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Purpose of Review: Elevated lipoprotein(a) (Lp[a]) is a genetically determined cardiovascular risk factor, causally linked to both atherosclerotic coronary artery disease and aortic stenosis. Elevated Lp(a) is widely prevalent, and several cardiovascular societies now recommend performing Lp(a) screening at least once in all adults. However, there are currently no approved drugs aimed specifically at lowering Lp(a). In this review, we describe several promising Lp(a)-lowering therapies in the drug development pipeline and outline what role these may have in future clinical practice. Recent Findings: Pelacarsen and olpasiran are two novel RNA-based injectable therapies which are being studied in ongoing phase 3 clinical trials, with the earliest of these to be concluded in 2025. These drugs act by degrading transcribed LPA mRNA, which would normally yield the apolipoprotein(a) constituent of Lp(a). Other candidate drugs, such as Lepodisiran, Zerlasiran, and Muvalaplin, are also in early-stage development. Summary: While there are presently no Lp(a)-lowering drugs available for routine clinical use, several promising candidates are currently under investigation. If these prove to be effective in randomized clinical trials, they will expand the cardiovascular care armamentarium and will allow clinicians to treat a presently unmitigated cardiovascular risk factor. [ABSTRACT FROM AUTHOR]

Background: Older adults with severe aortic stenosis (AS) may receive care in a nursing home (NH) prior to undergoing transcatheter aortic valve replacement (TAVR). NH level of care can be used to stabilize medical conditions, to provide rehabilitation services, or for long‐term care services. Our primary objective is to determine whether NH utilization pre‐TAVR can be used to stratify patients at risk for higher mortality and poor disposition outcomes at 30 and 365 days post‐TAVR. Methods: We conducted a retrospective cohort study among Medicare beneficiaries who spent ≥1 day in an NH 6 months before TAVR (2011–2019). The intensity of NH utilization was categorized as low users (1–30 days), medium users (31–89 days), long‐stay NH residents (≥ 100 days, with no more than a 10‐day gap in care), and high post‐acute rehabilitation patients (≥90 days, with more than a 10‐day gap in care). The probabilities of death and disposition were estimated using multinomial logistic regression, adjusting for age, sex, and race. Results: Among 15,581 patients, 9908 (63.6%) were low users, 4312 (27.7%) were medium users, 663 (4.3%) were high post‐acute care rehab users, and 698 (4.4%) were long‐stay NH residents before TAVR. High post‐acute care rehabilitation patients were more likely to have dementia, weight loss, falls, and extensive dependence of activities of daily living (ADLs) as compared with low NH users. Mortality was the greatest in high post‐acute care rehab users: 5.5% at 30 days, and 36.4% at 365 days. In contrast, low NH users had similar mortality rates compared with long‐stay NH residents: 4.8% versus 4.8% at 30 days, and 24.9% versus 27.0% at 365 days. Conclusion: Frequent bouts of post‐acute rehabilitation before TAVR were associated with adverse outcomes, yet this metric may be helpful to determine which patients with severe AS could benefit from palliative and geriatric services. [ABSTRACT FROM AUTHOR]

Over the past few years, transcatheter aortic valve implantation (TAVI) imposed itself as the first-choice therapy for symptomatic aortic stenosis (AS) in elderly patients at surgical risk. There have been continuous technological advancements in the latest iterations of TAVI devices and implantation techniques, which have bolstered their adoption. Moreover, the favorable outcomes coming out from clinical trials represent an indisputable point of strength for TAVI. As indications for transcatheter therapies now include a low surgical risk and younger individuals, new challenges are emerging. In this context, the matter of prosthesis durability is noteworthy. Initial evidence is beginning to emerge from the studies in the field, but they are still limited and compromised by multiple biases. Additionally, the physiopathological mechanisms behind the valve's deterioration are nowadays somewhat clearer and classified. So, who outlasts who—the valve or the patient? This review aims to explore the available evidence surrounding this intriguing question, examining the various factors affecting prosthesis durability and discussing its potential implications for clinical management and current interventional practice. [ABSTRACT FROM AUTHOR]

Abstract Transcatheter aortic valve replacement (TAVR) is a well‐established procedure using a catheter‐introduced valve prosthesis for patients with severe aortic stenosis (AS). This retrospective study investigated sex‐related differences in pre‐ and post‐TAVR clinical and hemodynamic outcomes and analyzed data of the first 100 cases at Kaohsiung Medical University Chung‐Ho Memorial Hospital (KMUH) between December 2013 and December 2021. Baseline characteristics, procedural outcomes, mortality rates, and echocardiographic parameters were analyzed and compared between sexes. Among the 100 patients, male (46%) and female (54%) were of similar age (mean age, male 86.0 years vs. female 84.5 years) and of the same severity of AS (mean pressure gradient, male 47.5 mmHg vs. female 45.7 mmHg) at the time receiving the TAVR procedure. Women had smaller aortic valve areas calculated by continuity equation (0.8 ± 0.3 cm2 vs. 0.7 ± 0.2 cm2, p

Transcatheter aortic valve replacement (TAVR) is a well‐established procedure using a catheter‐introduced valve prosthesis for patients with severe aortic stenosis (AS). This retrospective study investigated sex‐related differences in pre‐ and post‐TAVR clinical and hemodynamic outcomes and analyzed data of the first 100 cases at Kaohsiung Medical University Chung‐Ho Memorial Hospital (KMUH) between December 2013 and December 2021. Baseline characteristics, procedural outcomes, mortality rates, and echocardiographic parameters were analyzed and compared between sexes. Among the 100 patients, male (46%) and female (54%) were of similar age (mean age, male 86.0 years vs. female 84.5 years) and of the same severity of AS (mean pressure gradient, male 47.5 mmHg vs. female 45.7 mmHg) at the time receiving the TAVR procedure. Women had smaller aortic valve areas calculated by continuity equation (0.8 ± 0.3 cm2 vs. 0.7 ± 0.2 cm2, p < 0.001). In addition, women had better left ventricle ejection fraction (59.6 ± 14.0% vs. men 54.7 ± 17.2%, p < 0.01). In the post‐TAVR follow‐up, regression of left ventricle mass and dimension was better in women than in men. None of the patient died within 30 days after the procedure, and women tended to have a more favorable survival than men (2‐year mortality and overall mortality rate in 8.3 year, women 9.1% and 22.2% vs. men 22.2% and 34.8%; p = 0.6385 and 0.1277, respectively). In conclusion, the sex‐based difference in post‐TAVR regression of LV remodeling suggests a need for sex‐based evaluation for patients with severe AS and their post TAVR follow‐up. [ABSTRACT FROM AUTHOR]

Goal: To evaluate the suitability of seismocardiogram (SCG) and gyrocardiogram (GCG) recorded at the skin level to classify aortic stenosis (AS) patients from healthy volunteers, and to determine the optimal sensor position for the classification. Methods: SCG and GCG were recorded along three axes at five chest locations of fifteen healthy subjects and AS patients. Signal frames underwent feature extraction in frequency and time-frequency domains. Then, binary classification was performed through three machine learning and three deep learning methods, considering SCG, GCG, and their combination. Results: The highest classification accuracies were achieved using Support Vector Machine (SVM) classifier, with the best sensor locations being at the mitral valve for SCG signals (92.3% accuracy) and at the pulmonary valve for GCG (92.1%). Combining SCG and GCG data allows for further improvement in the achievable accuracy (93.5%). Jointly exploiting SCG and GCG signals and both SVM- and ResNet18-based classifiers, 40 s of monitoring allows for reaching 97.2% accuracy with a single sensor on the pulmonary valve. Conclusions: Combining SCG and GCG with adequate machine learning and deep learning classifiers allows reliable classification of AS patients.

Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta‐analyses identified preexisting right bundle branch block (RBBB), LAHB, and new‐onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self‐expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post‐TAVR, highlighting the need for further research and standardized treatment strategies. [ABSTRACT FROM AUTHOR]

BackgroundCoronary artery disease (CAD) is a common finding in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). However, the impact on prognosis of chronic total occlusions (CTOs), a drastic expression of CAD, remains unclear.Methods and resultsWe retrospectively reviewed 1,487 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 11.2% (n = 167) patients had a CTO. There was no significant association between the presence of a CTO and in-hospital or 30-day mortality. There was also no difference in long-term survival. LV ejection fraction and mean aortic gradients were lower in the CTO group.ConclusionsOur analysis suggests that concomitant CTO lesions in patients undergoing TAVR differ in their risk profile and clinical findings to patients without CTO. CTO lesion per se were not associated with increased mortality, nevertheless CTOs which supply non-viable myocardium in TAVR population were associated with increased risk of death. Additional research is needed to evaluate the prognostic significance of CTO lesions in TAVR patients.

BackgroundThe outcomes of transcatheter aortic valve replacement (TAVR) employing the second-generation retrievable VenusA-Pro and VenusA-Plus delivery systems with the self-expanding VenusA-Valve have not been described yet. This study aims to report the outcomes of these two second-generation delivery systems.MethodsFrom January 2022 to April 2023, we prospectively enrolled patients with severe aortic stenosis undergoing TAVR with VenusA-Pro from three centers across China in this first-in-man study and retrospectively identified those undergoing TAVR with VenusA-Plus. All outcomes were reported according to the Valve Academic Research Consortium 3 definition. The primary outcome was 30-day all-cause mortality.ResultsA total of 156 patients were included, of which 46 underwent TAVR with VenusA-Pro and 110 underwent TAVR with VenusA-Plus. The Society of Thoracic Surgeons median score was 2.1%, bicuspid anatomy prevalence rate was 55.1%, and the mean aortic root calcification volume was 693 mm3. The technical success rate was 91.7%, comparable between the VenusA-Pro and VenusA-Plus groups (87.0% vs. 93.6%, P = 0.169). The 30-day all-cause mortality was 2.6%, similar between the VenusA-Pro and VenusA-Plus groups (2.2% vs. 2.7%, P = 0.842). No myocardial infarction occurred. The incidences of stroke (0.6%), major bleeding (3.8%), major vascular complications (5.1%), acute kidney injury (9.0%), permanent pacemaker implantation (5.1%), new-onset atrial fibrillation (5.8%), and moderate-to-severe paravalvular aortic regurgitation (6.0%) were favorable and comparable between the two groups. The clinical outcomes were similar between the patients with bicuspid and tricuspid aortic valve, except that the incidence of permanent pacemaker implantation was lower in patients with bicuspid anatomy (1.2% vs. 10.6%, P = 0.010).ConclusionsThe 30-day outcomes of TAVR with VenusA-Pro and VenusA-Plus were favorable and comparable.

BackgroundTranscatheter aortic valve implantation (TAVI) is a standard treatment for patients with aortic valve stenosis due to its very low mortality and complication rates. However, survival and physical integrity are not the only important factors. Quality of life (QoL) improvement is a crucial part in the evaluation of therapy success.MethodsPatients with TAVI were questioned about their QoL before, one month and one year after the intervention as part of the INTERVENT registry trial at Mainz University Medical Center. Three different questionnaires were included in the data collection (Katz ADL, EQ-5D-5l, PHQ-D).ResultsWe included 285 TAVI patients in the analysis (mean age 79.8 years, 59.4% male, mean EuroSCORE II 3.8%). 30-day mortality was 3.6%, complications of any kind occurred in 18.9% of the patients. Main finding was a significant increase in the general state of health measured on the visual analog scale by an average of 4.53 (± 23.58) points (BL to 1-month follow-up, p = 0.009) and by 5.19 (± 23.64) points (BL to 12-month follow-up, p = 0.016). There was also an improvement of depression symptoms, which was reflected in a decrease in the total value of the PHQ-D by 1.67 (± 4.75) points (BL to 12-month follow-up, p = 0.001). The evaluation of the EQ-5D-5l showed a significant improvement in mobility after one month (M = −0.41 (± 1.31), p

BackgroundData on outcomes following transcatheter aortic valve replacement with SAPIEN 3 in China is limited as it was approved by the National Medical Products since 2020. The present study was designed to collect clinical data on the SAPIEN 3 aortic valve in Chinese patients with bicuspid aortic valve and tricuspid aortic valve stenosis.MethodsWe analyzed the patient characteristics, procedural features and procedural outcomes of the first 438 patients (223 for bicuspid aortic valve and 215 tricuspid aortic valve) from 21 provinces in 74 sites treated with the SAPIEN 3 valve system for transcatheter aortic valve replacement between September 2020 and May 2022.ResultsProcedural mortality was 0.7%. 5 cases during the operation were converted to surgery. Among 438 cases, permanent pacemaker implantation was performed in a total of 12 cases (2.7%). The patient had severe leaflet calcification of the aortic valve, with moderate and severe calcification reaching 39.7% and 35.2% respectively. The size of the implanted valves was predominantly 26 mm and 23 mm, reaching 42.5% and 39.5% respectively. The incidence of moderate or severe perivalvular leak in the postoperative period was 0.5%, with a predominance of 90/10 and 80/20 valve deployment height. There was a significant difference in the deployment height of the valve between bicuspid aortic valve and tricuspid aortic valve, with the bicuspid aortic valve having a more deployment height of 90/10. Annulus size in bicuspid aortic valve group was significantly larger than tricuspid aortic valve group. Valve sizing for oversized, within size, and undersized were different between bicuspid aortic valve and tricuspid aortic valve.ConclusionsProcedural success rates were high, with similar and good results for bicuspid aortic valve and tricuspid aortic valve, low perivalvular leak for both valve types, and low permanent pacemaker implantation rates for both valve types. Annulus size, valve sizing and coronary artery height were significantly different in the BAV and TAV group.

BackgroundThe advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras.MethodsFrom January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000–2011, n = 2,426) and post-TAVR era (2012–2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed.ResultsThe median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p

Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.

