Contemporary Management of Severe Symptomatic Aortic Stenosis

A Multimodal Video-Based AI Biomarker for Aortic Stenosis Development and Progression

Importance

Aortic stenosis (AS) is a major public health challenge with a growing therapeutic landscape, but current biomarkers do not inform personalized screening and follow-up. A video-based artificial intelligence (AI) biomarker (Digital AS Severity index [DASSi]) can detect severe AS using single-view long-axis echocardiography without Doppler characterization.

Objective

To deploy DASSi to patients with no AS or with mild or moderate AS at baseline to identify AS development and progression.

Design, Setting, and Participants

This is a cohort study that examined 2 cohorts of patients without severe AS undergoing echocardiography in the Yale New Haven Health System (YNHHS; 2015-2021) and Cedars-Sinai Medical Center (CSMC; 2018-2019). A novel computational pipeline for the cross-modal translation of DASSi into cardiac magnetic resonance (CMR) imaging was further developed in the UK Biobank. Analyses were performed between August 2023 and February 2024.

Exposure

DASSi (range, 0-1) derived from AI applied to echocardiography and CMR videos.

Main Outcomes and Measures

Annualized change in peak aortic valve velocity (AV-Vmax) and late (>6 months) aortic valve replacement (AVR).

Results

A total of 12 599 participants were included in the echocardiographic study (YNHHS: n = 8798; median [IQR] age, 71 [60-80] years; 4250 [48.3%] women; median [IQR] follow-up, 4.1 [2.4-5.4] years; and CSMC: n = 3801; median [IQR] age, 67 [54-78] years; 1685 [44.3%] women; median [IQR] follow-up, 3.4 [2.8-3.9] years). Higher baseline DASSi was associated with faster progression in AV-Vmax (per 0.1 DASSi increment: YNHHS, 0.033 m/s per year [95% CI, 0.028-0.038] among 5483 participants; CSMC, 0.082 m/s per year [95% CI, 0.053-0.111] among 1292 participants), with values of 0.2 or greater associated with a 4- to 5-fold higher AVR risk than values less than 0.2 (YNHHS: 715 events; adjusted hazard ratio [HR], 4.97 [95% CI, 2.71-5.82]; CSMC: 56 events; adjusted HR, 4.04 [95% CI, 0.92-17.70]), independent of age, sex, race, ethnicity, ejection fraction, and AV-Vmax. This was reproduced across 45 474 participants (median [IQR] age, 65 [59-71] years; 23 559 [51.8%] women; median [IQR] follow-up, 2.5 [1.6-3.9] years) undergoing CMR imaging in the UK Biobank (for participants with DASSi ≥0.2 vs those with DASSi <.02, adjusted HR, 11.38 [95% CI, 2.56-50.57]). Saliency maps and phenome-wide association studies supported associations with cardiac structure and function and traditional cardiovascular risk factors.

Conclusions and Relevance

In this cohort study of patients without severe AS undergoing echocardiography or CMR imaging, a new AI-based video biomarker was independently associated with AS development and progression, enabling opportunistic risk stratification across cardiovascular imaging modalities as well as potential application on handheld devices.

A Multimodality Video-Based AI Biomarker For Aortic Stenosis Development And Progression

Importance

Aortic stenosis (AS) is a major public health challenge with a growing therapeutic landscape, but current biomarkers do not inform personalized screening and follow-up.

Objective

A video-based artificial intelligence (AI) biomarker (Digital AS Severity index [DASSi]) can detect severe AS using single-view long-axis echocardiography without Doppler. Here, we deploy DASSi to patients with no or mild/moderate AS at baseline to identify AS development and progression.

Design Setting and Participants

We defined two cohorts of patients without severe AS undergoing echocardiography in the Yale-New Haven Health System (YNHHS) (2015-2021, 4.1[IQR:2.4-5.4] follow-up years) and Cedars-Sinai Medical Center (CSMC) (2018-2019, 3.4[IQR:2.8-3.9] follow-up years). We further developed a novel computational pipeline for the cross-modality translation of DASSi into cardiac magnetic resonance (CMR) imaging in the UK Biobank (2.5[IQR:1.6-3.9] follow-up years). Analyses were performed between August 2023-February 2024.

