Treatment Of Heart Valve Disease Research Articles

Impact of a PROgram of Cardiovascular nursE interventionS in a VALVular haEmodynamic Unit (PROCESS-VALVE) on Quality Indicators: A Quasi-Experimental Ambispective Study.

The percutaneous treatment of heart valve diseases carried out in the hemodynamic service is constantly growing. After analyzing the mortality, readmissions, success of the procedure, and complications, several studies support this type of percutaneous procedure. The increase in these procedures has required the creation of multidisciplinary teams and new diagnostic and care circuits, such as presurgical consultations and postsurgical follow-ups. Even so, there is little evidence regarding the effect of these consultations on quality indicators. The objective of this study is to evaluate the impact of a program of presurgical and postsurgical nurse interventions (PROCESS-VALVE) on quality indicators of the health of patients undergoing percutaneous valve procedures. The influence of presurgical and postsurgical consultations on quality indicators will be evaluated through an ambispective quasi-experimental study. Patients will be recruited at a tertiary-level hospital in Barcelona, Spain. For the control group, data will be collected retrospectively from patients who underwent percutaneous valve procedures but did not receive pre- or postsurgical consultations. The intervention group comprises those patients agreeing to participate in the study and the hemodynamic nurse valve consultation program (PROCESS-VALVE). In addition, we will assess whether a face-to-face postsurgical consultation equally improves quality indicators compared to postsurgical telephone consultation; for this, a sub-study will be carried out comparing face-to-face or telephone postsurgical follow-up by means of a randomized controlled clinical trial with simple blinding in the intervention group. This study will generate scientific evidence regarding the impact on quality indicators of a nursing intervention via presurgical and postsurgical consultations. In addition, it will allow us to decide the most appropriate follow-up strategy for this type of patient. ClinicalTrials.gov NCT05179278, registration date 01/05/2022.

A versatile drug-controlled release polymer brush hybrid non-glutaraldehyde bioprosthetic heart valves with enhanced anti-inflammatory, anticoagulant and anti-calcification properties, and superior mechanical performance

Transcatheter heart valve replacement (THVR) is a novel treatment modality for severe heart valves diseases and has become the main method for the treatment of heart valve diseases in recent years. However, the lifespan of the commercial glutaraldehyde cross-linked bioprosthetic heart valves (BHVs) used in THVR can only serve for 10–15 years, and the essential reason for the failure of the valve leaflet material is due to these problems such as calcification, coagulation, and inflammation caused by glutaraldehyde cross-linking. Herein, a kind of novel non-glutaraldehyde cross-linking agent bromo-bicyclic-oxazolidine (OX-Br) has been designed and synthesized with both crosslinking ability and in-situ atom transfer radical polymerization (ATRP) function. Then OX-Br treated porcine pericardium (OX-Br-PP) are stepwise modified with co-polymer brushes of reactive oxygen species (ROS) response anti-inflammatory drug conjugated block and anti-adhesion polyzwitterion polymer block through the in-situ ATRP reaction to obtain the functional BHV material MPQ@OX-PP. Along with the great mechanical properties and anti-enzymatic degradation ability similar to glutaraldehyde-crosslinked porcine pericardium (Glut-PP), good biocompatibility, improved anti-inflammatory effect, robust anti-coagulant ability and superior anti-calcification property have been verified for MPQ@OX-PP by a series of in vitro and in vivo investigations, indicating the excellent application potential as a multifunctional heart valve cross-linking agent for OX-Br. Meanwhile, the strategy of synergistic effect with in situ generations of reactive oxygen species-responsive anti-inflammatory drug blocks and anti-adhesion polymer brushes can effectively meet the requirement of multifaceted performance of bioprosthetic heart valves and provide a valuable reference for other blood contacting materials and functional implantable materials with great comprehensive performance.

