Severe Valvular Aortic Stenosis Research Articles

870 COMBINING PERCUTANEOUS CORONARY INTERVENTION AND TRASCATHETER AORTIC VALVE REPLACEMENT PROCEDURES: THE IMPORTANCE OF INTRAVASCULAR LITHOTRIPSY

Abstract Background Calcified coronary artery disease and severe valvular aortic stenosis (AS) often coexist. For instance, severely calcified lesions may strongly influence the revascularization strategy in patients undergoing transcutaneous aortic valve replacement (TAVR). Shock wave intravascular lithotripsy (S-IVL) (Shockwave Medical Inc. Santa Clara, CA) is the only technology available that cracks both medial and intimal calcium while minimizing trauma to the vessel wall, thus allowing a safe plaque debulking. We report a case of percutaneous coronary intervention (PCI) and TAVR in the same procedure, where S-IVL has been used to treat a heavily calcified lesion and optimize stent under-expansion. Case Report A 79 years-old male patient with a history of diabetes mellitus type 2, hypertension, and peripheral artery disease, was admitted to our institution with symptomatic severe AS and severe calcified left anterior descending (LAD) artery lesion at CT scan. Deemed eligible for TAVR, Heart Team planned a percutaneous coronary intervention (PCI) of LAD and TAVR in the same procedure. Through the left radial artery, coronary angiography confirmed 90% stenosis of the LAD at the central segment. Accordingly, pre-dilatation of the stenosis was performed with a 2.5×12 mm non-compliant balloon (NCB) and, because of the severe calcification, S-IVL with a 3.0×12 mm balloon inflated at 4-6 Atmospheres (ATM), delivering 40 pulses. Following, a 3.5×18-mm drug-eluting stent was implanted at 18 ATM. After implantation, an inadequate expansion of the stents was observed, which persisted despite post-dilation with 3.75×8 mm NCB at high-pressure. Bail-out S-IVL was then performed with the 3.0×12 mm balloon inflated at 4-6 ATM, delivering 40 pulses in-stent, followed by a further stent post-dilated with a 3.75×8 mm NCB up to 20 ATM. The final angiogram showed a satisfactory stent expansion. Since the low contrast volume was used, we decided to go ahead with transfemoral TAVR. Therefore, through the left femoral artery access, a 34-mm self-expandable Evolut R valve was implanted. Transthoracic echocardiography showed optimal valve implantation with a trivial periprosthetic leak. No complications were observed after the procedures and the patient was discharged after 6 days with 6 months of mandated dual antiplatelet therapy (Aspirin and Clopidogrel). Discussion In this case, the bail-out use of S-IVL was essential for an optima stent implantation, allowing TAVR procedure and avoiding prolonged theoretical antithrombotic therapy underlying suboptimal stent implantation. Despite encouraging initial results, future large studies with long-term observation are required to evaluate the safety and efficacy of S-IVL in this scenario.

Circulating metabolome does not predict development of aortic stenosis

Abstract Background Calcific aortic valve disease (CAVD) is the most common valvular heart disease in Western world. CAVD is ranging from mild aortic valve sclerosis to severe obstructive aortic stenosis (AS). The development of AS has been associated with several risk factors including age, sex and hypertension. However, there is limited knowledge about factors that predict the development of aortic stenosis. Purpose We investigated if the circulating metabolite profile can predict the development of aortic stenosis in Finnish males. Methods We did a non-targeted LC-MS metabolomics analysis to baseline (1984–1989) serum samples from a prospective population-based Kuopio Ischemic Heart Disease risk factor study (KIHD) cohort of 2682 random Finnish males aged from 42 to 60 years. During the follow-up (until year 2020), 53 subjects developed either moderate (peak flow gradient 36–64mmHg or mean flow gradient 20–40mmHg) or severe aortic valvular stenosis (peak flow gradient over 64mmHg or mean gradient over 40mmHg). The AS patients were collected from the KIHD database using appropriate ICD-10 -codes for aortic valvular disease (from baseline to the end of the year 2017) and the diagnosis was checked manually using hospital medical records of the individuals. Results The AS patients seemed to have altered lipid metabolism and possibly altered composition of gut microbiota, since several acylcarnitines (e.g. octanoylcarnitine [Cohen's d=−0.40], decanoylcarnitine [d=−0.43], layroylcarnitine [d=−0.41], and oleoylcarnitine [d=−0.40]), and branched chain amino acids (BCAA, e.g. leucine [d=0.39], and isoleucine [d=0.49]) had p-values below 0.05. However, after correction for multiple testing, there were no significant differences between the cases and controls. Conclusions The present preliminary results, in need of verification with a larger set of samples, suggest that subjects, who will later develop AS might have reduced levels of acylcarnitines and increased levels of BCAA when compared to matched controls. However, these changes do not have large effects sizes and are likely not good candidates for biomarkers to predict future diagnosis of AS. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Finnish Cultural Foundation, The Finnish Foundation for Cardiovascular Research.

