Prior Aortic Valve Replacement Research Articles

RATE OF ASCENDING AORTIC ENLARGEMENT IN A LARGE ECHOCARDIOGRAPHIC COHORT: ASSOCIATED RISK FACTORS AND ADVERSE AORTIC EVENTS

BackgroundUnderstanding ascending aortic aneurysm growth and associated risk factors is critical to advising appropriate echocardiographic follow-up intervals for patients. This study aimed to identify aortic aneurysm growth rate on serial echocardiograms as well as the clinical and demographic variables that contribute to baseline aortic size and subsequent aortic growth. MethodsPatients identified with ascending aortic aneurysm and undergoing serial echocardiograms within five years were evaluated. Ascending aortic size was measured as part of routine echocardiogram exams. Clinical and demographic variables including aortic valve type (trileaflet, bicuspid or prosthetic) were evaluated for association with baseline aortic size as well as with aortic progression rate. Clinical events including aortic dissection, elective or emergent surgical repair were recorded. Results3639 patients were identified, (78% males, median age of 69 years, 175 (4.8%) with bicuspid valve, and 206 (5.6%) with prior aortic valve replacement (AVR). Patients with larger aorta at baseline were older with higher tobacco use and prior prosthetic valves. Over a mean of 2.4 years, aortic growth was observed and differed by valve type (trileaflet valve: 0.08 mm/year , bicuspid valve: 0.4 mm/year , p<0.001). In six patients who developed aortic dissection the estimated average annual growth rate was 0.98 mm/year. ConclusionsIn a large echo cohort, aortic aneurysm growth rate was 0.08 mm/year though higher in those with bicuspid valves ( 0.4 mm/ year), but initial aortic size did not correlate with change in the aortic progression rate. This data may help inform recommended echocardiographic surveillance intervals.

TCT-834 Percutaneous Coronary Interventions in Patients With Prior Transcatheter Aortic Valve Replacement

TCT-834 Percutaneous Coronary Interventions in Patients With Prior Transcatheter Aortic Valve Replacement

Prognostic value of the electrocardiogram in patients with bicuspid aortic valve disease

BackgroundIdentifying bicuspid aortic valve (BAV) patients at risk for cardiac events remains challenging and the role of the electrocardiogram (ECG) has not yet been described. Therefore, this study aims to describe ECG parameters in BAV patients, and investigate their prognostic value. MethodsIn this single-center prospective study patients with BAV without a prior aortic valve replacement (AVR) were included. Transthoracic echocardiogram and 12‑lead resting-ECG were obtained. Associations between ECG parameters and the composite endpoint of all-cause mortality and AVR were assessed using Cox-proportional hazard analysis. Results120 patients with BAV were included (median age 30 years, 61% male). Median aortic jet velocity was 2.4 m/s [IQR: 1.7–3.4] and 5 patients (4%) had severe aortic regurgitation. All patients were in sinus rhythm. Any ECG abnormality was present in 57 patients (48%). Median PR-interval was 156 [IQR: 138–170] msec. A deviating QRS axis was found in 17 patients (14%) and Cornell criteria for LVH were fulfilled in 20 patients (17%). Repolarization abnormalities were present in 12 patients (10%). Median follow-up duration was 7.0 [6.3–9.8] years, during which 23 patients underwent AVR and 2 patients died. After adjusting for age, a longer PR-interval was associated with worse intervention-free survival (HR 1.02, 95% CI: 1.01–1.04). ConclusionAlmost half of the patients with BAV had abnormalities on their ECG. Moreover, the PR-interval may be an interesting prognostic marker for intervention-free survival in BAV patients.

Incidence, risk factors, and long-term outcomes associated with permanent pacemaker implantation after aortic root replacement

