Cardiac amyloidosis (CA) is an underdiagnosed cause of heart failure with overlapping phenotypes, such as aortic stenosis (AS) and hypertrophic cardiomyopathy. The apical sparing ratio (ASR) derived from echocardiographic strain imaging has been widely adopted as a potential screening tool for CA, though performance across clinical contexts remains uncertain. We performed a systematic review and meta-analysis of studies evaluating the diagnostic accuracy of ASR for identifying CA among patients with left ventricular hypertrophy (LVH), including a prespecified subgroup of patients with severe AS, in September 2024. Random-effects models incorporating multiple ASR thresholds were used to estimate pooled sensitivity, specificity, and area under the summary receiver operating characteristic curve (AUC). Among 3501 records screened, 22 studies (n = 4144) met inclusion criteria for primary analysis. An optimal Youden ASR of threshold = 0.83 yielded pooled sensitivity (95% confidence interval) of 73% (66%, 79%) and specificity of 77% (67%, 84%), with an AUC of 0.81 (0.69, 0.89). In the severe AS subgroup (5 studies, n = 911), pooled sensitivity and specificity were 65% (47%, 80%) and 74% (58%, 85%), respectively, with an AUC of 0.79 (0.70, 0.92). Across analyses, high heterogeneity was observed. Sensitivity analyses, excluding high-bias or low-threshold studies, produced similar findings. ASR demonstrates only modest diagnostic performance for differentiating CA from hypertrophic phenotypes, with limited sensitivity at conventional thresholds. These findings underscore the limitations of ASR as a standalone screening tool and highlight the need for alternative approaches to improve diagnostic accuracy.

Diagnostic performance of aortic valve calcium scoring for severe aortic stenosis in patients with chronic kidney disease.

P189. Early Aortic Valve Replacement in Asymptomatic Severe Aortic Stenosis: A Meta-Analysis of Time-to-Event Data of Randomized Controlled Trials

There are uncertainties regarding long-term outcomes of low-flow, low-gradient (LFLG) severe aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR). This study investigates long-term outcomes of TAVR for high-gradient (HG), classical LFLG, and paradoxical LFLG AS. We systematically searched PubMed, Embase, Scopus, and Cochrane Library databases until January 2025 for studies comparing HG, classical LFLG, and paradoxical LFLG AS outcomes following TAVR. The primary outcome was all-cause mortality, analyzed using reconstructed individual patient data meta-analysis. Secondary outcomes included cardiovascular mortality, heart failure hospitalization, acute kidney injury, bleeding events, stroke, myocardial infarction, permanent pacemaker implantation, and echocardiographic outcomes, analyzed using multivariate meta-analysis. We included 19 observational studies comprising 20 493 patients who underwent TAVR for severe AS. Time-to-event meta-analysis indicated a higher risk of 5-year all-cause mortality in patients with classical and paradoxical LFLG AS compared with HG AS (hazard ratio [HR], 1.92 [95% CI, 1.62-2.27] and HR, 1.20 [95% CI, 1.07-1.34], respectively). Multivariate meta-analysis indicated an increased risk of cardiovascular mortality in patients with LFLG versus HG AS (classical LFLG HR, 1.94 [95% CI, 1.74-2.16]; paradoxical LFLG HR, 1.40 [95% CI, 1.25-1.57]). Classical and paradoxical LFLG AS were also associated with a higher risk of heart failure hospitalization (HR, 4.12 [95% CI, 2.16-7.83]; HR, 1.80 [95% CI, 1.14-2.85], respectively) compared with HG AS. Classical and paradoxical LFLG AS were associated with higher all-cause and cardiovascular mortality following TAVR compared with HG AS. Future studies are needed to determine strategies to improve outcomes following TAVR in patients with LFLG AS.

Transcatheter aortic valve replacement (TAVR) is a viable alternative for patients with symptomatic severe aortic stenosis. Acute myocardial infarction is a contraindication to TAVR. The efficacy of emergency TAVR combined with percutaneous coronary intervention for patients presenting with acute myocardial infarction, severe aortic stenosis, and cardiogenic shock remains an explorable subject.

