Degree Of Regurgitation Research Articles

Prognostic value of deep echocardiographic phenotyping in pulmonary arterial hypertension.

A novel approach to derive prognostic information from echocardiography in pulmonary arterial hypertension (PAH) is to define a phenotype of right heart function combining standard echocardiographic parameters which describe right ventricular pump function and systemic venous congestion. We tested the hypothesis that the combination of advanced strain imaging parameters could yield high prognostic accuracy. This was a prospective observational study with a single centre derivation cohort and a second centre validation cohort. The derivation cohort included 49 naive PAH patients who underwent right heart catheterisation and echocardiographic evaluation at baseline and 4-12 months after diagnosis. The validation cohort included 83 prevalent PAH patients who underwent the same examinations at 12 months after diagnosis. We stratified the risk of the derivation cohort according to three models: Model 1, based on haemodynamic parameters; Model 2, based on standard echocardiographic parameters; and Model 3, based on advanced echocardiographic parameters. The median follow-up period was 21 months; the end point of the analysis was clinical worsening. In the derivation cohort, haemodynamic and echocardiographic parameters obtained at diagnosis were not associated with outcome, whereas a significant association was observed at first reassessment. Model 3 yielded a better predictive accuracy (Harrell's C index 0.832) as compared to Model 2 (Harrell's C index 0.667), and to Model 1 (Harrell's C index 0.713). The validation cohort confirmed the accuracy of Model 3. A comprehensive assessment of right heart function using right ventricular strain, right atrial reservoir strain and degree of tricuspid regurgitation provides accurate prognostic information in prevalent PAH patients.

A better method to evaluate the reliability of echocardiography for assessment of pulmonary hypertension: comparison of tricuspid regurgitant spectrum quality grading and tricuspid valve regurgitation degree.

Transthoracic echocardiography (TTE) is recommended as the most important noninvasive screening tool for the diagnosis of pulmonary hypertension (PH), sonographers usually measure the volume of regurgitant flow rather than evaluating the spectral quality, so physicians will determine whether the ultrasound measurements of pulmonary arterial systolic pressure (US-PASP) are reliable based on the volume of tricuspid regurgitation (TR). Therefore, for the first time, we grade the quality of TR spectrum (TRS) based on its integrity and clarity, aiming to assess clinical application value of different tricuspid regurgitant spectrum quality grades (TR-SQG), and investigate whether the accuracy of US-PASP is more trustworthy than TR. We retrospectively analyzed 108 patients with chronic thromboembolic PH (CTEPH) to compare the correlation and agreement between US-PASP and right heart catheterization measurements of PASP (RHC-PASP). TR area (TRA) and TRS were measured in each patient, and TR-SQG was performed. The correlation coefficients between US-PASP and RHC-PASP were r=0.622 (P<0.001), r=0.754 (P<0.001), r=0.595 (P<0.001) in mild, moderate, severe TR, and r=0.301 (P=0.135), r=0.747 (P<0.001), r=0.739 (P<0.001), r=0.828 (P<0.001) in TR-SQG I-IV, respectively. Bland-Altman analysis revealed the mean biases of 5.05, 3.06, 7.62 mmHg in mild, moderate, severe TR, and -16.47, -8.07, 1.82, 6.09 mmHg in TR-SQG I-IV, respectively. In mild TR with the TR-SQG III and IV, the correlation coefficients between US-PASP and RHC-PASP were r=0.779 (P<0.001), intraclass correlation coefficient (ICC) =0.774, paired t-test P=0.160, respectively; and the consistency was significantly higher than that of mild TR without considering TR-SQG. In moderate TR with the TR-SQG III and IV, the r=0.749, ICC =0.746, paired t-test P=0.298 between US-PASP and RHC-PASP. The US-PASP with TR-SQG III or IV is trustworthy, and its accuracy and consistency are better than those predicted by the traditional severity of TR. The establishment of the ultrasound evaluation system of TR-SQG helps clinicians to judge whether the US-PASP is accurate, credible, and reliable.