ObjectivePermanent pacemaker implantation (PPI) after aortic valve replacement is associated with long-term mortality. However, data regarding PPI after aortic root replacement (ARR) is lacking. Herein we describe the incidence, risk factors, and long-term outcomes of PPI after ARR. MethodsConsecutive patients undergoing ARR from 2005 to 2020 were selected after excluding those with endocarditis, type A dissection, or preoperative PPI. Patients requiring PPI after ARR were identified, along with the indication and timing. Independent factors associated with PPI after ARR were identified and long-term survival was assessed. ResultsThe incidence of PPI was 3.8% (n = 85) among 2240 patients undergoing ARR. PPI was performed a median of 7 days (interquartile range, 5-12 days) after ARR most commonly for complete heart block (73%). Bicuspid aortic valve (odds ratio [OR], 1.89; P = .02), female sex (OR, 1.74; P = .04), preoperative heart block (OR, 2.70; P = .02), and prior aortic valve replacement (OR, 2.18; P = .01) were independently associated with PPI while preoperative aortic insufficiency (OR, 0.52; P = .01) and valve-sparing root replacement procedure compared with bio-Bentall (OR, 0.40; P = .01) were protective. Patients requiring PPI after ARR were not at increased risk of operative or long-term mortality compared with patients not requiring PPI (P = .26); however, those undergoing PPI experienced significantly longer hospital length of stay (13 vs 7 days; P < .001). ConclusionsThe incidence of PPI after ARR remains low, particularly after VSRR. Preoperative conduction disturbance, prior AVR, and bicuspid aortic valve are all associated with increased risk of PPI. Although PPI is associated with longer length of stay, it is not associated with early or late mortality.

Age-Based Outcomes After Surgical Aortic Valve Replacement With Bioprosthetic Versus Mechanical Valves

Recommendations for prosthesis type in older patients who underwent surgical aortic valve replacement (SAVR) are established, albeit undervalidated. The purpose of this study is to compare outcomes after bioprosthetic versus mechanical SAVR across various age groups. This was a retrospective study using an institutional SAVR database. All patients who underwent isolated SAVR were compared across valve types and age strata (<65 years, 65 to 75 years, >75 years). Patients who underwent concomitant operations, aortic root interventions, or previous aortic valve replacement were excluded. Objective survival and aortic valve reinterventions were compared. Kaplan-Meier survival estimation and multivariate regression were performed. A total of 1,847 patients underwent SAVR from 2010 to 2023. A total of 1,452 patients (78.6%) received bioprosthetic valves, whereas 395 (21.4%) received mechanical valves. Of those who received bioprosthetic valves, 349 (24.0%) were aged <65 years, 627 (43.2%) were 65 to 75 years, and 476 (32.8%%) were older than 75 years. For patients who received mechanical valves, 308 (78.0%) were aged <65 years, 84 (21.3%) were between 65 and 75 years, and 3 (0.7%) were >75 years. The median follow-up in the total cohort was 6.2 (2.6 to 8.9) years. No statistically significant differences were observed in early-term Kaplan-Meier survival estimates between SAVR valve types in all age groups. However, the cumulative incidence estimates of aortic valve reintervention were significantly higher in patients aged under 65 years who received bioprosthetic than those who received mechanical valves, with 5-year reintervention rates of 5.8% and 3.1%, respectively (p = 0.002). On competing risk analysis for valve reintervention, bioprosthetic valves were significantly associated with an increased hazard of aortic valve reintervention (hazard ratio 3.35, 95% confidence interval 1.73 to 6.49, p <0.001). In conclusion, SAVR with bioprosthetic valves (particularly, in patients aged <65 years) was comparable in survival to mechanical valve SAVR but significantly associated with increased valve reintervention rates.

Usability and accuracy of two different aortic annulus sizing software programs in patients undergoing transcatheter aortic valve replacement

BackgroundSemi-automated software is essential for planning and prosthesis selection prior transcatheter aortic valve replacement (TAVR). Reliable data on the usability of software programs for planning a TAVR is missing. The aim of this study was to compare software programs ‘Valve Assist 2’ (GE Healthcare) and 3mensio ‘Structural Heart’ (Pie Medical Imaging) regarding usability and accuracy of prosthesis size selection in program-inexperienced users.MethodsThirty-one participants (n = 31) were recruited and divided into program-inexperienced users (beginners) (n = 22) and experts (n = 9). After software training, beginners evaluated 3 patient cases in 129 measurements (n = 129) using either Valve Assist 2 (n = 11) or Structural Heart (n = 11) on 2 test days (T1, T2). System Usability Scale (SUS) and ISONORM 9241/110-S (ISONORM) questionnaire were used after the test. The valve size selected by each beginner was compared with the valve size selected from expert group.ResultsValve Assist 2 had higher SUS Score: median 78.75 (25th, 75th percentile: 67.50, 85.00) compared to Structural Heart: median 65.00 (25th, 75th percentile: 47.50, 73.75), (p < 0,001, r = 0.557). Also, Valve Assist 2 showed a higher ISONORM score: median 1.05 (25th, 75th percentile: − 0.19, 1.71) compared to Structural Heart with a median 0.05 (25th, 75th percentile: − 0.49, 0.13), (p = 0.036, r = 0.454). Correctly selected valve sizes were stable over time using Valve Assist 2: 72.73% to 69.70% compared to Structural Heart program: 93.94% to 40% (χ2 (1) = 21.10, p < 0.001, φ = 0.579).ConclusionThe study shows significant better usability scores for Valve Assist 2 compared to 3mensio Structural Heart in program-inexperienced users.

