2021 ESC/EACTS Guidelines for the management of valvular heart disease

Edge-to-edge repair for tricuspid regurgitation: 1-year follow-up and clinical implications from the TR-Interventional Study

AIMS

Tricuspid regurgitation affects 7% of the population, with moderate-to-severe tricuspid regurgitation contributing to up to 12% of heart failure-related hospitalizations. Traditional treatments have several limitations, prompting the exploration of innovative interventions. Our study aims to investigate the efficacy and clinical outcomes following transcatheter edge-to-edge repair (TEER) in patients with severe, symptomatic tricuspid regurgitation through a 1-year follow-up.

METHODS

The TR-Interventional study (TRIS) is a prospective, single-arm study conducted at the Fondazione Policlinico Universitario Campus Bio-Medico. From March 2021 to December 2023, we enrolled 44 symptomatic patients with at least severe tricuspid regurgitation referred for tricuspid TEER with the TriClip System.

RESULTS

The study cohort had a mean age of 78.3 ± 7 years with a median TRISCORE 5.4% (interquartile range 3.5-9.0). Significant reduction in tricuspid regurgitation grade occurred immediately after the procedure with durable results at 30 days and 1-year follow-up (P < 0.001). The primary efficacy endpoint, which assesses the successful implantation and performance of the device at 30 days, was attained in 82.9% of patients. The secondary efficacy endpoint, evaluating the stability of tricuspid regurgitation reduction at 12 months, was achieved in 82.3% of patients. The NYHA Functional Class and KCCQ scores significantly improved from baseline to 1 year (P < 0.05; P < 0.0001). Echocardiographic assessments reveal sustained positive right ventricle remodeling throughout the 1-year follow-up period.

CONCLUSION

Evidence from the TRIS study confirms that tricuspid TEER is a valuable and effective therapeutic option in contemporary practice. The lasting reduction in tricuspid regurgitation at 1 year is associated with sustained clinical benefits and reverse structural remodeling of the right ventricle.

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.

Management of Acute Ischemic Stroke Following Transcatheter Aortic Valve Implantation: A Systematic Review and Multidisciplinary Treatment Recommendations

Background/Objectives: Acute ischemic stroke is an uncommon but potentially devastating complication of Transcatheter Aortic Valve Implantation (TAVI). Despite improvements in device technology and procedural techniques, stroke rates have remained stable, with cerebral embolic protection devices demonstrating only limited efficacy to date. Therefore, the management of acute ischemic stroke complicating TAVI (AISCT) remains a key priority. We conducted a systematic review of the management of AISCT and provided multidisciplinary consensus recommendations for optimal management. Methods: PubMed, Google Scholar, and Cochrane databases were searched from inception to October 2023. All the original studies focusing on the treatment of AISCT were included. Non-English language studies, review articles, and studies in pediatric populations were excluded. Consensus recommendations were made by a working group comprising experts in stroke medicine and structural interventional cardiology. Results: A total of 18 studies met the inclusion criteria, including 14 case reports/series and 4 observational studies. No clinical trials were identified. The included case reports and series suggest that tissue-type plasminogen activator (tPA) and mechanical thrombectomy (MT) might be effective strategies for managing AISCT. However, significant bleeding complications were reported in two out of the four patients receiving tPA. Four observational studies also suggest an association between tPA and/or MT and improved functional outcomes and survival compared to conservative management. Higher bleeding rates were reported following tPA. Observational data suggest that there is currently little real-world utilization of either reperfusion strategy. Conclusions: There is an absence of high-quality randomized data to guide clinical decision making in this important area. Observational data suggest reperfusion strategies are associated with improved clinical outcomes once important confounders such as stroke severity have been accounted for. While MT can be recommended as the standard of care in appropriately selected patients, significantly increased rates of bleeding with tPA following large-bore arterial access raise important safety concerns. We present simple clinical guidance for AISCT based on the limited available data. Close multidisciplinary work and patient-specific consideration of ischemic and bleeding risk is essential.

ECMO in the Management of Noncardiogenic Pulmonary Edema with Increased Inflammatory Reaction After Cardiac Surgery: A Case Report and Literature Review

Noncardiogenic pulmonary edema after cardiac surgery is a rare but severe complication. The etiology remains poorly understood; however, the issue may arise from multiple sources. Possible causes include a significant inflammatory response or an autoimmune process. Pulmonary edema resulting from noncardiac etiologies can necessitate extracorporeal membrane oxygenation (ECMO) because most of the cases present a substantial volume of fluid expelled from the lungs and the medical team must manage the inability to achieve effective ventilation. A 64-year-old patient with known heart disease was admitted to our clinic with acute pulmonary edema. His medical history included Barlow's disease, severe mitral regurgitation (IIP2), moderate-severe tricuspid regurgitation, and moderate pulmonary hypertension. The patient had a coronary angiography performed in a prior hospitalization before the surgical intervention which indicated the absence of coronary lesions. Preoperative screening (nasal, pharyngeal exudate, inguinal pouch culture, and urine culture) was negative, with no active dental infections. The patient was stabilized, and 14 days post-admission, mitral and tricuspid valve repair was performed via a thoracoscopic approach. After being admitted to intensive care post-surgery, the patient quickly developed pulmonary edema, producing a large volume (4.5 L) of yellow secretions through the intubation tube followed by hemodynamic instability necessitating high doses of medications to support circulation but no cardiorespiratory arrest. Due to his worsening condition, the patient was urgently taken back to the operating room, where veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated to support oxygenation and stabilize the patient.

Cerebral Embolic Protection: Is There a Benefit for Left Atrial and Mitral Valve Procedures?

PURPOSE OF REVIEW

This review aims to highlight the current evidence on the use of cerebral embolic protection devices (CEPD) in left atrial and transcatheter mitral valve procedures. It also aims to summarize the antithrombotic management of patients undergoing such procedures.

RECENT FINDINGS

Ischemic stroke is one of the most devastating complications of structural heart procedures. The manifestation of periprocedural stroke can range from asymptomatic and detectable only through brain imaging to major stroke with neurological deficits. CEP devices were initially developed to mitigate the risk of stroke associated with transcatheter aortic valve replacement (TAVR). However, the efficacy of such devices during different cardiac interventions is yet to be fully demonstrated, especially in left atrial appendage closure (LAAO), and mitral valve interventions. Few studies demonstrated that the risk of periprocedural strokes after LAAO and mitral valve interventions is not negligible and is highest during the periprocedural period and then falls. The majority of patients undergoing those procedures have cerebral ischemic injuries detected on diffusion-weighted magnetic resonance imaging (DW-MRI). Moreover, a reasonable number of those patients had debris embolization on the filters of the CEPD. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is crucial and should be tailored to each patient's risk of bleeding and ischemia. Close monitoring that includes a full neurological assessment and frequent follow-up visits with cardiac echocardiography are important. The risk of periprocedural stroke in left atrial and transcatheter mitral valve procedures is not negligible. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is important to mitigate the risk of stroke, especially the long-term risk. More prospective studies are needed to assess the efficacy of CEPD in such procedures.

Five-Year Multiple Comparison of Transcatheter Aortic Valves: Insights From the OBSERVANT II study

BACKGROUND

Head-to-head comparisons of second and third generations of transcatheter heart valves (THVs) are mostly limited to 2-arm studies and to mid-term follow-up. The aim of this study was to simultaneously compare clinical outcomes of transcatheter aortic valve replacement (TAVR) with 4 different THVs at 5 years.

METHODS

Patients undergoing transfemoral TAVR with 4 second-generation THV platforms and enrolled in the multicentre prospective OBSERVANT II study from December 2016 to September 2018 were compared according to the THV received. Outcomes were adjudicated through a linkage with administrative databases and adjusted by means of inverse propensity of treatment weighting (IPTW) based on propensity score. The primary end points were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 5 years. Cumulative rates were reported consecutively for Evolut R/Pro, Sapien 3, Acurate Neo, and Portico groups.

RESULTS

A total of 2493 patients were considered. The median age was 83 years and median EuroSCORE 2 was 4.9%. After IPTW adjustment, the rates of all-cause death (53.6%, 46.7%, 50.5%, and 46.3%; P = 0.06) and MACCE (57.2%, 51.2%, 54.4%, and 50.6%; P = 0.08) did not differ among the groups at 5 years. The rate of rehospitalisation for heart failure (HF) (33.9%, 27.0%, 31.6%, 33.7%; P = 0.02) was significantly lower for Sapien 3 at 5 years.

