Severe Bicuspid Aortic Valve Stenosis Research Articles

Progression of the ascending aorta diameter after surgical or transcatheter bicuspid aortic valve replacement.

Ascending aorta dilatation in patients with bicuspid aortic valve is related both to genetic and haemodynamic factors. Aim of this study is to compare late progression of ascending aorta dilatation in bicuspid aortic valve patients undergoing surgical aortic valve replacement (SAVR) vs transcatheter aortic valve implantation (TAVI). Data of 189 consecutive patients who underwent aortic valve replacement for severe bicuspid aortic valve stenosis were prospectively collected. Patients who underwent SAVR were compared to patients who underwent TAVI. Indication to the procedure was validated by the institutional Heart Team. Aortic diameters were evaluated by transthoracic echocardiogram. Differences between preoperative and long-term follow-up ascending aorta diameters were compared in the two groups. Between January 2015 and December 2021, 143(76%) patients underwent SAVR and 46(24%) patients underwent TAVI. At 4.6 (Standard Deviation, SD 1.7) years follow-up, patients in the TAVI group showed significantly lower survival (P = 0.00013) and event-free survival (P < 0.0001). Ascending aorta diameter progression was lower in surgical compared to transcatheter patients, 0.95(0.60,1.30) mm vs 1.65(0.67, 2.63) mm, P = 0.02. Ascending aorta diameter progression indexed for body surface area and height, was lower in the surgical group: 0.72(0.38,1.05) mm/m2 vs 1.05(0.39,1.71) mm/m2 P = 0.02, and 0.59(0.36,0.81) mm/m vs 1.11(0.44,1.78) mm/m, P = 0.001, respectively. At multivariable linear regression analysis transcatheter procedure, baseline aortic diameter, and paravalvular leak were significantly associated with increased postoperative ascending aorta dilatation. Bicuspid aortic valve patients who underwent SAVR, showed significantly less long-term ascending aorta diameter progression than patients who underwent transcatheter procedure.

Abstract 14046: Cardiac Tamponade: A Handy Case of Early Detection

Case Presentation: A 63-year-old man with severe bicuspid aortic valve stenosis underwent surgical aortic valve replacement and the post operative echocardiogram was normal.In the month after discharge, the patient developed progressive episodes of lightheadedness, fatigue, and exertional weakness. He had no associated dyspnea on exertion, chest pain or fever. He was alerted of new sinus tachycardia on his Apple Watch, and the ECG morphology began changing with an overall decrease in QRS amplitude as well as alternating QRS amplitudes consistent with electrical alternans (Figure 1). These ECG strips were sent to the patient’s cardiologist who suspected a pericardial effusion due to these characteristic ECG findings.The patient underwent outpatient echocardiography which showed a normal functioning bioprosthetic valve with new large circumferential pericardial effusion and signs of cardiac tamponade physiology. The patient was admitted and underwent urgent pericardial drain placement with removal of 250cc of serosanguineous fluid. He recovered and was discharged with 3 months of colchicine. Discussion: Pericardial effusions are a known potential complication after cardiac surgery and often have an occult presentation making detection difficult. Smart watches with ECG capabilities provide valuable data because they can be used to detect the development of a new tachycardia and changes in QRS morphology. By observing the progressive changes in the QRS morphology from baseline, it is possible to monitor for the development of electrical alternans. This finding coupled with the patient’s clinical presentation prompted rapid evaluation and treatment. Conclusions: The Apple Watch can perform single-lead ECGs which are capable of diagnosing arrhythmias including atrial fibrillation. This case now opens the door to the early detection of postoperative pericardial effusions by monitoring the Apple watch for electrical alternans.

Última generación de prótesis percutáneas expandibles con balón y autoexpandibles en la estenosis aórtica bicúspide: estudio TRITON

Introduction and objectivesNo comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis. MethodsMulticenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days. ResultsA total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation. ConclusionsIn patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.Full English text available from:www.revespcardiol.org/en

Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study

Introduction and objectivesNo comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis. MethodsMulticenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days. ResultsA total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation. ConclusionsIn patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.

Definition of trAnscatheter heart Valve orIeNtation in biCuspId aortic valve: The DA VINCI pilot study.

