variation in study inclusion criteria, current RCTs on the management of asymptomatic AS indicated a significant reduction in rates of major adverse cardiovascular events when comparing early intervention to clinical surveillance (hazard ratio [HR] 0.52 [0.42, 0.63]), driven primarily by reductions in unplanned hospitalizations (HR 0.41 [0.32, 0.52]).

CONCLUSION

While there is broad consensus on classic indicators of severity such as left ventricular dysfunction as indication for intervention, guidelines diverge on other high-risk features warranting intervention. Early studies indicate the overall safety of early intervention, although further work is needed to identify whether it can reduce the risk of hard clinical endpoints. This underscores the need for further research and updated guidelines to clarify the optimal thresholds for intervention and harmonize treatment pathways for the growing number of patients with asymptomatic AS.

Exercise Right Ventricular-Pulmonary Arterial Coupling and Functional Outcome in Patients Undergoing Surgery for Secondary Ischemic Mitral Regurgitation

BACKGROUND

The exercise assessment of the right ventricular-pulmonary arterial (PA) coupling adds diagnostic and prognostic value in patients with heart failure. In patients with ischemic mitral regurgitation undergoing surgery, data on the exercise assessment of the right ventricular-PA coupling are not available. Resting and exercise echocardiographic predictors of functional outcome in patients with ischemic mitral regurgitation were tested.

METHODS

Six-minute walking test and exercise echocarrdiogram performed at baseline, at 1 years, and at a median follow-up of 6 years (interquartile range, 3.70; range, 4.5-8) on 50 patients (67±8 years; ejection fraction: 35±5%) undergoing valve replacement or repair. Linear mixed models were used to evaluate the predictive value of preoperative echocardiographic parameters on the longitudinal distribution of the 6-minute walking test.

RESULTS

Preoperative exercise tricuspid annular plane systolic excursion (TAPSE)/PA systolic pressure strongly correlated with the long-term 6-minute walking test (r=0.81, P<0.01). The receiver operating characteristic analysis found a preoperative exercise TAPSE/PA systolic pressure <0.34 predicted the lowest quartile of the 6-minute walking test in the long term (sensitivity: 79%; specificity: 100%) as well as a composite outcome of heart failure and death from any cause (positive predictive value: 91.3%, negative predictive value: 100%). On multivariable analysis, TAPSE and TAPSE/PA systolic pressure were significantly associated with a better long-term 6-minute walking test.

CONCLUSIONS

A preoperative exercise TAPSE/PA systolic pressure <0.34 predicts a poor functional performance and a higher likelihood of clinical adverse events. In patients with ischemic mitral regurgitation the exercise right ventricular -PA coupling could improve risk stratification. Larger studies are needed.

Effect of Bicuspid Versus Tricuspid Aortic Valve Morphology on the Fate of the Ascending Aorta

BACKGROUND

Bicuspid aortic valves are associated with ascending aortic pathology, but their impact on long-term outcomes, including aortic growth and adverse events, remains unclear.

METHODS AND RESULTS

This prospective cohort-study included adult patients undergoing aortic valve surgery or ascending aortic surgery at a single center (2007-2013). The primary outcome was aortic diameter growth; secondary outcomes included all-cause mortality and adverse aortic events. Inverse probability of treatment weighting was used to adjust for baseline differences. Among 570 patients, 204 underwent echocardiographic follow-up, and 566 were followed for adverse aortic events. At 10-year follow-up, ascending aortic diameter increased significantly (mean 4 mm, P<0.001), with no difference between patients with BAV and TAV (P=0.68). After multivariable adjustment, there was no difference in all-cause mortality (HR, 0.87 [95% CI, 0.65-1.18]), but BAV was associated with a decreased risk of adverse aortic events (HR, 0.39 [95% CI, 0.19-0.82]). Concomitant ascending aortic surgery was associated with an increased risk of adverse aortic events in patients with TAV (HR, 8.89 [95% CI, 3.36-23.6]) but was associated with a decreased risk in patients with BAV (HR, 0.06 [95% CI, 0.01-0.29]).

CONCLUSION

Ten years after surgery, ascending aortic growth occurred regardless of valve morphology. Adverse aortic events were more common in patients with TAV, whereas patients with BAV benefited from concomitant ascending aortic surgery. These findings suggest a more liberal approach to ascending aortic surgery in patients with BAV undergoing valve replacement, but improved risk stratification is needed.

