Degenerative Aortic Valve Disease Research Articles

Elevated lipoprotein a level in heart transplant patients is associated with cardiac allograft vasculopathy

Abstract Introduction Lipoprotein A (LpA) is considered a cardiovascular disease (CVD) risk factor and its interest has grown in recent years. High LpA levels (above 50 mg/dL) are associated with an increase in the occurrence of CVD and degenerative aortic valve disease despite treatment with statins and low LDL levels. The prevalence of elevated LpA levels after heart transplantation (HT) and the implication on the development of cardiac allograft vasculopathy (CAV) is not well known. Objective To assess the prevalence of elevated LpA levels in patients with HT and the relationship between higher LpA levels and CAV at 1 year. Methods Retrospective, unicentric and observational study based on the historical cohort of HT patients. We selected those patients in whom a pre-transplant serum sample was available in the biobank for LpA analysis. CAV was diagnosed with coronary angiography. Results We studied 80 HT patients. Baseline characteristics are in table 1. Median LpA levels were 14.5 (5.0-35.3), and from the 80 HT patients, 16 (20,0%) had LpA≥50 mg/dl (figure 1A). Out of the 80 patients, 68 had a coronary angiography at 1 year follow up (3 died before 1 year and 9 patients did not have angiography at 1 year for diverse reasons). Twenty patients (29.4%) presented CAV in the first year. Patients with elevated LpA levels had more frequency of CAV at 1 year [11/16 (68.8%) vs 9/43 (17.3%); p<0,001]. LpA levels in patients with CAV was higher (62.5+-58.8 vs 23.9+29.8; p<0,001) (figure 1B). LDLc and Total cholesterol were significantly lower in patients with CAV at 1 year in this population. In univariate analysis, smoker donors were associated with CAV development (60.0% vs 33.3%; p 0.042). We did not find differences in other recipient or donor cardiovascular risk factors, rejection episodes or CMV infection in the first year. Conclusion Elevated LpA levels (≥50 mg/dl) are frequent in HT patients (20%) and in our cohort, were associated with CAV at 1-year post-HT. Further studies are needed to verify these results and study the relationship with the development of other cardiovascular events in HT patients.Table 1Figure 1

The Role of Advanced Glycation End-Product Levels Measured by Skin Autofluorescence in the Development of Mitral Annular Calcification.

As a person ages, mitral annular calcification develops in the mitral annulus with increasing frequency. Lipid deposition, inflammation, and aging-related degeneration have been cited as potential causes of this pathophysiology, though there is currently no conclusive evidence to support this. AGEs accumulate in tissues due to the glycation of proteins and lipids, increasing the release of proinflammatory cytokines secondary to oxidative stress through the AGE receptor. The AGE levels increase in diabetic microvascular complications and degenerative aortic valve disease. Our study was planned prospectively as a case-control study involving 94 MAC-positive patients and 94 MAC-negative patients. The demographics, echocardiographic data and AGE levels of the patients were measured and recorded using the skin autofluorescence method. AGE levels were significantly higher in the MAC-positive patient group (3.2 vs. 2.7; p < 0.001). The AGE levels were observed as an independent predictor of MAC development in a regression analysis (OR: 8.05, 95% CI: 3.74-17.33, p < 0.001). In a ROC-curve analysis, the AUC was 0.79 (95% CI: 0.72-0.85). At a cut-off value of 2.7, 79.7% sensitivity and 69.1% specificity were observed. AGE levels can be used to cheaply, easily and non-invasively identify patients at risk of developing MAC.

Congenital aortic valve stenosis: from pathophysiology to molecular genetics and the need for novel therapeutics.

Congenital aortic valve stenosis (AVS) is one of the most common valve anomalies and accounts for 3%-6% of cardiac malformations. As congenital AVS is often progressive, many patients, both children and adults, require transcatheter or surgical intervention throughout their lives. While the mechanisms of degenerative aortic valve disease in the adult population are partially described, the pathophysiology of adult AVS is different from congenital AVS in children as epigenetic and environmental risk factors play a significant role in manifestations of aortic valve disease in adults. Despite increased understanding of genetic basis of congenital aortic valve disease such as bicuspid aortic valve, the etiology and underlying mechanisms of congenital AVS in infants and children remain unknown. Herein, we review the pathophysiology of congenitally stenotic aortic valves and their natural history and disease course along with current management strategies. With the rapid expansion of knowledge of genetic origins of congenital heart defects, we also summarize the literature on the genetic contributors to congenital AVS. Further, this increased molecular understanding has led to the expansion of animal models with congenital aortic valve anomalies. Finally, we discuss the potential to develop novel therapeutics for congenital AVS that expand on integration of these molecular and genetic advances.

