Acute Heart Valve Emergencies

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

The future of valvular heart disease assessment and therapy

Valvular heart disease (VHD) is becoming more prevalent in an ageing population, leading to challenges in diagnosis and management. This two-part Series offers a comprehensive review of changing concepts in VHD, covering diagnosis, intervention timing, novel management strategies, and the current state of research. The first paper highlights the remarkable progress made in imaging and transcatheter techniques, effectively addressing the treatment paradox wherein populations at the highest risk of VHD often receive the least treatment. These advances have attracted the attention of clinicians, researchers, engineers, device manufacturers, and investors, leading to the exploration and proposal of treatment approaches grounded in pathophysiology and multidisciplinary strategies for VHD management. This Series paper focuses on innovations involving computational, pharmacological, and bioengineering approaches that are transforming the diagnosis and management of patients with VHD. Artificial intelligence and digital methods are enhancing screening, diagnosis, and planning procedures, and the integration of imaging and clinical data is improving the classification of VHD severity. The emergence of artificial intelligence techniques, including so-called digital twins-eg, computer-generated replicas of the heart-is aiding the development of new strategies for enhanced risk stratification, prognostication, and individualised therapeutic targeting. Various new molecular targets and novel pharmacological strategies are being developed, including multiomics-ie, analytical methods used to integrate complex biological big data to find novel pathways to halt the progression of VHD. In addition, efforts have been undertaken to engineer heart valve tissue and provide a living valve conduit capable of growth and biological integration. Overall, these advances emphasise the importance of early detection, personalised management, and cutting-edge interventions to optimise outcomes amid the evolving landscape of VHD. Although several challenges must be overcome, these breakthroughs represent opportunities to advance patient-centred investigations.

Valvular Heart Disease

Valvular heart disease is a common abnormality seen in the primary care setting. There are many causes of valvular heart disease including congenital, degenerative, infectious, traumatic, and many more. There is a wide variety of types of valvular heart disease with each valve having the ability to develop both regurgitation and stenosis by multiple mechanisms. All these complexities make diagnosis and management of valvular heart disease complicated, especially in the context of comorbidities. For this reason, it is important for primary care physicians to have a thorough understanding of how these diseases present and when interventions are indicated.

Valvular Heart Disease in the Cardiac Intensive Care Unit

Valvular heart disease pathologies are commonly encountered in the cardiac intensive care unit (CICU). Clinical presentations may range from an acute pathology of the aortic or mitral valve necessitating emergency intervention to a more subtle decompensation of longstanding valvular disease. With growing numbers of transcatheter valvular interventions, CICU providers must recognize and manage common complications after transcatheter aortic, mitral, and tricuspid interventions. In addition, prosthetic valve dysfunction should always be excluded in a CICU patient presenting with an acute cardiopulmonary decompensation. Multidisciplinary valve teams can assist with challenging valvular pathologies to determine candidacy for potential interventions.

Valvular heart disease and cardiomyopathy: reappraisal of their interplay

Cardiomyopathies and valvular heart diseases are typically considered distinct diagnostic categories with dedicated guidelines for their management. However, the interplay between these conditions is increasingly being recognized and they frequently coexist, as in the paradigmatic examples of dilated cardiomyopathy and hypertrophic cardiomyopathy, which are often complicated by the occurrence of mitral regurgitation. Moreover, cardiomyopathies and valvular heart diseases can have a shared aetiology because several genetic or acquired diseases can affect both the cardiac valves and the myocardium. In addition, the association between cardiomyopathies and valvular heart diseases has important prognostic and therapeutic implications. Therefore, a better understanding of their shared pathophysiological mechanisms, as well as of the prevalence and predisposing factors to their association, might lead to a different approach in the risk stratification and management of these diseases. In this Review, we discuss the different scenarios in which valvular heart diseases and cardiomyopathies coexist, highlighting the need for an improved classification and clustering of these diseases with potential repercussions in the clinical management and, particularly, personalized therapeutic approaches.

Bicuspid aortic valve and its ascending aortopathy

PURPOSE OF REVIEW

To synthesize and critically assess recent clinical and research advancements in pediatric bicuspid aortic valve (BAV) and its associated aortopathy.

RECENT FINDINGS

In pediatric patients with BAV, progressive aortic dilation (i.e. bicuspid aortopathy) is commonly present and associated with increased risk for aortic aneurysm, dissection, and surgery in adulthood. Ongoing research explores the cause, incidence, and progression of bicuspid aortopathy to promote earlier diagnosis and improve preventive management. Recent findings include: high familial incidence and need for improved familial screening; safety of recreational physical activity in most affected children; potential for medical management to slow aortic growth; feasibility of pediatric registries to evaluate longitudinal outcomes; and potential genetic and hemodynamic biomarkers for disease risk stratification.