Fluid-Structure Interaction Analysis on the Influence of the Aortic Valve Stent Leaflet Structure in Hemodynamics.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgical treatment for heart valve disease. At present, personalized TAVR valves are not available for some patients. This study adopts the fluid-structure interaction (FSI) model of the research object that has a three-disc leaflet form and structural design in the valve leaflet area. The valve opening shape, orifice area, stress-strain, and distribution of hemodynamic flow and pressure were compared under the condition of equal contact area between valve and blood. The FSI method was used to simulate the complex three dimensional characteristics of the flow field more accurately around the valve after TAVR stent implantation. Three personalized stent systems were established to study the performance of the leaflet design based on computational fluid dynamics. By comparing the different leaflet geometries, the maximum stress on leaflets and stents of model B was relatively reduced, which effectively improved the reliability of the stent design. Such valve design also causes the opening area of the valve leaflet to increase and the low-velocity area of the flow field to decrease during the working process of the valve, thus reducing the possibility of thrombosis. These findings can underpin breakthroughs in product design, and provide important theoretical support and technical guidance for clinical research.

Transcatheter treatment of heart valve diseases in China: rapid progress and huge task ahead

近年来，心脏瓣膜病的介入治疗发展迅猛，各瓣膜领域的循证医学证据逐步积累、器械研发不断推陈出新。我国瓣膜病介入治疗开展相对较晚，但现开展瓣膜病介入治疗的中心和团队快速增多，对各瓣膜领域的研究热点、当前应用与将要面临的困难及挑战应有足够的认识。该文主要总结了2021年主动脉瓣、二尖瓣、三尖瓣、肺动脉瓣4个领域国外发展的新形势及我国的应用现状。.

Trans-catheter Bioprosthetic Heart Valve Implantation in Iran (Tehran Heart Centre Experiance)

Introduction: With the development of interventional cardiology in the world, in addition to coronary and aortic diseases, the treatment of heart valve diseases through catheters has recently begun. The treatment of aortic stenosis (which was only possible with open surgery and valve replacement) was first performed in the world in 2002 by Alain Cribier in France with catheter insertion of the valve and was called Trans catheter Aortic valve implantation TAVI. Trans catheter Aortic valve implantation (TAVI) was performed in Iran in 2009 in the Heart Centre of Tehran and now is routinely performed by both Balloon Expanding and self-expanding valves. In addition, we do valve in valve implantation for degenarative biopresthetic valve, in all Heart valve positions too. The short and medium term results of this treatment were reviewed in the form of research projects and published in several articles. In this review, we have explained the initiating of this new procedure in our country with the following results.

AN UNEXPECTED INTRAOPERATIVE UNUSUAL CASE OF AORTIC STENOSIS

Introduction Aortic stenosis is the most frequent valvular pathology in the developed countries (1). It is most often due to the calcified or degenerated aortic valve as a manifestation of ageing. Sub-valvular aortic stenosis is rare in the adult population being more common in children accounting for 8-20% of left ventricular outflow tract (LVOT) obstructions (2). Stenosis degree may change depending on the malformation varying from a minor ridge to a complete fibrous ring or tunnel. Although proper timing for surgery is unclear, diagnosis might be more difficult in the adult patient with transthoracic echocardiography as subvalvular portions of the LVOT might be shaded by calcium and difficult to visualize. We report a case of a 65 years old lady diagnosed with severe aortic stenosis and scheduled for aortic valve surgery. Methods The patient presented to our department with recent history of shortness of breath and clinical and transthoracic echocardiographic diagnosis os severe aortic stenosis. The maximum blood velocity across the aortic valve was 4.8 m sec-1 at continuous Doppler sampling. She was scheduled for aortic valve replacement. After establishing hemodynamic monitoring, general anaesthesia induction was performed with remifentanil, propofol and cisatracurium and maintained as TIVA. According to our protocol, a transesophageal echocardiography (TEE) was positioned and a baseline TEE was performed. Results TEE demonstrated a massive concentric hypertrophy of the left ventricle, a membranous subaortic stenosis and a normal aortic valve (fig. 1A,1B,1C). Surgery was then halted as the patient's written consent had been obtained for a valve replacement. Then the patient was further investigated by ECG gated cardiac CT scan, which confirmed the subvalvular membrane. The patient was then operated to remove the subvalvular membrane and a partial septal myectomy was also executed (fig 1D). She completely recovered and was discharged home on p.o. day 5. Discussion Differential diagnosis between aortic valvular stenosis or stenosis due to a subvalvular obstruction might be tricky, but is crucial for the operation result. TEE 2D and 3D imaging recognised the anomaly prior to surgery and so allowed to properly address the cardiac disease leading to post-operative success. Perioperative TEE should be performed in a systematic manner according to the current guidelines (3), but beyond the level of re-confirming the expected findings prior to surgery. TEE allowed for rapid and thorough recognition of previously undiscovered pathology leading to proper patient's management and case resolution, so confirming the importance of perioperative TEE in the setting of surgical treatment of heart valve diseases.

