Aortic Valve Replacement Research Articles

Case Report: Leaflet thrombosis after transcatheter valve-in-valve aortic valve replacement in prosthetic valve endocarditis

A 70-year-old female patient with a history of bioprosthetic aortic valve replacement and coronary artery bypass graft presented with bioprosthetic valve failure secondary to prosthetic valve endocarditis. The patient was deemed unsuitable for surgery by the heart team, following which she underwent transcatheter aortic valve-in-valve replacement. This resulted in early death due to myocardial infarction and acute heart failure. A computed tomography revealed subclinical leaflet thrombosis. This case highlights the importance of postoperative anticoagulation therapy.

Role of Routine Electrophysiological Study Performed During Transcatheter Aortic Valve Replacement to Predict AV Block.

Periprocedural electrophysiological (EP) testing may be useful to predict high degree atrioventricular block (HAVB) risk in patients undergoing transcatheter aortic valve replacement (TAVR). To determine whether pre- and immediate post-TAVR ECG and HV interval findings are predictive of HAVB. Consecutive TAVR patients without prior pacemaker (PM) implantation underwent ECG and standardized HV interval measurements pre- and post-TAVR using the quadripolar catheter for rapid pacing. The primary outcome was HAVB >24 h after TAVR or ventricular pacing need RESULTS: Out of 97 included patients, 8 experienced the primary outcome (7 with HAVB and 1 with PM need). On univariate analysis, pre- and post-TAVR PR, post-TAVR HV, and Delta-HV intervals were predictors of the primary outcome. A Delta-HV interval ≥18ms predicted HAVB with sensitivity = 50% and specificity = 90% (AUC = 0.708, PPV = 31%), while an HV interval ≥60ms after TAVR had sensitivity = 63% and specificity = 79% (AUC = 0.681, PPV = 21%). None of the patients with a PR interval ≤180ms post-TAVR experienced the primary outcome. Among patients with new-onset LBBB, an HV interval post-TAVR >65ms was the only predictor of HAVB (AUC = 0.776, PPV = 33%, and NPV = 97%). The yield of periprocedural EP assessment during TAVR is limited considering that about half of the at-risk patients fail to be identified. However, early periprocedural risk stratification may be more useful in the subset of patients with new-onset LBBB. Among ECG findings, a post-TAVR PR interval ≤180ms identifies a subgroup at very low risk, independently of QRS interval and morphology.

Neoaortic Dilation and Polyvalvar Dysfunction: The Coexistence of Marfan Syndrome with Hypoplastic Left Heart Syndrome.

We present a unique case of progressive neoaortic root and neoascending aortic dilatation, with poly-valvar regurgitation in a patient with Marfan syndrome and hypoplastic left heart syndrome palliated to Fontan procedure. This progressive dilation and valvar dysfunction necessitated a modified Bentall procedure and tricuspid valve repair. Our case highlights the impact of both a primary and secondary aortopathy complicating the Fontan procedure and the need for mechanical aortic valve replacement.

A Novel Transcatheter Device to Treat Calcific Aortic Valve Stenosis: An Ex Vivo Study.

Aortic valve stenosis (AVS) is the most common valvular disease in developed countries. Surgical or transcatheter bioprosthetic aortic valve (AV) replacement is the standard treatment for severe AVS. However, bioprostheses are prone to structural degeneration. Hence, in terms of lifetime management, there is a need for therapies that can postpone AV replacement. With the aim of fragmenting calcifications and restoring AV leaflets flexibility, a new transcatheter debridement device (TDD) exploiting ultrasound is under development. We performed an ex-vivo study on human hearts to quantify how TDD treatment affects stenotic AVs hemodynamic. Additionally, a qualitative histological analysis was performed to assess TDD's impact on AV leaflets. Three human hearts affected by AVS were characterized pre- and post-treatment in an ex-vivo beating heart simulator. To replicate physiological flowrates, a pulsatile pump was connected to the left ventricle, while a systemic impedance simulator connected to the aortic root and a reservoir connected to the left atrium closed the hydraulic circuit. Transvalvular pressure drop (ΔPsys), backflow volume, and effective orifice area (EOA) were evaluated. For histological analysis, AV leaflets sections were stained with Haematoxylin/Eosin and AlizarineRedS to highlight calcifications. The treatment induced a reduction in ΔPsys in all tested samples, improving EOA, but caused an increase in backflow volume. Moreover, histology suggested AV leaflets integrity. The TDD procedure improved AV fluid-dynamics during systole in all tested samples, without evidence of damage to tissues. This suggests TDD could be a promising option to postpone AV replacement for patients with AVS.