SUMMARY

Pediatric bicuspid aortopathy is an important area for investigation and preventive management to improve long-term cardiovascular outcomes. Recent literature promotes familial screening, recreational exercise, medical prophylaxis, registry-based longitudinal evaluation, and continued scientific inquiry.

Diagnosis, Classification, and Management Strategies for Mitral Annular Calcification: A Heart Valve Collaboratory Position Statement

Mitral annular calcium (MAC) with severe mitral valvular dysfunction presents a complex problem, as valve replacement, either surgical or transcatheter, is challenging because of anatomy, technical considerations, concomitant comorbidities, and advanced age. The authors review the clinical and anatomical features of MAC that are favorable (green light), challenging (yellow light), or prohibitive (red light) for surgical or transcatheter mitral valve interventions. Under the auspices of the Heart Valve Collaboratory, an expert working group of cardiac surgeons, interventional cardiologists, and interventional imaging cardiologists was formed to develop recommendations regarding treatment options for patients with MAC as well as a proposed grading and staging system using both anatomical and clinical features.

ACC/AHA and ESC/EACTS Guidelines for the Management of Valvular Heart Diseases: JACC Guideline Comparison

Valvular heart disease (VHD) is common and poses important challenges from the standpoints of diagnosis and therapeutic management. Clinical practice guidelines have been developed to help health care professionals to overcome these challenges and provide optimal management to patients with VHD. The American College of Cardiology, in collaboration with the American Heart Association, and the European Society of Cardiology, in collaboration with the European Association for Cardio-Thoracic Surgery, recently updated their guidelines on the management of VHD. Although these 2 sets of guidelines are generally concordant, there are some substantial differences between these guidelines, which may have significant implications for clinical practice. This review prepared on behalf of the EuroValve Consortium describes the consistencies and discrepancies between the guidelines and highlights the gaps in these guidelines and the future research perspectives to fill these gaps.

Racial, Ethnic, and Gender Disparities in Valvular Heart Failure Management

Racial, ethnic, and gender disparities are present in the diagnosis and management of valvular heart disease. The prevalence of valvular heart disease varies by race, ethnicity, and gender, but diagnostic evaluations are not equitable across the groups, which makes the true prevalence less clear. The delivery of evidence-based treatments for valvular heart disease is not equitable. This article focuses on the epidemiology of valvular heart diseases associated with heart failure and the related disparities in treatment, with a focus on how to improve delivery of nonpharmacological and pharmacological treatments.

[Update Valvular Heart Disease: Heart Team Decision-Making Based on Patient Examples]

INTRODUCTION

In Europe, mitral regurgitation and aortic stenosis are the most common valve lesions requiring interventions. In advanced stages, these valve pathologies affect patients' quality of life and prognosis. The prevalence of mitral regurgitation and aortic stenosis is increasing with age. In view of an aging population and the comorbidities associated with age, these valve defects represent an increasing challenge to health care providers. Nowadays, surgical as well as catheter-based treatment options are available to treat affected patients. Therapeutic strategies suitable to the individual patient should be discussed in interdisciplinary heart teams. The aim of the present article is to give an overview of possible guideline-conform heart team decisions based on patient examples.

Managing acute cardiac valvular emergencies in the emergency department

Valvular heart disease is becoming more prevalent as the United States' population ages, with aortic and mitral valves most commonly affected. Complications, including syncope, heart failure, dyspnea, and chest pain, can arise from slow progression of stenosis and regurgitation, though acute regurgitation from an ischemic or traumatic event can be life-threatening. Patients with valvular disease may present with cardiogenic shock, and vasoactive agent treatment will depend on determination of the valvular etiology. This issue reviews aortic and mitral valvular disease as potential causes of a patient's emergency department presentation, including history, diagnostic testing, and physical examination findings that can help guide treatment.

Characteristics, interventions and outcomes of patients with valvular heart disease hospitalised in China: a cross-sectional study

OBJECTIVES

Little is known about contemporary characteristics and management of valvular heart disease (VHD) in China. This study aimed to examine the clinical characteristics, aetiology and type of VHD, interventions and in-hospital outcomes of patients with VHD hospitalised in China.

METHODS

We used a two-stage random sampling design to create a nationally representative sample of patients with VHD hospitalised in 2015 in China and included adult patients with mild, moderate or severe VHD. We abstracted data from medical records, including echocardiogram reports, on patient characteristics, aetiology, type and severity of VHD, interventions and in-hospital outcomes. We weighted our findings to estimate nationally representative hospitalisations. We performed multivariable logistic regression analysis to identify factors associated with valve intervention.

