Aortic Valve Research Articles

Severe pulmonary hypertension in weaning from cardiopulmonary bypass following double Ozaki procedure: a case report

Abstract Background Ozaki surgery, which reconstructs cardiac valves using autologous pericardium, is commonly performed for aortic valve replacement and offers benefits such as avoiding anticoagulation and reducing valve degeneration. However, its application to pulmonary valve replacement remains rare, and anesthetic management for such cases is not well documented. Case presentation A 71-year-old woman with severe aortic and pulmonary valve stenosis underwent double valve replacement using the Ozaki procedure and coronary artery bypass grafting. Post-cardiopulmonary bypass, she developed severe pulmonary hypertension and systemic hypotension. Norepinephrine exacerbated pulmonary hypertension, while arginine vasopressin effectively stabilized systemic pressure without worsening pulmonary pressure. Conclusions This is the first reported case of anesthetic management for double valve replacement using the Ozaki procedure. Adequate use of vasopressin led to ameliorating pulmonary hypertension after cardiopulmonary bypass. Assessing preoperative right ventricular pressure and selecting appropriate vasopressors are crucial in mitigating perioperative pulmonary hypertension.

Potential role of targeted echocardiography as a screening test for select diagnoses in the paediatric population: bicuspid aortic valve and left ventricular hypertrophy.

We explore the role of targeted echocardiography as a screening tool for bicuspid aortic valve and left ventricular hypertrophy, specifically assessing the risk of missing significant cardiac findings that would otherwise be identified by comprehensive echocardiograms. Children < 18 years at initial echocardiogram for indications of "family history of bicuspid aortic valve" and "left ventricular hypertrophy on electrocardiogram" were queried. Cardiology clinic notes and complete echocardiogram reports were reviewed for additional background histories and incidental findings. Follow-up clinic visits, if any, and management for those with incidental findings were reviewed. Bicuspid aortic valve group included 138 patients, 71 (51%) males and mean age at comprehensive echo was 8.4 ± 4.8 years. Bicuspid aortic valve was found in 3.6%, incidental findings were found in 15 (11%), and follow-up was recommended in 4 (2.8%). Left ventricular hypertrophy group included 70 patients, 58 (83%) males and mean age at echo 10.9 ± 4.7 years. Left ventricular hypertrophy was found in 2.8%, incidental findings were found in 9 (13%), and follow-up was recommended in 2 (2.8%).None of the follow-up group developed symptoms or required cardiac medications, exercise restrictions, or catheter or surgical-based interventions, except for one case of mild aortic root dilation who was restricted from heavy weightlifting. The risk of missing clinically important findings with targeted echocardiography that would have been identified with comprehensive echocardiography is extremely low for screening indications of isolated left ventricular hypertrophy on electrocardiogram or family history of bicuspid aortic valve, suggesting that targeted echocardiography could be an effective screening tool.

LncRNA NEAT1 sponges miR-214-3p to promote osteoblast differentiation through regulating the PI3K/AKT/mTOR pathway in aortic valve calcification

LncRNA NEAT1 sponges miR-214-3p to promote osteoblast differentiation through regulating the PI3K/AKT/mTOR pathway in aortic valve calcification

High-flow oxygenation therapy for a sedated elderly frail patient with hiccups undergoing transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) can be performed under sedation, but body movements may lower the efficacy of the procedure and may increase the risk of complications, such as cardiac tamponade. Additional sedatives and analgesics may be required to prevent body movements; this would increase the risk of upper airway obstruction and of respiratory depression. We report a frail patient with hypoxemia and hiccups, in whom high-flow nasal oxygenation facilitated TAVI by effectively inhibiting body movements and respiratory complications. In an 82-year-old patient with severe aortic stenosis, heart failure, hypoxemia, and hiccups, TAVI was planned under sedation with dexmedetomidine, fentanyl, and ketamine. High-flow nasal oxygenation effectively prevented hiccups and associated body movements, and prevented upper airway obstruction and respiratory depression, during TAVI. High-flow nasal oxygenation therapy is potentially useful during cardiac catheterization procedure under monitored anesthesia care, in elderly frail patients with reduced cardiopulmonary function.

