Significant Aortic Regurgitation Research Articles

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations.

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.Methods and Results: Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men. Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Real-time regurgitation estimation in percutaneous left ventricular assist device fully supported condition using an unscented Kalman filter

Objective. Significant aortic regurgitation is a common complication following left ventricular assist device (LVAD) intervention, and existing studies have not attempted to monitor regurgitation signals and undertake preventive measures during full support. Regurgitation is an adverse event that can lead to inadequate left ventricular unloading, insufficient peripheral perfusion, and repeated episodes of heart failure. Moreover, regurgitation occurring during full support due to pump position offset cannot be directly controlled through control algorithms. Therefore, accurate estimation of regurgitation during percutaneous left ventricular assist device (PLVAD) full support is critical for clinical management and patient safety. Approach. An estimation system based on the regurgitation model is built in this paper, and the unscented Kalman filter estimator (UKF) is introduced as an estimation approach. Three offset degrees and three heart failure states are considered in the investigation. Using the mock circulatory loop experimental platform, compare the regurgitation estimated by the UKF algorithm with the actual measured regurgitation; the errors are analyzed using standard confidence intervals of ±2 SDs, and the effectiveness of the mentioned algorithms is thus assessed. The generalization ability of the proposed algorithm is verified by setting different heart failure conditions and different rotational speeds. The root mean square error and correlation coefficient between the estimated and actual values are quantified and the statistical significance of accuracy differences in estimation is illustrated using one-way analysis of variance (One-Way ANOVA), which in turn assessed the accuracy and stability of the UKF algorithm. Main results. The research findings demonstrate that the regurgitation estimation system based on the regurgitation model and UKF can relatively accurately estimate the regurgitation status of patients during PLVAD full support, but the effect of myocardial contractility on the estimation accuracy still needs to be taken into account. Significance. The proposed estimation method in this study provides essential reference information for clinical practitioners, enabling them to promptly manage potential complications arising from regurgitation. By sensitively detecting LVAD adverse events, valuable insights into the performance and reliability of the LVAD device can be obtained, offering crucial feedback and data support for device improvement and optimization.

Valvulitis: un nuevo criterio ecocardiográfico para el diagnóstico de endocarditis infecciosa de bioprótesis de válvula aórtica

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Contemporary Valvular Mechanisms of Aortic Regurgitation in Tricuspid Aortic Valves: Importance in Repair Versus Replacement Strategy.

This study was performed to determine cusp causes of aortic regurgitation in patients with tricuspid aortic valves without significant aortic dilatation and define cusp pathologies amenable to surgical repair (aortic valve repair [AVr]) versus aortic valve replacement. We retrospectively reviewed surgical reports of consecutive adults with tricuspid aortic valves undergoing surgery for clinically significant aortic regurgitation within a prospective registry from January 2005 to September 2019. Valvular mechanisms were determined by systematic invivo intraoperative quantification methods. Of 516 patients, 287 (56%) underwent repair (AVr; mean±SD age, 59.9±12.4 years; 81% men) and 229 (44%) underwent replacement (aortic valve replacement; mean±SD age, 62.8±13.8 years [P=0.01 compared to AVr]; 67% men). A single valvular mechanism was present in 454 patients (88%), with cusp prolapse (46%), retraction (24%), and perforation (18%) being the most common. Prolapse involved the right cusp in 86% of cases and was more frequent in men (P<0.001). Two-dimensional transesophageal echocardiography accuracy for predicting mechanisms was 73% to 82% for the right cusp, 55% to 61% for the noncoronary cusp, and 0% for the left-coronary cusp. Cusp prolapse, younger age, and larger patient size were associated with successful AVr (all P<0.03), whereas retraction, perforation, older age, and concomitant mitral repair were associated with aortic valve replacement (all P<0.03). Right cusp prolapse is the most frequent single valvular mechanism in patients with tricuspid aortic valve aortic regurgitation, followed by cusp retraction and perforation. The accuracy of 2-dimensional transesophageal echocardiography is limited for left and noncoronary cusp mechanistic assessment. Prolapse is associated with successful AVr, whereas retraction and perforation are associated with aortic valve replacement. With systematic intraoperative quantification methods and current surgical techniques, more than half of tricuspid aortic valve aortic regurgitation cases may be successfully repaired.

Prognostic Implications of Left Atrial Strain in Bicuspid Aortic Valve With Chronic Aortic Regurgitation.

