Calcific aortic stenosis

Nonlinear ageing gero-marker dynamics of transcriptomic profile during calcific aortic valve mouse modeling

The prevention and management of degenerative heart disease remain challenging and could potentially be significantly improved by understanding of ageing biomarker dynamics. In this study, we constructed the calcific aortic valve mouse model at different age points, measured valve function degeneration along with valve calcification, and investigated the nonlinear dynamics using sequencing data and deep learning models. In C57BL/6 N mouse model, the older mice had higher levels of peak transvalvular jet velocity in terms of valve function. Regarding valve calcification, collagen and elastic fiber calcification in the middle layer increased significantly at 48-week-old (p < 0.001), and the calcification spread to the inner endothelial cells at 72-week-old (p < 0.0001). RNA sequencing illustrated that 30 genes, including Acadsb, L2hgdh, and Cpped1, showed increased expression with age. Among them, four genes, namely Hipk2, 9430069I07Rik, Peli3, and Slc22a12, increased more than threefold in aortic tissues in 72-week-old mice compared to 6-week-old mice. Moreover, a large proportion of genes changed in a nonlinear pattern (6,325 out of 12,160, 52%). In conclusion, both linear and nonlinear gero-markers were found in the calcific aortic valve mouse modeling, which highlighted specific periods of significant wave with accelerated ageing (48-week-old in mice).

Aortic valve calcification across stages of dysglycemia in middle-aged individuals from the general population

BACKGROUND

Aortic valve calcification (AVC) is an underlying pathophysiological mechanism in aortic stenosis, which shares many risk factors with diabetes. However, the association between dysglycemia and early stages of AVC remains unclear. The aim was to examine the associations between stages of dysglycemia and signs of AVC among middle-aged individuals from the general population.

METHODS

This was a cross-sectional study from the Swedish CArdioPulmonary bioImage Study (SCAPIS) randomly enrolling 30,154 middle-aged men and women from six study sites in Sweden between 2013 and 2018. Glycemic status was based on the World Health Organization criteria (fasting blood glucose and/or HbA1c) and questionnaire-based answers on previous diseases and categorized as normoglycemia, prediabetes, newly detected diabetes and known diabetes. AVC was assessed on cardiac computed tomography (CT) and defined as evident or not.

RESULTS

Of 29,331 individuals with data on glycemic status and AVC available, mean age was 57.5 years and normoglycemia was present in 76%, prediabetes in 16%, newly detected diabetes in 3% and known diabetes in 5%. The prevalence of AVC increased progressively across glycemic categories, particularly in males (8%, 11%, 14% and 17%; P < 0.01) compared to females (5%, 6%, 8% and 9%; P < 0.01). There was an association with AVC already in the early stages of dysglycemia; prediabetes (OR 1.16, 95% CI 1.02-1.31), newly detected diabetes (1.34 [1.05-1.71]) and known diabetes (1.61 [1.34-1.93]) after adjusting for age, sex, smoking, study site, low density lipoprotein-cholesterol and hypertension.

CONCLUSIONS

In this large, contemporary, and randomly selected population of middle-aged individuals, prediabetes, newly detected diabetes and known diabetes were all associated with CT-detected AVC. Further studies are warranted to investigate if managing dysglycemia, even in its early stages, may help slow down AVC progression.

Plasma Proteomic Assessment of Calcific Aortic Valve Disease in Older Adults

BACKGROUND

Calcific aortic valve disease (CAVD), and ensuing severe aortic stenosis (AS), is the foremost valvular disorder of aging, yet preventive therapies are lacking. A better understanding of the molecular underpinnings of aortic valve calcification (AVC) is necessary to develop pharmacologic interventions.

METHODS AND RESULTS

We undertook large-scale plasma proteomics in a cohort study of adults ≥65 years old, the CHS (Cardiovascular Health Study), to identify individual proteins associated with echocardiographic AVC and incident moderate/severe AS. Proteomics measurements were performed with the aptamer-based SomaLogic platform of ~5000 proteins. Significant proteins were validated in a second cohort, the AGES-RS (Age, Gene/Environment Susceptibility-Reykjavik Study), which assessed AVC and AS by computed tomography. The potential causal associations of replicated proteins were tested in 2-sample Mendelian randomization using identified cis protein quantitative trait loci in consortia having computed tomography-quantified AVC or AS as outcomes. Six proteins showed Bonferroni-corrected significant relationships with AVC in CHS. Three of these, CXCL-12 (C-X-C chemokine ligand 12), KLKB1 (kallikrein), and leptin, replicated in AGES-RS, of which the former 2 are novel. Only 1 protein, CXCL6, which showed a near-significant association with AS in the replication cohort, was significantly (positively) associated with incident AS. Mendelian randomization analysis was conducted for KLKB1, CXCL12, and CXCL6, which supported a causal relationship for higher KLKB1 with lower AVC (beta=-0.25, P=0.009).

CONCLUSIONS

This study of older adults newly identified and largely replicated associations of 3 circulating proteins with calcific aortic valve disease, of which the relationship of plasma KLKB1 may have a causal basis. Additional investigation is necessary to determine if KLKB1 could be harnessed for calcific aortic valve disease therapeutics.

A collagen-based laboratory model to mimic sex-specific features of calcific aortic valve disease

Calcific aortic valve disease (CAVD) shows in the deposition of calcium phosphates in the collagen-rich layer of the valve leaflets. This stiffens the leaflets and eventually leads to heart failure. Recent research suggests that CAVD follows sex-specific pathways: at the same severity of the disease, women tend to have fewer and less crystalline calcifications, and the phases of their calcifications are decidedly different than those of men; namely, dicalcium phosphate dihydrate (DCPD) - one of the mineral phases in CAVD - occurs almost exclusively in females. Furthermore, the morphologies of heart valve calcifications might be sex-specific, but the sex dependence of the morphologies has not been systematically investigated. Herein, we first show that male CAVD patients have more compact and less fibrous calcifications than females, establishing sex-dependent morphological features of heart valve calcification. We then build a model that recapitulates the sex differences of the calcifications in CAVD, which is based on a collagen gel that we calcify in simulated body fluid with varying fetuin A concentrations. With increasing fetuin A concentration, the calcifications become less crystalline and more fibrous, and more DCPD deposits in the collagen matrix, resembling the physicochemical characteristics of the calcifications in female valves. Lower fetuin A concentrations give rise to a model that replicates male-specific mineral characteristics. The models could be used to develop sex-specific detection and treatment methods for CAVD. STATEMENT OF SIGNIFICANCE: Although calcific aortic valve disease (CAVD) affects ∼10 million people globally, researchers have only discovered recently that the disease follows sex-specific pathways, and many of its sex-specific features remain unknown. To further our understanding of sex differences in CAVD and to develop better detection and treatment methods, there is an urgent need to establish models for CAVD that account for its sex-specific manifestations. In this study, we first show that CAVD calcifications in men and women take on different morphologies. Second, we present a model that can replicate physicochemical calcification characteristics of male or female valves, including morphology, and that can help to develop sex-specific detection and treatment methods for CAVD.

Circulating inflammatory cytokines and risk of aortic stenosis: A Mendelian randomization analysis

BACKGROUND

Observational studies have consistently reported positive associations between inflammatory biomarkers and the risk of developing aortic stenosis (AS). However, it is crucial to acknowledge that conventional observational studies are prone to various forms of bias, including reverse causation and residual confounding. To delve deeper into unraveling the potential causal relationship between inflammatory biomarkers and aortic stenosis, we conducted a comprehensive two-sample Mendelian randomization (MR) analysis.

METHODS

In order to explore the causal effect of exposure to various circulating cytokines on the risk of developing AS, we carefully selected AS datasets as the exposures from the summary statistics of the genome-wide association study (GWAS) conducted by FinnGen. The dataset consisted of a sample size of 3283 for AS cases and 210,463 for controls. To estimate the MR analysis, we primarily adopted the inverse variance weighted (IVW) method. Additionally, we employed complementary methods, including Weighted Median, MR Egger, Weighted Mode, and Simple Mode, to analyze the causal associations comprehensively. In order to assess the presence of heterogeneity, we utilized Cochran's Q statistic and MR-Egger regression. To ensure the robustness and consistency of our findings, we conducted a leave-one-out analysis.

RESULT

We observed a positive association between interleukin-18 (IL-18) levels and AS (odds ratio [OR] per standard deviation [SD] = 1.080; 95 % confidence interval [CI] 1.024 to 1.139), as well as between interferon-gamma levels (IFN-γ) and AS (OR per SD = 1.157; 95 % CI 1.028 to 1.302). Conversely, we found an inverse association between interleukin-13 (IL-13) levels and AS (OR per SD = 0.942; 95 % CI 0.890 to 0.997), as well as between interleukin-5 (IL-5) levels and AS (OR per SD = 0.892; 95 % CI 0.804 to 0.990).

CONCLUSION

Our research enhances the current understanding of the role of specific inflammatory biomarker pathways in aortic stenosis. Nevertheless, further validation is required to assess the viability of targeting these cytokines through pharmacological or lifestyle interventions as potential treatments for aortic stenosis.

