2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

A 'dreaded' complication of stuck prosthetic valve in the first trimester pregnancy

A dramatic rise in cardiac output with a decrease in afterload are the hallmark of hemodynamic variations induced by normal pregnancy, which requires significant cardiac adaptation. Females with rheumatic mitral valve disease who have had a mitral valve replacement in the past are increasingly choosing to become pregnant. Hypercoagulability of pregnancy, problems with anticoagulant therapy along with hemodynamic changes in pregnancy increase the risk of cardiac complications in this subset. There is a paucity of research on the management of problems in patients with cardiac prosthetic valves. We present a case of primigravida with a history of mitral valve replacement, presenting with a stuck valve.

Learning objectives

•Pregnancy is a pro-thrombotic state•Pregnancy with a mechanical heart valve has high risk of stuck vale despite adequate anti-coagulation•Management of such high-risk cases must be carried out at a tertiary care center with all facilities•Multi-disciplinary approach is required to deal with pregnant women with mechanical heart valve.

Segmental and global longitudinal strain measurement by 2-dimensional speckle tracking echocardiography in severe rheumatic mitral stenosis

BACKGROUND

The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method.

METHODS

In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device.

RESULTS

Absolute strain values in myocardial segments 1-8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P < 0.05 for all). The absolute global longitudinal strain (GLS) value was higher in the control group (-19.56 vs. -18.25; P = 0.006). After adjustment for age, gender, and systolic blood pressure, the difference in GLS between the two groups was as follows: mean difference=-1.16; 95% CI: -2.58-0.25; P = 0.110.

CONCLUSION

In patients with severe rheumatic MS and preserved EF, the absolute GLS tended to be lower than healthy controls. Furthermore, the segmental strain values of LV were significantly lower in most of the basal and some mid-myocardial segments. Further studies are warranted to investigate the underlying pathophysiology and clinical implications of this subclinical dysfunction in certain segments of patients with severe rheumatic MS.

Effect of Sinotubular Junction Size on TAVR Leaflet Thrombosis: A Fluid-structure Interaction Analysis

Purpose

TAVR has emerged as a standard approach for treating severe aortic stenosis patients. However, it is associated with several clinical complications, including subclinical leaflet thrombosis characterized by Hypoattenuated Leaflet Thickening (HALT). A rigorous analysis of TAVR device thrombogenicity considering anatomical variations is essential for estimating this risk. Clinicians use the Sinotubular Junction (STJ) diameter for TAVR sizing, but there is a paucity of research on its influence on TAVR devices thrombogenicity.

Methods

A Medtronic Evolut® TAVR device was deployed in three patient models with varying STJ diameters (26, 30, and 34mm) to evaluate its impact on post-deployment hemodynamics and thrombogenicity, employing a novel computational framework combining prosthesis deployment and fluid- structure interaction analysis.

Results

The 30 mm STJ patient case exhibited the best hemodynamic performance: 5.94 mmHg mean transvalvular pressure gradient (TPG), 2.64 cm 2 mean geometric orifice area (GOA), and the lowest mean residence time (T R ) - indicating a reduced thrombogenic risk; 26 mm STJ exhibited a 10 % reduction in GOA and a 35% increase in mean TPG compared to the 30 mm STJ; 34 mm STJ depicted hemodynamics comparable to the 30 mm STJ, but with a 6% increase in T R and elevated platelet stress accumulation.

Conclusion

A smaller STJ size impairs adequate expansion of the TAVR stent, which may lead to suboptimal hemodynamic performance. Conversely, a larger STJ size marginally enhances the hemodynamic performance but increases the risk of TAVR leaflet thrombosis. Such analysis can aid pre- procedural planning and minimize the risk of TAVR leaflet thrombosis.

Effect of etelcalcetide versus alfacalcidol on left ventricular function and feature-tracking cardiac magnetic resonance imaging in hemodialysis-a post-hoc analysis of a randomized, controlled trial

BACKGROUND

Calcimimetic therapy with etelcalcetide (ETEL) has been shown to attenuate the advancement of left ventricular (LV) hypertrophy in hemodialysis patients measured by cardiac magnetic resonance (CMR). The aim of the study was to evaluate whether this effect is accompanied by alterations in LV function and myocardial composition.

METHODS

This was a post-hoc analysis of a randomized-controlled trial of ETEL versus Alfacalcidol (ALFA) in 62 hemodialysis patients. LV function was assessed using LV ejection fraction (LVEF) and LV global longitudinal strain (GLS) on feature-tracking (FT) CMR. Myocardial tissue characteristics were analyzed using parametric T1 and T2 mapping.

RESULTS

Of the total study cohort (n = 62), 48 subjects completed both CMR scans with sufficient quality for FT analysis. In the one-year follow-up, LV GLS deteriorated in the ALFA group, whereas the ETEL group remained stable (LV GLS change: + 2.6 ± 4.6 versus + 0.3 ± 3.8; p = 0.045 when adjusting for randomization factors and baseline LV GLS). We did not observe a difference in the change of LVEF between the two groups (p = 0.513). The impact of ETEL treatment on LV GLS over time remained significant after additional adjustment for the change in LV mass during the study period. ETEL treatment did not significantly affect other CMR parameters. There were no changes in myocardial composition between treatment groups (T1 time change: + 15 ± 42 versus + 10 ± 50; p = 0.411; T2 time change: - 0.13 ± 2.45 versus - 0.70 ± 2.43; p = 0.652).

CONCLUSIONS

In patients undergoing hemodialysis, treatment with ETEL was protective against deterioration of LV longitudinal function, as evaluated through FT CMR, when compared to the control therapy of ALFA. This effect was not mediated by the change in LV mass. Trial registration URL: https://clinicaltrials.gov/ct2/show/NCT03182699 . Unique identifier: NCT03182699.

Modulation of inflammatory M1-macrophages phenotype by valvular interstitial cells

BACKGROUND

Aortic valve stenosis involves inflammation, excess deposition of a collagen-rich extracellular matrix, and calcification. Recent studies have shown that M1 or inflammatory macrophages derived from infiltrating monocytes promote calcification of valvular interstitial cells, the most prevalent cell type of the aortic valve. We hypothesized that valvular interstitial cells could modulate inflammatory macrophages phenotype.

METHODS

We first assessed macrophage phenotype in human aortic valve stenosis and control aortic valves from donors. Then, we examined profibrotic and inflammatory-related gene expression in valves and valvular interstitial cells. Finally, we investigated whether valvular interstitial cells can modify the phenotype of inflammatory macrophages.

RESULTS

Circulating monocytes and plasma transforming growth factor beta-1 levels of patients with aortic valve stenosis were significantly higher compared with patients without aortic valve stenosis. Histologic analysis of thickened spongiosa of the aortic valve from patients with aortic valve stenosis showed a high macrophage infiltration but a low matrix metalloproteinase-9 expression compared with control aortic valves. On the other hand, valvular interstitial cell culture of aortic valve stenosis exhibited a profibrotic phenotype with a high expression of transforming growth factor beta-1 and transforming growth factor beta-1/transforming growth factor beta-3 ratio but a decreased expression of the peroxisome proliferator-activated receptor gamma nuclear receptor. Valvular interstitial cell-conditioned media of aortic valve stenosis led to a decrease in enzymatic activity of matrix metalloproteinase-9 and an increase in production of collagen in inflammatory macrophages compared with valvular interstitial cell-conditioned media from control aortic valve donors.

CONCLUSIONS

These findings indicate that profibrotic valvular interstitial cells promote the imbalance of extracellular matrix remodeling by reducing matrix metalloproteinase-9 production on inflammatory macrophages that lead to excessive collagen deposition observed in aortic valve stenosis. Further investigation is needed to clarify the role of transforming growth factor beta-1/proliferator-activated receptor gamma nuclear receptor/matrix metalloproteinase-9 in aortic valve stenosis.

