Treatment Of Aortic Valve Stenosis Research Articles

Transcatheter Mitral Valve Interventions: Current Therapies and Future Directions.

Transcatheter interventions for the treatment of aortic valve stenosis have become commonplace since the advent of transcatheter aortic valve implantation. However, transcatheter mitral valve therapies have lagged in development due to the complexity of mitral valve anatomy. Transcatheter edge-to-edge leaflet repair using the MitraClip device provides an option for the treatment of severe primary mitral valve regurgitation in high or prohibitive surgical risk patients, and multiple novel approaches are evolving to replace or repair the mitral valve. Devices for the treatment of calcific mitral stenosis, primary mitral regurgitation, and functional mitral regurgitation have been developed and are currently either being evaluated in clinical trials or are in earlier stages of preclinical development. We are optimistic that our armamentarium will soon expand to include a myriad of transcatheter interventions for mitral valve disease.

Procedural and 30-day clinical outcomes following transcatheter aortic valve replacement with lotus valve: Results of the RELEVANT study.

We report procedural and 30-day clinical outcomes following transcatheter aortic valve replacement (TAVR) with Lotus Valve system in a high-risk population. Lotus valve is a second-generation TAVR fully repositionable and retrievable device. RELEVANT (REgistry of Lotus valvE for treatment of aortic VAlve steNosis with Tavr) study is an Italian prospective multicentre registry. Five major centers performing TAVR using Lotus participated. All high-risk symptomatic patients with severe aortic stenosis were evaluated by a heart team and screened for eligibility for TAVR. Primary end-points were procedural and 30-day mortality. Secondary endpoints included procedural and 30-day safety/effectiveness metrics according to Valve Academic Research Consortium (VARC)-2 criteria. Two hundred and twenty-five patients undergoing TAVR with Lotus were enrolled. Mean age was 82.6 ± 6.3 years, 51.6% females. Mean STS score for mortality was 8.3 ± 5.6. Procedural success was achieved in 98.7% of patients. All-cause mortality was 2.2% at discharge and 2.7% at 30-day. Stroke rate was 2.2% at discharge and 3.1% at 30-day. Patients requiring a new permanent pacemaker implantation were 30.7% at discharge and 31.8% at 30-day. Paravalvular regurgitation (PVR) was trace/mild in 99.1% of patients at discharge. Only two patients (0.9%) had moderate PVR at discharge and at 30-day, whereas none had severe PVR. RELEVANT study showed that TAVR using Lotus, in a real-world population of patients with severe aortic stenosis at high surgical risk, was associated with excellent device success implantation and early safety according to VARC-2 definition. The pacemaker implantation rate was about a third of patients. © 2017 Wiley Periodicals, Inc.

Is there evidence for statins in the treatment of aortic valve stenosis?

Research revealed that the pathogenesis of aortic stenosis (AS) not merely comprises of a mechanical wear and tear process yet that active biological processes, similar to those of coronary artery disease are involved, a promising role for statins in disease-modifying therapy was suggested. However, recently, many prospective studies could not observe decreased progression nor regression of the disease. Here, we review the current knowledge on the pathomechanisms of AS and its similarities and differences with atherosclerosis. Moreover, we discuss whether there is still a place for statins in the treatment of particular AS patient subgroups.

Редкий случай оперативного лечения клапанного стеноза аорты у ребенка 5 месяцев жизни с костной прогрессирующей гетероплазией

Представлен редкий случай успешного проведения транслюминальной баллонной вальвулопластики клапанного стеноза аорты у мальчика 5 мес жизни с костной прогрессирующей гетероплазией (КПГ) – редким генетическим заболеванием, обусловленным мутациями в гене GNAS1, вызывающими аномальное эктопическое костеобразование в коже, подкожно-жировой клетчатке и подлежащих тканях. С учетом сопутствующей генетической патологии для снижения риска развития интра- и послеоперационных осложнений хирургическая коррекция врожденного порока сердца была выполнена на фоне медикаментозной поддержки согласно действующему международному протоколу ведения больных с аномальным эктопическим костеобразованием. В результате в течение 3 мес послеоперационные осложнения, касающиеся прогрессирования КПГ, отмечены не были; показатели гемодинамики, в том числе и градиент давления на аортальном клапане, имели стойкую положительную динамику.