Left atrial reservoir strain (LARS) is a novel imaging biomarker of left ventricular diastolic dysfunction. This study aimed to examine the prognostic implications of LARS in patients with bicuspid aortic valve and significant (moderate-severe to severe) aortic regurgitation. A total of 220 patients with bicuspid aortic valve and significant aortic regurgitation were prospectively enrolled in our study. LARS and left ventricular global longitudinal strain were derived from speckle-tracking echocardiography. The end point was a composite of all-cause mortality, heart failure hospitalization, and aortic valve repair or replacement. The threshold value of LARS <24% was used to identify impaired left atrial mechanics based on prior results. During a median follow-up of 364 (interquartile range, 294-752) days, 46 patients (20.9%) reached the composite end points. On multivariable Cox analysis, impaired LARS (adjusted hazard ratio, 2.08 [95% CI, 1.05-4.11]; P=0.036) was a statistically significant predictor of composite end points after adjustment for other statistically significant predictors. Finally, adding impaired LARS to other statistically significant predictors (New York Heart Association functional class and left ventricular global longitudinal strain) significantly improved the global χ2 (from 32.19 to 36.56; P=0.037) and reclassification (continuous net reclassification index=0.55; P<0.001) of the prediction model. In patients with bicuspid aortic valve and significant aortic regurgitation, the impairment of LARS is a strong independent prognostic predictor and confers incremental prognostic utility over clinical and other echocardiographic parameters. These findings suggest that LARS could be considered in risk stratification for such populations.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: Multimodality imaging assessment

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital heart disease with a limited body of literature. This retrospective cohort study investigates QAV morphology, function, and clinical outcomes. MethodsEchocardiography was used to assess valvular function. Morphological characteristics such as phenotypes, raphe, regurgitant orifice area (ROA), and aortic dilation (diameter >40 ​mm) were assessed by cardiac CT. Patients were followed up for the combined event of all-cause death and aortic valve replacement (AVR). ResultsNinety QAV patients (screened from 322385 CT scans) were included (mean age 55.2 ​± ​13.6 years, 61.1 ​% male). Isolated significant aortic regurgitation (AR) was present in 75.6 ​% of patients. The cohort was dominated by type I (four equal leaflets, 37.8 ​%) and type II (3 larger and 1 smaller leaflets, 42.2 ​%) QAV. Fused raphe was present in 26.7 ​% of patients. ROACT was correlated with AR severity and aortic dilation (41.1 ​%, n ​= ​37). Among patients without AVR at baseline (n ​= ​60), one died and 17 underwent AVR during a median follow-up of 35.0 months (IQR:17.3–62.8). ROACT was associated with an increasing risk of combined event (as a categorical variable with a cut-off of 21.4 ​mm2, HR ​= ​4.25, 95%CI 1.49–12.17, p ​= ​0.007; as a continuous variable (per mm2 increment), HR ​= ​1.04, 95%CI 1.01–1.07, p ​= ​0.003). Additionally, ROACT had incremental prognostic value when added to the AR severity model (area under the receiver-operating characteristic curve increased from 86.8 to 88.4, p ​= ​0.004). ConclusionQAV is characterized by variable anatomy, progressive AR, concomitant cusp fusion and aortic enlargement. ROACT may be a potential ancillary prognostic marker in patients with QAV.

Veno-Venous Coiling as A Strategy to Wean Extracorporeal Membrane Oxygenator Post Adult Fontan Completion

We discuss a case of veno-venous collaterals in a patient with Fontan circulation post complex redo-surgery, which impeded veno-venous extracorporeal membrane oxygenation (VV-ECMO) weaning. A 31-year-old male, born with complex congenital heart disease (D-transposition of the great vessels, tricuspid atresia, aortic coarctation, ventricular septal defect, and hypoplastic right ventricle) with single ventricle physiology. The patient underwent multiple cardiac surgeries leading to Fontan completion. He subsequently developed significant aortic regurgitation with progressive left ventricular dilatation requiring multiple readmissions for congestive heart failure. Despite maximal medical optimisation he remained symptomatic and was offered further surgery. Complex 6th redo-operation with aortic valve replacement, modification to intracardiac fenestrated Fontan and insertion of intra-aortic balloon pump was performed. At 72 hours postoperative, VV-ECMO was required for refractory hypoxia. Right heart catheterisation was performed with coiling of two large fistulous venous connections. Post-coiling saturations improved from 92% to 98%. The patient was successfully weaned from VV-ECMO and decannulated the following day. This case demonstrates successful embolisation for veno-venous collaterals causing significant right to left shunt and hypoxia, in a patient with Fontan circulation.

