Severe Degenerative Aortic Stenosis Research Articles

Association of Lipoprotein(a) With Severe Degenerative Aortic Valve Stenosis

BackgroundLipoprotein(a) (Lp[a]) is associated with the development of aortic valve calcification. ObjectivesThe aim of this study was to evaluate the association between the serum level of Lp(a) and the development of severe degenerative aortic stenosis (AS) and subsequent aortic valve replacement (AVR). MethodsA total of 44,742 patients with Lp(a) measurements and echocardiography at baseline evaluation between 2000 and 2020 were included from a single tertiary heart center. The primary outcome was the development of severe degenerative AS, defined as a transaortic maximal velocity of ≥4.0 m/s. ResultsDuring a median follow-up period of 6.8 years (Q1-Q3: 2.3-12.4 years), severe degenerative AS was diagnosed in 472 patients (1.1%), and subsequent AVR was performed in 387 patients (0.9%). Lp(a) levels were associated with risk for severe degenerative AS, with levels of 30 to 50, 50 to 100, and >100 mg/dL demonstrating adjusted HRs of 1.02 (95% CI: 0.78-1.34; P = 0.88), 1.18 (95% CI: 0.91-1.53; P = 0.22), and 1.96 (95% CI: 1.31-2.94; P = 0.001) compared to <30 mg/dL. Similarly, the risk for AVR due to severe degenerative AS was significantly associated with higher levels of Lp(a) (>100 mg/dL) (adjusted HR: 2.05; 95% CI: 1.31-3.19; P = 0.002). Such associations were not observed in the development of severe bicuspid (P = 0.63) or rheumatic (P = 0.96) AS. ConclusionsLp(a) levels >100 mg/dL were significantly associated with risk for severe degenerative AS and subsequent AVR, regardless of the baseline severity of AS. Such associations were not observed in other etiologies of severe AS.

Procedural and clinical outcomes of patients undergoing a TAVI in TAVI procedure: Rationale and design of the multicentre, prospective, observational ReTAVI registry.

Transcatheter aortic valve implantation (TAVI) is increasingly being used in younger patients and those with lower peri-procedural risk, meaning more patients will live long enough to experience structural valve deterioration (SVD) of the bioprosthesis, indicating repeated TAVI. Experience of repeated TAVI-transcatheter heart valve (THV) implantation into an index THV is limited. This registry aims to assess the peri-procedural and short-term safety, efficacy and durability of repeated TAVI. The ReTAVI Prospective observational registry is an investigator-initiated, multicentre, international, prospective registry of patients undergoing repeated TAVI using balloon-expandable SAPIEN prosthesis to evaluate procedural and short-term safety, efficacy and durability as well as anatomical and procedural factors associated with optimal results. The registry will enrol at least 150 patients across 60 high-volume centres. Patients must be ≥18 years old, have had procedural success with their first TAVI, have index THV device failure, intend to undergo repeated TAVI and be considered suitable candidates by their local Heart Team. All patients will undergo a 30-day and 12-month follow-up. The estimated study completion is 2025. The registry will collect pre-, peri-, postoperative and 12-months data on patients undergoing repeated TAVI procedures with THVs for failure of the index THV and determine VARC-3-defined efficacy and safety at 30 days and functional outcome at 12 months. The registry will expand existing data sets and identify patient characteristics/indicators related to complications and clinical benefits for patients with symptomatic severe calcific degenerative aortic stenosis.

Improved Endothelial and Autonomic Function after Transcatheter Aortic Valve Implantation.

Degenerative aortic stenosis is an atherosclerotic-like process associated with impaired endothelial and autonomic function. Transcatheter aortic valve implantation (TAVI) has become a treatment of choice for patient with severe degenerative aortic stenosis at high surgical risk. The effect of this procedure on endothelial function measured with flow mediated dilatation (FMD) and autonomic function measured with heart rate variability (HRV) at different time-points of disease management (early and late follow-up) remains unknown. We prospectively included 50 patients with severe aortic stenosis who were deemed suitable for TAVI by the Heart Team. FMD and HRV parameters were collected at baseline ( 24 h pre-TAVI), at early follow-up (up to 48 h post-TAVI) and at late follow-up (3-6 months post-TAVI). 43 patients (mean age 81 (75-85); 60% women) completed the study. FMD significantly improved from 2.8 1.5% before TAVI to 4.7 2.7% early after TAVI (p 0.001) and was later maintained on late follow-up (4.8 2.7%, p = 0.936). Conversely, high-resolution ECG parameters remained preserved at early and improved at late follow-up after TAVI. Significant improvement was detected in a high frequency-domain parameter-HF (from 5231 1783 to 6507 1789 ; p = 0.029) and in two Poincare plot parameters: ratio of the short- and long-term R-R variability in the Poincare plot-SD1/SD2 (from 0.682 to 0.884 ; p = 0.003) and short-term R-R variability in the Poincare plot-SDRR (from 9.6 to 23.9 ms; p = 0.001). Echocardiographic parameters comprising baseline maximal aortic valve velocity (R = 0.415; p = 0.011), mean aortic gradient (R = 0.373; p = 0.018), indexed stroke volume (R = 0.503; p = 0.006), change in aortic valve maximal velocity (R = 0.365; p = 0.031), change in mean aortic gradient (R = 0.394; p = 0.019) and NT-proBNP (R = 0.491; p = 0.001) were found as significant predictors of change in FMD. Endothelial function measured with FMD and autonomic function obtained with HRV parameters significantly improve after TAVI. While endothelial function improves early and is maintained later after TAVI, autonomic function remains stable and improves on late follow-up. This is most likely caused by early hemodynamic changes after resolution of aortic valve obstruction and gradual left ventricular remodeling. www.clinicaltrials.gov, identifier NCT04286893.