A single centre retrospective analysis of the management and outcomes of cardiac device-related infective endocarditis

Abstract Background/intro Cardiac device-related infective endocarditis (CDRIE) is a rare but serious complication of cardiac device insertion with a high mortality rate. Cardiac devices are increasingly being implanted in older patients amid an ageing population with more comorbidities. Our centre is a large cardiac surgery referral centre in London. The centre implants a large number of cardiac devices per year (an average of 2168 per year from 2016 - 2019). The IE multidisciplinary team (IE MDT) manages approximately 150 IE referrals from the region per year. Purpose We aimed to describe a cohort of patients with CRDIE, referred to the IE MDT over 5 years (2015-2020), to generate a contemporary representation of patients with CDRIE. Methods We carried out a retrospective review of all referrals to the IE MDT between 2015 and 2020, identifying all patients with CDRIE - infection extending to the electrode leads, cardiac valve lead(s) or endocardial surface (ESC). All patients who were discussed at the IE MDT between October 2015 and March 2020 were screened, based on inclusion criteria according to the ESC's definition of CDRIE. Patients who had an infection of the cardiac device pocket with no evidence of IE were excluded. Results 60 out of 928 IE patients had confirmed CRDIE after discussion in the IE MDT from 10/2015 and 03/2020. The average age of the cohort was 70.3 (male =44, 73%). 61.7% of the devices were PPM (n=37), 10% were ICD, 20% were CRT-D, and 8.3% were CRT-P. The average duration of device therapy before removal was 64 months. 66.7% of devices were extracted (n=40) and 33.3% were managed medically (n=20). 43.3% of the cohort had prosthetic valves (n=26), and 13.3% of the total cohort had tissue aortic valve implants (TAVI) (n=8). 85% had a transesophageal echo (TOE) procedure (n=51) and 61.7% went on to have a PET CT scan (n=37). The overall inpatient mortality was 25% (n=15), rising to 45% at 12 months (n=27). Patients managed medically had a significantly higher mortality at 6 and 12 months compared to those who received an extraction and antibiotics (figure 1). There was no difference in left or right ventricular systolic function pre- and post- treatment on average or degree of tricuspid regurgitation. Medically managed patients were frailer by Charlson Index (average Charlson Index score 3) than surgically managed patients (average Charlson Index score 2). Conclusions In a retrospective assessment of CRDIE, we found that there is a low incidence of CRDIE complicating cardiac device insertion at BHC when compared to the national average. We found that surgical removal improves the likelihood of survival at 6 and 12 months when compared to medical management in those with a severe Charlson score, suggesting that even in cases of frailty and multiple morbidities, device extraction is preferable (figure 2).Survival curve of all CDRIE patientsSurvival curve in the severely frail

Right ventricular-arterial coupling and exercise-induced tricuspid regurgitation

Abstract Background Right Ventricular-pulmonary Artery (RV-PA) coupling is prognostic in a variety of cardiovascular disorders, including heart failure with preserved ejection fraction, pulmonary hypertension and severe aortic stenosis. The functional aspects of RV-PA coupling are less investigated than rest ones especially in what is their interaction with tricuspid regurgitation (TR). Purpose We sought to understand the association of RV-PA coupling with extent of exercise induced TR by combining gas exchange abnormalities through cardiopulmonary exercise test (CPET) imaging. Methods We prospectively studied patients with indication to perform a CPET imaging test due to dyspnoea and underlying heart disease of any left ventricular ejection fraction. Demographics, baseline characteristics, echo and CPET parameters [(e.g. VE/VCO2 slope and peak oxygen consumption (pVO2)] were evaluated across 3 sub-cohorts phenotyped according to TR severity pattern at rest and at peak exercise . Mitral and tricuspid regurgitation degree were adjudicated accordingly to ESC guidelines. RV-PA coupling function was assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE), and non-invasive pulmonary artery systolic pressure (PASP) with echocardiography. Dynamic TR was defined as detection of at least moderate TR grade from rest to stress. Results A total of 73 patients (age 67±13 years, 52% men), with a mean LVEF of 50±14% were studied. Overall 50 (69%) patients had less than moderate TR which did not increase during stress (Controls), 11 (15%) patients exhibited a dynamic TR pattern (Group 1), and 12 (16%) already had significant TR at rest (Group 2). TAPSE/PASP at rest and peak exercise were significantly lower in Group 1 and 2 compared to Controls (Figure), while the mean PAP/cardiac output (CO) ratio at rest and at peak exercise were significantly higher (Table). As to gas exchange data, Group 1 and 2 exhibited a lower median peak VO2, while Group 2 patients had also a higher median VE/VCO2 slope compared to Controls (Table). 10 (14%) patients showed at least moderate mitral regurgitation (significant MR) at rest and the prevalence of significant MR at peak was higher in group 1 and 2 compared to Controls (Table). A weak negative correlation was found between TAPSE/PASP slope and E/e’ ratio at peak exercise (r =-0.435, p&amp;lt;0.01). Conclusion In presence of exercise dyspnoea, patients with dynamic TR during maximal exercise exhibit a worse degree of RV-PA coupling and gas exchange profile compared to the group without significant exercise-induced TR. Moreover, the exercise-induced TR profile behaves similarly to the one of those presenting with moderate to severe TR already detectable at rest. Phenotyping dynamic TR and RV-PA warrants further evidence on therapies and outcomes prediction in exertional dyspnoea patients.FigureTable