Aortic Valve Replacement Versus Conservative Management in Patients With Asymptomatic Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aortic valve replacement (AVR) is recommended for symptomatic severe aortic stenosis (AS) patients. However, evidence of its role in asymptomatic patients with severe AS remains controversial. Hence, a systematic review and meta-analysis of randomized controlled trials comparing AVR to conservative management in patients with asymptomatic severe AS was conducted. A systematic literature search was performed on electronic databases including MEDLINE (via PubMed), Embase, and Cochrane CENTRAL Library until November 2024. A random effects model was used to pool individual risk ratios (RRs) with their corresponding 95% confidence intervals (CIs) using Review Manager Version 5.4.1 to calculate pooled effect estimates. Three randomized controlled trials with 1203 patients (42% females) were included. On pooled analysis, AVR significantly reduced the risk of hospitalization for heart failure (RR = 0.11, CI: 0.02-0.56, P = 0.008) compared with conservative care. However, there were no significant differences between the 2 groups in all-cause mortality (RR = 0.63, CI: 0.36-1.11, P = 0.11), stroke (RR = 0.59, CI: 0.35-1.01, P = 0.05), myocardial infarction (RR = 0.43, CI: 0.06-2.92, P = 0.38), or thromboembolic events (RR = 0.54, CI: 0.13-2.29, P = 0.40). In asymptomatic patients with severe AS, AVR significantly reduces the risk of hospitalization due to heart failure, with comparable risks in terms of all-cause mortality, myocardial infarction, stroke, and thromboembolic events compared with conservative management.

The association between aortic stenosis and the risk of consecutive eyelid inflammatory diseases

Aortic stenosis (AS) is a fatal cardiovascular disease characterized by an inflammatory response. Blepharitis and hordeolum are two eyelid conditions that also involve ocular inflammation. The aim of this study is to assess the association between AS and the subsequent development of eyelid inflammatory diseases. This retrospective cohort study included individuals diagnosed with AS, who were matched to a control group of non-AS individuals from the TriNetX database. A total of 431,027 individuals were assigned to both the AS and non-AS groups. The primary outcomes of this study were the incidence rates of eyelid inflammatory diseases, including blepharitis and hordeolum. Cox proportional hazards regression was used for statistical analysis. After the follow-up period, 4,464 cases of blepharitis were recorded in the AS group, compared to 3,139 in the non-AS group. Additionally, there were 2,184 cases of hordeolum in the AS group, compared to 1,724 in the non-AS group. Cox proportional hazards regression analysis revealed that the AS group had a significantly higher risk of developing blepharitis (P < 0.001) and hordeolum (P < 0.001) compared to the non-AS group. The AS group also showed significantly higher cumulative probabilities of both blepharitis and hordeolum than the non-AS group (both P < 0.001). In subgroup analyses, AS patients exhibited a higher risk of developing blepharitis than the non-AS population, except for the Asian population and individuals aged 20-45 years. Similarly, the AS group showed a higher risk of developing hordeolum than the non-AS group, with exceptions in the African and Asian populations and individuals aged 20-45 years. In conclusion, the presence of AS is associated with a higher risk of developing subsequent eyelid inflammatory diseases.

Effect of Sodium-Glucose Cotransporter-2 Inhibitors on the Progression of Aortic Stenosis

BACKGROUND

Aortic stenosis (AS) is the leading cause of valvular heart disease-related morbidity and mortality, but there are no medical treatments to slow its progression. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have pleiotropic effects which could be disease modifying in AS.

OBJECTIVES

Determine if SGLT2i usage is associated with slower progression of AS.

METHODS

A target trial emulation comparing the effect of the initiation of SGLT2i compared with no SGLT2i in patients with nonsevere AS was performed using retrospective electronic medical record data from the Yale New Haven Health System from January 2016 to September 2022. Patients with native aortic valve sclerosis or nonsevere AS with at least 12 months of echocardiographic follow-up were included. Patients were excluded if they had an estimated glomerular filtration rate <30 mL/min/1.73 m2 or had initiated SGLT2i >1 year before the index echocardiogram. The prespecified primary outcome was progression to severe AS.

RESULTS

458 patients prescribed SGLT2i and 11,240 patients never prescribed SGLT2i were included. Patients were on SGLT2i for a median of 0.9 years. Patients on SGLT2i were younger and had higher rates of diabetes and chronic kidney disease. Patients on SGLT2i were more likely to have ejection fraction ≤40%. There were no differences between groups in baseline AS severity (66% sclerosis, 23% mild stenosis, and 11% moderate in overall cohort). Patients ever prescribed SGLT2i were less likely to progress to severe AS (HR: 0.61; 95% CI: 0.39-0.94; P = 0.03) with a progressively lower risk among patients on SGLT2i for >3, 6, and 12 months (HR: 0.54, 0.48, and 0.27, respectively).

CONCLUSIONS

This retrospective, multicenter, observational study suggests that SGLT2i may slow the progression of nonsevere AS.

Interleukin-37 attenuates aortic valve lesions by inhibiting m6A-mediated IRAK-M degradation

AIMS

Calcific aortic valve disease (CAVD) has become an increasingly important global medical problem without effective pharmacological intervention. Accumulating evidence indicates that aortic valve calcification is driven by inflammation. Interleukin-1 receptor-associated kinase M (IRAK-M) is a well-known negative regulator of inflammation, but its role in CAVD remains unclear.

METHODS AND RESULTS

Here, we stimulated aortic valve interstitial cells (AVICs) with low-dose lipopolysaccharide (LPS) to mimic the inflammatory response in aortic valve calcification and observed the expression pattern of IRAK-M. Furthermore, we generated IRAK-M-/- mice to explore the effect of IRAK-M deficiency on the aortic valve in vivo. Additionally, overexpression and knockdown experiments were performed to verify the role of IRAK-M in AVICs. MeRIP‒qPCR was used to detect the N6-methyladenosine (m6A) level of IRAK-M, and recombinant interleukin (IL)-37-treated AVICs were used to determine the regulatory relationship between IL-37 and IRAK-M. We found that IRAK-M expression was upregulated in the early stages of inflammation as part of a negative feedback mechanism to modulate the immune response. However, persistent inflammation increased overall m6A levels, ultimately leading to reduced IRAK-M expression. In vivo, IRAK-M-/- mice exhibited a propensity for aortic valve thickening and calcification. Overexpression and knockdown experiments showed that IRAK-M inhibited inflammation and osteogenic responses in AVICs. In addition, IL-37 restored IRAK-M expression by inhibiting m6A-mediated IRAK-M degradation to suppress inflammation and aortic valve calcification.

CONCLUSIONS

Our findings confirm that inflammation and epigenetic modifications synergistically regulate IRAK-M expression. Moreover, IRAK-M represents a potential target for mitigating aortic valve calcification. Meanwhile, IL-37 exhibited inhibitory effects on CAVD development both in vivo and in vitro, giving us hope that CAVD can be treated with drugs rather than surgery.

Association Between the Malnutrition Status and All-Cause Mortality in Patients With Moderate and Severe Aortic Stenosis: A Prospective Cohort Study

BACKGROUND

Malnutrition status is an important predictor of prognosis in patients after aortic valve replacement. However, the prognostic value of malnutrition status in patients with moderate-to-severe aortic stenosis is unclear. This study aimed to evaluate the effect of malnutrition on all-cause mortality in patients with moderate-to-severe aortic stenosis using the Patient Controlled Nutritional Status (CONUT) score, nutritional risk index, and prognostic nutritional index.

METHODS AND RESULTS

A total of 536 patients with moderate-to-severe aortic stenosis were selected in the ARISTOTLE (Aortic Valve Diseases Risk Factor Assessment and Prognosis Model Construction) study conducted between January 2013 and December 2022 in 3 academic institutions. Patients were grouped according to different nutritional status assessment methods. CONUT, nutritional risk index, and prognostic nutritional index were calculated at baseline. The primary study outcome was all-cause mortality. Cox regression was used to assess the association between nutritional status and all-cause mortality. During a median 34.2-month follow-up period, a total of 120 (22.4%) patients died. All-cause mortality was significantly higher in lower prognostic nutritional index, lower nutritional risk index, and higher CONUT groups. Compared with normal nutrition, malnutrition was associated with an increased risk for all-cause death (adjusted hazard ratio for mild and moderate-severe malnutrition, respectively: 2.82 [95% CI, 1.69-4.71; P<0.001] and 3.31 [95% CI, 1.74-6.32; P<0.001] for the CONUT).

CONCLUSIONS

In patients with moderate or severe aortic stenosis, we found that high CONUT scores, low nutritional risk index scores, and low prognostic nutritional index scores were associated with all-cause death. The poorer the nutritional status, the greater the risk of malnutrition-related all-cause mortality.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT06069232.

Atherosclerosis, calcific aortic valve disease and mitral annular calcification: same or different?

There are similarities in the pathophysiologic mechanisms of atherosclerosis, calcific aortic valve disease (CAVD) and mitral annular calcification (MAC), however, medical treatment to slow or stop the progression of CAVD or MAC has been more elusive as compared to atherosclerosis. Atherosclerosis and CAVD share common demographic, clinical, protein, and genetic factors even more so than with MAC, which supports the possibility of shared medical therapies, though abrogating calcific extracellular vesicle shedding could be a common target for all three conditions. Herein, we summarize the overlapping and distinct pathways for further investigation, as well as key areas where additional research is needed.