New strategies in the management of valvular heart disease : Acritical appraisal on the top10 messages of the 2020 ACC/AHA guidelines for the management of patients with valvular heart disease.

The advent of transcatheter procedures for treatment of valvular heart disease has accelerated the pace of research in the diagnosis and treatment of heart valve disease. Rapid accumulation of novel knowledge in the field necessitates timely revisions of clinical guidelines. This paper comments on some important and novel issues addressed in the recently published American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

Xenoimmune Response Can Elicit Postoperative Bioprosthetic Valve Degeneration

<h3>Purpose</h3> Bioprosthetic heart valves (BHVs) are widely used for the surgical or interventional treatment of heart valve disease. However, BHVs are prone to structural valve degeneration (SVD), and a certain amount of cases develop SVD during the early postoperative period. Recent studies implicate that the immunogenicity of the BHVs can be an underlying cause of SVD development.In the present study, we investigated whether a xenoimmune response against α-Gal (galactose-alpha-1,3-galactase) is associated with the early deterioration of BHVs or not. <h3>Methods</h3> A total of 392 porcine and bovine BHV explanted at the time of reoperation due to clinically severe SVD between 2015 and 2019 were investigated. Among those, SVD occurred within 2 years from the surgery was defined as early SVD, and that occurred later than 10 yeas was defined as late SVD. The results of immunohistoligical analysis of BHD with early SVD (n=42) were compared with those of late SVD (n=293), the unused BHVs (glutaraldehyde-fixed) provided from the manufacturer, and the degenerated homografts (n=9) also retrieved during reoperation. <h3>Results</h3> Unused BHVs were positive for a-Gal irrespective of glutaraldehyde-fixation. In BHV with early SVD, α-Gal was positive in 72% of the specimen, and T lymphocyte dominant inflammatory cell infiltration was observed. In contrast, in BHV with late SVD, α-Gal was positive in 13% (p<0.01) and the inflammatory cells were mainly macrophages around calcification. The degenerated homografts showed a presence of small number of macrophages and B cells around the calcification but T cells were poorly detected (Figure). <h3>Conclusion</h3> BHV have been considered to be free from xeno-immunogeneity. However, a residual immunogeneity, revealed by a-Gal positivity found in the unused valves, might provoke xenoimmune response of the human immunity against the valve. Our findings suggest the bioprosthetic valve degeneration may be the result of xenograft rejection. Further study is warranted to reveal the exact mechanism of the failure.

Is surgery the fair competitor for MitraClip?

In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for nonhigh risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors. In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta-analysis by Abdul Khader et al. summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: "NO." Is therefore not a case if recently two trials, MITRA-FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation (MR), surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet.