冠動脈病変を有する大動脈弁狭窄症の治療

冠動脈病変を有する大動脈弁狭窄症の治療

TCT-677 Comparison of surgical versus interventional treatment of aortic valve stenosis in kidney transplant recipients

Surgical aortic valve replacement (SAVR) in kidney transplant recipients (KTR) with severe aortic stenosis (AS) is associated with high morbidity and mortality, especially due to cardiovascular and infectious complications, as well as an increased risk of postoperative kidney failure potentially

Is Surgical Intervention the Optimal Therapy for the Treatment of Aortic Valve Stenosis for Patients With Intermediate Society of Thoracic Surgeons Risk Score?

Patients at intermediate risk (IR) according to The Society of Thoracic Surgeons risk score are today frequently oriented toward the transfemoral aortic valve replacement (TAVR) option. Our goal was to evaluate the best treatment strategies for IR patients with severe aortic stenosis. Of a consecutive series of 1,144 surgical aortic valve replacements (AVRs) performed in our institution between 2008 and 2014, we reviewed the early and late outcomes of two different groups: a low-risk (LR) group of 470 patients, and an IR group of 620. We eliminated from the analysis 54 high-risk patients who were currently candidates for TAVR. All patients underwent surgical AVR with or without concomitant coronary artery bypass grafting. Social Security database interrogation provided long-term information. The early mortality rate (30 days) between LR and IR patients was similar (1.70% vs 2.74%, p= 0.25) and both lower than predicted mortality rates. However, cumulative 5-year survival was significantly higher in LR patients (86.3%) than in IR patients (75.4%; p= 0.0007 by log-rank test), although excellent in IR group. Comparing IR survivors and nonsurvivors, ages at operation were 69.5 ± 12.7 years for survivors vs 75.4 ± 9.6 years for those experiencing late deaths (p= 0.002). Risk factors for late deaths after multivariate analysis were age, hemodialysis, and chronic lung disease. Most IR patients today should undergo surgical AVR, but because of survival rates combined with still unavailable late structural deterioration rates in TAVR valves, patients in the IR group with high Society of Thoracic Surgeons scores and known risk factors may be better served with TAVR as data regarding late percutaneous valve function accrue.

Health-related quality-of-life after transapical transcatheter aortic valve implantation

Purpose. Transcatheter aortic valve implantation (TA-TAVI) is a well-established treatment for aortic valve stenosis in high-risk patients and indications have been continuously expanding to also include intermediate-risk patients. However, in low-risk patients, experiences are still sparse and although clinical outcomes have been shown favorable results, HRQoL has remained unexplored. The aim of this report was to describe the long-term health-related quality-of-life (HRQoL) in low-risk patients randomized to TA-TAVI or surgical aortic valve replacement (SAVR). Methods. In a prospective, randomized trial, patients with aortic valve stenosis were randomized to either TA-TAVI or SAVR. TA-TAVI was performed through a mini thoracotomy with the introduction of prosthesis via the apex of the heart and antegradely advancement over the pre-dilated native valve. SAVR was performed during cardiopulmonary bypass with resection of the native valve and replacement with a prosthesis valve through a median sternotomy. Afterwards, patients were followed yearly with echocardiography and HRQoL assessment. Results. A total of 58 patients were included; 29 patients for TA-TAVI and 29 patients for SAVR. The only difference in HRQoL was found in the physical component summary after 1 year; 44 ± 9 in the TA-TAVI group compared with 36 ± 9 in the SAVR group, p = .03. There were no differences in any of the remaining timepoints in neither physical nor mental component summary, p = .19 and p = .98, respectively, and there were no differences in survival during the 5 years. Conclusions. In low-risk patients with aortic valve stenosis undergoing TA-TAVI, no differences appeared in HRQoL compared with SAVR during a 5-year follow-up period.

Transcatheter aortic valve implantation: from revolution to evolution.

The advent of transcatheter aortic valve implantation has transformed the treatment of aortic valve stenosis. This disease, which previously could only be managed by open-heart surgery, can now be treated via a percutaneous technique.