Abstract 12359: Does E/e’ Independently Predict Atrial Fibrillation Recurrence Post Catheter Ablation?

Introduction: Left atrial size has been traditionally used as a surrogate of atrial fibrillation (AF) chronicity and prognosticator for success post catheter ablation (CA). The importance of other echocardiographic parameters in predicting maintenance of sinus rhythm post CA has not been well studied. Research Question: Which echocardiographic parameter best predicts 1 year AF-free survival post CA? Goal: Elucidate which parameter best independently predicts AF recurrence and identify which patients may benefit from earlier intervention. Methods: We conducted a retrospective cohort study of patients with symptomatic AF. We included patients who were undergoing first-time ablation and had follow-up visits for at least 24 months post CA. Baseline echocardiographic and laboratory data were extracted from common electronic medical records across a large healthcare system. Clinical outcomes were determined after manual review of each 6, 12, and 24-month visit. Echocardiographic measures were used in a stepwise estimation logistic regression model using STATA /IC 16.1. Results: Out of a cohort of 1,435 patients (age 67.1 ± 10.4 years, 565 female) who received CA for AF between 2014 and 2022, 402 had AF recurrence at their 12-month follow-up visit (28%). Larger left atrial volumes (p = 0.01), higher mitral valve E/e’ ratios (p = 0.008), and higher degree of aortic regurgitation (p = 0.02) were univariately associated with AF recurrence in 1 year. Stepwise estimation regression model showed that after adjusting for age, sex, BMI, mitral valve E/e’, and left atrial volume, the only independently associated predictor was mitral valve E/e’. The R 2 of our model was 0.31 and its predictive accuracy for recurrence was 85%. Conclusion: Among all echocardiographic measures, the diastolic dysfunction parameter of E/e’ was the only independent predictor of 1-year AF recurrence.

Prognostic significance and clinical utility of left atrial reservoir strain in transcatheter aortic valve replacement.

Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS). All consecutive patients undergoing TAVR between January 2018 and December 2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2D-speckle-tracking. Patients were grouped into three tertiles according to LARS. DD was analysed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available [age 80 years, interquartile range (IQR) 77-84], including 53% women. Median LARS was 13.0% (IQR 8.4-18.3). Patients were classified by LARS tertiles [mildly impaired 21.4% (IQR 18.3-24.5), moderately impaired 13.0% (IQR 11.3-14.6), severely impaired 7.1% (IQR 5.4-8.4), P < 0.0001]. The primary outcome occurred more often in patients with impaired LARS (mildly impaired 7.4%, moderately impaired 13.4%, and severely impaired 25.7%, P < 0.0001). On adjusted multivariable Cox regression analysis, LARS tertiles [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.44-0.86, P = 0.005] and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23-2.98, P = 0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47-0.87, P = 0.003). Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.

Echocardiographic characteristics and clinical outcomes in fetuses with pulmonary stenosis or pulmonary atresia with intact ventricular septum

To summarize echocardiographic characteristics of the anatomy and hemodynamic and clinical outcomes in fetuses with isolated pulmonary stenosis (PS) or pulmonary atresia with intact ventricular septum (PA/IVS). This was a single-center retrospective study of fetuses with isolated PS or PA/IVS. Echocardiographic variables and clinical outcomes after delivery were evaluated and compared. Between 2016 and 2021, 115 livebirths with isolated PS or PA/IVS were included. Proportion of fetuses with mild, moderate and critical PS and PA/IVS was 41.7%, 18.3%, 26.1% and 13.9%. Fetuses with more severe PS had worse anatomic and hemodynamic profiles. Specifically, the cardiothoracic ratio, pulmonary valve (PV) velocity, degree and velocity of tricuspid regurgitation increased as PS severity increased; and the pulmonary artery/aorta ratio, right ventricle/left ventricle long-axis (TV/MV) ratio, tricuspid valve/mitral valve annulus (TV/MV) ratio, and tricuspid valve inflow duration/cardiac cycle ratio decreased as PS severity increased (P <0.001 for all). PV velocity ≥2m/s predicted PV pressure ≥40mm Hg after delivery, with an AUC of 0.81; TV/MV ratio combined with RV/LV ratio predicted clinical outcomes, with an AUC of 0.88. Live births with more severe PS had higher mortality rate (mild 0 vs. moderate 0 vs. critical 11% vs. PA-IVS 36%) and lower rate of developing bi-ventricles (mild 100% vs. moderate 95% vs. critical 89% vs. PA-IVS 36%). Findings of this study help better understand the anatomy and hemodynamic and clinical outcomes in fetuses with isolated PS or PA/IVS, which could have implications for prenatal counseling and prediction of fetal outcome.