AimsPredictors of progression of moderate aortic valve stenosis (AS) are incompletely understood. The objective of this study was to evaluate the prognostic value of left ventricular hypertrophy (LVH), diastolic dysfunction, and right ventricular (RV) load in moderate AS.Methods and resultsModerate AS was defined by aortic valve area (AVA), peak transvalvular velocity (Vmax) or mean pressure gradient (PGmean). A total of 131 Patients were divided into two groups according to the number of pathophysiological changes (LVH, diastolic dysfunction with increased LV filling pressures and/or RV load):

Objective: The aim of this study was to compare outcomes of transcatheter heart valve (THV) choice in patients with left ventricular (LV) systolic dysfunction. Background: The management congestive heart failure with combined LV systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. Head‐to‐head comparisons among the balloon‐expandable (BEV) and self‐expandable (SEV) THV remain limited in this subgroup of patients. Methods: In this retrospective study, we included patients with severe AS with LV systolic dysfunction (LVEF ≤40%) who underwent TAVR at four high volume centers. Two thousand and twenty‐eight consecutive patients were analyzed, of which 335 patients met inclusion criteria. One hundred fourty‐six patients (43%) received a SEV, and 189 patients (57%) received a BEV. Results: Baseline characteristics were similar except for a higher proportion of females in the SEV group. The primary composite endpoint of in‐hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve reintervention, and/or need for permanent pacemaker (PPM) was no different among THV choice. There was more PVL in the SEV group, but higher transaortic gradients in the BEV group. Clinical outcomes and quality of life measures were similar up to 1 year follow‐up. Conclusion: The choice of THV in patients with severe AS and systolic dysfunction must be weighed on a case‐by‐case basis. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis evaluates the potential of four-dimensional flow magnetic resonance imaging (4DFM) in assessing aortic stenosis (AS) compared to traditional imaging modalities like two-dimensional phase contrast MRI (2D MRI) and transthoracic echocardiography (TTE). AS is a common and severe valvular heart disease, particularly in older adults, requiring accurate diagnosis for proper clinical management. Conventional imaging methods have limitations in capturing complex flow dynamics, prompting the need for advanced modalities like 4DFM. The objectives of the review were to determine whether 4DFM offers superior diagnostic metrics, including peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA), and to identify potential advantages of 4DFM in overcoming the limitations of traditional modalities. This review included six cohort studies with 285 participants, examining the diagnostic accuracy of 4DFM in terms of peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA). Studies were selected from MEDLINE (PubMed), Cochrane Library, and Google Scholar databases between December 2010 and October 2024. The study pool was limited by stringent inclusion criteria focusing on cohort studies that directly compared 4DFM with TTE or 2D MRI for AS assessment. The National Institutes of Health Quality Assessment Tool and Cochrane ROBINS-I tool were used to assess bias. Quantitative results showed that 4DFM typically measured higher AVA values than TTE, with a mean difference of 0.48 cm² (95% CI: -0.16 to 1.12). For mean pressure gradients, 4DFM reported slightly higher measurements in individual studies, but pooled results showed no significant difference compared to TTE (mean difference: 3.32 mmHg, 95% CI: -2.30 to 8.93). In terms of peak aortic jet velocity, 4DFM demonstrated a pooled mean difference of -0.18 m/s (95% CI: -0.44 to 0.08) compared to TTE. High heterogeneity was observed across studies (e.g., I² = 97% for peak velocity, I² = 93% for AVA), likely due to differences in patient populations, imaging protocols, and software for data analysis. 4DFM demonstrates potential as a complementary imaging tool, particularly in complex AS cases where conventional methods like TTE may provide inconclusive results. Its capacity to capture intricate flow dynamics and deliver high spatial resolution could inform clinical decision-making, potentially influencing practice guidelines to integrate 4DFM as a supplementary tool. Limitations such as high costs, specialized training requirements, and access challenges currently restrict widespread adoption. Limitations of this review include small sample sizes, high heterogeneity, and variability in patient populations and imaging protocols. Despite these challenges, 4DFMI demonstrated superior spatial resolution and complex cardiovascular flow assessment, suggesting it could serve as a valuable complement to TTE for more detailed AS evaluation, particularly in complex cases. Future studies should aim to standardize imaging protocols, incorporate larger and more diverse populations, and conduct cost-benefit analyses to support the integration of 4DFM into clinical practice, potentially shaping future diagnostic guidelines., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Chandrasekar et al.)

The prevalence of coronary microvascular dysfunction (CMD) beyond the spectrum of chronic coronary syndromes (CCS) is non-negligible, pertaining to pathophysiological and therapeutical implications. Thanks to the availability of accurate and safe non-invasive technique, CMD can be identified as a key player in heart failure, cardiomyopathies, Takotsubo syndrome, aortic stenosis. While CMD is widely recognized as a cause of myocardial ischemia leading to a worse prognosis even in the absence of obstructive coronary artery disease, the characterization of CMD patterns beyond CCS might provide valuable insights on the underlying disease progression, being potentially a "red flag" of adverse cardiac remodeling and a major determinant of response to therapy and outcomes. In this review, we aimed to provide an overview of the latest evidence on the prevalence, mechanistic and prognostic implications of CMD beyond the spectrum of CCS (i.e. heart failure, cardiomyopathies, Takotsubo syndrome, aortic stenosis)., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024. Published by Elsevier Inc.)

The clinical use indications for transcatheter aortic valve replacement (TAVR) for the treatment of severe symptomatic aortic stenosis (AS) have expanded from patients at high surgical risk to those at low risk based on the results of multiple large-scale randomized trials. However, patients with bicuspid AS have traditionally been excluded from clinical trials due to their unfavorable morphological characteristics. Bicuspid aortic valve (BAV) is the most frequent congenital heart disease, occurring in 1% to 2% of the total population and affects more than 20% of octogenarians undergoing isolated aortic valve replacement for AS. In recent years, TAVR in patients with bicuspid AS has been the focus of research, especially with respect to the standard of prosthesis size selection. Annulus-based prosthesis size selection using computed tomography (CT) is the standard sizing strategy for tricuspid AS, but no standard sizing for bicuspid AS has been developed thus far. According to Western TAVR experiences, transcatheter heart valve (THV) size selection for BAV patients should be based on the annular structure assessment by CT measurement, whereas Chinese experiences favor adopting the supra-annulus structure assessment for THV size selection. This article will review annular and supra-annular sizing for prosthesis size selection in patients with bicuspid AS before TAVR and discuss which has more favorable clinical outcomes.

Since the first groundbreaking procedure in 2002, transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis (AS). Through striking developments in pertinent equipment and techniques, TAVI has now become the leading therapeutic strategy for aortic valve replacement in patients with severe symptomatic AS. The procedure streamlining from routine use of conscious sedation to a single arterial access approach, the newly adapted implantation techniques, and the introduction of novel technologies such as intravascular lithotripsy and the refinement of valve-bioprosthesis devices along with the accumulating experience have resulted in a dramatic reduction of complications and have improved associated outcomes that are now considered comparable or even superior to surgical aortic valve replacement (SAVR). These advances have opened the road to the use of TAVI in younger and lower-risk patients and up-to-date data from landmark studies have now established the outstanding efficacy and safety of TAVI in patients with low-surgical risk impelling the most recent ESC guidelines to propose TAVI, as the main therapeutic strategy for patients with AS aged 75 years or older. In this article, we aim to summarize the most recent advances and the current clinical aspects involving the use of TAVI, and we also attempt to highlight impending concerns that need to be further addressed.

BackgroundOld age and the presence of aortic stenosis are associated with the unfolding of the intrathoracic aorta. This may result in increased difficulties navigating catheters from the right compared to the left radial approach.ObjectiveTo investigate whether increasing age or presence of severe aortic stenosis was associated with increased catheterization success rates from left (LRA) compared to right radial artery approach (RRA).MethodsWe compared coronary angiography success rates of RRA and LRA according to different age groups and in a subgroup of patients with severe aortic stenosis.ResultsA total of 21,259 coronary angiographies were evaluated. With increasing age, the first pass success rate from either radial access decreased significantly (p < 0.001). In patients aged

Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complications associated with TAVI, the main current strategies for their prevention, and the implications of its pharmacological management at the follow-up in a TAVI population, mostly frail and predisposed to bleeding complications.

