Peak Transvalvular Gradient Research Articles

Right parasternal view in dobutamine stress echocardiography for aortic stenosis assessment.

Dobutamine stress echocardiography is an integral part of the evaluation of aortic stenosis (AS) severity in low-gradient AS. In transthoracic echocardiography, in 20% of the patients, the highest aortic valve peak transvalvular velocity and mean gradient are achieved with continuous wave Doppler, from the suprasternal or right parasternal view. We present a case of a 79-year-old-male, with low-gradient aortic stenosis, where the highest peak aortic valve velocity and mean gradient, were consistently obtained from the right parasternal view, during all stages of a dobutamine stress echocardiogram. Use of the right parasternal view was important in avoiding overestimation of aortic valve area and underestimation of aortic valve mean gradients and therefore AS severity at rest. Furthermore, it correctly identified significant increase of aortic valve mean gradients during stress and therefore confirmed the diagnosis of severe AS. This case report highlights the importance of routinely attempting right parasternal view, in patients undergoing stress echocardiography to ensure the maximum possible aortic valve gradient is obtained.

AORTIC STENOSIS AND ULTRASOUND EVALUATION OF RENAL VESSELS IN HYPERTENSIVE PATIENTS

Objective: Aortic stenosis (AS) and arterial hypertension often clusterize and increase cardiovascular disease burden. Renal artery (RA) stenosis, the main form of secondary hypertension, can act as an upstream factor of resistance at the same way of AS. Aim of the study: to investigate if the presence of AS is able to interfere with the ultrasound (US) parameters in the diagnosis of RA stenosis. Design and method: In hypertensive subjects with AS we evaluated US indirect parenchymal parameters: resistive index (RI) and index of maximal systolic acceleration (AImax: the maximal acceleration of flow waveform in early systole divided by the peak systolic velocity), and US direct RA parameters: peak systolic velocity (PSV) and Renal/Aortic Ratio (RAR). Results: We compared hypertensive patients (mean age 74 years) with preserved left ventricular function with severe AS (n=18) or mild AS (n=21). No statistically differences were detected between groups regarding gender, age, smoke, ABI, CV risk factors, lipids, and renal function. Direct US parameters of RA did not differ significantly between patients with severe or mild AS (mean PSV 113 vs 127 cm/sec; mean RAR 1.3 vs 1.6). RI showed the same behavior (0.75 vs 0.73). AImax was significantly lower in patients with severe vs mild AS (8.74 vs 15.56 1/sec, p<0.0005). We found an inverse correlation between AImax and the mean (r2=0.435) and peak (r2=0.424) transvalvular gradient. Among 14 patients with severe AS underwent correction of valvular disease. At 6 months, US showed a significant increase in AImax (from 10.0 to 19.8 1/sec, p<0.005), while RI did not differ significantly (0.74 vs 0.73). Conclusions: Severe AS act as a proximal resistance that can attenuate the systolic acceleration phase of the flow profile of the renal intraparenchymal vessels, in particular of AImax, which is restored after surgical correction of the valve defect. Presence of AS may affect the diagnostic workup of RA stenosis.