Predictors and timeline of spontaneous conversion to normal sinus rhythm: A single center retrospective cohort study of patients with symptomatic atrial fibrillation

INTRODUCTION

Annual healthcare expenditures associated with atrial fibrillation (AF) in the United States (US) continue to grow as more symptomatic patients present to emergency departments (ED). Predictors of spontaneous conversion to normal sinus rhythm (ScNSR) remain poorly understood, as well as the timeline of ScNSR remains unclear. We sought to 1) to assess the association of key demographics, anthropometric, and clinical factors to ScNSR and 2) to evaluate the timeline of ScNSR, and 3) determine clinical predictors of ScNSR.

METHODS

This single center, retrospective cohort study analyzed patients aged ≥18 years with symptomatic AF as diagnosed and evaluated through the ED of a rural tertiary care center in West Virginia from September 2015 to December 2018.

RESULTS

Our cohort consisted of 375 AF patients (mean age 65 years, 54% male). A total of 177 patients attained ScNSR either in the ED or after hospital admission with a mean conversion time of 14.7 h (±12). Onset of symptoms <24 hrs has strong positive association to ScNSR 3.97 (95% CI: 2.24-7.05; p < 0.0001). Male gender 0.55 (95% CI: 0.35-0.85; p = 0.007) and hypertension 0.48 (95% CI: 0.31-0.76; p = 0.002), showed a strong negative association to ScNSR. Of the patients that converted spontaneously (177), the majority, 136 (76.8%) achieved ScNSR within 24 h of ED triage without use of electrical or chemical cardioversion.

CONCLUSION

Most patients with AF in the ED converted spontaneously to sinus rhythm within the first 24 h which underscores the importance of earlier watchful waiting over interventions to achieve normal sinus rhythm (NSR).

Candida endocarditis: Update on management considerations

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

Valve Surgery in a Low-Volume Center in a Low- and Middle-Income Country: A Retrospective Cross-Sectional Study

Background

Valvular heart disease (VHD) has a significant prevalence and mortality rate with surgical intervention continuing to be a cornerstone of therapy. We aim to report the outcome of patients undergoing heart valve surgery (HVS) in a low-volume center (LVC) in a low- and middle-income country (LMIC).

Methods

A cross-sectional retrospective study was conducted at the Jordan University Hospital (JUH), a tertiary teaching hospital in a developing country, between April 2014 and December 2019. Patients who underwent mitral valve replacement (MVR), aortic valve replacement (AVR), tricuspid valve replacement (TVR), double valve replacement (DVR), CABG + MVR, and CABG + AVR patients were included. Thirty-day and two-year mortalities were taken as the primary and secondary outcomes, respectively.

Results

A total number of 122 patients were included, and the mean age was 54.46 ± 14.89 years. AVR was most common (42.6%). There was no significant association between STS mortality score or Euroscore II with 30-day and 2-year mortality.

Conclusion

LVC will continue to have a role in LMICs, especially during development to HICs. Further global studies are needed to assert the safety of HVS in LVC and LMICs.

Prognostic Value of Patient-Reported Outcomes in Predicting Long-Term Mortality After Transcatheter Aortic Valve Replacement

Background Patient-reported outcome measures have been shown to have important prognostic value after various cardiac interventions. We assessed the association between the change in Kansas City Cardiomyopathy Questionnaire 12 (KCCQ-12) score after transcatheter aortic valve replacement and mortality. Methods and Results We included patients who underwent transcatheter aortic valve replacement at Mayo Clinic between February 2012 to June 2022 and who completed a KCCQ-12 before and 30 to 45 days after the procedure. Patients were categorized into 3 groups: those who experienced significant (>+19 points; group 1), modest (1-19 points; group 2), and no (≤0 points; group 3) improvement. A total of 1124 patients were included: 60.8% men; 97.6% White. Mean age was 79.4±8.3 years, baseline KCCQ-12 score was 53.9±24.5, and median Society of Thoracic Surgeons score was 4.9% (interquartile range, 3.1-8.0). At 45 days, the mean change in KCCQ-12 score was 19±24 points; 46.3% (n=520) of patients had a significant improvement in their KCCQ-12 score, while 33.4% (n=375) and 20.4% (n=229) had modest and no improvement, respectively. Median survival was higher in group 1 (5.7±0.2 years) compared with groups 2 and 3 (5.1±0.3 and 4.1±0.4 years, respectively; P<0.001). Compared with patients in group 1, those in groups 2 and 3 had higher long-term risk-adjusted mortality (adjusted hazard ratios, 1.54 [95% CI, 1.20-1.96], and 2.30 [95% CI, 1.74-3.04], respectively). Conclusions Patients who experience modest or no improvement in KCCQ-12 score after transcatheter aortic valve replacement have substantially higher long-term mortality. Delta KCCQ-12 is a cost-effective, efficient tool that can identify patients at increased risk of death at long-term follow-up post-transcatheter aortic valve replacement.

Navigating the challenges of bicuspid aortic valve-aortopathy

Bicuspid aortic valve (BAV) is a congenital heart defect that affects 0.5-2% of the general population with familial predominance. The modifications in hemodynamics and structure change at cellular level contribute to the dilation of aorta, resulting in bicuspid aortopathy, which can result in catastrophic aortic events. The American Heart Association recommends screening first-degree relatives of patients with bicuspid aortic valve and aortic root disease. BAV may or may not be associated with a syndrome, with the non-syndromic variety having a higher chance of predisposition to congenital and vascular abnormalities. Many genes have been implicated in the etiology of non-syndromic aortic aneurysm such as ACTA2, MYH11, FLNA, and SMAD3. Common diagnostic modalities include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), multi system computer tomography (MSCT), and cardiac MRI. Medical management reduces the rate of disease progression and surgical management is indicated based on the diameter of the ascending aorta, which differs in American and European guidelines. Our article aims to explore the current understanding of the pathophysiology, clinical aspects, and surgical management of bicuspid aortic valve disease. Additionally, we have included a discussion on the management of this condition in special populations, such as athletes and pregnant women, who require distinct treatment recommendations.

Effect of Edoxaban Versus Antiplatelet Therapy on Leaflet Thrombosis and Cerebral Thromboembolism After TAVI According to Major Clinical and Anatomic Factors in Prespecified Subgroup Analysis from the ADAPT-TAVR Trial

It is unknown whether edoxaban versus dual antiplatelet therapy (DAPT) has differential treatment effects on leaflet thrombosis, cerebral thromboembolism, and neurologic or neurocognitive dysfunction according to clinical and anatomic factors after transcatheter aortic valve implantation. To investigate the relative effects of edoxaban and DAPT on leaflet and cerebral thromboembolism in patients with major risk factors. The primary end point of this study was the incidence of leaflet thrombosis on computed tomography at 6 months. The secondary end points were new cerebral lesions on brain magnetic resonance imaging and neurologic and neurocognitive dysfunction between baseline and 6-month follow-up. Cox regression models assessed the consistency of the treatment effects in the prespecified subgroups. The favorable effect of edoxaban versus DAPT on the leaflet thrombosis was consistent across multiple clinical or anatomic subgroups, without significant interaction between the drug effect and each subgroup (p for interaction for age = 0.597, gender = 0.557, body mass index = 0.866, Society of Thoracic Surgeons score = 0.307, valve type = 0.702, edoxaban reduction criteria = 0.604, and valve morphology = 0.688). However, the incidence of new cerebral lesions on brain magnetic resonance imaging and worsening of neurologic and neurocognitive function were not significantly different between the groups among the various key subgroups. The relative effects of edoxaban and DAPT on the risk of leaflet thrombosis, cerebral thromboembolism, and neurologic dysfunction were consistent across a diverse spectrum of clinical or anatomical factors. Further studies are required to define tailored antithrombotic therapy for high-risk groups with specific clinical or anatomic characteristics.

