Management Of Aortic Stenosis Research Articles

Differences in life expectancy within and between countries: implications for domestic TAVI guidelines in Australia and Aotearoa New Zealand.

The advent of transcatheter aortic valve implantation (TAVI) has caused a paradigm shift in the management of aortic stenosis away from traditional surgical aortic valve replacement (SAVR). However, uncertainty remains about the long-term (>10 year) durability of TAVI valves, especially in younger patients. This viewpoint collates life expectancy data from Australia and Aotearoa New Zealand to propose sex-specific age-based recommendations for choice of SAVR versus TAVI in their respective general populations and among Aboriginal and Torres Strait Islander people in Australia and both Māori and Pacific peoples living in Aotearoa New Zealand.

Non-invasive assessment of left ventricular filling pressure in aortic stenosis.

The assessment of left ventricular (LV) filling pressure (FP) is important for the management of aortic stenosis (AS) patients. Although, it is often restricted for predict LV FP in AS because of mitral annular calcification and a certain left ventricular hypertrophy. Thus, we tested the predictive ability of the algorithm for elevated LV FP in AS patients and also applied a recently-proposed echocardiographic scoring system of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score. We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LV FP. LV diastolic dysfunction (DD) was graded according to the ASE/EACVI guidelines. The VMT score was defined as follows: time sequence of opening of mitral and tricuspid valves was scored to 0-2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava was dilated, one point was added and VMT score was finally calculated as 0-3. Of the 116 patients, 29 patients showed elevated PAWP. Ninety patients (93%) and 67 patients (63%) showed increased values for left atrium volume index (LAVI) and E/e', respectively when the cut-off values recommended by the guidelines were applied and thus the algorism predicted elevated PAWP with a low specificity and positive predictive value (PPV). VMT≥2 predicted elevated PAWP with a sensitivity of 59%, specificity of 90%, PPV of 59%, and negative predictive value of 89%. An alternative algorithm that applied tricuspid regurgitation velocity and VMT scores was tested, and its predictive ability was markedly improved. VMT score was applicable for AS patients. Alternative use of VMT score improved diagnostic accuracy of guideline-recommended algorism.

Artificial Intelligence in the Screening, Diagnosis, and Management of Aortic Stenosis

Artificial Intelligence in the Screening, Diagnosis, and Management of Aortic Stenosis

Transcatheter Aortic Valve Replacement: Current Status and Future Indications.

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

Aortic stenosis management: current evolution and future challenges.

Aortic stenosis management: current evolution and future challenges.

EE7 Optimizing Aortic Stenosis Management: Evaluating the Clinical and Economic Impact of Transcatheter and Surgical Valve Replacement in Taiwan

EE7 Optimizing Aortic Stenosis Management: Evaluating the Clinical and Economic Impact of Transcatheter and Surgical Valve Replacement in Taiwan

Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls.

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.

Transcatheter versus surgical aortic valve replacement in patients with aortic stenosis: molecular pathways and correlation with clinical and echocardiographic parameters