Value of NT-proBNP and Galectin-3 as Biomarkers in the Follow-Up of Asymptomatic Elderly Patients with Severe Aortic Stenosis.

Recognizing symptoms in elderly patients with severe aortic stenosis (AS) can be a challenge. Serum biomarkers such as Galectin-3 or N-terminal prohormone B-type natriuretic peptide (NT-proBNP) are involved in remodeling and heart failure (HF) development and could support the diagnosis of AS. We set out to test the usefulness of NT-proBNP and Galectin-3 in predicting events in this population. We designed a prospective observational case-control study, including 50 asymptomatic patients older than 70 years, diagnosed with severe degenerative AS, and 50 control individuals. The NT-proBNP and Galectin-3 levels were measured. A follow-up was carried out at 12 months to determine the occurrence of hospital admission for HF, all-cause mortality or the appearance of symptoms. The patients with severe AS had higher Galectin-3 and NT-proBNP concentrations. The area under the receiver operating characteristic curve of the NT-proBNP was 0.812 (95% CI, 0.646-0.832), and that of the Galectin-3 was 0.633 (95% CI, 0.711-0.913). NT-proBNP was a good predictor of events [HR 3.45 (95% CI 1.32-9.03), p = 0.011]. A Kaplan-Meier analysis showed that the probability of freedom from events was significant in patients who exhibited a combination of higher NT-proBNP and Galectin-3 levels (log-rank p = 0.032). Therefore, NT-proBNP was the most reliable predictor of events in asymptomatic patients with severe AS. A combination of NT-proBNP and Galectin-3 levels may be vital in the clinical follow-up of these patients and in the decision-making process.

CT Detection of an Anomalous Left Circumflex Coronary Artery from Pulmonary Artery (ALXCAPA) in 81-Year-Old Female Patient

The left circumflex coronary artery from the pulmonary artery is a very rare congenital anomaly with few cases described, so far, worldwide. An 81-year-old female presented complaining of dyspnea. The transthoracic echocardiogram revealed severe degenerative aortic stenosis in addition to a hypertrophied left ventricle with normal function and no wall motion abnormalities. As part of the pre-TAVI planning, she underwent a CT examination, which revealed an anomalous left circumflex artery originating from the right pulmonary artery. The case is currently being managed conservatively. The presented congenital coronary anomaly is, to our knowledge, the first to be described in the literature in this age group (80+).

Abstract 11101: Q Fever Endocarditis Combined With Thrombus and Antiphospholipid Syndrome

A 63-year-old-man presented to our institution with dyspnea. Transthoracic echocardiography (TTE) showed severe degenerative aortic stenosis with regurgitation and decreased left ventricular contractility. Subsequent transesophageal echocardiography (TEE) and cardiac computed tomography (CT) revealed an outpouching structure at aortomitral intervalvular fibrosa (AMIVF) (Fig A to D), which was compatible with pseudoaneurysm and suggested sequelae of previous infective endocarditis. On surgery, thickened AV leaflets were noted, especially on NCC and LCC (Fig E). When extracting the AV leaflets, subannular pouching was seen without evidence of active inflammation or infection (Fig F). AV replacement with 25-mm Sorin Mitroflow was performed.One-year TTE follow-up showed markedly increased transAV pressure gradient. TEE and cardiac CT revealed symmetric nodular thickening of bioprosthetic AV leaflets with opening limitation (Fig G to J). The patient was admitted on the diagnosis of subclinical bioprosthetic valve thrombosis, and anticoagulation with warfarin and aspirin was started. During the hospitalization, the patient had persistent fever with bicytopenia and hepatosplenomegaly, but repetitive blood cultures were negative. There was no definite fever focus even in 18F-FDG PET CT (Fig K). Since the patient worked on a farm in Dangjin, Chungcheongnam-Do, South Korea, where Q fever is prevalent, an indirect immunofluorescence assay for Coxiella burnetii was conducted and the result turned out to be positive. Additional coagulopathy laboratory findings showed positive for lupus anticoagulant, anti-cardiolipin IgM, and anti-beta2 GPI IgM. Finally, the patient was diagnosed with Q fever endocarditis combined with antiphospholipid syndrome and treated with doxycycline with hydroxychloroquine and maintained anticoagulation. Recent follow-up of TTE and cardiac CT showed complete resolution of prosthetic AV thrombus.