Surgical treatment of heart valve disease and cardiac tumors via the right-sided minithoracotomy

To evaluate the early outcomes of surgical treatment of heart valve disease and cardiac tumors via the right-sided minithoracotomy. There were 77 interventions via the right-sided minithoracotomy for the period from 2017 to March 2021 (29 men (37.7%) and 48 women (62.3%) aged 50.9±13 years (95% CI 48-53.9)). Heart failure NYHA class III prevailed (45.5%). The following interventions were performed: mitral valve replacement - 32 (41.5%) patients, mitral valve repair - 22 (28.6%) patients, atrial septal defect closure - 13 (16.9%) patients, resection of the left atrial myxoma - 4 (5.2%) patients, atrial septal defect closure + tricuspid valve repair - 2 (2.6%) patients, tricuspid valve replacement - 2 (2.6%) patients, mitral valve repair + atrial septal defect closure - 1 (2.6%) patient, mitral valve repair + atrial septal defect closure + right middle lobectomy - 1 (2.6%) patient. There were no in-hospital mortality and major cardiac events. Conversion was required in 1 case (1.3%). Enlargement up conventional to thoracotomy was required in 1 case (1.3%). Surgery time was 217 min (Q1-Q3 188-258), cardiopulmonary bypass time - 106 min (Q1-Q3 91-124), aortic cross-clamping time - 82±29 min (95% CI 76-89). Intraoperative blood loss was 500 ml (Q1-Q3 400-600). Mean postoperative hospital-stay was 6.7±1.8 days (95% CI 6.3-7.1). Heart valve surgery and resection of cardiac tumors via the right-sided minithoracotomy is a safe and effective approach to ensure chest stability, fast postoperative recovery and favorable cosmetic result. Surgery time is decreased along the learning curve.

The biofunctionalization of titanium nanotube with chitosan/genipin heparin hydrogel and the controlled release of IL-4 for anti-coagulation and anti-thrombus through accelerating endothelialization.

The valve replacement is the main treatment of heart valve disease. However, thrombus formation following valve replacement has always been a major clinical drawback. Accelerating the endothelialization of cardiac valve prosthesis is the main approach to reduce thrombus. In the current study, a titanium nanotube was biofunctionalized with a chitosan/genipin heparin hydrogel and the controlled release of interleukin-4 (IL-4), and its regulation of macrophages was investigated to see if it could influence endothelial cells to eventually accelerate endothelialization. TNT60 (titanium dioxide nanotubes, 60 V) with nanoarray was obtained by anodic oxidation of 60 V, and IL-4 was loaded into the nanotube by vacuum drying. The hydrogel (chitosan : genipin = 4 : 1) was applied to the surface of the nanotubes following drying, and the heparin drops were placed on the hydrogel surface with chitosan as the polycation and heparin as the polyanion. A TNT/IL-4/G (G = gel, chitosan/genipin heparin) delivery system was prepared. Our results demonstrated that the biofunctionalization of titanium nanotube with chitosan/genipin heparin hydrogel and the controlled release of IL-4 had a significant regulatory effect on macrophage M2 polarization, reducing the inflammatory factor release and higher secretion of VEGF (vascular endothelial growth factor), which can accelerate the endothelialization of the implant.

翻訳論文：心臓弁膜症手術の最近の知見：歯科口腔疾患との関連もふまえて

翻訳論文：心臓弁膜症手術の最近の知見：歯科口腔疾患との関連もふまえて

European heart health survey 2019.

BackgroundRising life expectancy in the western population is increasing the prevalence of heart valve diseases (HVD).HypothesisThe level of awareness and initial screening for HVD should be sufficient. The potential impact of HVD on the daily activities of the elderly population in Europe might affect our society.Methods and ResultsA survey was conducted, including a total of 12 832 people aged ≥ 60 years in 11 European countries. Of all the people surveyed, 5.6% could correctly describe aortic valve stenosis. Most participants (75.0%) claimed they regularly do activities like sports or social activities, 29.2% provide care for a family member, friend or acquaintance. The majority (69.2%) would be prevented from doing these activities by symptoms such as chest pain, fatigue or shortness of breath. Having chest pain (76.5%) and shortness of breath (57.8%) were reasons for most people to arrange an appointment with their GP, whereas only 26.2% would visit a GP for fatigue. 67.6% of respondents claimed to be checked with a stethoscope by their GP occasionally, never, or only when they ask. The preferred treatment option for HVD is a keyhole procedure (45.8%), whereas open heart surgery would only be preferred by 7.0%.ConclusionKnowledge about HVD is still low. Neither appointments with a GP driven by symptoms nor regular use of a stethoscope are a reliable guarantee for early diagnosis. With the over 60s in Europe playing an active role in social life, awareness campaigns and regular heart health checks may guarantee early diagnosis and treatment of HVD.

