Aortic Valve Area Research Articles

Investigation of von Willebrand factor multimer abnormalities before and after aortic valve replacement using the Hydragel-5 assay

BackgroundSevere aortic stenosis (sAS) is associated with acquired von Willebrand syndrome (AVWS) by loss of high-molecular-weight multimers (HMWM) of von Willebrand factor (VWF), potentially resulting in perioperative bleeding. Analysis of VWF multimers remains challenging. Recently, the new, rapid Hydragel 5 assay has been developed, using electrophoretic protein separation for dividing VWF-multimers into low (LMWM), intermediate (IMWM), and HMWM, the hemostatically active part of VWF. Here, we evaluated its impact on predicting blood loss in presence of AVWS after surgical aortic valve replacement (SAVR). MethodsWe prospectively examined 52 patients (age: 68 ± 7 years; 54 % male) admitted to SAVR. They were divided in two groups (A: normal VWF, n = 28; B: abnormal VWF, n = 24, defined as VWF-activity/antigen (VWF:Ac/Ag)-ratio < 0.7 and/or HMWM loss). Blood samples and echocardiographic data were collected before, seven days and three months after SAVR. Blood loss and transfusions were recorded. ResultsBaseline characteristics and clinical data were similar in both groups. HMWM loss was present in 38.5 % of all patients. HMWM, the VWF:Ac/Ag- and HMWM/(IMWM+LMWM)-ratios were significantly decreased preoperatively in group B but normalized after SAVR. Bleeding, re-thoracotomy and transfusion rates were comparable. HMWM loss was inversely correlated with the peak aortic gradient (Pmax) and positively with the aortic valve area (AVA), while HMWM/(IMWM+LMWM)-ratio negatively correlated with the mean aortic gradient (Pmean). ConclusionHMWM and HMWM/(IMWM+LMWM)-ratio inversely correlate with severity of AS and normalize after SAVR. The Hydragel-5 assay's might be valuable for routine diagnostics to assess bleeding risk and postoperative normalization of AS and VWF abnormalities in SAVR patients.

Reverse left ventricular remodeling after aortic valve replacement for aortic stenosis: a systematic review and meta-analysis.

Reverse left ventricular (LV) remodeling after aortic valve replacement (AVR), in patients with aortic stenosis, is well-documented as an important prognostic factor. With this systematic review and meta-analysis, we aimed to characterize the response of the unloaded LV after AVR. We searched on MEDLINE/PubMed and Web of Science for studies reporting echocardiographic findings before and at least 1 month after AVR for the treatment of aortic stenosis. In total, 1,836 studies were identified and 1,098 were screened for inclusion. The main factors of interest were structural and dynamic measures of the LV and aortic valve. We performed a random-effects meta-analysis to compute standardized mean differences (SMD) between follow-up and baseline values for each outcome. Twenty-seven studies met the eligibility criteria, yielding 11,751 patients. AVR resulted in reduced mean aortic gradient (SMD: mmHg, 95% CI: to , ), LV mass (SMD: g, 95% CI: to , ), end-diastolic LV diameter (SMD: mm, 95% CI: to , ), end-diastolic LV volume (SMD: ml, 95% CI: to 3.51, ), increased effective aortic valve area (SMD: 1.10 cm2, 95% CI: 1.01 to 1.20, ), and LV ejection fraction (SMD: 2.35%, 95% CI: 1.31 to 3.40%, ). Our results characterize the extent to which reverse remodeling is expected to occur after AVR. Notably, in our study, reverse remodeling was documented as soon as 1 month after AVR.

Relationships Between Aortic Valve Calcium Quantification And Valve Area By Contrast-enhanced Computed Tomography In Aortic Stenosis Patients Undergoing Transcatheter Aortic Valve Replacement

Relationships Between Aortic Valve Calcium Quantification And Valve Area By Contrast-enhanced Computed Tomography In Aortic Stenosis Patients Undergoing Transcatheter Aortic Valve Replacement

The Relative Apical Sparing Strain Pattern in Severe Aortic Valve Stenosis: A Marker of Adverse Cardiac Remodeling.

