Heart Valve Research Articles

Novel heart valve leaflet designs with stiff polymeric materials and biomimetic kinematics

Despite continuous efforts to improve the robustness of cardiac valve implants, neither bioprosthetic nor mechanical valves fulfill both hemodynamic and durability requirements. This study discussed novel flexible leaflet designs, focusing on polymeric materials with proven hemocompatibility, such as polyether ether ketone, of much higher stiffness than native tissue, aiming at optimal valve implants. A biomimetic valve with a single-curvature belly-curve (B-C) was used as a reference for new design variants with a double-curvature B-C with varying radii. Soft (13.2 MPa) and stiff (2.4 GPa) leaflet materials and different thicknesses were studied using lean simulations and in vitro experiments under physiologic hemodynamic conditions. The performance was assessed using opening pressure (OP) and orifice area (OA). The latter was determined by a newly developed automatized image processing tool. Experimental trends are in agreement with simulations and demonstrated that a buckling-inspired double-curvature leaflet design significantly enhances the trileaflet valve opening behavior, which is particularly advantageous for stiffer leaflet materials. Compared to the reference, the best-performing variant showed an OP improvement of 47% and 44% based on simulations and experiments, respectively. In contrast, the achieved mean pressure differential was directly comparable to state-of-the-art bioprosthetic valves. The OA was slightly reduced for new variants but still in the satisfying range.Graphic abstract

Late-Term Outcomes of Surgical Treatment of Infective Endocarditis.

Background: This study aims to evaluate the long-term outcomes of surgical interventions in patients with infective endocarditis (IE) who underwent surgical treatment and to determine the treatment approach for new patients. Patients and Methods: We retrospectively examined the long-term results of patients who underwent surgical treatment for IE between 2007 and 2017. The evaluation included late-term outcomes of IE surgery, surgical procedures, complications, the postoperative period, and clinical findings. Results: The study included 20 patients (12 male, 8 female) with a mean age of 45.1 ± 17.25. The most common cardiac risk factors for endocarditis development were the presence of prosthetic valves and heart valve disease. In addition, non-cardiac risk factors included chronic renal failure, systemic lupus erythematosus, and pemphigus vulgaris. Preoperative and postoperative laboratory findings were compared with in terms of morbidity and mortality, revealing no significant differences. The most prevalent preoperative laboratory findings were anemia (100%), elevated CRP (100%), and leukocytosis (50%). Anemia persisted as the most common laboratory finding in the postoperative evaluation. Conclusion: Our study identified comorbid chronic medical conditions, neurological complications because of IE, postoperative impaired left ventricular function, and treatment strategies such as monotherapy as poor prognostic factors in patients who underwent surgical treatment for IE. The management of IE is observed to be complex in the presence of comorbidities and complications, adversely affecting both survival and quality of life.

Development of Transcatheter Tissue-Engineered Heart Valves with Dual Crosslinking and Nitric Oxide Releasing Decellularized Matrix Composites for in-situ Regeneration

Development of Transcatheter Tissue-Engineered Heart Valves with Dual Crosslinking and Nitric Oxide Releasing Decellularized Matrix Composites for in-situ Regeneration

Bloodstream infection in patients with cardiac implantable electronic devices and prosthetic heart valves: the role of PET-CT

Bloodstream infection in patients with cardiac implantable electronic devices and prosthetic heart valves: the role of PET-CT

Heart valve clinics: an expanding role for the clinical scientist's validation of a framework for competency and certification

BackgroundValvular heart disease (VHD) represents a significant burden on healthcare systems worldwide, necessitating specialised care through multidisciplinary valve clinics. However, there is a lack of a standardised training and certification...

Atopic dermatitis increases the risk of infective endocarditis in prosthetic heart valve patients – A retrospective study

Atopic dermatitis increases the risk of infective endocarditis in prosthetic heart valve patients – A retrospective study

‘If you’ve lost your personality, there’s no point in changing the valve’—a qualitative study of older adults’ attitudes towards treatment of aortic stenosis with comorbid dementia

ObjectivesDue to prognostic uncertainty and limited decision-making capacity, the choice to perform transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS) and comorbid dementia is challenging. This...