Design and rationale of the multicenter randomized clinical trial (REVERSE): Efficacy and safety of rivaroxaban in the early postoperative period for patients with bioprosthetic valve replacement or valve repair

BACKGROUND

Rivaroxaban, a Non-vitamin K oral anticoagulant (NOAC), is extensively employed for patients at heightened risk of thrombosis, including those with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). However, to date, there is a lack of robust clinical data to explore the efficacy and safety of rivaroxaban in thromboprophylaxis during the early postoperative period (<6 months) in patients following surgical bioprosthetic valve (BPV).

METHODS

The REVERSE trial is a prospective, multicenter, non-inferior, randomized controlled trial enrolling a planned 250 patients in China. Patients are randomly assigned 1:1 to receive rivaroxaban (20 mg once daily) or dose-adjusted warfarin (target international normalized ratio 2.0-3.0) for 6 months. The primary outcome is defined as the composite of all-cause death, major cardiovascular events, or major bleeding. The safety outcome is all bleeding events defined by the International Society on Thrombosis and Haemostasis (ISTH).

CONCLUSIONS

The REVERSE trial stands as the inaugural multicenter study dedicated to evaluating the efficacy and safety of rivaroxaban for early postoperative anticoagulation in BPV surgery patients. Its findings are anticipated to contribute pivotal evidence regarding the clinical advantages of NOACs.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT06476301.

Baseline characteristics and outcomes of rheumatic mitral valve disease: the EURObservational Research Programme Valvular Heart Disease II Survey

BACKGROUND AND AIMS

Rheumatic heart disease is the commonest acquired cardiovascular disease worldwide. About 20 years have elapsed since the original Euro Heart Survey on valvular heart disease (VHD) was conducted with multiple changes in practice due to advances in treatment techniques. In this study, we aimed to analyse the management of patients with severe native valve disease or those with previous valvular intervention in comparison with existing European Society of Cardiology guidelines.

METHODS

The European Society of Cardiology VHD II registry is an international, prospective, longitudinal multicentre, observational study, which was conducted in 222 centres. The registry included patients with severe native VHD or with previous valvular intervention. Follow-up was undertaken at 6 months at the investigating centre or by telephone.

RESULTS

Amongst patients recruited in the European Society of Cardiology VHD II registry, 470 had severe rheumatic mitral valve disease and 332 had previous rheumatic mitral valve intervention. Amongst the patients with Class I recommendation for intervention, it was undertaken in only 70%. Adherence to guideline recommendations was more in patients with native VHD than in those with previous intervention. Total mortality was 1.5% in hospital and 3.5% at 6 months follow-up. Independent predictors of death at 6 months were age, chronic pulmonary disease, New York Heart Association Classes III and IV at presentation, liver dysfunction, and previous myocardial infarction.

CONCLUSIONS

Compliance with guideline recommendations for intervention is poor overall in patients with rheumatic valve disease. Concerted educational efforts are needed to improve the management of this vulnerable patient cohort.

Current status of aortic valve repair surgery

Severe aortic valve regurgitation, if not timely treated, can significantly impact patients' survival both for tricuspid aortic valve and bicuspid aortic valve patients, with the latter being significantly younger. Increased understanding of the root anatomy and its physiology has opened the way to techniques of aortic valve repair surgery. The techniques mainly relate to re-establishing a correct root and annular geometry and eliminating leaflet prolapse. These techniques are applied both in the presence of a dilated and normal root and are equally valid for tricuspid or bicuspid valve. Techniques for repairing a bicuspid valve might vary depending on the different valve phenotypes. Medium and long-term results appear favourable and potentially superior to those of prosthetic replacement in terms of valve-related complications and quality of life. Optimal surgical treatment, especially in younger and selected patients, should aim to avoid aortic valve replacement and its related complications.

Mitral annular disjunction and mitral valve prolapse: long-term risk of ventricular arrhythmias after surgery

BACKGROUND AND AIMS

Mitral valve prolapse (MVP) is associated with progressive mitral regurgitation (MR) requiring surgical correction. A subset of patients with MVP experience ventricular arrhythmias (VA), and mitral annular disjunction (MAD) has been reported as a risk factor. This study aimed to assess the long-term risk of VA in patients with MAD and MVP undergoing mitral valve surgery for MR.

