ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons

In Vivo Three-Dimensional Geometric Reconstruction of the Mouse Aortic Heart Valve

Aortic valve (AV) disease is a common valvular lesion in the United States, present in about 5% of the population at age 65 with increasing prevalence with advancing age. While current replacement heart valves have extended life for many, their long-term use remains hampered by limited durability. Non-surgical treatments for AV disease do not yet exist, in large part because our understanding of AV disease etiology remains incomplete. The direct study of human AV disease remains hampered by the fact that clinical data is only available at the time of treatment, where the disease is at or near end stage and any time progression information has been lost. Large animal models, long used to assess replacement AV devices, cannot yet reproduce AV disease processes. As an important alternative mouse animal models are attractive for their ability to perform genetic studies of the AV disease processes and test potential pharmaceutical treatments. While mouse models have been used for cellular and genetic studies of AV disease, their small size and fast heart rates have hindered their use for tissue- and organ-level studies. We have recently developed a novel ex vivo micro-CT-based methodology to 3D reconstruct murine heart valves and estimate the leaflet mechanical behaviors (Feng et al. in Sci Rep 13(1):12852, 2023). In the present study, we extended our approach to 3D reconstruction of the in vivo functional murine AV (mAV) geometry using high-frequency four-dimensional ultrasound (4DUS). From the resulting 4DUS images we digitized the mAV mid-surface coordinates in the fully closed and fully opened states. We then utilized matched high-resolution µCT images of ex vivo mouse mAV to develop mAV NURBS-based geometric model. We then fitted the mAV geometric model to the in vivo data to reconstruct the 3D in vivo mAV geometry in the closed and open states in n = 3 mAV. Results demonstrated high fidelity geometric results. To our knowledge, this is the first time such reconstruction was ever achieved. This robust assessment of in vivo mAV leaflet kinematics in 3D opens up the possibility for longitudinal characterization of murine models that develop aortic valve disease.

Factors influencing ultrasound cardiac output monitor waveform quality in patients admitted to the emergency intensive care unit

Objective

The ultrasonic cardiac output monitor (USCOM), an instrument that monitors the evolution of a patient's hemodynamic status and determines the type of shock, has become an important tool for assessing cardiac pathology and predicting changes in disease, but there are some variations in the instrumental findings for different physical conditions of patients. This article examines whether there are differences in the quality of USCOM waveforms measured in different types of critically ill patients based on clinical characteristics and test parameters.

Methods

Baseline data, diagnoses, echocardiograms, ventilation patterns, and USCOM results were retrospectively collected from patients in the emergency intensive care unit. Waveform quality was quantified using the Fremantle score to determine the extent to which age, body mass index (BMI), chronic obstructive pulmonary disease (COPD), respiratory failure, cardiac enlargement, valvular heart disease, and ventilation pattern influenced USCOM waveform quality.

Results

Age, body mass index, chronic obstructive pulmonary disease, respiratory failure, right and left heart enlargement, aortic valve disease (excluding aortic stenosis), and ventilation mode did not have a significant effect on USCOM waveform quality in critically ill patients (P > 0.05).

Conclusions

Various physical conditions of critically ill patients may have limited effect on the quality of the USCOM waveform, potentially rendering USCOM suitable for early assessment of hemodynamic status during ICU admission.

Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: Multimodality imaging assessment

BACKGROUND

Quadricuspid aortic valve (QAV) is a rare congenital heart disease with a limited body of literature. This retrospective cohort study investigates QAV morphology, function, and clinical outcomes.

METHODS

Echocardiography was used to assess valvular function. Morphological characteristics such as phenotypes, raphe, regurgitant orifice area (ROA), and aortic dilation (diameter >40 ​mm) were assessed by cardiac CT. Patients were followed up for the combined event of all-cause death and aortic valve replacement (AVR).

RESULTS

Ninety QAV patients (screened from 322385 CT scans) were included (mean age 55.2 ​± ​13.6 years, 61.1 ​% male). Isolated significant aortic regurgitation (AR) was present in 75.6 ​% of patients. The cohort was dominated by type I (four equal leaflets, 37.8 ​%) and type II (3 larger and 1 smaller leaflets, 42.2 ​%) QAV. Fused raphe was present in 26.7 ​% of patients. ROACT was correlated with AR severity and aortic dilation (41.1 ​%, n ​= ​37). Among patients without AVR at baseline (n ​= ​60), one died and 17 underwent AVR during a median follow-up of 35.0 months (IQR:17.3-62.8). ROACT was associated with an increasing risk of combined event (as a categorical variable with a cut-off of 21.4 ​mm2, HR ​= ​4.25, 95%CI 1.49-12.17, p ​= ​0.007; as a continuous variable (per mm2 increment), HR ​= ​1.04, 95%CI 1.01-1.07, p ​= ​0.003). Additionally, ROACT had incremental prognostic value when added to the AR severity model (area under the receiver-operating characteristic curve increased from 86.8 to 88.4, p ​= ​0.004).

CONCLUSION

QAV is characterized by variable anatomy, progressive AR, concomitant cusp fusion and aortic enlargement. ROACT may be a potential ancillary prognostic marker in patients with QAV.

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BACKGROUND

This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2).

METHODS

From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.

RESULTS

Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).

CONCLUSIONS

PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Impact of Variation in Commissural Angle between Fused Leaflets in the Functionally Bicuspid Aortic Valve on Hemodynamics and Tissue Biomechanics

In subjects with functionally bicuspid aortic valves (BAVs) with fusion between the coronary leaflets, there is a natural variation of the commissural angle. What is not fully understood is how this variation influences the hemodynamics and tissue biomechanics. These variables may influence valvar durability and function, both in the native valve and following repair, and influence ongoing aortic dilation. A 3D aortic valvar model was reconstructed from a patient with a normal trileaflet aortic valve using cardiac magnetic resonance (CMR) imaging. Fluid-structure interaction (FSI) simulations were used to compare the effects of the varying commissural angles between the non-coronary with its adjacent coronary leaflet. The results showed that the BAV with very asymmetric commissures (120∘ degree commissural angle) reduces the aortic opening area during peak systole and with a jet that impacts on the right posterior wall proximally of the ascending aorta, giving rise to elevated wall shear stress. This manifests in a shear layer with a retrograde flow and strong swirling towards the fused leaflet side. In contrast, a more symmetrical commissural angle (180∘ degree commissural angle) reduces the jet impact on the posterior wall and leads to a linear decrease in stress and strain levels in the non-fused non-coronary leaflet. These findings highlight the importance of considering the commissural angle in the progression of aortic valvar stenosis, the regional distribution of stresses and strain levels experienced by the leaflets which may predispose to valvar deterioration, and progression in thoracic aortic dilation in patients with functionally bicuspid aortic valves. Understanding the hemodynamics and biomechanics of the functionally bicuspid aortic valve and its variation in structure may provide insight into predicting the risk of aortic valve dysfunction and thoracic aortic dilation, which could inform clinical decision making and potentially lead to improved aortic valvar surgical outcomes.

