Candidates For Aortic Valve Replacement Research Articles

Frailty in Older Adults with Severe Aortic Stenosis: The Role of Systemic Inflammation and Calcium Homeostasis.

Background: Frailty and severe aortic stenosis (AoS) are critical conditions in older adults, both of which share pathophysiological mechanisms including chronic inflammation and calcium metabolism dysregulation, potentially influencing the development and progression of these conditions. This study aimed to analyze systemic inflammation and calcium homeostasis biomarkers and their associations with frailty in older adults with severe AoS. Methods: This prospective study included 191 patients aged ≥75 years with severe AoS who were candidates for aortic valve replacement and were evaluated at a Geriatrics Frailty Assessment and Intervention Clinic. Frailty was defined as a score ≤6 on the Short Physical Performance Battery (SPPB). Biomarkers analyzed included aortic valve calcium score, parathyroid hormone (PTH), calcidiol (vitamin D), calcium, phosphate, creatinine, interleukin-6 (IL-6), and the Systemic Immune-Inflammation Index. Multivariate logistic regression was performed to identify independent predictors of frailty. Results: Of the 191 patients studied, 53.9% were women, with a mean age of 84.1 ± 4.1 years. Frailty was identified in 28.3% of patients (mean SPPB score 7.6 ± 2.5). Statistically significant differences between frail and non-frail patients were observed for PTH (87.7 ± 61.1 pg/mL vs. 70 ± 44.4 pg/mL, p = 0.028) and IL-6 (10.4 ± 11.2 pg/mL vs. 7 ± 8.2 pg/mL, p = 0.049). Notably, in the multivariate model, IL-6 emerged as a significant independent predictor of frailty (OR 1.037; CI 1.001-1.074, p = 0.043). Conclusions: IL-6 was identified as a biomarker significantly associated with frailty in older adults with severe AoS. Evaluating IL-6 could enhance the precision of frailty assessments, complement functional measures, and support clinical decision-making in this population.

Pictorial rendition of author’s observations on balloon valvuloplasty/angioplasty procedures: Aortic stenosis

Balloon aortic valvuloplasty (BAV) effectively decreases peak pressure gradients through the aortic valve both at the time of the procedure and during follow-up. This paper presents the author’s observations on the utility of BAV in treating congenital aortic valve stenosis (AVS). Previous work by the author noted intermediate-term restenosis and late-onset aortic insufficiency (AI). Factors contributing to restenosis include age under 3 years and post-balloon residual aortic valve gradients exceeding 30 mmHg. Repeat balloon valvuloplasty has been found to address restenosis effectively. However, the onset of AI at late follow-up is a significant disadvantage of BAV. Despite this, BAV is currently considered a beneficial treatment option for managing AVS in children, adolescents, and young adults. In contrast, seniors with calcific AVS do not experience relief from obstruction with BAV and are candidates for aortic valve replacement through transcatheter methodology, a procedure not reviewed in this paper. BAV provides relief of obstruction across the aortic valve and functions as an alternative to surgical intervention. Consequently, BAV is considered a preferred choice in addressing aortic stenosis in the pediatric patient.

Fully Automated Functional Assessment Of Pre-procedural Cardiac Ct Predicts Outcome In Transcatheter Aortic Valve Replacement Candidates

Fully Automated Functional Assessment Of Pre-procedural Cardiac Ct Predicts Outcome In Transcatheter Aortic Valve Replacement Candidates

Is There Still a Role for Invasive Assessment of Aortic Gradient?

Advances in technology and imaging have expanded the range of tools for diagnosing aortic stenosis (AS). The accurate assessment of aortic valve area and mean pressure gradient is crucial to determine which patients are appropriate candidates for aortic valve replacement. Nowadays, these values can be obtained noninvasively or invasively, with similar results. Contrariwise, in the past, cardiac catheterization played a major role in the evaluation of AS severity. In this review, we will discuss the historical role of the invasive assessment of AS. Moreover, we will specifically focus on tips and tricks for properly performing cardiac catheterization in patients with AS. We will also elucidate the role of invasive methods in current clinical practice and their additional value to the information provided through non-invasive techniques.

Hematopoietic Somatic Mosaicism Is Associated With an Increased Risk of Postoperative Atrial Fibrillation.