Machine learning cluster analysis identifies increased 12-month mortality risk in transcatheter aortic valve replacement recipients

BackgroundLong-term mortality risk is seldom re-assessed in contemporary clinical practice following successful transcatheter aortic valve implantation (TAVR). Unsupervised machine learning permits pattern discovery within complex multidimensional patient data and may facilitate recognition of groups requiring closer post-TAVR surveillance.MethodsWe analysed and differentiated routinely collected demographic, biochemical, and cardiac imaging data into distinct clusters using unsupervised machine learning. k-means clustering was performed on data from 200 patients who underwent TAVR for severe aortic stenosis (AS). Input features were ranked according to their influence on cluster assignment. Survival analyses were performed with Kaplan–Meier and Cox proportional hazards models. Nested cox models were used to identify any incremental prognostic benefit cluster assignment achieved beyond conventional risk scores.ResultsAnalysis identified two distinct clusters. Compared to Cluster 1, Cluster 2 demonstrated significantly worse all-cause mortality at 12 months (HR 6.3, p < 0.01), and was characterised by more advanced cardiac remodelling with worse indices of multi-chamber cardiac function, as quantified by strain imaging. Cluster assignment demonstrated greater predictive power for 12-month mortality as compared with conventional risk and frailty calculators.Conclusionk-means clustering identified two prognostically distinct phenogroups of patients who had undergone TAVR with better discriminatory power than conventional risk and frailty calculators. Our results highlight the utility of machine learning applications for clinical risk prediction and scope to improve patient surveillance.

Accelerated Structural Valve Deterioration in Systemic Sclerosis Patients Following Transcatheter Aortic Valve Replacement: A Case Series

Abstract Background Systemic sclerosis (SSc) is marked by an excessive systemic accumulation of collagen. Recent literature implies that aortic stenosis is more prevalent in patients with SSc than previously thought. While there are limited feasibility studies on transcatheter aortic valve replacement (TAVR) in this population, the long-term outcomes remain uncertain. Case summary We report two cases of patients with SSc who developed early structural valve deterioration following TAVR, necessitating successful redo-TAVR procedures. Both patients exhibited extensive soft tissue calcinosis as a manifestation of their underlying condition. Discussion The fibrotic and calcific processes inherent to certain SSc subtypes could potentially adversely impact the durability and functionality of transcatheter aortic valves. Our observation highlights the need for vigilant post-procedural surveillance and individualized management strategies in this unique patient population. Further investigation into the mechanisms underlying valve degeneration in this patient subset is warranted. Nevertheless, redo-TAVR procedure appears to be a viable option.

Association Between the Malnutrition Status and All-Cause Mortality in Patients With Moderate and Severe Aortic Stenosis: AProspective Cohort Study.

