Curva de Aprendizagem da Mortalidade Hospitalar da Substituição da Válvula Aórtica Transcateter: Insights do Registro Nacional Brasileiro / Learning Curve for In-Hospital Mortality of Transcatheter Aortic Valve Replacement: Insights from the Brazilian National Registry

Resumo Fundamento Dados robustos sobre a curva de aprendizagem (LC) da substituição da válvula aórtica transcateter (TAVR) são escassos nos países em desenvolvimento. Objetivo Avaliar a LC da TAVR no Brasil ao longo do tempo. Métodos Analisamos dados do registro brasileiro de TAVR de 2008 a 2023. Pacientes de cada centro foram numerados cronologicamente em número sequencial de caso (NSC). A LC foi realizada usando um spline cúbico restrito ajustado para o EuroSCORE-II e o uso de próteses de nova geração. Ainda, os desfechos hospitalares foram comparados entre grupos definidos de acordo com o nível de experiência, com base no NSC: 1º ao 40º caso (experiência inicial), 41º ao 80º caso (experiência básica), 81º ao 120º caso (experiência intermediária) e 121º caso em diante (experiência alta). Análises adicionais foram conduzidas de acordo com o número de casos tratados antes de 2014 (>40 e ≤40 procedimentos). O nível de significância adotado foi p <0,05. Resultados Foram incluídos 3194 pacientes de 25 centros. A idade média foi 80,7±8,1 anos e o EuroSCORE II médio foi 7±7,1. A análise da LC demonstrou uma queda na mortalidade hospitalar ajustada após o tratamento de 40 pacientes. Um patamar de nivelamento na curva foi observado após o caso 118. A mortalidade hospitalar entre os grupos foi 8,6%, 7,7%, 5,9%, e 3,7% para experiência inicial, básica, intermediária e alta, respectivamente (p<0,001). A experiência alta foi preditora independente de mortalidade mais baixa (OR 0,57, p=0,013 vs. experiência inicial). Centros com baixo volume de casos antes de 2014 não mostraram uma redução significativa na probabilidade de morte com o ganho de experiência, enquanto centros com alto volume de casos antes de 2014 apresentaram uma melhora contínua após o caso de número 10. Conclusão Observou-se um fenômeno de LC para a mortalidade hospitalar do TAVR no Brasil. Esse efeito foi mais pronunciado em centros que trataram seus 40 primeiros casos antes de 2014 que naqueles que o fizeram após 2014.

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR's LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

A Case of Three Directional Cuff Leakage from the Stent Posts of an Inspilis RESILIA Aortic Valve during Surgical Aortic Replacement / 日本心臓血管外科学会雑誌

We present the case of a 72-year-old male with Inspiris RESILIA aortic valve (Inspiris) transvalvular leakage during surgical aortic valve replacement (AVR). The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography (TEE) captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.

Evaluation of the Aortic Root Using 3D-CT Following Aortic Valve Replacement Employing the Bo Yang Root Enlargement Technique / 日本心臓血管外科学会雑誌

A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient's relatively small native aortic valve area, a concurrent root dilatation maneuver (Bo Yang method) was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.

Anticoagulación precoz con warfarina en pacientes sometidos a sustitución valvular aórtica por bioprótesis: ensayo prospectivo randomizado: análisis interino / Early anticoagulation with warfarin in patients undergoing bioprosthetic aortic valve replacement: randomized prospective trial: interim analysis / Anticoagulação precoce com varfarina em pacientes submetidos à troca valvar aórtica por bioprótese: ensaio prospectivo randomizado: análise provisória

