Changing demographics of valvular heart disease and impact on surgical and transcatheter valve therapies

The Role of Palliative Care in Cardiovascular Disease

The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.

Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward

The prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD.

Temporal trends and socioeconomic differences in treatment and mortality following a diagnosis of aortic stenosis

AIMS

This study aims at determining the temporal trends and the socioeconomic differences in treatment and mortality following a diagnosis of aortic stenosis.

METHODS AND RESULTS

A total of 45,026 patients with a first-time diagnosis of aortic stenosis were identified in the Danish National Patient Registry in the period 2000-17. The risk of AVR within the first year after diagnosis decreased (OR = 1.84 in 2000-02 compared to 2015-16) and the risk was lower in the low-level educational group (OR = 0.85) and in the medium-level group (OR = 0.94) compared to high-level education. The risk of death after AVR within the first year decreased (OR = 2.25 in 2000-02 compared to 2015-16) and the risk was higher in the low-level educational group (OR = 1.32) and in the medium-level group (OR = 1.28) compared to high-level education. The risk of death within the first year after diagnosis, for those patients who did not get an AVR during the follow-up, decreased (OR = 3.08 in 2000-02 compared to 2015-16) and the risk was higher in the low-level educational group (OR = 1.21) and in the medium-level group (OR = 1.10) compared to high-level education.

CONCLUSION

Since 2000 there has been a decrease in both AVR treatment rate, mortality rate after AVR and mortality rate in patients not receiving AVR. For patients with lower-level education there is lower AVR treatment rate, higher mortality rate after AVR and higher mortality rate in patients not receiving AVR.

A workflow for patient-specific fluid-structure interaction analysis of the mitral valve: A proof of concept on a mitral regurgitation case

The mechanics of the mitral valve (MV) are the result of the interaction of different anatomical structures complexly arranged within the left heart (LH), with the blood flow. MV structure abnormalities might cause valve regurgitation which in turn can lead to heart failure. Patient-specific computational models of the MV could provide a personalised understanding of MV mechanics, dysfunctions and possible interventions. In this study, we propose a semi-automatic pipeline for MV modelling based on the integration of state-of-the-art medical imaging, i.e. cardiac magnetic resonance (CMR) and 3D transoesophageal-echocardiogram (TOE) with fluid-structure interaction (FSI) simulations. An FSI model of a patient with MV regurgitation was implemented using the finite element (FE) method and smoothed particle hydrodynamics (SPH). Our study showed the feasibility of combining image information and computer simulations to reproduce patient-specific MV mechanics as seen on medical images, and the potential for efficient in-silico studies of MV disease, personalised treatments and device design.

Palliative care in end-stage valvular heart disease

Valvular heart disease (VHD), particularly aortic valve disease, is prevalent with increasing incidence. When surgery is not possible, or when risks outweigh benefits, percutaneous treatment options may offer effective alternatives. However, procedures may not always go as planned, and frail patients or those whose symptoms are caused by other comorbidities may not benefit from valve intervention at all. Significant effort should be made to assess frailty, comorbidities and patient goals prior to intervention. Palliative care (PC) should play a critical role in the care of patients with severe valve disease. PC is specialised medical care that aims to optimise health-related quality of life by managing symptoms and clarifying patient values and goals of care. It should be implemented at the time of diagnosis and continue throughout the disease course. Because of the paucity of studies dedicated to the provision of PC to patients with advanced VHD, further research is needed.

Is TAVR Ready for the Global Aging Population?

The emergence of the global pandemic of chronic diseases necessitates critical assessment of interventions that can be targeted at both the individual and population levels. Among cardiovascular diseases, the increasing prevalence of valvular heart diseases such as aortic stenosis parallels the rising burden of atherosclerotic cardiovascular diseases. As an alternative to surgical aortic valve replacement, technological innovation has allowed development of minimally invasive transcatheter aortic valve replacement (TAVR). This review examines whether TAVR can be applicable in low-resource regions across the world. Although revolutionary, TAVR is currently complex and requires a "Heart Team" approach for optimized patient care. We propose the emergence of telemedicine networks, newer valve designs that allow implementation of minimal approaches, and the use of minimal numbers of specialists for adapting TAVR to settings where surgical backup is not available. With efforts to reduce resource utilization, these alternate strategies have the potential to affect implementation of TAVR globally.