Factors associated with heart failure events in patients with new-onset persistent left bundle branch block at discharge after transcatheter aortic valve replacement

BACKGROUND

New-onset persistent left bundle branch block (NOP-LBBB) at discharge after transcatheter aortic valve replacement (TAVR) is frequent, but its association with death and hospitalization for heart failure (HHF) remains unclear.

OBJECTIVE

We aimed to assess the association of LBBB persistence or resolution after discharge and of permanent pacemaker (PPM) implantation before discharge with these outcomes.

METHODS

We analyzed consecutive patients undergoing TAVR at Nancy University Hospital from 2009 to 2021 with NOP-LBBB at discharge and available 1-year follow-up. We assessed the association of LBBB persistence (LBBB+) or resolution (LBBB-) at 3 months and in-hospital PPM implantation (PPM+) or absence (PPM-) with the 1-year risk of the composite outcome of mortality or HHF.

RESULTS

Of 1646 TAVR patients, 287 (17.4%) had NOP-LBBB, with complete follow-up data available for 234 patients. Of them, 73 patients (31.2%) required in-hospital PPM implantation, 142 patients (60.7%) experienced LBBB persistence at 3-month follow-up, and 45 (19.2%) had both. The 1-year mortality or HHF rate was 6.3% (PPM-/LBBB-), 10.7% (PPM+/LBBB-), 20.6% (PPM-/LBBB+), and 22.2% (PPM+/LBBB+). LBBB persistence was significantly associated with the composite outcome irrespective of PPM implantation (adjusted hazard ratio [aHR] compared with PPM-/LBBB-: aHR for PPM-/LBBB+, 4.91 [1.64-14.64; P = .004]; aHR for PPM+/LBBB+, 4.58 [1.43-14.68; P = .010]), whereas PPM implantation with LBBB- was not (P = .29). This association was mainly driven by HHF (aHR for PPM-/LBBB+, 8.36 [1.90-36.83; P = .005]; aHR for PPM+/LBBB+, 8.36 [1.80-38.89; P = .007]).

CONCLUSION

The persistence of LBBB beyond discharge, rather than in-hospital PPM implantation, was associated with a higher risk of 1-year mortality or HHF in patients with NOP-LBBB at discharge after TAVR. Assessing postdischarge LBBB persistence may improve prognostic accuracy.

The Role of Paraoxonase-1 Activity, Apolipoprotein B Levels, and Apolipoprotein B/Apolipoprotein A-I Ratio as Risk Markers for Aortic Stenosis in Patients with a Bicuspid Aortic Valve

The bicuspid aortic valve (BAV) is commonly associated with the early degeneration of the aortic valve. Up to 45% of BAV patients over the age of 50 develop aortic stenosis (AS). Although published data indicate a robust interplay between lipids and calcific AS in tricuspid aortic valve patients, the studies on the BAV population are lacking. We aimed to evaluate the association between selected lipid markers and the occurrence of AS in BAV patients. Methods: The study included 76 adults (21 female) with a BAV diagnosed by echocardiography, divided by age and AS diagnosis. Biochemical parameters concentrations in serum were measured: high density lipoprotein cholesterol (HDL-C) levels by standard enzymatic colorimetric tests, low density lipoprotein cholesterol (LDL-C) levels by the Friedewald formula, apolipoprotein A-I (Apo AI) and apolipoprotein B (Apo B) serum concentration by the nephelometric method, and paraoxonase-1 activity (PON-1 ASE) and arylesterase activity (PON-1 ARE) based on paraoxon and phenyl acetate hydrolysis. Results: A total of 54 patients (15 female) were more than 45 years old and 22 (6 female) were 45 or less years old. BAV patients with AS aged ≤45 had higher levels of Apo B, compared to those without AS [110.5 (102-132) vs. 95.6 (77-101) mg/d; p 0.044]. Similarly, Apo B/Apo AI ratio was higher in BAV patients with AS aged ≤45, compared to those without AS [(0.8 (0.7-1) vs. 0.6 (0.5-0.7); p 0.029]. In the group aged ≤45, Apo B showed a positive correlation with the aortic valve peak transvalvular velocity (AV Vmax) measurement (R Spearman 0.6, p 0.004). We found also that, among young BAV patients, those with AS had a lower level of PON-1 ARE compared to the cohort without AS [63.4 (52-80) vs. 85.3 (70-102); p 0.012]. We did not find any differences in lipid parameters in patients aged >45. Conclusions The metabolic link between Apo B level and Apo B/AI ratio with AS presence in BAV patients under 45 years of age suggests a significant impact of these parameters on the earlier development of AS in the BAV population. Molecules associated with high density lipoprotein and its antioxidant function, such as PON1, are valuable markers for AS development, compared to HDL-C and LDL-C levels.

Targeting Sphingosine-1-Phosphate Signaling to Prevent the Progression of Aortic Valve Disease

BACKGROUND

Aortic valve disease (AVD) is associated with high mortality and morbidity. To date, there is no pharmacological therapy available to prevent AVD progression. Because valve calcification is the hallmark of AVD and S1P (sphingosine-1-phosphate) plays an important role in osteogenic signaling, we examined the role of S1P signaling in aortic stenosis disease.

METHODS

AVD progression and its consequences for cardiac function were examined in a murine wire injury-induced AVD model with and without pharmacological and genetic modulation of S1P production, degradation, and receptor signaling. S1P was measured by liquid chromatography-mass spectrometry. Calcification of human valvular interstitial cells and their response to biomechanical stress were analyzed in the context of S1P signaling. Human explanted aortic valves from patients undergoing aortic valve replacement and cardiovascular magnetic resonance imaging were analyzed for S1P by liquid chromatography-mass spectrometry.

RESULTS

Raising S1P concentrations in mice with injury-induced AVD by pharmacological inhibition of its sole degrading enzyme S1P lyase vastly enhanced AVD progression and impaired cardiac function resembling human disease. In contrast, low S1P levels caused by SphK1 (sphingosine kinase 1) deficiency potently attenuated AVD progression. We found S1P/S1PR2 (S1P receptor 2) signaling to be responsible for the adverse S1P effect because S1PR2-deficient mice were protected against AVD progression and its deterioration by high S1P. It is important to note that pharmacological S1PR2 inhibition administered after wire injury successfully prevented AVD development. Mechanistically, biomechanical stretch stimulated S1P production by SphK1 in human valvular interstitial cells as measured by C17-S1P generation, whereas S1P/S1PR2 signaling induced their osteoblastic differentiation and calcification through osteogenic RUNX2/OPG signaling and the GSK3β-Wnt-β-catenin pathway. In patients with AVD, stenotic valves exposed to high wall shear stress had higher S1P content and increased SphK1 expression.

CONCLUSIONS

Increased systemic or local S1P levels lead to increased valvular calcification. S1PR2 antagonists and SphK1 inhibitors may offer feasible pharmacological approaches to human AVD in prophylactic, disease-modifying or relapse-preventing manners.

Effect of Early Menopause and Hormonal Therapy Replacement on Aortic Stenosis Progression

BACKGROUND

Early menopause has been associated with several cardiovascular diseases. Its effect on the progression of aortic stenosis (AS) remains unknown. We conducted an analysis to examine the effect of early menopause without hormonal replacement therapy (HRT) on the progression of AS in postmenopausal women with AS.

METHODS

This subanalysis included 33 female patients with at least mild AS (mean age 65 ± 10 years) who were prospectively enrolled in the Metabolic Determinants of the Progression of Aortic Stenosis (PROGRESSA) study. Anatomical assessment of AS was performed using multidetector computed tomography, whereas hemodynamic assessment of AS was performed using Doppler echocardiography.

RESULTS

Over a median follow-up of 2 (range, 1-4) years, early menopausal women without HRT showed faster progression of aortic valve calcification (AVC; median, 100 [25th-75th percentiles, 58-130] vs 23 [25th-75th percentiles, 2-71] arbitrary units per year; P = 0.03; median mean pressure gradient, 2.37 [25th-75th percentiles, 0.82-3.61] vs 0.33 [25th-75th percentiles, 0.01-1.78] mm Hg per year; P = 0.04) and aortic valve area indexed to body surface area (median, -0.12 [25th-75th percentiles, -0.23 to 0.002] vs -0.004 [25th-75th percentile, -0.07 to 0.78] cm2/m2/y; P = 0.07). In multivariate analysis adjusted for several clinical, echocardiographic, and anatomic factors, early menopause without HRT remained independently associated with faster AVC progression (P = 0.003). Women who received HRT showed a slower progression of AVC compared with those who never received HRT (median, 62 [25th-75th percentile, 2-100] vs 20 [25th-75th percentile, 10-42] arbitrary units per year; P = 0.13). Multivariate analysis also showed that AVC progressed less rapidly in women who received HRT (P = 0.04).

CONCLUSIONS

In this study of postmenopausal women with AS, early menopause without HRT was associated with faster progression of AS, anatomically and hemodynamically. However, the use of HRT was associated with slower progression of AS.

[Sex and age distribution of global disease burden of calcific aortic valve disease]

OBJECTIVES

To analyze sex and age distribution of global disease burden of calcific aortic valve disease (CAVD) from 1990 to 2021.