Clinical Outcomes in Patients With Bicuspid Aortic Valves and Ascending Aorta ≥50 mm Under Surveillance

Background

Clinical outcomes of bicuspid aortic valve (BAV) patients with ascending aortic diameters ≥50 mm who are under surveillance are poorly defined.

Objectives

The purpose of this study was to assess clinical outcomes in BAV patients with ascending aorta ≥50 mm.

Methods

Multicenter retrospective cohort study of BAV adults with ascending aorta diameters ≥50 mm by transthoracic echocardiography (TTE). Patients were categorized into 50 to 54 mm and ≥55 mm groups. Clinical outcomes were aortic dissection (AoD), aorta surgery, surgical mortality, and all-cause death.

Results

Of 875 consecutive BAV patients (age 60 ± 13 years, 86% men, aortic diameter 51 mm [interquartile range (IQR): 50-53 mm]), 328 (37%) underwent early surgery ≤3 months from index TTE. Of the remaining 547 patients under surveillance, 496 had diameters 50 to 54 mm and 51 had diameters ≥55 mm and were collectively followed for 7.51 (IQR: 3.98-12.20) years. Of 496 patients with diameters 50 to 54 mm under surveillance, 266 (54%) underwent surgery 2.0 (IQR: 0.77-4.16) years from index TTE. AoD occurred in 9/496 (1.8%) patients for an incidence of 0.4 cases per 100 person-years, surgical mortality was 5/266 (1.9%); and ≥moderate aortic stenosis (but not aorta size) was associated with all-cause death, hazard ratio: 2.05 (95% CI: 1.32-3.20), P = 0.001. Conversely, in 547 total patients under surveillance (including 50-54 mm and ≥55 mm), both aorta size and ≥moderate aortic stenosis were associated with all-cause death (both P ≤ 0.027). AoD rate in patients ≥55 mm under surveillance was 5.9%.

Conclusions

In BAV patients with ascending aorta 50 to 54 mm under surveillance, AoD incidence is low and the overall rates of AoD and surgical mortality are similar, suggesting clinical equivalence between surgical and surveillance strategies. Conversely, patients with aortas ≥55 mm should undergo surgery. Aortic stenosis is associated with all-cause death in these patients.

Secondary analysis of REPRISE III trial: The Lotus valve's persistence after withdrawal

INTRODUCTION

Aortic stenosis (AS) is the leading heart valve disease in developed countries, often caused by calcific degeneration. In low-and-middle-income countries, it's primarily due to RHD. Prevalence of AS increases with age and up to 22.8% of those affected over the age of 75. While surgical aortic valve replacement is standard treatment for AS, many older individuals are not ideal candidates. Transcatheter aortic valve replacement (TAVR) offers an alternative. The REPRISE III trial showed the Lotus valve outperformed the CoreValve/EvolutR TAVR valves in various metrics over 2 years. Despite its success and over 10,000 implantations, the Lotus valve was pulled from the market, highlighting the need to understand its long-term outcomes. Study and results: In the REPRISE III trial, the long-term outcomes of TAVR using the Lotus valve were compared to the CoreValve/EvolutR over 5 years across 55 global centers. Of the participants, 581 (95.7%) used the Lotus valve and 285 (93.4%) used CoreValve/EvolutR. Event rates for all-cause mortality were similar between the groups, but the Lotus valve group had lower rates of disabling stroke and pacemaker implantation. The Lotus valve showed a higher aortic gradient but lower effective orifice area. Additionally, the Lotus valve had reduced mild PVL, valve malpositioning, and the need for a second valve. Both groups showed comparable long-term improvements in heart and cardiomyopathy assessments.

LESSONS LEARNED

The REPRISE III analysis highlights the favourable long-term outcomes of the Lotus valve and CoreValve/EvolutR for high-risk surgical patients. These findings underscore the importance of ongoing management post-valve procedure and the potential advantages of the Lotus valve design. Further studies comparing these valves to surgery will inform aortic stenosis management and potentially expand TAVR indications. The future goal is to develop a tissue-engineered living heart valve to improve survival and quality of life.

Comparison of Two Techniques Performing the Supine-to-Sitting Postural Change in Patients with Sternotomy

Patients with sternotomy are advised to follow sternal precautions to avoid the risk of sternal complications. However, there are no standard recommendations, in particular to perform the supine-to-sitting postural change, where sternal asymmetrical force may be applied. The aim of this study was to compare the rotational movement and the use of a tied rope (individual device for supine-to-sitting, "IDSS") to perform the supine-to-sitting postural change. A total of 92 patients (26% female) admitted to a rehabilitative post-surgery ward with sternotomy were assessed for sternal instability. Levels of pain and perceived effort during the two modalities of postural change and at rest were assessed. Patients reported higher values of pain and perceived effort (both p < 0.0005) during rotational movement with respect to the use of the IDSS. Moreover, patients with sternal instability (14%) and female patients with macromastia (25%) reported higher pain than those stable or without macromastia (both p < 0.05). No other risk factors were associated with pain. Thus, the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change. Future studies with quantitative assessments are required to suggest the adoption of this technique, mostly in patients with high levels of pain or with sternal instability.

Health Related Quality of Life of Ugandan Children Following Valve Replacement Surgery for Rheumatic Heart Disease

Background

Valve replacement surgery (VRS) improves clinical outcomes in patients with severe rheumatic heart disease (RHD). However, lifelong anticoagulation and frequent monitoring are required, which potentially impacts health-related quality of life (HRQoL). In this study, we assessed the HRQoL of people with RHD in Uganda following VRS.

Methods

This was a hospital-based, cross-sectional study conducted between March and August 2021. Eligible participants were individuals who had VRS before the age of 18 years. The Pediatric Quality of Life Inventory-Cardiac Module (PedsQL-Cardiac module) was used to evaluate HRQoL. A total mean score of ≥ 80% was considered as optimal HRQoL.

Results

Of the 83 eligible participants, 52 (60.5%) were female, with a median age of 18 (interquartile range: 14-22) years. Most participants had NYHA I functional status (n = 79, 92%). Most (n = 73, 92.4%) surgeries were performed outside of Uganda, and 61 (72.6%) were single mechanical valve replacement. Almost half (n = 45, 54%) expressed no concern about being on life-long warfarin therapy. However, 24 (29.3%) feared bleeding. The optimal mean score of cardiac-specific HRQoL was achieved in 50 (60.2%) of participants. Factors associated with optimal HRQoL were body mass index (BMI) (adjusted odds ratio (aOR), 1.2, 95% Confidence Interval: 1.1-1.3, p = 0.006), being afraid of bleeding or bruising (aOR: 1.5, 95% CI: 1.21-2.47, p = 0.004), acceptance of having an artificial valve (aOR: 2.7, 95% CI; 1.64-3.81, p < 0.001).