Introducción: aunque las bioprótesis son menos trombogénicas que las válvulas mecánicas; la trombosis de estas es una entidad cada vez más reconocida como causa de disfunción protésica potencialmente reversible. No está definido el beneficio de la anticoagulación rutinaria versus antiagregación plaquetaria luego de la sustitución valvular aórtica (SVA) por bioprótesis. La anticoagulación precoz podría asociarse a menores gradientes transprotésicos con similar riesgo de complicaciones. Objetivos: el objetivo primario es determinar si existe una diferencia significativa en la variación del gradiente transprotésico medio al año de la SVA entre las dos estrategias de tratamiento antitrombótico. Los objetivos secundarios son la comparación de la variación del gradiente máximo y del área valvular aórtica, y parámetros clínicos que incluyen la Clase Funcional de la New York Heart Association, las tasas de sangrado mayor y menor y la incidencia de eventos embólicos. Este trabajo representa el análisis interino a 3 meses de un proyecto a más largo plazo, y se propone mostrar los resultados preliminares de los puntos finales previamente definidos. Métodos: se presenta el análisis interino de un ensayo randomizado multicéntrico. Todos los pacientes sometidos a SVA por bioprótesis porcinas fueron sucesivamente reclutados en dos centros de cirugía cardíaca desde el 01/01/2019 hasta el 01/09/2019. El grupo anticoagulación recibió warfarina durante los primeros 3 meses y ambos recibieron aspirina a largo plazo. Se realizaron instancias de seguimiento clínicas y ecocardiográficas antes del alta, a los 3 meses y al año. Resultados: se reclutaron 107 pacientes; 46% de ellos fueron randomizados al grupo anticoagulación y 54% al grupo control. No existieron diferencias en las características basales. Tampoco existieron diferencias significativas entre ambos grupos en la variación entre el alta y los 3 meses del área valvular protésica, coeficiente de obstrucción, gradiente máximo ni gradiente medio ni en la clase funcional. En cuanto a las complicaciones, no existieron eventos embólicos y los sangrados no difirieron significativamente entre ambos grupos. Conclusiones: la anticoagulación no modificó la variación de los gradientes transprotésicos a los 3 meses. Asimismo, no produjo mayor incidencia de efectos adversos. Todavía no está dilucidado si la anticoagulación precoz con warfarina luego de la SVA tiene impacto en los resultados a largo plazo.

Introduction: although bioprostheses are less thrombogenic than mechanical valves, bioprosthesis valve thrombosis is an increasingly recognized entity that can cause potentially reversible prosthetic valve dysfunction. There is a lack of consensus whether to use anticoagulation after aortic valve replacement (AVR) or antiplatelet therapy. Our hypothesis is that early anticoagulation is associated with lower transprosthetic gradients with similar risk of complications. Objective: primary objective is to determine if there is a significant difference in the variation of the mean transprosthetic gradient (ΔGm) one year after SVA between the two antithrombotic treatment strategies. Secondary objectives are the comparison of the variation of maximum gradient and aortic valve area, and clinical parameters including NYHA functional class, major and minor bleeding rates, and the incidence of embolic events. This work represents the 3-month interim analysis of a longer-term project, and is intended to show the preliminary results of the previously defined end points. Methods: this is an interim analysis of a multicenter randomized trial. All patients who underwent AVR by porcine bioprostheses were successively recruited in two cardiac surgery centers in Montevideo between 01/01/2019 and 01/09/2019. The anticoagulation group received warfarin for 3 months. Both groups received aspirin. Clinical and echocardiographic follow-up consultations were performed before discharge, at 3 months, and at 1 year. Results: 107 patients were recruited, 46% were randomized to the anticoagulation group and 54% to the control group. There were no differences in baseline characteristics. There were no significant differences between the two groups in the variation between discharge and 3 months of effective orifice area, doppler velocity index, peak gradient and mean gradient. There were also no differences between both groups in functional class. Regarding complications, there were no embolic events and bleeding did not differ significantly. Conclusions: in this study, anticoagulation did not modify the variation of transprosthetic gradients at 3 months. Likewise, it did not produce a higher incidence of adverse effects. It remains unclear whether early anticoagulation with warfarin after AVR has an impact on long-term outcomes.

