2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis

OBJECTIVES

Screening for obstructive coronary artery disease (CAD) with coronary computed tomography angiography (CCTA) could prevent unnecessary invasive coronary angiography (ICA) procedures during work-up for trans-catheter aortic valve implantation (TAVI). CT-derived fractional flow reserve (CT-FFR) improves CCTA accuracy in chest pain patients. However, its reliability in the TAVI population is unknown. This systematic review and meta-analysis assesses CCTA and CT-FFR in TAVI candidates.

METHODS

PubMed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.

RESULTS

Thirty-four articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 7235 and 1269 patients, respectively. Reference standard was mostly anatomical severity of CAD. At patient level, pooled CCTA sensitivity was 94.0% and specificity 72.4%. CT-FFR sensitivity was 93.2% and specificity 70.3% with substantial variation between studies. However, in studies that compared both, CT-FFR performed better than CCTA. Sensitivity of CCTA versus CT-FFR was 74.9% versus 83.9%, and specificity was 65.5% versus 89.8%.

CONCLUSIONS

Negative CCTA accurately rules out CAD in the TAVI population. CCTA could lead to significant reduction in pre-TAVI ICA, but false positives remain high. Diagnostic accuracy of CT-FFR was comparable to that of CCTA in our meta-analyses, but in studies performing a direct comparison, CT-FFR performed better than CCTA. However, as most studies were small and used CT-FFR software exclusively available for research, a large study on CT-FFR in TAVI work-up using commercially available CT-FFR software would be appropriate before considering routine implementation.

KEY POINTS

Question Coronary artery disease (CAD) screening with invasive coronary angiography before trans-catheter aortic valve implantation (TAVI) is often retrospectively unnecessary, revealing no obstructive CAD. Findings Coronary CTA ruled out CAD in approximately half of TAVI candidates. CT-derived fractional flow reserve (CT-FFR) performed similarly overall but better than coronary CTA in direct comparison. Clinical relevance Addition of coronary CTA to TAVI planning-CT to screen for obstructive CAD could reduce negative invasive coronary angiographies in TAVI work-up. CT-FFR could reduce false-positive coronary CTA results, improving its gatekeeper function in this population, but more data is necessary.

Predictive Value of Preoperative Hypersensitive C-Reactive Protein in the Incidence of Postoperative Cognitive Impairment in Valvular Disease Patients: A Retrospective Study

Objective

Postoperative cognitive dysfunction (POCD) is associated with adverse outcomes of cardiac surgery. This study investigated the potential of pre-operative hypersensitive C-reactive protein (Hs-CRP) as a prognostic indicator of POCD in valvular disease (VHD).

Methods

This study retrospectively analyzed 372 VHD patients admitted to the Department of Cardiac Surgery, Fujian Medical University Union Hospital from January 2024 to July 2024. POCD was evaluated by neuropsychological examination before and one month after surgery. Demographics, disease history, blood biochemical parameters, and perioperative data were collected. Patients were divided into a POCD group (N = 103) and a non-POCD group (N = 269) according to the occurrence of POCD. A logistic regression model was used to analyze the relationship between Hs-CPR and POCD in VHD patients.

Results

The 1-month incidence of POCD in VHD patients was 27.6%. There was statistical significance in age and years of education between the two groups (P = 0.047, P = 0.001). The red blood cell count in the POCD group was lower than that in the non-POCD group (P = 0.025), and the Hs-CRP and mechanical ventilation duration in the POCD group was higher than that in the non-POCD group, with statistical significance (P < 0.001). No significant differences were observed in the results of demographic characteristics and other laboratory measures. The incidence of hospitalization days, ICU stay time, acute renal insufficiency, and new cerebral infarction in the POCD group were higher than those in the non-POCD group (P < 0.001, P < 0.001, P = 0.001, P = 0.029). Univariate and multivariate analysis showed that Hs-CRP was an independent risk factor for POCD in patients undergoing surgery for VHD disease.

Conclusion

Our study shows that preoperative Hs-CRP is significantly elevated in POCD patients undergoing VHD surgery, and preoperative Hs-CRP is an independent predictor of POCD.

Research on rheumatic heart disease from 2013 to early 2024: a bibliometric analysis

OBJECTIVES

The aim of this bibliometric analysis was to highlight potential future areas for the practical application of research on rheumatic heart disease (RHD), considering past and current research efforts.

METHODS

A systematic search was conducted in the WoSCC to find articles and reviews focused on RHD published between 2013 and 2024. Microsoft Excel 2019 was used to chart the annual productivity of research relevant to RHD, while ArcGIS (version 10.8) was employed to visualize the global distribution of publications. Analysis tools such as CiteSpace (version 6.1.R6) and VOSviewer (version 1.6.18) were utilized to identify the most prolific countries or regions, authors, journals, and resource-, intellectual-, and knowledge-sharing in RHD research, and to perform co-citation analysis of references and keywords. Additionally, the Bibliometrix R Package was used to analyze topic dynamics.

RESULTS

From the search, a total of 2,428 publications were retrieved. In terms of countries or regions, the United States was the most productive country (566, 23.31%). As for institutions, most publications have been contributed by the University of Cape Town (149, 6.14%). Regarding authors, Jonathan R. Carapetis produced the most published works, and he received the most co-citations. The most prolific journal was identified as the International Journal of Cardiology (70, 2.88%). The study published in Circulation received the most co-citations. Keywords with ongoing strong citation bursts included "surgical treatment" and "valvular heart disease".

CONCLUSION

Despite the rapid advancements in the field of RHD research, future efforts should prioritize strengthening collaboration among national institutions to facilitate information dissemination. Current research on RHD mainly focuses on prognosis of patients. While, the emerging research trends in RHD encompass treatment strategies for complications, including atrial fibrillation (AF), heart failure (HF), and infective endocarditis, as well as screening strategies for RHD and surgical interventions for patients with rheumatic mitral valve disease.

Prognostic Implications of Right Ventricular Dysfunction in Severe Degenerative Mitral Regurgitation

BACKGROUND

The prevalence and impact of right ventricular dysfunction (RVD) in degenerative mitral regurgitation (DMR) is unknown. We aimed to determine whether RVD assessed by echocardiography in routine clinical practice is independently associated with mortality in patients with DMR.

METHODS AND RESULTS

We used data from the MIDA-Q (Mitral Regurgitation International DAtabase-Quantitative) registry, which included patients with isolated DMR due to mitral valve prolapse from January 2003 to January 2020 from 5 tertiary centers across North America, Europe, and the Middle East. A cohort of 2917 (mean age: 66 years, 70.8% male patients, follow-up: 5.2 [3.3-8.3] years) consecutive patients with severe DMR was included and long-term mortality was analyzed. RVD, identified in 426 (14.6%) patients, was associated with reduced 8-year survival (55%±3% versus 77%±1%; P <0.001), overall and in all subgroups of patients, even after comprehensive adjustment including left ventricular dilatation and dysfunction, DMR severity, pulmonary pressures, and surgery (adjusted hazard ratio, 1.44 [95% CI, 1.17-1.77]; P <0.001). This excess mortality was observed under medical management (adjusted hazard ratio, 1.57 [95% CI, 1.20-2.05]; P=0.001) and after surgical correction of mitral regurgitation (adjusted hazard ratio, 1.45 [95% CI, 1.02-2.05]; P=0.039). Patients with RVD undergoing surgery within 3 months of diagnosis experienced a better 8-year survival (73%±4% versus 43%±4%; P <0.001), even after adjustment (adjusted hazard ratio, 0.44 [95% CI, 0.29-0.67]; P <0.001) despite an increase of 1-month postoperative mortality (7.1% versus 0.5% for patients without RVD; P <0.001).

CONCLUSIONS

RVD is observed in 14.6% of severe DMR and exhibits a powerful and independent association with excess mortality partially attenuated by mitral surgery. Therefore, assessment of right ventricular systolic function should be included in routine DMR evaluation and in the clinical decision-making process.

Global, Regional, and National Burden of Valvular Heart Disease, 1990 to 2021

BACKGROUND

Valvular heart disease poses an escalating global health challenge with an increasing impact on mortality and disability. This study aims to comprehensively analyze the global burden of valvular heart disease.