CONCLUSIONS

Data from real-world practice showed sustained and similar effectiveness of TAVR considering all the available THVs up to 5 years, but Sapien 3 showed a lower rate of rehospitalisation for HF.

Long-term survival after TAVI in low-flow, low-gradient aortic valve stenosis

BACKGROUND

In patients undergoing transcatheter aortic valve implantation (TAVI), the presence of a low-flow, low-gradient (LFLG) status has been associated with higher mortality at short-term follow-up.

AIMS

We aimed to evaluate long-term survival after TAVI in patients with classical (cLFLG) and paradoxical LFLG (pLFLG) aortic stenosis (AS) compared to high-gradient (HG)-AS.

METHODS

Patients undergoing TAVI at our centre with a hypothetical minimum 5-year follow-up were divided into 3 groups: (1) HG-AS (mean gradient [MG] >40 mmHg), (2) cLFLG-AS (MG <40 mmHg, ejection fraction [EF] <50%), and (3) pLFLG-AS (MG <40 mmHg, EF ≥50%). The primary endpoint of the study was all-cause mortality. Propensity score-weighted survival analysis was performed to adjust for possible baseline confounders.

RESULTS

A total of 574 subjects were included (73% HG-AS, 15% pLFLG-AS, 11% cLFLG-AS). The median survival time was 4.8 years, with a maximum of 12.3 years. Patients with cLFLG-AS presented the highest baseline cardiovascular risk. At unadjusted survival analysis, patients with cLFLG-AS showed the worst long-term prognosis, with a rapid decrease in survival within the first year, while pLFLG- and HG-AS patients presented similar survival rates (p=0.023). At weighted long-term analysis, cLFLG- and HG-AS had similar survival rates. Baseline EF was not related to long-term mortality, while patients with a post-TAVI left ventricular ejection fraction (LVEF) improvement >10% lived significantly longer (p=0.02).

CONCLUSIONS

Classical LFLG-AS patients had lower long-term survival rates as compared to pLFLG-AS and HG-AS patients. However, after adjustment for possible baseline confounders, a low-flow status per se did not have an impact on long-term mortality after TAVI. Post-TAVI LVEF recovery was associated with improved long-term outcome.

Prevention of left ventricular outflow tract obstruction in transapical mitral valve replacement: the MitraCut procedure

BACKGROUND

The MitraCut procedure employs beating heart transapical (TA) cannulation and endoscopic scissors for dividing the anterior mitral leaflet (AML) to prevent left ventricular outflow tract (LVOT) obstruction in transapical transcatheter mitral valve replacement (TA-TMVR).

AIMS

We present the first multicentre experience of the MitraCut procedure prior to TA-TMVR to prevent LVOT obstruction.

METHODS

In 6 European centres, the clinical outcomes of all 13 high-risk patients who had undergone the MitraCut procedure during TA-TMVR procedures were retrospectively reviewed regarding technical success, procedural details and outcome.

RESULTS

The MitraCut procedure was successfully completed in 11 patients with 1 cutting attempt, while 2 patients had 2 cutting attempts, with an average procedure duration of 9.0±5.4 min. No patient demonstrated postoperative LVOT obstruction, and all mitral valve (MV) prostheses were competent throughout the follow-up period. However, 1 patient developed a MitraCut-related paravalvular leak (PVL; technical success rate: 12/13). The mean LVOT gradient was 3.9±4.4 mmHg directly after valve expansion and 3.6±3.1 mmHg at follow-up. In-hospital and 30-day mortality were 0%. One patient experiencing MitraCut-related PVL was successfully treated by interventional PVL closure (reintervention rate: n=1). One patient died at 47 days due to cardiac arrhythmia, unrelated to the AML-directed procedure. The mean follow-up at the time of data analysis was 52±34 days.

CONCLUSIONS

The MitraCut procedure was effective and reproducible for preventing potential LVOT obstruction in TA-TMVR patients during its initial exploration in 6 European hospitals. Considerations regarding the scissors' characteristics, their handling and cut length are mandatory for safe performance of the procedure.

Impact of prior coronary artery bypass grafting and coronary lesion complexity on outcomes of transcatheter aortic valve replacement for severe aortic stenosis

OBJECTIVE

To investigate the impact of prior coronary artery bypass grafting (CABG) and coronary lesion complexity on transcatheter aortic valve replacement (TAVR) outcomes for aortic stenosis.

METHODS

Clinical outcomes of TAVR were retrospectively compared between patients with and without prior CABG, and between patients with prior CABG and without coronary artery disease (CAD). The impact of the CABG SYNTAX score was also evaluated in patients with prior CABG.

RESULTS

The study included 1042 patients with a median age and follow-up of 82 years and 25 (range: 0-72) months, respectively. Of these, 175 patients had a history of CABG, while 401 were free of CAD. Patients with prior CABG were more likely to be male and had higher rates of diabetes, peripheral artery disease and atrial fibrillation compared with patients without prior CABG. After 2 : 1 propensity score matching, all-cause mortality ( P  = 0.17) and the composite of all-cause mortality, stroke and coronary intervention ( P  = 0.16) were similar between patients with (n = 166) and without (n = 304) prior CABG. A 1 : 1 propensity score-matched analysis, however, showed lower rates of all-cause mortality ( P  = 0.04) and the composite outcome ( P  = 0.04) in patients with prior CABG (n = 134) compared with patients without CAD (n = 134). The median CABG SYNTAX score was 16 (interquartile range: 9.0-23), which was not associated with better/worse clinical outcomes in patients with prior CABG.

CONCLUSION

Prior CABG may positively affect mid-term TAVR outcomes for aortic stenosis compared with no CAD when adjusted for other comorbidities. The CABG SYNTAX score did not influence the prognosis after TAVR.

Early clinical and hemodynamic outcomes of balloon-expandable versus self-expanding transcatheter aortic valve replacement in patients with large aortic annulus: a study-level meta-analysis

Purpose

This study aimed to compare early clinical and hemodynamic outcomes of transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis and large aortic annulus using either balloon-expandable valves (BEVs) or self-expanding valves (SEVs).

Methods

A comprehensive search of PubMed, Scopus, and the Cochrane Central Register of Controlled Trials was conducted through September 10, 2023, to perform a meta-analysis comparing the clinical outcomes of BEV versus SEV for large aortic annulus (annulus perimeter ≥ 80 mm).

Results

Seven studies (one propensity-matched study and six observational studies) met our eligibility criteria, including a total of 2167 patients (BEV, 1521; SEV, 646). The rates of procedural stroke (pooled odds ratio 0.55, 95% confidence interval 0.32-0.98), valve embolization (0.11, 0.05-0.24), need for second valve implantation (0.21, 0.17-0.26), permanent pacemaker implantation (0.43, 0.28-0.67), and aortic regurgitation ≥ moderate (0.23, 0.08-0.68) were significantly lower in the BEV group. Conversely, postoperative transvalvular gradient was significantly lower in the SEV group (pooled standard mean difference 0.55, 0.12-0.98). Subgroup analysis with newer-generation valves also showed significant differences in the need for second valve implantation and permanent pacemaker implantation, as well as aortic regurgitation ≥ moderate, favoring BEVs.

Conclusions

BEV provides better early outcomes in TAVR for large aortic annulus in terms of lower rates of stroke, valve embolization, need for second valve, permanent pacemaker implantation, and aortic regurgitation ≥ moderate. Conversely, SEV provides a better transvalvular gradient in the early period after TAVR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01770-1.

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.

Outcomes and Complications of Mitral and Tricuspid Transcatheter Edge-to-edge Repair

In the realm of innovative medical procedures, TEER (transcatheter edge-to-edge repair) has emerged as a promising field, showcasing significant growth and advancements. Mitral TEER has been performed for the last two decades; in contrast, tricuspid TEER is newer, with long-term outcomes pending. This article aims to provide a comprehensive review of the current literature, with a primary focus on outcomes and potential complications associated with both procedures. Both procedures carry a low risk of complications when done by experienced providers. A team approach involving specialists in cardiology, cardiothoracic surgery, cardiac imaging and heart failure ensures comprehensive care. A unified approach encompassing preprocedural workup, risk assessment, and standardised care throughout the procedure and recovery contributes to successful outcomes.