MID-TERM ECHOCARDIOGRAPHIC OUTCOMES OF AORTIC VALVE REPLACEMENT USING AUTOLOGOUS PERICARDIUM

Highlights:The mid-term echocardiographic outcomes of aortic valve replacement with autologous pericardium presented in the literature are limited to the basic parameters related to transvalvular hemodynamics;This study is the first in the world to conduct a comprehensive detailed analysis of echocardiographic parameters after neocuspidization using autologous pericardium, both in comparison with standard replacement and between different age populations;Aortic valve neocuspidization using autologous pericardium adult patients of any age group in comparison with mechanical replacement in the mid-term period is characterized by a higher effective orifice area, significant dynamics of left ventricular myocardial mass regression, low potential for the preservation of significant mitral regurgitation. AbstractAim. To analyze echocardiographic parameters after aortic valve replacement using autologous pericardium in various age groups of the adult population.Methods. The multicenter prospective non-randomized cross-controlled study included 71 patients evaluated after surgical correction of aortic valve (AV) stenosis in the mid-term. The population (n = 71) is divided into the following populations: 1 – AVNeo Y (n = 24) – patients aged 19 to 50 years who underwent neocuspidization using autologous pericardium; 2 – AVNeo A (n = 23) – patients aged 51 to 79 years who underwent neocuspidization using autologous pericardium; Group 3 – AVR (n = 24) are patients aged 26 to 50 years who have undergone mechanical replacement. The end points were as follows: index of effective orifice area (EOA), left ventricular mass index (LVMI), peak gradient on AV, peak velocity on AV, pulmonary hypertension (PH), frequency of significant mitral regurgitation (MR), end-diastolic LV volume, LV ejection fraction.Results. In the group 3 (AVR), the lowest EOA index was noted in comparison with the group 1 (AVNeo Y) (p < 0.01) and the group 2 (AVNeo A) (p = 0.02). Significant dynamics of LVMI decrease was observed in groups 1 (AVNeo Y) (p < 0.01) and 2 (AVNeo A) (p < 0.01). In the group 3 (AVR), there was also a decrease in the LVMI in the mid-term, but it went beyond the limits of reliability (p = 0.07). The peak gradient between the groups in the mid-term period was 8.5±2.7 mmHg in the group 1 (AVNeo Y), 8.5±2.6 mmHg in the group 2 (AVNeo A) and 15.6±4.1 mmHg in the group 3 (AVR) (p < 0.01). With respect to significant MR, there was a significant increase in its frequency in the group 3 (AVR) in comparison with other groups (p < 0.01). Moreover, in the group 3 (AVR), a more frequent occurrence of PH was noted in comparison with the group 1 (AVNeo Y) (p < 0.01).Conclusions. AV mechanical replacement in young patients in comparison with neocuspidization using autologous pericardium in adult patients of any age in the mid-term period is characterized by a lower EOA index, the absence of significant dynamics of LVMI regression, a higher peak transvalvular gradient, and a high potential to preserve significant MR and PH.

Determinants of trans-prosthetic gradients after isolated surgical aortic valve replacement and effect on survival

Abstract Background Surgical aortic valve replacement (sAVR) remains the primary therapeutic approach for severe symptomatic aortic stenosis. Patient-prosthetic mismatch (PPM) occurs when the implanted valve is too small for the patient and is characterized by a small orifice area and elevated trans-valvular pressure gradient identified on post-operative transthoracic echocardiography (TTE). PPM is thought to be associated with adverse clinical outcomes, especially when severe, however data is conflicting. Purpose We sought to determine the impact of patient- and prosthesis-related parameters on post-operative trans-valvular pressure gradient, as a surrogate of PPM, and identify its influence on survival in a large single centre study. Methods This was a retrospective study of patients who underwent isolated sAVR between June 2003 and February 2017 at our tertiary cardiothoracic centre. Patients were excluded if their clinical and surgical records were incomplete, they hadn’t attended post-operative follow up or they had undergone valve replacement with anything other than a conventional stented tissue or mechanical prosthesis. All patients underwent postoperative follow up at eight weeks, six months and annually thereafter in keeping with local guidelines. TTE was performed between six and 12 months after surgery. Peak trans-valvular gradient was calculated using the continuity equation based upon continuous wave doppler assessment through the aortic valve. The highest value obtained from multiple views was recorded. Independent predictors of post-operative gradient were determined using a cox-proportional hazards model. Survival analysis was evaluated by Kaplein-Meier curves and log-rank test. Results One thousand seven hundred and ninety patients underwent isolated SAVR during the study period, of which 604 patients satisfied the inclusion and exclusion criteria. Mean age was 69.5 (±11.4) years and 346 (59%) were male. Mean peak pressure gradient was 29.96 (±12.4) mmHg. Independent predictors of increased post-operative gradients were: smaller valve size, postoperative diuretic use, age, gender and operating surgeon (p<0.001) (Table 1). Seventy-two patients (12%) died during follow-up. Mean survival was 12.1 years. After adjusting for confounders, post-operative pressure gradient was identified as a significant predictor of mortality (HR 1.02, p=0.001), alongside age (HR 1.06, p=0.001) and diabetes mellitus (HR 2.18, p=0.007) (Figure 1). Conclusion In a large cohort of patients undergoing sAVR at a single centre in the UK, valve size was the biggest determinant of postoperative pressure gradient alongside sex, diabetes, diuretic use and operating surgeon. Postoperative pressure gradient was a significant predictor of all-cause mortality. Accordingly, implanting the largest possible valve size should be considered the single most effective way of reducing the post-operative gradient and long-term mortality in patients undergoing sAVR.Table 1:Multivariate linear regressionFigure 1:K-M curve