METHODS

Patients with MVP with moderate or severe degenerative MR undergoing mitral valve surgery (repair or replacement) in 2010-22 at Karolinska University Hospital were included. Mitral annular disjunction length, referring to true MAD, was measured at end systole on pre- and post-operative transthoracic echocardiography. The primary outcome consisted of VA including hospitalizations, outpatient visits or ablation for confirmed sustained or non-sustained ventricular tachycardia, or high burden of premature ventricular complexes and assessed from medical records.

RESULTS

Of 599 patients undergoing mitral valve surgery, 96 (16%) had pre-operative MAD. The median MAD length was 8.0 [inter-quartile range (IQR) 5.0-10.0] mm. Compared with patients without MAD, patients with MAD were younger (55 ± 15 vs 63 ± 11 years), were more often women (31% vs 17%), and had more Barlow's disease (70% vs 27%). Mitral annular disjunction was surgically corrected in all patients. During a median follow-up time of 5.4 (IQR 2.8-7.5) years, patients with pre-operative MAD had a higher risk of VA (hazard ratio adjusted for age and sex 3.33, 95% confidence interval 1.37-8.08) regardless of repair/replacement (Pinteraction = .18).

CONCLUSIONS

Mitral annular disjunction in patients with MVP and MR was associated with a three-fold increased long-term risk of VA post-mitral valve surgery, despite anatomical correction of MAD.

Tricuspid regurgitation and outcomes in mitral valve transcatheter edge-to-edge repair

BACKGROUND AND AIMS

The association between periprocedural change in tricuspid regurgitation (TR) and outcomes in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER) is unclear. This study aimed to examine the prognostic value of TR before and after M-TEER.

METHODS

Patients in the OCEAN-Mitral registry were divided into four groups according to baseline and post-procedure echocardiographic assessments: no TR/no TR (no TR), no TR/significant TR (new-onset TR), significant TR/no TR (normalized TR), and significant TR/significant TR (residual TR) (all represents before/after M-TEER). Tricuspid regurgitation ≥ moderate was defined as significant. The primary outcome was cardiovascular death or heart failure hospitalization. Tricuspid regurgitation pressure gradient was also evaluated.

RESULTS

The numbers of patients in each group were 2103 (no TR), 201 (new-onset TR), 504 (normalized TR), and 858 (residual TR). Baseline assessment for TR and TR pressure gradient was not associated with outcomes after M-TEER. In contrast, patients with new-onset TR had the highest adjusted risk for the primary outcome, followed by those with residual TR [compared with no TR as a reference, hazard ratio 1.83 (95% confidence interval: 1.39-2.40) for new-onset TR, 1.45 (1.23-1.72) for residual TR, and 0.82 (0.65-1.04) for normalized TR]. Similarly, from baseline to post-procedure, TR pressure gradient changes were associated with subsequent outcomes after M-TEER. New-onset and residual TR incidence was commonly associated with dilated tricuspid annulus diameter and atrial fibrillation.

CONCLUSIONS

Post-procedural TR, but not baseline TR, was associated with outcomes after M-TEER. Careful TR assessment after the procedure would provide an optimal management for concomitant significant TR in patients undergoing M-TEER.

Informed Consent and Shared Decision-Making in Modern Medicine: Case-Based Approach, Current Gaps and Practical Proposal

Advances in personalized medicine and Systems Biology have introduced probabilistic models and error discovery to cardiovascular care, aiding disease prevention and procedural planning. However, clinical application faces cultural, technical, and methodological hurdles. Patient autonomy remains essential, with shared decision-making (SDM) gaining importance in managing complex cardiovascular treatment options. Effective SDM relies on collaboration between providers and patients, guided by P5 Medicine principles, which combine psycho-cognitive considerations with predictive, personalized, preventive, and participatory care. Here we propose a 3-step methodological proposal for implementing SDM and enhancing consent acquisition in cardiovascular care. The approach emphasizes personalized patient engagement and the need for clear, comprehensive consent processes. It identifies and addresses significant gaps in current practices, including the complexity of consent language, information dispersion, and the specific needs of vulnerable populations. Issues of Medical Responsibility and/or Liability may raise in the case of absence of consent acquisition or invalid consent due to insufficient/incorrect information. The International Guidelines on Medico-Legal Methods of Ascertainment and Evaluation Criteria are reported. In conclusion, the paper proposes practical solutions, including the use of artificial intelligence (AI) to enhance decision-making and patient counseling, and strategies to ensure that consent processes are both thorough and legally sound and respectful to the individual's autonomy.