On-pump cardiac surgery triggers sterile inflammation and postoperative complications such as postoperative atrial fibrillation (POAF). Hematopoietic somatic mosaicism (HSM) is a recently identified risk factor for cardiovascular diseases and results in a shift toward a chronic proinflammatory monocyte transcriptome and phenotype. The aim of this study was to assess the prevalence, characteristics, and impact of HSM on preoperative blood and myocardial myeloid cells as well as on outcomes after cardiac surgery. Blood DNA from 104 patients referred for surgical aortic valve replacement (AVR) was genotyped using the HemePACT panel (576 genes). Four screening methods were applied to assess HSM, and postoperative outcomes were explored. In-depth blood and myocardial leukocyte phenotyping was performed in selected patients using mass cytometry and preoperative and postoperative RNA sequencing analysis of classical monocytes. The prevalence of HSM in the patient cohort ranged from 29%, when considering the conventional HSM panel (97 genes) with variant allelic frequencies≥2%, to 60% when considering the full HemePACT panel and variant allelic frequencies≥1%. Three of 4 explored HSM definitions were significantly associated with higher risk for POAF. On the basis of the most inclusive definition, HSM carriers exhibited a 3.5-fold higher risk for POAF (age-adjusted OR: 3.5; 95%CI: 1.52-8.03; P=0.003) and an exaggerated inflammatory response following AVR. HSM carriers presented higher levels of activated CD64+CD14+CD16- circulating monocytes and inflammatory monocyte-derived macrophages in presurgery myocardium. HSM is frequent in candidates for AVR, is associated with an enrichment of proinflammatory cardiac monocyte-derived macrophages, and predisposes to a higher incidence of POAF. HSM assessment may be useful in the personalized management of patients in the perioperative period. (Post-Operative Myocardial Incident & Atrial Fibrillation [POMI-AF]; NCT03376165).

One-Year Outcomes after Myval Implantation in Patients with Bicuspid Aortic Valve Stenosis-A Multicentre Real-World Experience.

Bicuspid aortic valve (BAV) affects approximately 1.5% of the general population and is seen in nearly 50% of candidates for aortic valve replacement (AVR). Despite increasingly utilised transcatheter aortic valve implantation (TAVI) in aortic stenosis (AS) patients, its use among patients with severe bicuspid AS is limited as BAV is a heterogeneous disease associated with multiple and complex anatomical challenges. To investigate the one-year outcomes of TAVI using the balloon-expandable Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd., Vapi, India) in patients with severe bicuspid AS. We collected data from consecutive patients with bicuspid AS who underwent TAVI with the Myval THV and had at least one-year follow-up. Baseline characteristics, procedural, and 30-day echocardiographic and clinical outcomes were collected. Sixty-two patients were included in the study. The median age was 72 [66.3, 77.0] years, 45 (72.6%) were males, and the mean STS PROM score was 3.2 ± 2.2%. All TAVI procedures were performed via the transfemoral route. The median follow-up duration was 13.5 [12.2, 18.3] months; all-cause mortality was reported in 7 (11.3%) patients and cardiovascular hospitalisation in 6 (10.6%) patients. All-stroke was reported in 2 (3.2%), permanent pacemaker implantation 5 (8.3%), and myocardial infarction 1 (1.6%) patients. The echocardiographic assessment revealed a mean pressure gradient of 10 [8, 16.5] mmHg, effective orifice area 1.7 [1.4, 1.9] cm2, moderate AR in 1 (2%), mild AR in 14 (27%), and none/trace AR in 37 (71%). In total, 1 patient was diagnosed with valve thrombosis (2.1%), Stage II (moderate) haemodynamic deterioration was seen in 3 (6.4%), and stage III (severe) haemodynamic deterioration in 1 (2.1%) patient. TAVI with the Myval THV in selected BAV anatomy is associated with favourable one-year hemodynamic and clinical outcomes.

Elevated Fasting Glucose and C-Reactive Protein Levels Predict Increased All-Cause Mortality after Elective Transcatheter Aortic Valve Implantation.