To assess the impact of conventional transcatheter heart valve (THV) commissural alignment techniques on THV/coronary overlap and coronary access (CA) after transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV). Specific Evolut Pro/Pro + and Acurate Neo2 THV orientations are associated with reduced neo-commissural overlap with coronary ostia in tricuspid aortic anatomy. Whether standard orientation techniques are effective also in the setting of BAV anatomy has not been studied. The DA VINCI (Definition of trAnscatheter aortic Valve orIeNtation in biCuspId aortic valve) pilot study is a prospective registry enrolling consecutive patients with severe BAV stenosis undergoing TAVR with last generation supra-annular tall-frame THVs implanted with a cusp overlap view-based commissural alignment. Patients underwent pre- and post-TAVR computed tomography (CT) and coronary angiography. The study endpoint was the rate of favorable THV/coronary overlap, defined as an angle > 40° between the THV commissural post and coronary ostia. Other endpoints were the rates of successful THV alignment with respect to the raphe and of selective CA after TAVR. Moreover, different virtual THV alignment models were tested to identify which one would produce the lower degree of THV/coronary overlap. Thirty-four patients with type 1 BAV with right-left raphe undergoing TAVR (23 with Evolut Pro/Pro + and 11 with Acurate Neo2) were included. At pre-TAVR CT, moderate/severe cusp asymmetry was found in 50% of patients, severe coronary ostia eccentricity was observed in 47.1% for the RCA vs. 8.8% for the LCA (P < 0.007). Correct TVH orientation was achieved in 29 cases. At post-TAVR CT, optimal THV alignment/mild misalignment to the raphe was observed in 86.2%, but a moderate/severe overlap with the coronaries was seen in 13.7% for the RCA and 44.8% for the LCA (P = 0.019). After TAVR, selective RCA cannulation was possible in 82.8% vs. 75.9% for the LCA (P = 0.74), while combined selective CA of both coronaries was possible in less than two-thirds of the patients. Virtual THV alignment in the coronary ostia overlap view assuming a hypothetical circular THV expansion would produce an optimal THV/coronary overlap in almost 90% of cases. Given cusp asymmetry and coronary ostia eccentricity of BAV combined with potential THV asymmetrical expansion, conventional commissural alignment techniques are associated with higher rates of THV misalignment and of moderate/severe neo-commissure overlap with the coronary ostia as compared to tricuspid aortic stenosis, resulting in lower rates of selective CA after TAVR. A modified THV orientation technique based on the coronary ostia overlap view might be preferable in BAV patients.

Transcatheter versus surgical aortic valve replacement for stenotic bicuspid aortic valve: Systematic review and meta-analysis

ObjectivesBicuspid aortic valves have been excluded from randomized trials comparing transcatheter aortic valve replacement with surgical aortic valve replacement. We aimed to evaluate the outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with severe bicuspid aortic valve stenosis using a meta-analysis. MethodsMEDLINE and EMBASE were searched through March 2022 to identify observational studies comparing transcatheter aortic valve replacement and surgical aortic valve replacement for severe bicuspid aortic valve stenosis. Outcomes of interest were in-hospital outcomes, including all-cause mortality, stroke, vascular complication, permanent pacemaker implantation, acute kidney injury, blood transfusion, paravalvular leak, and all-cause mortality during follow-up. ResultsFour propensity score–matched studies and 54,047 patients (transcatheter aortic valve replacement, n = 3841; surgical aortic valve replacement, n = 50,206) yielding 3142 pairs using propensity score were included. Median follow-up periods were 21 to 24 months. There were no significant differences in in-hospital mortality (risk ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .19) or stroke (risk ratio, 0.86; 95% confidence interval, 0.64-1.14; P = .29). Although transcatheter aortic valve replacement was associated with higher risks of permanent pacemaker implantation rate (risk ratio, 1.87; 95% confidence interval, 1.23-2.84; P = .0003), transcatheter aortic valve replacement was associated with lower risks of acute kidney injury (risk ratio, 0.58; 95% confidence interval, 0.38-0.88; P = .01) and transfusion (risk ratio, 0.25; 95% confidence interval, 0.21-0.29; P = .0001). There were no significant differences in in-hospital vascular complication, paravalvular leak, and all-cause mortality during follow-up. ConclusionsIn selected patients with severe bicuspid aortic valve stenosis, no significant differences in in-hospital mortality or stroke were observed between transcatheter aortic valve replacement and surgical aortic valve replacement. Further investigations with long-term follow-up and morphological features are warranted.

