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

Viability of Partial Heart Transplant Grafts During Prolonged Cold Preservation Suggests That Longer Donor Cold Chain Logistics May Be Feasible

BACKGROUND

Partial heart transplantation (PHT) is a new type of transplant that delivers growing heart valve implants for children. However, the acceptable ischemia time for PHTs remains unexplored. Therefore, the ischemia time for PHTs is empirically limited to orthotopic heart transplant (OHT) ischemia time of 4-6 h because the valves contained in OHTs are known to grow. This limits the distance from where PHT grafts can be procured. Without longer procurement distances, children who need PHT must wait a long time for suitable donor hearts. We previously demonstrated that PHTs remain viable for an ischemia time of 48 h in a rat model. Here we expand on this work in a porcine model.

METHODS

Porcine pulmonary valve (PV) and aortic valve (AV) leaflets were preserved in DMEM culture medium, Belzer UW, Unisol, or HTK solution (n = 6/group) at 4°C. At preset intervals, the cellular viability was measured using the alamarBlue assay. The valves were also analyzed with flow cytometry and histology.

RESULTS

While the metabolic activity of the valves slowly decreased over time, there was significant cellular viability for up to 21 days of cold preservation with Belzer UW solution. Flow cytometry and histology further corroborated the results, showing cellular preservation at 7 days of ischemia time.

CONCLUSIONS

OHT preservation is limited to only 4-6 h because longer ischemia times are associated with primary graft dysfunction from reduced contractility of ventricular myocardial cells. In contrast, PHTs spare the native ventricles. Our results indicate that PHT grafts remain viable much longer than OHT grafts. In vivo data are needed to verify that PHT grafts can grow and function after this significantly increased ischemic time.

A decade of follow-up: atrial fibrillation, pulmonary pressure, and the progression of tricuspid regurgitation

BACKGROUND AND AIMS

Long-term data on atrial fibrillation (AF) impact on tricuspid regurgitation (TR) progression and its relation to pulmonary pressure are scant. We investigated this association in a study spanning over a decade.

METHODS AND RESULTS

Adults with echocardiographic evaluation before 2014, free of significant TR, were included. Patients were dichotomized by baseline AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The development of new significant TR and its impact on mortality were studied. Study population included 21 502 patients (median age 65, 40% female), 13% had baseline AF. During a median follow-up of 12 years, 11% developed significant TR. Compared with patients free of AF, patients with baseline AF were 3.5 and 1.3 times more likely to develop significant TR in univariate and multivariate models, respectively (95% CI 3.27-3.91, 1.18-1.44, P < 0.001 for both). The risk of TR progression was higher in patients with permanent AF and those treated with rate control strategy (hazard ratio 1.95 and 2.01, respectively; P < 0.001 for both). The association of AF with TR progression was sPAP-related, being more pronounced among patients with normal sPAP than among those with elevated sPAP (HR 1.5 vs. 1.18; P for interaction <0.001). TR progression was independently linked to a two-fold higher mortality risk, consistent regardless of baseline AF (P < 0.001).

CONCLUSION

AF is an independent predictor of TR progression, especially in patients with normal sPAP. Subsequent research on strategies to prevent TR progression in this patient population is warranted.

Poststernotomy Imaging: Pictorial Review of Expected Postsurgical Findings and Complications

Sternotomy is a widely used incision technique in cardiac and thoracic surgeries. Multiple sternotomy techniques exist, such as the Robicsek technique for redo sternotomy and transverse (clamshell) thoracosternotomy for bilateral lung transplantation. Various complications after sternotomy can occur, and imaging plays a key role in their identification. Complications may involve the hardware, sternum, and peristernal soft tissues and are divided into acute, subacute, and late. Acute complications primarily involve hemorrhage and dehiscence, while subacute complications include superficial or deep sternal wound infections and late complications are typically osseous or hardware related. Imaging also plays a critical role in assessment of cardiovascular structures and their relations to the sternum in those undergoing redo sternotomy, which has become increasingly performed. CT allows radiologists to identify the relationship of vascular anatomy to the sternum as well as other factors that may complicate repeat surgery, allowing surgeons to strategize safe surgical approaches. ©RSNA, 2025 Supplemental material is available for this article.

A novel staging system of cardiac damage in aortic stenosis based on multi-chamber myocardial deformation

AIMS

This study evaluates whether multi-chamber myocardial deformation analysis using speckle tracking echocardiography (STE) can enhance validated current staging systems and improve risk stratification for patients with moderate-to-severe aortic stenosis (AS).

METHODS AND RESULTS

We reanalysed 2D, Doppler, and STE data obtained from two cohorts: derivation (654 patients, median age: 82 years; 51% men) and validation (237 patients, median age: 77 years; 55% men) with at least moderate AS (aortic valve area < 1.5 cm2). The receiver operator characteristic curve analysis identified optimal cut-off values linked to outcomes: 15% for left ventricular global longitudinal strain (LVGLS), 13% for peak atrial longitudinal strain (PALS), and 19% for right ventricular free-wall strain (RVFWS). Patients have been divided into five stages: Stage 0, no left-side damage (LVGLS ≥ 15% and PALS ≥ 13%); Stage 1, partial left-side damage (LVGLS < 15% or PALS < 13%); Stage 2, definite left-side damage (LVGLS < 15% and PALS < 13%); Stage 3, no right-side damage (RVFWS ≥ 19%); and Stage 4, right-side damage (RVFWS < 19%). In a multivariable Cox regression analysis, the new staging scheme remained independently associated with an increased risk of all-cause death [adjusted-hazard ratio: 1.28; 95% confidence interval (CI): 1.10-1.48; P = 0.001]. This new staging classification exhibited higher predictive power [area under the curve (AUC) 0.67; 95% CI 0.62-0.73] than those proposed by Généreux et al. (Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J 2017;38:3351-8.) (AUC 0.62; 95% CI 0.56-0.67; P = 0.002) and Tastet et al. (Staging cardiac damage in patients with asymptomatic aortic valve stenosis. J Am Coll Cardiol 2019;74:550-63.) (AUC 0.64; 95% CI 0.58-0.70; P = 0.041) for 2-year all-cause death, with similar findings in the validation cohort.

CONCLUSION

Our staging system for detecting cardiac damage, incorporating multi-chamber myocardial deformation, exhibits a stronger association with outcomes than previously validated systems.

Physical activity characteristics in adults with bicuspid aortic valve versus age- and sex-matched controls

BACKGROUND

A bicuspid aortic valve (BAV) is associated with a higher lifetime risk of cardiovascular morbidity. Management of modifiable risk factors, including physical (in)activity, is therefore key. However, little is known about physical activity (PA) and sedentary behavior (SB) characteristics in BAV individuals. Therefore, we compared objectively measured PA and SB characteristics between BAV individuals and controls.

METHODS AND RESULTS

100 BAV adults (45 ± 16 years; 59 % male) and 100 age- and sex-matched controls were recruited. SB and PA characteristics were objectively assessed for 8 consecutive days using thigh-worn accelerometers. SB was comparable between BAV and control groups (9.3 [8.5-10.2] vs. 9.3 [8.2-10.2] hrs/day, p = 0.84), but time spent in MVPA (72 [59-89] vs. 98 [75-116] min/day, p < 0.001) and step count (4826 [4004-5801] vs. 6252 [4784-7484] steps/day, p < 0.001) were markedly lower in BAV individuals. BAV individuals were categorized into none-to-mild (n = 46) or moderate-to-severe (n = 54) disease subgroups based on the presence of valvular dysfunction and/or aortic dilatation. A more prominent decrease in MVPA (-16.9 and - 27 min/day) and step count (-967 and - 1685 steps/day) was observed with increased BAV disease severity. PA characteristics were positively associated with mental QoL in BAV, whereas no association was found with cardiac anxiety. Forty-eight percent of BAV individuals expressed uncertainty regarding allowed PA levels and 56 % was interested in additional information on PA recommendations.

