Prosthetic Valve Implantation Research Articles

Using machine learning to improve the diagnostic accuracy of the modified Duke/ESC 2015 criteria in patients with suspected prosthetic valve endocarditis – a proof of concept study

IntroductionProsthetic valve endocarditis (PVE) is a serious complication of prosthetic valve implantation, with an estimated yearly incidence of at least 0.4-1.0%. The Duke criteria and subsequent modifications have been developed as a diagnostic framework for infective endocarditis (IE) in clinical studies. However, their sensitivity and specificity are limited, especially for PVE. Furthermore, their most recent versions (ESC2015 and ESC2023) include advanced imaging modalities, e.g., cardiac CTA and [18F]FDG PET/CT as major criteria. However, despite these significant changes, the weighing system using major and minor criteria has remained unchanged. This may have introduced bias to the diagnostic set of criteria. Here, we aimed to evaluate and improve the predictive value of the modified Duke/ESC 2015 (MDE2015) criteria by using machine learning algorithms.MethodsIn this proof-of-concept study, we used data of a well-defined retrospective multicentre cohort of 160 patients evaluated for suspected PVE. Four machine learning algorithms were compared to the prediction of the diagnosis according to the MDE2015 criteria: Lasso logistic regression, decision tree with gradient boosting (XGBoost), decision tree without gradient boosting, and a model combining predictions of these (ensemble learning). All models used the same features that also constitute the MDE2015 criteria. The final diagnosis of PVE, based on endocarditis team consensus using all available clinical information, including surgical findings whenever performed, and with at least 1 year follow up, was used as the composite gold standard.ResultsThe diagnostic performance of the MDE2015 criteria varied depending on how the category of ‘possible’ PVE cases were handled. Considering these cases as positive for PVE, sensitivity and specificity were 0.96 and 0.60, respectively. Whereas treating these cases as negative, sensitivity and specificity were 0.74 and 0.98, respectively. Combining the approaches of considering possible endocarditis as positive and as negative for ROC-analysis resulted in an excellent AUC of 0.917. For the machine learning models, the sensitivity and specificity were as follows: logistic regression, 0.92 and 0.85; XGBoost, 0.90 and 0.85; decision trees, 0.88 and 0.86; and ensemble learning, 0.91 and 0.85, respectively. The resulting AUCs were, in the same order: 0.938, 0.937, 0.930, and 0.941, respectively.DiscussionIn this proof-of-concept study, machine learning algorithms achieved improved diagnostic performance compared to the major/minor weighing system as used in the MDE2015 criteria. Moreover, these models provide quantifiable certainty levels of the diagnosis, potentially enhancing interpretability for clinicians. Additionally, they allow for easy incorporation of new and/or refined criteria, such as the individual weight of advanced imaging modalities such as CTA or [18F]FDG PET/CT. These promising preliminary findings warrant further studies for validation, ideally in a prospective cohort encompassing the full spectrum of patients with suspected IE.

B-41 | Insights into a Rare Clinical Phenomenon: Selective and Isolated Native Valve Endocarditis Subsequent to Prosthetic Valve Implantation

B-41 | Insights into a Rare Clinical Phenomenon: Selective and Isolated Native Valve Endocarditis Subsequent to Prosthetic Valve Implantation

Percutaneous Thrombovegectomy as an Alternative to Surgery for Tricuspid Valve Endocarditis

BackgroundUndergoing an urgent valve surgical procedure to treat patients with tricuspid valve endocarditis carries a high risk of operative morbidity and mortality. Use of a percutaneous vacuum-assisted system to treat tricuspid valve endocarditis is an alternative to surgical procedures. MethodsThis study retrospectively analyzed data from 187 transcatheter vacuum-assisted aspiration procedures performed in 177 patients with tricuspid valve vegetations at 3 different centers between 2017 and April 2022. The device was deployed through the internal jugular or femoral vein into the right atrium by using transesophageal echocardiography and fluoroscopy guidance with the return cannula placed in the femoral vein. The following data were analyzed: intravascular material aspirated, collected in an external filter, and cultured; hospital length of stay; procedural complications; blood culture clearance; and tricuspid regurgitation. ResultsThe mean age of participants was 35.5 ± 10.8 years (range, 18-79 years). A total of 107 procedures (57.2%) were performed in female patients, and 163 (87.2%) procedures were performed in intravenous drug users. All patients survived the procedure, and there were no procedural complications. The average length of stay was 26.8 ± 18.5 days (range, 1-96 days). Most preoperative positive blood cultures showed Staphylococcus aureus (80.3%), with postoperative cultures converting to negative in 103 (70.1%) of 147 procedures. Tricuspid regurgitation remained unchanged after 95 (50.8%) procedures and worsened after 40 (21.4%) procedures. ConclusionsPercutaneous vacuum-assisted aspiration system provides a safe alternative to urgent tricuspid valve surgical procedures for removal of vegetations, especially in patients with endocarditis. Initial vegetation debulking can expedite clearance of blood cultures while avoiding major cardiac surgery operations and implantation of prosthetic valves in these high-risk patients.