METHODS AND RESULTS

Using the Global Burden of Disease 2021 data, we analyzed the prevalence and disability-adjusted life years, examining implications across demographics and geographic regions. In 2021, an estimated 54.8 million (95% uncertainty interval [UI], 43.3-67.6) cases of rheumatic heart disease, 13.3 million (95% UI, 11.4-15.2) cases of nonrheumatic calcific aortic valve disease (CAVD), and 15.5 million (95% UI, 14.5-16.7) cases of nonrheumatic degenerative mitral valve disease (DMVD) were reported globally. Despite the rising prevalence, disability-adjusted life years declined between 1991 and 2021. Among individuals aged 70 years or older, the age-standardized prevalences were 1803.6 per 100 000 (95% UI, 1535.5-2055.7) for CAVD and 2148.9 per 100 000 (95% UI, 2001.4-2310.1) for DMVD. Sub-Saharan Africa had the highest age-standardized prevalence for rheumatic heart disease; Conversely, high-income regions led in CAVD and DMVD prevalence. Rheumatic heart disease had the highest age-standardized prevalence of 1184.2 per 100 000 (95% UI, 932.4-1478.2) in low Socio-Demographic Index (SDI) regions, whereas CAVD peaked at 349.8 per 100 000 (95% UI, 303.6-395.8) in high SDI regions. The most substantial increases in age-standardized prevalences of CAVD from 1990 to 2021 occurred in the middle SDI and low-middle SDI regions. A parallel trend was noted for DMVD.

CONCLUSIONS

Rheumatic heart disease remains a significant burden in low SDI regions, whereas CAVD and DMVD pose challenges in high SDI regions with aging populations.

Lifetime management considerations to optimise transcatheter aortic valve implantation: a practical guide

Transcatheter aortic valve implantation (TAVI) is a safe and effective procedure for the treatment of aortic stenosis. With the recently broadened indications, there is a larger cohort of patients likely to outlive their first transcatheter heart valve (THV). This review discusses relevant lifetime planning considerations, focusing on the utility of preprocedural computed tomography imaging to help implanters future-proof their patients who are likely to outlive their first valve. The initial priority is to optimise the index procedure by maximising THV haemodynamic function and durability. This involves maximising the effective orifice area, minimising the risk of new pacemaker implantation, reducing paravalvular regurgitation, and preventing coronary obstruction and annular rupture. In patients requiring a second valve procedure, a significant proportion will require a TAVI-in-TAVI, and implanters should consider the key priorities for a redo procedure, including the increased risks of patient-prosthesis mismatch and conduction abnormalities, promoting coronary reaccessibility, and preventing coronary obstruction and sinus sequestration. Careful planning can identify potential hurdles as well as predict the feasibility and likely outcomes of redo-TAVI, to help individualise care over the lifetime of each patient.

Five-year outcomes of mitral valve repair for leaflet prolapse at a medium-sized Norwegian university hospital

Objective. To evaluate patient characteristics and 5-year outcomes after surgical mitral valve (MV) repair for leaflet prolapse at a medium-sized cardiothoracic center. Background. Contemporary reports on the outcome of MV repair at medium-sized cardiothoracic centers are sparse. Methods. Patients receiving open-heart surgery with MV repair due to primary mitral regurgitation caused by leaflet prolapse between 2015 and 2021, without active endocarditis, were included. Clinical data, complications, re-interventions, mortality, and echocardiographic data were retrospectively registered from electronical patient charts, both pre-operatively and from post-operative follow-ups. Results. One hundred and three patients were included, 83% male, with a mean age of 62 years. All-cause mortality was 9% during a median follow-up time of 4.9 years. Re-intervention rate on the MV was 4%. Post-operative complications before last available follow-up visit at median 3.0 years were infrequent, with new-onset atrial fibrillation/flutter in 16%, post-operative MV regurgitation grade II or above in 17% and post-operative tricuspid regurgitation grade II or above in 14%. Conclusions. These data demonstrate that surgical MV repair for leaflet prolapse at a medium-sized cardiothoracic center was associated with low re-intervention rate and few severe complications. The presented results are comparable to data from surgical high-volume centers, indicating that surgical MV repair can be safely performed at selected medium-sized cardiothoracic centers.

Severe acute recoil following transcatheter aortic valve replacement with a self-expanding prosthesis in a heavily calcified bicuspid aortic valve

Bicuspid aortic valve (BAV) is one of the most common congenital valvular heart diseases occurring in 0.5-2% of the general population, in 2-6% of patients with severe aortic stenosis (AS) and up to 20% of octo/nonagenarians undergoing surgery. In this regard, Transcatheter aortic valve replacement (TAVR) has emerged as a therapeutic alternative. At the present time, there is not enough evidence to determine which is the best therapeutic approach for AS in BAV. We report a severe acute recoil following TAVR with a self-expanding prosthesis in heavily calcified BAV. In addition, we provide an updated review of the clinical significance of prosthesis underexpansion in the medium-term.

Association of Yeo's index with clinical outcomes in rheumatic mitral stenosis

Yeo's index, the product of the mitral leaflet separation index and dimensionless index of mitral valve (MV), was recently described to accurately identify severe rheumatic mitral stenosis (MS). We assess the association between Yeo's index and clinical outcomes in patients with rheumatic MS. We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo's index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, MV intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. The median follow up was 6.3 years; 145 patients (48.8%) developed the composite outcome. Yeo's index (p < 0.001), mitral valve area (MVA) by pressure half-time (PHT) (p = 0.028) and planimetry (p < 0.001), age (p = 0.016), history of diabetes mellitus (p = 0.029), previous HF (p = 0.021), left ventricular ejection fraction (p = 0.022), and pulmonary artery systolic pressure (p = 0.007) were univariately associated with the composite outcome. Yeo's index remained independently associated with the composite outcome in multivariate analysis (p < 0.001, HR 0.094, 95% CI 0.260-0.340). This was primarily driven by MV intervention. In a subgroup analysis of patients without pre-existing AF, Yeo's index was independently associated with new onset AF (p = 0.024, HR 0.354, 95% CI 0.143-0.874). This demonstrated that Yeo's index was independently associated with clinical outcomes in patients with rheumatic MS which was mainly driven by MV intervention.

Heart valve clinics: an expanding role for the clinical scientist's validation of a framework for competency and certification

BACKGROUND

Valvular heart disease (VHD) represents a significant burden on healthcare systems worldwide, necessitating specialised care through multidisciplinary valve clinics. However, there is a lack of a standardised training and certification framework for clinical scientists and specialist physiologists (CSSPs) working within specialist valve clinics (SVCs). This study aimed to design, implement and validate a competency framework dedicated to training and certifying valve CSSPs to enhance patient outcomes and establish standardised care.

METHODS

A comprehensive competency framework was developed and implemented, consisting of two levels: Enhanced Valve Clinic Training (EVCT) and Advanced Valve Clinic Training (AVCT). The programme was trialled at Guy's Valve Clinic, London, over a 12-month period. Validation was undertaken through trainee and patient feedback, including multiple-choice questions, clinical skills assessments, and patient satisfaction surveys.

RESULTS

Nine CSSPs completed the EVCT and four the AVCT. All participants passed their certification examinations with scores ranging from 80% to 95%. The time to complete each programme averaged 6 months. After certification, clinical queries raised by EVCT trainees averaged 1.2 per session but dropped by 75% to 0.3 per session in the AVCT group, indicating greater confidence and independence in managing cases. Physician review of trainee-led cases led to additional tests or treatment changes in 23% of cases and referrals to physician clinics in 11%. Patient feedback was positive: 95% felt confident in the clinical scientists' knowledge, and 100% were satisfied with the clarity of their care plans and follow-up.

CONCLUSIONS

The implementation of this training and certification framework demonstrated enhanced clinical outcomes and care delivery in SVCs. By advocating for formal recognition and accreditation of valve clinic training, this framework could serve as a model for national and international standardisation in valve care and clinical training.

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations

BACKGROUND

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.

METHODS AND RESULTS

Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men.

CONCLUSIONS

Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Cardiovascular magnetic resonance imaging in mitral valve disease

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure episodes, and excess mortality. Cardiovascular magnetic resonance assessment is recommended for MR when routine ultrasound imaging information is insufficient or discordant. A well-planned CMR can provide an in-depth assessment of the mitral valve apparatus, leaflet morphology, and papillary muscles. In addition, it can precisely inform the impact of MR on left atrial and ventricular remodelling. The review aims to highlight established and emerging techniques for morphological assessment, flow assessment (including regurgitation and stenosis), myocardial assessment, and haemodynamic assessment of mitral valve disease by CMR. It also proposes a simplified clinical flow chart for CMR assessment of the mitral valve.