Introdução: embora as biopróteses sejam menos trombogênicas que as mecânicas, a trombose de biopróteses é uma entidade cada vez mais reconhecida como causa de disfunção protética potencialmente reversível. A anticoagulação de rotina após a substituição da valva aórtica por bioprótese (SVA) não está definida. Nossa hipótese é que a anticoagulação precoce está associada a menores gradientes transprotéticos com risco semelhante de complicações. Objetivo: o objetivo principal é determinar se há uma diferença significativa na variação do gradiente transprotético médio (ΔGm) um ano após SVA entre as duas estratégias de tratamento antitrombótico. Os objetivos secundários são a comparação da variação do gradiente máximo e da área valvar aórtica e parâmetros clínicos, incluindo NYHA CF, taxas de sangramento maior e menor e incidência de eventos embólicos. Este trabalho representa a análise intercalar de 3 meses de um projeto de longo prazo, e pretende mostrar os resultados preliminares dos pontos finais previamente definidos. Métodos: apresenta-se a análise interina de um estudo multicêntrico randomizado. Todos os pacientes submetidos a SVA por biopróteses suínas foram sucessivamente recrutados em dois centros de cirurgia cardíaca em Montevidéu, durante um período de recrutamento de 1/1/2019 a 1/9/2019. O grupo de anticoagulação recebeu warfarina por 3 meses. Ambos os grupos receberam aspirina. Foram realizadas consultas médicas clínicas e ecocardiográficas antes da alta, aos 3 meses e ao 1 ano. Resultados: foram recrutados 107 pacientes, 46% foram randomizados para o grupo anticoagulação e 54% para o grupo controle. Não houve diferenças nas características basais. Não houve diferenças significativas entre os dois grupos da variação entre alta e 3 meses na área valvar, coeficiente de obstrução, gradiente máximo ou gradiente médio. Também não houve diferenças entre os dois grupos na classe funcional. Em relação às complicações, não houve eventos embólicos e sangramentos não diferiram significativamente. Conclusões: neste estudo, a anticoagulação não modificou a variação dos gradientes transprotéticos aos 3 meses. Da mesma forma, não produziu maior incidência de efeitos adversos. Ainda não está claro se a anticoagulação precoce com varfarina após SVA tem impacto nos resultados a longo prazo.

Status and prospect of transcatheter valve-in-valve implantation for biological valve degeneration / 中国胸心血管外科临床杂志

@#Along with the coming of aged society, the prevalence of heart valvular disease is significantly increasing, and the use of bioprosthetic valves for treating patients with severe valve disease has increased over the last two decades. As a consequence, a growing number of patients with surgical bioprosthesis degeneration is predicted in the near future. In this setting, valve-in-valve (ViV) transcatheter aortic/mitral valve replacement (TAVR/TMVR) has emerged as an alternative to redo surgery. A deep knowledge of the mechanism and features of the failed bioprosthetic heart valve is pivotal to plan an adequate procedure. Multimodal imaging is fundamental in the diagnostic and pre-procedural phases. The immediate and mid-term clinical and hemodynamic results have demonstrated the safety and feasibility of ViV techniques, but the development of these techniques faces several specific challenges, such as coronary obstruction, potential post-procedural mismatch and leaflet thrombosis. This article reviews the current status and prospects of ViV-TAVR technology in the treatment for biological valve degeneration, and suggests that ViV-TAVR should be promoted and implemented in existing medical centers with good surgical aortic valve replacement experience, so as to provide better treatment for patients.

Outcome analysis of functional mitral regurgitation after transcatheter aortic valve replacement in patients with severe bicuspid aortic stenosis / 复旦学报（医学版）

Objective To explore the relationship between the types of bicuspid aortic valves(BAV)and the outcome of functional mitral regurgitation(FMR)and the affecting factors of FMR.Methods From Jun 2018 to Sep 2022,patients with severe BAV aortic valve stenosis(AS)complicated with FMR underwent post transcatheter aortic valve replacement(TAVR)in Zhongshan Hospital,Fudan University were retrospectively analyzed.The baseline information and imaging data of different BAV patients were collected.Logistic regression was used to analyze the factors affecting the outcome of FMR(improvement and non-improvement).Result A total of 100 patients with TAVR were included,including 49 patients with type 0 of BAV and 51 patients with type 1 of BAV.Compared with patients of type 1,patients of type 0 had younger age[(72.78±6.09)y vs.(77.00±8.35)y,P=0.050],lower male ratio(47%vs.73%,P= 0.009)higher BMI[(23.19±2.62)kg/m2 vs.(21.99±3.13)kg/m2,P=0.041],and lower incidence of aortic regurgitation(69%vs.92%,P=0.040).Compared with the non-improvement group,the improvement group had a lower incidence of coronary heart disease(5%vs.18%,P=0.042),higher incidence of pulmonary hypertension(20%vs.2%,P=0.007),larger left ventricular diastolic diameter[(51.98±6.74)mm vs.(48.04±7.72)mm,P=0.009]and higher maximum flow velocity[(4.86±0.95)cm/s vs.(4.47±0.75)cm/s,P= 0.023]of the aortic valve.The results of Logistic regression analysis showed that preoperative pulmonary hypertension,left ventricular end-diastolic diameter and maximum valvular flow velocity of BAV patients were the potential affecting factors of FMR improvement after TAVR.Conclusion No significant difference was found in FMR improvement between BAV patients of type 0 and type 1 after TAVR.For BAV patients with AS,preoperative pulmonary hypertension,larger left ventricular end-diastolic diameter,and faster aortic valve flow velocity were associated with higher FMR improvement rate.