Exposure

DASSi (range: 0-1) derived from AI applied to echocardiography and CMR videos.

Main Outcomes and Measures

Annualized change in peak aortic valve velocity (AV-Vmax) and late (>6 months) aortic valve replacement (AVR).

Results

A total of 12,599 participants were included in the echocardiographic study (YNHHS: n=8,798, median age of 71 [IQR (interquartile range):60-80] years, 4250 [48.3%] women, and CSMC: n=3,801, 67 [IQR:54-78] years, 1685 [44.3%] women). Higher baseline DASSi was associated with faster progression in AV-Vmax (per 0.1 DASSi increments: YNHHS: +0.033 m/s/year [95%CI:0.028-0.038], n=5,483, and CSMC: +0.082 m/s/year [0.053-0.111], n=1,292), with levels ≥ vs <0.2 linked to a 4-to-5-fold higher AVR risk (715 events in YNHHS; adj.HR 4.97 [95%CI: 2.71-5.82], 56 events in CSMC: 4.04 [0.92-17.7]), independent of age, sex, ethnicity/race, ejection fraction and AV-Vmax. This was reproduced across 45,474 participants (median age 65 [IQR:59-71] years, 23,559 [51.8%] women) undergoing CMR in the UK Biobank (adj.HR 11.4 [95%CI:2.56-50.60] for DASSi ≥vs<0.2). Saliency maps and phenome-wide association studies supported links with traditional cardiovascular risk factors and diastolic dysfunction.

Conclusions and Relevance

In this cohort study of patients without severe AS undergoing echocardiography or CMR imaging, a new AI-based video biomarker is independently associated with AS development and progression, enabling opportunistic risk stratification across cardiovascular imaging modalities as well as potential application on handheld devices.

Living in disadvantaged neighborhoods linked to less intervention for severe aortic stenosis

To investigate the association between area deprivation index (ADI) and aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Patients aged 40-95 years with severe AS confirmed by echocardiography were included. The 9-digit zip code of patient residence address was used to identify the ADI ranking, based on which patients were divided into 5 groups (with Group E being most deprived). The rates of AV intervention were compared among 5 groups using competing risks analysis, with death as a competing event. We included 1751 patients with severe AS from 2013 to 2018 followed for a median 2.8 (interquartile range, 1.5-4.8) years. The more distressed ADI groups tended to be younger (P = 0.002), female (P < 0.001), and of African American race (P < 0.001), have higher presentation of sepsis (P = 0.031), arrhythmia (P = 0.022), less likely to have previous diagnosis of AS (P < 0.001); and were less likely to undergo AVR (52.5% vs 46.9% vs 46.1% vs 48.9% vs 39.7%, P = 0.023). Using competing risk analysis, the highest ADI group (E) were the least and the lowest ADI group (A) the most likely to undergo AVR (Gray's test, P = 0.025). The association between ADI ranking and AVR rates was influenced by sex and race. Within group analysis, there was significant association between race and AVR (Gray's test, P < 0.001), and between sex and AVR (Gray's test, P < 0.001). Patients with severe AS living in more deprived neighborhoods were less likely to undergo aortic valve interventions, which was influenced by female gender, and African American race.

Electrocardiography versus Echocardiography in Severe Aortic Stenosis with the Consideration of Coexistent Coronary Artery Disease

