Low Transvalvular Gradient Research Articles

Phenotype of patients with severe aortic stenosis and small aortic annulus: how does it impact on hemodynamics and on transcatheter aortic valve implantation outcomes

Abstract Background Discordant grading of severe aortic stenosis can result from a tight aortic valve area (<1cm2) with a low transvalvular mean gradient (<40 mmHg). Small aortic annulus dimensions and low flow status may contribute to discordant grading of severe aortic stenosis. However, the frequency of patients with small aortic annulus and discordant grading, along with their characteristics and outcomes after intervention, remains unknown. Purpose To investigate the frequency of discordant grading severe aortic stenosis in patients with a small aortic annulus and to evaluate their clinical characteristics, as well as outcomes after transcatheter aortic valve implantation (TAVI). Methods Patients with an aortic annulus diameter < 23 mm determined by cardiac computed tomography who underwent TAVI between 2018 to 2023 were retrospectively evaluated. Patients were followed for the occurrence of the composite endpoint of of all-cause mortality, rehospitalizations for heart failure, non-fatal myocardial infarction, and non-fatal stroke. Results Among 230 patients with severe aortic stenosis and a small aortic annulus, 52 (23%) had discordant gradient (24 with low flow low gradient (LFLG) and 28 with normal flow low gradient (NFLG)) while 120 (52%) exhibited normal flow high gradient (NFHG) and 58 (25%) had low flow high gradient (LFHG). The majority of the patients were female (Table 1). Differences were noted among the three groups regarding aortic transvalvular gradients, stroke volume index and ejection fraction. During a median follow-up of 2 years, the composite endpoint occurred in 20% of the total cohort. Patients with discordant grading severe aortic stenosis experienced the worse outcome (Figure1). Conclusions Most patients with severe aortic stenosis and small annulus have high gradient and only 23% of patients presented discordant grading. Patients with discordant grading severe aortic stenosis showed worse outcomes, suggesting potential delays in referral due to challenges in diagnosing severe aortic stenosis among patients with small aortic annulus.Basal clinical characteristicsKaplan-Meier survival curves

Stroke volume index (SVI) predicts all-cause mortality following transcatheter aortic valve replacement (TAVR)

BackgroundLeft ventricular systolic dysfunction in patients with severe aortic stenosis (AS) may result in low transvalvular gradients and underestimation of AS severity. A low-flow state may occur with reduced LVEF. Little is known about the implications of low compared to normal flow in patients with reduced LVEF undergoing transcatheter aortic valve replacement (TAVR). ObjectivesWe compared survival rates with degree of flow across stenosed aortic valves and left ventricular dysfunction. We hypothesized that the stroke volume index (SVI) offers essential information regarding survival following TAVR. MethodsWe retrospectively reviewed patients with LVEF <50 % undergoing TAVR at the Gates Vascular Institute in Buffalo, New York, from 2012 to 2017. We performed Receiver Operator Characteristics to examine the value of SVI in predicting the postoperative outcome of patients. Kaplan-Meier and Cox regression analyses were used to investigate the effect of a low-flow state on five-year survival in patients with systolic dysfunction undergoing TAVR. ResultsFive-year survival following TAVR was decreased in patients with low-flow AS (SVI <35 mL/m2) compared to patients with normal flow. Seventy-four percent (n = 50) of patients with low-flow compared to 43 % (n = 22) of patients with normal flow were deceased five years post-TAVR (p ≤0.001). ROC curve indicated SVI to be a clinical predictor of five year survival (AUC 0.732, 95 % CI: 0.641–0.823, p < 0.001). ConclusionPatients with systolic dysfunction and low transvalvular flow AS had increased mortality five years following TAVR. These findings highlight a better prognosis in patients with normal flow and LV systolic dysfunction. Condensed abstractLow-flow aortic stenosis can occur with reduced left ventricular function. We compared survival rates of patients with known reduced left ventricular function in low-flow and normal flow aortic stenosis. This retrospective single-center study examined mortality rates following transcatheter aortic valve replacement. The mean gradient was not a predictor of mortality. This study shows patients with low-flow aortic stenosis have decreased five-year survival following valve replacement.

