Clinical Implications of Serum Biomarkers of Cardiac Stress in Aortic Stenosis

[Anesthesia for aortic valve stenosis : Anesthesiological management of patients with aortic valve stenosis during noncardiac surgery]

Aortic valve stenosis is a common condition that requires an anesthesiologist's in-depth knowledge of the pathophysiology, diagnostics and perioperative features of the disease. A newly diagnosed aortic valve stenosis is often initially identified from the anamnesis (dyspnea, syncope, angina pectoris) or a suspicious auscultation finding during the anesthesiologist's preoperative assessment. Interdisciplinary collaboration is essential to ensure the optimal management of these patients in the perioperative setting. An accurate anamnesis and examination during the preoperative assessment are crucial to select the most suitable anesthetic approach. Additionally, a precise understanding of the hemodynamic peculiarities associated with aortic valve stenosis is necessary. After a short summary of the overall pathophysiology of aortic valve stenosis, this review article focuses on the specific anesthetic considerations, risk factors for complications, and the perioperative management for noncardiac surgery in patients with aortic valve stenosis.

Troponin as a predictor of outcomes in transcatheter aortic valve implantation: systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is emerging as a therapeutic gold standard in the management of aortic stenosis. However, post-procedural complications of this procedure are being increasingly recognised. We therefore performed this systematic review and meta-analysis on the prognostic value of elevated troponin prior to TAVI to predict risk of post-procedural complications.

METHODS

We searched Medline (Ovid), Embase (Ovid), and the Cochrane Library from inception until May 2022, and included studies on the association between elevated pre-procedural troponin with 30-day mortality, long-term mortality, and post-procedural myocardial injury (PPMI). We generated summary odds ratios (OR) and hazards ratios (HR) using random-effects meta-analysis and performed subgroup analyses to evaluate differences in troponin threshold selection. Inter-study heterogeneity was tested using the I² test.

RESULTS

We included 10 studies involving 4200 patients. Serum troponin elevation prior to TAVI was significantly associated with long-term mortality [HR = 2.09 (95% CI 1.30-3.36)], but not with 30-day mortality [OR 1.76 (95% CI 0.96-3.22)]. Subgroup analysis showed a trend towards increased effect size and statistical significance for 30-day mortality as troponin elevation was more narrowly defined. Two studies reported on PPMI and found no statistically significant mean difference between groups.

CONCLUSIONS

Raised serum troponin is associated with increased long-term mortality following TAVI. Further clarification on the optimal troponin threshold for risk identification is required. High-quality studies that utilise ROC analysis for threshold selection are warranted.

Models and Techniques to Study Aortic Valve Calcification in Vitro, ex Vivo and in Vivo. An Overview

Aortic valve stenosis secondary to aortic valve calcification is the most common valve disease in the Western world. Calcification is a result of pathological proliferation and osteogenic differentiation of resident valve interstitial cells. To develop non-surgical treatments, the molecular and cellular mechanisms of pathological calcification must be revealed. In the current overview, we present methods for evaluation of calcification in different ex vivo, in vitro and in vivo situations including imaging in patients. The latter include echocardiography, scanning with computed tomography and magnetic resonance imaging. Particular emphasis is on translational studies of calcific aortic valve stenosis with a special focus on cell culture using human primary cell cultures. Such models are widely used and suitable for screening of drugs against calcification. Animal models are presented, but there is no animal model that faithfully mimics human calcific aortic valve disease. A model of experimentally induced calcification in whole porcine aortic valve leaflets ex vivo is also included. Finally, miscellaneous methods and aspects of aortic valve calcification, such as, for instance, biomarkers are presented.