Transcatheter Mitral Valve Repair for Wide Prolapse With Large Flail Facilitated by Ventricular Pacing

BACKGROUND

Transcatheter edge-to-edge repair (TEER) has been established as a safe and effective option for treating patients with severe symptomatic degenerative mitral regurgitation (MR) who are at high surgical risk.

CASE SUMMARY

This paper presents a case of a 74-year-old male patient with severe MR accompanied with wide prolapse and large flail, treated using an innovative TEER system, GeminiOne, and ventricular pacing. Postoperative echocardiography demonstrated a significant reduction in MR.

DISCUSSION

This case report highlights the successful use of the GeminiOne TEER system to treat severe MR with complex anatomical challenge. The innovative use of ventricular pacing for leaflet capture can be valuable for managing complex mitral valve pathologies in high-risk patients.

TAKE-HOME MESSAGE

This case highlights the safety and efficacy of the device and introduces a novel leaflet capture strategy.

Unusual Case of Acute Type A Aortic Dissection During TAVR Bailout With a Self-Expanding Valve

BACKGROUND

Over the past 2 decades, transcatheter aortic valve replacement (TAVR) has emerged as a widely accepted treatment for patients with severe aortic valve stenosis. Acute aortic dissection, although rare, is a life-threatening complication associated with TAVR.

CASE SUMMARY

An older man with severe aortic stenosis underwent TAVR. During valve deployment, catheter manipulation caused intimal disruption, leading to acute type A aortic dissection (TAAD). Remarkably, the dissection spontaneously sealed after prosthetic valve placement, thereby avoiding emergency surgery. A 6-month follow-up computed tomography angiography scan showed no extension of the dissection.

DISCUSSION

In the case we report, the dissection spontaneously sealed with the use of a prosthetic valve, a finding that reinforces the feasibility of nonsurgical management of iatrogenic TAAD during TAVR in select cases.

TAKE-HOME MESSAGE

The use of a biological valve offers a novel perspective on the conservative management of iatrogenic aortic dissection in high-risk patients during TAVR.

Impact of mitral valve transcatheter edge-to-edge repair on haemodynamic parameters in cardiogenic shock

BACKGROUND

Transcatheter edge-to-edge repair (TEER) has been shown to be an effective treatment option for patients experiencing cardiogenic shock (CS) with concomitant high-grade mitral valve regurgitation. However, haemodynamic changes following M-TEER have not been thoroughly investigated. Afterload mismatch, leading to the deterioration of haemodynamics subsequent to mitral regurgitation correction, could potentially occur and adversely impact prognosis. Our objective was to analyse the effect of TEER on haemodynamic and echocardiographic parameters in patients with CS.

METHODS AND RESULTS

We conducted a retrospective study of patients undergoing TEER for mitral valve regurgitation in the setting of CS. Haemodynamic and echocardiographic parameters before and after TEER were systematically analysed. A total of 25 patients underwent TEER in the context of CS. All patients were successfully treated with at least of one grade reduction in mitral regurgitation. The median left atrial mean pressure decreased from 23 mmHg (IQR 17-30) to 16 mmHg (IQR 11-20, P < 0.01), and the V-wave decreased from 36 mmHg (IQR 27-44) to 21 mmHg (IQR 14-25, P < 0.01) following the procedure. The stroke volume index and cardiac index increased from 25 mL/m2 (IQR 18-29) to 34 mL/m2 (IQR 25-44, P < 0.01) and from 1.90 L/min/m2 (IQR 1.41-2.30) to 2.50 L/min/m2 (IQR 1.99-2.86, P < 0.01), respectively. We did not observe any worsening of the ejection fraction after the procedure. Ten patients (40%) died during their hospital stay.

CONCLUSIONS

Our study demonstrates that TEER leads to favourable haemodynamic changes in patients with CS. We observed a significant reduction in left atrial pressure, V-wave, and an elevation in cardiac index. Importantly, we did not observe any deterioration in left ventricular function following the procedure. This supports the concept of haemodynamic stabilization with TEER in patients with CS and high-grade mitral regurgitation.

