Aortic Regurgitation Research Articles (Page 1)

Blood transfusion is common in patients with infectious endocarditis (IE) treated surgically. Limited literature on RBC transfusion outcomes in surgical IE. We aimed to clarify impacts of red blood cell (RBC) transfusion on long-term results of IE patients with surgical intervention. We conducted a retrospective study on the medical records of patients with IE undergoing cardiac surgery from 2006 to 2022 in our hospital. In our investigation, 814 IE patients were enrolled into RBC ≥ 2 units group (n = 305) and RBC < 2 units group (n = 509). There were 305 RBC ≥ 2 units patients (37.5%, 305/814). Compared with RBC < 2 units group, all-time mortality (26.2% vs 10.4%, P <.001) significantly increased in RBC ≥ 2 units group. We found vegetation diameter ≥ 10 mm, cardiopulmonary bypass length ≥ 120 minutes, aortic occlusion length ≥ 90 minutes, preoperative aortic regurgitation ≥ 4 cm2, postoperative left ventricular end diastolic diameter ≥ 70 mm, ventilation length ≥ 72 hours, ang intensive care unit stay ≥ 3 days to be related to RBC ≥ 2 units. RBC ≥ 2 units is significantly related to 1- and 5-year mortality after cardiac operation and all-time mortality. The presence of RBC ≥ 2 units in IE is a risk factor of long-term survival. In our investigation, the presence of RBC ≥ 2 units has adverse impact on long-term results of IE patients with surgical intervention. The management strategies for IE anemia may not be limited to blood transfusions, but also include drug treatments such as iron supplements and red blood cell stimulants. This study provides valuable information for clinical practice of blood transfusion in cardiac surgery.

Abstract Backgorund Quantifying the severity of aortic regurgitation (AR) using transthoracic echocardiography (TTE) remains challenging. A multi-parametric approach considering quantitative, semi-quantitative, and qualitative variables is recommended, but this increases inter-observer variability. The usefulness of these parameters has not been evaluated in patients with bicuspid aortic valve and regurgitation. In some patients, there is discordance between parameters, and it is unclear which is most useful for defining severity. The absence of a hierarchical weighting of discordant parameters could cause interobserver variability and aortic valve morphology could add more complexity. This study compared the utility of different AR severity parameters in patients with bicuspid aortic valves (BAV) versus trileaflet aortic valves (TAV). Methods 221 consecutive patients with moderate or severe AR on comprehensive TTE were included in this study. Aortic valve morphology, left ventricular (LV) dimensions, volumes, LV ejection fraction and AR qualitative, semi-quantitative and quantitative parameters were assessed. Regurgitant mechanisms were classified according to El Khoury. Results 151 patients had BAV and 70 had TAV. Patients with BAV and significant AR were younger (39 vs 70 years, p &amp;lt; 0.001), more frequently male, and had fewer cardiovascular risk factors. Regurgitation effective orifice area (EROA) was unmeasurable in 39% due to eccentric or multiple jets or inadequate PISA visualization. The prevalence of the different parameters according to aortic valve morphology is reflected in Figure 1. There were no significant differences between bicuspid and trileaflet AR in the presence of aortic flow reversal (100% TAV vs. 97,1% BAV), vena contracta width &amp;gt;0.3 cm (99% vs.85,3%) or LV dilatation (91,2% vs 88,9%). However, eccentric jets were more frequent in BAV morphology (97,1% vs 33,3%, p&amp;lt; 0,01) and presented less frequently with half-pressure time &amp;lt;500ms and jet width &amp;gt;25%, which were more frequent in TAV morphology. Aortic root dilatation (38.8%) was the most frequent isolated regurgitant mechanism, followed by valvular restriction (30.5%). 39.8% exhibited mixed regurgitation mechanisms; prolapse + dilatation predominated in BAV (67%), while restriction + dilatation was more common in TAV (96%, p=0,04). Conclusions While clinical differences exist between BAV and TAV AR, aortic flow reversal, VC width, and LV dilatation were significantly associated with severe AR regardless of valve phenotype. Eccentric regurgitant jets were frequent in BAV morphology and in these patients EROA was frequently unmeasurable due to jet eccentricity. The utility of individual parameters varied with valve phenotype, highlighting the need for a more standardized approach to AR quantification considering valve morphology.Figure 1Table 1

To assess the impact of chronic inflammatory burden on the risk of aortic valve outcomes and atrioventricular block (AVB) in spondyloarthritis (SpA). Ambispective cohort study of 461 SpA patients meeting ASAS criteria between September 2022 and April 2024. Chronic inflammation burden was measured by symptom duration, number of DMARDs discontinued due to inefficacy, and total exposure to persistent inflammation. Statistical analysis was performed with multiple time-dependent Cox regression, maintaining a variable-to-event ratio. Disease duration, especially from initial musculoskeletal (MSK) symptoms, affected all outcomes. Every five-year increase in symptom duration raised the risk of aortic regurgitation (HR 1.21, 95% CI 1.06-1.37), valve sclerosis (HR 1.07, 95% CI 1.02-1.12), root dilation (HR 1.31, 95% CI 1.08-1.59), and AVB (HR 1.34, 95% CI 1.05-1.71). Age also increased risks, particularly for aortic regurgitation (HR 1.46 per decade) and valve sclerosis (HR 1.74 per decade). Surprisingly, hypertension showed a consistent protective effect, decreasing the risk for aortic root dilation (HR 0.55, 95% CI 0.36-0.84), valve sclerosis (HR 0.62, 95% CI 0.40-0.96), and aortic regurgitation (HR 0.60, 95% CI 0.37-0.98). Peripheral SpA significantly predicted aortic valve sclerosis (HR 1.95, 95% CI 1.13-3.36), and enthesitis strongly influenced AVB risk (HR 3.04, 95% CI 1.24-7.44). The duration of MSK symptoms more strongly predicted all outcomes than extra-MSK symptoms. Age's impact mirrored general population trends. Surprisingly, hypertension protected against aortic conditions, prompting further research into IL-17 therapies. Peripheral SpA significantly predicted aortic valve sclerosis, and enthesitis strongly predicted AVB.