The presence of a relative apical sparing (RAS) echocardiographic strain pattern raises a suspicion of underlying cardiac amyloidosis (CA). However, it is also increasingly observed in patients with aortic stenosis (AS). We aimed to evaluate the prevalence, dynamics, and clinical characteristics of the RAS strain pattern in severe AS patients who had been referred for surgical aortic valve replacement (SAVR). A total of 77 patients with severe AS and without CA were included with a mean age of 70 (62-73) years, 58% female, a mean aortic valve area index of 0.45 ± 0.1 cm2/m2, and a mean gradient of 54.9 (45-70) mmHg. An RAS strain pattern was detected in 14 (18%) patients. RAS-positive patients had a significantly higher LV mass index (125 ± 28 g/m2 vs. 91 ± 32, p = 0.001), a lower LV ejection fraction (62 ± 12 vs. 68 ± 13, p = 0.040), and lower global longitudinal strain (-14.9 ± 3 vs. -18.7 ± 5%, p = 0.002). RAS strain pattern-positive patients also had higher B-type natriuretic peptide (409 (161-961) vs. 119 (66-245) pg/L, p = 0.032) and high-sensitivity troponin I (15 (13-29) vs. 9 (5-18) pg/L, p = 0.026) levels. Detection of an RAS strain pattern was strongly associated with increased LV mass index (OR 1.03, 95% CI 1.01-1.06, p < 0.001). The RAS strain pattern had resolved in all patients by 3 months after SAVR. Our findings suggest that the RAS strain pattern can be present in patients with severe AS without evidence of CA. The presence of an RAS strain pattern is associated with adverse LV remodeling, and it resolves after SAVR.

Electronic physician notification to facilitate the recognition and management of severe aortic stenosis: Rationale, design, and methods of the randomized controlled DETECT AS trial

BackgroundSymptomatic severe aortic stenosis causes substantial morbidity and mortality when left untreated, yet recent data suggest its undertreatment. ObjectiveTo evaluate the efficacy of electronic physician notification to facilitate the guideline-directed management of patients with severe aortic stenosis. HypothesisWe hypothesize that patients with severe aortic stenosis who are in the care of physicians who receive the notification are more likely to undergo aortic valve replacement within 1-year. Methods/DesignThe Electronic Physician Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis (DETECT AS) trial is a randomized controlled trial and quality improvement initiative designed to evaluate the efficacy of electronic provider notification versus usual clinical care in the management of patients with severe aortic stenosis. Providers ordering an echocardiogram with findings potentially indicative of severe aortic stenosis, defined by an aortic valve area ≤1.0 cm2, are randomized in a 1:1 fashion to receive electronic notification (intervention) or usual care. Providers in the notification arm are sent a notification within the electronic health record inbox outlining customized guideline recommendations for the management of patients with severe aortic stenosis based on the 2020 ACC/AHA Clinical Practice Guidelines for Valvular Heart Diseases for the index and all subsequent echocardiograms. Providers in the control arm receive no notification. Randomization continues until 940 patients have been enrolled. SettingMulti-centered, academic health system OutcomesThe primary endpoint is the proportion of patients with severe AS receiving an aortic valve replacement within 1-year of the index echocardiogram. Secondary endpoints include mortality, heart failure hospitalization, transthoracic echocardiogram utilization/surveillance, aortic stenosis billing code diagnosis, and cardiology/Heart Valve Team referral. ConclusionThe DETECT AS trial will provide insight into whether electronic notification of providers on the presence of severe aortic stenosis and associated clinical guideline recommendations will facilitate recognition and guideline-directed management of severe aortic stenosis. Trial RegistrationClinicalTrials.gov, NCT05230225, https://clinicaltrials.gov/ct2/show/NCT05230225

Aortic valve area index values of Trifecta implants correlate with energy loss and increased valve stress.

Biological valves are becoming more frequently used in aortic valve replacement. While several reports have evaluated the performance of biological valves, echocardiography studies during exercise stress remain scarce. Furthermore, no current reports compare rate changes in the aortic valve area of biological valves under increased exercise load. Here, we performed exercise stress echocardiography in patients after AVR with Trifecta or Inspiris valves and compared the rates of change in aortic valve areas (AVA). In addition, hydrodynamic analysis at rest was conducted with four-dimensional flow magnetic resonance imaging (4D-flow MRI). Exercise stress echocardiography was performed in seven Trifecta and seven Inspiris patients who underwent AVR at our hospital while 4D flow MRI was performed in all but two Trifecta cases. Comparing the percentage change in AVA when loaded to 25W versus at rest, Trifecta was greater than Inspiris (28.7 ± 36.0 vs - 0.8 ± 12.4%). The smaller AVA at rest was considered causative for this. Meanwhile, Trifecta systolic energy loss in the prosthetic valve segment on 4D-flow MRI (97.5 ± 35.9 vs 52.7 ± 25.3mW) was higher than Inspiris. The opening of the Trifecta valve was considered to be restricted at rest and this may reflect the current reports of early valve degradation requiring reoperation. Taken together, we observed that the Trifecta design may promote faster wear due to higher valve stress.