Incidence and predictors of transthyretin cardiac amyloidosis in patients with degenerative aortic stenosis

Abstract Background The approval of new therapies for treating transthyretin (TTR) cardiac amyloidosis has led to significant interest in identifying patients at high risk for this disease. Investigators have identified a correlation between severe degenerative aortic stenosis (AS) and TTR cardiac amyloidosis in older patients, with several studies finding up to 20% of patients who undergo transcatheter aortic valve replacement (TAVR) having TTR cardiac amyloidosis. These initial TAVR studies were conducted when TAVR was performed almost exclusively in high surgical risk populations. Therefore, the true incidence of TTR cardiac amyloidosis in an all-comers with severe degenerative AS referred for TAVR is unknown. Purpose To identify the true burden of TTR cardiac amyloidosis in a contemporary population of severe degenerative AS undergoing TAVR screening. Methods All patients ≥70 years with severe native valve degenerative AS seen in a multidisciplinary valve clinic were referred for technetium-99m pyrophosphate cardiac scintigraphy (PYP scan) for evaluation of cardiac amyloidosis. Diagnosis was made via combination of planar grade and heart to contralateral lung ratio, confirmed on single positron emission computed tomography/computed tomography (SPECT/CT). Patients with a positive PYP scan were referred to a heart failure clinic where they underwent testing for AL amyloidosis. Results Over a 10 month period, 247 patients seen in valve clinic underwent a PYP scan. Of this cohort, 203 patients ultimately underwent TAVR, 15 surgical aortic valve replacement, and 2 balloon valvuloplasty with 27 patients having not yet undergone a procedure. The positivity rate was 4% (10/247) with 1 patient having an equivocal result. The patients with a positive PYP scan had higher rate of low-flow low-gradient (LFLG) AS (64% vs 29%, p=0.006) and classical LFLG AS (27% vs 8%, p=0.02). Echocardiographic measures associated with a positive PYP scan include a lower global longitudinal strain (−10.0% vs −16.1%, p=0.008), lower average e' (4.5 vs 6.5, p=0.003), and an increased E/A ratio (1.8 vs 1.1, p=0.018). Conclusions The incidence of TTR amyloidosis in a contemporary, severe AS population ≥70 years undergoing TAVR screening appears much lower than previously described in the literature. Echocardiographic traits may be able to predict which patients with severe AS should undergo evaluation for TTR cardiac amyloidosis. Funding Acknowledgement Type of funding sources: None.

Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making?

Abstract Background Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR. Purpose The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study. Methods A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI. Results All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042). Conclusions Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials. Funding Acknowledgement Type of funding sources: None.

Results of new-generation self-expanding transcatheter Porticoтм valve implantation in patients with degenerative aortic stenosis.

Aim To evaluate 30-day results of the transcatheter correction of degenerative aortic stenosis using a novel self-expandable valve, PorticoTM.Material and methods Transcatheter aortic valve implantation (TAVI) was performed in 42 patients with an intermediate surgical risk (mean age, 74.3±6.5 years, 8 men, 34 women, EuroSCORE II risk, 2.5 (1.5;4.1)) with severe degenerative aortic stenosis (AS). 20 (48 %) patients had ischemic heart disease; 8 (19%) of patients had atrial fibrillation, and 16 (38%) of patients had type 2 diabetes mellitus. Most of the patients (88 %) had preserved systolic function, and 5 patients had a pronounced decrease in left ventricular ejection fraction. Early efficacy and safety of the intervention were evaluated with VARC-2 criteria.Results In-hospital and 30-day mortality following TAVI was absent. Also, there were no adverse events, including cerebrovascular disorders, perioperative myocardial infarction, and conversion to open surgery. One patient had prosthesis migration to the aorta, which required implantation of the second self-expandable valve. Mean duration of the procedure was 90 min (80;110), fluoroscopy time was 21 min (19;24), and contrast volume 154 ml (200;240). Following TAVI, the mean aortic valve (AV) pressure gradient significantly decreased from 56.1±21.2 to 11.2±4.0 mm Hg, the maximal gradient decreased from 88.9±27.8 to 20.0±7.0 mm Hg, and the AV effective orifice area increased from 0.67±0.2 to 1.9±0.3 cm2 (p&lt;0.001). By the time of discharge from the hospital, all patients showed regression of AS clinical manifestations. The percentage of patients with NYHA functional class III chronic heart failure reduced from 62 % to 7 % (p&lt;0.001) after TAVI. In one case after the implantation, grade 3 aortic regurgitation was observed, which required endovascular occlusion to close the paraprosthetic fistula. Moderate paraprosthetic regurgitation (grade &lt;2) was observed in 3 (7 %) patients. Only 2 (4.8%) patients required permanent pacemaker implantation.Conclusion Results of the single-center prospective TAVI study using a novel self-expandable valve Porticoтм showed satisfactory hemodynamic parameters, efficacy and safety of the procedure for the 30-day follow-up period. A relatively low radial force of the carcass can be beneficial for reducing the incidence of permanent pacemaker implantation after TAVI.