Changes in aortic root dimensions post aortic root enlargement with Y-incision and modified aortotomy.

Lifetime management in aortic stenosis (AS) can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve (ViV) procedures. A mitral valve-sparing ARE technique ("Y-incision") and sinotubular junction (STJ) enlargement ("roof" patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking. Among 78 patients who underwent ARE by Y-incision technique (± roof aortotomy closure) we identified 45 patients with high-quality pre- and post-operative computed tomography angiography (CTA) scans to allow analysis of change in aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses were performed by an expert imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annulus when a bioprosthetic valve was present. Average age was 65±11 years, the majority were female (29, 64%), and 9 (20%) had undergone prior aortic valve replacement (AVR). Valve upsizing was ≥3 sizes in 41 (91%). Post-operative mean basal ring diameter was larger compared to the native annular diameter (26.3 vs. 25.3 mm, P<0.01) and substantially larger than prior prosthetic valve in redo AVR (25.6 vs. 19.3 mm, P<0.001). Diameters of the sinuses at pre-operative computed tomography (CT) increased by +7.7±2.8 [right sinuses of Valsalva (R SVS)], +6.7±3.0 [left sinuses of Valsalva (L SVS)], and +6.6±2.9 mm [non-coronary sinuses of Valsalva (N SVS)]. Mean diameter of the STJ increased to 38.3±3.7 post-operative (+8.1±3.2 mm). Left main (LM) and right coronary artery (RCA) heights decreased by -6.3±3.3 and -3.7±3.4 mm respectively due to the supra-annular position of the valve, however, the post-operative valve-to-coronary (VTC) artery distances were 6.6±2.3 and 4.9±2.0 mm, respectively. The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 6-7 mm while preserving VTC distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV).

Ventricular arrhythmias in patients with bicuspid aortic valves.

Bicuspid aortic valves (BAV) are the most common congenital heart defects and the extent of ventricular arrhythmias (VA) in patients with BAV is unclear. The objective of this study is to describe VAs and late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) in patients with BAV. A total of 19 patients with BAV (18 males, age: 58 ± 13 years) were referred for VA ablation procedures. Ten patients had BAVs at the time of ablation, nine patients had prior aortic valve replacement for a BAV. All but one patient had LGE-CMR and all patients underwent programmed ventricular stimulation at the time of the ablation. Frequent PVCs were the targeted VAs in 17/19 patients and VT in 2/19 patients. Monomorphic ventricular tachycardia (VT) was inducible in 6 patients. A total of 15 VTs were inducible (2.5 ± 1.0 VTs per patient with a mean cycle length of 322 ± 83 msec). LGE was present in 13 patients. Patients with inducible VT had larger borderzone and core scar compared to non-inducible patients (7.8 ± 2.1 cm3 vs. 2.5 ± 3.1 cm3 and 5.1 ± 2.6 cm3 vs. 1.9 ± 3.0 cm3, p-value < .05 for both). PVCs and VTs were mapped to the periaortic valve area in 12 patients and 4 patients, respectively. The PVC burden was reduced from 27 ± 13 to 3 ± 6 (p < .001) and the ejection fraction improved from 49 ± 13% to 55 ± 9% (p = .005). VAs in patients with BAV often originate from the perivalvular area and patients often have LGE and inducible VT. LGE may be due to ventricular remodeling secondary to the presence of BAV and harbors the arrhythmogenic substrate for VT.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review.