Conclusion

HRQoL was optimal in about three in five participants following VRS. Increasing BMI and acceptance of artificial valve were significantly associated with optimal HRQoL.

Impact of 1-week preoperative auto-CPAP treatment on postoperative outcomes in patients undergoing heart valve replacement surgery: a prospective randomized controlled trial

Background

Whether preoperative continuous positive airway pressure (CPAP) treatment improves postoperative outcomes in patients undergoing cardiac valve replacement (CVR) remains unknown.

Hypothesis

This study was to evaluate the effects of 1-week perioperative auto-continuous positive airway pressure (CPAP) treatment on postoperative heart and pulmonary outcomes in patients with obstructive sleep apnea (OSA) and valvular heart disease.

Methods

Thirty-two patients with OSA and valvular heart disease were randomly assigned to 1-week CPAP (n = 15) group and non-CPAP treatments (n = 17) group. After the treatment, all patients underwent CVR surgery. The length of ICU and hospital stays, postoperative cardiac and respiratory complications were assessed and compared between the 2 groups.

Results

The results showed there was no significant difference in the baseline characteristics between the CPAP and non-CPAP treatment groups. The length of postoperative ICU and hospital stays, as well as the duration of mechanical ventilation were significantly reduced in the CPAP treatment group compared to the non-CPAP treatment group; however, there were no significant differences in cardiac complications (postoperative arrhythmias, pacemaker use, first dose of dopamine in the ICU, and first dose of dobutamine in the ICU), and respiratory complications (reintubation and pneumonia).

Conclusion

We concluded that in patients underwent CVR, preoperative use of auto-CPAP for OSA significantly decreased the duration of mechanical ventilation, and postoperative stays in the ICU and hospital.Clinical Trial Registration: https://ClinicalTrials.gov, identifier NCT03398733.

The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.

A Left ventricle remodeling in patients with bicuspid aortic valve

PURPOSE

We assessed the impact of bicuspid aortic valve (BAV), aortic stenosis (AS), and regurgitation (AR) on the metrics of left ventricular (LV) remodeling, as measured by electrocardiogram (ECG), transthoracic echocardiography (TTE), and cardiac magnetic resonance (CMR).

METHODS

This retrospective CMR study included 11 patients with both AS and AR (BAV-ASR), 30 with AS (BAV-AS), 28 with AR (BAV-AR), 47 with neither AS nor AR (BAV-no_AS/AR), and 40 with trileaflet aortic valve (TAV-no_AS/AR). CMR analysis included the LV end-diastolic volume index (LVEDVi), mass index (LVMi), and extracellular volume fraction (ECV). The Sokolow-Lyon and Cornell products by ECG and TTE-derived E/e' were measured.

RESULTS

There were no differences in the ECG, TTE, and CMR parameters between BAV-no_AS/AR and TAV-no_AS/AR. However, the presence of aortic valve dysfunction resulted in an elevated Sokolow-Lyon product for BAV-ASR (p = 0.017) and BAV-AR (p = 0.001), as well as increased Cornell product (p = 0.04) and E/e' (p < 0.001) for BAV-AS compared with BAV-no_AS/AR. LVEDVi and LVMi were elevated in patients with BAV-ASR and BAV-AR compared with those with BAV-no_AS/AR (LVEDVi: 101 ± 29 ml/m² and 112 ± 32 ml/m² vs. 74 ± 15 ml/m², p = 0.005 and p < 0.001, LVMi: 75 ± 7 g/m² and 64 ± 14 g/m² vs. 47 ± 9 g/m², respectively; p < 0.001). There was no difference in ECV between the BAV and TAV-no_AS/AR subgroups.

CONCLUSION

Normally functioning BAV did not result in LV remodeling. However, concomitant AV dysfunction was associated with statistically significant morphological remodeling.

Association of Thoracic Aortic Aneurysm Size With Long-term Patient Outcomes: The KP-TAA Study

Importance

The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making.

Objective

To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non-referral-based health care delivery system.

Design, Setting, and Participants

The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021.

Exposures

TAA size.

Main Outcomes and Measures

Aortic dissection (AD), all-cause death, and elective aortic surgery.

Results

Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm.

Conclusions and Relevance

In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.

Mitral Regurgitation and Serum N-Terminal Pro-Brain Natriuretic Peptide Levels in Children: A Modification of Adult Criteria

Mitral regurgitation can result from congenital heart disease, rheumatic valve disease, or other congenital malformations of the mitral valve. Faulty valves require surgical repair or replacement. However, echocardiographic and biochemical parameters that inform surgical decision-making for adults may not be appropriate for children. To investigate whether adult parameters can be used in children, we correlated echocardiographic parameters with serum N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in children with chronic mitral regurgitation. Our sample comprised 45 patients and 38 healthy children. M-mode measurements, left atrial and left ventricular volumes, and Doppler and tissue Doppler echocardiograms were collected. We graded mitral regurgitation according to European Association of Echocardiography recommendations and indexed effective regurgitant area, vena contracta, and regurgitant volume to body surface area. Patients were grouped by regurgitation severity (mild vs moderate or severe) and left ventricular end-systolic dimension (normal vs enlarged). The NT-proBNP level was higher in patients than in controls (P=0.003), higher in patients with moderate or severe regurgitation (P=0.02), and higher in patients with an enlarged left ventricle (P=0.003). Serum NT-proBNP levels correlated with effective regurgitant area (r=0.47; P=0.002), vena contracta width (r=0.46; P=0.003), regurgitant volume (r=0.32; P=0.04), left ventricular end-systolic diameter (r=0.58; P <0.001), and left atrial diameter (r=0.62; P <0.001). An NT-proBNP value of 66 pg/mL differentiated the mild regurgitation group from the moderate or severe regurgitation group. Our results correlating NT-proBNP and echocardiographic parameters indexed to body surface area indicate that these adult criteria can be used in children to grade mitral regurgitation and inform surgical decision-making.

A lightweight hybrid deep learning system for cardiac valvular disease classification

Cardiovascular diseases (CVDs) are a prominent cause of death globally. The introduction of medical big data and Artificial Intelligence (AI) technology encouraged the effort to develop and deploy deep learning models for distinguishing heart sound abnormalities. These systems employ phonocardiogram (PCG) signals because of their lack of sophistication and cost-effectiveness. Automated and early diagnosis of cardiovascular diseases (CVDs) helps alleviate deadly complications. In this research, a cardiac diagnostic system that combined CNN and LSTM components was developed, it uses phonocardiogram (PCG) signals, and utilizes either augmented or non-augmented datasets. The proposed model discriminates five heart valvular conditions, namely normal, Aortic Stenosis (AS), Mitral Regurgitation (MR), Mitral Stenosis (MS), and Mitral Valve Prolapse (MVP). The findings demonstrate that the suggested end-to-end architecture yields outstanding performance concerning all important evaluation metrics. For the five classes problem using the open heart sound dataset, accuracy was 98.5%, F1-score was 98.501%, and Area Under the Curve (AUC) was 0.9978 for the non-augmented dataset and accuracy was 99.87%, F1-score was 99.87%, and AUC was 0.9985 for the augmented dataset. Model performance was further evaluated using the PhysioNet/Computing in Cardiology 2016 challenge dataset, for the two classes problem, accuracy was 93.76%, F1-score was 85.59%, and AUC was 0.9505. The achieved results show that the proposed system outperforms all previous works that use the same audio signal databases. In the future, the findings will help build a multimodal structure that uses both PCG and ECG signals.