Clinical Outcomes According to Aortic Stenosis Management: Insights From Real-World Practice

BACKGROUND

Real-world data regarding clinical outcomes according to aortic stenosis (AS) management are scarce. Therefore, we aimed to investigate long-term management across the spectrum of outpatients with AS.

METHODS AND RESULTS

Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (3-3.9 m/s), and severe AS (≥4 m/s) were included by 117 cardiologists in the VALVENOR (Follow-Up of a Cohort of Patients With Valvular Aortic Stenosis in the Nord-pas-de-Calais Region) study and followed-up for aortic valve replacement (AVR) and modes of death. Among 2704 patients included, 1156 (42.7%) had mild, 1121 (41.5%) moderate, and 427 (15.8%) severe AS. After a median follow-up of 5 years, 993 AVRs (488 surgical and 505 transcatheter) and 1098 deaths occurred. The 5-year cumulative incidence of AVR or of the composite of death or AVR was 13.3% and 45.2% in mild AS, 45.5% and 75.3% in moderate AS, and 62.8% and 90.6% in severe AS, respectively. Of the 292 patients who met the criteria for AVR but were not treated, AVR was considered futile in 137 patients and 155 patients refused AVR. Mortality rates after 3 years were high: 86% for anticipated futility and 72.3% for refusal. While patients at anticipated futility showed a well-balanced proportion of cardiovascular and noncardiovascular deaths, cardiovascular deaths predominated among those who refused AVR.

CONCLUSIONS

At 5-year follow-up, only two thirds of patients with severe AS underwent AVR. Patients with untreated severe AS experienced high mortality rates, mostly cardiovascular for patients who declined AVR. This advocates for better patient education based on shared decision making and for optimizing AS quality of care, from diagnosis to treatment.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in Chinese patients with intermediate and high surgical risk for aortic stenosis: a decision analysis on effect, affordability and cost-effectiveness

OBJECTIVE

Examine the cost-effectiveness of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) for Chinese patients with severe aortic stenosis (AS) at intermediate and high surgical risk.

DESIGN

A two-phase model, comprising a 1-month decision tree to simulate perioperative outcomes and a 5-year Markov model with monthly cycles to simulate long-term outcomes, has been developed to evaluate the cost-effectiveness of TAVI compared with SAVR for Chinese patients with AS at intermediate and high risk. The event rates for both phases are sourced from the Placement of Aortic Transcatheter Valves IA and IIA trials, while the cost inputs and utility values are sourced from local sources or published literature. Adjustments for inflation were made using consumer price indexes for healthcare to enhance precision. To ensure the reliability and robustness of the model, sensitivity analyses were conducted to assess their impact on outcomes.

SETTING

China healthcare system perspective.

PARTICIPANTS

A hypothetical cohort of Chinese patients with AS in intermediate and high surgical risk.

INTERVENTIONS

TAVI versus SAVR.

OUTCOME MEASURES

Cost, quality-adjusted life-years (QALYs), life-years gained and incremental cost-effectiveness Ratio (ICER).

RESULT

For both intermediate- and high-risk AS patients, offering TAVR resulted in high healthcare costs but moderate benefits compared with SAVR. Specifically, in the intermediate-risk population, TAVR led to a 0.34 QALY increase over SAVR, with an incremental cost of $16 707.58, resulting in an ICER of $49 176.60/QALY. Similarly, in the high-risk population, TAVR showed a 0.15 QALY increase over SAVR, with an incremental cost of $18 093.52, leading to an ICER of $122 696.37/QALY. However, both ICERs exceeded the willingness-to-pay threshold of $37 654.50/QALY. Sensitivity analyses confirmed the model's stability under parameter uncertainty.

CONCLUSION

TAVI was deemed not cost-effective compared with SAVR for patients with AS at intermediate or high surgical risk in the Chinese healthcare system. Lowering valve costs was considered an effective approach to improve the cost-effectiveness of TAVI.

Maternal heart failure: state-of-the-art review

Pregnancy is a period of substantial changes to the body's normal physiology, and the failure to adapt to these changes can lead to life-threatening pathology, particularly involving the cardiovascular system. In comparison to pre-pregnancy physiology, pregnant women have increased blood volume and physical demands which exert increased stress on the heart. This is important to consider in women with and without previously diagnosed cardiovascular disease, as the physiologic changes during pregnancy and postpartum can lead to sudden decompensation. The management of heart failure is particularly important as it remains the most common cardiovascular complication during pregnancy and is associated with substantial maternal and fetal morbidity and mortality. This is especially true in patients with pre-existing heart failure, who should receive counseling before conception and in certain cases be advised against pregnancy. For these reasons, healthcare professionals must be well-versed in the different strategies of diagnosis, management, treatment, and monitoring. This review will outline the pathophysiology, diagnostics, management, and general approach to heart failure in pregnant patients.

Cardiopulmonary exercise testing in aortic stenosis patients before and after aortic valve replacement

BACKGROUND

Knowledge about how patients with symptomatic aortic stenosis (AS) perform on cardiopulmonary exercise testing (CPET) is sparse. Since exercise testing in patients with symptomatic AS is not advised, submaximal parameters could be of special interest. We aimed to investigate maximal and submaximal physical capacity by CPET before and 1 year after surgical aortic valve replacement (sAVR) in patients with severe AS.

METHODS

In this prospective longitudinal study, 30 adult patients (age 66±10 years) with severe AS referred for sAVR underwent maximal CPET (respiratory exchange ratio ≥1.05) on a bicycle ergometer before (PRE) and 1 year after (POST) sAVR. Normally distributed data are presented as mean (±SD) and non-normally distributed data are presented as median (IQR).

RESULTS

Median peak workload increased by 8% from 133 (55) watts at PRE to 144 (67) watts at POST (p<0.001). Median ventilatory threshold (VO2@VT) increased from 1216 (391) to 1328 (309) mL/min (p=0.001, n=28). Mean peak oxygen uptake (peakVO2) was not significantly different between PRE and POST; 1871±441 vs 1937±404 mL/min (p=0.08). The oxygen uptake efficacy slope (OUES) was significantly correlated to PeakVO2 at both PRE (r=0.889, p<0.05) and POST (r=0.888, p<0.05) CONCLUSION: Physical work capacity was improved 1 year following sAVR, in terms of higher median peak workload and VO2@VT. The strong correlation between the submaximal variable OUES and peakVO2 suggests that OUES might be a useful surrogate of peakVO2 in this group of patients where maximal exercise testing is not always recommended.

Lipoprotein(a) and High-Sensitivity C-Reactive Protein Compound the Risk of Hypoattenuating Leaflet Thickening After Transcatheter Aortic Valve Replacement

BACKGROUND

The mechanism for hypoattenuating leaflet thickening (HALT) after transcatheter aortic valve replacement is still not well elucidated, and the role of Lp(a) (lipoprotein[a]) and hs-CRP (high-sensitivity C-reactive protein) has rarely been studied. This study sought to test the hypothesis that the risk of HALT is associated with an elevated level of Lp(a) or hs-CRP.

METHODS AND RESULTS

A total of 307 consecutive individuals who underwent a transcatheter aortic valve replacement procedure were included. All patients received their first postoperative computed tomography scans within 12 months, and raw data were analyzed on 3mensio software. HALT was defined as visually identified increased leaflet thickness with typical meniscal appearance and at least 2 different multiplanar reformation projections. Associations of Lp(a) or hs-CRP with the risk of HALT were evaluated using multivariable logistic regression analysis. The incidence of HALT within 12 months after transcatheter aortic valve replacement in this study was 36.2%, and the risk of HALT was associated with higher baseline Lp(a) (the multivariable adjusted odds ratio [OR] for every 10 mg/dL change was 1.18 [95% CI, 1.09-1.29]) and hs-CRP level (the multivariable adjusted OR for every 1 mg/L change was 1.08 [95% CI, 1.00-1.27]). Compared with individuals out of the top 25th percentile for both Lp(a) and hs-CRP, the multivariable adjusted OR for HALT was 4.74 (95% CI, 1.65-14.37) for the top 25th percentile. This result remained consistent after excluding patients receiving anticoagulant therapy.