Transcatheter aortic valve replacement (TAVR) has proven to be a safe, effective, and less invasive approach to aortic valve replacement in patients with aortic stenosis. In patients who underwent prior aortic valve replacement, transcatheter and surgical bioprosthetic valve dysfunction may occur as a result of structural deterioration or nonstructural causes such as prosthesis-patient mismatch (PPM) and paravalvular regurgitation. Valve-in-Valve (ViV) TAVR is a procedure that is being increasingly utilized for the replacement of failed transcatheter or surgical bioprosthetic aortic valves. Data regarding long-term outcomes are limited due to the recency of the procedure's approval, but available data regarding the short- and long-term outcomes of ViV TAVR are promising. Studies have shown a reduction in perioperative and 30-day mortality with ViV TAVR procedures compared to redo surgical repair of failed bioprosthetic aortic valves, but 1-year and 5-year mortality rates are more controversial and lack sufficient data. Despite the reduction in 30-day mortality, PPM and rates of coronary obstruction are higher in ViV TAVR as compared to both redo surgical valve repair and native TAVR procedures. New transcatheter heart valve designs and new procedural techniques have been developed to reduce the risk of PPM and coronary obstruction. Newer generation valves, new procedural techniques, and increased operator experience with ViV TAVR may improve patient outcomes; however, further studies are needed to better understand the safety, efficacy, and durability of ViV TAVR.

Prevalence of pulmonary hypertension in aortic regurgitation and its influence on outcomes

Abstract Background Pulmonary hypertension (PHT) is known to complicate left heart diseases (LHD) including left sided valvular pathologies such as aortic regurgitation (AR). However, there is a paucity of data on the prognostic importance of PHT in AR patients. Purpose We aimed to describe the prevalence and prognostic importance of PHT in adults with "isolated" ≥ moderate AR. Methods In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000-2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) &amp;gt;50%, with moderate or greater AR and without severe aortic stenosis or prior aortic valve replacement, were included (n= 8392). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 3.1 years, interquartile range 1.5-5.7 years). Results Subjects were aged 74±14 years and 58.4% (4901) were female. Overall, 1417 (16.9%) had no PHT (eRVSP&amp;lt;30.00mmHg); and 3253 (38.8%), 2249 (26.9%), 893 (10.6%) and 580 (6.9%) had borderline (30.00-39.99mmHg), mild (40.00-49.99mmHg), moderate (50.00-59.99mmHg) or severe PHT (&amp;gt;60.00mmHg), respectively. Mean eRVSP was slightly higher in females than males (41±13 vs 39±12mmHg, p&amp;lt;0.0001) and increased with age in both sexes. A typical phenotype of "left heart disease" was evident with E:e’ and the proportion of patients with RV functional impairments increasing progressively, from no PHT to severe PHT (p&amp;lt;0.0001, for all). After adjustment for age and sex, the risk of long-term mortality increased as eRVSP increased (adjusted hazard ratio (aHR) 1.20, 95% confidence interval 1.06-1.36 in borderline PHT, to aHR3.32, 95%CI 2.85-3.86 in severe PHT) (Figure 1). These trends were maintained on a sensitivity analysis excluding patients with ≥moderate mitral regurgitation (n=6753), though only became significant from mild PHT onwards (aHR 1.13, 95% CI 0.98-1.30 in borderline PHT, to aHR3.51, 95%CI 2.94-4.18 in severe PHT). Using decile distribution of eRVSP a mortality threshold seen from mild PHT onwards (eRVSP 41.36-44.15mmHg; aHR1.41, 95%CI1.17-1.68) (Figure 2). Conclusions In patients with ≥moderate AR, PHT is associated with a progressive risk of mortality, even in those with mild PHT.Adjusted Risk for All-Cause MortalityThreshold for Mortality

The impact of resting heart rate on adverse outcomes and haemodynamic progression of aortic stenosis