Review Article: Contemporary Transcatheter Heart Valves for TAVI in Bicuspid Aortic Anatomy

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5–2% of the population and often leading to early aortic valve degeneration. While surgical aortic valve replacement (SAVR) remains the gold standard for treating severe bicuspid aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) is emerging as a viable alternative in selected BAV anatomies. Initial experiences with first-generation transcatheter heart valves (THVs) showed the feasibility of this technique, but were associated with lower device success rates and higher complications, such as paravalvular leak (PVL) and pacemaker implantation. Advancements in second- and third- generation THVs, together with better pre-procedural imaging assessment and growing operator experience, have significantly enhanced TAVI outcomes in BAV patients, with results now comparable to those seen in tricuspid aortic valves (TAVs). Proper patient selection, pre-procedural sizing, and device implantation are key to improving TAVI success in BAV. Recent registry data on contemporary THV platforms demonstrate improved procedural success, hemodynamic performance, and the safety of TAVI in BAV. However, higher rates of PVL, pacemaker implantation, and strokes remain concerns. Ongoing advancements in THV design and procedural techniques will further enhance outcomes for this challenging population. Up to the present, there are no dedicated THVs for BAV, but the latest-generation THVs offer promising results.

Morbidity and Mortality of Double Valve Replacement/Repair: A Cohort Study

Background: Aortic and mitral valve replacement or aortic valve replacement with mitral valve repair (DVR) is often associated with a higher risk of morbidity and mortality. Therefore, this study aimed to review and analyze the outcomes of DVR to identify factors associated with morbidity and mortality. Methods: Few multicenter data are available on the clinical outcomes of concomitant DVR in China. In four centers, we performed a cohort study of 816 patients who underwent DVR between January 2016 and December 2021. The 30-day mortality and a 6.5-year follow-up were assessed. Results: A total of 722 patients were included in the final analysis. Overall, the median cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 164.5 minutes and 111 minutes, respectively. The overall 30-day mortality was 5.0% (n = 36). After propensity score matching (PSM), logistic regression analysis showed that EuroSCORE Ⅱ, preoperative ejection fraction (EF), and CPB duration were risk factors for death within 30 days. The median follow-up period was 1225.5 days. In total, 54 patients were lost during the follow-up; 61 patients died during the follow-up. Kaplan–Meier survival analysis revealed a cumulative survival rate of 86.0% at 6.5 years. Cox regression analysis identified ages ≥60 years and postoperative estimated glomerular filtration rates (eGFR) ≤65 mL/min/1.73 m2 as independent late mortality factors. Conclusions: Patients undergoing DVR still have a high risk of mortality and morbidity at 30 days and during follow-up. These patients aged ≥60 years and postoperative eGFR ≤65 mL/min/1.73 m2 are predictive of high mortality and poor prognosis during follow-up.

Transcatheter Aortic Valve Replacement Reverses Heyde Syndrome: A Case Report of Severe Aortic Stenosis and Gastrointestinal Bleeding

Background: Heyde syndrome is a rare condition characterized by the triad of severe aortic stenosis, gastrointestinal bleeding, and acquired type 2A von Willebrand syndrome. This case report highlights the diagnostic and therapeutic approach for a 72-year-old woman presenting with exertional chest pain, dyspnea, fatigue, and a history of melena. Methods: The diagnostic workup revealed severe microcytic anemia and a reduced vWF ristocetin-to-antigen ratio. Imaging confirmed severe degenerative aortic stenosis, while video capsule endoscopy identified angiodysplasia and telangiectasias in the small bowel as the source of gastrointestinal bleeding. Following evaluation by a multidisciplinary Heart Team, the patient underwent transcatheter aortic valve replacement (TAVR) with an Evolut Fx self-expanding prosthesis. Results: Post-procedural echocardiography showed mild paravalvular regurgitation. The patient’s clinical course was favorable, with resolution of anemia and no further gastrointestinal bleeding episodes. Conclusions: Heyde syndrome requires a high index of suspicion for diagnosis in patients with severe aortic stenosis and unexplained anemia or gastrointestinal bleeding. TAVR offers an effective treatment option that not only resolves valvular pathology, but also mitigates associated bleeding risks.