(1) Background: Coexistent coronary artery disease (CAD) might influence the ability of electrocardiogram (ECG) to identify echocardiographic left ventricular hypertrophy (ECHO-LVH) in patients with aortic stenosis (AS). We aimed to assess the relation between ECG-LVH (by the Sokolov-Lyon or Cornell criteria) and ECHO-LVH considering coexistent CAD. (2) Methods: We retrospectively analyzed the medical records of 74 patients (36 males) with severe AS who were hospitalized in the University Hospital in Cracow from 2021 to 2022. (3) Results: ECHO-LVH was present in 49 (66%) patients, whereas 35 (47.3%) patients had ECG-LVH. There was no difference between the rate of ECG-LVH in patients with vs. without ECHO-LVH. Single-vessel and multi-vessel CAD were diagnosed by invasive coronary angiography in 18% and 11% of patients, respectively. The sensitivity of the classical ECG-LVH criteria with regard to ECHO-LVH was low, reaching at best 41% for the Sokolov-Lyon and Cornell criteria. The results were similar and lacked a pattern when considering patients without significant stenosis, with single- and multi-vessel disease separately. Correlations between the left ventricular mass index and ECG-derived parameters were weak and present solely for the Lewis index (r = 0.31), R wave's amplitude >1.1 mV in aVL (r = 0.36), as well as the Cornell (r = 0.32) and Sokolov-Lyon (r = 0.31) voltage criteria (p < 0.01). The presence, location of stenoses, and CAD extent were not associated with the presence of either ECHO-LVH or ECG-LVH, irrespective of individual ECG-LVH criteria. (4) Conclusions: The sensitivity of classical ECG criteria for echocardiographic LVH in severe AS is low, regardless of coexistent CAD or its angiographic extent.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Usefulness of the N-Terminal of the Prohormone Brain Natriuretic Peptide in Predicting Acute Kidney Injury Requiring Renal Replacement Therapy in Patients Undergoing Heart Valve Surgery

Background and Objectives: By definition, acute kidney injury (AKI) is a clinical syndrome diagnosed when the increase in serum creatinine concentration is >0.3 mg/dL in 48 h or >1.5-fold in the last seven days or when diuresis < 0.5 mL/kg/h for a consecutive 6 h. AKI is one of the severe complications that may occur in the early postoperative period in patients undergoing heart valve surgery, significantly increasing the risk of death. Early implementation of renal replacement therapy increases the chances of improving treatment results in patients with postoperative AKI. The study assessed the predictive ability of selected preoperative and perioperative parameters for the occurrence of postoperative AKI requiring renal replacement therapy in the early postoperative period in a group of patients with severe valvular heart disease. Materials and Methods: A prospective study was conducted on a group of patients undergoing consecutive heart valve surgeries. The primary endpoint was postoperative AKI requiring renal replacement therapy. AKI was diagnosed with an increase in serum creatinine > 0.3 mg/dL in 48 h or >1.5-fold in the previous 7 days and/or a decrease in diuresis < 0.5 mL/kg/h for 6 h. The observation period was until the patient was discharged home or death occurred. Logistic regression analysis was used to assess which variables were predictive of primary endpoint, and odds ratios (OR) were calculated with a 95% confidence interval (CI). Multivariate analysis was based on the result of single factor logistic regression, i.e., to further steps, all statistically significant variables were taken into consideration. Results: A total of 607 patients were included in the study. The primary endpoint occurred in 50 patients. At multivariate analysis: NT-proBNP (OR 1.406; 95% CI 1.015-1.949; p = 0.04), CRP (OR 1.523; 95% CI 1.171-1.980; p = 0.001), EuroSCORE II (OR 1.090; 95% CI 1.014-1.172; p = 0.01), age (OR 1.037; 95% CI 1.001-1.075; p = 0.04) and if they stayed in the intensive care unit longer than 2 days (OR 9.077; 95% CI 2.026-40.663; p = 0.004) remained the independent predictors of the primary endpoint. The mean preoperative NT-proBNP level was 2063 pg/mL (±1751). Thirty-eight patients with AKI requiring renal replacement therapy died in intrahospital follow-up. Conclusions: The results of the presented study indicate that a high preoperative level of NT-proBNP and postoperative hemodynamic instability may be associated with a significant risk of a postoperative AKI requiring renal replacement therapy. The results of the study may also suggest that qualifying for heart valve surgery earlier may be associated with improved prognosis in this group of patients.

First description and validation of a new method for estimating aortic stenosis burden and predicting the functional response to TAVI

Background

Up to one-fifth of patients continue to have poor quality of life after transcatheter aortic valve implantation (TAVI), with an additional similar proportion not surviving 1 year after the procedure. We aimed to assess the value of a new method based on an integrated analysis of left ventricular outflow tract flow velocity and aortic pressure to predict objective functional improvement and prognosis after TAVI.