Sam68 promotes osteogenic differentiation of aortic valvular interstitial cells by TNF-α/STAT3/autophagy axis

Calcified aortic valve disease (CAVD) is a major non-rheumatic heart valve disease in the world, with a high mortality rate and without suitable pharmaceutical therapy due to its complex mechanisms. Src-associated in mitosis 68-KD (Sam68), an RNA binding protein, has been reported as a signaling adaptor in numerous signaling pathways (Huot in Mol Cell Biol, 29(7), 1933-1943, 2009), particularly in inflammatory signaling pathways. The effects of Sam68 on the osteogenic differentiation process of hVICs and its regulation on signal transducer and activator of transcription 3 (STAT3) signaling pathway have been investigated in this study. Human aortic valve samples detection found that Sam68 expression was up-regulated in human calcific aortic valves. We used tumor necrosis factor α (TNF-α) as an activator for osteogenic differentiation in vitro and the result indicated that Sam68 was highly expressed after TNF-α stimulation. Overexpression of Sam68 promoted osteogenic differentiation of hVICs while Sam68 knockdown reversed this effect. Sam68 interaction with STAT3 was predicted by using String database and was verified in this study. Sam68 knockdown reduced phosphorylation of STAT3 activated by TNF-α and the downstream gene expression, which further influenced autophagy flux in hVICs. STAT3 knockdown alleviated the osteogenic differentiation and calcium deposition promoted by Sam68 overexpression. In conclusion, Sam68 interacts with STAT3 and participates in its phosphorylation to promote osteogenic differentiation of hVICs to induce valve calcification. Thus, Sam68 may be a new therapeutic target for CAVD. Regulatory of Sam68 in TNF-α/STAT3/Autophagy Axis in promoting osteogenesis of hVICs.

Quadricuspid Aortic Valve: A Case Report of an Asymptomatic Middle-Aged Man

A quadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four leaflets in the aortic valve. We are reporting a case of a 59-year-old male who presented to the emergency department with non-cardiac chest pain. The discovery of QAV during the evaluation highlights the importance of considering cardiac causes, even in cases where the presenting symptoms may not appear directly related to the heart.

Irregular anatomical features can alter hemodynamics in Takayasu arteritis

Objective

Takayasu arteritis (TA) is a difficult disease to deal with because there are neither reliable clinical signs, laboratory biomarkers, nor a single noninvasive imaging technique that can be used for early diagnosis and disease activity monitoring. Knowledge of aortic hemodynamics in TA is lacking. This study aimed to fill this gap by assessing hemodynamics in patients with TA using image-based computational fluid dynamics (CFD) simulations.

Methods

Eleven patients with TA were included in the present study. Patient-specific geometries were reconstructed from either clinical aortic computed tomography angiography or magnetic resonance angiography studies and coupled with physiological boundary conditions for CFD simulations. Key anatomical and hemodynamic parameters were compared with a control group consisting of 18 age- and sex-matched adults without TA who had healthy aortas.

Results

Compared with controls, patients with TA had significantly higher aortic velocities (0.9 m/s [0.7, 1.1 m/s] vs 0.6 m/s [0.5, 0.7 m/s]; P = .002), maximum time-averaged wall shear stress (14.2 Pa [9.8, 20.9 Pa] vs 8.0 Pa [6.2, 10.3 Pa]; P = .004), and maximum pressure drops between the ascending and descending aorta (36.9 mm Hg [29.0, 49.3 mm Hg] vs 28.5 mm Hg [25.8, 31.5 mm Hg]; P = .004). These significant hemodynamic alterations in patients with TA might result from abnormal anatomical features including smaller arch diameter (20.0 mm [13.8, 23.3 mm] vs 25.2 mm [23.3, 26.8 mm]; P = .003), supra-aortic branch diameters (21.9 mm [18.5, 24.6 mm] vs 25.7 mm [24.3, 28.3 mm]; P = .003) and descending aorta diameter (14.7 mm [12.2, 16.8 mm] vs 22.5 mm [19.8, 24.0 mm]; P < .001).

Conclusions

CFD analysis reveals hemodynamic changes in the aorta of patients with TA. The applicability of CFD technique coupled with standard imaging assessments in predicting disease progression of such patients will be explored in future studies. Future large cohort study with outcome correlation is also warranted.

Clinical Relevance

Based on patient-specific computational fluid dynamics simulations, the present retrospective study revealed significant difference in aortic hemodynamics between the patients with and without Takayasu arteritis (TA). To the best of our knowledge, this study is the first to evaluate hemodynamic conditions within TA, demonstrating the potential of computational flow modeling in capturing abnormal hemodynamic forces, such as high wall shear stress, resulted from irregular morphological changes. In the future, assessing the hemodynamic parameters within patients with TA during the prestenotic period, together with longitudinal computational fluid dynamics studies may allow better monitoring and management of TA.

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.

A Case Report of Secondary Postpartum Hemorrhage in a Pregnant Woman With a Mechanical Mitral Valve: Challenges of Anticoagulation

A pregnant woman with rheumatic heart disease always runs the risk of developing both thromboembolic and hemorrhagic symptoms, necessitating careful monitoring of her anticoagulation treatments both throughout pregnancy and after delivery. Postpartum haemorrhage, a hemorrhagic manifestation, can be challenging to control and presents a significant challenge when it comes to beginning anticoagulation after delivery. Thus, pregnancy in these patients is an extremely risky endeavour. Given that these women take anticoagulants, managing these women with artificial heart valves throughout pregnancy can be difficult. The diminished clotting ability in these women may be the cause of postpartum haemorrhage, and a multidisciplinary approach is necessary for a successful treatment. To manage this potentially fatal illness, a well-equipped institution with proper support systems is essential. We present a 23-year-old primigravida who was 39 weeks and three days pregnant and had a repaired aortic valve as well as a prosthetic mitral valve. She was taking warfarin to prevent clotting when she was pregnant.

Electrocardiogram changes as predictors for new imaging findings in repeat transthoracic echocardiography

Aim: To determine if electrocardiogram (EKG) findings may be a useful tool to predict changes in repeat transthoracic echocardiogram (TTE). Methods: We evaluated patients who underwent TTE during hospitalization and their EKGs, and whether findings differed between studies. Results: Of 229 hospitalized patients who underwent repeat TTE, 183 (80%) were abnormal. Each minor and major EKG abnormality resulted in a 1.8 (1.2 to 2.6; p = 0.002) and 2.1 (1.3 to 3.3; p < 0.001) increased odds of abnormal imaging on TTE, respectively. The negative likelihood ratio for an unchanged EKG to predict an unchanged TTE was 0.68 (95% CI = 0.62 to 0.73). Conclusion: Among hospitalized patients with prior imaging results, an unchanged EKG predicts an unchanged TTE.

Echocardiographic Evaluation of Aortic Stenosis: A Comprehensive Review

Echocardiography represents the most important diagnostic tool in the evaluation of aortic stenosis. The echocardiographic assessment of its severity should always be performed through a standardized and stepwise approach in order to achieve a comprehensive evaluation. The latest technical innovations in the field of echocardiography have improved diagnostic accuracy, guaranteeing a better and more detailed evaluation of aortic valve anatomy. An early diagnosis is of utmost importance since it shortens treatment delays and improves patient outcomes. Echocardiography plays a key role also in the evaluation of all the structural changes related to aortic stenosis. Detailed evaluation of subtle and subclinical changes in left ventricle function has a prognostic significance: scientific efforts have been addressed to identify the most accurate global longitudinal strain cut-off value able to predict adverse outcomes. Moreover, in recent years the role of artificial intelligence is increasingly emerging as a promising tool able to assist cardiologists in aortic stenosis screening and diagnosis, especially by reducing the rate of aortic stenosis misdiagnosis.