METHODS

CAVD data during 1990-2021 were obtained from the IHME website for Global Burden of Disease (GBD). The prevalence, mortality, years lived with disability (YLDs), and disability-adjusted life years (DALYs) were analyzed by gender and age groups. Joinpoint regression was used to calculate annual percentage change (APC) and average annual percentage change (AAPC).

RESULTS

In 2021, there were 13.32 million CAVD patients and 142 000 deaths caused by CAVD globally. Age-standardized prevalence was higher in males (193.2/105) than that in females (128.9/105). Patients in 65-<85 age group accounted for 64.0% of total cases, while those ≥85 years old accounted for 16.1%. From 1990 to 2021, prevalence increased in both sexes with an AAPC of 0.72% for males and 0.57% for females, respectively. Prevalence grew fastest from 2000 to 2010, slowed thereafter, and declined from 2015 to 2021. In <65 years old, the mortality of males was 2.4 times higher than that of females, while in ≥85 years old, mortality of females (117.3/105) exceeded that of males (99.1/105). YLD rates increased with age, and were higher in males for all age groups. DALY rates decreased overall but increased in ≥85 years old, with a greater increase in females.

CONCLUSIONS

There are significant gender and age disparities in global disease burden of CAVD, with the elderly, especially super-elderly females deserving particular attention. It is recommended to develop personalized intervention strategies for these populations.

Balancing the risks: continuous vs. interrupted anticoagulation during TAVI - what does the evidence say?

Anticoagulation therapy is a critical component of post-transcatheter aortic valve implantation (TAVI) management, aimed at reducing the risk of thromboembolic events and mortality. This review examines the efficacy of continuous versus interrupted anticoagulation strategies in TAVI patients, focusing on mortality, stroke rates, and composite events. A literature review was conducted, analyzing recent studies that evaluate the impact of different anticoagulation regimens on clinical outcomes in TAVI patients. Key outcomes assessed include all-cause mortality, thromboembolic events, and major cardiovascular complications within 30 days and up to one year post-procedure. The review identifies a trend favoring continuous anticoagulation, particularly with direct-acting oral anticoagulants (DOACs), which was associated with lower mortality rates and reduced stroke incidence in high-risk patients. However, findings were inconsistent across studies, with some reporting no significant differences in outcomes between continuous and interrupted strategies. Additionally, the review highlights the need to balance the benefits of thromboembolic prevention with the increased risk of bleeding and vascular complications associated with continuous therapy. The findings show the importance of individualized anticoagulation strategies tailored to patient risk profiles. Clinicians should weigh the potential benefits of continuous anticoagulation against the risks, particularly in high-risk populations. Ongoing research is essential to refine anticoagulation protocols in TAVI patients, enhancing both safety and efficacy in clinical practice.

Progress on long non-coding RNAs in calcific aortic valve disease

Calcific aortic valve disease (CAVD) is a common cardiovascular condition in the elderly population. The aortic valve, influenced by factors such as endothelial dysfunction, inflammation, oxidative stress, lipid metabolism disorders, calcium deposition, and extracellular matrix remodeling, undergoes fibrosis and calcification, ultimately leading to stenosis. In recent years, long non-coding RNAs (lncRNAs) have emerged as significant regulators of gene expression, playing crucial roles in the occurrence and progression of various diseases. Research has shown that lncRNAs participate in the pathological process underlying CAVD by regulating osteogenic differentiation and inflammatory response of valve interstitial cells. Specifically, lncRNAs, such as H19, MALAT1, and TUG1, are closely associated with CAVD. Some lncRNAs can act as miRNA sponges, form complex regulatory networks, and modulate the expression of calcification-related genes. In brief, this review discusses the mechanisms and potential therapeutic targets of lncRNAs in CAVD.

Current Status of CT Imaging Before Common Transcatheter Interventions for Structural Heart Disease

Background: Over the past decade, several trials and observational studies have validated the use of minimally invasive cardiac interventions as viable treatment options for various cardiac diseases. Transcatheter techniques for severe aortic valve stenosis have rapidly emerged as alternatives to surgical aortic valve replacement in certain patient populations. Additionally, non-surgical treatment options have expanded for conditions affecting other cardiac valves, such as the mitral valve. These emerging minimally invasive interventions complement already well-established endovascular techniques for, among others, atrial septal defect closure, left atrial appendage occlusion and pulmonary vein isolation in patients with atrial fibrillation. Given their non-surgical nature and lack of direct visualisation of the targeted anatomy, these procedures heavily rely on precise pre-procedural radiological imaging for optimal patient selection and procedural success. Method: This paper is based on the expert opinion of the authors and an exhaustive literature research. Results: This manuscript reviews the most commonly employed minimally invasive cardiac interventions, highlighting the essential pre-procedural imaging information and key aspects that must be included in radiological reports to mitigate potential complications. Conclusion: Accurate pre-procedural imaging is crucial for ensuring safe and effective minimally invasive cardiac interventions, underscoring the importance of the radiologist in the pre-procedural work-up of these patients.

Prognostic Value of Advanced Echocardiographic Analysis for Transcatheter Aortic Valve Replacement: A Systematic Review

Transcatheter aortic valve implantation (TAVI) is the main treatment option for patients with severe aortic stenosis (AS) and older age. Improved imaging techniques have enabled better patient selection, and the main role is played by echocardiography. Methods more sensitive than LVEF in assessing cardiac function, such as global longitudinal strain (GLS) and myocardial work (MW), have become widespread, and other methods, like hemodynamic forces (HDFs), might be promising. The aim of this paper is to systematically review the parameters of GLS, MW, and HDF as predictors of reverse remodeling and their association with outcomes in patients with AS undergoing TAVI. In particular, the focus will be on the examination of the influence of TAVI on left atrial and ventricular function and right ventricular function.

The impact of bicuspid valve morphology on the selection of transcatheter aortic valve implantation devices: an in silico study

Aims

Bicuspid aortic valve (BAV) represents a challenge for transcatheter aortic valve implantation (TAVI). Few data are reported about the procedural implications of BAV using different self-expandable devices. The aim of this study is to investigate how BAV and tricuspid aortic valve (TAV) morphologies influence device selection and their impact on the potential development of post-operative conduction disturbances, using a novel in silico approach.

Methods and results

Five patients with BAV undergoing TAVI were enrolled. TAVs were virtually modelled within each BAV patient-specific anatomy, resulting in 10 virtual patients. Acurate Neo2 and Evolut R implantations were subsequently simulated across all cases. Post-implantation stresses exerted on both the stent and aortic root were measured, allowing a comparative analysis of the impact of the two valve morphologies. Comparing stent stresses between BAV and TAV configurations, the stress gap increased by 21.96 ± 5.35% (P = 0.01) in Acurate Neo2 cases (n = 6) compared with Evolut R cases (n = 4). The analysis of aortic root stresses showed no significant differences between BAV (n = 5) and TAV (n = 5) configurations, with a mean stress difference of 5.1 ± 8.17% (P > 0.05).

Conclusion

Our patient-specific model shows that high radial force devices, such as Evolut R, demonstrate consistent expansion regardless of valve morphology, without increasing the risk of post-implantation conduction disturbances, hence resulting more suitable for BAV cases. Incorporating this methodology into pre-operative planning could support clinicians in selecting the most suitable device with a patient-specific approach.

Transcatheter aortic valve implantation and its impact on endothelial function in patients with aortic stenosis

Vascular function is impaired in patients with aortic valve stenosis (AS). The impact of transcatheter aortic valve implantation (TAVI) on endothelial function is inconclusive so far. Therefore, we sought to assess the short-term influence of TAVI on endothelial dysfunction in patients with AS. We recruited 47 patients (76.6 % male, 80.04 years old) with AS scheduled for TAVI. Endothelial function was assessed by fingertip reactive hyperemia peripheral arterial tonometry (RH-PAT). Measurements were conducted one day before and three days after TAVI. Patients were grouped according to RH-PAT change after TAVI. Overall, RH-PAT measurements did not significantly improve after TAVI (Reactive Hyperemia Index: 1.5 vs 1.6, p = 0.883; logarithm of the Reactive Hyperemia Index: 0.44 vs. 0.49, p = 0.523). Interestingly, patients with no RH-PAT improvement after TAVI displayed a more severe AS and had lower blood pressure after TAVI. This might be due to a more disturbed blood flow in patients with a smaller aortic valve area and higher peak aortic valve velocity. The relationship between AS severity, endothelial dysfunction and TAVI has to be investigated in future research that apply longitudinal study designs.

Calcific Aortic Stenosis: A Review

Importance

Calcific aortic stenosis (AS) restricts the aortic valve opening during systole due to calcification and fibrosis of either a congenital bicuspid or a normal trileaflet aortic valve. In the US, AS affects 1% to 2% of adults older than 65 years and approximately 12% of adults older than 75 years. Worldwide, AS leads to more than 100 000 deaths annually.

