Severe Aortic Valve Stenosis Research Articles

Randomised study for the Optimal Treatment of symptomatic patients with low-gradient severe Aortic valve Stenosis and preserved left ventricular ejection fraction (ROTAS trial)

BackgroundThe best management of symptomatic patients with low-gradient (LG) severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) has not been established. The Randomised study for the Optimal...

Transcatheter aortic valve implantation for severe aortic regurgitation using the J-Valve system: A midterm follow-up study.

Transcatheter aortic valve implantation (TAVI) is a well-established intervention for severe aortic valve stenosis. However, its application for severe aortic regurgitation (AR) is still under evaluation. This study aims to present the 3-year follow-up outcomes of the J-Valve system in managing severe AR. The aim of this study was to evaluate the mid-term efficacy and durability of the J-Valve system in the treatment of severe AR and to provide new information on this intervention. In this retrospective, single-center study, we evaluated the prognostic outcomes of patients with AR, who underwent treatment with the J-Valve system at Nanjing Drum Tower Hospital. Consecutive patients who were treated with the J-Valve were included in the analysis. The study focused on the echocardiographic follow-up to assess the effectiveness and durability of the J-Valve system in managing AR. From January 2018 to December 2022, 36 high-risk AR patients treated with the J-Valve system had a procedural success rate of 97.2%, with one case requiring open-heart surgery due to valve displacement. Significant improvements were observed in left ventricular diameter (from 63.50 [58.75-69.50] mm to 56.50 [53.00-60.50] mm, p < 0.001) and left atrial diameter (from 44.00 [40.00-45.25] mm to 39.00 [36.75-41.00] mm, p = 0.003) postsurgery. All patients completed the 1-year follow-up, with an overall mortality rate of 2 out of 36 (5.6%). Among the surviving patients, there was one case of III° atrioventricular block and one case of stroke, both occurring within 90 days postsurgery. After a 3-year follow-up, 15.0% of patients had mild or moderate valvular regurgitation, with no cases of moderate or severe paravalvular leak. Additionally, 89.5% of patients were classified as New York Heart Association class I or II, showing significantly enhanced cardiac function. The J-Valve system has shown positive therapeutic outcomes in treating AR, with notable effectiveness in managing the condition and significant improvements in heart failure symptoms and cardiac remodeling. However, due to the limited sample size and partial follow-up data, it is important to emphasize the need for further research with comprehensive long-term follow-up, to fully validate these results.

Outcomes of 576 patients with extracorporeal life support for the treatment of perioperative cardiogenic shock.

This study aims to analyse the short- and long-term outcomes in patients who received extracorporeal life support for the treatment of perioperative low-output syndrome and identify risk factors for mortality. All consecutive patients who received extracorporeal life-support system during or after cardiac surgery at a high-volume German cardiac centre between 2008 and 2017 were identified retrospectively and followed up to December 2023. This cohort was characterized, and long-term survival (>10 years) was analysed. Univariate and multivariable regression analyses were performed to identify risk factors for mortality. Five-hundred and seventy-six patients were included; 21.7% underwent isolated coronary bypass, 16.5% single valve surgery, 34.3% combined cardiac surgery and 13.2% heart transplantation. The system was implanted peripherally in 60.8% of patients. In-hospital and 1-year mortality for all patients was 66.0% and 77.7%, respectively. In the multivariable Cox adjustment, severe aortic valve stenosis, previous cardiac surgery and intra-aortic balloon pump were independent risk factors for in-hospital mortality (P < 0.05). Older age, severe mitral regurgitation and patients on insulin were predictors for long-term mortality (P < 0.05). However, peripheral cannulation significantly reduced mortality. There was no time-dependent interaction of perioperative stroke with mortality. For patients who were discharged alive, the estimated 10-year survival was 32.4%. Treatment of perioperative low-output syndrome with extracorporeal life-support systems is associated with poor outcome and only 34% of patients could be discharged successfully. Peripheral cannulation is prognostically favourable. Special attention should be paid to these patients because age, insulin therapy and severe mitral regurgitation are strong predictors for mortality after 10 years.

Impact of surgical aortic valve replacement and transcatheter aortic valve implantation on cardiovascular and cerebrovascular controls: A pilot study.

Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are options in severe aortic valve stenosis (AVS). Cardiovascular (CV) and cerebrovascular (CBV) control markers, derived from variability of heart period, systolic arterial pressure, mean cerebral blood velocity and mean arterial pressure, were acquired in 19 AVS patients (age: 76.8 ± 3.1 yrs, eight males) scheduled for SAVR and in 19 AVS patients (age: 79.9 + 6.5 yrs, 11 males) scheduled for TAVI before (PRE) and after intervention (POST, <7 days). Left ventricular function was preserved in both groups. Patients were studied at supine resting (REST) and during active standing (STAND). We found that: (i) both SAVR and TAVI groups featured a weak pre-procedure CV control; (ii) TAVI ensured better CV control; (iii) cerebral autoregulation was working in PRE in both SAVR and TAVI groups; (iv) SAVR and TAVI had no impact on the CBV control; (v) regardless of group, CV and CBV control markers were not influenced by STAND in POST. Even though the post-procedure preservation of both CV and CBV controls in TAVI group might lead to privilege this procedure in patients at higher risk, the missing response to STAND suggests that this advantage could be insignificant.

Clinical implications of Sokolow-Lyon voltage less than 3.5 mV in patients who have undergone transcatheter aortic valve replacement.

Degenerative severe aortic valve stenosis (AS) is increasingly prevalent in the aging population, leading to the adoption of transcatheter aortic valve replacement (TAVR) as a less invasive alternative. While TAVR indications have expanded, the procedure is associated with a substantial incidence of major adverse cardiac events (MACE). The study aims to establish a preoperative risk-stratification system for TAVR candidates based on Sokolow-Lyon voltage (SLV) and other relevant factors. A total of 181 consecutive patients who underwent TAVR were retrospectively reviewed. Baseline characteristics, preoperative electrocardiogram (ECG) and echocardiography findings, and TAVR procedures were assessed. Low SLV (<3.5 mV) was defined based on ECG measurements. Baseline characteristics revealed a mean age of 84 years, with 71.8% females. The two-year incidence of MACE defined as a composite of cardiac death and hospitalization due to heart failure, was 11.6%, significantly higher in the low SLV group. Low SLV emerged as an independent prognostic factor. The Tokyo Bay Risk (TBR) Score, including low SLV, Body Mass Index <18.5 kg/m2, and previous coronary artery disease, effectively stratified MACE risk. Higher TBR scores (2 or 3) correlated with increased MACE risk. Patients with low SLV in pre-procedural ECG demonstrated a heightened risk of two-year MACE. The TBR score, incorporating low SLV, proved valuable for preoperative risk assessment. Careful consideration of TAVR indications, along with TBR score integration, is crucial for optimizing outcomes.

The Promise and Perils of Transcatheter Aortic Valve Replacement (TAVR) in Low Surgical Risk Patients with Severe Aortic Stenosis in the Current Era.

Transcatheter Aortic Valve Replacement (TAVR) has become the preferred treatment approach for many patients with symptomatic severe aortic valve stenosis (SsAS), particularly those who are deemed at high surgical risk. However, in low-risk surgical patients (LSRP) with SsAS, the choice between TAVR and surgical aortic valve replacement (SAVR) is often a matter of debate and depends on several clinical and anatomical considerations. Midterm data show similar clinical outcomes and durability of TAVR and SAVR bioprosthetic valves in LRSP. Data on long term durability and outcomes of TAVR in LRSP remains scarce. Both TAVR and SAVR are reasonable options in LRSP with SsAS. Nevertheless, many of these LRSP are expected to outlive their bioprosthetic valves and planning for the second aortic valve replacement should begin at the time of the index procedure with special consideration for coronary re-access, risk for coronary obstruction, and prothesis patient mismatch.

Preliminary report on depression prevalence in patients with coronary artery disease and severe aortic valve stenosis.

Preliminary report on depression prevalence in patients with coronary artery disease and severe aortic valve stenosis.

Two-year follow-up of transcatheter aortic valve replacement in low-risk patients with symptomatic severe bicuspid aortic valve stenosis.