Closed Mitral Valvotomy Reenvision

In developing countries, like the Indian subcontinent, population overload, malnutrition, poor socio-economic status of affected groups, and health care facilities affect the treatment outcome. Nowadays procedures such as percutaneous balloon mitral valvotomy (PBMV) and open heart mitral valve replacement are offered to patients with mitral stenosis. Whenever PBMV is unavailable due to financial constraints and open surgical management cannot be offered due to overburdened healthcare facilities, closed mitral valvotomy (CMV) provides an excellent choice for patients with favorable mitral valve pathology. Many centers do not practice CMV and thus this procedure is dying out. The young generation of surgeons are not been trained in CMV. The purpose of our study is to reenvision CMV and emphasize its vital role in mitral stenosis patient subsets like pregnant women and young adults. 

We reviewed the literature for various valvotomy techniques done for mitral valve stenosis and restenosis. Immediate and late outcomes were compared between the patients receiving Percutaneous balloon mitral valvotomy and closed mitral valvotomy.

The immediate and late-term results are comparable for PBMV and CMV and no statistically significant difference exists. The post-PBMV Mitral valve area (MVA) ranged from 2.1 +/- 0.7 cm^2 to 2.3 +/-0.94 cm^2 and post CMV MVA ranged from 1.3+/-0.3 cm^2 to 2.2+/-0.85 cm^2. Complications developing in both techniques are also nearly similar. Operative mortality in CMV patients ranged from 1% to 4.2%, also observed in PBMV patients in various studies. Mitral Regurgitation occurred in both groups equally and ranged from 0.3% to 14%. Restenosis was observed in both groups in the range of 4% to 5%. High fetal loss of around 20% mortality was witnessed in pregnant mitral stenosis patients undergoing open heart surgery.

It's time to re-envision CMV since it is providing substantial outcomes and remitting the need for open-heart surgery at a very low cost in patients with mitral stenosis with a pliable valve.

Bicuspid Aortic Valve in Children and Adolescents: A Comprehensive Review

Bicuspid aortic valve (BAV) is the most common congenital heart defect. Prevalence of isolated BAV in the general pediatric population is about 0.8%, but it has been reported to be as high as 85% in patients with aortic coarctation. A genetic basis has been recognized, with great heterogeneity. Standard BAV terminology, recently proposed on the basis of morpho-functional assessment by transthoracic echocardiography, may be applied also to the pediatric population. Apart from neonatal stenotic BAV, progression of valve dysfunction and/or of the associated aortic dilation seems to be slow during pediatric age and complications are reported to be much rarer in comparison with adults. When required, because of severe BAV dysfunction, surgery is most often the therapeutic choice; however, the ideal initial approach to treat severe aortic stenosis in children or adolescents is not completely defined yet, and a percutaneous approach may be considered in selected cases as a palliative option in order to postpone surgery. A comprehensive and tailored evaluation is needed to define the right intervals for cardiologic evaluation, indications for sport activity and the right timing for intervention.

Adding complexity to complexity: The role of concomitant cardiac surgery in lung transplantation

Outcomes of lung transplantation have greatly improved over recent years. While patients with concomitant cardiac pathology used to be excluded from lung transplant, today, most of these cardiac conditions can be addressed safely and effectively. Interventional techniques should be preferred. Lung transplant performed by cardiac surgeons allows for concomitant interventions.

Technical Details of Redo Aortic Valve Replacement Using St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Aortic Mechanical Prosthesis: A Video Presentation

Current consensus guidelines of the American Heart Association and European Society of Cardiology uniformly recommend either type of prosthetic valve for patients aged between 60 and 70 years and mechanical prosthesis for patients aged less than 60 years. These recommendations are based on the results of randomized controlled trials that demonstrated no significant difference in late survival. Two of these trials compared mechanical and bioprosthetic valve models implanted in 1970s and 1980s. The other two trials included patients undergoing aortic valve replacement. Contemporary data are limited to small single-center studies

Gender differences in bicuspid aortic valve Sievers types, valvulopathy, aortopathy, and outcome of aortic valve replacement

BACKGROUND

The gender difference of the bicuspid aortic valve (BAV) is not well understood.

OBJECTIVES

We evaluated the impact of gender on the Sievers types, valvulopathy, aortopathy, and outcomes of aortic valve replacement (AVR) of BAV patients in a cohort of Chinese patients.

METHODS

Among 992 BAV patients without aortic dissection nor congenital heart disease, 658 underwent AVR. The demography, Sievers types, valvulopathy, aortopathy, and outcomes of AVR were compared between genders.

RESULTS

Aortic regurgitation (AR ≥ 2+) (39.0% vs. 12.8%, p < .001), aortic root dilation only (3.8% vs. .8%, p = .014), and diffuse dilation (25.3% vs. 4.3%, p < .001) were more common in men, while moderate to severe aortic stenosis (AS) (21.3% vs. 45.7%, p < .001) and ascending dilation only (46.2% vs. 61.2%, p < .001) were more common in women. Men were more prone to develop preoperative AR ≥ 2+ (OR = 5.15, p < .001), moderate to severe AS + AR ≥ 2 + (OR = 2.95, p = .001), and Diffuse aortic dilation (OR = 3.91, p < .001). Sievers types did not have a significant effect on valvular dysfunction. Gender didn't predict early adverse events after AVR (n = 90) (HR = 1.21, p = .44), but male gender predicted a left ventricular ejection fraction <50% after AVR (OR = 3.07, p = .03).

CONCLUSIONS

In this BAV series of Chinese patients, gender didn't differ significantly in Sievers types of BAV but showed significant differences in valvulopathy, aortopathy, and LV function after AVR. In addition, the male patients developed more severe conditions at a younger age.

Mid-Term Mortality in Older Anemic Patients with Type 2 Myocardial Infarction: Does Blood Transfusion sImprove Prognosis?

