Valve Replacement In Patients Research Articles

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17,269 patients

Background: Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. Our meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR. Materials and Methods: Till august 2023, PubMed, Embase, and MEDLINE databases were searched for Randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% confidence intervals were calculated using Review Manager. Results: Forty-eight studies were included having 17,269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95%CI:0.50 to 1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95%CI:0.36 to 1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95%CI:5.81 to 11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:−0.58; 95%CI:−1.08 to −0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:−0.67; 95%CI:−1.42 to 0.08; I2=84%; P=0.08) when compared to FS. Conclusions: While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

Differential preoperative transcriptomic profiles are related to the quality of left ventricle reverse remodelling one year after valve replacement in patients with severe aortic valve stenosis

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Spain´s Ministerio de Economía y Competitividad [(PI21/00084, CIBERCV (CB16/11/00264), co-funded by Fondo Europeo de Desarrollo Regional (FEDER)] Instituto de Investigación Sanitaria Marqués de Valdecilla, IDIVAL (INNVAL21/24; PREVAL22/09) Background Aortic valve stenosis (AS) promotes a progressive remodelling of the left ventricle (LV) characterised by cardiomyocyte hypertrophy and increased deposition of extracellular matrix elements. These adaptive plastic changes may evolve towards heart failure over time. The extent of LV remodelling and its persistence after valve replacement are significant prognostic factors for the long-term outcome of AS patients. The biological processes that determine the reverse remodelling rate after surgery of AS patients are unknown. Purpose To ascertain preoperative LV transcriptomic determinants of favourable reverse remodelling one year after surgery in AS patients. To this end, a genome-wide transcriptomic analysis was performed in LV biopsies from AS patients and surgical controls. Methods and Results The study was performed in AS (n=24) and control patients (n=12) (age and sex matched) followed up for one year after surgery. RNA-seq was performed on LV biopsies obtained during surgery. AS patients were stratified according to the quality of the reverse remodelling at one year in good (LV mass index ≤51 g/m2.7, n=12) or poor (LV mass index >51 g/m2.7, n=12) performers. RNA-seq libraries were prepared and sequenced using an Illumina Next Seq Unit. Resulting reads were mapped against GRCh38.99 version of the human transcriptome. The results from the principal component analysis revealed a distinctive expression gene pattern for the AS condition, accounting for 60.1 % of the variance, with no difference for the sex condition (8.7 %). Differential gene expression was considered significant when yielding a Benjamini-Hochberg adjusted p-value < 0.05. Compared to controls, 339 and 443 genes were differentially expressed in AS with good and poor reverse remodelling, respectively, with 509 overlapping. Gene Set Enrichment Analysis (GSEA) of differentially expressed genes in patients with poor reverse remodelling compared to control patients, showed a significant enrichment (NES > 1.5) in genes associated with angiogenesis, epithelial-mesenchymal transition (EMT), and heart growth. The down-regulated genes (NES < 0) were associated with transcription processes, such as histone modification and RNA processing-related genes, highlighting the significance of epigenetic mechanisms in AS patients exhibiting poor reverse remodelling. In contrast, such transcriptomic profile patterns were not observed in AS with good-reverse remodelling. Conclusion Aortic stenosis patients with good or poor reverse remodelling one year after aortic valve replacement exhibited distinct preoperative LV transcriptome profile. Gene ontology enrichment analysis revealed angiogenesis, EMT, and epigenetic processes as critical biological functions associated with poor reverse remodelling in AS patients.

Transcatheter aortic valve replacement for aortic regurgitation: a systematic review and meta-analysis.