Sex-specific differences in patients with significant aortic regurgitation

Abstract Background Significant aortic regurgitation (AR) leads to left ventricular (LV) remodelling and poor outcomes if untreated; however, data on sex-differences in the setting of significant AR is scare. Purpose To examine contemporary clinical and echocardiographic differences between men and women with significant chronic AR. Methods and results Consecutive patients with significant AR evaluated in a heart valve clinic following a comprehensive clinical and imaging protocol were included. Comparison was performed between genders. A total of 206 patients with significant AR were included (130 grade III, 76 grade IV AR) (mean age 69 years, 49% women). Mean follow-up was 3.7 years. Women showed similar comorbidities, but were older (66.5 vs 71.4, p=0.017), and more symptomatic. Women were smaller in terms of height, weight and surface area, showing significantly smaller volumes and diameters (LVEDD 52 ± 6.2 mm men vs 47.0 ±6.7 mm women, p&amp;lt;0.001). However, when diameters were normalized, no significant differences were seen between men and women. Hospital admissions due to heart failure and number of surgeries were not significantly different between genders. Conclusion In patients with significant AR, indication for intervention in guidelines is based on the same values for both men and women. However, women were more symptomatic and showed significantly smaller volumes and diameters. Indexed values should be considered in decision making taking into account differences in gender.

Abstract 12123: Descending Aortic Diastolic Flow Reversal in Aortic Regurgitation: Optimizing Definitions and Assessment on Cardiac Magnetic Resonance

Introduction: Holodiastolic flow reversal (HDR) in the descending aorta (DA) may indicate hemodynamically significant aortic regurgitation (AR). However, the optimal definition and quantification of flow reversal on cardiac magnetic resonance (CMR) is unknown. Methods: We studied 346 chronic AR patients with regurgitant volume (RegVol) ≥30 mL or regurgitant fraction (RegF) ≥30%. The presence of HDR and quantitation of reverse volume in the DA (DA-RVol) was performed by a blinded observer. The threshold for DA-RVol that identified ≥ moderate-severe AR (RegVol ≥45 mL and RegF ≥40%) was established by derivation (50% random sample), validation (50% remaining sample), and ROC curve analysis. Multivariable logistic regression models adjusting for age, gender, NYHA Class, and indexed left ventricular end-diastolic volume were performed to compare HDR and DA-RVol. Results: The median age was 61 (IQR 50-70) years, 79.2% men, and 30.3% with bicuspid aortic valve. The median RegF was 37% (IQR 32-44) and DA-RVol was 12 mL (IQR 5-27). HDR was observed in 150 (43.2%), with 63% sensitivity and 77% specificity for detecting ≥ moderate-severe AR. The threshold of DA-RVol which identified ≥ moderate-severe AR was 17 mL (AUC 0.82, sensitivity 68%, and specificity 87%). The ROC curve analysis revealed a higher AUC for DA-RVol ≥17 mL relative to HDR (0.78 vs 0.70, P &lt;0.001) for predicting ≥ moderate-severe AR. On multivariable analysis models, DA-RVol ≥17 mL was superior to HDR (AUC 0.83 vs 0.80, P =0.008). Conclusion: Quantitation of flow reversal in the descending aorta is a more reliable method to identify hemodynamically significant AR compared to simple presence of holodiastolic flow reversal.

Machine learning in assessing the association between the size and structure of the ascending aortic wall in patients with aortic dilatation of varying severity