CONCLUSIONS

The top 25th percentile of Lp(a) level (≥40 mg/dL) combined with the top 25th percentile of hs-CRP level (≥3.5 mg/L) conferred a 4.74-fold risk of HALT.

FEBio FINESSE: An Open-Source Finite Element Simulation Approach to Estimate In Vivo Heart Valve Strains Using Shape Enforcement

PURPOSE

Finite element simulations are an enticing tool to evaluate heart valve function; however, patient-specific simulations derived from 3D echocardiography are hampered by several technical challenges. The objective of this work is to develop an open-source method to enforce matching between finite element simulations and in vivo image-derived heart valve geometry in the absence of patient-specific material properties, leaflet thickness, and chordae tendineae structures.

METHODS

We evaluate FEBio Finite Element Simulations with Shape Enforcement (FINESSE) using three synthetic test cases considering a range of model complexity. FINESSE is then used to estimate the in vivo valve behavior and leaflet strains for three pediatric patients.

RESULTS

Our results suggest that FINESSE can be used to enforce finite element simulations to match an image-derived surface and estimate the first principal leaflet strains within ± 0.03 strain. Key considerations include: (i) defining the user-defined penalty, (ii) omitting the leaflet commissures to improve simulation convergence, and (iii) emulating the chordae tendineae behavior via prescribed leaflet free edge motion or a chordae emulating force. In all patient-specific cases, FINESSE matched the target surface with median errors of approximately the smallest voxel dimension. Further analysis revealed valve-specific findings, such as the tricuspid valve leaflet strains of a 2-day old patient with HLHS being larger than those of two 13-year old patients.

CONCLUSIONS

FEBio FINESSE can be used to estimate patient-specific in vivo heart valve leaflet strains. The development of this open-source pipeline will enable future studies to begin linking in vivo leaflet mechanics with patient outcomes.

A Comparative Study of Aortic Valve Neocuspidization Techniques: Formula vs. Template Methods of Neocusp Formation

INTRODUCTION

The template method (TM), pioneered by Ozaki for aortic valve neocuspidization (AVNeo), has been widely adopted for aortic valve replacement, though it requires specialized instruments. This study introduces a novel formula method (FM), which uses the diameter of the aortic valve fibrous ring (AV-D) to determine the dimensions of the neocusps to be trimmed from autologous without the need for templates, potentially reducing costs and complexity. We aimed to compare the clinical outcomes of the FM with the established TM in patients undergoing AVNeo.

METHODS

A retrospective and prospective study was conducted on 31 patients who underwent isolated AVNeo between January 21, 2019 and December 15, 2022. Patients were divided into two groups: FM (n = 17) and TM (n = 14). The formula for the cusp free margin horizontal length is L1 = AV-D + 10 mm, cusp height is H = AV-D, cusp suture margin is L2 is a parabola that joins L1 and H, and cusp wings to be secured to aortic sinus = 3mm. The primary endpoints were major adverse valve-related events, including cardiac death, reoperation, and infective endocarditis. Secondary endpoints included significant aortic regurgitation, peak pressure gradients, aortic valve area, and New York Heart Association (NYHA) functional class. Intraoperative times, early postoperative outcomes, and mid-term hemodynamic performance were evaluated for both techniques.

RESULTS

Both the FM and TM demonstrated comparable intraoperative and postoperative outcomes. The cardiopulmonary bypass time, myocardial ischemia time, and blood loss were similar between the groups. Mid-term outcomes also showed no significant differences in valve function or hemodynamic parameters, with both groups exhibiting substantial reverse left ventricular remodeling. The FM group had a peak pressure gradient of 14.1 ± 4.3 mmHg compared to 18.4 ± 12.0 mmHg in the TM group (p = 0.219). The aortic valve area was 2.43 ± 0.3 cm² in the FM and 2.4 ± 0.2 cm² in the TM (p = 0.890). No significant differences were observed in freedom from reoperation or adverse events.

CONCLUSION

 Both techniques showed excellent mid-term hemodynamic performance and comparable intraoperative and postoperative outcomes. The FM for AVNeo provides a cost-effective and practical alternative to the TM, offering similar clinical outcomes without the need for expensive templates; it has the potential to improve the accessibility of AVNeo, particularly in resource-limited settings. However, further research with larger cohorts and long-term follow-up is needed to fully assess the durability and long-term benefits of the FM.

Characteristics and Outcomes of Patients With Valvular Cardiogenic Shock

Background

The clinical characteristics and outcomes of patients who develop cardiogenic shock (CS) secondary to primary valvular dysfunction (valvular cardiogenic shock [VCS]) remain unclear.

Objectives

The purpose of this study was to describe the cohort of patients with VCS and understand their outcomes compared to other forms of CS.

Methods

All patients admitted to Cleveland Clinic cardiac intensive care unit between January 1, 2010, and December 31, 2021, with a diagnosis of CS were retrospectively identified. Characteristics and outcomes for shock patients with VCS were compared to those without VCS.

Results

A total of 2,754 patients were admitted to our cardiac intensive care unit with CS, of which 442 (16%) had VCS. The median age of patients with VCS was higher than those with non-VCS (70 years vs 64 years, P < 0.001) and were more likely females (40.3% vs 32.1%, P = 0.001). VCS was predominantly due to native valve dysfunction as compared to prosthetic valve dysfunction (71% vs 29%, P < 0.001), with the aortic valve noted to be the most common valve affected. Patients with VCS had higher 1-year (44% vs 37%, P < 0.001) and 30-day all-cause mortality (28% vs 20%, P < 0.001) compared to those without VCS. When compared to percutaneous intervention and medical therapy alone, surgical intervention in VCS was associated with the best short- and long-term outcomes (P < 0.001).

Conclusions

VCS is associated with poor short and long outcomes. Native valvular dysfunction and aortic valve involvement account for the majority of patients with VCS. Definitive surgical therapy and expanding the role of percutaneous therapies may be pivotal in improving clinical outcomes in this high-risk cohort.

Canadian Association of Radiologists Cardiovascular Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Cardiovascular Expert Panel is made up of physicians from the disciplines of radiology, cardiology, and emergency medicine, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 30 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 48 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 125 recommendation statements across the 30 scenarios (27 unique scenarios as 2 scenarios point to the CAR Thoracic Diagnostic Imaging Referral Guideline and the acute pericarditis subscenario is included under 2 main scenarios). This guideline presents the methods of development and the referral recommendations for acute chest pain syndromes, chronic chest pain, cardiovascular screening and risk stratification, pericardial syndromes, intracardiac/pericardial mass, suspected valvular disease cardiomyopathy, aorta, venous thrombosis, and peripheral vascular disease.

The Promise and Perils of Transcatheter Aortic Valve Replacement (TAVR) in Low Surgical Risk Patients with Severe Aortic Stenosis in the Current Era

PURPOSE OF REVIEW

Transcatheter Aortic Valve Replacement (TAVR) has become the preferred treatment approach for many patients with symptomatic severe aortic valve stenosis (SsAS), particularly those who are deemed at high surgical risk. However, in low-risk surgical patients (LSRP) with SsAS, the choice between TAVR and surgical aortic valve replacement (SAVR) is often a matter of debate and depends on several clinical and anatomical considerations.

RECENT FINDINGS

Midterm data show similar clinical outcomes and durability of TAVR and SAVR bioprosthetic valves in LRSP. Data on long term durability and outcomes of TAVR in LRSP remains scarce. Both TAVR and SAVR are reasonable options in LRSP with SsAS. Nevertheless, many of these LRSP are expected to outlive their bioprosthetic valves and planning for the second aortic valve replacement should begin at the time of the index procedure with special consideration for coronary re-access, risk for coronary obstruction, and prothesis patient mismatch.

Three-Year Outcomes Following TAVR in Younger (<75 Years) Low-Surgical-Risk Severe Aortic Stenosis Patients

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis, but data are limited on younger, low-risk patients. This analysis compares outcomes in low-surgical-risk patients aged <75 years receiving TAVR versus surgery.

METHODS

The Evolut Low Risk Trial randomized 1414 low-risk patients to treatment with a supra-annular, self-expanding TAVR or surgery. We compared rates of all-cause mortality or disabling stroke, associated clinical outcomes, and bioprosthetic valve performance at 3 years between TAVR and surgery patients aged <75 years.

