Transcatheter aortic valve replacement in low-risk young population:A double edge sword?

Since the advent of transcatheter aortic valve replacement(TAVR)in 2002,it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis,particularly in intermediate to highsurgical risk patients.In 2019,the United States Food and Drug Administration approved TAVR in low-risk patients based on two randomized trials.However,these breakthrough trials excluded patients with certain unfavorable anatomies and odd profiles.While currently there is no randomized study of TAVR in young patients,it may be preferred by the young population given the benefits of early discharge,shorter hospital stay,and expedite recovery.Nonetheless,it is important to ruminate various factors including lifetime expectancy,risk of pacemaker implantation,and the need for future valve or coronary interventions in young cohorts before considering TAVR in these patients.Furthermore,the data on long-term durability(>10 years)of TAVR is still unknown given most of the procedures were initially performed in the high or prohibitive surgical risk population.Thus,this editorial aims to highlight the importance of considering an individualized approach in young patients with consideration of various factors including lifetime expectancy while choosing TAVR against surgical aortic valve replacement.

Current knowledge for the risk factors of early permanent pacemaker implantation following transcatheter aortic valve replacement and what is next for the primary prevention?

In this editorial,we comprehensively summarized the preoperative risk factors of early permanent pacemaker implantation after transcatheter aortic valve replacement(TAVR)among patients with severe aortic stenosis from several renowned clinical studies and focused on the primary prevention of managing the modifiable factors,e.g.,paroxysmal atrial fibrillation before the TAVR.

Isogeometric Analysis of Hyperelastic Material Characteristics for Calcified Aortic Valve

This study explores the implementation of computed tomography(CT)reconstruction and simulation techniques for patient-specific valves,aiming to dissect the mechanical attributes of calcified valves within transcatheter heart valve replacement(TAVR)procedures.In order to facilitate this exploration,it derives pertinent formulas for 3D multi-material isogeometric hyperelastic analysis based on Hounsfield unit(HU)values,thereby unlocking foundational capabilities for isogeometric analysis in calcified aortic valves.A series of uniaxial and biaxial tensile tests is executed to obtain an accurate constitutive model for calcified active valves.To mitigate discretization errors,methodologies for reconstructing volumetric parametric models,integrating both geometric and material attributes,are introduced.Applying these analytical formulas,constitutive models,and precise analytical models to isogeometric analyses of calcified valves,the research ascertains their close alignment with experimental results through the close fit in displacement-stress curves,compellingly validating the accuracy and reliability of the method.This study presents a step-by-step approach to analyzing themechanical characteristics of patient-specific valves obtained fromCT images,holding significant clinical implications and assisting in the selection of treatment strategies and surgical intervention approaches in TAVR procedures.

