Structural Valve Deterioration Research Articles

Physician attending cardiac magnetic resonance imaging for early aortic structural valve deterioration: non-invasive method to identify the regurgitate location.

Physician attending cardiac magnetic resonance imaging for early aortic structural valve deterioration: non-invasive method to identify the regurgitate location.

Long-Term Durability of Transcatheter Aortic Valve Prostheses in Patients With Bicuspid Versus Tricuspid Aortic Valve.

Currently, there is a lack of evidence for the long-term bioprosthetic valve durability of patients with bicuspid aortic valve (BAV) following transcatheter aortic valve replacement (TAVR). This study aimed to evaluate hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure during long-term follow-up after TAVR in patients with BAV versus patients with tricuspid aortic valve (TAV). Patients with BAV and TAV who underwent TAVR between 2012 and 2020, with echocardiography followed for at least 3 years, were included. Baseline characteristics, long-term valve hemodynamic performance, structural valve deterioration, and bioprosthetic valve failure were compared between patients with BAV and TAV. A total of 170 patients with BAV and 145 patients with TAV were included. The mean duration of follow-up for patients with BAV and TAV was 5.2±1.8 and 5.0±1.7 years. No significant differences were observed in the rates of structural valve deterioration and bioprosthetic valve failure between patients with BAV and TAV: structural valve deterioration, BAV 20 (11.8%) versus TAV 16 (11.0%) at last follow-up (P=0.861); bioprosthetic valve failure, BAV 3 (1.8%) versus TAV 7 (4.8%) at last follow-up (P=0.196). More than moderate intravalvular aortic regurgitation (1.8% versus 4.8%, P=0.196) and paravalvular leak (6.5% versus 3.4%, P=0.305) were rare in both patients with BAV and patients with TAV. This study indicated satisfactory long-term valve durability of TAVR in patients with BAV. Comparable hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure could be achieved in patients with BAV and TAV during long-term follow-up after TAVR.

Polymorphic size of Lipoprotein (a) and structural bioprosthetic valve degeneration

Abstract Background The use of biological heart valves (BHV) is constantly growing for the treatment of patients with aortic stenosis and their durability arises as a main concern in the field. Structural valve deterioration (SVD) of the BHV occurs gradually post-implantation and seems to reiterate, at least in part, the pathophysiological processes described in native valve stenosis. Lipoprotein (a) [Lp(a)] is an important genetically determine cardiovascular risk factors, associated with native valve calcification. The shorter polymorphic sizes of Lp(a), defined as low of apolipoprotein (a) [apo(a)] Kringle-IV copy number, have been associated with more deleterious cardiovascular phenotype. However, the association of Lp(a) plasma levels and/or its polymorphic sizes with SVD remains unclear. Purpose To determine whether Lp(a) plasma levels and/or the Lp(a) polymorphic size were associated with SVD. Methods 332 patients who underwent aortic valve replacement (AVR) with BHV from the Translink trial were included in this study. Clinically significant SVD has been defined as Stage 3 SVD based on the VARC-3 definition. Lp(a) concentration was determine by immunoturbidimetry method and the apo(a) Kringle-IV copy number by liquid chromatography-tandem mass spectrometry. Univariable and multivariable models, adjusted for clinically relevant and statistically significant variables, were used to determine the independent association between Lp(a) concentrations or apo(a) Kringle-IV copy numbers with SVD. Results Among the 332 patients included in this study, the mean age was 78 ±8 years and 71% were males. 76 patients (23%) presented clinically significant SVD. Low apo(a) Kringle-IV copy number was associated with an increased risk of SVD (per log decrease: OR=2.71 [1.34-5.50], p=0.006), but not Lp(a) plasma concentration (OR=0.99 [0.84-1.15], p=0.85). This association remained significant after comprehensive multivariable adjustments, including Lp(a) concentration (OR=3.21 [1.31-7.84], p=0.01). The analysis of the transprosthetic mean gradient, as a surrogate marker of SVD, provided consistent results (all p≤0.03). Conclusion This cross-sectional study from the Translink trial demonstrates the association between Lp(a) polymorphic size and SVD, highlighting a potential therapeutic option to limit the occurrence of SVD in selected patients who underwent AVR with surgical or transcatheter BHV.