Commentator Discussion: Transcatheter versus surgical aortic valve replacement in patients younger than age 65years in the United States.

Commentator Discussion: Transcatheter versus surgical aortic valve replacement in patients younger than age 65years in the United States.

Management of TAVR in asymptomatic or minimally symptomatic patients: Insights from resting angiographic microvascular resistance.

Management of TAVR in asymptomatic or minimally symptomatic patients: Insights from resting angiographic microvascular resistance.

Temporal Trends in Etiology of Aortic Valvular Diseases for Patients Undergoing Surgical Valve Replacement: A Report From 40 Years Pathological Experience.

Although aortic valvular disease has various etiologies, recently, calcific aortic valve stenosis has been increasing. We analyzed the trends in the pathological characteristics of aortic valvular disease in the past four decades in Japan. The pathology department data for aortic valvular disease operated in our hospital documented 4508 patients from 1978 to 2022. Subsequently, trend analyses were performed over four periods: Period 1, 1978-1989 (618 cases); Period 2, 1990-1999 (903 cases); Period 3, 2000-2010 (1179 cases); and Period 4, 2011-2022 (1808 cases). We reviewed the pathological characterization of the resected aortic valves and categorized them based on the representative etiology of aortic valvular disease as congenital bicuspid, chronic rheumatic change, infective endocarditis, degenerative calcific change, and myxoid change. Our pathologic analysis revealed a significant decrease in the proportion of chronic rheumatic disease from 47% to 14%, an increase in the congenital bicuspid valve from 8% to 24%, and a rise of the degenerative calcific change of the aortic valve from 4% to 27% (p < 0.001), especially significant increases in aortic stenosis. Calcification of the aortic valve may result from an active process similar to atherosclerosis, leading to aortic stenosis with increasing dyslipidemia in Japanese patients in 40 years.

Impact of Renal Function on Myocardial Remodeling and Outcomes in Patients with Moderate Aortic Stenosis.

Impact of Renal Function on Myocardial Remodeling and Outcomes in Patients with Moderate Aortic Stenosis.

Factors Contributing to Hospital-Associated Disability in Elderly Patients After Transcatheter Aortic Valve Implantation.

Hospital-associated disability (HAD), characterized by a worsening of activities of daily living and physical function following hospitalization, is a common complication in older adults during the course of acute care hospitalization. HAD is a significant concern affecting older adults undergoing transcatheter aortic valve implantation (TAVI). This retrospective study investigated 243 consecutive patients who underwent elective transfemoral TAVI between January 2016 and April 2022. HAD was defined as a decrease of at least 1 point in the Short Physical Performance Battery (SPPB) assessed before discharge compared with before TAVI. Logistic regression identified the first ambulation day after TAVI as an independent predictor of HAD incidence (odds ratio 1.500; 95% confidence interval [CI] 1.115-2.008; P=0.007). Patients with HAD had significantly lower body mass index, hemoglobin, and albumin, and higher serum creatinine. All-cause mortality was significantly higher in patients with than without HAD (log-rank P<0.001). Kaplan-Meier analysis confirmed poorer survival in patients with HAD, regardless of the degree of decline in SPPB. Multivariate Cox analysis regression identified HAD as a predictor of all-cause death (hazard ratio 4.249; 95% CI 1.798-10.04; P<0.001). The timing of the first ambulation was associated with the incidence of HAD. Promoting early mobilization may reduce the risk of HAD after TAVI.