Aim. To assess the association between pathological ascending aortic (AA) wall changes and its planimetric characteristics in non-syndromic non-familial (sporadic) aneurysm and dilation of the AA.Material and methods. The study included 174 patients with sporadic aneurysms and dilation of the AA, who underwent elective surgery between January 2010 and July 2015 and were divided into 2 groups: patients with AA aneurysm (AAA) (AA diameter &gt;50 mm) and tricuspid aortic valve (AV) with significant aortic stenosis (AS) or regurgitation (AR) (AAA group, n=120), and persons with borderline AA dilatation (AA diameter 45-50 mm), associated with a bicuspid aortic valve (BAV) and significant AS (BD group, n=54). Standard paraclinical investigations and pathological examination of the VA wall were used. Statistical processing was carried out in the SPYDER 4.1.5 environment (Python 3.8), and included univariate correlation analysis, logistic regression analysis, as well as supervised machine learning (ML) methods (support vector machine, k-nearest neighbor method, random forest).Results. Logistic regression revealed positive associations between AA atherosclerosis and age, cystic medial necrosis (CMN) and sinus of Valsalva (SV) diameters. The support vector machine method demonstrated a tendency towards AA expansion at the SV level in individuals with CMN (accuracy, 60,5%), as well as towards expansion of the tubular AA in atherosclerosis (accuracy, 79,2%). During the random forest analysis, the first stage was to construct decision trees to predict three following outcomes: the presence of CMN, atherosclerosis, or normal aortic structure. The model accuracy was 64,2%. Next, the variables "CMN" and "atherosclerosis" were combined, and prediction was made for the outcomes "normal AA wall structure" and "pathological AA wall structure". The model accuracy was 73,5%.Conclusion. The use of ML opens up new opportunities for predicting aortopathy and a patient-centered approach to treatment. In AR, a more aggressive AA intervention is warranted. To predict aortopathies, thoracic aorta diameters indexed to body surface area should not be used. Aortic wall sampling (circular section) followed by a continuous pathological examination may be promising.

Early Outcomes of a Next-Generation Balloon-Expandable Transcatheter Heart Valve - The Myval System: A Single-Center Experience From Serbia

Transcatheter aortic valve implantation (TAVI) is one of the most effective treatments for severe aortic valve stenosis (AVS). Different genres and generations of transcatheter heart valves (THVs) are accessible, offering operators an opportunity to choose a patient-tailored device. In this single-center study, we present the outcomes of Serbian patients treated with next-generation Myval THV for severe symptomatic AVS. Myval THV was implanted in all consecutive patients who underwent TAVI at the Dedinje Cardiovascular Institute of Belgrade, Serbia between October 2020 and September 2021. The primary endpoint was device success on day 30. Secondary endpoints included 30-day all-cause mortality, cardiovascular death, stroke, moderate/severe paravalvular leak (PVL), and new permanent pacemaker implantation (PPI). TAVI was performed as per the European Society of Cardiology guidelines. The study comprised thirteen patients, aged 72 ± 13 years with mean EuroSCORE (7.17%) and Society of Thoracic Surgeons (2.72%,) scores who underwent TAVI successfully with 92.3% using the percutaneous approach. Myval THV intermediate and extra-large sizes were implanted in 46% and 15% of patients, respectively. This acute procedure success rate was 100%. The primary composite endpoint of early device success was achieved in all patients. None of the patients had clinically significant aortic regurgitation or moderate/severe PVL. No patient experienced stroke, contrast-induced acute kidney injury, device-related vascular complications, or a new PPI. The all-cause mortality rate at 30 days was 0%. Myval THV system demonstrated a favorable safety/efficacy profile within 30 days post-procedure at a single center in Serbia. This is the first report of my experience with Myval THV from Serbia.

LONG-TERM HEMODYNAMIC OUTCOMES OF DIFFERENT AORTIC VALVE INTERVENTIONS – A REVIEW OF COMPARATIVE STUDIES

Highlights Valve replacements using mechanical prostheses are not inferior, and sometimes even advantageous to bioprostheses in terms of transvalvular hemodynamics and left ventricle reverse remodeling;During the average follow-up period, a significantly lower average pressure gradient and a higher effective opening area were recorded in the group undergoing neocuspidization with autologous pericardium compared to other types of implants;Despite the obvious hemodynamic advantages of transcatheter aortic valve replacement, the midterm follow-up has revealed significant residual aortic regurgitation, which is highly undesirable. AbstractCurrently, there are not enough data on the comparative analysis of echocardiographic outcomes, especially in regards to the state of the left ventricle in the long term after different aortic valve interventions. In this review, we present up-to-date literature data (publications published over 20 years) concerning echocardiographic outcomes after different aortic valve replacements. For the search of publications, the authors used international databases such as Scopus, Web of Science, Pubmed and Cochrane. The search keywords were: “aortic valve surgery”, “long-term period”, “echocardiographic outcomes”, “quality of life”. The analysis includes only comparative randomized, prospective or retrospective studies. A comparison between mechanical and biological prostheses has demonstrated that mechanical valves, in addition to displaying higher durability, can be advantageous in certain situations to bioprostheses in relation to transvalvular hemodynamics and reverse left ventricle remodeling. Regarding the comparison of stentless and stented bioprostheses with respect to peak transvalvular gradients and the effective orifice area, an obvious advantage was observed in the stentless bioprosthesis group. The majority of randomized clinical trials have showed great hemodynamic advantages of the Ross procedure in comparison with other types of aortic valve replacement, and an increase in the number of participants (due to future trials) may demonstrate even greater statistical significance. We have found only one publication that presents data on the comparison of the mid-term hemodynamic outcomes of neocuspidization of the aortic valve using autologous pericardium with other types of interventions. With an average follow-up period of 426±270 days, a significantly lower average pressure gradient and a higher effective orifice area were recorded in the neocuspidization group. Despite hemodynamic benefits of transcatheter aortic valve replacement in the mid-term period after surgery, the results of postoperative monitoring show significant residual aortic regurgitation, which is highly undesirable.