Risk Factors for Coronary Artery Complications After Prosthetic Pulmonary Valve Implantation in Patients With Congenital Heart Disease.

Coronary artery complications (CACs) in patients who undergoing prosthetic pulmonary valve implantation for congenital heart disease can lead to fetal outcomes. However, the incidence of and risk factors for CACs in these patients remain unknown. A retrospective cohort study was conducted on patients who underwent cardiac computed tomography or invasive coronary angiography after prosthetic pulmonary valve implantation at Seoul National University Hospital from June 1986 to May 2021. Among 341 patients, 25 (7.3%) were identified with CACs, and 2 of them died. Among the patients with CACs, congenital coronary anomalies and an interarterial course of the coronary artery were identified in 11 (44%) and 18 (72%) patients, respectively. Interarterial and intramural courses of the coronary artery were associated with a 4.4- and 10.6-fold increased risk of CACs, respectively. Among patients with tetralogy of Fallot and pulmonary atresia, the aortic root was rotated further clockwise in patients with coronary artery compression compared to those without it (mean [±SD] 128.0±19.9° vs. 113.5±23.7°; P=0.024). The cut-off rotation angle of the aorta for predicting the occurrence of coronary artery compression was 133°. Perioperative coronary artery evaluation and prevention of CACs are required in patients undergoing prosthetic pulmonary valve implantation, particularly in those with coronary artery anomalies or severe clockwise rotation of the aortic root.

Choice of the prosthetic valve in patients aged between 55 and 70 years

About 280 000 heart valve replacements are performed worldwide every year. Since the first prosthetic valve implantation in 1952 there have been notable developments. There are a lot of types of prosthetic valves that can be summarized into two categories: biological prosthetic valves or mechanical prosthetic valves. Biological prostheses, made of bovine or porcine pericardium, homografts, or autografts, degenerate over time becoming dysfunctional. Mechanical prostheses have a potentially unlimited lifespan but require oral anticoagulation which can affect patients' quality of life. Generally, biological prostheses are particularly suitable for elderly patients while mechanical prostheses for young people, with some distinctions. For example, in case of age <60 years, in the presence of preoperative oral anticoagulant therapy, metabolic syndrome, hemodialysis or hyperparathyroidism, a mechanical valve is the preference. The choice of the prosthesis in patients aged between 55 and 70 years is particularly challenging because the advantages and disadvantages of the two categories of prosthesis overlap in middle-aged patients. The choice of the prosthesis should be made after discussion with the surgeon, according to the patient's preferences, and keeping in mind the pros and cons of biological and mechanical prostheses.

Case Report of Absent Pulmonary Valve with Intact Interventricular Septum

Abstract Absent pulmonary valve syndrome is a rare cardiac malformation, usually associated with tetralogy of Fallot. Its presence with intact interventricular septum is even less common with case reports or very small series in the literature. We describe a case who presented with symptoms of right heart failure due to an absent pulmonary valve with severe pulmonary regurgitation and small atrial septal defect. Diagnostic evaluation revealed grossly dilated main pulmonary artery and rudimentary leaflets of the pulmonary valve with severe regurgitation. Ventricular septum was intact and there was no patent ductus arteriosus. Later, the patient underwent surgical prosthetic pulmonary valve implantation.