RESULTS

In 2015, 38 841 patients with VHD were hospitalised in 188 randomly sampled hospitals, representing 662 384 inpatients with VHD in China. We sampled 9363 patients, mean age 68.7 years (95% CI 42.2 to 95.2) and 46.8% (95% CI 45.8% to 47.8%) male, with an echocardiogram. Degenerative origin was the predominant aetiology overall (33.3%, 95% CI 32.3% to 34.3%), while rheumatic origin was the most frequent aetiology among patients with VHD as the primary diagnosis (37.4%, 95% CI 35.9% to 38.8%). Rheumatic origin was also the most common aetiology among patients with moderate or severe VHD (27.3%, 95% CI 25.6% to 29.0% and 33.6%, 95% CI 31.9% to 35.2%, respectively). The most common VHD was mitral regurgitation (79.1%, 95% CI 78.2% to 79.9%), followed by tricuspid regurgitation (77.4%, 95% CI 76.5% to 78.2%). Among patients with a primary diagnosis of severe VHD who were admitted to facilities capable of valve intervention, 35.6% (95% CI 33.1% to 38.1%) underwent valve intervention during the hospitalisation. The likelihood of intervention decreased significantly among patients with higher operative risk.

CONCLUSIONS

Among patients with VHD hospitalised in China, the predominant aetiology was degenerative in origin; among patients with moderate or severe VHD, rheumatic origin was the most common aetiology. Targeted strategies and policies should be promoted to address degenerative VHD. Patients with severe VHD may be undertreated, particularly those with high operative risk.

New strategies in the management of valvular heart disease : A critical appraisal on the top 10 messages of the 2020 ACC/AHA guidelines for the management of patients with valvular heart disease

The advent of transcatheter procedures for treatment of valvular heart disease has accelerated the pace of research in the diagnosis and treatment of heart valve disease. Rapid accumulation of novel knowledge in the field necessitates timely revisions of clinical guidelines. This paper comments on some important and novel issues addressed in the recently published American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

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

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Is there a role for blood purification therapies targeting cytokine storm syndrome in critically severe COVID-19 patients?

The coronavirus disease-19 (COVID-19) has spread over many countries and regions since the end of 2019, becoming the most severe public health event at present. Most of the critical cases developed multiple organ dysfunction, including acute kidney injury (AKI). Cytokine storm syndrome (CSS) may complicate the process of severe COVID-19 patients. This manuscript reviews the different aspects of blood purification in critically ill patients with AKI and increased inflammatory factors, and examines its potential role in severe COVID-19 treatment. Continuous renal replacement therapy (CRRT) has been practiced in many sepsis patients with AKI. Still, the timing and dosing need further robust evidence. In addition to the traditional CRRT, the high-throughput membrane with adsorption function and cytokine adsorption column are two representatives of recently emerging novel membrane technologies. Their potential in removing inflammatory factors and other toxins prospects for the treatment of severe COVID-19.

Outpatient management of heart valve disease following the COVID-19 pandemic: implications for present and future care

The established processes for ensuring safe outpatient surveillance of patients with known heart valve disease (HVD), echocardiography for patients referred with new murmurs and timely delivery of surgical or transcatheter treatment for patients with severe disease have all been significantly impacted by the novel coronavirus pandemic. This has created a large backlog of work and upstaging of disease with consequent increases in risk and cost of treatment and potential for worse long-term outcomes. As countries emerge from lockdown but with COVID-19 endemic in society, precautions remain that restrict 'normal' practice. In this article, we propose a methodology for restructuring services for patients with HVD and provide recommendations pertaining to frequency of follow-up and use of echocardiography at present. It will be almost impossible to practice exactly as we did prior to the pandemic; thus, it is essential to prioritise patients with the greatest clinical need, such as those with symptomatic severe HVD. Local procedural waiting times will need to be considered, in addition to usual clinical characteristics in determining whether patients requiring intervention would be better suited having surgical or transcatheter treatment. We present guidance on the identification of stable patients with HVD that could have follow-up deferred safely and suggest certain patients that could be discharged from follow-up if waiting lists are triaged with appropriate clinical input. Finally, we propose that novel models of working enforced by the pandemic-such as increased use of virtual clinics-should be further developed and evaluated.

18F-Sodium Fluoride (18F-NaF) for Imaging Microcalcification Activity in the Cardiovascular System

Accumulating preclinical and clinical evidence suggests that calcification is one of the body's primary responses to injury and a key pathological feature of cardiovascular disease. Calcification activity can now be imaged using 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) in combination with either computed tomography or magnetic resonance. These techniques allow visualization of calcification activity and, therefore, provide different information to the established macroscopic calcium imaged with computed tomography. Indeed, 18F-NaF PET has been used to investigate a wide range of valvular conditions, including aortic stenosis, mitral annular calcification, and bioprosthetic valve disease, as well as vascular conditions, including abdominal aortic aneurysm disease, coronary, and carotid atherosclerosis, peripheral vascular disease, and erectile dysfunction. In this brief review, we will focus on how 18F-NaF PET has improved our pathophysiological understanding of cardiovascular calcification and how it can be used as a marker of vascular calcification, providing a useful tool that can be utilized in clinical trials investigating the prediction of both disease progression and clinical events. Finally, we will discuss how 18F-NaF might be employed clinically to improve patient assessment and to guide decision-making.