ObjectivesThis study compared transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in terms of short- and long-term effectiveness.MethodsThis retrospective cohort study based on nationwide National Health Insurance claims data and Cause of Death data focused on adult patients (n = 3,643) who received SAVR (79%) or TAVR (21%) between 2015 and 2019. Propensity score overlap weighting was applied to account for selection bias. Primary outcomes included all-cause mortality (ACM), hospitalization for heart failure, and a composite endpoint of major adverse cardiac events (MACE). Secondary outcomes included medical utilization, hospital stay, and total medical costs at index admission for the procedure and in various post-procedure periods. The Cox proportional-hazard model with competing risk was used to investigate survival and incidental health outcomes. Generalized estimation equation (GEE) models were used to estimate differences in the utilization of medical resources and overall costs.ResultsAfter weighting, the mean age of the patients was 77.98 ± 5.86 years in the TAVR group and 77.98 ± 2.55 years in the SAVR group. More than half of the patients were female (53.94%). The incidence of negative outcomes was lower in the TAVR group than in the SAVR group, including 1-year ACM (11.39 vs. 17.98%) and 3-year ACM (15.77 vs. 23.85%). The risk of ACM was lower in the TAVR group (HR [95% CI]: 0.61 [0.44–0.84]; P = 0.002) as was the risk of CV death (HR [95% CI]: 0.47 [0.30–0.74]; P = 0.001) or MACE (HR [95% CI]: 0.66 [0.46–0.96]; P = 0.0274). Total medical costs were significantly higher in the TAVR group than in the SAVR in the first year after the procedure ($1,271.89 ± 4,048.36 vs. $887.20 ± 978.51; P = 0.0266); however, costs were similar in the second and third years after the procedure. The cumulative total medical costs after the procedure were significantly higher in the TAVR group than in the SAVR group (adjusted difference: $420.49 ± 176.48; P = 0.0172).ConclusionIn this real-world cohort of patients with aortic stenosis, TAVR proved superior to SAVR in terms of clinical outcomes and survival with comparable medical utilization after the procedure.

Aims Transcatheter aortic valve replacement (TAVR) procedural planning requires computed tomography angiography (CTA) which allows for the assessment of left ventricular global longitudinal strain (CTA-LVGLS). There is, however, limited data on the feasibility of CTA-LVGLS, and its prognostic value. This study sought to evaluate the incremental prognostic value of baseline CTA-LVGLS, change in CTA-LVGLS after TAVR, and their association with post-TAVR outcomes. Methods and results A total of 431 patients who underwent multiphasic gated CTA using dual-source system for TAVR planning at baseline and 1-month follow-up were included [median (interquartile range) age, 83 (77–87) years; 44% female, STS-PROM score: 3.3 (2.3–5.1)%, Echo-left ventricular ejection fraction (LVEF): 60 (55–65)%, CTA-LVGLS: −18.0 (−21.6 to −14.2)%, feasible in 97% of patients]. CTA-LVGLS was measured using dedicated feature-tracking software. Over a median follow-up of 19 (13–27) months, 99 endpoints of all-cause death or heart failure hospitalization occurred. The relative hazard of the endpoint increased as baseline CTA-LVGLS worsened with −18.2% as the threshold for higher events (P  = 0.005). After adjustment for baseline characteristics, CTA-LVGLS remained associated with the endpoint [hazard ratio (HR) (95% confidence interval, CI), 1.08 (1.03–1.14); P  = 0.005] and incrementally improved prognostication (C-index difference, 0.026). Although CTA-LVGLS improved after TAVR [−18.3 (−21.6 to −14.3)% vs. −18.7 (−21.9 to −15.4)%, P  < 0.001], patients without CTA-LVGLS improvement had higher risk of the endpoint than those with improvement or preserved baseline global longitudinal strain [HR (95% CI), 1.92 (1.19–3.12); P  = 0.008]. Conclusions In this predominantly low-risk TAVR cohort of patients, mostly with normal LVEF, assessment of CTA-LVGLS is highly feasible improving risk stratification by providing independent and incremental prognostic value over clinical and echocardiographic characteristics. [ABSTRACT FROM AUTHOR]

ObjectivesPatients with bicuspid aortic valve (BAV) stenosis were excluded from the pivotal trials of transcatheter aortic valve implantation (TAVI). We compared the in-hospital and long-term outcomes between patients undergoing TAVI for bicuspid and tricuspid aortic valve (TAV) stenosis.MethodsWe performed a retrospective registry-based analysis on patients who underwent TAVI for BAV and TAV at five different centers between January 2009 and August 2017. The primary outcome was long-term all-cause mortality. Secondary outcomes were in-hospital mortality, procedural complications, and valve performance.ResultsOf 1,451 consecutive patients who underwent TAVI, two propensity-matched cohorts consisting of 130 patients with BAV and 390 patients with TAV were analyzed. All-cause mortality was comparable in both groups up to 10 years following TAVI (HR 1.09, 95% CI: 0.77–1.51). Device success and in-hospital mortality were comparable between the groups (96 vs. 95%, p = 0.554 and 2.3 vs. 2.1%, p = 0.863, respectively). Incidence of procedural complications was similar in both groups, with a trend toward a higher rate of stroke in patients with BAV (5 vs. 2%, p = 0.078). Incidence of moderate or severe paravalvular leak (PVL) at discharge was comparable in both groups (2 vs. 2%, p = 0.846). Among patients with BAV, all-cause mortality was similar in self-expanding and balloon-expandable prostheses (HR 1.02, 95% CI: 0.52–1.99) and lower in new-generation devices compared to old-generation valves (HR 0.27, 95% CI 0.12–0.62).ConclusionPatients who had undergone TAVI for BAV had comparable mortality to patients with TAV up to 10 years after the procedure. The device success, in-hospital mortality, procedural complications, and PVL rate were comparable between the groups. The high rate of neurological complications (5%) in patients with BAV warrants further investigation.

BackgroundStudies on the association of Sievers bicuspid aortic valve (BAV) morphology with conduction disorders after transcatheter aortic valve replacement (TAVR) have not reached consensus.MethodsWe here performed a pooled-analysis to explore whether Sievers type 1 BAV morphology increased the risk of post-TAVR conduction abnormalities and permanent pacemaker implantation (PPI) compared to type 0. Systematic literature searches through EMBASE, Medline, and Cochrane databases were concluded on 1 December 2021. The primary endpoint was post-TAVR new PPI and pooled as risk ratios (RRs) and 95% confidence intervals (CIs). Conduction abnormalities as the secondary endpoint were the composites of post-TAVR PPI and/or new-onset high-degree of atrial-ventricle node block and left-bundle branch block. Studies that reported incidence of outcomes of interest in both type 1 and type 0 BAV morphology who underwent TAVR for aortic stenosis were included.ResultsFinally, nine studies were included. Baseline characteristics were generally comparable, but type 1 population was older with a higher surgical risk score compared to type 0 BAV morphology. In the pooled-analysis type 1 BAV had significantly higher risk of post-TAVR new-onset conduction abnormalities (RR = 1.68, 95%CI 1.09–2.60, p = 0.0195) and new PPI (RR = 1.97, 95%CI 1.29–2.99, p = 0.0016) compared to type 0. Random-effects univariate meta-regression indicated that no significant association between baseline characteristics and PPI.ConclusionSievers type 1 BAV morphology was associated with increased risk of post-TAVR PPI and conduction abnormalities compared to type 0. Dedicated cohort is warranted to further validate our hypothesis.