Adverse events following transcatheter aortic valve implantation (TAVI) in patients with amyloidosis: observations from a global federated network

Abstract Background A high proportion of patients with aortic stenosis are affected by cardiac amyloidosis, but there is a paucity of data describing the effect of amyloidosis on the clinical course of patients who underwent transcatheter aortic valve implantation (TAVI). Purpose To assess the one-year risk of adverse events following TAVI in patients with amyloidosis. Methods Retrospective study using data from a large multinational electronic health record network (TriNetX). Patients aged 18 years or older who underwent TAVI between 2005 and 2022 were included in the analysis. The patients were categorised in two groups based on the presence of amyloidosis (ICD-10-cm code E85). Primary outcome was the one-year risk of the composite of emergency department (ED) admission, acute heart failure (HF), stroke, conduction system disease, pacemaker (PM) implantation, acute kidney injury, and all-cause death. Secondary outcomes were the risks for each component of the composite outcome. We used Cox regression analysis to calculate hazard ratio (HR) and 95% confidence interval (CI) after propensity score matching (PSM) 1:1. Results We identified 477 TAVI recipients with a diagnosis of amyloidosis (age 78.6±8.1 years, 31.4% females) and 43,379 TAVI patients without a diagnosis of amyloidosis (78.1±8.8, 40.2% females). Before PSM, patients affected by amyloidosis were more likely to be Black or African American and had a higher prevalence of cardiovascular risk factors compared to TAVI patients without amyloidosis. After PSM, patients with a diagnosis of amyloidosis showed a higher one-year risk of composite outcome (HR 1.28, 95%CI 1.10-1.49) compared to those who underwent TAVI without amyloidosis. Regarding secondary outcomes, amyloidosis patients had a higher risk of ED admission (HR 1.41, 95%CI 1.13-1.75), acute HF (HR 1.56, 1.23-1.99), stroke (HR 1.55, 1.04-2.32), conduction system disease (HR 1.27, 1.04-1.55), PM implantation (HR 1.55, 1.06-2.28), but not acute kidney injury (HR 1.11, 0.84-1.48) and all-cause death (HR 0.98, 0.66-1.45). Conclusion Among patients undergoing TAVI, those affected by amyloidosis are at higher risk of adverse events in the first year after TAVI. More studies are needed to define the exact role of amyloid fibrils in structural valve deterioration and to elucidate whether subtypes of amyloidosis have a different impact on patients’ outcomes following TAVI.Risk of composite outcome following TAVI

Early structural valve deterioration following transcatheter aortic valve implantation in a patient with Scheie syndrome: a case report

BackgroundScheie syndrome, an attenuated subtype of mucopolysaccharidosis type I, is a rare storage disease that causes progressive glycosaminoglycans (GAGs) accumulation. Cardiovascular disorders determine the prognosis, and cardiac valve abnormalities are the most common cause. The patients are usually young so mechanical valve replacement is often performed, but because of the features of this disease, the surgical treatment is very risky. Recently, transcatheter aortic valve implantation (TAVI) has been reported as an alternative choice for aortic stenosis, but optimal choice is still unclear. Here, we introduce a patient that underwent TAVI and refer to the histological finding of a biological valve extracted in relation to GAGs accumulation.Case presentationA 54-year-old woman with Scheie syndrome underwent valve surgeries three times throughout her whole life. At age 41, she received a mitral valve replacement with a mechanical valve for mitral stenosis. She promptly developed severe diastolic dysfunction and low output syndrome after the release of aortic clamping, thus requiring temporary mechanical circulatory support4. At age 51, she suffered from heart failure due to severe aortic stenosis and underwent TAVI because conventional aortic valve replacement (AVR) was deemed too risky. Three years later, her heart failure relapsed, and an echocardiogram unexpectedly revealed thickened bioprosthetic valve leaflets and a significant pressure gradient across the valve, consistent with early structural valve deterioration. AVR was performed via median sternotomy with a mechanical valve. As with the first operation, she presented refractory heart failure requiring mechanical circulatory support and was meticulously managed. However, she steadily showed worsening of multiple organ systems and died 9 days after the operation. Pathological autopsy and histological examination revealed accumulation of tissue with GAGs on the leaflets of the bioprosthetic valve of TAVI, which may have been the cause of early structural valve deterioration.ConclusionFor patients with Scheie syndrome, a biological valve can be compromised by the accumulation of GAGs, thereby causing early SVD. These findings may support valve selection for these high-risk patients.