(1) Anemia often predisposes older patients to type 2 myocardial infarction (T2MI). However, the management of this frequent association remains uncertain. We aimed to evaluate the impact of red blood cell transfusion during the acute phase of T2MI in older anemic inpatients. (2) Methods and results: We performed a retrospective study using a French regional database. One hundred and seventy-eight patients aged 65 years or older, presenting with a T2MI and anemia, were selected. Patients were split into two groups: one that received a red blood cell transfusion (≥1 red blood cell unit) and one that did not. A propensity score was built to adjust for potential confounders, and the association between transfusion and 30-day mortality was evaluated with an inverse propensity score weighted Cox model. Transfusion was not associated with 30-day all-cause mortality (propensity score weighted hazard ratio (HR) 1.59 (0.55-4.56), p = 0.38). However, 1-year all-cause mortality was significantly higher in the transfusion group (propensity score weighted HR 2.47 (1.22-4.97), p = 0.011). (3) Conclusion: Our findings in older adults with anemia suggest that blood transfusion in the acute phase of T2MI could not be associated with improved short-term prognosis. Prospective studies are urgently needed to assess the impact of transfusion on longer-term prognosis.

The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.

Trends in Utilization of Aortic Valve Replacement for Severe Aortic Stenosis

BACKGROUND

Despite the rapid growth of aortic valve replacement (AVR) for aortic stenosis (AS), limited data suggest symptomatic severe AS remains undertreated.

OBJECTIVES

This study sought to investigate temporal trends in AVR utilization among patients with a clinical indication for AVR.

METHODS

Patients with severe AS (aortic valve area <1 cm²) on transthoracic echocardiograms from 2000 to 2017 at 2 large academic medical centers were classified based on clinical guideline indications for AVR and divided into 4 AS subgroups: high gradient with normal left ventricular ejection fraction (LVEF) (HG-NEF), high gradient with low LVEF (HG-LEF), low gradient with normal LVEF (LG-NEF), and low gradient with low LVEF (LG-LEF). Utilization of AVR was examined and predictors identified.

RESULTS

Of 10,795 patients, 6,150 (57%) had an indication or potential indication for AVR, of whom 2,977 (48%) received AVR. The frequency of AVR varied by AS subtype with LG groups less likely to receive an AVR (HG-NEF: 70%, HG-LEF: 53%, LG-NEF: 32%, LG-LEF: 38%, P < 0.001). AVR volumes grew over the 18-year study period but were paralleled by comparable growth in the number of patients with an indication for AVR. In patients with a Class I indication, younger age, coronary artery disease, smoking history, higher hematocrit, outpatient index transthoracic echocardiogram, and LVEF ≥0.5 were independently associated with an increased likelihood of receiving an AVR. AVR was associated with improved survival in each AS-subgroup.

CONCLUSIONS

Over an 18-year period, the proportion of patients with an indication for AVR who did not receive AVR has remained substantial despite the rapid growth of AVR volumes.

Variation in management of paediatric isolated bicuspid aortic valve: current practice survey

BACKGROUND

Prior to the recent release of appropriate use criteria for imaging valvulopathies in children, follow-up of valvular lesions, including isolated bicuspid aortic valve, was not standardised. We describe current follow up, treatment, and intervention strategies for isolated bicuspid aortic valve with varying degrees of stenosis, regurgitation, and dilation in children up to 18 years old and compare them with newly released appropriate use criteria.

METHODS

Online survey was sent to members of the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and PediHeartNet.

RESULTS

Totally, 106 responses with interpretable data were received. For asymptomatic patients with isolated BAV without stenosis, regurgitation, or dilation follow-up-intervals increased from 7+/-4 months in the newborn period to 28 +/- 14 months at 18 years of age. Respondents recommended more frequent follow-up for younger patients and those with greater disease severity. More than 80% of respondents treat aortic regurgitation or aortic dilation in the setting of bicuspid aortic valve medically. In general, intervention was recommended once stenosis or regurgitation became severe (stenosis of >4 m/s; regurgitation with LV Z score 4) regardless of age, but was not routinely recommended for younger children (newborn - age 6 years) with severe dilation. Exercise was restricted at 38+/-11 mmHg echocardiographic mean gradient.

CONCLUSIONS

Current follow-up, treatment, and intervention strategies for isolated bicuspid aortic valve deviate from appropriate use criteria. Differences between the two highlight the need to better delineate the disease course, clarify recommendations for care, and encourage wider adoption of guidelines.

Evaluating spatial disparities of rotor sites and high dominant frequency regions during catheter ablation for PersAF patients targeting high dominant frequency sites using non-contacting mapping

Purpose: Several studies have emphasised the significance of high dominant frequency (HDF) and rotors in the perpetuation of AF. However, the co-localisation relationship between both attributes is not completely understood yet. In this study, we aim to evaluate the spatial distributions of HDF regions and rotor sites within the left atrium (LA) pre and post HDF-guided ablation in PersAF. Methods: This study involved 10 PersAF patients undergoing catheter ablation targeting HDF regions in the LA. 2048-channels of atrial electrograms (AEG) were collected pre- and post-ablation using a non-contact array (EnSite, Abbott). The dominant frequency (DF, 4-10 Hz) areas with DF within 0.25 Hz of the maximum out of the 2048 points were defined as "high" DF (HDF). Rotors were defined as PSs that last more than 100 ms and at a similar location through subsequent phase frames over time. Results: The results indicated an extremely poor spatial correlation between the HDF regions and sites of the rotors in pre-versus post-ablation cases for the non-terminated (pre: CORR; 0.05 ± 0.17. vs. post: CORR; -0.030 ± 0.19, and with terminated patients (pre: CORR; -0.016 ± 0.03. post: CORR; -0.022 ± 0.04). Rotors associated with AF terminations had a long-lasting life-span post-ablation (non-terminated vs. terminated 120.7 ± 6.5 ms vs. 139.9 ± 39.8 ms), high core velocity (1.35 ± 1.3 mm/ms vs. 1.32 ± 0.9 mm/ms), and were less meandering (3.4 ± 3.04 mm vs. 1.5 ± 1.2 mm). Although the results suggest a poor spatial overlapping between rotors' sites and sites of AFCL changes in terminated and non-terminated patients, a higher correlation was determined in terminated patients (spatial overlapping percentage pre: 25 ± 4.2% vs. 17 ± 3.8% vs. post: 8 ± 4.2% vs. 3.7 ± 1.7% p < 0.05, respectively). Conclusion: Using non-contact AEG, it was noted that the correlation is poor between the spatial distribution of HDF regions and sites of rotors. Rotors were longer-lasting, faster and more stationary in patients with AF termination post-ablation. Rotors sites demonstrated poor spatial overlapping with sites of AFCL changes that lead to AF termination.

Inter-Ethnic Differences in Valvular Dysfunction, Aortopathy, and Progression of Disease of an Asian Bicuspid Aortic Valve Population

BACKGROUND

There are differences in bicuspid aortic valve (BAV) characteristics between Asian and European populations, but little is known about the inter-ethnic differences in bicuspid valve function and aortic root dimensions within the diverse Asian population.