Impact of Stress Echocardiography on Aortic Valve Stenosis Management.

Rest and stress echocardiography (SE) play a fundamental role in the evaluation of aortic valve stenosis (AS). According to the current guidelines for the echocardiographic evaluation of patients with aortic stenosis, four broad categories can be defined: high-gradient AS (mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, aortic valve area (AVA) ≤ 1 cm2 or indexed AVA ≤ 0.6 cm2/m2); low-flow, low-gradient AS with reduced ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, left ventricle ejection fraction (LVEF) < 50%, stroke volume index (Svi) ≤ 35 mL/m2); low-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, LVEF ≥ 50%, SVi ≤ 35 mL/m2); and normal-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, indexed AVA ≤ 0.6 cm2/m2, LVEF ≥ 50%, SVi > 35 mL/m2). Aortic valve replacement (AVR) is indicated with the onset of symptoms development or LVEF reduction. However, there is often mismatch between resting transthoracic echocardiography findings and patient's symptoms. In these discordant cases, SE and CT calcium scoring are among the indicated methods to guide the management decision making. Additionally, due to the increasing evidence that in asymptomatic severe aortic stenosis an early AVR instead of conservative treatment is associated with better outcomes, SE can help identify those that would benefit from an early AVR by revealing markers of poor prognosis. Low-flow, low-gradient AS represents a challenge both in diagnosis and in therapeutic management. Low-dose dobutamine SE is the recommended method to distinguish true-severe from pseudo-severe stenosis and assess the existence of flow (contractile) reserve to appropriately guide the need for intervention in these patients.

Prognostic Value of Aortic Valve Calcification in Nonsevere Aortic Stenosis with Preserved Ejection Fraction.

Aortic valve calcification(AVC) is prognostic in patients with aortic stenosis(AS). We assessed the AVC prognostic value in nonsevere AS patients. We conducted a retrospective study of 395 patients with nonsevere AS, LV ejection fraction ≥50%. The Agatston method was used for computed tomography AVC assessment. The log-rank test determined the best AVC cutoffs for survival under medical surveillance: 1185 AU in men and 850 in women, lower than the established-cutoffs for severe AS(2064AU in men and 1274 in women). Patients were divided into three AVC groups based on these cutoffs: low(<1185 AU men and <850 women), sub-severe(1185-2064AU men and 850-1274 women) and severe(>2064AU men and >1274 women). Of 395 patients(mean age 73 ± 12 years, 60.5% men, aortic valve area 1.23 ± 0.30cm2, mean pressure gradient 28 ± 8 mmHg), 218 underwent aortic valve intervention(AVI) and 158 deaths occurred during follow-up, 82 before AVI. Median survival time under medical surveillance was 2.1[0.7-4.9]years. Compared to the low AVC group, both sub-severe and severe AVC groups had higher risk for all-cause death under medical surveillance after comprehensive adjustment including echocardiographic AS severity and coronary artery calcium score(all p ≤ 0.006); while mortality risk was similar between sub-severe and severe AVC groups(all p ≥ 0.2). This mortality risk pattern persisted in the overall survival analysis after adjustment for AVI. AVI was protective of all-cause death in the sub-severe and severe AVC(all p ≤ 0.01), but not in the low AVC groups. Sub-severe AVC is a robust risk-stratification parameter in patients with nonsevere AS and may inform AVI timing.

Moderate aortic stenosis: Navigating the uncharted.