In 2019, the US Food and Drug Administration (FDA) approved transcatheter aortic valve replacement (TAVR) for low-risk patients with symptomatic severe tricuspid aortic stenosis. However, bicuspid aortic valve (BAV) patients were included only in single-arm registries of pivotal low-risk TAVR trials, resulting in limited data for this subgroup. The LRT (Low Risk TAVR) trial was an investigator-initiated, prospective, multicenter study and the firstFDA-approved investigational device exemption trial to evaluate the feasibility of TAVR with balloon-expandable or self-expanding valves in low-risk patients with symptomatic severe BAV stenosis. This analysis reports 2-year follow-up, assessing the primary outcome of all-cause mortality and evaluating clinical outcomes. From 2016 to 2019, a total of 72 low-risk patients diagnosed with symptomatic, severe BAV stenosis underwent TAVR across six centers. Six patients were lost to follow-up. At 2-year follow-up, mortality was 1.5% (1 of 66 patients). Among the remaining 65 patients, four experienced nondisabling strokes (6.2%), while 2 (3.1%) developed infective endocarditis. No new permanent pacemakers were required beyond the 30-day follow-up, and no patients, including those with endocarditis, needed aortic valve re-intervention. At the 2-year echocardiography follow-up (n = 65), 27.8% of BAV patients showed mild aortic regurgitation, with none exhibiting moderate or severe regurgitation. The mean aortic gradient was 12.1 ± 4.1 mmHg, and the mean valve area was 1.7 ± 0.5 cm². The 2-year follow-up confirms commendable clinical outcomes of TAVR in patients with bicuspid aortic stenosis, establishing its evident safety.

Insulin-like Growth Factor-Binding Protein 2 in Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Gender-Based Perspective.

Severe aortic valve stenosis (AS) and pulmonary hypertension (PH) are life-threatening cardiovascular conditions, necessitating early detection and intervention. Recent studies have explored the role of Insulin-like Growth Factor-Binding Protein 2 (IGF-BP2) in cardiovascular pathophysiology. Understanding its involvement may offer novel insights into disease mechanisms and therapeutic targets for these conditions. A total of 102 patients (46 female, 56 male) with severe AS undergoing a transcatheter aortic valve replacement (TAVR) in a single-center study were classified using echocardiography tests to determine systolic pulmonary artery pressure (sPAP) and the presence (sPAP ≥ 40 mmHg) or absence (sPAP < 40 mmHg) of PH. Additionally, serial laboratory determinations of IGF-BP2 before, and at 24 h, 96 h, and 3 months after intervention were conducted in all study participants. Considering the entire cohort, patients with PH had significant and continuously higher serum IGF-BP2 concentrations over time than patients without PH. After subdivision by sex, it could be demonstrated that the above-mentioned results were only verifiable in males, but not in females. In the male patients, baseline IGF-BP2 levels before the TAVR was an isolated risk factor for premature death after intervention and at 1, 3, and 5 years post-intervention. The same was valid for the combination of male and echocardiographically established PH patients. The predictive role of IGF-BP2 in severe AS and concurrent PH remains unknown. A more profound comprehension of IGF-BP2 mechanisms, particularly in males, could facilitate the earlier consideration of the TAVR as a more effective and successful treatment strategy.

Myocardial work and risk stratification in patients with severe aortic valve stenosis referred for transcatheter aortic valve replacement

BackgroundTranscatheter aortic valve replacement(TAVR) has shown clear survival benefits in severe aortic valve stenosis(AS). However, patients unable to recover left ventricle function remain at risk with poor long-term survival. This single-center prospective study aims to analyze the supplementary benefits of myocardial work(MW) assessment for baseline risk stratification in patients with severe AS referred for TAVR. MethodsA total of 110 patients with severe AS referred for TAVR were included in the study. Baseline ECG data, transthoracic echocardiographic(TTE) images and blood samples were obtained. The TTE examination was repeated one day and one month after valve replacement. The primary outcome of the study was a composite endpoint consisting of all-cause mortality and HF hospitalization. ResultsDuring a mean follow-up period of 521 ± 343 days, 29patients(26.4 %) reached the composite endpoint. Baseline troponins, NT-proBNP, sST2, GWI and GCW showed statistically significant differences between groups. Patients with a baseline GWI<2323 mmHg% (sensitivity 0.63 and specificity 0.76)had significantly worse outcome following TAVR. A basic predictive model included QRS-length, TAPSE, LAVI and E/e’. The addition of biomarkers did not yield any further advantages whereas incorporating the GWI cut-off value of 2323 mmHg% significantly enhanced the predictive value. Although there were no significant changes in LVEF and GLS, all patients exhibited a significant reduction in GWI and GCW immediately after TAVR. ConclusionOur findings provide evidence for the enhanced usefulness of MW analysis in the initial risk stratification of patients with severe AS referred for TAVR. Specifically, a baseline GWI<2323 mmHg% demonstrates an independent predictor associated with increased incidence of all-cause mortality and HF hospitalization following TAVR.