METHODS

From 1992-2017, 562 patients with index echocardiographic diagnosis of BAV in a tertiary health care institution in Singapore were analysed according to their ethnic groups: Chinese, Malay, Indian, and Eurasian. Study outcomes included BAV complications (infective endocarditis, aortic dissection) and clinical outcomes (aortic valve surgery, aortic root surgery, all-cause mortality). Total events were defined as composite outcome of all BAV complications and outcomes. Aortic dimensions and aortic dilatation rates were also studied.

RESULTS

There were 379 (67.5%) Chinese, 79 (14.0%) Malay, 73 (13.0%) Indian, and 31 (5.5%) Eurasian patients. Type 1 BAV (58.5%) was the most prevalent BAV morphology, with moderate-to-severe aortic stenosis (AS) (36.8%) being the most common complication in the overall population. There was a higher prevalence of type 0 BAV in Chinese and Indian groups, and type 1 BAV with fusion of left-right coronary cusp in Eurasian and Malay groups (p=0.082). There was no difference in significant AS among groups. The highest prevalence of moderate-to-severe aortic regurgitation was observed amongst the Eurasian group, followed by Chinese, Indian, and Malay groups (p=0.033). The Chinese group had the largest mean indexed diameters of the aortic root. Multivariable linear regression demonstrated that only the Chinese had significantly larger indexed diameters in the aortic annulus, sinotubular junction (STJ), and ascending aorta (AA), relative to the Eurasian group, after adjusting for age, sex, smoking, hypertension, hyperlipidaemia, diabetes, and aortic regurgitation. On follow-up echocardiography, there was a trend towards the highest dilatation rates of sinus of Valsalva and STJ amongst Indian, and AA amongst Malay groups. Kaplan-Meier curves showed the highest incidence of total events amongst Chinese, followed by Malay, Indian and Eurasian (log-rank=9.691; p=0.021) patients.

CONCLUSION

There were differences in BAV morphology, valve dysfunction, aortopathy, and prognosis within the Asian population. Chinese patients had one of the highest prevalence of significant aortic regurgitation, with the largest aortic dimensions and worst outcomes compared with other Asian ethnicities. Closer surveillance is warranted in BAV patients within the Asian population.

Model-based analysis of the sensitivities and diagnostic implications of FFR and CFR under various pathological conditions

Although fractional flow reserve (FFR) and coronary flow reserve (CFR) are both frequently used to assess the functional severity of coronary artery stenosis, discordant results of diagnosis between FFR and CFR in some patient cohorts have been reported. In the present study, a computational model was employed to quantify the impacts of various pathophysiological factors on FFR and CFR. In addition, a hyperemic myocardial ischemic index (HMIx) was proposed as a reference for comparing the diagnostic performances of FFR and CFR. Obtained results showed that CFR was more susceptible than FFR to the influence of many pathophysiological factors unrelated to coronary artery stenosis. In particular, the numerical study proved that increasing hyperemic coronary microvascular resistance significantly elevated FFR while reducing CFR despite fixed severity of coronary artery stenosis, whereas introducing aortic valve disease only caused a significant decrease in CFR with little influence on FFR. These results provided theoretical evidence for explaining some clinical observations, such as the increased risk of discordant diagnostic results between FFR and CFR in patients with increased hyperemic microvascular resistance, and significant increase in CFR after surgical relief of severe aortic valve disease. When evaluated with respect to the predictive value for hyperemic myocardial ischemia, the performance of FFR was found to be considerably compromised in the presence of severe coronary vasodilation dysfunction or aortic valve disease, whereas the relationship between CFR and HMIx remained relatively stable, suggesting that CFR may be a more reliable indicator of myocardial ischemia under complex pathophysiological conditions.

Whole blood viscosity in patients with aortic stenosis

Whole blood viscosity (WBV) may promote endothelial shear stress, inflammation, and can accelerate the atherosclerotic process. We aimed to evaluate the relationship between WBV and aortic stenosis. The study included 209 participants of whom 49 patients had severe aortic stenosis, 98 patients had mild-to-moderate aortic stenosis and 62 patients served as control. WBV values were significantly higher for high shear rate (HSR) (P = 0.001) and for low shear rate (LSR) (P = 0.002) in severe aortic stenosis group. HSR and LSR were correlated with mean systolic transaortic gradient (P < 0.001 and P < 0.001, respectively). WBV for both LSR and HSR were found to be independent predictors for the aortic stenosis severity (P = 0.034 and P = 0.049, respectively). We found a significant relationship between WBV and aortic stenosis.

Open transaortic implantation of 'Medlab-KT' prosthesis

AIM

The study was aimed at comparing the immediate clinical and haemodynamic results of open implantation of the balloon-expandable aortic prosthesis 'MedLab-KT' with the respective parameters of standard replacement of the aortic valve by a mechanical prosthesis in high-risk surgical patients.

PATIENTS AND METHODS

We analysed a total of 209 cases of prosthetic repair of the aortic valve. The Study Group comprised 28 patients subjected to open implantation of the 'MedLab-KT' prosthesis in conditions of extracorporeal circulation and myocardial ischaemia and belonging to a high-surgical risk cohort. The Comparison Group included 181 patients who endured standard open prosthetic repair of the aortic valve with a mechanical prosthesis. Using the ppropensity score matching method, we selected 28 patients from the Comparison Group, followed by assessing the incidence of adverse clinical events and haemodynamic parameters of the aortic valve prosthesis at the in-hospital stage.

RESULTS

There were no lethal outcomes in the study group, with one in the group of standard aortic valve repair - 3.6%. The mean operative time in the Study and Comparison Group patients amounted to 121.5±51.2 and 274.2±55.3 min (p=0.04), the duration of extracorporeal circulation to 56.1±19.5 and 119.9±23.4 min (p=0.04), that of myocardial ischaemia to 38.4±17.1 and 96.7±20.8 (p=0.03), respectively. The mean gradient on the aortic valve in the 'MedLab-KT' group was less (7.5±3.2 mm Hg) than in those of the second group (9±3.5 mm Hg), with no statistically significant differences in the parameters revealed (p=0.096). All patients of the study group were discharged from hospital in a satisfactory condition, with the haemodynamic result of the operation regarded as satisfactory.

CONCLUSION

Comparing the main clinical characteristics and haemodynamic parameters in the groups of 'MedLab-KT' and aortic valve prosthetic repair at the hospital stage revealed no statistically significant differences. Open implantation of the 'MedLab-KT' prosthesis proved safe and effective.