Aortic stenosis (AS) stands as the most common valvular heart disease in developed countries and is characterized by progressive narrowing of the aortic valve orifice resulting in elevated transvalvular flow resistance, left ventricular hypertrophy, and progressive increased risk of heart failure and sudden death. This narrative review explores clinical challenges and evolving perspectives in moderate AS, where discrepancies between aortic valve area and pressure gradient measurements may pose diagnostic and therapeutic quandaries. Transthoracic echocardiography is the first-line imaging modality for AS evaluation, yet cases of discordance may require the application of ancillary noninvasive diagnostic modalities. This review underscores the importance of accurate grading of AS severity, especially in low-gradient phenotypes, emphasizing the need for vigilant follow-up. Current clinical guidelines primarily recommend aortic valve replacement for severe AS, potentially overlooking latent risks in moderate disease stages. The noninvasive multimodality imaging approach-including echocardiography, cardiac magnetic resonance, computed tomography, and nuclear techniques-provides unique insights into adaptive and maladaptive cardiac remodeling in AS and offers a promising avenue to deliver precise indications and exact timing for intervention in moderate AS phenotypes and asymptomatic patients, potentially improving long-term outcomes. Nevertheless, what we may have gleaned from a large amount of observational data is still insufficient to build a robust framework for clinical decision-making in moderate AS. Future research will prioritize randomized clinical trials designed to weigh the benefits and risks of preemptive aortic valve replacement in the management of moderate AS, as directed by specific imaging and nonimaging biomarkers.

Dimensionless index and outcome in patients with aortic valve disease.

Assessment of aortic stenosis (AS) is based on aortic valve (AV) gradients and calculation of aortic valve area (AVA). These parameters are influenced by flow and dependent on geometric assumptions. The dimensionless index (DI), the ratio of the LVOT time-velocity integral to that of the AV jet, is simple to perform, and is less susceptible to error but has only been examined in small selected groups of AS patients. The objective of this study was to assess the DI and prognosis in a large cohort. All subjects who underwent echocardiography with an assessment of the AV that included DI were included. Association between AV parameters including mean gradient, AVA, DI and AV resistance and mortality and cardiovascular hospitalizations was examined. A total of 9393 patients (mean age 71±16 years; 53% male) were included. 731 (7.7%) patients had DI less than.25. Increasing age and a diagnosis of heart failure were significantly associated with lower DI. Subjects with low DI had significantly lower ventricular function, a higher incidence of mitral and tricuspid regurgitation, worse diastolic function and more elevated pulmonary pressures. Decreasing DI was associated with significantly decreased survival and event-free survival which remained highly significant on multivariate analysis. In a large population of patients with AV disease, decreased DI, was associated with increased mortality and decreased event-free survival. The easily obtained DI identifies a broad range of AS subjects with worse prognosis and should be integrated into the assessment of these complex patients.

Diagnostic Challenges in Aortic Stenosis.

Aortic stenosis (AS) is the most prevalent degenerative valvular disease in western countries. Transthoracic echocardiography (TTE) is considered, nowadays, to be the main imaging technique for the work-up of AS due to high availability, safety, low cost, and excellent capacity to evaluate aortic valve (AV) morphology and function. Despite the diagnosis of AS being considered straightforward for a very long time, based on high gradients and reduced aortic valve area (AVA), many patients with AS represent a real dilemma for cardiologist. On the one hand, the acoustic window may be inadequate and the TTE limited in some cases. On the other hand, a growing body of evidence shows that patients with low gradients (due to systolic dysfunction, concentric hypertrophy or coexistence of another valve disease such as mitral stenosis or regurgitation) may develop severe AS (low-flow low-gradient severe AS) with a similar or even worse prognosis. The use of complementary imaging techniques such as transesophageal echocardiography (TEE), multidetector computed tomography (MDTC), or cardiac magnetic resonance (CMR) plays a key role in such scenarios. The aim of this review is to summarize the diagnostic challenges associated with patients with AS and the advantages of a comprehensive multimodality cardiac imaging (MCI) approach to reach a precise grading of the disease, a crucial factor to warrant an adequate management of patients.

Diagnostic Value of Aortic Valve Calcification Levels in the Assessment of Low-Gradient Aortic Stenosis