CONCLUSION

BAV individuals were less physically active compared to age- and sex-matched controls, as evidenced by a lower MVPA time and step count, with greater levels of physical inactivity among individuals with more severe disease.

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.

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Key Words

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

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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

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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

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Isolated surgical valve replacement for tricuspid regurgitation: An international multicenter study

BACKGROUND

Although the management of tricuspid regurgitation during mitral surgery is standardized, the approach to patients with isolated tricuspid regurgitation is less clearly defined. This study examined the surgical outcomes of patients who underwent isolated surgical tricuspid valve replacement at 2 medical centers, providing insights into the postoperative and midterm outcomes.

METHODS

This retrospective observational study analyzed data from 2 tertiary cardiac surgery centers. All patients underwent isolated surgical tricuspid valve replacement between 2010 and 2023. The primary end point included 30-day and midterm survival. The secondary end points included postoperative and valve-related complications.

RESULTS

A total of 64 patients were included. The mean age was 58 ± 17 years, and 51.6% (33/64) were male patients. The median European System for Cardiac Operative Risk Evaluation II, TRISCORE, and Model for End-Stage Liver Disease scores were 2.16 [1.38-3.42], 3.00 [1.00-4.00], and 10.50 [9.00-16.25], respectively. More than 60% of the procedures were conducted on a beating heart. Thirty-day mortality was 7.8%. European System for Cardiac Operative Risk Evaluation II underestimated mortality, whereas the Model for End-Stage Liver Disease score was a more reliable predictor. Ten patients finally received a permanent pacemaker upon discharge. The overall survival rates at 1 and 6 years were 88.8 ± 4.0% and 80.3 ± 7.3%, respectively. Freedom from tricuspid valve reintervention rates at 1 and 6 years were 96.2 ± 2.6% and 75.0 ± 9.6%, respectively.

CONCLUSION

This study demonstrated that isolated surgical tricuspid valve replacement can be undertaken without exposing patients to an excessively high mortality risk. Risk assessment using specific scores may be useful in this regard. Nevertheless, these patients are at risk of postoperative complications, particularly permanent pacemaker implantation.

Outcomes of complex, high-risk percutaneous coronary intervention in patients with severe aortic stenosis: the ASCoP registry

BACKGROUND

There is a lack of evidence to guide treatment of patients with a concomitant indication for transcatheter aortic valve implantation (TAVI) and complex, high-risk percutaneous coronary intervention (PCI).

AIMS

We aimed to assess different strategies of PCI timing in this high-risk TAVI cohort.

METHODS

The ASCoP registry retrospectively included patients with a clinical indication for both TAVI and PCI with at least 1 criterion of complex or high-risk PCI. The primary endpoint was a composite of all-cause death and unplanned rehospitalisation for cardiovascular causes. The secondary endpoint was a composite of all-cause death, stroke, acute myocardial infarction, major bleeding, major vascular complication and unplanned revascularisation. Multivariable analysis was used to adjust for possible confounders.

RESULTS

A total of 519 patients were included: 363 (69.9%) underwent staged procedures and 156 (30.1%) concomitant TAVI and PCI. After 441 (interquartile range 182-824) days, the primary endpoint occurred in 151 (36.5%) cases, without any significant difference between the 2 groups (p=0.98), while the secondary endpoint occurred more frequently in the concomitant group (n=36 [25.8%] vs n=57 [17.4%]; p=0.014).

CONCLUSIONS

In patients undergoing TAVI and complex/high-risk PCI, a concomitant strategy is associated with a higher rate of adverse events and increased procedural risk. (ClinicalTrials.gov: NCT05750927).

Review Article: Contemporary Transcatheter Heart Valves for TAVI in Bicuspid Aortic Anatomy

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5-2% of the population and often leading to early aortic valve degeneration. While surgical aortic valve replacement (SAVR) remains the gold standard for treating severe bicuspid aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) is emerging as a viable alternative in selected BAV anatomies. Initial experiences with first-generation transcatheter heart valves (THVs) showed the feasibility of this technique, but were associated with lower device success rates and higher complications, such as paravalvular leak (PVL) and pacemaker implantation. Advancements in second- and third- generation THVs, together with better pre-procedural imaging assessment and growing operator experience, have significantly enhanced TAVI outcomes in BAV patients, with results now comparable to those seen in tricuspid aortic valves (TAVs). Proper patient selection, pre-procedural sizing, and device implantation are key to improving TAVI success in BAV. Recent registry data on contemporary THV platforms demonstrate improved procedural success, hemodynamic performance, and the safety of TAVI in BAV. However, higher rates of PVL, pacemaker implantation, and strokes remain concerns. Ongoing advancements in THV design and procedural techniques will further enhance outcomes for this challenging population. Up to the present, there are no dedicated THVs for BAV, but the latest-generation THVs offer promising results.

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.

Pregnancy with a prosthetic heart valve, thrombosis, and bleeding: the ESC EORP Registry of Pregnancy and Cardiac disease III

BACKGROUND AND AIMS

Pregnancy in women with a prosthetic heart valve is considered high risk, primarily due to the need for effective anticoagulation. However, data on the relationship between anticoagulation practices and pregnancy outcomes are very limited.

METHODS

The Registry of Pregnancy and Cardiac disease is a global registry that prospectively enrolled pregnancies in women with a prosthetic heart valve between January 2018 and April 2023. Detailed data on anticoagulation, including dosage and monitoring, and cardiovascular, pregnancy, and perinatal outcomes were collected.

RESULTS

In total, 613 pregnancies were included of which 411 pregnancies were in women with a mechanical valve and 202 were in women with a biological valve. The chance of an uncomplicated pregnancy with a live birth in women with a mechanical valve was 54%, compared with 79% in women with a biological valve (P < .001). Thromboembolic and haemorrhagic complications most frequently occurred when low-molecular weight heparin (LMWH)-based regimens were used. Valve thrombosis occurred in 24 (6%) women, and a prosthetic valve in mitral position was associated with valve thrombosis (odds ratio 3.3; 95% confidence interval 1.9-8.0). A thromboembolic event occurred in 12 (10%) women with anti-Xa monitoring and in 9 (21%) women without (P = .060). Foetal death occurred in 20% of all pregnancies.

CONCLUSIONS

More favourable outcomes were found in women with a biological valve compared with a mechanical valve. In women with a mechanical valve, the use of LMWH was associated with an increased risk of thromboembolic complications. A mitral prosthetic valve was identified as a predictor for valve thrombosis. The benefit could not be confirmed nor refuted, in terms of reduced thromboembolic events, from using anti-Xa level monitoring in women on LMWH.

Global Prevalence of Mitral Regurgitation: A Systematic Review and Meta-Analysis of Population-Based Studies

Background/Objectives: Mitral regurgitation (MR) is the most common left heart valve disease, but its exact prevalence remains uncertain. To estimate the prevalence of MR we conducted a systematic review and meta-analysis of population-based studies. Methods: We searched the Medline/PubMed, Embase, and Scopus databases, in January 2023, for studies reporting or allowing for the calculation of the prevalence of moderate-to-severe MR in the general population. Eligible studies included those using echocardiography or primary care databases from countries with universal healthcare. Studies where echocardiography was performed for medical indications were excluded. Random-effects meta-analysis was used to calculate the pooled estimates. Subgroup and meta-regression analyses were employed to investigate the reasons for heterogeneity. Mixed-model multivariable meta-regression was used to estimate age- and sex-specific prevalence. Results: After screening 13,847 records, we identified 20 eligible studies (22 study populations) including 6,036,691 individuals. The global prevalence of moderate-to-severe MR was 0.67% (95% CI, 0.33-1.11). Prevalence increased greatly with age, and it was estimated to be approximately 0.63% (0.25-1.16) at age 50, 2.85% (1.96-3.90) at 70, and 6.45% (4.17-9.16) by 90 years. North America showed the largest crude prevalence (1.11%; 0.52-1.88), followed by Europe (0.60%; 0.34-0.92), Asia (0.24%; 0.00-0.92), and Africa (0.16%; 0.03-0.37). Differences in prevalence by geographic region and ethnic group were primarily attributable to population age. Prevalence did not differ by sex, study year, or diagnostic criteria. Conclusions: Moderate-to-severe MR is a prevalent condition, particularly among elderly people. With rising life expectancy worldwide, ensuring universal access to interventions will be vital to reduce morbidity and mortality.

