[2017 ESC/EACTS Guidelines for the management of valvular heart disease]

Transcatheter tricuspid valve replacement: will it prevail?

Severe tricuspid regurgitation (TR) is a prevalent and challenging condition associated with poor survival outcomes and significant morbidity. Medical therapy alone often fails to provide adequate symptom relief, and stand-alone surgical intervention is linked to high mortality rates, making it a less favorable option unless combined with left-sided valve surgery. The advent of transcatheter tricuspid interventions has provided new therapeutic possibilities, particularly for high-risk patients who are ineligible for conventional surgery. However, many patients are still unsuited for transcatheter tricuspid repair or have only limited benefits from such procedures. In this context, Transcatheter tricuspid valve replacement (TTVR) has rapidly emerged as a promising alternative, offering the potential for more effective treatment outcomes. This review explores the latest advancements in TTVR devices, highlights key clinical findings, and discusses the challenges and limitations of this evolving strategy. Additionally, we address patient selection criteria, procedural outcomes, and future directions in the field, emphasizing the potential of TTVR to transform the management of severe TR.

Pregnancy outcomes in women with mitral valve stenosis: 10-year experience of a tertiary care center

INTRODUCTION

Mitral stenosis (MS) is recognized as one of the most common cardiovascular diseases during pregnancy and can result in adverse outcomes including maternal and fetal mortality if not diagnosed and treated in a timely manner. This study aimed to investigate the pregnancy outcomes of women with MS who were treated at the cardio-obstetric clinic in Alzahra Hospital, Isfahan, from 2011 to 2020.

METHODS

A total of 81 pregnant women diagnosed with MS were selected for the study. Their demographic and clinical data, along with echocardiography information-including systolic pulmonary artery pressure (SPAP), severity of MS, and NYHA class-were monitored throughout pregnancy. Additionally, the maternal and fetal outcomes were examined.

RESULTS

Among the participants, 38.3% were diagnosed with progressive MS, 56.8% exhibited severe stenosis, and 4.9% presented with very severe stenosis. Prior to pregnancy, no cases were classified as NYHA class 3 or 4. However, during the first trimester, six patients (7.4%) were classified as NYHA class 3. In the second trimester, 23 patients (28.4%) were in class 3, and 1 patient (1.2%) was classified as class 4. In the third trimester, 24 cases (29.6%) were in class 3, and 14 cases (17.3%) were in class 4. Notably, significant changes in NYHA class were observed throughout pregnancy (P < 0.001). Furthermore, 16% of participants required percutaneous balloon mitral commissurotomy, highlighting the severity of their condition. Additionally, 2.5% experienced decompensated heart failure and another 2.5% developed arrhythmia after delivery. Unfortunately, there was one case (1.2%) of mortality due to complications from MS. The study also documented one stillbirth (1.2%), 11 cases (13.6%) of spontaneous abortion, 17 cases (21%) of induced abortion, six cases (7.4%) of birth anomalies, three cases (3.7%) of prematurity, and four cases (4.9%) of intrauterine growth restriction, underscoring the critical need for careful management.

CONCLUSION

The results of the study suggest that cardiac function in women diagnosed with MS typically declines during pregnancy. Furthermore, even with optimal treatments, certain complications may still arise.

Cardiopulmonary Exercise Testing: Methodology, Interpretation, and Role in Exercise Prescription for Cardiac Rehabilitation

Cardiopulmonary exercise testing (CPET) is a crucial tool for assessing cardiorespiratory function, providing invaluable insights into individual physiological capacities. This review explores the clinical indications of CPET, its contraindications, as well as a comprehensive protocol for its execution. Additionally, it highlights key parameters measured during CPET and their interpretation, as well as the role of CPET in the prescription of aerobic training in cardiac rehabilitation. This review aims to provide a comprehensive, up-to-date synthesis of advances in the field of CPET and their clinical implications.

Cerebral Embolic Protection: Is There a Benefit for Left Atrial and Mitral Valve Procedures?

PURPOSE OF REVIEW

This review aims to highlight the current evidence on the use of cerebral embolic protection devices (CEPD) in left atrial and transcatheter mitral valve procedures. It also aims to summarize the antithrombotic management of patients undergoing such procedures.

RECENT FINDINGS

Ischemic stroke is one of the most devastating complications of structural heart procedures. The manifestation of periprocedural stroke can range from asymptomatic and detectable only through brain imaging to major stroke with neurological deficits. CEP devices were initially developed to mitigate the risk of stroke associated with transcatheter aortic valve replacement (TAVR). However, the efficacy of such devices during different cardiac interventions is yet to be fully demonstrated, especially in left atrial appendage closure (LAAO), and mitral valve interventions. Few studies demonstrated that the risk of periprocedural strokes after LAAO and mitral valve interventions is not negligible and is highest during the periprocedural period and then falls. The majority of patients undergoing those procedures have cerebral ischemic injuries detected on diffusion-weighted magnetic resonance imaging (DW-MRI). Moreover, a reasonable number of those patients had debris embolization on the filters of the CEPD. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is crucial and should be tailored to each patient's risk of bleeding and ischemia. Close monitoring that includes a full neurological assessment and frequent follow-up visits with cardiac echocardiography are important. The risk of periprocedural stroke in left atrial and transcatheter mitral valve procedures is not negligible. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is important to mitigate the risk of stroke, especially the long-term risk. More prospective studies are needed to assess the efficacy of CEPD in such procedures.

Efficacy and outcomes of antiplatelet therapy versus oral anticoagulants in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis

Background

Recent guidelines suggest that antiplatelet therapy (APT) is the standard of care in the absence of long-term oral anticoagulation (OAC) indications in patients post-transcatheter aortic valve replacement (TAVR). The superiority of one method over the other remains controversial.

Materials and methods

Several databases, including MEDLINE, Google Scholar, and EMBASE, were electronically searched. The primary endpoint was the all-cause mortality (ACM) rate. Secondary endpoints included cardiovascular death, myocardial infarction (MI), stroke/TIA, haemorrhagic stroke, bleeding events, systemic embolism, and valve thrombosis in post-TAVR patients receiving APT and oral anticoagulants (OACs). Forest plots were generated using Review Manager version 5.4, with a p value less than 0.05 indicating statistical significance. Subgroup analysis was performed to explore potential sources of heterogeneity.

Results

Twelve studies were selected. No significant differences were observed in APT and OAC group for ACM [risk ratio (RR): 0.67; 95% CI:0.45-1.01; P=0.05], cardiovascular death [RR:0.91; 95% CI:0.73-1.14; P=0.42], MI [RR:1.69; 95% CI:0.43-6.72; P=0.46], Stroke/TIA [RR:0.79; 95% CI:0.58-1.06; P=0.12], ischaemic stroke [RR:0.83; 95% CI:0.50-1.37; P=0.47], haemorrhagic stroke [RR:1.08; 95% CI: 0.23-5.15; P=0.92], major bleeding [RR:0.79; 95% CI:0.51-1.21; P=0.28], minor bleeding [RR:1.09; 95% CI: 0.80-1.47; P=0.58], life-threatening bleeding [RR:0.85; 95% CI:0.55-1.30; P=0.45], any bleeding [RR:0.98; 95% CI:0.83-1.15; P=0.78], and systemic embolism [RR:0.87; 95% CI:0.44-1.70; P=0.68]. The risk of valve thrombosis was higher in patients receiving APT than in those receiving OAC [RR:2.61; 95% CI:1.56-4.36; P =0.0002].

