Moderate-severe Aortic Regurgitation Research Articles

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations.

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.Methods and Results: Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men. Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Randomized comparison of TAVI valves: The Compare-TAVI trial

Based on technical advancements and clinical evidence, transcatheter aortic valve implantation (TAVI) has been widely adopted. New generation TAVI valve platforms are continually being developed. Ideally, new valves should be superior or at least non-inferior regarding efficacy and safety, when compared to best-in-practice contemporary TAVI valves. The Compare-TAVI trial (ClinicalTrials.gov NCT04443023) was launched in 2020, to perform a 1:1 randomized comparison of new vs contemporary TAVI valves, preferably in all comers. Consecutive cohorts will be launched with sample sizes depending on the choice of interim analyses, expected event rates, and chosen superiority or non-inferiority margins. Enrollment has just been finalized in cohort B, comparing the Sapien 3/Sapien 3 Ultra Transcatheter Heart Valve (THV) series (Edwards Lifesciences, Irvine, California, USA) and the Myval/Myval Octacor THV series (Meril Life Sciences Pvt. Ltd., Vapi, Gujarat, India) balloon expandable valves. This non-inferiority study was aimed to include 1062 patients. The 1-year composite safety and efficacy endpoint comprises death, stroke, moderate-severe aortic regurgitation, and moderate-severe valve deterioration. Patients will be followed until withdrawal of consent, death, or completion of 10-year follow-up, whichever comes first. Secondary endpoints will be monitored at 30 days, 1, 3, 5, and 10 years. The Compare-TAVI organization will launch consecutive cohorts wherein patients scheduled for TAVI are randomized to one of two valves. The aim is to ensure that the short- and long-term performance and safety of new valves being introduced is benchmarked against what achieved by best-in-practice contemporary valves.

Incidencia y predicción de hospitalización por insuficiencia cardiaca en pacientes con fibrilación auricular: escala REFLEJA

Introduction and objectivesHospitalization for heart failure (HHF) is common in patients with atrial fibrillation (AF) and is associated with increased mortality. The aims of this study were to determine the incidence of HHF, identify the clinical predictors of its occurrence, and develop a new risk scale. MethodsThe incidence of HHF was estimated using data from the prospective single-center REFLEJA registry of outpatients with AF (October 2017-October 2018). A multivariate Cox regression model was calculated to detect HHF predictors, and a nomogram was created for individual risk assessment. ResultsOf the 1499 patients included (mean age 73.8±11.1 years, 48.1% women), 127 had HHF (incidence rate of 8.51 per 100 persons/y) and 319 died (rate of death from any cause of 21.1 per 100 persons/y) after a 3-year follow-up. The independent predictors of HHF were age, diabetes, chronic kidney disease, pulmonary hypertension, previous pacemaker implantation, baseline use of diuretics, and moderate-severe aortic regurgitation. The c-statistic for predicting the event was 0.762 (95%CI after boostrapping resampling, 0.753-0.791). The cumulative incidences of the main outcome for the risk scale quartiles were 1.613 (Q1), 3.815 (Q2), 8.378 (Q3), and 20.436 (Q4) cases per 100 persons/y (P <.001). ConclusionsHHF was common in this AF cohort. The combination of certain clinical characteristics can identify patients with a very high risk of HHF.

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

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

Abstract 16055: Marantic Endocarditis - A Rare Paraneoplastic Presentation of Ovarian Carcinoma