BIOPROSTHETIC VALVE IMPLANTATION AS TYPE OF TRANSPLANTATION: IMMUNOLOGICAL CONSEQUENCES OF NEW CONCEPT

HighlightsImmune processes and mechanisms underlying bioprosthetic heart valve degeneration and rejection of allografts and xenografts are similar.Manufacturers and surgeons can implement effective approaches to prevent immune rejection in the process of production and implantation of prosthetic heart valves in order to delay the process of structural valve degeneration. AbstractBioprosthetic heart valves (BHV) are characterized by low thrombogenicity, thus circumventing the need for long‐term anticoagulation. However, BHV lifespan is limited to 10–15 years because its tissue components are subject to degeneration. Recent research data indicate that immune responses forming the basis of humoral and cellular rejection of allografts and xenografts play a major role in the development of structural valve degeneration (SVD). This review summarizes up-to-date data on immune processes involved in SVD pathogenesis. Moreover, the latest achievements in the development of strategies to reduce the immunogenicity of BHV, such as data on immune compatibility of allogeneic material and the process of deriving low immunogenic biomaterial from genetically modified animals, decellularization of BHV, and the ways of slowing the process of degeneration are analyzed.

Risk factors for coronary artery complications after prosthetic pulmonary valve implantation in congenital heart diseases

Abstract Background The incidence and risk factors for coronary artery complications in patients who underwent pulmonary valve replacement or valved conduit interposition for congenital heart diseases were unknown. Purpose This study was an extension of the previous study† to investigate the incidence and risk factors of coronary artery complications among patients who underwent prosthetic pulmonary valve implantation. Methods Retrospective cohort study was performed for the patients who underwent cardiac CT or invasive coronary angiography after the prosthetic pulmonary valve implantation at the tertiary referral hospital from June 1986 to May 2021. The rotation angle of the aorta and angles of both coronary artery orifices were measured on a Picture Archiving and Communication System (Figure 1). The Cox regression analysis was used to identify variables predicting the occurrence of coronary artery complications. Survival rates were assessed by Kaplan-Meier analysis. Results Coronary artery complications were identified in 25 patients among the 341 patients (7.3%), and two of them died. The median age at diagnosis of coronary artery complications was 20 years (interquartile range: 12.5-25 years). The coronary artery complication-free survival rate was predicted to be 97.3% at 5 years, 92.5% at 10 years, 85.5% at 20 years, and 61.1% at 30 years. The risk of cardiac death was 1.865 times higher [95% CI: 0.403, 8.628] in patients with coronary artery complications than in those without it; nevertheless, the difference was not statistically significant (p-value = 0.425). Among the patients with coronary artery complications, congenital coronary anomalies were identified in 11 (44 %), interarterial course of coronary artery in 18 (72 %), and intramural course in 4 patients (16%). Interarterial course and intramural course of the coronary artery were associated with a 4.4 and 10.6-fold increased risk of coronary artery complications, respectively. When subgroup analysis was performed in patients with tetralogy of Fallot and pulmonary atresia, the aortic root rotated more clockwise in patients with coronary artery compression than in patients without it (128.0°± 19.9° versus 113.5°± 23.7°, p-value = 0.024). The cut-off value of the rotation angle to predict the occurrence of coronary artery compression was 133˚ (Figure 2). Conclusion Preoperative and postoperative long-term coronary assessment should be performed in patients with conotruncal anomalies undergoing prosthetic pulmonary valve implantation, especially in those with abnormal courses of coronary arteries or severe rotation of aortic root. The rotation angle of aorta could be measured on cardiac CT angiography prior to surgery, and the location of the prosthetic valve or conduit should be carefully determined.Measurement of anglesKaplan-Meier curves

Direct transcatheter aortic valve implantation (TAVI) decreases silent cerebral infarction when compared to routine balloon valvuloplasty.