Abstract Background Transcatheter aortic valve replacement (TAVR) has reformed the management of aortic stenosis (AS), being firstly approved in high-risk patients and becoming progressively a therapeutic alternative to surgery (surgical aortic valve replacement, SAVR) for all the risk categories. Several data pointed out the role of inflammation, oxidative stress, and pathological remodeling in AS natural history. The aim of our study is to investigate the molecular pathways involved in the AS pathophysiology and in the early response to AV replacement in patients subjected to percutaneous or surgical approach. Secondary aims are to evaluate the variation in clinical and echocardiographic parameters of left ventricular (LV) function before and after procedure. Methods We enrolled 36 consecutive patients with a diagnosis of severe AS and preserved ejection fraction (17 SAVR patients and 19 TAVR patients). Biological samples, clinical and echocardiographic evaluation were gained before (T0) and 72 hours after the procedure (T1). We performed 3 gene expression arrays on pooled cDNA from peripheral blood mononuclear cells of the 2 study groups. Results SAVR patients were significantly younger (p=0.0003) and with a lower STS score (p=0.0004). After the procedure, SAVR showed a longer ICU stay (p=0.0019) and a more frequent need of inotropes/vasopressors (p=0.006). Gene expression analysis revealed a reduction of the pro-apoptotic gene CASP3 (n=13; median, IQR: 1.01, 0..89-1.62 for T0 vs 0.68, 0.58-0.85 for T1; p=0.019) and of the transcription factor MEF2C (n=13; 1.00, 0.57-1.31 for T0 vs 0.56, 0.42-0.87 for T1; p=0.028) in TAVR patients, together with significantly increased levels of the antioxidant molecule GPX1 (n=14; 1.04, 0..71-1.34 for T0 vs 1.37, 1.23-1.85 for T1;p=0.030). In SAVR patients, our data showed increased post-procedural levels of GPX1 (n=6; 0.99, 0.49-1.23 for T0 vs 1.81, 1.27-2.00 for T1; p=0.028), and of the oxidative markers CAT (n=10; 0.40, 0.27-0.69 for T0 vs 1.17, 0.59-2.06 for T1; p=0.022,) and NOX2 (n=8; 0.41, 0.31-0.63 for T0 vs 1.04, 0.73-1.54 for T1; p=0.012) (Fig.1). TAVR patients displayed a direct correlation between the gene expression of molecules involved in apoptosis (CASP3), myocardial remodeling (GTF2I, MEF2C) and oxidative stress (MPO, CAT, TXNIP) and indexed left ventricular volumes (Fig.2A), while SAVR patients showed an inverse correlation with LVEF for GTF2I, MEF2C, CAT and MPO gene expression levels (Fig.2B). Conclusions By demonstrating 1) a significant post-procedural downregulation in the expression of genes involved in oxidative stress pathways for TAVR patients if compared with SAVR patients, and 2) a significant correlation of the basal levels of genes involved in apoptosis, myocardial remodeling, and oxidative stress with post-procedural ventricular volumes and LVEF, our study provides a biological rationale to support the percutaneous approach for AS patients, independently from their class of risk.Figure 1Figure 2

Abstract 18205: Ethnicity and Aortic Stenosis: Presentation, Management and Outcomes

Background: Ethnic disparities exist in the diagnosis and management of aortic stenosis (AS), including decreased rates of transcatheter aortic valve implantation (TAVI) in Black patients. We sought to identify if disparities persist in the setting of universal healthcare and whether they are affected by social deprivation. Methods: A validated natural language processing pipeline was applied to the electronic health records of >1M patients at King’s College Hospital (UK) to identify 6214 patients with AS (4.5% Asian, 7.6% Black, 87.9% White self-reported ethnicity). All analyses are adjusted for age and social deprivation. Results: Black and Asian patients had more comorbidities (P<0.05), while Black patients had more cardiac symptoms compared to White patients (P<0.05). Mean time from first report of breathlessness to AS diagnosis was 2.61 years for Asian patients, 2.93 years for Black patients, and 2.09 years for White patients (P<0.05). For those with severe AS, TAVI was performed in 14.3% of Asian patients, 14.3% of Black patients, and 20.2% of White patients. The mean time from severe AS diagnosis to TAVI was 0.41 years for Asian patients, 0.88 years for Black patients, and 0.52 years for White patients (P= NS). Surgical aortic valve replacement (AVR) was performed in 12.5% of Asian patients, 15.5% of Black patients, and 15.4% of White patients. The mean time to AVR was longer for Black patients (1.07 years) compared to Asian (0.19 years) and White patients (0.35 years, P<0.05). The mortality benefit of TAVI or AVR interventions was similar between race and ethnicity groups in a Cox multivariate analysis. Conclusions: Ethnicity-based differences exist in the presentation, diagnosis and management of AS, despite correction for social deprivation. Further, Black patients with severe AS are less likely to receive TAVI intervention, and wait significantly longer for AVR, despite similar efficacy. These data should stimulate strategies to address inequity.

Challenges and Future Directions in Redo Aortic Valve Reintervention After Transcatheter Aortic Valve Replacement Failure.

Transcatheter aortic valve replacement (TAVR) is increasingly being performed in younger and lower surgical risk patients. Reintervention for failed transcatheter heart valves will likely increase in the future as younger patients are expected to outlive the initial bioprosthesis. While redo-TAVR has emerged as an attractive and less invasive alternative to surgical explantation (TAVR-explant) to treat transcatheter heart valve failure, it may not be feasible in all patients due to the risk of coronary obstruction and impaired coronary access. Conversely, TAVR-explant can be offered to most patients who are surgical candidates, but the reported outcomes have shown high mortality and morbidity. This review provides the latest evidence, current challenges, and future directions on redo-TAVR and TAVR-explant for transcatheter heart valve failure, to guide aortic valve reintervention and facilitate patients' lifetime management of aortic stenosis.