Introduction: Nonbacterial thrombotic endocarditis (NBTE) or Marantic endocarditis, involves formation of sterile platelet &amp; fibrin thrombi on undamaged cardiac valves &amp; adjacent endocardium. The vegetation is associated with embolization. Case presentation: A middle-aged female without cardiac history presented to the ED with blurred vision &amp; fatigue for 3 days. The patient was afebrile with a BP of 183/97mmHg. Physical examination showed decreased visual acuity in the left eye. The EKG was normal. The patient underwent a CT scan brain that showed suspicion of bilateral occipital strokes. MRI brain revealed multiple small acute infarcts in the bilateral cerebral hemispheres &amp; cerebellum. Blood cultures were negative. Telemetry did not show atrial fibrillation. Given a suspicion of cardioembolic stroke, the patient underwent a transesophageal echocardiogram (TEE) which demonstrated a trileaflet aortic valve (AV) with abnormal irregular thickening of leaflets, concerning for vegetation &amp; moderate-severe aortic regurgitation (AR). figure 1. Our patient was diagnosed with marantic endocarditis based on TEE &amp; serial negative cultures. Apixaban was started. Further workup of the patient revealed bilateral pulmonary emboli. Abdominal imaging revealed a pelvic mass, ultimately diagnosed as clear-cell ovarian cancer. Interval TEE at 3 months demonstrated complete resolution of vegetations with preserved cusp motion &amp; mild AR. A shared decision was made to continue lifelong anticoagulation. Discussion: NBTE commonly involves mitral &amp; AV. Risk factors include trauma, circulating immune complexes, hypercoagulability, malignancy &amp; acute inflammation. Symptoms result from embolization, valve dysfunction, or impaired cardiac function. It is based on imaging after ruling out infectious etiologies. Management is anticoagulation &amp; valve replacement with the treatment of the underlying etiology. Valve replacement prevents future embolic complications.

Growth of the Neo-Aortic Root and Prognosis of Transposition of the Great Arteries

BackgroundNeo-aortic root dilatation can lead to significant late morbidity after the arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA). ObjectivesWe sought to examine the growth of the neo-aortic root in d-TGA. MethodsA single-center, retrospective cohort study of patients who underwent the ASO between July 1, 1981 and September 30, 2022 was performed. Morphology was categorized as dextro-transposition of the great arteries with intact ventricular septum (d-TGA-IVS), dextro-transposition of the great arteries with ventricular septal defect (d-TGA-VSD), and double-outlet right ventricle-transposition of the great arteries type (DORV-TGA). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before the ASO and throughout follow-up. Trends in root dimensions over time were assessed using linear mixed-effects models. The association between intrinsic morphology and the composite of moderate-severe aortic regurgitation (AR) and neo-aortic valve or root intervention was evaluated with univariable and multivariable Cox proportional hazards models. ResultsOf 1,359 patients who underwent the ASO, 593 (44%), 666 (49%), and 100 (7%) patients had d-TGA-IVS, d-TGA-VSD, and DORV-TGA, respectively. Each patient underwent a median of 5 echocardiograms (Q1-Q3: 3-10 echocardiograms) over a median follow-up of 8.6 years (range: 0.1-39.3 years). At 30 years, patients with DORV-TGA demonstrated greater annular (P < 0.001), sinus of Valsalva (P = 0.039), and sinotubular junction (P = 0.041) dilatation relative to patients with d-TGA-IVS. On multivariable analysis, intrinsic anatomy, older age at ASO, at least mild AR at baseline, and high-risk root dilatation were associated with moderate-severe AR and neo-aortic valve or root intervention at late follow-up (all P < 0.05). ConclusionsLongitudinal surveillance of the neo-aortic root is warranted long after the ASO.

Comparison of middle-term valve durability between transcatheter aortic valve implantation and surgical aortic valve replacement: an updated systematic review and meta-analysis of RCTs.

This study aims to compare valve durability between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). We conducted a systematic review and meta-analysis using data from randomized controlled trials (RCTs). The primary outcome was structural valve deterioration (SVD). Secondary outcomes were bioprosthetic valve failure, reintervention, effective orifice area (EOA), mean pressure gradient, and moderate-severe aortic regurgitation (AR, transvalvular and/or paravalvular). Twenty-five publications from seven RCTs consisting of 7,970 patients were included in the analysis with follow-up ranges of 2-8 years. No significant difference was found between the two groups with regard to SVD [odds ratio (OR) 0.72; 95% CI: 0.25-2.12]. The TAVI group was reported to exhibit a statistically significant higher risk of reintervention (OR 2.03; 95% CI: 1.34-3.05) and a moderate-severe AR (OR 6.54; 95% CI: 3.92-10.91) compared with the SAVR group. A trend toward lower mean pressure gradient in the TAVI group [(mean difference (MD) -1.61; 95% CI: -3.5 to 0.28)] and significant higher EOA (MD 0.20; 95% CI: 0.08-0.31) was noted. The present data indicate that TAVI provides a comparable risk of SVD with favorable hemodynamic profile compared with SAVR. However, the higher risk of significant AR and reintervention was demonstrated. PROSPERO (CRD42022363060).

Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures

Background:Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel’s one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported.Methods:In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction.Results and conclusions:Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities’ risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.

Staging cardiac damage in patients with aortic regurgitation.

The impact of "downstream" pathophysiological cardiac consequences in aortic regurgitation patients were not well established. The aim of our study was to validate a staging system built for severe aortic stenosis in a large real-world cohort of aortic regurgitation (AR) patients, evaluating the prevalence of different stages of cardiac damage and assess its prognostic impact. Clinical, echocardiographic and outcome data of patients with moderate-severe AR who underwent transthoracic echocardiography between January/2014 and September/2019 were retrospectively analysed. Patients were classified according to the extent of cardiac damage: Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage) and Stage 4 (right ventricular damage). The primary endpoint was all-cause mortality. A total of 571 patients (median age 73, 51% male) were enrolled: Stage 0 (14.0%), Stage 1 (21.5%), Stage 2 (49.2%), Stage 3 (12.3%) and Stage 4 (3.0%). Median follow-up time was 39.5months (IQR 22.2 to 61.0). At the end of follow-up, cumulative death was significantly higher in more advanced disease stages (log-rank p < 0.001). On multivariable analysis, Stage 3-4 was associated with increased risk of all-cause mortality (HR 3.20; 95% CI 1.48-6.93; p = 0.003). Our study suggests that extra-valvular damage is common in patients with significant AR and that a staging system developed for aortic stenosis also provides prognostic information in these patients. This staging system may be helpful for clinical decision-making regarding the time of valvular intervention.

Balloon- vs Self-Expanding Valve Systems for Failed Small Surgical Aortic Valve Bioprostheses

BackgroundData comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) field have been obtained from retrospective studies. ObjectivesThe purpose of this study was to compare the hemodynamic results between the balloon-expandable valve (BEV) SAPIEN (3/ULTRA, Edwards Lifesciences) and self-expanding valve (SEV) Evolut (R/PRO/PRO+, Medtronic) in ViV-TAVR. MethodsPatients with a failed small (≤23 mm) surgical valve were randomized to receive a BEV or an SEV. The primary endpoint was valve hemodynamics (maximal/mean residual gradients, severe prosthesis patient mismatch [PPM], or moderate-severe aortic regurgitation) at 30 days as evaluated by Doppler echocardiography. ResultsA total of 102 patients were randomized, and of these, 98 patients finally underwent a ViV-TAVR procedure (BEV: n = 46, SEV: n = 52). The procedure was successful in all cases, with no differences in clinical outcomes at 30 days between groups (no death or stroke events). Patients in the SEV group exhibited lower mean and maximal transvalvular gradient values (15 ± 8 mm Hg vs 23 ± 8 mm Hg; P ˂ 0.001; 28 ± 16 mm Hg vs 40 ± 13 mm Hg, P ˂ 0.001), and a tendency toward a lower rate of severe PPM (44% vs 64%; P = 0.07). There were no cases of moderate-severe aortic regurgitation. In total, 55 consecutive patients (SEV: n = 27; BEV: n = 28) underwent invasive valve hemodynamic evaluation during the procedure, with no differences in mean and peak transvalvular gradients between both groups (P = 0.41 and P = 0.70, respectively). ConclusionsIn patients with small failed aortic bioprostheses, ViV-TAVR with an SEV was associated with improved valve hemodynamics as evaluated by echocardiography. There were no differences between groups in intraprocedural invasive valve hemodynamics and 30-day clinical outcomes (Comparison of the Balloon-Expandable Edwards Valve and Self-Expandable CoreValve Evolut R or Evolut PRO System for the Treatment of Small, Severely Dysfunctional Surgical Aortic Bioprostheses. The 'LYTEN' Trial; NCT03520101)