BackgroundIn patients with low-gradient aortic stenosis (AS) and low transvalvular flow, dobutamine stress echocardiography (DSE) is recommended to determine AS severity, whereas the degree of aortic valve calcification (AVC) supposedly correlates with AS severity according to current European and American guidelines. ObjectivesThe purpose of this study was to assess the relationship between AVC and AS severity as determined using echocardiography and DSE in patients with aortic valve area <1 cm2 and peak aortic valve velocity <4.0 m/s. MethodsAll patients underwent DSE to determine AS severity and multislice computed tomography to quantify AVC. Receiver-operating characteristics curve analysis was used to assess the diagnostic value of AVC for AS severity grading as determined using echocardiography and DSE in men and women. ResultsA total of 214 patients were included. Median age was 78 years (25th-75th percentile: 71-84 years) and 25% were women. Left ventricular ejection fraction was reduced (<50%) in 197 (92.1%) patients. Severe AS was diagnosed in 106 patients (49.5%). Moderate AS was diagnosed in 108 patients (50.5%; in 77 based on resting transthoracic echocardiography, in 31 confirmed using DSE). AVC score was high (≥2,000 for men or ≥1,200 for women) in 47 (44.3%) patients with severe AS and in 47 (43.5%) patients with moderate AS. AVC sensitivity was 44.3%, specificity was 56.5%, and positive and negative predictive values for severe AS were 50.0% and 50.8%, respectively. Area under the receiver-operating characteristics curve was 0.508 for men and 0.524 for women. ConclusionsMulti-slice computed tomography–derived AVC scores showed poor discrimination between grades of AS severity using DSE and cannot replace DSE in the diagnostic work-up of low-gradient severe AS.

The Flow Rate in Patients With Low-Gradient Aortic Stenosis.

The decision to assess the severity and determine the ideal timing of intervention for low-gradient aortic stenosis poses a greater challenge. Recently, a novel method for determining the flow status of patients with aortic stenosis has been introduced, utilizing flow rate measurements. In this study, we investigated whether the flow status of patients with low-gradient aortic stenosis is linked to mortality within a three-year timeframe. Twenty-nine patients diagnosed with low-gradient aortic stenosis and valve area ≤ 1 cmwere identified during 2010-2015. Each patient's flow rate across the aortic valve was computed, and the study scrutinized echocardiographic parameters to ascertain their correlation with mortality over a three-year timeframe. We observed that among patients with low-gradient aortic stenosis and a valve area of ≤1 cm, a decreased flow rate across the aortic valve emerged as an independent predictor of mortality. A flow rate < 210 ml/s was linked with a three-year mortality rate of 66.7%, whereas a low stroke volume index < 35 ml/m² did not show an association with three-year mortality. This observation might be attributed to the smaller body sizes prevalent among these older patients, particularly females, which could influence the calculation of the stroke volume index. In older patients with low-gradient aortic stenosis, the flow rate can better reflect flow status than the stroke volume index, and it also suggests a prognostic significance in predicting mortality. Additional studies are warranted to validate these findings across broader patient populations and to assess the potential efficacy of early intervention strategies in this particular patient cohort.

UNRAVELING GENDER DISPARITIES AND PROGNOSTIC INSIGHTS IN MODERATE AORTIC STENOSIS: A RETROSPECTIVE STUDY

Abstract Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries, associated with reduced survival if severe AS remains untreated. Recent reports note unfavorable outcomes in moderate AS (mAS) patients, challenging optimal intervention timing. Variations in pathophysiology linked to sex differences, involving sex hormones, activation of the renin–angiotensin–aldosterone system, and dysregulation in collagen synthesis, have been observed. Yet, limited data exists on sex–specific differences in mAS outcomes. This single–center, retrospective study included 150 patients (median age 79±13 years, female sex 48%) diagnosed with mAS who underwent comprehensive echocardiography in IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico of Milan from July 2022 to October 2023. Clinical data, encompassing demographics details and therapy, were obtained via record reviews and phone interviews. Death verification relied on the ‘Sistema Informativo Socio–Sanitario Regione Lombardia’ database. Echocardiographic records were digitally stored and post–processed by four independent investigators using Medimatic ComPACS workstation. Men were significantly younger than women (75±10 vs 79±9.7 years, p= 0.016). They exhibited lower left ventricular (LV) ejection fraction, larger LV end–systolic volume and stroke volume compared to women (54±7 vs 59±10%; p=0.028. 55±36 vs 31±13 ml; p&amp;lt;0.001. 83±18 vs 75±18 ml; p=0.030). Men had significantly smaller aortic valve (AV) area index to body surface area (BSA) (0.6±0.09 vs 0.7±0.1 cmq/mq; p&amp;lt;0.001) and lower doppler velocity index (0.32±0.07 vs 0.38±0.11; p&amp;lt;0.001) than women. Coronary artery disease and smoking were more frequent in men (53.3 vs 46.7%; p=0,002. 52.6 vs 47.4%; p&amp;lt;0.001). In survival analysis, 15% of women and 30.8% of men experienced events, with male gender independently associated with the composite outcome (all–cause mortality and AV replacement) over a mean follow–up time of 200 ± 133 days, showing a median survival of 244±16 vs 255±15 days for females (p–value=0.025). In multivariable analysis including relevant clinical variables (hemoglobin and AV index to BSA), male sex remained independently associated with the composite outcome (hazard ratio 2,01; CI 1.0–4.17; p=0.05). Women diagnosed with mAS exhibited a lower incidence of AV replacement and all–cause mortality. These findings may suggest the existence of different clinical and echocardiographic phenotypes among patients with AS.