Trimetazidine may normalize left ventricular systolic function and U wave polarity in severe calcific aortic stenosis

A case of severe calcific valvular aortic stenosis with reduced left ventricular ejection fraction is presented. Patient did not agree for surgery. He was advised trimetazidine (60 mg twice a day) in addition to Torsemide, Digoxin, Aspirin and Clopidogrel. After one month, patient showed significant improvement in symptoms, normalization of U waves in electrocardiogram and significant improvement in ejection fraction. Metabolic effects of trimetazidine could be responsible for improvement in left ventricular function in spite of no change in aortic stenosis. Keywords: Aortic valve stenosis; Electrocardiography; Left ventricular systolic function; Trimetazidine; U wave

Right-Sided Heart Failure Presentation in Severe Valvular Aortic Stenosis: How to Deal with Diuretic Use?

BACKGROUND: Patients with right-sided heart failure and severe aortic stenosis (AS) have many clinical challenges to overcome fluid retention. Typical diuretic therapeutic approach can be recommended for the guidance of removing fluid overload in severe AS with right ventricular (RV) failure. The aim of this case review is to understand how to assess and manage RHF and severe AS. CASE SUMMARY: A 65-year-old female with worsening bilateral leg swelling and she aware of shortness of breath for 3 months. Physical examination revealed a grade 3/6 ejection systolic murmur at the aortic area radiating to the neck, a grade 2/6 diastolic murmur at the pulmonic area, and a grade 3/6 systolic murmur at the apex radiating to the axilla, increased jugular venous pressure, prominent bilateral leg swelling, and minimal rhonci at the base of the lungs. The chest X-ray showed worsening cardiomegaly in the last 3 months. Echocardiography revealed high gradient severe valvular AS, decreased systolic RV function, and other valvular dysfunctions including moderate mitral regurgitation, moderate pulmonary regurgitation, and mild tricuspid regurgitation. She was introduced high dose furosemide infusion. The average urine output production was 5 L/day and negative fluid balance was 3 L/day. Furosemide dose was adjusted daily according to urine output production and she was discharged after 6 days hospitalization. DISCUSSION: This case report provides an example of RV failure in severe AS patient. Hemodynamic monitoring and typical approach of diuretic therapies should be needed in the management of fluid overload in severe AS. KEYWORDS: right-sided heart failure, severe aortic stenosis, diuretic.

234 The role of preprocedural assessment of aortic valve calcium volume for the optimization of percutaneous aortic bioprosthesis implantation (TAVI)

