Ten-year experience with transcatheter and surgical aortic valve replacement in Finland

Aim: We investigated the outcomes of transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in Finland during the last decade. Methods: The nationwide FinnValve registry included data from 6463 patients who underwent TAVR or SAVR with a bioprosthesis for aortic stenosis from 2008 to 2017. Results: The annual number of treated patients increased three-fold during the study period. Thirty-day mortality declined from 4.8% to 1.2% for TAVR (p = .011) and from 4.1% to 1.8% for SAVR (p = .048). Two-year survival improved from 71.4% to 83.9% for TAVR (p < .001) and from 87.2% to 91.6% for SAVR (p = .006). During the study period, a significant reduction in moderate-to-severe paravalvular regurgitation was observed among TAVR patients and a reduction of the rate of acute kidney injury was observed among both SAVR and TAVR patients. Similarly, the rate of red blood cell transfusion and severe bleeding decreased significantly among SAVR and TAVR patients. Hospital stay declined from 10.4 ± 8.4 to 3.7 ± 3.4 days after TAVR (p < .001) and from 9.0 ± 5.9 to 7.8 ± 5.1 days after SAVR (p < .001). Conclusions: In Finland, the introduction of TAVR has led to an increase in the invasive treatment of severe aortic stenosis, which was accompanied by improved early outcomes after both SAVR and TAVR. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915 Key Messages This study demonstrated that the introduction of transcatheter aortic valve replacement has led to its widespread use as an invasive treatment for severe aortic stenosis. Early and 2-year survival after transcatheter and surgical aortic valve replacement has improved during past decade. Transcatheter aortic valve replacement has fulfilled its previously unmet clinical needs and has surpassed surgical aortic valve replacement as the most common invasive treatment for aortic stenosis.

Rationale for aortic annuloplasty to standardise aortic valve repair

Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25-28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub- and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.

The Prophylactic Chimney Snorkel Technique for the Prevention of Acute Coronary Occlusion in High Risk for Coronary Obstruction Transcatheter Aortic Valve Replacement/Implantation Cases

Coronary occlusion (immediate or delayed) is an uncommon but potentially devastating complication of transcatheter aortic valve replacement/implantation (TAVR/TAVI). Several patient-related, anatomical, device and procedural risk factors can be assessed to risk-stratify patients and assist in procedural planning. In patients at high risk for coronary occlusion, coronary protection measures should be employed. In the highest risk patients, consideration should be given to prophylactic techniques to prevent coronary occlusion. This how-to-do-it report provides a framework for risk assessment for coronary occlusion followed by a step-wise description of the emerging chimney snorkel coronary stenting technique as a predictable procedural approach for the management of this potentially challenging clinical scenario.

Coronary microvascular dysfunction is associated with cardiac time intervals in women with angina and no obstructive coronary artery disease: An iPOWER substudy

BACKGROUND

Coronary microvascular dysfunction (CMD) may cause angina in the absence of obstructive coronary artery disease (CAD) and increases the risk of future adverse cardiovascular events. Transthoracic Doppler echocardiography (TTDE) with pharmacological stress can assess coronary flow velocity reserve (CFVR), a measure of coronary microvascular function. However, simpler methods would be preferable for diagnosing CMD. Therefore, we examined the relationship between CFVR and cardiac time intervals measured by TTDE in a cohort of women with angina and no obstructive CAD.

METHODS

In a prospective cohort study, we included 389 women with angina, left ventricular ejection fraction > 45%, and no obstructive CAD. CMD was defined as CFVR < 2.0. The study population was divided into three groups according to cutoff values of CFVR < 2, 2 ≤ CFVR ≤ 2.5, and CFVR > 2.5. Isovolumic contraction time (IVCT), ejection time (ET), and isovolumic relaxation time (IVRT) were measured by tissue Doppler M-mode, and the myocardial performance index (MPI = (IVCT + IVRT)/ET) was calculated.

RESULTS

Coronary microvascular dysfunction was associated with increasing age, hypertension, higher resting heart rate, and lower diastolic blood pressure. Moreover, CMD was associated with higher E/e' ratio (P = 0.002) and longer IVCT (P < 0.001), higher MPI (P < 0.001) and shorter ET (P = 0.002), but not with IVRT or conventional measures of left ventricular geometry, mass, and function. In multivariable analysis, longer IVCT (P < 0.001) and higher MPI (P = 0.002) remained associated with CMD.

