Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

Impact of Anticoagulation Therapy After Bioprosthetic and Homograft Pulmonary Valve Replacement

BACKGROUND

The effect of anticoagulation on early postoperative outcomes after pulmonary valve replacement (PVR) with bioprosthetic valves and homografts is not yet defined. We hypothesized that short-term anticoagulation would be associated with improved valve durability.

METHODS

Patients undergoing PVR or right ventricle-to-pulmonary artery conduits with a bioprosthetic or homograft valve >15 mm in diameter between January 2015 and April 2021 at Boston Children's Hospital were retrospectively compared by anticoagulation status. Survival, postoperative echocardiographic data, and the incidence of pulmonary valve reintervention and prosthetic valve dysfunction were compared using multivariable Cox and logistic regression analyses adjusted for a propensity score based on anticoagulation therapy.

RESULTS

Among 531 patients with a median follow-up of 1.16 years, 130 received anticoagulation therapy. Freedom from reintervention was 99%, 92%, and 86% at 1, 3, and 5 years, respectively. Adjusted for propensity score, there was no association between reintervention and anticoagulation (hazard ratio, 0.78; 95% CI, 0.18-3.47; P = .75). The propensity score-adjusted rates of valve dysfunction were 9% in anticoagulated patients and 15% in non-anticoagulated patients (odds ratio, 0.54; 95% CI, 0.18-1.56; P = .25). There was no difference in early major bleeding rates between groups (3.4% vs 2.4%, P = .59) or in other postoperative outcomes. Only 1 of 18 (6%) of all bleeding events in the anticoagulated group occurred after starting anticoagulation.

CONCLUSIONS

Anticoagulation therapy appeared safe with no association with major postoperative bleeding. However, additional follow-up is necessary to assess its impact on midterm to long-term valve durability after PVR.

The association of bisphosphonates, calcium levels and PTH levels with bioprosthetic aortic valve degeneration

BACKGROUND

Bioprosthetic aortic valve (bAV) degeneration represents a major concern following aortic valve replacement (AVR). The association of bisphosphonates, serum calcium and serum parathyroid hormone (PTH) with native AV degeneration have been studied extensively. However, their association with structural valve degeneration (SVD) is yet to be elucidated.

METHODS

Patients who underwent AVR and had a baseline transthoracic echocardiogram (TTE) and at least one follow-up TTE spaced three months apart were included. SVD diagnosis was made according to American Society of Echocardiography guidelines. Patients' exposure to bisphosphonates and serum calcium and PTH levels were collected. A cutoff of 10.2 mg/dL for calcium and 65 pg/mL for PTH were used, respectively, to define pathological thresholds. Multivariable Cox proportional hazards regression models were built to evaluate the association between predictors and SVD.

RESULTS

Overall, 2002 patients were included, of whom 214 (10.7 %) had SVD, with median degeneration time of 4 (IQR: 1.9, 6.1) years. Among them, reintervention occurred in 82 (4.1 %) without significant differences according to bisphosphonate use (Log Rank p = 0.300), elevated PTH or calcium levels (Log Rank p = 0.702 and p = 0.703, respectively). In the multivariate analysis, neither bisphosphonates use (HR: 0.95, 95 % CI: 0.56-1.60; p = 0.862), elevated calcium levels >10.2 mg/dL (HR: 0.74, 95 % CI: 0.31-1.72; p = 0.489), nor elevated PTH levels >65 pg/mL (HR: 1.91, 95 % CI: 0.99-3.68; p = 0.052) was associated with SVD.

CONCLUSIONS

The use of bisphosphonates, elevated serum calcium levels and elevated serum PTH levels were not associated with SVD nor with reintervention on the bAV.

Advanced Silicon Modeling of Native Mitral Valve Physiology: A New Standard for Device and Procedure Testing

Mitral valve regurgitation is among the most prevalent valvular heart diseases and increases with age. Percutaneous therapy has emerged for the management of mitral regurgitation in high surgical risk patients. However, the long-term consequences of these interventions are still not fully understood due to their novelty and the difficulty of developing a strategy specific to the patient's anatomy and/or pathology. To optimize these outcomes, an in vitro patient-specific approach could provide important insights for the most suitable strategy to use according to the patient profile. To ensure the reliability of this in vitro approach, the aim of this study was to reproduce the physiological behavior of the healthy native mitral valve for future applications. To do so, different silicon combinations reproducing the physiological anatomy of a healthy mitral valve were developed and tested under physiological hemodynamic conditions in a cardiac simulator. The hemodynamic and biomechanical behaviors of each mitral valve model were analyzed and compared to the physiological values provided in the literature. This study identified EcoFlex 00-50 and DragonSkin 10 (Smooth-On Inc., Easton, PA, USA) as the optimal silicon combination resulting in physiological strain values and hemodynamic parameters. These findings could be useful for future patient-specific applications, helping in the optimization of percutaneous mitral valve therapy.