Redo-Transcatheter Aortic Valve Replacement Procedural Optimization and Patient Selection: From Bench to Clinical Practice

With recent guidelines expanding transcatheter aortic valve replacement (TAVR) to younger patients, indications for redo-TAVR will also likely increase. When compared with TAVR, redo-TAVR is a rare and novel procedure. Current clinical data derived from registries suggest excellent safety, with low rates of 30-day and 1-year mortality following redo-TAVR. Proper understanding of data from bench studies regarding optimal valve configurations, of patient anatomy and of the technical properties of transcatheter heart valves (THV) is essential for patient selection and procedural success. Lifetime management of redo-TAVR should start before the index procedure, as the choice of the index THV has a major impact on the feasibility of redo-TAVR. Procedural optimization by adequate valve sizing, commissural alignment and adequate implant depth of both index and redo-THV are critical determinants of optimal hemodynamics for maximized valve longevity, as well as lifelong coronary access.

Three-Year Outcomes of Surgical Implantation of a Novel Bioprosthetic Valve for the Treatment of Deep Venous Reflux.

Three-Year Outcomes of Surgical Implantation of a Novel Bioprosthetic Valve for the Treatment of Deep Venous Reflux.

Discordance between aortic valve gradient and area: do I trust the significant gradient?

Aortic stenosis is an increasingly relevant pathology not only for its high prevalence in the population (especially elderly), but also because in recent decades traditional surgery has been accompanied by transcatheter aortic valve implantation, a technique that has allowed a significant increase in effective therapeutic procedures, even in patients previously considered at high surgical risk. It has become essential to make precise diagnoses, based mainly on echo-Doppler that allows to identify the aetiology and severity of the valvular disease. A stenosis is considered severe when the area is <1 cm2, the mean gradient exceeds 40 mmHg and the peak velocity is >4 m/s. Although in many cases these cut-offs are decisive, in others a discrepancy between area (<1 cm2) and gradient (<40 mmHg) is observed, requiring the inclusion of other variables such as ejection fraction (EF > or <50%) and the systolic volume index (normal SVi >35 mL/m2 or reduced <35 mL/m2) to define the severity of the stenosis. This article describes the reasons for this discrepancy, identifies echo-Doppler parameters that further improve the classification of stenosis severity, and defines the indications for second-level examinations such as computed tomography and transoesophageal echocardiography.

Even aortic insufficiency can be treated percutaneously: right?

Moderate or severe aortic insufficiency (AI) is a relatively rare condition but with significant clinical implications, especially in elderly patients at high surgical risk. Although surgical aortic valve replacement remains the gold standard for treatment, a significant proportion of patients are not eligible due to the high surgical risk. In recent years, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of aortic stenosis, but its application to AI has encountered significant challenges, mainly related to specific anatomical characteristics of this population. This review provides an overview of the evolution of the transcatheter treatment of AI, highlighting the critical issues of first-generation TAVI devices and the improvements achieved with new-generation and dedicated devices, such as JenaValve and J-Valve. Preliminary data demonstrate encouraging procedural results, including a reduction in residual insufficiency and improved safety in patients at high surgical risk. However, limitations remain, including the high incidence of pacemaker implantation and the lack of long-term randomized clinical trials. In light of technological advances, TAVI represents a promising therapeutic option for selected patients with AI, if performed in high-volume centres with extensive experience in the treatment of aortic disease.

Heart Failure With Preserved Ejection Fraction Phenotype Is Associated With Early Symptom Onset in Aortic Stenosis and Residual Symptoms After Transcatheter Aortic Valve Implantation.