Aortic Valve Area and Strain Measurements by Cardiac MRI and Transthoracic Echocardiography in Severe Aortic Stenosis with Normal Left Ventricular Function

Background

Transthoracic echocardiography (TTE) is the recommended imaging technique for the evaluation of patients with aortic stenosis (AS). However, in cases with inconclusive findings, cardiac magnetic resonance (CMR) planimetry is used to grade AS severity. This study aimed to compare the results derived from TTE and CMR in patients with severe AS with normal left ventricular (LV) function.

Methods

In a prospective study, 20 patients with severe AS were recruited and data derived from TTE and CMR modalities were compared with the archived records of 28 age- and sex-matched healthy controls. The data included aortic valve area (AVA), MRI-derived biventricular global strains, and TTE-derived global longitudinal strain (GLS). SPSS software was used to analyze the data with independent samples t test, intraclass correlation coefficient (ICC), and Pearson correlation. P<0.05 was considered statistically significant.

Results

An excellent agreement was found in AVA values derived from CMR and TTE with an average ICC of 0.932 (95% CI=0.829-0.973). There was a significant difference in LV-GLS, LV global radial strain (GRS), right ventricular (RV) GRS, and RV global circumferential strain between the groups. A good correlation was found between CMR- and TTE-derived GLS with an average ICC of 0.721 (95% C=0.255-0.896). The mean aortic valve pressure gradient in TTE had a significant inverse linear correlation with LV-GRS in CMR (r=-0.537). All P values were <0.05.

Conclusion

There was a good agreement between AVA and strain values derived from cardiac MRI and TTE. The myocardial strain was impaired in patients with severe AS and normal LV function and correlated with disease severity.

Balloon Aortic Valvuloplasty in the Transcatheter Aortic Valve Implantation Era

As the population continues to grow, and life expectancy has increased, aortic stenosis (AS) has become the most common valvular disease requiring surgical treatment. The evolution of valve replacement therapies has progressed significantly since 1960. In the last 20 years, transcatheter aortic valve implantation (TAVI) has been a game changer, and has potential to become the standard of care. Despite uncertain prognosis benefits, balloon aortic valvuloplasty (BAV) can be useful in a broad range of patients with AS, as well as being a bridging therapy to valve replacement, or as a destination therapy, besides its role in TAVI procedures. This review describes the contemporary role of BAV in AS treatment, and focuses on technical improvements that reframe BAV as an effective tool in a variety of clinical scenarios. One of these improvements is transradial BAV, either with the conventional approach of BAV or applying the bilateral technique with two balloons.

Anticoagulation decision-making before non-cardiac surgery in patients with mechanical heart valve: A retrospective study

Objective

To clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV.

Design

This is a single-center retrospective observational study.

Setting

and participants This study used data from the Hospital Information System, and the Surgery and Anesthesia Information System of the Second Affiliated Hospital of Army Military Medical University. Participants included 121 adult patients with MHV who underwent non-cardiac surgery from 2012 to 2021.

Results

Overall, 121 patients with MHV (15 aortic valve only, 56 mitral valve only, and 50 with multiple valves) underwent non-cardiac surgery. When the duration of warfarin discontinuation was ≤ 3 days, 3-5 days, and≥5 days, the INR was 1.45, 1.15, and 1.09, respectively. Bleeding between INR ≤1.2 and INR >1.2 groups was not statistically significant using Student's t-test (95% CI -0.57, 0.14 P = 0.24). Multivariate regression analysis revealed that Intraoperative bleeding volume correlated with preoperative albumin levels (OR = 0.68，95% CI 0.49, 0.89).

Conclusions

When need preoperative INR is less than 1.5 in patients with MHV undergoing non-cardiac surgery, preoperative warfarin discontinuation for 3 days is sufficient. If INR less than 1.2, preoperative warfarin discontinuation for 3-5 days is appropriate. And in patients with MHV underwent abdominal surgery, intraoperative bleeding is not significant reduced by lower INR after preoperative warfarin discontinuation. Furthermore, the effect of albumin levels on coagulation function cannot be ignored in patients with MHV.

Strengths and limitations

This study was derived from real-world clinical data. It's a retrospectively study to describe the INR changed according to the duration of warfarin discontinuation in patients with MHV and compared intraoperation of bleeding volume between INR>1.2 and INR ≤ 1.2after warfarin discontinuation. To clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV, while providing clinicians with a reference for preoperative warfarin adjustment. This study does have a few limitations. The number of cases is small because patients undergoing repeat noncardiac surgery after heart valve surgery are a special case population. And the patients were not followed up after non-cardiac surgery. The impact of changes in INR on postoperative complications could not be assessed in patients with MHV.

Mitral and Tricuspid Valve Disease in Athletes

Observing mitral or tricuspid valve disease in an athlete raises many considerations for the clinician. Initially, the etiology must be clarified, with causes differing depending on whether the athlete is young or a master. Notably, vigorous training in competitive athletes leads to a constellation of structural and functional adaptations involving cardiac chambers and atrioventricular valve systems. In addition, a proper evaluation of the athlete with valve disease is necessary to evaluate the eligibility for competitive sports and identify those requiring more follow-up. Indeed, some valve pathologies are associated with an increased risk of severe arrhythmias and potentially sudden cardiac death. Traditional and advanced imaging modalities help clarify clinical doubts, allowing essential information about the athlete's physiology and differentiating between primary valve diseases from those secondary to training-related cardiac adaptations. Remarkably, another application of multimodality imaging is evaluating athletes with valve diseases during exercise to reproduce the sport setting and better characterize the etiology and valve defect mechanism. This review aims to analyze the possible causes of atrioventricular valve diseases in athletes, focusing primarily on imaging applications in diagnosis and risk stratification.

The Positive Impact of Early Frailty Levels on Mortality in Elderly Patients with Severe Aortic Stenosis Undergoing Transcatheter/Surgical Aortic Valve Replacement

Background: Frailty is highly common in older patients (pts) undergoing transcatheter aortic valve replacement (TAVR), and it is associated with poor outcomes. The selection of patients who can benefit from this procedure is necessary and challenging. The aim of the present study is to evaluate outcomes in older severe aortic valve stenosis (AS) pts, selected by a multidisciplinary approach for surgical, clinical, and geriatric risk and referred to treatment, according to frailty levels. Methods: A total of 109 pts (83 ± 5 years; females, 68%) with AS were classified by Fried's score in pre-frail, early frail, and frail and underwent surgical aortic valve replacement SAVR/TAVR, balloon aortic valvuloplasty, or medical therapy. We evaluated geriatric, clinical, and surgical features and detected periprocedural complications. The outcome was all-cause mortality. Results: Increasing frailty was associated with the worst clinical, surgical, geriatric conditions. By using Kaplan-Meier analysis, the survival rate was higher in pre-frail and TAVR groups (p < 0.001) (median follow-up = 20 months). By using the Cox regression model, frailty (p = 0.004), heart failure (p = 0.007), EF% (p = 0.043), albumin (p = 0.018) were associated with all-cause mortality. Conclusions: According to tailored frailty management, elderly AS pts with early frailty levels seem to be the most suitable candidates for TAVR/SAVR for positive outcomes because advanced frailty would make each treatment futile or palliative.