Transcatheter aortic valve implantation (TAVI) is a cornerstone treatment for severe aortic stenosis; however, complications such as paravalvular leak (PVL), hypoattenuated leaflet thickening (HALT), and hypoattenuation affecting motion (HAM) can lead to persistent symptoms requiring reintervention. We report the case of a 70-year-old man with symptomatic severe aortic stenosis who underwent TAVI with a 27.5-mm Myval™ transcatheter heart valve (Meril Life Sciences, Vapi, Gujarat, India). Post-procedure, moderate PVL was identified, followed by persistent dyspnea at three months. Multimodal imaging, including transthoracic echocardiography, transesophageal echocardiography, and computed tomography, revealed HALT, HAM, and moderate-to-severe transvalvular leakage (TVL). Despite balloon post-dilation and anticoagulation therapy, symptoms persisted, necessitating a valve-in-valve redo TAVI with a 26-mm Myval™ transcatheter heart valve (Meril Life Sciences, Vapi, Gujarat, India). Follow-up imaging confirmed the absence of significant PVL or TVL, with complete resolution of symptoms. This case underscores the importance of multimodal imaging and individualized management strategies, including redo TAVI, in the treatment of complex post-TAVI complications.

Multidisciplinary Approach of Management for Obstetric Patient With Moderate to Severe Bicuspid Aortic Valve Stenosis: A Case Report

Anatomically Normal Aortic Valve Area in Relation to Age, Sex, Body Size, and Aortic Root Dimensions: A TEE Study.

Transcatheter aortic valve implantation (TAVI) was the preferred intervention for patients with severe aortic stenosis at high surgical risk and recently included intermediate and even low surgical risk patients. The transfemoral (TF) route is the standard approach, with alternative access reserved for patients with challenging peripheral artery disease. The transapical (TA) approach is rarely performed, especially in patients with left ventricular (LV) apical aneurysm due to risk of myocardial rupture and bleeding secondary to fibrosed myocardial tissue. We are presenting the first reported case, to our knowledge, of a TA TAVI performed from an LV apical aneurysm despite fibrosed myocardium after failed TF access with severe bicuspid aortic stenosis, advanced ischemic cardiomyopathy, peripheral vascular disease, and chronic obstructive pulmonary disease (COPD). A 29 mm Edwards Sapien S3 Ultra valve was successfully implanted with residual trivial paravalvular regurgitation and stable postoperative recovery. This case highlights the feasibility of TA TAVI in the presence of LV apical aneurysm when no other vascular access route is possible, contrary to the perceived view of the LV aneurysm being thin and friable, which should not preclude a case being done with TA access.

Background: Frailty is a common finding in elderly subjects with severe aortic stenosis (AoS) and a strong predictor of mortality and disability after aortic valve surgery. The atherogenic index of plasma (AIP) is related to different cardiovascular (CV) risk factors, which in turn are correlated to the progression of frailty as well as of AoS. Aim: to analyze the association of AIP with different CV risk factors and frailty scores and its value as a determinant of mortality in older adults with severe AoS. Methods: The association of AIP with a multidimensional assessment of frailty by using Fried criteria and the following indices; timed up-and-go test (TUG) for gait function; Charlson Index (CI), basic activities of daily living (BADL) and instrumental activities of daily living (IADL) for disability; mini–mental state examination for cognitive function evaluation (MMSE); Geriatric Depression Score for mood disorder (GDS); Mini Nutritional Assessment (MNA) for nutritional status was assessed in 102 elderly AoS patients (33 males; mean age 83 ± 6 yrs). Moreover, the relationship between AIP and demographic, lifestyle, traditional CV risk factors and CV mortality was also evaluated. Results: Significant relationships between AIP and glycemia and inflammatory parameters (CRP, ESR and fibrinogen) as well as with troponin I were found. Moreover, AIP significantly correlates with CI, BADL, IADL and MNA. However, the Kaplan–Meier analysis did not show any significant difference for survival rates according to AIP intervals of risk, whereas ejection fraction remained the only significant determinant after multivariate adjustment for mortality at the Cox proportional hazard models analysis in this patient population. Conclusions: Higher AIP is significantly associated with cardiometabolic risk and increased physical dysfunction risk and frailty in AoS pts, evidencing its potential use as a simple biomarker in this clinical setting, although it did not represent a significant determinant for mortality in this population.