Abstract Aims Paravalvular leaks (PVL) and conduction disorders requiring permanent pacemaker implantation (PPI) in patients with severe Aortic Valvular Stenosis (SA) undergoing percutaneous aortic valve prosthesis (TAVI) still have a significant and unacceptable incidence for patients at medium and low surgical risk, who represent, with increasing scientific evidence, the prevalent population. The appearance of these complications seems to be related to clinical, anatomical and procedural factors, which influence the decision-making process of the type and size of bioprosthesis to be implanted. Particular attention has been paid to the role of the volume of calcium present at the native aortic valve (VCA) as a predictor of these complications, in order to optimize the percutaneous procedure. The VCA can be quantified using algorithms derived from Multilayer Computed Computed Axial Tomography (MSCT), an examination that has become a pivotal element in the evaluation of the patient's eligibility for TAVI.The aim of our study was to document the pre-procedural added value of VCA in terms of possible containment of adverse events and how much it may affect the choice of the type of bioprosthesis to be implanted. Methods and results 111 patients underwent TAVIs at the Interventional Cardiology Unit of the AOU S. Giovanni di Dio and Ruggi D'Aragona, between 2017 and 2020, subsequently divided into 2 groups: group A (self-expandable bioprosthesis, Medtronic Evolut R or Evolut Pro) and group B (balloon expandable bioprosthesis, Edward Sapien 3).The clinical, electrocardiographic, echocardiographic and anatomical parameters of the enrolled patients were analyzed, and the VCA in the preprocedural phase was quantified for each of them, using an algorithm extracted from the MSCT reading software, OsiriX (OsiriX-MD v.2.8.2 64-bit). A univariate logistic regression analysis was performed for the risk of developing the composite event of significant PVL and IPP.In Group B, no significant variables were found, while in Group A, the VCA (OR: 1.001; 95% CI, 1.000-1.002; p < 0.043) and incomplete left branch block (OR: 5.781; 95% CI, 0.013-32.988; p < 0.048) were significant. Subsequently, these two variables were tested in a multivariate regression model according to which only the VCA emerged as an independent predictor for the composite event (OR: 1.001; 95% CI, 1.000-1.002; p < 0.039). Conclusion VCA is significantly associated with the risk of moderate to severe PVL and rhythm disturbances requiring PPI, in the group of patients in whom a self-expandable bioprosthesis was implanted, unlike patients who received a balloon-expandable bioprosthesis where this association is not significant.

Alcohol Septal Ablation for the Treatment of Hypertrophic Obstructive Cardiomyopathy in a Patient with Prior Transcatheter Aortic Valve Replacement

A 68-year-old man presented with chest distress recurring for the past 10 years. An echocardiogram demonstrated bicuspid aortic valve malformation with severe aortic stenosis and ventricular septal thickness of 22 mm. The patient underwent successful transcatheter aortic valve replacement (TAVR). Six months later, he complained of worsening dyspnea and chest distress (New York Heart Association Class III) on exertion. Besides a functional normal AV prosthesis, the echocardiography indicated the left ventricular outflow tract obstruction peak gradient of 122 mmHg at rest. Alcohol septal ablation was performed as the patient was unable to tolerate morrow procedure. His symptoms were relieved immediately after ablation, and no major cardiovascular events were observed during the 20-month follow-up. In conclusion, among patients with concomitant hypertrophic obstructive cardiomyopathy and severe aortic valvular stenosis, consideration for TAVR and alcohol septal ablation should only be made for patients who are at high surgical risk or cannot tolerate thoracotomy.

Assessment of Left Ventricular Function after Transcatheter Aortic Valve Implantation in Sever Aortic Stenosis: A Speckle Tracking Imaging Study

Background: Long standing aortic stenosis leads to elevated left ventricular (LV) pressure and as a result LV hypertrophy and myocardial fibrosis shall increase. The left ventricular ejection fraction (EF) usually remains adequately-preserved until advanced and late stages of aortic stenosis. But the preserved muscle of the LV is only limited to a portion of the entire myocardium. Speckle tracking echocardiography has proved its superiority to the standard two-dimensional echocardiography method in the detection of Left Ventricular (LV) function. Global Longitudinal strain (GLS) is considered as the most robust myocardial strain component. Objective: The aim of the study is to assess the early course of left ventricular reverse remodelling after Transcutaneous Aortic Valve Implantation (TAVI) in patients with symptomatic severe aortic valve stenosis. Methods: 50 patients with severe symptomatic valvular aortic stenosis undergoing TAVI as decided by the heart team after comprehensive discussion. Standard transthoracic echocardiography including Doppler analysis was performed. 2D speckle-tracking strain assessment of Global radial, circumferential and longitudinal strain at parasternal mid-ventricular short-axis view (at the level of papillary muscle) and from the apical long-axis, two-chamber and four-chamber views with a frame rate between 40 and 80 frames per second. Tracing of endocardial borders was done. Patients with significant coronary artery disease were fully revascularized by percutaneous coronary intervention prior to the study and the procedure. Results: 23 (46%) patients were males, while 27 (54%) were females. The patients’ stratification according to comorbidities/associated risk factors revealed that 54% of the patients had DM, 86% were hypertensive, 38% had chronic kidney disease (CKD), and 32% had a previous percutaneous coronary intervention (PCI). The mean age for our study participants ranged from 60 to 92 years (Mean ± SD = 76.60 ± 5.96). Left ventricular diastolic diameter (LVDd) was 44.24 ± 2.8 mm before TAVI that became 45.5 ± 2.6 mm after TAVI, and ejection fraction (EF) increased from 52.82 ± 6.3 before TAVI to 56.70 ± 5.4 after TAVI, both with highly significant difference (P P value less than 0.001. Global circumferential strain (GCS) also improved significantly from -20.14 ± 1.8 before TAVI to -21.72 ± 1.7 after TAVI with a P value less than 0.001. Global radial strain (GRS) also increased significantly from 37.38 ± 8 before TAVI to 41.68 ± 6.3 after TAVI with a P value less than 0.001. Conclusion: TAVI is effective in improving left ventricular function presented not only by ejection fraction (EF%), but also in global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS).