Methods

In a cohort of consecutive patients undergoing TAVI, flow velocity-pressure integrated analysis was obtained from simultaneous pressure recordings in the ascending aorta and flow velocity recordings in the left ventricular outflow tract by echocardiography. Objective functional improvement 6 months after TAVI was assessed through changes in a 6-min walk test and NT-proBNP levels. A clinical follow-up was conducted at 2 years.

Results

Of the 102 patients studied, 82 (80.4%) showed objective functional improvement. The 2-year mortality of these patients was significantly lower (9% vs. 44%, p = 0.001). In multivariate analysis, parameter "(Pressure at Vmax - Pressure at Vo)/Vmax" was found to be an independent predictor for objective improvement. The C-statistic was 0.70 in the overall population and 0.78 in the low-gradient subgroup. All echocardiographic parameters and the valvuloarterial impedance showed a C-statistic of <0.6 for the overall and low-gradient patients. In a validation cohort of 119 patients, the C-statistic was 0.67 for the total cohort and 0.76 for the low-gradient subgroup.

Conclusion

This new method allows predicting objective functional improvement after TAVI more precisely than the conventional parameters used to assess the severity of aortic stenosis, particularly in low-gradient patients.

Severe aortic stenosis detection by deep learning applied to echocardiography

BACKGROUND AND AIMS

Early diagnosis of aortic stenosis (AS) is critical to prevent morbidity and mortality but requires skilled examination with Doppler imaging. This study reports the development and validation of a novel deep learning model that relies on two-dimensional (2D) parasternal long axis videos from transthoracic echocardiography without Doppler imaging to identify severe AS, suitable for point-of-care ultrasonography.

METHODS AND RESULTS

In a training set of 5257 studies (17 570 videos) from 2016 to 2020 [Yale-New Haven Hospital (YNHH), Connecticut], an ensemble of three-dimensional convolutional neural networks was developed to detect severe AS, leveraging self-supervised contrastive pretraining for label-efficient model development. This deep learning model was validated in a temporally distinct set of 2040 consecutive studies from 2021 from YNHH as well as two geographically distinct cohorts of 4226 and 3072 studies, from California and other hospitals in New England, respectively. The deep learning model achieved an area under the receiver operating characteristic curve (AUROC) of 0.978 (95% CI: 0.966, 0.988) for detecting severe AS in the temporally distinct test set, maintaining its diagnostic performance in geographically distinct cohorts [0.952 AUROC (95% CI: 0.941, 0.963) in California and 0.942 AUROC (95% CI: 0.909, 0.966) in New England]. The model was interpretable with saliency maps identifying the aortic valve, mitral annulus, and left atrium as the predictive regions. Among non-severe AS cases, predicted probabilities were associated with worse quantitative metrics of AS suggesting an association with various stages of AS severity.

CONCLUSION

This study developed and externally validated an automated approach for severe AS detection using single-view 2D echocardiography, with potential utility for point-of-care screening.

Risk Factors of Postoperative Hospital-Acquired Pneumonia in Patients Undergoing Cardiac Surgery

Background and Objectives. Hospital-acquired pneumonia is one of the complications that may occur in the postoperative period in patients undergoing heart valve surgery, which may result in prolonged hospitalization, development of respiratory failure requiring mechanical ventilation or even death. This study investigated the preoperative risk factors of postoperative pneumonia after heart valve surgery. Materials and Methods: This was a prospective study in a group of consecutive patients with hemodynamically significant valvular heart disease undergoing valve surgery. The primary endpoint at the in-hospital follow-up was hospital-acquired pneumonia after heart valve surgery. Logistic regression analysis was used to assess which variables were predictive of the primary endpoint, and odds ratios (ORdis) were calculated with a 95% confidence interval (CI). Multivariate analysis was based on the results of single-factor logistic regression, i.e., in further steps all statistically significant variables were taken into consideration. Results: The present study included 505 patients. Postoperative pneumonia occurred in 23 patients. The mean time to diagnosis of pneumonia was approximately 3 days after heart valve surgery (±2 days). In multivariate analysis, preoperative level of high-sensitivity Troponin T (hs-TnT) (OR 2.086; 95% CI 1.211-3.593; p = 0.008) and right ventricular systolic pressure (RVSP) (OR 1.043; 95% CI 1.018-1.067; p 0.004) remained independent predictors of the postoperative pneumonia. Of the patients with postoperative pneumonia, 3 patients died due to the development of multiple organ dysfunction syndrome (MODS). Conclusions: Preoperative determination of serum hs-TnT concentration and echocardiographic measurement of the RVSP parameter may be useful in predicting postoperative pneumonia in patients undergoing heart valve surgery.

