Chronic Aortic Regurgitation Research Articles

Left ventricular remodeling in chronic aortic regurgitation: both age and sex matter

Abstract Background For chronic and severe aortic regurgitation (AR), both European and American guidelines recommend surgery in the setting of dilated left ventricle (LV). However, normal LV volumes are described according to age and gender (1) and differences in remodeling according to gender have been described in AR (2) and late referral bias has been suggested as a cause for outcome penalty in female patients with AR (3). Objective and methods To clarify the interactions of age and gender on LV volumes in the setting of AR with cardiac magnetic resonance (CMR). This is a single-center study performed in a referral center for cardiac surgery and aortic valve repair. Patients were adults identified or referred for an at least moderate AR (grade II) by transthoracic echocardiogram (TTE) and were invited to perform a CMR. Exclusion criteria were acute AR caused by bacterial infection or dissection, dilated cardiomyopathy from another identified cause, concomitant more than moderate left heart valve disease or intra-cardiac devices. Results Among 296 patients included (51+/-16 years, 56 (19%) females and 129 (44%) bicuspid), mean regurgitant fraction (RF) was 33%. Age was similar among men and women (50+/-16 vs 54+/-16; p=0.142) but RF was higher among men (35+/-18 vs 25+/-15%, p<0.001). Both LV end-diastolic (iLVEDV) and end-systolic (iLVESV) were moderately correlated to regurgitant fraction (Pearson R of respectively 0.605 and 0.569). Women had lower iLVEDV and iLVESV than men after correction for AR severity (respectively 105+/-24 vs 136+/-43ml/m²; p<0.001 and 48+/-17 vs 66+/-30ml/m²; p=0.007). Female gender was associated with a significantly lower susceptibility to dilate both iEDV and iESV in the setting of an increasing AR severity (p for interaction of respectively 0.048 and 0.041). Similarly, advancing age was associated with a continuous decrease in iEDV and iESV dilatation ability (p for interaction of respectively 0.006 and 0.048). Conclusion Sex and age are significant determinants for LV volumes in AR. Furthermore, both female sex and aging independantly lead to a decreased capability of LV dilatation, suggesting sex and aged-based CMR thresholds for LV dilatation should be further developed to avoid possible late referral bias for surgery in female or elderly population.Gender interaction on LV dilatationLV volumes prediction models

Abstract 18806: How Well Does Left Atrial Remodeling Predict Adverse Outcomes in Patients With Chronic Severe Aortic Regurgitation?

Introduction: Aortic regurgitation (AR) leads to left ventricular (LV) remodeling by increasing LV load. We recently showed that LV dimensions, widely adopted marker of severe AR, are not reliable predictors of adverse CV outcomes in older patients and female sex. Here we sought to study the effects of chronic severe AR on left atrial (LA) size and function as a prognostic adjunct to LV dimensions. Methods: Adult patients with ≥3+ AR on routine surveillance with serial echocardiograms between 1/2010 and 12/2016 were included in this study. We assessed longitudinal trends of LA volume indexed to body surface area (LAVI) and LA reservoir strain (LAr) stratified by age and sex. Clinical endpoints included the occurrence of heart failure hospitalization, urgent aortic valve surgery, or all-cause mortality and were used to assess the prognostic value of our studied parameters. Results: A total of 525 patients with 1,687 serial echocardiograms conducted over a median (IQR) follow-up duration of 2.0 (1.0-3.6) years were included. As shown in figure 1, we observed a substantial increase in LAVI (1.0 [95% CI: 0.76-1.2] mL/m2 per year of follow-up) and a decrease in LAr (-1.3% [95% CI: -1.6 to -0.92%]) over the study period. There was no significant interaction related to sex or age (p ≥0.17). 210 adverse events were recorded and were significantly predicted by both LA parameters. Optimal discriminatory threshold for LAVI was determined to be 37 mL/m2 and LAr at 35% and were both found to be consistent across categories of sex and age. Conclusions: This study indicates that LA remodeling, unlike LV remodeling, shows a similar rate of progression across different categories of sex and age among patients with chronic severe AR. Furthermore, LA parameters provide an added prognostic value over LV parameters and may therefore be better suited to inform the timing of AR intervention.