Device therapies for heart failure with reduced ejection fraction: a new era

Even with significant advancements in the treatment modalities for patients with heart failure (HF), the rates of morbidity and mortality associated with HF are still high. Various therapeutic interventions, including cardiac resynchronization therapy, Implantable Cardiovascular-Defibrillators, and left ventricular assist devices, are used for HF management. Currently, more research and developments are required to identify different treatment modalities to reduce hospitalization rates and improve the quality of life of patients with HF. In relation to this, various non-valvular catheter-based therapies have been recently developed for managing chronic HF. These devices target the pathophysiological processes involved in HF development including neurohumoral activation, congestion, and left ventricular remodeling. The present review article aimed to discuss the major transcatheter devices used in managing chronic HF. The rationale and current clinical developmental stages of these interventions will also be addressed in this review.

Prevalence and contributing factors associated with tricuspid regurgitation among patients underwent echocardiography assessment

BACKGROUND

Tricuspid regurgitation (TR) is common in patients evaluated by echocardiography. However, the prevalence and contributing factors of the disease remain limited. This hospital-based study was designed to analyze adult patients first diagnosed with tricuspid regurgitation by Doppler echocardiography to determine the prevalence and characteristics of clinically meaningful TR.

METHODS

A total of 22,317 patients over the age of 18 who underwent echocardiography at the Cardiac Ultrasound Center of the First Affiliated Hospital of Guangdong Pharmaceutical University from July 1, 2015 to December 31, 2019 were collected. We collected basic information about the patients, including age, gender, history of heart disease, etc. Patients with valvular heart disease were assessed by transthoracic echocardiography. According to the degree of regurgitation and regurgitation, TR was divided into 6 grades (0-5). Pericardial effusion was recorded and bilateral atrial and ventricular diameters were measured. Logistic regression analysis was used to assess risk factors for significant TR (≥ grade 2 reflux).

RESULTS

A total of 2299 significant TR cases were found in people over 18 years old, accounting for 10.3% of the total population. The occurrence of TR was found to be closely related to age. The prevalence rates of significant TR in different groups were: 3.3% in the younger than 45-year-old group, 4.1% in the 46-55-year-old group, 5.8% in the 56-65-year-old group, 10.1% in the 66-75-year-old group, and the prevalence of significant TR rose directly to 22.3% in patients over 75-year-old group. Further logistic regression analysis showed that male, age, pacemaker, congenital heart disease, pericardial effusion, pulmonary hypertension, mitral regurgitation, left ventricular diastolic dysfunction and aortic regurgitation were associated with the occurrence of significant TR. Both RVD and RA-1 were effective predictors of significant TR, with RVD ≥ 33.5 mm having a sensitivity of 0.638, specificity of 0.675, and ROC curve area of 0.722. The sensitivity of RA1 ≥ 45.5 mm was 0.652, the specificity was 0.699, and the area under the ROC curve was 0.736.

CONCLUSIONS

TR is common in people undergoing echocardiography. Gender, age, pacemaker implantation, congenital heart disease, pericardial effusion, pulmonary hypertension, mitral insufficiency, and aortic insufficiency are the influencing factors of TR.

Absolute coronary flow and microvascular resistance before and after transcatheter aortic valve implantation

BACKGROUND

Severe aortic stenosis (AS) is associated with left ventricular (LV) remodelling, likely causing alterations in coronary blood flow and microvascular resistance.

AIMS

We aimed to evaluate changes in absolute coronary flow and microvascular resistance in patients with AS undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Consecutive patients with AS undergoing TAVI with non-obstructive coronary artery disease in the left anterior descending artery (LAD) were included. Absolute coronary flow (Q) and microvascular resistance (Rμ) were measured in the LAD using continuous intracoronary thermodilution at rest and during hyperaemia before and after TAVI, and at 6-month follow-up. Total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac computed tomography. Regional myocardial perfusion (QN) was calculated by dividing absolute flow by the subtended myocardial mass.

RESULTS

In 51 patients, Q and R were measured at rest and during hyperaemia before and after TAVI; in 20 (39%) patients, measurements were also obtained 6 months after TAVI. No changes occurred in resting and hyperaemic flow and resistance before and after TAVI nor after 6 months. However, at 6-month follow-up, a notable reverse LV remodelling resulted in a significant increase in hyperaemic perfusion (QN,hyper: 0.86 [interquartile range {IQR} 0.691.06] vs 1.20 [IQR 0.99-1.32] mL/min/g; p=0.008; pre-TAVI and follow-up, respectively) but not in resting perfusion (QN,rest: 0.34 [IQR 0.30-0.48] vs 0.47 [IQR 0.36-0.67] mL/min/g; p=0.06).

CONCLUSIONS

Immediately after TAVI, no changes occurred in absolute coronary flow or coronary flow reserve. Over time, the remodelling of the left ventricle is associated with increased hyperaemic perfusion.

Feasibility and Safety of Post-Transcatheter Aortic Valve Replacement Coronary Revascularization Guided by Stress Cardiac Imaging

Background: Systematic revascularization of asymptomatic coronary artery stenosis before transcatheter aortic valve replacement (TAVR) is controversial. Purpose: The purpose of this study was to evaluate the feasibility and safety of functional evaluation of coronary artery disease (CAD) followed by selective ischemia-guided percutaneous coronary revascularization following TAVR. Methods: This prospective, bi-centric, single-arm, open-label trial included all patients with severe aortic stenosis (AS) eligible for TAVR and with significant CAD defined as ≥1 coronary stenosis ≥ 70%. Patients with left main stenosis ≥ 50%, proximal left anterior descending artery (LAD) stenosis ≥ 90% or > class 2 Canadian Classification Society (CCS) angina were excluded. Myocardial ischemia was evaluated by stress cardiac imaging one month after TAVR. The primary endpoint was a composite of all-cause death, stroke, major bleeding (Bleeding Academic Research Consotium ≥ 3), major vascular complication (Valve Academic Research Consortium 3 criteria), acute coronary syndrome (ACS) and hospitalization for cardiac causes within 6 months of receiving TAVR. Results: Between June 2020 and June 2022, 64 patients were included in this study. The mean age was 84 ± 5.2 years. CAD mostly involved LAD (n = 27, 42%) with frequent multivessel disease (n = 30, 47%) and calcified lesions (n = 39, 61%). Stress cardiac imaging could be achieved in 70% (n = 46) of the patients, while 30% (n = 18) did not attend the stress test. Significant myocardial ischemia was observed in only three patients (4.5%). At 6-month follow-up, fifteen patients (23%) reached the primary endpoint, including death in six patients (9%), stroke in three patients (5%) and major bleeding in three patients (5%). ACS was observed in only two patients (3%) but both had severe coronary stenosis (≥90%) and did not refer for stress imaging for personal reasons. Hospital readmission (n = 27, 41%) was mostly related to non-cardiac causes (n = 17, 27%). Conclusions: In patients with asymptomatic CAD scheduled to undergo TAVR, a selective ischemia-guided coronary revascularization after TAVR seems to be safe, with a very low rate of ACS and few cases of myocardial ischemia requiring revascularization, despite low adherence to medical follow-up in this elderly population. This strategy could be evaluated in a randomized study.

Real-time analysis of conduction disturbances during TAVR with the CARA monitor

BACKGROUND

The occurrence of conduction disturbances (CDs) remains the most frequent complication of transcatheter aortic valve replacement (TAVR). However, little is known about the timing of electrocardiogram (ECG) changes and CDs during the TAVR procedure.

OBJECTIVE

The objective of this study was to describe ECG changes throughout the TAVR procedure using the CARA monitor.

METHODS

This was a multicenter study including 196 prospectively enrolled patients without preexisting CDs undergoing TAVR. All patients were monitored with the CARA system, which uses a 12-lead ECG to measure PQ and QRS intervals, QRS axis, and variations with each heartbeat at every step: baseline, wire insertion, pre-dilatation, valve deployment, post-dilatation, and end of procedure.