Reoperative approach after extra-anatomic ascending-to-descending aortic bypass graft

BackgroundExtra-anatomic ascending-to-descending aortic bypass grafts have historically been utilized as a safe and effective solution for repairs of complex coarctation of the aorta. However, reports on reoperation in these patients remain rare. We present a case of an aortic valve replacement and coronary artery bypass grafting in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.Case presentationThe patient is a 59-year-old male with a complex aortic history, including repair of aortic coarctation with an ascending-to-descending aortic bypass graft 13 years prior, was admitted to the hospital for shortness of breath and chest pain that had developed over the past year. On further workup, he was found to have severe bileaflet aortic valve stenosis, non-ST elevation myocardial infarction, and moderate coronary artery disease. He underwent surgical aortic valve replacement and coronary artery bypass grafting. Given his unique anatomy, cardiopulmonary bypass approach involved separate cannulation of the right axillary and left common femoral arteries with cross-clamp of both the aorta and the extra-anatomic graft. Using this approach, the redo operation was successfully performed.ConclusionsReports on reoperation after ascending-to-descending aortic bypass grafting are rare. We describe our approach to cardiopulmonary bypass and reoperation in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.

Mitral complex geometric changes aggravate mitral stenosis after transcatheter aortic valve replacement.

Severe aortic valve stenosis (AS) often coexists with mitral valve stenosis (MS). MS aggravation after transcatheter aortic valve replacement (TAVR) is common, and its etiology is multifactorial. We hypothesized that geometric changes in the mitral complex (mitral valvular and annular deformities) are adjunctive factors aggravating MS after TAVR, particularly in older adults with a smaller left ventricle (LV). This study aimed to evaluate the mitral complex geometric changes before and after TAVR and to assess the important predictors of MS aggravation after TAVR. This retrospective study enrolled consecutive adult patients who underwent TAVR and surgical AVR (SAVR) for severe AS. The mitral valve area (MVA), the angle between the anterior mitral valve leaflet (AMVL) and left ventricular outflow tract (LVOT), AMVL length, mitral annular diameter, presence of mitral annular calcification, and LV size were evaluated using transthoracic echocardiography. This study included 258 patients who underwent TAVR and SAVR. MVA index decreased from 2.3 ± 0.6cm² to 1.9 ± 0.5cm² in the TAVR group. The angle between the AMVL and LVOT was 56.3 ± 9.7° preoperatively and increased to 67.3 ± 11.5° after TAVR. In multivariate analysis, the most important predictive factors of MS aggravation after TAVR were a smaller mitral annular diameter, restricted AMVL mobility, and implantation depth (odds ratio: 4.5, 5.3,3.0; 95% confidence interval: 1.6-14, 1.9-17, 1.0-8.9; and p = 0.005, p = 0.001, p = 0.042, respectively). The reduction in MVA after TAVR was related to the restriction of AMVL opening, depth of implantation and narrowing of the mitral annulus.

The Relative Apical Sparing Strain Pattern in Severe Aortic Valve Stenosis: A Marker of Adverse Cardiac Remodeling.