Abstract Introduction A high resting heart rate (RHR) is an established risk factor for cardiovascular disease, adverse cardiac events, accelerated calcification in coronary artery disease and carotid stenosis, and increased aortic valve calcification in patients with and without a confirmed diagnosis of aortic stenosis (AS). Aortic valve calcification is the most common precursor to AS and is associated with significantly faster disease progression. There are few studies exploring the effects of RHR on the progression of AS, the development of severe stenosis, and the risk of complications and death. Purpose We hypothesised that an elevated RHR would be associated with poorer outcomes and more rapid haemodynamic disease progression in patients with AS and tested this in a large cohort of patients without severe disease. Methods Using the National Echocardiography Database of Australia (NEDA) we undertook a retrospective observational study on patients without severe AS, a bicuspid aortic valve or prior aortic valve replacement. The association between baseline RHR and time to the composite primary endpoint of severe AS, aortic valve replacement or cardiovascular death was tested using Cox proportional hazards regression. In addition, the relationship between baseline RHR and the components of this composite was investigated. Subsequently, the relationship between annualised AS progression rate, defined as change in standard indices of AS severity (maximal jet velocity [Vmax], mean pressure gradient [MPG], and aortic valve area [AVA]), and RHR were analysed using general linear models. Results The initial study cohort comprised 55 585 individuals: 54% male, mean age 63 years and median baseline RHR 70 bpm. The composite primary endpoint, reached by 7 434 patients, was independently associated with RHR (hazard ratio [per 10bpm increase], 1.04; 95% CI, 1.02-1.05; p &amp;lt; 0.001). RHR was also independently associated with time to developing severe AS (hazard ratio [per 10bpm increase], 1.06; 95% CI, 1.01-1.12; p = 0.017) and cardiovascular death (hazard ratio [per 10bpm increase], 1.04; 95% CI, 1.02-1.06; p &amp;lt; 0.001). The event rate was significantly higher in patients with a RHR of at least 70 bpm (the median RHR) compared to those with an RHR less than 70 bpm. In addition, RHR was independently associated with rate of change of each individual measurement index of AS severity including Vmax (β = 0.65 cm/s/year [per 10 bpm increase]; p &amp;lt; 0.001), MPG (β = 0.05 mmHg/ year [per 10 bpm increase]; p&amp;lt;0.001), and AVA (β = -0.01 cm2/year [per 10 bpm increase]; p &amp;lt; 0.001). Conclusions RHR is independently associated with adverse clinical outcomes and haemodynamic progression of AS in patients without severe disease. Future randomised controlled trials should investigate the effect of lowering RHR on clinical endpoints and progression of AS.

Abstract 13731: Right-Sided Precordial U Waves as a Screening Tool for Aortic Stenosis

Introduction: AS affects 3% of individuals ≥ age 65 and portends an increased risk of morbidity and mortality. Cardiac auscultation to categorize AS severity depends on provider skill. Recent studies have identified an association between AS and right precordial U waves (RPUW) using machine learning. Therefore, the ECG may serve as an adjunctive screening tool for AS. Hypothesis: Are RPUW correlated with AS severity? Methods: A retrospective cohort analysis was performed of 50 patients ages 65-89 with a diagnosis of HTN, echocardiogram on file, and RPUW (V1-V3) in consecutive leads with U wave amplitude ≥ 0.5 mm in at least one lead. Patients with prior aortic valve replacement, ventricularly paced rhythms, AF or AFL, LBBB, potassium (K) &lt; 3, and HR &lt; 50 were excluded. A control cohort of 50 age- and gender- matched patients with RPUW &lt; 0.5 mm was included. Echocardiograms were unblinded only once patients were selected by ECG criteria. Results: In total, 976 charts and 294 charts were reviewed to identify 50 eligible patients for the experimental and control arms respectively. Median time between ECG and lab collection (to ensure a K ≥ 3) was 0 days for both arms. Median time between ECG and echocardiogram was 1 day and 1.5 days respectively for experimental and control arms. U waves were significantly correlated with AS severity using a chi-square test (X2 = 16.77, df = 3, p &lt; .001). A multinomial logistic regression analysis showed no significant association between gender (p = .69) or systolic blood pressure (SBP) as a categorical variable (SBP &lt; 125, 126-145, &gt; 145) (p = .35) and AS severity, but increasing age group (ages 65-73, 74-81, or 82-89) was associated with greater odds of moderate or severe AS (p = .002), OR 3.43 (95% CI: 1.59, 7.40). Conclusions: RPUW ≥ 0.5 mm demonstrate a significant correlation with AS severity. A prospective study which collects first-time echocardiograms for patients with RPUW serves as a next step in determining the utility of ECGs for screening of AS.

Reoperative aortic root replacement for prosthetic aortic valve endocarditis: impact of aortic graft.