A novel mouse model of calcific aortic valve stenosis

Background:Calcific aortic valve stenosis(CAVS)is one of the most challenging heart diseases in clinical with rapidly increasing prevalence.However,study of the mecha-nism and treatment of CAVS is hampered by the lack of suitable,robust and efficient models that develop hemodynamically significant stenosis and typical calcium deposi-tion.Here,we aim to establish a mouse model to mimic the development and features of CAVS.Methods:The model was established via aortic valve wire injury(AVWI)combined with vitamin D subcutaneous injected in wild type C57/BL6 mice.Serial transthoracic echocardiography was applied to evaluate aortic jet peak velocity and mean gradi-ent.Histopathological specimens were collected and examined in respect of valve thickening,calcium deposition,collagen accumulation,osteogenic differentiation and inflammation.Results:Serial transthoracic echocardiography revealed that aortic jet peak velocity and mean gradient increased from 7 days post model establishment in a time depend-ent manner and tended to be stable at 28 days.Compared with the sham group,sim-ple AVWI or the vitamin D group,the hybrid model group showed typical pathological features of CAVS,including hemodynamic alterations,increased aortic valve thicken-ing,calcium deposition,collagen accumulation at 28 days.In addition,osteogenic dif-ferentiation,fibrosis and inflammation,which play critical roles in the development of CAVS,were observed in the hybrid model.Conclusions:We established a novel mouse model of CAVS that could be induced efficiently,robustly and economically,and without genetic intervention.It provides a fast track to explore the underlying mechanisms of CAVS and to identify more effec-tive pharmacological targets.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND Transcatheter aortic valve replacement(TAVR)is a revolutionary procedure for severe aortic stenosis.The coexistence of chronic kidney disease(CKD)and TAVR introduces a challenge that significantly impacts patient outcomes.AIM To define readmission rates,predictors,and causes after TAVR procedure in CKD stage 1-4 patients.METHODS We used the national readmission database 2018 and 2020 to look into readmission rates,causes and predictors after TAVR procedure in patients with CKD stage 1-4.RESULTS Out of 24758 who underwent TAVR and had CKD,7892(32.4%)patients were readmitted within 90 days,and had higher adjusted odds of being females(adjusted odds ratio:1.17,95%CI:1.02-1.31,P=0.02)with longer length of hospital stay>6 days,and more comorbidities including but not limited to diabetes mellitus,anemia,and congestive heart failure(CHF).CONCLUSION Most common causes of readmission included CHF(18.0%),sepsis,and complete atrioventricular block.Controlling readmission predictors with very close followup is warranted to prevent such high rate of readmission.

Risk of permanent pacemaker implantation following transcatheter aortic valve replacement:Which factors are most relevant?

Transcatheter aortic valve replacement(TAVR)has emerged as a formidable treatment option for severe symptomatic aortic stenosis ahead of surgical aortic valve replacement.The encouraging results from large randomized controlled trials has resulted in an exponential rise in the use of TAVR even in the low-risk patients.However,this is not without challenges.Need for permanent pacemaker(PPM)post-TAVR remains the most frequent and clinically relevant challenge.Naturally,identifying risk factors which predispose an individual to develop high grade conduction block post-TAVR is important.Various demographic factors,electrocardiographic features,anatomic factors and procedural characteristics have all been linked to the development of advanced conduction block and need for PPM following TAVR.Amongst these electrophysiological variables,most notably a prolonged QRS>120 ms regardless of the type of conduction block seems to be one of the strongest predictors on logistic regression models.The index study by Nwaedozie et al highlights that patients requiring PPM post-TAVR had higher odds of having a baseline QRS>120 ms and were more likely to be having diabetes mellitus that those who did not require PPM.

Predictors of permanent pacemaker implantation following transcatheter aortic valve replacement-the search is still on!

Several anatomical,demographic,clinical,electrocardiographic,procedural,and valve-related variables can be used to predict the probability of developing con-duction abnormalities after transcatheter aortic valve replacement(TAVR)that necessitate permanent pacemaker(PPM)implantation.These variables include calcifications around the device landing zone and in the mitral annulus;pre-existing electrocardiographic abnormalities such as left and right bundle branch blocks(BBB),first-and second-degree atrioventricular blocks,as well as bifas-cicular and trifascicular blocks;male sex;diabetes mellitus(DM);hypertension;history of atrial fibrillation;renal failure;dementia;and use of self-expanding valves.The current study supports existing literature by demonstrating that type 2 DM and baseline right BBB are significant predictors of PPM implantation post-TAVR.Regardless of the side of the BBB,this study demonstrated,for the first time,a linear association between the incidence of PPM implantation post-TAVR and every 20 ms increase in baseline QRS duration(above 100 ms).After a 1-year follow-up,patients who received PPM post-TAVR had a higher rate of hospital-ization for heart failure and nonfatal myocardial infarction.

Pacemaker post transcatheter aortic valve replacement:A multifactorial risk?

Pacemaker post-transcatheter aortic valve replacement is related to multifactorial risk.Nwaedozie et al brought to the body of evidence electrocardiogram and clinical findings.However,procedural characteristics have at least as much impact on the final need for a permanent pacemaker and potentially on the pacing rate.In this regard,long-term follow-up and understanding of the impact of long-term stimulation is of utmost importance.