Evaluation of initial and medium-term follow-up results of balloon aortic valvuloplasty in severe aortic valve stenosis in newborns, infants and children in Alexandria, Egypt

Background: Aortic valve stenosis (AVS) represents 3%–7% of all congenital heart diseases. Balloon aortic valvuloplasty (BAoV) has been established as an alternative to surgery for therapy of AVS in infants and children; and has proven to be an effective method for decreasing the gradient between the left ventricle and the aorta. The objective of the study was to evaluate the initial and medium-term results of BAoV in newborns, infants and children with severe AS, treated at the Alexandria University Children’s Hospital.Methods: Thirty-seven newborns, infants and children with severe AS treated by B AoV between 2009 and 2017 were studied. They were followed-up for at least 1year post- ballooning by clinical and echocardiographic evaluation.Results: The mean AoV annulus diameter by echo was 13.1±4.4 mm and by angiographic measurement was 12.8±4.3 mm. The mean Doppler gradient across AoV was 91.8±14.7 mmHg, compared to mean catheter gradient of 66.1±13.4 mmHg. The mean inflated balloon diameter was 12.1±4.1 mm. The mean balloon/AoV annulus ratio by angiogram was 0.94±0.03 (0.88–1). The mean pressure gradient across the AoV post-ballooning was 21.5±6.9 mmHg by Doppler and was 10.3±4.7 mmHg by catheter, both were significantly less than pre-ballooning values (p<0.001). The procedure was successful in all the cases. Only one case died. Post -ballooning aortic incompetence was moderate in 2 cases (5.4%) and severe in only one case (2.7%).Conclusions: Balloon aortic valvuloplasty is an effective and safe technique for relieving severe aortic valvular stenosis with acceptable morbidity and minimal mortality, particularly with the new catheter and balloon technology.

Outcome of Patients Undergoing Transcatheter Implantation of Aortic Valve With Previous Mitral Valve Prosthesis (OPTIMAL) Study

BackgroundTranscatheter aortic valve replacement (TAVR) is the gold standard for severe valvular aortic stenosis in patients at high/prohibitive surgical risk. This procedure has also been used in patients with previous mitral valve (MV) prostheses, with contrasting outcomes reported. The aim of this study is to describe procedural and early outcomes of patients with previous MV prostheses undergoing TAVR. MethodsThis is a retrospective registry of 154 patients with previous MV prostheses who underwent TAVR across high-volume medical centres at a mean of 11.7 ± 8.4 years after mitral surgery. ResultsMean mitroaortic distance at computed tomography was 9.7 ± 4.8 mm. Procedural success was achieved in 150 (97.4%) patients, with reduction of aortic gradients (42.6 ± 14.2 to 10.0 ± 7.0 mm Hg; P < 0.001). Device success was achieved in 133 (86.3%) patients. MV prosthesis interference by the TAVR device was observed in 2 patients; in both, the mitroaortic distance was <5 mm, with 1 complicated by TAVR prosthesis embolization. Periprocedural complications included 4 (2.6%) cerebrovascular accidents, 10 (6.6%) major vascular complications, 22 (14.4%) severe bleedings, 1 (0.7%) myocardial infarction, and 5 (3.2%) in-hospital deaths (all cases cardiovascular or procedure related). At a median follow-up of 13.5 (interquartile range 1.0 to 36.0) months, 26 (16.9%) deaths occurred; 15 (9.7%) were cardiac related. Late fatal mitral prosthesis thromboses occurred in 2 patients. We recorded a case of fatal hemorrhagic stroke; hospital readmission was observed in 25 (16.2%) patients due to worsening heart failure. ConclusionsTAVR in patients with previous mitral prostheses appears to be safe and feasible, with good hemodynamic results at 30-day and at longer-term follow-up.