RESULTS

PQ and QRS intervals progressively increased throughout the procedure, with a cumulative increase from 169.2 ± 20.0 ms to 186.0 ± 31.6 ms (P < .001) for the PQ interval and from 101.3 ± 10.5 ms to 126.0 ± 25.4 ms (P < .001) for the QRS interval, from baseline to the end of the procedure. A significant increase in the number of patients with left axis deviation was observed (7.7% at baseline vs 31.8% at end of procedure; P < .001). A total of 161 (82.1%) patients exhibited at least 1 CD episode (PQ >200 ms, QRS ≥120 ms, advanced heart block) during the procedure, with most episodes occurring during pre-dilatation and valve implantation maneuvers.

CONCLUSION

The CARA system facilitated real-time ECG monitoring, detecting subtle and progressive changes during TAVR. ECG changes occurred at each step, with most patients experiencing CDs, especially during pre-dilatation and valve implantation. The potential clinical impact of monitoring ECG dynamics and timing for early detection of severe CDs should be explored in future studies.

Aortic regurgitation: from mechanisms to management

Aortic regurgitation (AR) is a common clinical disease associated with significant morbidity and mortality. Investigations based largely on non-invasive imaging are pivotal in discerning the severity of disease and its impact on the heart. Advances in technology have contributed to improved risk stratification and to our understanding of the pathophysiology of AR. Surgical aortic valve replacement is the predominant treatment. However, its use is limited to patients with an acceptable surgical risk profile. Transcatheter aortic valve implantation is an alternative treatment. However, this therapy remains in its infancy, and further data and experience are required. This review article on AR describes its prevalence, mechanisms, diagnosis and treatment.

Outcomes of transcatheter aortic valve implantation for native aortic valve regurgitation

BACKGROUND

Large datasets of transcatheter aortic valve implantation (TAVI) for pure aortic valve regurgitation (PAVR) are scarce.

AIMS

We aimed to report procedural safety and long-term clinical events (CE) in a contemporary cohort of PAVR patients treated with new-generation devices (NGD).

METHODS

Patients with grade III/IV PAVR enrolled in the FRANCE-TAVI Registry were selected. The primary safety endpoint was technical success (TS) according to Valve Academic Research Consortium 3 criteria. The co-primary endpoint was defined as a composite of mortality, heart failure hospitalisation and valve reintervention at last follow-up.

RESULTS

From 2015 to 2021, 227 individuals (64.3% males, median age 81.0 [interquartile range {IQR} 73.5-85.0] years, with EuroSCORE II 6.0% [IQR 4.0-10.9]) from 41 centres underwent TAVI with NGD, using either self-expanding (55.1%) or balloon-expandable valves (44.9%; p=0.50). TS was 85.5%, with a non-significant trend towards increased TS in high-volume activity centres. A second valve implantation (SVI) was needed in 8.8% of patients, independent of valve type (p=0.82). Device size was ≥29 mm in 73.0% of patients, post-procedure grade ≥III residual aortic regurgitation was rare (1.2%), and the permanent pacemaker implantation (PPI) rate was 36.0%. At 30 days, the incidences of mortality and reintervention were 8.4% and 3.5%, respectively. The co-primary endpoint reached 41.6% (IQR 34.4-49.6) at 1 year, increased up to 61.8% (IQR 52.4-71.2) at 4 years, and was independently predicted by TS, with a hazard ratio of 0.45 (95% confidence interval: 0.27-0.76); p=0.003.

CONCLUSIONS

TAVI with NGD in PAVR patients is efficient and reasonably safe. Preventing the need for an SVI embodies the major technical challenge. Larger implanted valves may have limited this complication, outweighing the increased risk of PPI. Despite successful TAVI, PAVR patients experience frequent CE at long-term follow-up.

Antithrombotic therapy for transcatheter structural heart intervention

Percutaneous transcatheter structural heart interventions have considerably expanded within the last two decades, improving clinical outcomes and quality of life versus guideline-directed medical therapy for patients frequently ineligible for surgical treatment. Transcatheter structural heart interventions comprise valve implantation or repair and also occlusions of the patent foramen ovale, atrial septal defects and left atrial appendage. These procedures expose structural devices to arterial or venous blood flow with various rheological conditions leading to potential thrombotic complications and embolisation. Furthermore, these procedures may concern comorbid patients at high risk of both ischaemic and bleeding complications. This state-of-the-art review provides a description of the device-related thrombotic risk associated with these transcatheter structural heart interventions and of the current evidence-based guidelines regarding antithrombotic treatments. Gaps in evidence for each of the studied transcatheter interventions and the main ongoing trials are also summarised.

Non-Invasive Ultrasound Therapy for Severe Aortic Stenosis: Early Effects on the Valve, Ventricle, and Cardiac Biomarkers (A Case Series)

Background: Transcatheter aortic valve replacement (TAVR) was developed for inoperable patients with severe aortic stenosis. However, despite TAVR advancements, some patients remain untreated due to complex comorbidities, necessitating less-invasive approaches. Non-invasive ultrasound therapy (NIUT), a new treatment modality, has the potential to address this treatment gap, delivering short ultrasound pulses that create cavitation bubble clouds, aimed at softening embedded calcification in stiffened valve tissue. Methods: In the prospective Valvosoft® Serbian first-in-human study, we assessed the safety and efficacy of NIUT and its impact on aortic valve hemodynamics, on the left ventricle, and on systemic inflammation in patients with severe symptomatic aortic stenosis not eligible for TAVR or surgery. Results: Ten patients were included. Significant improvements were observed in hemodynamic parameters from baseline to one month, including a 39% increase in the aortic valve area (from 0.5 cm2 to 0.7 cm2, p = 0.001) and a 23% decrease in the mean transvalvular gradient (from 54 mmHg to 38 mmHg, p = 0.01). Additionally, left ventricular global longitudinal strain significantly rose, while global wasted work significantly declined at one month. A dose-response relationship was observed between treatment parameters (peak acoustic power, intensity spatial-peak pulse-average, and mean acoustic energy) and hemodynamic outcomes. NIUT was safely applied, with no clinically relevant changes in high-sensitivity troponin T or C-reactive protein and with a numerical, but not statistically significant, reduction in brain natriuretic peptide (from 471 pg/mL at baseline to 251 pg/mL at one month). Conclusions: This first-in-human study demonstrates that NIUT is safe and confers statistically significant hemodynamic benefits both on the valve and ventricle.

Navigating the Landscape of Coronary Microvascular Research: Trends, Triumphs, and Challenges Ahead

Coronary microvascular dysfunction (CMD) refers to structural and functional abnormalities of the microcirculation that impair myocardial perfusion. CMD plays a pivotal role in numerous cardiovascular diseases, including myocardial ischemia with non-obstructive coronary arteries, heart failure, and acute coronary syndromes. This review summarizes recent advances in CMD pathophysiology, assessment, and treatment strategies, as well as ongoing challenges and future research directions. Signaling pathways implicated in CMD pathogenesis include adenosine monophosphate-activated protein kinase/Krüppel-like factor 2/endothelial nitric oxide synthase (AMPK/KLF2/eNOS), nuclear factor erythroid 2-related factor 2/antioxidant response element (Nrf2/ARE), Angiotensin II (Ang II), endothelin-1 (ET-1), RhoA/Rho kinase, and insulin signaling. Dysregulation of these pathways leads to endothelial dysfunction, the hallmark of CMD. Treatment strategies aim to reduce myocardial oxygen demand, improve microcirculatory function, and restore endothelial homeostasis through mechanisms including vasodilation, anti-inflammation, and antioxidant effects. Traditional Chinese medicine (TCM) compounds exhibit therapeutic potential through multi-targeted actions. Small molecules and regenerative approaches offer precision therapies. However, challenges remain in translating findings to clinical practice and developing effective pharmacotherapies. Integration of engineering with medicine through microfabrication, tissue engineering and AI presents opportunities to advance the diagnosis, prediction, and treatment of CMD.

Prevalence, mortality, cost, and disparities in transcatheter mitral valve repair and replacement in cancer patients: Artificial intelligence and propensity score national 5-year analysis of 7495 procedures

INTRODUCTION

We conducted the first comprehensive evaluation of the therapeutic value and safety profile of transcatheter mitral edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) in individuals concurrently afflicted with cancer.