Is there an indication for endocarditis prophylaxis in patients with cardiac devices?

Cardiac implantable electronic devices (CIED) are essential in treating cardiovascular disease, but their infections are serious complications. The number of patients with CIEDs is increasing, as are CIED infection rates and related endocarditis. These infections arise either from contamination during implantation or from secondary infections. Current guidelines do not support prophylactic antibiotics for CIED patients before dental or other invasive procedures, unless the patient has other risk factors (E.g. an artificial heart valve). Patients with fever or signs of a pocket infection should be treated in centers equipped for laser extraction.

Stroke Debility During Non-full Versus Full Sternotomy Access Cardiac Valve Operation

Stroke Debility During Non-full Versus Full Sternotomy Access Cardiac Valve Operation

Analysis of the Correlation Between the Expression of T-Helper Type 17 Cell-Related Cytokines and Valve Damage in Rheumatic Heart Disease.

Rheumatic heart disease (RHD) results from chronic inflammation and fibrosis of heart valves following untreated rheumatic fever, yet its immunopathology, particularly involving T helper 17 (Th17) cells and their cytokines, is not fully understood. Th17 cells are prominent drivers of inflammation and have been linked to various autoimmune diseases, suggesting their potential role in RHD-related valve damage. This study examines Th17-associated cytokines-interleukin (IL)-17, IL-6, IL-23, and IL-21-in RHD. IL-17 is known to amplify inflammation by inducing pro-inflammatory cytokines and recruiting neutrophils, likely exacerbating valve damage, while IL-6 plays a role in Th17 differentiation and may promote chronic inflammation linked to fibrosis. IL-23 sustains Th17 cells, thereby perpetuating the inflammatory cycle in RHD, and IL-21 influences Th17 cells and B cell responses, potentially linking adaptive immunity to valve pathology. Clarifying the roles of these cytokines could offer insights into novel therapeutic targets for mitigating inflammation and preventing disease progression in RHD. This study included 20 patients with RHD undergoing mitral valve replacement (Group O) and 20 patients with degenerative mitral valve prolapse (Group C) as controls. We utilized immunohistochemical staining and hematoxylin and eosin staining to assess the expression of Th17 cell-related cytokines in heart valves. To explore the relationship between cytokine expression and valve damage, Spearman correlation analysis was conducted. For inter-group comparisons, we employed the Mann-Whitney U test and Wilcoxon rank-sum test for non-parametric data, facilitating the evaluation of significant differences in cytokine levels and other relevant variables. In Group O, the percentage of IL-17-positive cells in mitral valve tissue was 51.6 ± 18.4%, with an immunohistochemistry score of 3.7 ± 2.2. IL-21-positive cells constituted 54.2 ± 16.5% with a score of 5.2 ± 1.3, IL-6-positive cells were at 29.4 ± 17.3% (score of 3.9 ± 1.5), and IL-23-positive cells accounted for 33.7 ± 17.9% (score of 4.3 ± 1.6). All these cytokine levels were significantly higher in Group O compared to Group C (P < 0.05), and the expression levels of IL-17, IL-21, IL-6, and IL-23 in valve tissue positively correlated with heart valve damage (P < 0.05). The main findings indicated that patients with RHD had significantly elevated levels of pro-inflammatory cytokines, including TNF-α, IL-6, and IL-10, compared to healthy controls. These elevated cytokine levels were associated with the severity of valve damage in RHD patients, suggesting a critical role of the inflammatory response in the progression of valve injury; specifically, higher concentrations of TNF-α correlated with more severe mitral regurgitation, while increased levels of IL-6 were linked to a higher grade of mitral stenosis. The study reveals a significant association between Th17 cell-related cytokine expressions and valve damage in RHD patients, suggesting that targeting these cytokines may offer a promising strategy for treatment and prevention while highlighting their potential as biomarkers for assessing valve damage and the importance of managing inflammation to mitigate further cardiac complications.