Background: Chronic Aortic Regurgitation (AR), a prevalent form of valvular heart disease, is associated with significant mortality and morbidity if left untreated. Emerging studies demonstrate significant sex-specific differences in AR presentation and clinical outcomes, yet current management guidelines do not account for these sex differences. Additionally, females with AR tend to exhibit increased symptoms despite reduced ventricular volume and preserved function. Research Question: How do left ventricular structure and geometry differ between sexes across varying severities of AR? Methods: A single-center, retrospective cohort study was conducted and included patients with an aortic regurgitant fraction &gt;20% by cardiac magnetic resonance (CMR) or ≥ moderate AR by echocardiography. AR severity was quantified using regurgitant fraction (ARFrac) thresholds, quantified by CMR (Mild: ARFrac &lt; 20, Moderate: 20 ≤ ARFrac ≤ 33, Severe: ARFrac &gt; 33). Cardiac geometry measured by CMR was determined using LV mass index (LVMassi), left ventricular end diastolic diameter indexed (LVEDDi), LV end systolic diameter index (LVESDi), interventricular septal thickness (IVS), posterior wall thickness (PWT), LV length, and derived indices including relative wall thickness (RWT) and sphericity. Volumetric measures included LVEDVi, LVESVi, and LVEF. Comparisons were stratified by sex, and significance was assessed using Wilcoxon rank-sum tests. Results: We evaluated 370 patients with AR, 63 female (17%), median age of 51 years. See Table 1 for the comparisons of age, hypertension, diabetes, ARFrac, and LV morphologic features stratified by sex. Radar plots significant sex differences in morphologic features across varying AR severity levels (mild, moderate, and severe). Opposite changes in RWT and sphericity were present in the setting of severe AR, based on sex. Conclusion: There are evident sex-specific differences in AR LV remodeling. Males exhibit more chamber dilation with increased sphericity and RWT with severe AR, while females maintain smaller, with decreased sphericity and increased RWT in the setting of severe AR. These differences may contribute to disparities in symptom presentation and AR severity. Recognizing sex-based remodeling patterns may inform the future development of more personalized clinical guidelines for AR management, including risk stratification and surgical referral thresholds.

Introduction: The combination therapy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and transaortic valve micro-axial flow pump catheter (Impella), so-called ECPELLA, provides powerful hemodynamic support and left ventricular (LV) unloading for cardiogenic shock (CS). However, aortic insufficiency (AI) caused by Impella placement reduces those benefits of ECPELLA. Research Questions: This study investigated the impact of Impella-induced AI on the effects of hemodynamic support and LV unloading by ECPELLA. We examined the relationship between AI severity and regurgitant flow (AI flow) using mock circulation and confirmed the presence of AI-induced hemodynamic deficit in a goat model of ECPELLA. Furthermore, we evaluated the impact of varying AI severity on hemodynamics and LV pressure-volume (PV) loop in ECPELLA circulation by our developed cardiovascular simulation. Methods: In a closed mock circuit with a centrifugal pump, we evaluated the relationship between the AI severity, which was altered by the position of the Impella at the aortic valve (Fig. 1A), and the effective regurgitant orifice area (EROA) estimated from AI flow and pressure gradient. Five Saanen goats (53±2 kg) were used for animal experiments of ECPELLA (Fig. 1B). VA-ECMO flow was set at 1.0, 1.5, and 2.0 L/min. AI flow was calculated from the difference between pulmonary artery and Impella flows. We developed a cardiovascular simulation that employed four cardiac chambers with resistance-compliance networks incorporating ECPELLA (Fig. 1C). Using four AI severity levels, we calculated the hemodynamics and illustrated PV loops by changing Impella CP settings from P0 to P9 under VA-ECMO support. Results: In mock circulation, AI flow increased according to the pressure gradient in each AI severity. Estimated EROA values were 0.018, 0.056, and 0.75 cm 2 for minimal, mild, and severe AI, respectively (Fig. 2A). In goats with ECPELLA, we observed the presence of AI with EROA of 0.18 cm 2 (Fig. 2B). In the simulation, the higher AI severity markedly attenuated the Impella impact on hemodynamic improvement and the leftward and downward shift in PV loop (Fig. 2C). Conclusion: Inappropriate Impella position can cause severe AI. Severe AI substantially reduces both hemodynamic support and LV unloading effects of ECPELLA. Systematic AI assessment is critical for optimal ECPELLA management in CS patients.