A one-stop comparative study of CTA scan delay protocol for TAVI/TAVR patients / 西安交通大学学报(医学版)

Objective To compare the effect of preoperative CTA examination using group injection test and group injection tracking delay protocol on image quality in patients with transcatheter aortic valve implantation(TAVI)/transcatheter aortic valve replacement(TAVR).Methods A total of 43 patients who underwent TAVI/TAVR preoperative one-stop CTA examination in our hospital were randomly divided into two groups,and preoperative CTA examination was performed using group injection tracking and group injection test.After the scanning was completed,the aortic root sinus(C1),the proximal left and right coronary arteries(C2,C3),the ascending aorta(A1),the abdominal aorta(A2),the left and right femoral arteries(A3,A4),and the CT value and SD value of the paraspinal muscles of the same layer were measured;the signal-to-noise ratio(SNR)and contrast-to-noise ratio(CNR)of the corresponding parts were calculated.The obtained data results were compared and analyzed from both subjective and objective aspects.Results There was no significant difference in image quality between the two groups in the aortic root sinus(C1),the proximal left and right coronary arteries(C2,C3),or the ascending aorta(A1)(P＞0.05).At the renal artery level,there was a significant difference in image quality between the abdominal aorta(A2)and the left and right femoral artery levels(A3,A4)(P＜0.05).Conclusion In the preoperative one-stop CTA examination of TAVI/TAVR patients,the CTA images below the renal artery level can obtain better image quality than the group injection tracking method.

Short-term effects of dapagliflozin on non-diabetic patients with severe aortic stenosis after tran-scatheter aortic valve replacement / 新乡医学院学报