COMPARISON OF PROPENSITY SCORES FOR SURGICAL TREATMENT OF BIOPROSTHETIC MITRAL VALVE DYSFUNCTION USING TRADITIONAL AND “VALVE-IN-VALVE” METHODS

HighlightsThe article describes the first conducted pseudorandomized comparative study of mitral valve replacement using either traditional or “valve-in-valve” techniques. AbstractAim. To compare short-term (perioperative) and medium-term (6 months) outcomes of surgical treatment of bioprosthetic mitral valve dysfunction using traditional and “valve-in-valve” methods.Methods. The study included 18 patients undergoing “valve-in-valve” replacement and 18 patients undergoing traditional mitral valve replacement (open mitral valve replacement) chosen according to the following criteria: heart disease type, predominant type of defect, age, gender, severity of the disease and the presence of concomitant pathology and using 1:1 matching on the propensity score.Results. No perioperative mortality was noted in both groups. The cardiopulmonary bypass and cross-clamping of the aorta time was significantly lower in the “valve-in-valve” group. Comparison of echocardiographic parameters revealed a decrease in the mean pulmonary arterial pressure gradient, and a decrease in the size of the heart chambers in both groups. The peak and mean transvalvular gradient were lower in the “traditional” group. There were no cases of patient-prosthesis mismatch. In the mid-term period, patients in both groups presented with a lower functional class of heart failure.Conclusion. Bioprosthetic mitral valve replacement using the “valve-in-valve” technique provides comparable clinical and hemodynamic results compared to the “traditional” technique in short-term and mid-term periods, and significantly reduces cardiopulmonary bypass and aortic cross clamping time.

Immediate hemodynamic effects of transcatheter aortic valve replacement on left ventricular stroke volume and carotid artery blood flow

IntroductionTranscatheter aortic valve replacement (TAVR) is performed in selected patients with severe aortic valve stenosis, leading to immediate relief of left ventricular outflow obstruction. The purpose of this study was to evaluate the immediate hemodynamic effects of TAVR on left ventricular stroke volume (SVLVOT) and common carotid artery stroke volume (SVCCA). Material and methodsTwenty-five TAVR patients were included in this prospective observational study. Patients were treated under either local, or general anesthesia. Echocardiographic, and carotid ultrasound measurements were performed in the operating room pre (T1), and post (T2) TAVR. Changes in SVLVOT, SVCCA, carotid peak systolic velocity (PSV), pulsatility index (PI) and other carotid Doppler parameters were evaluated. ResultsFollowing TAVR, the aortic valve area (AVA) increased from 0.8 [0.6–0.9] to 1.9 [1.6–2.3] cm2 (p < 0.001), and the peak transvalvular gradient (PGAV) decreased from 70 [65–81] to 15 [11-18] mm Hg (p < 0.001) from T1 to T2. SVLVOT increased from 58 ± 17 to 69 ± 24 ml, p < 0.01, whereas SVCCA remained unchanged (from 10 [7-11] to 10 [8-11] ml, p = 0.50). Δ SVLVOT was 19 [7–31] % and Δ SVCCA was 1 [-7-20] %, p < 0.05. PSV increased from 68 ± 17 to 81 ± 17 cm/s, p < 0.001, and PI increased from 1.7 [1.5–2.2] to 2.2 [1.7–2.6], p < 0.001. ConclusionSuccessful TAVR resulted in immediate improvement of left ventricular stroke volume, whereas carotid stroke volume remained unchanged.

Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis.

Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis.

