Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study.

OBJECTIVE: This study aimed to compare hemodynamic performances and clinical outcomes of patients with small aortic annulus (SAA) who underwent aortic valve replacement by means of sutureless aortic valve replacement (SUAVR) or transcatheter aortic valve implantation (TAVI). METHODS: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs). RESULTS: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2 vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012). CONCLUSION: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.

Outcomes among patients undergoing transcatheter aortic valve replacement with very low baseline gradients.

Background: While there is evidence that patients with low-flow, low-gradient aortic stenosis (AS) benefit from transcatheter aortic valve replacement (TAVR), data are lacking regarding outcomes of patients with a very low gradient (VLG). Methods: In this retrospective, single-center study of patients with severe AS who underwent TAVR, three groups were defined using baseline mean aortic valve gradient: VLG (≤25 mmHg), low gradient (LG, 26-39 mmHg), and high gradient (HG, ≥40 mmHg). The primary outcome was the composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 of <45, decrease in KCCQ-12 of ≥10 compared with baseline, or death at 1 year. Results: One-thousand six patients were included: 571 HG, 353 LG, and 82 VLG. The median age was 82.1 years [interquartile range (IQR) 76.3-86.9]; VLG patients had more baseline comorbidities compared with the other groups. The primary outcome was highest at 1 year in the VLG group (VLG, 46.7%; LG, 29.9%; HG, 23.1%; p = 0.002), with no difference between groups after adjustment for baseline characteristics. At baseline, <30% of VLG patients had an excellent or good (50-100) KCCQ-12, whereas more than 75% and 50% had an excellent or good KCCQ-12 at 30-day and 1-year follow-up, respectively. Conclusion: Although patients with VLG undergoing TAVR have a higher rate of poor outcomes at 1 year compared with patients with LG and HG severe AS, this difference is largely attributable to baseline comorbidities. Patients with severe AS undergoing TAVR have significant improvement in health status outcomes regardless of resting mean gradient.

The Endothelial Transcription Factor ERG Mediates a Differential Role in the Aneurysmatic Ascending Aorta with Bicuspid or Tricuspid Aorta Valve: A Preliminary Study.

The pathobiology of ascending aorta aneurysms (AAA) onset and progression is not well understood and only partially characterized. AAA are also complicated in case of bicuspid aorta valve (BAV) anatomy. There is emerging evidence about the crucial role of endothelium-related pathways, which show in AAA an altered expression and function. Here, we examined the involvement of ERG-related pathways in the differential progression of disease in aortic tissues from patients having a BAV or tricuspid aorta valve (TAV) with or without AAA. Our findings identified ERG as a novel endothelial-specific regulator of TGF-ß-SMAD, Notch, and NO pathways, by modulating a differential fibrotic or calcified AAA progression in BAV and TAV aortas. We provided evidence that calcification is correlated to different ERG expression (as gene and protein), which appears to be under control of Notch signaling. The latter, when increased, associated with an early calcification in aortas with BAV valve and aneurysmatic, was demonstrated to favor the progression versus severe complications, i.e., dissection or rupture. In TAV aneurysmatic aortas, ERG appeared to modulate fibrosis. Therefore, we proposed that ERG may represent a sensitive tissue biomarker to monitor AAA progression and a target to develop therapeutic strategies and influence surgical procedures.

Case Report: Transcatheter Aortic Valve Replacement in a Patient With Severe Aortic Stenosis, Left Ventricular Dysfunction, and an Anomalous Left Circumflex Artery.

The role of cardiac computed tomography in the evaluation of patients for transcatheter aortic valve implantation is well-established. However, its role in the evaluation of anomalous vessels in the pre-procedure planning, intra-procedural fusion imaging and post-procedure assessment of vessel patency is not yet defined. This case report illustrates the utility of cardiac CT throughout the management of complex structural interventions. Here, we describe an anomalous left coronary artery where the course of the anomalous vessel and its proximity to the aortic valve annulus is defined allowing the selection of the most appropriate balloon expandable valve with a planned deployment. Upon follow up, patency of this anomalous vessel is ascertained using CT as well as the transcatheter valve function and leaflet thickening.

Early hemodynamic profile after aortic valve replacement - a comparison between three mechanical valves

Abstract Introduction: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves. Methods: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months. Results: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P<0.001), and aortic prosthetic size (beta coefficient -0.547, P<0.001), but not the prosthesis type, were independent predictors of postoperative aortic prosthetic mean pressure gradient. Conclusion: The three bileaflet mechanical aortic prostheses (On-X, Bicarbon, and ATS) provide satisfactory early hemodynamics, which are comparable between the three valve types and among different valve sizes.

Early Hemodynamic Profile after Aortic Valve Replacement - A Comparison between Three Mechanical Valves.

INTRODUCTION: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves. METHODS: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months. RESULTS: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P<0.001), and aortic prosthetic size (beta coefficient -0.547, P<0.001), but not the prosthesis type, were independent predictors of postoperative aortic prosthetic mean pressure gradient. CONCLUSION: The three bileaflet mechanical aortic prostheses (On-X, Bicarbon, and ATS) provide satisfactory early hemodynamics, which are comparable between the three valve types and among different valve sizes.

