Aortic Stenosis: A Contemporary Review

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.

The Relationship Between Aortic Stenosis and the Possibility of Subsequent Macular Diseases: A Nationwide Database Study

Objectives: This study aimed to investigate the possible relationship between aortic stenosis (AS) occupancy and the incidence of subsequent macular diseases. Methods: A retrospective cohort study was conducted using the TriNetX database, and participants with AS were enrolled and matched to non-AS participants. A total of 421,860 and 421,860 participants were evenly divided into the AS and non-AS groups, respectively. The major outcomes of the present study include the development of age-related macular degeneration (AMD), retinal vascular occlusion (RVO), epiretinal membrane (ERM), and central serous chorioretinopathy (CSC). Cox proportional hazard regression was utilized for statistical analysis. Results: There were 4426 and 3013 AMD events; 7315 and 4753 RVO events; 2780 and 1910 ERM events; and 113 and 64 CSC events in the AS and non-AS groups, respectively. According to the results of Cox proportional hazard regression analysis, the AS group demonstrated significantly higher incidences of all macular diseases, including AMD, RVO, ERM, and CSC, compared to the non-AS group (all p < 0.05). The cumulative probabilities of all macular diseases were significantly higher in the AS group than in the non-AS group (all p < 0.05). In the sensitivity analysis, the developmental risks of AMD were significantly higher in the AS group than in the non-AS group with all traits. Conclusions: This study determined that AS occupancy is related to a higher risk of developing macular diseases, which positively correlated to the disease time of AS.

A call to consider an aortic stenosis screening program

Aortic stenosis (AS) is the most common age-related valvular condition with a prevalence of 13.1% in patients older than 75 years of age. Based on the severity of AS and symptoms, current guidelines recommend interval monitoring with transthoracic echocardiogram (TTE). However, no guidelines exist regarding screening asymptomatic persons for AS. Prevalence of AS is comparable to conditions such as colorectal cancer, lung cancer, breast cancer, and abdominal aortic aneurysm where dedicated screening programs are offered resulting in reduction of overall morbidity and mortality. We review recent advancements in treatment options, and we propose an AS screening program for high-risk individuals without known history of AS including all persons over age 75 and persons aged 70 years and older with dialysis dependent end-stage renal disease (ESRD).

Management of coronary artery disease in patients with aortic stenosis

Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.

The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience

Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

Impact of Cirrhosis in Patients Who Underwent Surgical Aortic Valve Replacement

Cirrhosis is known to adversely affect cardiac surgery outcomes. Our objective was to quantify the morbidity, mortality, and cost that cirrhosis adds to surgical aortic valve replacement. From 1998 to 2011, 423,789 patients in the Nationwide Inpatient Sample Healthcare Cost Utilization Project underwent isolated aortic valve replacement; 2,769 (0.7%) had cirrhosis. Multivariable linear regression and 1:1 propensity matching were used to determine the effect of cirrhosis on postsurgical outcomes. The number of patients with cirrhosis who underwent surgical aortic valve replacement per year more than tripled during the 13-year study period. Patients with cirrhosis were more likely to be younger (p <0.0001), insured by Medicaid (p <0.0001), and operated on at an academic or high-volume hospital (p <0.05). Risk-adjusted mortality for patients with cirrhosis was 16%, compared with 5% for patients without cirrhosis. Risk factors for death included congestive heart failure, fluid and electrolyte imbalances, pulmonary circulation disorders, and weight loss. Among propensity-matched pairs, patients with cirrhosis had a higher mortality (odds ratio [OR] 3.6), risk of any complication [OR 1.5], and acute renal failure (OR 2.2). There was no increased risk of stroke, wound infection, blood transfusion, or pneumonia. The risk-adjusted length of stay (15 vs 12 days) and cost ($68,000 vs 56,000) were higher in patients with cirrhosis. In conclusion, the presence of cirrhosis poses a significant risk of death in patients who underwent surgical aortic valve replacement. When performed, the cost and length of stay are increased compared with those without cirrhosis.