Patterns of Aortic Valve Replacement in Europe: Adoption by Age

INTRODUCTION

The management of patients with severe aortic stenosis may differ according to patients' age. The aim of this analysis was to describe patterns of aortic valve replacement (AVR) use in European countries stratified by age.

METHODS

Procedure volume data for AVR, including surgical aortic valve replacement (sAVR) and transcatheter aortic valve implantation (TAVI), for the years 2015-2020 were obtained from national databases for twelve European countries (Austria, the Czech Republic, Denmark, England, Finland, France, Germany, Norway, Poland, Spain, Sweden, and Switzerland). Procedure volumes were reported by patient age (<50 years, 5-year age groups between 50 and 85 years, and ≥85 years). Patients per million (PPM) population undergoing AVR each year were calculated using population estimates from Eurostat.

RESULTS

AVR PPM varied widely between countries, from 508 PPM in Germany to 174 PPM in Poland in 2020. TAVI rates ranged from 61% in Switzerland and Finland to 25% in Poland. AVR PPM increased with age to a peak at 80-84 years, after which it decreased again. AVR procedures increased from 2015 to 2019 at an average annual rate of 3.9%. AVR increased more substantially in people aged ≥80 years than in younger age groups; these older age groups accounted for 30% of all AVR procedures in 2015 and 35% in 2019. TAVI accounted for an increasing proportion of all AVR procedures as patient age increased; an overall average of 96% of males and 98% of females aged ≥85 years received TAVI as the treatment modality, although adoption of TAVI differed between countries.

CONCLUSIONS

There is considerable variation in the rates of AVR use and the adoption of TAVI versus sAVR between European countries. The use of TAVI has increased in recent years, particularly for older patients.

Impact of severe aortic stenosis on quality of life

INTRODUCTION

Among individuals ≥ 65 years old, aortic stenosis is highly prevalent and the number of cases is expected to increase in the coming decades, due to the increased life expectancy. Nevertheless, the actual aortic stenosis burden is not well known in population settings and the impact of aortic stenosis on quality of life has not been studied. The aim of this study was to evaluate aortic stenosis impact on health-related quality of life in patients > 65 years old.

METHODS

An epidemiological case-control study was carried out to compare quality of life in patients ≥65 years old with severe symptomatic aortic stenosis. Demographical and clinical information was prospectively obtained and quality of life information was collected with the Short Form Health Survey_v2 (SF-12) questionnaire. The association between quality of life and aortic stenosis was determined using multiple logistic regression models.

RESULTS

Patients with severe aortic stenosis self-perceived worse quality of life on all dimensions and summary components of the SF-12 questionnaire. In the final multiple logistic regression model a significant inverse association was observed between the dimensions 'physical role' and 'social role' (p = 0.002 and p = 0.005) and an association close to significance with 'physical role' (p = 0.052) of the SF-12 questionnaire.

CONCLUSION

The use of quality of life scales allows the assessment of the impact of aortic stenosis on quality of life and may improve the therapeutic approach to severe aortic stenosis, providing evidence for patient-centered care.

Invasive management of significant tricuspid regurgitation in clinical practice

BACKGROUND

Tricuspid regurgitation (TR) is a prevalent condition inside valvular heart disease (VHD) with relevant prognosis implications. However, concordance between real management in clinical practice and invasive treatment recommendations of European Society of Cardiology (ESC) guidelines is unknown.

METHODS

A substudy of ESC VHD II survey was performed to evaluate the real treatment of TR compared to the clinical ESC guidelines recommendations published in 2012, 2017 and 2021 was performed. TR cases with surgical indication were divided in 3 groups: 1: severe isolated TR without previous left VHD; 2: moderate/severe TR and concomitant severe left VHD; 3: severe TR plus previous left VHD surgery.