Malnutrition status is an important predictor of prognosis in patients after aortic valve replacement. However, the prognostic value of malnutrition status in patients with moderate-to-severe aortic stenosis is unclear. This study aimed to evaluate the effect of malnutrition on all-cause mortality in patients with moderate-to-severe aortic stenosis using the Patient Controlled Nutritional Status (CONUT) score, nutritional risk index, and prognostic nutritional index. A total of 536 patients with moderate-to-severe aortic stenosis were selected in the ARISTOTLE (Aortic Valve Diseases Risk Factor Assessment and Prognosis Model Construction) study conducted between January 2013 and December 2022 in 3 academic institutions. Patients were grouped according to different nutritional status assessment methods. CONUT, nutritional risk index, and prognostic nutritional index were calculated at baseline. The primary study outcome was all-cause mortality. Cox regression was used to assess the association between nutritional status and all-cause mortality. During a median 34.2-month follow-up period, a total of 120 (22.4%) patients died. All-cause mortality was significantly higher in lower prognostic nutritional index, lower nutritional risk index, and higher CONUT groups. Compared with normal nutrition, malnutrition was associated with an increased risk for all-cause death (adjusted hazard ratio for mild and moderate-severe malnutrition, respectively: 2.82 [95% CI, 1.69-4.71; P<0.001] and 3.31 [95% CI, 1.74-6.32; P<0.001] for the CONUT). In patients with moderate or severe aortic stenosis, we found that high CONUT scores, low nutritional risk index scores, and low prognostic nutritional index scores were associated with all-cause death. The poorer the nutritional status, the greater the risk of malnutrition-related all-cause mortality. URL:https://www.clinicaltrials.gov; Unique identifier: NCT06069232.

Thrombosed Mechanical Aortic Valve Treated with Low-Dose Ultraslow Alteplase Infusion

Background: Prosthetic valve thrombosis is a rare but serious complication of mechanical valve replacement. Traditionally, prosthetic valve thrombosis has been managed by surgical intervention; however, there is increasing data to support the use of thrombolytics. Methods: We present a case of a 74-year-old female with a history of rheumatic fever and subsequent mechanical aortic valve replacement on warfarin who presented to the emergency department with disequilibrium and chest pain. Results: She was found to have a subtherapeutic international normalized ratio and thrombosed mechanical aortic valve seen on transthoracic echocardiography, transesophageal echocardiography, and fluoroscopy. Conclusions: She was treated with a low-dose ultraslow alteplase infusion of 25 mg of alteplase administered over 25 h. Post-infusion transthoracic echocardiography immediately following infusion and four months later confirmed resolution of thrombosis.

Midterm Outcomes of Minimally Invasive Aortic Valve Replacement via Right Lateral Minithoracotomy.

Minimally invasive aortic valve replacement (MIAVR) procedures have been found to have good short-term results. However, no known reports regarding outcomes of MIAVR via a right lateral minithoracotomy (LT) approach over longer terms have been presented. The aim of the present study was to analyze the midterm outcomes of the use of MIAVR with the right LT approach over an 8-year period. Between September 2014 and February 2023, MIAVR was performed for 348 patients with severe aortic valve stenosis and regurgitation at our hospital. Operative mortality, all-cause mortality, and valve-related events were retrospectively examined. The mean patient age was 72.3 ± 10.9 years, while 78 patients (22.4%) were more than 80 years old. Surgical, cardiopulmonary bypass, and cross-clamp times were 194.7 ± 43.2, 118.6 ± 28.7, and 89.4 ± 23.3 min, respectively. The 30-day mortality rate was 0.3%. The mean follow-up period was 35.6 ± 25.9 months. Overall survival shown by Kaplan-Meier analysis at 1, 3, and 5 years was 96.4%, 90.3%, and 83.2%, respectively, and freedom from valve-related events at those time points was noted in 100%, 99.5%, and 96.9% of the cases, respectively. MIAVR via a right LT approach was found to be associated with excellent short-term and midterm outcomes and is considered to have the potential to become an established surgical option.

Platelet Volume Parameters as Predictors of Valvular Thrombosis Risk in Patients with Aortic and Mitral Valve Replacement.