P133 ZEBRA HOOFBEATS: A RARE CASE OF STEMI IN GRANULOMATOUS NECROTIZING AORTITIS

Abstract We present the unusual case of an AMI STEMI, complicated by ventricular fibrillation, in a 26 years old caucasic male patient, affected by necrotizing and granulomatous aortitis, in the context of a primary immunodeficiency. Initially the patient was referred to the Cardiology Unit for worsening dyspnea and fatigue. In his medical history he has primary immunodeficiency complicated by multiple opportunistic infections. We performed an echocardiography that revealed an aneurismatic ascending aorta (58 mm) with associated significant aortic valvular regurgitation. He was later referred to heart surgery OR where Bentall–De Bono operation was performed. Two years later he developed a lateral STEMI, complicated by ventricular fibrillation. The coronary angiography, performed in foreign country, showed total occlusion of the circumflex coronary artery with diffuse aneurismatic coronary disease, granulomatosis and ulcerative lesions. A percutaneous revascularization approach was tried, but ineffective. Actually the patient, during follow up, presents dilatative post–ischemic cardiopathy with moderate ejection fraction reduction, initial aortic bioprosthesis failure. We noted at follow up echocardiograms early dilatation of the native aortic arch (35 mm), suggesting a progressive disease. In conclusion, AMI‘s etiology includes many non atherosclerotic mechanisms that should be considered alongside common causes. This case shows a rare cause of STEMI in a very young male patient, and teaches us that aortitis is a progressive and complex pathology, often involving multiple arteriosus districts, that needs close follow–up and integrated management.

C35 A RARE CASE OF NON–BACTERIAL THROMBOTIC ENDOCARDITIS IN YOUNG WOMAN AFFECTED BY ADVANCED UTERINE CANCER

Abstract A 37–year–old woman affected by uterine HPV–related adenocarcinoma complicated by paraneoplastic pulmonary thromboembolism, came to the emergency department for recurrent episodes of dysarthria and blurred vision with spontaneous resolution. Home medications: Enoxaparin 5000 UI b.i.d, levofloxacin 500 mg/die, deltacortene 25 mg/die and omeprazole 20 mg/die. Blood analysis: normocytic anemia (Hb 9 gr/dl),elevated D–dimer (22.5 mcg/ml) and elevated C–reactive protein (18.3 mg/dl). Procalcitonin and blood cultures resulted negative. Brain CT scan: ischemic brain lesions of embolic nature in the right precentral gyrus and in the left post central gyrus. EKG: sinus rhythm, T–wave inversion in inferior leads. In the suspect of cardioembolic stroke a transthoracic (TTE) and subsequent transesophageal (TOE) echocardiography was performed: TTE: isoechoic oval–shaped thickening of the aortic valve cusp tips, producing aortic regurgitation with double jet regurgitation. TOE: evidence of multiple isoechoic masses involving all the aortic cusps, without perivalvular aortic extension, producing significant aortic regurgitation due to coaptation– gap (Figure 1). The diagnosis of non–bacterial thrombotic endocarditis (NBTE) was made up. Although the standard medical therapy (anticoagulation and chemotherapy) was promptly started, it wasn’t effective with progression of the disease leading to surgical indications of valve intervention. The patient underwent aortic valve replacement with bioprosthesis avoiding mechanical prosthesis, despite the young age, in anticipation of major surgery for the uterine cancer. Surgical specimen turned negative for microorganism growth confirming the diagnosis of marantic endocarditis. No further episodes of ischemic stroke appeared after the replacement of the valve and the patient had no neurological sequelae. NBTE is a rare condition of non–infective endocarditis characterized by the formation of aggregates of platelets and fibrin that affects usually undamaged heart valves in the absence of bacteremia and mostly occurs in patients with a predisposing state like hypercoagulability. Surgical indications of valve intervention are not well encoded but in most cases they follow the raccomandations for infective endocarditis. Our experience highlights the need of a prompt intervention in order to reduce the damage of systemic embolization and preserve patient’s hemodynamics with a strict checking of disease progression.