Surgical aortic valve replacement in the elderly is now being supplanted by transcatheter aortic valve implantation (TAVI). Scoring systems to predict survival after catheter-based procedures are understudied. Both diabetes (DM) and underlying inflammatory conditions are common in patients undergoing TAVI, but their impact remains understudied in this patient group. We examined 560 consecutive TAVI procedures and identified eight pre-procedural factors: age, body mass index (BMI), DM, fasting blood glucose (BG), left-ventricular ejection fraction (EF), aortic valve (AV) mean gradient, C-reactive protein levels, and serum creatinine levels and studied their impact on survival. The overall mortality rate at 30 days, 1 year and 2 years were 5.2%, 16.6%, and 34.3%, respectively. All-cause mortality was higher in patients with DM (at 30 days: 8.9% vs. 3.1%, p = 0.008; at 1 year: 19.7% vs. 14.9%, p = 0.323; at 2 years: 37.9% vs. 32.2%, p = 0.304). The presence of DM was independently associated with increased 30-day mortality (hazard ratio [HR] 5.38, 95% confidence interval [CI], 1.24-23.25, p = 0.024). BG levels within 7-11, 1 mmol/L portended an increased risk for 30-day and 2-year mortality compared to normal BG (p = 0.001 and p = 0.027). For each 1 mmol/L increase in BG 30-day mortality increased (HR 1.21, 95% CI, 1.04-1.41, p = 0.015). Reduced EF and elevated CRP were each associated with increased 2-year mortality (p = 0.042 and p = 0.003). DM, elevated BG, reduced EF, and elevated baseline CRP levels each are independent predictors of short- and long-term mortality following TAVI. These easily accessible screening parameters should be integrated into risk-assessment tools for catheter-based aortic valve replacement candidates.

Right ventricular mechanics and its association with symptoms in transcatheter aortic valve replacement candidates: a three-dimensional echocardiography study

Abstract Aortic valve stenosis is one of the most prevalent valvular disease with significant clinical burden. While it is initially a disorder of the left ventricle (LV), long-term effects of the disease also affect the right ventricle (RV) as well. Nevertheless, data are scarce regarding the changes of RV mechanics and their association with symptomatic status of the patients. 3D echocardiography allows a more detailed assessment of the RV, which may unveil distinct changes of its morphology and function in this clinical setting. Accordingly, our aim was to examine LV and RV mechanics in TAVR candidate patients with severe aortic stenosis using three-dimensional (3D) echocardiography. Seventy patients (51% male, age: 80±6 years) were enrolled. Detailed medical history and symptomatic status were obtained. Beyond conventional transthoracic echocardiographic protocol, 3D loops were also acquired. We measured 3D LV and RV end-diastolic volume indexed to body surface area (EDVi), ejection fraction (EF) and global longitudinal (GLS) using dedicated software. Furthermore, we have determined 3D RV global longitudinal (RV GLS) and circumferential strain (RV GCS) using the ReVISION method. LV EF (r=0.28, p<0.05) and LV GLS (r=−0.26, p<0.05) significantly correlated with age, while RV EF (r=0.21, p=0.11), RV GLS (r=−0.17, p=0.19) and RV GCS (r=−0.07, p=0.61) did not show association with it. 41% (n=29) of the patient population mentioned angina or had syncope. Patients with these symptoms had comparable LV EDVi (73±23 vs. 69±25 mL/m2, p=0.47), LV EF (47±15 vs. 51±10%, p=0.14) and LV GLS (−13.6±4.8 vs. −14.8±2.6%, p=0.25) to those who did not mention these complaints. On the other hand, patients with angina or syncope in their medical history had significantly lower RV EDVi (58±13 vs. 70±23 mL/m2, p<0.05), while having significantly higher RV EF (46±10 vs. 52±7%, p<0.05). Moreover, symptomatic patients had significantly lower RV GCS (−15.7±5.6 vs. −19.6±5.3%, p<0.01), while RV GLS did not differ (−15.8±4.8 vs. −17.4±4.1%, p=0.17). Patients with severe aortic stenosis have marked changes in not only the LV, but the RV mechanics as well. While the symptomatic status does not seem to be associated with LV morphology and function, patients with angina or syncope had distinct changes in RV size and the contraction pattern of the chamber. Funding Acknowledgement Type of funding sources: None.