Perfil clínico e hemodinâmico de pacientes consecutivos com estenose aórtica valvar estudados na era pré-implante transcateter valvar aórtico em instituição acadêmica. Análise comparativa da avaliação invasiva com a ecocardiográfica

Background: In view of the better understanding of the pathophysiology of aortic valve stenosis, the complexity of assessing its severity has simultaneously grown, with relevant uncertainty persisting as to the applicability of invasive methods by cardiac catheterization and non-invasive methods based on echocardiography. The objective of this study was to analyze the hemodynamic patterns of evaluation with echocardiography compared to the estimation of severity of aortic stenosis with catheterization in consecutive patients referred for diagnostic evaluation by the laboratory of a tertiary academic hospital in the 2016 to 2018 triennium. Methods: An observational, descriptive and retrospective study of clinical characteristics and results of assessments of severity of aortic valve stenosis obtained in 96 consecutive patients, through catheterization and echocardiography. Results: A population sample of 49 men and 47 women, with a median age of 66.5 (56.5 to 72.8) years, degenerative aortic valve stenosis in 49%, and rheumatic aortic stenosis in 40%, in addition to several comorbidities, including coronary disease (37%). Using catheterization, based on the peak gradient of 48 (20 to 68), aortic valve stenosis was assessed as severe in 56%, with ventricular end-diastolic pressure of 20mmHg (16 to 30mmHg). Using echocardiography, the valve area was 0.9cm2 (0.7 to 1.2cm2), indexed valve area was 0.5cm2/m2 (0.43 to 0.5cm2/m2), with peak gradient of 62±26mmHg. Aortic valve stenosis was considered severe in 69.2%. There was disagreement between the methods regarding severity of aortic valve stenosis in 30% of exams, with a Spearman coefficient between the valve area on the echocardiogram and the peak gradient on catheterization of -0.7 (p&lt;0.001). Conclusion: In a representative sample of various hemodynamic patterns, the assessment of severity of aortic valve stenosis, as routinely practiced in an academic laboratory, was limited to measuring the peak transvalvular gradient. The estimation of the valve area using the echocardiographic method was indirect and also subject to criticism, and contributed to the discrepancies found, rendering it justifiable to seek the improvement of both methods, in view of the clinical and hemodynamic complexity detected.

Energy loss index as a predictor of all-cause mortality after transcatheter aortic valve replacement: A long-term follow-up.

As transcatheter aortic valve replacement (TAVR) procedures become more widely available, there is a growing need to monitor and evaluate postoperative outcomes accurately. The energy loss index (ELI) of the ascending aorta has been commonly used to examine the agreement between the echocardiographic and Gorlin measurement of the aortic valve area. This project aims to demonstrate a link between ELI values and mortality following implanted TAVR valves and determine an ELI cutoff value associated with post-TAVR events. We retrospectively reviewed patients undergoing TAVR from 2012 to 2017. We calculated ELI values for patients immediately postoperative after a TAVR procedure. Using Receiver-Operator Characteristic and Cox Regression analyses, we identified a cutoff value to distinguish between "High ELI"(≥1.34) and "Low ELI"(<1.34) patients. This study showed low ELI (hazard ratio, 2.30; 95% confidence interval 1.57-3.36, p<.001) as representative of patients with a high risk of mortality post-TAVR. Additionally, post-TAVR, ejection fraction increased by 3.6% (p<.001), and the aortic valve effective orifice area increased by 1.41cm squared (p<.001) while the mean transvalvular gradient decreased by 32.8mmHg (p<.001) and the peak transvalvular gradient decreased by 49.0mmHg (p<.001). ELI is an additional prognostic factor that should be considered during risk assessment before TAVR. This study shows that patients with Low ELI had decreased cumulative survival post-TAVR. These patients almost had a fivefold increased risk of death following TAVR.

Abstract 10206: Misleading Transvalvular Hemodynamics for Patients With Moderate Aortic Stenosis

