The global burden of aortic stenosis

Transthyretin amyloid cardiomyopathy in severe aortic stenosis submitted to valve replacement: a multicenter study

Aim: To evaluate the prevalence of TTR amyloid cardiomyopathy (ATTR-CM) in severe aortic stenosis (SAS) patients, and to determine the independent predictors of major adverse events (MAE).Patients & methods: 91 SAS patients >65 years with an interventricular septum thickness ≥12.5 mm were referred for aortic valve replacement (AVR). 99mTc-DPD scintigraphy was applied to diagnose ATTR-CM, in the absence of monoclonal protein.Results: ATTR-CM was found in 11%. 78% of patients underwent AVR, but only 2 had ATTR-CM. There were no significant differences in the composite of all cause-mortality or cardiovascular hospitalizations. Lower left ventricle ejection fraction and not performing AVR were independent predictors of MAE.Conclusion: Not performing AVR was an independent predictor of MAE, regardless the ATTR-CM diagnosis.

Usefulness of frailty assessment using the revised Japanese version of the Cardiovascular Health Study on the prediction of clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Frailty assessment is essential for deciding the treatment strategy for patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Recently, the revised Japanese version of the Cardiovascular Health Study (J-CHS) criteria has been proposed for the frailty assessment; however, it is unclear whether the criteria are useful for the risk stratification in these patients. We investigated the impact of frailty assessment using the revised J-CHS criteria on clinical outcomes in patients with AS undergoing TAVR. We examined 205 consecutive severe AS patients who underwent TAVR at two tertiary hospitals from May 2018 to December 2022. Frailty was defined by the revised J-CHS criteria (score ≥ 3) before TAVR. The primary outcome was major adverse cardiac or cerebrovascular events (MACCE). Among the studied patients, the mean age was 84 years and 65% were female. Frailty was present in 51% of patients. During a median follow-up period of 1000 (interquartile range 677-1210) days, MACCE occurred in 22 patients. Frailty was significantly independently associated with higher risks of the MACCE adjusted for confounders related to nutritional status, severity of AS, comorbidities [hazard ratio (HR) 5.09, 95% confidence interval (CI) 1.70-15.23; HR 3.94, 95% CI 1.34-11.55; HR 3.12, 95% CI 1.14-8.53; HR 3.31, 95% CI 1.21-9.02, respectively]. Frailty determined by the revised J-CHS criteria was associated with clinical outcomes, suggesting these criteria would be useful for risk stratification in Japanese patients with AS undergoing TAVR.

Naples prognostic score as a predictor of mortality in surgical aortic valve replacement

Aim: Investigating the impact of nutritional and inflammatory status, assessed by the Naples-Prognostic-Score (NPS), on postoperative mortality in 173 older adults undergoing surgical aortic valve replacement(SAVR) for aortic stenosis(AS).Methods: Retrospective study calculating NPS from neutrophils/lymphocytes, lymphocytes/monocytes, total cholesterol and serum albumin.Results: Mean age was 69.39 ± 6.153 with 45.1% females. The post-operative mortality was 23.7% over a follow-up period of 50 ± 31 months. The 1-month mortality rate is 2.89%. High NPS significantly associated with increased mortality; multivariate logistic regression confirmed its independence (odds-ratio:3.494, 95% confidence-interval:1.555-7.849, p = 0.002). NPS cutoff of 2 showed 73.2% sensitivity, 56.8% specificity and area-under-the-curve of 0.758 for predicting all-cause mortality. Kaplan-Meier analysis supported lower NPS correlating with better survival.Conclusion: NPS independently predicts postoperative mortality in SAVR patients.

The development and testing of a smart sensorized guide wire for catheterization in a "blood" vessel phantom to support aortic valve implementation

PURPOSE

Heart valve disease is commonly treated by minimally invasive procedures with guide wires and catheterization. The main purpose of this study is to find out whether an extension of the guide wire with a sensor can support the surgeon within the blood vessel to reduce X-ray necessity.

METHODS

A smart guide wire is developed by an extension with a flex-bending sensor to evaluate the sensor signal with and without "blood" flow at a constant compression force. Various surgically relevant investigations are performed. For assessment, the mean temporal average of the moving averaged filtered ADC signal and a subsequent FFT are carried out.

RESULTS

Results show that there is a smaller sensor signal when the applied force or bending at the sensor is higher. In all investigations, there was a different sensor signal. The flex-bending sensor can detect the effect of pulsatile flow. The smallest temporal averaged signal difference between reference and clamp in the front wire's tip is 1.09%. For example, the mean temporal average of the filtered ADC signal for different clinically relevant scenarios is between 2550 and 2900.

CONCLUSIONS

The results show that the sensorized guide wire developed for catheterization can support aortic valve implementation. The sensor sensitivity is sufficient to detect even very small variations within the blood vessel and therefore is promising to support catheterization heart valve surgeries in future.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a revolutionary procedure for severe aortic stenosis. The coexistence of chronic kidney disease (CKD) and TAVR introduces a challenge that significantly impacts patient outcomes.

AIM

To define readmission rates, predictors, and causes after TAVR procedure in CKD stage 1-4 patients.

METHODS

We used the national readmission database 2018 and 2020 to look into readmission rates, causes and predictors after TAVR procedure in patients with CKD stage 1-4.

RESULTS

Out of 24758 who underwent TAVR and had CKD, 7892 (32.4%) patients were readmitted within 90 days, and had higher adjusted odds of being females (adjusted odds ratio: 1.17, 95%CI: 1.02-1.31, P = 0.02) with longer length of hospital stay > 6 days, and more comorbidities including but not limited to diabetes mellitus, anemia, and congestive heart failure (CHF).

CONCLUSION

Most common causes of readmission included CHF (18.0%), sepsis, and complete atrioventricular block. Controlling readmission predictors with very close follow-up is warranted to prevent such high rate of readmission.

Type 2 Diabetes, Circulating Metabolites, and Calcific Aortic Valve Stenosis: A Mendelian Randomization Study

Epidemiological studies have shown an association between type 2 diabetes (T2D) and calcific aortic valve stenosis (CAVS), but the potential causal relationship and underlying mechanisms remain unclear. Therefore, we conducted a two-sample and two-step Mendelian randomization (MR) analysis to evaluate the association of T2D with CAVS and the mediating effects of circulating metabolites and blood pressure using genome-wide association study (GWAS) summary statistics. The inverse variance weighted (IVW) method was used for the primary MR analysis, and comprehensive sensitivity analyses were performed to validate the robustness of the results. Our results showed that genetically predicted T2D was associated with increased CAVS risk (OR 1.153, 95% CI 1.096-1.214, p < 0.001), and this association persisted even after adjusting for adiposity traits in multivariable MR analysis. Furthermore, the two-step MR analysis identified 69 of 251 candidate mediators that partially mediated the effect of T2D on CAVS, including total branched-chain amino acids (proportion mediated: 23.29%), valine (17.78%), tyrosine (9.68%), systolic blood pressure (8.72%), the triglyceride group (6.07-11.99%), the fatty acid group (4.78-12.82%), and the cholesterol group (3.64-11.56%). This MR study elucidated the causal impact of T2D on CAVS risk independently of adiposity and identified potential mediators in this association pathways. Our findings shed light on the pathogenesis of CAVS and suggest additional targets for the prevention and intervention of CAVS attributed to T2D.