RESULTS

In patients <75 years, 352 were randomized to TAVR and 351 to surgery. Mean age was 69.1±4.0 years (minimum 51 and maximum 74); Society of Thoracic Surgeons Predicted Risk of Mortality was 1.7±0.6%. At 3 years, all-cause mortality or disabling stroke for TAVR was 5.7% and 8.0% for surgery (P=0.241). Although there was no difference between TAVR and surgery in all-cause mortality, the incidence of disabling stroke was lower with TAVR (0.6%) than surgery (2.9%; P=0.019), while surgery was associated with a lower incidence of pacemaker implantation (7.1%) compared with TAVR (21.0%; P<0.001). Valve reintervention rates (TAVR 1.5%, surgery 1.5%, P=0.962) were low in both groups. Valve performance was significantly better with TAVR than surgery with lower mean aortic gradients (P<0.001) and lower rates of severe prosthesis-patient mismatch (P<0.001). Rates of valve thrombosis and endocarditis were similar between groups. There were no significant differences in rates of residual ≥moderate paravalvular regurgitation.

CONCLUSIONS

Low-risk patients <75 years treated with supra-annular, self-expanding TAVR had comparable 3-year all-cause mortality and lower disabling stroke compared with patients treated with surgery. There was significantly better valve performance in patients treated with TAVR.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT02701283.

Predicting new-onset persistent conduction disturbance following transcatheter aortic valve replacement: the usefulness of FEOPS finite element analysis

BACKGROUND

Despite the frequency of persistent new-onset conduction disturbances after transcatheter aortic valve replacement (TAVR), few preoperative methods of prediction exist.

METHODS

Patients who underwent TAVR in the Department of Cardiology of the Second Affiliated Hospital of the Army Medical University from December 2020 to September 2021 and postoperative aortic root modeling via the FEOPS finite element analysis were included in this single-center case-control study, divided into persistent conduction disturbances (PCD) and non-PCD groups according to their pre- and postoperative electrocardiograms in the first month. Risk factors affecting PCD were identified by comparing the baseline data of these two groups, including echocardiograms, computed tomography angiography of the aortic root, surgical decision-making, and FEOPS data. Independent risk factors were screened using logistic regression modeling, and the receiver operating characteristic (ROC) curve was used to test the predictive ability.

RESULTS

A total of 56 patients were included in this study, 37 with bicuspid aortic valve (BAV) and 19 with trileaflet aortic valve (TAV), with 17 cases of PCD. The contact pressure index (CPI) of FEOPS, valve oversize ratio, differences between membranous interventricular septum length and implantation depth (ΔMSID) and valve implantation depth were statistically different (P < 0.05). CPI could be used as an independent risk factor for PCD (P < 0.05), and the ROC curve comparison showed that the CPI was more predictive (AUC = 0.806, 95% CI: 0.684-0.928, P = 0.001).

CONCLUSIONS

The CPI of FEOPS has better predictive value for new-onset conduction disturbance after TAVR compared to other known predictors.

Impact of Antibacterials on the Quality of Anticoagulation Control in Patients Initiating Warfarin Therapy

BACKGROUND

Warfarin interacts with antibacterials to prolong the prothrombin time international normalized ratio (PT-INR) and increase the risk of bleeding. Patients initiating warfarin therapy often undergo precise dosage adjustments; however, the clinical implications of these interactions with antibacterials remain unclear. This study aimed to clarify the effect of antibacterials on PT-INR during the warfarin induction phase.

METHODS

This was a retrospective, observational study. Patients who were newly treated with warfarin after cardiovascular surgery were included. The primary endpoint was the comparison of the maximum PT-INR and time in therapeutic range (TTR) after warfarin initiation between the antibacterial-treated (ABx) and non-treated (non-ABx) groups.

RESULTS

The maximum PT-INR was significantly higher in the ABx group (which included β-lactams, glycopeptides, quinolones, tetracyclines, and aminoglycosides) than in the non-ABx group (median [interquartile range] 2.37 [2.03-2.71] vs. 2.08 [1.93-2.33]; P = 0.005); however, the TTR did not differ significantly (65% [44-76] vs. 71% [43-85]; P = 0.150). The odds ratio for maximum PT-INR > 2.6 with antimicrobial therapy was 2.51 (95% confidence interval 1.21-5.21).

DISCUSSION

Antibacterial therapy was a risk factor for a maximum PT-INR >2.6. However, there was no association with the TTR, which is a marker of good outcomes. This was due to the strict warfarin dosing regimen according to the algorithm, which immediately and appropriately adjusted for PT-INR overexpansion.

CONCLUSIONS

Antibacterials have been suggested to increase PT-INR during the induction phase of warfarin. However, with strict dose adjustments, the clinical impact on the PT-INR and TTR is likely limited.

Burden of Mitral Regurgitation in Spain from 2016-2021: An Analysis by Aetiology and Sex

Objectives: Mitral regurgitation (MR) is the second most common valve disease in Europe, and differences between men and women have been described in relation to aetiology or management, which might impact the decision for intervention and patients' clinical and economic outcomes. Thus, the objective was to analyse the burden of MR in Spain by aetiology and sex, and the management of all patients suffering from MR being admitted to hospital between 2016-2021. Methods: An analysis was carried out with the Ministry of Health's database, including all patients in public and subsidised hospitals and defining two groups, general MR and those patients undergoing Transcatheter Edge-to-Edge repair (TEER), using a descriptive analysis of patients' characteristics, use of resources, and outcomes; standardised rates were calculated and observed outcomes were described. Results: Hospital admissions increased from 2016 (n = 32,806) to 2021 (total n = 61,036). In general, the women were older and presented more complications. The majority of patients suffered from degenerative MR (DMR) (n = 183,005, 59.55%), and 61.56% were women, contrary to functional MR (FMR) (n = 124,278), which consisted of 62.15% males. In total, 1,689 TEERs were performed, 23.33% of them in urgent admissions, and mostly in men (65.66%). All groups showed higher rates of intervention for males. Regarding costs, women presented lower mean costs in the general MR groups but those undergoing TEER presented, in all cases, costs higher than men. Conclusions: MR entails a significant burden for patients and the Spanish healthcare system, increasing over the period of study. Differences in aetiologies by sex have been found in patients' characteristics as well as outcomes. Further studies are needed to optimise patients' management and their outcomes in relation to sex and aetiology.

Left atrial volume assessed by echocardiography identifies patients with high risk of adverse outcome after acute myocardial infarction

BACKGROUND

The left atrial (LA) volume has been demonstrated to be an important predictor of adverse outcome in patients with various cardiac conditions, including acute myocardial infarction (AMI). However, new treatment strategies in patients with AMI have led to better patient outcomes. We hypothesised that increased LA size could still predict mortality in patients with AMI despite improved treatment strategies.

METHODS

We included patients with AMI in a prospective multicenter cohort study and the study patients were enrolled from 2014 to 2022. We recorded echocardiographic and clinical data during their index hospitalisation. Indexed LA volume (LAVi) was assessed in all patients and was used as a continuous variable in the univariate and multivariate Cox regression analysis. The study took place over a period of five years and median follow-up time was 3.8 years (range 3.1 to 5.0 years). The primary study outcomes were all-cause mortality and major adverse cardiac events (MACE). MACE was defined as hospital readmission due to myocardial infarction, cardiac arrest, stroke, heart failure, or onset of new atrial fibrillation.

RESULTS

We included 487 patients (69 ± 12 years old, 26% female) with AMI. During the follow-up period all-cause mortality was 50 (10.3%) and patients who reached the primary outcomes were 153 (31.4%). The deceased patients had higher LAVi compared to survivors (40.0 ± 12.9 mL/m2 vs. 29.7 ± 11.2 mL/m2, p < 0.001). Factors associated with all-cause mortality and MACE were age, year of enrollment, left ventricular (LV) ejection fraction, LV global longitudinal strain (GLS), LV filling pressure, moderate or severe mitral regurgitation and LAVi. GLS and EF were segregated into two distinct models due to their moderately high correlation (r = 0.57, p < 0.001). LAVi remained as an independent echocardiographic predictor of primary outcomes after adjusting for the covariates above in two separates multivariable Cox regression models (hazard ratio 1.02/1.02 mL/m2 [95% CI 1.01-1.03/1.01-1.03], p = 0.006/0.003).