CASE REPORT: SELF–EXPANDING TRANSCATHETER VALVE IMPLANTATION (ACURATE NEO 2) IN A VERY SMALL NATIVE AORTIC ANNULUS

Abstract We present the case of a 74–year–old female, symptomatic for dyspnea on exertion, evaluated by our Cardiac Team for severe aortic valve (AV) stenosis. The transesophageal echocardiography showed a stenotic tricuspid AV (valve area of 0.51 cm2, peak and mean gradients of 75 mmHg and 43 mmHg respectively), normal left ventricle (LV) ejection fraction without significant intraventricular gradient. Pre–operative thoraco–abdominal computed tomography angiography showed an AV without significant calcifications, an aortic annulus perimeter of 51.7 mm (area of 207,8 mm2) and a left ventricular outflow tract (LVOT) perimeter of 45.3 mm with elliptical shape (area of 149,9 mm2). The TAVR procedure was performed with an ‘off–label’ implantation of a SE THV with supra–annular location of leaflets (Acurate Neo 2 23 mm), without any predilation. The post–procedural transthoracic echocardiographic study highlighted the correct positioning of the bioprosthesis without significant protrusion in the LVOT and without any interference with the mitral valve apparatus. The main clinical, technical and procedural considerations have been: According to recommendations, the minimum perimeter of 56.5 mm and the minimum area of 254 mm2 represent the lower limits of the sizing guidelines for THV currently available. We used a SE valve with supra–annular location of the leaflets that offers a potential advantage over BE valves and intra annular SE valves, ensuring a larger effective orifice area. We avoided pre– and post–dilatation to reduce the risk of annular damage and/or rupture The precision of THV implantation (with minimal protrusion in LVOT) was maximized when the rapid pacing during phase 2 of the valve deployment was utilized. A short period of DAPT can be considered in order to prevent a potential increase of thromboembolic events secondary to small aortic valve area. In our opinion the main goal is to prevent high implantation and commissural misalignment in order to facilitate the subsequent coronary percutaneous interventions if needed. Even prophylactic coronary stenting (‘chimney fashion‘) should be avoided unless absolutely necessary. These technical considerations applies also to allow a subsequent valve–in–valve (VIV) procedure, if indicated. To our knowledge, this is among the smallest native aortic annulus so far described and treated percutaneously in a tricuspid stenotic aortic valve with a self–expanding (SE) THV Acurate Neo 2.

Impact of osteoporotic risk in men undergoing transcatheter aortic valve replacement: a report from the LAPLACE-TAVI registry.

Low body weight and advanced age are among the best predictors of osteoporosis. Osteoporosis Self-Assessment Tool (OST) values are calculated by a simple formula [(body weight in kilograms - age in years) × 0.2] to identify patients at increased risk of osteoporosis. In our recent single-center study, we demonstrated an association between OST and poor outcomes in postmenopausal women after transcatheter aortic valve replacement (TAVR). We aimed to investigate the impact of osteoporotic risk in men with aortic stenosis who underwent TAVR in a large cohort. In this multi-center study, 1,339 men who underwent TAVR between April 2010 and July 2023 were retrospectively analyzed. Women were excluded from the present study. All patients were deemed appropriate for TAVR after a review by a multidisciplinary team. Baseline characteristics of patients were compared by dividing patients into three tertiles, based on the OST value: ≤ -6.16, -6.16 to -4.14, and -4.14 < for tertiles 1, 2, and 3, respectively. Primary endpoint was all-cause mortality after TAVR. Tertile 1 (patients with the lowest OST values) included older patients with smaller body mass index, lower hemoglobin and albumin levels. In addition, they had greater clinical frailty scale, slower 5-meter walk test, weaker hand grip strength, and more cognitive impairment, indicating increased frailty. They were more severely symptomatic, with lower ejection fractions, smaller aortic valve areas, and more tricuspid regurgitation than were patients in the other two groups. Multivariate analysis revealed that OST tertiles 3 was associated with decreased risk of all-cause mortality (hazard ratio, 0.66; 95% confidence interval, 0.48-0.90), compared with OST tertile 1 as a reference. For OST tertiles 1, 2, and 3, the estimated 1-year survival rates of all-cause mortality post-TAVR were 83.6% ± 1.9%, 91.1% ± 1.4%, and 93.1% ± 1.3%, respectively, (log-rank, p <0.001). In conclusions, in men as same as women, osteoporotic risk assessed by OST values was overlapped with increased frailty. The simple OST formula was useful for predicting all-cause mortality in patients undergoing TAVR in large registry datasets.