Predictors of in-hospital complications after transcatheter aortic valve implantation in patients with degenerative aortic valve disease

Predictors of in-hospital complications after transcatheter aortic valve implantation in patients with degenerative aortic valve disease

501 CASEOUS CALCIFICATION OF THE MITRAL ANNULUS AND THE IMPORTANCE OF ITS IDENTIFICATION IN THE CLINICAL PRACTICE: A REPRESENTATIVE CASE

Abstract 1. Introduction Caseous Calcification of the Mitral Annulus (CCMA) is a rare condition characterized by a liquefaction degeneration that usually involves posterior mitral ring and it is considered a variant of mitral annulus calcification. Its prevalence is very low, but it is possible that it is often underdiagnosed or misdiagnosed. This condition is related with increased age, female sex, chronic kidney disease and calcium metabolism disorders. The lesion can be detected using imaging techniques and its management is conservative in most cases. 2. Case Study A 72-year-old man hospitalized for bilateral pneumonia complicated with ARDS has come to our attention. The patient had a history of stage IV renal failure, type 2 diabetes mellitus and calcific degenerative aortic valve disease. During its stay in the Intensive Care Unit a routine Transthoracic Echocardiogram showed a vegetation suspected for infective endocarditis that involved the posterior mitral leaflet. However, the clinical presentation did not support endocarditis diagnosis as no microorganisms were isolated at multiple blood cultures and other Duke Criteria were negative. Given the limited acoustic viewing of transthoracic echocardiogram it was necessary to perform a Transesophageal Echocardiogram (TEE) for a better characterization of the valve lesion. TEE showed the presence of a round lesion, about 2×2 cm in size, with smooth borders, located over the mitral annulus with extension up to the posterior mitral leaflet and with a partially mobile portion. The lesion had a corpuscular appearance inside with less echogenicity and without evidence of flow. No significant functional alterations of the mitral valve were detected (anterograde transmitral flow Mean Gradient 4-5 mmHg; Mild regurgitation). We therefore concluded for Caseous Calcification of the Mitral Annulus as the most likely diagnosis and decided for a conservative management. A new TEE was performed as a control after one week showing no significant changes on the valve lesion. 3. Conclusions It is important for echocardiographers to be familiar with CCMA and to know how to distinguish it from other valve lesions such as infective vegetation, abscesses or tumors. An integration with other cardiac imaging techniques, patient past medical history and clinical-laboratory data can help the physician in the correct characterization of valve lesions and subsequent most appropriate therapeutic approach for the patient.

Bicuspid aortic valve and its complications: from molecules to surgery

Bicuspid aortic valve is a relevant condition to the epidemiology of degenerative (stenosis, regurgitation) and infective (endocarditis) aortic valve disease. This review will address the topics of treatment of those valvular complications, focusing on the peculiar aspects distinguishing them from tricuspid aortic valve diseases, in particular transcatheter treatment of stenosis, valve repair/sparing surgery for regurgitation, prevention of endocarditis. Bicuspid aortopathy represents a clinical entity with remarkable prognostic, and likely also pathogenetic, heterogeneity. A deeper understanding of the tissue and molecular factors as well as flow-related and biomechanical aspects of its development and progression could help guiding better risk stratification (identification of more severe forms, prevention of acute aortic dissection), allowing for a personalized therapeutic approach. The present review will also summarize the state of the art about bicuspid aortopathy pathogenesis, moreover forwarding new hypotheses for the interpretation of the many sparse pieces of evidence currently available.

Spontaneous Degenerative Aortic Valve Disease in New Zealand Obese Mice.