Multimodality Imaging to Understand Mechanisms of Right Ventricular Disease

Right ventricular (RV) disease is commonly encountered in patients with cardiovascular conditions and is associated with adverse prognosis. The principal pathogenic mechanisms giving rise to RV pathology include RV pressure overload, RV volume overload, and RV myocardial diseases. Noninvasive cardiac imaging is commonly used to detect the conditions associated with RV disease and ultimately guide therapeutic decisions. Transthoracic echocardiogram is usually the first-line test in patients with suspected RV disease and it provides relevant information on biventricular size and function, valvular abnormalities, and cardiac hemodynamics including pulmonary pressures. Cardiac magnetic resonance imaging is considered the reference standard noninvasive imaging test for quantifying ventricular size and function and cardiac shunts and has a secondary role for assessing valvular disease when echocardiography is nondiagnostic. Cardiac magnetic resonance imaging also provides insight into RV myocardial diseases such as inflammation, infarction, and infiltration. Nuclear cardiology and cardiac computed tomography imaging can also be used to inform on specific RV disease mechanisms originating from lung disease and pulmonary vasculature disorders. In this review, we discuss the role and utility of cardiac imaging in characterizing RV mechanisms of disease and provide a suggested framework for clinicians to appropriately utilize imaging in these clinical scenarios.

The Year in Perioperative Echocardiography: Selected Highlights from 2024

This article is the ninth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

Paravalvular Leak in Transcatheter Aortic Valve Implantation: A Review of Current Challenges and Future Directions

Transcatheter aortic valve implantation (TAVI) has emerged as a revolutionary therapeutic modality for the management of severe aortic stenosis (AS), particularly in patients who are at high or prohibitive risk for surgical aortic valve replacement (SAVR). Over the past decade, extensive clinical evidence has expanded the indications for TAVI to include intermediate- and low-risk populations, which usually represent a population of younger age, in which the most common complications of TAVI, including paravalvular leak (PVL) and pacemaker implantation, should be avoided. This review focuses on the incidence and predictors of PVL in various types of TAVI implantation, its clinical implication, and the prevention strategies to tackle this complication.

The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field

The tricuspid valve has become a major focus of novel structural heart interventions, with the Conformité Européenne approval of 5 devices in Europe and the U.S. Food and Drug Administration approval of 2 devices in the United States. Multiple meta-analyses and large population-based registries have shown that although significant tricuspid regurgitation (TR) often accompanies left heart or pulmonary vascular diseases, it is associated with an increased risk of mortality and a reduced quality of life after adjusting for these comorbidities. Echocardiography remains the imaging modality of choice for diagnosing the etiology and assessing the severity of TR. However, advanced imaging techniques have played an essential role in the rapid advancement of the structural field and, in particular, transcatheter interventions for TR. Herein, we review the advances made in this field, focusing on the role that imaging has played in shaping a new field of study.

Best Practices for Imaging of Transcatheter Valve Failure: An Update From the Heart Valve Collaboratory

This updated Heart Valve Collaboratory framework addresses the growing concern for transcatheter valve failure (TVF) following transcatheter aortic valve replacement (TAVR). With the increasing volume of redo-TAV and surgical TAV explantation, there is a critical need for standardized pathways and protocols for evaluating TVF using echocardiography and cardiac computed tomography (CT) angiography. This document clarifies prior definitions of bioprosthetic valve deterioration and bioprosthetic valve failure in a practical, imaging directed context for TAVR. It discusses various imaging modalities for diagnosing TVF, including echocardiography, cardiac CT angiography, cardiac magnetic resonance, and positron emission tomography/CT. Recommendations are provided on the systematic imaging for: 1) follow-up post-TAVR; 2) procedural planning for redo-TAV; and 3) post-redo-TAV, emphasizing the importance of regular monitoring and the need for comprehensive imaging data to optimize patient outcomes in the lifetime management of aortic valve disease.

Novel Transthoracic Pulmonary Valve Implantation Using Self-Expanding Salus Valve: A Prospective Study of Safety and Mid-Term Outcomes

BACKGROUND

Transcatheter pulmonary valve replacement (TPVR) has emerged as a valuable treatment for severe pulmonary regurgitation (PR). The Salus valve (Balance Medical Technology Co. Ltd., Beijing, China) represents a novel self-expanding valve stent designed for deployment through a transthoracic approach with a small subxiphoid incision.

AIMS

The objective of this study was to evaluate the medium-term safety and efficacy of Salus valve stents in this patient population.

METHODS

This prospective cohort study enrolled patients who underwent transthoracic pulmonary valve stenting at Guangdong Provincial People's Hospital from September 2021 to September 2024. Inclusion criteria included moderate-to-severe PR following RVOT reconstruction, age ≥ 14 years, and specific clinical/imaging parameters. Primary endpoints were pulmonary regurgitation fraction < 20%, freedom from reintervention at 12 months, and major adverse events (MAE). MAE were defined as death, reintervention, recurrent severe PR, worsening heart failure, cardiac arrest, new severe ventricular arrhythmias, and third-degree AV block.

RESULTS

Among 38 patients (mean age 24.08 ± 8.12 years), all procedures were successfully completed, although intraoperative valve displacement occurred in three cases. During a median follow-up period of 24 months, significant improvements were observed in right ventricular volumes: Right Ventricular End-Diastolic Volume Index (RVEDVI) decreased from 141.45 to 109.98 mL/m2 and Right Ventricular End-Systolic Volume Index (RVESVI) decreased from 74.27 to 56.62 mL/m2 (both p < 0.01). No mortality or need for reintervention was observed during the follow-up period. The estimated freedom from major adverse events at 36 months was 87.2%.

CONCLUSION

The Salus valve demonstrated safety and efficacy for severe PR treatment through its transthoracic approach, which offers unique advantages in terms of direct access and immediate complication management. Longer follow-up is needed to assess long-term durability.