Left Axillary Access for Transcatheter Aortic Valve Implantation in a Patient With Two Dependent Internal Mammary Artery Grafts and a Permanent Left-Sided Implanted Pacemaker

Transfemoral access has been established as the gold standard approach for the majority of patients undergoing transcatheter aortic valve implantation (TAVI). However, in cases with anatomical difficulties or severely diffused peripheral arterial disease, alternative vascular access may be considered such as the transaxillary approach. We present the case of a 92-year-old gentleman with exertional dyspnea due to severe symptomatic aortic stenosis and a history of peripheral femoro-femoral bypass surgery, coronary arterial bypass surgery and a permanent dual-chamber left-side implanted pacemaker. Due to the high surgical risk and the severe anatomical difficulties, the method of TAVI using the left axillary approach was opted. A 14-F vascular sheath was inserted with surgical cutdown and with fluoroscopic guidance while small injections of contrast confirmed the non-occlusive position and the patency of the left internal mammary artery (LIMA) graft. A stiff guidewire was used to cross the heavily calcified aortic valve and subsequently was placed into the left ventricle. Balloon aortic valvuloplasty was performed followed by a successful TAVI with no significant aortic regurgitation or paravalvular leak. The patient recuperated uneventfully and was discharged after 72 h. Axillary access for TAVI is a feasible option for high-risk patients with extended peripheral arteriopathy. To our knowledge this is the first case report describing the implantation of a newer type of intra-annular self-expanding valve platform in a nonagenarian patient with severe comorbidities and such a remarkable history of multiple previous interventions in the selected access site. Meticulous upfront strategy planning and efficient collaboration between specialties is of outmost importance in hybrid procedures for favorable clinical outcomes, especially in cases with challenging anatomies.

Analysis of Left Ventricular Indexes and Mortality Among Asian Adults With Hemodynamically Significant Chronic Aortic Regurgitation

Chronic hemodynamically significant aortic regurgitation (AR) is associated with excess risk of death, yet data for Asian patients are lacking, and whether Asian patients can abide by Western guidelines as to when aortic valve surgery should be performed is unknown. To assess AR presentation and cutoffs of left ventricular ejection fraction (LVEF), LV end-systolic dimension index (LVESDi), and LV end-systolic volume index (LVESVi) that are associated with risk of death in Asian patients with AR. This retrospective cohort study included consecutive patients with chronic, moderately severe to severe AR from 3 tertiary referral centers (2 in Japan and 1 in Taiwan) from June 11, 2008, through November 19, 2020, with follow-up through November 11, 2021. Aortic regurgitation severity, graded by a comprehensive integrated approach. The primary outcome was the association between volume-derived LVEF, LVESDi, and LVESVi and all-cause death (ACD). The secondary outcome was the association of these LV indexes with cardiovascular death (CVD). Clinical and echocardiographic data were analyzed retrospectively. A de novo disk-summation method was used to derive LV volumes and volume-derived LVEF. Of 1259 patients (mean [SD] age, 64 [17] years; 934 [74%] male), 515 (41%) were Japanese and 744 (59%) were Taiwanese. The median follow-up was 4.1 years (IQR, 1.56-7.24 years). The mean (SD) body surface area was 1.67 (0.21) m2; LVEF, 55% (11%); LVESDi, 24.7 (5.7) mm/m2; LVESVi, 50.1 (28.0) mL/m2; and indexed mid-ascending aorta size, 24.7 (5.5) mm/m2. Aortic valve surgery occurred in 483 patients (38%); 240 patients (19%) died during follow-up. Overall mean (SD) 8-year survival was 74% (2%). Separate multivariate models adjusted for covariates demonstrated independent associations of LVEF, LVESDi, and LVESVi with ACD (LVEF: hazard ratio [HR] per 10%, 0.80; 95% CI, 0.70-0.92; P = .002; LVESDi: HR, 1.04; 95% CI, 1.01-1.06; P = .002; LVESVi: HR per 10 mL/m2, 1.11; 95% CI, 1.05-1.17; P < .001) and CVD (LVEF: HR per 10%, 0.69; 95% CI, 0.56-0.85; P < .001; LVESDi: HR, 1.05; 95% CI, 1.01-1.09; P = .01; LVESVi per 10 mL/m2: HR, 1.15; 95% CI, 1.06-1.24; P < .001). In the total cohort, spline curves showed that mortality started to increase for an LVEF of 53% or less, LVESDi of 22 mm/m2 or greater, and LVESVi of 46 mL/m2 or greater for both ACD and CVD. Early surgery was beneficial in 3 strata of LVESDi (<20, 20 to <25, and ≥25 mm/m2) and 2 strata of LVESVi (<46 and ≥46 mL/m2). This multicenter cohort study of Asian patients with hemodynamically significant AR found cutoff values of LVEF, LVESDi, and LVESVi that were associated with increased risk of death. These findings suggest that Western guidelines seem applicable in Asian patients and, most importantly, that indexed LV parameters with a lower cutoff could be used in discriminating patients with excess mortality risk.