Observations

Calcific AS is characterized by aortic valve leaflet lipid infiltration and inflammation with subsequent fibrosis and calcification. Symptoms due to severe AS, such as exercise intolerance, exertional dyspnea, and syncope, are associated with a 1-year mortality rate of up to 50% without aortic valve replacement. Echocardiography can detect AS and measure the severity of aortic valve dysfunction. Although progression rates vary, once aortic velocity is higher than 2 m/s, progression to severe AS occurs typically within 10 years. Severe AS is defined by an aortic velocity 4 m/s or higher, a mean gradient 40 mm Hg or higher, or a valve area less than or equal to 1.0 cm2. Management of mild to moderate AS and asymptomatic severe AS consists of patient education about the typical progression of disease; clinical and echocardiographic surveillance at intervals of 3 to 5 years for mild AS, 1 to 2 years for moderate AS, and 6 to 12 months for severe AS; and treatment of hypertension, hyperlipidemia, and cigarette smoking as indicated. When a patient with severe AS develops symptoms, surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) is recommended, which restores an average life expectancy; in patients aged older than 70 years with a low surgical risk, 10-year all-cause mortality was 62.7% with TAVI and 64.0% with SAVR. TAVI is associated with decreased length of hospitalization, more rapid return to normal activities, and less pain compared with SAVR. However, evidence supporting TAVI for patients aged younger than 65 years and long-term outcomes of TAVI are less well defined than for SAVR. For patients with symptomatic severe AS, the 2020 American College of Cardiology/American Heart Association guideline recommends SAVR for individuals aged 65 years and younger, SAVR or TAVI for those aged 66 to 79 years, and TAVI for individuals aged 80 years and older or those with an estimated surgical mortality of 8% or higher.

Conclusions

Calcific AS is a common chronic progressive condition among older adults and is diagnosed via echocardiography. Symptomatic patients with severe AS have a mortality rate of up to 50% after 1 year, but treatment with SAVR or TAVI reduces mortality to that of age-matched control patients. The type and timing of valve replacement should be built on evidence-based guidelines, shared decision-making, and involvement of a multidisciplinary heart valve team.

The influence of lipoprotein(a) on aortic valve calcification in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Elevated levels of lipoprotein(a) (Lp[a]) have been recognized as substantial risk factors for cardiovascular disease and aortic stenosis (AS). However, the specific role of Lp(a) in promoting aortic valve calcification (AVC) and influencing mortality in elderly, multimorbid patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear and warrants further investigation.

METHODS

A retrospective analysis was conducted on all consecutive patients who underwent TAVR between August 2019 and June 2020 at our clinic. Patients with missing data or prior aortic valve replacement were excluded. The study cohort was stratified based on an Lp(a) threshold of 60 mg/dl according to guidelines for lipoprotein apheresis in UK and Germany.1,2 RESULTS: In total, 454 patients were included into the analysis. Mean age was 81 ± 6 years and patients presented with a notable cardiovascular risk profile. Lp(a) values ≥ 60 mg/dl were detected in 102 (22.5%) patients, while 352 (77.5%) had Lp(a) values < 60 mg/dl. The median calcium volume of the total cohort was 894.5 [570.8; 1,382.8] mm2. No significant difference was observed between the groups (p = 0.83). Furthermore, Lp(a) did not emerge as a statistically significant predictor of calcium levels before TAVR. Notably, male gender (B = 404.11, p < 0.001) and mean trans-valvular pressure gradient (B = 15.64, p < 0.001) were identified as the strongest coefficients within the robust regression analysis. Log-rank tests indicated no prognostic utility of Lp(a) for 30-day all-cause mortality (p = 0.30) or 40 months long-term all-cause mortality (p = 0.60).

CONCLUSION

Lp(a) might not exert a significant effect on calcification levels or all-cause mortality in patients undergoing TAVR. Despite the study's highly selected population, these results align with current research, supporting the assumption that the influence of Lp(a) may be confined to the early stages of AS and its progression.

N-Acetylcysteine Inhibits Aortic Stenosis Progression in a Murine Model by Blocking Shear-Induced Activation of Platelet Latent Transforming Growth Factor Beta 1

Objective: Aortic stenosis (AS) is characterized by narrowing of the aortic valve opening, resulting in peak blood flow velocity that induces high wall shear stress (WSS) across the valve. Severe AS leads to heart failure and death. There is no treatment available for AS other than valve replacement. Platelet-derived transforming growth factor beta 1 (TGF-β1) partially contributes to AS progression in mice, and WSS is a potent activator of latent TGF-β1. N-acetylcysteine (NAC) inhibits WSS-induced TGF-β1 activation in vitro. We hypothesize that NAC will inhibit AS progression by inhibiting WSS-induced TGF-β1 activation. Approach: We treated a cohort of Ldlr(-/-)Apob(100/100) low density lipoprotein receptor (LDLR) mice fed a high-fat diet with NAC (2% in drinking water) at different stages of disease progression and measured its effect on AS progression and TGF-β1 activation. Results: Short-term NAC treatment inhibited AS progression in mice with moderate and severe AS relative to controls, but not in LDLR mice lacking platelet-derived TGF-β1 (TGF-β1platlet-KO-LDLR). NAC treatment reduced TGF-β signaling, p-Smad2 and collagen levels, and mesenchymal transition from isolectin B4 and CD45-positive cells in LDLR mice. Mechanistically, NAC treatment resulted in plasma NAC concentrations ranging from 75.5 to 449.2 ng/mL, which were sufficient to block free thiol labeling of plasma proteins and reduce active TGF-β1 levels without substantially affecting reactive oxygen species-modified products in valvular cells. Conclusions: Short-term treatment with NAC inhibits AS progression by inhibiting WSS-induced TGF-β1 activation in the LDLR mouse model of AS, motivating a clinical trial of NAC and/or other thiol-reactive agent(s) as a potential therapy for AS.

Immunotherapy in the Context of Aortic Valve Diseases

PURPOSE

Aortic valve disease (AVD) affects millions of people around the world, with no pharmacological intervention available. Widely considered a multi-faceted disease comprising both regurgitative pathogenesis, in which retrograde blood flows back through to the left ventricle, and aortic valve stenosis, which is characterized by the thickening, fibrosis, and subsequent mineralization of the aortic valve leaflets, limiting the anterograde flow through the valve, surgical intervention is still the main treatment, which incurs considerable risk to the patient.

RESULTS

Though originally thought of as a passive degeneration of the valve or a congenital malformation that has occurred before birth, the paradigm of AVD is shifting, and research into the inflammatory drivers of valve disease as a potential mechanism to modulate the pathobiology of this life-limiting pathology is taking center stage. Following limited success in mainstay therapeutics such as statins and mineralisation inhibitors, immunomodulatory strategies are being developed. Immune cell therapy has begun to be adopted in the cancer field, in which T cells (chimeric antigen receptor (CAR) T cells) are isolated from the patient, programmed to attack the cancer, and then re-administered to the patient. Within cardiac research, a novel T cell-based therapeutic approach has been developed to target lipid nanoparticles responsible for increasing cardiac fibrosis in a failing heart. With clonally expanded T-cell populations recently identified within the diseased valve, their unique epitope presentation may serve to identify novel targets for the treatment of valve disease.

CONCLUSION

Taken together, targeted T-cell therapy may hold promise as a therapeutic platform to target a multitude of diseases with an autoimmune aspect, and this review aims to frame this in the context of cardiovascular disease, delineating what is currently known in the field, both clinically and translationally.

Left Ventricular Hypertrophy Regression Following Transcatheter Aortic Replacement: A Comparison of Self-Expanding Versus Balloon-Expandable Prostheses

There are limited reports on the impact of prosthesis-patient mismatch (PPM) on the regression of left ventricular hypertrophy (LVH) after transcatheter aortic valve replacement (TAVR). We compared the relative effects of supra-annular, self-expanding (SE) versus intra-annular, balloon-expandable (BE) prostheses on TAVR LVH regression. Regression of left ventricular mass index (LVMi) was evaluated in 168 consecutive TAVR patients, including 60 treated with SE valves (Evolut series) and 108 treated with BE valves (Sapien 3). All patients had LVH determined at baseline by echocardiography and had repeat LVMi measurements at a mean follow-up time of 707 ± 528 days. SE patients were more likely female (68.3% vs 46.3%, p = 0.007), but otherwise, the 2 cohorts did not differ with respect to baseline demographics and Society of Thoracic Surgeons risk score. SE patients had a higher effective orifice area indexed to body surface area after TAVR (0.98 ± 0.29 vs 0.86 ± 0.25 cm²/m², p = 0.006), with lower mean aortic valve gradients (9.9 ± 6.5 vs 12.8 ± 5.8 mm Hg, p = 0.003) and a lower prevalence of moderate/severe PPM (33.3% vs 49.1%, p = 0.049). On follow-up, changes in LVMi were similar between the SE and BE groups, with similar absolute changes in LVMi (19.2 ± 26.8 vs 21.9 ± 31.7 g/m2, p = 0.578) and relative LVMi decrease (14.0 ± 19.5 vs 16.2% ± 24.2%, p = 0.547). No difference in LVMi regression was also noted comparing combined SE/BE patients with moderate/severe PPM versus those without PPM. In conclusion, despite differences in effective orifice area indexed to body surface area, mean aortic valve gradient, and PPM after TAVR, the degree of LVH regression during intermediate follow-up did not differ between patients receiving supra-annular SE and intra-annular BE prostheses.

Exploring the Prognostic Role of Red Blood Cell Distribution Width in Aortic Valve Calcification Evaluations via Multi-Slice Computed Tomography

Background

Previous reports have indicated an association between red blood cell distribution width (RDW) and cardiovascular disease. However, few relevant studies exist on the relationship between RDW and aortic valve calcification (AVC). Explore the correlation and predictive value of RDW concerning the occurrence and severity of aortic valve calcification.