Incidence, Outcomes and Predictors of Aortic Regurgitation After Transcatheter Aortic Valve Replacement in Al Azhar University Hospitals and National Heart Institute, Egypt

Background: Aortic regurgitation (AR), which has ill-defined predictors and an unknown long-term influence on outcomes, is a significant transcatheter aortic valve replacement (TAVR) constraint. Objective: this research aimed to assess the prevalence, identify predictors, and evaluate the outcomes of aortic regurgitation following trans catheter aortic valve implantation (TAVI). 1. To calculate the prevalence of aortic regurgitation in elderly patients receiving trans catheter aortic valve implantation who have severe symptomatic aortic stenosis. 2. To determine aortic regurgitation risk factors after trans catheter aortic valve implantation. Methods: From November 2017 to November 2020, this prospective observational study was done in the National Heart Institute on severe aortic valve stenosis patients above 65 years who were candidates for aortic valve replacement from the outpatient department. Results: LVEF significantly improved. Compared to before TAVI (55.08 ± 9.71), LVEF elevated to 58.9 ± 8.8 (P<0.001). Twenty-five patients (83.3%) showed class III/IV, four patients (13.3%) showed class II, and one patient (3.3%) showed class I before TAVI. While after TAVI, three patients (10%) only showed NYHA class III/IV, six patients (20 %) in class II, and 21 patients (70%) improved to be in class I. The left ventricular mass index mean was 158 ±32.37 before TAVI and 133.50 ±21.96 after TAVI (p<0.001). Compared to before TAVI (0.75 ± 0.2), mean aortic valve area was improved to 2.0 ± 0.2 following TAVI (P<0.001). A significant reduction in the mean pressure gradient from 47 ± 11.08 mmHg across the native valve prior to TAVI to 10.28 ± 3.21 mmHg across the prosthetic valve following TAVI (P <0.001). Expert commentary: The clinical and results of TAVR devices were clearly outlined in literature study. The study showed a high incidence of pacemaker implantation with Core valve and aortic regurgitation. This information strongly supports the need for a randomized trial with sufficient power to compare the most recent self-expandable valve generation to balloon expandable valves. In the 2019 PARTNER 3 prospective randomized trial, it was discovered that, when compared to surgical management, low-risk patients (defined as STS 4%) had a lower risk of the composite outcome of stroke, death, and rehospitalization at 1 year. Additionally, it was shown that TAVR had a lower risk of stroke and required less time in the hospital (3 days as opposed to 7, P0.001) than surgery [1]. In addition, despite an elevated permanent pacemaker implantation rate, the 2019 Medtronic Evolut Transcatheter Aortic Valve Replacement revealed no inferiority for composite all-cause stroke and death, as well as a statistically significant decrease in the rates of life-threatening bleeding, acute kidney injury and atrial fibrillation, compared with SAVR at 30 days following the procedure [2]. Conclusion: According to the study in high-risk patients with severe symptomatic aortic stenosis, TAVI is alternative, viable, safe, and successful therapy compared to traditional open-heart surgery.

Comparing Clinical and Hemodynamic Parameters between the Two Aortic Valve Replacement in Patients with Severe Aortic Stenosis.

Context:Various techniques have been proposed for suturing following prosthetic aortic valve implantation, but each has its potential side effects such as patient-prosthesis mismatch (PPM) and paravalvular leak (PVL).Aims:In the present study, we aimed to compare the postoperative sequels of aortic valve replacement (AVR) following the use of two suturing techniques including from the inside of the aorta as the common and classic suturing techniques as compared to new approach including from the outside of the aorta.Settings and Design:This cross-sectional study was performed on patients suffering from symptomatic severe aortic valve disease and candidates for AVR in one of three referral hospitals for cardiovascular disease patients in Shiraz from 2019–2021.Subjects and Methods:The patients underwent one of the two considered surgical techniques for AVR including traditional approach (n = 60) or the tested approach (suturing from the outside of the aorta) (n = 30).Statistical Analysis Used:For statistical analysis, results were presented as mean ± standard deviation for quantitative variables and were summarized by frequency (percentage) for categorical variables.Results:PVL and PPM were revealed in none of the participants undergoing the tested approach, while the pointed complications were found in 41.7% and 25.0% of patients underwent traditional approach, respectively, indicating a significant difference. There was no evidence of abnormal dimensionless valve index (DVI) in the patients undergoing sutures from outside the aorta, whereas the rate of DVI abnormality in the patients undergoing traditional procedures was shown to be 18.3%. The mean aortic valve gradient was significantly higher in the group scheduling for the traditional surgical method.Conclusions:Applying new suturing method as suturing from the outside of the aorta, due to the selection of appropriate valve size, the risk for adverse consequences including PPM, PVL, or DVI can be significantly reduced.