Impact of reintervention after index aortic valve replacement on the risk of subsequent mortality

ObjectivesThe use of bioprosthetic aortic valve replacement (AVR) is inherently associated with a risk of structural valve degeneration (SVD) and the need for aortic valve (AV) reintervention. We sought to evaluate whether AV reintervention, in the form of repeat surgical AVR (SAVR) or valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), negatively affects patients’ subsequent long-term survival after index SAVR. MethodsWe identified patients who had undergone bioprosthetic SAVR from 2002 to 2017 at our institution. Median longitudinal follow-up after index SAVR was 7.3 years (10.9 years for those with and 7.2 years for those without AV reintervention), and median follow-up after AV reintervention was 1.9 years. Cox regression analyses using AV reintervention (re-SAVR and ViV-TAVR) as a time-varying covariate were used to determine the impact of reintervention on subsequent survival. ResultsOf 4167 patients who underwent index SAVR, 139 (3.3%) required AV reintervention for SVD, with re-SAVR being performed in 65 and ViV-TAVR in 74. Median age at the index SAVR was 73 years (interquartile range, 64-79 years), and 2541 (61%) were male. Overall, there were total of 1171 mortalities observed, of which 13 occurred after re-SAVR and 9 after ViV-TAVR. AV reintervention was associated with a greater risk of subsequent mortality compared with those patients who did not require AV reintervention (hazard ratio, 2.53; 95% confidence interval, 1.64-3.88, P < .001). This increased risk of subsequent mortality was more pronounced for those who received their index AVR when <65 years of age (hazard ratio, 5.60; 95% confidence interval, 2.57-12.22, P < .001) versus those ≥65 years (2.06, 1.21-3.52, P = .008). Direct comparison of survival between those who underwent re-SAVR versus ViV-TAVR showed 5-year survival to be comparable (re-SAVR: 74% vs ViV-TAVR: 80%, P = .67). ConclusionsAmong patients receiving bioprosthetic AVR, an AV reintervention for SVD is associated with an increased risk of subsequent mortality, regardless of re-SAVR or ViV-TAVR, and this risk is greater among younger patients. These findings should be balanced with individual preferences at index AVR in the context of patients’ lifetime management of aortic stenosis.

Surgical Management of Aortic Stenosis and Regurgitation and Ascending Aortic Aneurysm in a Patient with Thalassemia

Surgical Management of Aortic Stenosis and Regurgitation and Ascending Aortic Aneurysm in a Patient with Thalassemia

Aortic valve replacement for aortic stenosis in patients under 65-years-old

Aortic valve stenosis is the most common valve disease in the world, with particularly poor prognosis if left untreated. Its management in young patients is based on surgical aortic valve replacement (bioprosthesis or mechanical prosthesis, and Ross or Ozaki technique), and rarely percutaneous (TAVR). In this population, the choice of the technique used is of primary importance in terms of hemodynamic performance and durability. The objective of this work is to compare 5 different techniques used in the management of aortic stenosis in patients under 65 years old at CHRU of Tours. We conducted a retrospective, single-center, observational study at the CHRU of Tours. Five cohorts (mechanical prosthesis, INSPIRIS bioprosthesis, Ross, Ozaki and TAVR) were compared in terms of pre-, per- and postoperative, clinical and hemodynamic parameters. We included 163 patients under 65-years-old with aortic stenosis operated at the CHRU of Tours between January 2015 and October 2021. Hemodynamically, after stratification on the prosthetic caliber, the best results were found with the Ozaki and Ross techniques, followed by TAVR, the INSPIRIS bioprosthesis and finally the mechanical prosthesis. A severe prosthesis-patient mismatch rate of 10% was found in all patients, with no significant difference between the different techniques (P = 0.1827). Clinically, there was no significant difference between the groups in terms of mortality or re-intervention related to the aortic valve after a mean follow-up of 19.2 months (P = 0.6545). However, pacemaker implantation was significantly higher in the TAVR group (P = 0.0178). Each surgical and percutaneous technique has its specific advantages and complications. The excellent short-term hemodynamic parameters of the Ross and Ozaki techniques seem to encourage the use of these techniques in the management of aortic stenosis in young patients. More powerful studies with a longer follow-up time would allow to confirm these preliminary results.

Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery.

Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.

Appropriate Use Criteria for the Management of Aortic Stenosis: Insight From the Japanese Expert Panel

BackgroundThe indication for transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) significantly varies among physicians and institutions. ObjectivesThis study aims to develop a set of appropriate use criteria for AS management to assist physicians in decision-making. MethodsThe RAND-modified Delphi panel method was used. A total of >250 common clinical scenarios were identified in terms of whether to perform the intervention for AS and the mode of intervention (surgical aortic valve replacement vs TAVR). Eleven nationally representative expert panelists independently rated the clinical scenario appropriateness on a scale of 1-9, as “appropriate” (7-9), “may be appropriate” (4-6), or “rarely appropriate” (1-3); the median score of the 11 experts was then assigned to an appropriate-use category. ResultsThe panel identified 3 factors that were associated with a rarely appropriate rating in terms of performing the intervention: 1) limited life expectancy; 2) frailty; and 3) pseudo-severe AS on dobutamine stress echocardiography. Clinical scenarios that were deemed rarely appropriate for TAVR were also identified: 1) patients with low surgical risk and high TAVR procedural risk; 2) patients with coexistent severe primary mitral regurgitation or rheumatic mitral stenosis; and 3) bicuspid aortic valve that was not suitable for TAVR. Importantly, any TAVRs for patients who were older than 75 years of age were not rated as rarely appropriate. ConclusionsThese appropriate use criteria provide a practical guide for physicians regarding clinical situations commonly encountered in daily practice and elucidates scenarios deemed rarely appropriate that are clinical challenges for TAVR.

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD. MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission. ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups. ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Non-invasive cardiovascular magnetic resonance assessment of pressure recovery distance after aortic valve stenosis

BackgroundDecisions in the management of aortic stenosis are based on the peak pressure drop, captured by Doppler echocardiography, whereas gold standard catheterization measurements assess the net pressure drop but are limited by associated risks. The relationship between these two measurements, peak and net pressure drop, is dictated by the pressure recovery along the ascending aorta which is mainly caused by turbulence energy dissipation. Currently, pressure recovery is considered to occur within the first 40–50 mm distally from the aortic valve, albeit there is inconsistency across interventionist centers on where/how to position the catheter to capture the net pressure drop. MethodsWe developed a non-invasive method to assess the pressure recovery distance based on blood flow momentum via 4D Flow cardiovascular magnetic resonance (CMR). Multi-center acquisitions included physical flow phantoms with different stenotic valve configurations to validate this method, first against reference measurements and then against turbulent energy dissipation (respectively n = 8 and n = 28 acquisitions) and to investigate the relationship between peak and net pressure drops. Finally, we explored the potential errors of cardiac catheterisation pressure recordings as a result of neglecting the pressure recovery distance in a clinical bicuspid aortic valve (BAV) cohort of n = 32 patients. ResultsIn-vitro assessment of pressure recovery distance based on flow momentum achieved an average error of 1.8 ± 8.4 mm when compared to reference pressure sensors in the first phantom workbench. The momentum pressure recovery distance and the turbulent energy dissipation distance showed no statistical difference (mean difference of 2.8 ± 5.4 mm, R2 = 0.93) in the second phantom workbench. A linear correlation was observed between peak and net pressure drops, however, with strong dependences on the valvular morphology. Finally, in the BAV cohort the pressure recovery distance was 78.8 ± 34.3 mm from vena contracta, which is significantly longer than currently accepted in clinical practise (40–50 mm), and 37.5% of patients displayed a pressure recovery distance beyond the end of the ascending aorta. ConclusionThe non-invasive assessment of the distance to pressure recovery is possible by tracking momentum via 4D Flow CMR. Recovery is not always complete at the ascending aorta, and catheterised recordings will overestimate the net pressure drop in those situations. There is a need to re-evaluate the methods that characterise the haemodynamic burden caused by aortic stenosis as currently clinically accepted pressure recovery distance is an underestimation.

Severe aortic stenosis management in heart valve centres compared with primary/secondary care centres

ObjectiveCurrent guidelines recommend use of heart valve centres (HVCs) to deliver optimal quality of care for patients with valve disease but there is no evidence to support this. The hypothesis...

In-hospital outcomes following percutaneous versus surgical intervention in the treatment of aortic stenosis and concomitant coronary artery disease

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD. MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission. ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups. ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.