Conclusions

Although the risk of valve thrombosis increased in patients receiving APT, the risk of other endpoints was comparable between the two groups.

Predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope: A systematic review and meta-analysis

Identifying the underlying cause of unexplained syncope is crucial for appropriate management of recurrent syncopal episodes. Implantable loop recorders (ILRs) have emerged as valuable diagnostic tools for monitoring patients with unexplained syncope. However, the predictors of pacemaker requirement in patients with ILR and unexplained syncope remain unclear. In this study, we shed light on these prognostic factors. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL were systematically searched until May 04, 2023. Studies that evaluated the predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope were included. The "Quality In Prognosis Studies" appraisal tool was used for quality assessment. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was calculated. The publication bias was evaluated using Egger's and Begg's tests. Ten studies (n = 4200) were included. Right bundle branch block (OR: 3.264; 95% CI: 1.907-5.588, p < .0001) and bifascicular block (OR: 2.969; 95% CI: 1.859-4.742, p < .0001) were the strongest predictors for pacemaker implantation. Pacemaker requirement was more than two times in patients with atrial fibrillation, sinus bradycardia and first degree AV block. Valvular heart disease, diabetes mellitus, and hypertension were also significantly more in patients with pacemaker implantation. Age (standardized mean difference [SMD]: 0.560; 95% CI: 0.410/0.710, p < .0001) and PR interval (SMD: 0.351; 95% CI: 0.150/0.553, p = .001) were significantly higher in patients with pacemaker requirement. Heart conduction disorders, atrial arrhythmias and underlying medical conditions are main predictors of pacemaker device implantation following loop recorder installation in unexplained syncopal patients.

Immediate, short-term, and long-term effects of balloon mitral valvuloplasty on the left atrial global longitudinal strain and its correlation to the outcomes in patients with severe rheumatic mitral stenosis

BACKGROUND

Left atrial global longitudinal strain (LA GLS) has been used as a new assessment tool for left atrial function. This article aims to investigate the effect of balloon mitral valvuloplasty (BMV) in patients with severe rheumatic mitral stenosis on LA GLS and its relation to the mitral valve area achieved after the procedure. The study included 95 patients with severe mitral stenosis who fulfilled the criteria for BMV (case group) and 80 normal healthy subjects (control group). All included participants underwent complete echocardiographic examinations. For the case group, LA GLS was assessed by 2D speckle-tracking Echocardiography before valvuloplasty, immediately after, within 24 h, at 6 months, and at 12 months, and the results were compared.

RESULTS

The impaired left-atrium strain in patients with severe mitral stenosis was improved immediately after BMV, and the improvement continued at 6 and 12 months post-BMV (23.1% ± 4.2 vs. 36.0% ± 4.9, 36.2% ± 4.5, and 40.1% ± 9.5, respectively p < 0.01). After BMV, there was a significant decrease in left atrial volume (76.3 ± 12.4 ml/m2 vs. 68.6 ± 10.4 ml/m2, p < 0.01) and a significant increase in the area occupied by the mitral valve (1.02 ± 0.18 cm2 vs. 1.60 ± 0.31 cm, p < 0.01). The immediate LA GLS and the mitral valve area were positively correlated (r = 0.64, p < 0.01). Furthermore, the immediate LA GLS was associated with significantly improved function class (p < 0.01).

CONCLUSIONS

LA GLS can indicate left atrial (mainly reservoir) function. The improvement observed in patients after BMV may indicate that LA GLS can be used to evaluate the progress after BMV.

TRIAL REGISTRATION

The study was approved by the local ethics committee of the Faculty of Medicine in Minia University (Registration No. MUFMIRB 324-4-2022). Institutional Review Board, Faculty of Medicine, Minia University, Egypt. 324-4-2022, 24 18 April, 2022.

Emerging PET Tracers in Cardiac Molecular Imaging

¹⁸F-fluorodeoxyglucose (FDG) and ¹⁸F-sodium fluoride (NaF) represent emerging PET tracers used to assess atherosclerosis-related inflammation and molecular calcification, respectively. By localizing to sites with high glucose utilization, FDG has been used to assess myocardial viability for decades, and its role in evaluating cardiac sarcoidosis has come to represent a major application. In addition to determining late-stage changes such as loss of perfusion or viability, by targeting mechanisms present in atherosclerosis, PET-based techniques have the ability to characterize atherogenesis in the early stages to guide intervention. Although it was once thought that FDG would be a reliable indicator of ongoing plaque formation, micro-calcification as portrayed by NaF-PET/CT appears to be a superior method of monitoring disease progression. PET imaging with NaF has the additional advantage of being able to determine abnormal uptake due to coronary artery disease, which is obscured by physiologic myocardial activity on FDG-PET/CT. In this review, we discuss the evolving roles of FDG, NaF, and other PET tracers in cardiac molecular imaging.

Multivariable Technique for the Evaluation of the Trans-stenotic Pressure Gradient

PURPOSE

This study establishes a reliable image-based multivariable technique for measuring the trans-stenotic pressure gradient.

METHODS

A self-made in vitro steady flow model based on adjustable velocities and stenotic properties were used as the experimental subject. The pre-stenotic flow velocity, severity, and length of the stenosis were used as the input variables. Based on equations used to fit the plots of the physically measured pressure gradient values versus each input variable, a multivariable formula for the pressure gradient measurement could then be derived. The flow model was scanned using velocity-encoded phase-contrast magnetic resonance imaging (PC-MRI) to validate the derived formula while simultaneously measuring the trans-stenotic pressure gradient. The correlation between the physically-measured pressure gradient values and the pressure gradient values calculated using the new formula were subsequently analyzed.

RESULTS

The results of linear regression analysis using the physically measured pressure gradient values for the new method were compared to values obtained using the simplified Bernoulli equation (R², 0.991, and 0.975, respectively). In a paired t-test, no statistically significant difference was found between the new method and the physical measurements.

CONCLUSIONS

The derived multivariable technique was found to reliably measure the trans-stenotic pressure gradient, with better performance than a traditional procedure based on the simplified Bernoulli equation.

Transcatheter Mitral Valve Repair or Replacement: Competitive or Complementary?

Over the last two decades, transcatheter devices have been developed to repair or replace diseased mitral valves (MV). Transcatheter mitral valve repair (TMVr) devices have been proven to be efficient and safe, but many anatomical structures are not compatible with these technologies. The most significant advantage of transcatheter mitral valve replacement (TMVR) over transcatheter repair is the greater and more reliable reduction in mitral regurgitation. However, there are also potential disadvantages. This review introduces the newest TMVr and TMVR devices and presents clinical trial data to identify current challenges and directions for future research.