Transcatheter aortic valve implantation (TAVI) is an innovative and less invasive treatment for most of the population with severe aortic stenosis (AS). Now a days TAVI has been included as class I indication in ACC guidelines for patient subset >65 years of age. Few of the patients among these have chronic kidney disease and required regular dialysis for the same. Such patient could not tolerate high volume contrast injection during Pre TAVI aortic valve assessment. We present a case of post renal transplant, CKD stage IV patient with severe calcific aortic stenosis. We have done pre TAVI aortic valve assessment via 3D TEE (Trans esophageal echocardiography) only to avoid high volume contrast injection. 3D TEE assessment for aortic annulus, aortic annulus to left main coronary ostium height, aortic annulus to right coronary ostium height, aortic valve area. All such parameters were derived by 3D TEE and procedure was successful with no procedural complications, annular prosthesis mismatch and no paravalvular leakage.

Although cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters. Patients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) ​< ​50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters. A total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44–3.22; p ​< ​0.001; HR for composite outcome, 2.11; 95% CI, 1.48–3.01; p ​< ​0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11–2.74; p ​= ​0.02; HR for composite outcome, 1.63; 95% CI, 1.09–2.44; p ​= ​0.02). Functional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR. TOC summary: This study evaluated the presence of right ventricular dysfunction (RVD) by functional cardiac computed tomography angiography (CCTA) in 502 patients undergoing routine evaluation for transcatheter aortic valve replacement. CCTA-RVD was defined as right ventricular ejection fraction <50%, and was tested for its prognostic value beyond conventional risk factors and echocardiography. In our study, 25% of patients have RVD on CT that was not present on 2D echocardiography. CT-RVD provides independent prognostic value that is incremental to conventional clinical and echocardiographic characteristics, and therefore should be considered in routine risk stratification of patients with severe AS. [ABSTRACT FROM AUTHOR]

Background Cardiogenic shock (CS) is associated with significant morbidity and mortality (27–51%). Little is known about the feasibility and safety of emergency transcatheter aortic valve replacement (TAVR) for critical aortic stenosis (AS) in acute myocardial infarction (AMI) with CS. Case summary A 57-year-old male with history of tobacco dependence and diabetes mellitus presented with acute posterior ST-segment elevation myocardial infarction and CS. The patient initially underwent successful primary percutaneous intervention to an anomalous circumflex artery coming off the right cusp. It was noted to have advanced CS out of proportion to his coronary anatomy. Echocardiographic assessment noted critical AS. Heart team decided to perform percutaneous aortic balloon valvuloplasty under support of extracorporeal membrane oxygenation. Percutaneous aortic balloon valvuloplasty was performed and was complicated by severe aortic regurgitation (AR). A balloon-expandable transcatheter heart valve was then placed with resolution of AR and stabilization of the patient. Then, the patient was subsequently decannulated within a week then was able to go home after 47 days (32 days intensive care unit). His course was notable for a minor stroke due to initial period of hypotension and CS. He was extubated and remained hospitalized for several weeks participating in rehabilitation. Follow-up echo showed a well-seated and functioning transcatheter heart valve. His left ventricular systolic function improved from 21% to 45%. Conclusion Emergency TAVR is feasible and can be performed in a patient with AMI and CS. Early initiation of mechanical support allowed the patient to receive definitive treatment. The multidisciplinary heart team is essential and reflected in the ultimate outcome of our patient. [ABSTRACT FROM AUTHOR]

Abstract Background Accumulation of advanced glycation end products (AGEs) leads to chronic glycation of proteins and tissue damage, particularly in patients with diabetes mellitus (DM). We aimed to evaluate whether increased accumulation of AGEs in patients with aortic stenosis (AS) and concomitant type 2 diabetes (DM) is associated with AS severity. Methods We prospectively enrolled 76 patients with severe AS (47.1% males; nonDM), aged 68 [66–72] years, and 50 age-matched DM patients with a median blood glucose level of 7.5 [5.9–9.1] mM and glycated hemoglobin (HbA1c) of 6.8 [6.3–7.8]%, scheduled for aortic valve replacement. Valvular expression of AGEs, AGEs receptor (RAGE), interleukin-6 (IL-6), and reactive oxygen species (ROS) induction were evaluated ex vivo by immunostaining and calculated as the extent of positive immunoreactive areas/total sample area. Plasma levels of AGEs and soluble RAGE (sRAGE) were assessed by ELISAs. Results Subjects with DM had increased valvular expression of both AGEs (6.6-fold higher, 15.53 [9.96–23.28]%) and RAGE (1.8-fold higher, 6.8 [4.9–8.45]%) compared to nonDM patients (2.05 [1.21–2.58]% and 2.4 [1.56–3.02]%, respectively; both p 7% (n = 24, 48%) we found that valvular expression of AGEs correlated with mean transvalvular pressure gradient (PGmean; r = 0.45, p = 0.027). Plasma AGEs levels in the whole DM group correlated with AVA (r = − 0.32, p = 0.02), PGmean (r = 0.31, p = 0.023), and PGmax (r = 0.30, p = 0.03). Conclusions Our study suggests that poorly-controlled diabetes leads to increased AGEs and RAGE valvular accumulation, which at least partially, might result in AS progression in DM patients.

Calcific aortic valve disease (CAVD) is a common acquired valvulopathy, which carries a high burden of mortality. Chronic inflammation has been postulated as the predominant pathophysiological process underlying CAVD. So far, no effective medical therapies exist to halt the progression of CAVD. This review aims to outline the known pathways of inflammation and calcification in CAVD, focussing on the critical roles of mechanical stress and mechanosensing in the perpetuation of valvular inflammation. Following initiation of valvular inflammation, dysregulation of proinflammatory and osteoregulatory signalling pathways stimulates endothelial-mesenchymal transition of valvular endothelial cells (VECs) and differentiation of valvular interstitial cells (VICs) into active myofibroblastic and osteoblastic phenotypes, which in turn mediate valvular extracellular matrix remodelling and calcification. Mechanosensitive signalling pathways convert mechanical forces experienced by valve leaflets and circulating cells into biochemical signals and may provide the positive feedback loop that promotes acceleration of disease progression in the advanced stages of CAVD. Mechanosensing is implicated in multiple aspects of CAVD pathophysiology. The mechanosensitive RhoA/ROCK and YAP/TAZ systems are implicated in aortic valve leaflet mineralisation in response to increased substrate stiffness. Exposure of aortic valve leaflets, endothelial cells and platelets to high shear stress results in increased expression of mediators of VIC differentiation. Upregulation of the Piezo1 mechanoreceptor has been demonstrated to promote inflammation in CAVD, which normalises following transcatheter valve replacement. Genetic variants and inhibition of Notch signalling accentuate VIC responses to altered mechanical stresses. The study of mechanosensing pathways has revealed promising insights into the mechanisms that perpetuate inflammation and calcification in CAVD. Mechanotransduction of altered mechanical stresses may provide the sought-after coupling link that drives a vicious cycle of chronic inflammation in CAVD. Mechanosensing pathways may yield promising targets for therapeutic interventions and prognostic biomarkers with the potential to improve the management of CAVD.