Transcatheter aortic valve replacement in China - a review of the available evidence

This paper discusses aortic stenosis (AS) in China, emphasising the role of transcatheter aortic valve replacement (TAVR) in treating AS in an ageing population. AS characteristics, its treatment and the clinical outcomes of transfemoral TAVR in Chinese patients are described via a systematic review. AS affects >1% of the Chinese population aged ≥65 years, with degenerative AS predominating over rheumatic AS among this age group. Chinese patients often have high aortic valve (AV) calcification with bicuspid AV morphology. In 2021, 38,000 surgical aortic valve replacements (SAVR) were reported in China, while the number of TAVR increased from 293 in 2017 to 7,357 in 2021. There are four self-expanding valves and one balloon-expandable SAPIEN 3 valve available in China. Among them, the Venus A-Valve is the most studied and widely used, whereas limited data are available for VitaFlow, TaurusOne, and SAPIEN 3. Notably, 10.0-16.5% of Venus A-Valve recipients and 0.2% of SAPIEN 3 recipients required multiple valve implantations. The rates of 30-day paravalvular leakage were 0-11.7%/0% for Venus A-Valve, 2.0%/0% for VitaFlow, and 0%/0% for SAPIEN 3, for moderate and severe leakage, respectively. Thirty-day all-cause mortality rates were 3.7-10.0% for Venus A-Valve, 0.9% for VitaFlow, and 0-3.2% for SAPIEN 3. One-year all-cause mortality rates were 5.9-13.6% for Venus A-Valve, 0-4.5% for VitaFlow, 6.7% for TaurusOne, and 6.2% for SAPIEN 3. The Venus A-Valve indicated lower 30-day permanent pacemaker implantation (PPI) rates (7.4-20.5%) than VitaFlow and TaurusOne. Outcomes for patients with bicuspid or tricuspid aortic valves were similar. AS is rising among the elderly Chinese population; SAVR is common, and TAVR is increasing. Limited device comparisons exist, but the Venus A-Valve seems to have lower PPI rates, and SAPIEN 3 has low 30-day mortality in China.

Postoperative quality of life and pain after upper hemisternotomy and conventional median sternotomy for aortic valve replacement: results of a randomized clinical trial

OBJECTIVES

Surgical aortic valve replacement through conventional sternotomy yields excellent results. Minimally invasive techniques are deemed equally safe and serve as a viable and less traumatic alternative. However, it is unclear how both surgical techniques affect patient-reported outcomes. The objective of this trial is to compare postoperative cardiac-related quality of life and postoperative pain after upper hemisternotomy and conventional surgical aortic valve replacement.

METHODS

In this single-centre, open-label, investigator-initiated randomized clinical trial, patients were randomized to upper hemisternotomy or conventional full median sternotomy. Patients unable to undergo randomization were monitored prospectively (registry group). Primary outcome was cardiac-specific quality of life, measured with the Kansas City Cardiomyopathy Questionnaire up to 1 year postoperatively.

RESULTS

Patients undergoing upper hemisternotomy had a significantly higher physical limitation domain score across all postoperative time points than patients undergoing conventional surgical aortic valve replacement (estimated mean difference 2.12 points; P = 0.014). Patients undergoing upper hemisternotomy were more likely to have a pain score <30 the first 2 days postoperatively than patients undergoing conventional surgical aortic valve replacement (odds ratio 2.63; P = 0.007). This was associated with reduced opioid analgesic intake. Postoperative surgical outcome did not differ between both groups.

CONCLUSIONS

Surgical aortic valve replacement through both conventional sternotomy and upper hemisternotomy resulted in clinically similar and important improvements in quality of life, with a small advantage for upper hemisternotomy, while there was no compromise in safety.

A Case Report of Sepsis Secondary to Perforated Cholecystitis in the Presence of Severe Aortic Stenosis: Diagnosis and Management

Gallbladder perforation is a rare complication of acute cholecystitis that is associated with significant morbidity and mortality. Many cases of gallbladder perforation are not diagnosed until surgery, as the physical symptoms closely mimic acute cholecystitis. Gallbladder perforation is most common among older males with associated comorbidities, and preoperative assessment of comorbidities, particularly cardiac, is critical to determine the appropriate clinical course. We report a case of a 77-year-old male who presented initially with low blood pressure and right upper quadrant pain (RUQ) after not feeling well for five days. CT of the abdomen/pelvis with IV contrast demonstrated acute perforated cholecystitis, and general surgery was consulted for a cholecystectomy. Due to the patient's past medical history of severe aortic stenosis (AS), cholecystectomy was deferred and a cholecystostomy tube was placed by interventional radiology. This report aims to provide an example of a case of perforated cholecystitis with sepsis and how it can be diagnosed and managed non-surgically in the presence of pre-existing severe AS.

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

Transcatheter aortic valve replacement (TAVR) has increasingly become a safe, feasible, and widely accepted alternative surgical treatment for patients with severe symptomatic aortic stenosis. However, the incidence of conduction abnormalities associated with TAVR, including left bundle branch block (LBBB) and high-degree atrioventricular block (HAVB), remains high and is often correlated with risk factors such as the severity of valvular calcification, preexisting conditions in patients, and procedural factors. The existing research results on the impact of post-TAVR conduction abnormalities and permanent pacemaker (PPM) requirements on prognosis, including all-cause mortality and rehospitalization, remain contradictory, with varied management strategies for post-TAVR conduction system diseases across different institutions. This review integrates the latest research in the field, offering a comprehensive discussion of the mechanisms, risk factors, consequences, and management of post-TAVR conduction abnormalities. This study provides insights into optimizing patient prognosis and explores the potential of novel strategies, such as conduction system pacing, to minimize the risk of adverse clinical outcomes.

Prognostic impact of main pulmonary artery to ascending aorta diameter ratio in patients with severe aortic stenosis underwent transcatheter aortic valve implantation

BACKGROUND

Pulmonary hypertension (PH) and right ventricular dysfunction are poor prognostic predictors in patients underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS).

AIMS

The prognostic impact of the main pulmonary artery/ascending aorta diameter ratio (MPA/AOr), measured simply by computed-tomographic angiography (CTA), was investigated in this patient group.

METHODS

A total of 374 retrospectively evaluated patients (mean age 78.1 ± 8.4 years, 192 [51.3%] females) who underwent TAVI for severe AS were included. MPA/AOr was measured on preprocedural CTA in all patients and the effect of this measurement on the presence of PH, in-hospital and 2-year-overall long-term mortality was investigated.

RESULTS

The presence of PH was defined as a systolic pulmonary artery pressure (sPAP) >42 mmHg measured by echocardiography. According to multivariate-logistic-regression analysis, MPA/AOr (adjusted [Adj] odds ratio [OR]: 1.188, confidence interval [CI] 95% [1.002-1.410], p = 0.048), tricuspid annular plane systolic excursion (TAPSE) (adj OR:0.736, CI 95% [0.663-0.816], p < 0.001) and left atrial diameter (adj OR:1.051, CI 95% [1.007-1.098], p = 0.024) were identified as independent predictors of PH. In addition, a statistically significant correlation was found between MPA/AOr and TAPSE (r: -0.283, p < 0.001). Furthermore, MPA/AOr was found to be an independent predictor of both in-hospital (adj OR:1.434, CI 95% [1.093-1.881], p = 0.009) and 2-year long-term (adj OR:1.518, CI 95% [1.243-1.853], p < 0.001) mortality in multivariate analysis including TAPSE, STS score and sPAP. In the 2-year Kaplan-Meier survival probability analysis, an MPA/AOr >0.86 was found to have a hazard ratio of 3.697 (95% CI: 2.341-5.840), with a log-rank p < 0.001.

CONCLUSION

MPA/AOr, which can be measured simply by CTA, may be useful as an indicator of the presence of PH and poor prognosis in patients planned for TAVI for severe AS.

Minimally Invasive and Full Sternotomy Aortic Valve Replacements Lead to Comparable Long-Term Outcomes in Elderly Higher-Risk Patients: A Propensity-Matched Comparison

BACKGROUND

Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population.

METHODS

Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52-93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7-42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs).

RESULTS

FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47-194) vs. 100 (46-246) min (p = 0.039) and 57 (33-156) vs. 69 (32-118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596).

CONCLUSIONS

In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.

MV-MS-FETE: Multi-view multi-scale feature extractor and transformer encoder for stenosis recognition in echocardiograms

BACKGROUND

aortic stenosis is a common heart valve disease that mainly affects older people in developed countries. Its early detection is crucial to prevent the irreversible disease progression and, eventually, death. A typical screening technique to detect stenosis uses echocardiograms; however, variations introduced by other tissues, camera movements, and uneven lighting can hamper the visual inspection, leading to misdiagnosis. To address these issues, effective solutions involve employing deep learning algorithms to assist clinicians in detecting and classifying stenosis by developing models that can predict this pathology from single heart views. Although promising, the visual information conveyed by a single image may not be sufficient for an accurate diagnosis, especially when using an automatic system; thus, this indicates that different solutions should be explored.

METHODOLOGY

following this rationale, this paper proposes a novel deep learning architecture, composed of a multi-view, multi-scale feature extractor, and a transformer encoder (MV-MS-FETE) to predict stenosis from parasternal long and short-axis views. In particular, starting from the latter, the designed model extracts relevant features at multiple scales along its feature extractor component and takes advantage of a transformer encoder to perform the final classification.