CONCLUSION

In women with angina and no obstructive CAD, CMD is associated with longer IVCT and higher MPI indicating a link between CMD and subtle alternations of systolic and combined measures of cardiac time intervals.

Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

The impact of antithrombotic regimen and platelet inhibition extent on subclinical leaflet thrombosis (SLT) detected by cardiac multidetector computed tomography (MDCT) after transcatheter aortic valve replacement (TAVR) is not well established. Hypoattenuation affecting motion (HAM) has been proposed as a surrogate marker of SLT, and is characterized by hypoattenuated leaflet thickening (HALT) and concomitant reduction in leaflet motion (RELM). We sought to investigate (i) the prevalence of HAM and HALT after TAVR detected by MDCT, (ii) the predictors of SLT, (iii) the impact of oral anticoagulant (OAC) and platelet inhibition extent assessed by platelet reactivity index vasodilator stimulated phosphoprotein (PRI-VASP) and closure time adenosine diphosphate (CT-ADP) on SLT. Of 187 consecutive patients who underwent TAVR from 1 August 2017 to 31 March 2018, 90 of them had cardiac CT at relevant follow-up. Clinical, biological, echocardiographic, procedural characteristics and treatments were collected before, at discharge, and 1 year after TAVR. P2Y₁₂ platelet inhibition extent and primary haemostasis disorders were investigated using platelet PRI-VASP and CT-ADP point-of-care assays. Eighty-five post-TAVR CTs out of 90 were ranked for clarity and assessed with sufficient diagnostic quality. HAM was evidenced in 13 patients (15.3%) and HALT in 30 patients (35%). Procedural characteristics, including aortic valve calcium score, annulus size, or procedural heparin regimens, were equivalent between groups. Likewise, no impact of P2Y₁₂ inhibition (PRI-VASP) nor primary haemostasis disorders (CT-ADP) on SLT could be evidenced. No impact of SLT on valve deterioration evaluated by transthoracic echocardiography (TTE) and clinical events could be established at 12 months follow-up. By multivariate analysis, lack of oral anticoagulant therapy at discharge (HR 12.130 CI 95% (1.394-150.582); p = 0.028) and higher haemoglobin levels were evidenced as the sole independent predictors of SLT. In four patients with HAM, MDCT follow-up was obtained after initiation of OAC therapy and showed a complete regression of HAM. SLT was evidenced in a sizeable proportion of patients treated by TAVR and was mainly determined by the lack of oral anticoagulant therapy. Conversely, no impact of platelet inhibition extent on SLT could be evidenced.

Analyses for Prevalence and Outcome of Tricuspid Regurgitation in China: An Echocardiography Study of 134,874 Patients

Background: The aim of this study is to investigate the prevalence and outcome of tricuspid regurgitation (TR) in the Chinese population. Methods: The echocardiography database, including 134,874 patients at our heart center from 2010 to 2012, was retrospectively analyzed. Results: The rates of mild, moderate, and severe TR were 2.96, 2.22, and 1.39%, respectively. Of these patients, 4.86% had primary TR, 91.41% had functional TR, and 3.73% had unexplained TR. The rate of TR was increased in elders (odds ratio: 1.038 for 1 year’s increment; 95% confidence interval: 1.037–1.040; p < 0.001) and females (odds ratio: 1.386; 95% confidence interval: 1.327–1.448, p < 0.001). The major etiologies of TR were left-sided valve heart disease (VHD) and dilated cardiomyopathy. The survival rate of severe TR patients with pulmonary artery hypertension (PAH) was lower than in those without PAH (p < 0.0001). There was a positive association between the prevalence of TR and impaired left ventricular ejection fraction. Compared to the non-left-sided VHD group, the left-sided VHD group had a better prognosis among severe TR patients. The 5-year survival rates were 79.69, 71.12, and 77.01% in the groups of left-sided VHD, non-left-sided VHD, and all patients. Conclusions: Patients with severe TR have a bad prognosis, especially those with non-left-sided VHD and those with PAH.

Early and long-term outcomes of mitral valve repair for Barlow's disease: a single-centre 16-year experience

OBJECTIVES

Following mitral valve repair for Barlow's disease, recurrent mitral regurgitation (MR) is believed to occur frequently and is mainly attributed to disease progression.