Choice of Treatment for Aortic Valve Stenosis in the Era of Transcatheter AorticValve Replacement in EasternDenmark (2005 to 2015).

The aim of this study was to evaluate the choice of treatment for severe aortic valve stenosis in the era oftranscatheter aortic valve replacement (TAVR) in Eastern Denmark. Until the early 21st century, the only therapeutic option for aortic valve stenosis was surgical aortic valve replacement (SAVR), but this has changed with the introduction of TAVR. Using the East Denmark Heart Registry, the evolution of AVR over time was studied for the period 2005to2015. TAVR has since its introduction in 2007 seen steady growth, with currently more than 35% of AVR procedures-and 45% of isolated AVR procedures-being performed by transcatheter-based technology. The number of SAVR procedures remained rather stable over the study period and even saw a slight decline since 2012-there was a marked decrease in the age at which surgical bioprostheses are considered appropriate. The age profile of TAVR patients remained unchanged over the study period, with a recent trend toward more low- and intermediate-risk patients. Currently, patients age ≥80 years and/or with a Society of Thoracic Surgeons (STS) surgical risk score >6 are automatically referred for TAVR, and one-half of patients age 70 to 80 years with an STS risk score of 4 to 6 are treated withTAVR. The number of TAVR procedures has increased steadily in recent years, with a TAVR penetration rateof35% in 2015 and close to 45% when considering isolated AVR. The number of SAVR procedures remained stableover the study period, and surgical bioprostheses are currently used at a much younger age than in2005.

0017 : Local versus general anesthesia for transfemoral aortic valve implantation: efficiency, safety, prognosis

Transcatheter aortic valve replacement (TAVR) is quickly spreading as an efficient and safe therapy for the treatment of aortic valve stenosis in patients denied for surgery. There is no clear guideline established regarding anesthetic modalities to perform TAVR procedures. This study was designed to assess the superiority of the local anesthesia for transfemoral TAVR, regarding major adverse events occuring in the early postoperative time. From January 2014 to June 2015, 236 consecutive patients were included in the study (99 under general anesthesia [GA] and 137 under local anesthesia [LA]). The primary endpoint was a combination of MACE, rehospitalization for heart failure, acute kidney injury (AKI) stage 2 or 3, lifethreatening bleeding, major vascular complication, cardiac or rythmologic reintervention and/or haemodynamic instability, in the first 30 days after TAVR (each defined by VARC-2 criteria). Baseline characteristics were similar between the two groups. Conversion to general anesthesia occured in only 2 cases and procedural success was 94.9% (p=NS). The combined endpoint was reached in 45 GA patients and in 41 LA patients (p=0.02). We observed significantly less AKIevents in LA patients (9 vs 22; p<0.001), less rehospitalization (0 vs 4; p=0.02) and less vascular access site complications (15 vs 29; p<0.001). Postoperative echocardiographic results were similar in both groups. Secondary analysis revealed a shorter hospital stay (9±6.2 days vs 11.4±6.1 days; p=0.003) and shorter ICU stay (2.2±3.9 days vs 3.4±3.6 days; p=0.016) in LA patients.Fig. 1 Local anesthesia significantly reduced the incidence of major adverse events after transfemoral TAVR, especially AKI and vascular access site complications (main predictors of early death after TAVR), without any significant change in echocardiographic results or procedural success. The author hereby declares no conflict of interestDownload : Download full-size imagePrimary endpoint and echocardiographic results Primary endpoint and echocardiographic results

Suture less Aortic Bio Prostheses a Reliable Tool for Minimally Invasive AVR in High Risk Patients