RESULTS

experiments were performed on the recently released Tufts medical echocardiogram public dataset, which comprises 27,788 images split into training, validation, and test sets. Due to the recent release of this collection, tests were also conducted on several state-of-the-art models to create multi-view and single-view benchmarks. For all models, standard classification metrics were computed (e.g., precision, F1-score). The obtained results show that the proposed approach outperforms other multi-view methods in terms of accuracy and F1-score and has more stable performance throughout the training procedure. Furthermore, the experiments also highlight that multi-view methods generally perform better than their single-view counterparts.

CONCLUSION

this paper introduces a novel multi-view and multi-scale model for aortic stenosis recognition, as well as three benchmarks to evaluate it, effectively providing multi-view and single-view comparisons that fully highlight the model's effectiveness in aiding clinicians in performing diagnoses while also producing several baselines for the aortic stenosis recognition task.

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

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

Transcatheter aortic valve implantation versus sutureless aortic valve replacement: a single-centre cost analysis

AIMS

Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are both viable therapeutic interventions for aortic stenosis in elderly patients. Meta-analyses show similar all-cause mortality for both techniques albeit with a different pattern of adverse effects. This study means to compare costs and, to a lesser extent, clinical outcomes of both techniques.

METHODS

A retrospective single-centre analysis was performed for patients receiving SU-AVR or TAVI from 2008 to 2019. Perioperative clinical data were collected from patient files. Costs were assessed by a cost allocation tool. In an attempt to avoid confounding, propensity score matching was carried out.

RESULTS

A total of 368 patients underwent either TAVI (n = 100) or SU-AVR (n = 268). After matching, there were 61 patients per treatment group. Length of stay was significantly longer in the SU-AVR group. Excluding device costs, total expenses for SU-AVR (median: €11,630) were significantly higher than TAVI (median: €9240). For both groups, these costs were mostly incurred on intensive care units, followed by nursing units. Non-medical staff was the largest contributor to expenses. Including device costs, SU-AVR (median: €14,683) was shown to be cost-saving compared to TAVI (median: €24,057).

CONCLUSIONS

To conclude, we found SU-AVR to be cost-saving compared to TAVI, largely due to higher device costs associated with the latter. Excluding device costs, TAVI was associated with lower expenses and shorter length of stay. Non-medical staff was the largest source of costs, suggesting length of stay to be a major financial determinant.

Prognostic Value of Cardiac Magnetic Resonance Feature Tracking Strain in Aortic Stenosis

BACKGROUND

Recent data have suggested that global longitudinal strain (GLS) could be useful for risk stratification of patients with severe aortic stenosis (AS). In this study, we aimed to investigate the prognostic role of GLS in patients with AS and also its incremental value in relation to left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE).

METHODS

We analysed all consecutive patients with AS and LGE-CMR in our institution. Survival data were obtained from office of national statistics, a national body where all deaths in England are registered by law. Death certificates were obtained from the general register office.

RESULTS

Some 194 consecutive patients with aortic stenosis were investigated with CMR at baseline and followed up for 7.3 ± 4 years. On multivariate Cox regression analysis, only increasing age remained significant for both all-cause and cardiac mortality, while LGE (any pattern) retained significance for all-cause mortality and had a trend to significance for cardiac mortality. Kaplan-Meier survival analysis demonstrated that patients in the best and middle GLS tertiles had significantly better mortality compared to patients in the worst GLS tertiles. Importantly though, sequential Cox proportional-hazard analysis demonstrated that GLS did not have significant incremental prognostic value for all-cause mortality or cardiac mortality in addition to LVEF and LGE.

CONCLUSIONS

Our study has demonstrated that age and LGE but not GLS are significant poor prognostic indicators in patients with moderate and severe AS.

Prevalence and Clinical Outcomes of Noncardiac Surgery After Transcatheter Aortic Valve Replacement

Aortic stenosis is a prevalent valvular heart disease, especially in the older people. They often coexist with other co-morbidities, and noncardiac surgery carries a higher risk because of the underlying valve condition. Despite the growing concern about the safety and optimal management of noncardiac surgery post-transcatheter aortic valve replacement (TAVR), there is limited evidence on this matter. This study aims to assess the clinical outcomes of noncardiac surgeries after TAVR. This retrospective study included 718 patients who underwent TAVR. Of these, 36 patients underwent noncardiac surgery after TAVR. The primary end point was the incidence of cardiovascular adverse events post-TAVR and the secondary end point was the incidence of structural valve deterioration. Composite end points included disabling stroke, heart failure requiring hospitalization, and cardiac death as defined by Valve Academic Research Consortium 3. Most of these surgeries were orthopedic and classified as intermediate risk. All noncardiac surgeries were performed without perioperative adverse events. There was no observed structural valve deterioration, and the incidence of composite end points did not significantly differ between the surgical and nonsurgical groups during the follow-up period. Noncardiac surgery after TAVR can be performed safely and does not have a negative impact on prognosis. Further studies are warranted to determine the optimal strategy for noncardiac surgery after TAVR.

Pro-osteogenic role of interleukin-22 in calcific aortic valve disease

BACKGROUND AND AIMS

Although calcific aortic valve disease (CAVD) is a common valvular disease among elderly populations and its incidence has markedly increased in recent decades, the pathogenesis of CAVD remains unclear. In this study, we explored the potential role of interleukin (IL)-22 and the underlying molecular mechanism in CAVD.

METHODS AND RESULTS

Our results showed that IL-22 was upregulated in calcific aortic valves from CAVD patients, and its main sources were CD3+ T cells and CD68+ macrophages. Human aortic valve interstitial cells (VICs) expressed the IL-22-specific receptor IL-22R1, and IL-22R1 expression also was elevated in calcified valves. Treatment of cultured human VICs with recombinant human IL-22 resulted in markedly increased expression of osteogenic proteins Runt-related transcription factor 2 (RUNX2) and alkaline phosphatase (ALP), as well as increased matrix calcium deposition. Moreover, siRNA silencing of IL-22R1 blocked the pro-osteogenic effect of IL-22 in VICs. In IL-22-treated VICs, we also observed increased phosphorylation of JAK3 and STAT3 and nuclear translocation of STAT3. Pretreatment with a specific JAK3 inhibitor, WHIP-154, or siRNA knockout of STAT3 effectively mitigated the IL-22-induced osteoblastic trans-differentiation of human VICs.

CONCLUSIONS

Together, these data indicate that IL-22 promotes osteogenic differentiation of VICs by activating JAK3/STAT3 signaling. Based on our results demonstrating a pro-osteogenic role of IL-22 in human aortic valves, pharmacological inhibition of IL-22 signaling may represent a potential strategy for alleviating CAVD.

Limited versus full sternotomy for aortic valve replacement

BACKGROUND

Aortic valve disease is a common condition easily treatable with cardiac surgery. This is conventionally performed by opening the sternum ('median sternotomy') and replacing the valve under cardiopulmonary bypass. Median sternotomy is well tolerated, but as less invasive options become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access have raised safety concerns with regard to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. This is an update of a Cochrane review first published in 2017, with seven new studies.

OBJECTIVES

To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.

SEARCH METHODS

We performed searches of CENTRAL, MEDLINE and Embase from inception to August 2021, with no language limitations. We also searched two clinical trials registries and manufacturers' websites. We reviewed references of primary studies to identify any further studies of relevance.

SELECTION CRITERIA

We included randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, transapical, transfemoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. We determined the certainty of evidence using the GRADE methodology and summarised results of patient-relevant outcomes in a summary of findings table.