Physical properties of Korean normal aortic valves based on fluid–structure interactions

Recently, numerical methods such as computational fluid dynamics (CFD), have been widely used in heart valve research. The CFD approach has fewer restrictions compared to clinical and experimental methods as it involves interpretations through computer calculations, and it can be used to predict and analyze fluids. For valve numerical analysis using CFD, the mechanical properties of the valve must be defined based on the physical properties. However, most of the existing heart valve numerical analysis studies have been conducted for westerners, and only a few studies on the same topic have focused on Asians. Thus, in this paper, we aim to determine the physical property parameters suitable for defining the mechanical properties of the normal aortic valves of Koreans over time. In this study, we used a fluid−structure interaction technique for the valve simulation and applied three representative valve characteristics presented in previous aortic valve simulation studies. Herein, the valve patency rates in case of simulation and multidetector computed tomography images were compared and analyzed through statistical techniques. Our results revealed that the physical properties, such as density (1050 kg/m3), Young’s modulus (2 MPa), and Poisson’s ratio (0.3), are like those of the Korean aortic valve over time. If hemodynamic evaluation of the Korean aortic valve is performed through simulation using these conditions, it can be effective in identifying the factors of heart valve disease.

The Relationship Between Carpal Tunnel Syndrome and Cardiac Involvement in Patients with Mucopolysaccharidosis

Background / Aims: Mucopolysaccharidoses (MPSs) are a group of progressive multisystemic diseases, and it is unknown whether there is a relationship between these system involvements. In this study, we aimed to investigate whether there is a relationship between cardiac involvement and carpal tunnel syndrome (CTS) in MPS patients. Methods: The study was conducted between May 12, 2023, and June 30, 2024, as a prospective study with a retrospective onset. Patients between the ages of 2 and 20 years who were diagnosed with MPS Types I, II, IV A, and VI enzymatically and genetically and who underwent electromyography for CTS screening and transthoracic echocardiography for cardiac involvement were included in the study. Results: Twenty-six MPS patients were included in the study. The mean age of the patients was 128±58 months. There was cardiac involvement in 21 (80.8%) of the patients. Heart valve involvement was present in 20 (76.9%) patients. Our study found that 14 (53.8%) of our MPS patients had CTS. CTS was present in all patients in the MPS type I, II, and VI groups but not in any MPS type IV A patients. As a result of the statistical analysis, the presence of MPS Type IV A was statistically significantly higher in the group without CTS than in the group with CTS (p&amp;lt;0.001). The presence of cardiac involvement, combined involvement of the aortic and mitral valves, and the severity of heart valve involvement were found to be statistically significantly higher in the patient group with CTS than in the patient group without CTS (p=0.007, p=0.005, p=0.009, respectively). Conclusions: Our study found that CTS was more common in patients with cardiac involvement, especially heart valve involvement. We recommend that CTS screening be performed, especially in MPS patients with cardiac involvement.

From the INVICTUS Trial to Current Considerations: It's Not Time to Retire Vitamin K Inhibitors Yet!

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies-e.g., osocimab, anti-sense oligonucleotides-e.g., fesomersen, and small molecule inhibitors-e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease.

Successful Anaesthetic Management of Triple Valve Surgery (Double Valve Replacement and Tricuspid Valve Ring Repair)- Challenges and Troubleshooting

Heart valve diseases are extensive and include double (mitral-aortic, mitral-tricuspid), or triple (mitral, aortic, and tricuspid) valvular regurgitation, stenotic or mixed lesions. The surgical correction of valvular lesions usually consists of the repair or replacement of all valves affected by a pathologic process.We present a challenging complex valvular case of a 61 year old hypothyroid female diagnosed with severe mitral stenosis with moderate mitral regurgitation, severe aortic stenosis with mild aortic regurgitation and severe tricuspid regurgitation with high pulmonary artery pressures.She successfully underwent Double valve replacement (Mitral and aortic) and Tricuspid Annuloplasty Ring repair.

Blood culture-negative endocarditis caused by Bartonella quintana in Iran.