An Unusual Case of Severe Aortic Stenosis and Triple-Vessel Coronary Artery Disease in a Patient Presenting With Intermittent Chest Pain

Although relatively uncommon, premature coronary artery disease (CAD) is a significant cause of mortality and morbidity. A key risk factor for this condition is the presence of familial hyperlipidemia (FH), which is a genetic disorder of impaired cholesterol metabolism. While aortic stenosis is relatively common in the older population, it is rare in young adults, and its presence should raise concern for a bicuspid valve. We present the case of a 37-year-old male patient with intermittent chest pain and physical examination findings of multiple-site xanthomas and echocardiography/angiography findings of severe aortic stenosis and severe three-vessel CAD, respectively. FH was noted as the most critical risk factor in this patient. He was subsequently managed with surgical aortic valve replacement (SAVR) and simultaneous coronary bypass graft surgery with interval symptom improvement. Cholesterol-lowering agents - high-intensity statins/ezetimibe - were started to control cholesterol levels. Guideline-directed medical therapy for CAD/aortic valve replacement (AVR) with beta-blockers, angiotensin-converting enzyme inhibitors, antiplatelet therapy, and warfarin therapy was also employed. This report highlights a case of acute coronary syndrome (ACS) in a young adult and how early detection and treatment of risk factors can lead to a good prognosis.

Pneumonia, Arthritis, and Liver Injury: A Cardiac Diagnostic Conundrum

A 40-year-old intravenous cocaine user presented with non-specific symptoms, including fever, headache, myalgias, and fatigue. After being provisionally diagnosed with rhinosinusitis and discharged on antibiotics, the patient returned with shortness of breath, dry cough, and persistent high-grade fevers. Initial workup showed multifocal pneumonia, acute liver injury, and septic arthritis. Blood cultures were positive for methicillin-sensitive staphylococcus aureus (MSSA) which led to the evaluation of endocarditis with a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). TEE was performed as the initial diagnostic imaging test, and it did not show any evidence of valvular vegetation. However, given the persistence of the patient's symptoms and clinical suspicion of infective endocarditis, TTE was performed which showed a 3.2 cm vegetation on the pulmonic valve with severe insufficiency, leading to a diagnosis of pulmonic valve endocarditis. The patient was treated with antibiotics and underwent a pulmonic valve replacement surgery, which showed a large vegetation on the ventricle portion of the pulmonic valve that was replaced with an interspersed tissue valve. The patient was discharged in stable condition after improvement of symptoms and normalization of liver function enzymes. It is important to note that TTE should be considered initially as a diagnostic tool in such cases. Sometimes, a TEE may not be required if the TTE provides a sufficient assessment.

Advantages of Multiposition Scanning in Echocardiographic Assessment of the Severity of Discordant Aortic Stenosis

AIM OF THE STUDY

The aim of this study was to perform a comparative analysis of severity of discordant aortic stenosis (AS) assessment using multiposition scanning and the standard apical window.

MATERIALS AND METHODS

All patients (n = 104) underwent preoperative transthoracic echocardiography (TTE) and were ranked according to the degree of AS severity. The reproducibility feasibility of the right parasternal window (RPW) was 75.0% (n = 78). The mean age of the patients was 64 years, and 40 (51.3%) were female. In 25 cases, low gradients were identified from the apical window not corresponding to the visual structural changes in the aortic valve, or disagreement between the velocity and calculated parameters was detected. Patients were divided into two groups: concordant AS (n = 56; 71.8%) and discordant AS (n = 22; 28.2%). Three individuals were excluded from the discordant AS group due to the presence of moderate stenosis.

RESULTS

Based on the comparative analysis of transvalvular flow velocities obtained from multiposition scanning, the concordance group showed agreement between the velocity and calculated parameters. We observed an increase in the mean transvalvular pressure gradient (ΔP_mean) and peak aortic jet velocity (V_max), ΔP_mean in 95.5% of patients, velocity time integral of transvalvular flow (VTI AV) in 90.9% of patients, and a decrease in aortic valve area (AVA) and indexed AVA in 90.9% of patients after applying RPW in all patients with discordant AS. The use of RPW allowed the reclassification of AS severity from discordant to concordant high-gradient AS in 88% of low-gradient AS cases.

CONCLUSION

Underestimation of flow velocity and overestimation of AVA using the apical window may lead to misclassification of AS. The use of RPW helps to match the degree of AS severity with the velocity characteristics and reduce the number of low-gradient AS cases.

Impact of Long-Term Steroid Use on the Disposition of Patients Undergoing Transcatheter Aortic Valve Replacement: A Retrospective Nationwide Sample Analysis

Background Chronic steroid use is debilitating to health, but, in some cases, it is necessary. We examined the effect of chronic steroid use on the discharge disposition of people undergoing transcatheter aortic valve replacement (TAVR). Methods We queried the National Inpatient Sample Database (NIS) from 2016 to 2019. We identified patients with current chronic steroid use with the International Classification of Diseases for the Tenth (ICD-10) code Z7952. Furthermore, we used the ICD-10 procedure codes for TAVR 02RF3. Outcomes were the length of hospitalization (LOS), Charlson Comorbidity Index (CCI), disposition, in-hospital mortality, and total hospital charges (THC).  Results Between 2016 and 2019, we identified 44,200 TAVR hospitalizations, and 382,497 were on current long-term steroid therapy. Of these, 934 had current chronic steroid use and underwent TAVR (STEROID) with a mean age of 78 (SD=8.4). About 50% were female, 89% were Whites, 3.7% were Blacks, 4.2% were Hispanics, and 1.3% were Asians. Disposition was 'home,' 'home with home health' (HWHH), 'skilled nursing home' (SNF), 'short-term inpatient therapy' (SIT), 'discharged against medical advice' (AMA), and 'died.'  A total of 602 (65.5%) were discharged home, 206 ( 22%) were discharged to HWHH, 109 (11.7%) to SNF, and 12 (1.28%) died. In the SIT and AMA groups, there were only three and two patients, respectively, p=0.23. The group that underwent TAVR and was not on chronic steroid therapy (NOSTEROID) had a mean age of 79 (SD=8.5), with 28731 (66.4%) being discharged home, 8399 (19.4%) to HWHH, 5319 (12.3%) to SNF, and 617 (1.43%) died p=0.17.  Comparing the STEROID vs. NONSTEROID group, according to the CCI, the STEROID group scored higher than the NOSTEROID group; 3.5 (SD=2) vs. 3 (SD=2) p=0.0001, while for LOS, it was 3.7 days (SD=4.3) vs. 4.1 days (SD=5.3), p=0.28, and the THC was $203,213 (SD=$110,476) vs. $215,858 (SD=$138,540), p=0.15. Conclusion The comorbidity burden of individuals on long-term steroids undergoing TAVR was slightly higher than those not on steroids undergoing TAVR. Despite this, there was no statistically significant difference in their hospital outcomes following TAVR with respect to dispositions.

The Ross Operation in Young Patients: A 15-Year Experience Focused on Right Ventricle to Pulmonary Artery Conduit Outcomes

Background

Data on long-term outcomes of the Ross operation in children and young adult patients are limited. The best pulmonary valve substitute for the right ventricular outflow tract reconstruction remains uncertain. This study aimed to assess the outcomes of right ventricular outflow tract reconstruction in the Ross operation in young patients using various pulmonary valve substitutes at a single institution. In addition, a comparison of reintervention rates between patients younger than 18 years and those older than 18 years was performed.

Methods

The study assessed all patients (N = 110) who underwent the Ross operation at the University Hospital of Bordeaux, France, between 2004 and 2020.

Results

The median follow-up time was 4.2 years, and the median age at operation was 15.9 years. There was no operative mortality and 1 late noncardiac death (0.8%). The overall survival rate at 10 years was 99.2%. The need for right ventricular outflow tract reoperation was lower with the pulmonary homograft compared with the Contegra conduit and Freestyle bioprosthesis: 94.3%, 93.8%, and 80% at 5 years, respectively, and 94.3%, 72.3%, and 34.3% at 10 years, respectively (P = 0.011). The probability of reintervention was not significantly different at 10 years among children vs adults (P = 0.22).

Conclusions

The Ross procedure in children and young adults was associated with a lower requirement for right ventricular outflow tract reoperation when pulmonary homografts were used instead of xenografts.