The presence of a relative apical sparing (RAS) echocardiographic strain pattern raises a suspicion of underlying cardiac amyloidosis (CA). However, it is also increasingly observed in patients with aortic stenosis (AS). We aimed to evaluate the prevalence, dynamics, and clinical characteristics of the RAS strain pattern in severe AS patients who had been referred for surgical aortic valve replacement (SAVR). A total of 77 patients with severe AS and without CA were included with a mean age of 70 (62-73) years, 58% female, a mean aortic valve area index of 0.45 ± 0.1 cm2/m2, and a mean gradient of 54.9 (45-70) mmHg. An RAS strain pattern was detected in 14 (18%) patients. RAS-positive patients had a significantly higher LV mass index (125 ± 28 g/m2 vs. 91 ± 32, p = 0.001), a lower LV ejection fraction (62 ± 12 vs. 68 ± 13, p = 0.040), and lower global longitudinal strain (-14.9 ± 3 vs. -18.7 ± 5%, p = 0.002). RAS strain pattern-positive patients also had higher B-type natriuretic peptide (409 (161-961) vs. 119 (66-245) pg/L, p = 0.032) and high-sensitivity troponin I (15 (13-29) vs. 9 (5-18) pg/L, p = 0.026) levels. Detection of an RAS strain pattern was strongly associated with increased LV mass index (OR 1.03, 95% CI 1.01-1.06, p < 0.001). The RAS strain pattern had resolved in all patients by 3 months after SAVR. Our findings suggest that the RAS strain pattern can be present in patients with severe AS without evidence of CA. The presence of an RAS strain pattern is associated with adverse LV remodeling, and it resolves after SAVR.

Low muscle quality on a procedural computed tomography scan assessed with deep learning as a practical useful predictor of mortality in patients with severe aortic valve stenosis

Background & AimsAccurate diagnosis of sarcopenia requires evaluation of muscle quality, which refers to the amount of fat infiltration in muscle tissue. In this study, we aim to investigate whether we can independently predict mortality risk in transcatheter aortic valve implantation (TAVI) patients, using automatic deep learning algorithms to assess muscle quality on procedural computed tomography (CT) scans. MethodsThis study included 1,199 patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) between January 2010 and January 2020. A procedural CT scan was performed as part of the preprocedural-TAVI evaluation, and the scans were analyzed using deep-learning-based software to automatically determine skeletal muscle density (SMD) and intermuscular adipose tissue (IMAT). The association of SMD and IMAT with all-cause mortality was analyzed using a Cox regression model, adjusted for other known mortality predictors, including muscle mass. ResultsThe mean age of the participants was 80 ± 7 years, 53% were female. The median observation time was 1084 days, and the overall mortality rate was 39%. We found that the lowest tertile of muscle quality, as determined by SMD, was associated with an increased risk of mortality (HR 1.40 [95%CI: 1.15 – 1.70], p<0.01). Similarly, low muscle quality as defined by high IMAT in the lowest tertile was also associated with increased mortality risk (HR 1.24 [95%CI: 1.01 – 1.52], p=0.04). ConclusionsOur findings suggest that deep learning-assessed low muscle quality, as indicated by fat infiltration in muscle tissue, is a practical, useful and independent predictor of mortality after TAVI.

Noradrenaline infusion prevents anesthesia-induced hypotension in severe aortic stenosis patients undergoing transcatheter aortic valve replacement: a retrospective observational study

BackgroundPatients with severe aortic valve stenosis (AS) are particularly prone to developing hypotension during general anesthesia induction, which increases postoperative morbidity and mortality. Although the preventive effect of a single vasopressor dose on anesthesia-induced hypotension has been reported, the effects of continuous vasopressor infusion are unknown. This study aimed to assess the effect of noradrenaline (NAd) infusion on hemodynamic stability during general anesthesia induction in severe AS patients undergoing transcatheter aortic valve replacement (TAVR).MethodsThis single-center, retrospective study included severe AS patients who underwent elective TAVR. Patients in the NAd group received a continuous prophylactic NAd infusion of 0.1 μg/kg/min from the time of anesthesia induction. The control group received inotropes and vasopressors as indicated by the occurrence of hypotension. The primary outcome was the lowest mean blood pressure (MBP) before the start of surgery.ResultsThe study included 68 patients in the NAd group and 113 in the control group. The lowest MBP before the start of surgery was significantly higher in the NAd group than in the control group (63 ± 15 vs 47 ± 13 mmHg, P < 0.01). MBP immediately before intubation was also significantly higher in the NAd group (75 ± 17 vs 57 ± 16 mmHg, P < 0.01). Differences in postoperative complications between the groups were negligible.ConclusionContinuous administration of NAd at 0.1 μg/kg/min in patients with severe AS might prevent hypotension during general anesthesia induction for TAVR.

