Severe Aortic Stenosis Research Articles

Accessibility to TAVI in a center without cardiac surgery : a Corsican example

Accessibility to TAVI in a center without cardiac surgery : a Corsican example

Procoagulant Effect of Neutrophil Extracellular Traps, Activated Platelets, and Endothelial Cells in Patients After TAVR.

Patients with severe aortic stenosis, undergoing transcatheter aortic valve replacement (TAVR), are more likely to develop thrombotic complications. However, the definite mechanisms underlying the hypercoagulation state remain unclear to date. Our objectives were to explore whether and how neutrophil extracellular traps (NETs) play a procoagulant role in patients after TAVR alone or TAVR with percutaneous coronary intervention within 1 year and further to evaluate their interactions with platelets and endothelial cells. The levels of plasma NETs, platelets, and endothelial cell activation markers were analyzed by ELISA. NET formation was observed by immunofluorescence. Procoagulant activity was measured by clotting time, fibrin, and TAT (thrombin-antithrombin) complex generation assays. Phosphatidylserine exposure on cells was assessed by flow cytometry. Compared with pre-TAVR, controls, or severe aortic stenosis without TAVR patients, the plasma NET levels in patients after TAVR alone, especially TAVR with percutaneous coronary intervention, increased from 7 days, peaking at 3 months, and then gradually decreased until the 12th month. Furthermore, neutrophils and plasma from patients post-TAVR are more prone to promote NET formation; NETs from these patients markedly decreased clotting time and increased fibrin and TAT generation. Additionally, a high concentration of NETs induced platelet aggregation and exerted a strong cytotoxic effect on endothelial cells and transformed them into a procoagulant phenotype. These results lead us to believe that NETs contribute to the hypercoagulability in patients post-TAVR. Our study may provide a new target for preventing thrombotic complications in patients post-TAVR by blocking NET generation.

Preservation of high-molecular-weight von Willebrand factor multimers in severe aortic stenosis: A 4-year follow-up from pregnancy through aortic valve replacement: A case report

Preservation of high-molecular-weight von Willebrand factor multimers in severe aortic stenosis: A 4-year follow-up from pregnancy through aortic valve replacement: A case report

Transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis aged 70 years or younger: A NOTION-2 substudy.

This NOTION-2 sub-study revealed distinct outcomes for transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in low surgical risk patients aged ≤ 70 years with a tricuspid or bicuspid aortic valve stenosis (AS). One year after intervention, the risk of death, stroke or rehospitalization in patients with tricuspid AS was similar after TAVR when compared to SAVR (absolute risk difference: -2.0%; 95% confidence interval (CI): -11.8% to 7.7%) Conversely, in patients with bicuspid AS, TAVR was associated with a significantly higher risk of adverse outcomes (absolute risk difference: 13.8%; 95% CI: 1.2% to 26.3%). These analyses are exploratory, but highlight the importance of tailoring the intervention to the patient's clinical risk profile, life expectancy, native aortic valve morphology and the anticipated risks associated with TAVR or SAVR.

Geriatric assessment and results of transcatheter aortic valve implantation.

Geriatric assessment and results of transcatheter aortic valve implantation.

Shockwave lithotripsy-assisted TAVI in a patient with severely calcified peripheral arteries and porcelain aorta

Abstract Background Transcatheter aortic valve implantation (TAVI) is the standard treatment for severe aortic stenosis (AS), particularly in high-risk patients. However, peripheral artery disease with extensive vascular calcification poses challenges for transfemoral access. Shockwave intravascular lithotripsy (IVL) has emerged as a promising technique to facilitate vascular access in such cases. Case presentation A 73-year-old male presented with non-ST elevation myocardial infarction. His condition necessitated urgent coronary revascularization and later, TAVI for severe AS. Pre-procedural computed tomography angiography revealed severe circumferential calcification of the entire aorta and both iliac and femoral arteries. Due to the extensive calcification and stenosis of the left common iliac artery, IVL was performed to optimize vessel diameter prior to TAVI. Post-IVL, optimal luminal expansion was achieved (6.8 mm), allowing safe passage of the delivery sheath. Conclusion IVL-assisted transfemoral TAVI is a safe and effective strategy in patients with extensive iliofemoral calcifications.

Impact of Coronary Artery Disease on Cardiovascular Outcomes Differs Between Men and Women With Severe Aortic Stenosis.