Background: Surgical aortic valve replacement (SAVR) with extracorporeal circulation (ECC) is currently the treatment of choice for patients with severe aortic stenosis. High-risk patients may benefit from reduced ECC time, crossclamp time (CCT) and a minimally-invasive approach. Minimally invasive aortic valve replacement (MIAVR) was first described by Cosgrove and Sabik [1] and have increasingly gained acceptance in the surgical realm, with the aim of achieving equivalent or superior out- comes compared with conventional AVR (CAVR). A new generation of “suture less” bioprostheses has recently been introduced in clinical practice. Sutureless fixation of the valve combines the advantages of open SAVR, i.e. complete removal of pathological tissue, with reduced ECC and CCT, and facilitates small incision surgery. Methods: Between November 2012 and October 2015 we operated on 70 consecutive patients with aortic valve stenosis, using suture less valves. Patients (25 males, mean age 77.9 ± 6.3 years, range 63-91) had a mean logistic Euro SCORE of 11.9 ± 10.8. Fifty-five patients received a Medtronic 3f Enable and 15 a Sorin Perceval S valve; 48 patients were operated through minithoracotomy, and 22 through ministernotomy. Results: Valve implantation resulted in a significant improvement in patients’ symptoms; mean preoperative and postoperative transvalvular gradient was 60 mmHg (120-40) and 8.5 mmHg (17-7), respectively. CCT time was66 ± 14.4 min, mean ECC time 71 ± 19.8 min, mean implant time 9 min. 30-day mortality was 1,5%. Early incidence of grade I paravalvular leakages and pacemaker implantation was, respectively, 2.0 % and 4%. 1 late PVL grade 2 was registered. Conclusion: MIAVR with suture less aortic bioprosthesisin high risk patients represents a safe and effective treatment for aortic valve stenosis, providing excellent hemodynamic and clinical results. A larger study is needed to confirm these initial promising results.

Hemodynamic Consequences of Two Different Surgical and Anesthetic Techniques for the Treatment of Aortic Valve Stenosis - A Randomized Comparison

There are two substantially different methods of doing aortic valve replacement in elderly patients with severe aortic valve stenosis: The trans-apical aortic valve replacement (TAVI) and the standard surgical aortic valve replacement (SAVR). The impact of surgery as well as anesthesia has great influence on perioperative hemodynamics. We compared the perioperative hemodynamic variables in comparable groups of patients going through either of these procedures. Methods: The present study is a subset of the STACATO trial, which was a multicenter trial with the objective of comparing the two treatment methods in patients with significant valvular aortic stenosis who were eligible for either procedure. This study analyses hemodynamic data as well as arterial blood gases and s-creatinine from the 58 randomized patients in our institution. Results: Patients in the SAVR group had lower values of cardiac index (CI) and stroke volume index (SVI) than the TAVI group at all times (p<0.001). At the end of surgery the SAVR group had a higher pO2 (p<0.0001), a higher s-lactate (p=0,003) and a lower hematocrit (p=0,045) than the TAVI group and in the postoperative period the pH was closer to normal in the TAVI group. The perioperative fluid balance was higher in the SAVR group (p<0.0001). A more pronounced increase in s-creatinine (p=0.034) was seen in the TAVI group. There were no differences in the perioperative use of inotropes, vasoconstrictors or vasodilators. Conclusions: The main finding in the present study was that the surgical and anesthesiological management of TAVI resulted in more stable hemodynamics both per- and postoperatively compared to SAVR patients.

Transcatheter aortic valve implantation (TAVI) in Germany 2008-2014: on its way to standard therapy for aortic valve stenosis in the elderly?

In Germany, all transcatheter aortic valve implantations (TAVI) and surgical aortic valve replacements (sAVR) are registered within an obligatory quality assurance programme led by the independent AQUA Institute. We have summarised patient and procedural characteristics, complication and mortality rates as reported in the annual, German language AQUA quality reports, freely accessible online, in order to provide a comprehensive overview of developments between 2008 and 2014. Since 2008, a total of 71,927 isolated sAVR and 48,353 TAVI procedures have been performed in Germany. The numbers of sAVR are steadily declining (2008: 11,205; 2014: 9,953). For TAVI, there has been a 20-fold increase since 2008, from 637 to 13,264 procedures in 2014, surpassing the annual numbers of isolated sAVR since 2013. The age profile of TAVI patients has remained unchanged over time (mean age: 80.9 years), with a recent trend towards lower-risk/intermediate-risk patients. TAVI complications are rapidly decreasing (2012: 9.4%; 2014: 3.9%); annular rupture, aortic dissection and coronary occlusions are rare (<0.3%), with fewer patients requiring surgical conversion to sternotomy (2012: 1.2%; 2014: 0.6%). In-hospital mortality after TAVI has halved in 2014 (4.2%) compared with 2008 (10.4%). Real-world clinical data from the obligatory quality assurance programme document the rapid adoption of TAVI in Germany, shifting treatment of aortic valve stenosis in the elderly from surgery to a catheter-based approach. Since 2008, similar to what happened with PCIs, complications of TAVI have declined considerably along with the need for emergency cardiac surgery. Most importantly, in-hospital mortality has halved from 2008 to 2014, while mortality for sAVR has remained unchanged.