Prognostic Value of Creatine Phosphate and Inflammatory Markers for Mitral Valve Replacement: A Systematic Review and Meta-Analysis

Purpose

The prognosis of mitral valve replacement is an important clinical issue and may produce unexpected mortality rates if not properly addressed. The postoperative examination results have important prognostic implications. This study was designed to determine the prognostic value of phosphocreatine and inflammatory markers after mitral valve replacement.

Method

Comparison and analysis of the data obtained using SPSS software. The computer retrieved PubMed, Science Citation Index (SCI), Embase, VIP, CNKI, CBM, and Wanfang database and manually retrieved randomized controlled trials (RCTs) published at home and abroad on the central muscle protection role of creatine phosphate in heart valve replacement, and the search period was established until February 2018. Two random literature reviewers independently screened the literature and extracted data, using Review Manager (RevMan) (Computer program), version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014). RevMan software version 5.0 assesses the risk of bias for inclusion in studies. The software performs a meta-analysis of the obtained data.

Results

Ten RCTs with a total of 464 participants were enrolled. The meta-analysis results showed that (1) elevated creatine kinase levels often predict a better prognosis after mitral valve replacement (RR = 1.36, 95% CI: 1.22 to 1.52, P < 0.00001), (2) the creatine kinase isoenzyme level in the venous blood of the phosphocreatine group after 24 h of aortic blocking was significantly lower than that in the control group (SMD = -2.90, 95% CI: -5.19 to -0.60, P = 0.01), and (3) Troponin I levels were significantly lower in the intravenous creatine group than in the control group 24 h after opening of the aortic block (SMD = -1.49, 95% CI: -2.02 to -0.97,P < 0.00001).

Conclusions

Creatine phosphate and inflammatory factor have good predictive value for the prognosis of mitral valve replacement.

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

Self-Expandable Transcatheter Aortic Valve Implantation Outcomes: Findings From the Western Region of Saudi Arabia

Background and objective The prevalence of aortic stenosis in Saudi Arabia is expected to increase owing to the rise in the life expectancy of the population. Such increase is expected to be met with higher demand for interventions including transcatheter aortic valve implantation (TAVI). In this study, we aimed to identify the outcomes of this procedure among the population of the Western region of Saudi Arabia. Methods This was a retrospective observational study involving patients who underwent TAVI at the King Faisal Cardiac Center (KFCC), Jeddah, Saudi Arabia from June 2018 to January 2020. All patients who had undergone TAVI were included, and patients who were lost to follow-up for more than 90 days were excluded. The collected data included sociodemographic characteristics, peri-procedural assessment, and outcomes within 90 days. Results The study included a total of 52 patients. There were 28 males (53.8%) and 24 females (46.2%). The mean age of the cohort was 78 years. Type two diabetes mellitus was present in 67.3%, and hypertension and dyslipidemia were seen in 80.8% of patients. Coronary diseases were seen in 55.8%. The majority had prior percutaneous coronary intervention (PCI) (53.8%) and 3.8% had coronary artery bypass grafting (CABG). Twenty patients (38.5%) had heart failure. Atrial fibrillation was encountered in 13 patients (25%). Chronic kidney disease was described in nine (17.3%) patients, and four (7.7%) were on regular hemodialysis. The median Society of Thoracic Surgery (STS) risk score was 2.4 (IQR: 1.97-5). High STS scores (>8) were only seen in 9% of the patients. The success rate was 98%, and the in-hospital mortality rate was 3.8%. Vascular complications were seen in eight patients (15.4%), and the majority of them were minor. One patient (1.9%) had a major vascular complication. There was a tendency toward high blood transfusions (19.2%). Clinically manifest stroke was seen in three patients (5.8%). Eight patients (15.4%) had post-procedure complete heart block (CHB). Endocarditis was seen in two patients (3.8%). Thirty-day cardiac readmission was observed in 17.3% of patients, and acute kidney injury was seen in eight patients (15.4%). Mild aortic regurgitation was seen in 51.9% of the patients, but moderate or severe aortic insufficiency (AI) was not encountered. Conclusion Transfemoral TAVI using a self-expandable valve is a safe and feasible procedure at KFCC, an intermediate-sized center. Our data is comparable to local and international centers of similar size. Program sustainability depends on the development of robust referral networks and implementing regulatory quality and patient safety standards.

Real-life outcomes and readmissions after a TAVI procedure in a Glasgow population

Transcatheter aortic valve implantation (TAVI) is a routine procedure for patients with symptomatic severe aortic stenosis who are deemed inoperable or high-risk surgical candidates. The aim of this study was to examine real-world data on death and readmission rates in patients following the procedure. Electronic health records for patients who underwent TAVI between April 2015 and November 2018 were reviewed. Details of the procedure, complications, length of initial hospital stay and outcomes of interest (subsequent admissions and mortality) were recorded. In our cohort of 124 patients, the mean age was 80.8 years and 43% were male. Cardiac comorbidities were common, more than 30% had myocardial infarction (MI) and 15% had a previous coronary artery bypass graft (CABG). One in five suffered from chronic obstructive pulmonary disease (COPD), with similar prevalence of diabetes mellitus and cerebrovascular accident (CVA). In-hospital mortality was low at 3.3%, however, 30-day readmission rates were high at 14.6%; 44.4% were readmitted to hospital within one year. TAVI is a successful procedure in Scotland with good outcome data. The potential benefit of the procedure in many patients is limited by comorbidities, which shorten life-expectancy and lead to hospital readmission. These data highlight the importance of effective multi-disciplinary discussion in a time of realistic medicine.

Factors associated with a high or low implantation of self-expanding devices in TAVR

OBJECTIVES

Optimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated. Therefore, we aimed to (1) evaluate the impact of different pacing maneuvers on ID, and (2) identify the independent predictors of deep ID.

METHODS

473 TAVR patients with newer-generation self-expanding devices were retrospectively enrolled and one-to-one propensity-score-matching was performed, resulting in a matching of 189 FP and RP patients in each cohort. The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis.

RESULTS

The highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification [OR 0.50 (0.31-0.81) p = 0.005*], a "flare" aortic root [OR 0.42 (0.25-0.71), p = 0.001*], and RP (OR 0.49 [0.30-0.79], p = 0.004*) as independent highly preventable predictors of a deep ID. In a model of protective factors, ID was significantly reduced with the number of protective criteria (0-2 criteria: - 5.7 mm ± 2.6 vs. 3-4 criteria - 4.3 mm ± 2.0; p < 0.0001*).

CONCLUSION

Data from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expanding devices. Randomized studies should prove for validation compared to fast and non-pacing maneuvers during valve delivery and their impact on implantation depth.

TRAIL REGISTRATION

Clinical Trial registration: NCT01805739.

STUDY DESIGN

Evaluation of the impact of different pacing maneuvers (fast ventricular pacing-FP vs. rapid ventricular pacing-RP) on implantation depth (ID). After one-to-one-propensity-score-matching, independent protective and risk factors for a very deep ID beneath 6 mm toward the LVOT (< - 6 mm) were identified. Stent frame pictures as a courtesy by Medtronic^®. AVC aortic valve calcification.

Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population-Based Study in Ontario, Canada

Background

The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization.

Methods and Results

TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals.

Conclusions

There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.