The efficacy and safety of new-generation devices (NGDs) for severe aortic regurgitation (AR) have mostly been based on single-arm studies with limited sample sizes. Our goal was to summarize the current evidence on NGDs and compare the safety and efficacy of 'off-label' and 'on-label' devices in NGDs. We searched MEDLINE, Embase, Cochrane Library, and Scopus for articles on transcatheter aortic valve replacement in patients with AR. A total of 31 studies that included 1851 patients were identified through April 2023. Among these, 1067 (57.6%) patients received treatment with 'on-label' devices (JenaValve and J-Valve). For NGDs, the total device success rate at 30days was 94.5% (on-label: 97.8%, off-label: 89.9%; P<0.001), the all-cause mortality was 4.2% (on-label: 2.6%, off-label: 5.1%; P=0.006), permanent pacemaker implantation (PPI) was 8.8% (on-label: 6.9%, off-label: 18.4%; P<0.001), and the rate of greater-than-mild paravalvular leak (PVL) was 1.2% (on-label: 0.9%, off-label: 3.8%; P=0.003). On-label devices showed significantly better safety and efficacy in terms of the success rate, PPI, greater-than-mild PVL, and 30day mortality than off-label devices.

Implementation of the International Consortium of Health Outcomes Measurement CHD standard set in patients undergoing pulmonary valve replacement.

Despite the burden of CHD, a high cost and utilization condition, an implementation of long-term outcome measures is lacking. The objective of this study is to pilot the implementation of the International Consortium of Health Outcomes Measurement CHD standard set in patients undergoing pulmonary valve replacement, a procedure performed in mostly well patients with diverse CHD. Patients ≥ 8 years old undergoing catheterization-based pulmonary valve replacement were approached via various approaches for patient-reported outcomes, with a follow-up assessment at 3 months post-procedure. Implementation strategy analysis was performed via a hybrid type 2 design. Of the 74 patients undergoing pulmonary valve replacement, 32 completed initial patient-reported outcomes with variable response rates by strategy (email and in-person explanation 100%, email only 54%, and email followed by text/call 64%). Ages ranged 8-67 years (mean 30). Pre-procedurally, 34% had symptomatic arrhythmias, which improved post-procedure. For those in school, 43% missed ≥ 6 days per year, and over half had work absenteeism. Financial concerns were reported in 34%. Patients reported high satisfaction with life (50% [n = 16]) and health-related quality of life (90% [n = 26]). Depression symptoms were reported in 84% (n = 27) and anxiety in 62.5% (n = 18), with tendency towards improvement post-procedurally. Pilot implementation of the International Consortium of Health Outcomes Measurement CHD standard set in pulmonary valve replacement patients reveals a significant burden of disease not previously reported. Barriers to the implementation include a sustainable, automated system for patient-reported outcome collection and infrastructure to assess in real time. This provides an example of implementing cardiac outcomes set in clinical practice.

Minimally invasive redo tricuspid valve replacement in patient with persistent left superior vena cava.

The management of cardiopulmonary bypass (CPB) is still challenging in certain circumstances, especially for patients with anatomical variations. This challenge is even harder for reoperations, which are associated with increased morbidity and mortality risk. We describe a minimally invasive, beating-heart redo tricuspid valve replacement in a 71-years old woman with persistent left superior vena cava. Preoperative planning via CT-scan, teamwork and custom-made management of CPB are crucial for reoperations with anatomical variations. The perfusionist has a pivotal role in constructing and managing the CPB. We describe a strategy achieving the benefits of minimally invasive endoscopic and beating-heart surgery (avoidance of resternotomy risk and associated morbidity, right ventricular protection) in reoperative tricuspid surgery with persistent upper left vena cava.

Medical treatment of heart failure with renin–angiotensin–aldosterone system inhibitors and beta-blockers in aortic stenosis: association with long-term outcome after aortic valve replacement