BackgroundDegenerative aortic valve (AoV) disease and resulting aortic stenosis are major clinical health problems. Murine models of valve disease are rare, resulting in a translational knowledge gap on underlying mechanisms, functional consequences, and potential therapies. Naïve New Zealand obese (NZO) mice were recently found to have a dramatic decline of left ventricular (LV) function at early age. Therefore, we aimed to identify the underlying cause of reduced LV function in NZO mice.Methods and ResultsCardiac function and pulmonary hemodynamics of NZO and age‐matched C57BL/6J mice were monitored by serial echocardiographic examinations. AoVs in NZO mice demonstrated extensive thickening, asymmetric aortic leaflet formation, and cartilaginous transformation of the valvular stroma. Doppler echocardiography of the aorta revealed increased peak velocity profiles, holodiastolic flow reversal, and dilatation of the ascending aorta, consistent with aortic stenosis and regurgitation. Compensated LV hypertrophy deteriorated to decompensated LV failure and remodeling, as indicated by increased LV mass, interstitial fibrosis, and inflammatory cell infiltration. Elevated LV pressures in NZO mice were associated with lung congestion and cor pulmonale, evident as right ventricular dilatation, decreased right ventricular function, and increased mean right ventricular systolic pressure, indicative for the development of pulmonary hypertension and ultimately right ventricular failure.ConclusionsNZO mice demonstrate as a novel murine model to spontaneously develop degenerative AoV disease, aortic stenosis, and the associated end organ damages of both ventricles and the lung. Closely mimicking the clinical scenario of degenerative AoV disease, the model may facilitate a better mechanistic understanding and testing of novel treatment strategies in degenerative AoV disease.

Heydeho syndróm

Gastrointestinal bleeding is a severe and potentially life-threatening condition associated with significant morbidity and mortality. In clinical practice, its differential dia­gnosis can sometimes be complicated, especially when bleeding is recurrent. One of the lesser-known reasons for recurrent gastrointestinal bleeding is the so called Heyde’s syndrome. It is a combination of bleeding from gastrointestinal angiodysplasia, aortic stenosis and acquired type 2A von Willebrand syndrome. In the submitted article, authors present a summary of the current knowledge on etiology and pathogenesis of the disease. The degenerative aortic valve disease, typically present in elderly patients, causes changes in the blood flow through stenotic opening. This results in elongation of otherwise globular von Willebrand’s factor (vWF) molecules, resulting in its reduced efficacy in hemostasis. According to new scientific discoveries, vWF also plays a role in angiogenesis and therefore in gastrointestinal angiodysplasia formation. This combination of factors results in recurrent bleeding typical for Heyde’s syndrome. Surgical aortic valve replacement is the gold standard treatment. A vicious circle can often be created between the gastroenterologist, who refers the patient for cardiac surgery procedures, and the cardiothoracic surgeon, who is waiting for a time when the patient will stop bleeding. A close communication and cooperation between the gastroenterologist, hematologist and cardiothoracic surgeon is required to properly manage the patient. The presence of angiodysplasia in an elderly patient, associated with recurrent gastrointestinal bleeding, should lead clinicians to look for aortic stenosis and consider Heyde’s syndrome as a potential dia­gnosis. Its interesting etiopathogenesis and rare occurrence led the authors to further investigate this topic. They also present a short summary of their own group of patients. Key words: Heyde’s syndrome – aortic stenosis – angiodysplasia – von Willebrand’s syndrome

Associations between aortic regurgitation severity and risk of incident myocardial infarction and stroke among patients with degenerative aortic valve disease: insights from a large Chinese population-based cohort study

ObjectivesFew studies have explored whether the risk of myocardial infarction (MI) or stroke varies among patients with degenerative aortic valve disease (DAVD) with different severity of aortic regurgitation (AR) or...