METHODS

Utilizing the National Inpatient Sample (NIS) dataset, we analyzed all adult hospitalizations between 2016 and 2020 (n = 148,755,036). The inclusion criteria for this retrospectively analyzed prospective cohort study were all adult hospitalizations (age 18 years and older). Regression and machine learning analyses in addition to model optimization were conducted using ML-PSr (Machine Learning-augmented Propensity Score adjusted multivariable regression) and BAyesian Machine learning-augmented Propensity Score (BAM-PS) multivariable regression.

RESULTS

Of all adult hospitalizations, there were 5790 (0.004%) TMVRs and 1705 (0.001%) TEERs. Of the total TMVRs, 160 (2.76%) were done in active cancer. Of the total TEERs, 30 (1.76%) were done in active cancer. After the comparable rates of TEER/TMVR in active cancer in 2016, the prevalence of TEER/TMVR was significantly less in active cancer from 2017 to 2020 (2.61% versus 7.28% p < 0.001). From 2017 to 2020, active cancer significantly decreased the odds of receiving TEER or TMVR (OR 0.28, 95%CI 0.13-0.68, p = 0.008). In patients with active cancer who underwent TMVR/TEER, there were no significant differences in socio-economic disparities, mortality or total hospitalization costs.

CONCLUSION

The presence of malignancy does not contribute to increased mortality, length of stay or procedural costs in TMVR or TEER. Whereas the prevalence of TMVR has increased in patients with active cancer, the utilization of TEER in the context of active cancer is declining despite a growing patient population.

Failure of Surgical Aortic Valve Prostheses: An Analysis of Heart Team Decisions and Postoperative Outcomes

Objectives: To analyze Heart Team decisions and outcomes following failure of surgical aortic valve replacement (SAVR) prostheses. Methods: Patients undergoing re-operations following index SAVR (Redo-SAVR) and those undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) following SAVR were included in this study. Patients who underwent index SAVR and/or Redo-SAVR for endocarditis were excluded. Data are presented as medians and 25th-75th percentiles, or absolute numbers and percentages. Outcomes were analyzed in accordance to the VARC-3 criteria. Results: Between 01/2015 and 03/2021, 53 patients underwent Redo-SAVR, 103 patients ViV-TAVR. Mean EuroSCORE II was 5.7% (3.5-8.5) in the Redo-SAVR group and 9.2% (5.4-13.6) in the ViV group. In the Redo-SAVR group, 12 patients received aortic root enlargement (22.6%). Length of hospital and ICU stay was longer in the Redo-SAVR group (p < 0.001; p < 0.001), PGmax and PGmean were lower in the Redo-SAVR group as compared to the ViV-TAVR group (18 mmHg (10-30) vs. 26 mmHg (19-38), p < 0.001) (9 mmHg (6-15) vs. 15 mmHg (9-21), p < 0.001). A higher rate of paravalvular leakage was seen in the ViV-TAVR group (p = 0.013). VARC-3 Early Safety were comparable between the two populations (p = 0.343). Survival at 1 year and 5 years was 82% and 36% in the ViV-TAVR cohort and 84% and 77% in the Redo-SAVR cohort. The variables were patient age (OR 1.061; [95% CI 1.020-1.104], p = 0.004), coronary heart disease (OR 2.648; [95% CI 1.160-6.048], p = 0.021), and chronic renal insufficiency (OR 2.711; [95% CI 1.160-6.048], p = 0.021) showed a significant correlation to ViV-TAVR. Conclusions: Heart Team decisions are crucial in the treatment of patients with degenerated aortic bioprostheses and lead to a low mortality in both treatment paths thanks to patient-specific therapy planning. ViV-TAVR offers a treatment for elderly or intermediate-risk profile patients with comparable short-term mortality. However, this therapy is associated with increased pressure gradients and a high prevalence of paravalvular leakage. Redo-SAVR enables the surgical treatment of concomitant cardiac pathologies and allows anticipation for later VIV-TAVR by implanting the largest possible valve prostheses.

Durability of transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is now utilised as a less invasive alternative to surgical aortic valve replacement (SAVR) across the whole spectrum of surgical risk. Long-term durability of the bioprosthetic valves has become a key goal of TAVI as this procedure is now considered for younger and lower-risk populations. The purpose of this article is to present a state-of-the-art overview on the definition, aetiology, risk factors, mechanisms, diagnosis, clinical impact, and management of bioprosthetic valve dysfunction (BVD) and failure (BVF) following TAVI with a comparative perspective versus SAVR. Structural valve deterioration (SVD) is the main factor limiting the durability of the bioprosthetic valves used for TAVI or SAVR, but non-structural BVD, such as prosthesis-patient mismatch and paravalvular regurgitation, as well as valve thrombosis or endocarditis may also lead to BVF. The incidence of BVF related to SVD or other causes is low (<5%) at midterm (5- to 8-year) follow-up and compares favourably with that of SAVR. The long-term follow-up data of randomised trials conducted with the first generations of transcatheter heart valves also suggest similar valve durability in TAVI versus SAVR at 10 years, but these trials suffer from major survivorship bias, and the long-term durability of TAVI will need to be confirmed by the analysis of the low-risk TAVI versus SAVR trials at 10 years.

Clinical outcomes and predictors of transapical transcatheter mitral valve replacement: the Tendyne Expanded Clinical Study

BACKGROUND

Transcatheter mitral valve replacement (TMVR) is a therapeutic option for patients with severe mitral regurgitation (MR) who are ineligible for conventional surgery. There are limited data on the outcomes of large patient cohorts treated with TMVR.

AIMS

This study aimed to investigate the outcomes and predictors of mortality for patients treated with transapical TMVR.

METHODS

This analysis represents the clinical experience of all patients enrolled in the Tendyne Expanded Clinical Study. Patients with symptomatic MR underwent transapical TMVR with the Tendyne system between November 2014 and June 2020. Outcomes and adverse events up to 2 years, as well as predictors of short-term mortality, were assessed.

RESULTS

A total of 191 patients were treated (74.1±8.0 years, 62.8% male, Society of Thoracic Surgeons Predicted Risk of Mortality 7.7±6.6%). Technical success was achieved in 96.9% (185/191), and there were no intraprocedural deaths. At 30-day, 1- and 2-year follow-up, the rates of all-cause mortality were 7.9%, 30.8% and 40.5%, respectively. Complete MR elimination (MR <1+) was observed in 99.3%, 99.1% and 96.3% of patients, respectively. TMVR treatment resulted in consistent improvement of New York Heart Association Functional Class and quality of life up to 2 years (both p<0.001). Independent predictors of early mortality were age (odds ratio [OR] 1.11; p=0.003), pulmonary hypertension (OR 3.83; p=0.007), and institutional experience (OR 0.40; p=0.047).

CONCLUSIONS

This study investigated clinical outcomes in the full cohort of patients included in the Tendyne Expanded Clinical Study. The Tendyne TMVR system successfully eliminated MR with no intraprocedural deaths, resulting in an improvement in symptoms and quality of life. Continued refinement of clinical and echocardiographic risks will be important to optimise longitudinal outcomes.

Gender-Specific Medicine in the European Society of Cardiology Guidelines from 2018 to 2023: Where Are We Going?

Background/Objectives: Evidence-based medicine (EBM) shapes most clinical guidelines. Although the advent of EBM marked a significant advancement, failure to include sex differences in the study design and analysis of most trials leads to an under-representation of gender-specific medicine (GM) in EBM-directed guidelines. In this review, we evaluated how the topic of GM was developed in the guidelines produced by the European Society of Cardiology (ESC) from 2018 to 2023. Methods: Two independent reviewers evaluated 24 ESC guidelines. Significant mentions of GM were counted and divided between epidemiology, diagnosis, and therapeutics. The qualitative and semi-quantitative analysis of information relating to GM was performed. Data on the number of citations of papers with a title concerning GM and the prevalence and role of women in guidelines' authorship were also analyzed. Results: Less than 50% of guidelines had a section dedicated to GM. Only nine guidelines were led by a woman, and 144/567 authors were female. In the most recent guidelines and in those with at least 30% of female authors, there was an increased mention of GM. On average, guidelines had four significant mentions of GM regarding epidemiology, two regarding diagnosis, and one regarding therapy. Articles with titles concerning GM made up, on average, 1.5% of the total number of citations. Conclusions: Although sex differences play a significant role in most clinical scenarios, ESC guidelines still do not sufficiently account for this. The problem does not seem to solely lie in the guidelines, but in the lack of attention to GM in research needed for their preparation.