Abstract 12123: Descending Aortic Diastolic Flow Reversal in Aortic Regurgitation: Optimizing Definitions and Assessment on Cardiac Magnetic Resonance

Introduction: Holodiastolic flow reversal (HDR) in the descending aorta (DA) may indicate hemodynamically significant aortic regurgitation (AR). However, the optimal definition and quantification of flow reversal on cardiac magnetic resonance (CMR) is unknown. Methods: We studied 346 chronic AR patients with regurgitant volume (RegVol) ≥30 mL or regurgitant fraction (RegF) ≥30%. The presence of HDR and quantitation of reverse volume in the DA (DA-RVol) was performed by a blinded observer. The threshold for DA-RVol that identified ≥ moderate-severe AR (RegVol ≥45 mL and RegF ≥40%) was established by derivation (50% random sample), validation (50% remaining sample), and ROC curve analysis. Multivariable logistic regression models adjusting for age, gender, NYHA Class, and indexed left ventricular end-diastolic volume were performed to compare HDR and DA-RVol. Results: The median age was 61 (IQR 50-70) years, 79.2% men, and 30.3% with bicuspid aortic valve. The median RegF was 37% (IQR 32-44) and DA-RVol was 12 mL (IQR 5-27). HDR was observed in 150 (43.2%), with 63% sensitivity and 77% specificity for detecting ≥ moderate-severe AR. The threshold of DA-RVol which identified ≥ moderate-severe AR was 17 mL (AUC 0.82, sensitivity 68%, and specificity 87%). The ROC curve analysis revealed a higher AUC for DA-RVol ≥17 mL relative to HDR (0.78 vs 0.70, P <0.001) for predicting ≥ moderate-severe AR. On multivariable analysis models, DA-RVol ≥17 mL was superior to HDR (AUC 0.83 vs 0.80, P =0.008). Conclusion: Quantitation of flow reversal in the descending aorta is a more reliable method to identify hemodynamically significant AR compared to simple presence of holodiastolic flow reversal.

Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation.

Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.

Impact of early versus class I–triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry

ObjectivesClass I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival. MethodsWe evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months. ResultsAmong 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m2 (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty. ConclusionsIn this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.

Aortic regurgitation in bicuspid aortic valve: know to decide

Abstract Funding Acknowledgements Type of funding sources: None. Chronic aortic regurgitation (AR) is the second cause of valve surgery in patients with bicuspid aortic valve (BAV) and has distinctive characteristics of trileaflet regurgitation. The quantification variables of aortic regurgitation do not take into account the unique characteristics of bicuspid regurgitation. Recognition of the mechanisms that lead to bicuspid AR is relevant as it allows correct treatment planning and valve repair in candidate patients. Objective a prospective study was designed to identify the mechanisms of AR and the factors (clinical and anatomical) associated with the development of significant AR (moderate/severe) in adult patients with BAV. Materials and methods We included consecutive adult patients with a confirmed diagnosis of BAV evaluated between 2014 and 2021 with at least 3 years of follow-up by the Structural Heart Disease group of our institution. Valve disease was evaluated by echocardiography and complementary methods. It was classified as mild, moderate (Mod), and severe (Sev) aortic regurgitation, according to current criteria (integral approach with quantitative and semi-quantitative criteria). The prevalence of regurgitation mechanisms, the progression of aortic regurgitation, and predictive variables of significant AR and major cardiovascular events (death, surgery) were analyzed using univariate and multivariate analyses. A p<0.05 was considered significant. Surgery was indicated following international recommendations (ESC guidelines): symptoms development or ventricular dysfunction. Results We included 300 patients (39.7 ± 14.9 years, 72.6% men). Regarding valvular phenotype 84% (257p) presented fused BAV (coronary leaflets) and the majority with raphe (87.5%). 71.7% of the patients had some degree of aortic regurgitation at the start of follow-up (24.1% Mod/Sev AR). Among the patients with significant AR, 50% had cusp prolapse (86% prolapse of the fused leaflet), 39.18% dilatation of the aortic root, 26.6% significant calcification of the valve, 1.3% valve perforation and 29.4% restriction of valve movement. 43% with Mod/Sev AR had mixed mechanisms of regurgitation and the combination, half represented by the combination of aortic root dilatation and cusp prolapse (Fig 2). During follow-up 18–6% of patients with Mod AR showed progression to Sev AR and 4.7% underwent surgery. On the other hand, 34.1% of patients with baseline Sev AR required aortic valve surgery (p<0.01). Conclusions In our cohort, AR was highly prevalent: 1 out of 4 patients had significant AR at the start of follow-up. Eccentric jets and the presence of valve prolapse were frequent in patients with significant AR. 43% of BAV patients with Mod/Sev AR exhibited mixed regurgitating mechanisms. Because mechanism affects the choice of surgical technique, comprehensive mechanism description is critical in patients with BAV and AR.