Impact of osteogenic activity on degenerative aortic valve disease in patients with osteoporotic hip fracture

BackgroundPrevious studies have proposed that osteogenic and apoptotic processes of valve interstitial cells contribute to the mineralization and then calcification of the aortic valve. Osteoblast-like cells subsequently mediate calcification of the aortic valve as part of a highly regulated process analogous to skeletal bone formation. The objective of this study was to evaluate the pathogenesis of the sclerotic/calcific changes in the aortic valve from histological and biological findings, and investigate the role of osteoblasts in the calcified pathway of aortic stenosis. MethodsPreoperative echocardiography in 550 consecutive patients with osteoporotic hip fracture were retrospectively examined (475 females, mean 25th–75th, 89 [85–93] years). One hundred sixteen patients were under medical treatment with anti-osteoporosis drugs. We evaluated the prevalence and degree of degenerative changes in the aortic valve and examined the associations of bone turnover biomarkers N-terminal pro-peptide of type 1 collagen (P1NP) and serum tartrate-resistant acid phosphatase (TRACP-5b) with degenerative calcific changes in the aortic valve. ResultsOf 550 patients, 112 patients (20.9%) showed no leaflet calcification; 296 (53.8%), 1 leaflet calcification; and 142 (25.8%), 2 ≥ leaflets calcification. Significant (peak velocity ≥ 3.0m/s) Aortic stenosis was found in 43 patients (7.8%). In patients who were not taking anti-osteoporotic drugs, P1NP was higher in the 2 ≥ leaflets calcification group than in the other groups (p < 0.01). TRACP-5b was not significantly different among the three groups (p = 0.15). ConclusionsDegenerative changes in the aortic valve were related to bone biomarker activation in osteoporotic hip fracture patients.

Homeostasis Regulating Factors, Innervation, Ischemia and Inflammatory Markers in the Right Atrial Tissue from Patients with Degenerative Aortic Valve Stenosis and Coronary Heart Disease

Abstract Both coronary heart disease (CHD) and degenerative aortic valve (AoV) stenosis have common risk factors, such as age, high blood cholesterol, diabetes, smoking, high blood pressure, inflammation, and metabolic syndrome. However, these diseases are not always observed together, confirming the existence of risk and pathogenesis factors specific to each disease. The aim of this study was to identify presence and distribution of common and different homeostasis regulating factors, innervation, ischemia and inflammatory markers in the right atrial tissue from patients with degenerative AoV stenosis and CHD. During elective cardiac surgery, right atrial tissue fragments were taken from 20 patients with CHD and from 9 patients with degenerative AoV stenosis. All tissue fragments were stained for immunohistochemical detection of protein-gene peptide 9.5 (PGP 9.5), atrial natriuretic peptide (ANUP), vascular endothelial growth factor (VEGF), chromogranin A, endothelin, interleukin 1 and 10 (Il-1 and Il-10) and β defensins 2, and 3 (βD2 and βD3). For the quantification of structures, a semi-quantitative counting method was used. Mostly numerous Il-10 positive cardiomyocytes and epi-/endocardial endothelial cells were detected in all specimens taken from patients with CHD, and statistically more than in specimens taken from patients with degenerative AoV disease (p = 0.007 and p = 0.016). Also, the number of βD3 positive cardiomyocytes was higher in the coronary heart disease group (p = 0.026). All other tested markers such as PGP 9.5, ANUP, VEGF, endothelin, chromogranin A, Il-1 and βD2 showed similar expression in both groups. Increased production of ANUP in right atrial tissue characterises both CHD and degenerative AoV stenosis. Production of ChgA in right atrial endocardial endothelial cells might represent regulation of sympathetic activity as a compensatory homeostatic response. Increased PGP 9.5-containing innervation is characteristic in patients with degenerative AoV disease and secondary mitral insufficiency. A stable increase of VEGF and variations of endothelin without statistically significant difference suggest influence of ischemia on the local vascular blood supply. Decreased production of Il-1α together with moderate to rich production of Il-10, βD2, and βD3 indicates the dominance of the local immune system over inflammation.

LncRNA AFAP1-AS1 promotes M1 polarization of macrophages and osteogenic differentiation of valve interstitial cells.