Decreased Glucagon-Like Peptide-1 Is Associated With Calcific Aortic Valve Disease: GLP-1 Suppresses the Calcification of Aortic Valve Interstitial Cells

Objectives: This study explores the concentration and role of glucagon-like peptide-1 (GLP-1) in calcific aortic valve disease (CAVD). Background: Calcific aortic valve disease is a chronic disease presenting with aortic valve degeneration and mineralization. We hypothesized that the level of GLP-1 is associated with CAVD and that it participates in the calcification of aortic valve interstitial cells (AVICs). Methods: We compared the concentration of GLP-1 between 11 calcific and 12 normal aortic valve tissues by immunohistochemical (IHC) analysis. ELISA was used to measure GLP-1 in serum of the Control (n = 197) and CAVD groups (n = 200). The effect of GLP-1 on the calcification of AVICs and the regulation of calcific gene expression were also characterized. Results: The GLP-1 concentration in the calcific aortic valves was 39% less than that in the control non-calcified aortic valves. Its concentration in serum was 19.3% lower in CAVD patients. Multivariable regression analysis demonstrated that GLP-1 level was independently associated with CAVD risk. In vitro, GLP-1 antagonized AVIC calcification in a dose- and time-dependent manner and it down-regulated RUNX2, MSX2, BMP2, and BMP4 expression but up-regulated SOX9 expression. Conclusions: A reduction in GLP-1 was associated with CAVD, and GLP-1 participated in the mineralization of AVICs by regulating specific calcific genes. GLP-1 warrants consideration as a novel treatment target for CAVD.

Outcomes of percutaneous balloon pulmonary valvuloplasty in congenital pulmonary valve stenosis

Percutaneous balloon pulmonary valvuloplasty (PBPV) is the primary treatment for pulmonary valve stenosis (PVS). The study consisted of 228 children with PVS who underwent PBPV from January 2004 to October 2019 at a single center. The risk factors for ≥moderate pulmonary regurgitation (PR), residual stenosis, and restenosis were analyzed based on the baseline patient characteristics and measured value of corresponding inspection results. Among 228 patients, follow-up results were obtained in 193 patients. The univariate analysis demonstrated that young age, low weight, small pulmonary annulus diameter, higher initial RV-PA PSEG, increased RV/systemic pressure ratio, and severe PVS were associated with ≥moderate PR. The multivariate analysis demonstrated that higher initial RV-PA PSEG and low weight were independently associated with ≥moderate PR, while higher initial RV-PA PSEG was independently associated with residual stenosis and restenosis. PBPV is a preferred tre atment in PVS children with a higher success rate. Higher initial RV-PA PSEG was a significant factor for ≥moderate PR, residual stenosis, and restenosis.

Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap

OBJECTIVE

To examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR).

PATIENTS AND METHODS

We retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed.

RESULTS

At baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m² was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11).

CONCLUSION

In contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m² or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.

Fate of preoperative moderate mitral regurgitation following left ventricular assist device implantation

OBJECTIVE

We examined for improvements in preoperative moderate mitral regurgitation following continuous-flow left ventricular assist device (cfLVAD) implantation.

METHODS

From 2006 to 2020, 190 patients with moderate MR underwent cfVLAD implant without concomitant mitral valve (MV) surgery. Cardiac dimensions and contractility, as well as valve function, were assessed with an echocardiogram (echo) pre-cfLVAD, and at approximately 1 month post-cfLVAD. Outcomes were determined by retrospective chart review.

RESULTS

Median echo follow-up was 0.94 (0.53, 1.38) months. Residual significant moderate or greater MR was present in 30/190 (15.8%) on follow-up. Patients with significant residual MR had larger preoperative left ventricular internal diameters in diastole (74.4 ± 8.7 vs. 71.1.0 ± 9.1 mm, p = .034). Significant residual MR was associated with higher preoperative mean pulmonary artery pressures (OR = 1.055, p = .035) and pulmonary capillary wedge pressures (OR = 1.060, p = .034). Significant residual MR on echo was not associated with any survival difference (p = .325). The 1, 5, and 10 year survival were 89.9%, 55.2%, and 34.2%, respectively.

CONCLUSIONS

For patients with moderate MR undergoing LVAD implantation, the likelihood of significant residual MR is low and mitral intervention in this population is not recommended. However, select patients with larger preoperative left heart dimensions and pulmonary vascular pressures may be at risk for persistent residual MR.

Implications of Coexisting Aortic Regurgitation in Patients With Aortic Stenosis

Background

Aortic regurgitation (AR) is a common comorbidity in patients with aortic stenosis (AS), but coexisting AR has often been excluded from major clinical studies on AS. The impact of coexisting AR on the natural history of AS has not been well-described.

Objectives

The authors compared clinical outcomes in medically managed patients with moderate-to-severe AS with or without coexisting AR.

Methods

Consecutive patients (N = 1,188) with index echocardiographic diagnosis of moderate-to-severe AS (aortic valve area <1.5 cm²) were studied. All patients were medically managed and were divided into those with coexisting AR (at least moderate severity) and those without. Adverse composite clinical outcomes were defined as mortality or admissions for congestive cardiac failure on subsequent follow-up. The authors compared differences in clinical profile and outcomes between the groups.

Results

There were 88 patients (7.4%) with coexisting AR and AS. These patients did not differ significantly in age, but had lower body mass index (22.9 ± 3.8 vs 25.3 ± 5.1 kg/m²), lower diastolic blood pressure (68.7 ± 10.7 vs 72.2 ± 12.3 mm Hg), larger end-diastolic volume index (68.8 ± 18.8 vs 60.4 ± 17.8 mL/m²) and larger left ventricular mass index (118.6 ± 36.4 vs 108.9 ± 33.1 g/m²). The prevalence of cardiovascular risk factors did not differ significantly. Coexisting AR was associated with increased incidence of adverse outcomes (log-rank 4.20; P = 0.040). On multivariable Cox regression, coexisting AR remained independently associated with adverse outcomes (HR: 1.36; 95% CI: 1.02-1.82) after adjusting for age, AS severity, left ventricular ejection fraction, and year of study.

Conclusions

In patients with AS, coexisting AR was associated with changes in echocardiographic profile and adverse outcomes.

Two-Dimensional Transesophageal Echocardiography Assessment of the Major Aortic Annulus Diameter in Patients Undergoing Transcatheter Aortic Valve Replacement

Background:

Multidetector computed tomography (MDCT) is the gold standard in annulus sizing before transcatheter aortic valve replacement (TAVR). However, MDCT has limited applicability in specific subgroups of patients, such as those with atrial fibrillation and chronic kidney disease. Two-dimensional transesophageal echocardiography (2DTEE) has traditionally been limited to the long-axis measurement of the anteroposterior diameter of the aortic annulus. We describe a new 2DTEE approach for the measurement of the major diameter of the aortic annulus.

Methods:

Seventy-six patients with symptomatic severe aortic valve stenosis and high surgical risk underwent MDCT and 2DTEE before TAVR. A modified five-chamber view was used to measure the major aortic annulus diameter. This was obtained starting from a mid-esophageal four chamber and retracting the TEE probe up until the left ventricular outflow tract and the left and noncoronary aortic cusps were visualized: major aortic annulus diameter was measured as the distance between their insertion points in systole.