Background: Fragility of the ascending aortic wall has been observed in patients with aortic regurgitation (AR), possibly due to turbulent retrograde flow. However, the underlying cellular and structural mechanisms remain unclear. To investigate the effects of AR-induced retrograde flow on endothelial cells (ECs) and smooth muscle cells (SMCs) in the ascending aorta, we developed a catheter-based AR model in rats and performed histological and single-cell analyses. Methods: AR was induced in 10-week-old Sprague–Dawley rats by echocardiography-guided perforation of the aortic valve via the right common carotid artery. Sham-operated controls underwent the same procedure without valve injury. Ascending aortic tissues were collected at 1, 2, and 4 weeks for histological analysis. EC polarity was assessed by whole-mount immunohistochemistry at one week. Single-cell RNA sequencing (scRNA-seq) was performed on aortic tissues, with differential gene expression and pathway enrichment analyzed using Seurat and clusterProfiler. Results: Confocal imaging revealed that ECs in AR rats showed disrupted polarity and a more rounded morphology compared to controls. Quantitative analysis demonstrated significantly reduced aspect ratio and cell orientation angle in the AR group. Histological analysis showed progressive medial degeneration by 4 weeks, including elastic fiber fragmentation, mucopolysaccharide accumulation, and fibrosis. Picro-Sirius Red staining demonstrated a significant increase in fibrotic area at 4 weeks. Furthermore, serial echocardiography revealed time-dependent dilation of the ascending aorta in AR rats. ScRNA-seq revealed that ECs downregulated shear stress–responsive and anti-inflammatory genes. SMCs showed decreased expression of contractile markers and extracellular matrix (ECM) remodeling genes. Gene Ontology analysis revealed upregulation of inflammatory signaling and suppression of shear stress–responsive pathways in ECs. ECs also exhibited increased Wnt and TGF-β signaling—pathways known to drive SMC phenotypic switching—which was accompanied by phenotypic modulation and impaired ECM remodeling in SMCs. Conclusion: AR-induced retrograde flow leads to early EC polarity disruption and progressive medial degeneration in the ascending aorta. These structural changes are accompanied by shear stress–dependent transcriptional suppression in ECs and phenotypic modulation in SMCs, potentially contributing to aortic wall fragility.

Introduction: Advancements in cardiac imaging technology have enabled the acquisition of detailed anatomical information. The mitral valve is anatomically adjacent to the aortic valve, connected through the aorto-mitral curtain, therefore suturing during mitral valve surgery potentially can interfere with the aortic valve. However, detailed information regarding the aorto-mitral length and its impact on surgical outcomes are little known. Methods: Among 857 patients who underwent mitral valve surgery between 2010–2022, those with planned concomitant aortic valve surgery, infective endocarditis, and history of aortic valve surgery (n=343) were excluded. Of the remaining 514 patients, 276 patients (53.7%) with preoperative enhanced cardiac computed tomography (CT) were included in the final analysis. The aorto-mitral length was measured as the shortest length between the non- or left-coronary cusp (NCC or LCC) and mitral annulus (Fig.1). Worsening of aortic insufficiency (AI) was defined as either (1) an increase of at least one severity grade relative to the pre-operative assessment or (2) the need for unplanned aortic valve surgery due to severe intra-operative AI. Data are presented as % or median (interquartile range). Results: The patient demographics were as follows: age, 68 [55–76] years; male, 65.2%; primary mitral valve surgery, 88.8% (all cases with mitral regurgitation), and redo mitral valve surgery, 11.2%. The NCC–mitral annulus length was 9.8 mm (8.3–11.2 mm). In redo cases, this length was shorter than in primary cases (7.6 mm [5.6–10.1 mm] vs 10.0 mm [8.7–11.3 mm]; P &lt;0.001). The LCC–mitral annulus length was 6.2 mm (5.3–7.4 mm), which was shorter than the NCC–mitral annulus length ( P &lt;0.001). Likewise, in redo cases the LCC–mitral annulus length was shorter than in primary cases (5.4 mm [4.8–7.0 mm] vs 6.3 mm [5.4–7.4 mm]; P =0.037: Fig.2). Postoperative worsening of AI occurred in 12.0% (n=33/276), including three patients requiring unplanned aortic valve replacement. LCC- and NCC-mitral annulus length of worsening AI group were shorter than those in the non-worsening AI group (6.8 [4.6–8.0] vs. 10.7 [8.7–11.8] mm, P &lt;0.001; 4.0 [3.6–5.8] vs. 6.5 [5.8–7.8] mm, P &lt;0.001), associated with worsening of AI (cutoff value, 4.93 and 8.83mm: Fig.3). Conclusions: The aorto-mitral length can be precisely measured using preoperative cardiac CT, and a shorter aorto-mitral length would be associated with worsening of AI following mitral valve surgery.