MAIN RESULTS

The review included 14 trials with 1395 participants. Most studies had at least two domains at high risk of bias. We analysed 14 outcomes investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy. Upper hemi-sternotomy may have little to no effect on mortality versus full median sternotomy (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.45 to 1.94; 10 studies, 985 participants; low-certainty evidence). Upper hemi-sternotomy for aortic valve replacement may increase cardiopulmonary bypass time slightly, although the evidence is very uncertain (mean difference (MD) 10.63 minutes, 95% CI 3.39 to 17.88; 10 studies, 1043 participants; very low-certainty evidence) and may increase aortic cross-clamp time slightly (MD 6.07 minutes, 95% CI 0.79 to 11.35; 12 studies, 1235 participants; very low-certainty evidence), although the evidence is very uncertain. Most studies had at least two domains at high risk of bias. Postoperative blood loss was probably lower in the upper hemi-sternotomy group (MD -153 mL, 95% CI -246 to -60; 8 studies, 767 participants; moderate-certainty evidence). Low-certainty evidence suggested that there may be no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.19, 95% CI -0.43 to 0.04; 5 studies, 649 participants). Upper hemi-sternotomy may result in little to no difference in quality of life (MD 0.03 higher, 95% CI 0 to 0.06 higher; 4 studies, 624 participants; low-certainty evidence). Two studies reporting index admission costs concluded that limited sternotomy may be more costly at index admission in the UK National Health Service (MD 1190 GBP more, 95% CI 420 GBP to 1970 GBP, 2 studies, 492 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence was of very low to moderate certainty. Sample sizes were small and underpowered to demonstrate differences in some outcomes. Clinical heterogeneity was also noted. Considering these limitations, there may be little to no effect on mortality. Differences in extracorporeal support times are uncertain, comparing upper hemi-sternotomy to full sternotomy for aortic valve replacement. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from also performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality of life analyses to be included as end points, as well as quantitative measures of physiological reserve.

Adipokines are possible risk markers for aortic stenosis requiring surgery

OBJECTIVES

Aortic stenosis (AS) is the most prevalent valvular heart disease among adults. The adipocyte-derived hormones, leptin and adiponectin, have profound metabolic actions. We examined whether these adipokines are independently associated with future aortic valve replacement (AVR).

DESIGN

In this longitudinal case-control study, we identified 336 cases who had undergone AVR due to AS, and who had previously participated in population-based health surveys. Two referents were matched to each case and leptin and adiponectin concentrations were analysed from stored baseline survey samples. Uni- and multivariable logistic regression analyses were used to estimate the risk of future AVR. An additional cohort was identified for validation including 106 cases with AVR and 212 matched referents.

RESULTS

Median age (interquartile range (IQR)) in years at survey was 59.9 (10.4) and at surgery 68.3 (12.7), and 48% were women. An elevated concentration of leptin was not associated with future AVR (odds ratio [95% confidence interval]) (1.10 [0.92-1.32]), although leptin was associated with a higher risk in patients with coronary artery disease (CAD) having more than 5 years between survey and AVR (1.41 [1.08-1.84]). Adiponectin was not associated with higher risk for future AVR (0.95 [0.82-1.11]), although after stratification for age, higher levels were associated with reduced risk for AVR in persons aged ≥60 years at surgery (0.79 [0.64-0.98]). In the validation study, leptin was associated with future AVR whereas adiponectin was not. None of the associations remained significant after adjustment for body mass index (BMI).

CONCLUSIONS

The adipokine leptin may promote the development of AS.

Aortic valve calcification is promoted by interleukin-8 and restricted through antagonizing CXC motif chemokine receptor 2

AIMS

Inflammatory cytokines play a critical role in the progression of calcific aortic valve disease (CAVD), for which there is currently no pharmacological treatment. The aim of this study was to test the hypothesis that interleukin-8 (IL-8), known to be involved in arterial calcification, also promotes aortic valve calcification (AVC) and to evaluate whether pharmacologically blocking the IL-8 receptor, CXC motif chemokine receptor 2 (CXCR2), could be effective in preventing AVC progression.

METHODS AND RESULTS

A cohort of 195 patients (median age 73, 74% men) diagnosed with aortic valve stenosis (severe in 16.9% of cases) were prospectively followed by CT for a median time of 2.6 years. A Cox proportional hazards regression analysis indicated that baseline IL-8 serum concentrations were associated with rapid progression of AVC, defined as an annualized change in the calcification score by CT ≥ 110 AU/year, after adjustment for age, gender, bicuspid anatomy, and baseline disease severity. In vitro, exposure of primary human aortic valvular interstitial cells (hVICs) to 15 pg/mL IL-8 induced a two-fold increase in inorganic phosphate (Pi)-induced calcification. IL-8 promoted NFκB pathway activation, MMP-12 expression, and elastin degradation in hVICs exposed to Pi. These effects were prevented by SCH527123, an antagonist of CXCR2. The expression of CXCR2 was confirmed in hVICs and samples of aortic valves isolated from patients with CAVD, in which the receptor was mainly found in calcified areas, along with MMP-12 and a degraded form of elastin. Finally, in a rat model of chronic kidney disease-associated CAVD, SCH527123 treatment (1 mg/kg/day given orally for 11 weeks) limited the decrease in aortic cusp separation, the increase in maximal velocity of the transaortic jet, and the increase in aortic mean pressure gradient measured by echocardiography, effects that were associated with a reduction in hydroxyapatite deposition and MMP-12 expression in the aortic valves.

CONCLUSION

Overall, these results highlight, for the first time, a significant role for IL-8 in the progression of CAVD by promoting calcification via a CXCR2- and MMP-12-dependent mechanism that leads to elastin degradation, and identify CXCR2 as a promising therapeutic target for the treatment of CAVD.

Exploring the significance of epicardial adipose tissue in aortic valve stenosis and left ventricular remodeling: Unveiling novel therapeutic and prognostic markers of disease

Aortic stenosis (AS) is a dynamic degenerative process that shares many pathophysiological features with atherogenesis, from initial proinflammatory calcification and focal thickening of the valve leaflets to obstruction of left ventricular outflow due to superimposed of severe calcification and immobilization of the valve leaflets. As the prevalence increases with age, AS is expected to become one of the most common heart diseases worldwide. In both obese and nonobese patients, persistent thickening of epicardial adipose tissue (EAT) is associated with a shift in its normal metabolic functions toward a dysmetabolic and proatherogenic phenotype that may impair the physiology of adjacent coronary arteries and promote the occurrence of coronary atherosclerosis. In tight analogy with atherosclerosis, recent clinical evidence indicates that EAT may also exert a deleterious role in promoting AS and contributing to myocardial dysfunction, leading to increased health risk for elderly patients with AS and an economic burden on the health care system. This review discusses the clinical and pathologic evidence for the association between EAT and AS and concomitant left ventricular hypertrophy, and provides new insights for the future direction of AS diagnosis and treatment.

CardioVision: A fully automated deep learning package for medical image segmentation and reconstruction generating digital twins for patients with aortic stenosis

Aortic stenosis (AS) is the most prevalent heart valve disease in western countries that poses a significant public health challenge due to the lack of a medical treatment to prevent valve calcification. Given the aging population demographic, the prevalence of AS is projected to rise, resulting in a progressively significant healthcare and economic burden. While surgical aortic valve replacement (SAVR) has been the gold standard approach, the less invasive transcatheter aortic valve replacement (TAVR) is poised to become the dominant method for high- and medium-risk interventions. Computational simulations using patient-specific models, have opened new research avenues for optimizing emerging devices and predicting clinical outcomes. The traditional techniques of generating digital replicas of patients' aortic root, native valve, and calcification are time-consuming and labor-intensive processes requiring specialized tools and expertise in anatomy. Alternatively, deep learning models, such as the U-Net architecture, have emerged as reliable and fully automated methods for medical image segmentation. Two-dimensional U-Nets have been shown to produce comparable or more accurate results than trained clinicians' manual segmentation while significantly reducing computational costs. In this study, we have developed a fully automatic AI tool capable of reconstructing the digital twin geometry and analyzing the calcification distribution on the aortic valve. The developed automatic segmentation package enables the modeling of patient-specific anatomies, which can then be used to simulate virtual interventional procedures, optimize emerging prosthetic devices, and predict clinical outcomes.