Clinical history and management of bicuspid aortic valve in children and adolescents

Bicuspid aortic valve (BAV) is one of the most common congenital heart defects in children, adolescents and adults. BAV can occur as an isolated lesion or in association with other congenital heart defects, such as coarctation of the aorta or genetic syndromes like Turner syndrome. Although the majority of long term complications associated with BAV manifest later in life, children and adolescents may present with early onset valvular dysfunction or dilation of the aorta. BAV is a heterogeneous disease with a wide array of presentations at various ages, depending on the degree of aortic valve dysfunction, aortic dilation and presence of associated lesions. Aortic valve stenosis and/or regurgitation are the primary indications for intervention in children and adolescents with BAV. Although a majority of young patients with BAV also have some aortic dilation, interventions on the aorta are very rare during this time frame. Children and adolescents with BAV benefit from comprehensive assessment of their risk profile to determine follow-up surveillance intervals, sports recommendations, and timing of surgical intervention. The morphologic phenotype of BAV is important to identify, as it may predict future complications and prognosis.

Specialist valve clinic in a cardiac centre: 10-year experience

Aims

Guidelines recommend specialist valve clinics as best practice for the assessment and conservative management of patients with heart valve disease. However, there is little guidance on how to set up and organise a clinic. The aim of this study is to describe a clinic run by a multidisciplinary team consisting of cardiologists, physiologist/scientists and a nurse.

Methods

The clinical and organisational aims of the clinic, inclusion and exclusion criteria, and links with other services are described. The methods of training non-clinical staff are detailed. Data were prospectively entered onto a database and the study consisted of an analysis of the clinical characteristics and outcomes of all patients seen between 1 January 2009 and 31 December 2018.

Results

There were 2126 new patients and 9522 visits in the 10-year period. The mean age was 64.8 and 55% were male. Of the visits, 3587 (38%) were to the cardiologists, 4092 (43%) to the physiologist/scientists and 1843 (19%) to the nurse. The outcomes from the cardiologist clinics were cardiology follow-up in 460 (30%), referral for surgery in 354 (23%), referral to the physiologist/scientist clinic in 412 (27%) or to the nurse clinic in 65 (4.3%) and discharge in 230 (15%). The cardiologist needed to see 6% from the nurse clinic and 10% from the physiologist/scientist clinic, while advice alone was sufficient in 10% and 9%.

Conclusion

A multidisciplinary specialist valve clinic is feasible and sustainable in the long term.

In vivo tissue engineering of a trilayered leaflet-shaped tissue construct

Aim: We aimed to develop a leaflet-shaped trilayered tissue construct mimicking the morphology of native heart valve leaflets. Materials & methods: Electrospinning and in vivo tissue engineering methods were employed. Results: We developed leaflet-shaped microfibrous scaffolds, each with circumferentially, randomly and radially oriented three layers mimicking the trilayered, oriented structure of native leaflets. After 3 months in vivo tissue engineering with the scaffolds, the generated leaflet-shaped tissue constructs had a trilayered structure mimicking the orientations of native heart valve leaflets. Presence of collagen, glycosaminoglycans and elastin seen in native leaflets was observed in the engineered tissue constructs. Conclusion: Trilayered, oriented fibrous scaffolds brought the orientations of the infiltrated cells and their produced extracellular matrix proteins into the constructs.

Immediate And Midterm Results Of Balloon Aortic Valvuloplasty In Children With Aortic Valve Stenosis With Special Reference To Dysplastic Aortic Valve

BACKGROUND

This study was conducted to determine the immediate and midterm outcome of balloon aortic valvuloplasty in children from age 1 month to 16 years, with special reference to mean balloon to aortic valve ratio along with dooming versus dysplastic valve.

METHODS

This was a retrospective cohort study. Patients who underwent balloon aortic valvuloplasty in a single tertiary care hospital were reviewed regarding immediate outcome, morphology of aortic valve, mean balloon to aortic valve ratio and complications during procedure from January 2006 till December 2016.

RESULTS

Of 171 patients, 80.11% had fall to good results while 73.1% had adequate outcome. Mean gradient fall of more than 50% or Peak systolic gradient decreased significantly post ballooning, which indicates good results. The age ranges from 1-92 months, 89.4% patients from age group less than1 year had adequate outcome, (p=0.017). In terms of morphology, 55.6% cases had doming while 44.4% cases had dysplastic aortic valve. There was no significant difference between dysplastic and doming valves in terms of outcome (p=0.224). Only 6 patients (3.5%) developed significant aortic regurgitation. Regarding short-term and intermediate outcome 92% of the patients were free from a second intervention and there was no significant difference between complications regarding balloon to aortic valve ratio also.