Abnormal Mechanics Relate to Myocardial Fibrosis and Ventricular Arrhythmias in Patients With Mitral Valve Prolapse

BACKGROUND

The relation between ventricular arrhythmia and fibrosis in mitral valve prolapse (MVP) is reported, but underlying valve-induced mechanisms remain unknown. We evaluated the association between abnormal MVP-related mechanics and myocardial fibrosis, and their association with arrhythmia.

METHODS

We studied 113 patients with MVP with both echocardiogram and gadolinium cardiac magnetic resonance imaging for myocardial fibrosis. Two-dimensional and speckle-tracking echocardiography evaluated mitral regurgitation, superior leaflet and papillary muscle displacement with associated exaggerated basal myocardial systolic curling, and myocardial longitudinal strain. Follow-up assessed arrhythmic events (nonsustained or sustained ventricular tachycardia or ventricular fibrillation).

RESULTS

Myocardial fibrosis was observed in 43 patients with MVP, predominantly in the basal-midventricular inferior-lateral wall and papillary muscles. Patients with MVP with fibrosis had greater mitral regurgitation, prolapse, and superior papillary muscle displacement with basal curling and more impaired inferior-posterior basal strain than those without fibrosis (P<0.001). An abnormal strain pattern with distinct peaks pre-end-systole and post-end-systole in inferior-lateral wall was frequent in patients with fibrosis (81 versus 26%, P<0.001) but absent in patients without MVP with basal inferior-lateral wall fibrosis (n=20). During median follow-up of 1008 days, 36 of 87 patients with MVP with >6-month follow-up developed ventricular arrhythmias associated (univariable) with fibrosis, greater prolapse, mitral annular disjunction, and double-peak strain. In multivariable analysis, double-peak strain showed incremental risk of arrhythmia over fibrosis.

CONCLUSIONS

Basal inferior-posterior myocardial fibrosis in MVP is associated with abnormal MVP-related myocardial mechanics, which are potentially associated with ventricular arrhythmia. These associations suggest pathophysiological links between MVP-related mechanical abnormalities and myocardial fibrosis, which also may relate to ventricular arrhythmia and offer potential imaging markers of increased arrhythmic risk.

Apixaban for Anticoagulation After Robotic Mitral Valve Repair

BACKGROUND

There is no consensus regarding postoperative anticoagulation after mitral valve repair (MVRep). We compared the outcomes of post-MVRep anticoagulation with apixaban compared to warfarin.

METHODS

We reviewed data of 666 patients who underwent isolated robotic MVRep between January 2008 and October 2019. We excluded patients who had conversion to sternotomy and those discharged without anticoagulation or on clopidogrel (n = 40). Baseline and intraoperative characteristics and antiplatelet/anticoagulation records were collected. In-hospital and post-discharge complications and overall survival were compared.

RESULTS

Among the 626 studied patients the median age was 58 years (interquartile range, 51-66), 71% were male, and 1% (n = 9) had atrial fibrillation. Eighty percent (n = 499) were discharged on warfarin and 20% on apixaban (n = 127). Almost all patients (126 of 127, 99%) in the apixaban group were also on aspirin at discharge, whereas in the warfarin group only 79% (n = 395) were also on aspirin at discharge. Baseline characteristics were similar, except that the apixaban group had more female patients (46 of 127, 36% vs 136 of 499, 27%, P = .047). There were no differences in in-hospital complications, including stroke. Readmission rate was higher in the apixaban group (15 of 127, 12% vs 30 of 499, 6%, P = .02), driven mostly by postoperative atrial fibrillation (6 of 127 [5%] vs 5 of 499 [1%], respectively; P = .01). There was no difference in other complications (including bleeding and thromboembolic events), or overall mortality within 3 years. Exclusion of patients who did not receive aspirin at discharge did not affect the results.

CONCLUSIONS

Anticoagulation with apixaban after minimally invasive robotic MVRep is safe and has similar rates of bleeding and thromboembolism compared to patients treated with warfarin.

Nonbacterial Thrombotic Endocarditis of the Mitral Valve With Echocardiographic Appearances Mimicking a Papillary Fibroelastoma in a Middle-Aged Female Patient

Papillary fibroelastoma (PFE) and nonbacterial thrombotic endocarditis (NBTE) account for <1% of all cardioembolic strokes. When there is no evidence of infection, and an exophytic valve lesion is seen on echocardiography, PFE may be an initial imaging diagnosis. NBTE, or Libman-Sacks endocarditis, is a rare entity and can present with varied imaging findings. This report presents a case of embolic stroke and NBTE mimicking a PFE. We discuss a 49-year-old female with a past medical history of diabetes mellitus who presented with headache and right-hand numbness. The initial CT head was negative and the MRI brain showed multiple infarcts in the watershed areas where anterior and posterior brain circulation meet and overlap. A transesophageal echocardiogram (TEE) showed a left ventricle (LV) mass initially diagnosed as PFE. The patient was started on aspirin only with no anticoagulation since we thought the stroke was related to an embolus from a tumor, not a thrombus. The patient underwent surgery but the pathology report revealed a diagnosis of organizing thrombus with abundant neutrophilic infiltration and no neoplastic proliferation. This case report highlights the importance of a comprehensive evaluation of valvular masses and the diagnostic approaches currently available to help clinicians differentiate between various causes of embolic stroke like PFE, bacterial endocarditis, and NBTE. Early differentiation is critical because it can affect the treatment and outcome. This report shows that echocardiography of endocardial and valvular lesions may provide a differential diagnosis, but a definitive diagnosis requires microbiology and histopathology. Advanced imaging techniques such as cardiac CT or cardiac MRI may assist in identifying select cases that are at lower risk for subsequent embolic events, in which surgical intervention may safely be avoided.

Impact of Residual Functional Mitral Regurgitation After Atrial Fibrillation Ablation on Clinical Outcomes in Patients With Left Ventricular Systolic Dysfunction

Functional mitral regurgitation (FMR) negatively impacts the prognosis in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although structural reverse remodeling after AF ablation can reduce FMR severity, the prognostic impact of FMR and its evolution remain unclear. Of 491 patients with baseline LVEF <50% who underwent first-time AF ablation, 134 patients (27%) had grade 2 to 4 FMR at baseline. Among them, 88 patients (66%) exhibited FMR improvement to grade 0 to 1 FMR 6 months after AF ablation. Conversely, among 357 with baseline grade 0 to 1 FMR, 13 patients (3.6%) exhibited FMR worsening to grade 2 to 4 FMR despite AF ablation. Assessment with multidetector computed tomography revealed that an increase in the left atrial emptying fraction (odds ratio 3.55 per 10% increase; 95% confidence interval 2.12 to 5.95) and a reduction in the LV end-diastolic volume index (1.35 per 10-ml/m² decrease; 1.04 to 1.76) were identified as contributors to the FMR improvement. During a follow-up of 43 months, patients with postprocedural grade 2 to 4 FMR more frequently experienced hospitalizations for heart failure or cardiovascular death than those with grade 0 to 1 FMR (30.5% vs 4.6%, log-rank p <0.001). An age-adjusted multivariate Cox regression analysis including baseline and postprocedural FMR revealed that postprocedural grade 2 to 4 FMR (hazard ratio, 3.24; 95% confidence interval 1.43 to 7.35) was significantly associated with unfavorable events. In conclusion, AF ablation modified and often improved FMR severity in patients with reduced LVEF. Residual grade 2 to 4 FMR 6 months after AF ablation was associated with a poor prognosis.

The Global Burden of Valvular Heart Disease: From Clinical Epidemiology to Management

Valvular heart disease is a leading cause of cardiovascular morbidity and mortality and a major contributor of symptoms and functional disability. Knowledge of valvular heart disease epidemiology and a deep comprehension of the geographical and temporal trends are crucial for clinical advances and the formulation of effective health policy for primary and secondary prevention. This review mainly focuses on the epidemiology of primary (organic, related to the valve itself) valvular disease and its management, especially emphasizing the importance of heart valve centers in ensuring the best care of patients through a multidisciplinary team.