Introduction: Aortic stenosis (AS) is a progressive disease that leads to cardiac remodeling. Appropriate management depends on accurate assessment of AS severity. Transvalvular gradients are central to echocardiographic assessment of AS though can be impacted by any conditions that decrease transvalvular flow. Hypothesis: 1) Decline in peak transvalvular gradient over time is associated with more significant cardiac remodeling and 2) Cardiac damage is associated with lower transvalvular flow and masks progression of AS. Methods: Retrospective single center study of patients with moderate AS (defined as peak gradient 25-40mmHg) from 2013-2020 with &gt; 1 transthoracic echocardiogram (TTE). Each TTE was classified into established stages of cardiac damage: no damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage or subclinical heart failure (Stage 4). Results: Sixty patients with at least 1 follow-up TTE were included. The mean age was 73.5 +/- 11 years with 47% women (28/60) and median time of 381 days (IQR 12.7 months) between echocardiograms. On initial assessment, mean AVA and peak AV gradient were 1.2cm 2 +/- 0.33 and 37mmHg +/- 11.3 respectively. At follow-up, the mean AVA and peak AV gradient were 1.1cm 2 +/- 0.20 and 38mmHg +/- 12.6. Forty-three of 60 patients (72%) had evidence of cardiac damage on initial assessment compared to 55 of 60 patients (92%) on follow-up. Thirty-five (58%) patients displayed a decrease in peak AV gradient over time (average decrease -16% +/- 0.12). Twenty-one of the patients with declining peak gradients (60%) demonstrated progressive cardiac damage compared to 9 of 25 patients (36%) with increasing peak gradients (p= 0.06). Conclusions: Over half of patients with moderate AS demonstrated a decrease in peak AV gradient over time. Reliance on transvalvular gradients as a reflector of AS severity can be misleading as there was a trend toward more significant cardiac damage in this subset of patients. The presence of underlying cardiac damage can obscure traditional echocardiographic assessment and progression of AS and should be incorporated into assessments of disease severity and progression.

Abstract 12668: Coronary CTA Finding of Libman Sacks Endocarditis Presenting as Chest Pain

Case Presentation: A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren's contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months. Discussion: Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.

Transcatheter Mitral Valve-in-Valve Implantation with the Balloon-Expandable Myval Device.

Background: The vast majority of transcatheter valve-in-valve (ViV) mitral procedures have been reported with the SAPIEN family. We aimed to report the preliminary experience with the Myval balloon-expandable device in this setting. Methods: Multicenter retrospective study of high-risk surgical patients with mitral bioprosthesis degeneration undergoing transcatheter ViV implantation with Myval device. Results: A total of 11 patients from five institutions were gathered between 2019 and 2022 (age 68 ± 7.8, 63% women). The peak and mean transvalvular gradients were 27 ± 5 mmHg and 14.7 ± 2.3 mmHg, respectively, and the predicted neo-left ventricular outflow tract (neo-LVOT) area was 183.4 ± 56 mm2 (range: 171 to 221 mm2). The procedures were performed via transfemoral access in all cases (through echocardiography-guided transeptal puncture (81.8% transesophageal, 11.2% intracardiac)). Technical success was achieved in all cases, with no significant residual mitral stenosis in any of them (peak 7.2 ± 2.7 and mean gradient 3.4 ± 1.7 mmHg) and no complications during the procedure. There were no data of LVOT obstruction, migration, or paravalvular leak in any case. Mean hospital stay was 3 days, with one major vascular complication and no stroke. At 6-month follow-up, there was one case with suboptimal anticoagulation presenting an increase in the transmitral gradients (mean 15 mmHg) that normalized after optimization of the anticoagulation, but no other relevant events. Conclusions: Transseptal ViV mitral implantation with the balloon-expandable Myval device was feasible and safe avoiding redo surgery in high-risk patients with bioprosthesis degeneration.

Avoiding oversizing in sutureless valves leads to lower transvalvular gradients and less permanent pacemaker implants postoperatively.