The pharmacology of antiplatelet agents for primary, secondary, and tertiary prevention of ischemic stroke

INTRODUCTION

Ischemic etiology accounts for two thirds of all strokes in which platelet activation and aggregation play a major role. A variety of antiplatelet therapies have been tested for primary, secondary, and tertiary prevention, with certain patient subtypes benefiting more than others from a specific regimen.

AREAS COVERED

This review aims at synthetizing current evidence on pharmacology of antiplatelet agents approved for primary, secondary, and tertiary stroke prevention and their application among possible patient subtypes that may benefit more from their administration.

EXPERT OPINION

Management of ischemic stroke has largely evolved over the past decades. A better understanding of stroke pathophysiology has allowed to identify patients who can benefit most from antiplatelet therapies, with varying degrees of benefit depending on whether these agents are being used for primary, secondary, or tertiary prevention. Importantly, the antiplatelet treatment regimens currently available have expanded and no longer limited to aspirin but include other drugs such as P2Y12 and phosphodiesterase inhibitors, also used in combination, as well as precision medicine approaches using genetic testing aiming at optimizing the safety and efficacy in this population.

Outcome for concomitant mitral regurgitation after surgery for aortic insufficiency

BACKGROUND

Moderate/severe aortic regurgitation (AR) with concomitant mitral regurgitation (MR) is a common multiple valve disease for which treatment strategies are controversial. The current study explored long-term outcomes of concomitant MR after AR surgery and the effect of combined mitral valvuloplasty.

METHODS

A total of 506 patients with moderate/severe AR and concomitant MR undergoing aortic valve surgery between January 2013 and December 2021 in our cardiac center were enrolled. Risk factors for early mortality, late mortality and persistent MR were identified by logistic regression and generalized linear mixed model.

RESULTS

At least one follow-up record was available for 96.3% patients up to May 2022 and 264 (66.8%) patients had no or trivial MR, 112 (28.4%) had mild MR, 16 (4.1%) had moderate MR and 3 (0.8%) patients had severe MR. Persistent MR was recorded for 92 (23.3%) patients during follow-up. Combined mitral valvuloplasty (odds ratio: 0.23; 95% confidential interval: 0.08-0.64; p = 0.005) and better left ventricular reverse remodeling (odds ratio: 0.99; 95% confidential interval: 0.986-0.996); p < 0.001) were found likely to reduce the possibility of persistent MR during follow-up.

CONCLUSIONS

Most patients with moderate/severe AR and concomitant MR had a good long-term post-surgical outcome for MR. However, a few had persistent MR during follow-up. Combined mitral valvuloplasty and better left ventricular reverse remodeling reduced the possibility of long-term persistent MR.

Impact of Atrial Fibrillation Type on Outcomes of Transcatheter Aortic Valve Replacement for Aortic Stenosis: A Single-Center Analysis

Background

Atrial fibrillation (AF) is a recognized risk factor for mortality after transcatheter aortic valve replacement for severe aortic stenosis, but the impact of different types of AF on clinical outcomes remains unclear.

Methods

This retrospective study included 982 patients divided into 3 groups: no AF, paroxysmal AF, and nonparoxysmal AF (persistent or permanent). Clinical outcomes were analyzed using inverse probability weighting and multivariate models.

Results

There were 610, 211, and 161 patients in the no-AF, paroxysmal AF, and nonparoxysmal AF groups, respectively. For the entire cohort, the mean (SD) age was 82 (7.7) years, and the periprocedural, 1-year, and 5-year mortality rates were 2.0%, 12%, and 50%, respectively. After inverse probability weighting, the periprocedural mortality rate was higher in the nonparoxysmal AF group than in the no-AF group (odds ratio, 4.71 [95% CI, 1.24-17.9]). During 5 years of follow-up (median [IQR], 22 [0-69] months), all-cause mortality was higher in the nonparoxysmal AF group than in the no-AF group (hazard ratio [HR], 1.56 [95% CI, 1.14-2.14]; P = .006). The paroxysmal AF group was not associated with worse clinical outcomes than the no-AF group (HR, 1.02 [95% CI, 0.81-1.49]) for all-cause mortality. Stroke rates were comparable among the 3 groups. Multivariate analysis also showed increased all-cause mortality in the nonparoxysmal AF group compared with the no-AF group (adjusted HR, 1.43 [95% CI, 1.06-1.93]; P = .018), while all-cause mortality was comparable between the paroxysmal AF and no-AF groups (adjusted HR, 1.00 [95% CI, 0.75-1.33]).

Conclusion

In patients undergoing transcatheter aortic valve replacement for severe aortic stenosis, having nonparoxysmal AF was associated with a higher risk of periprocedural and all-cause mortality compared with having no AF. Paroxysmal AF showed no such association.

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

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

Simultaneous Transcatheter Aortic and Mitral Native Valve Replacement: A Step-by-Step Procedural Approach

Multivalvular heart disease (MVHD) is present in one-third of patients with valvular heart disease (VHD). Compared to single VHD patients, these patients have a more significant hemodynamic impact and are often left under medical treatment. Most importantly, when undergoing multiple valve interventions, they show worse rates of heart failure and mortality. The guidelines-supported interventions in patients with MVHD in combined aortic regurgitation and mitral stenosis include percutaneous mitral balloon commissurotomy, open mitral commissurotomy, or surgical mitral valve replacement followed by transcatheter or surgical aortic valve replacement, trying to minimize the increased mortality risk of double-valve replacement. Simultaneous transcatheter valve replacement (STVR) for native MVHD is still off-label and not yet considered in clinical guidelines since the evidence of its results is limited to a few cases reported worldwide. However, fully percutaneous transfemoral STVR seems promising for MVHD patients thanks to its minimal invasiveness, the continuous improvement of the transcatheter heart valve devices, the likely shorter length of stay and the fastest recovery. To our knowledge, this is the first case ever reported of fully percutaneous STVR for native MVHD in aortic regurgitation and mitral stenosis. Deep understanding of both pathologies and their interactions, not only from a pathological point of view but from the procedural planning and procedural steps point of view is mandatory. Hereby we present the specific STVR procedural planning considerations, a step-by-step guide on how to perform an aortic and mitral STVR and its critical considerations, as well as the procedural and follow-up results.

Cerebrovascular events after transcatheter aortic valve implantation

Periprocedural stroke after transcatheter aortic valve implantation (TAVI) remains a significant issue, which is associated with high morbidity, and is increasingly important as intervention shifts to younger and lower-risk populations. Over the last decade of clinical experience with TAVI, the incidence of periprocedural stroke has stayed largely unchanged, although it is prone to underreporting due to variation in ascertainment methods. The aetiology of stroke in TAVI patients is multifactorial, and changing risk profiles, differing study populations, and frequent device iterations have made it difficult to discern consistent risk factors. The objective of this review is to analyse and clarify the contemporary published literature on the epidemiology and mechanisms of neurological events in TAVI patients and evaluate potential preventive measures. This summary aims to improve patient risk assessment and refine case selection for cerebral embolic protection devices, while also providing a foundation for designing future trials focused on stroke prevention.

The role of Matrix Metalloproteinase-2 and Galectin-3 as predictive biomarkers for all-cause mortality in patients undergoing transfemoral transcatheter aortic valve implantation

BACKGROUND

Currently available risk scores fail to accurately predict morbidity and mortality in patients with severe symptomatic aortic stenosis who undergo transcatheter aortic valve implantation (TAVI). In this context, biomarkers like matrix metalloproteinase-2 (MMP-2) and Galectin-3 (Gal-3) may provide additional prognostic information.

METHODS

Patients with severe aortic stenosis undergoing consecutive, elective, transfemoral TAVI were included. Baseline demographic data, functional status, echocardiographic findings, clinical outcomes and biomarker levels were collected and analysed.