Abstract 17189: Radiation-induced Accelerated Multi-valve Disease In A Patient With Subaortic Membrane

A 69-year-old woman with history of right breast cancer status post lumpectomy and radiation (4.2 cGy) 18 months prior, presented with progressive NYHA class III dyspnea. TTE obtained prior to her cancer diagnosis was notable for normal LV size and wall thickness, a subaortic membrane with systolic mean Doppler gradient of 21 mmHg and a mildly thickened mitral valve without significant stenosis or regurgitation. On presentation, TTE was notable for severely increased concentric LV wall thickness (LV mass index 140 g/m 2 ), preserved ejection fraction, increased RV wall thickness, subaortic stenosis with systolic mean Doppler gradient 35 mmHg, moderate-severe aortic regurgitation, thickened mitral valve with posterior leaflet tethering and anterior leaflet override causing severe mitral regurgitation and moderate mitral stenosis (valve area 1.7 cm 2 by pressure half-time). She underwent a surgical intervention with septal myectomy, subaortic membrane resection, aortic root reconstruction, aortic and mitral valve replacement with bioprostheses. She did well post-operatively and had complete resolution of symptoms following cardiac rehabilitation. Radiation-induced valvular heart disease is linked to the total dose of radiation, use of sequential chemotherapy and time since irradiation, with a typical latency of 10-20 years. However, there is paucity of data regarding the influence of these variables in patients with pre-existing valve disease. This case illustrates dramatic acceleration of underlying aortic and mitral valve pathology in a patient with a subaortic membrane, 18 months after radiation. We also noted development of significant concentric LV hypertrophy that was disproportionate to the degree of obstruction across the sub-aortic membrane. Potential candidates for radiation therapy must be carefully screened for pre-existing valve disease, which should warrant increased vigilance and early screening for progressive valve disease.

Valve phenotype and likelihood of surgery in patients with bicuspid aortic valve

Abstract Background It is well established, that patients with bicuspid aortic valve (BAV) are at increased risk of developing severe aortic valve and/or aortic disease early in life. Knowledge of factors placing patients at risk of early surgery is therefore essential. Several studies have found associations between aortic valve phenotype, aortopaty and type of valve dysfunction. Purpose To characterize the valve phenotype associated with increased likelihood of early surgery of the aortic valve and aorta in a large cohort of BAV patients. Methods A retrospective study of adult BAV patients seen in the outpatient clinics at two hospitals in Denmark from 2006 until May 2020. Clinical and anatomical data were obtained retrospectively from electronic health charts and hospital echocardiography databases. Bicuspid valve morphology was classified according to Sievers Classification; no raphe (Type 0), one raphe (Type 1 with fusion of the right-noncoronary cusps (R/N), Left-noncoronary cusp fusion (L/N) and Left-right coronary cusp fusion (L/R)) or 2 raphes (Type 2). Likelihood of surgery was calculated using odds ratio (OR). We performed multivariate regression models to adjust for potential confounding by sex, age, coarctatio aorta, aortic dilatation and cardiovascular risk factors. Results A total 983 BAV patients were identified of whom 877 had an available baseline echocardiography and were included. Clinical and echocardiographic characteristics are seen in Table 1. Noteworthy is that Type 2 patients had significantly higher occurrence of moderate-severe aortic regurgitation when compared to the whole population (38.9% vs 18.3%, p&amp;lt;0.01). During the study period 305 patients (34.8%) underwent surgery. Median age at time of surgery was 62 (IQR 55; 69) years. Using the most common phenotype (Type 1 L/R fusion) as a reference, patients with Type 0 had a lower likelihood of surgery (unadjusted OR 0.58, 95% CI: 0.39–0.85), while patients with Type 2 had a significantly higher likelihood of surgery (OR 2.76, 95% CI: 1.05–7.23). In a multiple regression analysis, adjusting for age, sex, coarctatio aorta and aortic dilatation did not change the primary finding of association between BAV phenotype and OR for surgery. Likelihood of surgery was lower for women (OR 0.66, 95% CI: 0.46–0.96) and increased with age. Further adjustments for cardiovascular risk factors (mentioned in Table 1) did not change the results. Median age at time of surgery was younger for patients with Type 2 (59 years, IQR 44; 65). Indications for valve surgery are shown in Table 2. Conclusion In this study we found significant association between valve phenotype and likelihood of surgery of the valve or aorta in patients with bicuspid aortic valve. Using BAV Type 1 L/R as reference, likelihood of surgery was lower in patients with BAV type 0, and higher in patients with BAV type 2. Results were consistent after adjustment for confounders in multivariate analyses. Funding Acknowledgement Type of funding sources: None.