Long-term comparative outcomes in patients undergoing transcatheter aortic valve implantation with self-expanding valves versus balloon-expandable valves

ABSTRACT Background This study aimed to compare long-term clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) with self-expanding (SEV) valve versus balloon-expandable valve (BEV), with a minimum follow-up period of five years. Materials and Methods Utilizing a prospectively maintained database, this observational study identified patients who underwent TAVI using either SEV or BEV for severe aortic stenosis and were followed for at least five years. Clinical outcomes encompassed both 30-day post-TAVI outcomes and long-term outcomes, including all-cause mortality, cardiovascular mortality, structural valve deterioration (SVD), heart failure related hospitalization, bioprosthetic valve failure, and valve related hospitalization and complications. Results A total of 74 patients were included in this study, with 64 patients in the SEV group and 10 patients in the BEV group. The median follow-up duration was 6.8 years, ranging from 5.0 to 10.2 years. Throughout the post-TAVI period, the SEV group consistently demonstrated a lower mean pressure gradient than the BEV group. No significant differences were observed between the two groups in terms of short-term or long-term outcomes. Within the study, four patients encountered moderate or severe SVD and one experienced thrombosis, and no cases of bioprosthetic valve failure or endocarditis were observed. Conclusions This study revealed that SEV and BEV demonstrated comparable long-term outcomes in patients undergoing TAVI, including all-cause and cardiovascular mortality, as well as the risk of SVD.

TCT-955 Pathology of Noncalcific Structural Valve Deterioration in Transcatheter and Surgical Aortic Bioprosthesis

TCT-955 Pathology of Noncalcific Structural Valve Deterioration in Transcatheter and Surgical Aortic Bioprosthesis

Redo surgical aortic valve replacement for bioprosthetic structural valve deterioration.

To compare isolated primary bioprosthetic surgical aortic valve replacement (SAVR) with isolated redo surgical aortic valve replacement (rSAVR) due to structural valve deterioration (SVD). Clinical data of consecutive patients who underwent primary isolated SAVR and isolated rSAVR due to SVD between January 1, 2011, and December 31, 2022, at Leipzig Heart Center were retrospectively compared with regard to the primary outcome of all-cause mortality or stroke during hospitalization. Secondary outcomes of interest included myocardial infarction, re-exploration for bleeding, and permanent pacemaker implantation. A total of 2620 patients, 39.5% females, with a median EuroSCORE II of 1.7 (interquartile Range [IQR] 1.1; 2.7] were identified, of which rSAVR was performed in 174 patients (6.6%). Patients undergoing primary SAVR were older (69 versus 67 years of age, p = 0.001) and were less likely to have a history of prior stroke (0.9% versus 4.0%, p = 0.003). Although both all-cause death and death or stroke occurred less often following primary SAVR (0.5% versus 5.8%, and 2.2% versus 6.9%, respectively; p < 0.001), prior surgery was not associated with adverse clinical outcome in multivariable analysis. In a matched comparison of 322 patients, rates of death or stroke did not differ between groups (4.8% for both rSAVR and SAVR, p = 1.0). Although redo surgery for SVD is associated with increased rates of early mortality and stroke by univariate analysis, much of this increased risk can be accounted for by comorbidities. Patients undergoing rSAVR on an elective basis can expect an outcome similar to that of primary SAVR.

Natural biomaterials in the management of the aortic valve pathology. Biomedical and clinical aspects: A review.

Heart valve diseases are a prevalent cardiovascular pathology worldwide, affecting nearly 2.5% of the population. Degenerative aortic stenosis is the most common form of heart valve disease. The treatment options include surgical or transcatheter procedures. There are two main categories of valve prostheses available: mechanical heart valves constructed from synthetic materials and bioprosthetic heart valves made from natural biomaterials. The choice of valve type depends on various factors, including the underlying medical condition, suitability for anticoagulation, valve durability, and the patient's age and preferences. Mechanical heart valves have the advantage of long-term durability. However, patients receiving mechanical implants are subjected to lifelong anticoagulation therapy with an increased risk of thromboembolism and bleeding. Natural biomaterials do not require long-term anticoagulation. However, they experience degenerative changes leading to structural valve deterioration that may require reoperation. The purpose of this article is to review the role of natural biological materials used for aortic valve replacement or repair, assess their biomedical and clinical advantages and limitations, and analyze the direction and perspectives of future development.