Existing aortic graft complicates the surgical management of prosthetic valve endocarditis (PVE); yet, its impact has not been well studied. We compared outcomes of patients with prior aortic valve replacement (AVR) versus aortic surgery plus AVR, who underwent reoperative aortic root replacement (ARR) for PVE of the aortic valve. All patients who underwent reoperative ARR for PVE between 2004 and 2021 from 2 aortic centres were included. Two groups were formed based on the presence/absence of aortic graft: prior aortic surgery (AO) and prior AVR (AV) alone. Inverse propensity treatment weighting matched the groups. The Kaplan-Meier method was used to analyse long-term survival, and Fine and Gray model was used to compare the cumulative incidence of reoperation. A total of 130 patients were included (AO n = 59; AV n = 71). After matching, AO patients had increased stroke incidence (12.4% vs 0.9%) and renal failure requiring dialysis (11.5% vs 2.5%). In-hospital mortality was comparable (21.5% AO and 18.6% AV). Survival over 5 years was 68.9% (56.6-83.8%) in AO and 62.7% (48.1-81.7%) in AV (P = 0.70). The cumulative incidence of reoperation was similar [AO 6.3% (0.0-13.2%) vs AV 6.1% (0.0-15.1%), P = 0.69]. Reoperative ARRs for prosthetic valve/graft endocarditis are high-risk procedures. AO patients had higher incidence of postoperative morbidity versus AV patients. For all patients surviving operative intervention, survival and reoperation rates over 5 years were comparable between groups.

Comorbidities and Symptom Status in Moderate and Severe Aortic Stenosis: A Multicenter Clinical Cohort Study

BackgroundSymptoms associated with severe aortic stenosis (AS) are used to guide management. ObjectivesThe purpose of this study was to examine the pattern of symptoms, comorbidities, and cardiac damage in moderate and severe AS. MethodsA total of 846,198 echocardiographic investigations from 330,940 individuals aged >18 years were selected for the most recent echocardiogram, moderate or severe AS (mean gradient 20.0-39.9 mm Hg, aortic valve peak gradient 3.0-3.9 m/s and aortic valve area >1.0 cm2; or ≥40.0 mm Hg, ≥4.0 m/s or ≤1.0 cm2, respectively), and a cardiologist consultation. Natural Language Processing was applied to letters to extract comorbidities, dyspnea, chest pain, and syncope. Patients with prior aortic valve replacement were excluded. Results2,213 patients (0.7% overall, 32.8% females) had moderate and 3,416 (1.0%, 47.3% females) had severe AS. Comorbidities were common, including hypertension, (56.6% moderate AS, 53.1% severe AS, P = 0.01), coronary disease (46.0% and 46.8%, respectively, P = 0.58) and atrial fibrillation (29.6% and 34.8%, respectively, P < 0.001). Symptoms were also common in both moderate (n = 915, 41.3%) and severe (n = 1,630, 47.7%) AS (P < 0.001). Comorbidities were more likely in symptomatic vs asymptomatic patients (P < 0.001). Dyspnea was more likely in severe AS, whereas angina and syncope were similar in moderate vs severe AS. In multivariable analysis, only dyspnea was associated with severe (vs moderate) AS (OR: 1.73, 95% CI: 1.41-2.13, P < 0.001). In both adjusted and unadjusted models, the degree of cardiac damage did not relate to presence of any symptoms but was associated with AS severity. ConclusionsDyspnea is common in both moderate and severe AS, is associated with comorbidities and is not related to the degree of cardiac damage. Symptom-guided management decisions in AS may need revision.

D-46 | Outcomes of Mitral Transcatheter Edge-to-Edge Repair in Patients With Prior Transcatheter Aortic Valve Replacement

D-46 | Outcomes of Mitral Transcatheter Edge-to-Edge Repair in Patients With Prior Transcatheter Aortic Valve Replacement

The Role of CT-Guided Optimal Fluoroscopic Viewing Angle for Coronary Engagement After TAVR

We report the case of an 89-year-old woman with prior transcatheter aortic valve replacement who underwent successful left coronary artery engagement and left circumflex percutaneous coronary intervention using patient-specific computed tomography fluoroscopic projections. (Level of Difficulty: Advanced.)

Sex-specific aortic valve calcifications in patients undergoing transcatheter aortic valve implantation.