Results:

Major aortic annulus diameters measured at 2DTEE showed good correlation with MDCT diameter (r = 0.79; P < 0.001) and perimeter (r = 0.87; P < 0.0001). Using factsheet-derived sizing criteria, 2DTEE alone would have allowed accurate sizing in 75% of patients, with 21% of oversizing predominantly with smaller annuli.

Conclusions:

We describe a new method for 2DTEE measurement of the major aortic annulus diameter; this approach is simple, correlates with MDCT, and allows adequate TAVR sizing in most patients. These findings may help in the assessment of patients with contraindications to or inadequate MDCT images.

Impact of Cardiac Computed Tomographic Angiography on Diagnostic and Therapeutic Decisions in Patients with Suspected Prosthetic Heart Valve Dysfunction

Introduction

Computed Tomography (CT) scan is a helpful tool to assess the coronary arteries and the great vessels. However, its routine use in the assessment of patients with suspected prosthetic valve dysfunction (PVD) has not been studied thoroughly.

Objective

To determine the impact of routine cardiac computed tomography angiography (CCTA) on diagnostic and therapeutic decisions in patients with suspected PVD.

Methods and results

This was a prospective cohort study that was conducted on 50 consecutive patients with suspected PVD who underwent both 64-slice ECG-gated CT and transesophageal echocardiography (TEE). The gold standard was the intraoperative findings. Surgery was performed in forty-six patients. ECG-gated CT showed findings that were not detected by TEE in sixteen patients (32%) namely aortic root abscess, aortic pseudoaneurysm, paravalvular leakage (PVL), sclero-calcific disruption of sutures as cause of PVL, mechanical prosthesis occluder malfunction, an underlying thrombus as cause of malfunction and finally presence of aortic dissection. Furthermore, CTA findings dictated treatment changes in fourteen patients (28%).

Conclusion

This study demonstrates that ECG-gated CTA has a complementary role to TEE in patients with suspected PVD. CCTA is more accurate in diagnosis of periannular complications (Aortic root abscess and Pseudo-aneurysm) and in delineating their anatomical relation to surrounding cardiac structures. Therefore CCTA can have important role in deciding and planning the method of correction whether surgical or percutaneous and has to be considered after TEE in patients with a high suspicion on PVD.

Prognostic Value of Peak Exercise Systolic Pulmonary Arterial Pressure in Asymptomatic Primary Mitral Valve Regurgitation

BACKGROUND

The contribution of exercise echocardiography in primary asymptomatic mitral regurgitation (MR) remains debated. The aim of this study was to gain evidence regarding its usefulness in this setting and to investigate the prognostic value of peak exercise systolic pulmonary artery pressure (SPAP).

METHODS

One hundred seventy-seven patients (mean age, 56 ± 13 years; 69% men) with moderate to severe (grade 3+) or severe (grade 4+) degenerative MR and preserved left ventricular ejection fraction, in sinus rhythm, referred for clinically indicated exercise echocardiography were identified. The end point, MR-related events, was a composite of all-cause death or occurrence of symptoms, heart failure, atrial fibrillation, left ventricular ejection fraction < 60%, left ventricular end-systolic diameter ≥ 45 mm, or resting SPAP > 50 mm Hg.

RESULTS

At rest, effective regurgitant orifice area was 48 ± 16 mm², regurgitant volume 74 ± 26 mL, and SPAP 32 ± 7 mm Hg, and MR was severe in 138 patients (78%). Peak exercise SPAP was 55 ± 10 mm Hg. Positive results on exercise testing motivated surgery in 26 patients, 11 underwent prophylactic surgery, 10 were lost to follow-up, and 130 were included in the outcome analysis. During a follow-up period of 19 ± 7 months, 31 MR-related events (24%) were reported. Peak exercise SPAP was predictive of outcomes in univariate analysis (P = .01) and after adjustment for age, gender, MR severity, and resting SPAP (P < .05). Peak exercise SPAP ≥ 50 mm Hg was associated with worse event-free survival (hazard ratio, 5.24; 95% CI, 1.77-15.53; P = .003), but not the threshold of ≥60 mm Hg proposed in previous guidelines (hazard ratio, 1.70; 95% CI, 0.71-4.03; P = .24).

CONCLUSIONS

The present findings support the use of exercise echocardiography for risk stratification in patients with asymptomatic primary MR and suggest a lower peak exercise SPAP threshold (50 mm Hg) than previously recommended to define the timing of intervention. Prospective studies are needed to confirm these findings.

The current diagnosis and treatment of high-risk patients with chronic primary and secondary mitral valve regurgitation

Mitral valve regurgitation (MR) is due primarily to either primary degeneration of the mitral valve with Barlow's or fibroelastic disease or is secondary to ischemic or nonischemic cardiomyopathies. Echocardiography is essential to assess MR etiology and severity, the remodeling of cardiac chambers and to characterize longitudinal chamber changes to determine optimal therapies. Surgery is recommended for severe primary MR if persistent symptoms are present or if left ventricle dysfunction is present with an EF <60% or a left ventricle end-systolic diameter ≥40 mm. For secondary MR, therapy of heart failure with vasodilators and diuretics improves forward cardiac output. Coronary artery bypass grafts (CABG) or percutaneous coronary intervention (PCI) should be considered for severe MR due to ischemia. This review summarizes the pathophysiology, the characteristics, the management and the different interventions for high risk patients with chronic primary and secondary MR.

Aortic strain in bicuspid aortic valve: an analysis

Bicuspid aortic valve (BAV) is monitored by transthoracic echocardiography and computed tomography (CT) angiography. However, it does not have any early marker of disease progression. This study evaluated speckle-tracking echocardiography (STE) aortic and left ventricular (LV) strain prognostic values, their discriminative power, and their correlation with the degree of valvular regurgitation. We conducted a retrospective analysis of a prospectively enrolled cohort of 45 diagnosed with BAV and 20 gender and age matched controls. We performed 2D-STE aortic and LV strain analysis of the selected population. The cohort was followed-up during a median period of 19.9 months (IQR 12.9-25.2), and outcomes (hospital admission for heart failure (HF), aortic valve replacement (AVR), and death) were determined. The mean patient age was 46.6 ± 15.5 years and 80 % were male. LV indexed volumes and aortic diameter were higher in BAV patients. LV global longitudinal strain (GLS) was impaired (p < 0.001) and aortic GLS was significantly augmented (p = 0.027) in BAV patients. Aortic global circumferential strain (GCS) did not vary between groups. Aortic diameter was the best parameter related to BAV (AUC 0.92) and aortic GLS was best correlated with significant AR (AUC 0.76). AVR was the only outcome observed and its only predictor was indexed LV end-diastolic volume. BAV had impaired LV-GLS values. Aortic GLS was abnormally augmented in BAV patients, which might reflect higher aortic diameters that distorted strain calculations. STE aortic strain is related to AR but does not appear to be a reliable predictor of surgery in BAV patients, at 19 months.