METHODS

Between January 2000 and December 2015, 180 patients (40% women, mean age 58.7 ± 13.5 years) with Barlow's disease underwent mitral valve repair. To provide a longitudinal assessment of mitral valve repair durability, a multistate model for interval-censored observations (4 states: 1, Grade 0/1+ MR; 2, Grade 2+ MR; 3, Grade 3+/4+ MR; 4, reintervention/death) was developed. The mechanism of recurrent MR was assessed echocardiographically.

RESULTS

Early mortality was 1.7%. After hospital discharge, 6 late reinterventions were performed. With death as a competing risk, the 10-year overall reintervention-free survival and reintervention rates were 79.8% (95% confidence interval 72.7-87.6%) and 4.5% (95% confidence interval 2.0-10.2%), respectively. Echocardiographic follow-up was available for 165 (93%) of hospital survivors with a total of 480 examinations. The incidence of both recurrent Grade 2+ and Grade 3+/4+ MR was relatively low up to 10 years after surgery. Grade 2+ MR did not always progress to higher regurgitation grade during the follow-up period. Grade 3+/4+ regurgitation was highly associated with valve-related morbidity and mortality. Recurrent MR (≥Grade 2+) was predominantly related to the technical aspects of valve repair.

CONCLUSIONS

Despite the complex valve abnormalities observed in patients with Barlow's disease, mitral valve repair can be performed with good early and late outcomes and low rates of recurrence of MR up to 10 years after surgery. Early and late valve repair durability is good and remains stable over time, suggesting that underlying disease progression has limited clinical significance.

Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation

OBJECTIVES

Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy.

METHODS

Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI.

RESULTS

The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31).

CONCLUSIONS

SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.

Evolving Surgical Approaches to Bicuspid Aortic Valve Associated Aortopathy

Bicuspid aortic valve (BAV) is the most common congenital cardiac pathology which results from the fusion of two adjacent aortic valve cusps. It is associated with dilatation of the aorta, known as bicuspid valve-associated aortopathy or bicuspid aortopathy. Bicuspid aortopathy is progressive and is linked with adverse clinical events. Hence, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. Over the past two decades resection strategies and surgical interventions have mainly been directed by surgeon and institution preferences. These practices have ranged from conservative to aggressive approaches based on aortic size and growth criteria. This strategy, however, may not best reflect the risks of important aortic events. A new set of guidelines was proposed for the treatment of bicuspid aortopathy. Herein, we will highlight the most recent findings pertinent to bicuspid aortopathy and its management in the context of a case presentation.

Unicuspid aortic valve replacement with development of complete heart block: a case report

BACKGROUND

Aortic stenosis is a progressive disease that frequently remains undiagnosed until late in the disease course. In patients that present with symptoms of heart failure and a systolic murmur at a young age, a congenital valvular abnormality must be on the differential. With patients that have accelerated symptoms of aortic stenosis and valvular dysfunction, a unicuspid aortic valve (UAV) could be present. A UAV is often difficult to distinguish from a bicuspid aortic valve (BAV) on transthoracic echocardiography. In patients with congenital valvular abnormalities an ascending aortic aneurysm can also be present. Aortic stenosis changes the jet of fluid emerging from the aortic valve leading to an increased risk for aortic aneurysm dissection and rupture. The gold standard treatment for aortic stenosis secondary to a congenital valvular abnormality is valve replacement. A known risk of aortic valve replacement is conduction abnormalities. In this case, we present a patient with a unicuspid valve who postoperatively develops complete heart block leading to pacemaker implantation.

CASE SUMMARY

We present a case of a 46-year-old Caucasian male with no prior medical history who presented with progressively worsening exertional dyspnoea and palpitations for 7 months. Transthoracic echocardiogram showed a BAV, however, further work up confirmed a unicommissural aortic valve with severe aortic stenosis and moderate regurgitation along with an ascending aortic aneurysm. Aortic valve replacement and aortic aneurysm repair via the Bentall procedure was successfully completed with postoperative course being complicated by a complete heart block and subsequent permanent pacemaker placement.