Intramyocardial Calcification As A Rare But Significant Indication For Transfemoral TAVI?

We report on a 69-year-old female patient with severe valvular aortic stenosis who was hospitalized for cardiac decompensation for aortic valve replacement. Preoperative imaging (X-Ray, cat-scan and CMR) revealed significant and extraordinary intramyocardial calcification pronounced globally in the left ventricle and around the mitral valve. Due to high operative/surgical risk we preferred to approach an aortic valve replacement by transfemoral transcatheter procedure (TAVI-TF). Within the context of an undeniably elevated risk for ventricular injuries and dissections in conventional operations, highly progressed myocardial calcifications should lead to consider and prefer the transfemoral transcatheter aortic valve replacement procedure. &#x0D; Keywords: Aortic stenosis, intramyocardial calcification, transcatheter aortic valve replacement.

Nt-ProBNP Discriminatory Role Between Symptomatic and Asymptomatic Patients with Severe Valvular Aortic Stenosis.

Abstract Background: The aim was to evaluate the Nt-proBNP discriminatory role between symptomatic and asymptomatic patients with severe aortic stenosis. Methods: 187 patients with severe valvular aortic stenosis, with normal EF &gt; 50%, were included, 61 asymptomatic and 126 symptomatic. We used clinical, laboratory (Nt-proBNP) and echocardiographic parameters. Endpoints of monitoring (occurrence of event) were: the onset of symptoms in asymptomatic patients and death in both groups. Results: The symptomatic group with severe AS had a significantly higher means of Nt-proBNP, in comparison with the asymptomatic group. Nt-proBNP was a significant predictor for the risk of event occurrence (HR 1.4). In the group of severe AS without CAD (n = 101), the subgroup with Nt-proBNP above the cut-off value, took significantly higher percentage of patients with chest pain, fatigue and syncope. In the group with Nt-proBNP above the cut-off value, we had a significantly higher percentage of patients with severe AS without CAD, compared to those with CAD (n = 142). Nt-proBNP was negatively correlated with AVA and LVEF, whether the positive correlation was expressed for: LVEDd, LVEDs, IVSd, AV_Vmax, AV_MaxGrad, LVM and LA. Patients with Nt-proBNP above the cut-off, had a significantly lower event free survival, compared to patients with Nt-proBNP below the cut-off (n = 187; n = 101). Conclusion: The Nt-proBNP cut-off&gt; 460 pg/ml was confirmed as a useful tool in the determination of event free survival in patients with severe AS. Nt-proBNP not only had relevance in the assessment of the severity of the disease, but also was a significant predictor for the risk of event occurrence.

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging

ObjectiveTo investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. MethodsWe enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels. ResultsConduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394). ConclusionsAfter AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply.

Aortic pseudocoarctation: a very rare finding

A 52-year-old Caucasian woman with a history of hypertension since age 30 was referred to cardiology department due to aortic stenosis. She had exertional dyspnoea, without thoracic pain or syncope....

Differential expression of osteopontin, and osteoprotegerin mRNA in epicardial adipose tissue between patients with severe coronary artery disease and aortic valvular stenosis: association with HDL subclasses

BackgroundPrevious studies suggest a relationship of the epicardial adipose tissue (EAT) with progression and calcification of the atherosclerotic plaque; however, it is unknown if this tissue expresses genes that may participate on these processes and if the expression of these genes is regulated by high-density lipoprotein (HDL) subclasses.MethodsTo explore this possibility, we determined the mRNA expression by qPCR of a pro-calcifying gene (osteopontin (OPN)), and two anti-calcifying genes (osteoprotegerin (OPG) and osteonectin (ON)), in biopsies of EAT obtained from 15 patients with coronary artery disease (CAD) determined by angiography, and 15 patients with diagnostic of aortic valve stenosis but without CAD as control group. We determined the distribution and composition of HDL subclasses by electrophoresis and their statistical relationship with the gene expression in EAT.ResultsEAT from CAD patients showed a higher expression level of OPN and OPG than control group, whereas ON expression was similar between groups. Large HDL subclasses were cholesterol-poor in CAD patients as estimated by the cholesterol-to-phospholipid ratio. A linear regression model showed an independent association of OPN expression with HDL3a-cholesterol, and OPG expression with the relative proportion of HDL3b protein. Logistic analysis determined that OPN expression was positively associated with the presence of atherosclerotic plaqueConclusionOPN, ON, and OPG genes are transcribed in EAT; to the exception of ON, the level of expression was different in CAD patients and control group, and correlated with some HDL subclasses, suggesting a new role of these lipoproteins.