Description of Case: A 58-year-old man presented with progressive fatigue and dyspnea. Echocardiography showed mixed valve disease with severe aortic stenosis (AS), severe aortic regurgitation (AR), left ventricular hypertrophy, and preserved ejection fraction. Coronary angiography was normal. Chest computed tomography angiography revealed a quadricuspid aortic valve (QAV) with severe calcification and aneurysmal dilation of the ascending aorta to 47 mm. At the time of the operation, the quadricuspid valve was functionally bicuspid, with two raphes. An additional cusp was present between the right and left coronary cusps (Nakamura Type 1) with 2 equal larger cusps and 2 unequal smaller cusps (Hurwitz and Roberts Type F). The right and supernumerary cusps, and the left and non coronary cusps, were fused respectively. All cusps were significantly thickened and calcified. The degenerated valve was excised and replaced with a size 27 bioprosthetic valve. The ascending aorta was resected and replaced with a straight graft. Postoperative echocardiography confirmed a low mean gradient and normal function, and the patient had an uncomplicated recovery. Discussion: QAV is a rare congenital anomaly found in less than 0.05% of the general population and less than 1.5% of patients undergoing aortic valve surgery. Anatomic QAV with functionally bicuspid morphology and ascending aortic dilation (&gt; 45 mm) is rarer still, with unclear etiology and surgical implications. The most common valvular dysfunction with QAV is AR, with pure AS and mixed valve disease occurring in only 0.7% and 8.4% of QAV cases, respectively. Although AR is typically managed with surgical repair, QAV-related AR often requires valvular replacement, either immediately or after initial repair attempts. The functional bicuspid nature of the QAV in this case may help explain the presence of severe AS and ascending aortic dilation, conditions that are less common in QAV but more prevalent in bicuspid aortic valves (BAVs). This case emphasizes the complexity of managing QAV, particularly when severe AS and calcification preclude valve repair. The concomitant ascending aortic aneurysm necessitated combined surgical intervention, highlighting the need for comprehensive preoperative planning. The case suggests that the association between QAV and ascending aortic aneurysms is understudied, especially in the setting of functionally BAVs.

Introduction: Continuous mitral regurgitation (MR) is a rare echocardiographic finding. Diastolic MR, although uncommon, is typically associated with atrioventricular (AV) dissociation such as complete heart block, bradycardia, or ventricular pacing. It may also occur when elevated left ventricular end-diastolic pressure (LVEDP) reverses the normal transmitral gradient. We present a case of a critically ill patient with acute embolic stroke, found to have multivalvular infective endocarditis with severe aortic regurgitation (AR) and continuous MR attributed to elevated LVEDP. Case Description: A 37-year-old male with a history of intravenous drug use, tricuspid valve endocarditis (2022), and hepatitis C presented as a Code Stroke after being found unresponsive with left sided weakness. Imaging revealed a large right middle cerebral artery infarct. Blood cultures grew Enterococcus faecalis. Transthoracic echocardiogram showed mild LV dilation with preserved EF (55–60%), a small vegetation on the mitral valve with mild-to-moderate MR, and multiple large vegetations on the aortic valve with leaflet prolapse causing severe AR. Notably, MR persisted into diastole despite sinus rhythm, with no AV dissociation on ECG or telemetry. He was admitted to the ICU for stabilization and surgical planning. Discussion: While diastolic MR typically results from AV dissociation, in this case, the diastolic component was due to markedly elevated LVEDP from acute-on-chronic severe AR. Chronic AR likely led to LV dilation, and acute worsening from valve destruction reversed the diastolic mitral pressure gradient, producing regurgitation during filling. Though previously described in isolated reports, continuous MR (with both systolic and diastolic components) is rarely documented in the setting of native valve endocarditis. This finding reflects critical hemodynamic compromise and carries implications for urgent surgical intervention. Conclusion: This case highlights continuous MR as a marker of elevated LVEDP in the absence of AV dissociation, occurring due to acute worsening of chronic AR in the setting of infective endocarditis. Recognizing this pattern is essential, as it signifies significant volume overload and impending decompensation.

Introduction: Severe aortic regurgitation (AR) is characterized by significant retrograde blood flow in the aorta and remains difficult to quantitively evaluate by echocardiography. By providing comprehensive insights into hemodynamic changes and quantifying regurgitant fraction (RF) across various locations of the aorta, this study investigated the potential of 4D flow MRI to enhance diagnostic accuracy and inform clinical decision-making. Methods: An institutional database was queried for patients with chronic AR on echocardiography and paired cardiac MRIs with aortic 4D flow MRI. Patients with LVEF &lt; 50%, concomitant mitral regurgitation and aortic stenosis were excluded. A fully automated 4D flow MRI processing tool, performing standard preprocessing corrections and aortic 3D segmentation using separately trained machine learning models (Dense U-net convolutional neural network architecture) was used. Through-plane flow was quantified at 7 AHA-standardized locations: aortic annulus, sinotubular junction, mid ascending aorta, distal ascending aorta, aortic arch, proximal descending aorta and mid descending aorta. 4D flow MRI-based quantifications of RF were assessed for differentiating severe AR, using echo gradings as reference classification. Adjudicated clinical outcome data included cardiac-related hospitalizations such as heart failure, arrhythmias, and inpatient management of valve intervention. Results: Of 59 patients with chronic AR, the mean age was 49 ± 14.5 years, LVEF 56.5 ± 8.3%, LV end diastolic volume 251 ± 74 mL, 90% male and 73% had bicuspid aortic valves. Receiver operator characteristic (ROC) analysis of 4D flow MRI RFs revealed the optimal anatomic location to differentiate severe AR, as graded by echo was the mid descending aorta (AUC = 0.79). In patients with moderate, moderate-severe, and severe AR on echo, Kaplan-Meyer analysis reveals significant differences in cardiac-related hospitalization rates and time to valve intervention when patients were median split by optimal mid-descending aorta ROC RF (35%) but not at other locations of the aorta nor RFs calculated by traditional 2D Phase Contrast MRI (Figure 1). Conclusion: The optimal location in discerning severe aortic regurgitation as per RF by 4D flow analysis is the mid-descending aorta. 4D flow quantified RF of 35% at the mid-descending aorta was associated with cardiac related hospitalizations.