Effect of minimally invasive versus conventional aortic root replacement on transfusion and postoperative wound complications in patients: A meta-analysis

We examined whether small incision aortic root replacement could reduce the amount of blood transfusion during operation and the risk of postoperative complications. An extensive e-review of the 4 main databases (PubMed, Cochrane, Web of Science and EMBASE) was carried out to determine all the published trials by July 2023. The search terms used were associated with partial versus full sternotomy and aortic root. This analysis only included the study articles that compared partial and full sternotomy. After excluding articles based on titles or abstracts, selected full-text articles had reference lists searched for any potential further articles. We analysed a total of 2167 subjects from 10 comparable trials. The minimally invasive aortic root graft in breastbone decreased the duration of hospitalization (MD, -2.58; 95% CI, -3.15, -2.01, p < 0.0001) and intraoperative red blood cell transfusion (MD, -1.27; 95% CI, -2.34, -0.19, p = 0.02). However, there were no significant differences in wound infection (OR, 0.88; 95% CI, 0.16, 4.93, p = 0.88), re-exploration for bleeding (OR, 0.96; 95% CI, 0.60, 1.53, p = 0.86), intraoperative blood loss (MD, -259.19; 95% CI, -615.11, 96.73, p = 0.15) and operative time (MD, -7.39; 95% CI, -19.10, 4.32, p = 0.22); the results showed that the microsternotomy did not differ significantly from that of the routine approach. Small sternotomy may be an effective and safe substitute for the treatment of the aorta root. Nevertheless, the wide variety of data indicates that larger, well-designed studies are required to back up the current limited literature evidence showing a benefit in terms of complications like postoperative wound infections or the volume of intraoperative red blood cell transfusion.

First-Phase Ejection Fraction and Long-Term Survival in Patients Who Underwent Transcatheter Aortic Valve Implantation

Early recognition of deteriorating left ventricular function plays a key prognostic role in patients with aortic stenosis (AS). First-phase ejection fraction (EF1), the ejection fraction (EF) up to time of maximal contraction, has been suggested for detection of early left ventricular dysfunction in patients with AS with preserved EF. This work aims to evaluate the predictive value of EF1 for assessment of long-term survival in patients with symptomatic severe AS and preserved EF who undergo transcatheter aortic valve implantation (TAVI). We included 102 consecutive patients (median age 84 years [interquartile range 80 to 86 years]) who underwent TAVI between 2009 and 2011. Patients were retrospectively stratified into tertiles by EF1. Device success and procedural complications were defined according to the Valve Academic Research Consortium-3 criteria. Mortality data were retrieved from a computerized interface of the Israeli Ministry of Health. Baseline characteristics, co-morbidities, clinical presentation, and echocardiographic findings were similar among groups. The groups did not differ significantly regarding device success and in-hospital complications. During a potential follow-up period of >10 years, 88 patients died. Kaplan-Meier analysis (log-rank p = 0.017) followed by multivariable Cox regression analysis showed that EF1 predicted long-term mortality independently, either as continuous variable (hazard ratio 1.04, 95% confidence interval 1.01 to 1.07, p = 0.012) or for each decrease in tertile group (hazard ratio 1.40, 95% confidence interval 1.05 to 1.86, p = 0.023). In conclusion, low EF1 is associated with a significant decrease in adjusted hazard for long-term survival in patients with preserved EF who undergo TAVI. Low EF1 might delineate a population at great risk who would benefit from prompt intervention.

Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks.

METHODS

We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time.

RESULTS

A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement.

CONCLUSIONS

TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

The Effects of Exercise Training on Exercise Capacity and Vascular Function after Transcatheter Aortic Valve Implantation-A Pilot Study

Transcatheter aortic valve implantation (TAVI) improves event-free survival in patients with severe aortic stenosis, but patients' exercise capacity remains poor after the procedure. Therefore, we sought to compare the effects of a supervised center-based exercise training program and unsupervised exercise routine on exercise capacity and vascular function in patients after TAVI. Patients were randomized to either center-based exercise training (12-24 sessions of combined aerobic and low-weight resistance training twice weekly for 8-12 weeks) or an unsupervised home-based exercise routine (initial appraisal with detailed recommendations and monthly follow-up). Exercise capacity (cardiopulmonary testing) and vascular function (ultrasonographic measurement of flow-mediated vasodilation (FMD) and arterial stiffness) were assessed at the baseline and after the study period. We included 23 patients (mean age of 81 years, 61% women), with higher-than-expected drop-out rates (41%) because of the coronavirus-19 pandemic outbreak. Exercise capacity improved over time, irrespective of the intervention group: 0.09 mL/min/kg increase in peak oxygen uptake (95% CI [0.01-0.16]; p = 0.02), 8.2 Watts increase in workload (95% CI [0.6-15.8]; p = 0.034), and 47 s increase in cumulative exercise time (95% CI [5.0-89.6]; p = 0.029). A between-group difference in change over time (treatment effect) was detected only for FMD (4.49%; 95% CI [2.35; 6.63], p < 0.001), but not for other outcome variables. Both supervised and unsupervised exercise training improve exercise capacity and vascular function in patients after TAVI, with supervised exercise training possibly yielding larger improvements in vascular function, as determined by FMD.

Emerging transcatheter heart valve technologies for severe aortic stenosis

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is the standard of care for selected patients with severe aortic stenosis, irrespective of the surgical risk. Over the last two decades of TAVI practice, multiple limitations were identified. In addition, the extension of TAVI into a wider patient spectrum created new challenges.

AREAS COVERED

This review provides an overview of emerging transcatheter heart valves (THVs) beyond the approved contemporary THVs for the treatment of aortic stenosis.

EXPERT OPINION

The incidence of degenerative aortic stenosis is expected to increase with more aging of the population. Therefore, TAVI needs to meet this increase in the number of patients indicated for aortic valve replacement alongside a wide and complex anatomical variability. An increasing number of Aortic THVs are available in the market. This includes upgraded iterations of contemporary devices and innovative devices developed by emerging manufacturers. The new devices aim for the reduction or elimination of undesirable outcomes like paravalvular leakage and conduction disturbances requiring permanent pacemaker implantation. Alternatively, emerging THVs should provide feasibility regarding yet unproven TAVI indications like Bicuspid aortic valve, aortic regurgitation, or very large anatomy. Furthermore, some of the emerging THVs are designed to tackle the long-term durability issue of biological valves.

Sternal-Sparing Surgical Options in Combined Aortic Valve and Coronary Artery Disease: Proof of Concept

OBJECTIVE

The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches.

METHODS

We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches.

RESULTS

Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days.

CONCLUSIONS

Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.

An Analysis of Early Results after Valve Replacement in Isolated Aortic Valve Stenosis by Using Sutureless vs. Stented Bioprostheses: A Single-Center Middle-Income Country Experience

Background and Objectives: There is a lack of data about the survival of patients after the implantation of sutureless relative to stented bioprostheses in middle-income settings. The objective of this study was to compare the survival of people with isolated severe aortic stenosis after the implantation of sutureless and stented bioprostheses in a tertiary referral center in Serbia. Materials and Methods: This retrospective cohort study included all people treated for isolated severe aortic stenosis with sutureless and stented bioprostheses from 1 January 2018 to 1 July 2021 at the Institute for Cardiovascular Diseases "Dedinje". Demographic, clinical, perioperative and postoperative data were extracted from the medical records. The follow-up lasted for a median of 2 years. Results: The study sample comprised a total of 238 people with a stented (conventional) bioprosthesis and 101 people with a sutureless bioprosthesis (Perceval). Over the follow-up, 13.9% of people who received the conventional and 10.9% of people who received the Perceval valve died (p = 0.400). No difference in the overall survival was observed (p = 0.797). The multivariate Cox proportional hazard model suggested that being older, having a higher preoperative EuroScore II, having a stroke over the follow-up period and having valve-related complications were independently associated with all-cause mortality over a median of 2 years after the bioprosthesis implantation. Conclusions: This research conducted in a middle-income country supports previous findings in high-income countries regarding the survival of people with sutureless and stented valves. Survival after bioprosthesis implantation should be monitored long-term to ensure optimum postoperative outcomes.

Reclassification of moderate aortic stenosis based on data-driven phenotyping of hemodynamic progression

The management and follow-up of moderate aortic stenosis (AS) lacks consensus as the progression patterns are not well understood. This study aimed to identify the hemodynamic progression of AS, and associated risk factors and outcomes. We included patients with moderate AS with at least three transthoracic echocardiography (TTE) studies performed between 2010 and 2021. Latent class trajectory modeling was used to classify AS groups with distinctive hemodynamic trajectories, which were determined by serial systolic mean pressure gradient (MPG) measurements. Outcomes were defined as all-cause mortality and aortic valve replacement (AVR). A total of 686 patients with 3093 TTE studies were included in the analysis. Latent class model identified two distinct AS trajectory groups based on their MPG: a slow progression group (44.6%) and a rapid progression group (55.4%). Initial MPG was significantly higher in the rapid progression group (28.2 ± 5.6 mmHg vs. 22.9 ± 2.8 mmHg, P < 0.001). The prevalence of atrial fibrillation was higher in the slow progression group; there was no significant between-group difference in the prevalence of other comorbidities. The rapid progression group had a significantly higher AVR rate (HR 3.4 [2.4-4.8], P < 0.001); there was no between-group difference in mortality (HR 0.7 [0.5-1.0]; P = 0.079). Leveraging longitudinal echocardiographic data, we identified two distinct groups of patients with moderate AS: slow and rapid progression. A higher initial MPG (≥ 24 mmHg) was associated with more rapid progression of AS and higher rates of AVR, thus indicating the predictive value of MPG in management of the disease.

Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery

Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.

Mechanical injury accentuates lipid deposition in ApoE-/- mice and advance aortic valve stenosis: A novel modified aortic valve stenosis model

Background

Current mouse models still have limitations in studying aortic valve stenosis (AVS). A suitable animal model bearing a close resemblance to the pathophysiological processes of humans needs to be developed. Here, we combined two risk factors to create a mouse model that mimics the pathological features of human AVS.

Methods and results

We combined WI and hyperlipidemia in ApoE^-/- mice to explore the synergistic effect on the stenosis of the aortic valve. Transthoracic echocardiography revealed progressively increased peak velocity with age in ApoE^-/- mice to velocities above C57 mice when fed a high-fat diet after wire injury. Moreover, ApoE^-/- mice demonstrated lower cusp separation and lower aortic valve area after 8 weeks vs. C57 mice. Gross morphology and MRI showed advanced thickening, sclerosis aortic valve, narrowing of the orifice area, and micro-CT showed obvious calcification in the aortic valves in the hyperlipidemia group after wire injury. Histopathology studies showed thickening and fibrosis of aortic valve leaflets in the hyperlipidemia group after wire injury. Notably, lipid deposition was observed in ApoE^-/- mice 8 weeks after wire injury, accompanied by overexpressed apoB and apoA proteins. After wire injury, the hyperlipidemia group exhibited augmented inflammation, ROS production, and apoptosis in the leaflets. Moreover, the combination group exhibited advanced fibro-calcific aortic valves after wire injury.

Conclusion

Overall, we present the synergistic effect of wire injury and hyperlipidemia on lipoproteins deposition in the development of AVS in ApoE^-/- mice, this model bear close resemblance to human AVS pathology.

Biological versus mechanical prostheses for aortic valve replacement

OBJECTIVES

Long-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population.

METHODS

This was a multicenter observational study including all patients aged between 50 and 65 years who underwent an aortic valve replacement because of severe isolated aortic stenosis between the years 2000 and 2018. A total of 5215 patients from 27 Spanish hospitals were registered with a follow-up of 15 years. Multivariable analyses, including a 2:1 propensity score matching (1822 Mech and 911 Bio) and competing risks analyses were applied.

RESULTS

Bio prostheses were implanted in 19% of patients (n = 992). No significant differences were observed between matched groups in long-term survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.88-1.47; P = .33). Stroke rates were higher for Mech prostheses, but not significant (HR, 0.72; 95% CI, 0.50-1.03; P = .07). Finally, higher rates of major bleeding were found in the Mech group (HR, 0.65; 95% CI, 0.49-0.87; P = .004), whereas reoperation was more frequent among the Bio group (HR, 3.04; 95% CI, 1.80-5.14; P < .001). Bio prostheses increased from 13% in the period from 2000 to 2008 to 24% in 2009 to 2018.

CONCLUSIONS

Long-term survival was comparable among groups in patients between 50 and 65 years of age. Mech prostheses were associated with a higher risk of major bleeding, whereas Bio prostheses entailed higher reoperation rates. Bio prostheses seem a reasonable choice for patients between 50 and 65 years in Spain.

Changes in cerebral autoregulation and vasoreactivity after surgical aortic valve replacement: a prospective study

NEW FINDINGS

What is the central question of this study? How are dynamic cerebral autoregulation and brain vasoreactivity influenced by severe aortic stenosis and its surgical treatment? What are the main findings and their importance? Dynamic cerebral autoregulation is preserved in the long term in patients with severe aortic stenosis and does not change after surgical aortic valve replacement. However, carbon dioxide vasoreactivity is impaired in these patients.

ABSTRACT

Surgical aortic valve replacement (SAVR) alters the natural course of severe aortic stenosis (AS). In this study, we aimed to determine the effects of the disease on dynamic cerebral autoregulation and vasoreactivity (VR) and to assess their changes after SAVR. We recruited 23 patients diagnosed with severe AS eligible for SAVR and 15 healthy matched controls. AS patients had lower mean VR to CO2 (P = 0.005) than controls, but dynamic cerebral autoregulation was preserved. Cerebral haemodynamics showed no significant change after SAVR. Patients with smaller baseline aortic valve areas presented with smaller low frequency phase changes after surgery (P = 0.016). Severe AS does not seem to impact dynamic cerebral autoregulation but does reduce VR to CO2 . SAVR does not alter cerebral autoregulation nor vasoreactivity.

Radiomic analysis of enhanced CMR cine images predicts left ventricular remodeling after TAVR in patients with symptomatic severe aortic stenosis

Objective

This study aimed to develop enhanced cine image-based radiomic models for non-invasive prediction of left ventricular adverse remodeling following transcatheter aortic valve replacement (TAVR) in symptomatic severe aortic stenosis.

Methods

A total of 69 patients (male:female = 37:32, median age: 66 years, range: 47-83 years) were retrospectively recruited, and severe aortic stenosis was confirmed via transthoracic echocardiography detection. The enhanced cine images and clinical variables were collected, and three types of regions of interest (ROIs) containing the left ventricular (LV) myocardium from the short-axis view at the basal, middle, and apical LV levels were manually labeled, respectively. The radiomic features were extracted and further selected by using the least absolute shrinkage and selection operator (LASSO) regression analysis. Clinical variables were also selected through univariate regression analysis. The predictive models using logistic regression classifier were developed and validated through leave-one-out cross-validation. The model performance was evaluated with respect to discrimination, calibration, and clinical usefulness.

Results

Five basal levels, seven middle levels, eight apical level radiomic features, and three clinical factors were finally selected for model development. The radiomic models using features from basal level (Rad I), middle level (Rad II), and apical level (Rad III) had achieved areas under the curve (AUCs) of 0.761, 0.909, and 0.913 in the training dataset and 0.718, 0.836, and 0.845 in the validation dataset, respectively. The performance of these radiomic models was improved after integrating clinical factors, with AUCs of the Combined I, Combined II, and Combined III models increasing to 0.906, 0.956, and 0.959 in the training dataset and 0.784, 0.873, and 0.891 in the validation dataset, respectively. All models showed good calibration, and the decision curve analysis indicated that the Combined III model had a higher net benefit than other models across the majority of threshold probabilities.

Conclusion

Radiomic models and combined models at the mid and apical slices showed outstanding and comparable predictive effectiveness of adverse remodeling for patients with symptomatic severe aortic stenosis after TAVR, and both models were significantly better than the models of basal slice. The cardiac magnetic resonance radiomic analysis might serve as an effective tool for accurately predicting left ventricular adverse remodeling following TAVR in patients with symptomatic severe aortic stenosis.

Development and analysis of a comprehensive diagnostic model for aortic valve calcification using machine learning methods and artificial neural networks

BACKGROUND

Although advanced surgical and interventional treatments are available for advanced aortic valve calcification (AVC) with severe clinical symptoms, early diagnosis, and intervention is critical in order to reduce calcification progression and improve patient prognosis. The aim of this study was to develop therapeutic targets for improving outcomes for patients with AVC.

MATERIALS AND METHODS

We used the public expression profiles of individuals with AVC (GSE12644 and GSE51472) to identify potential diagnostic markers. First, the R software was used to identify differentially expressed genes (DEGs) and perform functional enrichment analysis. Next, we combined bioinformatics techniques with machine learning methodologies such as random forest algorithms and support vector machines to screen for and identify diagnostic markers of AVC. Subsequently, artificial neural networks were employed to filter and model the diagnostic characteristics for AVC incidence. The diagnostic values were determined using the receiver operating characteristic (ROC) curves. Furthermore, CIBERSORT immune infiltration analysis was used to determine the expression of different immune cells in the AVC. Finally, the CMap database was used to predict candidate small compounds as prospective AVC therapeutics.