Magnetic resonance analysis of ventricular volumes in bicuspid and trileaflet aortic regurgitation

ObjectiveTo identify differences in left ventricular (LV) remodelling between patients with bicuspid aortic valve (BAV) and trileaflet aortic valve (TAV) with chronic aortic regurgitation (AR).MethodsRetrospective cohort study of 210 consecutive...

Echocardiographic Monoplane Left Ventricular Volumes to Assess Remodeling in Chronic Severe Aortic Regurgitation

Echocardiographic Monoplane Left Ventricular Volumes to Assess Remodeling in Chronic Severe Aortic Regurgitation

Aortic regurgitation: multimodal assessment of quantification and impact.

The assessment of severity of aortic regurgitation (AR) by transthoracic echocardiography (TTE) remains challenging in routine practice. Contemporary guidelines recommend cardiovascular magnetic resonance imaging (CMR) in patients with significant disease and suboptimal TTE images. The objective of this study was to assess the role of CMR in the evaluation of severity of AR and to compare both modalities in the quantification of regurgitation and left ventricular volumes. Fifty consecutive patients who had isolated chronic AR and who underwent TTE and CMR within an interval of less than three months between May 2009 and June 2020 were included. The main indication for CMR was difficulties in quantifying AR, either because of lack of multiparametric analysis (only one method possible) or because of discrepancies in the different methods by TTE. In 25 patients, precise grading of AR was not possible by echocardiography. Among them, CMR finally detected seven patients with mild AR, 11 with moderate AR and seven with severe AR. For the 25 patients who had AR quantification by TTE, there was concordance between TTE and CMR in only seven patients (28%), and the AR was re-graded by CMR in 18 patients, including eight patients with severe AR by TTE and moderate AR by CMR. The concordance between TTE and CMR was weakly significant (intraclass correlation coefficient = 0.39, 95% confidence interval: 0.003-0.67, p = 0.02). There was a moderate correlation between left ventricular volumes measured by TTE and by CMR (left ventricular end-diastolic volume: r = 0.57; p = 0.01; left ventricular end-systolic volume: r = 0.47, p = 0.01) but regurgitant volumes were not correlated (r = 0.04; p = 0.8). No TTE parameter of quantification was correlated with regurgitant volume measured by CMR. The concordance of AR quantification by CMR and TTE was weak. CMR re-graded some patients with severe AR by TTE into moderate AR. This should motivate practitioners to systematically assess all significant AR by CMR in order to improve quantification and optimise clinical management.

A novel new 3D volume echo derived method for regurgitation fraction quantification in isolated aortic regurgitation

Accurate quantification of chronic aortic regurgitation (AR) using 2D-TTE is sometimes challenging. Cardiac magnetic resonance imaging (CMR) is increasingly used to refine this assessment by estimating measurement of regurgitation fraction (RF), but remains not widely available. 3D echocardiography (3D-ETT) allows a non-invasive approach of right ventricular (RV) and left ventricular (LV) volumes with a good correlation with CMR measurements. The 3D-TTE volume method is based on the comparison of RV and LV stroke volumes, which is then used to calculate the RF of the aortic valve in isolated AR.The primary objective of this study was to investigate the ability of 3D-TTE to assess the severity of chronic AR based on the criterion of regurgitation fraction (RF) obtained by the volume method in comparison to PC-CMR. We enrolled 42 patients with isolated AR who underwent ASE algorithm-guided 2D echocardiography (2D-TTE), 3D echocardiography and CMR. Regurgitation fraction (RF) was calculated by 3D-TTE using the formula [(LV Stroke Volume–RV Stroke Volume)/LV Stroke Volume] × 100. Correlation and concordance between 3D-TTE-RF and PC-CMR-RF were analyzed. Reproducibility of 3D-TTE-RF measurement was evaluated. Seven (17%) had mild AR, 27 (64%) moderate AR, and 8 (19%) severe AR in PC-CMR. Mean RF was 32.7 ± 13.9% by 3D-TTE and 30,7 ± 14,9% by PC-CMR-RF (P < 0,05). 3D-TTE-RF and PC-CMR-RF had a good correlation (r = 0.90, P < 0,05). We found a good intra-operator (r:0.95, P < 0.05) and inter-operator (r:0.87, P < 0.05) reproductibility. The final gradation of AR was concordant between 3D TTE and PC-CMR in 88% of the cases. The assessment of isolated aortic regurgitation fraction in 3D-TTE by the volumetric method is a feasible and reproducible method in daily clinical practice, with a good correlation to PC-CMR. Estimation of the aortic regurgitation fraction in (Fig. 1).