To study sex-specific differences in the amount and distribution of aortic valve calcification (AVC) and to correlate the AVC load with paravalvular leakage (PVL) post-transcatheter aortic valve intervention (TAVI). This registry included 1801 patients undergoing TAVI with a Sapien3 or Evolut valve in two tertiary care institutions. Exclusion criteria encompassed prior aortic valve replacement, suboptimal multidetector computed tomography (MDCT) quality, and suboptimal transthoracic echocardiography images. Calcium content and distribution were derived from MDCT. In this study, the median age was 81.7 (25th-75th percentile 77.5-85.3) and 54% male. Men, compared to women, were significantly younger [81.2 (25th-75th percentile 76.5-84.5) vs. 82.4 (78.2-85.9), P ≤ 0.01] and had a larger annulus area [512 mm2 (25th-75th percentile 463-570) vs. 405 mm2 (365-454), P < 0.01] and higher Agatston score [2567 (25th-75th percentile 1657-3913) vs. 1615 (25th-75th percentile 905-2484), P < 0.01]. In total, 1104 patients (61%) had none-trace PVL, 648 (36%) mild PVL, and 49 (3%) moderate PVL post-TAVI. There was no difference in the occurrence of moderate PVL between men and women (3% vs. 3%, P = 0.63). Cut-off values for the Agatston score as predictor for moderate PVL based on the receiver-operating characteristic curve were 4070 (sensitivity 0.73, specificity 0.79) for men and 2341 (sensitivity 0.74, specificity 0.73) for women. AVC is a strong predictor for moderate PVL post-TAVI. Although the AVC load in men is higher compared to women, there is no difference in the incidence of moderate PVL. Sex-specific Agatston score cut-offs to predict moderate PVL were almost double as high in men vs. women.

Long term outcomes of congenital aortic stenosis in adults: preliminary results of a multicentre study

Abstract Background Congenital aortic stenosis (ConAoS) accounts for 4–8% of all congenital cardiac diagnosis and is associated with important morbidity and mortality. However, little is known about the natural history of ConAoS in adult patients. We aim to evaluate disease progression of ConAoS in young adults, describing both ventricular and valvular characteristics. Methods For this retrospective multicentre cohort study, data of one centre is collected up till now. We included ConAoS patients with a valvular stenosis (Vmax ≥2.5 m/s) aged 18–55 years from the Dutch CONCOR national registry from 2001 until 2019, excluding patients with prior aortic valve replacement (AVR) or severe aortic regurgitation. Echocardiographic data was used to determine presence of left ventricular (LV) hypertrophy (LV mass index &amp;gt;115 g/m2 in males and &amp;gt;95 g/m2 in females) and measure aortic jet velocity. Results A total of 92 patients (64% male, median age 24 years) were included with a median follow-up duration of 6.3 years (IQR 2.9–13.3). The median aortic jet velocity was 3.3 m/s (IQR 2.7–3.9) at baseline and significantly increased over time to 3.6 m/s (IQR 2.8–4.3) (p&amp;lt;0.001). LV hypertrophy was present in 33% of the patients and 17% of the patients showed signs of concentric remodelling at baseline. AVR was performed in 32 patients (35%, mean age 36±11 years) and one patient died during follow-up. Figure 1 shows significant differences in intervention-free survival for different AS severity groups (p&amp;lt;0.001) and presence of LV hypertrophy (p=0.02). Conclusion Although the progression rate of ConAoS seems to be slow, it is often necessary to perform AVR at a relatively young age. After data collection is completed, this study will enable us to identify risk factors for rapid disease progression and further improve current treatment protocols. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation, Hartekind

Outcomes benefit in asymptomatic patients with moderate aortic valve stenosis followed up in heart valve clinics