Management of pregnancy in left ventricular assist device and heart transplant recipients: a concise review

PURPOSE OF REVIEW

Women of reproductive age are increasingly undergoing heart transplantation (HT) or left ventricular assist device (LVAD) implantation for advanced heart failure. This review is intended to give an overview of the current state of the art management of pregnancy in patients with LVAD or HT recipients.

RECENT FINDINGS

Heart transplant recipients are at increased risk for graft rejection, renal dysfunction, preeclampsia and worsening of comorbidities (hypertension and diabetes). Patients with LVAD are at higher risk of thromboembolic events, infections, right ventricular failure and require close surveillance during pregnancy. Preconception counseling must be offered to all women of reproductive age group with HT or LVAD to avoid unplanned pregnancies.

SUMMARY

A multidisciplinary approach with close antepartum and postpartum surveillance is recommended.

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease

BACKGROUND

Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement.

METHODS

Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan's National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed.

RESULTS

We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P = .920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P = .040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P <.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65 years of age.

CONCLUSIONS

In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65 years.

Prognostic value of echocardiographic evaluation of cardiac mechanics in patients with aortic stenosis and preserved left ventricular ejection fraction

Left ventricular ejection function (LVEF) is not reliable in identifying subtle systolic dysfunction. Speckle Tracking (ST) plays a promising role and hemodynamic forces (HDFs) are emerging as marker of LV function. The role of LV myocardial deformation and HDFs was investigated in a cohort of patients with aortic stenosis (AS) and normal LVEF. Two hundred fifty three patients (median age 79 years, IQR 73 - 83 years) with mild (n = 87), moderate (n =77) and severe AS (n =89) were retrospectively enrolled. 2D echocardiographic global longitudinal strain (GLS), circumferential strain (GCS) and HDFs were determined. The worsening of AS was associated with raising inappropriate LV mass (p < 0.001) and declined LVEF, despite being in the normal range (p < 0.001). ST and HDFs parameters declined as the AS became severe (p<0.0001, for all). When patients were grouped based on the median of LV endocardial GLS value (> -19,9%) and LV systolic longitudinal force (LVsysLF) value (< 12,49), patients with impaired ST and lower HDFs components had increased incidence of aortic valve replacement (AVR) and worse survival (p <0.024 and p <0.037, respectively). Among ST and HDFs parameters, only LVsysLF was independently associated with AVR and all causes mortality on multivariable Cox regression analysis (HR 0.94; 95% CI 0.89-0.99; p= 0.012). Reduced values of LVsysLF were associated with AVR and reduced survival in AS patients. LVsysLF could provide useful information in the stratification of patients with AS and possibly in the choice of timing for AVR.

TAVR in 2023: Who Should Not Get It?

Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.

Temporal changes of patient characteristics over 12 years in a single-center transcatheter aortic valve implantation cohort

BACKGROUND

Beneficial results of transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR) in patients at all risk strata have led to substantial changes in guideline recommendations for valvular heart disease.

AIM

To examine influence of these guideline changes on a real-world TAVI cohort, we evaluated how risk profiles and outcomes of TAVI patients developed in our single-center patient cohort over a period of 12 years.

METHODS

Baseline, procedural and 30-day outcome parameters of TAVI patients were retrospectively compared between three time periods (period 1: 2008-2012, period 2: 2013-2017, period 3: 2018-2020).

RESULTS

Between 03/2008 and 12/2020, a total of 3678 patients underwent TAVI at our center. The median age was 81.1 years (25th, 75th percentile: 76.7, 84.9) with no significant change over time. The EuroSCORE II showed a continuous and significant decline from 5.3% (3.3, 8.6) in period 1 to 2.8% (1.7, 5.0) in period 3 (p < 0.001). Furthermore, rates of permanent pacemaker implantation, acute kidney injury, and paravalvular leakage ≥ moderate continuously declined over time. Accordingly, the 30-day mortality fell from 9.3% in period 1 to 4.3% in period 3 (p < 0.001).

CONCLUSION

Despite substantial guideline alterations, median patient age remained largely unchanged in our TAVI cohort over the past 12 years. Therefore, increased age still appears to be the main reason to choose TAVI over SAVR. However, risk profiles declined substantially. Significant improvements in early outcomes suggest favorable influence of less invasive access routes, improved device platforms and growing user experience.

Body Mass Index and Mortality from Nonrheumatic Aortic Valve Disease among Japanese Men and Women

AIM

We aimed to examine the impact of overweight and obesity on mortality from nonrheumatic aortic valve disease.

METHODS

In the Japan Collaborative Cohort Study, we analyzed data of 98,378 participants aged 40-79 years, with no history of coronary heart disease, stroke, or cancer at baseline (1988-1990) and who completed a lifestyle questionnaire including height and body weight; they were followed for mortality until the end of 2009. The Cox proportional hazards model was used to calculate the multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) of nonrheumatic aortic valve disease mortality according to body mass index (BMI) after adjusting for potential confounding factors.

RESULTS

During the median 19.2 years follow-up, 60 deaths from nonrheumatic aortic valve disease were reported. BMI was positively associated with the risk of mortality from nonrheumatic aortic valve disease; the multivariable HRs (95% CIs) were 0.90 (0.40-2.06) for persons with BMI ＜21 kg/m², 1.71 (0.81-3.58) for BMI 23-24.9 kg/m², 1.65 (0.69-3.94) for BMI 25-26.9 kg/m², and 2.83 (1.20-6.65) for BMI ≥ 27 kg/m² (p for trend=0.006), compared with persons with BMI 21-22.9 kg/m². Similar associations were observed between men and women (p for interaction=0.56). Excluding those who died during the first ten years of follow-up or a competing risk analysis with other causes of death as competing risk events did not change the association materially.

CONCLUSIONS

Overweight and obesity may be independent risk factors for nonrheumatic aortic valve disease mortality in Asian populations.

Differences in aortic valve area measured on cardiac CT and echocardiography in patients with aortic stenosis

BACKGROUND

A certain proportion of patients with severe aortic stenosis (AS) present with discordant grading between different diagnostic modalities, which raises uncertainty about the true severity of AS. The aim of this study was to compare the aortic valve area (AVA) measured on CT and echocardiography and demonstrate the factors affecting AVA discrepancies.

METHODS

Between June 2011 and March 2016, 535 consecutive patients (66.83±8.80 years, 297 men) with AS who underwent pre-operative cardiac CT and echocardiography for aortic valve replacement were retrospectively included. AVA was obtained by AVA on echocardiography (AVAecho) and CT (AVACT) using a measurement of the left ventricular outflow tract on each modality and correlations between those measures were evaluated. Logistic regression analysis was performed to identify factors affecting the discordance for grading severe AS.

RESULTS

The AVACT and AVAecho showed a high correlation (r: 0.79, P <0.001) but AVACT was larger than the AVAecho (difference 0.26 cm2, P <0.001). By using the cut-off values of AVACT (<1.2 cm2) and AVAecho (<1.0 cm2) for diagnosing severe AS, the BSA (odds ratio [OR]: 68.03, 95% confidence interval [CI]: 5.45-849.99; P = 0.001), AVAecho (OR: 1.19, 95%CI: 1.14-1.24; P <0.001), tricuspid valve morphology (OR: 2.83, 95%CI: 1.23-6.50; P = 0.01), and normalized annulus area (OR: 1.02; 95%CI:1.02-1.03; P <0.001) were significant factors associated with the discordance between the AVAecho and AVACT.

CONCLUSION

Patients with larger BSA, AVAecho, and annulus, and tricuspid valve morphology were associated with the AVA discordance between the echocardiography and CT. Complementary use of CT with echocardiography for grading severe AS could be helpful in such conditions.