Percutaneous valve implantation or surgical replacement with mechanical or biological valves are standard therapies for severe valvular heart diseases. Prosthetic valve thrombosis, though rare, is a serious complication, particularly with mechanical prostheses. This study aimed to investigate the predictive value of platelet volume parameters, including mean platelet volume (MPV), platelet distribution width (PDW), and platelet-large cell ratio (P-LCR), for valvular thrombosis risk in patients undergoing valve replacement therapy. A retrospective cross-sectional study was conducted from May 2002 to May 2020, involving 108 patients with a history of mitral or aortic valve replacement and valvular thrombosis, and 216 controls with a history of valve surgery without valvular malfunction. PDW was significantly associated with an increased risk of thrombosis after adjusting for confounders, while MPV showed a clinical difference but did not reach statistical significance. P-LCR did not exhibit a significant association. These findings suggest PDW as a potential predictor of valvular thrombosis in such patients. The ease of measuring platelet volume parameters suggests their utility in routine hematological analysis for identifying patients at higher risk of valvular thrombosis post-replacement surgery. Further studies are warranted to validate these findings and explore additional laboratory markers, such inflammatory markers, for thrombotic risk assessment in this population.

Definition and Validation of PrognosticPhenotypes in ModerateAortic Stenosis.

Adverse outcomes from moderate aortic stenosis (AS) may be caused by progression to severe AS or by the effects of comorbidities. In the absence of randomized trial evidence favoring aortic valve replacement (AVR) in patients with moderate AS, phenotyping patients according to risk may assist decision making. This study sought to identify and validate clusters of moderate AS that may be used to guide patient management. Unsupervised clustering algorithms were applied to demographics, comorbidities, and echocardiographic parameters in a training data set in patients with moderate AS (n=2,469). External validation was obtained by assigning the defined clusters to an independent group with moderate AS (n=1,358). The primary outcome, a composite of cardiac death, heart failure hospitalization, or aortic valve (AV) intervention after 5 years, was assessed between clusters in both data sets. Four distinct clusters-cardiovascular (CV)-comorbid, low-flow, calcified AV, and low-risk-with significant outcomes (log-rank P< 0.0001 in both data sets) were identified and replicated. The highest risk was in the CV-comorbid cluster (validation HR: 2.00 [95%CI: 1.54-2.59]; P< 0.001). The effect of AVR on cardiac death differed among the clusters. There was a significantly lower rate of outcomes after AVR in the calcified AV cluster (validation HR: 0.21 [95%CI: 0.08-0.57]; P = 0.002), but no significant effect on outcomes in the other 3 clusters. These analyses were limited by the low rate of AVR. Moderate AS has several phenotypes, and multiple comorbidities are the key drivers of adverse outcomes in patients with moderate AS. Outcomes of patients with noncalcified moderate AS were not altered by AVR in these groups. Careful attention to subgroups of moderate AS may be important to define treatable risk.

Glycemic control after aortic valve replacement: A retrospective study.

Aortic stenosis (AS) is treated through transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR), with diabetes being prevalent among these patients. Inflammation participates in the pathogenesis of AS, and emerging evidence suggests that TAVI may exert anti-inflammatory effects. Given the established link between diabetes and inflammation, we sought to evaluate the impact of aortic valve replacement (AVR) on glycemic control. Data from 10,129 consecutive patients undergoing either TAVI or SAVR between January 2010 and January 2022 were analyzed. Of these, 3,783 with diabetes had available pre- and post-procedural glycated hemoglobin (HbA1c) measurements. Analysis of 1,284 individuals with HbA1c≥7% was conducted. Propensity-score matching produced two well-matched cohorts of 266 TAVI and SAVR patients, enabling comparison of periprocedural HbA1c. In the total cohort (n=1,284), HbA1c decreased from 8.15±1.12 to 7.88±1.38 (p<0.001). After matching, the TAVI group showed a significant reduction from 8.31±1.31 to 7.86±1.56 (p<0.001), while a modest decrease from 8.33±1.33 to 8.15±1.61 (p=0.046) was observed in SAVR group. The TAVI group showed a trend toward a greater percentage change in HbA1c (p=0.051). Clinically meaningful improvement in HbA1c (≥ 0.3%) was similar between TAVI (53.1%) and SAVR (45.6%) patients (OR=1.34, 95% CI 0.93-1.95). Management of AS through either intervention improved post-procedural glycemia in patients with uncontrolled diabetes. The extent of glycemic improvement was more pronounced with TAVI. Further investigations through controlled and prospective studies could provide more conclusive insights into this matter.