Operative Morbidity and Mortality of Aortic Stenosis with Left Ventricular Dysfunction

Objectives: Study of the operative morbidity and mortality of aortic stenosis with left ventricular systolic dysfunction (LVEF &lt; or = 35%). Method: 73 patients with a mean age of 55+/-8 years, 59 of whom were men, underwent surgery between January 2014 and december 2019; 14% (10/73) of these patients had a pre-operative low trans-valvular aortic gradient (&lt;30mmHg). We determined the factors predictive of operative mortality using univariate and multivariate analyses, analysed changes in functional status and left ventricular ejection fraction, and compared operative mortality and late survival in these 73 patients with those in a control group with no left ventricular dysfunction. Results: The mean NYHA stage, before and after aortic valve replacement, fell from 3.8 to 1.7, and the mean improvement in LVEF was 28+/-13. In univariate analysis, the parameters significantly associated with operative mortality were arterial hypertension (p=0.039), congestive heart failure (p=0.030), a smaller indexed left ventricular mass (p=0.039), a mean gradient of less than 30mmHg (at the limit of significance (p=0.053)), a low cardiac index (p=0.0045), and mono-truncular coronary involvement (p=0.042). In multivariate analysis, no variable was identified as an independent predictor of operative mortality. Conclusion: Operative mortality was significantly higher 11.7%vs 2.9% (p=0.048) in the group with left ventricular dysfunction, although late survival rates were similar in the 2 groups (86.8% vs 93%). Given the spontaneous prognosis and the increased operative risk, these patients should be operated on.

Optimal stroke volume index cut off for survival of severe aortic stenosis patients undergoing TAVI - where should we draw the line?

Abstract Funding Acknowledgements Type of funding sources: None. Background Low-flow status in patients with severe aortic stenosis (SAS) is currently defined using stroke volume index (SVi), at a cut off below 35mL/m2. Low-flow has been associated with higher mortality in patients undergoing transcatheter aortic valve implantation (TAVI). However, different cut offs have been recently suggested to more accurately define a low-SVi associated with worse survival after valvular intervention. Purpose Determine the impact of SVi in mortality of SAS patients undergoing TAVI and define a prognostically relevant threshold in this context. Methods A database comprising all patients treated with TAVI between 2011 and 2019 in a single-centre was retrospectively analyzed, and cases with echocardiograms performed before intervention in our centre were included. Primary endpoint was defined as time to all-cause death or last follow-up over the five years after intervention. Surv_cutpoint from survival package in R was used to evaluate optimal low-SVi cutpoints associated with worse survival in SAS patients undergoing TAVI. Low-flow patients were compared with normal-flow counterparts using the determined low-SVi definition. The prognostic values of continuous and categorical SVi at a &amp;lt;35mL/m2 cut off and using the newly determined threshold were tested using Kaplan-Meier curves, log-rank test and Cox proportional hazard model adjusted for EuroSCORE II. Patients were further divided as having preserved or reduced ejection fraction (EF, &amp;lt;52%). p&amp;lt;0.05 was considered statistically significant. Results Of 657 TAVI performed, 488 (74.6%) patients were included in the present analysis, over a median follow-up of 56 months. A SVi&amp;lt;35ml/m2 was not associated with higher mortality after TAVI (p = 0.07). An optimal cutpoint of low-SVi was defined at &amp;lt;29mL/m2 (n=115, 24%), and these patients were on a more advanced NYHA class, were of higher estimated surgical risk, were more frequently hypertensive and anemic, and had a higher prevalence of atrial fibrillation. Echocardiographic data revealed lower EF, lower functional aortic valve area and lower transvalvular gradients in low-SVi patients. Regarding TAVI design, a balloon-expandable valve was more frequently used in this setting. SVi&amp;lt;29ml/m2 was associated with higher mortality after intervention [p = 0.003, hazard ratio (HR) 1.60 (1.18–2.17)], including after adjusting to EuroSCORE II, and in a reduced (but not preserved) EF context. When analyzed as a continuous variable, a higher SVi was associated with better survival after TAVI. Conclusions SVi is a prognostically relevant parameter in SAS patients undergoing TAVI. Contrary to a classically defined threshold of &amp;lt;35mL/m2, a SVi&amp;lt;29mL/m2 was associated with higher mortality after intervention in our population.

Historical aspects of aortic valve replacement using autologous pericardium: do we know everything?

Highlights. The article describes the contribution of foreign and Russian surgeons to the development of aortic valve replacement using autologous tissue, and presents the evolution of the technique. The authors tried to answer the question whether the Japanese professor S. Ozaki actually developed something new or the discovery was already made 40 years ago. At the end of the article, the technique developed by a Russian cardiac surgeon is presented, casting doubt on the use of templates in this procedure.Abstract. Aortic valve replacement using autologous pericardium (neocuspidalization) is becoming an increasingly attractive option that can be applied to a wide range of aortic valve diseases. This technique avoids the need for lifelong administration of anticoagulant drugs, and provides the maximum effective orifice area, resulting in a low transvalvular gradient. The new technique, introduced by Shigeyuki Ozaki, has made the procedure more reproducible with promising medium- and longterm results. But is Ozaki the predecessor of this technique or is “all new is well forgotten old”? This review focuses on the historical aspects of the development of neocuspidalization of the aortic valve using autologous pericardium, the first interventions for valve reconstruction are mentioned, the evolution in the technique of preparation and fixation of the leaflets is reflected.