Successful Pregnancy in a Patient with Ebstein’s Anomaly: A Rare Case Report

Ebstein’s anomaly, a rare congenital heart disease, occurring in 1 in 20,000 live births. The leaflets are placed deeper into the right ventricle instead of the normal position. Pregnancy however is well tolerated and the maternal risks of pregnancy co-relates well with the degree of tricuspid regurgitation, right ventricular function and presence of cyanosis. Aim is to emphasize the meticulous follow-up with fetal &amp; maternal medicine specialist with multidisciplinary approach can give a successful outcome. Proper diagnosis and meticulous follow-up with good ANC have made this case, pregnancy with Ebstein’s anomaly successful. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(1): 68-70

Valve-Sparing Neo-Aortic Root Replacement for Neo-Aortic Root Dilatation 20 Years after Arterial Switch Operation for Transposition of the Great Arteries: A Case Report.

A 25-year-old man returned to Seoul National University Children's Hospital with mild dyspnea on exertion. He had undergone an arterial switch operation at 1 month after birth to correct a complete transposition of the great arteries and a ventricular septal defect. When the patient was 15 years old, dilatation of the neo-aortic sinus and annulus was first identified; since then, it had gradually increased. Given the young age of the patient and the degree of aortic regurgitation (AR), which was mild to moderate, we opted to perform a valve-sparing neo-aortic root replacement with aortic valve repair. Postoperative echocardiography showed successful reductions in the sizes of the aortic sinus and annulus, with only mild AR remaining.

Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis.

The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords "PAIVS/CPS", Ebstein's anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice.

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&amp;lt;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&amp;lt;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.

Chondromatous metaplasia within native cardiac valves: clinicopathologic characterization with particular focus upon aortic valves.

Native cardiac valves in the setting of chronic injury may become thickened and disrupted by dystrophic calcification, which impede valve structure/function, and there may be evidence of chondromatous (i.e., cartilaginous, CM) metaplasia admixed with dystrophic calcification. In order to characterize the presence of CM in native cardiac valves - with particular focus upon aortic valves - a retrospective review of the histologic features of 46 native aortic valves (identified from 1094 sequentially reviewed native valves of all types) containing CM were focused upon, as well as correlation with other histopathologic features, and clinical and echocardiographic findings. The prevalence rate of CM was low, and greatest among aortic valves, less in mitral valves, and never identified in tricuspid or pulmonic valves. CM in aortic valves was less commonly identified in patients with a history of autoimmune disease. The rate of CM increased with degree of valve thickening and/or calcification. The proportion of aortic valves with CM increased with an increasing degree of stenosis and decreasing degree of regurgitation, and aortic valves with CM were more commonly associated with a smaller aortic valve area, and greater peak and mean gradients. The rate of osseous metaplasia, arterial vessels, capillary bed formation, and chronic inflammation were greater in aortic valves with CM compared to valves without. CM within aortic valves is an infrequent albeit identifiable histopathologic alteration associated with chronic valve disease alongside changes in valve thickening and calcification.

The Impact of Postoperative Left Atrioventricular Valve Regurgitation on Outcomes of Complete AVSD Repair

Left atrioventricular valve (LAVV) regurgitation is the major cause of morbidity and mortality following repair of complete atrioventricular septal defects (cAVSD). However, the impact of different postoperative degrees of LAVV regurgitation (LAVVR), and thus indication for early reintervention, remains unclear.

SPREAD multicentre study: sports practice and its effect on bicuspid aortic valve disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Bicuspid aortic valve (BAV) is the most common congenital cardiac condition among the general population and competitive athletes. BAV could be associated with progressive aortic dilatation, stenosis and/or regurgitation. There are concerns about the possible detrimental effects of exercise training on aortic size and valve function due to the hemodynamic stress on the aorta during exercise. However, data in the literature are scarce and sometimes discordant. Objectives This multicenter study aimed to analyze the influence of sport on aortic size and valve function in BAV patients. Methods Three groups were analyzed: competitive athletes with BAV, athletes with tricuspid aortic valve (TAV) and sedentary controls with BAV, age- and sex-matched. We assessed the morphology and degree of aortic valve stenosis, regurgitation, aortic dimension, and left ventricular (LV) characteristics by 2D echocardiography. Individuals with moderate-severe stenosis and regurgitation or relevant aortic dilation (&amp;gt; 45 mm (men) or &amp;gt;41 mm (women) were excluded from the study. Results The study population was composed of 500 subjects:184 BAV athletes (84% males; mean age 30±11 years), 191 TAV athletes (82% males; mean age 30±11 years), 125 BAV sedentary controls (82% males; mean age 34±10 years). The aortic annulus was greater in BAV athletes (25.0±3.6 mm) than in TAV athletes (21.7±2.9 mm) and BAV controls (23.9±3.6 mm), p&amp;lt;0.005. Sinuses of Valsalva, sinotubular junction and ascending aorta diameters were smaller in TAV athletes than in BAV subjects (&amp;lt;0.005), but there were no significant differences between BAV athletes and BAV controls. LV index volumes and mass were greater in BAV athletes than in the other two groups (p&amp;lt;0.005). Moreover, BAV athletes showed higher gradients than sedentary controls (p&amp;lt;0.005). Conclusions This multicenter study demonstrated that athletes with BAV have larger aortic diameters than athletes with TAV. However, no differences between BAV athletes and sedentary controls were observed, suggesting that exercise training does not significantly affect aortic dilation, with the exception of aortic annulus. Conversely, sports practice negatively influenced valve function in BAV athletes. Valvular dysfunction seems to affect the LV geometry, with a trend for being more dilated and hypertrophic in BAV athletes than in the other groups.

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own.

Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own. This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Influencing factors of prognosis in children with pulmonary atresia with intact ventricle septum after transthoracic balloon dilation of pulmonary valve and construction of a nomograph prediction model

ABSTRACT This study aimed to identify factors that affect the prognosis of children with pulmonary valve atresia and intact ventricular septum treated with transthoracic balloon dilation of the pulmonary valve. The study included 148 participants who were followed up for 5 years. Of these, 10 died, while 138 survived. Independent sample t-test and χ2 test were used to analyze clinical data of children in the death and survival groups. It was found that height, weight, body surface area, arterial oxygen saturation, degree of tricuspid regurgitation, pulmonary valve cross valve pressure difference, ICU length of stay, length of stay, reoperation intervention, and complications were statistically significant (P<0.05). ROC curve analysis of the measurement indicators with statistically significant differences showed that height, weight, body surface area, arterial oxygen saturation, ICU length of stay, and length of stay had AUCs ranging from 0.723 to 0.870. Logistic regression analysis revealed that the degree of tricuspid regurgitation, pulmonary valve cross valvular pressure difference, ICU length of stay, reoperation intervention, and complications were independent risk factors that affect the prognosis of patients with PA/IVS undergoing transthoracic balloon dilation of pulmonary valve. The study proposed a nomogram prediction model using R language software 4.0 ”rms” package, which was validated using calibration curve and decision curve. The model had a C-index of 0.667 (95% CI: 0.643-0.786) and high degree of fit. This study provides clinicians with a prediction model to identify children with poor prognosis after treatment with transpulmonary valve balloon dilatation.

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

Nonischemic Dilated Cardiomyopathy With Quadricuspid Aortic Valve.

A 54-year-old man with a history of HIV, substance use disorder, and hyperlipidemia presented at the emergency department with dyspnea worsening on exertion and lower-extremity edema. Electrocardiogram showed a new-onset bifascicular block, whereas the echocardiogram revealed a 24% left ventricular ejection fraction and a 4-leaf clover appearance of the aortic valve, with moderate to severe regurgitation. A quadricuspid aortic valve was discovered (Fig. 1).The quadricuspid aortic valve, which resembles a 4-leaf clover on a transthoracic echocardiogram, is a rare congenital cardiac condition seen in 0.0059% to 0.0065% of patients.1 The majority of cases often appear in the fifth decade of life, with varying degrees of aortic regurgitation. Reverse blood flow to the left ventricle is facilitated by the uneven blood shear force on 4 rather than 3 valves. Backflow that is left untreated for a long period remodels the ventricle to accept the extra jet, resulting in dilated cardiomyopathy. Surgical repair rather than valve replacement is performed on an individual patient basis, typically saved for situations with significant cardiac insufficiency.Despite receiving a full explanation of the treatment plan and tricuspidation technique, this patient declined further interventions. Stabilized heart failure with reduced ejection fraction was achieved medically; the patient also underwent implantable cardioverter-defibrillator placement. Notably, no ventricular perfusion abnormalities were detected during a nuclear stress test.