412 Polytetrafluoroethylene(PTFE) Pledgets Masquerading As A Pseudo-Aneurysm Of Left Ventricle Apex. A Case Report

Abstract Background TransCatheter Aortic Valve Implantation (TAVI) is now established as an alternative for open aortic valve replacement in high-risk patients with severe calcified degenerative aortic stenosis. Case presentation Here we report a case of a 78 tears old female patient who presented six months following transapical TAVI with a pulsatile mass over the left anterior mini thoracotomy wound. Transthoracic echocardiography showed suspicion of a left ventricular apical aneurysm with no evidence of free pericardial fluid.Contrast enhanced CT reported a large pseudo-aneurysm arising from the apex of the left ventricle extending through the left anterior thoracic wall. She was scheduled for emergency surgical exploration via median sternotomy. Upon median sternotomy there were dense pericardial adhesions limiting the mobilization of the heart specially the apex, which necessitated establishment of cardiopulmonary bypass. The heart was arrested, and the dissection was completed. The cavity in connection with the ventricular apex had purulent contents and the site of the TAVI ventriculotomy was secure with the PTFE pledgets in place with no evidence of leakage. Samples of the cavity fluids had pus cells, but no organisms were grown. The patient made an uneventful recovery and was discharged home 6 days postoperatively. Discussion PTFE pledgets are frequently used in cardiac surgery to support surgical closure. These pledgets on a contrast enhanced CT scan can make it difficult to correctly diagnose and may mimic anastomotic leaks as both give similar hyper-dense appearance on contrast enhanced CT scan

Preserved Th2 lymphocytes improve prognosis of diabetic patients undergoing TAVR

Abstract Introduction Previous studies have shown that presence of diabetes (DM) worsens outcome of patients after transfemoral aortic valve (TAVR). DM has been associated with pathological T-lymphocyte (T-cell) polarization, marked by decreased anti-inflammatory Th2 cells and increased pro-inflammatory Th1 cells. However, the risk-modulatory impact of T-cell polarization in diabetic patients with severe aortic stenosis has not been shown thus far. In this study we assessed the role of T-cell subsets in diabetic patients undergoing TAVR. Methods and results A total of 129 patients (76% male, median age [IQR]: 83 years [79–86]) admitted for TAVR at the University Clinic Frankfurt were enrolled. The patients were evaluated using classical risk scores and the Th1/Th2 T-cell polarization was assessed using flow cytometry. The endpoint of the study was all-cause death. Kaplan-Meier survival, ROC curve analysis and Mann-Whitney-U-Test were used in statistical analysis. The differences were considered significant by error probability p&amp;lt;0.05. Twenty-six patients died within follow up of 274 (188–367) days. The conventional risk parameters were distributed as follows: STS score: 3.45 (2.47–4.97), LVEF: 60% (45–65), CRP: 0.33 mg/dl (0.15–0.79), hsTropT: 24.5 pg/ml (16.5–40.0), IL6: 6.7 pg/ml (4.1–12.2), Hb: 12.3 g/dl (11.00–13,75), Creatinine: 1.15 mg/dl (0.93–1.54), Th1 cells = 79.88 cells/μl (55.69–122.16), Th2 cells: 25.31 cells/μl (19.69–38.33), NT-proBNP: 2033 pg/ml (1076–5531). All these parameters were associated with mortality. Hence, only Hb (AUC=0.761), NT-proBNP (AUC=0.726), Th2 cells (AUC=0.712) and STS score (AUC=0.737) provided AUC&amp;gt;0.7. Diabetes was revealed to be significantly associated with mortality in patients with and without DM (15/48 (31%) vs. 11/81 (14%), respectively, P=0.019). There were no significant differences in the counts of Th-cell subsets between diabetic and non-diabetic patients (Th1 (90.95 (62.41–154.22) vs 76.36 (53.16–100.49), P=0.072); Th2 (29.18 (20.13–43.77) vs 24.74 (20.27- 35.11), p=0.245), for DM and non-DM respectively). However, the survival rate in patients with DM and Th2 cell counts higher than or equal to the calculated optimal cut-off of 24.3 cells/μl was comparable with patients without DM (25/28 (89%) vs. 36/38 (95%), p=0.453). In contrast, diabetic patients with reduced Th2 cells (&amp;lt;24.3 cells/μl) were much more likely to die (10/15 (67%) vs. 8/34 (24%), p=0.003, patients with DM and without, respectively). Conclusion Our results show for the first time a risk-modulatory impact of T-cell immunity in diabetic patients with severe degenerative aortic stenosis. Reduced Th2 cells are strongly associated with mortality in patients considered for TAVR and significantly deteriorate prognosis in patients with concomitant diabetes. Funding Acknowledgement Type of funding source: None