Man With Progressive Exertional Dyspnea.

A 65-year-old man with a history of hypertension and left ventricular hypertrophy presented with progressive exertional dyspnea for one month. Physical examination showed a blood pressure of 155/82 mmHg, a pulse of 102 beats/min, mild icteric sclera, and a high-pitched midsystolic murmur at the left lower sternal border. Laboratory tests reported a normal hemoglobin level. Electrocardiography was typical for left ventricular hypertrophy, and chest radiography showed mild cardiomegaly without active lung infiltrate (Figure 1). Ultrasonography with the parasternal long-axis view of the heart revealed increased thickness of the interventricular septum and an obvious aortic valve fluttering when the leaflets were open (Figure 2 and Video E1). The aortic valve fluttering during the systolic phase was confirmed by the M-mode echocardiogram (Figure 3).Figure 2Ultrasonography with the parasternal long-axis view of the heart revealed increased thickness of the interventricular septum (asterisk) and an obvious aortic valve fluttering when the leaflets were open (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3The aortic valve fluttering during the systolic phase (arrows) was shown on the M-mode tracing at the aortic valve in the parasternal long-axis view of the heart.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Hypertrophic obstructive cardiomyopathy. After consultation with cardiovascular specialists, the patient received an elective left ventricular myomectomy for hypertrophic obstructive cardiomyopathy. The fluttering of the cusps of the aortic valve is mostly reported during diastole, and it is associated with flail cusps with significant aortic regurgitation.1Qamar S. Ammar K.A. Paterick T.E. et al.Diastolic fluttering of the aortic valve: pathognomonic M-mode features of flail cusp.Eur Heart J Cardiovasc Imaging. 2013; 14: 204Crossref PubMed Scopus (1) Google Scholar Systolic fluttering of the aortic valve has been reported, which was explained by turbulent systolic flow downstream of an aortic valve.2Becsek B. Pietrasanta L. Obrist D. Turbulent systolic flow downstream of a bioprosthetic aortic valve: velocity spectra, wall shear stresses, and turbulent dissipation rates.Front Physiol. 2020; 11577188Crossref PubMed Scopus (12) Google Scholar Before the widespread use of Doppler echocardiogram, systolic fluttering was used to diagnose a patient with severe aortic stenosis.3Chin M.L. Bernstein R.F. Child J.S. et al.Aortic valve systolic flutter as a screening test for severe aortic stenosis.Am J Cardiol. 1983; 51: 981-985Abstract Full Text PDF PubMed Scopus (8) Google Scholar Systolic fluttering of the aortic valve indicates a large pressure gradient during the systole, which is pathognomonic for hypertrophic obstructive cardiomyopathy.4Pollick C. Shmueli H. Maalouf N. et al.Left ventricular cavity obliteration: mechanism of the intracavitary gradient and differentiation from hypertrophic obstructive cardiomyopathy.Echocardiography. 2020; 37: 822-831Crossref PubMed Scopus (1) Google Scholar Since left ventricular hypertrophy is common in the elderly, recognizing the aortic valve fluttering by clinicians facilitates the correlation of clinical symptoms, consultation, and timely treatment for hypertrophic obstructive cardiomyopathy. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1YzAxZjJmZDVmYjg2ZTM4ZGFjM2EwMjc4ZDUyMGQ4YiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNDg4fQ.l8n6GzpnK5MPpC1H1vaaZNBSV9NXyo8dNwHvQgC-HV8KCQK6B7P0Eb2wyRB1OKRFVvXIu8cVL4pTqPEIchOdRO7GgaY6-MTWE-ZZZ8wFG9AaDLZGd3SK_NVRyPuThLWyjmXP5gQXvoFcqAmT3XqT3VZVCRfD5JbkLNTd8kms7lZw2PGWPRexp3Q2d_Dw5dWL8eBCZ5NaEBEAmvhio4GuUNjVoHR7tfEV8q06Hqur4PFADzFXVcNGWW87aGJxI9HcWgK6F86W17-3k0DTUt4BPMMDatDekNdROGq9X_ekBZ_Yv53pq652T6lVJYliLhMQNt19sqJR5r6mY2rzWF6O5A Download .mp4 (2.98 MB) Help with .mp4 files Video E1Ultrasonography with the parasternal long-axis view of the heart revealed a thick interventricular septum indicating left ventricular hypertrophy. In the brightness mode, a remarkable aortic valve fluttering in the systolic phase was noted (white arrow, 00:05). Color Doppler (00:09 to 00:13) demonstrated turbulent flows originating from the left ventricular outflow tract (black arrowheads, 00:10), which was compatible with hypertrophic obstructive cardiomyopathy. (Used with permission of Nin-Chieh Hsu, Taipei City Hospital, Taiwan.)