CONCLUSIONS

Our study demonstrated that LA dilatation is an independent echocardiographic predictor of mortality and MACE in patients with AMI despite improved treatment strategies. This finding highlights the potential of using LAVi as a marker for prognostication in these patients.

A WeChat platform program (WCPP) for full-process management of patients with cardiac valve interventional surgery based on psycho-cardiology: protocol of a mixed-method study

BACKGROUND

Valvular heart disease is the third most common cardiovascular disease; it significantly diminishes patients' quality of life and imposes burdens on individuals, families, and healthcare systems. In recent years, psycho-cardiology has emerged as a prominent field in which to explore the link between mental illness and heart disease. This mixed-method study aims to assess the effectiveness of the WCPP, which includes hospital-to-home transitional care, remote intelligent monitoring, and decision aids, in improving the physical and mental health of patients.

METHODS

A mixed-method study was conducted at a cardiac valve interventional surgery (CVIS) center in Southwest China. A total of 154 CVIS patients participated, with the intervention group receiving the WCPP and the control group following the traditional CVIS management program. Both groups were followed up at 1, 3, 6, and 12 months. The primary outcome is measured via the Chinese version of the 36-item Short Form Health Survey (SF-36). The Secondary outcomes included the 6-min walk test (6MWT), modified Barthel index (MBI), major adverse cardiovascular events (MACE), patient satisfaction, and length of hospital stay (LOS). Additionally, qualitative research will assess the psychological state and experiences of the patients.

DISCUSSION

Our study is one of the few involving patients with CVIS and the first to apply psycho-cardiology through a full-process management platform. The study population is predominantly from Southwest China and includes a diverse range of demographic and socioeconomic backgrounds. Upon completion, this study will provide valuable insights into the use of a remote, full-process management platform for CVIS patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400081052. Registered on 21 February 2024. The trial complies with the SPIRIT and CONSORT guidelines.

Impact of a New Preoperative Stratification Based on Cardiac Structural Compromise in Patients with Severe Aortic Stenosis Undergoing Valve Replacement Surgery

Introduction and objectives: Aortic valve replacement surgery (SAVR) remains a recommended indication, though its pre-surgical stratification is an ongoing challenge. Despite the widespread use of scores like the STS and EuroSCORE II, they have a number of limitations, while often neglecting structural parameters like left ventricular hypertrophy or left atrium volume. This study aimed to evaluate whether a new adaptation of the Généreux classification in the preoperative risk stratification of severe aortic stenosis (AS) is associated with the primary outcome, and to compare it with the original classification versus the traditional scores in short- and long-term follow-up. Methods: We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent SAVR. The new stratification categorized patients into three stages. Cox regression analyses were conducted to identify factors associated with mortality, with survival analysis performed using Kaplan-Meier curves. A p-value < 0.05 was considered statistically significant. Results: A total of 508 patients were included. Stage 3 patients had a lower median age (67 years). The median EuroSCORE II and STS scores were 2.75 and 2.62%, respectively (p ≤ 0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan-Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p ≤ 0.001). Multivariable analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44-7.20], p = 0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92-0.99], p = 0.021) as independent variables of mortality. The original Généreux scale AUC was higher (AUC: 0.760, 95% CI: 0.692-0.829) compared to the modified Généreux scale (AUC: 0.758, 95% CI: 0.687-0.829). However, no statistical differences were found between the different scales. Conclusions: Preoperative three-stage classification and low transaortic gradient are factors associated with increased all-cause mortality in patients undergoing SAVR. The proposed staging system performed better in the mortality analysis than EuroSCORE II and STS and was similar to the original classification.

Sex-related differences in severe native valvular heart disease: the ESC-EORP Valvular Heart Disease II survey

BACKGROUND AND AIMS

To assess sex differences in disease characteristics and treatment of patients with severe native valvular heart disease (VHD) included in the VHD II EURObservational Research Programme.

METHODS

A total of 5219 patients were enrolled in 208 European and North African centres and followed for 6 months [41.2% aortic stenosis (AS), 5.3% aortic regurgitation (AR), 4.5% mitral stenosis (MS), 21.3% mitral regurgitation (MR), 2.7% isolated right-sided VHD, 24.9% multiple left-sided VHD]. Indications for intervention were considered concordant if corresponding to class I recommendations specified in the 2012 ESC or 2014 AHA/ACC VHD guidelines.

RESULTS

Overall, women were older, more symptomatic, and presented with a higher EuroSCORE II. Bicuspid aortic valve and AR were more prevalent among men while mitral disease, concomitant tricuspid regurgitation (TR), and AS above age 65 were more prevalent among women. On multivariable regression analysis, concordance with recommended treatment was significantly poorer in women with MS and primary MR (both P < .001). Age, patient refusal, and decline of symptoms after conservative treatment were reported significantly more often as reasons to withhold the intervention in females. Concomitant tricuspid intervention was performed at a similar rate in both sexes although prevalence of significant TR was significantly higher in women. In-hospital and 6-month survival did not differ between sexes.

CONCLUSIONS

(i) Valvular heart disease subtype varied between sexes; (ii) concordance with recommended intervention for MS and primary MR was significantly lower for women; and (iii) survival of men and women was similar at 6 months.

The association of coronary artery disease with heart rate at anaerobic threshold and respiratory compensatory point

Background

There is limited knowledge regarding the association between heart rate (HR) during different exercise phases and coronary artery disease (CAD). This study aimed to evaluate the relationship between four exercise-related HR metrics detected by cardiopulmonary exercise testing (CPET) and CAD. These metrics include HR at the anaerobic threshold (HRAT), HR at respiratory compensatory point (HRRCP), maximal HR (HRmax), and HR 60 s post-exercise (HRRec60s).

Methods

The 705 participants included 383 with CAD and 322 without CAD in Beijing Hospital, who underwent CPET between January 2021 and December 2022. The Logistic regression analysis was applied to estimate the odds ratio and the 95% confidence interval. Additionally, the multivariable Logistic regression analyses with restricted cubic splines were conducted to characterize the dose-response association and explore whether the relationship was linear or nonlinear.

Results

Our primary finding indicates that for each one-beat increase in HRAT, there is a 2.8% reduction in the adjusted risk of CAD in the general population. Similarly, a one-beat increase in HRRCP corresponds to a 2.6% reduction in the adjusted risk of CAD. Subgroup analyses revealed significant interactions between HRAT and factors such as sex, hypertension, and lung cancer, as well as between HRRCP and sex and hypertension, in relation to CAD. The dose-response analysis further confirmed that higher HRAT and HRRCP are associated with a reduced risk of CAD.

Conclusion

These results are suggestive of a good association between HRAT, HRRCP, and CAD. The lower HRAT, and HRRCP are signs of poor HR response to exercise in CAD. HRAT and HRRCP are potentially good indicators of poor HR response to exercise without considering maximal effort.

Short-term outcomes of robotic left ventricular patch ventriculoplasty for significant mitral annular calcification

Objective

Surgical management of mitral annular calcification remains challenging. Our institution pursued a strategy of total mitral annular calcification resection with pericardial patch reconstruction of the left ventricle when primary atrioventricular groove closure was not possible. We present the short-term outcomes derived after implementing this strategy.

Methods

A single-institution retrospective analysis included patients with significant mitral annular calcification undergoing totally endoscopic robotic mitral valve surgery between October 2009 and August 2023. Mitral valve repair was performed in patients with sufficient posterior leaflet length. Patients requiring pericardial patch ventriculoplasty were compared with those in whom primary atrioventricular groove closure was possible (non-pericardial patch ventriculoplasty).

Results

Of 1441 patients who underwent totally endoscopic mitral valve surgery, 217 (15.1%) presented with significant mitral annular calcification. Pericardial patch ventriculoplasty was performed in 69 patients (31.8%). Patients undergoing non-pericardial patch ventriculoplasty were significantly younger than patients undergoing pericardial patch ventriculoplasty (63.4 vs 67.8 years, P = .01). Mitral valve repair was conducted in 145 patients (98.0%) in the non-pericardial patch ventriculoplasty group versus 56 patients (81.2%) in the pericardial patch ventriculoplasty group (P < .01). The median postoperative length of stay was significantly shorter in the non-pericardial patch ventriculoplasty group (3 vs 5 days, P < .01). There was no significant difference in postoperative stroke (0.7% vs 2.9%, P = .50) or 30-day mortality (1.4% vs 1.4%, P = 1.00). Three-year survival was comparable between the groups (97.4% vs 93.7%, P = .52).