Horizontal Aorta in Transcatheter Self-Expanding Valves: Insights From the HORSE International Multicentre Registry.

[Figure: see text].

Growth Differentiation Factor 15 in Severe Aortic Valve Stenosis: Relationship with Left Ventricular Remodeling and Frailty.

Background: Frailty is an important outcome predictor in patients with aortic stenosis who are candidates for transcatheter or surgical aortic valve replacement (AVR). Growth/differentiation factor 15 (GDF15) is a cytokine playing a role in the pathophysiology of ventricular remodeling. We assessed its potential role as an independent soluble biomarker of frailty in these patients. Methods: We studied 62 patients (age, mean 79 years, 95% confidence interval (CI) 77–81; 54.8% female) with severe aortic valve stenosis and candidates for AVR. We systematically assessed pre-intervention GDF15 levels for their relationship with frailty (Katz score) and echocardiographic parameters of left ventricular dysfunction/remodeling. Fifteen hypertensive patients with left ventricular (LV) hypertrophy served as controls. Results: Patients with aortic valve stenosis featured higher GDF15 levels than controls (1773, 95% CI 1574–1971 pg/mL vs. 775, 95% CI 600–950 pg/mL, respectively, p < 0.0001). Subjects in the upper GDF15 tertile were older (p = 0.004), with a more advanced NYHA functional class (p = 0.04) and a higher prevalence of impaired renal function (p = 0.004). Such patients also showed a higher frailty score (p = 0.04) and higher indices of LV dysfunction, including reduced global longitudinal strain (p = 0.01) and a higher left ventricular mass (p = 0.001). GDF15 was significantly related to the Katz score, and predicted (OR 1.05; 95% CI 0.9–1.1; p = 0.03) a low (<5) Katz score, independent of the relationship with LV mass, age, renal function or indices of LV dysfunction. Conclusions: GDF15 is increased in patients with severe aortic stenosis and appears to be a soluble correlate of patients’ frailty, independent of indices of left ventricular dysfunction.

A RARE CASE OF CORYNEBACTERIUM STRIATUM NATIVE VALVE ENDOCARDITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Corynebacterium diphtheroids species are aerobic, Gram-positive bacilli often considered as part of normal skin flora and mucous membranes. Though frequently isolated in cultures, they are often assumed to be skin contaminants. Nonetheless, over the last decade they are reported to cause life threatening diseases including bacteremia and endocarditis. They cause 4-9% of prosthetic vale endocarditis but are only responsible for 0.2 to 0.4% of native valve endocarditis (NVE)(1). CASE PRESENTATION: 54 years old female with past medical history significant for hypertension, hyperlipidemia, mild intermittent asthma, anemia, seizure disorder, transient ischemic attack, cerebrovascular accident without any residual deficit, atrial fibrillation on coumadin, schizophrenia, chronic back pain, cocaine use, recent colitis presented with complains of intermittent fever, chills for few weeks and mechanical fall one day prior to presentation. She was recently treated for colitis at outside hospital (OH) and was discharged on oral co-amoxiclav. She reported that she had bacteremia. Vitals: temp 101.5F, Blood pressure (BP) 102/67mmhg. Physical examination: irregular heart rate, wheezing, positive cervical and lumbar paraspinal tenderness. Labs: normocytic anemia with hemoglobin of 10.4, platelet count of 115 x 109/L, sub-therapeutic international normalized ratio (INR) of 1.11 and cervical spine X-ray suggestive of disc space narrowing at C5-C6. Cefepime 1gm IVSS q8h and vancomycin 1gm IVSS q12h were started. Hospital course was complicated by hypotension with BP of 80s-90s systolic/50’s to 60’s diastolic, non-responsive to intravenous fluids and drop in oxygen saturation to 80’s due to development of pulmonary edema. Blood cultures were positive for gram positive rods. Medical records from OH revealed blood cultures positive for gram positive rods. Antibiotic was changed to ampicillin to cover possible listeria monocytogenes (blood cultures positive for gram positive rods). Transthoracic echocardiogram (TTE) was suggestive of aortic valve vegetation with severe regurgitation (See Figure 1). She was considered candidate for aortic valve replacement and transferred to cardiothoracic surgery. She successfully underwent aortic valve replacement. Final results of blood cultures grew “Corynebacterium Striatum (C. Striatum)”. DISCUSSION: This case highlights a patient with native valve endocarditis secondary to C. Striatum and its management. C. striatum is being recently recognized as a nosocomial opportunistic pathogen (2,3) and can rarely cause NVE. CONCLUSIONS: We stress that clinicians should be vigilant and consider Corynebacterium species as potential culprits while managing patients with bacteremia due to gram positive bacilli and should be cautious while labelling them as skin contaminants. Reference #1: Belmares J, Detterline S, Pak JB, Parada JP. Corynebacterium endocarditis species-specific risk factors and outcomes. BMC Infect Dis. 2007;7:4. Reference #2: Lee JY, Lee SH, Kim WH. Three-valve Endocarditis Caused by Corynebacterium striatum. Korean Circ J. 2018;48(9):861-2. Reference #3: McMullen AR, Anderson N, Wallace MA, Shupe A, Burnham CA. When Good Bugs Go Bad: Epidemiology and Antimicrobial Resistance Profiles of Corynebacterium striatum, an Emerging Multidrug-Resistant, Opportunistic Pathogen. Antimicrob Agents Chemother. 2017;61(11). DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by Dileep Kumar, source=Web Response