MicroRNA Expression Signature in Human Calcific Aortic Valve Disease

Altered microRNA (miRNA, miR) expression has been related to many disease processes; however, the miRNA expression signature in calcific aortic valve disease (CAVD) is unclear. In this study, microarrays were used to determine the miRNA expression signature of tissue samples from healthy individuals (n = 4) and patients with CAVD (n = 4). TargetScan, PITA, and microRNAorg 3-way databases were used to predict the potential target genes. DIANA-miRPath was used to incorporate the aberrant miRNAs into gene pathways. miRNA microarrays identified 92 differentially expressed miRNAs in CAVD tissues. The principal component analysis (PCA) of these samples and the unsupervised hierarchical clustering analysis based on the 92 aberrantly expressed miRNAs noted that miRNA expression could be categorized into two well-defined clusters that corresponded to healthy control and CAVD. Bioinformatic analysis showed the miRNA targets and potential molecular pathways. Collectively, our study reported the miRNA expression signature in CAVD and may provide potential therapeutic targets for CAVD.

ANP and BNP plasma levels in patients with rheumatic mitral stenosis after percutaneous balloon mitral valvuloplasty

INTRODUCTION

Atrial (ANP) and B-type (BNP) natriuretic peptides are hormones secreted by the heart as a response to volume expansion and pressure overload.

AIM

To assess the changes of ANP and BNP after percutaneous balloon mitral valvuloplasty (PBMV) and to investigate factors associated with endpoints.

MATERIAL AND METHODS

The study included 96 patients (90.7% females, age 51.6 ±12.2 years) with rheumatic mitral valve stenosis (mitral valve area (MVA) 1.18 (1.01-1.33) cm2, mean mitral gradient (MMG) 8.2 (7.1-9.2) mm Hg, NYHA 2.09 (1.9-2.5)). Patients were followed up for 29.1 months for the search of endpoints.

RESULTS

The PBMV was successful in all cases. After the procedure MVA increased (1.18-1.78 cm2, p < 0.01) and pulmonary capillary wedge pressure (PCWP) decreased (29.8-21.8 mm Hg, p < 0.01). Concentration of ANP significantly rose 30 min after the PBMV (79.2 vs. 134.2 pg/ml, p = 0.012) and dropped significantly after 24 h (134.2 vs. 70.4 pg/ml, p = 0.01). Furthermore, after 36 months concentration of ANP did not differ from the baseline value (p = NS). BNP concentration at day 1 was lower than at baseline (94.5 vs. 80.2 pg/ml, p = 0.032). Moreover, during the follow-up period BNP continued to fall at all time points. In univariate analysis parameters associated with endpoint occurrence were baseline PAP (p = 0.023), baseline PCWP (p = 0.022), baseline NYHA (p = 0.041) and increase in 6-minute walk test (6MWT) (p = 0.043). In multivariate analysis the only factor associated with endpoint occurrence was baseline NYHA (HR = 1.52, 95% CI: -1.3-1.91, p = 0.022).

CONCLUSIONS

Patients with MS had increased levels of both BNP and ANP. Baseline NYHA class was found to be associated with outcomes after the procedure.

Prevalence and correlates of valvular heart diseases in the elderly population in Hubei, China

We sought to determine the prevalence and correlates of valvular heart diseases (VHD) in the elderly population. The participants' personal information, medical history, behavioral habits and clinical status were assessed by questionnaire, while the left ventricular dimensions, function and the presence and severity of VHD were evaluated by transthoracic echocardiography. This study analyzed the data of 3948 participants who were older than 60 years. Significant VHD was present in 1.93% of participants; the standardized prevalence of VHD among the elderly population in Hubei was 2.05% (95% CI: 1.61-2.49). The most frequent VHD was aortic regurgitation, followed by tricuspid regurgitation, mitral regurgitation and multiple valve diseases. Univariate analysis results indicated that compared with participants without VHD, those with VHD were older (p < 0.001), with a higher body mass index (BMI) (p < 0.001), were more likely to smoke (p = 0.04), and had higher rates of coronary artery disease (CAD) (p < 0.001) and arrhythmia (p < 0.001). The results of multinomial regression analysis of complex sampling indicated that combined mitral and aortic valve diseases were related to older age, male sex and smoking; CAD was associated with single left-sided VHD.