DISCUSSION

When assessing patients with symptoms of heart failure with a systolic murmur that suggests aortic stenosis at a young age, a UAV must be kept on the differential. The symptoms of aortic stenosis and valvular dysfunction are accelerated in UAVs when compared with BAVs. Currently, the treatment for patients with congenital valvular abnormalities presenting with aortic stenosis is aortic valve replacement using traditional open surgery. A known sequelae of isolated aortic valve replacement is conduction abnormalities that can sometimes lead to permanent pacemaker placement. After the confirmation of unicuspid or bicuspid valve postoperatively, it is important to report any postoperative conduction abnormalities. This is because, currently, there is no literature that compares the incidence of conduction abnormalities after unicuspid replacement to that of other BAV syndromes.

Impact of patient's health-related quality of life on physicians' therapy and perceived benefit in acute coronary syndromes: protocol for a systemic review of quantitative and qualitative studies

INTRODUCTION

Percutaneous coronary interventions (PCIs) and coronary angiography are two of the treatments administered to acute coronary syndrome (ACS) patients. However, whether and how patients' health-related quality of life (HRQoL) influences treatment decisions and subsequent risk benefit analyses is unclear. In this study, we will review the available evidence on the impact of patients' HRQoL on physicians' prescribing or treatment decisions and on the estimation of mortality and bleeding risk in ACS patients.

METHODS AND ANALYSIS

We will undertake a systematic review of all quantitative and qualitative studies. The search will include studies that describe the impact of HRQoL on prescribing PCIs or angiography, and impact of HRQoL on perceived risks in terms of mortality and bleeding events. We will conduct an initial search on Google scholar and MEDLINE to build the searching terms followed by a full search strategy using all identified keywords and index terms across the five databases, namely MEDLINE, PubMed, CINAHL, SCOPUS and Web of Sciences. We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for protocol guidelines to present the protocol. Only English language articles will be included for the review. We will use a standardised Joanna Briggs Institute data extraction tool to synthesise the information extracted from the selected studies into themes with summary findings presented in a table.

ETHICS AND DISSEMINATION

We will not require a formal ethical approval as we will not be collecting primary data. Review findings will be disseminated through a peer-reviewed publication, workshops, conference presentations and a media release.

PROSPERO REGISTRATION NUMBER

CRD42018108438.

Preservation of a Regurgitant Quadricuspid Pulmonary Autograft by the David Procedure

We report a case in which a quadricuspid pulmonary valve was used for the Ross operation in a young male patient. The patient demonstrated severe pulmonary autograft regurgitation due to a neosinus of Valsalva aneurysm 16 years after the primary operation. Preservation of the quadricuspid pulmonary autograft was performed by the David procedure, resulting in a competent valve function.

Outcome in elderly patients with aortic stenosis undergoing hip fracture surgery. Results may suggest a different postoperative strategy?

Background

Five to ten percent of patients with hip fracture have severe aortic valve stenosis (AS). The aim of the present investigation was to evaluate the impact of AS on early and long-term outcome after surgery for hip fracture.

Methods

145 patients with AS and 283 consecutive patients without AS (control group) aged >70 years referred to Azienda Ospadaliera Universitaria (AOU) Careggi for hip fracture were included in the study. The endpoints were incidence of postoperative myocardial infarction, 30-day and 1-year mortality, and a composite endpoint (30-day mortality + myocardial infarction).

Results

66 patients had mild, 47 moderate and 32 severe AS according to the European Society of Cardiology guidelines. 30-day mortality was 6.2% in AS and 3.1% in controls. Postoperative non-fatal myocardial infarction and composite endpoint were more frequent in AS than in the control group (8.3% vs 1.1%, p<0.001 and 14.5% vs 4.2%, p<0.001, respectively). The risk was significantly higher for patients with severe AS (28.1%). 1-year mortality in patients with moderate/severe AS was 46% in comparison with 16% in mild AS or in the control group (p<0.001). Coronary disease, atrial fibrillation, age, and aortic gradient were independent predictors of mortality in AS.

Discussion

AS significantly affects postoperative outcome after surgery for hip fracture. Since not infrequently AS is incidentally diagnosed during hospitalization after trauma, which should be the management in these patients after hip surgery? How many might benefit from surgical valve replacement or transcatheter aortic valve replacement? A heart team evaluation may be suggested before discharge for most of these patients.

Level of evidence

IV.