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.

Multimodality Imaging of Arrhythmic Risk in Mitral Valve Prolapse

Mitral valve prolapse (MVP) affects 2% to 3% of the general population and is typically benign. However, a subset of patients may develop arrhythmic complications, including sudden cardiac arrest and sudden cardiac death. This review explores the critical role of multimodality imaging in risk stratification for arrhythmic MVP, emphasizing high-risk features such as bileaflet involvement, mitral annular disjunction, the double-peak strain pattern, mechanical dispersion, and myocardial fibrosis. Echocardiography remains the first-line imaging tool for MVP diagnosis, enabling detailed assessment of leaflet morphology, mitral annular disjunction, and mitral regurgitation quantification. Speckle tracking provides insights into abnormal valvular-myocardial mechanics as a potential arrhythmogenic mechanism in MVP. Cardiac magnetic resonance (CMR) offers detailed myocardial tissue characterization through assessment of replacement and interstitial fibrosis using late gadolinium enhancement and T1 mapping/extracellular volume fraction, respectively. Hybrid Positron Emission Tomography/CMR highlights the role of inflammation, which may coexist with fibrosis, in explaining the presence of malignant arrhythmias even with relatively limited fibrosis. The assessment of diffuse fibrosis and inflammation by CMR and Positron Emission Tomography/CMR is particularly valuable in patients without classic imaging risk factors such as mitral annular disjunction, severe mitral regurgitation, or replacement fibrosis. We propose an algorithm integrating clinical, rhythmic, echocardiographic, CMR, and Positron Emission Tomography/CMR parameters for arrhythmic risk stratification and management. Although multimodality imaging is essential for comprehensive risk assessment, most available parameters have not yet been validated in prospective studies nor linked directly to mortality. Consequently, these imaging findings should be interpreted alongside the presence of complex ventricular ectopy, which remains the most robust predictor of mortality in arrhythmic MVP.

Noteworthy in Cardiothoracic Surgery 2024

Noteworthy in Cardiothoracic Surgery 2024 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery this past year. Specifically, this year saw the release of many in-depth reports comparing the long-term outcomes of transcatheter aortic valve replacement (TAVR) vs surgical approaches for aortic valve replacement, data which is expected to move the transcatheter pendulum. In particular, this included a national analysis of trends reporting the rapid increase of post-TAVR surgical aortic valve replacement (SAVR). This year's literature also reported ground-breaking milestones related robotics in cardiothoracic surgery, with publication of the first multicenter series of robotic aortic valve replacements, the first entirely robotic double lung and heart transplants, as well as the first combined robotic aortic valve replacement and coronary artery bypass grafting. Specific to lung cancer, data continues to emerge regarding the de-escalation of magnitude of surgical resection from lobectomy to sublobar when able, and in the benefit of immunotherapy in the neoadjuvant treatment of non-small cell lung cancer. Frequent in the literature this year were concerns about toxicity, surgical challenges after therapy, and potential increases in perioperative complications following neoadjuvant chemoimmunotherapy, with calls for surgeons to crucially assess these effects on surgical outcomes to help refine patient selection criteria. Finally, 2024 saw many advancements in intraoperative tumor localization focused on enhancing precision, minimizing invasiveness, and improving surgical outcomes, including robotic-assisted bronchoscopy, electromagnetic navigation bronchoscopy (ENB), and encouraging data regarding intraoperative molecular imaging.

Effect of Transcatheter Edge-to-Edge Repair on Left Ventricular Flow Features

PURPOSE

This study aims to investigate the effects of transcatheter edge-to-edge repair (TEER) on left ventricular hemodynamics and its potential implications for patient health.

METHODS

An in vitro experimental platform was designed to replicate the anatomical and functional characteristics of the left ventricle (LV). This platform integrates native porcine mitral and aortic valves with a patient-specific 3D-printed silicone LV. The LV hemodynamics after TEER is assessed using echocardiography and particle image velocimetry, focusing on critical indices such as vorticity, Reynolds shear stress (RSS), viscous shear stress (VSS), and energy dissipation rate (ε).

RESULTS

TEER effectively reduces the degree of mitral regurgitation (MR); however, it significantly increases RSS, VSS, and ε due to the formation of numerous small-scale vortices in the LV.

CONCLUSION

These hemodynamic changes may lead to adverse left ventricular remodeling, red blood cell damage, and reduced cardiac pumping efficiency, which have to be taken into consideration to optimize the TEER procedure and improve patient outcomes.

Rationale and Design of the CREATE Trial: A Multicenter, Randomized Comparison of Continuation or Cessation of Single Antithrombotic Therapy at 1 Year After Transcatheter Aortic Valve Replacement

BACKGROUND

Current guidelines and expert consensus recommend lifelong single antiplatelet therapy for patients undergoing transcatheter aortic valve replacement who have no indication for anticoagulation or dual antiplatelet therapy. However, there is no direct evidence from randomized controlled trials supporting this practice. Furthermore, the optimal duration of antiplatelet therapy in this population has not been adequately investigated.

METHODS AND RESULTS

CREATE (A Multicenter Randomized Controlled Study to Evaluate Cessation of Antithrombotic Therapy at 1 Year in TAVR Patients-The CREATE Study) is a prospective, multicenter, open-label, randomized controlled trial for patients who have undergone successful transcatheter aortic valve replacement and have no indication for long-term oral anticoagulation or antiplatelet therapy. Eligible patients are free from major bleeding and ischemic events for 1 year postprocedure before being randomized 1:1 to single antiplatelet therapy (control group) or no antiplatelet therapy (experimental group). The primary efficacy end point is the incidence of bleeding events, defined by the VARC-3 (Valve Academic Research Consortium-3) criteria, at 1-year postrandomization. The primary safety end point is a composite of cardiac death, myocardial infarction, and ischemic stroke at 1 year. The trial is powered for both superiority in efficiency and noninferiority in safety. Accordingly, a total of 3380 patients will be enrolled.

CONCLUSIONS

The CREATE trial aims to assess if stopping antiplatelet therapy at 1-year after transcatheter aortic valve replacement reduces bleeding risk without increasing ischemic events in patients not requiring chronic antithrombotic therapy.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2400087454.

Clinical Variability in Presentation and Management of Quadricuspid Aortic Valve: A Case Series

•Rare presentation of three QAV cases with varied clinical manifestations is reported. •Multimodal imaging is crucial for accurate QAV diagnosis and classification. •QAV is often associated with aortic regurgitation requiring intervention. •Surgical repair is preferred over replacement in suitable patients with QAV. •Long-term follow-up is essential for patients with QAV, even if asymptomatic.