Non-insulin-based insulin resistance (IR) indices, including the estimated glucose disposal rate (eGDR), metabolic score for IR, and triglyceride-glucose indices (TyG-BMI, TyG-WC), have been implicated in cardiovascular diseases. However, few studies have investigated their associations with valvular heart disease (VHD). We conducted a prospective cohort study of 354 265 eligible participants from the UK Biobank. The primary outcome was incident VHD, including aortic valve stenosis, mitral valve regurgitation, and aortic valve regurgitation. eGDR, metabolic score for IR, TyG-BMI, and TyG-WC were categorized into quartiles, with eGDR ranked inversely due to its negative correlation with IR. Multivariable Cox proportional hazards regression was used to assess associations between IR indices and VHD risk. Over a median follow-up of 13.60 years, 8568 (2.42%) participants developed VHD, including 3793 (1.07%) aortic valve stenosis, 1371 (0.39%) aortic valve regurgitation, and 4040 (1.14%) mitral valve regurgitation cases. Participants in the highest quartile of non-insulin-based IR indices had significantly higher risks of incident VHD, with hazard ratios of 1.90 (95% CI, 1.75-2.06) for eGDR, 1.53 (95% CI, 1.41-1.65) for TyG-WC, 1.52 (95% CI, 1.42-1.63) for TyG-BMI, and 1.25 (95% CI, 1.17-1.34) for metabolic score for IR. The strongest associations were observed with aortic valve stenosis, with hazard ratios of 2.95 and 2.43 for eGDR and TyG-WC, respectively. Sensitivity analyses confirmed the robustness of these findings. Non-insulin-based IR indices, including eGDR, metabolic score for IR, TyG-BMI, and TyG-WC, are significantly associated with increased risk of incident VHD, particularly aortic valve stenosis. These findings may contribute to improved early risk stratification and targeted prevention strategies for VHD.

Background: Takayasu arteritis is a rare, granulomatous large-vessel vasculitis primarily affecting the aorta and its branches. Its non-specific presentation often delays diagnosis and can increase the risk of cardiovascular complications. Case Summary: A healthy 42-year-old woman with a BRCA mutation presented for breast cancer screening via a magnetic resonance imaging (MRI). This revealed cardiomegaly, for which she was referred to our hospital for workup. Her exam revealed a widened pulse pressure (70 mmHg) and a diastolic murmur at the right upper sternal border. Subsequently, a computed tomography (CT) and transthoracic echocardiogram showed perivascular fat-stranding concerning for aortitis (Figure 1A) and aortic regurgitation (AR) with left ventricular (LV) dilation and dysfunction, respectively. These findings were confirmed with a cardiac MRI (Figure 2) and transesophageal echo. Subsequent coronary CT angiogram ruled out aortic dissection but revealed 70% ostial left main (LM) coronary artery stenosis (Figure 1B), which was confirmed on coronary angiogram (Figure 3A). Given these findings, she was started on empiric steroids for presumed Takayasu arteritis after multidisciplinary discussions. Due to her severe AR associated with LV dysfunction and severe left main disease, she met Class I indications for surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG). A multidisciplinary discussion was held between cardiology, cardiothoracic surgery, and rheumatology regarding surgical timing given concerns for ongoing inflammation and associated surgical risks. However, her course was complicated by refractory chest pain requiring nitroglycerin infusion. After extensive discussions, via shared decision-making we proceeded with a temporizing, high-risk coronary stenting as a bridge to surgery following successful tapering of immunosuppressive therapy. She underwent a successful PCI (Figure 3B) and was initiated on dual-antiplatelet therapy. Ultimately, she was discharged on a prednisone taper and methotrexate, with plans for interval SAVR and CABG once on the lowest dose steroid. Discussion: Timely diagnosis and treatment is crucial to improving outcomes in Takayasu arteritis. Complications such as coronary artery stenosis and AR often require surgery but can be complicated by inflammation leading to friable tissue and an increased operative risk. Multidisciplinary management is key for optimal management and timing of such.

Background: Treponema pallidum causes syphilis, a sexually transmitted infection that can lead to various cardiovascular (CV) complications. However, large scale studies demonstrating the CV effects of syphilis are limited. Our study aims to characterize the possible CV effects of the growing syphilis epidemic. Hypothesis: Syphilis independently increases the risk of adverse CV outcomes. Methods: This retrospective cohort study examines patients receiving care between 2016-2025 at a tertiary care healthcare system in New Orleans, Louisiana. Syphilis patients were identified based on ICD10 and matched 1:5 to unaffected controls based on age, sex, diabetes, hypertension, hyperlipidemia, coronary artery disease, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, autoimmune disease, and cancer. Patients were excluded for having a history of CV comorbidity or HIV infection. Outcomes included acute myocardial infarction (MI), ischemic and hemorrhagic stroke, heart failure (HF), aortic regurgitation (AR), atrial fibrillation (AF), aortic aneurysm/dissection (AA/AD), non-atherosclerotic peripheral arteritis disease (PAD) and venous thromboembolism (VTE) were assessed. Kaplan-Meier and multivariable Cox proportional hazards models were used to estimate hazard ratios of syphilis for each cardiovascular outcome. Results: The matched cohorts included 7,345 controls compared to 1,469 patients with syphilis. Gender distribution was similar between the groups (54.1% female vs. 53.9%, p = 0.84), and the mean ages were comparable (50.07 ± 17.03 vs. 49.96 ± 17.62 years; p = 0.77. During the study period, patients with syphilis demonstrated a significantly higher risk of AA/AD (HR: 1.84, p = 0.001), ischemic stroke (HR: 1.51, p &lt; 0.001), hemorrhagic stroke (HR: 1.92, p = 0.004), PAD (HR: 1.28, p = 0.039) and MI (HR: 1.36, p = 0.012) compared to matched controls. HF, AF, VTE and AR did not differ significantly between groups. Conclusion: Syphilis is associated with independent increased risk of cardiovascular outcomes, particularly aortic aneurysm/dissection, ischemic stroke, hemorrhagic stroke, non-atherosclerotic peripheral artery disease and myocardial infarction.