Abstract Aims There is a lack of robust data on the optimal medical treatment of heart failure in patients with severe aortic stenosis, with no randomized controlled trials guiding treatment. The study aimed to study the association between exposure to renin–angiotensin–aldosterone system (RAS) inhibitors or beta-blockers and outcome after aortic valve replacement in patients with aortic stenosis and heart failure. Methods and results The study included all patients with heart failure undergoing aortic valve replacement for aortic stenosis in Sweden between 2008 and 2016 (n = 4668 patients). Exposure to treatment was assessed by a continuous tracking of drug dispensations, and outcome events were all-cause mortality and hospitalization for heart failure collected from national patient registries. After adjustment for age, sex, atrial fibrillation, hypertension, diabetes mellitus, and prior myocardial infarction, Cox regression analysis showed that RAS inhibition was associated with a lower risk of all-cause mortality in patients with reduced left ventricular ejection fraction (LV-EF) [hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51–0.65] and preserved LV-EF (HR 0.69, 95% CI 0.56–0.85). Beta-blockade was associated with a lower risk of all-cause mortality in patients with reduced LV-EF (HR 0.81, 95% CI 0.71–0.92), but not in preserved LV-EF (HR 0.87, 95% CI 0.69–1.10). There was no association between RAS inhibition or beta-blockade and the risk of hospitalization for heart failure. Conclusion The RAS inhibition was associated with a lower all-cause mortality after valve replacement in patients with both reduced and preserved LV-EF. Beta-blockade was associated with lower all-cause mortality only in patients with reduced LV-EF.

OR7-6 | The Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pure Aortic Regurgitation: A Systematic Review and Meta-analysis

OR7-6 | The Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pure Aortic Regurgitation: A Systematic Review and Meta-analysis

E-40 | Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement in Patients with Bicuspid Aortic Stenosis: A Propensity Score Matching Analysis

E-40 | Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement in Patients with Bicuspid Aortic Stenosis: A Propensity Score Matching Analysis

E-31 | In-Hospital Complications and Outcomes of Transcatheter Aortic Valve Replacement in Patients with End-Stage Renal Disease

E-31 | In-Hospital Complications and Outcomes of Transcatheter Aortic Valve Replacement in Patients with End-Stage Renal Disease

E-22 | Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Aortic Stenosis and Cardiogenic Shock

E-22 | Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Aortic Stenosis and Cardiogenic Shock

Stroke risk after transcatheter aortic valve replacement in patients with carotid stenosis: A systematic review and meta-analysis

BackgroundStroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS. MethodsWe searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality. ResultsWe identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95–2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02–2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79–1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85–1.45; p = 0.43, respectively). ConclusionsCAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS.

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

Outcomes of transcatheter aortic valve replacement in patients with history of chest wall irradiation: Propensity matched analysis of five years data from national inpatient sample (2016–2020)

IntroductionChest radiotherapy has been utilized to treat intra-thoracic and mediastinal tumors. Chest wall irradiation (C-XRT) survivors frequently develop valvular disease, including aortic stenosis, which eventually requires valve replacement. Previous trials have shown worse outcomes with surgical aortic valve replacement. However, transcatheter aortic valve replacement (TAVR) outcomes-related data in patients with C-XRT is limited. MethodsThe national inpatient sample (NIS) database was queried from 2016 to 2020 to identify adult hospitalizations with TAVR, which were dichotomized based on a history of C-XRT using ICD-10-CM codes. Propensity score matching was performed to derive age, sex, hospital characteristics, and co-morbidities matched controls without a history of C-XRT. The outcomes studied were inpatient mortality and complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression were used to analyze the outcomes. ResultsOf 296,670 patients who underwent TAVR between 2016 and 2020, 515 had a history of C-XRT. Upon propensity score matching in patients undergoing TAVR, Patients with a history of C-XRT showed significantly lower adjusted odds of in-hospital mortality (adjusted odd ratio [aOR] 0.04, 95 % CI [0.003–0.57], p = 0.017), lower mean LOS by 1.6 days (−1.88 to −1.26 days, p < 0.001) and reduced mean THC (−$74,720, [−$88,784 to -$60,655], p < 0.001). Additionally, patients with C-XRT had significantly lower adjusted odds of inpatient complications, mainly acute myocardial infarction, cerebrovascular events, acute respiratory failure, acute kidney injury, need for vasopressors and cardiopulmonary resuscitation, whereas similar odds of complications, including a requirement of intubation, mechanical ventilation, hemodialysis, and cardiogenic shock. ConclusionOur analysis showed reduced adjusted odds of in-hospital mortality, length of stay, total hospital charges, and inpatient complications in patients undergoing TAVR with a history of C-XRT. TAVR appears to be a safe and viable alternative in this population subgroup.