Coronary Artery Disease and Transcatheter Aortic Valve Replacement

Concomitant coronary artery disease (CAD) and severe aortic stenosis (AS) are frequently encountered in patients evaluated for transcatheter aortic valve replacement (TAVR). Invasive coronary angiography remains the mainstay for anatomical assessment of CAD, whereas coronary computed tomography angiography may be used in patients with a low pretest probability of CAD. Adjunctive functional evaluation of coronary lesions has proven safe in the presence of AS, but uncertainty remains over the impact of AS on the results of functional testing. For patients with CAD, revascularization of significant lesions (≥90% stenosis, fractional flow reserve ≤0.80) is associated with improved clinical outcomes compared to medical therapy. However, the optimal timing of percutaneous coronary intervention (PCI) remains unclear with no clear benefit to revascularization in advance of TAVR. When planning post-TAVR PCI, careful consideration should be given to the type of valve implanted, with short-frame valves having more favorable coronary access after TAVR. Planning for future coronary access is particularly relevant for patients who have either unrevascularized obstructive coronary lesions or unknown coronary anatomy in advance of TAVR. Moreover, post-TAVR PCI will likely increase, given the younger age profile of patients being treated and the trend to defer revascularization until after valve replacement.

Transcarotid Versus Surgical Aortic Valve Replacement for the Treatment of Severe Aortic Stenosis

BACKGROUND

Current guidelines recommend surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and unfavorable iliofemoral access. Transcarotid transcatheter aortic valve replacement (TC-TAVR) has emerged as an alternative access in suboptimal transfemoral candidates, but no data exist comparing TC-TAVR and SAVR. The main objective of this study was to compare the clinical outcomes in a propensity-matched population of TC-TAVR and SAVR patients with severe aortic stenosis.

METHODS

A total of 786 patients (SAVR, 352; TC-TAVR, 434) were included, and a total of 182 patients were propensity-matched and included in each group. The primary outcome was a composite of death from any cause, stroke/transient ischemic attack, and procedure-related or valve-related hospitalization at 30 days and at 1 year. Data were prospectively collected in dedicated databases, and clinical events were defined according to Valve Academic Research Consortium-3 criteria.

RESULTS

Baseline characteristics were well balanced between the matched groups, and the mean age and Society for Thoracic Surgeons score of the study population were 75 years and 3.6%, respectively. At 30 days, the SAVR group showed a higher rate of the primary composite outcome compared with the TC-TAVR group (12.6% versus 4.3%; hazard ratio, 2.93 [95% CI, 1.45-5.94]). Acute kidney injury stages 2 to 4, bleeding events, and new-onset atrial fibrillation occurred more often in the SAVR group during the hospital period (P<0.001). In contrast, vascular complications and the need for permanent pacemaker implantation occurred more often in the TC-TAVR group (P=0.01 and P=0.001, respectively). At 1-year follow-up, there were no significant differences between groups in the primary outcome rates (SAVR, 19.7% versus TC-TAVR, 12.7%; hazard ratio, 1.63 [95% CI, 0.98-2.73]).

CONCLUSIONS

TC-TAVR was associated with improved 30-day clinical outcomes compared with SAVR, with no significant differences in death, stroke, and hospitalization at 1-year follow-up. These findings suggest that TC-TAVR may be a valid alternative to SAVR in nontransfemoral-TAVR candidates.

Outcomes of isolated tricuspid replacement versus repair among older patients with tricuspid regurgitation in the United States

Objective

Evidence is limited regarding early-term outcomes after isolated tricuspid operations for tricuspid regurgitation (TR). We compared the early-term outcomes after isolated tricuspid valve replacement versus repair using the contemporary data.

Methods

We analyzed the national data on Medicare beneficiaries aged ≥65 years who underwent isolated tricuspid valve replacement or repair for TR between January 2016 and December 2020. The primary outcome was early-term (up to 3 years) all-cause mortality. The secondary outcomes included early-term major adverse cardiovascular events (MACE) and heart failure hospitalizations. MACE encompassed all-cause mortality, heart failure hospitalization, stroke, and tricuspid reoperations. A propensity score matching analysis was conducted to compare between replacement and repair.

Results

A total of 1501 patients were included (replacement: 610 patients, repair: 891 patients). In the matched cohort (n = 547 in each group), the overall mortality and MACE were 39% and 46% at 3 years, respectively. Tricuspid valve replacement was associated with similar all-cause mortality in comparison to repair (adjusted hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.86-1.30; P = .600). Similarly, the rates of MACE and heart failure hospitalizations were similar (adjusted HR, 1.01; 95% CI, 0.84-1.22, P = .910; subdistribution HR, 1.04; 95% CI, 0.72-1.49, P = .850, respectively) between these 2 procedures.

Conclusions

Isolated surgical tricuspid valve replacement was associated with similar clinical outcomes compared to repair. Importantly, the high overall early-term mortality and morbidity with either treatment underscores the need for alternative intervention choices and further research to optimize the indication and timing of intervention.

Optimizing Revascularization in Ischemic Cardiomyopathy: Comparative Evidence on the Benefits and Indications of CABG and PCI

Ischemic cardiomyopathy remains a leading cause of heart failure, yet the optimal revascularization approach for patients with reduced left ventricular function remains uncertain. This review synthesizes current evidence on coronary revascularization strategies, emphasizing real-world applicability and individualized treatment. It critically evaluates the benefits and limitations of coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI], highlighting key knowledge gaps. Findings from the STICH trial demonstrate that CABG improves long-term survival despite an elevated early procedural risk, particularly in patients with extensive multivessel disease. In contrast, the REVIVED-BCIS2 trial suggests that PCI enhances quality of life but does not significantly reduce mortality compared to optimal medical therapy, making it a viable alternative for high-risk patients ineligible for surgery. This review underscores the role of advanced imaging techniques in myocardial viability assessment and emphasizes the importance of comprehensive risk stratification in guiding revascularization decisions. Special attention is given to managing high-risk patients unsuitable for CABG and the potential benefits of PCI in symptom relief despite uncertain survival benefits. A stepwise algorithm is proposed to assist clinicians in tailoring revascularization strategies, reinforcing the need for a multidisciplinary Heart Team approach to optimize outcomes.

Cardiogenic shock in a patient with combined severe aortic and mitral regurgitation treated by a totally percutaneous approach: a case report

Background

Combined severe aortic regurgitation and severe mitral regurgitation is a condition associated with high mortality, where evidence, about proper management, is still scarce, especially in critical clinical conditions such as cardiogenic shock.

Case summary

An 86-year-old female with severe aortic and mitral regurgitation was admitted due to acute pulmonary oedema, rapidly deteriorating in cardiogenic shock refractory to medical treatment. Haemodynamic stabilization was achieved only after implantation of an Impella CP, through a trans-femoral approach. Considering the prohibitive surgical risk, the mitral valve regurgitation was treated with a transcatheter edge-to-edge repair procedure, which allowed to successfully wean the patient from Impella. Subsequently, a transcatheter aortic valve implantation was performed. The patient's clinical status improved to such a level that a rehabilitation program was successfully implemented.

Discussion

Our report shows that an entirely percutaneous approach, to manage a combined severe aortic and mitral regurgitation, complicated by cardiogenic shock, is feasible and effective.

Short-Term, Mid-Term, and Long-Term Outcomes of Transcatheter Aortic Valve Replacement With Balloon-Expandable Versus Self-Expanding Valves: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Comparisons of outcomes after transcatheter aortic valve replacement with balloon-expandable (BEV) versus self-expanding (SEV) valves are limited.

HYPOTHESIS

This study aimed to compare clinical and hemodynamic outcomes of BEV and SEV at short-term (30 days), midterm (1 year), and long-term (> 1 year) endpoints.

METHODS

PubMed, Embase, Scopus, and Cochrane Library databases were searched until July 2024 for randomized controlled trials. Random-effect model (DerSimonian-Laird method) was used to pool the risk ratios (RR), mean differences, and 95% confidence intervals (CI).

