Aortic Valve Intervention Research Articles

Risk Factors for Reduced Long-term Survival Following Isolated Surgical Aortic Valve Replacement in Different Age Groups.

According to recent guidelines, the selection of transcatheter vs. surgical aortic valve replacement (TAVR vs SAVR) in low-risk patients depends on age and life expectancy. Our objective was to understand independent risk factors for reduced life expectancy following isolated SAVR and the rate of re-do aortic valve (AV) intervention in different age groups, to delineate optimal intervention depending on patient characteristics. Between 2000-2015, 2026 patients underwent isolated SAVR with Edwards pericardial tissue valves. Multivariable models were conducted to determine independent risk factors for long-term survival in three age groups. The 10-year survival rates were 83.4±2.3%, 72.7± 2.6% and 39.8±3.0% in Group I (age <65 years, n=577), II (age 65 - <75 years, n=693) and III (age ≥75 years, n=756), respectively. Independent factors for the reduced long-term survival were pulmonary hypertension (PH), renal failure, peripheral vascular disease, diabetes, and NYHA class IV in Group I; PH, diabetes, current smoking, and atrial arrhythmia in Group II; and PH, anemia, and NYHA class IV in Group III. The re-do AV intervention rate at 10 years was much higher in Group I than in Groups II and III (14.7±2.5% vs. 3.4±1.1% and 0.8±0.4%, P<0.001). We identified risk factors for reduced long-term survival following isolated SAVR in different age groups and PH being the only risk factor across all ages, which should assist in decision-making for SAVR vs. TAVR. Our results also support the current recommendation of bioprostheses in patients aged >65 years given extremely low rate of re-do AV intervention.

Prognostic and therapeutic implications of low aortic valve calcium score in patients with low gradient aortic stenosis.

Low gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic value of AVCS in LGAS has not been thoroughly studied. Our aims were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI). 327 symptomatic patients (78.5±7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS<2000 AU in men and<1200 AU in women was considered low AVCS. 243 patients had high gradient (HG) and 84 had LGAS. Low AVCS was present in 25(10%) of the HG and 34(40%) of the LGAS cases. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among HGAS (aHR:2.317; CI:1.104-4.861; p= 0.026), but not among LGAS (aHR:0.848; CI:0.434-1.658; p=0.630) patients. After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LG AS patients with low AVCS even after adjustment for clinical variables (aHR:0.102, CI:0.028-0.369; p<0.001). The prevalence of low AVCS is much higher in LGAS than in HGAS. In symptomatic severe LGAS low AVCS did not entail a better prognosis. AVI is equally beneficial in LGAS patients with high or low AVCS, similarly to HGAS.

Left ventricular flow dynamics and energetics derived from 4D flow CMR in patients with low gradient severe aortic stenosis

Abstract Background Up to 40% of patients with severe aortic stenosis (SAS) determined by current guidelines present with discordant Doppler echocardiography findings and demonstrate divergent prognosis. Differentiation of true SAS who generally benefits from aortic valve intervention among this subset of patients is important albeit challenging for clinical management. Purpose Left ventricular (LV) 3-dimentional flow characterization was analyzed to illustrate altered intracardiac hemodynamics in different types of low gradient SAS and to investigate its application for the identification of true SAS in comparison with LV stroke volume index (LVSVI) and transaortic flow rate. Methods Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) was performed in 126 patients with low gradient SAS and 30 age- and gender-matched controls. All patients were categorized into 3 groups according to left ventricular ejection fraction (LVEF) and LVSVI as follows: classical low-flow low-gradient (CLFLG, n=37), paradoxical low-flow low-gradient (PLFLG, n=41), and normal-flow low-gradient (NFLG, n=48). Left ventricular flow was partitioned into 4 components: direct flow, retained inflow, delayed ejection flow, and residual volume. Average kinetic energetic parameters indexed to end-diastolic volume (KEiEDV) throughout the systolic phase were analyzed. Results Patients with CLFLG and PLFLG SAS had reduced LV direct flow proportion (CLFLG vs. control: 10±5% vs. 35±5%, P&amp;lt;0.001; PLFLG vs. control: 29±6% vs. 35±5%, P&amp;lt;0.001, Figure 1) and systolic ejection-flow KEiEDV (CLFLG vs. control: median, 5.3μJ/ml vs 8.7μJ/ml, P&amp;lt;0.001; PLFLG vs. control: median, 6.0μJ/ml vs. 8.7μJ/ml) compared with controls. Reduced systolic ejection-flow KEiEDV correlated with decreased LVSVI (R=0.47, P&amp;lt;0.001) and transaortic flow rate (R=0.72, P&amp;lt;0.001). Among 126 patients in the study cohort, 74 (59%) were determined as true SAS according to standardized criteria based on flow-independent parameters and demonstrated elevated systolic ejection-flow KEiEDV than patients with pseudo-SAS (median, 6.5μJ/ml vs 5.6μJ/ml, P&amp;lt;0.001). Systolic ejection-flow KEiEDV≥6.1μJ/ml demonstrated an optimal positive predictive value of 90% for distinguishing true SAS from pseudo-SAS among patients with low gradient SAS (Figure 2). Conclusion Alterations in LV flow components and kinetic energy were associated with the presence and type of low gradient SAS. LV systolic outflow energetic markers responsible for aortic valve opening could aid the evaluation of AS severity with Doppler-based parameters.Comparison of LV flow componentsROC analysis for discriminating true SAS