Redo isolated tricuspid valve replacement in a patient with isolated persistent left superior vena cava: a case report

BackgroundRedo isolated tricuspid valve surgery has high in-hospital mortality and morbidity and is a challenging procedure. We report a successful case of redo isolated tricuspid valve replacement for structural valve deterioration of a bioprosthesis in a patient with isolated persistent left superior vena cava (PLSVC).Case presentationAn 81-year-old man with a history of tricuspid valve replacement using a porcine bioprosthetic valve 9 years previously presented with dyspnea on exertion. Right heart failure due to worsening transvalvular leakage in the bioprosthetic tricuspid valve was considered to be the cause of his symptoms, and the decision was made to replace the tricuspid valve. An isolated PLSVC is considered to be an obstacle in right-sided heart valve surgery. The PLSVC was located deep to the left of the pulmonary artery and, after some effort, was cannulated by obtaining an excellent surgical view using retraction sutures on the left side of the pericardium. Cardiopulmonary bypass was initiated after cannulation of the ascending aorta, PLSVC, and femoral vein. After cross-clamping of the ascending aorta, cold blood cardioplegic arrest was induced under moderate hypothermia, and the PLSVC and inferior vena cava were snared. The right atrium was opened and the prosthetic tricuspid valve was examined. One of the leaflets was shortened, which appeared to cause the transvalvular leak. The prosthetic valve was explanted, the annulus was trimmed, and a new bioprosthetic valve was implanted. The postoperative course was uneventful.ConclusionsIt is important to treat structural valve deterioration of a prosthetic tricuspid valve in a timely manner. We hope that our intervention timing and surgical strategy can help surgeons to consider early intervention in similar cases, even if there are surgical obstacles such as isolated PLSVC.

Le gradient reste élevé après mon TAVI, que faire?

Over the past two decades, transcatheter aortic valve implantation (TAVI) has become a safe and effective therapeutic option for symptomatic and severe aortic stenosis, regardless of the surgical risk spectrum. With the expansion of TAVI indications to low-risk and younger patients, it is crucial to ensure satisfactory and durable hemodynamic outcomes to guarantee transcatheter heart valve (THV) longevity. However, secondary THV dysfunction may occur, often manifested by an increased transvalvular gradient. According to VARC-3 criteria, these dysfunctions can be attributed to four main mechanisms: 1) structural valve deterioration; 2) non-structural valve dysfunction; 3) thrombosis; 4) and endocarditis. Each mechanism leads to specific abnormalities, requiring a systematic diagnostic approach and appropriate treatment. This article illustrates, through two clinical cases, the diagnosis and management of secondary transvalvular gradient elevation after TAVI.

Decellularized aortic homografts versus mechanical composite grafts for aortic root replacement.

Mechanical composite valve grafts (MCVGs) are the first-line therapy for aortic root replacement in young adults. Decellularized aortic homografts (DAH) present a promising novel alternative due to their lower thrombogenicity. We aimed to compare both treatment options regarding survival and valve-related adverse events. This study was designed as a single-centre retrospective cohort study including patients who underwent root replacement with MCVG or DAH between 2000 and 2022. Urgent or emergent procedures were excluded. The study cohort included 289 patients (MCVG n = 216, DAH n = 73) with a mean age of 48.5 ± 12 years (MCVG 49 ± 12 years vs DAH 47 ± 11 years; P = 0.23) and a median EuroScore II of 1.7% (1.2, 2.6). The 30-day mortality was 1% (n = 3). Cumulative survival at 3 years was 99% for DAH and 94% for MCVG, respectively (P = 0.15). Mean follow-up was 98.9 ± 72.7 months. Bleeding events (n = 14, 6.5%) and thromboembolism (n = 14, 6.5%) were only observed in the MCVG group (P = 0.19 and 0.09, respectively). Four cases (5%) of moderate structural valve deterioration occurred, all in the DAH group (P ≤ 0.001). The cumulative incidence of a composite end point of valve-related adverse events was significantly higher in the MCVG group (P = 0.0295). Aortic root replacement with MCVGs and decellularized aortic homografts showed low mortality in an elective setting. Patients in the homograft cohort demonstrated significantly higher freedom from valve-related adverse events. DAH present a promising treatment option for young patients requiring root replacement; however, data on long-term durability are needed.