The Manchester experience – a novel technique for supra-annular placement of the Edwards SAPIEN 3 Ultra TVH prosthesis in severe bicuspid aortic valve stenosis

Abstract Background Bicuspid AV disease has been excluded from the seminal trials evaluating transcatheter heart valve (THV) placement in severe aortic stenosis. Although registry data has shown good results overall, case selection likely involves more challenging anatomical subsets being treated either surgically or medically in this very heterogenous condition. Conventional annular placement, as well as high annular placement in tapered anatomies remain the commonest deployment techniques. We reasoned that marked supra-annular placement with the mid-portion of the SAPIEN 3 Ultra (S3U) valve sealing skirt placed at the narrowest opening point at commissural level could be an alternative strategy allowing treatment of additional patient groups. This proposed technique takes advantage of elliptical expansion at commissural level with more circular expansion above and below this point to prevent embolisation, as well as sealing skirt positioning at the narrowest opening point to prevent paravalvular leak. Aims We examined the feasibility of marked supra-annular placement of the balloon-expandable S3U prosthesis with the mid-point of the sealing skirt placed at commissural level in patients with severe bicuspid aortic valve stenosis and relative contra-indications to annular placement. Methods We assessed patients with severe bicuspid aortic stenosis undergoing TAVI at our centre over a 9-month period and identified those with relative contra-indications to conventional annular placement. These included: (i) excessive annular size (ii) severe leaflet and raphe calcification with risk of rupture into the right ventricle (iii) excessive leaflet length with potential leaflet overhang. CT imaging was used to define the narrowest opening location at commissural level, typically 10–15mm supra-annular. The diameter at this level was used to select THV size. Calculations were made to approximate the mid skirt level to this supra-annular position. In most cases this involved supra-annular positioning with the lower THV border 5–8mm supra-annular. This was achieved in most cases by aligning the unexpanded border with the annulus. Results Out of 9 patients with biscupid AV, 4 had relative contra-indications for annular placement. In all 4 cases, excellent valvular expansion with only minimal paravaulvar leak was achieved with placement of the S3U prosthesis at 5–7mm above the annulus and with supra-annular sealing at commissural level. Annular dimensions of 35.5mm and 31.5mm were successfully treated with 29mm and 26mm valves due to significant tapering at commissural level in 2 patients. There were no procedural complications, incidences of AV blocks or valve embolisation. Conclusion As a proof of concept, we have demonstrated excellent outcomes with marked supra-annular TAVI placement in patients with severe bicuspid AV stenosis and anatomy unfavourable for conventional annular placement. This is the first description of this completely novel deployment technique. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Manchester Royal Infirmary

Debate: Severe bicuspid aortic valve stenosis in non-high-risk surgical patients. In favor of TAVI

Debate: Severe bicuspid aortic valve stenosis in non-high-risk surgical patients. In favor of TAVI

Debate: Severe bicuspid aortic valve stenosis in non-high-risk surgical patients. In favor of surgery

Debate: Severe bicuspid aortic valve stenosis in non-high-risk surgical patients. In favor of surgery

Latest Advances in Transcatheter Aortic Valve Implantation (2022)

Since the last decade, transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with symptomatic severe aortic stenosis (AS) who are ineligible or at higher risk for surgery. Due to the high safety profile of current device generation, TAVI has emerged as a qualified alternative to surgical aortic valve replacement (SAVR) in patients with classic aortic stenosis and intermediate surgical risk, severe bicuspid aortic valve stenosis, and isolated pure aortic regurgitation. Moderate aortic stenosis, with and without concomitant heart failure with reduced ejection fraction, are under investigation in randomized controlled clinical trials from which we will gain exciting insights on the best timing of TAVI to protect the left ventricle from further functional deterioration due to increasing AS. In these cases, a meticulous diagnostic approach including advanced imaging is becoming more and more important. Current evidence on antithrombotic strategies after TAVI is weak, contributing to poor levels of standardization and high variability in daily clinical practice. This review will provide a short overview of recent clinical trials including best timing for TAVI with moderate AS and antithrombotic strategies after TAVI with current and future TAVI generations.