Transcatheter Aortic Valve Replacement in Low-Risk Patients at Four or More Years

BackgroundTranscatheter aortic valve replacement (TAVR) is accepted as an alternative to surgical aortic valve replacement (SAVR) in patients with severe symptomatic aortic valve stenosis. Prior studies have shown that TAVR has comparable or superior outcomes to SAVR in intermediate and high-risk patients. However, there is paucity of data about outcome of TAVR vs SAVR in low-surgical-risk patients evaluated at 4 or more years post-procedure. MethodsA systematic review of all published randomized controlled trials comparing TAVR and SAVR in low-risk patients was completed. A random-effects model meta-analysis was performed to study major outcomes, including all-cause mortality, stroke, myocardial infarction, and aortic valve reintervention. ResultsThree randomized trials comprising 2644 patients (1371 TAVR and 1273 SAVR) with a mean age of 74.3 ± 5.8 years were included in this analysis. There was no significant difference in all-cause and cardiovascular mortality, stroke, myocardial infarction, or aortic valve reintervention between the TAVR and SAVR groups at long-term follow-up. Transcatheter aortic valve replacement was associated with higher rate of pacemaker implantation, whereas SAVR was associated with more atrial fibrillation. ConclusionsAt 4 or more years of follow-up, TAVR is safe and has comparable outcomes to SAVR in low-surgical-risk patients. Possibility of TAVR and its risks and benefits should be discussed with low-surgical-risk patients.

Transcatheter Aortic Valve Implantation (TAVI) In Small Island Nation- Maldives, Leading Cardiac Care to A Higher Standard

Background: Surgical aortic valve replacement is still considered the preferred treatment option for patients with severe aortic valve stenosis, and it is known to improve the survival of the patients. However, about 30-50% of patients are not operated on due to several reasons including old age, high risk and other comorbidities. Transcatheter Aortic Valve Implantation (TAVI) is emerging as an alternative treatment option for elderly patients with high surgical risk. Methods: In our study, four patients have undergone TAVI from February 2022 till May 2023 using Medtronic Transcatheter Aortic Valve, Core valve Evolut R (Medtronic Inc., Minneapolis, MN, USA) bioprosthesis. Results: All the patients were discharged early. Follow-up Echocardiography showed decreased transaortic gradient with improved quality of life. Conclusion: We conclude, implementation and use of this emerging technology in small Island Nations like Maldives would help to treat many patients, mostly elderly and high-risk as well as patients with intermediate risk requiring aortic valve surgery with less morbidity and comparable mortality in comparison to SAVR.

Interventional treatment in elderly patients with severe aortic valve stenosis and coronary artery disease

Aortic stenosis (AS) is a valvular heart disease commonly found in the elderly patients and frequently is associated with coronary artery disease (CAD). The impact of CAD severity and of the percutaneous coronary intervention (PCI) on post-TAVI outcomes is frequently debated. Purpose. Comparison of clinical and hemodynamic outcomes, as well as the rate of major adverse cardiovascular and cerebrovascular events (MACE) in patients undergoing TAVI with PCI (patients with AS and CAD) versus isolated TAVI (patients with AS). Material and methods. Our team conducted a prospective study that included 41 patients, with an age greater than 70 years old, who were diagnosed with severe aortic valve stenosis. After performing coronary angiography, the patients were divided into two groups: 32 patients without significant coronary lesions and 9 patients with multivessel lesions with a Syntax Score &lt;22 and who subsequently underwent coronary angioplasty (PCI). Results. The TAVI procedure was performed with a 100% success rate. After the procedure, the ejection fraction increased inconsiderably in all patients, but the average pressure gradient decreased impressively, the average value being12.59 ± 5.62 mmHg vs 14.78 ± 8.73 mmHg, p&lt; 0.001. The peak velocity of the jet through the aortic valve is 2.36 ± 0.50 m/s vs 2.53 ± 0.83 m/s, p&lt; 0.001.Conclusion. The one-year post-procedural follow-up showed that both groups of patients had a similar rate of MACE, with a significant improvement in clinical-hemodynamic parameters according to transthoracic echocardiography data.