Long-Term Impact of Gender Differences After Transcatheter Aortic Valve Implantation

BackgroundThe short-term and midterm impact of gender differences on transcatheter aortic valve implantation (TAVI) has been studied. However, the impact on long-term clinical outcomes remains unclear. The objective of the study was to investigate the impact of gender differences after TAVI on long-term clinical outcomes and structural valve deterioration (SVD). MethodsOf the 672 consecutive patients who underwent TAVI, with balloon- or self-expandable valves, between 2013 and 2018, a total of 511 who underwent multidetector computed tomography analysis within 30 days after TAVI were included. Echocardiographic data were analyzed annually. ResultsThe number of women was 343 (67.2%), and 90.7% of them had a small annulus (< 430 mm2). The effective orifice area was significantly smaller in women compared with that in men, whereas no difference occurred in the incidence of prosthesis–patient mismatch. The incidence of leaflet thrombosis detected by multidetector computed tomography was similar for women vs men (15.2% vs 13.1%, respectively; P = 0.53). During the median follow-up of 1844 days (interquartile range: 1190-2311 days), women showed a significantly decreased incidence of all-cause mortality (hazard ratio, 0.69; 95% confidence interval, 0.54-0.90; P = 0.005). The development of SVD was comparable (hazard ratio, 0.99; 95% confidence interval, 0.78-1.25, P = 0.90). Severe frailty and the balloon-expandable valves were the independent risk factors for all-cause mortality and SVD in women, respectively. ConclusionsWomen had superior long-term clinical outcomes, compared with those of men, despite their having a small annulus. During long-term follow-up, the incidence of SVD in women was similar in the entire cohort, compared to that in men; however, balloon-expandable valves were possible risk factors for SVD in women.

Durability of transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is now utilised as a less invasive alternative to surgical aortic valve replacement (SAVR) across the whole spectrum of surgical risk. Long-term durability of the bioprosthetic valves has become a key goal of TAVI as this procedure is now considered for younger and lower-risk populations. The purpose of this article is to present a state-of-the-art overview on the definition, aetiology, risk factors, mechanisms, diagnosis, clinical impact, and management of bioprosthetic valve dysfunction (BVD) and failure (BVF) following TAVI with a comparative perspective versus SAVR. Structural valve deterioration (SVD) is the main factor limiting the durability of the bioprosthetic valves used for TAVI or SAVR, but non-structural BVD, such as prosthesis-patient mismatch and paravalvular regurgitation, as well as valve thrombosis or endocarditis may also lead to BVF. The incidence of BVF related to SVD or other causes is low (<5%) at midterm (5- to 8-year) follow-up and compares favourably with that of SAVR. The long-term follow-up data of randomised trials conducted with the first generations of transcatheter heart valves also suggest similar valve durability in TAVI versus SAVR at 10 years, but these trials suffer from major survivorship bias, and the long-term durability of TAVI will need to be confirmed by the analysis of the low-risk TAVI versus SAVR trials at 10 years.

Transcatheter aortic valve replacement with corevalve self-expanding bioprosthesis: Clinical and durability data up to 12 years