Transcatheter aortic valve replacement is a well-established treatment for high-surgical-risk patients with severe aortic disease, providing a less invasive alternative to traditional surgery. While TAVR has been widely studied, few cases describe its use in patients with complex conditions like chronic aortic dissection and the case presentation below describes a successful case. A 68-year-old female with a history of hypertension, atrial flutter, and persistent type B aortic dissection, status post open repair, presented with worsening dyspnea. She also had moderate-to-severe aortic valve insufficiency. An echocardiogram showed severe regurgitation, aortic valve area of 1.9 and left ventricular dysfunction EF 50%. Cardiac catheterization revealed no significant coronary artery disease. CT imaging showed a complex aortic anatomy with both a true and false lumen extending from the distal ascending aorta into the abdominal aorta. Given her frailty and the complexity of her anatomy, a transfemoral approach for TAVR was chosen over surgical aortic valve replacement or other methods. The procedure was conducted under general anesthesia with primary access via the right common femoral artery and secondary access via the right radial artery. After heparinization, a 6-French pigtail catheter was placed in the aortic root. The valve delivery system (Medtronic Evolute Pro 29 mm valve) was carefully advanced across the aortic valve. During valve deployment, the procedure was complicated by the valve dislodging into the ascending aorta, causing the patient to enter cardiogenic shock. This required immediate pressor support and cardiopulmonary resuscitation. After stabilization, the valve was recaptured and redeployed successfully. Post-deployment imaging, including aortography and echocardiogram, showed proper valve placement, a trace paravalvular leak, an AV peak gradient of 10 mmHg, and an estimated aortic valve area of 2.2. Clinical course was complicated by complete heart block requiring a permanent pacemaker. A follow-up echocardiogram confirmed that the bioprosthetic valve was well-seated, with mild paravalvular leakage. TAVR is a less invasive option for high-risk patients with severe aortic disease but presents unique challenges in chronic aortic dissection, especially the risk of stroke due to lack of embolic protection. In this case, the Medtronic Evolute Pro valve was successfully used, highlighting the need for improved embolic protection strategies.

Introduction: Sydenham chorea (SC) is a form of acquired chorea of childhood and is linked to Acute Rheumatic Fever (ARF), which is an autoimmune response to infection with Group A Streptococcus (GAS). Historically called St Vitus Dance, SC is reported in some patients with ARF and forms part of the major criteria for ARF in the Jones Criteria. Case Presentation: A 12 years old female presented with 10-day history involuntary movements. She suffered sudden, involuntary, irregular twitching of the right upper, lower limbs and facial mouthing or grimacing. She developed irritability, restlessness, easy crying, anger over minor events, deteriorating handwriting and slurring of speech. A thorough history was taken from patient and family, it was discovered that she had recurrent episodes of sore throat in the last one year, last episode being 1.5 months before the onset of chorea. Her throat infections were never treated by a qualified doctor. Physical examination revealed spooning sign of the hands, milkmaid grip sign, pronator sign of the arms and darting tongue sign. Tonsillar hypertrophy grade I was also noted. Pansystolic murmur was present over apex, 2D Echo was performed which showed moderate MR and mild AR, LVEF was 65%. Blood work showed highly elevated Anti Streptolysin O levels of &gt;650 IU/ml. MRI of the brain didn’t detect any abnormality. Based on the history and findings, a diagnosis of Acute Rheumatic Fever with Sydenham chorea and valvular heart disease was made. The patient was started on Phenoxymethyl Penicillin, Carbamazepine and Pantoprazole after which her choreiform movements started to ameliorate significantly. Discussion: Despite progress in earlier diagnosis and treatment of streptococcal infection, Sydenham Chorea is still an essential feature of acute rheumatic fever in developing nations. The exact pathophysiology of SC hasn’t been understood, various theories have been suggested for the same. Most accepted theory of SC is an autoimmune one, which occurs in response to the group A streptococcal infection. These antibodies are created against streptococcal antigens and react with neuronal protein tissues particularly in the basal ganglia that account for choreiform movements made by SC patients. Carditis is another severe manifestation of ARF. The cardiac lesion frequently encountered in ARF is mitral regurgitation, aortic regurgitation is the other frequently observed valvular disease.