Dental screening prior to valve interventions: Should we prepare transcatheter aortic valve replacement candidates for “surgery”?

Background40% of cases of infective endocarditis (IE) are likely caused by oral bacteria. IE prevalence after transcatheter aortic valve replacement (TAVR) is comparable to IE following surgical prosthetic valve replacement (SVR). Current guidelines recommend pre-operative dental screening for SVR, without specific recommendations regarding TAVR.We aimed to compare oral dental findings in TAVR vs. surgical valve replacement (SVR) candidates and assess the need for routine dental screening and treatment prior to TAVR similar to the SVR patients. Methods150 patients (58 TAVR candidates and 92 surgical candidates) were all referred for screening and appropriate treatment before intervention to our Oral medicine team, blinded to the planned interventional type. All patients were scored for oral hygiene and dental findings that required intervention. An oral health score (OHS, general hygiene: 0-good, 1-bad, need for immediate treatment: 0-no, 1-yes, need for future treatment: 0-no, 1-yes) was calculated and compared. Patients were clinically followed for IE for 14 ± 5 months (rage 8–28) post intervention. ResultsWhile candidates for SVR were younger than TAVR (66 + 10 vs. 81 ± 6 respectively, P < 0.0001), oral-dental findings were similar. OHS was 1.6 for SVR and 1.7 for TAVR candidates, p = 0.45). Half of patients in either group had findings requiring pre-procedural dental treatment. There were two IE cases during follow-up, one in each group. ConclusionOral health and need for pre-procedural dental treatment were not different among candidates for SVR and TAVR. IE preventive oral-dental care seems to be justified in patients undergoing TAVR initially denied SVR due to prohibitive operative risk.

Mid-term Results of First Experience in Sutureless Aortic Valve Replacement in Iran

Background: Although the TAVI technique has been widespread in Europe and America, concerns have emerged regarding the associated complications, mainly paravalvular leakage, vascular complications, stroke, post-operative pacemaker implantation due to complete AV block, optimal access sites, long-term valve durability, and economic sustainability, therefore controversy remains about the ideal treatment of high-risk operable patients. Sutureless tissue valves like Perceval S may be a good option for these high risk operable patients. We will present the clinical outcomes of first cases of Perceval S in Iranian patients. Methods: From July 2015 to August 2016, 11 patients (8 male, 3 female) with severe aortic stenosis who were candidates for aortic valve replacement were included in this study. The mean age of patients was 73 ± 8 ranged from 65 to 86 years. The most common presenting symptom was dyspnea and three of the patients had coronary artery disease in need for concomitant revascularization. Preoperative peak gradient across the aortic valve ranged from 72 to 135 mmHg (mean = 97 ± 25). All patients were followed up from 3 to 20 months with a median of 13 months. Results: Dramatic reduction of trans-aortic peak gradients was seen in all patient (mean postoperative gradient = 29 ± 8 mmHg). Small degrees of transvalvular and paravalvular leakage were seen in intraoperative echocardiographies but only one patient had small asymptomatic paravalvular leakage during midterm follow up. Two patients need for transient pace maker; however we had no case of complete heart block. Mean post-operative mediastinal bleeding was 480 ± 150 mL and no patient needed re-exploration for bleeding or tamponade management. ICU stay time was 3 ± 1.54 days, and there was no in-hospital mortality. All patients were discharged in good status and there was no mortality during follow-up period. Conclusions: Preliminary clinical results of the first experience was encouraging; however we need to continue the study with more study volume, more follow up period and more high risk or complicated patients.