The predictive value of intraprocedural mitral gradient for outcomes after MitraClip and its peri-interventional dynamics

BACKGROUND

The current data on the impact of the increased mitral gradient (MG) on outcomes are ambiguous, and intraprocedural assessment of MG can be challenging. Therefore, we aimed to evaluate (a) peri-interventional dynamics of MG, (b) the impact of intraprocedural MG on clinical outcomes, and (c) predictors for unfavorable MG values after MitraClip.

METHODS

We prospectively included patients who underwent MitraClip. All patients underwent echocardiography at baseline, intraprocedurally, at discharge, and after 6 months. 12-month survival was documented.

RESULTS

One hundred and seventy five patients (age 81.2 ± 8.2 years, 61.2% male) with severe mitral regurgitation (MR) were included. We divided our cohort into two groups according to intraprocedural MG with a threshold of 4.5 mm Hg, determined by a multivariate analysis of predictors for 12-month mortality (<4.5 mm Hg: Group 1, ≥4.5 mm Hg: Group 2). Intraprocedural MG ≥4.5 mm Hg was found to be the strongest independent predictor for 12-month mortality (HR: 2.33, P = .03, OR: 1.70, P = .05), and >3.9 mm Hg was associated with adverse functional outcomes (OR: 1.96, P = .04). The baseline leaflet-to-annulus index >1.1 was found to be the strongest independent predictor (OR: 9.74, P = .001) for unfavorable intraprocedural MG, followed by the number of implanted clips (P = .01), MG at baseline (P = .02), and central clip implantation (P = .05).

CONCLUSION

An intraprocedural MG <3.9 mm Hg appears to be the best strategy for 1-year survival and favorable functional outcomes after edge-to-edge MV repair with MitraClip independently from MR etiology. Peri-interventional echocardiographic and procedural parameters are useful for the adequate assessment of intraprocedural MG.

Transcatheter Mitral Valve Replacement and Thrombosis: A Review

Mitral regurgitation is the most prevalent form of moderate or severe valve disease in developed countries. Surgery represents the standard of care for symptomatic patients with severe mitral regurgitation, but up to 50% of patients are denied surgery because of high surgical risk. In this context, different transcatheter options have been developed to address this unmet need. Transcatheter mitral valve replacement (TMVR) is an emergent field representing an alternative option in high complex contexts when transcatheter mitral valve repair is not feasible or suboptimal due to anatomical issues. However, TMVR is burdened by some device-specific issues (device malposition, migration or embolization, left ventricular outflow tract obstruction, hemolysis, thrombosis, stroke). Here we discuss the thrombotic risk of TMVR and current evidence about anticoagulation therapy after TMVR.

Clinical and Technical Challenges of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Implantation

Prosthesis-patient mismatch (PPM) is present when the effective area of a prosthetic valve inserted into a patient is inferior to that of a normal human valve; the hemodynamic consequence of a valve too small compared with the size of the patient's body is the generation of higher than expected transprosthetic gradients. Despite evidence of increased risk of short- and long-term mortality and of structural valve degeneration in patients with PPM after surgical aortic valve replacement, its clinical impact in patients subject to transcatheter aortic valve implantation (TAVI) is yet unclear. We aim to review and update on the definition and incidence of PPM after TAVI, and its prognostic implications in the overall population and in higher-risk subgroups, such as small aortic annuli or valve-in-valve procedures. Last, we will focus on the armamentarium available in order to reduce risk of PPM when planning a TAVI procedure.

Coronary Assessment and Revascularization Before Transcutaneous Aortic Valve Implantation: An Update on Current Knowledge

Transcutaneous aortic valve implantation (TAVI) has led to a paradigm shift in the treatment of severe aortic stenosis (AS) in the elderly and is expanding to still younger and lower-risk patients with severe AS as an alternative to surgical aortic valve replacement (SAVR). While the role of coronary artery bypass grafting with SAVR is well-documented, the analog of percutaneous coronary intervention with TAVI is less so. The aim of this review is to provide an overview of the important challenges in treating severe AS and co-existing coronary artery disease in patients planned for TAVI.

Diagnostic and Prognostic Accuracy of Aortic Valve Calcium Scoring in Patients With Moderate-to-Severe Aortic Stenosis

Background: Assessing the true severity of aortic stenosis (AS) remains a challenge, particularly when echocardiography yields discordant results. Recent European and American guidelines recommend measuring aortic valve calcium (AVC) by multidetector row computed tomography (MDCT) to improve this assessment. Aim: To define, using a standardized MDCT scanning protocol, the optimal AVC load criteria for truly severe AS in patients with concordant echocardiographic findings, to establish the ability of these criteria to predict clinical outcomes, and to investigate their ability to delineate truly severe AS in patients with discordant echocardiographic AS grading. Methods and Results: Two hundred and sixty-six patients with moderate-to-severe AS and normal LVEF prospectively underwent MDCT and Doppler-echocardiography to assess AS severity. In patients with concordant AS grading, ROC analysis identified optimal cut-off values for diagnosing severe AS using different AVC load criteria. In these patients, 4-year event-free survival was better with low AVC load (60-63%) by these criteria than with high AVC load (23-26%, log rank p < 0.001). Patients with discordant AS grading had higher AVC load than those with moderate AS but lower AVC load than those with severe high-gradient AS. Between 36 and 55% of patients with severe LG-AS met AVC load criteria for severe AS. Although AVC load predicted outcome in these patients as well, its prognostic impact was less than in patients with concordant AS grading. Conclusions: Assessment of AVC load accurately identifies truly severe AS and provides powerful prognostic information. Our data further indicate that patients with discordant AS grading consist in a heterogenous group, as evidenced by their large range of AVC load. MDCT allows to differentiate between truly severe and pseudo-severe AS in this population as well, although the prognostic implications thereof are less pronounced than in patients with concordant AS grading.

Percutaneous Coronary Intervention in Transcatheter Aortic Valve Implantation Patients: Overview and Practical Management

Coronary artery disease (CAD) is present in 40-75% of patients undergoing transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis. Currently, the indication for TAVI is expanding toward younger patients at lower surgical risk. Given the progressive nature of CAD, the necessity for coronary angiography (CA), including percutaneous coronary intervention (PCI), will subsequently increase as in the future TAVI patients will be younger and have a longer life expectancy. Data on the impact of PCI in patients with severe CAD scheduled for TAVI are controversial, and although European and US guidelines recommend PCI before TAVI, the optimal timing for PCI remains unclear due to a lack of evidence. Depending on the valve type, position, and axial alignment of the implanted device, CA and/or PCI after TAVI can be challenging. Hence, every interventionalist should be familiar with the different types of transcatheter heart valves and their characteristics and technical issues that can arise during invasive coronary procedures. This review provides an overview of current data regarding the prevalence and clinical implications of CAD and PCI in TAVI patients and includes useful guidance for practical management in the clinical routine.