Intraprocedural delayed reassessment of paravalvular regurgitation in TAVR significantly reduces the use of postdilatation.

We sought to investigate the effect of a 15-min delayed intraprocedural reassessment of paravalvular aortic regurgitation (PVR) after an immediate evaluation of posttranscatheter aortic valve replacement (TAVR) on the regurgitation grading and usage of postdilatation. PVR after TAVR is associated with poor prognosis, but postdilatation may increase the risk of other complications. In a prospective cohort of consecutive patients treated with balloon-expandable valve ES-3 ultra, the degree of PVR was assessed immediately and 15 min after that first evaluation (excluded severe cases), with the indication of postdilatation based on the delayed assessment. As a control group, the previous consecutive series of patients also treated with the same model of valve prosthesis was used. A total of 180 patients were included in the prospective study cohort and 152 in the retrospective control group. In the study group, the immediate PVR assessment showed none-trace 27.5%, mild 52%, moderate 19%, and severe 1.5%, and the delayed re-evaluation graded PVR as none-trace 83%, mild 15.6%, and moderate 1.2% (p < 0.001 as compared to immediate). In the control group, the immediate PVR assessment showed none-trace 33.5%, mild 52%, moderate 13%, and severe 1.5%. The rate of postdilatation was 2.8% in the study group versus 10.5% in the control group (p = 0.006). At discharge, no differences were observed between groups in PVR echocardiographic grading. A post-TAVR delayed intraprocedural reassessment of the PVR shows a clearly lower degree of regurgitation as compared to immediate evaluation, which significantly decreased the indication of postdilatation.

Clinical outcomes of percutaneous balloon valvuloplasty in patients with critical mitral stenosis

Background: Clinical outcomes after percutaneous balloon valvuloplasty in patients with critical mitral stenosis is challenging and widely discussed. Aim of the study was to analyze the results of balloon mitral valvuloplasty (BMV) using the Inoue technique in patients with critical mitral valve stenosis. Material and Methods: From January 2020 to 2022, balloon mitral valvuloplasty was performed in 31 patients with critical mitral valve stenosis using the Inoue technique. There were 14 men (45.2%), women - 17 (54.8%). The patients were aged from 19 to 59 years, on average 42.4±6.1 years. All patients data were analyzed to evaluate the possible outcomes. Results: In 30 (96.4%) patients, a successful BMV was performed. In 1 (3.2%) patients, PMV failed, including puncture was unsuccessful, and it was not possible to pass a balloon catheter from the LA to the LV through the critically narrowed mitral valve opening. These failures took place at the initial stages of mastering the technique. A lethal outcome was noted in 0 (0.0%) case. In all 30 (96.8%) patients after BMV, positive results were obtained: the area of the mitral orifice increased by an average of 2.5 times, from 0.85±0.17 to 2.16±0.76 cm2 (p&lt; 0.001), the maximum gradient at the level of the mitral valve decreased by 60.5%, on average from 26.9±2.95 to 8.9±0.6 mm Hg. (p&lt;0.0001). The maximum pressure in the LA statistically significantly decreased from 40.29±6.01 mm Hg. Art. up to 21.43±3.83 mm Hg (p&lt;0.05), in LA - from 49.7±10.9 to 29.7±8.2 mm Hg. (p&lt;0.05). According to EchoCG data, regurgitation on the mitral valve after BMV appeared in 6 (24.1%) patients up to I degree, in 1 (3.2%) - up to II, and in 1 (3.2%) - up to III. In 16 (61.5%) of 26 patients with initial mitral insufficiency after BMV, the degree of regurgitation remained at the same level, in 8 (30.7%) the latter increased to II, in 2 (7.7%) - to III degree. Conclusion: BMV using the INOUE technique is a highly effective minimally invasive treatment method, accompanied by a low morbidity and mortality rate.