Clinical outcomes following surgical mitral valve plasty or replacement in patients with infectious endocarditis: A meta-analysis

Background

For degenerative mitral disease, more and more evidences support that mitral valve plasty (MVP) has much better clincial outcomes than mitral valve replacement (MVR). However, the advantages of MVP in patients suffering from infectious endocarditis (IE) are unclear. To evaluate the appropriateness of MVP in IE patients, we conducted this meta-analysis. Based on the difference between active and healed phase, we not only compared the result of patients with IE, but also identified the subgroup with active IE.

Methods

We systematically searched the clinical trials comparing clinical outcomes of MVP and MVR in patients suffering from IE. Relevant articles were searched from January 1, 2000 to March 18, 2021 in Pubmed and Cochrane Library. Studies were excluded if they were with Newcastle-Ottawa Scale (NOS) score less than 6 or lacking of direct comparisons between MVP and MVR.

Results

23 studies were involved and 25,615 patients were included. Pooled analysis showed fewer adverse events and early or long-term death in the MVP group. However, more reoperations existed in this patient group. And the reinfection rate was close between two groups. Similar results were observed after identifying active IE subgroup, but there is no difference in the freedom from reoperation due to all-events.

Conclusions

Although limitimations exited in this study, patients suffering from IE can benefit from both MVP and MVR. For surgeons with consummate skills, MVP can be the preferred choice for suitable IE patients.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Prognostic role of aortic distensibility in patients with bicuspid aortic valve: a CMR study

To evaluate the prognostic value of aortic distensibility measured by cardiovascular magnetic resonance (CMR) as predictors of prophylactic aortic valve or aortic surgery in patients with bicuspid aortic valve (BAV). 110 patients with BAV were included. Distensibility of middle ascending aorta (AscAo) and proximal descending aorta (DescAo) at baseline was determined using CMR. The association between aortic distensibility and primary endpoint of aortic valve and/or aortic surgery was investigated with Cox proportional hazard regression analyses. The receiver operating characteristics curves (ROC) of the area under receiver-operator (AUC) and DeLong test were used to evaluate and compare the performance of different models. During a median follow-up of 66.5 months [IQR 13-75 months], 42 patients experienced surgical treatments. After adjusting for traditional risk factors, aortic distensibility (P = 0.003) and severe valve dysfunction (P < 0.001) were found significantly associated with aortic valve and/or aortic surgery. The model 2 (aortic distensibility and severe valve dysfunction) is slightly better in predicting primary endpoint than the model 1 (aortic diameter and severe valve dysfunction) (AUC: 0.893 vs. 0.842, P = 0.106). In BAV patients, aortic distensibility and severe valve dysfunction are valuable predictors for final aortic valve and/or aortic surgery.

Long-term survival after surgical or transcatheter aortic valve replacement for low or intermediate surgical risk aortic stenosis: Comparison with general population

BACKGROUND

Long-term survival after surgery for severe aortic stenosis (AS) provides important information regarding the choice between surgical (SAVR) and transcatheter (TAVR) aortic valve replacement. This study investigated the long-term survival of AS patients with low or intermediate surgical risk who underwent SAVR or TAVR in our institution versus that of the Japanese general population.

METHODS

From 2009 to 2019, 1276 consecutive patients underwent SAVR or TAVR for severe AS. Among them, we retrospectively investigated those with low (n = 383) or intermediate (n = 137) surgical risk treated with SAVR and those with low (n = 86) or intermediate (n = 333) surgical risk treated with TAVR. Their post-intervention survival was compared with that of an age- and gender-matched Japanese general population.

RESULTS

The overall 5-year survival rate of SAVR for patients with low surgical risk (mean age, 72 ± 9 years) was not significantly different from that of the general population (90 % vs. 89 %, respectively; p = 0.58), whereas that of patients with intermediate surgical risk (77 ± 6 years) was significantly lower than that of the general population (77 % vs. 84 %, respectively; p = 0.03). After TAVR, the 5-year survival of patients with low (78 ± 8 years) or intermediate (83 ± 5 years) surgical risk was significantly lower than that of the general population (low risk, 64 % vs. 81 %, p < 0.01; intermediate risk, 66 % vs. 71 %, respectively, p = 0.01).

CONCLUSIONS

Our study demonstrated that long-term survival after SAVR for AS patients with low surgical risk was as good as that of the age- and gender-matched general population, while the long-term survival after SAVR for intermediate-risk or TAVR for low- or intermediate-risk patients was lower than that of the general population. These findings suggest that SAVR is an appropriate option for AS patients with low surgical risk and good life expectancy, especially in Japan, where the life expectancy is the longest worldwide.

Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons

OBJECTIVE

The survey aimed to assess the practice patterns of Canadian cardiac surgeons on the size threshold at which patients with ascending aortic aneurysm would be offered surgery.

METHODS

A 18-question electronic survey was electronically distributed to 148 practicing cardiac surgeons in Canada via email from January to August 2020. Questions presented clinical scenarios focusing on modifying a single variable, and respondents were asked to identify their surgical size threshold for each of the clinical scenarios.

RESULTS

The individual response rate was 62.0% (91/148) and institutional response rate was 89.3% (25/29). For an incidental asymptomatic ascending aortic aneurysm in a 60-year-old otherwise-healthy male patient with a tricuspid aortic valve and bicuspid aortic valve of 1.9 m², 20.2% of the respondents would recommend surgery when the aneurysm was <5.5 cm. A significant number of surgeons modified their surgical threshold in response to changes to BSA, bicuspid aortic valve, growth rate, age, occupation, symptom, and family history (P < .01). Notably, if the patient had a bicuspid aortic valve, 41.0% of respondents lowered their threshold for surgery, with only 43.0% recommending surgery at ≥5.5 cm (P < .01).

CONCLUSIONS

Practice variations exist in the current size threshold for surgery of ascending aortic aneurysms in Canada. These differences between surgeons are further accentuated in the context of bicuspid aortic valve, smaller body stature, younger age, low growth rate, family history, and for the performance of isometric exercise. These represent important areas where future prospective studies are required to inform best practice.

Superiority of complete bi-atrial ablation procedure for atrial fibrillation in rheumatic mitral valve disease

INTRODUCTION

The necessity of complete bi-atrial lesion created by radiofrequency clamp and pen for nonparoxysmal atrial fibrillation (AF) in patients with rheumatic mitral valve disease (RMVD) remains unclear.

METHODS

From January 2014 to December 2018, patients with RMVD concomitant with nonparoxysmal AF who underwent mitral valve surgery concomitant surgical ablation were retrospectively enrolled. We divided patients into Group A (complete bi-atrial lesion set created by radiofrequency clamp and pen) and Group B (simplified lesion sets created by radiofrequency clamp alone including bi-atrial ablation with incomplete mitral isthmus line and stand-alone left atrial ablation) according to the surgical ablation lesion sets. Propensity score matching was applied to analyze freedom from atrial tachyarrhythmias between the two groups.

RESULTS

Two hundred eight (38.5%) and 332 (61.5%) patients were divided into Group A and Group B, respectively. In Group B, the proportion of patients with recurrent atrial flutter in the subgroup of bi-atrial ablation with incomplete mitral isthmus line was higher than that in Group A (p = .044). After propensity score matching, there were 203 patients in each group. Better freedom from atrial tachyarrhythmias without antiarrhythmic drugs was obtained in Group A (83.1%, 79.6%, and 65.4%) than Group B (73.1%, 68.4%, and 52.7%) at 12, 36, and 60 months after operation (p = .012).

CONCLUSION

The application of radiofrequency clamp and pen to create complete bi-atrial lesion set in surgical ablation for nonparoxysmal AF in RMVD was associated with superior long-term efficacy.