BackgroundCardiac amyloidosis (CA) has been recently recognized as a condition frequently associated with aortic stenosis (AS). The aim of this study was to evaluate: the main characteristics of patients with AS with and without CA, the impact of CA on patients with AS mortality, and the effect of different treatment strategies on outcomes of patients with AS with concomitant CA.Materials and MethodsA detailed search related to CA in patients with AS and outcomes was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies enrolling 1,988 subjects (1,658 AS alone and 330 AS with CA) were included in the qualitative and quantitative analysis of main patients with AS characteristics with and without CA, difference in mortality, and treatment strategy.ResultsThe prevalence of CA resulted in a mean of 15.4% and it was even higher in patients with AS over 80 years old (18.2%). Patients with the dual diagnosis were more often males, had lower body mass index (BMI), were more prone to have low flow, low gradient with reduced left ventricular ejection fraction AS phenotype, had higher E/A and E/e', and greater interventricular septum hypertrophy. Lower Sokolow–Lyon index, higher QRS duration, higher prevalence of right bundle branch block, higher levels of N-terminal pro-brain natriuretic peptide, and high-sensitivity troponin T were significantly associated with CA in patients with AS. Higher overall mortality in the 178 patients with AS + CA in comparison to 1,220 patients with AS alone was observed [odds ratio (OR) 2.25, p = 0.004]. Meta-regression analysis showed that younger age and diabetes were associated with overall mortality in patients with CS with CA (Z-value −3.0, p = 0.003 and Z-value 2.5, p = 0.013, respectively). Finally, patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) had a similar overall mortality risk, but lower than medication-treated only patients.ConclusionResults from our meta-analysis suggest that several specific clinical, electrocardiographic, and echocardiographic features can be considered “red flags” of CA in patients with AS. CA negatively affects the outcome of patients with AS. Patients with concomitant CA and AS benefit from SAVR or TAVI.

ObjectiveWe sought to conduct a systematic review and meta-analysis of clinical adverse events in patients undergoing transcatheter aortic valve replacement (TAVR) with bicuspid aortic valve (BAV) vs. tricuspid aortic valve (TAV) anatomy and the efficacy of balloon-expandable (BE) vs. self-expanding (SE) valves in the BAV population. Comparisons aforementioned will be made stratified into early- and new-generation devices. Differences of prosthetic geometry on CT between patients with BAV and TAV were presented. In addition, BAV morphological presentations in included studies were summarized.MethodObservational studies and a randomized controlled trial of patients with BAV undergoing TAVR were included according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.ResultsA total of 43 studies were included in the final analysis. In patients undergoing TAVR, type 1 BAV was the most common phenotype and type 2 BAV accounted for the least. Significant higher risks of conversion to surgical aortic valve replacement (SAVR), the need of a second valve, a moderate or severe paravalvular leakage (PVL), device failure, acute kidney injury (AKI), and stroke were observed in patients with BAV than in patients with TAV during hospitalization. BAV had a higher risk of new permanent pacemaker implantation (PPI) both at hospitalization and a 30-day follow-up. Risk of 1-year mortality was significantly lower in patients with BAV than that with TAV [odds ratio (OR) = 0.85, 95% CI 0.75–0.97, p = 0.01]. BE transcatheter heart valves (THVs) had higher risks of annular rupture but a lower risk of the need of a second valve and a new PPI than SE THVs. Moreover, BE THV was less expanded and more elliptical in BAV than in TAV. In general, the rates of clinical adverse events were lower in new-generation THVs than in early-generation THVs in both BAV and TAV.ConclusionsDespite higher risks of conversion to SAVR, the need of a second valve, moderate or severe PVL, device failure, AKI, stroke, and new PPI, TAVR seems to be a viable option for selected patients with severe bicuspid aortic stenosis (AS), which demonstrated a potential benefit of 1-year survival, especially among lower surgical risk population using new-generation devices. Larger randomized studies are needed to guide patient selection and verified the durable performance of THVs in the BAV population.

BackgroundThere is no evidence of hemodynamic performance during exercise in patients with aortic stenosis (AS) after transcatheter aortic valve implantation (TAVI). This study aimed to investigate the changes in kinematic hemodynamics during exercise and determine the impact of prosthesis-patient mismatch (PPM) on the hemodynamics of transcatheter heart valves using exercise stress echocardiography (ESE) in AS patients after TAVI.Methods and ResultsThis study enrolled 77 consecutive patients (mean age 82 ± 5 years, 50.6% male) who underwent ESE 3–6 months after TAVI with a balloon-expandable valve. The effective orifice area index at rest was significantly correlated with the mean pressure gradient (PG) during exercise (p

This state-of-the-art review aimed to synthesize evidence from various sex-stratified studies on aortic stenosis (AS), focusing on the difference in clinical presentation, anatomical characteristics, pathophysiology, and management of AS. In comparison to men, women with AS are present at later stages, are older, more symptomatic, frailer, and exhibit higher operative risk [Society of Thoracic Surgeons (STS) score]. Women tend to have smaller aortic valve (AV) areas and left ventricular (LV) outflow tract, leading to lower stroke volumes (SVs) than men and have a higher prevalence of paradoxical, low-flow, low-gradient AS. In women, chronic pressure overload due to AS results in concentric LV remodelling and hypertrophy, characterized by reduced LV cavities, higher filling pressures, lower wall stress, and more diastolic dysfunction. Conversely, men exhibit more dilated eccentric LV remodelling and hypertrophy. AVs in women are less calcified but more fibrotic. Moreover, women are often underdiagnosed, have severity underestimated, and experience delays or receive fewer referrals for AV replacement (AVR). However, women tend to benefit from transcatheter AVR (TAVR) with a long-term survival advantage over men, although the incidence of vascular complications and bleeding events in 30 days after TAVR is higher in women. Surgical AVR (SAVR) in women has high operative risk, is technically demanding and has poorer outcomes with increased mortality at 30 days compared to men. According to the STS score and EuroSCORE, the female sex itself is considered a risk factor for SAVR. Therefore, addressing sex-related disparities in AS and increasing awareness among physicians promises improved diagnosis and treatment, facilitating equitable care and the development of sex-specific personalized medicine., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-406/coif). C.A. reports that she received speaker honoraria and has received travel support from Edwards Lifesciences, Medtronic and Boston. S.B. received speaker honoraria from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic. IPPMed, Cloppenburg, Germany, represented by P.B., has received honoraria (or research funding) for consultancy and medical writing from Edwards Lifesciences. V.D. received honoraria for lectures, presentations, and speakers from Abbott Vascular, Edwards Lifesciences, GE Healthcare, JenaValve, Medtronic, and Novartis Products & Features. Also, she received research grants from Philips and consultation fees from Edwards Lifesciences, Novo Nordisk, and MSD. H.E. received honoraria for lectures from Edwards Lifesciences. C.G. was supported by research grants from the Novartis Foundation, Switzerland; GE Healthcare, US; Gerresheimer AG, Switzerland; Bayer Pharmaceuticals, Switzerland; AMGEN, Switzerland; and Advisis AG, Switzerland, outside of the submitted work; has received travel support from Siemens Healthineers, Germany, and Biotronik, Switzerland; and has received speaker’s fees from Sanofi Genzyme, France. C.H. received institutional grant/research support from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Meril; received consultant fees and honoraria from Edwards Lifesciences, Boston Scientific, and Meril. J.K. is an employee of Edwards Lifesciences and owns stocks from that company. P.M. is a scientist working for Edwards Lifesciences. T.K.R. received research support for medical writing from IPPMed, Germany. W.W. received honoraria for lectures, presentations, speakers and travel support from Abbott Vascular, Medtronic, and Edward lifesciences; received research consultancy fees and received payment for participation in data safety monitoring board or advisory board from Medtronic. The authors have no other conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Rheumatic heart disease (RHD) is one of the leading causes of valvular heart disease worldwide and still persists in the USA, particularly among vulnerable populations with limited healthcare. Depending on the risk, severity, and types of valve involvement, treatment includes guideline-directed medical therapy (GDMT) and surgical interventions like valve repair or replacement. Here, we present a unique case of a patient in his late fifties who presented with worsening heart failure symptoms and several heart murmurs. A transthoracic echocardiogram (TTE) revealed moderate to severe mitral regurgitation (MR), aortic regurgitation (AR), and mild aortic stenosis (AS) with a bicuspid aortic valve. However, coronary angiography and right heart catheterization showed no blockages, right ventricular dysfunction, or pulmonary hypertension. Furthermore, no valvular vegetation was noticed on the transesophageal echocardiogram. The patient had a history of acute rheumatic fever (RF) in adolescence and was treated until age 21. Despite potential alternative causes like myocardial infarction or endocarditis, the lack of ischemic findings, negative blood cultures, and absence of valvular vegetation suggested that RHD was the possible cause of his valvular issues. This case highlights the rare occurrence of RHD impacting multiple valves despite proper antibiotic prophylaxis and draws attention to the importance of considering RHD when diagnosing multiple valvular problems, as many patients are identified too late for surgical intervention., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Hayee et al.)