Conclusions

Totally endoscopic robotic mitral valve repair is a safe and feasible technique for the management of mitral annular calcification with promising results at 3 years. Patients who required atrioventricular groove pericardial patch reconstruction had similar outcomes to those in whom primary closure was possible.

Evaluation and management of coronary artery disease in transcatheter aortic valve implantation candidates with severe aortic stenosis and coronary artery disease: technology and techniques

INTRODUCTION

Patients with severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI) often present with concomitant coronary artery disease (CAD). The management of CAD in these patients remains a topic of debate, encompassing the evaluation and timing of percutaneous coronary intervention (PCI).

AREAS COVERED

This review article aims to offer an overview of the role of coronary revascularization in TAVI patients, highlighting the advantages and disadvantages of different strategies: PCI before, concomitant with, and after TAVI. Considering that TAVI indications are expanding and patients with low surgical risk are now being referred for TAVI, the rate of PCI among patients undergoing TAVI is expected to increase. Historically, PCI was performed before TAVI. However, there is now a growing trend to defer PCI until after TAVI.

EXPERT OPINION

It is plausible that in the future, there will be an increase in PCI after TAVI due to several factors: first, multiple studies have shown the safety of TAVI even in patients with severe untreated CAD; second, improvements in TAVI device implantation techniques, such as commissural alignment and patient-specific device selection, have improved access to the coronary arteries post-TAVI.

Prognostic Value of Pulmonary Artery Systolic Pressure in Severe Rheumatic Mitral Stenosis

BACKGROUND

Current guidelines recommend intervention for asymptomatic rheumatic mitral stenosis (MS) with mitral valve area ≤1.5 cm2 based on indicators including pulmonary arterial systolic pressure (PASP) >50 mm Hg and new-onset atrial fibrillation; however, evidence supporting this is lacking.

METHODS

This single-center retrospective study included patients with rheumatic MS between 2006 and 2022. Pulmonary hypertension was evaluated by using echocardiography to estimate PASP. Primary outcomes were major adverse cardiovascular events (MACE), including all-cause mortality, hospitalization for heart failure, and arterial thromboembolic events for up to 5 years.

RESULTS

Overall, 287 patients with severe rheumatic MS were enrolled (mean age, 62.5±11.3 years; 74.6% women). During a median follow-up of 2.52 years, MACE occurred in 99 patients. There were no differences in echocardiographic parameters, such as the mean mitral valve pressure gradient, mitral valve area, and proportion of mitral valve area <1.0 cm2, between patients who developed primary outcomes and those who did not. Survival analysis showed a worse prognosis in patients with estimated PASP (ePASP) >50 mm Hg than in those with ePASP ≤50 mm Hg (log-rank P<0.001); however, atrial fibrillation was not a significant prognostic indicator. As a continuous variable, ePASP (mm Hg) was a significant predictor of MACE (adjusted hazard ratio, 1.027 [95% CI, 1.011-1.042]; P<0.001). Receiver operating characteristic analysis revealed an optimal ePASP threshold of >45 mm Hg, which was an independent predictor of MACE in patients with severe rheumatic MS (adjusted hazard ratio, 2.127 [95% CI, 1.424-3.177]; P<0.001). Competing risk analysis considering mitral valve intervention as a competing risk showed similar results.

CONCLUSIONS

Our study demonstrated the prognostic significance of ePASP, rather than atrial fibrillation, in relation to MACE among patients with severe rheumatic MS. Additionally, we proposed a lower ePASP threshold (>45 mm Hg) as a predictor of an unfavorable prognosis.

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.

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.

An Updated Comprehensive Review of Existing Transcatheter Aortic Valve Replacement Access

For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).

Identifying the Severity of Heart Valve Stenosis and Regurgitation Among a Diverse Population Within an Integrated Health Care System: Natural Language Processing Approach

BACKGROUND

Valvular heart disease (VHD) is a leading cause of cardiovascular morbidity and mortality that poses a substantial health care and economic burden on health care systems. Administrative diagnostic codes for ascertaining VHD diagnosis are incomplete.

OBJECTIVE

This study aimed to develop a natural language processing (NLP) algorithm to identify patients with aortic, mitral, tricuspid, and pulmonic valve stenosis and regurgitation from transthoracic echocardiography (TTE) reports within a large integrated health care system.

METHODS

We used reports from echocardiograms performed in the Kaiser Permanente Southern California (KPSC) health care system between January 1, 2011, and December 31, 2022. Related terms/phrases of aortic, mitral, tricuspid, and pulmonic stenosis and regurgitation and their severities were compiled from the literature and enriched with input from clinicians. An NLP algorithm was iteratively developed and fine-trained via multiple rounds of chart review, followed by adjudication. The developed algorithm was applied to 200 annotated echocardiography reports to assess its performance and then the study echocardiography reports.

RESULTS

A total of 1,225,270 TTE reports were extracted from KPSC electronic health records during the study period. In these reports, valve lesions identified included 111,300 (9.08%) aortic stenosis, 20,246 (1.65%) mitral stenosis, 397 (0.03%) tricuspid stenosis, 2585 (0.21%) pulmonic stenosis, 345,115 (28.17%) aortic regurgitation, 802,103 (65.46%) mitral regurgitation, 903,965 (73.78%) tricuspid regurgitation, and 286,903 (23.42%) pulmonic regurgitation. Among the valves, 50,507 (4.12%), 22,656 (1.85%), 1685 (0.14%), and 1767 (0.14%) were identified as prosthetic aortic valves, mitral valves, tricuspid valves, and pulmonic valves, respectively. Mild and moderate were the most common severity levels of heart valve stenosis, while trace and mild were the most common severity levels of regurgitation. Males had a higher frequency of aortic stenosis and all 4 valvular regurgitations, while females had more mitral, tricuspid, and pulmonic stenosis. Non-Hispanic Whites had the highest frequency of all 4 valvular stenosis and regurgitations. The distribution of valvular stenosis and regurgitation severity was similar across race/ethnicity groups. Frequencies of aortic stenosis, mitral stenosis, and regurgitation of all 4 heart valves increased with age. In TTE reports with stenosis detected, younger patients were more likely to have mild aortic stenosis, while older patients were more likely to have severe aortic stenosis. However, mitral stenosis was opposite (milder in older patients and more severe in younger patients). In TTE reports with regurgitation detected, younger patients had a higher frequency of severe/very severe aortic regurgitation. In comparison, older patients had higher frequencies of mild aortic regurgitation and severe mitral/tricuspid regurgitation. Validation of the NLP algorithm against the 200 annotated TTE reports showed excellent precision, recall, and F1-scores.

CONCLUSIONS

The proposed computerized algorithm could effectively identify heart valve stenosis and regurgitation, as well as the severity of valvular involvement, with significant implications for pharmacoepidemiological studies and outcomes research.

What Do We Know about Peripartum Cardiomyopathy? Yesterday, Today, Tomorrow

Peripartum cardiomyopathy is a disease that occurs during or after pregnancy and leads to a significant decline in cardiac function in previously healthy women. Peripartum cardiomyopathy has a varying prevalence among women depending on the part of the world where they live, but it is associated with a significant mortality and morbidity in this population. Therefore, timely diagnosis, treatment, and monitoring of this disease from its onset are of utmost importance. Although many risk factors are associated with the occurrence of peripartum cardiomyopathy, such as conditions of life, age of the woman, nutrient deficiencies, or multiple pregnancies, the exact cause of its onset remains unknown. Advances in research on the genetic associations with cardiomyopathies have provided a wealth of data indicating a possible association with peripartum cardiomyopathy, but due to numerous mutations and data inconsistencies, the exact connection remains unclear. Significant insights into the pathophysiological mechanisms underlying peripartum cardiomyopathy have been provided by the theory of an abnormal 16-kDa prolactin, which may be generated in an oxidative stress environment and lead to vascular and consequently myocardial damage. Recent studies supporting this disease mechanism also include research on the efficacy of bromocriptine (a prolactin synthesis inhibitor) in restoring cardiac function in affected patients. Despite significant progress in the research of this disease, there are still insufficient data on the safety of use of certain drugs treating heart failure during pregnancy and breastfeeding. Considering the metabolic changes that occur in different stages of pregnancy and the postpartum period, determining the correct dosing regimen of medications is of utmost importance not only for better treatment and survival of mothers but also for reducing the risk of toxic effects on the fetus.

Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves

OBJECTIVE

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

METHODS

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

RESULTS

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

CONCLUSION

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

Multi-modality artificial intelligence-based transthyretin amyloid cardiomyopathy detection in patients with severe aortic stenosis

PURPOSE

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a frequent concomitant condition in patients with severe aortic stenosis (AS), yet it often remains undetected. This study aims to comprehensively evaluate artificial intelligence-based models developed based on preprocedural and routinely collected data to detect ATTR-CM in patients with severe AS planned for transcatheter aortic valve implantation (TAVI).

METHODS

In this prospective, single-center study, consecutive patients with AS were screened with [99mTc]-3,3-diphosphono-1,2-propanodicarboxylic acid ([99mTc]-DPD) for the presence of ATTR-CM. Clinical, laboratory, electrocardiogram, echocardiography, invasive measurements, 4-dimensional cardiac CT (4D-CCT) strain data, and CT-radiomic features were used for machine learning modeling of ATTR-CM detection and for outcome prediction. Feature selection and classifier algorithms were applied in single- and multi-modality classification scenarios. We split the dataset into training (70%) and testing (30%) samples. Performance was assessed using various metrics across 100 random seeds.

RESULTS

Out of 263 patients with severe AS (57% males, age 83 ± 4.6years) enrolled, ATTR-CM was confirmed in 27 (10.3%). The lowest performances for detection of concomitant ATTR-CM were observed in invasive measurements and ECG data with area under the curve (AUC) < 0.68. Individual clinical, laboratory, interventional imaging, and CT-radiomics-based features showed moderate performances (AUC 0.70-0.76, sensitivity 0.79-0.82, specificity 0.63-0.72), echocardiography demonstrated good performance (AUC 0.79, sensitivity 0.80, specificity 0.78), and 4D-CT-strain showed the highest performance (AUC 0.85, sensitivity 0.90, specificity 0.74). The multi-modality model (AUC 0.84, sensitivity 0.87, specificity 0.76) did not outperform the model performance based on 4D-CT-strain only data (p-value > 0.05). The multi-modality model adequately discriminated low and high-risk individuals for all-cause mortality at a mean follow-up of 13 months.

CONCLUSION

Artificial intelligence-based models using collected pre-TAVI evaluation data can effectively detect ATTR-CM in patients with severe AS, offering an alternative diagnostic strategy to scintigraphy and myocardial biopsy.

Effect of Vascular Senescence on the Efficacy and Safety of Warfarin: Insights from Rat Models and a Prospective Cohort Study

Warfarin, with its narrow therapeutic range, requires the understanding of various influencing factors for personalized medication. Vascular senescence, marked by vascular stiffening and endothelial dysfunction, has an unclear effect on the efficacy and safety of warfarin. Based on previous studies, we hypothesized that vascular senescence increases the risk of bleeding during warfarin therapy. This study aimed to explore these effects using animal models and clinical cohorts. We established rat models of vascular senescence and calcification using d-galactose, vitamin D, and nicotine. After validating the models, we examined changes in the international normalized ratio (INR) at fixed warfarin doses (0.20 and 0.35 mg/kg). We found that vascular senescence caused significantly elevated INR values and increased bleeding risk. In the prospective clinical cohort study (NCT06428110), hospitalized warfarin patients with standard dose adjustments were divided into vascular senescence and control groups based on ultrasound and computed tomography diagnosis. Using propensity score matching to exclude the influence of confounding factors, we found that the vascular senescence group had lower steady-state warfarin doses and larger dose adjustments, with a higher probability of INR exceeding the therapeutic range. The vascular senescence group tended to experience more bleeding or thromboembolic/ischemic events during 1 year of follow-up, while there was no statistical difference. In conclusion, vascular senescence leads to unstable INR values and increases higher bleeding risk during warfarin therapy, highlighting the importance of considering vascular senescence in future precision warfarin therapies. SIGNIFICANCE STATEMENT: Many factors influence warfarin efficacy; however, the effect of vascular senescence remains unclear. This study aimed to investigate the effects of vascular senescence on the efficacy and safety of warfarin. Through both rat models and clinical cohort studies, our findings indicated that vascular senescence may compromise the stability of warfarin, presenting challenges in maintaining its efficacy and safety.

Cellular and extracellular proteomic profiling of paradoxical low-flow low-gradient aortic stenosis myocardium

Aims

Patients with severe aortic stenosis (AS), low transvalvular flow (LF) and low gradient (LG) with normal ejection fraction (EF)-are referred to as paradoxical LF-LG AS (PLF-LG). PLF-LG patients develop more advanced heart failure symptoms and have a worse prognosis than patients with normal EF and high-gradient AS (NEF-HG). Despite its clinical relevance, the mechanisms underlying PLF-LG are still poorly understood.

Methods

Left ventricular (LV) myocardial biopsies of PLF-LG (n = 5) and NEF-HG patients (n = 6), obtained during transcatheter aortic valve implantation, were analyzed by LC-MS/MS after sequential extraction of cellular and extracellular matrix (ECM) proteins using a three-step extraction method. Proteomic data are available via ProteomeXchange with identifier PXD055391.

Results

73 cellular proteins were differentially abundant between the 2 groups. Among these, a network of proteins related to muscle contraction and arrhythmogenic cardiomyopathy (e.g., cTnI, FKBP1A and CACNA2D1) was found in PLF-LG. Extracellularly, upregulated proteins in PLF-LG were related to ATP synthesis and oxidative phosphorylation (e.g., ATP5PF, COX5B and UQCRB). Interestingly, we observed a 1.3-fold increase in cyclophilin A (CyPA), proinflammatory cytokine, in the extracellular extracts of PLF-LG AS patients (p < 0.05). Consistently, immunohistochemical analysis confirmed its extracellular localization in PLF-LG AS LV sections along with an increase in its receptor, CD147, compared to the NEF-HG AS patients. Levels of core ECM proteins, namely collagens and proteoglycans, were comparable between groups.

Conclusion

Our study pinpointed novel candidates and processes with potential relevance in the pathophysiology of PLF-LG. The role of CyPA in particular warrants further investigation.

Transcatheter Aortic Valve Replacement is Ready for Most Low-risk Patients: A Systematic Review of the Literature

Transcatheter aortic valve replacement (TAVR) has undergone rapid expansion, emerging as a viable therapeutic option for low-risk patients in lieu of surgical aortic valve replacement. This paper aims to provide a review of the scientific evidence concerning TAVR in low-risk patients, encompassing both observational and clinical trial data. Furthermore, a substantial proportion of low-risk patients possesses a bicuspid aortic valve, necessitating careful examination of the pertinent anatomic and clinical considerations to TAVR that is highlighted in this review. Additionally, the review expands upon some of the unique challenges associated with alternate access in low-risk patients evaluated for TAVR. Last, this review outlines the pivotal role of a multidisciplinary heart team approach in the execution of all TAVR procedures and the authors' vision of 'minimalist TAVR' as a new era in low-risk TAVR.

Floppy Mitral Valve/Mitral Valve Prolapse and Manifestations Not Related to Mitral Regurgitation: Time to Search the Dark Side of the Moon

BACKGROUND

Floppy mitral valve/mitral valve prolapse (FMV/MVP) is a complex entity in which several clinical manifestations are not directly related to the severity of mitral regurgitation (MR).

SUMMARY

Patients with FMV/MVP and trivial to mild MR may have exercise intolerance, orthostatic phenomena, syncope/presyncope, chest pain, and ventricular arrhythmias, among others. Several anatomical and pathophysiologic consequences related to the abnormal mitral valve apparatus and to prolapse of the mitral leaflets into the left atrium provide some explanation for these symptoms. Further, it should be emphasized that MVP is a non-specific finding, while FMV (redundant mitral leaflets, elongated/rupture chordae tendineae, annular dilatation) is the central issue in the MVP story.

KEY MESSAGE

The purpose of this review was to highlight the clinical manifestations of FMV/MVP not directly related to the severity of MR and to discuss the pathophysiologic mechanisms contributing to these manifestations.