Cardiac damage predicts the outcome of calcific aortic valve disease regardless of the severity of aortic stenosis

Abstract Title: Cardiac damage predicts the outcome of patients with calcific aortic valve disease in both mild and moderate aortic stenosis Background Although the burden of calcific aortic valve disease (CAVD) is increasing, there is no current universal consensus for prognostic prediction. A staging system based on cardiac damage has been proposed to better stratify risk and evaluate the benefit of aortic valve intervention (AVI). Purpose We sought to evaluate this staging system’s prognostic value in mild and moderate aortic stenosis (AS). Methods Data from clinically indicated echocardiograms performed between 2010 and 2018 in patients aged over 18 years were extracted and linked to national outcome data. A time to first event analysis was performed with a primary outcome of mortality or heart failure hospitalization. Stages were categorized as described in previous literature: no extravalvular damage (stage 0); left ventricular damage (stage 1); left atrial damage (stage 2); elevated right ventricular pressures (stage 3); or right ventricular damage (stage 4). Results Amongst 24,699 patients in the study cohort, 513 had moderate AS and 920 had mild AS. Associated cardiac damage in those with moderate AS was graded as follows: Stage 0 - 9.4%; Stage 1 - 53.7%; Stage 2 - 31.1%; Stage 3 - 3.2%; Stage 4 - 2.6%. Increasing severity of CAVD correlated closely with increased risk of the primary outcome in both moderate (HR 1.62 per stage; 95% CI 1.36 – 1.92) and mild AS (HR 1.93 per stage; 95% CI 1.69 – 2.21), whilst increasing stage of cardiac damage was associated with mortality when censoring at the time of AVI in both moderate (HR 1.97 per stage; 95% CI 1.66 – 2.34) and mild AS (HR 2.06 per stage; 95% CI 1.81 – 2.35). Conclusion Cardiac dysfunction predicts prognosis to a similar extent in both mild and moderate AS. These data suggest that adverse outcomes may not be fully attributable to the haemodynamic consequences of valve disease, and therefore may not be reversed by valve intervention. Strategies to treat cardiac dysfunction in parallel with management of the anatomical valve pathology may be required.Mortality in mild AS by CAVD stageMortality in moderate AS by CAVD stage

Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis

Development of myocardial fibrosis in patients with aortic stenosis precedes left ventricular decompensation and is associated with an adverse long-term prognosis. To investigate whether early valve intervention reduced the incidence of all-cause death or unplanned aortic stenosis-related hospitalization in asymptomatic patients with severe aortic stenosis and myocardial fibrosis. This prospective, randomized, open-label, masked end point trial was conducted between August 2017 and October 2022 at 24 cardiac centers across the UK and Australia. Asymptomatic patients with severe aortic stenosis and myocardial fibrosis were included. The final date of follow-up was July 26, 2024. Early valve intervention with transcatheter or surgical aortic valve replacement or guideline-directed conservative management. The primary outcome was a composite of all-cause death or unplanned aortic stenosis-related hospitalization in a time-to-first-event intention-to-treat analysis. There were 9 secondary outcomes, including the components of the primary outcome and symptom status at 12 months. The trial enrolled 224 eligible patients (mean [SD] age, 73 [9] years; 63 women [28%]; mean [SD] aortic valve peak velocity of 4.3 [0.5] m/s) of the originally planned sample size of 356 patients. The primary end point occurred in 20 of 113 patients (18%) in the early intervention group and 25 of 111 patients (23%) in the guideline-directed conservative management group (hazard ratio, 0.79 [95% CI, 0.44-1.43]; P = .44; between-group difference, -4.82% [95% CI, -15.31% to 5.66%]). Of 9 prespecified secondary end points, 7 showed no significant difference. All-cause death occurred in 16 of 113 patients (14%) in the early intervention group and 14 of 111 (13%) in the guideline-directed group (hazard ratio, 1.22 [95% CI, 0.59-2.51]) and unplanned aortic stenosis hospitalization occurred in 7 of 113 patients (6%) and 19 of 111 patients (17%), respectively (hazard ratio, 0.37 [95% CI, 0.16-0.88]). Early intervention was associated with a lower 12-month rate of New York Heart Association class II-IV symptoms than guideline-directed conservative management (21 [19.7%] vs 39 [37.9%]; odds ratio, 0.37 [95% CI, 0.20-0.70]). In asymptomatic patients with severe aortic stenosis and myocardial fibrosis, early aortic valve intervention had no demonstrable effect on all-cause death or unplanned aortic stenosis-related hospitalization. The trial had a wide 95% CI around the primary end point, with further research needed to confirm these findings. ClinicalTrials.gov Identifier: NCT03094143.

Continuation of beta-blockers at discharge is associated with improved outcome in patients with HFpEF and concomitant moderate aortic stenosis

Abstract Background In patients with severe aortic stenosis or decompensated heart failure with preserved ejection fraction (HFpEF), beta-blockers are usually discontinued despite the absence of unequivocal evidence. The data on the effect of beta-blockers in patients with moderate aortic stenosis (MAS) are scarce. Aim To investigate the relationship between beta-blocker use and outcome in patients with MAS, who were hospitalized for decompensated HFpEF. Methods The current study includes 61 patients admitted for decompensated HFpEF with concomitant MAS. The mean age of the population was 82.7±7.59 years old and 41% were females. The diagnosis MAS was established on criteria including aortic valve area between 1-1.5 cm², mean gradient - 20-39 mmHg, and max velocity between 3-3.9 m/s. For those with borderline measurements, the Doppler Velocity Index (DVI) was calculated (DVI &amp;lt; 0.25 indicates severe aortic stenosis). All echocardiographic data were assessed by an experienced echocardiographer. Patients with previous aortic valve replacement and a severe mixed of multivalvular disease were excluded. Result The median follow-up was 52 months (interquartile range 34-63 months). During this period 38 patients (62.3%) died from any cause while 42 (68.9%) individuals experienced a composite endpoint, of all-cause death or hospitalization due to worsening HFpEF. In survivors, we observed higher prescription of beta-blockers at hospital discharge (66% vs. 34%, p&amp;lt;0,05) and better diastolic function than in patients with endpoints. In multivariate Cox regression analysis the use of beta-blockers (HR = 0,27; 95% CI 0,13-0,57; p&amp;lt;0.01) and better diastolic function, defined as higher septal e` (HR=0,76; 95% CI 0,61-0,94; p=0.01) were identified as independent predictors for both - survival and composite endpoint (Figure 1). Advanced age was recognized as an associated factor for outcomes. Conclusion In the present study, continuation of beta-blockers at discharge was independently associated with better survival in patients with decompensated HFpEF and concomitant MAS. It remains to be addressed in future studies, whether or not beta-blockers should be started in these patients or if there is any prognostic interaction between beta-blockers and aortic valve intervention for MAS.Figure 1.Kaplan-Meier survival curve

Aortic valve calcium score to mean gradient ratio: a new frontier in aortic stenosis prognostication