RESULTS

The study cohort consisted of 89 patients (age 80.4 ± 5.1 years, EuroScore II 7.1 ± 5.8%). During a median follow-up period of 526 d, 28 patients (31.4%) died. Among those who died, median baseline MMP-2 (alive: 221.6 [170.4; 263] pg/mL vs. deceased: 272.1 [225; 308.8] pg/mL, p < 0.001) and Gal-3 levels (alive: 19.1 [13.5; 24.6] pg/mL vs. deceased: 25 [17.6; 29.5] pg/mL, p = 0.006) were higher than in survivors. In ROC analysis, MMP-2 reached an acceptable level of discrimination to predict mortality (AUC 0.733, 95% CI [0.62; 0.83], p < 0.001), but the predictive value of Gal-3 was poor (AUC 0.677, 95% CI [0.56; 0.79], p = 0.002). Kaplan-Meier and Cox regression analyses showed that patients with MMP-2 and Gal-3 concentrations above the median at baseline had significantly impaired long-term survival (p = 0.004 and p = 0.02, respectively).

CONCLUSIONS

In patients with severe aortic stenosis undergoing transfemoral TAVI, MMP-2 and to a lesser extent Gal-3, seem to have additive value in optimizing risk prediction and streamlining decision-making.

New-onset atrial fibrillation detected by ambulatory ECG monitoring after transcatheter aortic valve implantation

BACKGROUND

Little is known about the occurrence of subclinical new-onset atrial fibrillation (NOAF) after transcatheter aortic valve implantation (TAVI).

AIMS

We aimed to evaluate the incidence, predictors, and clinical impact of subclinical NOAF after TAVI.

METHODS

This was a multicentre study, including patients with aortic stenosis (AS) and no previous atrial fibrillation undergoing TAVI, with continuous ambulatory electrocardiogram (AECG) monitoring after TAVI.

RESULTS

A total of 700 patients (79±8 years, 49% female, Society of Thoracic Surgeons score 2.9% [1.9-4.0]) undergoing transarterial TAVI were included (85% balloon-expandable valves). AECG was started 1 (0-1) day after TAVI (monitoring time: 14121314 days). NOAF was detected in 49 patients (7%), with a median duration of 185 (43-421) minutes (atrial fibrillation burden of 0.7% [0.3-2.8]). Anticoagulation was started in 25 NOAF patients (51%). No differences were found in baseline or procedural characteristics, except for a higher AS severity in the NOAF group (peak gradient: no NOAF: 71.9±23.5 mmHg vs NOAF: 85.2±23.8 mmHg; p=0.024; mean gradient: no NOAF: 44.4±14.7 mmHg vs NOAF: 53.8±16.8 mmHg; p=0.004). In the multivariable analysis, the baseline mean transaortic gradient was associated with a higher risk of NOAF after TAVI (odds ratio 1.04, 95% confidence interval: 1.01-1.06 for each mmHg; p=0.006). There were no differences between groups in all-cause mortality (no NOAF: 4.7% vs NOAF: 0%; p=0.122), stroke (no NOAF: 1.4% vs NOAF: 2.0%; p=0.723), or bleeding (no NOAF: 1.9% vs NOAF: 4.1%; p=0.288) from the 30-day to 1-year follow-up.

CONCLUSIONS

NOAF detected with AECG occurred in 7% of TAVI recipients and was associated with a higher AS severity. NOAF detection determined the start of anticoagulation therapy in about half of the patients, and it was not associated with an increased risk of clinical events at 1-year follow-up.

A deep dive into the percutaneous mitral valve data

PURPOSE OF REVIEW

This review offers insights into percutaneous mitral valve management, emphasizing pivotal trials that contributed to its evolution.

RECENT FINDINGS

Mitral regurgitation (MR) is a highly prevalent heart valve disease, with surgical intervention being the gold standard for managing primary MR. However, a notable proportion of patients face ineligibility criteria or are at high surgical risk, particularly in the setting of secondary MR. To fill this gap, transcatheter therapies have emerged as less invasive alternatives. Initially guided by the EVEREST trial criteria, transcatheter leaflet repair techniques have shown impressive technological improvements, addressing nowadays a wide range of anatomical scenarios. Evidence supporting the safety and efficacy of transcatheter leaflet repair is derived from pivotal trials, including EVEREST II, COAPT, MITRA-FR, and CLASP IID, and large multicenter registries including EXPAND, EXPAND G4, and EuroSMR. However, not all patients meet the anatomical and clinical criteria for leaflet repair. For those patients, transcatheter mitral valve replacement may be a minimally invasive option and multiple clinical trials are current underway.

SUMMARY

From MitraClip to newer and more innovative technologies, the landscape of percutaneous mitral valve interventions continues to evolve, offering new hopes to patients who may not be ideal candidates for conventional surgery.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.

Outcomes and predictors of left ventricle recovery in patients with severe left ventricular dysfunction undergoing transcatheter aortic valve implantation

BACKGROUND

Data on the likelihood of left ventricle (LV) recovery in patients with severe LV dysfunction and severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and its prognostic value are limited.

AIMS

We aimed to assess the likelihood of LV recovery following TAVI, examine its association with midterm mortality, and identify independent predictors of LV function.

METHODS

In our multicentre registry of 17 TAVI centres in Western Europe and Israel, patients were stratified by baseline LV function (ejection fraction [EF] >/≤30%) and LV response: no LV recovery, LV recovery (EF increase ≥10%), and LV normalisation (EF ≥50% post-TAVI).

RESULTS

Our analysis included 10,872 patients; baseline EF was ≤30% in 914 (8.4%) patients and >30% in 9,958 (91.6%) patients. The LV recovered in 544 (59.5%) patients, including 244 (26.7%) patients whose LV function normalised completely (EF >50%). Three-year mortality for patients without severe LV dysfunction at baseline was 29.4%. Compared to this, no LV recovery was associated with a significant increase in mortality (adjusted hazard ratio 1.32; p<0.001). Patients with similar LV function post-TAVI had similar rates of 3-year mortality, regardless of their baseline LV function. Three variables were associated with a higher likelihood of LV recovery following TAVI: no previous myocardial infarction (MI), estimated glomerular filtration rate >60 mL/min, and mean aortic valve gradient (mAVG) (expressed either as a continuous variable or as a binary variable using the standard low-flow, low-gradient aortic stenosis [AS] definition).

CONCLUSIONS

LV recovery following TAVI and the extent of this recovery are major determinants of midterm mortality in patients with severe AS and severe LV dysfunction undergoing TAVI. Patients with no previous MI and those with an mAVG >40 mmHg show the best results following TAVI, which are at least equivalent to those for patients without severe LV dysfunction. (ClinicalTrials.gov: NCT04031274).

A study of ChatGPT in facilitating Heart Team decisions on severe aortic stenosis

BACKGROUND

Multidisciplinary Heart Teams (HTs) play a central role in the management of valvular heart diseases. However, the comprehensive evaluation of patients' data can be hindered by logistical challenges, which in turn may affect the care they receive.

AIMS

This study aimed to explore the ability of artificial intelligence (AI), particularly large language models (LLMs), to improve clinical decision-making and enhance the efficiency of HTs.

METHODS

Data from patients with severe aortic stenosis presented at HT meetings were retrospectively analysed. A standardised multiple-choice questionnaire, with 14 key variables, was processed by the OpenAI Chat Generative Pre-trained Transformer (GPT)-4. AI-generated decisions were then compared to those made by the HT.

RESULTS

This study included 150 patients, with ChatGPT agreeing with the HT's decisions 77% of the time. The agreement rate varied depending on treatment modality: 90% for transcatheter valve implantation, 65% for surgical valve replacement, and 65% for medical treatment.

CONCLUSIONS

The use of LLMs offers promising opportunities to improve the HT decision-making process. This study showed that ChatGPT's decisions were consistent with those of the HT in a large proportion of cases. This technology could serve as a failsafe, highlighting potential areas of discrepancy when its decisions diverge from those of the HT. Further research is necessary to solidify our understanding of how AI can be integrated to enhance the decision-making processes of HTs.