RESULTS

A total of 78 strong DEGs were identified. The leukocyte migration and pid integrin 1 pathways were highly enriched for AVC-specific DEGs. CXCL16, GPM6A, BEX2, S100A9, and SCARA5 genes were all regarded diagnostic markers for AVC. The model was effectively constructed using a molecular diagnostic score system with significant diagnostic value (AUC = 0.987) and verified using the independent dataset GSE83453 (AUC = 0.986). Immune cell infiltration research revealed that B cell naive, B cell memory, plasma cells, NK cell activated, monocytes, and macrophage M0 may be involved in the development of AVC. Additionally, all diagnostic characteristics may have varying degrees of correlation with immune cells. The most promising small molecule medicines for reversing AVC gene expression are Doxazosin and Terfenadine.

CONCLUSION

It was identified that CXCL16, GPM6A, BEX2, S100A9, and SCARA5 are potentially beneficial for diagnosing and treating AVC. A diagnostic model was constructed based on a molecular prognostic score system using machine learning. The aforementioned immune cell infiltration may have a significant influence on the development and incidence of AVC.

Mini-sternotomy versus full sternotomy for isolated aortic valve replacement: A single-center experience

BACKGROUND

Minimally invasive approaches to isolated aortic valve replacement (AVR) are well-described and widely utilized. While there are numerous proposed benefits, there is limited literature describing significant morbidity or mortality benefits for minimally invasive isolated AVR resulting in hesitancy in its universal adoption. In this retrospective study, we compare the 5-year outcomes of patients undergoing isolated AVR via full sternotomy (FS) or mini-sternotomy (MS).

METHODS

756 patients underwent isolated AVR between 2014 and 2019. Propensity matching resulted in 142 matched pairs that received either FS or MS. The primary outcome was mortality during the follow-up period. Secondary outcomes included intraoperative variables and postoperative morbidity.

RESULTS

Intraoperative variables including total operative, cardiopulmonary bypass, and aortic cross-clamp times did not differ significantly between groups. Postoperative mortality was similar between the matched groups with nonsignificant differences at 30 days (2.12% vs. 1.4%, p = .657), 1 year (4.9% vs. 2.1%, p = .0.223), and 5 years (7.5% vs. 3.5%, p = .174). Rates of postoperative morbidity were comparable between groups with no significant differences.

CONCLUSION

This study examined the long-term outcomes of propensity-matched patients undergoing isolated AVR via FS or MS and identified no significant differences in outcomes over a 5-year follow-up period. The decision for surgical approach is multifactorial and should be decided on a case-by-case basis taking into consideration patient anatomy, surgeon experience, and comfort, as well as patient preference.

Multimodality Imaging in Valvular Structural Interventions

Structural valvular interventions have skyrocketed in the past decade with new devices becoming available and indications for patients who would previously have been deemed inoperable. Furthermore, while echocardiography is the main imaging tool and the first line for patient screening, cardiac magnetic resonance and CT are now essential tools in pre-planning and post-procedural follow-up. This review aims to address imaging modalities and their scope in aortic, mitral and tricuspid structural valvular interventions, including multimodality imaging. Pulmonary valve procedures, which are mostly carried out in patients with congenital problems, are discussed. This article presents a guide on individualised imaging approcahes on each of the available interventional procedures.

Cellular Senescence, Aging and Non-Aging Processes in Calcified Aortic Valve Stenosis: From Bench-Side to Bedside

Aortic valve stenosis (AS) is the most common valvular heart disease. The incidence of AS increases with age, however, a significant proportion of elderly people have no significant AS, indicating that both aging and nonaging pathways are involved in the pathomechanism of AS. Age-related and stress-induced cellular senescence accompanied by further active processes represent the key elements of AS pathomechanism. The early stage of aortic valve degeneration involves dysfunction and disruption of the valvular endothelium due to cellular senescence and mechanical stress on blood flow. These cells are replaced by circulating progenitor cells, but in an age-dependent decelerating manner. When endothelial denudation is no longer replaced by progenitor cells, the path opens for focal lipid deposition, initiating subsequent oxidation, inflammation and micromineralisation. Later stages of AS feature a complex active process with extracellular matrix remodeling, fibrosis and calcification. Echocardiography is the gold standard method for diagnosing aortic valve disease, although computed tomography and cardiac magnetic resonance are useful additional imaging methods. To date, no medical treatment has been proven to halt the progression of AS. Elucidation of differences and similarities between vascular and valvular calcification pathomechanisms may help to find effective medical therapy and reduce the increasing health burden of the disease.

Circulating Irisin Level as a Biomarker for Pure Aortic Stenosis and Aortic Valve Calcification

Irisin, a myokine mainly secreted by skeletal and cardiac muscles, is actively involved in cardiovascular diseases. However, whether irisin is associated with aortic stenosis remains unknown. Two hundred ninety-three severe AS patients who underwent transcatheter aortic valve implantation were enrolled and followed-up for 35 months on average. Enzyme-linked immunosorbent assay (ELISA) was applied to measure circulating irisin levels. Patients were divided into two groups based on the median plasma irisin level. We found that high plasma irisin levels were independently associated with pure aortic stenosis (PAS) after adjusting for age, body mass index, history of peripheral vascular disease, and creatinine (OR = 3.015, 95% CI 1.775-5.119, P < 0.001). ROC curve analysis showed a significant predictive value of irisin for PAS (AUC = 0.647, 95% CI 0.583-0.711, P < 0.001). The severity of aortic valve calcification was negatively associated with plasma irisin levels (P < 0.05). In conclusion, irisin is an independent predictor for PAS and is negatively associated with the severity of aortic valve calcification.

The application of 3D printing in preoperative planning for transcatheter aortic valve replacement: a systematic review

BACKGROUND

Recently, transcatheter aortic valve replacement (TAVR) has been suggested as a less invasive treatment compared to surgical aortic valve replacement, for patients with severe aortic stenosis. Despite the attention, persisting evidence suggests that several procedural complications are more prevalent with the transcatheter approach. Consequently, a systematic review was undertaken to evaluate the application of three-dimensional (3D) printing in preoperative planning for TAVR, as a means of predicting and subsequently, reducing the incidence of adverse events.

METHODS

MEDLINE, Web of Science and Embase were searched to identify studies that utilised patient-specific 3D printed models to predict or mitigate the risk of procedural complications.

RESULTS

13 of 219 papers met the inclusion criteria of this review. The eligible studies have shown that 3D printing has most commonly been used to predict the occurrence and severity of paravalvular regurgitation, with relatively high accuracy. Studies have also explored the usefulness of 3D printed anatomical models in reducing the incidence of coronary artery obstruction, new-onset conduction disturbance and aortic annular rapture.

CONCLUSION

Patient-specific 3D models can be used in pre-procedural planning for challenging cases, to help deliver personalised treatment. However, the application of 3D printing is not recommended for routine clinical practice, due to practicality issues.

Epigenetics: a new warrior against cardiovascular calcification, a forerunner in modern lifestyle diseases

Arterial and aortic valve calcifications are the most prevalent pathophysiological conditions among all the reported cases of cardiovascular calcifications. It increases with several risk factors like age, hypertension, external stimuli, mechanical forces, lipid deposition, malfunction of genes and signaling pathways, enhancement of naturally occurring calcium inhibitors, and many others. Modern-day lifestyle is affected by numerous environmental factors and harmful toxins that impair our health rather than providing benefits. Applying the combinatorial approach or targeting the exact mechanism could be a new strategy for drug designing or attenuating the severity of calcification. Most of the non-communicable diseases are life-threatening; thus, altering the phenotype and not the genotype may reveal the gateway for fighting with upcoming hurdles. Overall, this review summarizes the reason behind the generation of arterial and aortic valve calcification and its related signaling pathways and also the detrimental effects of calcification. In addition, the individual process of epigenetics and how the implementation of this process becomes a novel approach for diminishing the harmful effect of calcification are discussed. Noteworthy, as epigenetics is linked with genetics and environmental factors necessitates further clinical trials for complete and in-depth understanding and application of this strategy in a more specific and prudent manner.

What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making

Background

Guidelines recommend including the patient’s values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS.

Methods

This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients’ most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters.

Results

51 adults with sAS and 3 caregivers with experience choosing treatment (age 36–92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making.