CONCLUSIONS

Our 10-year experience showed that balloon aortic valvuloplasty is a safe and effective therapy, irrespective of age groups. The complications rate is low and good outcome is achieved by keeping balloon to aortic valve ratio of ±0.9 irrespective of morphology of valve..

[Percutaneous closure of paravalvular leak]

Paravalvular leaks (PVL) are a serious complication after surgical or transcatheter aortic valve replacement. They are mostly small and unimportant. When they manifest clinically (1 to 5 % of PVL), they can become responsible for severe hemolytic anaemia or cause congestive heart failure. For years, surgical re-intervention has been considered the treatment of choice for symptomatic patients with PVL. However, surgical re-intervention is associated with a high risk of morbidity and mortality. Percutaneous PVL closure is a less invasive alternative to surgical re-intervention. The safety and feasibility of percutaneous PVL closure has been confirmed in several studies. In this article, we discuss the issue of PVL and their percutaneous management.

Comparison of two radiofrequency ablation devices for atrial fibrillation concomitant with a rheumatic valve procedure

BACKGROUND

Perioperative and median-term follow-up outcomes have not been compared among procedures using radiofrequency ablation devices for permanent atrial fibrillation with concomitant rheumatic valve disease. We compared the sinus rhythm restoration efficacy of "non-irrigation" ablation forceps and an "irrigation" ablation device in patients with rheumatic valve disease undergoing a modified Cox maze radiofrequency ablation procedure due to permanent atrial fibrillation.

METHODS

Data of 278 patients with rheumatic valve disease from the Cardiac Surgery Department of Sichuan Provincial People's Hospital who underwent the modified Cox maze radiofrequency ablation procedure between May 2013 and May 2017 were reviewed. The procedure was performed using "non-irrigation" ablation forceps (AtriCure, group A) in 149 patients and an "irrigation" ablation device (Medtronic, group M) in 129 patients. Data were collected prospectively, and follow-up was documented and compared between the groups.

RESULTS

The radiofrequency procedure duration was 28.9 ± 3.8 min in group A and 29.5 ± 2.8 min in group M (t = 1.623, P = 0.106). The predicted radiofrequency time to the left atrium diameter was (Ya = 0.4964 X + 0.3762, R = 0.74) in group A and (Ym = 0.4331 X + 4.3563, R = 0.8435) in group M. The sinus rhythm (SR) conversion rate without use of anti-arrhythmic drugs was similarly good in groups A and M, with 75.2%, 72.5%, and 70.5% vs. 73.6%, 71.3%, and 69.8% at discharge, 6 and 12 months, respectively (F = 0.084, F = 0.046, F = 0.046, P > 0.05, respectively).

CONCLUSION

Two types of radiofrequency ablation devices characteristic of "non-irrigation" and "irrigation" bipolar ablation forceps were similarly efficient at SR restoration.

Biologically Inspired Scaffolds for Heart Valve Tissue Engineering via Melt Electrowriting

Heart valves are characterized to be highly flexible yet tough, and exhibit complex deformation characteristics such as nonlinearity, anisotropy, and viscoelasticity, which are, at best, only partially recapitulated in scaffolds for heart valve tissue engineering (HVTE). These biomechanical features are dictated by the structural properties and microarchitecture of the major tissue constituents, in particular collagen fibers. In this study, the unique capabilities of melt electrowriting (MEW) are exploited to create functional scaffolds with highly controlled fibrous microarchitectures mimicking the wavy nature of the collagen fibers and their load-dependent recruitment. Scaffolds with precisely-defined serpentine architectures reproduce the J-shaped strain stiffening, anisotropic and viscoelastic behavior of native heart valve leaflets, as demonstrated by quasistatic and dynamic mechanical characterization. They also support the growth of human vascular smooth muscle cells seeded both directly or encapsulated in fibrin, and promote the deposition of valvular extracellular matrix components. Finally, proof-of-principle MEW trileaflet valves display excellent acute hydrodynamic performance under aortic physiological conditions in a custom-made flow loop. The convergence of MEW and a biomimetic design approach enables a new paradigm for the manufacturing of scaffolds with highly controlled microarchitectures, biocompatibility, and stringent nonlinear and anisotropic mechanical properties required for HVTE.