Aortic stenosis can lead to cardiac adaptations and symptoms similar to heart failure with preserved ejection fraction. We hypothesized that a heart failure with preserved ejection fraction phenotype in aortic stenosis is associated with earlier onset of symptoms and reduced symptomatic response after transcatheter aortic valve implantation (TAVI). This retrospective cohort study included 469 patients with moderate aortic stenosis. We determined heavy, hypertension, atrial fibrillation, pulmonary, elder, filling pressure (H2FPEF) score at diagnosis and compared aortic peak jet velocity at onset of dyspnea in patients with low (<6) and high (≥6) H2FPEF score. In a separate cohort of 601 patients undergoing TAVI, we compared New York Heart Association class, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and cardiovascular mortality post-TAVI between patients with low and high H2FPEF scores. In patients with aortic stenosis and a high H2FPEF score (n=43, 9.2%), the median peak jet velocity at onset of dyspnea was 4.2 versus 4.4 m/s in patients with a low H2FPEF score (P<0.001). After TAVI, a high H2FPEF score (n=123, 20%) was associated with a lower proportion of New York Heart Association class I at 30 days (49% versus 61%; P=0.04), persistently elevated NT-proBNP, and higher 5-year rate of cardiovascular mortality (36% versus 30%; P=0.012), compared with a low H2FPEF score. Patients with aortic stenosis with a heart failure with preserved ejection fraction phenotype are more likely to develop symptoms at lower gradients and have worse outcomes post-TAVI. Randomized trials are warranted to investigate whether medical therapy targeted at heart failure with preserved ejection fraction delays onset of symptoms and improves symptomatic response after TAVI.

Ten years of transcatheter aortic valve implantation in the NOTION study: the good and the bad.

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis, becoming a preferred option for patients at high and moderate surgical risk and for individuals over 75 years of age. The NOTION study represents the first randomized clinical trial to reach a 10-year follow-up in patients at low surgical risk, comparing TAVI with surgical valve replacement (SAVR). The results show comparable clinical outcomes between TAVI and SAVR in terms of all-cause mortality, stroke, and myocardial infarction. TAVI demonstrated a better haemodynamic profile and a lower incidence of structural valve deterioration (SVD), but showed higher rates of pacemaker requirement and paravalvular leakage compared with surgical replacement. The trial highlights the excellent durability of transcatheter bioprostheses, although new-generation devices and advanced techniques could further reduce adverse events. The study confirms the increasing role of TAVI even in younger patients, but further long-term data will be needed to evaluate its full potential.

Use of complementary electrocardiogram-gated cardiac computed tomography in the assessment of aortic valve repairability: a pilot study.

In young patients with type I/II aortic regurgitation, the feasibility of aortic valve repair has been traditionally evaluated with echocardiography. We evaluate electrocardiogram-gated cardiac computed tomography as a complement to transoesophageal echocardiography in the preoperative assessment of aortic repairability. Patients undergoing non-urgent aortic valve repair with or without aortic root replacement from October 2016 to May 2023 who had both imaging tests for the evaluation of aortic valve repairability were included. The measurements obtained with echocardiography and electrocardiogram-gated scan of geometric height, aortic annulus and commissural orientation were compared using the Intraclass Correlation Coefficient for inter-rater reliability. All 24 patients were males, with a median age of 47,5 years (41,9-59,3). Of these, 87,5% presented severe aortic regurgitation; 62,5% had associated aortopathy. 58,3% were in New York Heart Association class I and the remnant 41,7% in class II. The aortic valve was bicuspid in 62,5% of the patients. The Intraclass Correlation Coefficient indicated excellent reliability of electrocardiogram-gated scan for commissural orientation (ICC = 0,98, 95% CI: 0,96 to 0,99) and conjoined cusp geometric height (ICC = 0,91, 95% CI: 0,74 to 0,97) in bicuspid aortic valves, while in tricuspid valves it showed good reliability for left cusp geometric height (ICC = 0,76, 95% CI: 0,19 to 0,93) and annular diameter (ICC = 0,8, 95% CI: 0,33 to 0,95). Electrocardiogram-gated cardiac scan complements echocardiography in aortic repair, showing excellent agreement for morphologic evaluation and commissural orientation. It is particularly reliable for geometric height in bicuspid valves and annular diameter and left cusp geometric height in tricuspid valves.

Cardiac computed tomography imaging biomarkers for prediction of new-onset heart failure: Multi-ethnic study of atherosclerosis.

Cardiac computed tomography imaging biomarkers for prediction of new-onset heart failure: Multi-ethnic study of atherosclerosis.