Transcatheter Aortic Valve Replacement: What Really Matters for Women?

The prevalence of senile calcific aortic stenosis, a degenerative disease, mirrors the portion of the population that survives other processes to reach an advanced age. Thus, because of longer life expectancy, increasing numbers of women are candidates for aortic valve replacement (AVR). In current cardiovascular medicine, transcatheter AVR (TAVR) has proved to be suitable in the elderly and in those otherwise at high risk for surgical AVR (SAVR).Early TAVR trials appeared to harbor a recruitment bias against women—related, in part, to the use of large-profile devices, which precluded insertion in smaller femoral arteries. Even so, sex-specific examination of TAVR in early cohorts suggested distinct profiles of outcome for men and women, including an apparent survival advantage for women.In the Partner high-risk trial, sex-specific all-cause mortality rates at 2 years were reported.1 The investigators concluded that early and late mortality rates in women were better with TAVR than with SAVR; in contrast, there was no late survival benefit with TAVR in men, although their general clinical outcomes from both methods were similar. Thus, in the high-risk cohort, late mortality rates with TAVR were lower in women than in men, especially in women who underwent transfemoral TAVR.In a patient-level meta-analysis that included 47,188 subjects, women who underwent TAVR had more strokes, major bleeding, vascular complications, and need for transfusion within 30 days than did men, but lower mortality rates at one year.2 Likely factors contributing to complications were older age, lower body surface area, and vessels of smaller diameter. Increased occurrences of bleeding and vascular complications in women did not negatively affect their long-term survival benefit. Women had a lower risk of permanent pacemaker placement after TAVR; however, their increased 30-day risk of stroke and transient ischemic attack remained significantly higher after one year.The investigators2 concluded that women had better one-year and long-term survival prospects (mean follow-up duration, 3.28 ± 1.4 yr) than did men, despite more risk of early (30-d) postoperative bleeding and vascular complications and a greater long-term risk of stroke. The long-term survival advantage in women was consistently observed in multiple sensitivity and subgroup analyses of the cohorts, vascular access methods, geographic variations, and valve types.Smaller annular size in the women probably reduced the incidence of prosthesis undersizing. In comparison, the men tended to receive undersized valves, which resulted in more paravalvular leaks. In addition, the men had markedly worse baseline vascular disease and comorbidities than did the women, including hypertension, diabetes mellitus, coronary artery disease, prior revascularization, lower left ventricular ejection fraction, and higher risk scores. Of note, women's hearts may exhibit more favorable remodeling when hemodynamically stressed by aortic stenosis, mainly through less fibrosis and collagen deposition, thus enabling the reversal of cardiac remodeling after TAVR.One-year outcomes were recently reported in the Women's International Transcatheter Aortic Valve Implantation Registry.3 The investigators noted that baseline characteristics differ in men and women who undergo TAVR, and that these can affect short- and long-term events. Women have smaller peripheral vessels and aortic valve annuli, lower origins of the coronary arteries, more prevalent osteoporosis and frailty, greater risk of bleeding, and more prevalent concomitant valve disease and heart failure.Composite TAVR efficacy in women at one year was reported.3 The rate of all-cause death, and of all stroke, myocardial infarction, and hospitalizations for valvular symptoms or worsening congestive heart failure or valve-related dysfunction, was 16.5%. The rate for composite all-cause death or stroke was 13.9%; for death alone, 12.5%; and for stroke, 2.2%. EuroScore I, baseline atrial fibrillation, and prior percutaneous coronary intervention (PCI) were independent predictors of one-year death or stroke. Independent predictors of the Valve Academic Research Consortium-2 efficacy endpoint were EuroScore I and prior PCI or coronary artery bypass grafting.3Other investigators studied sex-related outcome differences with the use of lower-profile devices, specifically the Edwards Sapien 3 valve (Edwards Lifesciences) in intermediate and high-risk cohorts.4 At one year, the rates of death, disabling stroke, and repeat hospitalization were 22.4% in women and 20.9% in men. Even so, the one-year all-cause mortality rate slightly favored the women (9.4% vs 10.4%).Like the outcomes in earlier patient cohorts, these recent trial results continue to suggest a slight survival advantage for women after TAVR, especially when devices compatible with their physical characteristics are implanted.