Influence of EPICardial adipose tissue in HEART diseases (EPICHEART) study: Protocol for a translational study in coronary atherosclerosis

IntroductionAccumulation of epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD) and increased risk of coronary events in asymptomatic subjects and low-risk patients, suggesting that EAT promotes atherosclerosis in its early stage. Recent studies have shown that the presence of CAD affects the properties of adjacent EAT, leading to dynamic changes in the molecular players involved in the interplay between EAT and the coronary arteries over the history of the disease. The role of EAT in late-stage CAD has not been investigated. ObjectivesIn a comparative analysis with mediastinal and subcutaneous adipose tissue, we aim to investigate whether the volume of EAT assessed by computed tomography and its proteome assessed by SWATH-MS mass spectrometry are associated with late stages of CAD in an elderly cohort of severe aortic stenosis patients. MethodsThe EPICHEART study (NCT03280433) is a prospective study enrolling patients with severe degenerative aortic stenosis referred for elective aortic valve replacement, whose protocol includes preoperative clinical, nutritional, echocardiographic, cardiac computed tomography and invasive coronary angiographic assessments. During cardiac surgery, samples of EAT and mediastinal and subcutaneous thoracic adipose tissue are collected for proteomics analysis by SWATH-MS. In addition, pericardial fluid and peripheral and coronary sinus blood samples are collected to identify circulating and local adipose tissue-derived biomarkers of CAD. ConclusionWe designed a translational study to explore the association of EAT quantity and quality with advanced CAD. We expect to identify new biochemical factors and biomarkers in the crosstalk between EAT and the coronary arteries that are involved in the pathogenesis of late coronary atherosclerosis, especially coronary calcification, which might be translated into new therapeutic targets and imaging tools by biomedical engineering.

Low vitamin D levels affect left ventricular wall thickness in severe aortic stenosis.

Vitamin D [25(OH)D] deficiency and degenerative aortic stenosis represent emerging conditions, linked to a progressive ageing of the population and increased frailty. Previous studies have associated lower levels of 25 (OH)D to the pathogenesis of atherosclerosis and vascular calcifications. However, few studies have evaluated, so far, the impact of vitamin D deficiency in patients with aortic stenosis, which was therefore the aim of present study. Consecutive patients with severe degenerative aortic stenosis undergoing nonurgent coronary angiography were included. Aortic stenosis was defined as aortic valve area (AVA) less than 1 cm and/or mean gradient more than 40 mmHg. Indexed area and stroke volume or dobutamine stress evaluation were performed when indicated. Fasting samples were collected at admission for 25 (OH)D levels assessment. We included 137 patients with severe degenerative aortic stenosis (48.9% men, mean age 78.4 ± 6.4 years) who were divided according to vitamin D median values (≥12.4 ng/ml). Patients with lower vitamin D had a more frequent history of coronary artery bypass graft (P = 0.02) and received more often angiotensin-converting enzyme-inhibitors (P = 0.03). Among them, 38.7% had vitamin D levels less than 10 ng/ml and only five patients were in therapy with vitamin D supplementation. We observed no significant relationship between vitamin D levels and echocardiographic parameters for the severity of aortic stenosis (AVA, peak and mean gradients, volumes, ejection fraction) except for a greater wall thickness in patients with lower vitamin D levels (r = -0.34, P = 0.03). Results did not change when excluding patients with renal failure or treated with vitamin D supplementation. Among patients with severe degenerative aortic stenosis, vitamin D deficiency is common. We found a significant association between left ventricular wall thickness and vitamin D levels, suggesting a potential role of this hormone in modulating hypertrophic remodelling in these patients. However, future larger studies are certainly needed to confirm our findings and to define their prognostic implications.

The prognostic value of fQRSTa in patients with aortic stenosis undergoing surgical aortic valve replacement.