Safety and Efficacy of Myval Implantation in Patients with Severe Bicuspid Aortic Valve Stenosis-A Multicenter Real-World Experience.

Bicuspid aortic valve (BAV) is the most common valvular congenital anomaly and is apparent in nearly 50% of candidates for AV replacement. While transcatheter aortic valve implantation (TAVI) is a recommended treatment for patients with symptomatic severe aortic stenosis (AS) at all surgical risk levels, experience with TAVI in severe bicuspid AS is limited. TAVI in BAV is still a challenge due to its association with multiple and complex anatomical considerations. A retrospective study has been conducted to investigate TAVI’s procedural and 30-day outcomes using the Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd. Vapi, Gujarat, India) in patients with severe bicuspid AS. Data were collected on 68 patients with severe bicuspid AS who underwent TAVI with the Myval THV. Baseline characteristics, procedural, 30-day echocardiographic and clinical outcomes were collected. The mean age and STS PROM score were 72.6 ± 9.4 and 3.54 ± 2.1. Procedures were performed via the transfemoral route in 98.5%. Major vascular complications (1.5%) and life-threatening bleeding (1.5%) occurred infrequently. No patient had coronary obstruction, second valve implantation or conversion to surgery. On 30-day echocardiography, the mean transvalvular gradient and effective orifice area were 9.8 ± 4.5 mmHg and 1.8 ± 0.4 cm2, respectively. None/trace aortic regurgitation occurred in 76.5%, mild AR in 20.5% and moderate AR in 3%. The permanent pacemaker implantation rate was 8.5% and 30-day all-cause death occurred in 3.0% of cases. TAVI with the Myval THV in selected BAV anatomy is associated with favorable short-term hemodynamic and clinical outcomes.

90 Annular size and interaction with trans-catheter aortic valves for the treatment of severe bicuspid aortic valve stenosis: insights from the beat registry

Abstract Aims Transcatheter aortic valve replacement (TAVR) is safe and feasible in patients with bicuspid aortic valve (BAV), but whether annular size may influence TAVR results in BAV patients remains unclear. We aimed at evaluating the impact of aortic annular size on procedural and clinical outcomes of BAV patients undergoing TAVR, as well as potential interactions between annular dimension and trans-catheter heart valve (THV) type [balloon-expandable (BEV) vs. self-expanding (SEV)]. Methods and results BEAT is a multicentre registry of consecutive BAV stenosis undergoing TAVR. For this sub-study patients were classified according to annular dimension in small-annulus (area &amp;lt; 400 mm2 or perimeter &amp;lt;72 mm), medium-annulus (area ≥ 400 and &amp;lt; 575 mm2, perimeter ≥72 mm and&amp;lt; 85 mm), large-annulus (area ≥575 mm2 or perimeter ≥85 mm). Primary endpoint was Valve Academic Research Consortium-2 (VARC-2) device success. 45(15.5%) patients had small, 132(45.3%) medium, and 114(39.2%) large annuli. Compared with other groups, patients with large annuli were more frequently male, at younger age, had higher body mass index, larger aortic valve area, higher rate of moderate-severe calcification, lower mean trans-aortic valve gradient and lower left ventricular ejection fraction. In large-annuli SEVs were associated with a lower VARC-2 device success (75.9% vs. 90.6%, P = 0.049) driven by a higher rate of paravalvular valvular leak (PVL) compared to BEVs (20.7% vs. 1.2%, P &amp;lt; 0.001). However, no differences in clinical outcomes were observed according to annular size nor THV type. Conclusions TAVR in BAV patients is feasible irrespective of annular size. However in patients with large aortic annulus SEVs were associated with a significantly higher rate of PVLs compared to BEVs.