Peri- and postinterventional antithrombotic therapy in TAVI. Do we need antiplatelet therapy?

Interventional treatment of aortic valve stenosis by transcatheter aortic valve replacement (TAVR) has become routine practice in elderly and high risk patients in recent years. Similar to other vascular interventional or surgical procedures TAVR carries thrombotic risks such as stroke, myocardial infarction or systemic embolism as well as peri-procedural bleeding risks. These risks comprise the access site, the type of prosthesis, and the individual risk profile of the patient. Not only during the peri-procedural period but also during longterm follow-up the current target population for TAVR procedures carries a high risk for thrombotic events in particular if atrial fibrillation is present. On the other hand side the bleeding risk is also increased in these patients. Thus, to provide the optimal strategy of antithrombotic therapy during and after TAVR remains a clinical challenge.

The Treatment of Aortic Valve Stenosis in Patients at Intermediate-High Risk

Aortic valve stenosis (AS) is the most common valvular pathology in the elderly with an estimated prevalence of 4.6% in patients older than 75 years. Most of the patients remain asymptomatic for decades and when they develop symptoms, the prognosis became drastically poor with an estimated mortality of 50% in two years without surgical treatment. Aortic valve replacement (AVR) represents the gold standard for treatment of patients affected by aortic valve stenosis. Introduced in 1960s, AVR is associated with excellent long-term outcomes and low perioperative mortality and morbidity. With the aging of population, number of patients with AS increased progressively and the typical patient's profile has become more and more complex with more associated pathology and higher surgical risk. In this complex scenario the introduction of transcatheter aortic valve implantation (TAVI) has profoundly altered the landscape of cardiovascular medicine.

Эффективность открытой комиссуротомии в хирургическом лечении стеноза аортального клапана у пациентов педиатрической группы

Background. This study was designed to evaluate short-term and long-term outcomes after open aortic valve commissurotomy in the pediatric patients at our center over a period of 10 years. Methods. A retrospective study of 94 patients who underwent open surgical commissurotomy because of aortic valve stenosis between 2003 and 2013 is presented. Follow-up time was in the range of 1 to 7 years. Results. The open aortic valve commissurotomy combined with debridement of leaflet free edge 36.1 %, LVOT myectomy 11.7%, leaflet suture plastic 7.4%, modified Konno procedure 6.3%, Brom's aortoplasty 4.2% was performed for all patients. Average cardiopulmonary bypass time was 59.2 30.7 min. Median aortic cross-clamping time was 31.52 15.1 min. Hospital complications were observed in 38.2% of cases. ICU time was in the range of 1 to 31 (mean 3.2 5.1) day. Artificial lung ventilation time varied from 2 to 76 (mean 15.3 18.3) hours. Inotropic support was needed in 26.5% of cases. Mean hospital stay time was 17.1 7.3 days. At follow-up between 2 and 7 years, reoperations were required for 3 patients who underwent a Ross procedure. Conclusions. The results evidence that open surgical commissurotomy is an effective way of treatment for aortic valve stenosis, considering the accuracy of plasty and additional techniques of leaflet correction. The best children age group for this type of operation is from first to five years of life.