RESULTS

A total of 10 studies comprising 4325 patients (2295 BEV, 2030 SEV) were included. In short-term, cardiovascular (RR: 0.56, 95% CI: 0.36-0.87) and all-cause mortality (RR: 0.54, 95% CI: 0.35-0.81) were lower in the BEV group. Risk of moderate to severe paravalvular leak (PVL) was lower among BEV patients in short-term (RR: 0.28, 95% CI: 0.17-0.49) and long-term (RR: 0.28, 95% CI: 0.1-0.79). A limited number of studies showed a greater risk of clinical valve thrombosis on BEV in midterm and long-term. The need for permanent pacemaker implantation was lower in BEV at both short-term (RR: 0.56, 95% CI: 0.37-0.87), and midterm (RR: 0.78, 95% CI: 0.64-0.94). The SEV group had a larger effective orifice area with lower mean transvalvular pressure gradient at all endpoints.

CONCLUSIONS

BEV is associated with reduced risk of clinical outcomes in short-term; however, most differences diminish in longer evaluations, except for moderate to severe PVL, which remains elevated for SEV. SEVs had better hemodynamic results and lower risk of clinical valve thrombosis.

Comprehensive assessment of aortic flow before and after aortic valve replacement in an ex vivo porcine model with four-dimensional flow magnetic resonance imaging

OBJECTIVES

Aortic valve replacement (AVR) has shown to induce secondary flow patterns deviating from main flow. It is impossible to analyse the impact of surgical access and different AVR techniques under standardized conditions in patients or silicone models. Therefore, we developed an ex vivo swine model to analyse the impact of surgical access and to compare flow patterns after different AVR techniques within the ascending aorta.

METHODS

Porcine aortas (n = 6) were anastomosed to a custom-made piston pump. The pulse duplicator perfused the aortas with a blood-mimicking fluid at 2.5 l/min and 64 bpm. 4D flow magnetic resonance imaging of each aorta was acquired prior to surgery (NAV, n = 6), after sham surgery (aortotomy and closure thereof without valve replacement, NAV-A, n = 6) and after Ozaki procedure (AVneo, n = 2), biological valve (BV, n = 2) or mechanical valve (MV, n = 2). Secondary flow patterns and peak velocity were analysed with GTFlow (GyroTools, Switzerland).

RESULTS

Sham surgery alone induced secondary flow patterns in the ascending aorta in all specimens. After AVR, more secondary flow patterns were observed distal to BV compared to AVneo or MV. Three flow patterns developed after BV, two after AVneo and one after MV. In addition, peak velocity within the aortic sinuses of Valsalva increased after all AVR procedures, most strikingly after BV (NAV = 75 ± 22 cm/s, NAV-A = 79 ± 29 cm/s, AVneo = 115 ± 36 cm/s, BV = 142 ± 21 cm/s, MV = 107 ± 4 cm/s; mean±standard deviation).

CONCLUSIONS

We successfully established an ex vivo model suggesting that flow alterations not only depend on the type of AVR but are associated with surgical access. The strongest secondary flow patterns developed after BV followed by AVneo and MV.

Artificial intelligence-enabled echocardiography as a surrogate for multi-modality aortic stenosis imaging: post-hoc analysis of a clinical trial

Background

Accurate aortic stenosis (AS) phenotyping requires access to multimodality imaging which has limited availability. The Digital Aortic Stenosis Severity Index (DASSi), an AI biomarker of AS-related remodeling on 2D echocardiography, predicts AS progression independent of Doppler measurements. Whether DASSi-enhanced echocardiography provides a scalable alternative to multimodality AS imaging remains unknown. We sought to evaluate the ability of DASSi to define personalized AS progression profiles and validate its performance against multimodality imaging features of functional, structural, and biological disease severity.

Methods

In the SALTIRE-2 trial of participants with mild-or-moderate AS, we performed blinded DASSi measurements (probability of severe AS, 0-to-1) on baseline transthoracic echocardiograms. We evaluated the association between baseline DASSi and (i) disease severity by hemodynamic (peak aortic valve velocity [AV-Vmax]), structural (CT-derived aortic valve calcium score [AVCS]) and biological features ([18F]sodium fluoride [NaF] uptake on Positron Emission Tomography-CT), (ii) disease progression (change in AV-Vmax and AVCS), and (iii) incident aortic valve replacement (AVR). We used generalized linear mixed, or Cox models adjusted for risk factors and aortic valve area, as appropriate.

Results

We analyzed 134 participants (72 [IQR: 69-78] years, 27 [20.1%] women) with a mean baseline DASSi of 0.51 (standard deviation [SD]: 0.19). DASSi was independently associated with disease severity: each SD increase was associated with higher AV-Vmax (+0.21 [95%CI: 0.12-0.30] m/sec), AVCS (+284 [95%CI: 101-467] AU) and [18F]NaF TBRmax (+0.17 [95%CI: 0.04-0.31]). Higher DASSi was also associated with disease progression by Doppler (AV-Vmax) and CT (AVCS) at 24 months (p interaction for DASSi (x) time<0.001), and future AVR (75 events over 5.5 [IQR: 2.4-7.2] years, adj.HR 1.47 [95%CI: 1.12-1.94] per SD).

Conclusions

DASSi is associated with functional, structural and biological features of AS severity as well as disease progression and outcomes. DASSi-enhanced echocardiography provides a readily accessible alternative to multimodality imaging of AS which has potential value both in clinical practice and as a clinical trial biomarker.

Investigating mortality trends and disparities in tricuspid valve disorder: a U.S. nationwide study from 1999 to 2023

Tricuspid valve disorder (TVD), a critical aspect of valvular heart disease (VHD), significantly impacts cardiovascular health, yet its mortality trends are not well understood. This study aimed to investigate demographic and geographic disparities in TVD-related mortality across the United States from 1999 to 2023. Using data from the CDC WONDER database, death certificates were analyzed to identify TVD-related fatalities, and age-adjusted mortality rates (AAMRs) were calculated per 1,000,000 individuals. Joinpoint regression analysis was conducted to assess annual percent changes (APCs) in mortality rates. A total of 72,805 deaths were attributed to TVD. An initial steep increase in mortality rate from 1999 to 2003 (APC: 7.9%; 95% CI: 3.9 to 14.1) followed by a stable period from 2003 to 2014 (APC: 0.1%; 95% CI: -2.7 to 1.0) and a sharp increase in AAMR from 2014 to 2023 (APC: 6.5%; 95% CI: 5.2 to 8.4). Females consistently had higher mortality rates than males, with a sharper increase after 2012. Racial and ethnic disparities were evident, with American Indian and white populations experiencing higher mortality rates than black populations. Geographic disparities were also noted, with states like Oregon, Minnesota, and Vermont, as well as the West census region, showing significantly higher mortality rates. Rural areas had higher mortality rates compared to urban areas. TVD-related mortality trends have followed a complex trajectory, with marked disparities across demographic and geographic factors. Further research is required to fully understand the factors driving these trends and their public health implications.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2024 Update on National Trends and Outcomes

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the most robust and advanced clinical database in cardiac surgery. With more than 8.3 million procedures and more than 1000 participating institutions encompassing more than 97% of cardiac surgery in the United States, the ACSD is the specialty's vital instrument for quality improvement, patient safety, and outcome reporting in cardiac surgery. The database continues to advance initiatives to achieve these goals, which recently have included adding new risk models for multivalve procedures, isolated tricuspid valve surgery, aortic valve replacement after transcatheter aortic valve replacement, and mitral valve surgery for degenerative mitral regurgitation. In addition, the ACSD can now provide longitudinal survival data through linkage to the National Death Index. This report reviews current trends in the ACSD through the end of 2023, impactful research during the past year, and database innovations being implemented.

Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients With Cardiogenic Shock: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with severe mitral regurgitation and cardiogenic shock demonstrate a poor prognosis. Mitral transcatheter edge-to-edge repair could alter patient management.

METHODS AND RESULTS

We systematically reviewed PubMed/Medline, Scopus, and Cochrane Library until January 2023, including studies assessing transcatheter edge-to-edge repair in patients with severe mitral regurgitation and cardiogenic shock. Studies with <5 patients were excluded. The primary outcome was device success and all-cause death, while secondary outcomes included myocardial infarction, stroke, and heart failure hospitalization rates at 30-day and intermediate-term follow-up. A fixed-effects meta-analysis was used to estimate pooled rates. Risk of bias was assessed with the Newcastle-Ottawa Scale. A total of 24 studies and 5428 patients were included, with a mean age of 71.2±3.3 years and a high mean Society of Thoracic Surgery score (15.2±8.9). Device success was achieved in 86% (95% CI, 85%-87%) and mitral regurgitation ≤2+ in 89% (95% CI: 88%-90%). The 30-day all-cause mortality rate was 14% (95% CI, 13%-15%). Stroke, myocardial infarction, and heart failure hospitalization rates were 2% (95% CI, 1%-2%), 15% (95% CI, 13%-18%), and 9% (95% CI, 8%-10%), respectively. Patients with acute myocardial infarction had similar device success (81% [95% CI, 74%-87%]), a 30-day mortality rate of 20% (95% CI, 16%-25%), and intermediate-term mortality rate of 14% (95% CI, 9%-19%). In non-myocardial infarction populations, the 30-day mortality rate was 13% (95% CI, 13%-14%), and the intermediate-term mortality rate was 35% (95% CI, 34%-36%).

CONCLUSIONS

In patients with mitral regurgitation and cardiogenic shock, transcatheter edge-to-edge repair is associated with favorable 30-day and intermediate-term outcomes. Limitations, including the observational design of included studies and considerable heterogeneity, necessitate further research in this setting.

Angiographic Microvascular Resistance Is an Independent Predictor of Adverse Clinical Outcomes After Transcatheter Aortic Valve Replacement

BACKGROUND

The coronary microcirculatory resistance index plays a crucial role in predicting patient prognosis. Coronary angiography-based methods for assessing coronary microcirculatory function offer advantages such as simplicity and cost-effectiveness. This study aimed to confirm the prognostic value of a novel angiographic microvascular resistance (AMR) index in patients undergoing transcatheter aortic valve replacement.

METHODS AND RESULTS

We prospectively included 335 patients with severe aortic stenosis who underwent transcatheter aortic valve replacement at Fuwai Hospital. The AMR was calculated based on coronary angiography performed before prosthetic valve implantation. Patients were divided into 2 groups based on an AMR cutoff value of 250: AMR ≤250 and AMR >250. The primary end point was major adverse cardiovascular events, defined as a composite of all-cause mortality, readmission for heart failure, and myocardial infarction. At a median follow-up of 40 months (interquartile range [IQR], 25-50), AMR was significantly higher in patients who experienced the primary end point (257 [IQR, 186-299] versus 226 [IQR, 177-264]; P<0.001), identifying it as an independent risk factor for major adverse cardiovascular events, all-cause mortality, and new-onset atrial fibrillation. Kaplan-Meier analysis indicated that patients with AMR >250 had significantly lower event-free survival rates for major adverse cardiovascular events (62.9% versus 75.1%; hazard ratio, 1.94 [95% CI, 1.34-2.81]; log-rank P<0.001), mainly driven by all-cause death (75.7% versus 83.4%, log-rank P=0.018). Subgroup analyses supported these findings for major adverse cardiovascular events.

CONCLUSIONS

AMR is an independent predictor of adverse clinical outcomes after transcatheter aortic valve replacement. An AMR >250 can be used as a novel indicator for long-term prognostic management.

Extracellular Matrix Proteins Improve Risk Prediction in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Cardiac fibrosis is common in patients with severe aortic stenosis and an independent predictor of death. Therefore, we examined the additional value of circulating fibrosis markers as a putative biomarker platform to identify patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) who are at a higher risk of death.

METHODS

In this study, 2-year survival analyses were conducted in 378 consecutive patients undergoing TAVR to evaluate the association between fibrosis marker and risk of adverse long-term outcome. Implementation of fibrosis marker into TAVR risk stratification was tested by a machine-learning algorithm.

RESULTS

Among 20 circulating fibrosis markers involved in pathological extracellular matrix remodeling, high tissue inhibitor of metalloproteinase-1 (TIMP-1) levels independently predicted risk of death in univariable (hazard ratio, 5.0 [95% CI, 2.6-9.7]; P<0.001) and multivariable (adjusted hazard ratio, 2.2 [95% CI, 1.0-4.7]; P=0.046) Cox regression analyses. Consequently, higher TIMP-1 levels offered a significantly higher overall prediction of reduced survival compared with the conventional Society of Thoracic Surgeons Predicted Risk of Mortality score (area under the curve, 0.753 [95% CI, 0.682-0.824] versus area under the curve, 0.656 [95% CI, 0.578-0.734]; P<0.05). Applying an independent machine-learning algorithm allowed identification of a simple combination of 2 biomarkers (TIMP-1 and high-sensitivity cardiac troponin T) with superior prognostic value compared with Society of Thoracic Surgeons Predicted Risk of Mortality alone (area under the curve, 0.757 [95% CI, 0.686-0.828] versus 0.656 [95% CI, 0.578-0.34]; P<0.05).

CONCLUSIONS

Circulating TIMP-1 is an independent predictor of reduced 2-year overall survival in patients undergoing TAVR. Combined with high-sensitivity cardiac troponin T, circulating TIMP-1 should be incorporated into risk stratification to identify patients undergoing TAVR who are at a higher risk of death.

Impact of Antibacterials on the Quality of Anticoagulation Control in Patients Initiating Warfarin Therapy

BACKGROUND

Warfarin interacts with antibacterials to prolong the prothrombin time international normalized ratio (PT-INR) and increase the risk of bleeding. Patients initiating warfarin therapy often undergo precise dosage adjustments; however, the clinical implications of these interactions with antibacterials remain unclear. This study aimed to clarify the effect of antibacterials on PT-INR during the warfarin induction phase.

METHODS

This was a retrospective, observational study. Patients who were newly treated with warfarin after cardiovascular surgery were included. The primary endpoint was the comparison of the maximum PT-INR and time in therapeutic range (TTR) after warfarin initiation between the antibacterial-treated (ABx) and non-treated (non-ABx) groups.

RESULTS

The maximum PT-INR was significantly higher in the ABx group (which included β-lactams, glycopeptides, quinolones, tetracyclines, and aminoglycosides) than in the non-ABx group (median [interquartile range] 2.37 [2.03-2.71] vs. 2.08 [1.93-2.33]; P = 0.005); however, the TTR did not differ significantly (65% [44-76] vs. 71% [43-85]; P = 0.150). The odds ratio for maximum PT-INR > 2.6 with antimicrobial therapy was 2.51 (95% confidence interval 1.21-5.21).

DISCUSSION

Antibacterial therapy was a risk factor for a maximum PT-INR >2.6. However, there was no association with the TTR, which is a marker of good outcomes. This was due to the strict warfarin dosing regimen according to the algorithm, which immediately and appropriately adjusted for PT-INR overexpansion.

CONCLUSIONS

Antibacterials have been suggested to increase PT-INR during the induction phase of warfarin. However, with strict dose adjustments, the clinical impact on the PT-INR and TTR is likely limited.

Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves

OBJECTIVE

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

METHODS

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

RESULTS

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

CONCLUSION

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

Differentiation of the severity of rheumatic mitral stenosis using dimensionless index and its association with outcomes

Introduction

The severity of mitral stenosis (MS) is commonly assessed using mitral valve area (MVA) measured with transthoracic echocardiography (TTE). The dimensionless index (DI) of mitral valve (MV) was recently studied in degenerative MS. We evaluated DI MV in rheumatic MS and studied its relationship with clinical outcomes.

Methods

We studied 406 cases of rheumatic MS in a retrospective single centre cohort study, with 174 in a derivation cohort, 121 in a TTE validation cohort, and 111 in a transoesophageal echocardiography (TEE) validation cohort. DI MV was calculated by dividing the left ventricular outflow tract pulsed-wave Doppler time-velocity integral (TVI) by the MV continuous-wave Doppler TVI. DI MV was compared against MV area using the two-dimensional planimetry, pressure half-time and continuity equation methods, or, in the TEE validation cohort, TEE-derived three-dimensional planimetry. Severe MS was defined as an MV area ≤1.5 cm2. Outcomes pertaining to all-cause death and mitral valve intervention were studied in the former two cohorts.

Results

All-in-all, 231 patients (56.9 %) across the three cohorts had severe MS. In the derivation cohort, ROC analysis showed that DI MV could accurately classify MS severity (AUC = 0.838, 95 % CI, 0.780-0.897, p < 0.001). DI MV ≤ 0.25 and DI MV ≥ 0.40 had high specificity for identifying severe (93.7 %) and non-severe MS (93.7 %) respectively. In the validation cohorts, these respectively showed similar specificity for identifying severe (93.8 %) and non-severe MS (91.4 %). In the derivation and TTE validation cohorts, the median follow up duration was 6.32 years (interquartile range, 4.22-10.3 years) with 90 deaths (30.5 %) and 50 patients (17.0 %) undergoing MV intervention. DI MV was univariately significant (HR = 0.075, 95 % CI 0.0215-0.378, p = 0.002) in Cox regression for a composite outcome of death and MV intervention. DI MV remained independently associated with the composite outcome in multivariate analysis.

Conclusion

DI MV can help rule-in or rule-out severe MS with high specificity, and is independently associated with composite outcomes of death and MV intervention.

The Myval Balloon-Expandable Transcatheter Heart Valve Implant in Aortic and Mitral Interventions: A Single-Center Experience

BACKGROUND

Balloon-expandable valve implants are widely used for percutaneous aortic and mitral valve replacement. This study presents our experience with the Myval implant (Meril Life Sciences, Vapi, India) in these positions.

METHODS

This is a retrospective single-cohort observational study. Between March 2019 and August 2024, 15 patients underwent Myval implantation; out of them, 14 patients (93.33%) underwent transcatheter aortic valve implant (TAVI), and one underwent transcatheter mitral-valve-in-ring implant (TMViR). The mean age of our patients was 75.87±7.51 years (range: 64-90 years), with a slightly higher proportion of females (53.33%). All the patients were symptomatic and presented in New York Heart Association (NYHA) functional class II to IV. The mean EuroSCORE II was 7.99±5.64%, indicating more higher operative risk patients. Fourteen patients who underwent TAVI had severe aortic stenosis with varying degrees of regurgitation. The mean aortic annulus area in these patients was 390.20±74.49 mm², with a mean area-derived diameter of 22.19±2.17 mm. The most commonly used Myval implant sizes were 23 mm (33.33%) and 24.5 mm (33.33%). The procedures were conducted under deep conscious sedation unless general anesthesia was specifically necessary. All cases were performed through the femoral route, with three patients (20%) requiring a femoral arterial cut-down approach and the remaining 12 (80%) cases utilizing the percutaneous Seldinger technique, guided by an angiographic roadmap. Pre-ballooning was not mandatory and was required in only five of the TAVI cases and the TMViR case.

RESULTS

In our study, no instances of valve migration, embolization, or deformation were reported. Coronary protection was required in four patients (28.6%) of TAVI procedures, while none required coronary stenting post-valve deployment. One patient underwent emergency coronary stenting under extracorporeal membrane oxygenation support before valve deployment as guide-induced left-main coronary dissection during a coronary protection procedure. Post-procedure, two patients had significant paravalvular leak, and two had residual stenosis against Myval, but both improved by post-ballooning with additional volume. The failure rate of the ProGlide percutaneous closure device was 13.3%. One patient had a navigator balloon rupture below the rated burst pressure, and one had a Python sheath tear during retrieval of the delivery system. No patients required permanent pacemakers (PPMs). The mean post-procedural hospital stay was 2.9 days. There were no procedural or 30-day mortalities. During a mean follow-up of 22 months, two patients (13.4%) died, one of them attributed to non-cardiac causes.

CONCLUSION

Our experience with Myval has shown it to be an effective and user-friendly option for both aortic and mitral interventions, demonstrating good procedural success rates and a favorable safety profile despite some minor concerns, making it a cost-effective choice for balloon-expandable transcatheter heart valves, particularly in developing countries like India.

A murine model of aortic regurgitation generated by trans-apical wire destruction of the aortic valve

BACKGROUND

The mechanisms underlying cardiac remodeling in aortic valvular (AoV) disease remain poorly understood, partially due to the insufficiency of appropriate preclinical animal models. Here, we present a novel murine model of aortic regurgitation (AR) generated by trans-apical wire destruction of the AoV.

METHODS

Directed by echocardiography, apical puncture of the left ventricle (LV) was performed in adult male C57BL/6 mice, and a metal guidewire was used to induce AoV destruction. Echocardiography, invasive LV hemodynamic and histological examination were conducted to assess the degree of AR, LV function and remodeling.

RESULTS

AR mice exhibited rapid aortic regurgitation velocity (424 ± 15.22 mm/s) immediately following successful surgery. Four weeks post-surgery, echocardiography revealed a 54.6% increase in LV diastolic diameter and a 55.1% decrease in LV ejection fraction in AR mice compared to sham mice. Pressure-volume catheterization indicated that AR mice had significantly larger LV end-diastolic volumes (66.2 ± 1.5 μL vs. 41.8 ± 3.4 μL), reduced LV contractility (lower dP/dtmax and Ees), and diminished LV compliance (smaller dP/dtmin and longer Tau) compared to sham mice. Histological examination demonstrated that AR mice had significantly larger cardiomyocyte area and more myocardial fibrosis in LV tissue, as well as a 107% and a 122% increase of heart weight/tibial length and lung weight/tibial length, respectively, relative to sham mice.

CONCLUSIONS

The trans-apex wire-induced destruction of the AoV establishes a novel and efficient murine model to develop AR, characterized by significant eccentric LV hypertrophy, heart failure, and pulmonary congestion.

Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis

OBJECTIVES

Screening for obstructive coronary artery disease (CAD) with coronary computed tomography angiography (CCTA) could prevent unnecessary invasive coronary angiography (ICA) procedures during work-up for trans-catheter aortic valve implantation (TAVI). CT-derived fractional flow reserve (CT-FFR) improves CCTA accuracy in chest pain patients. However, its reliability in the TAVI population is unknown. This systematic review and meta-analysis assesses CCTA and CT-FFR in TAVI candidates.

METHODS

PubMed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.

RESULTS

Thirty-four articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 7235 and 1269 patients, respectively. Reference standard was mostly anatomical severity of CAD. At patient level, pooled CCTA sensitivity was 94.0% and specificity 72.4%. CT-FFR sensitivity was 93.2% and specificity 70.3% with substantial variation between studies. However, in studies that compared both, CT-FFR performed better than CCTA. Sensitivity of CCTA versus CT-FFR was 74.9% versus 83.9%, and specificity was 65.5% versus 89.8%.