LIFETIME MANAGEMENT OF AORTIC STENOSIS IN EXTREME SETTING

Abstract A 51–year–old male patient returned to our attention due to symptomatic severe aortic stenosis. Despite the severity of the aortic valve disease, he had been previously turned down from aortic valve replacement by us because of lack of symptoms and very unfavorable anatomy. Indeed he had been irradiated at the age of 3 due to Hodgkin’s Lymphoma and presented with porcelain aorta, small ascending aorta and aortic annulus. The patient returned to us with a 3–month history of progressive dyspnea (NYHA class IIa) and one episode of lipothymia during physical exercise. Physical examination, hematologic and biochemical investigations at admission were normal. Our trans–thoracic echocardiogram confirmed a trileaflet aortic valve (AV) that was severely stenotic and calcified with a mean gradient of 60 mmHg and an AV area of 0.5 cm2 (0.3 cm2/m2), in presence of good left ventricular systolic function with an ejection fraction (EF) of 60%. CT excluded coronary disease but, confirmed severe calcified aortic stenosis and porcelain aorta with small calcific sino–tubular junction and ascending aorta and protruding LVOT calcium. (Ascending aorta 19 mm; STJ 19 mm). The heart–team judged the patient not suitable for AVR and decided to perform a high–risk TAVI, leaving apical conduit as the last resort. From a technical standpoint, the LVOT calcium and the short and narrow STJ were high risk features for rupture with balloon expandable devices. On the other hand the short and narrow STJ with the narrow ascending aorta would represent a serious issue for the expansion of self–expanding devices and an even more troublesome feature for future coronary access and coronary occlusion in the setting of TAVI–in–TAVI down the road. Given the patient’s young age, a balloon expandable SAPIEN ultra 23 mm was chosen to be implanted with a two–step inflation to minimize the risk of STJ rupture. The prosthesis was partially expanded until anchoring was achieved on the aortic leaflets then, on continuous pacing, the balloon was rapidly collapsed, pushed down deeper under the STJ and fully inflated to achieve prosthesis’ inflow expansion. Intra–procedural and post–procedural course were uneventful and the patient was discharged home in 5th Day. Transthoracic echocardiogram at the dismission reveal a trans–aortic mean gradient of 18 mmhg, the absence of significant paravalvular leaks and a preserved ejection fraction. Pre–discharge CT scan confirmed feasibility of future TAVI–in–TAVI in case of need.

Acute Aortic Dissection After Transcatheter Aortic Valve Replacement

Acute aortic dissection (AAD) is a rare and potentially fatal complication associated with transcatheter aortic valve replacement (TAVR). Owing to the paucity of existing institutional data, we sought to assess the incidence of postimplant AAD in patients who underwent TAVR at a single institution. All patients who underwent TAVR from 2013 to 2022 were retrospectively reviewed to identify those who possessed clinical or radiologic evidence of AAD after TAVR. Follow-up and survival data were retrieved for all included patients. A total of 4,317 patients underwent TAVR, of whom 9 (0.2%) sustained an AAD. These patients had a mean age of 80 years (range 53 to 92), mean Society of Thoracic Surgeons 30-day mortality risk of 5.7% (2.4% to 16.7%), and mean effective aortic valve area of 0.8 cm2 (0.4 to 1.5 cm2). Preoperative maximum aortic diameter was 3.9 cm (2.6 to 4 cm). Of these 9 patients, 6 (67%) showed evidence of Stanford type A dissection, whereas 3 (33%) were diagnosed with Stanford type B dissection. The most common causes of dissection were posterior annular rupture by the transcatheter valve (THV) (44%) and THV embolization or "pop-out" into the ascending aorta (22%). A total of 6 patients (66.7%), comprising 5 type A (55.6%) and 1 type B (11.1%) aortic dissections, died within 30 days of AAD. The median time to follow-up in those surviving TAVR with intraoperative AAD was 1,042 days (range: 648 to 2,666). Surviving patients were managed through thoracic endovascular aortic repair and medical management. In conclusion, in this highly selected cohort of patients, our experience indicates that AAD after TAVR is a rare but often lethal intraprocedural sequela of THV implantation, especially in cases of type A aortic dissection.