Silent cerebral infarctions (SCI), as determined by neuron-specific enolase (NSE) elevations, may develop after the transcatheter aortic valve implantation (TAVI) procedure. Our aim in this study was to compare the SCI rates between patients who underwent routine pre-dilatation balloon aortic valvuloplasty (pre-BAV) and patients who underwent direct TAVI without pre-BAV. A total of 139 consecutive patients who underwent TAVI in a single center using the self-expandable Evolut-R valve (Medtronic, Minneapolis, Minnesota, USA) were included in the study. The first 70 patients were included in the pre-BAV group, and the last 69 patients were included in the direct TAVI group. SCI was detected by serum NSE measurements performed at baseline and 12h after the TAVI. New NSE elevations > 12 ng/mL after the procedure were counted as SCI. In addition, SCI was scanned by MRI (magnetic resonance imaging) in eligible patients. TAVI procedure was successful in all of the study population. Post-dilatation rates were higher in the direct TAVI group. Post-TAVI NSE positivity (SCI) was higher in the routine pre-BAV group (55(78.6%) vs. 43(62.3%) patients, p = 0.036) and NSE levels were also higher in this group (26.8 ± 15.0 vs. 20.5 ± 14.8 ng/ml, p = 0.015). SCI with MRI was found to be significantly higher in the pre-BAV group than direct TAVI group (39(55.1%) vs. 31(44.9%) patients). The presence of atrial fibrillation and diabetes mellitus (DM), total cusp calcification volume, calcification at arcus aorta, routine pre-BAV and failure at first try of the prosthetic valve implantation were significantly higher in SCI (+) group. In the multivariate analysis, presence of DM, total cusp calcification volume, calcification at arcus aorta, routine pre-BAV and failure at first try of the prosthetic valve implantation were significantly associated with new SCI development. Direct TAVI procedure without pre-dilation seems to be an effective method and avoidance of pre-dilation decreases the risk of SCI development in patients undergoing TAVI with a self-expandable valve.

Y Incision and Roof Technique for Aortic Root Enlargement: A Minimally Invasive Approach

The Y incision and roof technique for aortic valve replacement enable implantation of a large prosthetic valve and extensive enlargement of the sinotubular junction. Surgeons have been reluctant to adopt a minimally invasive approach for this procedure because of its complexity and risk. The Stonehenge technique was designed to achieve an ideal surgical view of the aortic root through a small right thoracotomy. Herein, we report implementing a Y incision and roof technique for aortic valve replacement through a minimally invasive approach facilitated by the Stonehenge technique.

Temporal trends in the incidence of infective endocarditis in patients with a prosthetic heart valve

ObjectiveThe incidence of infective endocarditis (IE) is increasing, as is the insertion of prosthetic heart valves. We aimed to examine nationwide temporal trends in the incidence of IE in patients...

Spectral CT Imaging of Prosthetic Valve Embolization after Transcatheter Aortic Valve Implantation

Transcatheter heart valve (THV) embolization is a rare complication of transcatheter aortic valve implantation (TAVI) generally caused by malpositioning, sizing inaccuracies and pacing failures. The consequences are related to the site of embolization, ranging from a silent clinical picture when the device is stably anchored in the descending aorta to potentially fatal outcomes (e.g., obstruction of flow to vital organs, aortic dissection, thrombosis, etc.). Here, we present the case of a 65-year-old severely obese woman affected by severe aortic valve stenosis who underwent TAVI complicated by embolization of the device. The patient underwent spectral CT angiography that allowed for improved image quality by means of virtual monoenergetic reconstructions, permitting optimal pre-procedural planning. She was successfully re-treated with implantation of a second prosthetic valve a few weeks later.

Effects of Porosity on Piezoelectric Characteristics of Polyvinylidene Fluoride Films for Biomedical Applications.

Objective: The objective of this work is to study the effects of porosity on mechanical and piezoelectric properties of polyvinylidene fluoride (PVDF) films for biomedical applications. Impact Statement: By investigating the piezoelectric properties of PVDF and the porosity effect on its electromechanical performance, there is potential for further development of PVDF as a hemodynamic sensor that can lead to further technological advancements in the biomedical field, benefiting patients and physicians alike. Introduction: PVDF thin films have shown potential in the application of hemodynamic flow sensing and monitoring the effects on blood flow caused by prosthetic valve implantation via the transcatheter aortic valve replacement operation. The piezoelectric performance of PVDF films can be influenced by the porosity of the material. Methods: In this study, strain tracking was performed on thin film PVDF specimens with various levels of porosity and pore sizes to determine the mechanical properties of the specimens. The mechanical properties were used to model the PVDF material in COMSOL multiphysics software, in which compression test simulations were performed to determine the piezoelectric coefficient d33 of the PVDF. Results: A decline in the elastic modulus was found to be highly inversely correlated with porosity of the specimens and the simulation results show that elastic modulus had a much greater effect on the piezoelectric properties than Poisson's ratio. Conclusion: A combination of experimental and computational techniques was able to characterize and correlate the mechanical properties of PVDF films of varying porosities to their piezoelectric properties.

Outcomes after Transcatheter Mitral Valve Implantation: A Literature Review.