Conclusions

These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients’ value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients’ priorities.

Trial registration

ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.

Integrated Analysis of LncRNA-Mediated ceRNA Network in Calcific Aortic Valve Disease

BACKGROUND

The high morbidity and mortality of calcific aortic valve disease (CAVD) represents an unmet clinical need to investigate the molecular mechanisms involved. Evidence suggests that long non-coding RNAs (lncRNAs) can act as competitive endogenous RNAs (ceRNAs) by binding to microRNAs and regulating target genes in cardiovascular diseases. Nevertheless, the role of lncRNAs related ceRNA regulation in CAVD remains unclear.

METHODS

RNAseq data of human diseased aortic valves were downloaded from GEO data sets (GSE153555, GSE199718), and differentially expressed lncRNAs (DElncRNAs), mRNAs (DEmRNAs) between CAVD and non-calcific aortic valve tissues with limma R package. Gene Ontology (GO) annotation, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and Gene Set Enrichment analysis (GSEA) were performed with clusterProfiler and gesaplot2 R package. The pivotal microRNAs were predicted by three databases intersection including TargetScan, MiRwalk, miRDB according to the genes related to the crucial pathways. ENCORI was used to predict targeted lncRNAs of hub microRNAs. We constructed lncRNA-miRNA-mRNA ceRNA network with Cytoscape software. The lncRNAs in ceRNA network were verified by RT-qPCR in human 30 calcific and 20 noncalcified aortic valve tissues.

RESULTS

In total, 1739 DEmRNAs and 266 DElncRNAs were identified in CAVD. GO, KEGG pathway, GSEA annotations suggested that most of these genes are enriched in extracellular matrix (ECM)-reporter interaction pathways. The ceRNA networks associated with ECM-reporter interaction are constructed and related lncRNAs including H19, SNHG3 and ZNF436-AS1 were significant upregulated in human calcific aortic valve tissues, which might be potential therapeutic targets for CAVD.

CONCLUSIONS

In this study, we proposed a novel lncRNA-miRNA-mRNA ceRNA network related to ECM-reporter interaction pathways, which potentially regulates CAVD progression.

Progression of aortic stenosis after an acute myocardial infarction

Background

Myocardial infarction (MI) has been shown to induce fibrotic remodelling of the mitral and tricuspid valves. It is unknown whether MI also induces pathological remodelling of the aortic valve and alters aortic stenosis (AS) progression. We thus compared AS progression after an acute MI and in patients with/without history of MI, and assessed post-MI pathobiological changes within the aortic valve leaflets in a sheep model.

Methods

Serial echocardiograms in human patients with AS were retrospectively analysed and compared between 3 groups: (1) acute MI at baseline (n=68), (2) prior history of MI (n=45) and (3) controls without MI (n=101). Annualised progression rates of AS severity were compared between these 3 groups. In addition, aortic valves were harvested from 15 sheep: (1) induced inferior MI (n=10) and (2) controls without MI (n=5), for biological and histological analyses.

Results

In humans, the acute MI, previous MI and control groups had comparable baseline AS severity. Indexed aortic valve area (AVA_i) declined faster in the acute MI group compared with controls (−0.07±0.06 vs −0.04±0.04 cm²/m²/year; p=0.004). After adjustment, acute MI status was significantly associated with faster AVA_i progression (mean difference: −0.013 (95% CI −0.023 to −0.003) cm²/m²/year, p=0.008). In the post-MI experimental animal model, aortic valve thickness and qualitative/quantitative expression of collagen were significantly increased compared with controls.

Conclusions

The results of this study suggest that AS progression is accelerated following acute MI, which could be caused by increased collagen production and thickening of the aortic valve after the ischaemic event.

Observational and Genetic Associations of Modifiable Risk Factors with Aortic Valve Stenosis: A Prospective Cohort Study of 0.5 Million Participants

Background: Observational studies have shown that modifiable risk factors are associated with aortic valve stenosis (AVS). However, the causality behind these associations remains largely unknown. Objectives: To explore the associations of modifiable risk factors, including metabolic factors, biochemical measures, education, and lifestyles with AVS and their potential causal associations. Methods: We enrolled 361,930 British white people with genetic data in the UK biobank. Cox proportional risk regression models were used to estimate the hazard ratios between 28 modifiable risk factors and AVS. We used genetic instruments for modifiable risk factors to determine the potential causal relationships using a one-sample Mendelian randomization (MR) approach. Results: A total of 1602 participants developed AVS during an 8.4-year follow-up. Observational analyses showed higher adiposity, blood pressure, heart rate, low-density lipoprotein, urate, C-reactive protein, creatinine, albumin, and glycated hemoglobin, but lower serum vitamin D, and education, unhealthy lifestyle, and poor sleep quality were related to a higher risk of AVS after adjusting for the Bonferroni correction (p < 0.0013). Genetically predicted 1-SD higher levels of body mass index [HR: 1.09, 95% CI: 1.03 to 1.16], body fat percentage (1.17, 1.03 to 1.33), triglyceride (TG) [1.08, 1.00 to 1.16], low-density lipoprotein (LDL) (1.15, 1.08 to 1.21) and serum total cholesterol (TC) (1.13, 1.02 to 1.25) were associated with a higher risk of AVS, respectively. Genetically determined per category higher insomnia (1.32, 1.13 to 1.55) was also associated with AVS. The abovementioned genetic associations with the incident AVS showed an increasing relationship pattern. Conclusions: This study provides strong evidence for the potential causal roles of cardiometabolic factors in developing AVS, highlighting that an idea of metabolic status through a healthy lifestyle may help prevent AVS.

New Evidence About Aortic Valve Stenosis and Cardiovascular Hemodynamics

Aortic stenosis (AS) is the most common degenerative valvular disease in western word. In patients with severe AS, small changes in aortic valve area can lead to large changes in hemodynamics. The correct understanding of cardiac hemodynamics and its interaction with vascular function is of paramount importance for correct identification of severe AS and to plan effective strategies for its treatment. In the current review with highlight the importance of pressure recovery phenomenon and valvular arterial impedance as novel tools in the evaluation of patients with aortic stenosis.

Clinical outcomes of transcatheter aortic valve replacement stratified by left ventricular ejection fraction: A single centre pilot study

Introduction

To define baseline echocardiographic, electrocardiographic (ECG) and computed tomographic (CT) findings of patients with heart failure undergoing transcatheter aortic valve replacement (TAVR) and analyze their overall procedural outcomes.

Methods

Between 2018 and 2021, patients with severe aortic stenosis (AS) who performed transcatheter aortic valve replacement (TAVR) in Sabah Al Ahmad Cardiac Centre, Al Amiri Hospital were identified. A retrospective review of patients' parameters including pre-, intra-, and post-procedural data was conducted. Patients were grouped in 2 subgroups according to their EF: EF <40% (HFrEF) and EF ≥ 40%. The data included patients’ baseline characteristics, electrocardiographic and echocardiographic details along with pre-procedural CT assessment of aortic valve dimensions. Primary outcomes including post-operative disturbances, pacemaker implantation and in-hospital mortality following TAVR were additionally analyzed.

Results

A total of 61 patients with severe AS underwent TAVR. The mean age was 73.5 ± 9, and 21 (34%) of the patients were males. The mean ejection fraction (EF) was 55.5 ± 9.7%. Of 61 patients, 12 (20%) were identified as heart failure with reduced EF (<40%). These patients were younger, more often males, and were more likely to have coronary artery disease (75% versus 53.1%). Left ventricular hypertrophy and diastolic dysfunction was documented in 75% and 58.3% of patients with heart failure with reduced ejection fraction (HFrEF) respectively. Post TAVR conduction disturbances, with the commonest being LBBB was observed in 41.7%. Permanent pacemaker was implanted in 3 of patients with HFrEF (25%). There were no significant differences between the two groups with regards to in hospital mortality (p = 0.618).

Conclusion

Severe AS with EF <40% constitute a remarkable proportion of patients undergoing TAVR. Preliminary results of post-operative conduction disturbances and in hospital mortality in HFrEF patients were concluded to not differ from patients with LVEF ≥40%.

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This is the first reported outcome study of TAVR in patients with heart failure in Kuwait.

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Conduction disturbances induced by TAVR was observed in almost half of the patients.

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Systolic dysfunction was not a predictor of in hospital complications or mortality outcomes.