The Epidemiology, Pathophysiology, and Novel Treatment of Calcific Arterial Disease

Endovascular treatment of arterial diseases has become first-line in most cases due to improved technology. However, until recently, excessive atherosclerotic calcification has been a major limiting factor in the endovascular management of peripheral arterial disease, as well as vascular access for endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR). The Peripheral Intravascular Lithotripsy (IVL) System (Shockwave Medical, Inc., Fremont California) applies pulsatile mechanical energy under fluoroscopic guidance to disrupt calcified lesions. The purpose of this paper is to introduce IVL in the treatment of calcific access vessels in preparation for EVAR and TAVR, as well as peripheral arterial disease applications to enhance luminal gain. Using the IVL System, angioplasty can be performed with lower pressures, which may minimize arterial dissection. Further, the lithotripsy effect on calcium will enhance vessel compliance. We describe several cases where IVL was applied successfully and present additional cases that may have benefitted from the use of this technology.

Contemporaneous management of valvular heart disease and aortopathy in aircrew

Valvular heart disease (VHD) is highly relevant in the aircrew population as it may limit appropriate augmentation of cardiac output in high-performance flying and predispose to arrhythmia. Aircrew with VHD require careful long-term follow-up to ensure that they can fly if it is safe and appropriate for them to do so. Anything greater than mild stenotic valve disease and/or moderate or greater regurgitation is usually associated with flight restrictions. Associated features of arrhythmia, systolic dysfunction, thromboembolism and chamber dilatation indicate additional risk and will usually require more stringent restrictions. The use of appropriate cardiac imaging, along with routine ambulatory cardiac monitoring, is mandatory in aircrew with VHD.Aortopathy in aircrew may be found in isolation or, more commonly, associated with bicuspid aortic valve disease. Progression rates are unpredictable, but as the diameter of the vessel increases, the associated risk of dissection also increases. Restrictions on aircrew duties, particularly in the context of high-performance or solo flying, are usually required in those with progressive dilation of the aorta.

Acupuncture in Patients with Valvular Heart Disease and Prosthetic Valves

Endocarditis has been reported in patients with valvular heart disease who have undergone acupuncture treatment, although most have been associated with the use of semi-permanent needles. This has led reviewers to suggest that acupuncture may not only be contraindicated in such patients but that prophylactic antibiotics should be given.

This study investigated the use of acupuncture treatment in patients with proven valvular heart disease and observed whether endocarditis developed in such patients. All patients in a single-handed GP practice with proven valvular heart disease, including those with prosthetic valves, were identified over a ten-year period. Those who had undergone acupuncture treatment underwent a clinical examination and diagnostic tests, which focused on the signs, symptoms and laboratory criteria for the diagnosis of endocarditis and included a transthoracic echocardiogram. Autopsy findings were reviewed in any patient who died.

Based on these clinical and laboratory data, using the modified Duke's criteria for the diagnosis of endocarditis, patients were identified as having definite or possible endocarditis, or the diagnosis was rejected.

All patients underwent brief acupuncture with no skin disinfectant and no prophylactic antibiotics were given. Semi-permanent needles were avoided. Thirty-six patients with valvular heart disease underwent a total of 479 acupuncture treatments over a ten-year period. The median number of treatments was 9 (range 1 – 72), with a follow-up after treatment of 5.75 years (range 0.5 – 10 years). Definite endocarditis was not found in any patient, but two patients had possible endocarditis, eventually discounted by both negative blood cultures and echocardiography.

In conclusion, brief acupuncture was safe in this small cohort of valvular heart disease patients and no case of endocarditis was detected over a ten-year period.

INCA (Peru) Study: Impact of Non-Invasive Cardiac Magnetic Resonance Assessment in the Developing World

Background Advanced cardiac imaging permits optimal targeting of cardiac treatment but needs to be faster, cheaper, and easier for global delivery. We aimed to pilot rapid cardiac magnetic resonance ( CMR ) with contrast in a developing nation, embedding it within clinical care along with training and mentoring. Methods and Results A cross-sectional study of CMR delivery and clinical impact assessment performed 2016-2017 in an upper middle-income country. An International partnership (clinicians in Peru and collaborators from the United Kingdom, United States, Brazil, and Colombia) developed and tested a 15-minute CMR protocol in the United Kingdom, for cardiac volumes, function and scar, and delivered it with reporting combined with training, education and mentoring in 2 centers in the capital city, Lima, Peru, 100 patients referred by local doctors from 6 centers. Management changes related to the CMR were reviewed at 12 months. One-hundred scans were conducted in 98 patients with no complications. Final diagnoses were cardiomyopathy (hypertrophic, 26%; dilated, 22%; ischemic, 15%) and 12 other pathologies including tumors, congenital heart disease, iron overload, amyloidosis, genetic syndromes, vasculitis, thrombi, and valve disease. Scan cost was $150 USD, and the average scan duration was 18±7 minutes. Findings impacted management in 56% of patients, including previously unsuspected diagnoses in 19% and therapeutic management changes in 37%. Conclusions Advanced cardiac diagnostics, here CMR with contrast, is possible using existing infrastructure in the developing world in 18 minutes for $150, resulting in important changes in patient care.