Three decades of reimplantation of the aortic valve-the Brussels experience.

Over the last three decades, the importance of native valve preservation has increasingly become evident. Valve-sparing root replacement procedures, such as the reimplantation or remodeling technique, are therefore being progressively used for aortic root replacement and/or aortic valve repair. Herein, we are summarizing our single-center experience with the reimplantation technique. We queried our prospective database for aortic valve repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacement with the reimplantation technique between March 1998 and January 2022. We subcategorized the patients into three distinct groups: root aneurysm without aortic regurgitation (AR) (grade ≤1+), root aneurysm with AR (grade >1+) and isolated chronic AR (root <45 mm). Univariable logistic regression analysis was performed to identify variables of interest, which were further analyzed by multivariable Cox-regression analysis. Survival, freedom from valve reintervention, and freedom from recurrent regurgitation, were analyzed with the Kaplan-Meier method. A total of 652 patients were recruited for this study; 213 patients underwent reimplantation for aortic aneurysm without AR, 289 patients for aortic aneurysm with AR, and 150 patients with isolated AR. Cumulative survival was 95.4% (95% CI: 92.9-97.0%) after 5 years, 84.8% (80.0-88.5%) after 10 years, and 79.5% (73.3-84.5%) after 12 years, which was comparable to the age-matched Belgian population. Older age (HR 1.06, P≤0.001) and male gender (HR 2.1, P=0.02) were associated with late mortality. Freedom from reoperation on the aortic valve at 5 years was 96.2% (95% CI: 93.8-97.7%), and 90.4% (95% CI: 87.4-94.2%) at 12 years. Age (P=0.001) and preoperative left ventricular end-diastolic dimension (LVEDD) (P=0.03) were associated with late reoperation. Our long-term data supports our reimplantation approach as a viable option for aortic root aneurysms and/or aortic regurgitation, with long-term survival that mirrors that of the general population.

Value of Speckle Tracking Echocardiography Combined with Stress Echocardiography in Predicting Surgical Outcome of Severe Aortic Regurgitation with Markedly Reduced Left Ventricular Function.

Predicting outcomes of surgical aortic valve replacement (AVR) in patients with chronic severe aortic regurgitation (AR) and markedly reduced left ventricular (LV) function remains a challenge. This study aimed to explore the preoperative echocardiographic index that could predict the recovery of LV systolic function after surgery in patients with chronic severe AR and reduced left ventricular ejection fraction (LVEF). The study group consisted of 50 patients diagnosed with chronic severe AR ( 6 months) and significantly reduced LVEF (18~35%, average 26.2 5.3%). Low-dose dobutamine stress echocardiography (DSE) was performed before surgery. Only patients with an absolute increase in LVEF 8% during DSE were referred for surgical AVR. During following up (over six months to one year after surgery), the patients were divided into two groups by postoperative LVEF ( or 40%). DSE- and speckle tracking echocardiography (STE)-derived LV functional parameters were compared between groups to identify predictors of post-operative improvement in LVEF. A total of 38 patients underwent AVR. One patient died before discharge. Post-surgical LV size and LVEF improved markedly after surgery in all patients (n = 37). Pre-surgical LV end-systolic diameter, baseline global longitudinal strain (GLS) and peak GLS were better in the group with LVEF 40% (n = 18; p 0.05, t test). Baseline GLS and peak GLS correlated moderately with post-surgery LVEF (R = -0.581, p 0.001; R = -0.596, p 0.001; respectively). Logistic regression analysis demonstrated baseline GLS and peak GLS were the independent predictors of post-surgery improvement of LVEF. Peak GLS had the highest prediction value (area under the curve = 0.895, sensitivity and specificity: 89.5% and 77.8%, respectively), with a cutoff value of -9.4%. This study shows that STE combined with DSE can provide sensitive quantitative indices for predicting improvement of LV systolic function after AVR in patients with chronic severe AR and significantly decreased LVEF.