Validation of "left ventricular early inflow-outflow index": A novel echocardiographic method for quantification of mitral regurgitation in an Indian population with special focus on rheumatic etiology

BACKGROUND

Quantification of mitral regurgitation (MR) has always required an "integrated approach" as there is no single gold-standard method. We investigated a new Doppler-derived parameter "left ventricular early inflow-outflow index (LVEIO)" for the quantification of MR and its likelihood to predict severe MR in correlation with already established parameters in an Indian population including a large subset of patients with rheumatic etiology.

METHODS

A prospective study was performed at a major tertiary care center in western India over a 5-month period. Five hundred patients diagnosed with isolated MR including 260 (52%) patients with rheumatic etiology were included in the study after applying exclusion criteria. We analyzed MR using color flow jet, effective regurgitant orifice area (EROA), and vena contracta (VC) width. LVEIO is a simplification of the regurgitant volume (RV) method, which was calculated as "E velocity divided by LV outflow velocity integrated over the systolic ejection period left ventricular outflow tract velocity time integral" and compared with the established parameters.

RESULTS

LVEIO was 4.65 ± 1.45, 6.56 ± 1.52, and 9.91 ± 3.70 among patients diagnosed with mild, moderate, and severe MR, respectively (p < 0.001). Those with LVEIO ≥8 were the most likely to have severe MR (positive likelihood ratio: 10.42). LVEIO had specificity of 93.25% for diagnosis of severe MR with positive predictive value of 86.36%. There was positive correlation observed between LVEIO and VC width (r = 0.591), RV (r = 0.410), and EROA (r = 0.778) (all p < 0.001) in the Pearson correlation test. The specificity of LVEIO remained consistent in diagnosing severe MR in patients with rheumatic etiology.

CONCLUSION

LVEIO is a simple yet specific Doppler echocardiographic parameter for estimation of severity of MR including that of rheumatic etiology.

Valve-Sparing Root Replacement in Elderly Patients With Annuloaortic Ectasia

BACKGROUND

We report early and midterm outcomes of elderly patients who underwent valve-sparing root replacement (VSRR) compared with younger patients and those with Bentall procedure.

METHODS

From October 1999 to October 2017, 73 patients greater than or equal to 65 years of age who underwent VSRR procedure were assigned as group S. Two hundred thirty-two VSRR patients who were between 15 and 64 years of age were assigned as group Y. Forty-five patients greater than or equal to 65 years of age who underwent Bentall procedure were assigned as group R. Preoperative grades of aortic regurgitation were 3.4 of 4 in group S, 3.1 of 4 in group Y, and 3.3 of 4 in group R (p = 0.07).

RESULTS

Hospital mortality was found in 1 (1.4%) patient in group S, 3 (6.7%) in group R, and 2 (0.9%) in group Y. Postoperative survival at 5 years was 88.5% in group S, 98.7% in group Y, and 82.4% in group R (p < 0.01). Freedom from more than mild aortic regurgitation at 5 years was 81.0% in group S and 85.4% in group Y. Follow-up echocardiography disclosed an effective aortic valve orifice area of 1.76 cm² in group R, 2.40 cm² in group Y, and 2.41 cm² in group S (p < 0.01), and peak pressure gradient across the aortic valve was 17.7 mm Hg in group R, 13.6 mm Hg in group Y, and 10.8 mm Hg in group S (p < 0.01).

CONCLUSIONS

Similar early and late outcomes were achieved in elder VSRR patients compared with younger patients. A better postoperative valve performance was demonstrated in VSRR patients than patients undergoing valve-replacement.

Long-term results after concomitant mitral and aortic valve surgery: repair or replacement?

OBJECTIVES

The reported superiority of mitral valve (MV) repair for isolated MV regurgitation has not been confirmed in mitroaortic valve surgery. Our goals were to evaluate the feasibility of repair in patients undergoing mitral and aortic valve surgery and to identify factors predisposing to MV replacement, to compare long-term outcomes (survival and MV reoperation) of repair and replacement and to perform a subgroup analysis in patients with rheumatic MV disease.