Surgical aortic valve replacement (sAVR) is the ultimate therapy for severe aortic stenosis (AS) in suitable patients. Prognostic factors of sAVR are great interest in recent studies. Frontal QRS-T angle (fQRSTa) is a novel marker of ventricular repolarization abnormalities. In this study, we aimed to investigate the prognostic value of fQRSTa in patients with severe symptomatic AS undergoing sAVR. A total of 372 patients with severe degenerative AS who underwent successful sAVR were included in this retrospective study. Then, patients were divided into two groups: patients with narrow fQRSTa (≤90°) as group 1 and wide fQRSTa (>90°) as group 2. Perioperative and postoperative clinical evaluation and time of death were recorded from all subjects. The incidence of total mortality was higher in patients with wider fQRSTa (13.8% [15]; 4.9% [9], P = .013) compared to patients with narrow fQRSTa. In multivariate logistic regression analysis, advanced age (odds ratio [OR] = 1.054; 95% confidence interval [CI] = 1.004-1.106; P = .034), dyspnea (OR = 7.687; 95% CI = 2.296-25.729; P = .001), lower efection fraction (OR = 0.924; 95% CI = 0.884-0.966; P = .001), in-hospital duration (OR = 1.051; 95% CI = 1.016-1.088; P = .004) and wider fQRSTa (OR = 4.029; 95% CI = 1.383-11.740; P = .011) were found to be independent predictors of mortality. Additionally, a Kaplan-Meier survival analysis also revealed that long-term survival was found to be significantly decreased in patients with wider fQRSTa (log-rank P = .014). fQRSTa was related with poor prognosis in patients with AS undergoing sAVR. fQRSTa was also an independent predictor of mortality in this population.

Research on the Effect of Aortic Valve Replacement with Mechanical Prosthesis on the Evolution of Ventricular Hypertrophy in Patients with Degenerative Aortic Stenosis

Aortic valvulopathies, and especially aortic stenosis (AS), are the most common valvular disorders. Untreated, 50% of patients with severe AS will die within 2-3 years from the onset of symptomatology. The standard treatment consists in the surgical replacement of the aortic valve with mechanical or biological prosthesis. 40 patients were included in the study after replacement of the aortic valve with double disc mechanical prosthesis for severe degenerative AS. The disks of the prosthesis are made of pyrolytic carbon characterized by extreme hardness, which provides wear protection over the years. The ring is composed of a graphite substrate coated with pyrolytic carbon and attached to a suture collar made of polyethylene (polytetrafluoroethylene - PTFE) or polyester (Dacron� or Teflon�). This study evaluates mass regression and left ventricular mass index at three months and one year postoperatively. The regression of the left ventricular mass at 3 months after the surgery is 25.86%, and at one year after the surgery this regression was reduced - 15.11%. The regression of the mass of the left ventricle and especially the premature regression, correlated with the degree of hypertrophy of the left ventricle preoperatively, highlight the beneficial effect of the double disc mechanical prosthesis.

The Prognostic Value of C-reactive Protein to Albumin Ratio in Patients with Isolated Degenerative Aortic Valve Stenosis Undergoing Surgical Aortic Valve Replacement.

ObjectiveTo evaluate the prognostic value of C-reactive protein to albumin ratio (CAR) in patients with severe aortic valve stenosis undergoing surgical aortic valve replacement (AVR).MethodsFour hundred seventy-six patients with severe degenerative aortic stenosis who underwent successful isolated surgical AVR were enrolled. Hospitalization due to heart failure, surgical aortic reoperation, paravalvular leakage rates, and long-term mortality were evaluated in the whole study group. The participants were divided into two groups, as 443 patients without mortality (group 1) and 33 patients with mortality (group 2) during the follow-up time.ResultsCAR was lower in patients without mortality than in those with mortality during the follow-up time (0.84 [0.03-23.43] vs. 2.50 [0.22-26.55], respectively, P<0.001). Age (odds ratio [OR]: 1.062, confidence interval [CI]: 1.012-1.114, P=0.014), CAR (OR: 1.221, CI: 1.125-1.325, P<0.001), ejection fraction (OR: 0.956, CI: 0.916-0.998, P=0.042), and valve type (OR: 2.634, CI: 1.045-6.638, P=0.040) were also found to be independent predictors of long-term mortality. Additionally, rehospitalization (0.86 [0.03-26.55] vs. 1.6 [0.17-24.05], P=0.006), aortic reoperation (0.87 [0.03-26.55] vs. 1.6 [0.20-23.43], P=0.016), and moderate to severe aortic paravalvular leakage (0.86 [0.03-26.55] vs. 1.86 [0.21-19.50], P=0.023) ratios were associated with higher CAR.ConclusionIt was firstly described that CAR was strongly related with increased mortality rates in patients with isolated severe aortic stenosis after surgical AVR. Additionally, rehospitalization, risk of paravalvular leakage, and aortic reoperation rates were higher in patients with increased CAR than in those without it.