Abstract Introduction Aortic stenosis (AS) presents diagnostic challenges, especially in patients with discordant low gradient AS (LGAS), i.e., small aortic valve area (AVA) and low Doppler mean gradient (MG). LGAS is associated with worse outcomes compared to concordant AS. Aortic valve calcium score (AVCS) is a measure of AS severity independent of flow and helps diagnose severe AS. It is unknown if the degree of discordance in AVCS and MG is of any clinical significance. A high AVCS/MG ratio may indicate impaired ventricular function and response to pressure overload despite preserved LVEF, potentially contributing to worse outcomes. Purpose This study aims to elucidate the prognostic significance of the AVCS/MG ratio in patients with severe AS and preserved left ventricular ejection fraction (LVEF) undergoing TAVR. We hypothesized a higher AVCS/MG ratio correlates with increased mortality. Methods Patients who underwent transcatheter aortic valve replacement (TAVR) from 2010 to 2020 for native valve severe AS with LVEF≥50% were identified from an institutional database. AVCS were obtained within 90 days of pre-TAVR echocardiography. Patients were divided into tertiles based on their AVCS/MG ratio. Primary outcome was overall mortality. Results The analysis included 1067 patients (mean age 79±9 years, 43% female); overall AVA was 0.80±0.14 cm², LVEF 63±6%, MG 46±12 mmHg, AVCS 2630±1528 AU, and AVCS/MG ratio 58±31. Patients stratified by AVCS/MG tertiles showed no difference in overall comorbidity index across tertiles (Figure 1). However, the group in the highest tertile was the oldest (80±8 vs 79±8 vs 77±9 years), predominantly male (87% vs 61% vs 24%), with the highest prevalent atrial fibrillation (44% vs 28% vs 25%) and stroke volume index &amp;lt;35 mL/m² (16% vs 11% vs 5%). 9-year survival was 15% vs 25% vs 36% (p&amp;lt;0.001, Figure 2). In multivariate analysis adjusted for age, sex, comorbidities, LVEF and AVA, AVCS/MG ratio was independently associated with increased risk of mortality (HR 1.005; 95% CI [1.001-1.008], p=0.005). Conclusion Higher AVCS/MG discordance is associated with increased risk of mortality following TAVR. Serial AVCS measurements during progressive AS may help identify patients at higher risk who may potentially benefit from earlier aortic valve intervention.

Incidence of aortic valve reintervention in patients with aortic stenosis undergoing TAVI vs SAVR: A systematic review and meta-analysis of randomised controlled trials

Abstract Introduction Transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) are two established treatments for severe aortic stenosis (AS). The relative comparison between TAVI and SAVR for recurrent aortic valve interventions is not well defined. Purpose We aimed to perform a systematic review and meta-analysis comparing the incidence of aortic valve reintervention in patients undergoing TAVI versus SAVR. Methods MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials (RCT) that compared TAVI with SAVR for the treatment of AS reporting the occurrence of aortic valve reinterventions. We also performed a subgroup analysis of different types of TAVI prosthesis. We performed a meta-regression to evaluate the effect of age and Society of Thoracic Surgeons (STS) risk score in the outcome of interest. Statistical analysis was performed using RevMan 5.4.1 and RStudio 2023.12.1. Heterogeneity was assessed with I2 statistics. Results We included 8 RCTs with 8,698 patients, of whom 4,443 (51%) underwent TAVI. Mean follow-up ranged from 1 to 10 years. Aortic valve reintervention was significantly more common in patients treated with TAVI compared with SAVR (RR 1.89; 95%CI 1.24-2.88; p = 0.003). In a subgroup analysis stratified by balloon-expandable or self-expandable valves, there were no significant subgroup differences in their respective comparisons with TAVR (p = 0.20). In meta-regression analysis, older age (p = 0.008) and higher STS score (p = 0.009) were significantly associated with a higher incidence of aortic valve reinterventions with TAVI relative to SAVR. Conclusion In patients who undergo aortic valve replacement, TAVI is associated with a significantly higher incidence of aortic valve reinterventions relative to SAVR, particularly in populations with older age or higher STS score.