Valvular Heart Disease

This article outlines the diagnosis and management of commonly occurring valvular heart diseases for the primary care provider. Basic understanding of pathologic murmurs is important for appropriate referral. Echocardiography is the gold standard for diagnosis and severity grading. Patients with progressive valvular heart disease should be followed annually by cardiology and imaging should be performed based on the severity of valvular dysfunction. Surgery or intervention is recommended only when symptoms dictate or when changes in left ventricular function occur. Surgery or intervention should be performed after discussion by a heart team, including cardiologists and cardiac surgeons.

Risk factors for heart valve calcification in chronic kidney disease

Cardiovascular disease (CVD) is a common cause of death in patients with chronic kidney disease (CKD). Aortic and mitral valve calcification (AVC and MVC, respectively) are critical indicators of CVD and all-cause mortality in CKD patients.We conducted a single center retrospective study of Chinese inpatients with CKD to identify risk factors associated with valve calcification (VC).Of 288 enrolled CKD patients, 22.9% had VC, all of which exhibited AVC, while 21.2% exhibited MVC. The VC group were significantly older than the non-VC group (70.42 ± 11.83 vs 56.47 ± 15.00, P < .001), and contained more patients with history of coronary artery disease (12.1% vs 4.5%, P = .025) or stroke (18.2% vs 5.4%, P < .001). Subjective global assessment scoring indicated that more VC patients were mid/severely malnourished. Levels of prealbumin, cholesterol (Ch), triglycerides, low-density lipoprotein (LDL), apolipoprotein E, ejection fraction, and fraction shortening were significantly lower, and blood C reactive protein, IL-6, left ventricular internal end diastole diameter measured in end diastole, and interventricular septum thickness (IVST) levels were significantly higher in the VC group. Bone metabolism did not differ significantly between the 2 groups. Multivariable logistic regression analysis indicated that age, blood Ch, and LDL levels were significantly associated with VC.Advanced age, increased IVST, hypocholesterolemia, and hyper-LDL cholesterolemia were key risk factors for VC in Han patients with CKD.

Heart valve scaffold fabrication: Bioinspired control of macro-scale morphology, mechanics and micro-structure

Valvular heart disease is currently treated with mechanical valves, which benefit from longevity, but are burdened by chronic anticoagulation therapy, or with bioprosthetic valves, which have reduced thromboembolic risk, but limited durability. Tissue engineered heart valves have been proposed to resolve these issues by implanting a scaffold that is replaced by endogenous growth, leaving autologous, functional leaflets that would putatively eliminate the need for anticoagulation and avoid calcification. Despite the diversity in fabrication strategies and encouraging results in large animal models, control over engineered valve structure-function remains at best partial. This study aimed to overcome these limitations by introducing double component deposition (DCD), an electrodeposition technique that employs multi-phase electrodes to dictate valve macro and microstructure and resultant function. Results in this report demonstrate the capacity of the DCD method to simultaneously control scaffold macro-scale morphology, mechanics and microstructure while producing fully assembled stent-less multi-leaflet valves composed of microscopic fibers. DCD engineered valve characterization included: leaflet thickness, biaxial properties, bending properties, and quantitative structural analysis of multi-photon and scanning electron micrographs. Quasi-static ex-vivo valve coaptation testing and dynamic organ level functional assessment in a pressure pulse duplicating device demonstrated appropriate acute valve functionality.

[Conservative treatment of thrombosis of aortic valve bioprosthesis]

Case report of successful conservative treatment of patient with thrombosis of aortic valve bioprosthesis after 8 months postoperatively is presented.

The decellularized porcine heart valve matrix in tissue engineering

An approach in tissue engineering of heart valves is the use of decellularized xenogeneic matrices to avoid immune response after implantation. The decellularization process must preserve the structural components of the extracellular matrix to provide a biomechanically stable scaffold. However, it is known that in vascular lesions platelet adhesion to extracellular matrix components occurs and platelet activation is induced. In the present study we examined the effects of a decellularized porcine heart valve matrix on thrombocyte activation and the influence of re-endothelialisation in vitro. Porcine pulmonary conduits were decellularized using Triton X-100, Na-deoxycholate and Igepal CA-630® followed by a ribonuclease digestion. Cryostat sections of decellularized heart valves with and without seeding with human umbilical vein endothelial cells (HUVEC) were incubated with platelet rich plasma. Samples were either stained with fluorescent antibodies for CD41 and PAC-1 (recognizing the activated fibrinogen receptor) or fixed with glutaraldehyde. Thereafter, the samples were processed for laser scanning microscopy (LSM) or scanning electron microscopy (SEM). Examination by LSM showed numerous platelets with co-localized staining for CD41 and PAC-1 on the nonseeded decellularized heart valve matrix whereas after seeding with endothelial cells no platelet activation was detected. SEM revealed platelet adhesion and aggregate formation only on the surface of the non-seeded or partially denuded matrix specimens. We show in this study that the decellularized porcine matrix acts as a platelet-activating surface. Seeding with endothelial cells effectively abolishes the platelet adhesion and activation and therefore is necessary to eliminate thrombogenicity in tissue engineered heart valves.