METHODS

From January 1992 through December 2016, 1122 consecutive patients were submitted to concomitant aortic and MV surgery in 2 different centres (Coimbra and Santiago). Of these, 837 patients underwent MV repair (74.6%) and 285 patients had MV replacement (25.4%). Rheumatic aetiology was predominant (666 patients; 59.4%). Cumulative follow-up was 9522.6 patient-years (25th-75th percentile 2.6-13.2 years) and was complete for 95.6% of patients. Propensity score matching (1:1) was performed in 232 patients for comparing each treatment option (MV repair and MV replacement).

RESULTS

Previous MV intervention, rheumatic aetiology, chronic obstructive pulmonary disease, higher degrees of tricuspid and mitral regurgitation and pulmonary hypertension were independently correlated with MV replacement. The 30-day mortality rate was higher in patients with MV replacement (4.2% vs 1.8%, P = 0.021) and was confirmed in the propensity score matching (4.7% vs 1.7%, P = 0.06). Late survival was lower in the MV replacement group (53.3 ± 4.5% vs 61.7 ± 2.0% at 12 years; P = 0.026) and was confirmed in the propensity score matching (54.6 ± 4.9% vs 63.2 ± 3.8%, P = 0.062) and rheumatic subgroup (57.9 ± 4.8% vs 68.0 ± 2.5%, P = 0.018). Freedom from MV reoperation at 12 years was higher in the MV repair group (94.7 ± 1.1% vs 89.0 ± 3.1%, P = 0.004) but similar in patients with rheumatic MV disease.

CONCLUSIONS

MV repair can be performed in most patients undergoing aortic valve replacement. It should be the procedure of choice whenever feasible, because it is associated with lower early and late mortality rates and with freedom from reoperation in non-rheumatic patients.

Natural history of mild aortic valve disease untreated at the time of rheumatic mitral valve replacement

OBJECTIVES

The aim of this study was to examine long-term clinical outcomes and to assess the eventual need for aortic valve replacement (AVR) in patients with mild aortic valve disease (AVD) at the time of mitral valve replacement.

METHODS

Between 1990 and 2015, 1231 patients undergoing mitral valve replacement were reviewed, stratifying subjects as those with AVD (n = 363) or without AVD (NA; n = 868). Primary end points were progressive AVD (grade ≥ II) and subsequent AVR. Overall mortality and valve-related complications served as secondary end points. Propensity score matching was used for risk adjustment (n = 320 in each group).

RESULTS

No differences in postoperative complications or clinical outcomes were observed between groups. The 20-year overall survival was similar (before matching: NA 86.1% vs AVD 80.8%, P = 0.128; after matching: 83.5% vs 81.1%, P = 0.425). Of the entire cohort, progressive AVD was observed in 162 patients, and significant AVD (grade ≥ III) was observed in only 60 patients. Subsequent AVR was required in 37 patients due to mitral valve (MV) dysfunction or severe aortic stenosis. The 20-year freedom from significant AVD and subsequent AVR was significantly higher in the NA group than in the AVD group before and after matching (before: NA, 96.5% vs 73.7%, P < 0.001; AVD, 98.5% vs 82.3%, P < 0.001; after: 98.1% vs 73.3%, P < 0.001; 99.3% vs 82.5%, P < 0.001, respectively).

CONCLUSIONS

Although progressive AVD did not significantly impact long-term survival during the follow-up period, those patients qualifying initially as mild AVD may eventually progress to significant AVD after the first 5 postoperative years. Therefore, aggressive echocardiography should be performed at 5-year lapse after mitral valve replacement to determine the appropriate timing of AVR.

Prevalence of moderate-to-severe TR suitable for percutaneous intervention in TTE patients

Moderate-to-severe tricuspid regurgitation is associated with higher mortality and morbidity yet remains significantly undertreated. The reasons for this are complex but include a higher operative mortality for patients undergoing isolated tricuspid valve surgery. This study sought to determine the prevalence of patients with moderate-to-severe tricuspid regurgitation and identify those who could be potentially suitable for percutaneous tricuspid valve intervention by screening patients referred for transthoracic echocardiography (ECHO) at a tertiary center. Our results showed that the prevalence of moderate-to-severe tricuspid regurgitation in our total ECHO patient population was 2.8%. Of these, approximately 1 in 8 patients with moderate-to-severe tricuspid regurgitation would be potentially suitable for percutaneous intervention, and suggests a large, unmet clinical need in this population.