Transthoracic echocardiographic assessment of ventricular function in functional single ventricle: a comprehensive review

BACKGROUND

Functional single ventricle represents a complex congenital cardiac malformation where ventricular function directly impacts patients' quality of life and prognosis. Accurate assessment of ventricular function in FSV patients is crucial for treatment planning, surgical intervention, and monitoring therapeutic efficacy.

MAIN TEXT

Echocardiography, as a non-invasive, readily available, and real-time cardiac imaging modality, has emerged as the preferred method for evaluating functional single ventricle ventricular function. With continuous advancement and innovation in echocardiographic technology, methods for evaluating functional single ventricle ventricular function have become increasingly diverse and refined. This review synthesizes recent research developments in echocardiographic assessment of functional single ventricle ventricular function and analyzes the advantages, limitations, and future applications of various techniques.

CONCLUSION

Strain and strain rate derived from two-dimensional speckle tracking imaging have progressively entered clinical application, demonstrating substantial potential as crucial parameters for evaluating single ventricular function. Emerging technologies, including three-dimensional speckle tracking imaging and non-invasive pressure-strain loops, show promise for contributing to multi-dimensional, integrated assessment as research continues to advance.

Association between lipoprotein(a) and long-term prognosis in patients receiving transcatheter aortic valve replacement

BACKGROUND

Lipoprotein(a) (Lp[a]) has been identified as a significant risk factor for aortic stenosis (AS). However, its impact on outcomes post-transcatheter aortic valve replacement (TAVR) remains unknown.

OBJECTIVE

To investigate the association between Lp(a) levels and long-term outcomes as well as its impact on the bioprosthetic valve degeneration in patients post-TAVR.

METHODS

Patients with severe AS who underwent TAVR were consecutively recruited. Lp(a) was measured before TAVR procedure. The subjects were divided according to levels of Lp(a). The outcomes were all-cause mortality and possible structural valve degeneration (SVD) measured by Doppler echocardiography. Cox regression models and competing risk models were used to explore the association between Lp(a) levels and outcomes.

RESULTS

Of the 601 included patients (mean age: 75.5 ± 7.2, male: 58.7%), 137 patients (22.7%) experienced mortality after a median follow-up of 3.9 years. After multivariable adjustment, elevated Lp(a) (defined as ≥30 mg/dL) was identified as an independent predictor of all-cause mortality (hazard ratio [HR]: 1.81, 95% CI: 1.27-2.57, P = .001) and cardiovascular mortality (HR: 2.02, 95% CI: 1.12-3.66, P = .020). Elevated Lp(a) was also associated with increased risk of possible SVD (subdistribution HR: 3.40, 95% CI: 1.32-8.79, P = .012). Using a threshold value of 50 mg/dL for elevated Lp(a) still supported the main findings.

CONCLUSIONS

Elevated baseline Lp(a) levels are associated with poor clinical outcomes and possible SVD in patients with severe AS undergoing TAVR. Further research is warranted to confirm these findings.

Intraoperative Transesophageal Echocardiographic Guidance in Cardiac Surgery

Transesophageal echocardiography (TEE) is a valuable tool for diagnosing structural heart diseases, offering superior resolution compared to transthoracic echocardiography. It allows for real-time evaluation of cardiac valves and both systolic and diastolic heart function. Additionally, TEE facilitates the prompt detection of potential complications during cardiac surgeries, such as paravalvular leaks, iatrogenic aortic dissections, and pericardial effusions. Advances in imaging, including 3D echocardiography, have further enhanced the visualization of complex structures like cardiac valves, providing "surgical views" that improve preoperative planning. These features have also made TEE indispensable for postoperative evaluation of cardiac valve repairs and for intraoperative guidance during minimally invasive procedures. This review article aims to summarize the indications for using TEE as an intraoperative tool in cardiac surgery.

A Retrospective Analysis of Standardized Gradient Calculations for Evaluating Patient-Prosthesis Mismatch Following Mechanical Aortic Valve Replacement

Background: Aortic stenosis (AS) is one of the most common valvular heart diseases, particularly in the elderly, with a prevalence of approximately 3% in individuals over 75 years of age. Aortic valve replacement (AVR) remains the standard treatment, yet postoperative hemodynamic assessment is often complicated by variations in prosthetic valve size, left ventricular ejection fraction (LVEF), effective orifice area (EOA), and body surface area (BSA). These factors significantly influence prosthetic valve function and contribute to patient-prosthesis mismatch (PPM), which has been associated with worse clinical outcomes. Traditional transvalvular gradient measurements often fail to account for these patient-specific variables. This study introduces a novel approach to standardized gradient calculations, aiming to enhance the accuracy and comparability of prosthetic valve assessments. Methods: A retrospective analysis was conducted on 115 patients who underwent mechanical AVR at a single center. Patients were categorized into three groups based on the prosthetic valve type: St. Jude Medical (SJM) HP (n = 31); SJM Regent (n = 54); and those who underwent aortic root enlargement (ARE) (n = 30). Preoperative and postoperative transthoracic echocardiography (TTE) was performed to measure conventional and standardized transvalvular gradients. Four novel standardized gradient calculations were developed to adjust for individual hemodynamic differences, improving the accuracy of prosthetic valve function assessment. Results: Standardized gradient calculations demonstrated significant differences between prosthesis types. Postoperative standardized gradients were significantly higher in the SJM HP group compared to the SJM Regent and aortic-root-enlargement groups (p < 0.001, p < 0.05). The lowest standardized gradients were observed in patients who received the SJM Regent prostheses (p < 0.05). Although conventional measurements showed no significant differences, standardized calculations revealed that patients with 19 mm prostheses exhibited significantly higher transvalvular gradients than those with 21 mm prostheses (p < 0.05), emphasizing the clinical importance of prosthesis size in postoperative hemodynamics. Conclusions: Standardized gradient calculations provide a more objective, reliable, and patient-specific assessment of prosthetic valve function by minimizing interpatient variability. This approach improves the detection of patient-prosthesis mismatch and optimizes postoperative hemodynamic evaluation, potentially leading to better prosthesis selection and surgical decision-making. However, further validation is required in larger cohorts before these methods can be widely adopted into clinical practice. Future studies should assess their impact on long-term clinical outcomes, including left ventricular remodeling and patient survival.