Transcatheter Intervention for Multiple Valve Diseases in a Patient With Cardiogenic Shock

The combination of aortic regurgitation (AR) and mitral regurgitation (MR) is not uncommon in clinical practice, and varying degrees of regurgitation often result in severe hemodynamic disorders. Combined AR and MR often present a therapeutic challenge given the difficulty of attributing symptoms to 1 or both valves and the lack of reliable clinical trial data to guide clinical decision making. Transcatheter valve intervention has brought a new light to patients with high-risk valve disease. We report a patient with high-risk multiple valve disease and discuss the hemodynamic characteristics of the diagnostic process as well as therapeutic ideas.

Surgical Mitral Valve Repair vs Replacement After Failed Mitral Transcatheter Edge-to-Edge Repair: The CUTTING-EDGE Registry

BACKGROUND

The impact of mitral valve (MV) surgery type after failed mitral transcatheter edge-to-edge repair (M-TEER) has not been well studied.

OBJECTIVES

The aim of this study was to compare the outcomes of MV repair vs replacement after failed M-TEER.

METHODS

From 2009 to 2020, a total of 332 patients across 34 centers from the CUTTING-EDGE registry underwent MV surgery after M-TEER. Outcomes were compared between MV repair and replacement. Primary outcomes included 30-day mortality and 1-year survival after MV surgery.

RESULTS

Among enrolled patients (mean age 73.8 ± 10.1 years, median Society of Thoracic Surgeons Predicted Risk of Mortality 3.9% [Q1-Q3: 2.2%-6.8%]), 25 (7.5%) underwent repair and 307 (92.5%) underwent replacement. The replacement group had a significantly higher rate of comorbidities, including atrial fibrillation, prior cardiac surgery, more secondary mitral regurgitation, and more devices implanted at index M-TEER (P < 0.05 for all). Replacement patients showed a trend toward higher 30-day mortality (17.7% [52 of 294] vs 4.0% [1 of 25]; P = 0.094). The observed-to-expected ratio of 30-day mortality was 3.6 (95% CI: 1.9-5.3) overall, 3.8 (95% CI: 2.1-5.5) in the replacement group, and 1.7 (95% CI: 0.7-3.3) in the repair group. Replacement patients had higher 1-year mortality (33.3% [65 of 195] vs 10.5% [2 of 19]; P = 0.041). Significantly lower survival rates were observed after replacement at 2 years (P = 0.033) and persisted in the risk-adjusted Cox regression analysis (HR for replacement: 4.24; 95% CI: 1.04-17.31; P = 0.044).

CONCLUSIONS

MV surgery after failed M-TEER is a high-risk procedure associated with higher than expected 30-day mortality, with higher mortality associated with MV replacement. Compared with repair, replacement is associated with higher 1-year mortality and a lower 2-year survival.

Geriatric assessment and results of transcatheter aortic valve implantation

INTRODUCTION

Comprehensive geriatric assessment (CGA) prior to transcatheter aortic valve replacement implantation (TAVI) for severe aortic stenosis (AS) may improve the selection of patients targeted for this strategy. Despite the fact that CGA includes multiple scales, comparative data among them are limited. Our aim was to evaluate the discriminative capacity of different scales used in CGA on the decision of suitability for TAVI implantation and the influence on prognosis after TAVI implantation.

METHODS

Single-center prospective observational study including consecutive patients with severe AS referred for TAVI implantation. A CGA was performed in all patients including scales of functionality, frailty, cognitive impairment and comorbidities. The predictive capacity of each of the scales was evaluated. The development of major adverse cardiovascular events (MACE: cardiovascular mortality, heart failure [HF] and stroke) was analyzed during follow-up.

RESULTS

A total of 142 patients were selected as candidates for TAVI (80.2%), and 121 were finally implanted. The mean age was 83±4.9 years. Patients who were candidates for TAVI had less valvular area, less atrial fibrillation (AF), less cognitive impairment, more autonomy and less frailty. The SPPB frailty and Barthel functional assessment scales were the main scales of the CGA for the TAVI candidacy decision. After TAVI implantation, 21.5% presented a MACE event, with an overall mortality of 19.8% (6.6% cardiovascular). Patients with a higher rate of events and mortality had more AF, HF, renal disease and malnutrition, as well as less family coverage.

CONCLUSIONS

In elderly patients with severe AS, the CGA is a determining factor in the selection of candidates for TAVI, with frailty and functional assessment being the most important aspects. Family support and nutritional status have a high impact on the prognosis of patients after TAVI.