Objective To investigate the short-term efficacy of dapagliflozin in the treatment of non-diabetic patients with severe aortic stenosis after transcatheter aortic valve replacement(TAVR).Methods A total of 84 non-diabetic patients with severe aortic stenosis after TAVR who were admitted to Zhengzhou Cardiovascular Hospital from March 2019 to September 2022 were selected as research subjects.According to the postoperative treatment,the patients were divided into control group and observation group,with 42 patients in each group.Patients in both groups underwent TAVR.The patients in the control group were given routine treatments such as antiplatelet drugs,cardiac remodeling improvement drugs,and diuretics after TAVR;patients in the observation group were given dapagliflozin 10 mg daily for 6 months in addition to treatment in the control group.The left ventricular ejection fraction(LVEF),left ventricular end-systolic diameter(LVESD),left ventricular end-diastolic diameter(LVEDD),aortic valve peak gradient(AVPG)and aortic valve peak velocity(AVPV)of patients in the two groups were measured by using an ultrasound diagnostic instrument before surgery,3 days and 6 months after TAVR;before surgery and 6 months after the TAVR,low-density lipoprotein cholesterol(LDL-C)in serum of patients in the two groups was detected by direct measurement method,lipoprotein a[Lp(a)]level in serum was detected by latex agglutination reaction method,hypersensitive C-reactive protein(hs-CRP)level in serum was detected by rate scattering turbidimetry;the levels of N-terminal pro B-type natriuretic peptide(NT-proBNP),interleukin-6(IL-6),tumor necrosis factor-α(TNF-α)and interleukin-1 β(IL-1 β)in serum were detected by using enzyme-linked immunosorbent assay;the glycated hemoglobin level of patients in the two groups was measured by ion exchange chromatography.Results There was no statistically significant difference in LVEF,LVESD and LVEDD of patients in the two groups before and 3 days after surgery(P＞0.05);after 3 days of surgery,the AVPG and AVPV of patients in the two groups were significantly lower than those before surgery(P＜0.05).Six months after surgery,the LVEF of patients in the two groups was significantly higher than that before and 3 days after surgery,while LVESD,LVEDD,AVPG and AVPV were significantly lower than those before and 3 days after surgery(P＜0.05).There was no statistically significant difference in LVEF,LVESD,LVEDD,AVPG and AVPV between the control group and the observation group before and 3 days after surgery(P＞0.05).After 6 months of surgery,the LVEF of patients in the observation group was significantly higher than that in the control group,while LVESD and LVEDD were significantly lower than those in the control group(P＜0.05);there was no statistically significant difference in AVPG and AVPV of patients between the observation group and control group(P＞0.05).Before surgery,there was no statistically significant difference in body mass index(BMI),LDL-C and Lp(a)of patients between the two groups(P＞0.05).Six months after surgery,the BMI,LDL-C and Lp(a)of patients in the two groups were significantly lower than those before surgery,and the BMI,LDL-C and Lp(a)of patients in the observation group were significantly lower than those in the control group(P＜0.05).Before surgery,there was no statistically significant difference in the hs-CRP,NT-proBNP,IL-6,TNF-α and IL-1 β of patients between the two groups(P＞0.05);six months after surgery,the hs-CRP,NT-proBNP,IL-6,TNF-α and IL-1 β of patients in the two groups were significantly lower than those before surgery,and the hs-CRP,NT-proBNP,IL-6,TNF-α and IL-lβ of patients in the observation group were significantly lower than those in the control group(P＜0.05).There was no statistically significant difference in glycated hemoglobin of patients between the two groups before and six months after surgery(P＞0.05),and no statistically significant difference in glycated hemoglobin of patients in the two groups six months after surgery compared with that before surgery(P＞0.05).Conclusion Dapagliflozin can effectively improve cardiac structural remodeling,regulate lipid metabolism,reduce the expression of inflammatory factors and promote the recovery of heart function in non-diabetic patients with severe aortic stenosis after TAVR.

Progress of transcatheter aortic valve replacement in 2023 / 中国介入心脏病学杂志

Transcatheter aortic valve replacement(TAVR)has become one of the effective methods for treating patients with aortic valve disease.With the continuous maturity of technology,innovation of instruments and increasing experience,the indications for TAVR has been expanded.Following international trends,the number of TAVR in China has steadily increased with each passing year.In 2023,the long-term follow-up results of TAVR in low-risk AS patients further confirm the long-term benefits of TAVR.The relevant research on TAVR for patients with aortic regurgitation and patients with bicuspid aortic stenosis provide evidence support for the expansion of TAVR indications.At the same time,the development of valve devices and new technological innovations are emerging in an endless stream,and the new concept of full life cycle management is increasingly being valued.Especially in China,the development of local devices is progressing rapidly,and multiple devices have entered the clinical research stage.The clinical manifestations and research results are worth pursuing.

Prediction and risk factor analysis of new-onset conduction disturbance after transcatheter aortic valve replacement / 中国介入心脏病学杂志

Objective To explore the relevant factors of new-onset conduction disturbance(NOCD)after transcatheter aortic valve replacement(TAVR),such as anatomical structure,device type,surgical strategies,etc.,discover relevant predictive factors,and establish a predictive model to assess the risk of conduction blockages.Methods From January 2016 to March 2022,clinical data of symptomatic patients with severe aortic valve stenosis or severe regurgitation who underwent TAVR at Xiangya Second Hospital of Central South University were collected through the hospital information system and imaging database.ECG,echocardiography,CTA,surgical materials,etc.,were extracted and analyzed by specialists.SPSS software was used for statistical analysis,and a multi-factor regression prediction model for NOCDwas built.Results A total of 184 patients were included,the occurrence rate of NOCD after TAVR was 31.0%,pure regurgitation patients'NOCD occurrence rate was 63.6%(7/11).The NOCD group had a larger aortic angles[(57.7±10.3)°vs.(52.0±9.0)°,P＜0.001],larger Oversizing[(129±28)%vs.(120±21)%,P=0.018],deeper implantation depth[(7.2±5.1)mm vs.(4.8±4.2)mm,P=0.001],and higher pure regurgitation patients'proportion[12.3%vs.3.1%,P=0.037]than the non-NOCD group.Multifactorial Logistic regression analysis indicated that an aorta angle＞54.5°(OR 3.78,95%CI 1.86-7.63,P＜0.001)or implantation depth＞5.7 mm(OR 3.39,95%CI 1.68-6.85,P＜0.001)are independent risk factors for new onset conduction disturbances after TAVR,and a predictive model was established with aortic angle,implantation depth,and Oversizing ratio as variables.The receiver operating characteristics curve showed area under ROC curve 0.709,95%CI 0.623-0.795,predicting NOCD after TAVR.Conclusions A retrospective analysis carried out at a single center discovered that the aortic angle in the NOCD group was larger than that in the non-NOCD group,the Oversizing ratio was higher,the implantation location was deeper,and there was a higher proportion of patients with pure regurgitation lesions.An aortic angle greater than 54.5°or an implantation depth more than 5.7 mm were identified as independent risk factors for NOCD after TAVR.