Severe degenerative aortic stenosis with preserved ejection fraction does not change adipokines serum levels.

The role of the adipokines in the pathogenesis of aortic stenosis (AS) is not well established. The aim was to evaluate the relationship between adipokines and clinical characteristics as well as echocardiographic indices and noninvasive markers of vascular remodeling in patients with severe AS with preserved ejection fraction (EF). Sixty-five patients (F/M: 38/27; age: 68.3 ± 9.0 years; body mass index [BMI]: 29.6 ± 4.3 kg/m2) with severe AS with preserved EF: 33 patients with paradoxical low-flow low-gradient AS (PLFLG AS) and 32 patients with normal flow high-gradient AS (NFHG AS) were prospectively enrolled into the study. Twenty-four subjects (F/M: 14/10; age: 65.4 ± 8.7 years; BMI: 29.6 ± 4.3 kg/m2) who matched as to age, sex, BMI and coronary artery disease (CAD) constituted the control group (CG). Clinical data and markers of vascular remodeling were related to the serum adipokines. There were no differences in the adipokines concentrations in the AS/CG. Patients with AS and coexisting CAD were characterized by decreased serum adiponectin (9.9 ± 5.5 vs. 12.7 ± 5.8 μg/mL, p = 0.040) and leptin (8.3 ± 7.8 vs. 21.6 ± 17.1 ng/mL, p < 0.001) levels compared to subjects without CAD. There were no differences in the serum adipokines concentrations between patients with PLFLG AS and NFHG AS. Systemic hypertension, diabetes, hyperlipidemia or markers of vascular remodeling did not discriminate adipokines concentrations. Multivariate regression analysis indicated that age (F = 3.02; p = 0.015) and E/E' index (F = 0.87, p = 0.032) were independent predictors of the adiponectin level in the AS group. The presence of AS with preserved EF did not change the adipokine serum profile. Adipokines levels were modified by coexisting atherosclerosis but not the typical cardiovascular risk factors or the hemodynamic type of AS.

Better Myocardial Function in Aortic Stenosis with Low Left Ventricular Mass: A Mechanism of Protection against Heart Failure Regardless of Stenosis Severity?

About one-tenth to one-third of patients with severe aortic stenosis (AS) do not develop left ventricular hypertrophy (LVH). Intriguingly, the absence of LVH despite severe AS is associated with lower prevalence of heart failure (HF), which challenges the classical notion of LVH as a beneficial compensatory response. Notably, the few studies that have attempted to characterize AS subjects with inadequately low left ventricular (LV) mass relative to LV afterload (i-lowLVM) described better prognosis and enhanced LV performance in AS associated with i-lowLVM, but those reports were limited to severe AS. Our aim was to compare myocardial function between moderate and severe AS with i-lowLVM. We retrospectively analyzed in-hospital records of 225 clinically stable nondiabetic patients with isolated moderate or severe degenerative AS in sinus rhythm, free of coexistent diseases. Subjects with i-lowLVM were compared to those with appropriate or excessive LVM (a/e-LVM), defined on the basis of the ratio of a measured LVM to the LVM predicted from an individual hemodynamic load. Patients with i-lowLVM and a/e-LVM did not differ in aortic valve area, LV end-diastolic diameter (LVd, a measure of LV preload), and circumferential end-systolic LV wall stress (cESS), an estimate of LV afterload. Compared to a/e-LVM, patients with i-lowLVM had increased LV ejection fraction (EF) and especially higher LV midwall fractional shortening (a better index of LV myocardial function than EF in concentric LV geometry) (p < 0.001–0.01), in both moderate and severe AS. LVd and cESS were similar in the four subgroups of the study subjects, i.e., moderate AS with i-lowLVM, moderate AS with a/e-LVM, severe AS with i-lowLVM, and severe AS with a/e-LVM (p > 0.6). Among patients with i-lowLVM, LVM did not differ significantly between moderate and severe AS (p > 0.4), while in those with a/e-LVM, LVM was increased in severe versus moderate AS (p < 0.001). In conclusion, the association of the low-LVM phenotype with better myocardial contractility may already develop in moderate AS. Additionally, cESS appears to be a controlled variable, which is kept constant over AS progression irrespective of LVM category, but even when controlled (by increasing LVM), is not able to prevent deterioration of LV function. Whether improved myocardial performance contributes to favorable prognosis and the preventive effect against HF in AS without LVH, remains to be studied.