Optimizing Device Selection in Percutaneous Paravalvular Leak Closure: A Comparative Study of Different Transthoracic and Transesophageal Echocardiographic Techniques

BACKGROUND

Clinically significant paravalvular leak (PVL) may complicate both surgical and transcatheter valve implantation. Percutaneous PVL closure (PPVLC) is becoming an increasingly attractive alternative to redo surgery, with demonstrated lower mortality and morbidity rates. Echocardiographic techniques are crucial for accurate diagnosis, defect sizing, and determining the appropriate size of the sealing devices.

AIMS

There is no consensus on the optimal imaging modality for PVLs. We aimed to compare transthoracic and transesophageal echocardiographic measurements to accurately determine defect size and estimate device size.

METHODS

We reviewed hospital records to identify patients diagnosed with moderate to severe and severe PVL from 2018 to 2024. A total of 81 patients who underwent PPVLC were evaluated. Eight of these patients were excluded due to unsuccessful PPVLC, leaving 73 patients who were successfully treated. The defect size for all patients was evaluated using 2D transthoracic echocardiography (TTE), 2D transesophageal echocardiography (TEE), direct 3D TEE cropped volume rendering vena contracta (VC) measurement, and 3D TEE multiplanar reconstruction (3D TEE MPR).

RESULTS

Among the 73 patients, 42 underwent aortic PPVLC and 31 underwent mitral PPVLC. Proportional odds logistic regression analysis identified 3D TEE MPR measurement as the strongest predictor of device size accuracy, both overall and within the aortic/mitral subgroups. In the mitral subgroup, the predictive power of direct 3D TEE cropped volume rendering VC measurement and 3D TEE MPR measurement were similar. Furthermore, a cut-off value of 7 mm was identified for hemodynamically significant jets as measured by 3D methods.

CONCLUSION

Our findings suggest that using 3D TEE MPR significantly improves the accuracy of device size selection in both mitral and aortic PVL. Additionally, direct 3D TEE cropped volume rendering VC measurement can serve as a viable alternative for patients with mitral PVL.

Hemodynamic response of the aortic valve during dobutamine onset then progressive aortic banding

An increasing number of procedures over the past two decades for aortic stenosis (AS) reflects the combination of an aging population and less invasive transcatheter options. As a result, the hemodynamics of the aortic valve (AV) have gained renewed interest to understand its behavior and to optimize patient selection. We studied the hemodynamic relationship between pressure loss (ΔP) and transvalvular flow (Q) of the normal AV as well as the impact of a variable supravalvular stenosis. Our mechanistic study included 11 healthy swine monitored during dobutamine stress and followed by acute aortic banding to simulate AS. Hemodynamics were continuously recorded, and transvalvular ΔP versus Q were analyzed using proportional and linear models. During dobutamine infusion, normal valves exhibited a highly linear relationship between ΔP and Q (median R2 of 0.93). Progressive aortic banding eventually displayed a highly linear relationship between an increasing ΔP and the decreasing Q, characterized by a constant systemic circulatory resistance (median R2 of 0.91). Consequently, a normal AV can be described by a single parameter: its resistance, median 0.37 Wood units (WU) in swine. During dobutamine stress and aortic banding, the systemic bed behaves like a constant and stable resistance, median of 11.9 WU in swine. These findings carry significant implications for quantifying normal and diseased AV behavior and potentially might improve patient selection and treatment outcomes.NEW & NOTEWORTHY This study demonstrates that the normal aortic valve functions like a resistor with a proportional pressure loss ΔP versus transvalvular flow Q relationship. During dobutamine stress and progressive aortic banding, a "load line" of constant resistance characterizes the systemic circulation. Consequently, during stress conditions, the relative pressure loss over a stenotic aortic valve (the stress aortic valve index, SAVI) quantifies the relative reduction in maximal flow. Potentially, SAVI might optimize patient selection for procedures to treat aortic stenosis.