Maximal Aortic Valve Cusp Separation and Severity of Aortic Stenosis.

An integrated approach that incorporates two dimensional, M mode and Doppler echocardiographic evaluation has become the standard means for accurate quantification of severity of valvular aortic stenosis. Maximal separation of the aortic valve cusps during systole has been shown to correlate well with the severity of aortic stenosis measured by other echocardiographic parameters. To study the correlation between Maximal Aortic valve Cusp Separation (MACS) and severity of aortic valve stenosis and to find cut-off values of MACS for detecting severe and mild aortic stenosis. In the present prospective observational study, we have compared the accuracy of MACS distance and the aortic valve area calculated by continuity equation in 59 patients with varying degrees of aortic valve stenosis. Aortic leaflet separation in M mode was identified as the distance between the inner edges of the tips of these structures at mid systole in the parasternal long axis view. Cuspal separation was also measured in 2D echocardiography from the parasternal long axis view and the average of the two values was taken as the MACS. Patients were grouped into mild, moderate and severe aortic stenosis based on the aortic valve area calculated by continuity equation. The resultant data regarding maximal leaflet separation on cross-sectional echocardiogram was then subjected to linear regression analysis in regard to correlation with the peak transvalvular aortic gradient as well as the calculated aortic valve area. A cut-off value for each group was derived using ROC curve. There was a strong correlation between MACS and aortic valve area measured by continuity equation and the peak and mean transvalvular aortic gradients. Mean MACS was 6.89 mm in severe aortic stenosis, 9.97 mm in moderate aortic stenosis and 12.36 mm in mild aortic stenosis. MACS below 8.25 mm reliably predicted severe aortic stenosis, with high sensitivity, specificity and positive predictive value. MACS above 11.25 mm practically ruled out significant aortic stenosis. Measurement of MACS is a simple echocardio-graphic method to assess the severity of valvular aortic stenosis, with high sensitivity and specificity. MACS can be extremely useful in two clinical situations as a simple screening tool for assessment of stenosis severity and also helps in decision making non invasively when there is discordance between the other echocardiographic parameters of severity of aortic stenosis.

Balloon Dilation in a Dog with Severe Aortic Valvular Stenosis

Balloon Dilation in a Dog with Severe Aortic Valvular Stenosis

Transcatheter aortic valve replacement: perioperative stroke and beyond

ABSTRACTIntroduction: The definition of stroke has changed over time, from a clinical only-based diagnosis to a more complex classification, including both clinical and imaging-based criteria, in part due to widespread use of magnetic resonance imaging (MRI). The increasing number of transcatheter aortic valve replacement (TAVR) procedures in patients with severe aortic valvular stenosis who are considered high-risk surgical candidates has influenced our view on the diagnosis, interpretation, and significance of perioperative stroke during these procedures.Areas covered: In this perspective, we summarize changes in the definition and diagnostic criteria for stroke and transient ischemic attacks. We examine how the introduction of MRI and standardized cognitive tests has affected our understanding of the safety of TAVR procedures. Finally, we review the growing evidence regarding the role of cerebral protection technology during TAVR procedures on cognitive function.Expert commentary: Standardized MRI-based protocols and prospective evaluation of neurologic deficits with a battery of cognitive assessment tests are needed to ensure accurate recognition of postprocedural clinical events in patients undergoing TAVR procedures and to confirm the effectiveness of embolic protection technology.