We report the case of a 12-year-old boy with a history of type I truncus arteriosus repaired in early infancy. He underwent initial correction at 2 months of age, conduit replacement between the right ventricle and pulmonary artery at 4 years, and truncal valve replacement with a bioprosthesis at 8 years. He was referred with severe aortic regurgitation, severe aortic stenosis, free regurgitation of the right ventricle-pulmonary artery conduit with moderate stenosis and preserved biventricular function. Long-term anticoagulation was formally contraindicated due to immune thrombocytopenic purpura treated with eltrombopag since 2020. A fourth redo sternotomy for mechanical aortic valve replacement was considered to be exceedingly high risk in the context of his complex anatomy, prior operative history, and haematological risk profile. In light of these factors, we elected to perform a partial heart transplantation, as recently described by Turek et al., to replace the dysfunctional aortic and pulmonary root and valve while preserving the patient's heart muscle, therefore minimizing the need for immunosuppression. This case illustrates the potential role of partial heart transplantation as an alternative to conventional valve replacement in complex congenital heart disease when anticoagulation is contraindicated.

Transcatheter aortic valve implantation (TAVI) has become the standard of care for patients with severe aortic stenosis. Despite significant procedural refinement, vascular complications (VCs) remain among the most frequent and clinically relevant adverse events associated with TAVI. These complications are closely associated with adverse clinical outcomes and continue to represent one of the most significant limiting factors for the broader expansion of TAVI indications to larger patient populations. Over the past decade, their incidence has declined substantially, largely due to device evolution, improved closure techniques, and the widespread adoption of meticulous pre-procedural imaging and planning. This narrative review provides a comprehensive overview of VCs in TAVI, focusing on contemporary incidence rates, underlying mechanisms, and patient as well as procedural-related risk factors. Additionally, the role of alternative access routes is discussed, alongside emerging technologies and future perspectives aimed at further reducing complication rates.

Transcatheter aortic valve implantation (TAVI) carries a risk of left main (LM) coronary obstruction, particularly in elderly patients with low coronary height, small sinus of valsalva, or bulky calcified leaflets. Intracoronary imaging such as intravascular ultrasound (IVUS) may provide real-time anatomical assessment and aid in identifying patients at extremely high risk. At the Cardiovascular Centre, E hospital, we report the case of an 88-year-old woman with severe symptomatic aortic stenosis, stage IV chronic kidney disease, and frailty who underwent TAVI using a self-expanding Evolut FX valve. pre-procedural computed tomography revealed a very high risk of LM obstruction. immediately after valve deployment, IVUS assessment demonstrated that the displaced native aortic leaflet was located only 4,5 mm from the LM ostium, indicating a critical risk of obstruction despite preserved TIMI 3 coronary flow. Therefore, a prophylactic chimney stent was deployed from the LM into left anterior descending artery (LAD) to prevent delayed obstruction. Concomitantly, a severe LAD stenosis (90%) was treated with percutaneous coronary intervention. The patient remained hemodynamically stable, with excellent valve performance and patent coronaries at 7-day follow-up. Conclusion: IVUS plays a crucial role in detecting the risk of LM obstruction after TAVI. Prophylactic chimney stenting is justified even when coronary flow is preserved that the anatomical risk is extremely high.

Correction to: Prevalence of Obstructive Sleep Apnea in Thai Patients with Severe Symptomatic Aortic Stenosis

Percutaneous transcatheter angiography can cause various undesirable complications due to factors related to equipment, the operator, or the patient. In this case, we present a patient who had undergone coronary artery bypass grafting eight years earlier and in whom a balloon catheter shaft remained lodged in the coronary artery during stent placement in the right coronary artery one year prior. One year later, during valve surgery for severe aortic stenosis, the balloon catheter shaft was removed from the coronary artery. Interestingly, the retained balloon catheter shaft did not cause ischemic problems in the coronary artery for one year; however, it did cause an aneurysm in the ascending aorta. This case is presented to highlight surgical findings and the complications that may occur during the chronic course.

Isolated Transcatheter and Surgical Aortic Valve Replacement in the Evolut Low-Risk Trial: 5-Year Comparative Outcomes.