New advances in stroke and cerebral embolism protection devices in transcatheter aortic valve replacement / 中国介入心脏病学杂志

Stroke is one of the most serious complications of transcatheter aortic valve replacement(TAVR),tremendously increasing mortality and the loss of neurocognitive function.Since TAVR is expected to further spread into lower-risk patient groups,there will be greater emphasis to obviate such serious complications.One possible technique for preventing stroke is using cerebral embolic protection devices(CEPDs).CEPDs are designed for capturing or deflecting emboli that are enter route to the brain and hence to protect the brain from embolism.Since this is a rapidly growing field with recent advances,and the impact of CEPD on preventing neurological events is still limited,there is an urgent need for understanding the role of CEPD in preventing clinically significant strokes.Although their clinical utilization is increasing,the risk factors for stroke related to TAVR and evidence for using CEPDs are not yet clear.In this review,we present an overview of the available literature on TAVR related stroke and CEPD,and outline recent advances within this field.

Analysis of related factors of new-onset conduction disturbance after transcatheter aortic valve replacement with self-expanding valve / 中国介入心脏病学杂志

Objective To investigate the baseline clinical characteristics,ascending aortic root anatomical characteristics,and related factors of the surgical strategy of patients with new-onset conduction disturbance(NOCD)after transcatheter aortic valve replacement(TAVR)with self-expanding valve(SEV)implantation.Methods A retrospective study was conducted on 245 patients who underwent TAVR at the Xiamen Cardiovascular Hospital Xiamen University between December 2014 and November 2022.According to the inclusion and exclusion criteria,167 patients with SEV implantation during surgery were continuously included.They were divided into tricuspid aortic valve group(TAV group,113 cases)and bicuspid aortic valve group(BAV group,54 cases)according to aortic valve morphology.The TAV group was divided into NOCD group(43 cases)and non NOCD group(70 cases)according to postoperative electrocardiogram characteristics.The BAV group was divided into NOCD group(16 cases)and non NOCD group(38 cases).Collect clinical data such as preoperative electrocardiogram and ascending aortic root CT angiography from patients.Results The right-non valvular calcification quantification(P=0.005)in the non-NOCD group was significantly greater than that in the NOCD group,but the aortic angle(P=0.002)was smaller in TAV patients.Multivariate analysis suggested that the risk of NOCD after TAVR is reduced by 2.6％for every 10 mm3 increase in right-non valvular calcification in patients(OR 0.974,P=0.039),the risk of postoperative NOCD nearly 7.3％for every degree increase in aortic angulation(OR 1.073,P=0.003).In BAV patients the increase of the risk of NOCD after TAVR is nearly 3.3％for every l ms increase in preoperative PR interval(OR 1.033,P=0.041),the risk of NOCD is reduced by 6.6％for every 10 mm3 increase in calcification quantification in the right coronary valve area(OR 0.934,P=0.013).Conclusions In TAV patient,right-non valvular calcification may have a protective effect on the cardiac conduction system,but a larger aortic angle increases the risk of NOCD.In BAV patients,a longer preoperative PR interval is a risk factor for NOCD,and the right coronary valve area may protect the cardiac conduction system.