Animal Model of Aortic Valve Calcification: Their Methodology Helps Us Understand Aortic Valve Calcification

Aortic valve calcification disease (CAVD) is the most prevalent degenerative valve disease in humans, leading to significant morbidity and mortality. Despite its common occurrence, our understanding of the underlying mechanisms remains incomplete, and available treatment options are limited and risky. A more comprehensive understanding of the biology of CAVD is essential to identify new therapeutic strategies. Animal models have played a crucial role in advancing our knowledge of CAVD and exploring potential treatments. However, these models have inherent limitations as they cannot fully replicate the complex physiological mechanisms of human CAVD. In this review, we examine various CAVD models ranging from pigs to mice, highlighting the unique characteristics of each model to enhance our understanding of CAVD. While these models offer valuable insights, they also have limitations and shortcomings. We propose that the guide wire model shows promise for future CAVD research, and streamlining the methodology could enhance our understanding and expand the research scope in this field.

A Rare Case of Aortic Valve Endocarditis and Acute Meningitis Due to Haemophilus influenzae

HACEK organisms represent a rare but important group of causative pathogens in endocarditis. These bacteria have historically been associated with culture-negative endocarditis;however, modern laboratory techniques have made this less common. In this case, we present a 74-year-old man who presented with acute onset altered mentation, fever, and sepsis. He was ultimately found to have Haemophilus influenzae meningitis, cerebral empyema, aortic valve endocarditis, psoas myositis, and L2 - L3 diskitis with osteomyelitis. Although HACEK organisms are commonly found in the oropharynx and upper respiratory tract in humans, our patient did not report recent preceding dental or ENT procedures. H. influenzae is responsible for approximately 0.16% of all cases of bacterial endocarditis, representing a very limited subset. Although generally considered low virulent pathogens, this case demonstrates the unusual extent of infection from a HACEK organism, H. influenzae, causing aortic valve endocarditis as well as atypical non-cardiac sequelae, including acute meningitis.

Transcatheter Aortic Valve Dislocation in Left Ventricular Outflow Tract with Successful Repositioning Using “Double Snare” Technique

Background: Transcatheter aortic valve implantation (TAVI) is a widely used treatment of severe aortic stenosis. Implantation of a self-expanding valve into a dense calcified aortic annulus can be challenging and may result in device malposition and malfunction. Aim: The aim of our case report is to present a novel technique of transcatheter aortic valve dislocation treatment. Case presentation: An 86-year-old woman with severely calcified aortic valve underwent TAVI using a 27-mm self-expanding Portico valve (Abbott Vasc, USA). In the last phase of implantation, the valve dislocated deep into the left ventricular outflow tract resulting in significant paravalvular regurgitation and patient instability. Repositioning of the valve with a single snare was ineffective because of severe aortic ring calcifications. A novel “double snare” technique was applied and the valve was successfully repositioned upward with an excellent anatomic and haemodynamic result. Conclusion: “Double snare” technique can be an effective strategy for repositioning of deeply implanted self-expanding transcatheter aortic valves. It represents an efficient bailout strategy in case of single snare approach failure, especially in cases of severe aortic ring calcifications.

Aortic valve stenosis： treatments options in elderly high-risk patients

In the last decades, a trend towards a worldwide aging has been reported and diseases which are common in the elderly people would have important implications in clinical practice. Aortic stenosis （AS） is perhaps the most common and most often cause of sudden death among valvular heart diseases. Its prevalence is low among adults aged 〈 60 years, but increases to almost 10% in adults ≥ 80 years.[2] Since the degenerative calcific disease represents the lead- ing cause of AS in developed countries, the improved understanding on its pathogenesis （atherosclerotic processes and/or skeleton key） may offer potentially new targets for preventing and inhibiting AS development and progres- sion.[3] Patients with AS are generally asymptomatic for a prolonged period and the development of symptoms is a critical point in the natural history. Indeed, the prognosis changes dramatically with the onset of symptoms of angina,

