Medical management of symptomatic severe aortic stenosis in patients non-eligible for transcatheter aortic valve implantation

1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The preferred treatment in symptomatic severe aortic stenosis(SAS) is surgical aortic valve replacement(SAVR), but in the elderly, the surgical risk can be greater than the benefit.([3]).

Balloon valvuloplasty as destination therapy in elderly with severe aortic stenosis： a cardiac catheterization study

Background In the current era of transcatheter aortic valve replacement, there is renewed interest in balloon aortic valvuloplasty （BAV） and invasive hemodynarnic evaluation of aortic stenosis （AS）. The current report aimed to study the invasive hemodynamics of se- vere AS patients treated with BAV as destination therapy and to identify factors associated with better hemodynamic outcome and prognosis. Methods From 2009 to 2012, 63 high risk elderly patients were treated with BAV as destination therapy for symptomatic severe AS and were all prospectively included in the study. Their hemodynamies were invasively evaluated during catheterization, pre- and post-BAV at the same session. All Post-BAV patients were regularly followed-up. Results The patients （82 ~ 6 years, 52% male） had post-BAV aortic valve area index （AVAi） significantly increased and mean pressure gradient （MPG） significantly reduced. During the follow-up of 0.9 （maximum 3.3） years, those with post-BAV AVAi 〈 0.6 cm2/m2 compared with the AVAi _〉 0.6 cm2/m2 group had significantly higher mortality （60% vs. 28%, log-rank P = 0.02）, even after adjusting for age, gender, atrial fibrillation, chronic kidney disease, diabetes mellitus, coronary artery disease and EuroSCORE [HR： 5.58, 95% confidence interval （CI）： 1.62-19.20, P = 0.006]. The only independent predictor of moderate AS post-BAV was the pre-BAV AVAi increase by 0.1cm^2/m^2 （OR： 3.81, 95% CI： 1.33-10.89, P = 0.01）. Pre-BAV AVAi 〉 0.39 cm^2/m^2 could predict with sensitivity 84% and specificity 70% the post-BAV hemodynamic outcome. Conclusions BAV as destination therapy for severe AS offered immediate and significant hemodynamic improvement. The survival was significantly better when a moderate degree of AS was present.

Emergency Treatment of Acute Decompensated Severe Aortic Stenosis with Transcatheter Aortic Valve implantation under the Coplane View Using J-Tipped Wires Fluoroscopy

Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for transcatheter aortic valve implantation(TAVI),computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure.This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVl.This approach reduces contrast usage during the TAVI procedure,significantly mitigating the risks of renal injury and heart function deterioration.

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis （AS）,even in patients without significant coronary artery disease （CAD）.However,the incidence of angina pectoris and related CAD in such patients is controversial.There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement （AVR） in patients with severe AS.The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population.Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995.Clinical and echocardiographic follow-up data were recorded into the database annually.Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70％ and left main coronary arteries having an estimated narrowing of ≥50％ on coronary angiography.We excluded patients with multiple valve disease,significant aortic regurgitation,or prior CAD or valve surgery.Results Totally 574 patients with severe AS （mean age,（65.9±9.6） years） were enrolled in this study.Significant CAD was found in 61 patients （10.6％）.Factors associated with increased likelihood of CAD were age,hypertension,diabetes mellitus,chronic renal failure,carotid disease,and aorta calcification.In Logistic regression analysis,the independent predictor of the presence of CAD was age （P=0.011）.The incidence of CAD increased significantly at 69.2 years of age.Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD.Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS.Therefore,coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age without risk factors for cardiovascular disease.