New cardiac bioprostheses: the case of 'sutureless' valves

Surgical aortic valve replacement (SAVR) with extracorporeal circulation (ECC) is currently the treatment of choice for patients with severe aortic stenosis, but high-risk patients may benefit from reduced ECC and cross-clamping times (CCTs) and a minimally invasive approach. A new generation of ‘sutureless’ (SU) bioprostheses has recently been introduced into clinical practice. Sutureless fixation of the valve combines the advantages of open SAVR (i.e. complete removal of pathological tissue) with reduced ECC and CCT, and facilitates small incision surgery. Between November 2012 and August 2014, we operated on 49 consecutive patients with aortic valve stenosis, using SU valves. Patients (18 males, mean age 78.9 ± 6.3 years, range 63–91) had a mean logistic EuroSCORE of 10.9 ± 10.8. Thirty-nine patients received a Medtronic 3f Enable and 10 a Sorin Perceval S valve; 24 patients underwent minithoracotomy, 11 ministernotomy, and 14 full sternotomy. Valve implantation resulted in a significant improvement in symptoms; mean preoperative and postoperative transvalvular gradients were 60 (120–40) mmHg and 8.5 (17–7) mmHg, respectively. Cross-clamping time was 55.6 ± 14.4 min, mean ECC time 71 ± 19.8 min, and mean implant time 9 min. There was no 30-day mortality. Early incidence of grade I paravalvular leakages and pacemaker implantation was, respectively, 2.0 and 4%. No perivalvular leak >grade I was registered. Aortic valve replacement with SU aortic bioprosthesis represents a safe and effective treatment for aortic valve stenosis, providing excellent haemodynamic and clinical results. A larger study is needed to confirm these initial promising results.

Early Outcomes in Japanese Dialysis Patients Treated With Transcatheter Aortic Valve Implantation

Although transcatheter aortic valve implantation (TAVI) is a new alternative treatment with acceptable midterm results for high surgical risk patients, at present performing the procedure in dialysis patients is not reimbursed in Japan. The study group of 17 dialysis patients (mean age, 76.7±5.0 years) underwent TAVI with the SAPIEN/SAPIEN XT. EuroSCORE and STS score were 25.0±19.0% and 15.4±12.3%, respectively. Transiliofemoral and transapical approaches were performed in 7 (41.2%) and 10 patients (58.8%), respectively. ICU and hospital stays after TAVI were 1.8±1.6 and 12.9±12.7 days, respectively. Mean transvalvular gradients at discharge significantly decreased from 45.9±13.3 mmHg to 10.7±4.3 mmHg (P<0.0001) and effective orifice area significantly increased from 0.78±0.17 to 1.69±0.37 cm(2)(P<0.0001). Device success was 87.5%. One patient required a valve-in-valve procedure on 187-postoperative-day for an acute increase in paravalvular leakage caused by initial lower implantation of the device. The overall mortality at 1 year was 0% and clinical efficacies at 30 days, 6 months, and 1 year were 93.8%, 83.3%, and 69.2%, respectively. Satisfactory early results were achieved with TAVI in Japanese dialysis patients with a high surgical risk, indicating it is a safe and effective alternative for the treatment of aortic valve stenosis in such patients.

Stent Maps--Comparative Visualization for the Prediction of Adverse Events of Transcatheter Aortic Valve Implantations.

Transcatheter aortic valve implantation (TAVI) is a minimally-invasive method for the treatment of aortic valve stenosis in patients with high surgical risk. Despite the success of TAVI, side effects such as paravalvular leakages can occur postoperatively. The goal of this project is to quantitatively analyze the co-occurrence of this complication and several potential risk factors such as stent shape after implantation, implantation height, amount and distribution of calcifications, and contact forces between stent and surrounding structure. In this paper, we present a two-dimensional visualization (stent maps), which allows (1) to comprehensively display all these aspects from CT data and mechanical simulation results and (2) to compare different datasets to identify patterns that are typical for adverse effects. The area of a stent map represents the surface area of the implanted stent - virtually straightened and uncoiled. Several properties of interest, like radial forces or stent compression, are displayed in this stent map in a heatmap-like fashion. Important anatomical landmarks and calcifications are plotted to show their spatial relation to the stent and possible correlations with the color-coded parameters. To provide comparability, the maps of different patient datasets are spatially adjusted according to a corresponding anatomical landmark. Also, stent maps summarizing the characteristics of different populations (e.g. with or without side effects) can be generated. Up to this point several interesting patterns have been observed with our technique, which remained hidden when examining the raw CT data or 3D visualizations of the same data. One example are obvious radial force maxima between the right and non-coronary valve leaflet occurring mainly in cases without leakages. These observations confirm the usefulness of our approach and give starting points for new hypotheses and further analyses. Because of its reduced dimensionality, the stent map data is an appropriate input for statistical group evaluation and machine learning methods.