Patient-Tailored Aortic Valve Replacement

Contemporary surgical and transcatheter aortic valve interventions offer effective therapy for a broad range of patients with severe symptomatic aortic valve disease. Both approaches have seen significant advances in recent years. Guidelines have previously emphasized ‘surgical risk’ in the decision between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR), although this delineation becomes increasingly obsolete with more evidence on the effectiveness of TAVR in low surgical risk candidates. More importantly, decisions in tailoring aortic valve interventions should be patient-centered, accounting not only for operative risk, but also anatomy, lifetime management and specific co-morbidities. Aspects to be considered in a patient-tailored aortic valve intervention are discussed in this article.

Changes of Right Ventricular Function After Transcatheter Aortic Valve Replacement and Association With Outcomes

BACKGROUND

Baseline right ventricular (RV) dysfunction represents a predictor for poor outcome in patients undergoing transcatheter aortic valve replacement (TAVR). However, RV function may improve after TAVR, which could have important implications on outcomes. The aim of the present study was to assess changes in RV function after TAVR and its prognostic value regarding clinical outcome.

METHODS AND RESULTS

Patients undergoing TAVR at our institution were consecutively enrolled and categorized into 4 groups according to changes in RV function during echocardiographic follow-up at 6 months. A total of 188 patients were included. Of those showing normal function at baseline, 87% (130/149) had preserved RV function at follow-up (group 1), whereas 13% (19/149) developed new RV dysfunction (group 2). Of those with RV dysfunction at baseline (39 patients), RV function normalized in 46% (18/39) (group 3) and remained impaired in 54% (21/39) (group 4). The Kaplan-Meier estimated survival at 3 years was highest in patients in group 1 (83%), intermediate in group 2 (65%) and 3 (69%), whereas group 4 had the worst survival (37%; P < .001). Furthermore, new or persistent RV dysfunction was identified to be independently associated with mortality during follow-up (hazard ratio 2.55; interquartile range 1.03-6.47, P = .004).

CONCLUSIONS

Patients with preserved RV function have a high 3-year survival. Normalization of RV function showed improved survival compared with patients with persistent RV dysfunction, who had a dismal prognosis despite TAVR.

Effect of Living Environment Factors on Quality of Life in Patients With Chronic Thromboembolic Pulmonary Hypertension After Completion of Balloon Pulmonary Angioplasty - A Cross-Sectional Study

Background: This study investigated factors related to quality of life (QoL) in patients with chronic thromboembolic pulmonary hypertension who completed balloon pulmonary angioplasty (BPA).

Methods and Results: Patient QoL and living environment after BPA were evaluated prospectively using the 5-level EQ-5D questionnaire and International Physical Activity Questionnaire Environmental Module (IPAQ-E), respectively. Patients were mailed copies of both surveys. In addition, we reviewed patient charts and collected retrospective clinical data. Relationship between the clinical data and QoL and environmental living factors were investigated. Of the 33 subjects mailed the surveys, sufficient responses were obtained from 22 (71%). Spearman’s rank correlation coefficient showed that psychiatric disorders (r=−0.6865, P<0.01) and IPAQ-E Question 5 (r=0.5192, P=0.02), Question 6 (r=0.5265, P=0.02), and Question 13 (r=0.4552, P=0.04) were significantly correlated with EQ-5D scores after BPA.

Conclusions: A living environment that was difficult to walk around was associated with a worse QoL. A multidisciplinary approach will be required to improve QoL even after completion of BPA treatment.

Assessment of 10-Year Left-Ventricular-Remodeling by CMR in Patients Following Aortic Valve Replacement

Aims: Aortic valve replacement (AVR) may result in reverse cardiac remodeling. We aimed to assess long-term changes in the myocardium following AVR by Cardiac Magnetic Resonance Imaging (CMR).

Methods: We prospectively observed the long-term left ventricular (LV) function and structure of 27 patients with AVR [n = 19 with aortic stenosis (AS); n = 8 with aortic regurgitation (AR)] by CMR. Patients underwent CMR before, as well as 1, 5, and 10 years after AVR. We evaluated clinical parameters, LV volumes, mass, geometry, ejection fraction (EF), global myocardial longitudinal strain (MyoGLS), global myocardial circular strain (MyoGCS), hemodynamic forces (HemForces), and Late Gadolinium Enhancement (LGE).

Results: The median of LVMI, EDVI, and ESVI decreased in both groups. Patients with AR had higher initial values of EDVI and ESVI and showed a more prominent initial reduction. In AS, MyoGLS improved already after 1 year and remained constant afterward, whereas, in AR no improvement of MyoGLS was found. MyoGCS remained unchanged in the AS group but deteriorated in the AR group over 10 years. Ejection fraction (EF) was higher in AS patients compared to AR 10 years post-AVR. Late gadolinium enhancement (LGE) could be found more frequently in AS patients.

Conclusion: CMR was well suited to investigate myocardial changes over a 10-year follow up period in patients with aortic valve disease. Regarding the long-term functional changes following AVR, patients with AR seemed to benefit less from AVR compared to AS patients. Fibrosis was more common in AS, but this did not reflect functional evolution in these patients. Close monitoring seems indispensable to avoid irreversible structural damage of the heart and to perform AVR at an appropriate stage.

Routine Echocardiography and Artificial Intelligence Solutions

Introduction: Echocardiography is widely used because of its portability, high temporal resolution, absence of radiation, and due to the low-costs. Over the past years, echocardiography has been recommended by the European Society of Cardiology in most cardiac diseases for both diagnostic and prognostic purposes. These recommendations have led to an increase in number of performed studies each requiring diligent processing and reviewing. The standard work pattern of image analysis including quantification and reporting has become highly resource intensive and time consuming. Existence of a large number of datasets with digital echocardiography images and recent advent of AI technology have created an environment in which artificial intelligence (AI) solutions can be developed successfully to automate current manual workflow. Methods and Results: We report on published AI solutions for echocardiography analysis on methods' performance, characteristics of the used data and imaged population. Contemporary AI applications are available for automation and advent in the image acquisition, analysis, reporting and education. AI solutions have been developed for both diagnostic and predictive tasks in echocardiography. Left ventricular function assessment and quantification have been most often performed. Performance of automated image view classification, image quality enhancement, cardiac function assessment, disease classification, and cardiac event prediction was overall good but most studies lack external evaluation. Conclusion: Contemporary AI solutions for image acquisition, analysis, reporting and education are developed for relevant tasks with promising performance. In the future major benefit of AI in echocardiography is expected from improvements in automated analysis and interpretation to reduce workload and improve clinical outcome. Some of the challenges have yet to be overcome, however, none of them are insurmountable.

Single- or dual-antiplatelet therapy after transcatheter aortic valve replacement: A protocol of systematic review and meta-analysis

BACKGROUND

The evidence related to bleeding and thromboembolic events after transcatheter aortic valve replacement (TAVR) compared single antiplatelet therapy (SAPT) with dual antiplatelet therapy (DAPT) treatment are inconsistent. Moreover, there are some limitations such as small sample size and the risk of bias in existing studies. We will conduct a comprehensive systematic review and meta-analysis to explore the safety and efficacy of SAPT or DAPT after TAVR.