Coverage of the 2011 Q fever vaccination campaign in the Netherlands, using retrospective population-based prevalence estimation of cardiovascular risk-conditions for chronic Q fever

Background

In 2011, a unique Q fever vaccination campaign targeted people at risk for chronic Q fever in the southeast of the Netherlands. General practitioners referred patients with defined cardiovascular risk-conditions (age >15 years). Prevalence rates of those risk-conditions were lacking, standing in the way of adequate planning and coverage estimation. We aimed to obtain prevalence rates retrospectively in order to estimate coverage of the Q fever vaccination campaign.

Methods

With broad search terms for these predefined risk-conditions, we extracted patient-records from a large longitudinal general-practice research-database in the Netherlands (IPCI-database). After validation of these records, obtained prevalence rates (stratified for age and sex) extrapolated to the Q fever high-incidence area population, gave an approximation of the size of the targeted patient-group. Coverage calculation addressed people actually screened by a pre-vaccination Q fever skin test and serology (coverage) and patients referred by their general practitioners (adjusted-coverage) in the 2011 campaign.

Results

Our prevalence estimate of any risk-condition was 3.1% (lower-upper limits 2.9-3.3%). For heart valve defects, aorta aneurysm/prosthesis, congenital anomalies and endocarditis, prevalence was 2.4%, 0.6%, 0.4% and 0.1%, respectively. Estimated number of eligible people in the Q fever high-incidence area was 11,724 (10,965-12,532). With 1330 people screened for vaccination, coverage of the vaccination campaign was 11%. For referred people, the adjusted coverage was 18%. Coverage was lowest among the very-old and highest for people aged 50–70 years.

Conclusion

The estimated coverage of the vaccination campaign was limited. This should be interpreted in the light of the complexity of this target-group with much co-morbidity, and of the vaccine that required invasive pre-vaccination screening. Calculation of prevalence rates of risk-conditions based on the IPCI-database was feasible. This procedure proved an efficient tool for future use, when prevalence estimates for policy, implementation or surveillance of subgroup-vaccination or other health-care interventions are needed.

Health-related quality of life of patients after mechanical valve replacement surgery: an integrative review

BACKGROUND

Heart valve replacement surgery is undertaken to improve cardiac function and health-related quality of life (HRQoL). Mechanical valves are typically used for younger people (aged <65 years). Implantation of these valves comes with life-long health self-management requirements which potentially impact on HRQoL.

AIMS

The purpose of this study was to identify the short and long-term impact on HRQoL after mechanical valve replacement surgery.

METHODS

Multiple electronic databases were searched for peer-reviewed studies published between 2000-2013, which focused on patients who had mechanical valve replacement, aged <65 years, and used a valid measure of HRQoL.

RESULTS

Eight papers were included, all of which used the Short-Form 36 Health Survey (SF-36). Preoperatively, HRQoL was impaired, particularly in the SF-36 health domains of role-physical, physical-functioning, vitality and role-emotional. Postoperatively, most people had positive and sustained HRQoL improvement. In the early postoperative period all data showed significant improvement in at least four of eight health domains (physical function, role-physical, vitality, social function). Two-thirds of people also had significant improvement in an additional two health domains (general and mental-health). Whilst most people sustained HRQoL over time, one-third of younger adults (age <24 years) showed impairment in three domains (physical-function, mental-health and general-health).

CONCLUSIONS

Mechanical valve replacement surgery results in important and sustained improvements in HRQoL. Future research should include investigation of HRQoL outcomes after mechanical valve replacement for specific groups such as younger adults and people in developing countries, and include evaluations of the potential impact of valve-specific factors and health self-management requirements.

Repair of posterior mitral valve prolapse with a novel leaflet plication clip in an animal model

OBJECTIVE

Recently, there has been increased interest in minimally invasive mitral valve prolapse repair techniques; however, these techniques have limitations. A new technique was developed for treating mitral valve prolapse that uses a novel leaflet plication clip to selectively plicate the prolapsed leaflet segment. The clip's efficacy was tested in an animal model.