Prognostic Implications of Discordant Low-Gradient Severe Aortic Stenosis: Comprehensive Analysis of a Large Multicenter Registry

BackgroundUp to 30% of patients with severe aortic stenosis (SAS) (indexed aortic valve area [AVAi] <0.6 cm2/m2) exhibit low-transvalvular gradient despite normal ejection fraction. There is intense debate regarding the prognostic significance of this entity. ObjectivesThe purpose of this study was to compare the outcome of patients with discordant low-gradient SAS (DLG-SAS) vs moderate aortic stenosis (MAS) and high-gradient SAS (HG-SAS). MethodsWe used the BEL-F-ASt (Belgium-France-Aortic Stenosis) registry including consecutive patients with AS. Survival was compared overall and after matching (inverse probability weighting and propensity-score matching) for clinical and imaging variables. The analysis was first performed in the overall population (n = 2,582) and then in the population of unoperated patients (n = 1,812). ResultsAfter-inverse probability weighting-matching, the 3 groups were balanced. Five-year survival was better in MAS than in DLG-SAS and HG-SAS-patients (58.9% vs 47% vs 41.2%, P < 0.001). Similar results were obtained in unoperated patients (54.1% vs 37.9% vs 28.1%, P < 0.001). To explore the impact of MG (≤40 vs >40 mmHg) and AVAi (<0.6 vs ≥0.6 cm2/m2) on outcomes, survival of propensity score-matched cohorts of HG-vs DLG-SAS and MAS vs DLG-SAS were compared. After matching for MG, survival was better in MAS than in DLG-SAS (52% vs 40%, P < 0.001). After matching for AVAi, survival was better in DLG-SAS than in HG-SAS patients (45% vs 33%, P < 0.001). ConclusionsSurvival of DLG-SAS is better than that of HG-SAS and worse than that of MAS patients. At comparable MG, the lower the AVAi, the worse the prognosis, whereas at comparable AVAi, the higher the MG, the worse the prognosis. These data argue that DLG-SAS is an intermediate form in the disease continuum.

5-Year Outcomes With Self-Expanding vs Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients With Small Annuli

BackgroundSelf-expanding transcatheter heart valves (THVs) are associated with better echocardiographic hemodynamic performance than balloon-expandable THVs and are considered preferable in patients with small annuli. ObjectivesThis study sought to compare 5-year outcomes between self-expanding vs balloon-expandable THVs in severe aortic stenosis (AS) patients with small annuli. MethodsConsecutive severe AS patients with an aortic valve annulus area <430 mm2 who underwent transcatheter aortic valve replacement (TAVR) with either the CoreValve Evolut (Medtronic) or SAPIEN (Edwards Lifesciences) THV between 2012 and 2021 were enrolled from the Bern TAVI registry. A 1:1 propensity-matched analysis was performed to account for baseline differences between groups. ResultsA total of 723 patients were included, and propensity score matching resulted in 171 pairs. Technical success was achieved in over 85% of both groups with no significant difference. Self-expanding THVs were associated with a lower transvalvular gradient (8.0 ± 4.8 mm Hg vs 12.5 ± 4.5 mm Hg; P < 0.001), a larger effective orifice area (1.81 ± 0.46 cm2 vs 1.49 ± 0.42 cm2; P < 0.001), and a lower incidence of prosthesis-patient mismatch (19.7% vs 51.8%; P < 0.001) than balloon-expandable THVs. At 5 years, there were no significant differences in mortality (50.4% vs 39.6%; P = 0.269) between groups. Disabling stroke occurred more frequently in patients with a self-expanding THV than those with a balloon-expandable THV (6.6% vs 0.6%; P = 0.030). Similar results were obtained using inverse probability of treatment weighting in the Bern TAVI registry and the nationwide Swiss TAVI registry. ConclusionsThe echocardiographic hemodynamic advantage of self-expanding THVs was not associated with better clinical outcomes compared with balloon-expandable THVs up to 5 years in patients with small annuli. (Swiss TAVI Registry; NCT01368250)

Ozaki procedure

Background and aim Mechanical heart valves require lifelong anticoagulation and therefore predispose to hemorrhagic events. Ozaki developed their aortic valve (AV) reconstruction technique at Toho University Ohashi Medical Center, where they standardized the use of glutaraldehyde-treated autologous pericardium to perform a trileaflet aortic valve. Therefore, it achieves maximum effective orifice area (EOA) and low transvalvular gradients. The current study aimed to assess the short-term Ozaki procedure in our center. Patients and methods A total of 86 patients were enrolled in the current study; group A included 43 patients who had undergone AVR using a biological aortic valve prosthesis, and group B included 43 patients who had undergone aortic valve replacement (AVR) using the Ozaki procedure. Results Both groups had comparable findings either at baseline, perioperative data, or during the follow-up. During follow-up either in the 3rd or 6th month both groups had insignificant differences. Renal dysfunction was reported in five (11.6%) patients of the biological valve group and two patients of the Ozaki group. Endocarditis was developed in only two patients with biological valves. Mild aortic regurgitation was noticed in one patient in the 3rd month and two patients in the 6th month in the case of the Ozaki procedure, while only one patient in the biological valve group developed mild AR in the 6th month of follow-up. Nearly all patients had improved NYHA classes in both groups. No patient in the Ozaki group was converted to AVR. Conclusion We have described our initial experience with the Ozaki procedure in adults. The current study reported promising results for the Ozaki procedure. Yet, multiple future studies in multiple centers are warranted to draw a firm conclusion and support our findings.

Prognostic implications of paradoxical low gradient severe aortic stenosis: a comprehensive analysis from a large multicentric registry

Abstract Background Up to 40% of patients with severe aortic stenosis (SAS; indexed aortic valve area (AVAi) &amp;lt;0.6 cm2/m2) present with low transvalvular mean gradient (MG) despite a normal left ventricular ejection fraction (EF). There is intense debate about the prognostic significance of such entity, with some referring to it as an advanced form of the disease, others as an intermediate form between a moderate and a severe form. Objectives To compare outcome of patients with paradoxical low gradient SAS (PLG-SAS; i.e., mean gradient &amp;lt;40 mmHg and AVAi &amp;lt;0.6 cm2/m2) vs. moderate aortic stenosis (MAS; i.e. mean gradient &amp;lt;40 mmHg and AVAi &amp;gt;0.6 cm2/m2) and high gradient SAS (HG-SAS; i.e. mean gradient &amp;gt;40 mmHg and AVAi &amp;lt;0.6 cm2/m2). Methods 2582 consecutive patients with aortic stenosis (PLG-SAS, n=933; MAS, n=876 and HG-SAS, n=773) and a preserved EF (&amp;gt;50%) from an international multicentric registry were studied. Five years mortality between groups was compared using Kaplan Meier analysis. Inverse probability weighting was used to adjust for clinical and imaging baseline characteristics. Additionally, to explore the impact of MG (&amp;lt;40 mmHg vs. &amp;gt;40 mmHg) in patients with AVAi &amp;lt;0.6 cm2/m2 (PLG-SAS vs. HG-SAS) and to explore the impact of AVAi (&amp;lt;0.6 cm2/m2 vs. &amp;gt;0.6 cm2/m2) in patients with MG &amp;lt;40 mmHg (PLG-SAS vs MAS) we performed 2 different propensity score analyses. Patients were censored at the time of surgery. Results Overall, during 23 [IQR,10–47] months of follow-up 1003 patients died and 770 patients underwent aortic valve replacement. IPW-adjusted natural history was significantly better in patients with MAS, intermediate for patients with PLG-SAS and worst in patients with HG-SAS (59 vs. 47 vs. 41%, p&amp;lt;0.001, see Figure 1A). Furthermore, at equal MG (448 pairs), survival was significantly better in patients with MAS compared with PLG-SAS (54% vs. 39% p&amp;lt;0.001, see Figure 1B) and at equal AVAi (377 pairs), survival was significantly better in patients with PLG-SAS compared with HG-SAS (43% vs. 32% p&amp;lt;0.001, see Figure 1C). Conclusions In this large multicentric cohort, survival of PLG-SAS patients was better than that of HG-SAS patients and worse than that of MAS patients. Furthermore, with a comparable mean gradient, the smaller the calculated AVAi, the worse the prognosis whereas with a comparable AVAi, the higher the mean gradient, the worse the prognosis. Taking together, these data demonstrate that PLG-SAS is an intermediate form in the disease continuum, HG-SAS being the most malignant form of AS. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds National de la Recherche Scientifique (F.R.S.–FNRS)

Transvalvular Pressure Gradients andAll-Cause Mortality Following TAVR: AMulticenter Echocardiographic and Invasive Registry.

Low ejection fraction (EF) and low flow as determined by an echocardiographic stroke volume index(SVi)<35mL/m2 are associated with low transvalvular gradients and increased mortality in both severe aorticstenosis (AS) and post-transcatheter aortic valve replacement (TAVR). Absence of an elevated echocardiographic transaorticgradient post-TAVR is considered a marker of procedural success despite the absence of data on its impactonmortality. The authors sought to examine the association of invasive and echocardiographic gradients post-TAVR with all-cause mortality in relation to flow and EF. In a multicenter retrospective registry of patients undergoing TAVR, Cox models with regression splines explored the relationship between invasive and echocardiographic gradients post-TAVR with 2-year mortality. An invasive gradient<5mmHg was considered low, between≥5 and<10mmHg was considered intermediate, and≥10mmHg was considered high. An echocardiographic gradient<10mmHg was considered low,≥10 and<20mmHg was considered intermediate, and≥20mmHg was considered high. Higher mortality occurred in low echocardiographic gradients at discharge relative to intermediate gradients (P< 0.001), and low gradient was associated with lower EF and echocardiographic SVi (P< 0.001 and P< 0.008, respectively). Lower mortality occurred in low invasive gradients relative to intermediate gradients (P=0.012) with no difference in EF and echocardiographic SVi between groups (P = 0.089 and P=0.947, respectively). There were insufficient observations to determine the impact of high echocardiographic and invasive gradients on mortality. In this large retrospective analysis, the impact of transaortic gradients on mortality after TAVR wasnot linear and complex, showing opposite results among echocardiographic and invasive measurements in low-gradient patients.

Sutureless aortic valve replacement in high-risk patients with active infective endocarditis.

BackgroundSurgical aortic valve replacement remains the gold standard of treatment in patients with active infective endocarditis. Such procedures tend to carry a significantly higher operative risk when compared to the conventional aortic valve replacement for a non-infective aortic valve disease. Sutureless aortic valve replacement (SU-AVR) has been introduced into cardiac surgery to allow for a simpler implementation of minimally invasive procedures. Although SU-AVR in several extended indications has proven to be successful, the data on the implementation of SU-AVR in patients with infective aortic valve endocarditis remain scarce. The aim of the study was to examine the feasibility of SU-AVR in high-risk patients with active infective aortic valve endocarditis.MethodsBetween December 2019 and March 2022, a total of 151 consecutive patients underwent a SU-AVR for various indications at our institution. Of those, in 13 consecutive high-risk patients SU-AVR was indicated because of infective aortic valve endocarditis. In all cases Perceval S aortic valve prosthesis (Corcym, Saluggia, Italy) was used and the implantation has been performed with Snugger-method.ResultsThe mean age of the patients at operation was 74.05±11.6 years. Eight of the patients suffered from prosthesis endocarditis while the other five patients presented with the endocarditis of the native aortic valve. All patients suffered from multiple comorbidities, as reflected by a mean logistic EuroSCORE of 47.9%±23.1% and EuroSCORE II of 28.7%±22.0%. In 8 patients (61.5%) a concomitant procedure was necessary. Also 8 patients (61.5%) underwent a redo procedure. Bypass- and cross-clamp (CC) times were 89.8±33.6 and 59.1±27.8 minutes, respectively. We observed no paravalvular leakage and no cases of left-ventricular outflow tract obstruction. Postoperative mean gradients after SU-AVR implantation were 8.1±4.8 mmHg.ConclusionsSU-AVR in patients presenting with active infective endocarditis is a safe and feasible surgical alternative to the conventional operation. Clearly, this operative approach should be considered particularly for high-risk patients in whom successful operative outcomes are determined by a reduction in bypass and CC time. SU-AVR provides excellent hemodynamic performance with a low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure.

Biomechanically Compatible Hydrogel Bioprosthetic Valves

Bioprosthetic cardiac valves are efficient replacements to clinically treat the valvular heart diseases including stenosis and regurgitation, while these often suffer from the issues of mechanical mismatch, biocompatibility, thrombus, degradation, etc. Here, we report a big step toward the biomechanically compatible hydrogel heart valves by the reversible addition–fragmentation chain transfer polymerization compatible three-dimensional (RAFT-3D) printing tough hydrogels. The biocompatible hydrogel valves have favorable mechanical properties matching with native valves and long-term stability and durability owing to the wide and robust hydrogen-bonding networks, on which the heparin-like polymer with −SO3– is readily grafted through RAFT polymerization, endowing outstanding hemocompatibility including low hemolysis, anticoagulation, and acceptable inflammatory response. The proof-of-concept hydrogel aortic valve displayed a low transvalvular pressure gradient of 14–24 mmHg, which efficiently regulates the flow direction and regurgitation and, more importantly, endures a cyclic pressure of ∼80 mmHg for at least 1.8 × 105 cycles yet maintaining a stable transvalvular pressure gradient without any damage to the configuration and performance. It is believed that the engineered hydrogel cardiac valves pave a significant way toward addressing the complications of cardiovascular diseases.

Prognostic implications of paradoxical low gradient severe aortic stenosis: A comprehensive analysis from a large multicentric registry

Up to 40% of patients with severe aortic stenosis (SAS; indexed aortic valve area (AVAi) <0.6 cm 2 /m 2 ) present with low transvalvular mean gradient (MG) despite a normal left ventricular ejection fraction (EF). There is intense debate about the prognostic significance of such entity, with some referring to it as an advanced form of the disease, others as an intermediate form between a moderate and a severe form. To compare outcome of patients with paradoxical low gradient SAS (PLG-SAS; i.e., MG <40 mmHg and AVAi <0.6 cm 2 /m 2 ) vs. moderate aortic stenosis (MAS; i.e. MG <40 mmHg and AVAi >0.6 cm 2 /m 2 ) and high gradient SAS (HG-SAS; i.e. MG >40 mmHg and AVAi <0.6 cm 2 /m 2 ). 2582 consecutive patients with aortic stenosis (PLG-SAS, n = 933; MAS, n = 876 and HG-SAS, n = 773) and a preserved EF (>50%) from an international multicentric registry were studied. Five years mortality between groups was compared using Kaplan Meier analysis. Inverse probability weighting was used to adjust for clinical and imaging baseline characteristics. Additionally, to explore the impact of MG (<40 mmHg vs. >40 mmHg) in patients with AVAi < 0.6 cm 2 /m 2 (PLG-SAS vs. HG-SAS) and to explore the impact of AVAi (<0.6 cm 2 /m2 vs. >0.6 cm 2 /m 2 ) in patients with MG <40 mmHg (PLG-SAS vs MAS) we performed 2 different propensity score analyses. Patients were censored at the time of surgery. Overall, during 23 [IQR,10–47] months of follow-up 1003 patients died and 770 patients underwent aortic valve replacement. IPW-adjusted natural history was significantly better in patients with MAS, intermediate for patients with PLG-SAS and worst in patients with HG-SAS (59 vs. 47 vs. 41%, P < 0.001, see Fig. 1 A). Furthermore, at equal MG (448 pairs), survival was significantly better in patients with MAS compared with PLG-SAS (54% vs. 39% P < 0.001, see Fig. 1 B) and at equal AVAi (377 pairs), survival was significantly better in patients with PLG-SAS compared with HG-SAS (43% vs. 32% P < 0.001, see Fig. 1 C). In this large multicentric cohort, survival of PLG-SAS patients was better than that of HG-SAS patients and worse than that of MAS patients. Furthermore, with a comparable MG, the smaller the AVAi, the worse the prognosis whereas with a comparable AVAi, the higher the MG, the worse the prognosis. Taking together, these data demonstrate that PLG-SAS is an intermediate form in the disease continuum, HG-SAS being the most malignant form of AS.

Contemporary results of transcatheter mitral valve procedures: bi-centric retrospective analysis

BackgroundTranscatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement offer an alternative therapy for high risk patients. We aimed to highlight the operative and postoperative results of TMVIV and TMVIR procedures.ResultsWe included all patients underwent TMVIV and TMVIR procedures between 2017 and 2020 at two heart centers in Germany. We included a total of 36 high risk patients in our study where 12 received TMVIV and 24 received TMVIR. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). The mean age was 79 (75–83 years old). The median (IQR) preoperative STS score was 9 (7–13)% and EuroSCORE II was 14.5% (12–16). The majority of our patients were operated via transapical approach (n = 26) and the minority via transseptal approach (n = 10). Out of our records, none of our patients required reopening for bleeding or any other surgical complications. None of our patients required reintervention during the 6 months follow-up period. One mortality was recorded on fifth postoperative day due to low cardiac output syndrome (obviously because of LVOT obstruction by the anterior mitral leaflet). The average blood loss was 200 ml in the first 24 h in patients underwent transapical approach. Average operative time was 93 min and all patients were immediately extubated after the procedure in the operating room (even the patient with echocardiographically documented LVOT obstruction who died on the fifth postoperative day). Length of Intensive Care Unit stay was 2 ± 1.2 days and length of hospital stay was 4.1 ± 1.2 days. In the follow up period, echocardiograms showed normal prosthetic valve function with low transvalvular gradients, no LVOT obstruction in TMVIR cases and no evidence of valve migration or thrombosis (except in one patient). Concerning 6 months readmission, it was recorded in 2 patients due to right sided heart failure symptoms due to preexisting high degree of tricuspid valve regurge which did not disappear or even decrease after the operation and the other patient due to gastrointestinal bleeding.ConclusionsTMVIV and TMVIR offer an efficient, safe and less invasive alternative in high surgical risk patients.

30-Day and 1-Year Outcomes With HYDRA Self-Expanding TranscatheterAortic Valve: The Hydra CE Study.

This study sought to evaluate the 30-day and 1-year safety and performance of the Hydra transcatheter aortic valve (THV) (in the treatment of symptomatic severe aortic stenosis in patients at high or extreme surgical risk. The Hydra THV is a novel repositionable self-expanding system with supra-annular bovine pericardial leaflets. The Hydra CE study was a premarket, prospective, multicenter, single-arm study conducted across 18 study centers in Europe and Asia-Pacific countries. The primary endpoint was all-cause mortality at 30days. All endpoints were adjudicated by an independent clinical events committee. A total of 157 patients (79.2 ± 7.1 years of age, 58.6% female; Society of Thoracic Surgeons score 4.7 ± 3.4%) were enrolled. Successful implantation was achieved in 94.3% cases. At 30days, there were 11 (7.0%) deaths, including 9 (5.7%) cardiovascular deaths, of which 5 (3.2%) were device related. At 1 year, there were 23 (14.6%) deaths, including 13 (8.3%) cardiovascular deaths. At 30days, there were significant improvement of effective orifice area (from 0.7 ± 0.2cm2 to 1.9 ± 0.6cm2) and mean aortic valve gradient (from 49.5 ± 18.5mmHg to 8.1 ± 3.7mmHg), which were sustained up to 1 year. Moderate or severe paravalvular leak was observed in 6.3% of patients at 30days and 6.9% of patients at 1 year. The rate of new permanent pacemaker implantation was 11.7% at 30days and 12.4% at 1 year. The Hydra CE study demonstrated that transcatheter aortic valve replacement with Hydra THV offered favorable efficacy at 1 year, providing large effective orifice area and low transvalvular gradient as well as acceptable complication rates with regard to new permanent pacemaker and paravalvular leak. (A Clinical Evaluation of the HYDRA Self Expanding Transcatheter Aortic Valve; NCT02434263).

Mid-term clinical and haemodynamic results after aortic valve replacement with the Trifecta bioprosthesis.

The aim of this study was to evaluate the clinical and haemodynamic results after implantation of the Trifecta bioprosthesis. This study is a retrospective analysis of all patients undergoing Trifecta aortic valve replacement between 01 January 2012 and 31 December 2017 at the Ghent University Hospital. Univariable and multivariable analyses were performed to identify predictors of valve- and procedure-related complications and mortality. The haemodynamic performance was analysed by longitudinal Doppler echocardiography. The mean age of the 182 patients was 77 [standard deviation (SD): 5.5] years; 54.9% were women. The mean follow-up was 39.8 (SD: 24.3) months. Overall survival at 1 and 5 years was 86% (SD: 3%) and 68% (SD: 4%), respectively, and overall freedom from structural valve deterioration was 100% and 98% at 1 and 5 years, respectively. There was no valve thrombosis nor early endocarditis. Urgent surgery was the only risk factor for early mortality in the multivariable analysis [P = 0.009, odds ratio 0.06, 95% confidence interval (CI) 0.01-0.5]. Preoperative atrial fibrillation was the most important predictor of late mortality (P = 0.001, hazard ratio 3.68, 95% CI 1.65-8.21). The average peak gradients were stable from discharge up to 1 and 5 years postoperatively [15 (SD: 6) and 17 (SD: 8) mmHg]. These results confirm the excellent clinical performance of the Trifecta valve, particularly in an elderly age group. Through the 7-year follow-up period, low transvalvular gradients persisted, and only a few patients needed reoperation. Although structural valve degeneration occurred rarely, it was unrelated to valve size or age at implantation; therefore, further long-term follow-up remains mandatory.

Sutureless aortic valve replacement in multivalve procedures.

BackgroundDespite the rapid expansion of transcatheter approaches for aortic valve implantation, surgical aortic valve replacement remains the treatment of choice in patients presenting with multiple valvular heart disease. We sought to review our clinical experience with sutureless aortic valve replacement (SU-AVR) in the setting of multivalve procedures, addressing the postoperative outcomes and technical challenges.MethodsBetween December 2019 and December 2020, 20 consecutive high-risk patients at our institution underwent SU-AVR and concomitant mitral valve procedure for various indications.ResultsThe mean age of the patients at operation was 72.6±9.3 years. Fifty five percent of the patients (n=11) presented with moderate to severe symptomatic aortic valve stenosis, while 35% (n=7) suffered from severe aortic regurgitation. All patients had concomitant moderate to severe mitral valve disease, including regurgitation in 95% (n=19) and stenosis in 25% (n=5). Mean logistic EuroSCORE was 34.3%±24.7%. Cardiopulmonary bypass and cross-clamp times were 101 (88.0–123) minutes and 67.5 (51.7–85.2) minutes, respectively. Optimal sutureless aortic valve prosthesis device success was achieved in 20 patients (100%). One patient (5%) required permanent pacemaker implantation. Thirty-day mortality was 10% and no strokes were detected.ConclusionsSU-AVR is a safe and feasible surgical alternative to conventional procedures in patients presenting with multiple valvular heart disease. It provides excellent hemodynamic performance with low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure. Precise sizing and positioning of the valve prostheses is crucial to ensure optimal postoperative outcome.

Starting an aortic valve repair program: is it worthwhile? Aortic valve repair compared to replacement.

Increasing evidence suggests that aortic valve (AV) repair may have better long-term outcomes than AV replacement for aortic insufficiency. However, most literature is limited to centres of excellence and has not sufficiently been replicated in nascent programs. This single-centre experience of a newly established AV repair program aims to compare short-term outcomes of AV sparing versus replacement surgery. A retrospective cohort study of patients who underwent elective surgery for aortic regurgitation or aortic root dilatation at the Leuven University Hospital between 2013 and 2018 was performed. Patients with a critically ill presentation, endocarditis, aortic stenosis or requiring redo surgery were excluded. Patients were assigned to repair versus replacement based on preoperative intention to preserve the AV. Nearest neighbour propensity score matching was performed to compare both groups. Safety (mortality, morbidity), efficiency (cross-clamp and bypass times) and efficacy end points (repair rate, postoperative echocardiography) were compared. One hundred and seven patients underwent AV surgery (48 repair, 59 replacement), from which 2 groups of 23 matched patients were created. There were 1 death and 2 reoperations after repair and no death and 1 reoperation after replacement. Extracorporeal circulation and aortic cross-clamp time were significantly longer while ventilation and total hospital stay were significantly shorter after AV repair. Echocardiographic follow-up showed comparable aortic regurgitation but lower transvalvular gradients after repair. Freedom from major complications was comparable in both cohorts. Early results suggest the feasibility of replicating experienced centres' perioperative and short-term outcomes in nascent programs.

The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance

BackgroundThe incompetent bicuspid aortic valve (BAV) can be replaced or repaired using various surgical techniques. This study sought to assess the efficacy of external annuloplasty and postoperative reverse remodelling using cardiac magnetic resonance (CMR) and compare the results of external and subcommissural annuloplasty.MethodsOut of a total of 200 BAV repair performed between 2004 and 2018, 21 consecutive patients (median age 54 years) with regurgitation requiring valve repair with annuloplasty without concomitant aortic root surgery were prospectively referred for CMR and transthoracic echocardiography (TTE) one year after the operation. Two aortic annulus stabilization techniques were used: external, circumferential annuloplasty (EA), and subcommissural annuloplasty (SCA).Results11 patients received EA and 10 patients were treated using SCA. There was no in-hospital mortality and all patients survived the follow-up period (median: 12.6 months (first quartile: 6.6; third quartile: 14.1). CMR showed strong correlation between postoperative aortic recurrent regurgitant fraction and left ventricular end-diastolic volume (r = 0.62; p = 0.003) as well as left ventricular ejection fraction (r = -0.53; p = 0.01). Patients treated with EA as compared with SCA had larger anatomic aortic valve area measured by CMR (3.5 (2.5; 4.0) vs. 2.5 cm2 (2.0; 3.4); p = 0.04). In both EA and SCA group, aortic valve area below 3.5 cm2 correlated with no regurgitation recurrency. EA (vs. SCA) was associated with lower peak transvalvular aortic gradients (10 (6; 17) vs. 21 mmHg (15; 27); p = 0.04).ConclusionsThe repair of the bicuspid aortic valve provides significant postoperative reverse remodelling, provided no recurrent regurgitation and durable reduction annuloplasty can be achieved. EA is associated with lower transvalvular gradients and higher aortic valve area assessed by CMR, compared to SCA.

Stentless Pericarbon Freedom Versus Stented Perimount Aortic Bioprosthesis: Propensity-Matched Long-Term Follow-Up.

Stentless aortic valves have shown superior hemodynamic performance and faster left ventricular mass regression compared to stented bioprostheses. Yet, controversies exist concerning the durability of stentless valves. This case-matched study compared short- and long-term clinical outcomes of stentless LivaNova-Sorin Pericarbon Freedom™ (SPF) and stented Carpentier-Edwards Perimount (CEP) aortic prostheses. From 2003 through 2006, 134 consecutive patients received aortic valve replacement with SPF at our institution. This cohort was matched, according to 20 preoperative clinical parameters, with a control group of 390 patients who received CEP prosthesis during the same time. The resulting 55 + 55 matched patients were analyzed for perioperative results and long-term clinical outcomes. Early mortality was 0% for both groups. Lower transvalvular gradients were found in the SPF group (10.6 ± 2.9 versus 15.7 ± 3.1 mmHg, P < 0.001). Overall late mortality (mean follow-up: 10.03 years) was similar for both groups (50.1% versus 42.8%, P = 0.96). Freedom from structural valve degeneration (SVD) at 13 years was similar for both groups (SPF = 92.3%, CEP = 73.9%, P = 0.06). Freedom from aortic valve reinterventions did not differ (SPF = 92.3%, CEP = 93.5%, P = 0.55). Gradients at 13-year follow-up remained significantly lower in SPF group (10.0 ± 4.5 versus 16.2 ± 9.5 mmHg, P < 0.001). Incidence of acute bacterial endocarditis (ABE) and major adverse cardiovascular and cerebrovascular events (MACCE) was similar. SPF and CEP demonstrated comparable long-term outcomes related to late mortality, SVD, aortic valve reinterventions, and incidence of ABE and MACCE. Superior hemodynamic performance of SPF over time can make this valve a suitable choice in patients with small aortic root and large body surface area.