Transtoracical Ecocardiographic Assessment of Severe Degenerative Aortic Stenosis with Normal Ejection Fraction and Low Transvalvular Gradient

Purpose of the study: echocardiographic evaluation of the form of degenerative aortic stenosis (DAS) with preserved ejection fraction (EF) and low transvalvular gradient, in order to formulate the indication of valvular prosthesis as early as possible; retrospective observational study that includes patients admitted or sent for ambulatory evaluation by other medical services. The echocardiographic parameters used: systolic and diastolic indices, tissue and spectral, mitral and tricuspid veins, aortic orifice area, maximal aortic systolic velocity, maximal and medium aortic transvalvular gradient, myocardial mass index, volume of left atrium, left ventricular (LV) thickness. 42 patients with severe DAS and preserved EF, average age 71.7�3.85 years. Two groups were isolated: A - with increased gradient (22 patients) and B - with low gradient (20 patients). The gender distribution was comparable: women representing 33% in group A versus 30% in group B. The average age of women in both groups was higher than that of the men: in group A: 72�8 years in the case of women vs. 67�6 years in the case of men and in group B 72�3.5 years in women vs. 68�6 years in men. Apical displacement of the mitral ring: 14�2mm in lot A vs. 11�2mm in lot B. Myocardial mass index: 120 � 9g/m2 in lot A vs. 126 � 12g/m2 in lot B. Left ventricular filling ratio E/e�: 8�2 in lot A vs. 13�2 in lot B; maximum aortic systolic velocity: 4.3�0.9m/s in lot A vs. 3.1�0.8m/s in lot B; maximum gradient: 73.9�10mmHg in lot A vs. 37�12mmHg in lot B; aortic orifice area: 0.80�10.5 in lot A vs. 0.79�0.07 in lot B. Statistical analysis shows the Pearson correlation index r with the highest values of 95% at the significance threshold between the aortic orifice area and the valve opening (r=0.87), the ratio E/e� (r=-0.85) and diastolic thickness of the posterior wall of the aortic left ventricle (r = 0.78). Aortic stenosis with preserved ejection fraction and low gradient was more common in men. The filling ratio E/e� was increased (13 � 2) in group B, suggesting the increase of filling pressures of LV in patients with DAS and low transvalvular gradient. Tissue spectral systolic and longitudinal velocities were lower in group B, suggesting the onset of systolic LV dysfunction. The aortic valve opening and the E/e� ratio showed the highest correlation coefficient with the area of the aortic orifice in both groups. The myocardial mass index and the thickness of the walls of the LV cavity are similar in the two groups, suggesting that the reduction of the LV cavity through hypertrophy may not explain, at least in totality, the form of DAS with low gradient and preserved ejection fraction.

Low Left Ventricular Mass in Aortic Stenosis: A Distinct Mode of Adaptation to Pressure Overload Associated with Better Contractility?

Introduction About 10-30% of patients with severe aortic stenosis (AS) do not develop left ventricular hypertrophy (LVH). Intriguingly, the absence of LVH does not adversely affect outcome in AS, which challenges the classical notion of LVH as a beneficial compensatory response. Notably, only a few studies have attempted to characterize AS subjects with inadequately low LV mass (low-LVM) relative to afterload. We hypothesized that the low-LVM phenotype may be linked to myocardial function irrespective of AS severity. Aim: To assess relations between LV myocardial function and load in patients with low-LVM and moderate or severe AS. Methods We retrospectively analyzed hospital records of 227 patients with moderate or severe degenerative AS in sinus rhythm. Subjects with low-LVM were compared to those with appropriate or excessive LVM (ae-LVM), defined on the basis of the ratio of a measured LVM to the LVM predicted from an individual hemodynamic load. Circumferential end-systolic LV wall stress (cESS) and valvulo-arterial impedance (Zva), indices of LV afterload, were calculated from echocardiography and blood pressure. Assuming a constant LV wall volume during the cardiac cycle, we also computed LV midwall fractional shortening (mwFS), a better estimate of LV myocardial function than EF in concentric LV geometry. Results Patients with low-LVM and ae-LVM did not differ in aortic valve area, blood pressure, symptomatic status, prevalence of CAD or diabetes, end-diastolic LV diameter (a raw measure of LV preload), as well as Zva and cESS (estimates of LV afterload). Compared to ae-LVM, patients with low-LVM had higher mwFS (by 20−30%) in both moderate AS (p 0.5). Conclusions Subjects with low LVM maintain constant cESS during AS progression, probably due to higher LV contractility than in the majority of AS patients in whom the magnitude of LVH rises gradually over time. Thus, low LVM is associated with enhanced myocardial function, which may reflect a distinct mode of adaptation to chronic pressure overload, occurring already in less than severe AS. Whether better myocardial function contributes to favorable prognosis in AS without LVH, remains to be studied.