METHODS

Yorkshire pigs (n = 7) were placed on cardiopulmonary bypass (CPB), and mitral valve prolapse was created by cutting chordae supporting the P2 segment of the posterior leaflet. Animals were weaned off CPB and mitral regurgitation (MR) was assessed echocardiographically. CPB was reinitiated and the plication clip was applied under direct vision to the P2 segment to eliminate the prolapse. The animals survived for 2 hours. Epicardial echocardiography was obtained before and after prolapse creation and 2 hours after clip placement to quantify MR grade and vena contracta area. Posterior leaflet mobility and coaptation height were analyzed before and after clip placement.

RESULTS

There were no cases of clip embolization. Median MR grade increased from trivial (0-1.5) to moderate-severe after MR creation (2.5-4+) (P < .05), and decreased to mild after clip placement (0-3+) (P < .05). Vena contracta area tended to increase after cutting the chordae and decrease after clip placement: 0.08 ± 0.10 cm(2) versus 0.21 ± 0.15 cm(2) versus 0.16 ± 0.16 cm(2) (P = .21). The plication clip did not impair leaflet mobility. Coaptation height was restored to baseline: 0.51 ± 0.07 cm versus 0.44 ± 0.18 cm (P = 1.0).

CONCLUSIONS

The leaflet plication clip can treat mitral valve prolapse in an animal model, restoring coaptation height without affecting leaflet mobility. This approach is a simple technique that may improve the effectiveness of beating-heart and minimally invasive valve surgery.

Patient experiences of recovery after heart valve replacement: suffering weakness, struggling to resume normality

Background

Heart valve disease is becoming a public health problem due to increasing life expectancy and new treatment methods. Patients are at risk of developing depression, anxiety or post-traumatic stress disorder after heart valve surgery. To better plan proper care, describing and understanding patients’ perception of recovery after heart valve replacement is essential. The objective was to describe the experience of recovery at home after heart valve replacement.

Methods

Qualitative interviews were conducted with 10 patients representing the population and these were later transcribed. The analysis was inspired by Ricoeur’s theory of interpretation, which consists of three levels: naive reading, structured analysis, and critical interpretation and discussion.

Results

The overall concept that emerged was suffering weakness and struggling to resume normality. Patients all struggled to resume normal living, both in regaining physical strength and in reestablishing balance in overall living. The overall concept can be interpreted in terms of the following themes: Disturbed network: Invaluable relatives, Contact with healthcare staff, Rehabilitation. Disturbed body: Stressful complications, Bodily attention, Physically affected, Physical capability. Recovery: Interrupted living, Suffering weakness, Gradual recovery, Achieving normality. Reflections: Thoughts about the procedure and Feeling sad and fragile.

Conclusion

The study presents the main themes of network, body, recovery and reflection for ten patients after heart valve replacement. These main themes can overall be summarized as suffering weakness and struggling to resume normality. Patients felt weak with a changed body, but after a long recovery process regained vitality and returned to their daily life.

The state of surgical ablation for atrial fibrillation in patients with mitral valve disease

PURPOSE OF REVIEW

Atrial fibrillation has been shown to be associated with less favorable short and long-term outcomes in patients having mitral valve surgery. Despite the growing evidence related to the potential benefits of surgical ablation for atrial fibrillation at the time of the mitral valve operation, there is a significant variability among surgeons in their approaches to atrial fibrillation. The purpose of this review is to discuss the current state of surgical ablation for atrial fibrillation as reported in the literature, as well as to discuss the significance of atrial fibrillation and the different surgical approaches to treat patients with mitral valve disease who may also concurrently suffer from tricuspid valve disease and atrial fibrillation.

RECENT FINDINGS

Increased mortality and morbidity are expected when atrial fibrillation is left untreated in patients undergoing mitral valve surgery. Modern surgical ablations resulted in a shift from the cut and sew maze procedure to the vast majority of cases being performed using different ablation technologies. The use of ablation technology simplifies the procedure. The expectation is that the vast majority of patients with atrial fibrillation will be ablated at the time of their mitral valve surgery.

SUMMARY

Patients who have mitral valve with or without tricuspid valve disease with a significant history of atrial fibrillation may benefit from surgical ablation to eliminate atrial fibrillation. No increased perioperative morbidity or mortality has been documented with an improved long-term survival and very low incidence of thromboembolic events.