Methods

Blood examination results were analyzed from 1720 hospitalized patients at the Second Affiliated Hospital of Soochow University. Logistic regression analysis and the Cox proportional hazards model examined the relationship between RDW and the incidence and severity of AVC.

Results

The RDW value in cases with AVC was significantly higher than in the control group. Red cell distribution width-standard deviation (RDW-SD) and red cell distribution width-coefficient of variation (RDW-CV) increased with calcification severity. Both RDW-SD and RDW-CV demonstrated high predictive values for the occurrence of aortic valve calcification.

Conclusions

Red blood cell distribution width significantly correlated with the occurrence and severity of aortic valve calcification.

Association of TyG index with aortic valve calcification in valvular heart disease patients

BACKGROUND

In recent years, triglyceride glucose (TyG) index, as a popular metabolic index, has been proposed as an alternative index of insulin resistance, and it has been proved to be associated with many cardiovascular diseases, but the relationship between it and aortic valve calcification is still unknown.

METHODS

A total of 450 aortic valve disease patients were enrolled in this study, including 361 patients with aortic valve calcification (AVC) (calcification group) and 89 patients without (control group). According to the severity of AVC, patients with AVC included severe calcification, moderate calcification and low calcification. The TyG index was calculated based on fasting triglyceride and fasting blood glucose levels.

RESULTS

The TyG index in the calcification group was significantly higher than that in the control group (P < .05), and with the increase of the degree of calcification, the TyG index showed an increasing trend. The univariate and multivariate logistic regression analysis showed TyG index has a high predictive value for the presence of AVC (OR (95% CI): 1.743 (1.036-2.933)) and severe AVC (OR (95% CI): 1.608 (1.143-2.262)). In assessing the predictive value of the TyG index distribution width for AVC, with the first quartile as a reference, the last quartile of the TyG index had significant predictive value for the presence of AVC and severe AVC.

CONCLUSIONS

TyG index was significantly associated with the presence and severity of AVC, suggesting that TyG index may be a valid predictor of AVC.

Aortic Valve Replacement vs Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis

BACKGROUND

Current guidelines recommend a strategy of clinical surveillance (CS) for patients with asymptomatic severe aortic stenosis (AS) and a normal left ventricular ejection fraction.

OBJECTIVES

The aim of this study was to conduct a study-level meta-analysis of randomized controlled trials (RCTs) evaluating the effect of early aortic valve replacement (AVR) compared with CS in patients with asymptomatic severe AS.

METHODS

Studies were quantitatively assessed in a meta-analysis using random-effects modeling. Prespecified outcomes included all-cause and cardiovascular mortality, unplanned cardiovascular or heart failure (HF) hospitalization, and stroke. The meta-analysis is registered at the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY202490002).

RESULTS

Four RCTs were identified, including a total of 1,427 patients (719 in the early AVR group and 708 in the CS group). At an average follow-up time of 4.1 years, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (pooled rate 14.6% vs 31.9%; HR: 0.40; 95% CI: 0.30-0.53; I2 = 4%; P < 0.01) and stroke (pooled rate 4.5% vs 7.2%; HR: 0.62; 95% CI: 0.40-0.97; I2 = 0%; P = 0.03). No differences in all-cause mortality (pooled rate 9.7% vs 13.7%; HR: 0.68; 95% CI: 0.40-1.17; I2 = 61%; P = 0.17) and cardiovascular mortality (pooled rate 5.1% vs 8.3%; HR: 0.67; 95% CI: 0.35-1.29; I2 = 50%; P = 0.23) were observed with early AVR compared with CS, although there was a high degree of heterogeneity among studies.

CONCLUSIONS

In this meta-analysis of 4 RCTs, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization and stroke and no differences in all-cause and cardiovascular mortality compared with CS.

Elucidating common biomarkers and pathways of osteoporosis and aortic valve calcification: insights into new therapeutic targets

BACKGROUND

Osteoporosis and aortic valve calcification, prevalent in the elderly, have unclear common mechanisms. This study aims to uncover them through bioinformatics analysis.

METHODS

Microarray data from GEO was analyzed for osteoporosis and aortic valve calcification. Differential expression analysis identified co-expressed genes. SVM-RFE and random forest selected key genes. GO and KEGG enrichment analyses were performed. Immunoinfiltration and GSEA analyses were subsequently performed. NetworkAnalyst analyzed microRNAs/TFs. HERB predicted drugs, and molecular docking assessed targeting potential.

RESULTS

Thirteen genes linked to osteoporosis and aortic valve calcification were identified. TNFSF11, KYNU, and HLA-DMB emerged as key genes. miRNAs, TFs, and drug predictions offered therapeutic insights. Molecular docking suggested 17-beta-estradiol and vitamin D3 as potential treatments.

CONCLUSION

The study clarifies shared mechanisms of osteoporosis and aortic valve calcification, identifies biomarkers, and highlights TNFSF11, KYNU, and HLA-DMB. It also suggests 17-beta-estradiol and vitamin D3 as potential effective treatments.

Decision-Making Approach to the Treatment of Young and Low-Risk Patients With Aortic Stenosis

Over a decade of randomized controlled trial data demonstrate excellent outcomes with transcatheter aortic valve replacement or surgical aortic valve replacement for patients with symptomatic severe aortic stenosis regardless of surgical risk. The 2020 American College of Cardiology/American Heart Association guidelines recommend both options for low-risk AS patients aged 65 to 80 years. However, the fastest growing population of patients receiving transcatheter aortic valve replacement in the United States is <65 years old, with little data to support the practice. The American College of Cardiology's Cardiac Surgery Team Section Leadership and Interventional Cardiology Councils, a multidisciplinary collaboration of cardiologists and cardiac surgeons, sought to summarize the relevant data into a decision-making tool for heart valve teams. A literature review was completed, and guidelines, randomized controlled trials, and large observational studies were summarized into a pragmatic decision-making approach to treating young and low-risk patients with AS.

Niclosamide attenuates calcification in human heart valvular interstitial cells through inhibition of the AMPK/mTOR signaling pathway

Calcific aortic valve disease (CAVD) is a considerable health burden with a lack of effective therapeutic options. There is an urgent need to develop interventions that inhibit the osteogenic transformation of valvular interstitial cells (VICs) and delay the calcification process. Niclosamide, an FDA-approved anti-helminthic drug, has emerged as a promising candidate that demonstrates a negative regulatory effect on porcine VICs calcification. However, its molecular mechanism in human VICs (hVICs) remains to be investigated. In this study, high-resolution mass spectrometry-based proteomics and phosphoproteomics were employed, and 8373 proteins and 3697 phosphosites were identified in hVICs treated with a pro-calcifying medium and niclosamide. The quantitative proteomic and phosphoproteomic analysis resulted in the identification of calcification markers and osteogenesis-associated proteins. Bioinformatic analysis of the protein-protein interaction network and affected kinase prediction revealed that the AMPK/mTOR/p70S6K signaling cascade was altered upon calcific induction and niclosamide treatment. Further validation indicated that niclosamide inhibited the calcification of hVICs by targeting the mammalian target of the rapamycin (mTOR) signaling pathway. This study provides the first evidence that niclosamide could prevent osteoblastic differentiation in hVICs partially through the inhibition of the AMPK/mTOR/p70S6k signaling pathway, thereby mitigating hVICs calcification. These findings present a foundation for potential therapeutic strategies to impede the progression of CAVD and provide valuable insights into the pharmacological effects of niclosamide on human VICs.

Global, Regional, and National Burden of Nonrheumatic Valvular Heart Disease and Its Attributable Risk Factors in 204 Countries and Territories, 1990 to 2019: Results From the Global Burden of Disease Study 2019

BACKGROUND

Nonrheumatic valvular heart disease (NRVD) is increasingly becoming a significant public health concern, particularly among older people. In the context of population aging, a detailed report on the epidemiological trends of NRVD is crucial for policymakers to effectively allocate health care resources. This study aimed to explore these trends using data from the GBD (Global Burden of Disease) 2019 study.

METHODS AND RESULTS

We assessed the changing trends of the incidence, mortality, and disability-adjusted life years rates for NRVD by calculating the estimated annual percentage change for each. Additionally, we examined the impact of a region's level of social development on NRVD epidemiological trends and identified key risk factors contributing to NRVD-related deaths. Between 1990 and 2019, the global incidence of NRVD showed a gradual increase, with an estimated annual percentage change of 0.39 (95% CI, 0.30-0.48). The data revealed that women and older people are more likely to develop NRVD. High-sociodemographic index countries exhibited higher age-standardized incidence and mortality rates compared with low- and middle-sociodemographic index countries. The most significant risk factor for NRVD-related mortality was identified as high systolic blood pressure.

CONCLUSIONS

Over the past 3 decades, the burden of NRVD has intensified, indicating a need for more health care resources to address this issue, which is closely associated with an aging population. Currently, high-sociodemographic index countries report the highest incidences and deaths due to NRVD. However, low- and middle-sociodemographic index countries should also implement measures to manage the rapidly increasing burden of NRVD.