Four case reports: Effects of fucoidan and fucoxanthin on the treatment of degenerative heart valve disease in dogs

Degenerative heart valve disease (DHVD) is the most common heart disease in dogs, especially in small breed dogs weighing less than 20 kg. The incidence in dogs over 13 years old is as high as 85%, and more than 75% of these dogs have mitral valve problems. The valve, which includes the valve leaflet, chordae, and annulus, is mutinously degenerated due to the accumulation of abnormal collagen tissue and glycosaminoglycan, and nodules are formed at the edge of the valve as the disease progresses, eventually resulting in valve insufficiency. To improve the regular treatment of DHVD, especially medication, the natural supplements fucoidan and fucoxanthin were used in this case report. Four small-breed dogs were diagnosed with heart valve disease in the Yukang Veterinary Hospital, and the veterinarian used fucoidan and fucoxanthin as nutritional supplements for the adjuvant treatment of heart valve disease. In the first three cases, it was found that the cardiac function index, including the LA/Ao ratio, significantly improved after 3 to 6 months of continuous administration. Additionally, in the case of American College of Veterinary Internal Medicine (ACVIM) heart grading below Stage B2 after treatment, valve hypertrophy improved, thinned, and flattened, which either reduced the reflux condition caused by valve insufficiency or restored the complete valve closure function. However, in Case 4, the cardiac function index was not improved after 3 to 6 months of continuous administration without the supplement. To the best of our knowledge, this is the first documented clinical study showing that fucoidan and fucoxanthin can improve DHVD in different kinds of dogs.

Surgical treatment of heart valve disease: Considerations for the dental management

AbstractThe number of valve surgeries is increasing with a change in the disease structure from rheumatic valvular heart disease (VHD) to arteriosclerotic or degenerative VHD. The treatment strategies for VHD have also been changing over the last two decades. Repair techniques for valve regurgitation have been established with excellent long‐term clinical results. As valve repair has advantages over prosthetic valve replacement in terms of avoidance of anticoagulation and reduced risk of valve infection, it has become the first choice for treatment of degenerative VHD even for infective endocarditis, which is closely related to dental procedures. With the development of technologies, minimally invasive cardiac surgery is evolving, including the introduction of video‐assisted or robotically assisted valve surgeries via minithoracotomy, or percutaneous transcatheter therapies. Notably, recently introduced transcatheter aortic valve replacement has shown excellent clinical results compared to surgical aortic valve replacement and has become a standard therapy for aortic stenosis in the elderly. Reoperative aortic valve replacement for degenerated bioprosthetic valve can also be performed using the transcatheter “Valve in Valve” technique. These minimally invasive approaches are likely to become more widely adopted and may determine the scope of therapeutic strategies for VHD into the future.

Хирургическая реваскуляризация миокарда как фактор оптимизации результатов лечения заболеваний клапанов сердца у больных старшей возрастной группы

Цель – анализ результатов операций у пожилых пациентов с сочетанной патологией клапанов сердца и коронарных артерий, оптимизация тактики хирургического лечения.

Valve surgery in combination with cryoablation in the treatment of atrial fibrillation.