Multimodality Imaging Evaluation of Diseases of the Pulmonic Valve and Right Ventricular Outflow Tract for the Adult Cardiologist

Disorders of the pulmonic valve (PV) receive considerably less attention than other forms of valvular heart disease. Due to the dramatically improved survival of children with congenital heart disease over the last 5 decades, there has been a steady increase in the prevalence of adults with congenital heart disease, which necessitates that clinicians become familiar with the anatomy and the evaluation of right ventricular outflow tract and PV anomalies. A multimodality imaging approach using echocardiography, cardiac computed tomography, and magnetic resonance imaging is essential for a comprehensive evaluation of the anatomy and function of the right ventricular outflow tract, PV, and supravalvular region. As clinical presentation is often insidious with nonspecific symptoms, yet morbidity and mortality associated with severe untreated PV disease are significant, a high index of suspicion coupled with appropriate use of imaging techniques is critical in facilitating timely diagnosis and treatment. In this review, we aim to present a comprehensive approach to the diagnosis of PV disease and associated right ventricular outflow tract or supravalvular pulmonary stenosis, including optimal use of multimodality imaging to facilitate timely diagnosis, optimize therapeutic strategies, enhance postprocedural surveillance, and ultimately improve patient outcomes.

Accelerated structural valve deterioration in systemic sclerosis patients following transcatheter aortic valve replacement: a case series

Background

Systemic sclerosis (SSc) is marked by an excessive systemic accumulation of collagen. Recent literature implies that aortic stenosis is more prevalent in patients with SSc than previously thought. While there are limited feasibility studies on transcatheter aortic valve replacement (TAVR) in this population, the long-term outcomes remain uncertain.

Case summary

We report two cases of patients with SSc who developed early structural valve deterioration following TAVR, necessitating successful redo-TAVR procedures. Both patients exhibited extensive soft tissue calcinosis as a manifestation of their underlying condition.

Discussion

The fibrotic and calcific processes inherent to certain SSc subtypes could potentially adversely impact the durability and functionality of transcatheter aortic valves. Our observation highlights the need for vigilant post-procedural surveillance and individualized management strategies in this unique patient population. Further investigation into the mechanisms underlying valve degeneration in this patient subset is warranted. Nevertheless, redo-TAVR procedure appears to be a viable option.

Infective endocarditis following transcatheter mitral valve-in-valve replacement: a clinical case report

BACKGROUND

Transcatheter valve-in-valve replacement (TMViVR) is an alternative option for patients with bioprosthetic valve failure (BVF) who are at high surgical risk. Although infective endocarditis (IE) after transcatheter mitral valve-in-valve replacement is unusual, it is associated with significantly high mortality.

CASE PRESENTATION

An 81-year-old male patient was admitted with intermittent thoracic tightness, chest pain persisting for 3 years, and shortness of breath with nausea for 1 week. Two months prior, he received transcatheter mitral valve-in-valve replacement for recurrent heart failure and severe prosthetic mitral regurgitation. He developed a fever in the early postoperative period after TMViVR, with Staphylococcus lugdunensis bacteremia detected. He was discharged from the hospital after the blood culture turned negative following antibiotic treatment. During this hospitalization, prosthetic valve endocarditis was confirmed, resulting in severe prosthetic mitral stenosis and severe pulmonary hypertension. Blood cultures identified Staphylococcus lugdunensis again. Despite anti-infective therapy, the patient succumbed to complications from his complex medical history and comorbidities.

CONCLUSIONS

While transcatheter valve implantation provides an alternative option for dealing with valvular disease, prosthetic valve endocarditis (PVE) as an unusual but catastrophic complication with poor prognosis should be taken seriously. Early detection through echocardiography, especially in high-risk patients presenting with suspicious symptoms, is crucial for timely intervention. Additionally, an appropriate perioperative antibiotic regimen is essential to prevent infection and improve prognosis.

TAVI with the ACURATE neo2 in severe bicuspid aortic valve stenosis: the Neo2 BAV Registry

BACKGROUND

The ACURATE neo2 is a contemporary transcatheter aortic valve implantation (TAVI) system approved for the treatment of severe aortic stenosis in Europe. The ACURATE neo2 has not been evaluated in bicuspid aortic valve (BAV) stenosis.

AIMS

We sought to evaluate the safety and efficacy of ACURATE neo2 in patients with BAV stenosis.

METHODS

We retrospectively analysed consecutive severe BAV stenosis patients undergoing TAVI with ACURATE neo2 at 10 European centres. Imaging data from preprocedural multislice computed tomography, pre- and postprocedural echocardiography, and procedural cinefluoroscopy were evaluated by a core laboratory. Valve Academic Research Consortium 3 (VARC-3)-defined 30-day procedure safety and efficacy were the primary endpoints. Adverse events were site-reported according to VARC-3 criteria.

RESULTS

Among 181 patients with BAV stenosis treated with the ACURATE neo2, the mean age was 77.5±7.2 years, 58.0% were female, and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.3% (1.6-3.7%). Most procedures were transfemoral, and predilatation was performed in all cases. A second valve was required in 4 cases (2.2%). VARC-3-defined technical success was 95.6%. The primary endpoints of device success and early safety occurred in 90.6% and 82.3%, respectively. At 30 days, cardiovascular death occurred in 2.2% (N=4) and stroke in 1.6% (N=3). Core laboratory-adjudicated echocardiography reported an effective orifice area of 2.0 (1.7-2.5) cm2 and a mean transvalvular gradient of 6.5 (4.6-9.0) mmHg. Half of all cases (51.2%) had no paravalvular leak, while moderate leak occurred in 4.3%. A new permanent pacemaker was required in 11 patients (6.5%).

CONCLUSIONS

The ACURATE neo2 demonstrated favourable clinical outcomes and bioprosthetic valve performance at 30 days in selected patients with severe BAV stenosis.