Abstract Background The management of patients with asymptomatic moderate aortic stenosis (AS), particularly the follow-up and the choice between early intervention vs watchful waiting, remains debated. A progressively increasing number of patients with valvular heart disease (VHD) were diagnosed and followed in an ambulatory setting with a dedicated cardiologist and cardiac imaging specialist: the Heart Valve Clinics (HVC). However, the number of patients with VHD is that high, that these patients are also followed by routine cardiac care consultations (standard-of-care). Purpose To determine the benefit of a HVC approach and outcomes compared to standard-of-care for patients with moderate asymptomatic AS. Methods From November 2014 a HVC environment was introduced at our Cardiovascular Center, to follow patients with moderate and severe VHD by an imaging and valve specialist. Patients who received at least one visit in the Ambulatory HVC were included in a prospective registry. All consecutive patients with aortic valve velocity max&amp;gt;3 cm/sec diagnosed with 2-D echocardiography according to the ESC Guidelines were included in this study. Exclusion criteria included more than moderate aortic regurgitation and prior aortic valve replacement (AVR). Natural history, need for AVR, and survival of patients with baseline moderate AS were assessed at follow up. Cox proportional hazard model, Kaplan-Meier survival curves and propensity score matching where used to assess the HVC approach effect on the mortality. Results A total of 2130 patients were included (1879 in the standard-of-care group and 251 in the Ambulatory HVC group). 1187 (55.7%) were male, and the mean (SD) age was 77.2±12.2 years. A total of 919 patients (43.1%) had severe AS (aortic valve area &amp;lt;1.0 cm2). Mean clinical follow-up was 1.2±2.4 years. A total of 822 patients (38.6%) died during the follow up and 114 patients (55.6%) underwent AVR during the study period. After using 1:1, nearest neighbour, without replacement propensity score matching, baseline characteristics between the two groups were balanced. The introduction of Ambulatory HVC was associated with a reduction of adjusted all-cause mortality compared to the standard-of-care group (HR=0.53, 95% CI 0.35–0.82, p=0.004) (Figure1). At multivariable analysis, the Ambulatory HVC pathway was a significant predictor of reduced all-cause of death (HR=0.46, 95% CI 0.33–0.65, p&amp;lt;0.001), together with younger age and higher GFR, independently of AVA, tricuspid regurgitation gradient, LVEF and chronic obstructive pulmonary disease. Conclusions Patients with moderate AS followed up in HVC had lower rate of all-cause of death compared to the standard-of-care group. The Ambulatory HVC was a significant predictor of reduced all-cause of death and was associated with more efficient patient management and lower mortality. Dedicated HVC have the potential to improve patient care and clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Temporal changes in aortic valve replacement according to age in Denmark: nationwide data from 2008 to 2020

Abstract Background Since the introduction of transcatheter aortic valve implantation (TAVI), the management of symptomatic severe aortic stenosis has changed. Recent published European guidelines (2021) favours TAVI over surgical aortic valve replacements (SAVR) in patients with older age (≥75 years of age) or patients with high surgical risk. The study of nationwide practice patterns for AVR is important and renders the possibility to evaluate whether clinical practice differs from current guidelines. Purpose To evaluate temporal changes in use of isolated aortic valve replacement (AVR) procedures according to age in the era of TAVI in Denmark. Methods We identified all first-time aortic valve replacement procedures (TAVI or SAVR) from 2008 until the end of 2020 through administrative registries in Denmark. Patients with no prior diagnosis of aortic stenosis at time of AVR were excluded. Patients with prior AVR or valve repair were excluded. SAVR was divided according to type of prostheses: surgical bioprostheses and mechanical prostheses. To evaluate changes according to age the study cohort was divided into two age groups: &amp;lt;75 and ≥75 years of age. Results Between 2008 and 2020, 12,313 first-time isolated AVR procedures were performed in Denmark. Volume of isolated AVR increased from 621 to 1256 procedures per year (ptrend &amp;lt;0.001). Isolated SAVR was performed in 6,548 patients (53.2%) and TAVI in 5,765 patients (46.8%). Median age of TAVI patients was 81.4 [76.9–85.2] years of age compared to 73.1 [68.0-≥77.7] in patients receiving surgical bioprostheses and TAVI patients had a higher degree of comorbidity (TAVI: 70% of patients with Charlson comorbidity score ≥1, surgical bioprostheses: 50% of patients with Charlson comorbidty score ≥1). TAVI increased during study period compared to isolated SAVR, where a decreasing trend was observed from 2014 and onwards. In &amp;lt;75-year-old patients, volume of TAVI significantly increased during study period (ptrend&amp;lt;0.001), whereas volume of surgical bioprostheses remained stable. Volume of mechanical prostheses decreased over time (ptrend &amp;lt;0.001) TAVI increased in ≥75-year-old patients (ptrend &amp;lt;0.001) and TAVI accounted for 91.5% of all isolated AVR procedures in 2020. In contrast, volume of isolated SAVR declined driven by a decreasing use of surgical bioprostheses (ptrend=0.001). (Figure 1). Conclusions Volume of isolated aortic valve replacement (AVR) doubled from 2008 and 2020. The increase in isolated AVR was driven by transcatheter aortic valve implantation (TAVI). TAVI has become the predominant choice of isolated AVR in management of aortic stenosis and our results suggest that real-world practise patterns are in line with current guideline recommendations. Funding Acknowledgement Type of funding sources: None.