Mitral valve disease is the most common heart valve disease worldwide. Surgical mitral valve replacement or repair has been an established therapy in patients with severe mitral valve disease for many years. On the other hand, many patients with advanced mitral valve disease and severe comorbidities are treated conservatively and are excluded from the surgical procedure. Furthermore, in patients with severe comorbidities, transcatheter mitral valve repair by edge-to-edge technique with MitraClip or transcatheter mitral valve repair with a non-absorbable ring have been added as therapeutic options over the last few years. Alternative procedures for the treatment of patients with advanced prosthetic or native mitral valve diseases include transcatheter access for replacement or implantation of a new prosthetic valve in the diseased mitral valve. Promising results were published about short-term outcomes of patients who underwent the transcatheter mitral valve replacement. The current view and results of the transcatheter mitral valve implantation in patients with advanced native or prosthetic mitral valve disease are briefly discussed.

Granulicatella elegans infective endocarditis: A case report

Granulicatella elegans is a rare cause of infective endocarditis, accounting for 1–2% of all cases. It is well recognized that this pathogen can present in association with negative blood cultures. There are higher rates of both relapse and mortality compared with endocarditis caused by other bacteria. Microbiological diagnosis can be especially challenging because many conventional blood culture media lack pyridoxal, which can be found in automated blood culture broths like BACTEC™ or BACT/ALERT® and thus they may require ‘helper’ bacteria to be culture the organism. This current case report describes a 66-year-old male patient with a 10-year history of post-inflammatory combined aortic valve disease (moderate aortic stenosis and mild aortic regurgitation). He presented with a 3-month history of recurrent fever and general deterioration. Despite targeted, prolonged, combined antibiotic treatment with intravenous penicillin and gentamicin, surgery was eventually required. An aortic prosthetic valve implantation was performed with good results. In case of subacute endocarditis, especially when a causative organism proves difficult to detect, G. elegans should be considered. Identification is greatly enhanced by using polymerase chain reaction methods and this test should be considered in all cases of culture negative endocarditis.

Temporal trends in the incidence of endocarditis among patients with a prosthetic heart valve: a nationwide study

Abstract Background The incidence of infective endocarditis (IE) is increasing in the adult population, as is the insertion of prosthetic heart valves. Patients with prosthetic heart valves are considered at high risk of IE – a complication with a high mortality. However, data on temporal changes in the incidence of IE among patients with prosthetic heart valves from unselected cohorts are sparse Purpose We aimed to examine nationwide temporal trends in the incidence of IE in patients with an implanted prosthetic heart valve in Denmark from 1999 to 2018. Methods Using Danish nationwide health-care registries we identified all patients, who underwent heart valve implantation between 1996–2018. Crude annual incidence rates per 1,000 person years (PY) of IE were computed and presented in two year intervals. Analyses were stratified by sex and age groups (&amp;lt;50, 50–59, 60–69, 70–79, &amp;gt;80 years). Results We identified 26,604 patients with first time prosthetic valve implantation with a median age of 72.7 years at the time of implantation, 63.1% were men with a median follow-up of 6.5 years. We found 1,442 cases of first time IE. The IE incidence rate ranged from 5.4 /1,000 PY (95% CI 3.9–7.4) in calendar period 2001–2002 to 10.0/1,000 PY (95% 8.84–11.11) in calendar period 2017–2018 with an unadjusted increasing trend during the study period (ptrend&amp;lt;0.0001), (Figure 1). Overall, men had a higher crude incidence rate compared with women, however no significant temporal changes were seen in the incidence rate during the study period. For age groups, a trend of stepwise increase in the incidence rate of IE was observed for increasing age groups, however no temporal changes were observed (Figure 2). Conclusion The incidence of IE following prosthetic heart valve implantation has increased slightly over the last 20 years in Denmark. Funding Acknowledgement Type of funding sources: None.

Do valve type and post-ballooning affect transprosthetic gradients in patients undergoing transcatheter aortic valve-in-valve procedure?