OBJECTIVESThe aim of this study was to evaluate the impact of changing the sizing strategy in aortic valve replacement using the Perceval sutureless prosthesis on haemodynamic outcomes and postoperative pacemaker implantation.METHODSRetrospective analysis of patients implanted with the Perceval valve between 2007 and 2019 was performed by comparing patients implanted before the modification of sizing strategy (OLD group) and after (NEW group). The outcome parameters evaluated were the implanted prosthesis size, haemodynamical profile and postoperative pacemaker implantation.RESULTSThe entire patient cohort (784 patients) consisted of 52% female patients, with a mean age of 78.53 [standard deviation (SD): 5.8] years and a mean EuroSCORE II of 6.3 (range 0.7–76). In 55.5% of cases, surgery was combined. The NEW cohort had more male patients (54.6% vs 43.4%) (P = 0.002). Mean implanted valve size, corrected for body surface area, was significantly lower in the NEW cohort (13.1, SD: 1.4 vs 13.5, SD: 1.4 mm/m2, P < 0.001). The 30-day mortality was 3.4%. Peak and mean transvalvular gradients at discharge were significantly lower in the NEW versus OLD groups: 24.4 mmHg (SD: 9.2) versus 28.4 mmHg (SD: 10.3) (P < 0.001) and 13.6 mmHg (SD: 5.3) versus 15.5 mmHg (SD: 6.0) (P < 0.001). The mean effective opening area and the indexed effective opening area, respectively, increased from 1.5 cm2 (SD: 0.5) and 0.85 cm2/m2 (SD: 0.27) in the OLD group to 1.7 cm2 (SD: 0.5) and 0.93 cm2/m2 (SD: 0.30) in the NEW group (P < 0.001). No difference was found in paravalvular leakage ≥1/4. Centrovalvular leakage ≥1/4 significantly decreased from 18% to 7.9% (P < 0.001). With the new sizing, the new postoperative pacemaker implantation rate decreased significantly from 11% to 6.1% (P = 0.016).CONCLUSIONSCorrect sizing of sutureless aortic valves is crucial to obtain the best possible haemodynamics and avoid complications.

Revisiting the Aortic Valve Calcium Score in Evaluating the Severity of Aortic Stenosis in Japanese Patients - A Single-Center Study.

Background: In patients with aortic stenosis (AS), measurement of aortic valve calcification (AVC) using computed tomography (CT) is recommended in cases where echocardiographic measurements are inconclusive. However, sex-specific AVC thresholds proposed in the guidelines for predicting severe AS (women: 1,200 arbitrary units [AU]; men: 2,000 AU) are based on studies from Western countries.Methods and Results: We retrospectively included 512 Japanese patients with at least moderate AS who underwent transthoracic echocardiography and CT. AVC was quantified using the Agatston method. AVC was positively correlated with peak aortic jet velocity and mean transvalvular gradient (mPG), and negatively correlated with aortic valve area (AVA) and the AVA index (AVAi). In 257 patients with concordant AS grading (152 severe AS [AVAi ≤0.6 cm2/m2, mPG ≥40 mmHg], 105 moderate AS [AVAi >0.6 cm2/m2, mPG <40 mmHg]), receiver operating characteristic curve analysis of AVC predicting severe AS yielded an area under the curve of 0.91 (95% confidence interval [CI] 0.87–0.95; P<0.001) in women and 0.86 (95% CI 0.75–0.98; P<0.001) in men. The optimal thresholds (women: 1,379 AU; men: 1,802 AU) were close to those proposed in the guidelines. The diagnostic accuracy of the thresholds in the guidelines was similar to that of the optimal thresholds.Conclusions: The sex-specific AVC thresholds proposed in international guidelines can be applied to Japanese AS patients, yielding similar diagnostic accuracy as the optimal cut-off derived from the study patients.

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)

Prosthesis-patient mismatch as a predictor of accelerated structural dysfunction of biological aortic valve prostheses

OBJECTIVE. Identification of predictors of dysfunction of biological aortic valve prostheses in the long-term period after surgical treatment.METHODS AND MATERIALS. We analyzed the completed treatment cases for the period from 2015 to 2020 and echocardiography data of 74 patients (42 men and 32 women) with an average age of 67.0±4.2 years with bioprostheses implanted in the aortic position. The average follow-up period was 4 years. The transaortic flow velocity, the average and peak transvalvular gradients, the area of the effective opening of the prosthesis, the myocardium mass index, the thickness and mobility of the cusp of the biovalve were evaluated. The presence of the pronounced PPM in a patient was determined at iEOA values less than 0.65 cm2/m2, moderate - at values from 0.65 to 0.85 cm2/m2, mild - up to 0.85 cm2/m2.RESULTS. PPM was recorded in 27% of cases. Structural dysfunction was observed in 12.5% of cases, it mainly included stenosis of the bioprosthesis (10%). In 2.5% of cases, reintervention was performed for severe stenosis of the AV bioprosthesis. During the multifactorial analysis, we revealed that PPM was a predictor of the development of structural dysfunction of aortic valve bioprostheses in the long-term period after surgery (p&lt;0.005).