Aortic valve repair for aortic regurgitation and preoperative echocardiographic assessment

Aortic valvuloplasty (AVP) has been performed less frequently than mitral valvuloplasty. The survival benefit of AVP over replacement has been demonstrated. Therefore, standardization of AVP is crucial for its widespread adoption. The hemodynamic advantage of AVP of preserving the native aortic valve may be one reason for the survival benefit. Recent guidelines still recommend AVP in selected cases compared with the less restricted recommendation for mitral valvuloplasty, although recent studies have proposed earlier indication for surgical intervention. Indication for aortic root replacement is also still conservative, especially in Japan. However, more liberal root replacement should be recommended for better repair when AVP is indicated. Theoretically, all aortic regurgitation lesions can be repaired with acceptable durability. However, restricted cusp should be extended by a pericardial patch, which itself has emerged as a risk of recurrence. Therefore, indications for aortic regurgitation for type III lesions should be determined carefully. Special consideration is crucial for bicuspid aortic valve repair; prevention of postoperative stenosis is especially important. Arrangement of the commissure position is the most important consideration for this purpose, although it remains controversial. Therefore, detailed diagnosis is important in planning AVP, and echocardiography plays a key role in this process.

Short-term and 1-year outcomes after MitraClip therapy in functional versus degenerative mitral regurgitation patients: a systematic review and meta-analysis

Background

Differences in short-term and 1-year outcomes of percutaneous edge-to-edge mitral repair between patients with functional and degenerative mitral regurgitation (MR) remain unclear. We performed a systematic review and meta-analysis to investigate the safety and efficacy of MitraClip (MC) in patients with different MR etiologies.

Methods

This study systematically searched three common databases for studies on MC therapy until November 2017. The studies meeting the standard inclusion criteria were included. The data at baseline, short-term and 1-year clinical and echocardiographic outcomes were obtained and analyzed. All data were checked by another reviewer.

Results

Thirteen studies totalling 2,351 patients investigating the short-term and 1-year outcomes of MC in patients with functional MR (FMR) versus degenerative MR (DMR) were included for further analysis. FMR patients presented a higher risk profile at baseline. There was no difference in short-term outcomes between DMR and FMR for post-procedural MR grade 0-2 (76.8% vs. 77.1%; P=0.428), mean trans-mitral gradient (3.92 vs. 3.50 mmHg; P=0.098), 30-day mortality rate (0.05% vs. 0.03%; P=0.118) and 30-day NYHA I-II (85.3% vs. 78.7%; P=0.211). FMR patients had a higher rate of acute procedural success compared to the DMR patient group (91.2% vs. 95.2%; P=0.016). A greater portion of DMR patients implanted two or more MCs than the FMR patients (41.4% vs. 35.7%; P=0.043). For the 1-year outcomes, no difference was found in the mortality rate (13.0% vs. 15.2%; P=0.268) and proportion of patients with post-procedural MR grades 0-2 (75.0% vs. 80.7%; P=0.106).

Conclusions

Despite a higher risk profile in FMR patients, the short-term and 1-year outcomes were not significantly different. We conclude that MC therapy is similar between FMR and DMR patients until 1-year follow-up. Large randomized trials are warranted to fully and further assess the clinical impact of the procedure in these two MR etiologies over a longer period of time.

Patient screening for early detection of aortic stenosis (AS)-review of current practice and future perspectives

In Europe, approximately one million people over 75 years suffer from severe aortic stenosis (AS), one of the most serious and most common valve diseases, and this disease burden is increasing with the aging population. A diagnosis of severe symptomatic AS is associated with an average life expectancy of 2-3 years and necessitates a timely valve intervention. Guidelines for valve replacement therapy have been established but only a proportion of patients with symptomatic AS actually receive this life-saving treatment. The decision for valve intervention in asymptomatic patients with severe AS is often more challenging and likely results in fewer patients receiving treatment in comparison to their symptomatic counterparts. This article reviews the epidemiology and clinical manifestations of AS, the associated economic burden of AS to the healthcare system, the diagnosis of AS and the possible mechanisms for the introduction of routine screening in elderly patients. Elderly patients typically visit healthcare providers more frequently than younger patients, thereby providing increased opportunities for ad hoc AS screening and this, along with raising patient awareness of the symptoms of AS, has the potential to result in the earlier diagnosis and treatment of AS and increased patient survival.