Recent trends in aortic valve interventions: Data of the Netherlands heart registration.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve implantation (TAVI) has evolved from bailout for inoperable patients to an alternative to surgical aortic valve replacement (SAVR) in higher-risk groups. The aim of this study is to describe these clinical trends in TAVI and SAVR in patients with aortic valve disease. METHODS: We analyzed data of the Netherlands Heart Registration (NHR) up to 2018 to explore the trends in TAVI and SAVR among 14 cardiac centers in the Netherlands. RESULTS: Between 2013 and 2017, a total of 7432 isolated SAVR and 5929 TAVI procedures have been performed. A 43.9% increase in the total number of procedures was observed, mainly due to the considerable increase in the number of TAVI procedures. In 2017, there was a decrease in the number of SAVR procedures. In the TAVI group, 30- and 120-day mortality decreased significantly from 7.2% and 10.6% in 2013 to 3.4% and 5.7% in 2017, respectively. In the SAVR group, 30- and 120-day mortality decreased from 1.7% and 2.9% in 2013 to 1.2% and 1.7% in 2017, respectively. Outcomes showed a significant decrease in vascular complications after TAVI. The risk profile of TAVI patients has changed over time. CONCLUSIONS: The recent developments in TAVI have contributed to the increasing numbers of aortic valve interventions in the Netherlands. Mortality rates after SAVR and TAVI decreased as did the rate of complications after TAVI. Furthermore, a trend towards decrease of preoperative risk was observed.

Preprocedure CT Findings of Right Heart Failure as a Predictor of Mortality After Transcatheter Aortic Valve Replacement.

OBJECTIVE: The purpose of this study is to determine whether imaging features of right heart failure seen on CT performed before transcatheter aorta valve replacement (TAVR) predict poor outcomes after the procedure. MATERIALS AND METHODS: We retrospectively evaluated findings on CT performed before TAVR for 505 consecutive patients seen from 2014 to 2018. Of these patients, 300 underwent TAVR. Patient demographic characteristics and clinical and procedural data were recorded. Imaging features, including signs of right heart failure, left heart failure, lung disease, coronary artery disease, and concomitant mitral valve and apparatus calcifications were evaluated. The primary outcome was all-cause mortality at 1 year after TAVR. Patients were divided into two groups: those who were alive (group 1) and those who had died (group 2) by 1 year after TAVR. These groups were compared using the Mann-Whitney U test and the Pearson chi-square and Fisher exact tests when applicable. Multivariate logistic regression with a backward stepwise approach was performed. Results were correlated with echo-cardiography findings. RESULTS: A total of 31 patients (10.3%) died within 1 year of TAVR. The presence and size of pericardial effusions were strongly associated with mortality within 1 year after TAVR (p = 0.002). Pericardial effusion was noted in 25 patients in group 1 (9.3%) and eight patients in group 2 (25.8%). Increased size of the main pulmonary artery was associated with death (p = 0.024), with a median main pulmonary artery size of 2.9 cm (interquartile range, 2.6-3.3 cm) in group 1 and 3.2 cm (interquartile range, 2.9-3.5 cm) in group 2. In multivariate analysis, pericardial effusion size and pulmonary artery size, both of which are indicative of right heart failure, were predictors of death, independent of the routinely used clinical Society of Thoracic Surgeons score (AUC, 0.758; 95% CI, 0.671-0.845). Depressed right ventricular ejection fraction, as identified on echocardiography, was associated with mortality within 1 year after TAVR (p = 0.034), further corroborating the CT findings. CONCLUSION: Features related to right heart failure on pre-TAVR CT were associated with increased all-cause mortality within the first year after TAVR, even after adjustment for the Society of Thoracic Surgeons score. Such imaging findings can help in further risk stratification of patients before TAVR.

A rare case of aortic valve myxoma: easy to confuse with papillary fibroelastoma.

Myxoma of the aortic valve is an exceedingly uncommon condition. In this article, we report the case of a 72-year-old man with myxoma arising from the aortic valve. We extirpated the mass and repaired the aortic valve with the patient under cardiopulmonary bypass. The postoperative course was uneventful. Histological examination confirmed that the mass was a myxoma.

A Rare Case of Aortic Valve Myxoma: Easy to Confuse With Papillary Fibroelastoma

Myxoma of the aortic valve is an exceedingly uncommon condition. In this article, we report the case of a 72-year-old man with myxoma arising from the aortic valve. We extirpated the mass and repaired the aortic valve with the patient under cardiopulmonary bypass. The postoperative course was uneventful. Histological examination confirmed that the mass was a myxoma.

Expressions and roles of CTGF and MT1-MMP in extracellular matrix remodeling of left ventricle in patients with aorta valve stenosis / 第三军医大学学报

Objective To approach the expressions and the roles of connective tissue growth factor (CTGF) and membrane type 1 matrix metalloproteinases (MT1-MMP) in valve disease with pressure overload which induces extracellular matrix remodeling of left ventricle. MethodsOf 32 patients, 16 cases were pressure overload group (PO), who had the multiple valve disease with predominately aortic valve stenosis, having a ring diameter of aorta valve less than 1.3 cm, cross valve pressure gradient equal or more than 40 mmHg, and valvular regurgitation less than 4.0 cm2; The other 16 cases, as mitral stenosis group (MS), were simple mitral stenosis patients with single valve replacement. Meanwhile, 5 normal individuals served as control, who died from accident. Echocardiography was used to analyze the left ventricular function and detect the hypertrophic level of the left ventricle. Left ventricle muscle samples were obtained during operation. Histological features were studied by Masson staining, and collagenous contents were quantitated with a computer-assisted imaging analysis system. The mRNA expressions of CTGF and MT1-MMP were detected with RT-PCR. ResultsConcentric hypertrophy was observed significant in PO group, but myocardial hypertrophy was not found in MS group. Compare to the MS group and control, PO group had significantly more collagenous contents in left ventricle, thickened vessel wall, and narrow lumen of blood vessel (P0.05), but CTGF mRNA expression was increased in MS group compare to control (P