Sutureless aortic bioprosthesis.

Aortic valve replacement (AVR) is the treatment of choice for aortic valve disease, with excellent results reported in the short- and long-term follow-up. Due to the increasing number of patient comorbidities and older age, various technical alternatives have been developed such as transcatheter aortic valve implantation and, more recently, sutureless valve bioprostheses. For patients with very high surgical risk, transcatheter implantation is becoming the top therapeutic option. However, the percutaneous technique still has major disadvantages including those related to implantation without excision of the diseased native valve without direct view of the annulus, which increases the probability of developing perivalvular leaks and a high percentage of atrioventricular block. Due to the need for aggressive crimping of pericardial layers, there is uncertainty about their long-term durability. A new technique for AVR using sutureless bioprosthesis has recently been developed. The main advantages of this technique are the excellent haemodynamic performance and fast deployment under direct view, thereby avoiding the knotting of surgical stitches, which is especially advantageous in more technically demanding procedures (e.g. minimally invasive surgery, calcified aortic root and reoperations). The good clinical results of these valves have been supported by scientific evidence, making it a feasible option for patients who are candidates for AVR using biologic prosthesis, especially for those with mid-high surgical risk for standard AVR and percutaneous transcatheter valve implantation. In this article, we review the latest evidence on these new prostheses, including their advantages and possible disadvantages.

A Transcatheter Aortic Valve Implantation Without Aortography Guidance Due To Vascular Access Constraints Or Limitations

Introduction Aortic valve replacement (AVR) is an established treatment modality in patients with severe symptomatic aortic stenosis (AS)., Given the increased mortality and morbidity of AVR for the high-risk patients and the poor long-term results of balloon aortic valvuloplasty, transcatheter aortic valve implantation (TAVI) is increasingly accepted treatment option who are not candidates for AVR. We describe here a case of succesfully implanted Edwards SAPIEN XT transcatheter heart valve without aortography guidance due to multiple arterial access problems and complicated [...]

An Early Canadian Experience With the Correx Automated Coring and Apical Connector Device for Aortic Valve Bypass.

Aortic valve replacement is the standard of care for severe, symptomatic aortic valve stenosis (AS); however, anatomy or pre-existing comorbidities may preclude conventional or alternative transcatheter approaches. Aortic valve bypass (AVB) may be performed as a salvage procedure for the relief of symptomatic aortic stenosis in patients who are not suitable candidates for aortic valve replacement. At our institution, seven patients underwent AVB using the Correx automated coring and apical connector system. All patients had severe AS with New York Heart Association functional class 3 symptoms and were not candidates for conventional or transcatheter approaches. Via a left anterolateral thoracotomy to access the descending aorta and left ventricular apex, we used the Correx system (Correx, Waltham, MA USA) to anastomose a valve conduit to the left ventricular apex proximally and the descending aorta distally. Three patients required cardiopulmonary bypass. In all seven patients, the automated coring and apical connector was successfully deployed. There were two in-hospital deaths in this series. Immediately postoperatively and at 3 months, there was a significant reduction in mean and peak valve gradients, and all surviving patients performed at New York Heart Association functional class 1. Aortic valve bypass seems to be an acceptable alternative for the treatment of severe AS in high-risk patients who are not candidates for aortic valve replacement. The Correx automated system may improve the clinical applicability and surgical reproducibility of AVB in appropriately selected patients in which conventional or transcatheter aortic valve replacement is not a feasible options.

Transcatheter aortic valve implantation in patients with small aortic annuli using a 20 mm balloon-expanding valve

BackgroundWhile transcatheter aortic valve implantation (TAVI) is established for treating high-operative risk surgical aortic valve replacement candidates, until recently the smallest transcatheter heart valve (THV) measured 23 mm, posing greater...