There is heterogeneity in coronary artery disease (CAD) severity among individuals with severe aortic stenosis (AS), but whether this differentially influences prognosis is unknown. Patients with severe AS in the PARTNER 1, 2, and 3 trials and registries (Placement of Aortic Transcatheter Valves) were stratified by obstructive CAD (coronary stenosis ≥50%, prior myocardial infarction, or revascularization) or no obstructive CAD (all stenoses <50%). Multivariable Cox proportional-hazards models examined the association between CAD severity groups and clinical outcomes. The primary composite end point was death, heart failure hospitalization, or stroke at 5 years. Interaction between sex and CAD severity was evaluated. Among 7505 patients with severe AS, 2062 (27.5%) had no obstructive CAD and were more likely to be women (60.5%) with fewer CAD risk factors. After multivariable adjustment, the primary end point was significantly lower among patients with no obstructive CAD compared with those with obstructive CAD (adjusted hazard ratio, 0.92 [CI, 0.84-1.00]; P=0.04), irrespective of AS treatment. However, there were significant differences by sex (Pinteraction=0.0002). Men with no obstructive CAD had a 16% lower event rate compared with men with obstructive CAD (adjusted hazard ratio, 0.84 [CI, 0.73-0.96]; P=0.01). In contrast, women with no obstructive CAD did not have a significantly lower rate of death, stroke, or heart failure hospitalization compared with women with obstructive CAD (adjusted hazard ratio, 0.95 [CI, 0.85-1.07]; P=0.41). Women with no obstructive CAD had a more advanced heart failure phenotype and higher event rates compared with men with no obstructive CAD. Obstructive CAD was associated with a higher risk of long-term adverse events after treatment for severe AS, but there was a significant sex disparity in clinical outcomes among men and women with no obstructive CAD. Further study is needed to optimize the evaluation and management of women with severe AS.

Electronic Provider Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis: A Randomized Clinical Trial.

Symptomatic severe aortic stenosis (AS) remains undertreated with high resultant mortality despite increased growth and availability of aortic valve replacement (AVR) since the advent of transcatheter therapies. We evaluate the impact of electronic provider notifications (EPNs) on rates of AVR at 1 year. In a pragmatic cluster randomized clinical trial conducted within a multicenter academic health system from March 2022 through November 2023, 285 providers who had ordered a transthoracic echocardiogram (TTE) with findings potentially indicative of severe AS with an aortic valve area ≤1.0 cm2 were enrolled. Providers were randomly assigned to receive EPNs for each of their patients with severe AS on TTE or to usual care. Notifications highlighted the detection of severe AS and included patient-specific clinical guideline recommendations for its management. The primary end point was the proportion of patients with severe AS receiving AVR within 1 year of the index TTE. A total of 144 providers were randomized to intervention and 141 to control, resulting in 496 and 443 patients assigned to each group, respectively. The patient cohort had mean age of 77±11 years, was 47% female, and had a mean aortic valve area of 0.8±0.1 cm2. Rates of AVR within 1 year were 48.2% with EPNs versus 37.2% with usual care (odds ratio [OR], 1.62 [95% CI, 1.13-2.32]; P=0.009]) and 60.7% and 46.5%, respectively, among symptomatic patients (OR, 1.77 [95% CI, 1.17-2.65]; P=0.006). Notification treatment effect was highest with EPNs for patients >80 years of age (OR, 2.00 [95% CI, 1.17-3.41]; P=0.01), for women (OR, 2.78, [95% CI, 1.69-4.57]; P<0.001), and when the index TTE was performed within the inpatient setting (OR, 2.49 [95% CI, 1.44-4.31]; P<0.001). Within 1 year, the restricted mean survival time was longer with EPNs in all (12 days; P=0.04) and symptomatic patients (23 days; P=0.01). In this first study of EPNs for valvular heart disease, EPNs increased rates of AVR for severe AS, lessened sex and age disparities in AVR use, and improved survival time. EPNs may be a simple, scalable intervention to raise awareness of critical TTE findings and improve the quality of care for patients with severe AS. URL: https://www.clinicaltrials.gov; Unique identifier: NCT05230225.