Blood culture-negative endocarditis (BCNE) is a challenging disease because of the significant impact of delayed diagnosis on patients. In this study, excised heart valves and blood serum samples were collected from 50 BCNE patients in two central hospitals in Tehran, Iran. Sera were tested by IFA for the presence of IgG and IgM antibodies against Bartonella quintana and B. henselae. Genomic DNA extracted from the heart valves was examined for Bartonella-specific ssrA gene in a probe-based method real-time PCR assay. Any positive sample was Sanger sequenced. IgG titer higher than 1024 was observed in only one patient and all 50 patients tested negative for Bartonella IgM. By real-time PCR, the ssrA gene was detected in the valve of one patient which was further confirmed to be B. quintana. Bartonella-like structures were observed in transmission electron microscopy images of that patient. We present for the first time the involvement of Bartonella in BCNE in Iran. Future research on at-risk populations, as well as domestic and wild mammals as potential reservoirs, is recommended.

Case report: Infective endocarditis caused by Streptococcus pneumonia at Prof. Ngoerah Hospital, Denpasar, Bali

Introduction: Infective endocarditis (IE) is a rare infection of the endocardial surface that can be caused by Streptococcus pneumoniae (pneumococcal endocarditis/PE), with an incidence of between 1.4–12.7 per 100,000 people each year, and a mortality rate of &lt;3%. Infective endocarditis is associated with several complications including stroke and congestive heart failure. Here we report a case of IE in an adult caused by S. pneumoniae. Case Description: A 27-year-old woman complained of swelling in both legs, red spots, and a history of fever since 2 days before admission. Physical and supporting examinations including echocardiography and three-sided blood culture were carried out using VITEK-2. Streptococcus pneumoniae was identified from the culture which sensitive to Benzylpenicillin group including Cefotaxime, Ceftriaxone, Levofloxacin, Erythromycin, Clindamycin, Tetracycline, and Trimethoprim/Sulfamethoxazole. Infective endocarditis due to S. pneumoniae in adult is very rare. The attachment of S. pneumoniae to the heart valve, may be facilitated by its capsule, which is considered essential in bacteremia. Patient received empirical intravenous antibiotics with 3 grams Ampicillin every 6 hours and 150 mg Gentamicin every 24 hours. The patient improved and treatment was continued by intramuscular injections of 1.2 million IU Benzathine Penicillin G were given every 28 days until age 40. Conclusion: Infective endocarditis cases in adult patients are associated with high morbidity. Pneumococcal vaccination and adhering to rational antibiotic administration guidelines provide good prognosis to the patients.

Improved Cardiac Rehabilitation Referral Rates following Coronary Artery Bypass Graft and Heart Valve Replacement in an Inner-City Veteran Population.

Cardiac rehabilitation (CR) is underutilized due to various barriers, despite its known benefits in decreasing 5-year mortality after cardiac surgery. The authors initiated a quality improvement project to identify barriers and enhance CR referral rates and participation. The team conducted a retrospective review of cardiac surgery patients from 2015 to 2022 at the Detroit Veterans Affairs. Phase 1 covered 2015-2017 (preintervention), phase 2 was the intervention period, and phase 3 covered 2018-2022 (postintervention). Appropriate CR referral was defined as within 6 months postevent. Referral rates and 1-year post-op hospitalization were assessed. Group 1 (2015-2017) had 54 male patients, 44% Black, 89% hypertensive, with a 22% CR referral rate. Group 2 (2018-2022) had 98 male patients, 64% Caucasian, mean age 73 years, with a 36% CR referral rate postintervention (P = 0.0018). One-year hospitalization decreased from 26% to 13% (P = 0.20). CR is still an underutilized tool. Provider education and complete funding of CR can improve referral rates and participation.