Uncommon presentations of type A quadricuspid aortic valve in the Septuagenarian

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four cusps instead of the usual three. It is estimated to occur in less than 0.05% of the population, with Type A (four equal-sized leaflets) accounting for roughly 30% of QAV subtypes. Based on limited clinical series, the usual presentation is progressive aortic valve regurgitation (AR) with symptoms occurring in the fourth to sixth decade of life. Severe aortic valve stenosis (AS) and acute AR are very uncommon.Case presentationWe describe two cases of Type A QAV in patients who remained asymptomatic until their seventies with very uncommon presentations: one with severe AS and one with acute, severe AR and flail leaflet. In Case A, a 72-year-old patient with history of moderate AS presents to clinic with progressive exertional dyspnea. During work-up for transcatheter vs. surgical replacement pre-operative computed tomography angiogram (CTA) reveals a quadricuspid aortic valve with severe AS, and the patient undergoes surgical aortic valve replacement. Pre-discharge transthoracic echocardiography (TTE) shows good prosthetic valve function with no gradient or regurgitation. In Case B, a 76-year-old patient is intubated upon arrival to the hospital for acute desaturation, found to have wide open AR on catheterization, and transferred for emergent intervention. Intraoperative TEE reveals QAV with flail leaflet and severe AR. Repair is considered but deferred ultimately due to emergent nature. Post-operative TTE demonstrates good prosthetic valve function with no regurgitation and normal biventricular function.ConclusionsQAV can present as progressive severe AS and acute AR, with symptoms first occurring in the seventh decade of life. The optimal treatment for QAV remains uncertain. Although aortic valve repair or transcatheter option may be feasible in some patients, aortic valve replacement remains a tenable option.

Differential preoperative transcriptomic profiles are related to the quality of left ventricle reverse remodelling one year after valve replacement in patients with severe aortic valve stenosis

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Spain´s Ministerio de Economía y Competitividad [(PI21/00084, CIBERCV (CB16/11/00264), co-funded by Fondo Europeo de Desarrollo Regional (FEDER)] Instituto de Investigación Sanitaria Marqués de Valdecilla, IDIVAL (INNVAL21/24; PREVAL22/09) Background Aortic valve stenosis (AS) promotes a progressive remodelling of the left ventricle (LV) characterised by cardiomyocyte hypertrophy and increased deposition of extracellular matrix elements. These adaptive plastic changes may evolve towards heart failure over time. The extent of LV remodelling and its persistence after valve replacement are significant prognostic factors for the long-term outcome of AS patients. The biological processes that determine the reverse remodelling rate after surgery of AS patients are unknown. Purpose To ascertain preoperative LV transcriptomic determinants of favourable reverse remodelling one year after surgery in AS patients. To this end, a genome-wide transcriptomic analysis was performed in LV biopsies from AS patients and surgical controls. Methods and Results The study was performed in AS (n=24) and control patients (n=12) (age and sex matched) followed up for one year after surgery. RNA-seq was performed on LV biopsies obtained during surgery. AS patients were stratified according to the quality of the reverse remodelling at one year in good (LV mass index ≤51 g/m2.7, n=12) or poor (LV mass index &amp;gt;51 g/m2.7, n=12) performers. RNA-seq libraries were prepared and sequenced using an Illumina Next Seq Unit. Resulting reads were mapped against GRCh38.99 version of the human transcriptome. The results from the principal component analysis revealed a distinctive expression gene pattern for the AS condition, accounting for 60.1 % of the variance, with no difference for the sex condition (8.7 %). Differential gene expression was considered significant when yielding a Benjamini-Hochberg adjusted p-value &amp;lt; 0.05. Compared to controls, 339 and 443 genes were differentially expressed in AS with good and poor reverse remodelling, respectively, with 509 overlapping. Gene Set Enrichment Analysis (GSEA) of differentially expressed genes in patients with poor reverse remodelling compared to control patients, showed a significant enrichment (NES &amp;gt; 1.5) in genes associated with angiogenesis, epithelial-mesenchymal transition (EMT), and heart growth. The down-regulated genes (NES &amp;lt; 0) were associated with transcription processes, such as histone modification and RNA processing-related genes, highlighting the significance of epigenetic mechanisms in AS patients exhibiting poor reverse remodelling. In contrast, such transcriptomic profile patterns were not observed in AS with good-reverse remodelling. Conclusion Aortic stenosis patients with good or poor reverse remodelling one year after aortic valve replacement exhibited distinct preoperative LV transcriptome profile. Gene ontology enrichment analysis revealed angiogenesis, EMT, and epigenetic processes as critical biological functions associated with poor reverse remodelling in AS patients.