Simultaneous rota-stenting and transcatheter aortic valve implantation for patients with heavily calcified coronary stenosis and aortic stenosis

Given that coronary artery disease (CAD) in octogenarians undergoing transcatheter aortic valve implantation (TAVI) often presents with more complex lesions and extensive calcification, rotational atherectomy (RA) may be needed in some cases before stenting. However, data regarding the feasibility and safety of simultaneous RA during TAVI using the Medtronic CoreValve (MCV; Medtronic, Minneapolis, MN, USA) system are lacking. Three out of 107 (2.8%) patients (2 females, average age 85.6 years, mean aortic valve area 0.5 cm2, mean left ventricular ejection fraction 39%, mean Logistic EuroScore 70%), with complex, heavily calcified coronary stenosis, and severe valvular aortic stenosis (AS) were treated with TAVI and RA due to high surgical risk. After balloon valvuloplasty, all coronary lesions were successfully treated with RA and stenting, immediately followed by transfemoral TAVI with a self-expandable MCV. Our data suggested that in the very elderly patients with severe and heavily calcified CAD and AS who were turned down for cardiac surgery, RA and stenting followed by TAVI may be performed successfully in a combined, single-stage procedure.

Early Diastolic Strain Rate in Relation to Systolic and Diastolic Function and Prognosis in Aortic Stenosis

ObjectivesThis study examined the impact of early mitral inflow velocity-to-early diastolic strain rate (E/SRe) ratio on long-term outcome after aortic valve replacement (AVR) in aortic stenosis (AS). BackgroundIn AS, increased filling pressures are associated with a poor prognosis and can be estimated using the early diastolic mitral inflow velocity-to-early diastolic velocity of the mitral annulus (E/e′) ratio. Recent studies suggest that the E/SRe ratio surpasses the E/e′ ratio in estimating outcome. MethodsPre-operative evaluation was performed in 121 patients with severe AS (aortic valve area <1 cm2) and left ventricular ejection fraction (LVEF) of >40% who were scheduled for AVR. Patients were divided according to E/SRe median and followed for 5 years. The primary endpoint was overall mortality. ResultsLVEF was lower (53 ± 7% vs. 56 ± 7%, respectively; p = 0.03) and a restrictive filling pattern more common (28% vs. 8%, respectively, p = 0.005) in patients with increased E/SRe ratio. Five-year overall mortality was increased in patients with high E/SRe (40% vs. 15%, respectively; p = 0.007). In univariate Cox regression analysis, E/SRe, age, European System for Cardiac Operative Risk Evaluation (EuroSCORE), LV mass index, left atrial volume index, LVEF, global longitudinal strain, E/e′ ratio, and N-terminal pro–B-type natriuretic peptide level were univariate predictors of overall mortality, although when we adjusted for the predefined variables age, history of diabetes mellitus and LVEF, only E/SRe and left atrial volume index remained associated with overall mortality. Even when we included left atrial volume index in the multivariate model, E/SRe was significantly associated with overall mortality (hazard ratio [HR]: 2.2; 95% confidence interval [CI]: 1.1 to 4.4; p < 0.05); additionally, in a model with forward selection, E/SRe was the sole predictor (HR: 2.9; 95% CI: 1.6 to 5.5; p = 0.001. The overall log likelihood chi-square analysis of the predictive power of the multivariate model containing E/SRe was statistically superior to models based on the E/e′ ratio. ConclusionsPre-operative E/SRe ratio was significantly associated with long-term post-operative survival and was superior to the E/e′ ratio in patients with severe AS undergoing AVR. (Effect of Angiotensin II Receptor Blockers (ARB) on Left Ventricular Reverse Remodelling After Aortic Valve Replacement in Severe Valvular Aortic Stenosis; NCT00294775)

Antiplatelet Therapy in TAVI: Current Clinical Practice and Recommendations.

Transcatheter aortic valve implantation (TAVI) is all the more used therapeutic option for patients suffering from symptomatic severe aortic valvular stenosis declined by surgeons because of high surgical risk. Given the high bleeding and ischemic risk of this vulnerable population, their antithrombotic treatment becomes a crucial issue. There is no consensus on antithrombotic treatment after TAVI and dual antiplatelet therapy (DAPT) with aspirin (indefinitely) and clopidogrel (1-6 months) is, in general, recommended. With regards to patients with an indication for oral anticoagulation (OAC), a combination of OAC plus aspirin or clopidogrel is commonly suggested. This review underscores that it is extremely difficult to compare different antithrombotic regimens in patients undergoing TAVI because of their variable demographic characteristics. Nevertheless, available data suggest that DAPT results to more bleeding events. Still, whether it positively affects ischemic episodes is doubtful. Ongoing trials are expected to draw a clearer picture on the field.