СРАВНЕНИЕ ГЕМОДИНАМИЧЕСКИХ ПАРАМЕТРОВ И ОТДАЛЕННОГО ПРОГНОЗА У ПАЦИЕНТОВ ПОСЛЕ АОРТАЛЬНОГО ПРОТЕЗИРОВАНИЯ ИСКУССТВЕННЫМИ КЛАПАНАМИ СЕРДЦА «ПЛАНИКС-Э» И ЗАРУБЕЖНЫМИ АНАЛОГАМИ

The article presents the results of aortic valve replacement with artificial prosthetic heart valves. The study comprised 422 patients after aortic valve replacement with mechanical bicuspid valve prostheses of 19, 21, and 23 mm. The valves used were «Planiks-E», MedIng-2, Carbomedics, ATS Medtronic, St. Jude Medical. Hospital and long-term results are analyzed directly depending on the type-size of the AMHV used. There was a significant decrease in the peak and average transvalvular gradient on the all aortic valves (p &lt; 0.0015), as well as an increase in the effective orifice area (EOA) of the aortic valve. EOA of the prosthesis “Planiks E” was not significantly different from that of its foreign equivalents. The EOA of St.Jude Medical prostheses was significantly larger compared to the Sorin Carbomedics prostheses (p &gt; 0.005). The peak and mean gradients were different significantly (p = 0.007 and p &lt; 0.05). The highest maximum systolic gradient was observed with Sorin Carbomedics prostheses. The phenomenon of prosthesis-patient mismatch of moderate degree in the early postoperative period was observed in 30.3% of patients, and in 4.1% it was severe. For “Planiks-E” prostheses, severe PPM was observed in 3.2% of patients. “Planiks-E” and ATS Medtronic prostheses were less common related to moderate PPM, in 27.80% and 28.60% correspondently. Overall hospital mortality was 3.4%. The risk of developing moderate PPN was 1.66 (95% CI 1.087 – 2.539, p = 0.19). The follow-up period mediana was 3.4 (2.12÷5.93) years. There were no significant differences in survival between patients without or with different PPM degrees (log-rank test, p = 0.539). Among “Planiks-E” the five-year survival rate was 87%.The PPN phenomenon did not significantly affect long-term survival. The heart valve prosthesis “Planiks-E” is comparable in its hemodynamic parameters to similar imported prostheses, the risk of moderate PPN being significantly lower.

143 Incidence, predictors, and clinical impact of transient left bundle branch block in patients undergoing transcatheter aortic valve implantation

Abstract Aims This study aims to evaluate the incidence and prognostic impact of transient left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve implantation (TAVI) with balloon-expandable or self-expanding valves. Clinical, echocardiographic and electrocardiographic predictors of transient LBBB were also investigated. Methods and results 197 patients treated with TAVI at Federico II University hospital, Naples, Italy were enrolled. Electrocardiograms (ECGs) were obtained before and after TAVI procedure, at discharge and at 30-day follow-up. ECGs were anonymously digitalized and analysed by five cardiologists. Transient LBBB was defined as LBBB regressed within 30 days after procedure. All ECGs for each patient were analysed by the same cardiologist. The primary endpoint of the study was all-cause mortality and permanent pacemaker implantation (PPI) at 1-month after TAVI. Secondary endpoints included cerebrovascular accidents, acute myocardial infarction, vascular complications, acute kidney injury, endocarditis, and re-hospitalization for all causes. Out of 197 patients enrolled, 54 (27.4%) developed transient LBBB. Among patients with transient LBBB, 70.4% were female. Mean age was higher in transient LBBB group compared with control group (81.0 ± 6.4 years, vs. 78. 6 ± 6.5 years; P = 0.022). From logistic analysis, peak transvalvular gradient (OR: 1.01, 95% CI: 0.93–1.00; P &amp;lt; 0.034) and left ventricular ejection fraction (LVEF) (OR: 0.96, 95% CI: 0.93–0.99, P &amp;lt; 0.012) were identified as predictive factors of transient LBBB. No differences between the two studied groups were observed in primary and secondary endpoints (all-cause mortality: 1.9% vs. 0.7%; P = 0.46; PPI: 9.6% vs. 12%; P = 0.80). Conclusions Peak transvalvular gradient and LVEF predict onset of transient LBBB, a common conduction disturbance after TAVI. Onset of transient LBBB does not correlate with worse clinical outcomes at 30 days.