Ten-year Durability, Hemodynamic Performance, and Clinical Outcomes after Transcatheter Aortic Valve Implantation Using a Self-expanding Device.

The expansion of transcatheter aortic valve implantation (TAVI) to low-risk and younger patients has increased the relevance of the long-term durability of transcatheter heart valves (THV). The present study aims to assess the 10-year durability, hemodynamic performance, and clinical outcomes after TAVI using the CoreValve system. An analysis from a prospective registry with predefined clinical and echocardiographic follow-up included 302 patients who underwent TAVI with the CoreValve system between 2007 and 2015. Bioprosthetic valve failure (BVF) was defined as any bioprosthetic valve dysfunction-related death, re-intervention, or severe hemodynamic valve deterioration. At the time of TAVI, the mean age was 80.41 ± 7.01years, and the Society of Thoracic Surgeons (STS) score was 6.13 ± 5.23%. At latest follow-up (median [IQR]: 5 [2-7] years), cumulative all-cause mortality ratesat 3, 5, 7, and 10years was 23.7%, 40%, 65.8%, and 89.8%, respectively. Mean aortic valve area and transvalvular gradient post-TAVI and at 5, 7, and 10years were 1.94, 1.87, 1.69, and 1.98 cm2 (p = 0.236) and 8.3, 9.0, 8.2, and 10.1mmHg (p = 0.796), respectively. Overall, 11 patients had BVF, of whom six had structural valve deterioration (SVD). The 10-year actual and actuarial freedom from BVF was 96.1% and 78.8%, and from SVD was 97.9% and 80.9%, respectively. Three patients developed significant non-SVD due to severe paravalvular leakage, and two patients were diagnosed with infective endocarditis. Using an early-generation self-expanding bioprosthesis, we documented durable hemodynamic performance and low rates of BVF and SVD up to 10 years after TAVI.

Clinical efficacy of tolvaptan in acute decompensated heart failure patients with severe aortic stenosis and atrial fibrillation: a sub-analysis from the LOHAS registry.

Severe aortic valve stenosis (AS) and atrial fibrillation (AF) are risk factors of hemodynamic instability in heart failure (HF) management due to low cardiac output, respectively. Therefore, the treatment of HF due to severe AS complicated with AF is anticipated to be difficult. Tolvaptan, a vasopressin V2 receptor inhibitor, is effective in controlling acute decompensated heart failure (ADHF) with hemodynamic stability. However, its clinical efficacy against ADHF caused by AS with AF remains to be determined. Clinical information (from September 2014 to December 2017) of 59 patients diagnosed with ADHF due to severe AS (20 patients with AF; 39 patients with sinus rhythm [SR]) was obtained from the LOHAS registry. The registry collected data from seven hospitals and assessed the short-term effects of tolvaptan in patients hospitalized for ADHF with severe AS. We attempted to identify clinical differences from baseline up to 4days, comparing patients with AF (AF group) versus those with SR (SR group). There were no significant differences between the groups in age (83.7 ± 4.5 vs. 85.8 ± 6.9years, respectively; p = 0.11) and aortic valve area (0.60 [0.46-0.73] vs. 0.56 [0.37-0.70] cm2, respectively; p = 0.50). However, left atrial volume was larger (104 [85-126] vs. 87 [64-103] mL, respectively; p < 0.01), whereas stroke volume was lower (51.6 ± 14.8 vs. 59.0 ± 18.7mL, respectively; p = 0.08) in the AF group versus the SR group. Body weight decreased daily from baseline up to day 4 in both groups (from 55.4 to 53.2kg [p < 0.01] and from 53.5 to 51.0kg [p < 0.01], respectively) without change in heart rate. Notably, the systolic blood pressure decreased slightly in the AF group after 2days of treatment with tolvaptan. Short-term treatment with tolvaptan improved HF in patients hospitalized for severe AS, regardless of the presence of AF or SR. After achieving sufficient diuresis, a slight decrease in blood pressure was observed in the AF group, suggesting an appropriate timeframe for safe and effective use of tolvaptan.