Fluid-Structure Interaction in Problems of Patient Specific Transcatheter Aortic Valve Implantation with and Without Paravalvular Leakage Complication

Paravalvular Leakage(PVL)has been recognized as one of the most dangerous complications in relation to Transcathether Aortic Valve Implantation(TAVI)activities.However,data available in the literature about Fluid Structure Interaction(FSI)for this specific problem are relatively limited.In the present study,the fluid and structure responses of the hemodynamics along the patient aorta model and the aortic wall deformation are studied with the aid of numerical simulation taking into account PVL and 100%TAVI valve opening.In particular,the aorta without valve(AWoV)is assumed as the normal condition,whereas an aorta with TAVI 26 mm for 100%Geometrical Orifice Area(GOA)is considered as the patient aorta with PVL complication.A 3D patient-specific aorta model is elaborated using the MIMICS software.Implantation of the identical TAVI valve of Edward SAPIEN XT 26(Edwards Lifes ciences,Irvine,California)is considered.An undersized 26 mm TAVI valve with 100%valve opening is selected to mimic the presence of PVL at the aortic annulus.The present research indicates that the existence of PVL can increase the blood velocity,pressure drop and WSS in comparison to normal conditions,thereby paving the way to the development of recirculation flow,thrombus formation,aorta wall collapse,aortic rupture and damage of endothelium.

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis （AS） is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement （SAVR） has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged, Transcatheter aortic valve replacement （TAVR） is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety （e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing）. The impact of comorbidities （pulmonary hypertension, arterial hypertension and obesity paradox）, the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category （extremely high, high, intermediate and low risk） are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.

Bioprosthetic Valve Size Selection to Optimize Aortic Valve ReplacementSurgical Outcome: A Fluid-Structure Interaction Modeling Study

Aortic valve replacement(AVR)remains a major treatment option for patients with severe aortic valve disease.Clinical outcome of AVR is strongly dependent on implanted prosthetic valve size.Fluid-structure interaction(FSI)aortic root models were constructed to investigate the effect of valve size on hemodynamics of the implanted bioprosthetic valve and optimize the outcome of AVR surgery.FSI models with 4 sizes of bioprosthetic valves(19(No.19),21(No.21),23(No.23)and 25 mm(No.25))were constructed.Left ventricle outflow track flow data from one patient was collected and used as model flow conditions.Anisotropic Mooney–Rivlin models were used to describe mechanical properties of aortic valve leaflets.Blood flow pressure,velocity,systolic valve orifice pressure gradient(SVOPG),systolic cross-valve pressure difference(SCVPD),geometric orifice area,and flow shear stresses from the four valve models were compared.Our results indicated that larger valves led to lower transvalvular pressure gradient,which is linked to better post AVR outcome.Peak SVOPG,mean SCVPD and maximum velocity for Valve No.25 were 48.17%,49.3%,and 44.60%lower than that from Valve No.19,respectively.Geometric orifice area from Valve No.25 was 52.03%higher than that from Valve No.19(1.87 cm2 vs.1.23 cm2).Implantation of larger valves can significantly reduce mean flow shear stress on valve leaflets.Our initial results suggested that larger valve size may lead to improved hemodynamic performance and valve cardiac function post AVR.More patient studies are needed to validate our findings.

Advanced age and the clinical outcomes of transcatheter aortic valve implan-tation

Aortic valve stenosis （AS） is common in the elderly. Although surgical replacement of the valve has been the gold standard of management, many patients have been excluded from surgery because they were very old, frail, or had co-morbidities that increased operative risks. In the last decade, transcatheter aortic valve implantation （TAVI） has emerged as a new treatment option suitable for these patients. This article reviews the available literature on the role of TAVI in elderly patients with severe aortic stenosis. Published studies showed that elderly individuals who underwent TAVI experienced better in-hospital recovery, and similar short and mid-term mortality compared to those underwent surgical treatment of AS. However, long-term outcomes of TAVI in elderly patients are still unknown. The available data in the literature on the ef-fect of advanced age on clinical outcomes of TAVI are limited, but the data that are available suggest that TAVI is a beneficial and tolerable procedure in very old patients. Some of the expected complications after TAVI are reported more in the oldest patients such as vascular in-jures. Other complications were comparable in TAVI patients regardless of their age group. However, very old patients may need closer monitoring to avoid further morbidities and mortality.