Background and aimsTranscatheter aortic valve replacement (TAVR) determined a paradigm shift in the treatment of patients with severe symptomatic aortic stenosis but data on very long-term durability are lacking. We sought to evaluate the clinical and hemodynamic outcomes of the CoreValve porcine pericardial self-expanding bioprosthesis at 12-year follow-up. Methods882 inoperable or high-risk patients were treated with the CoreValve bioprosthesis in 8 Italian high-volume centers between 2007 and 2011. The endpoints were 12-year all-cause and cardiovascular mortality, and Cumulative Incidence Functions (CIFs) for severe Structural Valve Deterioration (SVD), Bioprosthetic Valve Dysfunction (BVD), Bioprosthetic Valve Failure (BVF), and severe Hemodynamic Valve Deterioration (HVD). VARC-3 definitions were applied. ResultsBaseline characteristics included a mean age of 83 ± 6 years, and NYHA class III or IV in 76.3 % of patients. The actuarial risk of death at 12 years after TAVR was 95.5 % (CI 93.5 %- 97.1 %).The actual risk of cardiovascular death, weighted against the risk of non-cardiac death at 12 years was 23.9 % (21.0 %–26.8 %). The 12-year actual risk of BVD was 7.0 % (5.3 %–8.9 %), of SVD was 3.6 % (2.5 %–5.2 %), of BVF was 3.12 % (2.02 %–4.57 %), and of severe HVD was 1.7 % (0.9 %–2.9 %). Mean transaortic gradient significantly decreased after the procedure (52 ± 15 mmHg vs 9 ± 5 mmHg, p < 0.001), and remained stable up to 12 years (12 ± 4 mmHg, P = 0.08 vs. discharge). ConclusionsThe first-generation CoreValve bioprosthesis showed reassuring clinical and hemodynamic performance at 12-year follow-up.

Long-term outcomes of the BalMedic bovine pericardial bioprosthetic valve in female patients ≤50 years: a multicenter retrospective study.

A bioprosthetic valve is recommended for women of childbearing age who require cardiac valve replacement in order to minimize the risk of blood clot formation. However, it should be noted that compared to mechanical valves, bioprosthetic valves have a shorter lifespan and a higher likelihood of requiring reoperation during follow-up. To assess the long-term postoperative results, including the incidence of structural valve deterioration (SVD) and other clinical outcomes, in female patients aged 50 years and younger who underwent BalMedic bovine pericardial bioprosthetic valve replacement, a multicenter retrospective study was implemented in China. Between 2004 and 2015, a cohort of 86 female patients across three medical centers underwent the implantation of 97 bioprosthetic valves. The primary outcome measure was overall survival (OS), while the secondary outcome measures were preliminary evidence of reoperation, SVD incidence, and bioprosthetic valve-related complications. In this cohort study, 21 patients (24.4%, 21/86) died, while 37 patients (43.0%, 37/86) underwent a second valve replacement. The OS rates at 5 and 10 years were 97.56% and 71.93%, respectively. Additionally, the reoperation-free rates at 5 and 10 years were 92.83% and 80.68%, respectively. Similarly, the rates of freedom from SVD at 5 and 10 years were 95.65% and 51.82%, respectively, and the average duration of bioprosthetic valve replacement in our study was 9.34±3.31 years. Despite the recruitment of younger female patients of child-bearing age in our cohort, the OS, reoperation-free survival, and SVD-free rates of the BalMedic bovine pericardial bioprosthetic valve were not inferior to those of the other age groups in the study or those reported in the literature.

Subclinical valve leaflet thrombosis following bioprosthetic aortic valve replacement.

Subclinical leaflet thrombosis (SLT) is often an incidental finding characterized by a thin layer of thrombus involving one, two or three leaflets, with typical appearance on multi-detector computed tomography (MDCT) of hypo-attenuating defect at the aortic side of the leaflet, also called hypo-attenuating leaflet thickening (HALT). SLT may occur following both transcatheter aortic replacement (TAVR) or biological surgical aortic valve replacement (SAVR). The aim of this review is to present an overview of the current state of knowledge on the incidence, diagnosis, clinical impact, and management of SLT following TAVR or SAVR. SLT occurs in 10-20% of patients following TAVR and is somewhat more frequent than following SAVR (5-15%). SLT may regress spontaneously without treatment in about 50% of the cases but may also progress to clinically significant valve thrombosis in some cases. Oral anticoagulation with vitamin K antagonist is reasonable if SLT is detected by echocardiography and/or MDCT during follow-up and is generally efficient to reverse SLT. SLT is associated with mild increase in the risk of stroke but has no impact on survival. SLT has been linked with accelerated structural valve deterioration and may thus impact valve durability and long-term outcomes. SLT is often an incidental finding on echocardiography or MDCT that occurs in 10-20% of patients following TAVR or 5-15% following biological SAVR and is associated with a mild increase in the risk of thrombo-embolic event with no significant impact on mortality but may be associated with reduced valve durability.

Bioprosthetic Aortic Valve Thrombosis: Definitions, Clinical Impact, and Management: A State-of-the-Art Review.