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.

Impact of Dual Atrioventricular Valve Disease on Outcomes in patients undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Current guidelines provide no recommendations for the management of patients with dual atrioventricular valve regurgitation (DAVR) undergoing transcatheter aortic valve replacement (TAVR), and existing data on its clinical impact remain absent.Therefore, we aimed to provide detailed insights into the impact of DAVR on outcomes after TAVR, with the potential to refine clinical risk-stratification tools and influence future management guidelines.

METHODS AND RESULTS

We retrospectively analyzed 3,491 consecutive patients who underwent TAVR between 2013 and 2021. DAVR was defined as the presence of both MR and TR ≥2+. Patients were divided into four groups based on echocardiography before TAVR: no/mild atrioventricular (AV) regurgitation, isolated MR≥2+, isolated TR≥2+, and DAVR.DAVR was present in 269 patients (7.7%) and was associated with significantly reduced 3-year survival (47.3%) compared to isolated MR (64.3%), isolated TR (54.4%), and no/mild AV regurgitation (73.0%, p<0.001). Multivariate analysis identified DAVR as an independent predictor of 3-year mortality (HR 1.36, 95% CI 1.1-1.8, p=0.021). A leading TR≥3+ in DAVR patients was associated with a particularly poor prognosis (3-year survival: 27%). While an MR improvement following TAVR was linked to better survival (HR 0.45, 95% CI 0.30-0.69, p<0.001), a TR improvement had no significant impact on survival (HR: 0.69, 95%CI: 0.45-1.05, p=0.086). Notably, 54% of DAVR patients continued to experience significant exertional dyspnea at follow-up (NYHA≥II).

CONCLUSIONS

These findings underscore the importance of recognizing DAVR as a high-risk condition in TAVR patients, highlighting the need for refined risk-stratification tools and potential adjunctive therapeutic strategies to improve outcomes.

Prevalence of low-flow state by automated machine-learning 3D echocardiography in patients with moderate-to-severe aortic stenosis and normal ejection-fraction

BACKGROUND

In aortic valve stenosis (AS), measurement of stroke volume index (SVi) by the 2D Doppler- technique is required to calculate the aortic valve area (AVA) and determine flow status but is prone to systematic errors.

PURPOSE

To investigate the prevalence of low-flow (LF) state (SVi ≤ 35 ml/m2) in patients with AS and concurrent SVi quantification by a validated 3D left ventricular volumetric method and standard 2D Doppler methods and its potential repercussions on flow status reclassification.

METHODS

Consecutive patients with moderate or severe AS (≤1.5 cm2 by continuity equation) and ejection fraction ≥ 50% underwent concurrent Dynamic Heart Model (DHM) evaluation with larger settings of the boundary detection sliders (end-diastolic position = 60/60; end-systolic position = 30/30).

RESULTS

We included 57 patients (median 78 years [70-85]); 40% were women. The mean AVA was 1.03 ± 0.37 cm2, median 1.00 [0.73-1.20] cm2. We found a significant but modest correlation between SVi assessed by DHM and 2D Doppler (Pearson corr.=0.48, p < 0.001). In the 25 patients with severe AS (AVA < 1 cm2) subgroup, 75% of patients categorized as LF by 2D Doppler were reclassified as normal flow by DHM. The observed proportion of overall agreement in these patients was 60% (Cohen's kappa = 0.178, p = 0.238), without significant correlation (Pearson coeff.: 0.358; p = 0.166).

CONCLUSIONS

In patients with moderate or severe AS and normal EF, the prevalence of LF state defined as SVi ≤ 35 ml/m2 may be significantly lower than previously reported when the LV volumetric metrics by DHM are employed, and the AVA is close to the replacement referral cut-off.

Echocardiographic Screening for Transcatheter Edge-to-Edge Mitral Valve Repair: Correlation Between Transthoracic and Transesophageal Assessment

BACKGROUND

In patients with significant mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (M-TEER), assessment of mitral valve (MV) anatomy is essential. While transthoracic echocardiography (TTE) is the initial diagnostic tool, transesophageal echocardiography (TOE) provides better anatomical details. The study aims to assess whether TTE is as effective as TOE in selecting patients with severe MR who are eligible for M-TEER.