E-30 | Valve-in-Valve Transcatheter Aortic Valve Replacement in Patients with Previous Aortic Homograft/stentless bioprosthetic valve

E-30 | Valve-in-Valve Transcatheter Aortic Valve Replacement in Patients with Previous Aortic Homograft/stentless bioprosthetic valve

Case report on Pharmacogenetic guided warfarin dosing in a postoperative valve replacement patient

Patient underwent mitral valve replacement with mechanical valve and was initiated on oral anticoagulation with standard dose of warfarin. She developed supra therapeutic INR levels. Genotyping of CYP2C9 and VKORC1 encoding genes revealed homozygous variation of CYP2C9*3*3 and heterozygous variation of VKORC1 G&gt;A making her hypersensitive to warfarin. Based on this study result and Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline, a low dose of warfarin (0.5mg per day) was prescribed, to achieve a therapeutic INR of 2.5 to 3.5 and adverse drug effects were avoided.

Influence of time in therapeutic range on postoperative complications in mechanical heart valve replacement patients operated with the indigenous TTK Chitra heart valve

Influence of time in therapeutic range on postoperative complications in mechanical heart valve replacement patients operated with the indigenous TTK Chitra heart valve

Simultaneous transapical transcatheter aortic and mitral valve replacement in patients with severe valve dysfunction: initial experience.

Simultaneous transcatheter mitral valve in valve (VIV) replacement and aortic valve replacement experience is limited. We report our initial experience with simultaneous transapical transcatheter aortic and mitral valve replacement in patients with severe valve dysfunction. A total of 8 patients had simultaneous transcatheter heart valve implants for severe mitral bioprosthesis failure (VIV), with a second valve procedure that included native aortic regurgitation (n = 3) or degenerated bioprostheses in the aortic position (n = 5). All patients were treated with a self-expandable J-valve transcatheter valve, using the transapical approach. The mean age of the patients was 73.1 ± 6.2years. The mean Society of Thoracic Surgeons score was 13.8 ± 6.3%. Device success was 100% according to Valve Academic Research Consortium-2 criteria. No other procedure-associated complications occurred, including left ventricular outflow tract obstruction and valve migration. The mean hospital lengths of stay after the procedure were 11.5 ± 8.0days. No deaths occurred at 30days. At a median follow-up period of 28.7 ± 22.3months, no patients died. All patients were in New York Heart Association functional classes I-II. Echocardiographic parameters at follow-up showed a normofunctioning J valve in the mitral position and a mean max mitral flow velocity of 2.0 ± 0.5m/s; the J valve in the aortic position was also normofunctioning, and the mean max aortic flow velocity was 2.3 ± 0.5m/s. Simultaneous transapical transcatheter aortic and mitral valve replacement using the self-expandable J valve appears to be a feasible and effective alternative to redo surgery.

Outcomes of Different Mitral Valve Approaches Combined with Aortic Valve Replacement in Patients with Degenerative Valve Disease

Introduction: The objective of this cohort study was to analyze the long-term relative survival of degenerative valve disease (DVD) patients who underwent mitral valve repair (MVP) or replacement and aortic valve replacement (AVR). Methods: A total of 146 patients underwent double valve replacement (DVR) or MVP+AVR at four institutions between 2016 and 2022. Kaplan–Meier method was applied to analyze survival rate. The potential predictors of mortality were investigated by Cox regression. Results: Of 146 patients, 62 underwent MVP+AVR, and 84 underwent DVR. The thirty-day mortality rate was 4.76% in the DVR cohort and 1.61% in the MVP+AVR cohort. At baseline, there were differences in age (63.39 ± 8.01 vs. 58.46 ± 9.92, p = 0.012), proportions of male patients (51.61% vs. 72.62, p = 0.014), smoking history (45.16% vs. 28.57%, p = 0.039). More biological valves were applied in the MVP+AVR cohort (77.42% vs. 47.62%, p &lt; 0.001). There was no significant difference in mortality between the cohorts (1339.5 [Interquartile range (IQR), 1021.25–1876.75] vs. 1026.00 [IQR, 679.50–1674.00], p = 0.252). The overall mortality rate was 16.67% for DVR and 6.45% for MVP+AVR. Mechanical valve replacement (hazard ratio (HR) = 3.7, 95% confidence interval (CI): 1.0–12.0, p = 0.029) was increased the risk of postoperative mortality. Conclusion: Although the superiority of MVP+AVR was not verified with statistical significance in our cohort, we believe that MVP+AVR should be the preferred strategy for treating most DVD patient because it is associated with higher survival rates during follow-up.