In low-gradient severe aortic stenosis (AS), reduced left ventricular ejection fraction (LVEF <50%) is practically used to define low flow and prompt dobutamine stress echocardiography to discern pseudo-severe AS. In patients with preserved LVEF, stroke volume index (SVI) <35 mL/m² is typically used. However, both are volume-based surrogates. Transaortic flow rate (TAFR), calculated as stroke volume divided by left ventricular ejection time, may better reflect true flow. Nonetheless, comparative data between TAFR and established metrics remain limited. We aimed to evaluate the prognostic value of TAFR in symptomatic low-gradient severe AS. We retrospectively identified patients with low-gradient severe AS (AVA ≤1 cm2 and peak velocity (Vmax) <4 m/s or mean gradient (MG) <40 mm Hg) who underwent transcatheter aortic valve replacement at Mayo Clinic sites (2017-2023). The primary outcome was 1-year all-cause mortality. Survival was assessed using Kaplan-Meier and Cox proportional hazards models. Among 475 patients included (mean age 85±8 years; 49% women), 242 (51%) had TAFR <220 mL/s, 165 (35%) had EF <50%, and 221 (47%) had SVI <35 mL/m2. Low TAFR was significantly associated with higher 1-year mortality even after stratifying by EF or SVI. In multivariate analysis, TAFR was an independent predictor of mortality (HR 2.38; 95% CI 1.19 to 4.76, p=0.014) after adjusting for reduced LVEF, low SVI, gender, chronic kidney disease and mitral and tricuspid regurgitation. In patients with symptomatic low-gradient severe AS, low TAFR, not SVI or LVEF, is independently associated with mortality and may offer more accurate measure of flow state for clinical staging.

Computed tomography-derived myocardial extracellular volume provides incremental prognostic value over clinical risk scores in patients with severe aortic stenosis.

Background &amp; Objective: Myocardial work (MW) indices offer an afterload-adjusted assessment of left ventricular (LV) function and may improve risk stratification in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). This systematic review and meta-analysis aimed to evaluate the prognostic significance of MW indices, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), in patients with severe AS undergoing TAVR. Methodology: PubMed, Embase, Web of Science, and Scopus were searched from inception to 26 November 2025 for studies assessing prognostic value of MW indices in TAVR-treated AS patients. Data were synthesised qualitatively, and a random-effects meta-analysis was performed when at least three studies reported comparable effect estimates. Results: Five cohort studies met the inclusion criteria. Across studies, GWI consistently demonstrated strong prognostic performance. Lower post-TAVR GWI predicted mortality in multiple cohorts, with thresholds ranging from 1,095 to 1,234 mmHg% and area-under-the-curve values up to 0.71. Pooled analysis confirmed that higher GWI was associated with reduced mortality (HR 0.94; 95% CI 0.90–0.98). GCW showed modest prognostic value, whereas GWW was not independently predictive. GWE was a significant predictor in select studies, but mostly in univariate models. Conclusion: Limited evidence shows that MW indices, especially GWI, may provide meaningful prognostic information in AS patients undergoing TAVR. Further studies are needed to improve the evidence.

The prevalence of severe symptomatic aortic stenosis is increasing with population aging. Although surgical aortic valve replacement (SAVR) has traditionally been the standard treatment, transfemoral transcatheter aortic valve replacement (TF-TAVR) is increasingly used. The optimal treatment for patients aged 60-75 remains debated. This retrospective cohort study analyzed 28,805 German patients who underwent isolated SAVR or TF-TAVR (2018-2022). We applied double/debiased machine learning estimators that combined adaptive lasso variable selection with propensity score-based weighting across 21 baseline characteristics. Cost-effectiveness was assessed via incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves from in-hospital and 1-year perspectives. Compared with SAVR, TF-TAVR was associated with a significant reduction in in-hospital mortality (causal risk ratio [RR] 0.65; p = 0.012), along with lower rates of bleeding (RR 0.29; p < 0.001), postoperative delirium (RR 0.32; p < 0.001), and mechanical ventilation > 48h (RR 0.39; p < 0.001). No significant difference was observed in acute kidney injury rates (RR 0.89; p = 0.150). However, reimbursement was substantially higher for TF-TAVR (€7071 more per case, p < 0.001). A hypothetical shift from SAVR to TF-TAVR was associated with an ICER of €857,413 (95% CI €472,195-€4,310,651) from the in-hospital perspective and €196,422 (95% CI €123,873-€457,813) from the 1-year perspective. Notably, unadjusted analyses indicated a narrowing cost gap over time: Reimbursement for TF-TAVR decreased by approximately 12% between 2018 and 2022, while SAVR costs remained stable. Consequently, TF-TAVR is becoming increasingly cost-effective. Given an estimated life expectancy of 11 to 25years in this population, the incremental costs per life saved associated with a hypothetical shift from SAVR to TF-TAVR appear justifiable. Nonetheless, individual patient circumstances must always be considered in decision-making.