Little is known about the biological functions and underlying mechanisms of long non-coding RNA AFAP1-AS1 in degenerative calcified aortic valve disease (DCAVD). This study aims to explore whether AFAP1-AS1 regulates macrophage polarization in aortic valve calcification. Macrophage polarization and AFAP1-AS1 expression were detected in normal and calcified aortic valves of DCAVD patients. To explore the effect of AFAP1-AS1 on macrophage polarization, gain and loss of function were performed in THP-1 cells, and the percentage of M1 and M2 and the expressions of M1 and M2 markers were analyzed. Meanwhile, osteogenic differentiation was examined in valve interstitial cells (VICs). Compared with normal valves, there were more M1, less M2, and high AFAP1-AS1 expressions in calcified aortic valves, which may indicate a relationship between AFAP1-AS1 and macrophage polarization. AFAP1-AS1 overexpression promoted M1 polarization in lipopolysaccharide (LPS) and interferon gamma (IFN-γ)-treated THP-1 cells but inhibited M2 polarization, as well as augmented VIC osteogenic differentiation. On the contrary, the silence of AFAP1-AS1 could induce macrophage to M2-type and inhibit VIC osteogenic differentiation. These results elucidate that AFAP1-AS1 can promote M1 macrophages polarization to aggravate VIC osteogenic differentiation, playing a role in aortic valve calcification.

ATRIAL SEPTAL ANEURYSM IN ADULTS – IS IT A DEGENERATIVE HEART DISEASE?

Objective: Atrial septal aneurysm (ASA) is a localised “saccular” deformity of the interatrial septum, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or on both sides. It is a well recognised cardiac abnormality that was previously diagnosed on autopsy only, but it is now frequently picked up on routine echocardiography or during evaluation of ischemic stroke. There is a dearth of data on atrial septal aneurysm in our environment, and the authors set out to find the common cardiac abnormalities associated with atrial septal aneurysm in adults who had transthoracic echocardiographic examination in Enugu, South-East Nigeria Design and method: Conquest Medical Imaging is a private medical diagnostic centre in Enugu, South-East Nigeria. The centre offers radiologic and ultrasonography diagnostic services. The echocardiographic records of 1390 patients done over a 4-year period were retrospectively reviewed. The examinations were done with a Logic 500MD Echocardiographic machine made by General Electric. Data obtained from the echocardiography register included presence of atrial septal aneurysm, age, gender, other cardiac abnormalities present. Results: A total of 1174 adults had echocardiographic examination during the period under review, and consisted of 667 males and 507 females. The mean age of the males was 43.1 ± 6.2 years, while the mean age of the females was 45.9 ± 7.1 years. Atrial septal aneurysm was present in 28 patients representing 0.2% of the total adult population, and made up of 11 males and 17 females. 25 patients had one or more additional cardiac abnormalities, representing 89.3% of all patients with atrial septal aneurysm. Degenerative aortic valve disease, degenerative mitral valve disease, and left ventricular diastolic dysfunction were the cardiac abnormalities noted in addition. Conclusions: The frequent association of degenerative valvular heart diseases with atrial septal aneurysm in adults may suggest that atrial septal aneurysm has a degenerative aetiology in adults.

Narrative review of the contemporary surgical treatment of unicuspid aortic valve disease.

Unicuspid aortic valve disease (UAVD) is a frequent and long-lasting challenge for adult congenital heart disease centers. UAVD patients become usually symptomatic in their twenties or thirties and require a surgical treatment plan which should respect their complete lifespan combined with an adequate quality of life. Unfortunately, all current surgical strategies of congenital aortic valve disease bear some important limitations: (I) Aortic valve replacement using bioprosthetic valves is associated with early structural degeneration and leads frequently to re-operations. (II) Mechanical valves are commonly associated with lifelong risk of severe bleeding due to oral anticoagulation. (III) Using a pulmonary autograft (i.e., Ross procedure) for aortic valve replacement is associated with excellent long-term results in non-elderly patients. However, failure of pulmonary autograft or pulmonary homograft may require re-operations. (IV) Aortic valve repair or Ozaki procedure is only performed in a few heart centers worldwide and is associated with a limited reproducibility and early patch degeneration, suture dehiscence or increased risk of endocarditis. In contrast to degenerative tricuspid aortic valve disease, UAVD remains relatively understudied and reports on UAVD treatment are rare and usually limited to retrospective single-center observations. For this review, we searched PubMed for papers in the English language by using the search words unicuspid aortic valve, congenital aortic valve, Ross procedure, Ozaki procedure, aortic valve repair, mechanical/bioprosthetic aortic replacement, homograft. We read the abstracts of relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for additional relevant reports. This review summarizes current surgical treatment strategies for UAVD including aortic valve replacement using bioprosthetic or mechanical valves, homografts, pulmonary autografts (i.e., Ross procedure) and aortic valve repair techniques for UAV. Furthermore, Ozaki procedure will be discussed.