RESULTS

Of 902 patients assessed, 123 had significant TR. Fifty (41%) cases demonstrated ESC guidelines 2012-2017 Class I or IIa recommendations for invasive treatment: 9(18%) of group 1, 37(74%) of group 2 and 4(8%) of group 3. Surgery was performed in 24 patients (48%); 1 in group 1(4%), 22 in group 2(92%) and 1 in group 3(4%). Overall concordance was 48% (group 1: 11%; group 2: 59%; group 3: 25%). Regarding the 2021 ESC guidelines only one patient changed groups with an overall concordance of 47% (group 1: 10%; group 2: 59%; group 3: 25%).

CONCLUSION

Concordance between 2012, 2017 and 2021 ESC guidelines recommendations and clinical practice for TR surgical intervention is low, especially in those without concomitant severe left VHD. These results suggest the need to improve further guideline implementation and alternative treatments, such as percutaneous, which could resolve potential discrepancies in those clinical scenarios.

A new integrative approach to assess aortic stenosis burden and predict objective functional improvement after TAVR

Background

A non-negligible rate of patients undergoing transcatheter aortic valve replacement (TAVR) do not report symptomatic improvement or even die in the short-midterm. We sought to assess the degree of objective functional recovery after TAVR and its prognostic implications and to develop a predictive model.

Methods

In a cohort of patients undergoing TAVR, a prospective evaluation of clinical, anatomical, and physiological parameters was conducted before and after the procedure. These parameters were derived from echocardiography, non-invasive analysis of arterial pulse waves, and cardiac tomography. Objective functional improvement 6 months after TAVR was assessed using a 6-min walk test and nitro-terminal pro-brain natriuretic peptide (NT-proBNP) levels. The derived predictive model was prospectively validated in a different cohort. A clinical follow-up was conducted at 2 years.

Results

Among the 212 patients included, objective functional improvement was observed in 169 patients (80%) and subjective improvement in 187 (88%). Patients with objective functional improvement showed a much lower death rate at 2 years (9% vs. 31% p = 0.0002). Independent predictors of improvement were as follows: mean aortic gradient of ≥40 mmHg, augmentation index₇₅ of ≥45%, the posterior wall thickness of ≤12 mm, and absence of atrial fibrillation. A simple integer-based point score was developed (GAPA score), which showed an area under the curve of 0.81 for the overall cohort and 0.78 for the low-gradient subgroup. In a validation cohort of 216 patients, these values were 0.75 and 0.76, respectively.

Conclusion

A total of 80% of patients experienced objective functional improvement after TAVR, showing a significantly lower 2-year mortality rate. A predictive score was built that showed a good discriminative performance in overall and low-gradient populations.

Budget impact analysis of a bovine pericardial aortic bioprosthesis versus mechanical aortic valve replacement in adult patients with aortic stenosis in Romania

AIMS

An analysis of the budget impact of using a bovine pericardial aortic bioprosthesis (BPAB) or a mechanical valve (MV) in aortic stenosis (AS) patients in Romania.

MATERIALS AND METHODS

A decision-tree with a partitioned survival model was used to predict the financial outcomes of using either a BPAB (the Carpentier-Edwards Perimount Magna Ease Valve) or MV in aortic valve replacement (AVR) procedure over a 5-year period. The budget impact of various resource consumption including disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments were compared for both types of valves. One-way sensitivity analyses (OWSA) were conducted on the input costs and probabilities.

RESULTS

The use of BPAB compared to MV approaches budget neutrality due to incremental savings year-on-year. The initial surgical procedure and reoperation costs for BPAB are offset by savings in acenocoumarol use, disabling strokes, major bleeding, minor thromboembolic events, and anticoagulation complications. The cost of the initial procedure per patient is 460 euros higher for a BPAB due to the higher valve acquisition cost, although this is partially offset by a shorter hospital stay. The OWSA shows that the total procedure costs, including the hospital stay, are the primary cost drivers in the model.