Abstract Introduction Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, high post-procedural transprosthetic gradients are very common after ViV-TAVI than after TAVI for native-valve aortic stenosis. Aim We sought to evaluate transprosthetic gradients (ΔP) and hemodynamic outcome in patients undergoing ViV-TAVI according to valve type and balloon post-dilation (balloon-expandable vs self-expandable with and without post-dilation). Material and methods We retrospectively analyzed 111 patients undergoing ViV-TAVI. A balloon-expandable valve was used in 35 patients (32%, Group 1), a self-expandable valve in 76 cases of which 39 (35%, Group 2) without balloon post-dilation and 37 (33%, Group 3) with balloon post-dilation. A comprehensive transthoracic echocardiography (TTE) was performed in all patients at baseline, at discharge and at 6-months follow-up. Results Successful ViV-TAVI was performed in 110 patients (99%). Baseline peak and mean ΔP, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. A significant improvement in all echocardiographic parameters was observed in all groups over time (Table 1). In particular, a significant reduction in postprocedural gradients was observed at discharge and at 6-months follow-up compared to baseline in all groups. Immediately after ViV-TAVI procedure, the lowest value of mean ΔP was observed in Group 3 (12±7 mmHg) compared to both Group 1 (20±9 mmHg) and Group 2 (17±8 mmHg, p=0.001). This result was confirmed at 6-months follow-up (p=0.012). Rate of small valve size (≤23 mm) implanted was similar among groups (Group 1: 78%, Group 2: 60%, Group 3: 62%, p=0.123). Similar 1-year all-cause mortality was observed among groups (9%, 13%, 0%, respectively, p=0.135). Conclusions In patients with failed surgical aortic prosthesis, ViV-TAVI is an effective option and is associated with sustained improved hemodynamics in all patients. Anyway, the choice of prosthetic valve type and implantation technique are relevant on residual transprosthetic gradients and should be taken into account for a better long-term outcome. Funding Acknowledgement Type of funding sources: None.

CASE REPORT: BIOPROSTHETIC VALVE ENDOCARDITIS CAUSING NON-ST-ELEVATION MYOCARDIAL INFARCTION

CASE REPORT: BIOPROSTHETIC VALVE ENDOCARDITIS CAUSING NON-ST-ELEVATION MYOCARDIAL INFARCTION

Review of Prosthetic Paravalvular Leaks: Diagnosis and Management.

Paravalvular leak (PVL) is a relatively uncommon complication associated with prosthetic valve implantation. PVL can occasionally lead to serious adverse consequences such as congestive heart failure, infective endocarditis, and hemolytic anemia. Surgical re-operation carries a high mortality risk. Transcatheter closure therapy provides a viable alternative for the treatment of this disorder with reasonable procedural and clinical success. The recent advent of hybrid imaging modalities has increased procedural success. This article summarizes the pathophysiology, clinical characteristics, and treatment modalities surroundings prosthetic paravalvular leak.

Dos and don'ts in large animal models of aortic insufficiency

Aortic insufficiency caused by paravalvular leakage (PVL) is one of the most feared complications following transcatheter aortic valve replacement (TAVI) in patients. Domestic pigs (Sus scrofa domestica) are a popular large animal model to study such conditions and develop novel diagnostic and therapeutic techniques. However, the models based on prosthetic valve implantation are time intensive, costly, and often hamper further hemodynamic measurements such as PV loop and 4D MRI flow by causing implantation-related wall motion abnormalities and degradation of MR image quality. This study describes in detail, the establishment of a minimally invasive porcine model suitable to study the effects of mild-to-moderate “paravalvular“ aortic regurgitation on left ventricular (LV) performance and blood flow patterns, particularly under the influence of altered afterload, preload, inotropic state, and heart rate. Six domestic pigs (Swiss large white, female, 60–70 kg of body weight) were used to establish this model. The defects on the hinge point of aortic leaflets and annulus were created percutaneously by the pierce-and-dilate technique either in the right coronary cusp (RCC) or in the non-coronary cusp (NCC). The hemodynamic changes as well as LV performance were recorded by PV loop measurements, while blood flow patterns were assessed by 4D MRI. LV performance was additionally challenged by pharmaceutically altering cardiac inotropy, chronotropy, and afterload. The presented work aims to elaborate the dos and don'ts in porcine models of aortic insufficiency and intends to steepen the learning curve for researchers planning to use this or similar models by giving valuable insights ranging from animal selection to vascular access choices, placement of PV Loop catheter, improvement of PV loop data acquisition and post-processing and finally the induction of paravalvular regurgitation of the aortic valve by a standardized and reproducible balloon induced defect in a precisely targeted region of the aortic valve.