Introduction: Haemophilus influenzae is a rare cause of native valve infective endocarditis. We present a case of double valve endocarditis with initial focal neurologic findings and subsequent progression to cardiogenic shock requiring emergent surgical intervention. Description of Case: A 41-year-old male with a history of hypertension presented with headache, dizziness, and blurred vision, with rapid progression to global aphasia. Initial neurologic imaging revealed a subarachnoid hemorrhage of the left posterior, frontal, and parietal sulci. Transthoracic echocardiogram showed a bicuspid aortic valve with moderate aortic and mitral regurgitation and a 2.5cm mobile mitral valve vegetation. Digital subtraction angiography identified multiple pseudoaneurysms and a 2mm mycotic aneurysm. His intra-procedural course was complicated by acute hypoxic respiratory failure requiring emergent intubation and SCAI-C valvular cardiogenic shock. His course was further complicated by acute respiratory distress syndrome requiring lung-protective ventilation and stress-dose steroids. Transesophageal imaging revealed a new aortic root vegetation with worsening severe aortic regurgitation and mitral regurgitation. He remained febrile despite negative blood cultures and empiric antimicrobial treatment. A Karius Spectrum panel detected ceftriaxone-sensitive Haemophilus influenzae . Despite maximal inotropic support, antibiotics, and ventilator settings, he remained in refractory valvular shock and hypoxic respiratory failure. Emergent surgical intervention with Commando procedure additionally revealed an abscess extending into the aorto-mitral curtain, and the mitral valve, aortic valve and root, left atria, and left ventricular outflow tract was replaced and reconstructed.His post-operative course was complicated by high degree AV block requiring a leadless pacemaker and was discharged nine days later to acute rehabilitation. ` Discussion Haemophilus influenzae is culture-negative microbe that is a rare cause of double valve endocarditis. Karius testing allowed for identification and targeted antimicrobial therapy. However, despite maximal supportive therapy, correction of acute severe valvular cardiogenic shock required urgent surgery. The Commando procedure can be used for treatment of native double valve endocarditis and aorto-mitral curtain reconstruction.This case reinforces the essential role of a multidisciplinary care team in improving outcomes in critically ill patients.

Background: The bicuspid aortic valve (BAV) is the most prevalent congenital heart defect and is frequently associated with aortopathy. The etiology of aortic dilation in BAV is multifactorial, involving both hemodynamic stress and intrinsic aortic wall abnormalities. While previous studies have proposed several mechanisms, the specific and valve-related predictors of aortopathy remain unclear. Research question: Which clinical and echocardiographic features independently predict the presence of aortopathy in patients with BAV? Goals: To identify the patient and value-related characteristics associated with aortopathy in a large, real-world BAV cohort using standardized imaging and statistical approaches. Approach: Between 2013 and 2017, across 33 echocardiography labs within a large U.S. health system, 1,227 patients diagnosed with BAV were retrospectively reviewed. BAV morphology, presence of raphe, calcification severity (grades 0-4), aortic regurgitation (AR), aortic stenosis (AS), age, sex, and body surface area (BSA) were collected. Aortopathy was defined based on measurements of the aorta at the sinus of Valsalva and mid-ascending portions, indexed to body surface area. Univariate analysis (Mann-Whitney U and Chi-square) identified candidate predictors. A multivariable logistic regression model was constructed to identify independent predictors of aortopathy. Multicollinearity was assessed using the variance inflation factor and tolerance. Results: Among 1,227 BAV patients, 755 (61.5%) had aortopathy. They were older (54.7 vs. 51.9 years, p=0.006), had higher BSA (2.09 vs. 2.00 m 2 , p&lt;0.001), and were more often male (73.1% vs. 58.3%, p&lt;0.001). Independent predictors of aortopathy included male sex, age, AR severity, and BAV Type 1 (vs. Types 2 and 3). Calcification was inversely associated. AS, BSA, and raphe were not significant predictors. The model demonstrated excellent calibration (Hosmer-Lemeshow p = 0.715). Conclusion: Clinical characteristics emerge to differentiate BAV patients with aortopathy. Although the relationships between aortopathy and BAV are complex, specific clinical and echocardiographic variables in this cohort, particularly BAV Type 1, age, Male sex, calcification, and AR severity, were independently associated with aortopathy. These findings support multifactorial pathogenesis of BAV-associated aortopathy and may inform future risk stratification and surveillance strategies.

Background: Libman-Sacks endocarditis (LSE) is a rare, non-infective form of endocarditis, often associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). It is characterized by sterile, verrucous vegetations that typically affect the mitral and aortic valves. While mitral regurgitation and aortic regurgitation are more frequently reported, severe aortic stenosis (AS) as the primary manifestation of LSE is exceedingly rare, with a reported prevalence of only 1.1% among affected patients. Even more unusual is its presentation as the first sign of undiagnosed SLE in a male patient, given the strong female predominance of the disease, with a female-to-male ratio of approximately 8:1. Case: A previously healthy 37-year-old male, presented with severe chest pain. A Transthoracic echocardiogram (TTE) revealed severe aortic stenosis (Figure1), with vegetations on the right coronary cusp (RCC) and non-coronary cusp (NCC) of the aortic valve. His left ventricular ejection fraction was reported as normal, and minimal pericardial effusion was also detected. Infective endocarditis and pericarditis were suspected and he was started on analgesics and colchicine. Empirical antibiotic treatment was initiated, and blood cultures were collected. Transesophageal echo revealed vegetation on the RCC and NCC of the aortic valve, confirming endocarditis (Figure2). His blood cultures returned with negative results, and an autoimmune workup was consistent with the diagnosis of SLE and APS (Table1). A diagnosis of Libman-Sacks endocarditis was suspected as the underlying cause of the valvular disease. He was started on prednisolone, enoxaparin, hydroxychloroquine, warfarin, and aspirin. On follow-up six months later, TEE and TTE showed no significant change in the severity of his AS, nor the vegetation. Therefore, an aortic valve replacement was planned. Discussion: This is a rare case of a male patient with no prior symptoms who presented with LSE as the first manifestation of SLE and APS. It involved severe aortic stenosis, a less common outcome, as LSE typically causes regurgitation. Diagnosis was challenging due to the atypical presentation and initial suspicion of infection. Despite immunosuppressive treatment, the stenosis persisted, necessitating eventual aortic valve replacement. Early diagnosis and management of SLE and APS are crucial to reduce the risk of thromboembolic complications and potentially prevent irreversible organ damage.