Annular size and interaction with trans-catheter aortic valves for treatment of severe bicuspid aortic valve stenosis: Insights from the BEAT registry

BackgroundTranscatheter aortic valve replacement (TAVR) is safe and feasible in patients with bicuspid aortic valve (BAV), but whether annular size may influence TAVR results in BAV patients remains unclear. We aimed at evaluating the impact of aortic annular size on procedural and clinical outcomes of BAV patients undergoing TAVR, as well as potential interactions between annular dimension and trans-catheter heart valve (THV) type (balloon-expandable (BEV) vs. self-expanding (SEV). MethodsBEAT is a multicenter registry of consecutive BAV stenosis undergoing TAVR. For this sub-study patients were classified according to annular dimension in small-annulus (area < 400 mm2 or perimeter <72 mm), medium-annulus (area ≥ 400 and < 575 mm2, perimeter ≥72 mm and< 85 mm), large-annulus (area ≥ 575 mm2 or perimeter ≥85 mm). Primary endpoint was Valve Academic Research Consortium-2 (VARC-2) device success. Results45(15.5%) patients had small, 132(45.3%) medium, and 114(39.2%) large annuli. Compared with other groups, patients with large annuli were more frequently male, younger, with higher body mass index, larger aortic valve area, higher rate of moderate-severe calcification, lower mean trans-aortic valve gradient and lower left ventricular ejection fraction. In large-annuli SEVs were associated with a lower VARC-2 device success (75.9% vs. 90.6%, p = 0.049) driven by a higher rate of paravalvular valvular leak (PVL) compared to BEVs (20.7% vs. 1.2%, p < 0.001). However, no differences in clinical outcomes were observed according to annular size nor THV type. ConclusionsTAVR in BAV patients is feasible irrespective of annular size. However in patients with large aortic annulus SEVs were associated with a significantly higher rate of PVLs compared to BEVs.

TCT-235 Annular Size and Its Interaction With Self-Expandable Versus Balloon-Expandable Transcatheter Heart Valves for the Treatment of Patients With Severe Bicuspid Aortic Valve Stenosis: Insights from the BEAT Registry

TCT-235 Annular Size and Its Interaction With Self-Expandable Versus Balloon-Expandable Transcatheter Heart Valves for the Treatment of Patients With Severe Bicuspid Aortic Valve Stenosis: Insights from the BEAT Registry

THE TUNNEL-VISION EFFECT OF COVID-19: AN INCIDENTAL DISCOVERY OF SEVERE BICUSPID AORTIC VALVE STENOSIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bicuspid aortic valve is the most common congenital valvular abnormality, and has an autosomal dominant pattern with incomplete penetrance. Early recognition in the outpatient setting is imperative to prevent the development of aortic stenosis, particularly before it becomes severe. Once the disease progresses to end stage, patients may begin to experience dyspnea on exertion, syncope, and orthopnea. CASE PRESENTATION: We present a case of a 52-year-old male with complaints of shortness of breath, retrosternal chest pain, and nonproductive cough. His dyspnea began 3 months ago, but have progressed to where he felt dyspneic at rest 6 hours prior to admission. He had a positive SARS-CoV-2 PCR two weeks prior at an ancillary testing site. He worked as an iron welder for 37 years, and stated that he hasn't seen a physician in years. Despite a negative SARS-CoV-2 PCR in the ED, he was placed in negative pressure isolation. His initial vitals were BP 114/84, HR 124, RR 36, SpO2 91% on room air, and temperature 102.2 F. There was a loud systolic murmur over the precordium (clearly audible over the ventilation equipment), bibasilar rhonchi on auscultation, minimally elevated JVD, and no bipedal edema. Labs revealed a troponin of 0.152 ng/dL and proBNP 2020 pg/mL, and CXR AP view showed an enlarged cardiac silhouette and minimal bibasilar infiltrate. EKG revealed sinus tachycardia of 120 bpm and LBBB. He was given IVF and IV antibiotics for suspected sepsis due to superimposed bacterial pneumonia. Transthoracic echocardiogram revealed severe bicuspid aortic valve stenosis (velocity 4.01 m/sec, mean PG 42.8 mm Hg, and AVA di 0.75 cm2) and LVEF 30-35%. The following morning, the patient went into flash pulmonary edema requiring urgent intubation and mechanical ventilation. Surprisingly, his repeat SARS-CoV-2 PCR was positive, however his clinical picture was more suggestive of decompensated heart failure rather than active COVID-19. He was aggressively diuresed and extubated 3 days later, and was successfully discharged home with close follow up for possible surgical intervention. DISCUSSION: Bicuspid aortic valve is one of the most significant risk factors leading to severe aortic stenosis (1). Symptoms may remain clinically silent for years, and usually occur only when there is an increase in LVEDP (1). In our case, the patient's recent diagnosis of COVID-19 two weeks prior was a smoke screen of his more insidious underlying valvulopathy. Luckily, he did not succumb to COVID-19, as an international registry of 74 patients with untreated severe aortic stenosis who developed COVID-19 had a mortality of 59.5% and 23.5% for those older and less than 80 years, respectively (2). CONCLUSIONS: It is imperative that we as clinicians remain vigilant and avoid becoming fixated on COVID-19 and its complications, as this may obscure an underlying disease with harmful repercussions if left untreated. REFERENCE #1: Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD;American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63(22):e57-185. doi: 10.1016/j.jacc.2014.02.536. Epub 2014 Mar 3. Erratum in: J Am Coll Cardiol. 2014 Jun 10;63(22):2489. PMID: 24603191. REFERENCE #2: Danny Dvir, Matheus Simonato, Ignacio Amat-Santos, Azeem Latib, Faraj Kargoli, Luis Nombela-Franco, Marco Agrifoglio, Francesco Giannini, Damiano Regazzoli, Bernhard Reimers, Emmanuel Villa, Victor M. Becerra-Munoz, Marco Mennuni, Andrea Rognoni, Thomas Modine, Lionel Leroux, Rodrigo Estevez-Loureiro, Roberto Nerla, Fausto Castriota, Alfredo Cerillo, Lars Sondergaard, Alessandro Iadanza, Alison Duncan, Flavien Vincent, Massimo Mancone, Lucia Bi tolo, Viviana Maestrini, Luca Testa, Wojtek Wojakowski, Stefano Salizzoni, Vinicius Esteves, Fernanda Mangione, Cleverson Zukowski, Nicolas Amabile, Mony Shuvy & Gregg W. Stone (2021) Severe Valvular Heart Disease and COVID-19: Results from the Multicenter International Valve Disease Registry, Structural Heart, DOI: 10.1080/24748706.2021.1908646 DISCLOSURES: No relevant relationships by Maie Abdullah, source=Web Response No relevant relationships by Nabil Braiteh, source=Web Response No relevant relationships by Kareem Ebeid, source=Web Response No relevant relationships by Altif Muneeb, source=Web Response No relevant relationships by Fnu Shailesh, source=Web Response