On-X aortic valve replacement patients treated with low-dose warfarin and low-dose aspirin.

To assess if warfarin targeted to international normalized ratio (INR) 1.8 (range 1.5-2.0) is safe for all patients with an On-X aortic mechanical valve. This prospective, observational registry follows patients receiving warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus daily aspirin (75-100 mg) after On-X aortic valve replacement. The primary end point is a composite of thromboembolism, valve thrombosis and major bleeding. Secondary end points include the individual rates of thromboembolism, valve thrombosis and major bleeding, as well as the composite in subgroups of home or clinic-monitored INR and risk categorization for thromboembolism. The control was the patient group randomized to standard-dose warfarin (INR 2.0-3.0) plus daily aspirin 81 mg from the PROACT trial. A total of 510 patients were enroled at 23 centres in the UK, USA and Canada. Currently, the median follow-up duration is 3.4 years, and median achieved INR is 1.9. The primary composite end point rate in the low INR patients is 2.31% vs 5.39% (95% confidence interval 4.12-6.93%) per patient-year in the PROACT control group, constituting a 57% reduction. Results are consistent in subgroups of home or clinic-monitored, and high-risk patients, with reductions of 56%, 57% and 57%, respectively. Major and total bleeding are decreased by 85% and 73%, respectively, with similar rates of thromboembolic events. No valve thrombosis occurred. Interim results suggest that warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus aspirin is safe and effective in patients with an On-X aortic mechanical valve with or without home INR monitoring.

Vascular complications and outcomes following transcatheter aortic valve replacement in patients on chronic steroid therapy: a meta-analysis.

Chronic steroid (CS) therapy was reportedly linked to increased vascular complications following percutaneous coronary intervention. However, its association with vascular complications after transcatheter aortic valve replacement (TAVR) remained uncertain, with conflicting results being reported. The authors aimed to compare the rate of vascular complications and outcomes between patients with and without CS use after TAVR. The authors conducted a comprehensive literature search in PubMed, Embase, and Cochrane databases from their inception until 18th April 2022 for relevant studies. Endpoints were described according to Valve Academic Research Consortium-2 definitions. Effect sizes were pooled using DerSimonian and Laird random-effects model as risk ratio (RR) with 95% CI. Five studies with 6136 patients undergoing TAVR were included in the analysis. The included studies were published between 2015 and 2022. The mean ages of patients in both study groups were similar, with the CS group averaging 80 years and the nonsteroid group averaging 82 years. Notably, a higher proportion of patients in the CS group were female (56%) compared to the nonsteroid group (54%). CS use was associated with a significantly higher risk of major vascular complications (12.5 vs. 6.7%, RR 2.32, 95% CI: 1.73-3.11, P <0.001), major bleeding (16.8 vs. 13.1%, RR 1.61, 95% CI: 1.27-2.05, P <0.001), and aortic annulus rupture (2.3 vs. 0.6%, RR 4.66, 95% CI: 1.67-13.01, P <0.001). There was no significant difference in terms of minor vascular complications (RR 1.43, 95% CI: 1.00-2.04, P =0.05), in-hospital mortality (2.3 vs. 1.4%, RR 1.86, 95% CI: 0.74-4.70, P =0.19), and 30-day mortality (2.9 vs. 3.1%, RR 1.14, 95% CI: 0.53-2.46, P =0.74) between both groups. Our study showed that CS therapy is associated with increased major vascular complications, major bleeding, and annulus rupture following TAVR. Further large multicenter studies or randomized controlled trials are warranted to validate these findings.