Application of 3D printing in the preoperative evaluation of transcatheter aortic valve replacement for patients at risk of coronary artery obstruction:two case reports / 中国介入心脏病学杂志

Transcatheter aortic valve replacement(TAVR)is currently one of the main therapeutic strategies for aortic valve disease.Preoperative imaging assessment is crucial for operation project planning and prevention of procedure-associated complications.Different from planar image reconstruction,3D printing technology can accurately depict the anatomical structure of the aortic root.It enables further assessment of operative risk and therapeutic strategy through in vitro simulation,especially for assessing the risk of coronary artery obstruction and planning interventional procedures.Here,we report on two patients who underwent a 3D printing aortic root anatomical simulation model,followed an by in vitro balloon dilatation/valve implantation test,to evaluate the risk of coronary artery obstruction suggested by CT angiography planar image reconstruction before TAVR.

Single-center Learning Curve Analysis of Transcatheter Aortic Valve Replacement / 中国循环杂志

Objectives:To evaluate the learning curve of transcatheter aortic valve replacement(TAVR)in a single center by single operator using Venus A valve. Methods:A total of 150 patients with severe aortic stenosis who underwent TAVR using Venus A valve in Fujian Provincial Hospital from July 2018 to May 2022 were selected.According to the time order of TAVR,the 1st-50th patients were included in group A,the 51st-100th patients were included in group B and the 101st-150th patients were included in group C.The basic clinical data,perioperative parameters and postoperative follow-up data of the three groups were analyzed. Results:All high-risk patients with severe aortic stenosis had an average STS score(7.9±1.5)and were treated with Venus A valve.The total operation time of group A,group B and group C was(226.2±86.3)min,(115.2±47.1)min,(108.2±38.1)min;the peripheral path operation time was(45±10)min,(20±7)min,(18±6)min;the valve release time was(13.0±2.3)min,(5.0±2.1)min,(3.0±1.7)min;the X-ray fluoroscopy time was(24±8)min,(11±5)min,(10±3)min;the radiation dose was(1 266±227)mGy,(532±132)mGy,(519±108)mGy;and the total incidence of perioperative adverse events was 46%,18%,16%,respectively.The differences were statistically significant(all P<0.05).The total incidence of adverse events during follow-up within 6 months for patients in group A,group B,and group C were 6%,2%,and 0%(P>0.05).With the increase of TAVR cases,the correlation curve of each time node of TAVR and radiation dose tended to be stable after the 50th-60th cases. Conclusions:With the increase of procedural experience,the total operation time,operative time nodes,radiation dose and perioperative adverse events of TAVR with Venus A valve decreases gradually,and the operator usually needs 50-60 cases to cross the TAVR learning curve.

The First Application of Domestically Produced Self-expanding Transcatheter Aortic Valve Controllable Bending Delivery System in China / 中国循环杂志

A domestically produced self-expanding transcatheter aortic valve controllable bending delivery system(VitaFlow? Ⅲcontrollable bending retrievable delivery system)was first used to perform transcatheter aortic valve replacement(TAVR)in a symptomatic severe aortic valve stenosis patient with severe heart failure and high risk of surgery in China on September 22,2023.The patient successfully completed TAVR under general anesthesia,with good valve position and function after the operation.Before discharge and at one month of follow-up,the patient's symptoms and degree of heart failure were significantly improved.The follow-up results of this case showed that the VitaFlow? Ⅲ controllable bending retrievable delivery system for TAVR is safe and feasible,and future prospective,multicenter clinical trials are expected to evaluate its efficacy.

Progression,Imaging Characteristics of Left Ventricular Remodeling and the Clinical Value on Decision-making of Intervention in Patients With Aortic Stenosis / 中国循环杂志

Aortic stenosis is a valve disease characterized by dynamic and continuous changes in structure and function of left ventricle.Left ventricular remodeling,which embodies pathological changes in myocardial cellular and ventricular geometry,is an important prognostic factor of patients with aortic stenosis.Aortic valve replacement is the only effective treatment for severe aortic stenosis.Current guideline recommendations for interventions are based on symptoms and left ventricular ejection fraction.With the improvements of modern imaging technology,different patterns of remodeling,including hypertrophy and fibrosis,could be identified now.Studies also explored the close association between left ventricular remodeling and function in the setting of aortic stenosis.In this review,we aim to elucidate the characteristic imaging features and potential mechanisms of left ventricular remodeling,and further,we highlight the clinical value of specific imaging features and clinical application of modern imaging methods in the evaluation,risk stratification,and intervention decision-making for patients with aortic stenosis.