Prevalence and Involvement of Different Valves in Rheumatic Heart Disease- An Observational Echocardiographic Study in a Tertiary Care Centre, Bengaluru, India

Introduction: Rheumatic Heart Disease (RHD) is a non suppurative sequelae of group A beta haemolytic streptococci, resulting from inadequately treated streptococcal sore throat or scarlet fever and leading to valvular heart disease. Rheumatic heart disease is a major cause of morbidity and mortality in younger population in developing countries. The present study was done at a tertiary care medical college hospital with the objective of establishing prevalence and involvement of different valve patterns by Echocardiography (ECHO). Aim: To analyse the valvular pattern of RHD over a period of four years in a tertiary care centre and highlight the importance of ECHO in the definitive diagnosis of RHD, and to know the continuing burden of RHD. Materials and Methods: This was a hospital based retrospective observational study conducted at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. A total of 518 cases of RHD were selected as a study population among the ECHO performed between January 2016 and January 2020 after an exclusion criterion of degenerative mitral and aortic valve disease, congenital aortic and mitral valve disease, myxomatous mitral valve disease, trivial and functional regurgitation. Analysis of valvular pattern was performed. Data analysis was done by tables, charts, percentages and ratio. Results: A total of 518 patients were diagnosed to have RHD by 2-Dimensional ECHO. Among them 276 (53%) were females and 242 (47%) were males. The average age was 41.9 years. The most common valve involved independently and in combined lesions was the mitral valve. Of the study population, 446 patients had Mitral Stenosis (MS) and 393 had Mitral Regurgitation (MR). Aortic Stenosis (AS) was found among 111 patients and 304 patients had Aortic Regurgitation (AR). Tricuspid Stenosis (TS) (organic) was found in seven cases. Multiple valves were involved in 204 cases. Among them 104 of the cases had MS, MR and AR, 69 cases had MS, MR, AS and AR, 21 cases had MS, AS and AR, seven cases had MR, AS and AR and three cases had MS, AS, AR and TS. Though aortic valve was involved in multi valvular lesions, significant AR (moderate and severe) was seen in 109 patients and significant AS (moderate and severe) was seen in 67 patients. Conclusion: RHD continues to be a major burden to population in developing countries. In the present study, various patterns of valvular involvement were noted. Drastic measures are to be taken primary and secondary prevention of RHD.

Thrombosis of Prosthetic Cardiac Valve: Difficulties of Diagnostics on the Example of a Clinical Case with Lethal Outcome

The article describes the clinical observation of thrombosis of prosthetic cardiac valve in a 51-year-old female patient, 9 years after surgical intervention for a degenerative aortic valve disease with the installation of mechanical prosthesis into the aortal position and further warfarin medication, with absence of international normalized ratio (INR) control over the past six months. The patient's condition worsened under the “mask” of decompensation of left ventricular circulatory failure; pulmonary embolism and acute coronary syndrome were also excluded. At the same time, the negative dynamics of the cardiac ultrasound data were underestimated: the appearance of prosthetic dysfunction, an increase in the degree of valve regurgitation, severe pulmonary hypertension, as well as anamnestic data (double acute cerebrovascular accident and lack of INR control for a long time, lability of its values during index hospitalization).This case can be important in terms of clarifying the reasons for the decompensation of chronic cardiac failure in patients with valvular defects and mechanical valve prosthetics, especially in cases of irregular INR monitoring or not being it in the target range, and progressive negative dynamics of the cardiac ultrasound data.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

P184511 years of transcatheter aortic valve implantation in a single centre and outcomes for all 1004 patient cases completed