Comparison of valve durability among different transcatheter and surgical aortic valve prostheses: a network meta-analysis

Abstract Background Durability of different transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve replacement (TAVR) expands to patients with longer life-expectancy. Purpose We aimed to compare the durability of THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis. Methods PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVR and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and longest available follow-up data for clinical outcomes. Results Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV 2,863; SAVR:3,963) were included. Follow-up ranged from 1–6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-years compared to BE-THV and SAVR (Figure 1). Structural valve deterioration (SVD) was less frequent in SE-THV compared to BE-THV and SAVR (HR 0.14, 95% CI 0.07–0.27; HR 0.34, 95% CI 0.24–0.47, respectively) (Figure 1). Total moderate-severe aortic regurgitation and re-intervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40–7.39; HR 2.22, 95% CI 1.16–4.26, respectively) and SE-THV (HR 7.51, 95% CI 3.89–14.5; HR 2.86, 95% CI 1.59–5.13, respectively) compared to SAVR. Conclusion TAVR with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared to BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of aortic regurgitation and re-intervention, and long-term data from newer generation valve is warranted. Funding Acknowledgement Type of funding sources: None.

Meta-Analysis Comparing Valve Durability Among Different Transcatheter and Surgical Aortic Valve Bioprosthesis

Durability of transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve implantation (TAVI) expands to patients with longer life-expectancy. We aimed to compare the durability of different THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis. PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVI and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and the longest available follow-up data for clinical outcomes. Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV: 2,863; SAVR: 3,963) were included. Follow-up ranged from 1 to 6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-year compared with BE-THV and SAVR. Structural valve deterioration (SVD) was less frequent in SE-THV compared with BE-THV and SAVR (HR 0.14, 95% CI 0.07 to 0.27; HR 0.34, 95% CI 0.24 to 0.47, respectively). Total moderate-severe aortic regurgitation and reintervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40 to 7.39; HR 2.22, 95% CI 1.16 to 4.26, respectively), and SE-THV (HR 7.51, 95% CI 3.89 to 14.5; HR 2.86, 95% CI 1.59 to 5.13, respectively) compared with SAVR. In conclusion, TAVI with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared with BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of AR and re-intervention, and long-term data from newer generation valves is warranted.

Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery.

IntroductionValve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm.MethodsNine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study.ResultsIn the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up.ConclusionFor the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Aortic regurgitation is not created equal: outcomes of bicuspid versus tricuspid aortic valve regurgitation