Natural progression of rheumatic aortic valve disease following rheumatic mitral valve intervention: 16-year single center experience

Abstract Backgrounds and Objectives Recognizing the natural progression of the aortic valve (AV) disease is helpful in planning the intervention of significant rheumatic mitral valve (MV) disease accompanying rheumatic AV disease. We aimed to investigate the long-term course of AV disease and the need for AV surgery in patients with rheumatic mitral valve disease who underwent MV intervention. Methods We retrospectively investigated the progression of AV disease with rheumatic changes following MV intervention in a single tertiary center. A total of 890 patients who underwent MV intervention for rheumatic MS or mitral regurgitation (MR) without concurrent AV intervention were initially screened for eligibility. Among them, 76 patients met the criteria for rheumatic etiology and had over a year of echocardiographic follow-up after MV intervention (64 surgery, 12 balloon valvuloplasty). Results The median follow-up period was 4 years (mean 5.8 years, ranging from 1 to 31 years). MS was the most common indication for mitral intervention. Overall, trans-aortic peak velocity (AV Vmax) changed from 2.2 ± 0.6 m/s to 2.4 ± 0.8 m/s, and mean pressure gradient (mean PG) changed from 11.1 ± 6.0 mmHg to 13.2 ± 8.2 mmHg. Six patients fell under severe aortic stenosis (AS) definition-wisely (Figure 1) and three of them were classified as low flow low gradient severe AS despite normal ejection fraction. Eventually, four patients were found to have true-severe AS and only one of them underwent AV surgery for severe AS per se. None of the patients with aortic regurgitation deteriorated to severe (Figure 2). Conclusions Only a small portion of rheumatic AV involvement progresses to severe AS after MV intervention, and performing MV intervention for severe mitral stenosis or mitral regurgitation in patients with concurrent mild or moderate AS or aortic regurgitation due to rheumatic changes might be reasonable.The changes in the grading of ASThe changes in the grading of AR

Excluding significant coronary artery disease in patients planned for TAVR using CT: Diagnostic accuracy of newest generation dual source photon counting scanner compared to coronary angiography

Abstract Introduction Patients with significant aortic stenosis routinely undergo CT for evaluation of the aortic root prior to interventional aortic valve replacement (TAVR). Assessment of CAD is usually performed by invasive coronary angiography. We assessed the diagnostic accuracy of the latest generation dual source photon counting scanner for exclusion of relevant CAD in a contemporary TAVR cohort. Methods Patients referred for cardiac CT prior to transcatheter aortic valve implantation were screened for inclusion this analysis. All cardiac CT exams were performed by dual source photon counting scanner (NAEOTOM alpha, Siemens healthineers, Germany). CT acquisitions were performed using retrospectively triggered spiral acquisition (30-70% of the cardiac cycle) without ultra-high resolution. For each patient, several reconstructions were rendered (thin slice reconstruction with 0.4 mm slice thickness: best diastolic phase, best systolic phase, 200-350 ms folllowing R-wave in 50 ms intervals as well as 0.6 mm slice thickness multiphase reconstruction 0-90% of the cardiac cycle in 10 % increments). Assessment of significant CAD was performed in CT and invasive angiography on a per-vessel analysis and a per-patient analysis using 2 thresholds: ≥ 50% stenosis and ≥ 70% stenosis. Assessment of stenoses in CT was performed using multiplanar reconstructions (MPR) and curved MPR and only in vessels &amp;gt; 1.5mm diameter. Assessment of stenosis in invasive angiography was performed using the projection with the most relevant lumen reduction. Image quality in CT was assessed on a likert scale from 1 to 4 (1=excellent, 2=minor artifacts, 3=major artifacts still assessable, 4=non-assessable). Results In this analysis 31 consecutive patients were included (mean age 79.5y, 64.5% males, 35.5% females). Mean heart rate was 66.5 bpm and 19% were in atrial fibrillation during CT acquisition. Mean image quality was 1.4. 13 Patients had no relevant CAD (stenosis ≥50%) in invasive angiography and in 18 patients at least 1 vessel was deemed to have ≥ 50% stenosis in invasive angiography. On a per vessel analysis, sensitivity, specificity and accuracy of cardiac CT to exclude stenoses using 50% and 70% thresholds were 98%, 93% and 94% vs. 97%, 93% and 94%, respectively. Negative likelihood ratio was 0.02 vs. 0.03 respectively. On a per-patient level, sensitivity and specificity were 100%. Out of 31 patients, only 2 vessels in 2 patients were deemed non-assessable. 3 patients with previous PCI as well as 3 patients with previous CABG were included in this analysis. Only 1 false negative vessel was reported in a very distal LAD segment. Conclusion Using newest generation dual source CT with photon counting, CT allowed highly reliable diagnostic workup regarding the presence of CAD in this TAVR cohort. The use of CT to assess CAD in TAVR patients seems clinically feasible especially in patients without previous percutaneous revascularisation.

Aortic root morphometry revisited-Clinical implications for aortic valve interventions.

The complex anatomy of the aortic root is of great importance for many surgical and transcatheter cardiac procedures. Therefore, the aim of this study was to provide a comprehensive morphological description of the nondiseased aortic root. We morphometrically examined 200 autopsied human adult hearts (22.0% females, 47.9 ± 17.7 years). A meticulous macroscopic analysis of aortic root anatomy was performed. The largest cross-section area of the aortic root was observed in coaptation center plane (653.9 ± 196.5 mm2), followed by tubular plane (427.7 ± 168.0 mm2) and basal ring (362.7 ± 159.1 mm2) (p < 0.001). The right coronary sinus was the largest (area: 234.3 ± 85.0 mm2), followed by noncoronary sinus (218.7 ± 74.8 mm2) and left coronary sinus (201.2 ± 78.08 mm2). The noncoronary sinus was the deepest, followed by right and left coronary sinus (16.4 ± 3.2 vs. 15.9 ± 3.1 vs. 14.9 ± 2.9 mm, p < 0.001). In 68.5% of hearts, the coaptation center was located near the aortic geometric center. The left coronary ostium was located 15.6 ± 3.8 mm above sinus bottom (within the sinus in 91.5% and above sinutubular junction in 8.5%), while for right coronary ostium, it was 16.2 ± 3.5 mm above (83.5% within sinus and 16.5% above). In general, males exhibited larger aortic valve dimensions than females. A multiple forward stepwise regression model showed that anthropometric variables might predict the size of coaptation center plane (age, sex, and heart weight; R2 = 31.8%), tubular plane (age and sex; R2 = 25.6%), and basal ring (age and sex; R2 = 16.9%). In conclusion, this study presents a comprehensive analysis of aortic-root morphometry and provides a platform for further research into the intricate interplay between structure and function of the aortic root.

Comparison of different surgical approaches for ascending aortic surgery with or without aortic valve involvement: Right anterior minithoracotomy versus conventional median sternotomy

ObjectivesMinimally invasive approach to cardiac surgery has been steadily developing and increasingly being performed since the early 1990s. We aimed to present our initial clinical experience and show the feasibility and safety of the right anterior minithoracotomy (RAT) approach for ascending aorta surgery with or without aortic valve involvement. MethodsThis single-center study included 112 patients who underwent ascending aortic replacement with or without aortic valve intervention, between September 2018 and March 2024. RAT was performed for 48 (42.9%) patients (RAT Group) and conventional median sternotomy (CS) was performed in the remaining 64 (57.1%) (CS Group). The primary end points included operative variables, reoperation for bleeding, transfusion requirements, extubation time, length of intensive care unit stay, hospital stay, and postoperative complications. ResultsThe mean age was 67.63 ± 6.67 years, and 65.1% of patients were men. Total operation time was significantly lower in the CS group (237.84 ± 24.87 minutes vs 259.57 ± 27.41 minutes, respectively; P = .0001). The mean ventilation time (12.73 ± 2.96 hours vs 19.43 ± 4.21 hours) and the mean intensive care unit length of stay (1.71 ± 0.86 days vs 3.6 ± 1.71 days) were both shorter in the RAT group (P < .0001 for both). Wound infection was significantly lower in the RAT group (P = .036). The length of the hospital stay was significantly shorter in the RAT group compared with the sternotomy group (7.48 ± 0.91 days vs 10.6 ± 1.43 days; P < .0001). ConclusionsRAT is a novel and promising approach for ascending aortic surgery with or without aortic valve involvement. This study confirms that this approach is feasible and safe.

Demographics and outcomes of patients younger than 75years undergoing aortic valve interventions in Rotterdam.

Transcatheter aortic valve implantation (TAVI) is considered asafe and effective alternative to surgical aortic valve replacement (SAVR) for elderly patients across the operative risk spectrum. In the Netherlands, TAVI is reimbursed only for patients with ahigh operative risk. Despite this, one fifth of TAVI patients are < 75years of age. We aim to compare patient characteristics and outcomes of TAVI and SAVR patients < 75years. This study included all patients < 75years without active endocarditis undergoing TAVI or SAVR for severe aortic stenosis, mixed aortic valve disease or degenerated aortic bioprosthesis between 2015 and 2020 at the Erasmus University Medical Centre. Dutch authority guidelines were used to classify operative risk. TAVI was performed in 292 patients, SAVR in 386 patients. Based on the Dutch risk algorithm, 59.6% of TAVI patients and 19.4% of SAVR patients were at high operative risk. There was no difference in 30-day all-cause mortality between TAVI and SAVR (2.4% vs 0.8%, p = 0.083). One-year and 5‑year mortality was higher after TAVI than after SAVR (1-year: 12.5% vs 4.3%, p < 0.001; 5‑year: 36.8% vs 12.0%, p < 0.001). Within risk categories we found no difference between treatment strategies. Independent predictors of mortality were cardiovascular comorbidities (left ventricular ejection fraction < 30%, atrial fibrillation, pulmonary hypertension) and the presence of malignancies, liver cirrhosis or immunomodulatory drug use. At the Erasmus University Medical Centre, in patients < 75years, TAVI is selected for higher-risk phenotypes and overall has higher long-term mortality than SAVR. We found no evidence for worse outcome within risk categories.

Aortic insufficiency in the patient on contemporary durable left ventricular assist device support: A state-of-the-art review on preoperative and postoperative assessment and management

The development of aortic insufficiency (AI) during HeartMate 3 durable left ventricular assist device support (dLVAD) can lead to ineffective pump output and recurrent heart failure symptoms. Progression of AI often comingles with the occurrence of other hemodynamic related events encountered during LVAD support, including right heart failure, arrhythmias, and cardiorenal syndrome. While data on AI burdens and clinical impact are still insufficient in patients on HeartMate 3 support, moderate or worse AI occurs in approximately 8% of patients by 1 year and studies suggest AI continues to progress over time and is associated with increased frequency of right heart failure. The first line intervention for AI management is prevention, undertaking surgical intervention on the insufficient valve at the time of dLVAD implant and avoiding excessive device flows and hypertension during long term support. Device speed augmentation may then be undertaken to try and overcome the insufficient lesion, but progression of AI should be anticipated over the long term. Surgical or transcatheter aortic valve interventions may be considered in dLVAD patients with significant persistent AI despite medical management, but neither intervention is without risk. It is imperative that future studies of dLVAD support capture AI in clinical endpoints using uniform assessment and grading of AI severity by individuals trained in AI assessment during dLVAD support.

The Impact of Bicuspid Aortic Valve on Long-term Outcomes After Bioprosthetic Valve Replacement

BackgroundThere are limited data comparing the outcomes of aortic valve replacement surgery between patients with bicuspid aortic valve (BAV) vs tricuspid aortic valve (TAV) morphology. MethodsFrom January 2000 to June 2022, 1122 patients with TAV (n = 562) or BAV (n = 560) underwent surgical aortic valve replacement for aortic stenosis with the same type of bovine pericardial stented bioprosthesis. Propensity score matching identified 350 pairs by matching for age, sex, operative status, chronic lung disease, prior stroke, diabetes, ejection fraction, renal failure on dialysis, coronary artery disease, prior cardiac surgery, and concomitant procedures. The primary end points were long-term survival and reoperation. ResultsPerioperative outcomes, including reoperation for bleeding, atrial fibrillation, heart block requiring pacemaker, stroke, need for dialysis, and operative mortality, were similar between the matched groups. Survival at 10 years was 67% (95% CI, 59%-74%) in the BAV group and 54% (95% CI, 46%-61%) in the TAV group (P = .001). BAV valve was a significant protective factor for late mortality, with a hazard ratio of 0.60 (95% CI, 0.45-0.81; P < .001). Risk factors for late mortality included age, chronic lung disease, low ejection fraction, and renal failure on dialysis. Cumulative incidence of aortic valve reintervention at 10 years was similar between the groups at 10% in the BAV group and 4.9% in the TAV group (P = .55). ConclusionsPatients with BAV likely could not be considered the same as patients with TAV when deciding on the approach of aortic valve intervention.

Long-term results of patients undergoing the Ross procedure after a previous aortic valve surgery

ObjectivesTo assess the long-term outcomes of patients undergoing a Ross procedure in the context of a redo aortic valve (AV) surgery. MethodsProspectively collected data in all consecutive adults who underwent a Ross procedure were analyzed to compare the Ross procedure performed as a first surgery (RF) or as a redo surgery (RP). ResultsBetween 1990 and 2021, 395 Ross procedures were performed at our center (RF, n = 345; RP, n = 50). A 2:1 propensity score matching was performed (RF, n = 100; RP, n = 50). The overall median follow-up was 11.6 years (interquartile range, 5.0-21.8 years) and 100% complete. Mean survival at 20 years was 87 ± 12% in the RF group and 87 ± 8% in the RP group (P = .30). The cumulative incidence of autograft reintervention at 10 years and 20 years was 6 ± 3% and 21 ± 6%, respectively, in the RF group and 9 ± 5% and 25 ± 8%, respectively, in the RP group (P = .74). The AV gradient remained stable up to 20 years in both groups (P = .42). The size of the sinuses of Valsalva tended to increase over time in the RF group but remained stable in the RP group (P = .03). ConclusionsThe ross procedure after a previous sternotomy for AV surgery is safe and offers good long-term results. Patients undergoing redo AV intervention have similar results as patients undergoing a primary Ross procedure, perhaps with a lower risk of autograft dilatation.

A Neuronal Network-Based Score Predicting Survival in Patients Undergoing Aortic Valve Intervention: The ABC-AS Score.

Background: Despite being the most commonly performed valvular intervention, risk prediction for aortic valve replacement in patients with severe aortic stenosis by currently used risk scores remains challenging. The study aim was to develop a biomarker-based risk score by means of a neuronal network. Methods: In this multicenter study, 3595 patients were divided into test and validation cohorts (70% to 30%) by random allocation. Input variables to develop the ABC-AS score were age, the cardiac biomarker high-sensitivity troponin T, and a patient history of cardiac decompensation. The validation cohort was used to verify the scores' value and for comparison with the Society of Thoracic Surgery Predictive Risk of Operative Mortality score. Results: Receiver operating curves demonstrated an improvement in prediction by using the ABC-AS score compared to the Society of Thoracic Surgery Predictive Risk of Operative Mortality (STS prom) score. Although the difference in predicting cardiovascular mortality was most notable at 30-day follow-up (area under the curve of 0.922 versus 0.678), ABC-AS also performed better in overall follow-up (0.839 versus 0.699). Furthermore, univariate analysis of ABC-AS tertiles yielded highly significant differences for all-cause (p < 0.0001) and cardiovascular mortality (p < 0.0001). Head-to-head comparison between both risk scores in a multivariable cox regression model underlined the potential of the ABC-AS score (HR per z-unit 2.633 (95% CI 2.156-3.216), p < 0.0001), while the STS prom score failed to reach statistical significance (p = 0.226). Conclusions: The newly developed ABC-AS score is an improved risk stratification tool to predict cardiovascular outcomes for patients undergoing aortic valve intervention.

The evolving landscape of transcatheter aortic valve intervention: a focus on native pure aortic regurgitation

The evolving landscape of transcatheter aortic valve intervention: a focus on native pure aortic regurgitation

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.

High Lp(a) levels are a potential risk factor for aortic valve interventions in patients with bicuspid aortic valve

High Lp(a) levels are a potential risk factor for aortic valve interventions in patients with bicuspid aortic valve