Introduction: Large Language Models (LLMs) are powerful tools for text extraction, but their tendency to hallucinate limits their reliability in clinical domains. We present a novel application of retrieval-augmented generation (RAG) to reduce hallucinations. Our approach restricts context to short, high-similarity segments within cardiac imaging reports, enabling more focused, conservative inference. We applied RAG to extract echocardiographic features from intraoperative transesophageal echocardiography (TEE) reports in a mixed cardiac surgery population to identify distinct patient phenotypes. Hypothesis: We hypothesized that RAG would outperform direct LLM querying in extracting key echocardiographic features by reducing hallucinations. We aimed to group patients into clinically meaningful clusters by their echocardiographic features. Methods: We developed a RAG pipeline that restricts LLM input to the most semantically relevant portions of TEE reports (Figure 1). We validated this pipeline on 500 manually labeled reports, extracting pre- and post-intervention left ventricular ejection fraction (LVEF), tricuspid regurgitation (TR), and right ventricular systolic function (RVSF), as well as pre-intervention aortic stenosis (AS), aortic regurgitation (AR), and mitral regurgitation (MR). RAG performance was compared to direct querying on these validation reports. Next, the pipeline was scaled to 7106 TEE reports to extract the features and intervention types. Patients were clustered using k-means, and each cluster’s characteristics were analyzed. Results: RAG’s conservative behavior—favoring “not found” over potential fabrications—resulted in fewer hallucinations compared to direct LLM queries (Figure 2): RAG improved adjusted accuracy across all validation features (LVEF pre: +1.24%, LVEF post: +0.47%, TR pre: +3.64%, TR post: +4.67%, RVSF pre: +5.31%, RVSF post: +4.33%, AS pre: +11.44%, AR pre: +3.93%, MR pre: +1.94%). Clustering revealed five distinct phenotypes: (1) an aortic disease group, (2) a CABG-dominant low risk group, (3) an advanced heart failure group, (4) a mixed valve disease group, and (5) a tricuspid disease group (Table 1). Conclusions: Our RAG pipeline improves the reliability of LLM-based clinical data extraction from TEE reports, enabling large-scale phenotyping of heterogeneous cardiac surgery populations. This approach has potential applications for personalized risk stratification and targeted clinical decision support in cardiac surgery.

Case Presentation: A 56-year-old woman with a history of hypertension and type 2 diabetes mellitus presented with acute, severe chest pain radiating to the back, which began while decorating her Christmas tree an hour prior to arrival. High-sensitivity troponin was elevated at 178 ng/L. Electrocardiogram revealed 1 mm horizontal ST elevations in the inferior leads without reciprocal changes. A triple-rule-out chest CT angiogram was obtained to evaluate for aortic dissection, pulmonary embolism, and coronary pathology. The scan showed no dissection, although contrast timing was optimized for pulmonary vasculature, limiting coronary and aortic detail. An ectatic ascending thoracic aorta (4.5 cm) was noted. Emergent left heart catheterization revealed mild, non-obstructive coronary artery disease. Diagnostic Evaluation: Given persistent suspicion for acute aortic syndrome, a dedicated CT angiogram of the aorta was performed, revealing an extensive intramural hematoma involving the aortic root, ascending aorta, arch, descending aorta, and abdominal aorta above the renal arteries. Treatment and Management: An esmolol infusion was initiated, and cardiothoracic surgery was urgently consulted. Imaging was interpreted as most consistent with a penetrating aortic ulcer and sub-adventitial hematoma. The patient underwent emergent surgical replacement of the ascending aorta and hemiarch. Intraoperative transesophageal echocardiogram did not reveal aortic regurgitation or pericardial effusion. Discussion: Intramural hematoma (IMH) is a form of acute aortic syndrome, with potential etiologies including rupture of vasa vasorum, neovascularization of atherosclerotic plaques, or microscopic intimal tears from penetrating ulcers. Prompt recognition is crucial, as IMH can mimic acute coronary syndrome (ACS) and misdiagnosis may result in harmful interventions. Tools such as the AORTAS score, which assigns two points for hypotension and one point each for aneurysm, pulse deficit, neurological deficit, severe pain, and sudden onset, can aid in risk stratification. A score &gt;2, as in our patient (score = 3), warrants definitive imaging. Complications include hemopericardium, aortic regurgitation, and coronary compromise. Type A IMH mandates emergent surgical repair. Conclusion: A high index of suspicion is essential to differentiate IMH from ACS. Early, targeted imaging is critical, as interventions such as anticoagulation or invasive catheterization may accelerate disease progression.