METHODS

A comprehensive literature search of PubMed, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials will be searched to retrieve studies involving SAPT versus DAPT after TAVR. Two investigators will independently select studies, extract data, and assess the quality of the included study. Any disagreement will be resolved by the third investigator. The study will use a random-effects model to pool the results of all studies and use the relative risk and 95% confidence intervals to summarize individual trial outcomes and estimate pooled effect. The study will use the Grading of Recommendations Assessment, Development, and Evaluation to assess the certainty of evidence.

RESULTS

This study will provide high-quality evidence for treatment of TAVR in terms of effectiveness and safety.

CONCLUSION

This systematic review aims to provide evidence for treatment of TAVR in different antiplatelet therapies.

REGISTRATION

The systematic review and meta-analysis is registered in the OSF REGISTRIES (10.17605/OSF.IO/Q42TE) international prospective register.

State-of-the-Art Review: Anatomical and Imaging Considerations During Transcatheter Tricuspid Valve Repair Using an Annuloplasty Approach

Transcatheter techniques for the treatment of tricuspid regurgitation (TR) are being more frequently used and several new devices are in development. Since 90% of patients with TR have secondary TR, catheter based systems which reduce the dilated tricuspid annulus area are of particular interest. In order to perform an annuloplasty procedure effectively and safely, knowledge about the anatomy of the tricuspid valve apparatus and especially of the annulus in relation to the important neighboring structures such as the aortic root, the RCA, the electrical pathways and the CS is fundamental. In addition, comprehensive understanding of the device itself, the delivery system, its maneuverability and the individual procedural steps is required. Furthermore, the use of multi-modality imaging is important. For each step of the procedure the appropriate imaging modality as well as the optimal; imaging planes are crucial to provide the necessary information to best guide the individual procedural step.

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium

Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm² and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.

Conservative Treatment of Unicuspid Aortic Valve with Newly Diagnosed Type A Aortic Dissection

We present a case of a 36-year-old male patient with known arthrogryposis multiplex congenita and an associated unicuspid aortic valve. The patient later developed a significant aneurysm of the ascending aorta, however refused surgical intervention and missed follow-up appointments for 5 years. During an urgent, general practitioner-initiated transthoracic echocardiography follow-up, a chronic type A aortic dissection was diagnosed as a result of progressive aortic dilatation. Due to the stationary pressure gradients and non-progressive leaflet fibrosis, a conservative approach for to the unicuspid aortic valve was chosen, combined with replacement of the ascending aorta and partial replacement of the aortic arch.

Current Devices in Mitral Valve Replacement and Their Potential Complications

Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical treatment is not feasible in all cases. The elderly and frail with several comorbidities and left ventricular dysfunction are often managed conservatively. Percutaneous treatment (repair or replacement) of the mitral valve has emerged as a potential option for those patients who are at a high risk for surgery. Mitral valve repair with the Mitraclip device proved both increased safety and mortality reduction in patients with severe mitral regurgitation. On the other hand, in the last decade, percutaneous mitral replacement opened new frontiers in the field of cardiac structural interventions. There are few mitral devices; some are in the early phase of development and some are waiting for CE mark of approval. The evolution of these devices was more complicated compared to the aortic technology due to the native mitral valve's complexity and access. This review aims to provide an overview of the current devices, their specific features, and their potential complications.

Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair

Percutaneous mitral valve repair has been increasingly performed worldwide after approval. We sought to investigate predictors of clinical outcome in patients with mitral regurgitation undergoing percutaneous valve repair. The MITRA-UMG study, a single-centre registry, retrospectively collected consecutive patients with symptomatic moderate-to-severe or severe MR undergoing MitraClip therapy. The primary endpoint was the composite of cardiovascular death or rehospitalization for heart failure. Between March 2012 and July 2018, a total of 150 consecutive patients admitted to our institution were included. Procedural success was obtained in 95.3% of patients. The composite primary endpoint of cardiovascular death or rehospitalization for HF was met in 55 patients (37.9%) with cumulative incidences of 7.6%, 26.2%, at 30 days and 1-year, respectively. In the Cox multivariate model, NYHA functional class and left ventricular end-diastolic volume index (LVEDVi), independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan–Meier analysis, a LVEDVi > 92 ml/m² was associated with an increased incidence of the primary endpoint. In this study, patients presenting with dilated ventricles (LVEDVi > 92 ml/m²) and advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis after percutaneous mitral valve repair.

Anticoagulation With or Without Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement for Patients With Atrial Fibrillation: A Meta-Analysis

BACKGROUND

Although current guidelines recommend oral anticoagulants (OAC) with or without antiplatelet therapy (APT) following transcatheter aortic valve replacement (TVAR) in patients with an indication for long-term anticoagulation therapy, the optimal antithrombotic strategy remains unknown in these population. Herein, we conducted a meta-analysis comparing the outcome of OAC alone versus OAC with APT following TAVR in patients with atrial fibrillation (AF).

METHODS

MEDLINE and EMBASE were searched through May 2020 to identify clinical trials that investigated OAC alone versus OAC with APT following TAVR in patients with AF. From each study, we extracted the hazard ratios (HRs) or risk ratios of major or life threatening bleeding, stroke, all-cause mortality and cardiovascular mortality.

RESULTS

1 randomized controlled trial and 3 observational studies were identified, which enrolled a total of 2032 patients with AF who underwent TAVR assigned to the OAC group (n = 722) or OAC with APT group (n = 1310). Pooled analyses demonstrated the rate of major or life threatening bleeding was significantly lower in the OAC group compared to the OAC with APT group (HR [95% Confidence Interval [CI] = 0.54 [0.38-0.77], P = .0006]). However, the rate of stroke was similar in both groups (HR [95% CI] = 1.22 [0.80-1.87], P = .36). All-cause and cardiovascular mortalities were also similar in both groups.

CONCLUSIONS

We observed that OAC with APT following TAVR in patients with AF increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke.

The modified MIDA-Score predicts mid-term outcomes after interventional therapy of functional mitral regurgitation

Aims

The preprocedural assessment of outcomes and patients’ prognosis after interventional therapy of functional MR (FMR) is uncertain. Therefore, we aim to develop an easy-to-handle scoring system for adequate prediction of individual outcomes in patients with FMR after the interventional treatment.

Materials and methods

We retrospectively used medical data of patients with symptomatic FMR, who underwent transcatheter mitral valve repair (TMVR) from January 2014 to August 2016 in our heart center. All patients had the mean follow-up of 18 months. All clinical and echocardiographic data originate from the “Bonner Mitral Valve Register Database”.

Results

We included 105 patients (76,7±8,8 years, 50,6% female) with symptomatic (NYHA functional class>II) moderate-to-severe or severe FMR at surgical high-risk. We modified the MIDA-Score for degenerative MR (DMR) according to the varying underlying pathomechanisms of FMR, called as “The modified MIDA Score”. We found all-cause mortality of 7% within 18 months after the procedure. 34,1% of our cohort was rehospitalized; 90% of those were due to cardiovascular causes. The modified MIDA score was found to be a strong predictor for mortality and rehospitalization in patients with FMR (AUC: 0,89) and superior to the other conventional scoring systems in prediction of mortality (The modified MIDA-Score: AUC: 0,8, EuroSCORE II: AUC: 0,57, STS-Score: AUC: 0,51). The logistic regression analysis showed the modified MIDA score > 9 points to be the strongest predictor for mortality and rehospitalization after TMVR (OR: 3,35, p = 0,011).