A randomised multicentre study of angiography- versus physiologyguided percutaneous coronary intervention in patients with coronary artery disease undergoing TAVI: design and rationale of the FAITAVI trial

The treatment of coronary artery disease (CAD) in patients with severe aortic valve stenosis (AVS) eligible for transcatheter aortic valve implantation (TAVI) is not supported by clinical evidence, and the role of physiology over anatomy as well as the timing of coronary intervention are not defined. FAITAVI (ClinicalTrials.gov: NCT03360591) is a nationwide prospective, open-label, multicentre, randomised controlled study comparing the angiography-guided versus the physiology-guided coronary revascularisation strategy in patients with combined significant CAD and severe AVS undergoing TAVI. Significant CAD will be defined as coronary stenosis ≥50%, as assessed by visual estimation in vessels ≥2.5 mm. Physiology will be tested by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The study will be conducted at 15 sites in Italy. In the angiography arm, percutaneous coronary intervention (PCI) will be performed either before TAVI, during the TAVI procedure - before or after the valve implantation - or within 1 month±5 days of the valve implantation, left to the operator's decision. In the physiology arm, FFR and iFR will be performed before TAVI, and PCI will be indicated for FFR ≤0.80, otherwise the intervention will be deferred. In case of borderline values (0.81-0.85), FFR and iFR will be repeated after TAVI, with PCI performed when needed. With a sample size of 320 patients, the study is powered to evaluate the primary endpoint (a composite of death, myocardial infarction, stroke, major bleeding, or ischaemia-driven target vessel revascularisation). TAVI indication, strategy and medical treatment will be the same in both groups. After discharge, patients will be contacted at 1, 6, 12 and 24 months after the procedure to assess their general clinical status, and at 12 months for the occurrence of events included in the primary and secondary endpoints. FAITAVI is the first randomised clinical trial to investigate "optimal" percutaneous coronary intervention associated with TAVI in patients with severe AVS and CAD.

Long-Term Mortality after Transcatheter Edge-to-Edge Mitral Valve Repair Significantly Decreased over the Last Decade: Comparison between Initial and Current Experience from the MiTra Ulm Registry

(1) Objective: We aimed to assess whether the candidate profile, the long-term outcomes and the predictors for long-term mortality after transcatheter edge-to-edge mitral valve repair (M-TEER) have changed over the last decade; (2) Methods: Long-term follow-up data (median time of 1202 days) including mortality, MACCE and functional status were available for 677 consecutive patients enrolled in the prospective MiTra Ulm registry from January 2010 to April 2019. The initial 340 patients treated in our institution before January 2016 were compared with the following 337 patients; (3) Results: Patients treated after 2016 showed significantly less ventricular dilatation (left ventricular end-systolic diameter of 43 ± 13 mm vs. 49 ± 16 mm, p < 0.007), lower systolic pulmonary pressures (50 ± 15 mmHg vs. 57 ± 21 mmHg, p = 0.01) and a lower prevalence of severe tricuspid regurgitation (27.2% vs. 47.3%, p < 0.001) at baseline than patients treated before 2016. Compared to the cohort treated before 2016, patients treated afterwards showed a significantly lower all-cause 3-year mortality (29.4% vs. 43.8%, p < 0.001) and lower MACCE (38.6% vs. 54.1%, p < 0.001), without differences for MR etiology. While severe tricuspid regurgitation and NYHA class IV remained independently associated with an increased long-term mortality over the last decade, severe left ventricular dilatation (hazard ratio, HR 2.12, p = 0.047) and severe pulmonary hypertension (HR 2.18, p = 0.047) were predictors of long-term mortality only in patients treated before 2016. (4) Conclusions: The M-TEER candidates are currently treated earlier in the course of disease and benefit significantly in terms of a better long-term survival than patients treated at the beginning of the M-TEER era.

Comparison of two self-expanding transcatheter heart valves for degenerated surgical bioprostheses: the AVENGER multicentre registry

BACKGROUND

There is a lack of comparative data on transcatheter aortic valve implantation (TAVI) in degenerated surgical prostheses (valve-in-valve [ViV]).

AIMS

We sought to compare outcomes of using two self-expanding transcatheter heart valve (THV) systems for ViV.

METHODS

In this retrospective multicentre registry, we included consecutive patients undergoing transfemoral ViV using either the ACURATE neo/neo2 (ACURATE group) or the Evolut R/PRO/PRO+ (EVOLUT group). The primary outcome measure was technical success according to Valve Academic Research Consortium (VARC)-3. Secondary outcomes were 30-day all-cause mortality, device success (VARC-3), coronary obstruction (CO) requiring intervention, rates of severe prosthesis-patient mismatch (PPM), and aortic regurgitation (AR) ≥moderate. Comparisons were made after 1:1 propensity score matching.

RESULTS

The study cohort comprised 835 patients from 20 centres (ACURATE n=251; EVOLUT n=584). In the matched cohort (n=468), technical success (ACURATE 92.7% vs EVOLUT 88.9%; p=0.20) and device success (69.7% vs 73.9%; p=0.36) as well as 30-day mortality (2.8% vs 1.6%; p=0.392) were similar between the two groups. The mean gradients and rates of severe PPM, AR ≥moderate, or CO did not differ between the groups. Technical and device success were higher for the ACURATE platform among patients with a true inner diameter (ID) >19 mm, whereas a true ID ≤19 mm was associated with higher device success - but not technical success - among Evolut recipients.

CONCLUSIONS

ViV TAVI using either ACURATE or Evolut THVs showed similar procedural outcomes. However, a true ID >19 mm was associated with higher device success among ACURATE recipients, whereas in patients with a true ID ≤19 mm, device success was higher when using Evolut.

The interventional care for patients undergoing transcatheter aortic valve replacement: Establishing indicators for optimal interventional care

OBJECTIVE

We evaluate the quality of interventional care for patients undergoing transcatheter aortic valve replacement (TAVR) using a set of quality indicators.

METHODS

We developed an initial list of quality indicators by incorporating current guidelines, observing practice discrepancies, and basing it on the Donabedian "structure, process, and outcome" three-dimensional quality evaluation model as the framework. The Delphi method was utilized in two rounds of consultation involving 31 experts to evaluate and revise indicators at all levels.

RESULTS

The response rate of expert questionnaires was 100% for both rounds, and the expert authority coefficients were 0.913 and 0.940, respectively. The Kendall harmony coefficients were 0.221 and 0.195, respectively, with P < 0.05. Eventually, a quality evaluation system of interventional care for patients undergoing TAVR was constructed, consisting of three structural indicators, nine process indicators, and 42 outcome indicators.

CONCLUSIONS

The quality evaluation system for interventional care of TAVR sought to establish specific, objective, and quantifiable criteria for assessing the quality of care. It is recommended to apply the set of quality indicators across hospitals to enhance the quality of care for TAVR.

Redo-TAVR Feasibility After SAPIEN 3 Stratified by Implant Depth and Commissural Alignment: A CT Simulation Study

BACKGROUND

Redo-transcatheter aortic valve replacement (TAVR) can pin the index transcatheter heart valve leaflets open leading to sinus sequestration and restricting coronary access. The impact of initial implant depth and commissural alignment on redo-TAVR feasibility is unclear. We sought to determine the feasibility of redo-TAVR and coronary access after SAPIEN 3 (S3) TAVR stratified by implant depth and commissural alignment.

METHODS

Consecutive patients with native valve aortic stenosis were evaluated using multidetector computed tomography. S3 TAVR simulations were done at 3 implant depths, sizing per manufacturer recommendation and assuming nominal expansion in all cases. Redo-TAVR was deemed unfeasible based on valve-to-sinotubular junction distance and valve-to-sinus height <2 mm, while the neoskirt plane of the S3 transcatheter heart valve estimated coronary access feasibility.

RESULTS

Overall, 1900 patients (mean age, 80.2±8 years; STS-PROM [Society of Thoracic Surgeons Predicted Risk of Operative Mortality], 3.4%) were included. Redo-TAVR feasibility reduced significantly at shallower initial S3 implant depths (2.3% at 80:20 versus 27.5% at 100:0, P<0.001). Larger S3 sizes reduced redo-TAVR feasibility, but only in patients with a 100:0 implant (P<0.001). Commissural alignment would render redo-TAVR feasible in all patients, assuming the utilization of leaflet modification techniques to reduce the neoskirt height. Coronary access following TAV-in-TAV was affected by both index S3 implant depth and size.

CONCLUSIONS

This study highlights the critical impact of implant depth, commissural alignment, and transcatheter heart valve size in predicting redo-TAVR feasibility. These findings highlight the necessity for individualized preprocedural planning, considering both immediate results and long-term prospects for reintervention as TAVR is increasingly utilized in younger patients with aortic stenosis.