A Novel Method for ECG-Free Heart Sound Segmentation in Patients with Severe Aortic Valve Disease

Severe aortic valve diseases (AVDs) cause changes in heart sounds, making phonocardiogram (PCG) analyses challenging. This study presents a novel method for segmenting heart sounds without relying on electrocardiograms (ECGs), specifically targeting patients with severe AVD. Our algorithm enhances traditional Hidden Semi-Markov Models by incorporating signal envelope calculations and statistical tests to improve the detection of the first and second heart sounds (S1 and S2). We evaluated the method on the PhysioNet/CinC 2016 Challenge dataset and a newly acquired AVD-specific dataset. The method was tested on a total of 27,400 cardiac cycles. The proposed approach outperformed the existing methods, achieving a higher sensitivity and positive predictive value for S2, especially in the presence of severe heart murmurs. Notably, in patients with severe aortic stenosis, our proposed ECG-free method improved S2 sensitivity from 41% to 70%.

Health Related Quality of Life (HRQoL) after transcatheter aortic valve implantation in aortic stenosis patients: exploring a novel threshold for clinically significant improvement after 12 months

AimThe study aimed to determine the proportion of patients with significant improvements in Health-Related Quality of Life (HRQoL) 12 months after Transcatheter Aortic Valve Implantation (TAVI), using a threshold for physical function (PF) and physical role (RP) domains of the SF-36 questionnaire. Additionally, we explored shared baseline characteristics of patients reporting these improvements.MethodologyIn this prospective observational study, 88 patients with symptomatic, severe aortic stenosis (AS) and preserved ejection fraction were enrolled between April 2017 and February 2020. Exclusion criteria were clinical instability, pacemaker, chronic AF, comorbidities with life expectancy < 1 year. HRQoL was evaluated before and 12 months after transfemoral TAVI using the Norwegian version 2.0 of SF-36, and presented as mean (95% confidence interval). Other outcome measures were 6-minute walking test and NYHA- classification. Independent samples t-test or Mann-Whitney U test was used for between-group comparisons as appropriate. Logistic regression or Chi2-test were used to explore associations between changes in PF and RP and clinical parameters. Statistical significance was set at p ≤ 0.05, and clinically significant changes in HRQoL were defined as increase of ≥ 15 points in the PF and RP categories.ResultsMean age of the cohort was 80 ± 6 years. 44 (50%) patients reported clinically significant improvement in PF, and 46 (52%) in the RP domain. Baseline scores were significantly lower in patients reporting clinical improvement after TAVI, with PF scores pre intervention 43.07 (37.37–48.78) vs. 65.34 (59.01–71.68), p < 0.001, and RP 36.01 (29.56–42.46) vs. 59.92 (50.91–68.92), p < 0.001. No significant associations were found between improvement in domain scores and parameters from the routine baseline examination, but having ≥ 15-point improvement correlated to baseline PF and RP scores.ConclusionOur study highlights the importance of defining a uniform threshold for clinically significant improvement in the SF-36 HRQoL questionnaire for patients undergoing TAVI. Half of the patients reported favorable long-term outcome for PF and RP aspects of SF-36. This emphasizes the importance of HRQoL assessment in the preoperative work up for patients undergoing TAVI.Trial registrationhttps://www.clinicaltrials.gov/ 05.04.2017 with ID NCT03107923.

Prevalence and Clinical Impact of Obstructive Sleep Apnea in Patients with Severe Aortic Stenosis Undergoing Valve Replacement.

Background/Objectives: Aortic stenosis (AS) is the most prevalent valvular disease among older adults. Although obstructive sleep apnea (OSA) has been linked to adverse cardiovascular outcomes, its specific impact on patients with severe AS remains unclear. This study aimed to determine the prevalence of OSA and its influence on postoperative recovery following aortic valve replacement. Methods: A prospective case-control study was conducted at the Instituto Nacional de Cardiología Ignacio Chávez. Patients aged 40-80 years with echocardiographically confirmed severe AS were categorized into groups with and without OSA, based on respiratory polygraphy (Apnea-Hypopnea Index [AHI] threshold of >15 events per hour). Clinical, biochemical, echocardiographic, body composition, and hemodynamic parameters were assessed. Daytime sleepiness and sleep quality were evaluated using validated questionnaires. Inflammatory biomarkers were also analyzed. This study was approved by the institutional ethics committee. Results: Of the 30 patients included, 66.6% were diagnosed with OSA. Compared to non-OSA patients, those with OSA had a higher left ventricular mass index (160 vs. 108; p = 0.001), greater postoperative increases in central venous pressure [8 (8-10) vs. 8 (6-8); p = 0.037], and lower mixed venous oxygen saturation within the first 24 h (69.2 vs. 76; p = 0.027). OSA patients also had longer hospital stays (11 vs. 8 days; p = 0.014). Trends toward a heightened subclinical inflammatory state were noted in the OSA group. Conclusions: OSA is frequent and underdiagnosed in patients with severe AS and is associated with more complicated postoperative recovery. Systematic OSA screening is recommended for candidates undergoing aortic valve surgery.