Background: Evaluating the severity of aortic stenosis (AS) can be challenging, particularly in patients with low-gradient (LG, Δp < 40 mmHg) AS., Objective: This study aims to improve the accuracy of assessing severity of AS using a novel functional index- Aortic Valve Coefficient (AVC). The AVC is defined as ratio of mean transvalvular pressure-drop (Δp) to the proximal dynamic pressure (1/2 × blood density × V LVOT 2 ; V LVOT : left ventricular outflow tract peak velocity)., Hypothesis: AVC, developed from fundamental fluid dynamic principles, is a better index for accessing AS severity as it incorporates square of V LVOT and downstream pressure recovery., Methods: This pilot prospective study enrolled 47 patients undergoing TAVR for AS. Using cardiac-catheterization-measured Δp and echocardiography-Doppler-derived V LVOT , AVC was evaluated. Pre- and post-TAVR pressure-velocity measurements were obtained, resulting in a dataset with 78 data points, including 32 data points specifically linked to LG AS. Linear regression analysis was performed to correlate AVC with Δp, V LVOT and aortic-valve-area. Welch 2-sample t-test was carried out to compare the means of AVC against aortic-valve-area., Results: Moderate correlation (r = 0.85) was observed between AVC and aortic-valve-area indicating AVC could be a prospective index. However, correlation decreased (r = 0.75) in LG AS patients, indicating increased discordancy. Comparing AVC and aortic-valve-area in LG AS patients with left ventricular ejection fraction (LVEF) < 50 % and LVEF ≥50 %, t-test showed that AVC values are significantly different (p < 0.05) as compared to aortic-valve-area (p = 0.48)., Conclusion: AVC, a novel index, has the potential to improve assessment of AS severity and clinical decision making for treating patients with AS., Condensed Abstract: Complex hemodynamics, such as paradoxical "low-flow low-gradient (LG)" Aortic stenosis (AS) can be difficult to diagnose. Currently, mean transvalvular pressure-drop and flow-derived aortic-valve-area assess AS severity. Aortic valve coefficient (AVC) is a novel index which combines both pressure-drop and flow measurements to assess the severity of AS. A total of 47 patients (72 data points) were studied undergoing TAVR. In LG AS patients, t-test comparing left ventricular ejection fraction (LVEF) < 50 % and LVEF ≥50 % showed that AVC are significantly different (p < 0.05) as compared to aortic-valve-area (p = 0.48). Therefore, AVC could be a better index., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Published by Elsevier Inc.)

Recent artificial intelligence (AI) advancements in cardiovascular medicine offer potential enhancements in diagnosis, prediction, treatment, and outcomes. This article aims to provide a basic understanding of AI enabled ECG technology. Specific conditions and findings will be discussed, followed by reviewing associated terminology and methodology. In the appendix, definitions of AUC versus accuracy are explained. The application of deep learning models enables detecting diseases from normal electrocardiograms at accuracy not previously achieved by technology or human experts. Results with AI enabled ECG are encouraging as they considerably exceeded current screening models for specific conditions (i.e., atrial fibrillation, left ventricular dysfunction, aortic stenosis, and hypertrophic cardiomyopathy). This could potentially lead to a revitalization of the utilization of the ECG in the insurance domain. While we are embracing the findings with this rapidly evolving technology, but cautious optimism is still necessary at this point., Competing Interests: Conflicts of Interest: Neither author acknowledged any financial or other conflicts of interest in producing this treatise., (Copyright © 2024 Journal of Insurance Medicine.)

Objective To study the effects of ascending aorta dilatation and aortic valve dysfunction on the elasticity of the middle ascending aorta (mid-AA) and proximal descending aorta (PDA) in patients with bicuspid aortic valve (BAV) by using magnetic resonance imaging (MRI). Methods From Oct 2019 to Mar 2021, a total of 130 BAV patients and 30 healthy volunteers from Zhongshan Hospital, Fudan University were prospectively undergone 3.0 T MRI for aortic distensibility. BAV patients were categorized into 4 groups according to the diameter of ascending aorta and aortic valve function as follows: BAV with normal or mild aortic valve dysfunction and nondilated ascending aorta (AA) (BAV-CTL, n=30), BAV with normal or mild aortic valve dysfunction and dilated AA (Dilated BAV-NF, n=40), BAV with moderate to severe aortic stenosis and dilated AA (Dilated BAV-AS, n=30), and BAV with moderate to severe aortic insufficiency and dilated AA (Dilated BAV-AI, n=30). The cross-sectional areas and distensibility of mid-AA and PDA were assessed at the level of right pulmonary artery.Student’s t test and Mann-Whitney U test were used to compare the continuous variables between the groups, while chi-square test or Fisher exact test was used to compare the categorical variables. Results Dilated BAV-NF group had decreased mid-AA distensibility［2.77 (IQR: 1.45-6.26) vs. 1.52 (IQR: 1.08-2.19), P=0.004] than BAV-CTL group. Compared with the Dilated BAV-NF, Dilated BAV-AI had elevated distensibility at mid- AA and PDA［mid-AA: 1.52 (IQR: 1.08-2.19) vs. 2.29 (IQR: 1.60-4.08), P=0.006；PDA: 3.70 (IQR: 2.89-4.70) vs. 4.79 (IQR: 2.93-6.80), P=0.024]. Compared with the Dilated BAV-AS, Dilated BAV-AI again showed elevated distensibility at mid-AA and PDA［mid-AA: 1.60 (IQR: 0.99-2.26) vs. 2.29 (IQR: 1.60-4.08), P=0.022；PDA: 3.73 (IQR: 2.38-4.40) vs. 4.79 (IQR: 2.93-6.80), P=0.014]. Conclusion Ascending aorta dilatation and aortic insufficiency are the main factors affecting aortic elasticity in patients with BAV. The effect of aortic dilatation on aortic elasticity is limited to the ascending aorta, while the effect of aortic insufficiency on aortic elasticity is more extensive. [ABSTRACT FROM AUTHOR]