CONCLUSIONS

Negative CCTA accurately rules out CAD in the TAVI population. CCTA could lead to significant reduction in pre-TAVI ICA, but false positives remain high. Diagnostic accuracy of CT-FFR was comparable to that of CCTA in our meta-analyses, but in studies performing a direct comparison, CT-FFR performed better than CCTA. However, as most studies were small and used CT-FFR software exclusively available for research, a large study on CT-FFR in TAVI work-up using commercially available CT-FFR software would be appropriate before considering routine implementation.

KEY POINTS

Question Coronary artery disease (CAD) screening with invasive coronary angiography before trans-catheter aortic valve implantation (TAVI) is often retrospectively unnecessary, revealing no obstructive CAD. Findings Coronary CTA ruled out CAD in approximately half of TAVI candidates. CT-derived fractional flow reserve (CT-FFR) performed similarly overall but better than coronary CTA in direct comparison. Clinical relevance Addition of coronary CTA to TAVI planning-CT to screen for obstructive CAD could reduce negative invasive coronary angiographies in TAVI work-up. CT-FFR could reduce false-positive coronary CTA results, improving its gatekeeper function in this population, but more data is necessary.

Imaging of the Acute and Chronic Cardiovascular Complications of Radiation Therapy

Chest radiotherapy (XRT) plays a crucial role in the treatment of a multitude of cancers including breast, lung, esophageal, and lymphoma. Although XRT enhances cancer survival rates, it may also expose healthy bystander tissues to radiation, potentially leading to severe complications. Initially considered relatively resistant to radiation damage, the heart has been shown over the past 4 decades to be susceptible to radiation-induced cardiovascular toxicity and despite advances in XRT which can minimize radiation exposure to heart tissue, no cardiac radiation dose is entirely safe. The clinical spectrum of radiation-induced cardiovascular toxicity is broad, encompassing coronary artery disease, myocardial dysfunction, valvular abnormalities, and pericardial disorders. Radiation-induced cardiovascular toxicity may manifest acutely or many years after XRT, with each condition more likely to present at certain time points post-XRT. Cardiac imaging is a crucial tool in both the screening and diagnosis of radiation-induced cardiovascular toxicity with an understanding of its pathophysiology, incidence, and progression required to implement a comprehensive, multimodality imaging approach to detect and manage these complications effectively.

A Case of Immediate Reduction of Severe Mitral Regurgitation After the Ablation of Atrial Flutter

Mitral regurgitation (MR) is a common valvular dysfunction often classified as primary or secondary, with the latter typically associated with left ventricular dysfunction or mitral annular dilation. A subset of MR is termed atrial functional MR, related to atrial fibrillation, but the relationship between atrial flutter and MR remains underexplored. This report describes the case of a 71-year-old man with severe MR and atrial flutter who experienced rapid improvement in MR severity following successful atrial flutter ablation and restoration of sinus rhythm. Initial echocardiography revealed severe left atrial dilation, moderate to severe eccentric MR, and moderate tricuspid regurgitation. Following ablation, MR severity significantly improved despite persistent left atrial dilation, with sustained improvement observed over two years alongside reverse remodeling of the left atrium. This case highlights the independent effect of atrial flutter on MR severity, separate from structural remodeling, and emphasizes the potential for rhythm control strategies to improve MR and avoid invasive valve interventions. It also raises important questions about the interplay between atrial arrhythmias and MR, underscoring the need for further studies to better understand atrial functional MR and its management.

Ten years of transcatheter aortic valve implantation in the NOTION study: the good and the bad

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis, becoming a preferred option for patients at high and moderate surgical risk and for individuals over 75 years of age. The NOTION study represents the first randomized clinical trial to reach a 10-year follow-up in patients at low surgical risk, comparing TAVI with surgical valve replacement (SAVR). The results show comparable clinical outcomes between TAVI and SAVR in terms of all-cause mortality, stroke, and myocardial infarction. TAVI demonstrated a better haemodynamic profile and a lower incidence of structural valve deterioration (SVD), but showed higher rates of pacemaker requirement and paravalvular leakage compared with surgical replacement. The trial highlights the excellent durability of transcatheter bioprostheses, although new-generation devices and advanced techniques could further reduce adverse events. The study confirms the increasing role of TAVI even in younger patients, but further long-term data will be needed to evaluate its full potential.

Maternal heart failure: state-of-the-art review

Pregnancy is a period of substantial changes to the body's normal physiology, and the failure to adapt to these changes can lead to life-threatening pathology, particularly involving the cardiovascular system. In comparison to pre-pregnancy physiology, pregnant women have increased blood volume and physical demands which exert increased stress on the heart. This is important to consider in women with and without previously diagnosed cardiovascular disease, as the physiologic changes during pregnancy and postpartum can lead to sudden decompensation. The management of heart failure is particularly important as it remains the most common cardiovascular complication during pregnancy and is associated with substantial maternal and fetal morbidity and mortality. This is especially true in patients with pre-existing heart failure, who should receive counseling before conception and in certain cases be advised against pregnancy. For these reasons, healthcare professionals must be well-versed in the different strategies of diagnosis, management, treatment, and monitoring. This review will outline the pathophysiology, diagnostics, management, and general approach to heart failure in pregnant patients.

Aortic Valve Calcification Is Induced by the Loss of ALDH1A1 and Can Be Prevented by Agonists of Retinoic Acid Receptor Alpha: Preclinical Evidence for Drug Repositioning

BACKGROUND

To date, the only effective treatment of severe aortic stenosis is valve replacement. With the introduction of transcatheter aortic valve replacement and extending indications to younger patients, the use of bioprosthetic valves (BPVs) has considerably increased. The main inconvenience of BPVs is their limited durability because of mechanisms similar as the fibro-calcifying processes observed in native aortic stenosis. One of the major gaps of the field is to identify therapeutic targets to prevent or slow the fibro-calcifying process leading to severe and symptomatic aortic stenosis. The aim was to identify new targets for anticalcification drugs to prevent aortic and BPV calcification using an unbiased translational approach.

METHODS

Explanted valves were collected from patients and organ donor hearts. A comparative transcriptomic analysis was performed on valvular interstitial cells (VIC) obtained from calcified (bicuspid and tricuspid) versus control valves. The mechanisms and consequences of aldehyde dehydrogenase 1 family member A1 (ALDH1A1) downregulation were analyzed in VIC cultures from control human aortic valves. ALDH1A1 was inhibited or silenced and its impact on osteogenic marker expression and calcification processes assessed in VIC. The effect of all-trans retinoic acid on calcification was tested on human VIC cultures and on 2 animal models: the model of subcutaneous implantation of bovine pericardium in rats and the model of xenograft aortic valve replacement in juvenile sheep.

RESULTS

Transcriptome analysis of human VIC identified ALDHA1 as the most downregulated gene in VIC from calcified versus control valves. In human VIC, ALDH1A1 expression is downregulated by TGF-β1 in a SMAD2/3-dependent manner. ALDH1A1 inhibition promotes an osteoblast-like VIC phenotype and increases calcium deposition through inhibition of retinoic acid receptor alpha signaling. Conversely, VIC treatment with retinoids decreases calcium deposition and attenuates VIC osteoblast activity. Last, all-trans retinoic acid inhibits calcification development of aortic BPV in both in vivo models and improves aortic valve echocardiographic parameters in the xenograft sheep model.

CONCLUSIONS

These results show that ALDH1A1 is downregulated in calcified valves, hence promoting VIC transition into an osteoblastic phenotype. Retinoic acid receptor alpha agonists, including all-trans retinoic acid through a drug repositioning strategy, represent a promising and innovative pharmacological approach to prevent calcification of native aortic valves and BPV.