Impact of Left Ventricular Mass on Mortality in Symptomatic Severe Aortic Stenosis: A Sex-Specific Analysis.

Aortic stenosis (AS) is a common and serious valvular disease in older adults, often leading to increased left ventricular mass (LVM) due to pressure overload. Excessive LVM is linked to adverse outcomes, but its sex-specific prognostic significance remains unclear. Focusing on sex-based differences, this study evaluated the left ventricular mass index (LVMi) prognostic value in patients with symptomatic severe AS. We retrospectively analyzed 531 outpatients (283 men, 248 women; mean age 74.7 years) with symptomatic but stable severe AS and no prior valve procedures. Clinical and echocardiographic data were collected between April 2020 and February 2024, with a mean follow-up of 2.67 years. A total of 165 patients (31.1%) died during follow-up, 86% from cardiovascular causes. Deceased patients had lower ejection fraction and higher LVMi. Multivariate Cox analysis identified LVMi and atrial fibrillation (AF) as independent predictors of mortality, while valve intervention predicted survival. In women, both LVMi and AF predicted mortality; valve intervention was protective. In men, only the lack of valve intervention predicted death. Elevated LVMi was a strong predictor of mortality in non-operated patients, with the most pronounced impact observed in women with severe AS.

Complex Transfemoral Access During Transcatheter Aortic Valve Replacement: A Narrative Review of Management, Complexity Scores, and Alternative Access.

Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for severe aortic stenosis across all levels of surgical risk. While transfemoral access remains the default approach, complications arising from vascular access-especially in patients with peripheral artery disease (PAD)-pose significant challenges. Hostile vascular access, characterized by narrow vessel diameters, severe calcification, and tortuosity, complicates the procedure and necessitates alternative strategies. Recent advancements, such as intravascular lithotripsy (IVL), have shown promise in managing severely calcified arteries, improving the feasibility of transfemoral TAVR in patients previously considered ineligible. IVL uses pulsatile sonic waves to fragment arterial calcifications, enhancing vessel compliance and facilitating safe device delivery. Studies have demonstrated that IVL-assisted TAVR improves procedural success and reduces complications in patients with PAD. Additionally, orbital atherectomy, an adjunctive therapy targeting both concentric and eccentric calcifications, may complement the management of complex arterial calcification. The Hostile and passage-puncture scores offer valuable risk stratification tools for predicting vascular complications, aiding in better access site selection. Post-procedural echocardiography, particularly femoral artery sonography, may also play a role in detecting vascular complications early, enabling timely intervention. Finally, alternative access sites are increasingly being explored, with emerging data helping to guide the final access site decision. As TAVR continues to expand into lower risk populations, optimizing vascular access strategies remains essential to improving procedural outcomes. This review highlights the importance of preoperative imaging, endovascular techniques, and post-procedural monitoring in overcoming vascular challenges and ensuring successful TAVR outcomes.

Transcarotid transcatheter aortic valve replacement combined with percutaneous coronary intervention for severe aortic stenosis with coronary artery disease in a tortuous aortic arch: a Case Report

Transcatheter Aortic Valve Replacement (TAVR) is currently the preferred treatment option not only for high-surgical-risk patients with severe aortic stenosis (AS) but also increasingly for those with intermediate and low surgical risk. Coronary artery disease (CAD) is one of the most common complications in severe AS patients, making percutaneous coronary intervention (PCI) a frequent clinical requirement in cases of severe AS complicated by CAD. The coexistence of Aortic Tortuosity and aortic stenosis is extremely rare.We report a case of an elderly male with severe aortic stenosis combined with coronary artery disease, who underwent successful transcarotid TAVR and PCI due to a Z-shaped fold tortuosity in the aortic arch, making femoral access challenging. The patient was able to ambulate the following day and was discharged on the fifth postoperative day with stable follow-up. As of this writing, no related reports of combined transcarotid TAVR and PCI have been published.