High-Gradient Aortic Stenosis With ValveArea >1.0cm2: The "Forgotten" Discordant Hemodynamic Phenotype.

Clinical features and outcomes in severe aortic stenosis (AS) have been described according to the hemodynamic phenotypes. The aim of this study was to investigate the clinical features and prognosis of patients with high-gradient (HG) AS with aortic valve area (AVA) >1.0cm2. A total of 3,209 patients were identified according to AVA (cm2), peak velocity (m/s), systolic mean pressure gradient (MG) (mmHg): HG-AVA >1=>1.0,≥4, and≥40, HG-AVA≤1=≤1.0,≥4, and≥40; LG-AVA≤1 (low-gradient) =≤1.0,<4, and<40; moderate AS=1.0<AVA≤1.5, 3 ≤ peak velocity<4, and 20≤ MG<40. HG-AVA >1 accounted for 230 individuals (7.2%). Compared with others, patients with HG-AVA >1 were younger (70.2 ± 12.0 years), more frequently male (85.7%), had fewer comorbidities, larger body surface area and stroke volume (115 ± 19.3mL), and had higher prevalence of bicuspid valve (39.6%). After a follow-up of 944days (Q1-Q3: 27-2,212days), 1,523 deaths occurred. Compared with the HG-AVA >1 group, all-cause mortality was higher in HG-AVA≤1 (HR: 1.4; 95%CI: 1.1-1.7), LG-AVA≤1 (HR: 2.8; 95%CI: 2.2-3.6), and moderate AS (HR: 1.4; 95%CI: 1.1-1.7). These differences were no longer significant after adjustment for age, comorbidities, bicuspid valve, and cardiac function. In the HG-AVA >1 group, patients with aortic valve replacement had better survival outcomes than those without aortic valve replacement (P< 0.001) after balancing the 2 groups. The underlying relative high-flow status is responsible for HG in patients with HG-AVA >1. This profile has better prognosis than others, being related to underlying younger age and better general and cardiac conditions, butaortic valve replacement may still benefit these patients.

Aortic Annuloplasty With Internal Geometric Ring; Single-Center Midterm Outcomes.

Surgical aortic valve replacement has been the mainstay of treatment against severe aortic insufficiency despite the high incidence of prosthesis-related complications and better long-term outcomes following aortic valve repair. Annuloplasty and leaflet reconstruction are the integral parts of the procedure. Safety and efficacy of HAART internal annuloplasty ring are hereby investigated through mid-term outcomes of a single referral center. Forty-three consecutive patients with either trileaflet or bicuspid aortic insufficiency along with ascending aorta and/or aortic root enlargement were included. Annular stabilization via the internal ring implantation was attempted, whereas leaflet repair was performed whenever required. Maximum follow-up was 6.3 years, whereas the mean was 2.7 years. Mean age was 54.2 years. At least moderate aortic insufficiency was noted in 69.8% (30/43) of patients, whereas 93% (40/43) of them had an ascending aorta or aortic root over 45 mm. Overall mortality was 2.3% (1/43). No more than mild aortic insufficiency was detected early postoperatively. At the last follow-up, there were 2 cases of ring-related adverse events who were reoperated for aortic valve replacement (4.7%). Mid-term outcomes revealed no more than mild aortic insufficiency, while aortic diameter was less than 50 mm in the vast majority of the patients. New York Heart Association class was also significantly lower compared to preoperatively, although moderate aortic stenosis was present in 16% of our cohort. Geometric ring annuloplasty is an easily reproducible valve-sparing approach. Midterm results, revealing 2.3% mortality and 95.3% freedom from reoperation, are promising, but long-term outcomes are yet to be discovered.

Predictors of in-hospital early mortality following valve-in-valve transcatheter aortic valve replacement

Predictors of in-hospital early mortality following valve-in-valve transcatheter aortic valve replacement

Snare-Assisted Management of Nose Cone Entrapment During Self-Expandable Transcatheter Aortic Valve Replacement

Snare-Assisted Management of Nose Cone Entrapment During Self-Expandable Transcatheter Aortic Valve Replacement

Clinical outcomes, hemodynamics, and leaflet thrombosis following transcatheter aortic valve replacement with novel intra-annular devices.