Hemodynamic effect of supra-annular implantation of SAPIEN 3 balloon expandable valve

The hemodynamic impact of the implantation depth for balloon-expandable valves is under-investigated, especially with higher implantation techniques. We assessed the hemodynamic performance of supra-annular SAPIEN 3 valve implantation. This retrospective study involved consecutive patients who underwent transcatheter aortic valve replacement (TAVR) using the SAPIEN 3. The device implantation depth and transcatheter heart valve (THV) leaflet-nadir position were angiographically analyzed, and supra-annular implantation was defined as a higher leaflet-nadir position than the original annular line. The Doppler hemodynamic status was evaluated at patient discharge. Among 184 patients, 120 (65%) underwent supra-annular implantation, and their mean implantation depth was significantly lower than that of intra-annular implantation (1.1 vs. 5.2 mm, p < 0.001). No patients developed valve embolization or coronary occlusion, and none required the TAV-in-TAV procedure. Two (1.6%) patients in the supra-annular implantation group had a mild or greater paravalvular leak. Echocardiography demonstrated that supra-annular implantation had better hemodynamic performance, showing a larger indexed effective orifice area (iEOA) compared with intra-annular implantation (1.09 vs. 0.97 cm2/m2, p < 0.01). There was a weak but negative correlation between the implantation depth and iEOA (r =  - 0.27, p < 0.01). Moderate or severe prosthesis-patient mismatch (PPM) was found in 35.9% of the intra-annular group and 9.2% of supra-annular of the supra-annular group (p < 0.01). In the multivariable analysis, supra-annular implantation was an independent predictor of better THV function (iEOA > 0.85). Supra-annular SAPIEN 3 implantation provides beneficial hemodynamic effects and reduces the PPM risk.

Contemporary Multi-modality Imaging of Prosthetic Aortic Valves

With the aging of the general population and the rise in surgical and transcatheter aortic valve replacement, there will be an increase in the prevalence of prosthetic aortic valves. Patients with prosthetic aortic valves can develop a wide range of unique pathologies compared to the general population. Accurate diagnosis is necessary in this population to generate a comprehensive treatment plan. Transthoracic echocardiography is often insufficient alone to diagnose many prosthetic valve pathologies. The integration of many imaging modalities, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, and nuclear imaging, is necessary to care for patients with prosthetic valves. The purpose of this review is to describe the strengths, limitations, and contemporary use of the different imaging modalities necessary to diagnose prosthetic valve dysfunction.

Advanced Cardiac Point-of-Care Ultrasound: A Systematic Review of Select Cardiac Diseases

Basic cardiac point-of-care ultrasound (POCUS)/focused cardiac ultrasound (FoCUS) often reveals incidental findings. Consider a patient with dyspnea in whom FoCUS reveals left ventricular (LV) hypertrophy, calcified valves, and pericardial effusion but "normal" LV systolic function. Such findings may trigger comprehensive echocardiography. Although advanced cardiac POCUS cannot replace comprehensive echocardiography, its role at the bedside is evolving. This systematic review identified studies suggesting that a sufficiently trained practitioner can leverage advanced techniques to evaluate conditions such as hypertrophic cardiomyopathy (4), LV diastolic dysfunction (6), severe valvular heart disease (6), and tamponade (8). This article discusses the use of advanced cardiac POCUS in these conditions.

Management of Surgical Aortic Valve Replacement Degeneration With Transcatheter Aortic Valve Implantation (TAVI in SAVR): Experience in Nicaragua

Severe aortic valve stenosis poses a significant risk for the aging population, often escalating from mild symptoms to life-threatening heart failure and sudden death. Without timely intervention, this condition can lead to disastrous outcomes. The advent of transcatheter aortic valve implantation (TAVI) has gained popularity, emerging as an effective alternative for managing severe aortic stenosis (AS) in high-risk patients experiencing deterioration of previously implanted bioprosthetic surgical aortic valves (SAV), which introduces complex challenges such as device compatibility and anatomical considerations. We report the case of a 76-year-old male with a history of stage III hypertension, compensated type 2 diabetes, and aortic valve disease who underwent bioprosthetic valve replacement in 2013. His medications included metoprolol, metformin/glibenclamide, and levothyroxine. He presented with moderate exertional dyspnea (NYHA II) over four months, relieved by rest. Physical examination revealed a crescendo-decrescendo systolic murmur at the aortic focus. The aortic prosthesis stenosis was confirmed by a transthoracic echocardiogram. A CT angiogram showed bioprosthetic degeneration and significant calcification, allowing for transcatheter aortic valve implantation in the surgical aortic valve. The procedure was successfully performed via the transfemoral route using a 21.5 mm MyVal balloon-expandable valve. The intervention improved the patient's quality of life, resolving NYHA class III dyspnea and enabling greater independence in daily activities. Echocardiographic findings demonstrated a significant reduction in the transvalvular gradient, enhancing cardiac function and eliminating the immediate risk of valvular dysfunction progression, contributing to increased life expectancy and emotional well-being. This case highlights the feasibility and clinical benefits of transcatheter aortic valve implantation in surgical aortic valves for managing valve degeneration in a resource-limited setting, thereby representing a significant advancement in the treatment of aortic valve disease. The successful outcome demonstrates the importance of adopting innovative, minimally invasive techniques, particularly in regions with limited advanced interventions, by alleviating dyspnea, enhancing cardiac function, and significantly improving the patient's quality of life, emotional well-being, and prognosis.