LIMITATIONS

Results are limited by cost data aggregation in the DRG system, exclusion of costs for consumables and capital equipment use, possible underestimation of outpatient complication costs, age-related variations of event rates, and valve durability.

CONCLUSIONS

Adopting BPAB as a treatment option for AS patients in Romania can lead to cost savings and long-term economic benefits. By mitigating procedure costs and increasing anticoagulation treatment costs, BPAB offers a budget-neutral option that can help healthcare providers, policymakers, and patients alike manage the growing burden of AS in Romania.

The Role of the N-Terminal of the Prohormone Brain Natriuretic Peptide in Predicting Postoperative Multiple Organ Dysfunction Syndrome

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is the progressive and potentially reversible dysfunction of at least two organ systems in the course of an acute and life-threatening disorder of systemic homeostasis. MODS is a serious post-cardiac-surgery complication in valvular heart disease that is associated with a high risk of death. This study assessed the predictive ability of selected preoperative and perioperative parameters for the occurrence of MODS in the early postoperative period in a group of patients with severe valvular heart disease.

METHODS

Subsequent patients with significant symptomatic valvular heart disease who underwent cardiac surgery were recruited in the study. The main end-point was postoperative MODS, defined as a dysfunction of at least two organs-perioperative stroke, heart failure requiring mechanical circulatory support, respiratory failure requiring mechanical ventilation, and postoperative acute kidney injury requiring renal replacement therapy. A logistic regression was used to assess relationships between variables.

RESULTS

There were 602 patients recruited for this study. The main end-point occurred in 40 patients. Preoperative NT-proBNP (OR 1.026; 95% CI 1.012-1.041; p = 0.001) and hemoglobin (OR 0.653; 95% CI 0.503-0.847; p = 0.003) are independent predictors of the primary end-point in a multivariate regression analysis. The cut-off point for the NT-proBNP value for postoperative MODS was calculated at 1300 pg/mL.

CONCLUSIONS

A high preoperative level of NTpro-BNP may be associated with the onset of MODS in the early postoperative period. The results of the study may also suggest that earlier cardiac surgery for significant valvular heart disease may be associated with an improved prognosis in this group of patients.

N-Terminal of the Prohormone Brain Natriuretic Peptide Predicts Postoperative Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

Aims: Heart valve surgery is associated with a risk of serious postoperative complications including postoperative cardiogenic shock (described as postcardiotomy shock (PCS)). The indication for extracorporeal membrane oxygenation (ECMO) is cardiogenic shock, which is resistant to optimal causal and pharmacological treatment, including the supply of catecholamines and/or an intra-aortic balloon pump (IABP). The aim of this study was to assess the usefulness of the selected preoperative biomarkers in the prediction of postoperative cardiogenic shock requiring ECMO in patients undergoing heart valve surgery. Methods: A prospective study was conducted on a group of consecutive patients with significant valvular heart disease that underwent elective valve surgery. The primary endpoint at the intra-hospital follow-up was postoperative cardiogenic shock requiring ECMO. Univariate analysis, followed by multivariate regression analysis, were performed. Results: The study included 610 patients. The primary endpoint occurred in 15 patients. At multivariate analysis, the preoperative N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) level (OR 1.022; 95% CI 1.011–1.034; p = 0.001) remained an independent predictor of the primary endpoint. Conclusions: An elevated NT-proBNP level was associated with a higher risk of postoperative cardiogenic shock requiring the use of ECMO.

What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making

Background

Guidelines recommend including the patient’s values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS.

Methods

This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients’ most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters.

Results

51 adults with sAS and 3 caregivers with experience choosing treatment (age 36–92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making.

Conclusions

These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients’ value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients’ priorities.

Trial registration

ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.

Strategies for Facilitating Totally Percutaneous Transfemoral TAVR Procedures

Transcatheter aortic valve replacement (TAVR) has transformed the treatment of aortic stenosis and should ideally be performed as a totally percutaneous procedure via the transfemoral (TF) approach. Peripheral vascular disease may impede valve delivery, and vascular access site complications are associated with adverse clinical outcome and increased mortality. We review strategies aimed to facilitate TF valve delivery in patients with hostile vascular anatomy and achieve percutaneous management of vascular complications.