Abstract Background Long-term outcome data after TAVI is of key importance as indications have extended from high risk patients to intermediate risk alongside contemporary study of low risk patients. Purpose We report our complete 11 y experience of TAVI. Methods All patients (n=1004) treated with TAVI in our institution between Feb 2008 &amp; Nov 2018 were included. Data was collected prospectively and all death certificates were reviewed. Independent predictors of mortality were determined by multivariable cox proportional hazard modelling. Annular sizing was performed via echocardiography +/or angiography until Aug 2012 after which time cardiac CT was used. Results Patients were 53% female &amp; had mean age 81.9±6.6 y, logistic EuroScore 18.5%. 89% were NYHA &gt;2, and 26.7% had a left ventricular ejection fraction (LVEF) of &lt;50%. TAVI was performed for severe degenerative aortic valve disease (93.5%), while valve-in-valve (2.4%) bicuspid (2.1%) &amp; rheumatic (2%) made up the remainder. Self-expanding valves were implanted in 73% cases. 98% cases were performed under local anaesthesia. A percutaneous transfemoral approach was used in 92% cases. For the first 6 y 19% procedures were performed for urgent inpatients, rising to 42% over the last 5 y. The mean time to discharge was 5.5 d, overall, &amp; 60% cases were discharged within 72 h in the last 5 y. Mortality, for those at risk, was 3.2%, 12.8%, 53% &amp; 88% at 30 d, 1 y, 5 y &amp; 10 y. The median time to death was 2.6 y. Non-cardiac death accounted for 62% deaths, with sepsis being the main cause (55%). The main cause of cardiac death was heart failure (HF (53%)). Independent clinical predictors of death were increased age, atrial fibrillation, pulmonary disease &amp; LVEF &lt;50%. Use of a 2nd generation valve was associated with better survival at 5 y (p&lt;0.001). 30 d new permanent pacemaker and stroke incidence were 13.7% and 2% respectively. 30 d readmission occurred in 13% patients. Independent clinical predictors of 1 y HF (7%) readmission were NYHA Class &gt;2 and LVEF &lt;50%. Endocarditis was seen in 1.6% during a mean follow-up 2,593 patient y. Mean aortic gradients at 1 y, 5 y &amp; 10 y were 9.7mmHg, 8.4mmHg &amp; 10.53mmHg. One patient had severe trans-aortic regurgitation during the follow-up. A 2nd TAVI procedure was performed in 5 patients with clinically significant paravalvular regurgitation, all within 30 d. Figure 1. A. Survival. B. Predictors death Conclusion This comprehensive evaluation of all patients treated with this innovative technology provides reassurance regarding the long-term clinical efficacy of TAVI &amp; gives insight into the evolution of our programme with time.

Impact of Cumulative Smoking Exposure on Subclinical Degenerative Aortic Valve Disease in Apparently Healthy Male Workers.

Little is known regarding the impact of cumulative smoking exposure and smoking cessation on subclinical degenerative aortic valve (DAV) disease. We examined associations of smoking status, cigarette-years of smoking, and years since quitting smoking with subclinical DAV disease defined by echocardiography. Of 756 apparently healthy male workers, 154 had DAV including 63 with DAV with ≥2 leaflets calcification (DAV ≥2 cal). Compared with never smokers, ever smokers had higher risk of DAV and DAV ≥2 cal; odds ratios (95% CI) were 2.883 (1.800-4.618) (p<0.001) and 5.281 (2.297-12.138) (p<0.001), respectively. Both current and former smokers had dose-dependent relationships of cigarette-years on DAV and DAV ≥2 cal (P for trend, <0.001 for both DAV, in both smokers). In current smokers with >400-≤800 and with >800 cigarette-years, odds ratios (95%CIs) were 3.201 (1.690-6.063) (p<0.001) and 5.326 (2.800-10.053) (p<0.001) for DAV, 7.460 (2.828-19.680) (p<0.001) and 8.397 (3.146-22.414) (p<0.001) for DAV ≥2 cal, respectively. In former smokers with >800 cigarette-years, odds ratios (95%CI) were 3.780 (1.970-7.254) (p<0.001) for DAV, 10.035 (3.801-26.496) (p<0.001) for DAV ≥2 cal. Compared with current smokers, former smokers with quitting smoking >10 years had significantly lower risk of DAV and DAV ≥2 cal. In apparently healthy male workers, DAV disease was strongly associated with smoking. Cumulative smoking exposure was associated with dose-dependent relationship on subclinical DAV disease both in current smokers and former smokers.

Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement.

Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy. Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed. Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m2. All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%. Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.