Minimally invasive aortic valve replacement with Perceval sutureless aortic bioprosthesis through upper ministernotomy or right anterior thoracotomy / 中国胸心血管外科临床杂志

@#Objective To evaluate the clinical effect of minimally invasive aortic valve replacement with Perceval sutureless aortic bioprosthesis in upper ministernotomy or right anterior thoracotomy. Methods From March to November 2022, the patients with simple aortic valve disease were enrolled in the Department of Cardiovascular Surgery of West China Hospital, Sichuan University. After preoperative evaluation, Perceval sutureless bioprosthesis was successfully used to perform aortic valve replacement through the upper ministernotomy or right anterior thoracotomy. The perioperative clinical data and ultrasonic measurement data of all patients were recorded. Results A total of 5 patients with simple aortic valve disease were included, including 3 females and 2 males, with a mean age of 71.2 years. Perceval sutureless bioprosthesis was successfully implanted in 5 patients, with a success rate of 100%. There were 3 patients receiving upper ministernotomy and 2 patients receiving right anterior thoracotomy. Two patients underwent ascending aortic plasty at the same time. The mean cardiopulmonary bypass time was 61.0 min, and aortic cross-clamping time was 32.2 min. All patients were discharged successfully without perivalvular leakage, atrioventricular block or stroke. Conclusion The implantation method of Perceval sutureless bioprosthesis is simple, which can effectively reduce the perioperative risk by shortening the overall operation time, cardiopulmonary bypass time and aortic cross-clamping time. At the same time, its clinical application has promoted the development and popularization of minimally invasive aortic valve replacement, which together with Perceval sutureless bioprosthesis effectively combinates surgical effect and minimally invasive treatment, and has a good clinical application prospect because of its reliable safety and effectiveness.

Transcatheter aortic valve replacement (TAVR) annual report 2023 / 中国胸心血管外科临床杂志

@#Transcatheter aortic valve replacement (TAVR) has seen a surge in clinical research, basic research, and innovative device development both domestically and internationally in the previous 2023. This article aims to review the progress of TAVR in the past year from the perspectives of international, and domestic research development of application. It highlights new clinical and basic research findings both domestically and internationally, the emergence of new devices and technologies, and the development and use of TAVR in China. Finally, it provides an outlook on the trajectory of TAVR development in 2024.

The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement

ABSTRACT Introduction: The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. Methods: A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. Results: Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. Conclusion: This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

The Association Between Ascending Aortic and Left Ventricular Dimensions in Patients After Aortic Valve Replacement

ABSTRACT Introduction: Aortic valve replacement (AVR) is often recommended for patients with severe aortic stenosis or chronic aortic regurgitation. These conditions result in remodeling of the left ventricle, including increased interstitial fibrosis that may persist even after AVR. These structural changes impact left ventricular (LV) mechanics, causing compromised LV diameter to occur earlier than reduced LV ejection fraction (LVEF). The aim of this study was to examine the effect of left ventricular end-diastolic diameter (LVEDD) and its role in aortic expansion one year after AVR. Methods: Sixty-three patients who underwent AVR were evaluated. All patients underwent standard transthoracic echocardiography, which included measurements of the ascending aorta, aortic root, LVEF, and LVEDD before the surgery and one year postoperatively. Correlations between these variables were calculated. Results: All patients underwent AVR with either a mechanical or biological prosthetic aortic valve. Following AVR, there was a significant decrease in the dimensions of the ascending aorta and aortic root (both P=0.001). However, no significant changes were observed in LVEDD and LVEF. Correlations were found between the preoperative ascending aortic size and the preoperative and one-year postoperative LVEDD (r=0.419, P=0.001 and r=0.320, P=0.314, respectively). Additionally, there was a correlation between the postoperative ascending aortic size and the preoperative and one-year postoperative LVEDD (r=0.320, P=0.003 and r=0.136, P=0.335, respectively). Conclusion: The study findings demonstrate a significant correlation between the size of the aortic root and ascending aorta, before and after AVR. Additionally, a notable correlation was observed between postoperative LVEDD and the size of the aortic root.