Transcatheter Aortic Valve Replacement in Low-risk Patients With Bicuspid Aortic Valve Stenosis

The outcomes of transcatheter aortic valve replacement (TAVR) in low-risk patients with bicuspid aortic valve stenosis have not been studied in a large scale, multicentered, prospective fashion. To evaluate the procedural safety, efficacy, and 30-day outcomes of TAVR in patients with bicuspid aortic stenosis at low surgical risk. The Low Risk Bicuspid Study is a prospective, single-arm trial study with inclusion/exclusion criteria developed from the Evolut Low Risk Randomized Trial. Follow-up is planned for 10 years. Patients underwent TAVR at 25 centers in the United States who were also participating in the Evolut Low Risk Randomized Trial from December 2018 to October 2019. Eligible patients had severe bicuspid aortic valve stenosis and met American Heart Association/American College of Cardiology guideline indications for aortic valve replacement. Patients underwent attempted implant of an Evolut or Evolut PRO transcatheter aortic valve, with valve size based on annular measurements. The prespecified primary end point was the incidence of all-cause mortality or disabling stroke at 30 days. The prespecified primary efficacy end point was device success defined as the absence of procedural mortality, the correct position of 1 bioprosthetic heart valve in the proper anatomical location, and the absence of more than mild aortic regurgitation postprocedure. A total of 150 patients underwent an attempted implant. Baseline characteristics include mean age of 70.3 (5.5) years, 48.0% female (n = 72), and a mean Society of Thoracic Surgeons score of 1.4 (0.6%). Most patients (136; 90.7%) had Sievers type I valve morphology. The incidence of all-cause mortality or disabling stroke was 1.3% (95% CI, 0.3%-5.3%) at 30 days. The device success rate was 95.3% (95% CI, 90.5%-98.1%). At 30 days, the mean (SD) AV gradient was 7.6 (3.7) mm Hg and effective orifice area was 2.3 (0.7) cm2. A new permanent pacemaker was implanted in 22 patients (15.1%). No patients had greater than mild paravalvular leak. Transcatheter aortic valve replacement in low-surgical risk patients with bicuspid aortic valve stenosis achieved favorable 30-day results, with low rates of death and stroke and high device success rate. ClinicalTrials.gov Identifier: NCT03635424.