Bioprosthetic aortic valve thrombosis is frequently detected after transcatheter and surgical aortic valve replacement due to advances in cardiac computed tomography angiography technology and standardized surveillance protocols in low-surgical-risk transcatheter aortic valve replacement trials. However, evidence is limited concerning whether subclinical leaflet thrombosis leads to clinical adverse events or premature structural valve deterioration. Furthermore, there may be net harm in the form of bleeding from aggressive antithrombotic treatment in patients with subclinical leaflet thrombosis. This review will discuss the incidence, mechanisms, diagnosis, and optimal management of bioprosthetic aortic valve thrombosis after transcatheter aortic valve replacement and bioprosthetic surgical aortic valve replacement.

Durability of porcine and pericardial prostheses in tricuspid valve replacement

ObjectiveBiologic valves dominate tricuspid valve replacement, yet data on different valve types are lacking. We compare the survival and durability of porcine and pericardial tricuspid prostheses. MethodsA retrospective review of consecutive patients undergoing tricuspid valve replacement with porcine (N = 542) or pericardial (N = 144) prostheses between 1975 and 2022 was performed using a prospectively maintained institutional database. Concurrent procedures were included. Cox proportional hazards and logistic regression were performed. ResultsPatients who received the porcine prosthesis, compared with pericardial, were younger (56 ± 17 years vs 63 ± 15 years) and more likely to present urgently (55% porcine, 44% pericardial); however, there were no differences in redo status or concomitant operations. Ten-year survival was not significantly different between the porcine and pericardial groups (35% ± 3% vs 28% ± 4%, respectively, P = .2). The 10-year cumulative incidence of structural valve deterioration (porcine 9% ± 2%, pericardial 11% ± 3%, P = .8), reoperation for structural valve deterioration (porcine 5% ± 1%, pericardial 4% ± 2%, P = .06), and severe regurgitation (porcine 4% ± 1%, pericardial 5% ± 2%, P = .7) were not significantly different between groups. The failure mode was similar, with no difference in severe stenosis (porcine 32/47 [68%], pericardial 11/16 [69%], P = .9) or severe regurgitation (porcine 18/47 [38%], pericardial 7/16 [44%], P = .7). On regression analysis, valve type was not associated with survival (P = .6). Valve type was not associated with structural valve deterioration (P = .1) or reoperation for structural valve deterioration (P = .9). ConclusionsIn our series, there were no differences in survival or durability between porcine and pericardial valves. In most patients undergoing tricuspid valve replacement, the choice of porcine versus pericardial prosthesis is unlikely to affect clinical outcomes.

Early Structural Valve Deterioration of Balloon Expandable Transcatheter Aortic Valve Leaflets Due to Intrinsic and Extrinsic Nodular Calcification in a Hemodialysis Patient: A Case Report

Abstract Background Several reports have shown that transcatheter aortic valves are comparable in durability to surgical aortic valves. However, early structural valve deterioration (SVD) is rarely reported to occur, especially in hemodialysis patients. Case Summary We present a case of rapidly progressive bioprosthetic aortic valve stenosis in a patient with end-stage renal disease (ESRD) secondary to diabetic nephropathy in an 83-year-old female admitted due to progressive dyspnea and orthopnea. A 23-mm sized SAPIEN3 bioprosthetic aortic valve showed normal function for the first year after transcatheter aortic valve implantation (TAVI), but then rapidly developed stenosis and required acute hospitalization for heart failure a year and a half after surgery. Emergent surgical aortic valve replacement (SAVR) with a 19-mm On-X valve (CryoLife, Kennesaw, GA, USA) was performed. Pathological examination of the explanted SAPIEN 3 valve demonstrated severely degenerated bioprosthetic pericardial leaflets with severe intrinsic and extrinsic nodular calcification, which could limit the leaflet motion. Discussion There is a lack of reports on the long-term procedural outcomes of TAVI in hemodialysis patients. The development of SVD in patients undergoing dialysis is multifactorial and has yet to be fully elucidated. In the presented case, the removed TAVI valve had severe extrinsic calcified nodules alongside a fibrin thrombus. Considering these pathological findings, antithrombotic therapy to prevent fibrin thrombus from adhering to the TAVI valve may be important to avoid early SVD.