VCAM-1 targeted nanocarriers of shRNA-Smad3 mitigate endothelial-to-mesenchymal transition triggered by high glucose concentrations and osteogenic factors in valvular endothelial cells

Endothelial to mesenchymal transition (EndMT) of valvular endothelial cells (VEC) is a key process in the development and progression of calcific aortic valve disease (CAVD). High expression of the Smad3 transcription factor is crucial in the transition process. We hypothesize that silencing Smad3 could hinder EndMT and provide a novel treatment for CAVD. We aimed at developing nanoparticles encapsulating short-hairpin (sh)RNA sequences specific for Smad3 targeted to the aortic valve. We synthesized VCAM-1-targeted lipopolyplexes encapsulating shRNA-Smad3 plasmid (V-LPP/shSmad3) and investigated their potential to reduce the EndMT of human VEC. VEC incubation in a medium containing high glucose concentrations and osteogenic factors (HGOM) triggers EndMT and increased expression of Smad3. Exposed to lipopolyplexes, VEC took up efficiently the V-LPP/shSmad3. The latter reduced the EndMT process in VEC exposed to HGOM by downregulating the expression of αSMA and S100A4 mesenchymal markers and increasing the expression of the CD31 endothelial marker. In vivo, V-LPP/shSmad3 accumulated in the aortic root and aorta of a murine model of atherosclerosis complicated with diabetes, without affecting the liver and kidney function. The results suggest that targeting activated VEC with lipopolyplexes to silence Smad3 could be an effective, novel treatment for CAVD mediated by the EndMT process.

Moderate Aortic Stenosis With Cardiac Damage: A New Type of Severe Aortic Stenosis

The clinical implications of severe aortic stenosis have been well established. Understanding of moderate aortic stenosis, however, continues to evolve. Athough moderate aortic stenosis may be less clinically impactful in patients with normal ventricular function, it may carry prognostic significance in those patients with a ventricle exhibiting signs of cardiac damage. Moderate aortic stenosis in the presence of cardiac damage or dysfunction may be prognostically comparable to that of severe aortic stenosis. Extravalvular risk parameters can inform aortic stenosis risk stratification. Three ongoing trials seek to evaluate transcatheter aortic valve assessment in patients with moderate aortic stenosis and signs of cardiac damage or left ventricular dysfunction.

Ultrasound Therapy as a Treatment for Valvular Aortic Stenosis: A Review

Calcific aortic stenosis is the most common form of aortic stenosis, and offers a poor prognosis in affected patients. Current treatment methods for aortic stenosis, including open surgical aortic valve repair and transcatheter aortic valve replacement, are invasive, and require the patient to undergo open-heart surgery with cardiopulmonary bypass. Ultrasound therapy offers a potential solution for patients ineligible for traditional surgical treatment. Noninvasive ultrasound therapy allows for decalcification of aortic valves without open sternotomy or cardiopulmonary bypass. This article reviews the use of ultrasound therapy for aortic stenosis, including this newer method of noninvasive ultrasound therapy.

Effect of aortic valve phenotype and sex on aorta dilation in patients with aortic stenosis

BACKGROUND

Bicuspid aortic valve (BAV) is often associated with a concomitant aortopathy. However, few studies have evaluated the effect of the aortic valve (AV) phenotype on the rate of dilation of the aorta. This study aimed to compare the progression rate of aorta dimensions according to AV phenotype (BAV vs tricuspid AV (TAV)), fusion type and sex in patients with aortic stenosis (AS).

METHODS

310 patients with AS (224 TAV and 86 BAV) recruited in the Metabolic Determinants of the Progression of Aortic Stenosis study (PROGRESSA, NCT01679431) were included in this analysis. Doppler echocardiography was performed annually to assess AS severity and measure ascending aorta (AA) dimensions. Baseline and last follow-up visit measurements were used to assess the annualised change.

RESULTS

Median AA annualised change was larger in BAV versus TAV (0.33±0.65 mm/year vs 0.21±0.56 mm/year, p=0.04). In the whole cohort, BAV phenotype and higher low-density lipoprotein (LDL) levels were significantly associated with fast progression of AA dilation in univariate analysis (OR 1.80, 95% CI 1.08 to 2.98, p=0.02; 1.37, 95% CI 1.04 to 1.80, p=0.03, respectively). AA dilation rate did not vary according to the BAV subtype (p=0.142). Predictors of AA progression rate were different between valve phenotypes, with higher apolipoprotein B/apolipoprotein A-I ratio, higher baseline peak aortic jet velocity (Vpeak) and smaller baseline AA diameter in the TAV cohort (all p<0.05) versus absence of hypertension, higher LDL levels and smaller baseline AA diameter in the BAV cohort (all p<0.02). In men, higher baseline Vpeak and smaller baseline AA (p<0.001) were independently associated with increased annualised AA dilation, while in women, higher LDL levels (p=0.026) were independently associated with faster AA dilation.

CONCLUSION

This study suggests that BAV is associated with faster dilation of the AA. Predictors of AA dilation are different between valve phenotype and sex, with higher LDL levels being associated with faster AA dilation in BAV.

Multiomics identification of ALDH9A1 as a crucial immunoregulatory molecule involved in calcific aortic valve disease

Mitochondrial dysfunction and immune cell infiltration play crucial yet incompletely understood roles in the pathogenesis of calcific aortic valve disease (CAVD). This study aimed to identify immune-related mitochondrial genes critical to the pathological process of CAVD using multiomics approaches. The CIBERSORT algorithm was employed to evaluate immune cell infiltration characteristics in CAVD patients. An integrative analysis combining weighted gene coexpression network analysis (WGCNA), machine learning, and summary data-based Mendelian randomization (SMR) was performed to identify key mitochondrial genes implicated in CAVD. Spearman's rank correlation analysis was also performed to assess the relationships between key mitochondrial genes and infiltrating immune cells. Compared with those in normal aortic valve tissue, an increased proportion of M0 macrophages and resting memory CD4 T cells, along with a decreased proportion of plasma cells and activated dendritic cells, were observed in CAVD patients. Additionally, eight key mitochondrial genes associated with CAVD, including PDK4, LDHB, SLC25A36, ALDH9A1, ECHDC2, AUH, ALDH2, and BNIP3, were identified through the integration of WGCNA and machine learning methods. Subsequent SMR analysis, incorporating multiomics data, such as expression quantitative trait loci (eQTLs) and methylation quantitative trait loci (mQTLs), revealed a significant causal relationship between ALDH9A1 expression and a reduced risk of CAVD. Moreover, ALDH9A1 expression was inversely correlated with M0 macrophages and positively correlated with M2 macrophages. These findings suggest that increased ALDH9A1 expression is significantly associated with a reduced risk of CAVD and that it may exert its protective effects by modulating mitochondrial function and immune cell infiltration. Specifically, ALDH9A1 may contribute to the shift from M0 macrophages to anti-inflammatory M2 macrophages, potentially mitigating the pathological progression of CAVD. In conclusion, ALDH9A1 represents a promising molecular target for the diagnosis and treatment of CAVD. However, further validation through in vivo and n vitro studies is necessary to confirm its role in CAVD pathogenesis and therapeutic potential.

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

AI-Enhanced Prediction of Aortic Stenosis Progression: Insights From the PROGRESSA Study

Background

Aortic valve stenosis (AS) is a progressive chronic disease with progression rates that vary in patients and therefore difficult to predict.

Objectives

The aim of this study was to predict the progression of AS using comprehensive and longitudinal patient data.

Methods

Machine and deep learning algorithms were trained on a data set of 303 patients enrolled in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study who underwent clinical and echocardiographic follow-up on an annual basis. Performance of the models was measured to predict disease progression over long (next 5 years) and short (next 2 years) terms and was compared to a standard clinical model with usually used features in clinical settings based on logistic regression.

Results

For each annual follow-up visit including baseline, we trained various supervised learning algorithms in predicting disease progression at 2- and 5-year terms. At both terms, LightGBM consistently outperformed other models with the highest average area under curves across patient visits (0.85 at 2 years, 0.83 at 5 years). Recurrent neural network-based models (Gated Recurrent Unit and Long Short-Term Memory) and XGBoost also demonstrated strong predictive capabilities, while the clinical model showed the lowest performance.

Conclusions

This study demonstrates how an artificial intelligence-guided approach in clinical routine could help enhance risk stratification of AS. It presents models based on multisource comprehensive data to predict disease progression and clinical outcomes in patients with mild-to-moderate AS at baseline.

Circulating Plasma Proteins in Aortic Stenosis: Associations With Severity, Myocardial Response, and Clinical Outcomes

BACKGROUND

Echocardiographic indexes of aortic stenosis may not comprehensively reflect disease morbidity. Plasma proteomic profiling may add prognostic value in these patients.