METHODS

From January to December 2024, patients with severe MR eligible for TEER were enrolled at the Fondazione Monasterio Heart Hospital, Italy. They underwent a comprehensive TTE and TOE examination. Cardiologists assessed the severity of MR and valve anatomy using specific protocols. Measurements included MV area, MV gradient, posterior leaflet length, fossa ovalis high, presence of fails, clefts, and calcifications. Three levels of anatomic complexity were defined to determine eligibility for TEER.

RESULTS

The study includes 40 patients with severe MR. The correlation between TTE and TOE for key parameters was strong, with coefficients ranging from 0.734 to 0.901, indicating high agreement between the two methods. The comparison of categorical features showed high agreement between TTE and TOE in detecting critical MV conditions, with kappa values ranging from 0.717 to 0.930. The agreement for classifying patients as suitable for M-TEER was 87.5%, indicating moderate consistency between the two methods.

CONCLUSIONS

TTE may be a viable alternative to TOE for assessing MV anatomy and function before M-TEER in MR patients, especially in high-volume centers. While TTE strongly correlated with TOE for most parameters, TOE was superior for some features. Further research is needed to refine the clinical application of TTE and to define patient selection criteria for its use as the primary imaging modality for pre-procedural M-TEER screening.

A novel approach to studying infective endocarditis: Ultrasound-guided wire injury and bacterial challenge in mice

BACKGROUND

Infective endocarditis (IE) is frequently caused by Staphylococcus aureus (S. aureus) and most commonly affects the aortic valve. Early diagnosis and treatment initiation are challenging because the involved immunological processes are poorly understood due to a lack of suitable in vivo models.

OBJECTIVES

To establish a novel reproducible murine IE model, based on ultrasound-guided wire injury (WI) induced endothelial damage.

METHODS

IE was established by inducing endothelial damage via ultrasound-guided wire injury followed by bacterial challenge with S. aureus using 104-6 colony-forming units (CFU) 24h to 72h after wire injury. Cross-sections of valvular leaflets were prepared for scanning electron microscopy (SEM) and immunofluorescence microscopy to visualize valvular invasion of macrophages, neutrophils, and S. aureus. Bacterial cultivation was carried out from blood and valve samples. Systemic immune response was assessed using flow cytometry.

RESULTS

Wire injury induced endothelial damage was observed in all mice after wire-injury in SEM imaging. We reliably induced IE using 105 (85%) and 106 (91%) CFU S. aureus after wire injury. Aortic regurgitation was more prevalent in wire injury mice after bacterial challenge. Mice undergoing bacterial challenge responded with significant neutrophilia and elevated pro-inflammatory cytokines in the blood. Immunofluorescence staining revealed significantly increased immune cell accumulations using our proposed model compared to controls.

CONCLUSION

Echocardiography and ex vivo histological staining demonstrated consistent infective endocarditis induction in our new model, combining a wire injury-induced endothelial damage and S. aureus administration. Further exploration of the initial immune cell response and biomarker expression could potentially identify indicators for early IE diagnosis and novel treatment targets.

Emergent Cardiac Surgery After Transcatheter Structural Heart Procedures: Narrative Review

Transcatheter structural heart procedures have become standard therapy for elderly patients with high surgical risk. Over time, these procedures have significantly increased worldwide, accompanied by a concomitant reduction of major complications, including those requiring emergent cardiac surgery (ECS). This marked decline in ECS is due to technological advancements, improved patient selection and procedural techniques, and increased institutional and operators expertize. Moreover, most major structural complications after transcatheter structural heart procedures are now managed percutaneously, with only a small proportion requiring ECS. It is important to note that outcomes for patients requiring ECS remain unfavorable, even in the optimal setting. Currently, ECS after percutaneous structural interventions is very rare, less than 0.5%, as reported in multicenter available studies. However, fragmented data exist in the literature on the need of ECS. Indeed, low incidence, different definitions, and lack of recent reports make it difficult to have a precise and up-to-date overview of bailout surgery for treatment of procedural complications. This is the first comprehensive analysis focusing on ECS following the major frequent percutaneous structural procedures, that is, transcatheter aortic valve replacement, mitral valve repair/replacement, and left atrial appendage occlusion. More in general, a collaborative approach among Heart Team members, along with thorough procedural planning guided by advanced imaging techniques, is essential for ensuring high-quality interventions thus minimizing the risk of adverse events.