A Contrast Frugal Approach to Transcatheter Aortic Valve Replacement in Chronic Kidney Disease: A Pilot Study.

Transcatheter aortic valve replacement (TAVR) is now regarded as a viable treatment option for all cases of severe aortic stenosis (AS). Acute kidney injury (AKI) is common and lowers the survival of patients after TAVR and iodine-based contrast-induced nephropathy (CIN) plays a significant adverse role in AKI. Therefore, in chronic kidney disease (CKD) patients requiring pre-operative evaluation for TAVR, the risk of CIN is of particular concern. It was a single-center study including eight CKD patients who underwent pre-operative evaluation for TAVR with minimized contrast exposure by means of pre-operative contrast-sparing evaluation and intra-operative contrast minimization. All patients had glomerular filtration rate (eGFR) calculated before TAVR and on a follow-up about one month and one year post-operatively to document the impact of this TAVR protocol on prognosis of kidney function in patients with advanced CKD. New York Heart Association (NYHA) functional classification demonstrated significant improvement of symptomatology (p = 0.0001) by one-year post-TAVR. Patients' mean AS gradient was significantly improved (p = 0.00004) after the TAVR procedure. No significant post-operative paravalvular aortic regurgitation was noted on follow up echocardiogram. eGFR data showed mean eGFR for the group was slightly better (27.38 ml/min/per 1.73 m2 BSA vs. 30.38 ml/min/per 1.73 m2 BSA) after TAVR. "Contrast frugal" approach is feasible and safe for pre-TAVR evaluation and the procedure itself. Our pilot study showed no significant paravalvular leak of the prosthetic valve following this proposed protocol. No statistically significant decrease in eGFR was noted on a one-year follow-up.

Prevalence and clinical associations of mitral and aortic regurgitation in patients with aortic stenosis.

Most guidelines directing clinicians to manage valve disease are directed at single valve lesions. Limited data exists to direct our understanding of how concomitant valve disease impacts the left ventricle (LV). We identified 2817 patients with aortic stenosis (AS) from the echocardiography laboratory database between September 2012 and June 2018 who had a LV ejection fraction (EF) ≥50%. LV mass, LV mass index, LV systolic pressure (systolic blood pressure + peak aortic gradient). Covariates were collected from the electronic medical record. Multi-variate analysis of covariance was used to generate adjusted comparisons. Our population was 66% female, 17% African-American with a mean age of 65 years. Of note, 7.3% were noted to have significant (moderate/severe) aortic regurgitation (AR), and 11% had significant (moderate/severe) mitral regurgitation (MR). Adjusting for covariates at different levels, significant MR had a much stronger association with heart failure compared to those with significant AR (p < .001 vs. p = .313, respectively) at all levels of adjustment. Both significant mitral and AR exhibited an association with increasing left ventricular mass, even with adjustment for baseline demographics and clinical features (p < .001 vs. p = .007, respectively). In patients with AS, 16% also experience at least moderate MR or AR. Further, significant MR has a stronger association with heart failure than significant AR, even though both increase left ventricular mass. Those with moderate AS and significant MR or AR experience similar or higher levels of heart failure compared to severe AS without regurgitation. Mixed valve disease merits further studies to direct longitudinal management.