IMPACT OF A TRANSCATHETER AORTIC VALVE COORDINATION PROGRAM ON HOSPITAL AND PATIENT OUTCOMES

IMPACT OF A TRANSCATHETER AORTIC VALVE COORDINATION PROGRAM ON HOSPITAL AND PATIENT OUTCOMES

ACUTE AORTIC ARCH PSEUDOANEURYSM AS A DELAYED COMPLICATION OF TAVR: SUCCESSFUL EMERGENCY BAIL–OUT WITH AN ENDOVASCULAR–HYBRID APPROACH

ACUTE AORTIC ARCH PSEUDOANEURYSM AS A DELAYED COMPLICATION OF TAVR: SUCCESSFUL EMERGENCY BAIL–OUT WITH AN ENDOVASCULAR–HYBRID APPROACH

TO BE OR NOT TO BE? AN UNCOMMON CASE OF AORTIC VALVE STENOSIS

TO BE OR NOT TO BE? AN UNCOMMON CASE OF AORTIC VALVE STENOSIS

SAFE AND EFFECTIVE REDO–TAVR WITH EDWARDS SAPIEN 3 IN A DEGENERATED ACURATE NEO2 VALVE: A CASE REPORT

SAFE AND EFFECTIVE REDO–TAVR WITH EDWARDS SAPIEN 3 IN A DEGENERATED ACURATE NEO2 VALVE: A CASE REPORT

MANAGING SEVERE AORTIC STENOSIS AND ATRIAL FIBRILLATION IN A FRAIL OCTOGENARIAN WITH HIGH SURGICAL AND BLEEDING RISKS: A CASE REPORT

MANAGING SEVERE AORTIC STENOSIS AND ATRIAL FIBRILLATION IN A FRAIL OCTOGENARIAN WITH HIGH SURGICAL AND BLEEDING RISKS: A CASE REPORT

Trends and Outcomes of TAVR: An Analysis Using the National Inpatient Sample and Readmissions Database.

Background: Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for severe aortic stenosis in high- and intermediate-risk patients, with expanding indications for lower-risk populations. However, post-procedural complications, such as stroke, conduction disturbances, and heart failure readmissions, remain concerns. The aim of our study is to analyze the national trends in TAVR procedures, in-hospital outcomes, major readmission causes, and the association of risk factors for readmissions following TAVR. Methods: We analyzed NIS data (2018-2022) to assess TAVR utilization trends, patient demographics, and in-hospital outcomes. The NRD (2021-2022) was used to evaluate 60-day readmission rates for stroke, complete heart block, and heart failure. Multivariate regression models were employed to identify risk factors having significant association with major readmission causes. Results: TAVR utilization increased from 10,788 cases in 2018 to 17,784 in 2022, with a concurrent decrease in in-hospital mortality (1.33% to 0.90%) and length of stay (3.88 to 2.97 days). Of 123,376 TAVR index admissions in 2021, 28,654 patients had 66,100 readmission events (53.57%) in the 60 days following discharge. Heart failure (17,566 cases, 26.57% of readmissions) was the most common readmission cause, followed by complete heart block (1760 cases, 2.66% of readmissions) and stroke (284 cases, 0.42% of readmissions). Predictors of post-TAVR stroke included uncontrolled hypertension (OR 2.29, p < 0.001) and chronic heart failure (OR 2.73, p < 0.001). Left bundle branch block (LBBB) was strongly associated with complete heart block (OR 12.89, p < 0.001) and heart failure readmissions (OR 7.65, p < 0.001). Conclusions: TAVR utilization has increased with improving perioperative outcomes, but post-TAVR readmissions remain significant, particularly for heart failure, stroke, and conduction disturbances. Pre-procedural uncontrolled hypertension, hyperlipidemia, congestive heart failure, and atrial fibrillation were risk factors with significant association with stroke in the 60 days following TAVR. The presence of documented pre-procedural LBB, RBB, as well as BFB were risk factors with significant association with complete heart block following TAVR placements. Pre-procedural LBB, RBB, BFB, and atrial fibrillation were risk factors having significant association with heart failure readmissions in the 60 days following TAVR.