Impact of Age and Sex on Left Ventricular Remodeling in Patients With Aortic Regurgitation

BackgroundCurrent guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex. ObjectivesThe purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes. MethodsWe included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex. ResultsA total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m2 vs 32.3 mL/m2, respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m2 vs 32.4 mL/m2). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m2), intermediate for older men (35 mL/m2), and lowest for women (27 mL/m2). ConclusionsOn serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes.

Analysis of Left Ventricular Indexes and Mortality Among Asian Adults With Hemodynamically Significant Chronic Aortic Regurgitation

Chronic hemodynamically significant aortic regurgitation (AR) is associated with excess risk of death, yet data for Asian patients are lacking, and whether Asian patients can abide by Western guidelines as to when aortic valve surgery should be performed is unknown. To assess AR presentation and cutoffs of left ventricular ejection fraction (LVEF), LV end-systolic dimension index (LVESDi), and LV end-systolic volume index (LVESVi) that are associated with risk of death in Asian patients with AR. This retrospective cohort study included consecutive patients with chronic, moderately severe to severe AR from 3 tertiary referral centers (2 in Japan and 1 in Taiwan) from June 11, 2008, through November 19, 2020, with follow-up through November 11, 2021. Aortic regurgitation severity, graded by a comprehensive integrated approach. The primary outcome was the association between volume-derived LVEF, LVESDi, and LVESVi and all-cause death (ACD). The secondary outcome was the association of these LV indexes with cardiovascular death (CVD). Clinical and echocardiographic data were analyzed retrospectively. A de novo disk-summation method was used to derive LV volumes and volume-derived LVEF. Of 1259 patients (mean [SD] age, 64 [17] years; 934 [74%] male), 515 (41%) were Japanese and 744 (59%) were Taiwanese. The median follow-up was 4.1 years (IQR, 1.56-7.24 years). The mean (SD) body surface area was 1.67 (0.21) m2; LVEF, 55% (11%); LVESDi, 24.7 (5.7) mm/m2; LVESVi, 50.1 (28.0) mL/m2; and indexed mid-ascending aorta size, 24.7 (5.5) mm/m2. Aortic valve surgery occurred in 483 patients (38%); 240 patients (19%) died during follow-up. Overall mean (SD) 8-year survival was 74% (2%). Separate multivariate models adjusted for covariates demonstrated independent associations of LVEF, LVESDi, and LVESVi with ACD (LVEF: hazard ratio [HR] per 10%, 0.80; 95% CI, 0.70-0.92; P = .002; LVESDi: HR, 1.04; 95% CI, 1.01-1.06; P = .002; LVESVi: HR per 10 mL/m2, 1.11; 95% CI, 1.05-1.17; P < .001) and CVD (LVEF: HR per 10%, 0.69; 95% CI, 0.56-0.85; P < .001; LVESDi: HR, 1.05; 95% CI, 1.01-1.09; P = .01; LVESVi per 10 mL/m2: HR, 1.15; 95% CI, 1.06-1.24; P < .001). In the total cohort, spline curves showed that mortality started to increase for an LVEF of 53% or less, LVESDi of 22 mm/m2 or greater, and LVESVi of 46 mL/m2 or greater for both ACD and CVD. Early surgery was beneficial in 3 strata of LVESDi (<20, 20 to <25, and ≥25 mm/m2) and 2 strata of LVESVi (<46 and ≥46 mL/m2). This multicenter cohort study of Asian patients with hemodynamically significant AR found cutoff values of LVEF, LVESDi, and LVESVi that were associated with increased risk of death. These findings suggest that Western guidelines seem applicable in Asian patients and, most importantly, that indexed LV parameters with a lower cutoff could be used in discriminating patients with excess mortality risk.

Proteomic Analysis in Valvular Cardiomyopathy: Aortic Regurgitation vs. Aortic Stenosis.