Bicuspid aortic valve repair with external or subcommissural annuloplasty-echocardiographic prospective trial.

The incompetent bicuspid aortic valve (BAV) can be repaired using various techniques. This study presents a prospective comparison of external and subcommissural aortic annuloplasty. Fifty consecutive patients (38 males, age: 43.9 ± 15.8 years) with BAV insufficiency with or without aortic dilatation underwent valve repair in a single institution. They were prospectively allocated to one of two groups based on the aortic annulus stabilization technique: 25 patients were operated on using the subcommissural annuloplasty (SCA) and 25 using the external complete annuloplasty (EA). Transthoracic echocardiography was performed in all patients before the operation and 1 and 3 years after the operation. Moreover, mortality and morbidity at 7 years were evaluated. In prospective echocardiographic comparison, EA was associated with smaller diameter of the aortic annulus (24.1 ± 2.6 mm vs. 25.8±2.1 mm, p < .05) and lower mean and peak transvalvular gradients (7 ± 4 mmHg vs. 13 ± 4 mmHg, p = .02 and 15.3 ± 9.7 mmHg vs. 20.7 ± 5.6 mmHg, p = .03, respectively). No patients died or required reoperation due to recurrent insufficiency at 6,81 (interquartile range-0,17) years after the operation. The Kaplan-Meier actuarial freedom from aortic regurgitation(AR) grade =2 or gradient > 20 mmHg at 35.1 ± 3.6 months years was 96% (24 out of 25) for patients who had external annuloplasty and amounted to 76% (19 out of 25) for those who had SCA, p = .05). External annuloplasty performed during repair of the BAV is associated with better hemodynamics at medium-term follow-up compared to SCA.

Late Clinical and Hemodynamic Outcomes in patients with degenerated bioprosthetic aortic valves undergoing transcatheter valve-in-valve implantation

Abstract Background Clinical studies have shown promising early outcomes for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI); however, the late outcomes of this procedure remain under-investigated. Purpose We performed the present analysis to assess the late clinical and hemodynamic outcomes of ViV-TAVI in patients with degenerated bioprosthetic aortic valves. Methods A comprehensive chart review was performed for eligible patients to retrieve data on procedural characteristics, admission details following the procedure, and echocardiographic parameters. Clinical outcomes included all-cause mortality, heart failure hospitalization and structural valve deterioration (SVD), as defined by VARC-II criteria, up to 5 years of follow-up. To assess the trends in mean and peak transvalvular gradients, data from the follow-up echocardiographic reports were analyzed using Syngo Dynamics imaging software. Results A total of 188 patients were included with a mean age of 75.8±10.4 years. Balloon- and self-expandable valves were used in 155 (82.4%) and 33 (17.6%) patients, respectively. At 30 days, 3 (1.6%) patients died and 8 (4.2%) required hospitalization for heart failure, while at 5 years, both events were recorded in 29 (15.4%) and 37 (19.7) patients, respectively. Kaplan-Meier survival analysis showed that patients with smaller surgical valves (internal diameter ≤21 mm) had a significantly higher mortality rate (log-rank p=0.021) than those with larger valves; however, no significant difference (log-rank p=0.59) was detected between different transcatheter valves (self vs. balloon-expandable). Three patients underwent re-intervention, performed via a transcatheter approach. Further, assessment of follow-up echocardiographic reports revealed 9 (4.8%) cases of SVD, as well as stable mean (16.3±6.9 at discharge and 16.9±11.3) and peak (30.3±12.1 at discharge and 30.7±18.4 at 5 years) transvalvular gradients. No difference (p&amp;gt;0.05) was observed based on transcatheter valve type or surgical valve internal diameter in terms of mean and peak transvalvular gradients throughout the follow-up period. Conclusion The present study showed good clinical outcomes among patients undergoing VIV-TAVI, with stable VIV performance over a five-year period. Future long-term studies are warranted to analyze the predictors of outcomes following ViV-TAVI and explore the role of this treatment option in the life-long management of aortic stenosis. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jennifer and Robert McNeil Donation to the Heart, Thoracic, and Vascular Institute at Cleveland Clinic. Figure 1