Prognostic value of the ratio between prosthesis area and indexed annulus area measured by MultiSlice-CT for transcatheter aortic valve implantation procedures

Background Postprocedural aortic regurgitations following transcatheter aortic valve implantation （TAVI） procedures remain an is- sue. Benefit of oversizing strategies to prevent them isn＇t well established. We compared different level of oversizing in our cohort of con- secutive patients to address if severe oversizing compared to normal sizing had an impact on post-procedural outcomes. Methods From January 2010 to August 2013, consecutive patients were referred for TAVI with preoperative Multislice-CT （MSCT） and the procedures were achieved using Edwards Sapien~ or Corevalve devices~. Retrospectively, according to pre-procedural MSCT and the valve size, pa- tients were classified into three groups： normal, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and measured on MSCT. Main endpoint was mid-term mortality and secondary endpoints were the Valve Academic Research Consortium （VARC-2） endpoints. Results Two hundred and sixty eight patients had a MSCT and underwent TAVI procedure, with mainly Corevalve~. While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pacemaker （PM） implantation rate was significantly higher in the severe oversizing group （P = 0.03）, while we observed more in-hospital congestive heart-failure （P = 0.02） in the normal sizing group. There was a trend toward more moderate to severe aortic regurgitation （AR） in the normal sizing group （P = 0.07）. Conclusions Despite a higher rate of PM implantation, oversizing based on this ratio reduces aortic leak with lower rates of post-procedural complications and a similar mid-term survival.

Aortic Valve in Black: A Case of Aortic Valve Ochronosis

Alkaptonuria is a rare inherited tyrosine metabolism disorder, resulting in homogentisic acid deposition in the connective tissues. The condition is commonly referred to as ochronosis and manifests as skin pigmentation, degenerative arthropathy, and black urine. Among the rare complications of this disease is the involvement of the cardiovascular system. We report a case of a 63-year-old woman with alkaptonuric ochronosis who had already undergone three joint replacements. She was referred to our center for aortic valve replacement after accidentally discovering severe aortic valve stenosis in the preoperative assessment prior to her fourth joint replacement. Intraoperative findings included ochronosis of a severely calcified black-pigmented aortic valve and black pigmentation of the aortic intima. Histopathological analysis and elevated homogentisic acid levels in the patient’s urine confirmed the diagnosis of alkaptonuria. However, alkaptonuria was not diagnosed until aortic valve replacement despite the previous symptoms and signs. This report aims to outline the history, etiology, pathogenesis, clinical presentation, and treatment of aortic valve ochronosis in addition to presenting the case.

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years： the effects of EuroSCORE and patient operability

Objective To determine the extent to which differences in generic quality of life （QOL） between transcatheter aortic valve implanta- tion （TAVI） and surgical aortic valve replacement （AVR） patients explained by EuroSCORE and heart-team operability assessment. Methods A total of 146 high-risk patients with EuroSCORE 〉 6 and aged 〉 75 years underwent TAVI （n = 80） or aortic valve replacement （n = 66） between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EUroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration. Results The AVR group required longer ventilation （〉 24 h） （TAVI 5.0% vs. AVR 20.6%, P = 0.004） and more units of red blood cells [TAVI 0 （0-1） vs. AVR 2 （0-3）, P = 0.01]. New renal failure was higher in TAVI （TAVI 5.0% vs. AVR 0%, P = 0.06）. TAVI patients reported significantly lower vitality （P = 0.01） by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% （general health） - 62.9% （physical role）] whereas deterioration in QOL occurred less frequently [range 9.3% （physical role） - 33.3% （mental health）]. Conclusions Clinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration.

Minimally invasive aortic valve surgery

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replace- ment is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper stemotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease.