Aortic Valve Replacement Therapy Research Articles

Predictors of New and Persistent New Left Bundle Branch Block One Year after the Implantation of a Sutureless and Rapid-Deployment Aortic Valve Prosthesis.

Conduction disorders following aortic valve replacement therapy (AVR), either surgical or percutaneous, are related to a higher risk of complete atrioventricular block and permanent pacemaker implantation (PPI). The objective of this study was to assess risk factors regarding the incidence of new postoperative and persistent new left bundle branch block (LBBB) 1 year after the implantation of a sutureless/rapid-deployment (SURD) aortic valve prosthesis. The current study included 200 consecutive patients treated with isolated or concomitant AVR between May 2014 and May 2017 at the Department of Cardiac Surgery in Pasawa with SURD aortic valve EDWARDS INTUITY EliteTM implantation. The patients were divided according to the presence of new postoperative LBBB (67 patients, 33.5%) and persistent new LBBB 1 year after AVR (35 patients, 17.5%). A comparative analysis was performed between patients with and without new LBBB after AVR and those with and without persistent LBBB 1 year after AVR. Univariate and multivariate regression analyses were conducted to extract the risk factors of LBBB occurrence. Among the risk factors for the lack of new LBBB development after AVR, Euroscore II (p < 0.001) was found, while for the occurrence of persistent new LBBB 1 year after AVR, atrial fibrillation (p = 0.001), length of hospital stay (p = 0.001) and body mass index (p = 0.004) were noted. Patients with new or persistent new LBBB 1 year after AVR had lower mean Euroscore II and BMI values. Their stay at the hospital was also shorter.

Did angiodysplasia associated with heyde’s syndrome disappear spontaneously?: a case report

BackgroundHeyde’s syndrome can be easily overlooked or misjudged in clinical practice because it shares common clinical manifestations with multiple diseases as well as limited accuracy of several corresponding examinations for diagnosing Heyde’s triad. Moreover, aortic valve replacement is often delayed in these patients due to the contradiction between anticoagulation and hemostasis. Herein, we present a rare case of atypical Heyde’s syndrome. The patient’s severe intermittent gastrointestinal bleeding was not completely cured even through a local enterectomy. In the absence of direct evidence of acquired von Willebrand syndrome (AVWS) or angiodysplasia, her long-standing gastrointestinal bleeding was finally stopped after receiving transcatheter aortic valve implantation (TAVI).Case presentationA 64-year-old female suffered from refractory gastrointestinal bleeding and exertional dyspnoea. A local enterectomy was performed owing to persistent hemorrhage and repeated transfusions; subsequently, histological examination revealed angiodysplasia. Heyde’s syndrome was not suspected until 3 years later, at which time the patient started bleeding again and was also found to have severe aortic valve stenosis upon echocardiography. TAVI was consequently performed when the patient was in a relatively stable condition even though the predisposition to bleed, but there was no evidence of angiodysplasia and AVWS during angiography at that time. The patient’s above symptoms were significantly relieved after TAVI and followed up for 2 years without any significant ischemic or bleeding events.ConclusionsThe visible characteristics of angiodysplasia or a shortage of HMWM-vWFs should not be indispensable for the clinical diagnosis of Heyde’s syndrome. Enterectomy could be a bridging therapy for aortic valve replacement in patients with severe hemorrhage, and TAVI may be beneficial for moderate to high surgical-risk patients even if they have a potential risk of bleeding.

Ventricular pacing burden in patients with left bundle branch block after transcatheter aortic valve replacement therapy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrophysiological (EP) testing has been proposed in the latest ESC guidelines for cardiac pacing to identify LBBB patients with infrahisian conduction delay (IHCD) after transcatheter aortic valve replacement (TAVR). While in general IHCD is defined by a His-ventricular (HV) interval of &amp;gt; 55ms, a cut-off of ≥ 70ms to trigger pacemaker (PM) implantation has been proposed in the latest ESC guidelines. The ventricular pacing (VP) burden during follow-up in such patients is largely unknown. Purpose To assess the VP burden during follow-up of patients receiving PM therapy for LBBB after TAVR based on an HV interval &amp;gt; 55 ms and ≥ 70ms. Methods All patients with new-onset or pre-existing LBBB after undergoing TAVR at a tertiary referral center underwent EP testing the day after TAVR. In patients with a prolonged HV interval (&amp;gt;55 ms), PM implantation was performed by a trained electrophysiologist in a standardized fashion. All devices were programmed to avoid unnecessary VP by specific algorithms (e.g., AAI-DDD). Results 701 patients underwent TAVR at our university hospital between October 2014 and November 2021. 177 patients presented with new-onset or pre-existing LBBB the day following TAVR and underwent EP testing. An HV interval &amp;gt; 55 ms was found in 58 patients (33%) and an HV interval ≥ 70 ms in 21 patients (12%). 51 patients (mean age 84 ± 6.2 years, 45% women) agreed to receive a PM, out of which 20 (39%) patients had an HV Interval over 70 ms. Atrial fibrillation was present in 53% of the patients. A dual chamber PM was implanted in 39 (77%), and a single chamber pacemaker in 12 (23%) patients, respectively. Median FU was 21 months (IQR 11-41). The median VP burden overall was 3%. The median VP burden was numerically higher in patients with an HV ≥70 ms (6.5% [0.8 - 52]) than in those with an HV between 55 and 69 ms (2% [0 – 17], p = 0.23). 31% of patients had a VP burden &amp;lt;1%, 27% 1-5% and 41% &amp;gt; 5% (Figure). The median HV intervals in patients with VP burden &amp;lt;1%, 1-5% and &amp;gt;5% were 66 (IQR 62 -70) ms, 66 (IQR 63 – 74) ms and 68 (IQR 60 – 72) ms respectively, p= 0.52. When only assessing patients with an HV interval 55-69 ms, 36% demonstrated a VP burden of &amp;lt;1%, 29% of 1-5% and 35% of &amp;gt;5 %. In patients with an HV Interval ≥ 70ms, 25% demonstrated a VP burden &amp;lt;1%, 25% of 1-5% and 50% of &amp;gt;5 %, p=0.64 (Table). Conclusion VP burden can be significant in patients with LBBB after TAVR and an HV interval of &amp;gt; 55 ms. Further studies are warranted to define the optimal cut-off to trigger PM implantation in patients with LBBB after TAVR.

Ventricular pacing burden in patients with left bundle branch block after transcatheter aortic valve replacement therapy.

Electrophysiological testing has been proposed in the latest European Society of Cardiology (ESC) guidelines for cardiac pacing to identify left bundle branch block (LBBB) patients with infrahisian conduction delay (IHCD) after transcatheter aortic valve replacement (TAVR). While in general IHCD is defined by a His-ventricular (HV) interval of >55 ms, a cut-off of ≥70 ms to trigger pacemaker (PM) implantation has been proposed in the latest ESC guidelines. The ventricular pacing (VP) burden during follow-up in such patients is largely unknown. As such, we aimed to assess the VP burden during follow-up of patients receiving PM therapy for LBBB after TAVR based on an HV interval > 55 ms and ≥70 ms. All patients with new-onset or pre-existing LBBB after undergoing TAVR at a tertiary referral center underwent EP testing the day after TAVR. In patients with a prolonged HV interval (>55 ms), PM implantation was performed by a trained electrophysiologist in a standardized fashion. All devices were programmed to avoid unnecessary VP by specific algorithms (e.g., AAI-DDD). 701 patients underwent TAVR at the University Hospital of Basel. One hundred seventy-seven patients presented with new-onset or pre-existing LBBB the day following TAVR and underwent EP testing. An HV interval > 55 ms was found in 58 patients (33%) and an HV interval ≥ 70 ms in 21 patients (12%). 51 patients (mean age 84 ± 6.2 years, 45% women) agreed to receive a PM, out of which 20 (39%) patients had an HV Interval over 70 ms. Atrial fibrillation was present in 53% of the patients. A dual chamber PM was implanted in 39 (77%), and a single chamber PC in 12 (23%) patients, respectively. Median follow-up was 21 months. The median VP burden overall was 3%. The median VP burden was not significantly different between patients with an HV ≥ 70 ms (6.5 [0.8-52]) and those with an HV between 55 and 69 ms (2 [0-17], p = .23). 31% of patients demonstrated a VP burden < 1%, 27% 1%-5% and 41% > 5%. The median HV intervals in patients with VP burdens < 1%, 1%-5% and >5% were 66 (IQR 62-70) ms, 66 (IQR 63-74) ms and 68 (IQR 60-72) ms, respectively, p = .52. When only assessing patients with an HV interval 55-69 ms, 36% demonstrated a VP burden of <1%, 29% of 1%-5% and 35% of >5%. In patients with an HV Interval ≥ 70 ms, 25% demonstrated a VP burden < 1%, 25% of 1%-5% and 50% of >5% %, p = .64 (Figure). In patients with LBBB after TAVR and IHCD defined by an HV interval > 55 ms, VP burden is relevant in a non-negligible amount of patients during follow-up. Further studies are warranted to define the optimal cut-off value for the HV interval or to develop risk models incorporating HV measurements and other risk factors to trigger PM implantation in patients with LBBB after TAVR.

Turbulent Systolic Flow Downstream of a Bioprosthetic Aortic Valve: Velocity Spectra, Wall Shear Stresses, and Turbulent Dissipation Rates.

Every year, a quarter million patients receive prosthetic heart valves in aortic valve replacement therapy. Prosthetic heart valves are known to lead to turbulent blood flow. This turbulent flow field may have adverse effects on blood itself, on the aortic wall and on the valve performance. A detailed characterization of the turbulent flow downstream of a valve could yield better understanding of its effect on shear-induced thrombocyte activation, unphysiological wall shear stresses and hemodynamic valve performance. Therefore, computational simulations of the flow past a bioprosthetic heart valve were performed. The computational results were validated against experimental measurements of the turbulent flow field with tomographic particle image velocimetry. The turbulent flow was analyzed for disturbance amplitudes, dissipation rates and shear stress distributions. It was found that approximately 26% of the hydrodynamic resistance of the valve was due to turbulent dissipation and that this dissipation mainly took place in a region about one valve diameter downstream of the valve orifice. Farther downstream, the turbulent fluctuations became weaker which was also reflected in the turbulent velocity spectra of the flow field. Viscous shear stresses were found to be in the range of the critical level for blood platelet activation. The turbulent flow led to elevated shear stress levels along the wall of the ascending aorta with strongly fluctuating and chaotic wall shear stress patterns. Further, we identified leaflet fluttering at 40 Hz which was connected to repeated shedding of vortex rings that appeared to feed the turbulent flow downstream of the valve.

Balloon Aortic Valvuloplasty – Remaining Indications in the Modern TAVR Era

ABSTRACT Objectives : A retrospective observational cohort study to report on contemporary indications of balloon aortic valvuloplasty (BAV). Background : As indications for transcatheter aortic valve replacement (TAVR) are increasing, BAV is reinforced as a bridging therapy. Methods : A total of 47 consecutive patients who underwent BAV in parallel to an existing TAVR program was retrospectively assessed for BAV indications and clinical events during 1 year of follow-up. Results : The following indications were distinguished: bridge to destination aortic valve replacement therapy (BTD), bridge to urgent non-cardiac therapy (BTN) or palliation. BAV was performed in 20 (43%) patients as BTD, in 18 (38%) as BTN and in 9 (19%) as palliative treatment. Patients in the BTN cohort were younger (age 74.1 ± 8.3% vs. 80.7 ± 8.3% years in BTD, p = 0.02) with lower STS-scores (2.2% [IQR 1.3–4.6] vs. 13.0% [IQR 7.6–22.2] p < 0.001). Overall baseline mean transaortic gradient was 43.2 mmHg and reduced by a mean of 16.0 ± 10.1 mmHg after BAV (p < 0.001). Procedural mortality was 8.5% (n = 4). All-cause mortality at 30 days and 1 year was 20% and 45% in BTD, 6% and 39% in BTN and 44% and 67% in the palliative group. Aortic valve replacement (AVR) was performed in 55% of the BTD and 50% of the BTN group at 1 year. Reasons for not undergoing definite AVR were clinical deterioration in BTD and terminal comorbidity in BTN. Compared to a contemporary TAVR cohort, procedural and 1 year mortality was significantly increased in the BAV cohort. Conclusion : BAV remains a valuable option in well-defined patient phenotypes to determine AVR feasibility, bridge to urgent non-cardiac therapy, and at times, palliation. These phenotypes represent vulnerable patients with overall poor clinical outcome.

The March of Transcatheter Aortic Valve Replacement Therapy—US Food and Drug Administration Perspectives on Device Approval for Patients at Low Surgical Risk

The March of Transcatheter Aortic Valve Replacement Therapy—US Food and Drug Administration Perspectives on Device Approval for Patients at Low Surgical Risk

P911High rate of cardiac amyloidosis in elderly patients with aortic stenosis: clinical presentation before and after aortic valve intervention

Abstract Background Aortic Stenosis (AS) is the most common valvular heart disease in the Western world. Wild-type transthyretin amyloid (wtATTR) affects the heart, causing restrictive cardiomyopathy. Deposits can be found in up to 25% of individuals &gt;85 years of age at autopsy. Recently several reports showed a relatively high prevalence of transthyretin cardiac amyloidosis (TTR-CA) in patients with AS. Objectives The aim of this study was to examine the clinical effects of TTR-CA in patients who have undergone aortic valve replacement therapy and evaluate the outcome of the intervention. Methods We recruited patients who underwent surgical (AVR) or percutaneous (TAVI) aortic valve intervention between 2011 and 2018. The patients underwent a Tc99m-PYP scan using SPECT technology which has been shown to be valid for the diagnosis of TTR-CA. We reviewed patient files before (time point 1) and after intervention (time point 2) and at 2 years (time point 3) follow up, and collected data on hospitalizations, laboratory, and echocardiography. Results The study included 86 patients, mean age 78±6 years, 55% women. Twenty-nine (33%) participants were diagnosed as positive (VAS 2 and 3) for transthyretin cardiac amyloidosis.There were no differences in baseline characteristics between patients with and without TTR-CA in cardiovascular risk factors and co-morbidities, laboratory parameters and nutritional status. There were no differences in baseline echocardiographic parameters including valve gradients and left ventricular hypertrophy. However, the patients with TTR CA had more advanced diastolic dysfunction compared to patients without TTR CA (P=0.03) and higher pulmonary artery pressure (44±14.75mmhg vs 30.5±11.38mmhg, p=0.06). Before the intervention, patients with transthyretin cardiac amyloidosis had 3.26 times more hospitalizations due to heart failure as compared to patients in the negative group (p=0.01). After the intervention, diastolic function remained more severely affected in the positive group at all follow-up points compared to the negative group (p=0.05). Similar observations were seen in the measurements of pulmonary arterial pressure (p=0.019 at time 2 and p=0.015 at time 3). Consistent with the echocardiographic findings, patients with transthyretin cardiac amyloidosis had 2.84 times more hospitalizations after intervention for heart failure than patients in the negative group (p=0.02). Conclusions Co-existence of transthyretin cardiac amyloidosis and aortic stenosis in the older population is associated with a more severe clinical presentation and with more advanced clinical and echocardiographic signs of heart failure. Improvement after valvular intervention might be limited in terms of symptoms and hospitalizations in this subgroup. Acknowledgement/Funding None

SJM Masters HP 15mm Rotatable Mechanical Heart Valve as Aortic Valve Replacement Therapy

SJM Masters HP 15mm Rotatable Mechanical Heart Valve as Aortic Valve Replacement Therapy

Current Status and the Future Prerspective of Transcatheter Aortic Valve Replacement Therapy

経カテーテル的大動脈弁置換術（Transcatheter aortic valve replacement: TAVR）は大動脈弁狭窄症（Aortic Stenosis: AS）に対する大動脈弁置換術（Aortic valve replacement: AVR）がハイリスクとされる患者に対する低侵襲治療として2013年10月に本邦で承認され，現在まで爆発的に普及してきた。欧米ではさまざまなrandomized trialの結果から中リスクさらには昨今開始された試験の結果次第では低リスク群の患者への適応が拡大されつつあるが，長期成績などが不明な現在，より一層ハートチームでの適応評価が重要となると考える。

Impact of patient-specific morphologies on sinus flow stasis in transcatheter aortic valve replacement: An in vitro study

ObjectiveThe goal of this study is to evaluate how sinus flow patterns after transcatheter aortic valve replacement in realistic representative patient roots vary. Sinus flow can affect transcatheter aortic valve operation and likely leaflet thrombosis occurrence due to stasis and poor washout. How the interaction between transcatheter aortic valve and representative patient aortic roots affects sinus hemodynamics is important to establish for future individualization of transcatheter aortic valve replacement therapy. MethodsTwo representative patient aortic roots were selected, segmented and 3-dimensional printed followed by deployment of Medtronic CoreValve (Medtronic Inc, Irvine, Calif) and Edwards SAPIEN (Edwards Lifesciences, Irvine Calif) transcatheter aortic valves. Sinus hemodynamics were assessed in vitro using high spatio-temporal resolution particle-image-velocimetry. Detailed sinus vortex tracking, shear stress probability density functions, and sinus washout were evaluated and assessed as a function of valve type and representative patient morphology as independent case studies. ResultsPeak velocity in the sinus with SAPIEN valve was approximately 3 times higher than with CoreValve for both models (0.30 ± 0.02 m/s and 0.34 ± 0.041 m/s vs 0.13 ± 0.01 m/s and 0.10 ± 0.02 m/s) (P < .01). Between representative patient models, vorticity magnitudes were significantly different (75 ± 1.1 s−1, 77 ± 3.2 s−1, 109 ± 2.3 s−1, and 250 ± 4.1 s−1) (P < .01) regardless of valve type. Sinus blood washout characteristic as a function of cardiac cycles was strongly both patient related and valve specific. Fluid dynamics favored shear stresses and washout characteristics due to a smaller sinus and sinotubular junction, further amplified by the SAPIEN valve. ConclusionsSinus flow dynamics are highly sensitive to aortic root characteristics and transcatheter aortic valve aortic root interaction. Differences in sinus-flow washout and stasis regions between representative patient models may be reflected in different risks of leaflet thrombosis or valve degeneration.

Sex-Specific Outcomes After Transcatheter Aortic Valve Replacement: A Review of the Literature.

Transcatheter aortic valve replacement (TAVR) is a safe and effective therapy for aortic valve replacement in patients ineligible for or at high risk for surgery. However, outcomes after TAVR based on an individual's sex remain to be fully elucidated. We searched PUBMED and EMBASE using the keywords: "transcatheter aortic valve replacement," "transcatheter aortic valve implantation," "sex differences," "gender," "sex characteristics" and collected information on baseline features, procedural characteristics, and postprocedural outcomes in women. Inclusion/exclusion resulted in 23 publications. Women had less preexisting comorbidities than men. Most studies reported better survival in women (range of hazard ratio [95% CI] = 0.27 [0.09-0.84] to 0.91 [0.75-1.10]). At 30 days, women also had more vascular complications (6-20% vs 2-14%) and higher bleeding rates (10-44% vs 8-25%). Stroke rates were similar at 30 days (women, 1-7%; men, 1-5%). This literature review showed better survival in women than men after TAVR. However, women had more vascular complications and bleeding; stroke rates were similar. These findings may partly be explained by fewer baseline comorbidities in women. These results should be interpreted with caution as most measures only include unadjusted percentages.

Transcatheter Double Valve Replacement of an Aortic and Mitral Valve in the Native Annulus

The role of percutaneous technology for aortic valve replacement therapy has been well established in the literature. However, transcatheter therapies for mitral valve disease are still in a very early phase. Successful transcatheter valve implantation in mitral valves with calcified annulae via different access sites has been reported. Most of the procedures that have been done are not well described or illustrated. We describe here the technique for performing a double transcatheter valve replacement in the native calcified aortic and mitral annulus utilizing a percutaneous transfemoral approach.

Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review.

ObjectiveTo investigate patients' values and preferences regarding aortic valve replacement therapy for aortic stenosis.SettingStudies published after transcatheter aortic valve insertion (TAVI) became available (2002).ParticipantsAdults with aortic stenosis who are considering or have had valve replacement, either TAVI or via surgery (surgical aortic valve replacement, SAVR).Outcome measuresWe sought quantitative measurements, or qualitative descriptions, of values and preferences. When reported, we examined correlations between preferences and objective (eg, ejection fraction) or subjective (eg, health-related quality of life) measures of health.ResultsWe reviewed 1348 unique citations, of which 2 studies proved eligible. One study of patients with severe aortic stenosis used a standard gamble study to ascertain that the median hypothetical mortality risk patients were willing to tolerate to achieve full health was 25% (IQR 25–50%). However, there was considerable variability; for mortality risk levels defined by current guidelines, 130 participants (30%) were willing to accept low-to-intermediate risk (≤8%), 224 (51%) high risk (>8–50%) and 85 (19%) a risk that guidelines would consider prohibitive (>50%). Study authors did not, however, assess participants' understanding of the exercise, resulting in a potential risk of bias. A second qualitative study of 15 patients identified the following factors that influence patients to undergo assessment for TAVI: symptom burden; expectations; information support; logistical barriers; facilitators; obligations and responsibilities. The study was limited by serious risk of bias due to authors' conflict of interest (5/9 authors industry-funded).ConclusionsCurrent evidence on patient values and preferences of adults with aortic stenosis is very limited, and no studies have enrolled patients deciding between TAVI and SAVR. On the basis of the data available, there is evidence of variability in individual values and preferences, highlighting the importance of well-informed and shared decision-making with patients facing this decision.Trial registration numberPROSPERO CRD42016041907.

TCT-892 Predictors of “futility” with transcutaneous aortic valve replacement therapy (TAVR): An analysis from the PARTNER randomized trial

TCT-892 Predictors of “futility” with transcutaneous aortic valve replacement therapy (TAVR): An analysis from the PARTNER randomized trial

Reducing operative mortality in valvular reoperations: The “valve in ring” procedure

FIGURE 1. Preoperative echocardiogram demonstrating a status-post mitral valve repair with severe mitral valve regurgitation. TEE, Transesophageal echocardiogram. Percutaneous valve therapy is an emerging therapy for aortic valve replacement in patients at high surgical risk. Favorable results have cautiously extended indications to high-risk patients with failing bioprostheses. Despite proven durability of mitral valve repair, some patients may require a reoperation and may represent a challenging surgical risk. The concept of ‘‘valve in ring’’ could be a solution for such patients, but this has, to our knowledge, been reported only in an experimental setting. We recently encountered a patient with failed mitral valve repair in whom a ‘‘valve in ring’’ procedure was performed.

Presence of fatty-acid-binding protein 4 expression in human epicardial adipose tissue in metabolic syndrome

Metabolic syndrome is a cluster of different clinical manifestations that are risk factors for atherothrombotic cardiovascular disorders. Fatty-acid-binding protein 4 (FABP4/aP2), which is highly expressed in adipocytes, specifically exerts intracellular lipid trafficking. A high level of fatty-acid-binding protein 4 expression present in obese subjects has also been found in mice and humans, especially in macrophages at atherosclerotic lesions. An in vivo study demonstrated that the inhibitor of aP2 would be a new therapeutic agent for treating metabolic diseases in mice. We have investigated the mRNA expression of fatty-acid-binding protein 4 in human epicardial adipose and ascending aorta tissues of metabolic syndrome and nonmetabolic syndrome patients. Paired epicardial adipose and ascending aorta tissue samples were obtained from 10 metabolic syndrome patients and 4 nonmetabolic syndrome patients during coronary bypass grafting and aortic valve replacement therapy, respectively. Fatty-acid-binding protein 4 gene expression was determined by quantitative real-time polymerase chain reaction. Fatty-acid-binding protein 4 expression of epicardial adipose tissue was significantly higher in metabolic syndrome patients than in nonmetabolic syndrome controls (P<.05). In metabolic syndrome patients, fatty-acid-binding protein 4 expression in epicardial adipose tissue was 66 times higher than fatty-acid-binding protein 4 expression in ascending aorta tissue. The expression level of fatty-acid-binding protein 4 in epicardial adipose tissue was found to be significantly correlated with waist circumference in all subjects (r=.535, P<.05). Our data showed for the first time that human epicardial adipose and ascending aorta tissues express fatty-acid-binding protein 4 and that its level of expression in epicardial adipose tissues of metabolic syndrome patients is elevated. Increased fatty-acid-binding protein 4 gene expression in epicardial adipose tissues of metabolic syndrome patients led us think that fatty-acid-binding protein 4 might be an important factor in metabolic syndrome.