Abstract Background Bicuspid aortic valve (BAV) is an important cause of AR; these patients belong to a young and male predominant population and are distinctively different from tricuspid aortic valve (TAV). However, the differences between BAV and TAV in AR have not been completely explored. Purpose To explore differences between patients with BAV and TAV in hemodynamically significant aortic regurgitation (AR). Methods Consecutive patients with ≥moderate-severe AR were retrospectively identified from 2006 to 2017. Results Of 798 patients (502 with TAV, mean age 67±14 years; 296 with BAV, mean age 46±14 years) followed for 6.1±3.6 years, 403 underwent AV surgery (AVS); 154 died during follow-up. BAV men (94%) tended to become symptomatic when left ventricle enlarged; TAV patients became symptomatic before left ventricular (LV) enlargement. During follow-up, BAV patients had lower mortality (hazard ratio [HR], 0.19; P&amp;lt;0.0001) and higher incidence of AVS (HR, 1.28; P=0.01) than TAV, which attenuated after adjusted on age, sex, comorbidities, LV ejection fraction (LVEF), functional class, and time-dependent AVS. In a propensity-matched cohort, differences of survival and incidence of AVS between BAV and TAV were not demonstrated. After a median of 6.3 (IQR: 3.3–9.3) years, 53 patients died post-AVS; TAV patients having class I surgical triggers had poor survival than TAV-non-class I patients and BAV patients with and without class I triggers (Figure). Class I triggers had no effect on BAV patients regarding post-AVS survival. LVEF&amp;lt;60% was associated with increased mortality in both TAV and BAV. Conclusions The correlation between larger LV size and symptomatic status only applied in BAV men. Patients with BAV and significant AR tended to have better survival and higher incidence of AVS, likely driven by inherent younger age and less comorbidity than patients with TAV. Class I surgical triggers had heavier negative impact on poor survival in TAV patients. The cutoff of LV dysfunction in AR may be LVEF 60%. Figure 1. Kaplan-Meier curves post-AVS Funding Acknowledgement Type of funding source: None

Procedural and clinical outcomes of type 0 versus type 1 bicuspid aortic valve stenosis treated with transcatheter valve replacement: insights from the BEAT international collaborative registry

Abstract Background Transcatheter aortic valve replacement (TAVR) is an established therapy for symptomatic severe aortic stenosis. Bicuspid aortic valves (BAV) were generally excluded from randomized trials due to anatomic features that may challenge TAVR (valve morphology, annulus geometry and size and severe calcifications). Nevertheless real-world registries have shown that a consistent number of BAV has been treated with TAVR. Whether BAV phenotype may affect acute or long-term outcomes following TAVR still remains unclear. Purpose Evaluate the impact of BAV phenotype on procedural and clinical outcomes after TAVR with new generation valves. Methods Patients included in the BEAT (Balloon vs Self-Expandable valve for the treatment of bicuspid Aortic valve sTenosis) registry were classified according to the BAV phenotype. Procedural and clinical outcomes of type 0 (2 cusps, 1 commissure, no raphe) vs type 1 (1 raphe) BAV are here reported. Primary endpoint was post-procedural device success, according to Valve Academic Research Consortium–2 (VARC-2) criteria. Secondary endpoints included procedural complications, rate of permanent pacemaker (PM) implantation and assessment of clinical outcomes at 30-day and 1-year follow-up. Results BAV 0 phenotype was present in 25 (7.1%) cases, and BAV 1 in 218 (61.8%). 3 (0.9%) patients with BAV 2 phenotype and 105 (29.8%) patients in whom BAV phenotype was undeterminable were excluded. Baseline characteristics of the two populations were well balanced. Mean STS score tended to be lower in type 0 vs type 1 BAV (3.35% ±1.8 vs 4.5% ± 3.0, p=0.062). Mean transvalvular gradient, aortic valve area (AVA), and left ventricular ejection fraction didn't differ between groups. According to CT findings moderate-severe aortic valve calcifications were less frequently present in type 0 vs type 1 (52% vs 71.1%, p=0.01). TAVR was performed under conscious sedation in most patients (89.7%), no differences were noted in terms of valve type, valve size, pre and postdilation between groups. There was no significant difference in any peri-procedural complication including pericardial tamponade, second valve implantation, valve embolization, annular rupture, aortic dissection, coronary occlusion, conversion to open surgery, and need of PM between groups however VARC-2 success tended to be lower in type 0 BAV versus type 1 (72% vs 86.7%; p=0.07). A higher rate of mean transvalvular gradient&amp;gt;20 mmHg was observed in the type 0 vs type 1 groups (respectively 24% vs 6%, p=0.007), while no differences were reported in the rate of moderate-severe aortic regurgitation. At 30-day and 1-year follow-up we did not find differences in clinical outcomes. Conclusions Our study confirms the feasibility of TAVR in both type 0 and type 1 BAV, however despite a lower rate of moderate-severe calcifications, a trend toward a lower VARC device success and a higher rate of mean transvalvular gradient &amp;gt;20 mmHg was observed in type 0 vs type 1 BAV. Funding Acknowledgement Type of funding source: None

Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation

ObjectiveTo comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR).MethodsConsecutive patients with chronic ≥moderate-severe AR from a...