The indication of transcatheter aortic valve replacement (TAVR) is becoming more prevalent among younger and lower-risk patients. However, data on the latest intra-annular TAVR devices are limited. This study aims to compare the short-term clinical outcomes of two intra-annular transcatheter aortic valve replacement (TAVR) devices in Japan: SAPIEN 3 Ultra RESILIA (S3UR) and Navitor. Of the 286 patients who underwent TAVR between May 2022 and October 2023 at our center, we enrolled 97 consecutive patients who received either S3UR or Navitor. We compared the intraprocedural invasive and echocardiographic hemodynamic assessment and post-procedural multidetector computed tomography (MDCT). The basic characteristics of the 97 patients (median age, 86 years [interquartile range, 81-89 years]) were similar. Technical success, defined by the Valve Academic Research Consortium, was achieved in all cases. Despite a smaller annulus, Navitor demonstrated decreased mean pressure gradient by TTE, 9.2 [7.3-13.6] mmHg versus 7.5 [5.9-9.5] mmHg, p = 0.006; but not by invasive measurement 5.1 [3.4-7.7] mmHg versus 5.3 [3.2-7.9] mmHg, p = 0.986). Discordance between echocardiographic and invasive assessment was more prominent with S3UR. However, severe prosthesis-patient mismatch was similarly noted between the two devices. Mild paravalvular leak (PVL) (24.5% vs. 54.5%, p = 0.002) was more frequent with the Navitor, despite no moderate-severe PVL in each group. The incidence of hypoattenuated leaflet thickening (HALT) detected by MDCT was similar between the two groups. Both intra-annular valves demonstrated excellent hemodynamic performance with minimal PVL after TAVR. The incidence of HALT in both devices was comparable.

Long-term clinical outcomes in patients between the age of 50-70 years receiving biological versus mechanical aortic valve prostheses.

The last two decades have seen an incremental use of biological over mechanical prostheses. However, while short-term clinical outcomes are largely equivalent, there is still controversy about long-term outcomes. All patients between the ages of 50-70 years undergoing elective/urgent isolated aortic valve replacement at our institute between 1996 to 2023 were included. Trends, early and long term outcomes were investigated. A total of 1708 (61% male) patients with a median age of 63.60 (IQR : 58.28,67.0) years were included of which 1191 (69.7%) received a biological prosthesis.After inverse propensity score weighting, there were no short-term differences when comparing patients receiving biological and mechanical valves. However, patients who received mechanical prostheses had better long-term survival (p < 0.001). Sub-group analysis revealed that patients with biological size 19 mm prosthesis had the worse long-term survival. Patients with a size 21 mm mechanical prosthesis had better survival compared to both size 19 mm (HR: 0.25, 95% CI: 0.17,0.37, p < 0.001), 21 mm (HR: 0.33, 95% CI: 0.23,0.48, p < 0.001) and 23 mm (HR: 0.40, 95% CI: 0.27,0.60, p = <0.001) biological prosthesis.Additionally, patients with severe patient-prosthesis mismatch exhibited the lowest survival rate compared to those with moderate or no (HR 1.56, 95% CI 1.21, 2.00, p < 0.001). Patients aged between 50-70 years with a mechanical aortic prosthesis had better long-term survival compared to those with a biological prosthesis. Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group.

Abstract TP316: Stroke Events in Cancer Versus Non-Cancer Patients With Aortic Stenosis During Transcatheter Aortic Valve Replacement

Abstract TP316: Stroke Events in Cancer Versus Non-Cancer Patients With Aortic Stenosis During Transcatheter Aortic Valve Replacement

Early Aortic Valve Replacement for Asymptomatic Severe Aortic Stenosis

Early Aortic Valve Replacement for Asymptomatic Severe Aortic Stenosis