[Cardiac rehabilitation, state of the art 2017]

Cardiovascular disease remains the leading cause of death in western countries. Despite advances in acute management of patients, secondary prevention remains essential and should include cardiac rehabilitation. Recent data have confirmed the interest of this management in the various conventional indications : coronary disease, valvular heart disease, heart failure and heart transplantation. New indications emerge with some benefit that should be evaluated : ventricular assistance, pulmonary hypertension, trans-catheter aortic valve implantation. However, the different rehabilitation programs proposed are still too uneven in content and duration and the number of patients participating in these programs remains low. Home based cardiac rehabilitation technologies have already shown some effectiveness and could improve some of the weaknesses of rehabilitation programs. Again protocols and tools need to be improved and standardized. The budgetary impact will also have to be studied further.

Pulmonic Valve Disease: Review of Pathology and Current Treatment Options

PURPOSE OF REVIEW

Our review is intended to provide readers with an overview of disease processes involving the pulmonic valve, highlighting recent outcome studies and guideline-based recommendations; with focus on the two most common interventions for treating pulmonic valve disease, balloon pulmonary valvuloplasty and pulmonic valve replacement.

RECENT FINDINGS

The main long-term sequelae of balloon pulmonary valvuloplasty, the gold standard treatment for pulmonic stenosis, remain pulmonic regurgitation and valvular restenosis. The balloon:annulus ratio is a major contributor to both, with high ratios resulting in greater degrees of regurgitation, and small ratios increasing risk for restenosis. Recent studies suggest that a ratio of approximately 1.2 may provide the most optimal results. Pulmonic valve replacement is currently the procedure of choice for patients with severe pulmonic regurgitation and hemodynamic sequelae or symptoms, yet it remains uncertain how it impacts long-term survival. Transcatheter pulmonic valve replacement is a rapidly evolving field and recent outcome studies suggest short and mid-term results at least equivalent to surgery. The Melody valve® was FDA approved for failing pulmonary surgical conduits in 2010 and for failing bioprosthetic surgical pulmonic valves in 2017 and has been extensively studied, whereas the Sapien XT valve®, offering larger diameters, was approved for failing pulmonary conduits in 2016 and has been less extensively studied. Patients with pulmonic valve disease deserve lifelong surveillance for complications. Transcatheter pulmonic valve replacement is a novel and attractive therapeutic option, but is currently only FDA approved for patients with failing pulmonary conduits or dysfunctional surgical bioprosthetic valves. New advances will undoubtedly increase the utilization of this rapidly expanding technology.

Comparison of the American College of Cardiology/American Heart Association and the European Society of Cardiology Guidelines for the Management of Patients With Valvular Heart Disease

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have developed guidelines to assist clinicians in making evidence-based decisions. This study compares the ACC/AHA and ESC guidelines for the management of patients with valvular heart disease (VHD).

METHODS

The current ACC/AHA and ESC guidelines for VHD, last updated in 2014 and 2012, respectively, were compared by class of recommendation (COR), level of evidence (LOE), and content.

RESULTS

The ACC/AHA and ESC VHD guidelines contain 229 and 85 recommendations, respectively. The COR distributions of the ACC/AHA and ESC VHD guidelines were 47.6% vs 44.7% class I [P=.65]; 46.3% vs 55.3% class II [P=.16]; and 6.1% vs 0.0% class III [P=.01], respectively. The LOE distributions were 3.1% vs 0.0% LOE A [P=.20]; 47.2% vs 10.6% LOE B [P<.001]; and 49.8% vs 89.4% LOE C [P<.001], respectively. The recommendation type distributions were 31.0% vs 2.4% diagnostic [P<.001]; 23.1% vs 16.5% medical therapy [P=.20]; and 45.9% vs 81.2% interventional/surgical recommendations [P<.001], respectively. The content of the guidelines was similar, with only minor differences in a few recommendations.

CONCLUSIONS

The ACC/AHA VHD guidelines contain significantly more recommendations. The distribution of COR was similar, but the ACC/AHA guidelines included more LOE B recommendations and fewer LOE C recommendations, suggesting that the ACC/AHA guidelines place greater emphasis on published data than expert opinion. Overall, the ACC/AHA and ESC guidelines provide similar recommendations, suggesting consistency in practice; however, the relative paucity of LOE A recommendations highlights the need for additional research.