Conclusion

The modified MIDA score was found to be a promising, easy-to-handle, elementary scoring system for adequate prediction of individual postinterventional prognosis in patients with FMR undergoing TMVR. Further evaluation and validation of this novel scoring system in prospective multicentric studies with a large number of patients is warranted.

Impaired Fibrinolysis in Patients with Isolated Aortic Stenosis is Associated with Enhanced Oxidative Stress

Aortic stenosis (AS) has been associated with impaired fibrinolysis and increased oxidative stress. This study aimed to investigate whether oxidative stress could alter fibrin clot properties in AS. We studied 173 non-diabetic patients, aged 51–79 years, with isolated AS. We measured plasma protein carbonylation (PC) and thiobarbituric acid reactive substances (TBARS), along with plasma clot permeability (K_s), thrombin generation, and fibrinolytic efficiency, which were evaluated by two assays: clot lysis time (CLT) and lysis time (Lys50). Coagulation factors and fibrinolytic proteins were also determined. Plasma PC showed an association with AS severity, reflected by the aortic valve area and the mean and maximum aortic gradients. Plasma PC was positively correlated with CLT, Lys50, plasminogen activator inhibitor-1 (PAI-1), and tissue factor (TF) antigens. TBARS were positively correlated with maximum aortic gradient, Lys50, and TF antigen. Regression analysis showed that PC predicted prolonged CLT (>104 min; odds ratio (OR) 6.41, 95% confidence interval (CI) 2.58–17.83, p < 0.001) and Lys50 (>565 s; OR 5.83, 95% CI 2.23–15.21, p < 0.001). Multivariate regression analysis showed that mean aortic gradient, PC, α2-antiplasmin, PAI-1, and triglycerides were predictors of prolonged CLT, while PC, α2-antiplasmin, and fibrinogen were predictors of Lys50. Our findings suggest that elevated oxidative stress contributes to impaired fibrinolysis in AS and is associated with AS severity.

Mitral and Tricuspid Transcatheter Interventions Current Indications and Future Directions

Valvular heart disease is responsible for a high rate of morbidity and mortality, especially in the elderly population. With the emergence of new transcatheter treatment options, the therapeutic spectrum for patients with valvular heart disease has considerably expanded during the past years. Interventional treatment of the mitral and tricuspid valve requires an individualized and versatile approach owing to the different etiologies of valvular dysfunction and the complex anatomy of the atrioventricular valves. This article aims to review recent developments, summarize the evidence, indications and limitations of the available systems, and provide a glimpse into the future of transcatheter interventions for the treatment of mitral and tricuspid valve disease.

Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

Better Myocardial Function in Aortic Stenosis with Low Left Ventricular Mass: A Mechanism of Protection against Heart Failure Regardless of Stenosis Severity?

About one-tenth to one-third of patients with severe aortic stenosis (AS) do not develop left ventricular hypertrophy (LVH). Intriguingly, the absence of LVH despite severe AS is associated with lower prevalence of heart failure (HF), which challenges the classical notion of LVH as a beneficial compensatory response. Notably, the few studies that have attempted to characterize AS subjects with inadequately low left ventricular (LV) mass relative to LV afterload (i-lowLVM) described better prognosis and enhanced LV performance in AS associated with i-lowLVM, but those reports were limited to severe AS. Our aim was to compare myocardial function between moderate and severe AS with i-lowLVM. We retrospectively analyzed in-hospital records of 225 clinically stable nondiabetic patients with isolated moderate or severe degenerative AS in sinus rhythm, free of coexistent diseases. Subjects with i-lowLVM were compared to those with appropriate or excessive LVM (a/e-LVM), defined on the basis of the ratio of a measured LVM to the LVM predicted from an individual hemodynamic load. Patients with i-lowLVM and a/e-LVM did not differ in aortic valve area, LV end-diastolic diameter (LVd, a measure of LV preload), and circumferential end-systolic LV wall stress (cESS), an estimate of LV afterload. Compared to a/e-LVM, patients with i-lowLVM had increased LV ejection fraction (EF) and especially higher LV midwall fractional shortening (a better index of LV myocardial function than EF in concentric LV geometry) (p < 0.001–0.01), in both moderate and severe AS. LVd and cESS were similar in the four subgroups of the study subjects, i.e., moderate AS with i-lowLVM, moderate AS with a/e-LVM, severe AS with i-lowLVM, and severe AS with a/e-LVM (p > 0.6). Among patients with i-lowLVM, LVM did not differ significantly between moderate and severe AS (p > 0.4), while in those with a/e-LVM, LVM was increased in severe versus moderate AS (p < 0.001). In conclusion, the association of the low-LVM phenotype with better myocardial contractility may already develop in moderate AS. Additionally, cESS appears to be a controlled variable, which is kept constant over AS progression irrespective of LVM category, but even when controlled (by increasing LVM), is not able to prevent deterioration of LV function. Whether improved myocardial performance contributes to favorable prognosis and the preventive effect against HF in AS without LVH, remains to be studied.

Going beyond classic echo in aortic stenosis: left atrial mechanics, a new marker of severity

BACKGROUND

There is limited information regarding left atrial (LA) mechanics in aortic valve stenosis (AS). We assessed LA mechanics in AS through speckle-tracking echocardiography (STE) according to severity and prognosis.

METHODS

We included 102 patients diagnosed with severe AS (sAS) and 80 patients with moderate AS (mAS), all with preserved ejection fraction and no coronary artery disease. LA mechanics and left ventricular global longitudinal strain (LV-GLS) were assessed by STE. The cohort was followed-up for a median of 30 (IQR 12.6-50) months, and outcomes were determined (combined outcome of HF, death, and aortic valve replacement).

RESULTS

In our sample set, values of LV-GLS (- 18.5% vs - 17.1, p = 0.025), E/e' ratio (15.8 vs 18.4, p = 0.03), and global LA mechanics (LA ɛsys, 23% vs 13.8%, p < 0.001) were worse for sAS compared to those for mAS. However, LA ɛsys (AUC 0.85, 95% CI 0.78-0.90, p < 0.001), ɛe (AUC 0.83, 95% CI 0.75-0.88, p < 0.001), and ɛa (AUC 0.80, 95% CI 0.70-0.84, p < 0.001) were the best discriminators of sAS, with sensitivities higher than 85%. LA ɛsys showed a stronger correlation with both aortic valve area (r² = 0.6, p < 0.001) and mean LV/aortic gradient (r² = 0.55, p < 0.001) than LV-GLS (r² = 0.3 and r² = 0.25, p = 0.01). Either LV-GLS or LA ɛsys, but not the E/e' ratio, TAPSE, or RV/RA gradient, were a significant predictors of the combined outcome.

CONCLUSIONS

LA global strain was the best discriminator of severity, surpassing E/e' ratio and LV-GLS, and a significant predictor of prognosis in AS.