Patient perspectives on health care models in cardiac surgery: a qualitative evaluation

BackgroundThe implementation of ERAS represents a promising solution to improve treatment efficiency and facilitate patient involvement. This innovative care model aims to optimize recovery processes following surgeries by adopting a holistic, interprofessional approach. At our hospital, ERAS was implemented in minimally invasive heart valve surgery, offering two distinct ERAS models. Additionally, there is also the standard of care without ERAS. The objective of the study is to gain insight into patient satisfaction and perceived differences across these various care models.MethodsPatients were interviewed using semi-structured interviews approximately two to three months after undergoing surgery. The data were analysed using qualitative content analysis in accordance with the methodology proposed by Kuckartz. Four main categories were established: Preoperative care, postoperative care and communication, patient participation and involvement, and rehabilitation and post-clinical course.ResultsComprehensive preoperative education and seamless communication throughout the perioperative care journey were identified as fundamental to patient satisfaction and optimal care processes. Patients in the ERAS + model reported higher overall satisfaction with their care compared to patients in the standard of care and ERAS groups.ConclusionPreoperative education establishes the foundation for patients’ subsequent behaviours and expectations regarding their treatment. Physical activity, nutrition, and mental health are significant aspects. The active involvement and participation of patients and their families in the treatment process facilitated superior postoperative care, intensive physiotherapy, mental support, and faster recovery. A functional flow of information throughout the entire care process is vital. Moreover, having a dedicated point of contact had a beneficial impact on patients´ well-being. The integration of innovative ERAS concepts, which encompass interprofessional preoperative patient education and psychosomatic support, represents a promising approach from a patient perspective, offering benefits to a broad spectrum of cardiac surgical patients.

A Review of Biomechanical Studies of Heart Valve Flutter

This paper reviews recent biomechanical studies on heart valve flutter. The function of the heart valves is essential for maintaining effective blood circulation. Heart valve flutter is a kind of small vibration phenomenon like a flag fluttering in the wind, which is related to many factors such as a thrombus, valve calcification, regurgitation, and hemolysis and material fatigue. This vibration phenomenon is particularly prevalent in valve replacement patients. The biomechanical implications of flutter are profound and can lead to micro-trauma of valve tissue, accelerating its degeneration process and increasing the risk of thrombosis. We conducted a systematic review along with a critical appraisal of published studies on heart valve flutter. In this review, we summarize and analyze the existing literature; discuss the detection methods of frequency and amplitude of heart valve flutter, and its potential effects on valve function, such as thrombosis and valve degeneration; and discuss some possible ways to avoid flutter. These findings are important for optimizing valve design, diagnosing diseases, and developing treatment strategies.

A Risk Prediction Model for Prolonged Length of Stay After Minimally Invasive Valve Surgery.

Minimally invasive surgery determines shorter postoperative hospital length of stay (LOS) even in cardiac surgery. Potential preoperative factors affecting LOS are still not known in minimally invasive heart valve surgery (MIVS). We aimed to identify preoperative variables influencing prolonged LOS in MIVS. We reviewed 189 patients who underwent MIVS via minithoracotomy at our institution. Prolonged LOS was defined as more than 7 postoperative days. Poisson and logistic regression were used to screen the predictors. The mean postoperative LOS was 9.13 days, and 64 patients (33.9%) experienced a prolonged LOS. These patients were older, more frequently in New York Heart Association (NYHA) class III or IV, showed worse left ventricular ejection function (LVEF), and had a higher incidence of reoperation and chronic kidney disease (CKD). At univariate analysis, the most significant preoperative factors affecting prolonged LOS were age (odds ratio [OR] = 1.04), NYHA class III or IV (OR = 3.03), reduced LVEF (OR = 3.22), CKD (OR = 2.7), and redo surgery (OR = 3.6). After adjustment, the most significant preoperative factors predicting prolonged LOS were age (OR = 1.03, 95% CI: 1.01 to 1.06, P = 0.02) and redo surgery (OR = 3.33, 95% CI: 1.29 to 8.9, P = 0.01). The most important factors affecting prolonged LOS after MIVS were represented by age and redo surgery, although other preoperative characteristics such as reduced LVEF, NYHA class III or IV, and CKD play a significant role in delaying recovery after MIVS. Further larger studies are needed to better identify potential preoperative predictors of prolonged LOS after MIVS.