METHODS AND RESULTS

Proximity extension assays (Olink) of 183 circulating cardiovascular and inflammatory proteins were performed in a prospective follow-up study of 122 asymptomatic/minimally symptomatic patients (mean±SD age, 69.1±10.9 years; 61% men) with moderate to severe aortic stenosis and preserved left ventricular ejection fraction. Protein signatures of higher-risk echocardiographic subgroups were determined. Associations of proteins with the primary composite outcome (heart failure hospitalization, progression to New York Heart Association class III-IV, or all-cause mortality) were evaluated using competing risk analyses, with aortic valve replacement being the competing risk. Network analysis unveiled mutually exclusive communities of proteins and echocardiographic parameters, connected only through NT-proBNP (N-terminal pro-B-type natriuretic peptide). Members of the tumor necrosis factor receptor superfamily (TNFRSF1A, TNFRSF1B, and TNFRSF14), and trefoil factor-3 were major hub proteins among the circulating biomarkers. Left ventricular global longitudinal strain >-15% was associated with higher levels of proteins, primarily of inflammation and immune regulation, whereas aortic valve area <1 cm2, E/e' >15, and left atrial reservoir strain <20% were associated with higher levels of NT-proBNP. Of 14 proteins associated with the primary end point, phospholipase-C, C-X-C motif chemokine-9, and interleukin-10 receptor subunit β demonstrated the highest hazard ratios after adjusting for clinical factors (q<0.05).

CONCLUSIONS

Plasma proteins involved in inflammation and immune regulation were differentially expressed in patients with aortic stenosis with reduced left ventricular global longitudinal strain, and associated with adverse clinical outcomes. Their incorporation into aortic stenosis risk stratification warrants further assessment.

Human epididymis protein 4 is a useful predictor of post-operative prognosis in patients with severe aortic stenosis

AIMS

The human epididymis protein 4 (HE4), a novel fibrosis marker, is expressed only in activated fibroblasts and is thought to reflect ongoing left ventricular (LV) fibrosis. LV fibrosis is a feature of severe aortic stenosis (AS) and is related to the post-operative outcome of patients with AS. We investigated the relationship between serum levels of HE4 and the post-operative prognosis of patients with severe AS.

METHODS AND RESULTS

We measured the serum HE4 levels of 55 participants (80.8 ± 8.0 years old, male n = 26, 46%) with severe AS prior to surgical aortic valve replacement (n = 31, 56%) or transcatheter aortic valve implantation (n = 24, 44%) at Kumamoto University Hospital in 2018. We followed them for cardiovascular (CV) death or hospitalization for heart failure (HF) for 3 years. Serum HE4 levels were positively correlated with computed tomography-extracellular volume (CT-ECV) values (r = 0.53, P = 0.004). Kaplan-Meier curves demonstrated a significantly higher probability of hospitalization for HF or CV-related death in the patients with high HE4 (greater than the median HE4 value) compared with the patients with low HE4 (lower than the median HE4 value) (log-rank P = 0.003). Multivariate analysis showed HE4 (log(HE4)) to be an independent prognostic factor [hazard ratio (HR): 7.50; 95% confidence interval (CI): 1.81-31.1; P = 0.005]. Receiver operating characteristic (ROC) curve analysis suggested that HE4 is a marker of increased risk of CV-related death or hospitalization for HF at 3 years after surgery, with an area under the curve (AUC) of 0.76 (95% CI: 0.62-0.90; P = 0.003).

CONCLUSIONS

We found that HE4 is a potentially useful biomarker for predicting future CV events in patients scheduled for AS surgery. Measuring serum HE4 values could help consider AS surgery.

Electronic physician notification to facilitate the recognition and management of severe aortic stenosis: Rationale, design, and methods of the randomized controlled DETECT AS trial

BACKGROUND

Symptomatic severe aortic stenosis causes substantial morbidity and mortality when left untreated, yet recent data suggest its undertreatment.

OBJECTIVE

To evaluate the efficacy of electronic physician notification to facilitate the guideline-directed management of patients with severe aortic stenosis.

HYPOTHESIS

We hypothesize that patients with severe aortic stenosis who are in the care of physicians who receive the notification are more likely to undergo aortic valve replacement within one year.

METHODS/DESIGN

The Electronic Physician Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis (DETECT AS) trial is a randomized controlled trial and quality improvement initiative designed to evaluate the efficacy of electronic provider notification versus usual clinical care in the management of patients with severe aortic stenosis. Providers ordering an echocardiogram with findings potentially indicative of severe aortic stenosis are randomized to receive electronic notification with customized guideline recommendations for the management of severe aortic stenosis or usual care (no notification). Randomization continues until 940 patients are enrolled.

SETTING

Multicentered, academic health system.

OUTCOMES

The primary endpoint is the proportion of patients with severe aortic stenosis receiving an aortic valve replacement within one year of the index echocardiogram. Secondary endpoints include mortality, heart failure hospitalization, transthoracic echocardiogram utilization, aortic stenosis billing code, and cardiology/Valve Team referral.

CONCLUSION

The DETECT AS trial will provide insight into whether electronic notification of providers on the presence of severe aortic stenosis and associated clinical guideline recommendations will facilitate recognition and guideline-directed management of severe aortic stenosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05230225, https://clinicaltrials.gov/ct2/show/NCT05230225.

Recent advancements in polymeric heart valves: From basic research to clinical trials

Valvular heart diseases (VHDs) have become one of the most prevalent heart diseases worldwide, and prosthetic valve replacement is one of the effective treatments. With the fast development of minimal invasive technology, transcatheter valves replacement has been exploring in recent years, such as transcatheter aortic valve replacement (TAVR) technology. In addition, basic research on prosthetic valves has begun to shift from traditional mechanical valves and biological valves to the development of polymeric heart valves. The polymeric heart valves (PHVs) have shown a bright future due to their advantages of longer durability, better biocompatibility and reduced cost. This review gives a brief history of the development of polymeric heart valves, provides a summary of the types of polymer materials suitable for heart leaflets and the emerging processing/preparation methods for polymeric heart valves in the basic research. Besides, we facilitate a deeper understanding of polymeric heart valve products that are currently in preclinical/clinical studies, also summary the limitations of the present researches as well as the future development trends. Hence, this review will provide a holistic understanding for researchers working in the field of prosthetic valves, and will offer ideas for the design and research of valves with better durability and biocompatibility.

Combinations of valvular calcification and serum alkaline phosphatase predict cardiovascular risk among end-stage kidney disease patients

Background

Valvular calcification (VC) refers to the calcified valvular remodeling associated with kidney dysfunction, especially end-stage kidney disease (ESKD). ESKD patients with VC had significantly higher cardiovascular risk than those without. Factors interacted with VC regarding prognostic prediction in this population were seldom investigated. We aimed to examine the potential synergetic effects of VC and alkaline phosphatase (Alk-P) on ESKD patients' cardiovascular risk and mortality.

Methods

ESKD patients undergoing hemodialysis were prospectively enrolled from a medical center in 2018. We identified patients with echocardiography and available serum Alk-P levels. Cox proportional hazard regression was performed to analyze the risk of major adverse cardiovascular events (MACEs), cardiovascular and overall mortality among 4 participant groups (with or without VC versus low or high Alk-P levels). The models were further adjusted for age, sex, and clinical variables.

Results

Of the 309 ESKD patients, 38, 46, 112, and 113 had no VC with low Alk-P, no VC with high Alk-P, VC with low Alk-P, and VC with high Alk-P, respectively. After adjusting for age and sex, patients with VC and high Alk-P had a higher risk of developing MACE, cardiovascular and overall mortality (HR, 3.07, 3.67, 3.65; 95% CI 1.38-6.84, 1.1-12.24, 1.29-10.36, respectively). Patients with VC and high Alk-P remained at higher risk of MACE (HR, 2.76; 95% CI 1.17-6.48) than did those without VC and with low Alk-P.

Conclusion

Serum Alk-P could be used to identify a subgroup of ESKD patients with elevated cardiovascular risk among those with VC.

Extracellular Vesicles to Predict Outcomes After Transcatheter Aortic Valve Implantation - a Prospective, Multicenter Cohort Study

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is an established treatment for aortic stenosis (AS) in patients at intermediate and high surgical risk. Circulating extracellular vesicles (EVs) are nanoparticles involved in cardiovascular diseases. We aimed to (i) determine the effect of TAVI on plasma concentrations of five EV subtypes and (ii) evaluate the predictive value of EVs for post-TAVI outcomes.

METHODS

Blood samples were collected 1 day before TAVI and at hospital discharge. Concentrations of EVs were evaluated using flow cytometry.

RESULTS

Concentration of leukocytes EVs decreased after TAVI, compared to the measurement before (p = 0.008). Among 123 patients discharged from the hospital, 19.5% experienced MACCE during the median of 10.3 months. Increased pre-TAVI concentration of phosphatidylserine-exposing EVs was an independent predictor of MACCE in multivariable analysis (OR 5.313, 95% CI 1.164-24.258, p = 0.031).

CONCLUSIONS

Patients with increased pre-TAVI concentration of procoagulant, PS-exposing EVs have over fivefold higher odds of adverse outcomes.

Unmet needs and knowledge gaps in aortic stenosis: A position paper from the Heart Valve Council of the French Society of Cardiology

Nowadays, valvular heart disease remains a significant challenge among cardiovascular diseases, affecting millions of people worldwide and exerting substantial pressure on healthcare systems. Within the spectrum of valvular heart disease, aortic stenosis is the most common valvular lesion in developed countries. Despite notable advances in understanding its pathophysiological processes, improved cardiovascular imaging techniques and expanding therapeutic options in recent years, there are still unmet needs and knowledge gaps regarding aortic stenosis pathophysiology, severity assessment, management and decision-making strategy. This review, prepared on behalf of the Heart Valve Council of the French Society of Cardiology, describes these gaps and future research perspectives to improve the outcome of patients with aortic stenosis.