Left ventricular (LV) reverse remodeling after aortic valve (AV) surgery is less predictable in chronic aortic regurgitation (AR) than in aortic stenosis (AS). We aimed to disclose specific LV myocardial protein signatures possibly contributing to differential disease progression. Global protein profiling of LV myocardial samples excised from the subaortic interventricular septum in patients with isolated AR or AS undergoing AV surgery was performed using liquid chromatography-electrospray ionization-tandem mass spectrometry. Based on label-free quantitation protein intensities, a logistic regression model was calculated and adjusted for age, sex and protein concentration. Web-based functional enrichment analyses of phenotype-associated proteins were performed utilizing g:Profiler and STRING. Data are available via ProteomeXchange with identifier PXD039662. Lysates from 38 patients, including 25 AR and 13 AS samples, were analyzed. AR patients presented with significantly larger LV diameters and volumes (end-diastolic diameter: 61 (12) vs. 48 (13) mm, p < 0.001; end-diastolic volume: 180.0 (74.6) vs. 92.3 (78.4), p = 0.001). A total of 171 proteins were associated with patient phenotype: 117 were positively associated with AR and the enrichment of intracellular compartment proteins (i.e., assigned to carbohydrate and nucleotide metabolism, protein biosynthesis and the proteasome) was detected. Additionally, 54 were positively associated with AS and the enrichment of extracellular compartment proteins (i.e., assigned to the immune and hematopoietic system) was observed. In summary, functional enrichment analysis revealed specific AR- and AS-associated signatures of LV myocardial proteins.

Differences in Myocardial Remodeling and Tissue Characteristics in Chronic Isolated Aortic and Mitral Regurgitation.

The left ventricular hemodynamic load differs between aortic regurgitation (AR) and primary mitral regurgitation (MR). We used cardiac magnetic resonance to compare left ventricular remodeling patterns, systemic forward stroke volume, and tissue characteristics between patients with isolated AR and isolated MR. We assessed remodeling parameters across the spectrum of regurgitant volume. Left ventricular volumes and mass were compared against normal values for age and sex. We calculated forward stroke volume (planimetered left ventricular stroke volume-regurgitant volume) and derived a cardiac magnetic resonance-based systemic cardiac index. We assessed symptom status according to remodeling patterns. We also evaluated the prevalence of myocardial scarring using late gadolinium enhancement imaging, and the extent of interstitial expansion via extracellular volume fraction. We studied 664 patients (240 AR, 424 primary MR), median age of 60.7 (49.5-69.9) years. AR led to more pronounced increases in ventricular volume and mass compared with MR across the spectrum of regurgitant volume (P<0.001). In ≥moderate regurgitation, AR patients had a higher prevalence of eccentric hypertrophy (58.3% versus 17.5% in MR; P<0.001), whereas MR patients had normal geometry (56.7%) followed by myocardial thinning with low mass/volume ratio (18.4%). The patterns of eccentric hypertrophy and myocardial thinning were more common in symptomatic AR and MR patients (P<0.001). Systemic cardiac index remained unchanged across the spectrum of AR, whereas it progressively declined with increasing MR volume. Patients with MR had a higher prevalence of myocardial scarring and higher extracellular volume with increasing regurgitant volume (P value for trend <0.001), whereas they were unchanged across the spectrum of AR (P=0.24 and 0.42, respectively). Cardiac magnetic resonance identified significant heterogeneity in remodeling patterns and tissue characteristics at matched degrees of AR and MR. Further research is needed to examine if these differences impact reverse remodeling and clinical outcomes after intervention.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Can Measuring the 'Dual Anchors of Aorta' Enhance the Success Rate of TAVR?-A Single-Center Experience.

Chronic severe aortic regurgitation (AR) has a poor long-term prognosis, especially among old-age patients. Considering their advancing age, the surgical approach of aortic valve replacement may not always be the best alternative modality of treatment in such patients. Therefore, this study's primary goal was to provide an initial summary of the medium- and short-term clinical effectiveness of transcatheter aortic valve replacement (TAVR) guided by accurate multi-detector computed tomography (MDCT) measurements in patients with severe and chronic AR, especially in elderly patients. The study enrolled retrospectively and prospectively patients diagnosed with severe AR who eventually underwent TAVR procedure from January 2019 to September 2022 at Fuwai cardiovascular Hospital, Beijing. Baseline information, MDCT measurements, anatomical classification, perioperative, and 1-year follow-up outcomes were collected and analyzed. Based on a novel anatomical categorization and dual anchoring theory, patients were divided into four categories according to the level of anchoring area. Type 1, 2, and 3 patients (with at least two anchoring regions) will receive TAVR with a transcatheter heart valve (THV), but Type 4 patients (with zero or one anchoring location) will be deemed unsuitable for TAVR and will instead receive medical care (retrospectively enrolled patients who already underwent TAVR are an exception). The mean age of the 37 patients with severe chronic AR was 73.1 ± 8.7 years, and 23 patients (62.2%) were male. The American Association of Thoracic Surgeons' score was 8.6 ± 2.1%. The MDCT anatomical classification included 17 cases of type 1 (45.9%), 3 cases of type 2 (8.1%), 13 cases of type 3 (35.1%), and 4 cases of Type 4 (10.8%). The VitaFlow valve (MicroPort, Shanghai, China) was implanted in 19 patients (51.3%), while the Venus A valve (Venus MedTech, Hangzhou, China) was implanted in 18 patients (48.6%). Immediate TAVR procedural and device success rates were 86.5% and 67.6%, respectively, while eight cases (21.6%) required THV-in-THV implantation, and nine cases (24.3%) required permanent pacemaker implantation. Univariate regression analysis revealed that the major factors affecting TAVR device failure were sinotubular junction diameter, THV type, and MDCT anatomical classification (p < 0.05). Compared with the baseline, the left ventricular ejection fraction gradually increased, while the left ventricular end-diastolic diameter remained small, and the N-terminal-pro hormone B-type natriuretic peptide level significantly decreased within one year. According to the results of our study, TAVR with a self-expanding THV is safe and feasible for patients with chronic severe AR, particularly for those who meet the criteria for the appropriate MDCT anatomical classification with intact dual aortic anchors, and it has a significant clinical effect for at least a year.