Functional Mitral Regurgitation Post-Isolated Aortic Valve Replacement

Background: The management of mitral regurgitation during aortic valve replacement remains a complex question. Secondary mitral regurgitation often improves post-aortic valve replacement without mitral valve surgery, but residual mitral regurgitation can significantly affect long-term outcomes. This study investigates the natural history of mitral regurgitation following isolated aortic valve replacement and identifies prognostic factors for persistent mitral regurgitation. Methods: A retrospective study was conducted on 108 patients who underwent isolated aortic valve replacement. Patients were categorized based on mitral regurgitation improvement. Additionally, patients were divided into patient-prosthesis mismatch and non-patient-prosthesis mismatch groups based on the aortic prosthesis. Preoperative and postoperative echocardiographic data were analyzed. Results: In total, 63% of patients showed mitral regurgitation improvement. The improved functional MR group showed significant reductions in peak and mean transvalvular pressure gradients. In contrast, the patient-prosthesis mismatch group had persistent mitral regurgitation improvement in 59.2% of patients. The non-patient-prosthesis mismatch group exhibited significant structural improvements and a reduction in mitral regurgitation severity in 68.6% of patients. Conclusions: The study shows that aortic valve replacement could significantly improve MR when patient-prosthesis mismatch is avoided. This approach maximizes hemodynamic outcomes, mitigates the risk of residual or worsening mitral regurgitation, and potentially reduces the need for additional mitral valve interventions.

Cardiac Computed Tomography for Cardioembolic Stroke Evaluation in a Patient With a Mechanical Aortic Valve

We present a case of cardioembolic stroke in a patient with a history of mechanical aortic valve who was compliant with anticoagulation medication. Cardiac computed tomography was used as an alternative, noninvasive means of evaluation for the cardioembolic source of stroke and identified subvalvular mobile pannus of the mechanical aortic valve.

Application of Echocardiography in Anaesthesia: From Preoperative Risk Assessment to Postoperative Care

Echocardiography has carved out a fundamental niche in anaesthesiology, revolutionizing the monitoring and management of cardiac function during surgery. Clinical practice has changed from simple 2D and 3D echocardiography to more sophisticated applications such as incorporating artificial intelligence. Echocardiography provides detailed real-time information about cardiac anatomy and function, helping anaesthesiologists make better decisions regarding tailoring anesthetic interventions and optimizing patient outcomes. From optimizing hemodynamic management in patients with severe aortic stenosis to fine-tuning fluid and vasopressor therapy in patients with right heart dysfunction, echocardiography has improved the care provided in the perioperative period. These applications permit the demonstration of not only technical advantages that could accrue from echocardiography but are also a part of individualized care to improve the outcomes of patients. The challenges in integrating echocardiography with anaesthesia include operator dependency, a steep learning curve in acquiring echocardiographic skills, and limitations due to patient factors and technological limitations, which lead to poor echocardiographic performance. Additionally, transoesophageal echocardiography (TEE) is an invasive procedure with several potential risks that must be considered cautiously. Continuing education, certification recommendations, and skill development are prerequisites for this echocardiography tool to remain robust and reliable in anaesthesiology. Technological innovation, especially in improving 3D imaging and integration with artificial intelligence, is where a very bright future lies ahead for echocardiography. It would further accelerate the process of echocardiographic evaluation and improve diagnostic accuracy. All these would turn out to be more person-centered for each patient. Anaesthesiologists must, therefore, pace themselves with such developments so these can be appropriately applied in the clinics. In summary, echocardiography became so integrally ingrained into anaesthesia that it propelled the specialty with essential tools anaesthesiologists use to manage patients for optimum outcomes. Its application has difficulties and limitations, but continued professional development and development of echocardiographic technology will make sure that its benefits are maximized. Quickly, echocardiography is becoming central to anaesthesiology's role in optimizing patient care and surgical success as we move into the application of evermore sophisticated echocardiographic techniques.

Higher-Than-Usual Target International Normalized Ratio (INR) Range Required With On-X Aortic Valve Secondary to Recurrent Thromboembolic Strokes: A Case Report

Although the On-X aortic valve (AO) is considered less thrombogenic compared to its counterparts, we present a case where recurrent thromboembolic ischemic stroke occurred, first with a slightly sub-therapeutic, then even with an elevated International Normalized Ratio (INR).  A 36-year-old male, the background of On-X AO replacement but no other risk factors, developed thromboembolic stroke twice while on Warfarin, first with INR 1.4, second with INR 2.4. Despite extensive investigation, other than elevated levels of low-density lipoproteins, no other treatable cause was found with the latter episode. The INR range was increased to 2.5-3.5, and aspirin and statin were added. The occurrence of thromboembolic stroke with an On-X AO despite maintaining an INR of 2.4, presents a dilemma for future prevention. The American Heart Association (AHA) and the American College of Cardiology (ACC) guidelines for thromboembolism prevention in case of an On-X AO recommend an INR range of 1.5-2 as being effective when warfarin is used along with aspirin. The take-home message is that the recommendation of an INR range of 1.5-2 with an On-X AO should be approached with caution; aspirin should be strongly considered regardless of the presence of thromboembolic risk factors. Patients developing thromboembolism have a high risk of recurrence. Therefore, a higher INR, along with the addition of aspirin and statin should be considered. Studies are needed to establish guidelines for a reliable INR range in these scenarios.

Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives

Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.

Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

Severe Prosthetic Mitral Valve Regurgitation Hidden by Acoustic Shadowing: The Importance of Spectral Doppler in Prosthetic Valve Assessment

•Acoustic shadowing limits Doppler evaluation in PHVs, potentially masking MR. •Spectral Doppler is an important tool to detect prosthetic MR. •TEE can supplement TTE, partially avoiding acoustic shadowing and reverberations.

Multidisciplinary Perspectives of Challenges in Infective Endocarditis Complicated by Septic Embolic-Induced Acute Myocardial Infarction

BACKGROUND

Infective endocarditis (IE) management is challenging, usually requiring multidisciplinary collaboration from cardiologists, infectious disease specialists, interventional cardiologists, and cardiovascular surgeons, as more than half of the cases will require surgical procedures. Therefore, it is essential for all healthcare providers involved in managing IE to understand the disease's characteristics, potential complications, and treatment options. While systemic embolization is one of the most frequent complications of IE, the coronary localization of emboli causing acute myocardial infarction (AMI) is less common, with an incidence ranging from 1% to 10% of cases, but it has a much higher rate of morbidity and mortality. There are no guidelines for this type of AMI management in IE.

METHODS

This narrative review summarizes the current knowledge regarding septic coronary embolization in patients with IE. Additionally, this paper highlights the diagnosis and management challenges in such cases, particularly due to the lack of protocols or consensus in the field.

RESULTS

Data extracted from case reports indicate that septic coronary embolization often occurs within the first two weeks of the disease. The aortic valve is most commonly involved with vegetation, and the occluded vessel is frequently the left anterior descending artery. Broad-spectrum antibiotic therapy followed by targeted antibiotic therapy for infection control is essential, and surgical treatment offers promising results through surgical embolectomy, concomitant with valve replacement or aspiration thrombectomy, with or without subsequent stent insertion. Thrombolytics are to be avoided due to the increased risk of bleeding.

CONCLUSIONS

All these aspects should constitute future lines of research, allowing the integration of all current knowledge from multidisciplinary team studies on larger patient cohorts and, subsequently, creating a consensus for assessing the risk and guiding the management of this potentially fatal complication.

Clinical Features and Patient Outcomes in Infective Endocarditis with Surgical Indication: A Single-Centre Experience

BACKGROUND

Infective endocarditis (IE) is marked by a heightened risk of embolic events (EEs), uncontrolled infection, or heart failure (HF).

METHODS

Patients with IE and surgical indication were enrolled from October 2015 to December 2018. The primary endpoint consisted of a composite of major adverse events (MAEs) including all-cause death, hospitalizations, and IE relapses. The secondary endpoint was all-cause death.

RESULTS

A total of 102 patients (66 ± 14 years) were enrolled: 50% with IE on prosthesis, 33% with IE-associated heart failure (IE-aHF), and 38.2% with EEs. IE-aHF and EEs were independently associated with MAEs (HR 1.9, 95% CI 1.1-3.4, p = 0.03 and HR 2.1, 95% CI 1.2-3.6, p = 0.01, respectively) and Kaplan-Meier survival curves confirmed a strong difference in MAE-free survival of patients with EEs and IE-aHF (p < 0.01 for both). IE-aHF (HR 4.3, 95% CI 1.4-13, p < 0.01), CRP at admission (HR 5.6, 95% CI 1.4-22.2, p = 0.01), LVEF (HR 0.9, 95% CI 0.9-1, p < 0.05), abscess (HR 3.5, 95% CI 1.2-10.6, p < 0.05), and prosthetic detachment (HR 4.6, 95% CI 1.5-14.1, p < 0.01) were independently associated with the all-cause death endpoint.

CONCLUSIONS

IE-aHF and EEs were independently associated with MAEs. IE-aHF was also independently associated with the secondary endpoint.

Paravalvular regurgitation after transcatheter aortic valve replacement: incidence, quantification, and prognostic impact

Transcatheter aortic valve replacement (TAVR) is the standard of care in aortic stenosis with results comparable to surgical aortic valve replacement. However, paravalvular regurgitation (PVR) is more common after TAVR. With the alteration of devices and implantation techniques, the incidence of moderate or more PVR has declined. Mild PVR is still common in around 30% of TAVR patients in low-risk trials. Progression of AS causes myocardial hypertrophy and varying degrees of diastolic dysfunction which may cause heart failure even in combination with small volumes of PVR. Any degree of PVR is associated with an increased risk of overall and cardiovascular mortality. Predictors of PVR are annular eccentricity, severe calcification of the aortic valve, bicuspid aortic valves, and type of prosthesis where balloon-expandable devices are associated with less PVR. PVR is diagnosed using echocardiography, aortic angiogram with or without videodensitometry, haemodynamic parameters, or cardiac magnetic resonance. PVR can be treated using post-dilation, interventional treatment using a vascular plug, or implantation of a second device. Successful post-dilation depends on balloon size which should at least be equal to or >95% of the mean annulus diameter. Implantation of a second device to reduce PVR is successful in ∼90% of cases, either through lengthening of the sealing skirt in case of inadequate position or through further expansion of the index device. Implantation of a vascular plug can successfully reduce PVR and reduce mortality.