Comparative study of human aortic and mitral valve interstitial cell gene expression and cellular function

Valve interstitial cells (VICs) are essential for valvular pathogenesis. However, the transcriptional profiles and cellular functions of human aortic VICs (hAVICs) and mitral VICs (hMVICs) have not been directly compared. We performed NimbleGen gene expression profiling analyses of hAVICs and hMVICs. Seventy-eight known genes were differentially expressed between hAVICs and hMVICs. Higher expression of NKX2-5, TBX15, OGN, OMD, and CDKN1C and lower expression of TBX5, MMP1, and PCDH10 were found in hAVICs compared to hMVICs. The differences in these genes, excepting OGN and OMD, remained in rheumatic VICs. We also compared cell proliferation, migration, and response to mineralization medium. hMVICs proliferated more quickly but showed more calcium deposition and alkaline phosphatase activity than hAVICs after culture in mineralization medium, indicating that hMVICs were more susceptible to in vitro calcification. Our findings reveal differences in the transcription profiles and cellular functions of hAVICs and hMVICs.

Signaling pathways in mitral valve degeneration

Heart valves exhibit a highly-conserved stratified structure exquisitely designed to counter biomechanical forces delivered over a lifetime. Heart valve structure and competence is maintained by heart valve cells through a process of continuous turnover extracellular matrix (ECM). Degenerative (myxomatous) mitral valve disease (DMVD) is an important disease associated with aging in both dogs and humans. DMVD is increasingly regarded as a disease with identifiable signaling mechanisms that control key genes associated with regulation and dysregulation of ECM homeostasis. Initiating stimuli for these signaling pathways have not been fully elucidated but likely include both mechanical and chemical stimuli. Signaling pathways implicated in DMVD include serotonin, transforming growth factor β (TGFβ), and heart valve developmental pathways. High circulating serotonin (carcinoid syndrome) and serotoninergic drugs are known to cause valvulopathy that shares pathologic features with DMVD. Recent evidence supports a local serotonin signaling mechanism, possibly triggered by high tensile loading on heart valves. Serotonin initiates TGFβ signaling, which in turn has been strongly implicated in canine DMVD. Recent evidence suggests that degenerative aortic and mitral valve disease may involve pathologic processes that mimic osteogenesis and chondrogenesis, respectively. These processes may be mediated by developmental pathways shared by heart valves, bone, and cartilage. These pathways include bone morphogenic protein (BMP) and Wnt signaling. Other signaling pathways implicated in heart valve disease include Notch, nitric oxide, and angiotensin II. Ultimately, increased understanding of signaling mechanisms could point to therapeutic strategies aimed at slowing or halting disease progression.

Local serotonin mediates cyclic strain-induced phenotype transformation, matrix degradation, and glycosaminoglycan synthesis in cultured sheep mitral valves

This study addressed the following questions: 1) Does cyclic tensile strain induce protein expression patterns consistent with myxomatous degeneration in mitral valves? 2) Does cyclic strain induce local serotonin synthesis in mitral valves? 3) Are cyclic strain-induced myxomatous protein expression patterns in mitral valves dependent on local serotonin? Cultured sheep mitral valve leaflets were subjected to 0, 10, 20, and 30% cyclic strain for 24 and 72 h. Protein levels of activated myofibroblast phenotype markers, α-smooth muscle actin (α-SMA) and nonmuscle embryonic myosin (SMemb); matrix catabolic enzymes, matrix metalloprotease (MMP) 1 and 13, and cathepsin K; and sulfated glycosaminoglycan (GAG) content in mitral valves increased with increased cyclic strain. Serotonin was present in the serum-free media of cultured mitral valves and concentrations increased with cyclic strain. Expression of the serotonin synthetic enzyme tryptophan hydroxylase 1 (TPH1) increased in strained mitral valves. Pharmacologic inhibition of the serotonin 2B/2C receptor or TPH1 diminished expression of phenotype markers (α-SMA and SMemb) and matrix catabolic enzyme (MMP1, MMP13, and cathepsin K) expression in 10- and 30%-strained mitral valves. These results provide first evidence that mitral valves synthesize serotonin locally. The results further demonstrate that tensile loading modulates local serotonin synthesis, expression of effector proteins associated with mitral valve degeneration, and GAG synthesis. Inhibition of serotonin diminishes strain-mediated protein expression patterns. These findings implicate serotonin and tensile loading in mitral degeneration, functionally link the pathogeneses of serotoninergic (carcinoid, drug-induced) and degenerative mitral valve disease, and have therapeutic implications.