Percutaneous Mitral Edge-to-Edge Repair: State of the Art and a Glimpse to the Future

Patients with severe symptomatic mitral regurgitation have a poor prognosis if left untreated. In those patients who are not eligible for mitral valve surgery, percutaneous edge-to-edge repair may improve clinical outcomes. Recent clinical trials have added to our knowledge and provide interesting insights into the management of such patients. With an increasingly aging global population, these technologies are likely to represent an important treatment option. This mini-review will examine the technology, the evidence and the latest developments in percutaneous mitral edge-to-edge repair.

Depressed systemic arterial compliance and impaired left ventricular midwall performance in aortic stenosis with concomitant type 2 diabetes: a retrospective cross-sectional study

Background

Degenerative aortic stenosis (AS), a disease of the elderly, frequently coexists with concomitant diseases, including type 2 diabetes (T2DM) which amplifies the cardiovascular (CV) risk. T2DM affects left ventricular (LV) structure and function via hemodynamic and metabolic factors. In concentric LV geometry, typical for AS, indices of LV midwall mechanics are better estimates of LV function than ejection fraction (EF). Effects of T2DM coexisting with AS on circumferential LV midwall systolic function and large artery properties have not been reported so far. Our aim was to compare characteristics of AS patients with and without T2DM, with a focus on LV midwall systolic function and arterial compliance.

Methods

Medical records of 130 electively hospitalized patients with moderate or severe isolated degenerative AS were retrospectively analyzed. Exclusion criteria included clinical instability, atrial fibrillation, coronary artery disease and relevant non-cardiac diseases. From in-hospital echocardiography and blood pressure, we calculated LV midwall fractional shortening (mwFS), circumferential end-systolic LV wall stress (cESS) and valvulo-arterial impedance (Zva), estimates of LV afterload, as well as systemic arterial compliance.

Results

Patients with (n = 50) and without T2DM (n = 80) did not differ in age, AS severity, LV mass and LV diastolic diameter. T2DM patients exhibited elevated cESS (247 ± 105 vs. 209 ± 84 hPa, p = 0.025) and Zva (5.8 ± 2.2 vs. 5.1 ± 1.8 mmHg per mL/m², p = 0.04), and lower stroke volume index (33 ± 10 vs. 38 ± 12 mL/m², p = 0.01) and systemic arterial compliance (0.53 ± 0.16 vs. 0.62 ± 0.22 mL/m² per mmHg, p = 0.01). mwFS (11.9 ± 3.9 vs. 14.1 ± 3.7%, p = 0.001), but not EF (51 ± 14 vs. 54 ± 13%, p = n.s.), was reduced in T2DM. mwFS and cESS were inversely interrelated in patients both with (r = − 0.59, p < 0.001) and without T2DM (r = − 0.53, p < 0.001) By multiple regression, higher cESS (p < 0.001) and T2DM (p = 0.02) were independent predictors of depressed mwFS.

Conclusions

In AS, coexistent T2DM appears associated with reduced systemic arterial compliance and LV dysfunction at the midwall level, corresponding to slightly depressed myocardial contractility.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0894-1) contains supplementary material, which is available to authorized users.

Association of Inadequately Low Left Ventricular Mass with Enhanced Myocardial Contractility in Severe Degenerative Aortic Stenosis

Background: Left ventricular hypertrophy (LVH), traditionally considered an adaptive mechanism that is aimed at the maintenance of LV systolic function, is absent in 10%–35% of patients with severe aortic stenosis (AS). Our aim was to estimate the clinical and hemodynamic characteristics in patients with severe AS and absent LVH, or inadequately low LV mass (i-lowLVM) relative to an individual hemodynamic load. Methods: We retrospectively analyzed in-hospital records of 100 patients with pure severe degenerative AS, preserved LV systolic function and without relevant coexistent diseases, except for well-controlled hypertension or diabetes. Results: Clinical characteristics were similar in patients with and without LVH, as well as those with and without i-lowLVM, except for slightly lower GFR at i-lowLVM. When compared to their counterparts, subjects without LVH or with i-lowLVM had smaller LV cavities, decreased LV wall thicknesses and higher EF. There were no significant differences in stenosis severity and indices of afterload (valvulo-arterial impedance and circumferential end-systolic LV wall stress), according to the presence or absence of either LVH or i-lowLVM. However, LV fractional shortening at the midwall level was elevated only in patients with i-lowLVM, but not in those without LVH, compared to the remainder (15.8 ± 3.3 vs. 12.9 ± 3.2%, p < 0.001 for those with and without i-lowLVM, respectively; 13.7 ± 3.7 vs. 13.8 ± 3.6% for LVH presence and absence, p = 0.9). Conclusions: Inadequately low LVM relative to the individual hemodynamic load could potentially reflect a different mode of the LV response to severe AS, associated with enhanced load-independent LV systolic performance, i.e., better LV contractility. If confirmed in a large series of patients, our small preliminary study may add to the possible mechanisms of a previously reported counterintuitive tendency of a lower, not higher, risk of adverse outcome in patients with low LV mass despite severe AS. Prospective studies are warranted, in order to determine a potential utility of LVM inadequacy in the risk stratification of patients with AS.

Increased risk profile in the treatment of patients with symptomatic degenerative aortic valve stenosis over the last 10 years

Introduction

Currently, Cardiology Centres are overfilled with patients with degenerative aortic valve stenosis (DAS), usually eldery, with severe concommittant comorbidities, who are referred for further decisions and possible intervention.

Aim

To evaluate changes in the risk profile of patients with severe DAS admitted to the cardiology department a decade ago compared with patients currently being admitted.

Material and methods

We retrospectively evaluated all patients admitted with confirmed severe DAS, hospitalized during 2005-2006 (group I: 140 patients) and in 2016 (group II: 152 patients), admitted for aortic valve intervention. A standard transthoracic echocardiogram, cardiovascular symptom and risk factor distribution, perioperative risk with the logistic EuroSCORE II and STS mortality scores were obtained.

Results

Patients in group II were significantly older (p < 0.001), had more cardiovascular risk factors, and more often presented with atrial fibrillation (27% vs. 11.4%, p = 0.001), renal impairment (34.9% vs. 22.8%; p = 0.024), severe lung disease (17.1% vs. 2.1%, p < 0.001), and extracardiac arteriopathy (40.1% vs. 17.8%, p < 0.001). The aortic valve area (AVA) (p = 0.356), mean-transvalvular pressure gradient (p = 0.215), and left ventricular ejection fraction (p = 0.768) were similar in both groups. However, the prevalence of pulmonary hypertension, severe mitral regurgitation, and low-flow, low-gradient DAS were 3.1-, 8.4- and 1.84-fold more frequent in group II than group I. The percentages of subjects with EuroSCORE II and STS scores ≥ 4% in 2005-2006 were 7.1% and 6.4%, as compared to 27% and 26.3% in 2016 (both p < 0.001). 22% of patients in 2016, as compared to 31% in 2005/2006, were considered ineligible for DAS intervention.

Conclusions

In just a decade, the risk profile of patients admitted with DAS has increased hugely, mainly due to older age, accumulation of comorbidities and more advanced disease at presentation. Although transcatheter aortic valve intervention has expanded the indications for intervention in high-risk patients, the number of patients disqualified from interventional treatment remains high.