Procedural and clinical outcomes of type 0 versus type 1 bicuspid aortic valve stenosis undergoing trans-catheter valve replacement with new generation devices: Insight from the BEAT international collaborative registry

BackgroundAlthough bicuspid aortic valve (BAV) is not considered a “sweet spot” to trans-catheter aortic valve replacement (TAVR), a certain number of BAV underwent TAVR. Whether BAV phenotype affects outcomes following TAVR remains debated. We aimed at evaluating the impact of BAV phenotype on procedural and clinical outcomes after TAVR using new generation trans-catheter heart valves (THVs). Methodspatients included in the BEAT registry were classified according to the BAV phenotype revealed at multi-slice computed tomography (MSCT) in type 0 (no raphe) vs. type 1 (1 raphe). Primary end-point was Valve Academic Research Consortium–2 (VARC-2) device success. Secondary end-points included procedural complications, rate of permanent pacemaker implantation, clinical outcomes at 30-day and 1-year. ResultsType 0 BAV was present in 25(7.1%) cases, type 1 in 218(61.8%). Baseline characteristics were well balanced between groups. Moderate-severe aortic valve calcifications at MSCT were less frequently present in type 0 vs. type 1 (52%vs.71.1%,p = 0.05). No differences were reported for THV type, size, pre and post-dilation between groups. VARC-2 success tended to be lower in type 0 vs. type 1 BAV (72%vs86.7%;p = 0.07). Higher rate of mean transprosthetic gradient ≥20 mmHg was observed in type 0 vs. type 1 group (24%vs6%,p = 0.007). No differences were reported in the rate of post-TAVR moderate-severe aortic regurgitation and clinical outcomes between groups. ConclusionsOur study confirms TAVR feasibility in both BAV types, however a trend toward a lower VARC-2 device success and a higher rate of mean transprosthetic gradient ≥20 mmHg was observed in type 0 vs. type 1 BAV.

Hemodynamic performance of the balloon-expandable SAPIEN 3 valve as assessed by cardiac magnetic resonance

BackgroundScarce data exist on transcatheter heart valve (THV) performance evaluated by cardiac magnetic resonance (CMR) in newer generation THV patients. Furthermore, it has been suggested that echocardiographic evaluation after TAVR may inaccurately assess residual AR in some patients. This study aimed to determine the incidence and severity of aortic regurgitation (AR) assessed by CMR in patients undergoing TAVR with the SAPIEN 3 valve, and evaluate the agreement between CMR and transthoracic echocardiography (TTE) on the assessment of AR severity in such patients. MethodsThis multicentric observational study included 146 SAPIEN 3 patients with TTE and CMR within the month following their procedure. According to the CMR regurgitation fraction (RF), AR was considered mild and moderate-severe if the RF was 15–<30% and ≥ 30%, respectively. TTE exams followed VARC-2 recommendations. ResultsBy CMR, SAPIEN 3 recipients displayed a mean RF of 5.0 ± 6.1%, and mild and moderate-severe AR rates of 3.4% and 0.7%, respectively. The agreement between CMR-TTE was modest (weighted κ = 0.2640, p<0.001), due to an overestimation of AR severity by TTE. A historical cohort of 139 SAPIEN XT patients with a post-procedure CMR, displayed a mean RF of 9.6 ± 10.7% and mild and moderate-severe AR rates of 18.7% and 3.6%, respectively (p < .001 vs. SAPIEN 3 group). ConclusionsSAPIEN 3 recipients exhibited very low rates of residual AR by CMR, suggesting a surgical-like performance regarding AR with this newer generation THV. TTE tended to overestimate the severity of AR, particularly among mild AR patients.