Objective:To investigate the effectiveness and safety of valve surgery in combination with cryoablation in the treatment of atrial fibrillation.Methods:Fifty patients who needed to undergo valve surgery because of heart valve disease and sixty-five patients who needed to undergo valve surgery in combination with cryoablation were selected as the research subjects. The perioperative technical characteristics, postoperative curative effect and complications were compared between the two different treatment modalities in our hospital between October 2013 and November 2015.Results:No significant differences were observed between the two groups in valve surgery mode, valve type and postoperative length of hospital stay (P>0.05), but the duration of extracorporeal bypass and aorta occlusion of the observation group was longer than that of the control group (P<0.05). The 3-month, 6-month and one-year atrial fibrillation cardioversion rates of patients in the observation group were superior to those of the control group, and the differences were notable (P<0.05). The improvement of left atrial diameter of the observation group was also superior to that of the control group (P<0.05). The incidence of postoperative complications of the two groups had no significant difference (P>0.05).Conclusion:Valve surgery in combination with cryoablation has favorable short-term clinical effect in the treatment of heart valve disease in combination with atrial fibrillation, which is worth promotion.

Calcification and Oxidative Modifications Are Associated With Progressive Bioprosthetic Heart Valve Dysfunction.

BackgroundBioprosthetic heart valves (BHVs), fabricated from glutaraldehyde‐pretreated bovine pericardium or porcine aortic valves, are widely used for the surgical or interventional treatment of heart valve disease. Reoperation becomes increasingly necessary over time because of BHV dysfunction.Methods and ResultsForty‐seven explanted BHV aortic valve replacements were retrieved at reoperation for clinically severe BHV dysfunction over the period 2010–2016. Clinical explant analyses of BHV leaflets for calcium (atomic absorption spectroscopy) and oxidized amino acids, per mass spectroscopy, were primary end points. Comorbidities for earlier BHV explant included diabetes mellitus and coronary artery bypass grafting. Mean calcium levels in BHV leaflets were significantly increased compared with unimplanted BHV (P<0.001); however, time to reoperation did not differ comparing calcified and noncalcified BHV. BHV dityrosine, an oxidized amino acid cross‐link, was significantly increased in the explants (227.55±33.27 μmol/mol [dityrosine/tyrosine]) but was undetectable in unimplanted leaflets (P<0.001). BHV regional analyses revealed that dityrosine, ranging from 57.5 to 227.8 μmol/mol (dityrosine/tyrosine), was detectable only in the midleaflet samples, indicating the site‐specific nature of dityrosine formation. 3‐Chlorotyrosine, an oxidized amino acid formed by myeloperoxidase‐catalyzed chlorinating oxidants, correlated with BHV calcium content in leaflet explant analyses from coronary artery bypass graft patients (r=0.62, P=0.01) but was not significantly correlated with calcification in non–coronary artery bypass graft explanted BHV.ConclusionsBoth increased BHV leaflet calcium levels and elevated oxidized amino acids were associated with bioprosthesis dysfunction necessitating reoperation; however, BHV calcium levels were not a determinant of implant duration, indicating a potentially important role for oxidized amino acid formation in BHV dysfunction.

Biomarkers show promise for treatment of heart valve disease

Biomarkers show promise for treatment of heart valve disease

Spontaneous retrotransposon insertion into TNF 3′UTR causes heart valve disease and chronic polyarthritis

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are chronic inflammatory diseases that together affect 2-3% of the population. RA and AS predominantly involve joints, but heart disease is also a common feature in RA and AS patients. Here we have studied a new spontaneous mutation that causes severe polyarthritis in bone phenotype spontaneous mutation 1 (BPSM1) mice. In addition to joint destruction, mutant mice also develop aortic root aneurism and aorto-mitral valve disease that can be fatal depending on the genetic background. The cause of the disease is the spontaneous insertion of a retrotransposon into the 3' untranslated region (3'UTR) of the tumor necrosis factor (TNF), which triggers its strong overexpression in myeloid cells. We found that several members of a family of RNA-binding, CCCH-containing zinc-finger proteins control TNF expression through its 3'UTR, and we identified a previously unidentified regulatory element in the UTR. The disease in BPSM1 mice is independent of the adaptive immune system and does not appear to involve inflammatory cytokines other than TNF. To our knowledge, this is the first animal model showing both polyarthritis and heart disease as a direct result of TNF deregulation. These results emphasize the therapeutic potential of anti-TNF drugs for the treatment of heart valve disease and identify potential therapeutic targets to control TNF expression and inflammation.