Aims: Left ventricular ejection fraction is the conventional measure used to guide heart failure management, regardless of underlying etiology. Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) is a more sensitive measure of intrinsic myocardial function. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on cardiovascular magnetic resonance (CMR) and validate the prognostic value of LV-GLS thresholds associated with fibrosis.Methods and results: LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57 ± 10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71 ± 12 years; 58% males; NYHA functional class I–II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, and myocardial infarction. In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74 [0.66–0.83]; P < 0.001) and calibration (Hosmer-Lemeshow χ2 = 6.37; P = 0.605) for replacement fibrosis. In the outcome cohort, 47 events occurred over 16 [3.3, 42.2] months. Patients with LV-GLS > −15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS < −21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P < 0.001). LV-GLS offered independent prognostic value over clinical variables, AS severity and echocardiographic LV mass and E/e′.Conclusion: LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF.

Background: The upper physiological threshold for tricuspid regurgitation velocity (TRV) of 2.8 m/s proposed by the Pulmonary Hypertension (PH) guidelines had been questioned. The aim of this study was to evaluate the prognostic significance of preoperative PH in patients with aortic stenosis, long-term after valve replacement, using two different TRV thresholds (2.55 and 2.8 m/s).Methods: Four hundred and forty four patients were included (mean age 73 ± 9 years; 55% male), with a median follow-up of 5.8 years (98% completed). Patients were divided into three PH probability groups according to guidelines (low, intermediate and high) for both thresholds (TRV ≤ 2.8 m/s and TRV ≤ 2.55 m/s), using right atrial area>18 cm2 and right ventricle/left ventricle ratio>1 as additional echocardiographic variables.Results: In patients with measurable TRV (n = 304), the low group mortality rate was 25% and 30%, respectively for 2.55 and 2.8 m/s TRV thresholds. The intermediate group with TRV > 2.55 m/s was an independent mortality risk factor (HR 2.04; 95% CI: 1.91 to 3.48, p = 0.01), in contrast to the intermediate group with TRV>2.8 m/s (HR 1.44; 95% CI: 0.89 to 2.32, p = 0.14). Both high probability groups were associated with an increased mortality risk, as compared to their respective low groups. When including all patients (with measurable and non-measurable TRV), both intermediate groups remained independently associated with an increased mortality risk: HR 1.62 (95% CI 1.11 to 2.35 p = 0.01) for the new cut-off point; and HR 1.43 (95% CI: 0.96 to 2.13, p = 0.07) for guidelines threshold.Conclusion: A TRV threshold of 2.55 m/s, together with right cavities measures, allowed a better risk assessment of patients with PH secondary to severe aortic stenosis, with or without tricuspid regurgitation.

Objectives: Transthoracic echocardiography (TTE) is the standard technique for assessing aortic stenosis (AS), with effective orifice area (EOA) recommended for grading severity. EOA is operator-dependent, influenced by a number of pitfalls and requires multiple measurements introducing independent and random sources of error. We tested the diagnostic accuracy and precision of aliased orifice area planimetry (AOAcmr), a new, simple, non-invasive technique for grading of AS severity by low-VENC phase-contrast cardiovascular magnetic resonance (CMR) imaging.Methods: Twenty-two consecutive patients with mild, moderate, or severe AS and six age- and sex-matched healthy controls had TTE and CMR examinations on the same day. We performed analysis of agreement and correlation among (i) AOAcmr; (ii) geometric orifice area (GOAcmr) by direct CMR planimetry; (iii) EOAecho by TTE-continuity equation; and (iv) the “gold standard” multimodality EOA (EOAhybrid) obtained by substituting CMR LVOT area into Doppler continuity equation.Results: There was excellent pairwise positive linear correlation among AOAcmr, EOAhybrid, GOAcmr, and EOAecho (p < 0.001); AOAcmr had the highest correlation with EOAhybrid (R2 = 0.985, p < 0.001). There was good agreement between methods, with the lowest bias (0.019) for the comparison between AOAcmr and EOAhybrid. AOAcmr yielded excellent intra- and inter-rater reliability (intraclass correlation coefficient: 0.997 and 0.998, respectively).Conclusions: Aliased orifice area planimetry by 2D phase contrast imaging is a simple, reproducible, accurate “one-stop shop” CMR method for grading AS, potentially useful when echocardiographic severity assessment is inconclusive or discordant. Larger studies are warranted to confirm and validate these promising preliminary results.

Summary: The advent of transcatheter procedures for treatment of valvular heart disease has accelerated the pace of research in the diagnosis and treatment of heart valve disease. Rapid accumulation of novel knowledge in the field necessitates timely revisions of clinical guidelines. This paper comments on some important and novel issues addressed in the recently published American College of Cardiology/American Heart Association (ACC/AHA) guidelines. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve replacement（TAVR） is a mature method to treat aortic valve stenosis （AS）. Almost all patients with AS have cardiac hypertrophy. At present，AS patients with hypertrophic obstructive cardiomyopathy （HOCM） are recommended for surgery firstly，not TAVR. However，the elderly and high-risk patients often cannot tolerate surgery，and whether intervention can treat such patients safely and effectively is still questionable.This paper reports that a 77-year-old female patient with severe AS and HOCM underwent one-stop TAVR+percutaneous transluminal septal myocardial ablation（percutaneous transluminal septal myocardial ablation，PTSMA）on the basis of careful evaluation. The patient is recovering well. This case is the first one-stop TAVR+PTSMA developed in China， providing a new basis for the treatment of emergency complications during TAVR and the expansion of indications. [ABSTRACT FROM AUTHOR]

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Lipoprotein(a), or Lp(a), is a distinctive lipoprotein particle linked to various cardiovascular diseases, notably atherosclerosis and aortic stenosis. Much like plasminogen, Lp(a) hinders normal fibrinolysis, leading to increased thrombosis and slower clearance of fibrin debris. It also causes inflammation, oxidative stress, and endothelial dysfunction, contributing to the formation of atherosclerotic lesions. Epidemiological studies have consistently shown that even slight increases in Lp(a) levels correlate with a heightened risk of cardiovascular events. Furthermore, Lp(a) plays a role in aortic stenosis by binding to leaflet valves, accumulating within them, and triggering calcium deposition and nodule formation. These calcium deposits gradually narrow the arteries, impeding blood flow. By raising inflammation and oxidative stress in the valve, Lp(a) accelerates tissue damage and calcium deposition. Traditional lipid-lowering therapies have limited efficacy in reducing Lp(a) levels. However, new treatments using RNA interference and antisense oligonucleotides to decrease Lp(a) production in the liver offer promising prospects for mitigating the risks and managing atherosclerosis and aortic stenosis associated with high Lp(a) levels. As Lp(a) screening becomes more common in healthcare, physicians will be better equipped to assess patients' risk levels and provide tailored treatments. This review aims to examine the role of Lp(a) in the development of aortic stenosis and atherosclerosis., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Obi et al.)