Association between monocyte to high-density lipoprotein cholesterol ratio and bicuspid aortic valve degeneration

Background/aim From a pathophysiological point of view, inflammation is thought to be more dominant in bicuspid aortic valve (BAV) stenosis than tricuspid aortic valve (TAV) stenosis. Our study aimed to determine the association between monocyte to high-density lipoprotein cholesterol (HDL-C) ratio (MHR), a new inflammatory marker, and the speed of progression of stenosis and pathophysiology of BAV stenosis.Materials and methods A total of 210 severe aortic stenosis patients (70 consecutive BAV patients, 140 matched TAV patients) were retrospectively enrolled in the study. Clinical and echocardiographic data and laboratory results related to our research were collected retrospectively from the patients’ records. MHR was measured as the ratio of the absolute monocyte count to the HDL-C value.ResultsSeventy BAV (mean age: 72.0 ± 9.1 years, 42.9% female) and 140 TAV patients (mean age: 77.9 ± 8.3 years, 51.4% female) with severe aortic stenosis were enrolled in this study. There was no difference between the two groups in terms of another baseline demographic or clinic findings except age (P < 0.001). Monocyte count, hemoglobin level, mean platelet volume was significantly higher, and HDL-C level was significantly lower in the BAV group, while other lipid and CBC parameters were found to be similar. In the multivariate analysis, MHR (P = 0.005, 95% CI: 0.90–0.98) and, as expected, age (P = 0.001, 95% CI: 1.02–1.11) were found to be significant as the independent predictor of BAV, after adjusting for other risk factors. Conclusion Our study showed a significant correlation between increased MHR and BAV. MHR was determined as a significant independent predictor for the speed of progression and diagnosis of severe BAV stenosis in multivariate analysis.

Expanding the indications for transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of symptomatic severe aortic valve stenosis. Current guidelines recommend TAVI in patients at increased operative risk of death. Advanced imaging planning, new transcatheter valve platforms, procedure streamlining and growing operator experience have improved procedural safety and bioprosthetic valve performance. As a result, TAVI has been explored for other indications. Two randomized trials published in 2019 to assess TAVI in patients with symptomatic severe aortic stenosis at low operative risk have set the stage for a new wave of indications. Inyounger and low-risk patients, TAVI had an early safety benefit over surgical aortic valve replacement and was associated with faster discharge from hospital and recovery and fewer rehospitalizations. In patients with symptomatic severe aortic stenosis, TAVI has now been explored across the entire spectrum of operative risk, from inoperable to low-risk populations, in properly designed, randomized clinical trials, although data on the long-term durability of these valves are lacking. The use of TAVI in severe bicuspid aortic valve stenosis, asymptomatic severe aortic stenosis, moderate aortic stenosis in combination with heart failure with reduced ejection fraction, and isolated pure aortic regurgitation is now under investigation in clinical trials. In this Review, we provide our perspective on these evolving indications for TAVI, discuss relevant available data from clinical trials, and highlight procedural implications and caveats of new and future indications.

Lactobacillus paracasei endocarditis in a consumer of probiotics with advanced and severe bicuspid aortic valve stenosis complicated with diffuse left ventricular mid-layer fibrosis

Lactobacillus paracasei endocarditis in a consumer of probiotics with advanced and severe bicuspid aortic valve stenosis complicated with diffuse left ventricular mid-layer fibrosis

Single-Stage Repair of a Critical Aortic Coarctation, a Bicuspid Aortic Stenosis and an Ascending Aortic Aneurysm

We report a 26-year-old man with critical aortic coarctation, severe bicuspid aortic valve stenosis, infective endocarditis and ascending aortic aneurysm. He underwent simultaneously in singlestage a Bentall’s procedure and an extra-anatomic ascending-descending aortic bypass grafting by 14-mm Dacron tube, through median sternotomy. The immediate postoperative outcome was favourable. The CT scan control for 7 years after surgery showed a good patency of the extra-anatomic bypass.