Clinical Profile and Outcomes of Patients With Pure Aortic Regurgitation Who Underwent Surgical Aortic Valve Replacement

Surgical aortic valve replacement (SAVR) remains the standard of care for patients with chronic severe aortic regurgitation (AR). The introduction of a dedicated transcatheter heart valve for AR has fueled interest in using transcatheter aortic valve replacement to treat patients with isolated AR. We aimed to characterize the profile and outcomes of patients with symptomatic severe AR who underwent isolated SAVR. We conducted a retrospective, observational study of patients who underwent isolated SAVR for symptomatic severe AR at our institution. The primary outcome was in-hospital all-cause mortality. Patients were followed up with 30-day clinical and echocardiographic assessment. A total of 979 patients who underwent SAVR for severe AR between January 2015 and June 2021 were screened for eligibility, of whom 112 patients (11.4%) underwent isolated SAVR for symptomatic severe AR and were included in this analysis. Approximately 25% of patients were deemed to be at intermediate or high risk (n=26 of 112). The primary outcome occurred in 2.7% of patients (n=3 of 112). In-hospital stroke occurred in 2.7% of patients (n=3 of 112), and new-onset atrial fibrillation occurred in 32.1% (n=36 of 112). At 30-day follow-up, all-cause mortality occurred in 3.6% of patients (n=4 of 112), and 0.8% (1 of 112) had >mild AR. In conclusion, in a tertiary referral center, the number of patients who underwent isolated SAVR for pure AR represented a small fraction of the overall SAVR patients. The vast majority were low risk and younger when compared with patients with severe aortic stenosis. SAVR yielded excellent short-term mortality and echocardiographic improvements.

Marfan Syndrome: an uncommon cause of heart failure with late presentation and management challenges in a Nigerian (case report)

Marfan syndrome is an autosomal dominant disorder with life-threatening cardiovascular complications. It is an uncommon cause of heart failure in our environment. We hereby highlight a case of Marfan syndrome presenting with heart failure, challenges of late presentation and management of Marfan syndrome in our environment. A 56-year-old man with a 4-year history of hypertension presented with 3 months history of exertional dyspnoea and orthopnoea. He had associated musculoskeletal abnormalities and reduced vision since childhood. No family history of Marfan syndrome. Examination revealed features of severe chronic aortic regurgitation, bilateral supero-nasally dislocated lenses, kyphoscoliosis, positive thumb and wrist signs. The resting electrocardiogram showed left ventricular hypertrophy with strain pattern. Ocular ultrasound confirmed bilateral ectopia lentis. Echocardiography revealed aortic root aneurysm, severe aortic regurgitation, left ventricular dilatation and reduced ejection fraction. The computed tomography (CT) aortogram revealed aortic root aneurysm, tortuous abdominal aorta, thoracolumbar scoliosis and pectus excavatum. Using revised Ghent's criteria, a diagnosis of Marfan syndrome in heart failure was made. Management was multidisciplinary with plans for aortic root replacement, family and genetic screening. He commenced beta blocker and angiotensin receptor blocker with symptomatic relief. He reportedly died at home after sudden onset tiredness. His management was hampered by late clinical presentation, difficulty assessing surgery and out of pocket health funding.